Week 5- Childbearing at Risk Nursing Management of Pregnancy at Risk: Pregnancy Related Complications

CH 19-20

when does a spontaneous abortion occur?

Occurs before 20 weeks gestation

what are the causes of spontaneous abortions? first trimester? Second trimester?

first trimester commonly due to fetal genetic abnormalities

Second trimester more commonly due to maternal conditions

what are the signs and symptoms of spontaneous abortions? (4)

• vaginal bleeding

• Cramping or contractions

• Altered vital signs

• Pain

what are the signs and symptoms of threatened abortions? (5)

• vaginal bleeding, often slight, early on in pregnancy 

• No cervical dilation or changes in cervical consistency 

• Mild abdominal cramping 

• Closed cervical os 

• No passage of fetal tissue 

what are the signs and symptoms of inevitable abortions? (4)

• Vaginal bleeding, greater than that associated with threatened abortions 

• Rupture of membranes 

• Cervical dilation 

• Possible passage of products of conception 

what is an incomplete abortion?

Passage of some products of conception

what are the signs and symptoms of incomplete abortions? (5)

• intense abdominal cramping

• Heavy vaginal bleeding

• Cervical dilation

What is a complete abortion?

passage of all products of conception

what are the signs and symptoms of complete abortions? (2)

• history of vaginal bleeding and abdominal pain 

• Passage of tissue with subsequent decrease in pain and a significant decrease in vaginal bleeding 

What is a missed abortion?

nonviable embryo retained in utero for at least 6 weeks

what are the signs and symptoms of missed abortions? (3)

• absent uterine contractions

• Irregular spotting

• Possible progression to inevitable abortion

what is a recurrent abortion?

history of 3 or more consecutive spontaneous abortions

Not carrying the pregnancy to viability or term

What are the nursing priorities for spontaneous abortions?

1. Continued monitoring- vaginal bleeding, pad count, passage of products of conception, pain level, risk for hemorrhage

2. Support- physical and emotional, grief support

3. Treatment

   1. Incomplete, inevitable, and missed- surgery (D&C) or meds (cytotec or oxytocin)

   2. Rh neg- rhogham- so antibodies do not develop

What is an ectopic pregnancy?

ovum implantation outside of the uterus

where is the most common location of an ectopic pregnancy?

fallopian tubes

what is the therapeutic management for an ectopic pregnancy? (3)

1. Drug therapy- methotrexate, prostaglandins, misoprostil, -mycin antibiotics

2. Surgery if rupture occurs ← often lose the fallopian tube

3. Rh immunoglobulin if woman is Rh negative

what is the hallmark sign of an ectopic pregnancy?

abdominal pain with spotting within 6-8 weeks after missed menses ← very early on

What are the risk factors that make a woman more susceptible to an ectopic pregnancy? (4)

1. Previous ectopic pregnancy

2. Hx of STIs 

3. Pelvic Inflammatory Disease (PID)

4. Endometriosis  

What are the nursing priorities for an ectopic pregnancy? (4)

1. Pain management

2. Prepare for treatment

   1. Administer meds

   2. Prep for surgery

3. Teach about s/sx

4. Emotional support

What is the therapeutic management of gestational trophoblastic disease? (2)

1. Immediate evacuation of uterine contents (D&C)

2. Long term follow ups and monitoring of serial hCG levels

What are the signs and symptoms of gestational trophoblastic disease? (4)

Clinical manifestations similar to spontaneous abortion at 12 weeks

1. High hCG levels

2. Brownish vaginal bleeding

3. Uterine size larger than expected for dates

4. No FHR → no baby

what is cervical insufficiency?

premature dilation of the cervix; spontaneous dilation without uterine contractions

what is the therapeutic management for cervical insufficiency?

bed rest, pelvic rest, avoid heavy lifting

Cervical cerclage → suture around the suture done at 18-19 wks; not always effective but can help sometimes

What are the risk factors for cervical insufficiency?

incompetent cervix

what are the signs and symptoms of cervical insufficiency? (3)

