2 Discussion replies to peers

1.Case

Scenario

1

Table1

StandardlevelofHCGduring pregnancy.

GA weeks	HCG level
3 weeks LMP	5 – 50 mIU/mL (Forbes, 2024).
4 weeks LMP	5 – 426 mIU/mL (Forbes, 2024).
5 weeks LMP	18 – 7,340 mIU/mL (Forbes, 2024).
6 weeks LMP	1,080 – 56,500 mIU/mL (Forbes, 2024).
7-8 weeks LMP	7,650 – 229,000 mIU/mL (Forbes, 2024).
9-12 weeks LMP	25,700 – 288,000 mIU/mL (Forbes, 2024).
13-16 weeks LMP	13,300 – 254,000 mIU/mL (Forbes, 2024).
17-24 weeks LMP	4,060 – 165,400 mIU/mL (Forbes, 2024).
25-40 weeks LMP	3,640 – 117,00 mIU/mL (Forbes, 2024).
Non pregnant	less than 5 mIU/mL (Forbes, 2024).

Table 2

Scenario

A normal ongoing pregnancy, the expectation for the beta HCG level is to 35% (hint: increase by how much) within 48-72 hours (Grunbaum, 2021).

During a spontaneous abortion (miscarriage), the expectation for the beta HCG level is to 49% (hint: decrease by how much) within 48-72 hour (Alves, 2019).

During an ectopic pregnancy, the expectation for the beta HCG level is more than 15% within 48-72 hour (Josie, 2024).

During a gestational trophoblastic pregnancy, the expectation for the beta HCG level is to 46% within 48-72 hour (GoldStein, 2019).

Table 3

Common complaints during pregnancy.

Keep in mind these symptoms are during pregnancy, make sure the cause, presentation, and treatment is related to pregnancy status of the patient.

