Pregnancy at Risk Flashcards
Pregnancies that are at risk
Hyperemesis Gravidarum Multifetal pregnancy Ectopic pregnancy Spontaneoius AB Incompetent cervix Placenta previa Abruption DIC Postpartum hemorrhage GH (PIH) Preterm, postterm Hydatidiform mole
What is the most common discomfort of pregnancy?
Morning sickness
Hyperemesis gravidarum
Excessive vomiting that can lead to electrolye, metabolic, and nutritional imblances
Hyperemesis gravidarum: Etiology
Exact casue unknown
Possibly homrones or psychogenic factors
Hyperemesis gravidarum: S&S
Persistent N/V Significant weight loss Dehydration Electrolyte/Acid base imbalances Unusual stress
Hyperemesis gravidarum: Assesment
- Frequency, amount, character of emesis
- Hydration status (I&O, skin turgor, mucous mebranes, daily weight, etc)
- Psychosocial assesment
- Fetus
Hyperemesis gravidarum: Medical management
- May need IVFs
- Antiemetics (Reglan, Zofran)
- Pyridoxine (B6) is also helpful
- Diet: low fat, high protein, non-spicy with frequent small meals
- Camomile tea, ginger ale, and some like PB on toast/crackers
- Parenteral nutrition(worse case scenario)
- Counseling/support
- Prognosis is good
Multifetal pregnancy
Twins- A- monozygotic (originate from one fertilized ovum) or B- diazygotic (two sepearte ova fertilized at the same time)
- Preterm labor
- Growth deficiencies
Multifetal pregnancy: S&S
Uterine enlargement excess “normal”
Abdominal palpation is done using Leopold’s manuevers
Two distinct heart tones
Ultrasonography= multiple fetuses
Ectopic pregnancy
Rupture of the fallopian tube and bleeding into the abdominal cavity
Ectopic pregancy: S&S
Slight vaginal bleeding
S&S of peritoneal irritation: sharp, localized, one-sided pain or pain referred to the shoulder
Abdomen may be rigid and tender
Ectopic pregnancy: Medical management
Rapid, surgical treatment Blood replacement Methotrexate administration for unruptrued ectopic pregnancy D+C D+E
Ectopic pregnancy: NIs
Frequent VS Assess lung and bowel sounds IVFs and blood Antibiotics Pain meds NPO pre-op Foley
Spontaneous abortion
Termination of pregnancy before the age of viability (20 wks)
Spontaneous abortion: S&S
Threatened: bleeding & cramping
Inevitable: bleeding increases & cervix dilates
Complete: all products of conception expelled
Incomplete: some, not all products of conception are expelled
Missed: fetus dies and gorwth ceases, but fetus remains in utero
Septic: malodorous bleeding, fever, cramping
Habitual: sontaneously aborted in three or more consecutive pregnancies
Spontaneous abortion: patient teaching
Need rest
Iron supplementation (if blood loss occured)
Emotional component
Incompetent cervix
Passive and painless dilation of the cervix during the 2nd trimester
Incompetent cervix: causes
- History of previous cervical lacerations
- Excess dilation for curettage or biopsy
- DES (diethylstilbestrol daughter)
- Congenitally short cervix or cervical or uterine anomalies
Incompetent cervix: medical management
- Prophylactc cerclage at 10-14 weeks of gestation
- No intercourse, prolonged standing, and heavy lifting
- After cerclage, monitor for contractions, symptoms, or rupture of membranes, and infection
- Provide support
Cerclage
a surgical procedure in which the cervix is sewn closed during pregnancy
______ _______ during pregnancy should always be reported to the physican
Vaginal bleeding
Placenta previa
Type of bleeding disorder
- Placenta implants in the lower uterine segment
- Unknown cause
- Painless, bright red vaginal bleeding
- Bleeding may be intermittent or occur in gushes
Placenta previa: Medical Management
- Cesarean birth is treatment of choice
- Following diagnosis, in hospital under close supervison
- Blood, typed and cross-matched, available for emergency use
Abruptio placentae (abruption)
- Premature separation of the normally implanted placenta from the uterine wall
- Generally occurs late in pregnancy, frequently during labor
Abruptio placentae: predisposing factors
Choronic hypertension and GH (PIH)
Blunt external abdominal trauma
Abruptio placentae: S&S
Sudden, severe pain accompanied by uterine rigidity
Abruptio placentae: Nursing Assesment
- Duration, amount, color, characteristic of bleeding
- VS
- Pain
- Fetal HR
- Emotional response
Abruptio placentae: Diagnostic tests
- H+H
- Blood type and cross match
- US
Abruptio placentae: Medical Management
C-section delivery
Hysterectomy
Abruptio placentae: NIs
- O2
- IV or blood replacement (may be needed)
- Support, attend, prepare her for possible loss
Disseminated Intravascular Coagulation (DIC)
Alterations in normal clotting mechanism
It may be seen with abruptio placentae, incomplete abortion, HTN disease, or infectious process
DIC: Assesment
All women with complications that me result in DIC should be observed closely for signs of bleedign
DIC: Diagnostic tests
H+H
Clotting factor studies
DIC: Medical Management
- IV administration of fibrinogen, blood, and other substances that will help restore normal clotting mechanisms
- May include heparin via continuous infusion pump and O2 therapy
- Delivery of fetus ASAP
DIC: NIs
Supprt medical treatment
Report S&S promptly
Postpartum Hemorrhage
Early postpartum hemorrhage- >500 mL in the 24 hours after delivery
Late- after the first 24h
What is the most common cause of early postpartum hemorrhaege?
