ch19

CHAPTER 19 NURSING MANAGEMENT OF PREGNANCY AT RISK: PREGNANCY RELATED COMPLICATIONS

HIGH-RISK PREGNANCY

  • Definition: A high-risk pregnancy poses a jeopardy to the mother, fetus, or both. It may arise due to conditions directly caused by pregnancy or from pre-existing conditions prior to pregnancy.

  • Consequences: Associated with higher morbidity and mortality.

  • Risk Assessment:
      - Conducted during the first antepartal visit and ongoing throughout pregnancy.

EXAMPLES OF HIGH-RISK CONDITIONS

  • Gestational Diabetes

  • Hypertensive Disorders

  • Polycystic Ovary Syndrome (PCOS)

  • Obesity

  • HIV/AIDS

  • Advanced Maternal Age

  • Substance Abuse (Tobacco and Alcohol)

  • Previous Preterm Birth

  • Multiple Gestation

BLEEDING DURING PREGNANCY

  • Statistics: Experienced by approximately 25% of women during the first trimester.

  • Types of Bleeding:
      - First Half of Pregnancy:
        - Spontaneous Abortion
        - Uterine Fibroids
        - Ectopic Pregnancy
        - Gestational Trophoblastic Disease
        - Cervical Insufficiency
      - Late Pregnancy (after 20 weeks gestation):
        - Placenta Previa
        - Placental Abruption
        - Placenta Accreta

SPONTANEOUS ABORTION

  • Definition: The most common complication of early pregnancy involves the loss of a fetus before 20 weeks gestation. Can be either spontaneous or induced.

  • Statistics: 80% of abortions occur in the first trimester.

  • Common Causes: Usually fetal genetic abnormalities.

  • Intervention: May require dilation and curettage (D&C) if not resolved independently.

SPONTANEOUS ABORTION: ASSESSMENT AND NURSING MANAGEMENT

Assessment:

  • Bleeding: Evaluate color, amount, and presence of clots or tissue.

  • Pain: Inquire about lower back or abdominal cramping.

  • Vitals: Monitor vital signs continuously.

  • Fetal Parts: Observe for presence of fetal elements.

Nursing Management:

  • Support: Offer physical and emotional support, including grief counseling.

  • Referral: Guide to community support groups.

  • RhoGAM: Administer within 72 hours if the mother is Rh-negative.

  • Unstable Patient Indicators: Pale, weak, increased heart rate, decreased blood pressure, cold/clammy skin, sluggish capillary refill, increased respiratory rate, altered level of consciousness, decreased urine output.

  • Actions: Administer IV fluids (LR, Saline), monitor vitals, document everything (QBL=1gm=1ml), and measure intake/output. Re-evaluate for improvement.

ECTOPIC PREGNANCY

  • Definition: Occurs when the ovum implants outside the uterus, commonly in the fallopian tubes, but may also occur in the cervix, ovaries, or abdominal cavity.

  • Risks: Can lead to organ rupture; occurs in 1 in 50 pregnancies and is a primary cause of first-trimester mortality in the USA.

  • High-Risk Groups: Includes those with IUDs, previous tubal ligation, frequent STI history, and pelvic inflammatory disease.

ECTOPIC PREGNANCY: ASSESSMENT AND MANAGEMENT

Assessment:

  • Classic Triad: Abdominal pain, amenorrhea, and vaginal bleeding (not all patients exhibit all three symptoms).

  • Hallmark Sign: Abdominal pain and spotting within 6-8 weeks post missed period.

  • Diagnostics: Confirm pregnancy via urine test, obtain pregnancy and sexual history.

  • Signs of Rupture: Severe, sharp pain in lower abdomen; dizziness; referred shoulder pain; hypotension; hypovolemic shock.

  • Monitor: Decreasing hCG levels due to non-implantation in the endometrium.

Management:

  • Medication: Methotrexate (single dose IM) if not at risk of rupture, alternative options like prostaglandins and actinomycin.

  • Surgery: Salpingostomy if needed.

  • Support: Provide emotional support; educate on the reduction of risks.

  • Pain Management: Important part of overall care.

GESTATIONAL TROPHOBLASTIC DISEASE

  • Types: Includes Hydatidiform Mole (benign neoplasm) and Choriocarcinoma (can arise from molar pregnancy).

