Complications of the Antepartal Period

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Complications of the Antepartal Period
2010-12-05 13:08:52
Ob antepartum

OB Exam antepartal
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  1. Ultrasound:
    Def: sound waves having a frequency >20,000 Hz

    2 types: TransVaginal ultrasound & TransAbdominal ultrasound
  2. TransVaginal Ultrasound (TVS)
    • Used primarily in 1st trimester
    • -Evaluates pelvic anatomy
    • -Assess developing embryo/fetus for # and size
    • -Locate the placenta
    • -Screen for fetal & placental anomalies
    • -Establish gestational age

    • *Do not need a full bladder
    • *Place in lithotomy pos. (stirrups)
    • *Latex covering
  3. TransAbdominal Ultrasound
    • Fetal viability
    • Number, position, gestational age
    • Fetal growth patter
    • Anomaly scan
    • Amniotic fluid volume
    • Placental location and maturity
    • Assessment of fetal well-being
    • *Gender is not 100%
    • *Full bladder can give a better pic
  4. Chorionic Villi Sampling (CVS)
    • Definition: Biopsy of fetal portion of placenta for fetal genetic studies
    • Indications: Age >35, frequent SAB, chromosomal anomalies/defects
    • Advantages: Done at 10-12 weeks, results in 2 weeks
  5. CVS Complications:
    • Vaginal spotting/bleeding
    • Spontaneous abortion
    • Rupture of membranes
    • Infection/chorioamnionitis
    • Possible limb anomalies (missing!)

    *Pelvic rest afterwards (no SEX)
  6. Maternal serum Alpha Fetoprotein (MSAFP) and Quad Screen:
    • Definition: measures MSAFP, HCG, estradiol, diameric Inhibin-A
    • Findings:
    • -Increased levels of MSAFP: neural tube defects, multiples, dates wrong
    • -Decreased levels of MSAFP and Increased HcG: Downs syndrome (Trisomy 21)
    • -Decreased MSAFP, estriol, & HcG: Trisomy 18

    *Not very accurate/specific, done around weeks 16-18
  7. Amniocentesis: when it's done/results
    • Done at 15-20 weeks
    • Results in 2 weeks
    • Prenatal diagnosis
  8. Indications for Amniocentesis:
    • Maternal age >35
    • Parent or previous child with chromosomal abnormalities
    • Family history of NTD's (Neural tube defects)
    • Fetal abnormalities per Ultrasound
    • Women with Xlinked chromosomal disorder
    • Fetal hemolytic disease
    • Fetal LUNG maturity
    • Evaluate alpha fetoprotein

    *Might do before c-section to evaluate lungs of fetus
  9. Complications of Amniocentesis:
    • OCCURS IN <1%
    • Pregnancy loss=0.5%
    • Maternal hemorrhage
    • Infection
    • Preterm labor
    • Placental abruption
    • Damage to intestine or bladder
    • Amniotic fluid leakage or embolism
    • Risk to fetus: death, hemorrhage, infection, direct injury

    *If RH-, needs Rogam for this procedure
  10. Amniocentesis Results:
    • Lecithin to sphingomyelin (L/S) ratio
    • Phosphatidylglycerol (PG) level [Both done for lung maturity]
    • Shake test
    • Karyotype
    • RH isoimmunization status
    • Alpha fetoprotein levels
    • Creatinine levels

    *Position in left lateral tilt to prevent fainting
  11. Biophysical profile
    • Definition: non-invasive dynamic assessment of a fetus that is based on acute and chronic markers of fetal disease.
    • Assess:
    • Fetal tone, fetal movements, fetal breathing movements, amniotic fluid volume (AFI=amniotic fluid index), Non stress test (NST)-
    • Scoring: 8-10-low risk for perinatal asphyxia, 4-6: possibly abnormal-repeat within 24 hrs, <6 & low amniotic fluid=delivery indicated and high risk for perinatal asphyxia.

    *Accurate indicator of impending fetal death!!!!!!!
  12. Non Stress Test (NST):
    • Advantages: non invasive, relatively inexpensive, no side effects, immediate results, a GOOD indicator of fetal well-being, Can be done regularly
    • Disadvantages: High # of false-positive results (fetal sleep, medications, fetal immaturity); NOT a good predictor of poor fetal outcomes
    • Indications: PIH (pregnancy induced hypertension), diabetes, placenta previa/abruption, postmaturity, decreased fetal activity.
  13. Results of Non Stress Test:
    Reactive NST: 2 or more FHR accelerations of 15bpm lasting at least 15 seconds over a 20 minute period

    Non reassuring (non reactive) NST: If these criteria are not met within 40 minutes
  14. Contraction stress test (CST)
    • Indications: Fetus at risk-IUGR, postdates, DM, non reactive NST, BPP <6
    • Contraindications: 3rd trimester bleeding, risk of PTL(preterm labor), PROM, multiple pregnancy, placenta previa, incompetent cervix
    • Test procedure: could induce labor!
  15. Contraction stress test findings:
    Reassuring (NEGATIVE): no late decelerations occur with 3 contractions in 10 minutes

