Module 8 pt 1: Pregnancy Related Complications, Childbearing Family

What are the most common bleeding conditions of early pregnancy?

abortion, ectopic pregnancy, gestational trophoblastic disease

What is the most common cause of spontaneous abortion?

chromosomal abnormalities incompatible with life

What factor increases the rate of spontaneous abortion?

increasing age (especially after 35 years)

What is treatment for spontaneous abortion?

- Preventing complications such as hypovolemic shock and infection

- Providing emotional support for grieving

What can be done to prevent complications of spontaneous abortion such as hypovolemic shock and infection?

medical/surgical evacuation of the uterus

close monitoring of vital signs and lab values

The loss of pregnancy prior to viability of the fetus; spontaneous or induced

Abortion

When do many miscarriages happen?

Before 12 weeks of pregnancy; first trimester

increasing maternal/paternal age, hypothyroidism, maternal infection, autoimmune disease, defect in uterus/cervix and diabetes can increase the risk for

spontaneous abortion

When there is bleeding during pregnancy, but fetus has a heartbeat and membrane is intact

threatened abortion

When there is bleeding and the fetus is no longer viable with life or the membranes have ruptured; cervix is open

inevitable abortion

Miscarriage is happening, but there is still some retained tissue

incomplete abortion

Abortion in which all of the uterine parts have passed and cervix is open; fetus is no longer viable

complete abortion

When the fetus dies in the uterus but is not expelled from the uterus; cervix is still closed and membranes still intact

missed abortion

three or more consecutive pregnancy losses before 20 weeks of gestation

recurrent/habitual abortion

procedure that involves dilating (opening) the cervix and removing tissue from the uterus; used for incomplete or missed abortions or induced abortion

Dilation and Curettage (D&C)

Past the first trimester, what kind of medications may be used to soften and dilate the uterus to help expel a fetus that has died?

prostaglandins

Recurrent spontaneous abortions caused by an incompetent cervix may require what surgery to keep a pregnancy?

Cerclage

How does cerclage surgery work?

cervix is sutured to keep from opening; suture removed near delivery

What are indications for cerclage surgery?

2nd mid-trimester loss due to cervical insufficiency

very short cervical length

What other interventions might a women receiving a cerclage receive?

progesterone therapy and close monitoring

Implantation of the fertilized ovum in an area outside of the uterine cavity

ectopic pregnancy

What are risk factors for ectopic prgnancy

STD's, pelvic inflammatory disease, previous ectopic, failedtubal ligation, intrauterine device, induced abortion, Advanced maternal age, assisted reproductive technologies

Scarring of the fallopian tubes or altered function that interferes with transport of the fertilized ovum increase risk for?

ectopic pregnancy

what are CM of ectopic pregnancy?

abdominal/pelvic pain, missed menstrual cycle, abnormal vaginal bleeding

What are CM of a ruptured fallopian tube?

acute abdominal pain, shoulder pain, signs of hypovolemic shock

What tests should be done to identify ectopic pregnancy?

ultrasound, HCG testing

What can be used for mgmt of an ectopic pregnancy that is smaller and has not ruptured the fallopian tube?

methotrexate

What can be used for mgmt of an ectopic pregnancy that is larger or has ruptured the fallopian tube?

surgery; removing affected fallopian tube

What are the therapeutic goals of treating ectopic pregnancy?

prevent hemorrhage, removing ectopic tissue, preserve future fertility, emotional support, education

A group of disorders that arise from abnormal trophoblastic tissue proliferation and pregnancy

Gestational trophoblastic disease

an abnormal growth in the uterus that develops during pregnancy. It occurs when an egg without a nucleus (empty egg) is fertilized by a sperm.

Hydatiform mole

What causes a complete/classic hydatiform mole?

fertilization of egg with lost or inactivated nucleus

What causes a partial hydatiform mole?

two sperm fertilizing a normal ovum; often results in some nonviable fetal tissue

Common CM of molar pregnancies

bleeding in the first half of pregnancy, uterus significantly larger than gestational age, nausea/vomiting

Diagnostic evaluation for molar pregnancies

obtain baseline HCG levels, perform metabolic/blood chemistry testing, chest xray to determine uterine state or metastasis

Management for molar pregnancy

evacuation of the mole (vacuum aspiration)

careful follow up to ensure residual trophoblastic tissue is not retained

close surveillance with frequent HCG monitoring for at least 1 year

What can retained residual trophoblastic tissue cause?

persistent gestational trophoblastic disease

choriocarcinoma (HIGHLY MALIGNANT)

What is critical about the 1 year period following a molar pregnancy?

postpone subsequent pregnancy; strict surveillance

Condition in which placenta implants in the lower uterus; causes painless uterine bleeding in the latter half of pregnancy

placenta previa

The placenta completely covers the internal opening of the cervix.

