chapter 20

Chapter 20: Conditions Occurring During Pregnancy

Multiple Pregnancy

• Definition of Multiple Pregnancy

  • Occurs when a woman carries more than one fetus during a single pregnancy. The two main types are:

  • Dizygotic (Fraternal) Twins: Arise from the fertilization of two separate eggs (ova).

    • Risks Associated with Dizygotic Twinning:

      • Use of fertility drugs.

      • Certain ethnic backgrounds.

      • Family history of twinning.

  • Monozygotic (Identical) Twins: Result from the fertilization of one ovum, which subsequently splits.

    • Monozygotic twinning is considered a random, spontaneous event.

• ### Risks of Multifetal Pregnancies

  • Multifetal pregnancies lead to various maternal and fetal risks including:

  • Gestational diabetes.

  • Hypertensive disorders (including preeclampsia).

  • Pulmonary embolism.

  • Fetal growth restriction.

  • Fetal anomalies.

  • Early pregnancy loss.

  • Stillbirth.

  • Placenta previa.

Embryonic Development Stages

• ### Cleavage Stages of Development

  • Days 1-3: Cleavage begins after fertilization, resulting in a morula.

  • Days 4-8: Formation of a blastocyst, leading to implantation.

  • Days 8-15: Different types of twin formations occur:

  • Dichorionic-Diamniotic: Two chorions and two amniotic sacs.

  • Monochorionic-Diamniotic: One chorion and two amniotic sacs.

  • Monochorionic-Monoamniotic: One chorion and one amniotic sac.

  • Conjoined Twins: Formed from late or incomplete cleavage, associated with high risks.

Hyperemesis Gravidarum (HG)

• ### Definition and Symptoms

  • HG is characterized by severe nausea and vomiting during pregnancy, leading to complications such as:

  • Significant weight loss.

  • Malnutrition.

  • Dehydration.

  • Ketonuria.

  • Electrolyte imbalances.

• ### Nursing Considerations

  • Nurses must evaluate signs of dehydration and malnutrition and perform laboratory tests.

• ### Treatment Options

  • May include:

  • Antiemetics (note: some have teratogenic effects).

  • Intravenous (IV) rehydration.

  • Administration of parenteral electrolytes.

• ### Risk Factors for HG (Box 20.1)

  • History of hyperemesis gravidarum.

  • Gestational trophoblastic disease.

  • Multiple pregnancy.

  • Hyperthyroidism.

  • Pre-existing gastrointestinal disease.

  • Pregnancy with a female fetus.

Bleeding in Pregnancy: Miscarriage

• ### Prevalence and Causes

  • Up to 20% of females experience vaginal bleeding during early pregnancy, which may indicate:

  • Miscarriage.

  • Ectopic pregnancy.

  • Gestational trophoblastic disease.

  • Miscarriage (spontaneous abortion) occurs before 20 weeks gestation with about 70% linked to chromosomal abnormalities.

• ### Symptoms and Evaluation

  • Indicators of potential miscarriage:

  • Symptoms of bleeding.

  • Cramping.

  • Passage of tissue.

  • Diagnostic methods include:

  • Ultrasound to evaluate pregnancy.

  • Measuring beta hCG levels.

• ### Types of Spontaneous Abortion (Table 20.1)

  1. Complete Abortion:

  • Symptoms: Passing of clots and tissue with heavy cramping and decreasing bleeding.

  1. Missed Abortion:

  • Symptoms: Amenorrhea, cervix closed, non-developing pregnancy.

  1. Inevitable Abortion:

  • Symptoms: Heavy cramping and bleeding; cervix open.

  1. Threatened Abortion:

  • Symptoms: Closed cervix but bleeding present.

  1. Recurrent Abortion:

  • Defined as two or more clinically documented losses.

Bleeding in Pregnancy: Ectopic Pregnancy

• ### Definition and Risks

  • Occurs when a pregnancy implants outside of the uterus, commonly in the fallopian tube and considered life-threatening.

