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Flashcards in OB EXAM 3 Deck (257):
1

Pregnancy threatened to hurt mom or baby

high risk pregnancy

2

goal of high risk PG

to prevent major complications from occuring

3

o Complicates 5-10% of all pregnancies

• Leading cause of infant and maternal morbidity and mortality worldwide

hypertensive disorder

4

morbidity

placental abruption
cerebral hemorrhage
hepatic or renal dysfunction
DIC
pulmonary edema
seizures

5

o BIGGEST problem – can cause death to the baby and/or the mother (high blood pressure may cause this)

placental abruption

6

• Deficient volume related to hemorrhaging
• Loosing clotting factors and platelets
• Cardiac output will decrease go into shock die

DIC

7

o Pregnancy-related HTN accounts for 10-15% of maternal deaths worldwide

mortality

8

gestational HTN requirements

systolic 140 or higher

diastolic 90 or higher

9

to be dx with gestational HTN what must occur?

high BP recorded must be on 2 occasions at least 4 hours apart

10

ask about what for toxemia of pregnancy?

convulsions

11

o Pregnancy-specific syndrome in which HTN develops after 20 weeks of gestation in a previously normotensive woman with cerebral or visual symptoms, pulmonary edema, impaired liver function, renal insufficiency, proteinuria.

Preeclampsia

12

which enzymes are elevated with Preeclampsia

liver (LDH, AST)

13

do Preeclampsia patients have convulsions?

NO

14

o Onset of seizure activity or coma in a woman with preeclampsia

Eclampsia

15

Eclampsia moms have no history of ?

preeclampsia pathology

16

o % develop eclampsia in the immediate postpartum period

30%

17

goal of high risk PG

to prevent major complications from occuring

18

o Complicates 5-10% of all pregnancies

• Leading cause of infant and maternal morbidity and mortality worldwide

hypertensive disorder

19

o HTN present before pregnancy or diagnosed before week 20 of gestation

Chronic HTN

20

• At 17 weeks gestation, Mary’s BP rose from a prepregnant baseline of 118/66 to 142/88. No other problematic signs and symptoms including proteinuria were noted.

Chronic HTN

21

o A condition unique to human pregnancy, animals don’t have preeclampsia
o S/S develop after 20 weeks of pregnancy and disappear after birth

Preeclampsia

22

common risk factors for Preeclampsia

• Primigravidy or new partner in this pregnancy
• Extremes of maternal age
• Multifetal pregnancy
• Obesity
• Preexisting medical condition

23

reason we think moms get preeclampsia

poor perfusion and endothelial cell dysfunction

24

what diminishes the diameter of blood vessels, which impedes blood flow to all organs and increases BP

arteriolar vasospasm

25

Main pathogenic factor for preeclampsia

• is vasospasm and reduced plasma volume

26

• contributes significantly to restriction of fetal growth in preeclampsia

decreased placental perfusion & hypoxia

27

o Laboratory diagnosis for a variant of severe preeclampsia that involves hepatic dysfunction

HELLP Syndrome (preeclampsia)

28

H

hemolysis

29

EL

elevated liver enzymes

30

LP

low platelets

31

breakdown of the RBCs

hemolysis

32

preeclampsia moms may complain of epigastric pain, which is because of?

vasospasms that decreases blood flow to the liver

33

only cure for preeclampsia

delivery of the fetus

34

preeclampsia leads to?

DIC

35

Is there a reliable screening tool for preeclampsia?

NO

36

health assessment of preeclampsia

BP
dependent edema
pitting edema
deep tendon reflexes
signs/symptoms
activity restriction
diet

37

• Goals of care are to ensure maternal safety, assess the degree of maternal and fetal risks, formulate a plan for delivery, and prevent eclampsia and other serious complications
• Usually these women are in the hospital

severe preeclampsia

38

the anticonvulsive agent of choice for preventing eclampsia

magnesium sulfate

39

magnesium sulfate requires careful monitoring of?

quiet environment
no stimulation
fetus
maternal VS
reflexes
respirations
urinary output

40

too much Mg

hyporeflexia

41

not enough Mg

hyperreflexia

42

make sure respirations are above ___ breaths a minute when on Mg therapy care;

12

43

if they fall below 12 breaths per minute along with other symptoms means she has ?

magnesium toxicity

44

how much urine per hour should they have while on Mg therapy?

