Week 3 Chapter 19 Flashcards
Name some complications for Antepartum
Bleeding during Pregnancy
Hyperemesis gravidarum
Gestational HTN
Gestational Diabetes
Blood Incompatibility
Amniotic Fluid Imbalances
Multiple Gestation
Premature Rupture of Membranes
Name Maternal Hemorrhagic disorders
SAB
TAB Ectopic
Molar pregnancy
Cervical Insufficiency
Bleeding during pregnancy can be what?
Placenta Previa
Membranous insertion of umbilical cord
Vomiting in pregnancy with weight loss, electrolyte, and dehydration
Hyperemesis Gravidarum
This is diagnosed with two markers
BP over 140/90
Protein in urine
Gestational Diabetes
When is gestational diabetes usually diagnosed?
24-28 weeks
Mother and father different blood types
Blood incompatibility
Mother attacks newborn. Rhogam given at 28 weeks
Biggest killer in pregnant women is
Hemorrhage
Bag of water ruptures early prior to term
PROM
Higher risk of complications
Multiple Gestation
Name some 1st Trimester Disorders
Abortion Therapeutic
SAB
Ectopic Pregnancy
Abortion usually involves D&C
Loss of products of conception prior to viability
Abortion
Purposeful termination
Therapeutic Abortion
Usually involves D&C
SAB is _____________loss of pregnancy
Unintentional
Implantations in a site other than the uterus
May result in severe bleeding and requires surgery
Ectopic Pregnancy
1st trimester commonly due to what?
Genetic Abnormalities
2nd Trimester more likely related to maternal disorders
Cervix is not dilated and placenta still attached to uterine wall
Threatened
Placenta has separated from uterine wall, cervix has dilated, and amount of bleeding has increased
Imminent
Embryo or fetus has passed out of the uterus but placenta remains
Incomplete
Threatened
Inevitable
Incomplete
Missed
Habitual
Types of Spontaneous Abortions
Continued monitoring
Vaginal bleeding, pad count, passage of products of conception, pain level, preparation for procedures, medications
Abortions
Important ti support in abortions
True
Physical and emotional. Stress woman is not cause of the loss. Verbalization of feelings, grief support, referral to community support group
Implantation of fertilized ovum in site other than the uterus.
Mortality declined almost 90%
Initially symptoms of pregnancy
Positive HcG present in blood and urine
Chronic villi grow into tube wall or implantations site
Rupture and bleeding into the abdominal cavity occurs.
Ectopic Pregnancy
Ovum implantation outside of the uterus
Obstruction to or slowing passage of ovum through tube to uterus
Ectopic Pregnancy
Therapeutic Management of Ectopic Pregnancy
Medical:
Drug therapy- Methotrexate, Prostaglandins, misoprostol, and actinomycin.
Surgery if rupture.
Rh immunoglobin if woman is Rh- (Rhogam)
Nursing Assessment for Ectopic Pregnancy
Hallmark sign: abdominal pain with spotting 6-8 weeks after menses
Contributing factors
Lab/ Diagnostic testing: Transvaginal ultrasound, serum beta Hcg, additional testing to rule out other conditions
Most common site for ectopic pregnancy is
The fallopian tubes. Hence name tubal pregnancy.