1. pink-tinged vaginal discharge

2. Pelvic pressure

3. Cervical shortening via transvaginal ultrasound  

what is the nursing priority for managing a pt with cervical insufficiency?

continuing surveillance and close monitoring for preterm labor ← remove cerclage with full labor or at 35-37 wks to avoid injury

what is placenta previa?

placenta implants over the cervical os

What does the therapeutic management of a placenta previa depend on? (5)

dependent on…

1. Bleeding

2. Amount of placenta over os

3. Fetal development and position

4. Maternal parity

5. Labor s/sx

What are the risk factors for developing a placenta previa? (4)

1. Prior previa

2. Maternal age >35

3. Previous uterine surgery → d&c or c/s ← uterine scarring

4. Multiparity

What are the s/sx of placental previa?

1. Vaginal bleeding → painless and bright red in second or third trimester

2. Spontaneous cessation then recurrence

32-33 wks → baby pushes on os → bleeding episode #1 → spontaneous cessation and upon recurrence bleeding is much worse and they often require a c/s

What are the nursing priorities when caring for a pt with a placenta previa? ()

1. Monitor maternal-fetal status

   1. Vaginal bleeding- pad count, weighing pads

   2. Avoidance of vaginal exams!!! ← risk for placental damage

   3. FHR (fetal monitoring)

2. Support and education- fetal movement counts, effects of prolonged bed rest (if necessary)

3. Prep for possible c/s

what is a placental abruption?

separation of the placenta after the 20th week gestation leading to compromised fetal blood supply

Can be partial or full (full = dead baby)

What are some risk factors for a placental abruption? (7)

1. Chronic HTN

2. Traumas- car accident, falls, assaults

3. Cocaine/drug use

4. Too many herbs

5. Smoking

6. Age >35

7. Multifetal pregnancy

what is the therapeutic management for placental abruption? (2)

1. Assessment/control/restoration of blood loss 

2. Prevention of DIC

What are some s/sx of a placental abruption? (6)

1. Dark red bleeding

2. Knife-like pain

3. Uterine tenderness

4. Contractions

5. Decreased fetal movement and activity

6. FHR ← determines when they are sectioned

What are the nursing priorities when caring for a pt with placental abruption? (2 with 6 interventions)

1. Tissue perfusion!

   1. Left lateral position

   2. Strict bed rest

   3. O2 therapy

   4. V/s

   5. Fundal height

   6. Continuous fetal monitoring

2. Support and education- empathy, understanding, explanations, possible loss of fetus

what is a placenta accrete?

Slight penetration of the myometrium 

what is placenta increta?

deep penetration of the myometrium

what is a placenta percreta?

full penetration of myometrium ← full hysterectomy required

Which finding would the nurse expect to assess in a woman with placenta previa?

A. Dark red vaginal bleeding

B. Uterine tenderness

C. Fetal distress

D. Relaxed uterus

d. Relaxed uterus

The woman with placenta previa would exhibit a soft relaxed uterus accompanied by painless bright-red vaginal bleeding that stops spontaneously only to recur. Abruptio placentae is associated with dark-red vaginal bleeding, uterine tenderness, and fetal distress.

What are the key differentiators of placental previa?

painless, bright red bleeding, soft uterus, diagnosed by ultrasound. Absolutely no vaginal exams!!

Painless, Bright red.

What are the key differentiators of placental abruption?

painful, dark red bleeding, rigid uterus, maternal HTN or cocaine common triggers, fetal distress likely.

Painful, Dark red.

What are the key differentiators of uterine rupture?

sudden tearing pain, loss of contractions, loss of fetal station, palpable fetal parts, catastrophic for mother and fetus, requires immediate surgery.

Sudden, Catastrophic tearing pain, rapid deterioration.

What is hyperemesis gravidarum?

severe form of nausea and vomiting

what are the s/sx of hyperemesis gravidarum?

symptoms usually resolve by week 20

• wt loss of >5% of pre-pregnancy weight

• Dehydration

• Metabolic Alkalosis

• Hypokalemia

What is the therapeutic management for hyperemesis gravidarum? (Conservative? Severe form?)

