What are the top 3 complications of pregnancy?
1. Bleeding (spontaneous abortion, ectopic preg, gestational trophoblastic disease, cervical insufficiency, placenta previa & abruptio placentae)
2. Hyperemesis gravidarum
3. Gestational Hypertension
What are top causes of maternal death in preg?
Pregnancy-induced hypertension (preeclampsia)
Heart Disease (a preexising condition that exacerbates in pregnancy)
What are goals of treatment for complicated preg?
To carry the preg as close to term as possible (try to get to 36 weeks if at all possible)
Outcomes should address both maternal & fetal welfare
Maintain psychological health of pt and family unit
In ethical situations, whose welfare is the main consideration, the mother or fetus?
Usually the welfare of the mother
Is bleeding during preg normal?
It is never normal. Should always be investigated.
Hypovolemic shock symptoms occurs with how much blood loss?
10% blood volume (2 Liters) loss
Fetal distress is with how much blood loss?
25% blood volume loss
Signs of HYPOVOLEMIC SHOCK
Increased heart rate
Cold, clammy skin / thirsty
Decreased urine output
Dizziness or decreased level of consciousness
Decreased central venous pressure
What are the interventions for hypovolemic shock in pregnancy?
Lateral maternal position
Continuous fetal / contraction monitoring
* NO VAGINAL EXAM *
Withhold oral food or fluid
Obtain blood sample for HGB/HCT, type & screen or crossmatch
IV fluid replacement (LR), blood product transfusions
Monitor urine output
Monitor maternal blood loss by assessing perineal pads frequently (MORE THAN 1 PAD per HOUR IS TOO MUCH)
Assist w/ ultrasound & other procedures
Keep an optimistic outlook on fetal outcome
Provide emotional support to mother & family
What is one of the 1st signs of shock?
Kidneys stop producing urine - < 30 mL/hr is concerning
What are 7 types of miscarriages.
FIRST TRIMESTER BLEEDING CONDITIONS
- Threatened miscarriage
- Imminent (inevitable) miscarriage
- Complete miscarriage
- Incomplete miscarriage
- Missed miscarriage
- Ectopic pregnancy
Any interruption of a pregnancy before a fetus is the age of viability
50% or more of spontaneous miscarriage occur because of...
a genetic defect
Viability can be verified by?
ultrasound. A beating heart can be visualized
2 Types of SPONTANEOUS MISCARRIAGE
EARLY if it occurs before 16 wks of preg
LATE if it occurs between 16 to 24 wks
At 6 wks the placenta is loosely connected to
the walls of the uterus
During the 6-12th wks the placenta is moderately well attached to the
After 12 wks, the placenta is
deeply embedded in the uterinal wall, and hemorrhage is heavier and more life threatening
Hemorrhage is most dangerous when?
After the 12th week
Threatened miscarriage is characterized by?
Bleeding - usually scant initially, bright red.
NO CERVICAL DILATION!
How does the nurse comfort the woman who thinks something she did caused threatened miscarriage (eg running up flight of stairs, forgetting to take iron pills, getting angry w/ someone) ?
Important to tell them that none of these events caused miscarriage. Can minimize guilt that most women feel.
Is there any cervical dilation with threatened miscarriage?
Causes of THREATENED MISCARRIAGE
Abnormal fetal development
Maternal immunologic response (b/c fetus is only 1/2 of the mom's cells)
Infection (from depression of immune function) (This is why yeast infections common in preg. Immune system has to be somewhat depressed for the preg to be maintained)
Teratogens - prescription meds, recreational drugs, alcohol, x-ray exposure
Relaxes smooth muscle
Signs/Symptoms of THREATENED MISCARRIAGE?
Initially, vag. spotting or bleeding & possibly cramping
Nurse should take hx of bleeding, ask "what have you done about the bleeding?" and "How much bleeding have you had over what period of time?" "Have you passed any big clots of tissue?" If pt has tried to self-abort, THIS IS AN EMERGENCY!
Amt of blood loss usu. measured by number of pads soaked per hr
Interventions for THREATENED MISCARRIAGE?
Fetal heart tones
Serum hCG now & 48 hr later (will be 2x normal if placenta is intact. If it is a miscarriage, the levels of hCG will begin to drop off)
Avoid strenuous activity for 24-48 hrs. No coitus.
