Pregnancy Complications Flashcards
What is hyperemesis gravidarim?
Excessive and persistent nausea and vomiting during pregnancy associated with ketosis and weight loss (>5% of pre-pregnant weight)
What is the incidence rate of hyperemesis gravidarium?
0.3 to 3% of all pregnancies.
What is the etiology of hyperemesis gravidarium?
Etiology is unclear, but there are some theories (biologyical, psycholoigcal, sociocultural)
Hormonal- linked to increased hCG to increased TSH in first trimester, increased estradiol, decreased prolactin, genetics may play a role
Infection (H pylori of GI), psychological factors
What is the objective and subjective data associated with hyperemesis gravidarium?
Progressive vomiting and retching, dehydration, fluid and electrolyte imbalance, alkalosis (untreated acidosis)
Hypotension, tachycarida, increased hematocrit and BUN, decreased output
Potassium loss -> cardiac and renal dysfunction
Fetal loss -> maternal mortality and morbidity
What is a spontaneous abortion?
Spontaneous loss of pregnancy prior to viability (20 weeks/500 grams)
What are the different types of spontaneous abortion? (7)
Threatened Imminent/inevitable Complete Incomplete Missed Recurrent pregnancy loss Septic
What are the signs of a threatened spontaneous abortion?
Bleeding, cramping, closed cervix
What are the signs or an imminent/inevitable spontaneous abortion?
Bleeding, cramping, dilated cervix
What is a complete spontaneous abortion?
All products expelled
What is an incomplete spontaenous abortion?
Not all products expelled (placenta usually retained)
What are the signs and symptoms of a missed spontaneous abortion?
Fetus dies, pregnancy changes reverse, brownish discharge (risk of DIC of not expelled after 6 weeks)
What is recurrent pregnancy loss? (due to spontaneous abortion)
Consecutive loss of 3 or more pregnancies.
What is a septic spontaneous abortion?
Presence of infection (premature rupture of membranes)
What is the incidence of spontaneous abortion?
12-26% of diagnosed pregnancies (increased risk with maternal age)
What is the etiology of spontaneous abortion?
Chromosomal and reproductive tract or placental abnormalities.
Implantation problems.
Teratogens eg. accutane, hot tubs
Endocrine imbalances (hCG, estrogen, progesterone)
Chronc maternal diseases, infections (TORCH) and UTIs
What is the objective and subjective data of a woman having a spontaneous abortion?
Depends on the type of spontaneous abortion
Spotting
Cramps and backache
Loss of products of conception
What is the treatment/nursing care for spontaneous abortion?
Determine source of blood loss (eg. cervix vs fetal
Speculum exam
Ultrasound
hCG (less useful)
Take HGB and Hct, cross match blood
Possible decreased activity/bed rest
No intercourse
Provide emotional support and referral prn
What is the treatment for an imminent/incomplete spontaneous abortion?
Hospitalized - IV, D&C/suction evacuation
- if >12 weeks induction to expulsion (PE2/cytotec)
Provide emotional support and referral prn
What is placenta previa?
Low implantation of the placenta
What are the types of placenta previa?
Marginal
Partial
Complete/total
What is marginal placenta previa?
On margin of internal os
What is partial placenta previa?
Covers part of internal os
What is complete/total placenta previa?
Completely covers internal os
What is the incidence rate of placenta previa?
2/1000 births
What is the etiology of placenta previa? what are the risk factors?
Etiology unknown Associated with: multiparity previous c-section previous induced abortions multiple gestations previous SA increasing age large placenta placenta accrete smoking male fetus Asian women
What are the objective and subjective data for placenta previa?
Bleeding - painless, abrupt, bright red
- not associated with activity
- usually around 30 weeks (upper and lower segment begin to differentiate)
How is placenta previa diagnosed?
Usually diagnosed by ultrasound
What is the assessment for placenta previa?
Assess re: onset and amount of blood, fetal heart, uterus, emotions
What precautions need to be taken with caring for a placenta previa patient?
No vaginal or rectal exams until placenta previa is ruled out
What is the nursing care for placenta previa?
Bedrest with bathroom privileges, side lying, IV O2 PRN, monitr pads, fetal heart rate, and uterine activity
Determine source of blood loss (placenta or cervix)
Vital signs, ultrasound (speculum exam if cervical problems)
HGB and HCT, group and cross-match, urinalysis
Emotional support
When should the birth be delyted until with placenta previa (if possible)?
