Quiz 5 ob

Perimenopause

Average age at onset in the late 40's Irregular menstrual cycles Somatic and psychological symptoms may emerge perimenopause (most is late 40s) is not menopause, period or transition from no time to 10 years. menstural cycles may be more irregular, they may experience mensturation changes, more spacing out, quality of mensturation changes. a lot of ppl will experience big range of somatic and psychological symptoms, but some ppl wont. someone will not be *diagnosed with menopause unless its been no period for a whole year.*

heavy show

it's normal, even in late pregnancy. some bleeding.

Common Complications of the IDM

*Hypoglycemia*- After birth, infant continues to produce high levels of insulin causing hypoglycemia. (it makes sense that it is hypoglycemia right after birth, before it had so much glucose, so the body is pumping out insulin, and it only have access to normal level of glucose after birth, but the pancreas is used to have more insulin, so the baby's sugar will have hypoglycemic crash. although babies will adjust, but still at risk of hypoglycemic crash. ) *Hypocalcemia*- b/c people w/ DM generally are low in Calcium (issue for ppl who is in active diabetic state. ) *Birth Trauma*- b/c of size *Hyperbilirubinemia*- b/c of immature liver (for people are in poor diabetic control, some development are delayed, like their lung maturation is delayed, and liver maturation is delayed. There is an increased risk of jaundice for baby.) *Respiratory Distress Syndrome (RDS)* ---Tachypnea- more than 60 respiration in a minute ----Apnea- episode of non breathing for more than 20 seconds (*lung maturation* and neural maturation more of an issue related to someone already diabetic before preg) *insulin antagonizes surfactant production* *Congenital birth defects*- Skeletal/Cardiac (ex: sacral agenesis) Pink & Fat HYPOGLYCEMIA During gestation high levels of maternal glucose cross the placenta and the fetus responsively increases insulin production leading to hyperplasia of pancreatic beta cells. After birth, infant continues to produce high levels of insulin causing hypoglycemia HYPOCALCEMIA If IDM is premature; if the pregnancy, labor, or birth was stressful; if maternal serum magnesium level was decreased causing secondary hypoparathyroidism in the infant BIRTH TRAUMA Related to LGA size HYPERBILIRUBINEMIA Occurs if decreased extra-cellular fluid volume increases hematocrit level; if hepatic immaturity is present; if hemorrhages from birth must reabosrb RESPIRATORY DISTRESS SYNDROME Insulin antagonizes cortisol-induced stimulation of lecithin synthesis necessary for lung maturation. There is also a decrease in the phospholipid phosphatdylglycerol (PG) which stabilizes surfactant. Therefore IDMs may have less mature lungs than expected for the gestational age. (NOTE: Infants born to diabetic mothers in White's classes D-F have increased production of steroids due to the stresses of poor uterine blood supply and are not LGA) CONGENITAL BIRTH DEFECTS May include transposition of the great vessels, ventricular septal defect, patent ductus arteriosus, small left colon syndrome, & sacral agenesis

Labor Induction vs. Augmentation

*Induction*: stimulating contractions to achieve effective labor pattern via medical intervention *Augmentation*: enhancing ineffective contractions after labor has begun *Indications: prolonged gestation, prolonged premature rupture of the membranes, gestational hypertension, cardiac disease, renal disease, chorioamnionitis* (inflammation of the fetal membranes (amnion and chorion) due to a bacterial infection), *dystocia* (difficult birth, large baby, bad position), * intrauterine fetal demise, and diabetes* when deciding if someone needs to be induced, its when someone is not in labor, and the best plan was for the person to be in labor, a lot of times thats not how pitocin is used. Most of the time, pitocin is used in augmentation, especially like when a person gets an epidural. *Augmentation happens when already in active labor,* and then contractions are ineffective or not effective enough, thus intervention or meds are used to help, simply *breaking the water* would be an augmentation.

low, med, high risk for pph

*Low (clot only)* - *no uterine incision* - *single pregnancy* - < or = previous vaginal births - no known bleeding disorder - *no history of PPH* *Med (type and screen)* - *prior c/s birth(s) or uterine surgery* - *multiple gestation* - >4 previous vaginal births - chorioamnionitis - *history of previous PPH* - large uterine fibroids - estimated *fetal weight greater than 4 kg* - morbid *obesity (BMI>35)* *High (type and crossmatch)* - *placenta previa, low lying placenta* - *suspected placenta accreta *(blood vessels and other parts of the placenta grow too deeply into the uterine wall) or *percreta *(part or all of the placenta remains firmly attached. This can cause severe blood loss after delivery) - *hematocrit <30* and other risk factors - *platelets <100,000* - Active bleeding (greater than show) on admit - Known *coagulopathy* pitocin at 3rd stage is to reduce post partum hemmorrhage 1st thing when there is PPH, primary nurse calls in the resources and the team (mobilization). give 2nd IVs, give meds.

Menopause

*Ovaries become less responsive to FSH and LH* Patterns of GnRH release from the hypothalamus become altered Pituitary gland becomes less responsive to GnRH The body responds by releasing more FSH before perimenopause is completed ovaries becomes less responsive to these hormones that tells it to ovulate, thus, *body in response makes more hormones (FSH) to stimulate ovary to do one more cycle, thus people may experience menopause symptoms. In menopause its where ppl have higher levels of hormones (higher FSH) trying to stimulate the ovary.*

Abruptio Placenta

*Premature separation of a normally implanted placenta from the uterine wall* *Hemorrhage can be completely concealed or obvious!* A leading cause of fetal and neonatal mortality placenta will pop up from the side of uterus, can be partial or complete, the difference here is that you dunno when this will happen, *no ultrasound that will tell you, not predicable.* the *first sign is also changes in the fetal heart rate,* because there is less blood going to the baby thru umbilical cord. At the same time, the preg is also actively going thru *blood loss, eventually goes into hypovolemic shock* you don't always see external bleeding, it will start collecting blood bubble in the back of placenta, a lot of times its not complete (not everything pops out), it's normally partial

Factors that may affect timing of menopause

*Smoking* *Genetics* *Body mass* things that can occur for early menopause is smoking, a genetic component, someone with more adipose tissue will make menopause occur later.

Signs and Symptoms of RDS

- Difficulty in establishing normal respiration, especially if infant has risk factors for RDS - *Expiratory grunting* while the infant is not crying - *Intercostal and sternal retractions* due to increased rib cage compliance and decreased lung compliance how do you know if newborn has rDS? it looks like infant has trouble breathing, newborn care postpartum, will have alot of grunting and initial respiratory transition. you dunno in this initial time they will convert to breathing or not. *retraction with collar bone (skin sinking in with breathing), cyanosis face+core not extremeties, and nose flaring.*

"Weak" Cervix ("Cervical Insufficiency, Incompetence")

- *CERCLAGE* (cervical stitch, is a treatment for cervical incompetence or insufficiency) - MONITOR UC'S, FHR - OBSERVE FOR R/M - BEDREST, ACTIVITY RESTRICTIONS - *TOCOLYTICS, PROGESTERONE INJECTIONS* - EDUCATION RE: LABOR SIGNS - RISK FACTORS: Cervical procedures, history of 2nd trimester SABs cervix is not holding together for as long as it needs to, it starts to dilate and soften before term, or it needs to. Usually use a cervical cerclage (stitch with heavy duty things, to hold the cervix together) often in early pregnancy it is hard to capture. very high risk for preterm and prebirth. may be asked to use tocolytics (drugs to stop contractions) they cannot hold off labor indefinitely, but they can quiet a burst of contractions. For some ppl progesterone injection can decrease chance of miscarriage in early gestation Risk factors: if someone had a procedure with cervix, removing a sig. portion of it, like cervical cancer, they will have higher risk. Someone who had previous losses related to cervical infections.

