1 HIGH RISK PREGNANCY Is one in w/c the mother or fetus has a significant increased chance of harm, damage, injury, or disability (morbidity), and loss of life or death (mortality)
Nov 22, 2014
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HIGH RISK PREGNANCY
Is one in w/c the mother or fetus has a significant increased chance of harm,
damage, injury, or disability (morbidity), and loss of life or death (mortality)
HIGH-RISK PREGNANCY A. DEMOGRAHPIC
FACTORS 1. Age 2. Weight 3. Height B. SOCIOECONOMIC
STATUS 1.inadequate
finances 2. overcrowding, poor
standard of housing, poor hygiene 2
3. Nutritional deprivation4. Severe social problem5. Unplanned and
unprepared pregnancy,specially among adolescents
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Adolescent Pregnancy: Contributing Factors Peer pressure Self-esteem Lack of role
models Gain attention Media Poverty Rite of passage
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Implications of Adolescent Pregnancy
Socioeconomic:
•reliance on welfare
•cycle repeats itself
Maternal health:
•CPD
•PIH
•anemia
•nut deficits
mortality
Fetal Health:
•LBW
•prematurity
•resp complications
•cp
•cognitive deficits
•death
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Adolescent Pregnancy: Assessment
Risks fundal height # of sexual partners knowledge of infant care/needs family unit/support system baseline VS/weight
C. OBSTETRIC HISTORY
1.Hx of infrtility or multiple gestation2. Grand multiparity3. prev. abortion or ectopic preg.4. Prev losses5. prev. operative OB,uterine or
cervical abnormalities6.prev. abnormal labor
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7. prev. high-risk infant8. prev. hydatidiform mole.
D. CURRENT OB STATUS1. Late or no prenatal; care2. Maternal anemia3. Rh sensitization4.Antepartal bleeding5.preg. Induce hypertension
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6.Multiple gestation7. pre-term- post term labor8.Polyhydramnios9. PROM10. Fetus inappropriately large or
small,abnormality in test fetal well being; abnormality in presentation
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E. MATERNAL MED.Hx/status
1. Cardiac or pulmonary dx2. Metabolic ds.3. Endocrine disoder4. Chronic renal ds.5.Chronic hypertension6.Veneral and other infectious ds.7.Major congenital disorder or rep.tract
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8. Hemoglobinopathies9.Seizure disorder10.Malignancy11. Major emotional dis, mental
retardation
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Diagnostic test in high-risk preg./prenatal det. Of fetal well being
1. Ultrasound-is a diagnostic technique which uses high-frequency soundwaves to create an image of the internal organs. A screening ultrasound is sometimes done during the course of a pregnancy to monitor normal fetal growth and verify the due date.
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PURPOSESIn the first trimester: to establish the dates of a
pregnancy to determine the number of fetuses
and identify placental structures to diagnose an ectopic pregnancy
or miscarriage to examine the uterus and other
pelvic anatomy to detect fetal abnormalities
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Mid-trimester: (sometimes called the 18 to 20 week scan)
to confirm pregnancy dates to determine the number of fetuses
and examine the placental structures to assist in prenatal tests such as an
amniocentesis to examine the fetal anatomy for
presence of abnormalities to check the amount of amniotic fluid to examine blood flow patterns
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to observe fetal behavior and activity
to examine the placenta to measure the length of the cervix to monitor fetal growth
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Third trimester: to monitor fetal growth to check the amount of amniotic fluid as part of other testing such as the
biophysical profile to determine the position of a fetus to assess the placenta
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NON – STRESS TEST Tocodynamometer records fetal movements and
Doppler ultrasound measures fetal heart rate to assess fetal well-being after 28 weeks.
Nonstress test is basically performed to evaluate on how the baby is doing inside. How often you need the test will depend on your doctor; it can be every week or more often till the baby is born.
• The test result is considered to be normal or reactive if baby's heart beats faster on two separate occasions during the 20 minute span.
• If baby is resting the result will most likely be non-reactive. However if results persist to be non-reactive even after one hour, it doesn't necessarily mean something is wrong with the baby.