37 weeks
What medication should be administered to a patient with placenta previa if premature birth is anticipated?
betamethasone
What are the outcomes of placenta previa?
Caesarean birth with complete placenta previa.
Induction and possible vaginal delivery with low lying/marginal previa (need cephalic presentation and minimal PV loss)
What is placenta abruptio?
Premature separation of the normally implanted placenta from the wall of the uterus during pregnancy/1st or 2nd stage of labour
What are the three types of placenta abruptio?
Marginal
Central
Complete
What is marginal placenta abruptio?
Mild separation, vaginal bleeding
What is central placenta abruptio?
Concealed hemorrhage
What is complete placenta abruptio?
Complete separation of the placenta
What is the incidence of placenta abruptio?
0.5-1% of pregnancies
What is the etiology of placenta abruptio?
Etiology unknown
What are the predisposing factors for placenta abruptio?
Maternal hypertension/PIH
Trauma, sudden intrauterine pressure changes
Previous abruption
Cocaine use, smoking, low socio-economic status
PPROM
Malformations of uterus, placenta, cord
Inherited thrombophilia
What is the objective and subjective data for placenta abruptio?
Pain - sharp, stabbing, high in fundal area, increased with contractions for some, tenderness of the uterus
Bleeding - overt (edge of placenta involved & route to escape)
- covert (if in centre of the placenta - uterus becomes hard and board-like)
Shock
DIC if fibrinogen reserves are used up
What is the main difference in presenting symptoms between placenta previa and placenta abruptio?
Abruptio has sudden stabbing pain, previa is painless
What is the treatment/nursing care for placenta abruptio?
OSB emergency!
IV
Monitor vital signs, pv loss, fetal heart (continous monitoring), contractions, O2 prn, left lateral position.
Stat blood work: HBG, HCT, blood group and type, cross match, fibrinogen levels
What is the prognosis/outcome of placenta abruptio?
ARM and induction, forceps/vacuum, caesarean delivery (fetal demise)
What is the onset of placenta previa vs placenta abruptio?
Previa: quiet and sneaky
abruptio: sudden and stormy
What is the difference in bleeding between placenta previa and abruptio placentae?
Previa: external
Abruptio: external or concealed
What is the difference in the colour of the blood in placenta previa vs placenta abruptio?
Previa: bright red
Abruptio: Dark venous
What is the difference in the level of anemia seen with placenta previa vs. abruptio?
Previa: equal to blood loss
Abruptio: Greater than apparent blood loss
What is the difference in the level of shock seen with placenta previa vs. abruptio?
Previa: equal to blood loss
Abruptio: Greater than apparent blood loss
What is the difference in the precenve of toxemia with placenta previa vs abruptio?
Previa: absent
Abruptio: may be present
What is the difference in pain levels for placenta previa vs placenta abruptio?
Previa: only labour
Abruptio: Severe and steady
What is the difference in uterine tenderness for placenta previa vs abruptio?
Previa: absent
Abruptio: present
What is the difference in uterine tone in placenta previa vs. abruptio?
Previa: soft and relaxed
Abruptio: firm to stony hard
What is the difference in uterine contour in placenta previa vs placenta abruptio?
Previa: normal
Abruptio: may enlarge and change shape
What is the difference in fetal heart tones in placenta previa vs. placenta abruptio?
Previa: usually present
Abruptio: present or absent
What is the difference in engagement in placenta previa vs abruptio?
Previa: absent
Abruptio: may be present
What is the difference in presentation with placenta previa vs abruptio?
Previa: May be abnormal
Abruptio: no relationship
What is cervical insufficiency?
Cervix dilates early and can not hold a fetus to term.
Painless dilation that occurs in the 4th or 5th month of pregnancy
What is the incidence of cervical insufficiency?
Up to 1% of obstetric populations
What are the types of cervical insufficiency?
Congenital
Acquired
Biochemical
What is the etiology of congenital cervical insufficiency?
DES, bicornate uterus
What is the etiology of acquired cervical insufficiency?
Infection, trauma, multiple gestations
What is the etiology of biochemical cervical insufficiency?
relaxin
What is the objective and subjective data for cervical insufficiency?
