Pregnancy Complications

maternal death

when a birthing person dies during pregnancy or up to 42 days after giving birth from health problems related to pregnancy.

pregnancy-related death

when a birthing person dies during pregnancy or within 42 days after giving birth from all deaths irrespective of cause.

increased risk of maternal mortality

rural mothers, Black mothers, Native American mothers

what is more prevalent than maternal mortality?

maternal morbidity

addressing morbidity and mortality issues

investing in healthcare infrastructure, empowering healthcare professionals, promoting education and awareness, and advocating for policy changes - ensure universal access to safe, quality maternal care

cardiovascular diseases in pregnancy

maternal hypertension, peripartum cardiomyopathy, myocardial infarction, thromboembolic disease

Peripartum cardiomyopathy

Heart failure with no identifiable cause can develop between last month of pregnancy to 5 months postpartum

Risk factors: Multiparity, age > 30, multiple gestations, preE

5 year mortality is 50%

risks for cardiovascular disease in pregnancy

maternal congenital heart disease (known or unknown), delayed pregnancy, obesity, substance use, chronic medical conditions like DM and HTN

hypertensive disorders in pregnancy

chronic HTN, gestational HTN, preeclampsia (eclampsia and HELLP syndrome)

SDOH r/t hypertensive disorders

higher prevalence in African American women

chronic HTN

high blood pressure levels of 140/90 mm Hg or higher that occur before the 20th week of gestation or persist beyond 12 weeks postpartum. classified into four subtypes

secondary HTN

elevated BP caused by underlying conditions such as atherosclerosis, endocrine disorders, renal disease, certain medications

severe HTN

BP of 160/110 or higher on two separate occasions four hours apart

primary (essential) HTN

elevated BP with no underlying cause

superimposed HTN

sudden increase in baseline HTN, proteinuria, elevated liver enzymes, new onset of thrombocytopenia

maternal risk r/t chronic HTN

cerebrovascular accident, pulmonary edema, renal failure, pregnancy complications (PPH, c/s, placental abruption, superimposed preeclampsia)

fetal risk r/t chronic HTN

intrauterine growth restriction, preterm birth, stillbirth, and neonatal death

end-organ damage from HTN is related to

severity and duration of HTN - requires comprehensive evaluation of organ function with lab tests and assessments

gestational HTN

new onset of BP 140/90 or higher on 2 separate occasions, 4 hours apart occurring after 20 weeks gestation. absence of proteinuria or multisystem features. can be considered chronic if doesn't go back to normal postpartum

complications r/t GHTN

thrombocytopenia, liver dysfunction, and long-term cardiovascular risks

preeclampsia etiologies

abnormal placenta, maternal factors, genetic predisposition, immunologic factors that can also contribute to abnormal placentation, placental ischemia

preeclampsia

onset of hypertension after 20 weeks of gestation, along with either proteinuria or multisystem disturbances indicative of disease severity.

risk factors of preeclampsia

•Advanced maternal age (>40 years old)

•Obesity

•Chronic HTN

•Family history of preeclampsia

•Preeclampsia with a previous pregnancy

•Gestational or diabetes

•Nulliparity

•Preexisting medical or genetic conditions

•Multiple gestation

symptoms of preeclampsia

•Severe HTN (≥ 160/90 mm Hg)

•Proteinuria

•Severe Headache

•Vision problems

•Epigastric pain

•Nausea/vomiting

•Altered mental status

•Diminished urine output

•Pulmonary edema

•Dependent edema

•Hemoconcentration

severe symptoms of preeclampsia

headaches unrelieved by meds, vision changes, photophobia, fatigue, N/V, decreased urine output, epigastric pain, pulmonary edema, decreased platelets, impaired liver function

assessments required for preeclampsia

•Vital Signs

•Pulmonary status

•Urinary output

•Deep tendon reflexes

•Neurologic status

•Laboratory values

•Worsening status

essential before initiating antihypertensives or seizure prophylaxis with magnesium sulfate

I/O for preeclampsia

preeclampsia can lead to reduced excretion of magnesium sulfate

mag toxicity

loss of reflexes, respiratory depression, respiratory arrest, or cardiac arrest

mag reversal agent

calcium gluconate

renal function tests for preeclampsia

24-hour urine or random UA, complete metabolic panel, protein/creatinine ratio

liver function tests for preeclampsia

AST, ALT, LDH

hematologic evaluation for preeclampsia

CBC with platelets

prevention of preeclampsia

supplements (zinc, calcium, magnesium, fish oil), antihypertensives, loop diuretics, low-dose aspirin (81mg)

hypertensives for preeclampsia

hydralazine, labetalol, nifedipine

magnesium sulfate

Seizure prophylaxis

- During labor & 24-hours postpartum

- 6 gm bolus, then 2 gm/hour

Calcium gluconate (reversal agent)

mode of birth with preeclampsia

expectant management, induction of labor and c/s

eclampsia

severe complication of preeclampsia and is associated with significant maternal and fetal mortality.

