Peri-partum Variations in Health B: Comprehensive Nursing Notes on Hyperemesis Gravidarum, Hypertensive Disorders, Placenta Previa, Placental Abruptio, and Postpartum Hemorrhage

Hyperemesis Gravidarum

• Definition and impact
  • Persistent and severe nausea/vomiting in pregnancy, more intense than morning sickness
  • Significantly affects intake and daily activities
  • Can cause significant weight loss (> 5% of prepregnant weight)
  • Most cases resolve by week $20$ of gestation
• Diagnostics
  • Rule out other causes: gastroenteritis, liver disorders, gallbladder disease, pancreatic disorders
• treatments and medications
  • Doxylamine/pyridoxine (Diclectin)
  • Dimenhydrinate
  • Metoclopramide
  • Ondansetron
• Nursing care and patient teaching
  • Identify and reduce triggers
  • Monitor intake and output; daily weights
  • Encourage frequent small amounts of fluids and bland foods; easily digestible carbohydrates
  • Sit upright after meals
  • Avoid strong odors
• Complications
  • Dehydration and malnutrition
  • Impaired placental perfusion → reduced delivery of blood (oxygen and nutrients)
  • Potential for restricted fetal growth, preterm birth, or small-for-gestational-age newborn
• Integrative and supportive care
  • Acupressure, mindfulness-based cognitive therapy, ginger supplements (additional/alternative options)
• Critical care considerations
  • IV fluids ± total parenteral nutrition (TPN) for severe cases
• References noted in transcript
  • Carstairs, S. (2016). Ondansetron use in pregnancy and birth defects: A systematic review. Obstetrics & Gynecology, 127(5), 878-883. doi: 10.1097/AOG.0000000000001388

Case notes: Lab values and pregnancy status (exemplars)

• Reference values and case context
  • Potassium (K⁺): $3.5 ext{ to } 5.1 ext{ mmol/L}$
  • Sodium (Na⁺): $136 ext{ to } 145 ext{ mmol/L}$
• Case 1
  • G2T1L1, 11 weeks gestation; Previous uncomplicated vaginal delivery
  • Morning sickness managed with gravol but patient avoided it due to pregnancy med concerns
  • Hydration maintained
  • Lab results: Na⁺ $137$, K⁺ $3.5$
• Case 2
  • G5P3T0L1, 21 weeks gestation; History of hyperemesis in previous pregnancies
  • On Diclectin (doxylamine/pyridoxine) managing vomiting but not nausea
  • Able to eat bland foods and stay hydrated
  • Lab results: Na⁺ $140$, K⁺ $3.8$
• Case 3
  • G4T3L3, 21 weeks gestation; History of hyperemesis in previous pregnancies
  • On Diclectin; vomiting managed, not nausea
  • Able to eat bland foods and stay hydrated
  • Lab results: Na⁺ $140$, K⁺ $3.8$

Physiologic note: Blood pressure in pregnancy

• Despite increases in blood volume and cardiac output during pregnancy, most pregnant individuals do not have a rise in blood pressure
• Reason (pathophysiology emphasized in slide): Vasodilation leading to reduced systemic vascular resistance, offsetting the expected rise in pressure

