High Risk Perinatal Care Flashcards
Diabetes mellitus
Cardiovascular disorders - adaptations in pregnancy; happens in labor
Respiratory - asthma
Integumentary
Substance abuse
Have these conditions and get pregnant
Pre-existing conditions
Pathogenesis
Classification of diabetes
Metabolic changes associated with pregnancy
Pregestational diabetes mellitus
DM
Diabetes may be caused by either or both:
Impaired insulin secretion
Inadequate insulin action in target tissues
Pancreas is not working - need insulin - drives glucose into target tissues
Pathogenesis - DM
type 1 diabetes - prior to pregnancy
type 2 diabetes - prior to pregnancy
Other specific types (caused by infection or drug-induced)
Gestational diabetes mellitus (GDM) is any degree of glucose intolerance with onset or recognition during pregnancy
Classification of diabetes - DM
Placenta - creates a resistance
2nd and 3rd trimesters: pregnancy exerts a diabetogenic effect on the maternal metabolic status - pseudo diabetic effect on woman’s body - someone already diabetic need more insulin in these trimesters; need less in end first and beginning 2nd trimester; by time viability until delivery need lot more inulin because of placenta - high levels of progesterone and estrogen making harder to control those BG
Already diabetic: Edu: diet (collab with endocrinologist or PCP on management of DM), on go up continually on insulin - BG going up
Metabolic changes associated with pregnancy - DM
Occurs in women who have pre-existing disease
After birth: Dive - no more placenta; estrogen and progesterone tanks; very conservative managing her - become hypoglycemic easily; often have insulin drips
Almost all of these patients are insulin-dependent - will be in pregnancy
Pregestational diabetes mellitus - DM
Require Preconception counseling
Maternal risks and complications
Fetal and neonatal risks
Care management
Metabolic disorders: pregestational DM
Fetal development first trimester - everything is forming; all organ sys; 13th week - have everything
When find out pregnant - halfway through first trimester - maybe 4-6 weeks
Not had well controlled BG - affect development of fetus - high BG - affects fetal development - potential congenital anomalies - imp maintain norm BG esp first trimester (risk for: heart issues, cleft palate)
Require Preconception counseling
Macrosomia
Hydramnios
Ketoacidosis
Hyperglycemia
Hypoglycemia
Maternal risks and complications
Means Big body - fetus is this
Risk to mom - if came out vaginally - lot pelvic floor damage - repetitive damage - things falling out
Macrosomia
Too much amniotic fluid - any anomalies in baby - affect amniotic fluid in baby - GI/renal issues
Hydramnios
BG has to get to go into this 200-250; DKA - happens quickly
Margin of error more narrow with prengnacy
Regular adult BG: 400-500
Ketoacidosis
Sudden and unexplained stillbirth/fetal death
Congenital malformations
Other problems that cause significant neonatal morbidity
Fetal and neonatal risks
Most concerned about
Not keep same set of prenatal appts - comes more often - in 3rd trimester - risk increases; BG harder control, baby bigger, NSTs, contraction stress test, biophys profiles, US
This can happen and not want this
Sudden and unexplained stillbirth/fetal death
Happen before found out pregnant - sugars high during development
Congenital malformations
Antepartum evaluation
Intrapartum care
Postpartum care
Care management
Deep dive: Fam hx, med hx, OB hx, same labs as reg woman
Interview
Physical examination
Laboratory tests - diabetic 2 more
Baseline renal function - diabetes screws up kidneys; pee more because GFR higher; kidney damage - lots issues - extra strain on kidneys - make sure kidneys not destroyed by diabetes
Glycosylated hemoglobin A1C - check q3months - check first come in
Check BG every time
Check urine - spilling glucose and ketones
Patient needs much more frequent monitoring
Diet and exercise - careful about this
Management more careful
Strict records of what eating; glucose log and food diary - reviewing - see if need increase insulin/change diet
Insulin therapy/Monitoring blood glucose levels
Urine testing
Determination of birth date and mode of birth - hopefully vaginal but sometimes not; tend not go to 40 weeks; happy get to 36 weeks; gestational related conditions: pre-eclampsia - DM affects CV sys - watch them and fetal development closely to see how are; want vaginal and close to term
Complications requiring hospitalization
Fetal surveillance
Antepartum evaluation
High risk
Insulin one on side and D5 or LR one on side - titrating all day - BG every hour; change based on BG
Often turn off insulin because burning off glucose as in labor
Monitor patient closely
Complications
Intrapartum care
Make sure not go hypoglycemic once delivers placenta
Insulin requirements decrease substantially
