HC3 Gestational conditions



hello and welcome again to this presentation in the healthcare of the client cause we are going to talk about high risk perinatal care by looking at gestational conditions in the previous presentation we talked about pre-existing conditions which are normally present before conception however we realized that hypertension and diabetes can be classified under both gestational and pre-existing conditions depending on when they were diagnosed whether before twenty weeks which will be pre-existing or after twenty weeks which will be your I'm gestational condition and the management whether is pre-existing or gestational are similar and that's why we group them together so today we are going to focus on hyperemesis gravidarum and we are also going to talk about some early and late pregnancy bleeding complications and then we will just take a few moments to talk about trauma and other things and that can okay that will impair the ability of the woman to carry the pregnancy to term so let's begin with hyperemesis gravidarum nausea vomiting is a very common complication of pregnancy affecting about 70 percent of all pregnancies a combination of factors including relaxation of the smooth muscle of the stomach and elevated levels of estrogen progesterone and ACG contributes to nausea in formalin it typically occurs in the first trimester starting at about four to eight weeks of gestation and many pregnant women get some relief from nausea vomiting around 16 weeks or in the second trimester however in some women nausea vomiting becomes severe enough to cause weight loss and electrolyte imbalance nutritional deficiencies and ketonuria this excessive vomiting is tamed as hyperemesis gravidarum just from the sound of the name high tech means high and so emesis means vomiting and gravida remember is pregnancy so this just means that severe vomiting drawing pregnancy clinical signs and symptoms includes significant weight loss due to the inability to keep down food and also dehydration and electrolyte imbalance and such as sodium and potassium loss assessment will will reveal that the patient has dry mouth and mucous membranes with decreased in decreases in blood pressure and an increase in pulse rate and pause can't take also the classic signs you will see in dehydration and then when lab results are drawn you will see a decrease in potassium sodium magnesium and albumin levels albumin is a marker for the amount of protein that the client has and if this is decreased then that is indicative of more nourishment or malnutrition care for the client who has hyperemesis include rehydration therapy to prevent hypovolemic shock in addition to electrolyte replacement and nutritional therapy such as TPN if the albumin is too low or if the client is so not able to hold anything down medications such as vitamin b6 in combination with Dogzilla mean or unisom is recommended for initial treatment there is now a single drug company shame of the prick dozen which is the b6 and the dogs a lemon which is called Dyke ledges and you can find this available in most pharmacy stores and um you need a prescription for that but that is a combination of the two medications so that the Klan can take it in one pill during the treatment for hyperemesis you as the nest will have to monitor the Klan for signs of complications such as metabolic acidosis second b2 starvation and we have seen this also in diabetic patients that we talked about we should also monitor the claim for jaundice and classic signs of jaundice include the yellowing of the mucous membranes and the sclera in the eye and also we will have to monitor the claim for potential hemorrhage and a lady health healthcare provider if we see any of these complications after the situation has resolved or even before the situation of hyperemesis gravidarum occurs we can give some health promotion education to our patients and we can begin by teaching the client to eat small frequent meals at least every two to three hours instead of big meals to help them keep the food down we can also educate them to separate their liquid from solids and alternate taking solid and liquid food every two to three hours so if they eat a liquid meal at this time they can eat something solid in another three hours and keep alternating they will also have to eat a high-protein snack at bedtime and also when they wake up immediately in the morning they can eat dry crackers to keep them from throwing up they can also use dry toast and to also achieve that and then to prevent nausea they should avoid food that are high in spices and eat a bland diet that is a food that basically has no spices or smell Muse should be non greasy so stay away from fatty foods and such as cheese's and all kinds of food that are high in oil the food should be dry and they should stick to foods that are either sweet or a little bit salty but then with the salty foods we have to be cautious and to make sure they don't have hypertension or gestational hypertension before we encourage them to eat salty foods but these foods will help the client to keep the food down now that we have talked about hyperemesis gravidarum let's move on to him or reject disorders he more reject disorders in pregnancy and medical emergencies because