Case studies High Risk Antepartum
"Oralia is a 22 year-old Hispanic married woman. This is her third pregnancy and
this will be her second child. She has a three year-old son who was born with
hydrocephalus. Her second pregnancy ended in a stillbirth at 34 weeks. This
pregnancy was not planned, but she is happy to be pregnant. She is eight weeks
pregnant and is coping well. This is her first visit at Healthy Moms and Babies.
Her living arrangements seem to me to be inadequate. She shares a six-bedroom
house with twenty different people, none of whom are relatives. She does have her
own room for her and her son and husband. Transportation is a problem. She has
been in the States for three months, and at this address for one month. Food access
is also inadequate. Her husband just found a job as a gardener with a landscape
company.
Oralia completed a sixth grade education in Mexico, and is monolingual Spanish
speaking. She denied any history of physical, sexual or emotional abuse and also
denied any substance abuse of drugs, cigarettes or alcohol. She admitted to having
drunk socially in the past, however. She reported a medical concern, saying she has
experienced severe pains and went to the Emergency Room. She had a yeast
infection and was prescribed Terazol. She also had a sonogram, which indicated
blood clots around her uterus, which concerns her. She also complained of her gums
bleeding rather severely. Her diet is very poor-indicating 1000 calories from
chocolate and 300 from soda. I have referred her to our dietician, whom she will see
on November 17th at 3:30 pm.
Oralia reported her stress level to be moderate to high, remarking that her stress
stems from her son’s illness. Every time he gets sick, she gets stressed. He has
undergone six surgeries due to his hydrocephalus. He is frightened of doctors. She
was very patient and attentive with him, however, showing a great deal of love. He
seems very secure with her, and was well mannered.
The client presented as outspoken, and was not nervous.
Please address the following:
1. What are Oralia’s problems related to her physical, mental and social health? What
would you say are her top two problems?
Severe pains, yeast infection, diet, mental health, clots, gums. Hydrocephalus, death of a
still born child. Limited education, moderate-high stress level. But she is positive about
her pregnancy.
Social: lives w/ 20 people in 6 bdrm house, not her relatives. Transportation is problem,
only in US for 3 months.
Top problems; diet, no nutritional value. Social support system at home, and her home
environment doesn’t seem adequate. JK agrees, but would want to look at the clots
and bleeding issues, and ask if she’s here legally or illegally. Bleeding gums could be
associated w/ diet, but if she’s preg she’s on medicare and can get dental care—but
she was here illegally. Also wants to know if this husband is also the father of her
first two kids.
2. What are Orelia’s top two strengths?
Positive attitude. She is getting prenatal care.
3. What would you like to accomplish at this first prenatal visit? List your top three
priorities and give a rationale for why you picked each of these.
1: nutrition for healthy body and baby
2: transportation for prenatal visits, grocery store, etc
3: living arrangement and social support: needs friends in a new country, she has a sick
son at home, dad is probably working, who will help?
4. What would you like to know about her pregnancy history?
What country did she live in? What prenatal care did she receive with her first
pregnancies, did docs state any health concerns in those pregnancies? What’s up with her
kid—was he term, vag or C/S, where did she give birth, issues with infertility. Second
pregnancy: stillbirth @ 34 weeks, but we’d like to know how the pregnancy went and
psych coping after the loss. Any HTN, n/v? What was her nutrition like with her other
pregnancies? How much social support did she have w/ her first pregnancies? Did she
work or stay home?
5. What would you like to know about her family history?
Did she have CHD or DM in her family, who is she living with? What’s it like at home,
what work does she have to manage at home, who else is around for helping her w/baby.
Does she have family around? Do she or her husband have jobs?
6. What would you like to know about her social history?
What country is she from, where’s her family. How involved is her husband? How does
she handle groceries, getting out of the house? What does she do to manage stress? How
does she get along with people in her household, how many BR are there and are they
clean? Does she have access to the kitchen to cook?
She was also fatigued and would wake up at 4 am and pack her husband’s lunch.
