Week 9: Gestational complications

Gestational Hypertensive Disorders

• Gestational HTN

• Preeclampsia

• Eclampsia

Gestational HTN

after 20 weeks gestation there is an increase in BP and there are no other changes

• BP is > 140/90

Cause of gestational HTN

placenta not getting enough blood so mom’s BP increases to increase BF to placenta

Preeclampsia

A serous BP disorder developing after 20 weeks of pregnancy, characterized by high blood pressure (≥140/90) and signs of organ damage

Preeclampsia types

• Kidney

• CNS

• Liver

Preeclampsia signs and symptoms

Kidney

• Proteinuria (kidney issues)

Neuro

• HA (can’t be treated with Tylenol)

• Blurred vision

Liver issues

• Epigastric pain

Preeclampsia vasospastic disease

widespread vasospasm and vascular dysfunction, leading to reduced blood flow (ischemia) in organs like the brain, kidneys, and liver

BP mild vs severe

• Mild: >140/90

• Severe: >160/110

Preeclampsia proteinuria methods to determine

• 30 mg/dl (1+ on dip) on at least 2 random connections 6 hrs apart

• Protein/creatinine ratio >0.3

• 24 hour urine collection — >300 mg

Preeclampsia core pathophysiology

Poor perfusion

• Not HTN

Pathophysiology of preeclampsia

Preeclampsia risk factors (12)

• Nulliparity or new partner

• Family or personal history of the disease

• Obesity

• Maternal age <20 or >35

• Multiple gestation (larger placenta)

• African decent

• Smoking

• Diabetes

• Chronic HTN

• Renal or collagen disease

• Periodontal disease and infections (UTI hx)

• Previous negative pregnancy outcome (IUGR, fetal death)

Mild preeclampsia diagnostics

• BP

• Protein

• Urine output In ml/hr

• HA

• Visual changes

• Epigastric pain/nausea

• Liver function

• Pulmonary edema

• General edema

• Placental perfusion

• Always: BP >140/90

AND

• Protein elevated

OR

• Urine output 25-30 mL/hr

• HA — absent/transient

• Visual changes — absent

• Epigastric pain/nausea — absent

• Liver function — normal

• Pulmonary edema — none

• General edema — face or fingers

• Placental perfusion — reduced

Severe preeclampsia diagnostics

• BP

• HA

• Visual changes

• Epigastric pain/nausea

• Liver function

• Pulmonary edema

• General edema

• Placental perfusion

• Always: BP >160/110

AND

• Protein/creatinine elevated

• HA — persistent or severe

• Visual changes — blurred, photophobia, scotoma

• Epigastric pain/nausea — may be present

• Liver function — may be impaired

• Pulmonary edema — may be present

• General edema — severe and sudden

• Placental perfusion — decreased perfusion, IUGR, none General edema-reassuring fetal testing

Eclampsia

life-threatening emergency defined by seizures (convulsions) in a pregnant or postpartum person with preeclampsia

• without history of seizures

Chronic HTN pregnancy

• HTN occurs before pregnancy or before 20 weeks gestation that is diagnosed during pregnancy

• Persists longer than 12 weeks postpartum

Antihypertensives for chronic HTN during pregnancy

Beta blockers during pregnancy

• cannot be on ACE inhibitors

Chronic HTN makes a pregnant woman at a higher risk for developing _____

preeclampsia

Chronic HTN with Superimposed Preeclampsia

HTN before 20 weeks gestation with:

• New onset proteinuria that is >500 mg in 24 hrs

• Sudden uncontrolled HTN

Chronic HTN with Superimposed Preeclampsia — diagnosis if woman has proteinuria before pregnancy

new thrombocytopenia and increased LFT

HELLP syndrome

A severe form of liver preeclampsia, characterized by:

• Hemolysis

• Elevated Liver enzymes

• Low Platelet count

**HELLP nursing assessment and physical examination

• BP

• Weight

• Edema

• Neurological changes

• Severe epigastric pain

• Pulmonary edema

• Labs

HELLP syndrome: weight

retention of water leads to 3rd spacing and edema of the hands and feet

HELLP syndrome: Neurological changes

• DTRs and clonus

• HA

• Blurry vision/spots

HELLP syndrome: DTRs

• normal DTRs is +2

• if HELLP is getting really bad, the woman may become hyperreflexic (+3 or +4)

