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1025c Exam 2 Exemplars

Placenta Previa 

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Placenta previa- the placenta is implanted in the lower uterine segment such that it completely or partially covers the cervical os or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces. o Complete placenta previa if it totally covers the internal cervical os. o Marginal placenta previa the edge of the placenta is seen on transvaginal ultrasound to be 2.5 cm or closer to the internal cervical os. Placenta previa affects approximately 1 in 200 pregnancies at term. Risk factors for placenta previa include: previous c-section, advanced maternal age (more than 35 to 40 years of age), multiparity, history of prior suction curettage, smoking, being an Asian women, carrying male fetuses, multiple gestation, and living at a higher altitude.

Clinical Manifestations  Placenta previa is typically characterized by painless bright red vaginal bleeding during the second or third trimester.  Vital signs may be normal, even with heavy blood loss, because a pregnant woman can lose up to 40% of her blood volume without showing signs of shock.  Clinical presentation and decreasing urinary output may be better indicators of acute blood loss than vital signs alone.  The fetal heart rate (FHR) is normal unless a major detachment of the placenta occurs.  The fetus usually remains high because the placenta occupies the lower uterine segment so the fundal height is often greater than expected for gestational age.

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Maternal and Fetal Outcomes Major maternal complication associated with placenta previa is hemorrhage. Most women with placenta previa give birth by cesarean, so surgery-related trauma to structures adjacent to the uterus, anesthesia complications, blood transfusion reactions, anemia, thrombophlebitis, and infection may occur. IUGR has also been associated with placenta previa

Diagnosis  A transabdominal ultrasound examination should be performed, followed by a transvaginal scan  If scanning reveals a normally implanted placenta, a speculum examination may be performed to rule out local causes Nursing Diagnoses and Management The woman is managed either expectantly or actively, depending on the gestational age, amount of bleeding, and fetal condition. Expectant management.

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Observation and bed rest is implemented if the fetus is at less than 36 to 37 weeks of gestation with normal fetal growth and if no other pregnancy-associated complications exist Initial laboratory tests include hemoglobin, hematocrit, platelet count, coagulation studies,“type and screen” blood sample should be maintained in case a transfusion is needed. If the woman is at less than 34 weeks of gestation, antenatal corticosteroids should be administered. Tocolytic medications may be given if the vaginal bleeding is preceded by or associated with uterine contractions No vaginal or rectal examinations are performed, and the woman is told to avoid intercourse. Ultrasound examinations are performed serially to assess placental location and fetal growth. Placenta previa should always be considered a potential emergency because massive blood loss with resulting hypovolemic shock can occur quickly if bleeding resumes. Home care. Sometimes women with placenta previa are discharged from the hospital before giving birth to be managed at home. The woman's condition should be stable, and she should have experienced no vaginal bleeding for at least 48 hours before discharge If bleeding resumes, she needs to return to the hospital immediately. She should be encouraged to participate in her own care and decisions about care as much as possible. Providing diversionary activities and participating in a support group made up of other women on activity restriction while hospitalized or online if at home may be a helpful coping mechanism Active management. She can give birth if she is at or beyond 36 weeks of gestation. If bleeding is excessive or there are concerns about the condition of the fetus, immediate birth is indicated Almost all women with placenta previa will give birth by cesarean. Maternal condition is assessed frequently for decreasing BP, increasing pulse rate, changes in level of consciousness, and oliguria. Fetal assessment is maintained by continuous electronic fetal monitoring (EFM) to assess for signs of hypoxia. Blood loss may not stop with the birth of the infant. Emotional support for the woman and her family is extremely important.

Placental Abruption 

Premature separation of the placenta, or abruptio placentae, is the detachment of part or all of a normally implanted placenta from the uterus.

Incidence and Etiology

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The overall incidence of placental abruption is 1 in 100 births Rick Factors: Maternal hypertension, Cocaine use, Blunt external abdominal trauma, most often the result of (motor vehicle accidents (MVAs) or maternal battering), cigarette smoking, a history of abruption in a previous pregnancy, and preterm premature rupture of membranes. Abruption is more likely to occur in twin gestations High risk in Pre-eclamptic patients

Clinical Manifestations Classic symptoms of placental abruption include vaginal bleeding, abdominal pain, uterine tenderness, and contractions  Bleeding may result in maternal hypovolemia (i.e., shock, oliguria, anuria) and coagulopathy.  Pain is mild to severe and localized over one region of the uterus or diffuse over the uterus with a boardlike abdomen.  Extensive myometrial bleeding damages the uterine muscle and the uterus appears purple/blue rather than its usual “bubble-gum pink” color, and contractility is lost. 

