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High Risk Pregnancy. Maternal Mortality: 10/100,000 pregnant women. Leading causes: hemorrhage, hypertension, infection, preeclampsia. High Risk Pregnancy:

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Presentation on theme: "High Risk Pregnancy. Maternal Mortality: 10/100,000 pregnant women. Leading causes: hemorrhage, hypertension, infection, preeclampsia. High Risk Pregnancy:"— Presentation transcript:

1 High Risk Pregnancy

2 Maternal Mortality: 10/100,000 pregnant women. Leading causes: hemorrhage, hypertension, infection, preeclampsia. High Risk Pregnancy: A. Maternal Age 35. B. Parity Factors - 5 or more - great risk. [PP hemorrhage] New preg.within 3 mos. [PP hemorrhage] New preg.within 3 mos. C. Medical-Surgical Hx - hx of previous uterine surgery &/or uterine rupture, DM, cardiac dis, lupus, HTN, PIH, HELLP, DIC etc.

3 Gestational Conditions Hyperemesis Gravidarum Hyperemesis Gravidarum Persistent vomiting past first trimester or excessive anytime. Persistent vomiting past first trimester or excessive anytime. Severe; usually 1st pregnancy. Severe; usually 1st pregnancy. Rate occurrence ^ with twins, triplets, etc. Rate occurrence ^ with twins, triplets, etc. 7 out of 1,000. Electrolyte imbalance results. 7 out of 1,000. Electrolyte imbalance results. Possible causes: ^ levels of hCG, ^ serum amylase, decrease gastric motility. Possible causes: ^ levels of hCG, ^ serum amylase, decrease gastric motility.

4 Hyperemesis cont. S/S: dry mouth, thirst, substantial wt. loss, signs of starvation, dehydration, decreased skin turgor; fruity breath - acidosis [metabolizing fat]. dry mouth, thirst, substantial wt. loss, signs of starvation, dehydration, decreased skin turgor; fruity breath - acidosis [metabolizing fat]. Management: admit to hospital for IV hydration. NPO then clears > full fluids> sm. solids. NPO then clears > full fluids> sm. solids. Reglan or Zofran IVPB q 6 hrs. Reglan or Zofran IVPB q 6 hrs. Hosp. for hrs. Add Multi Vit.& K to IVF to correct electrolyte imbalance. Hosp. for hrs. Add Multi Vit.& K to IVF to correct electrolyte imbalance. Use ½ NS Use ½ NS

5 Hydatidaform mole - "Molar preg." Hydatidaform mole - "Molar preg." Degenerative disorder of trophoblast (placenta) Degenerative disorder of trophoblast (placenta) Villi degenerate & cells fill with fluid Villi degenerate & cells fill with fluid Form clusters of vesicles; similar to grapes Form clusters of vesicles; similar to grapes Overgrowth of chorionic villi; fetus does not develop. Overgrowth of chorionic villi; fetus does not develop. Partial or complete. Complete - no fetus; Partial - dev. begins then stops. Partial or complete. Complete - no fetus; Partial - dev. begins then stops. Multiparous/older women. Multiparous/older women. Pathophysiology: unknown; theories: chromosomal abn., hormonal imbalances; protein/folic acid deficiencies. Pathophysiology: unknown; theories: chromosomal abn., hormonal imbalances; protein/folic acid deficiencies.

6 Hydatidaform Mole cont. S/S: from bright red spotting to bright red hemorrhage. S/S: from bright red spotting to bright red hemorrhage. Tissue resembles grape clusters Tissue resembles grape clusters Uterus appears larger than expected for gest. age. Uterus appears larger than expected for gest. age. Management: D&C; go to hosp. STAT; bring any passed tissue. Management: D&C; go to hosp. STAT; bring any passed tissue. Gestational trophoblastic disease - benign hydatidaform mole & gestational trophoblastic tumors aka & chorio carcinoma. Gestational trophoblastic disease - benign hydatidaform mole & gestational trophoblastic tumors aka & chorio carcinoma.

7 Hemorrhagic Disorders Placenta previa: Implantation near or over cervix. Implantation near or over cervix. ~ 1/2 of all preg. start as previa then placenta shifts to higher position ~ 1/2 of all preg. start as previa then placenta shifts to higher position By 35 wks. not likely to shift By 35 wks. not likely to shift Varying Degrees: Total: internal cervical os completely covered by placenta. Total: internal cervical os completely covered by placenta. Partial: os partially covered by placenta. Partial: os partially covered by placenta. Marginal: margin of internal os. Marginal: margin of internal os. Low-lying: region of internal os near placenta. Low-lying: region of internal os near placenta.

8 PLACENTA PREVIA CONT….. Cause: Unknown Cause: Unknown Risk factors: multiparity, AMA, multiple gestations, previous uterine surgery Risk factors: multiparity, AMA, multiple gestations, previous uterine surgery Manisfestations: Painless, bright red bleeding > 20th week; episodic, starts without warning, stops & starts again. Manisfestations: Painless, bright red bleeding > 20th week; episodic, starts without warning, stops & starts again. Prognosis: depends on amt. bleeding & gest.age Prognosis: depends on amt. bleeding & gest.age Management: Monitor FH, maternal VS, IVF; O2; assess I&O; amt. of bleeding, CBC, & complete BR. Type & cross for poss.transfusion. Management: Monitor FH, maternal VS, IVF; O2; assess I&O; amt. of bleeding, CBC, & complete BR. Type & cross for poss.transfusion. Ultrasound to confirm Ultrasound to confirm No pelvic exams/no vag. del.- May lead to hemorrhage No pelvic exams/no vag. del.- May lead to hemorrhage

9 Abruptio placenta: Separation of placenta from uterine wall > 20th wk gestation (during pregnancy) Separation of placenta from uterine wall > 20th wk gestation (during pregnancy) Placental Abruption- hemorrhage results; Severity depends on degree of separation. Placental Abruption- hemorrhage results; Severity depends on degree of separation. Common in multips, AMA. Common in multips, AMA. Fetal prognosis depends on blood lost & gest. age. Fetal prognosis depends on blood lost & gest. age. Grade 0: Separation not apparent until placenta examined > delivery. Grade 0: Separation not apparent until placenta examined > delivery. Grade 1: minimal - causes vaginal bleeding & alterations in maternal VS. Grade 1: minimal - causes vaginal bleeding & alterations in maternal VS. Grade 2: moderate - + signs of fetal distress. Uterus tense & painful when palpated. Grade 2: moderate - + signs of fetal distress. Uterus tense & painful when palpated. Grade 3: extreme (total) separation. Maternal shock/fetal death if immediate intervention not done. Grade 3: extreme (total) separation. Maternal shock/fetal death if immediate intervention not done.