What is the medical treatment for THREATENED MISCARRIAGE?
No medical tx. In the past we used DES for this purpose which turned out to be teratogenic. If the spotting is going to stop, it usually does within 24-48 hrs after the mom reduces her activity
What percentage of threatened miscarriage continue the pregnancy?
The other 50% progress to imminent or inevitable miscarriage.
Imminent (inevitable) miscarriage
CERVICAL DILATION. With cervical dilation, the loss of products of conception cannot be halted.
Interventions for Imminent (inevitable) miscarriage
Ask pt to save any tissue or clots she has passed, and bring to hospital with her.
Fetal heart tone check or ultrasound
Dilation & evacuation (D&E) if no fetal heart tones
Monitor for bleeding post procedure, more than 1 pad/hr is too much
Imminent (inevitable) miscarriage
* Cervical dilation
* Uterine contractions
* Loss of products of conception
Fetus, membranes & placenta spontaneously expelled w/o medical assistance. The bleeding usu. slows w/i 2 hrs and then ceases by 2 days
Usually the fetus is expelled and the placenta is retained.
Very dangerous bc the uterus cannot clamp down to stop bleeding
How is Incomplete Miscarriage usually treated?
With D&C or D&S to remove the remaining products of conception
Is there for risk for hemorrhage with incomplete miscarriage?
Yes. The uterus can't contract effectively with retained placental fragments. D&C may be performed or suction curettage to evaculate the remainder of the contents of the uterus
Missed Miscarriage (Fetal Demise)
a/k/a Early Pregnancy Failure. Fetus dies in utero but is not expelled.
What are Interventions for Missed Miscarriage?
D&E if under 14 wks OR labor induction w/ cytotec / oxytocin after 14 wks
What are 5 complications of miscarriage?
- Septic abortion (when a woman tries to self-abort. Any passed tissue needs to be retained for analysis)
- Isoimmunization - TX = immunoglobulin D (Rhogam)
-Anxiety, feeling of powerlessness
What are the 2 most common complications of miscarriage?
Hemorrhage & Infection
What are the interventions for hemorrhage?
If excessive vaginal bleeding, position the pt flat and massage the fundus to aid in contraction of the uterus (more than 1 soaked pad/hr. is too much). Large clots or an odorous discarge is not normal.
IV transfusion of blood or other blood products may be necessary to aid in clotting (eg. Fibrinogen, other clotting factors)
Methergine may be ordered IM or PO for a home med. Teach how to self administer at home.
Instruct pt at discharge about how to take her meds, and monitor her bleeding
Make sure she has contact phone or pager numbers
Interventions for Infections
Signs: fever > 100.4 degress F, is a warning sign of infection, abdominal pain or tenderness, and a foul vaginal discharge.
Teaching: Do not use tampons, clean front to back
Ectopic pregnancy a/k/a tubal pregnancy
Any pregnancy in which the fertilized ovum implants outside the uterine cavity.
What are 5 possible sites for ectopic pregnancies?
1. Fallopian tubes
2. Cornua of the uterus
3. the ovary
4. the cervix
5. the abdominal cavity
What is the most common site for implantation of an ectopic pregnancy?
The fallopian tubes
What is the rationale for adminisering Methotrexate to pts experiencing an ectopic pregnancy?
It is a folic acid antagonist that inhibits cell division in the developing embryo.
Is a ruptured ectopic pregnancy serious?
Yes! It is a medical emergency!
What is the 2nd most common cause for bleeding in pregnancy?
What are the risk factors for ectopic pregnancy?
* Pelvic inflammatory disease (PID) - # 1 cause
* Hx of IUD (intrauterine device)
* 10-20% risk of another ectopic pregnancy in the other tube. After ectopic, that tube will not be functional
What are the symptoms of a rupturing ectopic pregnancy?
One sided lower abdominal pain (sharp). Low back pain or pain referred to shoulder.
Scant vaginal bleeding to increasing bleeding (depending on site of implantation)
Shock: thready pulse, rapid respiratory rate and falling BP
Medical Interventions for Ectopic Pregnancy?
Serum hCG level & Hgb & type/cross-match
2. Pelvic exam
3. SURGERY: laparoscopy
4. PO methotrexate which stops the fetal cells from developing. Also stops the bleeding
5. IM injection of Immunoglobulin (i.e. Rhogam (if mom is Rh negative)
What classification of drug is methotrexate?
