Pregnancy complications Flashcards
What defines chronic hypertension in pregnancy?
- Systolic BP >140mmHg or diastolic BP >90mmHg prior to conception on 2 different occasions before 20 wks or after 12 wks.
- Persists after pregnancy/birth
- No proteinuria
What are the 4 medications to give for hypertension
“New Mothers Hate Labor”
* N: nifedipine
* M: methyldopa
* H: hydralazine
* L: labetalol
What antihypertensives to avoid during pregnancy
- Avoid Ace inhibitors (“pril): lisinopril, enalapril
- ARBs (“sartan”): losartan, valsartan
what is the drug of choice for anticonvulsions during pregnancy
Magnesium sulfate
what is the therapeutic range of magnesium sulfate
4 - 7 mEq/L
what are signs of toxicity with magnesium sulfate
- low deep tendon reflexes (early sign)
- low VS: respiratory depression
- decreased mental status
- low urine output: <30mL
What is chronic HTN with superimposed preeclampsia
- preexisting HTN + signs of preeclampsia
- increased BP that was previously controlled
- with new onset of proteinuria
this is previous HTN w/ new preeclampsia s/s, preeclampsia is just new HTN
what are s/s of chronic HTN with superimposed preeclampsia
- proteinuria
- increased liver enzymes
- thrombocytopenia (low platelets)
- RUQ pain
- headaches, blurred vision, scotoma (blind spot)
- pulmonary edema or congestion
What is gestational hypertension?
High blood pressure for the first time after 20 weeks.
can progress to preeclampsia
What characterizes preeclampsia?
Hypertension during pregnancy accompanied by proteinuria after 20 weeks gestation.
What are the risk factors for preeclampsia?
- first time pregnant
- Maternal age >35 years
- Prepregnancy obesity (BMI >30)
- Multiple gestation
- Family history
- Chronic hypertension, kidney disease, systemic lupus, thrombophilia, antiphospholipid syndrome, diabetes
- Assisted reproduction
What are suspected cause of preeclampsia
- remodeling of vessels are abnormal and doesn’t accomodate increased blood flow
- around 20wks, the fetus develops quickly, requiring more nutrients and O2
- the abnormality leads to ischemia -> inflammation -> endothelial dysfunction & thrombosis
- or just genetics
What are the diagnostic criteria for preeclampsia?
- SBP >160; DBP >110
- proteinuria
- serum creatinine 1.1mg/dL +
- liver enzymes elevated x2
- platelets <100,000/uL
- new onset cerebral or visual disturbances
- persistent epigastric pain
why does proteinuria, edema, and hemoconcentration change due to preeclampsia
increased permeability and capillary leakage
What are the criterions for proteinuria
how is the test done
- > = 300mg in 24 hr collection
- protein/creatinine >=0.3
- > =2+ on dipstick
why are platelets & RBC decreased in preeclampsia
intravascular coagulation leads to:
* hemolysis or RBC
* increased factor VIII antigen
* platelet adhesion
As a result of vasospasm, explain the cause of:
* IUGR: intrauterine growth restriction
* decreased GFR, oliguria
* headache, hyperreflexia, seizure
* blurred vision, scotoma
* N/V, Epigastric RUQ pain
- IUGR: decreased uteroplacental perfusion
- decreased GRR, oliguria: Glomerular damage
- headache, hyperreflexia, seizure: Cortical brain spasms
- blurred vision, scotoma: Retinal arteriolar spasm
- N/V, epigastric pain: Liver ischemia
Complications for the mother after getting preeclampsia
- lower extremity edema -> pulmonary edema, cerebral edema, CVA
- hemorrhage
- disseminated intravascular coagulation
- congestive HF
- HELLP, eclampsia
long term damage
* liver/kidney damage
* abruptio placenta
Complications for fetus after preeclampsia
- Fetal growth restriction (FGR)
- Fetal intolerance to labor
- Stillbirth
- Spontaneous or preterm delivery
Nursing care for preeclampsia
- seizure precautions
- decrease environmental stimuli
- ensure adequate protein intake
What does HELLP syndrome include
- Hemolysis
- Elevated Liver enzymes
- Low platelets
Complications for women with HELLP
- abruptio placenta
- renal failure
- liver hematoma
- rupture of blood vessels -> internal bleeding
Complications for the fetus with HELLP
- PTB
- death
treatment for HELLP
- magnesium sulfate drip
- IV push antihypertensives
- fluids
what is eclampsia
- seizures or coma in pt w/ preeclampsia
Labs for eclampsia
- Urinalysis
- Serum creatinine >1.1mg/dL
- hematocrit >35
- increased AST >40, ALT >56
S/S of eclampsia besides seizures
- loss of consciousness
- agitation
- headaches/muscle pain
- URQ pain
medical interventions for eclampsia
* Meds
- magnesium sulfate prophylactically & after
- antihypertensives
- corticosteroids if induced birth is necessary (enhance lung maturity)
- epidural if platelets >100,000
- platelet transfusion <50,000
medical interventions for eclampsia
* what to assess
- Lung sounds, RR, SpO2
- CNS: headache, vision changes, deep tendon reflexes
- Epigastric pain
Why is a quiet environment and bedrest in the lateral recumbent position recommended for women with preeclampsia, eclampsia, HELLP
- Reduce stress to prevent seizures
- lateral recumbent position promotes blood flow to the uterus and organs -> reduce maternal BP
What is gestational diabetes mellitus (GDM)?
