Pregnancy at Risk: Pregestational Onset

Alcohol Use in Pregnancy

• Maternal effects:– Malnutrition – Bone-marrow suppression– Increased incidence of infections– Liver disease

• Neonatal effects:– Fetal alcohol spectrum disorders (FASD)

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

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

Heroin Use in Pregnancy

• Maternal effects:– Poor nutrition and iron-deficiency anemia– Preeclampsia-eclampsia– Breech position– Abnormal placental implantation– Abruptio placentae– Preterm labor

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

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

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

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

Effect of Pregnancy on Carbohydrate Metabolism

• Early pregnancy:– Increased insulin production and tissue

sensitivity

• Second half of pregnancy:– Increased peripheral resistance to insulin

Maternal Risks with DM

• Hydramnios

• Preeclampsia-eclampsia

• Ketoacidosis

• Dystocia

• Increased susceptibility to infections

Fetal and Neonatal Risks with DM

• Perinatal mortality• Congenital anomalies• Macrosomia• IUGR• RDS• Polycythemia

Fetal and Neonatal Risks with DM (cont’d)

• Hyperbilirubinemia

• Hypocalcemia

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

Risk Factors

• Age over 40

• Family history of diabetes in a first-degree relative

• Prior macrosomic, malformed, or stillborn infant

• Obesity

• Hypertension

• Glucosuria

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

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

Fetal Assessment

• AFP

• Fetal activity monitoring

• NST

• Biophysical profile

• Ultrasound

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

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

Iron-deficiency Anemia (cont’d)

• Fetal complications:– Low birth weight– Prematurity– Stillbirth– Neonatal death

Iron Deficiency Anemia (cont’d)

• Prevention and treatment:– Prevention - at least 27 mg of iron daily– Treatment - 60-120 mg of iron daily

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

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

Sickle Cell Anemia

• Maternal complications:– Vaso-occlusive crisis– Infections– Congestive heart failure– Renal failure

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

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

HIV in Pregnancy: Maternal Risks

• Intrapartal or postpartal hemorrhage

• Postpartal infection

• Poor wound healing

• Infections of the genitourinary tract

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)

Treatment DuringPregnancy

• Counsel about implications of diagnosis on pregnancy:– Antiretroviral therapy– Fetal testing– Cesarean birth

Cardiac Disorders in Pregnancy

• Congenital heart disease

• Marfan syndrome

• Peripartum cardiomyopathy

• Eisenmenger syndrome

• Mitral valve prolapse

Less Common Medical Conditions in Pregnancy

• Rheumatoid arthritis

• Epilepsy

• Hepatitis B

• Hyperthyroidism

• Hypothyroidism

• Maternal phenylketonuria

Less Common Medical Conditions in Pregnancy (cont’d)

• Multiple sclerosis

• Systemic lupus erythematosus

• Tuberculosis

Pregnancy at Risk: Gestational Onset

Spontaneous Abortion

• Threatened abortion

• Imminent abortion

• Incomplete abortion

• Complete abortion

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.

B Imminent. The placenta has separated from the uterine wall, the cervix has dilated, and the amount of bleeding has increased.

C Incomplete. The embryo/fetus has passed out of the uterus; however, the placenta remains.

Spontaneous Abortion (cont’d)

• Missed abortion

• Recurrent pregnancy loss

• Septic abortion

Spontaneous Abortion: Treatment

• Bed rest

• Abstinence from coitus

• D&C or suction evacuation

• Rh immune globulin

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

Ectopic Pregnancy: Risk Factors

• Tubal damage

• Previous pelvic or tubal surgery

• Endometriosis

• Previous ectopic pregnancy

• Presence of an IUD

• High levels of progesterone

Ectopic Pregnancy: Risk Factors (cont’d)

• Congenital anomalies of the tube

• Use of ovulation-inducing drugs

• Primary infertility

• Smoking

• Advanced maternal age

Ectopic Pregnancy: Treatment

• Methotrexate

• Surgery

Various implantation sites in ectopic pregnancy. The most common site is within the fallopian tube, hence the name “tubal pregnancy

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

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

Gestational Trophoblastic Disease: Symptoms

• Low levels of MSAFP

• Hyperemesis gravidarum

• Preeclampsia

Gestational Trophoblastic Disease: Treatment

• D&C

• Possible hysterectomy

• Careful follow-up

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.

Gestational Trophoblastic Disease: Nursing Care

• Monitor vital signs

• Monitor vaginal bleeding

• Assess abdominal pain

• Assess the woman’s emotional state and coping ability

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

Cervical Incompetence: Treatment

• Serial cervical ultrasound assessments

• Bed rest

• Progesterone supplementation

• Antibiotics

• Anti-inflammatory drugs

• Cerclage procedures

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.