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• Results may also be non-reactive due to baby's age; babies below week 32 have not hit the required maturity for reactivity. • The test time may be extended or the mother may have to go for more comprehensive tests like biophysical profile• If your doctor is absolutely sure that baby is not thriving inside, the labor may be induced
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Preparationa. position- semi-fowler’s or left lateral
position slightly turn to the leftb. BP is check firstc. Explain >procedure takes 30 to 60 mins
long >mother needs to activate”mark
botton”w/ each fetal movement > does not need
hospitalization/ambulatory basis20
Who needs the nonstress test..• Women with preexisting medical conditions such as
diabetes• Women with pregnancy-induced medical conditions such
as hypertension• Baby is less active than normal• Baby is small for its age• Amniotic fluid is either too much or too little
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• Women who have previously lost their babies in the second half of their pregnancies
• Women with pregnancies continuing after week 40 to basically check on the well- being of baby
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INTERPRETATION
A. Normal:Reactive- increased FHT (acceleration) greater than 16 bpm /secor more in 10 to 20 min. period w/ fetal movement
B. Abnormal: Non reactive- No FHR ACCELERATION WITH FETAL MOVEMENT
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INTERPRETATION
A. Normal : high –risk pregnancy continue
b. Abnormal result: mother needs another test, maybe biophysical profile
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OXYTOCIN CHALLENGE TEST(OTC) OR CONTRACTION STRESS TEST (CST)
CST is based on the observation that during contractions, blood flow to the placenta lessens temporarily. An evaluation is done on how the fetus handles this stress. (utero-placental well being)
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Interpretation:
a. normal: negative – No late decelerations of FHR w/ each of 3 contractions during a 10 minute interval
b. Abnormal: positive – with late decelerations of FHR with 3 contractions in 10 minutes.
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E. BIOPHYSICAL PROFILE
A scoring combining ultrasound assessment of: a. Fetal breathing
b. Fetal movement c. Fetal tone d. Reactivity of the heart rate e. Amniotic fluid volume BPP could
be used to predict fetal well-being in high-risk pregnancy
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Purpose
The purpose of the BPP is to assess fetal well-being. It is a tool used near or at term by clinicians to assess the potential risk of fetal compromise or demise due to fetal hypoxia or acidosis. Intervention such as maternal hospitalization, or delivery may follow a BPP score of four or below
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Biophysical variable Normal ( score =2) Abnormal (score= 0)
Fetal breathing movement
Gross fetal movement
Fetal tone
Reactive fetal heart rate
Greater than or = to 1 episode of 30 sec. or more of fetal breathing movement in 30 min3 or more discreet movements of the body or any limb in 30 minutes
Absence of 30 secs. Or longer of fb movement in 30 min
2 or lesser discreet movement of body or a limb in full extension or absent fetal movementEither slow extension with return to partial flexion or movement of limb in full extension or absent fetal movement
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EVALUATION OF FETAL EVALUATION OF FETAL WELL-BEINGWELL-BEING
Surveillance of fetal well-being is based on 5 categories:
• Non-stress test (NST)• Amniotic fluid index• Fetal breathing movements• Fetal tone• Reactive heart rate
Note: each category carries a score of 2 and the summative number interpreted by the physician. A score of 8-10 is reassuring.
BIOPHYSICAL PROFILEBIOPHYSICAL PROFILE
AMNIOCENTESISAMNIOCENTESIS
AMNIOCENTESISAMNIOCENTESIS
EVALUATION OF FETAL EVALUATION OF FETAL WELL-BEINGWELL-BEING
AMNIOCENTESISAMNIOCENTESIS
Used to determine fetal maturity and detect certain birth defects such as DOWN SYNDROME, SPINAL BIFIDA, HEMOLYTIC DISEASE OF THE
NEWBORN, SEX AND CHROMOSOMAL ABNORMALITIES.
Used to determine fetal maturity and detect certain birth defects such as DOWN SYNDROME, SPINAL BIFIDA, HEMOLYTIC DISEASE OF THE
NEWBORN, SEX AND CHROMOSOMAL ABNORMALITIES.
Amniotic fluid is aspirated by a needle which is inserted through the abdominal wall and uterine walls.
Amniotic fluid is aspirated by a needle which is inserted through the abdominal wall and uterine walls.
Done at 16 weeks to assess L/S ratio and detect genetic disorder.Possible after week 14.
Done at 16 weeks to assess L/S ratio and detect genetic disorder.Possible after week 14.
