b334 final exam

Miscarriage (spontaneous abortion)

loss of pregnancy by 20th week (fertilization age)
o After 20 weeks (no heartbeat) = stillbirth

· 80% occur before 12 weeks
-25% due to chromosomal abnormalities

Miscarriage: Risk Factors

Chromosomal abnormalities
Advanced maternal age
Previous miscarriage
Infertility
Endometriosis
Immature (small) follicles
Short secretory phase
Low progesterone

early loss

o These are in addition to chromosomal abnormalities...

o Less than 12 weeks

o Endocrine imbalance (hypothyroidism, uncontrolled IDDM)
- If they have uncontrolled blood sugar diabetes, they can end up miscarrying

o Immunologic factors (antiphospholipid antibodies)
- Autoimmune disorder that causes clot formation

o Systemic disorders (Lupus)
- Autoimmune disorder which antibodies attack healthy tissue in that person's body
- Growing an embryo is healthy tissue, so it puts them at risk

late loss

o 12-20 weeks
o Demographic!!
o Racial/ethnic minority
o Extremes in maternal age
o Dietary deficiencies/morbid obesity
o Alcohol/Drug use
§ Excessive caffeine intake (500 milligrams a day)

Types of Miscarriage

· Threatened
o Cervix is not dilated

· Inevitable
o Cervix is open and there's a lot of bleeding

· Incomplete
o Cervix is open and there's heavy bleeding and the baby has delivered but the placenta tissue is still there

· Complete
o The fetus and the placenta has all delivered together
· Table 12.6 in book

· Mist abortion (AB)
o Not a bleeding issue, the baby has no heartbeat (baby has passed away)
o Body isn't expelling it

Threatened Miscarriage
· Symptoms

o Slight bleeding
o Mild cramping
o Cervix is not dilated
o Fetus is living

Threatened Miscarriage treatment

o May order US (ultrasound) and/or HCG blood levels to see if they rise or fall
§ Make sure placenta is still intake and there is still a heartbeat
§ HCG level will continue to rise while pregnant, if miscarrying then we will see that level fall

o Bedrest not evidence-based

Inevitable Miscarriage

· When we turn that threatened miscarriage and now, we've ramped up the bleeding and cervix is contracting
· CERVIX IS DILATED

Inevitable Miscarriage symptoms

o Moderate bleeding
o Mild-severe cramping
o Cervix IS dilated and cannot prevent it

Inevitable Miscarriage treatment

o Bedrest

o Medical management (Cytotec)
§ Help complete the miscarriage

o Dilation and curettage (D&C)
§ We put them to sleep and dilate their cervix and evacuate the contents of the uterus

Incomplete Miscarriage
· Symptoms

o Cervix is dilated
o Heavy bleeding
o Expulsion of fetus
o Retention of placenta
§ Baby is gone but placenta is in there!
§ Need to act quickly on this!

Incomplete Miscarriage treatment

o Hemodynamic stabilization
o Dilation and curettage (D&C)
§ Will need to have the surgery to evacuate everything from the uterus

Complete Miscarriage
· Symptoms

o Cervix is dilated

o ALL fetal tissue passes
§ All POC has passed

o Followed by mild cramping and bleeding

Complete Miscarriage treatment

o Pain management
o Supportive/Emotional care
o Investigation if there are multiple losses!

o Quantify bleeding, pain, VS

§ We need to way those pads of blood
§ 1gram=1L of blood loss

labs

§ Look at hemoglobin and hematocrit and platelets
§ Maybe look at WBC count for infection

Miscarriage: Follow-Up Care

· Stabilization of VS, bleeding, anesthesia recovery (if D&C)
o Make sure she has a gag reflux immediately afterwards
o Make sure pain is under control
o Make sure she can eat/drink without vomiting
o Make sure she can ambulate to bathroom

· Rhogam if necessary

· Discharge Teaching (p. 300)
o Physical care, rest, iron-rich food, sexual activity, and family planning
§ Iron-rich food bc/ of blood loss

· Bereavement support
o Grief expectations, support groups
§ Maybe the baby wasn't planned, and they might be okay with it
Maybe it was a miracle baby and they were super excited

· The defining difference between a threatened miscarriage versus an inevitable miscarriage is

cervical dilation

ectopic pregnancy

implantation of the fertilized egg in any site other than the normal uterine location

· Leading cause of infertility

Causes of Ectopic Pregnancy

· Sexually transmitted diseases (cause scarring of fallopian tubes, making descent of embryo difficult)
o STIs can cause scarring
o If there is scarring, it can get stuck

· BTL (bilateral tubal ligation)
· Surgical procedures to tubes
· Rupture of appendix
· Prior abdominal surgeries.

