Chapt 10 Stucy Guide: Complications of Pregnancy Practice Flashcards

High-Risk Pregnancy and Prenatal Care

• Definition of High-Risk Pregnancy: A pregnancy in which the mother, the baby, or both parties are at an increased risk for complications, illness, injury, or death.

• Causes of High-Risk Status:

  • Acquired during pregnancy: Conditions that develop specifically due to the gestational state, such as gestational hypertension or preeclampsia.

  • Pre-existing conditions: Factors present before conception, including diabetes, chronic hypertension, and obesity.

• Importance of Prenatal Care:

  • Allows for the early identification of pre-existing medical conditions.

  • Facilitates early intervention, which significantly improves outcomes for the mother and the fetus.

  • Key components include regular prenatal visits, screening tests, and comprehensive patient education.

• The Nurse's Role:

  • Identifying risk factors and recognizing early warning signs.

  • Monitoring both maternal and fetal status throughout the pregnancy.

  • Providing essential education and emotional support to the patient.

Hemorrhagic Conditions of Early Pregnancy: Spontaneous Abortion

• Definition of Spontaneous Abortion (Miscarriage): The loss of a pregnancy occurring before $20$ weeks of gestation.

• Post-$20$ Weeks Classification: Loss after this threshold is classified as a stillbirth or fetal demise.

• Causes of Miscarriage:

  • Chromosomal Abnormalities: Account for approximately $50\%$ of first-trimester miscarriages. These are usually random genetic errors and are not the fault of the mother.

  • Faulty Implantation: Inadequate blood supply to the placenta.

  • Maternal Infections: Viral, bacterial, or parasitic infections that interfere with proper fetal development.

  • Maternal Medical Conditions: Examples include uncontrolled diabetes, thyroid disorders, autoimmune diseases, and severe hypertension.

  • Placental Abnormalities: Improper development or functioning of the placenta.

  • Clotting Disorders: Conditions like Antiphospholipid syndrome, which causes small clots in placental vessels.

• Emotional Impact: The loss triggers a grief response related to the loss of hopes, dreams, and future plans. Nurses must provide compassionate care and acknowledge the loss's significance.

• Types of Miscarriage:

  • Threatened Miscarriage: Characterized by vaginal bleeding before $20$ weeks. The cervix remains closed, and the pregnancy may continue with close monitoring.

  • Inevitable Miscarriage: The loss cannot be prevented. Bleeding is present, the cervix has begun to dilate, and membranes may have ruptured as the body begins expelling the pregnancy.

  • Incomplete Miscarriage: Some, but not all, products of conception are expelled. Retained tissue prevents the uterus from contracting, leading to continued bleeding and risk of hemorrhage. Treatment includes Dilatation and Curettage ($D\&C$) or medications such as oxytocin, methergine, or cyotec.

  • Complete Miscarriage: All products of conception are expelled. The uterus is empty, the cervix closes, and symptoms like bleeding and cramping decrease.

  • Missed Miscarriage: The fetus has died in utero but has not been expelled. Symptoms of pregnancy diminish, and ultrasound reveals no fetal cardiac activity. Management options include expectant management, medication-induced evacuation, or surgical intervention.

  • Recurrent (Habitual) Miscarriage: Defined as $3$ or more consecutive pregnancy losses. This requires evaluation for genetic, uterine, hormonal, autoimmune, or clotting disorders.

• Assessment and Treatment:

  • Assess vaginal bleeding (amount, color, duration, presence of clots) and associated symptoms (cramping, abdominal/back pain).

  • Instruct the patient to save any passed tissue.

  • Interventions include $IV$ fluids, blood products, medications, and surgical procedures.

  • Rh-Negative Mothers: Must receive $RhoGAM$ to prevent sensitization.

Ectopic Pregnancy

• Definition: A condition where the fertilized ovum implants outside the uterine cavity.

• Common Sites:

  • Fallopian Tubes: The most common site, accounting for $90\text{-}95\%$ of cases.

  • Other Sites: Ovary, cervix, abdominal cavity, or a previous C-section scar.

• The Danger: Growing tissue can rupture the fallopian tube, leading to life-threatening internal hemorrhage.