About the US: as RN we don’t interpret but we need to tell MD/NP that the results
are there. Yeast infections are not treated with antibiotics but w/ antifungals. She
was part of ‘healthy moms and babies’ program.
Outcome: did develop gest DM, managed it well w/ diet. Did go into preterm labor,
at 33 weeks went to USCF, labor stopped and she delivered at 37 weeks. Happened
at same time as Prop 187—when providers were told not to provide care to illegal
immigrants. Which providers certainly wouldn’t do. This house didn’t have a stove,
but had a hotplate and a microwave.
This mommy had medical, even though she’s illegal. That law may change. You
can get presumptive medical before you’re even proved as a legal citizen, and get
care, and then disappear.
High Risk Antepartum Case Study #2: Pregnant woman with pre-gestational
diabetes
Lola, a 23-year-old newly married woman, was diagnosed with diabetes when she
was 16 years of age. Her diabetes has been fairly stable for several years, although
she occasionally experiences glucose control problems requiring re-evaluation of her
insulin dosage and diet. Lola and her husband are planning to become pregnant in
about a year.
1. Explain why Lola and her husband Anthony should seek preconception care as soon as
possible.
To improve outcome, need to control DM pre-conception, give education, and assess for
vascular problems.
2. Identify the maternal and fetal/newborn risks and complications associated with pregestational diabetes, especially if glucose control is not maintained within an acceptable
range. What are some of those risks?
Risks for mom: poor glycemic control leads to miscarriage. Incr in fetal macrosomia in
women w/ vascular disease, leads to more shoulder dystocia, C/S, instrumental birth.
Higher risk of preeclampsia and hydramnios [which leads to PPH, etc].
Fetal: stillbirth, congen malformations in CNS, cardio and skeletal systems. Microsomia.
Risk for shoulder dystocia and resp distress.
3. One year later, Lola does become pregnant. She is now 4 weeks pregnant. Describe
what Lola can expect regarding her insulin needs during pregnancy.
1st tri: insulin will be reduced.
2nd tri: insulin needs are increased
3rd: insulin needs may double or quadruple
4. At her second prenatal visit, Lola's glycosylated hemoglobin was 5%. Explain what
this finding indicates.
This means: over past 3 months, she has been in good control [within 2.5-5.9%, fair=up
to 8, with DM, over 8 means they need help]
5. How should Lola's diet be modified to meet the requirements of pregnancy?
Insulin has changed from 1st tri to third, so her diet will also change to manage
hyperglycemia. Need to remember her food habits, ethnic background, lifestyle,
knowledge, pre-preg weight. Goal is to make her preg as normal as possible.
Recommend 3 meals, 2-4 snacks, depending on individual needs. Esp bedtime snack to
prevent hypoglycemia in night. Less refined sugar, don’t skip a meal, etc. Less fat and
cholesterol, high fiber, no ETOH or caffeine.
6. Lola may experience increased stress as a result of the change in her diabetes
associated with pregnancy. What measures could you use to help prevent or reduce Lola's
level of stress?
Cheers: your blood tests look good, give info about changes in insulin and diet over preg,
assess social support and ensure she feels like she has help.
7. During the third trimester Lola asks what she can expect related to her birth. What will
you and her physician tell her? Be thorough! You can use bulleted points!
No reason to think things will go funny, but we’ll have an IV in her, we’ll manage her
fluids and her blood sugar during labor. WE don’t want hyper glygemia during labor b/c
then baby is hyperglycemia at birth. CFM. Needs to be in side lying position during
labor. She may have a large infant (macrosomia?) or a lot of fluid in her bag of waters.
She will likely be able to have a normal birth, but if the kid is really big may call a C/S.
If she wants to schedule a C/S, she should do it in AM for better glucose control, her MD
will give her specific orders, like when to take her insulin, and NPO. Want epid
anesthesia b/c need her awake to assess her blood sugars.
