NUR 3440 Exam 2, week 9

Fetal risks w/ placenta previa

Inc risk of: • Fetal death d/t preterm labor • Stillbirth • Poor growth (IUGR) • Fetal anemia

Diet for gestational HTN

Inc water intake Dec salt intake (chips, lunch/deli meats, unprocessed soups, canned veggies) Want them to inc protein intake ---> Eat fresh fruit & meats

The main reason for miscarriage in 2nd trimester is...

Incompetent cervix •• Cervix is too weak to keep fetus in Can be d/t: • Damage to cervix from previous pregnancy • Medications (Ex: diethylstilbestrol)

Therapeutic donor insemination is the partner's sperm t or f

false

Ovulation predictor kits

Dip urine every AM to tell if woman is ovulating

Gestational HTN

Onset of HTN in pregnancy WITHOUT S&S of preeclampsia Dev AFTER 20 wks EGA BP ≥140/≥90 *Usually resolves on its own, ~12th wk after delivery*

Cervical fluid & ovulation

Ovulatory fluids are very stringy (spin barkin) Consider it like a "super elevator" that helps to get sperm to the egg Usually very slippery & clear on day of ovulation

Premonitory signs of eclampsia

• *Persistent h/a & blurred vision* • Epigastric or RUQ pain • Altered mental status ---> Convulsion can appear w/o warning

Hydatiform mole (Molar pregnancy)

"Gestational trophoblastic disease" Not very common: Higher risk of Asian or Polynesian ---> Benign proliferative growth of placental trophoblast in which the chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in a grape like cluster Clusters fill up uterus *Most generally, there is no pregnancy though it can happen on rare occasions*

Risk factors for placenta abruption

*#1 risk factor is maternal HTN* • Hx of previous abruption • Smoking • Drug use, ESPECIALLY cocaine & meth as they inc BP TOO QUICKLY ---> Placenta cannot handle it • Premature ROM • Trauma • ≥ 35 yrs • Short umbilical cord • Women w/ lots of babies (multiparity, ~5-6 kids)

Preeclampsia

*Pregnancy-specific condition* Dev of HTN & proteinuria in a previous healthy woman AFTER 20 wks EGA Similar to gestational HTN but with proteinuria ---> SYSTEMIC INVOLVEMENT

What causes ectopic pregnancies?

*Tubular damage inc risk:* •• Primarily d/t PID from infections like gonorrhea •• Can also occur w/ failed tubal ligation *Motility problems:* •• Endometriosis can cause scar tissue that impedes fertilized egg's ability to move down •• High estrogen levels can prevent egg from moving down ---> *SMOKING CAUSES THIS* Women who smoke & women ≥35 yrs are at high risk for ectopic pregnancies

What causes PIH?

*placenta is the root cause* >>> Typically resolves after delivery of placenta WHAT HAPPENS: • Spiral arteries of uterus do not enlarge w/ PIH | | V • Causes dec placenta perfusion & hypoxia • Also causes endothelial inflammation that *AFFECTS THE WHOLE BODY*

In order for a woman to conceive what MUST the body do? (Ova cycle)

1.) Release egg from ovaries (Ovulation) 2.) Egg must go thru Fallopian tubes to uterus 3.) Fertilize egg must implant on inside of uterus ---> Infertility can occur if there is disruption w/ any of these steps

Any miscarriage after _____ weeks requires medical intervention

12 wks d/t placenta being well developed

Tests (besides ß hCG) to assess for miscarriage

US --> Can determine viability of fetus ---> If we hear FHR that dec chance of miscarriage by 86% H&H ---> Only helpful in evaluating blood loss

Chronic HTN

HTN that is present before 20 wks EGA May not be diagnosed until they come in *Will not go away after delivery like w/ gestational HTN* Can dev superimposed PIH (preeclampsia) ===>> *Diagnosed by sudden onset of proteinuria or symptoms that were controlled once are not controlled anymore*

Normal umbilical cord looks like...

Has Wharton's jelly that surrounds & protects BVs (2 arteries, 1 vein) Usually 22 inc (55 cm) ---> *short < 32 cm (13 in)* Inserted into central placenta May be knotted or twisted

Class A pregnancy medication

A = All right There are adequate, well controlled studies have not shown any inc in human fetal abnormalities during any trimester May even be useful to pregnancy Ex: • Levothryoxine for hypothyroidism • Diclegias + disalamine succinate (vit B6 + regular unison) for prevention of N/V

Male infertility causes (*Environment*)

Heat, tight clothing, frequent biking, hot baths, or sauna can dec sperm count Environmental exposure can dec sperm count

Postcoital test

Helps to assess for couple infertility Couple has sex & then woman is examined immediately after Goal is to see if fertility problems is a combination of sperm, woman's vaginal fluid, etc. *Usually done 1-2 days BEFORE ovulation*

If HELLP syndrome is not taken care of, what may happen?

