Iron Deficiency Anemia

Unit 2 Exam Details

• The exam has 50 questions and is worth 65 points.
• There are 4 math multiple-choice questions.
• There are also 4 NGN (Next Generation NCLEX) questions, with partial credit given.
• A blueprint of the exam content is available on Canvas.

Iron Deficiency Anemia

• Iron is essential for increased maternal red blood cell production and iron transfer to the fetus.
• Early pregnancy increases the risk of preterm birth.
• Late pregnancy may result in the patient not tolerating blood loss as well.
• Risk factors include pregnancies less than 2 years apart, heavy menses, low iron diet, and unhealthy weight loss.
• Findings include fatigue, weakness, unusual food cravings, and pica.
• The first trimester hemoglobin level will be <11 g/dL and hematocrit will be <33%.
• The second trimester hemoglobin level will be <10.5 g/dL and hematocrit will be <32%.
• The third trimester hemoglobin level will be <11 g/dL and hematocrit will be <33%.
• Ensure adequate iron stores supplementing with ferrous sulfate between 60-120 mg.
• Encourage co-administration with vitamin C to increase absorption; increase roughage and fluid in order to prevent constipation
• Increase dietary iron with red meat, seafood, poultry, beans, peas, dark leafy greens, and iron-fortified foods.

Postpartum Hemorrhage (PPH)

• PPH is classified as early or late.
• Early, acute, or primary PPH occurs within 24 hours of birth.
• Late or secondary PPH occurs more than 24 hours but less than 6 weeks after birth.
• The causes of PPH are the 4 T’s: Tone, Trauma, Tissue, and Thrombin.
• Tone refers to uterine atony, inversion, or subinvolution of the uterus, with uterine massage as a corrective action.
• Tissue refers to placental complications, with assistance from the provider with placental removal as the corrective action.
• Trauma refers to lacerations of the genital tract and hematoma, the corrective action is to assist provider with repair as needed.
• Thrombin refers to coagulation issues, the corrective action is to assess coagulation status as ordered.

Uterine Atony

• Marked hypotonia of the uterus and is the leading cause of PPH.
• Inadequate uterine contractions with a boggy uterus can result in rapid blood loss.
• Uterine Atony is associated with high parity, hydramnios, macrosomic fetus, obesity, multifetal gestation, and prolonged oxytocin use.
• Nursing interventions include massaging the uterus, emptying the bladder, managing IV fluids, and administering medications.

Inversion of the Uterus

• The uterus is turning inside out.
• The inversion of the uterus is potentially life-threatening but rare
• The cause will be excessive cord traction or fundal pressure.
• Symptoms will be sudden: hemorrhage, shock, pain, and a nonpalpable uterus.
• This is an OB emergency requiring manual replacement of the uterus by a provider, fluid resuscitation, tocolytics, anesthetics, and stopping oxytocin (Pitocin) if running.
• After replacement, administer oxytocin, antibiotics (increased risk of infection/endometritis), and careful fundal assessment.
  • Surgical treatment/removal (hysterectomy) if unable to replace.

Postpartum Hemorrhage: Interprofessional Care Management

• Standardized management protocols and practice with regular emergency drills are important.
• Early recognition and treatment of PPH are critical.
• Initial treatment includes continuous firm massage of the uterine fundus.
• Also elimination of bladder distention and continuous IV infusion with 10 to 40 units of oxytocin added.
• Notify the provider and determine the cause of bleeding (4 T’s: Tone, Tissue, Trauma, Thrombin).
• Key nursing interventions include massaging the uterus while continually establishing/managing IV fluids/blood, administering meds/oxygen, and emptying the bladder.
• If continued hemorrhage after initial treatment, administer additional Uterotonic medications as ordered:
• Oxytocin (Pitocin) IM/IV
• Methylergonovine (Methergine): Administered IM/PO. Take BP before administering and hold if BP >160/90 or preeclamptic
• Carboprost tromethamine (Hemabate) IM: Notify provider and use with caution if the patient reports a history of asthma.
• Prostaglandin E2 (Dinoprostone), Misoprostol (Cytotec)
• TXA (Tranexamic acid) Fibrinolytic, which blocks the breakdown of blood clots.
• Medical Management includes Oxygen, Balloon Tamponade (Bakri), Packing, Labs (H/H, platelets), and Fluid/Blood replacement therapy.
• Surgical Management covers Curettage, Ligation & Embolization, Hysterectomy