- glucose intolerance
- insulin resistance
Etiology for gestational diabetes mellitus
Hormonal changes (hPL, insulinase, P&E, etc.) from the placenta -> insulin resistance and hyperglycemia
S/S of gestational diabetes
- polyuria, polyphagia, polydipsia
- blurred vision
- frequent UTIs, vaginal candidiasis
- excessive fatigue
- sudden wt loss
- hypoglycemic episodes
antepartum care for GDM
- Diet and exercise
- insulin therapy
- NO oral hypoglycemic agents
- self-monitoring BG
- fetal kick counts/monitoring
diet education for antepartum with gestational diabetes
- switch to complex carbs, fruits and veggies
- eat small low-carb snacks throughout the day instead of 3 large meals
glucose monitoring education for antepartum with gestational diabetes
- test 1 fasting glucose + 3 postprandial checks per day
- fasting glucose <95, 1hr after meals <140, 2hrs after meals <120
- monitor fasting ketonuria levels prn
Risk factors for getting gestational diabetes mellitus
- Hx of fetal macrosomia (large baby)
- family hx
- obesity
- polycystic ovarian syndrome
- HTN
what are complications for the mother with gestational diabetes
- Hypoglycemia and DKA
- Preeclampsia or Hypertensive disorders
- C-section
what are the complications for the baby w/ gestational diabetes
- macrosomia (large baby>4000g) -> shoulder dystocia (shoulder trapped in pelvis)
- IUGR
- hypoglycemia first few hrs
- polycythemia (elevated HCT)
- hyperbilirubinemia
- resp distress syndrome - immature lungs
- assisted delivery, birth trauma
- preterm birth
- stillbirth
explain the process for glucose fasting tests
1hr glucose challenge test (non-fasting):
* drinks 50g glucose
* BG in 1hr: 135-140 mg/dL + is positive
if positive -> 3hr glucose tolerance test
* fasts for 8-12hrs prior
* drinks 100g glucose
positive if 2 or more of the following are elevated:
* fasting >= 95
* 1hr >=180
* 2hrs >=155
* 3hrs >=140
etiology for hyperemesis gravidarum
rapid rising serum hormones: hCG
What are the signs and symptoms of hyperemesis gravidarum?
- Prolonged, frequent, or severe vomiting
- Weight loss >5%
- Acetonuria/ketonuria
- Signs of dehydration (lightheadedness, dizziness, tachycardia, dry mucous membranes, hypotension, poor skin turgor)
What distinguishes hyperemesis gravidarum from morning sickness?
Hyperemesis gravidarum involves all-day vomiting that doesn’t improve with food, while morning sickness improves after eating.
treatment for hyperemesis gravidarum
- vitamin B6 and doxylamine
- dextrose and thiamine
- antihistamine H1 receptor blockers, phenothiazines, benzamides
- enteral tube feeding initially for nutrition support
What is a spontaneous abortion?
Loss of an intrauterine pregnancy before viability (20 weeks)
explain the difference between induced, elective, and therapeutic abortions
- induced: mifepristone-misoprostol regimen
- elective: termination before viability requested by mother
- therapeutic: termination r/t maternal-fetal complications
what is the difference between:
- complete vs. incomplete abortion
- inevitable abortion
- threated abortion
- missed abortion
complete: fully passed through uterus vs. incomplete: tissue left; bleed continuous
inevitable: the miscarriage is in progress and can’t be stopped
threatened abortion: cervix closed, pregnancy may be viable
missed abortion: embryo/fetus died, but body hasn’t expelled it
what is the treatment for medical abortions
- 800ug of vaginal misoprostol
dilates the cervix, stimulates contractions - surgical evacuation
What are the risk factors for early pregnancy loss?
