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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