10 Abruption cont. Cause: Unknown; risk factors: smoking, short umbilical cord, adv. mat. age, HTN, PIH, cocaine use, trauma to or near abdomen. Cause: Unknown; risk factors: smoking, short umbilical cord, adv. mat. age, HTN, PIH, cocaine use, trauma to or near abdomen. Manifestations: tenderness to severe constant pain; mild to moderate bleeding depending on degree of sep.. Manifestations: tenderness to severe constant pain; mild to moderate bleeding depending on degree of sep.. Total separation: tearing, knifelike sensation. Total separation: tearing, knifelike sensation. Management: Assess amt. & control blood loss Management: Assess amt. & control blood loss Assess FH & mat. VS, CBC, O2, IVF [RL-volume expander], type & cross. Assess FH & mat. VS, CBC, O2, IVF [RL-volume expander], type & cross. Neonate may be hypoxic, in hypovolemic shock d/t bl. loss. Prepare for emergency C/S. Neonate may be hypoxic, in hypovolemic shock d/t bl. loss. Prepare for emergency C/S.

11 Comparison: Abruption vs. Placenta Previa Abruptio Placenta Pathology: Sudden separation of normally implanted placenta. Pathology: Sudden separation of normally implanted placenta. Vaginal Bleeding: may not be obvious; concealed behind placenta. If visible, will be dark. Bleeding into uterine cavity. Vaginal Bleeding: may not be obvious; concealed behind placenta. If visible, will be dark. Bleeding into uterine cavity. Pain: Sharp, stabbing pain in abd. Pain: Sharp, stabbing pain in abd. Uterus: hard boardlike abd. Uterus: hard boardlike abd. Placenta Previa Pathology: Abnormal implantation of placenta; lower in uterine cavity. Pathology: Abnormal implantation of placenta; lower in uterine cavity. Vaginal Bleeding: Abrupt onset ; bright red. Vaginal Bleeding: Abrupt onset ; bright red. Completely painless. Completely painless. Uterus: Soft, unless uterine contraction is present. Uterus: Soft, unless uterine contraction is present.

12 Abnormal Amniotic Fluid Levels: AMF made up of fetal urine & fluid that is transported thru placenta from mat.cir.sys. AMF made up of fetal urine & fluid that is transported thru placenta from mat.cir.sys. Fetus swallows AMF & excretes urine. Fetus swallows AMF & excretes urine. Waste excreted by maternal kidneys. Waste excreted by maternal kidneys. CNS or GI abnormalities inhibits uptake of AMF. CNS or GI abnormalities inhibits uptake of AMF. Polyhydramnios: > 2,000 ml amniotic fluid. Polyhydramnios: > 2,000 ml amniotic fluid. Need ultrasound to make dx. AFI >/equal to 24= polyhydramnios. AFI of 8-23 cm. normal. Visual inspection may reveal rapidly enlarging uterus.

13 Risk Factors Fetal abnormalities: neonatal macrosomia, fetal or neonatal hydrops [swelling], ascites, pleural or pericardial effusions.Fetal abnormalities: neonatal macrosomia, fetal or neonatal hydrops [swelling], ascites, pleural or pericardial effusions. Skeletal malformations: congenital hip dislocation, clubfoot, & limb reduction defect.Skeletal malformations: congenital hip dislocation, clubfoot, & limb reduction defect. Abnormal fetal movement suggestive of neurologic abnormalities (CNS)Abnormal fetal movement suggestive of neurologic abnormalities (CNS) Obstruction of GI tract; prevents normal ingestion of amniotic fluid.Obstruction of GI tract; prevents normal ingestion of amniotic fluid. Rh iso immunization d/t mixing of maternal/fetal bloodRh iso immunization d/t mixing of maternal/fetal blood Maternal hx DM.Maternal hx DM. Assoc. w.spina bifida; anencephaly, hydrocephaly.Assoc. w.spina bifida; anencephaly, hydrocephaly. Fetal death may result from severe poly.Fetal death may result from severe poly. Not as common as oligohydramniosNot as common as oligohydramnios

14 Polyhydramnios cont. Management: Monitor wt. gain. Remove excess amniotic fluid q 1-2 wks.thru amniocentesis. Replaced quickly. Most women with mild poly.deliver healthy infants. Oligohydramnios: amniotic fluid < 1,000ml. Could be highly concentrated. Interferes w. normal fetal dev. Reduces cushioning effect around fetus. Causes: Failure of fetal kidney development; urine excretion blocked, IUGR, post-term preg., preterm ROM, fetal anomalies. Poor placental function. Causes: Failure of fetal kidney development; urine excretion blocked, IUGR, post-term preg., preterm ROM, fetal anomalies. Poor placental function.

15 Oligo cont. Manifestations: Facial & skeletal deformities: club foot. Facial & skeletal deformities: club foot. Fetal demise Fetal demise Pulmonary hypoplasia - improper dev. of alveoli; Pulmonary hypoplasia - improper dev. of alveoli; 2 nd trimester oligo: higher rate of congenital anomalies (50.7 % vs %) and lower survival rate (10.2 % vs %) than women with oligo. in 3 rd trimester. 2 nd trimester oligo: higher rate of congenital anomalies (50.7 % vs %) and lower survival rate (10.2 % vs %) than women with oligo. in 3 rd trimester. Prognosis: depends on severity of disease. Prognosis: depends on severity of disease. Management: Careful assessment of mother/fetus Do frequent ante-partum testing Do frequent ante-partum testing determine optimal time for delivery (early) determine optimal time for delivery (early) Antibiotics/corticosteroids with PPROM Antibiotics/corticosteroids with PPROM