Pathologic proliferation of trophoblastic cells
Includes hydatidiform mole
Invasive mole - Chorioadenoma destruens
Choriocarcinoma a form of cancer
Initially clinical picture similar to pregnancy
Gestational Trophoblastic Disease
Classic Signs
Uterine enlargement greater than gestational age
Vaginal Bleeding
Pregnancy is a vesicular swelling of placental villi and usually absence of an intact fetus
Hydatidiform Mole
Malignant, fast growing tumor that develops from trophoblastic cells- cells that help embryo attach to the uterus and help form the placenta
Choriocarcinoma
Therapeutic Management of Gestational Trophoblastic Disease
Immediate evacuation of uterine contents D&C
Long term follow up and monitoring of serial hCG levels
Nursing Assessment of Gestational Trophoblastic Disease
Clinicals manifestations similar to spontaneous abortion at 12 weeks
Ultrasound visualization
High HcG Levels
Nursing Management of Gestational Trophoblastic Diseases
Preoperative preparation
Emotional support
Education: Treatment, serial hCG monitoring, prophylactic chemotherapy
Classic signs present in about 50% of cases
May pass hydropic vesicles
Hyperemesis gravidarum
Higher serum hCG levels
Therapy is suction evacuation of the mole
- Uterine curettage for removal of placental fragments
- Hysterectomy for excessive bleeding
Gestational Trophoblastic Disease
Common sign is vaginal bleeding, often brownish, but sometimes bright red. Sometime hydropic vessels are being passed.
Hydatidiform Mole
Possible causes include
Cervical trauma
Infection
Congenital cervical or uterine anomalies
Increased uterine volume(as with a multiple gestation)
Associated with repeated second trimester abortions
Incompetent Cervix
Diagnosis: Positive history of repeated second trimester abortions
Premature dilatation of cervix and unknown
Possibly due to cervical damage
Therapeutic management
Bed rest, pelvic rest, avoidance of heavy lifting
Cervical cerclage
Incompetent Cervix
Cerclage
Shirodkar procedure for incompetent cervix
Modification of it by McDonald
Reinforces the weakened cervix
Purse- string suture is placed in the cervix
Done in 1st trimester or early 2nd trimester
Cesarean birth may be planned
Suture may be cut at term and vaginal birth permitted
Incompetent Cervix Tx : Surgical Procedures
More difficult less common, as it passes through the walls of the cervix, usually permanent stitch, must have c/s
Shirodkar
Placed at 16-18 week, removed at 37 weeks for natural delivery most common and least invasive
McDonalds
Nursing Assessment for Incompetent Cervix
Risk Factors
Pink Tinged vaginal discharge or pelvic pressure
Cervical shortening via transvaginal ultrasound
Nursing management for incompetent cervix
Continue surveillance and close monitoring for preterm labor
Emotional support
Education
Inserted in the cervix to prevent preterm cervical dilatation and pregnancy loss. After placement the string is tightened and secured anteriorly.
Cerclage
Painless bleeding with relaxed uterus
Avoid vaginal exams
Occurs when the placenta implants near or over the cervical os- Vaginal exams prohibited
Painless bleeding in the 3rd trimester
Placenta Previa
Complications of Placenta Previa
Hemorrhage
Fetal Distress/Demise d/t intrauterine hypoxia
Intrauterine Growth Restriction
Preterm Delivery or Premature rupture of membranes
Nursing Management client with Placenta Previa
Monitoring of maternal fetal status \
Vaginal bleeding and pad count
weight pads
Avoid vaginal exams
FHR
Support/ Education: Fetal movement counts, effects of prolonged bed rest; s/s to report
Preparation of possible cesarean birth
