PN Complications Flashcards
(36 cards)
Identifying the High-Risk Pregnancy
High-risk pregnancy
- A concurrent disorder, pregnancy-related complication, or external factor jeopardizes the health of the mother, fetus or both
- Also consider age (too young or too old, if too old might have high b/p/ diabetes), poverty, homelessness, no access to community resources
- Consider genetics- a lot of things passed on to the baby because of the parent’s genes.
- The woman’s eggs are as old as she is where as the man’s sperm is constantly being made new. So sometimes the chromosomes and genes can be messed up because of the woman’s age (the eggs age).
- Older woman and diabetics can sometimes have still born
- Teenagers- more premature babies. Probably because they don’t get prenatal care until late.
High-risk pregnancy: I’m already sick before pregnant
Complications: pregnancy caused
Assessing for Genetic Disorders
Physical assessment
Diagnostic testing:
- Karyotyping- look at the chromosomes and genes
Maternal serum screening (MSAFP)
- Chorionic villi sampling- take a little bit of tissue from underneath the placenta. Belongs to the baby so we can look at the chromosomes of the baby.
- Amniocentesis- take fluid which has baby cells and allows us to see if the baby has a genetic problem. Can also be used later on in the pregnancy to tell if the baby’s lungs are mature enough so I can know to stop the labor if necessary so I can give steroids to mature the lungs. Can also use this to treat polyhydramnios (too much fluid)
- Percutaneous umbilical blood sampling- take blood out the cord to look for chromosomal problems. Can also do a blood exchange with this (rH baby).
- Fetal imaging- CT scan, MRI
- Fetoscopy- Look with a camera to see if the spine is in tact. Can take a biopsy and pictures of the baby with this
Preimplantation diagnosis- Can take an egg that has been fertilized and place it inside the mother if it is healthy.
Invasive Testing Nursing Responsibilities:
- Education as to the purpose, technique, expectations
- Teach patient to go home and rest after amniocentesis
- Consents- these are invasive
- Maternal and fetal monitoring before, during and after procedure- will often keep for a couple of hours to monitor for complications
- Educate as to restrictions, and any warning signs
TERATOGENS
Environmental- Maternal stress can give the baby stress hormones, radiation, hot and cold (should not be in the sauna or hot tub), alcohol, nicotine.
Infectious agents- See next slide
Therapeutic agents- drugs that the mom may be on (dilantin), live viruses.
Results of exposure- Strength of the teratogens, timing of exposure to the teratogens, first couple of months is when everything is being formed.
2 diseases that don’t rely on timing- syphilis and ???
Affinity- to a specific organ – a drug can cause the baby not to have arms and legs, led- specific to brain, tetracycline- tooth enamel (brown teeth for the rest of their live), rubella- eyes, ears, heart, brain, DES- girls would end up with cancer of the vagina, overy, breast, reproductive cycle, vitamin A- (accutane)
1st trimester teratogen exposure:
- Time when organs being formed
- Time most damage can be done
- If treated, the baby could get high bilirubin
- infectious diseases - can occur before, during, or after conception. Transmitted via transplacental inoculation, fetal contact with infected areas or both
TORCH:
T = Toxoplasmosis- uncooked meat and cat litter
o = Other to include STDs (arithromycin in the eyeballs for clamydia and ghonerrhea) , Beta strep (GBS- baby can get meningitus, pneumonia)
r = Rubella- deaf cataracts, heart defects, cleft pallet, cleft lip, thrombocytopenia, mentally challenged. Need to stay away from people with rashes. Usually starts out like a cold (airborn), so they should avoid sick people.
c = Cytomeglovirus- droplet transfer, member of the herpes family. Acts similar to HIV. If mom gets it while she is pregnant, baby is exposed to the actual germ and both will be treated at the same time. Baby will probably have some neuro problems. If mom had it prior to the pregnancy, the baby will be protected by the mom’s antibodies.
h = Herpes- If mom has active herpes during birth, we must do c-section because there is no real cure, so if the baby passes through, they will become exposed to the virus with no cure
STIs and Pregnancy
Spread through sexual contact
Can be prevented – safe sex
Treatment:
***Prevent reinfection – treat partner, educate
Determine causative agent- what type of STI is it so we can treat it with a specific agent
Teach mode of transmission- most of the time it is transmitted sexual but some can also be transmitted elsewhere
Teach measures to reduce irritation caused
See handout
Cardiac Disease
Cardiac disease is decreasing in pregnant women -1%
- Better correction of anomalies
- Decreased rheumatic fever - because we are treating strep infections right away.
