High Risk OB

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High Risk OB
2012-04-19 15:14:29
High Risk OB

High Risk OB
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  1. Gestational Trophoblastic Disease (GTD)
    "molar pregnancy"
    • The chorionic villi of the placenta degenerates and becomes swollen, fluid filled grapelike clusters which fil up the uterus. 1:1200 pregnancies in the US.
    • Signficance: pregnancy loss and associated grief; possibility of choriocarcinoma (rapid, advancing, metastatic deadly cancer)

    Molar pregnancy: increase in BP before 20 weeks
  2. Complete mole
    • Develops from an "empty ovum" and a normal sperm with haploid # of chromosomes (23)
    • Concpetus has chromosomal set of totally paternal origin (46 XX)
    • Embryo dies early and no embryonic tissue is found.
    • 20% will develop choriocarcinoma
    • Fluid filled vesicles develop rapidly to fill uterus
    • Bleeding into uterus and out through vagina.
  3. Partial mole
    • Fertilization of normal ovum with 2 sperm (69 XXY)
    • Embryonic or fetal parts are found
    • Congential anomalies present
    • 5% incidnce of choriocarcinoma
    • Fetus usually survives 8-9 weeks
  4. Clinical manifestation of GTD(molar pregnancy)
    • Vaginal bleeding: prune juice or bright red color
    • Anemia due to loss of blood (low H&H)
    • Hydropic vesicles may be passed vaginally at 16 weeks
    • Uterine size doesn't match gestational dates
    • Absent fetal heart tones
    • Elevated serum hCG levels (>1-2 million IU)
    • Hyperemesis gravidarum
    • Preeclampsia (protein in urine; HTN) symptoms present in 1st trimester
    • No fetal movements detected

  5. Interventions for GTD (molar pregnancy) and choriocarcinoma follow up
    • Remove all molar tissue via D&C
    • Rh- women should receive Rhogam within 72 hours
    • Must be followed closely for 1 year to assess for choriocarcinoma
    • Baseline chest x-ray q6 months (metastasizes to lungs)
    • Weekly measurement for hCG until undetectable on two consecutive determinations, then measured q1-2 months for at least a year. Not completely clear until hCG is not seen for 3 months. (if hCG continues to go increase-->Cancer)
    • Fool prood birth control for 1 year
    • Metastasis occur to liver, lungs and brain
  6. Placenta previa-late bleeding complication
    • Placenta implants improperly in the lower uterine segment (where there is no uterine muscle) near or over the internal os (opening)
    • Risk for postpartum hemorrhage
    • Types:
    • Complete-covers the internal os completement (automatic c-section)
    • Partial-incomplete coverage of interal os (mostly c-section)
    • Low-lying-does not reach the internal os (some HCPs try a 6 hour trial labor)
    • Etiology: related to endometrial scarring (C-sections) and increased infections (endometritis). Incidence is 1:200 pregnancies. Bleeding occurs in 3rd trimester with placental separation.
  7. Placenta previa-clinical manifestation
    • painless bright red vaginal bleeding
    • First episode may be scant; others may be profuse
    • Uterus remains soft; FHT strong
    • Fetal malrepresentation is common (no space at the bottom of uterus for head)
    • Maternal vital signs within normal limits
    • Dx made via ultrasound to locate placenta
  8. Placenta previa-interventions
    • Care depends on gestational age and amount of bleeding
    • Bedrest with BRP (bathroom privelages) is ordered
    • No vaginal or rectal exams (can cause separation and hemorrhage)
    • Monitor blood loss (pad count), pain, and uterine contractions
    • Monitor FHR with external monitor
    • Replace fluids and type and cross match blood (may have to infuse her)
    • Pitocin to keep uterus clamped
    • C-section is usual mode of delivery
    • High risk for postpartum hemorrhage
  9. Abruptio placenta (OB emergency)
    • Premature separation of a normally implanted placenta from uterine wall. Incidence is 1:80 births and rising
    • Causes:
    • Maternal smoking due to vasoconstriction
    • HTN
    • diabetes
    • poor nutrition
    • cocaine and meth abuse
    • abdominal trauma (car air bag)
    • renal disease
    • *high recurrence
  10. 3 types of abruptio placenta-check the color of blood
    • Marginal: peripheral separation where the blood passes between fetal membranes and escapes vaginally (edges are separating, not a bright red color).
    • Central: central separation where blood is trapped between placenta and uterine wall; no vaginal bleeding but PAIN
    • Compete: TOTAL separation with accompanying massive vaginal bleeding.
    • Maternal/fetal risks:
    • maternal mortality rate is 6%
    • Perinatal mortality is 15%
    • Renal failure due to shock
    • DIC-clotting factors used up in the body-petechiae is an early sign
    • Sheehan syndrome-pituitary necrosis-loss of oxytoxin and ADH, TSH, metabolism gone-hormone replacement--mother will not lactate
  11. Disseminated Intravascular Coagulation (DIC)
    • Can occur with abruptio placenta
    • Freely bleeds because she can't clot her blood.
    • Treatment is heparn because she is creating micro-clots.
    • Sign is petechiae (can develop MI, pulmonary embolism, stroke)
    • Anemia and hypoxia for fetus
    • Sheehan syndrome: pituitary necrosis (no perfusion to pituitary gland, posterior--->oxytocin and ADH. Treat with synthetic hormones

