Maternity Exam 2

Asthma - Complications: antepartum and postpartum hemorrhage, pulmonary embolism, miscarriage - Treatment: optimize control + limit exacerbations. - Encourage: take their asthma medications, stop smoking, and evaluate asthma exacerbations with continuous pulse oximetry - While dyspnea is common, an asthma exacerbation may be recognized by dyspnea w wheezing or cough. - Asthma Attacks S/s: dyspnea, chest tightness, cough, wheezing, tachypnea, low O2 Epilepsy - Children of mothers with epilepsy are at increased risk for developing a seizure disorder - Complications: preeclampsia, preterm labor, and fetal death - Increased risk of congenital anomalies w antiseizure meds during their pregnancy - Take anti seizure meds despite risks to fetus and to avoid individual seizure triggers - Women on anti seizure meds should take 4 mg folic acid daily beginning 3 months before conception - Infants of mothers who take anti seizure meds are at increased risk for bleeding. A pregnant woman with an asthma exacerbation tells the nurse she stopped taking her medication because she didn't want it to affect her baby. What is the best response by the nurse? "You should still take your asthma medication while you are pregnant to help control your asthma." Asthma treatment goals during pregnancy are to optimize control and limit exacerbations. Asthma improves during pregnancy in some woman and gets worse with others. The patient should continue taking medications as ordered during her pregnancy, regardless if she experiences an exacerbation. Hypothyroidism - S/s: fatigue, weight gain, constipation, sensitivity cold - Maternal can cause preeclampsia, gestational HTN, postpartum hemorrhage, early pregnancy loss, preterm delivery, low birth weight - Fetal: Cognitive impairment and neuropsychological risk higher in 1st Trimester - Treatment incudes levothyroxine (a T4 replacement), adjusted based on TSH levels every 4 weeks to 3 months - Medication dose adjustments are typically required more frequently in early pregnancy than in later pregnancy - Women should be taught to take levothyroxine first thing in the morning and on an empty stomach with no further oral intake for one hour. Hyperthyroidism - S/s: heat intolerance, diaphoresis, tachycardia,weight loss, tremors, anxiety - Graves disease: goiter, ophthalmopathy, conjunctivitis, swelling,and bulging of the eyes - Maternal: Hyperthyroidism may cause pregnancy loss, low birth weight, and maternal heart failure. - Fetal: tachycardia, goiter, poor growth, advanced bone growth, premature fusion of the cranial sutured heart failure, and hydrops fetalis - Treatment: suppression of thyroid hormone synthesis with a class of medications called thioamides, Only required if Graves disease present - Thioamides cross the placenta, suppress fetal thyroid hormone synthesis, and have been associated with fetal anomalies - The nurse should encourage consistent medication use. Pregestational Diabetes - Receive preconception care and achieve excellent glycemic control prior to attempting pregnancy - Risks: Preeclampsia, Perinatal death, Macrosomic fetus, Congenital anomalies, Polyhydramnios, Fetal loss, + Preterm birth - Delivery considerations: Vaginal delivery is not contraindicated, although some providers recommend a c-section for fetal macrosomia diagnosed by ultrasound, Labor often induced between 39 and 40 weeks - Care considerations: Diet, exercise, and medications are important, should be closely monitored. Pregestational Diabetes Assessments - 1st trimester: HGB A1C, Women w diabetes will have an evaluation of baseline kidney fn with a 24-hour urine collection, also have a screening of her thyroid, heart, and eyes during the first trimester. - 2nd + 3rd trimester: Vasculopathy may be evidenced by fetal growth restriction, Antepartum testing for fetal well-being usually begins between 32 + 34 weeks gestation and may include: Nonstress test, Biophysical profiles, + Contraction stress tests Nonstress test A method for evaluating fetal status during the antepartum period by observing the response of the fetal heart rate to fetal movement. Contraction Stress Test (CST) Method for evaluating fetal status during the antepartum period by observing response of the fetal heart to the stress of uterine contractions that may induce recurrent episodes of fetal hypoxia. Which of the following recommendations should the nurse make to the patient with diabetes who is interested in becoming pregnant. "Achieving excellent glycemic control now will help ensure positive pregnancy outcomes." Excellent glycemic control before pregnancy improves maternal and fetal outcomes. A woman may need a cesarean birth, but vaginal deliveries are not contraindicated due to diabetes alone.Pregnancy risks for diabetic mothers include spontaneous abortion, fetal anomalies, and still birth in addition to risks caused by