Complications of Pregnancy

Hyper / Hypo Disorders

The difference between dependent edema and generalized edema is important.

The patient with PIH has generalized edema because fluid is in all tissues.

The Nurse Must Know

41Oliguria 100ml/4 hrs or less than 30 cc. / hour

Edema moves upward and becomes generalized (face, periorbital, sacral)

Excessive weight gain greater than 2 pounds per week

43Nausea and Vomiting

Epigastric pain often sign of impending coma46Infections62 Assessment: 1. First indication is usually NO fetal movement

2. NO fetal heart tones Confirmed by ultrasound

3. Decrease in the signs and symptoms of pregnancy 78 Heart Disease in Pregnancy87 Types of Abortions

ThreatenedImminentCompleteIncompleteMissedRecurrent/Habitual

75555Question???What are two main complications related to a missed abortion?

1.

2. 8 Cerclage procedure -- purse-string suture placed around the internal os to hold the cervix in a normal state

911111111 Key Concepts Related to Bleeding DisordersIf a woman is Rh-, RhoGam is given within 72 hours of abortion

Provide emotional support. Feelings of shock or disbelief are normal

Encourage to talk about their feelings. It begins the grief process

1013131313Ectopic PregnancyImplantation of the blastocyst in ANY site other than the endometrial lining of the uterus

(5) Cervicalovary1114141414 Assessment Ectopic PregnancyEarly:Missed menstruation followed by vaginal bleeding (scant to profuse)Unilateral pelvic pain, sharp abdominal painReferred shoulder painCul-de-sac massAcute:Shock blood loss poor indicatorCullens sign -- bluish discoloration around umbilicusNausea, VomitingFaintness1215151515Treatment Options / Nursing CareCombat shock / stabilize cardiovascular Type and cross match Administer blood replacement IV access and fluidsLaparotomy

Psychological support

Linear salpingostomy

Methotrexate used prior to rupture. Destroys fast growing cells 13

Gestational Trophoblastic DiseaseHydatiform Molar Pregnancy

A DEVELOPMENTAL ANOMALY OF THE PLACENTA WITH DEGENERATION OF THE CHORIONIC VILLI

As cells degenerate, they become filled with fluid and appear as fluid filled grape-size vessicles.

14181818 Assessment:Vaginal Bleeding -- scant to profuse, brownish in color (prune juice)Possible anemia due to blood lossEnlargement of the uterus out of proportion to the duration of the pregnancyVaginal discharge of grape-like vesiclesMay display signs of pre-eclampsia earlyHyperemesis gravidariumNo Fetal heart tone or QuickeningAbnormally elevated level of HCG Question 615191919Interventions and Follow-UpEmpty the Uterus by D & C or Hysterotomy

Extensive Follow-Up for One YearAssess for the development of choriocarcinomaBlood tests for levels of HCG frequentlyChest X-raysPlaced on oral contraceptivesIf the levels rise, then chemotherapy started usually Methotrexate16202020Critical Thinking ExerciseA woman who just had an evacuation of a hydatiform mole tells the nurse that she doesnt believe in birth control and does not intend to take the oral contraceptives that were prescribed for her.

How should the nurse respond?17Placenta PreviaLow implantation of the placenta in the uterusEtiology Usually due to reduced vascularity in the upper uterine segment from an old cesarean scar or fibroid tumorsThree Major Types:Low or MarginalPartialCompleteQuestion 8

18212121Interventions and Nursing CarePlacenta PreviaBed-restAssessment of bleedingElectronic fetal monitoringIf it is low lying, then may allow to deliver vaginallyCesarean delivery for All other types of previa

19Abruptio PlacentaPremature separation of the placenta from the implantation site in the uterusEtiology:Chronic Maternal HypertensionShort umbilical cordTraumaHistory of previous delivery with separationSmoking / Caffeine / CocaineVascular problems such as with diabetesMultigravida statusDefined as marginal, partial or complete202222Treatment and Nursing CareAbruptio PlacentaCesarean delivery immediatelyCombat shock blood replacement / fluid replacementBlood work assessment for complication of DIC

