Lecture 8: High Risk OB in the ICU Flashcards
Respectful OB Care (7)
1) Consent: Allow support person to remain at the bedside.
2) Encourage breast-feeding and bonding when feasible.
3) Family centeredness
4) Frequent updates about the newborn
5) Coordinate obstetrical and critical care.
6) Grief support
7) Collaboration with Labor and Delivery staff, psychiatric liaison nurses, social workers, psychologists, psychiatrists, and clergy
Physiologic Changes during Labor and Delivery (2)
1) Additional maternal stress related to pain and anxiety
2) Cardiovascular changes
- Increased cardiac output by 30-50%
- Changes in blood distribution
Cardiovascular Changes (7)
- blood plasma volume
- rbc
- hr
- co
- blood loss during vag/c section
- what occurs in a flat position?
- what is recommended instead?
- heart sound?
- Blood/Plasma volume increases by 40% to 50%.
- Red blood cell volume increases by 20%
- Heart rate increases 10 to 15 beats/minute.
- Cardiac output increases 30% to 50%.
- 500 mL blood loss during a vaginal birth and approximately 1,000 mL during a cesarean birth (?).
- Supine hypotension occurs in a flat position.
- Side-lying position is recommended.
- S3 heart sound
Respiratory Changes (10)
1) diaphragm
2) Rib cage, chest wall compliance
- Lung compliance
3) tidal volume
4) Airway mucosal
5) Respiratory rate
6) Oxygen consumption, during labor.
- metabolic demand
7) PaO2
8) PaCO2
9) maternal pH- slightly ____
10) Airway pressures
1) Upward shift of the diaphragm
2) Rib cage volume displacement, reduces chest wall compliance
- Although Lung compliance increases
3) Increases tidal volume by 30% to 35%
4) Airway mucosal changes
5) Respiratory rate remains unchanged
6) Oxygen consumption increases 15% to 20%, 300% during labor.
- Dramatically increased metabolic demand
7) Increased PaO2
8) Decreased PaCO2 (30-32)
9) Slight increase in maternal pH- slightly alkalotic
10) Airway pressures are augmented with low compliance chest cavity, does not indicate high alveolar pressure
Renal Changes 5
- increase in (2)
- renal blood flow
- higher clearance for?
- gfr
- elevations in clearance of what? reflected in?
- Increase in metabolic and circulatory requirements
- Renal blood flow increases by 30%.
- Higher clearance for certain drugs
- Glomerular filtration rate (GFR) increases by 50%.
- Elevations in the clearance of many substances, such as creatinine and urea, and are reflected in lower serum levels.
Gastrointestinal and Metabolic Changes (8)
- GI changes occur ..
- esophageal sphincter
- Passive ________ and _____
- Hormonal influences cause
- Smooth muscle relaxation = (3)
- gastric acid secretion in the ______ trimester
- ________ state; increased
- Hepatic and maternal fasting blood glucose levels ____ due to ?
- GI changes occur as a result of the growing uterus.
- Displacement of the esophageal sphincter into the thoracic cavity
- Passive regurgitation and aspiration
- Hormonal influences cause delayed gastric
emptying and motility - Smooth muscle relaxation = nausea, heartburn, and constipation
- Increased gastric acid secretion in the third trimester
- Diabetogenic state; increased resistance to insulin
- Hepatic and maternal fasting blood glucose levels decrease due to the constant transfer of glucose to the fetus.
Hematological Changes
- hct
- wbc
- clotting factors
- fibrinogen
- what remains the same in pregnancy (3)
Hematocrit decreases.
WBC elevated
Increase in clotting factors
Fibrinogen increases.
Bleeding, clotting times, and platelet counts remain the same in pregnancy.
Physiologic Alterations in Pregnancy: Pulmonary (3)
- o2 consumption
- ventilator changes?
- oxyhemoglobin dissociation curve shifts? why?
- Increased oxygen consumption
- Ventilatory changes- higher Pa02 (100+), lower PaCO2 (30-32)
- Maternal oxyhemoglobin dissociation curve shifts to the right: Gives O2 up more readily (increased metabolic demand)
Placenta
- what is it?
- produces what 4 hormones and functions of hormones?