maternal blood loss decreases the oxygen carrying capacity to the fetus which places the woman at an increased risk also for hypovolemia anaemia infection and preterm labor and this can also caused the fetus to go into distress and have some decelerations and we will look at fetal monitoring in another presentation haemorrhagic disorders are placed into two categories and these categories are early and late pregnancy bleeding so we will face discussed some examples of early pregnancy bleeding and then proceed to talk about examples in late pregnancy bleeding the first example or exemplar for early pregnancy bleeding is miscarriage and this is known as pon taneous abortion we use the term miscarriage because we don't want to and we want to avoid and the stigma that is attached to abortions and miscarriage can be spontaneous abortion and is any pregnancy that ends as a result of natural causes before 20 weeks of gestation and so that is before the fetus reaches viability 10 to 15 percent of all clinically recognized pregnancies end in miscarriage and the majority greater than 80 percent of miscarriages are early pregnancy losses are carrying before 12 weeks of gestation and these are mostly due to congenital defects in the fetal development risk factors for miscarriages include chromosomal abnormalities minority race and poverty and my not the minority race in poverty is as a result of the lack of adequate health care or accessibility to health care diabetes poor outcomes in previous pregnancies and extremes in maternal age such as ages that are younger than 19 years old or claims that are older than 25 years of age have a higher chance of having miscarriages severe died dietary arm deficiencies such as the lack of folic acid and also morbid obesity can also lead to miscarriages if the patient is using alcohol excessively that is about 500 milligrams daily and also is taking high amounts of caffeine that can also lead to the loss of pregnancy and contribute to miscarriage the types of miscarriage include threatened inevitable incomplete complete and missed all types of miscarriage can recur in subsequent pregnancies and all types except that threaten miscarriage can lead to infection so the general clinical signs and symptoms of miscarriage include uterine bleeding so the declines is going to see some bleeding and then they will have some contractions and they will always almost complain of abdominal pain and cramping management of miscarriages depends on the type of miscarriage so we are going to take each of them and look at them I'm separately if the miscarriage is classified as threatened then there will be a slight spotting or bleeding that will be noticed by the healthcare provider or the patient there will be mild uterine cramping with no passage of tissue or there will also be no cervical dilation and the treatment includes bed rest which is often ordered but this has not been proven to be effective in preventing the progression of the actual and miscarriage repetitive transvaginal ultrasounds and assessment of the chorionic gonadotropin hormone and also the progesterone levels may be done to determine if the fetus is still alive in the uterus or not and you can also do abdominal ultrasound to see if there is movement by the fetus further treatment depends on whether progression to actual miscarriage okay so if we are able to save the pregnancy by these steps that I talked about such as the bed rest and close monitoring them you just keep monitoring until the baby or the fetus reaches term but if it progresses to an actual miscarriage then we would take other or implement other interventions when the miscarriage is classified as inevitable you are going to see moderate bleeding with the assessment and the pain or cramping is going to be mild to severe with no passage of fetal tissue but there is going to be some semi car dilation and so you see an opening at a service which will indicate that this fetus is coming out and this is inevitable which means you cannot stop it the management of inevitable miscarriages is the use of includes the use of bed rest if no pain is present and also if no bleeding or infection is noticed if there is a rupture of membranes and there's pain and bleeding or infection is present then there is an indication for the prompt termination of the pregnancy and witches are complete by using dilation and curettage and that is the DNC to evacuate the fetus from the uterus for incomplete miscarriages you will see heavy profuse bleeding and due to retained fragments of of the placenta in the uterus and then there is going to be severe cramping with both cervical dilation and also with tissue passage in the cervix so you're going to see chunks of the fetus I'm passing through the service for management of incomplete miscarriages they may or mean this may or may not require additional cervical dilation before cartridge in such an cartridge may be performed to evacuate the fragments of the placenta and also any fetal tissue that is still remaining in the uterus and then the uterus will be cleaned out then we have also what is known as mist mist and miscarriage so for missed miscarriage you will see no bleeding or cervical dilation this is why it is missed and all you will notice is that there