complications of pregnancy Flashcards

Question

complete abortion

Answer 1

- all products of conception are entirely expelled | - very few complications, emotional support = necessary bc mom is grieving

Answer 2

- usually parts are retained, immediate termination of pregnancy by method appropriate to duration of pregnancy is needed - cervical culture and sensitivity studies are done and broad spectrum antibiotic therapy is started - vaginal vault is aerobic, uterine cavity is anaerobic so treat with both - often a self induced abortion... like coat hangers - treat for septic shock if necessary

Answer 3

- the fetus dies but continues to be retained in the uterus 8 weeks or longer - individual will spontaneously go into labor and fetus will pass

Answer 4

- after four weeks with a dead infant within the mother... the dead cells start to release enzymes that cause the breakdown of clotting factors and can lead to DIC in the mother - once fetus is dead for a while it will release enzymes and hemolysis can occur... seep past the placenta and into maternal circulation leading to he mother losing part of her ability to clot which would incr risk of hemorrhaging

Answer 5

- a purse string suture called a SHIRODKAR (cerclage) or McDonald procedure may be done to close the cervix temporarily or permanently (to maintain pregnancy) - usually done on the outside of the cervix but if damage to the cervix this will lead to going in through the abdomen and then going to the upper part of the cervix... then suture will just stay in there and patient needs a c-section - if they clip it will she go into spontaneous labor??? - will get into second trimester but weight of pregnancy starts to overcome what the cervix can hold - cervix dilates 15-20 weeks - done through vaginal vault, the shirodkar (cerclage) is clipped near full term - can also be done abdominally if there is damage to cervix - then they need a c-section

Answer 6

○ Trophoblastic disease- developmental error of placenta causes the development of cyst like clear vesicles resembling a bunch of grapes ■ Often not compatible with fetal life

Answer 7

■ Complete- all vesicles and no fetus ■ Partial- has vesicles and a rarely viable fetus - Fetus not well nourished - Uterus gets very large

Answer 8

○ Usually benign but can be choriocarcinoma, rapid growing cancer form with a high rate of cure ■ If a molar pregnancy develops very late in the pregnancy then there is a slight potential the fetus services… lungs are the most common site for tumor to metastasize ○ Incidence: 1 in 1000 pregnancies, incidence over age 45 10x greater

Answer 9

■ Apparently normal first trimester ■ Uterine bleeding is the most outstanding ● Often brownish (prune juice appearance) ■ Possible anemia ■ SOB ● Relates to metastasizing cancer ■ Uterine size often exceeds fundal height expected for gestation ■ Fetal activity and FH tones absent ■ Hyperemesis gravidarum common ■ Preeclampsia develops before 24 weeks ● Hypertensive disorder ■ Very high levels of serum hCG ● Hormone that is released very early on in pregnancy

Answer 10

Extreme form of morning sickness ● High hormone levels ● More placental tissue --> more hormone produced --> preeclampsia can develop earlier than 24 weeks gestation

Answer 11

- through ultrasound - requires IMMEDIATE EVACUATION of pregnancy and follow-up chemotherapy if malignant - tissues are VERY responsive to chemotherapy if this is done early

Answer 12

- serum hCG levels... until they are normal - ■ Non-pregnancy levels are achieved to watch for placental tissue growth throughout the body ■ Then q month x 6 months then q 2 months for 1 year ■ AT LEAST A YEAR YOU MONITOR ■ Want follow up chest x-rays done on her

Answer 13

- baseline x-ray of lungs is taken and compared to pre-evacuation x-ray

Answer 14

preg should be avoided during the 1 year follow up | any new pregnancy will create a hormonal situation that will encourage mastitis situation

Answer 15

- exaggerated form of morning sickness *may have weight loss, need lots of hydration* ○ Increased or prolonged nausea & vomiting in pregnancy potentially affecting the mother and fetus ○ Etiology-likely caused by a combination of factors ○ Appears to be related to high or rapidly increasing levels of hCG or estrogens ■ We know placental tissue is growing… we know we are at a good chance of having a viable pregnancy but this is very uncomfortable for the mother ○ Evidence of transient hyperthyroidism has been noted ○ Psychological and social factors, as family conflict, may play a role ○ IV therapy initiated to treat dehydration; adequacy of hydration assessed by measuring urinary output ○ Small, frequent feedings as tolerated; high calorie tube feedings is an option ○ Antiemetics often help (like zofran) ○ Acupressure has been used successfully

