Week 9 PP Complications/care Flashcards
Evaluating 1st trimester bleeding
- Start with ruling out any life-threatening condition: ectopic pregnancy, maternal hemorrhage
- Determine fetal viability
- Determines the origin of bleeding - vagina, the cervix, or the uterus.
spontaneous abortion
A natural termination of pregnancy by expulsion of the products of conception before 20 weeks, or embryo < 500 g
abortions:
- threatened
- inevitable
- incomplete
- missed
- Threatened abortion
- Vaginal bleeding without cervical dilation
- Inevitable abortion
- cervical os is dilated, products of conception can be visualized
- Incomplete abortion
- Some products of conception have expelled, but some remain in uterus
- Missed abortion
- Silent miscarriage
- Intrauterine pregnancy with fetal demise with no bleeding
managing abortion
- # 1 support
- If hemodynamically stable, choose:
- Expectant management
- 30% expel w/in 7 days
- 60% pass first 14 days
- 75% within 45 days
- Medical abortion
- Misoprostol + Mifepristone= pulls preg away form uterine wall + contractions = pass pregnancy
- Surgical intervention (D&C)
- Expectant management
sources/causes of 1st trimester bleeding
- assumed to be vaginal bleeding or
- rectal bleeding or hemorrhoids, hemorrhagic cystitis, perineal lesions, vulvar varicosities
- ectopic pregnancy, cervicitis, cervical polyps, implantation spotting, subchorionic hemorrhage, vulvar varicosities, hemorrhoids, cystitis, or molar pregnancy
history & PE for 1st tri bleeding
- Confirmation of dates
- the last normal menstrual period
- any contraceptive use that may have changed or impacted the dates of that last period,
- GTPAL
- Recent trauma
- Current meds
- drugs/etoh
- OLDCART for bleeding
- a/s sx’s (fever, UTI, abd pain, cramping)
- examination findings, ultrasound findings, including an estimated date of delivery, pregnancy test results, previous obstetric history, including spontaneous abortion or ectopic pregnancy in particular, in contraceptive history.
Physical Examination
- vital signs
- confirm pregnancy
- abdominal exam
- palpate for tenderness, pain, check fundal height,
- masses, any rebound tenderness, or costovertebral angle tenderness.
- bowel sounds
Evaluating 1st Trimester bleeding diagnostics
- CBC (anemia)
- serum quantitative beta hCG or progesterone measurement
- ultrasound
- hCG should double every 1.5 days thru week 5
- every 2-2.5 days in week 7
- Peaks end of 1st trimester then goes down
- hCG should double every 1.5 days thru week 5
- Progesterone level
- If cervical bleeding is noted, suspect infection.
- Screen gonorrhea, chlamydia, and trich.
- Consider if recent pap smear or cervical specimen collection, & intercourse.
- Transvaginal ultrasound (to see if there’s endometrial stripe = uterus is empty/flat on itself or if see yolk sac)
If pregnancy is intrauterine (using transvaginal US, see the yolk sac), cervical os is closed, bleeding is not from uterus
reassure and monitor
If pregnancy is intrauterine but evidence of ongoing bleeding and/or a/s cramping/pain/dilation of cervix
Educate on potential spontaneous abortion and monitor
If no evidence of IUP when evaluating 1st trimester bleeding with U/S and with a positive pregnancy test:
REFER ASAP TO ED for ectopic pregnancy management
transvaginal ultrasound
- show gestational sac (hCG level is 1,500 +);
- shows intrauterine pregnancy
- shows ectopic pregnancy, with a gestational age within 5 days
- fetal viability.
- dx molar pregnancy → grape-like clusters are in a honeycomb pattern or snowstorm effect
- Bleeding that occurs between the chorion and the myometrium, or the placenta → subchorionic hemorrhage.
- frequently in 1st trimester bleeding
- risk factor for spontaneous AB.
- but can spontaneously resolve
During abortion, educate to monitor what daily and report if:
any fever > 100.4
saturating 1 pad / hr
passing any large clots > than a 50cent coin
abortion f/u
- Support to the grieving process.
- Avoid intercourse until the bleeding has subsided ( 2 wks
- Referral if still bleeding after 45 days - infection risk/DIC
- Contraception and future pregnancy planning
- Consider pre conceptual care
- Genetic counseling and endocrine evaluation if 3 or more occurences
- give RhoGAM within 72 hours, if the patient is RH negative.
