Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications

High-Risk Pregnancy

  • Jeopardy to pregnant person, fetus, or both.
  • Condition due to pregnancy or a result of a pre-existing condition.
  • Associated with higher morbidity and mortality.
  • Risk assessment is conducted during the first antepartal visit and is ongoing.
  • Diverse factors contribute to high-risk pregnancies.

Pregnancy Complications

  • Bleeding during pregnancy
  • Hyperemesis gravidarum
  • Gestational hypertension
  • HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count)
  • Gestational diabetes
  • Blood incompatibility
  • Amniotic fluid imbalances
  • Multiple gestation
  • Premature rupture of membranes

Conditions Associated With Early Bleeding During Pregnancy

  • Spontaneous abortion
  • Ectopic pregnancy
  • Gestational trophoblastic disease
  • Cervical insufficiency

Spontaneous Abortion

  • First trimester abortions are commonly due to fetal genetic abnormalities.
  • Second trimester abortions are more likely related to maternal conditions.
  • Cause can be unknown and highly variable.
    • Nursing assessment includes:
      • Vaginal bleeding
      • Cramping or contractions
      • Vital signs, pain level
      • Patient’s understanding

Types of Spontaneous Abortion

  • Threatened
  • Inevitable
  • Incomplete
  • Complete
  • Missed
  • Habitual
Abortion Classification Characteristics:

  • Threatened:

    • Abdominal pain or bleeding in the first 20 weeks of gestation.
    • Cervical os is closed.
    • No passage of fetal tissue.

  • Inevitable:

    • Abdominal pain or bleeding in the first 20 weeks of gestation.
    • Cervical os is open.
    • No passage of fetal tissue.

  • Incomplete:

    • Abdominal pain or bleeding in the first 20 weeks of gestation.
    • Cervical os is open.
    • Some products of conception still remain in the uterus.

  • Complete:

    • Abdominal pain or bleeding in the first 20 weeks of gestation.
    • Cervical os is closed.
    • Complete passage of fetal parts and placenta; uterus contracted.

  • Septic:

    • Infection of uterus during miscarriage, fever and chills, usually due to Staph. aureus.
    • Cervical os is open with purulent cervical discharge. Uterine tenderness
    • None or may be incomplete.

  • Missed Abortion:

    • The pregnancy stops developing, but the body does not expel the tissue.
      • Symptoms:
        • Many women experience no symptoms or only mild ones, like a change in early pregnancy symptoms or brownish vaginal discharge.
      • Diagnosis:
        • Through ultrasound, which may show an embryo or fetus without a heartbeat or an empty gestational sac.
      • Causes:
        • Chromosomal abnormalities, hormonal imbalances, uterine problems, and infections.
      • Treatment:
        • Expectant management (waiting for the body to naturally expel the tissue),
        • Medical management (using medication to induce miscarriage), (Mifepristone together with misoprostol),
        • Surgical management (Dilation and Curettage to remove the tissue).
      • Outlook:
        • Most women who experience a missed abortion can successfully have a healthy pregnancy later

  • Habitual Abortion:

    • Also known as recurrent pregnancy loss or recurrent miscarriage, refers to the occurrence of three or more consecutive pregnancy losses before the 20th week of gestation
      • Causes of Habitual Abortion:
        • Uterine Abnormalities: like fibroids, polyps, or a uterine septum
        • Genetic Issues: Chromosomal abnormalities.
        • Hormonal Imbalances: hyperthyroidism or hypothyroidism
        • Immunological Factors: Autoimmune disorders
        • Infections: Infections during pregnancy, (BV, Chlamydia trachomatis, some viral infections like rubella, cytomegalovirus, and herpes simplex virus)
        • Lifestyle Factors: Smoking, alcohol consumption etc
      • Diagnosis and Treatment:
        • A thorough evaluation is needed after two or more miscarriages, a physical exam, karyotyping (genetic testing), and other tests to identify potential causes.
      • Treatment:
        • Identify the cause and may include surgical correction of uterine abnormalities, hormonal adjustments, medications to manage autoimmune conditions, or other interventions.
      • Prognosis:
        • Women can achieve successful pregnancies after identifying and addressing the underlying causes. Some women with habitual abortion may experience increased risks of later complications, such as preeclampsia, and should be monitored accordingly.