Answer 16

``` ○ Hypertensive disorders of pregnancy ○ Diabetes in pregnancy ○ Preterm labor ○ Hemorrhagic disorders ○ Hyperemesis gravidarum ○ Vasa previa ○ Uterine rupture ○ Lacerations ○ Pulmonary embolism ○ Cephalopelvic disproportion ○ Cord Prolapse ○ Fetal distress ○ Shoulder dystocia z ```

Answer 17

○ BP > 140/90 ○ A rise of 30 mmHg in the systolic BP over the woman’s baseline BP ○ Mean arterial BP of > 105 mmHg

Answer 18

HTN without proteinuria that develops after 20 weeks of pregnancy or within the first 24 hours after delivery ■ PIH superimposed on previous hypertensive state results in a worsening of the woman’s HTN ■ Woman does not have proper hormonal response to the 30-50% added blood volume during pregnancy ■ Doesn’t have protein urea, generalized edema (the preeclampsia symptoms)

Answer 19

preeclampsia eclampsia HELLP syndrome

Answer 20

● At least 2 of 3 of the classic triad: ○ Elevated BP ○ Proteinuria (damage to vascular bed, protein seeps out and excreted in urine) ○ Edema (generalized) ○ *** not everyone will have all three of these ***

Answer 21

``` ○ Signs of triad PLUS ○ Headache ■ Dull, frontal headache from cerebral edema ○ Nosebleeds ■ Lack of clotting factors ○ N/V ○ Epigastric pain ■ Liver is affected, high correlation with advancing to eclampsia ○ Visual disturbances ■ “Stars, flashing of lights” ■ Double vision? ○ Hyperreflexia ■ Cerebral edema → irritable CNS ■ CNS irritability ○ Oliguria ■ Kidneys affected ■ Renal damage! ○ Proteinurea ```

Answer 22

when preeclampsia progresses to develop seizures ● Edema can be cerebral edema (causing irritability of the CNS leading to seizures) ● Monitor seizures to figure out how engaged the CNS is

Answer 23

hemolysis, elevated liver enzymes and low platelets ● Often with ↑ BP ● Severe and life threatening ● Hormonal disruption of the vascular bed ○ As it gets more severe the blood vessels are going to continue to spasm… the worse the spasming the worse the preeclampsia ○ Spasming will cause shearing of the blood vessels

Answer 24

■ Serum leaks out from the vascular bed into the tissues  edema ■ Think liver, heart, lungs, brain… the areas that are more vascular are going to be more prone to damage with the serum leakage ● Celeste has seen patient’s liver rupture when it is severe ■ Platelets start to adhere to the areas of sheering to heal the damage… we only have a couple thousand platelets so then I think it will utilize a lot of our platelets (clotting factors)

Answer 25

``` ■ Fetal hydrops ● RH sensitization ● State of remarkable swelling in the newborn… this predisposes use to hypertensive episodes ■ Maternal age >35 ■ Nulliparity ● Or a baby with a new partner ● Often see in teenagers because it is a new pregnancy ■ History of preeclampsia in self or family ■ Hydatidiform mole ■ Multiple pregnancy ● Larger placenta, more hormone ■ Chronic HTN ■ Diabetes ```

Answer 26

``` ■ Bedrest in restful environment ■ Close monitoring ● Can cause premature separation of the placenta ● Increased risk of placental abruption ■ Deliver if necessary (true cure) ■ MgSO4 ■ Beta Blockers (Labetalol) ■ Antihypertensive medications (Apresoline) ■ GIVE BETAMETHAZONE ```

Answer 27

● Prevent seizures, not very safe (use in preeclampsia) ● Use in preterm labor, to quiet the uterus/muscle contraction ● Continuous infusion ● If there is a liver problem this will impede ○ Between 5 and 8 but if it gets up to 8 then this can lead to respiratory arrest, cardiac arrest and something else ■ Watch reflexes, urine output, RR, vitals signs (everyhour) ■ See visual distortion, difficulty walking, I don’t remember the rest ■ At risk for falls ■ Any level of physical activity will become a challenge

Answer 28

● May diminish placental perfusion for 20 minutes | ● Use this medication when we need to respond immediately

Answer 29

Administration of magnesium sulfate injection to pregnant women longer than 5-7 days may lead to low calcium levels and bone problems in the developing baby or fetus, including thin bones, called osteopenia, and bone breaks, called fractures. The shortest duration of treatment that can result in harm to the baby is not known

Answer 30

Magnesium sulfate is approved to prevent seizures in preeclampsia, a condition in which the pregnant woman develops high blood pressure and protein in the urine, and for control of seizures in eclampsia. Both preeclampsia and eclampsia are life-threatening complications that can occur during pregnancy. Preeclampsia can lead to eclampsia, seizures, stroke, multiple organ failure, and death of the woman and/or baby.