Hemorrhage DIC Pulmonary edema Hepatic rupture Death

Male infertility causes (*structural*)

40% of infertility issues are caused by male Undescended testes, hypospadius ---> Usually corrected early in life Variocele ---> Varicose vein around testicle ---> Inc temperature which affects sperm production ---> *Makes up 40% of all men w/ fertility issues*

What things cause DIC?

> Placenta abruption > Fetal demise (>4 wks) > Amniotic fluid embolism > Severe PIH > HELLP syndrome > Sepsis *DIC is very life threatening*

In caring for an immediate postpartum woman, you note petechiae and oozing from her IV site. You monitor her closely for which clotting disorder? A. Disseminated intravascular coagulation (DIC) B. Amniotic fluid embolism (AFE) C. Hemorrhage D. HELLP syndrome

A. Disseminated intravascular coagulation (DIC)

A couple who has sought fertility counseling has been told that the man's sperm count is very low. The nurse advises the couple that spermatogenesis is impaired when which of the following occurs? A. The testes are overheated. B. The vas deferens is ligated. C. The prostate gland is enlarged. D. The flagella are segmented.

A. The testes are overheated. --> This causes problems with the ability to PRODUCE sperm Answers B & C have to do with structural problems Answer D is a sperm defect

Chronic HTN puts the pregnant woman at risk for...

Abruptio placentae Superimposed preeclampsia Inc perinatal mortality ---> IUGR/preterm birth

Maternal & fetal outcomes of placenta previa depend on...

How much blood is lost --> Hemorrhage is a major complication for BOTH >> 1000 mL of blood flows thru placenta q1min ---> *Mom can bleed out in 10 mins*

Care of the woman w/ mild gestational HTN w/o severe features

GOAL: Keep baby in as long as possible & deliver healthy newborn • Monitor BP frequently • Urine dips for protein • Inc fetal assessments ---> NSTs 2x/week ---> Weekly biophysical profiles Dec activity but NOT complete bedrest • Monitor urine output

What causes HELLP syndrome?

Arteriolar vasospasm + endothelial cell dysfx --> Have fibrin deposits & adherence of platelets in BV

Pregnancy Category B medications

B = Be careful Animal studies have revealed no harm of fetus but there are not well-controlled studies for pregnant women OR Animal studies show adverse effects but studies on pregnant women fail to demonstrate risk to fetus at anytime in trimester Basically these drugs are OK but we still want to be cautious ---> Don't want to take any drugs are are not needed Ex: • Insulin ---> Take it because it's needed

Care for pregnant women w/ chronic HTN

Ideally care begins before conception ---> Limit salt intake ---> Frequent prenatal visits ---> Inc fetal surveillance ---> Week BPP ---> Freq US ---> NSTs 2x/wk (starting in 3rd trimester) ---> Encourage rest

Mild preeclampsia

BP: ≥140/≥90 Proteinuria (+1-+2) ••• >3 g/ 24 hr urine Weight gain & edema (no longer part of the criteria for it)

Severe preeclampsia

BP: ≥160/110 Proteinuria 3+ ••• >5 g/ 24 hr urine Weight gain, facial edema, pitting pretibial edema (Not required for diagnosis but often accompany PIH) *CNS irritation:* • Hyperreflexia • Severe headache • Visual changes ( "Little sparklers") Oliguria (< 30 mL/hr) Epigastric pain (bc of portal HTN) Abnormal labs (such as thrombocytopenia & abnormal LFT)

3 methods to detect ovulation

Basal body temp charts Cervical mucus charts Ovulation predictor kids

Pregnancy Category C Medications

C = Caution Animal studies have shown adverse effect but there are no good studies on pregnant women OR No good studies have been done on animals or pregnant women Most drugs are category C --> Looks at risk vs benefit Ex: • Tylenol --> Lots has come out saying you should not taking Tylenol while pregnant unless you have a bad fever or really really bad h/a that won't go away

Male infertility causes (*Health issues*)

Genetic illnesses like CF or chromosomal abnormalities, DM, & autoimmune d/o that target sperm can affect fertility Obesity in men can affect sperm Mumps as an adult can damage testicles where they are not able to produce sperm

Why is it so important to discover & treat molar pregnancies early?

If the pregnancy is left alone, the grape like clusters will dev into VERY INVASIVE, METASTATIC CANCER

A client who is undergoing ovarian stimulation for infertility with menotropins calls the infertility nurse and states, "My abdomen feels very bloated, my clothes are very tight, and my urine is very dark." Which of the following is the appropriate statement for the nurse to make at this time? A. "Please take a urine sample to the lab so they can check it for an infections." B. "Those changes mean that you will menstruate within the next 3 days." C. "It is important for you to come into the office to be examined today." D. "Abdominal bloating is an expected response to the medications."

C. "It is important for you to come into the office to be examined today." These are S&S of overstimulation of ovaries which is a medical emergency

A woman diagnosed with an ectopic pregnancy is given an IM injection of methotrexate. The nurse tells the woman that A. Methotrexate is an analgesic that relieves the dull abdominal pain that she is experiencing B. Only one dose of methotrexate is necessary. C. Follow-up blood test are required for 2 to 8 weeks after the injection of the methotrexate. D. She should continue to take her prenatal vitamins to promote healing.

