Antepartum - First Tri Mgmt

Front 1

What are the dates of the 1st tri?

Back 1

Conception to birth

Front 2

What are some psychological concerns of 1st tri?

Back 2

1) Is pregnancy desired (whether planned or unplanned)
2) Partner support
3) Partner violence
4) Pregnancy loss
5) Body image

Front 3

What are sxs of pregnancy loss?

Back 3

1) vaginal bleeding
2) cramping
3) no fetal heart tones
4) loss of products of conception

Front 4

What percentage of women with 1st tri vaginal bleeding will experience pregnancy loss?

Back 4

approx. 50%

Front 5

What are the Differential Diagnoses of 1st tri bleeding (R/O)?

Back 5

1) AB
2) infection
3) cervical polyps
4) cervical carcinoma
5) bleeding disorders
6) sexual assault or trauma
7) gestational trophoblastic disease (GTD)
8) ectopic pregnancy
9) implantation bleeding
10) hyperemia of cervix
11) multiple gestation
12) normal intrauterine pregnancy (IUP)

Front 6

What is gestational trophoblastic disease (GTD)?

Back 6

abnormal proliferation of trophoblastic tissue -- can be benign or malignant

Front 7

What is benign GTD?

Back 7

molar pregnancy

Front 8

What are the possible malignant manifestations of GTD?

Back 8

1) neoplasia
2) choriocarcinoma
3) placental site tumors

Front 9

What is the difference between complete vs. partial benign GTD?

Back 9

Complete: contains no genetic material
Partial: nonviable fetus

Front 10

What are the sxs of GTD?

Back 10

1) vaginal bleeding
2) severe N/V
3) uterus is large for dates
4) no fetal heart tones or activity
5) hCG levels high and rising rapidly

Front 11

What is the medical mgmt for GTD?

Back 11

MUST EVACUATE UTERUS

Front 12

What is the follow-up for GTD?

Back 12

Weekly measurement of hCG -- want to see declining levels to undetectable

Continued monitoring for up to 1 year

Front 13

How long should a woman wait before attemping pregnancy again following GTD?

Back 13

1 year

Front 14

What is ectopic pregnancy?

Back 14

Implantation outside the uterus

Front 15

Where do ectopic pregnancies most often occur?

Back 15

Most implantations occur in fallopian tube (95-98%)

Front 16

How do we diagnose ectopic pregnancy?

Back 16

1) hCG < EGA
2) sonogram
3) serial beta-hCG

Front 17

What are sxs of ectopic pregnancy?

Back 17

1) Patient reports:
a) pregnancy and/or
b) vaginal spotting/bleeding

2) Clinical findings
a) low or slowly rising hCG levels
b) adnexal tenderness and fullness on exam
c) referred shoulder pain

Front 18

Name history taking questions for vaginal bleeding.

Back 18

1) When did the bleeding start?
2) Color of blood?
3) Heaviness of flow?
4) Pain/cramping?
5) sxs or possible exposure to infection?
6) Current IUD use?
7) SxS pregnancy present?

Front 19

What other medical/gyn information should a FNP ask for when evaulating vaginal bleeding?

Back 19

History of:
1) STD/PID
2) spontaneous AB
3) ectopic pregnancy
4) abnormal pap
5) bleeding disorder

Front 20

Which physical exam techniques should be employed for vaginal bleeding?

Back 20

1) VS
2) abdominal exam
3) speculum*
4) bimanual*

*depending on suspected patient condition

Front 21

Which situations of vaginal bleeding are appropriate for FNP to manage?

Back 21

1) threatened AB
2) normal hyperemia of pregnancy
3) polyps
4) implantation bleeding
5) infection

Front 22

In which situations of vaginal bleeding should a FNP consult with MD?

Back 22

1) spontaneous AB
2) missed/septic AB
3) sexual assault/trauma (plus other referrals)

Front 23

In which situations of vaginal bleeding should FNP refer patient out?