Painless dilation of the cervix Increased pelvic pressure (possible SRM) Contractions Birth of a premature baby (20 weeks) Funneling of cervix on ultrasound
What is the nursing treatment for cervical insufficiency?
History, vaginal ultrasound (15-28 weeks)
Conservative treatment - bed rest, no intercourse, no heavy lifting
What is the surgical treatment for cervical insufficiency?
Cerclage/suture @14-18 weeks
Suture removed at term SVD or C-section (or left in)
What is the success rate for cerclage/suture for cervical insufficiency?
Success rate 92-93%
What is the medical treatment for cervical insufficiency?
Progesterone
Anti inflammatories
Antibiotics
What are some hypertensive disorders in pregnancy? (classifications)
Preeclampsia-eclampsia, chronic hypertension, chronic hypertension with superimposed preeclampsia, gestational hypertension
(Also known as HIP or PIH or HDP)
What is the incidence rate of hypertensive disorders in pregnancy?
7-9% of pregnancies
What is preeclampsia?
(Mild-severe) increase in BP after 20 weeks gestation accompanied by proteinuria in a previously normotensive woman (5-8%)
What is eclampsia?
Severe form of preeclampsia with generalized edema or coma
What is the occurrence of preeclampsia? (when does it happen)
Last 10 weeks or pregnancy, during labour and delivery, or in first 48 hours after birth.
What is the cure for preeclampsia?
Delivery of fetus and placenta
What are the predisposing factors for preeclampsia?
Teens and >35 year old primips, previous history, large placental mass, Rh incompatability, diabetes
What are the possible etiologies of preeclampsia/eclampsia?
Abnormal placentation, immunological genetics, prostacycin-thromboxane imbalance
What is the pathophysiology behind preeclampsia/eclampsia?
Prostaccyin thromboxane ratio altered (prostacycin decreased.
Causes loss of resistance to angiotensin II.
Causes increased blood pressure and increased platelet aggregation.
Causes decreased nitric oxide (increased BP).
Renal perfusion is decreased (related to vasospasm).
Causes decreased GFR, increased serum creatinine, increased BUN, increased uric acid.
Causes decreased urine output.
Sodium retained and serum albumin decreased.
CAuses fluid shift (edema)
Loss of albumin related to stretching of capillary walls of the glomerular endothelial cells.
What is the objective and subjective data for preeclampsia and eclampsia? (mild disease)
Mild disease - 140/90 four hours apart. Proteinuria.
+1 +2 edema
>3.3 lbs month or 1.1 lbs week
What is the objective and subjective data for severe preeclampsia?
BP 160/110 six hours apart on bedrest. Proteinuria
+3 +4 edema
What are some general symptoms of preeclampsia?
Oliguria Visual or cerebral disiturbances Cyanosis/pulmonary edema Epigastric/upper left quadrant pain Impaired liver function Thrombocytopenia Generalized edema Hyper-reflexia
What is the treatment/nursing care for a patient with preeclampsia and eclampsia?
Frequent assessment of vital signs, intake and output, fetal heart, uterus and pv loss, edema (pulmonary also), and weight, reflexes, signs of eclampsia, LOC and psychosocial
Bedrest (left side)(decrease stimuli)
Diet increase in protein
Monitor fetus
What meds are given for preeclampsia?
Anticonvulsants (MgSo4) and sedatives
Antihypertensives
Corticosteroids
Fluid and electrolyte replacement
What lab tests are done for preeclampsia and exlampsia?
Hct, BUN, creatinine, uric acid levels, clotting studies, liver enzymes, Fluid and electrolyte imbalances and Mg levels)
What is the prognosis for preeclampsia and eclampsia?
In severe PIH< stabilize then deliver baby by induction/c-section (only cure)
What are some complications that might arise (that we need to prevent) from pre-eclampsia/eclampsia?
Cerebral hemorrhage Seizures Hematologic complications Renal and hepatic diseases Fetal/infant complications
What is HELLP syndrome?
Hemolysis
Elevated Liver enzymes
Low Platelet count
What is DIC associated with?
Preeclampsia/eclampsia/HELLP Abruptio placenta Amniotic fluid embolism Maternal liver disease Septic abortions Dead fetus
What characterizes diabetes mellitus? (4 cardinal signs)
Polyuria
Polydispia
Polyphagia
Weight loss
What is gestational diabetes mellitus? (GDM)
Onset of diabetes occurs during pregnancy.
