NCM 109

ABNORMAL OB
 Objectives:
The learners will be able to
 review the anatomy and physiology of Female

Reproductive System
 Identify the different Sexually Transmitted

Infections
 Distinguish the signs and symptoms

 Discuss the management

 Formulate the Nursing Diagnosis

FEMALE REPRODUCTIVE
ORGAN
 HIGH RISK PREGNANCY: WOMEN WITH
PRE EXISTING OR NEWLY ACQUIRED ILLNESS

HIGH RISK PREGNANCY

 One which a concurrent disorder, pregnancy

related complication or external factor

jeopardizes the health of the mother, the fetus
or both.
SEXUALLY TRANSMITTED INFECTIONS AND
PREGNANCY
 Spread through sexual contact with an infected
partner.
 All STIs can be prevented to some extent by the
use of safer practices, including use of condoms.
 Treatment begins with determining the
causative organism so that appropriate
antibacterial /antifungal agent can be prescribed.
CANDIDIASIS
 Vaginal infections spread by the fungus.

CANDIDA
 It very common that as many as 90% of women

will have it sometime in their lifetime.

 Results in a THICK vaginal discharge : CREAM

CHEESE and extremely pruritic .

 Vagina appears red and irritated.

 Most common in pregnancy. ( increased

estrogen level, vaginal ph less acidic)

 Most common in women in
antibiotic therapy,
gestational Diabetes, HIV.
 Diagnosed by microscopic
analysis of the vaginal
discharge mounted on a wet
slide.
 Treated by vaginal
application of over the
counter anti fungal cream:
Miconazole (Monistat) for 7
days or Oral Fluconazole
( Diflucan).
 May cause thrush in the
newborn.
 Caution pregnant women
before using over the counter
drug.
TRICHOMONIASIS
 An infection caused by a single cell protozoan
spread by coitus.
 Yellow –gray, frothy, odorous vaginal discharge.
 Diagnosed by examination on a wet slide (KOH) or
vaginal culture.
 Maybe associated with preterm labor, pre mature
rupture of membranes, post cesarian infections.
 Drug of Choice: Metronidazole ( single oral dose)
BACTERIAL VAGINOSIS
 Most common ( pregnant/non
pregnant)
 Screening thru vaginal culture
on the 1st pre natal visit, may
be repeated on 3rd tri.
( multiple sex partner)
 Caused by a gram negative
intra cellular parasite.
 Heavy gray-white vaginal
discharge.
 Diagnosed by a culture of
organism from vaginal
discharge using Chlamydia kit.
 Therapy : Doxycycline ( Vibramycin)- non pregnant.(
may cause fetal long bone deformities)
 Azithromycin (Zithromax) or Amoxicillin is used-
( pregnant).
 Partner should also be treated.
 Associated with gonorrhea.
 If not treated may cause PROM, preterm labor,
endometritis of postpartum.
 Infant may suffer conjunctivitis, or pneumonia after
birth.
 Long term effects are PID leading to Infertility.
SYPHILIS
 Caused by spirochete Treponema Pallidum.

1st stage:
 painless ulcer (chancre) on vulva/vagina,

(before week 18, placenta produce some

protection against disease. After then,
spirochete crosses placenta freely and may
cause spontaneous miscarriage, pre term labor,
still birth or congenital anomalies in newborn)
 Pregnant are screened at 1st pre natal visit by
VDRL, ART or FTA-ABS anti body reaction test
 those with multiple partner are tested at 36
weeks, beginning of labor and newborns by a
cord sample.
 Injection of Benzathine Penicillin is the drug of
choice during pregnancy.
 After therapy, may experience hypotension,
fever, tachycardia and muscle aches. JARISCH-
HERXHEIMER reaction that last for 24 hours
then fades.
HERPES SIMPLEX VIRUS TYPE 2
 Genital Herpes Infection caused by Herpes

Simplex Virus (HSV) type 2.

 Painful, small, pinpoint vesicles on an

erythematous base develop in vulva or vagina,

low grade fever 3 to 7 days after exposure.
 Symptoms may fade in a few days but virus

remains in local nerve ganglion, activated

again when she has break in skin or possibly
by stress.
 Primary Infection: herpes can be transmitted across
placenta which causes congenital infection in newborn.
If lesion is present during birth, herpes can be
transmitted thus Cesarean operation is performed.
 Diagnosis is made by the appearance of lesion, Pap
smear, ELISA- Enzyme linked immunosorbent assay.
 Drug of choice is Acyclovir (Zovirax)or Valacyclover.
 May take sitz bath, warm moist tea bag to the area.
 Condom use.
GONORRHEA
 Caused by gram negative coccus Neisseria
Gonorrhea
 Yellow-green vaginal discharge.
 A woman maybe asymptomatic but her male
partner usually has severe symptoms:
 pain on urination

 purulent yellow penile discharges.

