Complications of Pregnancy Flashcards
Characteristic Causes of High Risk Pregnancies
Can relate to the pregnancy itself
Can occur because the woman has a medical condition or injury that complicates the pregnancy
Can result from environmental hazards that can affect the mother or her fetus
Can arise from maternal behaviour or lifestyles that have a negative effect on the mother or fetus
Danger Signs in Pregnancy
Sudden gush of fluid from the vagina Vaginal bleeding Abdominal pain Persistent vomiting Epigastric pain Edema of face and hands Severe, persistent headache Blurred vision or dizziness Chills with fever over 38ºC Painful urination or reduced urine output
Pregnancy- Related Complications
Hyperemesis Gravidarum
Bleeding disorders: Abortion, ectopic pregnancy, placenta previa and abruptio
Hypertension
Blood incompatibility between the woman and fetus - Erythroblastosis Fetalis
Diabetes
Infections
Hyperemesis Gravidarum: Manifestations
Excessive N/V Significant weight loss Dehydration Electrolyte and Acid-Base imbalances Reduced delivery of blood, oxygen, and nutrients to the fetus Psychological Factors Can affect fetal growth
Types of Abortion: Spontaneous, Induced
Spontaneous (non intentional): - Threatened - Inevitable - Incomplete - Complete - Missed - Recurrent Induced: - Therapeutic - Elective
Ectopic Pregnancy
95% occur in fallopian tube Scarring or tubal deformity may result from: - Hormonal abnormalities - Inflammation - Infection - Adhesions - Congenital defects - Endometriosis
Ectopic Pregnancy: Manifestations
Lower abdominal pain, may have light vaginal bleeding
If tube ruptures:
- May have sudden severe lower abdominal pain
- Vaginal bleeding
- Signs of hypovolemic shock
- Shoulder pain may also be felt
S&S of Hypovolemic Shock
Changes in fetal heart rate (increased, decreased, less fluctuation)
Rising, weak pulse (tachycardia)
Rising respiratory rate (tachypnea)
Shallow, irregular respirations (air hunger)
Falling BP (hypotension)
Decreased, or absent urinary output (less than 30 mL/hr)
Pale skin of pale mucous membranes
Cold, clammy skin
Faintness
Thirst
Bleeding Disorders of late pregnancy
Placenta previa
- Abnormal implantation of the placenta
- Bright bleeding occurs when cervix dilates resulting in PAINLESS bleeding
Abruptio placentae
- Normal implantation of placenta
- Dark bleeding with PAIN, and enlarging uterus suggests blood is accumulating in the cavity
Complications or Risks: Placenta previa
Infection, because of vaginal organisms
Postpartum hemorrhage, because if lower segment of uterus is the site of attachment, then there are fewer muscle fibres so weaker contractions may occur
Complications or Risks: Abruptio placentae (Predisposing Factors)
Hypertension Cocaine or alcohol use Cigarette smoking and poor nutrition Blows to the abdomen Prior history of abruptio placentae Folate deficiency *MAY BE ACCOMPANIED BY DIC - A SERIOUS CLOTTING DISORDER
Hypertension During Pregnancy
Gestational hypertension (GH previously called toxemia)
- BP >140/90 in a normotensive woman after 20 weeks
Preeclampsia
- GH plus renal involvement with proteinuria
Eclampsia
- Preeclampsia plus CNS involvement with seizures/ convulsions, serious liver and coagulation issues
Chronic Hypertension
- Hypertension present before 20 weeks
Preeclampsia with superimposed chronic hypertension
- New occurrence of proteinuria or thrombocytopenia before pregnancy
Risk Factors for GH
- First Pregnancy
- Obesity
- Family hx of GH
- Age >40 or >19
- Multifetal pregnancy
- Chronic hypertension
- Chronic renal disease
- DM
Manifestations of GH
- Hypertension
- Edema above the waste
- Sudden, excessive weight gain
- Proteinuria
- CNS
- Eyes
- Urinary tract
- Respiratory system
- GI system and liver
- Blood clotting; HELLP Syndrome
Bleeding Incompatibilities
Rh- negative blood type is an autosomal recessive trait
Rh - positive blood type is a dominant trait
Rh - incompatibility can only occur if the woman is Rh- negative and the fetus is Rh- positive
Isoimmunization
