Complicated Pregnancy & High-Risk Antepartum; Ch 19-21

What is the simple high-risk pregancy framework?

• Recognize cues: Vital signs, symptoms, bleeding/fluid loss, labs, fetal status

• Name the threat: Perfusion, oxygenation, infection, hemorrhage, seizure, preterm birth

• Stabilize first: Maternal ABCs, urgent medications, IV access, monitoring, escalation

• Plan forward: Fetal surveillance, delivery timing, teaching, resources, follow-up

What are the spectrum of hypertensive disorders ?

• Chronic hypertension: Present before pregnancy, before 20 weeks, or known preexisting hypertension.

• Gestational hypertension: New BP ≥140/90 after 20 weeks without proteinuria or other preeclampsia features.

• Preeclampsia: New hypertension after 20 weeks with proteinuria and/or evidence of maternal organ dysfunction.

• Preeclampsia with severe features: Severe-range BP and/or significant neurologic, hepatic, renal, hematologic, or pulmonary findings.

• Eclampsia: New-onset seizure in a patient with preeclampsia when another cause is not more likely.

• Severe hypertension: systolic ≥160 and/or diastolic ≥110 mm Hg → urgent confirmation and treatment per protocol.

What is the pathophysiology of preeclampsia: connect pathophysiology to the symptoms?

• The placenta initiates a systemic maternal endothelial disorder.

• There is abnormalities in the vasculator when it originally develops thus leading to endothelial function

• Abnormal placentation: Impaired trophoblastic remodeling → reduced uteroplacental perfusion.→ Endothelial dysfunction: Inflammatory and vascular signaling affects vessels throughout the body.→ Vasoconstriction + leak: Higher vascular resistance + capillary leak → edema and reduced effective perfusion. →Organ / placental injury: Brain, liver, kidney, lungs, platelets, uteroplacental; circulation can be affected.

• Clinical translation: headache/visual change = brain • RUQ/epigastric pain = liver • oliguria = kidney • dyspnea = pulmonary edema • abnormal fetal growth/tracing = placental disease

What are the severe features of preeclampsia that indicate organ injury?

• BP: Persistent severe-range BP ≥160 systolic or ≥110 diastolic

• Brain: Severe persistent headache or visual symptoms

• Liver: Severe RUQ/epigastric pain or abnormal liver function

• Kidney: Worsening renal function / reduced urine output

• Lungs: Pulmonary edema or new respiratory compromise

• Blood: Thrombocytopenia / HELLP pattern

• Nursing habit: symptoms + BP + labs + fetal status are interpreted together—not one cue at a time.

What should nurses do to assess and care for severe preeclampsia?

• Immediate assessment

  • Repeat/confirm severe BP appropriately

  • Focused neuro + respiratory assessment

  • Pain, bleeding, edema, reflexes, urine output

  • Continuous fetal assessment when appropriate

• Prepare + intervene

  • Notify/activate severe-hypertension pathway

  • IV access; CBC/platelets, creatinine, liver tests, urine studies as ordered

  • Give urgent antihypertensive medication per protocol

  • Begin magnesium sulfate when indicated

    • smooth muscle relaxant → to prevent seizure → too much check for resp. distress

• Anticipate

  • Seizure precautions and quiet environment

  • Strict I&O / fluid awareness

  • Corticosteroids if preterm birth is anticipated and appropriate

  • Possible delivery if maternal or fetal condition worsens

• Do not delay escalation while waiting for every laboratory result if the patient has severe symptoms or severe-range BP.

• Persistant low fetal hr indicates poor perfusion

Magnesium sulfate: Purpose, monitoring, toxicity

• Why we give it

  • Seizure prophylaxis in severe preeclampsia → Prevent seizure & stop contractions (tocolytic)

  • Treatment/prevention of recurrent eclamptic seizures

  • Also used in selected early preterm birth situations for fetal neuroprotection

  • It is NOT the primary medication for lowering severe blood pressure.

