Pregnancy at Risk I PDF

Pregnancy at Risk I: CHO Metabolism in Normal Pregnancy: First 20 Weeks ANABOLIC (building up) Estrogen and Progesterone stimulate moms insulin production and increase tissue response Building up glycogen stores in liver and other tissues Second 20 Weeks CATABOLIC (breaking down) Human placental lac...

Pregnancy at Risk I: CHO Metabolism in Normal Pregnancy: First 20 Weeks ANABOLIC (building up) Estrogen and Progesterone stimulate moms insulin production and increase tissue response Building up glycogen stores in liver and other tissues Second 20 Weeks CATABOLIC (breaking down) Human placental lactogen (hPL) and prolactin increase peripheral resistance to insulin ○ Ensuring glucose for fetus Mom has to produce more insulin to meet her own need Result: postprandial hyperglycemia and hyperinsulinemia Influences of Pregnancy on Type 1&2 Diabetes: Hyperglycemia is teratogenic Goal: A1C 9 pounds (4090gm) ○ >25 y/o ○ Ethical racial group with high prevalence of diabetes Those who have average risk and those who had normal screen at 1st prenatal visit ○ Screen again 24-28 weeks ○ If screening test abnormal then 3hr GTT for diagnosis Antepartum DM Management: Mom: ○ ○ ○ Baby ○ ○ ○ ○ ○ ○ Glucose monitoring essential Type1: diet and exercise therapy Type2: Meds (oral hypoglycemic and insulin therapy prn) 1st trimester US for congenital anomalies Quadruple screen with alpha-fetoprotein (APP) for neural tube defects Fetal activity monitoring Weekly NST starting at 28 weeks BPP Frequent US to assess growth Intrapartum Management of DM: Timing of Birth - possible IOL at 39 weeks Labor Management ○ Q1 hour glucose checks (goal: 70-110 mg/dL) ○ IV management Goals ○ Euglycemia (70-110 mg/dL) ○ Prevention of NB rebound hypoglycemia Postpartum Management of DM: Babies born with DM can look healthy but they are at greater risk Close assessment of baby to watch for hypoglycemia Moms insulin requirements drop after 3rd stage of labor (delivery) Lactation encouraged Diabetic control and bonding Anemia in Pregnancy: Preconception anemia common due to menstruation Iron deficiency most common pregnancy complication ○ Hgb: 18 hours ○ Previous infant w/GBS ○ Birthing Person does not receive adequate intrapartum antibiotics ○ Chorioamniotis in Labor GBS infection in neonates ○ Up to 75% cases develop in < 24 hr of birth ○ Neonatal mortality: 11% Septicemia Meningitis Pneumonia Chorioamnionitis: Infection of the amniotic fluid, membranes, or placenta Potential for sepsis in both mom and baby Caused by normal flora (e.coli, gbs) or introduction of new bacteria (multiple SVE) Highest Risk: prolonger ROM Diagnosis: ○ Fever >100.4F ○ Tachycardia (mom and baby) ○ Tender uterus ○ Foul odor Treatment: ○ Antibiotics (ampicillin and gentamicin) Influenza & Covid 19 Viruses: Severe illness more likely in pregnancy due to changes in immune system, heart, lungs Patient Education ○ Mask Up ○ Get vaccinated Inactive IMs allowed in any trimester Nasal spray NOT allowed ○ Clinical Therapy Antivirals Acetaminophen for fever Educate on s/s sever illness Pregnancy at Risk II: Perinatal Hepatitis B: Hepatitis B Virus ○ Found in Blood, semen, bodily fluids ○ Perinatal Transmission CAN cross placental BUT majority of exposure during delivery Prenatal Screening: HBsAG (surface antigen) HBsAG+ Mom: ○ Limit Exposure: NO AROM or internal monitors Newborn Prophylactic Tx w/in 12hr of birth ○ Hep B Vaccine and Hep B Immune Globulin ○ Safe to breastfeed Perinatal HIV/AIDS: HIV Virus: ○ Found in