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Sophomore 1 Test 5 > Pregnancy at Risk > Flashcards

Pregnancy at Risk Flashcards

1
Q

Non-Stress Test

A

Evaluation of fetal well-being
Reactive: 2 accelerations of 15 bpm lasting 15 seconds or more over 20 minutes
Nonreactive: reactive criteria not met

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2
Q

Biophysical Profile

A

Assessment of 5 variables to evaluate fetal status

- Score 1-10, 2 points for each variable

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3
Q

5 Variables of the Biophysical Profile

A
  1. Breathing movement (U/S)
  2. Body movement (U/S)
  3. Tone (U/S)
  4. Amniotic fluid volume (U/S)
  5. Fetal reactivity (NST)
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4
Q

Obesity in Pregnancy

A

BMI of 30 or greater (pre-pregnancy)

- Preventative is the best therapy!!!!

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5
Q

Medical and Obstetric Complications in Obese Pregnant Women (Early Pregnancy)

A
  1. Spontaneous abortion

2. Congenital anomalies (NTDs)

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6
Q

Medical and Obstetric Complications in Obese Pregnant Women (Late Pregnancy)

A
  1. Gestational HTN/preeclampsia
  2. GDM
  3. Preterm delivery
  4. Intrauterine fetal demise
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7
Q

Medical and Obstetric Complications in Obese Pregnant Women (Post Partum)

A
  1. Endometritis
  2. Wound breakdown
  3. Thrombophebitis
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8
Q

Medical and Obstetric Complications in Obese Pregnant Women (Fetus/Neonate Risks)

A
  1. Macrosomia (birth weight greater than 4 kg)
  2. Fetal obesity
  3. Childhood obesity
  4. Fetal demise
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9
Q

What is an abortion?

A

Expulsion of embryo or fetus before it is viable (can be spontaneous or induced)

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10
Q

Threatened Abortion

A

A threatened abortion refers to vaginal bleeding during the first 20 weeks of pregnancy, which can be an indication of a possible miscarriage. Many women who experience a threatened abortion will still be able to carry the pregnancy to term.

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11
Q

Inevitable Abortion

A
  • Vaginal bleeding (greater than that of threatened abortion)
  • ROM
  • Cervical dilation
  • Strong abdominal cramping
  • Possible passage of products of conception
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12
Q

Incomplete Abortion

A
  • Passage of some of the products of conception
  • Cervical dilation
  • Intense abdominal cramping
  • Heavy bleeding
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13
Q

Complete Abortion

A
  • Passage of all products of conception
  • History of vaginal bleeding and abdominal pain
  • No medical or surgical intervention necessary
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14
Q

Missed Abortion

A
  • Non-viable embryo retained in utero for at least 6 weeks
  • Absent uterine contractions
  • Irregular spotting
  • Possible progression to inevitable abortion
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15
Q

Habitual Abortion

A
  • History of three or more consecutive spontaneous abortions
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16
Q

Reason for spontaneous abortion during 1st trimester

A

Congenital

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17
Q

Reason for spontaneous abortion during 2nd trimester

A

Maternal

  • Incompetent cervix
  • Uterine anomaly
  • DM
  • Acute infections like CMV, rubella, herpes, toxoplasmosis
  • Drug use
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18
Q

Timeline for Medical Abortion

A

Up to 9 weeks gestation

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19
Q

First Line Method for Medical Abortion

A
  • 90-98% successful
  • Methotrexate then misoprostol 3-7 days later
  • Methotrexate is toxic to trophoblastic tissue (growing embryo)
  • Misoprostol (prostaglandin) causes uterine contractions which ripens the cervix (causes N/V)
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20
Q

Second Line Method for Medical Abortion

A
  • 95% effective up till day 49 of LMP
  • Mifepristone (progesterone antagonist) RU-486 (blocks action of progesterone)
  • Misoprostol 48 hours later
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21
Q

Types of Surgical Abortion

A
  1. Dilation and suction/aspiration
  2. Dilation and evacuation
  3. Dilation and extraction
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22
Q

Timeline for dilation and suction/aspiration

A

Up to 12 weeks

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23
Q

Timeline for dilation and evacuation

A

12-20 weeks

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24
Q

Timeline for dilation and extraction

A

Third trimester abortions

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25
Q

When will menstruation resume after an abortion?