- New onset of generalized tonic-clonic seizures

- Seizures can occur in the antepartum, intrapartum, or postpartum period

- any stage of pregnancy after 20 weeks gestation or postpartum

believed etiology of eclampsia

cerebral overperfusion -> vasoconstriction in middle cerebral artery

increased permeability of blood-brain barrier during preeclampsia

symptoms of eclampsia

tonic-clonic seizures lasting 60-90 seconds

warning signs of eclampsia

-Persistent headache

-Vision changes

-Photophobia

-Altered mental status

-Abdominal pain/epigastric pain

-Severe range blood pressure

≥ 160/110 mm Hg

not all people will exhibit warning signs

eclampsia management

securing the airway, assessing O2 sat, monitor BP, administer magnesium sulfate, assess fetal status for bradycardia or decreased ureteroplacental perfusion

seizure actions

person should be positioned on their side, with the head of the bed slightly lowered. after:

securing the airway, maintaining oxygen levels, monitoring blood pressure and oxygen saturation, administer magnesium sulfate and antihypertensive medications. assess for signs of magnesium toxicity. Detailed documentation should include the onset and duration of the seizure

HELLP syndrome

hemolysis, elevated liver enzymes, and low platelets

manifests in 3rd trimester or postpartum period

may not exhibit hypertension or proteinuria

complications r/t HELLP

placental abruption, renal failure, hepatic hemorrhage, and maternal and fetal death

symptoms of HELLP syndrome

-Nausea

-Vomiting

-Malaise

-Epigastric pain

management of both preeclampsia and HELLLP requires

timely delivery and optimization of organ perfusion

HELLP syndrome risk factors

-Hypertensive disorders in pregnancy

-Chronic HTN

->30 years of age

-Multiparity

-Multiple gestation

-European descent

-Obesity

-Placental disorders

-Congenital anomalies

-Chronic cardiac conditions

-Pre-pregnancy diabetes

HELLP syndrome management

monitor OB complications, manage HTN if any, seizure prophylaxis, planning for delivery (primary treatment is immediate delivery regardless of GA)

peripartum cardiomyopathy causes

-Hemodynamic changes during pregnancy

-Viral infections (myocarditis-associated viruses)

-Hormonal changes

-Genetic factors

-Pro-inflammatory states

-Autoimmune responses

hemodynamic changes that can contribute to peripartum cardiomyopathy

Increased preload and cardiac output during pregnancy are potential triggers but not the sole cause

timing of peripartum cardiomyopathy

after 36 weeks or in first month PP, may occur earlier in those with other cardiac conditions

symptoms of peripartum cardiomyopathy

-Paroxysmal nocturnal dyspnea

-Pedal edema

-Orthopnea

-Dyspnea on exertion

-Dry cough

-Palpitations

-Increased abdominal girth

-Lightheadedness

-Chest pain

clinical examination findings in peripartum cardiomyopathy

- JVD

- displaced apical pulse

- presence of 3rd heart sound

- murmurs from mitral regurg

- reflecting cardiac and hemodynamic changes

management of peripartum cardiomyopathy

medications (beta blockers, hydralazine, inotropes)

*diuretics require close monitoring

* ACE and ARB contraindicated

* potential for anticoagulation therapy

interventions with peripartum cardiomyopathy

evaluation of ICDs and cardiac resynchronization therapy, LVADs

myocardial infarction

most common in 3rd trimester and postpartum. risk factors include HTN, obesity, DM, MA, PP infection, blood transfusion.

diagnosis with ECG and cardiac troponin I

ECG abnormalities will show elevated ST segments

therapy for MI

rapid re-perfusion of the cardiac muscle through percutaneous coronary intervention with the placement of a bare metal stent to restore blood flow to the affected coronary artery

maternal mortality risk with MI

significantly higher if childbirth occurs within two weeks of the MI

management of cardiovascular disease

- vaginal birth preferred or if needed C/S

- early epidural anesthesia to reduce workload

- lateral positions

- passive fetal descent in lateral position during second stage of labor

- pulmonary edema and hemorrhage watch. - open glottis pushing, operative delivery, proper anesthesia

thromboembolic disease

The condition in which a patient has a deep vein thrombosis or pulmonary embolism. treated with anticoagulant therapy

risk factors for thromboembolic disease

- Physiological changes in pregnancy

- Medical condition

- Pregnancy complications

- Thrombophilia

--Factor V Leiden

--von Willebrand

risk factors for venous thromboembolism

hypercoagulability, increased venous stasis, uterine compression of pelvic veins, obesity, hypertension, autoimmune diseases, heart disease, preeclampsia, clotting disorders

signs of VTE

pain and swelling in an extremity, with a calf circumference difference of 2 cm or more being suggestive of DVT. Other classic signs of DVT include dependent edema, unilateral leg pain, erythema, and low-grade fever

