Pregnancy & LD Complications

OLDCARE

used to assess complex symptoms

onset

location

duration

characteristics

aggravating factors

relieving factors

treatments tried 

Assess

vital signs

pulse O2 and symptoms of oxygenation

mental status

tissue perfusion

fetal status 

bleeding and assess for DIC

urine output (consider foley)

labwork and testing

Managing Crisis

repeat assessments of appropriate intervals → Q5/15/1hour

keep provider informed of status changes

remember the patient and family may be scared and need info/support so do not offer false reassurance

consider assigning a scribe to document

call for additional personnel until patient is stable

effective communication and teamwork are essential

Maternal Mortality

leading cause of death in immediate postpartum period is hemorrhage

leading cause of death if including entire pregnancy and first year postpartum is cardiovascular conditions

other causes → HTN, infections, amniotic embolism, other direct and indirect (trauma, suicide, drug overdose)

First Trimester Complications

ectopic pregnancy

miscarriage 

hydadtiform mole pregnancy 

hyperemesis gravidarum 

Ectopic Pregnancy

gestation implanted outside the uterus in fallopian tubes, ovary, cervix, or abdomen

in women 20-29 years of age usually

2% of all pregnancies in the US (higher in non whites and increase with age) and incidence has tripled due to increased STDs and pelvic inflammatory disease and IUDs

responsible for 10% of maternal mortality and most common cause of maternal mortality before 20 weeks

25% of pregnancies after ectopic will result in another ectopic

Ectopic Risks

pelvic inflammatory disease and endometriosis 

use of IUDs

tubal surgery, tumors, or congenital tubal anomalies (accessory tubes or long tubes)

history of previous ectopic, abdominal/pelvic surgery, appendicitis or therapeutic abortio/infertility

Ectopic Signs

abdominal pain → vague, colicky, cramping and can be localized to the left or right pelvic area or may be bilateral

amenorrhea

abnormal vaginal bleeding

swelling in one leg

shoulder pain

Ectopic Treatment

if fallopian tube is intact it can be surgically fixed or the patient can be given methotrexate (chemo agent) to dissolve the pregnancy but maintain tube patency and potential fertility

if tube ruptures symptoms include abdominal pain, N/V, dizziness, and hypovolemic shock → needs surgery

Early Miscarriage

spontaneous abortion occurring before 12 weeks 

Late Miscarriage

spontaneous abortion occurring between 12 and 20 weeks

Habitual Abortion

when a women has three or more consecutive spontaneous abortions

Chromosomal Aberrations 

estimated that as many at 50% of spontaneous abortions

most common is autosomal trisomies 

Threatened Abortion

suggested when a women experiences vaginal spotting or bleeding early in pregnancy

occurs in approx 20% of all diagnosed pregnancies, half abort

cervix is not dilated and the placenta is still attached to the uterine wall but some bleeding occurs

Inevitable Abortion

occurs when the cervix has begun to dilate and uterine contractions are painful and vaginal bleeding increases

membranes rupture as the process proceeds

type cannot be prevented bc placenta has separated from the uterine wall, cervix has dilated, and bleeding has increased

Incomplete Abortion

occurs when cervical dilation results in partial expulsion of the products of conception with some products retained in the uterus 

excess vaginal bleeding occurs and risk of infection increases

embryo or fetus has passed out of the uterus but the placenta remains

Complete Abortion

all products of conception are entirely expelled

very few physical complications occur but emotional support is necessary

Septic Abortion

immediate termination of pregnancy by method appropriate to duration of pregnancy

cervical culture and sensitivity studies are done and broad spectrum antibiotic therapy is needed

treatment for septic shock is initiated if necessary

Missed Abortion

the fetus dies but continues to be retained in the uterus 8 weeks or longer

Autolysis

after 4 weeks with an infant dead within the mother

dead cells start to release enzymes that cause the breakdown of clotting factors and can lead to DIC in the mother

