Complications of Pregnancy

1
Complications of Pregnancy
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Assessment of Fetal Well-being

• Detect physical abnormalities
• Monitor fetal condition
• Fetal movement
• Complex diagnostic testing
• Risks and benefits

3
Amniocentesis

• Aspiration of amniotic fluid
• Determine genetic disorders
• Sex of fetus
• Fetal lung maturity
• Risks
• Nursing management

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Amniocentesis
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Chorionic Villus Sampling

• Aspiration of small sample of chorionic villus
  tissue
• 8 to 12 weeks gestation
• Detects genetic abnormalities
• Risks and benefits
• Nursing management

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Hormone Levels

• Estriol
• Human chorionic gonadotropin
• Maternal serumalpha fetoprotein

7
Alfa-Fetoprotein Screening

• MSAFP
• Time sensitive
• Low MSAFP levels associated with Down syndrome
• High MSAFP levels associated with neural tube
  defects

8
Triple Marker Screening

• Alpha-fetoprotein
• Human chorionic gonadotropin
• Unconjugated estriol

9
High Risk Assessment

• Daily fetal movement count
• Nonstress test
• Biophysical profile
• Contraction stress test

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Daily Fetal Movement Count

• Begin at 27th week
• Consider
• Fetal sleep-wake cycles
• Maternal food intake
• Drug-nicotine use
• Environmental stimuli
• Maternal position
• Procedure

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Fetal Monitor
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Fetal Monitoring

• Normal fetal heart rate
• Baseline

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Baseline FHR

• Rate
• Variability
• Assesses average rate for at least 2 minutes
  within a 10 minute window
• Normal 110 to 160 bpm
• Bradycardia lt 110 bpm for 10 minutes
• Tachycardia gt 160 bpm for 10 minutes

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Variability

• Normal irregularity of fetal cardiac rhythm
• Short-term
• Beat-to-beat changes
• Need fetal scalp electrode
• Long-term
• Rhythmic changes (waves) from the baseline value
• Usually 3 to 5 beats

15
Nonstress Test

• Assess response of FHR to periods of fetal
  movement
• After 27th to 30th week
• Frequency depends on condition of maternal-fetal
  unit
• Indications

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Procedure

• Perform test during a time of activity
• Maternal preparation
• Maternal vital signs
• Attach monitor
• Monitor fetal movement

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Interpretation

• Reactive result
• Nonreactive result
• Unsatisfactory result

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Contraction Stress Test

• Assess ability of fetus to withstand the stress
  of uterine contractions
• Assesses placental oxygenation and function
• Determines fetal well being
• Performed if NST is abnormal

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Interpretation

• Negative CST
• Positive CST
• Equivocal
• Unsatisfactory

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Biophysical Profile

• Assess fetal status
• NST
• Fetal breathing movements
• Fetal body movements
• Fetal muscle tone
• Amniotic fluid volume
• Placental grading

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Biophysical Profile Scoring
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Hyperemesis Gravidarum

• Intractable nausea and vomiting that persists
  beyond the first trimester and causes
  disturbances in nutrition, electrolytes, and
  fluid balance

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Assessment

• Nausea most pronounced on arising
• Persistent vomiting
• Weight loss
• Signs of dehydration
• Electrolyte imbalances
• Ketonuria
• Increased hematocrit levels

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Nursing Interventions

• Monitor vital signs
• Monitor FHR, fetal activity and fetal growth
• Monitor for dehydration and electrolyte imbalance
• Daily weight, IO, calorie count
• Monitor urine for ketones
• Administer IV fluids, antiemetics

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Bleeding Disorders of Early Pregnancy

• Spontaneous abortion
• Ectopic pregnancy
• Hydatidiform mole

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Abortion

• Threatened
• Imminent
• Complete
• Incomplete
• Missed
• Habitual
• Elective

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Threatened Abortion
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Imminent Abortion
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Incomplete Abortion
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• A 22 year old gravida i, para 0, is 11 weeks
  pregnant. She was admitted to the hospital with
  moderate vaginal bleeding and some abdominal
  cramping. Vaginal examination reveals that the
  cervix is dilated 2 cm. She is diagnosed as
  having an imminent abortion. What nursing
  interventions are indicated when caring for this
  patient?

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Nursing Interventions

• Save perineal pads / tissue
• Emotional support
• Observe for shock
• Bed rest / diversional activity
• RhoGAM
• Possible surgery
• Medication / Blood

32

• Ectopic pregnancy is often difficult to
  diagnose because its symptoms are similar to
  those of abdominal conditions. Identify at least
  five signs or symptoms of ectopic pregnancy and
  briefly explain why each occurs.

