What is placenta abruptio
when the placenta detachs before the birth pf the baby
what is the role of the placenta
- maintains pregnancy- delivers oxygen and nutrients- removes waste
when should the placenta detach
after the birth of the baby
what are the causes of abruptia placenta
- chronic hpt- preclampsia- trauma to the abdomen- history of many pregnancies- cocaine or smoking- multiple babies- history of previous abruptia placenta
what are the signs and symptoms of abruptia placenta
- dark red bleeding- extended fundal height- tender uterus- abdominal pain/contraction- concealed bleeding- hard abdomen - experience of disceminated intervascular coagulation- distressed baby
when a patient has abruptia placenta what do you have to monitor for
- monitor for DIC (disceminated intervascular coagulation)- monitor for bleeding
what do you have to check and monitor if a patient is going into DIC
- low platelet, fibronogen and prothombin levels- bleeding gums- oozing from iv sites- petecnia or echymosis- micro emboli
a patient who is 33 weeks pregnant comes in complaining of dark red bleeding, tender uterus and abdominal pain. the patients bp is 180/120 p= 120 bpm. The day before the bleeding started the patient had fallen and injured herself. What is your nursing diagnosis for the patient and what is your nursing interventions.
nursing diagnosis - patient is experiencing abruptia placentanursing interventions - - monitor patient for DIC and concealed bleeding- pad checks - check vital signs every 15mins- check patients platelet count and clotting factors- check for cleeding gums- check for oozing from the iv site- observe any bruising ( echymosis) - observe if patient has shortness of breath, chest pain, mental status changes, urine output decreases - this could indicate a clot in any of these major organs - check fundel height- NO pv or abdominal exams - patient should lay on their left side and not in a supine position in order to prevent supine hypertension (lying on the left side helps increase perfusion to the uterus)- monitor babys hr - prep patient for delivery. if they are stable they ma be able to deliver vaginally but if the patient is unstable they shoudl deliver via c section.
what is placenta previa
abdominal attachment of rhe placenta in the uterus near or over the cervical opening
where should the placenta attach
at the top or the side of the uterus
how do you manage a patient with hypertension at an MOU
- If patients BP is stable discuss patient with doctor and change meds to alpha methyldopa 500mg 8hourly via oral- patient should then be transferred to high risk facility at 24 weeks in order to go for blood tests for early detection of pre eclampsia and placental functions- if patients BP remains stable they are an intermediate risk and all the tests performed at a high risk facility remains normal- patient should attend HR clinic at MOU until 36 weeks if BP remians stable
how do you manage hypertension at a district hospital
- do ultrasound in order to determine the relation between GA and fetus weight - if no dating u/s available- use the umbilical artery doppler test in order to test for fetal well-being- for viable baby a CTG should be coordinated and a fetus kickchart started- test for proteinuria- in order to exclude pre clampsia with unsure dip stick protenuria the first time, do another one 24hrs later- control BP: anti HPT methyldopa 1g orally if BP is raised, after that 500mg 8 hourly via oral (if patient is on hpt meds then proceed with that)- delivery should commence at 37 weeks of gestation
when does gestational hypertension occur
after 20 weeks GA
what do you check for in a women diagnosed with gestational hypertension at a clinic
proteinuriaoedemaincreased weight gain
what should you ask a patient about when they have been diagnosed with gestational hypertension at a clinic
- family history of hypertension- history of gestational hypertension- previous stillbirths- neonatal deaths- bleeding in previous or index pregnancy- any symptoms of persistent headaches
who is at risk for pre clampsia
- primigravs- multigravs with new partners- wmen aged 35 and above- chronic hpt, previous pre clampsia- multiple pregnancies- diabetics- previous abruptio placentae- obesity
why should you not use diuretics in pre clampsia
patient is already hypovoleamic
what may help a women reduce her chance of getting pre eclampsia
- calcium supplementation: 1g elemental calcium daily ( 2 tab orally x 3 times a day) - low dose aspirin: 75mp daily from the 12 weeks ga to 34 weeks ga
what effect does pre eclampsia have on utero-placental circulation
IUGRFetal distressabruptio placenta
these could cause - fetal death - pre term birth
what is antepartum bleeding
bleeding from the genital tract from 20 weeks of pregnancy up to delivery of the baby
what is the 3rd most important cause of maternal death in south africa
antepartum bleeding
what is the time frame for a highest risk of death for antepartum bleeding
24 hours
what are the types of antepartum bleeding
- spotting bleeding- minor haemorrhage- major haemorrhage- massive haemorrhage
how much blood would a women have to lose for the antepartum bleeding to be considered a minor haemorrhage
50ml or less