- what can diminish blood flow to the placenta and fetus ? (4)
1) Metabolic exchange of O2/CO2, nutrition, and waste removal between the pregnant person and the fetus.
2) Produces four hormones necessary to maintain the pregnancy:
- (HCG) Human chorionic gonadotropin is the basis for pregnancy tests and is originally produced by the embryo and then the placenta, preserves the function of the corpus luteum.
- (hPL) Human placental lactogen, stimulates maternal metabolism to supply needed nutrients for fetal growth; is responsible for the increase in insulin resistance.
- Progesterone and estrogen are eventually produced by the placenta and are responsible for uterine growth and utero-placental blood flow.
3) Hypertension, covid (especially in a particular trimester) cocaine use, or smoking can diminish blood flow to the placenta and fetus.
Critical Care Conditions in Pregnancy
1) ___________ instability:
- 4 examples
2) the most common cause of maternal mortality overall are (2)
3) the most common cause of death in pp period are? (4)
4) the most common cause of death during delivery are? (3) (hint: obstetric emergencies)
tip:
what is the most common cause for icu admissions in pregnant and postpartum people?
1) Hemodynamic instability:
- Obstetrical hemorrhage
- Placenta previa
- Placental abruption
- Uterine rupture
2) The most common causes of maternal mortality overall are heart disease and stroke
3) The most common causes of death in the postpartum period are severe bleeding, high blood pressure (pre-eclampsia and hypertensive disorders), cardiomyopathy, and infection
4) The most common causes of death during delivery are the following obstetric emergencies:
- Disseminated intravascular coagulation (DIC)
- Amniotic fluid embolus
- Hemorrhage
tip:
Most common causes for ICU admission in pregnant and postpartum people are PPH and hypertensive disorders
66% of maternal deaths occur during birth or in the first 6 postpartum weeks.
Worlwide leading cause of death is hemorrhage
Rupture- 50% fetal death rate, 15% maternal death rate.
60% of maternal deaths are preventable according to CDC
Critical Care of the Obstetric Patient: Other things you may see (6)
Trauma
Respiratory Failure/ ARDS /Covid
Infection/sepsis
DKA
Liver disease
VTE
Cardiac Disease and Pregnancy (3)
Preexisting conditions
Primary cardiac disease
Maternal mortality risks – what is going on?
tip:
People come into pregnancy with all kinds of things, some have pre-existing cardiac disease. SOme will develop during pregnancy. Mostly congenital that people know about or don’t; cardiomyopathy also d/t expanded blood volume
Maternal Cardiac Disease: Preexisting Conditions (High Risk Pregnancy) (13)
- Atrial septal defect
- Ventricular septal defect
- Pulmonary ductus arteriosus
- Pulmonic/tricuspid disease
- Valve prosthesis
- Anticoagulation w/ mechanical valves
- Mitral stenosis
- Aortic stenosis 🡪 Pulmonary edema
- Tetralogy of Fallot
- Previous myocardial infarction
- Marfan syndrome
- Pulmonary hypertension and
Eisenmenger syndrome (RV Failure) - Coarctation of the aorta
tip:
Marafn syndrome- concerns for spontaneous pneumothroax. All of these patients, if they have prenatal care will be followed by a high risk OB and will come to you with a plan of care. Sometimes they’re induced at a certain point and can’t push very long, sometimes they’re c sections
Cardiac Disease and Pregnancy - CHF
- what is the most common cause of heart failure in pregnant women?
- when does cardiac failure usually occur?
- do you need a previous history of cardiac disease to develop cardiac disease during pregnancy?
- what medication is teratogenic and during which trimester and why?
- which medications are fine to take (4)
- when do cardiac symptoms usually resolve?
- what does it indicate?
1) Peripartum cardiomyopathy
Most common cause of heart failure in pregnant women
Cardiac failure during the last month of pregnancy or the first 6 months postpartum
No previous history of cardiac disease
Symptoms and treatment identical to classic heart failure
- ACE-I is teratogenic in the 2nd and 3rd trimesters- why? they can cause fetal damage, including kidney problems, low amniotic fluid, and potential birth defects, due to their impact on the fetal renin-angiotensin system
- Hydralazine, Labetolol, Metoprolol, nifedipine is fine
Usually resolves after pregnancy (~50%)
Candidates for transplant
tip:
Nifedipine- is a tocolytic (Prevents labor). sometimes given in preterm labor to slow contractions
Cardiac Disease and Pregnancy -MI
1) what is it?