Ectopic: Signs and Symptoms

· Missed period

· Pain
o Ranges from dull to colicky as tube stretches
o Unilateral, deep lower abdomen
o Increases with rupture of tube (sharp, stabbing)
o Referred shoulder pain from blood accumulation in peritoneal cavity

· Bleeding
o Mild, dark red or brown vaginal bleeding
o Concealed intrabdominal bleeding (Cullen sign)
§ Bruising color at umbilicus

· Shock

Treatment for Ectopic

· Surgery: laparoscopy or laparotomy to remove ectopic pregnancy
o If the embryo is not too big, they can go into the fallopian tube and remove it and save that fallopian tube
o If it is too big, then they have to remove the fallopian tube
§ Could affect her fertility

Treatment for Ectopic pt 2

· Methotrexate: chemotherapeutic agent given to destroy fetal tissue-can be given IM
o Destroys rapidly dividing cells (an embryo is rapidly dividing)
o Give it IM...hazardous drug
o Box 12.4!!!
This is for early ectopic pregnancies

Hydatiform Mole: Molar Pregnancy

Abnormal development of the trophoblast, a placenta develops, but no fetus


· Gestational trophoblastic disease

· Persistent trophoblastic tissue that is presumed to be malignant

· 1 in 1200 pregnancies

· Suction D and C

· Follow-up with HCG levels q month for 6 months then q 2 months for 1 year. Can lead to cancer because trophoblastic tissue can migrate to other places

· Empty egg: no genetic material, no fetus at all, just a growth (no placenta)
o Once we find it we need to remove it... suction D&C

· If this travels elsewhere in the body, it can become cancerous and malignant
o So follow the HCG levels
o If the HCG levels are continuing to rise after D&C we need to figure it out

Molar Pregnancy: Signs & Symptoms

· Vaginal bleeding (prune juice or bright red from maternal blood supply feeding this non-existent placenta); feeding into uterine cavity; can be small or perfused
· Increased N/V
· Anemia
· Hypertension
· Hyperthyroidism
· Pulmonary embolism

· US: larger than normal uterus, grapelike clusters in uterus
o If 20 weeks then uterus should be 20cm
o Maybe at 20 weeks she is measuring 24cm= molar pregnancy

· No viable embryo; there is fluid-filled vesicles

An acute rupture of a fallopian tube is a surgical emergency. Nursing care is aimed at

o Combatting shock

Placenta Previa

the abnormal implantation of the placenta in the lower portion of the uterus

o Plants in the lower uterine segment rather than up high in the frontal area of the uterus and it ends up near the cervix or covering cervix

· Major cause of bleeding in late pregnancy
o 3rd trimester (after 24 weeks)

Placenta Previa risks

prior C/S, prior previa, endometrial scarring, maternal age, smoking, multiparity, high altitude, multiple gestation
o When there is scar tissue from a prior C-section it looks for somewhere else to implant and it intends to go lower

o Endometrial scarring= D&C

o High altitude= air is very thin, decrease in O2 in placenta

More baby to nourish if twins, triplets, etc

Complete Placenta Previa

totally covers the internal cervical os

· Indication for c-section

Marginal Previa

· Placental edge is found by US to be within 2.5 cm or closer of cervical os
o She will need to have a C-section if 2.5cm or closer
o Low-lying placenta, but as the uterus grows, the placenta moves up and out of the way

Placenta Previa: Signs and symptoms

· Painless, bright red vaginal bleeding (bright red bc/ placenta is right there!)

· Soft, non-tender uterus

· 70-80% have at least one episode of bleeding

· Suspect when pt has any bleeding after 24 weeks.

· Bleeding occurs when uterus is not able to contract adequately and stop blood flow from open vessels.