how much blood would a women have to lose in order for the antepartum bleeding to be considered major haemorrhage
50-1000ml minus the shock
how much blood would a women have to lose in order for her antepartum bleeding to be conidered a massive haemorrage
more than a 1000ml including shock
what are the causes of APH
> placental - abruptio placentae, placenta praevia, vasa praevia> non-placental - vaginal and cervical lesions including cancer, cervical infections, trauma and decidual bleeding> unknown - cause of APH unknown origin
what cayses bleeding in the first trimester of pregnancy
- abortion/miscarriage- ectopic pregnancy- implantation of the placenta in the uterus- infection- trauma
what are causes of bleeding in late pregnancy (after 20 weeks)
- vasa previa- show
major- placental previa- placental abruption
what are some complications of antepartum haemorrhage
- hypovalaemic shock - couvelaire uterus- disseminated intravascular coagulation- high rist of premature delivery- fetal hypoxia- maternal death- perinatal mortality- pph
can occur as a complication of placenta previa
vasa previa
if a patients membranes ruptures and clear blood is visible what could be the diagnosis
vasa previa
vasa previa
the presentation of the umbilical or fetal blood vessels that run in the membranes and lie in front of the cervical os
placenta praevia
the implantation of the placenta in the lower segment of the uterus
placenta abruption
the accidental haemorrhage where the placenta has separated partially or completely from the uterine wall
the placenta is usally implanted in the upper segment of the fundus
when is the peak time for a miscarriage
from week 6 - 10 of pregnancy
interuption of pregnancy before the doetus becomes viable at 26 weeks of gestation
miscarriage
abortion
the termination of a pregnnacy before the fetus is viable
what are causes of miscarriage
- abnormal zygote development - foetal death - advanced maternal age- chronic disease- decreased progesterone - malnutriion- recreational drugs- abnormalities of the reproductive tract- specific infections such as syphilis, rubella ad toxoplasmosis
what are two types of threatening miscarriages
retained and term pregnancy
threatening miscarriage
indicated by mild bleeding in early pregnancy without cervical dilation
blood tests measures what hormones in a womens body if abnormal hormones is the cause of a threatening miscarriage
- HCG - progesterone
what are the symptoms for a threatening miscarriage
- pregnant women has slight bleeding or spotting through an undilated cervix and no abdominal pain- they may also pass tissue with clot like material from the vagina
what are threatening miscarriages most likely due to
chromosomal abnormalities in the embryo
what are less common factors of a threatening miscarriage in pregnancies
- an incompetent cervix- uterine fibroids- intra uterine inflammation, viral infection- multiparity- obesity- uncontrolled diabetes
inevitable miscarriage
when a threatening miscarriage progresses, the volume of vaginal bleeding increases and the cervix dilates
if a women who has vaginal bleeding increases, her cervix dilates and has an increase of cramping and lower abdominal pain, what is she experiencing
inevitable miscarriage
if a women is experiencing an inevitable miscarriage at 18 weeks how will she be treated
she will have an evacuation of uterine contents
if a women is 14 weeks pregnant and experiences an ineveitable miscarriage, what will be the plan t treat her
we will wait for a spontaneous expulsion of the products of conception
complete miscarriage
when all products of conception includes the embryo and placenta with intact membranes from the uterus are expelled from the uterusbleeding is usually mild and os is closed
incomplete miscarriage
cervix will remain open. the products of coneption may be visible or felt, usually the fetus is passed while the placenta and membranes are retained. there may be profuse/light bleeding as the uterus cannot contract and retract effectively due to the products of conception being retained in utero
habitual or recurrent miscarriage
three or more consecutive spontaneous miscarriages after 14 weeks
what are the causes of habitual miscarriage
- uterine abnormality- cervicaal incompetence
hydatidiform mole
the abnormal development of the primitive chorion, where hydropic or cystic degeneration of the centre of the villi occurs
products of conception resemble a large bunch of grapes
hydatidiform mole
what are the signs and symptoms of hydatidiform mole
- vaginal bleeding - excessive nausea and vomiting- hypertension may develop before 20 weeks of pregnancy - uterus large for the period of gestation, soft and bulky
embryo is absorbed and no fetus or placenta can be identified
hydatidiform mole
not all products of conception are expelled
incomplete miscarriage
all products of conception are expelled
complete miscarriage
vaginal bleeding with closed cervix and no pain
threatening miscarriage
vaginal bleeding and pain with cervical dilation
inevitable miscarriage
three or more consecutive miscarriages after 14 weeks
habitual miscarriages
a patient who comes in complaining of LAP. she is 17 weeks GA. She has ROM and on speculum insertion she is internal os open. what would her diagnosis be and what is the management for her.
