Ch 19, 20, 21 Flashcards
Biophysical risk factors for women
Genetic conditions
Chromosomal abnormalities
Multiple pregnancies
ABO incompatibility
Large fetus
Medical and oB conditions
Preterm
Cardiovascular disease (HTN)
Cervical insufficiency
Placental abnormalities
INfection, diabetes
Maternal collagen disease
Thyroid, asthma
Post term preg
Hemoglobinopathies
Nutritional status
Underweight/overweight
Hematocrit less than 33%
Psychosocial risk factors affecting womens pregnancy
Smoking
Caffeine
Alcohol and substance abuse
Maternal obesity
Inadequate support system
Situational crisis
History of violence
Emotional distress
Unsafe cultural practices
Sociodemographic risk factors affecting womens pregnancy
Poverty
Lack of prenatal care
Younger than 15, older than 35
Parity - all 1st and more than 5
Matiral statis - increased risk for unmarried
Ethnicity - increased risk for non-white women
Environmental risk factors affecting womens pregnancy
Infections
Radiation
Pesticides
Illicit drugs
industrial pollutants
Second hand cig smoke
Personal stress
Abortion
Loss of early pregnancy, usually before week 20
Can be spontaneous or induced
Spontaneous abortion
Loss of fetus resulting from natural causes
Stillbirth
Loss of fetus after 20th week
Miscarriage
Loss before week 20
What are the maternal conditions that can contribute to spontaneous abortions in 2nd trimester?
Cervical insufficiency, congenital or aquired anomaly of uterine cavity, hypothyroidism, DM, Chronic nephritis, cocaine, thrombophilias, lupus, PCOS, HTN, acute infection - rubella, cytomegalovirus, herpes, BV and toxoplasmosis.
Ectopic preg occur 1 in every ____
50
2% of preg in US
What medications are used for ectopic pregnancy?
Methotrexate
Prostaglandins
Misoprostol
Actinomycin
What is methotrexate typically used for
Chemotherapeutic treatment of leukemia, lymphomas, and carcinomas
Linear salpingostomy
used to preserve the tube - important for women who want to keep their fertility for future
The complete mole is assoc with development of
Choriocarcinoma
Partial mole has __karyotype?
triploid 69 chromosomes bc two sperm cells provided a double contribution by fertilization ovum
How does a complete mole present
uterine enlargement greater than expected, hyperemesis and pre-eclampic symptoms
What happens in molar pregnancy?
Trophoblastic cells that normally would form placenta proliferate and chorionic villi become edematous. They become grapelike clusters
What are 5 remarkable features of molar pregnancy?
Ability to invade into the wall of uterus
Recur in subseq pregnancies
Poss develop into choriocarcinoma
Influence of nutritional factors, protein def
Affect older women more
Symptoms of choriocarcinoma
SOB - indicative of metastasis to the lungs (most common site)
*asian, native and African increased risk
What is the patho for cervical insufficiency
Increased relaxin, when pressure of expanding uterus becomes greater than ability of cervical sphincter, cervix relaxes, allowing effacement and dilation
What is possibly the reason for cervical insufficiency
Congenital cervical hypoplasia, inutero DES exposure, trauma to cervix, amputation, OB lacteration, forced cervical dilation, prolonged 2nd stage of labor, increased relaxin and profesterone, increased uterine volume
Cervical cerclage
Sewing closed the cervix
Cervical pessary
a round silicone device at mouth of cervix
Complications assoc with cervical cerclage
suture displacement
rupture of membranes,
chorioamnionitis
How is cervical shortening viewed on ultrasound
as funneling. Amount can be determined by dividing funnel length by cervical length
Placenta accreta
placenta directly attached to myometrium
Placenta increta
Placenta penetrated into myometrium
Placenta percreta
Placenta invade myometrium into peritoneal covering, causing rupture of uterus
What are the risks for placental abruption
Ob hemorrhage, need for blood transfusions, em hysterectomy, DIC, sheehan syndrome, pp gland necrosis, renal failure
If a women develops DIC treatment focuses on
underlying cause
replacement therapy by transfusion of fresh frozen plasma factors along with cryoprecipitate
What is DIC
bleeding disorder characterized by an abnormal reduction in elements involved in blood clotting resulting from widespread intravascular clotting
DIC can occur secondary to
placental abruption, amniotic fluid embolism, endotoxin sepsis after abortion, retained fetus, posthemorrhagic shock, hydatidiform mole, HELLP syndrome, gyn malignancies
Complications of DIC
acute kidney failure
hepatic dysfunction
cardiac tamponade
gangrene
loss of digits
shock
death
What labs assist in diagnosis of DIC
Decreased fibrinogen and platelets
prolonged PT and aPTT
Positive D-dimer test and fibrin degradation products
Signs and symptoms of DIC
Bleeding gums
tachycardia
oozing from IV insertion site
petechiae
When is placenta accreta typically diagnosed
after birth
What are the theories for hyperemesis gravidarum
Endocrine
Metabolic
Genetic
Psycholigical
Endocrine - high level of hCG and estrogen
Metabolic - vit b def
Genetic - may predispose
Psycholigical - stress increase symptoms
What is the first choice for fluid replacement for hyperemesis gravidum
Normal saline which aids in preventing hyponatremia, which vitamins b6 and electrolytes added
What are nonpharmacological methods to treat myeremesis gravidum
Acupressure, hypnosis, massage, therapeutic touch, ginger, wear se-bands,
What happens if hyperemesis gravidum goes untreated?
