Pregnancy at Risk: Pregestational Onset

Alcohol Use in PregnancyMaternal effects:Malnutrition Bone-marrow suppressionIncreased incidence of infectionsLiver diseaseNeonatal effects:Fetal alcohol spectrum disorders (FASD)

Cocaine Use in Pregnancy: Maternal EffectsSeizures and hallucinationsPulmonary edemaRespiratory failureCardiac problemsSpontaneous first trimester abortion, abruptio placentae, intrauterine growth restriction (IUGR), preterm birth, and stillbirth

Cocaine Use in Pregnancy: Fetal EffectsDecreased birth weight and head circumference Feeding difficulties Neonatal effects from breast milk:Extreme irritabilityVomiting and diarrheaDilated pupils and apnea

Heroin Use in PregnancyMaternal effects:Poor nutrition and iron-deficiency anemiaPreeclampsia-eclampsiaBreech positionAbnormal placental implantationAbruptio placentaePreterm labor

Heroin Use in Pregnancy (contd)Maternal effects:Premature rupture of the membranes (PROM)Meconium stainingHigher incidence of STIs and HIVFetal effects:IUGR Withdrawal symptoms after birth

Substance Use in Pregnancy: Maternal EffectsMarijuana: difficult to evaluate, no known teratogenic effectsPCP - maternal overdose or a psychotic responseMDMA (Ecstasy) - long-term impaired memory and learning

Pathology of Diabetes Mellitus (DM)Endocrine disorder of carbohydrate metabolismResults from inadequate production or utilization of insulinCellular and extracellular dehydrationBreakdown of fats and proteins for energy

Gestational Diabetes (GDM)Carbohydrate intolerance of variable severityCauses:An unidentified preexistent diseaseThe effect of pregnancy on a compensated metabolic abnormality A consequence of altered metabolism from changing hormonal levels

Effect of Pregnancy on Carbohydrate MetabolismEarly pregnancy:Increased insulin production and tissue sensitivitySecond half of pregnancy:Increased peripheral resistance to insulin

Maternal Risks with DMHydramniosPreeclampsia-eclampsiaKetoacidosisDystociaIncreased susceptibility to infections

Fetal and Neonatal Risks with DMPerinatal mortalityCongenital anomaliesMacrosomiaIUGRRDSPolycythemia

Fetal and Neonatal Risks with DM (contd)HyperbilirubinemiaHypocalcemia

Screening for DM in PregnancyAssess risk at first visit:Low risk - screen at 24 to 28 weeksHigh risk - screen as early as feasible

Risk FactorsAge over 40Family history of diabetes in a first-degree relativePrior macrosomic, malformed, or stillborn infantObesityHypertensionGlucosuria

Screening TestsOne-hour glucose tolerance test:Level greater than 130-140 mg/dl requires further testing3-hour glucose tolerance test:GDM diagnosed if 2 levels are exceeded

Treatment GoalsMaintain a physiologic equilibrium of insulin availability and glucose utilizationEnsure an optimally healthy mother and newbornTreatment:Diet therapy and exerciseGlucose monitoringInsulin therapy

Fetal AssessmentAFPFetal activity monitoringNSTBiophysical profileUltrasound

Nursing ManagementAssessment of glucoseNutrition counselingEducation about the disease process and managementEducation about glucose monitoring and insulin administrationAssessment of the fetusSupport

Iron-deficiency AnemiaMaternal complications:Susceptible to infectionMay tire easilyIncreased chance of preeclampsia and postpartal hemorrhageTolerates poorly even minimal blood loss during birth

Iron-deficiency Anemia (contd)Fetal complications:Low birth weightPrematurityStillbirthNeonatal death

Iron Deficiency Anemia (contd)Prevention and treatment:Prevention - at least 27 mg of iron dailyTreatment - 60-120 mg of iron daily

Folate DeficiencyMaternal complications:Nausea, vomiting, and anorexiaFetal complications:Neural tube defectsPrevention - 4 mg folic acid dailyTreatment - 1 mg folic acid daily plus iron supplements

Folate DeficiencyMaternal complications:Nausea, vomiting, and anorexiaFetal complications:Neural tube defectsPrevention - 4 mg folic acid dailyTreatment - 1 mg folic acid daily plus iron supplements

