Chapter 19 Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications Flashcards
High-Risk Pregnancy
One in which a condition exists that jeopardizes the health of the mother, her fetus, or both
The condition may result from the pregnancy, or it may be a condition that was present before the woman became pregnant
1 in 4 pregnant women considered to be at high risk or diagnosed w/ complications
Examples of High-Risk Conditions
Gestational diabetes
HTN
PCOS
Obesity
Older/younger age
Autoimmune disease
Tobacco use
Birth defects
Multiple gestation
Many obstetric complications & conditions are…
…life-threatening emergencies w/ high morbidity & mortality rates.
When does risk assessment begin?
Begins at the 1st prenatal visit and continues w/ each subsequent visit because factors may be identified in later visits that were not apparent during earlier visits
The nurse can encourage the client to inform her health care provider of these concerns, and necessary interventions or referrals can be made
Examples of Pregnancy-Specific Stress
Prenatal stress and distress have been shown to have significant consequences for the mother, child, and family
Depression, anxiety, & perceived stress
- May increase the risk for adverse birth outcomes
- Associated w/ preterm births & intrauterine fetal growth restriction
What are the current 4 categories of risk?
1) Biophysical
2) Psychosocial
3) Sociodemographic
4) Environmental
Biophysical Risk Factors for High-Risk Pregnancy
Genetic Conditions
Chromosomal abnormalities
Multiple pregnancies
Inherited disorders
Large fetal size
Preterm labor and birth
Cardiovascular disease
Placental abnormalities
Infection
Diabetes
Nutritional Status
Post-term Pregnancy
Environmental Risk Factors for High-Risk Pregnancy
Infections
Radiation
Pesticides
Illicit rugs
Psychosocial Risk Factors for High-Risk Pregnancy
Smoking
Caffeine
Alcohol & Substance Abuse
Inadequate support system
Maternal Obesity
Situational Crisis
History of Violence
Emotional Distress
Unsafe cultural practices
Sociodemographic Risk Factors for High-Risk Pregnancy
Poverty
Lack of Prenatal Care
Age younger than 15 or older than 35
Marital Status
Accessibility to Healthcare
Ethnicity
(T/F) True or False: Bleeding at any time during pregnancy is potentially life-threatening
True
What is the biggest killer of pregnant women?
Obstetric hemorrhage
Can occur early or late in the pregnancy
Bleeding is experienced by approximately 25% of women during the first trimester of pregnancy
Management of Obstetric Hemorrhage
The presence of an attendant at every birth and access to emergency obstetric care are helpful in reducing maternal morbidity and mortality
Involves early recognition, assessment, & resuscitation
Pharmacological methods to induce contractions (clamps down uterus-> halt hemorrhage): oxytocin, ergometrine, and prostaglandins
Surgical interventions: balloon tamponade, compression sutures, or arterial ligation
Conditions Commonly Associated w/ Early Bleeding (1st half of pregnancy)
Spontaneous abortion, uterine fibroids, ectopic pregnancy, gestational trophoblastic disease, and cervical insufficiency.
Conditions Commonly Associated w/ Late Bleeding
Conditions associated with late bleeding include placenta previa, placental abruption, and placenta accreta, which usually occur after the 20th week of gestation.
Abortion
Loss of an early pregnancy, usually before week 20 of gestation
Can be spontaneous or induced
Spontaneous Abortion
Refers to the loss of a fetus resulting from natural causes, that is, not elective or therapeutically induced by a procedure
Nonmedical people often use the term “miscarriage” to denote an abortion that has occurred spontaneously
Can occur during early pregnancy, and many women who miscarry may not even be aware that they are pregnant
About 80% of spontaneous abortions occur w/in the 1st trimester
Risk Factors for Spontaneous Abortion
AMA
Drug use
Weakened cervix
Placental abnormalities
Chronic maternal disease
Pathophysiology of Spontaneous Abortion
Cause is varied & unknown
- Most common cause in 1st trimester: Genetic abnormalities (not related to mom)
-> Usually chromosomal
Maternal disease as a cause is more common in 2nd trimester
- Cervical insufficiency
- Congenital or acquired anomaly of the uterine cavity (uterine septum/fibroids)
Cause of Spontaneous Abortion in 4-8 Weeks Gestation
Chromosomal Abnormalities
Cause of Spontaneous Abortion in 4-10 Weeks Gestation
Insufficient/ Excessive Hormones
Cause of Spontaneous Abortion in 4-12 Weeks Gestation
Maternal Infections
Cause of Spontaneous Abortion in 12-19 Weeks Gestation
Usually caused by a maternal factor such as cervical insufficiency or maternal disease
What are the classifications of abortions?
