Week 3: High Risk Antenatal Care Flashcards
when does high risk preg status extend to
6 weeks postpartum
what are common causes of early bleeding, and what increases the risk
common causes:
- miscarriage
- premature dilation of cervix
- ectopic pregnancy
- molar pregnancy
increased risk w advanced client age, smoking exposure, prior preterm birth
describe miscarriage/spontaneous abortions
prior to 20 weeks gestation or 500g fetal wt
i) early under 12 wks
ii) late btwn 12-20 wks
approx 15-20% of preg end in miscarriage
- 50% of early miscarriage come from chromosome abnormalities
- risks: maternal endocrine imbalances, immunological factors, systemic disorders
w an inevitable miscarriage, B-hCG levels will be
lower than norm
s/s of miscarriage
- uterine bleeding
- cramping
- low back pain
- test: B-hCG, ultrasound to confirm viability or loss
- CBC to screen for anemia and infection
- emotional support
what are types of spontaneous abortion (6)
- threatened
- inevitable
- incomplete
- complete
- missed
- recurrent
what is a threatened miscarriage
Mild to moderate spotting
bedrest, decreased stress, supportive care
no effective treatment
inevitable miscarriages
Cervix is beginning to dilate
Bleeding is heavy and tissues are starting to pass
Mild-severe cramping
And some ruptured membranes
if all POC passed, no intervention
if retained POC, suction curettage normally
incomplete miscarriage
Bleeding, but placenta is still there
Risk of hemorrhage, infection, and bleeding
Products of conception need to be passed
Malodourous discharge
Cervix remains open
complete miscarriage
Client has passed all products of conception
Now it is beginning to close
missed abortion
Fetus died (missed abortion)
No bleeding, no cramping, internal oz is closed
Needs inducing to manage this
Get a referral to an infertility specialist
most eventually end spontaneously
what happens w premature dilation of cervix
- passive painless dilation of cervix os w/o contractions
- caused by cervical insufficiency or incompetent cervix
- may result in miscarriage or preterm birth
- etiology: hx of cervical trauma, short cervix, uterine anomalies
- transvaginal US to diagnose
how do you manage premature dilation
- restricted activity
- hydration
- cervical cerclage to constrict the internal OS
- risks: PROM, preterm labour, chorioamnionitis
- cerclage removed btwn 35-37 wks
what is an ectopic pregnancy
fertilized ovum is implanted outside uterine cavity
95% of ectopic preg occur in fallopian tube
s/s: abdominal pain progresses from dull to sharp, stabbing pain, delayed menses, abnormal vaginal spotting occuring 6-8 wks after LMP
- Dx: serial B-hCG (lower), transvag ultrasound
how to you manage a ectopic preg (med wise)
- can result spontaneously by tubal abortion
- methotrexate dissolves tubal pregnancy
- follow up care until B-hCG is not detectable
If they have taken methotrexate, they should not have any folic acid, no vitamins, or alcohol as they have adverse effects with the medication and exacerbate the rupture
Also if their pain becomes uncontrollable it can cause internal bleeding, vertigo, hypotension, tachycardia, shoulder pain so they need to be alert. We cannot be masking these symptoms.