- Uterine atony
- Retained placenta or fragments of it
- Lacerations of the perineum/cvx
Postpartum Hemorrhage: Assessment
Uterine contraction and lochia
Bleeding- color, amount source
VS
Postpartum Hemorrhage: Medical Management
- D&C
- Repair of lacerations
- Fundal massage; keep bladder empty, administer oxytocics
- Failure to control bleeding may necessitate a hysterectomy
Postpartum Hemorrhage: NIs
Fundal massage
VS
Prepare for surgery if indicated
Administer oxytocin or other drugs as ordered
Postpartum Hemorrhage: Teaching
Teach pt. how to perform the postpartum checks of the fundus and lochia
Call physician if bleeding is excessive
Hydatidiform Mole
a rare mass or growth that forms inside the womb (uterus) at the beginning of a pregnancy
Hydatidiform Mole: S&S
- Bleeding (from spotting to hemorrhage)
- Rapid uterine growth
- Failure to detect fetal heart tone
- Signs of hyperemesis gravidarum
- Diagnosed early
- Higher levels of hCG
- Snowstorm pattern of ultrasound
Hydatidiform Mole: Treatment
Vacuum aspiration
D+E
Recheck hCG for 1 year
Emotional support
Gestational Hypertension (AKA PIH)
- Characterized by increasing HTN, albuminuria, and generalized edema
- Includes preeclampsia and eclampsia
- Unknown cause
- Increasd risk in multiple pregnancy, DM, or family history of GH
What do complex hormonal and vascular changes lead to?
Increased blood pressure Decreaed placental perfusion Decreased renal perfusion Altered glomerular filtration rate F&E imbalance
Gestational Hypertension: Assesment
Weight BP (S about 30 mmHg above baseline; D about 15 mmHg above baseline) Edema: scale of 1+-4+ Urine tested for albumin Visual changes RUQ pain
Gestational Hypertension: Diagnostic tests
Hematocrit BUN CBC Clotting studies Liverenzymes Type and Screen Urine for specific gravity and protein Electrolyte panels
Gestational Hypertension: Medical Management
May or may not need hospitilization Bed rest; Lateral recumbant position Well-balanced diet with adequate protein IV therapy for emergency situations Sedatives and antihypertensives Mag sulfate to prevent seizures Deliver baby
Gestational Hypertension: NIs
Assess for H/A, edema, and blurry vision Monitor I&O (catheter may be necessary) Monitor fetal status Perform kick count Monitor daily weight Enforce bedrest Provide emotional support
Gestational Hypertension: Patient teaching
- Educate on danger signs of complications of pregnancy
- Stress importance of regular medical supervision
- Encourage high-quality protein, vitamin, and mineral intake
- Exercise may have to be curtailed
- Avoid weight loss programs
- DC smoking and ETOH
- Primary management is without drugs since normal falls in the first 2 trimesters
- Fetal Kicks
- Side lying postion
What should you watch for in a pt. with PIH (GH)?
