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High Risk Gestational Conditions

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1 Turn head to one side 2 Place pillow under one shoulder or back if possible

Eclampsia (Seizure) Interventions · Keep airway patent 1 2 · Call for assistance § DO NOT leave bedside · Protect with padded side rails up (pad with pillows, blankets if possible) · Observe and record convulsion activity

lower HOB and turn head to the side to prevent aspiration. Don't leave unattended until fully alert!

Eclampsia (Seizure) Interventions · Keep airway patent § Turn head to one side § Place pillow under one shoulder or back if possible · Call for assistance § DO NOT leave bedside · Protect with padded side rails up (pad with pillows, blankets if possible) · Observe and record convulsion activity · After the Convulsion: § Immediately after seizure, ____________________________________________________________________ § Observe for post-convulsion confusion, coma, incontinence. She may be combative and confused, and restrains may be needed. It may take several hours for normal mental functioning to return. § Assess airway, breathing circulation; Suction PRN § O2 non-rebreather 10L/min § Start IV fluids § Give magnesium sulfate as ordered § Insert urinary catheter § Monitor BP, pulse, RR, fetal and uterine/cervical status · FHR: can show bradycardia, late decels, absent/minimal variability, or compensatory tachycardia; but it usually stabilizes after seizure § Get labs as ordered: kidney function, liver function, coagulation, drug levels § Provide hygiene and quiet environment § Support mom and family § Be prepared to assist with birth when woman is in stable condition

tampons, douching, or vaginal intercourse for 2 weeks

Follow-Up Care for Miscarriage · Iron supplements for blood loss · Try to completely resolve the loss before becoming pregnant again · Referral to support groups · Clean perineum after voiding or bowel movement, change perineal pads · Shower (no tub baths) for 2 weeks · Avoid ________________________________________________ · A small amount of blood loss is normal for 1-2 weeks · Notify doctor of signs of infection, fever, foul-smelling vaginal discharge, or heavy, bright-red vaginal bleeding · Eat foods high in iron and protein to promote tissue repair

developing preeclampsia in future pregnancy

Future Health Care for Preeclampsia · Women with preeclampsia are at a significantly increased risk for ________________________________ · They need counseling during preconception visits for future pregnancies · Weight loss and increase physical activity should be encouraged · Use of low dose aspirin will probably be recommended during future pregnancy

Recurrent (habitual) early miscarriage

6 Types of Spontaneous Abortions · Septic Spontaneous Abortions: Malodorous bleeding/discharge, fever, ABD tenderness, may be dilated, severe infection after an abortion. · ________________________ miscarriage is 3 or more spontaneous pregnancy losses before 20 weeks gestation

Complete Spontaneous Abortions

6 Types of Spontaneous Abortions · _________________________ Spontaneous Abortions:. § Slight, minimal bleeding § mild uterine cramping § All pregnancy tissue passed through dilated cervix (cervix closes after tissue is passed) § Management: no further intervention needed if no infection or bleeding

C. Hydatidiform mole

A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea and vomiting and scant, prune-colored discharge. She has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect? A. Hyperemesis gravidarum B. Threatened abortion C. Hydatidiform mole D. Preterm labor

D. Calcium gluconate

A nursing is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? A. Nifedipine (Adalat) B. Pyridoxine (vitamin B) C. Ferrous sulfate D. Calcium gluconate

Hydralazine, Labetalol, Nifedipine, Methyldopa

Nursing Interventions/Treatment for Preeclampsia § Intrapartum care: · Continuous FHR monitoring and uterine contraction monitoring · Assessing CNS, cardio, pulmonary, hepatic, and renal systems/ vitals · To reduce risk for pulmonary edema, fluids should not exceed 125mL/hr · Give magnesium sulfate to prevent seizures § Control blood pressure · Antihypertensives are needed when BP exceeds 160/110 · Avoid foods high in sodium · Avoid alcohol, tobacco, and caffeine · Drink 6-8 glasses of water per day · Maternal risks of HTN: left ventricular failure, cerebral hemorrhage, placental abruption · _________________________________________________________ are effective at treating HTN intrapartum (avoid ACE inhibitors and ARBs while taking) § Postpartum Care: · Continue assessments · Magnesium sulfate is often given for 24 hours or more after birth · Clinical s/s that indicate resolution of preeclampsia include diuresis and decreased edema Usually women are monitored for 72hr after birth in the hospital

B. Obtain an ultrasound.

The nurse is admitting a client at 35 weeks gestation with painless vaginal bleeding. What is the priority action? (most likely it's a placenta previa) A. Complete vaginal examination for preterm labor. B. Obtain an ultrasound. C. Discuss the need for immediate Cesarean section. D. Obtain a toxicology screen for drugs of abuse.

biliary colic, epigastric or RUQ pain that can radiate to the back/shoulders, pain that occurs spontaneously or after eating a meal (especially fatty meals)

· Cholelithiasis and Cholecystitis: § Cholelithiasis: gall stones in gall bladder; symptoms include _________________________________________ § Cholecystitis: inflammation of the gall bladder which usually occurs when a gallstone obstructs a cystic duct; symptoms include epigastric or RUQ pain that is more severe/prolonged, nausea, vomiting, fever § Often surgical intervention is postponed until postpartum period because women can be managed conservatively for the remainder of pregnancy: · Assess diet for foods that cause discomfort, gas, triggers · Reduce fat intake to 40-50g/day · Limit protein to 10-12% of total calories · Choose foods so most calories come from carbohydrates · Prepare food without adding fats or oils as much as possible · Avoid fried foods

§ 1. Hemolysis (H): resulting in anemia and jaundice § 2. Elevated liver enzymes (EL): resulting in high ALT/AST, epigastric pain, n/v § 3. Low platelets (LP): thrombocytopenia, abnormal bleeding/clotting time, bleeding gums, petechiae, possible DIC

· HELLP Syndrome: a variant of severe preeclampsia/GH that involves hepatic dysfunction, characterized by: 1 2 3

Chronic Hypertension

· ________________________: Hypertension that is present prior to 20 weeks gestation (before pregnancy) or that lasts longer then 12 weeks postpartum · Most women with mild chronic hypertension experience uncomplicated pregnancies · Severe chronic hypertension increases risk of perinatal mortality · Chronic Hypertension with superimposed preeclampsia: Hypertensive before 20 weeks + proteinuria

Missed Spontaneous Abortions

6 Types of Spontaneous Abortions · __________________ Spontaneous Abortions: § No bleeding or slight spotting § No uterine cramping § cervix remains closed § no passage of tissue, but fetus has died, no heartbeat, no increase in uterine size (or decreases in size). The fetus and placenta can be retained for days, weeks, or even months. § Management: monitor for DIC and bleeding if tissue retained longer than 5 months. Usually treated with dilation and curettage (D&C), misoprostol

Incomplete Spontaneous Abortions

6 Types of Spontaneous Abortions · _____________________________ Spontaneous Abortions: § Heavy, profuse bleeding § Severe cramping § dilation of the cervix § passage of some tissue (often just the fetus). Retained placental tissue causes continued bleeding and possible infections § Management: usually dilation and curettage (D&C) recommended

Threatened Spontaneous Abortions

6 Types of Spontaneous Abortions · __________________________________ Spontaneous Abortions: § Slight bleeding, spotting § mild uterine cramping § no dilation of cervix § no passage of tissue. § Pregnancy may continue. § Management: bed rest, ultrasounds to determine fetal life

Inevitable Spontaneous Abortions

6 Types of Spontaneous Abortions · _______________________________________ Spontaneous Abortions: § Moderate bleeding § Mild-moderate cramping § Usually dilation of the cervix, ROM can occur § no passage of tissue § will definitely lose pregnancy § Management: bed rest, if ROM them termination of pregnancy occurs (D&C)