Definition and Cause	Presentation (include possible DDX)	Treatment	Education
Constipation	This is due to pregnancy predisposes women to constipation due to the rise in progesterone and delayed gastric motility (Jordan, 2018).	Difficult and painful defecation, hard stools, and feeling of incomplete evacuation (Jordan, 2018).	Adequate hydration, exercise routinely, fiber supplements such as Metamucil and a stool softener such as Colace (Jordan, 2018).	“The majority of cases are simple constipation that occurs due to a combination of hormonal, dietary, and mechanical factors affecting normal gastrointestinal (GI) function” (Jordan 2018).
Back pain	Influence of progesterone and relaxin which soften connective tissue including the ligaments and joints (Jordan, 2018).	“Lower backache is attributed to the lumbar lordosis required to counterbalance the weight of the growing uterus. Upper backache is caused by increasing weight of the breasts, postural factors, and employment requiring extended sitting” (Jordan, 2018).	Acetaminophen, pelvic floor exercises, and pelvic tilt exercises (Jordan, 2018).	Some factors that may cause lower back pain in pregnancy are occupation, heavy lifting, constant standing (Jordan, 2018).
GERD	Increased estrogen and progesterone cause the LES to relax which allows acid from stomach to flow back up The second reason is because when the uterus grows it crowds the stomach and intestines which causes the stomach and acid to back up into the esophagus (Jordan, 2018).	Heartburn and acid reflux by eating spicy foods, drinking coffee, and eating too quickly (Jordan, 2018).	Avoid a large meal before bedtime, avoid caffeine, and encourage smaller meals. OTC medications, Antacids, and lastly, histamine 2‐receptor antagonists like ranitidine (Zantac) (Jordan 2018).	Serious reflux complications are uncommon in pregnancy (Jordan, 2018).
Fatigue	This is due to the increase of progesterone (Jordan, 2018).	Decrease of energy and/or motivation, insomnia, and a feeling of sadness, heaviness, or apathy (Jordan, 2018).	Daytime nap, adequate nighttime sleep, 30 minutes of daily exercise, and adequate protein intake (Jordan, 2018).	“Fatigue onset corresponding to 5–7 weeks’ gestation is the most significant clue as to the normal common discomfort of pregnancy or pathology.” (Jordan, 2018).
Heart palpitations	Increased blood volume and heart rate during pregnancy (Jordan, 2018).	Palpitations or ectopic beats are most commonly seen between 28 and 32 weeks’ gestation. Sinus tachycardia is seen in the third trimester due to the physiological increase in heart rate (Jordan, 2018).	“If the perception of palpitations is accompanied by dizziness, shortness of breath, or the woman has a history of cardiac problems, it is appropriate to have her evaluated by an obstetric or cardiac consultant immediately“ (Jordan, 2018).	Heart palpitations can be perceived as a pause in the regular heartbeat, followed by rapid palpitations. This symptom is often very concerning for the woman experiencing this (Jordan, 2018).
Urinary frequency	This is due to the uterus grows, it may press on the bladder causing a sensation of bladder fullness and the urge to urinate (Jordan, 2018).	The fetal head descends into the pelvis (Jordan, 2018)	“Voiding soon after feeling the urge, urinate 2–3 hours, urinating before and after intercourse, and reducing fluid intake in the later evening hours” (Jordan, 2018).	Urinary frequency tends to reoocur during the 3rdtrimester (Jordan, 2018).
Nausea and Vomiting	Increased levels of progesterone causing delayed gastric emptying (Jordan, 2018).	Typically starts around the sixth week of gestation, peaks at 9–11 weeks’ gestation, and tends to subside by 12–14 weeks’ gestation (Jordan, 2018).	Small frequency of meal, sip clear carbonated liquids, decrease dietary fats, avoid spicy foods, Benadryl, Compazine, Dramamine, Reglan, Zofran (Jordan, 2018).	Prescription pharmacologic measures are considered for women who report continuous, more severe Nausea and Vomiting (Jordan, 2018).
Round ligament pain	As the uterus expands in size and increases in weight, these ligaments are stretched like rubber bands (Jordan, 2018).	Shooting pain after a sudden movement or sharp, knifelike pain in the lower abdomen or on one side, typically the right side, extending into the groin area (Jordan, 2018).	Avoid sudden movement from sitting to standing, arise slowly from bed in the morning, and support the uterus with a pillow under the abdomen (Jordan, 2018).	“Round ligament pain can mimic symptoms of ectopic pregnancy, preterm labor, threatened abortion, and appendicitis” (Jordan, 2018).
Hyperpigmentation	Hyperpigmentation tends to decrease after birth, the nipples, areola, and genital areas do not usually return to their pre‐pregnant pigmentation (Jordan, 2018).	The areola, nipples, and genitalia also the axilla, inner thighs, and periumbilical (Jordan, 2018).	Topical treatments containing vitamin C or azelaic acid are helpful to lighten the patches	“Breast skin changes are seen on the areola with the development of a line of pigmentation surrounding the areola” (Jordan, 2018).
Sleep disturbance	Nighttime waking, insomnia, daytime fatigue, restless legs, and difficulty maintaining a comfortable sleep (Jordan, 2018).	The first trimester which suggests that sleep needs may increase in early pregnancy. The third trimester is characterized by a decrease in sleep time (Jordan, 2018).	The most common nonprescription medications that can help with sleep in pregnancy are antihistamines such as Benadryl, and Unisom, and melatonin.	Fresh air, relaxation, cutting caffeine, and eating healthy might improve sleep

Tonia is an 18-year-old female who presents to your office complaining of two months of amenorrhea. Her pregnancy test is positive and her LMP indicates she is 5.6 weeks EGA. She reports she has had some bleeding for the past 3 days, that started as spotting, but has continued to be a light period- like bleeding today. She denies any pain. She indicates plans to continue the pregnancy.

Subjective:

Chief Complaint: 2 mo amenorrhea, + pregnancy, LMP 5.6 weeks and has had some bleeding for the past 3 days.

HPI: 18 year-old female presents to the clinic for 2 mo/ amenorrhea. Patient stated that LMP was 5.6 weeks ago and is currently expecting. She is concerned about bleeding for the past 3 days that started as spotting and now has progressed to a light period. Denies pain, fever, cramps.

PMH: Iron-Deficiency Anemia

• Past Surgical Hx

: Wisdom Teeth Extraction (Dental)

• Allergies

: Flagyl

• Family Hx

:

Mother, 40, Alive, Lupus

Father

, 45, Alive, Anemia

Brother, 15, Alive

Maternal

Grandmother

, 80, Alive, Diabetes

Maternal

Grandfather

, 83, Deceased, Brain Cancer

Paternal Grandmother, 85, Deceased, Heart Attack

Paternal Grandfather, 99, Deceased, Failure to Thrive

Social Hx:

Occupation, Social Worker

Alcohol, Does not drink

Substance Abuse, No hx of substance abuse

Sexual Hx: One male sexual partner

Are you having any fatigue? Are you having any fever? Are you having cramping? Are you having any pain? Have many partners have you been with sexually? Have you ever been pregnant? Do you have a support system? Do you feel safe at home? Have you received a pap smear? When did you become sexually active? Do you use condoms? Are you on birth control? Are you planning on keeping the baby when continuing the pregnancy? Would you like to learn about prenatal care?