    • Would given antihypertensive to lower bp like labetalol is commonly given in preeclampsia

• What to monitor

  • Respiratory rate and effort

  • Deep tendon reflexes

  • Level of consciousness

  • Urine output / renal function

  • Maternal vital signs + fetal status

  • Infusion rate and concurrent medications

  • Can be fall risk b/c relaxing muscle

• Toxicity cues

  • Depressed or absent reflexes

  • Respiratory depression

  • Progressive weakness / decreased LOC

  • Low urine output can increase risk of accumulation

  • Stop infusion / escalate per protocol

  • Calcium gluconate is the antidote.

• Two medications may be needed: magnesium prevents seizures; antihypertensives treat severe blood pressure.

Pregestantional diabetes v. Gestational diabetes

• The nursing priorities overlap, but timing of hyperglycemia changes fetal risk.

• Pregestational diabetes

  • Type 1 or type 2 diabetes exists before pregnancy.

  • Early-pregnancy glycemic control matters because organ

  • development is occurring.

  • Pregnancy changes insulin needs and can worsen vascular/renal disease.

  • Requires close maternal and fetal surveillance throughout pregnancy.

• Gestational diabetes

  • Hyperglycemia first recognized during pregnancy in a patient without known preexisting diabetes.

  • Pregnancy hormones increase insulin resistance.

  • For most patients not diagnosed earlier, screening occurs at 24–28 weeks.

  • Nutrition, activity, glucose monitoring, and medications as needed reduce risk.

• Key distinction: congenital anomaly risk is linked mainly to significant hyperglycemia during early organogenesis in pregestational diabetes.

How does maternal glucose control affect the fettus and what are the concerns?

• Maternal hyperglycemia

  • Glucose crosses the placenta.

• Fetal hyperglycemia

  • Fetal pancreas increases insulin production.

• Fetal hyperinsulinemia

  • Promotes excess growth and changes neonatal transition.

• Maternal concerns

  • Preeclampsia / hypertension

  • Polyhydramnios

  • Operative birth / birth trauma risk

  • Future type 2 diabetes after GDM

• Fetal concerns

  • Large-for-gestational-age growth

  • Shoulder dystocia risk

  • Stillbirth risk rises with poor control

  • Pregestational DM: congenital anomalies with poor early control

• Newborn concerns

  • Hypoglycemia after cord is cut

  • Respiratory transition concerns

  • Jaundice / polycythemia may occur

  • Feeding + glucose monitoring are priorities

How is gestational diabetes managed?

• The nurse translates glucose data into practical daily behaviors and escalation.

• Monitor

  • Self-monitor blood glucose as prescribed

  • Bring logs / device data to visits

  • Look for patterns, not one isolated value

• Eat + move

  • Individualized meal pattern

  • Regular meals/snacks as directed

  • Safe activity when not contraindicated

• Medication

  • Medication when lifestylemeasures do not meet targets

  • Insulin is commonly used during pregnancy

  • Teach injection and hypoglycemia safety

• Follow through

  • Growth / fetal surveillance based on treatment and control

  • Birth planning individualized

  • Postpartum glucose testing + long-term prevention

  • Teaching goal: make the plan doable in the patient’s real life—work, food access, culture, cost, family support, and health literacy all matter.

How does pregestational diabeties change in pregnancy?

• More surveillance is needed because diabetes affects multiple maternal systems.

• Before / early pregnancy

  • Optimize glucose control when possible

  • Review medications and comorbidities

  • Assess renal, retinal, cardiovascular, thyroid status as appropriate

• Across pregnancy

  • Insulin needs may shift by trimester

  • Watch closely for hypoglycemia and hyperglycemia

  • Monitor BP, fetal growth, and fetal well-being

• Birth + postpartum

  • Coordinate intrapartum glucose management

  • Insulin needs typically fall sharply after

  • placental delivery

  • Support breastfeeding and long-term diabetes care

• Nursing risk check: vomiting + diabetes in pregnancy can become dangerous quickly—assess hydration, glucose, ketones, and signs of DKA per protocol.

Third Trimester bleeding: Placenta previa v abruption?

