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Complications in Pregnancy - Maternal Care Challenges Flashcards

1
Q

Gestational Conditions

A
  • Disorders that did not exist before pregnancy
  • Occurrence puts woman and fetus at risk
    Hypertension in in pregnancy (chronic hypertension, preeclampsia, HELLP syndrome, eclampsia)
  • Gestational diabetes mellitus
  • Hyperemesis gravidarum
  • Hemorrhagic complications (PPH)
  • Surgery during pregnancy
  • trauma
  • infections during pregnancy
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2
Q

Hypertension in Pregnancy: Significance and Incidence

A
  • hypertensive disorders of pregnancy are increasingly common, involving 5-10% of pregnancies
  • not the most common issue, but the more common ones dont have the same negative consequences
  • women over 40 years of age are a highest risk
  • hypertension is the leading cause of maternal and perinatal morbidity and mortality worldwide
  • SOGC has recommendations regarding prevention of pre-eclampsia and its associated complications
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3
Q

Hypertensive Disorders of Pregnancy: Definition

A

Systolic BP > 140 mm Hg and diastolic BP > 90 mm Hg
Severe Hypertension: systolic BP > 160 and diastolic BP > 110

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4
Q

Chronic hypertension

A

hypertension present before pregnancy

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5
Q

Superimposed preeclampsia

A

chronic hypertension in association with pre-eclampsia (after 20 wks gestation)

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6
Q

Gestational hypertension

A

Hypertension develops at or after 20 weeks of gestation in previously normotensive woman without proteinuria

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7
Q

Preeclampsia

A

Hypertension develops at or after 20 weeks of gestation in previously normotensive woman with proteinuria. determined through ketones on a pee stick

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8
Q

Severe preeclampsia S&S

A
  • hypertension
  • proteinuria
  • cerebral disturbances
  • epigastric pain
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9
Q

Eclampsia

A

seizure activity or coma in woman diagnosed with preeclampsia (no other reason)

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10
Q

Preeclampsia Pathophysiology

A
  • differs from chronic hypertension (because NOT pregnant)
  • the main pathogenic factor is not an increase in BP but poor perfusion resulting from vasospasm
  • believed to be an interaction between cardiovascular and uteroplacental responses to pregnancy
  • caused by disruption in placental perfusion and endothelial cell dysfunction
  • arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and increases BP
  • women who are pregnant have increased BV and more cardiac requirements, more effort. risk for vasospasm is higher
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11
Q

Maternal Risk Factors

A
  • age
  • parity
  • obesity
  • diabetes
  • hypertension
  • autoimmune diseases
  • sickle cells anemia
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12
Q

Signs and Symptoms of Preeclampsia (9)

A
  • swelling of face and hands
  • fluid retention (decreased urine output)
  • sudden weight gain (>2 lbs/weeks/6lbs/mos)
  • persistent headache
  • seeing spots or changes in eyesight
  • pain in the upper abdomen or shoulder
  • Nausea and vomiting (in the second half of pregnancy)
  • Difficulty breathing (dyspnea)
  • Tachycardia
    It is easy to write off all these symptoms as normal pregnancy symptoms.
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13
Q

Nursing Care Management Preeclampsia: Assessment

A

First Sign - Elevated BP
2nd Sign - Proteinuria
3 Questions: do you have a headache? Visual disturbance? RUQ epigastric pain?
Fetal health surveillance (nonstress test, contraception stress test, laboratory stress)
women get their BP check eery prenatal appointment. checked and cataloged, pee on the stick every visit is no longer used. it wasnt indicating it and most women produce ketones to some level in pregnancy. proteinuria has to be accompanied by other symptoms

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14
Q

Plan of care Preeclampsia - ensure maternal safety & healthy baby. Mild preeclampsia

A

home care
- fetal health surveillance
- activity restriction
- diet

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15
Q

Plan of care Preeclampsia: severe preeclampsia and HELLP Syndrome

A
  • hospital care (O2 for perfusion) -
  • magnesium sulphate (1-1 care)
  • control of BP (<160/100)
  • no NSAIDS (elevate liver enzymes)
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16
Q

HELLP Syndrome

A

hemolysis, elevated liver enzymes, and low platelets - factors very specific to HTN in pregnancy. If not treated immediately maternal death.