- *any time any mixing of blood (car crash and pregnant and rh -, give rhogam)
- Rhogam protect future pregnancies from preventing antibodies
Ectopic pregnancy
- blastocyst implants anywhere other than the endometrium. Others implant in the ovaries, the abdomen, or the cervix.
- If left to grow it may damage nearby organs and cause life-threatening loss of blood
ectopic risk factors and triad sx’s
- Risk factors:
- IUD in situ, previous ectopic pregnancy, prior tubal surgery, pelvic infection.
- Age < 25 or > 35
- 3.5x more common in June and Dec
- Triad sx’s:
- Spotting or vaginal bleeding
- Unilateral lower sharp abdominal pain
- Palpable adnexal, Tender adnexal mass on PE in 5–70%
ectopic pregnancy treatment
- Refer to hospital ASAP!
- If caught early and no unstable bleeding= can tx with methotrexate
- If caught late = surgery
- Segmental resection
- Remove whole tube
Hydatidiform mole pregnancy
- filling the uterine cavity with an edematous, grape-like structure
- snowstorm on ultrasound
- atypical growth of trophoblastic cells resulting from abnormal union of sperm and egg.
- no fetal tissue, aka blighted ovum
- It implants in the placenta and results in proliferation of abnormal placental tissue.
- benign neoplasm, but can become malignant and cause choriocarcinoma
Hydatidiform risk factors
- Extremes in maternal age
- 2x higher change < 21 or > 35
- 7.5 x higher > age 40,
- Previous history of molar pregnancy
- 1% chance of recurring- which is 10-20x the general population
- Previous history of miscarriage
Hydatidiform s/sx’s
- severe/persistent n/v,
- uterine bleeding
- LGA from expected by her EDD.
- enlarged, tender ovaries
- Passage of grape like fluid filled cysts
- No fetal parts are palpable
- No hetal heart tones/activity
- may develop preeclampsia before 20 or 24 weeks.
- elevated hCG levels
Hydatidiform diagnosis and treatment
- If molar preg sus:
- Get US: shows classic “snow storm” pattern
- Just see a cluster of cells
- Look like fluid filled vesicles in grapelike pattern
- Get HCG level
- Get US: shows classic “snow storm” pattern
-
Tumor must be removed to avoid malignancy development
- Preferred D&C
- hysterectomy if fertility preservation is not a concern
Hydatidiform follow up
- After removed, molar tissue may remain and continue to grow- called GTN (gestational trophoblastic neoplasia)
- One sign is persistently elevated HCG level
- Persistent GTN can usually successfully be treated with chemotherapy
- can metastasize into choriocarcinoma (rare)
- **Follow HCG levels to zero
- **Recommend NO conceive for 6-12 months after HCG no longer detectable
Hyperemesis gravidarum
- severe n/v usu before 9 weeks gestation (but may be entire preg)
- weight loss (greater than 5%), dehydration, electrolyte disturbances (hypokalemia)
- Multifactorial cause; unknown
Hyperemesis gravidarum risk factors
- Obesity
- Nulliparous
- previous molar pregnancy, multiple gestation, GI disorders, hyperthyroidism
- Elevated hCG levels
Hyperemesis gravidarum evaulation
**consider transvaginal US to r/o multiple gestation pregnancy, r/o ectopic or molar pregnancy to be causing it
- Compare old weights and VS
- skin turgor and mucous membranes
- Abdominal exam
- palpation, bowel cells, and uterine size should be examined.
- CBC
- UA (specific gravity and ketones, electrolytes)
- LFT
- r/o hepatitis, pancreatitis, and cholestasis.
- A TSH and T4 to rule out any thyroid disorders.
Hyperemesis gravidarum management
- replace normal saline solution IV
- NO IV dextrose
- (Wernicke’s encephalopathy)
- NPO x 24-48 hrs
- sips of clear fluids
- ice chips
- If pre-pregnancy weight gain stabilizes, there is no adverse outcome associated with hyperemesis.
