Pregnancy at Risk: Gestational Onset Chapter 15. Abortion 20 wk or less than 500 gms Threatened Imminent Complete Incomplete Missed Habitual.

Pregnancy at Risk:Gestational Onset

Chapter 15

Abortion

• 20 wk or less than 500 gms

• Threatened

• Imminent

• Complete

• Incomplete

• Missed

• Habitual

Nursing Interventions

• S/S backache and bleeding• Monitor for S/S of shock• Assess blood loss• IV• HX• ABO and Rh• Comfort and support• Anticipatory guidance• 1st trimester deliver in ER

Ectopic

• Ovum implants outside of uterus

• S/S of pregnancy present(+ preg. test)

• Tube may rupture and cause bleeding

• S/S - sharp pain, syncope, rigid ab., referred shoulder pain, adnexal pain

• hCG levels fall

• Methotrexate, salpingostomy or salpingectomy

Nursing Management

• Assess for abdominal pain and missed menses

• Report of continued pain after Methotrexate may indicate tx failure

• Give emotional support

• Nursing consideration-EP = fetal loss

Gestational Trophoblastic DX

• Abnormal development of placenta and proliferation of trophoblastic tissue

• Complete- only placenta, no baby, sperm fertilizes empty egg

• Associated with choriocarcinoma

• Partial – two sperm fertilize an egg

Clinical Manifestation

• Bleeding-size greater than dates

• hCG levels high- “morning sickness”

• Often develop PIH

• Need close follow-up –chemo X 1 yr.

• Check hCG levels

• Do not get pregnant for 1 year

• At risk for choriocarcinoma

Incompetent Cervix

• Premature dilation of cervix

• Painless and bloodless second trimester losses

• Consider cerclage

• Contact HCP for ROM or contractions

Hyperemesis

• Risk for dehydration- assess urinary output

• Risk for electrolyte imbalance

• Acidosis

• Give K+ to prevent hypokalemia

• Allow dietary choices

• Check weight

Premature Rupture of Membranes

• ROM prior to 37 weeks

• Causes- infection, polyhydramnios

• At risk for infection

• Fetal risk for RDS, sepsis, malpresentation, high risk for morbidity and mortality

Management

• Use speculum for exam, NO VE• Confirm with Nitrazine paper- Alk.=blue• Gestational age determines management• Prophylactic abx• NST, BPP• Steroids given prior to 32 weeks• Monitor- V/S, color, odor, amt. of amniotic

fluid

Preterm Labor

• Labor between 20-37 weeks

• Risk factors

• Teach S/S of PTL

• fFN- protein present, predictive for 1 wk

• Transvaginal UTZ- shortening of cervix

• DX- more than 6-8 uc q hr, cervical change, =fFN, 2cm dilation

Tocolysis

• MgS04-CNS depressant and smooth muscle relaxer

• SE- pulmonary edema, flushing, resp. depression, lethargy, HA, lethargy

• \• Antidote= calcium gluconate

Nursing Care

• Report ucs, rom, cramps, backache, pressure

• Monitor- resp, pulse, BP, breath sounds, I&O’s, dtr’s

• Keep left lat.

• Minimize vaginal exams

• Assess labs, keep labs current

Pregnancy Induced Hypertension

• Most common and serious disorder • Hypertension with proteinuria and edema• 140/90 or increase of 30 systolic and 15

diastolic increase• More frequent in the extremes of the

reproductive years, mutiparas, DM, GTD, Rh incompatibility

• Does not manifest until 20wks• Eclampsia presence of seizure

Pathophysiology

• Unknown- delivery is cure• Loss of resistance to angiotensin II• Thromboxane cause platelets to aggregate and

pressure to increase• Vasospastic changes = decrease in placental

perfusion• Edema = decrease in GFR, sodium retained,

damage to vascular epitheleal lining• Less intravascular volume increases viscosity of

blood cause hemoconcentration

HELLP

• Hemolysis -elevated liver enzymes low platelets• Hemolysis- caused by damage to RBCs as pass

through damaged vessels• Elevated liver- due to obstruction caused by

fibrin deposits and liver pain due to distention of liver capsule.

• Vascular damage cause platelets to aggregate at site of damage, drop in platelets

Maternal and Fetal Risks

• Hyperreflexia- increased intracellular sodium• Headache- vasospasms, cerebral edema, • Seizures due to vasoconstriction• Hypertension causes fetal hypoxia and

malnutrition• At risk for prematurity• Hypermagnesia• Nursing-h/a, epigastric pain,visual changes

Mild Preeclampsia

• Managed at home

• Encourage side lying position

• Teach- S/S of worsening preeclampsia

• Weight gain, headaches, epigastric pain, visual changes

• In hospital evaluate fetal status, amnio, doppler

Severe Preeclampsia

• Can develop suddenly• Excessive weight gain, 5lbs/ week• Protein in urine• Assess for H/A, “Spots”, N/V, retinal edema,

pulmonary edema, epigastric pain• Bed rest• Diet• MgSo4• Monitor I&Os- reflexes, respiratory status

Eclampsia

• Give MgSo4 and Diazepam

• Auscultate lungs

• Keep safe

• At risk for abruption

• Monitor fetus

• Keep family notified

• Decrease stimuli

Intrapartal Management

• Provide good pain relief

• Consider epidural

• Keep wedged to left lateral

• Give 02

• Be prepared for hemorrhage, hypovolemia

• PP- 48 hrs at risk for seizure

Nursing Care

• Maintain quiet environment

• Side rails up and padded

• Have suction available

• Provide supportive care

• Provide continuity of care

• Explain complication of pregnancy

Chronic Hypertension

• Occurs before 20 weeks

• At risk for preeclampsia

• Rest L lat

• Self monitor BP

• Limit salt

• Continue to take antihypertensive meds

Rh Sensitization

• Rh negative exposed to Rh positive blood• Antigen –antibody response occurs• Antibody response slow• Danger is to subsequent pregnancy• Crosses placenta and causes fetal anemia• First PNC visit determine ABO and Rh • Rh- need indirect Coombs to determine

antibodies in mother• If positive increase fetal surveillance

Rhogam

• Give at 28 weeks and before discharge

• Give mini dose if chance of exposure

• Do not give if mother sensitized

• Assess level of knowledge

ABO Incompatibility

• Rarely causes hemolysis

• Limited to O mothers with AB newborn

• Anti-A Anti B antibodies are naturally occurring in O mothers

• Antibodies cross placenta and can produce some hemolysis

• Assess for hyperbilirubinemia

Surgery

• Increases risk for AB, PTL, IUGR in first tri• Second tri less risky• Keep client wedged during surgery and recovery• Decrease gastric emptying-Increased secretions• Assess FHR• Deep breath and cough• Thrombophlebitis

Trauma

• Fall, assaults, care accident, domestic violence

• Increase risk for abruption

• Increase risk for PTL

• Goals- maintain volume, monitor fetus

• Monitor for ucs

Abuse

• Under reported

• Screen for old injuries

• Provide safe supportive, nonjudgmental environment

• Give referrals to community resources

TORCH

• Toxoplasmosis– raw meat, feces of cat

• Identify woman at risk

• Test serologically

• Rubella- risk in first trimester

• Do not give attenuated virus to pregnant woman

Cytomegalovirus

• CMV - transmitted to fetus by asymptomatic mother

• CMV in urine

• HSV-2, transmission occurs after ROM, or during delivery

• Active lesions deliver by C/S