can lead to neurological disturbances, renal damage, dehyrdation, ketosis, hypokalemia, retinal hemorrhage and/or death
What do the following lab tests tell about hyperemesis gravidum
Liver enzymes
CBC
Urine keytones
Liver enzymes - rule out hepatitis, pancreatitis, cholestasis; elevation of aspartate aminotrasnferase (AST) and (ALT) are usually present
CBC - elevated rbc and hematocrit - dehydration
**Urine keytones **- postive when body breasks down fat with inadequate intake
What do the following lab tests tell about hyperemesis gravidum
TSH and T4
Blood urea nitrogen
Urine specific gravity
serum electrolytes
Ultrasound
**TSH and T4 **- rule out thyroid disease
**Blood urea nitrogen **- increased in presence of salt and water depletion
Urine specific gravity - greater than 1.025 - linked to inadequate fluid intake or excessice loss, ketouria
serum electrolytes - decreased levels of potassium, sodium, and chloride, hydrochloric acid
Ultrasound - eval for molar preg or muliple gestation
Chronic HTN
exists prior to preg or develops before 20wks with bp greater than 140/90
Gestational htn
New onset bp elevation (140/90) id after 20 wks without proteinuria; bp returns to normal by 12 weeks pp
PreE/E and HELLP
develops with proteinuria after 20wks
Multisystem of:
elevated creatinine, liver involvement, epigastric or ab pain, neurological complications, hematologic and ueteroplacental dysfunction
Chronic htn w. superimposed pE
Develops afte 20wks
increased maternal / fetal morbidity rates
Risk factors for development of preE
Multifetal gestation, prev preg with preE, renal disease, autoimmune disease, DM, 1st preg, periodontal disease, chronic HTN, obesity
Define proteinuria
300mg or more of urinary protein per 24hrs more than 1+ protein by chemical reagent strip or dipstick of at least 2 random urine samples collected at least 4-6 hours apart
What to monitor when giving mag sulf
Serum mag levels
Assess DTRs, check for ankel clonus
Monitor for signs of toxicity, flushing, sweating, hypotension, cardiac and CNS dep
What to monitor when giving hydralazine hydrocholride
Use parenteral form immediate after opening , withdrawl slowly,
Monitor for palpitations, headache, tachycardia, anorexia, nausea, vomit, diarrhea
What to monitor when giving labetalol hydrochloride
What does drug do?
Monitor for?
drug lowers bp w/o decreasing maternal hr or C/o
Monitor for gastric pain, flatulence, constipation, dizzy, vertigo, fatigue
What to monitor with nifedipine
dizzy, peripheral edema, angina, diarrhea, nasal congestion, cough
W
What to monitor with sodium nitroprusside
Apprehension, restlessness, retrosternal pressure, palpitations, diaphoresis, ab pain
What to monitor with furoesmide
dizzy, veritgo, orthostatic hypo, anorexia vomit, electrolyte imbalance, muscle cramp and spasm
What are signs of mag toxicity
RR less than 12
absence of DTRs
decrease in urinary output (less than 30ml.hr)
Mag levels
4-7mEq
8
10
15
25
4-7mEq - therapeutic
8 - toxic
10 - possible loss of DTR
15 - possible respiratory dep
25- possible cardiac arrest
Monozygotic
identical twins
developed from a sinlge fertilizated ovum that splits during 1st 2 weeks after conception
Dizygotic twins
Not identical / fraternal
2 sperm fertilizing 2 ovum - separate amnions, chorions and placentas are formed
What happens if membranes were ruptures more than 24 hours
increased risk for infection
When is gestational DM usually diagnosed
2nd or 3rd trimester
WHat are 2 key components of gestational DM
Pancreatic beta cell dysfunction prior to preg
unmasking of problem by development of insulin resistance during pregnancy
What criteria do moms need to meet to not be screened for DM at their first visit?
