Hehi Test #3 - Pregnancy Complications

Front 1

Classifications of Hypertension in labor

Back 1

1. Chronic hypertension
2. Pre-eclampsia/ Eclampsia
3. Chronic hypertension with superimposed pre-eclampsia
4. Gestational hypertension

Front 2

Chronic Hypertension

Back 2

- Before pregnancy or prior to 20 weeks gestation
- Does not resolve postpartum (persists after 12 weeks post partum)

Front 3

Pre-eclampsia

Back 3

- After 20 weeks Estimated Gestational Age
- Previous Names - toxemia & PIH (pregnancy induced hypertension)

*In presence of trophoblastic disease, preeclampsia can occur before 20 weeks gestation

Front 4

Pre-eclampsia - after 20 weeks EGA

Back 4

- Hypertension - BP>140/90
- Proteinuria - 0.3 grams in 24 hr. urine (30 mg/dl); 1 + dipstick
- Edema (may/ may not be present) - generalized, weight gain of 2 kg or more/ week

Front 5

Eclampsia

Back 5

Pre-eclampsia with SEIZURE ACTIVITY

Front 6

Chronic hypertension with superinposed pre-eclampsia

Back 6

1. New onset of proteinuria
2. Sudden increased in BP (previously well controlled)
3. thrombocytopenia (plt. < 100,000
4. Increased liver enzymes

Front 7

Gestational Hypertension

Back 7

- Increased BP
- PIH = pregnancy induced hypertension

*No proteinuria, No edema, No systemic disease process

Front 8

Risk Factors for developing hypertension

Back 8

1. Nulliparity or 1st pregnancy with new partner (possible autoimmune reaction)
2. Age: <19 or >353. multiple gestation
3. Hydatiform mole
4. Aftican-American
5. Family History of preeclampsia
6. Obesity
7. Chronic hypertension
8. Diabetes mellitus
9. chronic renal disease
10. Preeclampsia in previous pregnancy
11. Vascular and connective tissue disease
12. Thrombophilias

Front 9

Hypertensive disorders in pregnancy

Back 9

- 6-8% of all pregnancies
- Most common medical conplication in pregnancy
- Increasing in incidence; eclampsia is decreasing in incidence
- 2nd leading cause of maternal death in U.S. (after DVT)

Front 10

Cure of hypertension in pregnancy

Back 10

DELIVERY

We have no idea as to what causes it

Front 11

Preeclampsia/ Eclampsia

Back 11

1. Cure = delivery = preterm patient

*Preterm infants delivered due to preeclampsia tend to do better because of intrauterine stress

Front 12

Pathophysiology of Preeclampsia

Back 12

- Intermittent vasoconstricion
- Platelet plugs form in attempt to repait endothelial lining
- Constricted areas become weak and porous - endothelial lining with holes causes 3rd space leaking (edema)
- Leaking causes decreased volume in vessel
- Decreased CO2 and organ perfusion

Front 13

Maternal Cardiac complications of preeclampsia

Back 13

1. Dysrrhythmias
2. Congestive heart failure
3. Myocardial infarction

Front 14

Maternal Cerebral complications of preeclampsia

Back 14

1. Hemorrhage
2. thrombosis
3. Hypoxia
4. Edema

*#1 reason women seize

Front 15

Maternal Hematologic complications of preeclampsia

Back 15

1. Disseminated intravascular coagulation - massive consumption of platelets
2. Hemorrhage

Front 16

Maternal Hepatic complications of preeclampsia

Back 16

1. Elevated liver enzymes
2. Necrosis
3. Rupure

*Liver operations = massive blood loss

Front 17

Maternal Pulmonary complications of preeclampsia

Back 17

1. Acute airway obstruction - eclampsia
2. Pulmonary edema - non-cardiogenic = vascular damage in pulmonary vasculature; Cardiogenic = fluid volume overload

Front 18

Maternal Renal complications of preeclampsia

Back 18

1. Oliguria - volume + decreased perfusion to kidney
2. Acute tubular necrosis
3. Cortical necrosis - chronic renal failure

