ANTEPARTUM COMPLICATIONS Flashcards
ANTENATAL COMPLICATIONS
STD?TORCH/BV in pregnancy ectopic pregnancy -hyperemesis gravidarum cervical insufficiency spontaneous abortion diabetes in preganacy hypertension in pregnancy pre elampsia and eclampsia
INFECTIONS OF PREGNANCY
T-toxoplasmosis O- other like hepatitis R- rubella C- CMV H- herpes simplex
HERPES SIMPLEX VIRUS
- 1 in 6 americans infected
- HSV-1 or HSV2 with type 2 causing more outbreaks
- following primary infection clearing, viral shedding continues for up to 3 months ,subsequent outbreaks vary thereafter
- 50% risk of fetal transmission with presence of lesion and primary infection
- 60-90% of infections are truly asymptomatic or unrecognized
DIAGNOSIS
- viral culture is primary test in most clinics
- confirmed diagnosis by PCR
- lesions begin as small macules that progress to vesicles on an erythematous base that eventually ulcerate, very painful
TREATMENT OF NEW ONSET HSV
- acyclovir or a similar antiviral agent
- hygiene measures to avoid secondary infection
- pain management with lidocaine based topical if needed
- diet rich in B vitamins, vitamin C, zinc, and calcium (boosts immunity)
-education and emotional support -greatest risk for transmitting to newborn occurs when mother gets infected in third trimester
TREATMENT OF HSV
- acyclovir reduces length of time of outbreak and severity and asymptomatic viral shedding . use as suppressive to reduce transmission and @ 36wks gestation to protect fetus
- if no lesion visible and on suppressive can safely deliver vaginally
- teach clients about AVS
- condoms reduce spread, but are not full proof
- HSV most important STD in enhancing HIV transmission
- psychological support need to empower client
EFFECTS ON NEONATE (HSV)
- infant may be asymptomatic at birth but 2-12 days later may develop fever or hypothermia ,jaundice, seizures and poor feeding and half develop vesicular lesions
- herpes encephalitis untreated is fatal
- anti viral medications tremendously helpful
- best treatment is primary prevention. treat mom when symptoms present and consider C/S . acyclovir does not appear to harm fetus but best avoided in 1st trimester
HERPES NURSING DIAGNOSIS
- pain r/t lesions secondary to HSV
- sexual dysfunction
prenatal visits include assessing for history of HSV in woman and partner
THE FOLLWING CAN LEAD TO PRETERM BIRTH
- syphilis
- HIV
- chlamydia: fastest spreading std in US women 1in 20 girls between 14-19 has had it
- bacteria vaginosis: BV techinically isn’t an STD ,irritates the uterus
EFFECTS OF SYPHILIS ON PREGNANT WOMEN
- 25% will have stillbirth or neonatal death
- 40-70% will have syphilis infected babies if untreated
- can transplacentally be transmitted
- if they survive, many of these babies have long term health problems even with aggressive therapy
NURSING CARE OF THE PREGNANT PATIENT WITH SYPHILIS
- screen all patients at first visit and later -VDLR, or RPR
- treat pregnant women with parental penicillin G and if allergic to penicillin try to desensitize if this isn’t possible can give erythromycin or azithromycin
- assess newborns for symptoms
BABIES WITH CONGENOTAL SYPHILIS
- can have symptoms at birth or symptoms may take weeks to develop
- anemia,fever, rashes and skin sores, mist sores or congenital syphilis are infectious, liver and spleen and various deformities
- the rise in infant syphilis morbidity is a public health concern
HIV AND AIDS IN CHILDBEARING POPULATION
- at the end of 2012 an estimated 1.2 million persons aged 13 and older were living with HIV infection in the US .including 156,300 persons who had not been diagnosed
- incidence of HIV in US obstetric population 1/1000
- 90% of pediatric cases r/t perinatal transmission
- sero-conversion to HIV is 6-12 weeks after exposure
- use antiretrovirals before ,during and after labor
FACTORS THAT INCREASE VIRAL TRANSMISSION
- previous child with HIV
- preterm birth
- decreased maternal CD4 counts
- first born twin
- SVD (vaginal delivery)
- chorioamionitis
- intrapartum blood exp.