she is having an inevitable miscarriage. Her management would be to perform an MVA
induced abortion
when a procedure is done or medication is taken to end a pregnancy or the intentional termination of a pregnancy before the fetus can live independently viable interruption of pregnancy on demand
elective abortion
a women chooses to end her pregnancy and it is not for maternal or fetal health reasons
therapeutic abortion
performed in order to preserve the ehalth or save the life of a pregnant women
septic abortion
infection of th uterus following a miscarriage
placental abruption
is the premature seperation of a placenta from its implantation in the uterus
what are the two forms of placenta abruption
- concealed (20%) - revealed (80%)
what is a concealed placenta abruption
where the bleeding is confined within the uterine cavity. it is also more severe form because the amount of blood loss is easily underestimated
what is a revealed placental abruption
this is where the blood drains through the cervix usually with incomplete or detachment
risk factors of placental abruption
- uterine abnormalities- hypertension / pre-eclampsia- cigarette smoking- multiple pregnancies- short umbilical cord- decompression of uterus (polyhydramnios)- folic acid deficiency - anemia - poor nutrition and social conditions
what is the cause of placental abruption
- the maternal vessels tearing away rom the decidua basalis. Seeperatoin results in bleeding into the decidua basalis h=behind the placenta causing a retroplacental clot- direct trauma to the uterus
what are the degrees of abruptio placenta
- asymptomatic- grade 1 - grade 2- graade 3
what degree of abruption placenta is mary having. She has a small amount of vaginal bleeding nd uterine contractions. There is ni sign of fetal distress or low blood pressure
grade 1
explain what would occur if a women is experiencing a grade 2 placental abruption
she would have mild to moderate bleeding, uterine contractions and there will be some sign of fetal distress
describe grade 3 placental abruption
there will be moderate to severe bleeding which could be concealed. there would be uterine ontractions that does not relax, abdominal pain, low blood pressure and fetal death
what are the onset and symptoms for abruption placenta
- more common after 28 weeks- retroplacental clot may begin to develop overtime- pain with or without external and concealed vaginal bleeding - uterus is hard (woody) and tender- dark clots of blood (may be concealed but if not then clots)- large SFH for expected dates- difficult to feel baby or hear fetal heart- FM may be absent or reduced
what would you do for a patient if she shows signs of abruption placenta at an MOU
- admit her to labour ward- start an iv of ringers lactate- if mother is in shock then resuscitate with 1-2L of ringers lactate- no vaginal exams should be done- monitor vital signs every 15min- give oxygen with a face mask at 60% 6-8L in order to help improve tissue perfusion- insert a catheter- monitor her blood loss- contact referral hospital- monitor fetal heart rate
what would you do for a patient who presents with placental abruption with mild bleeding at a hospital setting.