Complete Placenta previa

The placenta partially covers the internal opening of the cervix; within 3 cm of internal cervical os

Partial placenta previa

The placenta is located at the edge of the cervix but does not cover the opening.

Marginal placenta previa

What is the hallmark sign of placenta previa?

PAINLESS uterine bleeding in latter half of pregnancy

What should be avoided to prevent hemorrhage in placenta previa?

vaginal exams and procedures that stimulate contractions; prior to confirmation of placental location via US

Key considerations in mgmt of placenta previa

-quantify blood loss

-continuous monitoring of mother and fetus; assessing gestational age

-labs/imaging to guide decision making

If bleeding is profuse or maternal fetal compromise is present in placenta previa, what should be done?

Rapid preparation for an emergency c-section

Premature separation of a normally implanted fetus from the uterine wall before the fetus is born

Abruptio placentae

What happens when placental separation occurs in abruptio placentae?

bleeding and formation of a hematoma on the maternal side of the placenta; bleeding may be visible or concealed

What are the signs women with abruptio plaentae will present with

achy or dull abdominal/lower back pain

uterine tenderness

uterine irritability; low intensity contractions

may or may not have visible bleeding

What are complications of abruptio placentae

non-reassuring FHR

hypovolemic shock in mother (internal hemorrhage)

fetal death

disseminated intravascular coagulation

end organ damage from blood loss

What is the priority in abruptio placentae?

rapid stabilization of mother

continuous monitoring of fetus

emergency c-section

What are signs and symptoms of concealed hemorrhage in abruptio placentae?

• Increase in fundal height

• Hard board-like abdomen

• High uterine base-line tone on electronic monitoring strip

• Persistent abdominal pain

• Tachycardia, failing blood pressure, restlessness

• Persistent late decelerations in fetal heart rate

• Vaginal bleeding can be slight or absent

uncontrollable vomiting that begins in the first weeks of pregnancy and may continue throughout

Hyperemesis gravidarum

What effects on mom and baby is hyperemesis gravidarum associated with

5% weight loss from pre-pregnancy weight

low pregnancy weight gain

low birth weight

What complications often occur with hyperemesis gravidarum?

dehydration

fluid and electrolyte imbalance

inadequate nutrition

What are treatment options for hyperemesis gravidarum?

IV fluids

antiemetic medications

dietary modifications

hospitalization if severe

What are nursing considerations for a patient with hyperemesis gravidarum?

-Assess I/O

-Rule out other potential causes (cholecystitis/h.pylori_

-Smaller portions Q 2-3 hours

-Daily weights

-B6 and ginger

A life threatening complication of missed abortion, abruptio placentae, or preeclampsia in which there is a decrease in clotting factors and increase in anticoagulation; blood is unable to clot properly

Disseminated intravascular coagulation (DIC)

What complications is the patient with DIC at high risk for?

bleeding AND thrombosis

What is the priority intervention to stop the production of thromboplastin in DIC?

delivery of the fetus and placenta

What is supportive treatment the mother with DIC may need?

Replace whole blood, packed Red blood cells, cryoprecipitate

What 2 conditions must exist for Rh incompatibility?

(1) the expectant mother is Rh-negative

(2) the fetus is Rh-positive.

What is the main complication of Rh incompatibility

Hemolytic disease of the newborn in subsequent pregancies

What are the major complications of Hemolytic Disease of the Newborn (HDN)?

Anemia (from red blood cell destruction)

Hydrops fetalis (severe fetal edema, heart failure, possible stillbirth)

When is Rhogam given?

28 weeks and within 72 hours of delivery (if fetus is Rh positive)

What are risk factors for pregnancy-related (gestational) hypertension?