    • Manifestations:
    • Aching pain in abdomen (especially with central separation)
    • uterine irritability
    • Painful dark red vaginal bleeding
    • Shock symptoms
    • Meconium stained amniotic fluid-due to fetal distress
  12. DIC interventions
    • Assess for bleeding
    • Assess maternal behavior (confusion, decreased LOC)
    • Stat delivery (C-section)
    • Fluid and blood replacement
    • Assess for DIC symptoms-petechiae usually on trunks and arms is an early sign
    • Rh- women should receive Rhogam
  13. Hyperemesis Gravidarum
    • *or hyperemesis, not a bleeding disorder
    • Pernicious vomiting during pregnancy
    • peaks at 10 weeks with hCG peak
    • 1% of all pregnancies
    • dehydration and weight loss are paramount

    • Interventions:
    • control of vomiting via meds usually by IV (antiemetics)
    • Restore fluid and electrolyte balance
    • Psychotherapy advise-disorder is considered to be possibly created because of negative issues due to pregnancy or other personal issues.
  14. Hypertonic labor patterns
    • The resting tone of the uterus is >15mmHg and may rise to as high as 85mmHg.
    • Increase frequency of contractions (starts with quick intense contractions).
    • Decrease in intensity
    • Usually occurs priot to 4cm dilated
    • Contractions are painful, but ineffective in changing the cervix
    • Leads to prolonged latent phase (usually dilates 1cm/hour-dilated to 1 in 4hrs).
    • Occurs in very anxious primips and post term pregnancy (after 42 weeks)

    • Risks:
    • fetal distress occurs early (early deceleration pattern which usually occurs at the end of labor around 9-10 cm)
    • Prolonged pressure on fetal head can lead to cephalohematoma, caput succedaneum (whole head is spongy), excessive molding (cone head).

    • Management:
    • Bed rest and sedation with morphine
    • After rest-normal labor pattern may ensue (will normally start)
  15. Hypotonic labor patterns
    • consists of infrequent uterine contractions of mild to moderate intensity
    • Marked slowing or arrest of cervical dilation
    • Uterine resting tone is <8mmHg
    • <2-3 contractions occur in 10 minutes
    • Occurs >4 cm dilation
    • May happen with twins, LGA babies or hydramnios (too much amniotic fluid
    • Can be caused by over use of Demerol, Nubian, Stadol
    • Usually seen in active phase labor

    • Risk:
    • increased chance of intrauterine infection with early eruption of membranes
    • maternal exhaustion
    • Increased risk of postpartum hemorrhage
    • Fetal sepsis as demonstrated by tachycardia secondary to ascending infection

    • Management:
    • Rule of CPD (cephalopelvic disproportion) or fetal malrepresentation
    • Give pitocin to improve quality of contractions
    • Perform an amniotomy (rupture membranes) to augment labor
    • Give IV to hydrate patient
    • C/S if pattern doesn't change
  16. Prolonged labor
    • lasting >24 hours
    • Incidence varies from 1-7%
    • Most common in primips

    • Causes:
    • CPD and malrepresentation
    • Excessive use of analgesics
    • High anxiety of client

    • Risks:
    • maternal exhaustion
    • Infection and hemorrhage
    • fetal distress
    • prolapsed cord

    Treatment: identify cause and treat it
  17. Precipitous labor
    extremely rapid labor lasting <3 hours

    • Causes:
    • thin maternal tissues
    • strong uterine contractions (maybe hypertonic)
    • multiparity
    • large pelvis/small fetus
    • pitocin overdose

