L&D Ch 19 - Pregnancy-Related Complications

A _____ pregnancy is one in which a condition exists that jeopardizes the health of the birthing parent, their fetus, or both. the birthing parent and fetus/newborn are at increased risk of morbidity or mortality prenatally, during the gestation, or postnatally.

high risk

Conditions commonly associated with early bleeding (first half of pregnancy) include _____

spontaneous abortion, uterine fibroids, ectopic pregnancy, GTD, and cervical insufficiency

Conditions associated with late bleeding include _____, which usually occur after the 20th week of gestation.

placenta previa, placental abruption, and placenta accreta

An _____ is the loss of an early pregnancy, usually before week 20 of gestation. this can be spontaneous or induced. It is considered not only a major reproductive health matter but also a health risk factor for the patient’s well-being.

abortion

_____ is the most common complication of early pregnancy

spontaneous abortion aka miscarriage

While a miscarriage is a loss before the 20th week, _____ is the loss of a fetus after the 20th week of development. this is much less common than miscarriages, occurring in about six of every 1,000 pregnancies in the United States

stillbirth

In the first trimester, if the spontaneous abortion/miscarriage is not complete and products of conception remain, what is the treatment?

d&c or prostaglandin analog (misoprostol)

In the second trimester, if the spontaneous abortion/miscarriage is not complete and products of conception remain, what is the treatment?

the patient is admitted to the hospital for an augmented L&D

If the patient who has experienced a miscarriage is Rh-negative and not sensitized, expect to _____ after the abortion is complete.

give RhoGAM within 72 hours

Stimulates uterine contractions to terminate a pregnancy and to evacuate the uterus after abortion to ensure passage of all the products of conception; taken 24-48 hours after mifepristone - describes what drug?

misoprostol aka cytotec

Acts as a progesterone antagonist, allowing prostaglandins to stimulate uterine contractions; causes the endometrium to slough; may be followed by administration of misoprostol within 48 hours - describes what drug?

mifepristone aka korlym

Stimulates uterine contractions, causing expulsion of uterine contents; expels uterine contents in fetal death or spontaneous abortion during the second trimester; effaces and dilates the cervix in pregnancy at term - describes what drug?

postoglandin analogs PGE2 or dinoprostone

an _____ is any pregnancy in which the fertilized ovum implants outside the main cavity of the uterus, including the fallopian tubes, cervix, ovary, and the abdominal cavity. this usually results from conditions that obstruct or slow the passage of the fertilized ovum through the fallopian tube to the uterus.

ectopic pregnancy

_____ is a folic acid antagonist given to treat ectopic pregnancy that inhibits cell division in the developing embryo. It typically has been used as a chemotherapeutic agent in the treatment of leukemia, lymphoma, and rheumatoid arthritis.

methotrexate

what are the treatment options for a clinically stable patient with an ectopic pregnancy that has not ruptured yet?

IM methotrexate, actinomycin, or laparoscopic surgery

what are the treatment options for a patient with an ectopic pregnancy that has ruptured?

laparotomy with possible removal of the fallopian tube (salpingectomy)

• history of ectopic pregnancy

• History of pelvic inflammatory disease (PID), other genital infections, or endometriosis

• Infertility and assisted reproduction use

• Sterilization failure or intrauterine device use

• Cigarette smoking

• Routine vaginal douching

• In-utero exposure to diethylstilbestrol (DES)

the above listed items are risk factors for what?

ectopic pregnancy

The hallmark of _____ is abdominal pain with spotting within 6 to 8 weeks after a missed menstrual period. Many people have symptoms typical of early pregnancy, such as breast tenderness, nausea, fatigue, shoulder pain, and low back pain.

ectopic pregnancy

_____ is a proliferation of trophoblastic tissue in pregnant or recently pregnant people, and is a spectrum of benign and malignant disorders that are created from abnormal trophoblastic tissue. The classification includes disorders of placental development (hydatidiform mole, complete and partial) and neoplasms of the trophoblast (choriocarcinoma, invasive mole, epithelioid trophoblastic tumor, and placental site trophoblastic tumor)

gestational trophoblastic disease (GTD)

what assessments can be done to detect an ectopic pregnancy?