HELLP syndrome: Hyperreflexic DTRs treatment ent

magnesium sulfate

HELLP syndrome: Clonus

When a pregnant woman’s food is flexed and rather than falling back into place (normal), the foot will “click” back into place

• these are involuntary muscle contractions and relaxations

• to be positive there must be 3 or more “clicks”

Preeclampsia: nursing assessments for mother and fetus

Mother:

• patient education of cardiac, renal, and pulmonary system

• provide a quiet environment

Fetus:

• kick counts

• EFW at diagnosis

• NST

• BPP

• umbilical artery Doppler

Preeclampsia: bed rest position

side lying

Preeclampsia: diet

• NO sodium restriction

• limit excessively salty foods

• No caffeine

• No ETOH

Preeclampsia: medications (2)

• MgSO4 — seizure prophylaxis

• Anti-HTN meds (hydralazine and labetalol)

Preeclampsia: delivery indications

Always in the mom’s best interest when s/s are severe

• Labor can be induced as early as 30 weeks if severe

• Induction planned at 34 weeks for severe

• Induction at 37 weeks for mild

Eclampsia

progression of preeclampsia to a more severe form, characterized by the same sx as preeclampsia but also seizures

• this is a medical emergency!

Eclampsia: seizure injury prevention

Seizure requires immediate treatment — may not have any warning

• Side rails up

• Side lying

• Be ready to suction and administer O2

Eclampsia: assessment post-seizure (7)

• Pulmonary edema

• Circulatory and renal failure

• Cerebral hemorrhage

• Abruption

• Contractions

• Cervix

• FETUS!

Eclampsia: delivery

delivery after stabilization and is most often a c/s

Eclampsia: delivery and Pitocin indications

Pitocin induction if >30 weeks gestation or if <30 weeks and favorable cervix

Eclampsia: c/s indications

if <30 weeks gestation and unfavorable cervix

• reduces risk associated with delivery of very preterm infant

Eclampsia: MgSO4

used for seizure prophylaxis

• NOT for HTN

• Used through induction, labor, and 24 hours after delivery

*MgSO4 dosing for seizure prophylaxis

1. 4-6 grams over 30-60 mins

2. Followed by 2 g/hr

3. Therapeutic serum levels is 4-7.5 mEq/dl

How long with MgSO4 used for eclampsia?

Used through induction, labor, and 24 hours after delivery

Symptoms of MgSO4 toxicity

• During bolus she will feel very hot and horrible, but after bolus she should feel fine — if she doesn’t feel better after bolus this is a bad sign

• Slowed speech

• Decreased LOC

• Solemness

• Hyporeflexia

• Slowed RR

*Eclampsia nursing assessment

• BP

• RR

• UO

• Neurological

• DTRs

• ____ in protein in urine or edema

• BP >160/110

• RR <12 breaths/min

• UO <30 cc/hr

• Neuro: HA, visual changes

• DTR: increase (worsening condition) or decrease (mag tox)

• Increase in proteinuria or edema

Eclampsia: abnormal lab values — high or low

High

• MgSO4

• Platelets

• Creatinine clearance

• Uric acid levels

• AST and ALT

• PT and PTT

Down

• Fibrinogen

Antidote for mag toxicity

calcium gluconate

Early Pregnancy Bleeding (EPB)

bleeding that occurs within first 12 weeks of pregnancy

EPB causes

• Spontaneous abortion (miscarriage)

• Incompetent cervix

• Ectopic pregnancy

• Hydatiform Mole

Hydatiform Mole

Non-cancerous tumor that develops in the uterus due to an abnormal fertilization, causing grape-like cysts instead of a healthy placenta

Spontaneous Abortion (SAB)

