Disorders of Pregnancy Flashcards
Defining factors of hyperemesis gravidarum
Severe nausea and vomiting of pregnancy
Begins before 9 weeks gestation
Associated with weight loss >5% of pre-pregnancy weight
Results in dehydration, nutritional deficiencies, electrolyte imbalances and/or ketosis
Causes/etiology of hyperemesis gravidarum
Increased HCG levels
Decreased vitamin B6
Genetics
Psychosocial factors
Risk factors of hyperemesis gravidarum
Increased incidence with multiple gestation and molar pregnancies
Duration of hyperemesis gravidarum
Peak incidence 8-12 weeks
Typically resolves by 20 weeks
May persist duration of pregnancy
S&S of hyperemesis gravidarum
Protracted vomiting
Intolerance of liquids/solids
Weight loss >5%
Increased HR, decreased BP
Poor skin turgor, dry mucous membrances
Ketonuria, increased urine SG (>1.030)
Decreased Na, K, Cl
Increased HCT, RBCs
Nursing management of hyperemesis gravidarum
VS, weight, I&O
NPO for gut rest
IV fluids: TPN or enteral feeds if protracted
Antiemetic administration
Pt. education
What is iron deficiency anemia in pregnancy
Hgb <11 mg/dL in 1st and 3rd trimesters
Hgb <10.5 mg/dL in 2nd trimester
Nursing management/Pt. education for iron-deficiency anemia in pregnancy
Iron supplementation 325 mg 1-3x/daily
-take on empty stomach with OJ/vit c
-do not take with coffee or tea
-increase fluids and fiber to decrease constipation
Iron rich foods
-meats, green leafy veggies, legumes and nuts, enriched breads and cereals
Rest PRN
What are TORCH infections?
Toxoplasmosis
Other (syphilis, hepatitis, varicella, parvo, HIV, Zika, listeria)
Rubella
Cytomeglovirus
Herpes simplex virus
Considerations with TORCH infections
Prevention is key
Handwashing
Avoid soft cheeses, hot dogs, deli meats, unpasteurized milk, raw meats, undercooked eggs
Avoid cat litter
Wear gloves while gardening
Safe sex
C-section if active genital HSV lesions
What is spontaneous abortion
A pregnancy that ends due to natural causes before 20 weeks gestation
S&S of spontaneous abortion
Vaginal bleeding
Passage of products of conception
Back pain
Sudden relief of morning sickness
Rupture of membranes (2nd trimester)
Classifications of spontaneous abortion
Threatened
Inevitable
Incomplete
Complete
Missed
Nursing management of spontaneous abortion
Vital signs
Labs: CBC, HCG
Assess bleeding volume (pad counts/QBL)
Assess passage of products of conception
Assess and manage pain
Prepare and educate for procedures if needed
Administer RhoGAM if Rh negative
Acknowledge grief, active listening
Patient education of spontaneous abortion
Anticipatory guidance
-educate at first prenatal visit about signs and symptoms of miscarriage
After-care
-report heavy bleeding, fever, foul-smelling vaginal discharge
-pelvic rest x2 weeks (no tubs, sex, tampons)
-iron supplement education if needed
-provide referral to community grief support groups
S&S ectopic pregnancy
Unilateral lower abdominal pain
May have vaginal spotting
Typically occurring 6-8 wks gestation
If ruptured ectopic pregnancy
-s/s of hypovolemic shock
-shoulder pain
-cullen sign- ecchymosis around umbilicus
Treatment of ectopic pregnancy
Surgical: salpingectomy or salpingotomy
Medical: IM methotrexate
-inhibits cell division (stops embryo/fetal growth) by disrupting folic acid, cells are then reabsorbed
Nursing management of ectopic pregnancy
Vital signs
Labs
-HCG (typically lower than expected)
-CBC, blood type/Rh
Assess bleeding
Assess and manage pain
Prepare for procedures/treatment
Administer RhoGAM if Rh negative
Acknowledge grief, active listening
Patient education of ectopic pregnancy
Weekly bHCG until non-pregnant range
Defer pregnancy for 3 months
Routine post-op teaching if surgical
If methotrexate treatment:
-No folic acid supplements or PNV/MVI
-Avoid sun exposure
-Teach S/S of ectopic rupture: severe/sharp unilateral abdominal pain, shoulder pain, dizziness/syncope
What is gestational trophoblastic disease (Molar pregnancy)
Pregnancy related tumor that forms from an abnormal growth of trophoblastic cells after conception without development of a viable pregnancy
20% will progress to choriocarcinoma
S&S of gestational trophoblastic disease (Molar pregnancy)
Uterine size greater than expected
Dark brown bleeding: looks like prune juice, usually 2nd trimester
Excessive vomiting (rule out hyperemesis)
Persistent elevation of bHCG after 10-12 weeks gestation
Preeclampsia diagnosed <24 weeks gestation
Nursing management gestational trophoblastic disease (molar pregnancy)
Prepare for surgical intervention
Acknowledge fear and grief
Patient education of gestational trophoblastic disease (molar pregnancy)
Stress importance of follow up
bHCG weekly until negative x3, then monthly x1 year
Avoid pregnancy for 1 year
Contraceptive counseling
What is cervical insufficiency
Premature dilation of the cervix that occurs without uterine contraction, after the first trimester
S&S of cervical insuffuciency
Painless and passive cervical effacement and dilation
Cervix <25mm and/or cervical funneling on ultrasound
Pelvic pressure
Backache
Increased mucoid or pink tinged vaginal discharge
Nursing management of cervical insufficiency
Prepare for procesure- Cerclage
Assess for s/s PTL
Patient education with cervical insufficiency
Activity restriction
Cerclage removed at 36 weeks
Report S/S of PTL
-cramping/contractions
-ROM
-backache
-significant increase in vaginal discharge
What are some causes of bleeding in late pregnancy?
Placenta previa
Placental abruption
Vasa previa
Nursing managment of late pregnancy bleeding
Recognize risk factors
Early identification of s/s
Maximize maternal/fetal perfusion
-side lying
-increase IV fluids
-O2 via NRB mask
Assess blood loss- OBL
What are S/S of placenta previa
PAINLESS bright red bleeding in 2nd/3rd trimester
Risk factors of placenta previa
Previous placenta previa
Prior c-section or uterine surgery
Multiple gestation
Closely spaced pregnancies
Age >35
Smoking
S/S of placental abruption
PAINFUL dark red vaginal bleeding
Sudden onset of localized abdominal pain
Uterine tenderness
Uterine contractions/hypertonicity
Board-like abdominal rigidity
Fetal distress
Risk factors of placental abruption
maternal hypertension/preeclampsia
Trauma
Smoking
Cocaine use
Muliple gestation
Abnormal fluid levels
Prolonged PROM
Signs and symptoms of DIC
Bleeding from 3+ unrelated sites:
-spontaneous epistaxis
-oozing from incisions or IV sites
-petechiae/ecchymosis/hematomas
Hypotension and tachycardia
Signs of thrombosis
-renal impairment
-peripheral cyanosis
-confusion>coma
-cardiorespiratory failure
Treatment of DIC
Treat underlying cause
Oxygen admin
Fluid replacement
Blood products
What is preterm labor
- Gestational age 20 )/7 to 36 6/7 weeks
- Regular UCs accompanied by a change in dilation and/or effacement
OR
Initial presentation with regular UCs and dilation >2cm
What is preterm birth
Any birth that occurs between 20 0/7 and 36 6/7 weeks gestation
Preterm birth classifications
Extremely preterm: <28 weeks
Very preterm: 28-31 weeks
Moderately preterm: 32-33 weeks gestation
Late preterm: 34-36 weeks
Risk factors for preterm labor
50% of women will have no risk factors or indicators
Lots of risk factors:
-black women
-underweight
-obesity
-smoking
-and all that
Diagnostic predictors of preterm birth
Cervical length
-changes in cervical length MAY identify women at risk
Fetal fibronectin test (fFN)
-vaginal swab
-better predictor of who will NOT go into labor
S/S of preterm birth
