Transcript Pregnancy at Risk: Pregestational Onset

Pregnancy at Risk:
Pregestational Onset
Alcohol Use in Pregnancy
• Maternal effects:
– Malnutrition
– Bone-marrow suppression
– Increased incidence of infections
– Liver disease
• Neonatal effects:
– Fetal alcohol spectrum disorders (FASD)
Cocaine Use in Pregnancy:
Maternal Effects
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Seizures and hallucinations
Pulmonary edema
Respiratory failure
Cardiac problems
Spontaneous first trimester abortion,
abruptio placentae, intrauterine growth
restriction (IUGR), preterm birth, and
stillbirth
Cocaine Use in Pregnancy:
Fetal Effects
• Decreased birth weight and head
circumference
• Feeding difficulties
• Neonatal effects from breast milk:
– Extreme irritability
– Vomiting and diarrhea
– Dilated pupils and apnea
Heroin Use in Pregnancy
• Maternal effects:
– Poor nutrition and iron-deficiency anemia
– Preeclampsia-eclampsia
– Breech position
– Abnormal placental implantation
– Abruptio placentae
– Preterm labor
Heroin Use in Pregnancy
(cont’d)
• Maternal effects:
– Premature rupture of the membranes (PROM)
– Meconium staining
– Higher incidence of STIs and HIV
• Fetal effects:
– IUGR
– Withdrawal symptoms after birth
Substance Use in Pregnancy:
Maternal Effects
• Marijuana: difficult to evaluate, no known
teratogenic effects
• PCP - maternal overdose or a psychotic
response
• MDMA (Ecstasy) - long-term impaired
memory and learning
Pathology of Diabetes
Mellitus (DM)
• Endocrine disorder of carbohydrate
metabolism
• Results from inadequate production or
utilization of insulin
• Cellular and extracellular dehydration
• Breakdown of fats and proteins for energy
Gestational Diabetes (GDM)
• Carbohydrate intolerance of variable
severity
• Causes:
– An unidentified preexistent disease
– The effect of pregnancy on a compensated
metabolic abnormality
– A consequence of altered metabolism from
changing hormonal levels
Effect of Pregnancy on
Carbohydrate Metabolism
• Early pregnancy:
– Increased insulin production and tissue
sensitivity
• Second half of pregnancy:
– Increased peripheral resistance to insulin
Maternal Risks with DM
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Hydramnios
Preeclampsia-eclampsia
Ketoacidosis
Dystocia
Increased susceptibility to infections
Fetal and Neonatal Risks
with DM
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Perinatal mortality
Congenital anomalies
Macrosomia
IUGR
RDS
Polycythemia
Fetal and Neonatal Risks
with DM (cont’d)
• Hyperbilirubinemia
• Hypocalcemia
Screening for DM
in Pregnancy
• Assess risk at first visit:
– Low risk - screen at 24 to 28 weeks
– High risk - screen as early as feasible
Risk Factors
• Age over 40
• Family history of diabetes in a first-degree
relative
• Prior macrosomic, malformed, or stillborn
infant
• Obesity
• Hypertension
• Glucosuria
Screening Tests
• One-hour glucose tolerance test:
– Level greater than 130-140 mg/dl requires
further testing
• 3-hour glucose tolerance test:
– GDM diagnosed if 2 levels are exceeded
Treatment Goals
• Maintain a physiologic equilibrium of
insulin availability and glucose utilization
• Ensure an optimally healthy mother and
newborn
• Treatment:
– Diet therapy and exercise
– Glucose monitoring
– Insulin therapy
Fetal Assessment
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AFP
Fetal activity monitoring
NST
Biophysical profile
Ultrasound
Nursing Management
• Assessment of glucose
• Nutrition counseling
• Education about the disease process and
management
• Education about glucose monitoring and
insulin administration
• Assessment of the fetus