2) _____ during pregnancy?
3) increased ______ associated with (4)
4) treatment is focused on (2)
- can also include what procedures (3)
1) Acute myocardial infarction
(a) Rare during pregnancy
(b) Increased mortality associated with
- Occurrence during third trimester
- Patient age younger than 35 years
- Cesarean section delivery
- Delivery occurring within 2 weeks of infarction
(c) Treatment focused on restoring blood flow and balancing myocardial oxygen supply and demand
- Cardiac Cath, IV heparin, Nitro etc.
Cardiac Disease and Pregnancy – Shock States
1) what is shock?
2) 3 types of shock that can occur?
- what are the complications associated with each shock?
- (4) 1st shock + PPH (5), (3) 2nd shock, (1) 3rd shock type
1) Shock: tissue hypoxia that results in decreased perfusion—look for causes unique to pregnancy
(a) Hemorrhagic
- Abruptio placentae, ectopic pregnancy, placenta previa, and postpartum hemorrhage (PPH- Uterine atony, genital tract lacerations, hematoma formation, retained placenta, uterine prolapse)
(b) Septic
- Chorioamnionitis, septic abortion, postpartum pyelonephritis
(c) Cardiogenic
- Severe valve disease
Cardiac Disease and Pregnancy: resuscitation
1) ______ outcomes are related to maternal condition
2) BLS:
- where do you do compressions for pregnant women?
- what other interventions can be done for compressions (2)
3) ACLS:
- (2) may necessitate smaller ett
- what kind of medications for resuscitation are used?
4) what else do you want to monitor?
(a) Fetal outcome related to maternal condition
(b) Basic Cardiac Life Support
- Chest compressions slightly above center of sternum
- Use wedge or manual manipulation to displace uterus laterally
(c) Advanced Cardiac Life Support
- Airway edema and swelling may necessitate smaller endotracheal tube
- Standard recommendations for resuscitation medications
(d) Monitoring of fetal condition
Hypertension
4 types
1) Classification of hypertensive disease in pregnancy –Number one cause of maternal mortality in the U.S.
I. Chronic hypertension
II. Preeclampsia-eclampsia
III. Preeclampsia superimposed on
chronic hypertension
IV. Gestational hypertension
Preeclampsia—Physiological Principles (7)
1) Vascular endothelial damage caused by arteriolar vasospasms and
vasoconstriction (Increasing BP)
2) Platelets activate > Intravascular coagulation (Similar to DIC)
3) Colloidal osmotic pressure decreases, endothelium becomes disrupted (Shifting fluid out of vasculature)
- Increased plasma volume, cardiac output, heart rate and capillary permeability, and decrease in colloid osmotic pressure predispose to pulmonary edema.
4) Decreased perfusion to the kidneys
5) Decreased perfusion to the liver
6) Neurological sequelae may include seizures, stroke.
7) Baby- Intraurine growth restriction, placental abruption, stillbirth
Preeclampsia
1) occurs in how many pregnancies?
2) etiology
3) prediposing factors: (7)
4) manifestations: (9)
1) Preeclampsia occurs in 5% to 7% of pregnancies
2) Unknown etiology
3) Predisposing risk factors:
- Nulliparity
- Multiple gestation
- Diabetes
- Age younger than 18 or older than 35 years
- Chronic hypertension
- Obesity
- Covid infection during pregnancy
4) Manifestations:
Preeclampsia = BP >140/90 after 20 weeks gestation with proteinuria
Severe features of preeclampsia = BP >160/110
Higher levels of proteinuria: >5g/24h
Oliguria
Visual and cerebral disturbances- scotoma
Epigastric pain
Hepatic dysfunction
Thrombocytopenia
Pulmonary edema
Preeclampsia - Management (5)
- what is the main treatment?
- what do you want to prevent? control? monitor? maintain?
- frequent measurements of what?
- what do you never want to give to pre-e patients? treat with what instead?
- what kind of care will provide the best results?
