Antepartal Risk

• Gestational HTN (Previously PIH)
• Preeclampsia
• Eclampsia (seizures)
• Superimposed Preeclampsia
• Chronic HTN (htn prior to pregnancy)

• Preexisting but remains after pregnancy
• May not be discovered until after
• May be mistaken for gestational HTN

• Preeclampsia
• (BP => 140/90, Urine dipstick of 1+ protein or .3g in 24 hours, Seizures post delivery, Edema)

• High BP after 20 weeks gestation
• Proteinuria (dipstick of 1+ or .3g in 24 hours)
• Edema (pulmonary and generalized...face swollen, 4lbs heavier)
• Seizures post delivery (within 1st 24 hours)
• Vascular Changes (eye exam)
• Liver, renal, hepatic abnormalities
• Low Platelets 
• Hyperrelexia (DTRs)

• 7%
• (major cause of death)

• 1st preg
• <19 or >40 yrs old
• Obesity
• Family Hx
• HTN or vascular disease
• Chronic Renal Disease
• DM
• Periodontal Disease  
• Multiple Gestation
• Clotting Disorders (Antiphospholipid synd)
• African American
• Mother/Sister with preeclampsia
• Father of baby with preeclamptic mother
• Angiotensin gene T235

Lack of compensatory mechanism of normal pregnancy to increase volume and cardiac output

No resistance to angiotensin 2; vasoconstrictor

Vasoconstriction and vasospasm impede flow to major organs (PVR- peripheral vascular resistance)

• Renal
• Hepatic
• Cerebral
• Pulmonary
• Placenta

• Silent Killer- when symptoms arise, disease is advanced
• Generalized Edema
• H/A, drowsiness, confusion
• Visual disturbances (double vision, spots)
• Numbness, tingling of extremeties
• Epigastric pain (ominous)
• Oliguria

To catch potential complications of preeclampsia early...ie: epigastric pain

• Cure > delivery!
• BP 140-159/90-110
• Blood levels WNL
• 1+ proteinuria
• Minimal Increase in Liver Enzymes (or no increase)
• No severe HA
• Normal feta growth

• Cure= Delivery! (SEND TO HOSPITAL IMMEDIATELY bc BP IS SO HIGH!!!)
• BP >160/>110
• Elevated Serum Creatinine
• Elevated Liver Enzymes
• Decreased Platelets
• Severe HA
• Visual Disturbances
• RUQ pain, nausea, vomiting
• Pulmonary Edema
• Reduced Amniotic Volume
• IUGR

• Eclampsia
• (Seizures may occur post partum!!!)

During prenatal, intrapartum, or post partum periods

Facial Twitching, body rigidity, tonic clonic motions about 1 min in length

Uterine irritability (baby gets brady/tachy)

Aspiration 

Oliguria and Pulmonary Edema

Cerebral Hemorrhage may occur

• Hemolysis
• Elevated Liver Enzymes
• Low Platelets
• Severe preeclampsia or eclampsia may proceed to HELLP or it may develop without preeclampsia

• Liver Distention (avoid deep palpation)
• Jaundice
• Bleeding
• Hypovolemic shock
• RUQ pain/Lower right chest pain/mid epigastric pain
• Delivery if >32 weeks!!!!

can be managed at home if woman follows plan

Frequent rest periods in L lateral position for 1 1/2 hours per day (improves perfusion)

BP home monitoring 2-4 times per day (same position, same arm)

Daily weights

Daily Urine Dipstick

Diet-- protein and calories (no need to alter salt or fluid intake...not the cause of edema)

• Put in Hospital for a period of time:
• Bed Rest- left lateral position
• Quiet and dark atmosphere
• Padded Side Rails

• Antihypertensives (ACE inhib are contraindicated)
•    -Hydralazine for vasodilation
•    -Nifedipine (CC blocker)
•    -Labetalol (BBlocker)

• Seizure Prevention: Magnesium Sulfate IV with piggyback (4-6gm diluted in 100ml over 15-20 min...then 2 m per hour)
•    -CNS depressant (check every 15 min for Mg toxicity), reduces vasoconstriction and helps fluid shift

Vasodilates and increases cardiac output and blood flow to the placenta

• Increased Serum Levels
• Diminished Urine Output (watch for oliguria!!!)
• Possible decreased variability of FHRs
• Decreased DTRs
• Thirst
• Confusion
• Decreased Ox Sat (<95%)
• Decreased Resp Rate (<12)

Be a careful observer of what your patient came in with and what you are comparing her to now...some s/s will be similar to preeclampsia

