Gestational conditions Flashcards
(97 cards)
1
Q
highest rate of pregnancy related hypertension
A
first pregnancy over 40
2
Q
maternal death associated with severe hypertension result of?
A
hepatic rupture, placental abruption and eclampsia (characterized by seizures)
3
Q
classification of hypertensive disorders in pregnancy
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pre-existing hypertension (with or without combined conditions and with or without evidence of pre-eclampsia) - appears before 20 wks
gestational hypertension (with or without combined conditions and with or without evidence of pre-eclampsia) - appears after 20 wks
transient hypertension - elevated BP due to external stimuli
white coat hypertension - BP elevated in clinicians office but normal outside
masked hypertension - BP normal in clinicians office but elevated outside
4
Q
pre-existing hypertension with superimposed pre-eclampsia
A
associated with severe maternal and fetal complications
presence of the following:
hypertension before 20 wks with new or worsening proteinuria
hypertension and proteinuria before 20 wks
sudden increase in BP in women whose hypertension was previously well controlled
thrombocytopenia
elevated liver enzymes
5
Q
pre-eclampsia
A
hypertensive disorder most commonly defined by onset of proteinuria and other end organ dysfunction and may result in maternal complications or intrauterine fetal morbidity and mortality due to uteroplacental insufficiency and placental abruption
6
Q
HELLP syndrome
A
lab diagnosis for variant of severe pre-eclampsia characterized by (H) hemolysis, (EL) elevated liver enzyme, (LP) and low platelets
7
Q
GESTATIONAL DIABETES MELLITUS (GDM)
A
defined as elevated glucose levels that are first recognized
during pregnancy. In the first trimester of pregnancy, uncontrolled hyperglycemia can impact fetal development resulting in
malformations. women with GDM have twice the risk of developing pre-eclampsia, particularly if they have chronic hypertension already
8
Q
Risk factors for GDM
A
Age ≥35 years • Previous GDM • Prediabetes • High-risk population among Indigenous, Latin American, South Asian, Asian, African • Body mass index (BMI) ≥30 kg/m2 • Polycystic ovarian syndrome • Acanthosis nigricans • Corticosteroid use • History of macrosomic infant • Current fetal macrosomia or polyhydramnios
9
Q
early pregnancy bleeding
A
common bleeding of early pregnancy include miscarriage, premature dilation of the pregnancy, ectopic pregnancy, hydatidiform mole (molar pregnancy)
10
Q
pregnancy loss
A
early pregnancy loss - before 12 weeks
late pregnancy loss - between 12 and 20 weeks
11
Q
threatened abortion: management
A
bleeding in early pregnancy with no loss of placenta or fetus
slight bleeding, mild cramping. bedrest ordered but not proven to prevent progression to miscarriage. repeated testing done to determine if fetus is still viable
12
Q
inevitable abortion: management
A
cervix dilated but conception products not expelled
moderate bleeding, mild to severe cramping, cervical dilation. bedrest for no pain, fever, or bleeding. If ROM, bleeding, pain, or fever present, uterus emptied properly by dilation and curettage (removal of leftover placenta/fetus)
13
Q
incomplete abortion: management
A
partial loss of fetus/placenta
heavy bleeding, severe cramping, cervical dilation with tissue in cervix and passage of tissue. may or may not require additional cervical dilation for curettage
14
Q
complete abortion: management
A
slight bleeding, mild cramping, passage of tissue. no further intervention needed if uterine cramping adequate to prevent hemorrhage. suction curettage sometimes done to remove leftover tissue
15
Q
missed abortion: management
A
fetus not viable but does not get expelled by uterus
spotting, no cramping. if spontaneous evacuation of the uterus does not occur within 1 month, pregnancy terminated in method appropriate for gestational age. coagulation monitored for hemorrhage
16
Q
septic abortion: management
A
uterus infected by microorganism
malodorous bleeding, varied cramping, varied tissue passage, cervical dilation. immediate termination of pregnancy by appropriate method. treatment for sepsis
17
Q
recurrent abortion: management
A
3 consecutive pregnancy losses prior to 20 weeks gestation.
varied bleeding, varied cramping, passage of tissue and cervical dilation. tx varies depending on type but prophylactic cerclage (using a ring or loop to bind the opening of the cervix) performed if cause if early cervical dilation
18
Q
dilation and curettage (D&C)
A
surgical management in which the cervix is dilated and a curette inserted to remove uterine contents. Commonly used for inevitable and incomplete miscarriage.
dilation and evacuation is performed after 16 weeks and is a wide cervical dilation with instrumental removal of uterine contents
19
Q
Misoprostol
A
for late, incomplete, inevitable, or missed pregnancy loss (16 to 20 weeks) given orally or vaginally to induce labour and deliver the fetus.
