pregnancy at risk: pregestational onset. alcohol use in pregnancy maternal effects: –malnutrition...
TRANSCRIPT
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Pregnancy at Risk: Pregestational Onset
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Alcohol Use in Pregnancy
• Maternal effects:– Malnutrition – Bone-marrow suppression– Increased incidence of infections– Liver disease
• Neonatal effects:– Fetal alcohol spectrum disorders (FASD)
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Cocaine Use in Pregnancy: Maternal Effects
• Seizures and hallucinations
• Pulmonary edema
• Respiratory failure
• Cardiac problems
• Spontaneous first trimester abortion, abruptio placentae, intrauterine growth restriction (IUGR), preterm birth, and stillbirth
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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
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Heroin Use in Pregnancy
• Maternal effects:– Poor nutrition and iron-deficiency anemia– Preeclampsia-eclampsia– Breech position– Abnormal placental implantation– Abruptio placentae– Preterm labor
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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
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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
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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
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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
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Effect of Pregnancy on Carbohydrate Metabolism
• Early pregnancy:– Increased insulin production and tissue
sensitivity
• Second half of pregnancy:– Increased peripheral resistance to insulin
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Maternal Risks with DM
• Hydramnios
• Preeclampsia-eclampsia
• Ketoacidosis
• Dystocia
• Increased susceptibility to infections
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Fetal and Neonatal Risks with DM
• Perinatal mortality• Congenital anomalies• Macrosomia• IUGR• RDS• Polycythemia
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Fetal and Neonatal Risks with DM (cont’d)
• Hyperbilirubinemia
• Hypocalcemia
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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
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Risk Factors
• Age over 40
• Family history of diabetes in a first-degree relative
• Prior macrosomic, malformed, or stillborn infant
• Obesity
• Hypertension
• Glucosuria
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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
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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
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Fetal Assessment
• AFP
• Fetal activity monitoring
• NST
• Biophysical profile
• Ultrasound
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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
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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
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Iron-deficiency Anemia (cont’d)
• Fetal complications:– Low birth weight– Prematurity– Stillbirth– Neonatal death
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Iron Deficiency Anemia (cont’d)
• Prevention and treatment:– Prevention - at least 27 mg of iron daily– Treatment - 60-120 mg of iron daily
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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
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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
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Sickle Cell Anemia
• Maternal complications:– Vaso-occlusive crisis– Infections– Congestive heart failure– Renal failure
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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
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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
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HIV in Pregnancy: Maternal Risks
• Intrapartal or postpartal hemorrhage
• Postpartal infection
• Poor wound healing
• Infections of the genitourinary tract
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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)
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Treatment DuringPregnancy
• Counsel about implications of diagnosis on pregnancy:– Antiretroviral therapy– Fetal testing– Cesarean birth
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Cardiac Disorders in Pregnancy
• Congenital heart disease
• Marfan syndrome
• Peripartum cardiomyopathy
• Eisenmenger syndrome
• Mitral valve prolapse
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Less Common Medical Conditions in Pregnancy
• Rheumatoid arthritis
• Epilepsy
• Hepatitis B
• Hyperthyroidism
• Hypothyroidism
• Maternal phenylketonuria
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Less Common Medical Conditions in Pregnancy (cont’d)
• Multiple sclerosis
• Systemic lupus erythematosus
• Tuberculosis
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Pregnancy at Risk: Gestational Onset
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Spontaneous Abortion
• Threatened abortion
• Imminent abortion
• Incomplete abortion
• Complete abortion
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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.
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B Imminent. The placenta has separated from the uterine wall, the cervix has dilated, and the amount of bleeding has increased.
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C Incomplete. The embryo/fetus has passed out of the uterus; however, the placenta remains.