Back 23

1) ectopic pregnancy
2) GTD
3) cervical cancer
4) bleeding disorder
5) symptomatic blood loss

Front 24

What is some appropriate patient education for vaginal bleeding?

Back 24

1) cause of bleeding
2) expectations
3) consults/referrals
4) tests ordered
5) sxs complications
6) counseling -- grief or assault (prn)
7) contraception/conception
8) STD tx, partner screen/tx
9) Rhogam (prn)
10) Follow-up (appointments, reasons for FU, etc)

Front 25

What is women's #1 fear with pregnancy?

Back 25

MISCARRIAGE -- vaginal bleeding

Front 26

What is a signicant finding/test in the first tri?

Back 26

evidence of fetus --> identification of heartbeat

Front 27

What is one thing that can be done to identify that fetus is still viable with early pregnancy bleeding?

Back 27

identify fetal heart tones via sonogram or auscultation --> if btwn 6-7 weeks gestation (developmentally, no FHR before then)

CAUTION: establishing heart tones with bleeding does not guarantee pregnancy loss will not occur

Front 28

What information is pertinent to implantation bleeding?

Back 28

1. bleeding ranges from light spotting to heavy spotting
2. may be mistaken for light period
3. may not be evident in every woman
4. can occur 6-12 days after ovulation

Front 29

What is hyperemia of cervix?

Back 29

cervix becomes highly vascularized --> benign

Front 30

What is a possible reason for early pregnancy bleeding if miscarriage, implantation bleeding, and hyperemia of cervix have been ruled out?

Back 30

normal intrauterine pregnancy -- no known reason for bleeding but fetal heart tones are identified and pregnancy continues

Front 31

What are the symptoms of a threatened AB?

Back 31

Presents with vag bleeding with or without abdominal cramping and has NO passage of clots or tissue

Front 32

What follow-up should be done for a threatened AB?

Back 32

follow-up with sonogram -- min. gestational age must be btwn 6-7 weeks (heart not developed before then)

Front 33

How long should a woman wait after a spontaneous AB before attempting pregnancy again?

Back 33

generally, recommend 3 months for recovery

Front 34

What is inevitable AB?

Back 34

vag bleeding, abdominal cramping, with passing of clots and tissue

--> products of conception have not been expelled
--> non-reassuring clinical scenario (e.g., ROM) not compatible with on-going pregnancy

Front 35

What is complete AB?

Back 35

hx of cramping, bleeding, passing of clots/tissue AND resolution of pregnancy-related symptoms

Front 36

How is complete AB diagnosed?

Back 36

Can make dx based on history alone

- urine or serum pregnancy testing is appropriate --> levels will be decreased

Front 37

What is incomplete AB?

Back 37

actively bleeding, cramping, and passing clots/tissue

-products of conception are expelling (may see them in os upon inspection)

Front 38

What should be done if woman is undergoing incomplete AB?

Back 38

1. sonogram if she is >6-7 wks
2. CBC panel
3. counsel her on sxs of anemia

Front 39

What are the options for inevitable and incomplete AB?

Back 39

1. expectant mgmt: wait-and-see*
*IMPORTANT: woman can choose this and then at any time change her mind and decide on intervention
2. intervention: D&C or manual aspiration/evacuation

Front 40

At what point does expectant mgmt vs. intervention no longer become a choice?

Back 40

woman's CBC levels seem to indicate risk to herself -- counsel toward intervention

Front 41

What is septic AB?

Back 41

pregnancy loss in context of infection

Front 42

What puts woman at increased risk for septic AB?

Back 42

IUD was present at time of conception

Front 43

What is missed AB?

Back 43

intrauterine death of embryo/fetus; not accompanied by bleeding (asymptomatic)

Front 44

What are some indications that woman had missed AB?

Back 44

1. no fetal heart tones - may be discovered at reg pre-natal visit
2. clinical assessment of uterine sie does not correlate to gestation -- sonogram follow-up
3. may be diagnosed with nuchal transparency testing

Front 45

What are the interventions for missed AB?

