Mat P1 Flashcards
What is an abortion? What is considered viable? What is it after this?
is a medical term for any interruption of a pregnancy before a fetus is viable (20-24 wks of gestation or one that weighs at least 500g). a fetus born before this point is considered a miscarriage or is termed a premature or immature birth.
time frame for early vs. late miscarriage?
when is bleeding more of a problem and why?
early- week 16
late- 16-24
week 12+ because placenta is imbedded in uterus and it is more life threatening
% of spontaneous abortions in pregnancies?
15-30%
what are torc infections?
they are associated with inc risk of spontaneous abortions
Toxoplasmosis- cat litter/feces
Other- chicken pox
Rubella- immune? There is an inc risk of SA and fetal affects to death to mental retardation or systemic rash
Cytomegalo virus
Herpes
What are some other causes of spontaneous miscarriages?
abnormal fetal development d/t teratogenic, immune system response, corpus letup does not produce enough progesterone, alcohol, UTI, systemic infections cause sloughing of endometrium
what is antiphospholipid antibody syndrome?
it is an autoimmune disease that occurs more freq in women than in men. Abnoral protein (antiphospholipid autoantibodies) initiate coagulation and so lead to clotting in arteries and veins. If this occurs in placental vessels- blocks placenta growth and thrombi can loosen the placenta and interfere with o2 and nutrient exchange
how do you treat antiphospholipid antibody syndrome?
o Prophylaxis therapy to prevent miscrriages is oral low dose aspiri and subcu heparin started at beginning of pregnancy
o Alt therapies- IV immunoglobulin infusions or administration of a corticosteroid such as prednisone can be added if heparin and aspirin are not adequate.
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what are some postpartum risks for antiphospholipid Ab syndrome?
DVT
clotting inc w bed rest, smoking, obesity and birth control pills
what is the result of antiphospholipid Ab syndrome?
recurrent miscarriage or hypertension in preg
what are some complications of miscarriage?
hemorrhage, infection, septic abortion (abortion d/t infection), isoimmunization (ab against rh positive blood
what is an ectopic pregnancy?
implantation occurs outside the uterine cavity. (most commonly the fallopian tube in the ampler area- distal portion)
where can fertilization occur in an ectopic pregnancy?
o Fertilization still occurs in the distal third of the fallopian tube but there is an obstr present such as an adhesion of the fallopian tube from a previous infection, congenital malformations, scars from tubal surgery or a uterine tumor pressuing on the proximal end of the tube, the zygote cannot travel the length of the tube
if you have one ectopic pregnancy can you have another? why or why not?
o If you have on ectopic preg more likely to have another, because salpingitis general leaves scarring which is bilateral.
S&S of ectopic preg?
sharp, stabbing pain in one of her lower abdm quadrants at the time of the rupture, followed by scant vaginal spotting. (amount doesn’t indicate amount lost)
what are you at risk for in ectopic preg?
inc blood los- hypovolemic shock
what happens if you wait too long after ectopic pregnancy before getting help?
abdm becomes rigid from peritoneal irriation and umbilicus may develop a bluish- tinged hue (Cullen sign)
Tx for ectopic preg?
some spont end before the rupture and are reabsorbed over the next few days requiring no tx.
• Usually treated by PO med of methotrexate. Adv: tube is left intact with no surgical scarring that oculd cause a 2nd ectopic implantation
• Therapy is laparoscopy to ligate the bleeding v and remove or repair damaged fallopian tube. A rough suture on tube may lead to another tubal preg so either tube is removed or suturing is done microsurgical technique. If tube removed she is 50% fertile. Not reliable cause ova can still move to other tube and fertilize there.
if a woman comes in with an ectopic pregnancy, how do you get the EBL?
not just the external blood loss. get a Hgb, RBC, Hct lab done and might have to cross match
what is gestational trophoblastic disease? (hydatidiform mole)
o Abnormal proliferation and then degernation of the trophoblastic villi. As the cells degenerate they become filled with fluid and appear as clear fluid-fille, grape sied vesicles. The embryo fails to develop beyond a primitive start.
why is it important for (hydatidiform mole) cells to be identified?
because they are associated with choriocarcinoma, rapid mets malignancy
who is more likely to get (hydatidiform mole)?
