When vomiting becomes excessive enough to cause a weight loss of at least 5% accompanied by dehydration, electrolyte imbalance, ketosis, and acetoneuria.
Risk factors for hyperemesis gravidarum
- increased body weight
- history of migraines
- multiple gestation
- hydatidiform mole
- psychological component
Hyperemesis gravidarum is more likely when the sex of the baby is ________
Hyperemesis gravidarum occurs mostly in the ___ trimester and has a ______ outcome.
1st trimester, favorable outcome
Meds to give to moms with hyperemesis gravidarum.
- Pyridoxine (vit B6)
- doxylamine (unisom)
- promethazine (phenergan)
- ondasteron (zofran)
- metoclopramide (reglan)
Nursing care for hyperemesis gravidarum
- IV fluids
- NPO until dehydration is resolved and 48 hours after vomiting has ceased
- Meds (phenergan, zofran, reglan, Vit B6)
- Record nausea, retching without vomiting and vomiting
- I&O's, oral hygiene, daily weight, VS assessment and foods as tolerated beginning with clear liquids
_____ is a pathologic form of clotting that is diffuse and consumes lg amounts of clotting factors causing wide spread external or internal bleeding or both.
In DIC an over-activation of the clotting cascade and the fibrinolytic system results in the depletion of _____ & _____
platelets and clotting factors
What occurs in the vessels during DIC?
Blood cells are destroyed as they pass through fibrin choked vessels resulting in a clinical picture of hemorrhage, anemia, & ischemia
What most often triggers DIC?
- abruption placentae
- retained dead fetus
- amniotic fluid embolus
- severe preeclampsia
How is DIC diagnosed?
By clinical factors and labs
What labs are used when diagnosing DIC?
- antihemophilic factor
- -Bleeding time is normal
- -coagulation time shows no clot
- -Clot retraction time shows no clot
- PTT is increased
Treatment for DIC
Fix the underlying cause!
- Treat infection, preeclampsia or removeal of the placenta or fetal demise
- volume replacement with IVF, packed RBC's, FFP or cryoprecipitate, and platelets
- ***Be sure to warm any fluids and blood products
- Monitor I&Os-watching for possible renal failure 30mL is minimum
- Administer O2, monitor for S&S of bleeding and shock
- Vasospastic disease process of reduced organ perfusion characterized by the presence of:
- HTN & Proteinuria (30mg in 2 random samples 6 hours apart in 24 hour period)
- SBP >140, DBP >110
- MAP >105
- Proteinuria-30mg/dl w/o infection in 2 random samples 6 hours apart in 24hr period
- Proteinuria is rated as 0,1+,2+,3+,4+
- Hyperuricemia: >6mg/dl
Hospital care of preeclampsia or HELLP
- Mag-to prevent convulsions 4-6g/100mL NS, maintenance dose 2g to maintain therapeutic level of 4-7.5mEq/L
- Control BP with antihypertensives (hydralazine) want SBP <160, DBP <110
What drug has a tocolytic effect that can prolong labor?
S&S of mild magnesium sulfate toxicity
- Decreased DTR's
- feeling of warmth
- muscle weakness
- decreased reflexes
- slurred speech
Why is methotrexate given after a salpingostomy?
It dissolves residual tissue.
Another use is to treat women who have had an ectopic pregnancy to decrease chances of another ectopic pregnancy while increasing intrauterine pregnancy rate.
Where do ectopic pregnancies occur most often?
- 95% - in uterine tubes (fallopian)
- 0.5% - ovary
- 1.5% - abdominal cavity
- 0.3% - cervix
What is the leading cause of 1st trimester maternal death?
S&S of ectopic pregnancy?
- Dull colicky pain when the tube stretches
- unilateral, bilateral or diffuse pain over abd
- Dark-red/ brown vag bleeding (50-80%)
- Increased pain with rupture-deep low quadrant pain caused by blood irritating the peritoneum
- Referred shoulder pain from diaphragmatic irritation from blood in peritoneal cavity
- Signs of shock-bleeding into abd, not necessarily out the vagina
- Ecchymotic blueness around the umbilicus (Cullen sign) indicating hematoperitoneum
Treatment for ectopic pregnancy?
- Check for progesterone and hcG levels with 48 hour recheck if needed
- US=to confirm intrauterine pregnancy
- Removal by salpingostomy, then give methotrexate
If a 1st trimester pregnant woman presents with bleeding and abd pain suspect___?
ectopic pregnancy and undergo screening to either rule it in or out
What is Cullen sign?
Ecchymotic blueness around the umbilicus of a pregnant woman indicating hematoperitoneum
S&S of severe magnesium sulfate toxicity
- Loss of patellar reflexes
- Respiratory and muscular depression
- decreased LOC
What is the antihypertensive of choice to treat preeclampsia?
What is the antidote for magnesium sulfate?