• ### Symptoms

  • Severe pelvic pain (may be referred to the shoulder) and bleeding.

• ### Diagnosis

  • Identified through serial beta hCG tests and transvaginal ultrasound.

• ### Risk Factors for Ectopic Pregnancy

  • History of pelvic infection or previous ectopic pregnancy.

  • History of subfertility or fertility treatments.

  • Smoking.

  • Douching.

  • Increased maternal age.

• ### Treatment Options

  • Medical or surgical management, depending on discovery timing.

• ### Nursing Considerations

  • Nurses should provide both physical and emotional support to patients.

Bleeding in Pregnancy: Gestational Trophoblastic Disease (GDP)

• ### Definition

  • GDP (molar pregnancy) is a nonviable mass of trophoblastic tissue that grows abnormally.

• ### Symptoms and Diagnosis

  • Produces abnormally high levels of beta hCG detectable via ultrasound.

• ### Treatment Options

  • May require hysterectomy or dilation and curettage; potential prophylactic chemotherapy and monitoring of serum hCG levels for 6 months to 1 year. Patients should avoid pregnancy for 1 year post-treatment.

Hypertensive Disorders of Pregnancy

• ### Gestational Hypertension

  • Diagnosed when systolic blood pressure exceeds 140 mm Hg or diastolic exceeds 90 mm Hg without protein in urine or signs of organ dysfunction by 20 weeks.

  • Complications may include:

  • Development of preeclampsia (risk in ~50% of cases).

  • Premature birth.

  • Small for gestational age (SGA) infants.

  • Placental abruption.

Preeclampsia and Eclampsia

• ### Preeclampsia

  • Occurs in 2% to 5% of pregnancies; can lead to:

  • Oligohydramnios.

  • Placental abruption.

  • Intrauterine growth restriction (IUGR).

  • Affects maternal organs leading to renal failure, pulmonary edema, hepatic damage, or cerebral edema.

• ### Diagnosis of Preeclampsia

  • Requires systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg on two occasions at least 4 hours apart during pregnancy with previously normal BP.

  • Proteinuria criteria are included:

  • Protein ≥300 mg/24 hours or protein:creatinine ratio ≥0.3 or 1+ on dipstick.

  • Additional criteria include thrombocytopenia, elevated serum creatinine, elevated liver enzymes, pulmonary edema, and visual or cerebral symptoms.

• ### Assessment Considerations

  • Frequent assessments include monitoring blood pressure, urine output, laboratory tests, headache severity, vision changes, and fetal monitoring.

• ### Treatment Approaches

  • High-risk patients may start aspirin and calcium supplements.

  • Outpatient monitoring for mild preeclampsia may not require medication.

  • Induction may be necessary for patients with severe preeclampsia.

  • Magnesium sulfate is administered to prevent seizures, reducing CNS irritability and hypertension.

Magnesium Sulfate Administration

• Administration Guidelines:

  • Begin with a loading dose of 4-6 g IV over 15-30 minutes, followed by a maintenance dose of 1-3 g/hour aimed for a serum magnesium level of 4-7 mEq/L.

• Signs of Magnesium Toxicity include:

  • Respiratory depression, oliguria, absent reflexes, lethargy, slurred speech, and loss of consciousness.

  • Interventions for toxicity: Discontinue infusion and administer calcium gluconate (1 g slow IV push).

Gestational Diabetes

• ### Definition and Prevalence

  • Occurs in about 6% of pregnancies, characterized by insulin resistance leading to high blood glucose levels.

• ### Screening Recommendations

  • High-risk patients screened early; all patients screened at 24-28 weeks using a 50 g non-fasting glucose tolerance test.

  • Diagnostic testing involves a 100 g fasting glucose tolerance test.

  • Elevated thresholds for diagnosis:

    • Fasting ≥95 mg/dL.

    • 1 hour ≥180 mg/dL.

    • 2 hours ≥155 mg/dL.

    • 3 hours ≥140 mg/dL.