ROS:

General:

Alert and Oriented x4, speaks clearly and comfortably throughout.

BREAST: normal breast exam, Breasts, BL: no abnormalities, (-) erythema, (-) symmetric at rest, (-) symmetric with pectoral tension, (-) tender to palpation

Nipples, BL: no abnormalities, (-) discharge without pressure, (-) expressed discharge, (-) clear discharge, (-) bloody discharge, (-) purulent discharge, (-) bruising, (-) areolar bleeding

Axillae BL: no abnormalities, (-) mass, (-) tender to palpation, (-) erythema, (-)pectoral lymphadenopathy, (-)subscapular lymphadenopathy, (-)brachial lymphadenopathy, (-) acanthosis nigricans

RESP: lungs clear to auscultation bilaterally, no rales, wheezes or rhonchi, nonlabored breathing, no use of accessory of muscles of respiration.

CV: RRR, no m/r/g

GI: +BS, nontender to palpation, no masses, no HSM

GU/RECTAL: external genitalia NL appearance,

Urethral meatus: (-)lesions, (-) erythematous, (-)discharge, (-)tender

Bladder: normal, (-)tender, (-)cystocele

Vagina: NL appearance, NL pelvic support, (-)burning (-)discharge, (-)lesions, (-) fluid-filled vesicles

Cervix: moderate cervicitis, (-)lesions, (-)discharge, (+) bleeding, (+) spotting

Uterus: no abnormalities, NL position, NL mobility, (-)enlarged, (-)tender,

Adnexae, BL: no abnormalities, (-)tender, (-)masses, (-)enlarged,

Anus/rectum: no abnormalities, NL tone, (-)perianal lesions, (-)external hemorrhoids,

Rectal exam deferred: not indicated

DERM: skin warm and dry

Patient is not up to date on immunizations

Objective:

VS: BP: 110/72, HR:74, RR: 18, Temp: 98.3,O2 Sat: 97%, HT 62 inches WT: 130lb

General:

• General: Alert and Oriented x4, speaks clearly and comfortably throughout.

BREAST: normal breast exam, Breasts, BL: no abnormalities, (-) erythema, (-) symmetric at rest, (-) symmetric with pectoral tension, (-) tender to palpationNipples, BL: no abnormalities, (-) discharge without pressure, (-) expressed discharge, (-) clear discharge, (-) bloody discharge, (-) purulent discharge, (-) bruising, (-) areolar bleeding

• Axillae BL: no abnormalities, (-) mass, (-) tender to palpation, (-) erythema, (-) pectoral lymphadenopathy, (-) subscapular lymphadenopathy, (-)brachial lymphadenopathy, (-) acanthosis nigricans

RESP: lungs clear to auscultation bilaterally, no rales, wheezes or rhonchi, nonlabored breathing, no use of accessory of muscles of respiration.CV: RRR, no m/r/gGI: +BS, nontender to palpation, no masses, no HSMGU/RECTAL: external genitalia NL appearance,Urethral meatus: (-)lesions, (-) erythematous, (-)discharge, (-)tenderBladder: normal, (-)tender, (-)cystocele

• Vagina: NL appearance, NL pelvic support, (-)burning, (-)discharge, (-)lesions, (+) fluid filled vesicles

Cervix: moderate cervicitis, (-)lesions, (-)discharge, (+) bleeding, (+) spottingUterus: no abnormalities, NL position, NL mobility, (-)enlarged, (-)tender,Adnexae, BL: no abnormalities, (-)tender, (-)masses, (-)enlarged,Anus/rectum: no abnormalities, NL tone, (-)perianal lesions, (-)external hemorrhoids,

• Rectal exam deferred: not indicated

DERM: skin warm and dry

Assessment: (listed below)

Diff Dx:

O26.851 Spotting complicating pregnancy

The pertinent positives includes a light period for 3 days, spotting

The pertinent negatives includes dizziness, fainting, fever, and trouble breathing.

O00.9 Ectopic pregnancy

The pertinent positives includes light vaginal bleeding

The pertinent negatives includes pelvic pain and the most common gestational stage is 6 to 10 weeks (Cleveland Clinic, 2024).

Final Diagnosis:

Assume you ordered an HCG today and the result was 1200. She returns to the clinic in 2 days and her HCG results is 550.