VTE Disorders

• Venous stasis and hypercoagulation are major causes.
• Cesarean birth nearly doubles the risk.
• Clinical manifestations: pain and tenderness in the lower extremity, redness, warmth, and edema.
• Assessment involves comparing extremities by measuring leg circumference.
• Interprofessional care management includes ongoing assessments and patient education.
• You can prevent VTE through early ambulation, TEDs, SCDs, and anticoagulants (Lovenox).

Postpartum Infections

• Postpartum infections are present with a fever of 38° C (100.4° F) or more on 2 successive days of the first 10 postpartum days (not including the first 24 hours after birth).
• Risk factors will include comorbidities, immunosuppressive conditions, C-section or operative vaginal delivery (forceps/vacuum), prolonged rupture of membranes, prolonged labor, internal monitoring, and manual replacement of uterus (endometritis).

Endometritis

• Endometritis is an infection of the lining of the uterus.
• It usually begins at the placental site but can spread to the entire endometrium.
• Endometritis is the most common postpartum infection.
• Signs/symptoms include fever, chills, increased pulse, fatigue, nausea, pelvic pain, uterine tenderness, and profuse, foul-smelling lochia.
• The management for endometritis is IV broad-spectrum antibiotic therapy.

Urinary Tract Infections (UTI)

• UTIs occur in 2% to 4% of postpartum women
• Risk factors include urinary catheterization, frequent pelvic exams, epidural anesthesia, and genital tract injury.
• May be difficult to determine an infection in the early postpartum period because many women experience frequency and dysuria.
• Prevent UTIs utilizing a strict sterile technique with urinary catheterizations/pelvic exams/delivery, limit number of vaginal exams
• Treatment consists of culture, then antibiotics.

Mastitis

• Mastitis occurs after milk "comes in".
• Usually unilateral, nipple fissure infection which progresses to the duct, with possible progression to breast abscess if not treated.
• Signs/symptoms may include fever, chills, local breast tenderness, swelling, and axillary adenopathy (flu-like).
• Promote lactation with proper breastfeeding to prevent, while potentially continuing to nurse on that side (both sides).
• Empty both breasts completely every 2-4 hours, education key for "flulike" symptoms.
• Treatment is antibiotics.

Wound Infections

• Wound infections often develop after mothers are discharged home
• Rates of wound infection after cesarean birth are 3% to 5%.
• Tears, episiotomy, and C-section incisions should be treated as any other surgical incision.
• Symptoms of infection can include redness, warmth, febrile state, odor, purulent drainage, and swelling.
• To manage the infection-do a culture then antibiotics, debriding prn, wound vac if needed.
• Nursing care consists of frequent VS including Temp, IV therapy, wound assessment/care, analgesics, sitz bath, warm compresses, perineal care.

Baby "Blues"

• Common, experienced by 50-80%, with emotional lability and crying for no apparent reason.
• Depression, restlessness, fatigue, insomnia, anxiety, and sadness.
• Peaks around day 5 and subsides by day 10, cause is unknown/hormones.
• Supportive treatment includes rest, sleep, family support, support groups, healthy lifestyle behaviors, and avoiding alcohol/street drugs.

Postpartum Depression (PPD)

• Experienced by 10-15%
• Intense and pervasive sadness, severe and labile mood swings, more serious and persistent than baby blues.
• May have intense fears, anger, anxiety, and despondency, similar to major depression but may be compounded by worries about being an incompetent parent.
• Symptoms rarely disappear without help.
• Treatment will consist of antidepressants, antianxiety agents, mood stabilizers, antipsychotics.

