Unit 32 High Risk Prenatal/Postpartum Depression/Genetics Flashcards
What is Maternity “baby blues”? What are the symptoms? The treatment?
- Can be normal reaction to hormonal changes after delivery
- Occurs within 3-5 days
- Lasts 3 days to 3 weeks and usually goes away on it’s own
Symptoms include: crying, irritability, fatigue, anxiety
If persisting more than ~10 days needs to be evaluated because could progress to PP
Treatment: support, reassurance, and follow up
What is Postpartum Depression? What must they have in order to be dx? what do the symptoms range from? When does the depressive episode begin?
- Major Depressive Disorder
- Must have 5 or more symptoms for at least 2 weeks and including depressed mood or loss of interest
- Symptoms range from insomnia to suicidal ideations
- Depressive episode can begin within 4 weeks of postpartum and can last up to 1 year
What are symptoms of PP Depression?
Depressed mood Loss of interest or pleasure in daily activities Sleep changes Fatigue or loss of energy Loss of appetite Inability to concentrate or think Suicidal Ideations
Somatic symptoms like: headache, constipation, diarrhea, and severe anxiety
What are examples of genetic prenatal testing and prenatal testing?
- Chorionic Villi Sampling (CVS)
- Biophysical Profile Kickcount (looks at overall health of baby)
- Amniocentesis (do not let PT see needle)
- Non stress test/Stress test (Don’t push Pitocin)
What is important to stress to a client with heart disease being seen for her first prenatal visit?
It is important to take prenatal vitamins and iron as prescribed
What is the best non weight bearing exercise?
Swimming
Why is Heparin chosen over warfarin in pregnancy?
warfarin (Coumadin) in teratogenic
What is hyperemesis gravidarum? What does it cause? what is the fetus at risk for?
Extreme nausea and vomiting during the first 20 weeks.
- Creates maternal dehydration, weight loss, electrolyte imbalances
- Cause unknown
- Fetus at risk for macrosomia, abnormal development, IUGR, or death from lack of nutrition, hypoxia, and maternal ketoacidosis
What can dehydration lead to in pregnancy?
Premature labor
What is a natural nausea relief?
Chewing on ginger
What is the care for hyperemesis gravidarum?
- IV therapy of D5LR to restore fluid and electrolyte balance
- Common to see TPN and antiemetics
- Encourage 6 or more SMALL meals a day; clear liquids such as lemonade and teas and salty foods are sometimes tolerated better first.
- Fetal growth monitored by serial ultrasounds
What are substance abuse issues in pregnancy and how are substances screened for?
Issues from substance abuse include:
- Spontaneous abortion
- IUGR
- Preterm labor
- Placental abruption
- Stillbirth
- Fetal alcohol syndrome
Substances are screened by urine toxicology
What is the difference between a diabetic and a women who has gestational diabetes?
One has diabetes and becomes pregnant vs one that does not have diabetes, becomes pregnant and develops gestational diabetes, which after delivery of child does not.
An insulin dependent diabetic client gives birth, the nurse expects the client’s insulin requirements in the first 24 hrs to what? Why?
Drop significantly
Think: The energy needed to recuperate after delivery uses the body’s glucose.
-The placenta causes insulin resistance and is no longer there after delivery
What laboratory test bests provides information on insulin control for a gestational diabetic?
A1C/Glycosylated hemoglobin
Describe pregnancy’s effect on insulin during the first half and second half of pregnancy.
First half of pregnancy, increasing maternal hormones increase the demand for insulin
Second half of pregnancy there is insulin resistance due to human placental lactogen
What are complications that are more common with insulin dependent diabetes mellitus?
- polyhydramnios
- pregnancy induced hypertension
- stillbirths
- neonatal macrosomia, hypoglycemia, hyperbilrubinea, congenital anomalies, delayed fetal lung maturity
Following birth, the infant of a woman with preexisting diabetes mellitus is at greatest risk for the development of what?
Hypoglycemia
What is the management for GDM? what is a better choice for hypoglycemia and why? What is the urine testing for in relation to the management?