20
Q
premature dilation of cervix
A
passive and painless dilation of the cervical os without labour or contractions of the uterus (cervical insufficiency or incompetent cervix). miscarriage or preterm birth may occur. tx: restricted activity and hydration, cervical cerclage such as Shirodkar or McDonald procedure,
21
Q
shirodkar procedure
A
maternal fascia lata (muscle from thigh) is threaded submucosally in the cervix anteriorly and posteriorly and tied
22
Q
mcdonald procedure
A
nonabsorbable ribbon is placed around the cervix beneath the mucosa to constrict the internal os of the cervix
23
Q
ectopic pregnancy
A
fertilized ovum is implanted outside the uterine cavity. increased incidence in women with reproductive therapy. majority occur in the fallopian tube on the ampullar (largest portion of the tube). 3 clinical signs of ectopic tubal pregnancy are abdominal pain, delayed menses, and abnormal vaginal bleeding approx 6 to 8 weeks after last period. in ruptured ectopic pregnancy, shoulder pain is evident.
24
Q
treatment of ectopic pregnancy
A
can resolve spontaneously with tubal abortion or regression of the pregnancy from the tube. Medical management is methotrexate to dissolve the tubal pregnancy (it is a antimetabolite and folic acid antagonist that destroys rapidly dividing cells). surgical management depends on cause of pregnancy, extent of tissue involvement, and women’s desire to get pregnant again. Could be salpingectomy (removal of entire tube) or if women would like to get pregnant again, salpingostomy (incision in tube and removal of conception products - not sutured but left to close to reduce scarring)
25
magnesium sulfate
used to prevent seizures in preeclampsia, slow or stop preterm labour, and prevent injury to preterm baby brain
26
molar pregnancy
benign proliferative growth of the placental trophoblast in which the chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in a grape like cluster. hydatidiform mole is a gestational trophoblastic disease (GTD) which is a group of pregnancy related trophoblastic proliferative disorders without a viable fetus that are caused by abnormal fertilization.
27
molar pregnancy types and risk factor
at risk if in teens or older than 40 or had molar pregnancy before
complete molar: fertilization of an egg in which the nucleus has been lost or inactivated. contains no fetus, placenta, amniotic membranes, or fluids, just grape like cluster of hydropic vesicles. Maternal blood has no placenta to receive it, therefore, hemorrhage in uterine cavity and vaginal bleeding occur.
partial molar: two sperms fertilizing an apparently normal ovum. partial molar have embryonic or fetal parts and an amniotic sac. congenital anomalies present
28
molar pregnancy management
most moles pass spontaneously, suction curettage offers safe, rapid, and effective method of evacuating the mole. another option is hysterectomy. admin of Rh immune globulin recommended in Rh negative women
29
placenta previa
placenta is implanted in the lower uterine segment so that it completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces. placenta previa during second trimester is risk factor for vasa previa (fetal vessels in placenta are near cervical opening). complete placenta previa - total cervical covering, Marginal placenta previa - edge of placenta seen in vaginal ultrasound to be 2.5cm or closer to internal cervical os. Low lying placenta - exact relationship of placenta and interval os not determined or apparent placenta previa in second trimester. dx: painless bright red vaginal bleeding after 20 weeks gestation
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expectant management of placenta previa
less than 36 weeks of gestations and not in labour, bleeding is mild or has stop, expectant management - reduced activity and close observation - is treatment of choice. ultrasound done every 2 weeks, fetal surveillance (NST or BPP) one or twice weekly. venous access with heparin lock in case of blood therapy. antepartum steroids (betamethasone) for lung maturation if fetus under 34 weeks. vaginal rest ordered (nothing in vagina)
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active management of placenta previa
at or beyond 36 weeks or bleeding is excessive or persistent, immediate C section indicated. in women with partial or marginal placenta previa vaginal birth may be attempted. Natural mechanism to control bleeding after pregnancy not present in lower uterine segment so bleeding may continue after fetal birth and hemorrhage may occur even if fundus contracted firmly
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placental abruption (premature separation of placenta)
detachment of part of all of the placenta from its implantation site. maternal hypertension most common risk leading to placenta abruption.
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3 types of placenta abruption
mild abruption: minimal, dark red bleeding, no pain. normal FHR
moderate abruption: moderate dark red blood, mild shock, occasional DIC, increased uterine tone, atypical FHR, moderate pain
severe abruption: heavy dark red blood, sudden and profound shock, frequent DIC, tetanic uterine tone, agonizing pain, abnormal FHR
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couvelaire uterus
blood accumulates between uterine wall and separated placenta due to placental abruption resulting in uterus appearing purplish and copper coloured, ecchymotic, and contractility is lose
35
diagnosis of placental abruption
strongly suspected in the women with sudden onset of intense, usually localized uterine pain, with or without vaginal bleeding.