- Antiemetics
- Promethazine, compazine (suppositories)
- Zofran
- Metoclopramide– Reglan– with diphenhydramine
- refer if unable to tolerate meds
what is the single most cause of neonatal mortality and a primary issue in long-term morbidity
preterm birth/prematurity (< 37 wks birth)
2nd trimester complication: premature risk factors/complications
- Uterine overdistention
- Infection
- Cervical disease/history of LEEP
- Stress
- Decline in progesterone action
- Low socioeconomic status
- Smoking
- BMI < 19.8
- Maternal age <15 or >40
- cocaine, crack, heroine
- Short intervals between pregnancies (<18 months)
- Previous preterm delivery
- African American
complications: CNS , cerebral palsy, developmental delay. Vision defects, hearing loss. Altered pulmonary function. Metabolic and cardiovascular risks
prematurity s/sx’s
- Pelvic pressure or low back pain.
- Abdominal tightness or cramps.
- Contractions > 6 in 1 hour.
- fetus dropping low into the pelvis before 36 weeks gestation
- Increased vaginal discharge
- Vaginal bleeding
- ROM
diagnostic criteria for preterm labor
- labor between 20 and 36 weeks gestation.
- Uterine contractions
- Cervical effacement of 80%
- cervical dilation of > 1 cm
evaluating preterm labor
- *NO/delay speculum exam if suspect preterm labor
- *Refer to OB Triage/OB ASAP!
- women with backache, contractions, pelvic pressure, vaginal discharge
patho of gestational diabetes
- first 20 wks, cells more responsive to insulin = less glucose in serum. increasing human placental lactogen causes cellular resistance to insulin increases leading to higher levels of glucose.
- insulin resistance peaks around 24-28 wks (admin tests)
- beta cells exhausted eventually and insulin diminished = elevated sugar levels
- native Americans highest
risk factors gestational db
- Native American, Hispanics, African-Americans, South or East Asian ethnicity
- obesity, previous history of abnormal glucose tolerance results,
- steroids
- PCOS, hypertension
- a first degree relative with diabetes
- previous history of gestational diabetes
- infant weighing >9 pounds at birth
Complications for gestational diabetes
- Mom
- pregnancy loss
- Hypertension/Preeclampsia
- c section (macrosomnia)
- Prolonged labor
- Risk of developing Type 2 diabetes within 10 yrs (50%)
- Pyelonephritis
- For baby
- fetal anomalies
- IUGR
- premature birth
- Hypoglycemia
- Hyperbilirubinemia
- Obesity and Type 2 diabetes in adulthood
Screening for gestational diabetes
- at 24-28 weeks gestation
- Give 50g oral glucose. if over 130-140, do 3 hour GTT:
- if 2 values are over, have GD:
- fasting > 95
- 1 hr > 180
- 2 hr > 155
- 3 hr > 140
Uncontrolled or undiagnosed maternal hypoglycemia during the time of organogenesis preceding pregnancy is associated with
risk of congenital anomalies and pregnancy loss
if have bleeding in late preg/3rd trimester, what are you worried about?
- Placental abnormalities
- placental structure/size abnormalities
- abnormal placement of the placenta
- abnormal attachment, or premature attachment
Cause maternal or fetal bleeding and affect fetal growth and oxygenation.
- Need early delivery to prevent compromise to the fetus, as well as the mom.
vasa previa
- velamentous vessels cross the cervix
- common with velamentous cord insertions, low-lying placentas, or multilobar placentas
- suspected on vaginal exam when pulsations from the cord are palpated
cardinal signs placenta previa
sudden onset painless vaginal bleeding
no contractions
low lying placenta/partial previa
- lacental edge covers the cervical os
- 3cm of os
- As pregnancy/gest age progresses, the placenta typically migrates up the uterine wall and away from that cervical os as gestational age increases.
- watchful waiting
in partial previa, when is vaginal birth contraindicated?
if placenta remains encroaching over cervix into 3rd trimester
complete previa management
- Serial ultrasound
- Pelvic rest NOTHING INSERTED INSIDE IN AND NO SEX, NO ORGASMS
if have placenta previa and have vaginal bleeding
REFER TO HOSPITAL ASAP
leading cause of obstetric hemorrhage in late pregnancy
abruptio placentae
abruptio placentae
- premature separation of a normally-implanted placenta
- blood accumulates behind the placenta with no obvious vaginal bleeding.
