Chapter 19 Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications Flashcards

Question

Threatened Abortions

Answer 1

Assessment Findings: - Vaginal bleeding (often slight) early in a pregnancy - No cervical dilation or change in cervical consistency - Mild abdominal cramping - Closed cervical os - No passage of fetal tissue Diagnosis: - Vaginal ultrasound to confirm if sac is empty - Declining maternal serum hCG and progesterone levels to provide additional information about viability of pregnancy Therapeutic Management: - Conservative supportive treatment - Possible reduction in activity in conjunction with nutritious diet and adequate hydration

Answer 2

Assessment Findings: - Vaginal bleeding (greater than that associated with threatened abortion) - Rupture of membranes - Cervical dilation - Strong abdominal cramping - Possible passage of products of conception Diagnosis: - Ultrasound and hCG levels to indicate pregnancy loss Therapeutic Management: - Vacuum curettage if products of conception are not passed to reduce risk of excessive bleeding and infection - Prostaglandin analogs such as misoprostol to empty uterus of retained tissue (only used if fragments are not completely passed)

Answer 3

Passage of all products of conception Assessment Findings: - History of vaginal bleeding and abdominal pain - Passage of tissue with subsequent decrease in pain and significant decrease in vaginal bleeding Diagnosis: - Ultrasound demonstrating an empty uterus Therapeutic Management: - No medical or surgical intervention necessary - Follow-up appointment to discuss family planning

Answer 4

Passage of some of the products of conception Assessment Findings: - Intense abdominal cramping - Heavy vaginal bleeding - Cervical dilation Diagnosis: - Ultrasound confirmation that products of conception still in uterus Therapeutic Management: - Client stabilization - Evacuation of uterus via D&C or prostaglandin analog

Answer 5

Nonviable embryo retained in utero for at least 6 weeks Assessment Findings: - Absent uterine contractions - Irregular spotting - Possible progression to inevitable abortion Diagnosis: - Ultrasound to identify products of conception in uterus Therapeutic Management: - Evacuation of uterus (if inevitable abortion does not occur): suction curettage during 1st trimester, dilation and evacuation during 2nd trimester - Induction of labor with intravaginal PGE2 suppository to empty uterus without surgical intervention

Answer 6

Assessment Findings: - History of 3 or more consecutive spontaneous abortions - Not carrying the pregnancy to viability or term Diagnosis: - Validation via client’s history - No diagnostic ultrasound findings Therapeutic Management: - Identification and treatment of underlying cause (possible causes such as genetic or chromosomal abnormalities, reproductive tract abnormalities, chronic diseases or immunologic problems) - Cervical cerclage in 2nd trimester if incompetent cervix is the cause

Answer 7

Assessment Findings: - Diagnosis: - Therapeutic Management: -

Answer 8

A pregnant woman who reports vaginal bleeding must be seen IMMEDIATELY by a provider!!! Signs & Symptoms: - Varying degrees of vaginal bleeding - Low back pain - Abdominal cramping - Passage of products of conception tissue Ask the woman about the color of the vaginal bleeding (bright red is significant) and the amount - Question her about the frequency of changing her peripads (saturation of one peripad hourly is significant) and the passage of any clots or tissue. Instruct her to save any tissue or clots passed and bring them with her to the health care facility. Obtain a description of any other signs and symptoms the woman may be experiencing, along w/ a description of their severity and duration Remain calm and listen to the woman’s description. When the woman arrives at the health care facility: - Assess her VS - Observe the amount, color, and characteristics of the bleeding - Ask her to rate her current pain level, using an appropriate pain assessment tool - Evaluate the amount and intensity of the woman’s abdominal cramping or contractions, and assess the woman’s level of understanding about what is happening to her

Answer 9

Focus on providing continued monitoring and psychological support because the family is experiencing acute loss and grief. - Reassure the woman that spontaneous abortions usually result from an abnormality and that it is NOT HER FAULT Women experiencing a 1st-trimester abortion at home w/out a dilation and curettage (D&C) to resolve it require frequent monitoring of hCG levels to validate that all the conceptus tissues have been expelled. Women going through a 2nd-trimester abortion are admitted to the hospital to have an augmented labor and delivery. - Nursing care would focus on care of the laboring women with tremendous attention paid to providing emotional support to the woman and her family