  • Incidence: Can occur during pregnancy, post-childbirth, or years after. High remission rate (90%).

  • Symptoms: Similar to pregnancy signs, magnified by 10-12 weeks including exaggerated early signs of pregnancy such as amenorrhea, persistent nausea and vomiting, and inability to detect fetal heart rate.

GESTATIONAL TROPHOBLASTIC DISEASE: ASSESSMENT AND MANAGEMENT

Assessment:

  • Clinical: Brownish vaginal bleeding, early pregnancy signs, and persistent high levels of hCG.

  • Diagnostic: Expect to perform D&C for evacuation.

Management:

  • Preparation: Preoperative education and emotional support are crucial.

  • Monitoring: Serial hCG levels to ensure they are dropping; educate patients on avoiding pregnancy for a year due to cancer risk.

  • Nursing Considerations: Higher than expected fundal height indicates potential issues.

CERVICAL INSUFFICIENCY

  • Definition: Characterized by premature dilation of the cervix without contractions, potentially due to cervical trauma or changes in collagen and elastin levels.

  • Risk: Particularly in patients with previous preterm deliveries.

Assessment:

  • Symptoms: Pink-tinged discharge or pelvic pressure, loss of amniotic fluid.

  • Diagnostics: Utilize transvaginal ultrasound and ongoing surveillance for signs of preterm labor.

Management:

  • Interventions: Ensure bed rest and pelvic rest. Avoid heavy lifting and consider cerclage (surgically placing stitches to keep the cervix closed).

  • Support: Emotional support and education on managing the condition.

PLACENTA PREVIA

  • Definition: The placenta is improperly located at the lower uterine segment, partially or wholly covering the cervical opening.

  • Timing of Bleeding: Typically occurs in the last two trimesters.

  • Common Causes: Previous cesarean deliveries, scarring, closely spaced pregnancies, or multiple gestations may increase risk.

Nursing Management:

  • Assessment: Monitor for vaginal bleeding (bright red), uterine palpation may reveal a soft, non-tender uterus.

  • Monitoring and Support: Avoid vaginal exams; monitor fetal and maternal status, and encourage bed rest.

  • Education: Teach patients warning signs for complications such as contractions or decreased fetal movement.

PLACENTAL ABRUPTION

  • Definition: The premature separation of the placenta, impacting fetal blood flow.

  • Statistics: Fetal mortality rate is approximately 40% with maternal mortality at 5%. Often linked to gestational hypertension and preeclampsia.

  • Triggers: Conditions that cause vasoconstriction (e.g., issues related to hypertension, cocaine use, trauma).

Assessment and Management:

  • Symptoms: Dark red bleeding, knife-like abdominal pain, contractions, and decreased fetal activity.

  • Monitoring: Careful maternal vital sign monitoring and fetal distress analysis.

  • Actions: Oxygen administration, strict bed rest (left lateral position), and laboratory testing to assess maternal condition.

  • Interventions: Start IV fluids, give oxygen, fetal monitoring, and prepare for surgical intervention if necessary.

PLACENTA PREVIA VS. PLACENTAL ABRUPTION

Manifestation

Placenta Previa

Placental Abruption

Onset

Insidious

Sudden

Type of Bleeding

Always visible; becomes profuse

Can be concealed or visible

Blood Description

Bright red

Dark red

Discomfort/Pain

None (typically painless)

Constant, painful (uterine)

Uterine Tone

Soft and relaxed

Firm to rigid

Fetal Heart Rate

Usually in normal range

Fetal distress or absent

Fetal Presentation

May be breech or transverse

No discernible relationship

CASE STUDY EXAMPLE

  • Scenario: A 21-year-old female with severe abdominal pain and light vaginal bleeding, history of irritable bowel syndrome, and use of IUD for contraception.

Clinical Notes:

  • Initial Symptoms: Light bleeding, severe abdominal pain, headache, low blood pressure, and elevated heart rate.

  • Lab Results: Elevated WBC count, low hematocrit, and hemoglobin.

  • Diagnostic Procedures: Transvaginal ultrasound indicates active bleeding with no products of conception in the uterus.