    • Risks:
    • birth canal lacerations (can lead to prolonged labor, uterine prolapse, stress incontinence)
    • Uterine rupture (vaginal after section delivery)
    • Postpartum hemorrhage

    • Treatment:
    • check for history of this
    • MgSO4 to slow contractions
  18. Preterm labor
    • occurs between 20-37 weeks gestation
    • 7-8% of all pregnancies end in early labor

    • Risk factors:
    • multiple gestation
    • hydramnios (too much amniotic fluid, caused by congenital defect)
    • Previous preterm birth
    • UTIs (bladder infection causes preterm labor due to bladder inflammation irritating uterus).
    • Smoking >10 cigarettes a day (irritates uterus)
    • Biggest risk: a preterm infant with the inability to support extrauterine life

    • Prevention:
    • progesterone supplementation between 19-34 weeks
    • Mecana (natural progesterone) $1200/month if purchased through drug company. $200 if through compounding pharmacy

    • Treatment if <34 weeks:
    • prenatal corticosteroids (BetaMethazone)
    • MgSO4 for 48 hours (trying to stop labor)
    • Antibiotics if positive for UTI or STI of bacterial vaginosis

    • Management:
    • Prevention
    • early identification of hgih risk women
    • Education about s/s (low nack pain, contractions)
    • Arrest preterm labor with MgSO4
  19. Teaching about prevention of preterm labor
    • Rest BID on left side
    • Drink 2-3 quarts of water daily
    • empty badder q2hrs while awake
    • avoid nipple stimulation
    • wipe front to back
    • avoid lifting heavy objects
  20. Early Postpartum hemorrhage
    early: occurs in the first 24 hrs post birth

    Cause of early hemorrhage: uterine atony (no tone, not contracting); lacerations

    • Predisposing factors:
    • uterine overdistention -big baby
    • grandmultiparity (over 7/8 pregnancies)
    • prolonged or precipitous labors
    • Use of pitocin

    • Management:
    • early identification of high risk patients
    • constant monitoring of fundus post birth
    • bimanual compression of uterus (massage)
    • pitocin IV to contract uterus
  21. Diabetes in pregnancy
    • after 20 weeks gestation 50% increase in insulin resistance in all pregnant women--->hPl
    • Hyperglycemia risks:
    • transfers to fetus inducing fetal hyperinsulinemia which causes increase in fat deposits which results in macrosmia in newborn---> risk for shoulder dystocia and CPD

    • Cardinal symptoms:
    • polyuria
    • polydipsia
    • weight loss
    • polyphagia

    Timing of birth is based on placental aging and not on fetal size. Placenta ages early in diabetic woman. Birth is usually at 37 weeks. IV insulin given during labor.
  22. Late postpartum hemorrhage
    Retained placental fragments that haven't been removed

    • Treatment:
    • manual removal of placenta
    • Pitocin or Methergine to force fragments out of uterus

    Good assessment before leaving birth room (check to see if the fundus is firm before the doctor leaves). Look for stream of bright red trickling blood from vaginal area to rule out laceration. Look at maternal side of placenta for missing fragments and no clots coming out of vagina.
  23. Risk factors for diabetes
    • positive family history
    • history of repeated infections
    • history of delayed wound healing
    • maternal obesity prior to pregnancy
    • histoy of LGA babies >9lbs
    • Unexplained perinatal mortality
    • cardiac congenital anomalies
    • hydramnios

    • Maternal risks:
    • hydramnios in 20% of pregnancies
    • gestational hypertension in 25% of pregnancies
    • ketoacidosis episodes are frequent
    • dystocia (difficult labor) due to CPD
    • chronic monilial vaginitis (yeast)
    • increase in UTIs and infections (bacteria grows in glucose)
    • progression of diabetic conditions

    • Fetal-neonatal risks:
    • 50% mortality rate in ketoacidosis episode
    • Macrosomnia (large baby at birth) due to hyperinsulinemia
    • Hypoglycemia within an hour after birth
    • IUGR due to vascular involvement
    • RDS due to insulin's interference of surfactant (high insulin impedes the production of surfactant).
    • Congetical anomalies-neural tube defects--cardiac most common
    • Polycythemia (increase RBCs in blood causing slow circulation-low 02 environment which causes brain damage). and hyperbilirubinemia (RBC breakdown and will be jaundice at birth
    • Childhood obesity (if born macrosomic)
  24. Hemoglobin A1c values in gestational diabetes
    a screening test-will show trend of glucose level for past 90 days.