• Support
Iron-deficiency Anemia
• Maternal complications:
– Susceptible to infection
– May tire easily
– Increased chance of preeclampsia and
postpartal hemorrhage
– Tolerates poorly even minimal blood loss
during birth
Iron-deficiency Anemia
(cont’d)
• Fetal complications:
– Low birth weight
– Prematurity
– Stillbirth
– Neonatal death
Iron Deficiency Anemia
(cont’d)
• Prevention and treatment:
– Prevention - at least 27 mg of iron daily
– Treatment - 60-120 mg of iron daily
Folate Deficiency
• Maternal complications:
– Nausea, vomiting, and anorexia
• Fetal complications:
– Neural tube defects
• Prevention - 4 mg folic acid daily
• Treatment - 1 mg folic acid daily plus iron
supplements
Folate Deficiency
• Maternal complications:
– Nausea, vomiting, and anorexia
• Fetal complications:
– Neural tube defects
• Prevention - 4 mg folic acid daily
• Treatment - 1 mg folic acid daily plus iron
supplements
Sickle Cell Anemia
• Maternal complications:
– Vaso-occlusive crisis
– Infections
– Congestive heart failure
– Renal failure
Sickle Cell Anemia
(cont’d)
• Fetal complications include fetal death,
prematurity, and IUGR.
• Treatment:
– Folic acid
– Prompt treatment of infections
– Prompt treatment of vaso-occlusive crisis
HIV in Pregnancy
• Asymptomatic women - pregnancy has no
effect
• Symptomatic with low CD4 count pregnancy accelerates the disease
• Zidovudine (ZDV) therapy diminishes risk
of transmission to fetus
• Transmitted through breast milk
• Half of all neonatal infections occurs
during labor and birth
HIV in Pregnancy:
Maternal Risks
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Intrapartal or postpartal hemorrhage
Postpartal infection
Poor wound healing
Infections of the genitourinary tract
HIV Effects on Fetus
• Infants will often have a positive antibody
titer
• Infected infants are usually asymptomatic
but are likely to be:
– Premature
– Low birth weight
– Small for gestational age (SGA)
Treatment During
Pregnancy
• Counsel about implications of diagnosis on
pregnancy:
– Antiretroviral therapy
– Fetal testing
– Cesarean birth
Cardiac Disorders
in Pregnancy
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Congenital heart disease
Marfan syndrome
Peripartum cardiomyopathy
Eisenmenger syndrome
Mitral valve prolapse
Less Common Medical
Conditions in Pregnancy
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Rheumatoid arthritis
Epilepsy
Hepatitis B
Hyperthyroidism
Hypothyroidism
Maternal phenylketonuria
Less Common Medical
Conditions in Pregnancy (cont’d)
• Multiple sclerosis
• Systemic lupus erythematosus
• Tuberculosis
Pregnancy at Risk:
Gestational Onset
Spontaneous Abortion
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Threatened abortion
Imminent abortion
Incomplete abortion
Complete abortion
Types of spontaneous abortion. A Threatened The cervix is
not dilated, and the placenta is still attached to the uterine wall, but some
bleeding occurs.
B Imminent. The placenta has separated from the uterine wall, the
cervix has dilated, and the amount of bleeding has increased.
C Incomplete. The embryo/fetus has passed out of the
uterus; however, the placenta remains.
Spontaneous Abortion
(cont’d)
• Missed abortion
• Recurrent pregnancy loss
• Septic abortion
Spontaneous Abortion:
Treatment
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Bed rest
Abstinence from coitus
D&C or suction evacuation
Rh immune globulin
Spontaneous Abortion:
Nursing Care
• Assess the amount and appearance of
any vaginal bleeding
• Monitor the woman’s vital signs and
degree of discomfort
• Assess need for Rh immune globulin.
