Exam 2 Wk3 Obstetrics Flashcards
What are anatomic and physiologic changes associated with pregnancy?
Cardiovascular -
CO peaks to 30-50% above non-pregnant levels by end of 2nd trimester
Respiratory
Increase in tidal volume and respiratory rate, causes partially compromised alkalosis which leaves woman with a decreased buffering capacity after trauma
GI
↑ compartmentalization of the small intestine into the upper abd and a progesterone- induced ↓ in GI motility (constipation, regurgitation); nausea
Urinary
Dilation of the ureters and renal pelvises; Bladder is displaced anteriorly and superiorly by the enlarging uterus making it more vulnerable to injury
Reproductive
protruding abdomen causes ↑susceptibility to blunt and penetrating trauma
Hematology Dilutional anemia (due to ↑plasma volume); Physiologic leukocytosis (d/t hormones); Fibrinogen and coagulation factors ↑ causing a hypercoagulable state which may ↑risk of emboli
Supine Hypotension syndrome
compression of the abdominal aorta and inferior vena cava
turn left lateral position
An increase in tidal volume and respiratory rate causes partially compromised alkalosis which leaves the woman with a decreased buffering capacity after trauma. This puts her at risk for ___.
hypoxic insult
Supplemental oxygen is a priority
What is first-line therapy for nausea in pregnancy?
Doxylamine Succinate (Unisom) and Vitamin B6 (Pyridoxine)
Zofram used less often d/t risks
Peripartum Cardiomyopathy
Patients usually present with symptoms of congestive heart failure late in pregnancy or in the early postpartum period.
Treatment
1. Bed rest,
2. fluid and salt restrictions,
3. meds: diuretics, vasodilators, and blockers.
In addition, prophylactic anticoagulation during pregnancy and full anticoagulation for 1–2 weeks after delivery recommended (If Ejection fraction less than 30%)
Anticoagulants = Lovenox, heparin, NOT coumadin
Gestational Hypertension (preeclampsia and eclampsia): What are the risk factors, signs and symptoms, and complications?
Risk factors:
primigravida, anomalies, multifetal pregnancy, stress, pre-existing disease, poor nutrition, age extremes, obesity, chronic hypertension
S/S:
Vasospasm, hematologic changes, and endothelial damage causes tissue hypoxia and multiple organ involvement
Complications: seizure, cardiopulmonary failure, hepatic rupture, CVA, DIC, HELLP, retinal detachment
Gestational Hypertension (preeclampsia and eclampsia): What are the diagnostic criteria?
Blood pressure > 140/90mmHg
• on 2 occasions 4 hours or more apart
• After 20 weeks,
• without proteinuria
Pre-eclampsia (mild): BP >140/90
• with proteinuria (1+ or >300mg/24 hrs),
• edema and weight gain
Pre-eclampsia (severe): BP >160/110
• with proteinuria (>3+ or >500mg/24 hrs)
• Symptoms: hyperreflexia, headache, blurry vision, pulmonary edema, thrombocytopenia, RUQ pain (liver disfunction)
Eclampsia – grand mal seizures
• Resolved by delivery
Gestational Hypertension (preeclampsia and eclampsia): What are the nursing interventions and neonatal considerations?
Nursing Interventions: • • Primary goal is to prevent seizures. If a seizure occurs, provide support of the airway through suctioning and oxygen
• Intensive placental-fetal monitoring. Continuous electronic fetal monitoring, ultrasound, stress tests
• Antihypertensives as needed - Hydralazine (lower bp), labetalol (lower HR and BP)
• Administration of steroids to speed fetal lung development
• IV magnesium sulfate to depress the CNS
What is the antidote for magnesium toxicity? Calcium gluconate
Neonatal Considerations
Possible complications include growth restriction,
hypoxia, respiratory depression due to mag, preterm gestation, hypotension, hypoglycemia, bradycardia
• Obtain IV and provide respiratory support as needed
• Infant will usually be depressed first 24 hours of life
• May need to stimulate (rub) their back to get them breathing
Gestational Hypertension (preeclampsia and eclampsia):
IV Magnesium sulfate is used to _____.
depress the CNS
Note: Usually give IV mag and then prep for emergency c-section
Magnesium Administration
• Always use a pump to avoid tissue extravasation
• Loading dose 4-6g over 15-20 minutes. Then 2g/hr.
Monitor
• reflexes and clonus
• for signs of toxicity: flushing, diaphoresis, hypotension, CNS depression (lower LOC), cardiac depression
• Foley to watch I/O (if pressure too low)
What is the antidote for magnesium toxicity?
