Week 5 Flashcards
Problems during pregnancy
When might an incompetent cervix happen?
Starts in the second trimester or early in the third trimester
what is it called when there is dilation of the cervix but there is no pain and might lead to possible delivery of a premature fetus?
Incompetent or insufficient cervix
What is the difference between dilation in an incompetent cervix and actual labor?
there is painless dilation in an incompetent cervix
how might cervical insufficiency be diagnosed?
Ultrasound
what are risks of cervical insufficiency to the woman?
Repeated second or third trimester births
recurrent pregnancy losses such as spontaneous abortions
Preterm delivery
Rupture of membranes and infection
what are the assessment findings of cervical insufficiency?
Reports of pelvic pressure and increased mucoid vaginal discharge
Shortened cervical length or funneling of the cervix
obstetrical history of second trimester cervical dilation or fetal losses
Live fetus and intact membrane
incompetent cervix is associated with_____, _____, and_____ factors
advanced maternal age
Congenital structural defects
Trauma to cervix
What is the medical management treatment for an incompetent cervix?
Obtain ultrasound
cervical cultures for chlamydia, gonorrhea, and other infections
cerclage
administer antibiotics or tocolytics if indicated
remove sutures when membranes rupture, infection or labor
What are signs and symptoms of incompetent cervix?
pink vaginal discharge
Increased pelvic pressure
can progress to PROM, contractions, labor, and birth
What are two types of cervical cerclage regarding timing?
Prophylactic between 12 and 16 weeks
rescue after 24 weeks gestation
What is the cerclage procedure that involves sewing a suture in the cervix?
Shirodkar
What are management for cervical insufficiency?
Bedrest
Pelvic rest
Cerclage
What is twin-to-twin transfusion syndrome?
There is an imbalance in blood flow through the vasculature of the placenta due to arteriovenous anastomosis in the placenta, leading to overperfusion in one and underpufusion and anemia of the other
Dizygotic twins have how many eggs and sperm?
Two eggs and two sperm
Dichorionic means how many what?
Two placentas
Which type of sac and placental configuration are dangerous? Why?
Monochorionic and monoamniotic because cord entanglement and discordant growth, conjoined twins, twin anemia-polycythemia sequence, and TTTS
What hormone increases the risk of Gestational diabetes?
Increase in hPL antagonizes insulin in the body to spare glucose for the developing fetus
Hyperemesis gravidarum is typically related to rapidly rising hormones such as____.
hCG
Hyperemesis gravidarum is vomiting during pregnancy that is so severe that it leads to what four things?
Dehydration, electrolyte, acid base imbalance, starvation ketosis, and weight loss
what is the medical management of hyperemesis gravidarum?
Vitamin B6 or B6 and doxylamine, IV fluids, dextrose and vitamins
In refractory cases of nausea and vomiting and pregnancy, what are some effective treatments?
H1 receptor blockers, phenothiazine, and benzamides
what are some signs and symptoms of hyperemesis gravidarum dehydration?
Dry mucus membrane, poor skin turgor, malaise, low blood pressure
What are some hormones abnormalities of hyperemesis gravidarum?
Thyroid (TSH)
Liver (ALT/AST)
what are some lab studies to monitor during hyperemesis gravidarum?
Kidney and liver function
what are some things that a woman can do to limit hyperemesis gravidarum?
Assess factors that reduce nausea and vomiting such as foods and odors
using anti emetics
remain NPO until vomiting is controlled and then slowly advance diet
ginger products potentially
What is one of the main concerns of hyperemesis gravidarum?
Correcting electrolytes and fluids
What are the symptoms of Hyperemesis gravidarum?
Vomiting more than 3-4 times a day, sever dehydration, weight loss, decrease in urination, hypotenision
What is the difference between preeclampsia and eclampsia syndrome?
Eclampsia is the onset of convulsions or seizures that can’t be attributed to other causes in a woman
What is the 3-hr GTT on a separate day after 8-12 hrs?
If there is a positive test of 135-140 with the initial, test, take another after 8-12 hrs of fasting
Ingest 100g glucose load
Take plasma levels at 1,2,3 hrs
Fasting is 95 or hgher
1 hr of 180 or higher
2 hrs of 155 or higher
3 hrs of 140 of higher
*if 2+ are higher, then GDM
What do you never do when someone has a seizure?
Put something in their mouth and leave the patient
What type of seizures are common in eclampsia?
Grand mal
what are some things you do when controlling the airway of a patient with seizures?
Lower the head of the bed and turn the head to one side
Anticipate the need of suctioning do decrease operation risk by having supplies on hand
what type of drug is used to control seizures in eclampsia and preeclampsia during labor?
Magnesium sulfate
What are some cardiovascular and neurological complications of cocaine use?