B. Ectopic pregnancy

A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states, "I missed one menstrual cycle and cannot be pregnant because I have an intrauterine device." The nurse should suspect which of the following? A. Missed abortion B. Ectopic pregnancy C. Severe preeclampsia D. Hydatidiform mole

A. Respirations fewer than 12/min B. Urinary output less than 25 mL/hr D. Decreased level of consciousness

A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? (SATA) A. Respirations fewer than 12/min B. Urinary output less than 25 mL/hr C. Hyperreflexic deep-tendon reflexes D. Decreased level of consciousness E. Flushing and sweating

D. Report of severe shoulder pain

A nurse is caring for a client who has a diagnosis of ruptured ectopic pregnancy. Which of the following findings is seen with this condition? A. No alteration in menses B. Transvaginal ultrasound indicating a fetus in the uterus C. Serum progesterone greater than the expected reference range D. Report of severe shoulder pain

B. Urine ketones present

A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following findings is a clinical manifestation of this condition? A. Hgb 12.2 g/dL B. Urine ketones present C. Alanine aminotransferase (ALT) 20 fU/L D. Serum glucose 114 mg/dL

A. Obesity B. Multifetal pregnancy D. Gestational trophoblastic disease

A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. The nurse should identify that which of the following are risk factors for the client? (SATA) A. Obesity B. Multifetal pregnancy C. Maternal age greater than 40 D. Gestational trophoblastic disease E. Oligohydramnios

A. Betamethasone

A nurse is providing care for a client who is at 32 weeks of gestation and who has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following types of medications should the nurse anticipate the provider will prescribe? A. Betamethasone B. Indomethacin C. Nifedipine D. Methylergonovine

B. Blunt abdominal trauma C. Cocaine use E. Cigarette smoking

A nurse is providing care for a client who is diagnosed with a marginal abruptio placentae. The nurse is aware that which of the following findings are risk factors for developing the condition? (Select all that apply.) A. Fetal position B. Blunt abdominal trauma C. Cocaine use D. Maternal age E. Cigarette smoking

C. "I plan to drink more orange juice while taking this pill."

A nurse is reviewing a new prescription for ferrous sulfate with a client who is at 12 weeks of gestation. Which of the following statements by the client indicates understanding of the teaching? A. "I will take this pill with my breakfast." B. "T will take this medication with a glass of milk." C. "I plan to drink more orange juice while taking this pill." D. "I plan to add more calcium-rich foods to my diet while taking this medication."

D. Raise and pad the siderails.

A nurse notices the client on magnesium sulfate for preeclampsia has hyperactive DTRs. What action should the nurse take to promote client safety? A. Stop the magnesium sulfate infusion. (no, this would increase seizure risk) B. Administer calcium gluconate as ordered. (no, this would increase seizure risk) C. Notify the provider. (no, hyperactive DTRs are expected with preeclampsia) D. Raise and pad the siderails. (YES, this helps protect mom if she has a seizure)

Tonic contraction of the body muscles (arms flexed, hands clenched, legs inverted) precedes the tonic-clonic convulsion (muscle relax and contract) § Respirations halt and then resume with stertorous, long, deep inhalations § Hypotension follows seizure § Muscle twitching, disorientation, and Amnesia persist for a while after seizure § Incontinence or vomiting can occur

Eclampsia = Seizures · Eclampsia is sometimes preceded by warnings: § Persistent headache § Blurred vision § Severe epigastric pain § RUQ pain or abdominal pain § Altered mental status § BUT - may start without warning, even with lower BPs · Eclampsia seizures: ______________________________________________ - - -

always abnormal and must be investigated to determine the cause. It can impair both the outcome of the pregnancy and the mother's life.

Hemorrhagic Disorders: Bleeding in Pregnancy · Vaginal bleeding during pregnancy is _________________________________________________________________________ · Maternal Risks of Hemorrhagic Disorders: § Decreased oxygen-carrying capacity § Hypovolemia § Anemia · Fetal Risks of Hemorrhagic Disorders: § Fetal blood loss or anemia § Hypoxia, anoxia § Preterm birth · Causes of 1st trimester bleeding: spontaneous abortion, ectopic pregnancy · Causes of 2nd trimester bleeding: gestational trophoblastic disease · Causes of 3rd trimester bleeding: placenta previa, abruptio placentae, vasa previa · Other causes of bleeding: premature cervical dilation, preterm labor, hydatidiform mole

fertilization of an egg where the nucleus has been lost or inactivated. It contains no fetus, placenta, amniotic membranes, or fluid. Maternal blood has no placenta to receive it, so bleeding occurs · Ovum has no genetic material or material is inactive. Genetic material is all paternally derived · 20% will progress to choriocarcinoma

Hydatidiform Mole (Molar Pregnancy) · Gestational Trophoblastic Disease = Hydatidiform Mole and Choriocarcinoma (Cancer). These are groups of pregnancy-related trophoblastic proliferative disorders without a viable fetus that are caused by abnormal fertilization. · Hydatidiform Mole (molar pregnancy): Benign proliferative growth of the placental trophoblast, in which chorionic villi develop into edematous, cystic, avascular vesicles in a grape-like cluster. It is a type of Gestational Trophoblastic Disease § Embryo fails to develop beyond a primitive state § Can become a rapidly metastasizing malignancy (choriocarcinoma) § Complete mole results from _________________________________________________________________________________ · Risk Factors for Hydatidiform Mole (molar pregnancy): § Age extremes: Early Teens or more than 40 years old § Assisted reproductive medications (Clomid)

one apparently normal ovum is fertilized by 2 or more sperm. They can have embryonic or fetal parts and an amniotic sac; often congenital anomalies · Genetic material is both paternal and maternal · 6% progress to a choriocarcinoma

Hydatidiform Mole (Molar Pregnancy) · Gestational Trophoblastic Disease = Hydatidiform Mole and Choriocarcinoma (Cancer). These are groups of pregnancy-related trophoblastic proliferative disorders without a viable fetus that are caused by abnormal fertilization. · Hydatidiform Mole (molar pregnancy): Benign proliferative growth of the placental trophoblast, in which chorionic villi develop into edematous, cystic, avascular vesicles in a grape-like cluster. It is a type of Gestational Trophoblastic Disease § Embryo fails to develop beyond a primitive state § Can become a rapidly metastasizing malignancy (choriocarcinoma) § Partial mole: __________________________________________ - - · Risk Factors for Hydatidiform Mole (molar pregnancy): § Age extremes: Early Teens or more than 40 years old § Assisted reproductive medications (Clomid)

Hydatidiform Mole (molar pregnancy)

maternal age younger than 19 or older than 40, first pregnancy, obesity, multifetal gestation, renal disease, hypertension, family history, DM, RA, SLE

Hypertension in Pregnancy · Most common gestational complication, occurring in 5-10% of all pregnancies · Major cause of maternal and perinatal morbidity and mortality worldwide § Gestational hypertensive diseases are associated with placental abruption, kidney failure, hepatic rupture, preterm birth, and fetal/maternal death § Risk factors: _______________________________________ · 5 Classifications of Pregnancy Hypertension: § 1. Gestational Hypertension § 2. Preeclampsia § 3. Eclampsia § 4. Chronic Hypertension § 5. Superimposed Preeclampsia or Eclampsia

analgesics, sedatives, prostaglandin, oxytocin, antibiotics (septic abortion), Rh immune globulin (for Rh-negative moms)