A

Within 6 weeks

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26
Q

Abnormal Findings After Abortions

A
  1. Heavy bleeding
  2. Intense cramping
  3. Fever
  4. Foul discharge or odor
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27
Q

What is an ectopic pregnancy?

A

The implantation of a fertilized ovum in a site other than the endometrial lining of uterus.

  • Ampulla of fallopian tube most common site
  • Normal symptoms of pregnancy may be present early
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28
Q

Factors contributing to ectopic pregnancy

A
  1. Pelvic inflammatory disease
  2. Endometriosis
  3. Presence of IUD
  4. Previous tubal surgery
  5. Previous ectopic pregnancy
  6. Congenital tubal anomaly
  7. DES exposure (chemical exposure)
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29
Q

S/Sx of Ectopic Pregnancy

A
  1. Number 1 symptom is amenorrhea

2. Vaginal bleeding when embryo dies (may begin with dark brown spotting)

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30
Q

Symptoms of Tubal Rupture (ectopic pregnancy)

A
  1. Intraabdominal bleeding
  2. Sharp, one-sided pain (peritoneum irritated from bleeding)
  3. Syncope
  4. Referred shoulder pain
  5. Adnexal tenderness (mass may or may not be palpable)
  6. Abdomen becomes rigid, tender
  7. Extensive bleeding leading to hemorrhage leading to shock
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31
Q

Ectopic Pregnancy Diagosis

A
  1. hCG levels

2. USG-TV (transvaginal)

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32
Q

Surgical Treatment for Ectopic Pregnancy

A
  1. Laparoscopy with salpingostomy (tube left open)

2. Laparoscopy with salpingectomy (tube removed) if the tube is ruptured

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33
Q

First thing to do when a fallopian tube ruptures?

A

Immediate IV line to compensate for impending shock

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34
Q

When is a pharmacological treatment for ectopic pregnancy indicated?

A
  1. When the fallopian tube has not ruptured
  2. 4 cm size or less
  3. No fetal cardiac motion
  4. Stable condition - no evidence of acute abdominal bleeding, blood disorder, kidney or liver disease
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35
Q

Medical Treatment for Ectopic Pregnancy

A

Methotrexate IM

  • 2nd injection may be necessary
  • Serum hCG titer monitored (may rise for 1-4 days but then decline)
  • Transient abdominal pain (will not be a sharp or referred pain) (4-12 hours); must differentiate between pain of ruptured fallopian tube
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36
Q

Placenta Previa?

A
  • Placenta is positioned over the cervix and the baby is above it
  • Can cause bleeding during 2-3 trimesters
  • Graded according to its location in relation to cervical os
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37
Q

Total placenta previa

A

The internal cervical os is completely covered by the placenta

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38
Q

Partial placenta previa

A

The internal os is partially covered by the placenta

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39
Q

Marginal placenta previa

A

The placenta is at the margin or edge of the internal os

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40
Q

Low-lying placenta previa

A

The placenta is implanted in the lower uterine segment and is near the internal os but does not reach it

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41
Q

Management of Placenta Previa depends on what?

