complications of pregnancy Flashcards
Assessment and triage (think acronym)
OLDCART
Onset
Location
Duration ** how long has it been happening, how long have the current symptoms lasted **
Characteristics **color of bleeding is significant ** discomfort? skin lesions? cough?
Aggravating factors
Relieving factors
Treatments tried patient tried and what provider tried
Management of a crisis situation assess
VS FIRST THING WE NEED TO DO IS DETERMINE THE MOTHERS BASELINE
Pulse O2 and symptoms of oxygenation
mental status
tissue perfusion capillary refill
fetal status will deteriorate with mother
bleeding, assess for DIC
Urinary output (consider foley catheter)
what is a very serious indicator of placental perfusion
fetal status
what has one of the highest fetal loss rates associated with it?
DKA!
VASCULAR BED DRIES UP VREMARKABLY WITH DKA
LACK OF PLACENTAL PERFUSION IS WHAT IS RESPONSIBLE
what is the minimum amount of output we want to see
30 mL per hour
lab work and testing ???
not sure what to go here
maternal mortality
- 880 women die DAILY from complications with childbirth ** need trained provider, MD, midwife
- western, central and sub-sahara africa 1:28, over 200 in Asia
- western europe = greater access to health care 1:11,900
- US 1:5,000
- lower income countries have much higher mortality rates 1:45 births
leading cause of maternal mortality
hemorrhage in immediate postpartum period
** at risk for up to 6 weeks after **
other causes of maternal mortality
- leading cause after 365 days is cardiovascular conditions ** potentially d/t the extra circulating blood flow, increase cardiac load
- HTN 14%
- infections
- amniotic embolism
- sepsis 11%
- embolism 3% (hypercoagulable state)
- other direct 10% other conditions worsened by pregnancy
- indirect 28% trauma, suicide, drug OD
complications during first trimester
- ectopic pregnancy
- miscarriage
- hydatidiform mole pregnancy
- hyperemesis gravidarum
what is an ectopic pregnancy?
- gestation implanted outside of the uterus
sites for ectopic pregnancy
- fallopian tube 98%
- ovary 1%
- cervix 1%
- abdomen <1%
what increases the risk of ectopic pregnancy
- damage to fallopian tubes
EX PELVIC INFLAMMATORY DISEASE
incidence of ectopic pregnancy
women 20-29
2% of US pregnancies, higher in nonwhite women and increases with age
tripled since 1970s d/t higher incidence of STDs, pelvic inflammatory disease, increased use of IDUs
25% of ectopic pregnancies will have another ectopic pregnancy ** bc cause is still there, whatever caused the first one to exist can cause the same thing in additional pregnancies **
what is the most common cause of maternal morbidity before 20 weeks gestation
ectopic pregnancy
risk factors for an ectopic pregnancy
- PID and endometriosis ** bc of scarring and adhesions **
- use of IUDs
- tubal surgery ** bc of scarring and something to cilia **
- tubal tumors/congenital tubal anomalies (accessory tubals and excessively long tubes)
history of: previous ectopic pregnancy, abdominal/pelvic surgery, appendicitis/therapeutic abortion/infertility … esp with ruptured appendix… materials throughout the abdomen that can cause scarring and adhesions
** infertility might tell us there have been scarring of the tissues and something happened **
manifestations of ectopic pregnancy
- abdominal pain (L/R/bilateral
- amenorrhea
- abnormal vaginal bleeding (esp spotting around the time that they’re supposed to get their period)
- swelling in one leg (puts pressure on the lymphatic system that is trying to bring fluid black up from the leg… obstructs fluid from getting back)
- shoulder pain referred pain when something is wrong with the tubes
if the fallopian tube is still intact during ectopic preg
- treatment may be surgical
- pt may be treated with METHOTREXATE chemotherapy agent to dissolve the pregnancy but maintain tube patency and potential fertility
methotrexate will cause the death of fetal tissue and allow for reabsorption of it without making the situation worse
if fallopian tube ruptures during ectopic preg
- symptoms may include abdominal pain, N/V, diarrhea, unilateral palpable pelvic mass (hematoma), dizziness and hypovolemic shock
- surgery is required (potential for hemorrhage) NEED TO GET THE BABY OUT!!! SHE IS AT RISK FOR PPH
Spontaneous abortion (miscarriage)
- early = before 12 weeks
- late = btw 12 and 20 weeks
- habitual abortion = individual had 3 or more consecutive miscarriages ** usually d/t an incompetent cervix
- chromosomal aberrations estimated to account for as many as 50% of spontaneous abortions autosomal trisomies
- threatened abortion - suggested when a woman experiences vaginal spotting or bleeding early in pregnancy
what is a threatened abortion
- falls under spontaneous abortion
- occurs in 20% of all diagnosed pregnancies half abort
- cervix is not dilated, placenta is still attached to uterine wall but some bleeding occurs
- stuff is going on but will not necessarily lead to miscarriage
- placenta is still attached to uterine wall but still experiencing some bleeding
inevitable abortion
- occurs when cervix has begun to dilate, uterine contractions are very painful and vaginal bleeding increases… membranes rupture as the process proceeds
- CANNOT BE PREVENTED
- placenta has separated from the uterine wall, the cervix has dilated and bleeding has increased
incomplete abortion
- occurs when cervical dilation results in partial expulsion of the products of conception, some of these products are retained in the uterus
- excessive bleeding occurs, risk of infection increases
- embryo or fetus has passed out of the uterus, but the placenta remains
classifications of spontaneous abortion 5
- complete
- septic
- missed
- autolysis
- habitual abortion
complete abortion
- all products of conception are entirely expelled
- very few complications, emotional support = necessary bc mom is grieving
septic abortion
- usually parts are retained, immediate termination of pregnancy by method appropriate to duration of pregnancy is needed
- cervical culture and sensitivity studies are done and broad spectrum antibiotic therapy is started
- vaginal vault is aerobic, uterine cavity is anaerobic so treat with both
- often a self induced abortion… like coat hangers
- treat for septic shock if necessary
missed
- the fetus dies but continues to be retained in the uterus 8 weeks or longer
- individual will spontaneously go into labor and fetus will pass
autolysis
- after four weeks with a dead infant within the mother… the dead cells start to release enzymes that cause the breakdown of clotting factors and can lead to DIC in the mother
- once fetus is dead for a while it will release enzymes and hemolysis can occur… seep past the placenta and into maternal circulation leading to he mother losing part of her ability to clot which would incr risk of hemorrhaging
habitual abortion
- a purse string suture called a SHIRODKAR (cerclage) or McDonald procedure may be done to close the cervix temporarily or permanently (to maintain pregnancy)
- usually done on the outside of the cervix but if damage to the cervix this will lead to going in through the abdomen and then going to the upper part of the cervix… then suture will just stay in there and patient needs a c-section
- if they clip it will she go into spontaneous labor???
