Chapter 19 Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications

Question 1

High-Risk Pregnancy

Answer 1

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

Question 2

Examples of High-Risk Conditions

Answer 2

Gestational diabetes

HTN

PCOS

Obesity

Older/younger age

Autoimmune disease

Tobacco use

Birth defects

Multiple gestation

Question 3

Many obstetric complications & conditions are…

Answer 3

…life-threatening emergencies w/ high morbidity & mortality rates.

Question 4

When does risk assessment begin?

Answer 4

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

Question 5

Examples of Pregnancy-Specific Stress

Answer 5

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

Question 6

What are the current 4 categories of risk?

Answer 6

1) Biophysical
2) Psychosocial
3) Sociodemographic
4) Environmental

Question 7

Biophysical Risk Factors for High-Risk Pregnancy

Answer 7

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

Question 8

Environmental Risk Factors for High-Risk Pregnancy

Answer 8

Infections

Radiation

Pesticides

Illicit rugs

Question 9

Psychosocial Risk Factors for High-Risk Pregnancy

Answer 9

Smoking

Caffeine

Alcohol & Substance Abuse

Inadequate support system

Maternal Obesity

Situational Crisis

History of Violence

Emotional Distress

Unsafe cultural practices

Question 10

Sociodemographic Risk Factors for High-Risk Pregnancy

Answer 10

Poverty

Lack of Prenatal Care

Age younger than 15 or older than 35

Marital Status

Accessibility to Healthcare

Ethnicity

Question 11

(T/F) True or False: Bleeding at any time during pregnancy is potentially life-threatening

Answer 11

True

Question 12

What is the biggest killer of pregnant women?

Answer 12

Obstetric hemorrhage

Can occur early or late in the pregnancy

Bleeding is experienced by approximately 25% of women during the first trimester of pregnancy

Question 13

Management of Obstetric Hemorrhage

Answer 13

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

Question 14

Conditions Commonly Associated w/ Early Bleeding (1st half of pregnancy)

Answer 14

Spontaneous abortion, uterine fibroids, ectopic pregnancy, gestational trophoblastic disease, and cervical insufficiency.

Question 15

Conditions Commonly Associated w/ Late Bleeding

Answer 15

Conditions associated with late bleeding include placenta previa, placental abruption, and placenta accreta, which usually occur after the 20th week of gestation.

Question 16

Abortion

Answer 16

Loss of an early pregnancy, usually before week 20 of gestation

Can be spontaneous or induced

Question 17

Spontaneous Abortion

Answer 17

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

Question 18

Risk Factors for Spontaneous Abortion

Answer 18

AMA
Drug use
Weakened cervix
Placental abnormalities
Chronic maternal disease

Question 19

Pathophysiology of Spontaneous Abortion

Answer 19

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)

Question 20

Cause of Spontaneous Abortion in 4-8 Weeks Gestation

Answer 20

Chromosomal Abnormalities

Question 21

Cause of Spontaneous Abortion in 4-10 Weeks Gestation

Answer 21

Insufficient/ Excessive Hormones

Question 22

Cause of Spontaneous Abortion in 4-12 Weeks Gestation

Answer 22

Maternal Infections

Question 23

Cause of Spontaneous Abortion in 12-19 Weeks Gestation

Answer 23

Usually caused by a maternal factor such as cervical insufficiency or maternal disease

Question 24

What are the classifications of abortions?

Answer 24

Threatened
Imminent/Inevitable
Complete
Incomplete
Missed
Recurrent Pregnancy Loss
Septic

Question 25

Threatened Abortions

Answer 25

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

Question 26

Imminent/Inevitable Abortion

Answer 26

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)

Question 27

Complete Abortion

Answer 27

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

Question 28

Incomplete Abortion

Answer 28

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

Question 29

Missed Abortion

Answer 29

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

Question 30

Recurrent Pregnancy Loss

Answer 30

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

Question 31

Septic Abortion

Answer 31

Assessment Findings:
-
Diagnosis:
-
Therapeutic Management:
-

Question 32

Nursing Assessment of Spontaneous Abortion

Answer 32

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

Question 33

Nursing Care of Spontaneous Abortion

Answer 33

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

Question 34

Nursing Care of Spontaneous Abortion: Providing Continued Monitoring

Answer 34

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

Question 35

Nursing Care of Spontaneous Abortion: Providing Support

Answer 35

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

Question 36

Stillbirth

Answer 36

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

Question 37

Postmortem Care After a Perinatal Loss

Answer 37

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

Question 38

Preterm Labor (PTL)