macrosomia. Multiple Sclerosis (MS) - Chronic immune-modulated demyelinating disease of the CNS that often includes relapses and remissions. - Pregnancy is often a time of disease remission, while postpartum is a significant time for relapse - In pregnancy, MS may slightly increase the risk for a cesarean birth and a decrease in neonatal birth weight. - Some meds for MS are teratogenic and contraindicated, others have limited information available - Breastfeeding is not contraindicated, but the meds used to treat MS may not be safe for breastfeeding infant - May choose not to take MS meds while breastfeeding. Cardiovascular Disease - Only complicates a small number of pregnancies, but is a significant cause of maternal morbidity and mortality in pregnancy - CO increases 50% during pregnancy + may exacerbate any underlying cardiac conditions Chronic Hypertension - Associated w higher rate of poor pregnancy outcomes including intrauterine growth restriction, stillbirth, preeclampsia, and stroke. - Severe hypertension goal: Maintain systolic BP of 140 to 150 + diastolic of 90 to 100 (may be lower if she has evidence of organ damage) - Preferred antihypertensives ncludel abetalol, methyldopa, and nifedipine - Women w chronic HTN should be carefully monitored for preeclampsia and HELLP syndrome. Obesity - Complications: Higher risk for gest. diabetes, Preeclampsia, Labor induction + induction failure, Slower 1st stage labor, Macrosomic infants, Postpartum thromboembolism - Prepregnancy weight loss can improve outcomes. Eating Disorders - Associated with poor health and psychologic outcomes - Although women with an eating disorder may not menstruate, nurses should inform them that they may ovulate. anorexia nervosa an eating disorder in which an irrational fear of weight gain leads people to starve themselves bullimia nervosa an eating disorder involving gorging with food, followed by induced vomiting or laxative abuse binge eating disorder significant binge-eating episodes, followed by distress, disgust, or guilt, but without the compensatory purging, fasting, or excessive exercise that marks bulimia nervosa Iron Deficiency Anemia - About 16% to 29% will become anemic during pregnancy - Severe anemia is associated with nonreassuring FHR, prematurity, fetal loss, and maternal death. - Physiologic anemia is an expected finding during pregnancy, normal HGB level in pregnancy is 11 to 14 g/dL. - Supplementing with iron improves maternal HGB + HCT levels - Supplemental iron can cause pruritus, rash, + GI distress -Inform pt that iron is best absorbed if taken on an empty stomach but this may lead to GI distress. Intimate Partner Violence (IPV) - Many women experience psychologic and sexual abuse during pregnancy, which often goes underreported. - Screened for IPV during prenatal visits, hospitalizations, and during postpartum appointments - Asking about IPV can be intimidating; using a standardized screening tool can help with questioning - Question pt about IPV when they are alone with the pt - Be prepared to make appropriate referrals in the event of a positive screen. Substance Abuse - May not seek prenatal care cuz they feel ashamed or they are worried about the involvement of social services. - Complication:• Bby exposed to opioids + opioid replacement drugs are at a high risk for neonatal abstinence syndrome - Alcohol is a teratogen that can cause fetal alcohol syndrome. - There is no known safe amount of alcohol that can be consumed in pregnancy - Smoking can cause preterm birth, intrauterine growth restriction, and stillbirth. - All women should be screened for substance abuse during pregnancy - Counseling about the negative impact of substance abuse in pregnancy followed by a referral for treatment should be included in care - Stopping consumption of Alc or drugs at any point during pregnancy can improve outcomes. Depression - Untreated can lead to substance abuse, poor adherence to care, less prenatal care, and suicide risk - Usually treated w SSRIs - SSRIs do not have any known teratogenic effects but may lead to lower Apgar scores - Antidepressants are not contraindicated in breastfeeding Anxiety -S/s: fatigue, tension, irritability, and a pervasive sense of apprehension - Assessed with a seven-item scale (GAD-7). - Treatment: Antidepressants (particularly SSRIs), counseling, and, occasionally, benzodiazepines. - Benzos may cause withdrawal in the neonate and a higher risk of fetal loss and preterm birth - Nurses can empower patients with realistic education about therapies and selfcare measures such as mindfulness,exercise, and good nutrition. Is the following statement true or false? Often preconception care involves assessing and treating preexisting conditions and can have apositive impact on pregnancy outcomes. True. Evaluating the extent of preexisting conditions and controlling them as much as possible can improve the