Threatened
Imminent/Inevitable
Complete
Incomplete
Missed
Recurrent Pregnancy Loss
Septic
Threatened Abortions
Assessment Findings:
- Vaginal bleeding (often slight) early in a pregnancy
- No cervical dilation or change in cervical consistency
- Mild abdominal cramping
- Closed cervical os
- No passage of fetal tissue
Diagnosis:
- Vaginal ultrasound to confirm if sac is empty
- Declining maternal serum hCG and progesterone levels to provide additional information about viability of pregnancy
Therapeutic Management:
- Conservative supportive treatment
- Possible reduction in activity in conjunction with nutritious diet and adequate hydration
Imminent/Inevitable Abortion
Assessment Findings:
- Vaginal bleeding (greater than that associated with threatened abortion)
- Rupture of membranes
- Cervical dilation
- Strong abdominal cramping
- Possible passage of products of conception
Diagnosis:
- Ultrasound and hCG levels to indicate pregnancy loss
Therapeutic Management:
- Vacuum curettage if products of conception are not passed to reduce risk of excessive bleeding and infection
- Prostaglandin analogs such as misoprostol to empty uterus of retained tissue (only used if fragments are not completely passed)
Complete Abortion
Passage of all products of conception
Assessment Findings:
- History of vaginal bleeding and abdominal pain
- Passage of tissue with subsequent decrease in pain and significant decrease in vaginal bleeding
Diagnosis:
- Ultrasound demonstrating an empty uterus
Therapeutic Management:
- No medical or surgical intervention necessary
- Follow-up appointment to discuss family planning
Incomplete Abortion
Passage of some of the products of conception
Assessment Findings:
- Intense abdominal cramping
- Heavy vaginal bleeding
- Cervical dilation
Diagnosis:
- Ultrasound confirmation that products of conception still in uterus
Therapeutic Management:
- Client stabilization
- Evacuation of uterus via D&C or prostaglandin analog
Missed Abortion
Nonviable embryo retained in utero for at least 6 weeks
Assessment Findings:
- Absent uterine contractions
- Irregular spotting
- Possible progression to inevitable abortion
Diagnosis:
- Ultrasound to identify products of conception in uterus
Therapeutic Management:
- Evacuation of uterus (if inevitable abortion does not occur): suction curettage during 1st trimester, dilation and evacuation during 2nd trimester
- Induction of labor with intravaginal PGE2 suppository to empty uterus without surgical intervention
Recurrent Pregnancy Loss
Assessment Findings:
- History of 3 or more consecutive spontaneous abortions
- Not carrying the pregnancy to viability or term
Diagnosis:
- Validation via client’s history
- No diagnostic ultrasound findings
Therapeutic Management:
- Identification and treatment of underlying cause (possible causes such as genetic or chromosomal abnormalities, reproductive tract abnormalities, chronic diseases or immunologic problems)
- Cervical cerclage in 2nd trimester if incompetent cervix is the cause
Septic Abortion
Assessment Findings:
-
Diagnosis:
-
Therapeutic Management:
-
Nursing Assessment of Spontaneous Abortion
A pregnant woman who reports vaginal bleeding must be seen IMMEDIATELY by a provider!!!
Signs & Symptoms:
- Varying degrees of vaginal bleeding
- Low back pain
- Abdominal cramping
- Passage of products of conception tissue
Ask the woman about the color of the vaginal bleeding (bright red is significant) and the amount
- Question her about the frequency of changing her peripads (saturation of one peripad hourly is significant) and the passage of any clots or tissue.
Instruct her to save any tissue or clots passed and bring them with her to the health care facility.
Obtain a description of any other signs and symptoms the woman may be experiencing, along w/ a description of their severity and duration
Remain calm and listen to the woman’s description.
When the woman arrives at the health care facility:
- Assess her VS
- Observe the amount, color, and characteristics of the bleeding
- Ask her to rate her current pain level, using an appropriate pain assessment tool
- Evaluate the amount and intensity of the woman’s abdominal cramping or contractions, and assess the woman’s level of understanding about what is happening to her
Nursing Care of Spontaneous Abortion
Focus on providing continued monitoring and psychological support because the family is experiencing acute loss and grief.
- Reassure the woman that spontaneous abortions usually result from an abnormality and that it is NOT HER FAULT
Women experiencing a 1st-trimester abortion at home w/out a dilation and curettage (D&C) to resolve it require frequent monitoring of hCG levels to validate that all the conceptus tissues have been expelled.
Women going through a 2nd-trimester abortion are admitted to the hospital to have an augmented labor and delivery.
- Nursing care would focus on care of the laboring women with tremendous attention paid to providing emotional support to the woman and her family
Nursing Care of Spontaneous Abortion: Providing Continued Monitoring
Monitor the amount of vaginal bleeding through pad counts and observe for passage of products of conception tissue
Assess pain & provide appropriate pain management to address the cramping discomfort.
Assist in preparing the woman for procedures and treatments such as surgery to evacuate the uterus or medications such as misoprostol or prostaglandin E2 (PGE2).
If the woman is Rh-negative and not sensitized, expect to administer RhoGAM within 72 hours after the abortion is complete
Nursing Care of Spontaneous Abortion: Providing Support
Provide both physical and emotional support
Prepare the woman and her family for the assessment process and answer their questions
Explaining some of the causes of spontaneous abortions can help the woman understand what is happening and may allay her fears and guilt that she did something to cause the pregnancy loss.
Many women experience an acute sense of loss and go through a grieving process with a spontaneous abortion.
- Providing sensitive listening, counseling, and anticipatory guidance to the woman and her family will allow them to verbalize their feelings and ask questions about future pregnancies.
Encourage friends and family to be supportive but give the family space and time to work through their loss
Referral to a community support group for parents who have experienced a loss can be helpful during this grief process
Stillbirth
The loss of a fetus after the 20th week of development, while a miscarriage is a loss before the 20th week
Occurs later in pregnancy
Some stillbirths can occur right up to the time of labor and delivery.