blood, semen, vaginal fluid, human milk Staging (CD4 and T-Lymphocyte counts) Success of ART means possibility of pregnancy Perinatal Transmission Declining: W/treatment 1% transmission Clinical Therapy for MOM: ○ ART for all infected pregnant individuals ○ Evaluate and treat for other STI ○ Assess for serologic changes and early signs of complications (infection risk or poor wound healing) ○ Majority exposure during labor Viral load >1000 copies/ml = C-SECTION Viral load 140-159/90mmHg ○ Severe: BP > 160/110 mm Hg ○ High BP at least 2x, at least 4-6 hours apart 1. Chronic Hypertension: a. Onset before pregnancy b. Before 20 weeks gestation c. Or persists beyond 12 weeks PP d. No proteinuria or other symptoms of preeclampsia 2. Gestational Hypertension a. Transient elevation of BP after 20 weeks gestation (normotensive prior) b. Returns to baseline within 12 weeks PP c. No proteinuria or other s/s of preeclampsia Clinical Care of the Hypertensive Patient: Education: nutrition, reduced activity, medication BP self monitoring More frequent prenatal visits Lab Work ○ Routine prenatal blood panel ○ Urine dip for protein every visit ○ Baseline preeclampsia workup (CMP, LFT) Fetal Surveillance ○ Serial US for growth ○ FM counts starting 28 weeks ○ NST, BPPs in 3rd trimester Preeclampsia - Multisystem Inflammatory Disorder Hypertensive disorder that only occurs in PREGNANCY Disease of end organ dysfunction Etiology unclear Diagnosis: ○ Patient was normotensive prior to pregnancy and up to 20 weeks gestation ○ New onset of hypertension ○ Proteinuria and/or evidence of organ dysfunction that targets the CV system, CNS, liver and kidneys Complications: ○ MOM: CNS: Seizures Kidney: Acute tubular necrosis Lungs: Pulmonary Edema Heme: Thrombocytopenia/DIC Liver: Subcapsular hematoma of the liver PPH d/t use of magnesium sulfate for seizure prophylaxis Magnesium makes uterus relax not contract which causes PPH ○ BABY: IUGR causes hypoperfusion and late decels then Placental abruption which can lead to death d/t HTN Premie Over sedated at delivery due to the use of magnesium sulfate Mag sulfate raised the seizure threshold which lowers the chance of mom seizing Pathophysiology ○ Widespread vasospasm causes end organ dysfunction ○ Endothelial Injury Activation of coagulation cascade Increase sensitivity to vasopressors ○ Hypoperfusion of Placenta/fetus Kidneys Liver CNS Low and Moderate Risk Low Risk: prior uncomplicated delivery Moderate Risks: ○ Biology: Nulliparity Age (35 or older) Obesity (30 bmi or over) Family hx of preeclampsia IVF ○ Environmental/Social: Black Lower income HIGH RISK ○ Combination of moderate risk factors ○ Previous preeclamptic pregnancy ○ Preconception DM ○ Chronic HTN ○ Multifetal pregnancy ○ Autoimmune disease -lupus Preeclampsia progresses rapidly! EDUCATE ON S/S ○ Severe headache ○ Rapid weight gain d/t edema ○ Visual changes ○ Epigastric pain ○ N/V Antepartum Management of Preeclampsia: WITHOUT severe features: ○ No signs of renal or hepatic dysfunction ○ Management: Bed rest Self monitoring BP and weight and other s/s Labs: CBC, LFT, CMP, 24 hr urine Fetal surveillance WITH severe features ○ BP > 160/110 mm Hg ○ Cerebral/visual symptoms: retinal blood vessels thicken and narrow reducing blood flow ○ Pulmonary edema: pressure in the blood vessels increase and push/leak fluid into the alveoli of the lungs ○ ○ ○ ○ Epigastric pain: liver hypertrophy or enlargement causes elevated liver enzymes and pain Impaired liver function: from release of different mediators that