Pregnancy and Contraception: A Comprehensive Study Guide, Exams of Nursing

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NR 602

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STUDY

GUIDE

lOMoAR cPSD| 586

2 example, a 28 week gestation fetus should have a fundal height that measures between 26 and 30cm.

gestational weeks (+/- 2cm). Naegele’s rule

• The EDD is calculated by adding seven days to the first day of the last menstrual period, subtracting three months and adding one year. *For example, if the patient's last menstrual period, LMP, was on August 10, 2019, the EDD would be calculated as follows. LMP equals August 10, 2019 plus seven days. August 17, 2019, minus three months. May 17, 2019 plus one year and that equals May 17, 2020. Hematological changes during pregnancy-See Table 29.2 p. 777
• blood volume increases by 30% to 50%, or 1,100 to 1,600 mL and peaks at 30 to 34 weeks’ gestation.
• The increase in blood volume improves blood flow to the vital organs and protects against excessive blood loss during birth.
• Fetal growth during pregnancy and newborn weight are correlated with the degree of blood volume expansion.
• Of the blood volume expansion occurring during pregnancy, 75% is considered to be plasma
• There is also a slight increase in red blood cell volume (RBC).
• The blood volume changes result in hemodilution, which leads to a state of physiologic anemia during pregnancy.
• As the RBC volume increases, iron demands also increase. Between 25-35 weeks the fundal height should measure equally to the number of

3

• Leukocytosis occurs in pregnancy, with white blood cell counts increasing to as much as 14,000 to 17,000 cells per mm^3 of blood ( Table 29- 3 ).
• Clotting factors increase as well, creating a risk for clotting events during pregnancy.
• Systemic vascular resistance is reduced due to the effects of progesterone, prostaglandins, estrogen, and prolactin.
• This lowered systemic vascular resistance, in combination with inferior vena cava compression, is partly responsible for the dependent edema that occurs in pregnancy.
• Epulis of pregnancy, or hypertrophy of the gums accompanied by bleeding, may also occur and is due to decreased vascular resistance and increase in the growth of capillaries during pregnancy Indications and contraindications for prescribing combined estrogen vs. progesteroneonly birth control: See Appendix 11-A p. 248
• Most COC formulations now contain between 20 to 35 mcg of ethinyl estradiol plus one of 8 available progestins.
• Consider the “quick start” method when initiating oral contraceptives. If last menstrual period (LMP) was within the last 5 days, the method can be started immediately. In unprotected sex within last 2 weeks, start the contraceptive method today and advise patient to return to the clinic for a pregnancy test in 3 weeks. Instruct women who are using the pill, patch, ring, injection, or implant to use backup contraception for the first 7 days. Research shows that there are no significant differences in the number of bleedingspotting days or any other bleeding parameter between the immediate and conventional starters.
• Indications: Women with dysmenorrhea and menorrhagia Women who want to regulate menses Women who will use a daily method consistently
• Benefits of COC Decreased blood loss and anemia Decreased menstrual cramps and pain with more predictable menses Can be used to manipulate the timing of menses Decreases risk of ovarian cancer and endometrial cancer Reduces risk of ectopic pregnancy Effective to treat acne, hirsutism and other androgen excess/sensitivity states

5 Progestin-only pills are useful for women who want immediately reversible hormonal contraception but for whom estrogen is contraindicated because of breastfeeding, cardiovascular disease, and migraine with aura, for example.

