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OB > Complications of pregnancy (unit 2) > Flashcards

Complications of pregnancy (unit 2) Flashcards

1
Q

common pregnancy complications

A
  • blood incompatibilities
  • hemorrhage (early/late)
  • hypertensive disorders
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2
Q

Rh Incompatibility

A
  • b/t Rh- mom and Rh+ fetus (from dad)
  • fetus + antigens enter mom bloodstream
  • mom becomes sensitized (isoimmunized) and produces antibodies against +
  • in next + preg. antibodies will attack fetal blood cells
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3
Q

fetal hemolytic anemia

A
  • consequence of severe Rh incompatibility

* RBCs are destroyed

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4
Q

fetal hyperbilirubinemia (icterus gravis)

A
  • consequence of severe Rh incompatibility

* placenta unable to clear all bilirubin produced from RBC breakdown

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5
Q

erythrobastosis fetalis

A
  • consequence of severe Rh incompatibility

* fetus compensates by producing large # of immature RBC to replaced those hemolyzed by mom antibody

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6
Q

hydrops fetalis

A
  • most severe consequence of Rh incompatibility
  • anemia ( -> hypoxia)
  • cardio/hepato megaly
  • edema/ascites/effusion/hyrothorax
  • placental edema that can cause uterine rupture
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7
Q

what causes fetal and maternal blood to mix

A

•delivery of AB
•trauma***
•invasive procedures (version/amnio)
*only takes 0.1 mol Rh+ blood to cause mom sensitization

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8
Q

Prenatal management for blood incompatibilities

A 
•AP labs
-type
-Rh factor
-abody screen
•Indirect Coombs 
•FOB tested and if neg, baby neg
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9
Q

indirect Coombs

A
  • see if Rh antibodies present on mom RBC
  • expected test if mom received Rhogam during preg
  • if Rh- mom has neg. Indirect combs admin RhoGAM
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10
Q

RhoGAM admin

A 
•blood product that suppresses immune system to prevent sensitization in Rh- mom
•28 weeks gestation
-IM (300 mcg)
•after invasive procedure, AB, etc
•to baby w/in 72 hrs of birth if Rh+
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11
Q

if mom has positive indirect Coombs…

A 
•indicates isoimmunization
•draw titer frequently
•if > 1:8 need amniocentesis/US
•if raises to 1:16, fetus in jeopardy
•don't RhoGAM already sensitized 
*no fetal tx -> 30% mortality rate
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12
Q

amniocentesis

A
  • measures amnt bilirubin in amniotic fld. (fetal urine)

* used to determine severity of fetal hemolytic anemia if indirect Coombs > 1:8

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13
Q

ultrasound w/ positive indirect Coombs

A

•monitors for fetal edema and ascites

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14
Q

PUBS

A
  • intrauterine blood transfusion of O- blood via umbilical vein
  • increases fetal survival and reduces risk of disabilities
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15
Q

adverse effects of Rhogam

A
  • lethargy
  • fever
  • malaise
  • HA
  • localized tenderness
  • N/V
  • hypotension*
  • tachycardia*
  • allergy
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16
Q

who needs Rhogam

A

•Rh- mom w/ Rh+ fetus
•Rh- mom w/ ETOP @ 10 wks and unknown FOB
•Rh- mom w/ amniocentesis
*RhoGAM doesn’t do anything if already isoimmunized

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17
Q

other blood incompatibilities

A 
•A and B 
•O and A
•O and B
*A has B antibodies
*B has A antibodies
*O has A & B antibodies
*AB has no antibodies
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18
Q

ABO Incompatibility

A
  • mom O
  • fetus A, B, or AB
  • maternal antibodies attack infant antigens
  • most common cause of hemolytic dz in newborn
  • less severe than Rh, but CAN affect firstborns, unlike Rh
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19
Q

fetal response to ABO incompatibility

A
  1. hemolysis ->
  2. hyperbilirubinemia ->
  3. jaundice
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20
Q

diagnosis of ABO incompatibility

A 
•+ direct Coombs
•jaundice w/in 24 hr of delivery
•bilirubin > 15 mg/dl (term)
•bilirubin > 10 mg/dl (preterm)
*pathologic jaundice
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21
Q

ABO incompatibility tx

A

•phototherapy
-UV rays promote hepatic excretion of bili
•exchange transfusion (rare)
*goal is to prevent acute bill encephalopathy

