Chapter 9: Medical Conditions

Chapter 9: Medical Conditions

Unexpected medical conditions can occur during pregnancy. Awareness, early detection, and interventions are crucial components to ensure fetal well-being and maternal health.

Unexpected medical conditions include cervical insufficiency, hyperemesis gravidarum, anemia, gestational diabetes mellitus, and gestational hypertension.

Cervical insufficiency

A condition where the cervix weakens and dilates too early, leading to pregnancy loss or preterm birth.

Cervical insufficiency Risk Factors & Expected Findings

Cervical Trauma – Previous births, excessive dilation, cervical surgeries (curettage, biopsy)

Pregnancy History – Short labors, early pregnancy loss, or advanced cervical dilation

In Utero Exposure – Diethylstilbestrol (hormone exposure during pregnancy)

Congenital Defects – Structural abnormalities of the uterus or cervix

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Symptoms: Increased pelvic pressure or urge to push

Physical Signs:

• Pink-stained vaginal discharge or bleeding

• Possible rupture of membranes (gush of fluid)

• Uterine contractions leading to fetal expulsion

• Postoperative monitoring (cerclage removal risks: contractions, infection, rupture of membranes)

Cervical insufficiency Labs/Dx

Ultrasound: Detects cervical shortening (<25 mm), funneling, or effacement (thinning)

Cervical insufficiency Care

Prophylactic Cervical Cerclage:

• Surgical reinforcement with a strong ligature to prevent early dilation

• Best performed between 12-14 weeks gestation

• Removed at 36-38 weeks or when labor begins

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Nursing Care

• Assess support system if bed rest or activity restrictions are prescribed.

• Monitor for vaginal discharge, pressure, and contractions.

• Check vital signs for signs of distress.

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Discharge Instructions

• Activity restriction or bed rest as prescribed.

• Increase hydration (dehydration can trigger contractions).

• Avoid intercourse to prevent cervical stimulation.

• Monitor for cervical or uterine changes (report any unusual pressure or contractions).

• Report immediately if experiencing:

  • Preterm labor signs (contractions <5 minutes apart, increased pelvic pressure).

  • Rupture of membranes or infection.

Prophylactic Cervical Cerclage

Surgical reinforcement with a strong ligature to prevent early dilation

Best performed between 12-14 weeks gestation

Removed at 36-38 weeks or when labor begins

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Cervical insufficiency Tx

Hyperemesis gravidarum

Severe, persistent nausea and vomiting

• Leads to weight loss, dehydration, nutritional deficiencies, electrolyte imbalances, and ketonuria.

Increased hCG levels may contribute to this condition.

Fetal risks include intrauterine growth restriction (IUGR), small for gestational age (SGA), and preterm birth.

Hyperemesis gravidarum Risk Factors & Expected Findings

Younger than 30 years old

Multifetal pregnancy (twins, triplets)

Gestational trophoblastic disease (GTD)

High stress levels or psychosocial issues

Hyperthyroidism, diabetes, or gastrointestinal disorders

Family history of hyperemesis

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Severe vomiting lasting prolonged periods

Signs of dehydration (dry mucous membranes, poor skin turgor)

Electrolyte imbalance symptoms (dizziness, confusion)

Weight loss

Increased heart rate, low blood pressure (due to dehydration)

Hyperemesis gravidarum Labs/Dx

Urinalysis:

• Ketones & acetones present

  • Indicates breakdown of fat due to starvation

• Elevated urine specific gravity → sign of dehydration

Chemistry Panel (Electrolyte Imbalance):

• ↓ Sodium, potassium, chloride (due to low intake & vomiting)

• Metabolic acidosis (if due to starvation)

• Metabolic alkalosis (if due to excessive vomiting)

• Elevated liver enzymes & bilirubin

Thyroid Function Test:

• May indicate hyperthyroidism

Complete Blood Count (CBC):

• Elevated hematocrit (Hct) due to hemoconcentration (fluid loss)

Hyperemesis gravidarum Care

Medications:

• IV lactated Ringer’s: Replenish fluids and electrolytes.

• Vitamin B6 (Pyridoxine): First-line treatment (alone or with doxylamine).

  • Safe & effective for nausea.

