ob exam 3

High risk pregnancy and risks for a high risk pregancy

life or well-being of pregnant woman or fetus are jeopardized

Risks include

Biophysical

• genetic, nutrition, medical disorder,

Psychosocial

• smoking, alchohol, caffeine illicit drugs, mental health disorders, poor family 

sociodemogrpahic

• low income, lack of care, marital status

environmental

• infections pollutants chemicals secondhand smoke

Hypertensive disorders

Gestational Hypertension (GHTN)
Preeclampsia (PreE)

Chronic Hypertension (CHTN)

Superimposed Preeclamspsia (SIPE)

Gestational Hypertension

(GHTN)
Gestational hypertension is a condition in pregnancy defined by new-onset high blood pressure after 20 weeks of gestation without proteinuria or other signs of organ damage.

• BP>140/90 but <160/110

• GA>20 weeks

Preeclampsia

PreE

pregnancy-specific syndrome characterized by new-onset hypertension after 20 weeks of gestation plus signs of organ dysfunction or proteinuria.

• BP>140/90 + proteinuria

• other symptoms also involved

• GA >20 weeks

Chronic Hypertension

CHTN

high blood pressure that exists before pregnancy or is diagnosed before 20 weeks of gestation

• BP > 140/90

• GA < 20 weeks or pre-pregnancy

preexisting hypertensive disorder

Superimposed Preeclampsia

occurs when a woman with pre-existing (chronic) hypertension develops preeclampsia during pregnancy. It’s essentially preeclampsia on top of chronic hypertension.

• chronic HTN + PreE

• sudden increase in BP when previously well controlled

• new onset proteinuria 

Preeclampsia

Pregnancy specific condition

Placenta is suspected to be the root cause of PreE wether that be placement which can lead to hypoxia and then release of endothelial changing substance

Patho

• vascular remodeling of small blood vessels

• results in altered perfusion and endothelial damage —> vasospasm —> poor tissue perfusion, increased peripheral resistance

Symptoms

• Headache (persistent, not relieved by Tylenol)

• Swelling/edema (hands, face)—not required for diagnosis

• Nausea or vomiting (especially if sudden in 2nd–3rd trimester)

• Sudden weight gain from fluid retention

• Visual changes

  • Blurry vision

  • Spots or flashing lights

  • Temporary vision loss

• Right upper quadrant/epigastric pain (from liver involvement)

• Shortness of breath (from pulmonary edema)
  
  clonus

clonus

Clonus is an involuntary, rhythmic, repetitive contraction and relaxation of a muscle after sudden stretch (e.g., rapid ankle dorsiflexion).
It indicates upper motor neuron (UMN) dysfunction and neuromuscular hyperexcitability.
Common in severe preeclampsia, stroke, MS, spinal cord injury, and serotonin syndrome.

variations of preE

• Preeclampsia without severe features (SF)

• PreE with severe features (SF)

• HELLP syndrome

• Eclampsia

Preeclampsia without sever features

is a milder form of preeclampsia where a pregnant woman meets the basic diagnostic criteria for preeclampsia but does not have any severe symptoms or organ dysfunction.

• BP>140-159 / 90-109

• 2 readings at least 4 hours apart

• proteinuria

PreE with severe features (SF)

more serious form of preeclampsia where, in addition to hypertension and proteinuria (or end-organ involvement), the patient develops severe symptoms or laboratory abnormalities that indicate high maternal or fetal risk.

• BP> or = 160/110

• 2 readings 15 min apart

• proteinuria + other symptoms / abnormal labs

  • abnormal labs indicate organ damage

• edema

patient can either have BP> 160/110 or the indication of organ damage

HELLP syndrome

• PreE with hepatic dysfunction

• Hemolysis, Elevated Liver Enzymes, Low Platelets

• can occur in women w/o sever HTN or proteinuria

HELLP syndrome is a severe form of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets due to widespread endothelial injury and microvascular thrombosis that damage red blood cells and hepatic vessels.

Pathophysiology:
Abnormal placentation → endothelial dysfunction → vasospasm and microthrombi → hemolysis, liver ischemia, and platelet consumption.

Clinical features:

• Right upper quadrant or epigastric pain

• Nausea, vomiting, malaise

• Hypertension and proteinuria

• Possible complications: DIC, hepatic rupture, renal failure

Danger of HELLP syndrome

1. Liver rupture or hemorrhage

• The damaged liver becomes friable (fragile).

• Can lead to subcapsular hematoma or even liver rupture, which causes internal bleeding and shock — a medical emergency.

2. Disseminated intravascular coagulation (DIC)

• Because platelets are low and clotting factors get consumed, the mother can go into DIC, where the body clots uncontrollably in some places and bleeds elsewhere.

3. Severe bleeding

4. Multi-organ failure

• The combination of hemolysis, liver injury, and poor perfusion can lead to renal failure, pulmonary edema, and shock.

5. Fetal risks

• Due to placental insufficiency, abruption, or premature delivery, fetal outcomes include growth restriction, hypoxia, and even fetal death.