1 in 1500
o occurs more often in low protein diets and woman older than 35 and of Asian heritage and blood group A and may blood group O men
assessment of (hydatidiform mole)?
• uterus tends to expand faster than usual or the uterus reaches its landmarks (just over symphysis brim at 12 wks and umbilicus at 20-24) before usual time
- gestational htn may present before wk 20
- US shows dense growth but no fetal growth
- at wk 16- if structure not identified might show through vaginal bleeding starting as dark red or perfuse fresh flow then clear fluid vesicles.
tx of • hydatidiform mole)?
suction curettage to evacuate the abnormal trophoblast cells. Following extraction women should have a baseline pelvic exam and a serum test for the beta subunit of hCG and hcg checked q2k until levels are normal. Then q4wk for next 6-12mths to see if declining
if a woman passes clear vesicles, what does this mean?
might have hydatidiform mole (gestational trophoblastic disease)
what is occurring at a cellular level in gestational trophoblastic disease?
o A partial mole has 69 chr. (69XX, 69XY) – 3 chr for every pair instead of 2 (triploid formation). One egg fertilized by 2 sperm or ovum fertilized by one sperim in which meiorsis or reduction division did not occr.
which type of mole is more likely to turn into cancer?
complete moles more likely lead to choriocarcinoma rather than partial
in gestational trophoblastic disease, will your hCG be high or low?
it will still be high because the trophoblastic cells release hCG until about day 100
in gestational trophoblastic disease, will you still have n + V?
yes, most likely from hCG
Tx of gestational trophoblastic disease?
suction curettage to evacuate the abnormal trophoblast cells. Following extraction women should have a baseline pelvic exam and a serum test for the beta subunit of hCG and hcg checked q2k until levels are normal. Then q4wk for next 6-12mths to see if declining
if your hCG level (following evac of cells) plateaus or inc, what could this mean?
malignant transformation aka choriocarcinoma
what is cervical insufficiency?
it is premature cervical dilation and cannot retain the fetus
when does cervical insufficiency occur?
around week 20 and fetus is too immature
symptom of cervical insufficiency?
• Painless and 1st sympt is show (pink-stained vaginal disch) or inc pelvic pressure which is then rupture of membranes and dichar of amniotic fluid
what is the treatment or procedure for cervical insufficiency?
cervical cerclage surgery following the loss to prevent this from happening again.
• As soon as US confirms fetus of second preg is healthy at 12-14 wk purse string sutures are placed in the cervix by the vaginal route under regional anesthesia. Procedure is called a mcdonalf or shirodkar procedure. Sutures strengthen the cervix and prevent it from dilating
what is the difference between Mcdonald and Shirdokar in cervical insufficiency?
- Mcdonald- nulon sutures are placed horizontally and vertically across cervix
- Shirodkar0 sterile tape is threaded in a purse-string mane ruder submucos layer of the cervix and sutured in place to achieve a closed cervix. Can be done by transabdominal route
what nursing care can you do following a cervical cerclage surgery?
keep women in trendelenburg position for a few days to dec pressure on new sutures
what is placenta previa?
where the placenta is implanted abnormally in the lower part of the uterus. most common cause of painless bleeding in the 3rd trimester
what are the different degrees placenta previa can occur?
implantation in the lower, rather than the upper part of the uterus (low-lying placenta), marginal implantation (the placenta edge approaches that of the cervical os), implantation that occludes a portion of the cervical os (partial placenta previa), and imlentation that totally obstructs the cervical os (total placenta previa)
why is placenta previa a life threatening condition?
it can cause hemorrhage
in placenta previa, why should you not do a internal exam?
because placenta might be covering cervix and could rupture
how is the baby delivered in placenta previa?
some can be vaginal but most C/S
what drug might you give the mom before C/S for placenta previa?
betamethasone IM to increase fetal surfactant
in a patient with placenta previa, should you be worried about a little bleeding from vagina?
yes, can be life threatening to fetus
epidiemology of placenta previa?
