theresa maurer Flashcards
habitual abortion
spontaneous abortion that has terminated the course of 3 or more consecutive pregnancies
first trimester bleeding and pain
ectopic pregnancy should always be suspected
Threatened abortion
s/s
Rx
diagnosis
bleeding in first half pregnancy
fresh or old brown blood
may or may not having cramping and low backache
Rx: pelvic rest, bed rest, no sex, notify midwife if there is fever, a gush, increased bleed or increase low back pain.
Rx: heavy bleeding/febrile, no bleeding but ctx and abnormal ultrasound-immediate physician eval
slight bleeding and no other abnormal findings, reiterate Rx regular RTC
gentle spec exam, screen vaginitis cervicitis
gentle bimanual exam, uterine size, effacement, dilation, membrane status
febrile
signs of fever
inevitable abortion
s/s
eval
treatment
follow up
combo of bleeding ctx, ROM, dilation
assess gestational age, amount bleeding, ab pain, emotional status, previous or stat hematocrit, dilation, vital signs
choices: if bleeding is not excessive, pain not excessive and emotional status good, hematocrit 30%
1. go to physician for induced abortion D&C
2. go home await spontaneous abortion
take temp every 4 hours
call midwife if a pad is soaked in less than 1 hr
clots larger than 2.5 cm
fever of 100 +
when aborted call midwife
followup: counsel, support, sex 2-4weeks, genetic counseling.
incomplete abortion
placenta is not expelled with fetus
can cause bleeding or infection
D&C
missed abortion s/s diagnosis plan follow up
vag spotting bleeding, low ab back pain
fundal height ceases to increase, uterus decreases
regressed mammary changes
loses weight
persistent amenorrhea
no fetal heart tones
diagnosis: ultrasound
severe coagulation problems may occur from carrying non viable fetus
order coagulation serums, prothrombin,fibronogen, platelets, partial prothrombin, endocrinologic workup, uterine abnormalities screen
followup: counsel, support, sex 2-4weeks, genetic counseling.
incompetent cervix
s/s
predisposed
rare in primigravidas
evidence in 2nd trimester
painless dilation, ROM, expulsion of fetus, vag discharge free from infection s/s (itching, odor etc)
previous fetal loss, cervical surgery
cerclage
reason for
follow up
Classic shirodkar-permanent suture stays until birth, csection delivery
Modified Shirodkar- purse string suture each pregnancy removed at delivery
Mcdonalds- purse string suture each pregnancy removed at delivery
can be done if cervix is 4 cm
vaginal exam every 2 weeks
counseling
client to report any s/s of bleeding, ROM, foul odor, fever.
suspicious history of incompetent cervix- assesment
History- s/s previous loss, infections in relation, discharge etc.
gestational age, genetic abnormalities, previous suction abortios, cervical traumas
Pelvic ex- consis, length, dilation (internal, ext) membranes, position station present part
history of cervical trauma without fetal loss
plan
vaginal exam every two weeks starting at 2nd trimester until fetal viability or
history of fetal loss but no current signs of cervical incompetence
vaginal exams every 1-2 weeks starting in 2nd trimester until viability or dilation
cerclage is removed in these cases
infection, suture not intact, or laceration cervix
after ROM, impending labor or 38 weeks, labor start
all unless it is a Classic Shirodkar suture
hydadtiform mole
complete/partial
chorionic villi are clear vessels with pedicles hanging like grapes, mass of cyst clear vesicles
complete- all vesicles
partial- vesicles with non viable fetus and sac
some are benign with potential to be malignant & proceed choriocarcinoma
benign
not harmful
malignant
infectious volatile
hydadtiform mole
likelyhood
s/s
10 times higher in women over 45 years
persistent nausea and vomiting, uterine bleeding evident at 12 weeks, brown blood, intermittent, anemia, large for dates baby, shortness of breath, tender ovaries, not fht, parts or palpation.