Still a problem enables women who would have never risked pregnancy to do so
- Valvular damage
- Congenital defects –Atrial/septal defect, uncorrected coarctation of aorta (CAN BE FIXED)
- Older women with coronary artery disease
- Chronic HTN
- Thromboembolytic disease- previous DVT so could have another one
- ***NEED TO BE MONITORED BY PHYSICIAN!
Classifications of heart disease
- Classifications of 1 or 2 expected to have normal pregnancy and birth
- Classification of 3 can complete the pregnancy with complete bedrest
- Classification of 4 – poor candidate as they are in cardiac failure even at rest
- ***Most dangerous time is between 28 and 32 weeks
- ***Need to start prenatal care asap
- ***Sometimes working with OB and cardiologist even before they get pregnant
Assessment in general
- ***Dyspnea, rapid RR, Cough
- Cyanosis lips nails long cap refill
- Distended jugulars
- Irregular pulses
- Chest pain
- Edema
- HTN
- Liver size (right sided)
- EKG, CXR, Echo- will have had these before labor, if they haven’t, will prbably get them
- Fetus – will probably be small, check growth pattern, watch carefully in labor
Nursing interventions during labor and birth
- Will need an IV not running quickly
- Anesthesia – Epidural- ***must bolus fluids before administration (400mL at least)
- Want to keep pain under control.
- Assisted delivery – Instrumented- vacuum or forceps because we don’t want to put stress on her cardiac output by pushing
- Monitor fetal heart tones and uterine contractions- probably internal
- Vital signs frequent
- Side-lying labor- prevent supine hypotension
- Evaluate fatigue
- Listen to lung sounds for pulmonary edema- raise HOB
Postpartum nursing interventions
- Now all extra blood from placenta etc is in general circulation – ***Problem takes place within 5 minutes
Assess for heart failure
- May need decreased activity, anticoags, digoxin, antiembolic stockings, prophylactic antibx because people with heart problems need prophylactic antibiotics
- Teach not to begin abdominal exercises without talking to provider- don’t want her to change bp too much. Kegal exercises are okay
- Stool softener- to avoid pushing
- Make sure she stays relaxed
- Should have beta blocker, nitroglycerine, digoxin on hand
- Will probably wear TED hose
- Careful with oxytocin because it lives next door to the ADH which could cause water intoxication (confused, headache, coma)
- Oxytocin could raise b/p
- Assess baby- will probably be fine but small
Hypertensive Disorders
Classifications:
Chronic- already have hypertension could get worse
Preeclampsia (no seizures) -eclampsia (seizures)
Chronic HTN with superimposed preeclampsia
Gestational transient- have high bp but no protein in the urine or weight gain
Hematologic Disorders
Iron-deficiency anemia:
- Small RBC, less hgb- if hgb is below 10 they will have symtpoms, if low after delivery must report
- Fatigue, exercise intolerance, sucking for air
- Associated with poor nutrition, closely spaced pregnancies- never had time to recover from the bleeding from before), twins, excessive bleeding prior to or with pregnancy
- Associated with preterm and small babies
- Associated with PICA – eat dirt, ice, etc
Management:
- Vitamin C
- Iron supplements , instruct about drug – make sure they know that their poop might be black, take with OJ because it works better, can cause GI irritation or constipation so teach to take with cracker or something.
Diet education- WIC can teach diet, refer them.