5in 1000 births
why would bleeding occur in placenta previa?
o Bleeding doesn’t usually begn until the lower uterine segment starts to differentiate from the upper segment late in the pregnancy (approx. wk 30) and cervix begins to dilate. Bc the placenta is unable to stretch to accommodate the differing shape of the lower uterine segment or the cervix, small portion loosens and damaged blood vessels begin to bleed.
what is abruption placentae?
premature separation of the placenta. the placenta is implanted correctly but begins to separate and bleeding results. Part of the placenta peels away from the uterine wall and blood is still being delivered to uterus and collects in space or comes out of the vagina (hidden bleeding –occult or obvious bleeding that comes out) some of the babies blood escapes
what are risks of abruption placentae
unknown causes. high parity, older age, short umbilical cord, chronic htn disease, htn of preg, direct trauma, vasoconstriction from cocaine or cigarette use and thrombophilitic conditions that lead to thrombosis formation. Or chorioamniotisi or infections of the fetal membranes and fluid
what is the most common cause of perinatal death?
aburtpio palcentae
what is the epidemiology of abruptio placentae?
10% of pregnancies
S&S of abruptio placentae?
usually occurs late in pregnancy or during labour, sharp, stabbing pain at fundus, tender uterus on palpation, heavy bleeding unless concealed, may be dark in colour, uterus becomes rigid, boardlike (COUVELAIRE uterus)
what bloodwork do you want for patient with abruptio placentae?
clotting time, platelets, cross match to prepare
is the delivery of fetus quick or slow in abuptio placentae?
very fast
Tx for abuptio placentae?
IV fluid monitor FHR and vitals keep in lateral no spine to prevent p on vena cava and fetal circulation preg must be terminated unless C/S Grading scale 0-3 ?
what is the epidemiology of preterm labour?
9-11% of pregnancies. responsible or 2/3 of all neonatal deaths
what are the risks for pre-term labour?
dehydration, UTI’s, periodontal disease, chorioamnionitis, low SE status, partner violence/abuse
what weeks are considered pre-term labour?
<37 wk
what does preterm labour feel like?
feels like baby is moving or brixton-hicks contractions
how can you determine if preterm labour?
Have a big glass of water and put hands on abdm and it tightens and relaxes – if it does more than 4 times in 20 minutes (preterm labour) , might not be painful but just feels tightening
what else will they be looking for to determine if it is preterm labour?
cervical changes, persistent, dull low backache, spotting, feeling of pelvic pressure, abdominal tightening, menstrual-like cramping, inc vaginal discharge, intestinal cramping
what should you do for pre-term labour
bedrest, hydration(helps halt contractions because pit release oxytocin and secretes AHDH, treat UTI
betamethason to mature lungs and turbutalane (tocolytic) to stop contractions, Abx for infections, magnesium sulfate (smooth muscle relaxant to stop uterus from contracting)
what is the epidemiology of preterm rupture of membranes?
5-10% of pregnancies
what causes premature rupture of membarnes?
infection, multiple gestation, risk of cord prolapse
is labour stopped in premature rupture of membranes?
no bc risk for infection
rush of water from premature rupture of membranes can cause risk of what?
pulling out the umbilical cord and can cause prolapse and stop circulation
what interventions do you do for premature rupture of membranes?
IV access, Abx, IV, bedrest, betamethasone
how can you confirm that it is the amniotic fluid that has ruptured as opposed to other fluids?
confirm with nitrazine paper bc amnionic fluid is alkaline and urine acidic so can test from so that and nitrazine paper- so on the paper it shows up bright blue and slide looks like ferns bc of salts
what can prevent you from going into preterm labour?
getting the flu shot
what is the epidemiology of gestational htn?
5-7%
what its he patho and cause of gestational htn?
vasospasm. Underlying cause unknown, some correlation with length of time the couple have known one another, younger and older mothers, risk for seizures, coma, and death r/t cerebral edema, • Assoc with women of colour, those w multiple preg, primiparas <20yrs or >40yrs, low socioeconomic status (?d/t nutrition), those w 5+ pregnancies, hydramnios, or underlying CVD, DM
what are the 3 cardinal signs of gestational htn?!!?
inc BP (30mmhG above baseline), edema, proteinuria
S&S of gestational htn?
headache, blurred vision or visual disturbance, epigastric pain and discomfort.
what do you assess for in gestational htn?
hyperreflexia, urine dips for protein, 24 hour creatinine clearance, liver function tests, clonus, daily weight.
what is the cure of gestational htn?
delivery of the infant
where is it bad to find edema in gestational htn ?
face and sacrum
how much weight gain is alarming in gestational htn?
