Class 3 - pregnancy complicated Flashcards
What are 2 leading causes of newborn morbidity and mortality?
- Preterm
- multiple births
What helps a new born achieve good mortality?
fetal wellbeing
What is an important factor in fetal well being (the foundational organ)
utero-placental function
ie) the placenta
What occurrences put a pregnant person and fetus at risk?
- hypertension in pregnancy
- Gestational DM
- Hyperemesis gravidarum
- hemorrhagic complications
- surgery during pregnancy
- trauma
- Infections during pregnancy
What morbidity issues do Hypertensive disorders in pregnancy cause in the maternal person?
Stroke
acute renal failure
pulmonary edema
HELLP syndrome
cerebral edema w/seizures
What does HELLP stand for?
Hemolysis (break down of RBC) - they get stuck on the thrombosis/platelets and tear
elevated liver enzymes - liver not being perfused
low platelets- thombosis collects platelets
What maternal mortality issues can hypertensive disorders cause in pregnancy?
hepatic rupture
placental abruption
eclampsia - seizures
What is the fetus of the pre-eclamptic patient at increased risk from?
Placental abruption
preterm birth
IUGR (intrauterine growth restriction)
acute hypoxia
what is IUGR
intrauterine growth restriction
what is considered non-severe hypertension in pregnancy?
> or = 140 sytolic
or = 90 diastolic
how many measurements of an abnormal BP are needed to diagnose non-severe hypertension?
at least 2 measurments
how many min should we wait before taking a second BP?
15 min apart
AFTER 5 min of rest
What is considered severe hypertension?
> or = 160 systolic
or = 110 diastolic
Which is an emergency, severe hypertension or non-severe hypertension and how quickly do we need to act?
severe hypertension
treat within 30-60 min (goal is ASAP)
Hypertensive disorders of pregnancy can cause death of the pregnant person by causing the following issues:
intracranial hemorrhage
eclampsia or cerebra edema
pulmonary edema
hepatic rupture
hepatic necrosis/HELLP
which BP number do we record if BP is consistently higher in one arm? The lower or higher arm?
go with the higher BP
should we use automated BP machine or manual for someone with pre-eclampsia?
manual
unless automated has been approved
What are the 3 types of hypertension in pregnancy?
- chronic hypertension <20 weeks
- gestational hypertension >20 weeks
- Pre-eclampsia - hypertension & proteinuria
How do we identify chronic hypertension?
<20 weeks gestation
no s/s of organ damage
high BP
How do we identify pre-eclampsia?
- High BP with complications
- > 20 weeks gestation
- Proteinuria
- organ damage s/s
- 3x hypertension treatment failure
Why are we worried if someone has chronic hypertension?
increased risk of:
1. poor fetal growth
2. fetal still birth
What is gestational hypertension?
- detected at or after 20 weeks in previous normotensive peeps
- hypertension but no pre-eclampsia (no complications)
- Systolic is > or = 140
- Diastolic > or = to 90
- no proteinuria
- no s/s of organ damage
25% go on to develop pre-eclampsia
What is pre-eclampsia defined as?
multisystem
vasospastic disease procress
What is the main pathogenic factor of pre-eclampsia and why?
poor perfusion d/t vasospasm
Is pre-eclampsia from high BP or vasospastic disease process, or both?
Vasospastic disease process
- the placenta impants funny and sends out inflammatory factors that cause endothelial cells to go wacko and increase BP to help with perfusion
Results in:
-reduced tissue perfusion to major organs
- increases blood pressure
What are the risks for developing pre-eclampsia?
- nullipartiy
- age >40 (35+)
- IVF
- 7 years between preggers
- family history
- pre preg BMI >30
- Gest. DM
- multifetal gestation
- pre-eclampsia in previous preggs
- previous pregs poor outcome
- PMHX/genetic conditions
- chronic HTN
13 . renal disease - DM 1
- antiphospholipid antibody syndrome
- factor V Leiden mutation
- OSA obstructive sleep apnea
what is the theory etiology of pre-eclampsia?
- something wrong with placenta
- signals to preggers person to increase perfusion
- endothelial cells control vasoconstriction/dilation but they get confused
- vessels leak out more protien and fluid causing edema
- edema in brain = seizures = eclampsia
How do we check for proteinuria?
pee dip stick
min 2 random samples <6hrs apart.
should not have UTI
how often do we check for proteinuria?
during an apt or if pesron has hypertension.
test 1 - pass - stop
test 1 - fail - 2nd test at least 6 hrs apart (no UTI)
24 hour urine test
If fail = has proteinuria = stop testing
What CNS symptoms in preesclampsia require close monitoring?