36
treatment of placental abruption
tx depends on severity of blood loss, fetal maturity and status. If mild abruption, fetus not in distress, and less than 36 weeks, expectant management implemented at hospital. fetal status closely monitored until fetal maturity is achieved. deteriorating condition indicates immediate birth - use of betamethasone for fetal lung maturation. if fetal to maternal hemorrhage occurs Rh negative mother treated w/ Rh immunoglobulin if fetus Rh positive. vaginal birth attempted if fetus is dead or fetus is alive in no distress and mother is hemodynamically stable - otherwise C section. blood and fluid volume replacement most likely ordered. Note: c section not attempted if mother has severe or uncorrected coagulopathy as may result in uncontrolled bleeding.
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placenta accreta
serious complication of placenta previa. trophoblastic invasion extends beyond the normal endometrial barrier. if extended into myometrium called placenta increta. if extends beyond uterus serosa called placenta percreta. massive hemorrhage can occur with any of these conditions. tx: c section with fundal incision, followed by total abdominal hysterectomy.
38
velamentous insertion of the cord
occurs when the umbilical vessels begin to branch at the membranes and then course onto the placenta.
39
treatment of HELLP syndrome
blood transfusion to treat anemia and low platelet
magnesium sulfate for seizures
antihypertensive meds for blood pressure
betamethasone to mature baby lung
40
battledore (marginal) insertion of the cord
umbilicus connects within 2cm of placental edge instead of the center
increases risk of fetal hemorrhage, especially after marginal separation of the placenta
41
succenturiate placenta
placenta divided into two or more separate lobes, each lobe has distinct circulation. vessels collect at the periphery and the main trunks eventually unite to form the vessels of the cord. during labour one of more of the separate lobes may remain attached to uterus, preventing uterine contraction and increasing risk of hemorrhage
42
disseminated intravascular coagulation in pregnancy
pathological form of clotting that results in depletion of platelets and clotting factor leading to external and internal bleeding. overactivation of the clotting cascade and fibrinolytic system results in minor fibrin clots in microcirculation, causing damage to RBC that attempt to pass through - results in anemia. signs of DIC are hemorrhage, anemia, and ischemia (reduced blood flow to body organs or tissues). in pregnancy DIC most often triggered by large amounts of tissue thromboplastin from placenta abruption, retained dead fetus syndrome, and amniotic fluid embolus. Severe pre-eclampsia, HELLP syndrome, and sepsis are conditions that cause damage to vascular integrity resulting in DIC
43
medical management of DIC in pregnancy
correction of underlying cause, volume expansion, rapid replacement of blood products and clotting factors, optimization of oxygenation, achievement of normal body temp, and continued assessment of lab results. supportive measure is keeping pregnant women in side lying tilt to maximize blood flow to uterus.
44
von willebrands disease in pregnancy
type of hemophilia from factor VIII deficiency and platelet dysfunction. factor VIII increases during pregnancy and should be sufficient to prevent hemorrhage, however VIII factor should be monitored and factor VIII/vWF plasma concentrate given as needed to mantain activity. hemorrhage may occur 4 to 5 days after birth so women should be kept in hospital longer for monitoring. primary treatment is desmopressin, which increased both VIII factor and vWF factor.
45
asymptomatic Bacteriuria (UTI) in pregnancy
persistent presence of bacteria within the urinary tract of women who have no symptoms. if untreated tends to become symptomatic infection in pregnancy. associated with preterm labour and low birth weight infants. tx: antibiotic, repeat urine culture 1 to 2 weeks after antibiotic course. if recurrent infection placed on suppressive therapy (nitrofurantoin) each night for rest of pregnancy
46
cystitis in pregnancy
bladder infection characterized by dysuria, urgency, and frequency, and abdominal or suprapubic pain. WBC and bacteria found in urine. tx: 3 day course of antibiotics and pyridium (urinary analgesic) for symptom relief - turns urine and tears orange.