1-2lb over night
why do you look at creatinine clearance and kidney function in gestational htn?
o Damage to kidneys → inc perm → proteinuria
• Dec GFR → inc creatinine
why is vision affected in gestational gyn?
because deem around the eye and ocular nerve causes vision problems
why might you have upper quadrant pain in gestational htn?
because liver is inflamed
how much protein is urine is bad for gestational htn?
2 or 3+
how can you test for clonus in gestational htn?
push against palmer surface of foot and ask to totally relax but if you have clonus your foot will beat
what tx do you do for gestational htn?
bedrest, wiet, antihypertensive (labetolol), anti-convulsant (mg sulfate)
what 2 diseases do you give magnesium sulphate?
gestational htn and pre-term labour
what is the difference between pre-eclampsia and eclampsia and PIH
Preeclampsia- high bp assoiated with preg, protein in urine, edematous
Eclampsia- u have had a seizure
PIH- old term
what does the baby usually present with in gestational htn?
IUGR (intrauterine growth retardation
why do you experience eclampsia gestation htn?
because the damage to the kidneys cause na and water retention which causes edema which can lead to cerebral and pulmonary edema and seizures
would Hct be high or low in gestational hypertension?
high because fluid is lost in the IS
is systolic or diastolic a better indicator of vasospasm
diastolic because it is an important indicator of degreee of peripheral arterial spasm
would you restrict salts in gestational htn?
No big salt restrictions as that will activate RAA and cause inc in BP
what does magnesium sulphate do?
reduces deem by causing shift from EC spaces into intestine, it is a CNS depressant and blocks neurmuscular transmission of Ach to half convulsions
what is magnesium sulphate antidote?
calcium gluconate
what is HELLP syndrome?
it is a variation of gestational Htn. preeclampsia and eclampsia can turn into this.
Hemolysis Elevated Liver Enzymes Low Platelets
what is a precursor for HELLP?
preeclampsia
what are you at risk for in HELLP?
bleeding and clotting, therefore birth is a risk
what is the cause of HELLP?
unknown
what is the cure for HELLP?
delivery of infant
also give transfusion
how long does it take for mom to recover if she has HELLP?
48-72 hours
usually ICU
what increases chance of multiple pregnancy?
invitro fertilization
more common in blacks and hispanics
what are the two different (common) kinds of multiple pregnancy
- Monozygotic = identical; from 1 egg + 1 sperm; one placenta, one chorion, two amnions; 1/3 of twins
- Fraternal (dizygotic) = from 2 separate ova + 2 sperm; have 2 of everything
what is vanishing twin syndrome? how will this appear?
• U/S may show multiple amniotic sacs but later only one = vanishing twin syndrome
what are you more susceptible to in multiple pregnancy?
• More susceptible to gest htn, hydramnios, placenta previa, preterm labor, + anemia
• More prone to postpartum bleeding b/c additional uterine stretching
more fatigue, need several small meals
what is hydramnios ?
> 2000ml of amniotic fluid (normal is 500-1000)
what does the additional space in hydramnios allow for fetus?
can turn around, malposition
rwhat are you at risk or in hydramnios?
premature rupture d/t possible infect, proloapsed cord, and preterm birth
how is amniotic fluid formed? what is it used for?
from cell os amniotic membrane and fetus urine
• Swallowed by fetus, absorbed across intestinal membrane into fetal bloodstream + transferred across the placenta.
what does hydramnios suggest for the fetus?
possible fetal inability to swallow, absorb, or excessive urine production
hyperglycemia in mom can be same in fetus–> polyuria
S&S of hydramnios?
rapid enlargement of uterus; hard to palpate fetus, fetal heart monitoring difficult, SOB, lower extremity varicosities + hemorrhoids d/t lack of VR, weight gain
tx for hydramnios?