30 ml

45

sx of magnesium toxicity

hyporeflexia
RR below 12
urine below 25
high BP but WNL

46

if BP gets to high when on Mg therapy give what drug?

apresoline (anti-hypertensive drug

47

person on Mg therapy will have what environment?

same as pre-eclamptic patient

48

initial dose of Mg is ?

4-6 grams over a 15-30 min period (loading dose)

49

then hang what

hang the mag 1000 cc

50

maintain the therapeutic level at?

1-2 grams each hour

51

antidote of Mg

calcium gluconate

52

when to admin antihypertensive meds?

over 160/90

53

premonitory signs of eclampsia

persistent headache & blurred vision

54

affects 4-5% of PG women

chronic HTN

55

o Postpartum complications of chronic HTN include:

• Pulmonary edema
• Renal failure
• Heart failure
• Encephalopathy

56

lifestyle changes recommended for chronic HTN

smoking and alcohol cessation, participating in aerobic exercise, and losing weight if indicated.

57

chronic HTN is associated with increased incidence of:

o Abruptio placentae
o Superimposed preeclampsia
o Increased perinatal mortality
• IUGR
• Preterm birth
v

58

λ Bleeding in pregnancy jeopardizes maternal and fetal well-being
λ Most prevalent

Antepartum Hemorrhagic Disorder

59

λ Maternal blood loss decreases oxygen-carrying capacity to her and her fetus, increase risk for:

Hypovolemia,
anemia,
infection,
& preterm labor and birth

60

λ She can have some major disorders if she doesn’t have ___ ______ she needs

blood volume

61

- a pregnancy that ends by natural causes before 20th week of gestation

miscarriages

62

early miscarriage

occurs before 12 weeks gestation

63

late miscarriage

occurs in 2nd trimester btwn 12-20 weeks

64

early miscarriage is due to

chromosomal abnormalities

65

late miscarriage is due to

maternal causes

66

∏ Pregnancy that ends as a results of natural causes before the 20th week of gestation
∏ Not related to abortion

λ Spontaneous

67

∏ Heavy, profuse amount of bleeding, severe uterine cramping, passage of tissue and cervical dilation with tissue in cervix

incomplete

(expels fetus but not placenta)

68

∏ Slight amount of bleeding, mild uterine contraction, passage of tissue, no cervical dilations, cervix has already closed after tissue passed

complete

69

risk factors for placenta previa

∏ Previous previa
∏ Previous C-section
∏ Induced abortion

70

risk for placenta previa increases with?

multiple gestation,
closely spaced pregnancies,
advanced maternal age,
smoking

71

sx of placenta previa

Present with painless bright red vaginal bleeding
∏ Uterus will be soft
∏ Fetal heart rate will be normal
∏ Mom may show signs of shock

72

why do they present with painless bright red vaginal bleeding?

due to abnormal implantation of the placenta in the lower part of the uterus

73

how to dx placenta previa?

transvaginal ultrasound

74

λ Placenta very low lying to cervical opening. When the uterus starts to contract and cervical opens and widens, and then what can happen?

the placenta can peak out first before the baby is born

75

λ Premature separation of the placenta
λ Classified in grades

abruption placenta

76

grade 1

∏ minor separation from uterine wall

77

grade 2

moderate separation

78

grade 3

severe separation

79

sx of abruption placenta

bleeding can occur
concealed bleeding
vaginal bleeding (dark red)
uterine tenderness
persistent abd. pain, but abd. is very rigid and broad like

80

where is the placenta in abruption of placenta?

implanted in the right place, just abrupted

81

abruption due to?

HTN
an accident
abuse
traumatized

82

why does canceled bleeding occur with abruption placenta?

two ends of the placenta are still attached to the uterine wall and there is a lot of bleeding going on between those two ends

83

baby problems with placental abruption

baby shows abnormalities

HR = low

no variability

84

how will this baby be born?

emergency c-section

85

deaths associated with placental abruption?