Hypertension
Tachycardia
Uterine contraction
Myocardial infarction
dysrhythmia
Thrombocytopenia
Subarachnoid hemorrhage
Seizures and death
In women over 40 the risk increases for____ ____, ____ ____, _____ ____, and ____ ____
Placenta previa, placenta abruptio, cesarean deliveries, gestational diabetes
what are the two classic presentations/signs of placenta previa?
Painless bright red hemorrhage and fetal malposition
What are the two major causes of antepartum hemorrhage?
Placenta previa and placental abruption
why does placenta previa cause bleeding in the third trimester?
When uterine contractions dilate the cervix it applies shearing forces to the placental attachment to the lower segment or when revoked by vaginal examination
what is it called when the placenta attaches to the lower uterine segment of the uterus near or over the internal cervical os instead of the body or fundus of the uterus?
Placenta previa
__ ___ is most often diagnosed before the onset of bleeding when an ultrasound is performed for other indications.
Placenta previa
what is it called when the placenta completely covers the internal cervical os?
Total placenta previa
what is a way to manage placenta previa in an emergency?
C-section delivery
vaginal delivery with low lying placenta
Blood transfusion
how would you confirm the placental location? And when?
With an ultrasound at 20 weeks
what are the four classifications of placenta previa
total
partial
marginal
low-lying
What are the risk factors that can cause placenta previa?
Endometrial scarring from previous placenta previa and c-section, and abortion
multi parity
impeded endometrial vascularization
advanced maternal age
diabetes or hypertension
Cigarette smoking
Urine abnormalities such as fibroids or endometriosis
Increased placental mass from a large placenta or multiple gestation
what are the risks to the fetus and newborn of placenta previa?
Detachment can result in progressive deterioration due to blood loss
blood loss, hypoxia, anoxia, and death
Fetal anemia from maternal blood loss
Neonatal morbidity and mortality from prematurity
how much blood might a woman lose before they start exhibiting signs of hemorrhagic hemodynamic changes in blood pressure and pulse?
About 40%
why is a sterile vaginal exam contraindicated in all pregnant women with extensive bleeding until the bleeding is identified?
Bleeding might be due to a placenta previa and an exam could dislodge the placenta
what are some things to monitor if woman has placenta previa?
FHR and UCs
labs such as CBC, platelets, and clotting studies
what are some risks to the women with placenta previa?
Hemorrhagic and hypovolemic shock
Large volume of maternal blood flow to the uteroplacental unit at term can result in exsanguinations in 10 minutes
Anemia
Potential RH sensitization for negative women
what are some things to do if a woman has placenta previa?
Start IV access with large bore
Ensure availability of hold clot and blood components
Give corticosteroids if indicated
Administer RhoGAM if necessary
what type of bleeding is associated with placenta previa?
Bright red painless at the end of the second trimester into the third, usually light
When does placenta previa usually bleed?
End of second to third trimester?
What are nursing actions for placenta previa?
Bedrest
Fetal monitoring
Monitoring for contractions and PTL
VS
IV
Observe for bleeding
Type and cross
what is it called when there is premature separation of normally implanted placenta?
Placental abruption
what is another word for placental abruption?
Abruptio placenta
placental abruption is initiated by____ into the____ ___
Hemorrhage
decidual basalis
how does a placental abruption form?
A hematoma forms that leads to destruction of the placenta adjacent to it
Sometimes spiral arterials that nourish the decidua and supply blood to the placenta ruptures
what are the signs and symptoms of abruption?
Sudden severe onset of intense abdominal pain
Uterine contractions and tenderness
Dark vaginal non clotting bleeding sometimes
signs of hypovolemia
abnormal fetal heart rate
how frequent do PLACENTAL abruption occur?
One out of 200 deliveries
What are risks of preeclampsia for the fetus and newborn?
Premature delivery
intrauterine growth restriction related to decrease in uteroplacental perfusion
low birth weight
Fetal intolerance to labor
Still birth
the separation of placenta can be graded how?
Grade one (mild)
grade 2 (moderate)
grade 3 (severe)
what is it called when the blood is trapped between the placenta and decidua? What are the S/S?
Concealed hemorrhage that occurs in about 10% of abruption leading to abdominal pain and uterine tenderness
what is considered a mild Grade 1 placental abruption?
Less than 1/6 of the placenta separates prematurely and there is a total blood loss of less than 500 milliliters
what grade of placental abruption would you find total blood loss between 1000 to 1500 milliliters?
Moderate or grade 2
what are the fibrinogen levels of a grade 2 placental abruption?
Fibrinogen of 150 to 300 mg/dL
from what grade and on of placental abruption would you have uterine tenderness and pain in the abdomen?
Grade two and on
what is the normal fibrinogen level?
450 milligrams per deciliter
when does DIC usually occur in a placental abruption?
Early signs start at a moderate or grade 2 and for sure in a severe unless treated immediately
what are some risks to the fetus and newborn of placental abruption?
Preterm birth
Hypoxia, anoxia, neural injury, and fetal death related to hemorrhage
IUGR
Neonatal death
what are some risks to the women of placental abruption?