Eclampsia

• seizure activity or coma in a woman with PreE

• Before, during after birth

  • not a specific time when it can happen

Preeclampsia Diagnostic Criteria

which assessments would you perfomr to identify signs and symptoms of PreE

• Edema: especially sudden facial/hand swelling (nonspecific but supportive)

• Hyperreflexia or clonus: suggests CNS irritability

• Headache, vision changes: warning signs of cerebral involvement

• Right upper quadrant or epigastric pain: possible liver involvement

• Shortness of breath: pulmonary edema

• Dipstick for proteinuria at routine visits.

lab tests you would expect a provider to order

Test	Purpose	Expected Findings
Urine protein (24-hour collection)	Quantify proteinuria	≥ 300 mg/24 h → diagnostic
Protein/creatinine ratio	Quicker alternative	≥ 0.3 → diagnostic
Urinalysis (dipstick)	Screening	≥ 1+ protein (if no quantitative test)

PreE management goals PreE w/o SF

• home management reduced activity

• PO antihypertensive PRN

• delivery goal - 37 weeks +

• more frequent assessments

  • bloodwork

  • BPs, weigth gain

  • NST, US

PreE with SF

• hospitalization

• Delivery Goals

  • if >37 weeks try expectant management

  • immediate delivery if uncontrolled BPs worsening labs

    • i.e. indication of organ damage stoke MI eclampsia, HELLP syndrome

• Medications

  • Magnesium Sulfate

  • IV antihypertensives - HTN crisis

  • betamethasone PRN

Magnesium Sulfate

Magnesium sulfate is a CNS depressant and smooth muscle relaxant used in pregnancy to prevent or treat seizures in preeclampsia and eclampsia, with careful monitoring due to risk of toxicity.

Prevents / treats seizure activity (is not given to reduce BP)

• action: vasodilation, reduce cerebral edema, smooth muslce relaxant

administered via secondary IV infusion

Therapeutic level: 4-7 mg/dl

HIGH Risk medication -

Why It’s High-Risk

1. Narrow therapeutic window

   • The dose that prevents seizures is close to the dose that causes toxicity.

   • Therapeutic serum level: 4–7 mEq/L

   • Toxic effects start above 8 mEq/L.

2. Depresses the nervous system

   • Magnesium is a CNS depressant and smooth muscle relaxant.

   • Too much can suppress reflexes, breathing, and the heart.

3. Excreted entirely by the kidneys

   • If the patient has reduced urine output (as in preeclampsia), magnesium can accumulate quickly → toxicity risk increases.

4. Requires continuous monitoring

   • Frequent checks of deep tendon reflexes, respiratory rate, level of consciousness, urine output, and serum magnesium levels are essential.

Magnesium Sulfate normal Side effects and S/S of toxicity

Side Effects

• flushing, diaphoresis, burning at IV site

• Nausea, fatigue / sedative

• neuromuscular relaxant - decreased RR, DTR

Signs and symptoms of Toxicity

• RR <12 BPM, O2 sats <95%

• UOP <30ml/hr

• Decreased LOC, slurred speech (level of consciousness)

• Loss of DTRs

If Toxicity supsected —> stop magnesium infusion, notify provider and administer

• Calcium gluconate 10% solution
  

Purpose

Calcium directly antagonizes the effects of magnesium at the neuromuscular junction and restores muscle and respiratory function.

Patho of Magnesium (DO NOT NEED TO KNOW)

Pathophysiology Overview

In preeclampsia and eclampsia, the endothelial dysfunction and vasospasm in the brain cause:

• Cerebral edema

• Increased excitability of neurons

• Reduced blood flow and ischemia
  These changes make the brain hyperreactive → leading to seizures (in eclampsia) or risk of seizures (in preeclampsia with severe features).

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🧠 How Magnesium Sulfate Works

Magnesium sulfate acts as a central nervous system depressant and smooth muscle relaxant by influencing calcium and acetylcholine activity:

Level	Mechanism	Effect
Neurotransmission	Competes with calcium at the neuromuscular junction → decreases acetylcholine release	↓ Neuromuscular excitability → prevents seizures
Cerebral circulation	Causes cerebral vasodilation	↓ Vasospasm → improved blood flow, ↓ ischemia
Smooth muscle	Relaxes vascular smooth muscle	↓ Peripheral resistance → mild BP reduction
Cell membrane stabilization	Reduces calcium influx into neurons	↓ Neuronal firing threshold → anticonvulsant effect

So, magnesium does not treat the hypertension itself — it prevents and controls seizures by calming the nervous system and reducing cerebral irritation.

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In summary:

Preeclampsia/Eclampsia patho:
Placental ischemia → endothelial injury → vasospasm → cerebral edema + hyperexcitability → seizures

Magnesium sulfate patho role:
Blocks calcium-mediated neuronal firing + relaxes cerebral vessels → prevents or stops seizures

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Key point:

Because magnesium depresses the CNS and muscle activity, high levels can also suppress reflexes, breathing, and cardiac conduction — which is why it’s a high-risk medication requiring close monitoring (reflexes, respirations, urine output, serum Mg levels).

vasospasm (DO NOT NEED TO KNOW)

Vasospasm is the sudden constriction of a blood vessel, which narrows its lumen and reduces blood flow to the tissue it supplies.