Labs and Diagnostics for Miscarriage · H/H, clotting factors, WBC, hCG · Ultrasound: determines viable or dead fetus, or partial/complete products of conception · Cervical exam · Dilation and curettage (D&C): dilate & scrape uterine walls to remove uterine contents · Dilation and evacuation (D&E): dilate & evacuate uterine contents after 16wks · Prostaglandins and Oxytocin: augment/induce uterine contractions to expulse contents Nursing Care for Miscarriage · Perform pregnancy test. Observe color/amount of bleeding (pad counts) · Bed rest (risk for fall if sedative meds prescribed) · Avoid vaginal exams, assist with ultrasound · Administer meds as ordered: _____________________________________________ · Determine how much tissue has passed and save passed tissue for examination · Assist with termination of pregnancy (D&C, D&E, prostaglandins) · Use the lay term "miscarriage" because "abortion" can be misunderstood · Provide education, emotional support, referral to support groups

1. Feeling of warmth or heat 2. Flushing 3. Diaphoresis 4. Burning at the IV site 5. Warmth in perineum 6. sedation

MAGNESIUM SULFATE for SEIZURE PREVENTION for Preeclampsia · Magnesium sulfate is administered by IV pump, loading dose of 4-6g over 15-30min & maintenance doses. Maintain serum magnesium level of 4-7mEq/L · Magnesium sulfate causes vasodilation so it is thought to prevent seizures by dilating peripheral and cerebral vessels (better circulation), preventing cerebral edema, or functioning as a central anticonvulsant, "hot flash" · Nursing Interventions for Magnesium sulfate: § Teach mom that its given to prevent seizures, not treat HTN § Position mom in side-lying during administration, and use infusion pump § Assess vitals, BP, HR, RR, FHR, UC, LOC, DTRs § Report TOXICITY: BP 160/110, RR less than 12, urine output less than 25-30mL/hr, headache, visual disturbances, epigastric pain, decreasing LOC, absent/loss of DTRs, increasing edema, cardiac dysrhythmias § Keep side rails up, lights dimmed, emergency drugs/O2 at bedside § FLUID RESTRICTION: 25-125mL/hr. Maintain UP of 25mL or higher § Must track hourly I/O's because magnesium is excreted in urine. If renal function declines, excretion of magnesium sulfate is inadequate (toxicity risk) · Common side effects of Magnesium sulfate: 1 2 3 4 5 6

1. Lethargy & muscle weakness 2. Decreased or absent DTR's 3. Double vision & slurred speech 4. Maternal hypotension 5. Maternal bradycardia 6. Decreased respirations; respiratory depression 7. Cardiac arrest

25-125mL/hr. Maintain UP of 25mL or higher § Must track hourly I/O's because magnesium is excreted in urine. If renal function declines, excretion of magnesium sulfate is inadequate (toxicity risk)

drinking alcohol, vitamins containing Folic Acid, gas-forming foods, sun exposure, sexual intercourse (until hCG is undetectable)

MEDICAL management of Ectopic Pregnancy (if small, unruptured) -Methotrexate: destroys/dissolves rapidly dividing cells, folate inhibitor. It inhibits cell division and embryo enlargement, dissolving the pregnancy § Side effects: GI distress, n/v, stomatitis, dizziness; rare side effects are neutropenia, reversible hair loss, and pneumonitis § Must avoid _________________________________________________________________________________________ § Mom must be hemodynamically stable and have normal liver/kidney function § REPORT severe ABD pain (can indicate impending or actual tubal rupture) § Do not take any analgesic stronger than acetaminophen due to risk of tubal rupture § Calculate mother's height and weight to calculate dosage § Don 2 pairs of gloves before removing drug from sealed bag. Remove the cap and replace with needle for IM injection § Do not expel air from the syringe because it will aerosolize the drug § Verify dose/drug/patient with a 2nd RN § Dispose of any items worn or used to prepare, dispense, or administer drug in a waste container for hazardous drugs § Wash hands immediately after removing gloves § Teach mom that urine will contain drug for 72 hours after treatment, so she needs to avoid getting urine on toilet seat and double flush when done. Stools can contain drug for up to 7 days

REPORT PAIN, INCREASED PERINEAL PRESSURE, POSSIBLE RUPTURE OF MEMBRANES, SIGNS OF INFECTION, Contractions less than 5 minutes apart, urges to push

Management of reduced cervical competence · Bed rest (?) activity restrictions; avoid sexual intercourse · Increase hydration to promote relaxed uterus · Pessaries · Antibiotics · Anti-inflammatory drugs · Progesterone supplementation · Monitor vaginal discharge and vitals · Cervical Cerclage: a suture is placed around the cervix to constrict cervical os, usually around 12-14 weeks gestation § McDonald technique § Removed at 36 to 38 weeks or when spontaneous labor occurs § CRITICAL INSTRUCTIONS: ___________________________________________________________

Abruptio Placentae (Placental Abruption)

Nursing Considerations for Trauma: § Assess mother first. Baby cannot live if mom doesn't live, so make sure she is stabilized, then assess baby. § CABDs: compressions, airway, breathing, defibrillation · Avoid hyperextension of the neck. Use the jaw through to establish airway · Give O2 nonrebreather 10L/min § 2 IVs started to infused crystalloids (LR or NS) at 3mL of fluid per 1mL of blood volume lost. · Avoid giving vasopressors because they reduce uterine bloodflow § Risk of aspiration if unconscious and head is lower than ABD · Elevate head if possible!!!! § Avoid supine position, even with cervical injury due to risk of decreased CO and vena cava compression. But uterine displacement must occur without any head movement. As soon as the neck is mobilized, the stretcher should be tilted laterally § For CPR, if mom is more than 20 weeks gestation (fundus at level of umbilicus), displace hips when doing compressions (100-120/min). Place defibrillator pads one rib interspace higher than usual because the heart is displaced by uterus § Second Survey: after resuscitation and stabilization, check on mom and fetus (include assessment of all body systems) · Assess for ______________________: 1. Uterine tenderness/ pain 2. Uterine irritability 3. Vaginal bleeding 4. Leaking of amniotic fluid 5. Assess fetus, fetal heart tones

ROM, stretching, Kegels, pelvic tilt to maintain blood flow, muscle tone, bowel function, and sense of well-being

Nursing Interventions/Treatment for Preeclampsia · Activity Restriction: complete or partial bedrest is recommended during pregnancy for preeclampsia. Lateral positioning is encouraged. Avoid stimuli that causes seizures § Immobility = increased risk for thrombophlebitis, cardiovascular decompensation, diuresis, psychologic stress § Diversionary activities: TV, computer/smart-phone use, radio, CD player, MP3 player, visits from friends, online prenatal classes, puzzles, crosswords, embroider, smock, crochet, knitting, mending, sewing, crafts, relaxation exercises, facial, manicure/pedicure, massages § Gentle exercise: _______________________________________________________________________ § Delegate family members or friends as much as possible to do laundry, pick up groceries, attend to child care, organize meals, etc. § Place a box near the bed/sofa to store items like, post-it notes, cups, straws, paper plates/forks/knives, baby monitor, walkie talkie, wet wipes, notebook to record questions for provider, stationery, take-out menus, reading materials, books, audiobooks, magazines § Stock a mini-fridge with cool water and healthy snacks § Plan for family time § If in the hospital, ask about positioning, activity level, bathroom use, children's visits/visitors, activities, personal hygiene, mobility, diet · Bring your own pillow, shampoo, conditioner, have a wheelchair for visits, laptop, ask family to bring snacks (not flowers), earplugs to block noise

