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Pregnancy at Risk: Gestational Onset

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hCG levels fall. Methotrexate, salpingostomy or salpingectomy. Nursing Management ... hCG levels high- 'morning sickness' Often develop PIH. Need close follow ... – PowerPoint PPT presentation

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Title: Pregnancy at Risk: Gestational Onset


1
Pregnancy at Risk Gestational Onset
  • Chapter 15

2
Abortion
  • 20 wk or less than 500 gms
  • Threatened
  • Imminent
  • Complete
  • Incomplete
  • Missed
  • Habitual

3
Nursing Interventions
  • S/S backache and bleeding
  • Monitor for S/S of shock
  • Assess blood loss
  • IV
  • HX
  • ABO and Rh
  • Comfort and support
  • Anticipatory guidance
  • 1st trimester deliver in ER

4
Ectopic
  • Ovum implants outside of uterus
  • S/S of pregnancy present( preg. test)
  • Tube may rupture and cause bleeding
  • S/S - sharp pain, syncope, rigid ab., referred
    shoulder pain, adnexal pain
  • hCG levels fall
  • Methotrexate, salpingostomy or salpingectomy

5
Nursing Management
  • Assess for abdominal pain and missed menses
  • Report of continued pain after Methotrexate may
    indicate tx failure
  • Give emotional support
  • Nursing consideration-EP fetal loss

6
Gestational Trophoblastic DX
  • Abnormal development of placenta and
    proliferation of trophoblastic tissue
  • Complete- only placenta, no baby, sperm
    fertilizes empty egg
  • Associated with choriocarcinoma
  • Partial two sperm fertilize an egg

7
Clinical Manifestation
  • Bleeding-size greater than dates
  • hCG levels high- morning sickness
  • Often develop PIH
  • Need close follow-up chemo X 1 yr.
  • Check hCG levels
  • Do not get pregnant for 1 year
  • At risk for choriocarcinoma

8
Incompetent Cervix
  • Premature dilation of cervix
  • Painless and bloodless second trimester losses
  • Consider cerclage
  • Contact HCP for ROM or contractions

9
Hyperemesis
  • Risk for dehydration- assess urinary output
  • Risk for electrolyte imbalance
  • Acidosis
  • Give K to prevent hypokalemia
  • Allow dietary choices
  • Check weight

10
Premature Rupture of Membranes
  • ROM prior to 37 weeks
  • Causes- infection, polyhydramnios
  • At risk for infection
  • Fetal risk for RDS, sepsis, malpresentation, high
    risk for morbidity and mortality

11
Management
  • Use speculum for exam, NO VE
  • Confirm with Nitrazine paper- Alk.blue
  • Gestational age determines management
  • Prophylactic abx
  • NST, BPP
  • Steroids given prior to 32 weeks
  • Monitor- V/S, color, odor, amt. of amniotic fluid

12
Preterm Labor
  • Labor between 20-37 weeks
  • Risk factors
  • Teach S/S of PTL
  • fFN- protein present, predictive for 1 wk
  • Transvaginal UTZ- shortening of cervix
  • DX- more than 6-8 uc q hr, cervical change, fFN,
    2cm dilation

13
Tocolysis
  • MgS04-CNS depressant and smooth muscle relaxer
  • SE- pulmonary edema, flushing, resp. depression,
    lethargy, HA, lethargy
  • \
  • Antidote calcium gluconate

14
Nursing Care
  • Report ucs, rom, cramps, backache, pressure
  • Monitor- resp, pulse, BP, breath sounds, IOs,
    dtrs
  • Keep left lat.
  • Minimize vaginal exams
  • Assess labs, keep labs current

15
Pregnancy Induced Hypertension
  • Most common and serious disorder
  • Hypertension with proteinuria and edema
  • 140/90 or increase of 30 systolic and 15
    diastolic increase
  • More frequent in the extremes of the reproductive
    years, mutiparas, DM, GTD, Rh incompatibility
  • Does not manifest until 20wks
  • Eclampsia presence of seizure

16
Pathophysiology
  • Unknown- delivery is cure
  • Loss of resistance to angiotensin II
  • Thromboxane cause platelets to aggregate and
    pressure to increase
  • Vasospastic changes decrease in placental
    perfusion
  • Edema decrease in GFR, sodium retained, damage
    to vascular epitheleal lining
  • Less intravascular volume increases viscosity of
    blood cause hemoconcentration

