OB EXAM 3

high risk pregnancy

a condition that threatens the health of the mother, fetus, or pregnncy

trimester zero

a social media trend where pregnancy will only occur and be healthy if the woman performs bizarre trends like no nail polish

increases maternal guilt and shame if pregnancy ends up being unhealthy and they didn't perform all requirements

components of prenatal/conception care

decrease teratogen exposure/risk factors like smoking

education

genetic testing

prenatal vitamins

how to deal with modifiable risk factors?

education/interventions

follow up

close monitoring

how to deal with non-modifiable risk factors

determine the need for additional testing

consider referral to specialty medicine (maternal fetal medicine)

causes of early pregnancy bleeding

miscarriage or abortion

ectopic pregnancy

cervical insufficiency

molar preg

most common complication of early pregnancy

abortions/miscarriages

most abortions/miscarriages occur in

the 1st trimester

causes of abortions/miscarriages in the 1st trimester

genetic abnormalities, not necessarily a syndrome

ex: zygote replication is abnormal

causes of abortions/miscarriages in the 2nd trimester

cervical insufficiency

maternal diseases

acquired infections (viruses from working with children)

abortion/miscarriage assessment findings/manifestations

risk factors

bleeding in the 1st/2nd trimester

pad count, quality (clots), cramping with bleeding

increased HR and decrease BP d/t pain, stress, and blood loss

decreased hcG and H+H

Rh/blood type

abortion/miscarriage management

pain relief

prep for D&C if indicated

expectant meds (help aid with miscarriage)

emotional support

D&C

dilation and curettage, which is a surgery to remove contents of conception

threatened miscarriage

vaginal bleeding with a closed cervical os

FHR remains with a transvag US

can't do anything but wait.... may continue to a healthy baby or evacuate eventually

inevitable miscarriage

vaginal bleeding with a dilated cervical os

products of conception may be seen or felt at or above cervical os

despite possibly having FHR, but since os is open, the miscarriage is inevitable

incomplete miscarriage

vaginal bleeding with a dilate os

some products of conception expelled and some remain

need meds and dc to help remove products

dangers of remaining products of conception

sepsis and infection

Complete miscarriage

vaginal bleeding with a closed cervical os

products of conception completely expelled

Misprostol (Cytotec)

stimulates uterine contractions to terminate a preg and evacuate the uterus AFTER abortion

ensures the passage of ALL products

taken 24-48 hrs after mifepristone

Mifepristone (Korlym)

Acts as progesterone antagonist, allowing prostaglandins to stimulate uterine contractions

causes the endometrium to slough;

may be followed by administration of misoprostol within 48 hours

rhoGAm

given to rh- mothers after abortion, miscarriage, or pregnancy

ectopic pregnancy

ovum implants outside the uterus, typically in the fallopian tube

causes of ectopic pregnancies

conditions that slow down the ovums passage to the uterus:

-fibroids

-endometriosis

-infections like STI and pelvic inflammatory disease d/t scarring of fallopian tubes

ectopic pregnancy s/s

early bleeding (6-8wks)

abdominal pain (ALL OVER)-> then localizes to the location of the preg

shoulder pain (referred)

results of a ruptured ectopic pregnancy

septic shock (decreased BP, increased HR, decreased O2, trouble breathing)

nursing management for ectopic pregnancy

catch before rupture (bc after they lose the fallopian tubes)

determine s/s and Rh status

education ab medications

prepare/educate for surgery

diagnosis of ectopic pregnancy

hCG levels and transvaginal ultrasound

if the ectopic pregnancy is early and unruptured, what is the treatment?

give methotrexate and follow with a transvag US to see if successful

if the ectopic preg is late and ruptured, what is the treatment?

surgery to remove the fallopian tube (salpingectomy)

Gestational Trophoblastic Disease

an abnormal proliferation of cells during pregnancy;

may also be referred to as molar pregnancy

Types of gestational trophoblastic disease

Hydatidiform mole

Choriocarcinoma

molar pregnancy manifestations

elevated hCG levels

vaginal bleeding

pelvic pressure or pain

enlarged uterus

hyperemesis gravidarum

molar pregnancy nursing managment

prepare for d/c

education (avoid preg for a year)

emotional support

strict adherence to follow up (serial hCG measurements to check for recurrence)

gestational trophoblastic disease can occur with

a fetus, but not often viable

can attempt to carry out if fetal activity is found.

gestational trophoblastic disease treatment

obtain hCG levels

transvag US

surgery to evacuate tissue

Fetal viability is defined as how many weeks of gestation?