Sickle Cell AnemiaMaternal complications:Vaso-occlusive crisisInfectionsCongestive heart failureRenal failure

Sickle Cell Anemia (contd)Fetal complications include fetal death, prematurity, and IUGR.Treatment:Folic acidPrompt treatment of infectionsPrompt treatment of vaso-occlusive crisis

ThalassemiaTreatment:Folic acidTransfusionChelation

HIV in PregnancyAsymptomatic women - pregnancy has no effect Symptomatic with low CD4 count - pregnancy accelerates the diseaseZidovudine (ZDV) therapy diminishes risk of transmission to fetusTransmitted through breast milkHalf of all neonatal infections occurs during labor and birth

HIV in Pregnancy: Maternal RisksIntrapartal or postpartal hemorrhagePostpartal infectionPoor wound healingInfections of the genitourinary tract

HIV Effects on FetusInfants will often have a positive antibody titerInfected infants are usually asymptomatic but are likely to be:PrematureLow birth weightSmall for gestational age (SGA)

Treatment DuringPregnancyCounsel about implications of diagnosis on pregnancy:Antiretroviral therapyFetal testingCesarean birth

Cardiac Disorders in PregnancyCongenital heart diseaseMarfan syndromePeripartum cardiomyopathyEisenmenger syndrome Mitral valve prolapse

Less Common Medical Conditions in PregnancyRheumatoid arthritisEpilepsyHepatitis BHyperthyroidismHypothyroidismMaternal phenylketonuria

Less Common Medical Conditions in Pregnancy (contd)Multiple sclerosisSystemic lupus erythematosus Tuberculosis

Pregnancy at Risk: Gestational Onset

Spontaneous AbortionThreatened 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 (contd)Missed abortion Recurrent pregnancy lossSeptic abortion

Spontaneous Abortion: TreatmentBed restAbstinence from coitusD&C or suction evacuationRh immune globulin

Spontaneous Abortion: Nursing CareAssess the amount and appearance of any vaginal bleedingMonitor the womans vital signs and degree of discomfortAssess need for Rh immune globulin.Assess fetal heart rateAssess the responses and coping of the woman and her family

Ectopic Pregnancy: Risk FactorsTubal damage Previous pelvic or tubal surgeryEndometriosisPrevious ectopic pregnancyPresence of an IUDHigh levels of progesterone

Ectopic Pregnancy: Risk Factors (contd)Congenital anomalies of the tubeUse of ovulation-inducing drugsPrimary infertilitySmokingAdvanced maternal age

Ectopic Pregnancy: TreatmentMethotrexateSurgery

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

Ectopic Pregnancy: Nursing CareAssess the appearance and amount of vaginal bleedingMonitors vital signsAssess the womans emotional status and coping abilitiesEvaluate the couples informational needs.Provide post-operative care

Gestational Trophoblastic Disease: SymptomsVaginal bleedingAnemiaPassing of hydropic vesiclesUterine enlargement greater than expected for gestational ageAbsence of fetal heart soundsElevated hCG

Gestational Trophoblastic Disease: SymptomsLow levels of MSAFPHyperemesis gravidarumPreeclampsia

Gestational Trophoblastic Disease: TreatmentD&CPossible hysterectomyCareful 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 CareMonitor vital signsMonitor vaginal bleedingAssess abdominal painAssess the womans emotional state and coping ability

Bleeding DisordersPlacenta previa - placenta is improperly implanted in the lower uterine segmentAbruptio placentae - premature separation of a normally implanted placenta from the uterine wall

Cervical Incompetence: TreatmentSerial cervical ultrasound assessmentsBed restProgesterone supplementationAntibioticsAnti-inflammatory drugsCerclage 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: TreatmentControl vomitingCorrect dehydrationRestore electrolyte balanceMaintain adequate nutrition

Hyperemesis Gravidarum: Nursing CareAssess the amount and character of further emesisAssess intake and output and weight.Assess fetal heart rateAssess maternal vital signsObserve for evidence of jaundice or bleedingAssess the womans emotional state