Folic acid-deficiency anemia
- Enlarged RBC- more volume in our blood stream
Often seen in twins during the 2nd trimester
- Associated with miscarriage, premature separation of placenta, and neural tube defects
- Side effect of certain anticonvulsants, oral contraceptives
Why do they get it?:
- Anticonvulsants (Dilantin)
- Oral contraceptives
Management:
- Vitamin C
- Iron supplements , instruct about drug
- Diet education
- Folic acid- 600-1,000mcg
- Green leafy vegetables, oranges, and dried beans have folic acid.
Sickle cell anemia
- Inherited recessively, African American- anyone in meditteranean, 1 in 10 have the trait (in America), 1 in 400 have the diease (in america)
- RBCs are irregularly shaped (sickle) when they become hypoxic! so can’t carry as much hgb
- ***HYPOXIA AND DEHYDRATION!
- High altitude – easier to become hypoxic, dehydration causes clumping- causes blockage to organs or placenta, then hemolyzes causing anemia
Assessment:
- Frequent H&H during pregnancy, urinalysis, and bili
- Watch for clots
- Assess for varicosities
- Monitor fetus by U/S at 16 – 24 weeks, NST and blood flow velocity through the placenta starting at 30 weeks
Management:
- Epidural- to avoid her straining and breaking blood vessels
- Oxygen during labor to avoid crisis
- Ensure adequate folic acid
- Ensure adequate fluids
- Will be monitored
- Prenatal- folic acid and fluids
- Exchange transfusions
Kidney Problems
Dehydration and kidney problems often lead to premature labor
Treat: bed rest, antibiotics to clear up infections and avoid early labor
Diabetes Mellitus
Diabetes before pregnant - (1 in 200 pregnancies)
- Placenta still manufactures the HDL
- Insulin level may go down at first but then raises to exceed normal height. Will need more shots
- Usually on regular insulin
- Will need to do CBGs 3-5 times a day to keep it at a reasonable rate
- A disease that makes the body unable to produce or use endogenous insulin in order to metabolize glucose)
- Placenta lactogen (Insulin antagonist) decreases tissue sensitivity to insulin action thus increasing the free floating sugar for fetal utilization. Also increases size of insulin producing cells due to Increased need for insulin - gestational
- Maternal effects= Risk of ketoacidosis, hyperinsulin, coma, Vascular disease (impacting placenta, kidney-PIH-)- if diabetic already, they have already damaged blood vessels which impact the placenta and kidney vessles, SAB, infections, hydramnios (excessive baby urination), dystocia, vag injury, preterm labor, prone to having preeclampsia because of damage to the kidney.
- Gestational diabetes: managed with diet and exercise before going on insulin. Will be normal post-partum
- Diabetic Mellitus before: Insulin requirement will be higher than usual. Will return to routine amount of insulin post-partum.
- Used to take patients off of metformin who were on it prior to pregnancy but they have found that it won’t change anything so they now keep them on orals.
- Baby will probably act like a diabetic (frequent urination, therefore a lot of amniotic fluid)
- Fetal effects= If Mom hypoglycemic = neuro problems- baby is reliant on glucose to feed it’s brain
if hyper then congenital defects-, LGA, SGA, delayed lung maturity (by 1 week) due to glucose interfering with surfactant manufacture - Neonatal effects (after birth) = will be born Hyper then within 20—30 minutes after delivery, baby becomes hypoglycemia, Take cbg before feedings for 24 hours and 20-30 minutes after delivery (should be higher than 40), if lower than 40, feed the baby, wait 20 minutes, take again and if it hasn’t raised cbg, call physician because you probably need to give IV.
