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In _____ there is evidence of hemolysis, elevated liver enzymes, and low platelets.
- HELLP syndrome
- -for this Dx platelet count must be <100,000
In ______ the mail pathogenic factor is not an increase in BP but poor perfusion as a result of vasospasm.
Why do 65% of women with HELLP syndrome experience epigastric pain?
In _____, the platelet count is low, PT, PTT and bleeding time remain normal.
_____ is a pregnancy specific syndrome in which HTN develops after 20 weeks of gestation in a previously normotensive woman, and is accompanied by proteinuria.
What is gestational HTN?
the onset of HTN during pregnancy or in the first 24 hours after birth, without other S&S of of preeclampsia and without preexisting HTN. BP returns to normal within 6 weeks of delivery.
S&S=malaise, epigastric pain, N&V you would suspect?
What is the most common medical complication of pregnancy?
Women who have severe preeclampsia or HELLP syndrome labor is usually induced at __-__ weeks?
Why is it important to assess uterine tone in women diagnosed with preeclampsia?
- They are at risk for abruptio placentae, a hard uterus could indicate internal hemorrhage.
- *uterine tenderness in the presence of increasing tone may be the earliest finding of an abruption.
What age group has the highest rates of HTN in pregnancy?
under 20 and over 40, over 40 is the highest
______ has a onset during pregnancy or in the first 24 hours after birth without other signs or symptoms of preeclampsia AND without preexisting HTN
To be gestational diabetes, BP elevation is detected for the first time after mid-pregnancy and returns to normal within ____ after delivery.
Pregnancy specific syndrome in which HTN develops after 20 weeks gestation in a previously normotensive woman.
Multisystem, voaospastic disease process of reduced organ perfusion characterized by the presence of HTN and protein uria with a clinical continuum from mild to severe.
What is the equation for MAP?
(2 x DBP) + SBP/3
concentration of 30mg/dL without infection in two random samples, 6 hrs apart OR in a 24hr collection of 300mL.
>6mg/dL for singleton pregnancy
What are risk factors for preeclampsia?
- -nulliparity (primip)
- -family history
- -multiple gestation (twins etc)
- -before age 20 or after 40
- -chronic medical disorders
- -Paternal factor
Severe preeclampsia is a SBP of ___ or a DBP of ____
- SBP of >160mmHg
- DBP of >110mmHg
AND proteinuria of 5g or more/24 hour collection
If a pregnant woman presents with: oliguria, cerebral distubances (altered LOC), confusion or headache, visual disturbances (blidn spot or blurred vision), hepatic involvemetn including epigastric pain, RUP pain, impaired liver function or elevated liver enzymes, thrombocytopenia, with l=platelet count <100,000, hemolytic anemai, or pulmonary edema and fetal growth restrictions....what are you going to think?
- laboratory diagnosis for a variant of severe
- preeclampsia that is characterized by:
- -Hemolysis (elevated PT, PTT and bleeding
- -Elevated Liver enzymes (elevated AST-aspartate aminotransferase, ALT-alanine
- -Low Platelets (<100,000/mm³)
Other S/S of severe preeclampsia
- -epigastric or RUQ pain (65%) from possible hepatic ischemia
- -malaise (90%)
- -nausea and vomiting (50%)
onset of seizure activity or coma in the woman diagnosed with preeclampsia with no seizure history
When does eclampsia present?
1/3 during pregnancy, 1/3 during labor, and 1/3 within 72 hours after birth
What is the drug of choice for chronic hypertension during pregnancy?
Approx _____ of women with chronic HTN develop preeclampsia or eclampsia.
What is the antihyperensive medication of choice in pregnancy?
- IV hydralazine
- *also can give labetalol hydrochloride, nifedipine, merapamil, and oral methyldopa
Magnesium sulfate is a tocolytic agent, its use can increase the duration of labor. What would you give to augment mag in a laboring woman with preeclampsia?
What is the drug of choice to control or prevent convulsions in women with preeclampsia?
- Magnesium sulfate
- Administered as a secondary infusion (piggyback by pump). Loading dose 4-6g/100mL NS. Maintenance dose usually 2g/hr (40g/1000mL NS)
- -maintain a therapeutic serum level of 4-7.5mEq/L
Care of woman on magnesium sulfate?
