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56 Cards in this Set
- Front
- Back
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Preeclampsia
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Unknown etiology
„ Risk factors „ Chronic renal failure „ Chronic hypertension „ Multifetal gestation „ Primigravida „ Maternal age < 20 or >40 years „ Diabetes „ Obesity „ Rh incompatibility |
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Preeclampsia(cont)
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„ HTN develops after 20 weeks in a previously normotensive woman
„ Multisystem, vasospastic disease process „ Reduced organ perfusion „ Proteinuria „ Categorized as mild or severe |
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Preeclampsia(cont)
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Can lead to potentially lethal complications
„ Eclampsia „ Abruptio placentae „ Disseminated intravascular coagulation (DIC) „ Acute renal failure „ Hepatic failure „ Adult resp distress syndrome „ Cerebral hemorrhage „ Pulmonary edema |
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Mild Preeclampsia
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„ BP reading of 140/90 x 2, > 4-6 hours apart
„ Proteinuria „ Pathologic edema „ Face, hands, or abdomen „ Rapid weight gain of more than 2 kg in 1 week |
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Severe Preeclampsia
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„ Systolic BP 160 or >
„ Diastolic BP 110 or > „ Proteinuria > 2 g/ 24 hour urine , Increase in AST and uric acid „ Oliguria- < 400 to 500 ml/24 h „ Cerebral or visual disturbances „ Hepatic involvement. Epigastric pain „ Thrombocytopenia „ Pulmonary or cardiac involvement „ Increased serum creatinine „ Development of eclampsia „ Development of HELLP syndrome |
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HELLP SYNDROME
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„ Laboratory diagnosis for a variant form of
preeclampsia with hepatic involvement „ Cause is unknown „ H – Hemolysis of Red Blood Cells „ EL- elevates liver enzymes „ LP- low platelets |
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H.E.L.L.P. SYNDROME
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COMPLICATIONS
„ SUBCAPSULAR LIVER HEMATOMA OR LIVER HEMORRHAGE „ RENAL FAILURE „ PULMONARY EDEMA „ SEVERE UTERINE HEMORRHAGE AT DELIVERY „ DIC „ PLACENTAL ABRUPTION „ THERAPY „ TRANSFUSE WITH FRESH PLASMA OR PLATELETS „ CORRECT HYPOGLYCEMIA WITH D5W „ DELIVER BABY ASAP |
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Nursing Care of a Woman with a
Hypertensive Disorder |
Assessment
„ Accurate BP readings „ Monitor HR and RR „ Dependent edema „ Pitting edema „ Deep tendon reflexes „ Clonus „ Monitor urine output „ STRICT I &O „ Weight „ Visual disturbances „ Epigastric pain Seizure activity |
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Nursing Care of a Woman with a
Hypertensive Disorder (cont) |
„ Fetal heart monitoring
„ Antenatal- at least q 4h „ Intrapartum- continuous „ NST „ Encourage decreased activity or complete bed rest „ Keep environment non-stimulating „ Psychosocial „ Interventions to decrease anxiety „ Emotional support |
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labs for HTN disorders
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„ CBC
„ Clotting studies „ 24 hour urine „ Urine dip „ Liver Function tests „ BUN and Creatinine „ Uric acid „ Glucose „ Magnesium „ Blood type and screen, possible cross match |
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Management of Severe
Preeclampsia or HELLP Syndrome |
„ Antihypertensive
„ Magnesium Sulfate Therapy „ Stabilize and prepare for delivery „ Induction of labor is preferred „ Cesarean section only when absolutely necessary |
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Magnesium Sulfate (MgSO4)
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„ Used to prevent or control seizures
„ Usually given 24-48 hours after delivery „ Anticonvulsant „ CNS and Respiratory depression „ Causes vasodilatation & diuresis „ Flushing and sweating „ Prevents or controls seizures by decreasing neuromuscular irritability. |
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Magnesium Sulfate (MgSO4) cont
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„ ALWAYS administered as a second infusion line
or piggybacked- NOT as a mainline „ ALWAYS administered via an IV pump „ Loading dose- 4 to 6 grams/100 ml- usually infused over 15- 30 minutes „ Follow MD orders and hospital protocol „ Maintenance dose: 1 to 3 grams per hour „ 40 grams of MgSO4/1000cc LR, serum levels 5-7mg/dl „ After delivery uterus may be boggy andincreases lochia |
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MgSO4 Toxicity
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„ Loss of patellar reflex
„ Respiratory depression „ Oliguria „ Decreased LOC „ If toxicity suspected STOP INFUSION „ Administer antidote if ordered „ Calcium gluconate „ 1 gram SLOW IV push (over 3 minutes) |
