nancy pares, rn, msn metro community college. apply basic knowledge of healthy maternal newborn...
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NURS 2410 Unit 1Nancy Pares, RN, MSN
Metro Community College
Apply basic knowledge of healthy maternal newborn care (recall from PN year)
Describe ethical and legal issues of maternal newborn nursing, current legislation and community resources available.
Demonstrate appropriate therapeutic communication and assessment of high risk pregnancy.
Objective 1 and 2 and 3
Context◦ Who is involved, what is the setting◦ What other information is needed◦ What personal beliefs of the nurse may impact
the situation Clarification of the issues
◦ What are the ethical issues◦ Who should decide the issue
Identification of alternatives and potential outcomes
Ethical decision making model
Ethical reasoning◦ What ethical theories have bearing on the
situation◦ Should some theories be given greater weight in
the decision making process◦ What legal or social constraints are factors ◦ What obligations might be present in the role of
the nurse
Decision making cont
Resolution◦ What is the best action in this situation◦ What strategy should be used to carry out this
action Evaluation
◦ What were the outcomes◦ Should this same action be used in the future for
similar dilemmas
Decision making model cont
Professional Nurse Certified Registered Nurse Nurse Practitioner Clinical Nurse Specialist Certified Nurse Midwife
Maternal-Newborn Nursing Roles
Religion and social beliefs Presence and influence of the extended
family Socialization within the ethnic group Communication patterns Beliefs and understanding about health
and illness Permissible physical contact with
strangers education
Factors Contributing to Family Values
Standards of care:◦ Minimum criteria for competent, proficient,
delivery of nursing care Institutional policies Ethical implications Scope of practice
◦ Defined by state Nurse Practice Act laws
Legal Issues
There was a duty to provide care. The duty was breached. Injury occurred. The breach of duty caused the injury
(proximate cause).
Negligence
Divergence between rights of mother and rights of fetus:◦ Mother may refuse fetal intervention.◦ Fetal intervention may be forced on mother.
Fetal research:◦ Therapeutic vs. non-therapeutic
Maternal-Child Issues
Intrauterine fetal surgery:◦ Therapy for anomalies incompatible with life◦ Health of the mother and fetus is at risk◦ Surrogate, frozen embryo, ◦ Female circumcision
Maternal-Child Issues
Abortion◦Can be performed until point of viability
◦After viability, if mother’s health in jeopardy
Nursing role◦Have right to refuse to assist◦Responsible for ensuring a qualified replacement is available
Maternal-Child Issues
Infertility Human stem cells Cord blood Maternal refusal for c/del Maternal refusal for fetal surgery
Maternal-Child Issues
Womens’ health standards by Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)
State Boards Individual facilities policy
Standards of Care
A holistic interpersonal approach Adequate documentation Communication Updated and realistic policies and
procedures Appropriate delegation Question deviations from the standar Follow chain of command
Practicing Safety
Transforms research findings into clinical practice:◦ Efficiency improvement◦ Better outcomes◦ Quality improvement
Benefits ofEvidence-Based Practice
Identify vulnerable periods during which malformations of various organs may occur and describe the resulting anomalies.
Describe the function and structure of the placenta during intrauterine life. (review PN year)
Objective 4 and 5
Mitosis:◦ Exact copies of original cell
Meiosis:◦ Production of new organism
Cell Division (review A&P)
Deletion◦ Loss of chromosome material
Translocation◦ Misplacement
Nondisjunction◦ Chromosomes don’t separate correctly
Karotype◦ Chromosomal make up of an individual
Mosaicismtwo or more genetically different cell populations in an individual
Genetic terms
Figure 11–2 Comparison of mitosis and meiosis.
Interphase Prophase Metaphase Anaphase Telophase
Mitosis
First division:◦ Chromosomes replicate, pair, and exchange
information.◦ Chromosome pairs separate, and cell divides.
Second division:◦ Chromatids separate and move to opposite poles.◦ Cells divide, forming four daughter cells.
Meiosis
Ovary gives rise to oogonial cells. Cells develop into oocytes. Meiosis begins and stops before birth. Cell division resumes at puberty. Development of Graafian follicle.
Oogenesis
Production of sperm First meiotic division:
◦ Primary spermatocyte replicates and divides. Second meiotic division:
◦ Secondary spermatocytes replicate and divide. Produce four spermatids.
Spermatogenesis
Figure 11–3 Gametogenesis involves meiosis within the ovary and testis. A, During meiosis, each oogonium produces a single haploid ovum once some cytoplasm moves into the polar bodies. B, Each spermatogonium, in contrast, produces four haploid spermatozoa.