EVALUATION OF FETAL EVALUATION OF FETAL WELL-BEINGWELL-BEING
AMNIOCENTESISAMNIOCENTESISPREPARATION:PREPARATION:
Prior to procedure, the patient’s bladder should be emptied.Ultrasound used prior to procedure to guide needle to prevent fetal and placental trauma.TEST RESULTS: within 2-4 weeks
COMPLICATIONS:COMPLICATIONS:COMPLICATIONS:COMPLICATIONS:
Premature labor, infection, Rh isoimmunizationMonitor fetus and uterine contractions after procedure. Teach client to report decreased fetal movement or increased abdominal discomfort.
EVALUATION OF FETAL EVALUATION OF FETAL WELL-BEINGWELL-BEING
ALPHA – FETOPROTEIN SCREENINGALPHA – FETOPROTEIN SCREENING
•Maternal serum screens for open neural tube defects. Alpha-fetoprotein is a glycoprotein produced by fetal yolk sac, GIT and liver.
•Test is done between 16-18 weeks gestation.
•High levels indicate neural tube defects and anencephaly and spinal bifida; also associated with congenital nephrosis, esophageal atresia, fetal demise.
EVALUATION OF FETAL EVALUATION OF FETAL WELL-BEINGWELL-BEING
• Uses amniotic fluid to ascertain fetal lung maturity through measurements of presence and amounts of lung surfactants Lecithin and Spingomyelin.
• At 35-36 weeks, ratio is 2:1 indicative of mature levels.
• May be done in laboratory or by “SHAKE” tests.
LECITHIN/SPINGOMYELIN RATIOLECITHIN/SPINGOMYELIN RATIO
EVALUATION OF FETAL EVALUATION OF FETAL WELL-BEINGWELL-BEING
• In conjunction with the L/S ratio, contributes to increased reliability of fetal lung maturity esp. in diabetics.
• Value equal or greater than 3% is needed.
• May be done in laboratory or by “SHAKE” tests.
EVALUATION OF PHOSPHATIDYL GLYCEROL (PG)EVALUATION OF PHOSPHATIDYL GLYCEROL (PG)
EVALUATION OF FETAL WELL-BEING
CREATININE LEVELCREATININE LEVELEstimates fetal renal maturity and function.
More than 2.0 mg indicates fetal age greater than 36 weeks.
DETERMINATION OF SEX-CHROMATINDETERMINATION OF SEX-CHROMATINDetects sex-linked disorders.( Hemophilia, Duchenne’s Muscular
Dystrophy, Color Blindness)
BILIRUBIN LEVELBILIRUBIN LEVELHigh in pregnancy then drops after 36 weeks’ gestation.
Increase in bilirubin needs evaluation for Rh incompatibility.
EVALUATION OF FETAL EVALUATION OF FETAL WELL-BEINGWELL-BEING
• Assess placental functioning.
INTERPRETATION OF RESULTS:INTERPRETATION OF RESULTS:
• Sudden drop = fetal hypoxia• Continuous drop = fetal compromise.
20% of cells stained orange indicates fetal weight at least 2500 gms.
URINARY/ SERUM ESTRIOL URINARY/ SERUM ESTRIOL
LIPID CELLS (NILE BLUE STAIN)LIPID CELLS (NILE BLUE STAIN)
EVALUATION OF FETAL WELL-BEING
• Involves inserting a needle into the fetal umbilical cord and aspirating blood for analysis.
• The procedure is guided by U/S and is used to screen karyotypes (chromosomes), examine antibodies for teratogenic viruses and provide assess for fetal blood transfusions..
PERCUTANEOUS UMBILICAL BLOOD SAMPLING
PERCUTANEOUS PERCUTANEOUS UMBILICAL CORD UMBILICAL CORD SAMPLINGSAMPLING
COMPLICATION OF PREGNANCY Pre-gestational conditions: Pregnancy induced hypertension (PIH)
is a condition of high blood pressure (HYPERTENSION) during pregnancy. Your blood pressure goes up, you retain water (EDEMA), and protein(PROTEINURIA) is found in your urine. It is also called toxemia or preeclampsia. The exact cause of PIH is unknown.