how to manage ectopic preg surgically
- depends on location, cause, extent
- salpingectomy (removal of entire tube)
- salpingostomy (incision over preg site in tube and POC gently removed)
molar pregnancy
tissue that normally would be a fetus becomes an abnormal growth in the uterus
benign proliferation of placenta trophoblasts triggers sympt of preg
appears: It is further descended, bc the cells are dividing really rapidly so their height is increased
complete molar preg
no fetus, placenta, amniotic membrane or fluid
(fertilized egg w no genetic maternal in it)
partial molar preg
when egg is fertilized by 2 sperm
embryonic or fetal parts and amniotic cell
how would pt w molar preg present
- Pts present with nausea, vomiting, preeclampsia, and hypertension
- Molar preg and preeclampsia are both thrombo… didn’t catch it all
- Pt comes in and have vaginal bleeding, like prune juice (brownish colour)
There is not a viable pregnancy w a molar pregnancy
Higher risk under the age of 17, and over the age of 35
w a molar preg the B-hCG levels will be
higher than norm
S/S of molar preg
- vag discharge from brown -> red (anemia)
- uterus is significantly larger than expected
- excessive nausea/vomiting
- abdo cramping
- maternal blood has no placenta; hemorrhage into uterine cavity and bleeding occurs
- 70% have preeclampsia
treatments for molar preg
most pass spontaneously
suction can be used
what is not recommended for molar preg
use of oxytocin or prostaglandins not recommended r/t increased risk of embolization of trophoblastic tissue
what are 3 common causes of bleeding late in preg
- placenta previa
- placenta abruption
- variations in insertion of cord and placenta
placenta previa
placenta implants in lower uterine segment and covers (completely or partially) the cervix
transvag ultrasound measurement noted
Placenta implants in lower uterus, sometimes covering the opening meaning it can easily bleed
○ Normal placenta implantation is higher than the uterus
○ Endometrial damage can make implantation more likely to lower uterus because upper uterus is not vascularized enough
○ After 20 weeks, bleeding (intermittent or continuous)
○ Cannot have a vaginal birth if person has this
○ Cervical os covered: bright red bleeding
○ Complete previa: os is fully covered
○ Marginal previa is only partial covered
Painless bleeding, relaxed abdomen
complete previa
covers internal os totally
marginal previa
edge of placenta is 2.5cm or closer to internal os
risk factors for placenta previa
having had it before, previous c-section, suction curettage causing scarring, multiparity, advanced maternal age, smoking, higher prevalence in black or asian individuals
placenta previa clinical manifestations
- painless, bright red bleeding
- occurs in 2nd or 3rd trimester
- abdomen soft, relaxed, non-tender w normal tone
- presenting part of fetus is high b/c placenta occupies lower uterine segment
diagnosis of placenta previa
transvag U/s
complications coming from placenta previa
hemorrhage
abnormal placenta attachment
IUGR, preterm birth, fetal anemia
placenta abruption
detachment of part or all of placenta from implantation side
Prematurity detaching from uterine wall
○ Painful dark red breathing
○ Higher correlation: hypertension, preeclampsia, cocaine use, blunt trauma to abdomen, previous history, smoking, carrying multiples, any coagulation issues
Classified based on the amount of bleeding
risk factors for placenta abruption
HTN, cocaine use, blunt trauma, cig smoking, previous abruption, PPROM, multiples, thrombophilia
- categorized as class 1, 2, 3 depending on amount of separation, amount of bleeding, pain
partial seperation placental abruption
Would not have any bleeding bc its being trapped
complete separation placental abruption
Is sealed
Blood flow to baby is severely compromised
S/S of placental abruption
will vary depending on degree of separation
dark red vag bleeding
abdominal or low back pain that can progress
more severe uterus fails to relax and becomes hypertonic
abnormal FHR or fetal death
maternal hypovolemia
clotting defects
maternal death
A client presents to the birthing unit with complaints of a new onset of a severe headache that has persisted for 2 days. The client is 37 weeks and denies any vaginal bleeding, leaking of fluid, contractions, cramping or abdominal pain. The client indicates she is feeling fetal movement. SFH is 34cm.
BP 168/96
HR 80
RR 20
O2 sat 99%
Temp 37.3
Fetal heart rate 148bpm
Based on these abnormal findings, what additional subjective and objective assessments is important to assess?
SFH should be 35-39, she is at 34 so its lower. This is concerning for low amniotic fluid, and growth restriction.