C. Follow-up blood test are required for 2 to 8 weeks after the injection of the methotrexate. Must continue to monitor ß-hCG levels to ensure pregnancy is finished ---> May need to give more than 1 dose if it's not

Partial & complete placenta previa usually require what kind of delivery?

C/S BECAUSE as the cervix dilates, placenta peels off so you have *bleeding from fetal side as cervix opens*

Types of HTN disorders in pregnancy

Gestational HTN Preeclampsia (pregnancy induced HTN) Eclampsia Chronic HTN before pregnancy ---> At risk of dev superimposed preeclampsia HELLP

A client at 36 weeks of gestation presents to labor and delivery complaining of a constant headache for the past 2 days. She also states that her face "seems more swollen than usual." What should be the nurse's first action? A. Obtain a urine sample. B. Place the client on a fetal heart monitor. C. Notify the physician of the client's concerns. D. Take the client's blood pressure.

D. Take the client's blood pressure. ---> #1 thing you should do It's important to notify HCP but first thing they will ask for is what their BP is ---> Get BP ---> Get urine sample ---> Notify HCP

Pregnancy Category D medications

D = Do not use Adequate studies in pregnant women *HAVE shown risk to fetus* However, benefits of therapy may outweigh risks in rare cases ex: Life threatening situation or serious disease when safer drugs can't be used or are ineffective --> If mom dev CA during pregnancy, we have to keep the CA under control or else we lose mom AND baby ---> We will treat CA during pregnancy w/ *the least harmful meds possible* *If we know the drug causes fetal organ development problems then we won't use it during 1st trimester*

Magnesium sulfate (Side effects for fetus)

Dec FHR variability Respiratory depression at delivery May be hypotonic Dec suck reflex

FHR with placental abruption

Deep, prolonged variables Dec variability Late decels

Goal of HELLP tx

Delivery baby safely May need to do platelet replacement

A nurse is providing instruction to a couple undergoing zygote intrafallopian transfer (ZIFT). The nurse is aware that instruction has been effective when the woman states: A. "My egg will be fertilized and then placed into my uterus." B. "My husband's sperm will be inserted into my uterus." C. "My husband's sperm and my egg will be placed into my fallopian tube." D. "A fertilized egg will be placed into my fallopian tube."

D. "A fertilized egg will be placed into my fallopian tube." Answer A describes IVF Answer B describes IUI Answer C described GIFT

Female infertility causes (*smoking/alcohol*)

Inc risk of ovulation issue Inc risk of miscarriages

Hypothalamic-pituitary-gonadal axis & fertility

The hormones for reproduction must be in the right order to allow for ovulation & in order to make sperm Body must also have an appropriate response the hormones (gonadal response) There must be an intact structural system ---> Blocked vas deferens, infection, etc. leads to infertility

Oocyte & embryo donation

Women can donate eggs & fertilized embryos

Risk factors for placenta previa

• Smoking • Cocaine use • Multiparity • Infertility tx (drugs that promote ovulation) • Hx of recurrent abortions • Prior uterine surgery, uterine scarring • ≥ 35 yrs • Short interval between pregnancies (1-*2* yrs recommended) • Multiple gestation (Lg placenta surface area) • Non-white ethnicity • Erythroblastosis

What kind of meds can be given to men to help w/ fertility issues?

• Thyroid/pituitary hormones • Viagra (for impotence) • Abx (for infections) • OTC cold med like Sudafed (for retrograde ejaculation) • *Folic acid & zinc supplements prior to conception*

Antidote for magnesium toxicity

TURN MAG OFF Give 1 g of calcium gluconate IV

Inevitable miscarriage

There's nothing we can do to stop the miscarriage ----> It is in the process ----> Cervix is open & dilated

Placental abruption tx

This is a medical emergency ---> Need STAT C/S LABS: • CBC • DIC panel • H&H • Platelets • pTT RhoGam if mom is Rh- *Women who have placental abruption are at high risk for PPH ---> Must continue to monitor them*

Risks for fetus to mom w/ PIH

• Dec placental perfusion • Growth restriction • Inc risk for abruption • Preterm birth • Perinatal mortality

Common risk factors for PIH

• Primigravidity in women ≤ 19 yrs or ≥ 40 yrs • First pregnancy w/ new partner • Hx of preeclampsia --> Family hx can affect it too • Pregnancy onset snoring • Obesity, pre-exisiting DM, Development of molar pregnancy

Ectopic pregnancy

Fertilized ovum is implanted outside of uterine cavity "Tubal pregnancy"

Abruptio placentae / placental abruption

Premature separation of placenta from implantation sight after 20 wks

Postpartum care of woman w/ HTN d/o

For most (PIH, eclampsia, HELLP), the cure is getting baby & placenta delivered Monitor VS, DTRs, LOC ----> 30% of eclampsia & HELLP syndrome occur PP These women are unable to handle excessive blood loss ---> Empty bladder q2h & massage fundus to prevent PPH

Aside from proteinuria, what are other symptoms of preeclampsia?

