Maternal Unit 5 (skin, SUD, HTN, hemorrhagic)

normal pregnancy skin changes

-melasma/chloasma (brown patches, esp on face)

-vascular spiders

-palmar erythema

-striae gravidarum

-may affect acne or psoriasis

pruritis gravidarum

-generalized itch, often on abdomen

-no rash

-d/t distention & striae

-a/t multiple gestation, fertility meds, DM, nullipara

-tx (S/S): lubricate, antipruritics, antihistamines, UV lights/sun

polymorphic eruption

-in primigravida, T3 (often male baby)

-lesions on abdomen, arms, thighs, back, buttocks

-itchy

-may cause weight gain, HTN, labor induction

-tx: antipruritics, steroids, antihistamines

intrahepatic cholestasis

-generalized pruritis in T3

-often on palms & soles of feet

-worse at night

-increased serum bile acid levels & LFTs

-S/S: jaundice, dark urine, pale stools

-risk fx: wintertime, multiple gest, over age 35

-may cause fetal asphyxia, meconium stain, meconium ileus, stillbirth, preterm birth, increased bile acids

care for cholestasis

-tx: ursodeoxycholic acid, antihistamines, cool bath with oatmeal or baking soda, oatmeal cream, menthol cream

-NST and BPP for baby

-induce at 37 weeks

-mom may need vitamin K to prevent PPH

SUD

-warning signs: late or intermittent prenatal care, leaving appointments early, noncompliance, poor nutrition, family problems, frequent encounters with police

-universal screening

effects of substances

-tobacco

—mom: decreased thyroid function, ectopic, previa, abruption, PPROM

—baby: clefts, IUGR, LBW

-alcohol

—mom: preterm birth

—baby: FAS, defects, LBW

effects of drugs

-marijuana

—baby: IUGR

-opioids

—mom: abruption, preterm birth

—baby: IUGR, meconium passed before birth, death

-cocaine

—mom: preterm birth, PROM, abruption, preeclampsia

—baby: IUGR, LBW, SGA

-meth:

—mom: preterm birth, abruption

—baby: LBW, microcephaly, decreased length, brain or heart malformations

care for SUD

-screening

—at first visit

—ask mom and/or dx test

—ask about caffeine and nicotine also

—ask about fam use and hx

-assessment

—screen for other diseases

—US

tx SUD

-alcohol: benzos

-opioids: opioid agonists (methadone & buprenorphine)

-cocaine, tobacco, meth: stop use now

-BF

—none at all if meth, alcohol, cocaine, heroin, marijuana

—allowed w/ opioid use if taking agonists

—no smoking 2 hr before

hypertensive disorders

-gestational HTN = develops after 20 wks

-preeclampsia = HTN + proteinuria develops after 20 weeks

—or HTN + thrombocytopenia, renal insufficiency, liver problems, pulmonary edema, cerebral/vision problems

-eclampsia = preeclampsia progresses to seizures or coma

-chronic HTN = dx before 20 weeks

-superimposed preeclampsia = chronic HTN that progresses to preeclampsia

gestational HTN

-over 140/90

—measured twice, at least 4 hr apart

-should resolve within 1 yr PP

-preeclampsia = w/ proteinuria >300 (or >2+)

—OR liver enzymes doubled

—OR CRT >1.1

preeclampsia risk fx

multi test, chronic HTN, hx, DM, thrombophilias, multipara, GDM, SLE, obese, over age 35, kidney disease, ART, OSA

patho of preeclampsia

-placenta perfusion disrupted, endothelial cell dysfunction

-not enough vascular remodeling in uterus → hypoxia

-toxic substances released by low-O2 tissue → vasospasm → more decreased perfusion → increased TPR and BP and cell permeability → protein and fluid moves out of blood → low BV

—fluid movement to interstitial causes increased blood viscosity and edema

effects of preeclampsia on organs

kidneys

-decreased perfusion → low GFR

—S/S: oliguria and proteinuria

-uric acid/sodium/water retention

liver

-low perfusion → high liver enzymes, hepatic edema, hemorrhage

—S/S: epigastric or RUQ pain

other effects of preeclampsia

-cerebral edema and hemorrhage → CNS irritability 

—S/S: HA, hyperreflexia, clonus, seizures

-vasospasms and decreased retinal perfusion

—S/S: scotoma, blurry vision, double vision

-HELLP syndrome

—lab values

—Hemolysis, Elevated Liver enzymes, Low Platelets 

—increases risk of pulmonary edema, acute renal failure, DIC, abruption, liver failure, ARDS, sepsis, stroke

-IUGR

care for preeclampsia

-aspirin may prevent (81 mg/day week 12-28)