- headache 8/10
- visual distrubances - aura sightings/ flashing lights
what are the signs & symptoms for eclampsia?
- headache
- severe epigastric pain
- Hyperreflexia (hammer to test. If you don’t need hammer , +3,+4 = not good
What is the worry during an eclampsia episode?
during the seizure, the pregnant person and fetus are not getting enough oxygen
Can someone with a history of seizures be diagnosed with eclampsia?
No. because eclampsia by definition is only when they have seizures but no other history to explain it
What cardiorespiratory symptoms in preesclampsia require close monitoring?
Chest pain/dyspnea = pulmonary edema
Oxygen saturation <97%
What adverse CNS conditions of preeclampsia require delivery regardless of gestational age?
- Eclampsia
- PRES - edema in the back of the brain
- cortical blindness (reversable) / retinal detatchment
- Stroke or TIA
- GCS <13
What adverse Cardiorespiratory conditions of preeclampsia require delivery regardless of gestational age?
- uncontrolled severe HTN >12 hours + fail 3 antihypertensives
- O2 sat <90%, need 50% O2 for >1 hr, intubation, pulmonary edema
- positive inotropic meds (ie: DIG)
- MI
What adverse Hematological conditions of preeclampsia require delivery regardless of gestational age?
- platelets <50
- transfusion of ANY blood product
What hematological symptoms in preesclampsia require close monitoring?
Low platelet count <100
What Renal symptoms in preesclampsia require close monitoring?
elevated serum creatinine
What adverse renal conditions of preeclampsia require delivery regardless of gestational age?
- AKI
- new indication for dialysis
What adverse Uteroplacental dysfunction
of preeclampsia require delivery regardless of gestational age?
- Abruption w/evidence of maternal or fetal compromise
- Absent or revered ductus venous A wave by doppler velocimetry
- Intrauterine fetal death
What Uteroplacental dysfunction
in preesclampsia require close monitoring?
1.Abnormal or atypical Fetal Heart Rate (FHR) – NST
2. Fetal growth restriction
3. Oligohydramnios
4. Absent or reversed end diastolic flow by umbilical artery Doppler velocimetry – we want continuous flow in ONE direction
5. Angiogenic imbalance - measure blood levels
What is HELLP syndrome considered a variant or complication of?
pre-eclampsia
How is HELLP diagnosed?
platelet count <100
AST, ALT elevated
HELLP syndrome can occur without what two complications?
- hypertension HTN
- proteinuria
What causes low platelets?
damaged endothelial cells (confused hall monitors) use them up
how long is postpartum surveillance after birth?
up to 6 weeks
What 3 things do we test in pre-eclampsia that we don’t test in gestational/chronic HTN?
- platelets
- serum creatinine
- AST or ALT
What antihypertensives can we NOT give because they are teratogenic?
ACEs & ARBS
What meds can be given to control HTN?
Labetolol – B-Blocking agent
Hydralazine
Nifedipine
Methyldopa (Aldomet)
what is the goal diastolic BP of a preggers person with chronic/gestational/preeclampsia?
diastolic = 85mm Hg
What med is given for seizure prevention?
Magnesium Sulphate IV
When would someone become an inpatient ?
severe hypertension or preclampsia with 1 or more maternal adverse conditions
When is magneisum sulphate indicated?
pre-eclampsia with severe features & severe gestational hypertension
all cases of severe >160/110, 15+ min, regardless of classification
What is really important to remember about magnesium sulphate ?
the person should not be left alone!
toxicity risk
What is the MOA of magnesium sulfate?
CNS depression
not antihypertensive
What do we montior for peopel with magnesium sulphate?
- test reflexes for big changes
- monitor FHR
What is the antidote for magnesium sulphate?
calcium gluconate
how do we know someone has magnesium toxicity?