Nursing Care of Clients with PROMDetermine duration of PROMAssess gestational ageObserve for signs and symptoms of infectionAssess hydration statusAssess fetal statusAssess childbirth preparation and coping

Nursing Clients with PROM (contd)Encourage resting on left sideProvide comfort measuresProvide education

Nursing Care of Clients with Preterm LaborIdentify risk for preterm laborAssess change in risk status for preterm laborAssess educational needs of the woman and her loved onesAssess the womans responses to medical and nursing interventionTeach about the importance of recognizing the onset of labor

Signs and Symptoms of Preterm LaborUterine contractions occurring every 10 minutes or lessMild menstrual like cramps felt low in the adbomenConstant or intermittent feeling of pelvic pressureRupture of membranesLow, dull backache, which may be constant or intermittent

Signs and Symptoms of Preterm Labor (contd)A change in vaginal dischargeAbdominal cramping with or without diarrhea

Classification of Hypertension in PregnancyPreeclampsia-eclampsia

Chronic hypertension

Chronic hypertension with superimposed preeclampsia

Gestational hypertension

Chronic Hypertension in PregnancyHypertension before 20 weeks without proteinurea or stable proteinureaAt a higher risk for adverse outcomesAt risk for development of pre-eclampsia

Chronic HypertensionIf target organ damage present, pregnancy can exacerbate the conditionLifestyle modifications: - Activity restrictions - Weight reduction - Sodium restriction - ETOH and tobacco strongly discouraged

Plan of Care Chronic Hypertension in PregnancyMedications can safely be withheld in patients:Without target organ damageBlood pressure less than 150-160 mmHg systolic and 100-110 diastolic

Pharmacological management: Chronic HTN in PregnancyMethyldopa (Aldomet) preferred alpha-2 adrenergic agonistLabetalol (normodyne, Trandate) beta blockerDiuretic, calcium antagonists, other beta blockers?ACE (angiotension converting enzyme) inhibitors are contraindicated in pregnancy IUGR, oligohydramnios, neonatal renal failure, and neonatal deathARB (angiotension receptor blockers)not researched in pregnancy but probably contraindicated

LabatalolBaby at risk for transient hypotension and hypogylcemia if mom on labatalolNo labatalol to clients with asthma or first degree heart block

Fetal AssessmentFetal growth restrictionUltrasound @ 18-20 weeks, 28-32 weeks & as needed thereafterNST or biophysical profile if growth restricted

Preeclampsia-eclampsiaIncreased blood pressure AND proteinureaHighly suspected if increased BP and headache, blurred vision, abdominal pain, low platelets and/or abnormal liver enzymes

MAPMean 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 usedTwo readings 4-6 hours apart

Hypertension in PregnancyHypertension complicates 5-7% of all pregnanciesOne-half to two-thirds have preeclampsia or eclampsiaHypertension is a leading cause of maternal and infant morbidity and mortality

Normal Adaptations to PregnancyIncreased blood plasma volumeVasodilationDecreased systemic vascular resistanceElevated cardiac outputDecreased colloid osmotic pressure

Preeclamptic Changes in PregnancyRenal 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 HypertensionVasospasms are one of the underlying mechanisms for the signs and symptoms of preeclampsiaEndothelial damage (from decreased placental perfusion) contributes to preeclampsiaWith endothelial damage, arteriolar vasospasm may contribute to increased capillary permeability. This increases edema and decreases intravascular volume

Other Suspected CausesThe presence of foreign protein (placenta or fetus) may trigger an immunologic responseThis 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 ChangesAt risk for development of pulmonary edemaPulmonary capillaries susceptible to fluid leakage across membranes due to endothelial damageLeft ventricular failure from increased afterload leading to backup of fluid in pulmonary bed

Renal Preeclamptic ChangesReduced kidney perfusion decreases the glomerular filtration rate which lead to degenerative changes and oliguriaProtein is lost in the urine, sodium and water are retainedFluid moves out of the intravascular compartment resulting in increased blood viscosity and tissue edema

Vascular Preeclamptic ChangesHematocrit level rises as fluid leaves the cellsBlood volume may fall to or below prepregnancy levels; severe edema develops and weight gain is seenDecreased liver perfusion causes impaired function. Epigastric pain or RUQ pain

