Pregnancy-Related Complications

Question 1

___ ___

• Leading cause of pregnancy loss
• Most commonly due to chromosomal abnormalities incompatible with life
• Rate increases with age (over 35)

Answer 1

Spontaneous abortion

• Common term we hear = miscarriage
• 1 in 4 experience this loss
• Textbook notes as “unexpected”

Question 2

Collaborative Management

• Prevent hypovolemic shock and infection; a PPH can happen with a spontaneous abortion
• Provide emotional support for those grieving
• Spontaneous abortions can happen as early as 5 weeks

Answer 2

Types of Spontaneous Abortions (can overlap, be interrelated)

* Threatened

* Inevitable

* Incomplete

* Complete

* Missed

* Recurrent

* Habitual Abortion

Question 3

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Occurs when the membranes have ruptured

* Cervical dilation can occur

* Can’t reverse these events

* D&C is done under IV sedation or general anesthesia

Answer 3

Inevitable abortion

Question 4

?

Occurs when there is any vaginal bleeding in the 1st half of pregnancy

• Provider will order US to determine viability
• Look for HR
• Assess beta hCG level
• Consider cessation of intercourse, going on bedrest
• Still at risk for a preterm birth or low birth weight infant

Answer 4

Threatened abortion

Question 5

?

When all products of conception are expelled from the uterus and the cervix closes after the products pass

Answer 5

Complete abortion

Question 6

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When some but not all products of conception are expelled from the uterus

• Is active bleeding occurring, severe abdominal cramping, cervix open; fetal and placental tissue has passed but something may be remaining
• Necessitates D&C or D&E (evacuation)

Answer 6

Incomplete abortion

Question 7

• Curettage can’t be performed > 14 weeks gestation
• These women would get oxytocin or prostaglandins to stimulate uterine contractions until all products of conception are expelled

Question 8

?

• These go hand-in-hand
• Where someone is having 3 or more consecutive spontaneous abortions
• Can be triggered by chromosomal or genetic abnormalities as well as anomalies in the reproductive tract of the woman
  e. g. a bicornuate uterus (2 uterine bodies);

an incompetent cervix (when the cervix dilates before it’s supposed to) (⇒ cerclage: stitching the cervix shut)

Answer 8

Recurrent and habitual abortions

Question 9

?

Occurs when the fetus dies during the 1st half of pregnancy but is retained in the uterus

• Risk for infection and D&C

Answer 9

Missed abortion

Question 10

___ abortion

Some products of conception have been expelled, but some remain

Answer 10

Incomplete

Question 11

___ abortion

Vaginal bleeding occurs

Answer 11

Threatened

Question 12

___ abortion

Membranes rupture, and cervix dilates

Answer 12

Inevitable

Question 13

?

Is a life-threatening complication of a missed abortion, abruptio placentae, and preeclampisa

• Pro-coagulation and anti-coagulation factors are simultaneously activated

* Activates widespread clotting in vessels throughout body; can see bleeding from any area

• Priority treatment is delivery of the fetus and placenta
• Blood replacement products (e.g. plasma, platelets, packed RBC’s) and cryoprecipitate are administered to maintain circulating volume

Answer 13

Disseminated Intravascular Coagulation (DIC)

Question 14

?

Implantation of the fertilized ovum in an area outside of the uterine cavity (most in fallopian tube)

• Incidence is increasing as a result of ___

⇒ From infections

Risk increased from IUD’s, those with endometriosis, smokers, vaginal douching

Answer 14

Ectopic pregnancy

pelvic inflammation

Question 15

Ectopic Pregnancy

(+) hCG

Abdomen and pelvic pain in 1 side

Risk of tubal rupture

Intra-abdominal hemorrhage, pain in diaphragm

⇒ hypovolemic shock

A transvaginal US can diagnose at ~ 7 weeks

Can occur with twins

Question 16

Ectopic Pregnancy - Collaborative Care

• Prevent severe hemorrhage and hypovolemic shock

___ prevents cellular reproduction from happening and baby doesn’t grow; it passes on its own

• Done as a multi-dose therapy

Surgical treatments include ___ (a cut in the fallopian tube) and ___ (removal of the fallopian tube, typically after rupture has occurred) [can still get pregnant again if 1 tube has been removed]

• Provide emotional support

Answer 16

Methotrexate

salpingostomy

salpingectomy

Question 17

Which one?

The isthmic, ampular, interstitial, or fimbrial part of the fallopian tube is where there is most risk; the ovum is in a narrow spot and NOT the uterine lining

* Higher risk of tubal rupture

Answer 17

interstitial

Question 18

Risk Factors for Ectopic Pregnancy

* History of STIs (because this leads to pelvic inflammation)

* History of pelvic inflammatory disease [PID] (issue with ovum being able to travel to uterus)

* History of previous ectopic pregnancy

* Failed tubal ligation

Answer 18

* Intrauterine device (IUD)

* Multiple induced abortions (therapeutic abortion, scar tissue formation)

* Maternal age > 35

* Use of assisted reproductive technologies

Question 19

Gestational Trophoblastic Disease - Hydatidiform Mole

* As a result of abnormal cellular growth, the placenta develops but not the fetus

* Must be evacuated (via D&C)

• Regular follow-ups are needed for one year to assess for malignant changes (choriocarcinoma - malignant changes of the residual trophoblastic tissue)