· VS may be normal: pregnant woman can lose 40% of blood volume before showing signs of shock

Placenta previa complications

· Preterm ROM
· PTL (preterm labor)
· Anesthesia complications with surgical delivery (C/S)
· Blood transfusion reactions
· Over infusion of IVFs
· PPH
· Anemia
· Higher risk of requiring hysterectomy at delivery

Placenta Previa ...

· A placenta previa can be diagnosed as early as 18 weeks of pregnancy.

· Often it will resolve spontaneously because as the uterus grows the placenta will migrate out of the way.

· If a placenta previa is diagnosed at 18 weeks via US, a repeat US will be done at 28 weeks and,

· If it is resolved (gone completely) then pt can deliver vaginally. If previa is still there at 28 weeks, will continue to monitor via US and plan for C/S delivery.

Placenta Previa: Nursing Care

· 3rd trimester bleeding→ Immediately evaluate for previa

· Obtain history: gravida and para, EDC, bleeding quality, quantity and pain
o Previous previa= risk factor; c-section=risk factor

· Abdominal exam→ soft, nontender
o Palpate abdomen

· Labs: CBC, Blood type, Rh factor, coagulation profile, and type and crossmatch
o If she is Rh negative= RHOGAM!! (to prevent antibodies from forming)
§ If we are breaking open those blood vessels then there is risk for mixing blood

· Standard for diagnosis is transabdominal ultrasound. If placenta is within 2.5 cm of os, requires C/S

Expectant Management of Placenta Previa

· If pt less than 36 weeks with minimum bleeding, not in labor, give fetus time to mature in utero

· Bed rest with BRP or BSC
o Bathroom privileges and a bedside commode

· Assess bleeding, VS, FHR, Ctx
o Every 4-8 hours

· US q 2 weeks, BPP once or twice weekly with NTSs
o To check on status of previa
o NTSs to establish well-being of baby

· Assess Hgb

· Maintain SL, current T&S
o Saline lock (next episode of bleeding could be major!)
o T&S on file

· Betamethasone (steroids) ordered for mom to promote fetal lung maturity
o 2 doses, 24 hours a part to mature those lungs (if less than 36 weeks)

· Document fetal lung maturity at 37 weeks (via amniocentisis) and, if mature, consider C/S delivery

· No Vaginal exams! No vaginal ultrasounds! These could poke hole right through placenta.
o Bc/ placenta is by cervical os, we could disrupt those vessels

· Your client has been diagnosed with placenta previa. As her pregnancy progresses, you would expect assessment of the uterus to

o Remain soft on palpation

Painless, bright-red bleeding with a soft, non-tender uterus!

Abruptio Placenta or Placental Abruption

· Premature separation (detachment) of placenta prior to delivery of the fetus

o Prematurely separates from uterus prior to the delivery of the fetus

o Ideally, we want the fetus to deliver and then the placenta detaches, that way the baby can have full blood supply and oxygen until delivery

o When the placenta detaches first, that decreases the blood supply and oxygenation to the baby and can cause a hemorrhage

Placental Abruption causes

· maternal hypertension, cocaine use, blunt trauma to abdomen
o Vascular destruction= HTN & cocaine use
§ Constricts those blood vessels and it wants to pull away from the uterus

placental abruption risk factors

· cigarette smoking, history of abruption, PPROM, twin gestation

placental abruption classifications

o Mild, moderate, severe
§ Severe abruption causes immediate intervention; we are delivering the baby immediate to prevent massive blood loss

o Complete or partial

Abruption: Signs & Symptoms

· Symptoms vary with degree of separation
· Dark red vaginal bleeding
· Abdominal pain/tenderness
· Contractions (uterine tetany -" board-like" abdomen)
o May see tachysystole
o May see uterine tetany (has a higher resting tone)
o What is the tone of the uterus? IT SHOULD BE SOFT!!! (in abruption it will be firm)

Couvelaire Uterus

· blood accumulates between separated placental and uterine wall.
-Contractility is lost in uterus and it appears purplish and ecchymotic

o Will see loss of variability because variability tells us about oxygenation and central nervous system (is it intact)
§ If we are hemorrhaging, we are losing oxygenation (loss of variability)

o Late or prolonged decelerations
§ Late decels are utero placental insufficiency, so there's not enough blood flow getting to the uterus and the placenta that's feeding the baby
§ They may turn into a prolonged deceleration because of the lack of oxygenation

o Bradycardia and then the sinusoidal pattern (sawtooth pattern on fetal HR, there is no variability to it, its just a waveform)
§ Think abruption if you see that