Hemorrhagic shock
DIC
Hypoxic damage to organs such as kidneys and liver
Postpartum hemorrhage
what are some risk factors of placental abruption?
Previous abruption increases risk to 15%
Hypertensive disorders of pregnancy
Abdominal trauma
Drugs and cigarette smoking
Preterm premature rupture of membranes
Thrombophilia
Uterine abnormalities and fibroids
at what grade level would you find total blood loss of greater than 1500 milliliters?
Severe or grade 3
what are the signs and symptoms of a grade 3 placental abruption?
Turn blood loss of 1500 milliliters or 30% of total blood loss
Dark vaginal bleeding
Abrupt onset of uterine pain like a tearing, knife like and continuous
Board like and hard uterus
what are some maternal assessment findings in a woman with placental abruption?
Hypovolemic shock, hypotension, oliguria, thready pulse, shadow and irregular respirations, pallor, cold clammy skin, and anxiety
Vaginal bleeding but can be concealed
severe abdominal pain
Uterine contractions, tenderness, hypertonus, increasing uterine distension
Nausea and vomiting
Decreased renal output
Port-wine colored amniotic fluid
Positive Kleihauer-Betke test (fetal RBC in maternal blood)
fetal assessment findings of a placental abruption include?
Tachycardia
Bradycardia
Category two or three FHR including loss or variability of FHR, late accelerations and decreasing baseline
emergency medical treatment of abruption of placenta?
Monitoring maternal volume status
Restoring blood loss
Monitoring fetal status
Monitoring coagulation status
Correcting coagulation defects next client expediting delivery
what would you palpate the uterus for in a placental abruption?
Contractions, tenderness, hypertonus, increasing uterine dissension
With placenta accreta spectrum, how much blood can the woman loose?
3,000mL
What do TORCH infections stand for?
Toxoplasmosis
other or hepatitis B
Rubella
Cytomegalovirus
Herpes simplex virus
What is the method of transmission of toxoplasmosis?
Transplacental
What are the fetal effects of toxoplasmosis?
Severity varies with gestational age and congenital infection, and incidence is low
Spontaneous abortion
Low birth weight
And panel splenomegaly
Icterus
Anemia
Chorioretinitis
Neurological disease
What are the effects of toxoplasmosis?
Mostly asymptomatic but can cause fatigue, muscle pains, pneumonitis, myocarditis and lymphadenopathy
What and when is the treatment for toxoplasmosis
Treat with sulfadiazine or pyrimethamine after the first trimester
what is a way to manage toxoplasmosis infection?
Avoid eating raw meat in contact with cat feces
Method of transmission with hepatitis?
Direct contact with blood or body fluid from an infected person
what are some ways to prevent hepatitis B infection?
Universal screening during pregnancy and HBV during pregnancy
what are the maternal effects of hepatitis B infection?
30-50% Of infected women are asymptomatic
Low grade fever
Nausea
Anorexia
jaundice
Have paddle megaly
Preterm labor and delivery
what are some ways to prevent rubella infection
rubella immunization three months before getting pregnant or postpartum
what is a way to manage hepatitis B infection for the infant?
Infant receives HBIG and hepatitis vaccine at delivery
what are the effects of hepatitis B infection to infants and fetus?
Infants have a 90% chance of becoming chronically infected, HBV carrier, and a 25% risk of developing significant liver disease
what are some effects of rubella on the fetus?
Deafness, eye defects, CNS abnormalities, and severe cardiac malformations
what are some ways rubella or German Measles are transmitted?
Nasopharyngeal secretions and transplacental
what are some maternal symptoms of rubella?
Erythematous maculopapular rash, lymph node enlargement, slight fever, headache, malaise
which torch infection does not have a treatment?
Cytomegalovirus
what are some ways cytomegalovirus can be transmitted?
Droplet contact and trans placental
what are some maternal symptoms of cytomegalovirus?
Mostly asymptomatic but 15% may have mononucleosis like syndromes
what are some effects on the fetus of cytomegalovirus infection?
Depends on which trimester the mother was infected.
May result in low birth weight
IUGR
Hearing impairment with microcephaly
CNS abnormalities
which torch infection does not have a treatment?
which torch infection does not have a treatment?
Cytomegalovirus
how does herpes simplex virus get passed on?
Contact at delivery and ascending infection
how does HSV present in mother?
Painful genital lesions on external or internal genitalia
what is the transmission rate from mothers to infants of HSV?
30 to 50% among women who acquire HSV near time of delivery and less than 1% among those with recurrent genital herpes
what happens if an infant is exposed to HSV?
50 to 60% of neonatal exposure is active primary lesion is related to neuro complications of massive infection sepsis and neurological complications
what is used to suppress the outbreak of lesions of HSV?
Acyclovir
what is the most common viral STI?
HSV
what is a way to protect the neonate from HSV exposure?
