Complications of pregnancy (unit 2) Flashcards
(113 cards)
1
Q
common pregnancy complications
A
- blood incompatibilities
- hemorrhage (early/late)
- hypertensive disorders
2
Q
Rh Incompatibility
A
- b/t Rh- mom and Rh+ fetus (from dad)
- fetus + antigens enter mom bloodstream
- mom becomes sensitized (isoimmunized) and produces antibodies against +
- in next + preg. antibodies will attack fetal blood cells
3
Q
fetal hemolytic anemia
A
- consequence of severe Rh incompatibility
* RBCs are destroyed
4
Q
fetal hyperbilirubinemia (icterus gravis)
A
- consequence of severe Rh incompatibility
* placenta unable to clear all bilirubin produced from RBC breakdown
5
Q
erythrobastosis fetalis
A
- consequence of severe Rh incompatibility
* fetus compensates by producing large # of immature RBC to replaced those hemolyzed by mom antibody
6
Q
hydrops fetalis
A
- most severe consequence of Rh incompatibility
- anemia ( -> hypoxia)
- cardio/hepato megaly
- edema/ascites/effusion/hyrothorax
- placental edema that can cause uterine rupture
7
Q
what causes fetal and maternal blood to mix
A
•delivery of AB
•trauma***
•invasive procedures (version/amnio)
*only takes 0.1 mol Rh+ blood to cause mom sensitization
8
Q
Prenatal management for blood incompatibilities
A
•AP labs -type -Rh factor -abody screen •Indirect Coombs •FOB tested and if neg, baby neg
9
Q
indirect Coombs
A
- see if Rh antibodies present on mom RBC
- expected test if mom received Rhogam during preg
- if Rh- mom has neg. Indirect combs admin RhoGAM
10
Q
RhoGAM admin
A
•blood product that suppresses immune system to prevent sensitization in Rh- mom •28 weeks gestation -IM (300 mcg) •after invasive procedure, AB, etc •to baby w/in 72 hrs of birth if Rh+
11
Q
if mom has positive indirect Coombs…
A
•indicates isoimmunization •draw titer frequently •if > 1:8 need amniocentesis/US •if raises to 1:16, fetus in jeopardy •don't RhoGAM already sensitized *no fetal tx -> 30% mortality rate
12
Q
amniocentesis
A
- measures amnt bilirubin in amniotic fld. (fetal urine)
* used to determine severity of fetal hemolytic anemia if indirect Coombs > 1:8
13
Q
ultrasound w/ positive indirect Coombs
A
•monitors for fetal edema and ascites
14
Q
PUBS
A
- intrauterine blood transfusion of O- blood via umbilical vein
- increases fetal survival and reduces risk of disabilities
15
Q
adverse effects of Rhogam
A
- lethargy
- fever
- malaise
- HA
- localized tenderness
- N/V
- hypotension*
- tachycardia*
- allergy
16
Q
who needs Rhogam
A
•Rh- mom w/ Rh+ fetus
•Rh- mom w/ ETOP @ 10 wks and unknown FOB
•Rh- mom w/ amniocentesis
*RhoGAM doesn’t do anything if already isoimmunized
17
Q
other blood incompatibilities
A
•A and B •O and A •O and B *A has B antibodies *B has A antibodies *O has A & B antibodies *AB has no antibodies
18
Q
ABO Incompatibility
A
- mom O
- fetus A, B, or AB
- maternal antibodies attack infant antigens
- most common cause of hemolytic dz in newborn
- less severe than Rh, but CAN affect firstborns, unlike Rh
19
Q
fetal response to ABO incompatibility
A
- hemolysis ->
- hyperbilirubinemia ->
- jaundice
20
Q
diagnosis of ABO incompatibility
A
•+ direct Coombs •jaundice w/in 24 hr of delivery •bilirubin > 15 mg/dl (term) •bilirubin > 10 mg/dl (preterm) *pathologic jaundice
21
Q
ABO incompatibility tx
A
•phototherapy
-UV rays promote hepatic excretion of bili
•exchange transfusion (rare)
