UNIT 2 HIGH RISK PRENATAL CHAPTER 12 Flashcards
What is the definition of Gestational conditions?
Disorders that did not exist before
pregnancy
Does Gestational conditions only put the fetus at risk?
A. True
B. False
B. False
Occurrence puts woman & fetus at
risk
Name 3 Gestational Conditions
- Gestational Hypertension
- Preeclampsia/eclampsia
- Hyperemesis gravidarum
- Hemorrhagic complications
- Surgery during pregnancy
- Trauma
- Urinary tract infections
Hypertension in Pregnancy
Chronic vs Gestational. What is the difference between them?
- Chronic hypertension: diagnosed
< 20 weeks gestation (UNDER 20 WEEKS GESTATION) - Gestational hypertension: onset
w/o proteinuria after 20 weeks
gestation
(OVER 20 WEEKS GESTATION)
Does hypertension increased risk for Preeclampsia?
Increased risk of preeclampsia
* Chronic hypertension
w/preeclampsia
Risk factors for Preeclampsia
Pregnancy specific syndrome
* > 20 weeks previously normotensive
* Decreased placental perfusion
causing systemic disorder
- Associated high risk factors
- Family history
- Multiple fetal pregnancy
- African-American race
- Obesity
- Before 19 & after 40 years old
- Pre-existing medical or genetic
conditions - Nulliparity
- Multifetalgestations
- Preeclampsiainpreviouspregnancy * Chronichypertension
- Pregestationaldiabetes
- Gestationaldiabetes
- Thrombophilia
- Systemiclupuserythematosus
- PrepregnancyBMI.30
- Antiphospholipidantibodysyndrome * Maternalage35years
- Kidneydisease
- Assistedreproductivetechnology
- Obstructivesleepapnea
Signs and symptoms of Mild Preeclampsia
BP 140/90 or greater
* Urine dipstick protein ≥ 1+
* Decreased placental perfusion
Signs and symptoms of Severe Preeclampsia
- BP 160/110 or greater
- Urine dipstick protein ≥ 3+
- Persistent or severe headache
- Blurred vision; photophobia
- Epigastric pain
- Intrauterine growth restriction of fetus
Signs and symptoms of Severe Preeclampsia
- BP 160/110 or greater
- Urine dipstick protein ≥ 3+
- Persistent or severe headache
- Blurred vision; photophobia
- Epigastric pain
- Intrauterine growth restriction of fetus
Pathphysiology of Preeclampsia
- Cause: cellular dysmorphic
development affects placental
perfusion & endothelial cell
function - Decreased placental perfusion
- Generalized vasospasm,
vasoconstriction, capillary
leaking - Reduced organ perfusion
- Can affect liver (HELLP) & brain
function (eclampsia-seizures)
Does the HELLP syndrome occur during mild or severe Preeclampsia?
A. Mild
B. Severe
B. Severe
variant severe
preeclampsia
lab diagnostic hepatic
dysfunction
What does HELLP stands for?
H - Hemolytic(destruction of red blood cells)
EL- Elevated Liver Enzymes
LP- Low platelets under 150,000
What does the HELLP predispose patients to?
- Pulmonary edema
- Renal failure
- Liver hemorrhage or failure
- Disseminated intravascular
coagulation (DIC) - Placental abruption
- Acute respiratory distress
syndrome - Sepsis
- Stroke
- Fetal and maternal death
What is Hyperemesis
Gravidarum
Defined: excessive vomiting with
ketosis, dehydration, electrolyte
imbalance, & acetonuria
- Etiology: unknown
- Clinical manifestations
- Symptoms: dehydration,
electrolyte imbalance, weight
loss - Care management
- Initial care, IV rehydration,
control vomiting - Follow-up care
Which one of the following lab values would indicate Hyperemesis Gravidarum?
A. Serum sodium level 160
B. Creatnine 0.7
C. BUN level 15
D. Calcium level 10
A. Serum sodium level 160
* Symptoms: dehydration,
electrolyte imbalance, weight
loss
S/S of Hyperemesis Gravidarum
- Symptoms: dehydration,
electrolyte imbalance, weight
loss
dry mucous membranes,
decreased BP, increased pulse rate,
and poor skin turgor.
Frequently she is unable to retain even clear liquids taken by mouth.
Laboratory tests may reveal electrolyte imbalances.