Abruption: Complications

· Hemorrhage, hypovolemic shock, thrombocytopenia, DIC, infection, renal failure and pituitary necrosis, Rh isoimmunization
o All the blood flow that is feeding into the placenta is separated so it just goes into the uterine cavity and can lead to hypovolemic shock

o Pregnant women have an increased blood supply so it takes up to 40% blood loss till we see signs of hemorrhage and shock

o Also pumping blood flow out fast, that cardiac output is really, really big so it can happen very quickly

o DIC: cascade of clotting factors that are consumed

o Pituitary necrosis (pituitary glands aren't being perfused)

· 60% of abruptions cause non-reassuring FHR patterns like late decelerations and loss of variability. You can also see uterine hyperstimulation and increased resting tone of uterus

· Fetal: IUGR, PTB, hypoxemia, stillbirth
o Intrauterine growth restriction (IUGR)
o Preterm birth (PTB)

Placental Abruption: Treatment

· If it is mild and less than 36 weeks, can watch in hospital. Observe closely for signs of bleeding and labor. NSTs and BPPs to assess fetal well-being.
o Lesser degree of separation
o Will observe closely for signs of bleeding in the hospital; will watch fetal well-being

· Corticosteroids (betamethasone) to develop lungs

· May need Rhogam if mom is Rh negative

· Delivery is treatment of choice if bleeding is severe and mom and baby at risk
o Are we going to induce a patient who has massive placental abruption? NO!!
--- C-section
o If she only has a 10-20% separation we can probably induce her

Abruption: Nursing Care

· Large-bore 16-18 gauge peripheral line
o Most likely 2 because we need to infuse her with fluids and blood products

· Monitor maternal VS, watching for ↑P and ↓BP

· Continuous FHR monitoring

· Foley cath to measure UO with goal of 30ml/hr or more
o In the middle of a hemorrhage, all of her blood supply that she can is being shunted to her heart, her brain and lungs and the kidneys get sometimes left out
o So we want to make sure she has good urinary output

· Blood and fluid volume replacement

· C/S avoided when woman has coagulopathy like DIC
o Try to avoid C-section if DIC but may not want to induce her either
o Major abruption= C-section
o DIC= avoid C-section

· Pt is monitored in hospital, never at home.

Disseminated Intravascular Coagulation (DIC)

· Widespread external bleeding, internal bleeding, caused by consumption of large amounts of clotting factors.

o Widespread bleeding (secondary diagnosis), something in her pregnancy that triggers this!!!

o Triggers a release of large amounts of thromboplastin (clotting cascade); so it uses up all of the clotting factors (there's this over activation of it)

o It causes fibrin formation and destruction of the blood cells and it causes damage to the vasculature

o Caused by triggers

DIC can result from

· abruptio placenta, amniotic fluid embolism, IUFD, preeclampsia, septicemia, cardiac arrest, and hemorrhage
o Intrauterine fetal demise (baby dies in the uterus and it can trigger DIC)

DIC
-diagnosis made by clinical findings

o Unusually heavy bleeding from gums, nose, IV sites, urethra, or any site that had been traumatized (IM injection site etc)
§ THEY BLEED FROM EVERYWHERE!!!!

o Labs show decreased platelets, fibrinogen, and prothrombin.
§ Using up these clotting factors

o Treatment is correction of underlying cause (deliver dead fetus, treat infection, remove abruption)
§ Not correcting the DIC, but rather the underlying cause

o Volume replacement, blood products, O2,

o Watch for renal failure

o Urinary output should be more than 30ml/hr

· Which of the following orders would you question on a 35-week gestation patient with placental abruption?

o Intermittent fetal monitoring

- These patients need continuous fetal monitoring, once she has an abruption, she will not go home regardless of degree of it and we are keeping that baby on a monitor because we need to make sure the baby is okay since it causes decreased oxygenation to the baby

· Preterm Labor

o Regular uterine contractions with progressive cervical effacement and/or dilation

preterm birth

A birth that occurs after the 20th week and before the start of the 38th week of gestation.

o Any birth that occurs between 20 0/7 and 36 6/7 weeks gestation

· Late-Preterm Birth

Birth that occurs between 34 and 36 weeks of gestation

Spontaneous Preterm Labor & Birth: Who's at risk?