Answer 10

Monitor the amount of vaginal bleeding through pad counts and observe for passage of products of conception tissue Assess pain & provide appropriate pain management to address the cramping discomfort. Assist in preparing the woman for procedures and treatments such as surgery to evacuate the uterus or medications such as misoprostol or prostaglandin E2 (PGE2). If the woman is Rh-negative and not sensitized, expect to administer RhoGAM within 72 hours after the abortion is complete

Answer 11

Provide both physical and emotional support Prepare the woman and her family for the assessment process and answer their questions Explaining some of the causes of spontaneous abortions can help the woman understand what is happening and may allay her fears and guilt that she did something to cause the pregnancy loss. Many women experience an acute sense of loss and go through a grieving process with a spontaneous abortion. - Providing sensitive listening, counseling, and anticipatory guidance to the woman and her family will allow them to verbalize their feelings and ask questions about future pregnancies. Encourage friends and family to be supportive but give the family space and time to work through their loss Referral to a community support group for parents who have experienced a loss can be helpful during this grief process

Answer 12

The loss of a fetus after the 20th week of development, while a miscarriage is a loss before the 20th week Occurs later in pregnancy Some stillbirths can occur right up to the time of labor and delivery. Stillbirths are much less common than miscarriages, - Occur in 1 out of every 100 pregnancies in the United States

Answer 13

Place appropriate signage on the outside of the room so everyone in the hospital is aware of the loss Give parents the opportunity to spend time with their baby Bathe and swaddle baby - Allow parents to participate or do this independently as desired Support parents’ wishes regarding photography (professional or otherwise) Allow visitation in accordance with the wishes of the parents Assist parents in the collection of keepsakes

Answer 14

Labor that occurs between 20 and 37 completed weeks of pregnancy #1 cause of neonatal morbidity

Answer 15

African-American race (double the risk) Maternal Age extremes (< 16, or > 40) Low socioeconomic status Alcohol, Smoking or Drug Use History of previous Preterm Birth (triple the risk) Multiple Gestations Short cervical length Infections (UTI, STI, Bacterial Vaginosis) Stress

Answer 16

Spontaneous rupture of membranes (SROM) Abdominal Pain Low, Dull Back Pain Pelvic Pain Menstrual-like cramps Vaginal Bleeding Increased Vaginal discharge Urinary Frequency Diarrhea Pelvic Pressure

Answer 17

Cervical Dilation and Effacement plus 4 uterine contractions in 20 minutes or 8 uterine contractions in 1 hour

Answer 18

Goal: Arrest labor and delay birth long enough to initiate prophylactic corticosteroid therapy Meds Used in Tocolytic Therapy: - Procardia (Nifedipine) - Indomethacin (Indocin) - Atosiban (Tractocile, Antocin) - Magnesium Sulfate

Answer 19

MEDICAL EMERGENCY!!! Any pregnancy in which the fertilized ovum implants outside the uterine cavity Locations include: the fallopian tubes, cervix, ovary, and the abdominal cavity General Pathophysiology: 1) Abnormally implanted embryo grows and draws its blood supply from the site of abnormal implantation. 2) As the embryo enlarges, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal development If left untreated: Can lead to massive hemorrhage, infertility, or death

Answer 20

Tubal obstruction/damage Delayed tubal transport Congenital anomalies Altered hormonal status Smoking AMA

Answer 21

Normally, the fertilized ovum implants in the uterus. In ectopic pregnancy, the journey along the fallopian tube is arrested or altered in some way. In ectopic pregnancy, the ovum implants outside the uterus. Most common site for implantation is the fallopian tubes (96%), but some ova may implant in the ovary, the intestine, the cervix, or the abdominal cavity - None of these anatomic sites can accommodate placental attachment or a growing embryo

Answer 22

Abdominal pain, amenorrhea, & vaginal bleeding Only ~1/2 of women present w/ all 3 symptoms

Answer 23

Assess the client thoroughly for signs and symptoms that may suggest an ectopic pregnancy The onset of signs and symptoms varies, but they usually begin at about the 7th or 8th week of gestation Unruptured Tubal Pregnancy: - A missed menstrual period - Adnexal fullness - Abdominal tenderness As the tube stretches, the pain increases. - Pain may be unilateral, bilateral, or diffuse over the abdomen

