Women’s Health Exam 3

Chronic Hypertension
 2 separate blood pressure elevations >4 hours apart
 Happens before 20 weeks’ gestation
 HTN >12 weeks postpartum
 Unknown impact on pregnancy
 Super-imposed Pre-eclampsia
 Sudden increase in BP or Proteinuria
 Uric Acid elevations
Gestational Hypertension
• 2 separate BP elevations >4 hrs. apart after 20 wks. gestation
• SBP ≥ 140 OR DBP≥ 90
• New onset HTN after 20 weeks’ gestation
• Up to 50% will progress to Pre-eclampsia
• BP returns to baseline by 12 weeks postpartum
Pre-eclampsia
• Cause is unknown & no screening test available to diagnose
• BP Criteria for GHTN of seizure activity
• Proteinuria
≥300 mg per 24 hr. urine collection
Protein/creatinine ratio of 0.3 mg/dL or more
Dipstick reading of 2+ protein
• OR in the absence of proteinuria, new onset HTN WITH
Thrombocytopenia (PLT<100,000)
Renal insufficiency: Creatinine >1.1 or a doubling of serum creatinine
Liver function: LFTs twice normal= 20
Pulmonary edema
Severe Preeclampsia symptoms• severe high BP
• severe HA
• nausea
• Heart burn (epigastric pain)- liver involved
• extreme edema or pitting edema
• 3+ or more reflexes,
• clonus
• vision changes
HELLP/Hemolysis Elevated Liver Enzymes Low Platelets
• Hemolysis (anemia & jaundice)
• Elevated Liver Enzymes
Epigastric Pain
Nausea & Vomiting
• Low Platelets
Abnormal bleeding
Petechiae
DIC
• into DIC= disseminated intravascular coagulation
• Signs
• Bleeding from any open sight
• Petechiae- pinpoint bruises
Eclampsia
• Same criteria for pre-eclampsia, except seizure activity is present
• Can occur during pregnancy or during the immediate postpartum period
• Treatment is to stabilize the mother by administering Ativan, then Magnesium Sulfate
infusion
TMT preeclampsia –
 dtr every hour
 daily weights
 VS qh
 fall precaution
 foley strict I and O
 NPO
 SCDS on legs
 fetal heart tones
 HTN meds
 Magnesium (6-8 therapeutic not over 9) alert value over 2.6
Magnesium toxicity
 decrease LOC
 lower 12 RR
 slurred speech
 urine <30ml/hr
 low BP
 low HR
 absent DTR
TMT= stop and check mag and get order for calcium gluconate
Labetalol protocol
 20mg/2 min wait 10 min double and doubles every time 20,40,80.
Discharge for mild PREE or gestational HTN
 Bedrest with bathroom privileges
 nothing strenuous
 take meds as told even with normal BP
 don’t take double dose if dose missed
 journal of readings
 decrease sodium
 increase water
Mag= given preterm for neuroprotection for preterm baby brain
Terbutaline
 tocolytic stops contractions also give when trying to turn baby (eversion procedure)
temporarily to buy time for magnesium
 causes increase HR and patient feels jittery
 take VS before given cannot give if pt has tachycardia
 given IM injection
Betamethasone
 steroid IM in vastus lateralis
 12mg/2ml thick and burns badly
 given in preterm labor to help lungs mature in baby
 given 24 hours apart
 diabetics= increase BS will be monitored (steroids increase blood sugar)
Preterm labor sign
 Positive fetal fibronectin- lab test protein released from cervix indicates labor could
happen
 Regular painful contractions
 Cervical dilation- dilated manually
 Cervical length (thickness) <3cm on ultrasound
 Incompetent cervix
o cervix dilates without contraction or pain weight of baby pushes cervix open
happens after something happens with cervix (HPV)
o tmt is cervical cerclage (sewing cervix shut) cannot induce- abortion with fetal
heart tones let things run course cerclage if dilated (rescue cerclage)
PROM- Premature rupture of membranes
 water breaks but nor in labor
 Full term 37+ weeks cervix closed long time for delivery could cause infection
 Monitor VS temp every 2 hours VS every hr on oxytocin
 antibiotics
o any sign of infection- fever, maternal or fetal tachycardia.