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Ectopic Sites

• l

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Ectopic Pregnancy

• Fertilized ovum implants outside the uterus
• Symptoms at 6 to 12 weeks of gestation
• Severe unilateral pelvic-abdominal pain
• Pain may refer to shoulder
• Tender abdominal mass
• Nausea, faintness
• Bleeding frank or occult

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Nursing Interventions

• Monitor vital signs
• Administer intravenous fluids
• Provide oxygen when needed
• Medicate for pain
• Assess lab results
• Prepare for possible surgery
• Provide emotional support

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Incompetent Cervix

• Premature dilation of cervix
• Occurs in 4th or 5th month of pregnancy
• Associated with cervical trauma
• Vaginal bleeding at 18 to 28 weeks
• Fetal membranes visible through cervix
• Treatment is surgical

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Hydatidiform Mole

• Gestational trophoblastic disease
• Developmental anomaly of placenta
• Changes chorionic villi into a mass of clear
  vesicles
• Edematous grapelike cluster
• May develop into choriocarcionoma

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Hydatidiform Mole
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Assessment

• FHR not detectable
• Vaginal bleeding
• Symptoms of PIH
• Fundal height gt expected for date
• Elevated hCG
• Ultrasound shows characteristic snowstorm pattern

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Bleeding Disorders of Late Pregnancy

• Placenta previa
• Abruption placenta

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Placenta Previa

• Painless
• Spotting or heavy bleeding
• Bright-red bleeding
• Soft, non-tender, relaxed uterus with normal tone
• Shock in proportion to observed blood loss
• Signs of fetal distress usually not present

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Placenta Previa
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Assessment

• Episodic painless vaginal bleeding after 20th
  week of pregnancy without contractions
• Each successive bleeding episode heavier than the
  last
• Profuse hemorrhage
• Ultrasound shows location of placenta

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Nursing Interventions

• No vaginal exams
• Bedrest
• Monitor vital signs and fetal well-being
• Assess blood loss
• IV access
• Provide adequate nutrition
• Provide emotional support

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Abruptio Placenta

• Severely painful
• Heavy bleeding may be partially or completely
  hidden
• Usually dark-brown bleeding
• Rigid, board-like, tender uterus possibly with
  contractions
• Shock seeming to be out of proportion to blood
  loss
• Signs of fetal distress

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Abruptio Placenta
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Assessment

• Painful, rigid, board-like abdomen with vaginal
  bleeding
• Central abruption
• Marginal abruption
• Fetal outcome

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Nursing Interventions

• Monitor vital signs
• Continuous EFM
• Assess for bleeding, uterine activity, abdominal
  pain
• Measure abdominal girth
• Review lab values
• IV access
• Provide oxygen

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Hypertensive Disorders

• Pregnancy induced hypertension
• Preeclampsia and eclampsia
• Chronic hypertension
• Superimposed preeclampsia
• Transient hypertension

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Pathophysiology

• Vasospasm reduces blood flow to mothers organs
  and placenta
• Vascular endothelial damage
• Hypertension
• Edema
• Proteinuria

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PIH - Assessment

• Mild preeclampsia
• Severe preeclampsia
• Systemic responses
• Lab values

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Nursing Interventions

• Bedrest -- left lateral position
• Monitor B/P and weight
• Monitor neurological status
• Monitor DTRs
• Provide adequate fluids
• Monitor I O
• Increase dietary protein
• Administer medications as prescribed

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Magnesium Sulfate ( Mg SO4 )

• Mg causes vasodilation
• Therapeutic levels 4 to 8 mg/dL

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Mg SO4 Therapy

• Monitor blood pressure closely
• Monitor maternal serum Mg SO4 levels every 6 - 8
  hours
• Monitor respirations closely
• Assess patellar tendon reflex
• Determine urinary output
• Monitor FHR continuously
• Continue Mg SO4 infusion for approximately 24
  hours after birth

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Maternal Side Effects

• Vasodilation
• Flushing
• Headaches
• Hot Flashes
• Blurred vision
• Nasal Congestion
• Decreased peripheral vascular resistance

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Maternal Side Effects

• Neuromuscular depression
• Respiratory depression
• Myocardial depression
• Gastrointestinal system
• nausea
• vomiting

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Neonatal Side Effects

• Hypocalcemia
• Hypermagnesemia
• Respiratory depression

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Chronic Hypertension

• Occurs before pregnancy
• Diagnosed before 20th week of gestation
• Diagnosed during pregnancy and persists beyond
  the 42 day postpartum

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Assessment

• Headaches
• Visual changes
• Blood pressure 140/90 mm Hg or gt
• Delayed fetal growth
• Oligohydramnios