PIH, preeclampsia, eclampsia, before 24 weeks!
very high Hcg levels
ectopic pregnancy
predisposed
types
diagnosis
pelvic infections, IUD, precious ectopic & tubal preg
types: cervical, tubal, ovarian, abdominal
order quantitative Hcg & ultrasound
cervical ectopic pregnancy
s/s
rare,not lasting after 20 wks
painless bleeding at implantation
cervical mass, distention, thinning of cervical wal, dilation of ex os, enlarged fundus
tubal ectopic pregnancy
s/s
differential diagnosis
labs
most common 95% or more cases
classic case of tubal cases knowing or unknowing suspected pregnancy but spotting has substituted menses.
s/s sharp stabbing pain, tearing, low ab pain
hypotension, shock, tenderness, painful exam, tender boggy mass to one side of uterus
pain in the neck or shoulder* especially inhaling
displaced uterus
low Hcg or neg pregnancy tests
differential: salpingitis, threatened/inc abortion, twisted ovarian cyst, ruptured corpus luteum follicular cyst
CBC with differential and quantitative beta Hcg
ultrasound
abdominal ectopic pregnancy
s/s
s/s sharp stabbing pain, tearing, low ab pain
hypotension, shock, tenderness, painful exam, tender boggy mass to one side of uterus, displaced uterus
pain in the neck or shoulder* especially inhaling
gastrointestinal upset, transverse lie, painful fetal movement, very audible heart tones, small parts outside of uterus, cervical displace, dilation no effacement.
hyperemesis gravidarum
s/s
plan
s/s: excessive nausea and vomiting, extends past 1st trimester, poor appetite and intake, weight loss, dehydration,electrolyte imbalance, extreme response to psycho social events, acidosis (starvation), alkalosis (no hydrochloric acid), hypokolemia(low potassium)
labs: BUN and electrolytes
urine dipstick for acetone and glucose
blood gases, serum pH,
spilling glucose and acetone- immediate eval, glucose to assess for diabetes
dehydration IV fluids
continues after IV fluids admit to hospital
Tuberculosis mycobacterium s/s history labs treatment
initial lesion develops on lung, exudate inflammed, necrosis of lung tissue-airborne droplets
s/s- fever, night sweats, weight loss, persistent colds and cough, chronic cough with yellow green mucous
pleurisy(chest pain, inflammation) rales
previously infected, exposure to, history, environmental, poverty, drug use, socioeconomic
Mantoux test, PPD test, not if active infection!
chest xray and sputum test
BCG vaccine can cause positive test- xrays everty 2 years. scar on arm from vaxx
treatment: INH (isoniazid chemotherapy) for women under age 35 during pregnancy with positive PPD neg xray and post PPD and post xray. If not in pregnancy then after pregnancy, treatment continued if pregnancy occurs mid treatment.
reportable disease.
A Sickle Cell screen should be offered to which group of clients?
african descent
cultures prone to certain disease african mediterranean french canadian jewish
Sickle cell anemia is found primarily in 1/375 birth of African-Americans.
Thalasemia is predominantly found in those of Mediterranean descent;
TaySachs disease is found in those of French Canadian descent
Ashkenazi Jewish descent.
hepatitis
most common in US
rare forms
inflammation of the liver via an infection hep A and hep B hep D is secondary to B -mediterranean D & E rare- Asia, south america reportable diseases
Hep A (infectious hepatitis) route of transmission
s/s
most common worldwide- impoverished pop, poor hygienic
fecal oral route is transmission - contaminated food and water
s/s- flu, fatigue, malaise, weak, nausea, low fever, upper right pain, rapid onset, 10-15 days acute to resolve 2 months
no risks to newborn,no transmission
vaccine for at risk or close contact ISG (immune serum globin)
routine screen
Hep B (serum hepatitis) route of transmission s/s transmission treatment labs
transmission through blood, blood products, needles , saliva, vag secretions, semen.
1-6 months incubation
may lead to chronic carrier, active hep, liver disease, cirrhosis.
s/s rash fever, fatigue, weak, nausea, vomit, low fever, upper right pain, tender enlarged liver, headache
vertical transmission to the baby is common, any route of delivery, postnatal close contact
infects all body fluids but breast milk!!!