23 wks (maybe...22)

cervical insufficiency

premature dilation of the cervix

cervical insufficiency is commonly a cause of

late miscarriage (after 12wks/2nd trimester)

pregnancy loss

preterm labor

cervical insufficiency risk factors

pre-existing collagen disorders

previous cervical trauma leads to scarring (cervical cancer/surgery)

uterine anomalies

cervical insufficiency s/s

painless dilation

pink spotting

pelvic pressure/fullness

cervical insufficiency nursing management

assess FHR/activity

education on sx of preterm labor

prepare for cervical exam and cerclage

cerclage

suturing of the cervix to prevent it from dilating prematurely or further during pregnancy

can lead to a healthy term pregnancy, but HEAVY follow ups

once ready to deliver, the stitch is removed.

for the next pregnancy, a cerclage is usually planned.

causes of bleeding late in pregnancy

placenta previa and placental abruption

placenta previa

placenta implants in the lower part of the uterus (near or over the cervical os)

placenta previa risk factors

scarring in the uterus (placenta lowers to find healthier tissue)

advanced maternal age

multiparity

smoking and substance abus

IVF and reproductive tech

placenta previa s/s

Painless bright red bleeding

may be intermittent

FHR usually normal

placenta previa management depends on

depends on gest and sx severity

placenta previa management

identified at the 20wk US

modify activity and pelvic rest

NOTHING IN THE VAGINA so no sex, no cervical or vag exams

ALWAYS C-section (scheduled prior to labor time)

placental abruption

Placenta detaches from uterine wall before delivery, leading to maternal blood loss and decreased BF to the baby

detachment can be partial or complete

placental abruption risk factors

substance abuse

previous abruption

MVA or trauma like a severe fall, IPV, kicked in the stomach

placental abruption s/s

dark red or port-wine bleeding

KNIFE-like pain

board like or rigid abdomen

fetal distress or absent FHT (SINUSOIDAL rhythm)

placenta abruption management

MEDICAL EMERGENCY

intrauterine resuscitation to increase perfusion

monitor fetus and mom with abruption labs (H+H, clotting factors like PT, INR)

watch for DIC and shock

prep for C-section

#1 priority with known or suspected placental abruption

FHR!!

hyperemesis gravidarum occurs usually in the

1st and 2nd trimester

when does hyperemesis gravidarum peak and resolve?

8-12 wks of preg and resolves by 20th week

hyperemesis gravidarum can result in

need for hospitalization

anxiety and depression

work performance impairment

consideration of termination of preg d/t poor health

hyperemesis gravidarum s/s

persistent and uncontrolled n/v

weight loss

ketosis

e- imbalances

nutritional deficiencies

HG management (if hospitalized)

assess VS

monitor labs (urinalysis, e-)

IVF

antiemetics (diclegis, phenergan, zofran)

NPO!! if really severe, parenteral nutrition

best way to assess hydration status is?

urine output

chronic HTN

HTN prior to pregnancy

>140/90

dont necessarily have preeclampsia always

gestational HTN

onset of HTN after 20 weeks

>140/90 but NO proteinuria or organ involvement

after 12wks PP, goes back to normal

preeclampsia

new onset HTN with signs of organ involvement and/or proteinuria

therapeutic management depends on the severity

preeclampsia patho

vasospasm happens thoughout the body in response to hypoperfusion, which increases BP

this leads to leaky capillaries d/t endothelial cell dysfunction

abnormal arteries develop (spiral arteries) leading to hypoperfusion, whcih affects the kidneys, livers, and CNS.

