Pregnancy Complications
Hemorrhagic Conditions of Early Pregnancy •Ectopic Pregnancy: --what do we worry about with ectopic pregnancy? ---how is it diagnosed -S/S of ectopic pregnancy 6 --goal of Tx
--We worry about rupture, rapidly growing fetal tissue can cause massive hemorrhage into the peritoneum --ruptured ectopic pregnancy are really big early pregnancy complications -Signs/Symptoms: •absence of gestational sac and heartbeat within the uterus in early ultrasound is how we make the diagnosis •Missed menses, mild pregnancy symptoms •Vaginal spotting or bleeding •Positve pregnancy test, but lower hCG levels than IUP --placenta isn't able to implant into the uterus: lower levels of hCG •Sudden severe pain in the right or left lower quadrant --s/s of ruptured Fallopian tube --d/t accumulation of blood in abdomen •Diaphragmatic irritation with referred neck and shoulder pain in 50% of cases --d/t accumulation of blood --By 10 weeks get increased pressure with referred shoulder pain. Pressure like need to defecate. Abdomial elicits pain. •GOAL OF TX: PREVENT Intra-abdominal hemorrhage and hypovolemic shock may develop rapidly often with no or minimal bleeding --first sign of shock: elevated heart rate
Hypertension During Pregnancy •Pre-eclampsia --cause 6
-Exact/single cause is unknown -Result of a decrease in vasodilators as pregnancy advances which exposes pt to vasoconstrictive problem.. and an increase in thrombaxane levels which causes vasoconstriction and platelet aggregation -Nutritional deficiencies (protein & calcium) have been suggested as contributing factors •this has led to the teachings we do about nutritional recommendations (high protein diet and adequate calcium) -Immune response triggered by placenta & fetus or possibly autoimmune tendencies have been implicated -Genetic predisposition -Combination of risk factors pre-eclampsia is very very common
Placental Abruption --FRH monitor signs -s/s 8 -management= •if mild + stable 3 •if unstable 2
--low baseline variability with late decels -S/S : bleeding, abdominal pain, uterine irritability, uterine tenderness, frequent contractions, back pain (aching or dull), non-reassuring fetal heart rate pattern (poor variability and late decels (malfunctioning/insufficent placenta + hypoxia), hypovolemic shock -Management: •Hospitalization •If mild & stable - Bed rest, steroids (betamethazone: stimulates surfactant production to accelerate lung maturity) for fetal lung development, buy the fetus more intrauterine time •If unstable - immediate delivery by Cesarean •Replace fluid & blood as needed --often these patients will deliver very rapidly (precipitous), so sometimes you can't section them Mention massive transfusion protocols, derived from military experience. Gaining wider acceptance. Early replacement of other factors, not just packed blood cells.
Placenta Previa: --Management 8 --Tx 3
--make an early diagnosis •Avoid cervical/vaginal exams (in late pregnancies esp.) •Avoid administration of oxytocin or prostaglandins •Bed rest, no intercourse, nothing in the vagina •Monitor bleeding •Assess fetal well-being •Assess uterine activity --important in any bleeding disorder, as the uterus accumulates blood is causes irritation of uterine muscle which causes contractions •TREATMENT: Deliver by C/S, waiting as long as possible, balancing maternal condition (bleeding) with gestational age of fetus [you dont want to deliver the baby too early if you dont have to]
Heart Disease in Pregnancy & Labor/Delivery
--these patients are delivered in level 3 hospitals with >>Rheumatic heart disease-not common in US >>Congenital heart disease-survival of those with repairable defects have increased incidence of pregnancy and management challenges >>Mitral valve prolapse-may require antibiotics >>Cardiomyopathy- rare, can occur during pregnancy or post-partum. 50% will have persistent CV problems >>Any cardiac problem is intensified due to the 30-50% overload of intravascular blood and fluids >>Cardiologist involvement - early diagnosis and ongoing management. Delivery in a level III facility
Hypertension During Pregnancy •Pre-eclampsia --Risk Factors 10
-< 18 or >35 years of age -Family history -Higher incidence in African-Americans -Chronic hypertension -Renal disease -Obesity -Diabetes -Multiple gestation -Immunologic disorders -Father's contribution
-DIC: Disseminated Intravascular Coagulation •associated with.. •Tx
-Associated with fetal demise after the first trimester, Abruptio placentae, and severe pre-eclampsia --as fetus begins to decompose it can trigger DIC, so we want the fetus out ASAP -Treatment •Delivery of fetus and placenta •Blood product replacement --Replace: Whole blood, packed red blood cells, cryoprecipitate, platelets, clotting factors --keeping someone warm is a really important for stabilizing someone who has had a lot of hypovolemia (hemorrhage), we try to keep hemorrhaging women warm even though they dont usually want a blanket
Hemorrhagic Conditions of Early Pregnancy >>Gestational trophoblastic disease --contributing factors (5) --s/s 5 (KNOW THESE)