• Assess fetal heart rate
• Assess the responses and coping of the
woman and her family
Ectopic Pregnancy:
Risk Factors
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Tubal damage
Previous pelvic or tubal surgery
Endometriosis
Previous ectopic pregnancy
Presence of an IUD
High levels of progesterone
Ectopic Pregnancy:
Risk Factors (cont’d)
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Congenital anomalies of the tube
Use of ovulation-inducing drugs
Primary infertility
Smoking
Advanced maternal age
Ectopic Pregnancy:
Treatment
• Methotrexate
• Surgery
Various implantation sites in ectopic pregnancy. The most common site
is within the fallopian tube, hence the name “tubal pregnancy
Ectopic Pregnancy:
Nursing Care
• Assess the appearance and amount of
vaginal bleeding
• Monitors vital signs
• Assess the woman’s emotional status and
coping abilities
• Evaluate the couple’s informational needs.
• Provide post-operative care
Gestational Trophoblastic
Disease: Symptoms
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Vaginal bleeding
Anemia
Passing of hydropic vesicles
Uterine enlargement greater than
expected for gestational age
• Absence of fetal heart sounds
• Elevated hCG
Gestational Trophoblastic
Disease: Symptoms
• Low levels of MSAFP
• Hyperemesis gravidarum
• Preeclampsia
Gestational Trophoblastic
Disease: Treatment
• D&C
• Possible hysterectomy
• Careful follow-up
Hydatidiform mole. A common sign is vaginal bleeding, often brownish (the
characteristic “prune juice” appearance) but sometimes bright red. In this figure,
some of the hydropic vessels are being passed. This occurrence is diagnostic
for hydatidiform mole.
Gestational Trophoblastic
Disease: Nursing Care
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Monitor vital signs
Monitor vaginal bleeding
Assess abdominal pain
Assess the woman’s emotional state and
coping ability
Bleeding Disorders
• Placenta previa - placenta is improperly
implanted in the lower uterine segment
• Abruptio placentae - premature separation
of a normally implanted placenta from the
uterine wall
Cervical Incompetence:
Treatment
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Serial cervical ultrasound assessments
Bed rest
Progesterone supplementation
Antibiotics
Anti-inflammatory drugs
Cerclage procedures
A cerclage or purse-string suture is inserted in the cervix to prevent
preterm cervical dilatation and pregnancy loss. After placement, the
string is tightened and secured anteriorly.
Hyperemesis Gravidarum:
Treatment
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Control vomiting
Correct dehydration
Restore electrolyte balance
Maintain adequate nutrition
Hyperemesis Gravidarum:
Nursing Care
• Assess the amount and character of
further emesis
• Assess intake and output and weight.
• Assess fetal heart rate
• Assess maternal vital signs
• Observe for evidence of jaundice or
bleeding
• Assess the woman’s emotional state
Nursing Care of Clients
with PROM
• Determine duration of PROM
• Assess gestational age
• Observe for signs and symptoms of
infection
• Assess hydration status
• Assess fetal status
• Assess childbirth preparation and coping
Nursing Clients
with PROM (cont’d)
• Encourage resting on left side
• Provide comfort measures
• Provide education
Nursing Care of Clients
with Preterm Labor
• Identify risk for preterm labor
• Assess change in risk status for preterm
labor
• Assess educational needs of the woman
and her loved ones
• Assess the woman’s responses to medical
and nursing intervention
• Teach about the importance of recognizing
the onset of labor
Signs and Symptoms of
Preterm Labor
• Uterine contractions occurring every 10
minutes or less
• Mild menstrual like cramps felt low in the
adbomen
• Constant or intermittent feeling of pelvic
pressure
• Rupture of membranes
• Low, dull backache, which may be
constant or intermittent
Signs and Symptoms of
Preterm Labor (cont’d)
• A change in vaginal discharge
• Abdominal cramping with or without
diarrhea
Classification of
Hypertension in Pregnancy
• Preeclampsia-eclampsia
• Chronic hypertension
• Chronic hypertension with superimposed
preeclampsia
• Gestational hypertension
Chronic Hypertension in Pregnancy
• Hypertension before
20 weeks without
proteinurea or stable
proteinurea
• At a higher risk for
adverse outcomes
• At risk for
development of preeclampsia
Chronic Hypertension
• If target organ damage present, pregnancy
can exacerbate the condition
• Lifestyle modifications:
- Activity restrictions
- Weight reduction
- Sodium restriction
- ETOH and tobacco strongly discouraged
Plan of Care – Chronic
Hypertension in Pregnancy
Medications can safely be withheld in
patients:
1. Without target organ damage
2. Blood pressure less than 150-160 mmHg
systolic and 100-110 diastolic
Pharmacological management:
Chronic HTN in Pregnancy
• Methyldopa (Aldomet) preferred alpha-2 adrenergic
agonist
• Labetalol (normodyne, Trandate) beta blocker
• Diuretic, calcium antagonists, other beta
blockers?