Answer 24

Severe, sharp, and sudden pain in the lower abdomen as the tube tears open and the embryo is expelled into the pelvic cavity Feelings of faintness Referred pain to the shoulder area, indicating bleeding into the abdomen caused by phrenic nerve irritation Hypotension & Hypovolemic Shock Marked abdominal tenderness w/ distention

Answer 25

Urine pregnancy test to confirm the pregnancy Beta-hCG concentrations to exclude a false-negative urine test Transvaginal ultrasound to visualize the misplaced pregnancy

Answer 26

Folic acid antagonist that inhibits cell division in the developing embryo Most often consists of a single-dose IM injection of methotrexate (Rheumatrex, Trexall) with outpatient follow-up - Ordered based on the client’s body surface area Eligibility Conditions: - MUST be hemodynamically stable - No signs of active bleeding in the peritoneal cavity - Low beta-hCG levels (lower than 5,000 mIU/mL) - The mass (which must measure less than 4 cm as determined by ultrasound) must be unruptured Advantages: Avoidance of surgery, the preservation of tubal patency & function, & LOWER cost Adverse Effects: N/V, stomatitis, diarrhea, gastric upset, increased abdominal pain, and dizziness Contraindications: - UNSTABLE patient - Severe, persistent abdominal pain - Renal or liver disease - Immunodeficiency - Active pulmonary disease - Peptic Ulcer - Suspected intauterine pregnancy - Poor client compliance

Answer 27

Prior to receiving the single-dose IM injection to treat unruptured pregnancies, the woman needs to be counseled on the: - Risks - Benefits - Adverse effects - Possibility of failure of medical therapy, which would result in tubal rupture, necessitating surgery Return weekly for follow-up laboratory studies for the next several weeks until beta-hCG titers decrease - A decreasing beta-hCG level is highly predictive of treatment success

Answer 28

Treatment for RUPTURED Ectopic Pregnancy Salpingectomy: Laporotomy w/ removal of the tube All patients are given Rhogam to prevent isoimmunization in future pregnancies

Answer 29

AKA "Molar Pregnancy" Condition in which a proliferation of trophoblastic cells (outermost layer of embryonic cells) results in the formation of a placenta characterized by hydropic (fluid-filled) grapelike clusters With GTD, there is abnormal hyperproliferation of trophoblastic cells that would normally develop into the placenta during pregnancy Gestational tissue is present, but the pregnancy is not viable

Answer 30

A benign neoplasm of the chorion in which the chorionic villi degenerate and become transparent vesicles containing clear, viscid fluid Complete or partial Embryo is not viable & dies

Answer 31

Contains no fetal tissue and develops from an “empty egg,” which is fertilized by a normal sperm (the paternal chromosomes replicate, resulting in 46 all-paternal chromosomes) Clinical Presentation: Uterine enlargement greater than expected for gestational dates, hyperemesis, and preeclamptic symptom

Answer 32

Has a triploid karyotype (69 chromosomes) because two sperm cells have provided a double contribution by fertilizing the ovum Clinical Presentation: Missed or incomplete abortion, including vaginal bleeding and a small- or normal-sized-for-date uterus Rarely transform into choriocarcinoma.

Answer 33

Report of early signs of pregnancy, such as amenorrhea, breast tenderness, fatigue Brownish vaginal bleeding/spotting: Like prune juice Anemia Inability to detect a fetal heart rate after 10 to 12 weeks’ gestation Fetal parts not evident with palpation Bilateral ovarian enlargement caused by cysts and elevated levels of hCG Persistent, often severe nausea and vomiting (due to high hCG levels): Hyperemesis Gravidarum Fluid retention and swelling Uterine size larger than expected for pregnancy dates Extremely high hCG levels present; no single value considered diagnostic Early development of preeclampsia (usually not present until after 24 weeks) Absence of fetal heart rate or fetal activity Expulsion of grape-like vesicles (possible in some women)

Answer 34

...the loss of the pregnancy and the possibility of developing choriocarcinoma, a chorionic malignancy from the trophoblastic tissue

Answer 35

Surgery Rhogam- if indicated Methotrexate (b/c of possible development of choriocarcinoma) No new pregnancies for 1 year

