Betty’s Unfolding Case

Betty is a 20 year old single black female. She has never been pregnant, and she does not have a history of any health conditions. Her family history includes HTN on her father’s side (PGF and F). Her MGM had breast cancer, and is now deceased. She does smoke, but states that she plans to quit when she stops being so “stressed out from school”. She presents in the health clinic complaining of a foul-smelling vaginal discharge. Which questions would you ask to elicit thorough information about her history?

1. Is she sexually active? (If so, at what age did she become sexually active?)

2. Has she had sex recently (with multiple partners or received oral intercourse)?

3. How many sexual partners has she had?

4. How many packs of cigarettes does she smoke a week? How long has she smoked?

5. Does she use street drugs or alcohol?

6. What is her diet like?

7. Does she exercise?

8. What color is the discharge? When did it start? Is she experiencing any vaginal itching or burning?

9. When did her last menstrual period start? What is her usual menstrual cycle like? What is her normal amount of menstrual discharge?

10. Does she do regular breast self-exams?

What is the likely cause of the discharge?

• Foul-smelling vaginal discharge is a sign of infection, such as bacterial vaginosis, which is caused by an overgrowth of bacteria and produces a white, gray, or milky discharge. It could also be trichomoniasis, a sexually transmitted infection (STI), which produces a foul smelling, frothy, yellow-green discharge.

Which tests do you anticipate?

• A specular exam and Pap smear to obtain a sample of vaginal secretions and check for overgrowth of anaerobic bacteria. The doctor may examine the vaginal secretions under a microscope to determine the responsible pathogen.

• The doctor may also check the acidity of this client’s vaginal environment using a pH test strip. A vaginal pH of 4.5 or higher is another sign of bacterial vaginosis.

Treatment options?

• If it is trichomoniasis, the treatment would be metronidazole 2g orally via a single dose.

• If it is bacterial vaginosis, the responsible organism would need to be cultured and identified and the treatment would be the appropriate antibiotic (such as Flagyl, Clindamycin, or Tinidazole) for that bacteria.

Teaching for Betty?

• The nurse needs to educate this client on minimizing vaginal irritation, including staying out of hot tubs and whirlpool spas. She will need to rinse her genital area of soap after a shower and dry it well in order to help prevent infection. A mild, non-deodorant soap and unscented tampons and pads should be used. Instruct the client not to douche, as it disrupts the normal vaginal flora and can increase her risk of infection.

• If her infection is diagnosed to be an STI, she will need to share this information with her sexual partner. The only 100% effective method for preventing the transmission of STIs is abstinence. Condoms are the next most effective method. Oral contraceptives do not protect against STIs. If she is placed on antibiotics, she should not drink alcohol while taking them and needs to finish the entire course even after her symptoms disappear. She should also avoid sexual intercourse until her treatment is complete.

Betty has now graduated from college, and plans to marry the man of her dreams. She is 24 years old, and has not developed any new medical conditions. She is not ready for children yet, but wants to explore birth control options now that she is monogamous. Explain Betty’s options.

• Fertility awareness methods in which intercourse is avoided during assumed periods of fertility.

o Natural family planning – avoid intercourse four days before and three days after ovulation

o Calendar rhythm – subtract eighteen days from the length of the shortest menstrual cycle as the start of the fertile period and eleven days from the end of the longest cycle as the end of the fertile period

o Standard days – avoid intercourse on days eight through nineteen of her menstrual cycle

o Basal body temperature – use body temperature to predict ovulation and fertile days

• Oral contraceptives – either combined (estrogen and progesterone) or progesterone only that are taken once daily

• Condoms – used to prevent entrance of semen into the vagina

• Intrauterine device (IUD) – implanted T-shaped device with either progesterone or copper

• Spermicides – kill sperm during intercourse

• Diaphragm – inserted over the cervix prior to intercourse to prevent entry of sperm

• Cervical cap – inserted to cover cervix to prevent entry of sperm

Now Betty presents to the clinic in tears. She forgot to replace her vaginal birth control ring, and realizes that she ovulated last night just after having intercourse with her husband. Betty is upset, because she is not ready to have a baby. She is starting a new internship, and wanted to delay childbearing for a little longer. What are Betty’s options?

