OB Theory Exam 3 Flashcards

What is considered a high risk pregnancy?

Can be physical, mental, environmental, and based on the social determinants of health. These patients are seen more often to assess the fetus, placenta, blood flow, amniotic fluid, etc. US, NST, and BPP are performed more often.

What are the four hypertensive disorders in pregnancy?

1. Gestational Hypertension: Blood pressure between 140/90 and 160/110 over 20 weeks on more than one occasion.

2. Preeclampsia: Blood pressure over 140/90 over 20 weeks and up to 6 weeks postpartum. Includes proteinuria or end organ dysfunction.

3. Chronic Hypertension: Blood pressure over 140/90 under 20 weeks.

4. Superimposed Preeclampsia: Chronic hypertension and preeclampsia, including other symptoms (sudden BP increases, proteinuria).

What are the types of preeclampsia? How are they managed?

Believed to be caused from vascular changes in the placenta and uterus, which damages endothelial cells of blood vessels, leading to edema (extremities, face) and glomerular damage. The body normalizes after delivering the placenta and the fetus. Blue band is used as a universal assessment for preeclampsia presentation for 6 weeks after delivery.

1. Preeclampsia Without Severe Features: Blood pressure is under 140/90 after 2 readings, 4 hours apart. Proteinuria is present. Can be managed at home if stable with PO antihypertensives.

2. Preeclampsia With Severe Features: Blood pressure is above or equal to 160/110 after 2 readings, 15 minutes apart. Proteinuria plus organ dysfunction is present. Inflammation and vasoconstriction is more severe. Requires magnesium sulfate often alongside an antihypertensive.

3. HELLP Syndrome: Preeclampsia with hepatic dysfunction (Hemolysis, Elevated liver enzymes, Low platelets). This may or may not include severe HTN or proteinuria. Pain on the right side; AST and ALT are significantly elevated.

4. Eclampsia: Seizure activity or coma after preeclampsia diagnosis before, during, or after birth. This happens from an increase in brain activity. May not always present with severe features beforehand.

   • Place side rails up, turn patient to side (recovery position), use seizure pads. After convulsing, assess ABCs, oxygen, LOC. May be combative. If pregnant, assess FHR (late decels) and uterus contractions (hypertonic/strong/frequent).

What is the diagnostic criteria for preeclampsia? What are some interventions?

Determined through vitals (BP on both sides, looking at levels over time, pain, weight), assessments (neuro, visual changes, LOC, cardiovascular, respiratory, I+O and urine output, fluid restriction, N/V, DTR), labs (CMP, CBC, UA) and medication assessments. Level of edema and check turgor. Having preeclampsia once makes you more likely to develop it in future pregnancies.

• Renal: Protein over 0.3 (3+ dipstick); creatinine over 1.1; uric acid over 6. If it affects multiple areas, we know that the kidney has lower GFR and dysfunction.

• Liver: N/V, RUQ pain. Labs are twice the upper range of normal.

• Platelets: Under 100,000, moreso associated with HELPP syndrome.

• Neuro: Headache with no response to meds, visual changes, hyperreflexia (3+ or 4+) significant responses/exaggerated, clonus (reflex in the foot, going up and down). Seizure precautions.

• Capillary Leakage: Edema (pitting, pulmonary).

NST and US should be determined to monitor the health of the fetus. If uncontrolled, delivery may be induced earlier if over 37 weeks pregnant. FHR monitoring inpatient, weight monitoring of the fetus.

What are the indications, therapeutic effects, mechanism of action, and adverse effects for labetalol?

Class: Adrenergic antagonist, alpha and beta blocker.

Mechanism of Action: Nonselective; blocks alpha and beta 1 receptors in the PNS and heart. This increases vasodilation for alpha 1 receptors. Beta 1 slows the heart and stimulates baroreceptors.

Therapeutic Effects: Reduces hypertension (as well as angina, dysrhythmia).

Adverse Effects: Flushing, orthostatic hypotension (a1), bradycardia (b1).

Key Considerations: First in line for HTN crisis (!V). Hold for heart rate under 60.

What are the indications, therapeutic effects, mechanism of action, and adverse effects for hydralazine?

Class: Direct Vasodilator.

Mechanism of Action: Dilates arterioles to reduce afterload and vascular resistance.

Therapeutic Effects: Decreases hypertension and reduces afterload (the pressure the body has to fight against to perfuse properly).

Adverse Effects: Flushing, weakness, headache, orthostatic hypotension. Symptoms from vasodilation.