Stillbirths are much less common than miscarriages,
- Occur in 1 out of every 100 pregnancies in the United States
Postmortem Care After a Perinatal Loss
Place appropriate signage on the outside of the room so everyone in the hospital is aware of the loss
Give parents the opportunity to spend time with their baby
Bathe and swaddle baby
- Allow parents to participate or do this independently as desired
Support parents’ wishes regarding photography (professional or otherwise)
Allow visitation in accordance with the wishes of the parents
Assist parents in the collection of keepsakes
Preterm Labor (PTL)
1 cause of neonatal morbidity
Labor that occurs between 20 and 37 completed weeks of pregnancy
Risk Factors for PTL
African-American race (double the risk)
Maternal Age extremes (< 16, or > 40)
Low socioeconomic status
Alcohol, Smoking or Drug Use
History of previous Preterm Birth (triple the risk)
Multiple Gestations
Short cervical length
Infections (UTI, STI, Bacterial Vaginosis)
Stress
Signs & Symptoms of PTL
Spontaneous rupture of membranes (SROM)
Abdominal Pain
Low, Dull Back Pain
Pelvic Pain
Menstrual-like cramps
Vaginal Bleeding
Increased Vaginal discharge
Urinary Frequency
Diarrhea
Pelvic Pressure
Criteria for Preterm Labor Diagnosis
Cervical Dilation and Effacement
plus
4 uterine contractions in 20 minutes
or
8 uterine contractions in 1 hour
Management of PTL: Tocolytic Therapy
Goal: Arrest labor and delay birth long enough to initiate prophylactic corticosteroid therapy
Meds Used in Tocolytic Therapy:
- Procardia (Nifedipine)
- Indomethacin (Indocin)
- Atosiban (Tractocile, Antocin)
- Magnesium Sulfate
Ectopic Pregnancy
MEDICAL EMERGENCY!!!
Any pregnancy in which the fertilized ovum implants outside the uterine cavity
Locations include: the fallopian tubes, cervix, ovary, and the abdominal cavity
General Pathophysiology:
1) Abnormally implanted embryo grows and draws its blood supply from the site of abnormal implantation.
2) As the embryo enlarges, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal development
If left untreated: Can lead to massive hemorrhage, infertility, or death
Risk Factors for Ectopic Pregnancy
Tubal obstruction/damage
Delayed tubal transport
Congenital anomalies
Altered hormonal status
Smoking
AMA
Pathophysiology of Ectopic Pregnancy
Normally, the fertilized ovum implants in the uterus. In ectopic pregnancy, the journey along the fallopian tube is arrested or altered in some way.
In ectopic pregnancy, the ovum implants outside the uterus.
Most common site for implantation is the fallopian tubes (96%), but some ova may implant in the ovary, the intestine, the cervix, or the abdominal cavity
- None of these anatomic sites can accommodate placental attachment or a growing embryo
Classic Clinical Triad of Ectopic Pregnancy
Abdominal pain, amenorrhea, & vaginal bleeding
Only ~1/2 of women present w/ all 3 symptoms
Physical Exam Findings of Ectopic Pregnancy
Assess the client thoroughly for signs and symptoms that may suggest an ectopic pregnancy
The onset of signs and symptoms varies, but they usually begin at about the 7th or 8th week of gestation
Unruptured Tubal Pregnancy:
- A missed menstrual period
- Adnexal fullness
- Abdominal tenderness
As the tube stretches, the pain increases.
- Pain may be unilateral, bilateral, or diffuse over the abdomen
Physical Exam Findings of Ectopic Pregnancy Rupture/ Hemorrhage
Severe, sharp, and sudden pain in the lower abdomen as the tube tears open and the embryo is expelled into the pelvic cavity
Feelings of faintness
Referred pain to the shoulder area, indicating bleeding into the abdomen caused by phrenic nerve irritation
Hypotension & Hypovolemic Shock
Marked abdominal tenderness w/ distention
Diagnostic Procedures for Ectopic Pregnancy
Urine pregnancy test to confirm the pregnancy
Beta-hCG concentrations to exclude a false-negative urine test
Transvaginal ultrasound to visualize the misplaced pregnancy
Medical Interventions for Ectopic Pregnancy: Methotrexate
Folic acid antagonist that inhibits cell division in the developing embryo
Most often consists of a single-dose IM injection of methotrexate (Rheumatrex, Trexall) with outpatient follow-up
- Ordered based on the client’s body surface area
Eligibility Conditions:
- MUST be hemodynamically stable
- No signs of active bleeding in the peritoneal cavity
- Low beta-hCG levels (lower than 5,000 mIU/mL)
- The mass (which must measure less than 4 cm as determined by ultrasound) must be unruptured
Advantages: Avoidance of surgery, the preservation of tubal patency & function, & LOWER cost
Adverse Effects: N/V, stomatitis, diarrhea, gastric upset, increased abdominal pain, and dizziness
Contraindications:
- UNSTABLE patient
- Severe, persistent abdominal pain
- Renal or liver disease
- Immunodeficiency
- Active pulmonary disease
- Peptic Ulcer
- Suspected intauterine pregnancy
- Poor client compliance
Nursing Education for Ectopic Pregnancy
Prior to receiving the single-dose IM injection to treat unruptured pregnancies, the woman needs to be counseled on the:
- Risks
- Benefits
- Adverse effects
- Possibility of failure of medical therapy, which would result in tubal rupture, necessitating surgery
Return weekly for follow-up laboratory studies for the next several weeks until beta-hCG titers decrease