PE: shortness of breath, tachypnea, tachycardia, dyspnea, pleural chest pain, fever, and anxiety

maternal obesity

BMI of 30 or greater

risks related to obesity

-Preeclampsia

-Deep vein thrombosis

-Urinary tract infections

-Gestational diabetes

-PTB

-Cesarean delivery

-Operative and postoperative complications

fetal risks related to maternal obesity

-Congenital anomalies

-IUGR

-Prematurity r/t medically indicated PTB

-Macrosomia

-IUFD

-Birth trauma

-Respiratory complications

-Childhood obesity

gestational diabetes

-Carbohydrate intolerance of any degree with onset during pregnancy

-Diagnosed between 24- and 28-weeks gestation. diet-controlled GDM-A1 or insulin controlled GDM-A2

glucose intolerance test

q1-hour

q3-hour

--Fasting ≥ 95 mm/dL

--1 hour ≥ 180 mm/dL

--2 hour ≥ 155 mm/dL

--3 hour ≥ 140 mm/dL

preterm premature rupture of membranes

ROM without labor onset before 37 weeks gestation

associated with 1/3 preterm births

risk factors of PPROM

-History of PPROM or preterm birth

-Short cervical length

-Multiple gestation

-STI's

-Low BMI

-Hydramnios

-Illicit drug use/cigarette smoking

-Low Socioeconomic status

assessment for PPROM

ultrasound to look for oligohydroaminos, confirmation of ROM with speculum exam and ferning

management of PPROM

depends on GA, but antibiotics or corticosteroids

preterm labor

labor and birth prior to 37 weeks gest. and are responsible for nearly 80% of neonatal death. concerns for preterm babies include neurological impairment and lung immaturity

possible causes of preterm labor

inflammation, maternal or fetal stress, bleeding, infection, uterine over distention due to multiple gestation or polyhydraminos

Tocolysis

repression of uterine contractions

management of preterm labor with tocolytics

- terbutaline (Brethine)

- indomethacin (Indocin)

(Do not give after 34 weeks- cause premature closure of the ductus arteriosus_

- nifedipine (Procardia)

magnesium sulfate

preterm labor corticosteroid

betamethasone for lung and GI function

two IM injections 12-24 hrs apart from 24 to 36 weeks gestation

tocolytic contraindication

Birthing people with preterm contractions without cervical changes and minimal dilation

mangnesium sulfate for preterm labor

2gm/hr helps buy time for corticosteroids to function

neuroprotection with mag sulfate

fetus less than 37 weeks, 4gm bolus and 1gm/hr

12 hr therapy

can reduce cerebral palsy incidence

hyperemesis gravidarum

-Persistent vomiting

-Acute starvation

-Weight loss (>5%)

-Electrolyte imbalances

caused by rising hormone levels

symptoms include severe vomiting and dehydration, hyponatremia, hypokalemia, ptyalism

ptyalism

excessive salivation

management of hyperemesis gravidarum

- IV hydration

- Antiemetics, Vit. B6, doxylamine

- Psychological support

- Monitor weight, fluid/electrolytes, hydration status

ectopic pregnancy

pregnancy that occurs outside the uterine cavity commonly when egg implants in the fallopian tube

risk factors for ectopic pregnancy

-Previous ectopic

-PID

-Endometriosis

-STI's

-Previous tubal surgery

-Smoking

-AMA

-DES exposure

clinical findings of ectopic pregnancy

pelvic and abdominal pain, dark red bleeding, shoulder pain

management of ectopic pregnancy

methotrexate, surgery

placental abnormalities

placenta previa, placenta accreta, placenta increta, placenta percreta

placenta previa

implantation of the placenta over the cervical opening or in the lower region of the uterus

risk factors for placenta previa

-Endometrial scarring

-Impeded endometrial vascularization

-Increased size of the placenta(s)

assessment placenta previa

ultrasound confirmation, painless vaginal bleeding, hemodynamic changes

management of placenta previa

c/s, expectant management

placenta accreta spectrum PAS

-Placenta accreta: is beyond the normal boundary (80%)

-Placenta increta: into the uterine myometrium (15%)

- Placenta percreta: into the uterine musculature and can adhere to other pelvic organs (5%)

risk factors for PAS

previous c/s, previous uterine scarring. assessed with ultrasound

management of PAS

scheduled c/s, possible hysterectomy - increased risk of intrapartum hemorrage

gestational trophoblastic disease

placental-related tumors, with two primary categories: molar and non-molar.

excessive growth of placental and trophoblastic cells, which create vesicles by absorbing maternal blood, ultimately lacking normal fetal development

Molar (gestational trophoblastic disease)

not cancerous - Hydatidiform

non-molar gestational trophoblastic disease

cancerous - gestational trophoplastic neoplasm - choriocarcinoma

risk factors for GTD

maternal age, previous molar pregnancy

assessment with GTD

-Vaginal bleeding

-Pelvic pain/pressure

-Anemia

-Hyperemesis

-GHTN

-Amenorrhea

-Nausea