transvaginal ultrasound and/or serum beta-hcg test

what are the treatment options for gestational trophoblastic disease (GTD)?

d&c or hysterectomy, chemotherapy if neoplasm develops

extremes of maternal age, prior molar pregnancy, infertility, prior spontaneous abortion, and vitamin A deficiency - risk factors for what condition?

molar pregnancy (GTD)

The main risk factor for the development of _____ is the history of complete hydatidiform mole

choriocarcinoma (GTD)

Clinical manifestations of a _____ include vaginal bleeding, pelvic pressure or pain, enlarged uterus, preeclampsia, and hyperemesis gravidarum.

molar pregnancy (GTD)

Typically, without symptoms, the first symptom of _____ may be shortness of breath (80% of patients demonstrate metastasis to the lungs)

choriocarcinoma (GTD)

_____ refers to painless cervical dilatation in the second trimester. Ultimately, an immature fetus will be expelled. It may result from cervical trauma or abnormal cervical development (possibly from in-utero DES exposure). this occurs more frequently in patients with Marfan syndrome and Ehlers-Danlos syndrome. The exact etiology of cervical insufficiency is not known.

cervical insufficiency

what is the prophylactic treatment for cervical insufficiency that is done during the second trimester?

cervical cerclage

With _____, the patient will often report a pink-tinged vaginal discharge or an increase in low pelvic pressure, cramping with vaginal bleeding, and loss of amniotic fluid. Cervical dilation also occurs. If this continues, rupture of the membranes, release of amniotic fluid, and uterine contractions occur, subsequently resulting in delivery of the fetus, often before it is viable.

cervical insufficiency

_____ is when the placenta is implanted into the lower uterine segment instead of the fundus, and may be partially or wholly covering the cervical opening. painless bright red bleeding is a typical finding with this, and the fetus typically has an abnormal lie

placenta previa

To reduce the risk of bleeding in a patient with ______, cervical examination is avoided. After 20 weeks’ gestation, the patient should avoid strenuous activity and sexual activity leading to orgasm. A patient with who demonstrates active vaginal bleeding is a potential obstetric emergency. The patient may be hospitalized for maternal and fetal assessment, fluid resuscitation and blood transfusion, and preparation for cesarean section if in active labor

placenta previa

• hx of placenta previa

• Previous cesarean birth

• Multiple gestation

• Increasing parity

• Increasing maternal age

• Previous uterine surgical procedure

• Infertility treatment

• Prior uterine artery embolization

• Endometriosis or abortion

• Maternal smoking or cocaine use

• Male fetus

the above listed items are risk factors for what condition?

placenta previa

_____ is the early separation of a normally implanted placenta after the 20th week of gestation prior to birth, which leads to hemorrhage. if separation is advanced or complete, loss of placental function results in fetal hypoxia and possibly fetal death.

placental abruption

s/s of _____ include a sudden onset of pain, dark red vaginal bleeding, board like tender abdomen, contractions, fetal distress, and hypovolemic shock s/s

placental abruption

risk factors for ______ include: HTN, trauma, cocaine or tobacco use, hx of the condition in previous pregnancy(s), multifetal gestation

placental abruption

Placenta accreta spectrum refers to a full range of accrete diagnoses, including _____ - trophoblast invasions of varying depths in which the placenta is anchored into the myometrium rather than the decidua. Consequently, the placenta does not separate at birth, and it must be manually removed. these disorders are potentially life-threatening obstetric hemorrhagic conditions that require a multidisciplinary approach to management.

placenta accreta, increta and percreta

Placenta accreta spectrum: _____ is the most common (80%) and is a condition in which the placenta attaches itself too deeply into the wall of the uterus but does not penetrate the uterine muscle.

accreta

Placenta accreta spectrum: _____ occurs (15%) when the placenta invades the myometrium

increta

Placenta accreta spectrum: _____ occurs (5%) when the placenta has extended through the myometrium, uterine serosa, and adjacent tissue

percreta

what are potential complications of placental accreta spectrum if not identified until the time of birth?

