DIC, HELLP SYNDROME, INCOMPETENT CERVIX & GDM

Disseminated Intravascular Coagulation (DIC)

an acquired d/o of blood clotting in which the fibrinogen level falls to below effective limits. It occurs when there is such extreme bleeding and so many plts. & fibrin from the general circulation rush to the site that there is not enough left in the rest of the body (Thrombohemorrhagic Disorder)

1. anti-platelets

2. anti-coagulants

3. fibrinolytics

(DIC)

Slowly evolving DIC/ Acute

primarily causes venous thromboembolic manifestations (e.g, deep venous thrombosis, pulmonary embolism), although occasionally cardiac valve vegetations occur; abnormal bleeding is uncommon. Heparin is useful in the treatment of this disease with venous thrombosis or pulmonary embolism.

Severe, rapidly evolving DIC/ Chronic

it causes thrombocytopenia, depletion of plasma coagulation factors and fibrinogen, and bleeding. Bleeding into organs, along with microvascular thromboses, may cause dysfunction and failure in multiple organs. Delayed dissolution of fibrin polymers by fibrinolysis may result in the mechanical disruption of RBC, producing schistocytes and mild intravascular hemolysis. Blood volume replacement when hpn is present is essential to arrest the DIC (Plt, FFP, Cryoprecipitate)

1. (obstetric complication) Inc. tissue thromboplastin d/t vascular damage

2. • premature separation of placenta

   • PIH

   • AF embolism

   • placental retention

   • septic abortion (retention of a fetus)

(DIC)

1. Cause: (obstetric complication)

2. Contributing Factors: (PPAPS)

1. hemostasis

2. blood

3. to stop

4. primary hemostasis

5. coagulation cascade

6. serine protease

7. zymogens

a series of steps in response to bleeding caused by tissue injury, where each step activates the next and ultimately produces a blood clot. The term (1)__ is derived from “hem-”, which means “(2)__”, and “-stasis”, which means “(3)__.” Therefore, hemostasis means to stop bleeding. There are two phases of hemostasis. First, (4)__ forms an unstable platelet plug at the site of injury. Then, the coagulation cascade is activated to stabilize the plug, stopping blood flow and allowing increased time to make necessary repairs. This process minimizes blood loss after injuries.

Second, (5)__ involves the activation of a series of clotting factors, which are proteins that are involved in blood clotting. Each clotting factor is a (6)__ an enzyme that speeds up the breakdown of another protein. The clotting factors are initially in an inactive form called (7)__

Extrinsic pathway

begins when there is injury to the endothelial tissue (i.e., skin tissue), exposing tissue factor (factor III) to the blood. Tissue factor then becomes bound with calcium and factor VIIa to activate factor X. Factor VII is present in the blood and requires vitamin K to be activated.

intrinsic pathway

begins when factor XII or the Hageman factor is exposed to collagen, kallikrein, and high molecular weight kininogen (HMWK) and is subsequently activated. Factor XIIa activates factor XI into XIa. With a calcium ion, factor XIa activates factor IX. Then, factor IXa, factor VIIIa, and calcium form a complex to activate factor X. Factor VIII is found in the blood and is often activated by thrombin (factor IIa).in

common pathway

1. clot formation

may result after the activation of factor X at the end of either pathway. It begins when factor Xa, Va, and calcium bind together, forming a prothrombinase complex. The prothrombinase complex then activates prothrombin (factor II) into thrombin (factor IIa). Next, thrombin cleaves fibrinogen (factor I) into fibrin (factor Ia). Afterwards, thrombin cleaves the stabilizing factor (factor XIII) into XIIIa. Factor XIIIa binds with calcium to then create fibrin crosslinks to stabilize the clot. Thrombin has several functions, including activating platelets (cell fragments involved in (1)__) and activating factorsV,VIII, and IX.

1. fibrin (factor Ia)

2. to form a stable blood clot to stop bleeding; allow time for the tissue to be repaired

1. is a long, thin protein with branches produced at the end of the coagulation cascade when fibrinogen (factor I) is converted to fibrin, which stabilizes the blood clot.