-Contributing Factors: •Hormonal abnormalities, infertility treatment (d/t hormonal stimulation). Frequency highest at both ends of age spectrum. Familial tendencies, higher risk of recurrence -Signs & Symptoms: •Vaginal bleeding - varies from scant to profuse and clear grape-like vesicles may be discharged from the vagina •Uterus always larger than expected for gestational age --uterus is distended with all these extra clusters of membrane •Severe nausea & vomiting most likely a result of --d/t high levels of hCG (d/t several pre-placental chorionic villus things, there are high levels of hCG being secreted, and we know that hCG plays a part in nausea and vomiting) •Extremely elevated hCG levels, as high as 1-2 million IU (300,000 in normal pregnancies) •Early development of preeclampsia (before 24 weeks) --d/t hormonal stimulation
Hemorrhagic Conditions of Early Pregnancy •Ectopic Pregnancy: -defintion -incidence 4 -causes (9)
-Definition: Implantation of a fertilized ovum outside the uterine cavity. 95% are in the distal portion of the Fallopian tubes -Incidence: 19.7 per 1000 (2%). Higher in non-white & older women (more life experience, more uterine infections and surgeries, more things that predispose them to having ectopic pregnancies) Incidence has increased dramatically since the 70's. (since IUD use have gone up) -Causes: Tubal occlusion/scarring/adhesions secondary to PID (pelvic inflammatory disease)/OR IUD use (d/t scarring in the Fallopian tube), smoking (vasoconstriction), causes associated with infertility, assisted reproduction, douching, anatomic or functional defects of the tubes, Low estrogen/progesterone that cause delay in transport of ovum, fibroids --if you've had one and lost a tube, you are more likely to have another
Hemorrhagic Conditions of Early Pregnancy >>Gestational trophoblastic disease/ Molar Pregnancy •diagnosis •Tx (7)
-Diagnosis: •Ultrasound -Treatment: •Chest x-ray (recommended follow up) --they could already have mestasticies of materials in other organ systems, we want to make certain there isnt anything in the lungs •Metabolic & blood chemistry •Baseline serum hCG and follow up levels up to 1 year --follow this woman for a minimum of 6-months to a year, to make sure that the levels return to normal and make sure this isnt going toward carcinoma •CBC, blood type and clotting factors •Treat hypertension •Evacuation of molar tissue by vacuum aspiration •Follow-up to detect malignant changes-persistent trophoblastic tissue can become metatastic CA
HELLP syndrome --symptoms7
-Generalized malaise (90%) -Pain in the right upper quadrant, the lower chest or epigastic area (liver distention from intrahepatic hemorrhage - subcapsular hematoma) (65%) -Nausea/vomiting, severe edema (30%) -Headache (31%) -Eventually critically ill as lab values change •Low platelets •Elevated liver enzymes
Diabetes and Pregnancy --goals for therapy --effects of fetus
-Normalize and maintain maternal blood glucose levels as near normal as possible -Insulin does not cross the placental barrier. Fetus starts producing insulin at 10 weeks. If exposed to high levels of glucose fetus will produce excessive insulin which acts as a growth hormone -leading to macrosomia (4000+gm babies) •insulin is a fetal growth hormone for babies -Avoid accelerated impairment of maternal blood vessels and damage to other organs
Hemorrhagic Conditions of Early Pregnancy >>Therapeutic Management of Spontaneous Abortion (9) --when can you get the first ultrasounds
-Ultrasound assessment of fetal viability •most people want to get in for a visit as soon as they've gotten a positive pregnancy test, but you want to wait at least 5-6 weeks, that's when you'll really be able to see a fetal pull, and get more accurate data -we want. to make the diagnosis as early as possible and figure out what is causing it, is it really a fetal wasting situation? -D&C - Dilation & Curettage for incomplete or missed ABs •prevents hemorrhage and infection -Prostaglandin administration (cervical ripening) •if you have one of those 18-19 week baby and deliver the fetus, prostaglandins may be need to ripen the cervix just as you would for an induction -Pitocin induction when indicated (2nd trimester) -Fluid and blood replacement as needed -Rest, hydration, assess for S&S of infection -Antibiotics as needed •if there are s/s of infection •often after a D&C -Support and education •absolutely crucial •this is a loss of a desired human being, be cautious with your choice of words -Grief counseling
A 24 week patient is being seen in the clinic. She states, "I have had a terrible headache for the past 2 days." Which should the nurse do next? 1.Check the patient's blood pressure 2.Obtain a urine sample 3.Take a detailed headache history 4.Offer the patient Tylenol
1
At 28 weeks' gestation, an RH-negative woman receives RhoGam. Which of the following would indicate that the medication is effective? 1. The baby's RH status changes to RH negative 2. The mother has a negative antibody screen. 3. The baby produces no RH antibodies. 4. The mother's RH status changes to RH positive.