Nursing Interventions for Hyperemesis Gravidarum
- Care management
- Initial care, IV rehydration,
control vomiting - Follow-up care
Risk factors for hyperemeisi gravidarum
Women with a history of motion sickness, migraines, or a previous pregnancy complicated by hyperemesis gravidarum are more likely to develop hyperemesis.
Diet and nursing interventions for Hyperemesis Gravidarum
Once the vomiting has stopped, feedings are started in small amounts at frequent intervals. In the beginning, limited amounts of oral fluids and bland foods such as crackers, toast, or baked chicken are offered.
- Avoid an empty stomach. Eat frequently, at least every 2–3 h. Separate liquids from solids, and alternate every 2–3 h.
- Eatahigh-protein snack at bedtime.
- Eat dry, bland, low-fat, and high-protein foods. Cold foods may be better
tolerated than those served at a warm temperature. - In general, eat what sounds good to you rather than trying to balance your
meals. - Follow the salty and sweet approach;evenso-called junk foods are okay.
- Eatproteinaftersweets.
- Dairy products may stay down more easily than other foods.
*If you vomit even when your stomach is empty,try sucking on a Popsicle. - Try ginger tea.Peel and finely dice a knuckle-sized piece of ginger and place it in a mug of boiling water. Steep for 5–8 min and add brown sugar to taste.
- Try warm ginger ale (with sugar, not artificial sweetener) or water with a
slice of lemon. - Drink liquids from a cup with a lid.
Risk of Hemorrhagic
Disorders of pregnancy
- Maternal blood loss decreases
oxygen-carrying capacity - Increased risk for hypovolemia,
anemia, infection, preterm labor
& delivery - Adversely affects oxygenation of
fetus - Fetal risks include blood loss or
anemia, hypoxemia, hypoxia, &
preterm birth
is Early Pregnancy Bleeding an emergency/ What could it indicate?
Yes it is an emergency, it may indicate spontaneous abortion, ectopic pregnancy, cervical insufficiency, hydatidiform mole:tumor that presents from a nonviable pregnancy
Spontaneous abortion
(miscarriage)
What are the types of Spontaneous abortion?
A. Threatened
B. Inevitable
C. Complete
D. Partial
E. Missed
Abortion is classified as a pregnancy that lasted under 20 weeks gestation
What can be a risk factor for abortion
Approximately half of all miscarriages are chromosomally normal, while the other half have a chromosomal abnormality. Other possible causes of miscarriage include various medical disorders (e.g., poorly controlled diabetes mellitus, obesity, thyroid disease, and systemic lupus erythematosus). Regular and heavy alcohol consumption, excessive (.500 mg/day) caffeine intake, environmental toxins, and increasing pa- ternal age are other possible causes of miscarriage. Infections, however, are not a common cause of miscarriage
Which 2 of the following spontaneous abortions results in having a closed uterus
A. Threatened
B. Inevitable
C. Complete
D. Partial
E. Missed
A. Threatened
E. Missed
Once the cervix begins to dilate, the pregnancy cannot continue, and miscarriage becomes inevitable.
Drug therapy after miscarriage
After evacuation of the uterus, oxytocin (Pitocin) is often given to prevent hemorrhage. For excessive bleeding after the miscarriage, ergot products such as ergonovine (Methergine) or a prostaglandin deriva- tive such as methylcarboprost tromethamine (Hemabate) may be given to contract the uterus
Care after miscarriage
- Clean the perineum after each voiding or bowel movement and change perineal pads often.
- Shower(avoid tub baths) for 2weeks.
- Avoid tampon use, douching, and vaginal intercourse for2 weeks.
- Notify your health care provider if an elevated temperature or a foul-
smelling vaginal discharge develops. - Eat foods high in iron and protein to promote tissue repair and red bloodcell
replacement. - Seek assistance from support groups, clergy, or professional counseling as
needed. - Allow yourself (and your partner) to grieve the loss before becoming preg-
nant again.
Where does 95% of Ectopic p-pregnancies occur
in fallopian tube, when discovered will result in immediate abortion due to health risk of mother and baby
Signs and symptoms of Ectopic Pregnancy
Abdominal pain, referred shoulder
pain
* Delayed menses or abnormal
vaginal bleeding
* Weakness, dizziness, hypotension
(hypovolemia)
Medical management and surgical management of Ectopic surgery
Medical: Methotrexate-Many women with an early diagnosis of ectopic pregnancy can be managed medically with methotrexate (ACOG, 2018b). Methotrexate is an antimetabolite and folic acid antagonist that destroys rapidly dividing cells, which ends the pregnancy.