JK says: about preconception care, we want her on folic acid. Hopefully all people
come for preconception care, but esp w/ DM pts. We want to check with her
endocrinologist to make sure her glucose is in really tight control—why? Make sure
she can manage it during preg, and if not in control at conception, the rates of
miscarriage and fetal anomalies incr. Good control means she’s more at risk for
hypoglycemia. Exercise decreases her insulin needs. During labor she’ll be burning
sugars and her insulin needs will go down. Pt education; good to talk about
changing insulin needs---esp to warn them if their insulin needs are going down at
end of pregnancy they need to call MD b/c kid is compromised. OB’s don’t like DM
pts going past 38 weeks—incidence of big kids and stillbirth goes up at that point.
OB is likely to induce at that point.
Breastfeeding and insulin requirements: BF decr insulin requirements.
Outcome: vag birth, LGA kid, kid had blood sugar control probs and needed some
formula.
High Risk Prenatal Case Study #3: Woman diagnosed with ruptured ectopic
pregnancy and endometriosis
Background: Hillary, a 30-year-old woman with a history of endometriosis, is
admitted to the emergency room complaining of severe unilateral lower abdominal
pain referred to her shoulder. She is accompanied by her husband John. Hillary is
restless and apprehensive and states that she feels lightheaded. Her pulse is rapid,
and she is slightly hypotensive. A small amount of vaginal bleeding is noted. To
assist with diagnosis a vaginal ultrasound and pregnancy test were performed. A
diagnosis of ruptured (tubal) ectopic pregnancy is made.
Endometriosis: uterine glands grow outside the uterus.
1. What factors may have placed Hillary at risk for ectopic pregnancy?
Mainly the endometriosis, but also she’s 30 yo and we don’t have a lot of medical
hx on her—she could have had prev pelvic surg, fertility tx, utero-tubule oddities, and
exposure to DES [causes lesions in vag and cervix, and problems in the offspring of
women who took DES: incompetant cervix etc, testicular and ovarian CA, etc etc.] We
don’t know if she smokes TOB which is another risk factor.
2. Identify the major care management concern related to Hillary's diagnosis.
Ruptured ectopic=emergency situation, needs surg, laparotomy to repair tissue
damage and hemorrhage. Make sure we prepped blood transfusions, fluids, warmth,
positioning. Lie her on back w/ feet elevated to keep hemorrhange controlled. Want to
monitor S&S of hemorrhage post op. Ectopic preg are leading cause of tri1 maternal
morb& mortality, may cause more miscarriages or infertility. Needs help coping with the
loss. Needs advice about having kids in the future or not.
3. State two priority nursing diagnoses for Hillary.
High risk for hemorrage [def fluid vol AEB hypotension, tach vaginal bleeding]
Pain r/t rupture AEB pt report of pain in shoulder
Anxiety r/t emergency situation.
4. Hillary is scheduled for surgery to remove the affected tube. Describe the preoperative
and postoperative nursing care measures Hillary will require (be complete.. you can use
bulleted points).
 Informed consent, tell her whats gonna happen
 NPO
 VS q 15
 Start IV and IVF as ordered
 Cath if ordered
 Labs: blood type and Rh factors. Check her serum Hcg, give rhogam if needed
 Give her time to verbalize her loss
Post op:
 Airway
 Turn, cough, deep breath
 Safety [bedrails, anesthesia etc]


Methotrexate if ordered: dissolves remaining tissue post op
Community referrals for support
5. Hillary and John are devastated by the diagnosis. They tell you that they had been
trying to have a baby for 2 years now and thought they had succeeded despite Hillary’s
problem with endometriosis. How could you help this couple deal with their loss?
Referrals, counseling, support group, educate that this can be great for their
relationship or bad for it. Warning about feelings of guilt, anger about loss. Ask about
visit w/ a chaplain or advisor.
6. Before discharge Hillary asks you if her endometriosis had anything to do with her
ectopic pregnancy. What should you tell Hillary about endometriosis and its effect on
fertility and pregnancy?
Puts her at risk for ectopic preg b/c of scarring in fallopian tubes. Egg cannot get
thru fertilized tube. Both these put her at risk for infertility. In vitro might help get her
pregnant again.