    Non reassuring (POSITIVE): late decels with at least 2 of the 3 contractions

    Suspicious (EQUIVOCAL): late decels with 1 of 3 contractions OR there are contractions q2 minutes in 10 min.
  16. Contraction stress test COMPLICATIONS:
    • Fetal distress
    • hyperstimulation of uterus
  17. Fetal Kick Counts:
    • Used in all high risk pregnancies >28 weeks. Measured by date, hour of day and # of movements
    • <10 movements in 2 hours or any change=emergency...CALL 911
  18. External Cephalic Version (ECV)
    • Turning the baby from a breech position to "head down" position.
    • Can cause fetal distress
    • Do ultrasound, IV-medications (Trabutaline-relaxes uterus but INCREASES HR-jitttteryyyy)
  19. Contraindications to external cephalic version (ECV)
    • Maternal problems: uterine anomalies, PIH or 3rd trimester bleeding
    • Pregnancy problems: ROM, oligohydramnios, polyhydramnios or placenta previa
    • Previous c-section or other uterine surgery
    • Multiples
    • Non reassuring FHR
    • Fetal abnormalities (IUGR, nuchal cord)

    *Can hear the FHR right about the umbilicus when baby is breech
  20. Pregnancy risk factors (3 main ones):
    • 1. Age: <16 or >35
    • 2. Parity: >8 years since last pregnancy, <3 months since last birth, >5 previous births
    • 3. Poor OB history: 2 or more previous preterm infants, 2 or more consecutive miscarriages, 1 or more stillbirths, 1 or more infants with gross anomalies, birth defects, history of dystocia (difficult labor), poor self care practices
  21. Pregestational-Cardiac Disease
    • Definition: impaired cardiac function
    • Pregnancy outcome: depends on degree of cardiac compromise
    • Greatest risk: cardiac output increases 30-50% by midpregnancy 28-32 weeks
  22. Classes of cardiac disease:
    • Class I: uncompromised
    • Class II: slightly compromised
    • Class III: Markedly compromised
    • Class IV: inability to perform any physical activity without discomfort
    • *Class III and IV=almost complete bed rest!!!
  23. Complications of cardiac disease on pregnancy:
    • Congestive Heart Failure: most common complication of HD during pregnancy
    • Bacterial Endocarditis-infections!
    • Decreased Placental Function: IUGR, fetal distress, preterm delivery
  24. Management of cardiac disease:
    Close medical supervision: rest-avoid exertion, limited sodium intake, prophylactic antibiotics (PCN)-for any invasive procedures including birth!

    Medications: Digitalis (Increases contractility of heart, don't give when HR is <60), Heparin (if anticoagulant indicated-doesn't cross placenta), furosemide (lasix)
  25. Signs of cardiac decompensation
    • Dyspnea on exertion or at rest
    • Increasing fatigue
    • Tachycardia or irregular pulse
    • Diastolic murmur at heart apex
    • Moist cough with/without hemoptysis
    • Palpitations
    • edema(pedal, pitting, generalized, & pulmonary)
    • Nail bed and circumoral cyanosis
    • rales at lung bases
  26. Diabetes Mellitus in pregnancy
    • Definition: relative or complete lack of insulin secretion AND/OR increased resistance to insulin
    • Early pregnancy: anabolic state-glucose use & glycogen storage increase by mother and fetus
    • 2nd half of pregnancy: increased insulin resisitance d/t increased human placental lactogen (HPL) which increases circulating glucose for fetal use & increases demand on maternal pancreas to produce more insulin.
    • Fetus produces own insulin but obtains glucose from mother across placenta; the amount of glucose in maternal circulation stimulates the fetal pancreas to produce more insulin
  27. Functional classification of DM in pregnancy
    • Gestational diabetes
    • Preconceptional diabetes:
    • *without complications: Type 1: insulin dependent; Type 2: non insulin dependent
    • *With complications: advanced retinopathy, nephropathy, autonomic neuropathy, coronary artery disease
    • *Significant problems for placenta bloodflow*
  28. Gestational diabetes:
    • Definition:
    • *any degree of glucose intolerance that has its onset or its first diagnosis in pregnancy
  29. Diabetes in pregnancy: by trimesters
    1st trimester: Decrease insulin needs, hyperglycemic=teratogenic

    2nd/3rd trimesters: Increase insulin needs

    After delivery: Decreased insulin needs
  30. Risk factors for DM:
    • Family history of DM
    • HIstory of previous stillbirth or SAB's
    • Previous baby with congenital anomalies
    • Previous baby >9lbs
    • Maternal obesity
    • recurrent yeast infections
    • recurrent glycosuria
    • Multiparity, hydramnios (too much fluid), and HTN
  31. Diagnostic tests for DM:
    • Fasting blood glucose at 28 weeks gestation
    • Results at 1 hour
    • -normal=<130 mg/dl
    • -If >130, do 3 hr 100g GTT fasting
    • Diagnose Gestational DM if 2 or more elevated levels
  32. Effects of DM on pregnancy and fetus
    • Effects are r/t the degree of control of blood glucose levels b/t 70-120 mg/dl & degree of vascular involvement
    • Long term glucose control: glycosylated hemoglobin (HbA1C)-measures % of Hbg with glucose bound to it, levels depend on amount of glucose available during the red blood cell's 120 day lifespan