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22
Q

hemorrhagic conditions of early pregnancy

A
  • abortion
  • ectopic preggo
  • incompetent cervix
  • gestational trophoblastic dx
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23
Q

abortion

A 
•pregnancy that ends < 20 wks gestation
•fetal wt < 500g
•¼ women
•3 types
-spontaneous
-elective
-therapeutic
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24
Q

abortion causes

A
  • 50% chromosomal abnormality
  • maternal age
  • maternal infection (BV; HSV)
  • endocrine disorder (progesterone insuff; IDDM)
  • environment- smoking, etoh
  • systemic disorders (lupus)
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25
Q

early abortion

A
  • before 12 wks (80%)

* caused by chromosome/endocrine/immune/systemic disorders

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26
Q

late abortion

A
  • b/t 12-20 wks

* caused by AMA, multiparous, chronic infection, anomalies of rep. tract, dz, drug use

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27
Q

spontaneous abortion

A 
•miscarriage
•5 types
-threatened
-inevitable
-incomplete
-compete
-missed
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28
Q

abortion s/sx

A
  • uterine cramping/pain
  • vaginal bleeding (significant)
  • weakly positive UPT
  • min./absent hCG or progesterone
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29
Q

abortion < 6 wks

A

•heavy period

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30
Q

abortion 6-12 wks

A

•moderate discomfort and some blood loss

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31
Q

abortion > 12 wks

A

•similar to labor complaints

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32
Q

threatened abortion

A
  • any vaginal bleeding in pregnancy

* s/sx: spotting, cramping, BACKACHE, pelvic pressure

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33
Q

tx for threatened abortion

A
  • pelvic rest until no blood for 24 hr
  • pad count
  • hCG/progesterone labs (don’t rise)
  • vaginal U/S
  • RhoGam if Rh-
  • psychological support
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34
Q

inevitable abortion

A
  • can’t be prevented

* s/sx: bleeding, cramping, ROM, dilation

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35
Q

inevitable abortion tx

A
  • allow nature to work
  • if incomplete, vacuum curettage or D&C
  • RhoGAM if Rh-
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36
Q

incomplete abortion

A
  • not all products of conception (POC) expelled
  • usually if > 12 wks
  • s/sx: profuse bleeding, severe cramping, cervix OPEN, retained placental pressure
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37
Q

incomplete abortion tx

A
  • IV
  • blood type/screen
  • D&C if < 14 wks
  • induction if > 14 wks
  • RhoGAM if Rh-
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38
Q

complete abortion

A
  • all POC expelled

* s/sx: ctx stop, bleeding subsides, cervix CLOSES, preg s/s disappear, preg test neg

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39
Q

complete abortion tx

A
  • no intervention unless excessive bleeding/infection
  • pelvic rest until bleeding stops
  • RhoGAM if Rh-
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40
Q

missed abortion

A
  • fetus dies but is retained inters for wks

* s/sx: preg s/s disappear, wt loss, uterus stops growing, RED/BROWN spotting

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41
Q

missed abortion tx

A
  • U/S to confirm fetal death (10 wk and no FHT)
  • hCG double q2d until wk 12
  • wait for SAB (1 month)
  • D&C (emotional)
  • RhoGAM if Rh-
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42
Q

complications of missed AB

A 
•sepsis
-temp
-foul vaginal d/c
-abd pain
•disseminated intravascular coagulation (DIC)
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43
Q

disseminated intravascular coagulation (DIC)

A

•Bleeding causes release of thromboplastin that activates clotting throughout the body
•Coagulation in microcirculation → tiny clots in blood vessels → ischemia of organs
•Uses up clotting factors (platelets, fibrinogen) → inability of blood to clot so massive bleeding occurs
*life threatening

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44
Q

when can DIC occur

A
  • missed AB or retained fetal demise
  • abruption
  • severed PIH
  • amniotic fld embolism
  • sepsis
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45
Q

s/sx DIC

A

•bleeding from orafices (IV, incision, nose, epidural site, placental site)
•dec. fibrinogen, platelets
•inc. PT/PTT
*low platelets and prolonged bleeding time