- failure to treat mom and fetus/newborn during perinatal period with zidovudine (AZT) aka (ADV)
CASE MANAGEMENT hiv
- screen all women , if a woman is treated for HIV early in preganacy the risk of transmitting HIV to her baby can be 1% or less
- test HIV positive women for other STDs , CMV and toxoplasmosis and offer PPD
- check varicells and rubella titers
- PAP
- all positive patients receive AZT throughout preganacy regardless of CD4 counts , watch for BM depression
- CD4 counts <200 get PCP prophylaxis
- immunize against Hep B, HIB, PCV , Flu
CASE MANAGEMENT HIV
-consider social ,cultural and spiritual needs of the mother and confidentiality
- a disproportionate number of women are minoritiea
- identify family strengths and capiltalize on them
- teaching includes safe sex throughout pregnancy
- while preganacy is discouraged in HIV positive women, provide a hopeful milieu if the patient is pregnant
CASE MANAGEMENT HIV
- support for immune system by discussing importance of rest, diet ,activity and stress reduction
- treatment and teaching for substance abuse
- deliver within 4hrs of ruotures mambranes
- a c section if viral load high
- avoid vacuum and forceps
- watch for postpartum bleeding and infection
- avoid breast feeding
- avoid internal fetal monitoring
BACTERIAL VAGINOSIS
- THE WHIFF TEST
- FISHY SMELL
- VERY COMMON IN PREGNANCY
- INTERRUPTION OF NORMAL VAGINAL BACTERIAL FLORA
- TREAT AS IT CAN LEAD TO PRETERM LABOR ,PROM OR CHORIOAMNIONITIS
- TREATED WITH FLAGYL
SYMPTOMS OF BV AND TREATMENT
- although more than 50% of women with BV have no symptoms, when they do occur they include :
- excessive ,thin gray or white vaginal discharge that sticks to the vaginal walls
- fishy or musty smell most noticeable after sexual intercourse
- vaginal itching and irritation
- flagyl used to treat, no breast feeding allowed , or metronidazole or clindamycin
ETOPIC PREGNANCY
-fertilized ovum implants outside uterine cavity
RISK FACTORS
- pid
- prior ep
- tubal surgery
- IUD
- endometreiosis
- assisted reproduction
SYMPTOMS
missed period adenexal tenderness variable abdominal pain vaginal bleeding and or shock Cullen's sign shoulder pain in some
Lab tests
low progesterone and HCG levels transvaginal ultrasound
etopic pregnancy management
-MANAGE SYMPTOMS
pain,bleeding and emotional support
MEDICAL TREATMENT
-requires pt to be healthy with an unruptured <4cm pregnancy and absence of FHR. Methotrexate drug of choice
SURGICAL
-to spare tube salpingotomy or removal of tube
check RH status of patient
HYPEREMESIS GRAVIDARUM = HG
- uncontrolled vomiting
- cause unknonwn
- start management through medical ,social and OB/GYN history and PE
MANAGEMENT OF HG
- for sig dehydration ,hospitalize with IV fluids
- pyridoxine (B6) and doxylamine first line agents
- metoclopramide and odansetron if above ineffective Phenergan
- diet: low fat,high protein , bland 5-6 small meals
- chamomile tea,ginger ale,crackers and peanut butter
- try to avoid corticosteroids
- parenteral nutrition
- conseling and support
CERVICAL INSUFFIECENCY
- painless dilation of the cervix without contractions that can lead to pregnancy loss in 2nd trimester
- can be related to congenital factorsor acquired factors like cervical trauma ,inflammation or surgical damage
- assessing cervical length using ultrasound helpful for women with shorter cervises , cerclage has not been effective in preventing preterm birth
TREATMENT FOR CERVICAL INSUFFEINCEY
- CERCLAGE PLACED AT 11-15WKS
- CONTINUE BEDREST
- ORAL TOCOLYTICS IF NEEDED