O03. 9 Unspecified spontaneous abortion

The pertinent positives includes spotting to a light period for 3 days

The pertinent negatives includes cramping, discharge, pain around the pelvic area or back, and fast heartbeat (Mayo Clinic, 2024).

Tonia’s HCG levels are dropping fast as they are supposed to be at 18 – 7,340 mIU/mL (Forbes, 2024) 5 weeks from her LMP.

Plan: (listed below)

Dx Plan:

Pregnancy test – positive – confirm pregnancy

HCG levels – 1200 and now is 550 and dropping will recheck again in 48 hours

Ultrasound

– positive – faint – will recheck in two weeks

Pap Smear – No Abnormal findings

STD Panel – No abnormal findings

Treatment Plan: Discuss all options with Tonia. There are two nonsurgical treatments which are letting the tissue pass on its own and medication. “The NICE guidelines recommend that you are given mifepristone first and another medication called misoprostol 48 hours later” (NICE, 2019). Recheck HCG levels in another 48 hours to determine plan. The surgical intervention is a D&C. Use pads to manage bleeding, rest, the bleeding is likely to taper off within a week. If having pain take, paracetamol. Emotional treatment will help such as

www.mend.orgLinks to an external site.

(CDC, 2024).

Education: In early pregnancy one might get some light bleeding called spotting and this is from the developing embryo planting itself on the wall of the womb (NHS, 2024). HCG levels should double within 48 hours of pregnancy from weeks 4 to 6. Since the HCG levels are trending downward this can be an indication of pregnancy loss. There is no cure for the HCG levels dropping. A healthy baby might still result, but it does not look promising seeing as HCG levels dropped in half within 2 days. Notify your partner to tell them and for support. Most of the tissue passes within 2 to 4 hours after the cramping and bleeding start. This can go on for 4 to 6 weeks. An OB will do an ultrasound to make sure that all the tissue passes. It is important to discuss that a miscarriage is not anyone’s fault. If no complications such as heavy bleeding or pelvic pain after a miscarriage you can resume sexual activity in 2 to 3 weeks from the miscarriage. Your menstrual cycle should start back up within 4 to 6 weeks and recovery should take you about 1 to 2 months, but all bodies are different. Birth control pills ca be started right away after a miscarriage or within the first 7 days (CDC, 2024). You can ovulate and become pregnant two weeks after a miscarriage if wanting to try again for a baby, if emotionally and physically ready. Since sexually active it is important to receive a pap smear for cervical cancer screening. A pap smear is also needed to test for any type of STI’s.

• Referral/Follow-up:

Follow up HCG levels drawn from a labcorp within 48 hours after visit to determine HCG levels. If bleeding persists after a week or developing a fever. Otherwise appointment in 2 weeks for f/u US to make sure the tissue has passed.

Recommend an annual physical exam and pap smear every three years.

2. Case Study #2

Tables 1

GA by weeks

Lab Testing and/or Diagnostic Testing

Medication

Expectations

6-10 weeks

NT test

Serum Markers

Pelvic exam

Ultrasound (dating/transvaginal)

Cervical length measurement

Genetic carrier screening

Infectious disease screen (

Rubella immunity

, syphilis,

HIV

)

Urine test

PAP

Prenatal

Folic Acid

Iron (If Iron deficiency anemia)

Vitamin D

Anti-Nausea med

Progesterone

Thyroid

(if thyroid disorder)

Heartbeat

detection

N/V

Fatigue + increased sleep

Breast tenderness/change in size

Frequent urination

Mood Swings

Slight weight gain

Routine prenatal care

Ultrasounds

Diet Nutrition changes

Precautions (avoiding strenuous activities/substances)

10-14 weeks

NT ultrasound

Blood tests (Chromosomal abnormalities)

CfDNA

CVS

Blood type + RH factor

Routine blood (cbc)

Urinalysis

Thyroid function

tests

Ultrasound

Cystic Fibrosis carrier screening

Tylenol (pain relief)

PrenatalFolic AcidIron (If Iron deficiency anemia)Vitamin DAnti-Nausea med

Progesterone

Thyroid (if thyroid disorder)

“Baby bump”

Reduced morning sickness

Increased energy

Weight gain

Development of fetal organs

Increased appetite

Decreased urination

Increase blood volume

Emotion change

15-20 weeks

MSAFP

Triple or Quad screen

Amniocentesis (offered) for high risk pts of chromosomal abnormalities

Anatomy scan (18-20 weeks)