Name types pf Placenta Previa
Low Lying
Partial Placenta previa
Total placenta previa
Premature detachment of the Placenta
Abruptio Placenta
Vaginal bleeding, mild uterine tetany- neither mother or fetus in distress
Mild Abruptio Placenta
Uterine tenderness/ tetany with or without external bleeding ; mother not in shock but fetal distress may be present
Moderate Abruptio Placenta
Uterine tetany; maternal shock, fetus dead or severely compromised
Severe Abruptio Placenta
Nursing Assessment Abruptio Placenta
Risk Factors
Bleeding- Dark red
Pain- Knife like, uterine tenderness, contractions
Fetal movement and activity(decreased)
FHR
Lab/ Diagnostic Testing: CBC, fibrinogen levels, PT/ aPTT, type and cross-match, nonstress test, biophysical profile
Tetany contractions longer than 60 Seconds
Helps to reduce blood loss when nml(blood clot formation)
Fibrinogen
Name Precipitating factors for Placental Abruption
Blunt trauma to abdomen
Drug abuse; especially cocaine
PIH
PROM
Smoking
Multifetal Pregnancies
Nursing management for Placental Abruption
Tissue perfusion
-Left lateral position, strict bed rest, oxygen therapy, vital signs, fundal height, continuous fetal monitoring
Support/ Education: Empathy, understanding, explanations, possible loss of fetus, reduction of recurrence
Want baby out ASAP to help prevent MOM from bleeding out
What position improves circulation, giving nutrient- packed blood an easier route from your heart, to the placenta to nourish your baby
Left Lateral Position
Labor contractions with subsequent cervical changes prior to 36.6 weeks
Preterm Labor
PROM
Premature rupture of membranes prior to onset of labor
PPROM
Preterm premature rupture of membranes- rupture of membranes prior to 36.6 weeks
Without ucs
Name Preterm Labor Medications
Terbutaline
Indomethacin
Nifedipine
Magnesium Sulfate
Betamethasone
Labor suppression/ tocolytic
Beta Adrenergic agonist
2.5 or 0.25 mg SQ or IV
Side Effects
Tachycardia
Trembling
Faint feeling
CHF
Cardiac Arrhythmias
Terbutaline
Brethine
NSAID
Prostaglandin inhibitor
50mg 48-72 hours
May cause nausea and vomiting, headache, fatigue, depression, tinnitus,
May cause failure of PDA to close
Indomethacin
Labor suppression/ tocolytic
Calcium channel blocker
20 mg PO q3-6 to prevent contractures
Low BP, faintness, dizziness, constipation
Nifedipine
Procardia
MGSO4
Labor Suppression
Myosin light chain inhibitor
4-6 gm loading dose, given IV over 30 min followed by 1-4 grams per hour
Side effects
flushing, fatigue, lethargy, resp. depression
Corticosteroid
Used to enhance lecithin/ sphyngomyelin production
12 mg IM every 24 hours x2doses
Betamethasone
Death of the intestines
Necrotizing Enterocolitis
Born between 24-36 weeks
Appearance depends on gestational age
Complications include
RDS
MAS
Hypothermia
Hypoglycemia
Nutritional problems, NEC
CNS trauma
Chronic HTN
Dx prior to pregnancy
Sudden spike in BP
Pre eclampsia
Eclampsia
is more severe and can include seizures and coma.
Diagnosed when preeclampsia occurs in a patient with preexisting chronic HTN
Preeclampsia superimposed on Chronic HTN
Primary or secondary HTN that precedes pregnancy or is present on at least two occasions before the 20th week of gestation or persists longer than 12 weeks postpartum
Condition happens when you only have high BP during pregnancy and do not have protein in your urine or other heart or kidney problems
Gestational HTN
HTN that arises in 2nd or 3rd trimester
HTN is usually detected in the clinic but then settles with repeated BP readings such as those taken during the course of several hours in a days assessment.