Encourage breastfeeding - burning glucose; less insulin after delivery; best for baby; requirements half as much as someone bottle feed - lactate have burn calories
Contraception
Careful giving extra estrogen - no cardiac involvement - can have estrogen in contraceptives but not if breastfeeding
DM rough on body and if pregnant - hard on body, kidneys, and heart - couple years to recover
Space pregnancies
Postpartum care
DM end 2nd almost into 3rd trimester; body work harder to move glucose - more resistance to insulin because higher levels progesterone and estrogen; all women tested 24-26 weeks - seeing rise in BG
Maternal-fetal risks
Screening for gestational diabetes mellitus
Care management: Gestational diabetes
Same as pre-gestational DM; not as huge risk congenital issues - later in pregnancy; not in formation of fetus
Biggest issue: Really big babies - macrosomia happens often - having learn manage BG; cannot manage BG well
Huge kid: Everything in baby is still 37 weeks - baby get tons fat with all sugar; babies not DM - pancreas killing it - concerned when cord clamped BG is going to tank: <40; 45 is normal in neonate - concern hypoglycemia - managed by NICU to keep BG up = hypoglycemia - brain screwed up
Maternal-fetal risks
Antepartum care
Intrapartum and postpartum care
Screening for gestational diabetes mellitus
Diet and exercise
Monitoring blood glucose levels
Insulin therapy
Fetal surveillance
1 hr oral glucose changes - easiest and most tolerated; 50 g glucose - drink whole thing - suck in 10-15 min - 1 hr after finish - draw labs; do not have to fast; <140 is standard - if pancreas working against placenta; bring something with protein after - feel like going to pass out after
3 hr glucose challenge test if 1 hr >140 = comes in another day; draw fasting - should be <95; then 100g of carb in 10 min - 1 hr later draw lab, 2 hr draw another, 3 hr draw another; feel like crud; any 2 abnormal - then gestational DM: typ about 25 weeks
Pregnancy in 3rd trimester - harder on body - baby packing weight - she will gain little bit weight - she having take BG all day; change way eats: salads, lean meats, no sugar, no sweet tea, lifestyle change in hardest part of pregnancy - huge adjustment; never had take BG - managing BG when babies getting big hard manage - baby getting bigger not usually through vagina
Oral hypoglycoemic agent
SQ insulin
Stop once deliver baby
Fetal surveillance regularly
Antepartum care
Major cardiovascular changes during pregnancy that affect women with cardiac disease are:
Lot happens to heart with heart - issues with heart lot manage
Increased incidence of miscarriage
Preterm labor and birth more prevalent
Intrauterine growth restriction is more common
Incidence of congenital heart lesions increased in children of mothers with congenital heart disease
Issue is: cannot perfuse body: preterm labor, miscarriage risk high, little baby, cannot perfuse well, worry about kidney
Antepartum assessment
Plan of care and implementation
CV disorders
Everything up except SVR
Increased intravascular volume
Decreased systemic vascular resistance - BP decreases
Cardiac output changes during labor and birth
Intravascular volume changes that occur just after childbirth
Major cardiovascular changes during pregnancy that affect women with cardiac disease are:
High likelihood miscarriage - need blood supply for embryo to implant - rich velvty luxurois - not perfusing well - not implant very well if issues with flow
Increased incidence of miscarriage
Fetus is a parasite - symbiotic relationship - body care for self - prioritizing care: preserve self before pregnancy; body having trouble perfusing self - go into labor early to preserve self
Preterm labor and birth more prevalent
Little babies
Not getting perfused
Not perfusing self well - not get as much nutrition or placenta as well as necessary
Intrauterine growth restriction is more common
Assessing baseline when first comes in
Not same routine care - pt coming in all time
Antepartum assessment
Therapy focused on minimizing stress on heart - not control adaptations to pregnancy since norm - focus on minimizing stress
Signs and symptoms of cardiac decompensation - heart giving out
Bed rest
Nutrition counseling
Cardiac medications as needed
Anticoagulant therapy
Intrapartum care - during labor
Postpartum care
Plan of care and implementation
HR lower
BP changes
Breathing issues - labored
Lots edema - extreme
SpO2 - low
Wet lungs
Color not appropriate or pink
Signs and symptoms of cardiac decompensation - heart giving out
Not fast food every night
Nutrition counseling
Risk vs benefit - some category C: consider risk for fetus or her die; measure out what more imp; some meds can change out
Cardiac medications as needed
Heparin: large-molecule drug does not cross placenta - baby not get it
Anticoagulant therapy
Care focuses on promoting cardiac function
O2 available
Encourage: Epidural - O2 consumption lower; less stress on heart; more comfy