cause vasoconstriction and hypoxia Thrombocytopenia: result of injured endothelium activating platelets that cause elevated consumption of platelets Progressive renal insufficiency: vasoconstriction which damages and weekends the vessels Treatment: Serial BPs, bed rest, daily weights NST/AFI/BPP/US Steroids (betamethasone) if delivery anticipated before 34wk GA Antihypertensives PRN (keep diastolic BP 90-100 mm Hg) ○ IV labetalol or hydralazine Mag sulfate for seizure prophylaxis ○ CNS depressant and smooth muscle relaxer to decrease seizure risk ○ Narrow TI so assess for toxicity (labs, respiratory rate, muscle strength) IOL Preeclampsia Postpartum Management & Care: Postpartum Assessment ○ Fundal Checks: at higher risk for PPH d/t magnesium sulfate ○ Vital Signs: BP should return to normal ○ Labs: CMP, CBC, LFT ○ Monitor S/S Patient Teaching ○ Delivery of placenta is the cure ○ But in some cases postpartum preeclampsia can occur Postpartum Preeclampsia ○ Most cases develop within 48 hr of delivery Continue magnesium sulfate for 24 hours PP Can occur up to 6 weeks after postpartum Seizures are still possible Eclampsia: Vasospasm in the CNS leading to a seizure or coma Nursing Assessment during seizure ○ Recognize s/s of seizures ○ Ensure immediate safety of the patient, including airway to prevent injury Treatment: ○ Magnesium sulfate ○ Antihypertensive agents ○ Delivery Fetus: FHR should recover when mother stabilizes HELLP Syndrome: A form of preeclampsia with severe features ○ H: hemolysis ○ E: elevated ○ L: liver enzymes ○ L: low ○ P: platelets Vascular damage/vasospasm leads to platelet aggregation and fibrin deposits in liver ○ Platelet aggregation: clotting due at site of vascular injury ○ Fibrin is a mesh like protein formed from fibrinogen during clotting process that impedes blood flow Symptoms: ○ Nausea, vomiting, malaise, epigastric pain Childbirth at Risk I: Cervical Insufficiency: Definition: ○ Structurally defective cervix (weak cervix) ○ Painless spontaneous dilation WITHOUT uterine contractions ○ Results in pregnancy loss in the 2nd trimester Etiology: ○ Exact causes unknow; primarily weakness of cervix ○ Less elastin & collagen than normal ○ Results in loss of sphincter tone Contributing Factors: ○ Anatomical malformations ○ Trauma to the cervix ○ Increased uterine volume (multiple gestation) Risk Assessment: ○ Hx of previous SAB or preterm delivery ○ Hx of cervical trauma or surgery Diagnostic Testing: ○ Short cervical length or funneling on US Interventions: ○ Bedrest, pelvic rest, avoidance of heavy lifting, cervical cerclage as indicated Nursing Management: patient education of s/s ○ Backache ○ Increased vaginal discharge ○ Rupture of membranes Cerclage Procedure: Placement of a “purse string” surgical stitch in the body of the cervix Indications: ○ 13-16wk GA ○ Painless cervical dilation per US ○ No apparent fetal anomalies ○ No evidence of infection ○ History of 2nd trimester pregnancy loss with painless cervical dilation ○ History of cerclage with previous pregnancy Removal at 37 wk GA or onset of labor, whichever comes first Preterm Labor (PTL): Regular UCs with cervical dilation and effacement before 37 wk GA Exact cause unknown and most people who have PTL have no known risk factors Diagnosis: ○ 1 cm or more dilated & 80% effaced with regular UCs ○ Contraction frequency alone not diagnostic of preterm labor Complication of PTL is preterm delivery and systemic maturational deficiencies in the neonate Preterm Labor Risk Factors and Nursing Care: 1. 