W3: Pregnancy at Risk Flashcards
Adolescent pregnancy
age 10-19yrs
increased of perinatal complications, maternal death
Adolescent friendly perinatal care
nonjudgmental care
forming connection
individualizing care
- ensure safety
- positive experience
Geriatic Pregnancy
> 35 yrs
increased risk of:
- maternal death
- miscarriage
- pre-term
-LBW
- perinatal mortality
- down syndrome
IPV is assoc w/
preterm labour
premature baby
LBW
neonatal/infant/maternal mortality
maternal depression
substance abuse
IPV screening tools
RADAR (routine, document, assess, review)
HITS
Role of nurse (IPV)
- report if child <16 in house
-reassure & believe
- don’t judge
not her fault
apologies don’t end abuse
explain effects on fetus
reinforce their safety
explore cocnerns + plan of care
referrals
documentation
Risk assoc. w/ substance abuse
bleeding complications
miscarriage
still birth
prematuritty
lbw
SIDS
congenital abnormalities
Is there a legal drug testing requirement during pregnancy in Canada?
No
legal considerations associated w/ substance use
non-jugemental person centred approach
harm reduction model
encourage prenatal care, counselling, tx
barriers to tx assoc. w/ substance use
guilt, fear, shame
tx programs don’t address pregnant women
lack of women-only spaces
long waitlists
NC: Substance Use
assess hx
confidentiality
trauma-informed
harm reduction
women more receptive to changes during pregnancy
OAT (opiod agnonist therapy), methadone or buprenorphine tx
cannabis use education
maternal-infant attachment
BF
Early Pregnancy Bleeding
miscarriage/spontaneous abortopn before 20w OR fetus <500g
early loss
before 12 w
chromosomal abnormalities
teratogenic drugs
faulty implantation
maternal abnormalities
infections
late loss
12-20w
advanced age
premature dilation of cervix
chronic infection
use of recreational drugs
Threatened Abortion
bleeding: slight, spotting
uterine cramping: mild
cx: closed
expulsion of products: no
bed rests, tests
Inevitable Abortion
bleeding: moderate
uterine cramping: mild-severe
cx: open
expulsion of products: yes
bed rest, dilation/cutterage
Incomplete abortion
bleeding: heavy, profuse
uterine cramping: severe
cx: open
expulsion of products: yes
dilation -> cutterage (suction)
complete abortion
bleeding: slight
uterine cramping: mild
cx: close
expulsion of products: yes
cutterage maybe
missed abortion
bleeding: none, spotting
uterine cramping: none
cx: close
expulsion of products: no
monitor
early pregnancy assessment:
confirmation of pregnancy
bleeding
pain
vaginal d/c
late pregnancy assessment
date of birth
bleeding
pain
vginal d/c
amniotic membrane status
uterine activity
fetal heart rate + movement
MGT of incomplete abortion
expectant: allow miscarriage to expel on its own
medical: 2 drug combo
- mifepristone - prepare uterus for miscarriage (blocks progesterone)
- misoprostol - given 24-48 hrs later, helps soften + dilate cervix
surgical: dilation & cutterage
D/C teaching after pregnancy loss
- report heavy, bright-red bleeding
- scant d/c for 1-2 weeks
- nothing in vagina for 2 weeks (until bleeding stops)
- take antibiotics
- report elevated temp + foul d/c
- foods high in Fe & protein
- post-pone pregnancy for at least 2mo
Ectopic pregnancy
fertilized ovum implanted outside uterine cavity (amupllar)
medical emergency!
clinical manifestations
- abdominal pain
- missed period
- abnormal vaginal bleeding (rupture)
-referred shoulder pain
-one-sided, deep lower quadrant pain
Ectopic pregnancy dx
ultrasound
serum progesterone
b-hCG
medical mangement of Ectopic pregnancy
methotrexate: antimetabolite & folic acid antagonist, destroys rapidly dividing cells
surgical: salpinostomy, salpingectomy to repair rupture
Patient Teaching for methotrexate
avoid folic acid
avoid gas-forming foods
avoid sun exposure
avoid sexual intercourse until b-hCG gone
keep all appointments
CONTACT DOC: severe abd pain (rupture)
Premature dilation of cervix
passive/painlexx dilation of the cervix
d/t trauma, collagen issues
Nursing care for premature cervical dilation
cervical cerclage (12-14weeks)
observation
report signs of pre-term labor, PROM, infection
HOSPITAL: contractions, pPROM, perineal pressure, urge to push
Placenta previa
placenta implented in lower uterine segment near/over internal cervical os
classifcation of placenta percia
complete placenta previa
marginal placenta previa
low-lying placenta
clinical signs of placenta previa
bright red bleeding
pain absent
uterine normal
normal fetal HR
complictions of placenta previa
bleeding (PAINLESS)
preterm birth
IUGR
Expectant Management of Placenta Previa
reduced activty + observation
patient <36w
no labor, minimal bleeding
no rectal/vaginal examinations
ultrasound q2w
NST, BPP 1-2 x weekly
antepartum steroids (betamethasone), fetal lung maturity
active mgt of placenta previa
c-section
- mature fetus
-excessive bleeding - active labor begins
Placenta Abruption
premature seperation of placenta
clinical signs ofplacenta abruption
vaginal bleeding (PAINFUL)
abd pain
uterine tenderness
contraction
placenta abruption is a major cause of ___
antepartum hemorrhage
Placenta Abruption: CLASS 1- mild seperation
bleeding: minimal
total blood loss: <500
colour: dark red
shock: rare, no
uterine tonicity: normal
pain: absent
fetal status: normal
DIC: rare
Placenta Abruption: CLASS 2- mod seperation
bleeding: 0-mod
total blood loss: 1000-1500
colour: dark red
shock: mild
uterine tonicity: increase
pain: mod-sev
fetal status: atypical
DIC: occasional
Placenta Abruption: CLASS 3- severe seperation
bleeding: 0 - heavy
total blood loss: >1500
colour: dark red
shock: common
uterine tonicity: !!!