• Antiemetics (Metoclopramide): Used cautiously for severe nausea/vomiting.

• Corticosteroids: For severe, refractory cases.

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Nursing Care:

• Monitor fluid balance: Intake & output (I&O).

• Assess hydration status: Skin turgor and mucous membranes.

• Check vital signs: Watch for dehydration-related hypotension and tachycardia.

• Monitor weight loss: Assess nutritional status.

• NPO (nothing by mouth) until vomiting stops to prevent worsening dehydration.

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Client Education & Discharge Instructions:

• Gradually reintroduce diet:

  • Start with clear liquids and bland foods (e.g., broth, tea, apple juice).

  • Progress to dry toast, crackers, baked chicken, then to a normal diet as tolerated.

• Frequent, small meals: Helps manage nausea and prevents vomiting recurrence.

• Severe cases: May require enteral (feeding tube) or total parenteral nutrition (IV nutrition).

Iron-deficiency anemia

Occurs during pregnancy due to low maternal iron stores and insufficient dietary iron intake.

Iron-deficiency anemia Risk Factors & Expected Findings

Short pregnancy spacing (<2 years between pregnancies).

Heavy menstrual periods before pregnancy.

Poor dietary intake

Unhealthy weight loss programs.

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Fatigue and weakness.

Pica (craving for non-food substances) like ice, clay, or dirt.

Iron-deficiency anemia Labs/Dx

Hemoglobin (Hgb):

• <11 mg/dL (1st and 3rd trimester).

• <10.5 mg/dL (2nd trimester).

Hematocrit (Hct) < 33%.

Blood ferritin <12 mcg/L (indicates low iron stores).

Iron-deficiency anemia Care

Ferrous Sulfate Iron Supplements

• Take on an empty stomach (better absorption).

• Pair with vitamin C (orange juice enhances absorption).

• Increase fiber & fluids to reduce constipation.

Parenteral Iron Therapy

• Given if oral iron is not tolerated.

• Severe cases may require blood transfusions.

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Nursing Care

• Daily iron intake for pregnant patients: 27 mg/day (prenatal vitamins contain ~30 mg).

• Severe deficiency may require 60-120 mg/day of iron supplements.

• Encourage iron-rich foods:

  • Legumes, dried fruit, dark green leafy vegetables, red meat.

• Educate on managing side effects (e.g., constipation, nausea).

Gestational Diabetes Mellitus (GDM)

A temporary glucose intolerance that occurs during pregnancy.

Blood Glucose Targets:

• Fasting or before meals: 60-99 mg/dL

• 2 hours after meals: ≤120 mg/dL

Postpartum Risk:

• Resolves after birth, but 50% of women may develop type 2 diabetes later in life.

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Increased Risks to Fetus

1. Macrosomia (large baby), birth trauma, electrolyte imbalances, and neonatal hypoglycemia.

2. Infections (urinary & vaginal) due to glucose in urine and reduced immune response.

3. Ketoacidosis from insulin resistance or poorly managed hyperglycemia.

4. Hypoglycemia from too much insulin, missed meals, or excessive exercise.

5. Hyperglycemia leading to excessive fetal growth (macrosomia).

Gestational Diabetes Mellitus (GDM) Risk Factors & Expected Findings

Obesity

Hypertension

Glycosuria (glucose in urine)

Maternal age >25 years

Family history of diabetes

Previous large or stillborn infant

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Hypoglycemia Symptoms (Low Blood Sugar)

• Nervousness, headache, weakness

• Irritability, hunger, blurred vision

Hyperglycemia Symptoms (High Blood Sugar)

• Increased thirst, hunger, and urination (polydipsia, polyphagia, polyuria)

• Nausea, abdominal pain

• Flushed, dry skin, fruity breath

Physical Signs

• Shaking, clammy skin, shallow breathing, rapid pulse

• Vomiting, excessive weight gain during pregnancy

Gestational Diabetes Mellitus (GDM) Labs/Dx

Glucose Screening Test (1-hour glucose tolerance test)

• Performed at 24-28 weeks of pregnancy.

• A 50g oral glucose load is given, and blood glucose is checked 1 hour later.

• If ≥130-140 mg/dL, a 3-hour glucose tolerance test is needed.