PreE Inpatient Interventions

• maintain calm non stimulating environment

• continous FHR monitoring

• Seizure Precautions

  • suction and oxygen equiptment available and ready to use

• educate patient and family

  • medications -expected side effects, assessment frequency and purpsoe of assessments

• notify NICU team

  • magnesium sulfate can cause respiratory depression in newborn, minila variability during labor, etc

    • Preterm birht more likely

Antihypertensives

• Labetalol (IV)

  • Beta blocker —> vasodilation in peripheral arteries

  • 20mg IV push, wait 10 min for clinical efects

  • HOLD for HR <60 bpm

• Hydralazine (IV)

  • Vasodilator —> decreaed systemic vascular resistance

  • 10 mg iv push

• Nifedipine 

  • calcium channel blocker —> relaxes arterial smooth muscles

  • 10 mg PO, wait 20 min for clinical effect

  • Given wehn IV access not available

HTN disorders

• continue magnesium sulfate x 24 hrs postpartum

• monitor BP x12-24 hrs after magnesium is stopped

• schedules PO antihypertensives

  • discharge teaching if prescriptions to be used at hom

You want to make sure blood pressure can be managed just with PO medications in a healhty range

Eclamspia

Eclampsia is the most severe form of preeclampsia, characterized by the onset of seizures (or sometimes coma) in a woman with preeclampsia that cannot be attributed to another cause.

• prioritize airway and safety

  • side rails up, pad if able, turn to side

• remain at bedside, call for help, note time

• Post convulsion

  • assess ABC’s

  • suction, oxygen, bag-mask if not breathing

  • IV access - magnesium sulfate 1st lin

  • lorazepam (ativan) 2nd line if seizures continue

  • confusion combative, coma - common,

  • fetal uterine status (if pregnant

    • Utuerus Hypercontractile hypertonic

    • fetus - bradycardia, late deceles minimal absent variability.

management of PreE with baby below GA

Maternal Stabilization

If severe features:

• Seizure prophylaxis: Magnesium sulfate

• Blood pressure control: IV hydralazine, IV or oral labetalol, or oral nifedipine

• Monitor: Vitals, reflexes, urine output, labs (CBC, LFTs, creatinine, urine protein)

If mild:

• Close monitoring inpatient or outpatient, depending on resources

• Serial BP checks and labs

• Education on warning signs: headache, visual changes, RUQ pain, decreased fetal movement

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Fetal Assessment

• Ultrasound: growth, amniotic fluid, Doppler

• Nonstress test / biophysical profile for viability and well-being

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Timing of Delivery

• Definitive treatment = delivery, but timing depends on gestational age (GA) and maternal/fetal status:

GA / Scenario	Approach
< 34 weeks & maternal/fetal stable	Expectant management:

• Hospitalization

• Daily maternal labs

• Fetal surveillance (NST, BPP)

• Corticosteroids for fetal lung maturity (betamethasone or dexamethasone)

• Magnesium sulfate for seizure prophylaxis |
  | ≥ 34 weeks or maternal/fetal deterioration | Delivery (usually induction or cesarean if unstable) |
  | Severe maternal compromise at any GA | Immediate delivery, regardless of GA |

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Supportive Measures

• Bed rest is not strongly recommended, but activity may be limited

• Fluid management: avoid overload (risk of pulmonary edema)

• Treat complications (HELLP, DIC, renal failure) as needed

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Summary

• Mild preE <34 wks: Expectant management + close monitoring + corticosteroids

• Severe preE or deterioration: Immediate stabilization → delivery, regardless of GA

• Always protect the mother first; prolong pregnancy only if safe

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Early pregnancy Bleeding

Spontaneous abortion (miscarriage)

• pregnancy ends naturally <20 weeks

• 25% of pregnancies

Cervical insufficiency

• cervical dilation without clear cause

• leads to preterm birth in 2nd trimerster

ectopic pregnancy

• fertilized Ovum implants outside of the uterus

• 3% of pregnancy related maternal deaths

spontaneous Abortion (SAB) aka Miscarriage

There are multiple types of textbooks 28.1 pg 601

Symptom:s Bleeding (light to heavy)

cervical dilation

uterine cramping (none to severe)

Management

• 75% are expectant management

• allow the body to do its thing instead of intervening

Medical

• usally prostagalndins - misoprostol

• surgical management if products not passed completely

surgical

• dilation and Curettag (D&C)

  • Dilation and Curettage (D&C) is a surgical procedure used to evacuate the contents of the uterus. In obstetrics and gynecology, it’s commonly performed for spontaneous abortion, missed abortion, retained products of conception, or abnormal uterine bleeding.

• post op oxytocin and other uterotonics

• epidural or sedation intra-op, NSAIDS post op

no sex tampos for 2 weeks

grief counseling

cervical insufficiency

determine cause: is it weak cerivcal tissue or early signs of preterm labor

• considered to have genetic component

Diagnosis

• US to assess cervical length (<25mm)

  • ultrasound (US)

• Speculum exams to identify dilation

symptoms

• painless and passive cervical dilation

management of cervical insufficiency

management

• cervical cerclage

  • suture through around external OS

    • opening of cervix

      

  • ca be prophylactic due to OB history or treatment in respone to short cervix

  • placed between 12-23 weeks

  • removed for PTL SROM or at 36 weeks

• Progestorone

  • route IM or vaginal

  • starts at 16weeks ends at 36

  • reduces preterm nirth by 30

ectopic pregnancy

implantation of a fertilized ovum outside the endometrial lining of the uterus

Location	% of cases
Fallopian tube (most common)	~95%
— Ampulla	70%
— Isthmus	12%
— Fimbrial end	11%
Other sites (rare)	Ovary, cervix, abdomen, C-section scar

Risks: hemorrhage, sever fetal malformations

Symptoms:

• abdominal pain (dull ache —> sharp stabbing pain)

• delayed menses

• abnormal vaginal bleeding

• if rupture —> shock, cullen sign, referred pain

cullen sign: Cullen sign = bluish discoloration around the umbilicus (belly button) caused by subcutaneous intraperitoneal bleeding that tracks along the fascial planes.

management and education of ectopic pregnancy

Management

Mthotrexate (IM injection) - early treament

• destroyes rapidly dividing cells

• prodicts of conception reabsorbed by body within 4-6 weeks

Surgical treatment

• depends on severity

• salpingectomy could be needed if ruptured

• Salpingectomy = excision (removal) of a fallopian tube.

