Antepartum
Definition: blueish purple discoloration to the uterus caused by blood dissecting into the myometrium.
"Couvelaire Uterus" (seen in abruptio placenta)
TERBUTALINE BRETHINE
"delay labor", inhibits uterine contractions. Beta 2 agonist/selective drug, used also in asthma "bronchodilator." SNS effects.
chloasma
"mask of pregnancy"; darkeneing of skin over forehead, nose, cheekbones
vascular spiders
"spider veins"- enlarged arterioles
Most frequent causes of maternal death #1 #2 #3
#1 Embolism #2 Hypertensive Disease #3 obstetrical hemorrhage
gait
("waddle-gait") is a result of relaxing cartilaginous joints of the pelvis by 10-12th week. This enlargement allows for easier delivery of the fetal head
Among inactive fetuses, approximately 50% are either-3
(1) stillborn, (2) tolerate labor poorly, or (3) require resuscitation at birth
Pregnancy Tests
- Blood: most accurate; HCG levels highest in AM, take it with first urination - Home tests
Self-Care During Pregnancy
- Breast care: supportive bra, cleanliness, no soap on nipples - Clothing: loose and comfortable, no high heels - Cleanliness: consider culture - Employment: can work until labor starts if no complications - Travel: no restrictions unless complications are present; frequent breaks during car travel; seat belts
delivery for HIV pt
- C-section at 38wks if viral load >1000
Iron-Deficiency Anemia: Risks to Pregnancy
- CBC drawn at first prenatal visit - Hgb <10 = treatment - Causes increased risk of infection and blood loss during delivery - Compromises fetal development d/t decreased O2 transmission
First Trimester Discomforts: Cravings
- High sodium, sugar, non-food substances (pica), Leukorrhea
Umbilical Cord
- One vein - Two arteries - Wharton's jelly - Amnion
testing for Hep B
- routine - HBsAG
Uterine souffle
-correlates to mother's pulse
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1. What is the initial treatment for gestational diabetes? 2. If fasting or post-prandial values remain elevated, what is the treatment?
1. Diet, Exercise 2. Treat with insulin
FETAL COMPROMISE Sequence of Events:
1. Loss of fetal heart rate reactivity 2. Loss of breathing movements 3. Loss of body movements 4. Loss of muscle tone
1. With what kind of a c-section can you try to deliver vaginally in subsequent births? 2. What kind of c-section? CANNOT deliver vaginally in subsequent births
1. Low transverse incision C section 2. Vertical incision
Infections During Pregnancy: Gonorrhea: Nursing Interventions
1. Review medication purpose, side effects. 2. Explain that untreated gonorrhea may result in pelvic inflammatory disease and infertility. 3. Discuss safer sexual practices.
Infections During Pregnancy: Chlamydia: Nursing Interventions
1. Review signs and symptoms: explain importance of taking entire dose of medication.
Quiescent state (quiet sleep); with narrow oscillatory bandwidth of the fetal HR; bladder volume increases
1. State 1F
4 Fetal Behavioral States according to fetal heart rate patterns,general body movements, and eye movements (Nijhuis and colleagues, 1982):
1. State 1F 2. State 2F 3. State 3F 4. State 4F
what are the possible maternal factors in abortion
1. infection 2. endocrine (hypothyroidism, diabetes, progesterone deficiency) 3. environmental factors and drugs (smoking, alcohol, caffeine, radiation, environmental toxins) 4. autoimmune 5. uterine defects 7. previous spontaneous abortion
2nd trimester SAb
12-20wks causes: infection uterine/cervical anatomic defects maternal systemic dz fetotoxic agents trauma
when does NV occur
2-12 weeks
How long does it usually take the first outbreak of herpes to resolve?
2-4 weeks
How long does perimenopause typically last?
2-8 years
At __ weeks, fundus is at umbilicus.
20-22
Transmission of HIV (without prophylactic therapy)
25%
when is the pregnant mother's BP usually lower?
2nd trimester
Continuous eye movements in the absence of body movements; no accelerations of the HR
3. State 3F
Vigorous body movement with continuous eye movements and fetal HR accelerations; corresponds to awake state in the fetus
4. State 4F
fetal stage
8th week until birth
nonstress test
A method for evaluating fetal status during the antepartum period by observing the response of the fetal heart rate to fetal movement.
When would treatment with medication for TB be given to a pregnant woman?
After delivery
PARA
Any birth that occurred after 20 weeks' completed gestation, whether the baby was born alive or not; also without reference to the number of fetuses
When does the zygote reach the endometrial cavity?
At endometrial cavity ~3 days s/p ovulation Adheres to endometrium by day 5-6 s/p ovulation
What are some causes of PID?
BV, clap, gonorrhea, strep
MC congenital viral infection
CMV
H&H, CBC
Check for anemia, infections, electrolyte imbalance, kidney function
FAMILY STRUCTURE
Consists of individuals each with a socially recognized status and position who interact with one another on a regular recurring basis in socially sanctioned ways, composition of family
SUMMARY CONCEPTS
Contraction stress tests evaluate response of the fetal heart to recurrent short interruptions in placental blood flow and oxygen supply that occur with uterine contractions.
What is the key to helping HIV infected pregnant women?
Early identification and prevention of transmission to the baby
CHRONIC HYPERTENSION
Elevated BP documented prior to 20 weeks' gestation
What are some implantation factors?
Estrogen facilitates "sticking" Progesterone inhibits sticking Prostaglandin E relaxes tube Prostaglandin F stimulates tubal motility
Cardiovascular System: Peripheral Vascular Resistance
Falls: - Smooth muscle relaxation in vessel walls - Addition of uteroplacental unit - Fetal heat production - Synthesis of prostaglandins
Infections During Pregnancy: Syphilis: Medical Therapy
For syphilis less than 1 year in duration: 2.4 million units benzathine penicillin G IM. For syphilis of more than 1 years' duration or of unknown duration: 2.4 million units benzathine penicillin G once a week for 3 weeks. Sexual partners should also be treated.
What hormone do pregnancy test test for?
HCG
what are all pregnancy tests based on
HCG
HELLP : H
HEMOLYSIS (resulting in anemia and jaundice)
If a patient presents with recurring yeast infections, what might you suspect?
HIV or DM
HELLP
Hemolysis Elevated Liver enzymes, Low Platelets
What is the most painful STI?
Herpes simplex (Type 1 or 2) -Type 2 is genital, but type 1 will grow on genitalia as well.
Hypertensive Disorders in Pregnancy Chapter 27 OB EXAM #4
Hypertensive Disorders in Pregnancy Chapter 27 OB EXAM #4
kidneys, eyes, and heart.
Hypoglycemia or hyperglycemia can result if the amount of insulin does not match the diet. Fluctuating periods of hyperglycemia and hypoglycemia damage small blood vessels throughout the body. This damage can cause serious impairment, especially in the ____________________.
To prevent getting toxoplasmosis, which two items should pregnant women avoid?
In order to avoid contracting toxoplasmosis pregnant women should avoid eating raw or undercooked meats and contaminated cat litter
There is an increased risk of UTI during pregnancy due to statis of urine where?
In ureters
THALASSEMIA
Inherited defect in ability to produce hemoglobin
Why is testing for hepatitis antigen recommended?
It has a prevalence in the general population
In a CST, what do late decelerations of FHR indicate?
Late decelerations in a CST indicate fetal oxygen reserves are inadequate to tolerate contractions, and fetal acidosis, myocardial depression, or both may result.
How do we know its oligohydraminos?
Less than 5cm
What happens to H&H during pregnancy?
Levels decline as a result of increased plasma volume
What cells are responsible for the secretion of testosterone?
Leydig cells
The ducts venous leaves behind a remnant. What is it called?
Ligamentum venosum
eclampsia (convulsion) > inmediate medication
MAGNESIUM SULFATE 2 to 4 g IV push
Infections During Pregnancy: Gonorrhea: Signs/Symptoms/Risk
Majority of women are asymptomatic; disease often diagnosed during routine prenatal cervical culture. If symptoms are present, they may include purulent vaginal discharge, dysuria, urinary frequency, inflammation, and swelling of vulva. Cervix may appear eroded.
What happens if the rubella vaccine is administered at the same time as Rho(D) immune globulin?
May not be effective
__ is the ability to flex the body of the uterus against the cervix.
McDonald's sign
biophysical profile (BPP)
Method for evaluating fetal status during the antepartum period based on five variables originating with the fetus: fetal heart rate, breathing movements, gross body movements, muscle tone, and amniotic fluid volume.
CMV (most infants present with)
Most axs - may present with: Petechiae, hepatosplenomegaly, jaundice, thrombocytopenia, microcephaly, chorioretinitis, nonimmune hydrops fetalis)
What does the cervix secrete to plug off the uterus?
Mucous plug
when should you not give magnesium sulfate
Myasthenia Gravis (maternal) Maternal cardiac conduction defects Caution in maternal renal impairment
Macrosomia, IUGR
Neonatal hypoglycemia, hypocalcemia, hyperbilirubinemia, and RDS
What are some characteristic findings if a duct ectasis is present?
Nipple retraction and thick, sticky nipple discharge
Is bacterial vaginosis (BV) an STI?
No
What are risks associated with gonorrhea?
PID, abscesses, can spread to blood and can also affect joints, infertility, increased risk for HIV contraction, harm to fetus during child birth
Reproductive System: Uterus: 12 weeks gestation
Palpated above symphysis pubis.
FAMILY ROLES
Position or status in the family structure
What is happening when the regional blood flow increases?
Renal - excretion Skin - heat transfer Uterus - 2% to 17% of CO
Infections During Pregnancy: Rubella: Signs/Symptoms/Risk
Rubella exposure in the first trimester is associated with spontaneous abortion and numerous defects in many parts of the fetus.
Possible effects of Syphilis
Serious systemic disease and possibly death. Much less common than gonorrhea or chlamydia.
When a patient has pica, what does this usually mean?
Shes anemic
Goodell's Sign
Softening of cervix
Hegar's Sign
Softening of lower uterine segment
Abortion: Incomplete
Some products of conception remain in utero
Describe the mechanical effects of the gravid uterus.
Supine hypotensive syndrome Varicosities, hemorrhoids, edema Predisposition to DVT
During pregnancy, the enlarging uterus may put pressure on the vena cava when the woman is supine, resulting in what? - pressure interferes with returning blood flow and produces a marked decrease in blood pressure with accompanying dizziness, pallor, clammy.
Supine hypotensive syndrome (vena cava syndrome)
Group B Strep
Tested by vaginal culture Treated with course of oral antibiotics Tested again at 36 weeks, and treat again if present. IV antibiotics are also started on the mother during labor. Can cause neonatal sepsis, respiratory infections, and maternal fever. All this from a bacteria that is part of our normal flora
What do normal biophysical activities indicate?
That the central nervous system is functional and that the fetus is not hypoxemic
polydipsia
The body attempts to dilute the glucose load by any means possible. The first strategy is to increase thirst ___________, a classic symptom of diabetes. Next, fluid from the intracellular spaces is drawn into the vascular bed, resulting in dehydration at the cellular level but fluid volume excess in the vascular compartment.
GDM: Nursing Considerations.
The care of a pregnant woman with diabetes focuses primarily on maintaining normal blood glucose. This maintenance involves a rather rigid schedule of controlling the diet, blood glucose tests, administration of insulin, and regular fetal surveillance.
when does a fetus double its weight?
The last 6-8 weeks
What are two signs/symptoms that BV may be present?
Two findings that are indicative of BV are a fishy odor and copious thin vaginal discharge
How is the diagnosis of placenta previa made?
U.S.
FUNDUS
Upper portion of uterus
Describe the levels of hCG.
Value doubles every 2.2 days Rises for 60-90 days, then declines to plateau lower in ectopic and spontaneous abortion higher in gestational trophoblastic neopasia (GTN)
If a patient has PID or you suspect, what labs might you anticipate?
WBC, ESR, gonorrhea and clap (WBC & ESR will be elevated)
Hypoglycemia.
When the maternal glucose supply is abruptly withdrawn at birth, the level of neonatal insulin exceeds the available glucose, and hypoglycemia develops rapidly.
When would a chest radiograph test be done on a pregnant woman to screen for TB?
Would not be performed until after 20 weeks of gestation after the fetal organs are formed
Pica
abnormal cravings for things that are not food such as dirt, rocks, laundry detergent, etc.
accidental hge equal to
abruption placenta
Hydatidiform Mole: Nursing considerations
assess for bleeding, infection
White's classification
based on age at onset, duration based on age, vascular complications
Why does the uterine wall become hypertrophied? (cells enlarge)
because of increased estrogen and progesterone
why placenta praevia vaginal bleeding is recurrent?
because of progressive formation of the lower uterine segment (effecement and dilatation)
chadwicks sign
blue/purple of vagina and cervix
Infections During Pregnancy: Syphilis: Diagnosed
by blood tests such as VDRL, RPR, FTA-ABS. May be passed transplacentally to fetus.
Check for proteinuria
by dipstick testing- or 24 urine. ( reuslts proteinuria is at least 30mg/dl or greater in at least 2 random urine specimens collected 6 hours apart. If 24 urine than reaults will be greater than 300mg/24hrs.
Seizure
call for help calmly provide safety roll to side pad side rails
goodell's sign
cyanoisis and softening of cervix
Rubella (time of infection)
defects mc when b5 20th week (1st tri)
What are the s&s of ovarian cancer?
dyspareunia, abnormal bleeding
salpingostomy
ectopic preg removed leaving fallopian tube in place
Multiple fetuses
gi defects, LBW, oligohydramnios, dec. maternal weight - Lower levels
progesterone
helps in ovum transport through felopion tube
What are some risk factors for duct ecstasis?
if the patient breast fed a lot
how late into pregnancy can women fly
if uncomplicated pregnancy 36 weeks, international up to 35 weeks
what is biological testing
inhumane, not sensitive, not cost effective
von fernwalds sign
irregular softening of fundus at site of implantation - 4-5 weeks
Considerations for STD treatment:
knowing the last 60 days of partners and providing expedited partner therapy
Doula
labor coach
Infections During Pregnancy: Toxoplasmosis: Diagnosis
made using serologic testing, physical findings, and history.
Substance Abuse During Pregnancy: Medical Therapy
management involves a team approach to provide care for women and fetus/newborn. Hospitalization may be necessary to achieve detoxification. "Cold turkey" withdrawal is not advised because of risk to fetus. Urine screening may be done regularly throughout the pregnancy for women who are known or suspected substance abusers.
Hyperpigmentation
melanocyte- stimulating hormone increases during pregnancy. This causes darkening of the nipples, areola, umbilicus, axillae and perineum.
What is the age range for an intraductal papilloma?
menopausal years
spontaneous abortion
miscarriage. pregnancy ends <20wks GA 15-25% all pregnancies (may be higher)
bladder
more blood flow (hyperemia) causing bladder to be easily irritated and bleed
Chlamydia
most common STD; typically asymptomatic. All women between 20 and 25 who are sexually active should be tested. -spotting and valvular itching -Pregnant clients should be retested 3 weeks after completing prescription -Zithromax and amoxil and erythromycin prescribed during pregancy.
preeclampsia stadistics
most common medical complication: 4.5% to 11% of all pregnancies.
HIV affect on pregnancy
no direct affect (course/outcome, and Pregnancy does not affect course of HIV) - Just lowers immune system
CMV (tx)
no effective vaccine or tx for maternal or fetal infection - wash hands
With mild preeclampsia, (Table 27-2.)
no evidence of organ dysfunction and severe cases
Define primary herpes
no evidence of prior HSV infection (greatest risk to fetus)
inevitable abortion
no expulsion of POC, but vaginal bleeding and cervical dilation tx: 1st trimest: D&C or misoprostol 2nd trimest: D&E or high dose oxytocin & prostiglandins
Herpes in routine testing?
no, not part of routine testing
physiologic anemia of pregnancy
normal Hg and Hct values decrease = state of hemodilation Iron is necessary for adequate RBC formation
routine screening for CMV
not recommended
Routine screening in pregnancy of toxo?
not recommended, except in presence of mom HIV inf.
METHYLDOPA is an...
oral hypertensive agent (for home)
Definition: The premature separation of the normally implanted placenta from its attachment to the uterus.
placenta abruptio
Classical Presentation is Painless, bright, red bleeding -20 % are associated with contractions. Dx?
placenta previa
Definition: Blood loss in excess of 500 ml for a vaginal delivery or 1000 ml for a cesarean section
postpartum hemorrhage
preeclampsia risk factors
primigravity, multifetal, obesity
What are the s&s for gonorrhea?
purulent green dc, bleeding between periods
ectopic pregnancy
sharp one sided pain syncope and referred shoulder mpain
Vulvovaginal candidiasis (dx)
wet mouht glastosphores or pseudohyphae
trich (tx, dx )
wet mount tx - metronidazole (no ETOH!)
Amniocentesis: Nursing management
• Pt to empty bladder • 20-min EFM to evaluate fetal well-being • Maternal VS
Amniocentesis: Risks
• Spontaneous abortion • Infection
Amniocentesis: proceedure
• Ultrasound, 5" needle, 22-guage • Placed in amber or foil-covered test tube
Nonstress test
(NST) - Done using specialized equipment - Normal fetus produces characteristic FHR in response to fetal movements - Acceleration of FHR with fetal movement - Twice weekly (after 28 wk) for high-risk - Noninvasive, quick, no side effects - "reactive" NST at least 2 FHR accelerations of at least 15 bpm for at least 15 sec in 20 min - "nonreactive" correlated w/higher incidence of fetal distress
Hyperactive reflexes
(clonus) best assessed at the ankel joint.
diabetes: Early Pregnancy.
(from 1-20 weeks), maternal metabolic rates and energy needs change little. During this time, however, insulin release in response to serum glucose levels accelerates. As a result, significant hypoglycemia may occur, particularly in women who experience the nausea, vomiting, and anorexia that often occur during the first weeks of pregnancy.
posture
(lordosis)- increase lumbosacral curve and compensatory curvature or "swat-back" may cause structures of the back to be severely stressed
A unique form of coagulopathy DIC)
(not occurs with HELLP syndrome. The platelet count is low, but coagulation factor assays, prothrombin time (PT), partial thromboplastin time (PTT), and bleeding time remain normal. In some instances hemolysis does not occur and the condition is called ELLP. NOT a separate illness!!!
Awarding 2 points id the ff parameters are met 1. NST 2. Fetal breathing 3. Fetal movement 4.Fetal tone 5. Amniotic Fluid Volume
*≥2 accelerations of≥15 bpm for ≥15 seconds in 20-40 mins *≥1 episode of rhythmic breathing lasting ≥30 secs within 30 mins ≥3 discrete body or limb movements within 30 minutes ≥1 episode of extension flexion, or within 30 minutes Single vertical pocket >2 cm
4. (MP@H) Gentle exercise (e.g., range of motion
, stretching, Kegel exercises, pelvic tilts) is important in maintaining muscle tone, blood flow, regularity of bowel function, and a sense of well-being. Relaxation techniques can help reduce the stress associated with a high risk pregnancy and prepare the woman for labor and birth.
Abruptio Placentae: Incidence
- 0.5%-1% - Accounts for 10%-15% perinatal deaths -Cause: unknown
Placenta Previa: Incidence
- 1/200 - Previous previa - C-sec - Pregnancy terminations - Older women - Multips rather than priimps - Cigarette smoking and cocaine use
Tx of Hep B
- ASAP, Hep B immune globulin and begin vaccination against Hep B
Pregnancy: Food Guide Pyramid: Vegetarianism
-Need ample and complete proteins from dairy products and eggs -Protein from brown rice and whole wheat, legumes, nuts, cooked and fresh vegetables and fruits -Vitamin B12 supplement
Placenta Previa: Managemen : Home
-No active bleeding -Can maintain bedrest -Reasonable distance to hospital -Emergency system available 24 yr/day
Gestational Diabetes
-Occurs during 2nd and 3rd trimesters -No prior diagnosis -Screened during 26th week -Glucose = 105 mg/dL -Diet -Medications -"Normal" after delivery
Anemia: Maternal effects
-Pallor -Fatigue -Lethargy -Headache -Inflammation of lips and tongue -Fetal and neonatal effects: -- Unclear -- In general, fetus will receive adequate stores at cost to mother
Benefits of AMNIOTIC FLUID VOLUME (AVF) EVALUATION
-Prediction of poor perinatal outcome -->fetal death -Identification of congenital anomalies -Prediction of fetal growth restriction and placental insufficiency
Hypertensive Disorders: Diabetes
-Pregnancy places demands on carbohydrate metabolism -Insulin requirements increase in 2nd and 3rd trimester - Insulin-dependent diabetes - Diabetes in pregnancy
Pregnancy: Medications
-Prenatal vitamins -Iron supplements -Folic Acid -Antacids
Weight Gain During Pregnancy: Nutritional intake more important than the weight gain.
-Recommendations for total weight gain - Based on prepregnancy weight for her height and body mass index (MNI).
Danger Signs of Third Trimester
- Abdominal or pelvic pain: UTI, PTL, pyelonephritis, appendicitis - Decreased or absent fetal movement: fetal demise - Prolonged NV: hyperemesis gravidarum, risk of dehydration - Fever, chills: infection - Dysuria, frequency, urgency: UTI (could cause preterm labor) - Vaginal bleeding: infection, friable cervix d/t pregnancy changes or pathology, placenta previa, placentae abruptio, PTL - Absence of fetal movement or heart tones - S/S of hypertensive disorders: severe HA that doesn't respond to normal measures, visual disturbances, facial and generalized edema - S/S of preterm labor: rhythmic lower abdominal cramping or pain, low backache, pelvic pressure, leaking of amniotic fluid, increased vaginal discharge
NONSTRESS TEST (NST)
- Accelerations = intact CNS - Acceleration patterns affected by gestational age - Accelerations must be 15 bpm above baseline, lasting 15 seconds - Top of strip shows FHR, bottom of strip shows uterine activity - "Reactive": 2+ accelerations within 20 minutes - "Nonreactive": insufficient accelerations over 40 minutes
DOPPLER VELOCIMETRY
- Assesses placental function - Measures bloodflow changes in maternal and fetal circulation - S/D over 3 = decreased placental perfusion
Positive Sx of Pregnancy
- Auscultation of fetal heartbeat (present at 10-12 weeks by Doppler, 16 weeks by fetoscope, 18 weeks by stethoscope) - Fetal movement - Fetal visualization
Gestational Onset Complications
- Bleeding disorders - Abortion - Miscarriage - Ectopic pregnancy - Trophoblastic Disease (molar pregnancy) - Hyperemesis gravidarum (severe morning sickness)
Abruptio Placentae: S&S
- Bleeding: may be evident or behind placenta - Uterine tenderness - Uterine irritability - Abdominal or low back pain - High uterine resting tone - Apparent bleeding does not always correspond with actual amount of blood loss - Abdominal pain related to type of separation
Types of Non-traditional Families
- Blended/reconstituted - Extended - Single parent - Binuclear - Polygamous - Communal - Gay, Lesbian, Bisexual, and Transgender
Pregnancy: Eye, Cognitive, and Metabolic Changes
- Decreased IOP - Thickening of cornea - Reports of decreased attention, concentration, and memory d/t hormone changes - Extra water, fat, and protein storage d/t hormone changes; fats more completely absorbed
First Trimester Discomforts: Constipation
- Decreased contractility of gi tract - Mechanical compression by enlarging uterus
Placenta Previa: Management
- Depends on amount hemorrhage - EFM status of fetus & gestational age - Conservative: If CV status stable & fetus immature
Physical exam: Extremities
- Edema -Pulses - Varicosities - Pelvic exam -Specimen collection - External genitalia - Free from lesions, discharge, hematomas, varicosities, inflammation -Culture for STDs
Hypertensive Disorders: Chronic hypertension
- Elevated blood pressure known to exist before pregnancy
Second Trimester Discomforts: Hemorrhoids
- External or internal - Progesterone-induced vasodilation - Women w/constipation, poor fluid intake or dietary habits, smokers, or hx - Increase fiber and fluids - Topical anesthetics, warm sitz baths, cold compresses
W. Psychologic Tasks of Pregnancy
- First trimester: acceptance; hopefully elated, happy, excited; may have ambivalence - Second trimester: role-playing; accepts fetus as separate human being from self - Third trimester: separation from fetus through birth process; burst of energy
Placenta / Function
- Fully functional by week 12 - Respiration - Nutrition - Waste removal - Protection - Endocrine
First Prenatal Visit
- G = gravida - T = term pregnancies - P = preterm births - A = abortions - L = living children
Vena Caval Syndrome
- Gravid uterus suppresses vena cava when mom is supine - Reduces blood flow return to heart, causing maternal HTN - Have mom rise slowly from exam table; tell her not to sleep on back
First Trimester Discomforts: Urinary frequency or incontinence
- Growing uterus compresses bladder Rule out infection and gestational diabetes
H.E.L.L.P. SYNDROME
- H: hemolytic anemia - E.L.: elevated livery enzymes - L.P.: low platelets - Interventions: frequent appointments to monitor BP and urine; bed rest with lateral side-lying to promote blood flow to placenta; magnesium sulfate IV therapy to relax smooth muscles and prevent seizures; drug therapy--monitor RR, deep tendon reflexes, and urine output (at least 30mL/hour) - Only cure = delivery of baby
Sickle Cell Disease: Risks to Pregnancy
- Increased # of crises - Increased risk for perinatal complications - Have fetus tested also
Third Trimester Discomforts: Dependent edema
- Increased capillary permeability
Preterm Labor: Assessment
- Increased or bloody discharge - Leaking amniotic fluid - Backache - Pressure and cramping - Palpable uterine contractions - Diarrhea
Third Trimester Discomforts: Braxton hicks contractions
- Irregular, painless contractions w/o dilation - Walking decreases them
First Prenatal Visit: Reason for seeking care
- LMP - Presumptive or probable signs, -Positive home test
POSTPARTUM PSYCHOSIS
- Occurs in 1-2:1000 mothers; evident in first 3 months - S/S: agitation; hyperactivity; insomnia; mood lability; confusion; irrationality; difficulty remembering or concentrating; poor judgment; delusions; hallucinations - Treatment: refer to mental health professional; if meds are prescribed, caution re: breastfeeding
Preconception care
- Optimal time for pregnancy - Identifying whether complications of diabetes exist in other body organs - Identifying whether obesity is a factor - Determining the current degree of glycemic control - Providing instruction in use of home monitoring and insulin administration - Taking a daily prenatal vitamin includes 400 mcg folic acid
Prelabor Complications
- PROM - Preterm delivery
Special needs
- Physical - Support - Role changes
Role of Nurse
- Physical assessment - Identify and reevaluate risk factors - Teach self-care - Nutrition counseling - Promote family's adaptation to pregnancy
Gestational Onset Complications: Hyperemesis Gravidarum (Severe Morning Sickness)
- Placental hormones (especially progesterone) cause intractable nausea and vomiting; patient is extremely weak - Interventions: monitor potassium and sodium; IV therapy; monitor for dehydration; slowly introduce foods; balance electrolytes; vitamin B6 injection; antiemetics (i.e. Reglan)
Second Trimester
- Planning for breast-feeding - Sexuality in pregnancy - Relief of common later-pregnancy discomforts
Preparation for Parenthood
- Preconception - Childbearing decisions - Prenatal education - Childbirth preparation
Frequency of Prenatal Visits
- Preconception care - First trimester (1-3 months): initial visit should occur; should have a visit every 4 weeks until 28 weeks - Second trimester (4-6 months): visits should occur every 4 weeks - Third trimester (7-9 months): beginning at 28 weeks, visits should occur every 2 weeks; at 36 weeks, visits should be weekly; at 40 weeks, visits should be twice per week
Reproductive System: Uterus: Pattern of uterine growth
- Predictable pattern - Helps confirm --Estimated date of birth (EDB) --Estimated date of delivery (EDD) --Estimated date of confinement (EDC)
Gestational Onset Complications: Hypertension Disorders
- Preeclampsia, eclampsia - Chronic hypertension - Chronic hypertension with superimposed preeclampsia (after 20 weeks' gestation) or eclampsia - Gestational or transient hypertension
Hypertensive Disorders: Diabetes: Nursing Interventions
- Prenatal visits bimonthly for 6 months than weekly - Maintain blood glucose between 65-130 mg/dL - Monitor for hypoglycemia / hyperglycemia - Glucose control - Monitor for infection, PIH, ketoacidosis - Reinforce diet instructions
Third Trimester
- Preparation for childbirth - Development of a birth plan - Relaxation techniques - Postpartum self-care - Infant stimulation - Infant care and safety
Discomfort Measures: Nosebleeds
- Present in all semester, but worst in 1st - Causes: increased O2 consumption and cardiac output - Interventions: hydration; humidifier; if excessive, call HCP
Discomfort Measures: Difficulty Sleeping
- Present in all trimesters, but worst in 3rd - Causes: growing and active fetus, nocturia, breathlessness - Interventions: massage; hot shower or bath; relaxation; frequent napping
Ectopic Pregnancy: Nursing considerations
- Prevent or identify hypovolemic shock - Pain control - Psychological support
GDM: Risk factors
- Previous birth of a large infant (>4000 g - 8.8#) - Previous birth of an infant with unexplained congenital anomalies - Previous unexplained fetal death - Gestational diabetes in previous pregnancy - Multifetal pregnancy - Fasting serum glucose >140 or random serum glucose >200
Preterm Labor: Risk Factors
- Previous history of preterm labor or birth - Demographic factors - Lifestyle factors - Health problems - Uterine factors
Second Trimester Discomforts: Leg cramps
- Primarily 2nd and 3rd tri - Pressure of gravid uterus - Diet - if not consuming certain minerals - Dorsiflex foot, warm moist towel - Elevating legs, wearing support hose - Avoid prolonged standing or crossing legs
Relaxin
- Produced by corpus luteum and placenta - Inhibits uterine activity - Softens connective tissue in cervix - Relaxes cartilage and connective tissue of pelvic joints
Alpha-fetoprotein analysis
- Produced by fetal liver 13-20 wks - Biomarker screening test for fetal neural tube defects (FNTD) - Maternal serum 12-14 wks (16-18 wks optimum) - Elevated levels (besides FNTD)
Hypertensive Disorders: Eclampsia
- Progression of preeclampsia to generalized seizures that cannot be attributed to other causes - May occur postpartum
Childbirth Education
- Provides information on pregnancy and childbirth to facilitate optimal decision making - Classes for special groups - Importance of exercise during pregnancy - Selection of birthing process - Infant care
Sexual Activity During Pregnancy
- R/t discomforts - First trimester: fatigue, NV - Second trimester: fewer discomforts, vascular congestion - Third trimester: fatigue, SOB, decreased mobility; avoid male superior position - Feelings affected by: previous relationship with partner; acceptance of pregnancy; attitudes toward partner's change of appearance; concern about hurting expectant mother or baby
Pregnancy tests
- Radioimmunoassay tests -Blood and urine: 1 wk - Enzyme-linked immunosorbent assay - Blood and urine: 5 days before missed period - Home pregnancy tests -Urine - >97% accuracy -False negative - When instructions not followed, too early, urine too dilute
Biophysical profile
- Real-time ultrasound -Fetal tone, breathing, motion and amniotic fluid volume, NST - Score 8-10 normal
Second Trimester Discomforts: Flatulence with bloating
- Reduced gi motility - Avoid gas-forming foods - Add fiber and fluids - Increase exercise
Hyperemis Gravidarum: Nursing interventions
- Reducing N&V -Small portions of food, attractive, no strong odors -Low fat and easily digested carbohydrates -Upright after meals - Maintaining nutrition and fluid balance -Eat every 2-3 hours -Potassium- and magnesium-rich foods -IV fluids and TPN - Providing emotional support
SHOCK
-Body attempts to compensate for decreased blood volume and need to oxygenation to tissues - Increases HR and RR -Shunting blood from less essential organs to more vital ones Signs: increased pulse, decreased BP, increased RR, weak pulses, cool and moist skin, cyanosis (late sign), decreased UO, decreased H/H levels, change in mental status.
1st trimester Problems / interventions
-Breast engorgement and tenderness- wear supportive bra and cleanse with warm water only. DONT use soap or any cleansing materials which will dry, crack, or be abrasive to the breast -Urinary frequency- empty bladder regularly. do kegals and report any pain on urination to DR. Dont attempt to restrict fluids to prevent frequency
Abortion: Inevitable
-Cannot be stopped -BOW rupture, cervix dilated -Natural expulsion common -Vacuum or C&C if needed
Reproductive System: Breasts
-Change in size and appearance -Veins often visible -Striations appear -Nipples increase in size, more erect - Areola larger, more pigmented -Montgomery's tubercles - Secrete lubrication -Colostrum
Metabolism Changes: Carbohydrate Metabolism
-Changes markedly -More insulin than needed - For some, however, gestational diabetes
Endocrine System: Pancreas
-Changes result of alteration in maternal blood glucose -Fluctuations in insulin production -Glucose levels 10%-20% lower -During 2nd half of pregnancy - Decrease tissue sensitivity to insulin -Pp blood glucose levels are higher - Makes more glucose available to fetus » Stimulates fetal pancreas to produce insulin
Musculoskeletal System: Calcium Storage
-Fetal demand for calcium increases -Maternal absorption doubles during pregnancy -Calcium stored to meet later needs of fetus
Missed Abortion
-Fetus dies 1st half of pregnancy, but remains in uterus
Maternal Weight Gain Distribution
-Fetus, placenta, amniotic fluid 11 pounds -Uterus 2 pound -Increased blood volume 3 pounds -Breast tissue 3 pounds -Maternal stores 5-10 pounds -Total 25-35 pounds
Management of uterine atony -IV ______ -Which manual technique? -_______ (ergonovine maleate) -Prostaglandin ______ -Cytotec/Misoprostol -Embolization of Uterine Arteries -Ligation of Uterine or Hypogastric arts. -_____ Stitch: works really well -Supracervical hysterectomy: last resort
-IV PITOCIN -Massage -Methergine (ergonovine maleate) -Prostaglandin F2-Alpha -Cytotec/Misoprostol -Embolization of Uterine Arteries -Ligation of Uterine or Hypogastric arts. -B-Lynch Stitch: works really well -Supracervical hysterectomy: last resort
MANAGEMENT of Uterine Inversion -Immediate IV. volume expansion -_______ anesthesia or _______to relax the uterus. -Replace with your fist and give immediate ______. -Possible _______ Suspension
-Immediate IV. volume expansion -Halothane anesthesia or terbutaline to relax the uterus. -Replace with your fist and give immediate pitocin. -Possible Surgical Suspension
Tables on 175 and 179
...
When can fetal movements be palpated by a trained examiner?
18 weeks
What is the recommended weight gain during pregnancy? What if you were overweight before pregnancy?
25-35lbs; 15-25lbs
EXTENDED FAMILY
At least one parent and one or more members other than parent or sibling
BLENDED/RECONSTITUTED FAMILY
At least one stepparent/sibling or half-sibling
What is ASKUS?
Atypical cells of undetermined significance.
what are the features of medical abortion
Avoids invasive procedures Usually avoids anesthesia Requires 2-more visits Days-weeks to complete Available during early pregnancy High success (95%) Bleed moderate to heavy for short time Requires follow up to ensure completion of abortion.
Are indeterminate Are not predictive of abnormal fetal acid-base status, yet presently there is not adequate evidence to classify these as Category I or Category III Require evaluation, taking into account the entire associated clinical circumstances. In some circumstances, either ancillary tests to ensure fetal well-being or intrauterine resuscitative measures may be used with Category II tracings
Category II
Are abnormal Associated with abnormal fetal acid-base status at the time of observation Require prompt evaluation
Category III
What are 8 subtypes of HPV linked to causing?
Cervical Cancer
What sign may also be evident in vaginal tissues at about 8-12 weeks
Chadwick's sign
Any STI increases the risk for _______?
Contraction of HIV
Eclampsia Key NTK interventions
Convulsions Aspiration Immediate Care
Chronic hypertension
Hypertension present before pregnancy or diagnosed before week 20 of gestation Chronic hypertension with superimposed preeclampsia Women with chronic hypertension may acquire preeclampsia or eclampsia
NURSE ALERT for Mg
IF Mg toxicity is suspected, prompt actins are needed to prevent respiratory or cardiac arrest. The magnesium infusion should be *discontinued immediately*.
Rubella infection of the mother during pregnancy can cause birth defects in the fetus. Should we vaccinate a woman during pregnancy if her levels of antibodies against rubella turn out to be low?
If a woman has low rubella antibody levels during pregnancy, we should not vaccinate her due to the risk of developing a live infection from the vaccine.
Nsg interventions for an ultrasonography?
If abd ultrasound being done, the woman may need to drink water to fill the bladder before the procedure to obtain a better image of the fetus. Transvag ultrasound, a lubricated probe is inserted into vagina. Client should be informed that test presents no known risks to client or fetus.
A second sample for alpha-fetoprotein is drawn and screened when?
If the level is elevated the first draw and the gestation is less than 18 weeks
The immediate goal of care during a convulsion
Immediate Care. is to ensure a patent airway (see Emergency box). When convulsions occur, turn the woman onto her side to prevent aspiration of vomitus and supine hypotension syndrome. Note the time and the duration of the convulsion. After the convulsion ceases, suction food and fluids from the glottis, and administer 10 L of oxygen by a facemask, insert an 18 gauge if one not in place, then start magnesium. ( may give valium or other meds if convulsions continue) Some facilities may continue the Magnesium for 12 to 24 hours after delivery for seizure prophylaxis.
What happens if the client has a negative Rubella titer (less than 1:8)?