    *In labor, try to keep blood sugar <100
  33. Complications of DM in pregnancy: (more common with type 1 DM)
    • 1. Maternal hydramnios (Increase in amniotic fluid)
    • 2. Pregnancy induced hypertenstion (PIH)
    • 3. infection
    • 4. Maternal Hypoglycemia
    • 5. Spontaneous abortion
    • 6. Preterm labor
    • 7. Intrauterine growth restriction (IUGR)= decreases blood supply which increases risk for stillbirth
    • 8. Worsening retinopathy
  34. *increase in fetal urine output=increase volume of amniotic fluid in mothers!!!! NOT GOOD
  35. Fetal/newborn complications/effects of DM
    • Increase incidence of stillbirth (usually after 36 weeks)
    • fetal congenital anomalies (cardiac, CNS)
    • Macrosomia (large body)
    • hypoglycemia
    • hyperbilirubinemia
    • Delayed fetal lung maturity=RDS (Respiratory distress syndrome)-bc of increase fetal insulin
    • Fetal asphyxia and death
  36. Teaching/management of DM in pregnancy
    • Understanding of disease process (s/s of hypoglycemia, ketoacidosis)
    • Diet/exercise
    • Medications-insulin use
    • Home monitor glucose levels/urine for ketones
    • Clinic appts q1-2 weeks
    • Fetal testing
  37. Fetal testing in diabetic pregnancy
    • Maternal serum alpha fetoprotein @ 16-18 weeks
    • Ultrasound (anomalies, amniotic fluid volume, size)
    • Non stress test-NST-weekly from 28-32 weeks
    • Fetal Kick counts
    • Biophysical profile (BPP)
    • Amniocentesis for lung maturity
    • Induction of labor
  38. Teaching for pregnant diabetics:
    • risks to self and newborn: Increase c-section, longer hospitalization, NICU for infant, risk of stillbirth
    • Postnatal DM: 35-50% of women with gestational DM develop DM within 15 yrs
    • Should be tested at 6 weekds pp with GTT
  39. Factor V Leiden Mutation
    • Autosomal dominant blood disorder: more common in women of European descent
    • Causes activated protein C resistance resulting in venous thromboembolic events (VTE)!!
    • Pregnancy-associated with 5-6x increased risk of VTE
    • Heterozygous (1 copy)=5-10x increased risk for VTE
    • Homozygous (have 50-100x risk)
    • complications: HTN, placental abruption, SAB, intrauterine fetal demise, IUGR
    • Prophylaxis: heparin therapy
  40. Spontaneous Abortion (SAB): definition and causes
    • def: premature expulsion of fetus <20 weeks or <500 grams
    • Increased risks: >35 years old, systemic diseases, hx of >3 SAB's, tobacco and alcohol use
    • CAUSES:
    • -Fetal factors: defective embryological development, faulty ovum implantation
    • -Placental factors: premature seperation of normally implanted placenta, abnormal implantation, abnormal platelet function
    • -Maternal factors: infection, sever malnutrition, reproductive system abnormalities, endocrine problems, trauma, drug ingestion
  41. Spontaneous abortion: signs and symptoms
    • Vaginal bleeding/spotting in 1st 20 weeks
    • May be lower abdominal cramping/dull backaches
    • ROM: tissue or clot-like material from vagina
    • May have thinning cervix, Increased cervical dilation
    • Fever
    • malaise, s/s of infection
    • grief reaction
  42. Complete abortion, missed, habitual, septic
    Complete: all of fetus and placental material has been expelled from uterus before 20 weeks gestation

    Missed: death of fetus with retained products of conception (POC)

    Habitual: >3 or more consecutive pregnancies

    Septic: SAB or TAB complicated by a pelvic infection, usually begins as endometritis and may spread, primary cause of maternal mortality in developing countries
  43. SAB diagnosis and management
    Diagnosis: falling HcG levels=death of fetus, by ultrasound

    Management: pelvic rest (nothing in VAG), CBCs, monitor VS, assess bleeding/cramping/pain, prepare for surgery prn, medical management: prostaglandins-misoprostel, Rhogam if RH negative
  44. TORCH Infections Definition:
    • T-Toxoplasmosis
    • O-Other: gonorrhea, syphilis, varicella, hep B, GBS, HIV
    • R-rubella
    • C-cytomegalovirus (CMV)
    • H-herpes
  45. TORCH infections: risk factors
    • pregnancy related or physiologic (UTI)
    • exposure to teratogenic infections
    • STIs
    • Children at daycare (cmv)
    • cat litter exposure (toxo)
  46. TORCH infections: diagnostic tests and Signs/symptoms
    Diagnostic tests: Screen throughout pregnancy-torch titer, IGM-recent infection (igM doesnt cross placenta) so IgM in baby=strongly suggestive of exposure, IgG-past.