regular or frequent contractions or uterine tightening
pelvic or lower abdominal pressure
constant dull, low backache
mild abdominal cramps with/without diarrhea
obvious rupture of membranes
increase or change in vaginal discharge
Patient education for preterm birth
Teach S/S of preterm labor early in pregnancy
If s/s of preterm labor:
-stop activity and lie down on side
-drink 2-3 glasses of water or juice
-if after one hour s/s countinue call provider or go to L&D
-if after one hour s/s stop, notify provider at next visit
Activity restriction
-bedrest
-pelvic rest
-work restrictions
Medications used in preterm labor
promotion of fetal lung maturity
-glucocorticosteroids: betamethasone
Tocolytics
-magnesium sulfate
-Nifedipine (Adalat)
-Indomethacin
-Terbutaline
Inevitable birth:
-neuroprotection with magnesium sulfate
Indications for betamthasone
Action: increases fetal lung maturity by stimulating fetal surfactant production
Reduces incidence of respiratory distress syndrome (RDS)
Administration/monitoring:
-given between 24-34 weeks gestation if risk of delivery within 7 days
-2 doses given IM 24 hours apart
-expect elevated WBC and platelets
-blood glucose, if DM may require increased insulin
Action of tocolytic: magnesium sulfate
CNS depressant, relaxes smooth muscle
Adminstration/monitoring tocolytic: magnesium sulfate
-HIGH RISK DRUG
–>label bag and lines
–>two person dose calculation check
–>disconnect from line if not infusing
-monitor serum magnesium: therapeutic range of 4-7 mEq/L
-educate pt about expected and common ADRs
–>hot flushes and sweating
–>burning at IV site
–>blurred vision
–>N/V
–>lethargy
What is preterm prelabor rupture of membrane (PPROM)
Membrane rupture before 37 weeks gestation
What causes PPROM
Inflammation
Uterine contractions
Infection
Intrauterine pressure
Complications of PPROM
Infection
Cord prolapse
Cord compression due to oligohydramnios
Placental abruption
Nursing managment of PPROM
If lungs mature: anticipate induction
-lung maturity = 34-36 weeks or <34 weeks with L/S ratio of >2
If lungs immature
-administer antenatal glucocorticoids as ordered
-administer antibiotics
-obtain GBS swab
-limit vaginal exams
-monitor for s/s of labor
-monitor for s/s of infection
-fetal surveillance
-anticipate delivery if s/s of infection or fetal distress
Non-stress test indications
Monitor pregnancy at risk as indicator of uteroplacental sufficiency and intact fetal CNS
Nursing interventions for non-stress test (NST)
Position patient in reclining chair or left-lateral
Instruct to push marker button when feels fetal movement
If no fetal movement, use vibroacoustic stimulator x3 sec
Reactive vs nonreactive non-stress test
Reactive: good
-2 or more accelerations in 20 minutes
Nonreactive: bad
-less than 2 accelerations in 20 minutes
Indication for contraction stress test
Earlier and more reliable test of health fetoplacental unit than NST as puts fetus under stress
Require stimulation of uterine contractions: oxytocin or nipple stimulation
Contraindications:
-Premature labor
-Multiple gestations
-Cervical insufficiency
-Placenta or vasa previa
-Prior classical cesarean section incision
Nursing interventions for contraction stress test/ oxytocin challenge test (OCT)
Obtain baseline FHR
Initiate IV oxytocin
Discontinue oxytocin if:
-UC longer than 90 sec
-UC > q2 min
-Administer tocolytic prn
Interpretation of contraction stress test
Negative: good
-No late or significant variable deceleration
-At least three UC in a 10-min period
Positive: bad
-Late decelerations occur with 50% or more of contractions
Five biophysical variables of biophysical profile (BPP)
Rated 2 or 0 each
NST
Fetal Breathing
Fetal body movements
Fetal tone
Amniotic fluid index