Key Considerations: Second in line for HTN crisis (!V).

What are the indications, therapeutic effects, mechanism of action, and adverse effects for nifedipine?

Class: Calcium channel blocker.

Mechanism of Action: Prevents calcium ions from entering the arterioles only, leading to less contraction of the smooth muscle here.

Therapeutic Effects: Helps with vasodilation and hypertension.

Adverse Effects: Flushing, weakness, headache, orthostatic hypotension. Symptoms from vasodilation.

Key Considerations: Given PO if IV not available, which can be challenging when vessels are under distress.

What are the indications, therapeutic effects, mechanism of action, and adverse effects for magnesium sulfate?

Class: Antiseizure Agent (preeclampsia), parenteral electrolyte supplement, tocolytic.

Mechanism of Action: Reduces cerebral edema, serving as a smooth muscle relaxant for vasodilation (but not main therapeutic effect). Epsom salt.

Therapeutic Effects: Reduces seizures in severe preeclampsia by slowing down the nervous system. Seizure and stroke risk is very high with HTN crisis. First line medication for seizures, Ativan is used second.

Adverse Effects: Flushing, diaphoresis, nausea, fatigue, malaise and not feeling well.

Key Considerations: Vesicant, delivered over 20-30 minutes; 1-4g per hour. High alert, dual-sign off med with narrow therapeutic range (4-7g). Respiratory paralysis and SA/AV node block in high doses, up to cardiac arrest. Accumulates easier if kidney and liver dysfunction.

• Toxicity: Respirations under 12, O2 under 95%, urine under 30 mL/hr, lower LOC, slurred speech, vomiting, loss of DTR (check hourly), grip strength. Check BP hourly for 12-24 hours after stopping medication.

  • Antidote: Calcium gluconate.

What is spontaneous abortion, and how is it treated?

Spontaneous Abortion: An early form of pregnancy bleeding. Pregnancies end before 20 weeks. Results in bleeding, cervical dilation (not full dilation), and uterine cramping (symptoms from mild to severe).

• Treatment: Most cases you provide education and let them know when to be seen, and resolves on own. Misoprostol (prostaglandin-necrosis of uterine lining); dilation & cutterage with post-op oxytocin. No sex for 2 weeks after.

What is cervical insufficiency, and how is it treated?

Cervical Insufficiency: An early form of pregnancy bleeding. Unknown cervical dilation that causes preterm birth in 2nd trimester (14-27 weeks), may be genetic or due to previous procedures. Depends on weak cervical tissue (painless dilation of the cervix. US determines cervical length (<25mm) and speculum for dilation (no palpation). Non-painful.

• Treatment: Cervical cerclage (12-23 weeks) or suturing the cervix to close it (removed for PTL; SROM; 36+ weeks). Progesterone (16-36 weeks) for cervical softening to help with tissue maintenance and strength.

What is an ectopic pregnancy, and how is it treated?

Ectopic Pregnancy: An early form of pregnancy bleeding. Ovum implants outside of the uterus. Also located in ovary, fallopian tube (infundibular, ampullar, outside in isthmus), interstitially, cervically, or in the abdominal area. Causes abnormal ache to stabbing pain, vaginal bleeding; when ruptured, shock, referred pain, and cullen sign (bruising and swelling around the abdomen). Increased risk for hemorrhage, malformations, and organ damage. Risk increases for future pregnancies if happened before. Pregnancy should not continue!

• Treatment: Methotrexate (folate antagonist to destroy cells in stable pregnancy with low hCG) to reabsorb in 4-6 weeks, surgery for contraindications.

What is placenta previa, and how is it treated?

Placenta Previa: A late form of pregnancy bleeding. When the placenta fully or partially covers the cervix or other areas of the uterus. Causes painless bright red bleeding with VS/FHR within normal limits until severe detachment of the placenta. Abdomen is soft and nontender. Increased risk for PPH.

• Treatment: Always assume that painless vaginal bleeding is placenta previa; before 36 weeks, hospitalize and monitor. After 36 weeks or grave concern for health of mother and fetus, deliver infant through c-section. Usually just watching and waiting.

What is placental abruption, and how is it treated?

Placental Abruption: A late form of pregnancy bleeding. When part of (or all of) the placenta detaches prior to the delivery of the infant. Causes bleeding, pain, uterine tenderness, contractions, and fetal distress as time goes on from lack of perfusion (late decels).

• Treatment: If before 36 weeks, perform additional testing and observe VS, FHR, clotting factors, and H+H. After 36 weeks or grave concern for health of mother and fetus, deliver infant through c-section.