Her BP is hypertensive and she has a headache. Ask her if she is having any visual changes - preeclampsia? Assess pt’s LOC, do a neuro assessment, Upper quadrant pain - liver? Liver is involved w preeclampsia.
look for protein in the urine, meaning the kidneys are not functioning well.
any chest pain? any SOB? any increased WOB? if kidneys are not working well, albumin builds up in there blood so edema starts to form. this can cause flash pulmonary edema.
HELP syndrome: do bloodwork to see if this is developing.
Periorbital edema - swelling around eyes.
Sudden weight increase due to swelling.
You review the client’s antenatal records and note the following information. What are potential risk factors for developing preeclampsia? Why would the client be on those medications in pregnancy?
38 year old female
G2P1
Pre-pregnancy BMI 23
Previous history of gestational hypertension in last pregnancy (2020), induced at 36 weeks due to a growth restriction.
Medications in pregnancy: Prenatal vitamin, ASA 162mg OD, Nifedipine
No alcohol or smoking.
See slides 33 & additional resources posted on onQ under week 3.
advanced maternal age, previous history = risk
ASA - look at the pharmacological actions: possible risk of stroke, anticoagulation
preeclampsia is a thrombolytic disease, ASA decreases risk of growth restriction to fetus in high risk pregnancies but we stop at 36 weeks to reduce chances of bleeding
Nifedipine - CCB, antihypertensive
Severe preeclampsia -> reflexes become overexaggerated, clonus, hyperreflexive
placenta abruption treatment
depends on gestational age + severity
- steroids to promote lung development
- fetal surveillance
- RH neg may give Winrho if fetal to maternal hemorrhage occurs
- if hemodynamically stable and no acute distress in fetus vaginal birth may be attempted
- c-section performed if fetal compromised, severe, coagulopathy, poor labour progress, increased uterine resting tone
3 categories of hypertension disorders in preg
- pre-existing (chronic) hypertension
- gestational hypertension
- preeclampsia
whats classified as HTN in bp
greater than 140 sBP and/or dBP of 90 mmHg or greater, taken at two seperate times at at least 15 min apart
def of gestational HTN
that appears for for the 1st time at or beyond 20 weeks gestation
what is pre-clampsia
2+ protein
Bp of equal or greater than 140//90 x 2 readings 15 min apart
new onset of proteinuria: concentration of 0.03g/L or more in at least 2 random urine specimens collected at 6hrs apart
what is the diagnosis of proteinuria
should be based on urinary protein: creatinine ratio or 24 hour urine collection
what would we expect from WBC in pre-eclampsia
increased
what would we expect from INR or PTT in pre-eclampsia
elevated
what would we expect from platelets in pre-eclampsia
low
what would we expect from creatinine, uric acid in pre-eclampsia
elevated
what would expect from AST, ALT, LDH, or bilirubin in pre-eclampsia
elevated
what would we expect from albumin in pre-eclampsia
low
what are severe complications of pre-eclampsia
- oliguria
- altered LOC, confusion, headache
- eclampsia or stroke
- scotoma or blurred vision
- hepatic damage or rupture
- RUQ pain
- impaired liver function, elevated liver enzymes
- thrombocytopenia w platelets less than 50x109/L
- anemia
- pulmonary edema
- fetal growth restrictions
what is eclampsia
rare but serious
causes seizures that can occur before during or after birth (usually 48hrs)
preceded by: headache, severe epigastric pain, hyperreflexia
placenta, liver, kidneys, brain is depressed as much as 40-60%
what causes the seizures in eclampsia
from the profound cerebral effects of pre-eclampsia
what are deep tendon reflexes
normal response to bicep and patellar reflexes is +2
hyperactive response noted w increasing severe preeclampsia
intermittent or transient clonus
HELLP syndrome
life threatening preg complications
symptoms of severe preeclampsia plus…
hepatic dysfunction categorized by:
(H) hemolysis
(EL) elevated liver enzymes
(LP) low platelets
- impaired liver function
- can exhibit RUQ pain