• Monitor BP and RR closely
• DTRs per protocol (every 15 min)
• Urinary Output q hour
• Keep ANTIDOTE nearby!!! (Calcium Gluconate)
• Have resuscitation equip available
• Watch for impending seizures (HAs, DTRs 4+, RUQ pain, N+V)
• Keep quiet, dark, minimal intrusion, dont startle, restrict visitors

Calcium Gluconate

• 4-14%
• (may be preexisting or induced by pregnancy)

• Early Pregnancy: insulin release is greater in response to glucose -> Hypoglycemia
• Fat stores increase for later use by growing fetus

• Later in Preg: insulin resistance occurs in mother so more glucose is available for baby
• Hyperglycemia in mother may occur in response to insulin resistance, normally pancreas will compensate by producing more insulin, otherwise hyperglycemia worsens

Type 2 DM later on

Mother's blood brings extra glucose to fetus

Fetus Makes more insulin to handle extra glucose

Extra Glucose gets stored as fat and fetus is larger than normal

• Miscarriage
• Preeclampsia
• Fetal Abnormalities (neural tube and cardiac)
• Ketoacidosis
• UTIs
• Polyhydramnios
• Macrosomia (hyperglycemia results in increased fetal insulin production which increases growth)
• Conversely, problems with vascular impairment result in decreased placental perfusion (Decreased O2 and glucose)

• Hypoglycemia (bc of accelerated insulin production)
• Hypocalcemia
• Hyperbiliruinemia (from hypoxia, excess erythrocytes)
• Respiratory Distress Synd (accelerated insulin retards cortisol production and slows lung maturity)

• Goal= keep safe glucose levels in mother
• Adherence to insulin therapy (frequent testing and dietary control)
• Increased insulin usually required during 2 and 3 Trimester
• Assess for organ damage (cardiac, eye- retinopathy, renal function)

• Overweight
• HTN
• Over age 25
• Family Hx
• Fasting Glu >140 or random >200
• Hx of: LGA babies, Congenital anomalies, unexplained fetal death, gestational dm

Glucose Challenge Test (GCT)-- weeks 24-28

Blood drawn one our after ingestion of 50g oral glucose (if above 140, do 3 hour OGTT)

Less chance of abnormalities than preexisting DM

Less Chance of Miscarriage

Increased morbidity and mortality later in pregnancy due to macrosomia and hypoglycemia

calories restricted for obese women (eliminate simple sugars)

• Exercise: safe, graduated program
• Monitor: Fasting <90 and 1hr Post Prandial 130-140
• Insulin may be ordered based on results
• Increased fetal surveillance (ultrasound, BPP, kick counts)
• HbA1c- discuss implications

• Assessment of her knowledge, understanding, and attitude
• Provide more information
• Education re: diet, BG timing, danger signs
• Instruction re: insulin administration (subcutaneous sites, angle of needle, aspiration, quick or slow, infusion pumps)

• Fatigue
• Flushed, Hot
• Dry mouth
• Thirsty
• Frequent urination
• Rapid, deep respirations
• Drowsy/HA
• Depressed Reflexes

• Shaking
• Sweaty
• Cold, Clammy
• Disoriented, Irritable
• Hungry
• Blurred Vision

Incidence of Adolescent pregnancy is declining

Rate= 39.1 births per 1000 girls (15-19)

US still remains the highest in all industrialized nations

Decreased

• "I'm in love"
• High Rate of sexual activity
• Low use of contraceptives
• Gaining or maintaining a love relationship
• Limited understanding of vulnerability
• Societal Controversy regarding sex education

Interruption in achieving normal tasks of adolescence 

Decision making about the pregnancy

Interruption of Education

Potential for lifelong dependence on Welfare

• Higher Maternal Mortality
• Increased Risk of Preeclampsia
• Anemia and Nutritional Deficiencies-- lack of knowledge or being afraid to gain weight
• High rate of STDs-- lead to preterm labor
• Absent or late prenatal care-- they could be in denial or trying to hide their pregnancy

• Higher newborn mortality rate
• Higher rate of prematurity
• Higher rate of low birth

(notice s/s of complications too late....education is priority)

• Risk for negative parent-infant interactions
• Poor understanding of growth and development
• Relationship with father of baby- may or may not be in the picture...need for support from family and friends...psychosocial issues

• Complete Physical Exam
• Knowledge of infant needs and care
• Cognitive development (egocentrism, present-future orientation, abstract thinking)
• Dx: Risk for Altered Health Mantenance
• Assessment of family and support system (who will be there when baby comes, who takes them to their appointments, if she has a car, etc)

*be able to evaluate maturity; many teens don't think bad things will happen to THEM so they have risky behaviors

• Encourage ongoing prenatal care
• Health education and counseling 
• Infant care teaching
• Long-term plans
• Returning to school
• Provide appropriate referrals