- A decreasing beta-hCG level is highly predictive of treatment success
Surgical Interventions for Ectopic Pregnancy
Treatment for RUPTURED Ectopic Pregnancy
Salpingectomy: Laporotomy w/ removal of the tube
All patients are given Rhogam to prevent isoimmunization in future pregnancies
Gestational Trophoblastic Disease (GTD)
AKA “Molar Pregnancy”
Condition in which a proliferation of trophoblastic cells (outermost layer of embryonic cells) results in the formation of a placenta characterized by hydropic (fluid-filled) grapelike clusters
With GTD, there is abnormal hyperproliferation of trophoblastic cells that would normally develop into the placenta during pregnancy
Gestational tissue is present, but the pregnancy is not viable
Hydatidiform Mole
A benign neoplasm of the chorion in which the chorionic villi degenerate and become transparent vesicles containing clear, viscid fluid
Complete or partial
Embryo is not viable & dies
Complete Hydatidiform 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)
Clinical Presentation: Uterine enlargement greater than expected for gestational dates, hyperemesis, and preeclamptic symptom
Partial Hydatidiform Mole
Has a triploid karyotype (69 chromosomes) because two sperm cells have provided a double contribution by fertilizing the ovum
Clinical Presentation: Missed or incomplete abortion, including vaginal bleeding and a small- or normal-sized-for-date uterus
Rarely transform into choriocarcinoma.
Clinical Manifestations of GTD
Report of early signs of pregnancy, such as amenorrhea, breast tenderness, fatigue
Brownish vaginal bleeding/spotting: Like prune juice
Anemia
Inability to detect a fetal heart rate after 10 to 12 weeks’ gestation
Fetal parts not evident with palpation
Bilateral ovarian enlargement caused by cysts and elevated levels of hCG
Persistent, often severe nausea and vomiting (due to high hCG levels): Hyperemesis Gravidarum
Fluid retention and swelling
Uterine size larger than expected for pregnancy dates
Extremely high hCG levels present; no single value considered diagnostic
Early development of preeclampsia (usually not present until after 24 weeks)
Absence of fetal heart rate or fetal activity
Expulsion of grape-like vesicles (possible in some women)
Having a molar pregnancy (either partial or complete) results in…
…the loss of the pregnancy and the possibility of developing choriocarcinoma, a chorionic malignancy from the trophoblastic tissue
Interventions for Molar Pregnancy
Surgery
Rhogam- if indicated
Methotrexate (b/c of possible development of choriocarcinoma)
No new pregnancies for 1 year
Therapeutic Management of GTD
Consists of immediate evacuation of the uterine contents as soon as the diagnosis is made and long-term follow-up of the client to detect any remaining trophoblastic tissue that might become malignant.
D&C is used to empty the uterus
- The tissue obtained is sent to the laboratory for analysis to evaluate for choriocarcinoma
Serial levels of hCG are used to detect residual trophoblastic tissue for 1 year.
- If any tissue remains, hCG levels will not regress. In 80% of women with a benign hydatidiform mole, serum hCG titers steadily drop to normal within 8 to 12 weeks after evacuation of the molar pregnancy.
In the other 20% of women w/ a malignant hydatidiform mole, serum hCG levels begin to rise
Follow-up Protocol for GTD
Baseline hCG level, chest radiograph, and pelvic ultrasound
Quantitative hCG levels every week until undetectable for three consecutive weeks; then serial hCG levels monthly for 1 year
Chest radiograph every 6 months to detect pulmonary metastasis
Regular pelvic examinations to assess uterine and ovarian regression
Systemic assessments for symptoms indicative of lung, brain, liver, or vaginal metastasis
Strong recommendation to avoid pregnancy for 1 year because the pregnancy can interfere with the monitoring of hCG levels
Use of a reliable contraceptive for at least 1 year
Incompetent Cervix
Painless dilation of the cervix w/out labor or uterine contractions
Cervical Insufficiency
AKA Premature Dilation of the Cervix
Describes a weak, structurally defective cervix that spontaneously dilates in the absence of uterine contractions in the second trimester or early third trimester, resulting in the loss of the pregnancy
Typically occurs in 4th/5th month of gestation
- If not arrested-> results in fetal loss (occur before point of viability)
Contributing Factors of Cervical Insufficiency
1) Congenital factors
2) Acquired
3) Biochemical factors
Risk Factors for Cervical Insufficiency
Previous cervical trauma
Preterm labor
Fetal loss in the 2nd trimester
Previous surgeries/procedures involving the cervix
Pathophysiology for Cervical Insufficiency
Cervix may have less elastin, less collagen, and greater amounts of smooth muscle than the normal cervix and thus results in loss of sphincter tone
Several theories have been proposed that focus on damage to the cervix as a key component of hormonal factors, such as increased amounts of relaxin.
- When the pressure of the expanding uterine contents becomes > than the ability of the cervical sphincter to remain closed, the cervix suddenly relaxes, allowing effacement and dilation to proceed.