• Risk Factors: History of pelvic inflammatory disease ($PID$), previous ectopic pregnancy, tubal surgery, infertility treatments, endometriosis, smoking, or any condition causing tubal scarring.

• Viability: Ectopic pregnancies are never viable; treatment is always necessary.

• Classic Presentation:

  • Unilateral pelvic or abdominal pain.

  • Referred shoulder (scapular) pain.

  • Vaginal spotting.

  • Missed period followed by bleeding.

  • Dizziness, weakness, and initial positive pregnancy test/symptoms.

• Ruptured Ectopic Pregnancy: An obstetrical emergency characterized by severe abdominal pain, rigidity, and hypotension. External bleeding does not necessarily reflect the extent of internal blood loss.

• Diagnosis: Lab studies showing quantitative $hCG$ levels rising slower than normal and transvaginal ultrasound to locate the gestational sac.

• Management:

  • Medication (Methotrexate): A folic acid antagonist used in stable, early cases to stop cell growth and allow reabsorption. Requires serial $hCG$ follow-ups.

  • Surgical Intervention: Necessary if the pregnancy is ruptured or the patient is unstable; involves removing the ectopic growth and potentially the fallopian tube.

• Education: Patients on Methotrexate must report severe pain, heavy bleeding, or dizziness immediately.

Gestational Trophoblastic Disease (Molar Pregnancy)

• Definition: Abnormal proliferation of trophoblastic cells that form fluid-filled, grape-like vesicles.

• Types:

  • Complete Mole: Entirely abnormal placental tissue with no fetal tissue present.

  • Partial Mole: May contain some fetal tissue, but chromosomal abnormalities make the fetus non-viable.

  • Complication: Risk of developing choriocarcinoma, a highly treatable cancer.

• Clinical Presentation:

  • Vaginal bleeding in the first trimester.

  • Uterus larger than expected for gestational age.

  • Extremely elevated $hCG$ levels.

  • Severe nausea and vomiting.

  • Passage of grape-like vesicles ($hallmark$ finding).

• Diagnosis and Treatment:

  • Ultrasound showing a "snowstorm appearance."

  • Treatment involves suction curettage or $D\&C$. Hysterectomy may be necessary for excessive bleeding.

  • Follow-up: Serial $hCG$ monitoring for months. Patients must avoid pregnancy for at least $1$ year to ensure $hCG$ readings are not masked by a new pregnancy and to monitor for malignancy.

Hemorrhagic Conditions of Late Pregnancy: Placenta Previa

• Definition: The placenta implants in the lower uterine segment, over or near the cervical opening.

• Mechanism: Uterine stretching disrupts placental attachment, causing bleeding.

• Types:

  • Low-lying: Near the cervical opening.

  • Marginal: At the edge of the opening.

  • Partial: Covers part of the opening.

  • Complete: Completely covers the cervical opening.

• Placental Migration: Many low-lying placentas appear to "move" upward as the uterus grows. This is a change in relative position, not physical migration, and may resolve by the third trimester.

• Risk Factors: Previous C-section (strongest factor), previous previa, multiple gestation, advanced maternal age, smoking, multiparity, and $IVF$.

• Classic Presentation: Sudden, painless, bright red vaginal bleeding after $20$ weeks. Uterus is typically soft and non-tender.

• Risks:

  • Maternal: Recurrent hemorrhage, anemia, shock, C-section, and prolonged hospitalization.

  • Fetal: Preterm birth, growth restriction, and hypoxia.

• Nursing Care and Safety:

  • Monitor bleeding, vital signs, and fetal heart rate.

  • Establish $IV$ access and obtain labs ($H\&H$, type, and crossmatch).

  • Safety Restriction: AVOID DIGITAL VAGINAL EXAMS until previa is ruled out by ultrasound; digital exams can cause catastrophic hemorrhage.

  • Teach pelvic rest (no sexual intercourse), activity restrictions, and the need to report bleeding immediately.

Abruptio Placentae (Placental Abruption)

• Definition: Premature separation of a normally implanted placenta from the uterine wall after $20$ weeks and before delivery.

• Risk Factors: Maternal hypertension, preeclampsia, abdominal trauma, smoking, substance abuse (cocaine/heroin), and previous abruption.