likelihood of conceiving, the health of the mother, and neonatal outcomes. (For example,diabetic women have better health outcomes when blood sugar is well controlled prior to pregnancy.) Fetal Surveillance: Non-stress test (NST) - Monitor FHR for 20 minutes - Results: Reactive -or- Nonreactive - Reactive = normal FHR, 2 accelerations in 20 minutes - Non-reactive = absence of 2 accelerations in 20 minutes Fetal Surveillance: Contraction stress test (CST) - Monitor FHR reaction to contractions (at least 3 in 10 min) - Interpreted by presence/absence of late decelerations - Positive (ABNORMAL) = FHR shows late decelerations w/ 50% or more of ctx - Negative: no late or significant variable decelerations Fetal Surveillance: Biophysical profile (BPP) Noninvasive, antepartum test for evaluating fetal well-being 1. Non-stress Test (NST) 2. Fetal breathing 3. Fetal activity 4. Fetal muscle tone 5. Amniotic fluid volume (AFI) Amnion Thin, tough sac of membrane that covers the embryo- protective, filled with amniotic fluid - inner membrane Chorion - Outer membrane that surrounds the amnion, it is a support platform for fetus and amnion, it provides nutrient exchange from mother to fetus + foundation for embryonic development - Chorionic villi - barrier between maternal & fetal blood Multizygotic - 2 or more eggs are fertilized at the same time - 2 eggs fertilized = dizygotic or fraternal twin - Risk factors for having a multizygotic pregnancy: artificial reproductive technology (ART), ethnicity (particularly African descent), family history, advanced maternal age (↑FSH can cause release of 1 egg as menopause approaches) - Each fetus has a separate amnion & chorion (placentas may grow together) Zygote fertilized ovum Monozygotic - All fetuses came from the same ovum, identical twins/triplets - Time of ovum split determines # of amnions, chorions, + placentas - Random / spontaneous event Multiple Pregnancy (Twins) - Typical discomforts of pregnancy amplified - Risks: gestational diabetes, preeclampsia, PE, preterm birth, perinatal mortality (3x more for twins, 4x more for triplets), placenta previa, fetal anomalies, cord entanglement, twin-to-twin transfusion syndrome Hyperemesis Gravidarum - Unusually acute nausea and vomiting - S/s: Weight loss, Malnutrition, Dehydration, Ketonuria, Electrolyte imbalances - Treatment: Rest, Possible anti-emetics, IV nutrition + fluids - Risks: History of HG, twins, depression, hyperthyroid, girl bby Bleeding in Pregnancy - Up to 20% of women report vaginal bleeding in early pregnancy - Implantation bleeding - usually around 6-11 days after fertilization, bright red or dark brown, lasting ~1 day - Other women: spotting due to infection, sex, increased blood flow to cervix - usually brief & painless - For some, vaginal bleeding may indicate a miscarriage, ectopic pregnancy, or gestational trophoblastic disease - All bleeding should be carefully evaluated Miscarriage - AKA spontaneous abortion occurs before 20 weeks gestation - Usually occurs ~5-8 weeks gestation - Likely due to chromosomal abnormalities - Risk factors: Advanced age, Drug/alcohol use, Poor nutrition, teratogenic meds, + certain maternal health conditions (diabetes, lupus, uterine abnormalities) - Report all episodes of Heavy bleeding, Fever, Foul-smelling discharge, + Abdominal tenderness - Referral for counseling &/or support resources Ectopic Pregnancy - Pregnancy occuring outside of uterus, often in fallopian tube - Ectopic pregnancies are considered life-threatening and must be ended urgently - Signs & Evaluation of an ectopic pregnancy: Severe pelvic pain that may be unilateral (may refer to one shoulder), Bleeding, Slow rise of Beta hCG levels (Beta hCG should at least double in 72 hrs), can also be asymptomatic - Should be able to see gestational sac via transvaginal ultrasound by week 5 of pregnancy - Risk Factors: History of Ectopic pregnancy, Pelvic infection or surgery, Advanced age, Cigs, IUD, STI: gonorrhea, chlamydia Ectopic Pregnancy Treatment - Methotrexate: Inhibits cell reproduction and DNA synthesis= stops cell growth & ends pregnancy - Surgical: Removal of ovum only if possible OR more structures depending on pregnancy progression - Salpingectomy = removal of one or both fallopian tubes - Administration of blood products if necessary - Rhogam administration for the woman who is Rh negative - Report signs of: Heavy bleeding, Dizziness, Tachycardia - Return for BhCG testing - Refer for counseling and support Gestational Trophoblastic Disease (GTD) - AKA: molar pregnancy - a nonviable mass of trophoblastic tissue - Failure of a fertilized egg to develop properly - Can grow beyond uterus & become carcinogenic: gestational trophoblastic neoplasia, gestational choriocarcinoma= malignancy to lungs, vagina, CNS - Ongoing monitoring for 6-12 months to monitor for s/s of CA - S/s: Brown vag bleeding, large uterine size , + nausea