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gestational complications
- terms
- premature labor
- preterm birth
- late preterm infant
- mod. preterm infant
- very preterm infant
- low birth weight infant
- very low birth weight infant
- extremely low birth weight infant
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PTL
- preterm labor
- labor that occurs btwn 20-36 weeks gestation
- #1 cause for neonate mortality
- #2 cause for infant cause of mortality
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pathophysiological pathway to preterm labor
abnormal uterine distention: multifetal pregnancy, plyhydramnios, structural uterine anomolies:uterine contraction, premature rupture of membranes.
decidual hemorrhage:abruption, thromnin activation:uterine contraction, premature rupture of membranes.
activation of maternal fetal HPA axis: prostaglandin production, placental estrogen, stress: uterine contraction, premature rupture of membranes
infection: uterine contractions, breakdown of membranes and cervix: uterine contraction, premature rupture of membranes
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management of preterm labor
- tocolytic drugs (meds that help control uterine contractions)
- bed rest
- intravenous hydration (can get pulmonary edema)
- antibiotic therapy
- corticosteroid therapy (to the babys benefit)
- ex: betamethasone steroid to help mature fetal lungs
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common tocolytic drugs
magnesium sulfate, nifedipine, terbutaline
magnesium sulfate: depresses myometrium contractility, relaxes smooth muscle of the uterus.
nifedipine: inhibits smooth muscle contractions of uterus by blocking calcium availability for muscle contraction, can delay delivery for 48-72 hrs
terbutaline: beta 2 adrenergic effects to suppress uterine activity, can delay delivery for 3 days
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fetal fibronectin
test to tell us if there is any protein in the cervix, if the test is positive then the mom will go into labor within the next 2 weeks
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premature labor: factors that allow delivery preterm
- -dilation greater than 4 cm
- -at risk for pregnancy inducted hypertension
- -lethal fetal anomaly-baby will die anyways
- -severe maternal disease
- -hemorrhage
- -acute fetal distress
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cerclage
purse string suture placed cervically to reinforce a weak cervix
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premature rupture of membranes
rupture of the chorioamniotic membranes before the onset of labor
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preterm premature rupture of membranes (PPROM)
rupture of membranes with a premature gestation less than 37 weeks
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prolonged rupture of membranes
- greater than 24 hours
- -baby at risk for infection
- -dry birth
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spontaneous rupture of membranes
- SROM
- -before onset of labor (term)
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chorioamnionitis
amniotic fluid infection
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endmetritis
postpartal infection of endometrium which causes scar tissue
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maternal risk factors
- -previous PPROM
- -previous preterm delivery
- -bleeding
- -multiple gestation
- -STD's
- -smoking
- -maternal infection: chorioamnionitis and endometritis
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fetal/neonate risks
- -respiratory distress with PPROM
- -fetal sepsis-ascending pathogens
- -malpresentation
- -prolapsed cord-because cord can come first which is bad
- -non reassuring FHR
- -premature birth
- -cord compression-baby not getting o2
- -fetal deformities if PPROM is less than 26 weeks
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incompetent cervix
mechanical defect in the cervix that results in painless cervical dilation and ballooning of the membranes into the vagina following by expulsion of a premature fetus during the second trimester
- -cerclage (18-20 weeks)may be placed prophylactically before cervical dilation or as needed
- -remove sutures if membranes rupture to decrease infection
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multiple gestations
pregnancies with more than 1 fetus
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monozygotic twins
- from one zygote that divides in the first week of gestation
- -identical
- -same gender
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dizygotic twins
- -fertilization of 2 eggs
- -may have same or different genders
- -placental types: monochorionic-1 chorion and dichorionic-2 chronions
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maternal risks for multiple gestation
- -preterm labor and delivery is 50% greater
- -PPROM
- -HTN, preeclampsia
- -gestational diabetes
- -antepartum, hemorrhage, abruptio placenta, placenta previa (placenta covers cervix)
- -anemia
- -SOB, etc
- -pulmonary edema
- -cesarean birth
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fetal/neonatal risks
- -increased morbidity and mortality rates
- -low birth weights
- -decreased intrauterine grown (IUGR)
- -increased fetal anomalies
- -prematurity
- -abnormal presentations
- -increased cord incidents
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hyperemesis gravidarum
- vomiting during pregnancy that is so severe it leads to dehydration, electrolyte and acid base imbalance and starvation ketosis.