15% maternal death
1/3 infant deaths

86

nursing management of placental abruption?

∏ Hospitalize pregnant woman that has been in crash for at least 24 hours to assess even if mother seems fine.

87

Ectopic Pregnancies occur 95% in?

tubes

88

how to know woman is having ectopic PG?

woman misses period and starts feeling tenderness in lower abdomen (dull to colicky pain)

89

pain in lower abd is due to

stretching tubes because the ovum implants

90

where does it usually implant?

in the fallopian tube

91

the pain may be?

unilateral or bilateral

92

might have referred pain where?

the shoulder

93

bluish ecchymosis bruising around the umbillical site

cullen sign

94

λ the bleeding is in the peritoneum and is usually ____-_____ectopic pregnancy

intra-abdominal

95

risk for ? occurs after ectopic pregnancy

infertility

96

treatment if it is unruptured

cut into tube and residual tissue will be dissolved with the drug

97

which drug for un-ruptured?

methotrexate

98

if ovum is ruptured how would you treat it?

medical emergency. have surgery, and remove tubes

99

folic acid analog
destroys rapidly dividing cells

methotrexate

100

aka gestational trophoblastic disease

hydatidiform mole

101

λ Includes molar pregnancy, invasive mole, and choriocarcinoma
λ Refers to persistent trophoblastic tissue that is presumed malignant

hydatidiform mole

102

Woman at high risk for mole formation are those who

λ undergo ovulation stimulation with Clomid

and those in early teens and older than 40 years of age

103

results from fertilization of an egg with lost or inactivated nucleus

mole

104

what comes out of vagina with hydatidiform mole

dark brown vaginal bleeding

cluster discharge (like cauliflower)

105

λ Usually have spontaneous abortion if not they will have to come in to have a suction curettage to remove all of the _____.

trophoblasts

106

λ Could be malignant so women who deliver a mole pregnancy will be followed for ____. and are advised not to get pregnant for _____ to make sure there are no signs of malignancy in her body

one year

107

λ Malignant disease follows molar pregnancies in about ___% of cases

50%

108

hydatidiform mole presents with what sx?

N/V
amenorrhea
abnormal vag bleeding
increased HCG

109

λ Recurrent premature dilation of the cervix
λ Painless dilation and effacement

Incompetent Cervix

110

Incompetent Cervix AKA

"cervical insufficiency"

111

Incompetent Cervix occurs when?

2nd trimester

112

Incompetent Cervix is due to

History of cervical surgery or manipulation of the cervix

113

λ Usually have to have another previous pregnancy with incompetence to be diagnosed with ______ ______.

incompetent pregnancy

114

how to fix incompetent cervix

placement of a cervical cerclage

115

∏ often the procedure of choice
∏ Suture is placed around the cervix beneath the mucosa to constrict the internal os of the cervix

McDonald technique

116

∏ The cerclage is electively removed when the woman reaches ___ weeks of gestation or it may be left in place until spontaneous labor begins

37

117

two options with incompetent pregnancy

tocolytic drugs
or cerclage

118

tocolytic drugs do what?

help relax the uterus

119

when will moms with incompetent pregnancy need to go to the hospital?

when contractions are less than 5 min apart or notices membranes have ruptured or having severe perineal pressure

120

mother has diabetes before she gets pregnant

pre-gestational

121

o Autoimmunity directed at the pancreatic beta cells. There is an absolute insulin deficiency

type 1: pre-gestational diabetes

122

when will type 1 usually occur

age 30

123

type 1 usually has to have?

insulin
dietary management
exercise

124

o Most prevalent form of the disease characterized by a combination of insulin resistance and inadequate insulin production.

type 2

125

type of people that have type 2 DM are usually

obese & over 40

126

type 2 doesn't always have to be treated with insulin....it can be treated with?

diet & exercise

or with oral diabetic agent

127

almost all diabetic pregnant women are?

insulin dependent

128

Over time, complications resulting from pre-gestational diabetes will include

o premature atherosclerosis, retinopathy, nephropathy and neuropathy

129

pregestational diabetic moms are more prone to?