- MONITORING
- HYDRATION
- REPORT TO HOSPITAL IS CONTRACTIONS <5 MIN APART ,sroM,OR URGE TO PUSH
SPONTANEOUS ABORTION
miscarriage= spontaneous abortion <20wks
-90% occur before 8wks and may be r/t fetal anonmalies, endocrine disturbances,infections including chlamydia and systemic disorders
CAUSES OF VAGINAL BLEEDING
1st trimester =miscarriage
2nd and 3rd trimester= placental issue, placenta location
PATIENT CARE FOLLOWING SPONTANEOUS ABORTION
threatended=bed rest
inevitable/incomplete=D&C with pre-post op care late miscarriages may require prostaglnadins and oxytocin to prevent hemorrhage
- shower for 2 weeks
- introduce nothing into vagina until bleeding stops
- diet high in protein and FE and plenty of rest
- notify MD if foul smelling discharge ,fever or fatigue persists
- avoid becoming pregnant for at least 2months
- provide emotional support and spiritual care
EXPECTED OUTCOMES FOLLOWING A SPONTANEOUS ABORTION
- pt does not develop excessive bleeding or infection
- verbalizes relief from pain
- identify and utilize support systems
- mother and family can discuss impact of loss o their lives
PRECONCEPTION COUNSELING
- for women with pregestational diabetes there is an increased risk of spontaneous abortion and birth defects directly related to glucose control at conception and during fetal development
- preconceptual counseling and diabetes control and management improve pregnancy outcomes
- increased thrombolytic events with metformin
MATERNAL COMPLICATIONS OF GDM
macrosomia- >4,000gm birth weight , 4500= c-section
HTN and preeclampsia- rates increased
HYdramnios= up to 2L extra fluid,
Infection=rates higher UTI and yeast and result in higher insulin resistance and ketoacidosis
ketoacidosis=r/t diabetogenic effects of pregnancy less than 200 pregnancy
retinopathy- women with type 1
FETAL AND NEONATAL COMPLICATIONS GDM
stillbirth- after 36wks r/t poor maternal glucose control
congenital anomaly rates of 5-10% per pregnancy with cardiac ,CNS and skeletal most common for pregestational diabetes
macrosomia leads to delivery complications
increased risk for respiratory distress
neonatal hypoglycemia ,electrolyte imbalances hyperbulirubinemia and polycythemia
DIABETES IN PREGNANCY
1ST TRIMESTER- insulin needs may drop due to decreased maternal food intake
2ND TRIMESTER - insulin needs begin to rise as human placental lactogen rises and causes maternal insulin resistance
3RD TRIMESTER- insulin needs may double or more due to increasing insulin resistance
AFTER DELIVERY- insulin needs drop abruptly and initially may be less than pregregnancy needs
insulin during labor
SCREENING FOR GDM
- screen for low risk patients at 24-28 weeks with 1hr 50gram glucose test
- is value >130-140mg/dl ,proceed to diagnostic 3hr 100gram glucose tolerance test
- if two or more values on GTT are elevated, GDM is diagnosed
TREATMENT FOR DIABETES
maintain FBS <95
maintain 2hr post prandial value <120mg/dl
self blood glucose monitoring FBS and 2hrs post-prandial
dietary:
- American diabetic association mealplan appropriate for pregnancy and diabetes ,with avoidance of concentrated CHO
-CHO counting id pt on intensive insulin regimen
MEDS DURING PREGNANCY
GDM AND TYPE 2: glyburide may be used to control maternal blood glucose
GDM,TYPE 2: insulin may be needed to control blood glucose
TYPE 1: insulin required
HYPERTENSION MEDICATIONS
LABETALOL: avoid if patient has hx of asthma
NIFEDIPINE: useful in treating preterm labor also
METHYLDOPA: “aldomet” and old standard
used when systolic >150-160 and diastolic BP>100