Education

• no analgesics stronger than acetaminophen (mask s/s rupture)

• notify proivder when prefnant again - risk for another ectopic 

• grief or infertility support groups PRN

Late pregnancy bleeding

placenta previa and placental abruption

placenta previa

is a condition where the placenta implants low in the uterus and partially or completely covers the cervical os (the opening of the cervix).

Risk factors: previous c/s, AMA(advanced maternal age), multiparity, D&C (dilation and curretage), smoking\

symptoms

• painless, bright red vaginal bleeding

• VS may be WDL

• soft nontender abdomen with NL uterine tone

• FHR may be WDL until sever detachment

Feature	Previa	Abruption
Pain	None	Present
Bleeding	Bright red	Dark red
Uterus	Soft	Rigid/tender
Fetal distress	Rare	Common
Delivery	C-section	Often urgent

Concerns

management of placenta previa

• all pateints with painless vaginal bleeding - assume previa until proven otherwise

expectant management <36 weeks

• 1st bleeding episode —> and observatoin

• 2nd/3rd bleeding episode —> hospitalized

active managemetn >36 weeks

• concerns about maternal fetal well - being —> delivery regardless of GA

C-section delivery

• increased risl of hemorrhage immediately after birth

• always give Cesearan cannot deliver placenta before baby

placental abruption

is when the placenta separates prematurely from the uterine wall before delivery.

Risk factors:

• HTN disorder, drug use, (meth or cocain), truama, hx of abruption, smoking, PPROM(Preterm Premature Rupture of Membranes.)

Symptoms

• vaginal bleeding,

• abdominal pain

• uterine tenderness - localized to specific region

• contractions - usally requent (blood irritates uterus)

• fetal distress with increased detachment

table

Feature	Previa	Abruption
Pain	None	Present
Bleeding	Bright red	Dark red
Uterus	Soft	Rigid/tender
Fetal distress	Rare	Common
Delivery	C-section	Often urgent

management of placental abruption

depends on blood loss and fetal maturity / status

• expectand management < 36 weeks

  • if mother and fetus are stable

  • additional antepartum testing (NST,BPP)

• active management

  • if GA > 36 weeks or there are signs of compromise

  • vaginal birth (if possible or cesarean)

  • closely observe VS, FHR, clotting factors, H&H (hemoglobin and hematocrit

Metabolic adaptations in pregnancy

• glucose corsses placenta

  • maternal glucose levels = fetal glucose levels

• insulin does not cross

diabetogenic effect

• caused by placental homrones 

• increased glucose production

• insulin resistance decreases - 

  • this means If insulin resistance decreases, it means the body’s cells are more sensitive to insulin again.

    So glucose moves into the cells more easily, and blood glucose levels drop.
    This can happen:

    • Early in pregnancy, when maternal metabolism is still geared toward storing nutrients.

    • After delivery, when the placenta (and its hormones) are gone, and insulin sensitivity returns to normal.

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    Summary:

    • Insulin resistance ↑ → more glucose for baby (normal in late pregnancy).

    • Insulin resistance ↓ → more glucose taken up by mom’s tissues, less available for baby.

diabetes Mellitus

occurs in about 6-7% of pregnancies

• 90% of those are GDM

hyperglycemic state

Main types

• type 1` DM

• Type 2 DM

• Gestational diabetes (GDM)

Gestational Diabetes (GDM)

• glucose intolerance that develops during pregnancy

• increased risk of 

  • miscarriage

  • macrosomia / LGA infant

  • neural tube defect

  • disproportionate chest / shoulder size

  • polydramnios

  • preeclampsia

  • ketoacidosis (DKA)

  • infection

what test is used to diagnose GDM

Two-step approach (most common in the U.S.):

1. Step 1 – 50 g Glucose Challenge Test (screening):

   • No fasting required.

   • Blood glucose checked 1 hour after drinking 50 g of glucose.

   • If ≥130–140 mg/dL, proceed to step 2.

2. Step 2 – 100 g OGTT (diagnostic):

   • Done after overnight fasting.

   • Blood glucose measured fasting, 1 hr, 2 hr, and 3 hr after drinking 100 g glucose.

   • Diagnosis: If 2 or more values are above thresholds (e.g. Carpenter-Coustan criteria).