· Medical Conditions
o Periodontal disease
o History of genital tract colonization, infection, or instrumentation

· Pregnancy-related Conditions
o Bleeding of uncertain origin in pregnancy
o History of a previous spontaneous preterm birth between 16 and 36 weeks of gestation
o Uterine anomaly
o Use of assisted reproductive technology
o Multifetal gestation

Causes for Indicated Preterm Delivery
· Maternal factors

o Preexisting or gestational diabetes
o Chronic hypertension
o Preeclampsia
o Obstetrical disorders or risk factors in the current or a previous pregnancy (previous classical c/s, cholestasis, placental abruption or previa)
o Medical conditions (seizures, thromboembolism, connective tissue disorders, asthma, chronic bronchitis, HIV or active HSV, obesity)
o Smoking
o Advanced maternal age

Causes for Indicated Preterm Delivery
· Fetal factors

o Fetal compromise
§ Chronic (poor fetal growth)
§ Acute (abnormal results on a NST or BPP)

o Polyhydramnios or oligohydramnios
§ Too much antinomic fluid and too little

o Fetal hydrops, ascites, blood group alloimmunization

o Birth defects

o Fetal complications of multifetal gestation (e.g., growth deficiency, twin-to-twin transfusion syndrome)

Cervical insufficiency

· Passive and painless dilation of the cervix leading to preterm birth in the second trimester without any other cause

· Risk Factors: cervical lacerations or surgery, excessive cervical dilation, D&Cs, congenital short cervix

· Diagnosed by US showing cervix less than 2.5cm or cervical funneling

· Management
o Cerclage placement: suture is placed around the cervix to "close" the internal os
§ Prophylactically or rescue
§ Placed at 11-15 wks, removed prior to 37 wks

Which of the following would indicate the need for prophylactic cerclage placement?

History of two late miscarriages at 14 and 18 weeks

Preterm Labor & Birth - Predictors

Fetal Fibronectin: biochemical marker used as a diagnostic test for preterm labor
o Glycoprotein in plasma present in vaginal/cervical secretions during pregnancy; "glue"
o Presence in late 2nd and early 3rd trimester can be related to placental inflammation -> PTL!
o The test is often used to predict who will not go into labor.
o Negative predictive value of fFn is high at 98%.
o Positive predictive value is low at 65% (between 22-24 wks) and 25% (before 35 weeks)

· Cervical Length: changes can occur in endocervical length before uterine activity. Can identify women whom have started the labor process.

· Completed via ultrasound.

· Normal cervical length: 3-5 cm (inner to outer os)

· "Short" cervix: 2.5cm or less
o Could be indicative of preterm labor

Preterm Labor & Birth: Prevention

· PRECONCEPTION COUNSELING & PRENATAL CARE!!
o Weight gain, PNV, smoking cessation

· Progesterone Supplementation
o Daily vaginal suppositories or weekly IM injections
o Can decrease PTB by 40% in women with history of PTB (preterm birth) or short cervix
o 16-36 weeks

Preterm Labor & Birth: signs/symptoms

· Uterine activity
o Regular or frequent contractions
o Often painless

· Discomfort
o Abd cramping, low dull back pain, suprapubic pain/pressure, pelvic pressure, urinary frequency

· Vaginal Discharge
o Rupture of Membranes
o Change in color/amount of vaginal discharge

Preterm Labor & Birth: Tocolytics

· Tocolytics: medications to stop progression of labor after contractions and cervical change have occurred

· U.S. FDA has not approved ANY medications for use as tocolytics
o Magnesium Sulfate
o Terbutaline
o Procardia

Preterm Labor & Birth: Tocolytics
-· Magnesium Sulfate

o CNS depressant, relaxes smooth muscle, including uterus

o 4-6 gram loading dose with maintenance rate 1-4 grams/hour IV/IM

o Short term use (<48 hours) for:
§ Fetal neuroprotection
§ Prolongs pregnancy to transfer to higher level of care, administer corticosteroids

o Side Effects: hot flashes, sweating, N/V, dry mouth, blurred vision, headache, muscle weakness, hypocalcemia, SOB, lethargy

· Nursing Considerations (Mag sulfate)

o Monitor ctx/FHR
o Monitor maternal VS, DTR's, LOC
o Monitor serum mag levels for toxicity (>8 mg/dL)
o FALL RISK!

o Adverse reactions: RR<12, pulmonary edema, chest pain, altered LOC, UO<30mL per hour, loss of DTR's, reduced FHR variability/breathing
§ STOP MAG IMMEDIATELY IF TOXICITY SUSPECTED!
§ CALCIUM GLUCONATE is antidote!!!