Indicates susceptibility to the rubella virus and she should receive the appropriate immunization postpartum
Greatly valuable when placental insufficiency is long-standing. This is a Routine role in low risk pregnancy requires further clinical investigation AND IT Clinically measured by a tocodynamometer, visualization with real-time US and maternal subjective perceptions
Indirect measure of the CNS integrity
Fetal Heart Rate Monitoring
Indirect measure of the CNS integrity Mother records fetal movements Real time ultrasonography Doppler ultrasound
PNSS
Pregnancy Nutrition Surveillance System developed to identify and reduce pregnancy related health risks
Preeclampsia
Pregnancy-specific syndrome in which hypertension develops after 20 weeks of gestation in a previously normotensive woman
Infections During Pregnancy: Gonorrhea: Medical Therapy
Pregnant women are treated with ceftriaxone orcefixime plus erythromycin. All sexual partners are treated.
What does Rh positive indicate?
Presence of antigen
Signs and Symptoms of Pregnancy: Positive Signs
Presence of fetal heartbeat distinct from mother's, fetal movement felt by someone other than the mother, and visualization such as an ultrasound.
Exercise.
Research results have been mixed about whether exercise reduces the need for insulin in the woman with GDM. Nevertheless, exercise and an active lifestyle can improve cardiorespiratory fitness.
Anytime the mother has a bleeding problem prior to 28 weeks, she should be given what?
Rhogam if she is Rh negative
Preeclampsia Risk Factors- *NTK*
Risk factors are Primigravidity or ( moms over 40 or under 19) Multifetal pregnancy or hydatidiform mole Obesity IUGR, placenta abruption, fetal death Chronic Renal disease & chronic HTN Collagen disease Diabetes ( type 1) RH Incompatibility Periodontal disease (See Box 27-1)
What are characteristics of fibroadenoma?
Rubbery, mobile, and well-defined mass without pain; does NOT increase risk for cancer
If a pregnant woman is diagnosed with chlamydia, should it be treated, and if so, how?
Yes, the infection should be treated because perinatal exposure to the disease can cause conjunctivitis or pneumonia. Additionally, chlamydia is the most common infectious cause of ophthalmia neonatorum. We can use erythromycin or amoxicillin to treat chlamydia in a pregnant woman
Gastrointestinal System: Stomach & Small Intestine
Stomach - Decreased tone and motility - Delayed emptying time Large/small intestine - Longer emptying time, more absorption - Bloating, abdominal distention - Constipation, hemorrhoids
What is polyhydraminos?
Too much fluid (~2L): Decreased elimination (swallowing)* - Esophageal atresia or tracheo-esophageal fistula Increased production (pulmonary)
...
Torch infections??
How is the fern test performed?
Using sterile technique, a specimen is obtained from the external os of the cervix and vaginal pool and is examined on a slide under a microscope.
ECLAMPSIA
VASOCONSTRICTION THAT AFFECTS NEUROLOGICAL SYSTEM CAUSING SIZURES
What is the volume of the amniotic fluid?
Vol: 1st tri: 5-25cc 32 wk: 250-800cc Term: 500cc
IV HYDRALAZINE is...
antihypertensive agent of choice
linea nirgre
darkening of nipples and lower midling of abdomen; from stimulation of melanophores
antihypertensive therapy must NOT
decrease arterial BP too much or too rapidly
*abruptio*
decreased placenta perfusion
Magnesium sulfate
decreases neuromuscular irritability, depressing cardiac conduction, and decreasing CNS irritability.
MILD preeclampsia: Home care
dependent edema, pitting edema, deep tendon reflexes, activity restriction, Diet (high protein, low salt)
The White classification
describes the age at onset of diabetes, in duration based on the woman's current age, and vascular complications, such as retinopathy, that are present. GDM descriptions in White's classification include A-1 (diet controlled) and A-2 (diet and insulin controlled).
what is evaluation for 2nd and 3rd trimester bleeding
determine extent of bleeding, associated pain? cervical insufficiency is indicated by light bleeding, pressure and intermittent or no pain in 2nd trimester fetal loss is indicted by absence of heart sounds by ultrasound
Probably Indication of Pregnancy: Objective findings
documented by examiner: -Related to physical changes in reproductive organs -Abdominal enlargement -Cervical softening -Changes in uterine consistency - Hegar's sign - soft lower uterine segment - Ballottement - 20 wks - Braxton Hicks contractions -Palpation of fetal outline
What are some things you can suggest to patients with genital herpes in regard to caring for themselves during an outbreak?
don't wear tight fitting clothing, keep area clean
DOPPLER VELOCIMETRY Non-invasive technique to assess blood flow by characterizing ____
downstream impedance
•Lacerations of Vagina/Cervix •Common following operative deliveries. •Diagnosis- Exploration which cause of postpartum hemorrhage?
genital tract trauma
RUBELLA
german measles
what is the MC presumptive manifestation of pregnancy:
history of amenorrhea
Fetal death risk factors
hydatidiform mole, inc. maternal weight gain, maternal type I diabetes, trisomy 21 (Down's), trisomy 18 (Edward's) - Must be done at correct gestational age
APRESOLINE
hydralazine - can be used for hypertensive emergency (eclampsia) - can cause lupus-like syndrome
if there is term PROM what is likely outcome
induction of labor at time of presentation decreases risk of neonatal infection without increasing risk of c-section can consider waiting for spontaneous labor for 6-24 hours
first prenatal visit
initial visit -head to toe assessment lab wk: UA, H&H, CBC, type and x match, rubella titre, Glucose tolerance, pap and cervical culture for STD's. skin tests PPD. also blood for alpha fetal protein, and multiple markers.
What are signs and symptoms of PCOS?
insulin resistance, amenorrhea, weight gain, hirsutism, infertility
what is criteria for fetal fibronectin testing
intact fetal membranes cervical dilation less than 3cm gestational age at least 22 weeks and less than 35 weeks
integumentary changes
integumentary systerm- most of these changes fade away after childbirth
Braxton-Hicks contractions
intermittent, irregular, painless uterine contractions. more noticeable by 28 wks. subside with mild exercise. -start at 4 months this helps increase blood flow thru the placenta
What is involved in the Intrapartum Management of gestational diabetes?
intrapartum= during labor •Patients requiring insulin are treated with IV insulin at a rate of 0.5-2.0 units of insulin per hour •Maintain glucose levels of 80-120mg/dl
antihypertensive agents administration depends on...
intravascular volume. Initial doses should be given with caution and monitored closely
XRAY
FETAL SKELETON SEEN ON THIS
What is Nagle's rule of determining EDB?
First day of LMP, subtract 3 months, add 7 days
PRIMIGRAVIDA
First time being pregnant
Nutritional Needs Before Conception
First trimester is crucial in terms of embryonic and fetal organ development. Healthy diet before conception ensures adequate nutrients are available for developing fetus. Folic Acid intake is important in preconception period because it can prevent neural tube defects
HELLP, who gets it?
older, caucasian, multiparous women
what happen to organs functions when PREECLAMPSIA occur?
placenta, kidneys, liver, brain DEPRESSED as much as 40% TO 60%
1st birth, lots of pain Think what cause of antepartum bleeding?
placental abruption
rest
plan regular rest periods especially as the pregnancy progresses
What is involved in the Antepartum Management of gestational diabetes?
•Serial ultrasounds •Serial tests for fetal well-being: Non-stress test Contraction stress test Biophysical profile Cord Doppler Studies •Maintain normal glucose levels
Treatment for retained placenta •Treatment- manual removal or _____. •If accreta etc. may necessitate a _________.
•Treatment- manual removal or D&C. •If accreta etc. may necessitate a hysterectomy.
ladins sign
sofeting of uterus - 6 weeks gestation
What is fundic souffle?
soft blowing sound of blood pulsating through umbilical arteries-same rate as fetal HR
ZIDOVUDINE
an antiviral drug (trade name Retrovir) used in the treatment of AIDS
Multifetal Pregnancy: Nursing Interventions
-Monitor vital signs -Monitor FHR, fetal activity, fetal growth -Monitor cervical changes -Ultrasound -Monitor for anemia -Monitor and treat preterm labor -Prepare for possible cesarean section
Multifetal Pregnancy
-Monozygotic or dizygotic -Assisted reproductive techniques -Diagnosis -Interventions -Complications
Why can diabetes occur during pregnancy?
Plasma levels of insulin increase during pregnancy probably bc of hormonal changes, and rapid destruction of insulin takes place within the placenta
alpha-fetoprotein (AFP)
Plasma protein produced by the fetus.
mcdonalds sign
uterus becomes flexible at uterocervical junction - 7-8 weeks
Preterm Labor: Trauma
-MVAs -Homicide -Abuse -Domestic violence
estrogen
causes increaae in vaginal secreation called leukorrhea
Pregnancy:Lactose Intolerance Lactose Intolerance
-Abdominal distention, discomfort, nausea, vomiting, loose stool, cramps -May tolerate milk in cooked form -Cheese and yogurt - Lactase may be prescribed -Lactase-treated milk -Lactose-free products
Musculoskeletal System: Abdominal Wall
-Abdominal muscles may stretch beyond capacity during 3rd trimester -Rectus abdominis muscles separate (diastasis recti)
Complications of Pregnancy: Hemorrhagic Complications
-Abortion -Ectopic pregnancy -Hydatidiform Mole -Placenta Previa -Abruptio Placentae
Abortion: Complete
-All products are expelled -Management: No additional intervention necessary
Metabolism Changes: Weight Gain
-Correlation between infant mortality and low birth weight -Women encouraged to gain 25-35 lbs -Fetus, placenta, and amniotic fluid less than half -Remainder in uterus, breasts, increased blood volume, increased interstitial fluid, and sub-q fat
Placenta Previa
-Implantation in lower uterus -Marginal (low lying): Lower border >3 cm from internal cervical os -Partial: Lower border within 3 cm of internal os -Total: Placenta completely covers internal os
Weight Gain During Pregnancy
-Important determinant of fetal growth -Insufficient weight gain - Preterm labor - Increased risk of fetal & newborn mortality & morbidity
Abruptio Placentae: Concealed hemorrhage
-Increase in fundal height -Hard, boardlike abdomen -High uterine bassline tone on EFM strip -Persistent abdominal pain
Physical exam: Internal genitalia
-Speculum - Cervix, uterus - Pap smear -Rectal exam - Bimannual - Uterus, ovaries
Management of placenta abruptio -Stabilize Mother -IV's -Serial ________Profiles -Keep ______products on hand (DIC) -Fetal Monitoring -What is the preferred route of delivery?
-Stabilize Mother -IV's -Serial Coagulation Profiles -Keep blood products on hand (DIC) -Fetal Monitoring -Vaginal Delivery preferred route. C-section for obstetrical reasons only.
frequency in accidental hge?
1 in 80 hospital deliveries
Nutrient Needs During Pregnancy
1 quart of FLUID a day, 60 grams or 6 servings of PROTEIN a day, Energy needs: increase of 300 calories a day.
pitting edema
1+ (2mm) , 2+ (4mm) , 3+ (6mm) , 4+ (8mm)
How long can HPV incubate before symptoms begin to appear?
3 weeks to several years; this being said there isn't always an easy way to know who you might have contracted the virus from
recurrent pregnancy loss
3+ consecutive SAbs <1% population risk SAb after one is 20-25% after 2, 25-30%
If a patient has more than _______ outbreaks per year they take a daily antiviral. This is known as _________.
4 or more outbreaks a year; suppressive treatment
definition
bleeding from genital tract occuring in 3rd trimester of pregnancy or during the first or second stages of labour
blood flow (renal)
blood flow to the kidneys increases about 50-80%. leads to a 40-60% increase in GFR
what labs should you order in a woman with a suspected spontaneous abortion
blood typing serum quantitative B-hCG (in normal pregnancy expect to see 66% rise in 48 hours)
Hep B (risk to baby)
90% will become infected and most will be chronic carriers
What are the BP ranges for pregnant mother?
90-140 systolic; 60-90 diastolic
Chadwick's sign
bluish color of the cervix, is a result of increase blood flow to the uterus and all of the lower pelvis (6-8 wks)
Diabetes Mellitus
A complex disorder of carbohydrate metabolism caused primarily by a partial or complete lack of insulin secretion by the beta cells of the pancreas. Without insulin, glucose accumulates in the blood, resulting hyperglycemia.
neural tube defect
A congenital defect in closure of the bony encasement of the spinal cord or skull. Includes defects such as anencephaly, spina bifida, meningocele, myelomeningocele, and others.
gestational diabetes: history
A detailed history should include the onset and management of the diabetic condition. The degree of glycemic control before pregnancy is of particular interest. Her knowledge of how diabetes affects pregnancy and pregnancy affects diabetes must be determined. All women with diabetes should be seen by a qualified nurse educator for an individualized assessment to ensure that they can monitor their blood glucose accurately. In addition to home monitoring of blood glucose, the nurse must observe the woman's skill in mixing and administering insulin, using a sliding scale for added insulin, or using an insulin pump if the drug will be given that way.
phosphatidylglycerol (PG)
A major phospholipid of surfactant whose presence in amniotic fluid indicates fetal lung maturity.
mastodynia:
breast tenderness due to mammary duct alveolar response, engorgement from circulating hormones
preumtive signs (subjective)
breast tenderness, amenorea, N&V,Breast enlargement
respiratiry system
breathing more diapram that abd ^oxygen consuption Nasal congestion second to increase vascularity
colostrum
can express after 12 weeks of gestation
presumptive
changes felt by the mother. ex. enlarged breasts, morning sickness
BETAMETHASONE
Is a corticosteriod administered to decrease the risk of respiratory distress to the neonate of preterm delivery occurs.
What happens if the ductus arterioles does not close?
It becomes a PDA Risk inversely proportional to gestational age
What is the pharmacological treatment for BV?
flagyl (metronidazole)
what immunizations should a pregnant women recieve
flu and H1N1 DO NOT give live vaccines such as MMR or varicella
What is the prognosis for ovarian cancer?
It can be pretty grim because it isn't always caught in time. By the time s&s even appear, the tumor is pretty big and has probably metastasized.
SUMMARY CONCEPTS
Alpha-fetoprotein assessment is performed on maternal serum or amniotic fluid with the primary goal of detecting open body wall defects such as neural tube defects. Additional tests are required if alpha-fetoprotein levels are abnormal. Other markers—human chorionic gonadotropin and estriol, and possibly inhibin A—may be assessed with maternal serum alpha-fetoprotein in a triple- or quad-screen for chromosomal anomalies such as trisomy 21.
The time between conception and onset of labor is known as?
Antepartum
__ is spontaneous or therapeutic before start of week 20. - occurs before 20 weeks
Abortion
What are the presumptive signs of pregnancy that are subjective and could be caused by something else?
Amenorrhea(period stopped), N&V(Increased hCG),fatigue, urinary frequency, breast changes, quickening(fetal movement)
What factors make a pregnant woman a candidate for amniocentesis?
Amniocentesis is most often performed to detect chromosomal abnormalities and other prenatally detectable genetic disorders or to identify if maternal sensitization to Rh-negative blood has affected the fetus. Additional indications include investigating abnormal levels of MSAFP, determining fetal lung maturity, and evaluating the fetus affected by Rh isoimmunization.
oligohydramnios
Amniotic fluid may be reduced ____________________ as the fetus conserves oxygen for the heart and brain.
Fluoride
Purpose: mother and fetus's teeth Sources: city water
Zinc
Purpose: skin integrity, components of numerous enzyme systems, possibly important in preventing congenital malformations Sources: liver, shellfish, meats, whole grains and milk
Vitamin C
Purpose: tissue formation and integrity, formation of connective tissue, enhancement of iron absorption Sources: citrus fruit, strawberries, melons, broccoli, tomatoes, peppers, and raw deep green leafy vegetables
What is the EBL criteria to diagnose postpartum hemorrhage for a vaginal delivery? A. 250 mL B. 500 mL C. 750 mL D. 1000 mL
Answer: B
The most common cause of postpartum hemorrhage is: A. Retained Placenta B. Coagulopathy C. Uterine Atony D. Genital Tract Laceration
Answer: C
What sometimes happens following the treatment of Syphilis in pregnant women?
Jerisch-Herxheimer reaction. The Jerisch-Herxheimer reaction is an acute febrile reaction accompanied by headache, myalgia, and arthralgia within the first 24 hours. If this occurs in the second half of pregnancy, pre-term labor or pre-term birth can ensue
Overt (pre-existing) diabetes Which White classification of diabetes in pregnancy?
B,C,D,R,F,G,H,T: the classification is based upon how long they have had diabetes, if they are insulin dependent and if they have end organ damage
Vegans who are pregnant who do not eat from animal sources may require what?
B-12 supplements- shot
what is naegle's rule for dating pregnancy
LMP + 7 days - 3 months LMP is always the first day of the last menstrual period
HELLP : LP
LOW PLATELETS ( <100,000/mm3) resulting in thrombocytopenia, abnormal bleeding and clotting time, bleeding gums, petechiae, and possible DIC
Nonreactive NST - if preterm, ____. If full term, ____
NORMAL investigate.
First Trimester Discomforts: misc
Nasal stuffiness, bleeding gums, epistaxis
organogenesis
Because gestational diabetes develops after the first trimester, the critical period of major fetal organ development _______________________, it usually is not associated with an increase in major congenital malformations.
what are the maternal side effects of nifedipine
Nausea/vomiting Flushing Headache Dizziness Palpitations Drop in blood pressure
what are the maternal side effects of indomethacin
Nausea/vomiting GER Gastritis Platelet dysfunction
ABRUPTION PLACENTA
PROMP DELIVERY OFFETUS LEADS TO COMPROMISE FETAL BLOOD SUPPLY SYMPTOMS: VAGINAL BLEEDING, ABD PAIN, ABNORMAL CONTRACTION, FETAL DEATH, PREMATURE LABOR FETAL DMOVEMENT DECREASES TESTS: CBC, PT ,aPTT
What is done to screen for cervical neoplasia?
Papanicolaou's smear
__ is birth after 20 weeks' gestation, regardless of whether the infant is born alive or dead. - the outcome of pregnancies
Para
preeclampsia assessment & nur.diagnosis
Blood pressure, edema, deep tendon reflexes (DTR) -normal +2, Labs,
What are some characteristics of an intraductal papilloma?
Bloody, greenish brown, unilateral nipple discharge; lump is hard to feel/palpate. While this does have the potential to become cancer, it is usually benign
Chadwick's Sign
Bluish coloration of cervix, vaginal mucosa, and vulva
four major neonatal complications
The _______________________ ____________________ of preexisting diabetes are hypoglycemia, hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome.
Why can hemorrhoids develop during pregnancy?
There is an increase in bv and a decrease in venous return and also constipation occurs
GENOGRAM
Family tree with symbols indicating persons and relationships
FAMILY SYSTEMS THEORY
Family viewed as a system that continually interacts with its members and environments; focuses on interactions and the changes they exert
macrosomia results when
Fetal ______________ elevated levels of blood glucose stimulate excessive production of fetal insulin, which acts as a powerful growth hormone.
Variations in Fetal Size
Fetal growth is related to maternal vascular integrity. If the woman is hyperglycemic, so is the fetus.
What are the only positive signs that are only seen during pregnancy?
Fetal heart beat, fetal movement palpated by trained examiner, visualization of fetus by ultrasound
___________ is the diagnosis for all causes of Postpartum hemorrhage except coagulation defects.
Inspection/Palpation
How is endometriosis confirmed?
Laparoscopy is the only definitive way to confirm
Vulvovaginitis Dx?
Microscopic exam under saline wet mount "clue cells"
Hypertensive Disorders: Preclampsia
Systolic BP of > 140 or diastolic BP >90 occurring after 20 wks - Accompanied by proteinuria (>0.3 in 24-hr collection), diptstick >+1 - Edema
How are pregnant women with genital warts treated?
TCA only
TORCH infections
TOxoplasmosis Rubella CMV Herpes
Useful acronym for remembering para?
TPAL term, preterm, abortion, living
Preeclamsia/eclampsia > morbidity & mortality
african-american higher rates
incomplete or missed abortion
after 10 weeks can be retention of fetal or placental portions cervix can be open or closed bleeding/cramping
Syphilis (crosses placenta, when?)
after 16weeks
Later postpartum eclampsia
after 48 hrs, before 4 weeks
Postpartum care ECLAMPSIA
careful assessment: VS, I & O, DTRs, consciousness, uterine tone, lochia, MAGNESIUM SULFATE 12 to 24 more hrs. (caution w/narcotics, CNS depressants, calcium channel blockers because are potentiated)
what populations are at risk and should be offered screening for cystic fibrosis
caucasian, european or ashkenazi jewish
Postpartum insulin needs should decline rapidly
after the delivery of the placenta and abrupt cessation of placental hormones. However, blood glucose levels should be monitored at least four times daily so that the insulin dose can be adjusted to meet individual needs. Women with type 1 diabetes usually return to their prepregnancy dosages. Women with type 2 diabetes are monitored, and insulin is ordered only if needed.
when is invasive prenatal testing indicated
age over 35 previous child with chromosomal abnormality or genetic disease parent with chromosomal rearrangement medical conditions such as sickle cell, muscular dystrophy, cystic fibrosis
what is mifepristone
aka RU-486 a medical abortive that acts as anti-progesterone, softens cervix and increases contractility of uterus usually followed by misoprostol in 48 hours
what is the number one cause of preventable mental retardation in a fetus
alcohol
SICKLE CELL ANEMIA
a genetic disorder that causes abnormal hemoglobin, resulting in some red blood cells assuming an abnormal sickle shape
Screening for syphilis
all pregnant women - non trep (VDRL, RPR) can be falsely + - Treponemal (FTA-ABS, TP-PA) + = active dz, remains + for life
respiratory anatomic changes
allow increased chest expansion 30-40% -rib cage-lower rib cage flares to allow for expansion as the abdomen enlarges
Nuchal translucency screening
also an ultrasound done in the 1st trimester. ultrasound may identify a nuchal translucency caused by a fatty deposit in the tissur behind the fetal neck. This is associated with fetal abnormalities. Eg trisomies 13, 18, and 21; and structural anormalities
How can you confirm that a patient has syphilis? (meaning how is it definitively diagnosed after screening has been performed)
You can do a fluorescent troponic antibody absorption test that is specific for syphilis, but once a person has had syphilis this will always be positive.
What zone is being penetrated during the acrosomal reaction?
Zona pellucida
What is Nitabuch's layer?
Zone of fibrinoid degeneration in the decidua basalis Prevents placental invasion into the uterus
expectant treatment of placental praevia
bed rest transfusion to replace bl loss tocolytic agent to prevent premature labour to prolong pregnancy to at least 36 weeks For selecting the optimum time for delivery do test for lung maturity and ultrasonic growth measurements
when can RIA diagnose pregnancy
before missed period
what are corpeal signs of pregnancy
cholasma, linea nigre, stretch marks, spider telangectases, palmar erythema
What kind of edema is normal in pregnant mom?
edema below waist
What causes N&V during first trimester?
elevated hCG
ruptured ectopic, stable
exploratory laparoscopy: evacuate hemoperitoneum, coagulate bleeding, resect ectopic pregnancy
What are the risk factors for osteoporosis?
female, thin, Asian, caucasian, early menopause, inactive lifestyle, excessive ETOH use, tobacco use, low life-time intake of Ca and vitamin D
zygote
fertilize egg through two weeks
The only cure for preeclampsia
is the birth of the fetus
braxton hicks -
painless contractions - disappear with exercise
What are some risk factors for uterine rupture?
previous C-section uterine surgery (removing fibroids) anything that has weakened the uterus
Partner becomes confused and anxious
- 1st tri: less interested in sex - 2nd tri: increased interest in sex -stability - 3rd tri: may experience
Management of HIV
- HARRT, and Zidovudine - begins after 1st tri to avoid unnecessary drug exposure
Pregnancy: Respiratory Changes
- Increased O2 consumption - Increased subcostal angle and anterposterior diameter - Breathing technique changes from abdominal to thoracic - Nasal congestion and epistaxis in 1st trimester d/t increased estrogen, causing increased vascularity
Pregnancy: Endocrine Changes
- Increased estrogen and progesterone - Decreased TSH; increased T4 and BMR - Increased PTH concentration - Thyrotropin and adenotropin alter maternal metabolism - Prolaction responsible for lactation - Secretion of oxytocin and vasopressin - Increased aldosterone - Increased need for glucose for developing fetus - Increased cortisone levels
Hydatidiform Mole: S&S
- Increased hCG - Visible vesicles and absence of fetal sac or heart activity - Uterus larger than expected - Vaginal bleeding - Excessive N&V - Early development of preeclampsia
PTSD R/T POSTPARTUM
- Risk increases in emergency C-section cases - S/S: emotional numbing; memories; reduced awareness of one's environment; derealization and depersonalization; intrusive thoughts; insomnia; impaired communication; avoidance behaviors; irritability; autonomic arousal (i.e. palpitations, hyperventilation, nausea); avoidance of reminders and hyperarousal must be present for 1 month to diagnose - Treatment: early recognition is very important; encourage patient to relive birthing experience, clarify misunderstandings, and give appropriate follow-through and referrals to support systems when indicated
Pregestational Complications: Diabetes
- Type I, type II, and GD provide risks to mother and baby - Pregnancy provides ideal state for diabetes--during 2nd and 3rd trimesters, hormones put mother in naturally insulin-resistant state --> more glucose is available to cross placenta and keep fetus growing - Entering pregnancy as an already-diabetic patient is dangerous; closely monitor and take at least 4 SQ insulin doses daily; type II may have to undergo insulin control - GESTATIONAL DIABETES: pregnancy-induced; may need insulin if not controllable by dietary changes; diagnosis = one abnormal glucose test out of the following--fasting >92, 1 hour test >180, 2 hour test >153 - Assessment: A1C screening for patients at risk during first prenatal visit, all others at 24-28 weeks; 75 g 2 hour oral glucose test
Missed Abortion: Management
- Ultrasound to confirm fetal death - Most will expel spontaneously - 1st trimester: D&C - 2nd trimester: D&C or prostaglandin to induce contractions
Abortion: Threatened: Management
- Ultrasound to verify condition of embryo or fetus - hCG levels - Activity - Count pads, watch for tissue passage
Pregnancy: Urinary Changes
- Urinary frequency d/t pressure on bladder - Dilatation of kidneys and urine - Increased GFR and renal plasma flow d/t release of hormones containing anti-insulin properties, causing gestational diabetes
Factors that influence weight gain: at risk
- Young - Unmarried - Low income - Poorly educated - Poor general health - Insufficient prenatal care - African-American, Southeast Asian, and Hispanic
Amniocentesis
- a transabdominal perforation of the amniotic sac to obtain a sample of amniotic fluid for analysis - Chromosomal abnormalities - Hereditoary metabolic defects - 2nd tri: 16-18 (14-20) - 3rd tri: to detect fetal lung maturity - Procedure
Pregnancy & the Partner: Physical symptoms
- couvade syndrome - Gain weight around middle, nausea - Ambivalence -Pride, joy/overwhelming sense of responsibility - Acceptance 2nd trimester - Prepares for reality 3rd trimester
Ectopic Pregnancy: S&S
- depends upon location - Missed menstrual period - Abdominal pain - Vaginal "spotting"
what are the contraindications to nifedipine
-Caution in women with left ventricular dysfunction and CHF -Concomitant use of CCB with Magnesium has synergistic effect and may cause respiratory depression- can still give both but you MUST watch for issues
Prenatal care: Follow-Up Visits
-Every 4 wks up to 28 wks -Every 2 wks 29-36 wks -Every wk 37 to birth -Weight, BP, UA, fundal height measurement, assessment for quickening/movement - Fundal height - Top of pubic bone to top of uterus (McDonald's method) - Used as an indicator of fetal growth - IUGR or multifetal gestation
Complications of Pregnancy: Abortion
-Loss of pregnancy before fetus is viable, 20 weeks, < 500 gm. -Lay term is miscarriage
Gastrointestinal System: Esophagus
-Lower esophageal sphincter tone decreases -Gastroesophageal reflux common (heartburn)
Preterm Labor: Nursing Interventions
-Maintain bedrest -Tocolytic agents -Betamethasone -Magnesium sulfate -Monitor fetal status
Pregnancy & the Partner
-Partners' reactions vary greatly -Some enjoy involvement -Some experience alienation - May seek comfort elsewhere -Some see pregnancy as proof of masculinity -Undergo less visible changes - Unexpressed, unappreciated
Self-Care Promotion
-Personal hygiene -Avoid hot tubs and saunas -Perineal care -Dental care -Breast care -Clothing -Exercise - Sleep and rest -Sexual activity and sexuality -Employment -Travel , Immunizations, medications
Things to look at
-Pg 300-301 table 11.3 placental hormones and table 11.4 Summary of general body system Adaptations -Pg 292 Figure 11.2 supine hypotensive syndrome -Pg 314 Box 12.1 assessment of risk factors -Pg 324 figure 12.5 pic of fundal ht measurement -Pg 318-319 fig. 12.2 sample health hx summary
Hyperemis Gravidarum: Drugs
-Phenergan, Benadryl, Pepcid, Zantac -Nexium, Reglan, Zofran - IV F&E replacement or TPN
discomfort with sex
-Woman's sexual health linked to self-image -Discuss alternative noncoital modes with spouse
sex
-conditions which contraindicate coitus: -more than one miscarriage -threatened abortion in 1st trim - impending abortion in 2nd trimester -bleeding - premature rupture of membranes (PROM) - abd pain
2nd tri problems
-constipation- exercise moderately, increase fiber and fluid. DONT take laxatives -flatulence- avoid gas forming foods, chew foods slowly. -headaches- stress management. if h/a is constant or frequent, consult dr. -carpal tunnel syndrome- elevate affected arms to relieve edema
Mx of placenta praevia
-correction of general condition - conservative Tx-complete rest, replacement therapy -active Tx- CS espcially in centralis, incomplete centralis and posterior implantation of placenta=> compress by sacrum=>fetal death
Rx of accidental hge
-correction of general condition (expectant Tx??) - Tx the DIC - active Tx: terminate the pregnancy medically by induction of labour if mild or surgically by CS if concealed, bad general condition and baby is still life - follow up of post partum to prevent PPH
postpartum hge in placental praevia can be dt?
-deficient retraction of the lower uterine segment (implantation site) -atony of the uterus as the pt is anaemic -possible lacerations in the cervix and the lower uterine segment dt a morbidly adherent placenta
full term placenta
-discoid w two surfaces - 15-20 cm diameter -1.5-3 cm thickness - 500mg wt -12-20 cotyledons - placenta/fetal wt ratio = 1/7
Discomforts of 3rd trimester
-dyspnea- sleep with extra pillows, avoid overfilling stomach, stay adequately rested. -Insomnia- relaxation, back massage, support body with pillows when in bed, warm milk or shower before bed time to relax. -gingivitis- frequent oral hygiene, adequate diet. -perineal discomfort- rest, good posture
rx of placenta praviae
-expectant Tx -active TX (CS or Vaaginal delivery) - postpartum follow up
follow- up visits
-fetal assessment, FHT, note fetal movement- "quickening" (around 20 wks) -fundal height- allow pt to empty bladder, stretch paper tape from symphysis pubis to top of uterus (fundus),measure in CM.
complications to feotus (acc. hge)
-fetal distress (possibility to CS) - premature labour - death
Medications
-generally ALL drugs (including OTC's) must be aproved by physician -Teratogens- means drugs that are harmful to the fetus -Keep a daily record of all drugs taken - even the most common cold meds can be teratogenic
Physical activity
-generally helpful to continue present activity level. If started a new exercise plan, discuss with physician. -AVOID risky activities ex. mountain climbing or activities not use to involving bouncing, jerking, bearing down, holding breath. (valsalva maneuver) -take pulse- slow down if above 140 -stop activity if experience dyspnea, dizziness, numbness, tingling, or pain of any kind.
obstetrical problems in placental praevia (complications)
-haemorrhagic shock -abnormal presentations -premature labour -inc rate of CS -endagering the integrity of the thin lower uterine segment (when placental praevia mb morbidly adherent) = adherent placenta -liability to postpartum haemorrhage (dt 1. atony, 2. retained placenta, 3. laceration of LUS or cx dt adherent placenta) -inc fetal mortality n morbidity
complications to mother (acc.hge)
-hge (postpartum hge) and shock - severe uterine pain=> neurogenic shock - hematoma => hypofibrinogenemia (<150) - DIC - avascular uterus=> uterine atony (utero-placental apoplexy or couvelaire uterus) => liable PPH - kidney failure-> degenerate ms=>myoglobin that precipitate in renal glomeruli, and also hypovolemia - sheehan's S (dt partial pituitary ischaemia=> 2ry amenorrheoa, failure of lactation, genital atrophy)
causes of accindental hge
-htn -traumatic -bl. dis -idiopathic
Travel
-in normal pregnancy, travel is safe provided conditions are sanitary adn medical care is available -In HI-Risk preg., travel is not recommended after the age of viability -In accidents placental seperation may occur
Gastrointestinal System: Appetite
-increases unless nauseated - Supplies needed additional calories
Missed Abortion: Two major complications
-infections -DIC (disseminated intravascular coagulation)
Disseminated Intravascular Coagulation
-life threatening defect in coagulation that may occur with several complications of pregnancy - No limited to OB -Fibrinogen and plateles usually decreased while PT and PTT will be increased - D-Dimer study confirms fibrin split products and is presumptive for DIC when positive -Tmt: blood replacement as whole blood, pRBC or cryoprecipitate - something initiates clotting mechanisms inappropriately: consumption of clotting factors, fibrin degredation products accumulate to interfere with coagulation, tiny clots in blood vessels blocking flow, excessive bleeding from vulnerable sites like IV's etc.
clothing
-loose, non restrictive -support hose should be put on before rising from bed to prevent edema -No tall heels or platform shoes
Nagel's rule cont...
-nagel's rule is only approximate, so a range is suggested for 7 days before and 7 days after the date calculated. ex.- 11/13/10 to 11/20/10. This is a much more realistic set of dates and is usually more accurate
1st trimester problems
-nasal stuffiness- use humidifier or saline nose drops. NO cold or flu meds unless Dr. approves them -Leukorrhea- clear vaginal discharge. wear peri- pad and change as frequently as possible to keep clean -mood swings- allow pt or significant other to express concerns. May refer to support groups or prenatal classes.
Dental health
-old wives tale is "a tooth for every child" is NOT true -gums may become swollen and have excessive salivation -work on good hygeine and prevention of dental caries with brushing and flossing -tooth or gum infections should be treated promptly to prevent infection of the fetus
sex continued
-old wives tale: sex will hurt the baby or mom - NOT true in normal pregnancy -listen to couples and allow them to express concerns -many temporary problems can be handled by changing positions, alternative methods of satisfaction -continue to protect from STD's
2nd tri. problems
-orthostatic hypotension- deep breathe, and rise slowly from sitting position. Avoid sudden changes in position or warm crowded areas -food cravings- satisfy cravings unless it calls for food which is unsafe to eat or interferes with a normal, well balanced diet. -Heartburn- limit fatty foods or foods that readily produce gas. avoid overeating and lying down after meals. May use antacids, but not bicarbonate.
posture and body mechaninics
-pelvic tilt exercises on hands and knees or standing against the wall will relieve lower back pain (10-12 reps) -use legs to bend- DONT bend from the waist -DONT lift heavy objects
musculoskeletal changes
-posture - Gait
what is the most important cause of accidental hge?
-preeclampsia - or any hypertensive states w pregnancy like preelampsia, essential htn, chronic nephritis
difference b/n length of pregnancy and gestation
-pregnancy is measured from the first day of the last mestrual period (40 wk) -gestation is measured from conception (aprox 38 wks) Which is longer? pregnancy Why is it longer? because its measured by your period before actual conception of the baby has happened.
Chorionic villi sampling
-procedure for obtaining a sample of chorrionic villi for prenatal evaluation of chromosomal d/os', enzyme deficiencies, and gender. -advantages: fewer risks if done later in pregnancies than amniocentesis, and results are available sooner (48 hrs). Can be done10-13 wks.
biophysical profile
-real time US over period of 10 minutes to look for:' -body movement -fetal tone -fetal breathing amniotic fluid -NST -each item can be given score of 0-2. Overall score of 8-10 is considered normal.
types of accidental hge
-revealed bleeding -concealed (m/dangerous) bl may escape to myometrium=> bluish colour=> atony=> removal of uterus -combined
aetiology of placenta praevia
-scarred or poorly vascularized endometrium (in advancing age, multiparity, previous caesarean .delivery) -large placenta (in multiple pregnancy, DM, Rh problem) -ectopic implantation (implantation of fertilized ovum over the isthmus) -abnormal placenta like placenta membranacea
when to do CS in placental praevia?
-serious uterine bleeding irrespective of the duration of pregnancy -placental praevia of 3rd and 4th degrees -post placental praevia -precious foetus -ass cephalopelvic disproportion -vasa praevia and foetus is alive
Percutaneous umbilical blood sampling
-take a sample of blood from the umbilical vessel. Using US, the umbilical vessel is cannulated and a sample withdrawn. Has risk of bleeding and puncture of cord. usually done to determine genetic abnormalities. Done in late 2nd trimester, or as early as 16 wks.