Habitual Abortion

a purse string suture called a shirodkar (cerclage) or mcdonald procedure may be done to close the cervix temporarily or permanently

Trophoblastic Disease

developmental error of placenta causes the development of cyst like clear vesicles resembling a bunch of grapes

two types → complete or partial

1/1000 pregnancies, age of 45 is 10x higher

Complete Trophoblastic

all vesicles and no fetus

Partial Trophoblastic

has vesicles and a rarely viable fetus

usually benign but can be a choriocarcinoma → rapid growing cancer form with a high rate of cure

Molar Pregnancy Symptoms

apparently normal during first trimester 

uterine bleeding is the most outstanding sign → brownish (prune juice like)

possible anemia

shortness of breath

uterine size often exceeds fundal heigh expected for gestation

fetal activity and FH tones absent

hyperemesis gravidarum common

preeclampsia develops before 24 weeks

very high levels of serum hCG levels

Molar Pregnancy Diagnosis

ultrasound confirms and requires immediate evacuation of the pregnancy and follow up chemo if malignant

serum hCG levels are monitored until normal

non pregnancy levels of hCG achieved to watch for placental tissue growth in the body

baseline xray of lungs taken and compared to pre evacuation xray

pregnancy should be avoided for 1 year

Hyperemesis Gravidarum

increased or prolonged nausea and vomiting in pregnancy potentially affecting the mother and fetus

likely caused by a combo → related to high or rapidly increasing levels of hCG or estrogens, transient hyperthyroidism noted

physiological and social factors like family conflict may play a role

Hyperemesis Gravidarum Treatment

IV therapy initiated to treat dehydration → measure urine output to assess need

small frequent feedings as tolerated, high calorie tube feedings optional

antiemetics often like zofran, reglan, phenergan, scopolamine

acupressure has been used successfully

Second and Third Trimester Complications

lacerations

pulmonary embolus

cephalo pelvic disproportion

cord prolapse

fetal distress

shoulder dystocia

also → HTN disorders, DM, preterm labor, hemorrhages, hyperemesis gravidarum, vasa previa, and uterine rupture

HTN Disorders 

BP over 140/90

a rise of 30 in systolic over baseline

mean arterial BP over 105

Pregnancy Induced HTN

HTN without proteinurea that develops after 20 weeks or within the first 24 hours after delivery

this superimposed on a previous HTN state results in a worsening of HTN

Preeclampsia

at least two of three of the classic triad → elevated BP, proteinurea, and edema

Eclampsia

when preeclampsia progresses to develop seizures

HELLP Syndrome

hemolysis, elevated liver enzymes, and low platelets

often with elevated BP

severe disorder that can be life threatening

HTN Factors

fetal hydrops → fluid buildup in fetus

maternal age over 35

nulliparity

history of preeclampsia in self or family 

hydadtiform mole

multiple pregnancy

chronic HTN

diabetes

Preeclampsia Signs

edema 

proteinurea 

elevated BP

headaches or nosebleeds

nausea, vomiting, epigastric pain

visual disturbances

hyperreflexia 

oliguria 

Preeclampsia and HELLP

mechanism of damage is severe vasospasm that can damage placenta, liver, kidneys, and brain

HELLP is a critical situation requiring close monitoring in ICU

HTN Management

bedrest in restful environment

close monitoring or status

delivery if necessary (true cure)

MgSO4

beta blockers (labetolol)

antihypertension meds (apresoline)

Gestational Diabetes 

develops progressively as the pregnancy puts additional demands on the mothers system → 2-5%

patients are screened at 28 weeks gestation with a 1 hour glucose screen than a 3 hour glucose screen if first is abnormal 

some patients are able to be controlled by diet alone others will require insulin

first diagnosed during pregnancy, there is impaired glucose tolerance and increased insulin resistance

mothers pancreas is challenged by normal changes in pregnancy and cannot respond to needs

both maternal and fetal hyperglycemia occur, 40% change it may develop into DM

reclassify individual after delivery (breastfeeding) 

oral hypoglycemic agents not used in pregnancy because of potential teratogenic effects 