RH Antibody

Glucose challenge

Thyroid function

BP monitor

ing

Cystic Fibrosis carrier check

Urinalysis

GDM medications (if diagnosed)

Tylenol (pain relief)PrenatalFolic AcidIron (If Iron deficiency anemia)

Vitamin D/Calcium

Anti-Nausea med

Progesterone

Thyroid (if thyroid disorder)

Fetal bump

Weight gain

Visible change on

U/S

Gender

Breast change (enlarge)

Skin changing

Heartbeat

Maternity clothing

Prenatal classes start

20- 24 weeks

Routine blood test

Gestational diabetes screen

RH antibody

BP monitoring

U/S

Fetal Kick counts

Iron levels

Thyroid functionUrinalysis

Antibiotics (if bacterial infection)

GDM medications (if diagnosed)Tylenol (pain relief)PrenatalFolic AcidIron (If Iron deficiency anemia)Vitamin D/CalciumAnti-Nausea med

Progesterone

Thyroid (if thyroid disorder)

Increased fetal movement

Larger baby bump

Weight gain

Continue skin change

Back pain/ligament

Breast changes

Increase for hunger

Urinary frequency

24-28 weeks

Gestational diabetes screen

RH antibody (if indicated)

Anemia screen

ing

BP monitorU/S

Fetal kick counts

ThyroidUrinalysis

Rhogam (if indicated)

Antibiotics (if bacterial infection)GDM medications (if diagnosed)Tylenol (pain relief)PrenatalFolic AcidIron (If Iron deficiency anemia)Vitamin D/CalciumAnti-Nausea med

Progesterone

Thyroid (if thyroid disorder)

Increased baby bump

Baby movement patterns

Braxton Hicks

Breathing changes

Weight gain

Back Pain

Increased blood volume

Stretch marks

Sleep changing

Nesting

Pelvic Pressure

28-32 weeks

Rh antibody (if indicated)

Anemia Screen

BP monitor

GBS

Fetal kick countsU/S

NST

Thyroid functionUrinalysis

Rhogam (If indicated)

BP medications (gestational hypertension)

Corticosteroids (if indicated)

Antibiotics (if bacterial infection)GDM medications (if diagnosed)Tylenol (pain relief)PrenatalFolic AcidIron (If Iron deficiency anemia)Vitamin D/CalciumAnti-Nausea med

Progesterone

Thyroid (if thyroid disorder) Increased baby bumpBaby movement patternsBreathing changesWeight gainBack Pain

Pelvic pressure

Swelling

Baby position

Nesting

34 weeks

Anemia screen

Rh antibody testing (if indicated)

BP monitoringFetal kick countsU/SNSTThyroid functionUrinalysis

BP medications (gestational hypertension)Corticosteroids (if indicated)Antibiotics (if bacterial infection)GDM medications (if diagnosed)Tylenol (pain relief)PrenatalFolic AcidIron (If Iron deficiency anemia)Vitamin D/CalciumAnti-Nausea med

Progesterone

Thyroid (if thyroid disorder)

Heartburn/indigestion

Sleep changes

Weight gain

Baby positioning

Swelling

Braxton HicksIncreased blood volumeBack painPelvic pressure

Fetal movement

36 weeks

Anemia screenRh antibody testing (if indicated)BP monitorFetal kick countsU/SNSTPelvic examThyroidUrinalysis

GBS (some doctors)

BP medications (gestational hypertension)Corticosteroids (if indicated)Antibiotics (if bacterial infection)GDM medications (if diagnosed)Tylenol (pain relief)PrenatalFolic AcidIron (If Iron deficiency anemia)Vitamin D/CalciumAnti-Nausea med

Progesterone

Thyroid (if thyroid disorder)

Lightning crotch

Pelvic pressureBraxton HicksBack pain

Increased urination

Gastrointestinal changes

Cervical changes

NestingSleep changes

37 weeks onwards

GBSAnemia screenRh antibody testing (if indicated)BP monitorFetal kick countsU/SNSTPelvic exam

BPP

Thyroid Function

UrinalysisBP medications (gestational hypertension)Corticosteroids (if indicated)Antibiotics (if bacterial infection)GDM medications (if diagnosed)Tylenol (pain relief)PrenatalFolic AcidIron (If Iron deficiency anemia)Vitamin D/CalciumAnti-Nausea med

Progesterone

Thyroid (if thyroid disorder)

Pelvic pain/pressure

Sleep changes

Emotional changes

Nesting instinct

Gastro changes

Weight gainCervical changes

Braxton hicks + True contractions

A hospital visit to go into labor!