- It may penetrate through the uterine decidua and collect in the peritoneum
- if suspected = refer! emergency
abruptio placentae risk factors
- uterine scar from c/s, smoking, Advanced Maternal Age (>35 yrs old), multiple gestations/parity
- hypertensive disorders, previous abruption, cocaine, abdominal trauma, polyhydramnios, or chorioamnionitis.
painful bright red vaginal bleeding and sudden onset of sharp, localized abdominal pain
OR
mild back or abdominal cramping and no bleeding can be sx’s too
Abruptio placentae
leading cause of maternal death (accounts for 20% maternal death)
hypertensive disorders of pregnancy
risk factors of hypertensive disorders
- nulliparity
- > 35 or older
- African-American race
- obesity
- hx/fam preeclampsia in a previous pregnancy
- chronic hypertension or renal disease; pre-gestational diabetes; multiple gestation; vascular and connective tissue disorders; antiphospholipid antibody syndrome;
- hydatidiform mole pregnancy.
hypertensive complications
- mom
- renal failure; liver failure; cerebral hemorrhage; DIC, abruption; emergent operative delivery; death
- fetus is at risk for:
- oligohydramnios
- abruption
- IUGR
- pre-term delivery.
define chronic hypertension
BP greater than 140/90 PRIOR to conception or 20 weeks gestation
define gestational hypertension
new onset BP > 140 / 90 at or beyond 20 weeks without signs of preeclampsia
preeclampsia diagnosis criteria
> 140/ > 90 in 2 measurements taken 4 or more hrs apart
AND at least 1 of these:
- Platelet count < 100,000
- Elevated LFTs (AST/ALT more than 2x normal)
- Pulmonary edema
- Headache, visual disturbance
- Proteinuria > 300 mg in 24-hr urine or spot urine >/= 1+ protein
- Elevated serum creatinine >1.1mg/dL
- Protein-creatinine ratio >/= 0.3
define severe preeclampsia
- Severe hypertension after 20 weeks
- > 160 systolic, > 110 on 2 occasions 4 hrs apart in pregnant, >20 weeks gestation, new onset CNS/visual hchanges, pulmonary edema, severe RUQ/epigastric pain
management of preeclampsia
- *Refer to high risk OB
- *Continue to monitor BP closely and look for any new symptoms
- *Delivery of baby only curative treatment
for mild preeclampsia, if its 37 wks gestation or more, non reassuring fetal status, labor or ROM at 34 or more….
delivery!
what is HELLP syndrome?
Hemolysis
Elevated Liver function tests
Low Platelet counts
(preeclampsia + liver involvement)
polyhydramnios
>1.5 - 2L or > 24 cm on amniotic fluid index using ultrasound
or via deepest vertical pocket of > 8 cm
Polyhydramnios is suspected with
- uterine enlargement on a size greater than gest age
- pelvic height, or increased abdominal girth
- fundal height is larger than the dates expected
- difficult to auscultate fetal heart tones or even palpate the fetus
- unstable fetal lie
- dyspnea, vulvar edema, n/v, GI upset
polyhydramnios complications
- pre-term labor, uterine distention, PROM
- fetal malpresentation, prolapse of the umbilical cord, placental abruption, dysfunctional labor.
- risk for a PP hemorrhage
polyhydramnios management
- US to confirm
- Consider rescreening for gestational diabetes and an antibody titer for isoimmunization.
- refer to OB care
Oligohydramnios. when present at 24-34 weeks, suspect?
- low volume of amniotic fluid < 5 cm / < 500 mL
- suspect
- inhibition fetal lung development
- renal agenesis
- fetal growth restriction (IUGR)
- get US to confirm! refer to OB! (hydration may help)
oligohydramnios clinical signs
- lagging fundal height
- molding of the uterus around the fetus
- Variable fetal heart rate decelerations during labor due to umbilical cord compression with contractions
premature rupture of membranes (PROM)
ROM before onset of labor
uterine contractions begin within 24 hours of premature rupture of the membranes in a term pregnancy
prolonged premature rupture of membranes (PPROM)
- rupture occurs prior to the onset of labor and before 37 weeks of gestation.
- 50% of these patients will deliver within one week.