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46
Q

DIC management

A 
•correct cause
•heparin
•blood products
•monitor for bleeding and coagulation levels
*NO epidural or spinal
47
Q

empty sac

A
  • embryonic development arrested very early or failed all together
  • Id w/ U/S (25 mm sac w/o embryonic tissue)
  • high incidence of chrom. anomalies
48
Q

septic abortion

A
  • more common in ETOP
  • s/sx: fever, chills, malaise, abd pain, bleeding, sanguinopurulent d/c, TACHYcardia/pnea, abd tenderness, boggy uterus, dilated cvx
49
Q

septic abortion tx

A
  • stabilize
  • obtain blood ctx
  • IV abx
  • surgically evacuate uterine contents
50
Q

recurrent spontaneous abortion

A 
•3+ consecutive SAb
•caused by 
-Chromosomal abnormalities (50%)
-Endocrine disorder:  IDDM, inad. progesterone
-Systemic dz:  Lupus, HTN
-Reproductive tract abnormality
-DES exposure
51
Q

diethylstilbestrol (DES)

A
  • estrogen drug given to 10,000,000 women b/t 1938-1975 to prevent miscarriage
  • causes uterine defects and vaginal cancer
52
Q

uterine abnormalities

A
  • placenta attempts to attach to nonvascular septum
  • uterus cannot expand
  • surgical correction
53
Q

septate uterus

A

•wedge of fibrous tissue dividing uterine cavity

54
Q

asherman’s syndrome

A

•adhesions crossing lining of uterus

55
Q

bicornuate uterus

A
  • incomplete uniting of uterus
  • r/o poor baby perfusion
  • r/o labor complications b/c head doesn’t push on cervix as effectively
56
Q

incompetent cervix

A
  • results in repeated preg losses @ 20-23 wks
  • caused by D&C, conization, DES, short cervix
  • tx w/ cerclage: suture placed @ 14-16 wks (taken out @ 36 or labor sign)
  • r/o ROM, PTL, infection
57
Q

ectopic pregnancy

A
  • implantation of fertilized egg outside uterus
  • 95% in falopian tube (others in ovary, cervix, and cavity)
  • can cause maternal hemorrhage and death
  • reduces chances of subsequent pregnancy
58
Q

causes of ectopic pregnancy

A

•scarring of fallopian tube

  • Infection: PID r/t Chlamydia and GC
  • Surgery: Failed tubal, ETOP, C/S
  • IUD
  • douching
59
Q

s/sx ectopic pregnancy

A
  • missed period/irreg. vag bleeding
  • unilateral abd pain
  • low hCG/progesterone
  • fallopian tube rupture (sudden pain, syncope, N/V) -> massive HEMORRHAGE risk
60
Q

ectopic pregnancy tx

A

•methotrexate
-antineoplastic
-admin if < 4 cm
•laparoscopic salpingectomy

61
Q

RN considerations ectopic pregnancy

A 
•early ID of shock (tachycard)
•monitor for dec. hct 
•pain control
•educate on methotrexate (anti-neoplastic- stops rapidly dividing cells)
-SE of N/V
-no etoh/sex until no hCG
-must be < 8 wks & < 4cm
*preferred b/c less scaring
62
Q

hydatidiform mole (gestational trophoblastic)

A
  • ovum fertilized by 2 sperm or sperm replicates its own DNA

* trophoblasts develop abnormally

63
Q

partial molar pregnancy

A
  • 69 XXX, 69XXY or 69 XYY
  • 2 sperm fertilize an otherwise normal ovum
  • 1 maternal, 2 paternal chromosome
  • molar tissue and fetal tissue
  • deformed/nonviable and resorbed
64
Q

complete molar pregnancy

A
  • 46XX
  • sperm fertilizes an egg with a lost or inactive nucleus
  • sperm duplicates itself resulting in 46XX
  • no fetal tissue, white fluid filled grapes
  • 20% advance to choriocarcinoma
65
Q

hydatidiform mole s/sx

A
  • hyperemesis gravidarum
  • vaginal bleeding - dark brown spotting to profuse hemorrhage
  • passage of grapelike clusters
  • no FHT’s
  • PIH before 24 weeks
  • High hCG levels
  • Snowstorm pattern on U/S
66
Q

hydatidiform mole tx

A

•D&C
•MRI to detect CA (-> chemo)
•F/U x 1 year to detect malignant changes
-hCG levels q 1-2 weeks until normal then q 1-2 months x 1 year
•must avoid pregnancy x 1yr (no IUD BC)