Immobility

Nursing Interventions/Treatment for Preeclampsia · Activity Restriction: complete or partial bedrest is recommended during pregnancy for preeclampsia. Lateral positioning is encouraged. Avoid stimuli that causes seizures § _________________ = increased risk for thrombophlebitis, cardiovascular decompensation, diuresis, psychologic stress § Diversionary activities: TV, computer/smart-phone use, radio, CD player, MP3 player, visits from friends, online prenatal classes, puzzles, crosswords, embroider, smock, crochet, knitting, mending, sewing, crafts, relaxation exercises, facial, manicure/pedicure, massages § Gentle exercise: ROM, stretching, Kegels, pelvic tilt to maintain blood flow, muscle tone, bowel function, and sense of well-being § Delegate family members or friends as much as possible to do laundry, pick up groceries, attend to child care, organize meals, etc. § Place a box near the bed/sofa to store items like, post-it notes, cups, straws, paper plates/forks/knives, baby monitor, walkie talkie, wet wipes, notebook to record questions for provider, stationery, take-out menus, reading materials, books, audiobooks, magazines § Stock a mini-fridge with cool water and healthy snacks § Plan for family time § If in the hospital, ask about positioning, activity level, bathroom use, children's visits/visitors, activities, personal hygiene, mobility, diet · Bring your own pillow, shampoo, conditioner, have a wheelchair for visits, laptop, ask family to bring snacks (not flowers), earplugs to block noise

ABD pain, significant headache, uterine contractions, vaginal spotting, or decreased fetal movement (4 or less movements in 1 hour)

Nursing Interventions/Treatment for Preeclampsia · Assess LOC, pulse oximetry, urine output, daily weights, vitals (BP), NST, daily kick counts, I/O · Some women can be managed at home, provided they have frequent maternal and fetal evaluation · Vaginal delivery by induction is recommended at 37 weeks gestation. At this gestational age, the risks to the fetus outweigh benefits of continuing the pregnancy · Regular diet without salt restriction is recommended · Teach moms to go to the hospital immediately if they develop ________________________________________________________ · Teach moms to keep a diary of assessments (BP, urine dipstick, s/s) · Routine Visits for Maternal and Fetal Assessment: § Serum creatinine, platelets, LFTs weekly § Assess for s/s: headaches, blurred/double vision, mental confusion, RUQ pain, epigastric pain, n/v, SOB, decreased urine output § BP assessment 2x/week § Proteinuria assessed weekly § Daily fetal movement counts, NST, biophysical profile once or twice weekly until birth § Ultrasound: Amniotic fluid status, estimating fetal weight

· Imminent or actual eclampsia · Uncontrollable severe hypertension · Pulmonary edema · Placental abruption · DIC · Non-reassuring fetal status · Fetal gestational age less than 24 weeks or fetal demise

Nursing Interventions/Treatment for Preeclampsia · Expectant Management: women who are less than 34 weeks of gestation and have no indication of giving birth immediately may be candidates for expectant management. § These women should be hospitalized at a tertiary care facility that can provide maternal and neonatal care management § Expectant management includes use of oral antihypertensives too keep BP between 140/90-155/105, ongoing maternal/fetal assessment, use of corticosteroids (betamethasone) for fetal lung maturation § Immediate birth is indicated if any of these complications are present: (per txbk) - - - - - -

headache, flushing, palpitations, tachycardia, n/v

Precautions with Preeclampsia · Environment § Quiet § Non-stimulating § Lighting subdued or dark · Seizure Precautions § Suction equipment tested and ready to use § Oxygen administration equipment tested and ready to use § Call button in reach § Siderails padded, bed low · Emergency medications/equipment available: § Hydralazine · Maternal side effects: ______________________________________________________ · Fetal side effects: tachycardia, late decels, bradycardia § Labetalol · Maternal side effects: lethargy, fatigue, sleep disturbance; minimal flushing, tremors, hypotension, and change in pulse § Nifedipine · Maternal side effects: headache, flushing, tachycardia § Magnesium Sulfate § Calcium Gluconate § Oxygen § Suction equipment · Emergency Birth Pack easily accessible - cure is delivery, sometimes labor very fast

only with pregnancy and disappear shortly after birth of the fetus and placenta

Preeclampsia · Signs and symptoms of preeclampsia develop _________________________ · Cause is unknown ??? § Abnormal placental invasion § Immunologic response to foreign genes of fetus and placenta § Stimulation of the inflammatory system by vascular changes § Dietary deficiencies (protein, calcium) § Genetic abnormalities - familial component

§ Headaches § Hyperreflexia and positive ankle clonus § Seizures § Visual disturbances (scotomata)

Preeclampsia: Pathophysiology · Changes present long before the diagnosis is made · Starts with poor circulation to placenta, leading to endothelial cell dysfunction · Generalized vasospasm results in poor perfusion in all organ systems § Increased peripheral resistance (BP going up!) § Loss of protein and water from the blood vessels results in § decreasing plasma volume, and hemoconcentration, increased blood viscosity, and edema · Reduced kidney perfusion decreases glomerular filtration rate (causes glomerular endotheliosis) causing oliguria § Protein is lost in the urine (proteinuria) § Serum uric acid levels increase (uric acid clearance is decreased) § Sodium and water are retained in cells causing EDEMA § Acute tubular necrosis and Renal failure may occur · As intravascular volume is reduced, arteriolar vasospasm can occur and damage vessel walls and contribute to pulmonary edema · Decreased liver perfusion can lead to impaired liver function and elevated liver enzymes § Liver edema and hemorrhage develop resulting in RUQ pain · Ruptured liver hematoma (life-threatening surgical emergency) · Neurologic complications include cerebral edema, hemorrhage and increase CNS irritability, so: 1 2 3 4

LOW DOSE ASPRIN

Preventing Preeclampsia · ___________________ between 12-28 weeks gestation only for women at risk for preeclampsia · Early prenatal care for identification of women at risk and early detection of preeclampsia · Interventions from clinical trials with MINIMAL/NO benefit: § Salt or protein restriction § Zinc, magnesium, fish oil, vitamin C and E supplements § Use of diuretics or other antihypertensives § Heparin

Short cervix, cervical funneling (beaking), cervical effacement, cervical length less than 25mm on ultrasound

Reduced Cervical Competence, or Recurrent Premature Dilation of the Cervix, or Cervical Incompetence · Cervical Insufficiency: Passive and painless dilation of the cervix during the second trimester, that often leads to preterm births · Manifestations of Cervical Insufficiency: § Pink-stained vaginal discharge or bleeding § Possible gush of fluid (ROM) § Uterine contractions with expulsion of fetus § Postop (cerclage) monitoring for uterine contractions, ROM, and manifestations of infections · Diagnosis of Cervical Insufficiency: § Based on history of 2nd trimester losses § _______________________________________________________

1 Cervical length: less than 25mm 2 Poor integrity of cervical tissue 3 Stress

Reduced Cervical Competence, or Recurrent Premature Dilation of the Cervix, or Cervical Incompetence · One cause of late spontaneous abortion · Cervical Insufficiency: Passive and painless dilation of the cervix during the second trimester, that often leads to preterm births · Cervical Insufficiency is Related to: 1 2 3 · Etiology: History of cervical trauma or treatment for cervical cancer · Risk factors for Cervical Insufficiency: collagen disorders, uterine/cervical anomalies, history of cervical trauma (curettage, cervical tears, dilations, surgery), treatment for cervical cancer, short labors, pregnancy loss early in gestation, diethylstilbestrol ingestion during pregnancy

Preeclampsia

Risk Factors for _________________________: · Primigravida, Nulliparity · Age extremes: <19 years old or older than 40 years old · Pregnancy associated with reproductive techniques · History: § Severe preeclampsia in a previous pregnancy, or poor outcome in previous pregnancy § Family history (mother or sister) of preeclampsia § Paternal history (partner fathered a preeclamptic pregnancy in another woman) § Women who were born small for gestational age · African American · Multifetal gestation (twins) · Maternal infection/ inflammation during current pregnancy (UTI, periodontal disease) · Gestational diabetes or obesity · Preexisting medical or genetic conditions: § Chronic hypertension § Renal disease § Pregestational diabetes § Connective tissue disease (Lupus, rheumatoid arthritis) § Obesity

A. Administer magnesium sulfate as ordered.

The nurse is admitting a client at 39 weeks with a BP of 190/89, 4+ proteinuria, and 3 + DTRs. Which action should the nurse implement? A. Administer magnesium sulfate as ordered. B. Assess respiratory status every 8 hours. (no, you need to assess respiratory status HOURLY) C. Ask the client to ambulate every 2 hours. (no, she needs to be on bed rest) D. Listen to fetal heart tones every 4 hours. (no, you need continuous FHR monitoring)

B. New onset of seizures

The nurse is assessing a client with gestational hypertension. What findings would determine that the disease has progressed to eclampsia? A. Severe headache B. New onset of seizures C. Proteinuria D. Thrombocytopenia

C. Amount of bleeding.

The nurse receives report on a postpartum client who delivered vaginally 2 hours ago, then had suspected amniotic fluid embolus. Which assessment has highest priority? A. Fluid intake. B. Temperature. C. Amount of bleeding. D. Attachment behaviors.