Front 19

Maternal Retinal complications of preeclampsia

Back 19

1. Detachment
2. Hemorrhage

Front 20

Fetal complication of preeclampsia

Back 20

1. Abruption
2. Placental infarction - seperation of placenta from uterine wall
3. IUGR
4. Acute hypoxia
5. Prematurity
6. Death

Front 21

HELLP syndrom

Back 21

H - Hemolysis
EL - Elevated Liver Enzymes
LP - Low Platelets

Front 22

HELLP - Hemolysis

Back 22

- Vasospasms -> RBC lysis (decreased oxygen carrying ability)

Front 23

HELLP - Elevated Liver Enzymes

Back 23

- Vasospasms
- Intra-arterial lesions
- Platelet aggregation
- Fibrin accumulation
- Microemboli in hepatic vasculature

Liver Enzymes - SGPT

Front 24

HELLP - Low Platelets

Back 24

- <150,000
- Vasospasms
- Platelet consumption

*Significantly low = <100,000

Front 25

Identification of HELLP syndrome

Back 25

- Labs - platelets and liver enzymes

- Symptoms: pre-eclampsia, headache, blurred vision, RUQ pain (indicates liver involvement), nausea, vomiting

*Jaundice is possible, but would be a very late symptom

Front 26

Clinical Management

Back 26

1. Magnesium Sulfate: indication - prevent vs. control seizures

Administration: 4-6 g. IV loading dose over 30 min.; 1-2 g./ hr IV basal rate; 10 g. IM (5+5) q4h
12-24 hours post partum

Front 27

Clinical Management - Pre-Eclampsia

MgSO4 - High alert medication

Back 27

1. MGSO4 Nursing Care (think neuromuscular blockade)
- VS - RR watch trends
- Check DTRs q1-2h
- Auscultate breath sounds q2h
- foley Catheter excreted in urine
- I&O qh (oliguria)
- Fluids on a pump
- Bedrest - pt. are weak and lethargic, side rails up

Front 28

Anti-hypertensive Therapy

Back 28

Pharmacologic Management in hypertensive Crisis (treat any BP with diastolic > 110
First line Meds:
- Hydralazine
- Labetolol (Beta Blocker)
- Nifedipine (Calcium channel blocker)

Second Line Meds:
- Sodium Nitroprusside (not used unless patient is about to deliver, because byproduct is cyanide, which is a taratogen that crosses the placenta)
- Nitroglycerince

Front 29

Eclampsia Protocol

Back 29

1. MgSO4 Initial Dose =4-6 g. IV over 5-10 min.
2. Continuous IV dose = 2-3 g/hr.
3. Recurrent Seizure = 2-4 g IV over 3-5 min.
4. Recurrent Seizure = Paralyze and Intubate

(Paralyze-Intubate-Sedate)

Front 30

Nursing Management of Eclampsia

Back 30

1. BP measurement - look for trends
- Positon: sitting position - ambulatory setting; Semi-reclining - hospital setting
- Arm Heart level
- Appropriate size cuff
- Other considerations: meds, anxiety, talking

Front 31

Nursing Management

Back 31

Measure Proteinuria
- > 0.3 g protein/ L of 24 hour urine
- > 0.1 g protein/ L (2 + urine dipsticl
* 2 random urine samples
* > 4 hours apart

Front 32

Nursing Management

Back 32

1. Nurse: Patient ratio
2. MgSO4: DTR's every hour
3. Frequent VS
4. Medications to control BP - do not drop below 90-95 (diastolic)
5. I&O every hour
6. Labs
7. Auscultate lungs

Front 33

Nursing Management: Eclampsia

Back 33

1. Protect patient - seizure precautions
2. Turn to side - decrease aspiration
3. Administer MgSO4 IV
4. Assess type of seizure, duration, physical activity, and fetal response (similar to code)
5. Suction and oxygenate after seizure
6. Document.

YOU CANNOT GET AN AIRWAY IN PATIENTS WHILE THEY ARE SEIZING SO DON'T TRY.