A pregnancy that ends before 20 weeks gestation

• < 500 grams

• Fetus cannot survive outside of uterus

Early SAB

pregnancy lost before 12 weeks gestation

Early SAB causes

• Endocrine imbalance

• Immunologic factors

• Maternal infection

• Systemic disorders

• Genetic factors (chromosomal abnormalities are the most common cause)

Late SAB

pregnancy lost between 12-20 weeks gestation and is a result from maternal causes

Late SAB causes (7)

• AMA

• Increased parity

• Chronic infections

• Incompetent cervix (cervical insufficiency)

• Reproductive tract anomalies

• Inadequate nutrition

• Recreational drug use

SABs 5 classifications

• Threatened

• Inevitable

• Incomplete

• Complete

• Missed

SAB: Threatened abortion

occurs when vaginal bleeding occurs before the 20th week of pregnancy, potentially signaling early pregnancy loss, though the fetus is usually still alive and the cervix remains closed

SAB : Threatened abortion characteristics

• Light bleeding

• Mild uterine cramping

• No passage of tissue

• No cervical dilation

SAB: Inevitable abortion

occurs when vaginal bleeding and cramping are accompanied by the opening of the cervix, making the loss of pregnancy unavoidable, generally before 20 weeks

SAB: Inevitable abortion characteristics

• Moderate to heavy bleeding with presence of tissue

• Mild to severe cramping

• Cervical dilation

• ROM

• Passage of products of conception (POC) inevitable

SAB: Incomplete abortion

Fetal expulsion with placental retention

SAB: Incomplete abortion characteristics (3)

• Moderate to heavy bleeding with passage of tissue

• Severe cramping

• Dilated cervix with tissue in os

SAB: Complete abortion

Passage of all fetal tissue — fetus and placenta

SAB: Complete abortion characteristics

• Closed cervix after all tissue has passed

• Slight bleeding

• Mild uterine cramping

SAB: Missed abortion

fetal death without expulsion

SAB: Missed abortion characteristics

• Uterus decreases in size

• Limited bleeding and cramping

• No cervical change

• Diagnosed by US

• At risk for DIC!

Why are people with a missed abortion at risk for DIC?

baby isn’t circulating blood back to mom anymore because it is dead

SAB: Missed abortion treatment

Providers suggest a D&C, but the mother could also go home and pass it on her own (unless she becomes septic)

SAB: Septic abortion

life-threatening uterine infection occurring before, during, or after a SAB

SAB: Septic abortion characteristics

• Bleeding varies — foul odor

• Uterine cramping varies

• Passage of tissue varies

• Cervix dilated

SAB: Septic abortion treatment

Immediate termination via D&C!!!

• Antibiotics

• Assess for shock

SAB management: Threatened

Will miscarry or carry to term

• should have reduced activity, not bedrest because it can increase chances of a clot developing

SAB: Threatened subchorionic hematoma

a collection of blood between the placenta and uterine wall, often causing bleeding in early pregnancy and acting as a common cause of "threatened abortion"

SAB: repetitive

• having previous miscarriage increases risk of another SAB

• once you have 3 miscarriages, your body “resets” and your risk for another SAB decreases

SAB: Inevitable and incomplete management

D&C to remove all tissue

SAB: Complete management

no treatment bc no leftover tissue

• must do u/s to make sure everything is out

SAB: Missed abortion management

• Aborts spontaneously

• May require uterine evacuation to prevent infection and DIC

If mom is ___, _____ must be administered after a SAB because…

If mom is Rh-, rhogam must be administered after a SAB because fetal blood could mix with mom’s after it dies

Symptoms associated with bleeding during pregnancy (3)

• Cramping

• Pain

• N/V

Cause of a late abortion

incompetent cervix

• results in the passive and painless dilation of the cervix during the second trimester

Incompetent cervix etiology

• Hx of cervical laceration/trauma

• Excessive cervical dilation during curettage/biopsy

• DES daughter (not used after 1971)

• Reproductive tract anomolies

DES Daughter

DES was used prior to 1971 to prevent abortion, miscarriage, and premature labor by preventing full expansion of the uterus. Since the uterus wouldn’t fully expand, it would limit/prevent complete fetal development.