- Cervical dilation is typically rapid, relatively painless, and accompanied by minimal bleeding
Structural cervical weakness is the likely cause of many recurrent second-trimester losses, but not the only etiology.
- Likely the clinical end point of many pathologic processes, such as congenital cervical hypoplasia, or trauma to the cervix
-Other conditions: previous precipitous birth, a prolonged second stage of labor, increased amounts of relaxin and progesterone, or increased uterine volume (multiple gestation, hydramnios) are associated with cervical insufficiency
How is cervical length associated w/ cervical insufficiency?
Recent studies have examined the association between a short cervical length and the risk of preterm birth.
Some have demonstrated a continuum of risk between a shorter cervix on ultrasound and a higher risk of preterm birth, leading to the hypothetical argument that women with a short cervix on ultrasound might benefit from cervical cerclage (the sewing closed of the cervix)
The ACOG does not recommend cerclage placement for women with short cervixes who do not have a history of preterm birth, as it has not been shown to be beneficial in this population
Therapeutic Management of Cervical Insufficiency
Bed rest (includes pelvic rest)
Avoidance of heavy lifting
Progesterone supplementation (women w/ risk for premature birth)
Placement of cervical pessary (round, silicone device that sits at the mouth of the cervix
Surgically via a cervical cerclage procedure in the 2nd trimester
Cervical Cerclage
Involves using a heavy purse-string suture to secure and reinforce the internal os of the cervix
Can be performed transvaginally or transabdominally
- Placement up to 28 weeks’ gestation
Indications:
- History of 2nd trimester pregnancy loss w/painless dilatation
- Prior cerclage placement for cervical insufficiency
- History of spontaneous preterm birth prior to 34 weeks’ gestation
- {ainless cervical dilatation on physical examination in the 2nd trimester
Complications: Suture displacement, rupture of membranes, and chorioamnionitis
Nursing Management of Cervical Insufficiency
Be alert for c/o vaginal discharge or pelvic pressure!
- With cervical insufficiency, the woman will often report:
- A pink-tinged vaginal discharge or an increase in low pelvic pressure
- Cramping with vaginal bleeding
- Loss of amniotic fluid
- Cervical dilation also occurs.
If this continues, rupture of the membranes, release of amniotic fluid, and uterine contractions occur, subsequently resulting in delivery of the fetus, often before it is viable
Monitor the woman closely for signs of preterm labor: backache, increase in vaginal discharge, rupture of membranes, and uterine contractions
Provide emotional support and education
Provide preoperative care and teaching as indicated if the woman will be undergoing cerclage.
Teach the client and her family about the signs and symptoms of preterm labor and the need to report any changes immediately.
-Also reinforce the need for activity restrictions (if appropriate) and continued regular follow-up
Placenta Previa
When the placenta is inserted wholly or partly into the lower uterine segment of the uterus, partially or completely covering the internal cervical opening
Occurs during the last 2 trimesters of pregnancy
Poses a high risk of prenatal and postpartum hemorrhage as well as perinatal mortality
Classical Presentation: Painless, bright-red bleeding
Risk Factors for Placenta Previa
Maternal age over 35 years
Previous cesarean birth
Multiparity
Uterine insult or injury
Cocaine use
Previous D&C
Endometrial ablation
Prior placenta previa
Infertility treatment
Multiple gestations
Previous induced surgical abortion
Smoking
Previous myomectomy to remove fibroids
Short interval between pregnancies
HTN or diabetes
Pathophysiology of Placenta Previa
Initiated by implantation of the embryo in the lower uterus,
- Potential Causes: uterine endometrial scarring or damage in the upper segment->may incite placental growth in the unscarred lower uterine segment.
- Lack of perfusion to the placenta: increase the surface area required for placental attachment & may cause the placenta to encroach on the lower uterine segment
As the placenta attaches & grows, the cervical os may become covered by the developing placenta.
- Vascularization is defective, allowing the placenta to attach directly to the myometrium (accreta), deeply attach to the myometrium (increta), or infiltrate the myometrium (percreta)
Covers the internal os
What are the 4 classifications of placenta previa?
1) Total
2) Partial
3) Marginal
4) Low-Lying Placenta
Placenta Previa: Total
Internal os is completely covered by the placenta
Placenta Previa: Partial
Internal os is partially covered by the placenta
Placenta Previa: Marginal
Edge of placenta is at the margin of the internal os
Placenta Previa: Low-Lying Placenta
Placenta is implanted in the lower segment but does not reach the os
- If the placental edge is less than 2 cm from the internal os but does not cover it
Nursing Assessment: Health History & Physical Exam
Ask the client if she has any problems associated with bleeding now or in the recent past
The classical clinical presentation is painless, bright red vaginal bleeding occurring during the second or third trimester.
- The initial bleeding is usually not profuse and it ceases spontaneously, only to recur again.
- The 1st episode of bleeding occurs (on average) at 27 to 32 weeks’ gestation.
Thought to arise secondary to the thinning of the lower uterine segment in preparation for the onset of labor.
- When the bleeding occurs at the implantation site in the lower uterus, the uterus cannot contract adequately & stop the flow of blood from the open vessels.
Assess the client for uterine contractions, which may or may not occur with the bleeding.
Palpate the uterus; typically, it is soft & non-tender upon examination.
Auscultate the fetal heart rate; it is commonly within normal parameters.
