Maternal mortality can be caused by from ectopic pregnancy or obstetric events such as
Hemorrage, pulmonary embolism and PIH
What is the major cause of perinatal mortality? (5 months before and 1 month after)
Prematurity
Risk factors for pregnancy complications?
Age ( younger than 17), socioeconomic status (urban, poor, lack of education), primiparity (first), multiple preg.
What is best prevention of pregnancy complications?
Prenatal care
Name two pregestational disorders?
Cardiovascular and diabetes
Name 4 pregestational cardiovascular diseases?
Rheumatic heart dz, congenital heart dz, mitral valve prolapse, and peripartum cardiomyopathy (dz of the heart muscle between tge last month of pregnancy and 5 months post partum)
Why is rheumatic heart dz decreased in preg women?
Better tx of strep inf
Why are we concerned with mitral valve prolapse in preg women?
Prevention of any infection that could travel to the heart and weaken valves, usually caused by stress. Give prophylactic IV antibiotic during labor.
Why is peripartum cardiomyopathy a concern?
Can be very severe, may go unnoticed until after delivery.
Pregnancy increases ------ on the heart causing symptoms and risks
Stress
T/F signs of cardiac decompression can be similar to normal responses to pregnancy
True (fatigue, dyspnea, palpitations, tachy, heart murmurs, edema and cough) decompensation is the functional deterioration of a previously working structure or system
What causes murmurs and palpitations?
Blood volume increase
Main sign of cardiac decompensation is due to -------b/c this the only sign that is not a common change in pregnancy
Class 1 and 2 heart dz in pregnancy is the milder form of heart dz, are these women able to have a normal pregnancy?
Yes- but need to be watched very closely, coordinate care OB with CV doctor
Can a woman with class 3 or 4 heart dz become pregnant?
Yes- but sadly it is in their best interest not to try to have a baby
What is primary goal of a pregnant woman with heart dz?
Adequate rest- other goals- prevention of respiratory infection ( adds stress to lungs), monitoring for signs of cardiac decompensation and attempt a trial of labor avoiding valsalva ( closed glottis) puts pressure on thoracic cavity
Why is diabetes worse with pregnancy?
Stress alters CHO metabolism (pregnancy is a diabetogenic state)
Gestational diabetes (type 3) stops once pregnancy ends but are at higher risk for mature onset diabetes-why
Because they have subclinical diabetes when not preggo, they are often overweight, so need to encourage to eat well and exercise
What are the influences of preg on diabetes (women who already have diabetes)?
Changes in CHO metabolism and control of blood glucose as well as vascular disease may increase b/c blood gets sticky, picks up debris and at capillaries oxygenation decreases leading to ulcers, poor healing, infection, and amputation
What are some maternal complications of diabetes in pregnancy?
Kidney problems, retinopathy, early pregnancy, increased insulin production= hypoglycemia, later in preg is lack of onsulin production= hyperglycemia
How much does insulin demand increase in later preg?
3-5x over non preg level
When is gestational dm picked up during preg?
After 26th week due to increased hyperglycemic effect, high rate of c-section
What are some fetal complications of maternal DM?
By 36 weeks- aged placenta, later in preg placenta releases an insulin destroying enzyme to make more glucose avail to fetus so mother uses protein
Which type 1,2, or 3 DM have the most have the most difficulty controlling blood glucose levels during preg?
Type 1
Which type 1,2, and or 3 DM in preg women are more likely able to control their DM with diet?
Type 2 and 3 (these women may go on insulin if needed) type 2 may use oral hypoglycemics agents, the newer ones dont have same tetrogenic effects
What other specialists may a preg woman with diabetes see?
Endocrinologist, opthalmologist
Poor control of insulin can lead to oversized or undersized babies?
Undersized! R/t placenta getting old too quickly and baby not getting adequate nutrition, generally fetal obesity due to growth acceleration ( macrosomia) if insulin is under control
Why is it important to assess newborn of a diabetic mother for hypoglycemia shortly after birth
Blood sugar can plummet after birth b/c glucose source is cut off and they are used to producing lots of insulin which is still in their system
Why does a fetus of a diabetic mother have hydramnios (excess amniotic fluid)
Fetus urinating higher glucose, hyperosmotic, pulls in more water
Nurses role of taking care of a diabetic mother
Assessment of dz process, education (anticipatory guidance), physiological support, and assessment of fetal well being, placental function, fetal maturity
Gestational disorders are health alterations associated with pregnancy and usually disappear when?
After delivery
T/F- premature rupture of membranes is an onset of preterm labor
Can be true- but- premature ROM occurs before onset of labor even if baby is full term
What is primary concern for premature ROM?
Infection (chorioamnionitis inflammatory condition of pregnancy affecting the uterus)
What diagnostic measures are used to determine if there has been Premature ROM?
Sample fluid - nitrazine paper (measures pH) amniotic fluid will be alkaline and urine acidic and ferning test
What is amniotic fluid?
Fetal urine and maternal plasma, so if premature ROM, can be replenished and hope it seals itself off, if no infection, preg can continue
Between which weeks is preterm labor?
20-37
Risk factors for preterm labor?
Previous preterm labor, drug use (especially stimulants), genital tract infections such as, bacterial vaginosis and Group b strep (GBS)
------- is the term for excessive N/V?
Hyperemesis gravidarum- the worst morning sickness, prolonged
Management of HG?
Dry CHO (then wait 1 hr for fluids b/c fluids trigger vomiting), antiemetics (start with smallest therapuetic dose) iv therapy (correct F&E and acid base imbalance) potential TPN (last resort), psychological (difficulty adjusting to pregnancy)
Results of hyperemesis grav
F&E imbalance (can affect fetus), weakness &fatigue, scant dark urine (identification of severe problem)
What is the diff between threatened abortion and imminent abortion?
