2155 Complications of Pregnancy

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2nd leading cause of Death

Preeclampsia

Gestational HTN

BP>140/90
Identified after 20 wks
No protienuria

Preeclampsia

BP>140/90
After 20 wks
Protienuria
Often edema (wt gain)

Eclampsia

Preeclampsia + seizures

Chronic HTN

BP up prior to 20 wks

Chronic HTN with preeclampsia

HTN before 20wks and protienuria/edema

HELLP syndrome

Complication of preeclamsia
Pt very ill
H- Hemolysis
EL- Elevated liver
LP- Low platelets

During a normal pg, cardiovascular resistance usually?

Decreases

In a normal pg the Glomerular Filtration Rate (GFR)

Increases

In a normal gp blood volume and cardiac output

Increase

Chronic HTN Diet

DASH- Dietary Approaches to Stop Hypertention
Exercise
Wt loss
No salt

What type of antihypertensives are contraindicated and why?

ACE inhibitors and Angiotensesin II receptor antagonists are terotogens.
They decrease uterine blood flow= IUGR or IUFD

Aldomet (methydopa)

May be given to pg woman if bp >160/100
750-2000mg/24hrs

Labetalol may also be used

If pt had HTN before pregnancy

they are 4-8x greater to have a placental abruption

Pathophys of HTN w/ pg

Exact cause unknown- linked to defective placentation

GFR lowers
Glomerular damage- increased permeability to protiens (increased protien in urine)
Decreased blood flow to brain of mom and placenta- On EFM you could see late decels and minimal variability

A pt with HTN during pg should increase protien in the diet

to promote fetal growth

Risk factors for G-HTN

Age under 19 and over 40
Hx of PIH
1st pg with new father
Primip or Multip >5
African Americans
Low Socioeconomic status
Preexisting disease (DM, Renal, Vascular)
Family hx HTN
Multiple Gestation pg
Obesity

presenting S/S G-HTN

Rise in BP over baseline 140/90
Sudden wt gain- d/t increase in ECF, not explained by caloric intake, edema check (fingers, face, feet)
Protienuria, Decreased urine output, Thirst
N/V, HA, Epigastric pain, visual disturbances, fatigue

Mild Preeclampsia

BP 140-160/90-100
Protienuria <500mg/24hrs

Severe Preeclampsia

>160/100
Protienuria >500mg/24hrs
(5grams/24hrs)

Pt can get critically ill very quickly!

Cure for preeclampsia

Delivery of baby

critical issue- is the fetus ready for extrauterine life?

Mild Preeclampsia Tx

Tx early to protect mom and baby
Monitor carefully, intervene prn
Bedrest (lying on either side with increase perfusion to maternal kidneys)
High protien diet, good hydration
Office visits 2x wk, NST and BPP done weekly

Teach pt and family signs of worsening condition!! It is vital, could save lives.

S/S severe preeclampsia

CNS- HA unrelieved by tylenol, "blind spots", hyper-reflexia with clonus

Renal- Decreased GFR, urine output (<30cc/hr), increased creatinine

Liver- epigastric pain, elevated liver enzymes (AST/ALT)

normal female creatinine level

0.5-1.5

normal AST (aspartate transaminase)

10-36

Normal ALT (alanine aminotransferase)

7-35

obesity also causes increased ALT

Tx of Severe Preeclampsia

Goal is to px further harm to mom and baby, px seizures, get baby viable
Hospitalization
MgSO4- px seizures
Monitor for development of HELLP
Delivery plan

MgSO4

anticonvulsant- increases seizure threshold. blocks neuromuscular transmission, relaxes smooth muscles so BP may decrease.
Excreted by kidneys- make sure adequate UO
Always give IVPB

MgSO4 loading and maintenance dose

Loading 4-6 grams over 20 minutes
Followed by 1-3 grams per hour

Therapeutic range 4-8mg/dl

Onset- STAT
Duration- 3-4hrs

Antidote for MgSO4

Calcium gluconate

always have it on hand when infusing mag

MgSO4 contraindications

Myasthenia Gravis

HELLP syndrome

H: Hemolysis= decrease in Hbg, RBCs, platelets
EL: Elevated Liver enzymes (AST (10--36) / ALT(7-35))
LP: Low Platelets (wnl platelets= 150,000-400,000)

Nursing care for Severe Preeclampsia

Hourly I&O (uriometer, all IVs, and any fluid intake)
Hourly Vital Signs- BP, AR, RR (listen for breath sounds for possible edema)
T q4h unless ruptured then q2h
Hourly LOC, reflexes- compare R/L, upper/lower, clonus, HA, epigastric pain, visual changes

May induce or C/S
Mag would affect induction w/ pit bc it is a smooth muscle relaxer.