HTN plus: • Thrombocytopenia • Impaired liver function • New dev of renal insufficiency • Pulmonary edema • New-onset cerebral or visual disturbances

Methods of assessing female fertility

• Detection of ovulation • Hormone analysis • US • Hysterosalpingogrpahy: Where HCP puts in dye & looks to see if dye goes into Fallopian tubes ---> Assess for latency & intactness of fallopian tubes w/ Xray • Hysteroscopy: Going up into uterus to look at it • Laparoscopy: Make small incision in abdomen ---> Look at outside of uterus, ovaries, & fallopian tubes ---> Checks for endometriosis

Female infertility causes (*Fallopian tubes*)

• Endometriosis, STIs, PID --> Cause scar tissue w/ in fallopian tubes • Previous ectopic pregnancies

Female infertility causes (*Vaginal/cervical*)

• Excessive mucous can make it so that sperm cannot pass thru vaginal canal • Prior cervical surgical procedure can cause excessive scar tissue to form *Can be treated w/ intrauterine insemination to bypass cervix* • If woman's pH is off, it can make it hard for the sperm to survive & get to egg

Female infertility causes (*Uterine problems*)

• Fibroids (Scar tissue-like growths) • Congenital abnormalities that preclude woman from getting pregnant

Complications from molar pregnancy

• Hemorrhage • Infection • PIH • Hyperthyroidism • Cancer • High risk for dev it again in future pregnancies

Maternal blood loss inc risk for what conditions?

• Hypovolemia • Anemia • Infection • Preterm labor • Impaired O2 to fetus

Ectopic pregnancy tx

• If it's early enough, HCP (NOT NURSES) can offer methotrexate or RUA42 • Surgical: Laparotomy (Removal of damaged fallopian tube)

Hydatidiform mole (Molar pregnancy ) diagnosis

• ß-hCG are *exceptionally HIGH* • Transvaginal US: "Looks like snow"

beta hCG & miscarriage

If woman is not bleeding too much we can go ß-hCG counts hCG should double q48hours ---> *Falling hCG indicates miscarriage* ----> Counts that stay the same indicate miscarriage or ectopic pregnancy

How do we treat hydatidiform moles?

Immediate suction & curettage ---> Dilate uterus & suction out all grape like clusters, scrape uterus If mom has molar pregnancy + living fetus, we will deliver fetus early & D&C mom

Why is it easier to put a cerclage in BEFORE cervix dilates?

It is harder to perform the procedure w/o breaking the BOW

Male infertility causes (*hormones*)

Low hormone levels can cause problems --> Ex: Low testosterone Pituitary & thyroid hormones can cause problems as well

Incomplete miscarriage

Miscarriage has occurred but there are still fetal parts inside of mom (small bits of placenta, bag of water, etc.) *These women are at very high risk for hemorrhage & may need cervical dilation & curettage* ---> Promotes rest of miscarriage

Septic miscarriage

Miscarriage where infection has occurred

Maternal & fetal complications re: placental abruption

Mom can have hemorrhage DIC may occur to stop bleeding

Threatened miscarriage

Mom has bleeding & there is the possibility that miscarriage will occur *but she hasn't yet* Amount of bleeding is not necessarily indicative of whether miscarriage will occur *Any bleeding is threatened as long as cervix remains closed* ---> Once cervix starts opening & dilating then it becomes inevitable

Care management of placenta previa

Monitor VS & bleeding May have to do C/S ---> Cut thru placenta (very short C/S) ---> Up & down incision to avoid going thru placenta *Be aware that if mom is Rh-, she is at high risk for being sensitized & needs RhoGam* ---> May need blood transfusion as well AND REMEMBER: NOTHING IN THE VAGINA

Substance abuse & smoking

Alcohol, smoking tobacco, cocaine, & steroids dec sperm count

With very long cord you're at risk for...

Nuchal cord ---> Cord wraps around baby's neck ---> Usually not a problem if it's loose

placental abruption classifications

Classified on amount of bleeding >> Grade 1 = mild >> Grade 2 = moderate >> Grade 3 = severe

What female infertility drugs are used most often & what side effects must you watch out for?

Clomid & Pergonal/hMG/menotropins *Abdominal & bloating w/ quick onset is a medical emergency* ---> Overstimulation of ovaries

Complete vs partial hydatidiform mole

Complete = NO embryonic or fetal parts ---> Only grape like clusters in uterus Partial = Fetal or embryonic parts w/ amniotic sac ---> Very rare ---> Thought that mom was pregnant w/ twins & only one dev into molar pregnancy

Complete miscarriage

Complete expulsion of ALL products of conception You do an US & everything is clear

Assisted reproductive therapy (ART)

Fertility treatments in which both egg & sperm are handled

Missed miscarriage

Fetus has died but has not been expelled There are usually no signs that miscarriage has occurred until we do an US & notice there is no FHR or we caught HR before but cannot now *If miscarriage occurs after 10 wks the mom at very high risk for hemorrhage if she miscarries on her own* If it has been *more than 4 wks* since fetal demise then the woman is at greater risk for *DIC*