A
  1. Gestational age
  2. Amount of bleeding
  3. Tolerance of mom and baby
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42
Q

Management of Placenta Previa

A
  1. Can wait to see how it progresses
  2. Can be admitted to antepartum care
    - Monitor for contractions
    - Avoid vaginal exams
    - Assess bleeding levels
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43
Q

Hydramnios

A

Too much amniotic fluid (more than 2000 mL) surrounding fetus between 32-36 weeks

  • Seen in gestational diabetes
  • Low apgar scores and poor tolerance to labor
  • Preterm births, cord prolapse, and fetal malpresentation
44
Q

Treatment for Hydramnios

A
  1. Monitoring closely
    - Fluid can be removed but its risky to the fetus
    - A non-invasive treatment may involve administering indomethacin to decrease amniotic fluid volume by decreasing fetal urinary output, but this may cause the premature closure of the fetal ductus arteriosus
45
Q

S/Sx of hydramnios

A
  1. Discrepancy between fundal height and gestational age
  2. Complaints of abdominal discomfort (such as being severely tight or stretched)
  3. Reports of uterine contractions
  4. SOB
  5. Often fetal HR is difficult to obtain because of the excess fluid present
46
Q

Oligohydramnios

A

Decreased amount of amniotic fluid (less than 500 mL) at 32-36 weeks

  • Results from fetus being unable to produce urine or urine being blocked from the amniotic sac
  • Increased risk for fetal hypoxia and cord compression
  • Once born worry about kidney function and swallowing issues
47
Q

Treatment for oligohydramnios

A
  1. Frequent monitoring to ensure fetal well being

2. If fetal well being is compromised, then delivery and amnioinfusion are ordered

48
Q

Hyperemesis Gravidarum

A

Excessive vomiting during pregnancy

49
Q

S/Sx of hyperemesis gravidarum

A
  1. Weight loss
  2. Dehydration
  3. Ketonuria
  4. Fluid-electrolyte imbalance
  5. Hypovolemia
  6. Hypotension
  7. Tachycardia
  8. Increased Hct and BUN
  9. Decreased urine output
  10. Metabolic acidosis
50
Q

Causes of hyperemesis gravidarum

A
  1. Hormones (increased hCG, estrogen, progesterone)
  2. Decreased GI motility
  3. Psychological factors
  4. Abnormalities of corpus luteum
  5. H. pylori
51
Q

When does hyperemesis gravidarum usually occur?

A

The peak incidence is at 8-12 weeks, and symptoms usually resolve by week 20

52
Q

Treatment/Management of hyperemesis gravidarum

A
  1. IVF possible TPN for most severe
  2. Antiemetics
  3. ID and avoid triggers (smells, sights…)
  4. Cool room temp
  5. Prenatal vitamins at night
  6. Do not use a straw to drink, sip between meals - do not drink with a meal
  7. Small frequent meals every 2-3 hours - never too hungry never too full
  8. Crackers before getting out of bed in morning
  9. Avoid greasy, spicy foods
  10. Weak tea,, ginger tea, very cold carbonated beverages, fruit juices
  11. Sit upright after meals
53
Q

Hypertensive Disorders During Pregnancy

A
  1. Preeclampsia-Eclampsia
  2. Chronic hypertension
  3. Chronic hypertension with superimposed preeclampsia or eclampsia
  4. Gestational (or transient) hypertension
54
Q

Chronic hypertension

A

Hypertension that exists prior to pregnancy or that develops before 20 weeks gestation

55
Q

Gestational hypertension

A

Blood pressure elevation (140/90) identified after 20 weeks gestation without proteinuria. Blood pressure returns to normal by 12 weeks postpartum

56
Q

Preeclampsia

A

Most common hypertensive disorder of pregnancy, which develops with proteinuria after 20 weeks gestation. It is a multi-system disease process, which is classified as mild or severe, depending on the severity of the organ dysfunction.