Val salva - Increased intrathoracic pressure not good on heart
Prophylactic antibiotics
Avoid endocartitis
Intrapartum care - during labor
Monitoring for cardiac decompensation
Huge changes after placenta - extra load on heart - 1-2 L on heart still present - big changes post-partum - diligent in assessment - high acuity pt
Postpartum care
Affects 4% - 8% of all pregnancies - unpredictable; do PFTs to see baseline
Ultimate goal of asthma therapy in pregnancy is maintaining adequate oxygenation of the fetus by preventing hypoxic episodes in the mother. - prevent hypoxic episodes in mom and baby
Effective pregnancies unpredictable
Care considerations
Asthma - Other medical disorders in pregnancy: pulmonary
Some have less exacerbations
Some have more!
Effective pregnancies unpredictable
Pulse oximetry during labor and postpartum
Epidural anesthesia - encourage: in labor: breathing; hyperventilating, screaming - not want that - decrease O2 consumption; not overbreathing
Are safer choices for systemic analgesia - short-acting analgesia
At increased risk for postpartum hemorrhage
Care considerations
Due to the risk of bronchospasm Hemabate should be avoided!
cause asthma exacerbation in both
No hemabate - any other med fine; need to contract
No tobuterlin - contracting too much
At increased risk for postpartum hemorrhage - Care considerations
Integumentary disorders induced by pregnancy
Skin problems aggravated by pregnancy
Other medical disorders in pregnancy: integumentary
Melasma (chloasma)
Vascular “spiders” - varicose veins
Palmar erythema
Striae gravidarum
Pruritic urticarial papules and plaques of pregnancy (PUPPs)
Integumentary disorders induced by pregnancy
Extremely irritating; give drug to help with itching; keep up at night - claw at self - less concerning than IHC
Pruritic urticarial papules and plaques of pregnancy (PUPPs)
Acne vulgaris (in the first trimester)
Intrahepatic cholestasis (IHC)
Skin problems aggravated by pregnancy
Increase bile salts under skin - do not know why - end 2nd and into 3rd trimester - no visible evidence something wrong except claw marks from itching self - palms and soles - want rip palms and soles feet off - scratch marks - liver enzymes
Comfort measures - drugs but not help with itch
#1 concern/risk - baby dies - no idea why - routine b ile care more often and common more often
Nothing see
Close to term as possible and deliver baby
Biophys profile - induce labor or C-section; waiting game
Intrahepatic cholestasis (IHC)
Barriers to Treatment
Care management
Substance abuse in pregnancy
Not want get in trouble, jail, lose custody, find out
Red flag: not provider on record and care in variety ER; story changes every time - prenatal care from on provider to next; urine specimen to check for ketones and glucose and also check for drugs
Fear criminal prosecution
Lot not getting prentatal care
Women fear losing custody of child and criminal prosecution
Less than 10% of pregnant women receive treatment
Substance-abuse treatment programs do not address issues affecting pregnant women
Long waiting lists and lack of health insurance present further barriers to treatment
Barriers to Treatment
Substance use during pregnancy hard during prengnacy
Drug testing during pregnancy = some forthcoming = be upfront test every time test; hold accountable
Methadone maintenance program
Breastfeeding definitely contraindicated in women who continue to use amphetamines, alcohol, cocaine, heroin, or marijuana
Antipsychotics: risk vs benefit
Is an illness
Hardest to manage pain
Involve social services
Substance abusers difficult to care for particularly during intrapartum and postpartum periods
Substance abuse is an illness; women deserve to be treated with patience, kindness, consistency, and firmness
Before discharge
If infant’s well-being is questionable, case will be referred to child protective services agency
Care management
Opioid addiction - eligible to switch do that
Understand baby go through withdrawal through first 2 weeks when baby born - prepare for that - not miserable during prengnacy - something not as strong - help manage them
Methadone maintenance program
Illicit and opioids - careful about advocating for breastfeeding - unless changed environment during pregnancy going to use again
Breastfeeding definitely contraindicated in women who continue to use amphetamines, alcohol, cocaine, heroin, or marijuana
Home situation must be assessed for safe environment
Someone available to meet infant’s needs if mother is unable
Family members or friends should become actively involved with mother before discharge
Before discharge
In assessing the knowledge of a pregestational woman with type 1 diabetes concerning changing insulin needs during pregnancy, which statement indicates that further teaching is warranted? (Select all that apply)
A) “I will need to increase my insulin dosage during the first 3 months of pregnancy.”