    S/S: asymptomatic or vague, nospecific s/s (fatigue, enlarged lymph nodes, fever, mono-like s/s, genital infection, cervical inflammation, rash)
  47. TORCH infections: Toxoplasmosis
    • Single celled parasite called toxoplasma gondii
    • Mostly asymptomatic
    • Transmission: Transplacental, ingestion of cat feces (litter box, gardening), eating/contact with contam. raw or partly cooked meat esp pork lamb venison, unpastuerized goat milk, drinking contaminated water, receiving infected organ transplant or blood transfusion (rare)
  48. TORCH infections: toxoplasmosis s/s, treatment, fetal effects
    • S/S: flu-like, swollen lymph nodes, incubation periods is 10 days
    • With active maternal infection is 40% risk fetus will get infection
    • Treatment: erythromycin, sulfadiazine
    • Fetal effects: SAB, fetal hydrocephalus, blindness, deafness, mental retardation
  49. TORCH infections: gonorrhea
    • Can be transmitted to newborn during birth!
    • Pregnancy/fetal effects: SAB, preterm delivery, PROM, opthalmia neonatorum (blindness)
  50. TORCH infections: Chlamydia
    • Transmitted to newborn during birth
    • Pregnancy/fetal effects: PROM, preterm labor, low fetal birth weight, fetal conjunctivitis, pneumonia, opthalmia neonatorum, chronic otitis media
  51. TORCH infections: Varicella
    • Increase risk varicella pneumonia if acquired during pregnancy
    • Fetal complications: risk of congenital varicella syndrome (1st trimester)-skin scarring, small head, eye problems, LBW, small limbs, retardation. If contracted within 5 days before and 2 days after delivery: newborn at risk for disseminated varicella infection=newborn mortality

    Treatment: antiviral meds: acyclovir and varicella zoster immunoglobulin (VZIG) for both women and newborn
  52. TORCH infections: Syphilis
    • Treponema pallidum
    • Transmitted: either in utero or at delivery
    • If mother is treated before 18th week, usually not transmitted to fetus
    • Preg/fetal effects: SAB, neonatal infection, fetal death, preterm delivery, neonatal CNS, dental, corneal disorders
  53. TORCH infections: Group B strep
    • Group B streptococcus (GBS): leading cause of neonatal sepsis. 40-70% pass bacteria to newborns during birth, only 1-2% actually get the infection
    • Recommended screening: vaginal swab at 36 weeks; Rx with PCN in labor to decrease rate of transmission
    • Preg/fetal effects: PTL, PROM, chorioamnionitis, UTI, PP sepsis in mom, stillbirth
    • Neonatal effects: sepsis, pneumonia, RDS, apnea, shock; meningitis
  54. TORCH infections: Hepatitis B
    • If acute infection in 1st trimester: 10% transmission, if in 3rd trim: 80-90% transmission!
    • If + or unknown maternal hepatitis status: newborn needs hepB vaccine and hepB immunoglobulin (HBIG) within 12 hours of birth
    • Preg/newborn effects: PTL, LBW, fetal death
  55. TORCH infections: CMV (cytomegalovirus)
    • (Herpes virus family)
    • Virus most frequently transmitted during pregnancy and most likely to cause neonatal disease
    • Maternal S/S: often asymptomatic, flu-like
    • Diagnosis: viral culture-CMV antibodies=recent infection
    • Transmission: respiratory droplet (hospitals, daycares)
    • No effective prevention or treatment