-assess: BP, edema, DTRs, clonus, proteinuria, S/S (HA, abdominal pain, vision changes)

-evaluate

—weekly labs: CRT, PLT, LEs, CBC, protein/CRT ratio

—measure weight and BP 2x/wk

—daily kick count, US every 3 wk, AFV weekly

tx preeclampsia

-restrict activity

-mag sulfate to decrease seizures, antihypertensives

-induce at 34 weeks (need betamethasone for fetal lungs)

-keep IVF <125 mL/hr (risk for pulmonary edema)

Rx preeclampsia

-mag sulfate

—IV loading dose 4-6 mg over 15-20 min

—maintenance: solution, 1-2 g/hr

—keep serum levels at 4-7

—continue for 24 hr PP

—*watch for toxicity: hyporeflexia, bradypnea, decreased LOC (give calcium gluconate)

-antihypertensives

—give if >160/11

—BP goal <155/105

—labetalol or nifedipine

eclampsia

-may develop even if preeclampsia was not serious or symptomatic

-seizures

—tonic contraction of all muscles, then tonic-clonic convulsion

—respiratory irregularity

—afterwards: hTN, muscle twitch, disoriented, amnesia, N/V, incontinence

-pt should not get regional anesthesia

immediate seizure care

-call for help

-stay w/ pt

-ensure ABCs

-raise and pad siderails

-lower HOB, turn pt on side

-have sxn and O2 ready

-rescue meds: mag sulfate (lorazepam if mag fails)

after:

-IVF and mag sulfate (lorazepam if mag fails)

-Foley

-stat labs

-check FHR( seizure may rupture membrane or quickly dilate cervix)

cervical insufficiency

-dilation of cervix that may lead to preterm labor and birth

-congenital risk fx: collagen problems, uterine anomalies

-acquired risk fx: hx of trauma to cervix (lacerations, mechanical dilation, biopsy)

-dx:

—speculum exam shows opening in os or prolapsed membrane

—transvaginal US shows cervical length under 25 mm

tx cervical insufficiency

-cerclage placement

—done if pt has hx of preterm birth, short cervix, and opening in os

—suture around cervix to constrict internal os

—done for prophylactic, therapeutic, or rescue

—done at 12-23 weeks

-progesterone

—IM or vaginal

—regularly from 16-36 wk

ectopic pregnancy

-embryo implants outside uterus 

-often in Fallopian tube (usually ampulla)

—may also be in abdomen, ovary, cervix, C/S scar

-risk fx: prior ectopic pregnancy surgery, ART/surgery, STI, smoking, IUDs

-tx:

—methotrexate to kill embryo

—surgery (salpingectomy or salpingostomy)

ectopic pregnancy S/S

-abdominal pain (dull, unilateral, lower)

-delayed menses, abnormal vaginal bleeding

-rupture → referred shoulder pain

-abdominal bleed → shock, bluish umbilicus

-dx: positive pregnancy test, increased progesterone

placenta previa

-placenta implants on lower uterine segment, covers os or is close to cervix

—complete = totally covers os

—marginal = <2.5 cm from os

-dilation and effacement causes bleeding

-risk fx: hx of C/S, over age 35, multipara, hx of curettage, smoking, nonwhite, cocaine use, ART, multiple gest, hx

-S/S: painless bright red vaginal bleed in T2-3, increasing fundal height, fetal malpresentation

—can lose 40% BV before S/S develop (watch UO!)

—usually develop after 20 wk

-may cause preterm birth or IUGR

tx placenta previa

-may need hysterectomy for severe hemorrhage

-dx:

—first thing to rule out for pt w/ vaginal bleed

—transabdominal US, then transvag

-tx:

—tocolytics

—steroids for fetal lungs

—bedrest, no vaginal or rectal exams, no intercourse

—iron supplement

—C/S at 36-37 weeks

placental abruption

-risk fx: HTN, cocaine/meth, trauma, smoking, PPROM, multi gest

-S/S: vag bleed, sudden sharp ab pain, uterine tenderness, increased uterine tone, contractions

—may cause hypovolemia and coagulopathy

-may cause Rh problems, organ damage, death

-fetal problems: IUGR, oligohydramnios, preterm birth, hypoxemia, death

—may die after birth, or develop CP

care for abruption

-dx:

—labs: positive Apt (blood in amniotic fluid), low Hgb/Hct, low coag fx

—US (not definitive)

—measure fundal height (increases over time)

-tx:

—steroids

—deliver right away if >34 wk or if moderate to severe bleed

—may need C/S (not w/ severe coagulopathy)

—catheter to watch UO

—IVF