2. 3. BIG 3 Previous preterm delivery Multiple Gestation Short cervix per ultrasound Other risk factors: ○ Past cervical procedures, past cervical lacerations, bleeding during pregnancy, infections during pregnancy, less than 18 months between deliveries younger, than 17 and older than 35 Nursing Care ○ Screen: Hx of preterm labor Current S/S of preterm labor Current S/S of infection * also educate on s/s and when to go to the hospital Call DR if ○ Abdominal pain like menstrual cramps ○ Low dull backache ○ Pelvic pain/pressure ○ Vaginal bleeding/discharge ○ Urinary frequency ○ N/V/D ○ Hospital Care: Rest, VS, FHR w/UC Deceased anxiety Preterm Labor: Clinical Therapy: Tocolytics (inhibit UCs) ○ Goal of med is to delay birth by 24 hours MINT ○ M: mag sulfate ○ I: indocin ○ N: nifedipine ○ T: terbutaline Steroids: betamethasone (BMZ) ○ 12mg IM, q 24hrx 2 doses ○ Only given between 24-34 weeks GA ○ Decreased likelihood of prematurity associated RDS Rupture of Membranes: Premature ROM (PROM) ○ Spontaneous ROM after 37 weeks but before labor onset Preterm PROM (PPROM) ○ Spontaneous ROM before 37 weeks Prolonger ROM ○ ROM> 24 hours before delivery Causes: ○ Prior PPROM ○ Incompetent Cervix ○ Infection (#1 RISK) ○ Bleeding/Abruption ○ Smoking Preterm Premature ROM (PPROM): MOM: ○ Infection Chorioamnionitis (before delivery) Endometritis (after delivery) ○ Abruptio Placenta More frequent with PPROM Infection causes premature separation of placenta from uterus Bleeding episodes contribute to weakening of membranes BABY: ○ ○ ○ Premature delivery Neonatal infection (sepsis) Oligohydramnios Fetal pulmonary hypoplasia Fetal growth restriction Limb position defects Rupture of Membranes: Clinical Therapy Assessment: ○ TACO and duration of ROM ○ Gestational age ○ Signs of infection (febrile, tachycardic, pain) ○ Fetal wellbeing (EFM) Sterile Speculum Exam (SSE) see if fluid is going out ○ Pooling of fluid ○ Ferning - microscopic examination ○ Nitrazine testing of fluid Amniotic fluid pH 7.0-7.5 Normal vaginal secretions pH 4.5-5.6 Amnisure: ○ RN administer test ○ Does not require SSE Preterm Premature ROM (PROM): Management Monitor for infection & labor onset No evidence of infection ○ Conservative Management ○ Home care if stable Evidence of infection ○ Antibiotics ○ Delivery Tocolytics generally not indicated ○ Infection will cause uterine irritability/contractions ○ Dont keep a fetus inside an infected environment Childbirth at Risk II: Multiple Gestation: MOM RISK: ○ Overstretched uterus - PTL, PPH, dysfunction labor ○ Gestational Diabetes ○ Hypertension/preeclampsia ○ Anemia ○ Preterm PROM FETAL: ○ Increased Risk for all multiple gestations Prematurity Complications of HTN/preeclampsia Diabetes Anemia ○ Dizygotic/fraternal twin Each fetus has its own placental membrane ○ Monozygotic/identical twins Share placenta- risk of twin to twin transfusion May share amniotic membranes and the more they share the greater risk they have Shared placenta and shared chorion Clinical Therapy: ○ Antepartum Care Early and frequent prenatal care Serial ultrasounds Increase caloric needs Management of medical complications Preterm labor/birth prevention ○ Intrapartum Care: Iv, Type & Cross, anesthesia consult EFM A vs B, label well Birth method depends on fetal positioning, examine placenta Success of vaginal delivery Vertex/Vertex: 40% Vertex/Breech: 40% Breech/Vertex: 20% Delivered in the OR, as an emergency C Section Pediatric teams for delivery Placenta Previa: Placenta partially or completely