    Preg/fetal effects: fetal/newborn death, retardation, deafness, hydrocephalus, microcephaly, learning disabilities. 90% of infected fetuses are asymptomatic at birth: develop s/s within 1 year!
  56. TORCH infections: HIV
    • Fetal/newborn HIV/AIDS:
    • Vertical transmission=infection via placenta (increased risk with inflammation of fetal membranes, maternal drug use, prolonged ROM)
    • Also transmitted via contact at birth, breast milk
  57. HIV treatment regimen:
    • 3 part ZDV (zidovudine, AZT, or retrovir)
    • starting at 14-34 weekds
    • reduces risk of transmission of fetus by 70%
    • IV ZDV in labor
    • Newborn: ZDV liquid form x6weeks
  58. TORCH infections: Rubella
    • Def: german measles/3day measles
    • S/S: fever, rash, cold sxs, mild lymphedema
    • Transmission: by respiratory droplets: highly infectious
    • Risk factors: contact with young children
    • No treatment
    • No immunization during pregnancy: need to postpartum-avoid pregancy for 3 months!
  59. TORCH infections: Rubella diagnosis, fetal effects
    • Diagnosis: screening early, IgG antibodies (titir of 1:10 or >=immune to rubella, titer of 1:8 or <=minimall/no immunity)
    • Fetal/neonatal effects of 1st trimester:
    • -in 1st 8 weeks, 80% with birth defects
    • -SAB, fetal blindness, hearing loss, heart disease, retardation, death
    • Fetal/neonatal effects of 2nd trimester:
    • -deafness, congenital cataracts, heart disease, liver impairment with jaundice, blood formation disorders (anemia thrombocytopenia)
  60. TORCH infections: Herpes
    • Initial outbreak: 2-7 days after exposure
    • Antibody test: 3-4 months after initial exposure
    • Antivirals used during 3rd trimester to decrease risk of transmission (Valacyclovir or Valtrex)
    • C-section recommended if visable lesions
    • Fetal effects: SAB, PTL, IUGR, neonatal infections of skin, eyes, nose, liver, CNS, seizure, jaundice
  61. Parvo B19 virus
    • common "fifth disease": mild rash in children-lasts 7 days and provides lasting immunity "slapped cheek", rash on face trunk and limbs
    • Adults with no immunity: may develop rash/joint pain for a week to months
    • More common in 1st half of pregnancy, severe fetal anemia, SAB
  62. Listeriosis
    • Pregnant women 20x more likely to contract than other adults
    • Mild flu-like s/s-stiff neck, confusion, loss of balance, convulsions
    • DX: blood test
    • Rx: antibiotics
    • Fetal effects: SAB, death, PTL, infection
    • PREVENTION: do not eat hot dogs/meat unless reheated until steaming hot, soft cheeses, refridgerated smoked seafood, do not drink raw unpasteurized milk/cider
  63. Preterm labor
    • Contractions between 20-37 weeks
    • Causes:
    • -maternal:CV and renal disease, DM, PIH infections, abdominal surgery, incompetent cervix, PROM.
    • -fetal: infection, hydramnios, multiple pregnancy, death
  64. Maternal risk factors for PTL
    • <18 or >35
    • Hx of preterm labor
    • Multiple pregnancy
    • Hydramnios
    • smoking
    • poor hygeine/nutrition
    • infection
    • uterine fybroids
    • sexual acitivity
    • drug use, dehydration
  65. Signs/symptoms of PTL
    • Rhythmic uterine contractions
    • Cervical dilation and effacement
    • Possibly ROM
    • Expulsion of musuc plug, bloody show
    • backache
    • feeling that "something is not right"
    • pelvic pressure
    • increase in vag discharge, abd cramping
    • Fetal fibronectin (fFN) not normally in fetal membranes and decidua: +fFN b/t 18-36 weeks, -fFN: very low risk of birth within 7 days

    *If >4 contractions in 1 hr=calll!!!!!!
  66. Management of PTL
    • Teaching of s/s of PTL & actions to be taken
    • Medical: assess s/s labor, cervical dilation and effacement, status of membranes, bloody show, sterile spectrum exam for amniotic fluid
    • -vag cultures r/o infection
    • -monitor uterine activity and fetal status
    • -VS, bedrest, side lying position
  67. Medications for PTL
    • Tocolytic meds:
    • -Ritodrine IV or PO
    • -Terbutaline sulfate IV, SQ, PO: beta adrenergic agonist, side effects: increase HR, decrease hyperglycemia
    • -Magnesium sulfate IV: cns depressent, side effects: warm, affects calcium, decrease respirations
    • -Nifedipine PO, SL: calcium channel blocker
    • -Indomethacin PO: prostaglandin synthetase inhibitors (stopped using!?)
    • Steroid therapY: stimulates lung maturity; 24-34 weeks, 24-48 hrs before delivery (betamethasone)
    • Antibiotics
  68. Pregnancy Induced Hypertension (PIH)
    • Def: HTN disorder of pregnancy developing after 20 wks
    • -gestational htn; no proteinuria/edema
    • -preeclampsia: htn >140/90 or increase >30mm hg systolic or >15mm hg , proteinuria, edema
    • -eclampsia: preeclampsia progressed to tonic-clonic seizures
  69. Risk factors/contributing factors for PIH
    • Family hx of HTN or previous hx of PIH
    • poor prenatal care
    • weight extremes and age extremes
    • primigravida
    • multiples
    • preexisting DM, HTN or renal disease
    • hydatiform mole
    • RH incompatibility
    • Infection, exposure to toxins
  70. Pathophysiology of Preeclampsia "Toxemia"
    • Unknown cause
    • Loss of resistance to angiotensin II-decrease prostacyclin (a vasodilator prostaglandin) which increases effect of thromboboxane (vasoconstricting prostaglandin)
    • Loss of normal vasodilation of uterine arterioles +maternal vasospasm +increase peripheral vascular resistance=decrease in placental perfusion
    • Decrease in renal perfusion=decrease urine output, increase serum creatine, BUN, uric acid, resulting in sodium retention (edema)
  71. Pathophysiology of Preeclampsia "toxemia"
    • Sodium retention=increase in extracellular volume, increase sensitivity to angiotensin II, edema
    • Stretching of glomerular endothelial walls-escape of protein molecules=decrease serum albumin and proteinuria
    • Decrease serum albumin concentration=decrease plasma colloid osmotic pressure=edema
    • Decrease intravascular volume=Increase blood viscosity and increase hct
  72. Cenral Nervous sytem effects
    • Increase intracellular sodium and decrease intracellular potassium levels=hyperreflexia
    • Cerebral vasospasm=headaches
    • Cerebral edema & vasoconstriction=seizures
  73. Signs and symptoms of mild preeclampsia
    • BP 140/90 or increase systolic BP of 30mm hg/15 mm diastolic twice, 6 hrs apart.
    • Proteinuria-trace to 1+,2+
    • Mild-mod pretibial edema with weight gain of 5 lb/week
  74. Severe preeclampsia
    • BP> 160/110
    • Proteinuria 3+, 4+ or >4-5 grams in 24 hrs
    • Sudden large weight gain, facial edema, pitting pretibial edema
    • CNS irritability (headache, hyperreflexia, retinal edema, dyspnea, epigastric pain, N+V)
    • Labs: Increase hct, liver enzymes (ALT, AST), BUN, creatinine, uric acid
  75. Eclampsia
    • BP >160/110
    • Grand mal seizures, coma, stroke, fetal and maternal death
    • -cerebral hemorrhage, pulm edema, CHF
  76. Eclampsia management
    • Side lying bedrest
    • quiet, calm environment
    • high protein diet, no salt restriction
    • Monitor VS, edema, lung sounds, DTR (deep tendon reflexes), renal function (I&O), fetal status
    • emergency meds/equip at bedside
  77. Primary medication for preeclampsia
    • Magnesium Sulfate:
    • Therapeutic blood levels: 5-8mg/dl
    • Assess urine output
    • Assess for TOXICITY!!! (depressed DTRs, R<12-14/min, flaccid muscles, over-sedation, confusion
    • Extreme thirst
    • Hypotension, circulatory collapse
    • ANTIDOTE TO magnesium sulfate: calcium gluconate!