Normal Mag level

1.8-2.6

MgSO4 therapeutic range

4-8 mg/dl

Loss of DTR 10mg

Respiratory paralysis 15mg

Signs Tx for preeclampsia is working

Decreasing BUN, creatinine and uric acid (diuresis in 18-36hrs)

The sicker she gets the more the BUN creat and uric acid increase

Monitor O2 sat (sign of pulmonary edema)

normal BUN

10-20

normal Creat

0.5-1.5

normal ALT

7-35

obesity causes increase

normal AST

10-36

Labetalol (Normodyne, Trandate)

Acute tx of severe HTN
20-40mg q 10-15min MAX 220mg

Long term tx- 100mg BID MAX 2400MG/24HRS

Pregnancy category C- adverse effects in animal fetus, no known info for humans

Blocks alpha-1 AND beta-adrenergic receptors
-cause vasodilation= decrease BP

Eclampsia

risk for seizures
generalized, clonic, lasting 30-60seconds and may be stuporous for several minutes after

Must notify MD
Discussion with pt and family regarding risk/benefits of the birth of infant

Tx for Seizures

S E I Z U R E
S- Safety- stay with pt, protect, lateral position
E- Establish Airways- head to side 10L with O2mask/stand by suction
I- IV MgSO4- 2grams over 3-5min to stop sz, up to 6 grams.
Valium IVP 5-10mg q10min Max 30mg
Z- Zealous observation- look at clock at beginning and time, activity,
aura?
U- Uterine activity- Contractions? Abruption?
R- Resuscitation- venitalion needed?
E- Evaluate Fetus- EFM, reassuring or not?

Resolution of G-HTN

After birth of infant, usually w/in 24hrs

Continue mag for 1st 24hrs with continued nursing assessments

Watch pt in early pp, still at risk for seizures and pulmonary edema r/t fluid shifts

Preeclampsia may initially appear 1st 72hr-1week pp

Remember to still support bonding, May still breastfeed but the infant will be hypotonic

Maternal Hemorrhagic Disorders

Miscarriage/Spontaneous Abortion

Ectopic Pg

Gestational Trophoblastic Disease (Molar)

Cervical Insufficiency

Placenta Previa

Placenta Abruption

Threatened abortion

might happen

Inevitable abortion

cannot be stopped

Incomplete abortion

not all of the products of conception (POC) have been passed

Complete abortion

all POC passed

Missed abortion

None of POC passed

Septic abortion

POC infected during process

Recurrent Spontaneous Abortions

2-3 or more

presenting s/s of spont abort

bleeding "spotting" to wearing a pad- RN must assess this bc the report is biased by their feelings

*No vag bleeding is WNL during pregnancy. Always advise pts to come in to be checked

Cramping to abdominal/pelvic pain

Loss of Pg symptoms d/t decreasing hormones

Fever and malaise(septic)

Pts/Family emotional state?

Etiology of spontaneous AB

May never find out why
fetal or maternal factors
50% of time its d/t fetal chromosome abnormalities
Implantation defect- inadequate endometrium, maternal anatomy- septum or uterine fibroids
Placental factors
Maternal trauma, endocrine,autoimmune (Lupus, Antiphospholipid Syndrome, alloimmune)

After 2-3 spont AB's mom is sent for genetic workup

Nursing Care

Emotional support (about 50% of pts who present with vag bleeding continue pg and deliver)
US and serial quantitative Beta-HCG (in a healthy pg it doubles q48hr)
Blood type/screen, CBC (Rh/Hgb)
Possible D&C

Always know pt RH status

if negative give Rhogam w/in 72hrs of loss

Referrals/Resources for loss

Hospital Chaplain, pts own religious group, local perinatal loss support group

First Candle- www.firstcandle.org

#1 reason moms die in 1st Tri

Ectopic pg

Ectopic pg

EMERGENCY for mom
Fetus will die
Pg outside of uterus
Presenting s/s= abdominal pain
Delayed menses
Vag bleeding

After rupture: abd/shoulder pain (bleeding irritating phrenic nerve) syncope, shock

Risk factors for Ectopic pg

hx of PID, gonorrhea, chlamydia

Tx for ectopic

depends on if it has ruptured or not
Methotrexate if non-ruptured (kills fast growing cells, do not drink alcohol)
Laparotomy salpingectomy most common tx if it has ruptured