B) “Insulin dosage will likely need to be increased during the second and third trimesters.”
C) “Episodes of hypoglycemia are more likely to occur during the second trimester.”
D) “Insulin needs should return to normal within 7 to 10 days after birth if I am bottle-feeding”
E) “Breastfeeding significantly reduces insulin requirements”
Answer: A, C
Which of these are wrong
Increase dosage 2nd and 3rd trimester
Hypoglycemia in first trimester
Hypertension in Pregnancy
Hyperemesis Gravidarum
Hemorrhagic Disorders
Trauma
Gestational conditions
Significance and incidence
Gestational hypertension
Chronic hypertension
Preeclampsia superimposed on chronic hypertension
Preeclampsia
Eclampsia
HTN in pregnancy
Issue managing BP in pregnancy - higher risk diff managing BP later in life
Preeclampsia complicates approximately 5% to 10% of all pregnancies or hypertensive disorder; despite drop vascular resistance - multisys issues - pre-eclampsia multisys issues - multiple types HTN issues: preeclampsia is a type
Hypertensive disorders of pregnancy are the most common medical complication reported during pregnancy; next hemorrhagic disorders (bleeding); then suicide
Significant contributor to maternal and perinatal morbidity and mortality
Significance and incidence
Onset of hypertension without proteinuria after the 20th week of pregnancy
Caused by prengnancy
Gestational hypertension
Present before the pregnancy or diagnosed before week 20 of gestation
See if there is a trend
Chance hypertensive and not know it
Chronic hypertension
When have HTN before pregnant then get preeclampsia
Preeclampsia superimposed on chronic hypertension
Hypertension develops after 20 weeks of gestation in previously normotensive women
On a continuum
Worse over time
More than just HTN
BP part of it
Multi-sys - affects entire body
Preeclampsia
Trying to prevent
Bad outcomes
Seizure activity or coma in woman diagnosed with preeclampsia
No history of pre-existing pathology/seizure disorder
Esp if after 20 weeks
Before 20 weeks look at other causes
Eclamptic seizures can occur before (most often), during, or after birth (up to 6-8 weeks after labor)
Eclampsia
Etiology
Pathophysiology
Assess her:
HELLP Syndrome
Care management: assessment
Care management: assessment & intervention
Pre-eclampsia
Signs and symptoms develop only during pregnancy or shortly after delivery and disappear after birth; only because pregnant
Higher risk to have HTN later in life
Associated high-risk factors
Etiology
Family history
Multifetal pregnancy - forced get pregnant higher risk
African-American race
Obesity - strain entire body
Before 19 and after 40 years old
Pre-existing medical or genetic conditions - DM
Associated high-risk factors
Check blood and good nursing assessments
Progresses along a continuum from mild to severe = goal: mild and delivered as close to term as possible
Often have smaller baby - perfusion issues
Caused by disruptions in placental perfusion and endothelial cell dysfunction - cells everywhere
Placental itching - spasms - irritating to it; adhered to placenta - placentas fault have preeclampsia - not just hers - have her and him; issue with placental perfusion
Generalized vasospasm
Reduced kidney perfusion
Pathophysiology
HTN
Glomerular damage - tiny vessels spasm - kidneys hurt - decreased urine output
Look at labs - issues with them - kidney func labs messed with - uric acid and Cr messed with
Ask about voiding and measure urine
Cortical brain spasm - headache (ask - unrelieved); Hyperreflexia - DTRs
Retinal arteriolar spasm (blurred vision - starting losing peripheral vision, floaters)
Hyperlipidemia - labs
Liver ischemia - labs; palpate liver: pain - not good blood supply - RUQ pain (aching all time)
Intravascular coag: clots - high risk clots because high estrogen - hemolysis RBCs - H&H drop; platelet adhesion - low platelet count because clumping, DIC (lots clots); increased factor VIII antigen - seeing labs
Looking lot labs
Listen to lungs and heart - increased permeability and cap leakage - Edema (pulm and gen edema): 3rd trimester: LE; issue around face, eyes (perioribital edema), arms
Dyspnea - wet lungs
