Pregnancy Related Complications and Concurrent Disorders During Pregnancy Study Notes
Pregnancy-Related Complications and Concurrent Disorders During Pregnancy
Early Pregnancy Bleeding
Definition
Bleeding before 20 weeks of gestation.
Common Causes
Three most common reasons for early pregnancy bleeding:
Abortion
Ectopic Pregnancy
Hydatiform Mole (a type of gestational trophoblastic disease)
Abortion
Definition
Loss of pregnancy before 20-22 weeks.
Viability: Babies less than 20 weeks or weighing less than 500 grams are generally non-viable.
Types of Abortion
Spontaneous (miscarriage) vs. Induced (elective termination, discussed later).
Statistics
Incidence rates:
12% in mothers < 20 years.
26% in mothers > 40 years.
Causes of Spontaneous Abortions
Congenital Abnormalities: 50-60% due to chromosomal abnormalities.
Maternal Infections
Endocrine Disorders: Particularly hypothyroidism and insulin-dependent diabetes mellitus (IDDM).
Anatomic Defects: Uterine or cervical issues.
Six Subtypes of Spontaneous Abortions
Threatened
Imminent/Inevitable
Incomplete
Complete
Missed
Recurrent
Threatened Abortion
First Sign: Bleeding.
Up to 25% experience light or spotted bleeding, with approximately half resulting in loss.
Hallmark Signs:
Closed cervix
Rising hCG levels
Increased uterine and fetal size
Therapeutic Management
Notify physician.
History taking of any discomforts: backache, cramping, pelvic pain, fever.
Common provider orders:
Ultrasound (U/S) for fetal assessment and heartbeat.
Beta-hCG level checks.
Patient education regarding no intercourse until bleeding ceases, pad counting, assessment of passed tissue, and odor.
Bed rest is not generally effective.
Imminent/Inevitable Abortion
Characteristics: Often cannot be stopped, ruptured membranes, open cervix, heavy bleeding.
Management:
Supportive care and monitoring.
If all products of conception (POC) are expelled, no further treatment is needed.
Excessive bleeding may require dilation and curettage (D&C).
Incomplete Abortion
Characteristics: Some but not all POC expelled, significant bleeding, open cervix.
Management:
Ensure cardiovascular stability due to potential heavy bleeding.
Type and screen, IV line for fluid replacement.
D&C is not typically performed after 14 weeks; Pitocin (Oxytocin) is used instead.
Complete Abortion
Definition: All POCs expelled; contractions and bleeding cease; cervix closes.
Management: Confirmation of complete expulsion; no further intervention unless excessive bleeding or infection occurs.
Missed Abortion
Definition: The fetus dies but remains in the uterus; pregnancy symptoms disappear.
Management: D&C or labor induction; potential complications include infection or disseminated intravascular coagulation (DIC).
Signs of Uterine Infection
Clinical Indicators:
Uterine tenderness/pain
Elevated temperature
Elevated WBC count
Foul-smelling vaginal discharge.
Disseminated Intravascular Coagulation (DIC)
Definition: Coagulation defect due to retained POC from missed abortion; leads to stimulation of both anticoagulation & coagulation factors.
Recurrent Spontaneous Abortions
Also known as habitual abortions, three or more consecutive spontaneous abortions.
Causes:
Genetic or chromosomal abnormalities (primary reason).
Reproductive tract anomalies, insufficient progesterone secretion, autoimmune diseases (e.g., lupus), diabetes, reproductive infections, and STIs.
Nursing Considerations for Abortions
Monitor for:
Hypovolemic shock (e.g., tachycardia, lightheadedness).
Emotional support and fluid/blood volume management as ordered.
Ectopic Pregnancy
Risk Factors
History of STDs (e.g., gonorrhea, chlamydia).
History of pelvic inflammatory disease (PID).
Previous ectopic pregnancies.
Failed tubal ligation.
Intrauterine device usage.
Multiple induced abortions.
Cigarette smoking.
Age > 35.
Use of assisted reproductive technologies (ART).
Definition
Ectopic Pregnancy: Implantation of a fertilized ovum outside the uterine cavity (more than 95% in the fallopian tube).
Incidence and Etiology
The number of worldwide from 4.5/1000 to 19.7/1000 since 1970.
Most common in non-white women over age 35 with anatomical defects or scarring in the fallopian tubes.
Ectopic Pregnancy Types:
Ampullary
Isthmic
Interstitial
Intraligamentous
Infundibular
Ovarian
Fimbrial
Intramural
Cervical
Abdominal
Signs and Symptoms
Missed menstrual period; abdominal/pelvic pain (intermittent or sudden); vaginal spotting or bleeding.