More Preeclamptic ChangesArteriolar vasospasms with decreased blood perfusion to the retina causes visual changes such as blind spots and blurringCNS changes caused by spasms as well as edema include headache, hyperreflexia, positive ankle clonus, and occasionally the development of eclampsia

Characteristics of PreeclampsiaMaternal vasospasmDecreased perfusion to virtually all organsDecrease in plasma volumeActivation of the coagulation cascadeAlterations in glomerular capillary endotheliumEdema

Characteristics of Preeclampsia Increased viscosity of the blood HyperreflexiaHeadacheSubcapsular 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 shockPulmonary 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 presentDisseminated Intravascular Coagulation: (DIC)Clotting factors are consumed by excess fluid, generalized bleeding occurs. Thrombocytopenia

Differential DiagnosisBP 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 hoursIncreased serum creatinine > 1.2 unless prior elevationPlatelet count less than 100,000Elevated ALT or ASTPersistent headache or visual changesPersistent epigastric pain, nausea and vomiting

LabsHgb & Hct: hemoconcentration supports dx of preeclamsia and is an indicator of severity. Values may be decreased, however, if hemolysis accompanies the diseasePlatelets: thrombocytopenia suggests severe preeclamsiaQuantification of protein excretion: if proteinurea should consider preeclamsiaSerum 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 lumenSerum albumin: hypoalbuminemia indicates extent of endothelial leakCoagulation profile: coagulopathy including thrombocytopenia

Specific LabsPreeclampsia HELLPHct>35 *Hemolysis-burr Uric Acid > 4.5mg cells presentBUN > 10mg/dl *bili 1.2mg/dPlt 72 U/LSGOT > 41 U/L *SGPT > 50 U/LSGPT > 30 U/L *Platelets

Hypertensive Effects on FetusSmall for gestational ageFetal hypoxiaDeath related to abruptionPrematurity

Home ManagementMonitoring for signs and symptoms of worsening conditionFetal movement counts Frequent rest in the left lateral positionMonitoring of blood pressure, weight, and urine protein dailyNSTLaboratory testing

Management of Severe PreeclampsiaBed restHigh-protein, moderate-sodium dietTreatment with magnesium sulfateCorticosteroidsFluid and electrolyte replacementAntihypertensive therapy

Fetal Indications for Delivery Severe IUGRNonreassuring fetal surveillanceoligohydramnios

Maternal Indications for DeliveryGestational age of 38 weeks or greaterPlatelet count below 100K Progressive deterioration of hepatic functionProgressive deterioration of renal functionSuspected placental abruptionPersistent severe headache or visual changesPersistent severe epigastric pain, nausea, or vomitingeclampsia

Plan of Care for the PreeclampticComplete bedrestLeft lying position-increases kidney glomerular function and urine outputProvide darkened quiet roomLimit visitationFluid restriction (125-150ml/hr)Seizure precautionsMagnesium sulfateAntihypertensives

Preeclampsia AssessmentEdemaDTRs and clonusAssess fluid balance-strict I & OBreath sounds (pulmonary edema)Vital signs: BP, respiratory rate & SaO2LOCc/o HA or visual disturbancesProteinureaEpigastric pain

Edema1+ edema is minimal (2mm) at pedal and pretibial sites2+ (4mm) edema of lower extrmities is marked3+ (6mm) edema is evident in hands, face, lower abdominal wall and sacrum4+ (8mm) generalized massive edema is evident including ascites from accumulaton of fluid in the peritoneal cavity

Assessment of CNS ChangesDTRs and ClonusDTRs 0-4+ patellar and brachial0=no response1+=low normal2+=average3+=brisk4+=hyperactive

ClonusExtreme hyperreflexiaInvoluntary oscillations that may be seen between flexion and extension when continuous pressure is applied to the sole of the footCounted in beats

Plan of Care for the PreeclampticMagnesium Sulfate: used to prevent or control seizures-it is a CNS depressant and smooth muscle relaxant-increases blood flow to the fetusIt does not treat the BPInterferes with the release of acetylcholine at the synapses, decreases neuromuscular irritability