Kegal exercises
-twice daily or as often as you think of it -helps prevent urinary incontinence -prepares pelvic muscles for labor
Nagel's Rule
-used to determin EDC mathmatically / uses 4 steps: 1. Determine the first day of the last menstrual period (LMP) 2. Subtract 3 months from months or add 9 months which ever is most convenient 3. add 7 days going into the next month if necessary 4. add 1 to the year if LMP is after march
Hygeine
-usually perspire freely so may require more frequen showers -avoid "hot" baths or showers to prevent fainting -take showers instead of baths after "water breaks" or expulsion of operculum (mucus plug)
Problems / interventions
-usually the kinds of problems the pt exhibit will change over the course of pregnancy. These problems are called the "discomforts of pregnancy". They are normal occurences in pregnancy which can usally be managed with nsg care. They are arranged according to trimesters so that you can change your care plan as pregnancy progresses.
Infections During Pregnancy: Syphilis: Nursing Interventions
1. Explain the risk factors and long-term effects if syphilis is not treated. 2. Explain implications for fetus/newborn. 3. Stress importance of receiving all three doses if syphilis is greater than 1 year duration.
The greatest accuracy in differentiation of the normal from the compromised fetus is achieved when multiple fetal and environmental parameters are considered together. 5 Parameters are_
1. Fetal breathing movements 2. Gross Body movements 3. Fetal tone 4. Fetal heart rate 5. Amniotic Fluid Volume
AVF Evaluation parts
1. Subjective Assessment- Normal,High,Low 2. Single Pocket Assessment- <1/2 cm - oligohydramnios, >8 cm - polyhydramnios 3. Amniotic Fluid Index
when can fetal movements be palpated
18 weeks
when can quickening be felt
18-20 weeks primgravidas: 14-16multigravidas
palpation of fetal movement
19-22 wks
Frequent gross body movements, continuous eye movements; wider oscillation of FHR; analogous to REM or active sleep in the neonate; FHR baseline bandwidth increased appreciably; bladder volume decreases due to fetal voiding and decreased urine production represent reduced renal blood flow during active sleep
2. State 2F
when is fetal outline palpable thorugh maternal wall
22 weeks
EX number 2
25 y/o women reports being pregnant 4 times counting this pregnancy. One baby was stillborn at 19wks. one pregnancy resulted in twins born at 35 wks, and both survived. one was born at 38 wks. the present time she is in her 6th wk of pregnancy. current pregnancy hx is: G4 T1 P1 A1 L3 -G4 P2
The total erythrocyte volume increases by about __ in women who receive iron supplementation. This increase is necessary to transport the additional oxygen required during pregnancy.
30%
Fibrocystic breast changes are most common for women ages:
30-50
Obstetrical Hemorrhage is the ____ most frequent cause of maternal death in the U.S.
3rd
HTN complicates
5 to 10% of all pregnancy. CHTN higher in women over 40 and older is nearly 10 times higher than for those younger than age 20. Morbidly 10 to 20% of maternal death world wide. Preeclampsia is the 2nd leading cause of mortality in the U.S.
An increase WBC count of ___ is considered normal in pregnancy.
5,000-15,000
Monohydramnios: is defined as___which is the normal of amniotic fluid index.
5-20cm
how sensitive is RRA
90% accurate 6-8 days after conception
DUVALL'S DEVELOPMENTAL THEORY
Addresses family change over time using family life cycle stages based on predictable changes in the family's structure, function, and roles; each stage has developmental task - Stage 1: Marriage and independent home - Stage 2: Family with infant - Stage 3: Family with preschooler - Stage 4: Family with schoolchildren - Stage 5: Family with teenager - Stage 6: Family as launching center - Stage 7: Middle-aged family - Stage 8: Aging family
Variations in Prenatal Care: Age Differences
Adolescents: much less likely than older women to receive adequate prenatal care, there are compliance issues and social/psychologic barriers Women Older than 35: multiparous women, primiparous women are more likely to have planned but some may have fertility issues
What are kick counts?
Aka: fetal movement counting. The client sits quietly or lies down on her side and counts the fetal kicks for a period of time, as instructed.
What is an amniocentesis and why is it done?
Aspiration of amniotic fluid; best performed between 15 & 20 weeks of pregnancy because amniotic fluid volume is adequate and many viable cells are present in the fluid by this time. Performed to determine genetic disorders, metabolic defects, and fetal lung maturity
What is a contraction stress test?
Assesses placental oxygenation and function, determines fetal ability to tolerate labor and determines fetal well bring.
Abortion: Incomplete: S&S
Bleeding, severe abdominal cramping
Urinary System: Kidneys & Ureters
Changes in size and shape - Renal pelves and ureters dilate
Effects of diabetes on pregnancy: Fetal
Congenital malformations Neural tube defects, cardiac defects, caudal regression syndrome Fetal variations in fetal size
Having BV puts the patient at greater risk for ______.
Contracting other STI's preterm labor if pregnant PID (can affect uterus and tubes)
where does the blastocyst adhere on the endometrium?
Decidua basalis
What are the layers of the endometrium?
Decidua basalis Decidua capsularis
hemolysis
Destruction of red blood cells
Adolescent Pregnancy
Developmental tasks - Adolescence - Pregnancy
what are the maternal side effects of magnesium
Diaphoresis Flushing/warmth Nausea/vomiting Headache Visual disturbances Chest pain/ shortness of breath Pulmonary edema
What machines are used to heart FHR at 10-12 weeks? 16-20 weeks? What is used if HR cannot be heard by 20 weeks?
Doppler, fetoscope, ultrasound
Dyspareunia is one of the possible manifestations of STI. What is dyspareunia?
Dyspareunia is painful sexual intercourse for either sex
What are possible causes for elevated levels of AFP?
Elevated MSAFP may be caused by open neural tube defects, esophageal obstruction, open abdominal wall defects, and undetected fetal demise. Additional causes include multifetal gestation, inaccurate fetal age or maternal weight, and maternal diabetes.
__ is term used for day 15- 8 weeks
Embryo
Ex. of Nagel's rule
Ex. : LMP is 2/6/10 1. subtract 3 months/ add 9 mo from date 2/6/10 + 9 mo. = 11/6/10 2. add 7 days 11/5/10 + 7 days = 11/13/10 answer= 11/13/10
What might you want to consider when discussing treatments with a patient with endometriosis? What is the definitive treatment for this d/o?
Fertility; definitive tx is to remove ovaries
What is the two-fold advantage for gas exchange?
Fetal hemoglobin has higher affinity for O2 Bohr effect—decreasing O2 affinity with decreasing pH
How is fetal lung maturity confirmed?
Fetal lung maturity is confirmed by a 2:1 ratio of lecithin/sphingomyelin and the presence of other lipoproteins such as PG and PI, which comprise pulmonary surfactant. A newer test (TDx) evaluates the quantity of surfactant in the amniotic fluid.
What causes bloating and constipation in pregnancy?
Gastric empyting time and intestinal motility are delayed
Gonorrhea
Genital to genital contact or anal to genital contact. Women are frequently asymptomatic. -males: urethral discharge, painful urination, frequency -females: lower abdom pain, dysmenorrhea -left untreated can cause pelvic inflammatory disease - Rocephin IM or Zithromax PO for 7 days abx
Infections in Pregnancy
Group B Streptococcus: - Bacterial infection found in the lower GI and urogenital tracts - Screening cultures at 35-37 weeks - Leading infectious cause of neonatal sepsis and mortality - Carriers often asymptomatic - Intrapartum prophylaxis Vaginal Infections: - Candidiasis - Bacterial vaginosis
NULLIGRAVIDA
Has never been pregnant
How can vena cava syndrome be corrected?
Have patient turn on left side
What is a test of cure?
Having the patient return for follow-up screening to ensure that the treatment has been effective and the STI has been eradicated
What nourishes the corpus luteum to produce progesterone for the 1st 8 weeks? Then what takes over producing progesterone until birth?
HcG (Human chorionic gonadotropin); placenta
Vaccination for hepatitis B antigen may be specifically indicated for who?
Health care workers, IV drug users, clients born in Asia, Africa, Haiti, Pacific Islands, clients previously undiagnosed with jaundice or chronic liver disease, tattoos, hx of blood transfusions, hx of multiple episodes of STIs, clients previously rejected as blood donors, clients with hx of dialysis or renal transplantation, clients from households having members infected with HepB or hemodialysis clients
__ is a softening of the uterus between the cervix and the body of the uterus- softening of the isthmus of uterus; occurs 6-8 weeks of pregnancy.
Hegar's sign
Infections During Pregnancy: Herpes Genitalis
Herpes genitalis caused by herpes simplex virus type 2 (HSV-2), is a chronic recurring infection that causes painful lesions in the genital area and is transmitted by sexual contact.
Reproductive System: Uterus: 36 weeks
Highest level at xiphoid process
FAMILY STRESS THEORY
How families react to stressful events; suggests factors that promote adaptation to stress
What does this cause?
Human Placental Lactogen (hPL) Increased unbound cortisol Reason for gestational diabetes screen at 28 weeks
Later signs of syphilis
Hutchinson's teeth mullberry molars saddle nose saber shins
ruptured ectopic, unstable
IV fluids, blood products, pressors then exploratory laparotomy
With an HIV-positive pregnant woman, as she goes into labor what precaution is taken?
IV zidovudine is administered to the mother during birth to suppress transmission of the virus. Also the child should be washed off immediately, and trauma should be avoided. Infant is also treated with Antiretroviral drugs for first 6 months.
What is supine hypotensive syndrome?
IVC and iliac vein compression Decreased preload leads to decreased cardiac output—syncope
When would you instruct the client to notify the hcp in regards to kick counts?
If there are fewer than 10 kicks in a 12-hour period or as instructed by hcp
Ectopic Pregnancy
Implantation of fertilized ovum outside uterus - 98% in fallopian tube - Significant cause of maternal death - Decreases chances of subsequent pregnancies - Increased rate due to fallopian tube scarring -PID, multiple induced abortion
gestational diabetes: Laboratory tests
In addition to routine prenatal laboratory examinations, baseline renal function should be assessed with a 24-hr urine collection for total protein excretion and creatinine clearance. A random urine sample should be checked at each prenatal visit for possible urinary tract infections, which are common in women with diabetes. Urine also should be checked using a dipstick for the presence of glucose, ketones, protein.
What is vibroacoustic stimulation and what is its expected result during the last trimester of pregnancy?
In vibroacoustic stimulation, an instrument similar to an artificial larynx is used to stimulate fetal movement and accelerations using sound and vibrations. Fetal accelerations are expected after stimulation. Otherwise, the procedure and interpretation are the same as those in a nonstress test. VAS should not be done earlier than 33 weeks' gestation.
Uterine blood flow
Increase in size and number of blood vessels - Expands blood flow dramatically - Late pregnancy blood flow to uterus and placenta reaches 450-650 ml/hr
What is the corpus luteum and what does it produce?
It is formed in an ovary at the site of a follicle, or sac, that has matured and released its ovum, or egg.The corpus luteum produces progesterone. Progesterone makes the lining of the uterus thick for implantation and is necessary to sustain a healthy pregnancy.
How is a Whiff test performed with BV?
KOH is put on a slide with the specimen; amines from the KOH will cause positive Whiff test b/c it will smell fishy
what are the risk factors for PROM
Labor Abruption/Bleeding Intrauterine infection Uterine distention Emergent cerclage (suturing around cervix in pre-viable fetuses) Low socioeconomic status, smoking, STI
cesarean birth
Large fetal size also increases the likelihood that a ______________will be necessary and the risk of postpartum hemorrhage.
Pregnancy
Last 10 lunar months of 28 days (280 days total) and is broken up into trimesters. First trimester is weeks 1-13, Second trimester is weeks 14-26 and third trimester is weeks 27-40.
diabetes: Late Pregnancy
Late Pregnancy. During the second half of pregnancy, when fetal growth accelerates, placental hormones rise sharply.
What happens during late pregnancy with oligohydraminos?
Late in pregnancy causes meconium, hypoxia, adhesions, umbilical cord compression
antihypertensive meds for BREASTFEEDING
METHYLDOPA or HYDRALAZINE
GTD
MOLAR PREGNABCY TREATMENT SERIAL HCG
Preclampsia Pathophysiology
Main pathogenic factor: disruptions in placenta perfusion and endothelial cell dysfunction. Arteriolar vasospasm diminishes diameter of blood vessels, which impedes blood flow to all organs and increases BP Function are depressed in organs (placenta, kidneys, liver, brain).
Definition: the edge of the placenta extends to the margin of the internal os.
Marginal Previa
SUMMARY CONCEPTS
Maternal assessment of fetal movement ("kick counts") is a noninvasive method of evaluating the fetus; another advantage of this test is that it has no cost. The poorly oxygenated fetus usually moves less than the well-oxygenated fetus. The woman may be advised to follow any of several protocols because no standard protocol exists.
What are the risks of amniocentesis?
Maternal hemorrhage, infection, Rh isoimmunization, abruptio placentae, amniotic fluid emboli, premature rupture of membranes (PROM)
GDM: Nursing considerations
Maternal, Fetal, and Neonatal Effects. With a few important exceptions, the effects of gestational diabetes are similar to those associated with preexisting diabetes. The exceptions are that gestational diabetes is not associated with an increased risk for maternal ketoacidosis or spontaneous abortion.
Mild Preeclampsia & Home Care (MP)
May be managed at home Stable, urine protein < 500mg (300-500) in a 24 hour collection Activity Restriction ( pg 663) Teaching ( Box pg 662) Diet
contraction stress test (CST)
Method for evaluating fetal status during the antepartum period by observing response of the fetal heart to the stress of uterine contractions that may induce recurrent episodes of fetal hypoxia.
Which medication is normally used to treat trichomoniasis?
Metronidazole or Tinidazole are the two preferred medications for the treatment of trichomoniasis
Reproductive System: Uterus: 16 weeks
Midway between symphysis pubis and umbilicus
insulin
Most pregnant women who need a hypoglycemic agent take__________ rather than an oral agent, even if the oral agent was effective in the woman with type 2 diabetes.
__ is a woman who is in her second or any subsequent pregnancy.
Multigravida
__ is a woman who has had two or more births at more than 20 weeks gestation.
Multipara
What does a Nonreactive Nonstress Test (Abnormal) mean?
No accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds in duration occur during a 40 mintue observation
Is the hepatitis B vaccine contraindicated for pregnancy?
No, and may even be recommended by the hcp
Should mothers with HIV breastfeed?
No, the virus can be transmitted via breast milk and the risk does not outweigh the benefits of breastfeeding
Can an HIV infected mother breastfeed?
No. The virus is passed through breast milk.
what are the fetal side effects of nifedipine
None known Potential for reducing uterine and umbilical blood flow??
What is a biophysical profile?
Noninvasive assessment of the fetus that includes fetal breathing movements, fetal movements, fetal tone, amniotic fluid index, and fetal heart rate patterns via a nonstress test.
Infections During Pregnancy: Chlamydia: Medical Therapy
Nonpregnant women treated with single dose of oral azithromycin or doxycycline orally for 7 days. Currently, CDC recommends that pregnant women be treated with erythromycin or amoxicillin, although neither is very effective. Many clinicians treat prenant women with azithromycin. Doxycycline is contraindicated in pregnancy.
Hemaglobin
Normal Range for women 11.7-15.5 <11 = anemic which could mean a decrease in oxygen carried through the blood stream
__ is a woman who has never been pregnant.
Nulligravida
__ is a woman who has not given birth at more than 20 weeks gestation.
Nullipara
Severe Preeclampsia KEY Interventions
Nutrition Magnesium sulfate Control of blood pressure *NEVER abbreviate MGSO4 any where in a medical record -safe med.*
Toxo (occurs)
Parasite occurs with undercooked meats and cats
Prenatal Period
Period of physical and psychologic preparation for birth and parenthood. This period is the best opportunity for nurses and members of the health care team to influence family heath and promote prenatal care.
ANTEPARTUM
Period of time beginning with conception and ending with onset of labor
POSTPARTUM
Period of time from delivery of placenta to approximately 6 weeks after delivery
INTRAPARTUM
Period of time that begins with onset of regular uterine contractions and lasts until expulsion of placenta
Bleeding disorders in late pregnancy fall into two categories . .
Placenta previa and abruptio placenta
Third Trimester causes of bleeding
Placenta previa, abruptio placenta, vasa previa (Rare)
What is happening when the total blood volume increases?
Plasma volume 50-70% early 1st tri RBC mass 20-35% in 2nd/3rd tri (needs iron) Leads to physiologic anemia of pregnancy and HCT is 33-35% in 3rd try
what are the contraindications to indomethacin use to delay labor
Platelet dysfunction or bleeding disorders Hepatic dysfunction GI ulcerative disease Asthma Renal dysfunction
Nsg interventions for the nitrazine test?
Position client in the dorsal lithotomy position, touch the test tape to the fluid, assess the test tape for a blue-green, blue-gray, or deep blue color which indicates that the membranes are ruptured causing leakage of the amniotic fluid.
Nsg interventions for fern test?
Position the client in the dorsal lithotomy position, instruct client to cough, which causes the amniotic fluid to leak from the uterus if the membranes are ruptured.
Consistent late decelerations occurring repeatedly with most (>50%) contractions Variability may be decreased and FHR may not accelerate with fetal movement Management depends on the presence of reactivity and fetal maturity
Positive Test
Sensory Organs: Ear
Possible blocked ears w/mild hearing loss
In DOPPLER VELOCIMETRY,No benefit has been demonstrated other than in pregnancies with suspected fetal growth restriction and in cases of___ Not proved of value as a screening test for detecting fetal compromise in the general obstetric population
Postterm pregnancy DM SLE Antiphospholipid antibody syndrome
•Macrosomia and associated traumatic delivery •Delayed organ maturation: esp the lungs •FGR (fetal growth restriction), aka IUGR (intra-uterine growth restriction) •Congenital anomalies -Cardiac -Neural tube -Sacral agenesis (caudal regression) These are complications of which type of diabetes?
Pre-existing Diabetes
What major risks are associated with CVS?
Pregnancy loss after CVS is similar to loss rates after amniocentesis. The likelihood that chromosome findings will be questionable and lead to additional testing such as amniocentesis is greater.
Vitamin D
Purpose: Involved in absorption of calcium and phosphorus, improves mineralization Sources: fortified milk and margarine, egg yolk, butter, liver, seafood and the SUN
Prenatal Care
Purpose: to identify existing risk factors and other deviations from normal. Emphasis on preventive care and optimal self-care. It is best for this to begin EARLY in pregnancy
Testingfor Rubella
Serologic (IgM, IgG) (routine testing, all pregnant women)
__ is a fetus born dead after 20 weeks' gestation.
Stillbirth
PREECLAMPSIA and ECLAMPSIA
Systemic pregnancy-induced disease process involving HTN and proteinuria
what are the fetal side effects of terbutaline
Tachycardia Neonatal hypoglycemia
What causes pyrosis in pregnancy?
The uterus pushes on stomach causing reflux of acid secretions from stomach into lower espohagus
NURSE ALERT
The woman is at risk for a boggy uterus and a large lochia flow as a result of the magnesium sulfate therapy. Uterine tone and lochia flow should be assessed frequently. *The preeclamptic woman is unable to tolerate excessive postpartum blood loss because of hemoconcentration. Oxytocin or prostaglandin products are used to control bleeding. Ergot products (e.g., Ergotrate and Methergine) are contraindicated, because they increase blood pressure.
why do some women develop ketosis between meals and overnight?
The woman's body switches from glucose metabolism to lipid metabolism once glucose from food intake had been used up.
What is occurring at ovulation during the cervical mucous fern test?
There is no progesterone to inhibit the estrogen-induced fern pattern.
Which precaution should a mother with Hepatitis B take in order to breastfeed without transmitting the infection to the newborn?
There is no specific treatment for the mother, as the disease usually resolves spontaneously within four months. However, the child should be treated prophylactically at birth and should adhere to the CDC's recommended schedule of vaccinations.
Treatment of Hepatitis B?
There is no specific treatment of Hep B infection. Usually resolves spontaneously in 3 - 16 weeks.
What do Braxton-Hicks contractions do?
They help move blood through the placenta
Abruptio Placenta
Third Trimester - Premature separation of placenta from uterus. After 20 weeks in third trimester. Significant morbidity. -Classic symptoms: vag bleeding, uterine tenderness, excess uterine activity with poor relaxation between contractions, abdominal pain sudden and severe with board like abdomen. - Sudden onset of pain, with bleeding -Board like abdomen, firm uterus with contractions. -Give blood and fluid -no time for steroids
diabetes and pregnancy
To understand the relationship between _____________________, an understanding of the way pregnancy and diabetes alter the metabolism of food is necessary.
chorionic villus sampling (CVS)
Transcervical or transabdominal procedure to obtain a sample of chorionic villi (projections of the outer fetal membrane) for analysis of fetal cells.
How does the procedure for first-trimester ultrasonography differ from that performed during the second trimester?
Transvaginal ultrasonography is most often performed during the first trimester, when the uterus lies within the pelvis. A transabdominal procedure is more common during the second and third trimesters, when the uterus is above the pelvic brim and the contents are clearly visible.
Infections During Pregnancy: Toxoplasmosis: Treatment
Treatment includes sulfadiazine, pyrimethamine, and spiramycin. If toxoplasmosis is diagnosed before 20 week's gestation, therapeutic abortion may be offered because damage to the fetus tends to be more severe than if the disease is diagnosed later in pregnancy.
Multifetal pregnancy
Twins or more pregnancies often end in prematurity, rupture of membranes before term is common, congenital malformations are twice as common in monozygotic twins as in singletons, no increase in incidence of congenital anomalies in dizygotic twins though
Classification
Type 1, type 2, gestational diabetes
Prenatal History
Used to identify risk factors to the mother and/or fetus - Current and past pregnancies - Gynecologic history - Current and past medical history, including substance abuse - Family medical history - Religious, spiritual, cultural, and occupational history - Partner history - Social history and preferences
•Turning inside out of the uterus. •Usually Iatrogenic •Patient can go into profound vasovagal shock. (REPLACE THE UTERUS IMMEDIATELY) •Diagnosis "It's in your face". Which cause of postpartum hemorrhage?
Uterine Inversion
Signs and Symptoms of Pregnancy: Probable Signs
Uterine enlargement, Goodell's Sign (Hegar's Sign), Braxton Hix contractions, Uterine souffle (auscultation of uterine blood flow), Ballotement (occurs at 20 wks and is a sudden tap on abdomine causes fetus to rise and rebound), and positive pregnancy test
What happens when the collecting system dilates?
Uterine mechanical obstruction Progesterone relaxation of smooth muscle Higer risk of UTI/pyelonephritis
•"Complete separation of the uterine musculature through all of its layers." •Usually the fetus is extruded in the abdomen. Dx?
Uterine rupture
Its use in cases of abnormal FHR tracings in labor reduces the need for fetal scalp blood sampling
VIBROACOUSTIC STIMULATION (VAS)
What are some umbilical cord abnormalities?
Velamentous insertion Single artery
What is velamentous insertion?
Velamentous insertion is when umbilical vessels divide prior to reaching the chorionic plate of the placenta.
Infections During Pregnancy: Cytomegalic inclusion disease: Signs/Symptoms/Risk
Very little problem for adult, but great danger to fetus.
Is fetal heart rate monitoring necessary?
Yes, for 1 hour after procedure, and a follow-up ultrasound to check for bleeding or hematoma formation is done 1 hour after the procedure
If a pregnant woman is diagnosed with syphilis, should it be treated, and if so, how?
Yes, syphilis should be treated because the disease can lead to serious systemic diseases and potentially death. Additionally, the disease can be transmitted transplacentally at any time during pregnancy. The recommended treatment is Benzathine penicillin G, with varying strength based on the stage of the disease. If a penicillin allergy, exists erythromycin can be used but it will not cross the placenta
what is management of placental abruption
always stabilize mother first if preterm: elestone, tocolysis, bed rest, fetal monitoring and determining best mode of delivery
PARVOVIRUS
any of a group of viruses containing DNA in an icosahedral protein shell and causing disease in dogs and cattle
Tx for vulvovaginal candidiassi
azole's (topical is better bc less tetro affects)
Dx: rule out ectopic
can't definitively dx IUP or ectopic. follow w/ serial hCG Q48h
main complaint of placenta praevia
causeless, painless, recurrent vaginal bleeding dt braxton-hicks contraction
Assess uterine activity,
cervical changes, and fetal status. Membranes may rupture, or fast dilatation may have occurred - delivery may be immediate. ( decelerations may occur, if delivering regional anesesthia is not recommended)
adrenal glands
cortisol increases (also called the "stress hormone") in pregnancy. - aldosterone increases- makes the plasma volume increase in pregnancy
what is immunologic pregnancy testing
cost effective; OTC
missed abortion
death of embryo/fetus <20wks, complete retention of POC tx: 1st trimest: D&C or misoprostol 2nd trimest: D&E or high dose oxytocin and prostiglandins
what are the goals in managing preterm labor
delay delivery for 48 hours to give steroids provide time for safe transport of the mother prolonging pregnancy while treating self limiting conditions that could have caused labor
general signs in placental praevia
depend on degree of bl loss pallor cold clammy sweat tachycardia subnormal temperature lowered BP
In pregnancy, the femoral venous pressure slowly rises as the uterus exerts increasing pressure on return blood flow, which can cause what? What else contribues to it?
dependent edema and varicose vein formation in legs, vulva, and rectum; reduction of plasma colloid osmotic pressure resulting from a reduciton in plasma albumin further maintains the presence of fluid in extravascular space.
renal changes
dilation of renal pelvis and ureters - both kidneys enlarge during pregnancy in length and weight. ureters elongate, widen and become more curved above the pelvic rim as early as 10 weeks gestation
edema assessment, we look for what?
distribution, degree, and pitting
facial melasma or "mask of pregnancy"
exacerbated by sun exposure. most fade by the end of pregnancy.
What is the dx criteria for TSS?
fever > 102 F, rash, nausea, vomiting, dizziness, hypotension, desquamation of skin after about a week, inflamed mucous membranes
What are the four benign conditions of the breast?
fibrocystic breast changes, fibroadenoma, intraductal papilloma, duct ectasis
What do you need to teach your patient when they are being treated for an STI?
finish entire coarse of antibiotics and do not have sex until both partners are free of symptoms and have completed antibiotic treatment therapy
when do you screen for fetal aneuploidy or abnormalities
first or early second trimester diagnosis allows for more time for decision making, greater privacy, and safer methods of termination optimal time is about 11 weeks
What are three functional ovarian cysts?
follicular cysts, corpus luteum cysts, and theca lutein cysts
The goals of therapeutic management
for a pregnant woman with diabetes are to: 1) maintain normal blood glucose levels, 2) facilitate the birth of a healthy baby 3) avoid accelerated impairment of blood vessels and other major organs. To achieve this outcome, an intensive, team approach to care required.
HELLP syndrome Laboratory diagnosis
for a variant of severe preeclampsia that involves hepatic dysfunction Hemolysis (H) Elevated liver enzymes (EL) Low platelets (LP) Diagnosis associated with increased risk for adverse perinatal outcomes
Since the woman with preeclampsia is at risk
for abruptio placentae, it is important to assess uterine tone and tenderness and the presence of vaginal bleeding.
Cervical Pap
for cervical cancer
Assess the edema
for distribution, degree and pitting. ( seen most in feet and ankle)
Glucose Tolerance
for gestational diabetes
Signs and symptoms of BV:
foul, fishy odor grey/white thin watery discharge clue cells (remember: if there's fish, you're gonna go fishing for clue cells) Positive Whiff test alkaline vaginal environment
Infections During Pregnancy: Rubella
german measles is caused by a virus.
why is placenta previa a concern
greatest risk is bleeding WORRY ABOUT PRETERM BIRTH slowed fetal growth birth defects always results in an operative delivery
risk factors for ectopic pregnancy
h/o STI's & PID prior ectopic tubal surgery pelvic/abdominal surgery endometriosis IVF or other ART DES exposure current use progesterone/estrogen IUD
risk factors cervial incompetence
h/o cervical surgery: cone biopsy, dilation of cervix h/o cervical lacerations w/ delivery uternine anomalies DES exposure in utero many have no known risk factors
Antepartal teaching
important part of each prenatal visit to help mom deal with changes occurring due to pregnancy
chronic hypertension > hypertension meds
important to discontinue or change any known to be embryotoxic. Reinsituted when BP increases, especially after 28 weeks
after birth preeclampsia/eclampsia resolve...
in about 48 hours. Manifested by <<< DIURESIS >>>
SEVERE PRECLAMPSIA INTERVENTIONS 1. HOSPITAL CARE
in severe preclampsia pt will be hospitalized.
why do menses stop?
increased estrogen and progesterone from corpus luteum
Effects of diabetes on pregnancy: maternal
increased spontaneous abortions, preeclampsia, ketoacidosis, UTIs, difficult labors
pregnant volume
increases 50% above pre-pregnant state pregnant volume =1500ml Begins at 10-12 wks and peaks at 32-34 wks, and decreases slightly by 40 wks
blood volume
increases both in blood cells and volume. increase in pregnancy to meet demands of increased perfusion of mothers and fetus's vital organs
cardiac output
increases by 30-50% over non pregnant state
GDM
is a carbohydrate intolerance of variable severity that develops or is first recognized during pregnancy. Some women diagnosed with gestational diabetes may actually have unrecognized type 2 diabetes. GDM is an added risk factor that a woman will develop type 2 diabetes later in life. Factors such as obesity, inactivity, abnormal cholesterol levels, vascular disease, or family members with type 2 diabetes further increase a woman's risk to develop type 2 diabetes outside pregnancy.
Preeclampsia Defined
is a condition unique to human pregnancy; signs and symptoms develop only during pregnancy and disappear quickly after birth of the fetus and placenta.
HELLP syndrome
is a laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction; it is characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). A woman's platelet count must be less than 100,000
2. (MP@H)Fetal movement
is counted daily. Non-stress test (NST), once or twice a week, and a biophysical profile (BPP) as needed.
Eclampsia
is the onset of seizure activity or coma in the woman diagnosed with preeclampsia, with no history of preexisting pathology that can result in seizure activity (Roberts & Funai , 2009, Sibai, 2007). The initial presentation of eclampsia varies, with one third of the women developing eclampsia during the pregnancy, one third during labor, and one third within 48 hours postpartum (Roberts and Funai).
visible abd changes
late in pregnancy
preeclampsia home care
lateral recumbent position rest, adequate fluid intake helps renal perfusion and bowel function
Reduced kidney perfusion
leads to possibly oliguria. Protein, primarily albumin, is lost in the urine. Uric acid clearance is decreased; however, and serum uric acid levels increase. Sodium and water are retained
Rupture of subcapsular hematoma (in liver) is a
life-threatening complication & surgical emergency
Linea nigra
line from symphysis pubis to top of fundus
varicella vaccine
live, avoid in prego
What are the characteristics of the primary episode of herpes genitalis?
longest and most severe outbreak prodromal symptoms include low grade fever, inguinal adenopathy (enlarged inguinal lymph nodes), and malaise typically occurs two weeks after exposure
when assessing 2nd and 3rd trimester bleeding with trans-vaginal ultrasound what do you look for
look for cervical incompetence, shortening and look at membranes look at placental location and separation look at cord flow with doppler
unruptured ectopic
methotrexate for <4cm w/o heart beat and reliable f/u assess transaminases, creatinine serially follow hCG (rises in 1st 3 days, then falls day4-7) if doesn't fall, repeat methotrexate monitor for incr abdom pain, bleeding, signs shock
At what age does ovarian cancer typically occur?
mid 50's
when to do vaginal delivery in placental praevia?
mild bleeding, 1st or 2nd degree with no cephalopelvic disproportion, normal lie n presentations, good uterine contractions, guard against PPH, good general condition
Describe the late/latent stage of syphilis.
more damage to internal organs occurs (brain, heart, bones, joints)
Definition: The implantation of the placenta over the cervical os
placenta previa
obstetric causes (usually placental sites)
placental praevia accidental hge rupture uterus (mb extra-placental) vasa praevia(mb extraplacental)
why placenta praevia vaginal bleeding is painless?
placental separation is caused by a painless braxton-hicks uterine contraction for formation of the lower uterine segments
causes
placental site incidental (not related to pregnancy) vasa praevia bl. dis (coaguability of blood)
what fetal complications are associated with placenta previa
preterm delivery and complications of preemies intrauterine growth restriction malpresentation congenital abnormalities vasa previa
Having trich while pregnant increases the risk for:
preterm labor and low birth weight
why is it important to get a detailed info about past obstetrical history
prior pregnancy problems recur! 20% risk for recurrence for most of these things
mitosis
process by which the nucleus and duplicated chromosomes of a cell divide and are evenly distributed, forming two daughter nuclei
palmer erythema
red blotches on palmer surface of hands
fundal hight
reliable gestational age until 36 weeks
What are some physical changes that occur during menopause?
reproductive changes, dry skin, palpitations and shifts in lipids, dyspareunia, cognitive changes, vasomotor changes (hot flashes)
varicosities in the legs, vulva, and perineum.
result of unstable valves in the viens and prolonged sitting and standing
positive
signs attributable only to the presence of the fetus. *legally diagnose pregnancy.
when should you deliver after PROM
signs of infection labor positive fetal lung maturity (32-34 weeks) at 34 weeks
what are signs of intrauterine infection, how do you confirm?
signs: fever, uterine tenderness, fetal tachycardia do amniocentesis to confirm chorioamnionitis: glucose < 20, positive gram stain and culture, WBC count
what is the ddx for first trimester bleeding
spontaneous abortion ectopic pregnancy postcoital bleeding vagina, vulvar or cervical lesions or lacerations gestational trophoblastic disease non-pregnancy causes
Dx: symptoms, signs and Ix
symptoms: bleeding not severe but ass w abdominal pain signs: abd: general abd tenderness, cannot easily palpate the fetal position need US, vaginal xm: nonclotting and small or moderate blood Ix: US
SEVERE preeclampsia S/S
sys >160, dias >110, proteinuria >2 or ≥2+ dipstick, Oliguria <500ml in 24hr (rapid weight gain), confusion, headache, epigastric pain, RUQ abdominal pain, thrombocytopenia <100,000, pulmonary edema, FGR
What cardiovascular change is common in pregnancies?
systolic murmur
How can chlamydia be dx?
taking a specimen of the dc; men used to get swabbed, but there is now a urine test for them
Effects of pregnancy on diabetes: Late
tendency to be hyperglycemic
Effects of pregnancy on diabetes: Early
tendency to be hypoglycemic
what are commonly used tocolytics
terbutaline nifedipine magnesium sulfate indomethacin
bladder tone
tone is decreased causing urinary frequency. also, the large uterus tends to compress the bladder - causing urgency
OLIGOHYDRAMNIOS
too little amniotic fluid LESS THAN 500 ml
POLYHYDRAMNIOS OR HYDRAMNIOS
too much amniotic fluid
HIV and breastfeeding
transmission can occur, do not b-feed
incidental hge dt
traumatic, polyps, neoplastic Mx: treat the causes
what is treatment for cervical insufficiency
treatment depends on gestational age cerclage placement (suture): mcDonald (pictured) Shirodkar abdominal
possible early sign of abruption
uterine tenderness with increasing tone or ideopathic preterm contractions
home care management option only for
who: stable, able to comply w/med regimen, reliable self-monitoring, immediate recognize and report S/S
Post-partum Management of Gestational Diabetes: •Insulin requirements drop sharply after delivery as insulin antagonists from the placenta are no longer present •Most ______________ diabetics do not need insulin for the first 48-72 hours after delivery -Monitor plasma glucose q6hr -Treat with insulin if glucose > 150mg/dl •____________ Diabetics usually do not need insulin post-partum -Test with 75 gram GTT at 6-8 weeks post-partum to assure return to normal -Yearly screening with FBS for diabetes. Increased likelihood of becoming diabetic later in life.
•Insulin requirements drop sharply after delivery as insulin antagonists from the placenta are no longer present •Most insulin dependent diabetics do not need insulin for the first 48-72 hours after delivery -Monitor plasma glucose q6hr -Treat with insulin if glucose > 150mg/dl •Gestational Diabetics usually do not need insulin post-partum -Test with 75 gram GTT at 6-8 weeks post-partum to assure return to normal -Yearly screening with FBS for diabetes. Increased likelihood of becoming diabetic later in life.
cardiovascular changes
-blood volume, -cardiac output, - blood pressure, blood components
Pregnancy: Vaginal Changes
- Mucosa thickens - Increased secretions d/t loosening of connective tissue - Yeast infections
pregnancy: Cardiovascular System:Heart: Size and position
- Myocardium enlarges slightly - Pushed upward and toward left
What causes TSS?
anything that blocks the cervical os (tampons, cervical cap, etc)
What causes nasal congestion and epistaxis in pregnancy?
estrogen-induced edema and vascular congestion of the nasal mucosa.
Definition: The placenta lies in the lower uterine segment, but does not extend to the cervical os. -Usually self-resolving
low-lying placenta
preeclampsia characteristics
(mild or severe) hypertension (vasospasm) and proteinuria > decreased placental perfusion > decreased organ perfusion (disappear after birth)
lateral recumbant position
(side-lying)- most efficient position to improve renal function. Also helpful to increase unrine output if mom has edema
local abdominal signs in placental praevia
uterus is lax, not tender, possible malpresentation (dt disturbed uterine ovoid), non engagement
hegar's sign
widening of softend uteral isthmus - compression of isthmus on bimanual exam
aetiology placenta praevia 1. m/c: 2. .... 3. persistent.....
-low lying implantation from start of zygote - large placenta, multiple pregnancy, Rh incompatibility - chorion laeve
Often pressure of the enlarging uterus on the abdominal muscles causes the rectus abdominis muscle to seperate, producing?