§ Dysuria § Polyuria § Nocturia § Urinary frequency § Hematuria § Back pain - (CVAT) § Contractions

Urinary Tract Infections · UTI's affect 20% of all pregnancies · Asymptomatic bacteriuria: persistent presence of bacteria in the urinary tract of women who have no symptoms. § If not treated, it can develop into pyelonephritis § Associated with preterm birth and low birth weight infants · Cystitis (bladder infection): dysuria, urgency, frequency, lower ABD/suprapubic pain · Pyelonephritis (kidney infection): can cause complications like septic shock, ARDs, preterm labor § Abrupt onset of fever, shaking, chills, aching in lumbar area, anorexia, n/v, costovertebral area tender to palpation · Symptoms of UTIs - - - - - -

Appendicitis

§ S/S of __________________: right lower quadrant (RLQ) pain, nausea, vomiting, increased WBC; rare symptoms include fever, tachycardia, dry tongue

miscarriage (spontaneous abortion)

· A pregnancy that ends as a result of natural causes before 20 weeks of gestation is a __________________________________________. § Due to natural causes, before 20 weeks gestation (before viability) § COMMON: 10-15% of clinically recognized pregnancies · 80% of abortions happen before 12 weeks of gestation (early spontaneous abortion), which commonly occurs due to: § Endocrine imbalance (hypothyroidism, DM) § Immunologic factors, systemic disorders, genetic factors § Chromosome abnormalities · 50% of abortions are due to chromosomal abnormalities

1 Advanced maternal age (AMA) over 35 years old 2 Premature dilation of cervix or cervical problems 3 Inadequate nutrition

· A pregnancy that ends as a result of natural causes before 20 weeks of gestation is a miscarriage (spontaneous abortion). · After 12 weeks, late spontaneous abortion, from maternal causes: 1 2 3 § late spontaneous abortion (after 12 weeks) risk factors: minority ethnic group, poor outcome in previous pregnancy, extremes of maternal age, dietary deficiencies, morbid obesity, regular/heavy alcohol use, excessive caffeine intake, bleeding in first trimester

cerebral palsy Death from SIDS following birth

· Abruptio Placentae (Placental Abruption): Premature placenta separation; partial or complete detachment of the placenta from uterus. This occurs after 20 weeks gestation (usually in 3rd trimester). DIC is often associated with moderate/severe abruption - Maternal Outcomes depend on § Extent of placental detachment § Overall blood loss § Degree of coagulopathy § Time between detachment and delivery § Complications: DIC, hemorrhage, shock, hypofibrinogenemia, thrombocytopenia, renal failure, pituitary necrosis - Fetal Outcomes § Prevent Complications: · IUGR - intrauterine growth restriction · Oligohydramnios, Preterm birth, hypoxemia, stillbirth · Size of hemorrhage is related to fetal survival · Neurologic defects like _________________________

surgical intervention to remove appendix

· Appendicitis: as pregnancy develops, the appendix is pushed out of its normal location and can become inflamed and rupture. § S/S: right lower quadrant (RLQ) pain, nausea, vomiting, increased WBC; rare symptoms include fever, tachycardia, dry tongue § Need radiologic imaging as soon as appendicitis is suspected, often with MRI § Prompt ______________

1500-2000

· Clinical Manifestations of Ectopic Pregnancy: § Abdominal pain: dull, lower quadrant, one side of ABD § Late period, or light period (period is often delayed by 1-2 wks) § Abnormal, irregular, scant vaginal spotting 6-8 weeks after LMP § Mild-to-Moderate dark red/brown intermittent vaginal bleeding § IF RUPTURED: · MOST BLEEDING IS INTERNAL (but may have bright red vaginal bleeding) · ABD pain changes to sharp, stabbing, colicky to diffuse, constant, severe pain that is generalized throughout the lower ABD · Referred shoulder pain from blood in the peritoneal cavity · Eventually exhibits signs of shock: faintness, dizziness, vertigo, hypotension, tachycardia · Ecchymotic blueness around the umbilicus (Cullen sign) may appear in undiagnosed, ruptured intraabdominal ectopic pregnancy · Diagnosing Ectopic Pregnancy: § B-hCG levels greater than ______________________________, but no intrauterine pregnancy visible on transvaginal ultrasound § Progesterone level less than 5ng/mL indicates ectopic pregnancy (progesterone greater than 25 rules out ectopic pregnancy) § Transvaginal ultrasound shows empty uterus

· Greatest risk is preterm birth · Possible risk of stillbirth · Risk of Malpresentation · Risk of Fetal anemia

· Clinical Manifestations of Placenta Previa: § PAINLESS, bright red vaginal bleeding after 20 weeks (2nd or 3rdtrimester) § Vital signs are normal until up to 40% of blood volume is lost § Decreasing urine output can indicate blood loss and shock § Fundus palpates as soft, relaxed, and nontender with normal tone § Fetal heart tones reassuring/normal unless placenta completely detaches § Presenting fetal part is high, fundal height is greater than expected for gestational age § Fetal malpresentation common: breech, oblique, or transverse lie · Diagnosis of Placenta Previa by ultrasound, may also get H/H (blood loss), CBC, blood type/Rh, coagulation profile, Kleihauer-Betke test (fetal blood in mom's circulation) -Placenta Previa outcomes: § MATERNAL · Major complication is maternal hemorrhage · Possible abnormal placental attachment: placenta accrete, increta, percreta · Hysterectomy if bleeding cannot be controlled § FETAL - - - -

Disseminated Intravascular Coagulation (DIC)

· Clinical Manifestations of ___________________________________: § BLEEDING § From gums and nose § From IV site or urinary catheter § Petechiae (on arm where blood pressure cuff was placed) or bruising § Hematuria § GI bleeding § Due to bleeding: · Tachycardia · Diaphoresis · Labs of ___________________________________: § Decreased platelets § Decreased fibrinogen § PT prolonged § PTT prolonged

Placenta Previa

· Clinical Manifestations of ___________________________________: § PAINLESS, bright red vaginal bleeding after 20 weeks (2nd or 3rdtrimester) § Vital signs are normal until up to 40% of blood volume is lost § Decreasing urine output can indicate blood loss and shock § Fundus palpates as soft, relaxed, and nontender with normal tone § Fetal heart tones reassuring/normal unless placenta completely detaches § Presenting fetal part is high, fundal height is greater than expected for gestational age § Fetal malpresentation common: breech, oblique, or transverse lie

Abruptio Placentae (Placental Abruption)

· Clinical Manifestations of ______________________________________: § Bright red vaginal bleeding (may be concealed), low H/H § PAINFUL: Abdominal pain, uterine tenderness (localized or diffuse) § Contractions: Uterine hypertonicity § Uterus (abdomen) is "board-like" § Bleeding can result in hypovolemia (shock, oliguria, anuria) and coagulopathy § Excess uterine bleeding can damage uterine muscle. If blood collects between uterus and placenta, it can cause Couvelaire Uterus (uterus is purple, blue and contractility is lost) § Fetal distress § CAN TRIGGER DIC!!!!!!! · Diagnosis: § Ultrasound used to rule out previa or show separation and bleeding § Positive Apt result (blood in amniotic fluid) can be used to assist diagnosis § H/H decreased § Coagulation factors decreased § Clotting defects (DIC) § Obtain blood type and cross match for blood transfusions § Kleihauer-Betke test (fetal blood in mom's circulation)