• Advantages: Progestin-only pills (COCs also are used) can be used to correct dysfunctional uterine bleeding. no estrogen-related side effects that COCs have, such as nausea, headache, and bloating, but they do cause irregular vaginal bleeding. These pills protect against cancer of the uterus and ovaries, benign breast disease, and pelvic inflammatory disease.
• Contraindication: o The only contraindication to taking progestin-only pills is current breast cancer.
• Disadvantages: The primary side effect is irregular menstrual bleeding, including spotting or breakthrough bleeding, amenorrhea, or shorted cycles. Irregular bleeding decreases in many users by cycle 12. Less common side effects are headache, breast tenderness, and dizziness.
• Counseling: The pill must be taken at the same time each day. If a pill is more than 3 hours late, a backup method of contraception should be used for at least the next 48 hours. Inform women about emergency contraception. Menstrual cycle physiology
• The initiation of menstruation, called menarche, usually happens between the ages of 12 and 15.
• Menstrual cycles typically continue to age 45 to 55, when menopause occurs.
• Changes in menstruation are one of the most frequent reasons why women visit their clinician.
• The ratio of total body weight to lean body weight is probably the most relevant factor, and individuals who are moderately obese (i.e., 20–30% above their ideal body weight) tend to have an earlier onset of menarche
• the normal menstrual cycle is 21 to 35 days with a menstrual flow lasting 4 to 6 days, although a flow for as few as 2 days or as many as 8 days is still considered normal
• The amount of menstrual flow varies, with the average being 50 mL; nevertheless, this volume may be as little as 20 mL or as much as 80 mL.
• Menstrual cycles that occur during the first 1 to 1.5 years after menarche are frequently irregular due to the immaturity of the hypothalamic–pituitary–ovarian axis

6 Hypothalamus GnRH FSH & LH The hypothalamus controls anterior pituitary functions via the secretion of releasing and inhibiting factors. Together with the pituitary, it manages the production of hormones that serve as chemical messengers for the regulation of the gynecologic system. The hypothalamus initially releases gonadotropin-releasing hormone (GnRH) in a pulsatile manner. On average, the frequency of GnRH secretion is once per 60 to 100 minutes during the early follicular phase, increases to once per 60 to 70 minutes during the middle of the menstrual cycle, and then decreases during the luteal phase The release of GnRH stimulates the pituitary gland to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Two other hormones necessary for gynecologic health, estrogen and progesterone, are secreted by the ovaries at the command of FSH and LH. Pituitary The oval-shaped, pea-sized pituitary gland is located in a small depression in the sphenoid bone of the skull. It is controlled by the hypothalamus, which secretes releasing factors into a special blood vessel network (hypothalamic–hypophyseal portal system) that feeds the pituicytes. These releasing factors either stimulate or inhibit the release of pituitary hormones that travel via the circulatory system to target organs. The anterior pituitary synthesizes seven hormones:

• Growth hormone (GH)
• Thyroid-stimulating hormone (TSH)
• Adrenocorticotropin (ACTH)
• Melanocyte-stimulating hormone (MSH)
• Prolactin (PRL)
• Follicle-stimulating hormone (FSH)
• Luteinizing hormone (LH) FSH and LH (both gonadotropins) are responsible for regulating gynecologic organ activities. FSH targets the ovaries, where it stimulates the growth and development of the primary follicles and results in the production of estrogen and progesterone. The release of FSH from the pituitary is governed by a negative feedback mechanism involving these steroids. In contrast, LH targets the developing follicle within the ovary; it is responsible for ovulation, corpus luteum formation, and hormone production in the ovaries. Prolactin is responsible for preparing the mammary gland for lactation and brings about the synthesis of milk

8 norgestrel are preferable to those with norethindrone, as failure rates are slightly higher with norethindrone (Zieman et al., 2015). Because the high dose of ethinyl estradiol causes unpleasant side effects, this regimen has largely fallen out of favor. o Until recently, the most widely used emergency contraception method was levonorgestrel ECPs, which contain either a 1.5-mg single dose (Plan B One-Step) or two doses of 0.75 mg taken 12 hours apart (Next Choice and Plan B). Women can take both doses in the two-dose products (Next Choice and Plan B) as a single dose. Levonorgestrel ECPs are available over the counter to women and men age 17 and older; women 16 and younger need a prescription to obtain them. Levonorgestrel ECPs are more effective than the Yuzpe regimen and have fewer side effects. o Ulipristal acetate (ella), a selective progesterone receptor modulator provided as a single 30-mg dose, is the most effective oral emergency contraception method. The effectiveness of this medication does not decline within the 120-hour window after UPI, as is the case for levonorgestrel and combined ECPs. Ulipristal acetate is available only by prescription. o The copper IUD can be inserted as long as 5 days after unprotected intercourse. Some contraceptive guidelines recommend its use up to 7 days after UPI. This method is rarely utilized as emergency contraception in the United States; however, recent evidence suggests some women might choose the copper IUD if it is offered as an option. It has the advantage of being highly effective in obese women and providing ongoing contraception. Tier 1, 2 & 3 methods of contraception and efficacy