Postpartum Psychosis

• Rare, experienced by 0.1 – 0.2%, having auditory and/or visual hallucinations.
• Present with paranoid or grandiose delusions, delirium and disorientation.
• Patient will have deficits in judgment and impulsivity, requiring treatment being hospitalization and utilizing Antipsychotics plus mood stabilizers.

Pregestational Diabetes Mellitus

• About 1% of pregnancies have preexisting DM
• Preconception Counseling includes maternal & fetal/neonatal risks
• Maternal risks/complications include macrosomia (large infant), with increased risks of birth complications.
• Additional risks are: Hydramnios (polyhydramnios), Infections, Diabetic Ketoacidosis (DKA), and Hypoglycemia/hyperglycemia
• Fetal/Neonatal Risks & Complications include a Perinatal mortality rate is three times higher for women with diabetes than those without.
• IUFD (stillbirth), Congenital malformations, Hypoglycemia at birth
• Preconception Counseling includes maternal & fetal/neonatal risks

GDM Screening

• Early Screening should be completed, before 24-28 weeks, for women with strong risk factors.
• Routine screening is completed during 24 to 28 weeks of gestation.
• A Two-step Screening Method: which is recommended by ACOG is the 1-hour, 50-g oral glucose.
  • A glucose value of 130 to 140 mg/dl, or higher, is considered a positive screen – but is NOT DIAGNOSTIC
• A 3-hour, 100-g oral glucose (OGTT) can diagnose GDM if two or more values are met or exceeded.

Hyperemesis Gravidarum

• Assessment includes severity, frequency, and duration of episodes, with determination of ketonuria and psychosocial assessment to determine the role of anxiety.
• Interventions include intravenous (IV) therapy for the correction of fluid and electrolyte imbalances.
• Additional interventions are medications – antiemetics as needed with enteral or parenteral nutrition as a last resort with follow-up care.

Gestational Hypertension (GH)

• Gestational Hypertension is the onset of hypertension without proteinuria or other systemic findings diagnostic for preeclampsia after week 20 of pregnancy.
• Characterized by a systolic BP greater than 140, and a diastolic BP greater than 90, on two separate occasions > 4 hours apart.
• Resolves after giving birth in about 12 weeks.
• Antihypertensive medications are indicated when the systolic BP is > 160 mm Hg or the diastolic BP is > 110 mm Hg, such as Labetalol, Nifedipine, and Hydralazine

Gestational Hypertension and Preeclampsia: Management

• The goal is to ensure maternal safety and formulate a plan for delivery.
• Treatment: Delivery of fetus and placenta, staying pregnant may not be an option, dependent on gestational age.
• Expectant Management is needed for women at less than 37 weeks gestation.
• For women less than 37 weeks, hospitalization is needed with care from interprofessional team, antihypertensive meds (Labetalol, Nifedipine, Hydralazine), and corticosteroids.
• Additional Intrapartum care includes Continuous FHR and uterine contraction monitoring and bed rest with side rails up with Seizure precautions.
• Initiate a Darkened environment and assess for signs of placental abruption.
  • Placenta detaches from the uterine wall.
• An anticonvulsant is needed as ordered(Mag Sulfate)

Magnesium Sulfate: High Alert Medication

• Anticonvulsant of choice for preventing/controlling eclamptic seizures.
• The initial loading dose is 4-6 grams/20 min, then continuous at 2 grams/h maintenance dose.
• Minimizes effect on maternal BP, with the unclear ability of preventing and treating eclamptic seizures.
• The magnesium sulfate Decreases CNS irritability and is administered intravenously as a secondary infusion (piggyback) administered by a volumetric infusion pump.
• Neuromuscular toxicity of magnesium sulfate manifests as diminished deep tendon reflexes, hypothermia, and progressive muscle weakness including respiratory muscle weakness.
• Monitor for Toxicity by careful monitoring of blood pressure, LOC (decreased), reflexes (absent), respirations (<12/min), renal (urine output < 30 ml/hr) function (foley catheter), pulse, cardiac dysrhythmias, headache, visual disturbances, epigastric pain, contractions, FHR, and fetal activity.
• The antidote is Calcium gluconate, available at the bedside (IV push slowly over 10 min).
• Client education will involve telling them of the Initial feelings of flushing, heat, sedation, diaphoresis, and burning at the IV site with bolus.

