Complications of pregnancy (unit 2) Flashcards
common pregnancy complications
- blood incompatibilities
- hemorrhage (early/late)
- hypertensive disorders
Rh Incompatibility
- 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
fetal hemolytic anemia
- consequence of severe Rh incompatibility
* RBCs are destroyed
fetal hyperbilirubinemia (icterus gravis)
- consequence of severe Rh incompatibility
* placenta unable to clear all bilirubin produced from RBC breakdown
erythrobastosis fetalis
- consequence of severe Rh incompatibility
* fetus compensates by producing large # of immature RBC to replaced those hemolyzed by mom antibody
hydrops fetalis
- most severe consequence of Rh incompatibility
- anemia ( -> hypoxia)
- cardio/hepato megaly
- edema/ascites/effusion/hyrothorax
- placental edema that can cause uterine rupture
what causes fetal and maternal blood to mix
•delivery of AB
•trauma***
•invasive procedures (version/amnio)
*only takes 0.1 mol Rh+ blood to cause mom sensitization
Prenatal management for blood incompatibilities
•AP labs -type -Rh factor -abody screen •Indirect Coombs •FOB tested and if neg, baby neg
indirect Coombs
- 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
RhoGAM admin
•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+
if mom has positive indirect Coombs…
•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
amniocentesis
- measures amnt bilirubin in amniotic fld. (fetal urine)
* used to determine severity of fetal hemolytic anemia if indirect Coombs > 1:8
ultrasound w/ positive indirect Coombs
•monitors for fetal edema and ascites
PUBS
- intrauterine blood transfusion of O- blood via umbilical vein
- increases fetal survival and reduces risk of disabilities
adverse effects of Rhogam
- lethargy
- fever
- malaise
- HA
- localized tenderness
- N/V
- hypotension*
- tachycardia*
- allergy
who needs Rhogam
•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
other blood incompatibilities
•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
ABO Incompatibility
- 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
fetal response to ABO incompatibility
- hemolysis ->
- hyperbilirubinemia ->
- jaundice
diagnosis of ABO incompatibility
•+ direct Coombs •jaundice w/in 24 hr of delivery •bilirubin > 15 mg/dl (term) •bilirubin > 10 mg/dl (preterm) *pathologic jaundice
ABO incompatibility tx
•phototherapy
-UV rays promote hepatic excretion of bili
•exchange transfusion (rare)
*goal is to prevent acute bill encephalopathy
hemorrhagic conditions of early pregnancy
- abortion
- ectopic preggo
- incompetent cervix
- gestational trophoblastic dx
abortion
•pregnancy that ends < 20 wks gestation •fetal wt < 500g •¼ women •3 types -spontaneous -elective -therapeutic
abortion causes
- 50% chromosomal abnormality
- maternal age
- maternal infection (BV; HSV)
- endocrine disorder (progesterone insuff; IDDM)
- environment- smoking, etoh
- systemic disorders (lupus)
early abortion
- before 12 wks (80%)
* caused by chromosome/endocrine/immune/systemic disorders
late abortion
- b/t 12-20 wks
* caused by AMA, multiparous, chronic infection, anomalies of rep. tract, dz, drug use
spontaneous abortion
•miscarriage •5 types -threatened -inevitable -incomplete -compete -missed
abortion s/sx
- uterine cramping/pain
- vaginal bleeding (significant)
- weakly positive UPT
- min./absent hCG or progesterone
abortion < 6 wks
•heavy period
abortion 6-12 wks
•moderate discomfort and some blood loss
abortion > 12 wks
•similar to labor complaints
threatened abortion
- any vaginal bleeding in pregnancy
* s/sx: spotting, cramping, BACKACHE, pelvic pressure
tx for threatened abortion
- pelvic rest until no blood for 24 hr
- pad count
- hCG/progesterone labs (don’t rise)
- vaginal U/S
- RhoGam if Rh-
- psychological support
inevitable abortion
- can’t be prevented
* s/sx: bleeding, cramping, ROM, dilation
inevitable abortion tx
- allow nature to work
- if incomplete, vacuum curettage or D&C
- RhoGAM if Rh-
incomplete abortion
- not all products of conception (POC) expelled
- usually if > 12 wks
