Complications of Pregnancy: Flashcards
Abortion/Miscarriage
- Less than 20 weeks gestation
- May be induced or spontaneous
- 15%-20% of all pregnancies end in miscarriage with most in the first trimester
- Incidence increases with age.
- Causes: Chromosomal abnormalities-60%
— Infection, endocrine abnormalities and anatomic defects of uterus, fallopian tube, cervix.
Ectopic Pregnancy: most common site
the fallopian tube
Ectopic Pregnancy: s/s
severe sudden pain on one side
- Tube rupture: internal hemorrhage signs
Ectopic Pregnancy: treatment
Chemo drug: Methotrexate
- Folic acid inhibitor
— Cells need folic acid to replicate; this drug stops the replication
— Dont give foods high in folic acid:
— Leafy green veggies
— Spinach/ Kale/ beans/ lagoons/ cereal or bread fortified with folic acid
Ectopic Pregnancy: causes
- previous sexually transmitted infection/ scarring
- Multiple partner; inflamation
- IUD; scarring
- Previous miscarriages
Hydatidiform Mole-Gestational Trophoblastic Disease: MOLAR Pregnancy
Abnormal development of the placenta.
*Brown to redish bleeding
*Uterine enlargement greater than gestational age or smaller than expected. (dependent on type)
Hcg levels high
Treatment- D&C : dilation and curettage
*Monitor for uterine cancer
Placenta Previa
- Placenta is improperly implanted in the wrong area (lower uterine segment)
- seen on ultrasound
- Schedule c-section
- Cause hemorrhage
- Sudden onset of painless uterine bleeding in the later half of the pregnancy or during labor
- No Vaginal exam
- No pitocin to augment labor
Abruptio Placentae
- Is the premature separation of a normally implanted placenta from the uterine wall
- Cause hemorrhage
- May not see bleeding; blood pools behind placenta
— Look for internal hemorrhage signs - Board like abdomen with tenderness, painful bleeding either visible or concealed.
- Vasoconstriction can cause this:
— Vasoconstriction drugs
— Cocaine
— Cigarettes
— Preeclampsia/ hypertensive disease - Precipitous labor
- Short umbilical cord
Hyperemesis Gravidarum: Definition
- Excessive vomiting during pregnancy
- More frequently under age 25
Hyperemesis Gravidarum: Diagnostic criteria
- Hx of intractable vomiting in 1st half of pregnancy
- Dehydration
- Ketonuria
- Weight loss of 5% of prepregnancy weight
Hyperemesis Gravidarum: Treatment
- Control vomiting with antiemetics
— Zofran (ondansetron) - Correct dehydration: IV fluids/ (TPN/ Lipids)
- Restore electrolyte balance
- Maintain adequate nutrition
Hypertensive Disorders:
Preeclampsia
indicates that this is a progressive disease unless there is intervention to control it
Hypertensive Disorders:
Eclampsia
means “convulsion.”
- If a woman has a convulsion, she is considered “eclamptic”
Hypertensive Disorders
*Preeclampsia
– characterized by development of hypertension, proteinuria, and *sudden onset of edema
- Increase in systolic blood pressure of 30 mm hg “or” an increase of diastolic pressure of 15 mm hg over baseline after 20 weeks gestation
- On at least two occasions 6 hours or more apart
- In the absence of baseline values, a blood pressure of 140/90 has been accepted as hypertensive
Pathophysiology of PIH: pregnancy induced hypertension
- Etiology is still unclear
- Abnormal development of placental spiral arteries
- It is a multi-systemic disorder characterized by vasoconstriction which reduces perfusion to maternal organs
- Response linked to the ratio between Prostaglandins:
— Decreased Prostacyclin (vasodilator)
— Increased Thromboxane (vasoconstrictor)
Mild Preeclampsia
- Blood pressure findings:
— Rise in systolic blood pressure of 30 mm hg or more or a rise in diastolic blood pressure of 15 mm hg or more above the baseline
— 2 occasions at least 6 hours apart - Generalized edema
- Wt gain more than 1.5kg/month 3 rd trimester
- Proteinuria 1+ to 2+
Severe Preeclampsia
- BP 160/110 or higher on 2 occasions at least 6 hours apart while the woman is on bed rest
- Proteinuria > or = 5 g/l in 24 hours or 3+ or greater on 2 random urine samples collected at least 4 hrs apart
- Oliguria: urine output < or = 500 ml in 24 hours
- Cerebral or visual disturbances
- Pulmonary edema or cyanosis
- Epigastric or RUQ pain
- Impaired liver function
- Thrombocytopenia: PLT aggregation at sites of vessel tears: less circulation PLTs
- Fetal growth restriction
Risks from Preeclampsia
Maternal:
- Impacts most organ systems
- Central nervous systems changes include hyperreflexia, headache, and eclamptic seizure
- Thrombocytopenia complicates severe preeclampsia in about 10% of women
- Can be treated with mag-sulfate
Risks from Preeclampsia
Fetal-Neonatal:
- SGA
- Premature
- Hypermagnesemia: if mom is treated with mag- sulfate
Severe Preeclampsia: Treatment
- Bed rest
- Diet- high-protein, moderate-sodium diet
- Anticonvulsants - Magnesium sulfate is the treatment of choice for convulsions; antidote calcium gluconate
- Corticosteriods - controversial; can affect surfactant production
- Fluid and electrolyte replacement
- Sedatives
- Antihypertensives: calcium channel blocker= Nifedipine
— Could lower BP too low
— Headache: Tylenol or ibuprophen
— Placental abruptio???