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Eclampsia
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„ Onset of seizure activity or coma
„ Caused by Cerebral Edema „ Can be the first sign of a pregnancy complicated by preeclampsia „ Convulsions can develop in a woman without warning in a seemingly stable woman with only mildly elevated BP |
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Immediate Care of Eclampsia
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„ Maintain a patent airway
„ Turn head to one side „ Turn on side „ After convulsions ceases- suction mouth „ Administer O2 10L/min via mask „ Adm. anticonvulsant as ordered „ Monitor FHR „ Monitor maternal VS – especially BP „ NEVER LEAVE UNATTENDED!! „ All women with preeclampsia should have padded side rails and side rail up at all times to prevent injury if a seizure occurs!!!! |
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Spontaneous Abortion
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„ Most lay people prefer the term
miscarriage „ 10 to 12 % of clinically recognized pregnancies end in miscarriage „ At least 50% result from chromosomal abnormalities „ Early occur < 8 weeks „ Late occur 12- 20 weeks „ Result from maternal causes—infection;cervical dilation |
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Types of Spontaneous Abortions
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Threatened
„ No passage of tissue, spotting „ No cervical dilation Inevitable „ ROM „ Cervical dilation Incomplete „ Expulsion fetus „ Retainment of placenta Missed „ Fetus had died „ Products of conception are retained in utero for up to several weeks |
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SPONTANEOUS ABORTION S/S
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„ BLEEDING
„ PAIN CONTRACTIONS |
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Nursing Management of spontaneous abortions
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Accurate history
„ How long has she been bleeding? „ Pain- location, duration etc „ LMP or EDD „ Any history of previous spontaneous ABs Vital signs „ Temp important since risk of infection Support „ Woman has suffered a loss |
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Incompetent Cervix
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„ Recurrent premature dilation of the cervix
„ Management „ Bed rest „ Hydration „ Tocolysis „ Cervical cerclage „ Refrain from intercourse „ Avoid prolonged standing and heavy lifting |
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Ectopic Pregnancy
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„ Fertilized ovum is implanted outside of the
uterus „ Accounts for 2 % of all pregnancies in the US „ 95% of ectopic pregnancies occur in the fallopian tube „ Can occur in the abdomen „ Increases risk of future ectopic pregnancies(10‐25%) |
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Clinical Manifestations - ectopic pregnancies
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„ Missed period
„ Abdominal fullness and tenderness „ Ranges form dull pain to colicky pain as the tube stretches „ Dark red or brown vaginal bleeding „ If rupture , pain increases „ Signs of shock may occur „ Cullen's sign- ecchymotic, blueness around the umbilicus Referred shoulder pain r/t diaphragmatic irritation. |
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Ectopic Pregnancy - mgmt
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„ Methotrexate
„ Destroys embryonic cells „ Salpingostomy „ Can be done before rupture Rupture = medical emergency!!! |
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Hydatidiform Mole
(Molar Pregnancy) |
„ RESULT OF IMPROPER FERTILIZATION
„ PRODUCES H.C.G. „ Increased levels „ COMPLETE MOLE „ EMPTY OVUM AND ONE SPERM „ RESEMBLE WHITE GRAPES „ NO FETAL OR PLACENTAL PARTS „ MATERNAL BLOOD HAS NO PLACENTA TO FILL SO BLEEDS INTO UTERINE CAVITY |
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Hydatidiform Mole
(Molar Pregnancy) cont |
„ PARTIAL MOLE
„ 2 SPERM AND A NORMAL OVUM „ SOME FETAL/PLACENTAL PARTS „ 6% CHANCE OF MALIGNANT TRANSFORMATION |
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Hydatidiform Mole
(Molar Pregnancy) - clinical manifestations |
„ Signs of normal pregnancy
„ Dark brown (prune juice) or bright red vaginal bleeding „ Signs of anemia due to blood loss „ Extreme nausea and vomiting „ Larger uterus than expected „ Abdominal cramping „ Preeclampsia prior to 20 weeks |
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Hydatidiform Mole
(Molar Pregnancy) - mgmt |
„ Most moles abort spontaneously
„ Dilatation with suction curettage Follow up „ Frequent physical and pelvic exams „ HCG levels are monitored „ Rising HCG and enlarging uterus = cancer „ Pregnancy needs to be avoided for one year after HCG levels normal |
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Placenta Previa
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„ Placenta is implanted in the lower uterine segment near or over the cervical os.