• Preexisting health problems (hypertension, IDDM, Uterine Fibroids)
• Complications of pregnancy
• Genetic-increased risk of chromosomal abnormality at age 40
• Preeclampsia, preterm labor, multiple gestation, gestational diabetes

• Psychosocially Mature
• Usually wanted and planned pregnancy
• Financially Secure
• Less Energy
• May lack peer support from other parents

Increased risk of chromosomal abnormalities (age 40 >) -- 1 in 100 risk for trisomy 21

• Preeclampsia
• Preterm labor
• Multiple gesdtation (naturally and with fertility treatments)
• Gestational diabetes
• Dysfunctional labor (c-sections increase)

1 in 10

(fetus receives any substance taken in by mother...drinking, snorting, injection...fetus cannot metabolize drugs which gives lasting effects to fetus)

Tobacco- (nicotine, carbon monoxide, cyanide)

Prematurity, low-birth weight, developmental delays

Spontaneous Abortion, Preterm Labor, Anemias

Fetal Alcohol Syndrome

Alcohol Abuse

Mental Retardation, Prenatal and Postnatal growth restrictions, Facial Anomalies (microcephaly, short palpebral fissures, flat midface, thin upper lip, IUGR-- intrauterine growth restriction, CNS impairment)

-Powerful short acting CNS stimulant

Maternal: Stimulates contractions (leads to abortions, preterm labor, abruptio placenta, still birth)

Fetal Effects: tachycardia, decreased variability, IUGR, fetal overactivity

Neonatal Effects: marked irritability, difficult to console

CNS Depressant-- mental dullness, drowsiness, stupor

• Intermittent Hypoxia
• Prematurity
• Low Birth Weight
• IUGR

Neonatal Abstinence Syndrome: withdrawal, neurological and gastrointestinal issues, happens within 1st 24 hours

• Rehabilitation Treatment
• Methadone Treatment (heroin addiction)
• Outpatient Treatment
• Support Groups

1%

• Septal Defects (acyanotic L-R shunt, cyanotic- R-L shunt)
• ASD-- atrial septal defect
• VSD-- ventricular septal defect
• PDA-- patent ductus arteriosis

Mitral Stenosis (beta blockers, calcium channel blockers)

Mitral Valve prolapse (most common- benign)

ampicillin, gentamycin

(if allergic to penicillin, Vanco and Gentamicin

Peripartum and Postpartum Cardiomyopathy

Age greater than 35 years, Preeclampsia, Multiple gestation, African descent

Cardiac Decompensation (CHF)

Rales, Cough, Dyspnea upon exertion, heart murmurs, syncope

Ongoing cardiac consultation

Monitor Weight Gain

Prevent Anemia and Infection

Antibiotic treatment for Mitral valve prolapse

Careful fluid management, lung assessment

Oxygen therapy, sedation, early epidural cardiac monitor

Very careful assessment 24-48 hours postpartum

Anemia

<11.0 (in 2nd tri)

<33%

fatigue, pallor, lethargy, h/a, pica

• Oral Iron Ferrus Sulfate 1-3 times daily
• (Give with 500 mg of ascorbic acid)

Folic Acid

Neural Tube Defects

Pallor, Lethargy, Fatigue

400; 600

• Dark, green leafy veggies
• Citrus Fruits
• Eggs
• Legumes
• Whole Grains

Vitamin C (take with orange juice)

Sickle Cell Anemia

Fever, Pain in abdomen, Joints, and Extremeties

Pylenoephritis, Bone Infection, Heart Disease

Preeclampsia, IUGR, Prematurity IUFD

• Biweekly physician visits
• Frequent Fetal Surveillance (biophysical profile, US, serum Fe, total iron-binding, surveillance for infection)
• Self Care Measures (good hydration, nutrition, folic acid, good hygiene)

Thalassemia

Beta Thalassemia Heterozygous form (MORE common!)

Beta Thalassemia Homozygous form (hepto-splenomegaly, bone deformities, cardiovascular complications)

TORCH

• T- toxoplasmosis
• O- other (gonorrhea, syphilis, varicella, hep B, HIV, parvovirus)
• R- rubella
• C- cytomegalovirus (CMV)
• H- herpes simplex virus (HSV infection)

by C Section

HBIG (prophylaxis) and Hep B vaccine series

VZIG

30-40%

at initial prenatal exam and at 28 weeks (if high risk)

• Oral ZDV therapy beginning after 14 weeks to 34 weeks gestation
• IV therapy starting 3 hours before delivery
• Delivery at 38 wks gestation
• Breastfeeding is Contraindicated!!! (teach to pump and dump)

ampicillin, gentamicin, cefazolin (ancef)