Answer 31

○ Develops progressively as the pregnancy puts additional demands on the mother’s system ○ 2-5% of pregnancies ○ Patients are screened at 28 weeks gestation with a 1-hour glucose screen, and then a 3 hr glucose screen if the first one is abnormal ■ Give her something with a controlled percentage of glucose in it ■ If it is elevated above 130 then we give a 3 hour glucose screen ● 1 hour then 2 hour follow up ● 2 abnormal values out of 4 we consider this diagnostic ○ Some patients are able to be controlled by diet alone, others will require insulin

Answer 32

■ Obesity ■ FH of Diabetes ■ Ethnicity (Hispanic, African American, Asian) ■ Advanced maternal age (>35 yo) ■ Prior GDM ■ Prior LGA (large for gestational age) baby

Answer 33

○ First diagnosed during pregnancy ○ Impaired glucose tolerance, increase insulin resistance ○ Mother’s pancreas is challenged by normal changes in pregnancy & cannot respond to needs ○ Both maternal and fetal hyperglycemia results ○ 40% chance → develop DM later in life ○ Reclassify individual after delivery, breastfeeding ○ Oral hypoglycemic agents not used d/t teratogenic effects

Answer 34

oral hypoglycemic agents are not used d/t teratogenic effects

Answer 35

``` ■ PIH ■ Polyhydramnios ● Excessive amount of amniotic fluid in uterus ■ Macrosomia (LGA) ■ Intrauterine growth restriction (IUGR) ● Especially true with type 1 diabetes … growth restriction ■ Stillbirth ■ Congenital abnormalities (heart, CNS, skeletal) ● During first 8 weeks I think ■ Infections ■ Ketoacidosis ● Type 1- high fetal loss rate ```

Answer 36

■ Glucose tolerance test (GTT) 1 hour 50gm (glucola) ■ 1 hour glucose screen at 24-28 wks <135 normal ■ 3 hours GTT indicated if elevated ● Fasting < 105 ● 1 hour < 190 ● 2 hour < 165 ● 3 hour < 145 ** won’t ask these levels on the exam ■ Two or more elevated levels = diagnostic

Answer 37

reflects control past 4-12 weeks measures % blood hb has glucose molecule attached normal: 6-8% Hb glycosylated

Answer 38

``` ○ Placenta previa ○ Placenta abruptio ○ Vasa previa ○ Uterine rupture ○ Lacerations ```

Answer 39

○ The placenta implants in the lower uterine segment (normally implants in the fundus), either partially or totally covering the cervix ■ Have to get her delivered!!! ■ If she continues with the pregnancy and the placenta is across the cervix we NEED TO  ○ Delivered by C/S @ 37 weeks if not before

Answer 40

■ Sudden onset of painless VAGINAL bleeding or hemorrhage ● They will just wake up in a pool of blood ■ May be accompanied by contractions

Answer 41

vaginal exams w KNOWN placenta previa or on any women with heavy vaginal bleeding and unknown placental location - we can cause placenta to break away more

Answer 42

* know the pic - low lying placenta - partial previa (might not need c-section if seen early) - complete previa (cannot migrate up at all, definitely requires a c-section)