Gestational Trophoblastic Disease (GTD) Assessment + Treatment - Assessment: Abnormally rapid growth, Abnormally ↑ beta hCG, Ultrasound - "snowstorm" (no expected fetal structures), often experience VB - Treatment:• Dilation & curettage (D&C) to remove products of conception if not passed spontaneously - Pregnancy should be avoided for at least 6-12 months after end of molar pregnancy Report signs of: Heavy bleeding, Foul-smelling vaginal discharge, Abdominal pain + tenderness, Fever - Refer for counseling and support - F/U HCG monitoring Gestational Hypertension - Diagnosed by Systolic BP ≥140 mm Hg &/or diastolic BP ≥90 mm Hg without protein in the urineor signs of end-organ dysfunction after 20 wks of pregnancy - 50% diagnosed w gestational HTN develop preeclampsia - Complications: preterm + small infants, placental abruption Preeclampsia Diagnosis - PT w HTN (≥ 140/90 mm Hg) on 2 occasions at least 4 hours apart AND has proteinuria OR - Patient w HTN with or without proteinuria AND: a platelet count 100,000, serum creatine liver 1.1 mg/dL, elevated liver enzymes, pulmonary edema, visual or cerebral symptoms Preeclampsia - Develops after 20 weeks of gestation in a previously normotensive pregnant woman, proteinuria - Patho: abnormal attachment of placenta or abnormal pregestational maternal inflammation or epithelial cell functioning - Risks: Poor circulation assoc. w/ preeclampsia may contribute to: Oligohydramnios (low vol. amniotic fluid), Placental abruption (premature detachment of placenta from uterine wall), + Intrauterine growth restriction (IUGR) Preeclampsia Treatment - High risk: aspirin + Calcium supplementation - Mild: may be monitored on an outpatient basis and not require medication - Severe: may need to be induced - Magnesium sulfate IV to prevent seizures (reduces CNS irritability; can lower seizure threshold), neuroprotection for the fetal brain - Magnesium sulfate slow IV push in 4-6 g bolus + maintenance dose - Oxygen Therapy - Maintain a safe environment - Hypertensive medications Home Management of Preeclampsia - Bedrest lying on side - Monitoring BP, weight gain: Edema from plasma leakage into maternal tissues - Monitor s/s + fetal activity: Late decelerations may indicate a deterioration of fetal reserve - Normal diet - no restrictions, increase protein intake Preeclampsia Assessment Nursing Assessment: BP, DTR, Epigastric pain, Headache, visual disturbances, Oliguria (↓ urine output), Peripheral edema, 24-hour urine test, Labs(CBC w/platelets, liver enzymes, serum creatinine) - Fetal Assessment: Non-stress test, BPP, Ultrasound to monitor placental degradation, Doppler flow studies to measure umbilical blood glow, Determination of fetal lung maturity for delivery In-Hospital Management of Preeclampsia - Magnesium Sulfate - Antihypertensive meds in severe preeclampsia (labetalol, hydralazine, methyldopa, nifedipine) - BP monitoring - Minimize stimulation: Low lights, noise, activity to decrease probability of seizures, prevention of injury from seizures - NST & BPP, Labs - Corticosteroids IM for fetal lung maturity (23-34 wks GA) Magnesium Sulfate Administration - Administered IV as secondary infusion: Loading dose of 4 to 6 g over 15 to 30 minutes, maintenance dose of 1 to 3 g/hour to maintain a serum Mg level of 4 to 7 mEq/L - Signs of magnesium toxicity include: Respiratory depression, bradycardia, oliguria, absent DTRs, Lethargy, Slurred speech, LOC, Muscle weakness - Interventions to address toxicity: Stop the infusion immediately, Administer calcium gluconate as ordered (typically 1 g by slow IV pushover 3 minutes). Eclampsia Preeclampsia with tonic-clonic seizure activity (or coma) Superimposed Preeclampsia Development of preeclampsia in women with chronic HTN Control of Blood Pressure - Antihypertensives are not typically given to women w gestational HTN or mild preeclampsia - Treatment of severely HTN pts (BP 160/110 or greater) - IV hydralazine or Labetalol - Correct blood pressure only to 140/90 - Antihypertensives are given w chronic HTN in pregnancy Gestational Diabetes Mellitus (GDM) - Associated with insulin resistance and results in high blood glucose levels - similar to Type 2 DM - Maternal Risks: Hydramnios, Infection, Ketoacidosis, Spontaneous Abortion, Preeclampsia - Fetal Risks: Stillbirth, Congenital Anomalies, Macrosomia, Intrauterine Growth Restriction (IUGR), Respiratory Distress Syndrome (RDS), + Fetal Hyperinsulinism Gestational Diabetes Testing - Routine screening for all patients between 24 to 28 weeks: Nonfasting 50 g oral glucose tolerance test (OGTT) (1-hour GTT), If blood glucose is 140, diagnostic testing indicated - Women at high risk may be screened at their first prenatal visit for pre existing diabetes - If two or more values elevated, the patient has gestational diabetes: Fasting ≥95 mg/dL, One hour ≥180 g/dL, Two hours ≥155 mg/dL, Three hours ≥140 mg/dL