COMPLICATIONS

OF

PREGNANCYJeanie Ward

Risk FactorsAge under 17 over 35Gravida and ParitySocioeconomic statusPsychological well-beingPredisposing chronic illness diabetes, heart conditions, renal, etc.Pregnancy related conditions hyperemesis gravidarum, PIH, etc.

High Risk Pregnancy Goals of CareProvide with optimum care for the mother and the fetus

Assist the patient and her family to understand and cope with the variations in a High Risk Pregnancy and cope with her feelings

Bleeding Disorders

AbortionsTermination of pregnancy at any time before the fetus has reached the age of viability

Either: spontaneous occurring naturally induced artificial

Etiology / Predisposing FactorsFaulty germ plasm -- imperfect ova or sperm, faulty implantation, genetic make-up (chromosomal disorders), congenital abnormalities

Decrease in the production of progesterone

Drugs or radiation

Maternal causes -- infections, endocrine disorders, malnutrition, hypertension

Assessment Types of Abortions ThreatenedSigns and Symptomsvaginal bleeding, spottingMild cramps, backacheCervix remains CLOSED

Treatment and Nursing CareBed rest, sedation, Avoid stress and intercourseProgesterone therapyA period of watchful waiting

Inevitable AbortionSigns and SymptomsLoss is certainBleeding is more profusePainful uterine contractionsCervix DILATESTreatment and Nursing CareAssess all bleeding. Save all pads. (May need to weigh the pads)Use the bedpan to assess all products expelledTreated by evacuation of the uterus usually be a D & C or suctionProvide Psychological Support

Complete AbortionAll products of conception are expelled

No treatment is needed, but may do a D & C

Incomplete AbortionParts of the products of conception are expelled, with placenta and membranes retained

Treated with a D & C or suction evacuation

Provide support to the family

Missed AbortionThe fetus dies in-utero and is not expelledUterine growth ceasesBreast changes regressMaceration occursTreatment:D & C Hysterotomy

Missed AbortionCritical Thinking Exercise The woman who has a missed abortion is at risk for what 2 conditions?

Habitual Abortion / Premature Cervical DilationAbortion occurs consecutively in three or more pregnancies

Usually due to an Incompetent Cervical Os, that results from cervical trauma, cervical lacerations, repeated D & C, or conization.

Occurs most often about 18-20 weeks gestation.

Habitual AbortionTreatment Cerclage procedure -- purse-string suture placed around the internal os to hold the cervix in a normal state

Nursing CareBedrest in a slight trendlenburg position to decrease the pressure on the new suturesTeach:Assess for leakage of fluid, bleedingAssess for contractionsAssess fetal movement and report decrease movement (if old enough)Assess temperature for elevations

DeliveryWhen time for delivery there are several options: physician will clip suture and allow patient to go into labor on her own induce laborcesarean delivery

Mrs. B. had a cerclage procedure done at 14 weeks gestation. She is now 39 weeks gestation and admitted to labor and delivery because she is in labor.

What is the MOST important assessment to make at this time?

Key Concepts to Remember!!If a woman is Rh-, RhoGam is given within 72 hours

Provide emotional support. Feelings of shock or disbelief are normal

Encourage to talk about their feelings. It begins the grief process

Bleeding Disorders Ectopic PregnancyImplantation of the blastocyst in ANY site other than the endometrial lining of the uterus(5) Cervicalovary

Etiology / Contributing FactorsSalpingitisPelvic Inflammatory Disease, PIDEndometriosisTubal atony or spasmsImperfect genetic development

Assessment Ectopic PregnancyEarly:Missed menstruation followed by vaginal bleeding (scant to profuse)Unilateral pelvic pain, sharp abdominal painReferred shoulder painCul-de-sac massAcute:Shock blood loss poor indicatorCullens sign -- bluish discoloration around umbilicusNausea, VomitingFaintness

Diagnostic Tests Ectopic PregnancyDiagnosis:UltrasoundCuldocentesisLaparoscopy

Interventions / Nursing CareCombat shock / stabilize cardiovascular Draw blood for type and cross matchGive blood replacements IVs.

Laparotomy

Psychological support

Linear salpingostomy

Methotrexate used prior to rupture. Destroys fast growing cells

Hydatiform Mole

EtiologyA DEVELOPMENTAL ANOMALY OF THE PLACENTA WITH DEGENERATION OF THE CHORIONIC VILLI

As cells degenerate, they become filled with fluid and appear as fluid filled grape-size vessicles.

Assessment:Vaginal Bleeding -- scant to profuse, brownish in color (prune juice)Enlargement of the uterus out of proportion to the duration of the pregnancyVaginal discharge of grape-like vesiclesMay display signs of pre-eclampsia earlyHyperemesis gravidariumNo Fetal heart tone or QuickeningAbnormally elevated levels of HCG

Interventions and Follow-UpEmpty the Uterus by D & C or Hysterotomy

Follow-Up for One YearAssess for the development of choriocarcinomaBlood tests for levels of HCG frequentlyChest X-raysPlaced on oral contraceptivesIf the levels rise, then chemotherapy started usually Methotrexate

Critical Thinking ExerciseA woman who just had an evacuation of a hydatiform mole tells the nurse that she doesnt believe in birth control and does not intend to take the oral contraceptives that were prescribed for her.