47
pyelonephritis in pregnancy
renal infection common serious medical complication of pregnancy. complications include anemia, septicemia, transient renal dysfunction, and pulmonary insufficiency. recurrent infection thought to cause fetal death and IUGR. hospital admittance and treated with IV antibiotics. once women is afebrile changed form IV to oral antibiotics. If no improvement seen in 48-72 hours ultrasound for urinary tract obstruction. recurrence common so kept on prophylactic antibiotics (nitrofurantoin) for rest of pregnancy
48
appendicitis in pregnancy
surgical removal of appendix. laparoscopic surgery in first two trimesters if appendix hasn't ruptured or dx is uncertain. antibiotic treatment (clindamycin and gentamicin) for uncomplicated appendicitis or if rupture, abscess, or peritonitis occurred
49
cholelithiasis and cholecystitis
cholelithiasis - gallstones in the gallbladder; incidence increases during pregnancy probably bc of increased hormone level and pressure of uterus on gallbladder
cholecystitis - inflammation of the gallbladder, usually caused when gallstone obstructs a cystic duct or during pregnancy due to increased pressure
gallbladder surgery postponed until six weeks after birth, during pregnancy tx is antibiotic therapy, analgesics, IV fluids, bowel rest, nasogastric suctioning, and changed diet (low fatty food)
women with recurrent biliary colic or acute cholecystitis require immediate cholecystectomy (removal of gallbladder) with can occur at any time during pregnancy (though second trimester best for surgery) - preoperative care includes analgesia, IV fluids, antibiotics, and discontinuation of oral intake
50
nursing care following trauma
immediate stabilization - patent airway, mother in tilted position (left) to maintain blood flow to uterus; in case of spinal injury tilt still recommended but done manually or tilt placed under stretcher to keep spine and head/neck straight. priority for care is pregnant woman stabilization and then fetal needs
primary survey - CABDs of resuscitation; compressions, airway, breathing, and defibrillation. oxygen needs in gestation increased necessitate rapid response. placement of two large bore IV lines necessary is serious injury; cardiac arrest sign of profound hypovolemia in which case rapid fluid resuscitation implemented with lactate ringers or normal saline. replacement of blood anticipated so blood drawn for type matching. baseline neurological status is essential
secondary survey - complete physical assessment including all body systems. greatest clinical concern is placental abruption. peritoneal lavage after abdominal trauma proven to be safe procedure; incision made in peritoneum and dialysis catheter inserted, if free flowing blood returned test is positive, and laparotomy performed. if presence of uterine injury, quick determination of benefits and risk of c section; fetus tolerates surgery if adequate uterine perfusion and oxygenation are maintained. history of pregnancy and trauma obtained
radiation exposure - If the pregnant woman has sustained serious injuries, any necessary radiographic examination should be performed,
regardless of fetal exposure
fetal - maternal hemorrhage - if determined to have occurred Rh immunoglobulin given to protect Rh negative mum from Rh positive fetal blood
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Fetal Health Surveillance
external FHR and contraction monitoring recommended after blunt trauma in a viable pregnancy for min 4 hours. palpation required for contraction intensity and uterine tone - palpate between contractions to make sure uterus able to relax properly. occasional uterine contraction common after trauma but resolve on their own with no adverse fetal outcome. monitoring should be continued if uterine contractions, abnormal FHR, vaginal bleeding, maternal injury, uterine tenderness or irritability, or ruptured membranes present.
52
perimortem c section
removal of stressor of pregnancy early in resuscitation efforts increases chance of survival. If women unconscious for more than 5 minutes and CPR unsuccessful, c section should be considered. fetal survival unlikely if C section more than 20 minutes after maternal death. Emphasis that perimortem c section rarely successful, especially in multisystem trauma
53
pregestational and gestational diabetes
hyperglycemia resulting from defects in insulin secretion, insulin action, or both. pregestational diabetes is diabetes 1 (B-cell destruction in pancreas) or 2 (insulin resistance or deficiency) that was present in women before pregnancy. gestational diabetes is women who have carbohydrate intolerance discovered during pregnancy - any degree of glucose intolerance with onset or recognition during pregnancy; applies whether insulin used for treatment or diabetes persists after pregnancy. Women who experience gestational diabetes should be followed up with 6 weeks and 6 months after birth for presence of underlying disease
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signs of diabetes in pregnancy
polyuria - large volumes of urine due to kidney excreting excess blood volume from hyperglycemia (hyperglycemia causes hyperosmolarity where intracellular fluid gets pulled into the vascular system to dilute the glucose concentration)
glycosuria - glucose in the urine
polydipsia - excessive thirst due to polyuria and cellular dehydration
polyphagia - excessive hunger caused by starvation due to tissue breakdown of fats and muscles for energy to compensate for inability of body to convert carbs (glucose) into energy
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two insulin conditions in diabetes
impaired insulin secretion due to beta cells of the pancreas being destroyed by an autoimmune process
inadequate insulin action in target tissues at one or more points along the metabolic pathway
- both these conditions present in same person, difficult to determine which abnormality is primary
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normal glucose cycle in pregnancy
glucose, primary fuel used by the fetus, is transported across the placenta through diffusion, thus glucose level in fetus directly proportional to maternal glucose level. Glucose crosses the placenta but insulin does not so around the 10th week the fetus secretes its own insulin level to match the glucose level crossing the placenta. in first and second trimester Estrogen and progesterone (pregnancy hormones) stimulate the B-cells in the pancreas to increase insulin production; increasing peripheral use of glucose and decreasing blood glucose. At the same time increases in tissue glycogen stores and decrease in hepatic glucose production lower fasting glucose. During latter part of second and all through third trimester pregnancy exerts a diabetogenic effect, decreasing tolerance of glucose, increasing insulin resistance, decreasing hepatic stores, and increasing hepatic production of glucose. insulin resistance is a glucose sparing mechanism to ensure enough glucose for the fetus. Insulin requirements increase from 18 or 24 weeks to 36 weeks where it levels out. at birth the expulsion of the placenta prompts an abrupt decrease in pregnancy hormones, cortisol, and insulinase. maternal tissue quickly regains its prepregnancy sensitivity to insulin. for non breastfeeding it prepregnancy insulin-carb balance restored in 7 to 10 days. in breastfeeding insulin requirement remains low until infant weaned.