- continue obs in order to detect hypovolaemic shock- take blood for FBC and cross match- do an ultrasound scan in order to help with the diagnosis- mmonitor uterine contractions (if she is having frequent uterine contractions >5/10 minutes) this could suggest abruptio placenta- if baby is in fetal distress and fetus is viable then deliver the women by an emergency c sections- insert a speculum in order to exclude a local cause- further management depends on cause
what other maternal illness is in collaboration with abruptio placenta
pre-eclampsia
if a patient is experiencing abruptio placenta and the fetus is not viable, how would you manage her
- rupture membranes - augment labour with oxytocic- monitor blood loss carefully
how would you manage a patient who has placenta abruptio and the fetus is dead
- deliver urgently - take bloods for a cross match, FBC, INR, PTT (partial thromboplastin test) and serum urea and creatine - blood tranfusion (2-4 units) is usually necessary- insert CVP line- insert catheter and monitor hourly urine outout- give fluids in order to maintain a systolic bp of 100mmhg or more- if there is no progress of labour with in 1-2 hours after AROM then augment- give analgesia - morphine 5mg IM 4 hourly
diagnose the patient
Mrs September who is 37 weeks pregnant. she has gestational hypertension for which she takes alpha methyldopa in order to help her BP. She comes into the clinic and her vitals are BP=150/90 P=111 T=37C FM= vary faint . she is experiencing pain which is always present. On in examination her abdomen is hard and tender and her SFH is large for her GA. she is also complaining of bleeding which is dark red and has blots
the patient is experience abruption placenta and should be transferred to a tertiary instution.
placenta previa
a condition in which the placenta is implanted in the lower segmant of the uterus and is too close to covering the cervix
what is the statistics for plcenta previa
1 in every 200 births
what are the four types of placenta previa
- total placenta previa- partial placenta previa- marginal placenta previa- low lying placenta
explain total placenta previa
this would be classified as a grade 4 completely ocvers the internal os
explain partial placenta plevia
classified as a grade 3when the edge of the placenta is partially over the nternal os when undilated and up to 4cm when dilated
explain a marginal placenta previa
classified as a grade 2 when the placenta reaches the edge of the internal os
explain a low lying placenta
classified as a grade 1 placenta is implanted in the lower segment
what is th emanagement of placenta previa dependent on
gestation of the pregnancy
how should the women be managed if placenta previa is diagnosed in the 2nd trimester
follow up and recheck the location in the 3rd trimester
how can placenta previa be monitored during the 2nd and 3rd trimester
- transvaginal ultrasound- trans abdominal ultrasound - mri scan
what are risk factors for placenta previa
- advanced maternal age- multiple pregnancy - grand multipara- damage of the endometrium in the upper segment due to previous dilation and curettage to remove any tissue from the uterus- previous c section- previous placenta previa
what are the symptoms of placenta previa
- sudden and painless vaginal bleeding - bright red blood with no clots- no abdominal pain or tenderness- baby in breach or transverse positiion
if a patient is 34 weeks and she is bleeding due to placenta previa with and bleeding, how will you manage her
admit to hopsital bed rest till bleeding stopsgive corticosteriods
what effect does placenta previa have on the mother
- preterm labour- c section- placenta accreta- shock and death
what is the effect of placenta previa on the baby
- preterm birth, foetal distress, high risk - perinatal death- IUGR
why is the mother given pitocin after a c sections
in order to cause the uterus to contract which can help stop bleeding
placenta accreta
deeply implanted placenta and doesnt seperate easily at delivery
how would you deliver a grade 2 Placenta previa
vaginallly is vertex and presenting part is engagde
how would you deliver a grade 4 placenta previa
c section because of risk of heavy bleeding in labour as cervix dilates
how would manage a patient at the MOU if they have placenta previa
- admit to labour wards- start an iv with ringers lactate- if mother is in shock resuscitate with 1-2 L of ringers lactarw- monitor vital signs every 15 minutes- give oxygen via face mask @60% (6-8L) in order to improve tissue perfusion- insert a catheter- Do not do a digital vagnial exam- monitor FHR- contact refferal hospital- transfer patient to tertiary instiude urgently.