• Types of Abruption:

  • Partial Abruption (Apparent): Blood escapes through the cervix; visible bleeding is present.

  • Partial Concealed Abruption: Blood is trapped behind the placenta; little to no visible bleeding.

  • Complete Concealed Abruption: The entire placenta separates, but blood is trapped. This is the most severe form, leading to fetal distress or demise and maternal shock.

  • Complete Apparent Abruption: Entire separation with massive vaginal hemorrhage.

• Signs/Symptoms: Sudden vaginal bleeding, severe abdominal pain, a "board-like" rigid uterus, uterine irritability, and fetal distress (e.g., late decelerations, decreased variability).

• Consequences:

  • Maternal: Disseminated intravascular coagulation ($DIC$), renal failure, shock.

  • Fetal: Hypoxic-ischemic encephalopathy, preterm birth, or death.

Hyperemesis Gravidarum

• Definition: A severe form of nausea and vomiting that interferes with nutrition and hydration.

• Etiology: Likely linked to high levels of $hCG$ and estrogen. Higher risk in multiple gestation or molar pregnancies.

• Distinction from Morning Sickness: Results in significant weight loss, dehydration, ketonuria, and electrolyte imbalances.

• Treatment Goals: Restore hydration via $IV$ fluids, correct electrolyte disturbances (especially potassium), improve nutrition via a gradual diet introduction (clear liquids to bland foods), and manage with anti-emetics (Ondansetron/Zofran, Vitamin $B6$).

Hypertensive Disorders of Pregnancy

• Gestational Hypertension: Hypertension ($≥ 140/90\,mmHg$) developing after $20$ weeks without proteinuria or organ dysfunction. Blood pressure usually returns to normal postpartum.

• Preeclampsia:

  • Definition: A pregnancy-specific syndrome starting after $20$ weeks involving hypertension and organ involvement.

  • Diagnostic Criteria: $BP ≥ 140/90\,mmHg$ on two occasions $4$ hours apart, plus organ involvement indicators:

    • Proteinuria: $≥ 300\,mg$ in $24$ hours or $≥ 2+$ on dipstick.

    • Thrombocytopenia: Platelets < 100,000/μ L.

    • Renal Insufficiency: Serum creatinine > 1.1\,mg/dL or doubling of baseline.

    • Impaired Liver Function: Elevated $AST/ALT$.

    • Other: Pulmonary edema, or new-onset cerebral/visual disturbances.

  • Symptoms: Headaches, blurred vision, flashing lights, edema in face/hands, and epigastric or right upper quadrant pain.

• Classification:

  • Mild Preeclampsia: $BP ≥ 140/90\,mmHg$, proteinuria $≥ 1+$, minimal lab changes.

  • Severe Preeclampsia: $BP ≥ 160/110\,mmHg$ (twice, $6$ hours apart), proteinuria $≥ 300\,mg$ or $≥ 3+$ dipstick, severe headaches, hyperreflexia, clonus, and decreased urine output.

Management of Preeclampsia and Eclampsia

• Magnesium Sulfate Therapy:

  • Purpose: Used as an anticonvulsant to prevent seizures, not for blood pressure control.

  • Dosing: Loading dose of $4\text{-}6\,g\,IV$, followed by a maintenance infusion of $1\text{-}2\,g/hr$.

  • Therapeutic Range: $4\text{-}8\,mg/dL$.

  • Monitoring: Hourly checks on neuro status, respiratory rate, $DTRs$, clonus, and urine output (Mg is excreted by the kidneys).

  • Toxicity Signs: Decreased $DTRs$ (early), muscle weakness, respiratory depression, and hypotension.

  • Antidote: Calcium gluconate (must be at the bedside).

• Eclampsia: Progression to grand mal seizures. Treatment focuses on stopping the seizure ($Magnesium Sulfate$ bolus), stabilizing the patient, and managing the fetus.

HELLP Syndrome and Chronic Hypertension

• HELLP Syndrome Acronym:

  • H: Hemolysis (RBC breakdown).

  • EL: Elevated Liver enzymes (obstructed flow causing pain/enlargement).

  • LP: Low Platelets (consumption at damage sites).

• HELLP Treatment: Delivery is the only definitive treatment.