Incompetence cervix: signs and symptoms (5)

• Pressure and sensation in vagina

• Leaking of fluid

• Speculum exam shows membranes bulging through os

• Fetal parts in vagina

• Short cervix on US

Cerclage

surgical procedure to stitch cervix closed

• Done at 10-28 weeks gestation for patients with have previous losses bc of an IC

Incompetent cervix: treatment

Prophylactic cerclage — placed at 10-28 weeks and removed at 37 weeks

• Repeated with each successive pregnancy

Ectopic pregnancy

fertilized ovum is implanted outside of the uterus

• most often in fallopian tube

• leading cause of 1st sem abortion And infertility

Ectopic pregnancy danger

may cause maternal hemorrhage and death

• The fertilized egg grows in the fallopian tubes and overwhelms it bc it can’t expands very much

Ectopic pregnancy: risk factors (10)

• Previous bilateral tubal ligation (BTL) — after reversal or failure after cautery (tubes tied)

• STIs/PID — chlamydia increases risk bc of pelvic inflammatory diseases

• Abd or pelvic surgery

• Previous ectopic pregnancy

• Endometriosis

• Previous uterine masses

• IUD

• Infertility meds/treatments

• Progestin-only contraceptive use

• Smoking

Adnexal

structures adjacent to the uterus

• Ovaries

• Fallopian tubes

• Surrounding connective tissue

Ectopic pregnancy: signs and symptoms

• Missed period

• Sx of pregnancy

• Adnexal (uterine adjacent) fullness

• Unilateral, bilateral, or diffuse dull adnexal pain

• Vaginal bleeding

• Increased pain with rupture (6-12 weeks)

• *Referred shoulder pain

• Shock r/t rupture and hemorrhage

Ectopic pregnancy: pharmacological treatment

Methotrexate

• stops cell growth and allows body to absorb cells

• can be primary treatment if un-ruptured ectopic

Ectopic pregnancy: treatment

• US for IUP

• hCG discriminatory zone

• Serial quantitative β-hCG levels — doubles daily

• Laparoscopy

• Progesterone levels

hCG discriminatory zone

threshold serum β-hCG level above which a normal intrauterine pregnancy should be visible. If hCG exceeds this level and no sac is seen, it suggests a potential ectopic pregnancy

• typically 1,500-2000 mIU/mL for transvaginal US

• 6000-6500 mIU/mL for abdominal US

Hydatidform Mole

noncancerous tumor that develops in the uterus due to abnormal fertilization, resulting in an abnormal placenta, no viable fetus, and grape-like cyst formation

• No fetus develops!

• Abnormal fertilization of egg whose nucleus has been lost — sperm duplicates itself very fast

Complete vs Partial Mole

• Complete moles: arise from an empty egg fertilized by one or two sperm (diploid, 46,XX/XY), resulting in no fetus and high-risk cancer potential, characterized by "grape-like" chorionic villi.

• Partial moles: occur when a normal egg is fertilized by two sperm (triploid, 69,XXX/XXY/XYY), often including fetal tissue and having lower malignant potential

Hydatidform Mole: signs and symptoms (8)

• Vaginal bleeding (dark brown to bright red)

• Size of fetus is > than expected based on date of conception

• No signs of IUP (no FHR, movement, or parts on US)

• Anemia from blood loss

• Abnormally high levels of hCG (>100,000)

• Preeclampsia btwn 9-12 weeks gestation (bc mole is accelerating everything)

• Passage of grape-like vesicles

• “Snowstorm” appearance on US

Hydatidform Mole: Treatment (5)

• Most vesicles pass spontaneously around 16 week

• Will have D&C

• Follow-ups with frequent US and labs

• Pregnancy contraindicated for 1 year

• Rhogam (bc sperm blood type is likely different than mom’s

3 types of late placental bleeding

• Placenta Previa

• Abruptio Placenta

• Cord Insertion

Placenta Previa

Placenta covers part or all of the cervix

Partial placenta previa

Complete placenta previa

Marginal placenta previa