• Tier 1 methods includes the most effective methods of contraception, generally those with a failure rate of less than 1%. o IUD o Depo o Progestin Implants (Nexplanon) o Sterilization (tubal/vasectomy)
• The tier 2 methods have a failure rate somewhere between 2-3%, depending upon your reference o Combined oral contraceptive (COC) pills- estrogen and progesterone o Oral contraceptive pill- progestin only "Minipill" o Emergency contraception o Transdermal patch o Ring
• Tier 3 methods are the least reliable methods which have a failure rate of up to roughly 20%. o Tier 3 methods include all of your barrier methods, natural family planning and coitus interruptus.

9 o These methods are the least effective in terms of preventing pregnancy with variable rates between them which are outlined in your textbook. o The biggest advantage that the barrier methods offer in addition to preventing pregnancy is that they offer protection in preventing STDs. Etiology, diagnosis, and treatment of amenorrhea: See table 24-7 p 596

• Amenorrhea simply means absence of menses and is part of the spectrum of ovulatory disorders classified as AUB-O.
• The most common causes of amenorrhea are pregnancy, hypothalamic amenorrhea, and PCOS
• women meeting any of the following criteria should be evaluated for amenorrhea: o No menses by age 14 in the absence of growth or development of secondary sexual characteristics o No menses by age 16 regardless of the presence of normal growth and development of secondary sexual characteristics o In women who have menstruated previously, no menses for an interval of time equivalent to a total of at least three previous cycles, or 6 months Primary amenorrhea is the failure to begin menses by the age of 16.
• Secondary amenorrhea is defined as 3 months without a menses once menses has been established.
• *** Ovarian function abnormalities are the most common cause of amenorrhea, and estrogen production is the most reliable measure of ovarian function.
• Athletic women, particularly long-distance runners, gymnasts, and professional ballet dancers, are at risk for amenorrhea, as are women who have anorexia and other eating disorders
• Women with a low BMI and low percentage of body fat combined with a high level of intensive physical activity have the highest risk for amenorrhea

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• A dopamine agonist is the treatment of choice for hyperprolactinemia o Ovarian failure is diagnosed when low estrogen production is identified while the serum FSH is high. Premature ovarian failure can be due to many causes, including genetic conditions. o Functional hypothalamic amenorrhea is characterized by “the absence of menses due to the suppression of HPOA in which no anatomic organic disease is identified”
• The typical picture of a woman diagnosed with functional amenorrhea is the adolescent who is underweight, overexercises, and is experiencing a great deal of stress.
• In this setting, an energy deficit occurs, with a resultant negative impact on the HPOA
• Treatment generally focuses on weight gain and exercise reduction, although psychological counseling may also be helpful.
• A goal of treatment is to offset the bone loss that occurs during the estrogendeficient periods of time
• All women with anovulation require management of this condition: If left untreated, endometrial cancer can occur, regardless of the woman’s age.
• Typically treatment consists of inducing menses using a progestogen such as medroxyprogesterone acetate 5 to 10 mg daily for the first 12 to 14 days of the cycle. Etiology, diagnosis, and treatment of dysmenorrhea (primary vs. secondary)
• Dysmenorrhea—defined as painful cramps that occur with menstruation—is the most commonly reported menstrual disorder, affecting as many as 81% of women
• Etiology-- The pain of dysmenorrhea originates from intense uterine contractions during the menstrual phase of the cycle, triggering endometrial prostaglandin production and release. o The excessive amount of prostaglandins causes the uterus to contract further, reducing uterine blood flow and causing ischemia and pain. o While the etiology of dysmenorrhea is not completely understood, studies support the hypothesis that uterine inflammation with menstrual cycles may also promote cross-organ pain sensitization, a mechanism by which dysfunction in one organ elicits neurogenic inflammation in another organ o The uterus lies in close proximity to the bladder, the bowel, and the peritoneum, and its contraction may elicit pain in those structures during the menstrual cycle. o This theory, along with the current knowledge about prostaglandins’ major role in dysmenorrhea, may help explain the chronicity of pain that may occur throughout the pelvic area during the menstrual cycle.
• Primary (absence of pelvic pathology) o more common than secondary dysmenorrhea, o often begins 6 to 12 months after menarche. o Typically symptoms are experienced with the onset of bleeding and continue for 8 to 72 hours into the menstrual cycle.