The leaking of fetal Rh- positive blood into the Rh-negative mother’s circulation, causing her body to respond by making antibodies to destroy the Rh- positive erythrocytes. Therefore, with subsequent pregnancy, the woman’s antibodies against Rh- positive blood cross the placenta and destroy the petals Rh- positive erythrocytes before the infant is born
Erythroblastosis Fetalis
Occurs when the maternal anti-Rh antibodies cross the placenta and destroy fetal erythrocytes
Requires RhoGAM to be given at 28 weeks and within 72 hours of delivery to the mother
- Also given after amniocentesis, and if woman experiences bleeding during pregnancy
Fetal assessment tests must be done throughout pregnancy
An intrauterine transfusion may be done for the severely anemic fetus
Diabetes Mellitus
Inadequate insulin to move glucose into the blood
Type 1 - insulin dependency
Type 2 - insulin resistance
GDM is classified as preceding or occurring during pregnancy
Diabetes Mellitus
In order to dilute glucose in the blood, thirst is increased (polyphasia)
Fluid moves from tissue into blood (to dilute)
Tissue dehydration and increased urine output occurs (polyuria with glucosuria)
Lose weight despite eating large amounts of food (polyphagia)
Fatigue and lethargy occurs (cell starvation)
Diabetes Mellitus
The pancreas - little or no insulin
Cells starve as they cannot obtain insulin
To compensate the body metabolizes protein and fat for energy which causes ketones and acids to accumulate (ketoacidosis)
Diabetes Mellitus
Gestational Diabetes Mellitus
Glucose intolerance with onset during pregnancy
In true GDM, glucose usually returns to normal 6 weeks postpartum
Effects of Pregnancy on Glucose Metabolism
Hormones (estrogen and progesterone), insulinase ( an enzyme), and increased prolactin levels have two effects:
- Increased resistance of cells to insulin
- Increased speed of insulin breakdown
Gestational Diabetes Mellitus (GDM)
If a woman cannot increase her insulin production, then she will have periods of hyperglycemia
Because the fetus is continuously drawing glucose from the mother, she will also experience hypoglycemia between meals and during the night
During 2nd and 3rd trimester, the fetus is at risk for organ damage from hyperglycemia because fetal tissue has increased tissue resistance to maternal insulin action
Pregestational DM
Major risk for congenital anomalies to occur from maternal hyperglycemia during the embryonic period of development
Women with pregestational DM - the fetus has a greater risk of congenital anomalies
With careful management, most will have successful pregnancies and healthy babies
Factors linked to GDM
Maternal obesity (>90 kg or 198 lbs)
Large infant (>4000g or 9 lbs)
Maternal age older than 25
Previous unexplained stillbirth or infant having congenital abnormalities
History of GDM
Family history of GDM
Fasting glucose level over 126 mg/dl or postal glucose over 200 mg/dl
GDM is common and resolves quickly after birth
Anemia
Anemia is the reduced ability of the blood to carry oxygen to the cells
Four types are significant during pregnancy
- Two are nutritional:
- Iron deficiency
- Folic acid deficiency (often present at the same time as iron deficiency)
- Two are genetic disorders:
- Sickle cell anemia
- Thalassemia
Nutritional Anemias
Symptoms - Easily fatigued - Skin and mucous membranes are pale - SOB - Pounding heart - Rapid pulse (with severe anemia) When women develop slowly they have less symptoms than women who develop quickly
Iron Deficiency Anemia
RBCs are small (microcytic) and pale (hypochromic)
Prevention:
- Iron supplements
- VC may enhance absorption
- Do not take iron with milk or antacids
* Calcium impairs absorption
Need additional iron for increased blood volume, for transfer to fetus, and for cushion against blood loss at birth
Infections
Acronym TORCH is used to describe infections that can be devastating to the fetus or newborn Toxoplasmosis Other infections Rubella Cytomegalovirus Herpes
Viral Infections
No effective therapy
Immunizations can prevent some infections
Cytomegalovirus
Infected infant may have: - Mental retardation - Seizures - Blindness - Deafness - Dental abnormalities - Petechiae Treatment - No effective treatment is known - Therapeutic abortion may be offered if CMV infection is discovered early in pregnancy
