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Hemorrhagic, Endocrine and Metabolic Disorders - Maternal
Terms in this set (89)
what does maternal blood loss decrease?
oxygen - carrying capacity
what does maternal blood loss increase the risk for?
impaired oxygen delivery to the fetus
what are fetal risks of maternal hemorrhage?
blood loss, anemia
what is a miscarriage (spontaneous abortion)?
a pregnancy that ends as a result of natural causes before fetal viability
how early are the majority of miscarriages?
before 12 weeks of gestation
what are the different types of miscarriage?
Condition that suggests a miscarriage might take place before the 20th week of pregnancy
moderate to heavy bleeding, mild to severe cramping, ROM, cervical dilation
some, but not all, of the products of conception have been passed; retained products may be part of the fetus, placenta or membranes
all fetal tissue expelled and cervix closed
fetus dead, but everything is still in utero
three or more consecutive pregnancy losses before 24 weeks gestation. This affects 1% of couples trying to conceive.
what should you assess for bleeding?
pregnancy history, vital signs, type and location of pain, quantity and nature of bleeding, and emotional status, lab tests
medical management of bleeding
surgical management of bleeding
dilation and curettage (D&C)
cervical insufficiency with bleeding
passive and painless dilation of the cervix during the second trimester
acquired or congenital
diagnosis for cervical insufficiency
measurement of cervical length
speculum/digital pelvic exams, transvaginal U/S
what is considered a short cervix
less than 25 mm
treatment for cervical insufficiency
suture is placed around cervix beneath mucosa to constrict internal os of the cervix (McDonald technique)
mersilene tape is placed at the junction of the lower uterine segment and the cerix
follow up care for cervical insufficiency treatment
watch for sign of preterm labor, rupture of membranes, infection
fertilized ovum is implanted outside the uterine cavity (tubal pregnancies)
what are clinical manifestations of ectopic pregnancy?
abnormal vaginal bleeding
ways to diagnose ectopic pregnancy
quantitative B-hCG levels and transvaginal ultrasound examination
B-hCG level above which a normal intrauterine pregnancy should be visible on ultrasound
medical management of ectopic pregnancy
surgical management of ectopic pregnancy
depends on ectopic pregnancy, tissue involved and woman's desires regarding future fertility
what is molar pregnancy?
type of gestational trophoblastic disease
benign proliferative growth of the placental trophoblast in which the chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in a grapelike cluster
what is the cause of molar pregnancy?
unknown, may be related to an ovular defect or nutritional deficiency
complete molar pregnancy
no embryonic or fetal parts
partial molar pregnancy
often have embryonic or fetal parts and an amniotic sac
manifestations of molar pregnancy
anemia from blood loss, excessive nausea and vomiting and abdominal cramps
what occurs in most women with large rapidly growing hydatidiform moles and occurs earlier than usual in pregnancy?
what is the diagnosis for molar pregnancy?
transvaginal ultrasound and serum hCG levels
how can you treat hydatidiform moles?
most abort spontaneously, suction curettage can safely be used
what is placenta previa?
placenta implanted in lower uterine segment near or over internal cervical os
what three types of placenta previa classify how much internal cervical os is covered by placenta?
complete placenta previa
marginal placenta previa
low-lying placenta previa
what are risk factors for placenta previa?
previous c-birth, advanced maternal age, multiparity, history of prior suction curettage, living at a higher altitude and smoking
what are the manifestations of placenta previa?
painless bright red vaginal bleeding in 2nd/3rd trimester
soft, relaxed, nontender uterus with normal tone
what is a major complication of placenta previa?
hemorrhage, abnormally firm placental attachment, surgery related trauma, preterm birth
what is the diagnosis for placenta previa?
initial transabdominal ultrasound examination
transvaginal ultrasound is better than transabdominal scan for location
what is premature separation of placenta?
detachment of part or all of placenta from implantation site after 20 weeks of gestation
what is a primary risk factor for premature separation of placenta?
blunt external abdominal trauma
cigarette smoking, history of abruption in a previous pregnancy, and preterm prelabor rupture of membranes
clinical manifestations of premature separation of placenta?
vaginal bleeding, abdominal pain, uterine tenderness and contractions
boardlike abdomen- couvelaire uterus
diagnosis for premature separation of placenta
what is vasa previa?
rare condition in which fetal vessels lie over the cervical os, and the vessels are implanted into the fetal membranes rather than into the placenta
what are the two types of vasa previa?
velamentous insertion of the cord: cord vessels branch at membranes and then onto placenta
succenturiate placenta: placenta has divided into two or more lobes
what is battledore insertion of the cord?
increases risk of fetal hemorrhage
what is considered normal clotting?
a delicate balance exists between opposing hemostatic and fibrinolytic systems
what is the fibrinolytic system?
process through which fibrin is split into fibrinolytic degradation products and circulation is restored
what is disseminated intravascular coagulation?
acquired syndrome characterized by intravascular activation of coagulation which is widespread and results in excessive clot formation and hemorrhage
what is DIC often triggered by?
the release of large amounts of tissue factor as a result of placental abruption
what is pregnancy characterized by?