Hyperemesis Gravidarum: Treatment

• Control vomiting

• Correct dehydration

• Restore electrolyte balance

• Maintain adequate nutrition

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

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

Nursing Clients with PROM (cont’d)

• Encourage resting on left side

• Provide comfort measures

• Provide education

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

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

Signs and Symptoms of Preterm Labor (cont’d)

• A change in vaginal discharge

• Abdominal cramping with or without diarrhea

Classification of Hypertension in Pregnancy

• Preeclampsia-eclampsia

• Chronic hypertension

• Chronic hypertension with superimposed preeclampsia

• Gestational hypertension

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

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

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

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

Labatalol

• Baby at risk for transient hypotension and hypogylcemia if mom on labatalol

• No labatalol to clients with asthma or first degree heart block

Fetal Assessment

• Fetal growth restriction

• Ultrasound @ 18-20 weeks, 28-32 weeks & as needed thereafter

• NST or biophysical profile if growth restricted

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

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

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

Normal Adaptations to Pregnancy

• Increased blood plasma volume

• Vasodilation• Decreased systemic

vascular resistance• Elevated cardiac

output• Decreased colloid

osmotic pressure

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%)

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

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)

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

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

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

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

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

Characteristics of Preeclampsia

• Increased viscosity of the blood

• Hyperreflexia• Headache• Subcapsular

hematoma of the liver

A In a normal pregnancy, the passive quality of the spiral arteries permits increased blood flow to the placenta.

B In preeclampsia, vasoconstriction of the myometrial segment of the spiral arteries occurs.

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

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

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

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

Hypertensive Effects on Fetus

• Small for gestational age

• Fetal hypoxia• Death related to

abruption• Prematurity

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

Management of Severe Preeclampsia

• Bed rest

• High-protein, moderate-sodium diet

• Treatment with magnesium sulfate

• Corticosteroids

• Fluid and electrolyte replacement

• Antihypertensive therapy

Fetal Indications for Delivery

• Severe IUGR

• Nonreassuring fetal surveillance

• oligohydramnios

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

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

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

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

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

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”

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

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

Renal Insufficiency

• Magnesium sulfate is hazardous to women with severe renal failure and maintenance dose must be reduced

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

Side Effects of Mag Sulfate

• Flushing• Sweating• Thirst• Drying mucous membranes• Depression of reflexes• Muscle flaccidity• Nausea• Blurred visoin• HA• tachycardia

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

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

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

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

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

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

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

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

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

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

PNEUMONIC

S safety

E establish airway

I IV bolus

Z zealous observation

U uterine activity

R rapid resuscitation

E evaluate fetus

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

REMEMBER!!!

• All medications and therapy are merely temporary measures

• Delivery is the only cure

Signs and Symptoms of Eclampsia

• Scotomata• Blurred vision• Epigastric pain• Vomiting• Persistent or severe headache• Neurologic hyperactivity Pulmonary

edema• Cyanosis

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

Management of Eclampsia (cont’d)

• To prevent injury, raise padded side rails

• Administer magnesium sulfate

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

Hemorrhage & Hypertension

• NO Methergine• Causes vasospasm

and increases blood pressure

• CONTRAINDICATED in pts with HTN

• Use hemabate or cytotec for PPH

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

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

DX

• Platelet < 100,000

• Liver enzymes AST ALT elevated

• Evidence of intravascular hemolysis must be present

Complications of HELLP

• Renal failure• Pulmonary edema• Ruptured liver hematoma• DIC• Abruptio placenta• Fetal death• Perinatal asphyxia• Maternal death

Sx of HELLP

• Epigastric pain

• Mailaise

• Nausea and vomiting

• Mild jaundice often noted

Sound like the flu?

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

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

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.

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

Rh Incompatibility

• Rh – mother, Rh + fetus

• Maternal IgG antibodies produced

• Hemolysis of fetal red blood cells

• Rapid production of erythroblasts

• Hyperbilirubinemia

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

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

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

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

Battering During Pregnancy

• Psychological distress

• Loss of pregnancy

• Preterm labor

• Low-birth-weight infants

• Fetal death

• Increased risk of STIs

Perinatal Infections

• Toxoplasmosis

• Rubella

• Cytomegalovirus

• Herpes simplex virus

• Group B streptococcus

• Human B-19 parvovirus

Fetal Risks: Toxoplasmosis

• Retinochoroiditis

• Convulsions

• Coma

• Microcephaly

• Hydrocephalus

Fetal Risks: Rubella

• Congenital cataracts

• Sensorineural deafness

• Congenital heart defects

Fetal Risks: Chlamydia

• Neurologic complications

• Anemia

• Hyperbilirubinemia

• Thrombocytopenia

• Hepatosplenomegaly

• SGA

Fetal Risks: Herpes

• Preterm labor

• Intrauterine growth restriction

• Neonatal infection

Fetal Risks: GBS

• Respiratory distress or pneumonia

• Apnea

• Shock

• Meningitis

• Long-term neurologic complications

Fetal Risks: Human B-19 Parvovirus

• Spontaneous abortion

• Fetal hydrops

• Stillbirth