- Teach how to manage hypoglycemia, in pregnancy skim milk is better choice than OJ as the protein lasts longer with a more steady blood sugar rise
- Urine testing for glycosuria and keytones
- Monitor for infections such as UTI’s and vaginal yeast infections
- Insulin generally given in multiple injections, 4 dose approach lispro before each meal and NPH added at bedtime
Why are some oral hypoglycemic meds not given during pregnancy or are avoided altogether?
Because they are teratogenic
What are ways to evaluate the fetal well being during pregnancy? and at how many weeks?
- Maternal serum alpha fetoprotein screening done at 16-20 weeks to assess for neural tube defects
- NST done at around 28 weeks
- Ultrasound done at 18 weeks to establish gestational age repeated at 28 weeks to monitor for macrosomia and anomalies
- Biophysical profile done in third trimester to monitor fetal well wing
Who is PIH/Pre-eclampsia/Eclampsia more common in? What are they at risk for?
More common in:
- Young primigravida
- Women over 35
- Multiples
- Diabetes Mellitus
At risk for:
- CVA
- DIC ( Dissemated Intravascular Coagulation)
- Renal failure
- Hepatic failure
What does severe epigastric pain signal in pregnancy?
Hepatic rupture during hypertensive episodes (pre-ecamplsia/ecampsia) from high liver levels.
What is Gestational Hypertension/PIH?
- Occurs during pregnancy and is resolved by delivery of the fetus.
- Very slight rise in BP
- IS NOT associated with proteinuria or edema
What is the Preeclamspa triad?
Hypertension > 140/90 or increase from prepregnancy BP > 30 systolic or 15 diastolic
Edema
Proteinuria
What is mild preeclampsia which is essentially the Preeclampsia triad?
Hypertension >140/90 or increase of 30/15 from baseline
Proteinuria +1
Mild to moderate pretibial edema with weight gain of 2 - 2.5 lbs per week
What is Eclampsia? What are PTs at risk for? What would the fetus show?
-Preeclampsia that has progressed to tonic-clonic seizures
-HELLP Syndrome: Part of PIH
Hemolysis of RBC’s, [H}
Elevated liver enzymes [EL]
Low Platelets [LP]
- At risk for hemorrhage, pulmonary edema, and hepatic rupture
- Fetus would show evidence of UPT (Utero-placental insufficiency) with late decelerations
What is considered severe preeclampsia?
- Hypertension > 160/110
- Proteinuria +3 to +4 or more than 5 in a 24 hr urine sample
- Sudden large weight gain w/facial edema
- Pitting pretibial edema
- Signs of CNS irritation
Risk for: Abruptio placenta
What are systemic responses/symptoms to preeclampsia/eclampsia?
- Severe or continuous headache
- Hyperreflexia > +2 baseline or clonus (Check patellar reflexes
- Visual disturbances (blurred vision, sports, flashing lights)
- Oliguria (signals renal damage)
- Portal hypertension signaled by epigastric pain and indicator of seizure and hepatic rupture
What is clonus?
involuntary muscle contractions
What Rx is given for severe preeclampsia?
Magnesium sulfate
How will the nurse assess for clonus/hyperreflexia?
- Checking the patellar reflexes
- Dorsiflex the foot, when there is hyperreflexia the foot will jerk
- Each movement or jerk is counted, so 2 beats of clonus means there were two movements after the foot is dorsiflexed
What lab values will you see in PIH/Preeclampsia/Eclampsia?
Increased HCT
Elevated BUN and serum uric acid
Increased liver enzymes (ALT and AST)
Decreased RBCs and platelets
What is the care for the Antepartum Preeclamptic?
- Bedrest at home or hospital
- Decrease neuro stimulus meaning, quiet room, low light, anything to decrease CNS and prevent seizures
- High protein diet W/O salt restriction or diuretics
- Foley if hospitalized to check output
-Need amniocentesis to check L:S ratio for early
delivery (determining factor in fetal lung maturity)
-Serial NST’s for fetal well being
Describe the Rx of choice for PIH/Preeclampsia/Eclampsia. What does it do? what is the antidote?
Mag sulfate :
-Used for seizure prevention (**osmotic diuretic **preventing convulsions pulls fluid from the brain)
- Normal level is 5-8 mg, anything > 8 is toxic
- Relaxes everything so check for LOC, output, RR, etc
- Antidote is calcium gluconate
Describe the loading dose for magnesium sulfate.