Protect the neonate from exposure with cesarean delivery if active lesion
What disease is the most common cause of meningitis, pneumonia, and sepsis
GBS
What is the most common infection in the mother?
If a mother tests positive for GBS, and is allergic to penicillin, what would you give them?
Cefazolin
When would you do a C-section with HSV?
Any lesion or active outbreak at the time of delivery
what are the risks to a woman with STI?
PID, which can lead to infertility, chronic hepatitis, cervical and other cancers
PTL, PROM, and uterine infection
what are the risks to the fetus of STI?
STI is crossing the placenta or during birth
preterm birth, low birth weight
Neonatal sepsis
Neurological damage
which disease is known as the silent disease?
Chlamydia because there are no symptoms usually
what are the symptoms of chlamydia?
Usually there are none but may have burning on urination or abnormal vaginal discharge
what are the fetal effects of chlamydia infection? When might the baby get it?
Contact at delivery can cause conjunctivitis or premature birth
how would you manage chlamydia infection?
Antibiotics such as amoxicillin, azithromycin, and erythromycin
Can lead to PID
Treat all infected partners and retest in three weeks
how does gonorrhea present?
Usually asymptomatic
May have burning on urination
Increased purulent green yellow discharge
Bleeding during periods
Rectal itching if infected with discharge and bleeding
how is gonorrhea passed on to the fetus?
Contact at birth
what are some effects of gonorrhea infection of the fetus?
Ophthalmia neonatorum May cause sepsis and or blindness
what is the management of gonorrhea?
Antibiotics such as Cephalosporin
what is a teaching for the treatment of gonorrhea?
It needs to be treated because it can lead to PID
Complete the entire treatment
what are the symptoms of Group B streptococcus?
Usually asymptomatic carriers but can include abnormal vaginal discharge urinary tract infections
Chorioamnionitis
what can happen with a GBS infected fetus?
Invasive GBS with permanent neurological sequelae
what happens if a patient was GBS positive at 35 to 37 weeks gestation or unknown?
Treat with antibiotics and labor to prevent neonatal transmission with penicillin or ampicillin IV
90% of infected infants with____ have chronic infection and cirrhosis of the liver
Hepatitis B
What happens if a woman has warts from HPV?
They can be removed during pregnancy
What is the treatment for syphilis?
Penicillin
which disease causes ulcers or chancres, then maculopapular rash advancing to CNS and multi organ damage
Syphilis
what can syphilis cause in fetuses and infants?
Preterm birth
Physical deformity
neurological complications
Still birth
Neonatal death
what is the treatment for trichomonas?
Metronidazole
what is are some signs and symptoms of trichomonas infection?
Malodorous yellow green vaginal discharge and vulvar irritation
what can happen to the fetus with trichomonas infection?
Premature rupture of membranes and preterm labor causing preterm delivery and low birth weight
respiratory and genital infection
what would you give for a patient with candida albicans?
Topical azole therapies
What kind of STI will cause a fishy odor and vaginal discharge?
Bacterial vaginosis
what are the fetal effects of bacterial vaginosis?
Premature rupture of membranes
Corio amnionitis
Preterm birth
what are the treatments for bacterial vaginosis?
Metronidazole or Clindamycin
for which STD is breastfeeding contraindicated?
HIV or AIDS
What has been shown to be effective treatment for HIV to not be passed on to the fetus?
Early antiretroviral treatment
What is the incidence of placental transmission of HIV to the fetus with and without antiretroviral medications?
With is less than 2%
Without is 15 to 25%
What are some ways HIV/AIDS can be transmitted?
Trans placental
Intraparietal
Breast milk exposure
Factors associated with increased perinatal transmission of AIDS?
Mother with aids
preterm delivery
decreased maternal CD4 count
high maternal viral load
chorioamnionitis
blood exposure due to episiotomy, vaginal laceration, and forceps delivery
what are some nursing actions in the antepartal period of HIV disease care?
Adequate sleep
Adequate diet as protein deficiency can depress immunity
Adequate zinc and vitamin A for solid growth
Avoidance of infection
What are some nursing actions in the intrapartum period of delivering a baby with a mother with AIDS?
Avoid using instruments during birth
the fetal membranes intact
Avoid fetal scalp electrode
Avoid episiotomy and assisted vaginal delivery
What are the top 3 estimated incidences of STI in pregnant women annually?
Bacterial vaginosis
Herpes simplex
Chlamydia
BACH
What is a trophoblast?
The outer cell layer of a blastocyst that will assist in implantation to become part of the placenta
what is the enzyme secreted by the trophoblast refer to and what does it do?
Now referred to as the chorion which digests the surface of the endometrium and to digest the surface of the endometrium and preparation for implantation of the blastocyst
What are the three layers of the endometrium?
Decidua basalis
Decidua capsularis
Decidua Vera
which layer of the endometrium directly forms the maternal portion of the placenta?
Decision basalis
What is it called when there is an abnormality of implantation defined by a degree of invasion into the uterine wall of trophoblasts of placenta?
