OB Antepartum Complications PDF

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Unit 3 OB complications after birth...

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E3 Study Guide

Antepartum Complications Complication Gestational Diabetes Mellitus Advanced Maternal Age Substance Abuse

Hyadatiform Molar pregnancy [aka Trophoblasts implanting improperly] Ectopic pregnancy [aka Bebe implants somewhere it isn’t supposed to] Spontaneous Abortion

Incompetent Cervix

Hyperemesis Gravidarum

Signs and Symptoms Testing at 24-28 weeks Glucosuria, proteinuria, excessive thirst, hunger Age 35+ Miscarriage, stillbirth, SIDS, Placenta previa, Placental abruption, bleeding Cocaine: placental infarcts Nicotine: prematurity, LBW, decreased oxygenation Vaginal bleeding, passing of tissue, excessive nausea and vomiting, abdominal pain, size/date discrepancy, no FHR

Sx: missed period, one-sided abdominal pain, positive preg test, vag spotting 7-8 weeks gestation Threatened: bright red bleeding, back ache, cramping Imminent: internal cervical os dilated Incomplete: embryo/fetus separates but placenta is left behind Missed: cervix is closed and brown discharge is passed Before 20wks, bleeding, abdominal pain, decreased sx of pregnancy, expelling tissue ~13-14 weeks, cervix begins to dilate, or cervix is short

Dehydration, electrolyte imbalance, acid-base imbalance, hypokalemia, starvation ketosis, weight loss

Interventions, etc Insulin needs increase during pregnancy, especially after 2nd trimester Bebes of T2DM moms will be LGA Higher risk for genetic anomalies Focus on prenatal care and bonding

Repeat mole is likely (this pop should avoid pregnancy ☹) Treatment is dilation and curettage(D&C) Risk: trophoblasts can change in to malignant cells and choriocarcinoma without sx Tx: medical or surgical (laparoscopic) Methotrexate will dissolve embryo Pelvic Inflammatory. Disease and Endometriosis can cause scarring and therefore blockage in uterine tubes Identify gestational age before pregnancy Gestational/transient —> comes and goes develops after 20 weeks gestation Preeclamsia see below “Before eclamsia,” which is seizures, coma, death

Pt will spill protein, high BP BP>140/90 Mild: proteinuria 3-5g Severe: >5g in 24 hours

HELLP Syndrome [aka Hemolysis, Elevated Liver enzymes, Low Platelets Group Beta Strep

Placenta Previa 3rd Trimester [aka placental implantation at the cervix]

Abruptio Placenta [aka separation of the placenta from the uterine wall]

Flu-like sx, epigastric pain from distended liver, jaundice, general malaise Multiple organ system failure All pregnant women are tested 35-37 weeks Painless bright red bleeding, presenting part is placenta, c/s usually indicated Usually detected in prenatal u/s

Severe pain, DARK, VENOUS vaginal bleeding Marginal: separation beginning at periphery Central: blood is trapped (Concealed) Complete: almost total separation and concealment

E3 Study Guide Corticosteroids can prompt surfactant production in preterm bebes Possibly send patient home on bedrest if membranes have not ruptured Infection and inflammation likely the cause.

Medical intervention

Preeclampsia caused by malformation of arterioles in placental Only cure is to remove the placenta, which means removing bebe Could lead to prolonged hypoxia and hypoxic encephalopathy in bebe Meds: labetalol, low-dose ASN, magnesium sulfate Platelets < 100,000 AST > 70 ALT > 50

Moms who are GBS+ will receive IV antibiotics during labor to prevent transmission to bebe NSVD possible for high partial ONLY Complete is a BIG NO NO vaginal exams Partial:Internal os is partially covered by the placenta Marginal: edge of placenta is at the margin of the internal os Complete/Total: Internal os is covered entirely by placenta Low-lying: placenta is implanted in lower segment but does not reach the os c/s as emergency, if mom is hemodynamically stable and already in labor, NSVD can work

FHR will spike

E3 Study Guide

Antepartum Tests / Scores Test Chorionic Villus Sampling

Timing 10-13 weeks

Nonstress Test (NST)

After 28 weeks

Biophysical Profile (BP)

3rd Trimester or after 24 weeks

PUBS

After 16 weeks

Alpha Fetal Protein Amniocentesis

15-20 weeks

U/S

Routine at 14-16 weeks or serially

Oral Glucose Tolerance Test Coombs

Before and after delivery

ABO Compatibility

Before and After delivery

Fetal fibronectin

After signs of PTL

What it tells you… INVASIVE sampling of the umbilical cord blood. Karyotyping to identify chromosomal abnormalities NONINVASIVE test that determines fetus’s reactivity and FHR; evaluates fetus’s CNS response to stimulation; assesses fetal well-being— uteroplacental fx NONINVASIVE— NST+U/S 5 parameters: ● Breathing movement ● Movements of limbs or body ● Tone: extension and flexion of extremities ● Amniotic fluid index (AFI) ● Reactive FHR w/activity (NST) Blood gas, CBC, coag, Rh