Answer 36

Consists of immediate evacuation of the uterine contents as soon as the diagnosis is made and long-term follow-up of the client to detect any remaining trophoblastic tissue that might become malignant. D&C is used to empty the uterus - The tissue obtained is sent to the laboratory for analysis to evaluate for choriocarcinoma Serial levels of hCG are used to detect residual trophoblastic tissue for 1 year. - If any tissue remains, hCG levels will not regress. In 80% of women with a benign hydatidiform mole, serum hCG titers steadily drop to normal within 8 to 12 weeks after evacuation of the molar pregnancy. In the other 20% of women w/ a malignant hydatidiform mole, serum hCG levels begin to rise

Answer 37

Baseline hCG level, chest radiograph, and pelvic ultrasound Quantitative hCG levels every week until undetectable for three consecutive weeks; then serial hCG levels monthly for 1 year Chest radiograph every 6 months to detect pulmonary metastasis Regular pelvic examinations to assess uterine and ovarian regression Systemic assessments for symptoms indicative of lung, brain, liver, or vaginal metastasis Strong recommendation to avoid pregnancy for 1 year because the pregnancy can interfere with the monitoring of hCG levels Use of a reliable contraceptive for at least 1 year

Answer 38

Painless dilation of the cervix w/out labor or uterine contractions

Answer 39

AKA Premature Dilation of the Cervix Describes a weak, structurally defective cervix that spontaneously dilates in the absence of uterine contractions in the second trimester or early third trimester, resulting in the loss of the pregnancy Typically occurs in 4th/5th month of gestation - If not arrested-> results in fetal loss (occur before point of viability)

Answer 40

1) Congenital factors 2) Acquired 3) Biochemical factors

Answer 41

Previous cervical trauma Preterm labor Fetal loss in the 2nd trimester Previous surgeries/procedures involving the cervix

Answer 42

Cervix may have less elastin, less collagen, and greater amounts of smooth muscle than the normal cervix and thus results in loss of sphincter tone Several theories have been proposed that focus on damage to the cervix as a key component of hormonal factors, such as increased amounts of relaxin. - When the pressure of the expanding uterine contents becomes > than the ability of the cervical sphincter to remain closed, the cervix suddenly relaxes, allowing effacement and dilation to proceed. - Cervical dilation is typically rapid, relatively painless, and accompanied by minimal bleeding Structural cervical weakness is the likely cause of many recurrent second-trimester losses, but not the only etiology. - Likely the clinical end point of many pathologic processes, such as congenital cervical hypoplasia, or trauma to the cervix -Other conditions: previous precipitous birth, a prolonged second stage of labor, increased amounts of relaxin and progesterone, or increased uterine volume (multiple gestation, hydramnios) are associated with cervical insufficiency

Answer 43

Recent studies have examined the association between a short cervical length and the risk of preterm birth. Some have demonstrated a continuum of risk between a shorter cervix on ultrasound and a higher risk of preterm birth, leading to the hypothetical argument that women with a short cervix on ultrasound might benefit from cervical cerclage (the sewing closed of the cervix) The ACOG does not recommend cerclage placement for women with short cervixes who do not have a history of preterm birth, as it has not been shown to be beneficial in this population

Answer 44

Bed rest (includes pelvic rest) Avoidance of heavy lifting Progesterone supplementation (women w/ risk for premature birth) Placement of cervical pessary (round, silicone device that sits at the mouth of the cervix Surgically via a cervical cerclage procedure in the 2nd trimester

Answer 45

Involves using a heavy purse-string suture to secure and reinforce the internal os of the cervix Can be performed transvaginally or transabdominally - Placement up to 28 weeks' gestation Indications: - History of 2nd trimester pregnancy loss w/painless dilatation - Prior cerclage placement for cervical insufficiency - History of spontaneous preterm birth prior to 34 weeks’ gestation - {ainless cervical dilatation on physical examination in the 2nd trimester Complications: Suture displacement, rupture of membranes, and chorioamnionitis