Spontaneous Abortion: Nursing Management

  • Continued monitoring:
    • vaginal bleeding
    • pad count
    • passage of products of conception
    • pain level
    • preparation for procedures, medications
  • Support:
    • physical and emotional
    • stress that birthing parent is not the cause of the loss
    • verbalization of feelings, grief support
    • referral to community support group

Ectopic Pregnancy

  • Ovum implantation outside the uterus.
  • Obstruction to or slowing passage of ovum through tube to uterus.
  • Therapeutic management
    • Medical: drug therapy (methotrexate, prostaglandins, misoprostol, and actinomycin)
    • Surgery if rupture
    • Rh immunoglobulin if birthing parent is Rh-negative
Nursing assessment
  • Hallmark sign: abdominal pain with spotting within 6 to 8 weeks after missed menses
  • Contributing factors:
    • Age > 35, cigarette smoking, fallopian tube pathology, infertility, PID, IUD in place, h/o ectopic pregnancy, previous fallopian tube surgery
  • Laboratory and diagnostic testing: Transvaginal ultrasound, serum beta HCG; additional testing to rule out other conditions
Nursing management
  • Preparation for treatment
  • Analgesics for pain
  • Medications for medical treatment: methotrexate ( single IM)
  • Teaching about the signs and symptoms of rupture: Sudden, severe abdominal or pelvic pain, shoulder pain, and dizziness or fainting, vaginal bleeding.
  • Surgery
  • Emotional support
  • Education

Gestational Trophoblastic Disease

  • Two types:
    • Hydatidiform mole (molar pregnancy) mostly benign.
    • Choriocarcinoma (a rare, aggressive cancer that arises from trophoblastic tissue, the cells that form the placenta)
  • Exact cause unknown
  • Therapeutic management:
    • Immediate evacuation of uterine contents (D&C)
    • Long-term follow-up and monitoring of serial hCG levels
Nursing assessment
  • Clinical manifestations similar to spontaneous abortion at 12 weeks
  • Ultrasound visualization
  • High hCG levels
Nursing management
  • Preoperative preparation
  • Emotional support
  • Education: treatment, serial hCG monitoring, prophylactic chemotherapy

Cervical Insufficiency

  • Premature dilatation of cervix
  • Cause unknown; possibly due to cervical damage
  • Therapeutic management
    • Bed rest, pelvic rest, avoidance of heavy lifting
    • Cervical cerclage
Nursing Assessment
  • Risk factors
    • Marfan syndrome: a connective tissue genetic disorder characterized by a tall and slender build, long arms, legs, and fingers, a sunken or protruding chest, curved spine, flat feet, and heart murmurs.
    • Ehlers-Danlos Syndrome: another connective tissue genetic disorder, overly flexible joints, stretchy skin, and easy bruising.
  • Pink-tinged vaginal discharge or pelvic pressure
  • Transvaginal ultrasound to check shortened cervix
Nursing Management
  • Continuing surveillance, close monitoring for preterm labor.
  • Emotional support
  • Education

Placenta Previa

  • Cause unknown; placental implants over the cervical os, lower uterine segment
  • Classification
  • Therapeutic management: dependent on bleeding, amount of placenta over os, fetal development and position, maternal parity, labor signs and symptoms
Nursing Assessment
  • Risk factors: previous C-sections, multiple pregnancies, and smoking
  • Vaginal bleeding (painless, bright red in second or third trimester, spontaneous cessation then recurrence)
Nursing Management
  • Monitoring of maternal–fetal status
    • Vaginal bleeding; pad count
    • Avoidance of vaginal exams
    • FHR
  • Support and education:
    • fetal movement counts
    • effects of prolonged bed rest (if necessary)
    • signs and symptoms to report
  • Preparation for possible cesarean birth

Placental Abruption

  • Separation of placenta leading to compromised fetal blood supply
  • Etiology unknown
  • Therapeutic management: assessment, control, and restoration of blood loss; positive outcome; prevention of DIC
Nursing Assessment
  • Risk factors:
    • previous placenta previa, C-section, surgery, multiple gestation, increasing parity, increasing mom age, infertility treatment, endometriosis/abortion, smoking, cocaine use, male fetus
  • Bleeding (dark red)
  • Pain (knife-like), uterine tenderness, contractions. A board-like abdomen is a physical sign
  • Fetal movement and activity (decreased)
  • Fetal heart rate
  • Laboratory and diagnostic testing: CBC, fibrinogen levels, PT/aPTT, type and cross- match, nonstress test, biophysical profile
Nursing Management
  • Tissue perfusion:
    • left lateral position
    • strict bed rest
    • oxygen therapy
    • vital signs
    • fundal height
    • continuous fetal monitoring
  • Support and education:
    • empathy, understanding, explanations, possible loss of fetus, reduction of recurrence

