High Risk Perinatal Care Flashcards by Kelsey Klipfel

Diabetes mellitus
Cardiovascular disorders - adaptations in pregnancy; happens in labor
Respiratory - asthma
Integumentary
Substance abuse
Have these conditions and get pregnant

Pre-existing conditions

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Pathogenesis
Classification of diabetes
Metabolic changes associated with pregnancy
Pregestational diabetes mellitus

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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

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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

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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

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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

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Require Preconception counseling
Maternal risks and complications
Fetal and neonatal risks
Care management

Metabolic disorders: pregestational DM

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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

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Macrosomia
Hydramnios
Ketoacidosis
Hyperglycemia
Hypoglycemia

Maternal risks and complications

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Means Big body - fetus is this
Risk to mom - if came out vaginally - lot pelvic floor damage - repetitive damage - things falling out

Macrosomia

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Too much amniotic fluid - any anomalies in baby - affect amniotic fluid in baby - GI/renal issues

Hydramnios

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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

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Sudden and unexplained stillbirth/fetal death
Congenital malformations
Other problems that cause significant neonatal morbidity

Fetal and neonatal risks

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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

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Happen before found out pregnant - sugars high during development

Congenital malformations

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Antepartum evaluation
Intrapartum care
Postpartum care

Care management

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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

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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

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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

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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

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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

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Antepartum care
Intrapartum and postpartum care

Screening for gestational diabetes mellitus

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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

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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

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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

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High Risk Perinatal Care Flashcards

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