how would you monitor a patient with placenta previa at a hospital
this is if bleeding is milk - continue obs in order to detect hypovolaemic shock- take blood for FBC and cross match- do an ultrasound scan to help with the diagnosis- if placenta previa is found manage accordingly- if no placenta previa exclude minor abruption by doing a full clinical examination and CTg- monitor uterine contractions - monitor FHR for fetal distress: if fetus is viable then deliver the women by an emergency c section - dp a speculum exam in order to exclude a local cause- further management depends on cause- measure blood loss- take bloods for cross matching and FBC - do a blood transfusion is HB is less than 10g/dl- if patient is less than 36 weeks and bleeding subsides then manage and allow fetus to grow - adminster corticosteriods
definition of hyoertension
a dystolic blood pressure of more than 90mmHg but less than 110mmHg taken two houra apart and a systolic blood pressure of more than 140mmHg but less than 160mmHg
chronic hypertension
hypertension that is present before 20weeks of gestation or is the women was already taking antihypertensive medication before pregnancy
gestational hypertension
new onset hypertensions that presents only after 20 weeks of gestation without a significant sign of proteinura
pre eclampsia
hypertension with significant proteinuria developing for the first time after 20 weeks of gestation. pre eclampsia can also be superimposed on chronic hypertension and present with significant proteinuria
what is imminent eclampsia
symptoms and signs that characterises severe pre eclamptic women
what are signs and symtpoms of severe pre eclampsia
- severe persistent headache- visual disturbances - epigastric pain- hyper-reflexia- clonus- dizzyness and fainting- vomiting
eclampsia
generalised tonic-clonic seizures after 20 weeks of pregnancy and within 7 days after delivery - its associated with hypertension and proteinuria
how would you manage a patient with chronic hypertension at an mou
- if patients blood pressure is within normal range and patient is compliant, then discuss patient and change oral medication to alpha methyldopa 500mg 8 hourly via oral- ensure patient is seen at 24 weeks at a high risk facility for blood tests related to the early detection of pre eclampsia and placental function- patient should then attend the high risk clinic at the MOU until 36 weeks if BP is still stable at each visit
how do you manage a patient with gestational hypertension at an MOU
- check for proteinuria, oedema and increased weight gain- ask about family hx of hypertension, hx of hypertension in previous pregnancies. basicalluy obstetric history- ask about bleeding during the pregnancy so far and if patient has any symptoms of persistent headache
what systems does pre eclampsia affect
- circulatory system- central nervous system- coagulation- liver
who is at risk for pre eclampsia
- primigravida- multi gravida with new partners- women of advanced maternal age - chronic hypertension- multiple pregnancies- diabetics - previous abruptio placentae- obesity
what type of drugs should not be used in pre eclampsia and why should not be used
diureticsthe woen is already hypovoleamic and these drugs may be dangerous
what tablets may help reduce the chance of women getting pre eclampsia
- calcium supplementation- low dose aspirin
how will calcium supplementation be adminstered to pregnant women
1g elemental calcium given in divided doses dailycalcium carbonate 168mg - 2 tablets orally 3 times daily with food. It is best taken before or after iron supplements
how will low dose aspirin be administered to pregnant women
75mg or quarter of a standard tablet to be taken daily from the 12th week of pregnancy until 34 weeks gestational age.it is usually prescribed to patients whoe have had previous pregnancy loss due to severe pre-eclampsia or abruptio placenta
imminent eclampsia
symptoms and signs in imminent eclamptic women - presents with severe headaches, visual disturbances, epigastric pain, hyperflexia, dizziness and vomiting
HELLP Syndrome
the presence of haemolysis, elevated liver enzymes and low platelets
what is capillary permeability affected by
hypertensions and changes in endothelial cells
when placenta protein leakes from the damaged blood vessels what occurs
a decrease in plasma colloid pressure and an increase in oedema within the intracellular space
what does the decrease in intravascular plasma volume cause
hypocolaaemia and heamoconceptration shown in elevated hematocrit
what causes a severe case of vasospasm which causes impaired oxygenation and cyanosis
lungs becoming congested with fluid and pulmonary oedema occurs
when is coagulation cascade activated
when vasoconstriction causes a distruption of the vascular endotheliem
what happens to the coagulation system during pre eclampsia
there is an increased platelet usage which produces thrombocytopeania and may be responsible for the development of disseminated intravascular coagulation
hypertension leads to vasospasm if the ______ ___________
afferent arterioles
in the renal systern, vasospasm of the afferent arterioles results in ...
a decreased renal blood flow, which in turn produces hypoxia an oedema of the endothelial cells of the gloerular capillaries
how is renal damage presented
- reduced creatinine clearance- increased serum creatinine and uric acid levels
oliguria
develops as the renal system condition becomes worse. this signifies the severity of the condition and kidney damage
due to pre eclampsia the placenta is hypoperfused, the proinflammatory proteins it releases cause ...