-No history of glucose intolerance
-Younger than 25
-NOrmal body weight
-No family history of DM
-No history of poor oB outcomes
-Not from a ethnic/race group of high DM
What are ADA and ACOG glucose targets
Fasting - less than 95
at 1 hr - 140
at 2 hr - 120
at 3 hr - 95
WHat are short acting insulins?
lispro (humalog)
Aspart (novolog)
*do not cross placenta
**may help episodes of hypoglycemia betweeen meals
Women with gestational DM are at increased risk for what conditions?
PreE
hypoglycemia
hyperglycemia
ketoacidosis
fetal macrosomia
What do you do to care for a laboring women with DM
-adjust IV rate and insulin based on glucose levels
-Monitor blood glucose q 1-2 hrs
-Keep syringe of 50% dextrose solution bedside
-Monitor FHR
-Assess maternal vitals q 1hr w/ output
after birth
-monitor blood glucose q 2-4 for 48hrs
-encourge breastfeeding
What congential heart conditions should avoid pregnancy
uncorrected tetrlogy of fallot
transposition of great arteries
Severe pulmonary htn
aortic valve stenosis
marfan syndrome
peripartum cardiomyopathy
eisenmenger syndrome
defect w/ both cyanosis and pulmonary htn
What is cardiac decompensation
refers to hearts inability to maintain adequate circulation
Severe persistent asthma has been linked to what in pregnancy
maternal htn
low birth weight
preterm birth
PreE
placenta previa
uterine hemorrhage
oligohydramnios
Untreated TB has what affect on newborn
underweight
low APGAR
perinatal death
ANemia
HGB below ___ in 1st and 3rd ti?
below ____ in 2nd?
redution in rbc, measured by hematocrit or a decrease in concentration of hemoglobin in peripheral blood. results in reduced capacity of blood to carry O2 to vital organs
Hgb below 11g/dl in 1st and 3rd tri
below 10.5 g/dl in 2nd
What are maternal and fetal consequences of iron deficiency anemia
Preterm, perinatal mortility, post partum depression. Low birth weight, cardiovascular strain, intellectual disability, poor mental and psychomotor performance
risk for hemorrhage and infection
What are 3 roles of iron
Transport of O2 and CO throughout body
aids in production of RBC
Plays role in immune response
What are maternal/fetal outcomes of sickle cell disease
PreE, E, preterm, UTI, placental abruption, IUGR, low birth weight, maternal mortalities. life expectancy shortened. Renal, cardiac damage and infection
To be diagnosed with systemic lupus erythematosus what are the 11 criteria and how many do they have to meet?
