Chapter 21 Sudden Pregnancy ComplicationChapter 21 Sudden Pregnancy Complication

BleedingBleeding

Development of shock

Blood pressure

Pulse

Fetal heart rate

Treatment

Disseminated Intravascular Coagulation (DIC)

Disseminated Intravascular Coagulation (DIC)

Disorder of blood clotting

Fibrinogen levels fall below effective limits

Symptoms

Bruising or bleeding

Causes

1st Trimester Bleeding1st Trimester Bleeding

Spontaneous miscarriage (Abortion)

Threatened

Imminent

Complete

Missed

Recurrent pregnancy loss

Complications of MiscarriageComplications of Miscarriage

Hemorrhage

Infection

Septic abortion

Isoimmunization

Powerlessness or anxiety

1st Trimester Bleeding1st Trimester Bleeding

Ectopic pregnancy

Implantation occurs outside of the uterine cavity

Abdominal pregnancy

2nd Trimester Bleeding2nd Trimester Bleeding

Gestational trophoblastic disease (hydatidform mole)

Abnormal proliferation and degeneration of the trophoblastic villi

Assessment Assessment

HCG

Ultrasound

Fundal height

Nausea

ManagementManagement• D&CD&C

• CXRCXR

• HCG Beta q 4 weeks for 12 monthsHCG Beta q 4 weeks for 12 months

• ContraceptionContraception

• No pregnancy 1 yearNo pregnancy 1 year

Premature cervical dilatation

Cannot hold the fetus until term

Cervical cerclage

3nd Trimester Bleeding3nd Trimester BleedingPlacenta previa

Low implantation of placenta, Partial previa, complete previa

Risk factors

Assessment: Painless vaginal bleeding

Management

Immediate care

Continuing care

3nd Trimester Bleeding3nd Trimester BleedingAbruptio Placentae

Premature separation of placenta

Occurs suddenly

Most frequent cause of perinatal death

Risk factors

Assessment: Painful

Management

Preterm LaborPreterm Labor• Labor before the end of 37 weeks gestation.

• Occurs in 9 to 11% of all pregnancies.

• Persistent uterine contractions 4 in 20 min.

• Actual labor is if uterine contractions that cause effacement over 80% and dilation over 1 cm.

• Preterm births are 2/3 of all infant deaths.

• Cause unknown, dehydration, UTI, chorioamnionitis (infection of fetal membranes and fluid), strenuous jobs, extreme fatigue.

Preterm LaborPreterm Labor• SS-persistent, dull, low backache, vaginal spotting,

feeling of pelvic pressure or abdominal tightening, menstrual like cramping, increased vaginal discharge, uterine contraction, intestinal cramping.

Management:

• Analyze changes in vaginal mucus (fetal fibronectine), short cervix, sonogram.

• May try to stop labor if not beyond 4 to 5 cm or 50% effacement

• Admit to hospital, bedrest, IV, cultures,

Preterm LaborPreterm LaborUA, oral tocolytic agent-terbutaline, good nutrition and no smoking.

• Antibiotic for strep B prophylaxis, corticosteroid (lung surfactant)

• Pregnancy <34 weeks betamethasone 2 doses 12 mg IM 24 hours apart, effect lasts 7 days.

• Magnesium sulfate 4 to 6 g IV bolus to halt contractions (CNS depressant) p. 399.

• Terbutaline (Brethine)-relaxes uterine muscles, blood vessels and bronchi.

Preterm LaborPreterm Labor• Monitor: VS, I&O, labs, lungs for edema, daily wt.,

FHR.

Fetal assessment:

• Count fetal movement-10 in 1 hour (lt. side)

Labor:

• ROM, cervix > 50% effaced or 3 to 4 cm dilated it is unlikely it can be halted.

• Fetus immature – cesarean birth

• Use caution giving analgesics (demerol) due to immaturity of fetus. Epidural is best.

• Episotomy is needed to decrease risk of hemorrhage of fetus. May be larger and forceps may be used.

Preterm LaborPreterm Labor

• Support, she needs to rebuild her self esteem.

Preterm Rupture of Membranes

Associated with infection of membranes.

Occurs in 2% to 18% of pregnancies.

If early it is a threat to the fetus, infection and pressure on cord or prolapse. Non fluid environment > Potter like syndrome of distorted facial features and pulmonary hypoplasia from pressure.

Preterm LaborPreterm Labor

Assessment:

• Labor will not be halted if ROM.

• Sudden gush clear fluid, test with nitrazine paper (alkaline reaction-blue), ferning (high estrogen), sonogram, cultures, labs.

Management:

• Bedrest, antibiotic, may apply fibrin-based sealant to ruptured membranes, amniotic fluid is always being formed.

Preterm Rupture of MembranesPreterm Rupture of MembranesRupture of fetal membranes with a loss

of amniotic fluid

Before 37 weeks’ gestation

Associated with chorioamnioitis

Complications

Assessment

Management

Pregnancy Induced HypertensionPregnancy Induced HypertensionPIH

• Vasospasm occurs during pregnancy.