- High dose to stabilize
- Normal loading dose 4-6 gm in 20% solution via IV pump over 15-20min.
- Maintenance dose is 2 gm/hr IV pump
- This would be piggybacked on mainline so if stopped you have open up main line.
What are three signs of magnesium toxicity?
- Diminished or absent reflexes
- Depressed respirations
- Marked lethargy
What are other antihypertensive Rx’s and the one for lung development in fetuses?
- Procardia and labetalol(Normodyne) or Apresoline
- Sedation with phenobarbital or valium
- bethamethasone to women whose fetus has immature lung profile
What is the cure for a laboring woman with PIH/Preeclampsia/Esclampsia? What simple intervention should you do until then?
- Only cure is delivery, usually C-section
- Keep on left side to increase uterine placental perfusion until ready to section
Describe what happens postpartum to the PIH/Preeclampsia/Esclampsia PT.
Comes back with two drips, Mag Sulfate to prevent seizures that could happen with 48 hrs and Pitocin to counteract the relaxing capacities of mag sulfate so the uterus firms up.
-Newborn should be watched for signs of cardiac ad respiratory depression due to mag sulfate
What is Premature Rupture of Membranes?
- Amniotic membrane rupture before labor begins, will usually begin spontaneously within 24 hrs of rupture
- Preterm rupture is prior to term gestation or 38 weeks and is driven by infection, incompetent cervix and trauma
What is prolonged rupture of the membranes?
- Membranes ruptured more than 12 hrs before birth without labor
- Given oxytocin
What is a major issue with membrane rupture? What would you do?
Prolapsed cord
Get woman off cord on left side with hips elevated
If preterm and membranes rupture what would the nurse do? When must you deliver?
- Will put to bedrest
- Head down, legs up; foley in
- Antibiotics for infection risk (ampicillin)
- Fetal monitoring
- Might see amniofusion
- Obtain cultures for group B strep
-If there is maternal temp then MUST deliver
(might see increased WBCs, abdominal tenderness)
What are Hemorrhagic pregnancy complications?
- Ectopic pregnancy
- Preterm labor
- Placenta Previa (placenta on bottom of cervix)
- Abruptio Placenta (usually from trauma)
- Postpartum Hemmorhage (usually from mag sulfate
or terbutaline, uterus remains boggy) - Uterine rupture
Describe Ectopics.
- Sharp UNILATERAL pain; may see abdominal rigidity with referred right shoulder pain
- Usually seen in ER and most common implantation site is fallopian tube
- Triggered by hx of ascending infections and IUD contraceptive use
- Ultrasound confirms extrauterine pregnancy, HcG lab test confirms pregnancy*
- Might see signs of hypovolemic shock
- Can save tube with use of methotrexate, (Rx that destroys cellular development)
Describe Preterm Labor.
Contractions occurring between 20-37 weeks gestation
Contractions every 10 minutes or less or without pain
Low abdominal cramping with or without diarrhea
Low backache
Increased vaginal discharge
Leaking amniotic fluid
What are immediate actions to do at home for preterm labor?
- Empty bladder
- Lay on left side
- Drink 3-4 glasses of water
- Call HCP
What is the medical management of preterm labor?
- Bedrest, preferably left lateral
- Monitoring
Administration of tocolytic agents which are Rx’s that relax uterus and stop contractions:
> terbutaline IV…oral is brethine
magnesium sulfate
ritrodrine (Yutopar) not used as much because K+ drops
betamethasone/celestone for lung maturity
What are the side effects of terbutaline, magnesium sulfate, ritrodrine(Yutopar), and betamethasone/celestone?
(rx’s used to relax uterus and stop contractions (preterm labor) except betamethasone.
terbutaline - nervousness, palpations, maternal or fetal tachycardia, nausea and vomiting, pulmonary edema
ritrodrine(Yutopar) - maternal/fetal tachycardia, SOB, pulmonary edema, hypokalemia, hyperglycemia
betamethasone/celestone - hyperglycemia, risk of pulmonary edema
magnesium sulfate - respiratory depression, decreased LOC, output, CNS
Describe Placenta Previa. How are the fetuses delivered? What confirms? What should you never do?