breastfeeding contraindicated if cracked sore nipples
90% change of transmission, 90% become carriers, transmitted to offspring, 25% die of cirrhosis, liver carcinoma
babies receive hep b vax at birth within 1 hour 90-95% protection, hep b vax is given to mothers who havent been vaxxed prior
IgM- active antibody IgG- antigen
routine screen
Hepatitis C
40-50% of hep cases in US
low incidence of vertical
transmission to baby
blood test positive for hepc antibody
rubella (German measles)
risks to newborn
s/s
labs
treatment
1st trimester infection- 20% chance of congenital malformations
1st month- 50% malformations
glaucoma, cardiac defects, deafness, brain and deafness, SA, eyes, heart, brain CNS
s/s low fever, drowsy, sore throat, rash, spreads rapid, swollen glands, lasts 3-5 days
routine screen- rubella titres
1:10 or above immunity
below 1:10- lack of immunity offer vaxx POSTPARTUM
1:64 or higher ACTIVE infection- consult -series of titers consult
live vaxx not in pregnancy!
1st trimester- option to abort
avoid pregnancy 3 months after vax
cytomegalovirus
s/s
transmission
common viral infection-various strains
most asymptomatic:
fever sore throat, swollen glands, fatigue
transmission is effective in fetal period (10-40 weeks)
not seen until birth
risks: microcephaly, hydrocephaly, small eyes, seizures, blindness, encephalitis. IUGR, oligiohydraminos
no vaxx and no treatment
test babies saliva, urine, blood high concentrations
toxoplasmosis
s/s
transmission
testing
parasitic protozoa, infected meats, raw or undercooked, cat feces, soil. raw milk
s/s fatigue, malaise, muscle pain, swollen lymph
death, preterm, CNS, anecephalus, hyrdocephalus, eye and brain defects. hydrops
the earlier the infection the more severe disease. 1st and 2nd trimester most transmission.
3rd transmission always congenital anomalies
preconception, skin test 48-72 hrs
ELISA lab, high titers recent infection, rising titers current infection, low titers immunity
IgG antibodies from previous infection protects baby
consult with virologist, routine screen
Spiraymicin
cordocentesis can check baby for infection
varicella (herpes zoster=shingles)
s/s
risks
treatment
highly contagious viral infection form of HSV
25-40% of babies have congenital varicella syndrome
infection in 1st 20 weeks of pregnancy greatest risk
incubation 10-21 days
contagious 2 days before lesions and 7-10 days after lesions are crusted
fever chills, malaise, lesions head neck to trunk, pneumonia, chest pain, cough, fever
risks: cataracts, chorioretinitis, limb hypoplasia, dydronepherosis, micorcephaly,
maternal pneumonia 40% maternal death
varicella contracted at the very end of pregnancy , no antibodies, 5% babies die
treatment VZIG- exposed first 20 weeks and 6 days before delivery 2 days after delivery
routine testing serological for antibodies, vax prior to pregnancy no conception atleast 3 months!
why are pregnant women more susceptible to UTI
normal hydronephrosis may cause urine stasis
preventing UTI
drink 8 glasses of water, empty bladder, cranberry, good hygeine
presence of bacteria significant in clean catch
50,000 bacteria of same species per mililitre
100,000 of nonpatho, or 100,000 mixed
contaminated specimen
bacteria reported in urinalysis
coliforms, e coli, enterococci, klebsiella.
s/s of UTI
risks
treatment
urinary frequency, dysuria, pain, suprapubic pain
preterm labor and birth, low birth weight, pyelonephritis, inflamed kidneys
amoxicillin, ampicillin repeat culture 2 weeks, if doesn’t work 2nd round of diff antibiotics, suppressive therapy if doesn’t work
recurring UTI factors
diabetes, sickle cell trait, history of UTI
cystitis
s/s
labs
inflammation of the bladder, bacterial infection
s/s urgency, frequency, dysuria, low ab pain, hematuria
culture- nitrates, high WBC, high bact, rbc in urine, blood in urine
treatment same
acute pyelonephritis cause s/s risks treatment
inflammation of both kidneys, bacterial
2% freq in pregnant women
compression of ureters by uterus
dilation and decreased tone of ureters from progesterone
urine stasis- decreased bladder tone, urine stasis
s/s fever, chills, hematuria,nause vomit, hx of UTI, frequency CVA tenderness (right side kidney), low abpain
risks- septic shock, respiratory distress, anemai, pretern labor/delivery
treatment: refer to physician IV therapy, electrolytes, IV antibiotics.suppression therapy
why is hemoglobin lowered in pregnancy
hemodilution results in blood expansion and increase in plasma but not rbc’s, ration of rbc’s to plasma is disproportionate.