obstructing cervix Complication: ○ Tissue tears away from uterine wall with each contraction ○ Hemorrhage of fetus and mom Presentation ○ Painless ○ Bright RED vaginal bleeding Risk Factors ○ Previous placenta previa ○ Multiparity ○ Prior C/S or uterine surgery ○ Recent spontaneous/induced AB ○ Large Placenta Placenta Previa Clinical Therapy: Assessment: ○ Ultrasound not SVE or SSE (do not stick anything into the vagina ○ Amount of bleeding ○ OB hx < 37 weeks and bleeding stabilized ○ Bed red w bathroom privileges ○ VS and IV labs/Type and Cross ○ Steroids BMZ if 37 weeks ○ Monitor bleeding ○ Deliver by C-Sections Placental Abruption: Placenta partially or completely detached from uterine wall before delivery ○ Decreased blood flow/degenerative changes in placental vessels leads to retroplacental clots or possible vessel rupture causing separation of placenta from uterus Presentation: ○ Severely painful ○ Dark red bleeding Risk Factors: ○ Mom HTN ○ Abd trauma ○ PPROM ○ Cocaine use ○ Chorioamnionitis ○ Uterine overdistension Multiple gestation Polyhydramnios Complications: ○ MOM: Depends on severity of bleed and time between separation and birth DIC as large amounts of clotting factors used up at placental site Shock resulting from moderate to severe hemorrhage Possible hysterectomy ○ BABY: Prematurity Anemia Hypoxia Mortality with grater placental separation Clinical Therapy ○ Maintain cardiovascular status of mom Hemodynamic monitoring Monitor urine output and labs IV (16G or 18G) x2 Type and Cross ○ Watch for DIC: fibrinogen and platelets decreased, PT/PTT prolonged Hypovolemic Shock: fluid replacement, whole blood, cryo, FFP ○ Assess Uterus Extreme tenderness to palpation RIgidity d/t tetany (prolonged contractions) Tachysystole (>5 UC/10 min) ○ ○ Assess FHR Tachycardia progressing to bradycardia Birthing method depends on fetal birthing person's condition Amniotic Fluid Disorders: OLIGO-hydramnios Not enough fluid ○ < 500ml amniotic fluid ○ AFI < 5 Associated with ○ Post term GA ○ Fetal renal malformations ○ IUGR/placental insufficiency Complications: ○ Umbilical cord compression ○ Pulmonary hypoplasia ○ Tissue adhesions/impaired movement Nursing Assessment: ○ Fundal height LESS than expected for GA ○ NST/BPP (less than 5 you've lost the most important parts) ○ Continuous EMF to observe for signs of cord compression Nursing Management: ○ Assist with AFI ○ Amnioinfusion possible in labor ○ Intrauterine resuscitation PRN ○ Possible indication for IOL Amniotic Fluid Disorder: POLY-hydramnios Too much fluid ○ > 200ml amniotic fluid ○ AFI > 25 Associated with ○ Fetal anomalies r/t swallowing ○ Diabetes in mom leading to polyuria in baby Complications ○ Preterm birth/dysfunctional labor ○ Risk of prolapsed cord Nursing Assessment: ○ Disproportionate fundal height INCREASE ○ Difficulty palpating fetus/auscultating FHR ○ Assist with AFI Nursing Management: ○ Birth person dyspnea and pain ○ No AROM with amnihook, this can lead to prolapsed cord Childbirth at Risk III: Dystocia: Abnormal Labor Problems with Powers ○ Protracted labor: slower than normal rate of dilation or descent ○ Arrest of Labor: no progress in dilation or descent ○ Precipitous Labor: onset of contractions to delivery in under 3 hours Problems with Passenger ○ OP malposition ○ Face/Brow and breech presentation ○ Shoulder dystocia ○ Multifetal pregnancy ○ Cephalopelvic disproportion: fetal head is too big to fit through the pelvis Problems with Passageway ○ Cephalopelvic disproportion: pelvis is too narrow for fetal