GDM: Pharmacological Rx

- *Insulin: does not cross placenta;* safe use ---Set dose or sliding scale (usually given a sliding skill, testing glucose at home, and figure out what to do with insulin based on result, ppl who use insulin during preg, uses insulin drip on labor) - *Oral hypoglycemic: may cross placenta* ---Some are safe to use during pregnancy ------Glyburide (maintenance dose 1.25-20 mg/day) ------Metformin (maintenance dose 2000-2500 mg/day)

Septic Abortion

- An abortion, spontaneous or planned, resulting in uterine infection (usually with pathogens from bowel and/or vagina) - Was leading cause of maternal mortality in US before Roe v. Wade - Staph, strep, Escherichia coli - Fever, chills, foul-smelling discharge - Results in endometritis, septicemia (blood poisoning), acute renal failure, septic shock (sepsis, which is organ injury or damage in response to infection, leads to dangerously low blood pressure and abnormalities in cellular metabolism.) serious infection of the uterus like *endometritis* related to an abortion. usually normal bacteria, like staph or e. coli, it is the leading cause of maternal deaths. it is related to lack of access to abortion services. potentially fatal, ppl can go into shock really quick, and die.

Placenta Previa

- Complete previa: the placenta completely covers the os; 20%-43% of previa presentations - Partial Previa: placenta partially covers os - 31% - Marginal Previa: placenta edge less than 2 cm from internal os - "Low-lying Placenta": placenta in lower segment of uterus but appears to be at least 2 cm from cervical os if its completely over cervical os, this is complete, partially over the cervical os, it is partial. marginal, it is anywhere within 2 cm of internal os. it's all about the ultrasound. we are not confident if there is no previa unless ultrasound said that the very edge is at least 2cm away from os. *low lying placenta*, something else noted on the ultrasound report, shows that it is at least 2 cm away but looks kind of low, this is *allowed to go into labor.*

Missed Abortion

- Death of an embryo/fetus without signs or symptoms of pregnancy loss - Products of conception may be retained for several weeks. - Inappropriate uterine size? - Absence of FHT's - Subjective loss of pregnancy symptoms (N/V, breast tenderness, fatigue) - hCG not rising Confirmed with US - Evacuation/suction/curettage/cervical dilators (ex: laminaria) preg ended, the product has all bee retained in uterus, and missed for a period of time. this is usually discovered after a visit. The preg stopped developing at a point, body did not expel it. You can note it on ultrasound or a sign if someone says they cant feel their preg. anymore. You can also use D&C (dilation and curettage.) = basic procedure - cervcal abortion, someone's cevix is dilated, special instrument used to scrape the lining of the uterus, it can be used to remove tissues or diagnose and treat abnormal uterus bleeding

Maternal Hemorrhage: most common & life-threatening complication of Placenta Previa:

- Definitive Dx with US. NO Vag. Exam!! - RISK FACTORS: >35y.o., AA, increased gravidity/parity, prior uterine surgery (C/S), smoking, multiple gestation, prior induced AB - CAUSE: Higher incidence of malpresentations, preterm delivery, PPROM, IUGR(Intrauterine Growth Restriction) - Bright red, PAINLESS bleeding (minimal to hemorrhage) with uterine irritability bleeding is the main issue, the *cure is c-section. prevention is best*. this is all about the placenta, things like smoking affect development due to affecting circulation, the more preg or surgery they have on cervical, the less place for placenta to implant on the cervix, may implant at a weird place. when placenta implants on the cervix, that area of the cervix would not give placenta good circulation, higher problems like* IUGR *(Intrauterine Growth Restriction - baby doesnt grow to normal weight in preg)

Diabetes Mellitus: Pathophysiology and Pregnancy

- Fetal demands - Role of placental hormones (human placental lactogen, somatotropin) - Changes in *insulin resistance; peaks in 3rd trimester *to provide adequate food for fetus - Effects on pregnant person can include postprandial hyperglycemia the body shifts to meet the increased fetal demands. as it grows, fetus needs more fuel and energy, thus creating this situation, body want to pump more energy out into the blood.

RDS Treatment (Continued)

- Focus is to prevent and minimize atelectasis (Complete or partial collapse of a lung or a section (lobe) of a lung.) - Minimize untoward (unexpected) effects of oxygen and barotrauma(increased air or water pressure,) or volutrauma. (excess tidal vol) - Treat underlying cardiovascular infectious and other physiologic problems. - Maintain a balanced physiologic environment. the lungs are not functioning by themselves its the whole circulatory vascular system, viewing the patient as a whole system

NIH Recommendations for Use of Antenatal Steroids

- Give to all pregnant women *24 to 34 weeks gestation who are at risk for preterm delivery within 7 days*: ---*2 doses of 12 mg of betamethasone* IM 24 hours apart OR ---*4 doses of 6 mg of dexamethasone* IM 12 hours apart - Repeat courses of corticosteroids should not be given routinely in pregnant women. directions of betamethazone, will be on board exams and kaplan. know dosing and recommendations. *could be given to anyone who you think might have preterm labor, very low risk of giving this,* altho some can have full term, but knowing it works, give it right away

Shoulder Dystocia

- Head is born, but anterior shoulder cannot pass under pubic arch - High risk for neonatal birth injuries --Brachial plexus injury, fractured clavicle - Maternal risks --Lacerations --Excessive blood loss --Extension of episiotomy (surgical cut made at the opening of the vagina during childbirth)/ tear --Endometritis anterior shoulder is stuck behind synphesis pubis. happens to large infant. head is out but the rest of the body is not leads to serious dmg. more pressure exerted to get the shoulder beneath the shoulder bone, which can cause brachial plexus injury, in which the shoulder will display weakness. *provide superpubic pressure,* pressure right behind pelvic bone, and helps the shoulder to go down, and easier for baby to be delivered and slip under. fundal pressure is not good, pressure from top of uterus, makes dystersia worse and can cause uterus rupture but superpubic pressure is good. *Prevention use McRobert's Maneuver, in the bed, pulls legs up, helps to make the pelvis open more. for someone who is mobile, getting on hands and knees would also help.*

GDM: Assessment

- Health history; physical examination; risk factors - Screening at *first prenatal visit (HbA1C)*; additional screening at 24 to 28 weeks (1) *nonfasting 50 g 1-hour OGTT* (glucose tolerant test), if positive, *fasting 100g 3-hour OGTT*; OR 2) *fasting 2-hr 75 g OGTT*), the first one, just a screen test, do not diagnose GDM, the 2nd 3hr is the diagnostic test different from the first one, this one determines GDM. Sometimes ppl skip the first test and just does the 2hr test (diagnostic), and if you are positive, you are GDM. - Maternal surveillance: urine for protein, ketones, nitrates, and leukocyte esterase; evaluation of renal function/trimester; eye exam in 1st trimester; HgbA1c every 4-6 weeks - Fetal surveillance: serial ultrasounds; alpha-fetoprotein levels; biophysical profile; non-stress testing; amniocentesis(test amniotic fluid thru sampling) anyone with risk factor hopefully get a A1C once they come in, *everyone else get screen btw 24 and 28 wks. * ppl who has GDM, needs extra survellance for preg and fetus, recommendations: increase ultrasound, Nonstress testing, and strong recommendation for prenatal testing

