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Obstetrics > Preterm Labor and Bleeding > Flashcards

Preterm Labor and Bleeding Flashcards

1
Q

What is the leading cause of mortality and morbidity in labor and birth for the newborn?

A

Preterm labor

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2
Q

Why are the rates of preterm labor and preterm birth increasing?

A

§ Assisted Reproductive Technology (ART)
§ Increasing role of infection in PTL / PTB

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3
Q

Most common indicator of preterm labor

A

Previous PTB

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4
Q

What are the causes of preterm labor?

A

§ Race
§ Age extremes (<17 or >35)
§ Smoking/Alcohol/Drugs
§ Infection/Inflammation/Toxicology
§ Stress (strenuous work, physical and emotional abuse)
§ Hypertensive disorder of pregnancy
§ Prenatal care, nutrition and oral health
§ Cervical abnormalities or surgery
§ Placental problems (previa, abruptio)
§ Uterine distention (multiples, polyhydramnios)
§ Previous PTB

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5
Q

What are the symptoms of preterm labor common to and why?

A

Normal labour but more subtle as fetus is smaller

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6
Q

5 Symptoms of Preterm Labor

A
  1. contractions: low abdominal pain, cramps backache, not recognized as contractions
  2. bleeding, spotting show, ROM
  3. increased amount or changes in vaginal discharge
  4. contractions every 10 min or more often
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7
Q

Fetal Fibronectin

A

Glycoprotein released into cervical/vaginal fluid in response to inflammation or separation of amniotic membranes

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8
Q

When is fetal fibronectin normal in secretions?

A

until 22 weeks gestation and again near the time of labour – after/inbetween that there should be none present unless client is actually in labour

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9
Q

Implication of negative ffn

A

pregnancy is likely to continue for at least another two weeks (95-98%); helpful in knowing if you can send patient home

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10
Q

Implication of positive ffn

A

present 24 through 34 weeks gestation indicates ↑ risk of preterm delivery

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11
Q

Is FFN a stronger positive or negative predictive value?

A

Negative

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12
Q

3 Points of Management of Preterm Labor

A
  1. Assess if labor should be stopped (rx, how far along, etc)
  2. Assess + monitor VS, contractions, fetus
  3. Avoid stimulation
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13
Q

What stimulation should be avoided in management of PTL?

A
  1. vaginal exams
  2. sexual intercourse
  3. nipple stimulation
  4. full bladder
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14
Q

What interventions are no longer recommended in the management of PTL?

A
  1. bedrest
  2. IV hydration
  3. Magnesium Sulfate
  4. Sedation
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15
Q

3 Drugs for medical management of PTL

A
  1. indomethacin
  2. nifedipine/CCB
  3. vaginal progesterone
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16
Q

MOA Indomethacin

A

Tocolytic: anti-prostaglandin inhibits uterine activity

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17
Q

What in indomethacin effective for and how long

A

tocolytic - effective in delaying delivery x 48 hours

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18
Q

Why is indomethacin not recommended for and why?

A

not recommended for long term - premature closure fetal ductus arteriosus

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19
Q

What is vaginal progesterone ONLY effective for?

A

May prevent and reduce incidence of PTB ONLY if prev. hx of PTB or short cervical length

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20
Q

Define cervical insufficiency

A

Premature painless dilatation of cervix without contractions

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21
Q

When is cervical insufficiency seen and why?

A

20-28 weeks because weight of fetus/placenta is such that cervix can’t stay close

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22
Q

What is the main cause of 2nd trimester abortion?

A

Cervical Insufficiency

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23
Q

3 Things that Increase Risk for Cervical Insufficiency

A
  1. anomalies of cervix
  2. infections
  3. multiple gestation, polyhydraminos (increased pressure
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24
Q

What cervical anomalies increase risk for cervical insufficiency?

A
  1. DES
  2. Previous 2nd trimester abortions
  3. Invasive cervical biopsy
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25
Q

Diagnosis of cervical insufficiency

A
  1. heaviness in pelvic area
  2. PPROM
  3. US for confirmation
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26
Q

Treatment of cervical insufficiency

A
  1. bedrest, pelvic rest, avoid heavy liftin
  2. cervical cerclage
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27
Q

Define cervical cerclage

A

treatment of cervical insufficiency

suturing the cervix shut

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28
Q

Risks of cervical cerclage

A
  1. infection blood loss
  2. PPROM
  3. Preterm labour
  4. damage to the cervix
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29
Q

When is cervical cerclage not appropriate?

A

if vaginal bleeding, infection, uterine contractions, membranes have ruptured

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30
Q

Who receives corticosteroids in pregnancy and when?

A

All pregnant clients between 24 and 34 weeks’ gestation, who are at risk of preterm delivery within 7 days should be considered candidates for antenatal treatment with a single course of corticosteroids.

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31
Q

A single course of corticosteroids antenatally reduces risk for what 3 things/what is overall effect?