Diastasis recti
Second Trimester causes of bleeding
Gestational Trophoblastic Disease
Discomfort Measures: Leg Cramps
- 2nd-3rd trimesters, more frequent at night - Causes: buildup of pyruvate and lactic acid - Interventions: stretching; hydration; proper footwear; hot shower or bath; massage; elevate legs after walking; dorsiflexion; Tums with calcium; supportive hosiery; if persistent, call HCP to evaluate for DVT
Dietary Reference Intakes
(DRIs) - Estimated Average Requirement (EAR) -Amount of a nutrient estimated to meet needs of half the healthy people in age group.
Hyperemis Gravidarum
(HEG) -Persistent uncontrollable vomiting <20 weeks -Can lead to weight loss >5% -Dehydration, acid-base imbalance, electrolyte imbalance -Cause unknown: possible allergy to fetal proteins, increase pregnancy hormones -Incidence: increased in unmarried white women, primips, Multifetal
dependent edema
(lowest parts of body) ambulatory > feet and ankles. Bedrest > sacral region
Infections During Pregnancy: Acquired Immunodeficiency Syndrome
(AIDS) cause by the human immunodeficiency virus (HIV), is a multisystem disorder that enters the body through blood, blood products, and body fluids such as semen, vaginal fluid, and urine, HIV affects T cells, thereby depressing the body's immune response. The highest incidence of AIDS occurs in homosexual or bisexual men, heterosexual partners of persons with AUDS, IV drug users, hemophilacs, and fetuses of women at risk or HIV positive. Persons generally test positive for HIV with in weeks to 6 months of exposure but may remain asymptomactic for 5 to 10 years or more. In the US the vast majority of pediatric AIDS cases have resulted from perinatal transmission from mother to child.
Infections During Pregnancy: Cytomegalic inclusion disease
(CID) is caused by the cytomegalovirus (CMV). Chronic persistent infection with viral shedding for years. Usually asymptomatic in adults and children.
Contraction stress test
(CST or OCT) - Determines FHR under stress of contractions - 3 contractions in a 10-min period - Nipple stimulation or oxytocin - Observe for hyperstimulation and assess BP q 15 mins - 3 contractions, 40 sec duration in 10 min - Negative if no late decals
Chorionic villus sampling
(CVS) - Evaluation of chromosomal disorders, enzyme deficiencies, fetal gender determination, sex-linked disorder - 8-12 wks - Continuous ultrasound guidance - Need full bladder
*Antidote for mg toxcity*
*ANTIDOTES--Calcium Gluconate* or calcium chloride (antidotes for magnesium sulfate can be given ----IV may be ordered *(10 ml of a 10% solution, or 1 g) OR ----slow IV push (usually by the physician) over at least a 3 minute period* to avoid undesirable reactions such as arrhythmias, bradycardia, and ventricular fibrillation ( Cunningham, 2010).
Pregnancy: GI Changes
- N/V - Ptylaism (increased salivation); cause unknown - Softening and bleeding of gums: seek dental care before pregnancy to avoid periodontal disease - Constipation d/t increased hormones, causing decreased peristalsis; possible separation of bowel wall - Heartburn - Gallstones d/t increased estrogen, causing relaxation of bile duct tubules, causing backup of fluid - Hemorrhoids d/t constipation, causing straining - Pica
Second Trimester Discomforts: Backache
- Shift in center of gravity - Muscle strain - Rule out uterine contractions, UTIs, ulcers, back disorders - Pelvic tilt or pelvic rock to alleviate pressure
CHORIONIC VILLUS SAMPLING (CVS)
- Used to detect genetic, metabolic, and DNA abnormalities - Needle aspiration of chorionic villi from placenta - Provides earlier dx than amniocentesis - Cannot detect neural tube defects - Pregnancy loss is 2x higher than amniocentesis - Potential for limb reduction
Discomfort Management: Breast Tenderness
- Usually present in 1st trimester but can be seen throughout pregnancy - Causes: increased estrogen and progesterone - Interventions: supportive bra
Abortion: Threatened: S&S
- Vaginal bleeding 1st sign - 1/3 experience "spotting" - Rhythmic uterine cramping - Persistent backache, pelvic pressure
LACERATION R/T POSTPARTUM HEMORRHAGE
- Vaginal bleeding that persists with firmly contracted uterus - Can be on perineum, vagina, or cervix - Risk factors: nulliparity, epidural, precipitous birth, operative birth, macrosomia
Maternal Emotional Responses: Change in body image
- Varies from person to person - Some feel beautiful - Some feel overweight & uncomfortable
First Trimester Discomforts: Fatigue
- Vast physical changes - Psychosocial changes - Rule out anemia, infection, and blood dyscrasias - Good posture, realistic schedule for rest
THROMBOPHELBITIS
- Venous thrombosis: thrombous formation in superficial or deep vein, usually in legs; life-threatening--can become PE - Causes: increased coagulability d/t pregnancy, venous stasis - S/S: tenderness; local heat and redness; edema; low-grade fever; positive Homan's sign; venography or Doppler ultrasound for diagnosis - Treatment: IV heparin; bedrest; leg elevation; analgesics; possibly antibiotics - Prevention: avoid leg trauma; early ambulation
Abortion: Spontaneous
-15%-20%, increases with age -Most in 1st 12 weeks - Causes: -- Congenital anomalies (most common) -- 50%-60% chromosomal --Infection: syphilis, toxoplasmosis, rubella, CMV -- Endocrine disorders hyperthyroidism -- Anatomical defects: uterus, cervix
-Insulin therapy
-1st trimester: insulin needs generally decline -2nd & 3rd trimester: insulin needs increase -During labor: tight glucose control -Postpartum: insulin needs decline rapidly - Timing of delivery - Get to at least 38 weeks if possible
Gestational Diabetes Mellitus
-A carbohydrate intolerance of variable severity that develops or is first recognized during pregnancy
Anemia
-A decline in circulating red blood cell mass occurs -Reduces the capacity to carry oxygen to vital organs of mother or fetus -HBG <11 - 1st & 3rd trimesters, <10.5 2nd trimester - 20%-60% incidence -Iron-deficinecy anemia
Pregnancy and Siblings
-Age dependent -Some excited, others negative reactions -Preparation - Reinforcement of love and caring - Include in plans
Immune System
-Altered to allow fetus to grow undisturbed -Resistance to infection decreased
Cardiovascular System: Blood Flow
-Altered to include placenta (500-800 ml/min) -50% more blood circulates through kidneys -Increased skin circulation to dissipate heat -Blood flow to breasts increased 2-3 times -Weight of uterus partially obstructs blood return from veins of legs - May lead to varicosities
Abruptio Placentae: Nursing management: Intervention
-Asses for shock -Monitor fetus -Promote tissue oxygenation -Collaborate with physician for fluid replacement -Prepare for surgery -Promote emotional comfort
fetal heart rate
-Auscultate with hand held Doppler -0-28 weeks - Weight, BP, urine, FH, FHR - 24-28 wk: blood glucose level - 29-36 wk: all previous assessments, plus edema - Tight rings, swelling around eyes, significant - RhoGAM if indicated (mini dose) - Pelvic exam - Select pediatrician - Feeding options -37-40 wks: screen for GBS, gonorrhea, chlamidia - Leopold's maneuvers
Positive Indications of Pregnancy
-Auscultation of fetal heart sounds - 18-20 wks by fetoscope - 10 wks by electronic Doppler - Rate depends on gestational age - Must distinguish between fetus and mother -Fetal movements felt by examiner -Visualization of the fetus - Ultrasonography: 4 wks after missed period
Hypertensive Disorders: Gestational hypertension
-BP elevation after 20 wks that is not accompanied by proteinuria -May progress to preeclampsia -If persists after birth, chronic hypertension is diagnosed
Category I should include all of the ff:
-Baseline rate: 110 - 160 beats per minute; Baseline FHR variability: moderate; Late or variable decelerations: absent; Early decelerations: present or absent; Accelerations: present or absent.
pregnancy: Cardiovascular System: Plasma Volume
-Begins to increase at 6-8 weeks -Peaks at 4700-5200 ml at 32 weeks - 50% above normal values -Needed for two reasons: - Transport nutrients and oxygen to placenta -Meet demands of expanded maternal tissue
postpartum hemorrhage -Blood loss in excess of _____ml for a vaginal delivery or _____ml for a cesarean section
-Blood loss in excess of 500 ml for a vaginal delivery or 1000 ml for a cesarean section
Recurrent Spontaneous Abortion
-Defined as 3 or more -Causes: -probably genetic - Chromosomal abnormalities and anomalies of reproductive tract - Inadequate hormones - Diabetes - Lupus - STDs - Incompetent cervix
Recognizing pre term labor
-Definition: labor at 20-37 wks which should be stopped to prevent preterm birth - Call Dr. if: -contractions q 10 min or more frequently for an hr - backache which is regular and hard for over an hr - bloody spotting or fluid leaking from the vagina
Cardiovascular System: Blood Components
-Erythorocytes increase by 25%-30% - Increases maternal demand for iron
Treatment of Abruptio Placenta
-Evaluate cardiac status of mom and fetus - If mild condition and fetus is ok: bed rest and tocolytic drugs to decrease activity (Rare due to high risk) - Aggressive TMT: prevent complications, delivery immediately if necessary if signs of fetal compromise exist of there is excessive bleeding, intense monitoring, blood volume replacement available and 2 large bore IV lines should be started.
1st trimester problems
-Fatigue- rest as needed. eat well balanced diet. -N&V- eat crackers and sprite on waking. keep at bedside. -Eat 5-6 small meals/day . spreading food intake out to prevent hypoglycemia -avoid gas forming or fatty foods -report n&v to dr. if not gone by 2nd trimester
Integumentary System: Skin
-Feels warm, perspire more -Hyperpigmentation: 90% Melasma: "mask of pregnancy" -Forehead, cheeks, bridge of nose - Linea nigra - Cutaneous vascular changes - Estrogen causes blood vessels to dilate - Angiomas, palmar erythema
Integumentary System: Hair & Nails
-Hair grows more rapidly -Less hair loss -Nail growth increases - Thinning and softening of nails
Reproductive System: Uterus: 40 weeks
-Head descends into pelvic cavity -Lightening - Contractility
Abruptio Placentae: Nursing management: Assessment
-Hemorrhage: evident or concealed -Pain -VS -Condition of fetus -Uterine contractions -OB history -Length of gestation -Lab data
Gastrointestinal System: Mouth
-Hyperemia leads to gingivitis and bleeding - Ptyalism: excessive salivation -Teeth unaffected
Urinary System: Bladder
-Increased urinary frequency 1st and 3rd trimesters -Capacity doubles by term -Nocturia -Burning or pain may indicate infection
Reproductive System: Vagina & Vulva
-Increased vascularity - similar to cervix -Hypermeia increased vaginal discharge • pH acidic (3.5-6) - Discourages growth of harmful bacteria - Favors growth of yeast infections • Tissues more pliable
Respiratory System: Oxygen Consumption
-Increases 15%-20%% - ½ used by fetus and placenta
Endocrine System: Pituitary Gland
-Increases in size -Most hormones are suppressed -Posterior pituitary secretes oxytocin: Stimulates milk-ejection, contractions of uterus
Urinary tract
-Infections are common. Steps to prevent include: -washing hands after toileting -avoid bath oils, bubble bath -clean front to back -wear cotton crotch underpants -use soft, white tissue -avoid tight fitting clothes -drink 2-3 L of liquid/day -increase liquids if urine is brown or concentrate -don't limit fluids to prevent going to bathroom -void as often as needed - dont try to retain urine for long periods of time -yogurt or acidophilus milk may prevent UTI
Braxton Hicks contractions
-Infrequent during 1st two trimesters -Mistaken for false labor
Grandparents
-Involvement -Changing roles -Classes
Integumentary System: Connective Tissue
-Linear tears: Strae gravidarum -Abdomen, breasts, buttocks -Antipruritic creams to control itching
Metabolism Changes: Water Metabolism
-Needed to meet needs of fetus, placenta, anmiotic fluid, and blood volume -Delicate balance
Pregnancy: Pica
-Non-nutritive eating -Associated with poverty and inadequate diets -Iron deficiency anemia
Preterm Labor
-Occurs after the 20th week and before the 37th week of gestation -Contractions every 10 minutes lasting 30 seconds or longer -Documented cervical change -Effacement of 80% -Dilation of 2 cm
Infections During Pregnancy: Syphilis: Signs/Symptoms/Risk
-Primary stage: Chancre, slight fever, malaise. Chancre lasts about 4 weeks, then disappears. -Secondary stage: Occurs 6 weeks to 6 months after infection. Skin eruptions (condyloma lata); also symptoms of acute arthritis, liver enlargement, iritis, chronic sore throat with hoarseness.
Cardiovascular System: Blood Pressure
-Remains stable during pregnancy -Decreases when lying on left side -Consistency of measurement important
Endocrine System: Thyroid Gland
-Rise in total thyroxin -Gland increases in size -Basal metabolic rate increases up to 25%
Abruptio Placentae
-Separation of normally implanted placenta - Hemorrhage may be apparnet of concealed -Clot forms, begins to enlarge ad separation occurs
Side effects and concerns with taking metronidazole
-Side effects of metronidazole are numerous, including sharp, unpleasant metallic taste in the mouth; furry tongue; central nervous system reactions; and urinary tract disturbances. -When oral metronidazole is taken, the woman is advised not to drink alcoholic beverages, or she will experience the severe side effects of abdominal distress, nausea, vomiting, and headache. -Gastrointestinal symptoms are common whether alcohol is consumed or not.
2nd trimester problems / interventions
-Skin pigment changes- shade face, hands, arms from the sun. Usually the darkened areas will disappear after pregnancy. -palpitations- report to Dr. if accompanied by dyspnea, pulmonary edema, or cough. -supine hypotension- caused by venacava being compressed by the enlarged uterus when pt lies on back. AVOID lying on back.
Presumptive Indication of Pregnancy
-Subjective changes: less reliable -Amenorrhea -Nausea and vomiting: Begins about 6 wks, disappears about 14 wks -Fatigue -Urinary frequency -Breast: About 6th wk: tenderness, increased size and pigmentation -Vaginal and cervical color changes - Pink to dark bluish violet - Chadwick's sign: 8 wks -Fetal movement: quickening Not until 2nd trimester 16-20 wks
MANAGEMENT of genital tract trauma -_______ Repair -Suture above ______ -Conservative management if possible
-Surgical Repair -Suture above apex -Conservative management if possible
•MANAGEMENT of genital tract trauma
-Surgical Repair -Suture above apex -Conservative management if possible
TORCH Infections
-T = Toxoplasmosis -O = Other infections -R = Rubella -C = Cytomegalovirus -H = Herpes a group of organisms capable of crossing the placenta and adversely affectiong the development of the fetus; infection may also occur during delivery
Preconception Care
-The promotion of health and well-being of a woman and her partner before pregnancy -Greatest environment sensitivity - days 17-56 -Commonly used previous practices may begin too late
pregnancy: Substance Abuse
-Tobacco -Alcohol - Marijuana - Cocaine -Heroin
Gestational Trophoblastic Disorder: Hydatidiform Mole
-Trophoblast cells develop abnormally -Placenta develops, but not fetus -Grape-like clusters of tissue grow rapidly -Age a facto: young/old -If one, 4-5 times the risk w/subsequent pregnancies -May undergo malignant change
Assessment of Fetal Well-Being
-Ultrasound: safe, accurate, cost-effective - Growth, activity, gestational age, well-being - 1st tri: to confirm pregnancy, exclude ectopic or molar pregnancy - 2nd tri: congenital malformations, multifetal - 3rd tri: fetal size, growth, placental position
First Prenatal Visit: Physical exam: Laboratory Tests
-Urine: albumin, glucose, ketones, bacteria casts - Blood: CBC, typing, Rh, Rubella, hepatitis B, HIV, VDRL & RPR, and cervical smears to detect STIs
Dx: symptoms: signs :....... investigations: abdomen and vaginal....
-causeless, painless, recurrent vaginal bleeding -signs : manifestation of shock or blood loss -abdominal xm: abnormal presentation is common, abdomen is lax -vaginal xm: not allow w pt antepartum hge exccept on operating table=> death in 5 minutes
substance abuse
-ciggerettes- cause growth retardation and increased fetal morbidity and mortality -caffeine- limit intake -alcohol- abstinence -marijuana, heroin, cocaine- harmful to fetus and may produce withdrawal symptoms after birth
what are the causes of bleeding in placental praevia?
-mechanical separation of placenta during effacement and dilatation of cervix in labour (dt painless braxton-hicks contractions) -intravaginal manipulation (PV xm may cause placental separation)
discomforts of 3rd tri
-mood swings- communication b/n partners adn reassure that these are r/t the hormones of pregnancy which alter normal emotional responses -Braxton hicks contractions- change position or mild exercise will usually stop them. frequently mistaken for labor in late pregnancy
What is the treatment for syphilis?
1 shot of penicillin if they have had the disease less than 1 year; if they have had the disease more than one year they will receive 3 rounds of treatment
*S/S of Preeclampsia* *NTK*
1+proteinura systloci BP >30 Diastoloic BP >15 of baseline WT gain in one week at least 2 lbs *Edema* (is not being used a primarly DX of preeclampsia)
When do signs and symptoms of chlamydia typically occur?
1-3 weeks after exposure
Infections During Pregnancy: Acquired Immunodeficiency Syndrome: Nursing Interventions
1. Assess history for risk factors. 2. Provide clear information about AIDS, ZDV therapy, and the implications for the woman, her partner, and a child should the woman become pregnant. 3. Monitor asymptomatic pregnant woman for nonspecific symptoms such as fever, weight loss, persistent candidiasis (vaginal yeast infection or thrush in mount), diarrhea, cough, skin lesions. 4. Implement appropriate isolation procedures including use of disposable latex gloves when in contact with nonintact skin, mucous membranes, or body fluids (changing chux pads, diapers, peripads; starting IV, drawing blood); use of protective covering such as plastic apron and glasses or eye shield when contamination form splashing may occur (vaginal exam, vaginal or cesarean birth, suctioning, care of newborn before initial bath). 5. Provide emotional support and nonjudgmental attitude; preserve confidentiality.
Substance Abuse During Pregnancy: Nursing Interventions
1. Be alert for signs of substance abuse. If it is suspected, ask direct questions, beginning with less threatening questions about use of tobacco, caffeine, and alcohol consumption. Then progress to questions about illicit drugs. 2. Provide information about the possible effects of substance abuse on the fetus
Infections During Pregnancy: Toxoplasmosis: Nursing Interventions
1. Explain methods of prevention to childbearing woman. She should avoid poorly cooked or raw meat, especially pork, beef, and lamb. Fruits and vegetables, should be washed. Litter box should be cleaned frequently by someone else, and woman should wear gloves when gardening.
Treatment for uterine rupture 1. Immediate __________ 2. Usually a ____ is performed. (Tx. of Choice). 3. Possibly a _________ of rupture site and primary closure if fertility is still desired by patient
1. Immediate Laparotomy 2. Usually a TAH is performed. (Tx. of Choice). -Total abdominal hysterectomy → removal of uterus and cervix 3. Possibly a debridement of rupture site and primary closure if fertility is still desired by patient
Predisposing factors to uterine atony 1. Overdistension of the uterus multiple _______ ____hydramnios fetal _____somia 2. Prolonged _____ 3. Grand Multip (>___) 4. _____stimulation/ _________ Tx. 5. Chorioamnionitis
1. Overdistension of the uterus multiple gestation polyhydramnios fetal macrosomia 2. Prolonged Labor 3. Grand Multip (>5) 4. Pitocin stimulation/ Magnesium Sulfate Tx. 5. Chorioamnionitis
Management of placenta previa 1. Stabilize ______ -IV's, CBC, Type & Cross 2. Assess ______ -monitor, U.S, determine gestational age/maturity 3. Preterm infant and mother stable- -________for Lung maturity -If mature, deliver by ______ -If immature, hospital bed rest, possible transfusions, cautious use of tocolytics (___________ is drug of choice). Beta mimetics could mask tachycardia etc. -Don't forget ______ if mother is Rh negative. 4. ____________: this will tell you how much bleeding there has been 5. If mother or baby unstable must deliver immediately by _________ 6. For low lying placentas, you can attempt a _______ delivery if mother and fetus stable. Fetal head should tamponade the bleeding. You must use a double set-up for delivery and have all personnel prepared for an emergency.
1. Stabilize mother -IV's, CBC, Type & Cross 2. Assess fetus -monitor, U.S, determine gestational age/maturity 3. Preterm infant and mother stable- -Amniocentesis for Lung maturity -If mature, deliver by c-section -If immature, hospital bed rest, possible transfusions, cautious use of tocolytics (magnesium sulfate is drug of choice). Beta mimetics could mask tachycardia etc. -Don't forget Rhogam if mother is Rh negative. 4. Kleihauer-Betke: this will tell you how much bleeding there has been 5. If mother or baby unstable must deliver immediately by C-section. 6. For low lying placentas, you can attempt a vaginal delivery if mother and fetus stable. Fetal head should tamponade the bleeding. You must use a double set-up for delivery and have all personnel prepared for an emergency.
Weight Gain During Pregnancy: Normal weight
11.5 - 16 kg (25-35 lb)
How is a benign ovarian mass diagnosed?
US
What is the most common cause of antepartum bleeding? 2nd most common?
1. placenta abruptio 2. placenta previa
what 5 things should you consider in managing PROM
1. review dating 2. assess fetal well being 3. fetal presentation 4. group B strep status 5. look for signs of intrauterine infection
how do you diagnose PROM
1. sterile speculum exam that includes visualization of pool of fluid and pH 7.1 -7.3 via nitrazine paper 2. slide of fluid shows ferning 3. cervical dilation 4. ultrasound eval that looks at amniotic fluid index and indigo carmine dye test
what is the earliest HCG can be seen
10 days in blood and urine
At __ weeks, fundus should be slightly above symphysis pubis.
10-12
How much does the pulse increase during pregnancy?
10-15 beats per minute more
doppler
10-17 wks sound of fetal heart tones
pre-pregnant volume
1000ml
Weight Gain During Pregnancy: Underweight
12.5 - 18 kg (28-40 lb)
What is the fetal HR range?
120-160
what is normal fetal heart rate
120-160
What are some suggestions for the prevention of osteoporosis?
1200 mg Ca supplement q day 800-1000 IU of vitamin D q day weight bearing exercise cessation of tobacco and ETOH decrease caffeine intake
When does ovulation usually occur?
14 days before onset of next menses
Oxygen consumption increases approx. ___ to meet the increased needs of the mother as well as those of the fetus and placenta.
15-20%
IUP seen on transvaginal US @ what level hCG?
1500-2000 mIU/mL
At __ weeks, fundus should be ahdlway between symphysis and umbilicus.
16
Weight Gain During Pregnancy: Twin pregnancy
16 - 20.5 kg (35-45 lb)
when can colostrum secretion begin
16 weeks
Fetal movement determination
16-20 wks - Gross indicator of fetal well-being - Fetal movement counts -Cardiff - sits or lies - 10 movements & length of time for all 10 (1hr) -Sadovsky - lies on left side - 4 within 1 hr
when can fetal heart tones be heard
17-18 weeks
stethescope
17-19 wks sound of fetal heart tones
classification of placenta praevia according to degrees
1st lateralis lower edge of placenta does not reach the int. os 2nd marginalis " " " " reaches the int. os but does not cover it 3rd incomplete centralis 4th complete centralis
Initial Response of Fetus to Hypoxia
1st tachycardia: because the heart tries to compensate first for the hypoxia. 2nd bradycardia: HR will decrease because the heart cannot do anything anymore.
When does urine frequency increase during pregnancy?
1st trimester - uterus puts pressure on the bladder; 3rd trimester - presenting part of fetus engages in the pelvis.
blood pressure
1st trimester = remain at pre-preg. level 2nd trimester = decreases 5-10 mmHg 3rd trimester = returns to pre-pregnancy level
Normal vitals
1st trimester:same as pr-epregnant state 2nd trimester: drops 5-10 mm systolic and diastolic from pre-pregnant state 3rd trimester: same as pre-pregnant state
spontanius abortion
1st trymester due to fetal factors 2nd maternal factors vaginal bleeding cramping and contraction
what are risk factors for preterm labor
2 biggest to remember are: previous preterm birth infection Others include: Multiple gestation Polyhydramnios Uterine anomaly/fibroids hx of second trimester abortion hx of cervical surgery Placenta previa Abruption Vaginal bleeding Substance abuse, Smoking Congenital anomaly Growth restriction Low socioeconomic status Mental or environmental stress Poor nutrition Maternal age (<18 or >40)
What levels of protein in the urine indicate infection or preeclampsia?
2+ to 4+
how to diagnose placenta praevia b4 symptom?
US
multiple-marker screening
Analysis of maternal serum for abnormal levels of alpha-fetoprotein, human chorionic gonadotropin, and estriols that may predict chromosomal abnormalities of the fetus; often called triple-screen. Addition of tests such as inhibin A has improved accuracy of the results, leading to alternate names for this package of tests.
non invasive, safe and accurate diagnostic in placental praevia?
US (only at 18-20 wk)
Gestation week
3 -brain develops 4- placenta formation 6- primitive heart, lungs 9-12 sexual differentation, RBC production, gender can be detremin week 12 10- faciel fetures, and fingers, eye lid close from 10 to 26 week. 13-14 lanugo is seen, blood vesels, sucking motion 17-20 baby very active,mom feels quickening,sweat gland develop, formation of eye lashes and eyebrows. 21-24 alveoli forms in lungs 25-28 nervous system controls some functions 26- can inhale and exhale and even cry, eye are formes adna togues can taste 30- can leave outside womb 29-32 rapid increase in body fat 33-38 antibodys are suply by mom term pregnancy- comletion of week 37 begining of 38 40 end of gestational period
what is the gold standard for diabetes screening
3 hour oral glucose tolerance test 2 abnormal values makes diagnosis of gestational diabetes
Additional screening tests for HIV
US recommended at 20wks
at what age is a mother at higher risk to have a baby with trisomy 21
35 The risk is almost constant at ages 15 to 25, rises slowly between ages 25 to 35, and then increases approximately fourfold from age 35 to 40 and tenfold from age 40 to 48.
What does a Positive Contraction Stress Test (Abnormal) mean?
A positive result is represented by late decelerations of FHR, with 50% or more of the contractions in the acsenxe of hyperstimulation of the uterus.
ultrasound
5-6 wks / presence of fetal sac or 6 weeks showing beat of fetal heart
risk of infection at time of delivery (herpes, primary infection)
50%
The increase in plasma volume averages about __ during pregnancy. Because the plasma volume increase is greater than the erythrocyte increase, the hematocrit which measures the portion of whole blood that is composed of erythrocytes, decreases slightly. This decrease is referred to as?
50%; physiologic anemia of pregnancy or pseudoanemia - appear anemic bc of more fluid volume
How much amniotic fluid is eliminated per day?
500cc/day swallowed, remainder osmotic exchange
What is the average age of menopause?
51-years of age.
1st trimester SAb
60-80% d/t chromo abnormalities incr w/ incr maternal/paternal age incr w/ incr parity d/t uterine scarring
What is pregnant mother's pulse? Respirations? Temp?
60-90 bpm - may increase 10 bpm; 16-24 breaths/min - can be up to 40 breaths/min; 36.2-37.6 C (98-99.6 F)
How long is the process of spermatogenesis?
64 day process changing spermatids into mobile spermatozoa
Toxoplasmosis (fetal sx's)
67% asx - chorioretinitis (15%) - Intracranial calcifications (10%) - anemia, thrombocytopenia, jaundice at birth - microcephaly has been reported - retardation, seizures, visual,
How many mL of amniotic fluid should there by by 3rd trimester?
700-1000mL
How much amniotic fluid is produced per day?
700cc urine and 250cc lungs/day
HELLP syndrome resolve in about...
72 to 96 hours
Pregnant mother with hemoglobin of ___ should have iron supplements.
<11 d/dL
What are risk factors for PID?
<24 years of age multiple sex partners douching previous dx of PID recent IUD insertion (poorly done)
incompetent cervic
=cervical insufficiency painless dilation & effacement of cervix, often in 2nd trimest infection, vag d/c and memb rupture common may have short-term cramping/contractions-->incr dilation amniotic sac bulging thru cervix (hourglass membranes)
The DEXA scan measures bone density by t-scores. What range indicates osteopenia?
> -1 = NO osteoporosis < -1 = osteopenia
fetal heart beat seen transvag US @ what level hCG?
>5000 mIU/mL
gestational diabetes: Physical Exam.
A baseline electrocardiogram (ECG) should be obtained to determine cardiovascular status. Evaluation for retinopathy should be performed, with referral to an ophthalmologist if necessary. The woman's weight and blood pressure must be monitored because of the increased risk for preeclampsia.
Blood Glucose Monitoring
A common method is measurement of fasting blood sugar (no food for the previous 4 hours) and postpradial blood sugar (2 hrs after each meal). If fasting blood glucose levels repeatedly exceed 95 or postprandial values exceed 120, insulin is begun.
Why is initiating contractions usually necessary in a CST? Under what circumstances would the nurse not initiate contractions?
A contraction stress test indicates fetal response to periodic hypoxia that occurs as a result of uterine contractions. Contractions are usually initiated by breast stimulation or by intravenous administration of oxytocin. As contractions compress the placental arterioles that supply oxygen to the fetus, a recurrent decrease occurs in fetal oxygen levels. No breast stimulation or oxytocin infusion is needed for the CST if the woman is having three spontaneous contractions in a 10-minute time frame.
What levels of H&H indicate anemia?
A decrease in the hemoglobin level to less than 10g/dL or in the hematocrit level to less than 30%
karyotype
A display of a cell's chromosomes, arranged from largest to smallest pairs with sex chromosomes displayed as a separate pair.
What indicates the presence of amniotic fluid?
A fern-like pattern produced by the effects of salts of the amniotic fluid
What is the fern test?
A microscopic slide test to determine the presence of amniotic fluid leakage.
What does a Negative Contraction Stress Test (Normal) mean?
A negative result is represented by no late decelerations of FHR
What is the nitrazine test?
A nitrazine strip is used to detect the presence of amniotic fluid in vaginal secretions
What is a doppler blood flow analysis?
A noninvasive (ultrasonography) method of studying the blood flow in the fetus and placenta
What is a nonstress test, and why is it so named?
A nonstress test (so-called because the fetus is not challenged or stressed to obtain data) measures acceleration of the fetal heart in response to fetal movement. Acceleration, even without fetal movement felt by the mother, provides reassurance of fetal health.
phosphatidylinositol (PI)
A phospholipid of surfactant that is produced and secreted in increasing amounts as the fetal lungs mature.
What is sperm capacitation and when does it occur?
A physiologic process where ejaculated sperm acquire the ability to fertilize ova Occurs after ejaculation (or in culture in media)
How could having an outbreak of primary herpes affect a woman's preferred method of delivery?
A primary outbreak of herpes changes the preferred method of delivery from vaginal to caesarian section as long as the C-section can be performed within four hours of labor initiation or rupture of membranes. If this is not possible, the newborn should be monitored and cultured
NITRAZINE TEST
A test for the presence of anmiotic fluid-Nitrazine paper is sensitive to pH and turns blue when in contact with the alkaline amniotic fluid
Δ OD450 (delta OD 450)
A test used to measure the change (delta, or δ) in optical density of the amniotic fluid caused by staining with bilirubin.
Descibe ejaculation.
A three-month process 2-5cc Alkaline 40-300 million sperm 200 to ova 1 to fertilize
What should be obtained at every antepartum visit?
A urine specimen for glucose and protein determination
Abnormal GTT, normal values after you institute diet & exercise. No insulin needed. Which White classification of diabetes in pregnancy?
A1
Abnormal GTT, abnormal values w/ diet & exercise. Insulin needed. Which White classification of diabetes in pregnancy?
A2
Why is blood typing and Rh factor done?
ABO typing is performed to determine the woman's blood type in the ABO antigen system. Rh typing is done to determine the woman's bood type in the rhesus antigen system.
how do levels of alpha fetoprotein and unconjugated estriol differ in 2nd trimester pregnancy affected by down syndrome? and how about hCG?
AFP and uE3 usually 25% lower hCG are usually twice as high
Commonly evaluated in women with decreased fetal movement/ This is the ONLY marker in the biophysical profile that will tell you if asphyxia is chronic
AMNIOTIC FLUID VOLUME (AVF) EVALUATION
FETAL HEARTBEAT
USES DOPPLER TO HEAR FETAL HEART TONES . HEARD AS EARLY AS 10 WEEKS FETAL HEART RATE WILL BE 150 BPM RATE MOTHERS RATE IS IN RANGE OF 78 BPM
CONTRACTION STRESS TEST (CST) is used for
UTEROPLACENTAL FUNCTION
What is the method used to diagnose a fibroadenoma?
Ultrasound
Maternal Adaptation
Accepting pregnancy, Identifying with the mothering role, Reordering personal relationships, Establishing relationship with fetus, Preparing for childbirth
What is the order of depth of invasion for abnormal placental attachment?
Accreta, Increta, percreta (AIP): alphabetical by depth of invasion
Physical Exam:
Accurate B/P essential Dependent edema Pitting edema ( 27-3) Deep tendon reflexes (DTRs) ( table 27-4) Urinalysis for protein S/S severe preeclampsia
The pH of the vaginal secretions is __ to help with what? But, what is the mom still prone ti?
Acidic; prevent infection; yeast infection (moniliasis)
Management for herpes
Acyclovir (save in prego)
How do you measure the amniotic fluid index?
Ultrasound 4 quadrant 5-25cm OR single 2x2cm pocket
if Magnesium TOXICITY suspected > interventions:
ASAP discontinue infusion, adm. Calcium gluconate (slow), prepare actions to prevent respiratory or cardiac arrest.
placenta previa
Abnormal implantation of the placenta in the lower uterus at or very near the cervical os.
What does Rh negative indicate?
Absence of antigen
If elevated levels of alpha-fetoprotein what is perfomed and why?
An ultrasound is performed to rule out fetal abnormalities or multiple gestation
What does an Unsatisfactory result mean for a contraction stress test?
An unsatisfactory result means that adequate uterine contractions cannot be achieved, or FHR tracing is of insufficient quality for adequate interpretation
If you resuscitate in a late pattern, make sure the mother is:
Afebrile Hydrated In left lateral recumbent position - prevents impingement of IVC to avoid decrease of cardiac output
Reproductive System: Ovaries
After conception, major function to secrete progesterone - "hormone of pregnancy" - 1st 6-7 weeks, then placenta takes over -Ovulation ceases during pregnancy
SUMMARY CONCEPTS
All perinatal nurses must be prepared to offer clear explanations of diagnostic procedures and any problems the woman should report. Support for the family requiring fetal diagnostic tests can reduce their anxiety.
What is the ductus venosus for?
Allows interstate-size bypass of hepatic circulation of oxygenated blood
tenth week
Although maternal insulin doe not cross the placental barrier, the fetus produces insulin by the _____________of gestation.
SUMMARY CONCEPTS
Amniocentesis is usually performed in the second trimester to identify fetal genetic defects or open defects such as neural tube defects. It may be used during the third trimester to evaluate fetal maturity or Rh incompatibility problems. Standard amniocentesis is performed at 15 to 20 weeks of gestation. Early amniocentesis (11 to 14 weeks) allows earlier diagnosis of genetic problems.
What does an Equivocal result mean for a contraction stress test?
An equivocal result contains decelerations, but with less than 50% of the contractions, or uterine activity shows a hyperstimulated uterus.
What is ptyalism?
An increase in saliva production during pregnancy
amniotic fluid index (AFI)
An ultrasound examination in which the vertical depth of the largest fluid pocket in each of the four quadrants of the uterus is measured and totaled.
Is it okay for pregnant women to take flagyl?
Yes. The CDC states that it is ok to give flagyl to pregnant women in any trimester
__ is the product of conception until day 15.
Zygote
self-care > report signs of preeclampsia
^ BP, protein in urine (also decrease output and burning), weight gain, decrease fetal movement
Cardiovascular changes
^ in blood volume ^ in CO ^venus return ^HR ^ RBC, Plasma > then RBC ^in iron demands Somewhat hypercoagulable state
if there is preterm PROM what is the likely outcome
most likely you will deliver within 1 week -there is a risk for placental abruption -worry about intrauterine infection
What is BrCa1 and BrCa2?
Breast cancer genes. If you have these genes you are more likely to have breast cancer later in life and the chances for ovarian and prostate cancer also increase. Just because you have active breast cancer does not mean you carry the gene though...but if you have the gene you are at a more increased risk of developing breast cancer.
Postpartum hemorrhage can be treated with all of the following except: A. Oxytocin/Pitocin infusion B. Uterine packing, tamponade C. Methylergonovine/Methergine D. Misoprostol/Cytotec E. Cervical cerclage
Answer: E
If glycosuria persists, what does it indicate?
Diabetes
what are risk factors of cervical insufficiency
history of cervical surgery (cone biopsy, cervical dilation, LEEP) history of cervical laceration uterine anomalies history of DES exposure
TERATOGEN
Any substance that adversely affects the growth and development of a fetus
Nsg interventions for nonstress test?
Apply an external ultrasound transducer and tocodynamometer to client (tracing of at least 20 mins obtained so that FHR and uterine activity can be observed), baseline bp and monitored frequently, place client in lateral (side-lying) position to avoid vena cava compression
Infections During Pregnancy: Rubella: Nursing Interventions
Assess for signs of rubella infection (maculopapular rash, lymphadenopathy, muscular achiness, joint pain). Provide emotional support and objective information for couples contemplating therapeutic abortion.
What is an alpha-fetoprotein screening?
