Reproductive Exam 2: Complications in the postpartum period and Maternal mortality

Fetal Growth Restriction description

• A pathological condition of an estimated fetal weight less than the 10th percentile for gestational age by prenatal ultrasound evaluation

• abdominal circumference is often <3%

• occurs as a sequelae of another complication

Fetal Growth Restriction risk factors

• Conditions the interfere with uteroplacental blood flow

  • Chronic HTN

  • Diabetes

  • SLE

  • Antiphospholipid syndrome

  • Severe cardiopulmonary or renal disease

  • Severe anemia

  • Substance misuse

  • Multiple gestations

  • 2 cord placenta

  • Low pre-pregnancy weight or poor pregnancy weight gain

  • Infections

Fetal Growth Restriction management

• Twice weekly testing

• Deliver if signs of fetal compromise; often cesarean

Postpartum hemorrhage description and categories

• ALWAYS >1000mL blood loss

• immediate: within 24 hours of delivery

  • uterine atony is most common cause

• Delayed: between 24 hours and 6 weeks PP

  • Caused by infection, retained placental tissue, or subinvolution of placental site

Postpartum hemorrhage causative events

• Tears/lacerations of vagina

• Uterine overdistension

• Induction of labor

• Prolonged or rapid labor

• Traumatic delivery (SD)

• Operative delivery

• Infection

• Placental abnormalities

• Magnesium sulfate therapy (given if preeclampsia)

Postpartum hemorrhage causes (4 Ts)

• Tone: uterine atony, full bladder

• Tissue: retained placenta/membrane/clots or invasive placenta

• Trauma: injury, hematomas, inversion or rupture

• Thrombin: coagulopathies

Postpartum hemorrhage symptoms (stages)

• Stage 1: blood loss >1000ml with normal vital signs and lab values

• Stage 2: Continued bleeding with EBL up to 1500 ml or already received >2 uterotonics and normal vital signs

• Stage 3: Continued bleeding with EBL > 1500 ml or >2 RBC given or possible occult bleeding/coagulopathy, or abnormal VS

• Stage 4: Cardiovascular collapse

Postpartum hemorrhage nursing care

• Call for help and notify provider

• Track blood loss: weigh everything 

• Uterine/fundal massage

• Empty bladder

• Ensure extra IV access

• Administer uterotonics and TXA

• Prepare Jada system

Postpartum infections risk factors

• UTI

• Endometritis: Prolonged ROM

Postpartum infections symptoms

• Temp > 100.4 in the first 10 days postpartum or 101.6 in the first 24 hours

• Fever and chills

• Uterine tenderness

• Foul-smelling lochia

• Increased pulse rate->100

• Lower abdominal/pelvic pain

• Headache

• Painful urination

• CVA tenderness

• Wound drainage, redness, drainage 

• Elevated WBCs (can have PP leukocytosis: normal)

Postpartum infections nursing care

• Watch vital signs closely (HR should gradually decrease)

• Promote rest, hydration, and bonding/breastfeeding

• Antibiotics

• Watch infant for signs of infection

Cardiovascular events (DVT/PE) risk factors

• Pregnancy (~1 in 10,000)

• Having obesity/High BMI

• AMA (age > 35)

• Cesarean delivery

• Stillbirth

• Multiple birth

• Preterm delivery (prolonged bed rest)

• Varicose veins

• Comorbidities: Diabetes, IBD, cardiac disease, hypertension, lupus

• Clotting disorder or autoimmune disease

• Smoking

• Infection

Signs & Symptoms VTE

• Pain or tenderness in leg or groin

• Change in skin temperature at site of tenderness

• Edema 

• Erythema

S&S Pulmonary embolism

• Tachycardia

• Chest pain

• Dyspnea, tachypnea, SOB

• Cough, hemoptysis

• Crackles in lungs

PE diagnosis and treatment

• Diagnosis: Spiral CT and labs

• Treatment: warfarin, LMWH, supportive treatment

VTE Nursing care

• Mechanical compression devices and early ambulation 

• Bedrest, elevate affected extremity

• Anticoagulant therapy

• Don’t perform Hosman’s sign (can dislodge clot)