2
A women has been diagnosed with a ruptured ectopic pregnancy. Which of the following s/s is characteristic of this diagnosis? 1. Dark brown rectal bleeding 2. Severe nausea and vomiting 3. Sharp unilateral pain 4. Marked hyperthermia
3
A women has just been sent up to L/D following a MVA. Her body appears to be uninjured. The nurse carefully monitors for which of the following complications? 1. Placenta Previa 2. Transverse fetal lie 3. Placental abruption 4. Severe preeclampsia
3
A client with 4+ protein and 4+ reflexes is admitted to the hospital with severe preeclampsia. The nurse must closely monitor the woman for which of the following? 1. Decreased urinary output 2. High platelet count 3. Visual disturbances 4. Grand mal seizure
4
Hemorrhagic Conditions of Late Pregnancy --Placenta Previa •incidence •risk factors 7 •types/degree 3 •diagnosis 2
:placenta previa: placenta first -Incidence:1 in 200-300 pregnancies -Risk factors: •Age, multiparity, prior c-section, prior D&C, previous placenta previa, smoking & cocaine use --any vasoconstrictive substances increase the risk of un-normal implantation & early separation -Types/Degree •Marginal, Partial, Total --Marginal: margin of placenta is near the margin of the cervical os, women can deliver vaginally with this, the fetal head acts as a tampon and blocks the bleeding.. but most previas are delivered c/s now days --partial: part of the placenta covers part of the cervical ox --complete: placenta completely covers the cervical os --know if the previa is anterior or posterior, if anterior a c/s could cut right through the placenta-- always have 2 units of crossmatched blood for mom in the OR and 2 units of O negative CMV negative blood (cyotomegalovirus) for baby (we don't know the babies blood type yet) -Diagnosis: •Usually diagnosed by US •Sudden onset of painless uterine bleeding in the latter half of pregnancy --for the test know that they are associated with painless bleeding
Diabetes and Pregnancy --Screening & Assessment
>>Glucose challenge test @ 24-28 weeks - 50 gram load - test in 1 hour - if > 140 mm/dl = schedule 3 hour oral glucose tolerance test (OGTT) >>Oral glucose tolerance test - take blood glucose values fasting and then at 1, 2 and 3 hours after ingestion of a 100 g oral glucose (see p. 650 for values) >>Urine dip for sugar non specific. Ketones are significant due to acidity of blood (pH) affecting fetus. Check for asymptomatic bacturia. >>Obtain baseline; ECG & opthalmic exam especially in Type I diabetics in poor control
Diabetes and Pregnancy --Maternal Risks 8
>>Hydramnios (10 - 20%) with PROM --nomal AFI >5 <20 -->20 >>Pre-eclampsia (roommates, present together a lot) >>Hyperglycemia & ketoacidosis >>UTI & vaginitis >>Labor dystocia (difficult labor) --large baby >>Birth Injury to maternal tissue
Hemorrhagic Conditions of Late Pregnancy >>Abruptio Placentae -definition -incidence -causes 7 -leads to: 4 -partial, marginal, complete
>>Abruptio Placentae - Placental Abruption: -Definition: Separation of placenta before the fetus is born -Incidence: .5% to 1% of pregnancies. Accounts for 10% - 15% of perinatal deaths --varies by population -Causes: Maternal hypertention, smoking, multigravida, short umbilical cord, abdominal trauma (more common if pt has an anterior placenta.. car accident pts must stay in hospital for minimum 4 hrs) , drug use (causes vasoconstriction), coagulopathies, autoimmune disorders -Leads to hemorrhage and hypovolemic shock in the mother and anoxia, blood loss and PT (preterm) delivery in the fetus Partial abruption: separation right in the center of the implantation of the placenta, you may not see any bleeding because its all encapsulated by the placenta. however you can see these on ultrasound.. so if someone is c/o abdominal pain with a firm stomach that does go away, we can look on ultrasound and see an accumulation of blood encapsulated in the placenta Marginal abruption: gives the most bleeding, because the separation is on the margin of the placenta and the blood escapes out of the vagina. very scary. Complete Abruption: placenta is completely separated from the wall of the uterus --all the blood is behind the placenta, so there may be minimal bleeding --as uterus fills with blood, it contracts, so you get this really hard dense abdomen.. and it is painful Abruption: causes PAIN (test question)
Other Preexisting Medical Conditions
>>Asthma >>Epilepsy- most anti-seizure meds are teratogens --hard to manage, almost all anticonvulsant meds are teratogens >>Hepatitis B --screen for this and give babies prophylaxis at delivery >>Hyperthyroidism --interfere with fertility >>Hypothyroidism --interfere with fertility >>Multiple Sclerosis --mobility issues r/t relaxants, and some of the mechanics of childbirth >>Rheumatoid Arthritis >>Systemic Lupus Erythematosus (SLE)- pregnancy can worsen maternal condition --hard to manage during pregnancy
Adolescent Pregnancy Cont.