Gestational Diabetes (GDM)

• normal levels

  • premeal = 60-95 mg/ dl

  • postprandial <140 mg/dl

    • Post” = after

    • “Prandial” = related to eating or a meal

• classifications

  • A1 GDM - diet controlled

  • A2 GDM - controlled with meds / insuling

diabetes management

• monitor blood glucose 4x daily

• lifestyle modifications

  • diet

    • count carbohydrates 2-3 snacks a day 

    • dont skip meals or go w/o food > 4 hours

  • excerisze

    • monnitor for hypoglycemia, increase carbs / snacks

• medications

  • insuling - type depends on blood glucose levles

  • oral hypoglycemics (metformin)

    • decrease glucose production and increases insulin sensitivity 

    • good alternate option to insulin

Nursing interventions for GDM antepartum

• antepartum care

  • ultra sound to monitor fetal growth and AFI (amniotic fluid index)

    • this is important because High maternal blood glucose can lead to fetal hyperglycemia → increased fetal urine output, causing polyhydramnios (too much amniotic fluid).

    • GDM can also cause macrosomia (large baby) and growth abnormalities.

  • ing

Nursing interventions for GDM intrapartum

• blood glucose q1-2 hours

• hypoglycemia < 70 mg/dl

  • signs and symptoms: palpitations, tremors (shakiness), hunger, headache, confusion, fatigue, blurred vision, seizure (severe)

  • treatment: glucose gel, juice, sugar / if unconscious, Iv infusion (D5LR or D5NS) of glucose

Nursing interventions for GDM postpartum

• insulin requirements drop

• blood gluces levels PRN

  • A1 GDM - serum leevels or no checks

  • A2 GDM - continue fasting and PP

• blood glucose at PP appoiuntment - 

  • women who had GDM are at higher risk of developing GDM later in life

  • purpose is to ensure levels have gone back to normal

  • typically 75mg test done 6 to 12 weeks PP

HCG

stands for human chorionic gonadotropin — a hormone produced by the placenta after implantation.

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Quick facts:

• Maintains the corpus luteum, which keeps producing progesterone to support early pregnancy.

• Detected in blood and urine — the basis of pregnancy tests.

• Normally rises rapidly in early pregnancy and then levels off.

Hyperemesis Gravidarum

excessive vomiting —> weight loss, electrolyte imbalance, dehydration

causes - rising HCG, relaxation of the GI tract

Treatment

• medications 

  • pyridoxine (Vit B6) + doxylamine (unisom)

  • Prescriptions - ondansetron (Zofran)

• IV therapy - fluid replacement

• slow diet progression when vomiting stops

  • dry, balnd, low-fat, high-protein foods

  • ginger - tea, lozenges, soda

Anemia in pregnancy main risks / concerns 

• hemoglobin < 11mg/dl in 1st or 3rd trimester

• reduction in oxygen carrying capacity

Main Risks / Concerns

• Maternal risks:

  • Fatigue, weakness

  • Increased risk of infection

  • Preterm labor or postpartum hemorrhage

  • Poor tolerance to blood loss during delivery

• Fetal risks:

  • Low birth weight

  • Preterm birth

  • Fetal growth restriction (IUGR)

  • Stillbirth (in severe, untreated cases)

Anemia in pregnancy common symptopms and types

Common Symptoms

• Fatigue, dizziness, or fainting

• Pale skin or mucous membranes

• Shortness of breath

• Rapid heartbeat (tachycardia)

• Headache

Types

• Iron deficiency

• Folic acid deficiency

• sickle cell

• thalassemia

Iron deficiency anemia

• most common anemia (75%)

• serum ferritin < 12 mcg/ L + low Hgb < 11g/dl

• pregnany body will ensure fetal iron stores are adequate

treatment

• iron supplements

• PO - 325 mg daily

  • Constipation (most frequent)

  • Nausea or upset stomach

  • Abdominal cramping

  • Dark or black stools (harmless, expected)

  • Metallic taste in mouth

• IV - Venofer

cholestasis

• liver condition where bile flow is reduced or blocked, causing bile acids to build up in the blood.

• occurs in pregnancy

• cause is unknown

Symptoms

• Severe itching (pruritus) — especially on palms and soles, worse at night

• Dark urine

• Pale or clay-colored stools

• Jaundice (yellowing of skin/eyes) — in some cases

• Fatigue or malaise

• Loss of appetite or nausea (sometimes)

diagnostics of Cholestasis

Bile Salts (or Bile Acids)

• Bile acids are made in the liver to help digest fats.

• In cholestasis, bile can’t flow properly, so bile acids build up in the blood.

• Measuring serum bile acids is the most specific test for intrahepatic cholestasis of pregnancy (ICP).

  • ↑ Elevated bile acids confirm the diagnosis.

LFTs (Liver Function Tests)

These are blood tests that measure how well the liver is working.
Key ones include:

• ALT (Alanine aminotransferase)

• AST (Aspartate aminotransferase)

• Alkaline phosphatase (ALP)

• Total and direct bilirubin

In cholestasis:

• ALT and AST are elevated (liver irritation/damage)

• Bilirubin may also rise if bile flow is severely impaired

fetal risk and treatment of cholestasis

Because bile acids build up in the mother’s blood, they can cross the placenta and affect the baby.