Oral Glucose Tolerance Test (OGTT)

• Requires overnight fasting, no caffeine, and no smoking for 12 hours.

• A 100g glucose load is given, and blood is tested at 1, 2, and 3 hours.

Ketone Testing

• Checks for ketones in urine to assess for ketoacidosis.

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Biophysical Profile (BPP): Checks fetal well-being.

Amniocentesis: Measures fetal lung maturity.

Nonstress Test (NST): Evaluates fetal heart rate response.

Gestational Diabetes Mellitus (GDM) Care

Medications

• First-line treatment: Diet and exercise.

• If blood glucose remains high, insulin is initiated.

• Oral hypoglycemics (e.g., glyburide) may be considered but are not widely recommended.

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Nursing Care

• Monitor blood glucose levels regularly.

• Monitor fetal well-being for any complications.

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Client Education

1. Daily Kick Counts – Monitor fetal movement for well-being.

2. Dietary Management:

   • Follow a diabetic diet with restricted carbohydrate intake.

   • Seek dietary counseling from a registered dietitian.

3. Exercise – Helps regulate blood sugar levels.

4. Self-Administer Insulin if prescribed.

5. Postpartum Follow-Up:

   • Oral Glucose Tolerance Test (OGTT) postpartum.

   • Monitor blood glucose levels to assess long-term diabetes risk.

Gestational Hypertension (GH)

Develops after 20 weeks of pregnancy.

BP ≥140/90 mmHg recorded twice (at least 4 hours apart)

No proteinuria.

BP returns to normal by 12 weeks postpartum.

Preeclampsia

Gestational hypertension + organ dysfunction.

Traditionally diagnosed with proteinuria, but diagnosis can be made without it.

Symptoms: Headaches, irritability, edema.

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Gestational Hypertension

• Develops after 20 weeks of pregnancy.

• BP ≥140/90 mmHg recorded twice (at least 4 hours apart)

• No proteinuria.

• BP returns to normal by 12 weeks postpartum.

Severe Preeclampsia

BP ≥160/110 mmHg.

Proteinuria >3+, Oliguria (<500 mL/day).

Signs of organ damage:

• Kidneys: Elevated creatinine (>1.1 mg/dL).

• Brain: Blurred vision, headaches.

• Liver: Epigastric/RUQ pain, hepatic dysfunction.

• Lungs/Heart: Pulmonary/cardiac involvement.

• Reflexes: Hyperreflexia, ankle clonus.

Eclampsia

Preeclampsia + Seizures or Coma.

Warning Signs: Headache, epigastric pain, hyperreflexia, hemoconcentration (thickened blood)

HELLP Syndrome

Severe Preeclampsia with Liver Dysfunction

Diagnosed by lab tests.

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Severe Preeclamspia

• BP ≥160/110 mmHg.

• Proteinuria >3+, Oliguria (<500 mL/day).

• Signs of organ damage:

  • Kidneys: Elevated creatinine (>1.1 mg/dL).

  • Brain: Blurred vision, headaches.

  • Liver: Epigastric/RUQ pain, hepatic dysfunction.

  • Lungs/Heart: Pulmonary/cardiac involvement.

  • Reflexes: Hyperreflexia, ankle clonus.

HEELP Syndrome Acronym

H: Hemolysis → Anemia, jaundice.

EL: Elevated liver enzymes → Liver damage, nausea, vomiting, RUQ pain.

LP: Low Platelets (<100,000/mm³) → Bleeding issues, petechiae, DIC risk.

Hypertension in Pregnancy

Types

• Gestational Hypertension (GH)

  • Develops after 20 weeks of pregnancy.

  • BP ≥140/90 mmHg recorded twice (at least 4 hours apart).

  • No proteinuria.

  • BP returns to normal by 12 weeks postpartum.

• Preeclampsia

  • Gestational hypertension + organ dysfunction.

  • Traditionally diagnosed with proteinuria, but diagnosis can be made without it.

  • Symptoms: Headaches, irritability, edema.

• Severe Preeclampsia

  • BP ≥160/110 mmHg.

  • Proteinuria >3+, Oliguria (<500 mL/day).