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pregestational diabetes and glucose levels in pregnancy
due to low glucose level as natural part of first and second trimester women with pregestational diabetes tend to be hypoglycemic. women with diabetes require insulin throughout pregnancy. Hormonal changes in pregnancy that affect glycemic control may accelerate vascular complications of diabetes. During first semester when blood glucose is low and insulin response to glucose is enhanced there is better glycemic control. Insulin dose must be adjusted during pregnancy for rising insulin resistance in second and third trimester (more insulin needed) and and hypoglycemia in first and second trimester (less insulin needed).
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preconception counselling for diabetic women
strict metabolic control important to reduce congenital anomalies and spontaneous abortion during organogenesis in early weeks of pregnancy. use of oral antihyperglycemic meds alone in pregnancy not recommended.
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Maternal risks with diabetes in pregnancy
risk factors include blood glucose control, length of time since diagnosis, and existing diabetic complications present. women with pregestational diabetes who have poor glycemic control (defined as glycosylated hemoglobin value greater than 7.0% around time of conception and in early pregnancy) have twofold increased incidence of early pregnancy loss. Poor glycemic control later in pregnancy increase the rate of fetal macrosomia (birth weight more than 400-4500g). assessment for retinopathy recommended in preconception, during first trimester, as needed throughout pregnancy, and 1 year postpartum. Hydramnios (Amniotic fluid index (AFI) greater than 24 and 25cm) frequently develop during third trimester of woman with diabetes thought to result from increase glucose concentration in amniotic fluid from maternal and fetal hyperglycemia.
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infection in diabetic pregnant woman
disorder of carbohydrate metabolism alter body's normal resistance to infection - inflammation response, leukocyte function, and vaginal pH all affected. infection may cause insulin resistance resulting in ketoacidosis. postpartum infection more likely to occur in woman with poor glycemic control. Most common concern in pregnancy is loss of hypoglycemic awareness - more common in long standing diabetes and safety concern for mothers- hypoglycemic awareness may return after pregnancy.
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ketoacidosis in pregnancy
build up of ketones in the blood due to hyperglycemia - the body breaks down fat too fast to accommodate for energy demands and releases ketones into the blood making it more acidic; leads to metabolic acidosis. occurs most often during second and third trimester when diabetogenic effect is greatest. DKA occur due to over or under administration of insulin. DKA occur with blood glucose levels barely exceeding 11 mmol/L because of increase in the body's resistance to insulin. Excessive blood glucose and ketones results in osmotic diuresis with subsequent loss of fluids and electrolytes, volume depletion, and cellular dehydration.
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Hypoglycemia in diabetic pregnancy
less than normal amount of glucose in the blood. Abnormal postnatal neurological development occurs when long term hypoglycemia results in ketosis (break down of fat or muscle to meet energy demands not provided by carbs - glucose)
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fetal and neonatal risks with diabetes
stillbirth significant risk. in third trimester fetal acidosis is most likely cause of death. most important cause of perinatal loss is congenital malformation - incidence of malformations directly related to severity and duration of diabetes. Hyperglycemia during organogenesis main cause of birth defects. Morbidity and mortality of fetal reduce with strict maternal glycemic control before and during pregnancy. Macrosomia due to increased insulin secretion (hyperinsulinism) to accommodate hyperglycemia acting as a growth hormone. Hypoglycemia also risk for infants depending on glycemic control of mother in last trimester of pregnancy (increased insulin demands)
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insulin shock (hypoglycemia) in pregnancy
due to: excess insulin, insufficient food (delayed or missed meals), excessive excersize or work, indigestion (vomiting or diarrhea). Rapid onset for regular insulin or gradual onset for modified insulin or oral hypoglycemic agents. s&s: hunger, blurred vision, personality changes,
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interventions for insulin shock in pregnancy
check blood glucose levels, eat 15g of fast sugar, recheck blood glucose in 15min and eat another 15g fast sugar if low, recheck blood glucose in 15min again, notify healthcare provider if no change in blood glucose level. If woman unconscious admin 50% dextrose IV push, 50 to 10% dextrose in water IV drip, or 1 mg glucagon subQ. obtain blood and urine specimen for lab testing
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diabetic ketoacidosis (hyperglycemia) in pregnancy
due to: insufficient insulin, excess or wrong kind of food, infection, injury, or illness, emotional stress, insufficient excersize. Slow onset (hours to days). S&S: thirst, abdominal pain, acetone (fruity) breath odour
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interventions for DKA in pregnancy
notify healthcare provider, admin insulin in accordance with blood glucose levels, give IV fluids such as normal saline solution or one half normal saline solution; potassium when urinary output adequate; bicarbonate for pH <7, monitor laboratory testing of blood and urine
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hyperthyroidism in pregnancy
most commonly caused by graves disease or human chorionic gonadotropin (hCG) mediated hyperthyroidism. symptoms generally begin 4 to 8 weeks of gestation and involve severe nausea and vomiting. dx: thyroid levels in blood. woman with minimal or mild symptoms - low thyroid stimulating hormone and mild elevated thyroxine - can be monitored without intervention. Signs to differentiate mild from severe hyperthyroidism include unplanned weight loss, loose nails, and HR 100bpm/min or higher. two primary meds to treat hyperthyroidism in pregnancy; propylthiouracil (PTU) and methimazole (MM). MM has teratogenic effects so is avoided in first trimester, PTU is associated with liver failure so only used in first trimester to prevent toxicity. Thyroid function test performed 2 to 4 weeks after switch from PTU to MM to be sure euthyroid maintained. Beta adrenergic blockers used for severe symptoms but not long term due to adverse effects on postnatal bradycardia, anoxic stress, hypoglycemia, and IUGR. med can be passed through breastfeeding so a breastfeeding newborn thyroid function should be monitored periodically to prevent hypothyroidism. In severe cases, hyperthyroidism can be surgically dealt with by removing the thyroid (subtotal thyroidectomy) in second or third trimester.