hemorrhage when removing placenta, possible need for hysterectomy

_____ is a severe form of morning sickness characterized by persistent, uncontrollable nausea and vomiting beginning by 5 to 6 weeks’ gestation. It results in dehydration, weight loss of more than 5% of prepregnancy body weight, ketosis, electrolyte imbalances, ketonuria, and nutritional deficiencies. It can be associated with acute starvation and may require hospitalization.

hyperemesis gravidarum

_____ is defined as blood pressure exceeding 140/90 mm Hg before pregnancy or before 20 weeks’ gestation.

chronic hypertension

______ is characterized by hypertension (higher than 140/90 mm Hg) in a previously normotensive patient without proteinuria after 20 weeks’ gestation and resolving by 12 weeks’ postpartum

gestational hypertension

_____ can be described as new-onset hypertension accompanied by proteinuria and/or maternal organ dysfunction that targets the cardiovascular, hepatic, renal, and central nervous systems (CNS)

preeclampsia

Current management of _____ includes perinatal blood pressure control and monitoring, prenatal aspirin therapy, betamethasone for patients prior to 34 weeks’ gestation, parenteral magnesium sulfate prophylaxis, and follow-up of postpartum blood pressures

preeclampsia

in a patient with _____, after delivery of the fetus and placenta, blood pressure returns to normal within 4 weeks to 3 months

preeclampsia

preeclampsia becomes eclampsia when?

the onset of seizure activity

preeclampsia without vs with severe features vs eeclampsia: s/s of ______ include a BP of >140/90

preeclampsia

preeclampsia without vs with severe features vs eeclampsia: s/s of ______ include a BP of >160/110, hyperreflexia, headache, blurred vision, HELLP syndrome, abdominal pain

preeclampsia with severe features

preeclampsia without vs with severe features vs eeclampsia: s/s of ______ include a BP of >160/110, seizures and/or coma, hyperreflexia, headache, blurred vision, cerebral hemorrhage, HELLP syndrome, abdominal pain, renal failure

eclampsia

_____ is a more severe variant of preeclampsia characterized by hemolysis, elevated liver enzymes, and low platelets

HELLP syndrome

_____ is sometimes indicated in patients with preeclampsia (based on severity of s/s) to prevent seizure activity, and may cause decreased FHR.

magnesium sulfate

In the patient receiving _____, toxicity is indicated by a respiratory rate of <12 breaths/min, absence of DTRs, and a decrease in urinary output (<30 mL/h). the nurse should prepare to administer calcium gluconate.

magnesium sulfate

The onset of _____ is between 27 weeks’ gestation and delivery and may also occur in the postpartum period. People with this condition are at increased risk for complications such as cerebral hemorrhage, retinal detachment, hematoma/liver rupture, DIC, placental abruption, eclampsia, acute renal failure, pulmonary edema, and maternal death

HELLP syndrome

_____ is the spontaneous rupture of membranes after 37 weeks gestation but before the onset of labor. Complications include prolapsed cord, placental abruption, and preterm labor

premature rupture of membranes (PROM)

_____ is the rupture of membranes before onset of labor prior to 37 weeks gestation

preterm premature rupture of membranes (PPROM)

_____ is characterized by an excessive volume of amniotic fluid (>2,000mL).

polyhydramnios aka hydramnios

_____ is characterized by a low volume of amniotic fluid (<500mL).

oligohydramnios

patients with _____ are at high risk for preterm labor, polyhydramnios, hyperemesis gravidarum, anemia, preeclampsia, and antepartum hemorrhage. Fetal/newborn risks or complications include prematurity, respiratory distress syndrome, birth asphyxia/perinatal depression, congenital defects, twin-to-twin blood transfusion syndrome, intrauterine growth restriction, and becoming conjoined twins

multiple gestation

If labor does not start within _____, the patient with PPROM may be discharged home on expectant management, which may include antibiotics, activity restriction, fetal monitoring

48 hours

_____ is when an Rh-negative patient develops antibodies against Rh-positive fetal RBCs. This usually occurs during a second or subsequent pregnancy after exposure to Rh+ fetal blood, leading to hemolytic disease of the fetus and newborn (HDFN), which can cause jaundice, anemia, or severe hydrops fetalis. It is preventable by giving RhoGAM when appropriate during the first pregnancy.

Rh isoimmunization