Answer 46

Be alert for c/o vaginal discharge or pelvic pressure! - With cervical insufficiency, the woman will often report: - A pink-tinged vaginal discharge or an increase in low pelvic pressure - Cramping with vaginal bleeding - Loss of amniotic fluid - Cervical dilation also occurs. If this continues, rupture of the membranes, release of amniotic fluid, and uterine contractions occur, subsequently resulting in delivery of the fetus, often before it is viable Monitor the woman closely for signs of preterm labor: backache, increase in vaginal discharge, rupture of membranes, and uterine contractions Provide emotional support and education Provide preoperative care and teaching as indicated if the woman will be undergoing cerclage. Teach the client and her family about the signs and symptoms of preterm labor and the need to report any changes immediately. -Also reinforce the need for activity restrictions (if appropriate) and continued regular follow-up

Answer 47

When the placenta is inserted wholly or partly into the lower uterine segment of the uterus, partially or completely covering the internal cervical opening Occurs during the last 2 trimesters of pregnancy Poses a high risk of prenatal and postpartum hemorrhage as well as perinatal mortality Classical Presentation: Painless, bright-red bleeding

Answer 48

Maternal age over 35 years Previous cesarean birth Multiparity Uterine insult or injury Cocaine use Previous D&C Endometrial ablation Prior placenta previa Infertility treatment Multiple gestations Previous induced surgical abortion Smoking Previous myomectomy to remove fibroids Short interval between pregnancies HTN or diabetes

Answer 49

Initiated by implantation of the embryo in the lower uterus, - Potential Causes: uterine endometrial scarring or damage in the upper segment->may incite placental growth in the unscarred lower uterine segment. - Lack of perfusion to the placenta: increase the surface area required for placental attachment & may cause the placenta to encroach on the lower uterine segment As the placenta attaches & grows, the cervical os may become covered by the developing placenta. - Vascularization is defective, allowing the placenta to attach directly to the myometrium (accreta), deeply attach to the myometrium (increta), or infiltrate the myometrium (percreta) Covers the internal os

Answer 50

1) Total 2) Partial 3) Marginal 4) Low-Lying Placenta

Answer 51

Internal os is completely covered by the placenta

Answer 52

Internal os is partially covered by the placenta

Answer 53

Edge of placenta is at the margin of the internal os

Answer 54

Placenta is implanted in the lower segment but does not reach the os - If the placental edge is less than 2 cm from the internal os but does not cover it

Answer 55

Ask the client if she has any problems associated with bleeding now or in the recent past The classical clinical presentation is painless, bright red vaginal bleeding occurring during the second or third trimester. - The initial bleeding is usually not profuse and it ceases spontaneously, only to recur again. - The 1st episode of bleeding occurs (on average) at 27 to 32 weeks’ gestation. Thought to arise secondary to the thinning of the lower uterine segment in preparation for the onset of labor. - When the bleeding occurs at the implantation site in the lower uterus, the uterus cannot contract adequately & stop the flow of blood from the open vessels. Assess the client for uterine contractions, which may or may not occur with the bleeding. Palpate the uterus; typically, it is soft & non-tender upon examination. Auscultate the fetal heart rate; it is commonly within normal parameters. - Fetal distress is usually absent but may occur when cord problems arise

Answer 56

Bed rest until 37 weeks No vaginal exams Monitoring blood loss Monitor fetal heart tones Betamethasone (for fetal lung development) IV fluids and monitor mom’s vitals Pelvic rest including no intercourse If previa doesn’t resolve, C-Section will be required for safe delivery

Answer 57

AKA Placental Abruption The early separation of a normally implanted placenta after the 20th week of gestation prior to birth, which leads to hemorrhage

Answer 58

Sudden pain, blood can be visible or concealed, may have fetal distress and uterus may be firm or rigid

Answer 59

Cigarette Smoking Increased maternal age Alcohol Cocaine Short umbilical cord Multiparity Trauma HTN: Most common cause

Answer 60

1) Marginal 2) Central 3) Complete

Answer 61

Blood passes between the fetal membranes and the uterine wall and escapes vaginally (may or may not become more severe)

Answer 62

Placenta separates centrally and blood is trapped between the placenta and the uterine wall (concealed bleeding)

Answer 63

Massive vaginal bleeding (almost total separation)

Answer 64

Asymptomatic Clinically unrecognized before birth, diagnosis is made retrospectively after birth

Answer 65

Mild (Most common) No sign of vaginal bleeding or minimal bleeding (less than 500 mL), marginal separation (10% to 20%), tender uterus, no coagulopathy, no signs of shock, no fetal distress