- what is a mjor factor of pre-e to remember?
1) Delivery of the fetus is treatment. However, pre-e can develop post partum.
- 34 weeks before consideration of delivery (Can go sooner)
2) Prevent seizures and respiratory complications, control hypertension, monitor cardiovascular status, and maintain fluid status.
3) Frequent blood pressure measurements, strict I & O, labs, aggressive anticonvulsant and antihypertensive drug therapy
- Patients are intravascularly dry, treat with fluids, never diuretics
Fetal monitoring
4) Collaboration between critical care and obstetrical staff
5) Fetus is a patient
Preeclampsia - Interventions for icu (4)
1) Fluid restriction depending on CVP, side position -
2) Monitor for hypovolemia (CVP, PAP, and PAWP)
3) Drug therapy to prevent seizures and hypertensive crises.
- Intravenous or IM magnesium sulfate
- Magnesium precautions- bed rest, I&O, DTR, calcium gluconate
4) Hydralazine hydrochloride (Apresoline), labetolol, nifedipine
- Avoid ACE-I, Nitroprusside, Diuretics
Preeclampsia – Nursing Interventions (9)
Evaluate neurological symptoms.
Decrease light and sound stimulation.
Coordinate treatments and interventions to optimize rest periods.
Seizure precautions
Assess for symptoms of magnesium toxicity (respiratory depression and hyporeflexia)
Continue magnesium sulfate x 24 hours post-delivery.
Assess uterine bleeding.
The uterus should be firm post-delivery.
Magnesium effects on the fetus? (neuroprotection, risk of bone problems and low calcium levels in fetus)
HELLP syndrome (3) + complications (6)
1) Hemolysis
- Microangiopathic hemolysis
2) Elevated Liver enzymes
3) Low Platelet syndrome: <150,000
4) Complications: Abruptio placenta, liver hematoma, disseminated intravascular coagulation (DIC), pulmonary edema, liver rupture, acute renal failure
HELLP Syndrome
- accompanies ______ ________ and ________ in approximately ______ to _____ cases
- increased risk for developing complications such as (6)
- s/sx similar to?
- what other 2 symptoms?
Accompanies severe preeclampsia and eclampsia in approximately 10% to 20% of cases
Increased risk for developing complications such as renal failure, pulmonary edema, DIC, placental abruption, ARDs, and liver hematoma and rupture
Signs and symptoms similar to those of severe preeclampsia, however, hypertension may be absent in 20% of cases
Decreased platelets (<100,000/mm3) and elevated liver enzymes.
HELLP—Management (7)
- what is the number #1 treatment for any situation?
- if not, what else can be done? (5)
- what agents can be given? (2)
- monitor (3)
- assess (2)
- what 3 things may indicate liver hematoma or rupture?
- accurate what is needed?
- Delivery!! regardless of gestational age
- Bed rest, frequent BP checks, frequent LFTs, coagulation status, and intensive fetal surveillance
- Magnesium sulfate and antihypertensive agents as needed
- Monitoring VS, bleeding, pain, and labs
- Assess fetal heart rate and S & S of placental abruption- may present with abruption
- Worsening pain, vascular collapse, or shock may indicate liver hematoma or rupture
- Accurate I & O
Thrombolytic Thrombocytopenia Purpura
1) overlap of symptoms with _____
- more likely to have ____ ______ _____
- _____ (2) may not be present
- s/sx do not what?
2) treat with (2)
1) Overlap of symptoms with HELLP
- More likely to have mental status changes
- Hypertension may not be present
- Abnormal LFTs may not be present
- Sign/symptoms do not resolve after delivery
2) Treat with:
- Dexamethasone
- Plasmaphoresis
tip:
Plateltes are being destroyed. - Looks like help.
Low platelets, hemolytic anemia, micorvascular emboli
-Donor plasma is given after
Hemorrhagic Shock
1) __________ cause of _______ in pregnant women in the world, _____ in the US
2) causes: (5)
1) Number 1 cause of death in pregnant women in the world
- Number 2 in the U.S.
2) Causes:
- Miscarriage
- Ectopic pregnancy
- Abruptio Placentae
- Uterine Rupture
- Postpartum hemorrhage
tip:
Miscarriage
Ectopic pregnancy – rupture of fallopian tubes.
