Module 6 Study Guide Flashcards
How does the size of the thyroid gland change during pregnancy?
It enlarged up to 30% by the third trimester
Smooth enlarge gland can be felt
How do thyroid lab values (TSH, T3, and T4) adjust (rise, drop, or stay the same) during pregnancy?
TSH is lower during the first trimester because hCG decreases the release of TSH but theen normalize during the second and third trimester. High levels of hCG can result in gestational hyperthyroidism.
T3 and T4 increase due to estrogen
Free T3 and T4 remain the normal
What are the clinical signs and symptoms of hypothyroidism?
Low=slow
Fatigue, constipation, cold intolerance, weight gain, and hair loss
Relaxed DTRs, cardiac arrhythmias
What are the risks of uncontrolled hypothyroidism on the birthing person? On the fetus and newborn?
Maternal: GHTN, pre-E, abruption, PTB, cardiac dysfuntion, miscarriage/loss, infertility
Fetal: Cognitive impairment, low birth weight, prematurity, FGR
What lab test(s) should the nurse-midwife order to diagnose hypothyroidism?
TSH (high)
FT4 (low)
How should the nurse-midwife manage a patient with hypothyroidism?
New hypothyroid=collab with MD or endocrinologist referral
TSH testing q4-6weeks and adjust levo to patient requirements
Encourage iodine intake
Medication: Levothyroxine
What are the clinical signs and symptoms of hyperthyroidism?
Hyper=everything is fast
Nervousness, tachycardia, excessive sweating, heat intolerance, weight loss, elevated blood pressure, and palpitations.
What are the risks of uncontrolled hyperthyroidism on the birthing person? On the fetus and newborn?
Maternal: loss/stillbirth, cardiac arrythmias, HF, pre-E, HTN, placental abruption, thyroid storm
Neonatal: prematurity, low birth weight, FGR, tachycardia/cardiac decompensation, nonimmune hydrops, 1-5% fetal/neonatal thyrotoxicosis
What lab test(s) should the nurse-midwife order to diagnose hyperthyroidism?
TSH (low)
FT4 (high)
Total T3 (high)
Consider TPOAb testing
How should the nurse-midwife manage a patient with hyperthyroidism? What medications are used to manage hyperthyroidism?
Collaborate/refer to MD
Antithyroid Medication: Propylthiouracil (PTU) or methimazole (MMI)
Goal: Maintain FT4 slightly above/high normal
Labs every 2-4 weeks when treatment started then every 4-6 weeks
How should the nurse-midwife manage a patient with hyperthyroidism? What medications are used to manage hyperthyroidism?
Collaborate/refer to MD
Antithyroid Medication: Propylthiouracil (PTU) or methimazole (MMI)
Goal: Maintain FT4 slightly above/high normal
Labs every 2-4 weeks when treatment started then every 4-6 weeks
What is postpartum thyroiditis?
Inflammation of the thyroid gland usually within 12 month PP that can result in hyperthyroidism
Patients at risk: patients with family hx, prior hx of PP thyroiditis, positive antithyroid antibody test, autoimmune disease (DM I)
What are the clinical signs and symptoms of postpartum thyroiditis?
Hypertensive (2-6m PP): Fatigue, palpitations, anxiety, insomnia, irritability, weigh loss, goiter
Hypotensive (3-12m PP): Fatigue, impaired concentration, depression, dry skin, constipation, weight gain, goiter
What laboratory testing should the nurse-midwife use to diagnose postpartum thyroiditis?
TSH followed by FT4 if TSH is abnormal
How should the nurse-midwife manage a patient with postpartum thyroiditis?
Refer to endocrinologist. There is no recommendation for management
What is hyperemesis gravidarum?
Vomiting during pregnancy that is extremely hard to manage and treat. It often leads to weight loss and volume depletion in the pregnant person. There is no consensus on a specific definition or diagnostic criteria, but it generally refers to the most severe form of nausea and vomiting in pregnancy. The CNM must recognize the significant impact that hyperemesis gravidarum poses on the quality of life of patients
What are the diagnostic criteria for hyperemesis gravidarum? How should the nurse-midwife assess for hyperemesis gravidarum?