Answer 66

Moderate: Mom & fetus show signs of distress No sign of bleeding or moderate bleeding (1,000 to 1,500 mL), moderate separation (20% to 50%), continuous abdominal pain, mild shock, normal maternal blood pressure, maternal tachycardia, evidence of fetal distress

Answer 67

SEVERE: Maternal shock & fetal death likely!!! Absent to moderate bleeding (more than 1,500 mL), severe separation (more than 50%), profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased maternal blood pressure, significant maternal tachycardia and the development of DIC

Answer 68

Starting two large-bore IV lines with normal saline or lactated Ringer’s solution to combat hypovolemia Obtaining blood specimens for evaluating hemodynamic status values and for typing and cross-matching Frequently monitoring fetal and maternal well-being - C-section if fetal distress is evident - If fetus is not in distress: Close monitoring continues with birth planned at the earliest signs of fetal distress

Answer 69

CBC: Determines the current hemodynamic status; however, it is not reliable for estimating acute blood loss. Fibrinogen levels: Typically, are increased in pregnancy (hyperfibrinogenemia); thus, a moderate dip in fibrinogen levels might suggest DIC, and if profuse bleeding occurs, the clotting cascade might be compromised. Prothrombin time (PT)/activated partial thromboplastin time (aPTT): Determines the client’s coagulation status, especially if surgery is planned. Type and cross-match: Determines blood type if a transfusion is needed. Nonstress test: Demonstrates findings of fetal jeopardy manifested by late decelerations or bradycardia. Biophysical profile: Aids in evaluating clients with chronic abruption; a low score (less than 6 points) suggests possible fetal compromise

Answer 70

A severe form of N/V of pregnancy associated with significant costs and psychosocial impact Characterized by: - Persistent, uncontrollable N/V that begins before 9 weeks’ gestation and causes dehydration, nutritional deficiencies, ketosis, electrolyte imbalances, and weight loss of more than 5% of prepregnancy body weight

Answer 71

Previous pregnancy complicated by hyperemesis Molar pregnancies History of Helicobacter pylori infection Multiple gestation Prepregnancy history of genitourinary disorders Clinical hyperthyroid disorders Prepregnancy psychiatric diagnosis

Answer 72

In hyperemesis gravidarum, the hCG levels are often higher and extend beyond the first trimester Symptoms exacerbate the disease Decreased fluid intake and prolonged vomiting cause dehydration - Dehydration increases the serum concentration of hCG, which in turn exacerbates the N/V

Answer 73

Diagnosis of EXCLUSION 1st Line of Treatment: Conservative Management - Focuses on dietary & lifestyle changes - If conservative management fails-> hospitalization is REQUIRED 1st Choice for Fluid Replacement: Normal Saline - Aids in preventing hyponatremia - Vitamins (pyridoxine or vitamin B6 added) Oral food and fluids are w/held for the first 24 to 36 hours to allow the GI tract to rest. Antiemetics may be administered rectally or intravenously to control the N/V initially because the woman is considered NPO - Once her condition stabilizes and she is allowed oral intake, medications may be administered PO

Answer 74

Ask about: - Onset, duration, & course of N/V - Treatments used & their efficacy - Diet history: Diet recall for past week - Client's knowledge of nutrition & need for appropriate intake - Complaints of ptyalism (excess saliva), anorexia, indigestion, & abdominal pain or distention - Blood or mucus in stool Review possible risk factors Weigh the client and compare this weight with her weight before she began experiencing symptoms and to her prepregnancy weight to estimate the degree of loss. - With hyperemesis, weight loss usually exceeds 5% of body mass. Inspect the mucous membranes for dryness and check skin turgor for evidence of fluid loss and dehydration Assess BP for hypotension - Also note any complaints of weakness, fatigue, activity intolerance, dizziness, or sleep disturbances

Answer 75

Avoid noxious stimuli, such as strong flavors, perfumes, or strong odors like frying bacon, that might trigger nausea and vomiting. * Avoid tight waistbands to minimize pressure on abdomen. * Eat small, frequent meals throughout the day. * Separate fluids from solids by consuming fluids in between meals. * Avoid lying down or reclining for at least 2 hours after eating. * Use high-protein supplement drinks. * Avoid foods high in fat. * Increase your intake of carbonated beverages. * Increase your exposure to fresh air to improve symptoms. * Eat when you are hungry, regardless of normal mealtimes. * Drink herbal teas containing peppermint or ginger. * Avoid fatigue, and learn how to manage stress in life. * Schedule daily rest periods to avoid becoming overtired. * Eat foods that settle the stomach, such as dry crackers, toast, or soda.