(Alexander, 2017).

Table 2

Scenario

A normal ongoing pregnancy, the expectation for the beta HCG level is to double within 48-72 hours

During a spontaneous abortion (miscarriage), the expectation for the beta HCG level is to _Decrease by 50% (hint: decrease by how much) within 48-72 hour

During an ectopic pregnancy, the expectation for the beta HCG level is to _increase at a slower rate or decrease___ within 48-72 hour

During a molar pregnancy, the expectation for the beta HCG level is to __increase rapid/abnormally within 48-72 hour

Case Study:

Lisa is a 29-year-old female G3P2 at 28 weeks EGA who is coming to the clinic for her routine checkup. She is Rh negative. Her VS are normal and prenatal routine screenings are WNL. Lisa asks if it is normal to be experiencing frequency and mild burning when she urinates which she says has increased over the last 2 days. She has been drinking more water recently and thinks that maybe this is causing the urinary frequency.

SOAP Note

Demographic Data: 29-year-old Female

Subjective

• Chief Complaint (CC): “I have experienced frequency and mild burning when I urinate”

History of Present Illness (HPI): 29 y/o G3P2 female presents to the clinic this morning at 28 weeks gestation ℅ frequency and mild burning when urinating that has increased over the last two days.

O- When did you first start experiencing the frequency, and mild burning?

L- How often do you have frequency, and mild burning? How often are you using the bathroom? How many times during the night? Pt states it has increased over the last two days.

D- Is the frequency, and mild burning consistent?

C-Describe the amount of urine, and the characteristics (dark yellow, light yellow, ect)?

A- Do you experience any pain or discomfort associated with the frequency, and mild burning, any flank pain or back pain?

R- If yes, does anything relieve it, have you taken any OTC medications?

T- Have you noticed any changes including a fever?

What other relevant questions should you ask regarding the HPI?

Severity

1.How often are “accidents” occurring if any?

2.Do you leak urine when you cough, laugh, or sneeze?

3.Do you wear pads/protection while this is happening?

4.If yes, how many pads/day?

5.Does this problem interfere with your social life or work?

Infection, Malignancy

1.Do you have a history of bladder or kidney infections?

3.Have you ever had blood in your urine?

Voiding Dysfunction

1.Is the urine stream slow or intermittent?

2.Do you have to strain to get the urine out?

3.After urination, do you have dribbling or a sensation that your bladder is still full?

Urge/Detrusor Instability

1.Do you ever have an uncomfortable need to rush to the bathroom to urinate?

2.If yes, do you ever have an “accident” before you reach the toilet?

3.How many times during the day do you urinate?

7.Do you ever have leakage during intercourse?

(Alexander, 2017).

Past Med. Hx (PMH):

• Do you have any past medical history/conditions?
• Have you ever been hospitalized?

What other medical history questions should you ask?

Do you have a hx of previous urinary tract infections, especially during the current pregnancy? If so, when and what were you prescribed?

Have you had any recent illnesses or conditions that might compromise the immune system?

Inquire about recent sexual activity

Have there been any concerns or complications during the current pregnancy?

Have you noticed any fever or chills?

Have you noticed any lower back pain, in the mid back (kidney pain)?

• LMP: When was your last menstrual period?

Gyn/OB history:

1. What other OB history questions should you ask?

Can you share with me any past experiences you’ve had with OB/GYN care or any specific concerns you may have? Have you felt the baby moving as normal? Any past STIS/STDS? Are there any specific family planning or reproductive health goals you’d like to discuss now that you are pregnant again? Do you use any scented products to clean your genital area? What is your typical genital hygiene routine?

1. What important lab results should you review prior to 28 weeks?

Blood type + RH factor
• CBC
• Blood glucose levels

Rubella immunity

• Syphilis screen
• Heb B + C screening
• Genetic screening

Thyroid Function

• STI screen

Urinalysis

• Urine Culture

PAPHIV

• Cystic fibrosis carry
• Ultrasound and Nuchal Translucency Screening

Past Surgical Hx

• Have you had any surgeries in the past?

Family Hx

Do you have any family history of medical conditions? HTN, DM or any other cardiac/endocrine disease/cancer?

• Mother

Father

• Siblings

GrandmotherGrandfather

• Current Medications

Are you currently taking any medications or OTC supplements?

Are you taking a prenatal vitamin?

Are you taking your medications as instructed/prescribed?

Have you taken anything OTC for your symptoms you are complaining about today?