PIH: Nursing Assessment & Diagnosis
- T,P,R,BP every1-4 hrs
- Fetal heart rate
- Urinary output
- Urine protein
- Urine specific gravity
- Edema
- Weight - daily
- Strict I & O
- ## Bed pan
- Pulmonary edema
- Deep tendon reflexes
- Placental separation
- Headache.
- Visual disturbance.
- Epigastric pain.
Deep tendon reflex rating scale:
- 4+: hyperactive; very brisk, jerky, or clonic response; abnormal
- 3+: brisker than average; may not be abnormal
- 2+: average response; normal
- 1+: diminished response; low normal
- 0: no response; abnormal
Eclampsia
- Characterized by convulsion or coma
- Occurring before the onset of labor, during labor, or early in the postpartal period
- The only known cure for PIH and eclampsia is birth of the infant
Severe eclampsia: HELLP
- Hemolysis: lycing of RBC as they pass through narrowed placental arteries
- Elevated Liver function tests: ALT/AST
- Low Platelet count
Symptoms may include - nausea, vomiting, malaise, flu like symptoms, or epigastric pain
- Perinatal morbidity and mortality with HELLP syndrome are high
- Platelet transfusions are indicated for platelet counts below 20,000/mm
ABO Incompatibility
- Type A or B has an antigen. Type O does not.
- Usually occurs with Type O mother and Type A or B infant.
— Babies blood lyces mothers blood and causes excess bilirubin= jaundice/ hyperbilirubinemia
— Combs test can be done
Rh factor
- Rh is a protien on the surface of erythrocytes, either you have it or you don’t have it
- If you have it you’re RH+
- If you dont have it you’re RH-
- If an RH neg. person is exposed to Rh pos. blood, an antigen-antibody response occurs, antibodies are formed and the person becomes sensitized.
- During pregnancy there is very little blood exchange between mother and fetus if any at all; mostly occurs during delivery
— Sensitization happens if a mom is Rh neg. And fetus is RH+
— Moms body creates antibodies against the baby’s blood (bc baby’s blood has an antigen)
— After her first birth her body will recognize the antigen and create antibodies towards it; no issue for fetus bc antibodies aren’t abundant enough to cause harm
— But during second pregnancy the moms blood has antibodies that could attack the fetus
— when antibodies attack fetus it is called erythroblastosis fetalis
— Causes agglutination and hemolysis of RBCs
—— Leads to bilirubin increase in the brain= causes Kernicterus= retardation or death
when antibodies attack fetus it is called
erythroblastosis fetalis
— Causes agglutination and hemolysis of RBCs
— Leads to bilirubin increase in the brain= causes Kernicterus= retardation or death
Rh testing/ Diagnosis: Antepartal
- At 28 weeks- Rh neg mother= titer drawn: to see if she has antibodies formed yet
- No antibody (means she’s not sensitized yet)= give RhoGam (prevents her body from developing antibodies)
- not sensitized and father is Rh positive or unknown=RhoGam
- Also give post abortion/ miscarriage
- After amniocentesis= RhoGam
Rh testing/ Diagnosis: Postpartal
- Indirect Coombs- done on mother to determine the number of Rh positive antibodies
- Direct Coombs- done on infant to detect antibody coated Rh positive
- If both negative=no sensitization-give RhoGam within 72 hrs
- If both positive= monitor infant for hemolytic disease
- If Mom negative and infant positive- give RhoGam
Rh Postpartal Management
- RhoGam prevents antibodies from being formed which prevents problems in subsequent pregnancies
- This protocol reduces the incidence of antenatal sensitization by 93%
- If not treated- leads to severe hemolysis of the infant which could lead to erythroblastosis fetalis, mental retardation or death.