Oligospermia

Few sperm cells produced (< 20 million/mL)

cerclage & cervical insufficiency

Early dilation can be treated w/ cervical or abdominal cerclage ----> Stitching up the cervix to keep fetus in ----> Cerclage is removed before delivery (usually ~36 wks) Can be put in place prophylactically or as a rescue procedure after dilation has begun Woman is often placed on bed rest until cerclage is paced to prevent pressure on cervix

Male infertility causes (*Ejaculation problems*)

Erectile dysfx Premature ejaculation ED: Can be caused by psychological problems, physical problems (DM, HTN, high cholesterol, heart disease) ---> Can also be cause by medications (antidepressants, certain antihypertensive meds, etc.) Retrograde ejaculation ---> Semen doesn't come out of penis --> instead it enters the badder ••• Found in some men w/ DM, certain meds, surgery to bladder/prostate/urethra•••

Diethylstilbestrol

Estrogen derivative used in 1980s/1990s Women exposed to it while in utero have more problems w/ cervix as adults

A woman comes into the triage because of bright red blood from her vagina. She is 22 wks pregnant. The nurse knows the best way to check the woman is w/ a vaginal exa m to visualize placenta is front of cervical os. t or f

FALSE!!!! ---> If a woman presents with ANY kind of bleeding in late trimester *DO NOT DO A VAGINAL EXAM* Nothing should go into vagina ---> Transabdominal US should be done instead

Nursing care for pt w/ ectopic pregnancy

Fallopian tube can rupture VERY easily *Take care of risk for bleeding FIRST* Do VS q15min Look for pallor, diaphoresis, early signs of shock Will need O2, IV Will need RhoGam 48-72 hrs after tx

Ohio laws say that nurses can give medications to end a pregnancy as long as the miscarriage is inevitable t or f

False Ohio laws say that only doctors can give medications to end pregnancies Not even nurse practitioners can give these meds

Bedrest is the best thing for a woman miscarrying or at risk for it t or f

False There is no evidence that bed rest will prevent miscarriage ---> If there are problems with the fetus, it will miscarry no matter what HOWEVER, saying no heavy lifting or sex is OK

You should question to a HCP's order to heparin in a pt suffering DIC t or f

False: Low dose heparin can be order to prevent fine clots from continuing to grow as you treat DIC

Clomid

Female infertility drug *ovulatory stimulant* >> Often used in women w/ PCOS

HTN causes morbidity & mortality in pregnancy mostly because of what 2 consequences?

placental insufficiency premature birth

Bleeding & pain of molar pregnancy

prune juice bleeding Painless

Basal body temperature & ovulation

Woman uses the basal body thermometer everyday --> Does an oral temp *BEFORE getting out of bed in the morning* ---> Taking temp after moving around will throw off results OVULATION: • When the temp falls & then sharp rises --> Ovulation occurs within that sharp rise

Nursing care after miscarriage

• If the miscarriage happened after 10 wks or it was a missed miscarriage < 4 wks then pt qualifies for D&C • Provide support • If mom was Rh- & the pregnancy *≥6 wks* or we had a heartbeat, will give RhoGam within 72 hrs PRIMARY NURSING CARE IS TO MONITOR BLEEDING

How to diagnose ectopic pregnancies

• Quantitative ß-hCG levels ---> Lower than we what we would expect for age or pregnancy ---> Levels don't rise OR fall • Transvaginal US ---> Can see that there's nothing in uterus • Progesterone level ----> Can be examined but not the main method

What complications can HTN in pregnancy cause the mother?

• Renal failthure • Coagulopathy • Cardiac or liver failure • Placenta abruption • Seizures • Stroke *Pregnancy related HTN causes 10-15% of maternal deaths worldwide*

succenturiate placenta

Type of vasa previa Placenta is divided into 2 or more lobes ---> 1 lobe is for baby, 1 lobe is accessory RISK: We may not know 2 lobes exist & may deliver one, leaving the other behind ----> *INFECTION* ----> This is one of the reasons nurses don't do ROM anymore

What labs might you see in a mom w/ PIH?

• Inc Hct (>35%) • Inc uric acid/ BUN • Inc liver enzymes ---> Esp AST & ALT ---> AST > 70 in HELLP • Dec RBCs & platelets (<100,000) ----> Platelets will initially bc OK but drop significantly w/ HELLP • Inc fibrinogen ----> Inc risk for clots • Dec albumin • Inc creatinine *These labs all have to do w/ dec perfusion or liver & kidneys & the fluid leaking out of BVs*

Clinical manifestations of ectopic pregnancies?

Typically occur 6-8 wks after last normal period: • Pain ---> In one side of abdomen ---> Pain in shoulder of affected side d/t referred pain from blood in abdomen • Delayed menses • Abnormal vaginal bleeding ---> Very light spotting, not the usual heavy bleed of miscarriage • May present w/ dizziness, fainting & shock ----> They're having a huge loss of blood in the abdominal cavity (not coming out of vagina)

Experimental tests for IDing PIH

Tyrosine kinase (sFLt) & serum placenta growth factor Abnormal uterine a. Doppler velocimetry in 1st or 2nd trimester

What position helps w/ conception in a couple w/ subfertility?