A
  • perinatal mortality
  • respiratory distress syndrome,
  • and intraventricular hemorrhage
  • Matures fetus quicker
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32
Q

Corticosteroid Dosage Antenatally

A

Betamethasone 12 mg IM q 24 hr x 2 doses or Dexamethasone 6 mg IM q 12 hr x 4 doses

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33
Q

What drug is used for fetal neuroprotection antenatally?

A

MgSO4

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34
Q

How far along would a client be for MgSO4 be prescribed antenatally?

A

Imminent preterm birth at < 31 w 6

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35
Q

Along with imminent preterm birth, what 2 other factors could lead to a client to receive MgSO4 antenatally?

A
  • Active labor with ≥ 4cm dilation with or without PROM
  • Planned preterm birth for fetal or pregnant client indications
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36
Q

Dosage/administration of MgSO4 for fetal neuroprotection

A

4g IV loading dose over 30 mins then 1g/hour maintenance until delivery

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37
Q

Why is MgSO4 only given to infant up to 31 w 6

A

Effect is negligible about 32 weeks

38
Q

Magnesium Sulfate is used for ________ birth

A

imminent

39
Q

Bleeding in pregnancy is divided into

A
  1. First/second trimester (before 20-24 weeks)
  2. Antepartum (after 20-24 weeks)
40
Q

3 Causes of bleeding in first and second trimester

A
  1. spontaneous abortion
  2. ectopic/tubal pregnancy
  3. gestational trophoblastic disease
41
Q

Abortion is defined as

A
  • Expulsion of fetus before 20 wks gestation
  • OR
  • Expulsion of fetus less than 500g
42
Q

Treatment of spontaneous abortion with minimal bleeding

A

Bed rest and abstinence from sex

43
Q

Treatment of spontaneous abortion with persistent/heavy bleeding, pain and fever

A
  1. misoprostol/cervidil to evacuate uterus
  2. winrho to prevent sensitization for future pregnancies
  3. IV therapy/blood transfusion
  4. Surgical dilation and curettage/suction evacuation
44
Q

What is an ectopic/tubal pregnancy?

A

Implantation of fertilized ovum outside uterus

45
Q

Initial symptoms of ectopic/tubal pregnancy

A

Similar to symptoms of pregnancy - positive hCG

46
Q

Where is an ectopic/tubal pregnancy most common?

A

Can be anywhere; commonly in fallopian tube.

47
Q

Symptoms/problem arises from ectopic/tubal pregnancy arise when

A

Tube/structure pregnancy was in ruptures

48
Q

Result of rupture tubal/ectopic pregnancy

A
  1. sharp unilateral pain
  2. decreased BP
  3. syncope
49
Q

Presentation of ruptured ectopic pregnancy

A
  1. referred shoulder pain/low abd pain r/t shifting of organs
  2. vaginal bleeding
  3. hypovolemic shock
50
Q

What is gestational trophoblastic disease?

A

RARE (< 1/1000) pathologic tumor of childbearing age client, abnormal overdevelopment of the placenta overtaking pregnancy

51
Q

In GTD, ________ cells that __________ the pregnancy

A

trophoblastic

obliterate

52
Q

GTD can also be called __________ and develop into _________

A

hydatidiform mole (benign)
choriocarcinoma (rare)

53
Q

What are the classic signs/classic presentation of GTD?

A

Pregnancy on steroids/exacerbated

  • uterine enlargements greater than gestational age
  • vaginal bleeding with clots
  • hyperemesis gravidarum
  • pre-eclampsia development prior to 24 weeks
54
Q

What is antepartum hemorrhage?

A

Vaginal bleeding from 20 weeks to delivery

55
Q

Antepartum hemorrhage is by and large caused by

A

Placental alterations

56
Q

2 main causes of antepartum hemorrhage

A
  1. placenta previa
  2. abruptio placentae
57
Q

Uteroplacental blood flow is __________ ; if issues with _________ that blood can drain into __________

A

700-1000ml/min

placenta

uterus and be lost

58
Q

_______________ may be the first indication of compensation by pregnant client secondary to hemorrhage.. ______ issue before ________

A

A change in fetal status

fetal, maternal

59
Q

Define placenta previa

A

Absolutely normal placenta implanting in the wrong place

60
Q

4 Categories of Placenta Previa

A

o Total/Complete: completely (highest risk)
o Partial: partial coverage
o Marginal: touching opening
o Low-lying placenta: not covering (lowest risk)

61
Q

Result of placenta previa

A

All will result in c-section except low lying

62
Q

Detection of placenta previa

A

Can be detected at routine ultrasound

or at Ultrasound at time of presentation with bleeding to r/o previa as cause

63
Q

What percent of placentas migrate during pregnancy

A

80%

64
Q

Goal of gestation for placenta previa and why

A

Goal is to get to 36-37 weeks gestation

Not 40 to avoid contractions, labor, dilation because separation could occur and risk of bleeding increases

65
Q

5 Risk Factors of Placenta Previa

A
  1. previous placenta previa (why did it go to that location in first place)
  2. uterine abnormalites/endometrial scarring
  3. impeded endometrial vascularization
  4. large placental mass
  5. unknown
66
Q

Define abruptio placentae

A

Premature separation of normally implanted placenta from uterine wall

67
Q

What cause of antepartum hemorrhage is more common

A

abruptio placentae

68
Q

What occurs regarding blood flow in abruptio placentae?