Answer 76

Gestational HTN: Pregnancy Induced Hypertension (PIH) Preeclampsia Eclampsia HELLP

Answer 77

Chronic HTN Diabetes History of preterm birth Moderate to severe obstructive sleep apnea Non-Hispanic black ethnicity Obesity Age: Older than 40 years Strong family history of cardiovascular disease

Answer 78

HTN that exists prior to pregnancy or that develops before 20 weeks’ gestation w/ BP readings greater than 140/90 mm Hg 25% of women w/ chronic HTN develop preeclampsia during pregnancy Management: If BP exceeds 160/100 drug treatment is recommended

Answer 79

AKA "Pregnancy Induced Hypertension" (PIH) Gestational hypertension: A new-onset blood pressure elevation (140/90 mm Hg) identified after 20 weeks’ gestation W/OUT proteinuria BP returns to normal by 12 weeks’ postpartum MUST have an elevated BP on 2 occasions, 6 hrs apart

Answer 80

MOST COMMON hypertensive disorder of pregnancy Develops w/ proteinuria after 20 weeks’ gestation Multisystem disease process, which is accompanied by at least one of the following: - proteinuria - Elevated creatinine - Liver involvement - Epigastric or abdominal pain - Neurologic complications - Hematologic complications - Uteroplacental dysfunction Eclampsia occurs when seizure activity develops

Answer 81

Vasospasm which results in elevated BP reducing the blood flow to the brain, liver, kidneys, placenta, and lungs. Decrease liver perfusion presents as epigastric pain and increased liver enzymes Decreased brain perfusion leads to headaches, visual disturbances, and hyperactive deep tendon reflexes (DTRs) Decreased kidney perfusion leads to decreased urine output Proteinuria of 300mg or greater in a 24-hour urine specimen

Answer 82

No signs of renal or hepatic dysfunction Bed Rest (lateral recumbent position) Diet Monitor Fetal Status Frequent evaluation of CBC, liver enzymes, platelet levels, and clotting factors Monitor protein in urine

Answer 83

Bed Rest (dark and quiet room to decrease stimulation) Diet Anticonvulsants (Magnesium Sulfate) Corticosteroids (Betamethasone) Fluid and Electrolyte Replacement Antihypertensive

Answer 84

Calcium antagonist and CNS depressant Uses: Prevents seizures; lowers blood pressure MOA: Relaxes smooth muscle of the uterus through calcium displacement - Crosses the placenta - Excreted by the kidneys Common Side Effects: Headache, visual disturbance, lethargy, N/V

Answer 85

Absence of reflexes, respiratory depression, oliguria, confusion, cardiac arrest *Use with caution in women w/ renal insufficiency and Myasthenia Gravis*

Answer 86

Blood Pressure Magnesium Levels (every 6-8 hours) Respirations Reflexes Urinary output Fetus Calcium Gluconate at bedside (reversal agent for Magnesium toxicity) After birth, the neonate should be monitored and observed for magnesium toxicity for 24-48 hours

Answer 87

Help prevent or reduce the frequency and severity of respiratory distress syndrome and intraventricular hemorrhage in the premature infant Stimulate surfactant production in the unborn baby Administered 2 doses IM 24 hours apart Effects seen as soon as 48 hours after initial administration Nursing Implications: Monitor maternal lung sounds and signs of infection

Answer 88

Increasing edema Worsening headache Epigastric Pain Visual Disturbances Decreasing Urinary Output Nausea/vomiting Bleeding Gums Disorientation Generalized complaints of not feeling well Hyperactive Reflexes

Answer 89

Eclamptic seizures are a MEDICAL EMERGENCY!!! - Convulsive activity starts w/ facial twitching - Next is generalized muscle rigidity The hallmark neurologic complication of preeclampsia, the onset of seizure activity Signs & Symptoms: - BP of 160/110 mm Hg - Marked Proteinuria - SEIZURES - Hyperreflexia Other symptoms may include: severe headache, generalized edema, epigastric pain, visual disturbances, cerebral hemorrhage, renal failure, HELLP Face distortion w/ protruding eyes & foaming at the mouth Respirations cease for the duration of the seizure, resulting from muscle spasms->compromising fetal oxygenation