What are the SECOND TRIMESTER BLEEDING CONDITIONS?
* Gestational Trophoblastic Disease (Hydatidiform Mole)
* Premature cervical dilation
What is Gestational trophoblastic disease (GTD)?
Comprises a spectrum of neoplastic disorders that originate in the placenta. Gestational tissue is present, but the pregnancy is not viable.
Two most common types of GTD are:
Hydatidiform mole (partial and complete)
What is hydatidiform mole?
A benign neoplasm of the chorion in which the chorionic villi degenerate and become transparent vesicles containing clear, viscid fluid.
The complete mole contains?
No fetal tissue and develops from an "empty egg," which is fertilized by a normal sperm (the paternal chromosomes replicate, resulting in 46 all-paternal chromosomes). The embryo is not viable and dies.
The complete mole is a/w the development of ?
Choriocarcinoma, which is a malignant carcinoma - less likely if fetal parts are present
The partial mole has?
a triploid karyotype (69 chromosomes), bc two sperm have provided a double contribution by fertilizing the ovum.
What are the S&S of trophoblastic disease?
1. Overly large uterus (fundal height at umbilicus by 12 wks. The trophoblastic vesicles fill it & make it larger than it should be).
2. No fetal heart tones present
3. Positive hCG level (abnormally high)
4. Marked N/V (byproducts are very nauseating)
5. Ultrasound shows no fetal growth, uterus has grape-like vesicles
6. Vaginal bleeding at 16 wks (brownish, not bright red bleeding)
What is the medical management for GTD?
1. Suction curettage
2. Serial serum hCG levels q 2 wks for 6-12 mos
3. Baseline pelvic exam, CXR
4. Delay subsequent pregnancy for 1 year
5. If Choriocarcinoma, then complete Hysterectomy
6. Psychologically, parents will grieve as there was a real pregnancy
Premature Cervical Dilatation (a 2nd trimester bleeding condition)
a/k/a Incompetent Cervix.
Cervix dilates prematurely, can't hold weight of developing fetus to term. Usual onset of symptoms at 20 wks gestation
What are the S&S of premature Cervical Dilatation?
2. Pink vaginal discharge
3. Increased pelvic pressure
4. Possible rupture of membranes & onset of labor
5. Uterine contractions begin, and the fetus is born after a short labor
What is a surgical treatment for premature cervical dilatation?
Cervical cerclage. Involves using a heavy purse-string suture to secure and reinforce the internal os of the cervix.
What are the Third Trimester Bleeding Conditions?
1. Placenta previa
2. Premature separation of the placenta
3. Disseminated Intravascular Coagulation (DIC)
List 5 nursing interventions with rationales for Placenta Previa
Establish IV access - to allow for administration of fluids, blood, and meds as necessary
Obtain type & cross-match for at least 2 U blood products - to ensure availability should bleeding continue
Obtain specimens as ordered for blood studies, such as CBC and clotting studies - to establish a baseline and use for future comparison
SEE LIST OF INTERVENTIONS ON P. 562 FOR MORE!!
What are the S&S of Placenta Previa?
Sudden, bright red vaginal bleeding
Usually around 30 wks
Medical Emergency! putting both mom & fetus at risk
What is Placenta Previa?
A bleeding condition that occurs during the last two trimesters of pregnancy. The placenta implants over the cervial os, low in the uterus.
Risk Factors for Placenta Previa?
Increased # of pregnancies (parity) (subsequent fetuses cannot implant until down lower in the uterus b/c of scars from previous pregnancies
Advanced maternal age
Multiple gestation (twins, etc.)
Higher rate of fetal defects if implantation site interferes with fetal nutrition or oxygen supply
High risk of preterm labor with placental previa
What are the 3 type of Placenta previa?
(Classified according to the degree of coverage or proximity to the internal os).
1. Total placenta previa - cervical os completely covered by the placenta
2. Partial placenta previa - internal os is partially covered by the placenta
3. Marginal placenta previa - placenta is at the margin or edge of the internal os
4. Low-lying placenta previa - placenta is implanted in the lower uterine segment and is near the internal os but does not reach it
What are Interventions for Placenta Previa?