7. After Hillary's recovery her primary health care provider places her on Synarel for her
endometriosis. This is the first time Hillary will be taking this medication. What would
you teach Hillary about this medication?
Synarel: synthetic Gonadotropin releasing hormone. Will inhibit development of
her endometrium that’s causing trouble—she also won’t menstruate. It’s inhaled—spray
into each nostril 1 day after start of menses? Store it somewhere coolish and dark. SE:
cramps, hot flashes, bloating, dec libido, vag dryness, etc. Look out for breakthrough
bleeding—means she has missed some doses. Needs a barrier contraceptive during this
treatment.
JK says: if you ever have a woman of childbearing age, on any unit, you need to ask
her when her LMP was. Ectopic preg: LMP might have been a missed period,
might not be regular periods, or a common sign of ectopic: they have a ‘light
period’ recently. RH factor is very important for miscarriage and ectopic. Synarel:
right on. It basically put people into menopause. We’ll have her on synarel for 6
mo to decr endometrial scarring and may shrink it. After that if she doesn’t want to
get preg, put her on birth control pill b/c that keeps down endometrium.
Outcomes: one woman had an IUD, called MD and said she had spotting, and felt
weird. Her blood preg test came back negative. She started having abd and
shoulder pain (pain likes to refer to the shoulder from under the diaphragm) came to
ED and her VS was fucked up, her preg test was positive now. She nearly coded—
bled massively into peritoneum, actually lost 5 units of blood, did surg on her w/o
anesthesia b/c she was so gone. She did make it.
She’s on a surg floor, and no nurses talked to her like she lost a baby b/c they
acted like she had an appendectomy.
High Risk Case Study # 4: Pregnant woman at risk for preterm labor
Background: Keisha is a 24-year-old unmarried multigravida (4-0-1-2-1) woman.
She is 15 weeks pregnant and has finally come to the women's health clinic for her
first prenatal visit since she is afraid she will have another premature baby. Her
first two pregnancies resulted in miscarriages at 13 and 14 weeks. Her third
pregnancy resulted in the birth of her 4-year-old daughter at 30 weeks’ gestation.
Keisha smokes one pack of cigarettes every 1 to 2 days. Her health history reveals
that she has been hypertensive since 20 years of age and often experiences bladder
infections. Her stress level has increased since her boyfriend, the father of the baby,
has started to “pick fights with her and hit her.” She cannot understand why he is
doing this since he never hit her before when he would get angry.
Questions:
1. What risk factors associated with preterm labor and birth does Keisha's history reveal?
• Keisha has many risk factors that would predispose her to preterm labor: the most
common being her multiple pregnancies before 20 years of age (3): 2 resulted in
miscarriages and 1 preterm; unmarried; socioeconomic status (poor-I’m guessing); other
factors include hypertension; cigarette smoking; frequent bladder infections; high level of
stress; being non-white woman (inferring); previous history of inadequate prenatal care;
possibility of escalating abuse. Other factors in her life that would increase her
probability are excessive physical activity, poor nutrition, uterine anomalies such as
fibroids or irritability or cervical incompetence. (p926). Research indicates a link to
preterm births and an increased level of prostaglandins released by pathogenic bacteria as
with UTI’s. Also, getting lab results for her blood glucose levels (increases risk for
HTN), proteinuria, electrolytes, folic acid
• As nurses, we would like know what her support system is like? Is there anyone who is
able to care for her- extended family, friends, other relatives? We need to address the
many factors present in her life and her health that deem her an effective candidate for
preterm birth.
• (this relates to q. #3) Part of our responsibilities would be to teach Keisha early
recognition patterns of preterm symptoms: uterine contractions q 10 min or more, lasting
1 hr or more; lower abdominal cramping and may have diarrhea, dull intermittent painmenstrual like cramps, suprqapubic pain or pressure, pelvic pressure or heaviness, urinary
frequency; vaginal discharge that is thicker (mucoid) or thinner (watery) than usual,
bloody, brown, or colorless, perfuse, and has an odor, rupture of membranes
2. You recognize that violence has become part of Keisha's relationship with her
boyfriend. How would you address this problem with her? Why is he “picking fights”
with her when she is pregnant?