1. Conservative- diet and lifestyle changes

2. Severe- hospitalizations with parenteral therapy 

What are the medications used to treat hyperemesis gravidarum? (3)

1. Promethazine (Phenergan)

2. Pyridoxine and doxylamine (Diclegis)

3. Ondansetron (Zofran)

What is gestational hypertension?

hypertension WITHOUT proteinuria AFTER 20 weeks

what is preeclampsia?

new onset HTN with proteinuria and/or maternal organ dysfunction

What is eclampsia?

neurologic complication of preeclampsia: SEIZURES

what is chronic HTN?

exists prior to pregnancy or prior to 20 weeks of GA

How is mild preeclampsia managed? At home? (3) In hospital?

1. Bed rest ← avoid falls

2. Daily BP monitoring

3. Fetal movement counts

If/When hospitalized:

IV magnesium sulfate during labor!

How is severe preeclampsia managed? (9)

ALWAYS HOSPITALIZED

1. Oxytocin and magnesium sulfate

2. Prepare for birth

3. Quiet environment

4. Sedatives

5. Seizure precautions

6. Antihypertensives

7. DTR testing

8. Assessing for magnesium toxicity and signs of labor

9. Fetal monitors

How is eclampsia managed? (4)

1. Seizure management- padded side rails, suction/O2 at bedside, etc.

2. magnesium sulfate

3. Antihypertensive agents

4. Birth once seizures are controlled

What are some important nursing considerations when administering IV magnesium sulfate?

Magnesium can decrease RR and DTRs ← they should be frequently assessed

What is the antidote of IV magnesium sulfate?

calcium gluconate

What are some signs and symptoms of magnesium toxicity?

everything slows down!

• decreased RR

• Lethargy

What are the important intrapartum care considerations for a woman with elevated blood pressure?

1. Magnesium sulfate management- side effects, therapeutic effects

2. Renal balance- foley, strict I&O, urine dipstick/proteinuria, minimum urine output

3. Neuro checks- LOC, DTR

4. Pulmonary- pulmonary edema, dyspnea, rales, crackles, resp depression

5. Psychological- manage anxiety/ fear

6. Continuous fetal monitoring

what blood pressure is considered preeclampsia without severe features?

>140/90 after 20 wks gestation

what blood pressure is considered preeclampsia with severe features?

≥ 160/110 on 2 occasions at least 6 hours apart while on bed rest

what blood pressure is considered eclampsia?

>160/110

What are some more severe s/sx of preeclampsia? (9)

1. Headache

2. Oliguria

3. Blurred vision, scotomata (blind spots)

4. Pulmonary edema

5. Thrombocytopenia- platelet counts <100,000

6. Cerebral disturbances

7. Persistent epigastric or RUQ pain

8. HELLP

9. Progressive renal insufficiency

10. Hyperreflexia → but no seizures or coma

What are some s/sx of eclampsia?

1. Seizures/coma

2. Hyperreflexia

3. Severe headache

4. Generalized edema

5. RUQ or epigastric pain

6. Visual disturbances

7. Cerebral hemorrhage

8. Renal failure

9. HELLP

What does HELLP stand for?

Hemolysis

Elevated

Liver enzymes

Low

Platelets

what are some s/sx of HELLP syndrome?

Similar to severe preeclampsia

• nausea

• Epigastric pain

• Visual disturbances

• Headache

• Bleeding from sites- nose

• Changes in bloodwork- coags, AST, ALT

what are some nursing priorities in managing HELLP syndrome?

same as for severe preeclampsia

• stabilization of BP

• Fetal monitoring- VEAL CHOP

• Delivery of fetus ASAP

Why does hemolysis take place in severe preeclampsia?

Vasospasms in the CV system → destruction of RBCs AKA hemolysis

Why do liver enzymes become elevated take place in severe preeclampsia?

vasospasms cause a decrease in blood flow to the liver → tissue ischemia (low O2) and hemorrhagic necrosis

Why do platelets decrease in severe preeclampsia?

in response to endothelial damage caused by vasospasms (small openings develop in the vessels) → platelets aggregate at the site and a fibrin network is set up → leads to a decrease in circulating platelets

DIC