    *Risk for postpartum hemorrhage...boggy uterus*
  78. Hemolytic disease of fetus and newborn
    • Def: immune reaction by mother's blood against the blood group factor on fetus' red blood cells
    • ABO: mother O Fetus A,B
    • -20% of pregnancies
    • RH
  79. Pregnancy with Rh positive fetus
    **NOT normal for those (+'s) to get into mother's circulation
  80. Pregnancy with Rh positive after delivery
    After delivery, more is leaked into mother
  81. After pregnancy, antibodies start to form:
    Antibodies starting to form after pregnancy=NOT GOOD
  82. Subsequent pregnancies with an RH+ fetus
    Antibodies are trying to attack new fetus=not good! TREAT WITH RHOGAM/prevent. works up to 72 hours
  83. Fetal effects of RH sensitization
    • Hemolysis of fetal rbc-immature rbc production (erthryoblastosis fetalis)
    • Jaundice, marked fetal edema, CHF
    • Kernicterus, permanent neuro damage
  84. Diagnosis of RH disease
    • Blood group testing
    • Antibody screening (indirect Coombs test)
    • Direct coombs test on infant after birth
  85. Management of RH disease
    Unsensitized mother: Rhogam at 28 weeks and within 72 hrs of birth. Rhogam is an anti RH gamma globulin that prevents production of maternal antibodies to fetal cells.

    Sensitized mother (isoimmunization): close fetal monitoring, including amniocentesis, percutaneous umbilical cord blood sampling, indirect coombs test
  86. Hyperemesis Gravidarium
    • Def: persistant servere vomiting beyond 1st trimester, resulting in electrolyte, metabolic & nutritional imbalances.
    • Causes: ?Increase in HcG, ?Helobacter pylori. Increase incidence with primigravidass, multifetals, & women with psych disorders
  87. Hyperemesis Gravidarium: s/s, management, complications
    • S/S: electrolyte imbalance/acidosis (ketosis, confusion, drowsiness, muscle weakness)
    • Management: Hospitalization, IV, TPN prn, medications (zofran)
    • Complications: dehydration, electrolyte imbalance, severe weight loss, metabolic alkalosis [LAB finding: hypokalemia!]
  88. Hydatiform Mole: Definition, causes, s/s, diagnosis, manangement
    • Def: developmental placenta anomaly that converts chorionic villi into a mass of clear vesicles.
    • Causes: Unknown patho, neoplastic process, more common in Asians!
    • S/S: Increase uterine size, excess N+V, intermittent bright red/brownish vag bleeding by 12 weeks, very high hCG
    • Diagnosis: ultrasound, s/s of hyperthyroidism (weight loss, bulge eyes, hair falling out)
    • Management: D&E/hysterectomy, pelvic exam and HCG monitoring for 1 year bc malignant disease can develop, avoid pregnancy for 1 year!, chemo..
  89. Ectopic pregnancy
    • Def: embryo implants anywhere except uterine endometrium
    • Causes: conditions that alter ovum passage through tubes (Decrease incidence with combined ocps, increased in last 30 years bc of IUD's, STIs and surgery's)