*goal is to prevent acute bill encephalopathy
22
Q
hemorrhagic conditions of early pregnancy
A
- abortion
- ectopic preggo
- incompetent cervix
- gestational trophoblastic dx
23
Q
abortion
A
•pregnancy that ends < 20 wks gestation •fetal wt < 500g •¼ women •3 types -spontaneous -elective -therapeutic
24
Q
abortion causes
A
- 50% chromosomal abnormality
- maternal age
- maternal infection (BV; HSV)
- endocrine disorder (progesterone insuff; IDDM)
- environment- smoking, etoh
- systemic disorders (lupus)
25
early abortion
* before 12 wks (80%)
| * caused by chromosome/endocrine/immune/systemic disorders
26
late abortion
* b/t 12-20 wks
| * caused by AMA, multiparous, chronic infection, anomalies of rep. tract, dz, drug use
27
spontaneous abortion
```
•miscarriage
•5 types
-threatened
-inevitable
-incomplete
-compete
-missed
```
28
abortion s/sx
* uterine cramping/pain
* vaginal bleeding (significant)
* weakly positive UPT
* min./absent hCG or progesterone
29
abortion < 6 wks
•heavy period
30
abortion 6-12 wks
•moderate discomfort and some blood loss
31
abortion > 12 wks
•similar to labor complaints
32
threatened abortion
* any vaginal bleeding in pregnancy
| * s/sx: spotting, cramping, BACKACHE, pelvic pressure
33
tx for threatened abortion
* pelvic rest until no blood for 24 hr
* pad count
* hCG/progesterone labs (don't rise)
* vaginal U/S
* RhoGam if Rh-
* psychological support
34
inevitable abortion
* can't be prevented
| * s/sx: bleeding, cramping, ROM, dilation
35
inevitable abortion tx
* allow nature to work
* if incomplete, vacuum curettage or D&C
* RhoGAM if Rh-
36
incomplete abortion
* not all products of conception (POC) expelled
* usually if > 12 wks
* s/sx: profuse bleeding, severe cramping, cervix OPEN, retained placental pressure
37
incomplete abortion tx
* IV
* blood type/screen
* D&C if < 14 wks
* induction if > 14 wks
* RhoGAM if Rh-
38
complete abortion
* all POC expelled
| * s/sx: ctx stop, bleeding subsides, cervix CLOSES, preg s/s disappear, preg test neg
39
complete abortion tx
* no intervention unless excessive bleeding/infection
* pelvic rest until bleeding stops
* RhoGAM if Rh-
40
missed abortion
* fetus dies but is retained inters for wks
| * s/sx: preg s/s disappear, wt loss, uterus stops growing, RED/BROWN spotting
41
missed abortion tx
* U/S to confirm fetal death (10 wk and no FHT)
* hCG double q2d until wk 12
* wait for SAB (1 month)
* D&C (emotional)
* RhoGAM if Rh-
42
complications of missed AB
```
•sepsis
-temp
-foul vaginal d/c
-abd pain
•disseminated intravascular coagulation (DIC)
```
43
disseminated intravascular coagulation (DIC)
•Bleeding causes release of thromboplastin that activates clotting throughout the body
•Coagulation in microcirculation → tiny clots in blood vessels → ischemia of organs
•Uses up clotting factors (platelets, fibrinogen) → inability of blood to clot so massive bleeding occurs
*life threatening
44
when can DIC occur
* missed AB or retained fetal demise
* abruption
* severed PIH
* amniotic fld embolism
* sepsis
45
s/sx DIC
•bleeding from orafices (IV, incision, nose, epidural site, placental site)
•dec. fibrinogen, platelets
•inc. PT/PTT
*low platelets and prolonged bleeding time
46
DIC management
```
•correct cause
•heparin
•blood products
•monitor for bleeding and coagulation levels
*NO epidural or spinal
```
47
empty sac