If elevated—neural-tube or chromosomal defects. Next test would be u/s INVASIVE test that identifies fetal chromosomal or biochemical abnormalities. 3rd Trimester to assess fetal lung maturity, fetal hydrops, erythroblast fetalis Can detect pregnancy at 6wks, gestation, position of fetus and placenta, multiples, some anomalies, IUGR, fetal heart size

Indirect: “antibody screen” measures number of Rh+ anibodies in MOM —>Negative indirect: mother given RhoGAM —>Positive indirect: fetus monitored; no RhoGAM Direct: Detects antibody coated Rh+ cells in INFANT’s blood after delivery For mothers who have O-type blood with babies who have A, B, or AB Does not cause the same level of extensive hemolysis

Risks / Other info 0.5-2.0% chance of spontaneous abx, limb deformitites Indicated in T1DM

0-2, possible IUFD 4-5, c/s is likely 8-10 is normal Indications: DM, heart disease, HTN, sickle cell, renal probs, preeclampsia, IUGR Cord laceration, thromboemboli, infection, spontaneous abx, PROM

Spontaneous abx (2%), infection, PROM

Routine at 14-16 weeks

Risks: risk for hyperbilirubinemia?

Sx: pale skin, tachycardia, hyperbili

Glucose Challenge Test One hour Oral Glucose Tolerance Test

24-28 weeks

24-28 weeks

1hr, 2hr, 3hr

Bishop Score

Pre-labor

Indicated if at risk for GDM Blood glucose is abnormal is >130mg/dL Optimal is 95 Indicated if symptomatic at visits or significant hx or elevated GCT Abnormal if: 1hr > 180mg/dL 2hr > 155mg/dL 3hr > 140mg/dL Bishop’s score predicts whether labor should be induced. The lower the total score, the higher the failure rate Cervical dilation Cervical effacement Fetal station Cervical consistency Cervical position

E3 Study Guide If mom doesn’t do well, on to OGTT

Low Bishop Scores are associated with longer labor and higher rates or c/s

Intrapartum Drugs Drug Methotrexate

What it does Dissolves embryo in ectopic pregnancy

Watch out…

Magnesium Sulfate

Indicated in pts with hypertension, preeclampsia

E3 Study Guide Loss of reflexes is the first sign of toxicity; disappear 8-10mg/100mL

5-8mg/100mL Decreases gastric motility in bebe Calcium Gluconate

Antidote for Mag Sulfate

Betamethasone / Dexamethasone

Stadol / Butorphanol

Corticosteroid that influences surfactant production in fetal lungs. Indicated in premature labor so that preterm bebe lungs are better for real world IV pain relief Mixed agonist-antagonist

Labetalol Cytotec / Misoprostol

Anti-hypertensive Softens and ripens cervix, induces labor

NIFEdipine

Tocolytic—used to slow down labor

386, 569, 571 Pitocin

PCN Progesterone RHOgam

Acts on uterine myofibrils to cause uterine contractions to initiate or to reinforce labor

Indicated for GBS+ mums Used to maintain pregnancy. Adjuvant for cerclage Indicated for Rh- mums with Rh+ bebes

Toxicity? STOP the line, apply oxygen, give Calcium Gluconate If a woman is on mag, you MUST have this available

Respiratory depression

Contraindicated: NRFHR, uterine ctx, previous c/s, placenta previa

IV infusion Assess baseline VS, FHR S/E: uterine hypertonicity (hyperstimulation), tachysystole, hypotension Expensive AF

Intrapartum Complications Complication Dystocia

Hypertonic [labor pattern] Hypotonic [labor pattern] Shoulder dystocia [structural]

Signs and Symptoms Long, difficult, or abnormal labor as a result of powers, passenger, and passageway Occiput-posterior position of fetus; strong, painful, ineffective ctx; contributing factor is maternal anxiety Contractions decrease in frequency, intensity, excessive uterine stretching Bebe’s shoulder is stuck at the pubic symphysis, typically head has been

Interventions, etc.

Focus on mom chilling out

McRoberts Maneuver aka moving legs up to shoulders

E3 Study Guide delivered, can effect bebe’s brachial plexus

Umbilical cord prolapse

Contributing factors: IDM, LGA, Fetal anomalies, CPD Uterus follows placenta out Increased risk during VBAC Sharp referred pain at scapula, contractions stop, abdomen becomes misshapen Umbilical cord is wrapped around bebe’s neck Cord is the presenting part

Placenta Probs

Implantation

Uterine Inversion Uterine Rupture

Nuchal cord

Surgical repair

Obstetric emergency —> C/S Provider/Nurse finger should hold bebe in place until OR

Adherence Insertion of cord Infarcts

Oligo/polyhydramnios Chorioamnionitis

Meconium probs Perineal trauma

Insufficiency Either too much or not enough amniotic fluid Maternal fever 100.4 degrees Maternal and fetal tachycardia, tender uterus ROM that is foul-smelling and cloudy; WBCs >15,000 Pea-soup Meconium stained 1st-4th degree lacerations

Tocolytics (meds to stop labor) are contraindicated

Encourage lateral position with delayed pushing, warm compressed on perineum during second stage of labor Induction, epidural, prolonged 2nd stage, forceps, persistent OPP, nulliparity all risks for laceration

Tachysystole

5 contractions in 10 min, usually every 1.5 minutes, lasting 90 seconds...