Flashcards in OB Infertility and Antepartal Deck (107):
Incompetent cervix _ when weight of what inside uterus ~ 1lb = 20-22 wks then the cervix just opens up without contractions
what can be done to fix incompetent cervix during pregnancy
stitch it close during pregnancy, but very irritating to cervix;
usually know incompetent because mother has lots of prior preterm labor
Healthy male repro function requirements for conception
Adequate Sex drive
Ability to obtain normal ejaculation
Ability to transmit sperm to female vagina
uterus must not be __________ for healthy conception
heart shaped uterus due to septum in middle; baby can only implant on one side so baby will be very cramped, and mother will have preterm labor/miscarriage
can have to cervixs if septum goes all the way down
Primary: couple has never conceived, despite unprotected intercourse
For at least 12 months
Secondary: Has previously conceived, but is subsequently unable to conceive
within 12 months despite exposure to unprotected intercourse.
definition of infertility for men
For males: Inability to impregnate a female after 12 months regular unprotected intercourse.
definition of infertility for women
inability to achieve and bear a living child after 12 months of regular, unprotected intercourse
recurrent pregnancy loss
The woman is able to conceive but unable to produce a live birth (unable to carry fetus to viable age).
When are couples generally most fertile
Healthy reproductive anatomy and physiology including:
Vagina: no scarring obstructions
Normal cervical mucus to allow passage of sperm to upper reproductive track
Cervix: no scarring
Uterus: no scarring and correct shape no septum
Fallopian tubes: must be patent, so motility must be present
Regular ovulatory cycles: 14 days prior to when she is supposed to start next period. Because she needs those 14 days for implantation. So, sometimes if too soon in a woman you see chronic misscarriage
Adequate Progesterone to maintain pregnancy
10-50% below female baseline weight will decrease
fertility r/t obesity
at least 12% of infertile couples have an abnormal body weight as a cause for their infertility and 70% of women will conceive if their weight disorder is corrected. Male obesity causes low sperm count and poor sperm motility.
male obesity re: fertility
low sperm count
HTN in med, but rather the meds to treat HTN can cause
men responsible for
20% of couple infertility
women responsible for % of infertility in couples
chlamydia and gonorrhea re: fertility
chlamydia and gonorrhea these can cause infertility bc typically do not seek treatment quickly and that causes scarring and adhesions
cause scarring both male and female repro tracts
ruptured appendix and peritonitis can cause
pelvic inflammatory disease and so decrease infertility
ectopic labors put at risk for
Pituitary tumors affect
FSH and LH so can cause infertility
Stress is a factor in infertility, but
many couples do not take favorably to this even though this is a factor due to infertility
increase or decrease in thyroid hormone can?
can be benign and get still pregnant, but MANY INTERFERE with pregnancy
Illegal terminations put at risk for
damage or infection
Alcohol re infertility
decrease conception and increase in spontaneous loss
decrease conception and increase spontaneous
and sperm quality affected
sickle cell infertility
decreased placental perfusion
Cryptorchidism: undescended testes at birth can increase rate of testicular cancer, usually come down by yr old, if don't then have to do surgery.
inadequate number of sperm, drugs, weed, tobacco, ETOH
inflammation of testes, w/ any infection bad for fertility
Mumps in kids before puberty _____ but after puberty ____
in men especially before puberty ok but after puberty bad for infertility.
autoimmune response to own ______ can happen in men
autoimmune to sperm can occur
Does technique and timing affect fertility?
Yes, most direct way to get sperm into female tract is missionary. So, will discourage female from being on top. Will suggest put hips on pillow and woman stay there on pillow with hips elevated.
Timing - critical there is that time 14 days after; cervical mucus changes
antibodies to sperm?
possible women have antibodies to sperm, so literature suggests wear condoms except during ovulation
Autoimmune disorders can cause what in pregnancy
Men generally produce sperm until?
frequency of intercourse
couples that have intercourse once a wk 17% will achieve within 6 mo and goes up with number of times of intercourse
Recommend having sex every other day.
Timing of intercourse re: fertility
_ Egg is penetrable for 12-24 hours
_ Every other day beginning 3-4 days prior to ovulation and continuing for 2-3 after the expected time of ovulation may be best chance
_ Sperm survive ~ 72 hours
Multiple Sex Partners Infertility issues
_ Increased risk of STIs for both partners and PID for females
_ Increased for cervical dysplasia, thus cervical incompetence
_ Increased risk of female developing antibodies to sperm, but this is rare
zaps sperm count, undeniably
Evidence about elective abortions and fertility?