Sudden weight gain
Edema
High BP
Gestational Hypertension: Preeclampsia
GH
Protein in the urine
Gestational Hypertension: Eclampsia
HTN
Protein in urine
Seizures
Liver and coagulation abnormalities
HELLP Syndrome: What does it stand for?
- H= hemolysis of erythrocytes
- EL= elevated liver enzymes
- LP= low platelets
HELLP Syndrome
Variant of GH
- Represents an extension of the patholgy of preeclampsia and eclampsia
- Hemolysis occurs when RBCs are damaged when passing through small vessels
- Obstructoin of blood through livers causes elevated liver enzymes (look for RUQ pain)
- Low platelets from platelets adhering to site of blood vessel damage
What is the mag sulfate normal dose?
1.5-2.5 mEq/L
S&S of mag sulfate toxicity
Sudden drop in BP
Resp <25-30 mL/hr
-Decreased/absent DTRs
Assessments when giving mag sulfate
VS & FHR Q 15 mins DTR prior to administration 1st to go is loss of patellar refelx Mental status frequently Have resucitatoin equipment ready
What is the antidote to mag sulfate?
Calcium gluconate/chloride
What to look for with mag sulfate?
Patellar reflex goes first if mg toxic
Respiratory paralysis next
Cardiac conduction after that
If giving mag sulfate, you should MONITOR?
DTR (start at 3.5)
RR
Urine output
Serum concentrations
Complications of pregnacy related to the CV system
- Pregnancy increases demands on the CV system (the normal, healthy heart is able to adapt to increased demands)
- Women who have preexisting cardiac disease face increased risk when cardiac function is challenged by pregnancy
Complications of pregnacy related to the CV system: Etiology
Most common problems result from:
Rheumatic heart disease
Congenital heart defects
Mitral valve prolapse
Complications of pregnacy related to the CV system: Patho
- Increased blood volume, HR, and cardiac output overstress the cardiac muscle, valves, and vessels
- S&S of the underlying pathologic condition are exacerbated, resulting in cardiac decompesation, CHF, and other medical problems
Complications of pregnacy related to the CV system: S&S
Edema Cyanosis Tachycardia Palpitations Dysrhythmias and CP Dyspnea and fatigue Physical exertion may increase the symptoms Decreased cardiac output Pulmonary edema
Complications of pregnacy related to the CV system: Assesment
VS
Evaluate unusual fatigue with activity
Monitor for edema, weight gain, murmurs, cough, dyspnea, and abnormal lung sounds
Complications of pregnacy related to the CV system: Diagnostic tests
CXR
ECG, Echo
Blood gas analysis
Complications of pregnacy related to the CV system: NIs
Teach- diet, meds, pacing activity, and rest
Iron intake to prevent anemia
Sodium may be restricted
Stool softeners may be admistered
Cardiotonics, diuretics, prophylactic antibiotics, sedatives, and analgesics may be required
Semi-fowlers or side lying with HOB elevated during labor
Conservation of energy during delivery
Pre-term
0-37 wks of pregnancy
Term
38-41 wks of pregnancy
Postterm
42+ wks of pregnancy
Ideally, when are tests performed on the newborn?
Between 2-8 hours of age
Preterm infant: etiology/patho
Exact cause unknown
Some cases may be r/t maternal or placental problems
Infant is devlopmentally mature (not producing enough surfactant; circulation may not have adapted from fetal to neonatal as it should)
Problems with heat conservation
F&E/Acid base imblances observes
Problems with absorption of nutrients are common
In what way can a preterm infant be neurogically immature?
Gag, suck, and swallow reflexes may be weak or even absent
Preterm infant: assesment
All systems must be assessed
What is the greatest potential problem with a preterm infant?
Respiratory distress syndrome
- grunting on expiration
- Nasal flaring
- Circumoral cyanosis
- Substernal retractoins
- Tachypnea
An accurate assessment of what is a good indicator of the problems the preterm infant is likely to experience?
Gestational age
What is the main nursing goal with a preterm infant?
Maintain and stabilize preterm infants until they are mature
Preterm infant: NIs
Respiratory regulation Thermal regulation F&E regulation Sensory stimulation Promote bond with parents
Complications of a postterm infant
Placental insufficency (aging placenta is not fully functioning) Increase risk for perinatal mortality resulting from intrauterine hypoxia during labor and birth Risk for asphyxia, respiratory distress, hypoglycemia