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17
Q

Nursing Care management: Eclampsia

A
  • immediate care
  • postpartum nursing care
  • future health care
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18
Q

Magnesium Sulphate Side Effects

A
  • facial flushing
  • hypotension
  • metallic taste
  • N&V
  • palpitations
  • sweating
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19
Q

Magnesium Sulphate Toxicity

A
  • muscle weakness
  • loss of DTRs
  • hypothermia
  • respiratory depression
  • altered cardiac condition
  • circulatory collapse
20
Q

How to fix hypertensive disorders in pregnancy (HDP)

A

the only was to fix HDP is to delivery the baby and remove the placenta. The method of delivery will depend on severity and condition of fetal well-being

21
Q

Gestational Diabetes Mellitus

A
  • hyperglycemia that is first recognized in pregnancy
  • prevalence: 3.8-6.5%
  • higher among aboriginal, latin american, south asian, asian, and african women
    Maternal and fetal risks:
  • 2 times the risk of developing hypertensive disorders
  • uncontrolled GDM can impact fetus development (LGA)
22
Q

Risk factors for GDM

A
  • age, hx, obesity, polycystic ovarian syndrome
    Identify hyperglycemia early
23
Q

Interventions GDM: antepartum, intrapartum, postpartum

A

Antepartum:
- diet
- exercise
- monitoring blood glucose levels
- insulin therapy
- fetal surveillance
Intrapartum - monitor q1h, FHR, no glucose IV bolus
Postpartum - returns to N, reoccurs, risk of T2DM later

24
Q

Management of Infants of Mother with Diabetes

A

Critical to stabilize the newborn’s blood glucose
- in first two hours of life, even a healthy term newborn’s blood glucose falls
- early S2S & initiation of BF
- frequent BF
- blood sugar levels monitored as per protocol & intervention to maintain blood glucose in target range
- May be a medical indication of supplementation with expressed breast milk or if EBM not available, formula
Critical to ensure testing & feeds as per protocols
May need to be admitted to NICU for IV D10W