57
Q

Eclampsia

A

Onset of seizure activity in a woman with preeclampsia

58
Q

Chronic hypertension with superimposed preeclampsia

A

Occurs in approximately 20% of pregnant women with increased maternal and fetal morbidity rates

59
Q

Preeclampsia Pathology

A
  1. Gradual loss of resistance to angiotensin II
  2. Blood pressure rises (HTN)
  3. Vasoconstriction and platelet aggregation occur
  4. Loss of normal vasodilation of uterine arterioles and maternal vasospasm
    • Decreased placental perfusion
  5. Decreased renal perfusion (BUN, Creatinine, Uric Acid increase)
  6. Urine output decreased
60
Q

Preeclampsia Decreased Renal Perfusion

A
  1. Increased BUN, creatinine, uric acid
  2. Kidneys filter protein into urine (proteinuria)
  3. Loss of protein from vessels (hypoalbuminemia)
61
Q

Preeclampsia Urine Output Decreased

A
  1. Increased extracellular volume (edema)

2. Increased sensitivity to angiotensin II

62
Q

When is preeclampsia most often seen?

A
  • Last 10 weeks of pregnancy
  • During labor
  • First 48 hours after birth
63
Q

Women at Risk for Preeclampsia

A
  1. Teenagers
  2. Greater than 35 years old
  3. Hx of preeclampsia
  4. Large placental mass associated with multiple gestation
  5. Rh incompatibility
  6. DM
  7. Any vascular disease
  8. Obesity
  9. Familial tendencies
  10. Malnutrition
  11. Race
  12. First pregnancies
64
Q

Cardinal Signs of Severe Preeclampsia

A
  1. BP greater than 160/110 X2 (6 hours apart)
  2. 24 hour urine with proteinuria greater than 5 gm
  3. Dipstick urine protein 3+, 4+
  4. Oliguria: urine output less than 500 mL/24 hours OR less than 30 mL/hr
65
Q

Other S/Sx of Severe Preeclampsia

A
  1. Frontal headache
  2. Blurred vision
  3. Scotoma (spots/eyes)
  4. Cyanosis
  5. Pulmonary edema
  6. Epigastric pain or RUQ pain (secondary to increased vascular engorgement of liver)
  7. Impaired liver function (elevated liver enzymes)
  8. Irritability
  9. Seizure
  10. Hyperreflexia (DTR 4+)
  11. Clonus
  12. Retinal edema
  13. Edema (weight gain 3lb/24 hours OR 4lb in 3 days)
  14. Thrombocytopenia (less than 100,000)
  15. HELLP syndrome
66
Q

HELLP Syndrome

A

H - hemolysis (low RBC and platelets)
E - elevated
L - liver enzymes (LDH, AST, ALT)
L - low
P - platelets
** Early diagnosis is critical to prevent liver distention, rupture, and hemorrhage and the onset of DIC
** If the condition present prenatally, morbidity and mortality can affect both mother and baby

67
Q

Placental/Fetal risks during Preeclampsia

A
  1. Hypoxia of fetus
  2. Malnutrition of fetus (SGA, IUGR)
  3. Premature aging of the placenta (can see late decels)
  4. Abruption of placenta
  5. Preterm delivery
68
Q

Maternal Risks of Preeclampsia

A
  1. Stroke
  2. Heart failure
  3. Acute renal failure
  4. Acute liver failure
  5. Pulmonary edema
  6. Death
69
Q

Lab Tests for Preeclampsia

A
  1. 24 hour urine for protein and creatinine clearance
  2. Increased serum creatinine, BUN
  3. Increased liver enzymes
  4. Electrolytes
  5. CBC with platelets (less than 100,00)
  6. Clotting studies if thrombocytopenia
70
Q

Management of Preeclampsia

A
    • Clinical therapy depends on severity of disease
      1. Fetal status monitored by kick counts, NSTs, BPPs, USGs
      2. Increase protein intake to 80-100 mg/day
      3. Sodium restriction NOT indicated - should be moderate (less than 6 gm/day)
      4. Quiet environment
      5. Seizure precautions
      6. Bedrest left lateral position
      7. Daily weight, BP, protein at home
      8. Check DTRs
      9. Mom needs to report s/sx of increasing severity
71
Q