Gestational Diabetes Risks

obesity

family history of diabetes

ethnicity → hispanic, african american, and asian

advanced maternal age over 25

prior GDM or LGA 

Diabetes Effects

PIH

polyhydramnios

macrosomia (LGA)

intrauterine growth restriction (IUGR)

stillbirth

congenital anomalies → heart, CNS, skeletal

infections

ketoacidosis

Diabetes Diagnosis

glucose tolerance test (1 hr) at 24-28 weeks → under 135 is normal

3 hour test if elevated

two or more elevated levels is considered diagnostic

glycosylated hemoglobin HbA1C

HBA1C

reflects control over past 4-12 weeks

measures % of blood Hb that has glucose attached 

normal is 6-8% glycosylated 

Preterm Labor

labor between 20-37 weeks

risks → history of preterm, HTN, placental abnormality, PROM, amniotic fluid abnormality, low socioeconomic status, maternal age under 18 or over 40, low pre-pregnancy weight, non white, and multiple pregnancy

short interval between pregnancies, low/excess weight gain, previous laceration of cervix/uterus, maternal infection or medical condition, smoking, alcoholism or drug addiction, severe anemia, maternal trauma/burns, uterine abnormalities, cervical incompetence

Preterm Labor Treatment

bedrest

tocolysis to minimize contractions 

corticosteroids to accelerate fetal lung maturity

antibiotics 

Bleeding Issues

placenta previa

placenta abruptio

vasa previa

uterine rupture

lacerations 

Placenta Previa

the placenta implants in the lower uterine segment, either partially or totally covering the cervix 

delivered by C/S at 37 weeks if not before 

vaginal exams are not done on a women with a known placenta previa or on women with heavy vaginal bleeding and known placental location

blood loss for mother and infant can be substantial

Placenta Previa Signs

sudden onset of painless bleeding or hemorrhage

may be accompanied by contractions

Placenta Previa Risks

multiparity

maternal age over 35

multiple pregnancy

erythroblastosis

previous uterine surgery

smoking

previous placenta previa

previous therapeutic abortion

Placenta Abruptio

premature seperation of the normally implanted placenta

may be partial or complete

bleeding may be obvious or concealed behind the placenta 

warrants very close observation or c section

blood loss for mother and infant can be substantial

Placenta Abruptio Signs

board like abdomen

severe relentless abdominal pain out of proportion to labor

back pain

colicky discoordinate uterine contractions 

tetanic contraction 

bleeding

pain localized or generalized

FHR periodic changes late, variable, prolonged, sinusoidal 

loss of variability

aggressive fetal movement 

increasing fundal heaight

maternal shock

may not show on ultrasound

Placenta Abruptio Factors

maternal HTN

preeclampsia

folic acid deficiency

severe abdominal trauma

short umbilical cord

malnutrition

sudden decrease in uterine size

maternal age over 35

rough or difficult external version

cocaine or crack use

Vasa Previa

shearing of the umbilical vessels in utero

usually vessels are abnormally implanted and cross the membranes off the surface of the placenta, they can shear at ROM

infant will bleed, because they have a small circulating blood volume they can bleed to death very quickly

be suspicious if you see very dark red blood with ROM associated with changes in FHR → need immediate c section

Uterine Rupture

can be partial or complete 

potentially catastrophic for mother and baby bc it often involves simultaneous abruption of the placenta 

risks → previous uterine surgery (#1), trauma, uterine over distension, uterine abnormalities, placenta percreta, choriocarcinoma 