- decreased/absent reflexes
- lower BP, HR,
- RR (<12 for 15 min)
- lower O2 (94% for 15 min)
- Urine output <30ml/hr for 4 hr
When someone is on magnesium sulphate how often do we measure mom & fetal vitals?
mom- q 30 min
fetus >26 weeks continuous HR
how do we know that someone is having CNS symptoms from magnesium sulphate?
reflexes absent or slow
foot will continue to shake
what are our 2 greatest maternal concerns if someone is having eclampsia?
airway
patient safety
What placenta issues is someone at risk for who has eclampsia?
placental abruption
what is a risk of using magnesium sulphate?
hemorrhage because the uterus can’t contract the way it normally would to stop bleeding after delivery
What is Gestational diabetes mellitus?
any degree of glucose intolerance with onset during pregnancy
What are the risks if someone has either pre-existing DM or gestational DM?
-Fetal macrosomia
-Large for gestational age
-Fetal Hypoglycemia, IUGR (interurerine growth restriction) , intrauterine fetal death, fetal lung immaturity
-Neonatal hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia
-2x risk of hypertensive disorders (pre-eclampsia)
-Infection
-Trauma and injuries during birth
-Caesarean birth
-Shoulder dystocia and nerve injury
-Preterm delivery
Why does diabetes cause big babies?
high glucose causes the fetus to release insulin.
Insulin lets glucose into the cells
1. Stimulates fat storage
2. causes organs to grow
What are the 4 MAIN things that someone is at risk for with diabetes?
- c-section
- shoulder dystocia
- trauma
- pre-term birth
What medication makes someone at risk for developing GDM?
corticosteroid meds
how many weeks do we screen people for GDM?
24-28 weeks
When do we screen people who have type 2 diabetes ?
at initial prenatal visit
take A1C
If normal = <6.5 screen again at 24-28 weeks with 50g OGTT
What is the two step approach for screening GDM?
- Step 1= Random non-fasting 50g OGTT
- 1 hour Plasmas glucose <7.8mmol
STOP - Step 2 = 75g OGTT
- 1 hr plasma glucose >or = to 11.1 mmol/L
diagnosed GDM
STOP - Step 1 >11.1 stop
Automatic GDM
After 50g glucose challenge test how long do we wait to test plasma glucose?
1 hour
When someone has GDM how long do we wait for activity and lifestyle modification before starting pharmacology therapy?
1-2 weeks trial
What is the recommended weight gain for “normal weight?”
11.5-18 kg (25-35 lb)
What do we check for in urine of people with GDM?
leukocytes or nitrates
glucose
protein
What is very important for people with Diabetes to monitor with their fetus?
Kick counts
How many weeks should someone be induced who has diabetes?
consider induction 38-40 weeks
*reduces stillbirth & c-section
What is considered polyhydramnios?
Amniotic fluid >2000 ml
What is Oligohydramnios?
Amniotic fluid less than expected amount
What is polyhydramnios more common with?
Gestational diabetes
according to the AMI (amniotic fluid index), what is considered nomral, oligohydramnios, polyhydramnios?
- 10-25 cm normal
- <5 cm= oligohydramnios
- > 25cm = polyhydramnios
What are some signs and symptoms of polyhydramnios?
- vericose veins in legs
- swelling/edema
- stretched skin
- hard to find fetal heart - polyhydramnios
- polyuria
What are 4 things to measure in people with GDM intrapartum?
1.Monitor glucose closely, keep glucose between 4-7 mmol/L
2.Hydration (may require IV fluids)
3.Insulin may be required
4. Monitoring of uterine activity & FHR
How long does someone with GDM take insulin post partum and why?
Stop insulin and Diabetic diet immediately post partum
why? - cuz the placenta is out
What are we worried about with DMII and pregnancy in the 1st trimester and early 2nd trimester?
Metabolic changes = risk of hypoglycemia
- increased insulin production
- increased tissue glycogen storage (less in the serum)
- decreased hepatic production of glucose
What are we worried about with DMII and pregnancy in the later part of 2nd trimester and 3rd trimester?
hyperglycemia
- decreased glucose tolerance
- increased insulin resistance
- decreased glycogen stores
- increased hepatic production of glucose
- increase insulin - more is required
- increased glucose is normal for non DM preggs peeps too
What should we teach those who are DMII in the preconception phase?
- healthy weight goal
- folic acid (1 mg OD X 3 months before preggers and 1st trimester. then 0.4 mg for rest of pregnancy
- A1C </= 7.0 %
- review meds if any are teratogenic
what type of prenatal care do we do for someone with DMII?
- control blood glucose
- usually switch to insulin
- frequent prenatal visits
- more lab tests
- fetal health surveillance (FHS)
What is important to monitor for pregs peeps during intrapartum care?