12 o Increased endometrial prostaglandin production is believed to be the cause of the associated pain o It is associated with multiple symptoms, including abdominal cramps, headache, backache, general body aches, continuous abdominal pain, and other somatic discomforts. o The difference between primary dysmenorrhea and normal somatic and psychological changes prior to menses is that primary dysmenorrhea is perceived as more severe, with chronic, sometimes debilitating symptoms. o There is no evidence of organic pathology in the uterus, fallopian tubes, or ovaries with primary dysmenorrhea. o Women usually report repeated symptomology with each cycle. o When charting their cycles, it is evident that that pain, bleeding, and disruption of lifestyle occur at regular times in the cycle. o There is a higher prevalence of depression and anxiety in women who experience pelvic pain or dysmenorrhea

• Secondary (occurring from identifiable organic pathology). o Diagnosis of secondary dysmenorrhea includes pelvic pathology such as adenomyosis, leiomyomata, irritable bowel syndrome, interstitial cystitis, and endometriosis o Almost any process that can affect the pelvic viscera and cause acute or intermittent recurring pain might be a source of cyclic premenstrual pain, including urinary tract infection, pelvic inflammatory disease, hernia, and pelvic relaxation or prolapse o Clinical findings may differ from primary dysmenorrhea in that they may include reports of dyspareunia (pain with intercourse), postcoital bleeding, and abnormal uterine bleeding. o The pelvic pain associated with secondary dysmenorrhea may occur before, during, or after menses. o The most common cause of secondary dysmenorrhea is endometriosis—a chronic condition in which the endometrial lining is implanted outside the uterus. o Another cause of secondary dysmenorrhea is uterine fibroids (leiomyomas, myomas).
• The pain associated with either primary or secondary dysmenorrhea may be similar, although pain that has increased over time is more often associated with secondary dysmenorrhea.
• Treatment o Nonpharmacologic Treatments
• Heat
• Lifestyle changes

14 Anger/irritability Insomnia Changes in libido Confusion, decrease in mental sharpness Social withdrawal Feelings of low self-esteem/poor self-image increased interpersonal conflicts Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts Marked anxiety, tension, feelings of being “keyed up” or “on edge” Decreased interest in usual activities Subjective sense of difficulty concentrating Lethargy Insomnia or hypersomnia A subjective sense of being overwhelmed or out of control Diagnostic criteria Symptoms begin up to 7 days prior to menses Remission of symptoms occurs from cycle days 4– 13 Symptoms are significant enough to impair activities of daily living Symptoms are charted in at least 2 cycles Symptoms are not due to another disorder Symptoms are associated with clinically significant distress or interference with work, school, social activities, or relationships with others The disturbance is not an exacerbation of the symptoms of another disorder (e.g., major depressive disorder) Criteria should be confirmed by prospective daily ratings during at least 2 symptomatic cycles (the diagnosis may be made provisionally prior to this confirmation) Symptoms are not due to the direct physiological effects of a substance (e.g., drug abuse, medications other than treatment) or a general medical condition

• Premenstrual syndrome (PMS) describes the cyclical recurrence of symptoms that impair a woman’s health, relationships, and occupational functioning. o PMS can be defined as a cluster of mild to moderate physical and psychological symptoms that occur during the late luteal phase of menses and resolve with menstruation