  • Signs of organ damage:

    • Kidneys: Elevated creatinine (>1.1 mg/dL).

    • Brain: Blurred vision, headaches.

    • Liver: Epigastric/RUQ pain, hepatic dysfunction.

    • Lungs/Heart: Pulmonary/cardiac involvement.

    • Reflexes: Hyperreflexia, ankle clonus.

• Eclampsia

  • Preeclampsia + Seizures or Coma.

  • Warning Signs: Headache, epigastric pain, hyperreflexia, hemoconcentration (thickened blood).

• HELLP Syndrome (Severe Preeclampsia with Liver Dysfunction)

  • Diagnosed by lab tests.

  • H: Hemolysis → Anemia, jaundice.

  • EL: Elevated liver enzymes → Liver damage, nausea, vomiting, RUQ pain.

  • LP: Low Platelets (<100,000/mm³) → Bleeding issues, petechiae, DIC risk.

Gestational Hypertension Risk Factors & Expected Findings

Age: Younger than 19 or older than 40.

First pregnancy.

Obesity.

Multiple pregnancies (twins, triplets, etc.).

Chronic conditions:

• Chronic hypertension, renal disease, diabetes, rheumatoid arthritis, systemic lupus erythematosus.

Family history of preeclampsia.

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Severe, continuous headache.

Nausea.

Blurred vision.

Flashes of lights or dots in vision.

Hypertension.

Proteinuria.

Swelling (edema): Face, hands, abdomen, legs.

Vomiting, nausea.

Severe reflex responses (hyperreflexia).

Epigastric pain, right upper quadrant pain.

Breathing issues: Dyspnea, diminished breath sounds.

Neurological signs: Seizures, scotoma (visual disturbances).

Jaundice (in severe cases).

Signs of worsening condition: Liver/kidney failure, cerebral involvement, clotting issues.

Gestational Hypertension Labs/Dx

Liver enzymes (AST, ALT, LDH).

• Elevated liver enzymes (LDH, AST).

Kidney function: Blood creatinine, BUN, uric acid.

• Increased creatinine.

• Increased uric acid (kidney stress).

CBC (complete blood count).

• Hyperbilirubinemia → Jaundice

• Abnormal hemoglobin levels

  • Decreased in HELLP

  • Increased in preeclampsia

Clotting studies.

• Low platelet count (thrombocytopenia).

Comprehensive chemistry profile.

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Urine protein testing (dipstick, 24-hour collection).

Fetal well-being tests:

• Nonstress test, contraction stress test, biophysical profile, serial ultrasounds.

• Doppler blood flow analysis (assesses fetal circulation).

Daily fetal kick counts.

Gestational Hypertension Care

Medications

Antihypertensive Medications

• Methyldopa

• Nifedipine

• Hydralazine

• Labetalol

• Avoid: ACE inhibitors and Angiotensin II receptor blockers (harmful in pregnancy).

Anticonvulsant Medication: Magnesium Sulfate

• Purpose: Prevent seizures in eclampsia and severe preeclampsia.

• Antidote: Calcium gluconate or calcium chloride

• Route: IV infusion.

  • Use an infusion pump for accurate dosing.

• Monitor for signs of toxicity:

  • Absent deep tendon reflexes.

  • Urine output <30 mL/hr.

  • Respiratory rate <12/min.

  • Decreased level of consciousness.

  • Cardiac arrhythmias.

• Common side effects: Flushing, heat sensation, sedation, burning at IV site (normal with magnesium sulfate).

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Nursing Care

• Monitor: Level of consciousness, pulse oximetry, urine output, daily weight, and I&O.

• Blood Pressure (BP): Use correct cuff size, avoid talking to the client during measurement.

• Encourage: Lateral positioning (left side).

• Fetal Monitoring: Perform Non-Stress Test (NST) and daily fetal kick counts.

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Client Education

• Bed Rest: Stay in side-lying position to improve circulation.

• Diversional Activities: Engage in TV, gentle exercise, and social interactions to reduce stress.

• Limit sodium/caffeine, no ETOH/tobacco, hydrate (6-8)

• Avoid loud and light rooms

• Importance of daily low-dose aspirin (if history of early-onset preeclampsia).

• Monitor fetal movements (kick counts).