Uniting sperm and ovum form a zygote Ova are fertile for 12 to 24 hours Sperm are fertile for 72 hours Takes place in the ampulla of fallopian tube
Fertilization
Capacitation:◦ Removal of plasma membrane and glycoprotein
coat◦ Loss of seminal plasma proteins
Acrosomal reaction:◦ Release of enzymes ◦ Allows entry through corona radiata
Changes in Sperm
Figure 11–4 Sperm penetration of an ovum. A, The sequential steps of oocyte penetration by a sperm are depicted moving from top to bottom. B, Scanning electron micrograph of human sperm surrounding a human oocyte (750ラ). The smaller spherical cells are granulosa cells of the corona radiata. SOURCE: Used with permission from Nilsson, L. (1990). A child is born. New York: Dell Publishing.
Zone pellucida blocks additional sperm from entering
Secondary oocyte completes second meiotic division◦ Forms nucleus of ovum
Nuclei of ovum and sperm unite Membranes disappear Chromosomes pair up
After Sperm Entry
Fraternal: two ova and two sperm Identical: single fertilized ovum
- Originate at different stages
Twins
Cleavage Blastomeres form morula Blastocyst:
- develops into embryonic disc and amnion
Trophoblast: - develops into chorion
Pre-embryonic
Occurs 7 to 10 days after fertilization Blastocyst burrows into endometrium Endometrium is now called decidua
Implantation
Primary germ layers:◦ Ectoderm◦ Mesoderm◦ Endoderm
Embryonic Development
Metabolic and nutrient exchange Maternal portion:
◦ Decidua Fetal portion:
◦ Chorionic villi Fetal surface covered by amnion
Placenta
Chorionic villi form spaces in decidua basalis
Spaces fill with maternal blood. Chorionic villi differentiate:
◦ Syncytium: outer layer◦ Cytotrophoblast: inner layer
Anchoring villi form septa
Placental Development
Figure 11–13 Longitudinal section of placental villus. Spaces formed in the maternal decidua are filled withmaternal blood; chorionic villi proliferate into these maternal blood-filled spaces and differentiate into a syncytium layer and a cytotrophoblast layer.
Body stalk fuses with embryonic portion of the placenta
Provides circulatory pathway from chorionic villi to embryo:◦ One vein
Delivers oxygenated blood to fetus:◦ Two arteries
Umbilical Cord
Figure 11–14 Vascular arrangement of the placenta. Arrows indicate the direction of blood flow. Maternal blood flows through the uterine arteries to the intervillous spaces of the placenta and returns through the uterine veins to maternal circulation. Fetal blood flows through the umbilical arteries into the villous capillaries of the placenta and returns through the umbilical vein to the fetal circulation.
Nutrition Excretion Fetal respiration Production of fetal nutrients Production of hormones
Placental Functions
Beginning development of GI tract Heart is developing Somites develop—beginning vertebrae Heart is beating and circulating blood Eyes and nose begin to form Arm and leg buds are present
Fetal Development: Week 4
Trachea is developed Liver produces blood cells Trunk is straighter Digits develop Tail begins to recede
Fetal Development: Week 6
Eyelids are closed Tooth buds appear Fetal heart tones can be heard Genitals are well-differentiated Urine is produced Spontaneous movement occurs
Fetal Development: Week 12
Lanugo begins to develop Blood vessels are clearly developed Active movements are present Fetus makes sucking motions Swallows amniotic fluid Produces meconium
Fetal Development: Week 16
Subcutaneous brown fat appears Quickening is felt by mother Nipples appear over mammary glands Fetal heartbeat is heard by fetoscope
Fetal Development: Week 20
Eyes are structurally complete Vernix caseosa covers skin Alveoli are beginning to form
Fetal Development: Week 24
Testes begin to descend Lungs are structurally mature
Fetal Development: Week 28
Rhythmic breathing movements Ability to partially control temperature Bones are fully developed but soft and
flexible
Fetal Development: Week 32
Increase in subcutaneous fat Lanugo begins to disappear
Fetal Development: Week 36
Skin appears polished Lanugo has disappeared except in upper
arms and shoulders Hair is now coarse and approximately 1 inch
in length Fetus is flexed
Fetal Development: Week 38
Quality of sperm or ovum Genetic code Adequacy of intrauterine environment Teratogens
Factors Influencing Development
Maternal effects:◦ Malnutrition ◦ Bone-marrow suppression◦ Increased incidence of infections◦ Liver disease
Neonatal effects:◦ Fetal alcohol spectrum disorders (FASD)
Alcohol Use in Pregnancy
Figure 19–2 Percentages of pregnant females ages 15 to 44 reporting past month alcohol use, by trimester, 2003–2004. SOURCE: Substance Abuse and Mental Health Services Administration (SAMHSA). (2005).Results from the 2004 National Survey on Drug Use and Health: National Findings. Office of Applied Studies, NSDUH Series H-28 DHHS Publication No. SMA 05-4062. Rockville, MD: Author.