7-10%bof all preg. Major causes of MCn mortality 42
ETIOLOGIC FACTORS: A first-time mom Women whose sisters and mothers had
PIH Women carrying multiple babies; teenage
mothers; and women older than age 40 Women who had high blood pressure or
kidney disease prior to pregnancy,polyhydramnios, chronic hypertension and renal disease
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SIGN AND SYMPTOMS: headaches, blurred vision inability to tolerate bright light fatigue nausea/vomiting urinating small amounts pain in the upper right abdomen shortness of breath and tendency to bruise easily
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2 types of PIH
1. Preeclampsia (mild and severe)2. Eclampsia
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SIGN MILD PREECLAMPSIA SEVERE PREECLAMPSIA
Hypertension 40 /90 or symmHg or more above theBaseline; diastolic rise 15mm Hg or moresystolic inc. of 30
160/110 or systolic increase at or above the 160 or morethan 50 mmHg over the baseline; diastolic rise greater than 110 mmHg or more on 2 readings taken 6 hours apart after bed rest
Proteinuria 1+ or 1g/day 3+ to4+ or 5g/day
Edema Generalized, confined to face (periorbital) and fingers
Generalized, severe facial puffiness, severe swelling of face
Weekly wt. gain-greater than 1lb/week
Excessive wt gain- 5 lbs/week or moreEpig. Pain due to edema of liver capsuleCerebral disturbances• severe frontal headache• inc, irritability• blurring of vision• hyper reflexia
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SIGN MILD PREECLAMPSIA SEVERE PREECLAMPSIA
• severe dizziness• halo vision, blind spots• persistent vomiting•Disorientation
Oliguria Absent output above 500 ml in 24 hours
Present; output 400ml or less in 24 hours
IUGR (intra-uterine growth retardation )
absent Present
Others HypoproteinemiaHemoconcentrationHypernatremia
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TABLE 15–3 Deep Tendon Reflex Rating Scale
FIGURE 15–4 To elicit clonus, with the knee flexed and the leg supported, sharply dorsiflex the foot, hold it momentarily, and then release it. Normally
the foot returns to its usual position of plantar flexion. Clonus is present if the foot “jerks” or taps against the examiner’s hand. If so, the number of taps or
beats of clonus is recorded.
B. DIABETES MELLITUS
A chronic, metabolic disorder characterized by a deficiency in insulin production by islets of Langerhans resulting in improper metabolic interaction of carbohydrates, fats. Protein and insulin
GDM] is usually diagnosed around 24
to 28 weeks of pregnancy.50
SIGN AND SYMPTOMS 1.Hyperglycemia 2.glucosuria 3. Polyuria 4. Polydipsia 5. weight loss 6. Ketoacidosis
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RISK FACTOR A. Family history B. Rapid hormonal change in pregnancy C. tumor/ infection of the pancreas D. Obesity E. Stress
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Complication of dm in mother Preeclampsia Urinary tract infections Future diabetes Dystocia Maternal mortality Diabetic retinophaty Diabetic nephropathy
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Fetus/ infant Excess growth. Extra glucose will
cross the placenta, which triggers your baby's pancreas to make extra insulin. This can cause your baby to grow too large (macrosomia). Very large babies are more likely to become wedged in the birth canal, sustain birth injuries or require a C-section birth.
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Low blood sugar (hypoglycemia). Sometimes babies of mothers with gestational diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own insulin production is high. Severe episodes of this problem may provoke seizures in the baby. Prompt feedings and sometimes an intravenous glucose solution can return the baby's blood sugar level to normal
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Respiratory distress syndrome. If your baby is delivered early, respiratory distress syndrome — a condition that makes breathing difficult — is possible. Babies born to women with gestational diabetes have more breathing problems than do those born to women without the problem, even at the same gestational age. Babies who have respiratory distress syndrome might need help breathing until their lungs become stronger. 56
Jaundice. This yellowish discoloration of the skin and the whites of the eyes may occur if a baby's liver isn't mature enough to break down a substance called bilirubin, which normally forms when the body recycles old or damaged red blood cells. Although jaundice usually isn't a cause for concern, careful monitoring is important.
Type 2 diabetes later in life. Babies of mothers who have gestational diabetes have a higher risk of developing obesity and type 2 diabetes later in life.
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Developmental problems. If you have gestational diabetes, your child may have an increased risk of problems with motor skill development, such as walking, jumping, or other activities that require balance and coordination. An increased risk of attention problems or hyperactivity disorders also is a concern.
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CARDIAC DISEASE This involves a variety of heart
conditions both congenital and acquired that complicate pregnancy.