Front 34

Nursing Assessment and Management - Fetal Assessment and Uterine Activity assessment

Back 34

During a seizure, baby get bradycardia (mom is not breathing)
1. FHR - baseline, variability, patterns
2. Fetal movement

Uterine Activity Assessments:
1. Uterine contractions - frequency, duration, intensity
2. Resting tone

Front 35

Preterm Labor and Birth

Back 35

Defined:
- Delivery of neonate before 37 weeks pregnancy
- Late preterm birth: between 34-36 weeks: accounts for 8.9% of preterm births - 15% increase in 10 years
- Very preterm birth: prior to 32 weeks completed

*related to EGA NOT birth weight

Front 36

Preterm Labor

Back 36

Incidence: 5-15% of all births

Significance: 75-80% neonatal mortality; Neonatal morbidity

Front 37

Low Birth Weight

Back 37

<2,500 grams (5.5 lbs)

Very low birth weight: <1,500 grams
Moderately low birth weight: 1500-2499 grams

1 in 12 babies are low birth weight

Front 38

Preterm Birth - The problem

Back 38

Leading cause of neonatal death
- Major cause of early childhood morbidity and mortality including pediatric neurodevelopmental problems (cerebral palsy and developmental delay) - Thin blood vessels of neonates are likely to rupture - bleeding in brain and hypoxic injury in brain

- No approved drug to treatment of preterm labor currently marketed in the U.S.

- Drugs used off label for treatment of preterm labor have not been shown to improve perinatal outcomes in controlled trials

Front 39

Neonatal consequences of Prematurity

Back 39

1. Respiratory Distress syndrome
2. Intraventricula hemorrhage
3. Bronchopulmonary dysplasia
4. Apnea
5. Necrotizing enterocolitis
6. Patent ductus arteriosus
7. Retinopathy
8. Hyperbilirubinemia
9. Hypothermia
10. Hypoglycemia
11. Feeding problems
12. Long-term physiologic and developmental disability

Front 40

Activation of Maternal/ Fetal Hypothalamic Pituitary Axis

Back 40

1. Stress
2. Increased CRH (Hypothalamus)
3. Increased Cytokines -> Increased estrogen
4. Increased protaglandin production
5. Increased uterine contractions and cervical change

Front 41

Infections that are related to Preterm Labor

Back 41

1. Peridontal Disease
2. UTIs
3. Bacterial Vaginosis
4. STDs
5. Peritonitis
6. Pneumonia

Front 42

Decidual Hemorrhage

Back 42

disruption fo uterine tone - activation of clotting cascade; increased thrombin; uterotonic effect of thrombin: cervical ripening, uterine contractions; breakdown of fetal membranes

Example: abruption

Front 43

Pathologic Uterine Distention

Back 43

1. Multiple gestation
2. Hydramnios
3. Uterine abnormality

Front 44

Indicated Preterm Birth (25% of all pre-term births)

Back 44

1. Hypertension - Chronic (4.9%), Pre-eclampsia (42.5%)
2. Diabetes
3. Placenta previa
4. Placental abruption (6.7%)
5. IUGR (10%)
6. Fetal compromise (26.7%)
7. IUFD (6.7%)

Front 45

Obstetrical or reproductive Risk Factors

Back 45

1. Previous preterm birth
2. Multifetal pregnancy (twins, triplets, octo-mom)
3. Cervical or uterine abnormalities
4. Shrot interval between pregnancies
5. Preterm rupture of membranes
6. Vaginal bleeding
7. Anemia
8. Fetal anomalies
9. Lack ofprenatal care
10. Hydramnios

Front 46

Medical Risk Factors for Preterm labor

Back 46

1. Infections
2. autoimmune disorders
3. Thromboembolic disorders
4. Renal disease
5. Cardiovascular disease
6. Anemia

Front 47

Demographic Risk factors for Preterm labor

Back 47

1. Maternal age <12 or >35 (extremes)
2. Ethnicity (African-Americans)
3. Low socioeconomic status
4. Unmarried
5. Low level of education