Abruptio Placentae. - can conceal bleeding- 20 weeks, HTN, preeclampsia, trauma, illicit drugs
Uterine Rupture – contents are spilled into abdominal contents- 50% fetal rate, 5-15% maternal rate.
Postpartum hemorrhage – 24 hours, but also 12 weeks >1000ml with s/s of hypovolemia. – 15% of cardiac output goes to the placenta.
—Bimanual uterinecompressionmassageis performed by placing one hand in the vagina and pushing against the body of theuteruswhile the other hand compresses the fundus from above through the abdominal wall.
How do we treat hemorrhages? (7)
Meds: which ones?
Clot evacuation
D&C
Bimanual compression
Bakri balloon
Blood and FFP
Hysterectomy
Obstetric Disseminated Intravascular Coagulation (DIC)
1) obstetric causes: 5
what is DIC?
1) Obstetric causes:
- Abruptio placenta
- Preeclampsia-eclampsia
- Dead fetus syndrome
- Septic abortion
- Amniotic fluid embolism
tip:
What is DIC?: overactive clotting, then the body uses all of its clotting factors and has none left so uncontrolled bleeding. Usually post delivery if it happens.
DIC—Management (5)
- what if causes by septic shock?
- what if caused by abruptio placentae?
Identify and treat the underlying condition
Evaluate and monitor the coagulation system
Prevent further hemorrhage and thrombosis
If caused by septic shock, prompt delivery of the fetus and intravenous administration of broad-spectrum antibiotics
For abruptio placentae, prompt delivery of the fetus
Prevent further bleeding, monitoring coagulation studies, assess for multisystem involvement, altered tissue perfusion, and fluid volume deficits
Monitor respiratory status, administer intravenous fluids, assess hemodynamic values, and administer and evaluate antibiotics, blood replacement products, and antipyretics
tip:
Low platelet, low fibrinogen, prolonged PT, PTT.
Give plasma and platelets, blood. stop the bleeding
Pulmonary Dysfunction
1) what is the syndrome called?
- previous name?
- _________ cause of maternal death
- symptoms (8)
- diagnosis: (1)
- mgmt: (2)
1) Anaphylactoid syndrome of pregnancy
- Previously known as amniotic fluid embolism (AFE)
- Rare cause of maternal death
- Symptoms: Acute respiratory distress, hypoxia, hypotension from vasodilation and loss of circulatory integrity, shock, coagulopathy, altered mental status, fever
- Diagnosis: No specific diagnostic test- meet 4 requirements
- Management: Maintaining oxygenation and supporting cardiac function
tip:
- Acute hypotension or cardiac arrest.
- Acute hypoxia.
- Coagulopathy or severe hemorrhage in the absence of other explanations.
- All of these occurring during labor, cesarean delivery, dilation and evacuation, or within 30 min postpartum with no other explanation of findings.
Can happen during labor, delivery, postpartum
Anaphylactoid syndrome of pregnancy
1) causes of ____% of what in the US?
- occurs during? (3)
- amniotic fluid enters … and results in..
2) major symptoms: 2)
3) predisposing factors: 9
4) clinical manifestations: 4
1) Cause of 10% of maternal deaths in the United States
- Occurs during cesarean birth, uterine rupture, or small tears in the endocervical veins during a vaginal delivery
- Amniotic fluid enters the maternal venous circulation, is transported to the pulmonary vasculature, results in pulmonary emboli.
2) Transient pulmonary hypertension and profound hypoxia
3) Predisposing factors:
- preeclampsia
- multiple gestation
- polyhydramnios (excess amniotic fluid) - low insertion of placenta
- post term pregnancy
- hypertonic contractions during labor
- abruptio placentae
- uterine rupture
- maternal seizures
- umbilical cord prolapse
4) Clinical manifestations: sudden onset of dyspnea, cyanosis, and hypotension, decreased pulse ox followed by cardiopulmonary arrest
tip:
Within 20 minutes of delivery.