• Chronic Hypertension: Hypertension present before pregnancy or before $20$ weeks. Monitor for "superimposed preeclampsia" and fetal growth restriction.

Blood Incompatibility: Rh and ABO Systems

• Rh Incompatibility: Occurs when an Rh-negative mother carries an Rh-positive fetus.

  • Problem: Hemolysis of fetal red blood cells, leading to anemia, hyperbilirubinemia, and hydrops fetalis (generalized edema/heart failure).

  • Prevention: Administer $RhoGAM$ at $28\text{-}32$ weeks and within $72$ hours postpartum (if the infant is Rh-positive).

  • Testing: Indirect Coombs (maternal blood for antibodies) and Direct Coombs (cord blood for antibodies on fetal cells).

• ABO Incompatibility: Occurs when the mother is Type $O$ and the fetus is Type $A$, $B$, or $AB$.

  • Mechanism: Naturally occurring anti-$A$ and anti-$B$ antibodies in the mother cross the placenta.

  • Severity: Usually mild; results in newborn jaundice and mild anemia.

Diabetes Mellitus in Pregnancy

• Gestational Diabetes (GDM): First recognized during pregnancy; placental hormones (estrogen, progesterone, human placental lactogen) act as insulin antagonists, increasing resistance.

• Maternal/Fetal Complications: Higher risk of spontaneous abortion, $UTIs$, polyhydramnios (from fetal polyuria), congenital malformations (neural tube, cardiac), and macrosomia.

• Neonatal Hypoglycemia: At birth, high fetal insulin levels persist without the maternal glucose supply, risking neurologic damage.

• Respiratory Distress Syndrome (RDS): Excess insulin delays surfactant production.

• Screening Procedures:

  • 1-hour Glucose Challenge: $24\text{-}28$ weeks. Non-fasting. Positive if > 140\,mg/dL.

  • 3-hour Oral Glucose Tolerance Test (OGTT): Diagnostic test. Fasting required.

  • Normal OGTT Thresholds: Fasting < 95, 1-hr < 180, 2-hr < 155, 3-hr < 140\,mg/dL. (Diagnosis requires $2$ or more abnormal values).

• Management: Dietary modification (primary), insulin (preferred medication as it doesn't cross the placenta), and regular fetal surveillance ($NST$, $BPP$, ultrasound).

Obesity in Pregnancy

• Risks: Decreased fertility preconception; increased risk of $GDM$, preeclampsia, and C-section during pregnancy.

• Weight Gain Recommendation: $11\text{-}20$ pounds for women entering pregnancy with obesity.

• Clinical Challenges: Need for specialized equipment ($large\,BP\,cuffs$, bariatric beds) and difficulty with external monitoring.

• Postpartum Risks: Venous thromboembolism ($VTE$), poor wound healing, and infection.

TORCH Infections and Other Maternal Infections

• TORCH Overview: Acronym for group of infections causing miscarriage, stillbirth, or severe birth defects.

  • T (Toxoplasmosis): Parasite from undercooked meat or cat feces. Causes vision/neuro problems. Treatment: Spiramycin.

  • O (Other): Syphilis, $HIV$, Varicella.

  • R (Rubella): Risk of Congenital Rubella Syndrome (hearing loss, cataracts, heart defects). MMR vaccine is a live vaccine and must be given before pregnancy.

  • C (Cytomegalovirus/CMV): Most common congenital viral infection. Often asymptomatic in mothers. Causes microcephaly and developmental delays.

  • H (Herpes Simplex/HSV): Concern is neonatal transmission during labor. C-section required if active lesions present. Antivirals ($Valacyclovir$) given starting at $36$ weeks for suppression.

• Group Beta Streptococcus (GBS):

  • Diagnosis: Vaginal/rectal culture at $34\text{-}36$ weeks.

  • Treatment: $IV$ antibiotics (Penicillin) during labor. Goal is $2$ doses, $4$ hours apart, prior to delivery.

• HIV Management: Routine screening; treatment with Antiretroviral Therapy ($ART$) to reduce viral load. C-section recommended if viral load is high. Breastfeeding is avoided in the $US$ to prevent transmission.

• COVID-19: Breastfeeding is supported as the benefits and maternal antibody protection outweigh risks.