Maternal and Fetal Outcomes  Hemorrhage, hypovolemic shock, hypofibrinogenemia, and thrombocytopenia are associated with severe abruption.  Renal failure and pituitary necrosis may result from ischemia.  In rare cases, women who are Rh negative can become sensitized if fetal-to-maternal hemorrhage occurs and the fetal blood type is Rh positive.  Fetal complications, which include IUGR, oligohydramnios, preterm birth, hypoxemia, and stillbirth, are related to the severity and timing of the hemorrhage.  Fetal survival is related to the size of the hemorrhage. Diagnosis  Placental abruption is primarily a clinical diagnosis.  Although ultrasound can be used to rule out placenta previa, at least 50% of abruptions cannot be identified on ultrasound  Ultrasound can identify three main sources of abruption: o Subchorionic (between the placenta and the membranes) o Retroplacental (between the placenta and the uterine wall)WORST!!! o Replacental (between the placenta and the amniotic fluid  The diagnosis of abruption is confirmed after birth by visual inspection of the placenta  Placental abruption should be highly suspected in the woman who experiences a sudden onset of intense, usually localized, uterine pain, with or without vaginal bleeding.  The fundal height may be measured over time because an increasing fundal height indicates concealed bleeding. Expectant management. If the fetus is between 20 and 34 weeks of gestation and both the woman and fetus are stable, expectant management can be implemented.

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o The woman is monitored closely because the abruption may extend at any time. o The fetus is assessed regularly for evidence of appropriate growth because there is risk for IUGR. In addition, assessments of fetal well-being (e.g., nonstress testing, biophysical profile) are performed regularly. o Corticosteroids are given to accelerate fetal lung maturity

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Active management. Immediate birth is the management of choice if the fetus is at term gestation or the bleeding is moderate to severe and the mother or fetus is in jeopardy. o At least one large-bore (16 to 18 gauge) IV line should be inserted. o Maternal vital signs are monitored frequently to observe for signs of declining hemodynamic status such as increasing pulse rate and decreasing BP. o Serial laboratory studies include hematocrit or hemoglobin determinations and clotting studies. o Continuous EFM is mandatory. o An indwelling catheter is inserted for continuous assessment of urine output, an excellent indirect measure of maternal organ perfusion. o Fluid volume replacement may be necessary, along with administration of blood products to correct any coagulation defects. Emotional support is also extremely important because the woman and her family may be experiencing fetal loss and grief in addition to the woman's critical illness. Summary of Findings: Placental Abruption and Placenta Previa PLACENTAL ABRUPTION

Findings

Grade 1 Grade 3 Grade 2 Mild Severe Moderate Separation Separation Separation (20%–50%) (10%–20%) (>50%)

Placenta Previa

Physical and Laboratory Findings

Bleeding, external, vaginal

Minimal

Absent to moderate

Absent to moderate

Minimal to severe and lifethreatening

Total amount of blood loss

1500 mL

Varies

PLACENTAL ABRUPTION

Findings

Grade 1 Grade 3 Grade 2 Severe Mild Moderate Separation Separation Separation (20%–50%) (>50%) (10%–20%)

Placenta Previa

Color of blood

Dark red

Dark red

Dark red

Bright red

Shock

Rare; none

Mild shock

Common, often Uncommon sudden, profound

Coagulopathy

Rare, none

Occasional DIC

Frequent DIC

None

Uterine tonicity

Normal

Increased, may be localized to one region or diffuse over uterus; uterus fails to relax between contractions

Tetanic, persistent uterine contractions, boardlike uterus

Normal

Tenderness (pain)

Usually absent

Present

Agonizing, unremitting uterine pain

Absent

Hypertension in Pregnancy Significance and Incidence  Occurring in approximately 5% to 10% of all pregnancies.  Hypertensive disorders are a major cause of maternal and perinatal morbidity and mortality worldwide  The three most common types of hypertensive disorders occurring in pregnancy are: gestational hypertension, preeclampsia, and chronic essential hypertension.