Anaphylactoid syndrome of pregnancy mgmt (9)
- maintain ______ ______ ______ and adqeuate airway
- _______ and _____ with 100% O2, vasopressors, fluids, cpr, blood, and pa cath
- ______ in extreme cases
- complications: 5
- other nursing interventions (5)
Maintaining left ventricular output and adequate airway
Intubation and ventilation with 100% oxygen, IV vasopressors and crystalloid fluids, CPR, blood products, and pulmonary artery catheterization
Extracorporeal membrane oxygenation (ECMO) in extreme cases
Complications: acute pulmonary edema, respiratory distress, DIC, hemorrhage, and multi-system failure
ABCs
Pulse oximetry
Side position or a wedge under right hip
(as the uterus is still enlarged)
Large-bore IV
Assess cardiovascular, pulmonary, hematological, and neurological systems
Pulmonary Dysfunction: Asthma (5)
- _______ and ____ outcomes related to severity of the disease
- peak incidence of asthma exacerbation occurs when?
- what is the mgmt of asthma?
- what is used to monitor pulmonary function?
- rapid _____ and _______
- Maternal and fetal outcomes related to severity of disease
- Peak incidence of asthma exacerbation is at second and early third trimester
- Management
- Peak flow meter to monitor pulmonary function
- Rapid assessment and intervention
tip:
poorly controlled asthma related to low birth weight and preterm labor/birth.
treat and manage the same way as non-pregnant people.
People with severe asthma exacerbations will be hospitalized to stabilize and monitor baby
Pulmonary Dysfunction: Cystic fibrosis (what, increased what for mother and fetus, mgmt (4))
1) Normal pulmonary changes of pregnancy lead to pulmonary decomposition
2) Increased mortality and morbidity for both mother and fetus
3) Management:
Ongoing assessment
Bronchial drainage and chest physiotherapy
Replacement of pancreatic enzymes
Supplementation of nutrition
Pulmonary dysfunction: Pneumonia (results from, exacerbations are more common during, associated with what other maternal disease (4), physiologic changes of pregnancy decreases ability to? (2), typically has what kind of origins?
- Results from variety of factors; can be related to asthma, flu, covid
- Exacerbations more common in second and third trimesters
- Associated with other maternal disease
— Prior respiratory disease, HIV infection, drug/tobacco use, anemia - Physiologic changes of pregnancy decrease ability to clear secretions, increase risk of gastric aspiration
- Typically pneumonia has bacterial origin
tip:
use amox/clav or cephalosporins usually. do not use tetracyclines, fluoroquinolones, or clarithromycin
Pulmonary Dysfunction: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS)
1) results from a vartiety of conditions: (7)
2) presentation: ______ _______ rapidly deteriorates over 24H(1)
- sx: 4
3) mgmt of respiratory failure: 2 (what medications would you give 6)
1) Result from variety of conditions
- Pharmacologic agents
- Aspiration
- Preeclampsia-eclampsia
- Massive blood transfusions
- Anaphylactoid syndrome of pregnancy
- Pulmonary edema
- Covid infection
2) Presentation
- Pulmonary function rapidly deteriorates over 24 hours
- Symptoms:
Diffuse or basilar rales
Bilateral opacities on chest radiograph**
Deteriorating PaO2 with increasing FiO2 demands**
No evidence of left sided heart failure**
3) Management of respiratory failure:
- Mechanical ventilation
- Pharmacologic therapies - consider maternal-fetal risks and benefits:
Antibiotics
Corticosteroids - inhaled/systemic
Leukotriene receptor antagonist
Analgesics
Beta-mimetic tocolytics for prevention of labor induction
Neuromuscular blockade
tip:
Quinolones are teratogenic so avoid those-
Montelukast (Singulair)
TOCOLYTICS- Salbutamol, terbutaline (IV) — indomethacin. if someone is vented or in pulm distress, we do NOT want them to labor. their o2 demands increase dramatically
Pulmonary Dysfunction: Pulmonary embolism
- may be related to _____ _____ in pregnancy
- greatest rusk is in what period, which is increased if what is performed?
- what 3 things do not differ from non-pregnancy
- ______ _____ of anaphylactoid syndrome of pregnancy must be made
- what 2 medications are teratogenic for blood and what medication is the drug of choice
May be related to physiologic changes in pregnancy
Greatest risk is in immediate postpartum period, which is increased if C-section is performed
Assessment, management, and complications do not differ from nonpregnancy
Differential diagnosis of anaphylactoid syndrome of pregnancy must be made
Warfarin and most DOACs are teratogenic, Lovenox is the drug of choice- may require altered dose
tip:
Asymmetric lower extremity swelling.