pain: severe
fetal status: abnormal, death?
DIC: frequent
maternal complications of placenta abruption
hemorrhage
hypovelmic shock
hypofibrinogenemia, thrombocytopneia
couvelaire uterus
dic
infection
rh isoimmunization
fetal complications of placental abruption
IUGR
preterm birth
hypoxemia
stillbirth
neurological defects
cerebral palse
SIDS
Expectant mgt Placenta Abruption
<36w
hospitalized
monitor fetal status
maternal vitals
betamethasone
birth if deterioration
rho(d)immunogloblin
DIC
proteins that control blood clotting become overactive & utilizing clotting factors –> internal bleeding
triggered by tissue thromboplastin d/t placental abruption, retained dead fetus, amniotic fluid embolus, pre-eclampsia, HELLP, sepsis
stage 1 DIC
overactive clotting leads to blood clots throughout the blodo vessels
clots can reduce/block blood flow which can damage organs
stage 2: DIC
the overactice clottign uses up platelets & clotting factors that help blood clot
with absence of facors dic leads to bleeding
Physical Examination Findings DIC
spontaneous bleeding
excessive blood from puncture sites
petechiae
bruising
hematuria
GI bleeding
tachycardia
diaphoresis
Coagulation Test Results: DIC
decreased: platelets, fibrinogen, factor V, factor VIII
increased: fibrin degradation products, d-dimer test
prolonged: prothrombin time, partial thrombin time
red blood smear: fragmented rbcs
NC: DIC
tx underlying cause
volume expansion
labs
vit K & rcombianr activated factor Vlla, fibrinogen concentrate
protect from injury
I/O (30ml/hr)
fetal monitoring
side-lying- maximize blood to uterus
o2
keep pt warm
diagnosis of hypertensive disorder
> 140/90 x2 , 15 min apart
severe HTN
160/110<
chronic HTN
prepregnancy HTn present prior to 20w
gestational HTN
develops after 20w
no proteinuria
pre-eclampsia, eclampsia
gestational HTN + proteinuria
2 components of (pre)eclampsia
HTN + proteinuri (>0.3g/L)
addiitonal organ dysfunction
- kidney, renal, enurologcal, hematological
eclampsia
seizure activity/coma in women diagnosed w/ pre-eclampsia
Risk factors for pre-elcampsia/eclampsia
nulliparity
age >40
pregnancy w/ assisted tech
interpregnancy internal >7yrs
family hx
pt born small for gestational age
obesity, DM
multifetal gestation
hx of pre
previous poor pregnancy
chronic HTN
renal disease
type 1 DM
pre-eclampsia etiology
– poor perfusion resulting from vasospasm NOT BP increase
arteriolar vasospasm diminishes diameter of blood vessels, which impedes blodo flow to all organs & increases BP
organ function depressed
maternal complications: pre-eclampsia
multi organ faliure
CNS, kidney, lungs, hematological
fetal complications: pre-eclampsia
pre-term birth
still birth (IUFD)
fetal distress
uteroplacental insufficiency
placenta abruption (UGR, hypoxic)
HELLP Syndrome
Hemolysis (H)
elevated liver enzymes (EL)
low platelets (LP)
s/s of HELLP
HTN
Proteinuria
epigastric RUQ pain
n/v
headache
malaise
HELLP is associated w/ increased risk for
placental abruption
renal faliure
pulmonary edema
ruptured liver hematoma
DIC
NC: Pre-eclampsia & HELLP
BP
Reflexes: bicep, patellar, ankle clonus
Fetal: NST, CST, BPP, FHR, ultrasounf, fetal movement
activity restriction
NC Pre-eclampsia- BP
hydralazine
labetalol
methyldopa
adalat
NC: Pre-eclampsia- Magnesium Sulphate
antiseizure
assess for toxicity (loss of reflexes), respiratory depression
oliguria
decreased LOC
Patient teaching: Pre-eclampsia
report inc BP, proteinuria, decreased FM (less than 6/2hr)
dipstick clean catch sample (for proteinuria)
Seizure Precautions
quiet
non-stimulating room
lighting subdued
magnesium sulphate ready to go
o2 equippment
suction equipment
call bell
NC; Eclampsia
ensure patent airway
medication (magnesium sulphate)
assess fetal status
Signs preceeding Eclampsia
headache
blurred vision
photophobia
severe RUQ pain
fits
altered mental status
Seizure : immediate care
airway patency: turn head to one side, place pillow under one shoulder/back