Useful for cases like retroverted uterus (Uterus tips to back, cervix more anterior) Tell couple to have sex in any position but to make sure woman *lays on stomach for 20 mins after sex* ---> Allows the sperm & cervix to come into close proximity

Low-lying placenta previa

Usually identified early on in pregnancy & resolves on its own ---> Placenta itself does not really move but rather the lower 3rd of the uterus stretches more ---> Looks like placenta has moved but it hasn't ----> *Placenta is farther away from cervical opening*

Magnesium sulfate (Normal side effects for mom)

• Nausea • Flushing/diaphoresis, hot --> Get. afan • SOB • Dry mouth • Weakness --> Muscles are like wet noodles which is why we don't want them getting up • Headache • Blurred vision • Lethargy

Subfertility of both male & female

Accounts for 1/3 of all fertility issues w/ couples Both male & female have issue w/ fertility ---> Ex: Man not making enough sperm & woman not ovulating frequently Woman can have hypersensitivity to man's sperm Obesity can cause difficulty w/ sperm getting to woman's cervix

Female infertility causes (*Age*)

Age dec ability of women to have a baby bc the egg may not be released at regular intervals or health of egg may be declining As woman ages, she is more likely to have problems assoc w/ pregnancy Inc risk of miscarriages

HELLP syndrome

Variant of severe PIH that includes hepatic dysfx ----> When BP/PIH is unchecked, HELLP syndrome can develop WHAT YOU SEE: *H*emolysis ---> H&H dec ---> RBCs are destroyed as they travel thru constricted BV *E*evated *L*iver enzymes ---> Esp AST & ALT *L*ow *P*latelets ---> <100,000 bc of platelet aggregation at sites of injured endothelium ---> Dev thrombocytopenia *Fibrinogen is DEC in HELLP syndrome*

Semen analysis

Very easy way to assess male fertility. Very specific instructions: • Liquification occurs <1 hrs • Must be at least 2 mL of semen • Want at least 20 million sperm/mL • Want pH to be 7-8 Checking to make sure that there are enough sperm >> Want ≥ 30% to have normal morphology >> Want ≥ 50% moving in forward motion

Why is an inc H&H at 20 wks EGA a sign of PIH?

We have hemoconcentration of Hgb because the fluid is leaking out of vascular spaces d/t inc endothelial permeability >> Body is not hemodiluting to create the physiological anemia of pregnancy *Inc H&H is a red flag, want to keep an eye on these women*

velamentous insertion of cord

When cord vessels branch at membranes & then onto placenta rather than being directly implanted into placenta itself

subinfertility

When couple who is having regular intercourse w/ the desire to conceive has: • Inability to conceive after 1 yr • Frequent miscarriages FOR WOMEN ≥ 35 YRS: • Subfertility is inability to conceive after 6 mo EX: • Low sperm count • Vasectomy (can be reversed so not total sterility)

vasa previa

When fetal vessels lie over the cervical os & vessels are implanted into fetal membranes rather than into placenta itself

Cervical insufficiency

Premature dilation of cervix ---> Typically a 2nd trimester issue ---> These women are typically ~16-22 wks along Dilation is painless & passive ---> The fetus is developing fine but the body cannot hold it in Can be congenital or acquired (infection, cervical trauma, multiple fetuses)

Bleeding & pain of placenta previa

Bright red blood Painless

Bleeding & pain of miscarriage

Bright red blood (unless it's old blood) Can be painful or painless

Magnesium sulfate

Prevents *seizures* ---> Goal is not dec BP ---> Interferes w/ Ach release to dec neuromuscular irritability, cardiac conductibility, & CNS irritability LOADING DOSE: •• 4-6 g/100 mL IV over 15-30 mins CONTINUOUS INFUSION: •• 2 g/hr in 100 mL --> *continue up to at least 24-48 hrs after delivery* THERAPEUTIC LEVEL: •• 4-7 mEq/L

Clinical manifestations of *concealed* bleeding or central abruption

Concealed abruption = bleeding where edges are all sealed but bleeding is occurring (even if you can't see it) ---> FHR is affect & mom's complaints match that of abruption •• May be LITTLE or NO bleeding •• Mom complains of SEVERE pain If you touch the uterus where concealed bleeding is, it is HARD as a ROCK (Boardlike abdomen, couvelaire uterus) Painful bleeding is disproportionate to contractions

What population of pregnant woman is more at risk for gestational HTN?