• Betty could buy an OTC Plan B pill, or “morning after” pill, to be taken within 72 hours of intercourse. However; if fertilization has already occurred, this pill may not be effective. Plan B is used for the purpose of "emergency contraception", releasing progestin into the woman's system to prevent ovulation. Since she has already ovulated, this increases her likelihood that she is already pregnant. Another type of emergency contraceptive is a pill that contains ulipristal acetate. It can be taken up to 5 days after unprotected sex. A third type of contraceptive pill used both progestin and estrogen. These pills can cut your chances of getting pregnant by 75%, but the client will be more likely to experience side effects such as nausea and vomiting. • She could also wait and take a pregnancy test at home if she misses one or two menses. If the test shows positive, she should schedule a visit with her gynecologist. She may receive a vaginal ultrasound as early as 7 weeks of pregnancy to confirm the pregnancy. If she is pregnant, and decides she does not want to carry the baby, she could explore an abortion. This early in the pregnancy, a vacuum aspiration abortion is the preferred method, in which the components of the pregnancy are removed from the uterus in a one-time visit to the gynecologist. She also has the option of a medicated abortion in which drugs such as Misoprostol, Mifepristone, and Methotrexate are used to inhibit the effects of the hormones needed to sustain pregnancy and "induce" expulsion from the uterus.

Betty discussed her options with her husband, Frank, and they both agreed that they would just “wing it” and see what happens this month. Frank grew up in the Catholic Church in Honduras, and he believes that any medication that impedes implantation might be a violation of his religious practice. What is the appropriate nursing response?

• The appropriate nursing response would be to support the client’s wishes and respect their decision. This is a decision the couple will need to discuss between themselves. The nurse however, will provide as much education and support as she can for the couple.

Now it has been 2 months, and Betty has not had a period. She presents in the office requesting a pregnancy test. In which way does a pregnancy test detect pregnancy?

• A pregnancy test is specific to detecting human chorionic gonadotropin (hCG), a hormone produced after a fertilized egg implants in the wall of the uterus, which can be detected within 7-10 days. Both urine and serum tests will provide accurate results of hCG.

Betty’s test is positive. GTPAL? _G1 T0 P0 A0 L0____________

Her last menstrual period was 3/10/08. What is her EDC?__12/17/08_________________

Betty seems to be a little unsure about the pregnancy. She says that it is not great timing, but she has thought it through, and she is sure it will work out. As far as adjustment goes, what do you recognize is occurring at this stage of her pregnancy? What is the appropriate nursing response?

• During the first trimester there are a lot of hormonal, physical and emotional adjustments that women will go through. It’s normal for a new mom-to-be to be scared of the unknown. Her elevated hormones will also increase her emotional state. She is recognizing that a baby means a lot of adjusting and has not yet formed a strong attachment with the fetus. • Help the client understand the physiologic changes that are occurring to her body. Also, educate the client that having ambivalence (or doubts about pregnancy) isn’t unnatural. Provide her information on what to expect and when prenatal visits will need to occur.

Since this is Betty’s first prenatal visit, which labs will likely be drawn?

• Hemoglobin/hematocrit, blood type, Rh factor, rubella titer, cystic fibrosis screening, hCG levels, Hep B surface antigen, Sickle Cell prep test, HIV, history of vaccinations, check for STI’s, Varicella (or history of chicken pox), and Tay Sach’s screen. • A urine sample will also be taken to check for proteins and glucose in urine.

Betty asks how often she should come to the office, and if her eating habits should be altered. Which advice can you give to Betty?

• Betty should visit the clinic once a month for the first seven months, every two weeks during the eighth month, and once a week for the ninth month. • She should start taking a prenatal vitamin. During the first trimester her caloric needs will be roughly the same as before. During the second trimester she should increase her calories by 340/day and during the third trimester by 452/day. She should also increase her intake of dietary protein, folic acid, and iron. She should eat lots of fresh fruits and vegetables but avoid lunchmeats, undercooked/raw meat, and most shellfish. She should drink 2-3 liters of fluid daily, but limit her caffeine intake to less than 3 cups/day (less than 300mg/day). She should consume 1,000mg/day of calcium.