polycythemia due to placental insufficiency so had to carry more RBCs for oxygenation, increased Bilirubin, RDS and sometimes learning disabilities, may be more jaundice than other babies
Respiratory distress syndrome because of lung delay
TX - Timely Dx, Frequent office visits, diet restrictions, exercise, TEACHING, (CBG, injections, pump) may need insulin- how to give
Always look for protein, sugar, and folic acid
Most of the time, diabetic babies are delivered between 35 and 40 weeks
Hydramnios
Excess amniotic fluid (2000 cc) or elevated amniotic fluid index (24)
Cause:
- Fetal GI/GU problems
- Anacephalic (born without a brain), tracheoesogeal fistula (between the trachea and esophagus), intestinal obstruction
- Babies of Diabetic Moms- because of frequent voiding
Assessment
- Growing Girth- until she is so tight that this skin is starting to break and she feels as if she is going to explode
- Difficult to palpate fetal parts, listen to FHT
Management
- Amnio
- Avoid constipation- don’t want her pushing because she could pop the bag and the cord will be washed out first
- Bedrest if severe
PC-
- Can cause fetal malposition (posterior, shoulder first)
- PROM
- Prolapsed Cord
Oral Glucose Challenge Test Values for Pregnancy
Fasting: 95
1 hour: 180
2 hours: 155
3 hours: 140
Other Problems
Thyroid conditions- Will grow in size
Respiratory problems- Particularly asthma, if you’re low in the oxygen department, your baby is too, make sure they know how to take the inhaler, hold the breath for a little while after the puff
Cystic Fibrosis- could have respiratory problems
Venous thrombosis/pulmonary embolus- as time goes on, you’re building more clotting factors, so if you have verscostities could deny the baby of blood.
Psychiatric problems- medications above Pregnancy class D – should be taken off of the meds because they could harm the fetus. Usually feel better during pregnancy because of the increased hormones but after birth, they get a little crazy from the missing hormones.
Trauma
Trauma
Leading cause of non-obstetric maternal/fetal death
Usually car accidents
-Open
Falls, burns, shock, gunshot/stab wounds, physical abuse
Animal or snake bites
-Closed
Blunt abdominal trauma- car accident, physical abuse #2
MVA # 1
TX - As any emergency BUT consider fetus Get a good HX and do good PE Monitor FHT Need Rhogam within 72 hours if rH- Mother may die in the ER, try to deliver the fetus within 20 minutes and we have a good chance of the child surviving
Look at slide 38 for assessment following trauma
Violence
Tension Building Phase- Often been drinking, starts to show more violent behaviors as time goes on. Throws surrounding items. Woman begins to feel like
Battering Incident- hit, burn, beat, rape, woman is helpless. Can run it’s course in 2 hours or can last 24 hours or longer. Sometimes falls asleep
Honeymoon Phase- tries to make up for his actions. Makes promises. May insist on intercourse. Woman wants to believe it’s true
How to recognize: late for appointments, finds it difficult to follow advice (diet), anxious at appointments (leaves if not seen at exact time because the husband is tracking the time), anxious for you to listen to the heart tones, wearing conservative clothing to hide bruising, will not tell you they are being abused because they are afraid he will find out
How can we help?: Give number for safe house (tell her to put it inside shoe underneath sole insert, ask if they feel safe at home, teach to stay out of the kitchen (too many weapons), stay out of the way, have a small suitcase packed with necessities in case you need to leave because it’s getting too violent
Emergency Efforts
CPR Everything is higher on chest With growing fetus heart is higher Breaths are more forceful If using Ambu bag, need to squeeze harder Due to growing fetus
Shock – due to serious blood loss
S/S
Tachycardia, increased RR, cold clammy skin, decreased LOC, decreased urine output
TX
Get breathing under control first
Second: IV started with large bore catheter (RL)
Rapid infusion- change to saline after bolus to give blood
T&C and blood administration as ordered
Support O2 – May need blood gases
Frequent VS – Baby on monitor
Bedrest on Left side
PC- Multiorgan failure due to lack of circulation
FIRST VS TO GO IN SHOCK: PULSE!!!!
Hemorrhage: will see a rapid pulse and loss of LOC
Look at slides 40-42
1st Trimester bleeding: Spontaneous abortion (SAB)
call them miscarriages- 15% of all preg. are SAB –before 20 weeks - usually 1st 12 – 16 weeks
At risk -50 -80% due to embryonic/fetal anomalies, 15% due to maternal problems ie teratogen exposure, endocrine problems, rest- improper implantation, infections ?