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: Maternal Effects
Decreased birth weight and head circumference
Feeding difficulties Neonatal effects from breast milk:
◦ Extreme irritability◦ Vomiting and diarrhea◦ Dilated pupils and apnea
Cocaine Use in Pregnancy: Fetal Effects
Maternal effects:◦ Poor nutrition and iron-deficiency anemia◦ Preeclampsia-eclampsia◦ Breech position◦ Abnormal placental implantation◦ Abruptio placentae◦ Preterm labor
Heroin Use in Pregnancy
Maternal effects:◦ Premature rupture of the membranes (PROM)◦ Meconium staining◦ Higher incidence of STIs and HIV
Fetal effects:◦ IUGR ◦ Withdrawal symptoms after birth
Heroin Use in Pregnancy (cont’d)
Marijuana: difficult to evaluate, no known teratogenic effects
PCP - maternal overdose or a psychotic response
MDMA (Ecstasy) - long-term impaired memory and learning
Substance Use in Pregnancy: Maternal Effects
Figure 19–1 Percentages of females ages 15 to 44 reporting past month use of any illicit drugs, by pregnancy status and age, 2003–2004. SOURCE: Substance Abuse and Mental Health Services Administration (SAMHSA). (2005). Results from the 2004 National Survey on Drug Use and Health: National Findings. Office of Applied Studies, NSDUH Series H-28 DHHS Publication No. SMA 05-4062. Rockville, MD: Author.
Identify tests used to detect abnormalities, fetal well being and infertility management.
Discuss age related considerations of pregnancy.
Explain the nursing process as it relates to maternal fetal medical conditions.
Objective 7 and 8 and 9
Favorable cervical mucus Clear passage between cervix and tubes Patent tubes with normal motility Ovulation and release of ova
Essential Components of Fertility: Female
No obstruction between ovary and tubes Endometrial preparation Adequate reproductive hormones
Essential Components of Fertility: Female (cont’d)
Normal semen analysis Unobstructed genital tract Normal genital tract secretions Ejaculated spermatozoa deposited at the
cervix
Essential Components of Fertility: Male
Ovulation Cervix Uterine structures Tubal patency Semen analysis
Preliminary Investigation of Infertility
Figure 12–2 Sequence of events in a normal reproductive cycle showing the relationship of hormone levels to events in the ovarian and endometrial cycles.
Ovulatory:◦ Pharmacologic treatment◦ Donor oocytes
Cervical:◦ THI, IVF, GIFT
Treatment of Infertility Problems
Uterine/Tubal:◦ IVF, GIFT◦ Donor oocytes or gestational carrier
Sperm:◦ THI, IVF, GIFT◦ Micromanipulation
Treatment of Infertility Problems (cont’d)
Figure 12–8 Assisted reproductive techniques.
Marriage may be stressed Relationship affected by intrusiveness Guilt Frustration Anger Shame
Physiologic and Psychological Effects
Loss of control Feelings of reduced competency and
defectiveness Loss of status and ambiguity as a couple A sense of social stigma Stress on the personal and sexual
relationship A strained relationship with healthcare
providers
Physiologic and PsychologicalEffects (cont’d)
Counselor Educator Advocate
Nursing Management of Infertility
Maternal age 35 or over Family history:
◦ Known or suspected Mendelian genetic disorder◦ Birth defects and/or mental retardation
Indications for Preconceptual Genetic Testing
Previous pregnancies:◦ Previous child with chromosomal anomaly◦ Previous child with metabolic disorder◦ Two or more first trimester spontaneous abortions
Indications for Preconceptual Genetic Testing (cont’d)
Parental genetics:◦ Couples with a balanced translocation◦ Couples who are carriers for a metabolic disorder
Abnormal MSAFP Women with teratogenic risk
Indications for Preconceptual Genetic Testing (cont’d)
Multigenerational 50% chance of passing on the gene Males and females equally affected Varying degrees of presentation Diseases
◦ Achondroplasia◦ Marfans◦ Neurofibromotosis
Autosomal Dominant Disorders
Achondroplasia◦ Most common dwarfism, lifespan and IQ WNL
Marfans◦ Connective tissue disorder, triad of ocular,
skeletal and CV alterations Neurofibromotosis (Von Recklinhausen)
◦ Soft tumor development of peripheral nerves
Figure 12–19 Autosomal dominant pedigree. One parent is affected. Statistically, 50% of offspring will be affected, regardless of sex.