Long-Term Complications of the Preterm NewbornCan last for yrs

- Higher mortality rates from SIDS (sudden infant death syndrome ): even if everything went well, they are still at risk - *Retinopathy of prematurity (ROP)*: associated with blindness. *O2 administration, too much can rupture,* so now its titrated ---Vessels in eyes can rupture prematurely - *Bronchopulmonary dysplasia (BPD): lack of surfactant* ---Due to high pressures caused by lack of surfactant which caused stiffness - *Speech defects: can be related to prolonged stay in hospital. development of palate will be delayed due to vent tube* ---Possibly from prolong vent tube - Neurologic defects - Auditory defects: can be related to certain meds - Abuse and neglect: higher chance of these for babies that are born pre-term, ppl dont always get the support they need ---b/c of their high care demand

C/S Pre-op Care

- INCLUDE SUPPORT PERSON - ANESTHESIA VISIT, INFORMED CONSENT - FOLEY, ABDOMINAL PREP - *ANTACID- SODIUM CITRATE* (don't throw up and breath it in, life threatening potential, thus dont eat before surgery) - DISCUSS POSTOP CARE - PATIENT SUPPORT AND EDUCATION

Ectopic Pregnancy (often misdiagnosed)

- Implantation & growth of fetus & placenta outside the uterine cavity - Fallopian tubes, cervix, abdomen, ovaries - Sharp/stabbing pain (1 side?) & bright red bleeding - Treatment has evolved beyond saving the life of the mother to preserving her fertility - Risk Factors: PID (pelvic inflammatory disease- An infection of the female reproductive organs.), Assisted Reproductive Technologies, IUD, AMA, smoking, tubal myomas another thing happening when u see bleeding

Drugs for Preterm Labor

- Indocin T - Terbutaline T - Nifedipine T - Betamethasone - Magnesium sulfate (used primarily for seizure prophylaxis - to prevent seizures) top 3 are tocolytics. betamethasone = helps baby's lung to develop, when the baby is born preterm. gives it 48 hrs before birth to help it work. mag sulfate= no longer a drug for preterm labor, used to be, only used for seisure and prophylatic patient) it does that a side effect thats slowing down and spacing out contractions, it makes it so that muscle dont work, everything is floppy. however, if someone who has severe preeclampsia (triggers seizures) they are induced using mag sulfate, may need extra pitocin to get it to work because mag slows contractions.

Risk factos for postpartum infection

- operative procedure (forceps, c/s birth, vacuum extraction) - history of diabetes, including gestational-onset diabetes - prolonged labor (more than 24 hrs) - use of indwelling urinary catheter - anemia (prenatal hemoglobin <10.5 mg/dL) - multiple vaginal examinations during labor - prolonged rupture of membranes (>24 hrs) - manual extraction of placenta - compromised immune system (HIV)

Gestational Diabetes Mellitus

- New diabetes diagnosis in pregnancy (no pre-existing DM) - *Begins in second trimester and continues through the third* - Testing usually around *28 weeks* - In pregnancy the placenta secretes hormones, including *HPL, that inhibit the action of insulin *and clear it more quickly, creating *insulin resistance that elevates blood glucose levels slightly - this is normal* - The *pancreas also produces more insulin in pregnancy*- this usually keeps blood sugar from reaching dangerous levels - *True GDM is caused when the pancreas fails to make enough insulin to control the excess blood glucose caused by placental secretion of hormones*, and blood glucose reaches harmful levels theres no pre-existing diagnosis, continues for the rest of pregnancy, bet. 24 and 28 wks, everyone is recommended to have a GDM test. everyone who is preg, has a higher glucose level. *placenta secretes hormones that inhibits insulin so more food is circulating for the developing fetus*. the pancreas, produce more insulin. placenta tries to inhibit insulin. in ppl with GDM, pancreas cant keep up, so placenta is inhibiting insulin, it gets progressively worse during preg. so the amount of glucose keeps building in pregnancy.

Amniotic Fluid Embolism

- Obstetric emergency - Sudden onset of hypotension, hypoxia, and coagulopathy due to breakage in barrier between maternal circulation and amniotic fluid - Nursing Assessment: difficulty breathing, hypotension, cyanosis, seizures, tachycardia, coagulation failure, DIC, pulmonary edema, uterine atony with subsequent hemorrhage, ARDS(respiratory distress syndrom:fluid collects in the lungs' air sacs), cardiac arrest - Nursing Management: supportive measures to maintain oxygenation and hemodynamic function and to correct coagulopathy; critical care monitoring everything going fine, and *suddenly someone losing consciousness*, and seems like close to dying. it could be* stroke or embolism*. this could happen during labor but rare, if survive, it will take a long recovery, sometimes they fully recover, sometimes they dont.

Placenta Previa

- Occurs when the position of the placenta is such that it covers the cervical os, either partially or completely - A *leading cause of vaginal bleeding in 2nd & 3rd Trimesters* - 1 in 200 pregnancies; 1 in 20 grand multiparous women it doesnt matter how far over the placenta is

C/S Post-op Care

- Patient is first and foremost a parent who has given birth - Also major surgery: IV, Foley, incision - Complications: atelectasis/ pneumonia, urinary retention/ infection, wound infection, GI complications, hemorrhage - Postpartum care

DM Therapeutic Management

- Preconception counseling (ideal) - Blood glucose level control (HbA1C <7%) - Glycemic control - Nutritional and exercise (lifestyle) management - Oral hypoglycemic agents (Metformin, Glyburide) - Insulin - Close maternal and fetal surveillance - Management during labor and birth if people are on board with plan, they can manage their symptoms. people need to keep it up with education

Risk Factors for postpartum hemorrhage

- precipitous labor (less than 3 hrs) - uterine atomy (loss of tone in the uterine musculature.) - placenta previa or abruptio placenta - labor induction or augmentation - operative procedures (vacuum extraction, forceps, c/s birth) - retained placental fragments - prolonged third stage of labor (more than 30 min) - multiparity, more than 3 births closely spaced - uterine overdistention (large infant, twins, hydramnios:a condition in which excess amniotic fluid accumulates during pregnancy.)

Risk Factors for GDM

- Previous *infant with congenital anomaly* (skeletal, renal, central nervous system [CNS], cardiac) happening in 1st trimester, already diabetic when conceived, poor control, high risk for this. ppl should get A1C on the first visit, if concerned. - History of gestational diabetes or hydramnios in a previous pregnancy - Family history of diabetes - *Age 35 years or older (both for diabetes type 2 and GDM)* - *Previous infant weighing more than 9 pounds* (4,000 g) - probably had GDM in prior preg. high risk for GDM - Previous unexplained fetal demise or neonatal death- probably had GDM in prior preg.high risk for GDM - Maternal* obesity (body mass index [BMI] >30)* - *Hypertension before pregnancy or in early pregnancy* - *Hispanic, Native American, Pacific Islander, or African American ethnicity* - *Recurrent monilia* infections that do not respond to treatment (monilia: *vagina yeast infection*, ppl who has elevated glucose level, this can give recurrent yeast infection due to pH imbalance) - Signs and symptoms of glucose intolerance (polyuria:large volumes of urine., polyphagia:increased appetite, polydipsia: thirst, fatigue) - Presence of glycosuria (excess of sugar in the urine)or proteinuria

Incomplete Abortion

- Spontaneous expulsion of only part of the products of conception, with retained products remaining in the uterus (Prior to 10 wks, fetus & placenta most often expelled together; after 10 wks, placenta may be retained) - Continued bleeding!!! Passing "clots". Hemodynamically unstable - Infection? Disseminated intravascular coagulation (DIC)- Condition affecting the blood's ability to clot and stop bleeding. effect of prolonged bleeding, blood can no longer clot, exhausted the clotting factors. Endometritis (inflammation of the endometrium.) - D&C may be required (Dilation and curettage) pregnancy is no longer viable, but not everything has left the uterus. higher risk of this in the end first trimester up to 10 wks, placenta is usually expelled together, the higher gestational age, the higher chance the placenta could be retained in uterus.