- Fetal distress is usually absent but may occur when cord problems arise
General Nursing Management of Placenta Previa
Bed rest until 37 weeks
No vaginal exams
Monitoring blood loss
Monitor fetal heart tones
Betamethasone (for fetal lung development)
IV fluids and monitor mom’s vitals
Pelvic rest including no intercourse
If previa doesn’t resolve, C-Section will be required for safe delivery
Abruptio Placenta
AKA Placental Abruption
The early separation of a normally implanted placenta after the 20th week of gestation prior to birth, which leads to hemorrhage
What are the classic symptoms of placental abruption?
Sudden pain, blood can be visible or concealed, may have fetal distress and uterus may be firm or rigid
Causes of Placental Abruption
Cigarette Smoking
Increased maternal age
Alcohol
Cocaine
Short umbilical cord
Multiparity
Trauma
HTN: Most common cause
What is the most common cause of placental abruption?
HTN
What are the 3 classifications of abruptio placenta?
1) Marginal
2) Central
3) Complete
Abruptio Placenta: Marginal
Blood passes between the fetal membranes and the uterine wall and escapes vaginally (may or may not become more severe)
Abruptio Placenta: Central
Placenta separates centrally and blood is trapped between the placenta and the uterine wall (concealed bleeding)
Abruptio Placenta: Complete
Massive vaginal bleeding (almost total separation)
Class 0 Abruption
Asymptomatic
Clinically unrecognized before birth, diagnosis is made retrospectively after birth
Class I Abruption
Mild (Most common)
No sign of vaginal bleeding or minimal bleeding (less than 500 mL), marginal separation (10% to 20%), tender uterus, no coagulopathy, no signs of shock, no fetal distress
Class II Abruption
Moderate: Mom & fetus show signs of distress
No sign of bleeding or moderate bleeding (1,000 to 1,500 mL), moderate separation (20% to 50%), continuous abdominal pain, mild shock, normal maternal blood pressure, maternal tachycardia, evidence of fetal distress
Class III Abruption
SEVERE: Maternal shock & fetal death likely!!!
Absent to moderate bleeding (more than 1,500 mL), severe separation (more than 50%), profound shock, dark vaginal bleeding, agonizing abdominal pain, decreased maternal blood pressure, significant maternal tachycardia and the development of DIC
Emergency Measures for Placental Abruption
Starting two large-bore IV lines with normal saline or lactated Ringer’s solution to combat hypovolemia
Obtaining blood specimens for evaluating hemodynamic status values and for typing and cross-matching
Frequently monitoring fetal and maternal well-being
- C-section if fetal distress is evident
- If fetus is not in distress: Close monitoring continues with birth planned at the earliest signs of fetal distress
(T/F) True or False: Vital signs can be within normal range, even with significant blood loss, because a pregnant woman can lose up to 40% of her total blood volume without showing signs of shock
True
Diagnostic Lab Findings
CBC: Determines the current hemodynamic status; however, it is not reliable for estimating acute blood loss.
Fibrinogen levels: Typically, are increased in pregnancy (hyperfibrinogenemia); thus, a moderate dip in fibrinogen levels might suggest DIC, and if profuse bleeding occurs, the clotting cascade might be compromised.
Prothrombin time (PT)/activated partial thromboplastin time (aPTT): Determines the client’s coagulation status, especially if surgery is planned.
Type and cross-match: Determines blood type if a transfusion is needed.
Nonstress test: Demonstrates findings of fetal jeopardy manifested by late decelerations or bradycardia.
Biophysical profile: Aids in evaluating clients with chronic abruption; a low score (less than 6 points) suggests possible fetal compromise
Hyperemesis Garvidarum
A severe form of N/V of pregnancy associated with significant costs and psychosocial impact
Characterized by:
- Persistent, uncontrollable N/V that begins before 9 weeks’ gestation and causes dehydration, nutritional deficiencies, ketosis, electrolyte imbalances, and weight loss of more than 5% of prepregnancy body weight
Risk Factors for Hyperemesis Gravidarum
Previous pregnancy complicated by hyperemesis
Molar pregnancies
History of Helicobacter pylori infection
Multiple gestation
Prepregnancy history of genitourinary disorders
Clinical hyperthyroid disorders
Prepregnancy psychiatric diagnosis
Pathophysiology
In hyperemesis gravidarum, the hCG levels are often higher and extend beyond the first trimester
Symptoms exacerbate the disease
Decreased fluid intake and prolonged vomiting cause dehydration
- Dehydration increases the serum concentration of hCG, which in turn exacerbates the N/V
Therapeutic Management of Hyperemesis Gravidarum
Diagnosis of EXCLUSION
1st Line of Treatment: Conservative Management
- Focuses on dietary & lifestyle changes
- If conservative management fails-> hospitalization is REQUIRED
1st Choice for Fluid Replacement: Normal Saline
- Aids in preventing hyponatremia
- Vitamins (pyridoxine or vitamin B6 added)
Oral food and fluids are w/held for the first 24 to 36 hours to allow the GI tract to rest.