IOL at 37 weeks close monitoring otherwise

treatment

• Ursodeoxycholic acid (ursodial)

  • monitor lab trends (bile salts

  • antihistamine prn - diphenhydramine (benadryl)

  • itching management —> cool baths, oatmeal, products, topical creams

cardiopulmonary resuscitation (CPR) for pregnant patient

• 1 in12,000 women admitted for L7D care in us suffer from cardiac arrest

• women 27% less likely to receive CPR than men even more so for pregnant women

Main distinctions for CPR with pregnant women

• defribilation pads slightly higher

• more difficult airway

• first concern = resuscitate and stabilize mother

• Displace the uterus to the left to protect the aorta and allow blood to flow

• Perimortum c-section

  • for fetus >23 weeks

  • decision within 5 minutes

• CPR basics - CAB

  • Chest Compression Rate

    • 100–120 compressions per minute

    ---

    Compression-to-Breath Ratio

    • 30 compressions : 2 breaths
      (for both 1- and 2-rescuer adult CPR)

    ---

    Pulse Check

    • Before starting CPR: Check for ≤ 10 seconds

    • During CPR: Check pulse every 2 minutes (or after 5 cycles of 30:2)

    • Each pulse check should last ≤ 10 seconds

AHA algorithim

Perinatal modd disorders

commen and underreported

perinatal depression affects 1 in 7 women

• set of disorders that can occur during pregnancy or within 1 year postpartum

  • depression

  • anxiety

  • postpartum psychosis

Depression (MDD) (major depressive disorder)

• Diagnosis : at least 5 symptoms within a 2 week period

• Depressed mood (spontaneous crying)

• Diminished interest in all activities

• Insomnia or hypersomnia

• Increase/ decrease in weight

• Fatigue/ loss of energy

• Psychomotor agitation

• Feeling worthless/ overly guilty

• Diminished concentration

• Suicidal ideation

increased risk for postparum depression

Postpartum depression Baby blues

• baby blues - 50-70 percent of women

  • breif period of depressive symptoms

  • resolves in 2 weeks

  • symptoms

    • Baby blues are mild, short-term mood changes that many women experience after childbirth — usually due to hormonal shifts, fatigue, and emotional adjustment.

      Common Symptoms (Mild and Temporary)

      • Mood swings

      • Tearfulness or crying easily

      • Irritability or anxiety

      • Feeling overwhelmed

      • Trouble sleeping (even when the baby sleeps)

      • Difficulty concentrating

      • Mild loss of appetite

Postpartum depression

• 9-24 percent of women

• major depressive disorder w/o psychosis

• lasts >2 weeks

• potential causes: major hormone shifts, nutritional deficiencies, genetics

• History of anxiety or depression is biggest risk factor

• symptoms are same as MDD

perinatal depresion management

• psychotherapy - first choice

• antidepressants if needed

  • risk vs benefit analysis done by providers

  • selective serotonin reuptake inhibitors (SSRI’s)

    • Escitalopram (Lexapro), Sertraline (Zoloft)

  • brexanalone (Zulresso)

    • 1st FDA approved medication for treatment of PPD

    • inpatient via iv infusion due to needs for close monitoring

PPD interventions

Screening

• edinburgh postnatal depression screen

• scores > 13 need further assessment

• suicide statement positive require follow up

Promote rest / resolve sleep deprivation

• 4-5 hours of uninterrupted sleep

social support

encourage participation in newborn care

encourage aerobic excersize as able

postpartum psyuchosis

• commonly associated with bipolar disorder

• manifests within first 2-4 weeks

• symptoms

  • Severe confusion or disorientation

  • Delusions (false beliefs — e.g., believing the baby is evil or in danger)

  • Hallucinations (hearing or seeing things that aren’t there)

  • Extreme mood swings — mania or severe depression

  • Agitation, restlessness, or insomnia

  • Paranoia or irrational thoughts

  • Poor judgment and inability to care for self or baby

  • Thoughts of harming self or the baby

• This is a PSYCHIATRIC EMERGENCY

  • high risl of suiced and infanticide

treatment

• inpatient psych care

• antipsychotics, mnood stabilizers benzodiazepoines

• supervized visits with baby

differentiating baby blues, postpartum depression and postpartum psychosis

anxiety disorders

• 10% of women 

• symptoms impair functioning

• hx of anxiety or depression is most prominent risk factor

management

• 1st line psychotherpay

• pharmocoligc

  • antidperessants

  • benzodiazepiens for short term anxiety

anxiety disorders (GAD)

• generalized anxiety disorder (GAD)

  • excessive pervasive worry, restlesness difficult concnetratin

  • often overly worried about their infant

anxiety disorders, panic attacks, panic disorder

• rapid onset of fear with symptoms of palpitations, sweating, SOB, dizyy, numbness / tingling in hands, hot flashes, fear of losing control or dying

anxiety disorder PTSD

• due to serious injury (or risk of), threat of death or sexual violence

• also r/t difficult or traumatic birth —> next labor / brith could be triggering

• involuntary memories, flashbacks, nightmares, insomnia, angry outburst, irritability

Nursing interventions for anxiety disorders

• education at discharge - teaching for self maangement

• validated screening tools

• initiating convo - 

  • how are you feeling,

  • how are thing with the baby

• if signs and symptoms are present notify provider

• empower partner to help

substance use disorder

chemical dependency

• warning signs

  • limited late or no prenatal care

  • sporadic appointments

  • poor nutrition

• risk to fetus

  • ectopic pregnancy

  • FGR / IUGR

    • Intrauterine Growth Restriction, Fetal Growth Restriction

  • LBW infant

  • preterm birth

  • abruption

  • death

  • preeclampsia

  • physcial malformations

SUD screening

• universal screening

  • validated tools

  • non judgemental approach

  • alone is best

4 Ps SUD screenign

• Parents

  • did a parent have problems with alchohol / drugs

• partner

  • does partner have a problem with alchohol / driugs

• past

  • have you ever had beer win liqoure

• pregnancy

  • in the month before pregnancy how many cigarettes did you smoke / alchohol did you consume

state laws regarding Tox screening

SUD interventions

• collabertaive interdisciplinary approach

• abstinence recommended

  • pregannyc is often great motivator for lifestyle change

• support groups

• medication assisted treament

• therapy

Preterm labor (PTL)