Preterm Labor & Birth: Tocolytics
· Nifedipine(Procardia)

o Relaxes smooth muscles including the uterus by blocking calcium

o Given orally

o Side effects: hypotension, dizziness, headache, facial flushing and nausea

o Nursing Considerations
§ Monitor maternal VS
§ Monitor ctx/FHR

Preterm Labor & Birth: Tocolytics
· Terbutaline (Brethine)

o Relaxes smooth muscles, inhibiting uterine activity and causing bronchodilation

o Given subcutaneous injection for short term use (24 hours)

o Nursing Considerations
§ Monitor maternal VS
§ FHR monitoring

o Side effects: Tachycardia, chest discomfort, palpitations, tremors, dizziness, H/A, N/V, hypotension, hypokalemia, hyperglycemia

o Adverse effects: HR > 130, BP < 90/60, chest pain, MI, pulmonary edema, DEATH

When would tocolyic therapy be contraindicated?

o Mother?
§ Cardiac disease

o Fetus?
§ Fetus in distress
§ Would not stop labor after 37 weeks
§ If the amniotic fluid has an infection
§ Fetal anomaly

Preterm Labor & birth: fetal considerations
· Betamethasone (Celestone)

o Stimulates fetal lung maturity by releasing enzymes that produce lung surfactant
§ Decreases intraventricular hemorrhage, RDS, NEC, BPD, TTN, need for resuscitative/respiratory support and shorter NICU stays
§ One of the most cost-effective ways to DECREASE morbidity and mortality associated with PTL!

o Recommended to women at risk for preterm birth between 24-36 weeks gestation

o 12mg IM injection x2 q24h

o Side effects: Inc. WBC, hyperglycemia
§ WATCH OUR DIABETIC PATIENTS

Preterm Labor & Birth: Management

· Activity Restrictions
o Bed rest, limited work
§ Don't put pregnant women on bedrest bc/ they can get muscle atrophy, blood clots
o No current research supports this - actually has adverse effects

· Sexual Activity Restrictions (pelvic rest)
o No intercourse

· Home Care
o Plan for visitors
o Childcare and homecare help
o Internet chat groups as support
o Reading materials/childbirth education classes

A patient just arrived in triage to be evaluated. She is 32 weeks. Which of the following statements by the patient indicate that she may be in preterm labor?

"I've been having low back pain for 2 hours."

Preterm Premature Rupture of Membranes (PPROM)

rupture of membranes before 37 weeks

· Chorioamnionitis (bacterial infection of amniotic cavity) is most common complication
o Abruption, retained placenta, hemorrhage, sepsis and death can result

PPROM
· Care Management

o Based on risk: benefit ratio
o Hospitalization for monitoring of fetus, infection
o NST, BPPs
o Betamethasone
o Antibiotic treatment
o S/S of infection
o Mag for fetal neuroprotection if <32 weeks gestation and imminent risk of delivery

Post-term Pregnancy

· Definition: pregnancy that extends past the end of the 42nd week of pregnancy

· 2-13% of all pregnancies

· PLACENTAL AGING!

· Maternal Risks: dysfunctional labor, perineal injury, hemorrhage, infection, Pitocin/forceps/vacuum and c/s delivery

· Fetal risks: macrosomia, shoulder dystocia, birth injuries, oligohydramnios, MSF, stillbirth

· Kick counts daily
· NSTs/BPPs twice a week
· Emotional support

Multifetal Pregnancy

· Pregnancy with more than one fetus
· Women over 35 are more likely to have multiple birth due to fertility issues and treatments.