UTIs

130

goal for both types of DM

o To have an optimal pregnancy outcome

131

to achieve this goal the mother must?

have strict maternal glucose control.

132

• Glucose levels in fetus are directly proportional to

maternal levels

133

• Glucose crosses the placenta but____does not

insulin

134

• Fetus begins to secrete insulin around___ weeks to utilize glucose for fuel and energy

10

135

• Watch for _____ after birth because they are still producing insulin, but they are cut off from their source (mother)

hypoglycemia

136

insulin needs in 1st trimester

need is reduced

137

why is insulin needs reduced in first trimester

increased insulin production of pancreas

N/V of mother and decreased food intake

138

2nd trimester insulin needs

begin to increase

139

why do insulin needs begin to increase in 2nd trimester?

placental hormones act as insulin antagonists decreasing insulin's effectiveness; it will destroy the insulin

140

insulin requirements normally plateau after ___ weeks gestation

35

141

insulin requirements often drop significantly after ____ weeks gestations

38

142

after delivery her insulin needs will?

decrease

143

Poor glycemic control around time of conception and early weeks of pregnancy is associated with increased risk of

miscarriage

144

Poor glycemic control later in pregnancy, without vascular complication is associated with increased risk of

macrosomia

145

large baby; not necessarily the healthiest baby

macrosomia

146

• In women with vascular disease, you are more likely to see ____ r/t compromised perfusion of the placenta.

IUGR

147

occurs most often in women with pre-existing vascular changes

• Pre-eclampsia

148

• Women with _____ have the poorest outcomes of all

nephropathy

149

excessive amniotic fluid

polyhydraminos

150

polyhydraminos fluid levels =

2000 mL

151

accumulation of ketones in the blood)

ketoacidosis

152

diabetic ketoacidosis can lead to

fetal death

153

with diabetic ketoacidosis the mother becomes?

acidic (toxic)

154

DKA most often occurs when?

2nd or 3rd trimester

155

• Stillborn or fetal death for those with ?

poor glycemic control or vascular disease

156

most seen congenital abnormalities?

neural tube defects
cardiovascular
CNS
musculoskeletal

157

high insulin production by the fetus inhibits the production of surfactant.

RDS (respiratory distress syndrome)—

158

RDS (respiratory distress syndrome)— L/S ratio is?

3:1

159

physical exam for pre-gestational client

o Routine plus vascular; baseline ECG, B/P and fundal height for fetal growth

160

lab tests for pre-gestational client

o Routine plus 24 hour urine, U/A Thyroid function and glycosylated hemoglobin A1C

161

will have a urine culture how often?

every trimester

162

a good control level for A1C is?

2.5-5.9%

163

main goal for antepartum care of diabetic client?

euglycemia

164

pre levels

60-99

165

1 hour after meal levels

166

2 hour after meals level

167

best time to exercise is?

after a meal

168

during intrapartum care for diabetic mom when do you check blood glucose

every hour

169

when to get insulin if they're having Csection next morning?

full dose of insulin night before

170

performed at 16-20 weeks for increased risk of neural tube defects

MSAFP
maternal serum alpha-fetoprotein

171

• Baseline U/S is done when to determine fetal growth, hydramnios or macrosomia

during 1st trimester and then every 4-6 weeks

172

• Fetal echocardiography ___-___ weeks may be performed to make sure the baby’s heart is doing fine

20-22

173

o ___ trimester is when the fetus is at greatest risk from a diabetic mother

3rd

174

fetal kick counts begin when

28 weeks

175

non stress tests when

1 to 2 weekly

176

biophysical profile when?

as needed

177

Insulin produced in response, as preg progresses insulin demands increase as glucose rises

type 3

178

• Onset during pregnancy and return to normal glucose tolerance after delivery
• Hormonal changes during pregnancy act to increase maternal cell resistance to insulin so that an abundant supply of glucose is available to fetus
May include small number of previously undiagnosed type 1 and type 2 diabetic women

type 3

179

• Women who are obese prior to conception and develop gestational diabetes mellitus are at increased risk to give birth to infants with

CNS defects

180

risk factors for type 3

o Native American, Asian, Hispanic, and African-American
o Maternal age-older than 25 years of age
o Previous pregnancy with GDM
o Strong immediate family history of Type 2 Diabetes or GDM
o Obesity
o Fasting blood glucose 150-180 mg/dL

181

which levels indicate a positive screen for the glucose tolerance test?

