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Who is responsible for infertility?
40-65% female, 20-40% male, 15-20% idiopathic
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Define infertility
- <35yo inability to conceive after 1 year
- >35yo inability to conceive after 6mo
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Secondary Infertility
Have conceived in the past, but currently cannot.
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Hx Questions for 27yo c/o inability to conceive
- LMP? characteristics of menses..regularity, flow,
- STIs, PID, PAP smears
- ROS-->thyroid disease, hirsuitism, pelvic or abd pain,
- Fam Hx--> infertility, birth defects, mutations, retardation, fragil X
- Life style-->occupation, exercise, stress, smoking EtOH
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PE findings for infertility
- Incomplete secondary sex characteristics
- Turner syndrome appearance (hypogonadism)
- Tenderness of the pouch of Douglas (PID endometriosis)
- Adenexal masses
- Hyper
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Evaluation of filopian tubes and pelvis structure?
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Male Infertility approach considerations
- Seman analysis--90% normal seaman excludes male as cause for infertility
- Hypothalamic or pituitary tumor
- Drugs affecting the CNS
- Klinefelter's syndorm
- Prolactomas
- Anabolic steroid use
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Male Sperm Issues (MMAAL sperm)
- Motility issues--sperm antibodies, obstruction, infection
- Morphology issues--cryptochidism, toxins, varicocele
- Acidic sperm--ejac dysfunction, abscess of vas defrense
- Azzoospermia--genetic endo infection
- Low volume--hypogonad, ejac dysfunction
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The probability of achieving a pregnancy in menstrual cycles is...
fecundity
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Braxton Hicks Contractions are
- shorter in duration than labor
- not as intense as real labor
- not associated with cervical dilation
active labor begins when cervix is dilated 4 cm
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Initial prenatal visit includes...
- H&P-->Gp status, GYN Hx, Fam Hx, Chronic conditions
- Labs-->type and screen/CBC/UA/STI/HIV/Hep B
- Pt. Education
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EDD
- Estimated Delivery Date
- Three months back from the start of the LMP + 7 days
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Normal time for a single gestation?
Multiple gestations?
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Pregnancy catagoires
- A--safe in humans
- B--safe in animals, but unknown in humans
- C--risk/benefit?
- X--not safe
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Prenatal care should include regular updates on...
- BP
- Weight (normal is 25-35lbs or 3-4lbs/month)
- Fundal height
- FHR
- Uterine palpation
- Fetal presentation (Leupold maneuvers)
- U/A
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PE finding consistent with pregnancy
- Increased uterine size 1cm/wk after 4 wks gestation
- Chadwick sign--blueish discoloration of vagina
- Hegar sign--softening of the cervix
- Fuller and tender breasts
- areolar darkens
- increased visibility of breast veins
- Fetal heart sounds at 10-12 weeks gestation
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Stages of labor
- 1st--time of regular contractions to 10cm dilation two phases latent (up to 4 cm dilation) active (4cm-10cm)
- 2nd--time of full dilation to expulsion of fetus
- 3rd--expulsion of fetus to expulsion of placenta
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Goal of Intrapartum Fetal Surveillance
Recognize changes in fetal oxygenation which may result in complications--asses fetal stress
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Internal monitoring
- More specific--can tell us if contractions are adequate to cause cervical dilation
- can measure the intrauterine pressure
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Cardiovascular changes during normal pregnancy
- heart displaced up and out
- normal second heart sound
- systolic end murmur
- Diastolic murmur--->BAD
- Increased CO 30-50% (1/5 of CO goes to placenta increasing the risk of postpartum bleeding)
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Respiratory Changes in pregnancy
- increased total O2 consumption by 20%
- compensated respiratory alkalosis
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Hematologic changes in pregnancy
- increased plasma volume
- increased RBCs
- increased coagulation factors-->doubled risk for thromboembolism
- 5x the risk during peurperium (approx 6-8wks postpartum)
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Endocrine changes during pregnancy