A

Blood flow that should be going into placenta/fetus goes into uterus

69
Q

Total/Complete Abruptio Placentae Result

A
  • Hemorrhage (1000mls/min) in pregnant client
  • fetal death
70
Q

In partial abruptio placenta, fetus can tolerate:

A

up to 30 - 50% abruption

71
Q

True or false: patient will always present with vaginal bleeding in abruptio placenta

A

False; will not always be present in partial

72
Q

Risk factors for Abruptio Placentae

A
  • Previous abruption
  • Hypertension in pregnancy
  • Blunt abdominal trauma – MVA, IPV, falls
  • Overdistended uterus (multiples, polyhydramnios)
  • PPROM < 34 wks gestation
  • Previous C/section - scarring
  • Cocaine or crack use, alcohol use
  • Smoking, especially > 1 pack / day
  • Extremely short umbilical cord: As fetus grows, can pull placenta off wall
  • Uterine abnormalities – fibroids at implantation site
  • Advanced age in pregnancy (>35) or high parity
73
Q

Implications of abruptio placenta for pregnant client

A

§ Antepartum/intrapartum hemorrhage
§ Postpartum hemorrhage
§ DIC – imbalance in clotting factors
§ Hemorrhagic shock

74
Q

Implications of abruptio placenta for fetal/neonatal client

A

§ Sequelae of prematurity
§ Hypoxia
§ Anemia
§ Brain damage
§ Fetal demise

75
Q

Onset of placenta previa vs abruptio placentae

A

P: insidious

A: sudden

76
Q

Type of bleeding of placenta previa vs abruptio placentae

A

P: always visible, slight, then more profuse

A: can be concealed or visible

77
Q

Blood description of placenta previa vs abruptio placentae

A

P: bright red

A: dark

78
Q

Discomfort pain of placenta previa vs abruptio placentae

A

P: none

A: constant; uterine tenderness on palpation

79
Q

Uterine Tone of placenta previa vs abruptio placentae

A

P: soft and relaxed

A: firm to rigid

80
Q

Fetal heart of of placenta previa vs abruptio placentae

A

P: usually normal

A: fetal distress/absent

81
Q

Fetal presentation of placenta previa vs abruptio placentae

A

P: may be breech/transverse/engagement is absent

A: no relationship

82
Q

3 Issues of Abnormal Placentation/Overimplantation

A
  1. Placenta Accreta
  2. Placenta Increta
  3. Placenta Percreta
83
Q

Placenta Accreta

A

placenta attaches itself too deeply into the surface of the myometrium

84
Q

Placenta Increta

A

penetrates into the myometrium

85
Q

Placenta Percreta

A

WORST form- placenta through myometrium and into tissue or organs and onto outside of uterus

86
Q

Immediate Care for AP Bleeding

A

§ As able, a complete history and physical
§ Assess pregnant client cardiovascular status frequently. Include O2 saturation, output, LOC – similar to hemorrhaging patient of any kind
§ Fluid resuscitation if active bleeding or unstable
§ Monitor fetus and uterine activity electronically

87
Q

Nursing care for AP bleeding

A

§ Prepare equipment for examination
* Vaginal exams not done on anyone with bleeding – do not want to stimulate, rupture previa, etx
§ Oxygen per mask/prongs
§ Assess coping mechanisms of woman and family, support
§ Review and evaluate diagnostic tests
* Hgb, PT/PTT, Type and Cross match, Watch for DIC
§ Prepare for cesarean, as needed
§ Neonatal resuscitation team, as needed
§ Pain relief, as needed
§ Similar care for both placenta previa and abruptio
* Bed rest, may need hospitalization
* Avoid sexual activity
§ No vaginal exams!
* Why?
§ Objectively and subjectively assess ongoing
* blood loss, pain, uterine contractility, coping

88
Q

Velamentous Insertion of Cord

A

an abnormal cord insertion (CI) in which the umbilical vessels diverge as they traverse between the amnion and chorion before reaching the placenta. It is characterized by membranous umbilical vessels at the placental insertion site; the remainder of the cord is usually normal. Because of the lack of protection from Wharton’s jelly, these vessels are prone to compression and rupture

89
Q

Risk in Velamentous Insertion of Cord

A
  • Risk of torn vessel leads to fetal hemorrhage
  • leads to non-reassuring fetal status and high mortality
90
Q

What is vasa previa

A

cord and membranes over opening/os

Obstetrics (12 decks)

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