HELLP Syndrome – Preeclampsia Variant

• HELLP Syndrome is a Laboratory diagnosis (not clinically) for a variant of preeclampsia that involves hepatic dysfunction, characterized by:
• Hemolysis (H) - anemia and jaundice
• Elevated liver enzymes (EL) - ALT/AST, epigastric pain, N/V
• Low platelets (LP) - <100,000, abnormal bleeding/clotting time, possible DIC
• Can develop in women who do not have hypertension or proteinuria
• Is often misdiagnosed with a perinatal mortality rate ranging from 7.4% to 34%, with a maternal mortality rate of approximately 1%.

Placental Complications Related to PPH

• Retained Placenta: Fragments of placenta remain with excessive bleeding and boggy uterus which requires manual removal by provider or D&C.
• Unusual placental adherence such as placenta accreta, with slight penetration of myometrium.
• Placenta Increta occurs with deep penetration of myometrium.
• Placenta Percreta occurs with perforation of myometrium and uterine serosa, possibly involving adjacent organs which requires a Hysterectomy.

Premature Rupture of Membranes (PROM) & Premature Preterm Rupture of Membranes (PPROM)

• PROM is a spontaneous rupture of amniotic sac and leakage of fluid prior to the onset of true labor.
• PPROM, membranes rupture between 20 - 37 weeks of gestation with complications occurring in approximately 3% of all pregnancies in the United States which is often preceded by infection and Chorioamnionitis.

PROM & PPROM Findings & Lab Tests

• Gush or leakage of clear fluid from the vagina
• Presence of clear fluid
• Assess for prolapsed umbilical cord because of the Abrupt FHR which will vary or prolonged decel from a visible or palpable cord.
• The Nitrazine paper test will be positive with blue staining, pH 6.6-7.5
• A positive ferning test will indicate PROM or PPROM.

Suppression of Uterine Activity with Tocolytic Meds

• Administer to stop contractions to prolong pregnancy for Fetal Lung Maturity or Transfer with Nifedipine (Procardia) (CCB).
  • Relaxes smooth muscle by blocking calcium channels, may present with headache, flushing, dizziness, and nausea.
  • Do NOT give CCB with magnesium sulfate and hydration is important and the patient must change positions slowly.
• Terbutaline (Brethine) (beta-adrenergic agonist) that decreases levels of intracellular calcium which is contraindicated if cardiac disease, diabetes, preeclampsia/eclampsia, or hemorrhage.
• Indomethacin (Indocin) (NSAID) - Inhibits prostaglandins but only used if <32 weeks because it can cause premature closure of ductus arteriosus with treatment NOT to exceed 48 hours.
• Magnesium sulfate (CNS depressant)
  • Relaxes smooth muscle by blocking calcium channels and Mag sulfate has a neuroprotective effect on preterm brain.
• The signs of toxicity include respiratory depression, cardiac arrest, neuro (decreased DTR, altered mental status, muscle weakness) for which the antidote is calcium gluconate which requires following neuro checks per hospital protocol.
• Must be contraindicated if bleeding, >34 weeks, ≥6 cm CE, or fetal distress with SE nausea, flushing, or headaches.