There is NO evidence that there is increased risk of infertility with first trimester elective terminations.
Initial consultation of infertility
good initial education about timing of intercourse, get on prenatal vitamins, manage chronic diseases etc.
generally will not treat after 1st year
Urologists see men with ____________ problems
Partners are interview ___________ and then they are interviewed _______________ for infertility assessment
interviewed together and then separately
because men and women are reluctant to speak about past sexual history
Least __________ procedures for infertility done first
fertility clinical female hx:
Selected aspects of history and physical exam: chronic diseases, nutrition, meds, surgeries, menstrual hx, menarche, freq, duration, problems, symptoms of ovul, LMP, sexual hx, STI, PID, Prev Preg, Age at conception, intervals of unprotected intercourse, loss of any preg, freq of current intercourse, pain, social hx, lifestyle, work, stress, smoking drugs
fertility clinical male hx
Selected aspects of history and physical exam.: chronic illness, mumps after puberty, damage to testes/trauma, sexual and reprod hx, STI, previous fathering, social hx, occupation, heat exposure, toxic substances, lead, radiation, type of underwear, use of hot tubs, substance use, ETOH
Taking ______________ ________________ ______________ is vital to infertility
basal vital temperatures really helpful
BBT DX test
As ovulation approaches, production of estrogen increases and at its peak may cause a slight drop, then rise in the basal temp. After ovulation there is a surge of luteinizing hormone (LH), which stimulates production of progesterone. Because progesterone is thermogenic it causes a 05-1 degree F sustained rise in basal temp during the second half of the menstrual cycle. At menses, temp falls.
Sperm Analysis DX test:
if done at home, must be brought in within 1 hour. Normal: greater than 20 million/ml, greater than 50% forward progression
MUST BE COLLECTED 2-3 days after abstinence
Tests for Ovulation & Ovarian Hormone Function: Serum Progesterone DX Test
need increased progesterone for pregnancy, so check levels
Endometrial Biopsy DX test
must be done late in cycle to determine proper development; performed 2-3 days prior to menses
Tubal patency Tests: Hysterosalpingogram DX
shoot dye up to check patency of fallopian tubes; dye shooting can clear; so have to do it before ovulation or will kill the blastocyte.
Hysteroscopy or Laparoscopy:
scope inserted to view internal structure; scan also remove adhesions
clear adhesions, meds for endometriosis
can try tubal repair
ovarian treatments: Clomid
clomid stimulates ovaries to ripen follicles and release eggs; actually induces ovulation in 70% of women (30-40% of those achieve pregnancy)
10% multiple conception rate with this drug
Timing is crucial with taking the drug and intercourse
SEs: HA, mood swings, weight gain, and visual disturbances
Sperm production Tx:
try to correct causes of low count
Can surgically deposit sperm; i.e., therapeutic insemination
Shared causes tx:
many different technologies
Issues surrounding fertility
ethical, insurance cost, issues around embryos fertilized outside of the body - women's bodies were not made to carry litters of babies. Risk to multiples - some survive being barely viable. Psychosocial issues - denial, blame, what do wrong, starting later, too many partners, GRIEF RESPONSE, embarrassment, unfairness (how can 13 yo have a baby easily and bad care and I not?), DEEP SADNESS WITH EVERY PERIOD EVERY MONTH (FIRST SIGHT OF BLOOD), grandparent pressure, and being very difficult to talk about.
Routine assessment of fetal health done at
each prenatal visit
Interim assessment is done by
Interim assessment is done by the mother
*fetal movement recording - kick counts (starts at 28 wks; 3X a day 20-30 min.
fetal kick count observations requiring healthcare provider follow-up
_ Call provider anytime- fewer than 10 movements in 3 hours, decrease in fetal movements, abrupt change in fetal movements, no movement in the morning, fewer than 3 movements in 8 hours
fetal movement influenced by
time of day, gest age, glucose load, smoking, meds, fetal sleep
fundal height should correlate w/?
