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OB TEST 3 > Antepartum > Flashcards

Antepartum Flashcards

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1
Q

At risk –> prenatal testing

7

A

Maternal age > 35 years
Birth of previous infant with chromosomal abnormalities or neural tube defect
Chromosomal abnormality in family member
Gender if mom is carrier of X-linked disorder
Pregnancy after 3 or more spontaneous abortions
Maternal Rh sensitization
Elevated levels of maternal serum AFP

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2
Q

Genetic Counseling

A

Availability
Facilities with maternal-fetal medicine services
State agencies
Agencies focus on a specific birth defect
(i.e., March of Dimes)

Process of genetic counseling
Diagnosis may never be established

Supplemental services

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3
Q

Environmental Influences

Causative agents - 6

A

Teratogens
Agents that cause birth defects
Multifactorial

Causative agents
Maternal infectious agents
Drugs, Rubella & Vaccine
Pollutants
Ionizing radiation
Maternal hyperthermia
Maternal co-morbidities
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4
Q

Multifactorial Disorders

A

An interaction of genetic tendency and environmental factors.
Affected close relatives
Gender
Geography

Cardiac anomalies
Cleft lip and palate
Neural tube defects

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5
Q

Prevention and Treatment for genetic, multifactorial conditions

A

Ideally before conception
Appropriate medical therapy for diseases
Identification of risks
Preventive treatment tailored to identified risks
400 mcg of folic acid daily before conception

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6
Q

Evaluation of the Fetus

Diagnostic (3) and Assessment (2)

A 
Diagnostic Testing
Ultrasound
Amniocentesis
CVS
PUBS

Assessment of Fetal Well-Being
Nonstress Test
Biophysical Profile

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7
Q

Amniocentesis

A

Invasive test to identify chromosomal or biochemical abnormalities
Between 15 and 20 weeks
Risk of spontaneous abortion infection, ruptured membranes

In 3rd trimester to assess:
Fetal lung maturity
Detects fetal hydrops; erythroblastosis fetalis

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8
Q

PUBS – Percutaneous umbilical blood sampling

A

PUBS Invasive
after 16 wks
Blood gas, CBC, coag, Rh
Results in hrs

Cord laceration, thromboemboli, infection, spontaneous ab, PROM

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9
Q

Chronic villus sampling

A

CVS Invasive
10-13 wks
Karyotyping to identify chromosomal abnormalities
Results in 48 hrs
0.5% to 2.0% chance of spontaneous abortion & limb abnormalities

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10
Q

Non Stress Test
Accelerations indicate…
Reactive NST…

A

Assess fetal well-being – uteroplacental function
Noninvasive
After 28 wks

Accelerations in FHR indicative of
Adequate O2 of CNS
Healthy neural pathway from fetal CNS to FH
Ability of FH to respond to stimuli

Reactive NST
At least 2 FHR acceleration within 20 minute period
At least 15 beats above baseline
Lasting at least 15 seconds

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11
Q

Biophysical Profile (BPP)

A 
Ultrasound evaluation of 5 parameters in fetus
Breathing movement
Movement of limbs or body
Tone – extension/flexion of extremities
Amniotic fluid index (AFI)
Reactive FHR with activity  (NST)

2 points for each
(8 to 10 normal, 4 to 6 possible compromise 0 to 2 high perinatal mortality)
Usually in 3rd trimester but may be done after 24 wks

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12
Q

Indications for BPP (10)

A 
Maternal diabetes mellitus
Maternal heart disease
Maternal chronic hypertension
Maternal sickle cell anemia
Maternal renal disease
Hx previous stillbirths
Rh sensitization
Maternal preeclampsia or eclampsia
Suspected post maturity
Intrauterine growth restriction
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13
Q

Maternal Co-Morbidities

A

Acute and chronic illnesses present before pregnancy, develop during pregnancy affect fetal health and outcome

Assess for symptoms  
Neurologic
Respiratory
Cardiovascular
GI
GU
Musculo-skeletal
Integumentary
Psychosocial
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14
Q 
Maternal co-morbidities can affect fetal health and outcome
Respiratory
CV
Hemoglobinopathies
Endocrine
Autoimmune disorders
Developmental disabilities
A

