Care of Mother With Complications of Childbearing: During Pregnancy

Gestational Hypertension

• New-onset hypertension after 20 weeks of pregnancy

• Without proteinuria or signs of organ damage

• BP ≥ 140/90 mmHg

• Occurs after 20 weeks gestation

• No evidence of preeclampsia

• Often asymptomatic

Preeclampsia

• Pregnancy-induced hypertension with evidence of organ involvement

• Usually occurs after 20 weeks gestation

Classic Signs:

• Hypertension

• Proteinuria

• Edema (especially face/hands)

Severe Warning Signs:

• Severe headache

• Blurred vision / visual disturbances

• Epigastric or right upper quadrant pain

• Hyperreflexia

• Decreased urine output

• Sudden weight gain

• Shortness of breath

Mild Preeclampsia

≥140/90

Proteinuria or mild symptoms

Severe Preeclampsia

≥160/110

Organ dysfunction, severe symptoms of preeclampsia

Magnesium sulfate

Game Changer:

Prevention of seizures for preeclampsia

Calcium gluconate

Game Changer:

Antidote for magnesium toxicity

Left lateral position

Game Changer:

Improves uteroplacental circulation

Non-stress test (NST)

Biophysical profile (BPP)

Ultrasound for growth

Fetal movement monitoring

Fetal Assessment for Preeclampsia

Labetalol

Hydralazine

Nifedipine

Medications used to control severe hypertension for preeclampsia

Decreased/absent deep tendon reflexes

Respiratory depression

Decreased urine output

Toxicity Signs of Magnesium Sulfate

Left lateral position

Positioning to prevent injury for patient with preeclampsia

Eclampsia

Preeclampsia with seizures

Before Seizure:

• Severe headache

• Visual disturbances

• Hyperreflexia

• Epigastric pain

• Restlessness

During Seizure:

• Convulsions

• Loss of consciousness

After Seizure:

• Postictal confusion

• Possible fetal distress

Seizure symptoms in patient with Eclampsia

Side lying position

Positioning during seizure in patient with eclampsia

Severe headache and blurred vision

Game Changer:

Warning signs in patient with Eclampsia

Delivery of fetus and placenta

Game Changer:

Definitive treatment of eclampsia

Gestational hypertension, Preeclampsia, and Eclampsia Comparison Review

Gestational Diabetes Mellitus

• Glucose intolerance first diagnosed during pregnancy

• Usually develops during the 2nd or 3rd trimester

• Caused by increased insulin resistance due to pregnancy hormones

24–28

Game Changer:

GDM usually occurs during ___ weeks

Insulin resistance

Game Changer:

GDM is caused by ___ from placental hormones

Insulin

Game Changer:

___ is the drug of choice during pregnancy

Glucose Challenge Test (GCT)

Oral Glucose Tolerance Test (OGTT)

Diagnostic Tests for Gestational Diabetes Mellitus

Macrosomia

Large baby due to excess glucose transfer Fetal/Newborn Complication

Hypoglycemia after birth

High fetal insulin levels after delivery Fetal/Newborn Complication

Respiratory distress

Delayed lung maturity Fetal/Newborn Complication

Birth trauma

Large fetal size Fetal/Newborn Complication

Macrosomia

Game Changer:

Most common fetal complication

hypoglycemia

Game Changer:

After birth, newborn is at risk for ___

B – Blood glucose ↑

I – Insulin resistance

G – Gestational onset

B – Baby macrosomia

A – Assess glucose

B – Breastfeeding encouraged

Y – Yearly diabetes screening after pregnancy

Game Changer:

GDM = “BIG BABY” meaning

Hyperemesis Gravidarum

• A severe form of nausea and vomiting during pregnancy

• Causes dehydration, electrolyte imbalance, and weight loss

• Commonly occurs during the 1st trimester

IV fluids (commonly normal saline or lactated Ringer’s)

Fluid replacement for hyperemesis gravidarum

Vitamin B6 (pyridoxine)

Doxylamine

Ondansetron (as prescribed)

Antiemetic Medications for Hyperemesis gravidarum

Thiamine (Vitamin B1)

Game Changer:

Give ___ before glucose administration in severe cases of Hyperemesis gravidarum. This prevents Wernicke encephalopathy.

hCG

Game Changer:

Common hormone involved in Hyperemesis Gravidarum

Hydration status and weight loss

Game Changer:

Most important assessment for Hyperemesis Gravidarum

Ketonuria

Game Changer:

___ in Hyperemesis gravidarum indicates starvation/decreased nutrition

Placenta Previa

Implantation of the placenta in the lower uterine segment, partially or completely covering the internal cervical os.

Main concern: painless vaginal bleeding during the second half of pregnancy

Painless bright red vaginal bleeding

Game Changer:

Classic sign of Placenta Previa

Complete / Total previa

Placenta completely covers cervical os

Partial previa

Placenta partially covers cervical os

Marginal previa

Placenta reaches edge of cervical os

Low-lying placenta

Placenta implanted near cervix but does not cover os

Ultrasound

Transvaginal ultrasound

Fetal Monitoring

Game Changer:

Diagnostics for placenta previa

Cesarean

Game Changer:

Complete previa usually requires ___ delivery

No digital vaginal examination

Game Changer:

Important safety rule for placenta previa to prevent disrupt placenta and severe hemorrhage

Abruptio Placenta

Premature separation of a normally implanted placenta from the uterine wall before delivery of the fetus.