Placenta accreta
What is the difference between placenta accreta, increta and percreta?
Accreta- trophoblast is beyond the normal boundary
Increta- trophoblast extends into the uterine myometrium
Percreta- trophoblast extends into the uterine musculature and can adhere to other pelvic organs
Gestational trophoblastic disease is categorized into ____ and ___ tumors?
Molar and non molar
non molar tumors are grouped as____ or ____ ?
Gestational trophoblastic diseaseor malignant gestational trophoblastic disease
Hydatiform mole is a type of what gestational trophoblastic disease?
Non malignant
what is it called when there is a benign proliferating growth of the trophoblast where the chorionic villi develop into edematous, cystic, and vascular transparent vesicles that hang in grape like clusters without a viable fetus?
Hydatiform mole
Proliferation of the placenta and trophoblastic cells can absorb fluid from where?
Maternal blood
what are some risk factors for a woman with gestational trophoblastic disease?
Increase risk of choriocarcinoma
What are some risk factors that can cause a molar pregnancy?
Maternal age younger than 15 or older than 45
Previous molar pregnancy
what are some assessment findings for a woman with gestational trophoblastic disease?
Amenorrhea
Nausea and vomiting
Abnormal uterine bleeding ranges from spotting to perfuse hemorrhage
And large uterus
Abdominal crabby and expulsion of vesicles
what is the medical management of a molar pregnancy?
Immediate evacuation of mole with aspiration or suction D&C
follow up of hCG levels for at least six months to detect trophoblastic neoplasia
What are two kinds of pregnancies that result in no viable fetus do you administer RhoGAM to?
Ectopic and molar pregnancies
what has made the diagnosis of molar pregnancy much earlier than before?
Routine use of ultrasound in early pregnancy
what kind of factors can lead to preterm labor or birth? (MEBBING)
medical conditions
environmental exposures
Behavioral and psychological
biological factors
infertility treatments
N***** characteristics
Genetics
what are some medical indications for induction of preterm labor?
Hypertension
Preeclampsia
Hemorrhage
intrauterine growth restriction
most preterm births are a result of____ labor.
Spontaneous preterm
what is the number one cause of neonatal mortality?
Prematurity
When is it called preterm labor at what week?
before 37 weeks’ gestation
what is a late preterm infant in weeks?
Infant born between 34 and 36 weeks of gestation
what is a low birth weight infant? Very low birth weight infant? Extremely low birth weight infant?
2500 Grams
1500 Grams
1000 Grams
what are the pathways and contributing factors to preterm birth?
Uterine over distension
Decidual activation
Premature activation of normal physiological indicators of Labor such as activation of maternal-fetal-HPA axis
inflammation an infection of the decidua, fetal membranes, and amniotic fluid
what are some long term sequelae for preterm infants?
Cerebral palsy
hearing and vision impairment
chronic lung disease
learning problems
what are several components that characterize spontaneous preterm birth?
Uterine (preterm labor)
Chorioamniotic-decidual (premature rupture of membranes)
Cervical (cervical insufficiency)
what chemical causes uterine distension? How?
Prostaglandins can be produced, stimulating the uterus to contract when overdistended from multiple gestations, or polyhydramnios or uterine abnormalities
what are some common risk factors for preterm birth regarding previous pregnancies?
Prior preterm birth
History of second trimester loss history of incompetent cervix
short pregnancy interval less than nine months
how does inflammation trigger preterm birth?
Inflammatory cytokines or bacterial endotoxins can stimulate prostaglandin release resulting in cervical ripening, contractions, and weakening and rupture of membranes
why does decidual activation happen?
From hemorrhage
from fetal decidual paracrine system
from upper genital tract infection
preterm birth is more likely in the presence of____, _____,_____, and _____
intimate partner violence
Mental health issues
Substance abuse
psychosocial stressors
what are some common risk factors for preterm birth regarding the mother’s health?
Genital urinary infection and periodontal disease
chronic health problems such as hypertension diabetes or clotting disorders
Inadequate nutrition
Low BMI or pre-pregnancy weight
Obesity
low BMI
what are some common risk factors for preterm birth regarding socioeconomic factors?
Working long hours and standing
ancestry and ethnicity such as African Americans
maternal unmarried status
lack of social support
Smoking, alcohol, and illicit drug use
Lower education and socioeconomic status such as poverty
domestic violence
what are the tests for preterm birth prediction?
Decidual-membrane separation biomarkers such as fetal fibronectin
Proteomic to identify inflammatory activity
Genomics for susceptibility for preterm birth
when can a woman with a previous molar pregnancy try again for another baby?
After six months or after hCG levels fall to normal for six months
since 1998,_____, _____, and presence of_____ have been strongly linked to risk of spontaneous preterm births
cervical length, bacterial vaginosis, presence of fetal fibronectin
what is a very preterm infant in weeks?