*3-5 associated with little - no prenatal care

Front 48

Behavioral and Lifestyle Risks for Preterm Labor

Back 48

1. Smoking
2. Alcohol and substance abuse - Meth.
3. Domestic violence
4. Lack of social support
5. Stress - physical and emotional
6. Long working hours with long periods of standing

Front 49

Screening for Preterm Labor

Back 49

1. Assessment of risk factors
2. Cervical exam
3. Ultrasound - cervical length, dilation
4. Detection of fetal fibronectin in cervical and or vaginal secretions

Front 50

Diagnosis of Preterm Labor

Back 50

1. Persistent uterine contractions q10 min for 1 hour
AND
2. Documented cervical change
OR
3. Cervical effacement > 80%
OR
4. Cervical Dilation > 1 cm.

Front 51

Cervical Assessment related to Preterm Labor

Back 51

Risk of preterm birth associated with :
1. Cervical dialtion before 30 weeks gestation
2. Cervical length < 25 mm

Front 52

Management of Preterm Labor

Back 52

1. Patient Education:
- Risks
- Symptoms or preterm labor
2. Bedrest
3. Hydration
4. Tocolusos - stop uterine contrations

*2-4 not proven effective

Front 53

Management of Preterm Labor - Nursing Management

Back 53

1. Initial assessment and observation
2. Change in cervical dialtion - recheck cervix - same provider if possible
3. Uterine contraction monitoring
4. Electronic fetal heart rate monitoring
5. urinalysis
6. Ultrasound
7. Cultures

Front 54

Terbutaline

Back 54

Tocolytic Medication

Side Effects: maternal-fetal tachycardia, hypotension, pulmonary edema, hyperglycemia

Front 55

MgSO4

Back 55

Tocolytic Medication

Side Effects: Respiratory Depression, headache, flushing, nausea

Front 56

Nifedipine

Back 56

Tocolytic Medication

Side Effects: hypotension, headache, flushing, nausea

Front 57

Indomethacin

Back 57

Tocolytic Medication

Side Effects: Nausea, heart burn, oliguria, premature constriction of ductus arteriosus

Front 58

Adjunctive therapy for Preterm Labor

Back 58

1. corticosteroids (glucocorticoids)
- Promote fetal lung maturity and decrease the incidence of RDS in preterm infants

Front 59

Betamethasone

Back 59

Glucocorticoid medication administered to preterm infants to promote fetal lung maturity

Two doses, 12 mg IM q24h

Front 60

Dexamethason

Back 60

Glucocorticoid medication administered to preterm infants to promote fetal lung maturity

Four doses, 6 mg IM q12h

Front 61

Adjunct Therapy for Preterm Labor

Back 61

1. Antibiotics - infection is a major contributer to preterm labor

cultures first, if cultures are (-), antibiotics are stopped

* EES
* PCN/ Ampicillin
* Clindamycin

Front 62

Patient Education and Support

Back 62

* Signs of preterm labor
* Help women and families grieve and accept reality of impending preterm birth
* Involve families in developing maternal and newborn plan of care
* Prepare families and discss expectations for thebirth of preterm neonate

Front 63

Cervical Cerclage

Back 63

For cervical insufficiency which complicates 2% of all pregnancies and its responsible fore 20% of late 2nd trimester losses

- Prophylactic cerclage - 12-14 weeks

- Rescue Cerclage - when cervix changes already detected

Front 64

Preterm Labor considerations

Back 64

viability threshold/ Maternal Transport

Gestational Age/ Survival %

23 weeks/ 0-8%
24 weeks/ 15-20%
25 weeks/ 50-60%
26-28 weeks/ 80%
29 weeks/ 90%

Front 65

Considerations for Preterm Delivery

Back 65

1. Nursery capabilities
2. Risk benefit ratio with tocolytics

Front 66

Pretuerm Premature ROM

Back 66

1. Limit cervical exams (limits transmission of bacteria)
2. Assess for S/S of infection:
- Foul smelling AF
- Maternal fever
- Fetal tachycardia - maternal tachycardia
- BPP decreased scores
- Tender fundus
2. Bedrest
3. Prepare patient for preterm birth