    **It can implant anywhere: tube, in the muscle, cervix, ovary, ABDOMEN!!
  90. Ectopic pregnancy risk factors and s/s:
    • Risk factors: Scarring, adhesions (use of IUD, tubal surgery), previous ectopic pregnancy, tubal ligation
    • S/S: Last menstraul period consistant with possible pregnancy, may be asymptomatic or dizziness, sharp abd pain(often unilateral), referred shoulder pain, vag bleeding, adnexal mass tenderness (pain from "tube"), s/s of shock
  91. Ectopic pregnancy: Diagnosis and management
    • Diagnosis: Beta HcG confirms pregnancy; vaginal u/s after 4-5 wks confirms extrauterine pregnancy, pelvic exam.
    • Management: Monitor VS, bleeding, pain; prepare for surgery-lapratomy with ruptured tube, laparoscopy without.
    • Medical management: methotrexate (only if caught early enough) 4-5wks, Watch for Cullen's sign: blood in perineum (blueness around umbilicus)
  92. Incompetent cervix: definition, causes, management
    • Def: painless effacement and dilation of cervix usually in 2nd trimester, often diagnosed by repetitive 2nd trimester losses or by transvag ultrasound
    • Causes: many factors; abnormal cervix, biochemical alterations, uterine malformations (bicornuate uterus, pic above).
    • Management: elective cerclage at 14-16 wks, suture and tie uterus. Education r/t s/s of preterm labor, bedrest/trendelenberg position (puts pressure off cervix), hospitlization, remove suture with s/s of labor
  93. Iron deficiency anemia in pregnancy: definition, causes, risk factors
    • Def: Hgb<10 g/dL ; Hct<35% during 2/3 trimester, common
    • Causes: nutritional deficiences, acute and chronic blood loss
    • Risk factors: previous preprego anemia, poor nutrition, multiples, smoking, alcohol
  94. Iron defeciency anemia: s/s, management, complications
    • S/S: excess fatigue, HA, tachy, brittle fingernails, smooth red shiny tongue
    • Management: instruct about sources of iron and supplementation. iron best absorbed on empty stomach, high fluids/fiber to avoid constipation, vit C increases absorption, expect black stools, milk inhibits absorption
    • Complications: PTL or birth, poor wound healing, infection, cardiac failure in labor, Increase risk for postpartum hemorrhage
  95. Sickle cell anemia in pregnancy: def, risk factors, s/s, maternal/fetal risks, manangement
    • Def: autosomal recessive disorder-adult Hb A is abnormally formed hemoglobin S. Hgb S causes rbcs to be crescent shaped which clogs capillaries in spleen, bone marrow and placenta
    • risk factors: Africans, central america, caribbean...
    • S/S: Hx of frequent illness, acute reoccuring episodes of tissue, abd, and joint pain, appears unnourished, long thin extremities. *Antibiotics to prevent infections**
    • Maternal risk: vaso-occlusive crisis-infection. Fetal risk: IUGR, prematurity, death.
    • Manangement: Increase hydration, avoid infections, seek immediate treatment
    • Placenta previa:
    • -low lying: placenta is close to opening of for bleeding!
    • -Partial: placenta is partially covering opening
    • -Complete: entire placenta is blocking baby=c-section!
  97. Predisposing factors for placenta previa
    • Multiparity
    • Increase maternal age
    • Previous c-section or uterine incisions
    • Prior placenta previa
    • closely spaced pregnancies
    • uterine tumors
    • previous induced abortions
  98. S/S for placenta previa:
    • Bright red, PAINLESS BLEEDING, after 20th week of pregnany
    • Abd soft, non tender; uterus relaxes b/t contractions
    • FHR stable, fetal presenting part unengaged
    • Diagnose: ultrasound
  99. Nursing management for placenta previa:
    • NO CERVICAL EXAM with any prego woman with vaginal bleeding!!-you can stick fingers thru placenta..hemorrhage!
    • Monitor VS/bleeding; observe for shock
    • Monitor FHR
    • Blood work, IV, strict bed rest
    • If preterm..giver betamethasone so lungs develop
    • Complications: hemorrhage, fetal distress, IUGR, C/S, preterm birth, PROM
  100. Other placenta abnormalities: accreta, increta, and percreta
    • Placenta accreta: placenta attaches too deep in uterine wall but does not penetrate the uterine muscles.
    • Increta: placenta implants into uterine muscle.
    • Percreta: placenta penetrates thru entire uterine wall and attaches to another organ, such as bladder!!
  101. PLACENTA ABRUPTION: definition
    • Premature seperation of a normally implanted placenta during the 2nd half of pregnancy
    • Medical emergency=risk of maternal hemorrhage and fetal death, 10-30% develop clotting defects (DIC)
  102. Risk factors for Placental abruption:
    • Maternal HYPERTENSION (44%)
    • Cocaine abuse
    • Abdominal trauma
  103. S/S of placental abruption:
    • Concealed or external dark red bleeding
    • Uterus firm-board-like, uterine outline possibly enlarging or changing shape
    • FHR present or fetal distress
    • Couvelaire uterus (blood gets pushed back into uterus...pp hemorrhage!)
  104. Placental abruption: diagnosis, complications, management
    • Diagnosis: U/S, CBC, coagulation profile
    • Complications: severe hemorrhage, shock, renal failure, DIC, maternal and fetal death
    • Management: monitor VS, bleeding, FHR activity, degree of abd rigidity, signs of shock, NO VAG EXAM or anything that would stimulate uterine activity, abd girth
  105. HELLP syndrome: what does it stand for and s/s:
    • H-hemolysis
    • E-elevated
    • L-liver enzymes
    • L-low
    • P-platelets