MANAGEMENT

- THREATENED- Bedrest - INEVITABLE, INCOMPLETE, MISSED- D & C - SECOND TRIMESTER AB- D&E (2nd tri only Dilation and evacuation-requires more surgical instruments to remove the tissue (like forceps)) - SEPTIC AB- D&C, Antibiotics people are recommended to rest. little to recommend when it comes to pregnancy loss. physically resting doesnt have any impact. if someone was able to progress to the second trimester, add antibiotics for potential infections. D&C: very fast and complicated. dilation and curettage

Diabetes Mellitus: Pathophysiology and Pregnancy

- Undetected/uncontrolled GDM* increases risk of neonatal hypoglycemia, macrosomia, birth trauma, and cesarean * - Correlated with increased *risk of preeclampsia* - Undetected/uncontrolled DM early in pregnancy increases the risk of congenital anomalies - For people who go on to develop Type 2 diabetes after GDM, over time poor glucose control can result in damage to the eyes, kidneys, heart, nerves, and blood vessels - Preconception counseling for women with pregestational diabetes, swift detection of women with newly diagnosed or gestational diabetes, and good glucose control can greatly improve outcomes more urgent than ppl who are not preg with diabetes. someone with GDM, the neonate will have neonatal hypoglycemia and fetal macrosomia (large for gestational age - more shoulder dystercia. ) if someone has diabete diagnosed early on and managed it well, the outcome will be the same as someone without DM to have a baby. ppl who develop GDM go on have a higher risk of having type 2 diabetes later on in life.

Terbutaline

- β2-adrenergic receptor agonist - Side effects: --Uterine relaxation, bronchodilation, vasodilation, muscle glycogenesis --CNS- dizzy, drowsy, H/A, restlessness --BP- increase pulse pressure --HR- palpitations, tachycardia, chest pain --GI- nausea/ vomiting --Resp- SOB, cough, pulmonary edema --Metabolic- Maternal Hyperglycemia --Fetal- tachycardia, hypoglycemia terbutaline = initially an asthma med, but good for controlling contraction, has a lot of side effects, including fetal tachycardia and hypoglycemia.

Complications

-Anemia -*Shock*: a lot of blood loss quickly. -*IUGR* -IUFD: fetal demise. -Up to 3000-5000 ml EBL !! -Prolonged hospital stay -Septicemia (blood poisoning) -*Thrombophlebitis*(A condition in which a blood clot in a vein causes inflammation and pain.) -C/S -Blood transfusion -*Embolization*(formation of a blood clot, air bubble,) -*HYSTERECTOMY* (surgical removal of the uterus.)

Differential Diagnosis of Bleeding in Pregnancy:

-Coitus (penetrative intercourse, may not be very concerning cuz some may spot a little during preg with sex) -Implantation bleeding (spotting, when zygote implanting on wall of uterus) -Threatened abortion -Complete abortion -Incomplete abortion -Missed abortion -Septic abortion -Ectopic pregnancy -Hydatidiform molar pregnancy: A noncancerous tumor that develops in the uterus as a result of a nonviable pregnancy. (gestational trophoblastic disease: a group of conditions in which tumors grow inside a woman's uterus) -Cervical insufficiency: cervix begins to dilate (widen) and efface (thin) before the pregnancy has reached term there is a lot of different reasons why people experience bleeding during preg, ranges from normal, and nonconcerning to threatening and emergencies. if someone is bleeding during pregnancy, they always need to be assessed. abortion = end of any pregnancy.

Threatened Abortion

-Considered when any vaginal bleeding occurs during the first half of a pregnancy -Bright red, pink, brown 1st trimester bleeding -Uterine cramping -Do US, serum hCG, LMP (last menstrual period), EDC, date of 1st positive pregnancy test -Administer Rhogam if needed (to prevent Rh isoimmunization in mothers who are Rh negative) -WBC's-- fever showing) -Emotional support something is happening that makes provider to think the baby is lost, but it's not lost. Like bleeding, cramping, any time in the first trimester. (rule out spontaneous abortion). use ultrasound to determine if this is how far along the baby is, according to the person and predicted date. rhogam: if there is a risk of the exposure. rhogam is just about positive or negative. (making sure the fetus Rh and the mother Rh matches, can lead to risk of jaundice)

Postpartum Hemorrhage (PPH)

-Definition: -Loss of blood following a delivery EBL or QBL: -Vaginal delivery: 500 cc/ml accumilative OR C/S: 1000 cc/ml accumilative OR - >15% change in vital signs; HR >110; BP </= 85/45; 02 sat <95% or increased bleeding in postpartum period - Often resulting in hypovolemia or otherwise causing the patient to become symptomatic Pitocin-never give undiluted as a bolus injection IV Cytotec(miso)-allergy, active CVD, pulmonary or hepatic disease Methergine-if the woman is hypertensive, do not administer Hemabate-contraindicated with asthma due to risk of bronchial spasm if you don't meet these criterias but have these changes of VS, they still can have postpartum bleeding.

Hypotonic Uterine Dysfunction

-During active labor -Poor in quality -Lack intensity -Risk: hemorrhage hypotonic uterine function: The contractions are irregular, the iupc (intrauterine pressure catheter - measure length of contractions) will show not enough force to move labor along. This is hypontonic, *not enough contractions. * the complication with hypotonic uterine dysfunction is that there is a big* risk of hemorrhage* due to the muscles of uterine not functional properly.

Factors Associated with Abruptio Placenta:

-Grand multiparity (had five or more previous pregnancies) -Pre-eclampsia ( pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys.) or chronic hypertension -PROM (Premature rupture of membranes ) -Pregestational DM -Substance abuse (especially cocaine) -Polyhydramnios (excess of amniotic fluid in the amniotic sac.) -Blunt force trauma (MVA:Manual Vacuum Aspiration, maternal battering) -Smoking -Uterine fibroids (Noncancerous growths in the uterus.) -Multiple gestations -Extremes of maternal age (more about poor general health and above factors)

People with PCOS are at risk for:

-Infertility -Dysfunctional Bleeding -Endometrial Carcinoma -Obesity -Obstructive Sleep Apnea -Type 2 Diabetes -Dyslipidemia -HTN -Possibly Cardiovascular Disease -Other close relatives may also be a risk -May require lifelong therapy and find that access to healthcare coverage is limited. *There is a build up of endometrium layer without shedding, this can increase cancer risk, sets ppl up with irregular bleeding, because the thick lining will shed irregularly, causing spotting, this is also metabolic syndrome overlap, so there's more cardiovascular risk, sleep apnea would be a higher risk for ppl with PCOS.*