- infectious or inflammatory weakens membranes
- inc risk of chorioamniotis
- If you suspect: NO attempts to insert anything non-sterile into the vagina
- can use sterile speculum but caution
how to confirm dx of rupture of membranes
- nitrazine (but false + if blood, semen, urine)
- sterile swab of a collection of fluid from within the vagina → microscope slide
- allow it to dry. And this crystallization occurs = ferning pattern
Artificial rupture of membranes AROM
- using amniotomy to induce labor.
- Once happen = committed to giving birth.
- shorten labor when in active labor and is performed as augmentation of labor.
Intrauterine Growth Restriction (IUGH)
- on US: < 10% for gestational age or small for gestational age
- a/s with stillbirth and M&M
- by poor maternal weight gain, lagging fundal height, hypertension.
- If IUGR is confirmed by ultrasound, refer to OB
Symmetrical IUGR
- Entire fetal body is small; are equally small and rank in the same percentile.
- caused by congenital anomalies associated with severe maternal malnutrition, low pre-pregnancy weight, or poor weight gain, or multiple gestation, chromosomal abnormalities, perinatal infections, or exposure to drugs or environmental teratogens.
- TORCH
- More morbidity than asymmetrical
Asymmetrical IUGR
- fetal head is normal size but whole body is small
- after 30 weeks
- caused by decreased placental blood flow or decreased oxygenation to the fetus, an estimated fetal weight of < 10th percentile, but the head circumference >10th percentile.
- Maternal malnutrition
- It’s associated with maternal hypertension, renal disease, microvascular disease, or diabetes, heart disease, hemoglobinopathy, and collagen vascular disease.
Intrauterine fetal demise (IUFD) defined and first clue?
- A fetal loss after 20 wks or when the fetal weight is > 350 g
- Hispanic women have 14% higher
- Non-Hispanic Black 2x
- 1st clinical clue: decreased or lost fetal movement or undetectable fetal heart tones on examination.
- get US asap!
Intrauterine fetal demise management
- Get ultrasound to confirm
- Physician confirms IUFD
- Counsel regarding delivery options. She may have expectant management.
- majority spontaneous labor within 2 weeks
- DIC risk is present when the fetus in utero for more than 4 weeks.
- An induction of labor for delivery is another option.
- high risk for subsequent pregnancies based on this history of IUFD.
- Pre-conceptual counseling
myths about IUFD
- fall she may have had or raising her arms up over her head.
- lifting heavy objects.
- lots of guilt
Postpartum/puerperium begins with
- birth of the placenta
- involution of the uterus
- return of reproductive organs to the pre-pregnant state.
- over 6-8 weeks with significant physiologic changes
- CO and blood volume decrease. Estrogen and progesterone levels begin to drop.
loch rubra
- lasts 3-4 days
- bright red
- blood clots are normal
lochia serosa
- from day 4-10
- pink-brownish
- contains mucus
- few to no clots, flow is ongoing
lochia alba
- day 10-28
- yellow ish whiteish liquid
- little red blood
- no odor, no real flow
uterine involution
- pregnant to non-pregnant state
- Takes 5-6 weeks
- Fundal height decreases by 1cm/day until it is no longer palpable by postpartum day 10 behind pelvic bone
In non-lactating women, when does ovulation resume?
6 to 12 weeks postpartum
ovulation comes before first menses, so contraceptive counseling is critical.
the B’s of postpartum visit
- Breasts- lactation, breast conditions
- Belly- fundal height, surgical incisions
- Bladder- urinary retention, incontinence, trauma
- Bleeding- lochia
- Bottom- perineum laceration, hemorrhoids
- Bowel- constipation
- Birth control
- Baby blues- mood changes, depression
- Bonding- infant attachment
- Bodybuilding- nutrition, activity level
- Bullying- IPV
- Baby’s father- relationship, support, resuming intimacy
PP blues
- sx’s < 14 days
- tearful
- Irritability
- Mood swings
- Fatigue
- Appetite
pp depression sx’s
extreme:
Tearful
Irritability or anger
Mood swings
Fatigue
Lack of interest in the baby
Sleep disturbances
Appetite disturbances
Guilt or shame
Feelings of isolation
Hopelessness
Loss of pleasure
Feelings of harming the baby or self
PP psychosis
- Hallucinations
- Delusions
- Inability to communicate
- Rapid mood change
- Paranoia
- Inability to sleep
- Hyperactivity Disorganized thoughts
Late postpartum complication:
Infection risk factors and sx’s
- Prolonged labor
- C-section
- Retained placental fragments
- Preexisting vaginal infection
- sx:
- elevated temp > 38C
- malaise
- pain
- malodorous lochia
- most common
- endometritis
- wound
- mastitis
- peritonitis
- UTI
endometritis
risk increased from c section, prolonged labor, frequent exams, retained fragments
foul smelling lochia
endometritis management
- PE of the abdomen and the pelvis,
- urine C&S
- blood cultures
- CBC
- chest X-ray (pneumonia)
- IV clindamycin and gentamicin.