>>Birth rate in the 15-19 year age group dropped last year to a record low of 24.2 per 1000 births. >>This age group is generally less prepared for the emotional, psychological and financial responsibilities and challenges of parenthood >>Statistically more likely than their non-pregnant peers to experience: -Reduced educational attainment -Fewer employment opportunities -Relationship instability
Non Hemorrhagic Pregnancy Complications: Hyperemesis -characterized by: -when does it start? -can lead to: -may be due to: 5
>>Characterized by persistent, uncontrollable nausea and vomiting. 5% or more weight loss from pre-pregnant weight >>Starts early but may persist throughout pregnancy >>Can lead to acidosis, alkalosis, ketosis, vitamin deficiencies >>May be due to allergy to fetal proteins, excessive levels of HCG, estrogen, thyroid dysfunction or H Pylori.
HELLP syndrome -Dx -Tx 5
>>Diagnosis -CBC and liver function tests >>Treatment -Seizure precautions (Magnesium Sulfate) ↓CNS irritability -Regulate blood pressure <160/110 -If close to term - deliver ASAP -Transfusion as needed -Corticosteroids for fetus as indicated
Morbidly Adherent Placentas (MAPs) (not on test) -diagnosis -continuum of severity -incidence
>>Diagnosis made by Utrasound >>Continuum of severity: accreta, increta, percreta >>Incidence increasing with the rise in C/S >>Overall C/S rate in the 70's - 5.5% >>Increase to 32.8% by 2012 >>Type of abnormal implantation depends on the degree of trophoblastic invasion of the uterus.
Diabetes and Pregnancy Tips
>>Diet >>Exercise >>BG monitoring >>Fetal Surveillance •Perinatal mortality has decreased from 40% to 5% for those with pre-existing diabetic condition i.e. Type I or Type II •Perinatal mortality is now no different in Type I versus Gestational Diabetes •These outcomes are due to careful prepregnant management and prenatal care
Rh Incompatibility --what happens --% if women who need tx --what is given and when
>>Expectant mother is Rh - and fetus is Rh + >>15% of white women in the US are Rh - >>Isoimmunization happens when the fetal Rh+ blood mixes with the mothers Rh- blood >>Resulting antibodies destroy the fetal red blood cells >>First child is usually not affected, exposure is minimal --second pregnancy is where the issue comes up.. because mothers body has already began to make antigens.. your blood system will begin hemolysis of the fetal RBCs >>Pregnancy woman is not affected >>RhoGAM (immune globulin) prevents antibody formation, a Rh negative mother is given at 28 weeks gestation and after birth if baby is Rh+ --must be given first 72hr postpartum in the hospital, some women have to come back into the clinic and get a second dose --fetal index: looking at maternal serum for the presence of fetal hemoglobin, if levels are elevated you know she has had an exposure to the babies blood, and if she is Rh- she will need a dose
Role of Prenatal Care
>>Frequent monitoring of maternal & fetal status >>Opportunities for education >>Periodic testing >>Identification of risk and early intervention
Hypertension During Pregnancy •Pre-eclampsia --characterized by: 6
>>Generalized vasospasm/vasoconstriction >>Endothelial cell damage >>Peripheral vascular resistance increases >>Circulation to all body organs is decreased --why other organs are involved >>Hematologic changes, fibrin deposits in placenta and infarctions in the placenta, tissue ischemia, hypovolemia due to fluid shifting, and increased CNS irritability. --generalized edema (hands and face) associated with pre-eclampsia
Hemorrhagic Conditions of Early Pregnancy >>Gestational trophoblastic disease (other name?) -defined -complete/partial -tx -incidence
>>Gestational Trophoblastic Disease (Molar Pregnancy) -Defined: Abnormal proliferation/rapid reproduction of trophoblasts (cell which provide nutrients to the embryo and develop into a large part of the placenta) into grape-like masses of fluid filled cysts that fill the uterus. -Complete: No fetus or fetal tissue present. Ovum fertilized by sperm which duplicates its own chromosomal material and inactivates that of ovum. --no fetal tissue in most of these --rapidly growing vesticular, cyst like structures that fill up the uterus -Partial: Fetal tissue and membranes present. Paternal genetic contribution double that of the maternal. --can lead to the development of choriocarcinoma -Any fetus present will be anomalous (abnormal) -must clear the uterus out -Incidence: 1:1000-1500 pregnancies.