- hypertension- vasoconstriction- endothelial cell dysfunction- formation of thrombi- end organ damage
what does increased platelet consumption produce
thrombocytopenia
what is responsible for the `development of disseminated intravascular coagulation
increased platelet ocnsumption
what leads to vasospasm of the afferent arterioles
hypertension
how does hypertension affect the renal system
causes decreased renal blood bflow which produces hypoxia and oedema of the endothelial cells of the glomerular capilarries
how is proteinuria produced in the renal system
the glomeruler endothelial damage allows plasma proteins mainly in the for of albumin to filter into the urine, thus producing proteinuria
how do you detect renal damage
- reducued creatinine clearance- increased serum creatinine- increased uric acid levels
how does oliguria develop
as the renal systems condion becomes worse, this signifies the severity of the condition and kidney damage
what vasoconstriction of the hepatic vascular bed cause
hypoxia and oedema of the liver cells
how can you detect altered liver funtions
increased levels of liver enzymes and decreased albumin levels
what will increase the permability of the blood brain barriere
hypertension AND cerebrovascular endothelial dysfunction
why does hyperplasia and swellig of the layers of the chrionic villi happen
in order to overcome the hypoxia caused by vasospasm - cause more brnached villi
what effect does pre eclampsia have on the utero placental circulation
- IUGR - fetal distress- abruptio placenta- fetal death - preterm birth
what effect does pre eclampsia have on the kidney
proteinuriarenal failure
what effect does pre eclampsia have on the liver
- liver damage- liver enzyme elevation - liver rupture- acute fatty liver
what effects does pre eclampsia have on the haemotological system
- low platelet count- HELLP syndrome
what effect does pre eclampsia have on the pancreas
pancreatitis
what effect does pre eclampsia have on the lung
- pulmonary oedema
what effect does pre eclampsia have on the brain
- seizures- ischemia- cerebral oedema
what effect does pre eclampsia have on the heart
arrythmia
Mrs Adms come into the MOU for her ANC visit. She is 34+4 /40 GA. She was complaining of headaches and swollen feet. She was diagnosed with gestational hypertension and prescribed alpha methyldopa. She says she has trouble peeing and has a constant headache where she sometimes will see scars.BP - 171/111 and 180/119P - 121T - 36.9CONT - nil on palpationPV - os closed membranes intact - LAP urine= protein 2+ (10ml) what would her diagnosis be and how will you manage the patient at an MOU facility
severe pre eclampsia
admit pt to labour ward- immediate priority - place pt on left lateral side to increase oerfusion to the uterus- start an iv
1L ringers- restrict fluid to 80ml/h to prevent fluid overload- insert a catheter and attach urine bag to monitor urine output and proteinuria- administer magsul to prevent seizures- dilute 4g of MgSO4 in a 200ml bag of NaCl and connect line correctly- infuse MgSo4 via iv for 20 mins- if pt is still in the facility after 4 hurs administer 5g of magsul via IM in each buttock- therefore the pt should have recieved a total of 14g of MGSO4 - give a stat oral dose of 1g of methyldopa po in order to lower bp- administer adalat 10mg po to lower bp - recheck bp. if bp higher than 160/110 then administer 2nd dose of adalat- repeat every 30 mins and 3 doses max can be admin- monitor bp, p and resp every 15 mins- monitor urine output and it should not be less than 25-30mls- discuss with dr at HR facility- book flying squad for patient
if patient shows signs of MgSO4 overdose what antidote should be given
10mls of 10% calcium gluconate slowly via iv
what is the best managemnt of eclampsia
- EMERGENCY- immediate stabilisation