Antiemetics may be administered rectally or intravenously to control the N/V initially because the woman is considered NPO
- Once her condition stabilizes and she is allowed oral intake, medications may be administered PO
Nursing Assessment of Hyperemesis Gravidarum: Health History & Physical Exam
Ask about:
- Onset, duration, & course of N/V
- Treatments used & their efficacy
- Diet history: Diet recall for past week
- Client’s knowledge of nutrition & need for appropriate intake
- Complaints of ptyalism (excess saliva), anorexia, indigestion, & abdominal pain or distention
- Blood or mucus in stool
Review possible risk factors
Weigh the client and compare this weight with her weight before she began experiencing symptoms and to her prepregnancy weight to estimate the degree of loss.
- With hyperemesis, weight loss usually exceeds 5% of body mass.
Inspect the mucous membranes for dryness and check skin turgor for evidence of fluid loss and dehydration
Assess BP for hypotension
- Also note any complaints of weakness, fatigue, activity intolerance, dizziness, or sleep disturbances
Patient Teaching for Hyperemesis Gravidarum
Avoid noxious stimuli, such as strong flavors, perfumes, or strong odors like frying bacon, that might trigger nausea and vomiting.
- Avoid tight waistbands to minimize pressure on abdomen.
- Eat small, frequent meals throughout the day.
- Separate fluids from solids by consuming fluids in between meals.
- Avoid lying down or reclining for at least 2 hours after eating.
- Use high-protein supplement drinks.
- Avoid foods high in fat.
- Increase your intake of carbonated beverages.
- Increase your exposure to fresh air to improve symptoms.
- Eat when you are hungry, regardless of normal mealtimes.
- Drink herbal teas containing peppermint or ginger.
- Avoid fatigue, and learn how to manage stress in life.
- Schedule daily rest periods to avoid becoming overtired.
- Eat foods that settle the stomach, such as dry crackers, toast, or soda.
Hypertension Disorders
Gestational HTN: Pregnancy Induced Hypertension (PIH)
Preeclampsia
Eclampsia
HELLP
Risk Factors for HTN During Pregnancy
Chronic HTN
Diabetes
History of preterm birth
Moderate to severe obstructive sleep apnea
Non-Hispanic black ethnicity
Obesity
Age: Older than 40 years
Strong family history of cardiovascular disease
Chronic Hypertension
HTN that exists prior to pregnancy or that develops before 20 weeks’ gestation w/ BP readings greater than 140/90 mm Hg
25% of women w/ chronic HTN develop preeclampsia during pregnancy
Management: If BP exceeds 160/100 drug treatment is recommended
Gestational HTN
AKA “Pregnancy Induced Hypertension” (PIH)
Gestational hypertension: A new-onset blood pressure elevation (140/90 mm Hg) identified after 20 weeks’ gestation W/OUT proteinuria
BP returns to normal by 12 weeks’ postpartum
MUST have an elevated BP on 2 occasions, 6 hrs apart
Preeclampsia
MOST COMMON hypertensive disorder of pregnancy
Develops w/ proteinuria after 20 weeks’ gestation
Multisystem disease process, which is accompanied by at least one of the following:
- proteinuria
- Elevated creatinine
- Liver involvement
- Epigastric or abdominal pain
- Neurologic complications
- Hematologic complications
- Uteroplacental dysfunction
Eclampsia occurs when seizure activity develops
Pathophysiology of Preeclampsia
Vasospasm which results in elevated BP reducing the blood flow to the brain, liver, kidneys, placenta, and lungs.
Decrease liver perfusion presents as epigastric pain and increased liver enzymes
Decreased brain perfusion leads to headaches, visual disturbances, and hyperactive deep tendon reflexes (DTRs)
Decreased kidney perfusion leads to decreased urine output
Proteinuria of 300mg or greater in a 24-hour urine specimen
Management of Mild Preeclampsia
No signs of renal or hepatic dysfunction
Bed Rest (lateral recumbent position)
Diet
Monitor Fetal Status
Frequent evaluation of CBC, liver enzymes, platelet levels, and clotting factors
Monitor protein in urine
Management of Severe Preeclampsia
Bed Rest (dark and quiet room to decrease stimulation)
Diet
Anticonvulsants (Magnesium Sulfate)
Corticosteroids (Betamethasone)
Fluid and Electrolyte Replacement
Antihypertensive
Magnesium Sulfate
Calcium antagonist and CNS depressant
Uses: Prevents seizures; lowers blood pressure
MOA: Relaxes smooth muscle of the uterus through
calcium displacement
- Crosses the placenta
- Excreted by the kidneys
Common Side Effects: Headache, visual disturbance, lethargy, N/V
Magnesium Toxicity
Absence of reflexes, respiratory depression, oliguria, confusion, cardiac arrest
Use with caution in women w/ renal insufficiency and Myasthenia Gravis
Nursing Considerations for Patients on Magnesium Sulfate
Blood Pressure
Magnesium Levels (every 6-8 hours)
Respirations
Reflexes
Urinary output
Fetus
Calcium Gluconate at bedside (reversal agent for Magnesium toxicity)
After birth, the neonate should be monitored and observed for magnesium toxicity for 24-48 hours
Corticosteroids: Betamethasone (Celestone)
Help prevent or reduce the frequency and severity of respiratory distress syndrome and intraventricular hemorrhage in the premature infant
Stimulate surfactant production in the unborn baby
Administered 2 doses IM 24 hours apart
Effects seen as soon as 48 hours after initial administration
Nursing Implications: Monitor maternal lung sounds and signs of infection
Signs & Symptoms of Worsening Preeclampsia
Increasing edema
Worsening headache
Epigastric Pain
Visual Disturbances
Decreasing Urinary Output
Nausea/vomiting
Bleeding Gums
Disorientation
Generalized complaints of not feeling well
Hyperactive Reflexes
Eclampsia
Eclamptic seizures are a MEDICAL EMERGENCY!!!