130-140

182

what to not do before the test?

don't drink caffeine

no drinking or smoking 12 hours before or during the test

183

during the GTT, how often do they draw your blood?

every hour for 3 hours

184

postive for GDM =

2 or more values are met or exceeded

185

fasting glucose

95-100

186

1 hour glucose

180-190

187

2 hour glucose

155-165

188

3 hour glucose

140-145

189

monitor BGL before during and after exercise. if level is ___that is good, if levels exceed ___ that is bad

95; 120

190

o There is no incidence of birth defects has been found among infants in women who develop gestational diabetes mellitus after the ___ trimester because organs are formed

1st

191

1/3 of women levels postpartum do what

do not return to normal

192

may develop what later in life?

type 2 diabetes

193

o Maternal cardiovascular system undergoes changes during normal pregnancy such as

increase in her blood supply

194

o Changes that affect women with cardiac disease

♣ Increased intravascular volume (40-50%)
♣ Decreased systemic vascular resistance
♣ Cardiac output changes during labor and birth
♣ Intravascular volume changes after childbirth

195

incidence of _____ increases with cardiac disease

miscarriage

196

are more prevalent in pregnant women with cardiac problems

o Preterm labor and birth

197

o Impeded or delayed development of fetus is common

IUGR

198

o Incidence of ? is increased in children of mothers with congenital heart disease

congenital heart lesions

199

______ and _____ counseling are essential components of care

o Preconceptual and genetic

200

o Inability of the heart to maintain a sufficient output:
♣ You can lose the mother’s life or the baby’s life

cardiac decompensation

201

sx of cardiac decompensation

♣ Feeling of smothering
♣ Frequent moist cough
♣ Palpitations
♣ Irregular, weak, rapid pulse (100 beats or higher)

202

o Most common valve abnormality in women
o Valve is narrowed
o Valve does not open properly

mitral valve stenosis

203

mitral valve stenosis blocks from flow from where to where

left atrium to left ventricle

204

cause of mitral valve stenosis

"rheumatic fever"

205

"rheumatic fever" is caused by?

strep infection that was not treated with antibiotics

206

sx of mitral valve stenosis

dyspnea
pulmonary edema
endocarditis
a. fib
pulmonary embolus
death

207

tx of mitral valve stenosis

Lasix
BB
CCB
antibioitcs

208

if the drugs don't work they will do what to tx mitral valve stenosis

baloon valvelopathy

209

during mitral valve prolapse what happens

mitral valve buldges (prolapses) upward or back into the L atrium

210

o Can lead to blood leaking backward into the L atrium, a condition called

mitral regurgitation.

211

o Most do not require treatment or changes in lifestyle with?

mitral valve prolapse

212

sx of mitral valve stenosis

chest pain on L side @ rest
anxiety
dyspnea

213

• Helps to classify the degree of compromise in the woman, serves as practical guide for treatment, assuming patient is compliant & proper medical tx prescribed

New York Heart Association Classification
The Stages of Heart Failure

214

• No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea. She does have a heart disease but its not serious

Class I (mild)

215

• Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea
o If any activity is undertaken, discomfort

Class II- (Mild)

216

• Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea

Class III- (Moderate)

217

• Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. is increased. Lots of times these women will be hospitalized during pregnancy

Class IV- (Severe)

218

when will patients be re-classed?