Placenta PreviaPAINLESS vaginal bleedingBright red bleedingFirst episode of bleeding is slight then becomes profuseSigns of blood loss comparable to extent of bleedingUterus soft, non-tenderFetal parts palpable; FHTs countable and uterus is not hypertonicBlood clotting defect absent Abruptio PlacentaBleeding accompanied by PAINDark red bleedingFirst episode of bleeding usually profuseSigns of blood loss out of proportion to visible amount Uterus board-like, painful and low back pain Fetal parts non-palpable, FHTs non-countable and high uterine resting tone (noted with IUPC)Blood clotting defect (DIC) likely22232323Signs of Concealed HemorrhageIncrease in fundal heightHard, board-like abdomenHigh uterine baseline tone on electronic fetal monitoringPersistent abdominal pain and low back painSystemic signs of hemorrhage23WhyCritical ThinkingMrs. A., G3 P2, 38 weeks gestation is admitted to L & D with scant amount of dark red bleeding. What is the priority nursing intervention at this time?Assess the fundal height for a decreasePlace a hand on the abdomen to assess if hard, board-like, tetanicPlace a clean pad under the patient to assess the amount of bleedingPrepare for an emergency cesarean delivery242525Disseminated IntravascularCoagulation (DIC) Anti-coagulation and Pro-coagulation effects existing at the same time. 252727 EtiologyDefect in the Clotting CascadeAn abnormal overstimulation of the coagulation process Activation of Coagulation with release of thromboplastin into maternal bloodstream Thrombin (powerful anticoagulant) is produced Fibrinogen fibrin which enhances platelet aggregation and clot formation Widespread fibrin and platelet deposition in capillaries and arterioles262626 Assessment & Intervention

Precipitating factorsAbruptionPIH/HELLP syndromeSepsisAnaphylactoid SyndromeLabs to reviewPT, PTT, Platelets, D-Dimer, FSPInterventionsRemove the causeReplace fluids (Blood or blood products)Meds282828Hyperemesis GravidarumAssessmentPersistent nausea and vomitingWeight loss from 5 - 20 poundsMay become severely dehydrated with oliguria AEB increased specific gravity, and dry skinDepletion of essential electrolytesMetabolic alkalosis -- Metabolic acidosisStarvation30555Nursing Care / InterventionsHyperemesis GravidariumControl vomiting

Maintain adequate nutrition and electrolyte balanceAllow patient to eat whatever she wantsIf unable to eat Total Parenteral NutritionCombat emotional component provide emotional support and outlet for sharing feelings Mouth careWeigh dailyCheck urine for output, ketones

31666Hypertenison during pregnancy32 Classification of HTN in Pregnancy Gestational HTN = Systolic BP > or equal to 140/90 after 20 weeks (replaces term of PIH), protein negative or trace Pre-eclampsia = BP > or equal to 140/90 after 20 weeks, proteinuria, edema considered nonspecific Eclampsia = other signs plus convulsions not attributable to other causes Chronic HTN = BP > or equal to 140/90 that was known to exist before pregnancy or does not resolve after 6 weeks after delivery

33777Predisposing FactorsPrimigravidaMultiple gestation pregnancyVascular DiseaseAge >35Obesity34PATHOLOGICAL CHANGESPIH is due to:

GENERALIZED ARTERIOLAR CYCLICVASOSPASMSINCREASED PERIPHERAL RESISTANCE; IMPEDED BLOOD FLOW( in blood pressure) Endothelial CELL DAMAGE Intravascular Fluid Redistribution (decrease in diameter of blood vessel)Decreased Organ PerfusionMulti-system failure Disease35999Rationale for HYPERTENSIONThe blood pressure rises due to: ARTERIOLAR VASOSPASMS AND VASOCONSTRICTION causing (Narrowing of the blood vessels) an increase in peripheral resistance fluid forced out of vessels