Infant form between 32 completed weeks of gestation
in the pathophysiological pathway for preterm labor abnormal uterine distension leads to_____, _____, and _____
multifetal pregnancy
polyhydramnios
structural uterine abnormal
what does a negative fetal fibronectin test indicate?
There is no fetal fibronectin in the cervical fluid meaning there is less likelihood to deliver in the next two weeks
what are some common risk factors for preterm birth regarding the current pregnancy?
Cerclage
IVF pregnancy
Multiple gestation pregnancy associated problems: hypertension, diabetes, vaginal bleeding
hydramnios
Uterine or cervical abnormalities
Diethylstilbestrol exposure
Oligohydramnios
Late or no prenatal care
age younger then 17 or older than 35
premature rupture of membranes
previous
what does a positive fetal fibronectin test result indicate?
There is fibronectin present in cervical secretions to put the woman at risk for premature birth within seven days
what are some complications for the woman related to preterm labor?
Complications of bed rest and treatment with tocolytics
what are the general criteria for diagnosis of preterm labor?
Gestational age of less than 37 weeks and greater than 20
Persistent uterine contractions more than 6 an hour and at least one of the following
Dilated to 1cm or greater or 80% of effaced
rupture of membranes
what is the typical medical management of preterm labor?
Tocolytic drugs: CCB, NSAID (indomethacin), Beta-adrenergic receptor agonist (Terbutaline), mag sulfate
Progesterone supplementation
and glucocorticoids (betamethasone) to facilitate production of lung surfactant
What drug may long pregnancy for two to seven days?
Tocolytics
in the pathophysiological pathway for preterm labor decidual hemorrhage leads to_____, and _____
abruption and thrombin activation
why is delaying a pregnancy by 72 hours via tocolytics better than delivering immediately?
It gives several days for the corticosteroids to work and treat any Group B strep infections
are bed rest hydration and pelvic rest proven to improve the rate of preterm birth?
No they should not be routinely recommended but for the purposes of the test, bed rest is recommended.
in the pathophysiological pathway for preterm labor activation of maternal fetal HPA axis leads to_____, _____, and _____
prostaglandin production
Placental estrogen production
Stress
What are some potential adverse effects of bed rest?
Muscle atrophy
Cardiovascular deconditioning
Maternal weight loss
Stress for the woman and her family
why is fetal fibronectin a good indicator of spontaneous preterm births?
It has a low positive predictive value but a high negative predictive value, making it a useful test to protect those who will not deliver preterm
why might hydration be a common strategy to reduce preterm uterine contractions?
It increases vascular volume and may help to decrease contractions
what are some warning signs of preterm labor?
Rupture of membranes
Decrease fetal movement
Low backache, menstrual like cramps, pressure in the pelvis or intestinal cramps with or without diarrhea
Increased vaginal discharge
Fever higher than 100.4°F
A feeling that something isn’t right
what are some drugs that are used as tocolytics?
Magnesium sulfate
Prostaglandin synthesis inhibitors
Calcium channel blockers
Beta adrenergic blockers
how does magnesium sulfate help with protecting the fetal brain?
It reduces microcapillary brain hemorrhage and given to the mother for 12 hours to protect the brain
treatment of antenatal corticosteroids reduces the risk of neonatal ____, ____, ____, ____, and ____
neonatal respiratory distress syndrome
Cerebral ventricular hemorrhage
Necrotizing enterocolitis
Infectious morbidity
what are some contraindications to treating preterm labor
active hemorrhage
Severe maternal disease
Fetal compromise
Chorioamnionitis
Fetal death
Previable gestation and PROM
what are some general contraindications for tocolytics
severe preeclampsia
Placental abruption
intrauterine infection
Lethal congenital or chromosomal abnormalities
Event cervical dilation
Myasthenia gravis
Current treatment with nifedipine
Terbutaline use and previous four hours
Evidence of fetal compromise or placental insufficiency
what is the route and dose of betamethasone?
12 milligrams IM every 24 hours in two doses
what are adverse reactions to betamethasone?
Increase blood sugar and may require temporary insulin
what is the indication of betamethasone and when is it given?
Signs of preterm labor at risk to deliver preterm and given at 24 and 34 weeks gestation
what are some signs of pulmonary edema?
Shortness of breath, chest tightness or discomfort cough, oxygen sat less than 95 percent, increased respiratory and heart rates
Changes in behavior such as apprehension, anxiety or restlessness
what is some home care instructions for preterm labor?
Count baby movements and contractions while lying on the side for one hour
activity restrictions
Pelvic rest
diet so small meals and snacks may be easier to tolerate
fluids- drink at least 8 ounces of water milk or juices
medication schedule
What is there an increase of in preeclampsia within the liver and what does it cause?
Microvascular fat deposition and causes epigastric pain
Liver damage can progress to what?
HELLP syndrome
What does HELLP stand for?
Hemolysis
Elevated
Liver
Enzyme
Low
Platelets
What is the best determinant for possible preterm birth?