3. Keisha asks you what to look for in terms of signs that preterm labor is occurring.
“With my daughter, everything seemed to happen so fast without any warning.” What
should you teach Keisha about the signs of preterm labor and what to do if she detects
them? Her obstetrician did a fetal fibronectin test and it was positive. What does this
mean?
Keisha needs to watch for the following signs:
- uterine contractions occurring every 10 minutes or more and persisting for longer than
one hour (painful or painless)
- lower abdominal cramping similar to gas pains; may be accompanied by diarrhea
- dull, intermittent low back pain (below the waist)
- painful, menstrual like cramps
- pelvic pressure or heaviness – feeling like the baby is pushing down
- urinary frequency
- change in character or increase in amount of discharge (either thicker or thinner, change
in color or odor)
- rupture of water
It is important to contact her doctor or NP immediately if she experiences any of these
signs – even if she feels like they are just normal symptoms of pregnancy. If she is going
into preterm labor it is best that it be caught early so that it can be monitored and slowed
down if possible. It is also important that it be caught early so that antenatal
corticosteroids can be given to help develop the baby’s lungs. A preterm infant has higher
risk for respiratory distress syndrome and intraventricular hemorrhage. Do not wait to see
if the symptoms subside or go away, do not attribute them to another cause, do not write
them off as normal symptoms of pregnancy.
Explain to Keisha that onset of preterm labor is sometimes hard to detect and that she is
asking the right question as it’s important she knows the signs! For this reason it’s also
important that she comes to all of her prenatal visits!
Her obstetrician did a fetal fibronectin test and it was positive. What does this mean?
Fetal fibronectins are biochemical markers (proteins) that are used to try and predict risk
of preterm labor. They are a protein produced during pregnancy that functions to attach
the fetal sac to the uterine lining. Fetal fibronectins are normally present in vaginal
secretions until about 22 weeks of gestation and in most pregnancies they are not present
again until the end of the 3rd trimester, about one to three weeks prior to labor. The fact
that she has them at 15 weeks is normal. If she had them between 24 and 34 weeks we
would be more concerned as this could predict preterm labor. Unfortunately, they are
better at predicting who will NOT go into preterm labor than who will go into preterm
labor. So while a positive test indicates increased risk for preterm labor, it does not
guarantee it. On the other hand, a negative test would indicate that in all likelihood she
would NOT have preterm labor (94% predictive value).
Because she is high risk for preterm labor, a positive test between 24 and 34 weeks would
definitely be of concern. A good use of this test for Keisha would be if she were
developing symptoms of preterm labor. At this point the test could be redone, and a
negative result could help to rule out preterm labor as the cause of her symptoms.
4. Keisha goes into labor at 24 weeks’ gestation. Conservative measures fail to suppress
labor, necessitating admission to the hospital. Tocolytic therapy with magnesium sulfate
is successful and Keisha is discharged to home care. Home uterine monitoring (HUAM)
and nursing telephone consultation has been arranged. How would you prepare Keisha
for discharge? How about increasing the effectiveness of HUAM? What kind of life style
modifications and activities would you recommend?
First of all, I would want to fully understand Keisha’s living situation. If she lives with
the abusive boyfriend, I would want to find out if she has supportive parents or if another
family member or friend can help to take care of her and her daughter. I would also be
sure to set up consultations with a social worker (if she doesn’t already have one). Keisha
will also need to be educated regarding placement and use of the home monitoring device
– it consists of a pressure sensor that is held against the abdomen by a belt and a
recording/storage device that is carried by a belt or hung from the shoulder. Uterine
activity is typically recorded for 1 hour, twice a day while performing routine activities.
The stored data is then sent by telephone to a nurse and a receiving device prints out the
data. The nurse will then call Keisha to discuss results. The effectiveness of HUAM is
still controversial and I couldn’t find much in the way of suggestions to increase
effectiveness, but there are a few common sense interventions to increase success. First,
be sure that Keisha understands what the device measures and can demonstrate proper
placement. I would also instruct her to try to use the device consistently – place the
sensor on her abdomen in the same way every time, use the same time of day (to help her
remember), use in a quiet room (to eliminate interference from background noise).