Multifetal Pregnancy
· Higher Risk for:

o Anemia
o Placenta Previa & Abruption
o Premature labor & birth
o Congenital malformations (in monozygotic only)
o Two-vessel cords
o Twin-to-Twin Transfusion
o Higher rates of surgical births

Multifetal Pregnancy
· Considerations

o Increase strain on finances, space and coping abilities

o Increase in prenatal visits & ultrasounds

o Pregnancy weight gain
§ 37.4-55lbs in a normal BMI

o Parents may face decisions regarding selective reduction of the fetus
§ Decreases chance of PTL & improve pregnancy outcomes

Hyperemesis Gravidarum

· Excessive vomiting causing weight loss, electrolyte imbalance, nutritional deficiencies and ketonuria (Perry et al., 2018, p. 295).
o Begins within first 10 weeks of pregnancy
o Typically resolves by 20 weeks
o Etiology unknown
o Psychosocial & cultural factors

Hyperemesis Gravidarum Treatment

o Daily weight, I&Os, VS

o Physical exam

o Fluid and electrolyte balance
§ CBC, CMP, TSH, UA

o Clear liquids & bland diet

o Pharmacologic Methods
§ IVF, Antiemetics, Vitamin B6 & Unisom

Preeclampsia - Diagnostic Criteria

· Proteinuria = >300 mg on 24h urine
o OR
· protein: creatinine ratio > 0.3
o OR
· dipstick reading > +1

· Thrombocytopenia = Platelet < 100,000
· Renal insufficiency = serum creatinine > 1.1
· Liver function = Twice normal value of AST, ALT, LDH
· Elevated blood pressure = taken x2 q4

HTN in Pregnancy · Risk Factors:

o Age < 19 or > 40
o Self, family and paternal hx of preeclampsia
o African descent
o Multiple gestation
o IVF
o Preexisting conditions: CHTN, renal disease, DM (prepreg), lupus, RA, thrombophilia, obesity

Preeclampsia

· Unknown cause!

· MULTISYSTEMIC condition caused by inflammation and activation of endothelium.

· Effects:
o Cardiovascular System (HTN)
o Hepatic System (^ AST, ALT, LDH, R sided pain)
o Renal System (dec GFR, proteinuria, olgiuria)
o CNS (H/A, blurry vision, confusion, N/V, SEIZURE!)
o Pulmonary (SOB, pulmonary edema, CHF, ARDS)
o Placental (IUGR, low AFI, FHR, abruption)

Preeclampsia Assessment

· VS - BP (x2 q4), HR, RR, O2 sat
· Weight, I&O
· Lung sounds
· FHR
· Dependent edema
· DTRs (biceps, patellar)
· Clonus
· Urine collect (dipstick, 24h)
· Labs: CBC, LDH, AST, ALT, serum creatinine level

Preeclampsia Management

Rferral
Strict BR in left lateral recumbent position

Fetal Surveillance: NST, BPP, US, KC

Weekly B-methasone for lung maturity if <34wks gestation

Hospitalization, Delivery if:> 34wks or 2 doses of B-Methasone


· > 37 wks -> DELIVERY!
· Daily kick counts, NST/BPP x1-2/wk
o ^ water and fiber intake

Preeclampsia: Management
· Intrapartum Management

o Continuous FHR/contraction monitoring
o Assess for abruption - tense, tender uterus, may or may not see vaginal bleeding, NRFHR
o Maternal - frequent VS, CNS assessment (headaches, vision, reflexes), total IVF should not exceed 125ml/hr to decrease risk of pulmonary edema, decrease environmental stimuli

Preeclampsia: Management
· Magnesium Sulfate

o Short term treatment for prevention of seizures!

o 4-6 gram loading dose with maintenance rate 1-4 grams/hour IV

o Since kidney & liver function are DECREASED can lead to MAG TOXICITY!
§ Loss of DTRs
§ Loss of consciousness
§ RR < 12
§ Decreased UOP

· If toxicity suspected: stop IMMEDIATELY! Draw serum magnesium level. Administer CALCIUM GLUCONATE. Call MD.