Promotion of Fetal Lung Maturity

• Betamethasone (Celestone/Antenatal Glucocorticoids): 2 doses 24-hour apart deep IM ventral gluteal or vastus lateralis, and is administered between 24 hours and 7 days of birth ideally.
• It is important to monitor for maternal hyperglycemia and teach the patient to report to report s/s pulmonary edema.
• Significantly reduces the incidence of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and death in neonates.

DIC Findings

• Unusual spontaneous bleeding from the gums and nose (epistaxis) plus oozing, trickling, or flow of blood from incisions, lacerations, or episiotomy.
• Will see Petechiae and ecchymoses (bruising) plus excessive bleeding from venipuncture, injection sites, or slight traumas.
• You will also see Hematuria, gastrointestinal bleeding, with Tachycardia, hypotension, and diaphoresis

Types of Miscarriage (Spontaneous Abortion)

• Threatened: spotting, possible cramping, positive fetal heart tones, cervical os is closed.
• Inevitable: moderate to heavy bleeding, cramping, positive fetal heart tones, cervical os is open.
• Incomplete: the fetus has been delivered (cervical os is open) but the placenta remains.
• Complete: all products have been expelled from the uterus.
• Missed: Fetus does not have a heartbeat; mother does not have bleeding or cramping, cervical os is closed.

Miscarriage (Spontaneous Abortion) Lab Tests

• Rh Factor: If Rh negative, treat with RhoGAM (IM)/Rhophylac (IV) (Rho(D) Immune Globulin).
• H&H if considerable blood loss will also check Clotting factors for disseminated intravascular coagulopathy (DIC): a complication with retained products of conception.
• Lab WBC - Serum human chorionic gonadotropin (hCG) levels test to determine if the mother is pregnant

Miscarriage (Spontaneous Abortion) Diagnosis & Treatment

• Ultrasound to confirm diagnosis of a Viable fetus or fetal demise.
• A Cervical examination and Dilation & Curettage (D&C) will be completed for Inevitable & incomplete abortions.
• Followed by Dilation & Evacuation (D&E) to Evacuate uterine contents after 16 weeks gestation or Prostaglandins & Oxytocin to Augment or induce uterine contractions to Expulse products of conception.

Miscarriage (Spontaneous Abortion) Nursing Care

• Provide support, perform pregnancy tests, and observe color and amount of bleeding (pad count), and maintain bed rest with no vaginal exams.
• Administer an Ultrasound while determining how much tissue passed for proper saving of products.
• Utilized the term Miscarriage as the medical term Abortion which commonly is misunderstood.
• Provide needed education, assist during the D&C or D&E and during prostaglandin administration as indicated.
• Administer medications and blood products as prescribed as well as refer the patient to pregnancy loss support groups for mental and emotional support.

Miscarriage (Spontaneous Abortion) Medications

• Provide Analgesics and sedatives, give Prostaglandin (vaginal suppository) or Cytotec to induce labor (used off-label).
  • Followup with cervical ripening agents and Oxytocin (Pitocin) in addition to starting the patient on Broad-spectrum antibiotics if septic abortion is indicated.
• Rho(D) immune globulin (Rhogam) if Rh-negative.

Ectopic Pregnancy (AKA Tubal Pregnancy)

• The Ectopic "Out of Place" Pregnancy has a fertilized ovum implanted outside the uterine cavity, usually in the fallopian tube.
• Ectopic pregnancies can result in tubal rupture, cause internal bleeding, and result in fatal hemorrhage.
• Will not result in the birth of a live baby.

Ectopic Pregnancy Findings

• Unilateral stabbing pain is reported, with Tenderness in the lower abdominal quadrant.
• Menses is delayed by 1-2 weeks and is reported to be lighter than usual, or irregular with scant, dark/bright red, or brown vaginal spotting 6-8 weeks after the last normal menses.
• Vaginal red, vaginal bleeding if a rupture has occurred will be noted with the patient reporting Referred shoulder pain if tubal rupture has occurred because blood in the peritoneal cavity irritating the diaphragm or a phrenic nerve.
• Symptoms include hemorrhage & shock if a large amount of blood loss has occurred, hypotension, tachycardia, pallor, and dizziness.