Pre-term Labor

-Occurrence of regular contractions accompanied by cervical effacement and dilatation before the 37th week of gestation -Major contributor to perinatal morbidity (diseased) and mortality in the world -Exact cause is usually unknown (stress/genomics/environment/microbiome/infection?) -Prevention is the goal huge risk, and a real problem in the U.S. continues to be ongoing, social factor can be a big factors. It is defined as any regular contractions that is changing the shape of cervix, before 37th weeks, they are still early term, 37-39 wks is usually a safe window, usually wouldnt need additional support, thats why window is cut at 37wks

Parents' Potential Experiences of (Threatened) Pregnancy Loss

-Pregnancies, planned or unplanned, desired or undesired, bring complex emotional responses -Acute Stress Disorder? -PTSD? -Perinatal Mood Disorder? -Magnitude of the loss should not be underestimated/minimized -Partners also struggle with the loss, often manifesting grief differently -Physical healing AND emotional healing..... ppl experience preg loss in diff ways, this affects both partner and the mother and whoever is invested, it causes acute stress, ptsd, perinatal mood disorder. Manifest diff from partners than the physically preg person. The magnitude of experience, does not relate to how many kids the person has, length of preg., or wanted the child or not.

Differential Dx Bleeding in Pregnancy:(con't):

-Preterm labor -*Placenta Previa *(placenta is getting too low, part of it is covering opening of cervix os, can lead to hemmorrhage during labor and delivery) -*Vasa previa *(vessel running thru the membrane to the opening of the cervix, as cervix opens, putting pressure on vessel, it can break the vessel, and cause bleeding) fetal blood vessels cross or near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue. -Lower genital tract malignancy: abnormal changes, pre-cancerous lesions -Trauma -Cervicitis (inflammation and irritation of the cervix. ) -Cervical polyp (benign polyp or tumor on the surface of the cervical canal. They can cause irregular menstrual bleeding) -Vaginitis (vaginal inflammation) -Rectal sources of bleeding -Urologic sources of bleeding -Abruptio Placenta: where placenta pulls away from the walls of uterus during labor. -Normal pregnancy -Labor

Complete Abortion

-Spontaneous expulsion of the entire products of conception -Heavy vaginal bleeding & cramping -Passage of tissue -Do all of above labs and Hgb/Hct due to blood loss all products of contraceptions has left the uterus, abortion is completed. depending on far along the preg is, involves passing of tissue, cramping, still need to confirm preg is not longer there.

RDS Treatment

-Thermoregulation -Fluid balance and nutrition -Skin care -Pain assessment -Developmental care -Family care support (comfort/care) them until babies make their own surfactant, most do go thru the transition.

Abruptio Placenta Clinical Findings:

-Uterine bleeding -Uterine enlargement (concealed bleeding) -Abdominal pain -Uterine contractions -Uterine tenderness -Nonreassuring FHT's -Fetal death -DIC (Disseminating Intravascular Coagulation) -S/S depend on location of placenta and degree of separation (ex: on posterior uterine wall, may present with severe back pain!)

Hypertonic Uterine Dysfunction

-Uterus never relaxes between contractions -Erratic (unpredictable pattern) -Poorly coordinated -Contractions: frequent, intense and painful you have contractions too close together, not enough rest inbet. it is associated with poor uterine function (it is contracting all the time but not producing these big arches) You need a big arch (a muscle contraction), instead of disorganized archs, this may lead to inadequate process, cause pain and distress for infants. *Pitocin can cause this or misoprostol. (or caused by drug or like placental abruption)* irritability pattern, responding to a type of stimulants. *fetal anoxia* This could be an effective labor but wont get far, because fetus will end up in distress. tetanic contraction: taking way too long. like a mountain.

Factors (continued):

-Vascular abnormalities in placental bed -Hx of placenta abruption -Uterine anomalities -Thrombophilias (abnormality of blood coagulation that increases the risk of thrombosis) -Sudden decompression of uterus (ex: amniocentesis) -Unusually shaped placenta -*Vaginal bleeding is the hallmark sign of placental abruption* you can't predict it, altho vaginal bleeding is a sign, but you dont always see it right away

4 uterotonic meds for PPH

1. *pitocin (oxytocin)* - dose 10-40 units per 1000 ml, route: IV infusion, freq: continuous, side effects: usually none, nausea, vomiting, hyponatremia (water intoxication with prolonged IV admin.) *Contraindication:* hypersensitivity to drug. 2. *methergine* (ethlergonivine) - does 0.2mg, IM route, Q2-4 h, side effects: nausea vomiting, severe hypertension. *Contraindication*: *hypertension*, PIH (Pregnancy-Induced Hypertension), heart disease, hypersensitivity to drug, caution if multiple doses of ephedrine have been used. May exaggerate hypertensive response w/possible cerebral hemorrhage. 3. *Hembate* - dose 250 mcg, IM or intramyometrial, freq: Q15-90min. Side effects: nausea, vomiting, diarrhea, fever, headache, chills. *Contraindication*: caution in women with *hepatic disease, asthma,* hypertension, active cardiac or pulmonary disease, hypersensitivity to drug. 4. *cytotec(misoprostol)*: dose 800-1000 mcg, route per rectum, freq: one time, side effects: nausea, vomiting, diarrhea, shivering, fever. *Contraindication*: rare, known *allergy to prostaglandin*, hypersensitivity to drug.

For GDM treatment

1. take glyburide(med for type 2 diabetes) 30 min before meal 2. check blood sugar before each meal 3. eat smaller, more freq meals, carry a snack, avoid high sugar food, call if has symptoms, and keep log of diet and sugar levels

IDM Characteristics

1.*↑ weight due* to - *↑ wt of visceral organs* - Cardiomegally (abnormal enlargement of the heart.) - ↑ body fat 2.↑ growth due to constant exposure to maternal glucose 3. Glucose crosses the placenta, but insulin doesn't - Infant responds with ↑ insulin production (pseudo growth hormone) Has been associated with childhood obesity the whole baby is not proportionally bigger, they have larger viseral organs (i.e. heart), and more fat, the head (brain same size) is the same size. head will fit thru but the shoulders may have difficulites fitting thru. 1. more exposure to maternal glucose. 2. fetus makes its own insulin, its body is making higher level of insulin to deal with the glucose its getting, this insulin the baby is making is causing it to grow more

c/s birth 3 ways vertical vs. horizontal

1.vertical: vertical thru skin vertical thru uterus 2. horizontal: horizontal thru skin (first skin crease under hairline) then vertical through lower uterine segment. 3. horizontal: horizontal thru skin (first skin crease under hairline), then horizontal thru uterus (lower uterine segment). just becasue theres a transverse on the skin, does not mean the uterus is also transverse, it could be a vertical. you need to confirm if someone has a transverse incision if the person wanna do vaginal birth, cuz *vertical will increase chance of rupture.*

Post-menopause

12 months of amenorrhea On average, reached by the early 50's

High Risk Pregnancy

A PREGNANCY IN WHICH LIFE OR HEALTH IS COMPROMISED a low risk person is someone who have no complications, high risk means that the person has any number of complications, it doesnt mean they are in immediate danger. They need more monitoring, and routine checkups. High risk does not mean high risk in this moment right now, it means its more complicated.