Magnesium SulfateLoading dose: 4-6 grams over 15-30 minutesMaintenance dose: 1-2 grams/hourTherapeutic levels: 4.8-9.6 mg/dlAlways IVPB to mainlineCalcium gluconate available as antidate

Renal InsufficiencyMagnesium sulfate is hazardous to women with severe renal failure and maintenance dose must be reduced

Assessment of Patients on Magnesium SulfateBP, 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 seizuresMonitor I & O 30ml/hrSerum levels every 4-6 hours therapeutic 4.8-9.6 mg/dl

Side Effects of Mag SulfateFlushingSweatingThirstDrying mucous membranesDepression of reflexesMuscle flaccidityNauseaBlurred visoinHAtachycardia

Clinicial Manifestations of HypermagnesemiaWeaknessParesthesiasDcreased deep tendon reflexesLethargy, confusion, disorientationHypoventilatoinSeizuresParalysisBradyarrythmiasHeart blockDecreased cardiac contractilityImpaired protein synthesisDecreased skeletal mineralizationHepatic dysfunction

Calcium GluconateAntidote for mag sulfate1 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 resolvedShould be kept at the bedside

Control of BPAntihypertensives may be needed to lower the diastolic pressureThis reduces maternal mortality and morbidity associated with left ventricular failure and cerebral hemorrhagePlacental perfusion is controlled by maternal blood pressure, drug must be calibrated carefully

AntihypertensivesIf BP reaches 150/100 mmHg or higherLabatalol (alpha/beta adrenergic blocker)Begin with 20mg IVP slowly over 2 minutesOr continuous infusion of 1mg/kg can be usedMay double dose up to 80 mg every 15-20 minutesMaximum dose 220mgApresoline (vasodilator)Begin with 5-20 mg infused over 2-4 minutesMay be repeated every 20-30 minutesIf no success by 20 mg IV or 30 mg IM try another drug

EclampsiaDerives from the Greek word meaning like a flash of lightening a condition that seems to strike out of the blue75% of the time it occurs intrapartum

EclampsiaCharacterized by seizures or comaIs 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

EclampsiaRare 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 signsEarliest signs: drowsiness, HA, dimness of vision, rising BP, protein in the urine, edema, RUQ pain

EtiologyCerebral vasospasm, hemorrhage or edema, platelet and fibrin clots occlude vasculature leading to seizureBlood vessels in the uterus go into spasm cutting blood flow to the babySpasms lead to kidney failureTissues become water-logged because of fluid retentionHemorrhages happen in the liverBrain oxygen levels are lowered causing heightened brain sensitivity which shows as seizures

Signs and Symptoms of Impending SeizuresExtreme hypertension 200/140 not uncommonHyperreflexia4+ proteinureaGeneralized marked edemaSevere headache with or without visual distrubances

Management of Care During a SeizureCALL FOR HELP!Immediate care; Take care of the mother first-patent airway-adequate oxygenation-turn on side to prevent aspirationMagnesium Sulfate administrationAssessment of the fetus, birth if threatenedSteroid administration if fetal lungs are not mature

PNEUMONICS safetyE establish airwayI IV bolusZ zealous observationU uterine activityR rapid resuscitationE evaluate fetus

Postictal StateCentral venous pressure monitoringEstablish second indwelling catheterBlood glucose level to rule out hypogylcemia due to liver not functioning properlyBlood should be available for emergency infusion due to abruptioDo not leave patient alone

REMEMBER!!!All medications and therapy are merely temporary measuresDelivery is the only cure

Signs and Symptoms of EclampsiaScotomataBlurred visionEpigastric painVomitingPersistent or severe headacheNeurologic hyperactivity Pulmonary edemaCyanosis

Management of EclampsiaAssess characteristics of seizureAssess status of the fetusAssess for signs of placental abruptionMaintain airway and oxygenationPosition on side to avoid aspirationSuction to keep the airway clear

Management of Eclampsia (contd)To prevent injury, raise padded side railsAdminister magnesium sulfate

Postpartum ManagementSymptoms usually resolve within 48 hours of birthLab abnormalities usually resolve from 72-96 hours after birthCareful assessment continues, mag sulfate may continue to be infused for 12-48 hours after the birthBleeding must be assessed