HEMOCONCENTRATION

Increased blood viscosity = Increased hematocrit

36 Key Point to Remember !

HEMOCONCENTRATION develops because:Vessels became narrowed forcing fluid to shift out of the vascular space

Fluid leaves the intravascular space and moves to extravascular spaces

Now the blood viscosity is increased (Hematocrit is increased)

**Very difficult to circulate thick blood

37121212Proteinuria With renal vasospasms, narrowing of glomerular capillaries which leads to decreased renal perfusion and decreased glomerular filtration rate

PROTEINURIA Spilling of 1+ of protein is significant to begin treatment

Oliguria and tubular necrosis may precipitate acute renal failure38161616

Significant Lab WorkChanges in Serum ChemistryDecreased urine creatinine clearance (80-130 mL/ min)

Increased BUN (12-30 mg/dl.)

Increased serum creatinine (0.5 - 1.5 mg/dl)

Increased serum uric acid (3.5 - 6 mg/dl)

39Weight Gain and EdemaClinical Manifestation:

Edema may appear rapidlyBegins in lower extremities and moves upwardPitting edema and facial edema are late signsWeight gain is directly related to accumulation of fluid40Placenta

Due to Vasospasms and Vasoconstriction of the vessels in the placenta.

Decreased Placental Perfusion and Placental AgingFetal Growth is retarded - IUGR, SGAPositive CST / __________Decelerations With Prolonged decreased Placental Perfusion:42171717Central Nervous System ChangesCerebral edema -- forcing of fluids to extracellularHeadaches -- severe, continuous Hyper-reflexiaLOC changes changes in affect Convulsions / seizures44Visual ChangesRetinal Edema and spasms leads to:

Blurred vision

Double vision

Retinal detachment

Scotoma (areas of absent or depressed vision)45Pre-EclampsiaMildSevere140/90Protien 1+ to 2+Edema 1+ to lower legs< 1lb/ weekReflexes 1+ to 2+160/90Protein 3+ to 4+Edema 3+ to 4+>2 lb/ weekReflexes 3+ to 4+ (hyperreflexia)Clonus presentBlurred vision or ScotomaRetinal detachmentN&V, Epigastric painElevated Liver enzymesHeadache or change in LOCPremature aging of placenta, IUGR, & or late decelerations

Interventions and Nursing CareHome ManagementDecrease activities and promote bed rest Sedative drugsLie in left lateral positionRemain quiet and calm restrict visitors and phone calls

Dietary modifications increase protein intake to 70 - 80 g/day maintain sodium intake Caffeine avoidanceWeigh daily at the same time

Keep record of fetal movement - kick counts

Check urine for Protein4820HospitalizationIf symptoms do not get better then the patient needs to be hospitalized in order to further evaluate her condition.Common lab studies:CBC, platelets; type and cross matchRenal blood studies -- BUN, creatinine, uric acidLiver studies -- AST, ALT, LDH, BilirubinDIC profile -- platelets, fibrinogen, FSP, D-Dimer49Hospital ManagementNursing Care Goal1. Decrease CNS Irritability

2. Control Blood Pressure

3. Promote Diuresis

4. Monitor Fetal Well-Being

5. Deliver the Infant50212120Decrease CNS Irritability Provide for a Quiet Environment and Rest 1. MONITOR EXTERNAL STIMULI

Explain plans and provide Emotional Support

Administer Medications1. Anticonvulsant -- Magnesium Sulfate2. Sedative -- Diazepam (Valium)3. Vasodilator-- Apresoline (hydralazine) Assess Reflexes Assess Subjective Symptoms Keep Emergency Supplies Available