Diabetes and Pregnancy --Fetal and Neonatal Risks 10
>>Hypoglycemia, hypocalcemia, hyperbilirubinemia and respiratory distress syndrome >>Congenital malformations (5 - 10% 1st trimester teratogen) >>Congestive cardiomyopathy - CHF >>Respiratory Distress Syndrome --high glucose levels result in diminished surfactant production >>Macrosomia (>4000gm) & birth injury >>Decreased placental perfusion - IUGR (advanced DM with vascular involvement) >>Unexplained fetal death --stillbirth more common in gestational diabetics than normal >>Metabolic abnormalities
Diabetes and Pregnancy --incidence --management
>>Incidence: -Gestational diabetes will develop in about 7% of pregnancies (but the range is from 1-14% among different ethnic groups) >>Management of DM in pregnancy is complicated by changing insulin requirements -decreased in early pregnancy -Increased in second trimester -May double or quadruple by the end of pregnancy
Hypertension During Pregnancy •Pre-eclampsia --incidence --older term --how many pre-eclamptic before eclamptic? --maternal mortality --often associated with..
>>Incidence: 5 - 8% of pregnancies >>Older Term: Toxemia of pregnancy >>Pre-eclampsia versus Eclampsia -1% of pre-eclamptics become eclamptic -2nd leading cause of maternal mortality -Often associated with IUGR (intrauterine growth restriction): 40 weeks gestation but weigh 3.5lbs ---hypertension interferes with the functioning of the placenta, it ages and calcifies the placenta, it doesn't perfuse well, so it can really restrict the growth of the fetus -Distinction is now made between preeclampsia and preeclampsia with severe features when symptoms associated with organ damage occur. --multiorgan systems damage symptoms we warn people to be aware of: headaches, blurred vision, epigastric pain •when these symptoms occur, you know the disease has progressed and it effecting multiple organs (we call these severe features)
Non Hemorrhagic Pregnancy Complications: Cholestasis of Pregnancy -definition -physio -risk factors 3 -complications 3 -tx
>>Intra hepatic cholestasis is characterized by pruritis/itching without rash >>Bile acids are elevated and 60% of cases show elevated transaminase levels, and 20% will have elevated direct bilirubin levels >>Risk factors: multiple gestations, chronic Hepatitis C, prior HX of cholestasis (50-60% recurrence) >>Complications: Increased risk of PT delivery, abnormal FHR patterns, IUFD >>TX: Induction at 37-38 weeks, UCDA for itch --relatively new drug that reduces the itch
Anemia in Pregnancy
>>Iron deficiency anemia is the most common complication of pregnancy - associated with preterm labor and low birth weight in extreme cases >>Defined as - Hgb below 11 g/dL >>Folic Acid deficiency anemia >>baby robs you of all your iron >>Thalassemia & Sickle Cell are anemias with genetic components and specific treatments
Hypertension During Pregnancy •Pre-eclampsia Pathophysiology in Organs --kidneys --liver --placenta --labs we do for hypertensive workup
>>Kidneys -Capillary vessels narrow, Cells swell -GFR decreases allowing protein to leak across the glomerular membrane (Proteinuria) -Increase in blood urea nitrogen/BUN, creatinine and uric acid -Fluid shifts into interstitial space (causes edema) >>Liver - Decreased circulation to the liver (this causes epigastric pain) leads to hepatic edema and subcapsular hemorrhage and necrosis (epigastric pain) - Patients with severe features will have epigastic pain and elevated liver enzymes --figure out if the pain is d/t heartburn, take a tums, review history -Fibrin clots form with risk of possible hepatic hematoma --CBC w/ platelets (we want to make sure we are not moving towards thrombocytopenia--this could lead to DIC if hemorrhage occurs after a decreased platelet count), BUN, creatinine, uric acid, **AST/ALTs (liver enzymes) --Placenta is effected by the vasoconstrictive events too: placenta perfusion is diminished, age prematurely, fibrin deposits
Hypertension During Pregnancy •Pre-eclampsia Pathophysiology in Organs --Lungs --CNS --Placenta
>>Lungs -Pulmonary capillary leaks - Pulmonary edema and dyspnea -Hemorrhagic bronchopneumonia --lung finding are late findings >>CNS -Vasoconstriction of cerebral vessels - rupture of thin-walled capillaries - small cerebral hemorrhages -Headache and visual disturbances (blurred vision/spots) -Hyperreflexia as CNS irritability increases (+4 w/ clonis.. getting close to seizures -Seizures >>Placenta -Infarctions increasing risk of abruptio placentae and hemorrhage and DIC -Premature aging - IUGR -Thrombosis -Calcifications
Hyperemesis --more common in --wight gain --outpatient Tx -psychological
>>More common in white women >>Poor weight gain can lead to low birth weight infants >>Outpatient treatment with antiemetics most common today, but hospitalization for nutritional support may be needed. --zofran safe for first trimester use >>Strong psychological component, but this is not the major cause --used to be associated with an unwanted pregnancy, but this is not the case anymore --many women who have excessive emesis, do not miscarry. d/t the high hCG levels
Adolescent Pregnancy