1. NO VAGINAL EXAM by nurse
2. Bedrest w/ side-lying position
3. Monitor bleeding - count pads
4. Frequent V/S, O2 sat (Oxygen available)
5. Attach EXTERNAL fetal monitor & uterine contraction monitor
6. Vaginal birth is possible for 30% or less previous. Otherwise, C-section is best choice
7. Betamethasone may be prescribed for the mom to increase the fetal lung maturity
Name 8 nursing interventions for Abruptio placenta?
1. Place pt in a left lateral position to prevent pressure on the vena cava.
2. Administer O2 therapy via nasal cannula
3. Monitor O2 sat levels via pulse oximetry
4. Obtain maternal V/S frequently
5. Assess fundal height for changes.
6. Monitor amount and characteristics of any vaginal bleeding
7. Be alert for S&S of DIC, such as bleeding gums, tachycardia, oozing from the IV insertion site, and petechia, and administer blood products as ordered if DIC occurs
8. Institute continuous electronic fetal monitoring.
9. Assess uterine contractions and report any increased uterine tenseness or rigidity. Observe the tracing for tetanic uterine contractions or changes in fetal heart rate patterns suggesting fetal compromise
How does Placenta previa differ from Abruptio placenta?
With Abruptio placenta there is:
Sharp stabbing pain high in fundus.
May or may not be accompanied by bleeding. Bleeding may be concealed.
What is Premature separation of the Placenta / Abruptio placentae?
the separation of a normally located placenta after the 20th wk of gestation and prior to birth that leads to hemorrhage.
Placenta implants at the proper site, but abruptly separates from the uterine walls resulting in bleeding
#1 cause of perinatal death - MEDICAL EMERGENCY
Happens late in pregnancy or as late as the onset of labor
What are the risk factors for Abruptio placentae?
-Advanced materal age
-Short umbilical cord
-Trauma (eg, MVA)
-Cocaine and cigarette use
-Blood clotting problems
What are the S&S of Abruprio Placentae?
1. Sharp, stabbing pain high in fundus - may or may not be accompanied by bleeding (could be concealed)
2. Worse than contraction pain alone
3. Uterine tenderness on palpation
4. Couvelaire uterus - HARD, BOARD-LIKE feeling of the uterus on palpation
What are interventions for Abruptio Placentae?
1. NO VAGINAL EXAMS or ENEMAS
2. O2 by mask
3. IV Fluids (16 or 18 g)
4. Fetal / contraction monitoring
5. Frequent V/S
6. Hgb/Fibrinogen levels - to detect DIC
7. Lateral position in bed ON LEFT SIDE
8. High risk for infection pospartaly
THIS IS A MEDICAL EMERGENCY!
The management plan for Abruptio placenta is dependent on what?
1. Degree of placental separation
2. If DIC has developed
C-section preferred delivery mode if circumstances allow
What are the blood test results which determine if DIC is occurring?
1. Decreased fibrinogen and platelets
2. Prolonged PT and aPTT
3. Positive D-dimer test and fibrin (split) degradation products
What is Disseminated Intravascular Coagulation (DIC)?
a/k/a DIC - MEDICAL EMERGENCY and potentially life-threatening to Mom and Fetus!
- Blood clotting abnormality that occurs when the fibrinogen level falls below normal limits. Bleeding defect which causes BOTH BLEEDING AND CLOTTING AT THE SAME TIME
What are predisposing factors for DIC?
-Premature placental separation
-Pregnancy induced hypertension
-Amniotic fluid embolism (most deadly complication)
-Retention of a dead fetus
How is DIC diagnosed?
-Low fibrinogen level
-Prolonged prothrombin time (PT)
-Prolonged partial thromboplastin time
What are the major S&S of DIC?
*Bleeding from puncture sites, gums, eyes, hematuria and ecchymosis
How is DIC treated?
Treat cause - DELIVERY of fetus and placenta
STABILIZE mother and fetus
Move mother to ICU
What are Nursing Interventions for DIC?
1. Administer blood products (observe for transfusion reactions)
2. Observe for bleeding: apply direct pressure
3. Frequent V/S
4. Monitor urinary output w/ metered catheter
5. Central venous pressure catheter
6. Emotional support
What are nursing interventions to care for pts in Preterm labor?