• ACE (angiotension converting enzyme) inhibitors are
contraindicated in pregnancy – IUGR,
oligohydramnios, neonatal renal failure, and
neonatal death
• ARB (angiotension receptor blockers)not researched in
pregnancy but probably contraindicated
Labatalol
• Baby at risk for transient hypotension and
hypogylcemia if mom on labatalol
• No labatalol to clients with asthma or first
degree heart block
Fetal Assessment
• Fetal growth
restriction
• Ultrasound @ 18-20
weeks, 28-32 weeks
& as needed
thereafter
• NST or biophysical
profile if growth
restricted
Preeclampsia-eclampsia
• Increased blood
pressure AND
proteinurea
• Highly suspected if
increased BP and
headache, blurred
vision, abdominal
pain, low platelets
and/or abnormal liver
enzymes
MAP
• Mean Arterial Pressure – average of systolic and
diastolic blood pressure readings
SBP + DBP + DBP
3
• ACOG states hypertension exists when there is
an increase in the MAP of 20 mmHg, and if no
baselines are known, a MAP of 105 mmHg is
used
• Two readings 4-6 hours apart
Hypertension in Pregnancy
• Hypertension
complicates 5-7% of
all pregnancies
• One-half to two-thirds
have preeclampsia or
eclampsia
• Hypertension is a
leading cause of
maternal and infant
morbidity and
mortality
Normal Adaptations to Pregnancy
• Increased blood
plasma volume
• Vasodilation
• Decreased systemic
vascular resistance
• Elevated cardiac
output
• Decreased colloid
osmotic pressure
Preeclamptic Changes in
Pregnancy
• Renal lesions are
present, especially in
nulliparous women (85%)
• Arteriolar vasospasm:
diminishes the diameter
of the blood vessels
which impedes blood flow
to organs and raises
blood pressure (perfusion
to placenta, kidneys, liver,
and brain can be
diminished by 40-60%)
Etiology of Hypertension
• Vasospasms are one of the underlying
mechanisms for the signs and symptoms of
preeclampsia
• Endothelial damage (from decreased placental
perfusion) contributes to preeclampsia
• With endothelial damage, arteriolar vasospasm
may contribute to increased capillary
permeability. This increases edema and
decreases intravascular volume
Other Suspected Causes
• The presence of foreign protein (placenta or
fetus) may trigger an immunologic response
• This is supported by:
- the incidence of preeclampsia in first-time
mothers (first exposure to fetal tissue)
- women pregnant by a new partner (different
genetic material)
Pulmonary Preeclamptic Changes
• At risk for development of pulmonary
edema
• Pulmonary capillaries susceptible to fluid
leakage across membranes due to
endothelial damage
• Left ventricular failure from increased
afterload leading to backup of fluid in
pulmonary bed
Renal Preeclamptic Changes
• Reduced kidney perfusion decreases the
glomerular filtration rate which lead to
degenerative changes and oliguria
• Protein is lost in the urine, sodium and
water are retained
• Fluid moves out of the intravascular
compartment resulting in increased blood
viscosity and tissue edema
Vascular Preeclamptic Changes
• Hematocrit level rises as fluid leaves the
cells
• Blood volume may fall to or below
prepregnancy levels; severe edema
develops and weight gain is seen
• Decreased liver perfusion causes impaired
function. Epigastric pain or RUQ pain
More Preeclamptic Changes
• Arteriolar vasospasms with decreased
blood perfusion to the retina causes visual
changes such as blind spots and blurring
• CNS changes caused by spasms as well
as edema include headache,
hyperreflexia, positive ankle clonus, and
occasionally the development of
eclampsia
Characteristics of
Preeclampsia
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Maternal vasospasm
Decreased perfusion to virtually all organs
Decrease in plasma volume
Activation of the coagulation cascade
Alterations in glomerular capillary
endothelium
• Edema
Characteristics of
Preeclampsia
• Increased viscosity of
the blood
• Hyperreflexia
• Headache
• Subcapsular
hematoma of the liver
A In a normal pregnancy, the passive quality of the spiral arteries
permits increased blood flow to the placenta.