17
HELLP
  • Hemolysis -elevated liver enzymes low platelets
  • Hemolysis- caused by damage to RBCs as pass
    through damaged vessels
  • Elevated liver- due to obstruction caused by
    fibrin deposits and liver pain due to distention
    of liver capsule.
  • Vascular damage cause platelets to aggregate at
    site of damage, drop in platelets

18
Maternal and Fetal Risks
  • Hyperreflexia- increased intracellular sodium
  • Headache- vasospasms, cerebral edema,
  • Seizures due to vasoconstriction
  • Hypertension causes fetal hypoxia and
    malnutrition
  • At risk for prematurity
  • Hypermagnesia
  • Nursing-h/a, epigastric pain,visual changes

19
Mild Preeclampsia
  • Managed at home
  • Encourage side lying position
  • Teach- S/S of worsening preeclampsia
  • Weight gain, headaches, epigastric pain, visual
    changes
  • In hospital evaluate fetal status, amnio, doppler

20
Severe Preeclampsia
  • Can develop suddenly
  • Excessive weight gain, 5lbs/ week
  • Protein in urine
  • Assess for H/A, Spots, N/V, retinal edema,
    pulmonary edema, epigastric pain
  • Bed rest
  • Diet
  • MgSo4
  • Monitor IOs- reflexes, respiratory status

21
Eclampsia
  • Give MgSo4 and Diazepam
  • Auscultate lungs
  • Keep safe
  • At risk for abruption
  • Monitor fetus
  • Keep family notified
  • Decrease stimuli

22
Intrapartal Management
  • Provide good pain relief
  • Consider epidural
  • Keep wedged to left lateral
  • Give 02
  • Be prepared for hemorrhage, hypovolemia
  • PP- 48 hrs at risk for seizure

23
Nursing Care
  • Maintain quiet environment
  • Side rails up and padded
  • Have suction available
  • Provide supportive care
  • Provide continuity of care
  • Explain complication of pregnancy

24
Chronic Hypertension
  • Occurs before 20 weeks
  • At risk for preeclampsia
  • Rest L lat
  • Self monitor BP
  • Limit salt
  • Continue to take antihypertensive meds

25
Rh Sensitization
  • Rh negative exposed to Rh positive blood
  • Antigen antibody response occurs
  • Antibody response slow
  • Danger is to subsequent pregnancy
  • Crosses placenta and causes fetal anemia
  • First PNC visit determine ABO and Rh
  • Rh- need indirect Coombs to determine antibodies
    in mother
  • If positive increase fetal surveillance

26
Rhogam
  • Give at 28 weeks and before discharge
  • Give mini dose if chance of exposure
  • Do not give if mother sensitized
  • Assess level of knowledge

27
ABO Incompatibility
  • Rarely causes hemolysis
  • Limited to O mothers with AB newborn
  • Anti-A Anti B antibodies are naturally occurring
    in O mothers
  • Antibodies cross placenta and can produce some
    hemolysis
  • Assess for hyperbilirubinemia

28
Surgery
  • Increases risk for AB, PTL, IUGR in first tri
  • Second tri less risky
  • Keep client wedged during surgery and recovery
  • Decrease gastric emptying-Increased secretions
  • Assess FHR
  • Deep breath and cough
  • Thrombophlebitis

29
Trauma
  • Fall, assaults, care accident, domestic violence
  • Increase risk for abruption
  • Increase risk for PTL
  • Goals- maintain volume, monitor fetus
  • Monitor for ucs

30
Abuse
  • Under reported
  • Screen for old injuries
  • Provide safe supportive, nonjudgmental
    environment
  • Give referrals to community resources

31
TORCH
  • Toxoplasmosis raw meat, feces of cat
  • Identify woman at risk
  • Test serologically
  • Rubella- risk in first trimester
  • Do not give attenuated virus to pregnant woman

32
Cytomegalovirus
  • CMV - transmitted to fetus by asymptomatic mother
  • CMV in urine
  • HSV-2, transmission occurs after ROM, or during
    delivery
  • Active lesions deliver by C/S
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