Answer 90

Tongue biting Head trauma Broken bones Aspiration Coma usually follows the seizure activity, with respiration resuming

Answer 91

Use ABC Prioritization: Clear the airway & provide supplemental oxygenation Position the woman on her left side and protecting her from injury during the seizure Suction equipment must be readily available to remove secretions from her mouth after the seizure is over IV fluids are administered after the seizure at a rate to replace urine output and additional insensible losses Monitor fetal HR closely Magnesium sulfate is administered IV to prevent further seizures and continued for at least 24 hours after the woman’s last seizure Serum magnesium levels, respiratory rate, reflexes, and urine output in women receiving magnesium sulfate are closely monitored to avoid magnesium toxicity and prevent cardiac arrest. Hypertension is controlled with antihypertensive medications. If she is found stable, birth via induction or cesarean birth is performed -Remains stable, she will be transferred to the postpartum unit for care. - Becomes unstable after giving birth, she may be transferred to the critical care unit for closer observation

Answer 92

Deliver Placenta

Answer 93

H: Hemolysis EL: Elevated Liver Enzymes LP: Low Platelet Count Symptoms include: N/V, flulike symptoms, epigastric pain Variant of Preeclampsia and Eclampsia Increased risk of cerebral hemorrhage, retinal detachment, hematoma/liver rupture, acute renal failure, disseminated intravascular coagulation (DIC), placental abruption, and maternal death

Answer 94

Anemia: Low Hemoglobin Thrombocytopenia: Low platelets <100,000 Elevated liver enzymes: - AST aspartate aminotransferase exists within the liver cells and with damage to liver cells, the AST levels rise > 20 u/L. - LDH – When cells of the liver are lysed, they spill into the bloodstream and there is an increase in serum > 90 u/L

Answer 95

Focuses on stabilization of blood pressure and assessment of fetal well-being to determine the optimal time for birth Treatment based on the severity of the disease, the gestational age of the fetus, and the condition of the mother and fetus Lower high BP w/ rapid-acting antihypertensive agents, prevention of convulsions or further seizures with magnesium sulfate, and use of steroids for fetal lung maturity if necessary, followed by the birth of the infant and placenta Client should be admitted or transferred to a tertiary center with a neonatal intensive care unit. Magnesium sulfate is used prophylactically to prevent seizures. Antihypertensives such as hydralazine or labetalol are given to control blood pressure Birth may be delayed up to 96 hours so that betamethasone or dexamethasone can be given to stimulate lung maturation in the preterm fetus

Answer 96

Arises when a mother w/ blood type O becomes pregnant with a fetus w/ different blood type (type A, B, or AB) - Most commonly involves one of two issues: blood type or Rh factor The mother’s serum contains naturally occurring anti-A and anti-B, which can cross the placenta and hemolyze fetal red blood cells Usually less severe than Rh incompatibility

Answer 97

1) Rh (-) woman & Rh (+) man conceive a child 2) Rh (-) woman carries Rh (+) child 3) Cells from Rh (+) fetus enters mom's bloodstream 4) Woman becomes sensitized: Antibodies form to fight Rh (+) blood cells 5) In the next Rh (+) pregnancy, maternal antibodies attack fetal RBCs

Answer 98

Hemolysis Generalized Edema CHF Jaundice

Answer 99

Measures # of Rh+ antibodies in maternal blood (indirect antiglobulin test) Screens pregnant women for antibodies that may cause hemolytic disease in the newborn Negative – Fetus at no risk Positive – Fetus at risk

Answer 100

On infant to detect antibody coated Rh+ blood cells (Direct antiglobulin test) A positive result indicates an immune mechanism is attacking the baby’s own RBC’s Rh incompatibility

Answer 101

Given to Rh(-) woman Given @ 28 weeks gestation Given within 72 hours after birth - After: Abortion, chorionic villus sampling, ectopic pregnancy, amniocentesis Given IV or IM Indication: to prevent Rh (-) woman from developing Rh antibodies

Answer 102

A condition in which there is too much amniotic fluid (more than 2,000 mL) surrounding the fetus between 32 and 36 weeks