16 Ectopic pregnancy: Causes: Scarring of fallopian tubes (Chlamydia/Gonorrhea). Scarring of fallopian tubes (Chlamydia/Gonorrhea). Implantation of ovum outside uterine cavity; usu. upper 1/3rd fallopian tube; rare on ovary, cervix, abdominal cavity. Implantation of ovum outside uterine cavity; usu. upper 1/3rd fallopian tube; rare on ovary, cervix, abdominal cavity. Leading cause of death from hemorrhage in preg. Leading cause of death from hemorrhage in preg. Reduces fertility Reduces fertility ~ 1 in 100 pregnancies ~ 1 in 100 pregnancies More common > infection of fallopian tubes or surgery to reverse TL. More common > infection of fallopian tubes or surgery to reverse TL. Previous ectopic Previous ectopic multiple induced abortions multiple induced abortions diethylstilbestrol (DES) exposure diethylstilbestrol (DES) exposure

17 EctopicSymptoms: Colicky, cramping pain in lower abdomen on affected side Colicky, cramping pain in lower abdomen on affected side Tubal rupture: sharp/steady pain before diffusing thruout pelvic region. Fetus expels into pelvic cavity. Tubal rupture: sharp/steady pain before diffusing thruout pelvic region. Fetus expels into pelvic cavity. Heavy bleeding causes shoulder pain, rectal pressure Heavy bleeding causes shoulder pain, rectal pressure N/V % pts. think its morning sickness. N/V % pts. think its morning sickness. Dizziness/weakness - If tube ruptures, weak pulse, clammy skin, fainting. Assess for s/s shock. Dizziness/weakness - If tube ruptures, weak pulse, clammy skin, fainting. Assess for s/s shock.Treatment: Immediate surgery to remove/repair tube. Immediate surgery to remove/repair tube. If no rupture, Methotrexate - stops cellular division in fetus; causes cell death. Conceptus expelled with bleeding. Best <6 wks. when chance of rupture less. If no rupture, Methotrexate - stops cellular division in fetus; causes cell death. Conceptus expelled with bleeding. Best <6 wks. when chance of rupture less.

18 Rh sensitization Rh (D) Immune Globulin aka Rhogam Rh – mom: no Rh factor. Rh – mom: no Rh factor. If Rh - mom receives cells from Rh + fetus, mother responds to (+) AG by producing AB. If Rh - mom receives cells from Rh + fetus, mother responds to (+) AG by producing AB. Treatment: Anti-Rho (d) immune wks. (Rhogam) delivery. Treatment: Anti-Rho (d) immune wks. (Rhogam) delivery. Prevents antibody formation if mom is Rh -. Prevents antibody formation if mom is Rh -. Rapid RBC lysis leads to ^ bilirubin levels. Rapid RBC lysis leads to ^ bilirubin levels. 1 st exposure [Rh+ blood] IgM, antibodies develop; too large to cross placenta. 1 st exposure [Rh+ blood] IgM, antibodies develop; too large to cross placenta.lacenta First Rh + fetus usually not harmed. First Rh + fetus usually not harmed. 2 nd exposure, smaller IgG antibodies formed; can cross placenta & destroy fetal red blood cells. 2 nd exposure, smaller IgG antibodies formed; can cross placenta & destroy fetal red blood cells.

19 Maternal-Fetal Blood Group Incompatibility: Mom is type O & baby is A, B or AB. Mom is type O & baby is A, B or AB. Blood types A, B, & AB contain antigen not present in type O blood. Blood types A, B, & AB contain antigen not present in type O blood. (O) blood type have anti A/anti B antibodies. (O) blood type have anti A/anti B antibodies. If exchange occurs, maternal antibodies attact fetal bl.cells, causing rapid lysis of RBC's. If exchange occurs, maternal antibodies attact fetal bl.cells, causing rapid lysis of RBC's. Leads to byproduct bilirubin. Leads to byproduct bilirubin. Results in jaundice. Results in jaundice. ABO less severe than Rh incompatibility b/c primary antibodies of ABO system are IgM which are too large to cross placenta. ABO less severe than Rh incompatibility b/c primary antibodies of ABO system are IgM which are too large to cross placenta. Bilirubin levels done & phototherapy if ^. Bilirubin levels done & phototherapy if ^.

20 Hypertensive States of Pregnancy: Global cause of maternal/fetal morbidity & mortality. Responsible for ~ 76,000 deaths/year. Global cause of maternal/fetal morbidity & mortality. Responsible for ~ 76,000 deaths/year. 4 categories: 1.Chronic HTN: ^ BP prior to pregnancy. Not associated w. proteinuria or end-organ damage; continues > delivery. Not associated w. proteinuria or end-organ damage; continues > delivery. 2. Preeclampsia: ^ BP during preg. > 20 wks. End-organ damage may occur % cases. 3. Superimposed preeclampsia on pt. w. Chronic HTN: 15-30% cases. 4. Transient HTN: BP >140 /90 without proteinuria or end-organ damage. Normotensive pt. may become hypertensive late in preg., during labor, or 24 hours postpartum. BP normal within 10 days postpartum.

21 Pre-eclampsia Pre-eclampsia Defined As: BP 140/90 BP 140/90 Systolic of 30mm Hg > pre-preg. levels Systolic of 30mm Hg > pre-preg. levels Diastolic of 15mm Hg > pre preg. levels. Diastolic of 15mm Hg > pre preg. levels. Presents with HTN, proteinuria, edema of face, hands, ankles. Presents with HTN, proteinuria, edema of face, hands, ankles. Can occur anytime > 20 th wk of pregnancy. Can occur anytime > 20 th wk of pregnancy. Usually occurs closer to due date. Will not resolve until > birth. Can progress to HELLP syndrome Usually occurs closer to due date. Will not resolve until > birth. Can progress to HELLP syndrome

22 General Signs of PREECLAMPSIA Rapid weight gain; swelling of arms/face Rapid weight gain; swelling of arms/face Headache; vision changes (blurred vision, seeing double, seeing spots) Headache; vision changes (blurred vision, seeing double, seeing spots) Dizziness/faintness/ringing in ears/confusion; seizures Dizziness/faintness/ringing in ears/confusion; seizures Abdominal pain, production of urine; nausea, vomiting, blood in vomit or urine Abdominal pain, production of urine; nausea, vomiting, blood in vomit or urine