2. The main goal of coagulation

1. • Petechia (1-2 mm)

   • Purpura (0.3-1 cm)

   • Ecchymoses (>1cm)

2. • Epistaxis (most common)

   • Bleeding from superficial scratch

   • Easy bruising

   • Gingival bleeding

   • Menorrhagia

   • GI bleeding

   • Hemoptysis

   • Hematuria

   • Intracranial hemorrhage (severe)

Clinical sx:

1ry Hemostasis:

• Asymptomatic

• Mucocutaneous (superficial) bleeding

  1.) Skin bleeding - (PPE)

  2.) Mucosal bleeding - (EBEGMGHHI)

1. ecchymosis

2. hematoma

3. petechiae

4. purpura

• Late re-bleeding (after surgery), Hemarthroses, Deep muscle bleeding (hematoma), Retroperitoneal bleeding, Intracranial bleeding, Neonates: bleeding after umbilical cord separation

• Bleeding from every orifice Bleeding from every wound Bleeding from every scratch

Clinical sx:

• 2ry Hemostasis Deep “anatomical” bleeding (LHDRIN)

• Fibrinolysis (BBB)

  Dx: No single blood test can confirm or rule out the dx ( Platelet count, BT, prothrombin time (PT), partial thromboplastin time (PTT), plasma D-dimer)

1. infection, preec., bleeding, shock

2. IVF(LR)

3. FBC

4. VS

5. PRBCs

6. Plt

7. cryoprecipitate

8. Fresh Frozen plasma (FFP)

9. Heparin

10. protamine sulfate (PS)

11. vitamin K -

12. organ injuring; maternal mortality

(DIC)

INTERVENTIONS:

1. Treat underlying condition (__. __. __, __)

2. __; O2 @ 6-10 L/min;

3. __ to monitor UO;

4. monitor __

5. Clotting factors replaced with __,

6. __(for acute bleeding & Pre-op.),

7. __(to replace fibrinogen) and

8. (to replace the coagulation factors)

9. __may be given to block coagulation cascade (Antidote for toxicity: (10__ (PS) or (11)__ )

COMPLICATIONS: (12)__; __

HELLP Syndrome: Hemolysis, Elevated Liver Enzymes, Low Platelets

1. 3

2. liver

3. low plts

4. destruction of blood cells

5. vasospasms

• Usually begins during the last (1)_ months of pregnancy or shortly after childbirth and the (2)__ is the target organ

• (3)__ leading to increased peripheral vascular destruction

• Hemolysis leads to (4)__ (+ anemia)

• (5)__ cause vasoconstriction and lead to reduction in blood flow to uterus and other organs

1. preexisting HPN or diabetes, AMA, multiple preg., preeclampsia/ eclampsia on the 3 rd trimester

2. nose bleeding, fatigue, swelling, RUQ pain (epigastric pain), blurry vision, N & V, malaise, HPN & proteinuria

3. hemolysis

4. el. liver enzyme

5. low plt

6. delivery

7. BT

8. dexamethasone

9. corticosteroid

10. NST; contraction test

11. antihypertensive therapy

12. MgSO4

(HELLP Syndrome)

1. hydralidazine

2. labetalol

3. nifedipine oral (not sublingual

4. sodium nitroprusside

Choices of Antihypertensive medication

1. Bolus of 5-10 mg IV q 20-40 min. If ineffective or unavailable, may use labetalol, nifedipine or sodium nitroprussiate.

2. initial bolus of 20 mg IV, with increases in dosage until a satisfactory BP is obtained or up to maximum dose of 300 mg.

3. Therapeutic doses range from 10-30 mg PO q 6-8 hours.

4. (inj.) a fast acting hypotensive agent(venous and arterial) which can be used in an hypertensive crisis when all other hypotensive drugs have failed. Loading dose: 0.25 μg/kg/min, increasing up to 10 μg/kg/min. Above this dose there is a greater risk of cyanide infection of the fetus. When using, remember it’s photosensitivity and severe rebound effect.

1. MgSO4

2. phenytoin

Preventing Convulsions in Eclampsia

1. Initial bolus of 4-6g IV, followed by a continuous infusion at 1.5-4g/h, individualized according to the patient. Continue for 48 hours or more postpartum until clinical and laboratory signs of improvement are obtained.