Placenta on bottom of cervix. Due to scarring, fibroids, the fertilized ovum implants near or over the internal cervical os
- Key to this is PAINLESS bleeding WITHOUT contractions
- Delivery is by C-section
- Ultrasound to confirm
- High chance with multigravida or multiparty
NEVER perform a vaginal exam as you can create profuse hemorrhage
What is Abruptio Placenta? What is it usually from? Symptom? What confirms? How.is baby delivered?
Placenta detaches from the womb.
- Emergency/Crisis
- Usually due to trauma, substance abuse (cocaine), PIH
- Painfully rigid board like abdomen because of bleeding in closed cavity
- Ultrasound will confirm
- Emergency C-Section
- Fetal monitor will show late decelerations, sinussoidal if dying.
- High chance for amniotic fluid emboli
When does postpartum hemorrhage occur due to uterine atony(boggyness) and lacerations?
Occurs due to medication such as mag sulfate or terbutaline
Occurs when there’s retained placental tissue
Occurs with multiple births or multiparty
Occurs with low platelets
Occurs with dysfunctional or prolonged labors
Occurs if resident exams uterus post delivery
What are the Uterine Stimulants used to prevent and manage uterine atony(boggyness)?
- oxytocin (Pitocin or Syntocinon) creates mild hypertension
- methylergonovine(Methergine) creates hypertension, headache, chest pain, flushing
- ergonovine(Ergotrate) hypertension, dizziness
- oxytocin (Pitocin or Syntocinon) creates mild hypertension
- prostaglandin (PGF2, hemabate, Prostin 15M) nausea, vomiting, bradycardia
- used in example questions
Describe Uterine rupture. When can it occur? What is the result? What happens to neonate?
- Can occur with too aggressive Pitocin use
- Can occur with previous scar tissue from C-section during vaginal delivery
- Can occur with multiples
Result is to rescue and salvage, usually have a hysterectomy with delivery of compromised neonate
Often neonate is dropped into the abdominal cavity from back of ruptured uterus
What is the most common fetal malposition? What side do you want to avoid turning the patient onto?
LOP or ROP most common malposition:
Maternal risk includes prolonged labor, and potential for C-section if failure to rotate
AVOID turning patient to side the fetus’s back is facing
example, ROP- DO NOT turn on right side
What is the greatest risk of vaginal delivery of a breech infant?
umbilical cord prolapse
What causes problems with the passageway resulting in fetal hypoxia and birth trauma?
- Abnormal size or shape of the pelvis
- Have CPD (cephalopelvic disproportion) fetal head too large to pass through
- Fetal macrosomia
Shoulder dystocia results from inability to deliver shoulders
What medications help ripen the cervix (help initiate contractions)?
prostaglandin (PGE2 gel)
laminaria
What drugs are used in the induction of labor?
- prostaglandins: Cervidil or Prepidil intravaginally
- misoprostol (Cytotec) orally or intravaginally
- oxytocin (Pitocin) titrated to produce contractions that mimic normal labor
Describe when Pitocin infusion should be stopped and what it is given in.
Should be stopped if:
- Contractions are closer than 2 minutes apart or last longer than 90 seconds
- Signs of fetal distress showing late decelerations or severe variable decels or bradycardia
Pitocin given in electrolyte FREE solution
What is Hypotonic Uterine Dysfunction? Risks? Treatment?
-Infrequent contractions with decreased intensity
Risks are related to non progression of labor which usually comes with prolonged rupture of membranes and frequent vaginal exams leading to infection.
Treatment: Augmentation with Pitocin as long as CPD (Cephalopelvic Disproportion) is ruled out
Describe Precipitous (dangerous) labor or rapid transit. What are the maternal risks and fetal risks?
- Labor under 3 hrs from start to finish
- Maternal risks: hemorrhage and lacerations
-Fetal risks result in: hypoxia, intracranial hemorrhage, and injury at birth
Baby will display reddened sclera, high pitched crying, inconsolability)
Why would sedation be order for hypertonic contractions?
Sedation helps to provide rest and allows for the uterine contractions to become coordinated so that labor is progressive.
What are some side effects of oxytocic meds?
edema in legs and feet
increased BP
decreased urine output