B In preeclampsia, vasoconstriction of the myometrial segment of
the spiral arteries occurs.
What is the possible end result?
• Heart failure, caused by circulatory collapse and
shock
• Pulmonary edema, associated with severe
generalized edema (weak, rapid pulse, lowered
blood pressure, crackles)
• HELLP Syndrome: Multisystem disease in which
hemolysis, elevated liver enzymes and low
platelets are present
• Disseminated Intravascular Coagulation: (DIC)
• Clotting factors are consumed by excess fluid,
generalized bleeding occurs. Thrombocytopenia
Differential Diagnosis
• BP of > 160 systolic or > 110 diastolic
• Proteinurea of 1-2+ on 2 dipsticks at least 4
hours apart or .3 grams or more in 24 hours
• Increased serum creatinine > 1.2 unless prior
elevation
• Platelet count less than 100,000
• Elevated ALT or AST
• Persistent headache or visual changes
• Persistent epigastric pain, nausea and vomiting
Labs
• Hgb & Hct: hemoconcentration supports dx of preeclamsia and is
an indicator of severity. Values may be decreased, however, if
hemolysis accompanies the disease
• Platelets: thrombocytopenia suggests severe preeclamsia
• Quantification of protein excretion: if proteinurea should consider
preeclamsia
• Serum creatinine: abnormal rising levels especially in conjunction
with oligurea (thickening of the renal arterioles)
• Serum uric acid: increases as urate clearance decreases due to
enlargement of glomerular endothelial cells and occlusions of
capillary lumen
• Serum albumin: hypoalbuminemia indicates extent of endothelial
leak
• Coagulation profile: coagulopathy including thrombocytopenia
Specific Labs
Preeclampsia
• Hct>35
• Uric Acid > 4.5mg
• BUN > 10mg/dl
• Plt <150,000
• SGOT > 41 U/L
• SGPT > 30 U/L
HELLP
*Hemolysis-burr
cells present
*bili 1.2mg/d
*SGOT >72 U/L
*SGPT > 50 U/L
*Platelets<100,000
Hypertensive Effects
on Fetus
• Small for gestational
age
• Fetal hypoxia
• Death related to
abruption
• Prematurity
Home Management
• Monitoring for signs
and symptoms of
worsening condition
• Fetal movement
counts
• Frequent rest in the
left lateral position
• Monitoring of blood
pressure, weight, and
urine protein daily
• NST
• Laboratory testing
Management of Severe
Preeclampsia
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Bed rest
High-protein, moderate-sodium diet
Treatment with magnesium sulfate
Corticosteroids
Fluid and electrolyte replacement
Antihypertensive therapy
Fetal Indications for Delivery
• Severe IUGR
• Nonreassuring fetal surveillance
• oligohydramnios
Maternal Indications for Delivery
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Gestational age of 38 weeks or greater
Platelet count below 100K
Progressive deterioration of hepatic function
Progressive deterioration of renal function
Suspected placental abruption
Persistent severe headache or visual changes
Persistent severe epigastric pain, nausea, or
vomiting
• eclampsia
Plan of Care for the Preeclamptic
• Complete bedrest
• Left lying position-increases kidney glomerular
function and urine output
• Provide darkened quiet room
• Limit visitation
• Fluid restriction (125-150ml/hr)
• Seizure precautions
• Magnesium sulfate
• Antihypertensives
Preeclampsia Assessment
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Edema
DTRs and clonus
Assess fluid balance-strict I & O
Breath sounds (pulmonary edema)
Vital signs: BP, respiratory rate & SaO2
LOC
c/o HA or visual disturbances
Proteinurea
Epigastric pain
Edema
• 1+ edema is minimal (2mm) at pedal and
pretibial sites
• 2+ (4mm) edema of lower extrmities is marked