Gestational Diabetes
- Gestational Diabetes occurs in 6.8%-16.3% of pregnancies
- 50% will develop Type 2 diabetes later in life
Influences of pregnancy on Diabetes:
- Disease may be more difficult to control
- Increased energy needs
- The renal threshold for glucose decreases (120-130: spills into urine)
- Increased risk of ketoacidosis
- Vascular disease may progress
- Nephropathy & retinopathy
Detection and Diagnosis of Gestational Diabetes:
Two Screening Tests
- Urine testing
- 50 g oral glucose tolerance test
Detection and Diagnosis of Gestational Diabetes:
Diagnostic Tests
3 hour glucose tolerance test
Maternal Risks: Gestational Diabetes
- Hydramnios (increased amniotic fluid; bc fetus urinates more)
- Pregnancy-induced hypertension (PIH)
- Preeclampsia
- Ketoacidosis
- Dystocia - difficult labor: baby tends to be larger in a pt with diabetes
- monilial vaginitis: yeast infections
- Urinary tract infections
- Retinopathy
Fetal Risks: Gestational Diabetes
- Congenital anomalies 5% to 10% and are the major cause of death for infants of diabetic mothers
- Anomalies often involve the heart, central nervous system, and skeletal system
- Large for gestational age (LGA) = Birth trauma
— Shoulder dystocia
— Clavicle fracture
Newborn Risks: Gestational Diabetes
- Hypoglycemia
- Lethargic/ tired
- Poor feeding
- Sweating
- Intrauterine growth restriction (IUGR)
- Respiratory distress syndrome
- Polycythemia: produce more RBC
- Hypocalcemia
- Hyperbilirubinemia
Insulin Needs
- *First trimester- decreased due to low placental hormones which are antagonistic to insulin, N/V
- *Second and Third Trimester- Increase due to resistance to insulin, increased metabolic demand
- *Labor- Maintain tight level of 80-110 mg/dl
- *Postpartum- decreases significantly- may not need at all.
Care of the Woman with Heart Disease
- Most common cause of maternal death
- Maintain cardiac output, heart rate and blood volume.
- Decrease overexertion
— Bed rest/ bed pan
— No labor
— Planned C-section
TORCH: common infections during pregnancy
- T toxoplasmosis
- O other infections
- R rubella
- C cytomegalovirus
- H herpes
Toxoplasmosis
- Caused by the protozoan, Toxoplasma gondii
- 40% to 50% of adults have antibodies to this organism
- The highest rate of fetal infection (65%) occurs when the mother contracts the infection in the third trimester
- Contracted from eating undercooked meat, drinking unpasteurized milk, contact of cat feces.
GBS- group B strep
- Leading cause of neonatal sepsis
- 20%-30% of woman are carriers
GBS treatment
- All women are screened at 35-37 weeks
- For vaginal births, if GBS positive, will receive IV antibiotic prior at the onset of birth.
Rubella (German measles)
- Are no more severe for pregnant women, nor are there greater complications in pregnant women
- Greatest teratogenic effects of rubella on the fetus is during the first trimester
- Early in the second trimester, the resultant fetal effect is most often permanent hearing impairment, microcephaly, or psychomotor retardation
Cytomegalovirus (CMV)
- Herpes simplex virus group and causes both congenital and acquired disorders
- Most frequent agent of viral infection in the human fetus
- Can result in extensive intrauterine tissue damage that leads to fetal death
- SGA, tissues and organs affected are the blood, brain, and liver, mental retardation, learning disabilities, hearing loss.
Herpes Simplex Virus
- Estimated that more than 30 million people are infected with genital herpes and that more than 500,000 new cases are diagnosed in the united states each year
- Herpes simplex virus (HSV-I or HSV-II) infection can cause painful lesions in the genital area
- if no outbreak= can be delivered vaginally.
Incompetent Cervix
- Premature dilation of the cervix.
- Cerclage- suture to hold cervix closed.
- Usually placed on bedrest.
Substance Abuse
- Alcohol- No amount is safe. Increased risk of miscarriage, preterm labor, FAS.
- Tobacco/Nicotine- vasoconstrictive
- Marijuana- cognitive, emotional, behavioral deficits in child
- Cocaine- vasoconstrictive- miscarriage, preterm birth, abruptio placentae
- Amphetamines- NAS- poor feeding, jittery, irritable, high pitched cry
- Opiates- placental abruption, IUGR, preterm labor and fetal death. NAS, seizures, birth defects, mental retardation.