- *VS-hourly BP,P,RR, & temp q 4hrs
- *I&O- foley with urometer, DTR's, clonus, LOC
- *FHT and UC frequency Q15min
- *Auscultation of chest and bowel tones q 4hrs
Side effects of magnesium sulfate (mild and severe)
- Mild: decreased DTRs, nausea, feeling of warmth, flushing, muscle weakness, slurred speech
- Severe: loss of patellar reflexes, resp and muscular depression, oliguria, and decreased LOC
What is the antidote for magnesium sulfate?
Calcium Gluconate, 10mL of 10% solution OR 1g slow IVP over 3 minutes.
What happens if you give calcium gluconate rapidly?
dysrhythmias (bradycardia and v-fib)
Hospital care for preeclampsia or HELLP:
Control of BP?
-antihypertensives to perfuse the uterus, target of SBP <160, DBP<110-Hydralazine (drug of choice), labetalol, nifedipine, verapamil, oral methyldopa
Rapid, involuntary eye movements
- When vomiting becomes excessive enough to:
- -cause weight loss of at least 5%, accompanied by:
- -dehydration (low BP, increased pulse, poor skin turgor), electrolyte imbalance, ketosis, and acetonuria.
Nursing care for hyperemesis gravidarum
- -IV fluids, NPO until dehydration resolved and 48 hrs after vomiting has stopped
- -Meds: phenergan, ondansetron(Zofran), metoclopramide(reglan)
- -other meds: meclizine(antivert, dimenhydrinate(dramamine), diphenhydramine(benadryl), prochlorperazine(compazine).
- -Record-nausea, retching w/o vomiting, and vomiting
- -I&O, oral hygiene, daily weight, VS assessment, reintroducing foods as tollerated
Types of bleeding in 1st trimester?
- -ectopic pregnancy
- -hydatidiform mole (molar pregnancy)
How much blood is delivered per minute to uterine vasculature and placenta?
*8-10 minutes for maternal exsanguination
What is cytotec used for?
Misoprostol(Cytotec) - Induction of vaginal deliver for incomplete, inevitable or missed (16-20 weeks) miscarriages
Types of bleeding in 3nd trimester?
- -placenta previa
- -abruptio placentae
Types of postpartum bleeding?
- -hemorrhage due to:
- -retained tissues
- -cervical lacerations
- -uterine atony
- Miscarriage is a spontaneous abortion
- -ends w/o medical/surgical intervention
- -occurs before 20 weeks, or 500g birth weight
- -10-12% of all pregnancies
- -50% chromosomal abnorms
- -90% occur before 8 weeks gestation
- -late (12-20) weeks, usually from maternal causes such as age and parity, infection, premature dilation of cervix...
5 types of miscarriage
- 1. threatened-spotting with a closed cervical os and mild cramping
- 2. inevitable-moderate to heavy bleeding, tissue may be present, mild to severe cramping, rupture of membranes, cervical dilation and passage of products of conception
- 3. incomplete-moderate to heavy bleeding, tissue may be present, mild to severe cramping, expulsion of the fetus with retention of placenta
- 4. complete-all fetal tissue is passed, cervis is closed, slight bleeding and mild uterine cramping
- 5. missed-refers to a pregnancy in which the fetus has died but products of conception are retained in uterus for up to several weeks. Usually no bleeding or cramping, cervical os closed
Habitual miscarriage or recurrent spontaneous abortion?
- 3 or more consecutive pregnancy losses before 20 weeks gestation.
- -etiology unknown
- -these women have increased risk for preterm birth, placenta previa and fetal anomalies
testing hCG during pregnancy
- hCG is a placental hormone that can be detected 8-9 days after ovulation if pregnant
- -levels should double every 1.4-2 days until 60-70 days of gestation
- -Two levels are measured 48hrs apart (will double if normal)
Medical management of miscarriage?
- -Lab tests: hCG
- -D&C (inevitable and incomplete)
- -For late incomplete, inevitable or missed miscarriages (16-20 weeks) misoprostol (cytotec) can be used either vaginally or orally to induce vaginal delivery of fetus
- -pitocin can be used after 20 weeks
Recurrent premature dilation of cervix(incompetent cervix)
-passive and painless dilation of the cervical os without labor or contraction of the uterus (incompetent cervix) may occur in the 2nd trimester or early in the 3rd trimester.