Transient
Present and observable before pregnancy
or HTN that is diagnosed before the 20th week of gestation
Persists beyond the 84th day postpartum
Chronic HTN
84th day PP this is why pp tx and close monitoring is key
Chronic HTN
Pt will be readmitted and way from their baby
HTN that is present and observable before pregnancy or htn that is diagnosed before the 20th week of gestation and persists beyond the 84th day pp
Chronic HTN
Pregnancy specific systemic syndrome
Increase in blood pressure
Systolic: greater than 140
Diastolic greater than 90
Occurring twice, 4 hours apart after 20 weeks gestation accompanied by proteinuria
Excretion of greater than or equal to 300 mg protein/ 24 hours
Pre Eclampsia
HTN and no proteinuria prior to 20 weeks gestation and new onset proteinuria - defined as the urinary excretion of 0.3 mg of protein in a 24 hour specimen)
HTN and proteinuria before 20 weeks gestation :
1. Sudden increase in protein - urinary excretion of 0.3 g protein or more in a 24 hour specimen, or two dipstick test results of 2+ with the values recorded at least 4 hours apart, with no evidence of UTI
- Sudden increase in BP after period of good control
- Thrombocytopenia lower than 100,000
- Increase in liver enzymes ALT or AST to abnormal levels
Preeclampsia Superimposed on Chronic HTN
Temporary diagnosis that refers to blood pressure elevation occuring after mid pregnancy without proteinuria
Gestational HTN
Used only after pregnancy, describe women who develop gestational HTN but have no preeclampsia and whose blood pressure returns to normal within 12 weeks pp
Transient HTN
Gestational HTN Signs and Symptoms
Sudden Weight Gain
High BP
Edema
Progression of Events of Preeclampsia
Vascular Sensitivity
HTN
Renal Ischemia
Proteinuria
Intravascular to Interstitial Fluid Shift
Edema
Hemoconcentration
Diseased of pregnancy of unknown causes
Can occur antepartum, intrapartum, or postpartum periods
Most often characterized by HTN, proteinuria, and edema, may also see
H/A, epigastric pain, seizure
Gestational Hypertension
Vasoconstriction
HTN
edema
hypovolemia
hemoconcentration
decreased perfusion to vital organs
Pathology of Preeclampsia
Increased sensitivity and response to vasopressors=
Vasoconstriction
Increased peripheral resistance =
HTN
Loss of fluid in to interstitial space
Edema
Decreased fluid in intravascular space
Hypovolemia
Reduced blood volume =
Decreased perfusion to vital organs
Medications for Preeclampsia with severe features
Mag sulfate
Calcium gluconate
Labetalol
Apresoline
Aldomet
Nifedipine
Magnesium Sulfate
1gram to 6 grams per hour via IV
Always on an infusion pump
Careful observation
Reversal agent for magnesium sulfate
10% 10 ml iv push over 1-2 minutes
Calcium Gluconate
Use caution for asthma, diabetes, liver or kidney complications 20 mg IV push
repeat 20-80 mg every 5 minutes until desired effect or total of 300 mg
Labetalol
PO 100 mg intially
increased dose by 100 mg q12h every 2-3 days
Usual dose range 200-400 mg PO q12hr
not to exceed 2400 mg/ day
Labetalol PO
5-10 mg IVP every 20 min until desired effect
Apresoline
250 -500 mg PO TID up to 750mg-1000 mg
Aldomet
10-30 mg PO daily
up to 30-90 mg daily
Nifedipine
Careful monitoring required to prevent respiratory collapse
Should include hourly VS, O2 saturation, auscultation of lung sounds and DTRs, I/Os
Infusion should always be on a pump
Lab survelliance of Mag sulfate
Calcium gluconate and toxemia box and monitoring available
Discontinue infusion if pt exhibits s/s of resp. depression
Fall risk precautions
Care of GH Pt on Mag Sulfate
Kaiser MgSO4
bag /100 ml - 4 g bolus and 2 gm per hour
Change bag every two hours, VS, resp. assess, DTR’s i/o
Sutter 40 gm/1L
4-6 gm bolus, 2 gm hour change bag less often vs, resp. assess, I/O, DTRs
Severe and life threatening complication related to pre-eclampsia
Occurs in 3rd trimester
Hemolysis- RBC breakdown
Elevated Liver enzymes
Low Platelet count
HELLP Syndrome
Result of the arterio lar vasospasms in the CV system that occur in preeclampsia, circulating RBCs are destroyed as they try to navigate through the constricted vessels (Hemolysis)
Vasospasms decrease blood flow to the liver, resulting in tissue ischemia and hemorrhagic necrosis.