Assesses the quantity of fetal serum proteins
SEVERE PRECLAMPSIA INTERVENTIONS 4.
Assessments of fetal well-being (e.g., NST, BPP) are ordered because of the potential for hypoxia related to uteroplacental insufficiency. Electronic fetal monitoring is carried out at least once a day. Vaginal examination may be done to check for cervical changes. Abdominal palpation establishes uterine tonicity and fetal size, activity, and position. The woman with severe preeclampsia is maintained on bed rest, and seizure precautions are initiated. Noise and external stimuli should be minimized. ( box 27-2)
Chronic Hypertension
Associated with increased incidence of: Placenta abruption Superimposed preeclampsia Increased perinatal mortality Fetal growth restriction PTL Diets sodium limited to 2. 4 g sodium. Tx- Aldomet ( Methyldopa) Labetalol and Nifedipine ( 27-5)
What treatments are available to women who contract CMV (cytomegalovirus) during pregnancy?
At this time there are no available treatments for a woman who contracts CMV during pregnancy.
is associated with increased neonatal morbidity and morality.
poorly controlled gestational diabetes, characterized by maternal hyperglycemia during the third trimester, _______________________.
Who cannot have flagyl?
Breastfeeding women
MILD preeclampsia S/S
BP > 140/90 twice 4 hrs apart. / proteinuria ≥ 300mg in 24 hr specimen, ≥ 1+ dipstick, no evidence organ dysfunction
What is BV?
Bacterial Vaginosis. - Most common type of vaginitis today. - Associated with preterm labor and birth. - Symptoms include "fishy odor," Profuse thin, white to grey or milky discharge Decreased pH of vaginal discharge Sometimes mild irritation and pruritus
Irregular uterine contractions that do not dilate the cervix or move the fetus are known as?
Braxton-Hicks contractions
HEMOLYTIC DISEASE
results from complications with rh factor incompatibility during pregnancy
Why is the mother more prone to develop postural hypotension?
Because of increased blood volume in the lower extremities.
gestational diabetes: Fetal Surveillance
Because of the increased risk for congenital anomalies or fetal death, surveillance should begin early for women with preexisting diabetes. Testing for anomalies includes triple marker screening (or multiple marker screening) to identify possible neural tube or other open defects and for possible chromosome abnormalities. During the third trimester, the goal of fetal surveillance is to identify markers that suggest a worsening intrauterine environment with a higher probability of fetal death. Surveillance may include maternal assessment of fetal movement (kick counts), biophysical profiles, nonstress tests, and contraction stress tests. Ultrasonography is also used to document fetal growth rates.
ketosis
Because the body cannot metabolize glucose, it begins to metabolize protein and fat to meet energy needs. The metabolism of fat results in the build up of ketone bodies or _____________.
Medication for Syphilis
Benzathine penicillin G. If allergic to penicillin, erythromycin will do
Infections During Pregnancy: Rubella: Medical Therapy
Best therapy is prevention by vaccination. Women of childbearing age should be tested for immunity and vaccinated if susceptible. Pregnant women are not vaccinated but will be offered vaccination postpartum.
PRETERM
Birth that occurs before 37 weeks' gestation
TERM
Birth that occurs between 37 and 42 weeks' completed gestation
Preconception Care: Nursing management
Complete health hx & physical exam Woman & partner - Immunization status - Underlying medical conditions - Reproductive health - Sexuality and sexual practices - Nutrition - Lifestyle practices
Definition: the placenta completely covers the os.
Complete or Total Previa
ULTRASOUND
CAN SEE EMBRYO AS EARLY AS 4WKS; MAY BE DONE TRANSVAGINALLY ; USUALLY PREFORMED AROUND THE 20TH WEEK OF PREGNANCY
What is the major advantage of CVS compared with amniocentesis?
CVS is performed slightly sooner than even early amniocentesis, at 10 to 12 weeks of gestation. Obtaining information about fetal anomalies earlier in the pregnancy allows the woman to make a decision about pregnancy termination before the second trimester. CVS is more expensive than amniocentesis and does not provide amniotic fluid for analysis of AFP level that might be needed to clarify MSAFP results.
MATERNAL INFECTIONS
CYTOMEGALOVIRUS, RUBELLA, HERPES SIMPLEX, HEPATITIS B, PARVOVIRUS, TOXOPLASMOSIS, STD
Magnesium sulfate antidote
Calcium gluconate
What are the cardiovascular maternal adaptations?
Cardiac output increases w/ peak at 2nd try BP drops just a little bit, then normalizes at 24 weeks Mechanical effects of the gravid uterus Total blood volume increases Regional blood flow increases
Three-Tiered Fetal Heart Rate Interpretation System: Are normal and are strongly predictive of normal acid-base status at the time of observation May be monitored in a routine manner and no specific action is required.
Category I
Endocrine System: Adrenal Glands
Changes in two adrenal hormones - Cortisol - elevated - Regulates carbohydrate and protein metabolism - Aldosterone - elevated • Regulates absorption of sodium • Closely related to water metabolism
what are contraindications to medical abortion
Confirmed or suspected ectopic pregnancy Adnexal mass IUD in place Chronic adrenal failure Severe anemia Coagulation defect Severe liver, renal respiratory and cardiac disease. For misoprostol, include uncontrolled seizure disorders Compliance issues-requires more than 1 visit
What should the client notify the hcp for after an amniocentesis or chorionic villus sampling?
Chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping.
What STIs commonly present with no symptoms in the early stage?
Chlamydia and Gonorrhea
The effects of gonorrhea on mother and fetus
Chlamydia → premature labor / preterm birth, neonatal / maternal sepsis, growth restrictions leading to LBW. Most commonly the child has ophthalmia neonatorum
an irregular pigmentation of the cheeks, forehead, and nose during pregnancy that is accentuated by sun exposure and is known as the "mask of pregnancy" is called?
Cholasma
Nutrition During Pregnancy
Choose foods from food guide pyramid -Encourage diet high in folic acid with supplements -Calcium needs increase nearly 50% -stores - Drink 8 to 10 glasses of water day
SUMMARY CONCEPTS
Chorionic villus sampling is performed at 10 to 12 weeks of gestation to provide parents with information about chromosomal and other congenital defects in the first trimester of pregnancy. Chorionic villus sampling does not provide a sample of amniotic fluid for alpha-fetoprotein testing.
What are the renal maternal adaptations?
Collecting system dilates Blood flow and GFR increases to 140% by mid-gestation Tubular function
Infections During Pregnancy: Acquired Immunodeficiency Syndrome: Medical Therapy
Currently there is no definitive therapy for AIDs, although a variety of drugs are available that delay the onset of symptoms. Zidovudine (ZDV) is primary treatment for pregnant women. Current goal is to detect women at risk and educate the public about the spread of AIDS. Women at risk who are pregnancy or planning a pregnancy should be offered HIV antibody testing. Women who test positive should be counseled about the implications for themselves and the fetus/newborn. They may be offered a therapeutic abortion. Women who continue pregnancy need excellent prenatal care with attention to psychosocial and teaching needs.
CMV
Cytomegalo Virus
type I (insulin deficient) or type 2 (insulin resistant, with a relative deficiency of insulin to metabolize carbohydrate)
Diabetes that exists before pregnancy is classified as ___________________________according to whether the client requires the administration of insulin to prevent ketoacidosis.
Infections During Pregnancy: Cytomegalic inclusion disease: Medical Therapy
Diagnosis is confirmed by serologic tests to detect CMV antibodies, No effective treatment is available at this time.
What test is usually done to detect osteoporosis?
DEXA scan
POSITIVE SIGNS OF PREGNANCY (4)
DIFINATE SIGNS OF PREGNANCY FETAL HEART BEAT FETAL MOVEMENT XRAY ULTRASOUND
What are the layers of the placenta?
Decidua basalis + chorion frondosum
What is something you might suggest as a nurse to help with fibrocystic breast changes?
Decrease caffeine intake
what are the fetal side effects of magnesium
Decrease in heart rate baseline and variability Neuroprotective effect (less Cerebral Palsy?)
Why is amniotic fluid volume an important parameter in the BPP?
Decreased amniotic fluid volume is associated with prolonged fetal hypoxia, in which blood is shunted away from the fetal lungs and kidneys, which produce amniotic fluid, and toward vital organs such as the fetal heart and brain.
Glycosuria is a common result of what?
Decreased renal threshold that occurs during pregnancy
When is hCG detectable?
Detectable 7-10 days post-fertilization Preserves corpus luteum until placenta takes over (Menses deferred) Pregnancy testing & component of "triple screen"
Estimated Date of Birth (EDB)
Determine first day of last menstrual period (LMP), subtract 3 months and add 7 days plus 1 year. or Add 7 days to LMP and count forward 9 months
Nutritional Requirements
Dietary Reference Intakes (DRIs) - Recommended Dietary Allowance (RDQ) -Amount of a nutrient sufficient to meet the needs of almost all healthy people in an age group - Adequate Intake (AI) -Nutrient intake assumed to be adequate when RDA cannot be determined - Fluoride, fiber, and vitamin K - Tolerable Upper Intake Level (UL) - Highest amount of nutrient that can be taken w/o probable adverse effects
Patterns of Deceleration Rate in CST, for each uterine contraction there is a __
Drop of fetal HR **Shape of acceleration is mirror image to deceleration
What is the fetal cardiovasculature?
Ductus venosus Ductus arteriosus Foramen ovale
Diabetes: During the first trimester
During the first trimester, when major fetal organs are developing, the effects of the abnormal metabolic environment, such as hypoglycemia, hyperglycemia, and ketosis, may lead to increased incidence of spontaneous abortion or major fetal malformation. Preeclampsia is two to three times more likely to develop if the woman has preexisting diabetes. The development of ketoacidosis is a threat to women with type 1 diabetes and is most often precipitated by infection or missed insulin doses. Untreated ketoacidosis can progress to fetal and maternal death. Urinary tract infections are more common, possibly because of glucose in the urine, which provides a nutrient-rich medium for bacterial growth. Other effects include hydramnios, which may result from fetal hyperglycemia and sequent fetal diuresis, and premature rupture of membranes, which may be caused by overdistention of the uterus by hydramnios or a large fetus.
Hypocalcemia.
During the last half of pregnancy, large amounts of calcium are transported across the placenta from the mother to the fetus. At the time of birth, this transfer is abruptly stopped, leading to a dramatic decrease in total and ionized calcium.
•Fragments pieces that did not come out •Accreta, Increta and Percretas. •Diagnosis: exploration which cause of postpartum hemorrhage? tx?
Dx: retained placenta •Treatment- manual removal or D&C. •If accreta etc. may necessitate a hysterectomy.
what interventions needed when administering MAGNESIUM SULFATE?
EDUCATE: will feel flushing, hot, sedation; MONITOR: BP, P, RR, DTRs, consciousness, output, headache, visual disturb., epigastric pain, contractions, FHR and activity; FLUID RESTRICTION: fluid restriction of 100 to 125 ml/hr, and urine output ≥ 30ml/hr
HELLP : EL
ELEVATED LIVER ENZYMES
HIV screening/testing
ELISA, If that + confirm with western blot test - 3rd trimester repeat screening recommended for at-risk populations
Why is early amniocentesis sometimes chosen over standard amniocentesis for prenatal diagnosis of genetic disorders? What possible problems make the early procedure less desirable?
Early amniocentesis has the same advantage as CVS: information is available early in the pregnancy, allowing parents to make decisions about the pregnancy as early as possible. However, the amount of amniotic fluid that can be withdrawn may be inadequate for the indicated test(s) and there is a higher fetal loss rate.
What happens during early pregnancy with oligohydraminos?
Early in pregnancy leads to pulmonary hypoplasia (Potter's syndromes - renal agenesis)
Effects of pregnancy on diabetes
Early: tendency to be hypoglycemic Late: tendency to be hyperglycemic
Eclampsia- Defined
Eclampsia is usually preceded by various premonitory symptoms and signs, including persistent headache, blurred visions, severe epigastric pain, and altered mental status. However, convulsions can appear suddenly and without warning in a seemingly stable woman with only minimum blood pressure elevations (Sibai, 2007). The convulsions that occur in eclampsia are frightening to observe.
Perinatal Education Goals
Establish lifestyle behaviors for optimal health, Prepare psychologically for pregnancy and the responsibilities that come with parenthood, Identify, minimize and treat risk factors, Screen health hazards in workplace and home such as chemicals, radiation, lead, etc., Obtain genetic counseling for inherited diseases, compare perinatal care options available.
Limitations of monitoring fetal movements
Expense and patient compliance Failure to anticipate certain stillbirths Failure to detect growth abnormalities Failure to detect malformations Failure to distinguish between twins Limitations with doppler ultrasound NO STANDARD CRITERIA
ABORTION
Expulson of fetus <20 weeks' gestation; can be spontaneous or induced
Nsg interventions for a contraction stress test?
External fetal monitor applied to client, and a 20-30 min baseline strip recorded, frequent maternal bp readings and mother is closely monitored while increasing doses of oxytocin are given.
BST is done to obtain the___ but the disadvantages are_____
FETAL CONDITION Has a high false positive rate, additional back-up tests are highly desirable.
S/S severe preeclampsia
FRONTAL HEADACHE HEARTBURN C/O RUQ pain w hard rock ab *abruptio* visual disturbances Seizures (call for help and provide safety for pain)
Modalities to monitor fetal well being:
Fetal Movement Monitoring AFV Assessment Non-stress Test (NST) Contraction Stress Test (CST) Vibroacoustic Fetal Stimulation (VAS) Doppler Velocimetry Biophysical Profile (BPP)
Ectopic Pregnancy
First Trimester - abrupt unilateral lower quadrant pain with or without bleeding - abnormal implantation of fertilized ovum outside uterus in fallopian tube usually. Can result in tubal rupture or fatal hemorrhage. Second most frequent cause of bleeding in early pregnancy. - scant, dark red, brown vaginal spotting if tube ruptures -shoulder pain common -empty uterus shown -Liner Salpingostomy: salvage tubes if not ruptured - Laparoscopic salpingostomy: removal of tube if ruptured - Methotrexate inhibits cell division and enlargement of embryo. It also prevents rupture of fallopian tubes. (Avoid alcohol on methotrexate)
Spontaneous Abortion
First Trimester - vaginal bleeding, cramping, partial or complete expulsion - terminated before 20 weeks or fetal weight <500g -backache, ROM, dilation, fever -Ultrasound to see viability, D&C, D&E. -Prostaglandin is administered into the amniotic sac or by vaginal suppository to augment labor to expulse products of conception.
When does the foramen ovale close?
Flap fusion is usually complete by age 2 in 75% of children
When does the ductus venosus functionally close?
Functionally closed within minutes of delivery and structurally closed within 3-4 days
GTPAL
G= number of pregnancies including the current one T= term births i.e. pregnancies ending after 37 wks P=preterm births i.e. pregnancies ending after 20 wks but before completion of 37 wks A= abortions i.e. pregnancies ending before 20wks L= current living children
Group B Hemolytic Strep
GBS -bacterial infection passed to neonate during delivery -can cause PROM, preterm labor, chorioamnionitis, UTI, maternal sepsis. -Vag and rectal cultures performed at 35-37 weeks -Prophylaxis ABX like PCN to treat pos GBS
__ is the number of weeks since the first day of the last menstrual perios. (LMP)
Gestation
length of gestation
Gestation- number of wks from conception or actual time fetus has been growing inside the mom (aproximately 38 wks)
•Macrosomia and associated traumatic delivery •Delayed organ maturation •FGR (fetal growth restriction), aka IUGR (intra-uterine growth restriction) These are complications of which type of diabetes?
Gestational Diabetes •No congenital anomalies: The congenital anomalies occur in the first half of pregnancy, gestational diabetes doesn't occur until the second half of pregnancy
Development of a Birth Plan
Get a support person, Determine preferences for delivery including type of anesthesia, and Enroll in childbirth classes
Infections During Pregnancy: Toxoplasmosis: Medical Therapy
Goal is to identify women at risk.
eclampsia (convulsion) > inmediate care
Goal: ensure patent airway > TURN WOMAN into HER SIDE to prevent aspiration (leading cause of morbidity and mortality) of vomitus and supine hypotension syndrome.
Cervical bv increase in number, and causes what two signs?
Goodell's sign - softening of cervix Chadwick's sign - blue-purple discoloration of cervix
What are the probable signs of pregnancy that are rarely caused by something else?
Goodell's sign(softening of cervix), Hegar's sign(softening of isthmus of uterus), McDonald's sign( ease in flexing the body of uterus against cervix), abdominal enlargement, Braxton-Hicks, uterine souffle, fundic souffle, uterine enlargement, linea, nigra, abdominal striae, changes in pigmentation, cholasma, ballottement, preg test
ECOMAP
Graphical representation that shows all of the systems at play in an individual's life
__ is the number of pregnangies, regardless of outcome, including present pregnancy.
Gravida
Pregnancy History Gravida (G)
Gravida- number of pregnancies ex.: gravida 3 means the patient had 3 pregnancies. if she is in her first pregnancy, she is called a primigravida. 2nd time is secundagravida, 3rd or all there after is "multigravida"
How do we know if we have polyhydraminos?
Greater than 23cm
What is GBS?
Group B streptococci. - Considered part of a non-pregnant woman's normal vaginal flora, and present in 20%-30% of pregnant woman also. - Problematic with pregnancy because can cause neonatal infection as neonate travels through the birth canal.
What is the most common STI?
HPV -Extremely contagious
What happens when the tidal volume rises?
Hence minute ventilation rises...CO2 FALLS Due to rise in inspiratory capacity fall in functional residual capacity
What happens to the cervical mucous during ovulation?
High estrogen levels help to: Increase mucous quantity Becomes more alkaline Decrease in viscosity (spinnbarkheit) Ferning Creates a favorable electrolyte content
Multifetal Pregnancy Probability Increased by:
History of dizygous twins in female lineage, Use of fertility drugs, Rapid uterine growth for weeks of gestation, Hydramnios (excess of amniotic fluid), palpation of more small or large parts than expected. An ultrasound is done to verify
gestational diabetes: Maternal assessment
History, physical exam, laboratorytests
What happens to the tubular function?
Homeostatic for Na and K Dumping HCO3 - Compensates for respiratory alkalosis - Maintains blood pH @ 7.3 - Decreased buffering capacity predisposes to metabolic acidosis
What is the typical treatment for menopause?
Hormone replacement therapy
MULTIGRAVIDA
Pregnant for at least the 2nd time
National Health Goals 2010
Increase the proportion of preg women: - Early & adequate prenatal care , Inc. abstinence from alcohol, cigarettes, & illicit drugs - Who attend prepared child birth classes
what are risk factors for placental abruption
Increased age and parity Hypertension PPROM Prior abruption Cocaine use Cigarette smoking Thrombophilias Trauma
What happens when the blood flow and GFR increase?
Increased creatinine clearance
pregnancy: Cardiovascular System: Blood Volume
Increases about 40%-50%
When is screening for sickle cell done?
Indicated for clients at risk for sickle cell disease, a positive test may indicate a need for further screening
Summary of Substance Abuse During Pregnancy
Indiscriminate use of alcohol or drugs such as cocaine, PCP, opiates, and methadone may affect the woman and her fetus/newborn. Alcohol abuse has been associated with fetal alcohol syndrome. Use of addicting drugs may cause the infant to be born addicted or to have serious and permanent problems.
What does WBCs in the urine indicate?
Infection
PUERPERAL INFECTION
Infection of reproductive tract occuring <6 weeks postpartum
What are TORCH infections?
Infections that are capable of crossing the placenta and infecting the fetus. - Toxoplasmosis - other (hepatitis) - Rubella virus - Cytomegalovirus (CMV) - Herpes Simplex
what infections should preggo's take precautions against
Influenza Toxoplasmosis Cytomegalovirus Listeria Parvovirus
Ketonuria may result from what?
Insufficient food intake or vomiting
What is oligohydraminos?
Insufficient production of amniotic fluid
generally decline
Insulin needs _______________during the first trimester because the secretion of placental hormones antagonistic to insulin remains low. The woman also may experience nausea, vomiting, and anorexia, resulting in decreased intake of food, and therefore requires less insulin.
when do you not attempt to delay premature delivery for 48 hours IF:
Intrauterine fetal demise Lethal fetal anomaly Non-reassuring fetal status Severe growth restriction Severe preeclampsia or eclampsia Maternal hemorrhage with hemodynamic instability - do not csection her! Need to try to get her stable first- give her lots of fluids/transfusions THEN can go to the operating room Chorioamnionitis
what are the features of surgical abortion
Involves invasive procedure Sedation/anesthesia Usually requires one visit Complete in predictable amount of time Available in early pregnancy Bleeding usually light No follow up is required Single step patient participation
The increase of erythrocyte levels results in an increased need for what?
Iron
What happens to the BP during pregnancy?
It decreases slightly during pregnancy-lowest point during the second trimester; then the BP gradually increases during 3rd trimester
What does relaxin do?
It inhibits uterine activity, diminishes the strength of uterine contractions, aids in the softening of the cervix, and has the long-term effect of remodeling collagen.
Why do we not give the rubella vaccine during pregnancy?
It is a live attenuated virus and may cross the placenta and present a risk to the developing fetus
What does hPL do?
It is an antagonist to insulin; it increases the amount of circulating free fatty acids for maternal metabolic needs and decreases maternal metabolism of glucose to favor fetal growth
COMMUNAL FAMILY
Live in commune, share all responsibilities
what does spina bifida look like on US
Longitudinal coronal scan of the fetal spine notes a large lumbo- sacral myelomeningocele. The splaying of the spinal process is typical and diagnostic in this condition.
What is the relationship between loss of fetal tone and hypoxia?
Loss of fetal tone in a biophysical profile indicates advanced hypoxia and fetal acidosis. Fetal tone develops early in gestation and is one of the parameters of the biophysical profile that is most resistant to the effects of hypoxia.
Birth Outcomes for Babies with Inadequate Prenatal Care
Low birth rate and infant mortality
What are possible causes for low levels of AFP?
Low levels of AFP suggest chromosomal abnormalities or inaccurate gestational age and maternal weight. Gestational trophoblastic disease may also cause low AFP levels.
Why is MSAFP considered a screening test?
MSAFP must be viewed as the first step in a series of diagnostic procedures offered if abnormal concentrations are found.
What are major advantages and disadvantages of ultrasonography?
Major advantages of ultrasonography are that it allows clear visualization of the fetus and surrounding structures; it is safe, noninvasive, and relatively comfortable; and the results are available immediately. The major disadvantage is the cost. Also, ultrasonography may reveal findings that might indicate a problem but for which data are inadequate to make a clear diagnosis, thereby requiring further decisions by the woman and her support person.
What are the major indications for ultrasonography during the first trimester? During the second and third trimesters?
Major reasons for ultrasonography during the first trimester are to confirm pregnancy, verify gestational age, locate the embryo or fetus, determine multifetal pregnancy and gestational age, confirm viability, identify markers that suggest fetal abnormalities, and identify and guide chorionic villus sampling (CVS). Indications during the second and third trimesters are to confirm fetal viability, gestational age, and growth; evaluate fetal anatomy, umbilical cord and vessels, and placenta; evaluate multifetal pregnancies; locate the placenta; determine fetal presentation; evaluate amniotic fluid volume and fetal activity for biophysical profile; and plan guide needle placement for amniocentesis and umbilical cord sampling.
What is multiple-marker screening? Why is it performed?
Multiple marker screening, often called triple marker screening or other names, determines maternal serum levels of AFP, hCG, and unconjugated estriols. Elevation of hCG level with low levels of AFP and estriols suggests chromosome abnormalities. Further testing with amniocentesis to positively identify the fetal karyotype will be offered to the woman if triple marker screening is abnormal. A fourth marker that increases identity of chromosome abnormalities in the woman younger than 35 years is becoming more common and is often called a quad screen.
Musculoskeletal System: Postural Changes
Musculoskeletal changes are progressive - begin in 2nd trimester - Gradual softening of pelvic cartilage and connective tissue - Loosening and widening of symphysis pubis - Waddling - Lean backward to maintain balance
What teaching needs to be done to a client who recieved a rubella immunization postpartum?
Must be using effective birth control at time of immunization and must be counseled not to become pregnant for 1-3 months after immunization and to avoid contact with anyone who is immunocompromised
what testing or exam should be done in suspected placenta previa
NO VAGINAL EXAM as it may trigger further bleeding evaluation by ultrasound is 99% sensitive
can you rule out a placental abruption with ultrasound evaluation
NO!
Most widely used primary testing method for assessment of fetal well-being.The Basis: the normal fetus will produce characteristic heart rate patterns in response to fetal movements
NONSTRESS TEST (NST)
What is an ultrasonography?
Outlines and identifies fetal and maternal structures, assists in confirming gestational age and EDD and evaluating amniotic fluid colume, may be done abdominally or transvaginally during pregnancy
What are the respiratory maternal adaptations?
Oxygen consumption increases 15-20% Rate—stable Tidal volume rises (40% at term)
Methods for CONTRACTION STRESS TEST (CST)
Oxytocin Challenge Nipple Stimulation Method
PLACENTA PRIVIA
PAINLESS BRIGHT RED BLEEDING IN 2ND ,3RD TRYMESTER SYMPTOMS: HYPOTENSION, NON TENDER UTERUS, AVOID VAGINAL EXAMS
FETAL MOVEMENT
PALPATED BY EXPERIENCED EXAMINER; MOTHER MAY ALSO FEEL INTESTINAL MOVEMENTS THAT FEEL SIMILAR TO FETAL MOVEMENTS
Herpes testing
PCR (better then culture)
testing for CMV if suspected done with
PCR and culture
PID
Pelvic Inflammatory Disease
Contraindications to CST for CST
Placenta Previa - it can provoke bleeding PROM Previous Caesarian Section Multifetal Pregnancy Third Trimester Bleeding Polyhydramnios - uterus is overly distended Incompetent Cervix - it can provoke labor and bring about preterm delivery
*Hallmark is "painful vaginal bleeding in association with uterine tenderness, hyperactivity and increased tone." -80% will have associated vaginal bleeding. -The blood is usually dark red -Pain 66% -Fetal Distress 60% -Uterine Hyperactivity 34% -Fetal Demise 15% Dx?
Placenta abruptio
__ is the number of infants born after start of week 20, but before end of 37th week, living or stillborn
Preterm
Iron
Purpose: Maternal hemoglobin formation; fetal liver iron storage Sources: Liver, meats, whole grain or enriched breads and cereals, deep green leafy vegetables, legumes and dried fruit. Suggestion: Take with Vitamin C for absorbtion
blood components
RBC's = increase to a level of 25-34% higher thatn non -pregnant state
DDx 1st trimester bleeding
SAb post-coital bleeding ectopic vaginal/cervical lesions extrusion of molar pregnancy implantation bleeding blighted ovum nonpregnancy causes...
MAGNESIUM SULFATE
SMOTH MUSCLE RELAXANT, PRE-CLAMSIA ECLAMSIA PRE-TERM ALBOR
What is the proper management of coagulation disorders?
STABILIZATION -Support respiratory, cardio etc. -Reverse coagulopathy with blood products, cryoprecipitate, FFP etc.
Gestational Trophoblastic Disease
Second Trimester -Uterine size increasing abnormally fast, high hCG, n/v, no fetus on ultrasound, scant or profuse bleeding dark brown/red - Embryo fails to develop beyond a primitive state and these structures are associated with choriocarcinoma, which is a rapidly metastisizing malignancy. -vaginal bleeding around 16 weeks resembling prune juice -hyperemesis -rapid uterine growth -PIH symptoms -UA for proteinuria, hCG every 1-2 weeks until normal levels, every 2 to 4 weeks for 6 months, then every 2 months for a year. -Suction curettage to aspirate mole -No pregnancy for 12 months
Insulin needs increase markedly
Second and Third Trimesters. ___________________________ during the second and third trimesters when placental hormones, which initiate maternal resistance to the effects of insulin, reach their peak.
HYPEREMESIS GRAVIDARUM
Severe nausea and vomiting in pregnancy that can cause severe dehydration in the mother and fetus
Infections During Pregnancy: Chlamydia: Condition/Overview
Sexually transmitted infection caused by Chlamydia trachomatis often found in association with gonorrhea.
Infections During Pregnancy: Gonorrhea
Sexually transmitted infection caused by Neisseria gonorrhoeae.
Infections During Pregnancy: Syphilis
Sexually transmitted infection caused by the spirochete Treponema pallidum.
Physical exam: Pelvis
Shapes Gynecoid: normal female: optimum diameters Android: male, funnel-shaped - Anthrapoid - "ape-like" - Platypelloid - flat female, least common Measurements - Diagonal conjugate - True conjugate - Ischial tuberosity diameter
What happens is the client is Rh negative and has a negative antibody screen?
She will need repeat antibody screens and should receive Rho(D) immune globulin (RhoGAM) at 28 weeks' gestation
what are signs and symptoms of placental abruption
Signs and symptoms may vary Mild to severe vaginal bleeding (80%) Uterine tenderness or back pain (66%) Fetal distress (50%) High frequency Contractions (20%) Preterm labor (25%) Fetal demise (15%) Shock/DIC/Renal failure
Laboratory findings. ( 27-3)
Table 27-3
What is the age range for a fibroadenoma?
Teens to early 20's
What is the only medication available to treat HPV in pregnancy?
The application of trichloracetic acid (TCA) or bichloracetic acid (BCA) 80-90% applied weekly. Cryotherapy at the time of birth can lower the probability of transmission. Remember HPV --> genital worts. TCA-treatment is very uncomfortable, and many women refuse treatment after the first application.
Preexisting Diabetes Mellitus: Maternal Effects
The course of pregnancy for women with diabetes mellitus has improved greatly as a result of new treatments and more effective methods of fetal surveillance. However, the incidence of complications affecting the mother and fetus remains higher than that experienced by nondiabetic women.
Why is bilirubin in amniotic fluid evaluated?
The degree of bilirubin staining of amniotic fluid reflects the degree of erythrocyte destruction in an Rh-positive fetus whose mother is Rh-sensitized.
Therapeutic Management.
The diet should provide the calories and nutrients needed for maternal and fetal health, avoid ketosis, and promote appropriate weight gain.
What happens during a contraction stress test?
The fetus is exposed to the stress of contractions to assess the adequacy of placental perfucsion under simulated labor conditions.
Hyperbilirubinemia
The fetus who experiences recurrent hypoxia compensates by production of additional erythrocytes to carry oxygen supplied by the mother. After birth the excess erythrocytes are broken down, releasing large amounts of bilirubin into the neonate's circulation. Prematurity, more likely in the woman with poor glycemic control, further reduces the infant's ability to metabolize and excrete excess bilirubin.
polyuria,
The kidneys attempt to excrete large volumes of this fluid and the heavy solute load of glucose. The excretion produces the second hallmark of diabetes,___________ as well as glycosuria (glucose in the urine).
macrosomia,
The major fetal complications are __________________ leading to birth injuries or necessitating cesarean birth, and neonatal hypoglycemia.
If a menopausal patient has a uterus, what type of hormones will be administered and why?
The patient should receive both estrogen and progestin because the progestin will help to prevent uterine tissue build-up or abnormalities.
What is chorionic villus sampling and why is it done?
The physician aspirates a small sample of chorionic villus tissue at 10-13 weeks gestation. Performed for the purpose of detecting genetic abnormalities.
What becomes the major sex-hormone producing gland after hCG and the first 5.5 weeks?
The placenta It secretes increasing amounts of estrogen and progesterone through pregnancy.
What are the potential effects of primary genital herpes on a pregnancy?
The potential side effects of primary genital herpes on pregnancy include miscarriage, preterm labor, and intrauterine growth restrictions.
When should a woman perform a self-breast exam?
The week after her menstrual cycle; the same time each month.
Signs and Symptoms of Pregnancy: Presumptive Signs
These signs are least reliable. Missed menstrual period (amenorrhea) , positive home pregnancy test, nausea, vomiting, breast tenderness, urinary frequency, fatigue, quickening (fetal movement occurs at 16 wks), and Chadwick's sign (dark bluish color of the vaginal mucosa)
Placenta Previa
Third Trimester - painless vaginal bleeding -abnormally implants in lower segment of uterus over cervical os; may feel contractions early; in 1/200 births; do not use pitocin because could cause too strong of contractions. - NEVER attempt vaginal exam; dx by ultrasound -Total (placenta covers os), Partial (lower border of the placenta w/in 3cm of os), and marginal (common in early pregnancy and appear to move up as fetus grows - only 10% remain a previa after 28 weeks) -betamethasone for fetal lung maturity is anticipated before the cesarean section to follow.
TORCH Ex's
Toxoplasmosis Other (symphillus, HIV, Hep B) Rubella, CMV, Herpes
amniocentesis
Transabdominal puncture of the amniotic sac to obtain a sample of amniotic fluid that contains fetal cells and biochemical substances for laboratory examination.
SUMMARY CONCEPTS
Ultrasound is widely used during pregnancy to determine a variety of fetal and placental conditions and aid in the performance of other tests such as amniocentesis. It is also used in gynecology and infertility care as well as medical and surgical conditions. Color Doppler ultrasound is a variation that allows estimation and direction of blood flow and vascular resistance in fetal structures.
vibroacoustic stimulation
Use of sound stimulation to elicit fetal movement and acceleration (speeding up) of the fetal heart rate.
ultrasound
Use of sound waves for visualizing deep structures of the body by recording the reflections (echoes) of high-frequency sound waves directed into the tissue.
•DIAGNOSIS? -Must have high index of suspicion. -Sudden onset of intense abdominal pain and vaginal bleeding -Hyperventilation, agitation and tachycardia -Momentary relief of pain but it returns. -Fetal Distress -Palpable fetal parts in abdomen. Dx?
Uterine rupture
•Risk Factors -Previous Uterine Scar assoc. 40% -C/s most common- with prior LTCS -0.5% risk, with a previous vertical incision 5% risk. -myomectomy -metroplasty -60 % occur in a previously unscarred uterus. (Grand multip (>5)) etc. •COMPLICATING FACTORS -Maternal Mortality 1% -Fetal Mortality 32% Dx?
Uterine rupture
What are some risk factors for placenta previa?
Uterine surgery Multiple pregnancies Anything that scars the uterus and makes it hard for the placenta to implant
*NURSE ALERT* *Abruptio*
Uterine tenderness in the presence of increasing tone may be the earliest finding of an abruption. Idiopathic preterm contractions also may be an early sign. abdomen will be HARD. *IMMERGENT C-SECTION* Intense PAIN, do not wait on LABs. REPORT IMMEDIATELY!
In general, we can treat all forms of sexually transmitted diseases, with the exception of which type?
Viral
When do fathers bond with the child?
When they can feel the child move.
What is Chandelier sign?
When you move the cervix it hurts the patient incredibly bad. This is a sign of PID. Remember, you touch the cervix and it hurts so bad they want to jump up and grab the chandelier
1. (MP@H) Maternal assessment should include:
hematocrit, platelet count, liver function tests, and 24 urine once each week.
Gestational diabetes is which White classification of diabetes in pregnancy?
White classification A Pre-existing diabetes is everything else
SEVERE PRECLAMPSIA INTERVENTIONS 2.
With a gestational age of 34 weeks or greater, labor induction usually is performed. Vaginal birth is considered safer than cesarean birth and should be attempted. In pregnancies of less than 34 weeks, the plan includes pharmacology to prevent seizures and control BP and continue maternal fetal surveillance for indicators of worsening conditions. Corticosteroids may be given to promote fetal lung maturation. If the birth can be delayed for 48 hours, steroids such as betamethasone (12.5 mg intramuscularly [IM] 24 hours apart) may be given to the woman (Benefits begin 24 after the first dose is administered)
When does the ductus arteriosus functionally close?
Within 24 hours
polyphagia
Without glucose the cells starve, so weight loss occurs even though the person ingests large amount of food____________.
A rubella titer of 1:18 means? a rubella titer of 1:8 means?
Woman is immune- made antibodies against it Womena is susceptible
Example GTPAL:
a 35 yr old pt came into office bc she had a positive pregnancy test.She had a hx of one elective abortion at 22 wks when she was 15 y/o. then she had a 39 wk baby who died. This pregnancy was estimated to be about 12 wks along. Her current pregnancy hx: G3 T1 P0 A1 L0 -G3 P2
Members of the team include
a diabetologist, an obstetrician, a dietitian, a diabetes educator, and a neonatologist.
Pre-existing Diabetes •Can be previously diagnosed •Present but not yet diagnosed •For this reason you should perform what on all pregnant patients during the first trimester?
a fasting blood sugar
What is a corpus luteum cyst?
a functional ovarian cyst that occurs when the follicle never matures into the corpus luteum
What is a theca lutein cyst?
a functional ovarian cyst that thrives on HCG and is typically found in pregnant women
* Preeclampsia*
a pregnancy-specific syndrome in which hypertension develops *after 20 weeks of gestation* in a previously normotensive woman, is characterized by the presence of hypertension and proteinuria.