- Euthryroid--
- -gland enlargement
- -placental Hcg-->stimulation of T4
- Estrogen-->hepatic synthesis of TBG-->increased levels of total T3 and T4
- Thyroid is working normally, but other hormones are affecting serum levels
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Description of the fetus during labor
- Stations--0=presenting part is level with ischial spine
- (-) values are superior to ischial spines
- (+) values are inferior to ischial spines
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Placenta Previa defined
placental location near the cervical os
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Placenta previa signs and symptoms, risk factors, Dx, Tx
- painless bleeding in 3rd trimester
- Dx-->transvag US
- RF-->smoking, previous placenta previa, advanced age, multiparty, cocaine use, prior cesarean or other uterine surgery
- Tx-->cesarean
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Placental abruption defined
abnormal preseperation of the placenta
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placental abruption signs and symptoms, risk factors, Tx & complications of
- SS-->vag bleeding with PAIN
- RF-->HTN, preecclampsia, multiple gestation, smoking, cocaine use, multiparty, PRIOR abruption
- Tx--immediate delivery
- MC cause of coagulopathy in pregnancy
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Preeclampsia
- HTN
- proteninura
- or
- platelet <100K, creatinine 2x, AST or ALT 2x, pulmonary edema
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Eclampsia
preeclampsia + seizures
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Gestational diabetes risk factors
- Hx of gestational diabetes
- AA, Pacific islander, native american, hispanic american, asian
- Fam Hx of diabetes in 1st degree relative
- BMI >30
- previous delivery of baby >9lbs
- glycosuria at 1st prenatal visit
- PCOS, current use of glucocoticoids
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Gestational diabetes effects on newborn
- baby produces high insulin in response to high sugar from mother, when born the transfer of sugar to baby ceases and the newborn experiences a transient hypoglycemic episode b/c of the insulin overload
- additionally it cause babies to be born with large heads and overall heavier babies as the unused glucose in converted to fat
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Routine glucose testing is done when..
- 24-28 weeks gestation w/o risk factors
- fasting not required--ingest 50g and check after 1 hour
- 3 hour glucose test if inital is >140
- need two abnormals for Dx
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Other complications of GDM
- macrosomia
- excessive weight gain for mom
- shoulder dystocia
- need for cesarean
- preeclampsia
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HELLP syndrome
- Hemolysis
- Elevated Liver enzymes
- Low Platelet counts
- occurs in 4-12% or pts with preeclampsia
- Tx platelet transfusions, delivery
- Schistocytes
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Risk Factors for HELLP
- Hx of preeclampsia or ecclampsia
- FHx of HELLP
- nulliparity
- multigestations
- >35yo
- HTN
- DM
- Vascular, connective tissue, antiphospholipid
- AA & obesity
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Threatened abortion...
bleeding with a viable pregnancy
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Missed abortion..
nonviable intrauterin gestation less than 20 weeks with the cervical os closed
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Incomplete abortion
intrauterine gestation less than 20 weeks with the os open and some tissue already passed
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Inevitable abortion...
cervix is open but no tissue has passed
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Complete spontaneous abortion..
passage of all tissue and an empty uterus
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Septic abortion...
is abortion with retained products f conception with symptoms and signs of infection
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Suspected abortion work up
- US
- HCG levels (should be doubeling every 48 hours with an intrauterine fetus)
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Five Cardinal Movements of Labor
- Flexion
- Descent
- Internal rotation
- Extension
- External rotation
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Post Partum Hemorrhage PPH
primary vs secondary
MC cause
Risk factors
Tx
- primary 1st 24 hours after delivery
- secondary after 24 hours
- MC cause--uterine atony
- Occurs in 1-5% of deliveries
- Risk factors-->prolonger labor, augmented labor, Hx of PPH, episiotomy, operative delivery
- Oxytocin 10-40 units/L of saline
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