is going to be some infection brewing okay and that means that the fetus has been dead for a while so if spontaneous evacuation of the uterus does not occur within one month then the pregnancy is terminated by method appropriate to the duration of the pregnancy so an example is using a pill or if a DNC is indicated such as if the pregnancy gestation is advanced then we will have to do a DNC and to remove the fetal remains blood clotting factors are monitored until the uterus is empty and also we will monitor for disseminated intravascular coagulopathy and called quad and clotting of the blood with uncontrolled hemorrhage if we have a missed miscarriage so if hemorrhage developed then there is going to be steps that has to be taken to increase the blood volume and also to help maintain the mother's and circulatory system to prevent circulatory collapse if the conception are retained for longer than five weeks which is more than one month then the mother may be at risk for intrauterine infection and so we will also have to do an evacuation missed miscarriages may be treated with dilation and curettage or misoprostol or cytotec and which is given orally or vaginally so either of these steps can be used to terminate the pregnancy depending on whether the pregnancy is older or if is an early gestation there is also another type of miscarriage known as septic or miscarriage and there may be foul-smelling bleeding with this type of miscarriage so just think about sepsis as an infection so septic means that there is going to be a degree of infection and there is going to be varying degrees of abdominal pain and cervical dilation with some passage of tissue with this immediate termination of the pregnancy is required and we can use a method that is appropriate for the duration of the pregnancy and so's a cervical culture and sensitivity studies are also performed to determine the type of bacteria causing the sepsis and then a broad-spectrum antibiotic therapy such as and piston can be started so you are going to treat the patient for septic shock which is maintaining the vascular system to prevent vascular collapse with IV fluids and also giving antibiotics for infection and monitoring for fevers and also controlling the fevers the last type of miscarriage that we are going to talk about is this is the recurrent miscarriage and with this prophylactic circle it may be performed if there is semi cow insufficiency if this is the cause cervical insufficiency is the early dilation of the cervix and before birth test of value include karyotyping of both partners and also miscarriage specimen and assessment of the placenta to evaluate to see if the cause is also from the uterine cavity and testing of the woman for antiphospholipid antibody syndrome and also for thyroid disease remember we say that hyperthyroidism can contribute to early or preterm labor so we will have to test them for all these to rule out that there is the existence of any of these consists of these conditions so for general care and the nurse will have to consider and provide teaching regarding perineum cane so you're going to educate the client who has had any of these types of miscarriages to cleanse the perineum after each voiding or bowel movement and change perinea pass often remember that when you are wiping a female client you wipe from the front to the back and not from the back to the front you will also ask them to shower and avoid any tub bath or soaking in a bath for at least two weeks after a miscarriage and avoid the use of tampons I am doing and also avoid vaginal intercourse for at least two weeks educate them to also notify their health care provider if there is an elevation in temperature or if they see foul-smelling vagina discharged then you want to encourage them to eat foods which are high in iron and protein because of the loss of blood which was associated with the miscarriage and this will promote tissue repair and also promote red blood cell replacement and then you will ask them to seek assistance from support groups such as dia pasta or clergy or professional counseling as needed especially if they have had multiple miscarriages and then tell them to allow themselves and their partner to grieve the loss before becoming pregnant again it is very important that they go through the grieving process and to allow themselves to heal before they become pregnant again one other complication that will cause early pregnancy bleeding is reduce cervical competence or recurrent premature dilation of the cervix and I kind of touched on it when we were talking about the miscarriages but let's take a time to look closely at this so reduce cervical competence is also known as cervical incompetence or insufficiency and it's a passive and painless dilation of the cervix this results from shortening of the cervix and can lead to preterm birth or labor especially in the second trimester of pregnancy management of cervical and insufficiency includes cervical cerclage which is placed at the tip or the base of the service this has been the treatment of toys for women with cervical insufficiency due to cervical weakness and indications for sacred placements include pure our poor obstetric history which is three or more previous early preterm birth or second