Answer 38

1 cause of neonatal morbidity

Labor that occurs between 20 and 37 completed weeks of pregnancy

Question 39

Risk Factors for PTL

Answer 39

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

Question 40

Signs & Symptoms of PTL

Answer 40

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

Question 41

Criteria for Preterm Labor Diagnosis

Answer 41

Cervical Dilation and Effacement
plus
4 uterine contractions in 20 minutes
or
8 uterine contractions in 1 hour

Question 42

Management of PTL: Tocolytic Therapy

Answer 42

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

Question 43

Ectopic Pregnancy

Answer 43

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

Question 44

Risk Factors for Ectopic Pregnancy

Answer 44

Tubal obstruction/damage
Delayed tubal transport
Congenital anomalies
Altered hormonal status
Smoking
AMA

Question 45

Pathophysiology of Ectopic Pregnancy

Answer 45

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

Question 46

Classic Clinical Triad of Ectopic Pregnancy

Answer 46

Abdominal pain, amenorrhea, & vaginal bleeding

Only ~1/2 of women present w/ all 3 symptoms

Question 47

Physical Exam Findings of Ectopic Pregnancy

Answer 47

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

Question 48

Physical Exam Findings of Ectopic Pregnancy Rupture/ Hemorrhage

Answer 48

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

Question 49

Diagnostic Procedures for Ectopic Pregnancy

Answer 49

Urine pregnancy test to confirm the pregnancy

Beta-hCG concentrations to exclude a false-negative urine test

Transvaginal ultrasound to visualize the misplaced pregnancy

Question 50

Medical Interventions for Ectopic Pregnancy: Methotrexate

Answer 50

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

Question 51

Nursing Education for Ectopic Pregnancy

Answer 51

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

Question 52

Surgical Interventions for Ectopic Pregnancy

Answer 52

Treatment for RUPTURED Ectopic Pregnancy

Salpingectomy: Laporotomy w/ removal of the tube

All patients are given Rhogam to prevent isoimmunization in future pregnancies

Question 53

Gestational Trophoblastic Disease (GTD)

Answer 53

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

Question 54

Hydatidiform Mole

Answer 54

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

Question 55

Complete Hydatidiform Mole

Answer 55

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

Question 56

Partial Hydatidiform Mole

Answer 56

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.

Question 57

Clinical Manifestations of GTD

Answer 57

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)

Question 58

Having a molar pregnancy (either partial or complete) results in…

Answer 58

…the loss of the pregnancy and the possibility of developing choriocarcinoma, a chorionic malignancy from the trophoblastic tissue

Question 59

Interventions for Molar Pregnancy

Answer 59

Surgery

Rhogam- if indicated

Methotrexate (b/c of possible development of choriocarcinoma)

No new pregnancies for 1 year

Question 60

Therapeutic Management of GTD

Answer 60

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

Question 61

Follow-up Protocol for GTD

Answer 61

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

Question 62

Incompetent Cervix

Answer 62

Painless dilation of the cervix w/out labor or uterine contractions

Question 63

Cervical Insufficiency

Answer 63

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)

Question 64

Contributing Factors of Cervical Insufficiency

Answer 64

1) Congenital factors
2) Acquired
3) Biochemical factors

Question 65

Risk Factors for Cervical Insufficiency

Answer 65

Previous cervical trauma
Preterm labor
Fetal loss in the 2nd trimester
Previous surgeries/procedures involving the cervix

Question 66

Pathophysiology for Cervical Insufficiency

Answer 66

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

Question 67

How is cervical length associated w/ cervical insufficiency?

Answer 67

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

Question 68

Therapeutic Management of Cervical Insufficiency

Answer 68

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

Question 69

Cervical Cerclage

Answer 69

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

Question 70

Nursing Management of Cervical Insufficiency

Answer 70

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

Question 71

Placenta Previa

Answer 71

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

Question 72

Risk Factors for Placenta Previa

Answer 72

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

Question 73

Pathophysiology of Placenta Previa

Answer 73

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

Question 74

What are the 4 classifications of placenta previa?

Answer 74

1) Total
2) Partial
3) Marginal
4) Low-Lying Placenta

Question 75

Placenta Previa: Total

Answer 75

Internal os is completely covered by the placenta

Question 76

Placenta Previa: Partial

Answer 76

Internal os is partially covered by the placenta

Question 77

Placenta Previa: Marginal

Answer 77

Edge of placenta is at the margin of the internal os

Question 78

Placenta Previa: Low-Lying Placenta

Answer 78

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

Question 79

Nursing Assessment: Health History & Physical Exam

Answer 79

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

Question 80

General Nursing Management of Placenta Previa

Answer 80

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

Question 81

Abruptio Placenta

Answer 81

AKA Placental Abruption

The early separation of a normally implanted placenta after the 20th week of gestation prior to birth, which leads to hemorrhage

Question 82

What are the classic symptoms of placental abruption?