    • Scale 0-12
    • Want it to be under 6
  25. Insulin regulation during pregnancy
    hPL impairss insulin action during pregnancy-fights against the insulin

    First half of pregnancy (<4.5 months):insulin dosage may be reduced by 50% (all glucose crosses over to baby).

    Second half of pregnancy: insulin dosage may be double bc of hPL

    Postbirth: may vary depending on maternal glucose levels

    Dosing: 2/3 in am; 1/3 pm

    • Dietary regulation: no simple sugars; 3 meals and 3 snacks; 30% fat, 20% protein; 50% complex carbohydrates
    • Exercise: walk after meals to lower glucose
  26. Hypertension during pregnancy
    multiorgan disease process that develops during the last half of pregnancy and frequently regresses in the postpartum period. occurs in 8% of pregnancies

    • HTN defined as being +30mmHg systolic and +15mmHg diastolic above baseline. The elevated BP must be pres ent on two occasions at least 6 hours apart. 140/90 if no baseline is charted.
    • *all BP decreases in women during pregnancy due to progesterone dilating their vessels
  27. Pre-existing HTN
    • present before pregnancy or <20 weeks
    • >140.90 reading taken 6 hours apart
    • 1st diagnosed in pregnancy
    • does not resolve by 12 weeks postpartum--will continue
  28. Gestational HTN
    • transient HTN of pregnancy detected >20 weeks gestation with previous normal BP
    • mild and severe forms, no moderate forms
    • >140/90 readtings taken 6 hours apart without proteinuria
    • BP returns to normal by 12 weeks postpartum
  29. Preeclampsia
    • elevated BP >140/90 taken 6 hours apart
    • Proteinuria >0.3 grams protein in 24 hours
    • >1+urine dipstick reading
    • no evidence of a UTI
    • >20 weeks gestation

    • risk factors:
    • underlying HTN or renal disease
    • DM
    • Obesity
    • positive family history of DM
    • Primip <19 or >35 years old
    • Hydramnios
    • Mulitple gestations
    • molar pregnancy

    • Risk for women:
    • cerebral edema
    • DIC
    • pulmonary edema/heart failure
    • Hepatic failure

    • Risk for fetus:
    • Prematurity
    • IUGR
    • still birth

    • Causes:
    • abnormal placenta development due to-
    • abnormal trophoblast differentiation
    • immunologic factors exposure from fetus/father
    • medical conditions causing vascular insufficiency
    • genetics
    • inflammation?
  30. Management of preeclampsia
    • Mild preeclampsia management:
    • hospitalization not necessary
    • bed rest and BP meds not beneficial
    • plan for vaginal birth >37 weeks
    • MgSO4 given with seizure precautions for <12-48 hours post birth

    • Preeclampsia managment:
    • bed rest in left lateral recumbant position
    • high protein, moderate sodium diet
    • MgSO4-anticonvulsant; peripheral vasodilator (prevent seizures)
    • Monitor Mg serum levels (4-7mEq/liter=therapeutic)
    • Antitode for toxic dose is calcium gluconate IV
  31. Post-term infant
    • born after 42 weeks gestation
    • comprise of 12% of all pregnancies bc of lack of prenantal care, hormones don't slak off to induce labir and patients dont know their due dates.
    • Major concern: placental insufficiency due to aging (lose weight inside); hypoxia (will need resuscitation at birth) and malnourishment are issues

    • Results in:
    • diminished fetal growth and oligohydramnios (not enoug amniotic fluid)
    • poor oxygen reserves during labor
    • meconium can be passed into amniotic fluid
  32. Post maturity syndrome
    • meconium stained cord, skin and nails (green trolls)
    • hyperalert; wide eyed, worried look--(look three months old)
    • polycythemia: can cause blood clots, baby looks mottles, extremities will continue to look cyanotic
    • no vernix caseosa and dry cracked skin
    • long, thin wasted appearance
    • loose skin around thighs and buttocks (fragile, hanging skin)
    • abundant hair on head
    • lack of subcutaneous fat similar to preterm infants