23 Mild: mild HTN; no end-organ damage; minimal proteinuria. Severe: Significant HTN; severe proteinuria (>5.0 g/d); end-organ damage d/t systemic vaso- constriction. Significant HTN; severe proteinuria (>5.0 g/d); end-organ damage d/t systemic vaso- constriction. Headache; visual changes; confusion; abdominal pain; impaired liver function w.hyperbilirubinemia; oliguria; proteinuria; pulmonary edema; hemolytic anemia; thrombocytopenia; fetal growth retardation. Headache; visual changes; confusion; abdominal pain; impaired liver function w.hyperbilirubinemia; oliguria; proteinuria; pulmonary edema; hemolytic anemia; thrombocytopenia; fetal growth retardation. Eclampsia (seizures) may follow Eclampsia (seizures) may follow

24 Eclampsia: Seizures or coma d/t hypertensive encephalopathy; most serious complication. Seizures or coma d/t hypertensive encephalopathy; most serious complication. Affects ~ 0.2% preg; 1 in 1000 preg. terminated. Affects ~ 0.2% preg; 1 in 1000 preg. terminated. Major cause of maternal death d/t intracranial hemorrhage. Maternal mortality rate is 8-36%. Major cause of maternal death d/t intracranial hemorrhage. Maternal mortality rate is 8-36%. Deliver by C/S ASAP. Deliver by C/S ASAP.

25 Risk factors: Twins, triplets; primagravida Twins, triplets; primagravida Molar pregnancy Molar pregnancy Preexisting: HTN, Diabetes mellitus Preexisting: HTN, Diabetes mellitus Renal or vascular disease Renal or vascular disease Prior hx of preeclampsia/eclampsia Prior hx of preeclampsia/eclampsia Frequency: 5% {all pregnancies in US} Causes: Unknown. Theories: maternal immune reaction that leads to systemic peripheral vascular spasm >> Theories: maternal immune reaction that leads to systemic peripheral vascular spasm >> leads to endothelial cell damage >> vasoconstriction> ^BP. leads to endothelial cell damage >> vasoconstriction> ^BP. Affects multiple organs. Reduced bl.supply to kidneys, liver, placenta, brain. Can lead to placental abruption and fetal & maternal death. Affects multiple organs. Reduced bl.supply to kidneys, liver, placenta, brain. Can lead to placental abruption and fetal & maternal death.

26 Management: Usually only cure is delivery- Depends on symptoms. Mild preeclampsia: Bedrest. home or hospital. Deliver close to EDC. Frequent BPs, 24 hr.urine, liver enzymes, FHR, & ultrasounds. Severe preeclampsia: Goal: prevent convulsions & control mat. BP. BP = 160/110, epigastric pain, 2-4+ proteinuria, ^ liver enzymes, thrombocytopenia [ 100,000]. * Magnesium sulfate [drug of choice]

27 Magnesium Sulfate Bronchodilating effects; prevent seizures; lowers BP. Bronchodilating effects; prevent seizures; lowers BP. Steroids to mom for fetal lung maturity if premature delivery imminent Steroids to mom for fetal lung maturity if premature delivery imminent Infusion pump – IVPB into mainline of RL before/during labor & 24 hrs > delivery. Infusion pump – IVPB into mainline of RL before/during labor & 24 hrs > delivery. Infuse slowly. Infuse slowly. Baseline VS & UO before therapy. least 16/min Baseline VS & UO before therapy. least 16/min Mag SO4 removed solely by kidneys. Mag SO4 removed solely by kidneys. Dont use in pts. w.renal disease. Other drugs: Dilantin & Valium. Dont use in pts. w.renal disease. Other drugs: Dilantin & Valium. Patellar reflex, place foley, RR, fetal status q hr. Patellar reflex, place foley, RR, fetal status q hr.

28 Monitor mag.levels q 2hrs. Mag level 4-6 meq./liter therapeutic. Magnesium Toxicity based on clinical signs: sharp drop in BP sharp drop in BP respiratory paralysis respiratory paralysis disappearance of patellar reflex. disappearance of patellar reflex. STOP infusion, give O2 & calcium gluconate ASAP.

29 HELLP Syndrome:Hemolysis, Elevated Liver Enzymes, Low Platelets Can progress to DIC. Target organ is liver. Target organ is liver. Vasospasms cause vasoconstriction & lead to reduction in blood flow to uterus/other organs. Vasospasms cause vasoconstriction & lead to reduction in blood flow to uterus/other organs. Leads to BP, visual disturbances, low UO, HCT Leads to BP, visual disturbances, low UO, HCT Anemia; Epigastric/RUQ pain & tenderness d/t liver swelling. Weakness, fatigue, jaundice. Anemia; Epigastric/RUQ pain & tenderness d/t liver swelling. Weakness, fatigue, jaundice. Hemolysis > destruction blood cells; + anemia. Hemolysis > destruction blood cells; + anemia. ^ liver enzymes > sign of liver damage. ^ liver enzymes > sign of liver damage. Low platelets - ^ peripheral vascular destruction. Low platelets - ^ peripheral vascular destruction. CBC, platelet count, PT, PTT, LFTs, uric acid. CBC, platelet count, PT, PTT, LFTs, uric acid.

30 DIC: DISSEMINATED INTRAVASCULAR COAGULATION [acute disorder] Blood begins to coagulate throughout entire body. Widespread fibrin deposits in capillaries/arterioles. Body depleted of platelets & coagulation factors; ^ risk of hemorrhage. Over activation of clotting cascade. Blood begins to coagulate throughout entire body. Widespread fibrin deposits in capillaries/arterioles. Body depleted of platelets & coagulation factors; ^ risk of hemorrhage. Over activation of clotting cascade.loodcoagulateplateletshemorrhageloodcoagulateplateletshemorrhage Results in decreased blood flow & ^ tissue damage Always a secondary dx. Causes: ^ tissue thromboplastin d/t vascular damage Triggers: amniotic fluid embolism, eclampsia, eclampsia abruption, pre-eclampsia, HELLP, trauma, gram – sepsis.

