Antepartum Complications Flashcards
TORCH
T: Toxoplasmosis O: other like hepatitis R: Rubella C: CMV H: Herpes Simplex
Symptoms of some infections may appear in mother as ____ and in baby as ____
flu-like, more serious
Herpes Simplex Virus
HSV
- 1 in 6 americans
- 1 and 2 with type 2 causing more outbreaks than 1
Following primary herpes infection clearing, ……
viral shedding continues for up to 3 months
subsequent outbreaks vary thereafter
_____ risk of fetal transmission with presence of lesion and primary infection of herpes
50%
__ to __ of herpes infections are truly asymptomatic or unrecognized
60 to 90%
Primary test for herpes
- viral culture in most clinics
- confirm diagnosis by PCR
Clinical Manifestations of Herpes
- lesions begin as small macules that progress to vesicles on an erythematous base that eventually ulcerate
- very painful
Tx of New onset HSV
- Acyclovir or a similar antiviral agent
- hygiene measures to avoid secondary infection
- pain management with an NSAIDs or a lidocaine based topical if needed
- diet rich in B vitamins, vitamin C, zinc and calcium
- education and emotional support
Greatest risk for transmitting to NB occurs…
when mother gets infected in the third trimester
Acyclovir
reduces length of time of outbreak and severity and asymptomatic viral shedding (ASV)
-use as suppressive Rx to reduce transmission and at 36 weeks gestation to protect fetus
When can herpes infected patient deliver vaginally?
- if no lesions visible
- on suppressive rx
Condoms and Herpes
-reduce spread but no full proof
HSV most important STD in enhancing _____
HIV transmission
Herpes effects on neonate
-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
Tx for infants infected with herpes
- anti-viral medications help tremendously
- best tx is primary prevention (tx mom when symptoms present and consider C/S, Acyclovir does not appear to harm fetus but best avoided in 1st trimester)
Can Lead to pre-term birth
- syphilis
- HIV
- chlamydia
- bacteria vaginosis
Fastest spreading STD in US women
Chlamydia
1 in 20 girls between 14-19 has had it
______ isn’t technically isn’t an STD
Bacteria Vaginosis (BV)
Effects of Syphilis on pregnant women
- 25% will have stillbirth or neonatal death
- 40-70% will have syphilis-infected baby if untreated
- if they survive, many of these babies have long term health problems even with aggressive therapy
Nursing care of Pregnant patient with syphilis
- screen all patients at first visit and later - VDRL and RPR
- tx pregnant women with parental PCN-G and if allergic to PCN try to desensitize. If this isn’t possible, erythromycin and azithromycin
- PCN-G can be given throughout pregnancy, but best results with the least negative fetal outcomes occur if tx by 18 weeks
- assess NB for symptoms
When do babies have symptoms of congenital syphilis
-at birth or may take several weeks to develop
Symptoms of babies with congenital syphilis
- anemia
- fever
- rashes and skin sores
- moist sores of congenital syphilis are infectious
- liver and spleen and various deformities
HIV and AIDS in childbearing population
- end of 2012, an estimated 1.2 mil aged 13 and older living with HIV infection
- incidence of HIV in obstetrics: 1/1000
- 90% of pediatric cases r/t perinatal transmission
- sero-conversion to HIV is 6-12 weeks after exposure
Factors that increase viral transmission
- previous child with HIV
- preterm birth
- decreased maternal CD4 counts
- firstborn twin
- SVD
- chorioamnioitis
- intrapartum blood exposure
- failure to tx mom and fetus/NB during perinatal period with zidovudine “AZT” aka “ZDV”
Bacterial Vaginosis
- whiff test
- very common in preg. pts
- interruption of normal vaginal bacterial flora
- tx as it can lead to preterm labor, PROM, or chorioamnionitis
chorioamnionitis
intra-amniotic infection (IAI) is an inflammation of the fetal membranes (amnion and chorion) due to a bacterial infection. It typically results from bacteria ascending into the uterus from the vagina and is most often associated with prolonged labor.
