At-Risk Pregnancies - Nursing Care Management

At-Risk Pregnancies Overview

  • Focus: Understanding high-risk prenatal clients, complications, and nursing care planning.
  • Primary complications: Those that can affect maternal and fetal outcomes.

Ectopic Pregnancy

  • Definition: Implantation occurs outside the uterine cavity (99% in fallopian tubes).
  • Common Symptoms:
    • Vaginal bleeding
    • Missed menstruation
    • Abdominal tenderness or pain, especially after rupture.
    • Referred shoulder pain due to diaphragmatic irritation.
Risk Factors:
  • History of pelvic inflammatory disease or STIs.
  • Previous ectopic pregnancies.
  • Prior tubal or pelvic surgery.
  • Endometriosis.
  • Assisted reproductive techniques (IVF, etc.).
  • Use of intrauterine device (IUD).
Assessment:
  • Abdominal pain (unilateral/bilateral).
  • Missed period.
  • Possible palpable mass during bimanual examination.
  • Symptoms of active bleeding (hypotension, tachycardia, vertigo).
Diagnosis:
  • Increased WBC count.
  • Transvaginal ultrasound (TVS).
Management:
Non-surgical:
  • Methotrexate: Used for unruptured ectopic pregnancies (mass ≤4 cm).
  • Criteria for use: Unruptured, ≤4 cm, no cardiac activity, no acute abdomen.
Surgical:
  • Salpingectomy: Removal of ruptured tube.
  • Salpingostomy: Incision in fallopian tube to remove ectopic tissue.

Gestational Trophoblastic Disease (GTD)

  • Definition: Abnormal placental development leading to fluid-filled masses instead of normal tissue.
    • Types: Hydatidiform mole (complete/incomplete), metastatic mole, choriocarcinoma.
  • Epidemiology: Occurs in 1 in 1200 pregnancies.
Types of Molar Pregnancies:
  1. Complete Mole:
    • Trophoblastic proliferation, no fetal parts.
    • All chromosomes paternally derived.
  2. Incomplete Mole:
    • Fetus coexists with abnormal placental tissue (triploidy).
Diagnosis of Mole:
  • Ultrasound: “Snowstorm” appearance of the placenta.
Management:
  • Removal of uterine contents: Followed by serial beta-hCG assessments until undetectable on two consecutive tests.
  • Contraception: Essential for at least one year post-treatment to prevent confusion in hCG levels.

Hyperemesis Gravidarum

  • Severe nausea/vomiting; leading cause of hospital admission in early pregnancy.
  • Associated Factors: Elevated estrogen/hCG, multiple gestations, previous history, etc.
Effects:
  • Maternal: Weight loss, psychosocial issues (depression, anxiety).
  • Fetal: Intrauterine growth restriction (IUGR).
Diagnosis:
  • Persistent vomiting without identifiable cause, weight loss >5% of pre-pregnancy weight, ketonuria.
Management:
  • Lifestyle: Small, frequent bland meals, avoiding triggers.
  • Supplements: Multivitamins before pregnancy, ginger for nausea.

Abortion Types

  • Definition: Expulsion of embryo ≤500 grams, incapable of independent survival.
Classifications:
  1. Spontaneous Abortion (SAB):
    • Types:
      • Threatened, Inevitable, Complete, Incomplete, Missed, Recurrent.
    • Management: Ultrasound, possibly dilation and curettage (D&C).

Placenta Previa

  • Definition: Placenta covers or is near the internal cervix, causing risk of bleeding.
  • Types: Complete, Partial, Marginal.
Risk Factors:
  • History of C-sections, multiparity, advanced maternal age, smoking.
Symptoms:
  • Painless vaginal bleeding.
Management:
  • No vaginal examinations, monitor fetal heart tone, possible administration of Betamethasone for lung maturity if delivery is premature.

Abruptio Placenta

  • Definition: Premature separation of normally implanted placenta from uterine wall.
Classifications:
  • Grade 1: Slight bleeding, normal fetal heart rate.
  • Grade 2: Moderate bleeding, possible fetal heart rate compromise.
  • Grade 3: Severe complications, possible fetal death.
Nursing Considerations:
  • No vaginal examinations, continuous fetal monitoring, readiness for blood transfusions, administration of steroids if premature delivery is expected.

Hypertensive Disorders in Pregnancy

  • Gestational/Transient Hypertension: Detection of elevated blood pressure without proteinuria.
Preeclampsia:
  • Defined by high blood pressure and proteinuria after 20 weeks of gestation.
  • Risk Factors: Primigravida, extremes of age, multiple gestation, obesity, family history, etc.
Management:
  • Delivery is the only cure.
  • Home management possible for mild cases after careful monitoring of symptoms and laboratory results.