DOAC: direct acting oral anticoag xaralto and eliquis
Lovenox has an air bubble of hydrogen.
Tocolytic-Associated Pulmonary Edema
1) what medications (class, 4)
- what to look out for?
2) etiology
3) discontinue what agent
4) what other medication may help
5) what may be avoided with non-invasive ventilation
1) B2 agonists- albuterol, terbutaline, isoxsuprine, ritodrine
Refractory edema
2) Etiology not defined
3) Discontinue tocolytic agent
4) Diuretics may help
5) Mechanical ventilation may be avoided with non-invasive ventilation
Trauma
1) what occurs in 6-7% of pregnancies and can result in what 4 disorders
2) common types of trauma (3)
3) _______ ______ depends on maternal survival
4) how much blood can a pregnant women lose up to before becoming hemodynamically unstable
1) Accidental injuries occur in 6% to 7% of all pregnancies and are associated with spontaneous abortion, preterm labor, abruptio placentae, and fetal death.
2) Common types of trauma include blunt trauma from motor vehicle crashes (49%), falls and domestic violence (18% to 25%) and penetrating trauma from stab wounds or gunshots (4%).
3) Fetal survival depends on maternal survival.
4) A pregnant woman can lose up to 2,000 mL of blood before becoming hemodynamically unstable.
Trauma - Management (11)
what do you want to assess? (3)
ABCs
NG tube to avoid aspiration
Wedge under the right hip increases cardiac output up to 30%
- Gets the Uterus off the IVC
ACLS
Avoid vasopressors if possible, use fluids
instead
Large bore IV
Control bleeding
Fluids
Assess neurological status.
Fetal assessment, including determination of life. Fetal monitoring at least 24 hours after event. Highest risk of abruption is in the first 4 hours
Assess: onset of regular contractions, vaginal bleeding, and amniotic rupture
Management of trauma in pregnancy
1) ______ differences from other trauma patients
- women beyond ____ to ____ should have atleast how many hours of fetal monitoring?
- RH blood when transferring
2) goals:
- first priority is?
3) what other intervention would occur and when?
1) Minimal differences from other trauma patients
- Women beyond 22 to 24 weeks’ gestation should have at LEAST 4 hours of fetal monitoring
- Rh- blood when transfusing
2) Goals
- First priority is mother’s survival
3) Emergency C-section
- If fetus has reached point of viability and mother is at risk for immediate demise
A pregnant person at 28 weeks was a restrained passenger in an MVA. On arrival, she is lethargic on a backboard with a C-collar in place. BP 70/40mmHg, HR 120/min, RR 20/min
Which of the following is the most appropriate initial intervention?
A- Transfusion of Rh(-) blood
B- Emergent operative delivery
C- Intubation and mechanical ventilation
D- Turn patient on the left
E- 2 Liters of D5W and Dopamine infusion
Neurologic Dysfunction: Epilepsy
- frequency?
- goal:
- what medication should be taken during pregnancy if seizure disorder?
Seizure frequency increases during pregnancy
Goal: keep mother seizure-free and avoid teratogenic effects from anticonvulsant medications
If mom has a seizure disorder, should take more folate than people without seizure disorder (1-2mg/day)
Neurologic Dysfunction: Intracranial hemorrhage
- causes (2)
- mgmt (1)
1) Causes
- Ruptured cerebral aneurysm or arteriovenous malformation
- Cocaine use increases risk - vasospasm
2) Management
- Same as nonpregnant except cautious use of hypotensive agents
Neurologic Dysfunction: Myasthenia Gravis
- what is common
- mgmt
- mother may need interventions when?
Postpartum exacerbations are common
Management during pregnancy same as when not pregnant
Mother may need interventions during second stage of labor to meet pushing requirements
- Forceps, vacuum-assistance, C-section
tip:
Acetyl choline receptor dysfunction at nicotinic receptors of muscle at NMJ
Does not affect uterine muscles, but the pelvic floor muscles nec to push