symphasis pubis to top of funds this should correlate with date
Milestone FHT and baby activity
ex: if 15 wks and no fetal heart tones, should be able to hear, so either wrong conception date, or baby not alive. So FHT and Activity need to match up
ultrasound first trimester
*MUST BE DONE PRIOR TO GENETIC TESTING
*detect maternal abnormalities
*good for confirming viability,
*check for ectopic
***earlier done the more accurate it is for dating the bay, so 5 wk ultrasound confirms very well, accurate w/n day or 2***
ultrasound second trimester
*better than nothing for confirming date but not as accurate as first trimester
*External Cephalic Version
*amniotic fluid volume
*detect congenital anomalies
*Look for IUGR
*confirm placental placement
*visual for amnioscentesis
ultrasound third trimester
*head in tact/size
*macrosomia = baby too big
*abruption - placenta pulls away from uterine wall
*BPP - biophysical profile
*amniotic fluid volume
*doppler flow study
electronic fetal monitoring and ultrasound combined to score baby in five areas; two points if there, if not there 0 and no partial credit like 1 in APGAR
CRITERIA VERY SPECIFIC - but will not ask specifics
Doppler Blood Flow Analysis
used with mothers suspecting IUGR, looking for properly perfused placenta.
UPI = Uteroplacental insufficiency
Uterplacental insufficiency if determined by doppler blood flow analysis to determine whether baby better inside or outside
*Taking fetal cells and growing them this is DIAGNOSTIC
*lung maturity = test for surfactant
*Left lateral tilt to prevent hypotension due to
pressure on inferior vena cava
*if just ultrasound you want bladder full
*if doing amnio want bladder empty because can nick it
*complications - vaginal spotting, amnio leaking, injuries
SCREENING TOOL - it screens, if abnormal value it will recommend further testing on confirm or DX anything
*maternal serum afp
*4 things: Alphafetoprotein (AFP), human chorionic gonadotropin (hcg), unconjugated estriol (UE), and inhibin-A.
Alpha Fetal Protein
found in Mom's serum, this helps detect neurotube defects, so will do ultrasound to confirm; these things are not chromosomal so amnio not done because structural, but found that trisomies have very very low AFP and so will try to look for trisomy on
Chorionic Villus Sampling (CVS):
Diagnostic, detect genetic abnormalities, limb defect if done before 10 wks so why not done before 10-12 wks; may be better for genetic abnormalities.
Non-Invasive Prenatal Testing (NIPT):
*NOT FDA approved yet; highly accurate but not diagnostic, so considered SCREENING;
*Fetal genetic fragments found in mother's blood done at 10 wks
*DETECTS TRISOMY 21&18 with 99% accuracy, 13 (79%), 1% false positive rate
*Indications: abnormal quad screen and maternal age
*DOES NOT DETECT NEUROTUBE DEFECTS
Non stress test (NST)
*does not use ultrasound
*WANT REACTIVE NST, nonreactive may require follow-up
*FHR monitor around mom
*detects fetal movements; looking for accelerations with movement
*NO CONTRAINDICATIONS, INEXPENSIVE, NO REASON NOT TO DO
*Pattern of fetal heart rate can be affected by numerous factors
*wake baby up with acoustic vibrator
Pattern of fetal heart rate
not do well if: hypoxic, acidodic, drugs, congenital defects, or sleeping
contraction stress test
what is baby's heart rate in reaction to a contraction. So, mother could be having natural contractions or have them in some way we made her have.
**CONTRAINDICATIONS - PRETERM, OR THIRD TRIMESTER BLEEDING, OR ANYONE WHO SHOULD NOT HAVE CONTRACTIONS
*INDICATIONS IF BABY IS GOING TO TOLERATE BEHAVIOR
*NEGATIVE IS GOOD no late decels while positive is bad because had some latex
Tests for lung maturity
*use amniotic fluid
*always measuring surfactant _ L/S or Lecithin/Sphingomyelin surfactant ratio:
*2/1 ratio considered mature
* Phosphatidylglycerol (PG) another component of surfactant, study either positive or negative
*if blood contaminating amnio fluid not accurate
little bit of fetal stress can?
produce surfactant and cause lungs to mature, but we never intentionally stress fetus
infections bad for pregnant women
*cat feces, undercooked meats, bird droppings
*should not be changing liter box
*gardening wearing gloves
*eat only cooked meats
*can cause physical anomalies all depends on when contract it
*ONCE YOU HAVE TOXOPLASMOSIS YOU ARE IMMUNE, AT WORSE FEEL LIKE FLU THOUGH MOST ARE ASYMPTOMATIC, EXCEPT BAD TO CONTRACT DURING PREG. MISCARRIAGE
*transmission rate low, 15% at 1st trimester, but damage more severe - microcephaly, hydrocephaly, brain damage
lesions and rash on baby
*BLUEBERRY MUFFIN RASH - has to be a TORCH
*cannot get vaccine while pregnant, but if not vaccinated then in postpartum try to give rubella; don't want to get pregnant for a month after you had rubella
German measles microceph, visual, cardiac,
1in 4 women of childbearing IUGR, cataracts, petechial
Age non-immune, rash, hepatosplenomegaly
10-20% pop non-immune
Infants are infectious and should be isolated, may have rash, muscular aches, joint pain.