o 18+ hr after rupture
o Water drains out, baby can press on its cord lots of variables usually does
amnioinfusion (puts water back in)
PPROM- preterm premature rupture
 Less than 37 weeks
 Depends on how preterm
 Betamethasone if close to term with antibiotics after 24 hrs. of betamethasone help
deliver
 If not viable <23 weeks some pts go home 21 wks. and water breaks might not make it to viability can’t do anything, so we send
home and monitor from home especially temp every few hrs. no baths or anything in
vagina bleeding contraction and report foul smell and decrease in fetal movement
Oxytocin high risk with this starts low and go slow
 2ml/hr go up every 15-20 minutes
 stop with decels or contraction too much (tachysystole) contraction <2 min apart stress
baby out
 IUPC recommended with oxytocin but not required (gives better view not used much)
 VS every hour minimum and reposition a lot to encourage contraction
 bishop score >6 = how favorable cervix is (dilated, thinned, baby engaged)
Contraindication vertical c section
 positive contraction stress test (late)
 placenta previa
 no more than twins or breech
Cervical ripening
 start with prostaglandins= a lot safer
 need continuous fetal monitoring
 keep in bed first hour after given
 cervadil or misoprostol
 cannot start oxytocin with prostaglandins
 take BP every 30 min for an hour then space out
Operative vaginal delivery
 Forceps- facial lacerations or bruising
 Vacuum- chignon- suction cup head, caput- baby in same spot swelling,
cephalohematoma- blood gets under skin
 Risk for shoulder dystocia (head comes out but shoulders don’t deliver)
 Nurses perform McRoberts maneuver- pull her legs back as far as possible, suprapubic
pressure when physician says trying to get shoulder under pubic bone cannot do anything
but vaginal delivery because head is already out
Cesarean
 Scheduled but dome unplanned
 Antibiotics before delivery
 Trim lower pubic hair
 Antiacids
 SCDS
 Assist with spinal
 Position on bed wedge under hip
 Insert foley (bladder damage)
 FHT
 Strap to table
 Turn SCD on
 Blankets on patient
 Nurse charts
TOLAC- trial of Labor after cesarean
 Uterine rupture- scar could open
o No heart tones
o uterus changes shape
o nothing in vagina
o sharp pain
o no contractions
External Cephalic Version= ECV
 Turning baby
 Start IV
 Give the tocolytic
 Use ultrasound as trying to turn
 Around 36 weeks- not preterm but baby not too big
 FHT
 Monitor mom before and after
 Goes home until induction or labor happens
Prolapsed cord- cord out
o Call help
o Stop oxytocin
o Hand in vagina
o Stay on bed
o Pt in Trendelenburg
o Pt on L side
o Never give tocolytic C-section
o No O2 until in OR
Chorioamnionitis
o Infection of amniotic cavity
o Temp
o VS
o Tachycardia and fetal tachycardia
o Antibiotics
Bleeding and of childbearing age
o pregnancy test
o HCG level
o ultrasound and doppler if positive
o lab work for CBC
Threatened Abortion
 Miscarriage possible
 Mild Cramps
 Slight spotting
 No heavy bleeding
 No Passed Tissue
 Cervix closed
 -Clinical manifestations: slight bleeding, mild cramping, no tissue passed
 -Tx: bedrest, repeat US & HCG levels to determine if fetus still alive
Inevitable Abortion
 Miscarriage will occur eventually
 Mild to Moderate Cramping
 Moderate bleeding
 Cervix open
 Fluid Leaking
 No tissue passed
 Clinical manifestations: mild to severe cramping
 -Tx: bedrest if no pain, bleeding, or infection; D&C if bleeding, pain, or infection
Incomplete Abortion
 Severe Cramps
 Heavy, profuse bleeding
 Cervix open
 Tissue and/or fetus expelled
 Placenta retained
 Fetus is expelled, placenta retained (not unusual, especially if really early first trimester)
 -Clinical manifestations; heavy, profuse vaginal bleeding, severe cramping, cervix dilated
 -Tx: D&C, suction possible or Cytotec (induction medication) is given to expel POC, or
Pitocin given
Complete Abortion
• Mild Cramps
• Minimal Bleeding
• Fetal tissue is passed
• Cervix closes after
• Monitor for hemorrhage
• -Tx: possible suction curettage to remove any POC
Missed Abortion
 No Bleeding
 No cramping
 Cervix closed
 Fetus has no heartbeat
 products remain in uterus for up to several weeks
 dx by ultrasound after uterus stops growing
 -Pt may be allowed to pass POC at home
 -Pt may be given Cytotec to take at home
 -If unable to pass, D&C performed
Ectopic Pregnancy
 in fallopian tube
 give methotrexate which stops pregnancy from growing for body to pass
 must have surgery to have that part of tube removed
Signs of rupture
o Signs of shock from bleeding into abdomen
o Excruciating pain
o Cullen’s sign- bruising
Molar pregnancyo vesicles in uterus
o Uterus large
o No FHT
o Abnormally high HCG
o Could have Cancer at some point very dangerous sign
Anemia
o Diet- foods beef, greens, legumes, beans
o Risk for transfusion before delivery
o Catch early iron infusion- multiple before delivery
o Continuous monitoring
o Signs of iron allergy
MATCHING
Placental Abruption
o Rapid dilation
o Dark red bleeding with clots
o Abdomen very hard and tender
o Can’t dx by ultrasound
 Caused by drug use, HTN, trauma
Placenta Previa
o Can’t check for dilation (don’t want to cause dilation)
o Bright red bleeding
o Bleeding with no contraction so abdomen can be soft
o Transvaginal US shows placenta at cervix
 Caused: abnormal implantation of placenta
Hyperemesis Gravidarum
 nausea and vomiting
 worse than any other sickness
 really sick not just morning sickness
 Weight loss
 electrolytes abnormal
 ketones in urine
 BP low
Diabetes
o Signs and symptoms
o Check BS= Hyper- insulin Hypo- sugar (popsicle or IV sugar D50)
o Hemoglobin A1C shows levels past few months
o 28 weeks drink sugar and an hour later take BS >140 abnormal could be wrong no
fasting
o 3-hour test fasting drink more and take BS every hr for 3 hours if more that 2 >140
diabetes and go to endocrinologist
o Insulin needs change as pregnancy progresses usually 2&3 trimester
o After delivery women go back to normal