• 3+ (6mm) edema is evident in hands, face, lower
abdominal wall and sacrum
• 4+ (8mm) generalized massive edema is evident
including ascites from accumulaton of fluid in the
peritoneal cavity
Assessment of CNS Changes
DTRs and Clonus
• DTRs 0-4+ patellar and brachial
0=no response
1+=low normal
2+=average
3+=brisk
4+=hyperactive
Clonus
• Extreme hyperreflexia
• Involuntary oscillations that may be seen
between flexion and extension when
continuous pressure is applied to the sole
of the foot
• Counted in “beats”
Plan of Care for the Preeclamptic
• Magnesium Sulfate: used to prevent or
control seizures-it is a CNS depressant
and smooth muscle relaxant-increases
blood flow to the fetus
• It does not treat the BP
• Interferes with the release of acetylcholine
at the synapses, decreases
neuromuscular irritability
Magnesium Sulfate
• Loading dose: 4-6 grams over 15-30
minutes
• Maintenance dose: 1-2 grams/hour
• Therapeutic levels: 4.8-9.6 mg/dl
• Always IVPB to mainline
• Calcium gluconate available as antidate
Renal Insufficiency
• Magnesium sulfate is
hazardous to women
with severe renal
failure and
maintenance dose
must be reduced
Assessment of Patients on
Magnesium Sulfate
• BP, pulse, and respiratory status should
be monitored at least every 5 minutes with
the loading dose, and every 15 minutes
while on maintenance
• Continued the first 24 hours postpartum to
prevent seizures
• Monitor I & O 30ml/hr
• Serum levels every 4-6 hours –
therapeutic 4.8-9.6 mg/dl
Side Effects of Mag Sulfate
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Flushing
Sweating
Thirst
Drying mucous membranes
Depression of reflexes
Muscle flaccidity
Nausea
Blurred visoin
HA
tachycardia
Clinicial Manifestations of
Hypermagnesemia
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Weakness
Paresthesias
Dcreased deep tendon reflexes
Lethargy, confusion, disorientation
Hypoventilatoin
Seizures
Paralysis
Bradyarrythmias
Heart block
Decreased cardiac contractility
Impaired protein synthesis
Decreased skeletal mineralization
Hepatic dysfunction
Calcium Gluconate
• Antidote for mag sulfate
• 1 g of 10% calcium gluconate is
administered slow IV push over 3 minutes
and repeated every hour until signs and
sxs of toxicity have been resolved
• Should be kept at the bedside
Control of BP
• Antihypertensives may be needed to lower
the diastolic pressure
• This reduces maternal mortality and
morbidity associated with left ventricular
failure and cerebral hemorrhage
• Placental perfusion is controlled by
maternal blood pressure, drug must be
calibrated carefully
Antihypertensives
• If BP reaches 150/100 mmHg or higher
Labatalol (alpha/beta adrenergic blocker)
- Begin with 20mg IVP slowly over 2 minutes
- Or continuous infusion of 1mg/kg can be used
- May double dose up to 80 mg every 15-20 minutes
- Maximum dose 220mg
Apresoline (vasodilator)
- Begin with 5-20 mg infused over 2-4 minutes
- May be repeated every 20-30 minutes
- If no success by 20 mg IV or 30 mg IM try another drug
Eclampsia
• Derives from the
Greek word
meaning “like a
flash of lightening”
• a condition that
seems to strike out
of the blue
• 75% of the time it
occurs intrapartum
Eclampsia
• Characterized by seizures or coma
• Is a major hazard with poor outcomes in:
- gestations of less than 28 weeks
- mothers older than 35 years of age
- multigravidas
- chronic HTN, renal disease or diabetes
Eclampsia
• Rare in the Western world because
doctors can diagnose the condition in its
earliest phase (preeclampsia) and they are