Hemoconcentration - all sudden going up - getting worse increased H&H
Watching trends and labs
Assess her:
Continuum of preeclampsia
On labs
Laboratory diagnostic variant of severe preeclampsia involves hepatic dysfunction, characterized by:
Associated with increased risk for:
Full CV and multi-sys collapse
HELLP Syndrome
Hemolysis (H)
Elevated liver enzymes (EL)
Low platelets (LP)
Looking for elevations - liver higher; platelets lower, and monitor CBC; got to deliver baby and placenta
Laboratory diagnostic variant of severe preeclampsia involves hepatic dysfunction, characterized by:
Pulmonary edema
Renal failure
Liver hemorrhage or failure
Disseminated intravascular coagulation (DIC)
Placental abruption
Acute respiratory distress syndrome (ARDS)
Sepsis
Stroke
Fetal and maternal death
Associated with increased risk for:
Identifying and preventing preeclampsia
Physical examination
Laboratory tests
Care management: assessment
Dependent edema
Pitting edema
Deep tendon reflexes (DTRs)
Clonus - feels like deep itch
Physical examination
Proteinuria
Laboratory tests
Mild gestational hypertension and mild preeclampsia
Severe gestational hypertension and severe preeclampsia
Care management: assessment & intervention
Do more Maternal and fetal assessments
May need do some Activity restriction - if exacerbating conditions
Diet
Not do - not put on low Na diet; not advocate eat fast food often
Mild gestational hypertension and mild preeclampsia
Greater risk for pregnancy complications - cure deliver baby and placenta
Viability - amniocentisis, check baby
Intrapartum care
DELIVERY!
Magnesium sulfate
Control of blood pressure
Future health care
Been through severe preeclampsia - severe equola - some kidney damage and HTN anyway - wreaks havoc
Severe gestational hypertension and severe preeclampsia
Treatment of choice to prevent eclampsia - keep nice and relaxed
Chills out vasospasms - administer exclusively IV; can do IM in emergencies
Drug of choice for prevention and treatment of eclampsia
Administered almost exclusively intravenously
Therapeutic levels (4-7mEq/L); non pregnant person that is high
Mg in relationship to heart: cardiac electrolyte
Watch I&O, DTRs, at bed all day
Excreted by the kidneys
Common side effects:
Toxic quickly
Manage preeclampsia before delivery; further along in pregnancy
Mild Toxicity:
Severe Toxicity:
Often in hub in wrist to easily reverse it
Managing toxicity
Magnesium sulfate
4-6gm loading dose
Titrate - Followed by maintenance dose of 2gm/hr
In labor - LR, need pitocin (need contract), and give mag
Administered almost exclusively intravenously
horrible; educate before started; start load - burn IV then slow down - hurt 15-20 min; big boar IV - tear up IV; put on ice; feel on fire on inside
BP get better and prevent causing seizure - watch closely; assessments - BP, HR, SpO2, output qhr - excreted by kidneys - preeclampsia messed with kidneys - output will decrease - not emptying body Mg will go up
Warming
Flushing
Diaphoresis
IV site irritation
Common side effects:
Drunk on tequila
Lethargy
Muscle weakness
Decreased DTRs - no response
Double vision
Slurred speech
Mild Toxicity:
Maternal hypotension - BP tanked
Bradycardia
Bradypnea
Cardiac arrest - dies
Severe Toxicity:
Discontinue Magnesium Sulfate
Call provider - say toxic; get mag level - stop it and give antagonist - often deliver baby; stop mag and call doc
Calcium Gluconate - whole vial to reverse it
Managing toxicity
Defined: excessive vomiting accompanied by dehydration, huge electrolyte imbalance, ketosis, and acetonuria; entire pregnancy; all day; sig weight loss; often hospitalized
electrolyte imbalance - hospitalized to replace it
Hyperemesis gravidarum
Etiology
Clinical manifestations
Care management
Initial care
Follow-up care
electrolyte imbalance - hospitalized to replace it
Hemorrhagic disorders in pregnancy are medical emergencies
Maternal blood loss decreases oxygen-carrying capacity
Spontaneous Abortion
Reduced Cervical Competence (Cerclage)
Ectopic Pregnancy
Hydatidiform Mole
Previa
Abruption
Trauma
Hemorrhagic disorders
Mom losing blood: Increased risk for hypovolemia, anemia, infection, preterm labor, and preterm birth with her