Back 45

1. manual aspiration and evacuation -- before 9-10 wks
2. D&C: electric, mechanical suction with scraping of uterine lining -- >9-10 wks
3. medications: misoprostol or mifepristone --> induce passage of products of conception
4. expectant mgmt with reg monitoring over 1-2 wks --> HCP may intervene if process does not complete after that time bc risk of infection increases >2 wks

Front 46

What are some signs of GTD?

Back 46

1. uterine size much greater than size expected for gestational age
2. hCG levels higher than gestational dates

Front 47

What is used to diagnose GTD?

Back 47

ultrasound

Front 48

What is the only option for treating GTD?

Back 48

complete uterine evacuation (surgery)

Front 49

What is the follow-up for surgery to GTD?

Back 49

follow beta-hCG levles until they decline to zero (undetectable)
1. weekly for 3-4 weeks then monthly for 3-6 months
2. individual and HCP preferences may indicate following levels for another 6 months to 1 year

Front 50

Why is it important to make sure that beta-hCG levels are undetectable?

Back 50

tissue has the potential to grow back --> complications including risk of cancer

Front 51

What is a molar pregnancy?

Back 51

type of GTD in which grape-like clusters of cells accumulate in uterus (non-cancer)
1. complete: either sperm or egg did not contribute genetic material to embryo
2. partial

Front 52

Besides the fallopian tube, where can other ectopic pregnancies occur?

Back 52

ovaries, cervix, or abdomen

Front 53

What lab values are abnormal with ectopic pregnancy?

Back 53

hCG levels are lower than expected for gestional age
--> levels should double every 2 days so follow-up at that time to retest beta-hCG

Front 54

How is ectopic pregnancy diagnosed?

Back 54

sonogram, but note:
1. gestational sac is not visible until 4-5 wks
2. transvaginal sonogram can detect gestational sac at 1500-2000 beta-hCG

Front 55

What if diagnosis of ectopic pregnancy is not immediately possible (because gestation is not far enough along to detect gestational sac)?

Back 55

Patient teaching:
woman should report to ER if she experiences bleeding, pain, or fever --> risk of rupture

Front 56

What are the possible interventions for ectopic pregnancy?

Back 56

1. Methotrexate (IM) is medication of choice
2. surgery if embryo is too large*
*fallopian tube may also need to be removed because of inherent defect or damage from ectopic pregnancy

Front 57

With history-taking for vag bleeding, what does pain/cramping mean?

Back 57

if present, thinking more of threatened or spontaneous AB

Front 58

How does current use of IUD when pregnancy occurred affect care?

Back 58

1. removal of IUD may or may not affect pregnancy
2. leaving the IUD and patient may or may not carry to term
3. if pregnancy is to be terminated, IUD should be removed and discussion of whether to insert new IUD

Front 59

How may vital signs be affected with vaginal bleeding?

Back 59

1. hypotension
2. fever, including low-grade: a) ectopic pregnancy or b) septic AB
3. tachycardia

Front 60

What are some possible findings of an abdominal exam when patient has vag bleeding?

Back 60

1. Adnexal tenderness
2. masses

Front 61

With which scenarios would you want to perform a speculum exam when a patient has vag bleeding?

Back 61

1. infection
2. polyps
3. carcinoma
4. cervicitis/vaginitis

Front 62

With which scenarios would you NOT perform a speculum exam?

Back 62

1. suspected GTD
2. ectopic pregnancy
3. threatened or incomplete AB

Front 63

In which clinical scenarios would you NOT perform a bimanual exam?

Back 63

threatened or incomplete AB

Front 64

When would we refer patients who have vaginal bleeding?

Back 64

symptomatic blood loss --> not great candidate for expectant mgmt

Front 65

What patient education is appropriate for vaginal bleeding?

Back 65

1. explain cause of bleeding in plain terms
*if cause is uncertain, counsel on sxs to look for and seek medical attn if noticed
2. follow-up visit: contraception and pregnancy planning
3. Rhogam (prn) -- will definitely need if patient had spontaneous AB