1. Bedrest, fetal/contraction monitoring
2. Oral hydration and/or IV hydration
3. Clean catch urine, pelvic cultures
4. If labor stops, home on oral terbutaline, bedrest & adequate oral fluids
5. IV antibiotics for group B streptococcus
6. Betamethasone for fetal lung maturity
7. Magnesium sulfate - #1 drug used to stop labor
8. Sterile vag speculum exam to test for ROM & vag cultures
a. Nitrazine paper test
b. Fern test
c. US (amniotic fluid index)
d. Serum WBC
e. Vaginal Cultures
9. Avoid frequent vaginal exams
What is Preterm Labor?
-Labor before end of 37th wk
-Causes 2/3 of neonatal deaths
-Definition of labor: experiencing uterine contractions THAT RESULT IN CERVICAL DILATION OVER 1 CM AND EFFACEMENT OVER 80%
Preterm Labor is frequently brought on by?
Dehydration, UTI's, chorioamnionitis
What is the goal in Preterm Labor?
Identify causative factor and fix it
What are the Risk Factors for Preterm Labor?
* Inadequate prenatal care
* Strenuous job / shift work
What are the S&S of Preterm Labor?
Low back pain
Pelvic pressure / abdominal tightening
Increased vaginal discharge
When are medical interventions used to stop Preterm Labor?
If fetal membranes are intact
If there is no bleeding
If cervix is less than 5 cm dilated
If cervical effacement is no more than 50%
What is Betamethasone and how is it used in Preterm Labor?
A corticosteroid that is given to the mother. It passes to the placenta and the fetus and affects the development of surfactant in the lungs so they can open. Given prior to delivery of a fetus less than 34 wks
What is the onset of Betamethasone?
How long does Betamethasone last?
What is the timing and dose used with Betamethasone in Preterm Labor?
May be given in 2 does of 12 mg, 12 hrs apart over 24 hr period.
Or 4 dosesof 6 mg 6 hrs apart
What is the preferred route when giving Betamethasone for Preterm Labor?
What is pregnancy-induced hypertension (a/k/a gestational hypertension)?
Vasospasm of the small and large arteries during pregnancy
Cause is unknown
# 1 COMPLICATION SEEN IN PREGNANCY
What are 3 classic symptoms of Pregnancy-induced hypertension (Gestational Hypertension)?
Edema (the kind that doesn't go away overnight).
Fluctuates in the first and second trimesters as it should and in the third trimester keeps going up.
What are the risk factors for Pregnancy-induced hypertension (aka Gestational Hypertension)?
Women of color
Multiple pregnancy (twins)
Primipara under 20 yrs or over 40 yrs
Low socioeconomic background
What is the pathophys of Pregnacy-induced Hypertension (a/k/a Gestational Hypertension)?
Vasoconstriction and vasospasm cause increased strain on the cardiac system which in turn reduces blood flow to essential organs like the kidneys, pancreas, liver, brain and placenta
What are the symptoms of Preeclampsia?
- Sudden weight gain
- High blood pressure
- Edema (in the hands, face, peri-orbital area in addition
to ankles and feet
When is preeclampsia seen?
In preeclampsia, the blood pressure is ?
Above the level of gestational hypertension and below the condition of having seizures. The fetal mortality rate is about 10%
How is preeclampsia classified?
- 2 levels of severity:
What are the S&S of Mild Preeclampsia?
1. BP 140/90 twice at least 6 hrs apart
2. Systolic BP greater than 30 mm Hg &
Diastolic BP greater than 15 mm Hg
over prepregnancy baseline reading
-Proteinuria = 1+ to 2+
-Edema in upper body as well as lower (* can get carpal tunnel syndrome from the edema)
What are Nursing Interventions for Mild Preeclampsia?
- Promote bedrest
- Promote good nutrition (regular diet)
- Decrease salty foods
- Provide emotional support
- Administer Magnesium sulfate
What are the S&S of Severe Preeclampsia?
1. BP readings of 160/110 twice at least 6 hrs apart
2. Diastolic BP is 30 mm Hg above pre-pregnancy level
3. Marked proteinuria = 3+ to 4+........ OR more than 5 g
in a 24 hr sample of urine
4. Extensive edema (esp. face/hands)
5. Decreased urine output - down to 400-600 mL in 24 hrs
6. Severe epigastric pain (precursor to seizures; caused by congestion in liver)
7. N/V and visual disturbances
8. Short of breath; Headache
9. Hyperreflexia, possibly clonus --- 1 step before seizures from cerebral edema (clonus = a contraction that holds)
What are Nursing Interventions for Severe Preeclampsia?