• regular contractions in a person who is <37 weeks GA

• about 10% babies are preterm

• Risk Factors

  • History of preterm labor or birth

  • genetics

  • recurrent UTI’s

  • IVF pregnancy

  • smoking, drug use

  • uterine anomaly

  • low socioeconomic status

  • late entry to care

  • black race

Preterm labor signs and symptoms and management

signs and symptoms

• low uterine back pain

  • low back present at any GA but can be written off in early GA

• regular contractions

• pelvic pressure

• change in vaginal discharge

• (SROM)

• Regular contractions

• Painful or rhythmic low back pain

• Fluid or bleeding + pelvic pressure

Diagnosis

• symptoms, vervical change, fetal fibronectin

management

• treat cause (ex cervical insufficiency —> Vaginal progesterone

• inpatient observatoin at a hospital equipped to manage that GA

• limit activity and work, (less working on feet)

• pelvic rest

• if body wants to deliver baby nothing can really be done

medications for PTL

• magnesium sulfate

• terbutaline

• nifedipine

• glucocorticoids

magnesium sulfate 

Medication	Route	Indication / Purpose	Side Effects / Nursing Considerations
Magnesium sulfate	IV infusion 4 g loading dose, then 1–2 g/hr	- Neuroprotection for fetus <32 wks (↓ risk of cerebral palsy) - Can provide mild tocolysis	SE: flushing, warmth, nausea, vomiting, muscle weakness, ↓ DTRs, respiratory depression, pulmonary edema NC: monitor RR, DTRs, I/O, urine output >30 mL/hr; have calcium gluconate at bedside; caution with nifedipine; monitor for magnesium toxicity

terbutaline

Terbutaline (beta-2 agonist)	0.25 mg Subcutaneous injection	Short-term tocolysis (used to temporarily stop contractions)	SE: tachycardia, palpitations, tremors, anxiety, hyperglycemia, hypotension; can cause fetal tachycardia NC: hold if maternal HR >120; avoid in cardiac disease; monitor maternal & fetal HR
Medication	Route	Indication / Purpose	Side Effects / Nursing Considerations

nifedipine

Nifedipine (Procardia) (Ca channel blocker)	10–20 mg PO, 2–3× daily	Longer-term tocolysis (reduces uterine contractions)	SE: hypotension, headache, flushing, dizziness NC: check BP before giving; use caution if also on magnesium sulfate (risk of hypotension); avoid with grapefruit juice
Medication	Route	Indication / Purpose	Side Effects / Nursing Considerations

gluucocorticoids

Medication	Route	Indication / Purpose	Side Effects / Nursing Considerations

Glucocorticoids (Betamethasone or Dexamethasone)

IM injection, 2–4 doses, 12 hrs apart

Accelerate fetal lung maturity; reduce risk of RDS, IVH, NEC

SE: hyperglycemia, injection site pain, decreased fetal movement for 72 hrs NC: monitor maternal blood glucose (especially in diabetics); given between 24–34 weeks; best effectiveness if birth occurs 24 hrs–7 days after completion

Preterm pre-labor rupture of membranes (PPROM)

Rupture of membranes before labor begins and less than 37 weeks

symptoms

• sudden gush or slow leak of fluid

• can feel like peeing without control

Diagnosis

• symptoms, obvious presence of fluid, amniotic fluid test

primary complication

• infection

management

• between 34-37 weeks —> delivery

• less than 32 weeks, expectant management

  • hospitalized, routine monitoring with NST

  • magnesium sulfate glucocorticoids

  • antibioitcs x7 days - ampicillin, amoxicillin or erythromycin

intrauterine infection OR Chorioamnionitis (chorio)

infection of the amniotic fluid, fetal membranes (chorion and amnion), and sometimes the placenta

Risk factors

• long labor

• prolonged ROM

• multiple cervical exams

• internal monitors (FSE, IUPC)

• Meconium-stained fluid

Maternal risk: sepsis, dysfunction labor

Neonatal risk: infection respiratory distress, death

intrauterine infection OR Chorioamnionitis (chorio) symptomd and treatment

symptoms

• fever greater than 38C or 100.4 F indicates infectino

• uterine tenderness

• elevated WBC above 14

• foul smelilng amniotic fluid

• Fetal tachycardia

• mother tachycardia

Treatment

• IV antibiotics

• acetaminiphen for fever

• cool down maternal body - ice, remove layers, education

• blood cultures and lactate levels

Vaginal delivery is still preferred

operative vaginal birth

a vaginal delivery assisted with an instrument, either forceps or a vacuum extractor, to help guide the baby out when the mother alone cannot complete the delivery safely or quickly.