Precipitous Labor

Active labor < 3 hours from onset of regular contractions to delivery may be spontaneous or drug (usually cocaine) induced Complications: ·Placental abruption ·Uterine rupture ·Lacerations of maternal structures ·Postpartum hemorrhage (most common) ·Fetal hypoxia (no O2) It is considered risky if the entire labor(from start to finish) is less than 3 hrs. Contractions are squeezed closely together, baby is not getting rest or deoxygenated bet. contractions *(fetal hypoxemia)* There might be *lacerations*, due to not allowing the skin to stretch and accomodate baby's head. Increased risk of precipitous labor can occur due to drug use, and *cocaine/stimulants use causes placental abruption* ( the placenta is pulling away from the side of uterus before the baby is born. ) *Hemorrhage* is also because the muscle are getting exhausted, and harder to clamp down to control the bleeding right after birth

Cesarean Birth

Additional Factors - Elective cesarean birth - Surgical techniques --Low transverse incision - Complications and risks

GDM: epidemiology

Affects 5-10% of pregnant people 70% will be diagnosed with type 2 diabetes within 10 years Lifestyle changes can delay or prevent onset of type 2 diabetes 9.2% preg are affected by GDM, pretty common

Lipid Profiles and PCOS

Almost 70% of patients with PCOS have an abnormal lipid profile and high triglycerides and low high-density lipoprotein (HDL) cholesterol are often found. if this is not caught this will not affect someone, but set them up for sig. problem in life later on if not diagnosing it now

The Preterm Newborn

Alteration in respiratory physiology Inadequate amount of surfactant in the lungs allows alveoli to collapse = respiratory distress syndrome (RDS) Treated with artificial surfactant down the ET(endotracheal tube) tube Ventilation Therapy rates of preterm birth are rising. hugely related to race and racism. lung maturation and lung function. the lung needs to be functioning in some sense for the baby to survive. main limitation is the the surfactant. we don't always get 36 hr notice to deliver the *betamethazone* to the preg person, to build up the *surfactant*. if theres not enough surfactant, there might be *respiratory distress syndrome *cuz alveoli in the lung are not popped open and staying in open, and keeps collapsing in the lungs, so lungs cannot expand completely with O2 exchange. For *premmy that has signs of respiratory distress and ppl that didnt get betamethazone, theres artificial surfactant that will be put directed on to the ET tube, this can help but not as effective cuz lungs are already collapsing * Treatment goals are adequate oxygenation & ventilation; correct acid-base imbalance, & provide for homeostasis In the normal or mature newborn lung, surfactant is continuously synthesized during breathing, & replenished. This process speeds up for the premature once born but may experience barotrauma(injuries caused by increased air or water pressure) during the interim time from supportive ventilation Pulmonary vascular system reacts to hypoxia by constricting The ductus arteriosus may remain open or re-open increasing the blood volume to the lungs resulting in pulmonary congestion Without adequate pulmonary capillary blood flow, type II pneumocytes become deficient in the precursor material required for surfactant. Surfactant deficiency and decreased lung compliance promote increased work of breathing, fatigue, & atelectasis as the cycle escalates

GDM Glucose Range

Before a meal (preprandial): *95 mg/dl or less* 1-hour after a meal (postprandial): *140 mg/dl or less* 2-hours after a meal (postprandial): *120 mg/dl or less*

Genetics of PCOS

Complex Genetic Trait Disorder While the precise mode of inheritance is still uncertain, a familial basis for the syndrome is well established and it is not uncommon to find a mother or sister with 1 or more symptoms of PCOS genetic component and overlaps with metabolic syndrome almost 50%, and insulin resistance, and overlaps with obesity.

RDS (Continued)

Complex respiratory disease characterized by diffuse alveolar atelectasis of the lungs, primarily caused by a deficiency of surfactant. This leads to higher surface tension at the surface of alveoli, which interferes with normal exchange of oxygen and carbon dioxide.

Cesarean Birth Indications

Contributing factors - Fetal macrosomia - Advanced maternal age - Obesity - Gestational diabetes - Multifetal pregnancy - Malpractice concerns

Gestational Diabetes Mellitus (GDM)

Definition: Glucose intolerance with onset or first recognition during pregnancy first recognition during preg. most ppl diagnosed are in a normal to borderline glucose level state before preg. usually at 24-28 wks, they might have progressed to a diabetic level. normal people can progress to the prediabetic stage but never been tested. ppl with high risk should be tested earlier on

DIC-Disseminating Intravascular Coagulation

Disseminated intravascular coagulation is a *condition in which small blood clots develop throughout the bloodstream, blocking small blood vessels. The increased clotting depletes the platelets and clotting factors needed to control bleeding, causing excessive bleeding.* Precipitating events Thromboplastin release Fibrin clot formation Fibrinogen and platelet depletion

Nursing Care for the IDM Newborn

Early detection of hypoglycemia Early detection of polycythemia ( your marrow makes too many red blood cells, which causes your blood to get too thick) and hyperbilirubinemia Assess for birth trauma Assess for congenital anomalies Flash fact: Insulin antagonizes/prevents surfactant production betamethazone causes fetus to produce surfactant in their lungs (lubricant that allows lung to flex), allowing fetal to breath and lung to function, the increase of insulin reduces/delays surfactant, more risk of respiratory problems

Post-term birth: fetal risks

Fetal risks - Prolonged labor - Shoulder dystocia - Birth trauma - Asphyxia (no O2) - Macrosomia (newborn larger than average. >9 lbs) - "Aging" placenta a week or two after due date, the placenta will get old, no longer in its prime. If you look at a placenta, There might be calcifications on it, white hard spots on it. Usually not affecting much until during labor, because labor is giving stress to the whole system, the aging placenta that might not be causing issues before is now causing distress on the baby due to its calcification.

Approximately 20-25% of pregnancies are accompanied by vaginal bleeding

Identifying potential causes, appropriate assessments, & treatment required is critical to intervening in a timely and meaningful way In all cases, compassionate, systematic, & thorough approach of evaluation will improve patient safety and satisfaction of care *placenta previa* used to be an emergency, *pretty common, 1/200* pregnancies. someone who had more than 4 babies its 1/20 chance. It is potentially fatal, and no signs beforehand, *ultrasound will help identify* these anomalies, and everyone gets ultrasound at 20 wks, and that is a check for placenta position, if placenta is in previa position, they have followup ultrasound, dr would know if the labor will be safe depending on the position of the placenta. the issue with *vasa previa, it doesnt always show up on ultrasound.*

Insulin Resistance

Insulin resistance is commonly, though not universally, found in PCOS, with prevalence being estimated in 50-70% of cases.

PCOS Treatment-Key Points

Pharmacologic treatments include the following: oral contraceptives *CHC = progesterone and estrogen* (replaces indogineous hormones, so body stops producing normal cycle of hormones which will lowering androgen, calm down ovary, and thinning out endometrium) *antiandrogen drugs (usually spironolactone) spironolactone (pill w/ this in it)* insulin sensitizers statins (cholesterol lipid-lowering medications) highest chance of preg the month right after they stop taking CHC, because PCOS cycle has started yet.