- BG level
- Ketones in urine
- Hydration
- shoulder dystocia
- continuous fetal HR montitor if birther has insulin
What do we monitor in someone with DMII during post partum care?
- Blood glucose levels
- preeclampsia/eclampsia
3.hemorrhage - infection
- breast feeding
- family planning
What is bleeding in pregnancy to be treated as?
a medical emergency
In the first trimester what is most bleeding a result of?
Spontaneous abortion
ectopic pregnancy
What is 50% of bleeding in the 3rd trimester from?
placenta previa
placenta abruption
why is checking for disruption of vascular integrity so important in pregnant people?
because they can bleed out within 8-10 min d/t increased fluid volume
How many weeks is considered a miscarriage or spontaneous abortion?
a loss less than 20 weeks
What are the 5 types of miscarriage?
- threatened pre loss (cramping)
- inevitable loss
- incomplete loss
- complete loss
- missed abortion
What are the symptoms of inevitable loss?
moderate bleeding, cramping mild. cervix is dilated. stuff is coming out and they are losing the fetus
What are the s/s of incomplete loss?
heavy bleeding, severe cramping. no more fetal parts inside but it’s ongoing heavy bleeding . sometimes D&C needed
What are the s/s of a complete miscarriage?
everything is out of the cervix and the cervix closes
What are the s/s of a missed abortion?
no heart beat but everything is in the urterus still . no cramping. >5 weeks there’s a risk for the person. risk of infection
if someone is bleeing, what test should we order or have ready?
Usually check serum BhCG 2x over 48 hours. should double in a normal pregnancy
Other tests will depend on symptoms and history (i.e. CBC)
Blood type and RhD antigen screening
what are two things that can happen if we don’t know the Rh status of the mother?
- placental abruption
- placental previa
(if fetus is Rh+ and mom is Rh -)
What is premature dilation of the cervix (cervical insufficiency)?
- passive and painless dilation of cervix
- can cause late miscarriages
- can lead to recurrent preterm births
what is cerclage?
closing the cervix to prevent premature birth
- until 35-37 weeks or active labour
What are the 3 causes of late pregnancy bleeding?
- placenta previa
- placental abruption
- variations in cord insertion on the placenta (should be center)
What are the risk factors for placenta previa?
- previous one
- previous c-section
- D&D
- multiples
- age >35+
- smoking
- higher altitude
What are the clinical manifestations of placenta previa?
- painless
- bright red vaginal bleeding
- 2nd and 3rd trimester
- uterus is soft, relaxed and nontender with normal tone
What are the risks of placenta previa to the fetus?
- preterm birth
- still birth
- breech etc
- fetal anemia
- IUGR
What should we never examine with placenta previa?
NO PELVIC/VAGINAL exam
how often do we monitor fetus in placenta previa?
1-2x per week
NST or BPP
what do we do (assessments/interventions) for placenta previa peeps?
- NST or BPP
- regular labs (bleeding factors)
- IV sometimes
- Winrho to help develop lungs (24-46+6 weeks)
What is a velamentous cord insertion problem?
cord gets bumped and bleeds cuz its not nice and strong
What is a battledore cord insertion problem?
cord isn’t central
What is responsible for 1/3 of all antepartum bleeding?
Placental abruption
what are the risk factors for placental abruption?
- HTN disorders with pregnancy
- cocaine use
- MVA/blunt trauma
- smoking
- previous history of one
- preterm/premature rupture of membranes
- thrombophilia
What are the S/S of placental abruption?
- sudden onset of intense pain (usually localized)
- with or without bleeding
- dark nonclotting bleeding
- hard abdomen
What is different between previa and abruption?
previa :
painless
bright red blood
soft abdomen
abruption:
painful
dark red blood - not clotting
very hard abdomen
what are maternal complications of placental abruption?
1.Hemorrhage
2.Hypovolemic Shock
3.Couvelaire Uterus (purple)
4.Infection
5. DIC - more likely with moderate or severe separation
6. Hypofibrinogenemia
7.Thrombocytopenia- low platelets
8.Organ damage
9. Rh sensitization
what are the fetal complications of an abruption?
- IUGR (intrauterine growth restriction)
- Oligohydramnios
- preterm birth
- fetal hypoxemia
- still birth
What are newborn complications of placental abruption?
- neurological defects
- cerebral palsy
- newborn death
When should someone with placental abruption not have a c-section?
if coagulopathy is severe and uncorrected