Amniocentesis
a sample of amniotic fluid can be obtained by puncturing the abd. Can be done by 14-16 wks. Most commonly done in second trimester. Info about genetic d/o, congenital abnormalities and lung maturity can be obtained from the sample. results take up to 3 wks
what is radioreceptor assay testing (RRA)
highly sensitive and accurate - 6-8 days after conception
presumptive manifestations of pregnancy:
history of amenorrhea, N, V, fatigue, breast changes, quickening, urinary tract symtamology; corpeal signs
what is placenta previa
abnormal implantation of the placenta over or near the internal cervical OS can be: total, marginal or low-lying should be suspected in any woman who presents with bleeding in the second half of pregnancy will cause no uterine pain but may have contractions due to blood causing uterine irritability
Chronic hypertension, associated with
abruption placentae, and superimposed preeclampsia. Increased perinatal mortality. FGR, small-for-gestational-age
signs Magnesium sulfate TOXICITY
absence patellar reflexes , urine output <30ml/hr , respirations < 12/min , decreased consciousness
DDx
accindental hge incidental bleeding (mainly diagnosed by speculum xm) vasa praevia in cases with velamentous insertion of the umbilical cord
what is the pathogenesis of preterm labor
activation of maternal or fetal HPA axis infection decidual hemorrhage pathologic uterine distention
classification of placenta praevia according to position
anterior posterior (more foetal risk)
Magnesium sulfate (severe preeclampsia) > USE
anti-seizures or anti-convulsant. Is also a tocolytic. (if using it, oxytocin must be agumented)
What are risk factors for vulvovaginal candidiasis?
antibiotic use, pregnancy, diabetes mellitus, immunosuppression
During seizure the most important things
are patent airway and client safety!!! ( page 667)
Postpartum care ECLAMPSIA > convulsions
could occur in postpartum. Assess for headache, visual dist., epigastric pain
Recognizing Preterm Labor
can occur after the 20th week and before the 37th week, Uterine contractions if untreated can cause the cervix to open earlier resulting in preterm labor. The symptoms are pain/cramping in the abdomen, constant back pain, and pelvic pressure.
stretch marks
caused by separtation of underlying collagen layer - adrenocorticoid response
antiphospholipid antibody
causes recurrent preg loss
Rubella
children with rashes or neonates who are born to mothers with rubella at pregnancy - joint and muscle pain -rash, mild lymphedema, fever, miscarriage, death. -Vaccine after delivery to mom, avoid crowds.
how can you test for sickle cell, cystic fibrosis, huntington's and other muscular dystropies
chorionic villi sampling done at 10-12 weeks gestation risk of fetal loss is 1%
what accounts for 50% of cause of abortion
chromosomal abnormalities
What are some signs and symptoms of endometriosis?
chronic pelvic pain, dyspareunia, infertility
how do you diagnose preterm labor
clinically you have regular painful contractions accompanied by cervical dilation and effacement specifically you see at least 8 contractions per hour with cervical effacement of at least 80% and/or dilation of at least 2cm
complete abortion
complete expulsion all POC before 20wks
hormones, particularly estrogen, progesterone, and human placental lactogen (hPL),
create resistance to insulin in maternal cells. This resistance allows an abundant supply of glucose to be available for the fetus. However, the hormones have a diabetogenic effect in that they may leave the woman with insufficient insulin and episodes of hyperglycemia. For most women, insulin resistance is not a problem. If the pancreas is unable to respond adequately, the woman will have periods of hyperglycemia
What are provider applied treatments for genital warts?
cyro treatment, TCA weekly, laser removal, surgical removal
What are three benign ovarian neoplasms?
cystadenoma - epithelial teratoma - germ cell stromal - Sertoli-Leydig
What are the signs and symptoms of vaginitis?
discharge, irritation, pruritus, external dysuria, dyspareunia, bleeding with intercourse, foul odor
embrionic starge
day 15 thru 8th week
cure of preeclampsia/eclampsia
delivery of fetus and placenta
What stimulates pigmentation changes during pregnancy? what increases these levels?
estrogen, progesterone, and a-melanocyte-stimulating hormone; hyperactivity of the pituitary gland
What are some things you could teach your patient in regard to maintaining comfort during menopause?
dress in layers use fans avoid ETOH, spicy foods, and caffeine
Cytomegalovirus
droplet, person to person, found in semen, cervical and vaginal secretions, breast milk, placental tissue, urine, feces, blood. - asymptomatic or mono like symptoms -no tmt exists
What are some good dietary sources of nonheme iron?
dry beans, nuts, veggies, fruits, whole grains, tofu, peanut butter
In a Late pattern,Apex of contraction comes ___than the deceleration Fetus cannot cope up with the contractions. This is abnormal so monitor the fetus because if you deliver this baby, he would most likely have ______
earlier acidosis, low APGAR score (Immediate resuscitation needed)
embrionic layers
ectodern- outer layer, makes the CNS special senses, skin and glands mesoderm-forms skeletal, urinary,circulatory, and reproductive organs endoderm- forms respiratory system, liver, pancreas, and digestive sistem
what should pregnant women do about: exercise? work? sex?
exercise: can continue but be wary of injuries work: can work until labor but know that long periods of standing are associated with preterm labor sex: avoid only if preterm labor or vaginal bleeding, not associated with increased risk of preterm labor
Fetal well-being
fetal assessment: FHT- using doppler note fetal movement ****all same as follow up visits with fetal assessment******
positive manifestations
fetal heart tones, palpation of fetus, xray of fetus, sonigraphic idendification, pregnancy testing
Stored iron in the ___ compensates in the first 4 months of neonatal life for the normal inadequate amounts of iron available in breast milk and non-iron-fortified formulas.
fetal liver
abortus
fetal lost <20wks GA, <500g, <25cm
...... is essential and if distress develops or bleeding inc, ......is mandatory
fetal monitoring rapid shift to CS
home care fetal monitoring > preeclampsia
fetal movement count daily, ultrasound every 3 weeks, nonstress test, biophysical profile
what is likely cause of fetal antepartum bleeding
fetal vessel rupture
What are risk factors for developing BV?
frequent sex w/o condoms, douching, multiple sex partners, cigarette smoking, flora imbalance
Candida Albicans
fungal infection -vulvular itching -thick creamy white vaginal discharge with redness -white patches on vaginal walla and gray white patches on neonates gums. - Potassium Hydoxide prep and presence of hyphae and pseudohyphae indicate positive findings - Diflucan : antifungal
As a result of prolonged gallbladder emptying time, hypercholesterolemia may follow, and can predispose the woman to what? Why can pruritis occur?
gallstone formation; it is caused by retained bile salts
Second most common cause of Postpartum hemorrhage.
genital tract trauma
what is evaluated during ultrasound
gestational age placental location number of fetuses amniotic fluid volume Medical test: evaluate fetal anatomy and look for down syndrome markers
The pregnant woman has increased insulin needs, and the islets of Langerhans are stressed to meet this increased demand, and a deficiency may become apparent during pregnancy, producing symptoms of what?
gestational diabetes
eclampsia > emotional stress decrease ability to process information
give written information at discharge
SEVERE preeclampsia care
hospital (Magnesium sulfate, control BP
chronic hypertension > teaching self monitoring
how to perform BP, fetal movements counting, importance of bed rest
HCG
human chorionic gonadotropin
gestational diabetes mellitus
in which any degree of glucose intolerance has its onset of first recognition during pregnancy. The onset of glucose intolerance during pregnancy is termed ____________________-(GDM).
Barriers to Prenatal Care
inadequate number of providers, unpleasant facilities or procedures, inconvenient clinic hours, distance to facilities, lack of transportation, fragmentation of services, inadequate finances, personal and cultural attitudes
Expected side effects of MAG SULFATE (loading dose only)
include a feeling of warmth, diaphoresis, burning at IV site. Symptoms of mild toxicity include: lethargy, muscle weakness, decreased or absent DTRs, double vision, an slurred speech. Increasing toxicity may be indicated by maternal hypotension, bradycardia, bradypnea, and cardiac arrest. Serum magnesium levels are obtained per hospital protocol or if any signs of toxicity are present *NTK-- drug cal for MAG SULFATE*
Complications reported with HELLP syndrome
include renal failure, pulmonary edema, ruptured liver hematoma, DIC<, ARSDS, VARIANT OF DIC, placental abruption, and preterm birth.
With preeclampsia, the main pathogenic factor
is not an increase in BP but poor perfusion as a result of vasospasm and reduced plasma volume. Arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and increases BP Function in organs such as the placenta, kidneys, liver, and brain. Fig. 27-1. *Plasma colloid osmotic pressure* decreases as serum albumin levels decrease. Intravascular volume is reduced as fluid moves out of the intravascular compartment, resulting in hemoconcentration, increased blood viscosity, and tissue edema. ( this increase risk for pulmonary edema) *Decreased liver perfusion* results in impaired liver function and elevated Liver enzyme.The women may complain of epigastric or right upper quadrant pain. Hemorrhagic necrosis in the liver can cause a subcapsular hematoma is a life-threatening complication and a surgical emergency
decidua
is what the endometrium is called after implantation
During Labor
maintenance of tight maternal glucose control during birth is desirable to reduce neonatal hypoglycemia. Continuous infusion of a regular or Humalong insulin solution combined with a separate intravenous solution containing glucose, such a 5% dextrose in Ringer's lactate, allows titration to maintain blood glucose levels between 80 and 110 mg/dl.
ovaries
make estrogen and progesterone
pregnancy:
maternal condition of developing a fetus in the body
Probable sign's
most of time do indicate pregnancy , but in certain cases might be false -positive pregnancy test -goodell sign -chadwick sign -hegar's sign (softening of the isthmus) -uterine enlargement -abd enlargement -ballottment -braxton hicks -palpation of fetal
heterotopic pregnancy
multiple gestation w/ at least 1 intrauterine preg and 1 ectopic. risk w/ IVF w/ >1 embryo
When does the uterine wall begin to thin?
near 3rd trimester
What is the age range for duct ectasis?
near or at menopause
what nutrition considerations should be taken during pregnancy
need PREconceptual folic acid median weight gain vitamin supplementation: iron, zinc, A, E, selenium REMEMBER: needs 30mg elemental iron avoid certain fish, soft cheese and nitrites no sweet 'n low- saccharin
What is the reason for fibrocystic breast changes?
not sure why, but could be imbalance between estrogen and progesterone
Factors known to increase the risk to develop GDM include:
overweight, chronic hypertension, maternal age older than 25 years, family history of diabetes in close relatives, previous birth of a large infant (>4000 g), previous birth of an infant with unexplained congenital anomalies, previous unexplained fetal death, GDM in previous pregnancy, multiple pregnancy, and fasting serum glucose >140 mg/dl or random serum glucose >200 mg/dl. • Maternal, fetal, and neonatal effects • Similar to those associated with preexisting diabetes • Not associated with inc'd risk for ketoacidosis or spontaneous abortion
-Uterine Atony -Genital Tract Trauma -Retained placental fragments -Uterine Inversion -Low Placental Implantation -Coagulation disorders abruption retained dead fetus inherited coagulopathy amniotic fluid embolism These are all causes of what?
postpartum hemorrhage
The uterus fails to contract around the myometrial spiral arterioles and decidual veins at the attachment site after placental separation. This causes what?
postpartum hemorrhage
Tonic contraction of all body muscles (seen as arms flexed, hands clenched, legs inverted)
precede the tonic-clonic convulsions. Seizures may recur within minutes of the first convulsion, or the woman may never have another.
Length of pregnancy
pregnancy- 40 wks from first day of last menstrual period (approximately 9 months) 1st trimester- 1-13 wk 2nd trimester- 14-26 wks 3rd trimester- 27-40 wks
what are the fetal side effects of indomethacin
premature narrowing or closure of ductus arteriosus (cannot use more than 48 hours before delivery because of this) oligohydramnios
what is PROM
premature rupture of membranes breaking water before the onset of labor there is also PPROM - aka preterm premature rupture of membranes
signs of pregnancy
presumptive, probable, positive
What are some complications secondary to herpes?
psychological issues, increased risk for HIV contraction
chronic hypertension > postpartum monitor
pulmonary edema, renal failure, heart failure, encephalopathy.
Hydatidiform Mole: Screening
q 1-2 wks until no hCG, q 1-2 months for a yr - Avoid pregnancy for 1 year
WIC
qualify if you are anemic
VIBROACOUSTIC STIMULATION (VAS)Produces profound changes in fetal behaviour and heart rate.Loud external sounds have been used to startle the fetus and thereby provoke heart rate acceleration— acoustic stimulator is positioned on thematernal abdomen, and a stimulus of 1 to 2 seconds is applied. This may be repeated up to three times for up to 3 seconds.A positive response is defined as the____
rapid appearance of a qualifying acceleration following stimulation.
assessment after convulsion (eclampsia)
rapid assessment of uterine activity, cervical status, fetal status. Birth may be imminent
Fetal hyperinsulinemia
retards cortisol production, which is necessary for synthesis of surfactant needed to keep the newborn's alveoli open after birth, thereby increasing the risk for respiratory distress syndrome. Complications in a mother and her fetus and newborn can be reduced if the mother maintains normal and stable blood glucose levels.
eclampsia postpartum ALERT
risk for BOGGY UTERUS and large LOCHIA due to magnesium sulfate therapy. Assess uterine tone and lochia flow often
Herpes Simplex Virus
spread by contact with oral or genital lesions. Transmission greatest at vaginal birth if woman has active lesions. -presents with lesions -get cultures from women HSV or near term.
uterine position (non-pregnant state)
stays inside pelvis
what do you do to manage preterm labor and delay delivery for 48 hours
steroids (for baby's lungs) bed rest antibiotics (group B strep) tocolytic drugs (to try to relax uterus/prevent contractions) hydration (known to decrease contractions)
What risks are associated to pregnant women with syphilis?
still birth or neonatal death shortly after birth
What are some triggers for outbreaks in patients suffering from genital herpes?
stress, pregnancy, menses (hormonal), ovulation
chorion
the thin outer membrane that encloses the embryo
NURSE ALERT Immediately after a seizure,
the woman may be very confused and can be combative. Pad the side rails to prevent injury, and maintain a quiet, darkened environment. It may take several hours for the woman to regain her usual level of mental functioning. The woman should not be left alone. Provide emotional support to the family and discuss with them the management and its rationale and the woman's progress.
once preeclampsia is evident
therapeutic intervention is palliative: bed rest, diet. May slow progression of disease.
why should preggo's pay attention to dental health
there is an association between poor dental health and preterm delivery
the three major causes of 1st trimester bleeding is
threatened or impending miscarriage ectopic pregnancy cervical, vaginal or uterine pathology
fetal assessment ultrasonography
ultrasonography- performed to assess fetal age and well being. measurements that can be taken are: Head circumference, and femur length. From these measurements, gestational age can be determined. Also , visualization of heart, spine, kidneys, and genitalia can be done.
How is PCOS dx?
ultrasound
what testing should be done in a woman with suspected spontaneous abortion
ultrasound eval looking for gestational sac with yolk sac or embryo if embryo with 5mm rump crown length look for cardiac activity if no sac need B-hCG to confirm viability
Positive signs
ultrasound, doppler, stethescope, palpation of fetal movement, visible abd changes
ectopic: sx & signs
unilateral/lower abdominal pain vaginal bleeding tender adnexal mass uterus SGA b-hCG low for GA
Presumptive Sign's
urinary frequency, fatigue, hyperpigmentation, fetal movement
when a woman presents in preterm labor what labs should you do
urine culture group B strep culture GC/chlamydia fetal fibronectin (used as predictor for preterm delivery, best there but has high false positive rates)
What are the characteristics of recurrent outbreaks (not including the first initial outbreak)?
usually lasts 2-5 days and is not as severe as first outbreak
-Someone with PIH (pregnancy induced hypertension); treated with Mg Sulfate to prevent pre-eclampsia. Mg sulfate is a tocolytic (relaxes the uterus) Pre-eclamptic patient that you are inducing They are at risk for what complication?
uterine atony
What is the number one cause of postpartum hemorrhage?
uterine atony
Estrogen is produced primarily by placenta. What does it stimulate?
uterine development to provide a suitable environment for the fetus. It also helps to develop the ductal system of the breasts in preparation for lactation.
Definition: Complete separation of the uterine musculature through all of its layers.
uterine rupture
Previous C-section think which cause of antepartum bleeding?
uterine rupture
what is likely cause of maternal antepartum bleeding
uterine rupture
uterine position (at term)
uterus has risin in the abd cavity to the tip of ziphoid and tilted to rt side of abd. volume increases from 10 ml-5000ml. the uterine growth in both the number of cells and the "stretching" in the length of cells.
HELLP, vaginal or cesarean?
vaginal birth considered safer
threatened abortion
vaginal bleeding <20wks, no expulsion of POC, no cervical dilation tx: monitor, pelvic rest and nothing per vagina, RhoGAM for Rh neg moms incr risk: preterm labor, PROM
diagnosis by symptoms?
vaginal bleeding which is causeless, painless and recurrent + symptoms of anaemia like pallor, dizziness etc
Signs and symptoms of yeast infection:
vaginal pH does NOT change itching, burning, cottage cheese dc, yeasty smell shows up like spaghetti and meatballs on a slide KOH doesn't kill the specimen on the slide
How is HPV transmitted?
vaginal, oral, anal
Definition: When the unprotected vessels from a velamentous insertion, pass over the os. They are predisposed to rupturing.
vasa previa
Definition: The vessels of the umbilical cord insert between the layers of the amnion and chorion away from the placenta.
velametous cord insertion
how does RRA testing work
whole HCG cross reacts with LH
Multivitamin/Mineral Supplement
will cause constipation and darken stools and may worsen nausea and vomiting early in pregnancy take with food later in the day if it does not have folate take a folate supplement 600mcg a day
what do neural tube defects look like on US
will see 2 openings
at what time should you see intrauterine pregnancy
within 5 weeks of last menstrual period
pt can have hypertension
without preclampsia
when should you perform hemoglobin electrophoresis on
women with MCV less than 80 in the absence of iron deficiency a family, ethnic or medical history that puts them at higher risk for hemoglobinopathy
Breast feeding with Hep B
yea, it's okay (as long as infant has received both vaccinations and HBIG within 12 hrs of delivery)
Breast feed with Rubella infection?
yea, it's okay.
is colin awesome?
yes
varicella virus (routine screening)
yes
Screening for Gestational Diabetes •___-___ weeks gestation. Gest. DM usually presents in the _____ half of pregnancy. (first or last?) •1 hour 50 gram glucola test (GGT) •If value exceeds ______, perform 3 hour glucose tolerance test, 100 gram loading dose F:95, 1hr:180, 2hr:155, 3hr:140 •Gestational diabetes is diagnosed if _____ abnormal values found on 3ºGTT
•24-28 weeks gestation. Gest. DM usually presents in the last half of pregnancy. •1 hour 50 gram glucola test (GGT) •If value exceeds 140, perform 3 hour glucose tolerance test, 100 gram loading dose F:95, 1hr:180, 2hr:155, 3hr:140 •Gestational diabetes is diagnosed if two abnormal values found on 3ºGTT
how sensitive is immunologic testing
+ 4-7 days after first missed period
POSTPARTUM BLUES
- "Adjustment reaction/depressed mood"; occurs in 50-80% of mothers; self-limiting (a few hours to 10 days); mild depression interspersed with happiness - S/S: feeling overwhelmed; unable to cope; fatigue; anxiousness; irritability; oversensitivity; episodic tearfulness without cause - Treatment: reassurance, assistance with self and infant care
Pregestational Complications: Substance Abuse
- 1:10 women in the U.S. are substance abusers, 15% of which are pregnant - i.e. alcohol, tobacco, cocaine, crack, marijuana, club drugs, heroine, methadone - No definitive data on amount of alcohol that is safe during pregnancy; may cause fetal alcohol syndrome - Tobacco causes transient hypoxia; includes second-hand smoke and quantity doesn't matter - Cocaine and crack are vasoconstrictive, causing periods of decreased O2 to fetus - Marijuana has no specific negative outcome on fetus, but may experience withdrawal - Methadon is safe alternative for pregnant women who are addicted to other substances - Interventions: early prenatal care, assessment and observation skills, preconception care, education
Discomfort Management: Fatigue
- 1st and 3rd trimesters - Causes: energy demands of fetus, general discomfort that causes inconsistent sleep at night - Interventions: exercise; rest; relaxation; napping; comfort measures in bed (i.e. support with pillows); if excessive, have HCP test for anemia
Discomfort Management: Frequent Urination and Bladder Control Problems
- 1st and 3rd trimesters - Causes: fetus pressing on bladder - Interventions: Kegels; keep weight gain moderate; train bladder; avoid diuretics; call HCP if excessive or having pain
Discomfort Management: Nausea/Vomiting
- 1st trimester - Causes: carb metabolism, emotional factors, fatigue, hormone changes - Interventions: avoid odors; eat small, frequent meals; vitamin B6; Unisom (OTC antihistamine) or prescription steroid (used as last resort); contact HCP if vomiting more than once a day or if dehydrated; encourage dry carb intake; avoid greasy foods; increase fluid intake
Maternal Role Tasks: Seeking acceptance of infant by others
- 1st trimester: acceptance of pregnancy - 2nd trimester: family needing to relate to fetus - 3rd trimester: unconditional acceptance
Maternal Role Tasks: Learning to give of oneself
- 1st trimester: identification of what must be given up to assume new role - 2nd trimester: identification with infant, learning how to delay own desires - 3rd trimester: questioning her ability to become a good mother
Pregnancy: Increase of calories / day
- 1st trimester: little increase - 2nd trimester: 340 calories - 3rd trimester: 450 calories
Maternal Role Tasks: Seeking acceptance of self in maternal role
- 1st trimester: mother accepting idea of pregnancy, but not infant - 2nd trimester: with quickening, mother acknowledging fetus as separate entity - 3rd trimester: mother longing to hold infant; tired of being pregnant
degrees of placenta praevia
- 1st- lateralis or parietalis - 2nd-marginalis - 3rd- incomplete lateralis - 4th- centralis
Maternal Emotional Responses: Acceptance
- 2nd trimester - Feels movement, hears heart beat, sees image - Able to see fetus as separate individual - New body image
Discomfort Measures: Breathlessness
- 2nd-3rd trimesters - Causes: Fetus putting pressure on diaphragm - Interventions: sleep on side or upright; decrease activity if possible; meditation; relaxation; pillow supporting pressure point; exercise; if excessive, call HCP for anemia evaluation
Discomfort Measures: Hemorrhoids
- 2nd-3rd trimesters - Causes: constipation, increased pressure on from uterus on hemorrhoid vein - Interventions: ice packs; topical ointment; anesthetic agents; warm soaps; Sitz bath; do NOT let patient reduce--call HCP
Discomfort Management: Faintness and Dizziness
- 2nd-3rd trimesters - Causes: increased blood volume, postural HTN, anemia, large crowds, sudden position change - Interventions: sit with head between knees; lie supine; get fresh air; rise up slowly; if excessive, have H&H checked for possible anemia
Discomfort Measures: Heartburn and Indigestion
- 2nd-3rd trimesters - Causes: increased progesterone, decreased peristalsis, increased relaxing of cardiac sphincter, displaced stomach d/t uterine growth - Interventions: raise HOB; eat small, frequent meals; stay upright after eating; avoid spicy foods; don't eat before bed; avoid chocolate; if excessive, see HCP (i.e. Maalox, low-sodium antacids)
Discomfort Measures: Varicose Veins
- 2nd-3rd trimesters - Causes: lower venous congestion; weakened vein walls d/t heredity; age; weight gain - Interventions: elevate legs frequently; supportive hosiery; avoid crossing legs and standing for prolonged periods; avoid garters and hosiery with restrictive bands
Discomfort Management: Constipation
- 2nd-3rd trimesters - Causes: pressure of enlarged uterus on small intestine, iron supplements, diet, lack of exercise - Interventions: increase fluid, fiber intake, and exercise; regular bowel habits (use stool softeners as recommended by HCP)
Discomfort Measures: Edema and Swelling
- 2nd-3rd trimesters, but worst in 3rd - Causes: prolonged standing, increased sodium d/t hormone changes, circulatory congestion in lower extremities, increased capillary permeability - Interventions: frequent dorsiflexion, avoid constrictive shoes and pants, elevate legs frequently
Discomfort Management: Back Ache
- 3rd trimester - Causes: lordosis, fatigue, increased uterine size - Interventions: no lifting heavy loads; no high heels; sleep on side and support with pillows; massage; warm bath or shower
Pregnancy: Cardiac Changes
- 40-45% increase in blood volume; decreased Hct - Physiologic anemia - Decreased systemic and pulmonary vascular resistance - Increased cardiac output - Somewhat hypercoagulable state d/t increased estrogen and progesterone - Dependant edema - Varicose veins - Pooling of blood when lying flat, causing dizziness when getting up
First Trimester Discomforts: Nausea and vomiting
- 50% - Generally associated with a positive preg outcome - Eat small, frequent meals, dry foods before getting out of bed on morning - Increase intake of foods high in vitamin B6 - Avoid strong smells, fatty foods, spicy foods, stress
POSTPARTUM HEMORRHAGE
- >500 mL; clinical underestimation by 50%--difficult to assess d/t blood mixing with amniotic fluid, absorption in linens, etc. - Compare Hct level antepartum vs. postpartum; a decrease of 10 = loss of 500 mL; need fluid replacement and/or iron supplement; <7 Hct requires transfusion - "Early": within first 24 hours - "Late": 24 hours-6 weeks; may be d/t part of placenta not being expelled--requires D&C (major surgery, general anesthesia) - S/S: excessive bright red bleeding; boggy fundus not responding to massage; abnormal clots; unusual pelvic or back discomfort; bleeding in presence of contracted uterus; rise in level of fundus; increased HR; decreased BP; hematoma; decreased LOC
POSTPARTUM MAJOR MOOD DISORDER
- AKA "Postpartum depression"; occurs in 7-30% of mothers; evident in first postpartum year, greatest risk at 4th week - Risk factors: primip, pregnancy ambivalence, history of depression, lack of support, poor body image - S/S: anxiety, irritability, poor concentration, forgetfulness, sleep difficulties, appetite changes, fatigue, tearfulness - Treatment: referral to mental health professional; if meds are prescribed, caution re: breastfeeding (all SSRIs except Prozac are safe)
Danger Signs of 1st Trimester
- Abdominal cramping or pain: threatened abortion, UTI, appendicitis - Vaginal spotting or bleeding: threatened abortion - Absence of fetal heart tones: missed abortion - Dysuria, frequency, urgency: UTI - Fever, chills: infection - Prolonged NV: hyperemesis gravidarum, risk of dehydration
Danger Signs of 2nd Trimester
- Abdominal or pelvic pain: preterm labor, UTI, pyelonephritis, appendicitis - Sudden absence of fetal movements: fetal demise - Prolonged NV: hyperemesis gravidarum, risk of dehydration - Fever, chills: infection - Vaginal bleeding: infection, friable cervix d/t pregnancy changes, placenta previa, abruptio placentae, preterm labor
Risk Factors for Gestational Onset Hypertensive Disorders
- Age (very young or older) - Personal or family hx of HTN or diabetes - Obesity
Mother's Response to Pregnancy
- Ambivalence - Acceptance - Introversion - Mood swings - Fear - Changes in body image
Presumptive Sx of Pregnancy
- Amenorrhea - N/V - Excessive fatigue - Urinary frequency d/t increased pressure on bladder - Breast changes d/t increased estrogen (i.e. enlargement, increased vascularity) - Quickening (fluttering, feeling of something being "different")
FAMILY
- An institution where individuals, related through biology or enduring commitments and representing similar or different generations and genders, participate in roles of mutual socialization, nuturance, and emotional commitment - Defined in many different ways according to individual's own frame of reference, values, and discipline; whatever the individual considers it to be
Postpartum Assessment for Psychiatric Disorders
- Anticipatory guidance - Postnatal depression scale
VIBROACOUSTIC STIMULATIONS (VAS)
- Application of sound and vibration to stimulate fetal movement - Used to facilitate NST
Weight Gain During Pregnancy: Pattern of weight gain
- As important as total weight gain - About 1.6 kg (3.5 lb) during 1st trimester - .044 kg (nearly 1 lb) per week 2nd & 3rd
Mild Preeclampsia: Assessment
- BP: >140/>90 - Proteinuria: 2+ on dipstick - Serum creatinine: increased - Hemolysis: normal - Liver enzymes: normal - Platelets: normal - Urine output: normal - Headache: not present - Epigastric pain: not present - Blurred vision: not present - Pulmonary edema: not present - IUGR: not present - Seizures: not present
Severe Preeclampsia: Assessment
- BP: >160/>110 - Proteinuria: 3-4+ on dipstick - Serum creatinine: increased, >2 - Hemolysis: increased - Liver enzymes: increased - Platelets: low, <100K - Urine output: oligura (low), <500 mL/24 hours - Headache: persistent - Epigastric pain:persistent - Blurred vision: persistent - Pulmonary edema: possibly present - IUGR: possibly present - Seizures: possibly present (present = "eclampsia")
Reproductive System: Uterus: Growth
- Before pregnancy • 50-70 g (1.8 to 2.5 oz.) • 10 ml capacity - 36 weeks' gestation • 800-1200 g (1.8-2.6 lb) • 5000 ml capacity - Results from hyperplasia and hypertrophy
Pregnancy: Uterine Changes
- Beginning early in pregnancy, have mom feel uterus periodically so she becomes familiar with size and the way it feels; as pregnancy progresses, she will be more likely to identify Braxton-Hicks and preterm labor - Enlargement d/t hypertrophy - Increased fibrous tissue - Increased blood flow
Fetal presentation of Rubella (utero, birth, congenitalk, early childhood, late childhood)
- Birth 70% normal - In utero (SAB, microcephaly, IUGR) - Congenital (deaf, eyes, neuro, cardiac) - Ealry childhood (radiolucent bone dz, blueberry rash, thrombocytopenia) - Late child (thyroid abnormalities, pancephalitis, pneumonitis/DM)
Pregnancy is a hypercoagulable state
- Changes clotting factors -Increased ability to form clots
Probable Sx of Pregnancy
- Changes in pelvic organs (i.e. Goodell's, Chadwick's, Hegar's Signs) - Abdominal enlargement - Braxton-Hicks contractions d/t increased estrogen - Abdominal striae - Uterine souffle d/t blood rushing through uterus - Ballottement (palpation of mass that moves backward) - Changes in skin pigmentation - Positive pregnancy tests - Palpation of fetal outline
Pregnancy and Sexuality: Physical and emotional demand
- Changing shape - Emotional status - Fetal activity - Changes in breast size - Pressure on bladder and other discomforts
First Prenatal Visit: Medical, surgical, & personal history
- Chronic diseases - Allergies to medications, foods, environmental substances - Occupation - Exposure to teratogens - Exercise and activity - Recreational patterns - Nutritional habits - General lifestyle
Pregestational Complications: Congenital Heart Disease
- Classes 1 and 2 tolerated pregnancy well - Interventions: more frequent office visits, antibiotics infused during labor to prevent endocarditis, too much pushing (especially holding breath with Valsalva maneuver) increases stress on heart--use vaccum or forceps during 2nd stage - Rheumatic fever causes valve damage; treat with antibiotics - PERIPARTUM CARDIOMYOPATHY: heart enlargement; cause unknown; no hx of congenital defects or rheumatic fever; can be fatal; dysfunction of left ventricle not detected until lend of pregnancy or first postpartum months; S/S--SOB, cough, easily fatigued
Amniotic Fluid
- Clear, slightly yellow, alkaline fluid - Approximately 1 liter at term - Derived from - Maternal plasma - Cells of the amnion - Fetal fluids from lung, skin, fetal urine
Qualities of Strong Families
- Commitment - Appreciation - Encouragement - Time - Purpose - Congruence - Communication - Rules - Values and beliefs - Coping strategies - Problem-solving - Positivity - Flexibility and adaptivity - Balance
Sensory Organs: Eye
- Cornea thickens, intraocular pressures decreases
Functions of Amniotic Fluid
- Cushions fetus from trauma - Facilitates fetal movement - Facilitates symmetrical growth - Regulates intrauterine temperature - Provides source of oral fluid - Cushions umbilical cord - Receptacle for fetal substances
HEMATOMA R/T POSTPARTUM HEMORRHAGE
- D/t injury to a blood vessel from birth trauma - Assess with patient in lateral Sims position - Risk factors: nulliparity, precipitous birth, prolonged 2nd stage, operative birth, macrosomia - S/S: perineal pain and/or rectal pressure, edema, tense/fluctuant/bulging/shiny mass
POSTPARTUM UTI
- D/t overdistension r/t trauma or effects of anesthesia - Treatment: straight cath or Foley; ice packs to perineal area; pain meds; antibiotics; avoid carbonated beverages; drink cranberry juice; vitamin C
Medical Risk for Older Expectant Mothers
- Death - Chronic medical condition - Miscarriage - GD - HTN - CV problems (i.e. MVP, chronic problem) - Placental previae (lies partially b/t or completely over cervix, possibly causing detachment) - Difficult labor - NB complications - LBW - Preterm births - Perinatal deaths - Down Syndrome
Reasons for Ultrasound
- Determining gestational age; most accurate at 6-10 weeks - Identifying FHR and fetal breathing movements - Estimating fetal size; measure biparietal diameter, femur length, estimate weight - Screening for fetal anomalies (i.e. Down Syndrome, anencephaly, cardiac defects) - Identifying amniotic fluid index - Identifying placental location and grading - Detecting fetal position and presentation - Detecting fetal demise
Pregnancy: Cervical Changes
- Development of mucus plug - Goodell's, Chadwick's, and Hegar's Signs
GDM: Management
- Diet - Exercise - Blood glucose monitoring - Fetal surveillance
Preconception care: Management
- Diet - Self-monitoring of blood glucose - Insulin therapy
First Trimester Discomforts: Breast tenderness
- Due to increased estrogen & progesterone - Wear a supportive bra
Missed Abortion: S&S
- Early symptoms of pregnancy cease - Uterus stops growing -Vaginal bleeding
Pregestational Complications: Interventions for Diabetes
- Education: diet, lifestyle changes, insulin - Monitoring: more frequent ultrasounds to monitor fetal growth--baby >8 pounds 13 oz is considered too large; >9 pounds 13 oz = scheduled C-section - Postpartum care: GD is a precursor to Type II within 5-10 years postpartum - Increased risk for other complications: C-section, stillbirth, preeclampsia, infection, hydraminos - Fetal risk: congenital anomalies (frequently CV), uncontrollable blood sugar, macrosomia and getting stuck in birth canal, respiratory distress d/t insufficient surfactant, hypoglycemia - Genetic imprinting for childhood obesity - Mother should be euglycemic (normal) prior to conception and maintain throughout pregnancy
Medications to avoid in prego (HIV drugs)
- Efavirenz (durring first tri) - Combo stavudine D4T and didanosine) - Nevirapine if CD4 >250
Special Concerns for Older Expectant Couples
- Enough energy to care for NB - Ability to deal with needs of child as they age - Only couple in peer group expecting new baby
Hydatidiform Mole: Management
- Evacuation of tissue by vacuum aspiration, then curettage - Continuous followup to detect malignant changes -Before evacuation screen for any metastatic disease
CONTRACTION STRESS TEST (CST)
- Evaluates uteroplacental function - Identifies intrauterine hypoxia - Observes FHR response to contractions - If compromised, FHR will decrease - Can be negative, positive, equivocal-suspicious, equivocal-hyperstimulatory, or unsatisfactory
Hydatidiform Mole: Diagnosis
- Excessive levels of hCG and ultrasound
Cultural Factors R/t Pregnancy
- Factors that influence woman's expectation of childbearing experience - Beliefs or practices that maintain her spiritual well-being or influence care (i.e. prohibition or receiving blood products, dietary restrictions) - Ask about specific practices
Father's Health History Re: Risk Factors for Mother/Fetus
- Family history of genetic conditions - Age - Significant health problems - Previous or present alcohol intake - Drug and tobacco use - Blood type and Rh factor
Diagnostic Uses of Amniocentesis
- Fetal health - Genetic testing for fetal abnormalities - Fetal lung maturity: lecithin/sphingomyelin ratio 2:1, phosphatidylglycerol presence, and lamellar body counts indicate maturity
Endocrine System: Placental Hormones: Progesterone
- First produced by corupus luteum, later by placenta - Most important hormone of pregnancy - Maintains endometrial layer - Prevents spontaneous abortion - Helps prevent tissue rejection of fetus - Stimulates development of breast lobes and lobules - Facilitates deposit of maternal fat stores - Relaxes other smooth muscle in body -Decreased motility of bowel dilation of ureters
G.T.P.A.L.
- G: "gravida"; number of pregnancies, including current pregnancy; twins/triplets count as ONE gravida and ONE para - T: "term"; # of pregnancies that were delivered at 37 weeks or later - P: "preterm"; # of pregnancies that were delivered b/t 20 and 37 weeks - A: "abortion"; # of pregnancies ending in therapeutic or spontaneous abortion - L: "living"; # of currently living children
T.O.R.C.H.
- Generally mild for adult but significant consequences to fetus - T: toxoplasmosis (i.e. pork, cat feces) - O: other; i.e. varicella, beta strep, UTI --> premature labor, bacterial vaginosis --> premature labor, HIV (treat with antiretroviral to prevent vertical transmission, no breastfeeding allowed, delivered by C-section) - R: rubella; causes congenital heart problems, fetal growth restriction, blindness, and MR - C: CMV (cytomegalovirus); most common; travels transplacentally, causing fetal death, hydrocephaly, and MR - H: herpes virus (types 1 and 2); causes spontaneous abortion, LBW, and prematurity; active lesions around genitalia --> C-section to prevent transfer to baby
Pregnancy: Breast Changes
- Glandular hyperplasia and hypertrophy - Areolae darken, superficial veins and Montgomery follicles become prominent - Possible striae - Colostrum secretion
Urinary System: Kidneys & Ureters : Functional changes
- Glomerular filtration rate increased by 50% - Glycosuria common - Mild proteinuria common
Ectopic Pregnancy: Management
- Goal to preserve tube and improve chance of future fertitlity - Methotrexate inhibit cell division - Surgery, control bleeding
Third Trimester Discomforts: Shortness of breath and dyspnea
- Growth of uterus prevents complete lung expansion - Dyspnea when lying on back - Raising head of bed, lying on her side
Info about Hepatitis B during pregnancy
- HBV is the most threatening virus to the fetus and neonate. -HBsAG is the antigen typically screened for in pregnant women. -Breast feeding is NOT contraindicated, as long as the infant received the standard Hep B vaccination at birth and is kept on the appropriate vaccination schedule.