Calcium gluconate
Gestational Hypertension (preeclampsia and eclampsia):
HELLP
Hemolysis, Elevated Liver enzymes, Low Platelets
- Microangiopathic hemolytic anemia (anemia)
- Liver damage secondary to fibrin obstruction of blood flow (elevated liver enzymes)
- Vascular damage causes platelets to aggregate
a. thrombocytopenia & thrombosis/ congregating and clotting similar to DIC - Renal damage due to decreased blood flow
a. elevated BUN, Creatinine
Nursing Interventions
- Aggressive blood pressure control
- Prevention of seizures
- Replacement of blood products: FFP (has clotting factors), PRBCs, Platelets
- Fetal lung maturation (steroids) and delivery (possible c-section)
- May need a liver transplant in mother
Placenta Previa:
What is it? Risk Factors?
The implantation of placenta in lower uterus near the cervix. It can be low lying or marginal or partially or complete covering cervix
Key finding: Painless bright red vaginal bleeding in 2nd half of pregnancy
Risk factors:
advanced age, multiparous, previous C-section, smoking, multifetal gestations, previous previa,
living in high altitudes
Diagnosed by transvaginal ultrasound, MRI
Placenta Previa:
What are the nursing interventions? Neonatal considerations?
Nursing Interventions
• Provide oxygen
• Establish IV access
• Type and cross
• Assess the abdomen, watch for bleeding
• Administer tocolytics (anti-contraction) if ordered
• Monitor fetal heart rate, movement
• Avoid digital vaginal exams! (HCP does this)
• Encourage bed rest. Why? Don’t want it to bleed! Decreases chance of labor and cervix open up.
Neonatal Considerations
• The fetus may experience poor blood flow resulting in growth restriction (assess for this via ultrasonography)
• Risks to fetus include hypoxia, asphyxia, infection, premature birth, hemorrhage, and anemia
Interventions for baby are similar to the Mother
- IV access,
- type and cross,
- frequent clinical assessment,
- and close monitoring of CBC
- May require mechanical ventilation
- Transfusion of PRBCs may be necessary
What indicates distress in a fetus?
Less movement!! Decels of heart rate and decrease fetal movement indicate stress
Abruptio Placentae:
What is it? key findings and risk factors include?
Separation of placenta from the myometrium. Can be partial or complete and is graded I-III.
Key findings:
• Large volume either dark or bright red vaginal bleeding
• Tender board-like abdomen with uterine hyperactivity
• Abdominal pain with vaginal bleeding is always an emergency!**
Risk factors :
Hypertension, drug use, trauma, placenta abnormalities (previa), uterine malformations, polyhydramnios, multifetal pregnancy, multiparous, chorio, smoking, poor nutrition, premature rupture of membranes
Abruptio Placentae:
What are the nursing interventions? Neonatal considerations?
Nursing Interventions • Provide oxygen • Establish IV access • Type and cross • Assess the abdomen, watch for bleeding • Position left lateral • Monitor maternal vital signs (note: 40% volume may be lost before symptoms occur) • Watch labs for DIC including CBC, coag studies-INR, PT, PTT
Neonatal Considerations
• Monitor for signs of fetal distress
• Prep for c-section if any late or variable decels, tachycardia, loss of fetal heart tones or movement
Interventions for baby are similar to Mother
- IV access,
- type and cross,
- frequent clinical assessment,
- and close monitoring of CBC
- May require mechanical ventilation
Risks for fetus:
anemia, preterm birth, hypoxia, asphyxia, hypovolemia, higher risk of SIDs, growth restriction
Note: Hypoxia can result in ischemia to the brain and may require cooling to prevent severe brain damage
Uterine Rupture
Risk factors:
Prior c-section, fetal malpresentation, cocaine use, trauma, placental invasion of myometrium
Fetal demise in 10-30 minutes
Nursing interventions: Oxygen, fluids, blood transfusions
Emergency c-section
(May require a hysterectomy)
Postpartum Hemorrhage:
What are the 5 T’s?
Tone, Tissue, Trauma, Thrombin, Traction
T’s mnemonic can be used to identify and address the most common causes of postpartum hemorrhage
- Tone = uterine atony or failure of the uterus to contract following delivery
- Trauma = laceration, hematoma, inversion, rupture
- Tissue = retained tissue or invasive placenta
- Thrombin = coagulopathy
- Traction = Uterine inversion called
Postpartum Hemorrhage
Most common cause of maternal mortality
Blood loss > 500 ml (vaginal) or >1000 ml (c-section), within 24 hours of delivery
5Ts: Tone, Tissue, Trauma, Thrombin, Traction
Assess: • amount of bleeding (weigh peri-pads), • uterine tone, • look for hematoma, • monitor VS, • check labs - CBC, clotting
Treatment depends on what the issue is, but most will administer meds to increase uterine tone to stop bleeding
- oxytocin,
- prostaglandin,
- methylergonovine
Pulmonary Emboli:
is due to what? signs and symptoms?