* embryonic development arrested very early or failed all together
* Id w/ U/S (25 mm sac w/o embryonic tissue)
* high incidence of chrom. anomalies
48
septic abortion
* more common in ETOP
* s/sx: fever, chills, malaise, abd pain, bleeding, sanguinopurulent d/c, TACHYcardia/pnea, abd tenderness, boggy uterus, dilated cvx
49
septic abortion tx
* stabilize
* obtain blood ctx
* IV abx
* surgically evacuate uterine contents
50
recurrent spontaneous abortion
```
•3+ consecutive SAb
•caused by
-Chromosomal abnormalities (50%)
-Endocrine disorder: IDDM, inad. progesterone
-Systemic dz: Lupus, HTN
-Reproductive tract abnormality
-DES exposure
```
51
diethylstilbestrol (DES)
* estrogen drug given to 10,000,000 women b/t 1938-1975 to prevent miscarriage
* causes uterine defects and vaginal cancer
52
uterine abnormalities
* placenta attempts to attach to nonvascular septum
* uterus cannot expand
* surgical correction
53
septate uterus
•wedge of fibrous tissue dividing uterine cavity
54
asherman's syndrome
•adhesions crossing lining of uterus
55
bicornuate uterus
* incomplete uniting of uterus
* r/o poor baby perfusion
* r/o labor complications b/c head doesn't push on cervix as effectively
56
incompetent cervix
* results in repeated preg losses @ 20-23 wks
* caused by D&C, conization, DES, short cervix
* tx w/ cerclage: suture placed @ 14-16 wks (taken out @ 36 or labor sign)
* r/o ROM, PTL, infection
57
ectopic pregnancy
* implantation of fertilized egg outside uterus
* 95% in falopian tube (others in ovary, cervix, and cavity)
* can cause maternal hemorrhage and death
* reduces chances of subsequent pregnancy
58
causes of ectopic pregnancy
•scarring of fallopian tube
- Infection: PID r/t Chlamydia and GC
- Surgery: Failed tubal, ETOP, C/S
- IUD
- douching
59
s/sx ectopic pregnancy
* missed period/irreg. vag bleeding
* unilateral abd pain
* low hCG/progesterone
* fallopian tube rupture (sudden pain, syncope, N/V) -> massive HEMORRHAGE risk
60
ectopic pregnancy tx
•methotrexate
-antineoplastic
-admin if < 4 cm
•laparoscopic salpingectomy
61
RN considerations ectopic pregnancy
```
•early ID of shock (tachycard)
•monitor for dec. hct
•pain control
•educate on methotrexate (anti-neoplastic- stops rapidly dividing cells)
-SE of N/V
-no etoh/sex until no hCG
-must be < 8 wks & < 4cm
*preferred b/c less scaring
```
62
hydatidiform mole (gestational trophoblastic)
* ovum fertilized by 2 sperm or sperm replicates its own DNA
| * trophoblasts develop abnormally
63
partial molar pregnancy
* 69 XXX, 69XXY or 69 XYY
* 2 sperm fertilize an otherwise normal ovum
* 1 maternal, 2 paternal chromosome
* molar tissue and fetal tissue
* deformed/nonviable and resorbed
64
complete molar pregnancy
* 46XX
* sperm fertilizes an egg with a lost or inactive nucleus
* sperm duplicates itself resulting in 46XX
* no fetal tissue, white fluid filled grapes
* 20% advance to choriocarcinoma
65
hydatidiform mole s/sx
* hyperemesis gravidarum
* vaginal bleeding - dark brown spotting to profuse hemorrhage
* passage of grapelike clusters
* no FHT’s
* PIH before 24 weeks
* High hCG levels
* Snowstorm pattern on U/S
66
hydatidiform mole tx
•D&C
•MRI to detect CA (-> chemo)
•F/U x 1 year to detect malignant changes
-hCG levels q 1-2 weeks until normal then q 1-2 months x 1 year
•must avoid pregnancy x 1yr (no IUD BC)
67
hemorrhagic conditions of late pregnancy