67
Q

hemorrhagic conditions of late pregnancy

A
  • placenta previa

* abruptio placentae

68
Q

placenta previa

A 
•placenta implants in lower uterine segment
•5% of all births
•associated w/
-Previous ETOP
-Multiparity (5 or more)
- >35 y/o
-Previous uterine incision
-Previous placenta previa
69
Q

marginal/low-lying placenta previa

A
  • common early in preggo (<26 wk)

* only 10% remain into 3rd trimester

70
Q

complete placenta previa

A
  • convers os

* won’t resolve

71
Q

placenta previa s/sx

A
  • painless, bright red vag bleeding
  • uterus soft/nontender
  • possible FHT distress, depending on blood loss
72
Q

RN assessment for placental previa

A
  • Assess/Monitor FHTs, maternal VS
  • Assess/Monitor vaginal bleeding (pad counts)
  • Assess contractions
  • Assess lab values
73
Q

RN Imp placental previa

A 
•maintain IV
•bedrest w/ BR privileges
•NO vag exams
•prepare for possible C/S
*pt D/C if on pelvic rest and stable
74
Q

normal bloody show

A

•mucous mixed w/ blood
•pink tinge
•small ant
*pathological is dark read and copious

75
Q

DONT do vaginal exam if bleeding until…

A

•know where the placenta is
•assess for placental previa
-if so, notify MD

76
Q

placental abruption

A
  • premature separation of a normally implanted placenta
  • usually have clot on maternal side
  • fetal bleeding possible if trauma induced
  • apparent or concealed bleeding
77
Q

risk factors for placental abruption

A
  • HTN
  • cocaine/nicotine
  • trauma (domestic, excess piton, short cord)
78
Q

placental abruption s/sx

A
  • Abdominal pain, board like
  • bleeding- dark red (may be concealed)
  • Uterine irritability/inc. tone (pressure)
  • poor relaxation between contractions
  • FHT- acute distress or absent
79
Q

grade I abruption

A
  • 10-20% placenta detached
  • vag bleeding possible
  • uterine tenderness
  • neither mom nor babe in distress
80
Q

grade II abruption

A
  • 20-50% placenta detached
  • no bleeding
  • uterine tenderness/tetany
  • mom in shock
  • baby in distress
81
Q

grade III abruption

A
  • > 50% placenta detached
  • vag bleeding possible
  • severe uterine tetany (board like abd)
  • mom in shock and has coagulopathy (r/o DIC)
  • fetus dead
82
Q

RN assessment abruption

A
  • VS for hypovolemic shock
  • Assess FHTs for LATE deceleration
  • blood loss (pad count), ctx
  • pain (location, type, intensity)
  • lab values
83
Q

RN implications abruption

A
  • large bore (16 or 18 G) IV

* prepare for possible C/S

84
Q

early s/sx hypovolemia

A 
•tachycardia
•thready pulse
•inc. resp. 
•BP normal 
*body trying to compensate
85
Q

late s/sx hypovolemia

A 
•falling BP
•cool, moist, pale skin
•dec. UOP (<30cc/hr)
•change in mental status (irritable, confused, agitated)
*body CANT compensate
86
Q

RN intervention hypovolemia

A
  • Position lateral, HOB flat, feet elevated
  • O2 per face mask
  • large bore IV patency (2 if possible)
  • IV NS fluid replacement until blood product ready
  • Obtain type and screen
87
Q

chronic HTN

A
  • dx < 20 wks
  • more likely in older, diabetes, obesity
  • doesn’t go away after delivery
88
Q

gestational HTN

A
  • dx after 20 wks
  • BP > 140/90 during 2nd half of pregnancy
  • no proteinuria
  • BP returns to baseline 6 wk PP
  • caused by primigravidas, age extremes ( 35), hx of PIH, obesity/diabetes, multiple gestation
89
Q

mild preeclampsia

A
  • GH AND kidney dysfunction
  • BP > 140/90 2x over 4 hr
  • proteinuria 1+ or > 300 mg/day
  • s/sx: HA, irritability, edema, abd pain
  • Tx: activity restriction; blood, urine, weight monitoring
90
Q

severe preeclampsia

A

•GH w/ at least one of….