call for ehlp
don’t leave bedside
protect pt from injurt, raise rails
oberve & record convulsion activity
seizure: aftercare
do not leave until alert
observe for post-seizure coma, incontinence
use suction
o2
magnesium sulphate
catheter for i/o
monitor BP
monitor fetal/uterine staatus
labs
hygiene
Gestational Diabetes
elevated glucose levels first recognized during pregnancy
higher risk of glucose intolerance later
adverse incidents
Gestational Diabetes Risk factors
35+
POC
corticosteriod medications
pregestational dm
obesity
hx of GDM
given birth to baby>4kg
family hx of T2 DM
PCOS
GDM Anteparum
blood glucose control
diet
exercise
monitor levels
pharmacological therapy
fetal surveillance
intrapartum GDM
macrosomia
birth injuries due to shoulder
newborn hypoglycemia
postpartum GDM
women dx w/ GDM, test again 6-12w PP
Rh isoimmunization
when 0.1 ml od rh+ fetal blood mixes with maternal rh negative blood
rbcs from fetus invade maternal circulation stimulating production of antibodies against rh+
doesn’t affect 1st child, but in second pregnacy = fetal demise d/t hemolysis + anemia (antibodies cross placenta)
Rh isoimmunization prevention
hx
determine blood type and & antibody screening
Rh (d) given (dad is + or unknown)
- given at 28w 72 hrs PP
hyperemesis gravidarum
vomiting that causes severe dehydration, wight loss, electrolyte imbalance, nutrtional deficiency, ketonuria
hyperemesis gravidarum maternal & fetal complictions
f: LBW, SGA, preterm
m: vit k deficiency, thiamine
NC: Hyperemesis Gravidarum
clear liquids, slow intro to small/bland meals (low in fat)
avoid odors, tastes, activities that trigger nausea (stuffy rome, lights, perfume)
IV therapy
medications for hypermesis gravidarum
pyridoxine
diphenhydramine
metoclopiramide
antiemetic
antacids
antihistamines
proton pump inhibitors
ondansetron
Coomb’s Test
test for Rh incompatibility
amniocenthesis
taking amniotic fluid for genetic testing
maternal & fetal complications assoc/ w amniocenthesis
M
leakage f amniotic fluid
hemorrhage
infection
isoimmunization
placental abruption
damage to organs
amniotic fluid embolism
f:
death
hemorrhage
infection (amninitis)
injury
chronic villus sampling:
test chromsomal abnormalities and other genetic disorders
earlier dx & rapid results
10-13w
remocal of small portion of placental tissue from fetal portion
third trimester asssessment for fetal well-being
determine whether intrauterine environment continues to be supportive to the fetus
fetal movement counting
NST
CST
BPP
ulrasound
Non-Stress Test
FHR in response to movement of the fetus
heart rate should increase when fetus moves
normal findings NST
2 fhr accelerations lasting 15 seconds and rising 15bpm above basline
abnormal findings NST
lacks accelerations over 40 mins
= further testing
Biophysical Profile
recommended for women at increased risk
non-invasive
low score = more testing
indications for BPP
post-term
multiple gestations
previous stillbirth
polyhydroamnios, oligohydramnios
GDM
preeclampsia/HTN
IUGR
components of BPP
1-NST
2-fetal breathign movements ( 1+ ryhtmic breathing for 30s+ in 30 mins)
3-fetal mocement (2-3 discrete movements / 30m)
4-fetal tone (1+ extension then flexion / opening+ closing of hand)
5- amniotic fluid movement (1 vertical pocket of 2cm+)
each component given score
2- normal
1- present
0- abnormal, absent
Contraction Stress Test
used to measureresponse of fetus (FHR) after uterus is stimulated to contract
to ensure during labor the fetus can handle contractiona dn get the o2 needed form placenta
when: abnormal BPP, NST
- niple stimulated contraction test
-oxytocin stimulated contraction test
Normal: negative CST
does not show deceleration or late decelation
Abnormal: positive CST
FHR showing decelerations and late decelerations
oligohydramnios
less than 300> ml amniotic fluid
renal abnormalities
polyhydraamnios
more than 2L of amniotic fluid
GI malformations