>>Often receive late prenatal care >>Smoking and drug use may be common >>Often have deficient diets >>Teens 15 - 19 have a higher incidence of STDs >>At increased risk for -Preterm births -Low birth weight -Pre-eclampsia -Iron deficiency anemia -CPD
Diabetes and Pregnancy --pathophysiology 7
>>Partial or complete lack of insulin secretion >>Glucose accumulates in the blood - hyperglycemia >>fetus attempts to dilute blood by over producing urine -Polydipsia -Fluid shift from intracellular space into vascular compartment - osmotic diuresis (polyuria and glycosuria) and subsequent dehydration --excess amniotic fluid// polyhydramnious >>Body metabolizes protein and fat - ketosis >>Damage to small blood vessels throughout the body
Hypertension During Pregnancy --pre-eclampsia --eclampsia -gestational hypertension -chronic hypertension
>>Pre-eclampsia: -SBP > 140mm Hg or DBP >90 mm Hg after 20 weeks gestation that includes multisystem involvement. -Proteinuria may be present with renal involvement (this used to be the thing that determined this diagnosis, not it has been found that someone can have pre-eclampsia without proteinuria) >>Eclampsia: --all our tx is directed as preventing eclampsia -Progression of pre-eclampsia to generalized seizures >>Gestational hypertension: -Elevated BP alone after 20 weeks gestation. 15-25% (high rate) of these patients will develop superimposed preeclampsia as pregnancy develops >>Chronic hypertension -Pre-existing hypertention: BP 140/90 prior to pregnancy or before the 20th week - 25% may develop Pre-eclampsia with greater perinatal risk of morbidity. This category includes patients with persistently elevated BP 12 weeks after delivery --often this diagnosis is given during pregnancy
Hemorrhagic Conditions of Early Pregnancy >>Spontaneous Abortions •Definition •Incidence (3) •Causes (6) •Complications associated with SAB (4) •TABs •POCs
>>Spontaneous Abortion (Miscarriage) (SAB) -Definition: Loss of pregnancy before the fetus is viable (24 weeks is the lower limit of viability) -Less than 20 weeks gestation -Less than 500 gms --we no longer weigh the products of conception (POCs: fetus, placentas, membranes) in a non-viable pregnancy --you may see a fetus at 18-20 weeks, being delivered as a SAB (still born) -Incidence: •<20 years old = 12% •>40 years old = 26% •Most SABs occur in the first 12 weeks of pregnancy -Causes: •Chromosomal abnormalities, Teratogens /chemical exposure can cause fetal death, Low thyroid and other low hormone levels, infections, implantation problems (as we've increased our assisted reproduction practices, we've seen more implantation problems and SABs), auto immune disorders -Complications: •Hemorrhage, Infection, RH factors, DIC (disseminated intravascular coagulation). •TABs: therapeutic abortions •POCs: products of conception: placentas, membranes, fetuses
Hemorrhagic Conditions of Early Pregnancy >>Spontaneous Abortions •Six Subgroups •NEED TO KNOW
>>Threatened SAB (50% will succeed) --these are the people that bleed, only 50% will go on to miscarry >>Inevitable or imminent --cervix is dilated/ROM present --woman walks into ER: cramping, bleeding, parts hanging from her vagina, fully dilated.. she will deliver that fetus imminently --generally these are complete abortions >>Incomplete --the baby comes out and the placenta and membranes do not --not all POC are evacuated from the uterus in the process of miscarriage --evacuating the uterus after an incomplete is very important (D&C): anything left inside increases risk of infection and hemorrhage (we can determine with ultrasound if anything is left inside) >>Complete --everything comes out >>Missed (no cramps/brownish discharge) --fertilization occurs, and fetal development starts but it doesn't continue, --mom may have some mild pregnancies symptoms and some spotting, when she goes in for her first transvaginal ultrasound for dating, they can see a gestational sac, but no heartbeat --often no s/s of a SAB but woman will need a D&C >>Habitual (3 or more SAB's) --primary cause: incompetent cervix, this is a cervix that does not have enough structural integrity to support the growing weight of a pregnancy •may be d/t: anatomically short cervix •as the uterus and fetus grow.. the cervix silently dilates and miscarriage will usually happen by the end of the first trimester --TX: do an ultrasound for cervical length, and then perform a cerclage: stitch the cervix in a circular fashion and pull the sutures tight, supports the cervix long enough to get the woman to the third trimester •a very effective Tx
Diabetes and Pregnancy -type 1 -type2 -gestational
>>Type I (IDDM) - 5-10% of diagnosed cases -Pancreatic beta cells that produce insulin are destroyed by the body's immune cells. Partial or complete lack of insulin production. Insulin deficient category >>Type II (NIDDM) - 90-95% of diagnosed cases -Insulin resistance - body cells do not metabolize carbohydrates properly >>Gestational Diabetes Mellitus- -Onset of glucose intolerance during pregnancy --similar to type 2 -Carbohydrate intolerance - 35-60% of women with GDM may progress to develop diabetes within 10-20 years.