• Pain pattern helps—but maternal and fetal status always come first.

• Placenta previa- Typical pattern

  • Placenta lies low and may partially or completely cover the cervix.

  • Bleeding is classically painless and may be bright red.

  • Ultrasound establishes placental location.

  • Persistent previa can require cesarean birth.

• Placenta abruption- Typical pattern

  • Placenta separates from the uterine wall before birth.

  • Bleeding often occurs with abdominal/back pain, tenderness, or frequent contractions.

  • Blood may be visible OR concealed.

  • Maternal hemorrhage, fetal hypoxia, and coagulopathy can develop rapidly.

• Never let “amount of visible blood” be the only severity measure—abruption can bleed behind the placenta

• ‘Placenta accreta: placenta grows too deeply into the uterine wall and fails to detach normally after childbirth

How is placenta previa treated to protect against provoking hemorrhage?

• Diagnosis and severity guide observation versus delivery planning.

• Assess

  • Maternal VS and symptoms

  • Amount/color of bleeding

  • Fetal heart rate and activity

  • Contractions / uterine activity

  • Hemodynamic signs may precede dramatic visible loss

• Prepare

  • IV access if significant bleeding

  • CBC, type & screen / crossmatch as ordered

  • `Ultrasound to define placental location

  • Avoid unnecessary cervical manipulation

  • Prepare blood / OR resources if unstable

• Teach / anticipate

  • Report any recurrent bleeding promptly

  • Activity recommendations are individualized

  • Delivery plan depends on placental location and bleeding

  • Persistent placenta covering the cervix → cesarean delivery

• If placenta previa is suspected in a bleeding patient, clarify placental location before a routine digital cervical examination.

How is placenta abruption treated (nursing priorties)?

• Recognize cues

  • Sudden abdominal or back pain

  • Uterine tenderness / rigidity

  • Frequent contractions

  • Vaginal bleeding may be present or absent

• Assess severity

  • Maternal tachycardia/hypotension

  • Increasing pain or shock signs

  • Nonreassuring fetal status

  • Falling fibrinogen / coagulopathy may emerge

• Nursing priorities

  • Rapid maternal and fetal assessment

  • IV access, labs, type/crossmatch, and hemorrhage readiness

  • Continuous fetal monitoring when viable

  • Oxygen/supportive measures as clinically indicated

  • Escalate rapidly; anticipate urgent birth if maternal or fetal status is unstable

  • Prepare for DIC / massive transfusion pathways in severe cases

Define PROM, PPROM, & preterm labor

• PROM

  • Rupture of membranes before labor begins.

  • At term, the major concern is timing of labor and infection risk as the interval lengthens.

  • Term PROM is ≥37 weeks.

• PPROM

  • Preterm prelabor rupture of membranes: membranes rupture before labor AND before 37 weeks.

  • Major concerns: infection, cord complications, fetal compromise, and preterm birth.

• Preterm labor

  • Regular uterine contractions with cervical change before 37 weeks.

  • Membranes may be intact or ruptured.

  • Management depends on gestational age, maternal/fetal status, and contraindications to prolonging pregnancy.

• Question to ask first: “Did the membranes rupture? Is labor present? How many weeks?”

How is suspected rupture of membranes assesed without increasing risk?

• Confirm the story, maternal status, and fetal response.

• History

  • Time of gush or ongoing trickle

  • Color / odor / amount

  • Contractions, bleeding, pain

  • Fetal movement

  • Recent intercourse / exam / trauma

  • Gestational age + GBS status if known

• Assessment

  • Maternal temperature and vital signs

  • Fetal heart rate

  • Uterine activity / tenderness

  • Sterile speculum evaluation as ordered

  • Tests for amniotic fluid per facility protocol

  • Minimize digital cervical exams when PPROM is possible

• Escalate for

  • Fever / uterine tenderness

  • Fetal tachycardia or nonreassuring status

  • Heavy bleeding / concern for abruption

  • Cord prolapse or abnormal presentation

  • Active labor

  • Maternal instability

How is prematurity risk with PPROM infection risk managed?