31 DIC cont. Physical Assessment Petechiae/ecchymotic areas on skin/mucous mem. Hemorrhaging [occult or obvious] Nose, gums, IV site, IM inj.site, etc… S/S shock; oligouria; ^HR; diaphoresis, seizures Diagnostic tests: CBC, prolonged prothrombin time LAB Findings: low plts, fibrinogen, other clotting factors. Intervention: Treat underlying condition. Infection, pre-eclampsia, abruption, bleeding, shock. IVF (RL); 6-10 L / min. IVF (RL); 6-10 L / min. Foley to monitor UO [30-50 ml/hr] Foley to monitor UO [30-50 ml/hr] Monitor VS; Clotting factors replaced with PRBCs, platelets & fresh frozen plasma. Monitor VS; Clotting factors replaced with PRBCs, platelets & fresh frozen plasma. Heparin may be given to block coagulation cascade. Heparin may be given to block coagulation cascade. Complications: organ injury; maternal mortality.

32 Incompetent Cervix: Passive dilation of cervix without contxs. Passive dilation of cervix without contxs. Usually in early pregnancy. Usually in early pregnancy. hx miscarriages. hx miscarriages. Causes: congenitally short cervix; composition of cervical tissue; DES exposure. Causes: congenitally short cervix; composition of cervical tissue; DES exposure. Dx: ultrasound Dx: ultrasound Management: Strict BR; trendelenberg position if + bulging membranes; hydration IVF, tocolysis. Cerclage best if placed by wks. – binds cervical os. No intercourse; 37 wks.80-90% success

33 Diabetes ^ 41% from in US; 4.9 to 6.9 respectively. Includes gest. DM. ^ 41% from in US; 4.9 to 6.9 respectively. Includes gest. DM. Contributing factor: ^ obesity Contributing factor: ^ obesity Since 1991, obesity ^ 57% in US Since 1991, obesity ^ 57% in US Perinatal mortality/morbidity 6x higher w. undx. pre-existing DM. Perinatal mortality/morbidity 6x higher w. undx. pre-existing DM. Most common complication of pregnancy. Most common complication of pregnancy. Mexican, Puerto Rican, American Indian, Asian Indian, Hawaiian: higher rates than other Hispanic, white, & black. [CDC, 1998] Mexican, Puerto Rican, American Indian, Asian Indian, Hawaiian: higher rates than other Hispanic, white, & black. [CDC, 1998]

34 Gestational Diabetes AKA GDM Glucose intolerance beginning in pregnancy. Glucose intolerance beginning in pregnancy. GDM occurs > 20 th wk. with no ^ incidence of anomalies. GDM occurs > 20 th wk. with no ^ incidence of anomalies. ~ 2% pts. have undx type II entering preg. ~ 2% pts. have undx type II entering preg. Type 1 & 2 have ^ anomalies d/t organogenesis (1 st trimester). Type 1 & 2 have ^ anomalies d/t organogenesis (1 st trimester). ~ 4% of preg.affected. May/may not require insulin. ~ 4% of preg.affected. May/may not require insulin. Maternal Risks: HTN disorders, PTL, Maternal Risks: HTN disorders, PTL, polyhydramnios, macrosomia (^ C/S rate). Infant Risks: Birth trauma, shoulder dystocia, Infant Risks: Birth trauma, shoulder dystocia, hypoglycemia, hyperbilirubinemia, RDS, thrombocytopenia, hypocalcemia, fetal death.

35 Pathophysiology: GDM Pregnancy hormones estrogen, HPL, Pregnancy hormones estrogen, HPL, prolactin, cortisol, progesterone, blocks insulin receptors > 20 wks. pregnancy. Results in ^ circulating glucose; Results in ^ circulating glucose; More insulin released to attempt to maintain glucose homeostasis. Pt. feels hungry d/t ^ insulin; vicious cycle of ^ appetite & wt.gain results. More insulin released to attempt to maintain glucose homeostasis. Pt. feels hungry d/t ^ insulin; vicious cycle of ^ appetite & wt.gain results.

36 Screening & Diagnosis of GDM screen ALL wks. screen ALL wks. HIGHER Risk pts. screened in 1 st trimester/1 st prenatal visit wks. HIGHER Risk pts. screened in 1 st trimester/1 st prenatal visit wks. Determining High Risk Clients: Family hx DM; Previous hx GDM Family hx DM; Previous hx GDM Marked obesity; Glycosuria Marked obesity; Glycosuria Maternal Age > 30 Maternal Age > 30 Hx infant > 4000g Hx infant > 4000g Member of high-risk racial/ethnic group Member of high-risk racial/ethnic group Hispanic, Native American, South or East Asian, African American, Pacific Islander. Hispanic, Native American, South or East Asian, African American, Pacific Islander. If results negative, wks.

37 Screening & Diagnosis cont. 1st Do: 1 hour glucose challenge test (GCT) - 50g oral glucola. No fasting needed. 1 hour glucose challenge test (GCT) - 50g oral glucola. No fasting needed. Recommended GCT value <140mg/dL (detects 80%) [130 value detects 90% women w.GDM] Recommended GCT value <140mg/dL (detects 80%) [130 value detects 90% women w.GDM] ADA & ACOG(2003) approved. ADA & ACOG(2003) approved. Follow GCT >/=140mg/dL with diagnostic 3hr.GTT [glucose tolerance test] 100 g. glucola. Do fasting, 1h, 2h, 3h serum. least 8 hrs. least 150 g. carb intake 3 days prior to test & normal activity level. Do fasting, 1h, 2h, 3h serum. least 8 hrs. least 150 g. carb intake 3 days prior to test & normal activity level.

38 GTT Diagnostic Thresholds: [ADA 2003] Fasting Blood Sugar: 95 mg/dL Drink 100 g glucola Drink 100 g glucola 1 hour: 180 mg/dL plasma level 2 hour: 155 mg/dL 3 hour: 140 mg/dL Diagnosis of GDM made if 2 or more values ^ than above plasma levels. Diagnosis of GDM made if 2 or more values ^ than above plasma levels.Management *May try standard diabetic diet 1 st *depends on lab values *May try standard diabetic diet 1 st *depends on lab values Initiate insulin for fasting > 95 & 2hr postprandial >120. Initiate insulin for fasting > 95 & 2hr postprandial >120.