* placenta previa
| * abruptio placentae
68
placenta previa
```
•placenta implants in lower uterine segment
•5% of all births
•associated w/
-Previous ETOP
-Multiparity (5 or more)
- >35 y/o
-Previous uterine incision
-Previous placenta previa
```
69
marginal/low-lying placenta previa
* common early in preggo (<26 wk)
| * only 10% remain into 3rd trimester
70
complete placenta previa
* convers os
| * won't resolve
71
placenta previa s/sx
* painless, bright red vag bleeding
* uterus soft/nontender
* possible FHT distress, depending on blood loss
72
RN assessment for placental previa
* Assess/Monitor FHTs, maternal VS
* Assess/Monitor vaginal bleeding (pad counts)
* Assess contractions
* Assess lab values
73
RN Imp placental previa
```
•maintain IV
•bedrest w/ BR privileges
•NO vag exams
•prepare for possible C/S
*pt D/C if on pelvic rest and stable
```
74
normal bloody show
•mucous mixed w/ blood
•pink tinge
•small ant
*pathological is dark read and copious
75
DONT do vaginal exam if bleeding until...
•know where the placenta is
•assess for placental previa
-if so, notify MD
76
placental abruption
* premature separation of a normally implanted placenta
* usually have clot on maternal side
* fetal bleeding possible if trauma induced
* apparent or concealed bleeding
77
risk factors for placental abruption
* HTN
* cocaine/nicotine
* trauma (domestic, excess piton, short cord)
78
placental abruption s/sx
* Abdominal pain, board like
* bleeding- dark red (may be concealed)
* Uterine irritability/inc. tone (pressure)
* poor relaxation between contractions
* FHT- acute distress or absent
79
grade I abruption
* 10-20% placenta detached
* vag bleeding possible
* uterine tenderness
* neither mom nor babe in distress
80
grade II abruption
* 20-50% placenta detached
* no bleeding
* uterine tenderness/tetany
* mom in shock
* baby in distress
81
grade III abruption
* > 50% placenta detached
* vag bleeding possible
* severe uterine tetany (board like abd)
* mom in shock and has coagulopathy (r/o DIC)
* fetus dead
82
RN assessment abruption
* VS for hypovolemic shock
* Assess FHTs for LATE deceleration
* blood loss (pad count), ctx
* pain (location, type, intensity)
* lab values
83
RN implications abruption
* large bore (16 or 18 G) IV
| * prepare for possible C/S
84
early s/sx hypovolemia
```
•tachycardia
•thready pulse
•inc. resp.
•BP normal
*body trying to compensate
```
85
late s/sx hypovolemia
```
•falling BP
•cool, moist, pale skin
•dec. UOP (<30cc/hr)
•change in mental status (irritable, confused, agitated)
*body CANT compensate
```
86
RN intervention hypovolemia
* Position lateral, HOB flat, feet elevated
* O2 per face mask
* large bore IV patency (2 if possible)
* IV NS fluid replacement until blood product ready
* Obtain type and screen
87
chronic HTN
* dx < 20 wks
* more likely in older, diabetes, obesity
* doesn't go away after delivery
88
gestational HTN
* dx after 20 wks
* BP > 140/90 during 2nd half of pregnancy
* no proteinuria
* BP returns to baseline 6 wk PP
* caused by primigravidas, age extremes ( 35), hx of PIH, obesity/diabetes, multiple gestation
89
mild preeclampsia
* GH AND kidney dysfunction
* BP > 140/90 2x over 4 hr
* proteinuria 1+ or > 300 mg/day
* s/sx: HA, irritability, edema, abd pain
* Tx: activity restriction; blood, urine, weight monitoring
90
severe preeclampsia
•GH w/ at least one of....