Answer 82

Sudden pain, blood can be visible or concealed, may have fetal distress and uterus may be firm or rigid

Question 83

Causes of Placental Abruption

Answer 83

Cigarette Smoking
Increased maternal age
Alcohol
Cocaine
Short umbilical cord
Multiparity
Trauma
HTN: Most common cause

Question 84

What is the most common cause of placental abruption?

Answer 84

HTN

Question 85

What are the 3 classifications of abruptio placenta?

Answer 85

1) Marginal
2) Central
3) Complete

Question 86

Abruptio Placenta: Marginal

Answer 86

Blood passes between the fetal membranes and the uterine wall and escapes vaginally (may or may not become more severe)

Question 87

Abruptio Placenta: Central

Answer 87

Placenta separates centrally and blood is trapped between the placenta and the uterine wall (concealed bleeding)

Question 88

Abruptio Placenta: Complete

Answer 88

Massive vaginal bleeding (almost total separation)

Question 89

Class 0 Abruption

Answer 89

Asymptomatic

Clinically unrecognized before birth, diagnosis is made retrospectively after birth

Question 90

Class I Abruption

Answer 90

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

Question 91

Class II Abruption

Answer 91

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

Question 92

Class III Abruption

Answer 92

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

Question 93

Emergency Measures for Placental Abruption

Answer 93

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

Question 94

(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

Answer 94

True

Question 95

Diagnostic Lab Findings

Answer 95

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

Question 96

Hyperemesis Garvidarum

Answer 96

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

Question 97

Risk Factors for Hyperemesis Gravidarum

Answer 97

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

Question 98

Pathophysiology

Answer 98

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

Question 99

Therapeutic Management of Hyperemesis Gravidarum

Answer 99

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

Question 100

Nursing Assessment of Hyperemesis Gravidarum: Health History & Physical Exam

Answer 100

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

Question 101

Patient Teaching for Hyperemesis Gravidarum

Answer 101

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.

Question 102

Hypertension Disorders

Answer 102

Gestational HTN: Pregnancy Induced Hypertension (PIH)
Preeclampsia
Eclampsia
HELLP

Question 103

Risk Factors for HTN During Pregnancy

Answer 103

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

Question 104

Chronic Hypertension

Answer 104

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

Question 105

Gestational HTN

Answer 105

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

Question 106

Preeclampsia

Answer 106

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

Question 107

Pathophysiology of Preeclampsia

Answer 107

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

Question 108

Management of Mild Preeclampsia

Answer 108

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

Question 109

Management of Severe Preeclampsia

Answer 109

Bed Rest (dark and quiet room to decrease stimulation)

Diet

Anticonvulsants (Magnesium Sulfate)

Corticosteroids (Betamethasone)

Fluid and Electrolyte Replacement

Antihypertensive

Question 110

Magnesium Sulfate

Answer 110

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

Question 111

Magnesium Toxicity

Answer 111

Absence of reflexes, respiratory depression, oliguria, confusion, cardiac arrest

Use with caution in women w/ renal insufficiency and Myasthenia Gravis

Question 112

Nursing Considerations for Patients on Magnesium Sulfate

Answer 112

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

Question 113

Corticosteroids: Betamethasone (Celestone)

Answer 113

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

Question 114

Signs & Symptoms of Worsening Preeclampsia

Answer 114

Increasing edema

Worsening headache

Epigastric Pain

Visual Disturbances

Decreasing Urinary Output

Nausea/vomiting

Bleeding Gums

Disorientation

Generalized complaints of not feeling well

Hyperactive Reflexes

Question 115

Eclampsia

Answer 115

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

Question 116

Eclampsia: Seizure Complications

Answer 116

Tongue biting
Head trauma
Broken bones
Aspiration

Coma usually follows the seizure activity, with respiration resuming

Question 117

Management of Eclampsia

Answer 117

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

Question 118

Cure for Preeclampsia & Eclampsia

Answer 118

Deliver Placenta

Question 119

HELLP

Answer 119

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

Question 120

HELLP Lab Work

Answer 120

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

Question 121

Therapeutic Management of HELLP

Answer 121

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

Question 122

Blood Incompatibility

Answer 122

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

Question 123

Rh Incompatibility

Answer 123

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

Question 124

Effects of Rh Antibodies Entering Fetal Circulation

Answer 124

Hemolysis

Generalized Edema

CHF

Jaundice

Question 125

Indirect Coombs Test

Answer 125

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

Question 126

Direct Coombs Test

Answer 126

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

Question 127

Rhogam

Answer 127

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

Question 128

Polyhydraminos

Answer 128

A condition in which there is too much amniotic fluid (more than 2,000 mL) surrounding the fetus between 32 and 36 weeks