Which women are never diagnosed with recurrent premature dilation of cervix or incompetent cervix?
primips...has to be REcurrent
When are cervical cerclages placed?
11-15 weeks, not after 25 weeks
In ectopic pregnancies 95% implant in the ________.
- Uterine (fallopian) tubes
- 0.5% in the ovary
- 1.5% in the abd cavity
- 0.3% in the cervix
What is the leading cause of 1st trimester maternal death?
- Ectopic pregnancy
- *these can bleed for a long time before it is noticed
With ectopic pregnancy, vaginal bleeding looks like?
Dark red or brown abnormal vaginal bleeding (50-80% of women).
Why may a woman with an ectopic pregnancy have referred shoulder pain?
From diaphragmatic irritation caused by blood in the peritoneal cavity.
What is Cullen sign?
Ecchymotic blueness around the umbilicus indicating hematoperitoneum (blood in the abd)
List the treatments for ectopic pregnancy
- With 1st trimester bleeding and abd pain suspect ectopic preg and undergo screening to either confirm or rule out the possibility.
- Lab studies: progesterone and hCG levels with 48 hour recheck
- Ultrasound: either abd or transvaginally to confirm intrauterine pregnancy
- Removal by salpingostomy: residual tissue dissolved with a dose of methotrexate given postop if ruptured or used in a single dose IM if unruptured
In ________ the placenta is implanted in the lower uterine segment near or over the internal cervical os.
What are the 3 types of placenta previa?
- Complete: internal os is entirely covered by the placenta when the cervix is fully dilated. (3rd trimester the placenta covers the os)
- Partial (marginal): incomplete coverage of the internal os. Only an edge extends over the os but during dilation many extend onto the os. (distance is 2-3cm & does not cover)
- Low lying: placenta is implanted in the lower uterine segment but does not reach the os.
What increases risk of placenta previa?
- Previous placenta previa
- previous cesarean birth
- D&C for miscarriage or abortion
- possibly endometriosis
- Risk increases with multiple gestation,
- Maternal age >35
- African or Asian ethnicity
What are S&S of placenta previa?
- Painless uterine bleeding (70%)
- Vaginal bleeding with uterine activity (20%)
- Vaginal bleeding after 20 weeks
- Bright red bleeding that can be small at first and will stop with clotting but can reoccur at any time
- Abd usually soft, relaxed, nontender with normal tone
- Fetus is breech, oblique or transverse due to abnormal placental placement
Complications of placenta previa?
- PTL and birth
- surgery related trauma
- abnormal placental attachments (placenta accrete)
- postpartum hemorrhage
Why are woman with placenta previa at risk for postpartum hemorrhage?
There are large vascular channels in the lower uterine segment and diminished muscle content. The natural mechanism to control bleeding is absent in the lower segment so hemorrhage may occur even if the uterus is firm and contracted. ...the fundus is what contracts, not the lower portion.
Premature separation of the placenta is the detachment of part or all of the placenta from its implantation site. This is a serious event that accounts for significant maternal and fetal morbidity and mortality.
________ is most commonly caused by maternal HTN.
S&S of abruption placentae
- Depending if it is a complete or partial separation, bleeding may be into the uterus or vagina.
- Typically vaginal bleeding,
- VERY PAINFUL,
- "port wine" stained amniotic fluid,
- uterine contractions
- hypertonus (board like abd),
- uterine tenderness
- abnormal FHR patterns or fetal death.
________ appears purplish and copper colored, ecchymotic and contractility is lost.
- Couvelaire uterus
- shock may occur out of proportion to obvious bleeding
- decreased H&H
- clotting factors develop in 10-30%
- Apt test positive for blood in amniotic fluid
What is the leading cause of maternal death?
What length is considered short for a cervix?
______ should be suspected with any woman who has sudden onset of intense localized uterine pain with or without vaginal bleeding.
Cervical cerclage is placed at _____ weeks. The woman is put on bed rest, no more than ___ minutes standing, no intercourse and no heavy lifting. Removed at ____weeks.
- placed at 11-15 weeks
- 90 min standing
- removed at 37
Cervical cerclage is not placed after ____ weeks.
25 weks gestation
Abruption placenta is most commonly caused by ____
Post partum hemorrhage is defined as a loss of ____ mL or more of blood after a vaginal birth and _____mL or more of blod after cesarean birth.
PPH meds to hlep uterus contract.