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Spontaneous Abortion (cont’d)
• Missed abortion
• Recurrent pregnancy loss
• Septic abortion
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Spontaneous Abortion: Treatment
• Bed rest
• Abstinence from coitus
• D&C or suction evacuation
• Rh immune globulin
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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
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Ectopic Pregnancy: Risk Factors
• Tubal damage
• Previous pelvic or tubal surgery
• Endometriosis
• Previous ectopic pregnancy
• Presence of an IUD
• High levels of progesterone
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Ectopic Pregnancy: Risk Factors (cont’d)
• Congenital anomalies of the tube
• Use of ovulation-inducing drugs
• Primary infertility
• Smoking
• Advanced maternal age
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Ectopic Pregnancy: Treatment
• Methotrexate
• Surgery
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Various implantation sites in ectopic pregnancy. The most common site is within the fallopian tube, hence the name “tubal pregnancy
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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
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Gestational Trophoblastic Disease: Symptoms
• Vaginal bleeding
• Anemia
• Passing of hydropic vesicles
• Uterine enlargement greater than expected for gestational age
• Absence of fetal heart sounds
• Elevated hCG
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Gestational Trophoblastic Disease: Symptoms
• Low levels of MSAFP
• Hyperemesis gravidarum
• Preeclampsia
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Gestational Trophoblastic Disease: Treatment
• D&C
• Possible hysterectomy
• Careful follow-up
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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.
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Gestational Trophoblastic Disease: Nursing Care
• Monitor vital signs
• Monitor vaginal bleeding
• Assess abdominal pain
• Assess the woman’s emotional state and coping ability
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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
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Cervical Incompetence: Treatment
• Serial cervical ultrasound assessments
• Bed rest
• Progesterone supplementation
• Antibiotics
• Anti-inflammatory drugs
• Cerclage procedures
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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.
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Hyperemesis Gravidarum: Treatment
• Control vomiting
• Correct dehydration
• Restore electrolyte balance
• Maintain adequate nutrition
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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
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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
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Nursing Clients with PROM (cont’d)
• Encourage resting on left side
• Provide comfort measures
• Provide education
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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
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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
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Signs and Symptoms of Preterm Labor (cont’d)
• A change in vaginal discharge
• Abdominal cramping with or without diarrhea
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Classification of Hypertension in Pregnancy
• Preeclampsia-eclampsia
• Chronic hypertension
• Chronic hypertension with superimposed preeclampsia
• Gestational hypertension
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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 pre-eclampsia
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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
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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
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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
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Labatalol
• Baby at risk for transient hypotension and hypogylcemia if mom on labatalol
• No labatalol to clients with asthma or first degree heart block
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Fetal Assessment
• Fetal growth restriction
• Ultrasound @ 18-20 weeks, 28-32 weeks & as needed thereafter
• NST or biophysical profile if growth restricted
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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
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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
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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
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Normal Adaptations to Pregnancy
• Increased blood plasma volume
• Vasodilation• Decreased systemic
vascular resistance• Elevated cardiac
output• Decreased colloid
osmotic pressure
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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%)
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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
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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)
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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
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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
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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
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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
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Characteristics of Preeclampsia
• Maternal vasospasm
• Decreased perfusion to virtually all organs
• Decrease in plasma volume
• Activation of the coagulation cascade
• Alterations in glomerular capillary endothelium
• Edema
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Characteristics of Preeclampsia
• Increased viscosity of the blood
• Hyperreflexia• Headache• Subcapsular
hematoma of the liver
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A In a normal pregnancy, the passive quality of the spiral arteries permits increased blood flow to the placenta.
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B In preeclampsia, vasoconstriction of the myometrial segment of the spiral arteries occurs.
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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
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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
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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
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Specific Labs
Preeclampsia HELLP
• Hct>35 *Hemolysis-burr
• Uric Acid > 4.5mg cells present
• BUN > 10mg/dl *bili 1.2mg/d
• Plt <150,000 *SGOT >72 U/L
• SGOT > 41 U/L *SGPT > 50 U/L
• SGPT > 30 U/L *Platelets<100,000
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Hypertensive Effects on Fetus
• Small for gestational age
• Fetal hypoxia• Death related to
abruption• Prematurity
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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
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Management of Severe Preeclampsia
• Bed rest
• High-protein, moderate-sodium diet
• Treatment with magnesium sulfate
• Corticosteroids
• Fluid and electrolyte replacement
• Antihypertensive therapy
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Fetal Indications for Delivery
• Severe IUGR
• Nonreassuring fetal surveillance
• oligohydramnios
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Maternal Indications for Delivery
• 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
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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
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Preeclampsia Assessment
• 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
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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
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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
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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”
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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
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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
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Renal Insufficiency
• Magnesium sulfate is hazardous to women with severe renal failure and maintenance dose must be reduced
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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
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Side Effects of Mag Sulfate
• Flushing• Sweating• Thirst• Drying mucous membranes• Depression of reflexes• Muscle flaccidity• Nausea• Blurred visoin• HA• tachycardia
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Clinicial Manifestations of Hypermagnesemia
• 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
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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
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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
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Antihypertensives
• If BP reaches 150/100 mmHg or higherLabatalol (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 220mgApresoline (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
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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
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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
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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
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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
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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
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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
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PNEUMONIC
S safety
E establish airway
I IV bolus
Z zealous observation
U uterine activity
R rapid resuscitation
E evaluate fetus
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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
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REMEMBER!!!