Life-style modifications / activities: There are so many issues for Keisha to manage. If
bed rest is required, she will need help caring for her 4-year old daughter. I would
educate or re-educate regarding the increased risks she is putting herself and her baby
through by smoking, and encourage her to stop or reduce the amount of cigarettes she
smokes. I would discuss nutrition, particularly with regard to her hypertension (lots of
fruits and veggies, lean meat, limit salt and refined foods). I would discuss the
importance of limiting external stress (the boyfriend) and see if she has other support. As
far as activities go, I would find out what kinds of quiet activities she likes and suggest
ways to organize her day. I would suggest a schedule to help alleviate boredom. Hygiene,
dressing, uterine monitoring, and eating meals will probably consume a lot of her day.
Examples of quiet activities might be reading, puzzles, journaling, artwork or crafts of
some kind, or movies.
5. Keisha comes into the hospital in labor at 30 weeks gestation. She has pre-term
premature rupture of the membranes (PPROM). She s given a dose of betamethesone.
Why was given this medication? She is also asked if she would like to transfer to UCSF
or stay here. How would you facilitate her decision-making about transferring or staying
put? What kind of information would you give her?
Betamethasone is: a corticosteroid that is used off label, it stimulates fetal lung
development by causing the baby to release enzymes that in turn cause surfactant to be
made. Not always recommended in women with PPROM. It is a jump start to the kid’s
lungs, and if it can be given 24-48 hours prior to labor, then it has a chance of preventing
respiratory depression, intraventricular hemorrhage and necrotizing enterocolitis.
About transfer to tertiary center: preterm births have better maternal/fetal outcomes.
However, this can lead to more anxiety, and can make it hard for family to visit. In this
woman’s case, it may relief some stress to get away from her man for a bit. She may have
some stress about money, and should be made aware that UCSF has a Financial Hardship
form available (that requires a tax return). I would tell her that the choice to transport
may be stressful, but that it is the best choice for her daughters’ survival. Not to mention
that the view from UCSF L&D is worth the trip for herself and her family.
JK says: Risks: DV (domestic violence), premature prenatal care. Do
abortions/miscarriages put her at risk? Yes, if they happened after tri 1.
Mandating reporting: we have to report what? If you read the law it’s really fuzzy
on reporting what she admitted, her report of DV. You have to report rape, you have
to report if you treated her for an injury, but she didn’t have an injury, and so we
don’t really have to report it. The issue is also that she will likely stay with this guy,
and that the incidence of death is higher if interventions are made or she leaves. But
one factor is that the more people know that she’s being beaten, she’s less likely to
be killed. WWJD? JK would talk to her about it and say it’s not ok, and that she
doesn’t have to report it, but what can be done etc. Reporting is to the police w/in 24
hours. If there’s a gun in the house, JK really loses it and will work w/ the woman
to get out or get the gun out. Also animal abuse goes in this party. Usually the kids
are also abused.
There is a relationship btwn preterm labor and DV. Kicks to abd are more common
DV injuries when a woman is pregnant. 8% of preg women are beaten according to
the book—BUT JK thinks that’s much higher. Most women who are killed have
seens a health care provider in the last 6 months.
Yes, there is a connection btwn substance abuse and DV, but its like a chicken and
egg issue.
Some PCP’s won’t report b/c they have to be called to testify, they lose money, it’s
stressful, etc.
Sign of preterm labor: “Do you have a ‘balling up’ feeling in your lower abd?”
That’s a really predictive question/sensation for preterm
Home monitoring: does it do any good? Let’s remember that she has a 4 yo kid who
doesn’t want her to lay around. Also, does she have support to get groceries and
stuff if she’s on bedrest.
Indicator that they are on bedrest: they hate you when they come for her visit—if
they are all happy they aren’t really staying in bed.