Respiratory Distress Syndrome (RDS)

Incidence 10% for all premature infants Incidence *50% for 26 week to 28 weeks* does not happen exclusively in premmy can also affect normal GE. *LGE is the highest risk factor* Risk factors: -Low gestational age -Male -Born to *diabetic mothers* -Born after an *asphyxial insult before birth: spent period of time w/o O2 in womb* -Born after *maternal-fetal hemorrhage*: is not post partum hemorrhage, but *exchange of blood btw maternal and fetal*, due to placenta releasing blood. -*Multiple gestation*

Care Management

Increased morbidity and mortality after 42 weeks Most providers induce at 41 to 42 weeks Others allow pregnancy up to 42-44 weeks -With assessment tests of fetal well-being normal -Non-stress test fetal heart rate monitoring, is a common prenatal test used to check on a baby's health. heart rate is monitored to see how it responds to the baby's movements.) and biophysical profile (A biophysical profile is a prenatal ultrasound evaluation of fetal well-being involving a scoring system) twice a week one major reason why induction is recommended from 40, 42., the risk of still birth goes up. Theres an increasing steep slope going up after 42 weeks, ppl need to be educated about the risk of still birth. If ppl who doesnt want to be induced, they go with a lot more checkups, surveillance, like amniotic fluid amount, nonstress test (checking baby's hear beat).

Pregnancy in PCOS

Increased risk of Pregnancy-related Hypertension Increased risk of Pregnancy-related Diabetes Increased risk for Miscarriages

PCOS and Infertility

Menstrual Irregularity, Non Ovulatory Cycles Ovaries Contain Small Cysts Cysts Produce Hormone Imbalance with Increased Estrogen AND Androgens Good chance of Pregnancy with IVF (In Vitro Fertilization) its a challenge to conceive initially. usually pt with PCOS is a good candidate for assisted fertility (high success rate). once they can ovulate or IVF, important to tell ppl when they get their diagnosis initially.

Sleep Apnea and Other Sleep Disorders

Multiple groups have documented an increased risk for sleep apnea and other sleep disorders including increased daytime somnolence, such as sleep disordered breathing This is surprising as sleep apnea is otherwise relatively uncommon in this demographic sleep apnea is uncommon, but seen in ppl of PCOS

Signs and Symptoms of RDS (Continued)

Nasal flaring Cyanosis Tachypnea if you see blue on face and not on the extremities. starts around the mouth

PCOS Treatment-Key Points

Nonpharmacologic measures are universally recommended - These measures include the following(Lifestyle Measures): A) Diet including seeing a dietician who is knowledgeable in PCOS B) Exercise C) Weight Reduction if the patient is obese or insulin-resistant huge precentage of improvement with moderate weight reduction

Polycystic Ovary Syndrome

PCOS is associated with hyperandrogenism and infertility early in life It is also a harbinger of a lifelong condition that can lead to serious sequelae such as diabetes mellitus, hyperlipidemia, endometrial hyperplasia/carcinoma, central obesity, sleep apnea, etc. *commonly diagnosed when ppl have issues with irregular cycles or if someone is having difficulties conceiving. this messes with ovarian cycle so ppl don't ovulate and causes infertility, ppl can end up with higher than normal androgen hormones (male). PCOS may have more male pattern hair loss, or more body hair, male pattern hair distribution, it is closely connected to life long risk overlapping with metabolic syndromes.*

Obesity in PCOS

Obesity, seen in approximately 60% of cases, amplifies the severity of PCOS presentation The prevalence of obesity varies according to geographic location: it is greater in the USA than in other places theres still ppl with PCOS without these syndromes

COCs and PCOS

One of the most commonly used medications in PCOS patients are COCs (and other combined hormonal methods) In addition to their androgen-lowering effects, it is likely that they protect the endometrium against hyperplasia (the enlargement of an organ or tissue caused by an increase in the reproduction rate of its cells, ) and cancer (as they do in the general population) and may also reduce the incidence of functional follicular ovarian cysts, as shown in the general population. lower their long term risk of cancer due to thinning out the lining.

Post-term birth

Pregnancy continues past the end of the 42 week of gestation Maternal risks - Related to excessively large infant - Increased risk 1.Dysfunctional labor 2.Birth canal trauma - Interventions more likely to be necessary - Fatigue and psychological reactions the person is gone from 40 wks to 42 weeks. Often ppl are induced btw 41 to 42 weeks, but up to 42 weeks, its still normal, when its more than 42 weeks, it is considered post term birth, you get a big baby. The risk here are: You can get trauma to the mom, Shoulder dystocia, dysfunctional labor: the body is having problems to fit thru.

2003 ESHRE/ASRM(Rotterdam,Netherlands) Consensus on the Dx of PCOS 3 criteria:

Requires the presence of *two out of the following three* criteria: *1.Oligoovulation (infrequent or irregular ovulation) and/or Anovulation (ovaries do not release an oocyte during a menstrual cycle. )* ppl have little cysts, but never turns into an egg and completes the cycle. *2.Hyperandrogenism (clinical and/or biochemical)* thru blood draw or physical exam *3.Polycystic Ovaries, with the exclusion of other etiologies* ultrasound found lots of cysts (12+)

ABRUPTIO PLACENTA

SYMPTOMS -Bleeding -Tenderness to Pain -Backache, abdominal firmness, rigidity, "boardlike abdomen" -Uterine Hypertonicity (a contraction frequency of five or more in 10 minutes.) -Contractions -Shock CARE -Stabilize Mother/Fetus -VS, IV's, CBC -NO VAG EXAMS -Monitor FHR, UC's -Observe -Unstable- Deliver C/S -LABS: Prothrombin time (PI)/Activated partial thromboplastin (aPTT) - *if its stable grade 1, the person may be able to deliver, and no vag. exam.* there is always a question about placenta is previa or abruption

PLACENTA PREVIA

SYMPTOMS -Painless Bleeding -Uterus- soft, non-tender CARE -Stabilize Mother/Fetus -VS, IV, CBC -Monitor- FHR -*NO VAG EXAMS * -Ultrasound -Bedrest -Unstable- Deliver infant no prenatal care and active bleeding, so which one previa or abruption? previa bleeding is painless, can be quite a bit, progress quickly to sig. amount, uterus is soft and nontender, no pain. you never do vag exam unless u see the ultrasound report, because if they have previa, the *vag. exam might trigger active bleeding with their finger*. this is usually someone *delivered surgically.*

DIC symptoms and care

SYMPTOMS Bleeding gums, nosebleed, petechiae, bruising with injections, venipuncture (puncture of a vein), tachycardia, diaphoresis(sweating) CARE: - LAB - (low) platelets, low fibrinogen, prolonged PT, PTT - Correct underlying problem (deliver) - Volume/ Blood/ Blood product replacement - Oxygen by the time someone is at DIC, they are dying, its hard for body to recover due to losing clotting factor, they start to bleed everywhere, from eyes, nose, etc. emergency ICU help body to produce clotting factors again