- Prior pregnancy loss
- Advanced maternal age
- Endocrine abnormalities
- Drug use/toxins
- Immunological factors
- Infections
- Systemic disorders
- Genetic factors
- Uterine or cervical abnormalities
- Black women
Peri care education for post abortion/miscarriage
- no tampons
- no douching
- no sexual intercourse for weeks
Dietary teachings for post abortion/miscarriage
- high Fe
- high protein
what type of examinations are done to confirm complete expulsion of fetus during abortion
hCG serum testing & U/S
what is ectopic pregnancy
- implantation outside the uterine cavity - mostly in fallopian tube
what are the risk factors for ectopic pregnancy
- recurrent STIs
- PID: pelvic inflammatory dx
- tubal sx, damage/scarring
- IUDs
What are the signs and symptoms of ectopic pregnancy?
- Sudden, severe one sided abdominal or pelvic pain
- Dizziness or fainting
- Lower back pain
- red vaginal spotting
what are s/s of ruptured ectopic pregnancy
hypovolemic shock
* hypotension
* tachycardia
* dizziness
shoulder pain: severe, sudden, and sharp
* pooling of blood from the abdomin
* can lead to peritonitis: rigid abdomen, tenderness, fever
how do you diagnose ectopic pregnancy?
- 6-12 week zygote large enough to rupture fallopian tube
- serial hCG levels
- transvaginal U/S
what is the treatment for ectopic pregnancy
- early: methotrexate (given until negative hCG titer)
methotrexate stops cells from dividing - salpingectomy: laparoscopy to ligate bleeding vessels and to remove or repair damaged fallopian tube
never viable and can’t be transplanted
What is a hydatidiform mole?
A benign proliferating growth of the trophoblast, resulting in grape-like clusters without a viable fetus.
What is the normal process of trophoblast cell development?
Trophoblast cells form the placenta and develop chorionic villi, then implant in the endometrium.
What characterizes a hydatidiform mole?
Abnormal growth of the placenta and trophoblastic cells leading to fluid accumulation in chorionic villi -> formation of cysts.
What is the difference between a complete mole and an incomplete mole?
- Complete mole: no fetal development
- Incomplete mole: abnormal fetal tissue is present but doesn’t mature.
What are some risk factors for developing a molar pregnancy?
- Age under 18 or over 40 years
- Previous molar pregnancy.
What is the relationship between hCG and TSH -> hyperthyroidsm in a pt with molar pregnancy
hCG and TSH have similar structures, and elevated hCG can bind to TSH receptors, stimulating thyroid hormone production.
What are the clinical manifestations of a molar pregnancy?
- Bleeding -> Anemia
- Enlarged uterus -> overestimated fundal height
- Pelvic pain or pressure
- high hCG -> Hyperemesis gravidarum
- Hyperthyroidsm
- Dark brown “prune juice color” uterine bleeding
What is the increased risk associated with a molar pregnancy?
Increased risk of choriocarcinoma, an aggressive cancer from trophoblastic tissue of the placenta.
How is a molar pregnancy diagnosed?
- Transvaginal ultrasound
- Serum hCG levels - elevated for the first 8-12 wks
What is the immediate medical management for a molar pregnancy?
Suction curettage for immediate evacuation of the mole.
Fill in the blank: In a molar pregnancy, serial hCG levels should be monitored for at least ______ months after removal.
6 months
avoid pregnancy until cleared by PCP
What is placenta previa?
Malposition or implant of the placenta in the lower uterine segment, covering the internal cervical opening partially or completely.
List the types of placenta previa.
- Total: completely covers cervix opening
- Partial
- Low-lying: lower part of the uterus but does not cover the cervix.
What are the 3 main risk factors for placenta previa?
Give examples
Endometrial scarring
* Previous C-section
* Abortion
* Multiparity
Impeded endometrial vascularization
* Advanced maternal age
* Diabetes
* Hypertension
* Smoking
* uterine fibroids, endometritis
Increased placental mass
* multiple gestation: twins, triplets
* large placenta
Complications of placenta previa for women?
- Hemorrhagic and hypovolemic shock
- Potential Rh sensitization
- Septicemia
- Death.
Complications of placenta previa for the baby?
- Intrauterine growth restriction (IUGR)
- Blood loss -> anemia
- Hypoxia
- Preterm birth.
What are the signs and symptoms of placenta previa?