It is an obstetric emergency because it can cause maternal hemorrhage and fetal compromise

Revealed

Concealed

Mixed

Types of abruption in abruptio placenta

Revealed (External)

Abruption where blood exits through v*gina

Concealed (Internal)

Abruption where blood trapped behind placenta; may have severe symptoms without visible bleeding

Mixed

Abruption where there is a combination of external and internal bleeding

Abruptio placenta

Game Changer:

Painful bleeding + rigid uterus

Hypertension/preeclampsia

Game Changer:

Most common risk factor for abruptio placenta

hypoxia/fetal distress

Game Changer:

Main fetal concern in Abruptio Placenta

Clinical

Game Changer:

Abruptio placenta diagnosis is primarily ___. Treat shock first, then manage delivery

Abortion

Termination of pregnancy before fetal viability

Commonly defined as before 20 weeks gestation or fetal weight <500 g

Threatened

Inevitable

Incomplete

Complete

Missed

Septic

Types of abortion

Cervix status

Game Changer:

___ is key in classification of Abortion

Threatened abortion

Game Changer:

Abortion from closed cervix, pregnancy may continue

Inevitable abortion

Game Changer:

Abortion with dilation → cannot be stopped

Incomplete abortion

Game Changer:

Abortion with retained products → bleeding continues

Missed abortion

Game Changer:

Abortion with fetal death without expulsion

Septic abortion

Game Changer:

Abortion with fever + infection + foul discharge

Iron Deficiency Anemia

• A condition where there is decreased hemoglobin due to insufficient iron

• Most common anemia in pregnancy

• Caused by increased iron demand during pregnancy not met by intake

Oral iron: ferrous sulfate is common

Take with vitamin C to enhance absorption

Iron Supplementation for Iron Deficiency Anemia in Pregnancy

Iron supplements

Best taken on empty stomach (if tolerated)

Avoid taking with milk, tea, or antacids

May cause black stools (normal)

Liver, red meat, fish

Heme iron

Non-heme iron

Beans, spinach, green leafy vegetables

Parenteral iron (IV iron)

Blood transfusion

Medical management for severe anemia in pregnancy

iron deficiency

Game Changer:

Most common anemia in pregnancy = __ anemia

Low serum ferritin

Game Changer:

Diagnostic marker for Anemia

Vitamin C

Game Changer:

Best absorption enhancer for iron deficiency anemia in pregnancy

Black stools + constipation

Game Changer:

Common side effect of iron

Blood volume

Game Changer:

Iron is needed because pregnancy increases ___

Folic Acid Deficiency in Pregnancy

• A condition where there is insufficient folic acid (Vitamin B9) intake

• Leads to megaloblastic anemia and fetal neural tube defects

Megaloblastic (macrocytic) anemia

Game Changer:

Folic acid deficiency

Neural tube defects

Game Changer:

Most important fetal effect of folic acid deficiency

Examples: Spina bifida and anencephaly

400–800

Game Changer:

Folic Acid Supplementation preventive dose for Folic acid deficiency = ___ mcg/day

Conception

Game Changer:

Folic Acid Supplementation for folic acid deficiency in pregnancy needs to be started before ___

Game Changer:

RBC type for fo= macrocytic (large cells)

Pre-existing diseases

Game Changer:

Medical conditions already present before pregnancy

Example: diabetes, hypertension, heart disease

Co-existing diseases

Game Changer:

Conditions that develop or are diagnosed during pregnancy

Example: infections, anemia, gestational diabetes

Chronic Hypertension

High BP before 20 weeks or before pregnancy

Diabetes Mellitus (Pre-gestational)

Type 1 or Type 2 diabetes before pregnancy

Heart Disease

Most dangerous maternal condition in pregnancy

Chronic Hypertension

Diabetes Mellitus

Heart Disease

Renal Diseases

Thyroid Disorders

Asthma

Common Pre-Existing Diseases in Pregnancy

Anemia

Infections

Gestational Diabetes

Hypertensive Disorders of Pregnancy

Common Co-Existing Diseases in Pregnancy

Maternal disease

Game Changer:

Controlling this is the key to fetal survival

IUGR, placental abruption

Fetal risk from hypertension of the mother

Macrosomia, hypoglycemia

Fetal risk from diabetes of the mother

Preterm birth

Fetal risk from heart disease of the mother

Low birth weight

Fetal risk from renal disease of the mother

Congenital anomalies

Fetal risk from infection of the mother

Basic Emergency Obstetric and Newborn Care

Game Changer:

BEmONC meaning

Services provided at primary health facilities (RHU, BHS, small hospitals)

Comprehensive Emergency Obstetric and Newborn Care

Game Changer:

CEmONC meaning

Provided at hospitals with surgical + specialist capability

BEmONC Signal Functions (7+1) Review

CEmONC Signal Functions Review

Key Differences of BEmONC and CEmONC Review

BEmONC

Game Changer:

Magnesium sulfate for eclampsia if function of the (BEmONC or CEmONC)

Uterotonics

Game Changer:

This prevent postpartum hemorrhage

Neonatal resuscitation

Game Changer:

Required in both levels (BEmONC and CEmONC)