Due to ↑in venous stasis, changes in coagulation factors, and tissue trauma
Can be d/t DVT so look for unilateral swelling and pain in calves
DVT (deep vein thrombosis)
• DVT occurs with equal frequency in all 3 trimesters while a PE is more common during post-partum period*
• Likelihood of developing a PE is affected by the adequate treatment of DVT. If left untreated 24% with DVT will suffer PE, mortality 15%. Treated with anticoagulants, risk of PE is 5%, and mortality rate is <1%.
Signs and symptoms • Tachypnea, • Dyspnea, • Pleuritic chest pain (pain when breathing), • Apprehension, • Cough, • Tachycardia, • Hemoptysis • & Fever
Pulmonary Emboli:
Diagnosis and treatment?
Diagnosis
May be difficult to diagnose as many symptoms are typical of pregnancy such as lower extremity edema, dyspnea, tachycardia
Treatment
• Infusion of Heparin (unfractionated). Heparin does not cross placenta due to high molecular weight. Give a Bolus 5,000 units, followed by 1,000 u per hr and adjusted to keep activated partial thromboplastin time (aPTT) at 1.5-2 times normal levels
• Full anticoagulation may be continued for up to 3 months
Amniotic Fluid Embolism
S/S: Sudden onset hypotension, hypoxia, coagulopathy
Enters maternal circulation by endocervical veins, Placental site, or Uterine trauma site
High mortality rate
Treatment is supportive care of: Oxygenation, circulation, control bleeding
Acute Asthma Exacerbation in Pregnancy
Asthma is the most common obstructive pulmonary disease in pregnancy.
Increased risk for maternal/fetal complications. Some studies have suggested ↑risk for
Gestational diabetes, Preeclampsia, Preterm delivery, and Intrauterine growth restriction (IUGR).
Treatment:
• Inhaled short acting β2 –agonists (Albuterol)
• Inhaled corticosteroids are mainstay-long-term management. They decrease airway inflammation
Note: Majority of corticosteroids are Pregnancy Category C except of bedesonide (Cat B)
Hyperthyroidism & Thyroid Storm/Thyroidtoxicosis in Pregnancy:
What is it? Symptoms?
Thyroid storm in pregnancy has been associated with significant maternal (25%) and neonatal morbidity. Thyroid storm occurs in 1% of all pregnant patients with hyperthyroidism
Symptoms:
Fever, neurologic changes from irritability to coma, cardiac arrhythmias and decompensation, GI distress (nausea & vomiting), leukocytosis, ↑LFT (AST, ALT)
Hyperthyroidism & Thyroid Storm/Thyroidtoxicosis in Pregnancy:
Thyroid Storm Treatment?
Supportive care
O2, IV, cardiac monitoring, antipyretics, antibiotics
Prompt identification of etiology
Medication
• Antithyroid medications
ex: PTU 1st trimester, Methimazole after 1st trimester. Used in preventing the release of T4, preventing the conversion of T4 to T3 and blocking the actions of thyroid hormone
• Beta-blockers if antithyroid medication ineffective with signs and symptoms (tachycardia, palpitations)
Diabetic Ketoacidosis in pregnancy:
Patho and Diagnosis?
Pathophysiology
• Absolute or relative insulin deficiency leading to Hyperglycemia
• Intracellular glucose unavailability leads to fatty acid breakdown–> ketones–>ketoacidosis–> metabolic acidosis
• Usually, a concurrent stressor such as an infection can cause release of glucagon, catecholamines, growth hormone, and cortisol. These glucose counter-regulatory hormones cause increased glycogenolysis, thus increases circulating glucose levels.
• Progression of the osmotic diuresis results in
1. ↓CO,
2. ↓b/p,
3. shock–> decrease perfusion to the baby
Diagnostic criteria • Maternal arterial pH < 7.30 • HCO3 <15 • Serum and/or urine ketones- present • Blood glucose ≥ 250mg/dL
DKA can occur with glucose levels less than 200 mg/dl with signs and symptoms-nausea vomiting.
Diabetic Ketoacidosis in pregnancy:
Management?
- ABCs - Ambu bag, oxygen, suction, fluids
- If obtunded: foley and NGT insertion(NG-prevent aspiration, Foley-strict I&O)
- Aggressive fluid volume resuscitation
- IV insulin infusion therapy with constant serum glucose monitoring
- Electrolyte replacement (Can lose electrolytes d/t osmotic diuresis: Potassium & Magnesium, Phosphorus, Sodium bicarbonate)
- Monitor movement, and fetal heart rate, etc
Note:Don’t drop glucose too quickly bc it causes cerebral edema