Physical exam: head-to-toe assessment
- Head and neck - ROM, swelling - Chest -Heart sounds -Breath sounds -Breast exam - Abdomen - Size and contour -Muscle tone -Fundal height
pregnancy: Cardiovascular System: Heart sounds
- Heart sounds altered - First heard between 12 and 20 weeks - Continue 2-4 weeks after pregnancy - Systolic murmur in 90% of pregnant women
Nurse's Role in Amniocentesis
- Help prepare patient: explain procedure and make sure informed consent was explained - Gather supplies: 22-gauge spinal needle with stylet, syringes, 1% xylocaine, povidone-iodine, three test tubes - Obtain baseline maternal VS and FHR - Assist with ultrasound to determine location of placenta, fetal parts, and amniotic fluid - Assist with procedure and managing test tubes - Monitor patient every 15 minutes during and after procedure - Educate patient on activity limitations and complications to report - Document procedure, patient response, and patient understanding of instructions
Immunizations During Pregnancy
- Hep A and Hep B: yes, if high risk - HPV: no - Flu TIV (IM): yes; Flu LAIV (intranasal): no (live viruus) - MMR: no (live virus) - Meningococcal, pneumococcal, TD: yes, if indicated - TDAP: yes, if high risk for pertussis - Varicella: no (live virus)
Psychosocial Risk Factors R/t Pregnancy
- History of deprivation or abuse - History of emotional problems (i.e. depression, anxiety, postpartum depression) - Support systems - Over/underuse of healthcare system - Acceptance of pregnancy, intended or unintended - Personal preferences about birth - Plans for care of child following birth - Feeding preference for baby
Abruptio Placentae: Management
- Hospitalize and evaluate immediately CV status and fetal status -Conservative treatment -If mild and fetus immature - Bedrest, tocolytic drug to decrease contraction - Immediate delivery if fetal distress or excessive bleeding
Gestational Onset Complications: Trophoblastic Disease (Molar Pregnancy)
- Hydatidiform mole and choriocarcinoma; generally no fetus other than development of the placenta, fluid-filled vesicles that look like grapes, and rapid growth - Assessment: rapid growth pattern, no FHR, high levels of pregnancy hormones, abnormally high fundal height, discharge with white flecks (vesicles expelling) - Interventions: must be evacuated--dilate cervix and scrape out uterus; must receive closely-monitored follow-ups d/t increased risk for choriocarcinoma (cancer of uterine lining); blood draws to monitor hormone levels
Pregnancy: Skin Changes
- Hyperpigmentation - Striae - Linea nigra (dark line down center of abdomen) - Chloasma ("mask of pregnancy"): brown discoloration on cheeks d/t increased estrogen - Vascular spider nevi - Decreased hair growth - Hyperactive sweat and sebaceous glands
Hyperemis Gravidarum: Nursing assessments
- I&O - Lab data evaluation - Daily weights - Assess for signs of dehydration -Intake <2000 ml/day -Increased urine specific gravity >1.025 -Dry skin or dry mucous membranes -Nonelastic skin turgor
Discomfort Management: Dental Problems
- I.e. ptyalism (bitter taste in mouth), pain, cavities, gingivitis - Present in all trimesters but worst during 1st - Causes: bad oral hygiene, increased estrogen - Interventions: get treatment immediately; try to have maintenance work done before pregnancy--if not, it's best to have it done during the 2nd trimester
Gestational Onset Complications: Ectopic Pregnancy
- Implantation anywhere other than the uterus, commonly fallopian tube; can be d/t obstruction or trauma - Assessment: constant unilateral pain; risk for rupture = medical emergency - SALPINGOSTOMY: attempt to repair tube - SALPINECTOMY: removal of tube
Exercise During Pregnancy
- Improves self-esteem - Increases energy - Improves sleep - Relieves tension - Helps control weight gain - Promotes regular bowel function - No hot tubs, saunas, or sports with risk of abdominal trauma - Pregnancy exercises: pelvic tilt, abdominal exercise, Kegels (may prevent postpartum rectal prolapse), tailor-sit stretch; certain yoga poses may be contraindicated
Respiratory System: Hormonal Factors: Estrogen
- Increased vascularity of mucous membranes - Nasal stuffiness, epistaxis, changes in voice -Physical changes - Elevation of diaphragm - Rib circumference enlarges
Second Trimester Discomforts: Varicosities of vulva and legs
- Increased venous stasis - Progesterone relaxes vein walls - Support hose
Red blood cell mass
- Increases about 25%-33% - Physiologic anemia - not true anemia - Iron deficiency anemia • Hgb less than 11 in 1st and 3rd trimesters • Hgb less than 10.5 in 3rd trimester - Protective function
Maternal Mortality
- Increasing number: 13.3:1000 - Higher risk of pregnancy-related complications d/t lack of insurance, poor family planning, unwanted pregnancies, insurance not covering family planning
MASTITIS
- Infection of the breast connective tissue d/t bacterial invasion following trauma to nipple - Causes: milk stasis, poor hygiene, nipple trauma, duct obstruction - S/S: warm, reddened, painful area of breast (usually upper outer quadrant); usually advances to include fever, chills, headache, and flu-like sx; 2nd-4th week postpartum - Treatment: bedrest for 24 hours; increase fluids; supportive bra; frequent breastfeeding; warm, moist packs; analgesics; antibiotics
METRITIS (ENDOMETRITIS)
- Infection/inflammation of uterine lining (endometrium) - Risk factors: C-section; PPROM (premature prolonged rupture of membranes); prolonged labor followed by C-section; compromised health status; internal EFM (i.e. scalp electrode); birth trauma; chorioamnionitis; DM; operative birth; manual placenta removal; BV or chlamydia; lapses in aseptic technique - Causes: beta strep (early), chlamydia (late) - S/S: bloody, foul-smelling lochia; uterine tenderness; temp spikes on 2 or more occasions; increased HR; chills; increased WBCs or more than 30% in 6 hour period - Treatment: antibiotics until afebrile for 48 hours; prophylactic antibiotics given for C-section
Anemia: Management
- Iron replacement Ferrous sulfate, 320 mg, 1-3 time per day With citrus drink absorption improved Folic acid-deficiency (megaloblastic) - Maternal effects: Folic acid needs double during pregnancy -Reduction in rate of DNA synthesis and mitotic activity of cells, resulting in large, immature erythrocytes (megaloblasts) - Fetal effects: Increased risk of spontaneous abortion, abruptio placentae, and fetal anomalies - neural tube defects - Increase sources of intake -Liver, kidney beans, lima beans, fresh dark-green leafy vegetables -400 mcg daily prepregnancy - 600 mcg daily during pregnancy
Pregestational Complications: Anemia
- Lack of blood to baby --> LBW - Hgb <11, Hct <33% in 3rd trimester - Treatment: dietary/supplemental iron--take supplements with vitamin C and stool softener
Weight Gain During Pregnancy: Excessive weight gain
- Macrosomia - Prolonged labor - Birth trauma - Cesarean birth
Risk Factors / Reproductive Outcomes
- Maternal age - Parity - Socioeconomic status - Ethnicity - Geographic factors - Behavioral and Lifestyle risks - Health risks - Previous pregnancies
McDonald's Method
- Mathematical formula to determine gestational age; used at 22-34 weeks - # of inches from symphisis pubis to fundus = # of weeks along
Doppler flow studies
- Measures velocity of blood flow - Detect fetal compromise in high-risk pregnancies - Assessment of Fetal Well-Being (cont.)
Reproductive history
- Menstrual Date of LMP - Nagele's rule -Regular or irregular periods - Past pregnancies
Congenital HSV infection presentation (infants)
- Microcephaly - hydrocephalus - chorioretinitis - vesicular skin lesions
Toxo (risk durring trimester)
- Mom infected durring 1st tri is less likely but more severe - mom infected during 3rd is more common but mild/non apparent at birth
Maternal Assessment of Fetal Activity
- Monitors fetal well-being - Begins at approximately 28 weeks - Reduction in movement may indicate hypoxia, growth restriction, or fetal demise - Count fetal movements at same time each day - Report to HCP: <10 movements in 3-hour period; significantly less than normal movement; perception of decreased movement in 24-hour period - Factors that may affect movement: sleep-wake cycle of fetus, smoking, maternal hypoglycemia, sound, drugs
Abortion: Incomplete: Management
- Need to stabilize cardiovascularly - D&C, followed by Pit or Methergine - D&C contraindicated if greater than 14 weeks • Danger of excessive bleeding, give Pit
Interpreting Results of CST
- Negative: stress of uterine contraction shows 3 contractions of good quality lasting 40+ seconds in 10 minutes without late decelerations - Positive: stress of uterine contraction shows repetitive persistent late deceleration with more than 50% of contractions - Equivocal: "suspicious" = inconsistent late declerations; "hyperstimulatory" = contraction frequency every 2 minutes or lasting >90 seconds with late decleration
BIOPHYSICAL PROFILE
- Normal--score = 2, abnormal--score = 0 - FHR acceleration: "nonstress test"; normal--2+ accelerations of >15 bpm for >15 seconds within 20-40 minutes; abnormal--0 or 1 acceleration in 20-40 minutes - Fetal breathing: normal--1+ episode of rhythmic breathing lasting 30+ seconds within 30 seconds; abnormal--less than 1 episode - Fetal movements: normal--3+ discrete body or limb movements in 30 minutes; abnormal--less than 2 movements in 30 minutes - Fetal tone: normal--more than 1 extension of fetal extremity with return to flexion, or opening/closing of hand; abnormal--no movements or extension/flexion - Amniotic fluid volume: normal--single vertical pocket >2 cm, AFI >5 cm; abnormal--largest single vertical pocket <2 cm, AFI <5 cm
Hazards to Fetal Growth and Development
- Occupational exposure - X-rays - Pesticides - Smoking (causes LBW) - Alcohol (no known safe amount) - Caffeine (can cause NB withdrawal) - Drugs (prescription and OTC)--keep OB informed of what you're taking; excessive vitamin D can be toxic to fetus - Substance abuse (illicit drugs)--can cause premature labor
Gestational Diabetes Mellitus: Risk factors
- Overweight - Chronic hypertension - Maternal age older than 25 yrs - Family history of diabetes in close relatives
Meds for Postpartum Hemorrhage
- Oxytocin (Pitocin) 50 mu/min IV—step 1 - Methylergonovine maleate (Methergine) 0.2 mg q 2-4 hrs IM—step 2 - Ergonovine maleate (Ergotrate Maleate) 0.2 mg q 2-4 hrs IM—step 2 - Hemabate (a prostaglandin) 0.25 mg IM—step 3; pt will be very comfortable if we reach this level of therapy d/t intense contractions, combine with pain meds - Cytotec (a prostaglandin) 100 mg rectally—step 3
Pregnancy: Musculoskeletal Changes
- Pelvic joint relaxation - Center of gravity changes - Separation of rectus abdominus
First Trimester
- Physical and psychosocial changes of pregnancy - Self-care in pregnancy - Protecting and nurturing the fetus - Choosing a care provider and birth setting - Prenatal exercise - Relief of common early pregnancy discomforts
Discomfort Management: Headache
- Present in all trimesters - Causes: fatigue, increased blood volume, stress, anxiety - Interventions: Tylenol; hydration; rest and relaxation; regular meals; gradual caffeine decrease; if not relieved with all above measures, call HCP for PIH evaluation
Discomfort Measures: Vaginal Discharge
- Present in all trimesters, but worst in 1st (milky white, thick) - Causes: hormone changes, causing increased mucus production in cervix - Interventions: pantyliners; good hygiene; cotton underwear; know what is abnormal (i.e. foul smell, bleeding, white/cheesy/chunky)
Maternal Role Tasks: Ensuring safe passage throughout pregnancy and birth
- Primary focus of woman's attention - 1st trimester: woman focusing on herself, not fetus - 2nd trimester: developing attachment to fetus - 3rd trimester: having concern for herself and fetus as a unit - Participating in positive self-care activities: Diet, exercise, overall well-being
Human placental lactogen: Human chorionic somatomammotropin (hPL)
- Primary function is to increase the availability of glucose for fetus
Endocrine System: Placental Hormones: Human chorionic gonadotropin
- Produced by cells surrounding embryo - Prevents deterioration of corpus luteum Continues to produce progesterone until placenta takes over - Produces positive pregnancy test
Endocrine System: Placental Hormones: Estrogen
- Produced by corpus luteum for 1st few wks - Produced by placenta afer 6-7 wks - Stimulates uterine growth - Increases blood supply to uterine vessels - Increases uterine contractions near term - Aids in development of glands and ductal system of breasts - Causes hyperpigmentation, vascular changes
Recurrent Spontaneous Abortion: Nursing considerations
- Psychological needs - patient frightened, loss and grief, guilt, anger disappointment - Listen, convey acceptance
• Nursing management
- Psychosocial issues - Medication and drug use - Support system -Stress importance of taking folic acid -Achieve optimal weight before pregnancy -Up-to-date immunizations - Address substance use issues -Identify victims of violence - get them help -Manage chronic conditions -Educate about environmental hazards -Offer genetic counseling -Suggest availability of support systems
Third Trimester Discomforts: Heartburn and indigestion
- Relaxation of cardiac sphincter - Pain may radiate to neck and throat - Review dietary intake
UTERINE ATONY R/T POSTPARTUM HEMORRHAGE
- Relaxation of the uterus; may be described as "boggy" (soft) - Blood loss may be slow/steady or sudden/massive - Risk factors: overdistension of uterus d/t macrosomia or multipara; rapid or prolonged labor; oxytocin induction (causes contractions to be stronger and closer together); grand multiparity; general anesthesia; prolonged 3rd stage; infection; preeclampsia; operative birth (i.e. forceps, vacuum); retained placental fragments - If after fundal massage and expression of clots plus emptying the bladder ("dextroversion"—full bladder displaces fundus to the right), there is a slow, steady, free flow of blood, weighing perineal pads may be necessary - 1 ml = 1 g - Maintain IV access, frequent VS, lab values (i.e. Hct), urinary output, fundal checks, lochia amount (saturating >1 pad/hour—call physician, may need meds)
Respiratory System: Hormonal Factors: Progesterone
- Relaxes smooth muscle - Heightened awareness of dyspnea
Third Trimester Discomforts: Constipation
- Relaxing effects of progesterone - Increase exercising, fiber, fluids
Amniocentesis : After procedure
- RhoGAM if Rh neg - VS and FHR - Report S&S of infection
Hypertensive Disorders: Diabetes: Assessment
- Risk factors - Classic symptoms - Frequent UTIs and yeast infections Screening at 24-28 weeks gestation
Cultural Factors During Pregnancy
- Rituals and customs that reflect values - Useful in predicting reaction to pregnancy - Male/female roles - Family lifestyles - Religious values - Meaning of children - Respect and study values and beliefs of others, incorporate them into care - Remember that variations exist within cultures
PROM (Premature Rupture of Membranes)
- Rupture prior to labor beginning; increases risk of infection - Avoid frequent vaginal exams - Montior temperature
Goals of Prenatal Care
- Safe birth - Health promotion - Self-care - Provide physical care - Provide anticipatory guidance
AMNIOCENTESIS
- Scanned by ultrasound to determine placenta site and to locate a pocket of amniotic fluid; needle inserted into uterine cavity to withdraw amniotic fluid - Used to determine genetic, metabolic, and DNA abnormalities - Can detect neural tube defects - Complications: vaginal spotting and cramping, mild fluid leakage
Family's Reaction to Pregnancy
- Siblings: rivalry; fear of change in relationship with parents; may need reassurance - Grandparents: closer relationships with expecting couple; clarify role of coping grandparent
Prenatal High Risk Factors
- Social-personal: low income and/or educational level, poor diet, living at high altitude, multiparity >3, weight <100 or >200 pounds, age <16 or >35 years, smoking 1+ packs/day, use of addicting drugs, excessive alcohol consumption - Preexisting medical disorders: DM, cardiac disease, anemia (Hgb <11, Hct <32%), HTN, thyroid disorder, renal disease, DES exposure - Obstetric considerations: previous pregnancy--stillborn, habitual abortion, C-section, Rh or blood group sensitization, large baby; current pregnancy--rubella (1st/2nd trimester), CMV, herpes, syphillis, UTI, abruptio placentae and plecenta previa, preeclampsia, multiple gestation, Hct >41%, SPROM
Third Trimester Discomforts: Elevated hormones, and blood volume
- Sodium and water retained - Increased thirst - Rule out preeclampsia
Naegele's Rule: Calculation of Due Date
- Standard formula for calculating EDD (AKA EDB, EDC) based on last menstrual period (LMP) - First day of LMP - 3 months + 7 days = EDD (i.e. April 27th - 3 months = January 27th + 7 days = EDD February 3rd) - Always give February 28 days
Placenta Previa: S&S
- Sudden onset of painless bleeding last ½ pregnancy - May not occur until labor starts - "Heavy bloody show" When in doubt, NEVER do a vaginal exam
Supine hypotension
- Supine position reduces output as much as 25%-30% - Supine hypotensive syndrome - Need to rest in lateral recumbent position
Gynecologic history
- Surgeries - Safe-sex practices - Hx of STDs
Abruptio Placentae: Systemic signs of early hemorrhage
- Tachycardia, tachypnea, falling BP, falling urine output -Persistent late decels in FHR or decreasing baseline variability; absence of accelerations -Slight or absent vaginal bleeding - Ultasound to r/o placenta previa does not diagnose abruptio placenta
Puerperal Morbidity
- Temp > 38 degrees C, 100.4 degrees F taken 4x/day on any 2 of first 10 days postpartum, excluding first 24 hours - Not all-encompassing--increased temp can be d/t dehydration, increased WBCs (d/t labor being an inflammatory process)
Pregestational Complications: HIV/AIDS
- Testing of all pregnant women is recommended - Can be transmitted through breastmilk, sexual relations, and blood contact--implement universal precautions with all patients - Intervention: treat fetus throughout pregnancy with antiretrovial, commonly ZBT therapy (good outcome); breastfeeding not recommended
Recurrent Spontaneous Abortion: Management
- Thorough exam to identify cause
Screening and Diagnostic Tests
- To validate pregnancy: transvaginal ultrasound of gestational sac volume, 5-6 weeks after LMP - To determine how advanced pregnancy is: crown-rump length ultrasound at 6-10 weeks; biparietal diameter, femur length, abdominal circumference at 13-40 weeks - To identify normal growth of fetus: biparietal diameter ultrasound at 20-30 weeks; head/abdomen ratio at 13-40 weeks; estimated fetal weight at 24-40 weeks - To detect congenital anomalies and problems: nuchal translucency testing at 9-13 weeks; ultrasound at 18-40 weeks; CVS at 10-12 weeks; amniocentesis at 15-20 weeks; fetoscopy at 18 weeks; 1st trimester combination screening test or quadruple test at 15-20 weeks - To assess fetal status: biophysical profile, maternal assessment of fetal activity, and nonstress test at 28 weeks to birth; CST after 28 weeks - To diagnose cardiac problems: fetal echocardiography at 2nd/3rd trimesters - To assess fetal lung maturity: amniocentesis at 33-40 weeks; L/S ratio, phosphatidylglycerol, phosphatidylcholine, and lamellar body counts from 33 weeks to birth - To obtain more info about breech presentation: ultrasound just before labor is anticipated or during labor
ULTRASOUND
- Transabdominal: transducer with transmission gel over abdomen; visualization facilitated with full bladder - Transvaginal: probe inserted into vagina; clearer images; utilized early in pregnancy
Ectopic Pregnancy: Diagnosis
- Transvaginal ultrasound - Decreased levels of hCG - Characteristic blue swelling within tube
3 subtypes of Herpes/mortality of them
- dz skin, eye, mouth (no mortality - Encephalitis w or w/o skin/eye (15% mortality) - Disseminated, CNS, lung, liver, eye/mouth (57% mortality, even w/ tx)
Maternal Emotional Responses: Introversion
- focusing on one's self - 1st and 3rd trimesters - May appear passive to family - Focuses on behaviors to ensure safety
discomfort of 3rd tri
- leg cramps- dorsoflex foot until spasm relaxes. aluminum hydroxide gel with each meal to eliminate the excess phosphorus. oral supplements of calcium carbonate or calcium lactate. -ankle edema- extra fluid intake, support hose, rest with legs elevated. Contact dr. if generalized edema ex. face, hands. most pedal edema should go away over night.
newborn with syphillis
- may be axs or classic signs - usually dev 14d's after delivery - maculopapular rash, "sniffles" mucous patches on oropharynx, hepatosplenomegaly, jaundice, lymphadenopathy, chorioretinitis
placental site causes
- placenta praevia- low lying placenta - accidental hge- premature separation of placenta
Hyperemis Gravidarum: Management
- r/o other causes - HGB, HCT - Home treatment - Vitamins and minerals
Cardiovascular System: Cardiac output
- the amount of blood discharged from the heart each minute -Increases 30%-50% by 3rd trimester -Output highest when lying on side
Due Date
- the aprox. date of delivery is sometimes called: -EDC- expected date of confinement -EDB- expected date of birth -Due date -Delivery date
endocrine changes
- thyroid gland -pituitarygland - posterior pituitary -pancrease -adrenal glands
2nd tri problems
-varicose viens- avoid sitting or standing for long periods, avoid restrictive clothing, and constipation. wear support hose and elevate legs and hips at rest periods. -round ligament pain- this ligament is stretched as it holds up the enlarged uterus. rest in horizontal position and heat may help. -Back ache and joint pain- wear low heel shoes. Apply heat, massage, and rest affected joint. For back, use pelvic rock exercises
Trichomona vaginalis
...
O'Leary Techniques for Monitoring Perceived Fetal Motion
0-5 movements / 30 mins for each of the 30-min periods record every Three 30 min periods, daily
Weight Gain During Pregnancy: Overweight
7 - 11.5 kg (15-25 lb)
Metabolism Changes: Dependent Edema
Colloid osmotic pressure slightly decreases - Favors development of edema 1.5 - 9 L of water are retained during pregnancy -Large part of weight gain -Feet and ankles
Reproductive System: Cervix
Color - Congested with blood - hypemia - Chadwick's sign - bluish purple -Consistency Goodell's sign - softening -Mucous plug
__, an antibody-rich, yellow secretion maybe expressed manually by the 12th week and may leak from the breasts during the last trimester of pregnancy. It is a precursor to milk.
Colostrum
surfactant
Combination of lipoproteins produced by the lungs of the mature fetus to reduce surface tension in the alveoli, thus promoting lung expansion after birth.
Laboratory Tests Table -( 27-3)
Complete blood count (CBC) (including a platelet count) Clotting studies (including bleeding time, PT, PTT, and fibrinogen) Liver enzymes (lactate dehydrogenase [LDH], AST, ALT) Chemistry panel (BUN, creatinine, glucose, uric acid) Type and screen, possible cross match LDH values differ according to the test/assays being done
Weight Gain During Pregnancy
Determined by BMI 1lb/month = first trimester (3lbs total) 1lb/week = second and third trimesters (24lb total) Average women should gain approximately 27lbs Women with a BMI of 26 or more, are overweight or obese will expect to gain <25lbs and someone expecting twins should gain around 35-45lbs
What is a blastocyst composed of?
Embryoblast - inner cell mass Trophoblast - outer cell mass (chorion)
Variations in Prenatal Care: Cultural Influences
Emotional response, Clothing, Physical activity and rest, Sexual activity, Diet, and Psychosocial support systems
What hormones does the pituitary gland secrete and what do they do?
FSH- stimulates follicle growth within ovary; LH- effects ovulation; thyrotropin and adrenotropin- alter maternal metabolism to support the pregnancy; Prolactin- responsible for initial lactation; oxytocin- promotion of uterine contractility and stimulation of milk ejection from breasts; vasopressin- causes vasoconstriction (increased BP) and has antidiuretic effect.
Complications of Herpes Simplex Virus during pregnancy?
If contracted during pregnancy, herpes can become viremic and infect the fetus. Neonatal herpes is a severely disabling and possibly fatal condition. Mothers are encouraged to consider Cesarean section. Must be PERFORMED WITHIN 4 HOURS OF MEMBRANE-RUPTURE.
Timing of Delivery.
If possible the pregnancy should be allowed to progress to 38 weeks to allow fetal lungs to mature, reducing the risk of neonatal respiratory distress syndrome.
What is the downside of a VDRL blood test for syphilis?
If you do it too early, it won't be positive.
uteroplacental insufficiency
Inability of the placenta to exchange oxygen, carbon dioxide, nutrients, and waste products properly between the maternal and fetal circulations.
What happens to glucose metabolism in late pregnancy?
Insulin resistance emerges - impaired glucose tolerance
FAMILY FUNCTION
Interactions of the family members especially focusing on the quality of relations and interactions
Follow-up Visits
Interview (Has anything changed since your last visit? Any new symptoms?, etc) Physical examination, Fetal assessment (Fundal height, tells you if the baby is growing at a normal rate, Gestation age, and Health Status of the baby, hearing the heart beat at 4-5 wks with vaginal ultrasound and 12 wks with the dop ultrasound) Laboratory test (multiple-marker or triple screen blood test or other blood test like RPR/VDRL, CBC, anti-Rh)
SEVERE PRECLAMPSIA INTERVENTIONS 4.
Magnesium Sulfate. ( Box 27-3) One of the important goals of care for the woman with severe preeclampsia is prevention or control of convulsions. Magnesium sulfate is administered as a secondary infusion (piggyback) to the main intravenous (IV) line by volumetric infusion pump. An initial loading dose of 4 to 6 g of magnesium sulfate, per protocol or physician's order, is infused over 15 to 20 minutes. This dose is followed by a maintenance dose of magnesium sulfate that is diluted in an IV solution per physician's order (e.g., 40 g of magnesium sulfate in 1000 ml of lactated Ringer's solution 1g= 25ml) and administered by infusion pump at 2 g/hour. This dose should maintain a therapeutic serum magnesium level of 4 to 7 mEq/L. Blood levels of magnesium sulfate are checked periodically. After the loading dose, there may be a transient lowering of the arterial blood pressure secon-dary to relaxation of smooth muscle by the magnesium sulfate
PELVIMETRY
Manual measurement of inlet and outlet - Estimate diagonal conjugate; extends from lower border of symphysis pubis to sacral promontory - Estimate anteroposterior diameter of the outlet; extends from lower border of symphysis pubis to tip of sacrum - Check manual estimation of anterposterior measurements using measuring devices
what are markers seen during ultrasound evaluation that can indicate trisomy 21 or down syndrome
Markers: Ventriculomegaly Absent nasal bone Choroid plexus cysts Nuchal fold Echogenic focus in left ventricle Echogenic bowel Mild hydronephrosis Clinodactyly Sandal gap Short long bones Abnormalities: Heart defects Duodenal atresia
Nsg interventions for chorionic villus sampling?
Obtain informed consent, client may need to drink water to fill the baldder before the prcedure to aid in the visualization of the uterus for catheter insertion, obtain baseline vitals and fetal heart rate (monitor these frequently after procedure, Rh-negative women may be given Rho(D) immune globulin because chorionic villus sampling increases the risk of Rh sensitization.
Nsg interventions for amniocentesis?
Obtain informed consent, if less than 20 weeks client should have a full bladder to support uterus, if more than 20 weeks client should have an empty bladder to minimize chance of puncture, prepare client for ultrasonography, obtain baseline vitals and fetal heart rate (FHR) monitor every 15 minutes, position the client supine during the examination and on the left side after the procedure
Describe the secondary stage of syphilis.
Occurs at 6 weeks or more classic syphilis rash on hands (palms) and feet condyloma enlarged liver weird eye infections sore throat and hoarseness
Describe the primary stage of syphilis.
Occurs within the first 4-6 weeks chancre (ulcer) on gentalia which will heal without tx low grade fever adenopathy
What is the treatment for trich?
One time dose of flagyl
Describe the umbilical cord.
One vein—oxygenated and pressurized R side Two arteries—deoxygenated and flaccid L side 50-60 cm in length
How long does a woman have to go without a period to be considered menopausal?
One year.
What are elevated levels of protein associated with?
Open neural tube and abdmonial wall defects
Trichomonas (PH)
PH >4.5
Vulvovaginitis (PH, sx)
PH >4.5 - gray-white or yellow discharge
PID can scar the pelvic viscera, including the fallopian tubes, which can render a woman infertile. Though it is often caused by STIs, there are other things that can cause it. What are those?
PID can be caused by both aerobic and anaerobic bacteria, which typically infect the woman after menses and ascend the vagina and endocervix to the upper genital tract
Having chlamydia increases the risk for:
PID, infertility (men and women), epididymitis, ectopic pregnancies, HIV contraction
Antepartum hemorrhage Initial Evaluation 1. History (abdominal pain, contractions, placenta previa, c-sections or other prior uterine surgeries, smoking, cocaine or bleeding disorders). 2. Physical (Vitals, amount of bleeding, uterine tenderness, DO NOT CHECK CERVIX UNLESS _________________ HAS BEEN RULED OUT!!!!
PLACENTA PREVIA
If straight line, no variability. This means that ____
PNS component of CN X is lost.
PROM
PREMATURE RUPTURE OF MEMBRAIN (AFTER 37 WEEKS)
what are risk factors for placenta previa
PRIOR cesarean section, uterine surgery or curretage also: Maternal age Multiparity Prior placenta previa Uterine abnormalities (fibroids) Smoking IVF Multiple gestations
pregnancy history- Para (P)
Para- Parity- number of pregnancies in which the fetus has reached the age of viability, regardless of whether or not the fetus is born live or dead. If she has delivered 1 baby after 20 wks gestation, she is primipara. after several deliveries, she called a multipara.
BINUCLEAR
Parents continuing parenting role while ending spousal unit
Definition: the placenta partially covers the internal os.
Partial Previa
Adaption to Pregnancy
Paternal adaptation (the same as maternal adaptation just add in the father figuring out his role), Sibling adaptation, Grandparent adaptation and Financial, space and other lifestyle changes (these can cause good or bad stress)
Prenatal Care Given to Women with Multifetal Pregnancies Include Changes in:
Pattern of care, Amount of weight gained, Nutritional intake, and also knowledge that uterine distention can cause severe backache.
What is always used to treat syphilis?
Penicillin
What two medications are used to treat GBS IV during labor?
Penicillin G or Ampicillin are the drugs of choice to treat GBS during labor.
SUMMARY CONCEPTS
Percutaneous umbilical blood sampling involves aspiration of blood from umbilical vessels to detect blood disorders, acid-base balance, or fetal disease. Therapeutic medications and blood products can also be injected by the same route. Fetal bradycardia is the most common complication.
What is percutaneous umbilical blood sampling (PUBS)?
Performed if fetal blood sampling is necessary. Involves insertion of a needle directly into the fetal umbilical vessel under ultrasound guidance
When is a contraction stress test done?
Performed if nonstress test is abnormal
What is a nonstress test?
Performed to assess placental function and oxygenation, test determines fetal well being, test evaluates FHR response to fetal movement
What is the time before menopause called?
Perimenopause.
GESTATION
Period of intrauterine development from conception to birth
DANGER SIGNS IN PREGNANCY
Persistent Vomiting, Sudden Gush of Fluid from Vagina, Vaginal Bleeding, Abdominal Pain, Temperature of 101 or 38.3, Dysuria, Dizziness, Blurred/Double Vision (Diplopia), Severe Headache, Edema of Face, Hands, Legs, Feet, Epigastric pain, Convulsion, Muscular Irritability, Oliguria (low output of urine), Absence of Fetal Movement
Education for Self-Care
Personal hygiene, Prevention of urinary tract infections, Kegal exercises, Preparation for breastfeeding, Dental Health (Fluoride), Immunizations, Physical activity, Posture and body mechanics, Rest and relaxation (left side lying), Employment and travel, Clothing, Medications and herbal preparations, Avoidance of alcohol, cigarettes, drugs, Warning signs of potential complications, Nutrition, Caffeine in moderation, Seat belt can and should be worn at all times throughout pregnancy.
MECHANISM OF ACTION -Hemorrhage into the decidua basalis with formation of a hematoma. -The seperation of the decidua from the basal plate perpetuates itself causing further separation as well as compression and destruction of tissue. -If the blood dissects upward into the fundus, it will cause a concealed hemorrhage. -If the blood dissects downward it will be revealed. Dx?
Placenta abruptio
What is the most common cause of DIC in pregnancy?
Placenta abruptio
•RISK FACTORS -Maternal Hypertension -Cocaine abuse, especially "crack" -Trauma -Smoking -Polyhydramnios and Multiple gestation (rapid decompression of an over- distended uterus). •COMPLICATING FACTORS -Perinatal mortality rate due to abruption, is 35%. -Accounts for 15% of third trimester stillbirths. -15% of livebirths have neurologic damage. -Most common cause of DIC in pregnancy. -Hypovolemic shock, renal failure. -Sheehan's syndrome Dx?
Placenta abruptio
Definition: when the placenta is directly attached to the myometrial wall. There is absence of the decidua basalis. (absent Nitabuch's layer).
Placenta accreta
What are some abnormal implantation problems?
Placenta accreta - adheres to myometrium Placenta increta - invades myometrium Placenta percreta - perforates through myometrium
Definition: the placenta invades the myometrium.
Placenta increta
Definition: the placenta penetrates the myometrium to the serosa or beyond.
Placenta percreta
What is the ductus arteriosus for?
Primary diversion that ensures improved oxygenation of brain and heart and limits flow to lungs
Herpes (poses greatest risk to fetus)
Primary herpes
__ is a woman who is pregnant for the first time.
Primigravida
__ is a woman who has had one birth at more than 20 weeks gestation, regardless of whether the infant is born alive or dead.
Primipara
macrosomia
Problems that arise during labor and childbirth if the fetus has _____________(weighs more than 4000 g, or 8.8 lb) may include a difficult labor, shoulder dystocia (delayed or difficult birth of fetal shoulders after the head is born), and consequent injury to the birth canal or the infant.
percutaneous umbilical blood sampling (PUBS)
Procedure for obtaining fetal blood through ultrasound-guided puncture of an umbilical cord vessel to detect fetal problems such as inherited blood disorders, acidosis, or infection; also called cordocentesis.
What is occurring at mid-luteal phase during the cervical mucous fern test?
Progesterone makes the mucous thick and cellular
___ plays the greatest role in maintaining pregnancy. It maintains what?
Progesterone; endometrium and also inhibits spontaneous uterine contractility, thus preventing spontaneous abortion due to uterine activity.
What can hCG cause during pregnancy in the 1st trimester?
Proposed etiology of N/V of pregnancy & hyperemesis gravidarum
Infections During Pregnancy: Cytomegalic inclusion disease: Nursing Interventions
Provide emotional support and objective information.
Infections During Pregnancy: Herpes Genitalis: Nursing Interventions
Provide information about the disease and its spread. Advise woman to inform future healthcare providers of her infection. A possible association exists between herpes and cervical cancer. Thus women should understand importance of yearly Pap smears. Provide emotional support and nonjudgmental attitude.
What is the foramen ovale for?
Provides direct shunt of oxygenated blood from R atrium to systemic circulation
Where odes fertilization occur?
Proximal fallopian tube (ampulla)
Calcium
Purpose: Fetal and infant skeleton and tooth formation; maintenance of maternal bone and tooth mineralization. Sources: Milk, cheese, yogurt, sardines or other fish eaten with bones left in, deep green leafy vegetables except spinach or Swiss chard, calcium-set tofu, baked beans and tortillas Suggestion: Take with Vitamin D for absorption
Vitamin E
Purpose: antioxidant especially important for preventing breakdown of RBCs Sources: vegetable oils, green leafy vegetables, whole grains, liver, nuts and seeds, cheese and fish
Vitamin A
Purpose: essential for cell development, tooth bud formation, and bone growth Sources: deep green leafy vegetables, dark yellow vegetables and fruits, chili peppers, liver, and fortified margarine and butter
Iodine
Purpose: increased maternal metabolic rate Sources: iodized salt, seafood, milk and milk products, commercial yeast breads, rolls and donuts
lecithin/sphingomyelin ratio (L/S ratio)
Ratio of two phospholipids in amniotic fluid used to determine fetal lung maturity; ratio of 2:1 or greater usually indicates fetal lung maturity.
What does a Reactive Nonstress Test (Normal, Negative) mean?
Reactive indicates a healthy fetus. The result requires 2 or more FHR accelerations of at least 15 beats/min, lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20 minute period.
What is the acrosomal reaction and when does it occur?
Readies the sperm head to penetrate the ova once in contact
Initial Visit
Reason for seeking care, current pregnancy, obstetric and gynecologic history, medical history such as immunizations, nutritional history, history of drug and herbal preparation use, family history, social and experiential history, history of physical abuse, review of systems, physical examination, laboratory tests such as CBC or H&H to get a baseline, WBC, Platelet, Electrolytes, Hematocrit, Hemoglobin, Group B Strep, STD's, Glucose, Blood type and Rh status.
GRAVIDA
Refers to number of times a woman has been pregnant without reference to how many fetuses there were with each pregnancy or when the pregnancy ended
Substance Abuse During Pregnancy: Signs/Symptoms/Risk
Signs of addiction in the pregnant woman may include dilated or constricted pupils, inflamed nasal mucosa, abscesses, edema or track marks on arms and legs, inappropriate or disoriented behavior, or excessive fatigue.