Intervention Plan:

  • Actions: Prepare for D&C, administer IV fluids, and monitor vital signs. Potential conditions to consider include spontaneous abortion, ectopic pregnancy, and appendicitis.

PLACENTA ACCRETA

  • Definition: A condition where the placenta attaches too deeply into the uterine wall; can lead to significant complications, especially postpartum hemorrhage.

  • Management: Often associated with emergency cesarean sections and may require hysterectomy.

HYPEREMESIS GRAVIDARUM

  • Definition: A severe and sustained form of nausea and vomiting in pregnancy, usually resolving by 20 weeks.

  • Symptoms: Weight loss >5% of pre-pregnancy body weight, dehydration, metabolic acidosis, and hypokalemia.

  • Risk Management: Includes bed rest, IV fluids, and medication to manage nausea (e.g., ondansetron, promethazine).

HYPERTENSIVE DISORDERS OF PREGNANCY

Types:

  • Gestational Hypertension: New onset HTN after 20 weeks.

  • Preeclampsia: Characterized by hypertension and proteinuria, leading to complications if untreated.

  • Eclampsia: Seizures due to preeclampsia.

  • Chronic Hypertension: Present before pregnancy and can persist post-12 weeks.

Risk Factors for Hypertensive Disorders:

  • Includes: Advanced maternal age, obesity, Hispanic ethnicity, familial cardiovascular history, and previous preterm births.

Preeclampsia Management:

Without Severe Features:

  • Symptoms: New hypertension after 20 weeks, proteinuria.

  • Management: Bedrest, antihypertensive therapy, and increased prenatal visits.

With Severe Features:

  • Symptoms: Severe hypertension, proteinuria, and signs indicating organ involvement (e.g., headaches, blurred vision).

  • Management: Bed rest, continuous fetal monitoring, seizure precautions, and potential hospitalization for closer observation.

ECLAMPSIA

  • Definition: New onset seizures in a patient with preeclampsia.

  • Management: Turn patient to the left side, maintain airway, and suction post-seizure; magnesium sulfate administration during a seizure event.

HELLP SYNDROME

  • Definition: Involves hemolysis, elevated liver enzymes, and low platelets. Associated with high risks for maternal and fetal complications.

  • Primary Risks: Includes cerebral hemorrhage, liver rupture, and disseminated intravascular coagulation (DIC).

BLOOD INCOMPATIBILITY

  • ABO Incompatibility: Occurs when type O mothers have fetuses with type A or B blood—a less severe condition than Rh incompatibility.

  • Rh Incompatibility: Involves sensitization of an Rh-negative mother to Rh-positive fetal blood, increasing risk with subsequent pregnancies.

  • Management: RhoGAM administered at 28 weeks and 72 hours post-birth, and in cases of trauma or any invasive procedures.

POLYHYDRAMNIOS

  • Definition: Occurrence of amniotic fluid >2,000 mL between weeks 32-36, linked to fetal anomalies such as GI obstruction or neural tube defects.

  • Nursing Assessment: Monitor risk factors, fundal height, and potential discomfort.

  • Management: Continuous fetal monitoring, potential therapeutic amniocentesis, and indomethacin administration to reduce fluid.

OLIGOHYDRAMNIOS

  • Definition: Occurrence of amniotic fluid <500 mL, associated with maternal diabetes, IUGR, and fetal urinary issues.

  • Assessment and Management: Monitor fluid levels and fetal wellbeing; manage with amnioinfusion and provide comfort measures.

MULTIPLE GESTATION

  • Risks: Includes anemia, excessive weight gain, and preterm delivery.

  • Management: Education for mothers, labor management with perinatal support, and monitoring postpartum for potential hemorrhage.

PREMATURE RUPTURE OF MEMBRANES (PROM)

  • Definition: Rupture of membranes before labor, with risks of infection if prolonged (>24 hours).

  • Preterm Premature Rupture of Membranes (PPROM): Early rupture before labor, requiring specific management based on gestational age.

  • Treatment: Betamethasone administration and antibiotics for infection prevention and strict monitoring of the maternal and fetal condition.

PATIENT EDUCATION FOR PPROM

  • Advice Includes: Daily temperature checks, hygiene practices to maintain cleanliness, monitoring for signs of labor, and fetal movement checks.