Calcium Gluconate-10mL of 10% solution or 1g slow IVP over 3 min
5 types of miscarriage
- 1. threatened
- 2. inevitable
- 3. incomplete
- 4. complete
- 5. missed
_____ miscarriage has spotting with a closed cervical os and mild cramping
____ miscarriage occurs with moderate to heavy bleeding, tissue may be present, mild to severe cramping, rutpture of membranes, cervical dilation and passage of products of conception.
_____ miscarriage has moderate to heavy bleeding, tissue may be present mild to severe cramping, expulsion of the fetus with retention of the placenta
_______ miscarriage. All fetal tissue is passed, cervix is closed, slight bleeding and mild uterine cramping
______ refers to a pregnancy in which the fetus has died but the products of conception are retained in the uterus for up to several weeks. Usually no bleeding or cramping, cervical os is closed.
Why is magnesium sulfate given during preterm labor?
It is a central nervous system depressant, relaxes smooth muscles (including the uterus)
Why would betamethasone or dexamethasone be given during preterm labor?
- It stimulates fetal lung maturation by promoting release of enzymes that induce production or release of lung surfactants.
- helps stress the baby=lung development
What 3 tocolytic meds are given to relax the uterus in preterm labor?
- 1. Terbutaline (B2 adronergic agonist) relaxes smooth muscles, inhibiting uterine activity and causing bronchodilation. Causesincreased HR, hot and flushed
- 2. Procardia -CCB
- 3. Mag Sulfate-
What is the nursing role in a prolapsed cord?
- Remove pressure from cord manually or with position changes (trendelburg, knee-chest)
- Prepare for immediate delivery either vaginally if fully dilated or c-section
The head is born but the anterior shoulder cannot pass under the pubic arch
Complications of shoulder dystocia
- Fetal: birth injuries
- brachial plexis damage
- fracture of humerus or clavicle
- Maternal Complications:
- excessive blood loss as a result of uterine atony or rupture
- extension of episiotomy or endometritis
Nursing care for shoulder dystocia
- Suprapubic pressure-attempt to push the shoulder under the symphysis pubis
- McRoberts maneuver-legs flexed apart on abdomen, straightens the sacrum
- Gaskin maneuver-mom on hands and knees, opens the pelvis and changes the center of gravity
S&S of baby born when mom was taking magnesium sulfate to prevent seizures.
- Poor respiratory effort at birth and decreased reflexes
- no effect on FHT
A 3rd trimester problem where you ALWAYS see bleeding.
- placenta previa
- bleeding is painless
In ________ the placenta is implanted in the lower uterine segment near or over the internal cervical os.
3 types of placenta previa
- 1. Complete-internal os is entirely covered by placenta when cervix is fully dilated
- 2. partial - (marginal) incomplete coverage of the internal os. Only an edge extends over the os but during dilation may extend onto the os
- 3. Low lying - placenta is implanted in the lower uterine segment but does not reach the os
When a pregnant woman presents with bleeding always confirm with ___ before performing a vaginal examination.
Ultrasound. If they have placenta previa, finger could penetrate the placenta resulting in maternal death!
Risk factors for placenta previa
- previous placenta previa
- previous cesarean birth
- D&C for miscarriage/abortion/endometriosis
- Risk increases with multiple gestation, multiparity, maternal age>35,
- African or Asian
S&S of placenta previa
- Painless uterine bleeding (70%)
- Vaginal bleeding with uterine activity (20%)
- Vaginal bleeding after 20 weeks
- Bright red bleeding that can be a small amount at first and will stop with clotting but can reoccur at any time.
- Abd usually soft, relaxed, nontender, normal tone
- Fetus=breech, oblique, transverse due to abnormal placental placement
Complications of placenta previa
- PTL and birth
- surgery related trauma
- abnormal placental attachments (placenta accrete)
- postpartum hemorrhage and infection
How is placenta previa diagnosed?
Transabdominal ultrasound (93-97% accutate)
Treatment for placenta previa
- home monitoring for bleeding and US studies every 2-3 weeks
- Plan a cesarean delivery
- monitor fetal and uterine activity
- anticipate possible hemorrhage post-delivery-due to large vascular channels in lower uterine segment and diminished muscle content
Hemorrhage may occur in placenta previa even if the uterus is ___&________
firm and contracted-due to the diminished muscle content in the lower uterine segment
Premature separation of the placenta or a portion of the placenta from its implantation site.
Abruption placentae is most commonly caused by _____
- maternal HTN
- other causes include cocaine, blunt external abd trauma and maternal smoking
S&S of abruption placentae
- bleeding into the uterus or vagina
- Typicall vaginal bleeding, with abd pain
- Port wine stained amniotic fluid
- uterine contractions or hypertonus (board like abd)
- uterine tenderness and abnormal FHR patterns or fetal death
- VERY PAINFUL!!!
- uterus appears purplish and copper colored
- contractility is lost
Shock may occur out of proportion to obvious bleeding with _____
What is the leading cause of maternal death?
Suspect _______ with any woman who has sudden onset of intense localized uterine pain with or without vaginal bleeding.