Carrier parents 25% chance of passing on abnormal gene 25% chance of an affected child If child is clinically normal, 50% chance
child is carrier Males and females equally affected Diseases: CF, Sickle Cell, PKU, Tay Sachs
Autosomal Recessive Disorders
Figure 12–20 Autosomal recessive pedigree. Both parents are carriers. Statistically, 25% of offspring will be affected, regardless of sex.
No male-to-male transmission 50% chance carrier mother will pass the
abnormal gene to sons (affected) 50% chance carrier mother will pass the
abnormal gene to daughters (carrier) Diseases: Hemophilia A, Duchennes MD,
Trisomies, Klinefelters, Turner’s Cri du chat, Fragile X
X-linked Recessive Disorders
Figure 12–21 X-linked recessive pedigree. The mother is the carrier. Statistically, 50% of male offspring will be affected, and 50% of female offspring will be carriers.
Genetic ultrasound Genetic amniocentesis Chorionic villus sampling Percutaneous umbilical blood sampling MSAFP
Genetic Testing
Figure 12–22 A, Genetic amniocentesis for prenatal diagnosis is done at 14 to 16 weeks’ gestation. B, Chorionic villus sampling is done at 8 to 10 weeks, and the cells are karyotyped within 48 to 72 hours.
Educate about tests Provide support Refer for counseling Resource during and after counseling
Nurse’s Role
Identify the maternal fetal effects of TORCH (toxoplasmosis, other, rubella, cytomegalovirus, herpes) infections and the corresponding nursing interventions.
Objective 10
Toxoplasmosis Rubella Cytomegalovirus Herpes simplex virus Group B streptococcus Human B-19 parvovirus
Perinatal Infections
Retinochoroiditis Convulsions Coma Microcephaly Hydrocephalus
Fetal Risks: Toxoplasmosis
Congenital cataracts Sensorineural deafness Congenital heart defects
Fetal Risks: Rubella
Neurologic complications Anemia Hyperbilirubinemia Thrombocytopenia Hepatosplenomegaly SGA
Fetal Risks: Chlamydia
Preterm labor Intrauterine growth restriction Neonatal infection
Fetal Risks: Herpes
Respiratory distress or pneumonia Apnea Shock Meningitis Long-term neurologic complications
Fetal Risks: GBS
Spontaneous abortion Fetal hydrops Stillbirth
Fetal Risks: Human B-19 Parvovirus
Discuss pathophysiology, treatment and nursing interventions for pregnant women with:◦ Cardiac Disease, Chorioamnionitis, Gestational
trophoblastic disease, diabetes, Rh sensitivity, pregnancy induced hypertension and HELLP syndrome, HIV, hyperemesis gravidarium .
Objective 11
Endocrine disorder of carbohydrate metabolism
Results from inadequate production or utilization of insulin
Cellular and extracellular dehydration Breakdown of fats and proteins for energy
Pathology of Diabetes Mellitus (DM)
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
Gestational Diabetes (GDM)
Early pregnancy:◦ Increased insulin production and tissue sensitivity
Second half of pregnancy:◦ Increased peripheral resistance to insulin
Effect of Pregnancy on Carbohydrate Metabolism
Hydramnios Preeclampsia-eclampsia Ketoacidosis Dystocia Increased susceptibility to infections
Maternal Risks with DM
Perinatal mortality Congenital anomalies Macrosomia IUGR RDS Polycythemia
Fetal and Neonatal Risks with DM
Hyperbilirubinemia Hypocalcemia
Fetal and Neonatal Risks with DM (cont’d)
Assess risk at first visit:◦ Low risk - screen at 24 to 28 weeks◦ High risk - screen as early as feasible
Screening for DM in Pregnancy
Age over 40 Family history of diabetes in a first-degree
relative Prior macrosomic, malformed, or stillborn
infant Obesity Hypertension Glucosuria
Risk Factors
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
Screening Tests
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
Treatment Goals
AFP Fetal activity monitoring NST Biophysical profile Ultrasound
Fetal Assessment
Assessment of glucose Nutrition counseling Education about the disease process and
management Education about glucose monitoring and
insulin administration Assessment of the fetus Support
Nursing Management
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
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
Iron Deficiency Anemia (cont’d)
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:◦ Vaso-occlusive crisis◦ Infections◦ Congestive heart failure◦ Renal failure
Sickle Cell Anemia
Fetal complications include fetal death, prematurity, and IUGR.