• Occurs in 5% to 10% of pregnancies.

• Cause unknown, in primiparas <20 yrs. or > 40 yrs., low socioeconomic background, 5 or more pregnancies, women of color, multiple hydraminios, heart disease, diabetes, essential hypertension, poor calcium or magnesium intake.

Patho:

• Normally blood vessels are resistant to the effects of pressor substances such as angiotensin and norepinephrine.

Pregnancy Induced HypertensionPregnancy Induced Hypertension

• With PIH vasoconstriction occurs and B/P increases dramatically.

• Cardiac system becomes overwhelmed, reduction of blood supply to kidney, pancreas, liver, brain and placenta.

• Hypoxia in maternal vital organs, poor placental perfusion reduce fetal nutrients and O2.

• Ischemia in pancreas; epigastric pain and amylase-creatinine ratio, retinal hemorrhages – blindness, proteinuria, edema.

Pregnancy Induced HypertensionPregnancy Induced Hypertension

Extreme edema can lead to cerebral and pulmonary edema and seizures (eclampsia)

Assessment:

• Classic signs: hypertension, proteinuria, and edema.

• Symptoms rarely occur before 20 weeks.

Classified as: gestational hypertension, mild eclampsia, severe preeclampsia &eclampsia

Pregnancy Induced HypertensionPregnancy Induced HypertensionVasospasm, hypoperfusion, and endothelial

injury occurs during pregnancy

Symptoms

Hypertension

Proteinuria

Edema

Causes

Physiologic changesPhysiologic changes

Gestational HypertensionGestational Hypertension

Elevated BP

Without

Edema or Proteinuria

No Drug Therapy or Low Dose ASA

May develop Hypertension in later life

Pre EclampsiaPre Eclampsia

Above gestational hypertension and below point of seizures (Eclampsia)

Mild preeclampsia

Severe preeclampsia

Mild Pre-eclampsiaMild Pre-eclampsia

• BP 30mm systolic and 15mm diastolic above pre-pregnancy values.

• BP > 140/90

• Proteinuria 1+ to 2+ that is not orthostatic

• Sodium Retention

• Lower Glomerular filtration rate

• Edema upper body

• Weight gain 1-2 lb week

Severe Pre-EclampsiaSevere Pre-Eclampsia• BP at REST:

– 30mm diastolic above pre pregnancy

– 160/110

• Marked Proteinuria 3+ to 4+

– Or > 5gm in 24 hour sample

• Edema

– Pitting or non pitting over bony surfaces

– 4+ is indentation that remains after removal of finger

– Extensive edema face and hands

• Epigastric Pain: Liver swelling

• Ankle Clonus: Cerebral Edema

• Urine output 400 to 600 mL/24 hours.

• SS-severe epigastric pain, nausea, vomiting, SOB, blurred vision, seeing spots, headache, marked hyperreflexia and muscle clonus.

• Review Patellar reflex and ankle clonus assessment

EclampsiaEclampsia

• Severe cerebral edema to cause SEIZURE or COMA

• Poor fetal prognosis: anoxia, acidity, and potential for premature separation of placenta

Management of PIHManagement of PIH

Nursing Interventions for Mild HypertensionNursing Interventions for Mild Hypertension

• Can be managed at home with frequent follow up care.

• Promote bedrest, lateral recumbent position.

• Promote Good Nutrition

• Provide emotional support-SS are vague, no meds., works, other children. Seen weekly.

Nursing Intervention for Severe Hypertension:Nursing Intervention for Severe Hypertension:• B/P > 160/110 after on bedrest, extensive edema,

proteinuria 3+-4+

• Support Bedrest, hospital, private room, side rails up if seizure, darken room, restrict visitors, less stress, explain everything.

• Monitor Maternal Well-Being

– VS, labs, DIC, high risk for premature separation of placenta and hemorrhage, cathether (>600 mL/24h or 30mL/h), daily weight,

• Monitor Fetal Well-Being:

– FHR, non stress test or biophysical profile daily, O2 to mother.

Support Nutritional Diet:

• Moderate to high protein, moderate sodium diet, IV TKO.

Nursing Intervention for Severe Hypertension:Nursing Intervention for Severe Hypertension:

Administer Medications to Prevent Eclampsia

• Table 21.7 pg. 580 drugs

• Magnesium sulfate, Apresoline or Normodyne, Valium

• Review treatment with Magnesium sulfate pg.581

• Calcium Gluconate

Nursing Intervention with Eclampsia:Nursing Intervention with Eclampsia:

• Cerebral irritation from increased cerebral edema and seizure results. Late in pregnancy or 48 hours after birth.

• SS-B/P increases, temp increases to 103-104, burning of vision, headache, reflexes hyperactive, “something is happening,” epigastric pain, nausea and decreased urinary output. Seizure.

Tonic-Clonic Seizures:

• Occurs in stages

• Maintain patent airway, O2 by face mask, pulse ox, FHR, turn on side, incontinent of urine and bowel, (valium, mag sulfate),third stage-semicomatose 1 to 4 hours.