- Bed rest to inc uteroplacental circ + reduce P on cervix to prevent preterm labour
- Avoid constipation (fiber, stool softener) – P could cause rupture
- Amniocentesis possibly to reduce fluid amounts – has to be done daily
- Tocolytics to halt early labour
what is oligohydramnios
less than average amniotic fluid
what is oligohydramnios usually d/t?
bladder or renal disorder in fetus–> not voiding or severe growth restriction of fetus (not voiding as much)
what effect does oligohydramnios have on fetus?
• Fetus cramped → weak muscles, lungs not fully developed (hypoplastic), distorted facial features
what is the normal term of pregnancy ?
38-42 weeks
are post-term babies also babies with wrong predicted due dates?
yes bc mom can have a long menstrual cycle
what dangers to the fetus result from post-term pregnancy?
<2wk overdue risk for meconium aspiration, macrosomia can create birth problem
how long does the placenta function for?
40-42 weeks, then calcium deposits and fetus now may not get adequate o2 and nutrients
at 41 weeks what do you check?
amniotic fluid level + state of placental perfusion - labour induced if abnormal results or fetus is term size
what kind of diseases what be worsened by pregnancy?
inflm disease bc we secrete lots of cortisol so when pregnancy, arthritis and IBS, etc would settle dow
what is the epideimilogy of cardiovascular disease in pregnancies?
1%
how much inc blood volume do you get in pregnancy? when and why?
30-50% inc and peaks in 28-32
inc in case of hemorrhage and provide blood for baby
which week are you more likely to lose the most blood?
28-32 when blood vol peaks
if fetus does not get enough blood what can it develop?
Intrauterine growth restriction (IUGR)
not enough o2 and waste products don’t get taken away
what do you do with meds that woman regulariliy take when pregnant?
if safe, inc dose
if not i.e.) warfarin, has to go off.
are beta blockers and ACE inhibitors safe? is heparin safe? is warfarin safe?
yes yes but give Vit k around birth if on heparin and warfarin is not safe
symptoms of CVD?
edema-profuse
- Pulmonary edema
- JVD
- inc fatigue, orthopnea (some need to sleep in recline chari)
- Renal function decline
- Chest pain
- SOB with slow recovery
symptoms of normal pregnancy?
-mild edema to hands and feet only
-Mild SOBOE- quick recovery
-Some postural SOB
-Orthostatic hypotension
-Supine hypotension (think lying down with baby laying on vena cava)
Btw safest position to lay is left lateral because gives most perfusion to the placenta
differences between CVD and healthy pregnancy?
SOB quick recovery in pregnancy, only deem to hands and feet not pulmonary, no east pain or renal function decline unless gestational hypertension,
what are cardiac patients at risk for?
infection. especially pulmonary infection
which woman more commonly have hematological disorders in pregnancy?
More common for women of lower Socioeconomic status, cant afford good food
epic of pregnancies affected by Fe deficiency?
12-15%
what is the effect of anemia on pregnant woman? fetus?
maternal fatugue
IUGR- palpcenta not well perfused (baby is smaller because placenta is not as well perfused in smokers)
differentiate from psuedoanemia blood is dilute in pregnancy
Hg in preg vs not pregnant?
non preg
12-16
9.5-15 in preg
Hct in preg vs not
non preg
35-44%
28-40 in preg
(more dilute)
platelets in preg vs not preg
165-415
in preg…146-429
WBC in preg vs not preg
- 5-9.1 in nonpreg
5. 6-16.9 in preg
what medications should pregnant woman be on to prevent hematollogical disorders?
iron with Vit C 27mg per day
Folic acid 400mcg
what medications would a pregnant woman be on if she had a hematological disorder?
IV iron sucrose
blood
iron supplements
what are common orders for obstetrical emergencies?
O2 by mask 10L
IV 16-18g with volume expander like RL or NS
EFM
Stat bloodwork (Hg, Hct, platelets, D-dimer, coagulation studies, CBC, X-match and type and screen for blood products)
Monitor urine output, catheterize-think renal function
Left lateral position
VS q5-15 minutes
Always remember to attend to the fear, anxiety in the woman and family
what are 4 common causes of bleeding in pregnancy?
Spontaneous abortion (miscarriage)
Ectopic pregnancy
Placenta previa
Abruptio placentae