Peripartum Cardiomyopathy (PPCM) risk factors

• Prolonged tocolysis

• thyroid dysfunction

• Multiple gestation, assisted reproduction

• Anemia

• Poorly controlled asthma or autoimmune disorders

• AMA

• HTN, diabetes, obesity, preeclampsia/eclampsia 

• History, genetics, environmental factors

• SDOH, geography

• Substance abuse

Peripartum Cardiomyopathy (PPCM) symptoms

• Shortness of breath at rest

• nocturnal cough and dyspnea

• Palpitations, tachycardia

• Fatigue

• Orthopnea

• Chest discomfort

• Cold extremities

• Peripheral edema

Peripartum Cardiomyopathy (PPCM) nursing care

• Diagnostic tests

  • Echocardiogram: LV ejection fraction <45%

  • BNP >100

  • Need high degree of suspicion: diagnosis of exclusion

• Medications: diuretics, ACE inhibitors, beta blockers, anti-coagulants

• Assessment: history, lungs, edema

• Heart transplant

Preeclampsia diagnostic criteria

• Diagnostic criteria

  • SBP ≥ 140 or DBP ≥ 90 on two or more occasions, 4 hours apart (after 20 weeks gestation)

  • SBP ≥ 160 or DBP ≥ 110

  • In absence of proteinuria and with new-onset HTN:

    • Thrombocytopenia

    • Renal insufficiency

    • Impaired liver function

    • Pulmonary edema

    • New-onset headache unresponsive to medication

Preeclampsia pharmacological management/treatment

• Magnesium Sulfate (just start to be safe)

  • Toxicity signs

    • Lose reflexes before respiratory depression

    • Track I+O (kidney toxicity)

    • Will see absent reflexes, RR < 12, and altered LOC

  • Antidote: Calcium gluconate

• Antihypertensives

  • Nifedipine (PO)

  • Hydralazine (usually IVPB)

  • Labetalol (IVPB)

common medications to manage hemorrhage

• Tranexamic Acid TXA

• Uterotonics

  • Oxytocin: first line for PP bleeding

  • Methergine: second line

  • Misoprostol (next choice if patient has HTN)

  • Hemabate/Carboprost (last resort after TXA)

Tranexamic Acid TXA function, side effects, contraindication

• inhibitor of fibrinolysis: keeps body from using up clotting factors

• Not first line: used to prevent coagulopathies or large amount of blood loss

• IVPB

• Side effects: N/V/D, headache

• Contraindicated in history of thromboembolism

Oxytocin route, side effects, use

• IM or IV

• Side effects: N/V, water intoxication with prolonged use

• Encourages uterine contractions

• Often started before delivery of placenta

Methergine route, side effects, contraindications

• PO or IM, NEVER IV push

• Side effects: N/V, increased BP

• contraindicated in any history of HTN/preeclampsia

Misoprostol route, side effects, contraindication

• generally per rectum for PPH, but also PO

• Side effects: N/V/D, shivering, fever

• contraindicated in severe asthma 

Hemabate/Carboprost route, side effects, contraindication

• IM/intrauterine

• Side effects: N/V/D, fever/chills, headache, increased BP, bronchoconstriction 

• Contraindicated in any history of asthma or HTN

major complications that account for nearly 75% of all maternal deaths

• CV events

• Severe bleeding

• Infections

• High BP (pre-eclampsia-eclampsia)

• Delivery complications

• Abortion complications

• Cardiovascular disease

• Mental health

Factors that contribute to maternal mortaility

• Racism

• Sexism

• SDOH

• Institutional policies and beliefs

Nursing care to reduce incidence of maternal mortality

• Safety Bundles: evidence based guidelines for the management of critical events/obstetrical emergencies (hemorrhage, sepsis, cardiovascular disease, maternal VTE, Hxn)

• Critical events training

• Quantify ALL blood loss

• Know historical and ongoing health inequities

Areas most affected by maternal mortality

• South Asia

• Subsaharan Africa