trimester losses and then a short cervical length which is generally less than 25 millimeters and also if there is any abnormalities such as an open cervix found on digital or speculum examination so as part of the care for a client that hysterical insufficiency you as the nurse will educate the client to report any signs of preterm labor including strong and consistent contractions which is less than five minutes apart pre temp premature rupture of membranes which we sometimes call that the water breaks so if they see any leakage they should inform the healthcare provider and then if they have severe perennial pressure and also have the edge to push those may be signs of preterm labor and if they have any signs of infection then they should report that also so abdominal cichlids may be done at around 11 to 13 weeks and to prevent the loss of pregnancies ectopic pregnancy is another early bleeding a condition that can adversely affect the pregnancy so with a topic pregnancy fertilization of the ovum or case and then the fertilized ovum is implanted outside of the uterine cavity 90 percent 95 percent of this okay in the fallopian tube and most are located in the ampulla or the tip of the fallopian tube size and symptoms that the client will report all that will be observed by the provider include abdominal pain and delayed menses and abnormal vaginal bleeding or spotting so when a client sees this they should and reported to the provider medical management include the use of methotrexate and this is a chemo a chemo agent agent and that is used in treating ectopic pregnancy in about 40 percent of the cases the nursing care and actions associated with ectopic pregnancy includes obtaining the woman's height and weight these measurements are used to calculate a body surface area in order to determine the correct dose of methotrexate that is needed and so you must measure this very accurate accurately the standard dose of Metro Transit's used to treat ectopic pregnancy is usually about 15 milligrams and this is given intramuscularly although it may also be ordered as IV one milligram per kilogram of body weight the dose of methotrexate should be prepared in the hospital pharmacy and a biologic safety cabinet and you Dennis handling it she where chemo gloves to be able to handle it I'm syringes containing the methotrexate should be dispensed from the pharmacy no more than 3/4 full in a sealed plastic bag without a needle attached to it so don't two pairs of gloves or chemo gloves before removing the syringe from the sealed plastic bag and then remove the syringe cap and replace with an appropriate needle for intramuscular injection make sure that you do not expel air from the syringe or primed the needle because these actions could transform the medication into an aerosol that can be inhaled and remember this is a chemo agent and so it is going to be i'm teratogenic and cause birth defects if this is inhaled by a pregnant nurse and so the nurse caring for such a patient shouldn't be an edge that is pregnant or is planning to be pregnant soon also before you give the medication make sure you check the patient's identity and the medication and for the right dose and the right time before injecting another nature will also perform an independent check before the injection is given and because this is considered a high alert medication and after injection make sure you dispose of any items worn or used to prepare or dispense or administer this medication in a waste container designed or designated specifically for hazardous drugs and then what your hands thoroughly after removing the gloves when a patient is suffering from ectopic pregnancy you want to also make sure that you avoid the use of heavy pain medications to prevent the masking of the signs and symptoms of to barrage average will be signified by severe abdominal pain there is also the use of surgical management that can be used to manage ectopic pregnancies and this includes the removal of the entire uterine tube or the fallopian tube I'm known as helping get to me and also Pingo storages evacuation of the zygote and nursing care include all care that will be associated for a surgery patient another disease process known as trophoblastic disease is one of the many causes of early pregnancy bleeding and this is also known as hide at t deform more and this masks the signs and symptoms of pregnancy occasion about 1 in every 10,000 pregnancies the cause is unknown but most providers or most experts believe that this is as a result of abnormal fertilization without available fetal such as if they have more chromosomes time they need or less chromosomes and that they need there are two distinct types of high DT foremost and these are the complete or classic mode and then the possible the treatment for this is just the evacuation of the more ones is identified and so nursing care will be associated with the kid that is associated with the performance of a DNC or surgery all right so now let's move to late pregnancy bleeding and we are going to start by talking about placenta praevia placenta previa is where the placenta is implanted in the lower uterine segment near or over the antenna Sarika also the opening of the cervix and as the fetus grows and then the arm fundus begins