Hemorrhage & HypertensionNO MethergineCauses vasospasm and increases blood pressureCONTRAINDICATED in pts with HTNUse hemabate or cytotec for PPH

Comparison of Risk Factors for HELLP Syndrome and PreeclampsiaHELLP PreeclampsiaMultiparous NulliparousMaternal age >25 Maternal age45Hx of poor preg Family hxOutcome Poor PNC Diabetes Chronic HTN Multiple gestation

HELLPHemolysis, Elevated liver enzymes, Low platelet countPrevalence is higher among older, white, multiparous womenCarries a mortality rate of 2-24%Occurs in 4-12% of severe preeclampsia

DXPlatelet < 100,000Liver enzymes AST ALT elevatedEvidence of intravascular hemolysis must be present

Complications of HELLPRenal failurePulmonary edemaRuptured liver hematomaDICAbruptio placentaFetal deathPerinatal asphyxiaMaternal death

Sx of HELLPEpigastric painMailaiseNausea and vomitingMild jaundice often noted

Sound like the flu?

DICProthrombin time, partial thromboplastin time and fibrinogenlevels are normal in patients with HELLPIn a patient with a plasma fibrinogen level of less than 300 mg/dL, DIC should be suspected, especially if other laboratory abnormalities are also presentOozing from venipuncture sited, hemorrhage, uterine atony

DICSystemic thrombohemorrhagic disorder involving the generation of intravascular fibrin and the consumption of procoagulants and plateletsCauses in pregnancy: abruptio placenta, IUFD with retained dead fetus, AFE, endotoxin sepsis, preeclampsia with HELLP and massive transfusion

TX of DICReplacement of volume, blood products, and coagulation componentsCardiovascular and respiratory supportElimination of underlying triggering mechanismAnticoagulationReplace blood products as indicated-packed RBCs, platelets, FFP, cryoAntithrombin III concentrateHematology, transfusionist, critical care consultants.

Treatment for HELLPDelivery is the only cureAntenatal administration of dexamethasone (Decadron) 10 mg IV every 12 hoursMag Sulfate bolus of 4-6 g as a 20% soln then mainenance of 2 g /hrAntihypertensive therapy should be initiated if BP > 160/110

Rh IncompatibilityRh mother, Rh + fetusMaternal IgG antibodies producedHemolysis of fetal red blood cellsRapid production of erythroblastsHyperbilirubinemia

Administration of Rh Immune GlobulinAfter birth of an Rh+ infantAfter spontaneous or induced abortionAfter ectopic pregnancyAfter invasive procedures during pregnancyAfter maternal trauma

ABO IncompatibilityMom is type OInfant is type A or BMaternal serum antibodies are present in serumHemolysis of fetal red blood cells

Surgery During PregnancyIncidence of spontaneous abortion is increased in first trimesterInsert nasogastric tube prior to surgeryInsert indwelling catheterEncourage patient to use support stockingsAssess fetal heart tonesPosition to maximize utero-placental circulation

Trauma During PregnancyGreater volume of blood loss before signs of shockMore susceptible to hypoxemia with apneaIncreased risk of thrombosisDICTraumatic separation of placentaPremature labor

Battering During PregnancyPsychological distressLoss of pregnancyPreterm laborLow-birth-weight infantsFetal deathIncreased risk of STIs

Perinatal InfectionsToxoplasmosisRubellaCytomegalovirusHerpes simplex virusGroup B streptococcusHuman B-19 parvovirus

Fetal Risks: ToxoplasmosisRetinochoroiditisConvulsionsComaMicrocephalyHydrocephalus

Fetal Risks: RubellaCongenital cataractsSensorineural deafnessCongenital heart defects

Fetal Risks: ChlamydiaNeurologic complicationsAnemiaHyperbilirubinemiaThrombocytopeniaHepatosplenomegalySGA

Fetal Risks: HerpesPreterm laborIntrauterine growth restrictionNeonatal infection

Fetal Risks: GBSRespiratory distress or pneumoniaApneaShockMeningitisLong-term neurologic complications

Fetal Risks: Human B-19 ParvovirusSpontaneous abortionFetal hydropsStillbirth