- Support bedrest
* private room
* restrict visitors to support people
* provide a therapeutic environment w/ restricted noise
* clear explanations of the condition
* side rails for safety (b/c might get seizures)
- Frequent BP's (q 15 min to half hr)
- Daily weights (at same time)
- I & O, urine protein studies (hourly outputs)
- High protein, moderate sodium diet
- Deep tendon reflexes (ankle clonus)
- Monitor fetal well-being
* EFM or doppler auscultation q 4 hrs
* Nonstress test daily
* Biophysical profile daily
What does Magnesium sulfate do?
Shifts fluid from interstitial spaces into the intestine (cathartic) and is a CNS depressant
How is Magnesium sulfate administered?
Bolus over 15 minutes followed by continuous infusion
What is the therapeutic level for Magnesium sulfate?
5 - 8 mg/ 100 mL
Magnesium doses will be adjusted PRN based on the serum Magnesium levels and the pt's symptoms / VS
What is the # 1 reason to use Magnesium sulfate?
It's a good CNS depressant to keep pt from having seizures.
Also lowers B/P
What are the side effects of Magnesium toxicity?
1. Respiratory depression (12/min or greater), cardiac arrhythmias, cardiac arrest
2. Decreased urine output (less than 100 mL/4 hrs or 30 mL/hr)
3. Decreased level of consciousness
4. Assess deep tendon reflex hourly - Should be minimal response
Magnesium sulfate can ONLY be excreted by
Magnesium Sulfate Administration
- Keep syringe of CALCIUM GLUCONATE in a secure place in pt's room (antidote)
- Inform delivery personnel that Magnesium Sulfate was given in labor. If given within 2 hrs of birth will cause newborn respiratory depression bc it crosses the placenta
- Complaints of ABDOMINAL PAIN may be a sign of IMPENDING SEIZURES!!!
Once a seizure occurs, preeclampsia is
What is Eclampsia?
- Seizure or coma occurs due to cerebral edema
- Maternal mortality rate up to 20% - Fetal mortality rate is 25%
- Premature separation of the placenta can be caused by vasospasm during seizures which makes fetal outcome even worse
More Eclampsia details
Preeclampsia advances to Eclampsia when seizures occur. Seizures are a result of irritation to the brain which is caused by swelling (cerebral edema) in the brain.
* CAN OCCUR UP TO 48 HOURS AFTER BIRTH *
Just before a seizure, temp & BP will rise sharply. Followed by severe headache, blurring of vision and hyperactive reflexes, epigastric pain, nausea and decreased urine output
What are Nursing Interventions for Eclampsia / Seizures?
Tonic-clonic seizures - tonic phase lasts 20 seconds. Priority is to maintain patent airway. No tongue blades. Give O2 by mask. Monitor O2 sat and VS. Apply EFM. Turn to side to prevent aspiration. Pad bed rails with blankets. Clonic phase lasts up to 1 minutes. Mag or valium is emergency medication given. Postictal state follows.
Seizures can cause premature separation of placenta, so close monitoring must be done in the post ictal period up to 4+ hours
What is HELLP syndrome?
Another complication of Pregnancy-induced Hypertension.
Initials stand for the symptoms that occur with HELLP
Maternal mortality rate up to 25%
Fetal mortality rate up to 35%
What are S&S of HELLP syndrome?
Right upper quadrant tenderness
Labs: Red cell hemolysis, high liver enzymes, thrombocytopenia
What is the treatment for HELLP syndrome?
Platelets of fresh frozen plasma (FFP) transfusions, observe for bleeding, treat accompanying preeclampsia
What are the complications of HELLP syndrome?
Liver damage, hyponatremia, renal failure, hypoglycemia, epidural contraindicated if platelet count too low
Fetus is delivered as soon as possible. Maternal hemorrhage is likely due to poor clotting ability. Lab results normalize shortly after delivery
How does the edema in HELLP syndrome affect the liver?
Liver is engorged. Presses against the capsule and can rupture the liver!