Vaccinate all children, young adult women and newly postpartum women who are non-immune.
first outbreak of herpes has?
most virus shedding and subsequent has a lot less
*mostly with herpes - transmission at time of L&D
*newborns are usually asymptomatic at birth but at 2-12 days of life fever
*baby can have systemic herpes and not get lesions
*CNS involvement likely
*active lesion only 50% transmission rate
*INFANTS WITH ACTIVE INFECTION HALF WILL DIE.
*HALF OF BABIES WITH SYSTEMIC HERPES ARE BORN TO WOMEN WITH NO HX OF THE DISEASE (MOTHERS MAY HAVE IT BUT DON'T KNOW IT) POSSIBLE TO TRANSMIT DISEASE FROM HANDS THOUGH
*NO ACTIVE LESION THEN VAGINAL BIRTH
Babys born to mom's with HPV r/t warts
babies can lyropharangeal warts from this, but rare
can be sexually transmitted
usually occurs during delivery or early post partum
***MOTHER CAN RECEIVE VACCINE WHILE PREGNANT****
Hep B: Transmission is sexually or through blood. Women can have: fever, jaundice, liver disease, malaise, PTL. Can be fatal
Newborns: Infection usually occurs during delivery or early PP
Hep B vaccine to all newborns. Mom can receive vaccine during preg.
HIV & pregnancy
Since mid-1990_s, a 90% decline in the number of children perinatally infected in the United States.
*All pregnant women should be screened
*18% of all people with HIV do not know their HIV status,
*Can occur in preg and breastmilk but most occur in L&D.
*good drug management, down to 1-2% with good drug management and C-Section at 38 weeks prior to ROM.
Transmission of HIV with no treatment
only 25%, but if do c-section before membrane rupture they can prevent transmission to children and cut it down to 1-2%; NO BREAST FEEDING
Prognosis for HIV infected child
very very poor
Nearly _________ woman is GBS at some point.
*every woman is GBS positive at some point
*just give mother antibiotics during labor and decrease transmission to almost zero.
*only 10% cases fatal
*Bring mother in, give antibiotics, and induce her SLOW
_ Women who have previously given birth to a baby with GBS should be treated.
_ If status is not known in labor, if she is preterm, ROM longer than 18 hours or has a temp of 100.4_. TREAT.
No treatment necessary if:
_ C-section and intact
_ Previous +GBS culture but now is -
Leading cause of neonate sepsis
Biophysical Profile (BPP) five scoring areas
*Fetal Breathing Movements
*Fetal tone (i.e. extension and flexion)
*Amniotic Fluid (oligo too little)
*Fetal Heart Rate Reactivity (movement of baby associated with increase of HR)
Full bladder is a requirement for an ultrasound by itself because?
*bladder nice landmark
*early pregnancy the bladder pushes up uterus so can more easily visualize
when placental partially or totally covers the cervix
External Cephallic Version
Another way of saying "Breech Baby" that is the head is facing up towards chest rather than down towards pelvis
Confirmation of Baby as HIV Positive
A child less than 18 months of age is categorized as definitely HIV infected if mother HIV positive and baby has 2 virologic HIV-positive results from separate specimens.
chlamydia and pregnancy woman
*postpartum endomitritis = i.e. postpartum infection
*pain and discharge
*bleeding post coidus
*cervicitis - inflamed cervix
chlamydia and fetus
*conjunctivitis - pink
*ophthalmia neonatorum - tissue inflamation around eyelids
gonorrhea and pregnant woman
PROM - premature rupture of membranes
pain urinating discharge
chorioamnionitis - inflammation of fetal membranes i.e., amniotic membrane etc
gonorrhea and fetus
*ophthalmia neonatorum - can lead to blindness
*Sepsis and meningitis
syphilis and pregnancy/fetus
charted as BDRL
*preterm loss/still birth