3 months & 7-8 months

219

maternal assessment

• Heart palpitations
• Fatigue
• Cardiac decompensation
• Anemia
Current medications

220

__-___ weeks = greatest stress on heart

28-32

221

treat valvular dysfunction with?

o prophylactic ATB to prevent endocarditis

222

why to give mom stool softenener

don't want her to strain & iron can cause constipation

223

why do moms get heparin while pregnant?

no PO meds allowed

224

intrapartum nursing care for cardiac conditions

calm environment
keep informed
promote comfort
position
delivery

225

what position to put then in?

head and shoulder elevated, body resting on pillows, delivering best position is SIDE LYING, develops positive hemodynamic

226

which type of delivery is preferred with cardiac problems?

vaginal

227

position of mom in postpartum care?

HOB elevated, lie on side

228

whats different about cardiac moms walking after deliery

progressive ambulation

229

• Most common disorder in pregnancy
• 20-60% of all pregnancies

anemia

230

types of anemia in PG

iron deficiency anemia
folic acid anemia
sickle cell anemia

231

♣ Increased ___ needs required for fetal development & maternal stores

iron

232

iron def. anemia is managed with?

iron supplements 60-120 mg/day

233

iron def. anemia will also need what tablet?

ferrous sulfate 325mg twice a day

234

what is given for high iron def?

iron imferon IM

235

♣ Can occur in well-nourished pregnant women
♣ More common with multiple gestation

folic acid anemia

236

decreased levels of folic acid anemia have been associated with?

fetal neural tube defects
cleft lip & palate

237

with folic acid anemia they are encouraged to consume

fresh, green leafy veggies & legumes

238

recommended daily intake of folic acid

600 mcg/day

239

♣ Disease caused by the presence of abnormal Hgb in blood (RBCs are sickled shape)

sickle cell anemia

240

some women with sickle cell do well in pregnancy but are at risk for ?

UTIs
hematuria
preeclampsia
bone pain
cardiomyopathy
dehydration
infections
respiratory depression
fever

241

individualized management of sickle cell may include

• Well balanced nutrition w/ folic acid supplement
• IV fluids
• Oxygen
• Blood transfusion
• Analgesics
• medications
• Pain management
• Urine cultures

242

Perinatal Outcomes if Pregnancy is Not Managed:

o Spontaneous abortion
o Preterm labor
o Premature birth
o Intrauterine infections
o Preeclampsia
o Poor placental perfusion
o Pulmonary Disorder

243

is a helpful tool in the management of pregnancies at risk because of maternal HTN and DM, IUGR, multiple fetuses, and preterm labor because it provides an indication of fetal adaptation and reserve.

doppler blood flow ananlysis

244

when a sound wave is reflected from a moving target, a change occurs in the frequency of the reflected wave to the transmitted wave, called the?

doppler effect

245

doppler ratios greater than 3 indicate?

placental vascular disease

246

is a noninvasive dynamic assessment of a fetus that is based on acute and chronic markers of fetal disease.

biophysical profile (BPP)

247

a BPP of what is considered normal with a normal AFV.

8 or 10

248

is performed to obtain amniotic fluid, which contains fetal cells.

under dierect ultrasonographic visualization, a needle is inserted transabdominally into the uterus, amniotic fluid is withdrawn into a syringe, and the various assessments are performed

amniocentsis

249

amniocenteis is possible after week __ of PG.

14

250

involves the removal of a small tissue specimen from the fetal portion of the placenta.

can be done transcervical or transabdominally

chorionic villus sampling

251

CVS can be done when?

10-13 weeks

252

levels are used as a screening tool for NTDs in pregnancy.

alpha-fetoprotein (AFP)

253

is produced in the fetal GI tract and liver, and increasing levels are detectable in the serum of pregnant women from 14-34 weeks gestation

AFP

254

the onset of hypertension without proteinuria or other systemic findings diagnostic for preeclampsia after week 20 of pregnancy.

gestational HTN

255

hypertension that is present before the pregnancy.
• Hypertension initially diagnosed during pregnancy that persists longer than 12 weeks postpartum is also classified as this

chronic HTN

256

is thought to cause endothelial cell dysfunction by stimulating the release of a substance that is toxic to endothelial cells.

placental ischemia

257

Mild gestational Hypertension and Preeclampsia Without Severe Features suggested birth

vaginal birth by induction at 37 weeks