  • BP > 160/110
  • proteinuria 3+ or > 5g/day
  • oliguria
  • inc. liver NZ and Cr
  • HA/visual disturbances (vasoconstrict)
  • hyperreflexia
  • peripheral edema
  • hepatic dysfunction
  • cardio/pulmonary dysfunction
  • epigastric pain
91
Q

severe preeclampsia tx

A
  • hospitalized bed rest
  • seizure precautions
  • quiet environment
  • induce labor w/ Pitocin
  • continuos EFM
  • fld. restriction
  • MgSO4
92
Q

MgSO4

A
  • CNS depressant to prevent seizure
  • Relaxes smooth muscle (↓ vasoconstriction)
  • SE is that BP is lowered
  • Next to Pit, most common drug used in labor and delivery
  • Given IVPB via pump
  • Effect is immediate
93
Q

MgSO4 SE

A 
•flushing/warmth
•HA
•nystagmus 
•nausea
•dizzy
•lethargy
*very small therapeutic level
94
Q

RN care during MgSO4 tx

A
  • assess VS, FHT, DTRs, UOP, LOC, edema q1hr
  • have O2, suction, and Ca gluconate in room
  • avoid narcotics
  • monitor levels (draw q4-6hr)
  • watch baby post-delivery
95
Q

therapeutic MgSO4 range

A

•4-8 mg/dl

96
Q

loss of patellar reflex MgSO4 range

A

•9-10 mg/dl

97
Q

respiratory arrest MgSO4 range

A

•12-17 mg/dl

98
Q

cardiac arrest MgSO4 range

A

•30-35 mg/dl

99
Q

s/sx MgSO4 toxicity

A
  • absent DTRs
  • resp. depression (< 12 min)
  • cardiac arrest
100
Q

MgSO4 toxicity tx

A
  • stop MgSO4 drip
  • open main line
  • another RN notify MD
  • airway
  • Ca gluconate IV 1g over 2 min
101
Q

MgSO4 PP

A
  • continue for 12 hr b/c seizures most common during first 12 hours post delivery
  • monitor for uterine atony (impaired involution and r/o hemorrhage)
102
Q

how is preeclampsia cured

A

•birth

103
Q

eclampsia

A
  • preeclampsia accompanied w/ seizures
  • twitching begins around mouth
  • respiration halted
  • leads to babe not getting O2
104
Q

RN care post-seizure

A
  • stay with pt & call for assistance
  • place on left side, suction
  • O2 face mask
  • Give meds (mag, valium)
  • mom V/S q 5-15 min
  • fetal V/S (EFM)
  • Monitor for labor, abruption, fetal hypoxia and death
105
Q

HELLP

A

•life-threatening variation of preeclampsia before 36 wks
H- hemolysis resulting in anemia & jaundice
EL- elevated liver NZ
LP- low platelets (<100,000)
*LAB, NOT clinical dx

106
Q

s/sx HELLP

A
  • N/V
  • edema
  • malaise
  • epigastric pain
  • may/may not have proteinuria or inc. BP
  • low hit
  • high liver NZ
  • high uric acid, low Cr (high renal fun)
  • platelets < 100,000 (thrombocytopenia)
107
Q

RN care HELLP

A
  • Intensive one-on-one nursing
  • No abd palp, could rupture liver hemotoma
  • MgSO4 to control seizures
  • Steroids given to mature fetal lungs
  • Labor induction (may delay up to 96 hr to develop fetal lungs)
108
Q

more likely to have uterus rupture

A

•large/edema baby
•hx of C/S or other uterine surgery
•D&C
*hypervascularized during PG, so big bleeding risk

109
Q

scarring of fallopian tube consequences

A
  • more likely to have ectopic PG

* due to previous ectopic, PID r/ Chlamydia and GC, surgery, IUD, etc

110
Q

how do you infuse Pit

A
  • pump when PG

* don’t want to hyperstim uterus

111
Q

Pit admin w/ woman on MgSO4

A

•begin pit and each time inc. you will decrease primary IV rate
*leave the MgSO4 rate

112
Q

why is MgSO4 given

A

•seizure prevention in HTN pt.
*side effect is to lower BP
•prevents cerebral hemorrhage in fetus receiving steroids (if admin in non-HTN mom)

113
Q

2 key signs of MgSO4 toxicity

A
  • decreased DTRs

* fluid in lungs

OB (17 decks)

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