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thyroid storm in pregnancy
uncommon but serious complication of untreated or partially treated hyperthyroidism. it occurs in response to stresses such as severe pre-eclampsia, infection, birth or surgery. Prompt treatment with PTU, IV fluids, and oxygen required. Potassium iodide, antipyretics, glucocorticoids, and beta adrenergic blockers may also be given; sedation may be necessary. symptoms include sudden fever, tachycardia, restlessness, vomiting, hypotension, or stupor. HF also may occur
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hypothyroidism in pregnancy
TSH levels high caused by underactive thyroid. most common cause of thyroid problems is iodine deficiency. signs of hypothyroidism include cool and dry skin, weight gain, coarsened hair, muscle weakness, cold intolerance, decrease in excersize capacity, constipation, and fatigue. hypothyroidism shown to cause neurological development impairment in early fetal development. fetus dependent on maternal transfer of thyroid hormones for first 18 weeks of pregnancy, specifically T4 - if mother deficient, fetal brain cannot develop properly. Thyroid hormone supplement treatment of choice, specifically levothyroxine as it is not a teratogenic. Thyroid hormone treatment must be adjustment for demand throughout pregnancy (demand generally goes up as pregnancy progresses). Take meds on empty stomach for increased absorption and take prenatal vitamins 4 hours after thyroid hormones as iron and calcium affect absorption of hormone.
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Maternal cardiac disease risk group 1
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mortality rate <1%
ASD and VSD
PDA
corrected tetralogy of fallot
pulmonic/tricuspid disease
mitral stenosis or aortic regurgitation
bioprosthetic valve
mitral valve prolapsed with regurgitation
```
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maternal cardiac disease risk group 2
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mortality rate 5-20%
aortic stenosis
coarctation of the aorta without valve involvement
artificial heart valves
mitral stenosis or with atrial fibrillation
uncorrected tetralogy of fallot
previous myocardial infarction
marfan syndrome with normal aorta
```
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maternal cardiac disease risk group 3
mortality rate 25-50%
pulmonary hypertension
coarctation of the aorta with valvular involvement
complicated marfan syndrome with aortic involvement
endocarditis
eisenmenger syndrome
peripartum cardiomyopathy with persistent left ventricular dysfunction
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Cardiovascular disorders in pregnancy
changes that occur in pregnancy that affect women with cardiac disease are increased vascular volume, decreased systemic vascular resistance, cardiac output changes in labour, and intravascular changes that occur just after birth
if myocardial disease develops, valvular disease exists, or congenital heart defect is present, cardiac decompensation (inability of the heart to maintain a sufficient cardiac output) may occur
Fever and infection major causes of cardiac decompensation in pregnancy
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New York Heart Association (NYHA) functional classification of heart disease
Class I: asymptomatic without limitation of physical activity
Class II: symptomatic with slight limitation of activity
Class III: symptomatic with marked limitation of activity
Class IV: symptomatic with inability to carry out activity without discomfort
note: woman assessed for classification at 3 months and then again at 7 or 8 months
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congenital cardiac disease in pregnancy
women at risk for cardiac event in pregnancy include those with a prior cardiac event, arrhythmia, NYHA functional class greater than II, cyanosis, left heart obstruction, and systemic ventricular dysfunction
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ASD in pregnancy
tends to be asymptomatic. most common CHD seen in pregnancy. usually uncomplicated pregnancy but some woman can develop heart failure or arrhythmias as a result of increased blood volume. another possible complication is emboli (blood clot)
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VSD in pregnancy
not commonly seen in pregnancy due to fixing earlier in life. Uncomplicated pregnancy with minor VSD. if defect is large risk of heart failure or pulmonary hypertension. tx: anticoagulants and rest
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PDA in pregnancy
generally fixed earlier in life. Small PDA minor or few complications. Large PDA that results in increased left to right shunting results in hemodynamic changes that evolve to eisenmenger syndrome which is fatal to mother and fetus - recommended termination
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coarctation of the aorta in pregnancy
uncorrected coarctation of the aorta is relatively safe during pregnancy. tx: rest and antihypertensive medications - preferably beta adrenergic blocking agents. Some recommendations for C birth to prevent blood pressure elevation during second stage labour that could lead to rupture of vessels or aorta
if bacteremia suspected - prophylactic antibiotics given during labour
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marfan syndrome in pregnancy
marfan syndrome - autosomal dominant condition of generalized weakness of connective tissue, resulting in characteristic feature of the disease, aortic wall and root dilation. S&S: dislocation of optic lens, deformity of anterior thorax, scoliosis, long limbs, joint laxity, and arachnodactyly (spidery fingers)
mortality rate as high as 50% - however, is aortic root dilation of 40mm or less, mortality less than 5%