- mother takes priority - tunr pt on her side, extend her neck, suction the airways and insert an oral airway if needed- give o2 by 40% facemask- administer mgso4 prophylaxis - dilute 4g of mgso4 in 200ml of ringers and infuse for 20 minutes- plus give 5g of MgSo4 IM into buttock- repeat with 5g every 4 hours IM into alternative buttocks - maintance dose- or if infusion pumps are available put 4 g in 200ml fluid and infuse at 50ml/h for maintanace dose- once patient is alert and orientated, lower BP with 1g methyldopa stat per os if BP is stil more thn 160/11 give nifedepine 10mg orally to swallow whole - repeat BP every 15 minutes until ambulance arrives- if Bp is still more than 160/11 give another dose of nifedepine but 3 doses max should be given - a nurse should stay with pt until flying sqaud arrives- discuss- book flying squad - document -
usually develops before 37th week of oregnancy but can occur shortly after delivery. many women are diagnosed with preeclampsia before hand
HELLP syndrome
what are the clinical signs of HELLP syndrome
- generalised malaise- some with epigastric pain- some with nausea and vomiting- others with headaches- with or without proteinuria
what are the main abnormalities of HELLP syndorme
heamolysiselevated liver enzymeslow platelet count
when should you stop magnesium sulphate injections or infusions
- patellar reflexes are absent - respiratory depression is less than 16 breaths / minute- urine outpt is less than 30m;/h- loss of consciousness
how do you manage a patient at a hospital for severe pre eclampsia
- assess fetus via ctg and ultrasound for fetus size- if less than 34 weeks or estimated fetal weight is less than 2kg, give steriods to help speed up fetal lung matuarity- take blood for FBD, urea, creatinine, uric acid and AST - delivery may be delayed for 24-48 hours to allow steriods for take effect - conservative management for patients who are 26-33 weeks or fetal weight is 900-1500g
how would you manage mild and moderate pre eclampsia at an MOU
Admit the patient to labour ward ► Once diagnosed as stable mild to moderate pre-eclampsia: ► Monitor for symptoms of imminent eclampsia (frontal headache, visual
disturbance, oedema etc) ► Administer alpha- methyldopa 1g stat per os to lower BP and 500 mg 8 hourly
and phone the district hospital for referral. ► Commence 200ml of Normal Saline/Ringer’s Lactate intravenously (for easy iv
access when needed) & restrict fluid intake to 80 ml /hr ► Insert an indwelling catheter : Assess urine again for protein ► Monitor output – should be at least 30ml/hr ► Discuss with doctor at high risk facility – same day referral is essential ► Book an ambulance for transfer ► NB Documentation!!
what would you consider mild and moderate pre eclampsia
dystolic BP of 90-109mmHg with 1+/2+ proteinuria
what is the best way to manage a patient with mild to moderate pre eclampsia as a district hospital
► district hospital, all patients should have an ultrasound assessment of the fetus in respect of g.ae or estimated fetal weight (if no previous dating ultrasound available). ► Test for fetal well-being with an umbilical artery Doppler test ► If the baby is viable (≥ 28 weeks), an antenatal CTG should also be carried out and fetal movement charts initiated. ► Confirm the diagnosis of mild to moderate pre-eclampsia with a 24 hr protein collection, except if there is persistent proteinuria ≥1+ on the dipsticks. ► With confirmed significant proteinuria (≥0.3 g/24 h or persistent ≥1+), do a platelet count, serum creatinine and serum ALT and LDH.► If the patient remains stable,she should be managed as an in-patient until 36 weeks, when delivery (induction of labour) is strongly advised. ► Do weekly platelet counts and twice daily CTGs. ► Remember to keep plotting the growth of the baby on the antenatal card every two weeks.