Outcome: she did fine! She delivered at 32 or 33 weeks. Stayed with the partner,
don’t know what happened at follow up b/c her medical ran out.
High Risk Pregnancy Case Study # 5 Unplanned pregnancy with spotting
Background: Ruby is a 45 year old G4P2T1A0L3 divorced woman. Her youngest
child is 23 years old. Ruby is an art teacher at a local middle school. She had been
having unusually heavy, irregular periods for approximately 6 months and her
previous MD told her she was probably in "the change of life." She has not had a
period for 3 months. During that time she has been fatigued and experiencing
nausea and vomiting at least twice a day. She is 5'4" tall and weighs 140 pounds.
Despite her nausea and vomiting, she thinks she has gained about 5 pounds in the
last 3 months.
Visit today: She comes to your clinic today to get information on menopause and to
find out why she is feeling so sick. You convince her that a pregnancy test would be
a good idea and to her shock it comes back positive. Her physical exams revels a 16
week size uterus and a FHR of 148. She is also having some spotting. She is going to
get into nursing school in the Spring and so has just finished her series of the HepB
vaccine.
Questions:
1. What is the most likely reason Ruby had heavy periods?
Over ½ of women over 30 have heavy. Means change tampon/pad 2x hour.
Often eggs are released immature and lots of estrogen goes with them and builds up the
uterine lining. The egg matures and usually spits out progesterone to stop the buildup,
but in older women their eggs don’t mature and so their lining grows big.
2. What are the risk factors associated with this pregnancy?
Age, chromosomal abn. Miscarriage, previa, fetal distress, LBW, growth
restriction, HTN, preeclampsia, gest DM, C/S, instrumental birth. Basically at risk for
everything.
3. What screening tests are available to screen for congenital anomalies?
Early dx: intrauterine surg, termination, etc.
US: limited, helps assess gest age, amniotic fluid, etc. Specific measures oligo or
polyhydramnios
AFI: amniotic fluid index: how much juice ya got in there
Amniocentesis: after 14 weeks, find alpha-fetal protein means NTDs, spina bifida, abd
wall defects, and metabolic d/o
CFS: remove a little placenta transcervically or abdominally.
PUBS: “pubes?” Fetal blood sample from the unbilical cord.
MRI: soft tissue abn, metabolic abn, etc.
4. List five common symptoms and signs of menopause.
Mood swings, hair chages, insomnia, hot flashed, dryness, heavy bleeding, fatigue
5. What information could you use to try to determine Ruby's due date?
Hasn’t had period for 3 mo, if she remembers first day estimate with Nagel’s
Rule. Only 5% of women deliver on this due date, but most are born w/in 10 days of due
date. If she has irregular periods or don’t remember date, a US will help. Baby can be
measured as early as 5-6 weeks. Best time to estimate w/ US is 10-18 weeks of preg.
6. Ruby's uterus is bigger than how many weeks pregnancy she is. Name at least two
possible reasons for this discrepancy.
Incorrect date of conception could make a big difference—most common reason.
Incr amniotic fluid, or have a big uterus. Multiple gestations. Endometriosis thickening
the uterus (this is a new one to JK), or fibroids [benign tumors].
7. Give some possible reasons for her spotting.
Sometimes ya just do. Or b/c of fibroids, threatened miscarriage, yeast infex,
vaginosis, beta strep, partial previa, chlamydia
8. Are there risks associated with getting the HepB vaccine during pregnancy?
It is ok to get it b/c it’s not a live virus. CDC says it’s not contraindicated but that
there’s not a ton of data. Preg women at risk in preg should be vaccinated. SE: redness,
swelling at site, a little fever.
Jk say: 1/40 change of chrom abn in women at this age. Last period was 3 months,
so go straight to US.
Outcome: b/c of abn periods, her MD put her on HRT b/c of menopausal symptoms,
then she said she felt really really weird, and it was the pregnancy. HRT during
pregnancy can be a risk factor for fetal abn. You can get preg on HRT.
Yay! Amniocentesis, baby was normal boy and they got married, delayed RN
school for a year, her partner had a vasectomy, and everything was happy.