Allergies

Do you have any allergies?

• Immunizations History

Are you up to date on your immunizations?

Have you had the gardasil/HPV vaccine?

Covid vaccine?

Yearly flu vaccine?

Hep B?

Varicella?

MMR?

Tdap?- will be given today since pt is 28 weeks (27-36 weeks given approx).

Health Maintenance

-When was your last annual physical?

-When was your last Women’s wellness exam?

-When was your last PAP?

-When was your last eye exam ?

-When was your last dental visit ?

-Have you ever had a mental health examination?

-How is your diet? Do you exercise?

• Social History

How long have you been sexually active with this partner?

How many intimate partners have you had?

Do you engage in oral, vaginal, or anal contact?

Do you have sex with males, females, or both?

Do you engage in alcohol or drug use?

Do you smoke tobacco or use tobacco products? If so, how long? How many packs a day?

What is your current living situation?

Do you feel safe where you live?

What do you do for work?

Any anxiety/depression?

How is your support system?

Review of Systems (ROS)

• General: Do you have any malaise, fatigue and weakness? Any weight loss, fever & chills?

• HEENT: Any recent, visual disturbance, nasal congestion, or sore throat?

• Endocrine: Any history of diabetes or thyroid disorders?

• Lymphatic: Any swelling in your lymph nodes?

• Cardiovascular: Have you noticed any chest pain and discomfort? Any palpitation, edema, swelling of extremities or changes? Any history of heart attack or heart failure?

• Respiratory: Any cough, shortness of breath, swelling? Any phlegm production?

• Skin & Breasts: Have you noticed any rashes, itching, or abnormalities on your skin? Any recent injuries? Any breast pain, discharge?

GI: Have you had any recent N/V/D, constipation, or abdominal cramping or tenderness?

• Musculoskeletal: Any weakness or pain in your joints?

• Neuro: Have you had any recent headache, dizziness, or numbness/tingling in extremities?

• Immunologic: Any hx of HIV?

• Genitourinary/GYN: Pt reports dysuria, frequency and urgency on visit. Any hx of bladder/kidney stones/infections? Any abnormal or change in discharge?Any sexual dysfunction or concerns? How many days does a typical period last? How heavy is your flow? Do you have pain, cramps, or headaches with your period? At what age did you become sexually active? Do you have any pain with intercourse? What sort of birth control and protective measures do you use when not trying to conceive? Have you ever been diagnosed or had symptoms of an STI? Have you ever been tested for STIs? Have you ever used any contraceptive methods besides condoms?

Objective

5. Describe the appropriate physical assessment that needs to be included in this visit.

• Abdominal examination- looking for tenderness
• Pelvic examination/Cervical- looking for infection, swelling, discharge, overall appearance
• Vital signs- temperature increase can be infection
• Back pain assessment- CVA tenderness (UTI traveled)

Vital signs:

ALL WNL

General: Vital signs are stable, in no acute distress. Alert, well developed and well nourished.

• HEENT: Normocephalic, atraumatic, no abrasions or bruising present, PERRLA, sclera white, no discharge present, uvula & tongue midline, no exudates present, bilateral nares patent, bilateral ear canals clear w/cone of light visualized bilaterally, thyroid midline with no tenderness or nodules noted on exam.

• Cardiovascular: S1, S2 has regular rate/rhythm.

• Respiratory/ chest: unlabored breathing, equal chest rise and fall with equal bilateral breath sounds.

• Integumentary: No rashes or abnormal moles noted on visualized skin

• Lymphatic: lymph nodes not palpable or tender

• GI: soft, non-tender, non-distended. Bowel tones normoactive in all 4 quadrants

• Musculoskeletal: Full ROM in all extremities, stable gait pattern

• Neuro: Mood and affect intact.

• Genital/Rectal/Urinary/GYN: Pt complains of very minimal suprapubic tenderness. No bladder bulges. No lesions, rashes, masses of swelling, no flank pain noted (CVAT) performed- would need to perform a full pelvic exam in the clinic to ensure.

1. Explain what test(s) you will order and perform, and discuss your rationale for ordering and performing each test.

1. Urinalysis/Urine Culture- Testing for a UTI, determine the specific bacteria
2. Pelvic Exam- Pregnant women with UTIs may be at an increased risk of complications, including pyelonephritis- also looking at color/consistency of discharge, signs of inflammation and vaginal pH.
3. CBC/electrolytes and serum creatine- Looking to ensure no systemic infection or inflammation

• NAAT test- see if there is bacterial DNA associated with BV

Assessment (Diagnosis/ICD10 code)

7 +8. What is your diagnosis + differential diagnosis?

