CONCEPTS V WEEK 05

Hormonal changes in pregnancy

hCG

Estrogen

progesterone

oxytocin

prolactin

hCG changes in pregnancy

hCG will increase until 9/10 wkis

earliest biomarker of pregnancy

abnormally high hCG can mean what

multiple gestation

abnormally low hCG can mean what

miscarriage

associated S/S of elevated hCG

NV

Fatigue

estrogen changes in pregnancy

fat deposits over abdo, back, upper thighs

promotes enlargement of uterus, genitals, breasts

relaxes pelvis

increase water retention and vascularity

associated S/S of elevated estrogen

excess salivation

nasal congestion

epistaxis

gingivitis

what is epistaxis

nose bleed

progesterone changes in pregnancy

maintains pregnancy via uterine mm relaxation

stimulates uterine growth

causes fat to deposit over abdo, back, thighs

associated s/s of increased progesterone

constipation

heartburn

flatulence

oxytocin changes in pregnancy

stimulates uterine contractions

prolactin changes in pregnancy

prepares breasts for lactation

associated s/s of prolactin

production of colostrum (premilk)

uterus changes in pregnancy

pear shape b4 conception, then round, then oval

uterus gets bigger

changes in position (fundal height)

changes in cervix in pregnancy

friability (increased sensitivity)

goodell sign

chadwick sign

hegar sign

goodell sign

softening of the cervix

chadwick sign

bluish discoloration of the vagina and cervix

hegar sign

softening of the uterine isthmus

what is the placenta

delivers oxygen and nutrients from mom to baby

vaginal changes in pregnancy

pH becomes more acidic

more yeast infections

formation of mucus plug

leukorrhea

what is leukorrhea

white mucus discharge from vagine w musty smell during pregnancy

breast changes in pregnancy

enlargement

areola darken

stretch marks

increased sensitivity

Discharge

BV more visible

colustrum

white yellow pre milk seen at 16+ weeks

skin changes in pregnancy

striae gavidarum

linea nigra

chloasma

spider nevi

striae gravidarum

stretch marks

linea nigra

Hormone-induced hyperpigmentation, moving down the midline

- Appears around 3 months during the first pregnancy

- In 2nd or later pregnancies, it shows up much earlier

chloasma

Blotchy, brownish hyperpigmentation around the cheeks, nose, and forehead

- Sun exposure makes them more noticeable

- Fades after birth

- Can recur with more pregnancies or oral contraceptives

spider nevi

Tiny, branched pulsating end-arterioles

- Found on neck, thorax, face, and arms

- Caused by ↑ estrogen → ↑ blood flow to skin

- Disappears within first 3 months postpartum

cardiac changes of pregnancy

increased CO

increased pulse

increased or decreased BP

supine hypotensive syndrome

increased BV

increased RBC and WBC

increased clotting

physiologic anemia

supine hypotensive syndrome

decreased BP when laying on back because uterus presses on vena cava

respiratory changes in pregnancy

increased/same RR

elevated diaphragm

increased chest expansion

increased O2 consumption

SOB

ABG

nasal congestion/bleeds

non severe HTN

>140/90

severe HTN

160/110

gestational HTN

HTN that appears for the first time at or beyond 20 weeks' gestation, in the absence of proteinuria and without changes in blood work

chronic HTN

HTN that either, predates the pregnancy, or appears before 20 weeks' gestation

transient HTN

HTN d/t stimuli

white coat HTN

elevated at clinic visits

masked HTN

Normal in office, high at home

What is preeclampsia?

a hypertensive disorder accompanied by new-onset proteinuria and, potentially, other end-organ dysfunction

patho of preeclampsia

poor perfusion d/t vasospasm which then increases BP

risk factors of preeclampsia

- Nuliparity

- Age > 40 years

- Pregnancy with assisted reproductive technology

- Interpregnancy interval > 7 years

- Family Hx of pre-eclampsia

- Obesity/gestational DM

- Multifetal gestation

manifestations of preeclampsia

edema on face and extremities

HTN

proteinuria

SOB

weight gain

neuro changes (vision, HA, irritable)

RUQ (poor perfusion to liver)

hyperreflexia

urine protein values

+1 - 0.3 g

+2 - 1 g

+3 3g

+4 - >10g

proteinuria for preeclampsia dx

concentration of 0.03 g/L or more in at least 2 random urine specimens collected at least 6 hrs apart where there is no evidence of a UTI

nursing assessment of preeclampsia

BP

DTR

fetal health (NST) (CST) (BPP)

interventions for preeclampsia

bed rest

diet (fluids, no caffeine, fibre)

magnesium sulfate

antiHTN (labetolol preferred)

preferred antiHTN for preeclampsia

labetolol

immediate care for eclampsia

ABC

doc time duration and characteristics of sz

magnesium sulphate

anticipate CXR and ABG to check for aspiration

what is eclampsia

preeclampsia + seizures

what meds are giving to eclamptic women in whom mag sulphate is contraindicated

phenytoin or benzos but not good for baby

magnesium sulphate goals of care

prevent or control sz activity

MOA of magnesium sulphate

Interferes with ACh release → ↓ neuromuscular irritability, ↓ cardiac conduction, ↓ CNS irritability

monitoring of pt on magnesium sulphate

kidney function and UO

watch more toxicity

common adverse effects of magnesium sulphate

lethargy

warmth

HA

N

signs of magnesium sulphate toxicity

V

resp distress

hypoTN

flushing

mm weakness

decreased DTR

slurred speech

antidote for magnesium sulphate toxicity

calcium gluconate

preeclampsia post partum

- After birth, symptoms of pre-eclampsia and eclampsia will resolve within 48hrs- But postpartum pt should still be monitored from days 3-6 after giving birth

- Diuresis within 24-48hrs indicates that the problem is resolving

What is HELLP syndrome

severe pre-eclampsia + abnormalities in laboratory blood results:

- Hemolysis (H)

- Elevated Liver enzymes (EL)

- Low Platelets (LP)

patho of HELLP syndrome

Arteriolar vasospasm and adherence of platelets in blood vessels → RBCs become damaged as they pass through narrow blood vessels → RBCs become hemolyzed → ↓ RBC, ↓ platelet count, hyperbilirubinemia.

Endothelial cell dysfunction with fibrin deposits in the liver → impaired liver function → hemorrhagic necrosis, ↑ liver enzymes (d/t hepatic tissue damage)

manifestations of HELLP syndrome

malaise

epigastric or RUQ pain

NV

renal failure

pulmonary edema

ruptured liver hematoma

DIC

placental abruption

diagnostics of HELLP syndrome

CBC (low platelets)

Liver function test (increased AST and ALT)

PT/PTT (normal)

Coagulation factor assay (normal)

uterine artery doppler velocimetry

what is AST and ALT

enzymes released from injured hepatocytes (liver cells)

management of HELLP syndrome

salt restriction

zinc, mag, fish oil, vit C and E

diuretics and antiHTN

heparin or low dose aspirin

what is DIC

disseminated intravascular coagulation

What is disseminated intravascular coagulation (DIC)?

small clots form all throughout body

how is DIC diagnosed

CBC - low platelets

coag panel - low PT/PTT

factor assays - decreased

decreased fibrinogen

smear - fragmented RBCs

DIC: collaborative care

correct cause

vol expansion

replace blood and factors

oxygenation

body temp

vit K