The pregnancy is then ab- sorbed by the body over the next 4 to 6 weeks.
- Surgical
- Salpingectomy: remove all or part
of tube - Salpingostomy: remove products
of conception repair fallopian
tube
Ectopic implanted
Abdominal cavity:
(rare) associated with
multiple anomalies of fetus
&significant damage to
maternal organs from
placental implantation if
fetus develops
What is cervical Insufficiency, What procedure would be recommended to resolve it?
One cause of late miscarriage is cervical insufficiency, which has tra- ditionally been defined as passive and painless dilation of the cervix leading to recurrent preterm births during the second trimester in the absence of other causes\
Cervical cerclage placement has been the treatment of choice for women with cervical insufficiency due to cervical weakness.
Is Methotrexate a hazardous drug and should HCP take caution when handling it?
- Don two pairs of gloves before removing the syringe(s) from the sealed plastic bag.
- Remove the syringe cap and replace with an appropriate needle for intra- muscular injection.
*Do not expel air from the syringe or prime the needle because these actions could aerosolize the methotrexate.
- Check the patient’s identity and the medication and dosage before injecting the methotrexate. A second nurse should also perform an independent check before the injection is given.
- Dispose of any items worn or used to prepare, dispense, or administer the methotrexate injection in a waste container designated specifically for hazardous drugs.
- Wash hands thoroughly after removing gloves.
What range of gestation is labeled as preterm labor
- Diagnosis based on 3 factors:
- 20-36 weeks gestation
- Uterine activity (contractions)
- Progressive cervical change
(effacement and/or dilation) - Risk factors: history of PTL (#1 risk),
multiple gestation, gestational
diabetes, advanced maternal age,
obesity, 2nd trimester bleeding,
African-American race, low pre-
pregnancy weight, urogenital tract
infections
S/S of preterm labor
Contractions every 10 minutes or less
for 1 hour or more (6 or more in an
hour)
* Lower abdominal menstrual-like cramps
* Dull, intermittent low back pain (below
waist)
* Suprapubic pain or pressure
* Pelvic pressure or heaviness (baby
“pushing down”)
* Character or amount change of cervical
discharge (leukorrhea)
* Rupture of amniotic membranes
* Signs of UTI
Treatment of Preterm Labor
Lifestyle modifications: ↓ activity,
lifting, riding long distances
* Hydration
* Tocolytic medications relax smooth
muscle:
* Magnesium sulfate (↓ seizure risk)
* Terbutaline: oral or SC (pulse rate,
>120 hold)
* Indomethacin (Indocin)
* Nifedipine (Procardia)
Is it common for a woman to experience a recurrent Ectopic Pregnancy
A. Yes
B. No
A. Yes
Every woman who has been diagnosed with an ectopic pregnancy should be instructed to contact her health care pro- vider as soon as she suspects that she might be pregnant because of the increased risk for recurrent ectopic pregnancy.
How would you define the term multiple gestation
- Pregnancy with multiple fetuses
(twins, triplets…) - Increased risk for complications:
- Increased blood volume required
to support multiple fetuses
(cardiovascular stress) - Over distention of uterus
(preterm labor, PP hemorrhage) - Placement of placenta (previa or
abruption) - Malpresentation (surgical
delivery) - Nutrition
During late pregnancy Is it an emergency when Bloody Show occurs?
A. Yes
B. No
B. No
Bloody show-not frank
bleeding, scant pink to
bloody mucous plug
What occurs during Placenta Previa?
Placenta cover cervical opening
There are 3 stages of Placenta Previa
Marginal-Placenta is implanted in lower uterus but its lower border is >3 cm from internal cervical os.
Partial-Lower border of placenta is within 3 cm of internal cervical os but does not fully cover it.
Total-Placenta completely covers internal cervical os.
If placenta previa has been found in your patient would they report of pain?
A. No
B. Yes
A. No
- Sudden onset of painless, bright red vaginal bleeding occurs in the last half of pregnancy.
- Uterus is soft, relaxed, and nontender.