Genitourinary Infections (UTIs)

• Temp of 102.2
• Flank Pain
• N/V

may need hospitalization and IV therapy

• S/S of UTIs
• Fluids 3000ml / day
• Good Hygiene

• Abortion: loss of pregnancy before 20 weeks or weighing less than 500gms
•    Spontaneous Abortion
•    Threatened Abortion
•    Missed Abortion
• Disseminated Intravascular Coagulation

Fetal or chromosomal abnormalities, congenital anomalies

Maternal infections, anatomic disorders of cervix and uterus, ectopic pregnancy

10-15%

Threatened Abortion

Inevitable Abortion

Incomplete Abortion

Missed Abortion (mom's body should have had spontaneous abortion, but didn't)

Ultra Sound, Beta hCG levels, Progesterone levels, Pelvic rest, Count perineal pads/color, quantity of blood and tissue, Odor

D&C (dilation and vacuum curettage)

D&C

D&C, Ultra Sound, hCG levels, Monitor for infection

• Advise to rest, watch for additional bleeding and infection, pelvic rest
• Ultra Sound, HCG levels, Monitor for infection, DIC
• NO SEX, NO TAMPONS (tell pt to come back in a week to do lab values in office)

chromosomal abnormalities, structural or hormonal, or immunological

Incompetant cervix

Cerclage (suture placed around cervix, 11-15 weeks and removed at 37 weeks)

Bedrest, Pelvic Rest, Teach for S/S of labor, Bleeding, Tocolytic (Terbutaline) -> stops contractions

Disseminated Intravascular Coagulation

Endothelial Damage (Severe Preeclampsia, HELLP)

• DECREASED fibrinogen and platelets
• LONGER prothrombin time and activated partial thromboplastin time (PT and aPTT)
• INCREASED fibrin degradation products

Correct the cause

Blood Replacement Products: Whole blood, packed red cells, cryoprecipitate

Assess bleeding from any body orifices, IV sites, nosebleeds, unexplained bruising

Ectopic Pregnancy

History of Pelvic Infection

IUD

Previous surgery (failed tubal ligation)

• Missed Menstrual Period
• Abdominal pain
• Vaginal spotting
• Positive Pregnancy Test

Transvaginal ultrasound, HCG level (present but lower than normal)

• Ampular
• Fimbrial
• Isthmic
• Interstitial

Medical Management (methotrexate, linear salpingostomy, salipingectromy if tube is damaged) Rhogam if RH negative!!!

Nursing Care: Prevention/early recognition of hypovolemic shock, pain control, psychological support

Monitor for S/S of tubal rupture (pelvic, should, neck pain); dizziness/faintness; increased bleeding;

Methotrexate, Linear Salpingostomy, Salpingectomy if tube is damaged

Hydatiform Mole (trophoblastic disease)

Hydatiform mole

Trophoblastic cells reproduce rapidle- placenta develops, but not fetal

Abnormally large uterine size for gestational age, large sac with vessicles- no fetal activity

• Higher HCG levels
• Excessive N/V
• Dark Brown Bleeding
• Early preeclampsia prior to 24 weeks

• Evacuation of Uterus (D&C)
• Continuous monitoring of woman for 1 year for metastatic disease (increased risk of choriocarcinoma)
• Beta-hCG levels every 2 weeks until not present
• Pregnancy must be avoided for 1 year (oral contraceptives suggested BP method)

1 year; oral contraceptives

Hyperemesis Gravidarum

Multifactorial, high HCG levels, estrogen, hyperthyroidism, possibly genetic, psychological disorders

5%

• Increased Ketones
• Hypokalemia
• Vitamin K deficiency

Careful monitoring of fluid (I&O) and electrolytes, hematocrit, hemoglobin, sodium, chloride, potassium, and creatinine

IV therapy, Hyperalimentation if necessary

Slow return to solid foods; small frequent feedings of low-fat, easily digestible foods

Home care: vitamin supplements, Vit B6 pyridoxine, ginger

Provide Emotional support

Drug Therapy (Phenergan, Ranitidine, Ondansetron, Methlyprednisone)

• Promethazine (Phenergan)
• Ranitidine (Zantac)
• Ondansetron (Zofran)
• Methylprednisolone (severe cases only bc category C drug)

• Mother is Rh-NEG 
• Fetus is Rh-POS

• 28 weeks;  72 hours
• *give them a card saying they've had the shot!

15%

Accidents, Assault, Suicide

MVAs (motor vehicle accidents)

Focus on the mother, THEN the fetus

Place wedge under one side of mother (tips the uterus)

• VS, urine output, fetal HR, CTX pattern
• S/S of abruptio placenta
• Kleihauer-Betke (KB test)-shows mixing of blood