- -due to rising chorionic gonadotropin and or estrogen levels
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diabetes mellitus
chronic metabolic disease characterized by hyperglycemia as a result of limited or no insulin production
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type 1 diabetes
result of autoimmunity of beta cells of the pancreas resulting in absolute insulin deficiency and is managed within insulin
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type 2 diabetes
- insulin resistance and inadequate insulin production
- -most prevalent form of diabetes
- -increasing because of obesity
- -controlled with diet, exercise and oral glycemic agents
- -oral hypoglycemic agents are not recommended for use during pregnancy in type 2 diatetic women
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gestational diabetes
diabetes that begins during pregnancy (increased maternal adipose in mom, or increased hormones from placenta)
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maternal risks for pregestational diabetes
- hypoglycemia
- HTN, preeclampsia
- preterm labor
- spontaneous abortion
- polyhydramnios
- oligohydramnios
- c section
- infection-because of delayed would healing
- induction of labor
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neonate risks of diabetes
- hypoglycemia
- hypocalcemia/hypo magnesemia
- IUGR
- RDS-resp. disease syndrome
- polycythemia (ruddy(
- hyperbilirubinemia
- prematurity
- congenital defects(mainly heart probs)
- cardiomyopathy
- macrosomia
- stillbirth
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hypertensive disorders
- chronic hypertension
- preeclampsia (protein uria), eclampsia(diff.= seizures with eclampsia)
- preeclampsia superimposed on chronic HTN
- gestational hypertension/pregnancy induced hypertension
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PIH
- pregnancy induced hypertension
- -includes preeclampsia (most common PIH)
- -primigravidas>multiparas
- -obesity
- -multiple gestation
- -family history
- -diabetes mellitus
- -seen more in teens less than 10 and greater in woman over 35
- -most often seen last 10 weeks of gestation, during labor or first 12-18 hours after delivery
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preeclampsia
- patho: increase arterial BP
- increased peripheral vascular resistance, vasospasms with arteriole vasoconstriction=decrease GFR and deacrease blood flow to all organs
- -cardinal symptoms: hypertension and proteinuria
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preeclampsia (2 categories)
- mild: preeclampsia: BP increased to 140/90 or greater
- -proteinurea 1+-2+
- -generalized edema of face, hands, ankles
- severe: preeclampsia: BP 160/100 or greater
- -proteinurea 3+-4+
- -oliguria-urine output less than 500 ml in 24 hours
- -increased generalized edema
- -frontal H/A, blurred vision, N/V, EPIGASTRIC PAINNNNNNN (cardinal sign of seizures)
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chronic hypertension
before 20th week of gestation may put the woman at high risk for developing preeclampsia
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preeclampsia-eclampsia
pre: systemic disease with hypertension accompanied by proteinuria after 20th week of gestataction
eclampsia: convulsive stage
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preeclampsia superimposed on chronic hypertension
hypertensive women who develop new onset proteinuria before 20th week gestation or sudden uncontrolled hypertension
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gestational hypertension
high blood pressure detected for the first time after mid pregnancy without proteinuria
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HELLP SYNDROME
- hemolysis, elevated liver enzymes, low platelets
- -complication of severe preeclampsia
- -only cure is to deliver
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placenta previa
- occurs when placenta attaches to the lower segment of the uterus, near or over the internal os
- -low lying
- -marginal
- -partial
- -total
- -symptoms: painless bright bleeding
- -treatment is dependent on degree of previa
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implications of placenta previa
if marginal or low lying-woman may be allowed to labor
changes in FHR and meconium staining of amniotic fluid
if profuse bleeding-fetus is compromised, suffers hypoxia
FHR imperative on admission-if non reassuring FHR=c section
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nursing implications of placenta previa
- -ultrasound
- -if no bleeding-bed rest with BRP
- -no vaginal exams because you can puncture the placenta
- -monitor blood loss, pain, contactions, fetal heart rate
- -Maternal VS
- -labs
- -H&H, urine, Rh, T&C
- -have 2 units of blood on hold
- -iv
- -anticipate c section
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Abruptio Placentae
- -premature separation of normally implanted placenta, may be marginal, partial or complete
- -signs: vaginal bleeding(may not have), hypertonus, hypercontractility, abdominal pain or back pain
- -sudden and severe
- -uterine tenderness
- -uterine contractions
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maternal implications of abruptio placentae
- -hemorrhage
- -DIC
- -preterm delivery
- -shock
- -renal failure
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fetal implications
- -perinatal mortality
- -anemia
- -hypoxia
- -brain damage
- -demise
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placenta accreta
- abnormal implantation of the placenta
- -roots grow deep into the muscle wall of the uterus
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placenta accrete
invasion of trophoblast is beyond normal boundary
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placenta increta
invasion of the trophoblast extends into uterine myometrium
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placenta percreta
invasion of the trophoblast extents into the uterine musculature and can adhere to other pelvic organs
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abortion
- -induced
- -elective
- -therapeutic
- -spontaneous
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ectopic pregnancy
- develops as a result of the blastocyte implanting somewhere other than the endometrial lining of the uterus
- -majority in the fallopian tube
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hydatiform mole
benign proliferating growth of the trophoblast in which the chorionic villi develop...grapelike clusters without a viable fetus
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TORCH
toxoplasmosis, other, rubella, cytomegalovirus, herpes simplex virus
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