How should the nurse respond?

Placenta PreviaLow implantation of the placenta in the uterusEtiology Usually due to reduced vascularity in the upper uterine segment from an old cesarean scar or fibroid tumorsThree Major Types:Low or MarginalPartialComplete

Abruptio PlacentaPremature separation of the placenta from the implantation site in the uterus

Etiology:Chronic HypertensionSudden decompression of an over-distended uterusTraumaInjudicious use of PitocinSmoking / Caffeine / CocaineVascular problems

Placenta PreviaPAINLESS vaginal bleedingBright red bleedingFirst episode of bleeding is slight then becomes profuseSigns of blood loss comparable to extent of bleedingUterus soft, non-tenderFetal parts palpable; FHTs countableBlood clotting defect absent Abruptio PlacentaBleeding accompanied Abruptio by PAINDark red bleedingFirst episode of bleeding usually profuse

Signs of blood loss out of proportion to visible amount Uterus board-like, painfulFetal parts non-palpable, FHTs non-countableBlood clotting defect (DIC) likely

Signs of Concealed HemorrhageIncrease in fundal heightHard, board-like abdomenHigh uterine baseline tone on electronic fetal monitoringPersistent abdominal painSystemic signs of hemorrhage

Interventions and Nursing CarePlacenta PreviaBed-restAssessment of bleedingElectronic fetal monitoringIf it is low lying, then may allow to deliver vaginallyCesarean delivery for All other types of previaAbruptio PlacentaDeliver by cesarean delivery immediatelyCombat shock blood replacement / fluid replacementBlood work assessment of DIC

Critical ThinkingMrs. A. , G3 P2, 38 weeks gestation is admitted to L & D with bleeding. What is the priority nursing intervention at this time?Assess the fundal height for a decreasePlace a hand on the abdomen to assess if hard, board-like, tetanicPlace a clean pad under the patient to assess the amount of bleedingPrepare for an emergency cesarean delivery

Disseminated Intravascular Coagulation (DIC) Anti-coagulation and Pro-coagulation effects existing at the same time.

EtiologyDefect in the Clotting CascadeAn abnormal overstimulation of the coagulation process Activation of Coagulation with release of thromboplastin Thrombin (powerful anticoagulant) is produced Fibrinogen fibrin which enhances platelet aggregation Widespread fibrin and platelet deposition in capillaries and arterioles

Resulting in Thrombosis (multiple small clots)Excessive clotting activates the fibrinolytic systemLysis of the new formed clots create fibrin split productsThese products have anticoagulant properties and inhibit normal blood clottingA stable clot cannot be formed at injury sitesHemorrhage occursIschemia of organs follows from vascular occlusion of numerous fibrin thrombiMultisite hemorrhage results in shock and can result in death

Disseminated Intravascular Coagulation (DIC)Precipating Factors:Abruptio placentaPIHSepsisRetained fetus (fetal demise)Fetal placenta fragments

Assessment Signs and Symptoms Spontaneous bleeding -- from gums and Epistasis, and injection and IV sites, incisions

Excessive bleeding -- Petechiae at site of blood pressure cuff, pulse points. Ecchymosis

Tachycardia, diaphoresis, restlessness, hypotension

Hematuria, oliguria, occult blood in stool

Mental changes if brain affected.

Diagnostic TestsLab work reveals:PT Prothrombin time is prolongedPTT Partial Thromboplastin Time increasedD-Dimer increased Product that results from fibrin degradation. More specific marker of the degree of fibrinolysisPlatelets -- decreased Fibrin Split Products increase

An increase in both FSP and D-Dimer are indicative of DIC

DICInterventions and Nursing CareRemove CauseEvaluate vital signsReplace blood and blood productsFluid replacement

May give Heparin -- interrupt the clotting cascade and prevent triggering the fibrinolytic system.

Structural Disorders

Fetal Demise / Intrauterine Fetal Death DEFINITION: Death of a fetus after the age of viability

Assessment: 1. First indication is usually NO fetal movement

2. NO fetal heart tones Confirmed by ultrasound

3. Decrease in the signs and symptoms of pregnancy

Interventions and Nursing CareAllow patient to decide when she wants to deliver

Most women go into labor on their own in 2 weeks, so may wait for labor to begin spontaneously

Induce labor Prostaglandin (Prostin E) causes smooth muscles to contract: Side effects - nausea, vomiting, diarrhea Cytogel

Provide with Emotional Support, allow to hold baby

The End

1111111222233334444555566667777888899991010101011111111121212121313131314141414161616151515151717171818181919192020202121212222232323242425252727262628282929222