Adversely affects oxygen delivery to fetus
Fetal risks include blood loss or anemia, hypoxemia, hypoxia, anoxia, and preterm birth - no O2
Maternal blood loss decreases oxygen-carrying capacity
Pregnancy implanted outside uterus
Clinical manifestations
+ pregnancy test - US and see pregnancy outside uterus - nothing in uterus - outside uterus - see swollen fallopian tube
End pregnancy
Management
Ectopic pregnancy
Abdominal pain
Delayed menses
Abnormal vaginal bleeding
Clinical manifestations - Ectopic pregnancy
Medical
Surgical
Management - Ectopic pregnancy
Methotrexate
Try meds first
Drug to help end pregnancy and reabsorbed into body
Medical
Salpingectomy - take out pregnancy and tube - not take out tube end up with scar tissue and get another ectopic pregnancy in there
Surgical
This is not a human
Looks like tumor - mass cells cont divide and get bigger
Empty genetic material - starting divide - somatic cells getting bigger; not human being or viable pregnancy
Mass of cells - molar pregnancy - uterus big quickly
Clinical manifestations
Management
At risk of getting cancer in uterus: choriocarcinoma - where corion would have been - education piece - mourn loss: still miscarriage: understand not human but edu biggest risk developing type cancer - measuring Hcg for next year - not get prengnacy for next year - good contraception for next year - monitor her for that - cannot monitor that if pregnant
Cancerous issue
Gestational trophoplastic disease (hydatidiform mole/molar pregnancy)
Vaginal bleeding
Positive Hcg - probable sign of pregnancy
Significantly larger uterus
Clinical manifestations - Gestational trophoplastic disease (hydatidiform mole/molar pregnancy)
Most pass spontaneously
Most need do DNC - suction out
Suction curettage is safe, rapid, and effective if necessary
Induction of labor with oxytocin or prostaglandins not recommended - not induce to give birth to mass cells
Management - Gestational trophoplastic disease (hydatidiform mole/molar pregnancy)
Placenta attached low in uterus and covering internal os
Does not hurt
Maternal and fetal outcomes
Diagnosis and medical management
Late pregnancy bleeding: placenta previa
Abnormal placental attachment
Excessive bleeding - ask if painful; belly hard when bleeding; happens every now and then - confirm this - US
Fetal risks include malpresentation, preterm birth, fetal anemia, and congenital anomalies
Complete: Edu - nothing in vagina; more bleeding
partial/marginal - seen early in pregnancy - placenta shifts away where can do vaginal
Cannot deliver placenta before baby
Maternal and fetal outcomes - Late pregnancy bleeding: placenta previa
Standard diagnosis is transabdominal ultrasound examination
Management includes:
Expectant management: observation and bed rest
Will have do Cesarean birth
Home care
Active management
Diagnosis and medical management - Late pregnancy bleeding: placenta previa
Placenta pulled away and bleeding away from it
Can do vaginal delivery - labor dicey at times
Often pouring blood - her and baby losing volume quickly
All high risk things can lead to this
Motor vehicle collision/falling down stairs is this
Partial separation - vaginal complete - quickly get out baby
Premature separation of placenta (Abruptio placentae)
Late pregnancy bleeding: abruption
Incidence and etiology
Classification systems
Clinical manifestations
Maternal, fetal, and neonatal outcomes
Management
Premature separation of placenta (Abruptio placentae) - Late pregnancy bleeding: abruption
Grades: 1 (mild - partial separation), 2 (moderate - partial separation with apparent hemorrhage), 3 (severe - complete separation)
Classification systems - Premature separation of placenta (Abruptio placentae) - Late pregnancy bleeding: abruption
Painful vaginal bleeding
Hard fundus
Hurts very badly
Bleeding in the muscle
Uterus contracts - contraction not stop and until baby out and stop bleeding
Clinical manifestations - Premature separation of placenta (Abruptio placentae) - Late pregnancy bleeding: abruption
Expectant
Active
Management - Premature separation of placenta (Abruptio placentae) - Late pregnancy bleeding: abruption