„ Classified according to the degree which the internal os is covered |
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Placenta Previa cont
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„ Painless vaginal bleeding
„ Initial bleeding is usually a small amount and stops once as clots form „ Bleeding can reoccur at any time „ Fetal position may be breech or transverse due to abnormal placental implantation |
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placenta previa - plan of care
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„ Active Management
„ If term pregnancy and bleeding persists or labor begins = immediate C/S „ Low-lying or marginal placentas „ Vaginal delivery may be attempted „ Expectant Management „ Less than 36 weeks, not in labor, bleeding is mild or stopped „ Bed rest and close observation „ IV access maintained „ Type and screen „ Pelvic rest |
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Abruptio Placentae
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„ Premature separation of the uterus after 20 weeks
„ Complete or partial detachment from implantation site „ Leading cause of maternal death |
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Abruptio Placentae - risk factors
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„ Preeclampsia
„ Cocaine use „ Multi fetal pregnancy „ Blunt abd trauma „ Maternal smoking „ Poor nutrition |
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Abruptio Placentae clinical manifestations
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-Bleeding may be evident (flow out of the vagina) or it
may remain concealed -Classic signs „ Vaginal bleeding „ Dark blood, clots „ Abdominal pain -Mild to severe „ Uterine tenderness contractions „ Abdomen may be board like „ Hypertonicity „ Increased fundal height -Concealed bleeding |
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Maternal /Fetal Complications of Abruptio Placentae
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„ Maternal
„ Hemorrhage „ Hypovolmeic shock „ DIC „ Fetal „ perinatal mortality „ Preterm birth „ Hypoxia = neurological defects |
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comparison of Abruptio placentae and placenta previa
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A/P
„ DARK Red Blood „ Mod-severe Uterine tonicity „ Pain: agonizing „ Can have abnormal fetal effects P/P „ Bright Red Blood „ Normal uterine tonicity „ NO Pain „ Fetal effects can be normal |
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RH ISOIMMUNIZATION
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„ PROCESS BY WHICH AN RH NEGATIVE MOTHER
DEVELOPS ANTIBODIES AGAINST FETAL RH POSITIVE BLOOD CELLS. |
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RH ISOIMMUNIZATION (cont)
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„ ANY ACT THAT ALLOWS CONTACT BETWEEN
RH POSITIVE FETAL BLOOD AND RH NEGATIVE MATERNAL BLOOD CAN SENSITIZE THE MOTHER „ SEPARATION OF PLACENTA AT DELIVERY „ MISCARRIAGE „ ECTOPIC PREGNANCY „ AMNIOCENTESIS/CHORIONIC VILLI SAMPLING „ ABDOMINAL TRAUMA „ ABRUBTIO PLACENTAE |
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PREVENTION OF RH
ISOIMMUNIZATION |
„ Rh Immune Globulin (Rhogam)
„ Suppresses immune response in nonsensitized women with Rh negative blood „ Suppresses antibody formation „ Given during prenatal period and/ or postpartum period |
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Erythroblastosis Fetalis r/t RH isoimmunity
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„ If sensitization has occurred
„ Mothers Rh positive antibodies destroy fetal erythrocytes = fetal anemia „ Fetus compensates by producing large numbers of immature erythrocytes „ Hydrops Fetalis- severe form „ Marked anemia „ Cardiac decompensation „ Cardiomegaly „ Hepatosplenomegaly |
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Metabolic Changes Associated with
Pregnancy |
„ Glucose is primary fuel used by fetus
„ Transported across the placenta „ Glucose levels in fetus are directly proportional to maternal levels „ Insulin does not cross the placenta „ Embryo or fetus secretes its own insulin „ If maternal glucose levels are increased than fetal glucose levels are increased = increased fetal insulin secretion |
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Diabetes Mellitus
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„ Type I
„ Absolute insulin deficiency „ Due to pancreatic beta cell destruction „ Prone to ketoacidosis „ Type II „ Insulin resistance „ Classic signs „ Polyuria „ Polydipsia „ polyphagia |