Hyperemesis is a clinical diagnosis made by ruling out other potential diagnoses. Symptoms generally occur before 9 weeks gestation. If newly onset nausea and vomiting occurs after 9 weeks gestation, other diagnoses should be suspected. Differential diagnoses include gestational trophoblastic disease, multiple gestation, and appendicitis or pancreatitis (if abdominal tenderness present). Hyperthyroidism may also be seen in hyperemesis gravidarum patients; however, this is often transient. If a goiter is present, thyroid disease should be suspected. However, if a goiter is not present and there is no history of thyroid disease, then further thyroid testing is not indicated and anti-thyroid medication is not recommended
When assessing a patient with hyperemesis gravidarum, CNMs should include a fetal heart rate (depending on gestational age) and an examination of fluid status during the physical exam. This includes an examination of blood pressure, heart rate, mucous membrane dryness, capillary refill, and skin turgor. A patient weight should also be obtained for comparison to previous and future weights in addition to a complete blood count and electrolyte evaluation
What effect(s) does hyperemesis gravidarum have on the birthing person? On the fetus?
Maternal: Significantly diminished quality of life and psychosocial effects, Hyponatremia, GI bleeding, Wernicke’s encephalopathy (Vit B1 deficiency)
Fetal: Determined by the severity of nausea and vomiting, Mild or moderate vomiting-little effect, FGR, Prematurity, SGA, LBW
How should the nurse-midwife manage a person with hyperemesis gravidarum?
First-line: Non-pharmacologic. Switch PNV, ginger supplements, admit if IV antiemetics and fluids required
Admission for hypovolemia (decreased UOP, tachycardia, dizzy, electrolyte imbalance, unable to hold down food/liquid
Pharm: Vit B6 is first line, then phenergan or reglan. Lastly is zofran (controversial)
What is the difference between SGA and FGR?
SGA: Same cut off as FGR but not at increased risk for increased morbidity and mortality
-Is made up of either FGR or constitutionally small (aka not at risk for adverse outcomes)
FGR (IUGR): birth weight below 10th percentile where secondary to environmental or genetic influences the fetus is prevented from reaching their expected growth potential.
What is the difference between symmetric and asymmetric fetal growth restriction?
Symmetric: here the fetal head and abdomen size are proportionally decreased. This is due to an insult early in gestation such as severe infection or chromosomal anomaly, which leads to a decrease in the overall number of cells in the body. Symmetrical FGR is associated with an increase in morbidity and mortality.
Asymmetric: “brain sparing” where the head circumference is relatively normal, compared to the smaller abdomen size. Asymmetrical FGR is more common and due to later insults such as hypertension. 75% of FGR are asymmetric and catch up of postnatal growth by three months without longterm consequences.
What are potential causes of symmetric FGR? When does symmetric FGR typically occur?
Occurs early in the pregnancy (often in 1st trimester)
Genetic disorders, infections, teratogenic insults, chronic malnutrition
What are potential causes of symmetric FGR? When does symmetric FGR typically occur?
Occurs early in the pregnancy (often in 1st trimester)
Genetic disorders, infections, teratogenic insults, chronic malnutrition
What are potential causes of asymmetric FGR? When does asymmetric FGR typically occur?
Occurs after 30 weeks of gestation. Normal number of cells by a smaller size
Chronic hypoxia, malnutrition, CHTN, Pre-E, Renal dx, abnormal placentation, multiple gestation, autoimmune dx, hemoglobinopathies, Alcohol, tobacco and drug use
What are risk factors for SGA and FGR?
Low prepregnancy weight
Poor gestational weight gain
Malabsorption
Malnutrition
What is the clinical presentation for SGA and FGR?
Slow or no increase in fundal height
Slow or no maternal weight gain
Fundal height less than 3cm or more than GA
How can the nurse-midwife diagnose SGA and FGR?
Confirm dating, assess accurate fundal height, obtain growth US, repeat U/S no sooner than 2 weeks if EFW <10%
U/S can be inaccurate under 4lb by 25%
What are the potential fetal and neonatal implications of SGA and FGR?
Prematurity, stillbirth/neonatal mortality, increased perinatal and neonatal morbidity, oligohydramnips, intrapartum asphyxia/fetal intolerance of labor
Neonatal: NEC, thrombocytopenia, polycythemia, temp instability, hypoglycemia, renal failure, delayed onset CP, Adult onset disease (DM II, obesity, HTN, osteoporosis)