Hyperemesis Gravidarum

  • Severe form of nausea and vomiting
  • Symptoms usually resolve by week 20
  • Weight loss > 5% of prepregnancy body weight
  • Dehydration, metabolic acidosis, alkalosis, and hypokalemia
  • Therapeutic management:
    • Conservative (diet and lifestyle changes)
    • Hospitalization with parenteral therapy
Nursing Assessment
  • Onset, duration, course of N/V; diet history; risk factors, weight, associated symptoms, perception of situation
  • Liver enzymes, CBC, BUN, electrolytes, urine specific gravity, ultrasound
Nursing Management
  • Comfort and nutrition (NPO, IV fluids, hygiene, oral care, I&O)
  • Support and education: reassurance; home care follow-up

Hypertensive Disorders of Pregnancy

  • Gestational hypertension
  • Preeclampsia
  • Eclampsia
  • Chronic hypertension
  • Chronic hypertension with superimposed preeclampsia
Gestational Hypertension: Management
  • Mild preeclampsia management:
    • Bed rest, daily BP monitoring, and fetal movement counts
  • Severe preeclampsia management:
    • Hospitalization; IV magnesium sulfate during labor
  • Eclampsia management:
    • Hospitalization; oxytocin and magnesium sulfate; preparation for birth
    • Seizure management, magnesium sulfate, antihypertensive agents; birth control once seizures are controlled
Nursing Assessment
  • Risk factors, BP, nutritional intake, weight, edema; urine for protein; other laboratory tests if indicated
Nursing Management
  • Home management for mild preeclampsia
  • Hospitalization for severe preeclampsia:
    • quiet environment, sedatives, seizure precautions, antihypertensives
    • DTR testing, assessing for magnesium toxicity and labor
  • Seizure management for eclampsia; fetal monitoring; uterine contraction monitoring; preparation for birth
  • Follow-up care

HELLP Syndrome

  • Hemolysis, Elevated Liver enzymes, Low Platelets
  • Symptoms include pain in the upper right abdomen, nausea, vomiting, headache, and vision changes.
Nursing Assessment
  • Similar to that for severe preeclampsia; laboratory test results (CBC, liver function tests, and a peripheral blood smear)
Nursing Management
  • Same as for severe preeclampsia
  • Stabilize BP, assess fetal wellbeing, and prevent convulsions and seizures
    • Magnesium Sulfate (MgSO4MgSO_4)
    • Dexamethasone for fetal lung maturity
  • Immediate delivery of baby as life saving

Blood Incompatibility

  • ABO incompatibility: type O pregnant people and fetuses with type A or B blood (less severe than Rh incompatibility)
  • Rh incompatibility: exposure of Rh-negative pregnant person to Rh-positive fetal blood; sensitization; antibody production; risk increases with each subsequent pregnancy and fetus with Rh-positive blood
Nursing Assessment
  • Maternal blood type and Rh status
Nursing Management
  • RhoGAM at 28 weeks

Hydramnios (Polyhydramnios)

  • Amniotic fluid > 2,000 mL
  • Therapeutic management:
    • close monitoring
    • removal of fluid
    • indomethacin (decreases fluid by decreasing fetal urinary output)
Nursing Assessment
  • Risk factors
    • diabetes, carrying multiples, and infections during pregnancy
  • Fundal height, abdominal discomfort, difficulty palpating fetal parts, or obtaining FHR
Nursing Management
  • Ongoing assessment and monitoring; assisting with therapeutic amniocentesis

Oligohydramnios

  • Amniotic fluid < 500 mL
  • Therapeutic management:
    • serial monitoring
    • amnioinfusion and birth for fetal compromise
Nursing Assessment
  • Risk factors
    • premature rupture of membranes, post-term pregnancy, maternal health conditions like hypertension or diabetes, and certain medications
  • Fluid leaking from vagina
Nursing Management
  • Continuous fetal surveillance; assistance with amnioinfusion, comfort measures, position changes

Multiple Gestation

  • Therapeutic management:
    • serial ultrasounds
    • close monitoring during labor
    • operative delivery (common)
Nursing Assessment
  • Uterus larger than expected for EDB; ultrasound confirmation
Nursing Management
  • Education and support antepartally; labor management with perinatal team on standby; postpartum assessment for possible hemorrhage

Premature Rupture of Membranes

  • PROM—pregnant persons beyond 37 weeks’ gestation
  • PPROM—pregnant persons less than 37 weeks’ gestation
  • Treatment: dependent on gestational age; no unsterile digital cervical exams until pregnant person is in active labor; expectant management if fetal lungs immature
Nursing Assessment
  • Risk factors, signs and symptoms of labor, electronic FHR monitoring, amniotic fluid characteristics; nitrazine test, fern test, ultrasound
Nursing Management
  • Infection prevention
  • Identification of uterine contractions
  • Education and support
  • Discharge home (PPROM) if no labor within 48 hours