Ectopic Pregnancy Interprofessional Care Management

• Early Rapid Treatment is vital because No treatment can be fatal which includes Medical management if rupture has not occurred & tube preservation desired or Methotrexate administration which inhibits cell division & embryo enlargement, and dissolves the pregnancy.
• The patient must avoid vitamins containing folic acid to prevent a toxic and Uses protection against sun exposure which causes photosensitivity.
• Also Surgical management with the Type of surgery dependent on the location and cause of the ectopic pregnancy, the extent of tissue involvement, and the woman's desires regarding future fertility (Salpingostomy VS. Laparoscopic Salpingectomy).

Molar Pregnancy Interprofessional Care Management

• Most moles abort spontaneously, utilize Suction curettage to aspirate & evacuate the mole safely with the addition of Rhogam to Rh-negative clients.
• Follow-up care involvesBaseline pelvic exams as well as Abdominal ultrasounds while monitoring hCG levels throughout a Weekly period in 3 week intervals, then monthly for 6 months to 1 year to detect gestational trophoblastic neoplasia (choriocarcinoma).

Molar Pregnancy Client Education

• Refer the client to pregnancy loss support groups and Use reliable contraception for at least one year.
• Pregnancy can make it difficult to assess choriocarcinoma via the monitoring of hCG levels, additionally, avoid IUD due to increased risk of infection and follow-up is important because of the risk of choriocarcinoma, so monitor hCG levels.

Placenta Previa Clinical Manifestations

• Common symptoms are Painless bright red vaginal bleeding during the 2nd or 3rd trimester.
• Now, most cases are diagnosed by ultrasound before significant vaginal bleeding occurs during the Abdominal examination where the uterus is Soft, relaxed, and non-tender with normal tone.
• Fundal height greater than expected for gestational age with the fetus having a breech, oblique, or transverse position with a Reassuring FHR and a Maternal VS WNL.

Placenta Previa Diagnosis

• Initial transabdominal ultrasound examination
• Transvaginal ultrasound is better than a transabdominal scan for accurately determining placental location
• Fetal monitoring to determine fetal well-being.

Placenta Previa Interprofessional Care Management

• Avoid vaginal examinations with continual Monitoring via Ultrasound.
• Placenta may move away from the cervical os as pregnancy progresses.
• Planned C-Sectionif placental edge within 2 cm of the cervical os at 36 weeks gestation with a complete/total previa.
• 36-38 gestation week timing if the C-Section is uncomplicated but is contingent on the absence of fetal growth restriction, superimposed preeclampsia, or other problems take precedent for the delivery's decision-making

Placental Abruption Risk Factors

• Maternal hypertension is a primary risk factor from Preeclampsia/Eclampsia plus Chronic or gestational hypertension.
• Other risk factors include Cocaine use, Blunt external abdominal trauma such as in battering or a MVA in addition to Cigarette smoking and having a History of abruption in a previous pregnancy.
• Preterm premature rupture of membranes, and Multifetal pregnancy are added risk factors as well.

Placental Abruption Clinical Manifestations

• Vaginal bleeding with Dark red blood and Abdominal pain which is has a Sudden onset with Localized uterine pain.
• Patient will demonstrate Uterine tenderness (Local or diffuse) and Contractions which will result in a with Board-like abdomen plus Fetal distress and S/S hypovolemic shock.

Placental Abruption Nursing Care

• Palpate the uterus for tenderness & tone, Perform serial monitoring of fundal height and Assess the FHR pattern.
• Immediate birth is the management when severe including Administering IV fluids, blood products, and medications as prescribed plus administering O2 at 8-10 L/min via face mask.
• Continue to Monitor maternal VS (observing for declining hemodynamic status) as well as Perform continuous fetal monitoring and Assess urinary output & monitor fluid balance.
• Provide education & emotional support for client & family.