Rubella
Mild viral disease
Low fever and rash
Destructive to developing fetus
- If it occurs early in pregnancy, it can disrupt formation of major body systems
- If it occurs later in pregnancy, it can cause damage to organs already formed
If the woman receives a rubella vaccine prior to pregnancy, then she should not get pregnant for at least 3 months
Not given during pregnancy because vaccine is from a live virus
Rubella (continued)
Effects on embryo or fetus:
- Microcephaly (small head size)
- Mental retardation
- Congenital cataracts
- Deafness
- Cardiac effects
- Intrauterine growth restriction
Herpesvirus
Two types:
- Type 1: Likely to cause fever blisters or cold sores
- Type 2: Likely to cause genital herpes
After primary infection, herpesvirus lies dormant in the nerves and can reactivate at any time
Initial infection during first half of pregnancy may cause spontaneous abortion, IUGR, and preterm labour
Herpesvirus (continued)
Infant can be infected in one of two ways:
- Virus ascends into the uterus after the membranes rupture
- Infant has direct contact with infectious lesions during vaginal delivery
Neonatal herpes
- Can be either localized or disseminated (widespread)
- High mortality rate
*Infant can be a chronic carrier
Hepatitis B
Transmitted by blood, saliva, vaginal secretions, semen, and breast milk; can also cross the placenta
Fetus may be infected transplacentally or by contact with blood or vaginal secretions during delivery
Upon delivery, the neonate should receive a single dose of Hepatitis B immune globulin, followed by the hepatitis B vaccine
Risk for Hepatitis B
- IV drug users
- Persons with multiple sex partners
- Person with repeated infection with STI
- Health care workers with occupational exposure to blood products and needle sticks
- Patients who are on hemodialysis
- Recipients of multiple blood transfusions or other blood products
- Household contact with hepatitis carrier or patient on hemodialysis
- Persons arriving from countries where there is a higher incidence of hepatitis B
Human Immunodeficiency Virus (HIV)
Virus that causes AIDS
Cripples immune system
No known immunization or curative treatment
Acquired in one of three ways:
- Sexual contact
- Parenteral or mucous membrane exposure to infected body fluids
- Perinatal exposure
Infant may be infected:
- Transplacentally
- Through contact with infected maternal secretions at birth
- Through breast milk
Toxoplasmosis
A parasite acquired by contact with cat feces or raw meat Transmitted through the placenta Congenital toxoplasmosis includes the following possible signs: - Low birth weight - Enlarged liver and spleen - Jaundice - Anemia - Inflammation of eye structures - Neurological damage
Group B Streptococcus (GBS) Infection
Leading cause of perinatal infection with high mortality rate
Organism found in woman’s rectum, vagina, cervix, throat, skin
The risk of exposure to the infant is greater if the labour is long or the woman experiences premature rupture of membranes
GBS significant cause of maternal postpartum infection. Symptoms include:
- Elevated temperature within 12 hours after delivery, rapid heart rate, abdominal distention
Can be deadly to the infant
Treatment:
- Penicillin
Sexually Transmitted Infections (STI)
Common mode of transmission is sexual intercourse
Infections that can be transmitted:
- Syphilis, gonorrhea, chlamydia, trichomoniasis, and condylomata acuminata
Vaginal changes during pregnancy increase the risk of transmission
Urinary Tract Infections
Pregnancy alters self-cleaning action due to pressure on urinary structures
Prevents bladder from emptying completely
Retained urine becomes more alkaline
May be asymptomatic - increased MOs may lead to cystitis or pyelonephritis
May develop cystitis:
- Burning with urination
- Increased frequency and urgency of urination
- Normal or slightly elevated temperature
Pyelonephritis:
- High fever
- Chills
- Flank pain or tenderness
- N/V
Environmental Hazards During Pregnancy
Substance abuse - drugs, alcohol
- Questions should focus on how the information will help nurses and physicians provide the safest and most appropriate care to the pregnant woman and her infant