head to fit through Precipitous Labor and Birth: Onset of labor and birth within 3 hours Causes: ○ Low resistance of soft tissue ○ Abnormally strong contractions MOM RISKS: ○ Very few have adequate passageway ○ Anxiety and fear of perineal laceration BABY RISK: ○ Non-reassuring FHR d/t intense contractions ○ Head trauma (intracranial bleeding) Cephalopelvic Disproportion (CPD): Narrowing in any part of the passageway (bony pelvis or soft tissue) Fetal size too large to fit through pelvis Implications ○ Prolonger labor ○ Lack of fetal descent ○ Uterine rupture Cephalopelvic Disproportion (CPD) - Management: Fetopelvic relationship ○ Pelvimetry (hands assess pelvic diameter) ○ Estimated weight of fetus Borderline diameters: TOLAC vs C/Section EFM for signs of fetal intolerance ○ Tachycardia ○ Minimal variability ○ Variable decelerations ○ Late accelerations Repositioning during labor to change pelvic angles OB EMERGENCIES: 1. Should Dystocia: Fetal head emerges, then retracts against maternal perineum because anterior shoulder is impacted behind pubic bone Complications: ○ Brachial plexus injury (nerves in this area are squeezed, stretched, or ruptured which can cause weakness and numbness in hands) ○ Fractured Clavicle ○ *Ideally identify macrosomia before labor onset but other than that cannot be predicted Management: ○ 1. Recognize Shoulder Dystocia Turtle Sign: baby's head retracts into maternal perineum Head delivered then shoulder retracts, if you use gentle tractions and head doesn't work ○ 2. Provider announces should dystocia ○ 3. Get these providers to the room: Obstetrician Extra nurses Neonatal doctor and nurse ○ 4. Open OR for emergency C/Section Goal: dislodge shoulder shoulder from behind pubic bone ○ 1. McRoberts Maneuver Flex thighs back onto abdomen and push knees back towards ears ○ 2. Subprapubic Pressure Firm continuous pressure because you are trying to dislodge shoulder from bone ○ Zavanelli Replace the fetal head into the vagina and deliver baby by emergency C-Section Post Delivery Nursing Care ○ MOM: Fundal Checks and assessment for signs of PPH ○ BABY: NB assessment for clavicle fracture or signs of bacterial plexus injury 2. Prolapsed Umbilical Cord: Umbilical cord in front of fetal presenting part ○ Presenting part not not firmly against cervix ○ Cord trapped between presenting part and moms pelvic outlet ○ CORD IS COMPRESSED (variable decels) ○ Persistent variable decelerations progression to prolonged declaration Higher risk when…. ○ 1. Presenting part does not fill pelvic outlet (breech or premies) ○ 2. Polyhydramnios (gush of extra fluid can carry fluid out) Clinical therapy: ○ PREVENT: Presenting part well engaged → minimal risk After AROM , EFM and bed rest EFM: variable to prolonged declarations ○ AFTER: SVE to maintain upward pressure on presenting part and off prolapse cord Notify anesthesia and NICU Patient on SIDE and knees on CHEST Deliver by emergency C-Section 3. Uterine Rupture: Partial or complete nonsurgical tear of uterine cavity ○ Tears from the inside and tears all the way through Risk Factors: ○ PREVIOUS UTERINE INCISION ○ Abdominal trauma ○ Operative vaginal delivery/uterine manipulation Only diagnosed via surgical incision Complications: ○ MOM: Pain and hemorrhage ○ BABY: Anema, hypoxia, and death Management: ○ Non-reassuring FHR Variable and late decels Bradycardia Undetectable FHR ○ Loss of fetal station ○ Abdominal Pain ○ Vaginal bleeding- QBL ○ Deliver by emergency C/S and have peds team ready for neonatal resuscitation