Hypertensive disorders in pregnancy

• Pathophysiology
  • Vasospasm impedes blood flow to the mother’s organs and to the placenta
• Common signs/symptoms and definitions
  • Hypertension, edema, proteinuria
  • Development of hypertension after 20 weeks’ gestation; BP typically returns to normal 6–12 weeks postpartum
• Conditions
  • Gestational hypertension
  • Preeclampsia: gestational or chronic hypertension with renal involvement leading to proteinuria
  • HELLP syndrome: Hemolysis, Elevated Liver enzymes, Low Platelets (variant of GH)
  • Eclampsia: seizure(s) in the setting of preeclampsia; risk of CNS events, placental abruption, fetal compromise, maternal or fetal death
• Important thresholds
  • Diagnostic criteria: ext{SBP} > 140 ext{ mmHg} ext{ or } ext{DBP} > 90 ext{ mmHg} on at least two readings 4 hours apart
  • Severe preeclampsia: ext{SBP} > 160 ext{ mmHg} ext{ or } ext{DBP} > 110 ext{ mmHg} (two readings, 4 hours apart)
• Pre-eclampsia specifics
  • Hypertension with renal involvement leading to proteinuria
  • Severe features increase risk to mother and fetus; may require early delivery
  • Treatment concept: Birth is the cure for preeclampsia; if the fetus is mature, delivery via labor induction or cesarean may be indicated
• Risk and prevalence
  • Risk of eclampsia events ranges in the literature; severe features carry higher risk of seizures and complications
• Risk factors
  • First pregnancy; obesity; family history; age extremes (≤19 or ≥35); multifetal pregnancy
  • Chronic hypertension; CKD; diabetes; autoimmune history; long interpregnancy interval (>10 years)
• Prenatal care and monitoring for preeclampsia
  • Activity restriction to conserve maternal circulation
  • Fetal activity monitoring (kick counts)
  • Blood pressure monitoring: $ext{BP} 2–4 ext{ times per day}$
  • Daily weight measurement
  • Urine protein testing
• Peri-partum care and medications
  • Fetal monitoring: Non-stress test (NST) at ≥36 weeks; electronic fetal monitoring (EFM) around peripartum
  • Seizure management: Magnesium sulfate (MgSO₄); other potential meds: Labetalol, Nifedipine
  • Uterine/medication considerations: Labetalol, Nifedipine, MgSO₄; NO definitive oxytocin indication here beyond obstetric context
• Signs and symptoms to recognize urgently
  • Visual disturbances (blurred vision, spots)
  • Severe, unrelenting headache
  • Hyperreflexia and CNS irritability
  • Pulmonary edema
  • Epigastric pain or nausea with liver edema/ischemia
  • Elevated liver enzymes due to hepatic involvement
  • Oliguria (reduced urine output)
  • Sudden weight gain (> about $1.8 ext{ kg}$ in 1 week during 2nd/3rd trimester)
• Patient education and awareness
  • Historical note: “toxemia” is an older term for preeclampsia

Case notes: Vital signs and clinical scenarios

• Example: Primagravida at 21 weeks gestation with prior HTN controlled by ramipril
  • Vitals: BP $139/89$, HR $76$, RR $16$, SpO₂ $99 ext{}</li></ul></li> <li>Example: G2T1L1, 36-year-old at 30 weeks; history of preeclampsia<ul> <li>Vitals: BP$110/65$, HR$76$, RR$16$, SpO₂$99 ext{%
    }
• Example: G3T2L3, 35-year-old at 30 weeks; reports headaches related to toddlers and dogs
  • Vitals: BP $127/65$, HR $76$, RR $16$, SpO₂ $99 ext{}</li></ul></li> </ul> <h3 id="placentaprevia">Placenta previa</h3> <ul> <li>Diagnostics<ul> <li>Painless vaginal bleeding or ultrasound finding in 2nd or 3rd trimester</li></ul></li> <li>Key concept<ul> <li>Placenta implanted near the cervix so exit canal is obstructed</li></ul></li> <li>Subtypes (degrees)<ul> <li>Marginal: placenta reaches within$2 ext{–}3 ext{ cm} of the cervical os
  • Partial: placenta partly covers the cervical opening
  • Total: placenta completely covers the cervical opening
  • Low-lying placenta: implanted near the cervix but does not cover the opening; not a true placenta previa
• Complications
  • Disruption of normal prelabor cervical changes can lead to malpresentation
  • Placental location can cause abnormal fetal presentation
• Risk factors
  • History of cesarean delivery
  • Smoking; cocaine use
  • Older maternal age; multifetal pregnancy
  • History of placenta previa
• Monitoring and nursing care
  • Monitor fetal heart activity
  • Interventions: provide oxygen as needed; nephrotoxic or sedation considerations omitted here; support and education
  • Teaching and restrictions: activity restrictions (sex, exercise, bathroom privileges); monitor bleeding (pad counts); signs of shock; position on the left side; prepare for cesarean if actively bleeding
• When to act
  • If bleeding persists or worsens, maintain bed rest if bleeding is controlled; if active bleeding persists, prepare for cesarean delivery
• Special considerations
  • Vaginal examination is contraindicated (may precipitate bleeding if placental attachment is disrupted)
• Potential fetal and maternal outcomes
  • Placenta previa can lead to fetal hypoxia and maternal hemorrhage; fetal position may complicate birth