Symptoms of BV
- 50% of women with BV have no symptoms
- excessive, thin gray or white vaginal discharge that sticks to the vaginal walls
- fishy, musty, unpleasant vaginal odor, most noticeable after sexual intercourse
- vaginal itching and irritation
Tx of BV
Rx with metronidazole or clindamycin
Ectopic Pregnancy
-fertilization implants outside uterine cavity
Symptoms of ectopic pregnancy
- missed period
- adenexal tenderness
- variable abdominal pain
- vaginal bleeding and or shock
- Cullen’s sign (unbilical bruising)
- shoulder pain in some
Risk Factors for Ectopic Pregnancy
- PID
- Prior EP
- TUbal surgery
- IUD
- Endometriosis
- Assisted Reproduction
Labs & Diagnostic Tests
- low progesterone and hCG levels
- transvaginal ultrasound
Managing Symptoms of Ectopic Pregnancy
- pain
- bleeding
- emotional support
Tx for Ectopic Pregnancy
- requires pt to be healthy with an unruptured less than 4cm pregnancy and absence of FHR
- Drug of choice: Methotrexate (MTX)
- Surgery to spare the tube (Salpingostomy) or removal of tube (Salpingectomy)
- check Rh status of patient
Hyperemesis Gravidarum
HG
- 70% in first trimester some N/V
- uncontrolled vomitting
- less than 1% develop HG
- exact cause unknown
Risk factors for HG
- less than 20 years
- obese
- multi-fetal
- GTD
Clinical Manifestations of HG
- greater than 5% pre-pregnancy weight loss
- dehydration
- F&E imbalance
- ketosis
- ketonuria
- BP may be low and HR rapid
Med Management of HG
- IVF for sig. dehydration
- Pyridoxine (B6) and Doxylamine first line agents
- Metoclopramide and ondansteron if first line ineffective
- avoid corticosteroids - risky
Diet Management for HG
low fat mod-high protein bland 5-6 smaller meals chamomile tea ginger ale PB on toast/crackers
Worst case scenario would be parenteral nutrition
Cervical insufficiency
(incompetent Cervix)
- painless dilatation of the cervix without CTX that can lead to pregnancy loss in 2nd trimester
- can be related to congenital factors or acquired factors like cervical trauma, inflammation or surgical damage
- assessing cervical length using ultrasound helpful.
- for shorter cervixes, cerclage has no been shown to be effective in preventing preterm birth
Tx for cervical insufficiency
- cerclage placed at 11-15 wks
- continue BR
- oral tocolytics if needed
- monitoring
- hydration
- report to hospital if CTX less than 5 min apart, SROM, or urge to push occurs
TAC
Trans-abdominal Cerclage is a more morbid procedure than transvaginal cerclage. It usually requires a laparotomy for placement and delivery by cesarean
Spontaneous Abortion
- up to 15% end in miscarriage
- miscarriage is spontaneous abortion less than 20 wks
- 90% occur before 8 weeks and may be r/t fetal anomalies, endocrine disturbances, infections including chlamydia, and systemic disorders
Patient care following spontaneous abortion
- threatened: BR and support
- inevitable/incomplete: D and C with pre-post op care
- late miscarriages may require prostaglandins and oxytocin to prevent hemorrhage
- shower for 2 weeks
- introduce nothing into vagina until bleeding stops
Diet for spontaneous abortion
- high in protein and Fe
- plenty of rest
Avoid becoming pregnant for at least _____ after miscarriage
2 months
Expected outcomes following a spontaneous abortion
- patient does not develop excessive bleeding or infection
- verbalizes relief from pain
- identify and utilize support systems
- mother and family can discuss impact of loss on their lives
Gestational Diabetes
-carbohydrate intolerance with onset first recognized in pregnancy
Preconception counseling for women with pre-gestational DM
- increased risk of spontaneous abortion
- birth defects directly related to glucose control at conception and during fetal development
- counseling and diabetes control improves pregnancy outcomes
Macrosomia with GDM
greater than 4000gm birth weight
about 25 percent of pregnancies
HTN and preeclampsia with GDM
rates increased
Hydramnios with GDM
rates 10x greater
-a condition in which excess amniotic fluid accumulates during pregnancy.
Infection with GDM
rates higher (UTI and yeast) and result in higher insulin resistance and ketoacidosis
Ketoacidosis with GDM
r/t diabetogenic effects of pregnancy (women with type 1)
Retinopathy with GDM
diabetes complication that affects eyes. It’s caused by damage to the blood vessels of the light-sensitive tissue at the back of the eye (retina).
women with type 1
Stillbirth and GDM
-after 36 wks r/t poor maternal glucose control
Insulin needs during 1st trimester
insulin needs may drop due to decreased maternal food intake
insulin needs during 2nd trimester
insulin needs begin to raise as human placental lactogen (hPL) rises and causes maternal insulin resistance
insulin needs during 3rd trimester
insulin needs may double or more due to increasing insulin resistance
insulin needs after delivery
with delivery, insulin needs drop abruptly and initially may be less than pre-pregnancy needs (for women with pre-gestational diabetes)
As many as ____ of women with GDM develop Type 2 DM later in life
50 percent
When is GDM often diagnosed?