Clotting everywhere; cont clot - use up all clotting factors then bleed
Pathologic form of diffuse clotting causing widespread external and internal bleeding
Triggered by large amounts of tissue thromboplastin (placental abruption or dead fetus)
Fetal death, preeclampsia, aburption
Triggered by widespread damage to vascular integrity (severe preeclampsia, HELLP, and gram negative sepsis)
complication
DIC - Clotting disorders in pregnancy
Significance
Maternal physiologic characteristics
Fetal physiologic characteristics
Nursing care management
Trauma during pregnancy
Special considerations for mother and fetus
Physiologic alterations of pregnancy - Role her to side - not have on back; on side; blood volume - normal lab values; appendix located; estrogen and progesterone; vascularlization; adapt to trauma; BLS - not same way - belly in way
Presence of fetus
Fetal survival depends on maternal survival - sometimes baby can be oximeter how well CPR going
Pregnant woman must receive immediate stabilization and care for optimal fetal outcome
Significance
Requires strategies adapted for appropriate resuscitation, fluid therapy, positioning, assessments, and other interventions
Because adaptations - how change care
Respiratory sys
CV sys
Renal sys
GI sys
Reproductive sys
MS sys
Hematologic sys
Uterus and bladder positioning
Elevated levels of progesterone
Decreased tolerance for hypoxia and apnea
Cardiac output
Circulating blood volume
Maternal physiologic characteristics
Increase oxygen consumption
Increase tidal volume
Decrease functional residual capacity
Decrease PaCO2
Decrease serum bicarbonate
Alteration - Respiratory sys
Increase risk for acidosis
Increase risk for respiratory mismanagement
Decrease blood-buffering capacity
Clinical responses - Respiratory sys
Decrease serum bicarbonate
Increase circulating volume, 1600 mL
Increase CO
Increase heart rate
Decrease SVR
Decrease arterial blood pressure
Heart displaced upward to left
Alteration - CV sys
Can lose 1000 mL of blood
No signs of shock until blood loss >30% of total blood volume
Decrease placental perfusion in supine position
Point of maximal impulse, fourth intercostal space
Clinical responses - CV sys
Increase renal plasma
Dilation of ureters and urethra
Bladder displaced forward
Alteration - Renal sys
Increase risk for stasis, infection
Increase risk for bladder trauma
Clinical responses - Renal sys
Decrease gastric motility
Increase hydrochloric acid production
Decrease competency of gastroesophageal sphincter
Alteration - GI sys
Increase risk for aspiration
Passive regurgitation of stomach acid if head lower than stomach
Clinical responses - GI sys
Increase blood flow to organs
Uterine enlargement
Alteration - Reproductive sys
Source of increase blood loss
Vena caval compression in supine position
Clinical responses - Reproductive sys
Displacement of abdominal viscera
Pelvic venous congestion
Cartilage softened
Fetal head in pelvis
Alteration - MS sys
Increase risk for injury, altered rebound response
Altered pain referral
Increase risk for pelvic fracture
Center of gravity changed
Increase risk for fetal injury
Clinical responses - MS sys
Increase clotting factors
Decreased fibrinolytic activity
Alteration - Hematologic sys
Increase risk for thrombus formation
Clinical responses - Hematologic sys
Careful monitoring of fetal status assists greatly in maternal assessment
Fetal monitor tracing works as “oximeter” of internal maternal well-being
Fetal physiologic characteristics
Immediate stabilization
Primary survey
Cardiopulmonary resuscitation
Secondary survey
Electronic fetal monitoring
Fetal-maternal hemorrhage
Ultrasound
Radiation exposure
Perimortem cesarean delivery
Good compressions - keeping baby alive - once heart stops beating few minutes before lose baby; take out scalpel and remove baby
Know effective - baby looks good
Nursing care management
HELLP Syndrome is associated with what manifestations? Select all that apply.
A) Mild preeclampsia
B) Elevated liver enzymes
C) Hemolysis
D) Low platelets
E) High blood sugar
Answer: B, C, D
More scenario and may give labs with reference range - interpret labs