- Painless vaginal bleeding during 3rd trimester that is bright red
- low HgB
How is placenta previa diagnosed?
Transabdominal ultrasound: 36wks and prior to onset of labor
what must you never do for placenta previa
- NO vaginal or rectal exams: can pierce the placenta and lead to hemorrhage
What is the management for a patient with placenta previa?
- Anticipate blood transfusion: initiate 2 large bore IVs, blood typing & screening
- FHR (1st sign)
- Count pads for blood loss
- prepare for C-section prior to labor
- betamethasone given for preterm lung development
- give O2 8-10L/mins prn
What is abruptio placenta?
Bleeding at the decidual-placental interface leading to hematoma and partial or complete placental detachment.
when are abruptio placenta typically diagnosed
after 20wks gestation
What are the grades of abruptio placentae?
- Mild: mild to moderate dark vaginal bleeding
- Moderate to severe: uterine rigidity, severe abdominal pain, dark vaginal bleeding, signs of shock, fetal distress
What are the risk factors for abruptio placenta?
- Previous abruption, c-section
- Hypertension, preeclampsia
- Maternal age
- abdominal trauma
- Drug use: coke, meth
- thrombophilias
complications for women with abruptio placenta?
- Obstetric hemorrhage
- Blood transfusions
- Emergency hysterectomy.
- Renal failure
- DIC
complications for the baby associated with abruptio placenta?
- Low birth weight
- Preterm delivery
- Asphyxia
- Stillbirth.
What are the signs and symptoms of abruptio placenta?
- dark red vaginal bleeding
- Hypovolemic shock:
- Severe continuous abdominal pain
- rigid & tender uterus
- abnormal FHR pattern
- uterine tachysystole: frequent contractions that can lead to fetal hypoxia
- Kleihauer-Betke test
interventions for abruptio placenta
- anticipate emergency C-section
- continuous FHR monitoring
- large IV bore access & blood typing for transfusion
- monitor for hypovolemic shock
What is the Kleihauer-Betke test?
A test to detect the presence of fetal red blood cells in maternal blood.
What does placenta accreta spectrum (PAS) include?
- Placenta accreta
- Placenta increta
- Placenta percreta.
Placenta accreta vs. increta vs. percreta
- Accreta (most common): beyond the boundary without invasion of the decidua
- increta: into uterine myometrium
- percreta: into uterine musculature and can adhere to other pelvic organs
What is the etiology of placenta accreta spectrum?
Defect of the endometrial-myometrial interface leading to abnormal deep placental anchoring.
What are the risk factors for placenta accreta spectrum?
- Myometrial damage from previous C-section
- previous placenta previa overlying uterine scar
- Advanced maternal age
- In vitro fertilization
- multiparity
complications for women with placenta accreta spectrum?
- Hemorrhagic shock
- Increased risk of infection, thromboembolism, pyelonephritis, pneumonia, adult resp distress syndrome, renal failure
What are the risks for the baby associated with placenta accreta spectrum?
- Preterm birth.
What is the medical management for placenta accreta spectrum?
- Preterm cesarean hysterectomy
- Delivery between 34 and 37 weeks.
what should you never do for the placenta accreta spectrum
No vaginal exams
assessment/management for 2nd and 3rd trimester bleeding
- description of bleed
- contractions and fetal activity
- observe for signs of shock
- NO vaginal exams
- U/S
What does the acronym TORCH stand for in infections during pregnancy?
- T: Toxoplasmosis
- O: Other (Hep B, syphilis)
- R: Rubella
- C: Cytomegalovirus
- H: Herpes simplex virus.
s/s of toxoplasmosis for mothers
- fatigue
- muscle pains
- pneumonitis
- myocarditis
- lymphadenopathy
s/s of toxoplasmosis for the fetus
- premature birth
- hydrocephalus
- vision problems
- hearing loss
patient teachings to avoid toxoplasmosis
- no changing cat litter
- wash soil-contaminated fruits & veggies
- no raw or undercooked meat
treatment for toxoplasmosis
- sulfadiazine or
pyrimethamine after the first trimester
when is group beta strep screening done
36-38weeks swab
What is the treatment for group beta strep (GBS) during labor?
IV antibiotics, typically penicillin during labor
what are complications for the fetus when the mother has group beta strep
- pneumonia
- septicemia
- meningitis
What are the effects of trauma during pregnancy?
- Risk of placental abruption
how long are you supposed to monitor the mother after experiencing trauma
4 hrs monitoring of:
* pain
* bleeding
* contractions