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TYPES OF SPONTANEOUS ABORTIONS
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Spontaneous Abortion Management
Threatened
Inevitable
Notify MD/MW Check fetus by U/S Bedrest, no sexual activity
for 2 weeks after bleeding stops
No false reassurance Check by U/S for complete
vs. incomplete Analgesics for D&C RhoGAM
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Spontaneous Ab Mgmt, cont.
Incomplete
Missed
Hospitalization Before 14 wks – D&C + IV
Pitocin After 14 wks – Pitocin or
Prostaglandins Wait 3 to 5 wks for spont Ab
(93%) Monitor for DIC
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Post Abortion Education Bldg, cramping X 1-2 wks vaginal rest X 1 wk temp BID f/u in 2 wks
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SITES OF ECTOPIC PREGNANCY
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S & S Ectopic Pregnancy Missed Period Abdominal Pain Vaginal Spotting Rupture ↓ hCG levels No gestational sac on U/S
Severe lower abd pain
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Surgical Management of Ectopic Pregnancy
Med Mgmt of Ectopic PG MTX
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S & S Hydatiform Mole Vaginal bleeding
anemia uterus size,
cramps No FHT’s N/V Early PIH
Therap. Mgmt: vacuum aspiration & curettage
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Spontaneous Abortion Matching – Choose all that apply.1. 1. Initial symptom is
vaginal bleeding2. 2. Membranes rupture and
cervix dilates3. 3. Some, not all, products
of conception are expelled.4. 4. Treatment includes D&C5. 5. All products of
conception passed6. 6. All unsensitized Rh neg
women should receive RhoGAM
7. 7. May be treated with bedrest
8. 8. Retained dead fetus9. 9. May be complicated by
DIC10. 10. Pregnancy may continue
A. Threatened abortionB. Inevitable abortionC. Incomplete
abortionD. Complete abortionE. Missed abortion
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Medical Mgmt of Placenta Previa
Mom stable,
fetus immature
•Bedrest
•no sex act
•report bldg
Fetus > 36 wks
•Amnio to lung maturity
•delivery
S&S hypovol in mom
•delivery
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S&S Abruptio Placentae
•Vag bldg (unless concealed)
•abd pain
U-act
•hemorrhage•boardlike abd
•late decels
•s&s shock
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Med Mgmt of Placental Abruption
Mom stable,
fetus immature
bedrest
tocolytics
bleeding,
fetal distress
Emergency CS
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DIC
Placental Bleeding
Thromboplastin release
Clot formation (systemic response)
clotting factors (fibrinogen, plts, PTT, FDP)
inability to form clots
profuse bleeding
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The Pathological Processes of Pre-eclampsia
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S&S Pre-eclampsia Rapid wt gain edema of hands & face proteinuria hyperreflexic DTR’s H/A, visual disturbances epigastric pain
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Treatment of Pre-eclampsia
Bedrest protein diet document fetal
activity weekly NST
Bedrest, stimuli Meds
Apresoline for severe HTN
MgSO4 (anticonvulsant & antihypertensive)
Delivery
Mild: diastolic < 100, trace to 1+ proteinuria, no H/A
Severe: diastolic > 110, 3+ proteinuria, U/O, H/A, visual disturbances
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S&S Eclampsia/HELLP Syndrome
Eclampsia facial twitching tonic-clonic sz pulmonary edema circ/renal failure
HELLP Syndrome RUQ pain n/v edema H/H, plts liver enzymes
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Treatment of Eclampsia/HELLP Syndrome
Bedrest Meds
MgSO4 Valium or Phenobarb (if Mg not effective,
not within 2 hr of delivery) Hydralazine (for severe ↑ B/P) steroids to fetal lung maturity
Delivery
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Assessment: Hypertensive Disorders of Pregnancy
Prenatal: wt, B/P, U/A, H/A, visual disturbances
Hospitalized Ct: daily wt hourly u/o, dipstick urine Q4H VS, FHR LOC, DTR’s, H/A clonus
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Risk Control Strategies for Hypertensive Disorders of Pregnancy Sz precautions monitor for s/s Mg toxicity(RR<12, absent
DTR’s, sweating, flushing, confusion, B/P) Ca gluconate @ BS Mg levels IV MgSO4 (should be “Y” connected to
another primary bag) D/C MgSO4 for RR < 12 or absent
DTR’s renal function (30 mL/hr)
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Incompetent CervixS&S
•advanced cervical dilation
•low abd pressure
•bloody show
•urinary frequency
Treatment
•cerclage
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Premature Labor/Rupture of Membranes
S&S contractions cramps backache diarrhea vag d/c ROM
Treatment Tocolytics IV hydration bedrest steroids, if needed abx, if needed
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Nursing Care for PTL/PROM Assessment
Thorough hx bleeding ROM BPP (for PROM)
Teaching Infection Control FMC