Possible positive urine pregnancy test.
Ruptured Fallopian Tube
Sudden severe pain; intra-abdominal hemorrhage; irritation of the diaphragm (pain may radiate tothe shoulder and neck).
Pain worsens on inspiration; signs of hypovolemic shock may occur with minimal external bleeding.
Diagnosis and Treatment
Diagnosis via transvaginal ultrasound and serum hCG (lower levels than expected).
Treatment Options:
Methotrexate: Cytotoxic drug (folic acid antagonist) that inhibits embryonic cell division, requiring monitoring of hCG levels.
Surgery: Performed if Methotrexate fails or if the tube ruptures (options include salpingostomy or salpingectomy).
Nursing Care for Ectopic Pregnancies
Key goals include:
Prevention/identification of hypovolemic shock.
Pain management.
Educating on Methotrexate side effects (e.g., nausea).
Avoiding alcohol and folic acid-containing vitamins, as they can reduce Methotrexate effectiveness.
Advise abstaining from intercourse until hCG levels are undetectable.
Provide emotional support and prompt care for signs of possible rupture.
Gestational Trophoblastic Diseases
Definition
Spectrum of diseases, including benign hydatidiform mole and gestational trophoblastic tumors (e.g., invasive moles, choriocarcinoma).
Hydatidiform Mole (Molar Pregnancy)
Description: Trophoblast cells develop abnormally, forming only a placenta, leading to grape-like clusters in the uterus.
Types:
Complete mole: No fetal tissue present.
Partial mole: May have fetal tissue or membranes.
Incidence, Etiology, and Symptoms
Occurs in 1 in 1000 to 1500 pregnancies; higher incidence at early and late reproductive ages and with previous molar pregnancy.
Symptoms include vaginal bleeding (may be dark brown or bright red), enlarged uterus, increased nausea/vomiting, and early pregnancy-induced hypertension (PIH).
Diagnosis and Treatment
Diagnosed via ultrasound; treatment involves evacuation of the mole (usually vacuum aspiration) and monitoring of Beta-hCG levels until normal levels are achieved.
Critical follow-up required to identify potential malignancy (choriocarcinoma).
Nursing Care for Early Pregnancy Bleeding
Comprehensive assessment of bleeding and vital signs; lab checks (e.g., hemoglobin, hematocrit, Rh factor, serum hCG).
Provider's ultrasound for further evaluation.
Administer Rho(D) immune globulin if Rh-negative.
Discharge teaching on pelvic rest, monitoring, and dietary advice (high in iron/protein).
Late Pregnancy Bleeding
Major Causes
After 20 weeks of pregnancy:
Placenta Previa
Abruptio Placentae
No intrapartal vaginal exam until the bleeding cause is established.
Placenta Previa
Definition
Implantation of the placenta in the lower uterine segment.
Characterized by painless, bright red bleeding.
Diagnosis
Confirmed by ultrasound; preferably vaginal ultrasound for accurate evaluation.
Management
Patients are advised to restrict activity and often require bed rest if bleeding occurs before 37 weeks.
Cesarean delivery is common due to the risk involved with vaginal birth.
Incidence & Etiology
Occurs in approximately 1 in 200-300 pregnancies.
Seen more in older mothers (advanced maternal age), multipara women, those with a history of C-section or suction curettage, and specific ethnic groups (Asian or African).
Signs & Symptoms
Key Indicators:
Sudden onset of painless bleeding in the latter half of pregnancy.
90% experience bleeding associated with cervical dilation, which may lead to severe maternal and fetal bleeding.
Pathophysiology
Unknown, with varying hypotheses.
Management Strategies
Based on maternal-fetal conditions, may require hospitalization for stabilization or home care to delay delivery and administer corticosteroids for fetal lung maturity.
Hospital vs. Home Care Considerations
Home Care: Clinical stability, bed rest, proximity to hospital, emergency transportation, understanding risks, and daily fetal monitoring without interference.
Hospital Care: Continuous monitoring for bleeding and preterm labor, preparedness for delivery via C-section if indicated.
Abruptio Placentae
Definition
Premature separation of the placenta, which can be marginal, partial, or complete, with risk of concealed bleeding.
Bleeding may lead to hematoma formation, impacting fetal gas and nutrient exchange.
Incidence & Etiology
Occurs in 0.5% to 1% of pregnancies but accounts for 10-15% of perinatal deaths, typically in the third trimester.
Risk Factors
Include hypertension, smoking, multigravida status, abdominal trauma, cocaine use, and history of previous abruption.