4/11
Red rash on face
photosensitivity
oral ulcers
arthritis
serositis
renal disease
Seizures
Fatique
weight changes
anemai
positive antinuclear antibody test
What can lupus inflammation do to pregnancy
inflammation of connective tissue of decidua can result in placental implantation problems and poor functioning
Nonimmune fetal hydrops
serious abnormal accumulation of fluid in 2 or more fetal compartments, including ascites, pleural effusion, pericardial effusion and skin edema
AIDS
progressive debilitating disease that suppresses cellular immunity. predisposing infected person to opportunistic infections
CD4 count below 200
Stages of HIV
Stage 1
Acute infection
Early stage w/ pervasive viral production
Flu-like symptoms 2-4 wks after exposure
Weight loss, low grade fever, fatique, sore throat, night sweats, myalgia
-ability to spread, highest at this point
Stages of HIV
Stage 2
Asymptomatic infection / clincal latency
Viral replication continues within lymphatics, but slows down
usually free of symptoms; lymphadenopathy
Stages of HIV
Stage 3
Persistent generalized lymphadenopathy
Possibly remaining in this stage for years; AIDS develops mostly within 7-10years
Opportunistic infections occur
Stages of HIV
Stage IV
End stage (AIDS)
Severe immune deficiceny, very vulnerable to infections
High viral load, low CD4 count
Bacterial, viral, fungal opportunistic infections, fever, wasting syndrome, fatique, neoplasms, cognitive changes
What BMI is sever obesity
over 40 kg.m
What BMI is obesity in preg
30kg/m
Alcohol effect on pregnancy
Spontaneous abortion, inadequate weight gain, IUGR, FASD
Caffeine effect on pregnancy
Vasoconstriction, mild diuresis in mother, fetal stimulation
Nicotine effect on pregnancy
VAsoconstriction, reduced uteroplacental blood flow, decreased birth weight, abortion, prematurity, placental abruption, fetal demise
Cocaine effect on pregnancy
VAsoconstriction, gestational HTN, placental abruption, abortion, CNS defects, IUGR
Marijuana effect on pregnancy
Anemia, inadequate weight gain, amotivational syndrome, hyperactive startle reflex, newborn tremors, prematurity, IUGR
Opiates/narcotics effects on pregnancy
Maternal/fetal withdrawal, placental abruption, preterm labor, PROM, perinatal asphyxia, newborn sepsis and death. intellectual impairment, malnutrition
Sedatives effect on pregnancy
CNS depressionn, newborn withdrawl, maternal seizures in labor, neonatal abstinence syndrome, delayed lung maturity
Characteristics of FASD
Caraniofacial dysmorphia (thin upper lip, small head circumference, small eyes)
IUGR, microcephaly, congenital anomalies such as limb abnormalities and cardiac defects
Dystocia
abnormal progression of labor
During what phase does dystocia become apparent?
DUring active phase
Frank breech
buttock as presenting part, hips flexed, legs and knees extended upward
Complete breech
Buttock as presenting part, with hips flexed and knees flexed in a “cannonball” position
Footling or incomplete breech
one or two feet as the presenting part, with one or both hips extended
Infants born prematurely are at risk for what
respiratory distress syndrome
infections
congenital heart defects
thermoregulation problems
acidosis, weight loss,
intrventricular hemorrhage
jaundice, hypoglycemia, feeding difficulties, neurological disorders
numerous lifelong diabilities
Indomethacin is contraindicated in
less tha 32 weeks preg
fetal growth restriction
history of asthma, urticaria or allergic type reactions to aspirin or NSAID
Fetal fibronectin
Define?
Present up to —wks and –?
not detected between – & —?
glycoprotein produced by chorion, found at the junction of chorion and decidua
Acts as biologic glue attaching fetal sac to uterine lining
normally present up to 22 wks and at end of preg / cannot be detected between 24-34 wks unless there is a disruption between chorion adn deciduas
What is fetal fibronectin a useful marker for
impending membrane rupture within 7-14 days if level increases to more than 0.5mcg/ml
Accuracy decreased in presence of lubricants, blood, recent intercourse or cervical manipulation within previoud 24hrs
What 3 parameters are evaluted during a transvaginal ultrasound
Cervical length of 3cm or more indicates?
Women with a short cervical lenght of 2.5cm or less during 3rd tri are at greater risk for?
Cervical lenth and width
Funnel width and length
% of funneling
- cervical lenght of 3cm or more indicates delivery in next 14 days unlikely
- ** women with short cervical lenght of 2.5cm during mid tri greater risk of birth prior to 35 wks
Contraindications to tocolytics
intrauterine infection
active hemorrhage
fetal distress
fetus before viability
fetal growth restriction
severe preE
heart disease
PPROM
intrauterine demise
Fetal risks assoc with post-term preg
macrosomia, shoulder dystocia, brachial plexus injuries, low apgar, postmaturity syndrome (loss of subQ fat and muscle and meconium stanining)
as placenta ages = perfusion decreases = olighydraminos, fetal hypoxia, cord compression, aspiration of meconium
Cervical ripening
process by which cervix softens via the breakdown of collagen leading to its elasticity and distensibility preceding cervical dilation
Alternative methods for cervical ripening
primrose oil, black haw, black and blue cohosh, red respberry leaves, castor oil, hot baths, enemas, sexual intercorse
What are mechanical methods for cervical ripening
Application of local pressure = stims the release of prostaglandins to ripen cervix
Indwelling foley catheter
**hygroscopic dilators **- absorb endocervical tissue fluids, they expand cervix and provide pressure
Natural osmotic (laminaria -dry seaweed) & synthetic containing mag (lamicel, dilapn) - expand over 12-24hrs
What are the surgical methods for cervical ripening
**Stripping of membranes **- inserting finger through internal cervical OS and moving it in circular motion
amniotomy- inserting a cervical hook through cervical os to deliberaly rupture membranes - pressure of presenting part on cervix and stims increase in prostaglandin
Risks - cord prolapse or compression, infection ,FHR decel, bleeding
VBAC
Contraindicated in?