Gestational hypertension is the onset of hypertension without proteinuria or other systemic findings diagnostic for preeclampsia after week 20 of pregnancy.  Gestational hypertension does not persist longer than 12 weeks postpartum and usually resolves during the first postpartum week  Some women who are initially thought to have gestational hypertension are eventually diagnosed with chronic hypertension instead. Classification of Hypertensive States of Pregnancy Type

Description

Gestational Hypertensive Disorders

Gestational hypertension

Development of hypertension after week 20 of pregnancy in a previously normotensive woman without proteinuria or other systemic findings (see description of Preeclampsia below)

Preeclampsia

Development of hypertension and proteinuria in a previously normotensive woman after 20 weeks of gestation or in the early postpartum period. In the absence of proteinuria, the development of new-onset hypertension with the new onset of any of the following: thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral or visual symptoms

Eclampsia

Development of seizures or coma not attributable to other causes in a preeclamptic woman

Chronic Hypertensive Disorders

Chronic hypertension

Hypertension in a pregnant woman present before pregnancy

Type

Superimposed preeclampsia

Description

Chronic hypertension in association with preeclampsia

TABLE 12.2 Diagnostic Criteria for Preeclampsia and Preeclampsia with Severe Features Preeclampsia

Preeclampsia with Severe Features

Blood pressure (BP) reading ≥140/90 mm Hg × 2, at least 4 hours apart after 20 weeks of gestation in a previously normotensive woman

BP reading ≥160/110 mm Hg × 2, at least 4 hours apart while the woman is on bed rest (unless antihypertensive therapy has already been initiated)

Component

Hypertension

Proteinuria

Proteinuria of ≥300 mg in a 24-hour specimen Protein/creatinine ratio ≥0.3 (with each measured as mg/mL) ≥1+ on dipstick (used only if quantitative measurement is not available

Massive proteinuria (>5 g in a 24-hour specimen) is no longer used as a diagnostic criterion

Thrombocytopenia

Platelet count 1.1 mg/dL or a doubling of the serum creatinine concentration) in the absence of other renal disease

Pulmonary edema

Present

Cerebral or visual disturbances

New onset

Preeclampsia is a pregnancy-specific condition in which hypertension and proteinuria develop after 20 weeks of gestation in a woman who previously had neither condition.  The signs and symptoms of preeclampsia also can develop for the first time during the postpartum period.  These include proteinuria, oliguria, presence of intrauterine growth restriction (IUGR), or fetal growth restriction as a requirement for the diagnosis of preeclampsia R i s k F a c t o r s f o r Pr e e cl a m p s i a • Nulliparity • Age >40 years • Pregnancy with assisted reproductive techniques • Interpregnancy interval >7 years • Family history of preeclampsia • Woman born small for gestational age • Obesity/gestational diabetes mellitus • Multifetal gestation

• Preeclampsia in previous pregnancy • Poor outcome in previous pregnancy • Preexisting medical/genetic conditions • Chronic hypertension • Renal disease • Type 1 (insulin-dependent) diabetes mellitus • Antiphospholipid antibody syndrome • Factor V Leiden mutation Common Laboratory Changes in Preeclampsia Normal Nonpregnant

Preeclampsia

HELLP

Hemoglobin, hematocrit

12–16 g/dL, 37%– 47%

May ↑

↓

Platelets (cells/mm3)

150,000– 400,000/mm3

600 units/L)

Aspartate aminotransferase (AST)

4–20 units/L

↑

↑ (>70 units/L)

Alanine aminotransferase (ALT)

3–21 units/L

↑

↑

Creatinine clearance

80–125 mL/min

130–180 mL/min ↓

Burr cells or schistocytes

Absent

Absent

Present

Uric acid

2–6.6 mg/dL

>5.9 mg/dL

>10 mg/dL

Bilirubin (total)

0.1–1 mg/dL

Unchanged or ↑ ↑ (>1.2 mg/dL)

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Preeclampsia is a progressive disorder, with the placenta as the root cause. The disease begins to resolve after the placenta has been expelled. Neurologic complications associated with preeclampsia include cerebral edema and hemorrhage and increased central nervous system (CNS) irritability. CNS irritability manifests as headaches, hyperreflexia, positive ankle clonus, and seizures.

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Arteriolar vasospasms and decreased blood flow to the retina can lead to visual disturbances such as scotoma (dim vision or blind or dark spots in the visual field) and blurred or double