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Postterm Pregnancy S&S
Wt loss uterine size Meconium in AF
Risks fetal mortality cord compression mec asp LGA shoulder
dystocia CS episiotomy/laceration depression
Treatment fetal surveillance
NST, CST, BPP Q wk
mom monitors mvmt
Induction Pitocin (10-20U/L)
@ 1-2 mU/min every 20-60 min
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Disorders of Amniotic Fluid Polyhydramnios
S&S uterine dist dyspnea edema of lower
extr Treatment
therapeutic amniocentesis
Oligohydramnios Risks
cord compression musculoskeletal
deformities pulmonary
hypoplasia Treatment
amnioinfusion
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Risks of Multifetal Gestation
PIH GDM PPH Anemia UTI PTL Placenta previa CS
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(Fetal) S&S Rh Incompatibility Hyperbilirubinemia
jaundice Kernicterus (severe neuro d.o. r/t
bili) anemia hepatosplenomegaly Hydrops fetalis
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Sequence of Assessments for Rh Sensitization
Blood Test for Type & Rh Factor
Rh-negative Rh-positive
No further testingIndirect Coombs
Give RhoGAM
Repeat frequently Titer increasing
amniocentesis ( bilirubin)Titer not increasing
continue to monitor No change
retest prn
Elevated
retest, U/S
intrauterine transfusion or early delivery
+-
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Management of Rh Incompatibility
Prevention RhoGAM at 28
weeks (unsensitized women only)
Postpartum direct Coomb’s RhoGAM to mom if
baby is Rh+ (within 72 hrs of birth)
Prenatal
•per algorithm
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Hyperemesis Gravidarum S&S
U/O wt loss ketonuria dry muc
membranes poor skin turgor
Treatment IVF, TPN antiemetics advance diet as
tol
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Glucose Tolerance Test
11 GTT GTT (24 - 28 wks)
drink 50g glucose,
if 1 BS > 140
33 GTT GTT•hi carb diet X 2 days, then NPO after MN
•FBS, then drink 100g glucose,
1, 2, 3 BS
Gestational Diabetes is diagnosed with FBS > 105 or with 2 of the following BS results:
1 > 190, 2 > 165, 3 > 145
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Effects of Pre-Existing DM
Maternal risk of:
PIH Cystitis DKA Spont Ab
Fetal risk of:
NTD’s Cardiac defects Macrosomia or IUGR Polycythemia hyperbilirubinemi
a
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Treatment of Pre-existing DM Team approach Monitor glycosylated Hgb A Diet: 50% carb, 20% prot, 30% fat Insulin TID Hourly glucoses during labor NST’s weekly (starting at 28-30 wks) Amnio ( lung maturity)
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Effects of Gestational Diabetes Maternal Effects
UTI hydramnios PROM/preterm
labor shoulder dystocia epis/lac CS HTN
Fetal Effects macrosomia hypoglycemia at
birth RDS
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Treatment of Gestational Diabetes
30 to 35 cal/kg/day (3 meals, 2 snacks)
Insulin FBS, post-prandial BS’ Q week NST, BPP Q week glycosylated Hgb A Amnio ( lung maturity)
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Diabetes: Patient Education
Glucose monitoring insulin administration
type, onset, peak, duration, times, sites, injection technique
diet s/s hypoglycemia
tremors, pallor, cold/clammy skin give milk & crackers or glucagon inj
s/s hyperglycemia fatigue, flushed skin, thirst, dry mouth, check glu, call MD for insulin order
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PPCM: Manifestations
dyspnea edema, wt gain chest pain palpitations jug vein distention enlarged heart spont ab, PTL
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PPCM: Energy Management Epidural Activity restriction Minimize anxiety
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PPCM: Cardiac Care Meds Sidelying, HOB ↑ Monitor VS, FHR, heart pressures
(Swan-Ganz) Strict I/O Assess lungs
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PPCM: Patient Education Avoid excessive wt gain/edema
Diet: 2200 cal, protein, NAS rest/avoid exertion avoid exposure to environmental
extremes emotional stress
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Sickle Cell Disease Maternal Effects
pain jaundice Pyelonephritis PIH/preeclampsia leg ulcers CHF
Fetal Effects IUGR/SGA skeletal changes
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Systemic Lupus Erythematosis
Maternal effects fatigue muscle/joint pain wt loss rash proteinuria PIH/preeclampsia/HELLP PG loss
Fetal effects IUGR preterm delivery
Treatment
•PO or IV Steroids
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AIDS Maternal Effects
vag candidiasis PID genital herpes HPV PCP
Fetal Effects Asymptomatic at birth Candidal diaper rash thrush diarrhea recurrent bacterial
infections FTT dev delay
Treatment:
ZDV (zidovudine) during PG, L&D
ZDV to neonate for 6 wks
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Which of the following socioeconomic factors contributes to the high incidence of adolescent pregnancy in the US?