Vaginal birth after C-section
Contra - prior classic uterine incision, prior transfundal uterine surgery, obesity, short stature, macrosomia, over 40, gestational DM, contracted pelvis
Intrauterine fetal demise
death that occurs after 20 wks gestation but before birth
Umbilical cord prolapse
Rare. When cord precedes fetus / Presenting part doesnt fill pelvis
Fetal perfusion deteriorates rapidly
Risk - multiparity, noncephalic presentations, long cord, preterm, low birth weight, placement of cervical ripening balloon
Often first sign - sudden fetal bradycardia or recurrent variable decls
Nurse mgmt for cord prolapse
call for help
membranes ruptured
relieve compression
change womens position to sims, trendelenburg, or knee chest
Do Not place cord back into uterus
Monitor FHR, bed rest and O2
Placenta previa
define
symptoms
complete or partial covering of uterine internal os or cervix
Signs - sudden painless bleeding, anemia, pallor, hypoxia, low bp, tachycardia, soft and nontender uterus, rapid weak pulse
Placental abruption
define
Risks?
premature separation of normally implanted placenta from maternal myometrium
Risk - preE, gestational HTN, serizure, over 34, uterine rupture, trauma, smoking, cocain, coag defects, chorioamnionitits, PPROM, fetal growth restriction, hydramnios, breech,
Uterine rupture
Castastrophic tearing of uterus at site of previous scar into ab cavity
Marked b y sudden fetal bradycardia / treat with rapid surgery
Anaphylactoid Syndrome of pregnancy
Aka Amniotic fluid embolism
unforseeable, life-threatening complication of childbirth
-Sudden onset of hypotension, cardiopulmonary collapse, hypoxia and coagulopathy
-Amniotic fluid enternal maternal circulation and obstructs pulmonary vessels, causing respiratory distress and circulatory collapse
What are predisposing factors assoc with amniotic fluid embolism
placental abruption, uterine overdistension, fetal demise, eclampsia, amnmiocentesis, uterine trauma, oxytocin-stimulated labor, multiparity, advanced maternal age, ruptured membranes
What are the 4 cardinal signs of ASP
Respiratory failure
Altered mental status
Hypotension
DIC
What is nursing mgmt for ASP
-Resucitation and 100% Oxygenation
-Intravenous fluids, inotropic agents to maintain cardiac output and bp
-oxytocic agents to control uterine atony and bleeding
-seizure precautions
-admin of steriods to control inflam response
Monitor vitals, pulse ox, skin color, observe for signs of coagulopathy (vag bleed, bleed from IV site, bleed from gums)
Forceps or vaccum assisted birth
apply traction to fetal head or provide a method of rotating head during bith
Forceps
-outlet
-low
Stainless steel instruments with rounded edges that fit around fetus head
OUTLET foceps are used when head is crowning
LOW forceps are used when head is at 2+ or lower but not yet crowning
Vaccum extractor
Cup shaped instrument attached to a suction pump used for extraction of head
Used to create negative pressure of apprx 50-60mmHg
What are indications of use for forceps or vaccum
Prolonged 2nd stage, distressed FHR, failure of presenting part to fully rotate and descend, limiited sensation and inability to push effectively due to regional anesthesia, fetal distress, maternal heart distress, acute pulm edema, intrapartum infection, maternal fatique, infection
What are the risks of forceps or vaccum
Maternal - Tissue trauma, lacerations, hematoma, extension of episiotomy into anus, hemorrhage and infection
Newborn - ecchymoses, lacerations, facial nerve injury, cephalohemoatomoa, caput succedaneum