why does a women need increased iron in pregnancy
because of the increase in rbc’s
factors that effect hemoglobin
race, sex, elevation, smoking meds,
Africans have a hemoglobin 1 gdl higher
women who smoke or live higher altitudes have a higher low
anemia levels and definition
decrease in # of rbc or decrease in the concentration
less than 12 in nonpregnant
less than 10 in pregnant
s/s of anemia
fatigue, dizzy, malaise, headache, sore tongue, skin pallor, hx of heavy menses, close pregnancies, pale nails, hx anemia, nause vomit no appetite, PICA
initial lab test of rbc size
microcytic-decreased rbc size, iron deficient, thallasemia, lead disease
normocytic- blood loss, sicke cell, G6PD, med side effects
macrocytic-vitamin B 12 deficient, folic acid deficient
high iron foods
green leafy veggies, liver, egg yolk, raisins, fortified
treatment anemia
true anemia= hypochromic*
start on iron, folic acid and vita C supplements
hemoglobin below 9 after supplementing
hx, reeval, do labs, consult
CBC, reticulocyte count, serum iron, serum ferritin, TIBS (binding), platelet count, hemog electrophoresis
MCV levels
high Mean Corpuscular Value = folate, b12 deficient
low MCV= iron deficiency
hemoglobin electrophoresis
AA = normal AS= sickle cell trait carrier SS= sickle cell disease (genetic disorder) africans
women with sickle cell trait have higher incidence of these conditions
asymptomatic bacteriuria, pyelonephritis close monitoring is needed
G6PD
x linked genetic disease affects enzyme G6PD, associated with rbc’s
prevalent in Mediterranean, African americans
hemolysis
destruction of rbc
treatment of G6PD clients
obtain status if not sure
avoid fava beans, sulfa drugs, oxidant drugs, surgeries, diagnose any and treat infections prompt such as UTI to reduce hemolysis risk
notify physician immediately in case of csection
normal pregnancy increase cardiac output by %?
when does increase occur?
40%
occurs early pregancy peaks at 20 weeks to 24 weeks
cardiac output increases, when, %?
during pregnancy and during birth
50% during contractions, highest immediate postpartum
heart disease/congestive failure
s/s
persistent rales in lungs, decreased physical activity, dysnpea, cyanosis, edema lower extremities
pregnancy can progress disease
rheumatic fever, heart failure, heart murmurs, dysrythmia, cardia enlargement, clubbed hands
treatment and s/s of heart disease
collaborative care, iron folic acid, close monitor 20-24 weeks, counseling
normal blood pressure in pregnancy rise and falls
how to take
drop in second trimester, rise in third trimester
sitting up with arm at heart level at rest, no crossed legs
left side supine,
hypotension pressure
90/60 mm Hg indicate low blood pressure, or hypotension
hypertension
140/90 mm Hg in pregnancy indicate high blood pressure, or hypertension
asthma
1 in 4 pregnant women
risks: perinatal mortality, hyperemisis gravidarum, preterm, chronic hypertension, preeclampsia, hemorrhage, low birth weight
OTC drugs that induce asthma attacks
aspirin and ibuprofen aleve,
medications contraindicated in pregnant women with asthma
demoral, morphine and hembate
type 1 diabetes
true insulin dependent
occurs before age 40
type 2
occurs after age 40
obesity can be controlled with diet, exercise, oral hypoglycemic agents
gestational diabetes
s/s
risks
abnormal carbohydrate metabolism
glucose monitor, diet exercise
diabetes mellitus cannot be diagnosed until postpartum
routine screen all women at 28 weeks
s/s polyuria, polydipsia (excessive thirst), weight loss, poor healing, polyhydraminos
shoulder dystocia, macrosomia, hypoglycemia, respiratory distress
screen for women with history of diabetes, previous large baby, recurring candida, glycosuria
initial screen, 28 weeks, 34-36 weeks
secondary risk factors to diabetes
preeclampsia, polyhydraminos, large for dates babies
screen at first signs and again at 34-36 weeks
most efficacious diabetic screening
fasting blood sugar, 1 - 2hr postglucose challenge
glucose challenge test
dont eat since midnight before test. drink entire glucose(100 g glucose)
mixture and draw blood at 1 or 2 hr mark
abnormal testing values for glucose challenge and fasting plasma, GTT
fasting plasma of > 105mg per 100 ml
1 -hr 50g glucose challenge of >135 mg
2-hr 75g glucose challenge of > 120 mg
does a woman with known or obivous diabetic get a GTT
no
3-hr 100g GTT diagnostic for diabetes if
fasting 90mg
1 hr 165mg
2 hr 145 mg
3 hr 125 mg
normal fast blood sugar, abnormal 1-2 hr, and abnormal GTT is gestational diabetic T or F
true
values for plasma are 15% higher then whole blood values in glucose testing T or F
true
any post and neg combo of fasting and 1 /2hr do GTT
T or F?