Primaps Those w/ more than 1 fetus

Placenta previa

When the placenta implants on the lower uterine segment near or over the cervical os 3 types: • Low-lying placenta • Marginal placenta previa • Complete placenta previa *Typically presents w/ painless bleeding*

battledore (marginal) insertion of cord

When the umbilical cord inserts at the edge of the placenta Problems if we have inc risk of fetal hemorrhage & poor growth d/t dec perfusion of placenta Fetus can also pull & tug at cord when moving around --> Risk of placental abruption by fetus lifting up edge of placenta

Partial placenta previa

Where part of placenta or edge of placenta is over cervical opening

Complete placenta previa

Where placenta is right smack dab over cervical os

Pergonal/Pepronex (Human menopausal gonadatropins (hMG)) & menotropins

Female infertility drug >> Often used in women who don't ovulate d/t pituitary problems >> *Acts directly on the ovaries to stimulate them* >> Injected

Metformin

Female infertility drug >> Used in women w/ insulin resistance or PCOS Does not cause ovulation but does lower high levels of male hormones found in women w/ these conditions Promotes favorable environment for ovulation

FHS/GnRH/hCG

Female infertility drug >> Used rarely except in fertility clinics

Parlodel

Female infertility drug Not used often anymore bc of risk for stroke

For a couple that is struggling to conceive, how often might a HCP recommend having sex?

No more than 1x/48 hr period

Azoospermia

No sperm cells produced

Female infertility causes (*Weight)

Obesity can cause too much exogenous estrogen to be stored in adipose tissue Severely underweight women may not have enough exogenous estrogen >>> Excessive exercise = burning off extra fat ----> Interferes w/ estrogen ----> May not have any periods at all d/t low body fat

S&S of HELLP

Often nonspecific, flu-like symptoms • Hx of malaise • Influenza-like symptoms • Muscle aches • Unexplained bruising • N/V • Epigastric pain or RUQ pain *Symptoms seem to worsen at night & improve during the day* May not see much change in BP between PIH & HELLP

Eclampsia

PIH that progresses to seizures Main goal is to keep mom safe ---> Maintain patent airway ---> Stabilize mom

Disseminated intravascular coagulation (DIC)

Pathological form of diffuse clotting that consumes lg maroons of clotting factors ---> Causes widespread external & internal bleeding NEVER A 1º DIAGNOSIS ----> Always the result of something else *To treat DIC, you must treat the underlying cause*

Bleeding & pain of placental abruption

Portwine though it can be bright red depending on its site Painful (unless it's just the edge of the placenta)

What is atypical preeclampsia?

Preeclampsia that can dev anywhere up to 4 wks after delivery Very rare tends to be more dangerous than typical preeclampsia

Miscarriage (Spontaneous abortion)

Pregnancy that ends before 20 wks EGA d/t natural causes ---> *any bleeding at 10-12 wks = risk for bleeding* ---> High progesterone can cause spotting after intercourse but this is brownish (OLD BLOOD) TYPES: • Threatened • Inevitable • Incomplete • Complete • Missed • Recurrent • Septic

What are 2 tests we KNOW can indicate HTN issues w/ pregnancy?

Quad screen w/ elevated inhibin A Elevated H&H at 28 wks

What might cause a cerclage to need to be removed before 36 wks?

S&S of infection S&S of premature labor *Important that we educate the woman on what to watch out for*

Care management for woman w/ severe gestational HTN or preeclampsia w/ severe features

Severe features = risk for seizures Will likely be monitored in hospital Will likely be on magnesium sulfate Mom is on bedrest w/ side rails up --> Mag sulfate will make her tired and weak Have a quiet, darkened environment May be on antihypertensive meds ---> Hospitalized = IV antihypertensives

How do you diagnose cervical insufficiency?

Speculum/digital pelvic exam Transvaginal US --> See that internal os is dilating Cervical funneling: Internal os is dilating, only thing holding fetus in is the external os

Timing & fertility

Timing is very important: • Sperm live 48-72 hrs but best time for fertilization is first 24 hrs • Egg lives 24 hrs, maybe 48 hrs for some ====> Egg is best fertilized 1-2 hrs after being released for ovaries

Sterility

Total inability to conceive The only people who are really sterile are those who no longer have the organs needed to conceive ---> EX: Hysterectomy

Recurrent miscarriage

Traditionally means ≥3 miscarriages in a row or an unusually high # of miscarriages

Intrauterine insemination (IUI)

Type of ART Collecting the man's sperm & releasing it up inside, close to uterus during ovulation Commonly used w/ male infertility, women who have problems w/ cervical mucus, or couple w/ unexplained infertility

In vitro fertilization-embryo transfer (IVF-ET)

Type of ART Egg & sperm are put together in Petri dish & fertilization occurs in the dish *3-4 days later, embryo is placed in uterus*

Intracytoplasmic sperm injection (ICSI)

Type of ART Inject sperm into egg --> Help w/ assisted hatching & preimplantation *in doing this, they can test embryo before it's implanted to make sure it has no genetic issues*

Zygote intrafallopian transfer (ZIFT)

Type of ART Petri dish fertilization where the *zygote is immediately transferred to Fallopian tube*

Gamete intrafallopian transfer (GIFT)

Type of ART Put egg & sperm separately into Fallopian tubes at the same time & hope they find each other

Placenta previa is differentiated from placenta abruption by....