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Antihypertensives

• Given for diastolic blood pressure of 105 to 110
  or above
• Methyldopa
• Hydralazine
• Labetalol
• Nifedipine

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Diabetes

• Pregnancy places demands on carbohydrate
  metabolism
• Insulin requirements increase in 2nd and 3rd
  trimester
• Insulin-dependent diabetes
• Diabetes in pregnancy

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Assessment

• Risk factors
• Classic symptoms
• Frequent UTIs and yeast infections
• Screening at 24-28 weeks gestation

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Nursing Interventions

• Prenatal visits bimonthly for 6 months than
  weekly
• Maintain blood glucose between 65-130 mg/dL
• Monitor for hypoglycemia / hyperglycemia
• Glucose control
• Monitor for infection, PIH, ketoacidosis
• Reinforce diet instructions

64
Gestational Diabetes

• Occurs during 2nd and 3rd trimesters
• No prior diagnosis
• Screened during 26th week
• Glucose 105 mg/dL
• Diet
• Medications
• Normal after delivery

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Cardiac Disease

• Rheumatic fever
• Congenital heart disease

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Assessment

• Dyspnea and fatigue
• Cough
• Peripheral edema
• Anginal-type pain
• Palpitations and tachycardia
• Signs of pulmonary edema
• Signs of respiratory infection

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Nursing Interventions

• Monitor VS, FHR, condition of fetus
• Activity and rest
• Encourage adequate nutrition
• Maintain bed rest as ordered
• Monitor for signs of respiratory infection
• Encourage adequate nutrition
• Administer cardiac medications

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Anemia

• Decrease in RBCs
• Types
• Iron deficiency
• Folic acid
• Hemoglobinopathies
• Sickle cell disease
• Thalassemia

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Assessment

• Fatigue
• Headache
• Pallor
• Tachycardia
• Diagnostic test H H
• Treatment Iron and folic acid

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Nursing Interventions

• Monitor H H every 2 weeks
• Iron and folic acid supplements
• Take iron with vitamin C
• Foods high in iron, folic acid and protein
• Monitor for infection
• May use parenteral iron / transfusions

71
Infection in Pregnancy

• Immunological system suppressed
• Genitourinary adaptations to pregnancy
• Risk factors increase severity
• Fever
• Pneumonia
• Direct infection of fetus
• Systemic infection

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TORCH Infections

• T Toxoplasmosis
• O Other infections
• R Rubella
• C Cytomegalovirus
• H Herpes

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Group B Streptococcus

• Bacterial infection found in the lower GI and
  urogenital tracts
• Screening cultures at 35-37 weeks
• Leading infectious cause of neonatal sepsis and
  mortality
• Carriers often asymptomatic
• Intrapartum prophylaxis

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Sexually Transmitted Diseases

• Syphilis
• Gonorrhea
• Chlamydia
• Trichomoniasis
• HPV
• HIV

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Vaginal Infections

• Candidiasis
• Bacterial vaginosis

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Urinary Tract Infections

• Cause preterm labor
• Untreated may cause pyelonephritis

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Rh Incompatibility and Sensitization

• Determine maternal blood type and Rh factor
• Antibody screen (indirect Coombs test)
• RhoGAM administration
• Serial ultrasounds
• Amniotic fluid analysis
• Erythroblastosis fetalis

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Nursing Interventions

• Client education
• RhoGAM protocol
• Kleihauer-Betke test
• Ultrasound
• EFM, BPP
• Intrauterine exchange transfusion

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Multifetal Pregnancy

• Monozygotic or dizygotic
• Assisted reproductive techniques
• Diagnosis
• Interventions
• Complications

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Nursing Interventions

• Monitor vital signs
• Monitor FHR, fetal activity, fetal growth
• Monitor cervical changes
• Ultrasound
• Monitor for anemia
• Monitor and treat preterm labor
• Prepare for possible cesarean section

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Substance Abuse

• Tobacco
• Alcohol
• Marijuana
• Cocaine
• Heroin

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Preterm Labor

• Occurs after the 20th week and before the 37th
  week of gestation
• Contractions every 10 minutes lasting 30 seconds
  or longer
• Documented cervical change
• Effacement of 80
• Dilation of 2 cm

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Risk Factors

• Previous history of preterm labor or birth
• Demographic factors
• Lifestyle factors
• Health problems
• Uterine factors

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Assessment

• Increased or bloody discharge
• Leaking amniotic fluid
• Backache
• Pressure and cramping
• Palpable uterine contractions
• Diarrhea

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Nursing Interventions

• Maintain bedrest
• Tocolytic agents
• Betamethasone
• Magnesium sulfate
• Monitor fetal status