Maternity Exam 2

Pregnancy Complications Associated with Obesity

-antepartum

• at least 1/5 overweight contributing to risks

• as estrogen levels rise in the body, so does risk for clotting- DVT, PE

• cardiac hypertrophy

• sleep apnea

• gastric reflux

• preeclampsia

• gestationsal DM

• fetal loss

• congenital defects

-Intrapartum

• abnormal progress of labor

• macrosomia- larger babies when moms are overweight

• shoulder dystocia- baby get stuck; invasive delivery

• operative vaginal or c/s delivery

• hemorrhage- big babies, longer labor, inability to get to fundus appropriately

-postpartum

• infection

• wound dehiscence

• thromboembolism

• early termination of breastfeeding

• anemia- lower iron levels depending on labor course

• depression and anxiety

Chronic Cardiovascular Disorders

-normal physiologic changes

• more common that complex issues are diagnosed as more of a concern bc more complex issues are being diagnosed- moms with congenital heart defects are living to adulthood and having babies to pass it on

• normal changes in blood with pregnancy- increased CO

-maternal complications

• pulmonary edema

• CHF

• emboli

-fetal complications

• decreased bloow flow and oxygenation

• risk increases for CHD

-nursing care- make sure fetuses with issues are lined up to see specialists

• catch concerns early

• check perfusion on mom, listen to mom and baby heart, monitor weight gain, I&O’s, labs

• Some warrant certain antenatal tests

Spontaneous Abortion (Miscarriage)

-pregnancy loss before 20 weeks

• often women’s body deciding the pregnancy is not safe to carry to term

• significant chromosomal abnormalities (if miscarriage happened)

-s/s- cramping, bleeding

-should give full assessment afterwards when they can come in the office

• history of symptoms

• ultrasound to check leftovers in uterus

• serial hCG levels- see trends

• CBC levels- to ensure not loosing too mcuh blood

-Nursing care

• VS- monitor and make sure hemodynamically stable (too much if more than a pad in an hour)

• assess bleeding and pain- analgesics

• IV fluids and pre-op assessment if further along

  • uterus needs to be fully emptied

• Rho(D) immune globulin if Rh- depending on gestational age

• psychological, sociocultral, and spiritual care

• discharge teaching- peri care, pelvic rest (2 wks; no intercourse until comfortable)

• follow-up care for health promotion, testing, counseling, bereavement support

Ectopic Pregnancy

-pregnancy occuring outside the uterus

• want to rule out ectopic pregnancy

• sperm and ovum meet and form embryo and implant in fallopian tube

• figure out around 8-10 wks; wouldn’t get passed bc tube would rupture

-etiology- usually result of scarring within tube and growing blastocyte cannot make ut all the day

• STI

• PID

• reversal of tubal ligation

• previous pelvic/abdominal surgery

• endometriosis

-s/s- severe pain and bleeding

-assessment-

• serial hCG

• transvaginal US

• serum progesterone

-treatment

• medical management- methotrexate (medication that causes pregnancy to abort) or laparoscopic salpingectomy (remove the falopian tube and fetus)

• RhoGAM if Rh -

• psycholgical, sociocultural and spiritual care

• discharge teaching: expected effects of treatmen; s/s of complications (cramping, bleeding, pain)

Hyperemesis Gravidarum

-severe vomiting and starvation

-dehydration

-electrolyte imbalance

-ketonuria

-weight loss- 5-10%

-try to eliminate triggers, while still ensuring proper nutrition

-Management

• medication

  • B6/Unisom (Doxylamine)- OTC as prescription expensive

  • Doxylamine-pyridoxine (Diclegis)- only one proven to be safe during pregnancy

  • Ondansetron- (zofran)- try to avoid as has increased chance of affecting baby if taken

• emotional support

• oral care- very draining

• assess for dehydration, weight loss, physical and emotional exhaustion

Chole’s

-cholelithiasis- bile stones (gallstones)

• etiology- gallstones; bile stays in gallbladder for longer; estrogen increases and gallbladder muscle tone decreases making it harder to push bile out

• s/s- colicky (comes and goes) RUQ pain, Nausea/vomiting, fever

• complications- usually mild; surgical intervention depending on symptoms and gestational age

• treatment- cholecystectomy, IV fluids, antibiotics

-cholestasis- bile slowing (build up of bile acids)

-intrahepatic cholestasis-liver

• unknown etiology

• s/s

  • intense pruritus (palms and soles)

  • systemic symptoms

  • bile acids >10 for diagnosis

    • >10 is considered abnormal

    • often screen ALT/AST, bilirubin (liver-related labs) often elevated because bile acids take awhile to come back

• complications- higher likelihood of PTL, HR abnormalities (hypoxia → death), stillbirth; try to deliver slightly early (27-29 wks)

• treatment- Ursodiol for symptoms only

Preterm Birth

-leading cause of neonatal mortality

• 20-36.6 wks

• most common cause for antepartum hospitalization

-reason

• spontaneous labor- mom just goes into labor

• medically indicated- baby has something indicating needs to come out (risk of stillbirth too great)

• elective- no medical reason to deliver (unlikely to find provider who will do this

-23 wks is earliest time of variability (ability to survive outside of the uterus)

• does not mean it will be normally functioning child after this

• will probably have long term medical care if survives

Preterm Labor

-progressive cervical change

• cervix has to change to be able to give birth

-presentation

• back pain

• pelvic pressure

• SROM- spontaneous rupture of membranes

• bleeding, spotting

• change in vaginal discharge (increases)