__ are small, bright red elevations of the skin radiating from a a central body. They may be caused by increased subcutaneous blood flow in response to increased estrogen levels.
Spider nevi
DOC for maternal or fetal Toxo?
Spiramycin (does not prevent sequelae in fetus if infection has occured)
First Trimester Causes of Bleeding
Spontaneous abortion, ectopic pregnancy
MISCARRIAGE
Spontaneous abortion; primarily d/t chromosomal abnormalities
What happens to the trophoblast (chorion) when it splits into what?
Syncytiotrophoblast Erodes into decidua basalis forming lacunae Nitabuch's layer (fibrinoid degeneration) Cytotrophoblast Chorion frondosum-forms fetal villi which coalesce into umbilical vessels Chorion laeve
What bacterial STI can cross the placenta at any time during pregnancy?
Syphilis
what are the maternal side effects to terbutaline
Tachycardia Tremors Palpitations Shortness of breath Lower blood pressure Chest discomfort Pulmonary edema DO NOT USE if: maternal cardiac disease hemorrhage diabetes
__ is the number of infants born at end of 37 weeks gestation (or 38-42 weeks), living or stillborn
Term
Fetal Surveillance
Testing to identify fetal compromise may begin as early as 28 weeks' gestation if the woman has poor glycemic control or by 34 week's gestation in lower-risk women with GDM. The surveillance testing often includes kick counts, ultrsonography for fetal growth and amniotic fluid volume, biophysical profile, nonstress test, contraction stress test, or amniocentesis for fetal lung maturity.
Infections During Pregnancy: Herpes Genitalis: Medical Therapy
The American College of Obstetricians and Gynecologists recommends antiviral therapy for women with primary HSV infection during pregnancy to decrease viral shedding and promote healing.
Infections During Pregnancy: Acquired Immunodeficiency Syndrome: Signs/Symptoms/Risk
The following women are considered at risk for AIDS: prostitutes; women with a history of sexually transmitted infection; IV drug users; partners (currently or previously) of IV drug users, bisexual men, hemophiliacs, or those who test positive for HIV. Women with AIDS may have any of the following: malaise, weight loss, lymphadenopathy, diarrhea, fever, neurological dysfunction, immunodeficiency, esophageal candidiasis, herpes simplex virus, vaginal Candida infections, and cervical disease, Maternal risks Complications such as intrapartal or postpartal hemorrhage, postpartal infection, poor wound healing, and infections of the GI tract.
Fetal Effects: Congenital Malformation
The most common major congenital malformations associate with preexisting diabetes are neural tube defects, caudal regression syndrome (abnormal development of lower spine), and cardiac defects.
What are the most important two components of preventing vertical transmission from the mother to the fetus in the case of an HIV-positive mother?
The most important aspect of care for the HIV-positive mother is to adhere to the antiretroviral regiment that has been prescribed by the physician. Additionally, IV zidovudine will be administered during birth to further suppress that transmission. Outside of the drug regiment, it is important to avoid birth trauma to the infant and promptly wash the child after the delivery. This does not allow the virus access to and removes residual virus copies from the infant. The infant will also be treated with antiretroviral drugs for the first 6 months of life
frequent doses of insulin
The need to maintain rigorous control of maternal metabolism during pregnancy requires more _______________________than usual. Most treatment regimens rely on three daily injections, with a combination of short-acting (regular) insulin and intermediate-acting (NPH) insulin given before breakfast, regular insulin before dinner, and NPH insulin at bedtime.
SUMMARY CONCEPTS
The nonstress test determines whether the fetal heart rate accelerates when the fetus moves. Accelerations of the heart rate, regardless of fetal movement, are a reassuring sign because they are associated with adequate fetal oxygenation and an intact neural pathway from the fetal brain to the heart. The healthy fetus younger than 32 weeks of gestation may not have accelerations that meet the criteria for a reactive nonstress test in the older fetus.
trophoblast
The outermost layer of cells of the blastocyst that attaches the fertilized ovum to the uterine wall and that becomes the placenta and fetal membranes
What does an Unsatisfactory for a nonstress test mean?
The result cannot be interpreted due to the poor quality of the FHR tracing
two to six times higher
The risk for a major congenital malformation is ________________than that of the general population. The incidence correlates directly with the degree of maternal hyperglycemia during the first trimester.
baseline risk
The risk, usually in reference to birth defects or spontaneous abortion, of the general population of pregnant women who have no identified high-risk factors or invasive procedures.
What causes a waddling gait during pregnancy?
The sacroiliac, sacrococcygeal, and pubic joints of pelvis relax as a result of hormonal changes.
late deceleration
The slowing of the fetal heart rate after the onset of a uterine contraction and persisting after the contraction ends.
Preeclampsia *NTK*
The ultimate cause remains unknown. is seen more frequently in primigravidas. Younger than 20 years and older than 40 years having the highest rates of occurrence.
Chronic hypertension Defined
This disorder is associated with severe maternal and fetal complications. Chronic hypertension with superimposed preeclampsia is defined with the following findings: *1*. In women with hypertension before 20 weeks of gestation, with new-onset proteinuria *2*. In women with both hypertension and proteinuria before 20 weeks of gestation *3*. Sudden increase in proteinuria *4*. A sudden increase in BP in a woman whose hypertension has previously been well controlled *5*. Thrombocytopenia *6*. Elevated liver enzymes
What happens if a pregnant patient has genital herpes?
Typically, the HCP will treat the patient with acyclovir 4 weeks before the scheduled due date in an attempt to prevent an outbreak. As long as an outbreak is not present and there are no lesions, the mom can deliver vaginally. If the mother has an active outbreak, she must deliver via c-section.
PRE- CLAMSIA
VASO CONSTRICTION CAUSING HYPERTENSION IF SEVERE: HOSPITALIZATION , OXYTOCIN, MAGNESIUM SUFITE,PREPARATION FOR BIRTH.
SEVERE PRECLAMPSIA INTERVENTIONS 3.
Weight is measured on admission and usually at the same time every day thereafter. Breath sounds are auscultated for crackles or diminished breath sounds, which may indicate pulmonary edema. An indwelling urinary catheter may be inserted to measure urinary output
Infections During Pregnancy: Chlamydia: Signs/Symptoms/Risk
Women are often asymptomatic. Symptoms may include thin or purulent vaginal discharge, frequency and burning with urination, or lower abdominal pain.
Access to Prenatal Care
Women of middle or high socioeconomic status tend to seek prenatal care routinely; however, women of poverty and/or those lacking health insurance often do not have access to public or private care. Immigrants women also may not seek prenatal care due to fear of being deported.
If a pregnant woman is diagnosed with gonorrhea, should it be treated, and if so, how?
Yes, the infection should be treated because the disease can cause numerous problems for the mother and the child. The mother can suffer from salpingitis in the first trimester. Additionally, perinatal complications include premature membrane rupture, preterm birth, chorioamnionitis, neonatal sepsis, intrauterine growth restrictions, and maternal sepsis postpartum. The child most commonly suffers from ophthalmia neonatorum. The treatment for pregnant women is ceftriaxone with treatment for chlamydia included due to the high percentage of dual infections
Should moms with Hepatitis C breastfeed?
Yes, there are no current research findings that indicate that Hepatitis C is transmitted in breast milk
Should mothers with Hepatitis C (HCV) breastfeed?
Yes. There is no evidence to date that indicates that HCV can be transmitted via breast milk.
If patients always test positive on FTA-abs, do providers run any tests after treatment has been completed? Why or why not?
Yes. Since FTA-abs will always test positive, the provider will run VDRL and RPR values to see if they "go down" after treatment.
HELLP complications
acute renal failure, pulmonary edema, subcapsular hepatic hematoma, hepatic rupture, and placental abruption (diagnosis associated w/increased risk for adverse perinatal outcomes)
Infections During Pregnancy: Herpes Genitalis: medications
acyclovir, valacyclovir, and famciclovir. Women with recurrent infection may also be treated with antiviral therapy. Vaginal birth is preferred if there is no evidence of genital infection. If there are any lesions or prodromal symptoms such as vulvar pain or burning, cesarean birth is indicated. Women with active HSV infection and ruptured membranes should give birth by cesarean as soon as possible.
What might you expect to do as a nurse if a patient presents with PID?
administer prescribed antibiotics and fluid
if rubell dx durring pregnancy
advice about getting an abortion
what are leopold maneuvers
after 28 weeks you can feel where they are in belly- specifically where the back is. If the heartbeat is under the belly button then they're head down, if above then they're breech
Blood pressure measurement > position
ambulatory > sitting ; or left lateral recumbent position w/art at heart level
where is the most common location of ectopic pregnancy
ampullary portion of the fallopian tube
After delivery the uterus make take longer to contract
and the patient may need HEAMABATE. ( some question about the use of methergine with these patients)
what environmental toxins can cause to abortion
anesthesia gases nitric oxide benzene formaldehyde
What are some good dietary sources of heme iron?
animal sources - meat, fish, eggs, pork/chicken liver
LABETALOL
antihypertensive drug that blocks alpha and beta-adrenergic receptors of the sympathetic nervous system (leading to a decrease in blood pressure)
HELLP syndrome
appears in approximately 5to 20% of women with preeclampsia. Common in Caucasian women, S/S malaise, flu like symptoms, Epigastric or right upper quadrant abdominal pain, nausea and vomiting and headache. Some may develop thrombocytopenia such as bruising or hematuria.
5. (MP@H) Diet. Diet and fluid recommendations
are much the same as for healthy pregnant women. Diets adequate protein ( 60 to 70 g), 1200 mg calcium, 400mcg of folic acid and adequate zinc and ( 2to 6 g of sodium have been suggested to prevent preeclampsia; however, the efficacy of these diets has not been proven. Adequate fluid intake helps maintain optimum fluid volume and aids in renal perfusion and bowel function. ( Gilbert 2011) *Eat foods with roughage* ( while grain, raw fruits, and vegetables), 6 to 8 glasses of water per day, and avoid ETOH and Tobacco- while limiting caffeine intake.
Whys is the empyting time of the gallbladder prolonged during pregnancy?
as a result of smooth muscle relaxation from progesterone
uterine souffle
ascultation of rushing sunds in area of uterus synchronous with maternal pulse
when should you ask about domestic violence
at first visit and EACH trimester
Weight Gain During Pregnancy: Obese
at least 7 kg (15 lb)
What are the treatments for chlamydia?
azithromycin and doxycycline
what is Preterm PROM managment
bed rest (no evidence this works but we still do it) fetal monitoring monitor for infection steroids Latency antibiotics increase time to delivery (ampicillin, amoxicillin or erythromycin) Tocolysis
measure of HCG
begins to rise 8-10 days after conception and peaks at 50-70 days after conception. thereafter it decreases
if less than 34 weeks -- [BLANK] -- for lung maturation can be given
betamethasone (corticosteroids)
what is maternal serum screening
between 15 and 22 weeks to look at risk of aneuploidy and fetal malformations: alpha-fetoprotein B-Hcg Unconjugated estriol Inhibin
what are types of pregnancy testing
biologic, immunologic, radioreceptor assay, radioimmunoassay,
what is considered a preterm delivery
birth prior to 37 weeks very preterm is before 32 weeks extremely preterm is before 28 weeks
complication of vaginal bleeding in placental praevia
bl loss=> fatigue, palpitation, shock if severe
accidental hge bleeding from ...... in ..... trimester or .....stage of labour dt...... of ...... situated placenta
bleeding from genital tract in 3rd trimester or 1,2 stage of labour dt premature separation of N situated placenta
what are the major causes of 2nd and 3rd trimester bleeding
bloody show associated with cervical insufficiency, preterm/term labor placenta previa abruption uterine rupture vasa previa
Third Trimester Discomforts: Edema face, hands, dizziness
blurred vision, headaches, elevated BP
decline in hair growth
body catches up in hair growth after delivery
Signs and symptoms of trich:
can be asymptomatic yellow/green frothy and odorous dc itching, dysuria, pain w/ejaculation, pain w/ intercourse cervix has subepithelial hemorrhage (strawberry cervix) pH is alkaline
What are the signs and symptoms of PID?
can be mild! fever, chills, irregular bleeding, vaginal discharge, abd pain, tender pelvis, adenexal tenderness (pain from the ovaries and tubes)
car and air travel
car- wear restraints both shoulder and lap. The straps go above and below the enlarged uterus. Make sure there is no restriction of blood circulation. Air- wear restaints as in car travel when required. Take frequent walks about to the plane to prevent thrombi. Increase hydration level.
Infections During Pregnancy: Toxoplasmosis
caused by the protozoan Toxoplasma gondii and is transmitted by eating raw or poorly cooked meat or by exposure to feces of infected cats. Innocuous in adults.
luteal phase defect
causes recurrent preg loss lack adequate progesterone to maintain preg
Medication used to treat gonorrhea?
ceftriaxone **Treatment for gonorrhea is always paired with treatment for chlamydia as well, due to the high occurrence of these diseases presenting together.
meiosis
cell only have half of chromosomes (gametes) to combine with second cell and produces baby (zygot)
what can mercury found in fish like shark, tile fish, swordfish, mackeral cause
cerebral palsy (can occur with exposure in 3rd trimester) CNS tumors deafness and blindness seizures
Body movements are influenced by the __ Muscle tone influenced by ___
cerebrum cerebrum and cerebellum
non obstetrics causes (extraplacental or incidental)
cervicitis, cervical erosion, polyps and other benign or malignant neoplasm vaginal lacerations, varices, benign or malignant neoplasms
what defines an inevitable spontaneous abortion
cervix is open
probable
changes observed by an examiner. including a pregnancy test. ex. pregnancy tests both urine and blood measure HCG. this is only considered a probable sign
•RARE •Von Willebrand's disease (Factor 8) •Amniotic Fluid Embolism 80% mortality DIC •Placenta Abruption- DIC •Thrombotic thrombocytopenia •DIAGNOSIS -EXCLUSION no other cause has been found. Which cause of postpartum hemorrhage?
coagulation disorders
Abruptio Placentae: Risk factors
cocaine, hypertension, smoking, multips, short cord, abdominal trauma, PROM
how does immunologic testing work
commercially prepared antibodies against whole HCG: corss reactivity with LH
spider telangectases
common skin lesion, high levels of circulating estrogen, vascular stellate marks that blanch
Labs for preeclampsia, HELLP, and chronic hypertension and its effects in liver and kidneys
complete blood count (CBC), clotting studies(PT,PTT, fibrinogen), liver enzymes (LDH, AST, ALT), chemistry panel (BUN, creatinine, glucose, uric acid), type and screen, possible crossmatch
Positive signs
completely objective -ultrasound -transvaginal U\S -fetus visible on x-ray -ausculation of FHT -fetal movement
Variable pattern is aCombination of early and late deceleration (mayor may not correspond to contraction) and is Secondary to ______ which depends on the frequency and duration of the uterine contraction
compression of umbilical cord
varicosities precautions:
elevate both legs when sitting or lying down , rest in left lateral postion, walk daily, avoid tight clothing or knee-hi hosiery, wear support hose.
Mood swings
emotionally liability - Cries w/o apparent reason - "emotional roller-coaster" - Can be difficult for spouse and family
Pituitary gland
enlarges during pregnancy and returns to normal after birth -anterior lobe- produces FSH and LH. these are suppressed during pregnancy and return after delivery. GH promotes fetal growth. -Produces prolactin. produced in high levels after the delivery of placenta. this begins lactation.
thyroid gland
enlarges slightly and becomes more active during pregnancy. -begins in 1st trimester and tapers off in a few wks after birth -BMR increases 25% along with heart rate and cardiac output
gum hypertrophy
epulis (gingival granuloma gravidarum)- red raised nodule of gums
Medications used to treat Chlamydia in a pregnant woman?
erythromycin and amoxicillin
ptyalism
excessive salivation
__ is term used for 8 weeks-birth
fetus
what is quickening
fist sensation of fetal movement
gestational diabetes: Management
goal: Maintain normal blood glucose levels - Facilitate birth of health baby - Avoid accelerated impairment of blood vessels and other major organs - Takes an intensive, team approach
What does the trophoblast produce?
hCG
The ___ is secreting early in pregnancy and it stimulates estrogen and progesterone production by the corpus luteum to maintain the pregnancy until the __ is developed sufficiently to assume that function.
hCG; placenta
Many women with HELLP syndrome may not
have signs or symptoms of severe preeclampsia or may ve only slight elevations in BP. As a result, women with HELLP syndrome are often misdiagnosed as having a variety of other medical or surgical disorders (Sibai et al., 2007).
Maternal Emotional Responses: Ambivalence
having conflicting feelings - Proud & excited/fearful & anxious - Universal feeling
health history
health history summary forms will be used to monitor throughout pregnancy, and usually made available to L&D when delivery is near.
What is uterine souffle?
heard when auscultating the abdomen over the uterus-soft blowing sound at same rate as maternal pulse and is due to increased uterine vascularization and blood pulsating through placenta.
The first organ affected by hypoxia is the one that matured last (so the____ will be affected first). The last organ affected by hypoxia still serves its function.
heart
what is included in routine prenatal testing
hematocrit and hemoglobin Rh group and antibody screen urine analysis and culture immunity to rubella Screening for: syphilis Hep B cystic fibrosis TSH complete physical exam including heart, thyroid, teeth and veins pap smear and culture for chlamydia and gonorrhea
Nonprimary herpes (define)
hx of prior HSV-1 inf, first HSV-2 infection
pharmacology to control hypertension in pregnancy
hydralazine (Aprelisone, Nepresol), labetalol hydrochloride (Normodyne), methyldopa (Aldomet), nifedipine (Procardia)
after eclampsia (convulsion), manage BP with
hydralazine or labetalol (goal: sys 140-160, dia 90-110)
clonus
hyperactive reflexes at ankle joint (supporting the leg w/knee flexed) count how many times
chronic hypertension
hypertension present before pregnancy or diagnosed before week 20
In DOPPLER VELOCIMETRY Absence of end diastolic blood flow - ___ Umbilical artery systolic/diastolic (S/D) ratio Abnormal =___ percentile for gestational age or diastolic flow is either ____ (increased impedance on umbilical artery blood flow)
hypoxia 95th absent or reversed
Placenta Previa: Teach
if home: - Assess amount & color of bleeding - Assess fetal kicking daily - Assess for uterine activity - Refrain from sexual intercourse In-pt care: - Assess bleeding episodes or signs of labor - Periodic EFM - Delivery scheduled of fetus >36 wks and lungs mature - Immediate C-sec if bleeding excessive
how accurate is ultrasound dating of pregnancy
if in first trimester it is accurate to 5-7 days if second, 10-14 days
intrauterine growth restriction
if vascular impairment occurs, placental perfusion may be decreased. As a result, the infant is likely to be small for gestational age. This condition is called ________________________ (IUGR).
take note of:
immunizations, wieght, chronic conditions, environmental hazards and genetic counseling to identify carriers
3. (MP@H) Activity Restriction. Bed rest
in the *lateral recumbent position* is a standard therapy for preeclampsia and may improve uteroplacental blood flow. Complete bed rest has been shown to be beneficial in decreasing blood pressure and promoting diuresis. Adverse physiologic outcomes related to bed rest include cardiovascular deconditioning; diuresis with accompanying fluid, electrolyte, and weight loss; muscle atrophy; thrombophlebitis, and psychological stress. These changes begin on the first day of bed rest and continue for the duration of therapy. Thus, modified bed rest with bathroom privileges may be ordered to help decrease negative effects
vital signs
including BP. 140/90 considered hypertensive in pregnancy
leukorrhea
increase in vaginal discharge
Fibrinogin and fibrin
increase making the pt have tendency to clot in pregnancey. these changes coupled with venous stasis and venous pooling in the lower extremities, contribute to increased risk for venous thrombosis.
GFR
increased early in pregnancy due to increase need for elimination of both mom and fetus
What causes fluid retention in pregnancy?
increased level of steroid sex hormones affects sodium and fluid retentiod, lowered serum protein, increased capillary pressure and permeability
what is nuchal translucency
independent marker for down syndrome and in combination with maternal age is associated with detection rates in range of 60-70%
Chronic hypertension
is present before the pregnancy or diagnosed *before 20 weeks of gestation*. Most will have uncomplicated pregnancies, but there is an increased risk of poor fetal growth and fetal demise.
Gestational hypertension
is the onset of hypertension, without proteinuria, after 20 weeks of pregnancy, which may be transient or chronic in nature. Most commonly occurs around 37 weeks. BPs return to normal within 6 weeks after delivery. Hypertension is defined as above 140 systolic and 90 diastolic.
Why is c-section used for HIV infected mothers?
it decreases the risk of transmission to the baby
importasnt ofv vaginal signs in placental praevia
it is important for avoiding the PV xm that can provoke uncontrollable haemorrhage w more placental separation
evaluation of recurrent preg loss
karyotype both parents and POC maternal anatomy w/ hysterosalpingogram (HSG) or hysteroscopic/laparoscopic exploration test hypothyroid, DM, antiPLsynd, SLE, hypercoag synd-- lupus anticoagulant, factor V Leiden, Prothrombin G20210A mutation, ANA, anticardiolipin ab, Russell viper venom, antithrombin III, protein S & C, serum progesterone during luteal phase culture cervix, vagina, endmetrium to r/o infection
what is smoking associated with
low birth weight placental abruption preterm delivery
HELLP symptoms
malaise, epigstric or right upper quadrant abdominal pain, nausea, and vomiting. (many DO NOT have S/S of severe preeclampsia)
What are some indications that a patient requires surgical intervention for a benign ovarian mass?
mass measures 6-7 cm over 40 yoa w/pain young girls infants post menopausal on hormonal birth control pills
Control of Blood Pressure. Antihypertensive medications
may be ordered to lower the diastolic blood pressure. Because a degree of maternal hypertension is necessary to maintain uteroplacental perfusion, antihypertensive therapy must not decrease the arterial pressure too much or too rapidly. The target range for the diastolic pressure is therefore less than 110 mm Hg and the systolic pressure less than 160 mm Hg (ACOG, 2002; Cunningham et al., 2007) Safe drugs to give includes: hydralazine, labetalol and nifedipine ( Table 27-5)
Infections During Pregnancy: Herpes Genitalis: Signs/Symptoms/Risk
may cause spontaneous abortion if active HSV-2 infection occurs in first trimester. Highest risk of infection for newborn who is born vaginally when mother has active HSV-2 in her vagina.
Approximately 25% of women with chronic hypertension
may develop preeclampsia or eclampsia.
what populations are at risk for thalassemias? what types of thalassemias are there?
mediterranean, middle east, southeast asia, africa, indian subcontinent beta thalassemia: decreased B-chains and excess alpha chains alpha thalassemia: deletion of alpha chains
chronic hypertension > antihypertensive meds used in pregnancy
methyldopa/Aldomet. If it does not work: hydralazine, beta-blockers, calcium channel blockers
VUlvovaginitis tx
metronidazole
what things can cause elevated maternal serum AFP
more advanced gestational age (wrong dating!) multiple gestation placental abnormalities maternal diseases (tumors) fetal abnormalities: -Open neural tube defects ( over 90% are detected) -Fetal demise -Ventral wall defects -Hydrops/Cystic hygroma -Urinary tract disease (Finnish nephrosis) -Sacrococcygeal teratoma
What are risks for ovarian cancer?
nullperi (0 children) history of breast cancer late menopause early menarche *think about it...the more a woman has ovulated, the more she is at risk
Antepartal teaching nutrition
nutrition: -well balanced diet -5-6 small feedings a day is better tolerated than 3 heavy meals
implantation
occurs 7-10 days after fertilizatio it also depends in progestarone
Jarisch - Herxheimer rx
occurs among pts with early syphilis (tx) - in prego, may result in PROM
what is frequency of placenta praevia?
one in 200 births one in 60 hospital deliveries 90% are parous in grand multiparas one in 20
gestational hypertension
onset of hypertension WITHOUT PROTEINURIA or edema after week 20 (considered benign diagnosis with good pregnancy outcomes)
what are the maternal complications associated with placenta previa
operative delivery need for transfusion hemorrhagic shock DIC renal failure hysterectomy placenta accreta, increta or percreta
How can hormone replacement therapy be administered?
oral, topical, vaginal, transdermal
corpus luteum
ovarian structure that forms from a follicle after ovulation; secretes progesterone and estrogen
respiratory changes
oxygenation requirements increase in response to increase in maternal and fetal tissue growth and maintenace
What is the pH of vaginal secretions?
pH of 4.5-5.5 and does not affect the nitrazine strip
What is the pH of amniotic fluid?
pH of 7.0-7.5, this will turn the nitrazine strip blue
after convulsion > ALERT
pad side rails, quiet & darkened room, not left alone, may take several hours to normal mental status, emotional support to family and give info
what is cervical insufficiency
painless dilation of cervix, often in 2nd trimester, as cervix dilates some vessels around cervix bleed as cervix dilates fetal membranes can be exposed to vaginal flora responsible for 15% 2nd trimester loss may also present with cramping and pressure
incomplete abortion
partial expulsion POC before 20wks tx: 1st trimest: D&C or prostaglandins (misprostol) to induce dilation/contractions 2nd trimest: D&E (dilation&evacuation)--need dilate w/ laminaria (seaweed rods) or high dose oxytocin and prostiglandins
What is ballottement?
passive fetal movement elicited by pushing up against the cervix with two fingers- pushes fetal body up and as it falls back, the examiner feels a rebound.
How is treatment for genital warts determined?
patient preference, provider preference, and available resources
pt is bleeding bright red blood but doesn't have pain Think what cause of antepartum bleeding?
placenta previa
•PREDISPOSING FACTORS -Previous Cesarean Section -Multiparity -Multiple Gestation -Advancing Maternal Age -Previous Placenta Previa •COMPLICATING FACTORS -1/25 will have an underlying accreta. -20% will have an underlying IUGR. -2x higher rate of congenital abnormalities. -30% malpresentation. -Higher incidence of PPROM. (preterm premature rupture of membranes; before 37weeks) -Risk of Vasa Previa. Dx?
placenta previa
what is likely cause of placental antepartum bleeding
placenta previa placental abruption vasa previa
def of accidental hge
placental site bleeding during 3rd trimester, the 1st or 2nd stages of labour dt premature separation of normally situated placenta
Biophysical profile score, interpretation, and pregnancy management
please study chart
Diabetes Mellitus: Classic symptoms
polyuria, polydipsia, and polyphagia
PPROM
preterm premature rupture of membranes (before 37 weeks)
why artificial rupture of the membranes is done during vaginal delivery in placental praevia?
prevent further separation of the placenta, will accelerate labour and the presenting part may compress an ant placental praevia
goals emergency intervention eclampsia:
prevent self-injury, ensure adequate oxygenation, reduce aspiration risk, seizure control w/magnesium sulfate, correct maternal acidemia
tx cervical incompetence
previable fetus: expectant management or termination viable (>24wks): betamethasone, bed rest, tocolysis OR placement emergent cerclage
Posterior pituitary
produces oxytocin which stimulates uterine contractions and "milk let down" in the breasts. So, breast feeding may increase "afterbirth pains."
preconceptual care
promotion of health and well being to ensure they are in the best possible health before they conceive. -counseling on environmental sensitivity on days 17-56, for poor outcomes. ex. effects of smoking, alcohol or drugs cause the most damage during this period.
Toxoplasmosis
raw undercooked meat, or cat feces -Influenza symptoms : malaise and muscle aches -fever and tender lymph nodes -TMT: sulfonamides or combo of pyrimethamine and sulfadiazine (harmful to fetus)
What are the treatment goals for PCOS?
reduce hirsutism, reverse infertility, control insulin resistance
Deep tendon reflexes (DTRs)
reflect the balance between the cerebral cortex and spinal cord. They are evaluated as a baseline and to detect any changes. The biceps and patellar reflexes and ankle clonus are assessed and the findings recorded. See Table 27-4
MAGNESIUM SULFATE requires close monitoring of:
reflexes, respirations and urinary output
what is magnesium toxicity
related to serum concentration -loss of DTR -respiratory paralysis -cardiac arrest symptoms resolve after infusion is stopped Use calcium gluconate IV to treat life threatening toxicity (always have this med on hand)
what does amniocentesis involve
removal of amniotic fluid cultured for chromosomal, metabolic and DNA studies can detect neural tube defects usually done at 15-20 weeks has risk of loss of 0.5%
salpingectomy
removal of entire fallopian tube w/ ectopic pregnancy
S/S during seizure include:
respirations which are halted and begin again with long deep stertorous inhalation, hypotension follows and muscular twitching disorientation and amnesia persist for awhile after the convulsion.
employment
restrict from environments which are toxic to the fetus and activities which require balance or standing for long periods of time
Infections During Pregnancy: Toxoplasmosis: Signs/Symptoms/Risk
results in a mild infection in adults but is associated with an increased risk of spontaneous abortion, prematurity, still birth, neonatal death, and a number of infant disorders.
HIV/AIDS
retrovirus attacks T lymphocytes. Mother to neonate perinatally through placenta and postnatally through breastmilk. -Avoid amniocentesis, amniotomy due to maternal blood exposure risk and avoid fetal monitors internally, vacuum extraction, and forceps during labor because of risk of fetal bleeding. - Injections and testing of blood during first bath only -Retrovir at 14 weeks gestation and throughout pregnancy and before onset of labor/cesarean. -Retrovir to neonate following delivery and for 6 weeks following
what is treatment for group B strep
risk for preterms is higher prophylax until maternal culture returns negative treat with i.v. penicillin
probably manifestations of pregnancy
same symptoms as above; chadwicks sign, leukorrhea, goodells sign, ladins sign hegars, mc donalds, vonfernwalds, abdominal enlargement, uterine contractions, uterine souffle
what other special screenings exist
screening for: Tay Sachs disease fragile X gaucher's disease franconi's anemia familial dysautonomia canavan disease bloom syndrome spinal muscular atrophy
Things that change the pH of the vaginal environment:
semen douching hygiene products STI's
what is placental abruption
separation of the placenta from the site of implantation before delivery of the fetus, can present with external bleeding or bleeding can be concealed
mild hypertension must be taken
seriously and managed as for preeclampsia
what is radioimmunoassay pregnancy testing (RIA)
serum testing, doesnt cross react with LH
eclampsia S/S
severe preeclampsia w/ seizures or coma (PRECEDED BY headache, severe epigastric pain, hyperreflexia and hemoconcentrations, all signs of probable convulsions) - convulsions can appear w/out S/S and minimal elevated BP
If the woman has mild preeclampsia (MP)
she may be managed at home with frequent maternal and fetal evaluation and bp less than 150/100. and proteinuria less than 500mg per day.
goodell's sign
softening of the cervix
Hegar's sign
softening of the lower 1/3 of uterus due to increase uterine blood flow. Allows for stretching of lower uterus with fetal growth and maintenace of strong connection of placenta to uterine wall.
Goodell's sign
softening of the tip of the cervix by the beginning of the 6th wk. the cervix has increase vascularity and increase in size. (hypertrophy /bleeds easily)
striae gravidarum
stretch marks over areas of rapid growth
supine hypotensive syndrome / vena cava syndrome
supine position produces a reflux bradycardia adn decreases cardiac output by 1/2. **RESULT IS SHOCK! TURN TO LEFT SIDE!
pancrease
supplies digestive enzymes, buffers, and insulin.
cerclage
suture placed vaginally around cervix at cervical-vaginal jx (McDonald) internal os (Shirodkar)
when do you screen for group B strep
swab lower vagina and rectum between 35 and 37 weeks, if heavily colonized need intrapartum prophylactic penicillin
GI System adaptation
swollen gums, ptyalism (saliva),dental problem, hemoroids, constipation,slowed gastric emptying, heartburn, prolong gaullbladder emptying, N&V
Fetal surveillance
testing for anomalies, kick counts, biophysical profiles, NST, CST, ultrasonography
what hemoglobinopathies should the fetus be screened for
thalassemias hemoglobin variants such as sickle cell
diabetes: uncomplicated pregnancy
the availability of glucose and insulin, favors the development and storage of fat during the first half of pregnancy. Accumulation of fat prepares the mother for the rise in energy use by the growing fetus during the second half of pregnancy.
placenta praevia definition
the placenta is partly or totally implanted over the lower uterine segment
What are the s&s of chlamydia?
thin or purulent dc, priable cervix (bleeds easily), bleeding with intercourse, increase urinary frequency Men: penile dc, burning @ meatus, testicular swelling and pain
Successful home care requires the woman
to be well educated about preeclampsia and highly motivated to follow the plan of care. COMPLIANCE WITH PLAN.
Type and X match
to have blood supply in case of emergency
Preeclampsia contributes significantly
to restrictions of fetal growth and incidence of placental abruption,premature birth, and early degenerative aging of the placenta. Impaired placental perfusion leads to early degenerative aging of the placenta. The rate of fetal complications is directly related to the severity of the disease
Arteriolar vasospasms and decreased blood flow
to the retina lead to visual symptoms such as scotomata (blind spots- dim vision, double visons) and blurring. Neurologic complications associated with preeclampsia include cerebral edema and hemorrhages and increased central nervous system (CNS) irritability, which manifests as headache, hyperreflexia, positive ankle clonus, and seizures
preeclamptic woman is unable to
tolerate excessive postpartum bloos loss because hemoconcentration
what should you evaluate during a physical exam in a woman with suspected spontaneous abortion
vitals cervix closed or dilated vaginal lacerations, growths, infection, polyps tenderness or masses on bimanual exam presence of clots or tissue presence of villi will make diagnosis of intrauterine gestation
What is the treatment for benign ovarian masses?
watch and wait because they may resolve on their own; if not, surgery is performed
McDonald's rule
weeks of pregnancy = cm. of fundal height. ex. uterine fundal ht of 20 wks = 20 cm, the uterus is at the level of the umbilicus. wk 38-40 uterus drops down. this is called "lightening" or the engaging of the fetal head into the pelvis in the last 2 wks of pregnancy prior to onset of labor
good pregnancy outcomes
when proteinuria develops it moves them into preeclampsia. ( this occurs in those women who are diagnosed with gestational hypertension prior to the 35 week of pregnancy.
what is vasa previa
when the fetal vessels course through the membranes and present at the internal os is associated with fetal demise and is an obstetrical emergency that is dealt with c-section delivery
How do we SCREEN for syphilis?
you can take a sample from the chancre, perform a VDRL screening, or a RPR (rapid plasma reagin)
Future Implications of Gestational Diabetes •History of previous gestational diabetes usually results in future pregnancies with ___________ •History of previous gestational diabetes increases the likelihood of future ______ diabetes. Yearly ______ recommended for patients with a history of gestational DM.
•History of previous gestational diabetes usually results in future pregnancies with gestational diabetes. •History of previous gestational diabetes increases the likelihood of future type 2 diabetes. Yearly FBS recommended for patients with a history of gestational DM.
What is involved in the post-partum management of gestational diabetes?
•Insulin requirements drop sharply after delivery as insulin antagonists from the placenta are no longer present •Most insulin dependent diabetics do not need insulin for the first 48-72 hours after delivery -Monitor plasma glucose q6hr -Treat with insulin if glucose > 150mg/dl •Gestational Diabetics usually do not need insulin post-partum -Test with 75 gram GTT at 6-8 weeks post-partum to assure return to normal -Yearly screening with FBS for diabetes. Increased likelihood of becoming diabetic later in life.
What are the Fetal Complications of Gestational Diabetes?
•Macrosomia and associated traumatic delivery •Delayed organ maturation •FGR (fetal growth restriction), aka IUGR (intra-uterine growth restriction) •No congenital anomalies: The congenital anomalies occur in the first half of pregnancy, gestational diabetes doesn't occur until the second half of pregnancy
What are the Fetal Complications of Pre-existing Diabetes?
•Macrosomia and associated traumatic delivery •Delayed organ maturation: esp the lungs •FGR (fetal growth restriction), aka IUGR (intra-uterine growth restriction) •Congenital anomalies -Cardiac -Neural tube -Sacral agenesis (caudal regression)
Hemodynamic changes in pregnancy •Maternal blood volume ______ •Plasma volume ______ •Erythrocyte volume ______ •2,3 DPG ______ •Maternal blood pressure ______ •Heart rate ______ •Stroke volume ______ •Cardiac output ______ •Systemic vascular resistance ______ Increased or decreased?
•Maternal blood volume increased (40%) •Plasma volume increased •Erythrocyte volume increased •2,3 DPG increased •Maternal blood pressure decreased •Heart rate increased (10-15 bpm) •Stroke volume increased •Cardiac output increased (30-40%) •Systemic vascular resistance decreased
Intrapartum Management of Gestational Diabetes: •Patients requiring _______ are treated with IV ________ •Maintain glucose levels of ____-_____ mg/dl
•Patients requiring insulin are treated with IV insulin •Maintain glucose levels of 80-120mg/dl
Antepartum Management of Gestational Diabetes •Serial ____________ •Serial tests for fetal __________: Non-stress test Contraction stress test Biophysical profile Cord Doppler Studies •Maintain normal _________ levels
•Serial ultrasounds •Serial tests for fetal well-being: Non-stress test Contraction stress test Biophysical profile Cord Doppler Studies •Maintain normal glucose levels
Reactive in NST Criteria:This means you have good fetal well-being for a week so repeat test the following week for monitoring.
≥2 accelerations of FHR with an amplitude of 15 bpm lasting for at least 15 seconds associated with fetal movement in a 10- minute period; OR ≥4 accelerations in a 20-minute period with the same amplitude and duration