All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. CHAPTER 12 High Risk Perinatal Care: Gestational Conditions KEY POINTS • Hypertensive disorders during pregnancy are a leading cause of maternal and perinatal morbidity and mortality worldwide. • Gestational hypertension is the onset of hypertension without proteinuria after week 20 of pregnancy. Hypertension is defined as a systolic blood pressure (BP) greater than 140 mm Hg or a diastolic BP greater than 90 mm Hg. This should be recorded on at least two separate occasions at least 4 to 6 hours apart but within a maximum of a 1-week period. • Preeclampsia is a pregnancy-specific condition in which hyper- tension and proteinuria develop after 20 weeks of gestation in a woman who previously had neither condition. Preeclampsia is a multisystem disease, and the pathologic changes are present long before clinical manifestations such as hypertension are evident. • The cause of preeclampsia is unknown, and there are no known reliable tests for predicting women at risk for developing preeclampsia. • Eclampsia is the onset of seizure activity or coma in a woman with preeclampsia who has no history of preexisting disease that can result in seizure activity. • HELLP syndrome, which is usually diagnosed during the third trimester, is a variant of severe preeclampsia, not a separate illness. • At 37 weeks or more of gestation, the plan of care for a woman with mild gestational hypertension or mild preeclampsia is most likely to be the induction of labor, preceded, if necessary, by cervical ripening. When mild gestational hypertension or mild preeclampsia is suspected before 37 weeks of gestation, close observation of maternal and fetal status is necessary. • Women diagnosed with severe gestational hypertension or severe preeclampsia should be hospitalized immediately for a thorough evaluation of maternal-fetal status. Magnesium sulfate, the anti- convulsant of choice for preventing or controlling eclamptic seizures, requires careful monitoring of reflexes, respirations, and renal function. • The intent of emergency interventions for eclampsia is to prevent self-injury, enhance oxygenation, reduce aspiration risk, and establish control with magnesium sulfate. • The woman with hyperemesis gravidarum may have significant weight loss and dehydration; management focuses on restoring fluid and electrolyte balance and preventing recurrence of nausea and vomiting. • Some miscarriages occur for unknown reasons, but fetal or pla- cental maldevelopment and maternal factors account for many others. • The type of miscarriage and the signs and symptoms direct care management. • The medical management for reduced cervical competence con- sists of bed rest, pessaries, antibiotics, antiinflammatory drugs, and progesterone supplementation. Surgical management may also be chosen with placement of a cervical cerclage. Ectopic pregnancy is a significant cause of maternal morbidity and mortality. • Hydatidiform mole occurs in 1 in 1000 pregnancies in the United States. The cause is unknown, although it may be related to an ovular defect or a nutritional deficiency. Women at increased risk are those who have had a prior molar pregnancy and those who are in their early teens or older than 40 years of age. • Placental abruption and placenta previa are differentiated by type of bleeding, uterine tonicity, and presence or absence of pain. • In the obstetric population, disseminated intravascular coagula- tion (DIC) is most often triggered by the release of large amounts of tissue thromboplastin, which occurs in placental abruption (the most common cause of severe consumptive coagulopathy in obstetrics), the retained dead fetus syndrome, and the amniotic fluid embolus (anaphylactoid syndrome of pregnancy). Severe preeclampsia, HELLP syndrome, and gram-negative sepsis are examples of conditions that can trigger DIC because of wide- spread damage to vascular integrity • Pyelonephritis is a serious medical complication of pregnancy and the second most common nondelivery reason for hospitalization. • Perioperative care for a pregnant woman differs from that for a nonpregnant woman in one significant aspect: the presence of at least one other person—the fetus. • Most maternal trauma results from MVAs and falls. Most mater- nal deaths are caused by MVAs. • Fetal survival depends on maternal survival. After trauma, the first priorities are resuscitation and stabilization of the mother before consideration of the fetus. • Maternal trauma can be associated with major complications for the pregnancy, including placental abruption, fetomaternal hem- orrhage, preterm labor and birth, and fetal death.
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Jan 18, 2016
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All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.