HELLP syndrome is associated w increased risk of
placental abruption
renal failure
pulmonary edema
ruptured liver hematoma
disseminated intravascular coagulation
fetal and maternal death
small for gestational age infants
Nursing management for severe pre-eclampsia and HELLP syndrome
- hospital care
- meds to control BP
- low dose aspirin
- monitor for seizure activity -> magnesium sulfate
- lateral position to facilitate blood flow to placenta
- monitor pain
- delivery of infant may be warranted
4 medications for HTN
-labetalol
-nifedipine (adalat)
-hydralazine (apresoline)
-aldomet (a-methyl-dopa) (not acute management but w chronic)
medication management of eclampsia
magnesium sulphate is best for seizures prophylaxis and therapy in preg
works on cerebral irritability
what is the magnesium sulphate dosage for eclampsia
4 gm IV bolus followed by 1-2 gm/hr IV
side effects of magnesium sulphate for eclampsia + what to monitor
weakness, paralysis, cardiac toxicity
monitor reflexes, respiration, LOC, urinary output
what to do if toxicity is suspected from mag sulphate in eclampsia
- discontinue and provide resp support
- notify physician
- monitor blood levels of MgSO4
- 10% calcium gluconate is the antidote!!
what are some MAJOR nursing alerts from mag sulphate
- at risk for boggy uterus and increased lochia flow related to muscle-relaxant action of mag sulphate
- uterine tone and lochia flow need to be monitored closely
what is GDM
- increased glucose levels recognized 1st in preg
- 3.8-6.5% of pregnancies
- risk of developing glucose intolerance later in life
- usually after 20 wks of preg
risk factors for GDM
- advance maternal age 35+
- previous GDM
- obesity BMI greater than 30
- PCOS
- corticosteroid use
- type 2 DM hx
screening for GDM
1. when to do it
screen at 24-28 wks
if there is a high risk
if initial is done before 24 wks redo btwn 24-28 wks
how do they screen for GDM
- sequential screening 50g glucose challenge and diagnostic 100g glucose tolerance test
one step: fasting 75g GTT
- In pregnancy blood sugars can be really hard to control - frequency of appointments will increase to monitor for complications and likely a plan for induction For the post-partum patient: - Risk for macrosomnia - overdistention - Really accurate assessments - Lactation - casues changes to metabolism, that are protective for an individual with gestational diaebtes (GD) - Breast milk for 8 months have a reduced risk of developing type 2 diabetes later in life - Increased risk of infection for GD mothers breast feeding
*many symptoms of hypoglycemia in pregnancy, just sound like normal changes in pregnancy for example lightheadedness, peeing more, confusion, sweating, trembling
what are complications of GDM
twice the risk for pre-eclampsia
- fetal macrosomia: increase rates of perineal lacerations, episiotomy, shoulder dystocia, birth trauma, caesarean birth
- newborn hypoglycemia, IUGR, intrauterine fetal death
what is the target blood glucose level for antenatal nursing care
3.7-6.7 mmol/L
when do u want to have ur induction of labour planned btwn
38-40 wks
what is the most common symptom of molar pregnancy
severe morning sickness (hyperemesis gravidarum)
A client at 7 weeks presents to ER with vaginal spotting, vertigo, shoulder pain, hypotension, and tachycardia. What potential complication is consistent with this presentation?
Tearing of the fallopian tubes
when does pre-eclampsia typically occur during preg
during the 3rd trimester
what is a possible symptom that could indicate a possible complication of preeclampsia
visual disturbances such as blurred vision or flashing lights
what is a condition where the placenta is located in the upper part of the uterus
typical presentation
a condition where the placenta attaches to deeply to the uterine wall
placenta increta
a condition where the placenta partially or completely covers the cervix
placenta previa
a condition where the placenta becomes detached from the uterine wall
placental abruption
why does a fetal deceleration happen
less blood flow to fetus therefore decreased HR