complex alterations in maternal glucose metabolism, insulin production, and metabolic homeostasis
what is the diabetogenic effect on the maternal metabolic status in the second and third trimesters?
decreased tolerance to glucose
increased insulin resistance
decreased hepatic glycogen stores
increased hepatic production of glucose
at birth, what does expulsion of the placenta prompt?
an abrupt drop in levels of circulating placental hormones, cortisol, and insulinase; maternal tissues quickly regain their prepregnancy sensitivity to insulin
group of metabolic disease characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both
body compensates for its ability to convert glucose into energy by burning muscle and fats
type 1 diabetes
onset at young age, insulin deficiency
type 2 diabetes
insulin resistance and relative insulin deficiency, cause is unknown
given to type 1 or 2 diabetes that existed prior to pregnancy
diabetes during pregnancy
White's classification of diabetes in pregnancy
A1 - 2+ abnormal OGtT results, blood glu is controlled
A2 - didnt have diabetes prior to preg, needs meds for glu control
B - onset after 20, lasts <10 years
C - onset btwn 10-19 years
F - diabetic neuropathy
R - retinities proliferans
T - renal transplant
take home message:
a-c = good outcomes if glu is controlled. d-t = poor outcomes via vascular damage
maternal risks and complications with pregestational diabetes
fetal and neonatal risks and complications of pregestational diabetes
perinatal mortality rate is 3x higher for women with diabetes than for women who do not have this disease
hypoglycemia at birth
antepartum care for pregestational diabetes
maintaining constant euglycemia
self-monitoring of blood glucose
complications requiring hospitalization
determination of birth date and mode
intrapartum care for pregestational diabetes
monitoring for dehydration, hypoglycemia, and hyperglycemia
blood glucose levels monitored
possible cesarean birth for macrosomia
postpartum pregestational diabetes care
first 24 hrs, insulin requirements drop substantially
risk of hemorrhage due to uterine distention
encouraged to breastfeed
contraceptive methods edu
risk factors for gestational diabetes
previous pregnancy resulted in unexplained stillbirth or birth of a malformed or macrosomic fetus
obesity, hypertension, glycosuria, maternal age older than 25 years
more than half of women with GDM have non of these risk factors
when should women with strong risk factors for gestational diabetes be screened?
before 24-28 wks
two step screening method for 24-28 wks for gestational diabetes
1 hr, 50 g oral glucose: glucose value of 130 - 140 mg/dL or higher>positive
3 hr, 100 g oral glucose: diagnosed with GDM if two or more values are met or exceeded
one step screening
maternal risks for gestational diabetes
development of type 2 diabetes later in life
fetal risks for gestational diabetes
macrosomia and risks for birth trauma
electrolyte imbalances including neonatal hypoglycemia and hyperinsulinemia
antepartum care with gestational diabetes
strict blood glucose control
self-monitoring of blood glucose
intrapartum care for gestational diabetes
blood glucose levels hourly in labor
maintain at 80-110 mg/dL
infusion of insulin
postpartum care of gestational diabets
return to normal glucose levels after birth
high risk for recurrent GDM in future pregnancies
assess women who had GDM for carb intolerance with a 75 g, 2 hr OGTT or a fasting plasma glucose level at 6-12 wks postpartum
lifelong repeat screening at least every 3 yrs
when does normal nausea and vomiting begin in pregnancy?
4-10 wks of gestation, resolves by 20 wks
excessive prolonged vomiting accompanied by the following:
when does hyperemesis gravidarum begin?
second most common reason for hospitalization
what are risk factors for hyperemesis gravidarum
younger maternal age, nulliparity, BMI less than 18.5 or greater than 25, low socioeconomic status
women with asthma, migraines, preexisting diabetes, psychiatric illness, hyperthyroid disorders, GI disorders, previous pregnancy complicated by this disorder
manifestations of hyperemesis gravidarum
sigificant weight loss and dehydration
dry mucous membranes
increased pulse rate
poor skin turgor
assessment for hyperemesis gravidarum
severity, frequency, duration of episodes
determination of ketoruria
psychosocial assessment: role of axiety
interventions for hyperemesis gravidarum
IV therapy for correction of fluid and electrolyte imbalances
enteral or parenteral nutrition as a last resort
hyperthyroidism in pregnancy manifestations
heat tolerance, diaphoresis, fatigue, anxiety, emotional lability, and tachycardia
may include weight loss, goiter and a pulse rate greater than 100 b per min
what is severe hypothyroidism associated with?
infertility and increased risk of miscarriage
symptoms of hypothyroidism
weight gain, lethargy, decrease in exercise capacity, and cold intolerance
what medication is given for hypothyroidism?
Inborn error of metabolism caused by an autosomal recessive trait that creates a deficiency in the enzyme phenylalanine hydrolase, impairs ability to metabolize foods with protein, can cause cognitive impairment
what can decrease cognitive impairment with maternal PKU
what level should PKU be at for at least 3 months before conception?
6 mg/dL and range 2 and 6 mg/dL throughout pregnancy
when is breastfeeding safe for women with pKU?
as long as baby does not also have PKU
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