HELLP syndrome is a laboratory diagnosis for a variant of preeclampsia that involves hepatic dysfunction, characterized by hemolysis (H), elevated liver enzymes (EL), and low platelet (LP) count.  Specific laboratory findings are needed to diagnose HELLP syndrome and distinguish it from other serious diseases that share the same signs and symptoms.  Women who develop one, two, or all three laboratory abnormalities are being diagnosed with incomplete HELLP, partial HELLP, or the HELLP syndrome  HELLP syndrome usually develops during the antepartum period. The clinical presentation is often nonspecific.  Most women with the disorder report a history of malaise, influenza-like symptoms, and epigastric or right upper quadrant abdominal pain.  Symptoms tend to worsen at night and improve during the daytime.  HELLP syndrome can progress rapidly  HELLP syndrome appears to occur more frequently in Caucasian women than women of other races.  A diagnosis of HELLP syndrome is associated with an increased risk for maternal death and adverse perinatal outcomes, including pulmonary edema, acute renal failure, disseminated intravascular coagulation (DIC), placental abruption, liver hemorrhage or failure, acute respiratory distress syndrome (ARDS), and sepsis Pr e ve nt i onofPr e e c l a mps i a Cr i t i c a lAppr a i s a loft heEvi de nc e Ri s kf a c t or sf orpr e e c l a mps i ai nc l udes moki ng,y oungorol da ge ,nul l i pa r i t y ,unma r r i e d s t a t us ,Af r i c a nAme r i c an r a c e ,mul t i pl ef e t us e s ,c hr oni chype r t e ns i on,di a be t e s ,a nd hi s t or yofpr i orpr e e c l a mps i a . I na ddi t i on t o ma na ge me ntofge s t a t i onalwei ghtga i n wi t hi nr e c omme nda t i ons , r e s e a r c h ha sf ound t hef ol l owi ngt obepr ot e c t i vea ga i ns tpr e e c l a mps i af orpr e gna nt wome na tl ow r i s kf orpr e e c l a mps i a : •Ca l c i um s uppl e me nt sofa tl e a s t1g/da y ,e s pe c i al l yf orwome nwi t hl owc a l c i um di e t s ( Ana l t e r na t i vet os uppl e me nt a t i oni s3 –4dai r ys e r vi ngsda i l y) •A pr e pr e gna nc yMe di t e r r a ne a ndi e t ,hi ghi nve ge t a bl e s , fis h,l e gume sa ndnut s ,i s a s s oc i a t e dwi t hapr ot e c t i vea ffe c ta ga i ns thype r t e ns i vedi s or de r sofpr e gna nc y Forwome na thi ghr i s kf orpr ee c l a mps i a,t hef ol l owi nga ddi t i ona lme a s ur e sma ybe bene fic i a l : •Lowdos ea s pi r i n, s t a r t e dbe f or e1 6we e ksofge s t a t i on. •LAr gi ni nes uppl e me nt . •I nc r e a s e dr e s ta thomei nt het hi r dt r i me s t e r

Wome nwi t hpr i orhi s t or yofpr e e c l amps i ac a nde c r e a s et he i rr i s kf orr e c ur r e ntdi s e a s e b ya voi di ngpr ol onge di nt e r pr e gna nc yi nt e r va l sa bove4ye a r s .Longe ri nt e r pr e gna nc y i nt e r va l sme a nol de rma t e r na la ge ,i nc r e a s e dwe i ght ,a ndma t e r na ldi s or de r s . Appl yt heEvi de nc e:Nur s i ngI mpl i c a t i ons •Pr e c onc e pt i onc ouns e l i ngf ormodi fia bl er i s kf a c t or s ,s uc has moki ng,we i ghtga i n, c a l c i um i nt a ke ,a ndMe di t e r r a ne a ndi e tc a nde c r e as epr e e c l a mps i ar i s k. •Thenur s ec a ne duc a t ewomenwhoha veha dpr e e c l a mps i aa boutt hebe ne fit sof i nt e r pr e gna nc yi nt e r val sofnomor et han4ye a r s . •Te a c hi ngs t r e s sma na ge me ntt e c hni que sf orl i f e l onga ndpr e gna nc ys t r e s sa r e i mpor t a nt ,e s pe c i a l l yi nt hepr e s e nc eofc hr oni chype r t e ns i on. •I naddi t i ont oa s s e s s i ngbl oodpr e s s ur e ,a l e r tnur s e sa r eof t e nt hefir s tt onot es ubt l e c l i ni c alc ha nge si ndi c a t i ngpr e e c l a mps i a , s uc ha ss uddenwe i ghtgai n, e de ma , he adac he ,ol i gur i a ,r i ght s i de dpa i n,a ndf e t a ldi s t r e s s . •I nt hee v e ntofe me r genthyper t e ns i vec r i s i s ,nur s e smus tbef a mi l i ara ndpr ofic i e nt wi t ha s s e s s me nt s , i nc l udi ngr e fle x e sa ndf e t a lmoni t or i ng,unde r s t a ndme di c a t i ons , a ndbepr oa c t i vei ne nvi r onme nt a la l t e r a t i on, s uc hasl i mi t i ngvi s i t or sa ndl owe r i ng l i ght sa nds oundi nt her oom. •Wome nwi t hahi s t or yofr e c ur r e ntpr e e c l a mps i aa r ea tt wi c et her i s kf orhe a r tdi s e a s e a ndt hr e et i ...