39 Interventions: Antepartum Goal: strict glucose control. Provide immediate education to pt./family Provide immediate education to pt./family Standard diabetic diet [ cal/day]. Standard diabetic diet [ cal/day]. Distribution of calories: 40-50% carbs, 20% protein, 30-40% fat, (< 1/3 rd from saturated fat, 1/3 rd polyunsaturated, rest monounsaturated). Recommend: 3 meals & 3 snacks evenly spaced to avoid swings in blood glucose. bedtime mg/day calcium, 30 mg/day iron, 400 mcg/day folate.

40 Antepartum Interventions Cont. Exercise [walking, swimming] 30 min.3-4 x/wk Exercise [walking, swimming] 30 min.3-4 x/wk Teach daily glucose self-monitoring & urine testing. Teach daily glucose self-monitoring & urine testing. Teach monitoring of fasting & postprandial levels. Teach monitoring of fasting & postprandial levels. If diet cant control glucose, start insulin. If diet cant control glucose, start insulin. Regular & NPH insulin < breakfast & dinner. Regular & NPH insulin < breakfast & dinner. Does not cross placenta. Abdomen site. Does not cross placenta. Abdomen site. Dose based on weight & gestational age Dose based on weight & gestational age Obese pts. ^ dose. Obese pts. ^ dose.

41 GDM - Interventions cont. Intrapartum: monitor glucose levels q 2hrs. [insulin 100mg/dL or <]. Postpartum: Most return to normal > del. 50% pts. with GDM develop type II later in life. 50% pts. with GDM develop type II later in life. 6 wk. PP serum glucose 6 wk. PP serum glucose Children of GDM pts. ^ risk for obesity/diabetes in childhood/adolescence. Children of GDM pts. ^ risk for obesity/diabetes in childhood/adolescence.

42 Diabetes Mellitus: Disorder of fat, CH0 [carbs], protein metabolism Disorder of fat, CH0 [carbs], protein metabolism Caused by insensitivity to insulin or partial or complete lack of insulin secretion by beta cells of pancreas Caused by insensitivity to insulin or partial or complete lack of insulin secretion by beta cells of pancreas exposes organs to chronic hyperglycemia causing tissue damage. exposes organs to chronic hyperglycemia causing tissue damage.

43 Type I - IDDM predates pregnancy. Autoimmune destruction of beta cells of pancreas resulting in absolute insulin deficiency. Autoimmune destruction of beta cells of pancreas resulting in absolute insulin deficiency. Individuals < 30 yrs.; any age. Affects ~ 1- 3/1000 preg. Individuals < 30 yrs.; any age. Affects ~ 1- 3/1000 preg. Need exogenous insulin to prevent ketoacidosis. Need exogenous insulin to prevent ketoacidosis. Symptoms: polyuria, polydipsia, significant weight loss. Do HgbA1c ASAP to assess recent serum glucose levels.

44 Type I cont. 1 st trimester: exogenous insulin needs may drop 10-20%. exogenous insulin needs may drop 10-20%. Hypoglycemia d/t fluctuations & N/V. Hypoglycemia d/t fluctuations & N/V. 2 nd half of pregnancy (> 20 wks.): insulin needs ^ by 50–60% for Type I & II, respectively compared to pre-pregnancy. insulin needs ^ by 50–60% for Type I & II, respectively compared to pre-pregnancy. Have higher levels of depression which negatively affects glucose control. Have higher levels of depression which negatively affects glucose control.

45 Management: Type I – Cont. insulin. Cont. insulin. incorporate exercise & diet into daily routine incorporate exercise & diet into daily routine monitor glucose levels 5-6/day. monitor glucose levels 5-6/day. Endocrinologist during pregnancy. Endocrinologist during pregnancy. set intervals. set intervals. Teach pt. s/s hypo & hyperglycemia. Teach pt. s/s hypo & hyperglycemia. Goal: Glucose control reduces risk of complications for pt. & fetus Goal: Glucose control reduces risk of complications for pt. & fetus

46 Type II: More common; individuals > 30. More common; individuals > 30. Recent data [AMA 2001] 9.1% ^ in yrs. & 69.9% ^ in 30–39 yrs. [1990 to 1998] Combination of insulin resistance & inadequate insulin production. Combination of insulin resistance & inadequate insulin production. Fewer symptoms Fewer symptoms Longer to dx (~ 6.5 yrs.) Longer to dx (~ 6.5 yrs.) Obesity prevalent in type II. Obesity prevalent in type II. May require exogenous insulin; may be controlled w.diet & exercise alone. May require exogenous insulin; may be controlled w.diet & exercise alone.

47 Pre-Conception Planning: begin during reproductive years with hx of type I & II. Pre-Conception Planning: begin during reproductive years with hx of type I & II. Maintain normal A1C 3-6 mos. before conception & during organogenesis (6-8 wks) - minimize risk of spontaneous AB & congenital anomalies Maintain normal A1C 3-6 mos. before conception & during organogenesis (6-8 wks) - minimize risk of spontaneous AB & congenital anomalies A1C level > 7: ^ risk for congenital anomalies & miscarriage. Normal A1C = 4-6 %. A1C level > 7: ^ risk for congenital anomalies & miscarriage. Normal A1C = 4-6 %. Multidisciplinary team: nutritionist, endocrinologist, high risk OB nurse. Multidisciplinary team: nutritionist, endocrinologist, high risk OB nurse. Educate pt.- managing diet, activity, insulin. Educate pt.- managing diet, activity, insulin. Daily food diary to assess compliance. Daily food diary to assess compliance. Home visits by RN as needed. Home visits by RN as needed.

48 Cardiac Disease: Impaired cardiac function mainly from congenital/rheumatic heart disease. Class Description: Class I: unrestricted physical activity. No symptoms of cardiac insufficiency. Class II: slight limitation physical activity. Class III: mod. limitation physical activity. Class IV: No physical activity.