leaky capillaries leads to

severe leg, facial, and periorbital edema

presentations of kidney injury d/t preeclampsia

proteinuria

abnormal kidney labs

presentations of liver injury d/t preeclampsia

RUQ pain and abnormal LFTs

presentations of neuro injury d/t preeclampsia

HA

blurred vision

decreased LOC (if severe)

preeclampsia without severe features

140/90 or higher after 20 wks gestation

no seizures, coma, hyperreflexia, or other s/s

home treatment for preeclampsia without severe features

no renal or liver impairment or coagulopathies

bedrest, kick counts, BP monitoring, limit Na+ in diet

more frequent visits

hospitalization for preeclampsia without severe features

keep pregnant as long as possible for fetus

monitoring for hyperreflexia, HA, BP, and labs

preeclampsia with severe features

160/100 or higher on two occasions at least 6 hours apart while on bed rest

no seizures or coma

presence of hyperreflexia

s/s of organ involvement like pulmonary edema, HELLP, RUQ pain, etc.

hospital management for preeclampsia with severe features

may develop quickly

treated aggressively to stabilize for birth

may deliver if preterm even

goal is to control HTN, prevent seizures, and prevent morbidity/mortality

Antihypertensive Medications for preeclampsia

hydralazine, nifedipine, labetalol

magnesium sulfate

CNS depressant administered as an IV piggyback to prevent and treat seizure activity

magnesium sulfate side effects

vasodilation leads to warmth, flushing, and diaphoresis

makes pt feel TERRIBLE, so OOB x 1

magnesium sulfate toxicity management

VS

SERUM LEVELS

strict I+Os to monitor for fluid overload/pulmonary congestion

lung assessments (resp depression, pulm congestion)

CNS assessments (hyporeflexia)

decreased urine output (<30ml/hr) is a red flag for decreased kidney function

Magnesium sulfate antidote

calcium gluconate

eclampsia

>160/110 with seizures, coma, hyperreflexia, and organ involvement

premonitory signs of eclampsia

HA

blurred vision, floaters, trouble w eye tracking

altered MS

abdominal pain

eclampsia features

tonic contractions

respirations stop

hypotension

vomiting or incontinence

immediate care for eclampsia

-ABCs, suction, O2

-side rails up, dim the lights, decrease visitation and noise

-mag sulfate, IVF

-prepare for delivery of baby

assessments that measures seizure risk the best?

REFLEXES!!

clonus, hypo/hyperreflexia

HELLP syndrome

occurs in up to 20% of people with severe features of preeclampsia

characterized by abnormal vascular tone, vasospasm, and coagulation defects

HELLP syndrome s/s

hemolysis, elevated liver enzymes, low platelets

n/v, RUQ pain, HTN, proteinuria

*do NOT always have HTN!!

individuals with HELLP syndrome are at an increased risk for

cerebral hemorrhage

retinal detachment

hematoma/liver rupture

DIC

placental abruption

death

multifetal pregnancies can lead to....

preterm labor

polyhydraminos

hyperemesis grav

congenital abnormalities

twin to twin tranfusion syndrome

intrauterine growth restriction

conjoined twins

prenatal care for multifetal pregnancies

serial US

BBP and NST

multifetal pregnancies will most likely require...

a c-section

multifetal pregnancy nursing assessments

fetal movement

fundal height measurements

nausea

fatigue

weight gain

there is a higher risk for twin to twin transfusion with...

a shared amniotic sac or placenta.

PROM vs PPROM

PROM: 37 wks gestation

PPROM: <37 wks gestation

PROM therapeutic management

dep on gest age

NOTHING in vagina

expectant management if fetal lungs are immature (corticosteroids)

corticosteroids

betamethasone helps speed up fetal lung maturity by increasing surfactant production

#1 concern with PROM

cord compression (monitor FHR!!)

PROM nursing assessment

Risk factors, s/s of labor, FHR monitoring, amniotic fluid characteristics and POC testing

PROM nursing management

Infection prevention

Identification of uterine contractions

NST and frequent monitoring!!

Discharge home (PPROM) if not labor within 48 hrs. with STRICT instructions

72-84 hrs max, then induce labor

an increased use of glucose in the 1st trimester leads to

increased insulin resistance and a compensatory increase of insulin secretion in the 2nd trimester

pre-gestational diabetes

having diabetes type 1 (autoimmune) or 2 (loss of insulin secretion) before pregnancy

risks/complications unique to pre-gestational diabetes

perinatal mortality

congenital malformations

A1C levels are...

teratogenic to babies, leading to congenital malformations and perinatal mortality