Preeclampsia: Management
Antihypertensives

o Labetolol (Normodyne)
o Hydralazine (Apresoline)
o Nifepidine (Procardia)
o Side Effects: H/A, flushing, hypotension
o Evaluate a minimum of 20 minutes before giving another dose
o Monitor VS closely

· If previous hx of preeclampsia:

o Low dose aspirin (60-80mg) qd starting in 1st trimester

o Increased risk of developing CHTN and cardiovascular disease later in life

Preeclampsia: Management
· Postpartum management

o Can continued Mag infusion after delivery for seizure prophylaxis, usually for 24 hours

o NSAIDS can contribute to elevated BP - use with caution in HTN patients

o Facilitate bonding, especially if baby is in NICU

o BP monitoring for at least 72 hours after birth and rechecked at 7-10 days postpartum

o Antihypertensive medication if BP 150/100 or greater

o Discharge teaching - call provider if any s/s of preeclampsia (HA, vision changes, epigastric pain)

Eclampsia

· Seizure activity - usually always preceded by persistent H/A, blurry vision, severe abd pain and altered LOC.

· OBSTETRICAL EMERGENCY!

o Safety
§ STAY AT BEDSIDE!
§ Side rails up, padded
§ Quiet, darkened environment
§ Delivery?

o Airway
§ Suction at bedside, O2 via NRB
§ Support head/neck
§ Lower HOB and turn mom on side immediately after seizure
§ DOCUMENT!

HELLP Syndrome

· Form of severe preeclampsia that is characterized by:
· Hemolysis
· Elevated Liver enzymes
· Low Platelets
· Occurs in < 1% of pregnancies
· Diagnosed by lab values
· Typically occurs in antepartum period

HELLP Syndrome pt 2

· May or may not have signs of preeclampsia
· Vasospasm -> endothelial cell damage -> RBCs damaged d/t constriction
· Patients may c/o of "flu-like" symptoms
· Increased risk of maternal and fetal death
o PTB rate 70%

Your patient is receiving magnesium sulfate for preeclampsia. Her husband is concerned and asks if the medication is necessary. You respond by saying:

"It is helpful to prevent her from having a seizure."

Pregestational Diabetes Mellitus

· Preexisting Type I OR Type II DM
o Type II more common
o Can be complicated by vascular disease, retinopathy, neuropathy or other diabetic complications
o Changes in hormones due to pregnancy can affect glycemic control & vascular complications
o Insulin needs increase throughout pregnancy & return to pre-pregnant levels within 7-10 days p birth (non-breastfeeding moms) or insulin needs can decrease during breastfeeding

Preconception CARE
· PRECONCEPTION CARE IS KEY!

o Recommended for all diabetic women of reproductive age
o Plan optimal time for pregnancy
o Need to have BS in tight control 3 months prior to pregnancy: can cause congenital heart defects
o Multidisciplinary approach with OB, MFM, endocrinologist, ophthalmologist, nephrologist, neonatologist, nurse, dietitian, and social worker

Insulin & Glucose in Pregnancy

· Glucose transported across placenta by diffusion during pregnancy
· Insulin does NOT cross placenta
· 10th week of pregnancy fetus secretes its own insulin to counteract glucose
*INSULIN IS A GROWTH HORMONE

Maternal & Fetal Risks
· Maternal:

o Preeclampsia
o Hydramnios
o Infections
o Hyperglycemia & DKA
o Hypoglycemia
o C-section & operative vaginal delivery

Maternal & Fetal Risks
· Fetal:

o Miscarriage/stillbirth
o IUFD
o Congenital malformations
o Macrosomia
o Hypoglycemia after birth

Gestational Diabetes Mellitus (GDM)

"Carbohydrate intolerance with the onset or first recognition occurring during pregnancy"

· Screened with glucola testing between 24-28 weeks
o If strong risk factors for DM, may test earlier in pregnancy

· Needs to be reclassified 6-12 weeks after pregnancy

· Increased risk for recurrent GDM in future pregnancies

Management of GDM

· Dietary modification
· Exercise
· Blood glucose monitoring
· 25-50% require insulin therapy or oral meds

A patient is newly diagnosed with gestational diabetes. Based on your knowledge of GDM, which management method would you recommend?

Diet and exercise

Dysfunctional Labor (Dystocia)

· The cause of dystocia is failure of the maternal uterus and cervix to contract and expand normally or maybe an alteration

· Maybe maternal pelvis is too small and baby is the right size or baby is very big and pelvis is the right size

· Maybe patient has experienced trauma (MVA)

· Most common indication for cesarean birth
o Unplanned C-section