Infections During Pregnancy
>>Vaginal Infections: -Candidiasis (Yeast), Bacterial vaginosis (Gardnerella) >>Urinary Tract Infections: -Asymptomatic Bacteriuria, Cystitis, Acute pyelonephritis >>Non-Viral: -Toxoplasmosis (if you've ever had a cat you're probably immune... dont clean the cat poop), Group B strep (GBS--normal flora in a woman's vagina, can only effectively tx GBS if its a UTI (because the bladder is a sterile separate organ), it is not a normal flora for baby.. at 36 weeks every woman is screened for GBS, they are negative or positive, if they are positive we want them in the hospital sooner rather than later esp. if they have ROM, and we start penicillin when labor begins, 2 doses 4hrs apart during labor is optimum, if there isnt time to treat with 2 doses (underrated) we ask mom to stay with baby in hospital for 48 hrs to watch the baby), Tuberculosis
Magnesium sulfate is responsible for: Decrease CNS activity and reduces seizure potential Encourages fetal maturation Lowers blood pressure Causes peripheral vasconstriction
Decrease CNS activity and reduces seizure potential
Hypertension During Pregnancy •Pre-eclampsia --strategies for minimizing risk/prevention
Diet and exercise to maintain a healthy weight Use of low dose aspirin (blocks thrombaxane) in women with previous HX, chronic HPTN, multiple gestations, pregestational diabetes, renal disease Post-partum: Recent studies show that preeclampsia can be exacerbated after delivery or present in PP. Use Magnesium Sulfate for new onset PP HPTN, especially if severe features are present. --mag sulfate is an anticonvulsant and is used to treat pre-eclamptics when signs are pointing towards severe features (elevated enzymes ) Monitor BP for as long as 4-6 weeks PP
D&C LPIs
Dilation and curettage refers to the dilation of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping. It is a therapeutic gynecological procedure as well as the most often used method of first trimester miscarriage or abortion. --LPIs: late preterm babies: 34-37 week
Hemorrhagic Conditions of Late Pregnancy -DIC: Disseminated Intravascular Coagulation
Disseminated Intravascular Coagulation --a response to hemorrhage --intravascular warfare, two separate factions trying to correct hemorrhagic problem, working against each other -Coagulation defect - anticoagulation and procoagulation factors are stimulated at the same time. -Thromboplastin is released into the maternal blood stream and activates clotting in small blood vessels all over the body consuming fibrinogen and platelets. -At the same time the fibrinolytic system is activated which works to destroy clots. -This results in a decrease in clotting factors and an increase in anticoagulants leaving the circulating blood unable to clot. -Bleeding can occur from any area: bleeding from IV sites, noses, ears, vaginally
Diabetes and Pregnancy --early pregnancy --late pregnancy
Early Pregnancy - Rise in estrogen, progesterone and other hormones stimulate increased insulin production & increased tissue response to insulin Later Pregnancy - increased human placental lactogen, prolactin, cortisol and glycogen levels cause increased resistance to insulin and decreased glucose tolerance --need for insulin goes up dramatically in later pregnancy
Ectopic Pregnancy -diagnosis 2 -treatment 5 -fetal mortality -maternal mortality
Ectopic Pregnancy -Diagnosis: Transvaginal ultrasound Serum hCG may be done -Treatment: Medical or surgical depending on whether or not the fallopian tube is intact. --Remove ectopic. Tuboplasty if possible (this will cause tube scarring and more chance of it happening again next pregnancy) --Methotrexate (Cytotoxic) or surgical removal •methotrexate is an anti-cancer drug: has the same action on the rapidly growing fetal tissue, that it has on tumor cells, kills fetus --antibiotics --Replace fluid loss: Pre/post care and Rhogam if Mom RH neg -Fetal Mortality: 100% -Maternal Mortality: 1 in 800 •because we are getting women in early and doing early transvaginal ultrasounds, this statistic is not increasing as the incidence increases
Gestational Hypertension Presents before 20 weeks and continues with vaspastic pathology Is observable before pregnancy Presents after 20 weeks and is associated with vaspastic pathology All the above
Presents after 20 weeks and is associated with vaspastic pathology
Morbidly Adherent Placenta -risk factors 4 -accreta, increta, percreta --all maps increase risk of:
Risk factors: prior uterine surgery, maternal age, placenta previa, parity of 3 or more (3+ c/s) Accreta involves invasion of trophoblastic cells into superficial layers of the uterus Increta involves invasion into the myometrium (deeper) Percreta involves invasion beyond uterine serosa (can actually exit the uterus) All MAPS increase risk of bleeding and cesarean hysterectomies, maternal mortality These abnormal implantations are the leading cause of cesarean hysterectomies. Mortality can be as high as 10%. Strong link between the incidence of accreta and C/S. With 5 prior C/S the risk can be as high as 5%. If the patient has a history of placenta previa the risk can be as high as 40%.