Respiratory
Asthma; Cystic Fibrosis

Cardiovascular Anomalies or Disease
Anomalies;

Hemoglobinopathies
Sickle cell disease; Thalassemia

Endocrine
Diabetes; Thyroid Conditions

Autoimmune Disorders
Multiple Sclerosis, Systemic Lupus, Erythematosis

Developmental Disabilities
Physical Disabilities
Cancer

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15
Q

Psychosocial Distress (9)

A 
Increasing Anxiety
Inability to establish communication
Inappropriate responses or actions
Denial of pregnancy
Inability to cope with stress
Intense preoccupation with the sex of the baby
Failure to acknowledge quickening
Failure to plan and prepare for the baby (e.g. living arrangements, clothing, feeding supplies
Indications of substance abuse
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16
Q

Behavioral Health Disorders – Nursing Interventions

A

Provide strategies to…

Help decrease anxiety
Keep her oriented to reality
Promote optimal functioning during pregnancy and while in labor.

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17
Q

Smoking during pregnancy has serious health risks including…
8
Alcohol and other drugs easily pass from mother to baby through placenta

A 
Bleeding complications 
Miscarriage 
Stillbirth 
Prematurity
Placenta previa
Placental abruption
Low birth weight (LBW)
Sudden infant death syndrome
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18
Q

Substance Abuse

Legal Considerations

A

Legal considerations

Some women who abuse substances may face criminal charges
Nurses who encourage prenatal care, counseling, and treatment are of greater benefit to mother and child than prosecution

The role of the nurse is to support the patient in her efforts to achieve a healthy outcome of her pregnancy

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19
Q

Perinatal Infections

STIs TORCH

A

STIs
Chlamydia, Gonorrhea, Syphilis, HPV, HIV + AIDS

TORCH
Toxoplasmosis
Other: Varicella, Hepatitis B
Rubella
Cytomegalovirus
Herpes Simplex
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20
Q

How perinatal infections affect the fetus
Nursing Dx? (4)
Outcome?
Interventions?

A 
Nursing Diagnoses?
Ineffective Health Maintenance
Grieving
Readiness for Enhanced Knowledge
Ineffective Coping

Outcome?
Interventions?

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21
Q

Diabetes Mellitus

Classifications

A

Classification
Pregestational - Diabetes Mellitus existing before pregnancy
Type 1 diabetes
Type 2 diabetes

Gestational diabetes mellitus (GDM) is any degree of glucose intolerance with onset or recognition during pregnancy (2nd or 3rd trim)

Prediabetes: impaired fasting glucose (IFG)

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22
Q

Pregnancy and Insulin Production

Steps to increased blood glucose

A

Placenta produces hormones (estrogen, cortisol and human placental lactogen

These hormones inhibit the functioning of insulin

Blood glucose is increased

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23
Q

Changing Insulin Needs during pregnancy

A

First trimester: Insulin need is reduced
Second trimester: Insulin need increases
Third trimester: Insulin requirement gradually increase to 36 weeks

Delivery: Maternal insulin requirement drops drastically to pre-pregnancy level - intervention: frequent BS during labor