constantly on the alert for the warning
signs
• Earliest signs: drowsiness, HA, dimness
of vision, rising BP, protein in the urine,
edema, RUQ pain
Etiology
• Cerebral vasospasm, hemorrhage or edema, platelet
and fibrin clots occlude vasculature leading to seizure
• Blood vessels in the uterus go into spasm cutting blood
flow to the baby
• Spasms lead to kidney failure
• Tissues become water-logged because of fluid retention
• Hemorrhages happen in the liver
• Brain oxygen levels are lowered causing heightened
brain sensitivity which shows as seizures
Signs and Symptoms of Impending
Seizures
• Extreme hypertension – 200/140 not
uncommon
• Hyperreflexia
• 4+ proteinurea
• Generalized marked edema
• Severe headache with or without visual
distrubances
Management of Care During a
Seizure
• CALL FOR HELP!
• Immediate care; Take care of the mother first
-patent airway
-adequate oxygenation
-turn on side to prevent aspiration
Magnesium Sulfate administration
Assessment of the fetus, birth if threatened
Steroid administration if fetal lungs are not mature
PNEUMONIC
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safety
establish airway
IV bolus
zealous observation
uterine activity
rapid resuscitation
evaluate fetus
Postictal State
• Central venous pressure monitoring
• Establish second indwelling catheter
• Blood glucose level to rule out
hypogylcemia due to liver not functioning
properly
• Blood should be available for emergency
infusion due to abruptio
• Do not leave patient alone
REMEMBER!!!
• All medications and therapy are merely
temporary measures
• Delivery is the only cure
Signs and Symptoms
of Eclampsia
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Scotomata
Blurred vision
Epigastric pain
Vomiting
Persistent or severe headache
Neurologic hyperactivity Pulmonary
edema
• Cyanosis
Management of Eclampsia
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Assess characteristics of seizure
Assess status of the fetus
Assess for signs of placental abruption
Maintain airway and oxygenation
Position on side to avoid aspiration
Suction to keep the airway clear
Management of Eclampsia
(cont’d)
• To prevent injury, raise padded side rails
• Administer magnesium sulfate
Postpartum Management
• Symptoms usually resolve within 48 hours
of birth
• Lab abnormalities usually resolve from 7296 hours after birth
• Careful assessment continues, mag
sulfate may continue to be infused for 1248 hours after the birth
• Bleeding must be assessed
Hemorrhage & Hypertension
• NO Methergine
• Causes vasospasm
and increases blood
pressure
• CONTRAINDICATED
in pts with HTN
• Use hemabate or
cytotec for PPH
Comparison of Risk Factors for HELLP
Syndrome and Preeclampsia
HELLP
Multiparous
Maternal age >25
White
Hx of poor preg
Outcome
Preeclampsia
Nulliparous
Maternal age<20
or >45
Family hx
Poor PNC
Diabetes
Chronic HTN
Multiple gestation
HELLP
• Hemolysis, Elevated
liver enzymes, Low
platelet count
• Prevalence is higher
among older, white,
multiparous women
• Carries a mortality
rate of 2-24%
• Occurs in 4-12% of
severe preeclampsia
DX
• Platelet < 100,000
• Liver enzymes AST ALT elevated
• Evidence of intravascular hemolysis must
be present
Complications of HELLP
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Renal failure
Pulmonary edema
Ruptured liver hematoma
DIC
Abruptio placenta
Fetal death
Perinatal asphyxia
Maternal death
Sx of HELLP
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Epigastric pain
Mailaise
Nausea and vomiting
Mild jaundice often noted
Sound like the flu?