51222221Magnesium SulfateACTION CNS Depressant, reduces CNS irritability Calcium channel blocker- inhibits cerebral neurotransmitter releaseROUTE IV effect is immediate and lasts 30 min. IM onset in 1 hour and lasts 3-4 hours

Prior to administration:Insert a foley catheter with urimeter for assessment of hourly output52232322Magnesium SulfateNURSING IMPLICATIONS 1. Monitor respirations > 14-16; < 12 is critical

2. Assess reflexes for hypo-reflexia -- D/C if hypo-refexia

3. Measure Urinary Output >100cc in 4 hrs.

4. Measure Magnesium levels normal is 1.5-2.5 mg/dl Therapeutic is 4-8mg/dl.; Toxicity - >9mg/dl; Absence of reflexes is >10 mg/dl; Respiratory arrest is 12-15 mg/dl; Cardiac arrest is > 15 mg/dl.

Have Calcium Gluconate available as antagonist53Test Yourself ! A Woman taking Magnesium Sulfate has a respiratory rate of 10. In addition to discontinuing the medication, the nurse should:

a. Vigorously stimulate the woman b. Administer Calcium gluconate c. Instruct her to take deep breaths d. Increase her IV fluids54242423Control Blood Pressure Check B / P frequently.

Give Antihypertensive Drugs Hydralazine Labetalol Nifedipine Check Hematocrit Do NOT want to decrease the B/P too low or too rapidly. Best to keep diastolic ~90. WHY?

55252524Promote Diuresis**Dont give Diuretic, masks the symptoms of PIH

Bed rest in left or right lateral position

Check hourly output -- foley catheter with urimeter

Dipstick for Protein

Weigh daily -- same time, same scale56262625Monitor Fetal Well-BeingFETAL MONITORING-- assessing for late decelerations.

NST -- Non-stress testCST contraction stress testBPP biophysical profile

If all else fails ---- Deliver the baby!!

57272726HELLP SyndromeA multisystem condition that is a form of severe preeclampsia - eclampsiaH = hemolysis of RBC

EL = elevated liver enzymes

LP = low platelets 20 u/L. - LDH when cells of the liver are lysed, they spill into the bloodstream and there is an increase in serum > 90 u/L/ 60HELLPIntervention:1. Bedrest any trauma or increase in intra- abdominal pressure could lead to rupture of the liver capsule hematoma.

2. Volume expanders

3. Antithrombic medications

61 Urinary Tract InfectionMost common infection complicating PregnancyEtiologyPressure on ureters and bladder causing Stasis with compression of uretersRefluxHormonal effects cause decrease tone of bladderAssessmentDysuria, frequency, urgency lower abdominal pain; costal vertebral painfever632525 T O R C H A Infections

T = ToxoplasmosisO = Other Syphilis, Gonorrhea, Chlamydial,Hepatitis A or BR = RubellaC = CytomegalovirusH = HerpesA = Aids

642626 ToxoplasmosisEtiologyProtozoan infection. Raw meat and cat litter Maternal and Fetal Effects Mom - flu-like symptoms, lymphadenopathy Fetus still, premature birth, microcephaly; mental retardation

* Instruct to cook meat thoroughly* Avoid changing cat litter* Advise to wear gloves when working in the garden Treatment: Sulfa drugs

652727 Syphilis

EtiologySpirochete Treponema PalliumMaternal and Fetal Effects May pass across the placenta to fetus causing spontaneous abortion. Major cause of late, second trimester abortion

Infant born with congenital anomalies

662828SyphilisIntervention:1. Penicillin

2. Advise to return for prenatal visits monthly to assess for re-infection

3. Advise that if treated early, fetus may not be infected

67

Gonorrhea

Etiology Neisseria GonorrhoeaeMaternal and Fetal Effects:May get infected during vaginal delivery causing Ophthalmia neonatorium (blindness) in the infantMom will experience dysuria, frequency, urgency Major cause Pelvic Inflammatory Disease which leads to infertility.