- Fundal height may be more than expected for
gestational age.
Are vaginal exams required when a pt is currently having vaginal bleeding g due to placenta previa?
A. No
B. Yes
A. No
What is the priority action for Placenta Previa during labor ?
- Monitor the client’s vital signs, fetal heart rate, and fetal activity.
Interventions for Placenta Previa
Diagnosis & medical management
* Diagnosis: transabdominal
ultrasound
* Antepartum: observation & bed rest
* Delivery: possible Cesarean birth
- Monitor the client’s vital signs, fetal heart rate, and fetal activity.
- Prepare for ultrasound to conirm the diagnosis. 3. Vaginal examinations or any other actions that would stimulate uterine activity are avoided.
- Maintain bed rest in a side-lying position as pre-
scribed. - Monitor amount of bleeding (treat signs of
shock). - Administer intravenous (IV) uids, blood prod-
ucts, or tocolytic medications as prescribed;
Rho(D) immune globulin may be prescribed. - If bleeding is heavy, a cesarean delivery may be
performed. - Complete placenta previa will require a cesarean
delivery.
Does Abruptio Placentae occur suddenly?
A. No
B. Yes
B. Yes
- Premature separation of placenta
from implantation site > 20 weeks. - Signs:
- vaginal bleeding
- abdominal pain-possibly severe, rigid
to board-like fundus - uterine contractions; hypertonus
- port wine-stained amniotic fluid
- 30% bleeding in pregnancy abruption
Signs and Symptoms of Abrup[tio Placentae
- Dark red vaginal bleeding. If the bleeding is high
in the uterus or is minimal, there can be an ab-
sence of visible blood. - Uterine pain or tenderness or both
- Uterine rigidity
- Severe abdominal pain
- Signs of fetal distress
- Signs of shock if bleeding is excessive
- vaginal bleeding
- abdominal pain-possibly severe, rigid
to board-like fundus - uterine contractions; hypertonus
- port wine-stained amniotic fluid
- 30% bleeding in pregnancy abruption
Risk factors for Abruptio Placentae
- Hypertension with this
pregnancy - Abdominal trauma
- Cigarette smoking
- Alcohol use
- Cocaine use
- Blood clotting disorders
- Diabetes
- Previous history
Mild, Moderate, Severe Abruptio placentae
Mild Blood loss’
-under 500ml
Moderate Blood loss
-1000-1500
Severe Blood Loss
-1500 ml
SEVERE PAIN
Nursing Intervention for Abruptio Placentae
- Monitor the client’s vital signs and fetal heart rate.
- Assess for excessive vaginal bleeding, abdominal
pain, and an increase in fundal height. - Maintain bed rest; administer oxygen, IV uids,
and blood products as prescribed. - Place the client in Trendelenburg’s position if in- dicated to decrease the pressure of the fetus on the placenta, or place in the lateral position with the head of the bed at if hypovolemic shock oc- curs.
- Monitor and report any uterine activity.
- Prepare for delivery of the fetus as quickly as possible, with vaginal delivery preferable if the fetus is healthy and stable and the presenting part is in the pelvis; emergency cesarean delivery is performed if the fetus is alive but shows signs
of distress. - Monitor for signs of disseminated intravascular
coagulation in the postpartum period.
Is hypercoagulationduring pregnancy cause medical emergencies?
A. No
B. Yes
B. Yes
-
Hypercoagulation
Normal increase in clotting factors late
pregnancy
Can cause…
Thrombophilia: V Leiden
Polycythemia
Risks: venous thrombosis, miscarriage
& intrauterine growth restriction
Clotting Disorders
Platelet disorders
* Thrombocytopenia, aplastic anemia,
leukemia
* VonWillebrand disease-A bleeding disorder caused by low levels of clotting protein in the blood
Decreased activity of clotting factors
* Liver disorder
* Medication: anticoagulants, NSAIDs,
Aspirin
Blood vessel defects, Vitamin K
deficiency
Risk factors of developing DIC Disseminated
Intravascular
Coagulation
Pathologic secondary disorder of
coagulation causing widespread external
& internal bleeding with unrelated clot
formation in other blood vessels
-s a rare but serious condition that causes abnormal blood clotting throughout the body’s blood vessels
■ Abruptio placentae
■ Amniotic uid embolism
■ Gestational hypertension
■ HELLP syndrome
■ Intrauterine fetal death
■ Liver disease
■ Sepsis
■ Severe postpartum hemorrhage and blood loss
Signs and Symptom of DIC Disseminated
Intravascular
Coagulation
- Uncontrolled bleeding
- Bruising, purpura, petechiae, and ecchymosis
- Presence of occult blood in excretions such as
stool - Hematuria, hematemesis, or vaginal bleeding
- Signs of shock
- Decreased fibrinogen level, platelet count, and
hematocrit level - Increased prothrombin time and partial throm-
boplastin time, clotting time, and brin degrada-
tion products
Presentation: petechiae, purpura, GI, GU,
mucous membrane bleeding, bleeding
from every break in skin
Treatment for DIC Disseminated
Intravascular
Coagulation
Treatment
Replace blood &
clotting factor
loss
Treat cause
Support vital
functions
Monitor for
ischemia from
clots
Can a UTI induce preterm labor?