In an imminent abortion, the cervix had dilated, cant do anything about it, placenta starts to seperate from uterine wall
What is the percentage of spontaneous abortions (miscarriage)?
10-30%, some women dont know they are pregnant before they miscarry
What is main concern of incomplete abortion?
Risk of hemorrage increased because uterus cant contract, may be a risk of infection- if cervix is open a D&C is done to expell everything and if closed then there will be an attempt to save the pregnancy
What are some causes of incompetent cervix
Multiple abortions, D&C (dilation of the cervix and curettage or scraping the uterus) possible previous large baby delivery
What is the procedure done for an incompetent cervix
Cerclage procedure- go around cervix and drawstring it closed, remove after 37 weeks unless signs of labor b4
What is main cause of implantation in a site other than the endometrium (ectopic pregnancy)
Pelvic imflammatory disease (pid) narrowing of tube (sperm gets thru but not the fertilized egg- may be caused from gonorrhea, chlamydia
Manifestations of ectopic preg
Shock from internal bleeding, pain in lower left or right quad, preg test is not a sign, may be negative
Dx of ectopic preg
Sonogram- if high WBC count is prob appendicitis
Management of ectopic preg
Laparascopic- removal of that portion of the tube
What is the sign of hemorrhagic shock?
Thirst- later signs are pale, sweaty, clammy, BP drop and elevated pulse also soaking more than one pad an hour
------- benign proliferation of trophoblastic tissue. Developing embryo implants somewhere, and the tissue surrounding it (trophoblastic tissue) starts growing uncontrollably, cutting off nutrition and necrosis occurs so body calcifies to prevent infection
Gestational trophoblastic disease (molar preg) generally not a viable preg
Manifestations of gestational trophoblastic disease ( molar preg)
Bleeding, scant dark to copious full blown bright red, fundal height bigger, n/v extreme
Tx of gestational trophoblastic dz (molar pregnancy)
D&C or methotrexate an antineoplastic which attacks fast growing tissue
Why should women be counseled one year after molar preg dz to not become preg?
Need to monitor for tissue that may not have been removed and continue to grow for a year, this tissue can be diagnosed via hCG levels. If a woman becomes pregnant hCH levels increase and can not differentiate between tissue and fetus
------- is a potential after gestational trophoblastic dz (molar preg) and can be fatal
Choriocarcinoma - a malignant and aggressive cancer, usually of the placenta. It is characterized by early hematogenous spread to the lungs
------ is a preg induced hypertension (pih) used to be called toxemia, 5% of all preg and diagnosed after 20-24 weeks gestation?
Preeclampsia/eclampsia
There are three signs to pih, preeclampsia has 2 and eclampsia will have 3?
HTN (>140/90), edema (>2 lbs/ week), and proteinuria (albumin in the urine)
Although >140/90 is diagnostic of gestational htn and increase of ----- systole or -------- diastole over baseline is considered?
Increase 30 systole or 15 diastole - especially diastole b/c indicated heart rest is stressed too (so if normal is 120/80, a pregnant 145/96 indicates htn due to diastole more than 15 over- not systole
Why should blood pressure be checked if more than 2 lb per week is gained?
Risk for pre-eclampsia, should gain 1 lb per week in later pregnancy, edema follows and it is a sign if seen when awakening in the morning
Other signs of pih
Clonus (muscular contractions due to sudden stretching of the muscle) HA, (prolonged/severe), blurred vision, and scotoma (spots in front of the eyes)
What is difference between mild and severe PIH?
Mild- BP 140/90- 160/110, proteinuria and edema are both 1+ or 2+, occasional HA
Severe- BP > 160/110, proteinuria and edema both 3+ to 4+ and may have oliguria (kidneys shutting down), pulmonary edema and RUQ pain r/t liver congestion
Increased incidence of PIH r/t?
Primigravidas, teens and over 35, hx of preeclampsia, multiple gestation, GTD ( genetic trophoblastic dz, Rh incompatibilty, and DM
SGA related to IUGR, 10% mortality with pre and 20% with eclampsia
What happens to blood volume in PIH?
Volume does not change with mild but will decrease with severe, normal preg will increase blood volume 30-50%
What happens to peripheral resistance, blood pressure and hematocrit in PIH?
Vessels dialate in normal pregnancy- with preeclampsia you have vasospasm so extra fluid is pushed out and get edema- dont treat with diuretics unless have pulm or cerebral edema, also do not use ace inhibitors
Tx of PIH?
Bed rest left side (off vena cava) decreased blood pressure and promotes diuresis due to fluid due to fluid back to organs, consume extra protein and push fluids due to loss of both
What do you assess with PIH?
BP, daily wt, proteinuria, reflexes, urine output
After the baby is born, the mother with PIH is given what?
Apresoline- during preg can take MgSO4
Why is MgSO4 the drug of choice for a preg woman with eclampsia? (eclampsia is preg related seizure activity that is usually caused by high blood pressure
Lowers blood pressure, makes woman seizure proof
Side effects of MgSO4 - used to treat pre-eclampsia
Flushing, muscle weakness, lack of energy, HA, n/v, fluid in lungs, chest pain slurred speech and blurry vision. Hypotension and hypocalcemia, arrhythmia and asystole
What is the antidote for MgSO4?
Calcium gluconate
What does HELLP syndrome stand for and when is it seen?
People with pre-ecpampsia are at risk, H=hemolysis, EL=elevated liver enzymes, LP=low platelets
Elevated liver enzymes in HELLP syndrome cause?
Intra-arterial lesions, platelet aggregation, fibrin accumulation, microemboli in hepatic vaculature and ischemia