Ectopic Pregnancy

· Clinical Manifestations of _____________________________________________: § Abdominal pain: dull, lower quadrant, one side of ABD § Late period, or light period (period is often delayed by 1-2 wks) § Abnormal, irregular, scant vaginal spotting 6-8 weeks after LMP § Mild-to-Moderate dark red/brown intermittent vaginal bleeding § IF RUPTURED: · MOST BLEEDING IS INTERNAL (but may have bright red vaginal bleeding) · ABD pain changes to sharp, stabbing, colicky to diffuse, constant, severe pain that is generalized throughout the lower ABD · Referred shoulder pain from blood in the peritoneal cavity · Eventually exhibits signs of shock: faintness, dizziness, vertigo, hypotension, tachycardia · Ecchymotic blueness around the umbilicus (Cullen sign) may appear in undiagnosed, ruptured intraabdominal ectopic pregnancy

hCG beyond the time it would be expected to decrease in pregnancy

· Clinical manifestations of Hydatidiform Mole (molar pregnancy): § Looks like a normal pregnancy early § Vaginal bleeding or discharge that is dark brown (prune juice) or bright red; and can be scant or profuse bleeding that is continuous or intermittent § Mother may pass vesicles from uterus § Rapid uterine growth: Size of uterus is larger than expected for gestational weeks § No fetal heart tones ever § Anemia from blood loss, excessive n/v (hyperemesis gravidarum), and ABD cramps caused by uterine distention § HCG related symptoms: nausea, gestational hypertension, preeclampsia § Complications: hyperthyroidism · Diagnosis of Hydatidiform Mole (molar pregnancy): § Elevated ___________________________________________________ § Larger than expected uterus, no fetal heart tones § Transvaginal Ultrasound shows uterine cavity filled with vesicles (no embryo). A pattern of multiple diffuse uterine masses (snowstorm pattern) can be seen

Hydatidiform Mole (molar pregnancy)

· Clinical manifestations of ________________________________________: § Looks like a normal pregnancy early § Vaginal bleeding or discharge that is dark brown (prune juice) or bright red; and can be scant or profuse bleeding that is continuous or intermittent § Mother may pass vesicles from uterus § Rapid uterine growth: Size of uterus is larger than expected for gestational weeks § No fetal heart tones ever § Anemia from blood loss, excessive n/v (hyperemesis gravidarum), and ABD cramps caused by uterine distention § HCG related symptoms: nausea, gestational hypertension, preeclampsia § Complications: hyperthyroidism

1 Esophageal rupture 2 Vitamin K deficiency, resulting in Wernicke encephalopathy 3 Pneumomediastinum 4 Infants born to mothers of poor weight gain due to hyperemesis have risk of small gestational age, low birth weight, or premature birth

· Complications of Hyperemesis Gravidarum 1 2 3 4

1 Persistent headache 2 Blurred vision 3 Severe epigastric pain 4 RUQ pain or abdominal pain 5 Altered mental status 6 BUT - may start without warning, even with lower BPs

· Eclampsia is sometimes preceded by warnings: 1 2 3 4 5 6 · Eclampsia seizures: Tonic contraction of the body muscles (arms flexed, hands clenched, legs inverted) precedes the tonic-clonic convulsion (muscle relax and contract) § Respirations halt and then resume with stertorous, long, deep inhalations § Hypotension follows seizure § Muscle twitching, disorientation, and Amnesia persist for a while after seizure § Incontinence or vomiting can occur

§ Pulmonary edema § Acute renal failure § Disseminated intravascular coagulopathy § Placental abruption § Liver hemorrhage or failure § Acute respiratory distress syndrome (ARDS) § Severe IUGR § Preterm birth

· HELLP Syndrome: a variant of severe preeclampsia/GH that involves hepatic dysfunction, characterized by: § 1. Hemolysis (H): resulting in anemia and jaundice § 2. Elevated liver enzymes (EL): resulting in high ALT/AST, epigastric pain, n/v § 3. Low platelets (LP): thrombocytopenia, abnormal bleeding/clotting time, bleeding gums, petechiae, possible DIC · 10-20% of all women with severe preeclampsia develop HELLP · HELLP syndrome usually develops in the antepartum period, and women shows symptoms of: § Malaise § Flu-like symptoms § Epigastric or right upper quadrant ABD pain § Symptoms worse at night and improve during daytime. S/s can progress rapidly § May not have s/s of preeclampsia with severe features. Most women may have HTN, but may not have proteinuria. •Risk of maternal death and adverse perinatal outcomes: - - - -

GI distress, n/v, stomatitis, dizziness; rare side effects are neutropenia, reversible hair loss, and pneumonitis

· MEDICAL management of Ectopic Pregnancy (if small, unruptured) -Methotrexate: destroys/dissolves rapidly dividing cells, folate inhibitor. It inhibits cell division and embryo enlargement, dissolving the pregnancy § Side effects: ________________________________________________________________________ § Must avoid drinking alcohol, vitamins containing Folic Acid, gas-forming foods, sun exposure, sexual intercourse (until hCG is undetectable) § Mom must be hemodynamically stable and have normal liver/kidney function § REPORT severe ABD pain (can indicate impending or actual tubal rupture) § Do not take any analgesic stronger than acetaminophen due to risk of tubal rupture § Calculate mother's height and weight to calculate dosage § Don 2 pairs of gloves before removing drug from sealed bag. Remove the cap and replace with needle for IM injection § Do not expel air from the syringe because it will aerosolize the drug § Verify dose/drug/patient with a 2nd RN § Dispose of any items worn or used to prepare, dispense, or administer drug in a waste container for hazardous drugs § Wash hands immediately after removing gloves § Teach mom that urine will contain drug for 72 hours after treatment, so she needs to avoid getting urine on toilet seat and double flush when done. Stools can contain drug for up to 7 days

Correct underlying condition · Removal of dead fetus · Treatment of preeclampsia or eclampsia · Removing abrupted placenta · Treating infection

· Management of Disseminated Intravascular Coagulation (DIC): § Stop the bleeding -> ____________________: - - - - § Volume expansion IV § Rapid replacement of blood products and clotting factors § Give oxygen via non-rebreather @ 10L/min § Normalize body temperature § Vitamin K administration § Assessing for bleeding and complications of blood administration § Monitor urinary output to check for renal failure § Left-Lateral Position to max blood flow to uterus § Fetal assessment if DIC occurs prior to birth

doxylamine, promethazine, chlorpromazine, prochlorperazine, trimethobenzamide, ondansetron, metoclopramide

· Management of Hyperemesis Gravidarum § MAKE NPO - no food or drink! Until vomiting stops § IV fluids (LR) for fluid/electrolyte imbalance, monitor I/O, skin turgor, mucous membranes, weight, vitals § Medications: · anti-nausea: ________________________________________________________________________ · supplements: pyridoxine (vitamin B6) · corticosteroids possible if unresponsive to antiemetics · heartburn drugs: antacids, histamine blockers, PPIs § Monitor for complications: metabolic acidosis, jaundice, hemorrhage § Oral hygiene, positioning, comfort, keep room free of odors § After food is tolerated, use small, frequent meals of limited fluids, crackers, toast, baked chicken. Slowly progress diet until she can consume a nutritionally sound diet § Follow-Up Care: · Advance to clear liquids and bland food once vomiting stops, then advance as tolerated (dry toast, crackers, cereal) · have someone else cook (odors can trigger n/v) · eat appealing foods (non-greasy, dry, sweet, salty) · cold foods may be better tolerated · try ginger tea or ginger ale · If you vomit, try sucking on a popsicle