49 RISKS FOR MATERNAL MORTALITY CAUSED BY VARIOUS HEART DISEASES Cardiac Disorder: Group 1 - Mortality (0-1 %) ASD; VSD; PDA; Pulmonic or tricuspid disease ASD; VSD; PDA; Pulmonic or tricuspid disease Tetralogy of Fallot (corrected), Bioprosthetic valve; Mitral stenosis Tetralogy of Fallot (corrected), Bioprosthetic valve; Mitral stenosis Group 2 – (5-15%) Aortic stenosis; Coarctation without valve Aortic stenosis; Coarctation without valve involvement, Tetralogy of Fallot (uncorrected), previous MI, Mitral stenosis with AF, artificial valve Group 3 – (25-50%) Marfan Syndrome; MI; pulmonary HTN; Cardiomyopathy. Marfan Syndrome; MI; pulmonary HTN; Cardiomyopathy. Group 4 – (> 50%) CHF; advanced pulmonary edema CHF; advanced pulmonary edema

50 Goal: optimal uteroplacental perfusion. Thorough medical hx: rheumatic heart dis., scarlet fever, lupus, renal disease Thorough medical hx: rheumatic heart dis., scarlet fever, lupus, renal disease Birth defects involving heart &/or valves. Birth defects involving heart &/or valves. Assess symptoms: SOB, chronic cough, Assess symptoms: SOB, chronic cough, arrhythmias, palpitations, rest, headache, chest pain, etc. Family Hx of cardiac disease. Family Hx of cardiac disease. Do PE. Do PE. Lab tests:12 lead EKG, echo, stress test, CBC, SMA12, uric acid levels, O2sat, CxR; ABGs. Lab tests:12 lead EKG, echo, stress test, CBC, SMA12, uric acid levels, O2sat, CxR; ABGs. Risks ^ with maternal age & parity. Risks ^ with maternal age & parity.

51 Arrhythmias: In Pregnancy Goal: to convert to sinus rhythm or control ventricular rate by beta-blockers or digoxin. Fetal-Neonatal Implications: General Prognosis: proceed with pregnancy if disease controlled and mild to moderate. EX. severe valve damage, possible termination advised d/t ^ risk maternal mortality. Correct valve lesions before preg. *Pre-conception planning.

52 Peripartum Cardiomyopathy : 1 in pregnancies. Findings: Cardiac failure last month of preg. or within 5 months PP Cardiac failure last month of preg. or within 5 months PP Absence of specific etiology for cardiac failure. Absence of specific etiology for cardiac failure. Absence of cardiac disease < last month of preg. Absence of cardiac disease < last month of preg. Symptoms: maternal dyspnea, cough, orthopnea [diff.breathing when lying down] & palpitations. maternal dyspnea, cough, orthopnea [diff.breathing when lying down] & palpitations. Management: minimize decreased cardiac performance. Give anticoagulants during/after delivery. High incidence of embolic events. Prognosis: 50% pt. recover good ventricular function within 6 mos.of delivery; 50% have persistent cardiomegaly w. mortality of 80%. Must weigh risks/benefits to mom/fetus.

53 Infections: A. Urinary Tract Infections Caused by: E coli, Klebsiella, Proteus. S&S: Asymptomatic Bacteriuria = + bacteria in urine cx w.no symptoms. S&S: Asymptomatic Bacteriuria = + bacteria in urine cx w.no symptoms. Rx: Early pregnancy: oral sulfonomides Bactrim]; Late: ampicillin, furodantin. Rx: Early pregnancy: oral sulfonomides Bactrim]; Late: ampicillin, furodantin. if left untreated, infection lead to acute pyelonephritis. if left untreated, infection lead to acute pyelonephritis. Can cause PTL; sexual activity > UTI. Can cause PTL; sexual activity > UTI.

54 B. Cystitis (lower UTI) - Same organisms S&S: Dysuria, urgency, frequency, low grade fever, clean catch leukocytes >100,000 S&S: Dysuria, urgency, frequency, low grade fever, clean catch leukocytes >100,000 Same as UTI; Same as UTI Same as UTI; Same as UTI C. Acute Pyelonephritis - infection of kidney. Caused by same. S&S: chills, fever, flank pain,dysyria, low urine output, ^ B/P, N/V, WBCs, dx with + urine culture. S&S: chills, fever, flank pain,dysyria, low urine output, ^ B/P, N/V, WBCs, dx with + urine culture. Rx: Hospitalization, IVAB; Safe meds.during pregnancy: Bactrim, a flouroquinolone (Cipro). Rx: Hospitalization, IVAB; Safe meds.during pregnancy: Bactrim, a flouroquinolone (Cipro). Increased risk of premature birth & IUGR. Increased risk of premature birth & IUGR.

55 D. Monilial Vaginal Infection Caused: 80% candida albicans. Caused by change in normal vaginal Ph; ph < 5 - acidic. Caused: 80% candida albicans. Caused by change in normal vaginal Ph; ph < 5 - acidic. S&S: Thick white curdy discharge, severe S&S: Thick white curdy discharge, severe itching dysuria. Wet Mount: hyphae, budding yeast. itching dysuria. Wet Mount: hyphae, budding yeast. Risk Factors: HIV, DM, pregnancy, stress, AB tx. Tx: Intravaginal miconazole hs for 1 wk. Tx: Intravaginal miconazole hs for 1 wk. Teach: yogurt in diet; no douching; cotton underwear. Teach: yogurt in diet; no douching; cotton underwear. Implic: Fetus may contact thrush during Implic: Fetus may contact thrush during delivery. Tx baby w.oral nystatin 1cc q 6h. delivery. Tx baby w.oral nystatin 1cc q 6h. Infant with thrush may give it to mom when breast fdg. Apply nystatin. Infant with thrush may give it to mom when breast fdg. Apply nystatin.

56 Bacterial Vaginosis & Trichomoniasis BV: Overgrowth of Gardnerella [normal vaginal flora] BV: Overgrowth of Gardnerella [normal vaginal flora] Loss of protective lactobacilli bacteria. Aka vaginitis. Loss of protective lactobacilli bacteria. Aka vaginitis. Thin, watery vaginal dc with fishy odor. Clue cells seen under microscope. Vaginal ph >5. Thin, watery vaginal dc with fishy odor. Clue cells seen under microscope. Vaginal ph >5. TX with Flagyl [Metronidazole 500mg BID x 7 days. Do not take med with alcohol. Similar to Antabuse –severe N/V. TX with Flagyl [Metronidazole 500mg BID x 7 days. Do not take med with alcohol. Similar to Antabuse –severe N/V. Risk factor for PTL and PROM. Risk factor for PTL and PROM. Trichomoniasis: Different organism caused by parasite Trichomonas vaginalis. Vaginal discharge (thin, greenish- yellow, frothy or foamy). Trichomoniasis: Different organism caused by parasite Trichomonas vaginalis. Vaginal discharge (thin, greenish- yellow, frothy or foamy). An STI An STI Same tx as above. Safe in pregnancy. Same tx as above. Safe in pregnancy. Risk factor for PTL and PROM. Risk factor for PTL and PROM.