- Convulsive activity starts w/ facial twitching
- Next is generalized muscle rigidity
The hallmark neurologic complication of preeclampsia, the onset of seizure activity
Signs & Symptoms:
- BP of 160/110 mm Hg
- Marked Proteinuria
- SEIZURES
- Hyperreflexia
Other symptoms may include: severe headache, generalized edema, epigastric pain, visual disturbances, cerebral hemorrhage, renal failure, HELLP
Face distortion w/ protruding eyes & foaming at the mouth
Respirations cease for the duration of the seizure, resulting from muscle spasms->compromising fetal oxygenation
Eclampsia: Seizure Complications
Tongue biting
Head trauma
Broken bones
Aspiration
Coma usually follows the seizure activity, with respiration resuming
Management of Eclampsia
Use ABC Prioritization: Clear the airway & provide supplemental oxygenation
Position the woman on her left side and protecting her from injury during the seizure
Suction equipment must be readily available to remove secretions from her mouth after the seizure is over
IV fluids are administered after the seizure at a rate to replace urine output and additional insensible losses
Monitor fetal HR closely
Magnesium sulfate is administered IV to prevent further seizures and continued for at least 24 hours after the woman’s last seizure
Serum magnesium levels, respiratory rate, reflexes, and urine output in women receiving magnesium sulfate are closely monitored to avoid magnesium toxicity and prevent cardiac arrest.
Hypertension is controlled with antihypertensive medications.
If she is found stable, birth via induction or cesarean birth is performed
-Remains stable, she will be transferred to the postpartum unit for care.
- Becomes unstable after giving birth, she may be transferred to the critical care unit for closer observation
Cure for Preeclampsia & Eclampsia
Deliver Placenta
HELLP
H: Hemolysis
EL: Elevated Liver Enzymes
LP: Low Platelet Count
Symptoms include: N/V, flulike symptoms, epigastric pain
Variant of Preeclampsia and Eclampsia
Increased risk of cerebral hemorrhage, retinal detachment, hematoma/liver rupture, acute renal failure, disseminated intravascular coagulation (DIC), placental abruption, and maternal death
HELLP Lab Work
Anemia: Low Hemoglobin
Thrombocytopenia: Low platelets <100,000
Elevated liver enzymes:
- AST aspartate aminotransferase exists within the liver cells and with damage to liver cells, the AST levels rise > 20 u/L.
- LDH – When cells of the liver are lysed, they spill into the bloodstream and there is an increase in serum > 90 u/L
Therapeutic Management of HELLP
Focuses on stabilization of blood pressure and assessment of fetal well-being to determine the optimal time for birth
Treatment based on the severity of the disease, the gestational age of the fetus, and the condition of the mother and fetus
Lower high BP w/ rapid-acting antihypertensive agents, prevention of convulsions or further seizures with magnesium sulfate, and use of steroids for fetal lung maturity if necessary, followed by the birth of the infant and placenta
Client should be admitted or transferred to a tertiary center with a neonatal intensive care unit.
Magnesium sulfate is used prophylactically to prevent seizures.
Antihypertensives such as hydralazine or labetalol are given to control blood pressure
Birth may be delayed up to 96 hours so that betamethasone or dexamethasone can be given to stimulate lung maturation in the preterm fetus
Blood Incompatibility
Arises when a mother w/ blood type O becomes pregnant with a fetus w/ different blood type (type A, B, or AB)
- Most commonly involves one of two issues: blood type or Rh factor
The mother’s serum contains naturally occurring anti-A and anti-B, which can cross the placenta and hemolyze fetal red blood cells
Usually less severe than Rh incompatibility
Rh Incompatibility
1) Rh (-) woman & Rh (+) man conceive a child
2) Rh (-) woman carries Rh (+) child
3) Cells from Rh (+) fetus enters mom’s bloodstream
4) Woman becomes sensitized: Antibodies form to fight Rh (+) blood cells
5) In the next Rh (+) pregnancy, maternal antibodies attack fetal RBCs
Effects of Rh Antibodies Entering Fetal Circulation
Hemolysis
Generalized Edema
CHF
Jaundice
Indirect Coombs Test
Measures # of Rh+ antibodies in maternal blood (indirect antiglobulin test)
Screens pregnant women for antibodies that may cause hemolytic disease in the newborn
Negative – Fetus at no risk
Positive – Fetus at risk
Direct Coombs Test
On infant to detect antibody coated Rh+ blood cells (Direct antiglobulin test)
A positive result indicates an immune mechanism is attacking the baby’s own RBC’s
Rh incompatibility
Rhogam
Given to Rh(-) woman
Given @ 28 weeks gestation
Given within 72 hours after birth
- After: Abortion, chorionic villus sampling, ectopic pregnancy, amniocentesis
Given IV or IM
Indication: to prevent Rh (-) woman from developing Rh antibodies
Polyhydraminos
A condition in which there is too much amniotic fluid (more than 2,000 mL) surrounding the fetus between 32 and 36 weeks