to stretch and enlarge or the uterus begin to straighten enlarge they are some separation that occurs between the placenta in the uterine wall and this causes bleeding they are various classifications based on the degree of internal silica oz and also by the amount of bleeding as well as the amount of coverage that the placenta is covering the cervical and opening so we have complete placenta previa which means that the placenta is completely covering the cervical ox and then we have marginal which means that is partially covering and then low-lying placenta previa which means that the placed placenta has been attached to the lower session of the uterus including the Sarika ox so figure a is an example of a complete and placenta praevia all right the incidence and etiology of preeclampsia is not well known and but there are many complications that resolved from placenta previa one of it is the I'm bleeding that can occur so mitaina in fetal outcomes include abnormal placenta attachment which will not support the pregnancy and then excessive bleeding leading to hypovolemia and also I'm low oxygen for both the mother and the fetus and then fetal risk may include more presentation drawing bed which means that the fetus is going to prevent a present with a part that is going to cause birthing complications and then pretend bed as well as fetal anemia and congenital anomalies diagnosis and medical management include the use of trans abdominal ultrasound and to determine where the placenta is in relation to the uterus and then management include expectant management which is observation and bed rest and because the bleeding is not severe enough to cause complication or the mother is not actively in labor so we put the mother on bed rest and observe the fetus to make sure that the fetus is developing and this can be done in the home I'm not necessarily in the hospital if the fetus has enriched variability and is at a higher risk for termination of the pregnancy then a cesarean bed may be indicated and also after a placenta previa has been diagnosed they can be active management which includes admission into the hospital with fluid replacement therapy and also medications that is going to prevent the preterm labor placenta abruptio on the other hand is a premature separation of the placenta and this can be classified into two types we have grid I'm into three types we have grid 1 which is mouth and then grid 2 which is moderate and then grade 3 which is severe and all are dependent on the severity of the detachment and the amount of bleeding that is going on this is usually associated with pain in the abdomen and also heavy bleeding management of placenta abruptio include the expectant which will be the observation and bed rest and then medications to prevent preterm labor as we saw in this the first figure shows mouth and separation and so there may not be any bleeding and the fetus may still be able to develop and properly and so we don't need to get the filters out but if the separation is severe as in the figure at the bottom of your screen then we will have to attempt to get the baby out because there is going to be there is going to be a fetal demise due to the complete separation of the placenta and so active management include if a question of the baby which will mean that cesarean birth placenta abruptio patients cannot have vaginal birth because of the separation of the placenta and so they are going to have cesarean birth which is going to be indicated there are also other forms of late pregnancy bleeding which include cord insertion or placental variations and these are real rare anomalies that can occur when the placenta is separated from as a result of multiple gestation or if the multiple fetuses in the intrauterine environment I'm caught vessels can also branch at the membranes and cause onto the placenta attaching to different part of the placenta and they can also be the rupture of membranes or traction on cord which may take one or more of the fetal vessels especially if the fetus wraps him or herself we the card and pulls on it then it might detach stretch and take as a result of the tear the fetus may rapidly bleed to death and so if this is noted then there is a race against time to get the fetus out late pregnancy bleeding can also include clotting disorders which okay I'm during pregnancy so normally there is a delicate balance which exists between opposing hemostatic and fibrinolytic systems to promote coagulation and if this is impaired then there is going to be adverse effects and because there is going to be potential bleeding so these hemostatic systems helps in the stop line of blood flow from injured vessels through formation of insoluble fibrin which act as a hemostatic platelet plug noble clotting of calculation involves the interaction of coagulation factors in which each factor sequentially activates the fact Ernest inline and so there is a cascade of events that happen for blood clots to occur if any of these factors are impaired then circulation cannot be restored and bleeding cannot be prevented and the woman stands a chance of having complications how will we recognize a clotting problems therefore so recognition in an Tepito period may decrease haemorrhagic problems and postpartum