Treated with

RocephinSpectinomycinTreat partner!!682929 Chlamydia

Three times more common than gonorrhea. Etiology - Chlamydia trachomatisMaternal and Fetal EffectsMom pelvic inflammatory disease, dysuria, abortions, pre-term labor Fetus -- Stillbirth, Chylamydial pneumoniaInterventionsErythromycin, doxycycline, zithromaxAdvise treatment of both partners is very important693030Hepatitis A or BHighly contagious when transmitted by direct contact with blood or body fluidsMaternal and Fetal Effects:All moms should be tested for Hep B during pregnancyFetus may be born with low birth weight and liver changesMay be infected through placenta, at time of birth, or breast milkIntervention:Recommend Hepatitis B vaccination to both mother and baby after delivery.7031 Rubella

EtiologySpread by droplet infection or through direct contact with articles contaminated with nasopharyngeal secretions.Crosses placentaMaternal and Fetal EffectsMom fever, general malaise, rashMost serious problem is to the fetus--causes many congenital anomalies (cataracts, heart defects)InterventionDetermine immune status of mother. If titer is low, vaccine given in early postpartum period713232 CYTOMEGALOVIRUSEtiology -- Member of the Herpes virusCrosses the placenta to the fetus or contracted during delivery. Cannot breast feed because transmitted through breast milkEffects on Mom and FetusMom no symptoms, not know until after birth of the babyFetus -- Severe brain damage; Eye damageInterventionNo drug available at this timeTeach mom should not breast feed babyIsolate baby after birth723333 Herpes Simplex Type 2

Maternal and Fetal EffectsPainful lesions, blisters that may rupture and leave shallow lesions that crust over and disappear in 2-6 weeksCulture lesions to detect if Herpes, No cureIf mom has an outbreak close to delivery, then cannot deliver vaginally. Must deliver by Cesarean birth *Virus is lethal to fetus if inoculated at birthIntervention:Zovirax

733434HIV/AIDS

Etiology: Human Immunodeficiency Virus, HIV

Transmission of HIV to the fetus occurs through: The placenta; birth canal Through breast milk **The virus must enter the babys bloodstream to produce infection.

743535Diagnosis:

ELISA test identifies antibodies specific to HIV. If positive = person has been exposed and formed antibodies

Western Blot used to confirm seropositivity when ELISA is positive.

Viral load - measures HIV RNA in plasma. It is used to predict severity lower the load the longer survival.

CD4 cell count markers found on lymphocytes to indicate helper T4 cells. HIV kills CD4 cells which results in impaired immune system. Goal: reduce viral load to below 50 copies /ml. and increase the CD4 cell count.

Nursing Care:**Provide Emotional Support

**Teach measures to promote wellnessAZT oral during pregnancyIV during laborliquid to newborn for 6 weeks.

**Provide information about resourcesAZT -Retrovir

Fetal Demise/ Intrauterine Fetal Death

77222Pre-Gestational Onset DisordersDiabetes in PregnancyDiabetes creates special problems which affect pregnancy in a variety of ways.

Successful delivery requires work of the entire health care team

801313Endocrine Changes During PregnancyThere is an increase in activity of maternal pancreatic islets which result in increase production of insulin.Counterbalanced by:Placentas production of Human Chorionic Somatomammotropin (HCS)

Increased levels of progesterone and estrogen--antagonistic to insulin

Human placenta lactogen reduces effectiveness of circulating insulin

d. Placenta enzyme-- insulinase

811515Gestational DiabetesDiabetes diagnosed during pregnancy, but unidentifable in non-pregnant womanKnown as Type III Diabetes - intolerance to glucose during pregnancy with return to normal glucose tolerance within 24 hours after deliveryGlucose tolerance test:1 hr oral GTT if elevated, do 3 hour GTTGestational diabetes if:Fasting 95 mg / dl1 hour - 180 mg/ dl2 hour - 155 mg/ dl3 hour 140mg/dl 821717