2. If contraindications of MgSO4 exist, use __-10·8-18 mg/kg for anticonvulsive prophylaxis to eclamptic patients

1. Hemotherapy (blood transfusion)

2. Plasmapheresis

3. Eculizumab

1. The usual dose is 1 unit per every 10 kg of corporal weight.  Spontaneous bleeding occurs in most cases with a platelet count of <50.000/mm3 . 

   Other therapeutic alternatives: -

2. __(method of removing blood plasma from the body by withdrawing blood, separating it into plasma and cells, and transfusing the cells back into the bloodstream) -

3. Immunoglobulins - __

incompetent cervix

• is characterized by a painless dilation of the cervical os without contractions of the uterus.

• occurs at about 20th week of pregnancy

• connective tissue structure of the cervix is not strong enough to maintain closure of the cervical os during pregnancy

1. • history of traumatic birth,

   • repeated dilation and curettage

   • client’s mother treated with diethylstilbestrol (DES) when pregnant with the client

   • congenitally short cervix

   • uterine anomalies

   • unknown etiology

2. • history of cervical trauma

   • history of repeated, spontaneous, second trimester terminations

   • possibly spontaneous rupture of the membranes

(incompetent cervix)

1. etiology (HRCCUU)

2. associated findings (HHP)

1. shidorkar-barter cerclage

2. mcdonald cerclage

1. permanent suture that allows the cervix to remain closed for all pregnancies; cesarean delivery is required

2. left in place until term, the remove before labor

Gestational Diabetes Mellitus (GDM)

1. 15,000

2. 24 and 28

• is abnormal CHO, fat, and CHON metabolism that is first diagnosed during pregnancy, regardless of the severity.

• About (1)__ infants are born to mothers with diabetes each year. Recommended universal screening for gestational diabetes between(2)__ weeks of gestation.

1. A1

2. A2

(GDM)

1. Gestational diabetes characterized by an abnormal glucose tolerance test (GTT) without other symptoms. FBS is normal and the diabetes is controlled by diet .

2. Gestational diabetes characterized by abnormal GTT and elevated FBS. This type must be controlled by insulin.

pancreatic islets/ islets of langerhans

are the regions of the pancreas that contain endocrine (hormone-producing) cells and are important in the metabolism of glucose.

1. alpha cells

2. beta cells

3. pp cells

4. delta cells

5. epsilon cells

Hormones produced in the pancreatic islets are secreted directly into the blood flow. Endocrine cell types are distributed as follows:

1. __ producing glucagon (20% of total islet cells)

2. __ producing insulin and amylin(≈70%)

3. __ (gamma cells or F cells) producing pancreatic polypeptide (<5%)

4. __ producing somatostatin (<10%)

5. __ producing ghrelin (<1%)

1. paracrine feedback

2. glucose/insulin

3. glycogen/glucagon

4. somatostatin

The (1)__ (a form of cell signaling, a type of cellular communication in which a cell produces a signal to induce changes in nearby cells) system of the pancreatic islets has the following structure:

2. activates beta cells and inhibits alpha cells

3. activates alpha cells which activates beta cells and delta cells

4. inhibits alpha cells and beta cells

liver

1. blood sugar levels

All the blood leaving the stomach and intestines passes through the __. It processes this blood and breaks down, balances, and creates the nutrients and also metabolizes drugs into forms that are easier to use for the rest of the body or that are nontoxic. A buildup of fat and damage in this organ can increase (1)__

diabetogenic effect of pregnancy

Pathophysiology

In gestational diabetes mellitus (type III, GDM), insulin antagonism by placental hormones, human placental lactogen, progesterone, cortisol, and prolactin leads to increased blood glucose levels. The effect of these hormones peaks at about 26 weeks’ gestation. This is called the __.

The pancreatic beta cell functions are impaired in response to the increased pancreatic stimulation and induced insulin resistance.

Pregnancy complicated by diabetes puts the mother at increased risk for the development of complications, such as spontaneous abortion, hypertensive disorders, and preterm labor, infection, and birth complications.