• ### Risks Associated with Gestational Diabetes

  • Stillbirth, fetal macrosomia, postpartum hemorrhage, and future diabetes risk.

• ### Patient Teaching for Nutrition

  • Follow weight gain recommendations per BMI.

  • Monitor carbohydrate intake, aiming for 35%-40% of total calories from complex carbohydrates.

  • Protein intake of 20%-30% and fats of 40%-45%.

  • Maintain regular eating intervals and avoid long fasting periods.

• ### Monitoring Recommendations

  • Fasting blood glucose <95 mg/dL; 1-hour <140 mg/dL; 2-hour <120 mg/dL. Control helps achieve optimal birth outcomes.

Infections in Pregnancy

• ### Common Infections and Their Risks

  • Includes STIs, vaginitis, TORCH infections, and UTIs.

• ### Specific Infections and Treatment

  • Chlamydia and Gonorrhea: Treat with antibiotics to reduce risk of preterm labor.

  • Herpes: Administer antivirals in late pregnancy if lesions present; cesarean delivery recommended.

  • HIV: Delivery via cesarean may be indicated to minimize transmission risk.

  • Hepatitis B: Infants should receive vaccination and immune globulin post-birth.

• ### TORCH Infections

  • A group of infections (Toxoplasmosis, Other infections, Rubella, CMV, Herpes) associated with fetal anomalies but often asymptomatic in mothers. UTIs should be treated even if asymptomatic.

Cervical Insufficiency

• ### Definition and Diagnosis

  • Characterized by painless premature dilation of the cervix, often leading to miscarriage or premature birth; diagnosed via history and cervical length measurement.

• ### Treatment Options

  • May include maternal progesterone supplementation and cervical cerclage (different types include McDonald, Shirodkar, transabdominal cerclage).

Trauma in Pregnancy

• ### Causes and Care Considerations

  • Trauma may originate from motor vehicle accidents, falls, or violence.

  • Care considerations include using a wedge to stabilize the patient, awareness of altered CPR effectiveness, and monitoring for hypoxia and placental abruption.

  • Rh-negative patients may require Rho(D) immune globulin.

Intrauterine Growth Restriction (IUGR)

• ### Definition and Risks

  • Indicates a pregnancy complication; diagnosed in 10% of pregnancies.

  • IUGR signifies that the fetus is not reaching its growth potential due to maternal, placental, or fetal factors.

• ### Key Differences

  • SGA (Small for Gestational Age) defines weight <10th percentile, whereas IUGR indicates an underlying pathological process.

• ### Causes of IUGR (Box 20.12)

  • Asymmetric IUGR: Associated with uteroplacental insufficiency, maternal health issues, and multiple gestation.

  • Symmetric IUGR: Linked to infections (TORCH), substance abuse, chromosomal abnormalities, and smoking.

Amniotic Fluid Volume Disorders

• # Polyhydramnios

  • Excess amniotic fluid; may be related to diabetes or twin-to-twin transfusion.

  • Diagnosed with ultrasound; abnormal AFI ≥24 cm.

  • Treatment may involve amnioinfusion or induction.

• ### Oligohydramnios

  • Decrease in amniotic fluid; diagnosed when AFI ≤5 cm.

  • Associated with poor prognosis, often requiring amnioinfusion.

Risks Associated with Amniotic Fluid Volume Disorders

• Patients may experience:

  • Preterm birth due to uterine overdistension (polyhydramnios) or fetal intolerance of labor (oligohydramnios).

  • Umbilical cord prolapse due to excess fluid or cord compression.

Dermatoses of Late Pregnancy

• ### Intrahepatic Cholestasis of Pregnancy

  • Caused by impaired bile flow; symptoms include intense itching, jaundice, fatigue.

  • Treatment focuses on minimizing symptoms and may necessitate early delivery.

• ### Pruritic Urticarial Papules and Plaques of Pregnancy

  • Characterized by pruritic papules; treat with topical corticosteroids and antihistamines. Resolves after birth.