C H A P T E R
12 High Risk Perinatal Care: Gestational Conditions
K E Y P O I N T S• Hypertensive disorders during pregnancy are a leading cause of
maternal and perinatal morbidity and mortality worldwide.• Gestational hypertension is the onset of hypertension without
proteinuria after week 20 of pregnancy. Hypertension is defined as a systolic blood pressure (BP) greater than 140 mm Hg or a diastolic BP greater than 90 mm Hg. This should be recorded on at least two separate occasions at least 4 to 6 hours apart but within a maximum of a 1-week period.
• Preeclampsia is a pregnancy-specific condition in which hyper-tension and proteinuria develop after 20 weeks of gestation in a woman who previously had neither condition. Preeclampsia is a multisystem disease, and the pathologic changes are present long before clinical manifestations such as hypertension are evident.
• The cause of preeclampsia is unknown, and there are no known reliable tests for predicting women at risk for developing preeclampsia.
• Eclampsia is the onset of seizure activity or coma in a woman with preeclampsia who has no history of preexisting disease that can result in seizure activity.
• HELLP syndrome, which is usually diagnosed during the third trimester, is a variant of severe preeclampsia, not a separate illness.
• At 37 weeks or more of gestation, the plan of care for a woman with mild gestational hypertension or mild preeclampsia is most likely to be the induction of labor, preceded, if necessary, by cervical ripening. When mild gestational hypertension or mild preeclampsia is suspected before 37 weeks of gestation, close observation of maternal and fetal status is necessary.
• Women diagnosed with severe gestational hypertension or severe preeclampsia should be hospitalized immediately for a thorough evaluation of maternal-fetal status. Magnesium sulfate, the anti-convulsant of choice for preventing or controlling eclamptic seizures, requires careful monitoring of reflexes, respirations, and renal function.
• The intent of emergency interventions for eclampsia is to prevent self-injury, enhance oxygenation, reduce aspiration risk, and establish control with magnesium sulfate.
• The woman with hyperemesis gravidarum may have significant weight loss and dehydration; management focuses on restoring fluid and electrolyte balance and preventing recurrence of nausea and vomiting.
• Some miscarriages occur for unknown reasons, but fetal or pla-cental maldevelopment and maternal factors account for many others.
• The type of miscarriage and the signs and symptoms direct care management.
• The medical management for reduced cervical competence con-sists of bed rest, pessaries, antibiotics, antiinflammatory drugs, and progesterone supplementation. Surgical management may also be chosen with placement of a cervical cerclage. Ectopic pregnancy is a significant cause of maternal morbidity and mortality.
• Hydatidiform mole occurs in 1 in 1000 pregnancies in the United States. The cause is unknown, although it may be related to an ovular defect or a nutritional deficiency. Women at increased risk are those who have had a prior molar pregnancy and those who are in their early teens or older than 40 years of age.
• Placental abruption and placenta previa are differentiated by type of bleeding, uterine tonicity, and presence or absence of pain.
• In the obstetric population, disseminated intravascular coagula-tion (DIC) is most often triggered by the release of large amounts of tissue thromboplastin, which occurs in placental abruption (the most common cause of severe consumptive coagulopathy in obstetrics), the retained dead fetus syndrome, and the amniotic fluid embolus (anaphylactoid syndrome of pregnancy). Severe preeclampsia, HELLP syndrome, and gram-negative sepsis are examples of conditions that can trigger DIC because of wide-spread damage to vascular integrity
• Pyelonephritis is a serious medical complication of pregnancy and the second most common nondelivery reason for hospitalization.
• Perioperative care for a pregnant woman differs from that for a nonpregnant woman in one significant aspect: the presence of at least one other person—the fetus.
• Most maternal trauma results from MVAs and falls. Most mater-nal deaths are caused by MVAs.
• Fetal survival depends on maternal survival. After trauma, the first priorities are resuscitation and stabilization of the mother before consideration of the fetus.
• Maternal trauma can be associated with major complications for the pregnancy, including placental abruption, fetomaternal hem-orrhage, preterm labor and birth, and fetal death.
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