What are some general interventions for someone experiencing hemorrhage?

• 18G IV - For rapid infusion of liquids to prevent hypovolemia and shock. May need two for blood infusion.

• Type & Screen - For transfusions from loss of blood. Pregnancy itself also often causes anemia.

• Vital Signs - Hypotension (hypovolemia), tachycardia (from increased pressure on heart for oxygenation; overcompensation mechanism), hyperventilation (metabolic acidosis from lack of oxygen/ starvation of tissues).

• Labs - hemoglobin, hematocrit, fibrinogen, PTT, and PT for clotting times, amount of red blood cells, and ability for them to carry oxygen.

• Urine Output - To monitor renal functioning due to its impact on controlling blood volume levels.

• Oxygen - 10L from non-rebreather mask for maximum pure oxygen for hemoglobin to deliver to the tissues and to control metabolic imbalances.

• External Warming - Hypothermia impairs clotting, decreases cardiac function, and compromises perfusion.

Why does gestational diabetes develop? How is it diagnosed and treated?

The body requires more glucose during pregnancy to support the growth of the fetus, but placental hormones and insulin resistance increase and overwhelms the body. When functioning normally, glucose stimulates the release of insulin, which allows cells to take in glucose for energy. In insulin resistance, the beta cells in the pancreas go on overdrive to release more insulin, but cannot keep up with the demand, resulting in hyperglycemia and decreased insulin release over time. This is also due to uncontrolled gluconeogenesis and glycogenolysis, because the body thinks we are starved of glucose. In pregnancy, resistance comes from estrogen, progesterone, cortisol, and lactogen. The symptoms of gestational diabetes are similar to T2D (polyuria, polyphagia, polydipsia), with the increased risk of abortion, neural tube defects, and the need for a c-section.

Glucose crosses the placenta, but insulin does not. This can result in macrosomia (increased birth weight) and polyhydramnios (too much amniotic fluid). Monitor fetal growth and amniotic fluid volumes.

• Diagnosis: BS should be 60-95 fasting, and under 140 postprandial. Blood glucose should be monitored 4 times daily. After the delivery of the placenta, for most, this goes away, but for some it may indicate preexisting diabetes during PP appointment.

• Treatment: Some forms are controlled with diet alone (A1), but others may require medications (A2). Limit carbs and snacks and have evenly-spaced meals. Increase carbs with increased activity and monitor for hypoglycemia (dizziness, confusion, sweating, palpitations, tachycardia, LOC changes; requiring glucagon/ quick sugar with protein later).

What are the indications, therapeutic effects, mechanism of action, and adverse effects for insulin?

Mechanism of Action: Binds to receptors in target cells to promote glucose uptake into muscle and adipose tissue. This inhibits gluconeogenesis and glycogenolysis so cells can use glucose for energy efficiently.

Therapeutic Effects: Lowers blood glucose levels.

Adverse Effects: Hypoglycemia (BG < 70).

Key Considerations: Can be short, intermediate, or long acting. Education on administration (SUBQ stomach, thigh, and arm), storage (chilled if unopened, room temp for one month after opening), and monitoring glucose before administration.

• Antidote: Glucagon.

What are the indications, therapeutic effects, mechanism of action, and adverse effects for metformin?

Mechanism of Action: Inhibits glucose production in the liver, increases glucose sensitivity in the tissues, and lowers glucose absorption in the GI tract. It does not affect the secretion, so risk of hypoglycemia is very rare.

Therapeutic Effects: Lowers blood glucose levels.

Adverse Effects: Lower appetite, GI symptoms, vitamin B12 and folic acid deficiency, lactic acidosis (muscle pain).

Key Considerations: Administered PO once or twice daily. Take with food.

What is hyperemeisis gravidarum? How is it treated?

Hyperemesis Gravidarum: Hyperemesis throughout the pregnancy that causes severe dehydration and struggle with nutrition (electrolytes, malnutrition).This is different from morning sickness, which primarily affects pregnant people in the first trimester. Hyperemesis gravidarum often requires hospitalization.

• Treatment: Medications, IV fluid replacement, BRAT diet and ginger tea.

What are the indications, therapeutic effects, mechanism of action, and adverse effects for ondansetron?

Class: Antiemetic.

Mechanism of Action: Serotonin antagonist in chemoreceptor zone and GI tract. Reducing the sensitivity of serotonin cuts of the signal in both of these areas that tells the body to throw up.