In response endothelial damage caused by vasospasms, platelets aggregate at the site and fibrin network is set up, leading to decrease in platelets
HELLP SYNDROME
Hemolysis
Elevated Liver enzymes
Low platelet count
HELLP tx is
Focused on decreasing BP and preventing seizures
Only give rhogam if mother is
Negative
Administered at mid pregnancy to prevent any development of anti -D antigen while fetus in utero.
Rhogam
When should newborn be tested for RH factor?
After delivery
If infant is positive
Rhogam should be administered to mom to prevent antibody formation and destroy any antibodies that may be formed in the mom and protects against future pregnancies. Infant should be observed for hyperbilirubinemia.
Should also be given for pt who have spontaneous or therapeutic abortion or injury to abdomen or placenta
Glucose norms for fasting
70-80 mg/dl
Pregnant glucose norm
65 mg/ dl
2hr PP= 660-110 mg/ dl
Pregnant < 140 mg/ dl
Hormone that metabolizes glucose
insulin
Hormone that stimulates conversion of glycogen to glucose
Glucagon
Polysaccharide stored in animal cells
Glycogen
Placental hormone which interferes with ability of insulin to transport glucose
HPL
Human Placental Lactogen
Placental enzyme which accelerates insulin breakdown
insulinase
What other hormones interfere with insulin effectiveness during pregnancy?
Cortisol, estrogen, and progesterone
Low blood glucose
Hypoglycemia
Treat ASAP
Acidosis accompanied by accumulation of ketones in the body, resulting in extensive breakdown of fats due to faulty carbohydrate metabolism
ketoacidosis
Juvenile onset and beta cell destruction
Type 1
Adult onset
Exhaustion of beta cells
Hyperinsulinemia
Impaired glucose tolerance
Type II
Other type includes genetics, pancreatic disease, endocrinopathies, drug induced, infection, immune mediated and syndromes
Type III
Glucose intolerance of pregnancy
Serum glucose alterations in pregnancy
Glycosuria
Facilitated transport of glucose from maternal to fetal system
1st trimester nausea and vomiting
Estrogen mediated storage of glucose as glycogen
HPL
Insulinase
Gestational Diabetes
Maternal effects of gestational diabetes
PIH
HTN
Vascular damage
UTI
Dystocia and C section
Polyhydramnios
Emotional
Infection or inflammation of the vagina caused by yeast like fungus
Monilial Vaginitis
Emotional- stressors, frequent visits, hospitalization, diabetic protocol and fetal damage
Fetal effects of gestational diabetes
Risk of
fetal demise/ stillbirth
RDS- insulin decreases surfactant
Macrosomia or IUGR
Neonatal hypoglycemia
Risk for congenital anomalies especially cardiac and neuro
Diabetes in pregnancy goal is to
Maintain euglycemic state and deliver viable fetus
Pre Gestational diabetes management include
History
Physical exam
Prenatal Assessments
Lab Surveillance
- Urine glucose, ketones, and protein
- 24 urine total protein and creatinine
- Serum glucose- accu-checks
- HgbA1C
Blood test used during pregnancy to check baby risk of birth defects and genetic disorders
such as Neural or Down syndrome
AFP Blood test
Fetal Surveillance
Ultrasound
AFP
Urine estriol and serum estriol
Weekly NST from 34 weeks
Biophysical profile
Amniocentesis
Hormone helps uterus grow and stay healthy. Prepares as their body for childbirth and breastfeeding.
Estriol
too high or low may indicate problem with baby or pregnancy
Way to assess lung maturation?
L/S ratio
12- 16 weeks for genetic analysis
Amniocentesis
3rd trimester for lung maturity
L/S should be 3:1 or greater
Positive PG
How many kcal in pregnancy per day
2000 -2200
Need 3 meals and 3 snacks
50 c
30 fats
20 protein
Glucose monitoring in diabetes in pregnancy
Fasting and after meals - 2hr PP preferred
Fasting< 95; PP 120-140
May require frequent changes in insulin dosages
Oral hypoglycemic are not used during pregnancy, why?