1. hypoglycemia, hyperglycemia, ketoacidosis

2. • Congenital defects

   • Macrosomia

   • Intrauterine growth restriction

   • Intrauterine fetal death

   • Delayed lung maturity

   • Neonatal hypoglycemia

   • Neonatal hyperbilirubinemia

1. The effects of diabetes on the fetus include (HHK)

2. Hyperglycemic effects can include: (CMIIDNN)

1. 4,000 g (8lb, 13 oz)

2. • Glycosuria on two successive office visits

   • Monilial vaginitis (recurrent)

   • Macrosomia of the fetus on ultrasound

   • Polyhydramnios

1. GDM associated findings can include a low birth weight or birth weight exceeding

2. clinical manifestations (GMMP)

• Extreme Tiredness/Fatigue (insulin resistant)

• Polyphagia/Insatiable Hunger (dysfunctional Leptin hormone)

• Polyuria (3 or more times esp. @ night)

• Polydipsia (reaction to fluid loss)

• Peripheral neuropathy (60%-70% cases)

early sx of DM (EPPPP)

• Acanthosis Nigricans

• Shin spots/ diabetic dermopathy

• Diabetic wound/ diabetic ulcer (slowhealing wounds

Sx of extremely high blood sugar/ Chronic: (ASD)

✓Shin spots/ diabetic dermopathy

✓Pruritus (lower legs and feet)

✓Slow-healing wounds

✓Extreme tiredness

✓Acanthosis Nigricans

Unusual Signs of DM: (SPSEA)

1. FBS

2. 50-g glucose screen; 1; 135-140 mg/dl

3. 3; oral glucose tolerance test

4. glycosylated hemoglobin (HbA 1c) test; 4-8; 6%

(GDM)

3.) Laboratory and diagnostic study findings.

1. __ will reveal elevated blood glucose levels.

2. A __ (blood glucose level is measured _ hour after client ingests a 50-g glucose drink) reveals elevated blood glucose levels. The normal plasma threshold is _.

3. 3. A _- hour _ (performed if 50-g glucose screen results are abnormal) reveals elevated blood glucose levels.

4. The __(measures glycemic control in the __ weeks before the test is performed; performed on women with pre-existing diabetes) results reflect enzymatic bonding of glucose to hemoglobin A amino acids. This is a useful indicator of overall blood glucose control. The upper normal level of HbA1c is _ of total hemoglobin.

1. maternal serum alpha-fetoprotein level

2. UTZ

3. NST; 30

4. lung maturity studies; amniocentesis

(GDM)

Screens for fetal (and later, neonatal) complications, including:

• __ to assess risk for neural tube defects in newborn.

• __to detect fetal structural anomalies, macrosomia, and hydramnios.

• __ (as early as _weeks), contraction stress test, and biophysical profile because of risk of unexplained intrauterine fetal demise in the antepartum period.

• __ (by __) to determine lecithin-sphingomyelin (L/S) ratio and to detect phosphatidylglycerol (PG); the adequacy of L/S and PG, predictor of the newborn’s ability to avoid respiratory distress

1. urine for ketones

2. diabetic ketoacidosis; 350 mg/dl

3. hypoglycemia

   a. 12 fluid oz of orange juice

1. __ harmful to the fetus

2. __ is a multisystem disorder resulting from hyperglycemia in which plasma glucose levels exceed __

3. __ is a disorder caused by too much insulin, insufficient food, excess exercise, diarrhea, or vomiting. Client and Family Teaching Table 4 list signs and symptoms of hypoglycemia and hyperglycemia.

   a. Discuss the management of hypoglycemia by administering __ (or 20 g of CHO) and waiting 20 minutes before repeating the procedure.

simmer this

1. diet

   4. insulin

(management for GDM)

1. __: 20% of calories from CHON, 50% from CHO, Increased dietary fibers (not less than 1800 Cal/day), 30% from Fats

2. EXERCISE: to lower blood glucose

3. Stress Management

4. __: usually short acting/regular insulin(Novolin R) combined with intermediate acting (Insulin NPH - Humulin N, Novolin N)

1. rapid-acting insulin analogue

2. short-acting (soluble/ regular insulin)