· Advance to clear liquids and bland food once vomiting stops, then advance as tolerated (dry toast, crackers, cereal) · have someone else cook (odors can trigger n/v) · eat appealing foods (non-greasy, dry, sweet, salty) · cold foods may be better tolerated · try ginger tea or ginger ale · If you vomit, try sucking on a popsicle

· Management of Hyperemesis Gravidarum § MAKE NPO - no food or drink! Until vomiting stops § IV fluids (LR) for fluid/electrolyte imbalance, monitor I/O, skin turgor, mucous membranes, weight, vitals § Medications: · anti-nausea: doxylamine, promethazine, chlorpromazine, prochlorperazine, trimethobenzamide, ondansetron, metoclopramide · supplements: pyridoxine (vitamin B6) · corticosteroids possible if unresponsive to antiemetics · heartburn drugs: antacids, histamine blockers, PPIs § Monitor for complications: metabolic acidosis, jaundice, hemorrhage § Oral hygiene, positioning, comfort, keep room free of odors § After food is tolerated, use small, frequent meals of limited fluids, crackers, toast, baked chicken. Slowly progress diet until she can consume a nutritionally sound diet § Follow-Up Care: - - - - -

Hyperemesis Gravidarum

· Manifestations of _________________________________: § Significant weight loss § Dehydration/electrolyte imbalance § Dry mucus membranes, decreased BP, increased HR, poor skin turgor § Unable to keep oral clear liquids down § Nutritional deficiencies: low sodium, potassium, chloride; metabolic acidosis (starvation), metabolic alkalosis (vomiting); elevated LFTs § Urinalysis: ketonuria and acetone (breakdown of protein/fats), high specific gravity § Thyroid test for hyperthyroidism § CBC: elevated Hct (hemoconcentration)

Hyperemesis Gravidarum

· Normal nausea & vomiting in up to 80% of all pregnancies § Typically begins at week 4, ends by week 20 § From relaxation of the smooth muscle of the stomach with increasing estrogen, progesterone & hCG · ______________________________________ is characterized by nausea and vomiting that is excessive (prolonged past 16 weeks) and causes weight loss, electrolyte imbalance, nutritional deficiencies, and ketonuria. § Usually begins in the first trimester, but some have symptoms throughout pregnancy § Cause of ______________________________________ is unknown: · ? High levels of estrogen or hCG · ?Transient hyperthyroidism · ?Esophageal reflux

Preeclampsia

· Objective Signs and Symptoms of ___________________________________: § Blood Pressure: manual BP measurement with cuff and stethoscope, measure in same position, readings of hypertension (140/90 or more) § Edema - present, generalized § Deep Tendon Reflexes - popliteal, (textbook says biceps reflex and patellar reflex § Clonus - present?, beats? Clonus occurs when the examiner sharply dorsiflexes the foot, maintains the position, then releases it, and rhythmic oscillations or "beats" are felt when the foot is in dorsiflexion § Proteinuria - urine dip (+1 protein) or 24 hour (greater than 300mg of protein) · Subjective Signs and Symptoms: § Sever Headaches (usually frontal) § Epigastric pain (heartburn) § Right upper quadrant pain § Vision changes (scotomata, photophobia, double vision)

NOTHING in the vagina: NO vaginal exams, rectal exams, or intercourse!!!!!!!!!!

· Placenta Previa management §1. _____________________________________ § Monitor for bleeding, leakage, or contractions · Pad counts, weighing § Corticosteroids (betamethasone) ASAP for fetal lung maturity if under 34 weeks § Observation and Bed rest. If bleeding stops, she might be put on bed rest and limited activity (use bathroom, shower, and move around room for 15-30 minutes at a time, 4x/day) § Start IV for fluids or blood products, measure H/H, platelets, coag studies, type and screen § Have O2 on hand in case of fetal distress § If home care is allowed: · Must be stable, with no vaginal bleeding for 48 hours · Comply with activity restrictions, and go to hospital if bleeding occurs · Live within short distance of hospital and have access to transportation § Cesarean birth ALWAYS INDICATED (especially if at or beyond 36 weeks gtn) · This is because there is risk of bleeding with vaginal birth

§ Previous placenta previa § Previous cesarean birth or scars on uterus (endometritis, curettage) § Advanced maternal age over 35-40 § Multiparity, multifetal gestation § History of D&C § Tobacco use, smoking § Living at higher altitude § Asian women, carrying male fetus

· Placenta Previa: Placenta is implanted in the lower uterine segment such that it completely or partially covers the cervical os, or is close enough to the cervix to cause bleeding when the cervix dilated or uterus effaces · Complete Placenta Previa: placenta totally covers the internal cervical os · Incomplete Placenta Previa: cervical os is only partially covered by the placental attachment · Marginal Placenta Previa: edge of placenta is 2.5cm or closer to internal cervical os · Low-Lying Placenta: exact location of placenta is not known or apparent placenta previa in the 2nd trimester · Risk factors for Placenta Previa: - - - - -

Severe Preeclampsia

· Preeclampsia: gestational hypertension + proteinuria that develop after week 20 of pregnancy in a woman who previously had neither HTN or proteinuria. The s/s can also develop for the first time during the postpartum period (transient HA, irritability, edema) § In the absence of proteinuria, it can be diagnosed as hypertension + thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral/visual symptoms · __________________________ Preeclampsia (only need one on list to qualify): consists of BP over 160/110, elevated blood creatinine (more than 1.1), cerebral/vision problems (HA/blurred vision), hyperreflexia, ankle clonus, pulmonary/cardiac involvement, peripheral edema, epigastric and right upper quadrant pain, and thrombocytopenia o MATERNAL EFFECTS: § BP >160/110 § Kidneys: · Proteinuria >3+ on dipstick x 2, or >5gm in 24 hr collection · Urine output <500ml/24hr § Neuro: · Headaches - persistent and severe · Visual changes - photophobia, scotomata, or blurred vision · Hyperreflexia - increased DTR and clonus § Liver: · Enlarged with epigastric or RUQ pain, nausea, vomiting · Impaired liver function (elevated liver enzymes to twice normal concentretion) § Thrombocytopenia: platelets less than 100,000 § Per textbook: pulmonary edema, cerebral visual disturbances § FETAL EFFECTS: Intrauterine growth restriction (IUGR) or · Abnormal antepartum testing (NST, BPP, CST, etc.)

Mild Preeclampsia

Hyperemesis Gravidarum

· Risk Factors for ___________________________________: § Young maternal age, nulliparity, BMI less than 18.5 or greater than 25 § Low socioeconomic status § Hyperthyroid disorders § Psychiatric diagnosis, high maternal stress § Previous pregnancy with hyperemesis gravidarum or family history § High hCG levels: molar pregnancy (GTD), multiple gestation § Diabetes § Gastrointestinal disorders § Asthma § Migraines § Carrying female fetus or multifetal gestation

miscarriage (spontaneous abortion)

· Risk factors for __________________________________________: § Chromosomal abnormalities (late/early spontaneous abortion) § Maternal illness or endocrine imbalance (such as DM) (early spontaneous abortion)advanced maternal age (late spontaneous abortion) § Premature cervical dilation (late spontaneous abortion) § Chronic maternal infections § Maternal malnutrition (late spontaneous abortion) § Trauma/injury § Anomalies in fetus or placenta § Substance use § Antiphospholipid syndrome

weekly until undetectable: usually 2-3 weeks, but possible 6-8 weeks

· SURGICAL management of Ectopic Pregnancy § Remove the tube (salpingectomy) or the pregnancy (salpingostomy) § Pre-op: vitals, blood type/Rh, CBC, hCG, ultrasound to confirm extrauterine pregnancy § Post-op: · hCG measured ____________________________________________________ · use contraceptive for 3 months to allow body to heal · contact provider if you think you are pregnancy due to risk of future ectopic pregnancy · Nursing Care for Ectopic Pregnancy: § Replace fluids, maintain electrolytes § Provide education and psychological support § Administer meds as ordered § Prepare for surgery and post-op nursing care § Provide emotional support and refer to support group § Obtain hCG, progesterone levels, liver/renal function studies, CBC, type and Rh

mother first. Baby cannot live if mom doesn't live, so make sure she is stabilized, then assess baby.