    • Problem list:
    • hypoglycemia-hourly blood glucose levels after birth. IV of D10 given (sugar can drop to zero)
    • meconium aspiration syndrome
    • polycythemia-plasma given
    • congenital anomalies (very prevalent)
    • seizures due to hypoxic insult
  33. Rh incompatibility of mother
    • Incompatibility between the blood of the mother and that of the fetus
    • Rh- mother forms antibodies when Rh+ blood from the fetus enters her circulation. The antibodies cross the placenta and destroy fetal RBCs
    • Rhogam is administered at 28 weeks and within 72 hours after delivery
    • Baby 2 is a risk of erythroblastosis fetalis:
    • enlarged placenta, spleen and liver
    • anemia
    • pallor or jaundice <24 hours old
    • neonate is edamatous with ascites
  34. HIV
    • acquired transplacentally and through breast milk
    • Asymptomatic at birth-signs appear 4-12 months later
    • Enlarged liver and spleen, lymphadenopathy, FTT, pneumonia, persistent yeast infections

    Managment: antiviral therapy
  35. Phenylketonuria (PKU) testing in newborns
    • Genetic metabolic disorder
    • Characterized by a deficiency of enzyme phenylalanine hyroxylase
    • lack of proper converstion result in a build up of toxic levles of phenylalanine----> causes CNS damage
    • done approximately 24 hours after birth or as close to discharge as possible
    • Infant needs to have eaten since delivery before test
  36. Transient tachypnea in the Newborn (TTN)
    aka RDS type 2
    • delayed clearance of fetal lung fluid as a result of hyperaeration of the fetal lungs and transient pulmonary edema from the fetal lung fluid (which is different from amniotic fluid) in the alveoli
    • air is trapped in the alveoli and hypoxia results due to poor lung ventilation
    • common in infants of diabetic mothers

    S/S: high resp rate 60-120breaths/min, grunting, retractions, nasal flaring

    Dx: blood gas should respiratory acidosis

    Tx: CPAP at 40% 02 for 24-48 hours, complete resolution may take 2-3 days, TTN is self limiting w no reported long term complications
  37. Bethamethasone and preterm infants
    • glucocorticoid
    • given 24 hrs prior to birth to prompt production of surfactant in infant's lungs before delivery
  38. Pulmonary emboli and thrombophlebitis
    • Risk factors:
    • preeclampsia
    • advanced age
    • increased parity
    • multiple gestation
    • obesity
    • dehydration

    Management: medications (anticoagulant therapy with heparin), bed rest with elevation of the involved extremity, application of warm moist heat.
  39. Cytomegalovirus (CMV)
    • spread by changing cat litter boxes
    • *mother is asymptomatic
    • most babies are asymptomatic at birth
    • SGA, blindness, seizures
    • Enlarged liver and spleen
    • Jaundice, mental retardation, hearing loss

    Management: most common perinatal infection, diagnosied by urine culture, antiviral drug therapy
  40. Hepatitis B
    • may contract on the way out-contracted during birth process
    • most infants are asymptomatic at birth
    • most become chronic carriers
    • risk of later liver cancer

    • Managment:
    • wash infant well to remove all blood after birth
    • administer hep B immune globulin and vaccine
  41. Herpes
    • contracted during birth process from vagina
    • infant presents with clusters of vesicles, temperature instability, lethargy, poor sucking, seizure, encephalitis, jaundice and purpura.
    • death and severe CNS damage is likely

    • Management:
    • contact precautions
    • culture lesions
    • antiviral drug therapy
  42. Rubella
    • contracted transplacentally
    • asymptomatic or SGA, cataracts, cardiac defects, deafness, mental retardation, hyperbilirubinemia, damage greatest in first trimester

    • Managment:
    • prevention by vaccinating all children
    • infant may shd virus for months
    • no treatment available
  43. Physiologic jaundice
    • typically ocurs after the first 24-48 hours of life
    • become visible when total serum bilirubin level is >5-7 mg/dL
    • levels typically peak between day 5-7 preterm infant. 3-5 days in term infant and gradually decline after 10-14 days of life
  44. Pathologic jaundice
    • appears within first 24 hours post birth
    • total bilirubin >12 mg/dL in term infant
    • >10 mg/dL in a preterm infant
    • Direct bilirubin level is >1mg/dL
    • jaundice continues beyond second week of life
    • >20mg/dL---->kernicterus---->encephalopathy

    • risk factors:
    • prematurity
    • cephalohematoma
    • asphyxia
    • Rh incompatibility
    • sepsis
    • breastfeeding

    • Therepeutic management:
    • prevention of kernicterus
    • identify cause and correct
    • check direct Coombs lab result
    • assess for jaundice by blanching skin over bone
    • phototherapy-bililights or fiber optic blanket
    • monitor hydration status
    • exchange transfusion w O-blood
  45. Retinopathy of prematurity (ROP)
    due to too much O2 provided by healthcare personnel--can cause blindness