57 E. STDs Chlamydia Chlamydia Caused By: bacterium Chlamydia trachomatis Caused By: bacterium Chlamydia trachomatis Most common STI in USA Most common STI in USA PID > infertility by blocking tubes. PID > infertility by blocking tubes. Often asymptomatic. Thin/purulent discharge, burning & frequency w.urination, lower abd. pain. Often asymptomatic. Thin/purulent discharge, burning & frequency w.urination, lower abd. pain. Pregnant women: Zithromax 1 g single dose; amoxicillin x 7 days. Pregnant women: Zithromax 1 g single dose; amoxicillin x 7 days. Newborn conjunctivitis (erythromycin ointment), neonatal pneumonia, PTL, fetal death. Perinatal transmission occurs in 50% infants where mom is time of del. Newborn conjunctivitis (erythromycin ointment), neonatal pneumonia, PTL, fetal death. Perinatal transmission occurs in 50% infants where mom is time of del.

58 Gonorrhea Caused by Neisseria Gonorrhea. Bacterial STI. Caused by Neisseria Gonorrhea. Bacterial STI. Can lead to PID > infertility. Green frothy dc. Can lead to PID > infertility. Green frothy dc. Often asymptomatic in females; males have burning with urination & penile dc. Often asymptomatic in females; males have burning with urination & penile dc. Dx - vaginal or urine cx.DOH notifies partners. Dx - vaginal or urine cx.DOH notifies partners. Rx with Rocephin IM [ceftriaxone]. Zithromax [azithromycin] 1 g single dose or amoxicillan po. Rx with Rocephin IM [ceftriaxone]. Zithromax [azithromycin] 1 g single dose or amoxicillan po. PID – caused by both. Cramping, fever, chills, purulent dc, N/V, uterine swelling, adnexal & cervical tenderness. Multiple sex partners, no condoms. Tx with Doxycycline po (contraindicated in pregnancy) & Rocephin IM. Clinda/genta/rocephin if pregnant. May need hospitalization. PID – caused by both. Cramping, fever, chills, purulent dc, N/V, uterine swelling, adnexal & cervical tenderness. Multiple sex partners, no condoms. Tx with Doxycycline po (contraindicated in pregnancy) & Rocephin IM. Clinda/genta/rocephin if pregnant. May need hospitalization.

59 Herpes Viral infection – no cure. Viral infection – no cure. HSV I – oral [cold sore] outer lesion. HSV I – oral [cold sore] outer lesion. HSV 2 – genital – painful, open lesions. HSV 2 – genital – painful, open lesions. Vesicles rupture & appear right after exposure or within 20 days. Vesicles rupture & appear right after exposure or within 20 days. Burning sensation with urination is 1 st sign. Burning sensation with urination is 1 st sign. Prodrome tingling occurs before new outbreak. Prodrome tingling occurs before new outbreak. Outbreaks several times/yr. Outbreaks several times/yr. Dx: vaginal cx or blood test Dx: vaginal cx or blood test Rx: Acyclovir or Valtrex 500 mg once/day during pregnancy reduces viral load enough to deliver vaginally. Rx: Acyclovir or Valtrex 500 mg once/day during pregnancy reduces viral load enough to deliver vaginally.

60 Syphilis: Treponema Palladium [Spirochete] Primary Stage: painless sores, chancre, approximately 2- 3 wks > initial exposure. fever, malaise. Primary Stage: painless sores, chancre, approximately 2- 3 wks > initial exposure. fever, malaise. Secondary Stage: 6 wks to 6 mos. Skin eruptions, arthritis, liver enlarged, sore throat, Secondary Stage: 6 wks to 6 mos. Skin eruptions, arthritis, liver enlarged, sore throat, Dx: VDRL, RPR, FTA-ABS (more specific), Dark field exam: for spirochetes. Dx: VDRL, RPR, FTA-ABS (more specific), Dark field exam: for spirochetes.Tx: <1 yr 2.4 million u benzathine penicillin x 1 dose <1 yr 2.4 million u benzathine penicillin x 1 dose >1 yr SAME MED 1x/wk x 3 wks. >1 yr SAME MED 1x/wk x 3 wks. Sexual partners screened /tx. [allergic to PCN]: tx ceftriazone >1 st trimester. Sexual partners screened /tx. [allergic to PCN]: tx ceftriazone >1 st trimester. ~ 40% chance of stillbirth or death > birth. Infant may be born w. congenital syphilis. Opthalmia neonatorium: can cause blindness. Appears as conjunctivitis in newborn. Give baby PCN q day x10. ~ 40% chance of stillbirth or death > birth. Infant may be born w. congenital syphilis. Opthalmia neonatorium: can cause blindness. Appears as conjunctivitis in newborn. Give baby PCN q day x10.

61 GENITAL WARTS – virus [aka condyloma] Soft pink lesions on vulva, vagina, cervix, anus. Cauliflower appearance Soft pink lesions on vulva, vagina, cervix, anus. Cauliflower appearance HPV Types 6 and 11 cause 90% of genital warts. HPV Types 6 and 11 cause 90% of genital warts. ~ 120 strains HPV ~ 120 strains HPV Tx: Trichloroacetic acid, Aldara. Category C Tx: Trichloroacetic acid, Aldara. Category C Benefits (pregnancy) may be acceptable over potential risks. Benefits (pregnancy) may be acceptable over potential risks. Contact occurs during vaginal birth. Infant may have laryngeal warts. Contact occurs during vaginal birth. Infant may have laryngeal warts. Gardasil Vaccine: 3 doses. HPV Types 16 & 18 – [70% cervical cancer] and Types 6 & 11 – [90% genital warts] Can be given to males also. HPV Types 16 & 18 – [70% cervical cancer] and Types 6 & 11 – [90% genital warts] Can be given to males also.


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