• All medications and therapy are merely temporary measures
• Delivery is the only cure
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Signs and Symptoms of Eclampsia
• Scotomata• Blurred vision• Epigastric pain• Vomiting• Persistent or severe headache• Neurologic hyperactivity Pulmonary
edema• Cyanosis
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Management of Eclampsia
• 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
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Management of Eclampsia (cont’d)
• To prevent injury, raise padded side rails
• Administer magnesium sulfate
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Postpartum Management
• Symptoms usually resolve within 48 hours of birth
• Lab abnormalities usually resolve from 72-96 hours after birth
• Careful assessment continues, mag sulfate may continue to be infused for 12-48 hours after the birth
• Bleeding must be assessed
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Hemorrhage & Hypertension
• NO Methergine• Causes vasospasm
and increases blood pressure
• CONTRAINDICATED in pts with HTN
• Use hemabate or cytotec for PPH
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Comparison of Risk Factors for HELLP Syndrome and Preeclampsia
HELLP PreeclampsiaMultiparous NulliparousMaternal age >25 Maternal age<20White or >45Hx of poor preg Family hxOutcome Poor PNC Diabetes Chronic HTN Multiple gestation
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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
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DX
• Platelet < 100,000
• Liver enzymes AST ALT elevated
• Evidence of intravascular hemolysis must be present
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Complications of HELLP
• Renal failure• Pulmonary edema• Ruptured liver hematoma• DIC• Abruptio placenta• Fetal death• Perinatal asphyxia• Maternal death
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Sx of HELLP
• Epigastric pain
• Mailaise
• Nausea and vomiting
• Mild jaundice often noted
Sound like the flu?
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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
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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
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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.
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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
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Rh Incompatibility
• Rh – mother, Rh + fetus
• Maternal IgG antibodies produced
• Hemolysis of fetal red blood cells
• Rapid production of erythroblasts
• Hyperbilirubinemia
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Administration of Rh Immune Globulin
• After birth of an Rh+ infant
• After spontaneous or induced abortion
• After ectopic pregnancy
• After invasive procedures during pregnancy
• After maternal trauma
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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
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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
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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
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Battering During Pregnancy
• Psychological distress
• Loss of pregnancy
• Preterm labor
• Low-birth-weight infants
• Fetal death
• Increased risk of STIs
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Perinatal Infections
• Toxoplasmosis
• Rubella
• Cytomegalovirus
• Herpes simplex virus
• Group B streptococcus
• Human B-19 parvovirus
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Fetal Risks: Toxoplasmosis
• Retinochoroiditis
• Convulsions
• Coma
• Microcephaly
• Hydrocephalus
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Fetal Risks: Rubella
• Congenital cataracts
• Sensorineural deafness
• Congenital heart defects
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Fetal Risks: Chlamydia
• Neurologic complications
• Anemia
• Hyperbilirubinemia
• Thrombocytopenia
• Hepatosplenomegaly
• SGA
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Fetal Risks: Herpes
• Preterm labor
• Intrauterine growth restriction
• Neonatal infection
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Fetal Risks: GBS
• Respiratory distress or pneumonia
• Apnea
• Shock
• Meningitis
• Long-term neurologic complications
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Fetal Risks: Human B-19 Parvovirus
• Spontaneous abortion
• Fetal hydrops
• Stillbirth