where des amnin fluid come fom
it is thought to be formed mainly by fluid diffusing through the chorionic and amniotic membranes from the maternal blood in the decidua of the uterus
what are the functions of amniotic fluid
- cushions baby and protects them from trauma- it prevents the umbilical cord from becoming compressed- it helps maintain a constant temperated in the uterus- it protects against infection- it allows the baby to move around so that his muscles and bones develop properly - helps with the digestive and respiratory systens development. ie swallow and excrete
at 10 weeks how much aniotic fluid liqour should be present
35ml
when does the amniiotic fluid liqor decrease
after 38 weeks it will decrease to about 600ml at term
when will the amniotic fluid liqour be 1000ml
between 30-38 weeks
placental insufficiency
a complication in pregnancy where the placenta cannot bring enough oxygen and nutrients to the growing fetus in utero
what are causes of placental insufficiency
- diabetes - hypertension- smoking- alcohol and drug abuse- infections- poor nutrition- multiple prenancies- placenta previa / abruptio placenta
non stress test
a test that measures the heart rate of an unborn baby as the baby ,oves in the uterus
how would you managae placental insuffieccy
• Important to get an early diagnose and
adequate prenatal care improve baby’s chances
of normal growth • Treating any underlying medical condition
(hypertension, diabetes) helps improve baby’s
growth. • Good antenatal nutrition (supplements)-anemia • Maintaining healthy lifestyle- smoke, alcohol • Bed rest –improve blood flow to uterus and
fetus • Fetal heart rate monitored & recorded 4hrly• Continuous fetal monitoring important if the
patient on anti-hypertensive drugs • Kick chart given • Fetal non-stress test - hypoxia • Ultrasonic scan for assessment of fetal
wellbeing and growth
Parameters for assessment of fetal wellbeing
include: - Fetal movement less due to less amiofluid - Fetal breathing - Amount of amniotic fluid (AFI)
what are complications of placental insufficency
- IUGR-fetal hypoxia and fetal distress- decrease in cardiac function of the fetus- IUD
IUGR
intrauterine growth restrictionis the failure of a fetus to achieve its growth potention
what are the two groups of iugr
- symmetric- asymetric
when will the SFH indicate IUGR
●Slow increase in uterine size until one measurement falls under
the 10th percentile line ● Three successive measurements without necessarily crossing
below the 10th percentile line ● A measurement which is less than that recorded 2 visits
previously without necessarily crossing below the 10th percentile
line
what is indicated on the graviodogram give a rationale
IUGR there is a slow increase in the uterine size and falls below 10th percentile line
in a patient with asymetrical iugr what would the piqour be like
volume may be reduced
what is the cause of symmetrical iugr
- fetal chromocomal disorders- intrauterine infections or exposure to teratogenics substances
what is the cause of assymetrical iugr
- placental insufficency- pre eclamspia- vascular disease
what are some of the obvious symptoms of assymetrical iugr
- dry skin- long nails- head is large in comparison to body
oligohydramnios
fetus may have a decreased cardiac output and thus decreased renal flow to produce less urine
how to prevent iugr
Early attendance at antenatal clinic and careful history taking ● Keep all of your pre-natal appointments – detect potential
problems early ● Eliminate or control risk factors that may inhibit baby's chances
of growing normal – manage chronic conditions e.g, heart
disease, chronic hypertension ● Avoid smoking, drinking – contribute to poor fetal growth ● Medication – make sure it did not have an effect on baby ● Balanced diet – prevent anaemia● Eat healthy – healthy foods high energy diet and ample calories
help keep baby well nourished ● Manage medical conditions – d/diabetes; g/hypertension ● After 28w or more - counting fetal movements ● Get plenty rest – improve blood flow and help with growth of
baby ● Refer to level 3 hospital for medical opinion in the case of: ○ Previous stillbirth; -perinatal death ○ Poor weight gain ○ Poor SFH ○ Reduced fetal movements
what is the best management for assymetrical iugr
○ Identify the cause and manage accordingly
○ There is a high risk for IUD ○ Perform amniocentesis for lung maturity
● At less than 34 weeks, admit to hospital for daily fetal
movement and CTG’s twice weekly ● Repeat ultrasound assessment after 2 weeks ● Delivery is indicated if there is any evidence of fetal distress
what is the best management for symmetrical iugr
● - exclude a cause, especially chromosomal and congenital
defect, or congenital infection
● -delivery is indicated at >37 weeks ● -<37 weeks evaluate the fetus by ultrasound for abnormalities ○ -if no fetal abnormalities, mother can go home with a fetal move chart ○ -and return for reassessment after 2 weeks
how do you manage iugr during labour
● Should be born in specialized high care facilities. ● Very careful monitoring of fetus is done throughout labour. ● Meconium-stain liquor should be noted & reported. ● The obstetrician decides on the mode of delivery. ● If the cervix ripen, an induction can be carried out with carefully
monitoring of the well-being of the fetus by CTG ● Protaglandins / oxytocin are used to ripen the cervix before
induction of labour can take place.