tue
dietary guidelines for diabetes
30 calories per kg, 50% carb, 20 protein, 30 fat
mulitple gestation
s/s
large for dates, rapid growth in 2nd trimester, palpation of multiple small parts, more then one fetal heart tone
antepartum management of multips
early signs of preterm labor, s/s preeclampsia
monitor fetal growth, nutrition calories and protein added for each baby, weekly appointments for weight gain, fetal growth and preeclampsia, weekly from 34 weeks for cervical changes
rh - mom and rh- dad =
negative baby no worries
rh - mom
labs
screened initial ABO blood type if Rh- then:
28 weeks & 36 weeks for titers below 1:16
rhogam is offered prophylactic at 28 weeks is last about 12 weeks.
a positive titer from rhogam should be no higher then 1:4
If mom is sensitized with postive Coombs check titers at 26 to 28 weeks, 32-36 weeks, and 38 weeks
indirect Coombs test if antibodies are present a titer is obtained and a
reasons for giving Rhogam to Rh- neg mother
uterine bleeding, trauma, hemorrhage, invasive procedures, SA, miscarriage, ectopic pregnancy, transfusion, postpartum in 72 hrs, prophylactic at 28 weeks
Rh- is the most sensitizing antibody!
NO rhogam if antibodies present and mother sensitized
HDFN
hemolytic disease of the fetus newborn
% of mothers sensitized in first pregnancy
13% of rh- mothers will be sensitized in first pregnancy
risk of having a subsequently affected baby if not receiving Rhogam in previous postpartum?
90-100% risk of affecting next baby
kernicterus
brain damage from extreme jaundice, sensitization, bilirubin fills the brain
hydrops fetalis
extreme hemolysis form of Rh incompatibility, shifted edema
how do antibodies attack baby in Rh- incompatibility
IgG antibodies cross the placenta and attack the baby
Rhogam class C category
thimerosal= toxic mercury based
50-300ug
given deep Im- side of muscle
atlease 72 hours before antibodies can be produced
labs for baby of rh- mother
blood typing from cord
bilirubin test
hemoglobin and cbc
hydraminos
predisposed factors
risks
plan/labs
factors : multip, diabetes, erythroblastosis, fetal malform
risks:
cord prolapse, hemorrhage!
fetal malpresentation
abruptio placenta
uterine dysfunction
s/s: uterine enlarged, tense uterine wall, hard to get fht, uterine fluid thrill, dyspnea, vulvar edema, pressur pains, nausea vomit, frequent change in baby lie
plan: screen diabetes, screen ABO/Rh disease
ultrasound
consult physician
oligohydraminos predisposed s/s risks plan
congenital anomalies, IUGR, PROM, postmature syndrome
s/s- molding contour of fetus, not ballotable, lagging fundal height.
risks: variable decels, less fluid for cord cushion, poor tolerance for labor, cord compression,
plan: hydration, bed rest, nutrition, ultrasound, AFI check, NST’s, kick counts, fetal monitor
Amniotic fluid production in pregnancy
increases in preg until it reaches about 1000 ml by third trimester, gradually decreases around 34 weeks to about 800 ml
signs of fetal demise
risks
ceased: fht, uterine growth, movement, retrogressed breast changes, fetal skull collapse with exam,
Spaldings sign- excessive overlap of bones
exaggerated curvature of spine
Birth 2/3 weeks of demise
risks: deseminated intravascular coagulation DIC, test prothrombin, platelet and fibrogen. drop in platelets fibro consult, incrase in prothrombin consult induce labor.