Breastfeeding mother maintains lower insulin requirement

Weaning breastfeeding mother returns to prepregnancy level

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24
Q

ADA Guidelines: Preconception Care

A

Maintain A1C levels

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25
Gestational Diabetes and Pregnancy | Screening
Glucose/Carbohydrate intolerance with onset during pregnancy 7% of all pregnancies – as high as 15% in some populations Screening: patient history, or clinical risk factors, or glucose challenge test
26
Symptoms warranting OGTT (6)
``` Persistent glycosuria on 2 visits Proteinuria Urinary frequency after 1˚ trimester Excessive thirst or hunger Recurrent monilial infections Polyhydramnios, suspected large fetal size, or increased fundal height for date ```
27
Low Risk for gestational Diabetes (4) | High risk for gestational diabetes (4)
``` Low Risk Normal weight before pregnancy Under age 25 No hx unexplained stillbirth No diabetes in immediate family ``` ``` High Risk Ethnicity: Af Am, Hisp, Native Am HTN Hypercholesterolemia GD or LGA in previous pregnancy ```
28
Tx for prenatal clinical development for different types of DM
Treatment for Mom Diet If not managed well on diet, add meds Drugs Type 1 Insulin - may be admitted during 2nd trimester to regulate Type 2 and GDM Oral hypoglycemic (Glyburide & Metformin) may be effective; Prescribed, though not approved by FDA (Category B / C) Insulin, if diet and oral hypoglycemics not effective Treatment for Baby - After delivery
29
Danger signs -- First Trimester (6)
Vaginal bleeding, Abdominal pain Severe, persistent vomiting Indicators of infection, hypoxia ``` Ectopic Hydatiform mole Spontaneous abortion Hyperemesis gravidarum Perinatal infections Hypoxia (maternal chronic or acute) ```
30
Hydatiform Molar Pregnancy | Symptoms and risks
Gestational Trophoblastic Disease Proliferation and degeneration of trophoblastic villi Symptoms Vaginal bleeding, size/date discrepancy excessive nausea/vomiting, abdominal pain Risks – choriocarcinoma -- repeat mole Tx: remove uterine contents (D+C)
31
Ectopic Pregnancy Symptoms Treatment in Fallopian tubes
``` Symptoms Missed period Positive pregnancy test (though low hCG) Abdominal pain Vaginal spotting ``` Treatment in Fallopian Tubes Medical If tube not ruptured, Methotrexate IM to dissolve embryo Surgical If tube not ruptured, laparoscopic salpingostomy to remove products of conception and salvage the tube If tube is ruptured, laparoscopic salpingectomy Counseling
32
Spontaneous Abortion
Before 20 weeks of gestation bleeding, cramping, abdominal pain, decreased symptoms of pregnancy D+C if necessary Emotional support
33
Incompetent Cervix aka Cervical Insufficiency
``` Painless dilation and cervical effacement Before second trimester Bedrest Cerclage McDonald Shirodkar ```
34
Severe Morning Sickness Hyperemesis Gravidarum Symptoms (5)
Excessive vomiting Unable to retain fluids ``` Dehydration Electrolyte imbalance Acid-Base imbalance Starvation Ketosis Weight Loss ```
35
Severe morning sickness | Dx and Interventions
``` 1. NPO + IVF Emotional Support 2. Slowly add food Monitor weight Continue support ```
36
Danger signs -- 2nd trimester | 9
Vaginal bleeding, Abdominal pain; Leaking amniotic fluid; Fundal height; Glycosuria; HTN/Proteinuria; Absence of fetal movement Spontaneous abortion Hyperemesis Gravidarum Perinatal infections Hypoxia ``` Fetal compromise PROM Preterm Labor Preeclampsia HELLP Syndrome ```
37
rH incompatibility
Rh- mom plus Rh+ dad AKA Rh Isoimmunization = antibodies (which can cross the placenta destroy the baby's RBCs resulting in massive hemolysis RhoGAM 28 -34 wks (prenatal dose) RhoGAM 24 to 72 hours post partum if baby is Rh+
38
Coombs Test Indirect vs. Direct Negative vs. Positive
Indirect = antibody screen -- measures number of Rh+ antibodies in mother's blood Direct = detects antibodies coated Rh+ cells in infant's blood Done after delivery Negative indirect coombs Mother given RhoGAM Positive indirect coombs “sensitized” Fetus monitored for hemolytic disease of the newborn (erythroblastosis fetalis)