period bleeding di see we have talked about is one of the pathologic forms of diffuse closing clotting causing widespread Stano in internal bleeding and this may be triggered by severe preeclampsia which causes the help syndrome that we talked about and this can also cause infection leading to gram-negative sepsis so treatment for coagulopathy s I'm in is dependent on the type of the problem so if the patient is having clotting then we may start using heparin as we learn when we be treated and when we talked about help on the other presentation that we can use i'm heparin to prevent clotting and we can use blood transfusions to also read increase the amount of platelets if the patient is at risk of bleeding so we will do exchange transfusions in addition to anticoagulation therapy to help the patient to recover in addition to all the other problems we have talked about they can also be complications and resulting from urinary tract infections and so these are different from the pregnancy bleeding that we talked about so these are other things that can happen UTI is very common in pregnancy due to the pressure on the bladder and also the decrease in the length of the urethra and so this because I'm kidney in risk including I'm cystitis and you will see this urea frequency and urgency with that and that can also cause pyelonephritis and this may also cause the same signs and symptoms that we described in addition to pain with surgical emergencies and there are various things that have to be considered including the health of the fetus and so most of the problems that occur during pregnancy are managed expectantly to help promote fetal development so appendicitis we will talk about this when we treat inflammation is an inflammatory disease and that if inflames the appendix and when this happens the woman is treated with antibiotics to try and resolve the infection and inflammation and surgery is certainly performed on women who are pregnant unless there is no other way to resolve the situation if a pregnant woman experiences any form of trauma then we will have to look at the physiologic alterations that can affect the pregnancy such as was the fetus involved is the fetus doing well in the intrauterine environment and then if the fetus is present then the survival depends on maternal survival so we are going to be considering what will be the risk versus the benefits of keeping the fetus alive while keeping the mother alive and those decisions also has some ethical components so pregnant women must receive immediate stabilization and care for optimal fetal outcome if there is any form of trauma such as blunt trauma to the stomach in a vehicle accident or in violence or in any other situation the matino physiological characteristics will require strategies that are adapted for appropriate resuscitation so with trauma if there is any blood loss then you are going to replace the blood volume by fluid IV through such as isotonic Flav's and also by blood infusion by positioning and assessment and other interventions so if there is an a decreased tolerance for hypoxia and there is the presence of apnea then we should be looking at the cardiac output and looking to see if the fetus is getting well perfused their fetal physiological characteristics that we will have to consider will be careful monitoring of the fetus and to see if the fetus is doing well or if there is a healthy fetus and so we are going to monitor the fetus on the fetal heart monitor as well as monitoring the as well as monitoring the mother with an oximeter so there can be various forms of trauma to the pregnant woman and this may include blunt abdominal trauma penetrating abdominal trauma or even thoracic trauma which may be am a thoracic injury nursing care and management as I said should include immediate stabilization and promoting of perfusion and this will be done with the notion of trying to save both the mother and the fetus and so you do a secondary survey to determine the fetal well-being by using the electronic fetal monitor and also to determine if there is any fetal maternal hemorrhage internally by using authors if there is radiation exposure then you will have to decontaminate the matter and then see if there are any complications as a result of that then if there is the fetal death in the intrauterine environment then you have to do a promoting more time cesarean bed so thank you for listening to this presentation and I will be entertaining questions through email or in the classroom I know that there is a lot of content to be covered and that these topics but and we have to make the video shot and so that it's not like three hours of videos and so if you have any questions you can ask me some of these illnesses or conditions are very important especially with the bleeding disorders that can occur in the early or late part of pregnancy but for the other management's you are probably not going to see this unless you choose to go into the OB you choose to be an OB nurse and so with this just have a general knowledge of what is expected and then when we meet in class we will talk about the specific interventions and use some of the in-class activities to expand your understanding of this concept

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