encouraged to view, touch and hold infant
dont try to diagnose death, most have no cause even after autopsy
hypertensive disorders of pregnancy
preeclampsia eclampsia chronic hypertensive PIH proteinuria, edema
hypertension
140/90 or higher! or 30 rise in top, 15 rise on bottom from base
MAP
= D x 2 + S
_________
3
2 readings 6 hours apart
proteinuria
more than .3 g in 24 hr spec/ 1-2+ on stick
2 or more occasions when 6 hours apart
edema
sudden weight gain, unquestionable in hands and feet
hypotension
predisposed factors
hydadtiform mole trophoblastic disease, multips, chronic hypertensive vascular disease (20%), chronic renal disease, diabetes, fetal hydrops, age 35+, previous hx of preeclampsia
preeclampsia
s/s
labs
Rx
headaches, blurred vision, upper edema, proteinuria increased weight and BP
labs: hemoglobin & hematocrit, platelet, liver function, kidney profile(BUN), urine protein, coagulation profile
leaning towards: bed rest, 2 hr in am and pm on left sideprotein, high protein high calorie
before 36 weeks ultrasound for IUGR, introuterineplacental insufficiency
NST, fetal kick count, liver & kidney function tests
progressive severe eclampsia
hyperflexia, headaches, visual disturbances, epigastric pain, oliguria, elevating BP, 160/100 severe, increasing proteinuria 3+ 4+
HELLP
may develop from preeclampsia,
hemolysis, elevated liver enzymes, low platelets,
eclampsia
when preeclampsia progresses to convulsions
most common prior to delivery can happy 10 days postpartum
magnesium sulfate to prevent future seizure
placenta previa
predisposed
more common in women: multiparity, 35+, multip, large placenta ( erythroblastosis), previous c section, smoking hx of IUD
signs of placenta previa
PAINLESS bleeding sudden onset
ultrasound repeat for vag bleeding
5-10% also have placenta accreta
complete placenta previa
hospitalization with labs:
Rh, indirect Coombs, platelets, DIC. NST, fetal kick
risk of hemorrhage, fetal distress, maternal distress
marginal and partial previa delivery
can be vaginally , presenting part is like tampon
placenta accreta
2 or more cesections
abruptio placenta
predisposing factors
hypertension, preeclampsia, folic acid deficient, ab trauma, short cord, malnutrition, sudden uterine decrease, ROM in polyhydraminos, difficult external version, cocaine usage
abruptio placenta
s/s
painful LOCALIZED tenderness, hypertonic boardlike uterus, decreased fetal movements, fetal distress, uterine enlargement, maternal shock. back pain, colicky uterus,
abruption placenta management
period of observation and obtain findings
management is delivery, vaginal if no distress.
emergent csection and immediate transfer
start IV, trendelburg position, vital signs, heart tones, oxygen, warm blankets
trendelburg postion
supine with feet at 15-30 degree elevation
size dates discrepancy definition
woman is sure of her dates and LMP, EDD is determined an uterus is smaller or larger for dates
ultrasound and complete intake
common reasons for size date descrp
3rd trimester- large baby
inaccurate dates
1st 2nd trimester- anomalies, disease, infection. small
differential diagnosis of size dates discrepancy
multip, IUGR, diabetes, thyroid (smaller), malnutrition, polyhydraminos, oligohydraminos, fetal lie, anomalies, station, hypertension preeclampsia, psychosocial, infections, drugs. placenta previa( larger longitudinal, smaller for tranverse, myomata (larger)
myomata
fibroids
IUG, SGA
intrauterine growth restriction
small for gestational age
most SGA is because of IUGR
SGA can also be malnutrion, or genetically predisposed smaller babies
symetrical
compromised growth of body length head and weight
assymetrical
compromised growth of body length and weight but head is normal
IUGR risk factors
preeclampsia
renal disease, poor nutrition, poor weight gain,infection,amomalies, multip, previous IUGR, drug use, pre-pregancy less then 90 lbs, anemia, diabetes, alcohol, hypoglycemia,
postmaturity syndrome
post dates plus oligiohydraminos, mec stained fluid, Newborn with:
lost of subcutaneous fat, long fingernails, peeling wrinkled skin, alert facies, no lanugo, no vernix