Medications Used with Preeclampsia and Eclampsia

A
  1. Magnesium sulfate
  2. Hydralazine HCl
  3. Labetalol
  4. Nifedipine
  5. Sodium nitroprusside
  6. Furosemide
72
Q

Magnesium sulfate

A

CNS depressant

  • Raises seizure threshold (SE is lowered BP)
  • Therapeutic level is 4.8-9.6
73
Q

Side Effects of magnesium sulfate

A
  1. Hot flush
  2. Sweating
  3. Nasal congestion
  4. Hypotension
  5. N/V
  6. Lethargy
  7. Drowsiness
  8. Weakness
74
Q

Symptoms of magnesium sulfate toxicity

A
  1. Urine output less than 30 mL/hr
  2. RR less than 12/min
  3. DTRs 0 or no response
  4. Confusion
  5. Unable to arouse
  6. Circulatory collapse
75
Q

Antidote for Magnesium Sulfate

A

Calcium gluconate (1 gm dose IV over 3 minutes)

76
Q

Betamethasone

A

Administered to the woman whose fetus has an immature lung profile; stimulates enzyme necessary for production of surfactant to induce pulmonary maturation and decrease risk for RDS in preterm infants.

    • If the baby has to be delivered early in preeclamptic/eclamptic mother
  • 12 mg IM every day for 2 days (gluteal deep IM)
77
Q

Contraindications for Betamethasone

A
  1. Inability to delay birth
  2. Adequate L/S ratio
  3. Gestational age greater than 34 completed weeks
78
Q

Antihypertensives used for Preeclampsia

A
  1. Hydralazine - most common in IV boluses
  2. Methyldopa - long term control of mild to moderate HTN
  3. Labetalol - also used long term control of HTN; 2nd line IV drug; avoid in asthma and CHF
79
Q

Medications Used in Management of Eclampsia

A
  1. Magnesium sulfate bolus
  2. Diazepam
  3. Dilantin for seizure prevention
  4. Furosemide
  5. Digitalis for circulatory failure
80
Q

Cure for Preeclampsia/Eclampsia

A

The birth of fetus and delivery of placenta (the best option is delivering vaginally because mom isn’t good at clotting)

81
Q

Gestational Diabetes

A

Any degree of glucose intolerance that has its onset or is 1st diagnosed during pregnancy

82
Q

Class A1 Gestational DM

A

Managed by diet

83
Q

Class A2 Gestational DM

A

Insulin dependent

84
Q

Classes B-R

A

Diabetics before pregnancy, managed with insulin

85
Q

Testing for GDM

A

All 24-28 weeks

  • 1 hour 50 gm GTT (normal less than 140)
  • 3 hour 100 gm GTT (2 or more abnormal values is a diagnosis)
    1. FBS should be less than 95
    2. 1 hour should be less than 180
    3. 2 hour should be less than 155
    4. 3 hour should be less than 140
86
Q

Risk Factors for Earlier Screening (DM)

A
  1. Older than 40
  2. 1st relative with DM
  3. Prior macrosomic, malformed, or stillborn infant
  4. Obesity
  5. HTN
  6. Glucosuria
87
Q

Insulin Requirements During Pregnancy (1st Trimester)

A

Decreased need for insulin perhaps due to N/V and fetal needs are low

88
Q

Insulin Requirements During Pregnancy (2nd and 3rd Trimesters)

A
  1. Insulin needs increase due to hPL production and increase glucose use
  2. Insulinase secreted by placenta accelerates breakdown of insulin
  3. Estrogen, Progesterone, Cortisol act as insulin antagonists
89
Q