Differential DX:

• Bacterial vaginosis N77. 1

BV infection has been linked to miscarriage, chorioamnionitis, premature rupture of fetal membranes, preterm labor, and delivery. Women with BV can have no symptoms or have a malodorous discharge. Some may encounter mild irritation, vulvar pruritus, postcoital spotting, irregular bleeding episodes, or vaginal burning after intercourse, while others may report urinary discomfort. Testing for BV is recommended in the early second trimester (this patient) for symptomatic pregnant women at risk of preterm labor, and for high-risk women reporting increased vaginal discharge or preterm labor symptoms. The efficacy of BV treatment in asymptomatic pregnant women at high risk for preterm delivery has been assessed in various studies, yielding mixed results (Alexander, 2017).

(+) Burning while urinating

(-) Abnormal discharge

(-) Itching/irritation

(-) Fish-like odor

Working DX:

• Unspecified infection of urinary tract in pregnancy, unspecified trimester O23.40

Pregnancy induces urinary tract changes that make women more susceptible to infection. Ureteral dilation occurs as the gravid uterus compresses the ureters. Additionally, the hormonal effects of progesterone can induce smooth muscle relaxation, resulting in dilation and urinary stasis. The most frequently isolated organism is Escherichia coli. If left untreated, bacteriuria can elevate the risk of preterm delivery, low-birth-weight infants, and gestational hypertension (Alexander, 2017)

(+) Pain/burning during urination

(+) Urinary frequency

(+) Urinary urgency

(+) Cloudy Urine

(-) CVA tenderness

(-) Fever/chills

TX Plan (POCT):

1. Urinalysis and clean catch urine culture

Pelvic exam

Diagnosis is made based on symptoms and/or urinalysis with a culture for sensitivity. A urine specimen is obtained for a urine dip, and a positive nitrite and/or leukocyte reading is indicative of a UTI. A urinalysis will reveal pyuria and bacteriuria. Most clinicians will treat a pregnant patient with complaints of a UTI, whether or not the urine dip is suspicious for infection (Alexander, 2017). All patients should be screened for UTI, have their postvoid residual (PVR) measured, and have simple cystometric studies done (Alexander, 2017).

In clinic Testing to be sent out

1. Complete blood count (CBC), electrolytes and serum creatine.
2. NAAT test for BV

Treatment plan

1. What will you prescribe for this patient? Why? Explain what medications and treatments you would recommend. HINT: patient should be receiving at least 2 injectable medications at this visit plus oral medication

Nitrofurantoin 100 mg BID for 7 days

Treatment using a 3-day regimen is 90% effective in curing bacteriuria (book). Clinicians should treat acute cystitis in pregnant individuals with a 5–7-day course of a targeted antibiotic. If empiric therapy is started before culture and sensitivity results are available, amoxicillin or ampicillin regimens should be avoided due to high rates of resistance in Escherichia coli to these antibiotics in most areas (ACOG, 2022).

• Tdap- protects mother and baby from Pertussis

1. Rh(D) Immunoglobulin (RhIg) Injection – patient is RH negative, given about 28 weeks as a preventive measure to reduce the risk of Rh isoimmunization.

Explain treatment guidelines and side effects including any possible side effects of the medication and treatment(s), partner notification, and follow-up plan of care.

– See below

11.Explain complications that can occur if a patient does not comply with the treatment regimen.

-See below

Medication Education

-Take the medication exactly as prescribed by the healthcare provider.

-Follow the recommended dosage and schedule.

-Take with food

-Side effects: N/V and mild gastrointestinal symptoms.

-Finishing all antibiotics even if symptoms improve before they are finished can develop antibiotic resistance or not clear the entire infection and become a systemic/kidney infection.

• Pt. Education for DX:

• Drink lots of fluids
• Vitamin C and cranberry juice are recommended.
• Finish all antibiotics even if symptoms subside
• Stay out of hot tubs, pools, baths
• Loose fitting clothing
• Do not use douching
• Maintain good hygiene
• Keep a journal about symptoms
• OTC pain relievers
• Do not resume vaginal intercourse until symptoms have subsided and antibiotics are completed.
• Limit/avoid alcohol during antibiotics

Referral/Follow-up:

1. When should the patient return?

F/U in clinic within a week of completing the course of antibiotics. Symptom assessment, and urinalysis will be performed to ensure cleared infection. Will call with culture results.