What is the incidence of gestational diabetes?
7% of all pregnancies
What are some associated risks for gestational diabetes?
Obesity
History of gestational diabetes
Have glycosuria
Family history
What is the etiology of gestational diabetes?
Inadequate insulin response to carbohydrates
Excessive resistance to insulin
Or a combination of both
When does gestational diabetes occur?
Usually occurs mid pregnancy
Is gestational diabetes typically symptomatic?
May be mild symptoms or asymptomatic
What is the test for gestational diabetes?
FBS >5.1 & GTT @1 hour 10.0 @ 2 hours and 8.5 = dx of gestational diabetes
Glucose present in urine
What are some maternal risks associated with gestational diabetes?
Polyhydramnious Preeclampsia-eclampsia Hyperglycemia Retinopathy Maternal trauma - related to large baby, labour and delivery complications
What is the treatment/nursing care for gestational diabetes?
Early diagnosis (women screened at 24-28 weeks. Should include an FBS and GTT 75g)
To be seen by a diabetic clinic.
Usually managed with diet but may progress to insulin in the 2nd and 3rd trimesters
Symptoms disappear after pregnancy (24 hours)
Risk of developing type 2 diabetes later in life.
What is the objective and subjective data associated with pregestational diabetes? (eg. how do insulin requirements change with pregnancy)
Changing insulin demands and dietary intake (1st trimester)
Double insulin requirements (2nd trimester)
Insulin requirements ~ 2-4 times by end of pregnancy
What is the treatment and nursing care for pregestational diabetes?
Ongoing and frequent management of diabetes starting preconceptionally (diabetic clinic)
Monitor glycosulated hemoglobin (BHA1c)
What is Rh Alloimmunization?
Incompatability between Rh + mom and Rh - baby
What is the incidence of Rh Alloimmunization?
Increased related to migration of rH sensitized women from countries with limited health care and resources.
What is the etiology of Rh alloimmunization?
Occurs with birth of the Rh positive baby/fetus/products of conception, or break in the placental barrier.
Amniocentesis/CVS/percutaneous cord blood sampling
Rh+ cells invade maternal circulation and stimulate production of antibodies (antigen-antibody response)
Most produced in 72 hours
If antibodies are formed… in future pregnancies the antibody will cross the placenta barrier and haemolyse fetal red blood cells
Fetus becomes anemic, hydrops fetalis (CHF, neuro problems, death)
What is the treatment/nursing care for Rh Isoimmunzation?
Early testing or Rh blood group in pregnancy
If Rh negative, indirect coombs done (determines the presence and amount of antibodies developed)
AntiD/Rhogam given at 28 weeks if no antibodies present.
At birth, if mom Rh negative, direct Coombs’ on cord blood (presence of maternal antibodies in fetal blood)
If negative, indicating a large number of antiboides are not present, mom will receive anti D (in 72 hours of birth)
Rh immunoglobulin not given if indirect and direct are both positive (monitor for hemolytic disease)
What is the incidence of ABO incompatability?
15-25% of pregnancies
What is the nursing care for ABO incompatability?
Become aware in pregnancy
Monitor babe for jaundice in first 24 hours
Treatment with phototherapy PRN
First infant is usually involved
When does ABO incompatability occur?
Mother O and baby A, B or AB. Occurs at birth
What is premature rupture of membranes (PROM)?
Ruptured membranes before labour
What are the risk factors for PROM?
Associated with low socioeconomic status, smoking, low BMI, infection, history of PROM
Incompetent cervix, amnio, placenta previa/abruptio, trauma, hdyramnious, multigestational
What is the outcome of PROM?
If less than 26 weeks, 50% will go into labour in 1 week. If 28-34 weeks, 80-90% will go into labout in 1 week.
What are the risks associated with PROM?
Infection (chorioamnionitis, endometritis), abruptio placenta
Premature birth
Neonatal sepsis
Cord prolapse
How is PROM diagnosed?
Nitrazine test - aniotic fluid pH 7-7.5 (not conclusice)
Speculum exam (pooling of fluid)
Fern test
What should be avoided with PROM?
Avoid vag exams unless in active labour
What is the treatment for PROM?
Conservative if <37 weeks (bedrest, CBC, weekly NST, vital signs Q4h, antibiotics, betamethasone, avoid intercourse, tampons and baths)
If >37 weeks induce