· Trauma During Pregnancy - Nursing Considerations for Trauma: § Assess __________________________________ § CABDs: compressions, airway, breathing, defibrillation · Avoid hyperextension of the neck. Use the jaw through to establish airway · Give O2 nonrebreather 10L/min § 2 IVs started to infused crystalloids (LR or NS) at 3mL of fluid per 1mL of blood volume lost. · Avoid giving vasopressors because they reduce uterine bloodflow § Risk of aspiration if unconscious and head is lower than ABD · Elevate head if possible!!!! § Avoid supine position, even with cervical injury due to risk of decreased CO and vena cava compression. But uterine displacement must occur without any head movement. As soon as the neck is mobilized, the stretcher should be tilted laterally § For CPR, if mom is more than 20 weeks gestation (fundus at level of umbilicus), displace hips when doing compressions (100-120/min). Place defibrillator pads one rib interspace higher than usual because the heart is displaced by uterus § Second Survey: after resuscitation and stabilization, check on mom and fetus (include assessment of all body systems) · Assess for placental abruption: 1. Uterine tenderness/ pain 2. Uterine irritability 3. Vaginal bleeding 4. Leaking of amniotic fluid 5. Assess fetus, fetal heart tones

DOMESTIC VIOLENCE

· Trauma During Pregnancy § Most trauma is from motor vehicle accidents (wear seatbelt) and falls, but other trauma results from partner violence, assaults, and suicide attempts § Trauma is the leading cause of non-obstetric maternal death in the U.S. § INCREASED INCIDENCE OF _______________________________! § Blunt Trauma: MVAs, falls, battering; blunt trauma to ABD can cause: · placental abruption (uterine pain, uterine irritability, contractions, vaginal bleeding, leaking amniotic fluid, change in FHR) · pelvic fracture · direct fetal injury · uterine rupture (rare) § Penetrating Trauma: bullet or stab wounds; when uterus is penetrated, fetus is more likely that mother to be seriously injured. § Thoracic Trauma: pulmonary contusion, pneumothorax, hemothorax

Prepare for emergency cesarean, but may deliver vaginally, very rapid labor.

· Treatment of Abruptio Placentae (Placental Abruption): § Nursing assessment is critical! · Pain · Amount of bleeding · Fetal status - EFM immediately for FHR · Uterine tone/tenderness and fundal height § Labs · H&H · Coagulation factors decreased · Type and cross § TIME CRITICAL! _______________________________________________________ · If fetus is between 20 and 34 weeks gestation, some doctors use expectant management, close monitoring, and fetal assessments § Immediate birth is used for term gestation or if bleeding is moderate-severe (mom and baby in jeopardy) · Initiate continuous electronic FHR monitoring and urinary catheter · IV fluids, blood, meds as prescribed · O2 8-10L/min via facemask · Monitor maternal vitals, observe for declining hemodynamic status · Assess urinary output and fluid balance § Provide emotional support for mom/family

hCG measured weekly until level decreases to normal for 3 weeks and then monthly measurements for 6-12 months

· Treatment of Hydatidiform Mole (molar pregnancy): § Suction & curettage to evacuate tissue from the uterus. Give Rh immune globulin after procedure to Rh negative clients § After procedure, client should have a baseline pelvic exam and ABD ultrasound § Serum ___________________________________________________________ § Avoid pregnancy until cleared after follow-up visits. This avoids confusion in regard to rising hCG which could indicate either normal pregnancy or GTD § Use any contraceptive method (oral contraceptives) except IUD § Older women may prefer a total hysterectomy for sterilization § Nursing Care: fundal height measurement, assess vaginal bleeding, GI status, provide support

Hemorrhage, fetal deformities (facial, cranial, joint, CNS deformity), tubal rupture

· What risks do ectopic pregnancy pose for the mother/baby? § _________________________

Placenta Previa

· ___________________: Placenta is implanted in the lower uterine segment such that it completely or partially covers the cervical os, or is close enough to the cervix to cause bleeding when the cervix dilated or uterus effaces § 1. Placenta completely covers cervical os, or § 2. Placenta partially covers cervical os (marginal placenta previa) § 3. Cervical dilation/uterine effacement causes vaginal bleeding

Eclampsia

· ___________________: the new onset of seizures or coma in a woman with preeclampsia who has no history of preexisting pathology that can result in seizure activity. § Eclamptic seizures can occur before or during labor, or postpartum § Approximately 1/3 of eclamptic seizures occur after birth, usually within 48 hours after delivery

Preeclampsia

· ____________________: gestational hypertension + proteinuria that develop after week 20 of pregnancy in a woman who previously had neither HTN or proteinuria. The s/s can also develop for the first time during the postpartum period (transient HA, irritability, edema) § In the absence of proteinuria, it can be diagnosed as hypertension + thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral/visual symptoms § Assess: is it Mild or Severe?

Abruptio Placentae (Placental Abruption)

· ____________________________: Premature placenta separation; partial or complete detachment of the placenta from uterus. This occurs after 20 weeks gestation (usually in 3rd trimester). DIC is often associated with moderate/severe abruption § Bleeding concealed or evident vaginally § High maternal & fetal morbidity & mortality § Affects approximately 1/75 to 1/226 pregnancies · Risk factors for ____________________________: § Maternal hypertension/vascular problems (diabetes mellitus) § Cocaine use (vasoconstriction) § Blunt external trauma to the abdomen (vehicle accidents, maternal battering) § Tobacco abuse, smoking/nicotine § Previous abruption § Preterm premature rupture of membranes § Thrombophilia § Twin gestations, multifetal gestation

Ectopic pregnancy

· __________________________________: Fertilized ovum is implanted outside the uterus. It is often called "tubal pregnancy", but the ovum may be inside or outside of the fallopian tube § Leading cause of infertility § 2% of all pregnancies in the U.S. are ectopic. Of these, they account for 9% of all pregnancy-related maternal death · Risk factors for __________________________________: anything that compromises tubal patency § Current or previous STI, tubal infection/damage § IUD's & tubal ligations/sterilization/surgery § Assistive Reproductive Technologies § History of ectopic pregnancy (women who have one ectopic, are less likely to have a successful subsequent pregnancy)

Gestational Hypertension

· _______________________________________ is the onset of hypertension (Defined as BP >140/90 mm/Hg) without proteinuria or other systemic findings after week 20 of pregnancy in a woman with a previously normal blood pressure. It does not persist longer than 12 weeks postpartum (usually resolves in 1st week after birth) § Blood pressure should be recorded after week 20 of pregnancy on 2 separate occasions at least 4-6 hours apart, but within a week. § S/S: severe continuous headache, nausea, blurred vision, flashes of light/dots in eyes · Only one of the pressures; either systolic or diastolic needs to meet the criteria to confirm the diagnosis § Mild >140/90 § Severe >160/110 · NO PROTEINURIA.

Disseminated Intravascular Coagulation (DIC)

·________________________: Consumptive coagulopathy; a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, resulting in widespread external/internal bleeding and clotting § It is a secondary diagnosis to some other problem that triggered the clotting cascade: · Placental abruption · Retained Dead Fetus Syndrome · Amniotic fluid embolus · Severe preeclampsia · HELLP syndrome · Sepsis

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