What are some tocolytics to postpone preterm labor?
CCB, NSAID, Tebutaline, Magnesium, Sulfate
What is the difference between PPROM and PROM?
Preterm premature rupture of membrane is ROM with a premature gestation less than 37 wks
PROM is ROM before they go into labor
What might the mother be ordered to be on bed rest for PPROM and PROM?
Open to infection and possible trauma
What are some PPROM management?
BS Antibiotics
Neonatologist, Perninatologist and OB test
Monitor for progression of infection
Hospitalization and bedrest
What is it called when a blastocyst implants somewhere other than the endometrial lining of the uterus?
Ectopic pregnancy
Where did 95% of ectopic pregnancies implant?
In the fallopian tube what can also implant in the ovary comma cervix comma or abdominal cavity
what is the leading cause of women in ectopic pregnancies?
Hemorrhage
what are some risks of the woman due to ectopic pregnancies?
Hemorrhage related to rupture of fallopian tube
Decreased fertility related to removal of fallopian tubes
what is a non-surgical option of ectopic pregnancy treatment?
Methotrexate, a folic acid antagonist and type of chemotherapy will cause dissolution of the ectopic mass
what are risk factors for ectopic pregnancy in order of risk?
Prior tubal damage from corrective surgery or sterilization or previous ectopic pregnancies
assisted reproduction
PID
Smoking
Abdominal adhesions
what are some assessment findings that present prior to tubal rupture?
Pelvic or abdominal pain the client abnormal bleeding 60 to 80%
Abdominal and pelvic tenderness is uncommon
Uterine changes are minimal
Vital signs are stable prior to rupture
how’s the diagnosis of ectopic pregnancy made?
Cullen’s sign
Ultrasound
Serial hCG levels
Transvaginal ultrasonography
Serum progesterone levels
___ is more likely to cause maternal death than any other complication of pregnancy.
Trauma
What is the most common cause of blunt injury in pregnant women?
MVA
what are assessment findings after tubal rupture?
Severe lower abdominal pain
Pelvic pain described as sharp or stabbing or tearing
Vertigo or syncope
Vital signs are unstable indicating hypovolemia if significant hemorrhage
Neck or shoulder pain with peritoneal hemorrhage because of diaphragmatic irritation
At term, __% of maternal cardiac output or ___mL to ___ mL/min flow through, which can lead to maternal exsanguination in __-__ minutes
15
750
1000
8-10 minutes
what is the preferred surgical method for hemodynamically stable women with ectopic pregnancies?
Laparoscopy
What is the most common cause of penetrating drama in pregnant women?
GSW
What is the leading cause of maternal death during pregnancy?
Trauma
The shunting of blood from the_____ ____ maintains____ BP at the expense of perfusion to the ____
utero placental unit
maternal
fetus
Are some physiological activities that happen when a pregnant women experiences trauma?
Vasoconstriction of uterine arteries shunting of blood to vital organs
blood gets shunted away from uteroplacental unit
decreased maternal oxygen reserves need to decrease blood buffering capacity
vulnerable to hypoxemia and cannot compensate with acidemia
what are two catastrophic events that can occur during pregnancy after a blunt trauma to the abdomen?
Placental abruption
Uterine rupture
Blood loss up to ___mL can occur without a change in maternal vital sign
1,500
After a comma uterine contractions more frequently than every __ _____ can indicate abruption
10 minute
What are some interventions for trauma
RhoGAM, Kleibauer Betke test
What is an indication for forceps/vacuum delivery?
Cardiovascular disease, so side lying positions can increase perfusion to the baby
What is the syndrome of reduced organ perfusion secondary to basal spasm and endothelial activation?
Preeclampsia
what is preeclampsia superimposed on chronic hypertension
It’s when those with pre-existing hypertension develop new onset proteinuria such as before the 20th week of gestation
What is it called if there is a systemic disease with hypertension accompanied by proteinuria after the 20th week of gestation?
Preeclampsia
what is the basic patho of preclampia?
Basal dilation in a normal pregnancy causes blood pressure to fall and then there is a 50% rise in total blood volume leading to an increased glomerular filtration rate. Then there is reduced organ perfusion secondary to vasospasm and endothelial activation the changes that predispose women to eclampsia and preeclampsia
what is the difference between eclampsia and preeclampsia?
Eclampsia is the same as preeclampsia but with seizures
what is the difference between gestational hypertension and preeclampsia?
Preeclampsia has hypertension and protein area but gestational is without and has hypertension or BP of greater than 140/90 for the first time after 20 weeks without proteinuria
Why does the platelet count increase in preeclampsia?
Possibly due to increased platelet aggregation and death position at lines of endothelial damage which activates the clotting cascade
______ ____ _____ May cause blurring or double vision, photophobia or scotoma
retinal artery spasms
what is HELLP syndrome?
Hemolysis, elevated liver enzymes, and low platelets
In preeclampsia there is an increase in_____ within the liver, which is proposed as one cause of_____pain.