Cephalo Pelvic Disproportion

also called dystocia or CPD

maternal bony pelvis is often a factor

soft tissue dystocia can occur in the obese

fetal positioning can play a role

CPD Signs

arrest of dilation or descent

abnormal labor patterns

acute maternal discomfort

maternal exhaustion

early FHR decelerations

CPD Interventions

reposition

assess labor pattern

assess fetal status 

keep MD appraised of progress or lack of 

keep hydrated 

consider analgesia or anesthesia 

Cord Prolapse

occurs when the umbilical cord escapes beyond the presenting part and becomes trapped between the presenting part and the bony pelvis

blood vessels in the cord become compressed and infant can become hypoxic

immediate c section is needed

Cord Prolapse Care

one person must do a continuous vaginal exam and hold the head up off the cervix

put the patient in trendelenburg or knee to chest

prepare for immediate c section

IV bolus

O2 via mask

prepare for resuscitation of the infant

Fetal Distress

diagnosed with electronic fetal monitoring

various causes like placental insufficiency, severe cord compression, hyperstimulation of uterus, and fetal exhaustion 

decelerations in FHR pattern can give indications of the cause → if not corrected deliver the baby via c section 

Fetal Distress Interventions

reposition the patient

increase IV rate

administer O2

assess labor progress

assess for cord prolapse

notify MD

prepare for delivery and resuscitation

turn off pitocin

Shoulder Dystocia

most cases involve the anterior shoulder impacting on the anterior pubic bone

some involve the posterior shoulder impacting on the sacral prominence

turtle sign is a classic retreating of the fetal head after it has been delivered

single most common risk of use of vacuum extractor or forceps 

incidence is based on fetal weight, equal in primigravida and multigravida but more common if mom has DM

Shoulder Dystocia Risks

maternal → abnormal pelvic anatomy, gestational diabetes, post dates pregnancy, previous dystocia, short stature 

fetal → suspected macrosomia 

labor related → assisted vaginal (forceps or vacuum), protracted active phase of first stage labor, or protracted second stage labor

Shoulder Dystocia Complications

maternal → hemorrhage, rectovaginal fistula, symphyseal separation or diathesis with/without transient femoral neuropathy, third/fourth degree tear, uterine rupture

fetal → brachial plexus palsy, clavicle fracture, fetal death, fetal hypoxia, and fracture of humerus

Shoulder Dystocia Prevention

encourage weight gain within normal range

induction of labor with larger infants

elective c section

good control of DM

Shoulder Dystocia Maneuvers 

delivers through the anterior shoulder

McRoberts → hyper flexion of maternal hips bilaterally 

episiotomy 

suprapubic pressure

rotational maneuvers → internal maneuver to rotate shoulder off pubic bone (rubin 2, woods, reverse woods) 

deliver the posterior shoulder

reposition the mother in knee to chest 

extreme → deliberate clavicle fracture, zavanelli, anesthesia, hysterotomy, or symphysiotomy

Zavanelli Maneuver 

cephalic replacement followed by c section

General Anesthesia SD

musculoskeletal or uterine relaxation with halothane (fluthane) or general anesthetic may bring about enough uterine relaxation to affect delivery

oral or IV nitroglycerin may be used as an alternative to general

Hysterotomy

general anesthesia is induced and c section preformed after which the surgeon rotates the infant transabdominally through the incision allowing shoulder the rotate like corkscrew

vaginal extraction is then done

Symphysiotomy 

intentional incision of the fibrous cartilage of the symphysis pubis under local anesthesia has been used more widely in developing countries than north america

should be used only when all other options have failed and c section is unavailable 

Postpartum Hemorrhage

common can can occur without risks factors in 20% of patients

cause of ¼ of maternal deaths worldwide and 12% of deaths in US

PPH Risks

antepartum hemorrhage

augmented labor

chorioamniotis

fetal macrosomia

maternal anemia

maternal obesity

multifetal gestation

preeclampsia

primiparity

prolonged labor

PPH Assessment

heavy bright red blood flow, normal loss is up to 500cc vaginal and 100cc c section → save all pads and chux

fundal assessment is firm (contracted) or flaccid (boggy) → massage fundus in a circular pattern if not well contracted