Type of bleeding Uterine tone Presence or absence of pain

Pregnancy category X medications

X = Death Adequate well controlled studies in pregnant women or animals have shown evidence of fetal abnormalities ---> We KNOW we will have birth defects, fetal abnormalities, etc. Use of any meds in this class are absolutely contraindicated ---> *THERE IS NEVER ANY REASON TO USE THESE DRUGS DURING PREGNANCY* Ex: • Thalidomide ---> Caused flipper like limb abnormalities ---> Still on market but only for certain skin CA ---> NEVER used on pregnant woman • Birth control ---> Doesn't cause fetal abnormalities but there is absolutely NO reason to prescribe it during pregnancy

circumvallate cord

You have a small fetal surface of the placenta exposed thru ring of chorion & amnion opening around the cord Instead of the BOW originating from edge of placenta, it originates from the middle Problem is not bleeding ---> Not enough of a fetal surface area of placenta exposed ---> *Baby doesn't get enough blood flow & so doesn't grow well* Inc risk of fetal loss w/ this condition Membranes have double back & haven't grown appropriately from edge of placenta

Placenta previa clinical manifestations

• Painless, *BRIGHT RED* vaginal bleeding ----> Fresh arterial blood • Typically happens during 2nd or 3rd trimester • Woman may experience anemia or shock ---> Depends on how bad bleeding is & how much damage has been made to placenta edge

Clinical manifestations of placenta abruption w/ visible bleeding

if you have a little bleeding at edge of placenta, you will have VISIBLE BLEEDING FROM CERVIX ---> *Bleeding is PORTWINE, may be bright red* HOWEVER mom is NOT in much pain Complete abruption = PROFUSE HEMORRHAGE

placenta accreta

invasive placenta Seen more in women w/: • Multiparity • Placenta previa • Endometrial defects • Scarring of uterus • ≥ 35 yrs • Scarring from C/S sites * BIGGEST PROBLEM IS PPH *

What med can you give (if there is not FHR) to help pass fetal pats w/ miscarriage?

misoprostol (Cytotec)

Proteinuria is a later sign of PIH t or f

true

low dose aspirin (60-80 mg) may be prescribed for a woman w/ hx of PIH next time she gets pregnant t or f

true --> Evidence is kind of wish-washy on it though

Female infertility causes (*Ovarian problems*)

~40% of infertility is d/t problems of the woman • Hormonal problems ---> Ovaries don't respond correctly • PCOS • Problems w/ ovulation

What things should be constantly assessed with a woman who has PIH?

• BP • Edema • DTRs • Clonus • Proteinuria • S&S of severe PIH (h/a, epigastric pain or RUQ pain, visual disturbances)

Fetal risks from maternal blood loss

• Blood loss & anemia • Hypoxemia (Lack of a little bit of O2) • Hypoxia (Lack of a lot of O2) • Anoxia (No O2 at all) • Preterm birth --> *Placenta doesn't get perfused bc of dec blood volume --> fetus doesn't get O2*

Risks for mom w/ PIH

• Cerebral vascular accident (CVA) • DIC • Renal failure • Hepatic rupture • Pulmonary edema • CHF

Reasons for miscarriage in 1st trimester

• Chromosomal abnormality • Placental problems • Teratogen exposure, medications • Infections, trauma • Chronic illness • Implantation d/o • Endocrine d/o • Inheritable blood clotting d/o ----> Leiden V, lupus, MWF diease

Clinical manifestations of molar pregnancy

• Chronic anemia from blood loss • Excessive N/V (hyperemesis gravidarium) ---> These moms can't hold anything down, need IV fluids • Abdominal cramps • *Prune juice bleeding* ---> May even pass grape like clusters • Preeclampsia before 20 wks ---> They have the h/a, edema, HTN, etc. ---> *if we see signs of TRUE PIH before 20 wks, we need to think hydatidiform mole* • *Most generally, there are NO FHTs*

Once a hydatidiform mole has been removed, what follow-up care Is necessary?

• Closely monitor mom for CA • Monitor ß-hCG for 1 yr (draw monthly) • *Woman should NOT get pregnant for 1 yr*

Signs of magnesium toxicity

• Dec RR (<12 bpm) • Absent DTRs • Pulmonary edema • Severe hypotension • Altered LOC • Extreme muscles weakness • Cardiac dysrhythmias • Oliguria (<30 mL/hr) Magnesium level of ≥ 12 mEq/L = risk for cardiac & respiratory arrest

What does the endothelial cell dysfx with PIH cause?

• Vasospasms not only in placental vessels but other vessels throughout body • Inc peripheral resistance --> Inc BP • Endothelial cell permeability --> Causes leaking of BV which leads to edema *CAUSES DEC TISSUE PERFUSION* --> Because we have inc endothelial permeability & dec perfusion we have kidneys dumping protein --> Dec albumin inc edema (not protein in vascular space to pul fluid back in)

At what age is a woman at risk for a molar pregnancy?

≤ 15 yrs or ≥ 45 yrs