Common Complications of the Preterm Newborn

Short Term Complications - *Apnea of prematurity b/c they forget to breathe* potential short term: this does not apply to everyone, if any. younger the GE age, the great risk, but highly individualized. premmys are not mature enough neurologically to breath all the time. baby apnea, needs to be waken up or startled to breath again, cuz they wont wake up to breath by themsevles. ---*Treat w/ Theophylline (long-term bronchodilator )* - *Patent Ductus Arteriosus (PDA)* some premmys may have patent(still open) ductus arteriosus, not a complete transition to the neonatal cardiac, from fetus cardiac. you cannot just close up the shunt for them, theres no change in pressure and getting that circulation to the lungs, so *lungs are not working probably.* Cardiac conversion is not working properly. - *Respiratory Distress Syndrome (RDS)* - *Intraventricular Hemorrhage of Brain (IVH) - bleeding into the ventricles of the brain.* IVH can results in *permanent delay* but u wont know until yrs later for the impact - *Necrotizing Entercolitis of Bowel (NEC)* NEC, this is not something the baby is born with, theres a *bacterial infection of the bowel*, cuz the baby is so vulnerable due to immature immune system, can be contract in hospital. this can kill the babies, but wouldnt be a problem for healthy baby. this is something that can manage and prevent with good nursing practice - Hyperbilirubinemia *hyperbilirubinemia: immature liver*, less efficient processing of bilirubin, *build up of bilirubin*, issue related to jaundice. - Hypoglycemia *hypoglycemic, unable to control their glucose yet*, not mature yet. - Sepsis *sepsis: high risk, because premmy needs extra support to grow, but longer it is in care, the longer it will contract an infection* and converts easily to sepsis due to vulnerability

Uterine Rupture : signs & management

Signs and symptoms -Vary with the extent of rupture -*Nonreassuring fetal tracing* -Loss of fetal station -Signs of *hypovolemic shock* ( hemorrhagic shock, is a life-threatening condition that results when you lose more than 20 percent of your body's blood or fluid supply.) -*Vaginal bleeding* -*Sharp pain between contractions* -Contractions that slow down or become less intense -Unusual abdominal pain or tenderness -Recession of the fetal head (baby's head moving back up into the birth canal) -Bulging over the pubic bone (baby's head has protruded outside of the uterine scar) -*Sharp onset of pain at the site of the previous scar* -Uterine atony (loss of uterine muscle tone) -Maternal tachycardia (rapid heart rate) and hypotension Management -Prevention is the best treatment -Surgical intervention a lot of times the baby is the first sign. it will pop back up due to not much force keep it down in the pelvis. if there is a previous c/s then baby will pop thru there, it will pop up under the skin, beneath the pelvic bone. There will be a sudden change of fetal tracing, due to a huge blood loss, preg. woman will go hypovolemic shock (an emergency condition in which severe blood or fluid loss makes the heart unable to pump enough blood to the body.) quickly, and die in 10 min

Cervical Cerclage

Successful 80-95% of cases, but difficult to tell because hard to ID true weak cervix

HEMORRHAGIC COMPLICATIONS/SPONTANEOUS ABORTION

THREATENED abortion: vaginal bleeding that occurs in the first 20 weeks of pregnancy. INEVITABLE abortion: presence of an open internal os in the presence of bleeding in the first trimester of pregnancy. INCOMPLETE COMPLETE MISSED RECURRENT SEPTIC abortion: is an infection of the placenta and fetus. Infection is centered in the placenta and there is risk of spreading to the uterus, causing pelvic infection or becoming systemic to cause sepsis and potential damage of distant vital organs."

Menopause Overview

The menopause transition Sexual changes during and after menopause Early menopause Hormone replacement therapy The "andropause" (ppl who have more androgen, will have a decrease as well)

The Metabolic Syndrome and PCOS

The prevalence of metabolic syndrome in people with PCOS is approximately 43-46%.* increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels

Infant of a Diabetic Mother (IDM)

This infant is at risk for hypoglycemia! - *Macrosomic "large"* - *Ruddy "reddish" in color* Typically LGA unless mother's diabetes is longstanding or severe (*women with type I*, White's classes D-F, or diabetic conditions associated with vascular complications may give birth to *SGA *infants) Macrosomic, ruddy color, with excessive adipose fat tissue. Weight is due to increased weight of the visceral organs, cardiomegaly, and body fat. Brain not affected (head size may not be proportional to large body) chubby babies. fat distribution is disporportionally - over the shoulder = should dystercia, the baby is more pink/red. they have GDM or 2 diabetes have given birth. not the pic for type 1

Diabetes Mellitus: Classifications

Typical classification -Type 1 diabetes -Type 2 diabetes common risk factor for type 2: obese, diet, exercise, family history, social economic, gestational diabetes. All of these are also same factors for gestational diabetes. -Impaired fasting glucose/ impaired glucose tolerance (Pre-diabetes) Classification during pregnancy -Gestational diabetes mellitus ppl with gestational diabetes, were *diagnosed with diabetes during their pregnancy, whereas they did not have diabetes before*. These ppl are* often in prediabetic state or destined to get diabetes*, they have higher chance of getting diabetes, thus when they are preg and undergo stress, the body flipped over and became diabetic state, whereas if they dont get preg. it might take 20 yrs type 1 and 2 are diff. *type 1 diabetic patient has more concerns with Intrauterine growth restriction (IUGR): *A condition in which a baby doesn't grow to normal weight during pregnancy. You worry about small babies preterm birth.

Uterine Rupture

Very serious obstetric injury, uterine rupture- abnormal FHR, and pain, vaginal bleeding, mat tachycardia, shock, referred pain in chest -Risk factors --TOL for VBAC (trial of labor for vaginal birth after c section) --Inductions, use of pitocin --Congenital uterine anomaly (abnormal uterus) --Prior uterine surgery --Multiparity --Trauma rupture is extremely rare. when uterus ruptures during labor, always related previous scar or incision on the uterus. spontaneous is possible but this is almost always a case where the *uterus is open at a place with a previous scar/cut. * increased risk of uterine rupture: with child of labor for vaginal birth after c-section. vaginal birth can be safer than another C/S. child of labor going into labor spontaneously, a mother whom previous had a c/s, tend to have a vag birth (slight increase of uterine rupture at the scar where previous c/s took place, but not high enough that its considered dangerous for labor.) as long as they have a low transverse uterine scar. someone who *tries for VBAC(vaginal birth after cesarean) will not get pitocin or miso* which will increase the risk, increase stress on uterus. any trauma, surgery, any uterine anomaly: will displays the force differently on areas, focused more on certain areas. ppl who has over* 10 kids (multipara), the uterine muscle gets thinner and weaker over time.*

Metformin and PCOS

While the long-term benefits have not been extensively documented, use of insulin-lowering and -sensitizing medications, such as metformin, would be advisable, although they are as yet unapproved for such use in the USA. metformin is super effective. in general diet, and exercise can have a great effect, but wont be useful for ppl who are not overweight

NSVD

normal spontaneous vaginal delivery

Abruptio Placenta

people who has *grade 1 rupture are allowed to keep laboring.* labor start to progress quickly, if baby looks ok, it's fine going thru labor, but if baby is not ok, or *a lot of blood loss, they go C/S* Grade 1(40%): *small amount vaginal bleeding*, uterine irritability, *MBP normal*, fetal status normal Grade 2(45%): bleeding *mild-moderate*, uterus irritable to tetanic, *MBP normal/pulse increased8, FHT's show signs of compromise!! Grade 3 (15%): moderate to *severe bleeding*, uterus TETANIC and PAINFUL, maternal *hypotension*, *fetal death* may have occurred *diff bet previa and abruptio, abruptio is very painful, uterus doesnt relax bet contractions. there is a lot of bleeding in the abdomen*. the whole abdomen tenses up. *previa is painless, uterus is relaxed. *anything that changes shape of uterus, increases risk of abruption. Ex: even if someone has *amniocentesis* (the sampling of amniotic fluid using a hollow needle inserted into the uterus, to screen for developmental abnormalities in a fetus.),* thats a risk, too much fluid is withdrawn, the uterus is decompressed,* placenta can't adapt and pulls away.