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Pregestational Diabetes Mellitus - fetal/neonatal risks
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„ Equal with Type I and II
„ Congenital anomalies „ Macrosomia „ Hypoglycemia „ Respiratory distress „ Hyperbilirubinemia |
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Pregestational Diabetes Mellitus - maternal risks
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„ Early pregnancy loss
„ Hydramnios „ Infections „ Ketoacidosis „ Hyperglycemia and hypoglycemia „ Polycythemia Preecclampsia |
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Management of Diabetes in
Pregnancy: Antepartum |
for both type 1 and 2
„ Monitor glucose levels „ Insulin therapy „ Diet & Exercise „ Assess fetal growth and well being |
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Gestational Diabetes Mellitus
(GDM) |
„ Diagnosed during pregnancy
„ May or may not need insulin therapy „ Higher risk of developing insulin resistance (glucose intolerance) later in life |
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Gestational Diabetes Mellitus
(GDM) risk factors |
„ Maternal age older than 30 years
„ Obesity „ Family history of Type II „ History of infant > 9 lbs „ Hydramnios, Infant with congential anomalies „ Multiple gestation Native American, Latino, African American |
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Gestational Diabetes Mellitus - maternal risks
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„ Include risks associated with pregestational diabetes
„ Hypertensive disorders |
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Gestational Diabetes Mellitus - fetal risks
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IUGR -
Caused by all or any of the following „ DIABETIC VASCULAR DISEASE AFFECTING THE PLACENTA „ PREGNANCY INDUCED HYPERTENSION „ DIABETIC KETOACIDOSIS- BABIES DON’T GROW WELL WHEN ACIDOTIC. |
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Gestational Diabetes Mellitus - fetal risks cont
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Macrosomia
„ Insulin is a growth hormone „ High birth weight infant „ Large skeleton (head and shoulders) „ Birth trauma and injury for mother and neonate „ Increased rate of cesarean section |
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Screening for GDM
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„ All women need to be screened for GDM
„ Screening includes history, clinical risk factors, or laboratory screening „ High risk for GDM „ 24 to 28 weeks gestation „ Glucola screening 50 gm vs 75 gm „ If 1 hr Glucola positive than a 3 hour glucose tolerance test (OGTT). |
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Antepartum Management of GDM
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„ Treatment begins immediately
„ Diet modifications „ Exercise „ Monitoring blood glucose levels (100-120 mg/dl) „ Insulin therapy „ 20% of women with GDM will require insulin „ Fetal surveillance „ Monitor for signs of infection |
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Intrapartum Management of GDM
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„ Prevent dehydration, hypoglycemia, and hyperglycemia
„ Monitor glucose levels „ Every 2 hours „ IV fluids with glucose should not be given as a bolus „ Continuous fetal heart monitoring „ Be prepared for a large baby |
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Postpartum Management of GDM
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„ Insulin requirements decrease because the
major source of insulin resistance is the placenta „ Monitor blood glucose levels „ Adjust insulin levels accordingly „ Breast feeding decreases insulin requirements „ Women with GDM „ Assess for carbohydrate intolerance should be assessed 6 to 12 weeks postpartum or after breast feeding has stopped |
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Hyperemesis Gravidarum
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„ Excessive vomiting during pregnancy
„ Weight loss of at least 5% pre-pregnancy weight „ Dehydration „ Electrolyte imbalance (Na, K) „ Ketosis „ Activity Intolerance „ Anxiety |
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Hyperemesis Gravidarum Treatment
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„ NPO for 24-48 hours or until vomiting is controlled
„ IV fluids „ Antiemetics ( Zofran, Phenergan, Vitamin B-6, Reglan) Severe cases „ TPN |