A. lack of adequate birth control
B. poverty
C. lack of information on safe sex
D. availability of public assistance for unmarried mothers
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Which genetic screening test for chromosomal abnormalities provides an older expectant couple with information within the first trimester?
A. Chorionic villus sampling (CVS)
B. Amniocentesis
C. Genetic karyotyping
D. Ultrasonography
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When caring for a woman with mild preeclampsia, the nurse would be concerned with which finding?
a. +4 proteinuria
b. +2 dependent edema in ankles
c. Blood pressure 156/100
d. +2 DTR’s, absent clonus
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The nurse is preparing to infuse magnesium sulfate to treat preeclampsia. In implementing this order the nurse understands the need to:
a. Prepare a solution of 20 g MgSO4 in 100cc D5W
b. Monitor maternal VS, FHR and uterine contractions every hour
c. Expect the maintenance dose to be approximately 4g/hr
d. Discontinue the infusion and report a respiratory rate of < 12 breaths/minute
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The primary expected outcome for care associated with the administration of MgSO4 would be met if the woman:
a. Exhibits a decrease in both systolic and diastolic blood pressure
b. Experiences no seizures
c. States that she feels more relaxed and calm
d. Urinates more frequently, resulting in a decrease in pathologic edema
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A primigravida at 10 weeks gestation reports slight vaginal spotting without passage of tissue and mild uterine cramping. When examined, no cervical dilation is noted. The nurse caring for this woman should:
a. Anticipate that the woman will be sent home and placed on bedrest with instructions to avoid stress or orgasm
b. Prepare the woman for a dilatation and curettage
c. Notify a grief counselor to assist the woman with the imminent loss of her fetus
d. Tell the woman that the doctor most likely will perform a cerclage to help maintain the pregnancy
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CASE STUDY I
A G3P2 woman, at 38 wks gestation, arrives at the obstetric unit with c/o painless vaginal bleeding.
1. What is the nursing priority at this time?
2. What assessments are necessary?
3. What is the most likely etiology of the bleeding?
4. What is the expected treatment for Anne?
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CASE STUDY II
A G1P0 woman, at 35 wks gestation, is visiting the midwife for a routine prenatal visit. On assessment, the nurse finds that she has gained 8 lbs in the past month.
1. What is the significance (if any) of this weight gain?
2. What other assessments should the nurse make at this time?
3. What is the required treatment for this client?
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CASE STUDY IIIA 22 y.o. G1P0 who has a history of IDDM X 6 yrs and whose LMP was 12 wks ago arrives at the prenatal clinic.
1. How will this client’s diabetes be affected by her pregnancy?
2. What changes will she most likely have to make to adjust to her pregnancy?
3. What routine assessments will be made at each prenatal visit?
4. What tests will be required as the pregnancy progresses?
5. What fetal effects occur with pre-existing diabetes?
6. How will L&D be altered by pre-existing diabetes?
7. What possible newborn complications could occur with pre-existing diabetes?
8. What nursing care will the infant require?
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MATH PROBLEM
For induction, Pitocin is ordered – 10 Units in 500 mL to start at 2 mU/min and increase by 1 mU/min every 20 minutes until effective contractions are achieved.
At what rate will the nurse start the IV? By how much will the rate be increased every 20 minutes?
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THE END