Therapeutic Effects: Manages N/V.

Adverse Effects: Headache, dizziness, diarrhea.

Key Considerations: IV, PO.

What are the indications, therapeutic effects, mechanism of action, and adverse effects for promethazine?

Class: Antiemetic; First generation antihistamine, antiemetic.

Mechanism of Action: Blocks histamine at H1 receptors; anticholinergic and antidopaminergic properties. Crosses the BBB easily to reduce nausea and insomnia by reducing dopamine and acetylcholine receptors, preventing them from triggering the chemoreceptor zone to induce vomiting.

Therapeutic Effects: Manages N/V, insomnia.

Adverse Effects: Anticholinergic (blurry vision, urinary retention, constipation, dry mouth, tachycardia), sedation, disorientation, extrapyramidal effects (rare). Rare risk of anticholinergic toxicity (seizure, coma, death).

Key Considerations: IM, IV, or PO; vesicant if given IV (up to tissue death, push slowly).

How does anemia happen in pregnancy? How is it treated?

Anemia: Diagnosed when hemoglobin is under 11 mg/dL in 1st or 3rd trimester. Caused from lack of iron (ferritin under 12 mcg/L), folic acid, or other conditions (sickle cell, thalassemia). Headache, pale skin, fatigue, orthostatic hypotension, difficulty regulating temperature are all symptoms. This can reduce fetal oxygen and may increase risk of hemorrhage around time of delivery.

• Treatment: Iron supplementation, consuming iron-rich foods (red meats, legumes, green leafy veggies, fortified foods, iron fish), avoiding caffeine around meals. Folic acid supplementation.

What are the indications, therapeutic effects, mechanism of action, and adverse effects for ferrous sulfate (PO) and iron dextran (IV)?

Class: Mineral, supplement.

Adverse Effects: PO (N/V, abdominal pain, constipation, black stools). IV (hypotension, flushing, anaphylaxis).

Key Considerations: Take on an empty stomach if PO; use alongside vitamin C to increase absorption.

What is intrahepatic cholestasis of pregnancy? How is it treated?

Intrahepatic Cholestasis of Pregnancy: During pregnancy, bile acid levels can rise and stagnate in the gallbladder, resulting in an increase in bile acid salts into the bloodstream. This causes severe itching (pruritus) without a rash around hands and feet, and worsens at night. It does not improve with antihistamine usage. This does little to harm the mother, but can cause preterm delivery, meconium in the amniotic fluid, and stillbirth.

• Treatment: Bile salt and LFT testing in 3rd trimester, cool baths, topicals, oatmeal products. Induction of labor at 36/37 weeks to prevent complications and fetal distress in the 3rd trimester.

What are the indications, therapeutic effects, mechanism of action, and adverse effects for ursodeoxycholic acid?

Mechanism of Action: Decreases cholesterol content of bile to reduce bile acids.

Therapeutic Effects: Reduces pruritus, lowers bile acids, AST, and ALP.

Adverse Effects: N/V, dizziness, headache.

Key Considerations: 1st line treatment for gallstones.

What are key considerations for giving CPR to a pregnant person?

• The primary concern is to stabilize the mother.

• Shove something under the patient’s hip to provide left lateral uterine displacement.

  • Pregnancy puts pressure on the inferior vena cava, already inhibiting venous return and cardiac output.

• Monitor for amniotic fluid embolism, which is when amniotic fluid enters the bloodstream.

• Detach fetal monitors and place the pads a little higher up.

• Edema causes swelling which may make giving breaths a little more difficult, as well as intubation.

• Perimortem c-section may be needed for a fetus over 23 weeks to improve success rate of CPR.

  • Prolonged oxygen deprivation can cause fetal distress, prompting removal.

• Rate is 100-120 BPM, with 30 compressions to 2 breaths every 2 minutes.

What are signs of substance use disorder in pregnancy? How is it screened? How is it treated?

Substance Usage Disorder: Chemical dependency to alcohol, marijuana, tobacco, or illicit drugs. Can be associated with lack of care and poor nutrition, with increased risks to the fetus (ectopic, FGR, LBW, preterm, abruption, preeclampsia, malformations).

• Screening: Parents (family history), partner (social), past (previous usage), and pregnancy (time leading up to pregnancy usage). Toxicology screenings (may require consent, chain of custody).

• Treatment: Abstinence recommended and lifestyle changes may be more common antepartum, AA/NA, medication (methadone, buprenorphine; may affect fetus so lack of access to these treatments), CBT.