3. intermediate or long-acting insulin (isophane or zinc insulin)

4. long-acting insulin analogue

apidra solostar

humalog kwikpen

novorapid flexpen

actrapid

novomix30 flexpen

humalog mix75/25 kwikpen

humalog mix50/50 kwikpen

mixtrad 30

1. macrosomia

2. hypoglycemia at birth

GDM adverse effects

macrosomia

• excessive fat deposition on shoulders/trunk

• predisposes to shoulder dystocia

• maternal hyperglycemia→ transfer of excess glucose to fetus →stimulate fetal insulin secretion which is a potent growth factor

• pathogenesis

  1. mother’s blood brings extra glucose to the fetus

  2. fetus makes more insulin to handle extra glucose

  3. extra glucose gets stored as fat and fetus becomes larger than normal

diabetic ketoacidosis; 350 mg/dL

• life-threatening complication that mainly affects people with dx or undx Type 1 DM. But, sometimes it also affects people with Type 2 DM.

• happens when the body doesn’t have enough insulin (normally the body needs insulin to make glucose in the blood enter the cells, where it’s used as fuel for energy). If there’s no insulin or not enough insulin, the body starts breaking down body fat for energy instead. As the body breaks down fat, it releases ketones (toxic acids) into the bloodstream a high amount of ketones causes blood to become acidic

• blood sugar levels above __ + ketones

Diabetic ketoacidosis coma

If DKA is left untreated, it can lead to __

1. toilet

2. thirsty

3. tired

4. thinner

Four most common signs of type 1 diabetes in relation to DKA:

1. Going to the __a lot; for babies- bed wetting by a previously dry child or nappies in babies.

2. Being really ___and not being able to quench the thirst.

3. Feeling more __than usual.

4. Losing weight or looking __than usual.

1. insulin drip therapy

2. IV fluids for rehydration

3. nutrient replacement via IV

4. Correction of concurrent infection, if present

Management of DKA:

1. —(Only short-acting insulin is used)- SQ absorption of insulin is reduced in DKA because of dehydration; therefore, using intravenous routes is preferable

2. – PNSS (0.9% sodium chloride, normal saline) to prevent cerebral edema (CE); The osmolar gradient caused by the high blood glucose results in water shift from the ICF to the ECF space and contraction of cell volume

3. – correction of electrolyte disturbance, particularly Potassium (NSS with KCL as drip)

4. – UTI, Pulmo. Infection (Treatment with empiric antibiotics- using broad-spectrum cephalosporins, fluoroquinolones, aminoglycosides, piperacillin– tazobactam, or carbapenems)

1. no open lesions/ healed lesions

2. superficial ulcer

3. deep ulcer

4. osteitis

5. partial gangrene of the foot

6. gangrene of the whole foot

1. Disseminated intravascular coagulation

2. 0.5 µ/mL

3. cardiac valve vegetation

4. schistocytes

5. concave

6. hemolysis

7. zymogens

1. consumptive coagulopathy; thrombohemorrhagic disorder

2. D-Dimer normal range

3. a term in which constriction occurs

4. irregular RBCs

5. normal shape of an RBC

6. breakdown of blood products; bleeding

7. inactive forms of the clotting factors

• liver

• kidney

• skin

3 pathways of coagulation

1. adenoma

2. liver infraction

3. 80-95

1. a benign growth

2. death because of constriction caused by vasospasm

3. how many % of blood products are plasma

1. insulin

2. amylin

3. glucagon

4. pancreatic polypeptide

5. somatostatin

6. ghrelin

1. it decreases blood glucose

2. it regulates blood glucose

3. it controls sugar level

4. it controls digestion

5. it prevents the release of insulin and glucagon the moment digestion occurs

6. it is the reason you crave

1. pancreas, kidney, liver

2. human placental lactogen, progesterone, cortisol, prolactin

3. glycosuria

4. vaginal progesterone

5. paracetamol, tramadol, ketorolac

1. in GDM, these are the most affected organs

2. the insulin antagonists (HPCP)

3. much presence of glucose in urine

4. a gel applied to strengthen the muscles (for incompetent cervix)

5. pain medication for Incompetent cervix