DIC
• Prothrombin time, partial thromboplastin
time and fibrinogenlevels are normal in
patients with HELLP
• In a patient with a plasma fibrinogen level
of less than 300 mg/dL, DIC should be
suspected, especially if other laboratory
abnormalities are also present
• Oozing from venipuncture sited,
hemorrhage, uterine atony
DIC
• Systemic thrombohemorrhagic disorder
involving the generation of intravascular
fibrin and the consumption of
procoagulants and platelets
• Causes in pregnancy: abruptio placenta,
IUFD with retained dead fetus, AFE,
endotoxin sepsis, preeclampsia with
HELLP and massive transfusion
TX of DIC
• Replacement of volume, blood products, and
coagulation components
• Cardiovascular and respiratory support
• Elimination of underlying triggering mechanism
• Anticoagulation
• Replace blood products as indicated-packed
RBCs, platelets, FFP, cryo
• Antithrombin III concentrate
• Hematology, transfusionist, critical care
consultants.
Treatment for HELLP
• Delivery is the only cure
• Antenatal administration of
dexamethasone (Decadron) 10 mg IV
every 12 hours
• Mag Sulfate bolus of 4-6 g as a 20% soln
then mainenance of 2 g /hr
• Antihypertensive therapy should be
initiated if BP > 160/110
Rh Incompatibility
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Rh – mother, Rh + fetus
Maternal IgG antibodies produced
Hemolysis of fetal red blood cells
Rapid production of erythroblasts
Hyperbilirubinemia
Administration of
Rh Immune Globulin
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After birth of an Rh+ infant
After spontaneous or induced abortion
After ectopic pregnancy
After invasive procedures during
pregnancy
• After maternal trauma
ABO Incompatibility
• Mom is type O
• Infant is type A or B
• Maternal serum antibodies are present in
serum
• Hemolysis of fetal red blood cells
Surgery During Pregnancy
• Incidence of spontaneous abortion is
increased in first trimester
• Insert nasogastric tube prior to surgery
• Insert indwelling catheter
• Encourage patient to use support
stockings
• Assess fetal heart tones
• Position to maximize utero-placental
circulation
Trauma During Pregnancy
• Greater volume of blood loss before signs
of shock
• More susceptible to hypoxemia with apnea
• Increased risk of thrombosis
• DIC
• Traumatic separation of placenta
• Premature labor
Battering During Pregnancy
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Psychological distress
Loss of pregnancy
Preterm labor
Low-birth-weight infants
Fetal death
Increased risk of STIs
Perinatal Infections
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Toxoplasmosis
Rubella
Cytomegalovirus
Herpes simplex virus
Group B streptococcus
Human B-19 parvovirus
Fetal Risks: Toxoplasmosis
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Retinochoroiditis
Convulsions
Coma
Microcephaly
Hydrocephalus
Fetal Risks: Rubella
• Congenital cataracts
• Sensorineural deafness
• Congenital heart defects
Fetal Risks: Chlamydia
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Neurologic complications
Anemia
Hyperbilirubinemia
Thrombocytopenia
Hepatosplenomegaly
SGA
Fetal Risks: Herpes
• Preterm labor
• Intrauterine growth restriction
• Neonatal infection
Fetal Risks: GBS
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Respiratory distress or pneumonia
Apnea
Shock
Meningitis
Long-term neurologic complications
Fetal Risks: Human
B-19 Parvovirus
• Spontaneous abortion
• Fetal hydrops
• Stillbirth