• First pregnancy, for mother and father

• Men who have fathered one preeclamptic pregnancy

• Age greater than 35 years

• Anemia

• Family or personal history of preeclampsia

• Chronic hypertension

• Chronic renal disease

• Obesity

• Diabetes

• Multifetal pregnancy

• Pregnancy from assisted reproduction technique

new onset elevated blood pressure after 20 weeks of pregnancy but returns to normal postpartum; >140/>90 on 2 separate occasions

Gestational hypertension

Is gestational hypertension accompanied by proteinuria?

NO

What may gestational hypertension progress to?

preeclampsia

If gestational hypertension persists more than 6 weeks after birth, what happens?

pt is diagnosed with chronic hypertension

What is management for gestational hypertension?

-monitor mom and baby

-regular blood pressure and urine protein checks

-assess fetal growth and well being

-mild: rest and outpt monitoring

severe: hospitalization, antihypertensive therapy, possible early delivery

Condition that develops after 20 weeks with proteinuria that is due to generalized vasospasm, decreasing circulation to all organs of the body including the placenta

Preeclampsia

What are parameters for preeclampsia?

Blood pressure >140/>90

>0.3 g of protein in a 24 hr urine collection

>1+ protein random urine dipstick

What are complications of preeclampsia

-renal and hepatic dysfunction

-impaired fetal growth and wellbeing

What is involved in home care for mild preeclampsia?

•Activity restrictions

•Monitoring of fetal activity

•Blood pressure monitoring

•Weight measurement

•Urinalysis for protein

•Diet without salt

•Fetal assessment

What is the overall goal in mild preeclampsia mgmt?

prolong pregnancy safely, while preventing progression to severe disease

What 2 factors can diagnose someone with severe preeclampsia?

-Blood pressure >160/>110

-evidence of multisystem involvement

What are clinical manifestations of severe preeclampsia?

severe headache, visual disturbances, epigastric or RUQ pain, generalized edema, proteinuria, elevated liver enzymes, increased creatinine, low platelets

When magnesium sulfate is used to treat preeclampsia, what often precedes respiratory depression?

hyporeflexia

What is the goal in using magnesium sulfate to treat preeclampsia?

prevent seizures

What non-pharmacological interventions should be in place to prevent seizures in preeclampsia pts?

-control external stimuli

-initiate seizure precautions

What does nursing assessment involve in the preeclampsia pt receiving magnesium sulfate?

-deep tendon reflexes

-respiratory rate

-level of consciousness

-urinary output

-serum magnesium level

-edema

Why must urinary output be carefull monitored in a preeclamspia pt receiving magnesium?

oliguria allows magnesium to accumulate

What are common antihypertensives for preeclampsia?

hydralazine, lopressor, nifedipine

What are the 3 hallmark signs of HELLP syndrome?

Hemolysis

Elevated Liver enzymes

Low Platelets

What causes hemolysis in HELLP syndrome?

fragmentation and distortion of erythrocytes during passage through damaged blood vessels

What causes elevated liver enzymes in HELLP syndrome?

obstruction of hepatic blood flow by fibrin deposits

What causes low platelet levels in HELLP syndrome?

vascular damage resulting from vasospasm

Where is there typically pain in HELLP syndrome

right upper quadrant or epigastric area; d/t liver swelling and pain

What does treatment of HELLP syndrome focus on?

treating the mother and expediting delivery, as the pregnancy continues to progress until delivery

Supportive care for HELLP syndrome

manage blood pressure

prevent seizures with magnesium sulfate

correcting abnormalities with blood products

What causes 75% of anemia in pregnancy?

Iron deficiency; due to it being difficult to meet pregnancy needs through diet alone

Maternal effects of iron deficiency anemia

fatigue, weakness, increased susceptibility to infection

Fetal and neonatal effects of iron deficiency anemia

growth restriction, preterm birth, low birth weight

What kind of deficiency leads to megaloblastic anemia?

folic acid deficiency

Maternal effects of folic acid deficiency anemia

fatigue, glossitis

Fetal and neonatal effects of folic acid deficiency anemia

congenital anomalies, growth restriction

Autosomal recessive genetic disorder that causes anemia due to abnormal hemoglobin, resulting in distortion and destruction of erythrocytes

Sickle cell anemia

What are maternal risks for a patient with sickle cell anemia

increased pain crises, infection, thrombolytic effects

What are fetal and neonatal risks for a patient with sickle cell anemia

growth restriction, preterm birth, higher rates of perinatal mortality