Answer 43

``` ■ Multiparity ● Scarring- placenta doesn’t know where to plant ● Placental implantation site with potential scarring ■ Maternal age > 35 ■ Multiple pregnancy ■ Erythroblastosis ■ Previous uterine surgery ■ Smoking ■ Previous placenta previa ■ Previous therapuetic abortion ```

Answer 44

○ A premature separation of the normally implanted placenta ■ Breaks away from fundus ○ May be partial or complete ○ Bleeding may be obvious or concealed behind the placenta ■ Concealed when from center of placenta ○ Marginal abruption with external hemorrhage ■ You can lose about 20% of surface contact something something idk but if you have a mother who is prone to not good placental formation to begin with they might be more affected

Answer 45

■ You can lose about 20% of surface contact something something idk but if you have a mother who is prone to not good placental formation to begin with they might be more affected ■ No clot visualized on ultrasound if blood is coming out ■ Might not actually see bleeding ■ Do ultrasound to look for abruption

Answer 46

- ultrasound can be diagnostic

Answer 47

... can have as much as 3 mL of blood in there

Answer 48

■ Board-like abdomen (rigid) ■ Severe, relentless abdominal pain out of proportion to labor ■ Back pain ■ Colicky, discoordination uterine contractions ■ Tetanic contraction ● Uterus can contract and just stay contracted ■ Bleeding ■ Pain localized or generalized ■ FHR periodic changes late, variable, prolonged, sinusoidal ● Late decelerations are the most common one you will see because these are symbolic of PLACENTAL INSUFFICIENCY ■ Loss of variability ■ Aggressive fetal movement ■ Increasing fundal height ■ Maternal shock ■ May not show on ultrasound

Answer 49

■ Maternal HTN ■ Preeclampsia ■ Folic acid deficiency ● Essential to healthy formation of placenta ■ Severe abdominal trauma ● Motor vehicle accidents, domestic abuse, etc ■ Short umbilical cord ● Baby drops → traction on the placenta can help it to separate ■ Malnutrition ● Poor placental formation ■ Sudden decrease in uterine size ● Changes placental implantation site ■ Maternal age over 35 ■ Rough or difficult external version ● Transverse lie/breech → manipulate uterus to head down position ● Go in internally to manipulate ● Can also cause an abruption as well ■ Cocaine use, especially crack ○ Warrants very close observation or C-section ○ Blood loss for the mother and infant can be substantial in both previa and abruptio

Answer 50

○ Abnormal implantation of umbilical cord on placenta- shearing of the umbilical vessels in utero ○ Usually the vessels are abnormally implanted and cross through the membranes of the surface of the placenta ○ At the time of ROM they can shear ○ In this situation it is the infant who bleeds out ■ Because the infant has such a small circulating volume → death quickly ■ Blood is thick & dark → higher Hgb and hct ○ Be suspicious if you see very dark red blood with the ROM associated w changes in the FHR ○ Immediate C section warranted ○ Vessels usually rise in the middle of the placenta … if membrane is ruptured then blood vessels will shear

Answer 51

○ Can be partial or complete ○ Potentially catastrophic for mother and baby ○ Often involves a simultaneous abruption of the placenta

Answer 52

``` ■ Previous uterine surgery (#1 cause) ● Ex. c-section ■ Trauma ■ Uterine overdistention ● Increased pressure with large babies ● Polyhydramnios ● Multiple pregnancies ■ Uterine abnormalities ■ Placenta percreta ● Placenta has gone behind normal level of implantation ● More invasive into the uterine wall ■ Choriocarcinoma ```

Answer 53

○ Too big/bad positioning → baby can’t get through ○ The maternal bony pelvis is often a factor ○ Soft tissue dysctocia can occur in the obese ○ Fetal positional can play a part

Answer 54

``` ■ Arrest of dilation or descent ● Reach a certain point where you will not dilate anymore ■ Abnormal labor patterns ■ Acute maternal discomfort ● “bone on bone pain” ■ Maternal exhaustion ■ Early fetal heart rate decelerations ```

Answer 55

``` ■ Reposition ■ Assess labor pattern ■ Assess fetal status ■ Keep provider appraised of progress or lack thereof ■ Keep hydrated ■ Consider analgesia or anesthesia ```

Answer 56

○ Occurs when the umbilical cord escapes beyond the presenting part and becomes trapped between the presenting part and the bony pelvis ○ Blood vessels in the cord become compressed and the infant can become hypoxic ○ An immediate C-section is warranted

Answer 57

■ One person must do a continuous vaginal exam and hold the head up off the cervix ● To avoid compression of blood vessels ■ Put the patient in the Trendelenburg or in knee chest position ■ Prepare for an immediate C-section ■ IV bolus ● Increase perfusion ■ O2 via mask ■ Prepare for resuscitation of the infant

Answer 58

○ Head is out, shoulders large → caught in anterior/posterior position ○ Most cases involve the anterior shoulder impacting on the anterior pubic bone ○ Some involve the posterior shoulder impacting on the sacral prominence ○ The “turtle sign” is a classic retreating of the fetal head after it has delivered ■ Head recedes back into vault

Answer 59

``` ● Abnormal pelvic anatomy ● Gestational Diabetes ● Post-dates pregnancy ● Previous shoulder dystocia ● Short stature ```

Answer 60

● Suspected macrosomia (large baby) ■ 0.6 to 1.4% of all infants with a birth weight of 5lb, 8oz to 8lb,13oz ■ Increasing to a rate of 5-9% among fetuses weighing 9lb, 4oz ■ Shoulder dystocia occurs with equal frequency in primigravid and multigravid women, although it is more common in infants born to women with diabetes

Answer 61

● Assisted vaginal delivery (forceps or vacuum) ● Protracted active phase of first-stage labor ● Protracted second-stage labor

Answer 62

is the use of a vacuum extractor or forceps during delivery

Answer 63

``` ● PP hemorrhage ● Rectovaginal fistula ● Symphyseal separation or diastasis, with or without transient femoral neuropathy ○ Anterior portion of pelvis separated ● 3rd or 4th degree episiotomy or tear ● Uterine rupture ```