• The goal is not “keep pregnant at all costs.”

• Maternal + fetal surveillance

  • Temperature, symptoms, uterine tenderness

  • FHR and fetal movement

  • Contractions / bleeding

  • Labs only when clinically useful

• Prepare the fetus

  • Antenatal corticosteroids when preterm birth risk and gestational age meet criteria

  • Magnesium sulfate for fetal neuroprotection in selected early preterm birth risk

• Prevent / treat infection

  • GBS testing and intrapartum prophylaxis as indicated

  • Latency antibiotics are used in appropriate expectant PPROM management

  • Suspected intraamniotic infection changes the plan

• Know when expectant management stops

  • Maternal infection

  • Significant hemorrhage / abruption

  • Nonreassuring fetal status

  • Active labor or other obstetric indication for delivery

• Management is gestational-age and condition dependent—students should know the purpose of each intervention, not memorize one universal timeline.

What are some medications used in pregnancy for different goals?

• Fetal Preperation: Betamethasone / corticosteroids

  • Goal: accelerate fetal lung and organ maturation when preterm birth is anticipated within an appropriate window.

• Two Purposes: Magnesium sulfate

  • Goal A: prevent/treat eclamptic seizures in severe hypertensive disease.

  • Goal B: fetal neuroprotection before selected early preterm births.

• Buy Time: Tocolytic therapy- stop or slow down contractions to delay preterm labor

  • Goal: short-term delay of preterm birth in selected patients so other treatments/transfer can occur.

  • Not appropriate when delaying birth is unsafe.

• Clinical judgment question: “Is prolonging this pregnancy safer than delivery right now?”

Rh incompatibility Patho

• The goal is prevention of maternal sensitization.

• Rh-negative patient; No anti-D antibodies initially. → Exposure to Rh-positive RBCs; Fetomaternal blood mixing can occur with birth, bleeding, trauma, or procedures. → Maternal anti-D antibodies; Without prophylaxis, immune sensitization can occur. → Future fetal RBC injury; Maternal antibodies cross the placenta and can cause fetal/newborn hemolytic disease.

• Rho(D) immune globulin supplies passive anti-D and prevents sensitization. It does not remove antibodies once the patient is already sensitized.

What should nurses consider with Rho(D) immune globulin?

• Ask: could fetal Rh-positive blood have entered maternal circulation?

• Routine prevention

  • Unsensitized Rh-negative patient

  • Antepartum prophylaxis around the usual third-trimester timing

  • After birth if the newborn is Rh-positive, with the recommended window

  • Confirm antibody-screen and newborn testing results

• Potential sensitizing events

  • Pregnancy bleeding

  • Abdominal trauma

  • Amniocentesis / CVS

  • External cephalic version

  • Pregnancy loss / termination depending

  • gestational age and current guidance

  • Other fetomaternal hemorrhage risk

• Nursing checks

  • Correct patient + Rh status

  • Verify patient is not already sensitized

  • Dose may depend on gestation / volume of fetomaternal hemorrhage

  • Document indication and administration

  • Teach: this is prevention for current/future pregnancies

• Important nuance: recommendations for RhIG in pregnancy loss before 12 weeks have changed—follow current institutional and obstetric guidance.

What are some risks that can come from physiology, medications, mental health, substance use, or structural barriers in pregnancy?

• Medical complexity

  • Cardiac, renal, autoimmune, endocrine, infectious, neurologic or other chronic conditions may destabilize during pregnancy.

• Age / body / obstetric factors

  • Advanced maternal age, obesity, multifetal pregnancy, prior complications, or assisted reproduction may increase surveillance needs.

• Mental health + substance use

  • Screen routinely and nonjudgmentally; untreated illness and abrupt medication changes can both carry risk.

• Social / structural risk

  • Housing, transportation, food access, intimate partner violence, insurance, work leave, language and health literacy can shape outcomes.

• Nursing stance: screen → ask what matters → reduce stigma → coordinate care → make the plan realistic and safe.