Preterm Labor Risk factors

-history of PTL- highest risk factor

-multiple gestation- uterus full or extra fluid making it seem so

-uterine/cervical abnormalities

-fetal abnormalities

-infection

-short pregnancy interval

-chronic/pregnancy related health issues

-age <17 or > 35

-late or no prenatal care

-obesity

-working or standing long hours

-ethnicity

-IPV, mental health complications, substance abuse

-lower education or socioeconomic status

Predicting Preterm Labor

-transvaginal cervical US to measure

• >30mm→ proably not PTL

• <20mm → strong positive predictor

-feral fibronectin fFN

• connecting point from uterus to fetal membrane- spider web; if have more fFH in vaginal secretions starting to break down and could indicate impending delivery

• done b/t 24-34 wks; increased levels can predict increased risk for PTL

• negative- usually unlikely to deliver in next 2 weeks

-prevention

• progesterone given in vaginal suppository (more common) or IM

Preterm Labor Medications

-indomethacin- 50 mg PO initally; 25-50mg q6hr

• mechanism of action- prostaglandin synthesis inhibitor

• must be short term and before 32 wks gestation

• adverse reactions: Gi upset; serious fetal complications (constriction of PDA, neonatal pulmonary HTN, IVH)

-nifedipine- 10-20 mg PO q4-6hrs

• mechanism of action- calcium channel blocker that relaxes SM blocking Ca2+ entry

• adverse reactions: fewer than other tocolytics; transient tachycardia, hypotension, nausea; hold for BP<90/60 or HR>120

-magnesium sulfate- 4-6 g in 20 min, 2 g/hr

• given prior to 32 wks for fetal neuroprotection

• adverse reactions- hot flushes, sweating, n/v, drowsiness, dizziness, transient hypotension, respiratory depression

-terbutaline- 0.25mg SQ q 3-4hr; not recommend longer than 48-72 hrs

• cardiac

• mechanism of action- beta2-adrenergic agonist that relaxes SM/bronchodilation

• adverse reactions: SOB, tachypnea, pulmonary edema, tachcardia, palipations, hypotension, fluid retention, tremors, muscle cramps, hyperglycemia, hypokalemia, hypocalcemia/ n/v

-all are antitolytic medications to stop the uterus from contracting

• given 24-34 weeks

• ***purpose is to prolong pregnancy for enough time to give steroids***

• significant side effects- only used to get to point to use steroids

-Contraindications

• maternal

  • severe preeclampsia

  • active vaginal bleeding

  • chorioamnioitis

  • medical/OB condition that contraindicates continued pregnancy

• fetal

  • EGA>34 wks

  • fetal death

  • lethal anomaly

  • acute fetal distress

  • chronic IUGR- really tiny baby

Antenatal Corticosteroids

-steroids given when up to term to expadite lung and brain maturity for fetus

-Betamethasone 12 mg IM every 24 hrs x2

• rescue dose can be given after 7 days if goes back in to PTL only once to help fetus mature more inutero

-adverse affects

• hyperglycemia

• pulmonary edema

• increased maternal susceptibility to infection (higher BG)

Rupture of the Membranes

-PROM- premature ROM

• water breaks and contractions do not start

• pr could be preterm or pronlong ROM (any P)

-PPROM- preterm premature ROM

• water breaks and contractions do not start, and baby is GA before 37 wks

-PPROM- prolonged preterm prematuer ROM

• longer than 24 hrs, before 37 wks, contractino do not start/in labor for too long

-Management

• medical

  • monitor for infection, labor, fetal distress

  • prophylactic antibiotics

  • tocolytics for corticosteroids

• nursing actions

  • EFM- NST/BPP

  • s/s infection and abruption

  • avoid cervical exams

• delivery- typpically around 34 wks, can sometimes push longer if doing well

Multiple Gestations

-chroionisity- makeup of placenta; key indicator if babies are from one or two

-dizygotic twins

• two eggs, two sperm, two different genetic makeups,

• dizygotic diamniotic- safest pregnancy with two separate starting points with separeate sacs and placentas

-monozygotic twins

• one starting point that splits into 2

• depends on when split occurs for; always same gender

• two types

  • shared placenta, different sacs- monozygotic, diamniotic- 2nd safest)

  • shared placenta and different sac- monozygotic, monoamniotic- least safest

Risks of Multifetal Gestations

• 3-4x increase in preinatal morbidity

• PTL/delivery (35 wks)

• intrauterine growth restriction

• polyhydraminos

• preeclampsia

• congenital anomalies

• postpartum hemorrhage

• placental abruption

• unbilical cord accidents

• intrauterine fetal demise

-Management

• Di/Di

  • similar to routine plus some…

  • monthly growth scans

  • observe for growth discordance (antenatal testing if discordant)

  • deliver in 38th week dependent on positioning

• mono/mono

  • management for Di/Di plus…

  • US q/2wks 16-28 wks to fonitor for twin to twin

  • hospitalization in 2nd trimester

  • delivery at 32-34 wks with c/s

    • fetal mortality rate of 50-60%

Twin-Twin transfusion Syndrome

-complication specific to monochorionic gestations

• one baby pulls everything and the other gives it all ip

• development of vascular anastomoses between fetuses

-donor twin- donates everything- blood, weight, amniotic fluid

-recipient twin- takes everything from other

-can be treated with lazers to stop transfusion and keep two healthy twins- veru high risk

• only in mono/mono twins