25
Symptoms of Hypoglycemia in a Baby (12)
- jittery - temp instability - sweating - apnea/bradycardia - irritability - tachypnea - pallor - poor feeding - weak cry - hypotonia - seizures - loss of consciousness
26
Hyperemesis Gravidarum
Nausea and vomiting during pregnancy is the most common medical condition affecting 50-90% of women at some point in their pregnancy - HG is protracted vomiting, retching, severe dehydration, and weight loss requiring hospitalization - usually begins during the first 10 weeks of pregnancy
27
Etiology of HG
not well understood, increased levels of Estrogen/ hCG, assoc. with transient hypothyroidism
28
Clinical manifestations and assessment of HG
- wt loss, dehydration, low BP, increased pulse, poor skin turgor - assessment: severity (freq, duration, diarrhea, wt. fluid/electrolytes, ketonuria, dehydration, CBC, psychosocial)
29
Care of HG
Initial care: clear fluids to diet with protein, IV, antiemetics, I &O Follow up care: small freq high protein/bland meals, Mg, K, decrease orders - compassionate, sympatheticcare
30
Hemorrhagic Disorders
hemorrhagic disorders in pregnancy are medical emergencies (hypovolemia) - 50% of bleeding in the third trimester is placenta previa or placental abruption
31
Early Pregnancy Bleeding
Miscarriage (spontaneous abortion) Clinical manifestations: back pain, cramping, bleeding - early pregnancy 1-6 weeks: heavy menstrual flow - early pregnancy 6-12 weeks: mod discomfort, blood loss - late pregnancy 12-20 weeks: age, parity, infection, cervical dilation
32
Types of Miscarriage
Threatened: seems like a miscarriage might happen Inevitable: started Incomplete: something is retained Complete: everything is out Missed: woman who didnt know she had one
33
Assessment of miscarriage
ultrasound, lab tests, infection, loss - medical-surgical management (rest, supportive care, cs dilation, D&C) - Nursing care - antibiotics, Transfusion, psychosocial care, & burial. - Home care - iron supp, bleeding, sexual activity, family planning, support groups, F/U phone call, loss
34
Premature Dilation of the Cervix
- incompetent cervix, cervical insufficiency - passive and painless dilation of the cervix without contractions or labour Etiology - past trauma, D&C, short cervix - medical surgical management - conservative management of restricted activity and hydration. Prophylactic cerclage (24 weeks) - removed at 35-37 wks Nursing care - monitor for contractions, PROM, infection Home Care - decrease activity, bedrest, bleeding Cervix is not staying closed. no contractions. incompetent cervix.
35
Ectopic Pregnancy: clinical manifestations
Fertilized ovum implanted outside uterine cavity 95% occur in uterine (fallopian) tube Clinical manifestations: missed menstrual period. Abdominal pain. Mild-to-moderate dark red or brown intermittent vaginal bleeding occurs in up to 80% of women
36
Nursing Care: Ectopic Pregnancy
Treatment options: salpingostomy (surgical opening of fallopian tube), salpingectomy: removal of fallopian tube Hospital care: pre-op/post-op, V/S, discuss future fertility Home care - loss & grief/infertility support groups No ectopic pregnancies are viable. they will not grow past the trophoblastic phase. it is going to burst the fallopian tube which is lifethreatening for the woman and decrease her fertility
37
Late Pregnancy Bleeding - Placenta Previa
placenta implanted in lower uterine segment near or over cervical os classification based on degree of cervical os is covered by placenta - complete placenta previa: covers internal cervical os completely - marginal placental previa: 2.5 cm or closer to the cervical os - low-lying placenta - no measurement of edge of placenta to cervical os Diagnosis: transabdominal u/s exam, transvaginal u/s
38
Risk factors, manifestations, fetal and maternal for placenta previa
Risk Factors: previous placenta previa, c/s, endometrial scarring Clinical Manifestations: diagnosed by u/s, painless bright red vag. bleeding Outcomes: hemorrhage, abnormal placental attachment, poor placental exchange, hysterectomy - fetal risk: malpresentation, stillbirth, fetal anemia preterm birth
39
Late Pregnancy Bleeding: Abruption
Premature separation of placenta - grades: mild, moderate, severe Clinical manifestations: partial or complete separation - dark, vaginal non-clotting bleeding - abdominal back pain - port-wine stained amniotic fluid - uterine contractions - uterine tenderness Maternal: hemorrage, hypovolemic shock, thrombocytopenia, renal failure Fetus: abnormal FHR patterns, neurological defects, IUGR, death, > incidence of SIDS
40
Infections Acquired During Pregnancy
Sexually transmitted infections: impact morbidity rates, infertility UTI: responsible for 10% of hospitalizations Asymptomatic bacteriuria: antibiotics, repeat urine culture Cystitis (bladder infection) - dysuria, urgency, suprapubic pain, 3-day course of antibiotics which may stain urine orange Pylenophritis - kidney stones. common, 2nd trimester, fever, chills, pain in lumbar area, N&V, admitted with IV antibiotics, monitor for sepsis, regular urine cultures
41
Trauma During Pregnancy
Physical Trauma: MVA, falls, burns, violence Effects of trauma on pregnancy is influenced by the following: length of gestation, type and severity of the trauma, degree of disruption of uterine and fetal physiological features - fetal death Significance - 6-7% of pregnancies are complicated by physical trauma. accounts for 46% of maternal mortality, special considerations for mother and fetus: physiological alterations of pregnancy, fetal survival depends on maternal survival, pregnant woman must receive immediate stabilization and care for optimal fetal outcome Fetal physiological characteristics - careful monitoring of fetal status - fetal monitor tracing works as an "oximeter" for fetal well-being
42
Perimortem C/S
- poor fetal survival with C/S > 20 min after maternal death - consider C/S after 4 minutes of resusc. with no response in the mother - rarely successful
43
Postpartum Hemorrhage Definitions and Incidence
Leading cause of maternal death worldwide, preventable Postpartum hemorrhage (PPH) traditionally defined as: Loss of >500 mL of blood after vaginal birth Loss of >1000 mL after Caesarean birth Any blood loss that has the potential to cause hemodynamic instability Among leading cause of maternal mortality worldwide Life-threatening, with little warning Early/ Primary – within 24 hrs of birth Late/secondary - > 24 hrs – 6 weeks post birth Due to retained placenta fragments /infection Subinvolution of uterus (retained frag, pelvic infection) Discharge teaching – signs of normal involution, complications
44
Etiology of PPH - 4 Ts
Tone: Uterine atony - marked hypotonia of uterus, leading cause of early PPH Trauma: lacerations of birth canal, uterine inversion, hematomas Tissue: retained placental fragments, placenta acreta, increta, percreta Thrombin: Various clotting disorders, correction of underlying cause
45
Nursing Care Management PPH
Assessment: - early recognition is critical 1. Evaluation of contractility of uterus. Firm massage of fundus Administer intravenous fluids and medication to manage bleeding. Active management of 3rd stage to prevent PPH Oxytocin admin after delivery of fetal shoulder Immediate fundal massage after complete birth Plan of care and implementation Hypotonic uterus – massage, elimination of bladder distention, IV Bleeding with a contracted uterus (manual exploration of uterine cavity for placenta Pharmacologic remedies – homeostatic actions or oxytocin agents
46
Postpartum Infections
Peurperal infections: any infection of genital canal within 28 days after abortion or birth - most common infecting agents are the numerous streptococcal and anaerobic organisms - endometritis - wound infections - UTI - mastitis
47
Structural Disorders Related to Child-bearing
- disorders of uterus and vagina related to pelvic relaxation and urinary incontinence are often the result of child-bearing - uterine displacement and prolapse - posterior displacement, or retroversion - uterine prolapse: more serious displacement Cystocele: protrusion of bladder downward into vagina when support structures are injured Rectocele: herniation of the anterior rectal wall through relaxed or ruptured vaginal fascia and rectovaginal septum Urinary incontinence

Maternity (16 decks)

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