Monitor falling b-HCG- takes weeks
Assess for family grieving and offer support

Molar pregnancy cells

Trophoblastic cells out of control

Molar Pg

Was never a fetus-genetic composition-extremely abnormal

several possibilities of genetic composition

Patient needs careful follow up in regards to the increased risk of CA by 20%

Advise against pg w/in the year

S/S Molar Pg

Vaginal bleeding- brown spotting to profuse hemorrhage
Excessive N/V
Uterus size greater than it should be for EDC but no FHR or fetal movement
Early development of G-HTN
Dx by routine US

If had previous molar, risk of recurrence is 10x

Tx of Molar pg

Search for metastasis (chest xray, CAT scan, MRI)
Immediate vacuum aspiration, curettage, used of Pit to contract uterus
Px pg within the year
Serial follow up of b-HCG to non-pg levels

Report irregular vag bleeding (endometrial/uterine CA), breast secretions (breast CA), hemoptysis (Lung CA), sever persistent HA (brain CA)

Cervical insufficiency

Painless dilation of the vervix without contractions, often occurs around 20wks and the fetus is expelled
0.1-2% of pg

Risk factors for Cervical insufficiency

Hx of traumatic births
repeated D&C
repeated voluntary abortions
hx DES (medication exposure from the 60s)
Short cervix

Diagnosis of cervical insufficiency

at 20 wks the cervix is at least 3-4cm (30-40mm)
Pt may c/o pressure, or PROM
US measurment of cervix
May see funneling-reduced cervical competence <2cm

Tx of cervical insufficiency

Possibly a cerclage
Prophylactic, Therapeutic, or Rescue Cerclage
Or prep for birth if fetus is viable

Risks of Cerclage

Infection- chorioamnionitis
ROM

Benefits of Cerclage

fetus obtaining viability

Pt education with cerclage

Antibiotics
No intercourse
No heavy lifting
No standing more than 90 min

When in labor GO to the HOSPITAL to have the cerclage removed preventing cervical damage and to deliver baby

Complete/Total Placenta Previa

Cervical os is covered by placenta when fully dilated

Partial Placenta Previa

incomplete coverage of os

Marginal Placenta Previa

Only an edge of placenta extends to the os, but could increase in labor

Low lying Placenta Previa

placenta implantation is in the lower uterine segment but not covering the os

Risk for Placenta Previa

Hx of previa
C/S
Voluntary abortion
Multigestation pregnancy (less room for placental implantation)
Over age 35
HTN,DM
Closely space pregnancies
Cocaine use
-previa usually dx with routine US

s/s placenta previa

painless bright red vaginal bleeding
abdomen soft, relaxed uterus, fetal malpresentation

What would you not perform on a mom that has a placenta previa?

NO VAG EXAM, especially with a speculum

COULD HEMORRHAGE

Tx of placenta previa

US to determine extent, C/S prn

if not term: stop bleeding, ABR, vag rest
pt and family education re: significan bleeding/maternal syncope go to ER or call 911

90% of low lying previas migrate

PP risk associated with previa

increases risk of hemorrhage

Placental Abruption

Premature separation of normally implanted placenta after 20wks gestation

risk for abruption

cocaine
HTN
MVA
abd trauma
previous abruption
smoking
multipara
PROM

Hyperemesis Gravidarum

severe, excessive n/v that leads to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems

Criteria for hospital admit with hyperemesis gravidarum

weight loss and ketones in the urine

Risk factors for Hyperemesis Gravidarum

Under 20 yrs of age
First pg, unmarried, white women
Conditions with increased b-HCG
Ambivalence toward pg or family related stress
Thyroid dysfunction
obesity
non-smokers
there is no relation to the sex of the fetus

s/s hyperemesis gravidarum

n/v
weight loss
decreased urine output
confusion
HA
lethargy
syncope

Goal of tx for hyperemesis gravidarum

for pt to establish a dietary patter w/ adequate calories for pregnancy and to get electrolytes WNL

for pt to maintain balanced I&O and stable VS

for pt to state the understanding of the condition and effective coping mechanisms are established

Medications in hyperemesis

Vitamin B complexes
Metoclopreamide (Reglan)
Ondansetron (Zofran)

Possible hospital admit w. IV hydration, NPO, consult with dietary, consult with social work to investigate stressors,
Labs for electrolytes, acid-base balance, Hgb/Hct, BUN, creat

Fetal test for nutrition status by assessing fundal height and US

On arrival to ER, Sally tells RN that she thinks she may be pg, has severe pain in lower abd and has a small amt of bleeding. BP 80/40, P 110. RN gets the MD state because

possibility of ectopic pregnancy

After D&C to evacuate molar pg, assessing the client for s/s of what would be most important?

hemorrhage

What week of pg do most complications arise?

20wks

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