- BP > 160/110
- proteinuria 3+ or > 5g/day
- oliguria
- inc. liver NZ and Cr
- HA/visual disturbances (vasoconstrict)
- hyperreflexia
- peripheral edema
- hepatic dysfunction
- cardio/pulmonary dysfunction
- epigastric pain
91
severe preeclampsia tx
* hospitalized bed rest
* seizure precautions
* quiet environment
* induce labor w/ Pitocin
* continuos EFM
* fld. restriction
* MgSO4
92
MgSO4
* CNS depressant to prevent seizure
* Relaxes smooth muscle (↓ vasoconstriction)
* SE is that BP is lowered
* Next to Pit, most common drug used in labor and delivery
* Given IVPB via pump
* Effect is immediate
93
MgSO4 SE
```
•flushing/warmth
•HA
•nystagmus
•nausea
•dizzy
•lethargy
*very small therapeutic level
```
94
RN care during MgSO4 tx
* assess VS, FHT, DTRs, UOP, LOC, edema q1hr
* have O2, suction, and Ca gluconate in room
* avoid narcotics
* monitor levels (draw q4-6hr)
* watch baby post-delivery
95
therapeutic MgSO4 range
•4-8 mg/dl
96
loss of patellar reflex MgSO4 range
•9-10 mg/dl
97
respiratory arrest MgSO4 range
•12-17 mg/dl
98
cardiac arrest MgSO4 range
•30-35 mg/dl
99
s/sx MgSO4 toxicity
* absent DTRs
* resp. depression (< 12 min)
* cardiac arrest
100
MgSO4 toxicity tx
* stop MgSO4 drip
* open main line
* another RN notify MD
* airway
* Ca gluconate IV 1g over 2 min
101
MgSO4 PP
* continue for 12 hr b/c seizures most common during first 12 hours post delivery
* monitor for uterine atony (impaired involution and r/o hemorrhage)
102
how is preeclampsia cured
•birth
103
eclampsia
* preeclampsia accompanied w/ seizures
* twitching begins around mouth
* respiration halted
* leads to babe not getting O2
104
RN care post-seizure
* stay with pt & call for assistance
* place on left side, suction
* O2 face mask
* Give meds (mag, valium)
* mom V/S q 5-15 min
* fetal V/S (EFM)
* Monitor for labor, abruption, fetal hypoxia and death
105
HELLP
•life-threatening variation of preeclampsia before 36 wks
H- hemolysis resulting in anemia & jaundice
EL- elevated liver NZ
LP- low platelets (<100,000)
*LAB, NOT clinical dx
106
s/sx HELLP
* N/V
* edema
* malaise
* epigastric pain
* may/may not have proteinuria or inc. BP
* low hit
* high liver NZ
* high uric acid, low Cr (high renal fun)
* platelets < 100,000 (thrombocytopenia)
107
RN care HELLP
* Intensive one-on-one nursing
* No abd palp, could rupture liver hemotoma
* MgSO4 to control seizures
* Steroids given to mature fetal lungs
* Labor induction (may delay up to 96 hr to develop fetal lungs)
108
more likely to have uterus rupture
•large/edema baby
•hx of C/S or other uterine surgery
•D&C
*hypervascularized during PG, so big bleeding risk
109
scarring of fallopian tube consequences
* more likely to have ectopic PG
| * due to previous ectopic, PID r/ Chlamydia and GC, surgery, IUD, etc
110
how do you infuse Pit
* pump when PG
| * don't want to hyperstim uterus
111
Pit admin w/ woman on MgSO4
•begin pit and each time inc. you will decrease primary IV rate
*leave the MgSO4 rate
112
why is MgSO4 given
•seizure prevention in HTN pt.
*side effect is to lower BP
•prevents cerebral hemorrhage in fetus receiving steroids (if admin in non-HTN mom)
113
2 key signs of MgSO4 toxicity
* decreased DTRs
| * fluid in lungs