Placental abruption (abruptio placentae)

• Diagnostics and definition
  • Premature separation of the placenta from the uterine wall
• Subtypes
  • Partial: some placenta separates
  • Marginal: separation at the edges
  • Total: all placenta separates
  • Central: separation in the middle
• Clinical presentation
  • Classic sign: dark red vaginal bleeding with abdominal pain (bleeding may be visible or concealed)
  • Uterus: tender or unusually firm due to blood within the uterine wall
  • Frequent cramping and uterine irritability
  • Fetus may or may not be compromised
• Pathophysiology and complications
  • Large intrapartum clot behind placenta consumes clotting factors → maternal coagulopathy and potential DIC (disseminated intravascular coagulation)
  • Can lead to emergency scenarios requiring stat cesarean delivery
• Monitoring and nursing care
  • Fetal heart activity monitoring; pad count for bleeding; monitor for shock; monitor vital signs every ~15 minutes if actively bleeding
  • Oxygen administration; side-lying position; prepare for cesarean if bleeding persists or fetus is compromised
• Clinical emphasis
  • Management is urgent and often similar to placenta previa but may require urgent cesarean depending on progression and maternal/fetal status

Postpartum hemorrhage (PPH)

• Definition
  • Blood loss > 500 ext{ mL} after vaginal birth or > 1000 ext{ mL}$$ after cesarean birth, with signs of hypovolemia
• Classifications
  • Early (primary) PPH: within 24 hours after birth
  • Late PPH: after 24 hours and within 6 weeks postpartum
• Normal puerperium expectations
  • Uterus: should be a firm mass at or near the umbilicus; fundus descends about 1 finger breadth (≈1 cm) per day
  • Lochia: rubra should be dark red; initial bleeding approximates ≤1 pad/hour; small clots may be normal
• Abnormal findings
  • Uterus boggy or difficult to locate; fundal height may be above the umbilicus or not midline
  • Lochia: frank/bright red with heavy bleeding, large clots, or gushing
• Nursing care and monitoring
  • VS every ~15 minutes until stable; frequent lochia assessment in the fourth stage
  • Monitor intake and output; track pad weights (1 g ≡ 1 mL)
  • Fundal assessments
• Hemorrhage management and interventions
  • Stop blood loss and stabilize circulation
  • Give IV fluids; administer oxygen; ensure bladder empty
  • Strict I&O; uterine massage; administer oxytocin
  • Encourage breastfeeding (which can promote uterine contraction)
  • PRBC transfusion as needed
• Emergency care scope
  • Oxytocin administration is a key emergency intervention; scope considerations noted for licensed practical nurse (LPN) and team roles

Breakout session and quick planning notes

• Exercise prompts from session
  • PA: Placenta Previa – formulate nursing diagnoses and prioritize interventions
  • CV: Pre-eclampsia – formulate nursing diagnoses and prioritize interventions
  • CR: Hyperemesis Gravidarum – formulate nursing diagnoses and prioritize interventions

Quick remembrance: Peri-partum terms and focus areas

• Peri-partum edition recap (keywords)
  • Morning sickness, Hyperemesis Gravidarum, Placenta Previa, Gestational Hypertension, Placental Abruptio, Preeclampsia, Hypertension in Pregnancy
• Conceptual linkage
  • Placental pathologies (previa, abruptio) directly impact fetal oxygenation and birth planning
  • Hypertensive disorders carry maternal and fetal risks; management often revolves around maternal stabilization and deciding timing of delivery
  • Hyperemesis gravidarum intersects with nutrition and hydration, fetal growth, and maternal well-being

Did you know?

• The term "toxemia" is an old label historically used for preeclampsia

Note on references in the notes

• Keenan-Lindsay, L. & Leifer, G. (2024). Leifer's Introduction to Maternity and Pediatric Nursing in Canada (10th ed.). Elsevier - Evolve.