2nd or 3rd trimester
Risk factors for GDM
- prior births over 4500gm
- over 30 y/o
- obesity
- family hx type 2 DM
- hydramnios
- unexplained stillbirth
- screen high risk women much earlier
Screening for GDM
- screen low risk patients at 24-28 weeks with a 1 hour 50 gram glucose test
- if value greater than 130-140, proceed to diagnostic 3 hour 100 gm glucose tolerance test
- if two or more values of GTT are elevated, GDM is diagnosed
Tx for GDM
- maintain FBS of less than 95
- maintain 2 hour post-prandial value less than 120
- self glucose monitoring FBS and 2 hours post prandial
Diet for GDM
- ADA mealplan appropriate for pregnancy and DM, with avoidance of concentrated CHO
- CHO counting if patient on intensive insulin regimen
Tx: GDM and Type 2
glyburide may be used to control maternal blood glucose
-insulin may be needed to control blood glucose
Tx: GDM and Type 1
insulin required
Fetal Surveillance with GDM
- est. EDD
- screen for fetal neural tube defects in early 2nd trimester
- screen for fetal cardiac malformations by week 22
- by 28 wks, NST weekly
- in presence of non-reactive NST, a CTX test or BPP is ordered
Classifications of HTN
(140/90)
- chronic HTN
- gestational HTN
Chronic HTN
onset occurs before pregnancy and continues for at least 42 days postpartum or longer
Gestational HTN
pt is hypertensive after 20 weeks gestation without proteinuria
-BP returns to normal range 3 months after birth
GH is leading cause of…
maternal mortality and is a leading medical complication of pregnancy
GH contributes to…
fetal death and perinatal mortality and morbidity
Incidence by race
NA: 46.5/1000 AA: 41.5/1000 W: 38.1/1000 Hisp: 26.3/1000 Asian: 20.8/1000
Anti-HTN Meds
- Labetalol
- Nifedipine
- Methyldopa
Labetalol
avoid if patient has hx of asthma
Nifedipine
useful in treating preterm labor also
Methyldopa
“Aldomet” an old standard
When are Anti-HTN meds used…
when systolic is greater than 150-160 and diastolic is greater than 100
Preeclampsia
HTN frequently with proteinuria
- most commonly occurring between 25-30 weeks and up to 48 hours after delivery
- edema is almost always present
- can be mild or severe
Risk factors for Preeclampsia
- fam hx
- hx of HTN, renal dz, DM
- NA and AA
- Poor nutrition, esp severe protein deficiency
- age less than 20 and greater than 40
- obesity
- Rh incompatibility
BP differences in mild and severe preeclampsia
mild: 140/90 x2 4 hrs apart
severe: 160/110 x2
UO differences in mild and severe preeclampsia
mild: Output matches intake, 30mL/hr
severe: 20mL/hr or less than 400/24 hr
Proteinuria differences in mild and severe preeclampsia
mild: trace to 1+ dipstick
severe: greater than 2+ dipstick
Epigastric pain differences in mild and severe preeclampsia
mild: absent
severe: present
Reflexes differences in mild and severe preeclampsia
mild: may be normal
severe: hyperreflexia, clonus
Headache differences in mild and severe preeclampsia
mild: absent
severe: severe HA with visual problems
Platelets differences in mild and severe preeclampsia
mild: normal
severe: low
Tx of Preeclampsia
- home care with close f/u if BP stable and urine protein less than 2+
- teach self monitoring of BP, weight, urine dipstick, fetal kick counts daily
- healthy diet, avoid high salt and drink 8-10 cups water/day
- coping with anxiety and BR
- identify support systems for family
- home care, remote NST
Magnesium Sulfate
(IV)
- position patient and inform her of drug effects
- O2 support and placment of foley
- monitor VS, DTRs, FHR, and fetal well being and CTX continuously with bolus, then q 15-30 until stable
- hourly strict I&O checking urine protein
- periodic monitoring of serum mag and chemistries
- continue infusing 24 hrs portpartum
antidote to mag
calcium gluconate
IV Labetalol and Apresoline
- critical to monitor maternal response closely
- if less severe, PO labetalol or Nifedipine may be ordered
Caring for postpartum is focused on…
- assessing BP q4 for 2 days
- fundal checks
- observing lochia amount administering oxytocin or prostaglandins if bleeding occurs
- observing and facilitating maternal bonding
- grief counseling if outcome is poor
Eclampsia
- seizure state following uncontrolled HTN
- severe HTN affects both fetus and mother
- may require emergency C/S once patient is stable
- birth is the cure for pre-eclampsia
HELLP
H: HEMOLYSIS
E: ELEVATED
L: LIVER ENZYMES L: LOW
P: PLATELET COUNT
- most common in older caucasian multips who may present with several days fatigue, abdominal pain and often N/V
- symptoms of severe eclampsia
- lab, not clinical diagnosis as previously described
- BUN and creatinine also elevated
Maternal consequences of HELLP
- mortality rates as high as 24 percent
- increased risk for abruptio placenta, DIC, cerebral, hemorrhage, liver failure, acute renal failure
Fetal consequnces
- IUGR
- increased risk for fetal demise. try to delay delivery in preterm infants until L/S ratio is 2 to 1 or BMS is given to mother
Tx HELLP Syndrome
- interventions include seizure precautions, educating mother and family about disorder and treatment plan and associated risks
- maintain strict BR
- incorporate stress reducers in plan of care
- prepare for birth, recovery, discharge, and followup with aim of extending pregnancy as long as is feasible
HTN in pregnancy could…
induce long-term metabolic and vascular abnormalities that might increase the overall risk of CVD later in life.