Alcohol
- A single episode of consuming two alcoholic drinks can lead to the loss of some fetal brain cells
Trauma During Pregnancy
3 leading causes of traumatic death - Automobile accidents - Suicide - Homicide Battering - Bruises in various stages of healing - Tend to have late prenatal care
Indications for Diagnostic Tests
3 reasons:
- To detect congenital anomalies
- To evaluate the condition of the fetus if the pregnancy is high risk and allow appropriate intervention
- To provide a baseline information such as more accurate gestational age
Types of Prenatal Tests
Ultrasonography
- Technique for visualizing deep structures of the body by recording the reflections (echoes) of sound waves directed in the tissue
- Safe, non-invasive and relatively comfortable
- Not reliable to identify every fetal structural defects (especially those that do not affect the body structures)
Types of Prenatal Tests
Doppler ultrasound blood flow assessment
- Placental insufficiency
- Assessment of blood flow through the umbilical artery to identify abn in the diastolic flow
- Colour doppler: clarify function of each body structure
Alpha - fetoprotein screening (AFP)
- Main protein in fetal plasma
- From fetal plasma to fetal urine and into the amniotic fluid
- Low levels: chromosomal abn
- High levels: neural tube defect
- Conditions r/t abn (pg. 327)
- Advantages: simple procedure - maternal blood
- Limitations: it should be viewed as a screening test
Types of Prenatal Tests
Multiple-Marker Screening
- Human chorionic gonadotropin (hCG), estriol, inhibin A
- Increases the detection of trisomy 18 and trisomy 21 (Downs Syndrome) and neural tube defects
- Maternal serum samples 16-18 weeks
- If positive, the woman is offered additional testing (amniocentesis/ ultrasound)
- Limitations: Detection rate ~75%, with a 5% false positive rate
Types of Prenatal Tests
Chorionic villus sampling
- Chorionic villi: microscopic projections from the outer chorion that develop into endometrial tissue as the placenta is formed
- Used for dx of fetal chromosomal, metabolic, or DNA abn.
- High risk women only
- Can be used to identify the Rh type of a fetus at risk for complications because of maternal isoimmunization
Types of Prenatal Tests
Amniocentesis
Aspiration of the amniotic fluid from the amniotic sac for examination
Early amnio is possible between 11-14 weeks
- Risk: higher fetal loss rate
Performed in the second trimester for fetal genetic abn. at 15-20 weeks
Purpose: to exam fetal cells present in amniotic fluid to identify:
- Chromosomal or biochemical abn
- Detect high levels of AFP
- Evaluate fetal condition - Rh - positive isoimmunization
- Diagnose amnionitis
Performed in the 3rd trimester to:
- Determine fetal lung maturity
- To diagnose fetal hemolytic disease
- Reduction amnio - remove excess fluids
Amniocentesis
The fetus and placenta and the largest area of amniotic fluid are identified by ultrasound
A 20 or 21 gauge needle is inserted. The first 1-2 mL of fluid is discarded to avoid contamination with maternal cells
20 ml of fluid is aspirated
Electronic fetal monitoring for 30-60 minutes
The woman can resume normal activities within 24 hours
Advantages: simple, relatively safe, and painless
Disadvantages: timing, results take 2 weeks (~22 weeks gestation) not all defects can be identified
Antepartum Fetal Surveillance
3 reasons:
- To determine fetal health or compromise as accurately as possible
- To guide intervention
- To reduce perinatal morbidity and mortality
Non-Stress Test
- Evaluate the ability of the fetal heart to accelerate with fetal movement
- Accelerations of the FHR r/t adequate oxygenation
- Assesses the fetal CNS
Antepartum Fetal Surveillance
Requires certification to perform as a skill
“non-stress” - it is monitoring only the fetus is not challenged or stressed by stimulated uterine contractions
An external electronic fetal monitoring device is applied to the abdomen to detect FHR and contractions/ fetal movement
Advantages: non-invasive, painless, no risk
Disadvantages: false positive often occurs (fetal sleep)