- will get into second trimester but weight of pregnancy starts to overcome what the cervix can hold
- cervix dilates 15-20 weeks
- done through vaginal vault, the shirodkar (cerclage) is clipped near full term
- can also be done abdominally if there is damage to cervix - then they need a c-section
hydatidiform mole (molar pregnancy)
○ Trophoblastic disease- developmental error of placenta causes the development of cyst like clear vesicles resembling a bunch of grapes
■ Often not compatible with fetal life
two types of molar pregnancies
■ Complete- all vesicles and no fetus
■ Partial- has vesicles and a rarely viable fetus
- Fetus not well nourished
- Uterus gets very large
are tumors in molar pregnancies malignant or benign
○ Usually benign but can be choriocarcinoma, rapid growing cancer form with a high rate of cure
■ If a molar pregnancy develops very late in the pregnancy then there is a slight potential the fetus services… lungs are the most common site for tumor to metastasize
○ Incidence: 1 in 1000 pregnancies, incidence over age 45 10x greater
symptoms of molar pregnancy
■ Apparently normal first trimester
■ Uterine bleeding is the most outstanding
● Often brownish (prune juice appearance)
■ Possible anemia
■ SOB
● Relates to metastasizing cancer
■ Uterine size often exceeds fundal height expected for gestation
■ Fetal activity and FH tones absent
■ Hyperemesis gravidarum common
■ Preeclampsia develops before 24 weeks
● Hypertensive disorder
■ Very high levels of serum hCG
● Hormone that is released very early on in pregnancy
hyperemesis gravidarum in molar preg
Extreme form of morning sickness
● High hormone levels
● More placental tissue –> more hormone produced –> preeclampsia can develop earlier than 24 weeks gestation
how is hydatidiform mole pregnancy confirmed
- through ultrasound
- requires IMMEDIATE EVACUATION of pregnancy and follow-up chemotherapy if malignant
- tissues are VERY responsive to chemotherapy if this is done early
what is monitored when hydatidiform mole pregnancy is confirmed
- serum hCG levels… until they are normal
- ■ Non-pregnancy levels are achieved to watch for placental tissue growth throughout the body
■ Then q month x 6 months then q 2 months for 1 year
■ AT LEAST A YEAR YOU MONITOR
■ Want follow up chest x-rays done on her
In regards to the lungs what is done when there is a hydatidiform mole preg
- baseline x-ray of lungs is taken and compared to pre-evacuation x-ray
how long should a preg be avoided after hydatidiform mole pregnancy
preg should be avoided during the 1 year follow up
any new pregnancy will create a hormonal situation that will encourage mastitis situation
hyperemesis gravidarum
- exaggerated form of morning sickness may have weight loss, need lots of hydration
○ Increased or prolonged nausea & vomiting in pregnancy potentially affecting the mother and fetus
○ Etiology-likely caused by a combination of factors
○ Appears to be related to high or rapidly increasing levels of hCG or estrogens
■ We know placental tissue is growing… we know we are at a good chance of having a viable pregnancy but this is very uncomfortable for the mother
○ Evidence of transient hyperthyroidism has been noted
○ Psychological and social factors, as family conflict, may play a role
○ IV therapy initiated to treat dehydration; adequacy of hydration assessed by measuring urinary output
○ Small, frequent feedings as tolerated; high calorie tube feedings is an option
○ Antiemetics often help (like zofran)
○ Acupressure has been used successfully
complications of the 2nd and 3rd trimesters
○ Hypertensive disorders of pregnancy ○ Diabetes in pregnancy ○ Preterm labor ○ Hemorrhagic disorders ○ Hyperemesis gravidarum ○ Vasa previa ○ Uterine rupture ○ Lacerations ○ Pulmonary embolism ○ Cephalopelvic disproportion ○ Cord Prolapse ○ Fetal distress ○ Shoulder dystocia z