Maternal risk of diabetes in pregnancy
HTN
Preeclampsia
Cesarean birth
Preterm birth
Maternal mortality
Polyhydramnios
Infection
DKA and hypoglycemia
Fetal risks of diabetes in pregnancy
Miscarriage
Congenital malformations
Extreme prematurity
Respiratory distress syndrome
IUFD
Placental insufficiency
Growth restrictions
Gestational:
-macrosomia: birth trauma (shoulder dystocia)
-neonatal hypoglycemia/hyperinsulinemia
Gestational diabetes: screening and diagnosis
Initial 1 hr screening at 24-28 weeks:
-non fasting, any time of day
-no regard to last meal time
3 hour Oral glucose tolerance test:
-in AM fasting (>8 hrs)
-avoid caffeine and smoking x12 hrs
Blood glucose goals
Fasting/premeal: <95
Postpradial (1 hr): <140
Postprandial (2 hr): <120
Gestational DM: fetal surveillance
Low risk pt with diet controlled GDM <40 weeks do not generally need routine fetal surveillance
Kick counts
If oral meds, insulin, or high-risk:
-twice weekly NSTs starting at 32 weeks
-US prn to monitor fluid and growth
Hypoglycemia vs DKA
Hypoglycemia:
-rapid onset
-normal BP
-normal or shallow respirations
-pale and sweating
-tremors, mental confusion, sometimes convulsions
-blood sugar lower than 70
DKA:
-slow onset- over several days
-ketoacidosis
-BP is subnormal or in shock
-Air hunger respirations
-Hot and dry skin
-general depression
-blood sugar elevated above 200
-Ketones elevated
Nursing considerations for postpartum insulin considerations
Check blood sugars q 2-4 hr in first 48 hr
Give dose of subcutaneous insulin before stopping IV insulin
Most with GDM can discontinue insulin after birth
Gestational hypertension
Begins after 20 weeks gestation in a previously normotensive women
BP >140 systolic or >90 diastolic
NO proteinuria
Preeclampsia
Hypertension and proteinuria after 20 weeks gestation in a previously normotensive woman
New-onset hypertension >20 weeks with any of the following:
-throbocytopenia
-renal insufficiency
-impaired liver fx
-pulmonary edema
-cerebral or visual symptoms
What is eclampsia
Development of seizures or coma in a preeclampic pt
Preeclampsia with severe features
Preeclampsia diagnosis with BP >160/110
Pulmonary edeam: CP, SPB
Thrombocytopenia: plt <100,000
Hepatic dysfunction: persistent RUQ/epigastric pain, liver enzymes >2x ULN
Progressive renal insufficiency: oliguria, serum creatinine >1.1
CNS dysfunction: hyperreflexia, visual changes, severe HA
HELLP syndrome
S/S of HELLP
Fatigue
N/V, RUQ pain
Bleeding (epistaxis)
Weight gain
Blurry vision
Lab findings with HELLP
Decreased H&H
Increased bilirubin
Abnormal peripheral smear
Increased AST/ALT
Decreased platelets
Preeclampsia nursing assessment
Accurate measurement of BP
Breath sounds, respiratory effort
Edema- pitting
DTRs
Clonus
Proteinuria: >300 mg in 24-hr urine specimen
Preeclampsia nursing assessment
Evaluate for s/s of severe preeclampsia
-HA
-Epigastric pain
-RUQ abd pain
-Visual disturbances
Preeclampsia management without severe features
Outpatient if asymptomatic
Instruct pr on daily BP checks and fetal kick counts
Increased surveillance: weekly BP, labs
Activity restriction
Induction of labor at 37 weeks
Patient education of warning s/s to report
Preeclampsia management with severe features
Inpatient management
Magnesium Sulfate
-to prevent seizures
-reduce dz progression
-NOT to lower BP
Antihypertensive meds if BP >160/110
Deliver if occurs at >34 wks
Expectant management if <34 wks and stable
Corticosteroids for fetal lung maturity if <34 wks
Nursing care for preeclampsia with severe features
Environment
-quiet, dim lights
-side rails up and padded
Seizure precautions
-Ox and suction equipment
Emergency medications available:
-Calcium gluconate (antidote for MgSO4)
-Hydralizine
-Labetolol
-Nifedipine