Microvascular fat deposition, epigastric
what causes seizures in eclampsia? Patho
endothelial damage to the brain resulting in fibrin deposition, edema, and cerebral hemorrhage which can lead to hyperreflexia severe headaches and eclampsia,
when is preeclampsia and eclampsia diagnosed?
After the 20th week of pregnancy
leakage of serum proteins into____ ____ and into______ by way of damage capillary walls, results in decreased_ _____ and_____ ____
extracellular spaces and urine, serum albumin and tissue edema
what might be the proteinuria measurement
greater than 3.0g or 300 milligrams per deciliter or more protein in a 24 hour collection.
What are risks of preeclampsia for the fetus and newborn?
Premature delivery
intrauterine growth restriction related to decrease in uteroplacental perfusion
low birth weight
Fetal intolerance to labor
Still birth
what are assessment findings for preeclampsia?
Elevated blood pressure over 140/90
proteinuria is 1+ or greater
lab values may indicate elevations in liver function tests and diminished kidney function
what are some risk factors for preeclampsia or eclampsia?
Nulliparity
Younger than 19 or older than 35
obesity
Multiple gestation
Family history of preeclampsia
Preexisting hypertension or renal disease
Previous preeclampsia or eclampsia
Diabetes mellitus
What is the antidote to magnesium sulfate?
Calcium gluconate
what are some risks for the woman with preeclampsia?
Cerebral edema or hemorrhage or stroke
disseminated intravascular coagulation
Pulmonary edema
Congestive heart failure
Hepatic failure next slide renal failure
Abruptio placenta
the primary goal in preeclampsia and preeclampsia superimposed on chronic hypertension is to control what and what?
Blood pressure and prevent seizure activity and cerebral hemorrhage
medical management for preeclampsia and eclampsia?
Magnesium sulfate to prevent seizure activity
Enter hypertensive medication to control blood pressure
what are antihypertensive medications for preeclampsia?
Hydralazine vasodilator
Methyldopa
labetalol beta blocker
Nifedapine- CCB
why would you ask cultivate the lungs for someone with preeclampsia?
Assess for signs of pulmonary edema such as shortness of breath, chest tightness or discomfort, cough, oxygen saturation less than 95%, increased respiratory and heart rates
why would you assess the deep tendon reflexes for a woman with preeclampsia?
look for increased reflexes and clonus and if on mag sulfate, then the they may be diminished
What are the grades of deep tendon reflexes?
None elicited- 0, normal-2, brisk with transient or sustained clonus-4
why would you assess the daily weight of a woman with preeclampsia?
Fluid retention due to proteinuria
what might epigastric or right upper quadrant pain in a woman with preeclampsia indicate?
Liver involvement
In patients with create eclampsia oliguria is a sign of what` two conditions?
Preeclampsia and kidney damage
why might a woman with preeclampsia have intake restricted to 2000 milliliters a day?
To maintain proper kidney function
what position should a women with preeclampsia resume?
Bed rest in a lateral recumbent position
Normal ALT and AST level
55
7-56
what are some potential side effects of a woman on magnesium sulfate?
Nausea
flushing and diaphoresis
lethargy
depressed reflexes
blurred vision
respiratory depression arrest
cardiac dysrhythmias and circulatory collapse
decreased platelet aggregation
how often should you assess vital signs for magnesium sulfate?
Once before
5 to 15 minutes during the loading dose
every 30 to 60 minutes until the patient stabilizes
assess DTR’s every two hours
what are some signs and symptoms of magnesium toxicity?
Decrease or loss of DTR
respiratory depression
oliguria or urine output less than 30 milliliters an hour
chest pain
EKG changes
what kind of patients are at risk for magnesium toxicity?
Oliguria or renal disease
Normal levels of platelets
140K to 400K
What are some fetal or neonatal side effects of magnesium sulfate?
Fetal heart rate decreased
Variability
Respiratory depression
Hypotonia
Decrease sock reflex
Signs and symptoms are of magnesium toxicity
what is the continuous infusion dose of magnesium sulfate?
2G an hour and 100 milliliters of Ivy fluid for maintenance
what is a loading dose of magnesium sulfate?
4 to 6 grams diluted in 100 milliliters of IV fluid administered over 15 to 20 minutes
what is the antidote to magnesium toxicity and how should it be given?
Antidote for magnesium toxicity is calcium gluconate or calcium chloride 5-10 mEq given IV slowly over 5 - 10 minutes
during a laboratory evaluation of magnesium sulfate how long after treatment should it be take in and what is a therapeutic level?
4-6 hours after onset of treatment and therapeutic level of 4 to 6 mEq/L
When should you discontinue IV infusion of magnesium sulfate?
24 hours after delivery
What are normal magnesium sulfate levels in pregnancy?
4.8-9.6
what is it called when the placenta completely covers the internal cervical os?
Total placenta previa