Potential teratogenic effects and can cause severe neonatal hypoglycemia.
Except for glyburide which does not cross placenta and can be used for GDM
______________ found to be comparable to insulin in improving glucose control without evidence of adverse maternal and neonatal complications
Glyburide
Glynase/ Micronase
Insulin Therapy
1st trimester same as prepregnancy
2nd and 3rd trimester dosages increase d/t HPL and insulinase - progressive insulin ineffectiveness.
Combination of NPH and regular insulin
May require hospitalization for insulin regulation
May use insulin pump if using prior to pregnancy
Glucose levels of mom directly affect and reflect glucose levels of fetus
Glucose crosses the placenta-insulin does not
At 10 weeks, the fetus begins to produce own insulin
Increased estrogen and progesterone lead to increased insulin production
HPL and Insulinase decrease insulin effectiveness
Diabetes fact on Pregnancy
Glucose testing initials glucose is
> 140 mg/ dl
1 hour is
FBS and 1 hour postprandial
Ingest 50 ml glucola after FBS and test in 1 hr
Norms is fasting 80-120 mg/ dl
1hr PP <140 mg/ dl
3 Hour GTT: FBS and 1,2, and 3 hr PP
Ingest 100 ml glucola after FBS and test X3
Norms- FBS- 80-120 mg/ dl
1hr- <190 mg/ dl
2hr- <165 mg/ dl
3hr- <145 mg/ dl
Test is abnormal if 2 out 3 results are abnormal
Oligohydramnios
Polyhydramnios
Meconium
Nuchal Cord
Other cord problems
True Knot
Body or Limp Wrap
Amniotic Fluid Complications
Low fluid volume
Oligohydramnios
Poly- High fluid volume
Meconium- fetal stool in amniotic fluid
Nuchal cord- cord around fetal neck
Other cord problems include- true knot, cord around limbs or body
Acute and rapid collapse of mother and or fetus caused by allergic reaction to amniotic fluid entering the maternal circulatory
System initially, causes rapid resp. collapse, then hemorrhage and leading to DIC
AFE/ASP
Tx for AFE/ ASP
Supportive
Massive transfusion therapy
Surgical removal of uterus may be needed to control bleeding
______ is unpredictable and often fatal and unpreventable. Diagnosis comes post mortem.
AFE/ASP
Amniotic fluid greater than 2000 ml
Hydramnios
Therapeutic management of Hydramnios
Close monitoring
Removal of fluid
Indomethacin- decreases fluid by decreasing fetal urinary output
Nursing Assessment of Hydramnios
Risk Factors
Fundal height
Abdominal discomfort
Difficulty palpating fetal parts or obtaining FHR
Nursing Management: Ongoing assessment and monitoring and assisting with therapeutic amniocentesis
Amniotic fluid less than 500 ml
Oligohydramnios
Therapeutic management: serial monitoring, amnioinfusion, and birth for fetal compromise
Nursing assessment : continuous fetal surveillance, assistances with amniofusion, comfort measures, position changes
May be admitted for hydration therapy, impending delivery
Symptoms usually resolve by week 20
Weight loss more than 5% of pre pregnancy body weight
Dehydration, metabolic acidosis, and hypokalemia
Hyperemesis Gravidarum
Severe form of nausea and vomiting
Therapeutic management: Conservative
Hospitalization with parenteral therapy
Nursing Assessment for Hyperemesis Gravidarum
Onset, duration, diet, risk factors, weight, associated symptoms, perception of situation, liver enzymes, CBC, BUN, Electrolytes, Urine Specific gravity , ultrasound
Nursing Management of HG
Comfort and nutrition
-NPO, IV fluids, hygiene, oral care, and I/O
Support and Education: reassurance
Women who experience this are miserable, often times will have PICC line places and have IV therapy at hoe of nausea meds and IVF