15 Premenstrual dysphoric disorder (PMDD) is a diagnostic label that applies to a much smaller number of menstruating women experiencing severe PMS with predominantly negative affective symptoms. o PMDD encompasses cognitive, behavioral, emotional, and negative symptomatic changes that severely impair daily functioning, relationships, parenting, and ability to work in the late luteal menstrual phase The diagnostic criteria for PMDD are as follows: o In the majority of cycles, five or more symptoms, including affective and physical symptoms, are present during the week before menses and are absent in the follicular phase. o One (or more) of the following symptoms is present: irritability, depressed mood, marked anxiety, tension, or affective lability. o One or more of the following symptoms must additionally be present (the combination of symptoms in I and II must total five): decreased interest in usual activities, difficulty concentrating, fatigue, appetite change (decreased or increased), changes in sleep patterns (hypersomnia or insomnia), sense of feeling overwhelmed, physical symptoms such as breast tenderness, joint or muscle pain, bloating, or weight gain. o The symptoms markedly interfere with occupational or social functioning. o The symptoms are not due to an exacerbation of another disorder. o The preceding criteria have been confirmed by prospective daily ratings over at least two menstrual cycles TABLE 23 - 1 Symptoms of Premenstrual Syndrome and Premenstrual Dysphoric Disorder Abnormal uterine bleeding terminology *In women of reproductive age, the most common cause of a bleeding pattern that suddenly differs from a woman’s established menstrual pattern is a complication of pregnancy, including threatened or incomplete abortion, ectopic pregnancy, retained products of conception, or gestational trophoblastic disease **As a consequence, clinicians treating women of childbearing age who present with AUB—especially adolescents who may not be forthcoming about their sexual activity— should always first exclude pregnancy or a complication of pregnancy as a cause of the bleeding. Menorrhagia: heavy or prolonged menstrual bleeding Metrorrhagia: “irregular” intermenstrual bleeding or bleeding between menstrual periods Menometrorrhagia: “irregular” and heavy intermenstrual bleeding Post-Coital: bleeding that occurs after intercourse

17 Evaluation and management of abnormal uterine bleeding: See Week 2 lesson Material

• Management: Management goals for treating AUB are to (1) normalize the bleeding, (2) correct any anemia, (3) prevent cancer, and (4) restore quality of life. o The clinician should always consider the woman’s choice of treatment when developing a plan of care. o Concomitant therapy may be necessary to achieve these goals, particularly if the bleeding is severe and threatens hemodynamic stability. o Estrogen therapy will provide rapid growth of a denuded endometrium. o Once the acute bleeding is under control, additional treatment options such as oral contraceptives, use of the levonorgestrel intrauterine system, and progestin therapy (among others) are available for long-term treatment

18 o If testing reveals that the woman is anemic because of the bleeding, she will need iron therapy. o Table 24.5 pg 591: Pharmacological management: A variety of pharmacologic choices are available for women with HMB, including combined oral contraceptives (COCs), progestogen-only therapy, and levonorgestrel-releasing intrauterine devices o Nonsteroidal anti-inflammatory drugs are useful for ovulatory–idiopathic HMB. The heavier the bleeding, the better the effectiveness of NSAIDs, o surgical management options for HMB include D & C, endometrial ablation, uterine artery embolization, and hysterectomy. In the presence of a thin endometrium, medical therapy for excessive uterine bleeding is reasonable. Breast mass types and diagnostic studies Fibroadenomas o Benign neoplasms which occurs most frequently in young women, usually within the first 20 years after puberty. o The frequency is a slightly higher and tends to occur at an earlier age in the African American population than in Caucasian women. o They are usually discovered accidentally and typically present as solid, well-defined masses which are non-tender and mobile. Multiple fibroadenomas are possible. o The incidence of fibroadenomas decrease with age but may still occur in menopause. o Etiology is unknown but a hormonal relationship is likely since they can increase in size during pregnancy or with estrogen therapy. Cysts o Benign fluid-filled sacs that are encapsulated within the breast. o Single or multiple cysts may be present occurring in one or both breasts. o Cysts are most common in women between the ages of 35 and 50, prior to menopause but can be found in women of any age pre- and post-menopause. Lipomas o Fatty tumors that can appear anywhere in the body, including the breast. They are usually not tender and occur in the later reproductive years. Hamartoma o Overgrowth of mature breast cells which may contain fatty, fibrous and/or glandular tissue. o Hamartomas are smooth and painless masses. Fat Necrosis o Usually the result of breast trauma or surgery. o Tenderness may or may not be present. o Sometimes indistinguishable from carcinoma. o If left untreated, fat necrosis masses usually gradually disappear without intervention. Phyllodes tumors o Rare benign breast tumor arising from the fibroepithelial cells. o The tumors tend to grow very quickly and become very large. o The lesion can be, but rarely is, malignant.