- s/sx: profuse bleeding, severe cramping, cervix OPEN, retained placental pressure
incomplete abortion tx
- IV
- blood type/screen
- D&C if < 14 wks
- induction if > 14 wks
- RhoGAM if Rh-
complete abortion
- all POC expelled
* s/sx: ctx stop, bleeding subsides, cervix CLOSES, preg s/s disappear, preg test neg
complete abortion tx
- no intervention unless excessive bleeding/infection
- pelvic rest until bleeding stops
- RhoGAM if Rh-
missed abortion
- fetus dies but is retained inters for wks
* s/sx: preg s/s disappear, wt loss, uterus stops growing, RED/BROWN spotting
missed abortion tx
- 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-
complications of missed AB
•sepsis -temp -foul vaginal d/c -abd pain •disseminated intravascular coagulation (DIC)
disseminated intravascular coagulation (DIC)
•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
when can DIC occur
- missed AB or retained fetal demise
- abruption
- severed PIH
- amniotic fld embolism
- sepsis
s/sx DIC
•bleeding from orafices (IV, incision, nose, epidural site, placental site)
•dec. fibrinogen, platelets
•inc. PT/PTT
*low platelets and prolonged bleeding time
DIC management
•correct cause •heparin •blood products •monitor for bleeding and coagulation levels *NO epidural or spinal
empty sac
- 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
septic abortion
- more common in ETOP
- s/sx: fever, chills, malaise, abd pain, bleeding, sanguinopurulent d/c, TACHYcardia/pnea, abd tenderness, boggy uterus, dilated cvx
septic abortion tx
- stabilize
- obtain blood ctx
- IV abx
- surgically evacuate uterine contents
recurrent spontaneous abortion
•3+ consecutive SAb •caused by -Chromosomal abnormalities (50%) -Endocrine disorder: IDDM, inad. progesterone -Systemic dz: Lupus, HTN -Reproductive tract abnormality -DES exposure
diethylstilbestrol (DES)
- estrogen drug given to 10,000,000 women b/t 1938-1975 to prevent miscarriage
- causes uterine defects and vaginal cancer
uterine abnormalities
- placenta attempts to attach to nonvascular septum
- uterus cannot expand
- surgical correction
septate uterus
•wedge of fibrous tissue dividing uterine cavity
asherman’s syndrome
•adhesions crossing lining of uterus
bicornuate uterus
- incomplete uniting of uterus
- r/o poor baby perfusion
- r/o labor complications b/c head doesn’t push on cervix as effectively
incompetent cervix
- 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
ectopic pregnancy
- 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
causes of ectopic pregnancy
•scarring of fallopian tube
- Infection: PID r/t Chlamydia and GC
- Surgery: Failed tubal, ETOP, C/S
- IUD
- douching
s/sx ectopic pregnancy
- missed period/irreg. vag bleeding
- unilateral abd pain
- low hCG/progesterone
- fallopian tube rupture (sudden pain, syncope, N/V) -> massive HEMORRHAGE risk
ectopic pregnancy tx
•methotrexate
-antineoplastic
-admin if < 4 cm
•laparoscopic salpingectomy
RN considerations ectopic pregnancy
•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
hydatidiform mole (gestational trophoblastic)
- ovum fertilized by 2 sperm or sperm replicates its own DNA
* trophoblasts develop abnormally
partial molar pregnancy
- 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
complete molar pregnancy
- 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
hydatidiform mole s/sx
- 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
hydatidiform mole tx
•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)
hemorrhagic conditions of late pregnancy
- placenta previa
* abruptio placentae
placenta previa
•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
marginal/low-lying placenta previa
- common early in preggo (<26 wk)
* only 10% remain into 3rd trimester
complete placenta previa
- convers os
* won’t resolve
placenta previa s/sx
- painless, bright red vag bleeding
- uterus soft/nontender
- possible FHT distress, depending on blood loss
RN assessment for placental previa
- Assess/Monitor FHTs, maternal VS
- Assess/Monitor vaginal bleeding (pad counts)
- Assess contractions
- Assess lab values
RN Imp placental previa