39
ABO incompatibility
Mother type O Previous exposure to a protein (antigen) Anti-antigen antibodies present in mom Fetus A, B, or AB A, B, AB all contain the protein antigen not present in O Hemolysis of fetal RBCs
40
PROM | Premature rupture of membranes
Cause: Multifactorial The earlier the gestation, the more likely infection and inflammation may be causative factors Symptom: gush / trickle / leaking of fluid from vagina Confirmation of amniotic fluid?? Nitrazine or ferning
41
PROM | Criteria influencing the treatment plan:
Establish gestational age Ultrasound to assess fetus In labor? Sxs of Infection? If advanced labor or infection, deliver fetus if viable -> induction or c/s depending upon gestational age, distress
42
Assessment: Twins | Ultrasound findings
Ultrasound: closed cervix normal growth for both fetus A & fetus B excessive amniotic fluid (polyhydramnios)
43
Discordant twins | Twin to Twin transfusion
Identical twins born at 28 weeks | Drastic Different weights
44
Multiple Gestation | Nursing Dx
Risk of Preterm Labor | Risk of Premature Rupture of Membranes
45
Warning signs of preterm labor (7)
``` Abdominal pain Contractions Pelvic Pressure Vaginal Discharge that is heavy Low dull backache Menstrual-like cramps Bleeding and spotting ```
46
Higher risk for preterm labor (6)
``` Smoke/drugs Carrying more than one baby Poor nutrition Underweight before pregnancy Previous preterm deliveries Infection ```
47
Preterm Labor characteristics (4)
``` Gestation 20-37 wks Persistent uterine contractions (4 every 20 mins or 8 per hour) Cervical effacement at least 80% Cervical dilation of more than 1 cm ```
48
Tocolysis
Inhibit labor
49
Treatment PTL... If fetus is viable If labor is progressing
Careful maternal monitoring & FHR monitoring Identify and report symptoms of fetal hypoxia If fetus viable: hydrate, home on bedrest, no work, no sex, no distress, stress reduction If labor is progressing: - > hydration - > tocolysis = Nifedipine, MgSO4, Propranolol - > corticosteroids = Dexamethasone, Betamethasone
50
Hypertensive Disorders
Chronic hypertension Present before pregnancy (therefore, in first trimester also) Possibly undiagnosed before prenatal visits Gestational/Transient [aka Pregnancy-induced hypertension] Develops in 2nd trimester Hypertension with no other symptoms Preeclampsia --> eclampsia Hypertension Proteinuria Chronic hypertension with superimposed preeclampsia
51
Gestational Vs. Preeclampsia
High BP but no proteinuria High BP and proteinuria
52
Preeclampsia Maternal Characteristics Other 3 factors
Disease of placenta – 7-10% of pregnancies Vasospasms Endothelial tissue damage -> Delivery of fetus is the only cure Second leading cause of maternal death - about 1/10-15 pregnancies Maternal Characteristics Age 35 Race – higher in African Americans Socioeconomic status – lower asso. W/poor diets, increase in smoking Primagravida 6-8 times more likely to develop PIH Genetic predisposition , oxidative stress, and the release of immune factors cause placental dysfunction
53
Preeclampsia Symptoms Medical Management
Symptoms B/P > 140/90 @ 20 wks or more Proteinuria Sometimes: pitting pedal edema, facial edema Medical Management - > stabilize blood pressure - > prevent eclampsia nifedipine, hydralazine, labetolol increased monitoring
54
Eclampsia
Seizures and coma Eclampsia is grand mal seizures as a result of the progression of preeclampsia Eclampsia does not have a B/P correlation, or proteinuria, etc. Mild pre can cause eclampsia
55
``` Preeclampsia Maternal Complications CNS -- 4 Hepatic -- 2 Renal --3 Pulmonary --1 ```
``` Maternal CNS Seizures Cerebral Edema Cerebral Hemorrhage Stroke (thrombosis) ``` Hepatic Liver rupture or Failure Subcapsular Hemorrhage Renal Renal Failure Oliguria Glomerulopathy Pulmonary Pulmonary Edema
56
Preeclampsia Fetal Complications | 5
``` Preterm Labor Fetal Demise Hypoxia IUGR Oligohydramnios ```
57
Preeclampsia Severity
