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Obstetrics > Health Complications in Pregnancy > Flashcards

Health Complications in Pregnancy Flashcards

1
Q

Cause of hypertensive disorders of pregnancy

A

Largely unknown - increasing difficulty for screening

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2
Q

Risk factors for gestational HTN

A
  • nullipara
  • first pregnancy with new partner
  • previous pregnancy with HTN/pre-eclampsia
  • history of chronic HTN, CKD, SLE
  • poor nutrition
  • BMI > 30
  • ethnicity (race v racism)
  • age > 40
  • multi gestation/use of ART
  • pre-gestational diabetes
  • previous stillbirth, IUGR, abruption
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3
Q

Chronic Hypertension

A

Hypertension that develops either before pregnancy or at <20 weeks

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4
Q

True or false: pregnancy can cause HTN at any point

A

False: Pregnancy can cause HTN but not until 20 weeks

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5
Q

Gestational Hypertension diagnostic values and criteria

A

 Systolic ≥ 140 mmHg and/or Diastolic ≥ 90 mmHg
 20 weeks and up to 12 weeks PP

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6
Q

Severe Hypertension diagnostic values

A

systolic ≥160 mmHg and/or diastolic ≥110 mmHg

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7
Q

Pre-Eclampsia diagnostic criteria

A

systolic ≥ 140 mmHg and/or diastolic ≥ 90 mmHg
proteinuria (2+ or greater) or 1 or more adverse conditions or severe complications

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8
Q

How does pre-eclampsia differ from gestational hypertension

A

Other organ involvement - not just CVS/PVS

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9
Q

What is eclampsia?

A

Seizure cause by over-perfusion of neurological system (cerebral edema - pressure on brain)
aka seizures that occur in those with pre-eclampsia

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10
Q

What 3 adverse conditions are most important to assess for in a woman with PIH?

A
  1. headache
  2. visual disturbances
  3. Abdominal/Epigastric/RUQ pain
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11
Q

Besides headache, visual disturbances and RUQ pain, what other adverse conditions should be assessed for in woman with PIH?

A
  • Nausea/Vomiting
  • Chest pain/SOB
  • Abnormal maternal lab values
  • Fetal morbidity – not growing, thriving in utero, poor tracing
  • Edema / Weight gain?
  • Hyperreflexia?
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12
Q

Why are edema/weight gain and hyper-reflexia not always the most predictive of pre-eclampsia in pregnancy?

A

Edema and weight gain are common in pregnancy - pitting edema in knees and swelling in the face most indicative

There are variations in reflex responses so it is difficult to assess without baseline; clonus is sign of problem

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13
Q

Maternal consequences of preeclampsia

A
  • Stroke
  • Pulmonary edema
  • Hepatic failure
  • Jaundice
  • Seizures
  • Placental abruption
  • Acute renal failure
  • HELLP syndrome & DIC
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14
Q

Fetal consequences of preeclampsia

A
  • IUGR
  • Oligohydramnios
  • Absent or reversed end diastolic umbilical artery flow by Doppler
  • Placental abruption
  • Prematurity (iatrogenic)
  • Fetal compromise (metabolic acidosis)
  • Intrauterine death
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15
Q

Etiology/cause of pre-eclampsia

A

Primarily abnormal placentation in combination with excessive fetal demand

Spiral arteries that normally supply placenta become fibrous/vasoconstrict (like other arteries in the body do with HTN) and can not meet the fetal/placental demand

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16
Q

pathophysiology of pre-eclampsia

A
  1. abnormal placentation + excessive fetal demands

leads to

  1. mismatch between uteroplacental supply + demand

= poorly perfused placenta that releases pro inflammatory proteins that cause…

  1. maternal endothelial dysfunction (vasoconstriction + increased permeability) and kidneys to retain more salt

> protein leakage - water follows - increased blood volume

  1. HYPERTENSION maternal/fetal pre-eclampsia manifestations

VASOCONSTRICTION leading to HYPOPERFUSION OF ORGANS

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17
Q

Why is RUQ/epigastric pain a cardinal sign of pre-eclampsia?

A

Reduced blood flow (hypoperfusion due to vasoconstriction) to the liver causing damage and swelling and elevate liver enzymes and stretches out capsule around liver

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18
Q

Prevention of Preeclampsia

A
  1. Low Dose Aspirin
  2. Calcium Supplementation
  3. Lifestyle
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19
Q

Explain the dosage of aspirin for pre-eclampsia prevention

A

In patients with increased risk low-dose aspirin (75 – 100 mg/day) starting pre-pregnancy or before 16 weeks’ gestation until delivery.

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20
Q

Explain the dosage of calcium supplementation for pre-eclampsia prevention

A

For all clients with low dietary intake of calcium (<900 mg/d), oral calcium supplementation of at least 500 mg/d is suggested

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21
Q

Why is calcium supplementation necessary for pre-eclampsia prevention?

A

o Works on negative feedback – if blood level is low there would be increased amount causing excessive contraction of vessels (calcium works in muscle contraction)

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22
Q

Initial Management of Preeclampsia

A
  • Assessment of pregnant client and fetus
  • Stress reduction/reduced activity (used to be bedrest)
  • Treat blood pressure w antihypertensives
  • Treat symptoms
  • Nausea & vomiting
  • Epigastric pain
  • Consider seizure prophylaxis if borderline symptoms
  • Consider timing / mode of delivery (>36 weeks) – decrease rx of consequences
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23
Q

Describe management of non-severe PIH

A

Home care

  • Client monitors own blood pressure
  • Measures weight and tests urine protein daily
  • NST’s performed daily or bi-weekly – for fetal assessment
  • Advised to report signs of adverse conditions
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24
Q

Describe management of severe HTN/pre-eclampsia

A
  • Fetal evaluation – more intensive workup:
  • Fetal movement counting, NST, Biophysical profile, ultrasound, measurement of AFI, serial U/S to assess growth, umbilical artery doppler flow,
  • Hourly intake and output
  • Frequent BP, pulse, resp
  • Blood work (liver enzymes, platelets, Hct)
  • Monitor for Adverse Conditions
  • DELIVERY is the definitive treatment
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25
Q

Most common antihypertensives used in pregnancy and class

A
  • Labetalol – adrenergic blocker
    o Most common
  • Nifedipine (Adalat) – calcium channel blocker
    o Common
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26
Q

Other antihypertensives used in pregnancy

A
  • Hydralazine (Apresoline) - Arteriolar dilators
    o More high alert
  • Aldomet (Methyldopa)-Centrally-acting sympatholytic
    o More high alert
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27
Q

What anti-hypertensive medications are contraindicated in pregnancy?

A

ACE-I

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28
Q

What is magnesium sulfate used for in pregnancy?

A

treatment of seizures in pregnancy NOT HTN effect but has large CVS effect – increase monitoring!
GOAL: reduce CNS irritability and prevent seizures

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29
Q

MOA of magnesium sulfate

A

anti convulsant

relaxing muscles/reducing neuromuscular irritability

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30
Q

Dose of magnesium sulfate for eclampsia

A

4g IV (in 100ml NS) over 20 min using pump then 1g/h IV

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31
Q

Effects of magnesium sulfate

A
  1. tachycardia
  2. monitor reflexes
  3. monitor u/o (excreted by kidneys)
  4. can slow labor r/t relaxing muscles/reducing nm irritability
  5. muscle weakness
  6. lack of energy/drowsiness
  7. respiratory depression
  8. lower BP (not reason its given)
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32
Q

4 Signs of Magnesium Toxicity

A
  1. CNS depression
  2. RR < 12
  3. Oligouria < 30ml/h
  4. Diminished/absent DTR
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33
Q

Therapeutic serum magnesium

A

4.8 - 9.6 mEq

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34
Q

Magnesium Sulfate Antagonist

A

Calcium Gluconate

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35
Q

Treatment of Eclampsia

A
  1. Anticonvulsant: bolus of magnesium sulfate
  2. sedation/other anticonvulsants: dilantin
  3. treatment of pulmonary edema if present (diuretics)
  4. treatment of circulatory failure: digitalis
  5. ICU

DELIVER

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36
Q

If forced to deliver due to eclampsia what must be administered to the fetus and why?

A

if fetus < 34 weeks give corticosteroids to increase fetal lung maturity

Not effective after 34 weeks

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37
Q

What is HELLP syndrome?

A

Severe complication of preeclampsia

Hemolysis
Elevated
Liver Enzymes
Low
Platelets

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38
Q

Why is hemolysis seen in HELLP?

A

RBC rupture due to slamming into thrombus, forced to move through constricted vessels

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39
Q

Why are elevated liver enzymes seen in HELLP?

A

Injury and swelling occur as a result of reduced blood flow (hypoperfusion), causing capsule to stretch and release enzymes into blood

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40
Q

Why are low platelets seen in HELLP syndrome?

A

Platelets aggregate at sites of endothelial injury, using them all up

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41
Q

When should platelets be administered in HELLP?

A

if < 20 10^9/L

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42
Q

What may not be an option during labour for HELLP patient and why?

A

Epidural; contraindicated in thrombocytopenia

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43
Q

What is DIC and patho?

A

Worst case of preeclampsia - Disseminated Intravascular Coagulation

  • Over-activation of normal clotting mechanism
  • Mini clots develop
  • Depletes platelets and clotting factors leads TO EXCESSIVE BLEEDING
    o Counter intuitive in a way – but TOO MUCH clotting DEPLETES platelets leading to BLEED
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44
Q

True or False: Preeclampsia develops during pregnancy

A

False: Preeclampsia may develop for the first time postpartum

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45
Q

When should BP be measured PP if patient had HTN?

A

At least 2x in first 2 weeks following delivery

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46
Q

Can anti-hypertensives be taken for lactating clients?

A

Yes

labetalol, methyldopa, nifedipine, enalapril, and captopril

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47
Q

3 Types of Diabetes patients present with

A
  1. pre-existing (type 1 or 2)
  2. gestational
  3. pre-existing undiagnosed
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48
Q

What is gestational diabetes?

A

Glucose intolerance with ONSET or FIRST RECOGNITION during pregnancy

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49
Q

How to differentiate between pre-existing undiagnosed and gestational diabetes

A

if continues following pregnancy it is likely pre-existing

if FIRST RECOGNITION during pregnancy will be classified as gestational

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50
Q

In what 2 ways does pregnancy alter carbohydrate metabolism

A
  1. Fetus continually takes glucose from the mother – increases glucose demand
  2. Placenta creates hormones, which alter effects of and resistance to insulin and glucose tolerance
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51
Q

Diabetogenic Effect of Pregnancy in First Trimester and result

A

rise in hormones stimulates insulin production and increases sensitivity to tissues

result: maternal insulin needs decrease because everything is working more efficiently

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52
Q

When do we see effects of gestational diabetes on pregnancy and why?

A

20th week

In first trimester insulin needs decreases due to alterations in hormones

53
Q

Diabetogenic Effect of Pregnancy in 2nd and 3rd Trimester

A
  1. Placenta secretes hPL which:
    - increases resistance to insulin for mom to assure
    - facilitate transfer to fetus for growth because fetal growth needs increase and thus glucose needs increase
  2. Insulin needs increase because mom needs glucose too
54
Q

Maternal Effects of Gestational Diabetes

A
  1. pre-eclampsia and eclampsia
  2. polyhydraminos, PROM
  3. preterm labor
  4. shoulder dystocia/c-section
  5. worsening myopathies of vessels, renal, retinal
  6. if pre-existing diabetic, increases ketosis
  7. gestational HTN
  8. diabetes later in life
55
Q

Fetal Effects of Gestational Diabetes

A
  1. macrosomia/LGA
  2. IUGR
  3. Fetal Demise
  4. Congenital Anomalies
56
Q

Why is macrosomia/LGA seen in gestational diabetes?

A

Not enough insulin for mom to use excessive glucose but baby produces own insulin so will gladly take on glucose and grow

57
Q

Why is IUGR seen in gestational diabetes?

A

Vascular changes can effect blood flow to fetus, decreasing

58
Q

Neonatal effects of gestational diabetes

A
  1. hypoglycemia
  2. hyperbilirubinemia
  3. immature respiratory development
59
Q

why is hypoglycemia seen as neonatal effect of gestational diabetes?

A

Fetus is used to high levels of blood sugar, cutting of cord cuts this off. Need to adjust high insulin that they have been producing

60
Q

why is hyperbilirubinemia seen as neonatal effect of gestational diabetes?

A

Insulinase produced by placenta helps fetus hold on to RBC – when fetus is delivered they have more RBC to breakdown and thus have more risk of jaundice

61
Q

why is immature respiratory development/RDS seen as neonatal effect of gestational diabetes?

A

High insulin production interferes with surfactant development

62
Q

What are the childhood effects of gestational diabetes?

A

Increased risk of developing diabetes and obesity

63
Q

“being” risk factors for gestational diabetes

A
  • 35 years of age or older
  • from a high-risk ethnic population (African, Arab, Asian, Hispanic, Indigenous, South Asian)
64
Q

“using” risk factors for gestational diabetes

A
  • Corticosteroid use (asthma, rheumatological conditions)
65
Q

“having” risk factors for gestational diabetes

A

Obesity (BMI ≥30 )
Prediabetes
GDM in a previous pregnancy
Previous newborn > 4 kg
A parent, brother or sister w type 2 diabetes
Polycystic ovary syndrome

66
Q

Recommendation regarding gestational diabetes prevention

A

breastfeeding immediately after birth and for a minimum of 4 months in order to prevent hypoglycemia in your newborn, obesity in childhood, and diabetes for both you and your child.

67
Q

Screening steps for gestational diabetes

A
  1. 24–28 weeks of gestation with a non-fasting 50 g glucose challenge test (GCT) 1 hr. post glucose
  2. If between 7.8-11, patients will do a 75g fasting GTT
68
Q

Values and interpretation of gestational diabetes screening test

A

o <7.8 mmol/L (140 mg/dL) NORMAL
o 7.8 -11.0 mmol/L  then you will do a 75 g fasting GTT performed
o >11.1 mmol/L GDM diagnosis

69
Q

Blood sugar goals for gestational diabetes management

A

to attain and maintain a euglycemic state
o (Glycated hemoglobin A1C less than 7%)
o Aim for fasting of ‹5.3 mmol/L, 1 hr pc ‹ 7.8 mmol/L

70
Q

Care and management of gestational diabetes in pregnancy

A
  • diet controlled
  • insulin as drug of choice if necessary
  • increased folic acid (up to 5mg r/t increased risk for congenital anomalies)
  • antenatal steroid if early delivery anticipated to mature lungs
  • risk for infection r/t high glucose
71
Q

Intrapartum/labor care of gestational diabetes

A

— If euglycemic on diet, no special considerations in labour
— For IDDM (insulin dependent):
— Balance insulin with need for ↑ energy in labor
— Monitor blood sugars q 1 – 2 h
— Individualize IV glucose and IV insulin

72
Q

True or false: insulin needs increase in post partum period

A

False: decrease significantly but 20% will have IGT

73
Q

Incidence of T2DM post partum of those with gestational

A

45-50%

74
Q

Why is a 75g OGTT recommended between 6 weeks and 6 months if gestational diabetic?

A

values usually normal in 24-48 hours we see them but as body normalizes at home values can change – need for monitoring

75
Q

Iron deficiency occurs in more than _____ of pregnancies

A

30%

76
Q

Symptoms of iron deficiency anemia

A

fatigue, weakness, dizziness, irritability, hair loss, dyspnea (often attributed to pregnancy not anemia)

77
Q

Adverse outcomes associated with iron deficiency anemia in pregnancy

A

o LBW, SGA, PTB in infant
o PPH, blood transfusion in PP client
o Long term neurocognitive effects in child

78
Q

Lab values indicative of iron deficiency anemia

A

ferritin (<30) and HgB (<110)

79
Q

Treatment of iron deficiency anemia in pregnancy

A

Oral iron is first line treatment; parenteral iron is safe in 2nd trimester onward. Treatment continues postpartum.

80
Q

What 2 reasons are multiple gestation rates increasing?