Betty also conveys that she is an athlete, and does not want to give up her daily workouts. What are the guidelines for exercise during pregnancy?

• Encourage Betty to continue about 30 minutes a day of moderate exercise. Activities that are preferred are: walking, running, racket sports and dancing. Excessive or strenuous exercise should be avoided due to the potential for hormonal imbalances. Exercise should be split into 15 minute increments with 10 minute rest periods in between.

List any other appropriate prenatal teaching for the initial prenatal appointment.

• Education on lifestyle practices, health and nutrition, and growth/development of the fetus • Warning signs you should report to your obstetrician • Avoid taking any medication (OTC, prescription, and “health” supplements) without obstetrician’s consent • Avoid alcohol, tobacco, and other drugs • Avoid hot tubs and saunas • Encourage the flu vaccine during fall months

Betty is here for her prenatal visit. She is 21 weeks pregnant, and thinks that she felt fetal movement last night. Her husband thinks it is too early, and she probably just felt gas. What can you tell Betty about fetal movement?

• Fetal movement can be felt between 18-22 weeks, so it could have been the fetus she felt.

What is the term for fetal movement?

• The term for fetal movements is quickening.

Now Betty’s exam begins. She is 24 weeks, and her uterus if measuring 28 cm. What does the nurse suspect?

• First, have Betty empty her bladder and re-measure. If the measurement is still not equal to weeks of gestation, this could be the result of gestational diabetes mellitus, which may cause hydramnios and macrosomia. It is important to begin glucose testing on Betty to assess whether she does have gestational diabetes mellitus so that proper management can begin. An increased measurement could also indicate the presence of more than one fetus.

Betty is sent for her glucose test. The results indicate that Betty needs further testing. Which test is used to detect gestational diabetes, and what are the parameters? Please give Betty instructions for the morning of the test.

• 3 hour Oral Glucose Tolerance Test (OGTT)

• Explain to Betty that before the test she cannot eat or drink anything after midnight. She must also avoid caffeine and smoking for 12 hours. She will need to drink 100 grams of oral glucose. Her blood will be drawn before she consumes the glucose, one hour after she drinks the glucose, again at two hours, and again three hours.

OGTT with 100 gram oral glucose load
|Time |Glucose Level |
|Fasting |95 mg/dL target |
|1 Hour |180 mg/dL target |
|2 Hours |155 mg/dL target |
|3 Hours |140 mg/dL target |

Just as we suspected, Betty has gestational diabetes. The nurse provides her with some educational information, and makes an appt. for her to meet with the diabetes educator. Betty is tearful, and states that she does not want to take insulin. What is the best nursing response?

• Most women that have gestational diabetes do not require insulin because use of diet and exercise are often enough to control blood glucose. However, if diet and exercise is not enough then insulin is necessary to ensure the health and wellbeing of Betty and her unborn child.

Betty has done well with the gestational diabetes. She is compliant with her diet and follow-up appts. She presents this morning at 31 weeks, and you notice that she is wearing “flip-flops” and no jewelry. She states that she cannot wear her wedding ring anymore, despite her healthy diet, she is so swollen. Betty’s BP is 149/99. What is the best nursing intervention?

• Initiate a urine dip stick to evaluate protein in Betty’s urine. Her signs indicate that she may have preeclampsia, but proteinuria of at least 2+ is required for a positive diagnosis. Once a definitive diagnosis is made then treatment can proceed. • The provider needs to be notified and fetal heart rate should be assessed.

Betty’s urine shows 2+ protein. Betty is sent to the hospital for a non-stress test, and 24- hour urinanalysis. What are the parameters for these tests?

NST: • Reactive: FHR is a normal baseline rate with moderate variability, accelerates to 15 beats/minute for at least 15 seconds and occurs two or more times during a 20 minute period • Nonreactive: FHR does not accelerate adequately with fetal movement. It does not meet the above criteria after 40 minutes.

24 hour urine analysis:

• Normal protein levels: