High Risk Antepartum Flashcards
spontaneous abortion
Early
* Majority in 1st 12 weeks
* 50% chromosomal abnormalities
Late
* 12-20 weeks
* Maternal conditions
s&s of sab
- Vaginal bleeding; Starts as dark
blood and changes to bright red - Abdominal pain/cramping
- Low backache
- Pelvic pressure
threatened abortion
Any bleeding before 20 weeks, no
cervical dilation
inevitable abortion
Bleeding and dilation, no expulsion of
products of conception
incompleted abortion
Partial expulsion of some but NOT ALL
products of conception
complete abortion
Complete expulsion of ALL products of
conception
missed abortion
Nonviable embryo retained for at least 6
weeks
recurrent abortion
3 or more consecutive SABs
sab management
Evacuation of uterine contents with
vacuum (D&E) or with curette (D&C)
* D&C likely for missed, incomplete, or
inevitable SAB <14 weeks. Rhogam if
indicated
induced abortion
Surgical
* D&C or D&E techniques
* Medical
* Oral pills
* mifepristone then misoprostol
ectopic pregnancy risk factor
Compromised fallopian
tube patency
* STIs, tubal
ligation/surgery,
IUD, IVF
s/s of ectopic pregnancy
Abnormal vaginal bleeding
* 2nd most common reason
* Nausea
* Amenorrhea
* Breast tenderness/fullness
* Pain
* Lower back, abdomen or
pelvis
* Shoulder on affected side
how common is ectopic pregnancy
1 in 50
management of ectopic pregnancy
Salpingectomy
* Removal of ruptured fallopian
tube
* Salpingostomy
* Incision into fallopian tube that
preserves future fertility
* Non-surgical management
* Methotrexate
* Chemotherapeutic agent
* Rhogam
* To Rh (-) mother
* Not already sensitized
what is hyperemesis gravidum
constant vomiting
exact cause unknown
* >5% weight loss from
pre-pregnancy weight
risk factor for hyperem
psychological
s/s of hyperem
Severe dehydration
- s/sx
- Weight loss – insufficient
nutrition
- Ketonuria
- Breakdown of fat for
energy
- Emotionally drained
non-pharmacologic management of hyperem
Acupressure – sea bands
* Ginger – pops, chews
* Small meals and timing of
snacks
* Registered Dietician
pharmacologic management hyperem
Promethazine (antihistamine)
* Pyridoxine and doxylamine (Vitamin B6 and
antihistamine)
* Antiemetics (ondansetron) used cautiously
* IV fluids and electrolytes
nsg interventions hyperem
Identify triggers
* Assess for dehydration
* Provide comfort measures
* Oral hygiene, daily wts, labs, F&E imbalance
maternal complications twins
Pre-term Labor
* Hypertensive
disorders
* PPROM
* Gestational diabetes
* Hemorrhage
fetal complications twins
IUGR
* PTB
* Discordant twin growth
* Congenital anomalies
* Abnormal cord insertion
* Fetal demise
oligohydramnios
Too little fluid (<500 ml)
* Monitoring: serial ultrasounds,
nonstress test, BPP, maternal
report of loss of fluid
polyhydramnios`
Too much fluid (>2,000 ml)
* Monitoring: ultrasound, signs of
preterm labor
purpose of amniotic fluid
temp
cushions
NO NUTRITION
1 risk factor for polyhydramnios
gestational dm
gestational diabetes
Carbohydrate intolerance diagnosed during pregnancy
Numerous risks to both mother and fetus during pregnancy
*A 2-step process
*One- or two-hour glucose tolerance test (GTT) at 24-28 weeks
*Three-hour GTT if one hour abnormal
Screening:
Puts mother at risk for Type 2 Diabetes later in life
Maternal insulin
cannot pass
through the
placenta.
Maternal Glucose
passes through
the placenta to the
fetus.
Yum….Glucose! I
better make some
insulin so I can use it!
Perhaps I will save
some for later as well!
Glycogen = large
glucose molecules,
created for storage.
non-pharm treatment for gestational dm
Maternal nutrition therapy
* Metabolic monitoring
* Exercise therapy
pharm treatment for gdm
Metformin
* Glyburide
* Insulin
chronic htn
presents b4 20 weeks
>140/90
gestational htn
after 20 weeks
NO PROTEINURIA
>140/90 on 2 occasions at least 4-6 hrs apart
preeclampsia
after 20 weeks
PROTEINURIA
s/s of preeclampsia
Increased BP
* Proteinuria
* Edema
* Assess lung sounds!
* Hepatic changes
* Epigastric pain
* Thrombocytopenia
* HA, Blurred vision
* Small vessels in eyes/brain are affected
* Clonus – neuromuscular irritability
labs preeclampsia
Urinalysis – proteinuria
* Liver enzymes (ALT, AST)
* Elevation indicates liver injury
* Serum Creatinine/Uric acid
* Increased serum level with kidney
disfunction
* CBC
* Thrombocytopenia
* Decreased H&H
severe features preeclampsia
Hypertension
* Systolic: > 160 Severe Pre-E =
DELIVER
* Diastolic > 110
* Thrombocytopenia
* Platelets < 100,000
* Impaired Liver function – abdominal pain
* New development of renal insufficiency
* Creatinine > 1.1
* Pulmonary edema
* New onset cerebral or visual disturbances
* Hyperactive reflexes
Preeclampsia + seizures = eclampsia
HELLP syndrome
Hemolysis
Due to: Fragmented
RBCs trying to pass
through narrowed
vessels
Elevated Liver
Enzymes
Due to:
Endothelial
damage and fibrin
deposition in liver
= necrosis
Low Platelets
Due to: Vascular
damage, vasospasm,
aggregation at sites of
damage
management preeclampsia
Seizure prophylaxis: Magnesium sulfate
* Labetolol – beta blocker, lowers BP and HR
* Hydralazine - vasodilator
* Nifedipine – Ca channel blocker
mag sulfate considerations
Seizure prevention in preeclamptic patients
High-risk medication
* VS, I&O, lung sounds, reflexes, neuro checks, assess for side effects, signs of toxicity
* Headache, lethargy, N/V are common side effects
* Signs of toxicity:
* Absent DTRs, decreased respirations/respiratory distress, decreased urine output
* Antidote for toxicity: Calcium Gluconate
Frequent assessments
Monitor fetal heart rate
Newborn side effects: sedation, hypotonia, hypothermia, respiratory depression, hypocalcemia
what to treat mag toxicity
calcium sulfate
placenta previa
placental is covering the cervix
cannot deliver
risk factors for placenta previa
Scars on uterus
Hx of previa
Drug use
multiples
complications of placenta previa
Bleeding/hemorrhage
Painless, bright red
vaginal bleeding
management of placenta previa
Dx – by US
Pelvic rest – nothing in the vagina
Monitor fetal well-being/bleeding
Assess need for Rhogam
Cesarean birth necessary
abruption placentae
Premature separation of
the placenta after 20
weeks
risk factors for abruption placentae
Drug use – cocaine, methamphetamines
Cigarette use
Hypertension disorders
Hx of abruption
PPROM
Uterine anomalies – fibroids
Trauma
abruptio placentae s/s
Uterine pain/rigid abdomen
* Increased fundal height
* Frequent contractions
* Possibly bright red bleeding
* FHR changes
management for abruptio placenae
preapre for birth
types of rupture of membrane
A-ROM = Artificial rupture of membranes
S-ROM = Spontaneous rupture of membranes
P-ROM = Prelabor rupture of membranes
prelabor rom
ROM before labor starts @ any
gestational age
preterm rom
ROM before 37 weeks gestation
preterm prelabor rom
a combination of both
terms (PPROM)
maternal risk factors for pprom
Previous history
- Bleeding
- Polyhydramnios
- Infection
- Smoking
- Multiples
- Drug use
risk to fetus pprom
Fetal Sepsis
- Pre-term birth
- Umbilical cord prolapse
- Intraventricular hemorrhage
risk to mother pprom
Chorioamnionitis
- Placental abruption
- Cord prolapse
- Pre-term labor/birth
pregnant female w/ sti
can lead to PRETERM LABOR
weaken wall of amniotic sac
pprom confirmation
Ferning
Salts from amniotic fluid
dry in a fern pattern.
Nitrazine
Basic Amniotic fluid turns
pH paper blue
* Vaginal pH is 4.5 – 5.5
* Amniotic fluid is more
alkaline (6.5-7.5)
Speculum exam
Visualize pooling of
amniotic fluid
pprom management
Establish gestational age
* Ultrasound: fetal growth and fluid levels
* Assess for infection, fetal well-being, labor
* Reasons for delivery:
* Advanced labor
* Vaginal bleeding
* Non-reassuring fetal heart rate
s/s of infection
Increased maternal and/or
fetal heart rate
* Uterine tenderness
* Malodorous amniotic fluid
* Maternal fever
preterm labor
Uterine contractions
and cervical change
between 20-37wks
why does ptl happen
Bleeding:
* Placenta previa
* Placental abruption
Uterine Stretching:
* Polyhydramnios
* Multiples
* Large for gestational
size
* Utereine abnormailites
Infections/Inflammation:
* STIs
* UTIs
* Amniotic fluid
Maternal/fetal stress:
* Stress hormones trigger
contractions
ptl labs/diagnostics
Fetal Fibronectin (FfN)
* “Glue” that holds amniotic sac to
uterine lining
* Sterile swab of cervical lining
* Cervical Length by transvaginal US
* Short means increase risk for PTL
* Ensure empty bladder
* Cervical cultures – r/o infection
* GC, Chlamydia
medical management of ptl
Corticosteroid
administration given to
mom for baby
Tocolytic medications
* Magnesium sulfate
* Prostaglandin synthesis inhibitors
* Ca Channel blockers
* Beta mimetics
how os betamethasone given
Betamethasone 12 mg
IM 24 hours apart for 2
doses
Dexamethasone given
IM every 12 hours for 4
doses
Monitor bg
why is betamethasone given
for fetal lung maturity
what are the 3 tocylytics
idomethacin
nifedipine
mag sulfate
indomethacin
Nonspecific COX inhibitor
* Maternal SE: nausea, reflux
* Feal SE: Premature
narrowing or closure of the
ductus arteriosus,
oligohydramnios
* Not to be used for more than
48 hours
nifedipine
Calcium channel blocker
* Maternal SE:
nausea, headache, flushin
g
* Contraindicated in patients
with known hypotension
mag sulfate
Antidysrhythmic (relaxes smooth
muscle)
* Maternal SE: Diaphoresis,
flushing
* Symptoms of Mag
Toxicity: Absent DTRs,
Decreased RR, Respiratory distr
ess
* Antidote for Mag toxicity is
Calcium Gluconate
* This is not a first line tocolytic-
More commonly used for preeclmpsia
terbutaline class
beta adrenergic receptor agonist
action of terbutaline
Derived from epinephrine
* Acts on beta adrenergic receptors related to flight fight reaction (like epinephrine) some muscles
relax (uterus) while other contract (heart)
maternal effects of terbutaline
Increase HR, flushing, tremors, restlessness
fetal effects terbutaline
Increase HR, Increase glucose
nsg considerations
Hold HR > 120
* HR > 120 causes a decrease in ventricular filling time and can lead to maternal MI
safety for terbutaline
Never give PO (given Sub-Q), Never give for > 72 hrs
NEVER GIVE IF MOTHER HAS A CARDIAC ISSUE