changes in VS → low BP, elevated pulse

lightheadedness, nausea, air hunger, changes in orientation/alertness

changes in labs → H&H, platelets, coagulation profile, D-dimer

PPH Causes

4 Ts 

tone → uterine atony 

trauma → laceration, hematoma, inversion, rupture

tissue → retained tissue or invasive placenta 

thrombin → coagulopathy 

PPH Management

uterine atony is common cause start assessment of the fundal contraction and do fundal massage if not well contracted

pitocin is first line med used via IV but can be given IM if needed

repeat fundus, flow, and VS assessments → initially every 5-15 mins depending on severity of hemorrhage

initial a team respone

PPH Complications

anemia

anterior pituitary ischemia with delay or failure of lactation (sheehan syndrome)

blood transfusion

death

dilutional coagulopathy (loss of clotting factors)

fatigue

myocardial ischemia

orthostatic hypotension

postpartum depression

Lacerations

types → perineal, periurethral, vaginal, cervical, cervical uterine 

responsible for 20% of postpartum hemorrhages → called sulcus tears 

periurethral are usually first degree

classified by both depth and tissues involved → 1st, 2nd, 3rd, 4th degree

vagina and cervix must be examined, repair vaginal before perineal

highly vascular area prone to hematoma formation

care must be taken to compress bleeding vessels as repair progresses to prevent hematomas 

1st Degree

involves the perineal skin and vaginal mucosa membrane 

2nd Degree

involves the perineal skin and vaginal mucosa membrane and muscles of the perineum body

rectal sphincter remains intact

3rd Degree

involves the perineal skin, vaginal mucosa membrane, and muscles of the perineum body and through the rectal sphincter

4th Degree

involves the perineal skin, vaginal mucosa membrane, muscles of perineum body, through the rectal sphincter, and through the rectal mucosa

Cervical Lacerations

can be an extension of a vaginal laceration and can extend up into the lower segment of the uterus or be confined to the cervix itself

most common sites are at 3 and 6 clock → most common with forceps/vacuum

cervix is highly vascular so there can be significant blood loss

can damage the integrity of the cervix and its ability to maintain future pregnancies 

Amniotic Fluid Embolus

pulmonary embolus → bilateral and extensive

severe and life threatening with 60-80% mortality

usually near to or after delivery

sudden and severe respiratory distress, hypoxia, altered mental status, pain hypotension, shock and arrest

needs to manage with 100% O2, aggressive IV fluids, hypotensive meds ASAP → may need ventilator

Intrapartum Postpartum Infections

amnionitis

endometritis aka chorioamnionitis

mastitis

Endometritis 

an inflammation of the endometrium occurs more often in c section

both anaerobic and aerobic bacteria can cause this

Endometritis Signs

lochia foul smelling, bloody, scant, or perfuse amounts

fever

tachycardia

chills

uterine tenderness

Endometritis Risks

C section (risk 20x higher)

prolonged premature rupture of membranes

prolonged labor preceding c section

multiple vaginal exams in labor

compromised health status (anemia, low se status, tobacco, drugs/alcohol)

use of internal FHR or contraction monitor

obstetric trauma (lacerations or episiotomy)

diabetes (4x more likely)

preexisting bacterial vaginosis or chlamydia 

instrument delivery (vacuum or forceps) 

manual removal of placenta

lapses in sterile technique 

Mastitis

an infection of the connective tissue that occurs primarily in lactating women

Mastitis Signs

redness (often wedge shaped because of septal division in breast)

swelling and warmth at site with pain

fever and headache

flu like symptoms

leukocyte count over 1 million or bacterial colony count over 10,000

Mastitis Risks

milk stasis

failure to change feeding position or alternate breasts

poor suck or poor letdown

actions that promote bacteria → poor handwashing and breast hygiene, failure to air dry breasts after feed, and use of plastic lined breast pads (trap moisture)

change in number of feedings that don’t empty breast

lowered maternal defenses → fatigue and stress

breast and nipple trauma → poor latch or aggressive pumping

obstruction of ducts → restrictive clothing like bras