A
  • assisted reproduction (ART)/in-vivo: by product of technologies – implantation of more than egg to assure success of technology
  • increasing maternal age: people are waiting until later in life to have children and potential to release more than one egg increases with age
81
Q

Multiple gestations are at increased risk for (8):

A
  • Preterm labor – overdistention of uterus triggering physiological response of onset
  • Anemia and hypertension of pregnancy
  • Abnormal presentation
  • Twin-to-twin transfusion syndrome
  • Uterine dysfunction: if stretched to maximum can interfere with contraction pattern
  • Abruptio placenta / placenta previa: if overdistended, (large or multiple) placenta may separate and move to a place it should not be
  • Prolapsed cord
  • Postpartum hemorrhage r/t overdistention
82
Q

What is the safest way to deliver multiple gestation?

A

c-section

83
Q

As number of gestations in multiple gestation increases ______ and ______decrease and _____ and risk for ____ and _____ increase

A

weight and gestational age

mortality, CP, IUGR

84
Q

Effects of multiple gestations on mother

A
  1. increased risk of c/s, HTN, PPH
  2. increased intensity of complaints
    - SOB
    - Edema
    - NV, heartburn
    - Insomnia, fatigue
    - weight gain
85
Q

Dizygotic

A

Twins from 2 eggs

86
Q

Diamniotic

A

Twins in seperate amniotic sacs

87
Q

Dichorionic

A

Twins with 2 placentas

88
Q

What is twin to twin transfusion syndrome

A

Whenever identical twins share a placenta
During development, anastomoses occur and shunt blood from one twin to the other

89
Q

Effects of twin to twin transfusion syndrome on “donor” twin

A

under-perfused, small, anemic

accelerate development as response to stress/protective response

90
Q

Effects of twin to twin transfusion syndrome on “recipient” twin

A

over-perfused, large

91
Q

Complications of Obesity in pregnancy

A

— Spontaneous Abortion/Stillbirth
— Hypertension
— Diabetes
— Preterm or Posterm

92
Q

Complications of obesity intrapartum

A

— Stillbirth
— Macrosomia causing Shoulder Dystocia
— Challenges in assessing fetus/contractions
— ↑ Cesarean
— Anesthesia challenges

93
Q

Neonatal complications of obesity

A
  • Macrosomia
  • Hypoglycemia r/t macrosomia
  • Breastfeeding issues r/t positioning
  • Congenital anomalies
94
Q

Postpartum complications of obesity

A
  • Depression
  • PPH
  • Infection
  • Thrombosis
  • Lifelong effects of obesity
95
Q

What is the most common cause of obesity later in life for woman

A

Excessive limitless weight gain in pregnancy is the most common cause of obesity in later life.

96
Q

Women who gain ________ in pregnancy have a very difficult time losing PP weight and often it remains a lifelong struggle

A

> 25kg

97
Q

Possible link to hypertension, diabetes and obesity in later life for ____________

A

for children borne of obese mother

98
Q

SOGC recommendations beginning weight for pregnancy

A

BMI < 30

99
Q

recommended weight gain during pregnancy if > 30BMI

A

7kg

100
Q

Pre‐conceptual assessment and counseling for obese clients

A
  • recommended weight gain (7kg)
  • increase folic acid if coming into pregnancy obese
  • exercise
  • knowledge of risk
  • anesthesiologist consult
  • VTE risk
101
Q

Physical risks in adolescent pregnancy

A

— Preterm birth
— Low birth weight infant
— CPD
— Anemia
— GHTN

102
Q

Psychosocial risks in adolescent pregnancy

A

— Interruption of developmental tasks
— Substance abuse,
— Poverty
— Interruption or cessation of education
— Less prenatal visits

103
Q

Considerations for pregnant clients > 35

A
  • decline in fertility
  • increase in chronic diseases
  • increase difficulties in pregnancies
  • increased rx of c-section/induction
  • increased rx of genetic conditions
104
Q

In general, pregnant women with substance use disorders are less likely to ________, and they have higher rates ________

A

seek prenatal care

of infectious diseases

105
Q

Effects of methadone on pregnant client

A
  • Better than opioid, use of more controlled substance – rx vs benefit
    o Blocks withdrawal symptoms
    o Reduces or eliminates the craving for narcotics
    o Crosses the placenta
106
Q

Methadone use in pregnancy is associated with

A

pregnancy complications and abnormal fetal presentation

107
Q

Prenatal exposure to methadone causes

A

o Reduced head circumference and lower birth weight
o Withdrawal symptoms – can be treated (known vs unknown entity)

108
Q

Cannabis can negatively effect

A

fertility

109
Q

Does cannabis cross the placenta?