• MD only —> must obtain consent

indications

• prolonged second stage of labor (> 2 hours)

• maternal exhaustion or cardiopulmonary disease

• fetal compromises

criteria for success

• ROM

• cervix 10cm dilated

• presenting part engaged (i.e., 0 station)

operative vaginal birith forceps and vacuum

• forceps

  • 2 curved blades that fit around baby’s ears and lock in place

• vacuum

  • vacuum cup attaches to fetal head and pressure is applied

• MD provides traction with maternal pushing efforts

maternal complications

• vaginal/cervical lacerations

• hematoma

fetal complications

• cephalohematoma

  • can lead to jaundice and anemia 

• face /scalp lacertaions or bruises 

  • can cause nerve damage

• facial palsy

shoulder dystocia

occurs when, after the fetal head is delivered, one or both shoulders get stuck behind the maternal pubic symphysis, preventing the rest of the baby from being delivered spontaneously.

• This is an obstetric emergency because the baby can suffer from hypoxia if delivery is delayed.

• Usually occurs after head delivery but before the body comes out.

risk factors

• large for GA baby 

• diabetes 

maternal complications

• 3-4th degree lacertaion

• postpartum hemorrhag

fetal complications

• fractures clavicle / humerus

• brachial plexus nerve injury

• asphyxia / death

management of shoulder dystocia

• The provider should identify the shoulder

• RN notes the time / starts a timer

• RN calls for extra assistance STAT

  • labor and delivery team

  • NICU

  • neonatal team

  • maybe anesthesia if needed

• 1st line

  • McRobert’s maneuver and suprapubic pressure

• 2nd line

  • hands and knees or posterium

prolapsed cord signs and symptoms and risk factor

A prolapsed umbilical cord occurs when the umbilical cord slips down through the cervix into the vagina ahead of or alongside the presenting part of the fetus, before or during labor, which can compress the cord and reduce or cut off blood flow and oxygen to the baby.

signs and symptoms

• long umbilical cord

• malpresentation

• non-engaged fetus

• polyhdramnios

• preterm labor

typicall happens wiht ROM; large gush —> expelled cord

prolapes cord fetal complication and management

fetal complication

• occlusion of blodo flow > 5 min —> central nervous system damage, asphyxia, death

management

• call for additional assistance

• hold up the presenting part

  • you keep your fingers in until baby is delivered

• trendelenburg or knee chest position

• 02 and iv fluid bolus

• emergency cesarean

uterine rupture

tear through the full thickness of the uterine wall, often including the endometrium, myometrium, and sometimes serosa, which can lead to fetal and maternal compromise.

Risk factor

• VBAC

• after uterine surgery

• multiparity

fetus can be ejected inot the abdominal cavity

signs and symptoms

• abnormal FHR tracing

• loss of fetal station

• sudden sharp abdominal pain - ripping / tearing

• hemorrhage / hypovolemic shock

uterine rupture

prevention is best

• patients with classical /vertical incision cannot labor

• close monitoring of patients doing TOLAC

• appropriate management of tachysystole

management

• depends on severity

• call for assistance / alert provider

• emergency cesarean

• IV fluids, 02 blood transfusions if hemodynamcially unstable

amniotic fluid embolism (AFE)

also known ans anaphylactoi syndrome of pregnancy (this is the more accurate term, it is what re recognize it to be now)

• sudden acute onset of hypotension, hypoxia, and hemorrhage cause by coagulaopathy

  • respiratory and cardiovascular collapse = similar pathway as anaphylaxis

  • very rare, unpreventable, difficult to diagnose, often fatal

maternal morbidity

• 50% of women die within 1 hour

• 85 of survivors have permanent damge

neonatal mortality

• 20-60 % and only half of those babies are neuroligically intact

Amniotic fluid embolism (AFE) signs and symptoms and management

signs and symptoms

• respiratory - restless / altered LOC, dyspnea, cyanosis —> respiratory arrest

• circulatory - hypotension, tachycardio, schock —> cardiac arrest

• hemorrhage (DIC) - profuse bleeding, petechiae, echhymosis, uterine atony

management

• call for additional assistance - anesthesia

• o2 via non rebreather mask

• position side lying

• administer iv fluids blood products

• prepare for cpr and intubation as needed

• emergency cesarean

PPH (postpartum Hemorrhage)

> 500 ml of blood for vaginal delivery

> 1000 ml of blood for cesarean

• leading cause of mortality and morbidity

• mostly occurs immediately or days and weeks later

Risk assessment PPH

• personal or family history

• prolonged labor / prolonged use of oxytocin 

  • think of like 24 hours or longer

• chorioamnionitis, HTN disorders

• placental issues - abruption, previa, accreta

• operative vaginal birth or cesarean

• coagulation disorders

• overextended uterus - muliitple, polyhydramnios

Risk assessment tools PPH

• low, medium and high risk patients

• anticipatory guidance

• GOAL = early recognition, determine cause and intervene before its life threatening

causes of PPH the four T’s

Tone, tissue, truama, thrombin

PPH Tone

TONE

• most common cause of early PPH

• a boggy uterus

• distended bladder

• bleeding

• management

  • massage fundus

  • empty bladder

  • utertonic medications

    • firms the fundus

PPH Tissue

Retained placenta (tissue)

• placenta not expelled within 30 minutes OR fragments of placenta still inside uterus

• this causes excessive bleeding 

  • physical barrier to clamping

  • placenta tricks uterus into not clamping down

• management

  • manual extraction by provider

  • dilations and curretage ( D&C) as needed

placental acreta syndrome

• placenta has abnormal or invasive implantation

• management

  • usually D&C or hysterectomy if severe

  • MASSIVE PPH