Continued:Continued:

• Unable to report contractions if placenta has separated. Check for vaginal bleeding.

Birth:

• Pregnancy > 24 weeks, decide about delivery, fetus may not grow after eclampsia occurs.

• Vaginal birth preferred, vascular system is low in volume.

Postpartal Hypertension:Postpartal Hypertension:

• Up to 10 to 14 days after birth. (48 hours) monitor B/P closely.

Hemolysis

Elevated Liver Enzymes

Low Platelets

Causes

Symptoms

HELLP SyndromeHELLP Syndrome

•Is a variation of PIH

•4% to 12% of PIH patients (1 in 150 births).

•Cause is unknown, SS-nausea, epigastric pain, general malaise and rt. upper quadrant tenderness.

•Labs, monitor for bleeding.

•Tx. Transfusion fresh-frozen plasma or platelets. IV dextrose if hypoglycemic.

•Deliver as soon as fetus is viable.

Multiple PregnancyMultiple Pregnancy

Considered a complication of pregnancy.

Account for 2% due to fertility drugs.

Multiples may be any combination.

Occurs more frequently in non whites, high parity and age, multiple gestation, inherited

Identical (monozygotic) twins:Identical (monozygotic) twins:

• Begin with single ovum and spermatozoon

• Fusion or 1st cell division, zygote divides into 2 identical individuals.

• Usually have 1 placenta, 1 corion, 2 amnions, and 2 umbilical cords.

• Always same sex.

Fraternal (dizygotic, non-identical) twins:Fraternal (dizygotic, non-identical) twins:

• Fertilization of 2 separate ova by 2 separate spermatozoa (possible not from the same sexual partner).

• 2 placentas, 2 chorions, 2 amnions and 2 umbilical cords.

• May be same or different sex.

• 2/3 of twins are dizygotic.

Assessment:Assessment:

• Uterus increases in size at a rate faster than usual.

• Elevated alpha-fetoprotein levels

• Sonogram reveals multiples.

• Quickening woman reports flurries of action

• If fetus has back toward woman’s back only one fetal heart sound may be heard.

ManagementManagement• Monitor for complications-PIH, hydramnios placenta

previa, preterm labor, anemia.

• Prone to postpartal bleeding.

• Delivery early, immaturity of fetus.

• High risk for congenital anomalies, spinal cord defect and cord inserted into fetal membranes.

• Shared circulation, overgrowth of 1 fetus, knotting or twisting of cord.

• Encourage rest especially last 2 to 3 months, eat 6 small meals a day, take vitamin supplements, monthly US

• Prepare for role changes

• Worries of premature labor and survival of the infants.

Hydramnios (Poly)Hydramnios (Poly)• Excessive amniotic fluid formation.

• Usual-500 to 1000 mL.

• 2000mL or index > 24 cm.

• Can cause fetal malpresentation due to extra space for fetus to turn.

• Premature ROM and preterm labor from increased pressure and prostaglandin release

Hydramnios cont’Hydramnios cont’Assessment:

• Suggests difficulty with fetus’ ability to swallow or absorb or excessive urine production.

• SS-rapid enlargement of uterus, tense uterus, fetal heart is difficult to hear, SOB, lower extremity varicosities and hemorrhoids, increased weight gain.

• Sonogram

Management:

• Admit to hospital for bed rest or rest at home.

• Educate on ROM, contractions, avoid constipation.

• VS, edema, may do amniocentesis to remove extra fluid, Indomethacin to reduce total volume, Magnesium sulfate to halt preterm labor, “needled” to allow slow controlled release of fluid.

OligohydramniosOligohydramnios

• Less than average amount amniotic fluid

• Bladder or renal disorder interferes with fetal voiding

• Muscles weak, lungs fail to develop

• Uterine slow growth

• Amnioinfusion

Post Term PregnancyPost Term Pregnancy

• Term is 38 to 42 weeks

• Ovulation period may be longer so EDD will be 12 to 17 days later.

• Trigger did not turn on for labor.

• High dose of salicylates interferes with synthesis prostaglandins, which initiate labor.

• 2 weeks beyond term are at risk for meconium aspiration, macrosomia, lack of growth.

• Placenta functions for 40 to 42 weeks.

At 41 weeks; nonstress test,maternal fibronectin level, and biophysical profile to document state of placental perfusion and amniotic fluid. May induce.

• Cytotec to initiate ripening, ROM,oxytocin.

PseudocyesisPseudocyesis

•False pregnancy can also be seen in men; N&V, amenorrhea enlarged abdomen.

•Occurs: wish fulfillment or fear of pregnancy, depression.

•Sonogram

•Refer for psychological counseling.

Isoimmunization (Rh Incompatibility)Isoimmunization

(Rh Incompatibility)Rh-negative mother is carrying a fetus

with Rh-positive blood

Hemolytic disease of the newborn

Assessment

Management

Fetal DeathFetal Death

Most severe complication

Assessment

Nursing care