A

Yes

o May harm a developing fetus (preterm delivery, low birth weight, birth defects)
o Associated with negative long-term effects in childhood and beyond (poor memory and verbal skills, behavioral issues)

110
Q

Does cannabis cross into breastmilk

A

Yes

may cause negative developmental effects (lethargy, poor feeding habits)

111
Q

Care of mother with substance use

A

— Education and Support
— Watch for signs of withdrawal
— Watch for signs of drug use
— Leave unit, leave baby unattended, high

112
Q

Care of infant with maternal substance use

A

— Watch for signs of withdrawal
— Active use
— NICU for observation and treatment?
— NAS Scoring?

113
Q

Caffeine recommendations in pregnancy

A

Pregnant women and breastfeeding mothers should have no more than 300mg of caffeine per day from all sources. This is approx.. 2 (250ml) cups of coffee

114
Q

Large amounts of caffeine in pregnancy increases risk of

A
  • Miscarriage
  • Premature delivery
  • Low birth weight
  • Withdrawal symptoms in newborn
115
Q

How do maternal infections infect newborn during pregnancy, in labor and post partum?

A
  • During Pregnancy
    o Can cross placenta
  • In Labour
    o If born through vagina
  • Postpartum
    o breastmilk
116
Q

4 Teratogen categories

A
  • Alcohol
  • Drugs
  • (Certain) Prescribed Medications
  • Pathogens/infections
117
Q

Infections of significant risk to infant

A

C: Chickenpox & shingles
H: Hepatitis B, C, D, E
E: Enteroviruses
A: AIDS
P: Parvovirus B19 (aka 5th disease)
T: Toxoplasmosis
O: Other (GBS, listeria, candida)
R: Rubella
C: Cytomegalovirus
H: Herpes simplex virus
E: Every STI (gonorrhea, chlamydia)
S: Syphilis

118
Q

Infections in pregnancy may cause

A
  • Spontaneous abortions
  • Preterm delivery
  • Maternal and fetal morbidity and mortality
119
Q

When is vaginal/rectal GBS screening done?

A

35-37 weeks

120
Q

Who is the risk to with maternal GBS infection?

A

Infant

121
Q

When are antibiotics administered for GBS

A

> 4 hr before birth for adequate cover

122
Q

Modes of HIV transmission in pregnancy

A
  • in utero (through the placenta)
  • during childbirth and delivery
  • postpartum through breastfeeding
123
Q

Risk of HIV transmission to infant with and without treatment

A

Without treatment: ≈ 25% chance of transmission
With proper treatment: less than 2% chance of transmission

124
Q

Factors reducing HIV transmission to infant

A
  1. behaviours that support healthy immune system
  2. CART
  3. mode of delivery dependent on maternal viral load and CART
  4. complimentary treatment
125
Q

Describe 3 part antiretroviral prophylaxis regimen to reduce risk of HIV to infant

A

pregnancy: cart

labor: add IV ZDV during birth/3 hr to c-section

infant: ZDV oral suspension

126
Q

How long is ZDV administered following birth from maternal HIV positive mother and when is testing done?

A

6 weeks

testing at 1 month, 3 month, 18 month

127
Q

True or false: following birth a baby who tested positive for HIV definitively has HIV

A

Positive antibody titer - Babies can test positive/have antibody response without being positive

o Reflects the passive transfer of maternal antibodies rather than HIV infection

128
Q

Function of hPL

A

Hormone secreted by placenta

hPL increases maternal insulin resistance and reduces maternal glucose utilisation, elevating maternal blood glucose levels (supporting transplacental glucose transfer and adequate fetal nutrition).

Obstetrics (12 decks)

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