Mild Systolic 140-160 Diastolic 90-110 Protein 3-5gm in 24 Severe Systolic >160 Diastolic >110 Protein >5 gm in 24
58
Medical Management -- prevent eclampsia | Uncontrolled or high HTN
``` Bedrest EFM IVF (NPO in case of c/s) Antihypertensive therapy -- labetalol, hydralazine Magnesium Sulfate -- To prevent seizures Fetal gestation >34 wks –> deliver Corticosteroids ``` MgSO4 protocol = prevent overdose from resp failure and cardiac arrest
59
Nursing Interventions What is the focused assessment for a pt being tx with MgSO4? 7
Vital signs -> blood pressure, temperature, FHR Neuro -> level of consciousness (A&Ox4), confusion, deep tendon reflexes, visual disturbances Pain -> headache, epigastric pain Respiratory -> respirations & sPO2, coughing, SOB, dyspnea, rales/rhonchi Uterus/Placenta -> uterine rigidity, vaginal bleeding Urine -> output, protein, specific gravity Weight (daily), pedal edema Labs P/S -> emotional state, knowledge -> teaching
60
For Magnesium Sulfate induced Respiratory Depression or Respiratory Arrest, institute Emergency Treatment: TOXICITY
STOP Magnesium Sulfate infusion immediately. Oxygen at 10LPM via face mask GIVE Calcium Gluconate 1 Gram slow IVP (in Pre-eclampsia tray or Crash cart) Continuous Pulse Oximetry and ECG monitors Contact anesthesia for airway management (Rapid Response)
61
HELLP Syndrome Symptoms (3) What does it lead to? Treatment? Delivery?
Hemolysis, Elevated Liver enzymes and Low Platelets Variant or Complication of Preeclampsia Flu-like symptoms Epigastric pain from distended liver Jaundice Multiple system organ failure FFP or platelet transfusion Delivery ASAP
62
HELLP Syndrome Hemolysis, Elevated Liver enzymes and Low Platelets Platelet Count
Platelets 100,000 AST > 70 ALT > 50
63
Danger signs -- third trimester
Vaginal bleeding; Abdominal pain Fundal height; Leaking amniotic fluid; Absence of fetal movement; Glycosuria; HTN/Proteinuria; Abnormal fetal heart rate ``` Perinatal infection Hypoxia Fetal compromise PROM PTL Preeclampsia HELLP Placenta Abruptio Placenta previa ```
64
``` Thrombophlebitis Deep Vein Thrombus Thromboembolism Pulmonary Emboli Increased risk during pregnancy -- 4 ```
Increased blood volume Venous stasis in legs Hypercoagulation Compression of inferior vena cava in 3rd trimester Teaching: encourage walking discourage sedentary activities
65
Chronic Infections | GBS
“GBS+ (Group Beta Strep) is the leading infectious cause of neonatal morbidity and mortality in the US” (CDC2010) All pregnant women are screened between 35-37 wks gestation via vaginal swab If culture is positive, IV antibiotics are administered at delivery
66
Chronic Infections | HIV
HIV Compliance with antiretroviral regimen Retesting at 34-36 wks ``` Nursing Diagnoses Ineffective Health Maintenance Interrupted Family Processes Risk for Infection Nursing Interventions? Prenatal Intrapartum ```
67
Acute Infections
``` Respiratory URI, Tb UTI Chorioamnionitis -> Septicemia ```
68
Hemorrhagic Disorders: Placenta Previa Dx Symptoms Medical management
Implantation of placenta near or obstructing the cervical os Dx – prenatal ultrasound Painless bright red vaginal bleeding in third trimester Presenting part – not engaged Possibly transverse lie Medical Management No vaginal examinations! -> c/s -> NSVD possible for high partial
69
Hemorrhagic Disorders: Abruptio Placenta Dx Symptoms Medical Management
Separation of the placenta from the uterine wall Dx – ultrasound, clinical presentation Severe pain and dark vaginal bleeding in third trimester Not in labor or Labor could be progressing normally ``` Medical Management -> c/s EMERGENCY -> NSVD possible If in labor If minimal bleeding If hemodynamically stable No uterine tenderness No fetal distress ```
70
Hemorrhagic Disorders: Complications
Hemorrhage Disseminated Intravascular Coagulation (DIC) clotting disorder: low fibrinogen –> bleeding from every orifice Fetal hypoxia, Fetal demise Postpartum risk: lack of contractions in lower uterus -> postpartum hemorrhage

OB TEST 3 (2 decks)

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