Euglycemia for Pregnancy

A

60 - 120 mg/dL

90
Q

Hgb A1C

A

Average glucose over last 100-120 days

  • Less than 7.5 (good control)
  • More than 9.0 (poor control)
91
Q

Fetal Testing in DM

A
  1. USG - 18 weeks to establish gestational age and detect anomalies, repeat at 28 weeks for fetal growth
  2. Fetal kick counts QD at 28 weeks
  3. NST weekly at 28-32 weeks, may increase to twice weekly; if non-reactive, BPP (5 or 6 means you have to deliver soon)
92
Q

Medications for DM

A
  1. Insulin usually a mixture of NPH and Regular given - individualized
  2. Oral hypoglycemics are used occasionally
  3. Glyburide 1st choice for oral hypoglycemic, Metformin also used
93
Q

Causes of Hypoglycemia

A
  1. Too much insulin
  2. Increased energy expenditure
  3. Vomiting/diarrhea
94
Q

S/Sx of hypoglycemia

A
  1. Hunger
  2. Sweating
  3. Weakness
  4. Cold, clammy skin
95
Q

Treatment of hypoglycemia

A
  1. Complex CHO, protein-prevents rebound effect

2. Hard candy if exercising

96
Q

Causes of Hyperglycemia

A
  1. Too little insulin
  2. Infection
  3. Decreased exercise
97
Q

S/Sx of Hyperglycemia

A
  1. Polydipsia
  2. Polyuria
  3. Polyphagia
  4. Vomiting
  5. Flushed, dry skin
98
Q

Treatment of Hyperglycemia

A

Administer insulin

99
Q

Maternal Risks Associated with DM

A
  1. Hydramnios
  2. Preeclampsia/eclampsia
  3. Ketoacidosis - develops slowly can lead to coma and death of mom and fetus
  4. Retinopathy - retinal hemorrhage possible; refer to ophthalmologist
  5. Infection - monilial vaginitis and UTI due to increased glycosuria creating favorable environment for bacterial growth
100
Q

Fetal Risks Associated with Diabetes

A
  1. Congenital anomalies
  2. LGA, excessive growth = macrosomia
  3. Hypoglycemia
  4. IUGR
  5. RDS
  6. Polycythemia
  7. Hyperbilirubinemia
  8. Fetal death due to placental degradation
101
Q

TORCH Infections

A 
T - Toxoplasmosis (cat litter)
O - other (syphilis, gonorrhea, chlamydia, group B strep)
R - Rubella
C - Cytomegalovirus
H - Herpes simplex virus
102
Q

Group B Streptococcal Infection

A

Bacterial Infection

  1. Colonized in lower GI and urogenital tracts
  2. All OBs cultured, vaginally and rectally at 35-37 weeks
103
Q

Neonatal Effects of GBS

A
  1. Pneumonia
  2. Overwhelming septicemia
  3. Meningitis
  4. Neurological complications
  5. Death
104
Q

Risk Factors for Neonatal GBS Sepsis

A
  1. Preterm labor
  2. Maternal fever during labor
  3. Prolonged ROM (greater than 18 hours)
  4. Previous infected neonate
  5. Prenatal GBS bacteriuria
105
Q

GBS Treatment

A
  1. PCN - should be completed 4 hours prior to delivery
  2. Prenatal bacteriruria treated in labor (GBS screen not necessary)
  3. Women with prior neonate GBS+ receives prophylaxis - screening not necessary
  4. Unknown status - antibiotics given if less than 37 weeks, ROM more than 12-16 hours, Temp higher than 100.4F
  5. Treatment of neonate varies per facility/physician protocol
106
Q

Hydatidiform Mole

A

Molar Pregnancy

  1. Abnormal development of the placenta; appears as a fluid-filled grapelike cluster
  2. Proliferation of trophoblastic tissue (outer layer of embryonic cells) that produce hCG
  3. Major risk: Choriocarcinoma (cancer)
    - High risk for hyperemesis gravidarium
    - Not true pregnancy but tests positive due to production of hCG
    - Can not get pregnant for 1st year after having it to make sure they don’t have cancer.

Sophomore 1 Test 5 (5 decks)

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