    S/S: epigastric or RUQ pain, N+V, flu-like s/s, history of malaise for past few days, sig weight gain with edema, HTN, increase D Dimer test (used to r/o throbotic disease)
  106. HELLP syndrome: causes/risk factors, management, complications
    • causes/risk factors: HTN/preeclampsia, thrombocytopenia, obesity, multiparity, hx of high risk pregnancies
    • Management: bedrest, monitor kidney/liver function, platelets (most reliable indicator of syndrome), evaluation of uteroplacental insufficiency: kick counts, NST, BPP, mag sulf infusion, prompt delivery of infant >32 wks
    • complications: IUGR, RDS, perinatal mortality worse than maternal, Increase risk acute renal failure, pulm edema,hepatic rupture, increase risk placenta abruption and DIC
  107. Pyelonephritis: def, causes, s/s, management, complications
    • Def: inflammation of upper urinary tract + urine culture
    • causes: #1 risk factor-hx of lower UTI; also kidney stones
    • s/s: severe colicky pain, N+V, dehydration, dysuria, freq/urgency, suprapubic discomfort, flank pain, fever, chills
    • Management: Hydration, in pregnancy-IV antibiotics followed by orals, bedrest, teaching of s/s of UTI
    • Complications: IUGR, preterm L&D
  108. Polyhydramnios: def, associated factors, s/s
    • Def: >2000cc of amniotic fluid, chronic or acute. exact cuase unknown
    • Associated factors: DM, congenital anomalies, RH isoimmunization, multiples
    • S/S: abd discomfort, dyspnea, orthopnea, edema of legs &abd, uterine size>expected, fetal outline diff. to palpate and hearing FHR
  109. Polyhydramnios: management and complications
    • Management: High protein, low salt diet, mild sedation, amniocentesis to remove excess fluid, induction of labor if fetus is mature.
    • Complications: umbilical cord prolapse +/or placenta abruption with ROM; Increase incidence malpresentations, increase perinatal mortality from fetal malformations, preterm births, uterine dysfunction in labor, Increase pp hemorrhage
  110. Oligohydramnios: def, associated factors
    • Def: severely reduced amniotic fluid; occurs with PROM; rare. Fetus easily palpable and outlined, ballotable
    • Associated factors: postmature infants, IUGR, renal anomalies, dysfunctional slow labor,diagnosed by u/s.
  111. Oligohydramnios: management and complications
    • Management: US, NST, BPP, kick counts, hydration, side lying bedrest, good nutrition, amnioinfusion (for variable decels...makes cord float)
    • Complications: prolonged dysfunctional labor, renal anomalies, wrinkled leathery skin, increase skeletal deformities, fetal distress in labor d/t cord compression
  112. Premature Rupture of Membranes (PROM)
    • Def: premature rupture of membranes prior to labor
    • -there is also PPROM (preterm premature rupture of membranes) prior to 37wks
    • -also prolonged rupture of membranes, >12hrs before birth.
  113. Causes/predisposing factors of PROM
    • Unknown, but associated with:
    • -previous hx of PROM
    • -multiple pregnancy
    • -malpresentation
    • -hydramnios
    • UTI, infections
  114. PROM s/s, diagnosis, complications
    • S/S: watery, clear, or meconium stained amniotic fluid leaking. Foul-smelling vag discharge assoc with uterine tenderness (infection!!)
    • Diagnosis: Sterile spectrum exam-+ferning+nitrazine paper+amnisure.
    • Complications: risk of RDS, fetal sepsis malpresentation, umbilical cord prolapse, increase risk for placenta abruption
  115. Management for PROM
    • Assess for amniotic fluid
    • Assess FHR
    • Temp q2 hours
    • avoid cervical exams
    • monitor uterine activity
    • Assess s/s of infection!! =fetal tachycardia
    • Bedrest, antibiotics, betamethasone for fetal lung maturity if <37wks
  116. Substance abuse: effects and signs
    • -Ages 21-24 most common-
    • Effects: IUGR, prematurity, death, seizures, SAB, abruption, fetal alcohol syndrome
    • Signs of maternal addiction: constricted pupils, dental acries, mood swings, rhinitis, anorexia, no prenatal care, fast hr, stds
  117. Signs of withdrawal in newborn:
    Listlessness, poor muscle reflexes, poor feeding, uncoordinated suck-swallow, HIGH pitched cry, jitterness, inability to be consoled when crying.
  118. Accident/trauma in pregnancy
    • *Trauma is the most common cause of non-obstetric death amoung prego women in the U.S.**
    • Causes: MVAs, domestic violence, falls