A. No
B. Yes
B. Yes
Increased risk premature labor,
ascending infection
What can UTI’s lead to if untreated>?
Asymptomatic bacteriuria refers to the persistent presence of bacteria within the urinary tract of women who have no symptoms. A clean- voided urine specimen containing more than 100,000 colonies per milliliter is diagnostic. If asymptomatic bacteriuria is not treated, about one-third of pregnant women will develop acute pyelonephritis. Therefore, all women should be screened for asymptomatic bacteriuria at their first prenatal visit (Duff, 2021). Asymptomatic bacteriuria has been associated with preterm birth and low birth weight infants (Cun- ningham et al., 2018).
Asymptomatic bacteriuria should be treated with an antibiotic. Antibiotics that are often prescribed include amoxicillin, ampicillin, a cephalosporin such as cephalexin (Keflex), ciprofloxacin (Cipro), levo- floxacin (Levaquin), nitrofurantoin (Macrodantin), and trimethoprim- sulfamethoxazole (Bactrim DS).
Cystitis - s/s dysuria, urinary frequency
Pyelonephritis- hospitalization needed
Mechanisms of trauma
etal physiologic characteristics
* Fetal monitor tracing works as
“oximeter” of internal maternal
well-being
* Mechanisms of trauma
* Blunt abdominal trauma-Blunt abdominal trauma is most commonly the result of MVAs but also may be the result of intimate partner violence or falls. Maternal and fetal mortality and morbidity rates are directly correlated with whether the mother remains inside the vehicle or is ejected.
* Penetrating abdominal trauma-Bullet and stab wounds are the most frequent causes of penetrating abdominal trauma in pregnant women
* Thoracic trauma-
Thoracic trauma is reported to produce 25% of all trauma deaths. Pulmonary contusion results from nearly 75% of blunt thoracic trauma and is a potentially life-threatening condition.
Care
- Immediate stabilization
- Primary survey
- Cardiopulmonary resuscitation-The systematic evaluation begins with a primary survey and the initial CABDs of resuscitation: compressions, airway, breathing, and defibrilla- tion. Increased oxygen needs during gestation necessitate a rapid re- sponse.
- Secondary survey-After immediate resuscitation and successful stabilization measures, a more detailed secondary survey of the mother and fetus should be completed. A complete physical assessment, including all body sys- tems, is performed.
- Electronic fetal monitoring-
- Fetal-maternal hemorrhage
- Ultrasound
- Radiation exposure
- Perimortem cesarean delivery(only 5 minutes after mothers death)
External FHR and contraction monitoring is recommended after blunt trauma in a viable gestation for a minimum of 4 hours, regardless of injury severity. Fetal monitoring should be initiated soon after the woman is stable
Does perineal pressure warrant immediate return to the hospital following a CERLAGE
Additional instruction includes the need to watch for and report signs of preterm labor, rup- ture of membranes, and infection. Finally, the woman should know the signs that would warrant an immediate return to the hospital, in-cluding strong contractions less than 5 minutes apart, preterm prela- bor rupture of membranes, severe perineal pressure, and an urge to push.
Can dehydration cause contractions?
Dehydration can cause contractions make sure mom is well hydrated
What is the cure for HELLP SYNDROME
- INDUCTION OF BIRTH ,JUST LIKE PREECLAMPSIA
Interventions for PREECLAMPSIA?
Induction of labor is the cure , giving birth