repair of aortic root recommended if diameter 5.5 to 6cm before pregnancy, if root less than 4cm can attempt pregnancy with modest risk
tx: limited physical activity, prevention of hypertensive or hypotensive complications, admin of beta blockers as needed to maintain resting HR of 70bpm, and tachycardia prevention in labour
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tetralogy of fallot in pregnancy
most common cyanotic heart disease seen in pregnancy (ASD most common acyanotic). components of TOF: pulmonary stenosis, VSD, overriding aorta, and right ventricle hypertrophy - right to left shunting. Surgical correction recommended as patched VSD and repaired pulmonary stenosis results in pregnancy with no significant risk. With uncorrected FOT right to left shunting results in reduced pulmonary blood flow and increasing hypoxemia, which can cause syncope (fainting) and death.
tx: maintenance of venous return critical in TOF therefore most dangerous time is third trimester and postpartum - when venous return reduced by large uterus and peripheral blood pooling after birth; blood volume must be adequately maintained. Prophylactic antibiotics given intrapartum period, pressure graded support hose recommended
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Eisenmenger syndrome in pregnancy
right to left or bidirectional shunting that can be at atrial or ventricular level and is combined with elevated pulmonary vascular resistance. Associated with underlying structural defect like VSD (most common) or PDA. high risk means pregnancy avoided or terminated in these women. Death can occur at any time but intrapartum and early postpartum period most common.
maternal morbidity: right ventricular failure and associated cardiogenic shock
tx: measures to maintain pulmonary blood flow, physical activity limited, pressure graded elastic support hose, oxygen therapy
during labour tx: narcotic based anesthesia provide pain relief without causing excessive hemodynamic instability
hypotension prevented at all cost bc it results in more right to left shunting, increasing hypoxemia, increasing pulmonary resistance, and worsening shunt. Volume overload or excessive systemic resistance prevented to stop further stress of the failing right side of the heart
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primary pulmonary hypertension in pregnancy
constriction of the arteriolar vessels in the lung, leading to increased pulmonary artery pressure- results in right ventricular hypertension, right ventricular hypertrophy with tricuspid regurgitation and systemic congestion. Pregnancy not advised with this condition. most dangerous time is intrapartum and early postpartum period bc of increased cardiac output and fluid shifts.
tx: limiting activity and avoiding supine position, diuretics, supplemental oxygen, and vasodilator meds
during labour: hypotension must be avoided by carefully establishing epidural analgesia and preventing blood loss - hypotension impairs ability of right ventricle to pump blood through pulmonary veins due to their high fixed resistance
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mitral valve stenosis in pregnancy
always caused by rheumatic heart disease (RHD). mitral valve stenosis - narrowing of the opening of the mitral valve caused by stiffening valve leaflets - causes obstruction of the blood flow from the atrium to the ventricles.
tight stenosis plus increase blood volume and cardiac output of pregnancy may cause complications in pregnancy
maternal mortality related to functional capacity - women with mild to moderate stenosis tolerate pregnancy well (NYHA classification III or IV associated with maternal deaths)
prevention: daily oral penicillin G or monthly penicillin benzathine if increased risk of exposure to streptococcal infection in pregnancy
tx: diuretics such as furosemide to prevent pulmonary edema and beta blockers or calcium channel blockers to prevent tachycardia, cardioversion for new onset atrial fibrillation, chronic atrial fibrillation need digoxin or beta blockers to control HR, anticoagulant therapy to prevent embolism, reduced activity, restricting dietary sodium, and bedrest. Prophylaxis antibiotics for intrapartum endocarditis and pulmonary infection
intrapartum care for severe disease: invasive hemodynamic monitoring during labour - goal to maintain adequate ventricular filling and cardiac output, give birth in lateral decubitus position, shortening second stage of labour with vacuum or forceps (to decrease cardiac workload)
surgical intervention necessary during pregnancy if medical therapy not effective - valve replacement and open commissurotomy or balloon valvotomy (preferred)
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aortic stenosis in pregnancy
medical management same for mitral stenosis
| rarely encountered as generally occurs after childbearing years
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mitral valve prolapse in pregnancy
common, benign condition. mitral valve leaflets prolapse into left atrium during ventricular systole, allowing some backflow of blood. generally asymptomatic, chest pain sometimes felt - give beta blocking drugs - if severe check thyroid function. antibiotic prophylaxis for invasive procedure and complicated vaginal birth
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oxytocin after pregnancy
Dilute IV oxytocin immediately after birth may be used to
| prevent hemorrhage. also used for induction of labour - causes uterine contractions
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anemia in pregnancy
reduction of the oxygen carrying capacity of the blood; heart tries to compensate by increasing the cardiac output - increased cardiac workload and stresses ventricular function. Anemia occurring with any other complication can result in HF.