- can lead to significant issues, salpingitis, septic thrombophlebitis, peritonitis, and necrotizing fasciitis.
UTI & pyelonephritis
- urinary stasis from this decreased bladder tone, increased bladder volume, epidural anesthesia = incomplete bladder emptying during labor and delivery, or a urethral catheterization (epidural)
- e coli, proteus, kelbsiella
- sx: urinary freq, urgency, dysuria, pubic pressure or pain
- pyelonephritis: low grade fever, flank pain, CVA tenderness, n/v
postpartum delayed hemorrhage
- most bleeding is 24-48 hrs PP
- Can have a secondary hemorrhage can happen up until 12 weeks postpartum, often within first two weeks in setting of subinvolution
- Sx: excessive vaginal bleeding, and possibly signs of shock and anemia. Most patients report to the ED with sudden, severe vaginal bleeding.
- Risk factors
- placental fragments or membranes
- previously undiagnosed vaginal-cervical laceration, hematoma, uterine infection, uterine atony, or coagulopathy (Von Willebrand)
PP delayed hemorrhage management
- depends on site of bleeding
- laceration → repair
- uterine → meds
- if no source → think bleeding disorder
- CBC
- platelet count, PTT, coat studies
- refer
Postpartum thrombophlebitis, deep vein thrombosis, or pulmonary embolism
- 5-7 x greater risk during pregnancy and PP
- Venous stasis, resulting from relaxed vascular walls in pregnancy, the hormonal influences, the hypercoagulation of pregnancy, and any vascular trauma from the inflammation.
- Immobility and prolonged venous compression
tachypnea, dyspnea, sudden chest pain, palpitations, cyanosis, hypotension in postpartum
pulmonary embolism (greatest concern)
unilateral leg pain/tenderness
swelling in extremity, increase temperature, pitting edema, primmest superficial vein
deep vein thrombosis
superificial venous thrombophlebitis (SVT / DVT) risk factors & management
- obesity, a maternal age greater than 35, a history of thrombosis, anti-phospholipid antibody syndrome, sickle cell disease, heart disease, diabetes
- no massaging/manipulating
- get doppler with venous US to confirm dx
- anticoag therapy & rest
PP complication: thyroiditis
- inflammation of the thyroid gland
- both hypo/hyper
- involves excessive release of TH followed by insufficient
- Sx’s difficult to recognize; similar to postpartum
hyperthyroid phase
- watch for thyroid storm = emergency!
- 1-4 months post partum
- sx: fatigue, palpitations, anxiety, difficulty sleeping, irritability, weight loss
- labs show low TSH, lack of peroxidase antibodies
hypothyroid phase
- 4-8 months PP
- sx: fatigue, difficulty focusing, depression, goiter, constipation, weight gain
- labs show elevated TSH
management of thyroiditis
- refer to endocrinologist
- tx: beta blocks
- thyroid supplements with hypo
- can still breastfeed
thyroid storm (thyrotoxicosis)
- abrupt, acute, potentially fatal exacerbation of hyperthyroidism
- In 1st month postpartum, have high T4 level.
- fever, nausea, vomiting, diarrhea, tremors, and tachycardia
- lead to dehydration, seizures, cardiomyopathy, heart failure, coma, and death if untreated.
- sx’s similar to preeclampsia but with high fever and neuropsychiatric sx’s
- Admit to ICU asap!!
for how long does preeclampsia exist in post partum?
up to 6 weeks
Postpartum preeclampsia risk factors
- gestational hypertension
- preeclampsia during pregnancy or labor and delivery
- risk of pulmonary edema (from lots of IV fluids)
- potential renal dysfunction.
postpartum preeclampsia management
- immediate antihypertensive therapy
- magnesium sulfate to prevent eclamptic seizures.