Types -Threatened,Inevitable, Incomplete, Complete (everything comes out and bleeding subsides quickly), Missed (nothing comes out other than blood so the baby stays), Habitual (multiple miscarriages following each other, often endocrine problem, incompetent cervix), Septic (Not clean abortion, slippery elm, coat hangers, etc., makes them infected and they come in super sick and abort)
Threatened abortion – a little bit of light bleeding and some cramps
Inevitable abortion- popped bag of waters and cervix dilate
Incomplete abortion- some products come out but some products are still in there, will continue to bleed
SS – Bleeding, cramping, decreased signs of pregnancy
TX - Limit activity for threatened- no intercourse. Others do D&C- scrapes the uterus to scrape everything out, vacuum aspiration, Missed use Prostiglandins 6 hrs prior, follow with pitocin & methergine
facilitate grieving- if habitual, might not be as sad as expected
PC = Infection - give Antibx, hemorrhage, Shock,DIC- give Heparin and blood products, Rh -Rhogam
1st Trimester bleeding: Therapeutic Abortions
D&E, RU486, Methotrexate- cancer drug, kills rapidly producing cells (baby), progesterone injections, Injection of prostaglandins or saline into fluid, and if over 12 weeks prostaglandin supp and insertion of laninaris to dilate, Pit ind.
Problems - Bleeding, infection, N&V , repeated Abs can affect the endometrium and therefore future pregnancies
Roe v Wade = First 12 weeks – OK to have an abortion, 12 - 20 weeks to protect health of mother, over 20 protect from life threatening event- Teen pregnancy need to consult each state’s law- different in each state
Nurses can refuse to PARTICIPATE in the procedure but to give care post op etc
Won’t see a lot of septic patients with therapeutic abortions vs. septic abortions
1st Trimester bleeding: Ectopic pregnancy
developed outside the uterus (usually in tube) 1:20 pregnancy
2nd reason for bleeds behind SAB (spontaneous abortion)
Risk factors -Infertility,PID,Std, previous ectopic pregnancy any condition that narrows tube
SS - Regular SS of pregnancy THEN Uterus not enlarging, lower quadrant pain (ask when last period was to rule out appendix problems or any problems outside of pregnancy), vaginal bleeding (maybe), subscapular pain, hypovolemic shock, Cullin’s sign (Blue inside belly button
Tube will rupture and blood will go into the stomach- stomach will get bigger, if you look inside of her belly button, it will be blue, will quickly go into shock after rupture. FIRST SIGN OF SHOCK: HR!- body recognizes you’re bleeding so adrenaline is raised, which raised b/p so b/p is the last to go! Will complain of being dizzy
Will have shoulder pain
TX –
- ***START IV FIRST because once they rupture, they can’t get the IV in anymore, Support blood volume, prepare for OR,
- If not ruptured, will do an ultrasound on the belly, put her on methotrexate (look at hCG levels)
- Doctor will do a vaginal exam (will hurt for the woman)
- Salpingjectomy- cut the tube around the egg and join the new ends together
- Salpingotomy- Suck the egg out
- Salpinostomy- Make a hole in the egg, grind it up and suck it out. Best way, less scarring
- Facilitate grieving - stand there and say ”this must really be rough on you” therapeutic communication!
LOOK FOR- unilateral abdominal pain (ask when was your last period)
PC: DIC, hemorrhage
hCG Levels in Loss
Looking at hCG- baby is in control of the hCG so if there is a problem, the baby will stop producing hCG so the signs of pregnancy will go away and hCG levels drop
Look at slide 49
1st Trimester: Hyperemesis Gravidarum
AKA Morning Sickness Gone Wild
Cause unknown but occurs more frequently among primiparas, multifetal pregnancies and with women with psychiatric disorders
S/S – Persistent N/V Decreased Output Signs/symptoms of dehydration/starvaton Labs , H&H, electrolytes, urine protein and acetone Starvation Weight loss Alcalosis- vomiting out all of her acids