hydremia - dilution of blood; pregnancy increases blood volume by 50% resulting in dilution of oxygen carrying RBC; also called physiological anemia of pregnancy
anemia in pregnancy - hematocrit level 0.32 or lower
when a woman have anemia during pregnancy, loss of blood at birth is not well tolerated - increased risk for blood transfusion.
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iron deficiency anemia in pregnancy
most common form of anemia. iron transported across placenta for fetal erythropoiesis. treatment through diet, oral supplement, prophylactic iron supplement, and if oral supplement not tolerated iron sucrose or iron dextran (parenteral iron)
iron sucrose preferred
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sickle cell hemoglobinopathy in pregnancy
women with sickle cell anemia high risk of developing stroke, pre-eclampsia, HF, cardiomyopathy, pyelonephritis, leg ulcers, and bone abnormalities. Encouraged to take low dose aspirin after first trimester to reduce risk pre-eclampsia. Crises managed with hydration, oxygen, and analgesia.
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asthma in pregnancy
increased risk of hemorrhage and pre-eclampsia. If excessive bleeding occurs, prostaglandin E2 or E1 given - pt respiratory status monitored
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bells palsy in pregnancy
unilateral weakness of the face, max weakness 48 hrs after onset, pain surround ear, eye cannot close completely, loss of taste and hyperacusis.
Cause unknown, thought to occur due to HIV or herpes virus. Increase risk of gestational hypertension. steroids 5 to 6 days after paralysis thought to be helpful. tx: prevention of injury to exposed cornea, facial muscle massage, careful chewing and removal of food in paralyzed cheek, and reassurance
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HIV and AIDS in pregnancy
ART decreases perinatal transmission rates and progression to AIDS. Preconception counselling should include HIV history, current physical status, and prenatal and HIV specific lab results. Care in pregnancy include strict adherence with ART regimen, follow through with regular HIV specific blood level monitoring (viral plasma levels and immune function), and education regarding labour, birth, and postpartum. Perinatal transmission of HIV can occur in the first trimester through maternal blood circulation, to the infant during labour, or through breastmilk.
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Factors increasing risk of mother infant HIV transmission
lack of maternal and infant treatment with ART and prevention
maternal plasma viral level greater than 1000 copies per milliliter
maternal vaginal infection during pregnancy
amniocentesis, chorionic villus sampling, or both
ruptured membranes
presence of chorioamnionitis
fetal scalp monitoring and venous scalp sampling
interventions such as forceps, vacuum, and external cephalic version
breastfeeding
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obstetrical complications of HIV in pregnancy
Many variables (poverty, drug use, mental health issues, etc) can account for a woman being at risk for preterm labour and birth, premature rupture of membranes, perinatal loss, and IUGR. The mode of birth for women who are HIV positive depends on the woman’s plasma viral level and her status of labour upon admission. If a woman’s plasma level is less than 1000 copies per millilitre and she has
received ART, she can proceed with a vaginal birth. In women positive for HIV who are not receiving antiretrovirals and have a plasma load greater than 1000, an unknown plasma level, or antepartum bleeding, a Caesarean birth is recommended
The postpartum period for the woman infected with HIV may be notable for infection, hemorrhage, or both
HIV-related thrombocytopenia may also increase the risk of
hemorrhage. It is critical that women remain on their antiretroviral medication throughout their pregnancy and into the postpartum period.
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HIV nursing care in pregnancy
All HIV-infected women should be treated with ART during
pregnancy, regardless of the CD4 counts. ART should include
three drugs from at least two classes of antiretroviral medications
The major adverse effect of these medications is bone marrow suppression
IV zidovudine is administered to the HIV-positive woman during the intrapartum period. A loading dose is initiated on her admission in labour, followed by a continuous maintenance dosage throughout labour
Increased duration of ruptured amniotic membranes has been associated with increased perinatal transmission - If rupture of membranes occurs before labour, induction of uterine contractions with oxytocin
Immediately after birth, infants should be wiped free of all body fluids. Prior to blood testing or any injections, the skin area should be cleansed well with soap and water
Oral zidovudine treatment for the infant is initiated within 6 hours of life and continues for up 6 weeks