Answer 64

● Brachial plexus palsy ○ Nerves shared, go over to arm ● Clavicle fracture ○ Can intentionally do to decrease the surface to get the baby out THIS IS LIFE OR DEATH ■ This will heal pretty easy with the newborn ● Fetal death ● Fetal hypoxia, with or w/o permanent neurologic damage ● Fracture of the humerus

Answer 65

■ Encourage weight gain within the normal range ■ Induction of labor w larger infants ■ Elective C-section ■ Good control of diabetes in pregnancy

Answer 66

■ “Deliver through” the anterior shoulder ■ McRoberts-Hyperflexion of the maternal hips bilaterally ● Mom on her back, bring her knees back to level of nipple line ■ Episiotomy ■ Subprapubic pressure ● Tries to displace shoulder off of the bone ■ Rotational maneuvers- internal maneuvers to rotate the shoulder off of the pubic bone ● Might see the fractured clavicle ■ Deliver the posterior shoulder ■ Reposition the mother to knee chest position ● Shoulder dystocia corrects itself ■ Don’t pull by the head ● Can cause shearing and lead to paralysis ■ Cut episiotomy if the first two tries don’t work ■ Woodscrew method??? Look it up ● This is the equivalent of CPR in L&D ● Deliver posterior arm first ■ HAVE HER KEEP PUSHING!

Answer 67

- deliberate clavicle fracture - zavanelli maneuver - general anesthesia - abdominal surgery w hysterotomy - symphysiotomy

Answer 68

● Cephalic replacement followed b C-section | ● Attempt the head

Answer 69

● Musculoskeletal or uterine relaxation with halothane or another anesthetic may bring about enough uterine relaxation to affect delivery ● Oral or IV nitroglycerin may be used as an alternative

Answer 70

● General anesthesia induced ● Cesarean incision performed ● Surgeon rotates the infant transabdominally through the hysterotomy incision, allowing the shoulders to rotate ● Vaginal extraction is then accomplished by another physician

Answer 71

● Intentional incision of the fibrous cartilage of the symphysis pubis under local anesthesia has been used more widely in developing countries ● Should be use only when all other maneuvers have failed and capability of C-section is unavailable

Answer 72

○ Common (approx 3-5%) & can occur in patients without risk factors for hemorrhage (20%) ○ Cause of 1/4th of maternal deaths worldwide ○ Requires prompt diagnosis and treatment ○ Repaid team-based care minimized morbidity and mortality associated with PP hemorrhage

Answer 73

``` ■ Antepartum hemorrhage ■ Augmented labor ■ Chorioamnionitis ● Infection of uterine cavity ■ Fetal macrosomia ■ Maternal anemia ■ Maternal obesity ■ Multifetal gestation ■ Preeclampsia ■ Primiparity ■ Prolonged labor ```

Answer 74

■ Heavy bright red blood flow- normal blood losses up to 500 cc vaginally and 1000 cc C-section ● Save all pads and Chux ■ Fundal assessment firm (contracted) or flaccid (atonic, “boggy”)- massage the fundus in a circular pattern if not well contracted ● Stimulate pacemaker ■ Changes in the vital signs- low BP, elevated pulse (30% blood loss, less if anemic before PPH) ● By the time these show, she’s already had a lot of blood loss ■ ℅ lightheadedness/nausea/air hunger/changes in orientation or alertness ● Lost around 50% ■ Changes in lab values- H&H, platelets, coagulation profile, D-dimer

Answer 75

■ The four T’s mnemonic can be used to identify and address the four most common causes: ● Tone- uterine atony 70-80% ○ Uterus not well contracted ● Trauma- laceration, hematoma, inversion, rupture 20% ○ Inversion- Uterus turns inside out and comes out of body ● Tissue- retained tissue or invasive placenta 10% ● Thrombin- coagulopathy 1%

Answer 76

■ Uterine atony most common cause → start w assessment of the fundal contraction & do massage if not well contracted ■ Pitocin is the first line medication used ● Usually given IV, can also give IM ■ Repeat fundus and flow and VS assessments frequently ■ Initiate a team response ■ Vessel embolization- compress uterine artery ■ Compression sutures go around entire uterus

Answer 77

``` ■ Anemia ■ Anterior pituitary ischemia with delay or failure of lactation (Sheehan syndrome) ■ Blood transfusion ■ Death ■ Dilutional coagulopathy (loss of clotting factors) ■ Fatigue ■ Myocardial ischemia ■ Orthostatic hypotension ■ PP depression ```

complications of pregnancy Flashcards

(101 cards)