Treatment Controlled mainly by dietMay use insulinNo use of oral hypoglycemics Effects of Diabetes on the PregnancyMATERNALIncrease incidence of INFECTION

Fourfold greater incidence of Pre-eclampsia

Increase incidence of Polyhydramnios

Dystocia large babies

Rapid Aging of PlacentaFETALincrease morbidity

Increase Congenital Anomalies neural tube defect (AFP)Cardiac anomalies

Spontaneous Abortions

Large for Gestation Baby, LGA

Increase risk of RDS

842121Effects of Pregnancy on the DiabeticInsulin Requirements are AlteredFirst Trimester--may drop slightlySecond Trimester-- Rise in the requirementsThird Trimester-- double to quadruple by the end of pregnancy

Fluctuations harder to control; more prone to DKAPossible acceleration of vascular diseases851818Interventions/ Nursing CareDiet Therapy

Insulin Regulation

Blood Glucose Monitoring

Exercise

Monitor Fetal Well Being

862323Cardiac Response in All Pregnancies Increase in Cardiac Output 30% - 50%

Expanded Plasma Volume

Increase in Blood (Intravascular) Volume Every Pregnancy affects the cardiovascular system A woman with a healthy heart can tolerate the stress of pregnancy,but a woman with a compromised heart is challenged Hemodynamically and will have complications8811 Effects of Heart Disease on Pregnancy Growth Restricted Fetus

Spontaneous Abortion

Premature Labor and Delivery

8922 Effects of Pregnancy onA Diseased HeartThe Stress of Pregnancy on an already weakened heart may lead to cardiac decompensation (failure).

The effect may be varied depending upon the classification of the disease9033 Classification of Heart Disease

Class 1Uncompromised No alteration in activityNo anginal pain, no symptoms with activity

Class 2Slight limitation of physical activityDyspnea, fatigue, palpitations on ordinary exertioncomfortable at rest

9144Class 1-normal pregnancyClass 3Marked limitation of physical activityExcessive fatigue and dyspnea on minimal exertionAnginal pain with less than ordinary exertion

Class 4Symptoms of cardiac insufficiency even at restInability to perform any activity without discomfortAnginal pain Maternal and fetal risks are high 9255 Nursing Care - AntepartumDecrease Stressteach the importance of REST! watch weightassess for infections - stay away from crowdsassess for anemiaassess home responsibilities

Teach signs of cardiac decompensation 9366

Assess for Signs of CHFCough (frequent, productive, hemoptysis)

Dyspnea, Shortness of breath, orthopnea

Palpitations of the heart

Generalized edema, pitting edema of legs and feet

Moist rales in lower lobes, indicating pulmonary edema

9499 EducationDiethigh in iron, proteinlow in sodium and calories ( fat )

Weight gain

MedicationsSupplemental ironHeparin, not coumadin monitor lab workDiuretics very careful monitoringAntiarrhythmics Digoxin, quinidine, procainamide. *Beta-blockers are associated with fetal defects.

Reinforce physicians care9577 Nursing Care: During LaborLabor in an upright or side lying positionRestrict fluidsOn O2 per mask throughout labor and cardiac monitoring. Sedation / epidural given earlyReport fetal distress or cardiac failureStage 2 - gentle pushing, high forceps delivery 961010Nursing Care PostpartumThe immediate post delivery period is the MOST significant and dangerous for the mom with cardiac problems because:

Following delivery, fluid shifts from extravascular spaces into the blood stream for excretion

Cardiac output increases, blood volume increases

Strain on the heart! Watch for cardiac failure971111Test Yourself !Mrs. B. has mitral valve prolapse. During the second trimester of pregnancy, she reports fatigue and palpitations during routine housework. As a cardiac patient, what would her functional classification be at this time? a. Class I b. Class II c. Class III d. Class IV

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