Infections
Viral: -Cytomegalovirus (CMV: fetuses are very susceptible to CMV infections.. virus that a lot of us have been exposed to and are portal immune to, but fetuses are very susceptible to it), Rubella, Varicella-Zoster (chicken pops you dont want to get during first or third trimester, Herpes 1 & 2, Parvovirus B19 (get from toddlers, hand foot mouth disease), Hepatitis B, HIV (no that moms with HIV should not breastfeed-- test question) STD's: -Syphilis, Gonorrhea, Chlamydia, Trichomoniasis, HPV
Magnesium Sulfate
anti-convulsant --usually start with 4gm bolus over 20 minutes and a maintenance dose of 1-2gm/hr.. follow reflexes and symptoms.. --important to Tx pre-eclampsia early before seizures check for: respirations (respiratory depressant), hypoactive reflexes
EBLs vaginal + c/s
estimated blood loss --vaginal delivery: 500 --c/s 800-1000
Which of the following signs is not an indication of magnesium toxicity? Muscle Weakness Decreased fetal variability Hypertension Bradypnea
hypertension profound vasodilator and anticonvulsant you will see all other things
Hypertension During Pregnancy •Pre-eclampsia --S/S 8
these are the ones to teach patients to look out for Elevated BP Proteinurea Brisk DTRs (deep tendon reflex) Headaches Visual disturbances - blurred or double vision or spots Edema and rapid weight gain Epigastric pain Decreased urinary output --follow very closely in postpartum --must put out >30ml an hour for their kidney function to return to normal
HELLP syndrome --definition --incidence --pathogenesis 3 --cascade/pathophysiology
•Definition: -Severe disorder exhibiting multiple organ damage. Hemolysis (rupture/destruction of RBC), Elevated Liver enzymes, and Low Platelet count •Incidence: .2 - .6% of all pregnancies, frequently associated with pre-eclampsia, but it can be a totally separate entity. Morbidity and mortality rates as high as 25% •Pathogenesis: is unclear. Attributed to abnormal vascular tone, vasospasm and coagulation defects. •Cascade: Microvascular endothelial damage with elevated bilirubin and intravascular platelet activation, Hct gradually declines, platelets drop, liver enzymes increase, high uric acid, decreased creatinine clearance, systemic thrombocytopenia
Hypertension During Pregnancy •Pre-eclampsia --Management •for pre-eclampsia 9 •for pre-eclampsia with severe features 3
•Delivery is the only definitive treatment for pre-eclampsia --although if you have multi-system organ damage don't tell family/partners that this is a 100% cure, long-term damage may have already taken place, there has been deaths in postpartum d/t severe organ damage, esp. CNS damage.. which lead to strokes (not on test) •For pre-eclampsia -Rest -Frequent fetal assessment-NSTs, AFI, ultrasounds for growth -Monitor BP, weight, DTR -Urine assessment for protein including 24 hr urine as indicated -Induction of labor after 37 weeks based on severity -For pre-eclampsia with severe features -Induction of labor after 34 weeks based on findings •Anticonvulsant medication (Magnesium Sulfate) ↓CNS irritablity •Antihypertensive medications (nifedipine or labetalol)
Anemia in Pregnancy --Risks + Tx
•More susceptible to infection •Delayed healing of wounds •Fatigue •PP Hemorrhage •LBW of infant, prematurity, stillbirth if severe •Prevention is KEY •30 mg/day supplements to start and increase to tolerance as needed -Prevent constipation -Give with Orange Juice to increase absorption (make sure it isnt calcium fortified, calcium and iron fight for binding sites) •Iron rich diet •Folate supplements- as high as 1mg daily
Hemorrhagic Conditions of Early Pregnancy --incidence --primary causes of bleeding + pregnancy loss (3)
•Vaginal bleeding occurs in up to 25% of first trimester pregnancies --can be very frightening, reassure women as much as we can, hold on and lets get a diagnosis •Primary cause -Spontaneous abortion -Ectopic pregnancy -Gestational trophoblastic disease