•maintain IV •bedrest w/ BR privileges •NO vag exams •prepare for possible C/S *pt D/C if on pelvic rest and stable
normal bloody show
•mucous mixed w/ blood
•pink tinge
•small ant
*pathological is dark read and copious
DONT do vaginal exam if bleeding until…
•know where the placenta is
•assess for placental previa
-if so, notify MD
placental abruption
- premature separation of a normally implanted placenta
- usually have clot on maternal side
- fetal bleeding possible if trauma induced
- apparent or concealed bleeding
risk factors for placental abruption
- HTN
- cocaine/nicotine
- trauma (domestic, excess piton, short cord)
placental abruption s/sx
- Abdominal pain, board like
- bleeding- dark red (may be concealed)
- Uterine irritability/inc. tone (pressure)
- poor relaxation between contractions
- FHT- acute distress or absent
grade I abruption
- 10-20% placenta detached
- vag bleeding possible
- uterine tenderness
- neither mom nor babe in distress
grade II abruption
- 20-50% placenta detached
- no bleeding
- uterine tenderness/tetany
- mom in shock
- baby in distress
grade III abruption
- > 50% placenta detached
- vag bleeding possible
- severe uterine tetany (board like abd)
- mom in shock and has coagulopathy (r/o DIC)
- fetus dead
RN assessment abruption
- VS for hypovolemic shock
- Assess FHTs for LATE deceleration
- blood loss (pad count), ctx
- pain (location, type, intensity)
- lab values
RN implications abruption
- large bore (16 or 18 G) IV
* prepare for possible C/S
early s/sx hypovolemia
•tachycardia •thready pulse •inc. resp. •BP normal *body trying to compensate
late s/sx hypovolemia
•falling BP •cool, moist, pale skin •dec. UOP (<30cc/hr) •change in mental status (irritable, confused, agitated) *body CANT compensate
RN intervention hypovolemia
- 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
chronic HTN
- dx < 20 wks
- more likely in older, diabetes, obesity
- doesn’t go away after delivery
gestational HTN
- 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
mild preeclampsia
- 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
severe preeclampsia
•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
severe preeclampsia tx
- hospitalized bed rest
- seizure precautions
- quiet environment
- induce labor w/ Pitocin
- continuos EFM
- fld. restriction
- MgSO4
MgSO4
- 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
MgSO4 SE
•flushing/warmth •HA •nystagmus •nausea •dizzy •lethargy *very small therapeutic level
RN care during MgSO4 tx
- 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
therapeutic MgSO4 range
•4-8 mg/dl
loss of patellar reflex MgSO4 range
•9-10 mg/dl
respiratory arrest MgSO4 range
•12-17 mg/dl
cardiac arrest MgSO4 range
•30-35 mg/dl
s/sx MgSO4 toxicity
- absent DTRs
- resp. depression (< 12 min)
- cardiac arrest
MgSO4 toxicity tx
- stop MgSO4 drip
- open main line
- another RN notify MD
- airway
- Ca gluconate IV 1g over 2 min
MgSO4 PP
- 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)
how is preeclampsia cured
•birth
eclampsia
- preeclampsia accompanied w/ seizures
- twitching begins around mouth
- respiration halted
- leads to babe not getting O2
RN care post-seizure
- 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
HELLP
•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
s/sx HELLP
- 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)
RN care HELLP
- 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)
more likely to have uterus rupture
•large/edema baby
•hx of C/S or other uterine surgery
•D&C
*hypervascularized during PG, so big bleeding risk
scarring of fallopian tube consequences
- more likely to have ectopic PG
* due to previous ectopic, PID r/ Chlamydia and GC, surgery, IUD, etc
how do you infuse Pit
- pump when PG
* don’t want to hyperstim uterus
Pit admin w/ woman on MgSO4
•begin pit and each time inc. you will decrease primary IV rate
*leave the MgSO4 rate
why is MgSO4 given
•seizure prevention in HTN pt.
*side effect is to lower BP
•prevents cerebral hemorrhage in fetus receiving steroids (if admin in non-HTN mom)
2 key signs of MgSO4 toxicity
- decreased DTRs
* fluid in lungs