Treatment:◦ Folic acid◦ Prompt treatment of infections◦ Prompt treatment of vaso-occlusive crisis
Sickle Cell Anemia (cont’d)
Treatment:◦ Folic acid◦ Transfusion◦ Chelation
Thalassemia
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
Intrapartal or postpartal hemorrhage Postpartal infection Poor wound healing Infections of the genitourinary tract
HIV in Pregnancy: Maternal Risks
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)
HIV Effects on Fetus
Counsel about implications of diagnosis on pregnancy:◦ Antiretroviral therapy◦ Fetal testing◦ Cesarean birth
Treatment DuringPregnancy
Congenital heart disease Marfan syndrome Peripartum cardiomyopathy Eisenmenger syndrome Mitral valve prolapse
Cardiac Disorders in Pregnancy
Rheumatoid arthritis Epilepsy Hepatitis B Hyperthyroidism Hypothyroidism Maternal phenylketonuria
Less Common Medical Conditions in Pregnancy
Multiple sclerosis Systemic lupus erythematosus Tuberculosis
Less Common Medical Conditions in Pregnancy (cont’d)
Tubal damage Previous pelvic or tubal surgery Endometriosis Previous ectopic pregnancy Presence of an IUD High levels of progesterone
Ectopic Pregnancy: Risk Factors
Congenital anomalies of the tube Use of ovulation-inducing drugs Primary infertility Smoking Advanced maternal age
Ectopic Pregnancy: Risk Factors (cont’d)
Methotrexate Surgery
Ectopic Pregnancy: Treatment
Figure 20–2 Various implantation sites in ectopic pregnancy. The most common site is within the fallopian tube, hence the name “tubal pregnancy.”
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
Ectopic Pregnancy: Nursing Care
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: Symptoms
D&C Possible hysterectomy Careful follow-up
Gestational Trophoblastic Disease: Treatment
Figure 20–3 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.
Monitor vital signs Monitor vaginal bleeding Assess abdominal pain Assess the woman’s emotional state and
coping ability
Gestational Trophoblastic Disease: Nursing Care
Control vomiting Correct dehydration Restore electrolyte balance Maintain adequate nutrition
Hyperemesis Gravidarum: Treatment
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
Hyperemesis Gravidarum: Nursing Care
Preeclampsia-eclampsia Chronic hypertension Chronic hypertension with superimposed
preeclampsia Gestational hypertension
Classification of Hypertension in Pregnancy
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
Characteristics of Preeclampsia (cont’d)
Figure 20–7 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.
Figure 20–7 (continued) 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.
Small for gestational age Fetal hypoxia Death related to abruption Prematurity
Hypertensive Effects on Fetus
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
Home Management
Bed rest High-protein, moderate-sodium diet Treatment with magnesium sulfate Corticosteroids Fluid and electrolyte replacement Antihypertensive therapy
Management of Severe Preeclampsia
Scotomata Blurred vision Epigastric pain Vomiting Persistent or severe headache Neurologic hyperactivity
Signs and Symptoms of Eclampsia
Pulmonary edema Cyanosis
Signs and Symptoms of Eclampsia (cont’d)
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
To prevent injury, raise padded side rails Administer magnesium sulfate
Management of Eclampsia (cont’d)
Hemolysis, elevated liver enzymes, low platelets◦ Hypertension and proteinuria may or may not be
present◦ 90% present with symptoms before 36 wks gest.◦ All with HELLP should deliver
HELLP Syndrome
Rh – mother, Rh + fetus Maternal IgG antibodies produced Hemolysis of fetal red blood cells Rapid production of erythroblasts Hyperbilirubinemia
Rh Incompatibility
Figure 20–10 Rh alloimmunization sequence. A, Rh-positive father and Rh-negative mother. B, Pregnancy with Rh-positive fetus. Some Rh-positive blood enters the mother’s blood. C, As the placenta separates, the mother is further exposed to the Rh-positive blood. D, The mother is sensitized to the Rh-positive blood; anti-Rh-positive antibodies (triangles) are formed. E, In subsequent pregnancies with an Rh-positive fetus, Rh-positive red blood cells are attacked by the anti-Rh-positive maternal antibodies, causing hemolysis of red blood cells in the fetus.
After birth of an Rh+ infant After spontaneous or induced abortion After ectopic pregnancy After invasive procedures during pregnancy After maternal trauma
Administration of Rh Immune Globulin
Mom is type O Infant is type A or B Maternal serum antibodies are present in
serum Hemolysis of fetal red blood cells
ABO Incompatibility
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
Surgery 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
Trauma During Pregnancy
Psychological distress Loss of pregnancy Preterm labor Low-birth-weight infants Fetal death Increased risk of STIs
Battering During Pregnancy