Management
Implement common N/V remedies-
***Correct fluid/electrolyte imbalance –(NPO with IVs)- FIRST START IV!
Once we have the fluid and electrolytes in order start on anti-emetics and crackers and water
Sedatives & antiemetics
Quiet atmosphere
PC-
Dehydration, electrolyte imbalance, severe weight loss, metabolic alkalosis
2nd Trimester Bleeding: Molar Pregnancy
Gestational trophoblastic disease (hydatidform mole)
Abnormal proliferation of chorionic villi (1/1500 pregnancies)
No baby- the egg didn’t have any chromosomes in it so the sperm starts to duplicate it’s own, or 2 sperms can go in and populate the empty egg
Risk factors - older women, low protein diets, Asian because of lack of protein in diet
SS - Normal at first, some bleeding early, eventually: exaggerated, fast uterine growth, putting out a lot of hCG because of the fast uterine growth leading to hyperemesis, No FHT
TX : Sonogram to confirm- will look like a bag of grapes, D&C, monitor bleeding, s/s infection, & facilitate grieving
***Precancerous - Will need careful follow up- hCG in 48 hrs to see if it starts to go down & then q 2wks till normal then q 1 months x 1 year. At the end of the yaer, do a CXR to make sure we didn’t send off cancerous cells to the lung
Goal: cancer free within 1 year
If hCG is going down and then plateus, give methrotrexate to kill the rest that we didn’t get
Should not get pregnant for one year
Send home with instructions that if they start to bleed a lot, they need to come in and bring any tissue to make sure it’s not just a miscarriage
2nd Trimester Bleeding: Premature cervical dilatation
Premature cervical dilatation
Cannot hold the fetus until term- too short or too weak, will start to dilate
Incompetent cervix
Habitual abortion caused by this
S/S
- Painless, pinkish discharge at first, then Cramping, then they will deliver
Tx-
- Cervical cerclage
- keeps the cervix closed
0 Done at approx 12 Weeks- ***Removed at 37 weeks or if in labor
- Mc Donalds- done in surgery, sew the cervix together and it wills tay together forever and will need to have C-section for future pregnancies or Schirodkar- Surgery, pull in and out
- Success rate- 80-90%
Post op Care
- Bedrest for one day, In Slight trendelenburg for few days then normal activities
- Often feel like failures for not being able to get pregnant
3rd Trimester Bleeding: Placenta Previa
Complete, partial, marginal
Risk factors hx of uterine scarring, multiple gestation with lg placenta, endometritis- infection inside of the uterus, previous low implantation, older, multips
Assessment
Routine sonogram- usually done early if consistent spotting
intermittent, painless bleeding - usually starts about 28 weeks- can become hypovolemic
Management -
Home:
- Bed rest, Pt to monitor bleeding , Watch color
Hospital:
- ***NO vag exams, T&C for 2 units (on call), double set up for delivery (take to OR, try to deliver vagnially but have set up for C-section), Marginal - can leak fluids thereby put pressure on bleeding point. Bedrest start IV immediately, frequent FHT, watch color of the blood, bed rest (hypovolemia is a PC so don’t want to get them up and walking around)
- Comes in bleeding at 34 weeks, do amniocentesis and if not bleeding give steroids
PC – hypovolemia, hemorrhage- FIRST VITAL SIGN TO GO- PULSE!
Look at slide 54
3rd Trimester Bleeding: Abruption Placenta
Marginal, central, complete
Premature separation of placenta
- Occurs suddenly at any time in the pregnancy
- Most frequent cause of perinatal death
Risk factors
- High parity, older, Short cord, HTN (smoking goes with this), trauma, Cocaine, smoking, thrombosis
Assessment
- May have vag bleeding,
- Fetus hyperactive at first because it’s not getting any oxygen then ceases to move,
- Uterine tenderness, pinpoint pain
- Change in contractions, (tone>hypertonic Fierce contractions- can tell you exactly where it hurts because that is where the stretch/separation is)
Management TX –
- Determine amt of separation and age of fetus with ultrasound
- May treat conservatively with BR, lateral lying, sedatives, and observation,
- If severe will need to support blood volume, O2 and do C-section
- May need to put in a central line to give blood if it is severe
PC- Shock, DIC- need to do special lab work (serial labs), Fetal Death- because we can’t get to it fast enough, Amniotic Fluid Embolus- amniotic fluid backs up into the mother causes an allergic reaction to the fluid