Classic Signs of Abruptio Placentae
Five Key Signs:
Vaginal bleeding (80%, may not reflect true volume).
Abdominal and low back pain.
Uterine irritability (35% with frequent low-intensity contractions).
High resting uterine tone (detected with an intrauterine pressure catheter).
Uterine tenderness (70% usually localized to the abruption).
Additional signs may include fetal distress and hypovolemic shock.
Concealed Hemorrhage Indicators
Increase in fundal height.
Hard, board-like abdomen.
Persistent abdominal pain and negative or minimal vaginal bleeding.
Nursing Care for Late Bleeding
Initial assessment of bleeding amount/nature; pain assessment; vital signs, and electronic fetal monitoring (EFM) to evaluate fetal condition and contractions.
Laboratory tests: CBC, Rh factor, Kleihauer-Betke test for fetal blood identification, coagulation studies, and drug screening if needed.
Provider management may include bed rest, tocolytics administration, and Rho(D) immune globulin for Rh-negative patients.
Hyperemesis Gravidarum (HEG)
Overview
More severe than typical morning sickness; may begin early in pregnancy and persist.
Associated with electrolyte imbalances, weight loss (≥5%), and dehydration.
Possible Causes
Uncertain, may link to high levels of hCG, particularly in cases of twins or molar pregnancies.
Treatment
Hospitalization, NPO, IV therapy until vomiting resolves for 48 hours, then gradual diet reintroduction. About 27% may require recurrent treatments.
Nursing Actions in HEG
Administration of antiemetics as prescribed.
Nutritional/dietary consultations are vital.
Encourage proper oral hygiene.
Daily weight monitoring and hydration status checks.
Monitor lab values to assess metabolic state.
Dietary considerations: small, frequent meals, use of ginger or vitamin B6 as complementary therapies. TPN/steroids (methylprednisolone) if necessary.
Infections During Pregnancy
Overview
Range of infections and implications for pregnant individuals and their fetuses covered in pages 569-575.
TORCH Infections
An acronym for major fetal infections:
Toxoplasmosis
Others (Hepatitis B, varicella-zoster virus, HIV)
Rubella
Cytomegalovirus (CMV)
Herpes Simplex Virus (HSV)
Cytomegalovirus (CMV)
Overview
Part of the herpesvirus group; no effective treatment.
If primary CMV infection occurs during pregnancy, there is a 20-30% mortality rate at birth; 10% of infected fetuses may show severe disabilities (including growth restriction and hearing loss).
Prevention Strategies
Frequent hand washing, especially after diaper changes or interactions with children.
Avoid sharing utensils, and clean surfaces contacting children's saliva/urine.
Rubella
Overview
Transmitted via droplets or direct contact; presents with flu-like symptoms and maculopapular rash.
Can induce miscarriage, stillbirth, or Congenital Rubella Syndrome (CRS) if contracted in the first trimester (90% risk).
CRS can result in serious effects such as hearing loss and heart defects.
Management
Prevention: Immunization before pregnancy; check immunity status during the postpartum period.
Genital Herpes
Usually caused by HSV-2; significant risk during pregnancy, as primary infections can severely affect the fetus.
Treatment includes Acyclovir to suppress symptoms; cesarean delivery is often indicated in case of visible lesions to prevent transmission.
Hepatitis B
Overview
Viral transmission through bodily fluids readily crosses the placenta.
Management
Screening during pregnancy; administer HBIG to newborns of infected mothers within 12 hours of birth, along with the vaccination schedule.
Human Immunodeficiency Virus (HIV)
Overview
Pregnancy does not accelerate HIV/AIDS; antiretroviral therapy (ART) helps reduce transmission risk.
Care requires closer prenatal visits.
Treatment Protocol
Early maternal treatment with Zidovudine (ZDV), combined with other medications, can start as early as 14-34 weeks of gestation.
Newborn treatment initiation begins within 6-12 hours after birth, lasting up to 6 weeks.
Prevention of Infant Transmission
Scheduled cesarean delivery before labor to minimize the chance of ruptured membranes (ROM).
Limit invasive procedures during labor and delivery.
Exclusive bottle-feeding is recommended to prevent breastfeeding transmission.
Nonviral Infections
Toxoplasmosis: Protozoal infection through raw meat or cat feces; can cause severe congenital abnormalities.
Group B Streptococcus (GBS): Common vaginal flora, but can cause neonatal pneumonia/sepsis. Screening and treatment during labor are needed to prevent complications.
Urinary Tract Infections: Common during pregnancy; can lead to severe complications if untreated—aggressive treatment with antibiotics advised.
STIs: Important to screen all women during the first prenatal visit and treat accordingly.