 Associated with spontaneous miscarriage, preterm
birth and endometritis in post partum period.
 Major cause of PID and Infertility.
 Diagnosis is made by culture of organism from
the vagina, rectum, urethra.
 Penicillinase- producing strains is ineffective.
 Recommended therapy: Cefixime ( Suprax)
oral, IM Ceftriaxone ( Rocephin).
 Pregnant: Amoxicillin or Azithromycin.
 Sexual partners should be treated.
 Should be identified and treated during
pregnancy. May cause severe eye infection,
blindness in newborn.
HUMAN PAPILLOMAVIRUS INFECTION
 HPV causes fibrous tissue overgrowth on external
vulva. ( condyloma acuminatum)
 Common in women with multiple sexual partners.
 Lesion appears discrete papillary structures, then
spreads, enlarge and coalesce to form large,
cauliflower-like lesion.
 Increase in size during pregnancy because of high
vascular flow in pelvic area. They may become
secondarily ulcerated and infected- foul valvular
odor develop.
 Therapy: Aimed in dissolving the lesion and ending
secondary infection present.
 Non Pregnant: Podophyllum(Podofin) applied directly to
lesions.
 Pregnant: Trichloroacetic acid TAI or Bichloroacetic acid
BCA applied to lesion weekly.
 Large lesion maybe removed by laser, cryocautery, knife
excision
 Lesion at birth that can obstruct birth canal : cesarean
operation.
 Associated with the development of Cervical cancer.
 Infected women should have Papsmear yearly for the rest of
their life.
GROUP B STREPTOCCAL INFECTION
 Usually no symptoms but consequences are UTI,
intra amniotic Infection, preterm birth, post partum
endometritis.
 CDC recommends all pregnant women to be
screened for streptococcus B at 35 to 38 weeks of
pregnancy.
 Infected neonates (placental transfer) may develop
severe pneumonia, sepsis, respiratory distress
syndrome, meningitis.
 Broad spectrum penicillin ( Ampicillin) is the
treatment of choice. May be given to mothers with
rupture of membranes at less than 37 weeks of
pregnancy.
HIV INFECTION
 Human Immunodeficiency Virus (HIV) is the
organism responsible for Acquired
Immunodeficiency Syndrome ( AIDS) is the most
serious because it can be fatal to both mother and
child.
 Contacted through Sexual intercourse, exposure to
infected blood, vertical transmission across placenta
to the fetus at birth, breastmilk to newborn.
 Caused by a retrovirus that infects and disables T
lymphocytes.
 Risk factors: multiple sexual partners, bisexual
partners, IV drug use, blood transfusion ( rare)
 HIV virus invades T lymphocytes(t4 cells) it
substitute its own RNA and DNA of the cell. T4
cells die reducing immune system functioning.
CD4 cell count determines the T4 cells present.
Below 500 cells/mm3 opportunistic infection
sets in.
 Early symptoms are subtle and difficult to
differentiate from other diseases or sx of early
pregnancy ( fatigue, anemia, diarrhea, weight
loss).
STAGES
 Initial invasion: mild, flulike symptoms

 Seroconversion: converts from no HIV

antibodies in her blood ( HIV serum negative) to

having antibodies against HIV (HIV serum
positive). Happens 6 weeks to 1 year after
exposure.
 Asymptomatic Period. Appears disease free

except for symptoms such as weight loss, fatigue

( wasting syndrome)- virus can be replicating
this time. 3-11 years.
 Symptomatic: Develops opportunistic infections

and possibly malignancies.

 Toxoplasmosis, oral, vaginal candidiasis,
gastrointestinal illness, herpes simplex,
Pnemocystis carinii pneumonia PCP, Candida
esophagitis, Kaposi sarcoma and HIV
associated dementia.
 CD4 count is below 200 cells/mm3.
 Testing: ELISA antibody reaction
 Confirmation: Western Blot Analysis
Therapeutic Management
 HIV positive are advised not to get pregnant.

 Goal therapy is to maintain CD4 greater than

500 cell/mm3.
 Ritonavir (Norvir) or Indinavir ( Crixivan) with

a Nucleoside Reverse Transcriptase Inhibitor

NRTI drug.
 HIV is associated with preterm birth and low

birth weight. 50% of infants born to HIV

positive mothers
( untreated) will contract the virus and develop
AIDS in the first year of life.
 Zidovudine (ZVD) is administerted to women
beginning 14th week of pregnancy and
newborn receives drug at 6 weeks after birth,
the risk of perinatal transmission can be
reduced to only 8 to 10% .
 Nevirapine an newer antiretroviral drug may
reduce the incidence even more
 PCP: Trimethoprim (teratogenic) with
sulfamethoxazole (bactrim)- increased bilirubin
levels. Pentamidine (pentan)- drug of choice for
PCP in non pregnant.
 Kaposi sarcoma: Chemotherapy.
 Thrombocytopenia ( low plt): platelet
transfusion for coagulation ability.
 Reduce risk of transmission: Cesarean
Operation.
Zidovudine treatment for the first 6 weeks is
important. At 4 month if child has 2 negative HIV
culture: HIV Infection is excluded
 1. A client’s diagnosis of gonorrhea is
confirmed with a culture. The recommended
drug therapy for the client is:
 1. spectinomycin
 2. doxycycline
 3. ceftriaxone
 4. probenecid (Benemid)
 3. ceftriaxone
 The drug of choice for treatment of syphilis is:
 1. spectinomycin
 2. doxycycline
 3. probenecid (Benemid)
 4. penicillin
 4. penicillin
 3. People are considered AIDS-diagnosed if
they have:
 1. T or CD count of 500/mm and HIV+
 2. T or CD count of <200/mm
 3. HIV+ and pulmonary tuberculosis
 4. HIV+ and cervical dysplasia
A CD T-cell count of <200/mm 3
and an increased viral
4
load are indicative of AIDS.
 Common complications of advanced HIV
infection include:
 1. euphoria
 2. obesity
 3. pneumonia
 4. constipation
 ANS: 3
 Patients with HIV tend to be thin, have diarrhea,
and be depressed. Pneumonia is a superinfection
caused by immunosuppression.
 HIV clients are monitored closely for the most
common adverse effect of treatment, which is:
 1. bone marrow suppression
 2. insomnia
 3. dystonic reaction
 4. seizures
 ANS: 1
 Bone marrow suppression is a common side
effect of antiretroviral therapy.