Answer 19

• Provide emotional support
• Surveillance for cancer
• Can spread rapidly
• Watch hCG level
• Patient may need chemotherapy

Question 20

Also known as a “molar” pregnancy

Uterus can advance to the size of a pregnancy and produce hCG if untreated

Occurs in younger and older reproductive ages

Believed to be caused by sperm duplicating its own chromosomes; XXX or XXY

Answer 20

• Fetus will not be compatible with life; anomalies present
• Vaginal bleeding that is spotting to full on hemorrhage experienced
• Uterus larger than expected
• Excessive nausea and vomiting due to increased level of hCG
• Early development of preeclampsia

Question 21

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Implantation of the placenta into the lower uterus

• Marginal
• Partial
• Complete/Total

* More common in older women, multiparas, women who have had cesarean births, and women who have had suction curettage for induced or spontaneous abortion

Answer 21

Placenta Previa

Question 22

Placenta Previa

• Manifested by an onset of sudden, painless uterine bleeding in 2nd half of pregnancy

* Risk from cervical exams - confirm location of placenta

• At risk of this in future pregnancies

Question 23

___ Placenta Previa

As cervical dilation occurs, begin to detach placenta

Can lead to hemorrhage from mother and baby

• Lower border of placenta is within 3 cm of internal cervical os but does not fully cover it

Answer 23

Partial

Question 24

___ Placenta Previa

Placenta completely covers internal cervical os

Hemorrhage from mother and baby

Answer 24

Total

Question 25

\_\_\_ Placenta Previa Diagnosed at ~ 20 weeks with transvaginal US/anatomy scan ! Can go on to have a normal pregnancy and delivery

Answer 25

Marginal

Question 26

? Separation of the normally implanted placenta before the fetus is born Bleeding and/or the formation of a hematoma on the maternal side of the placenta Accompanied by pain, uterine tenderness, and uterine hyperactivity

Answer 26

Abruptio Placentae

Question 27

Risk factors include: abdominal trauma (is why there is direction against going on rides if pregnant at parks); domestic violence, and autoimmune conditions Symptoms - Abruptio Placentae - Vaginal bleeding - Abdominal and lower back pain - Firmness to the abdomen, a "hardboard" - Uterine irritability and tenderness - High uterine resting tone (only detected if an IUPC is in place) - A nonreassuring fetal HR

Answer 27

- a Category III tracing - Mom at risk of developing symptoms of hypovolemic shock because of hemorrhage occurring and fetal death (clotting abnormalities like DIC) - Accounts for 10-15% of perinatal deaths - Occurs in less than 1% of pregnancies

Question 28

Answer 28

Question 29

During a _marginal_ abruption with external bleeding, mother and baby's blood is lost During a _complete_ abruption with concealed bleeding, no oxygen exchange is occurring

Answer 29

During a _partial_ abruption with concealed bleeding, we don't see bleeding out of the vagina - A hardboard abdomen, painful discomfort, and notice compromise on fetal HR monitors

Question 30

Signs & Symptoms of a Concealed Hemorrhage \* Increased fundal height (due to uterus filling with blood) \* Hard, board-like abdomen \* High uterine baseline tone on EFM ⇒ IUPC \* Persistent abdominal pain

Answer 30

\* Tachycardia, falling BP, restlessness (also symptoms of hypovolemic shock) \* Persistent late decelerations in the fetal HR (could see a sinusoidal pattern) \* Vaginal bleeding can be slight or absent

Question 31

Signs & Symptoms of Impending Hypovolemic Shock - Increased pulse rate, falling BP, increased RR - Weak, diminished, or thready peripheral pulses - Cool, moist skin or pallor - Decreased urinary output [oliguria] (less than 30 mL/hour) - Decreased hemoglobin and hematocrit levels - Changes in mental status and level of consciousness

Question 32

\_\_\_ \_\_\_ Persistent, uncontrollable vomiting that begins in the first weeks of pregnancy and may continue throughout Common and worsens in each pregnancy Give Zofran (ondansetron)

Answer 32

Hyperemesis Gravidarum (HG)

Question 33

Hyperemesis Gravidarum (HG) - Collaborative Management - Encourage good oral care - Ginger teas/ginger ale - Have saltine crackers before getting out of bed \* Maintain nutrition and fluid volume - IV fluids may be given; TPN in severe cases - Provide emotional support - Phenergan (promethazine) can cause drowsiness

Question 34

Hypertension During Pregnancy \* Gestational Hypertension \* Preeclampsia \* Eclampsia \* Chronic hypertension (preexisting)

Question 35

? Blood pressure elevation after 20 weeks of pregnancy NOT accompanied by proteinuria May progress to preeclampsia or stay as is If it persists more than 6 weeks after birth, chronic hypertension is diagnosed \* We should see that this resolves after delivery of the placenta

Answer 35

Gestational Hypertension ≥ 140 (systolic) or ≥ 90 (diastolic) over 2 readings

Question 36

Risk Factors for Pregnancy-Related Hypertension \* First pregnancy for both the mother and father (consider if woman has a new partner) \* Men who have fathered a prior preeclamptic pregnancy \* Age greater than 35 years \* Anemia \* Family or personal history of preeclampsia \* Chronic hypertension

Answer 36

\* Chronic renal disease \* Obesity \* Diabetes \* Multifetal pregnancy \* Pregnancy from assisted reproductive technology

Question 37

? Generalized vasospasm decreases circulation to all organs of the body, including the placenta Manifestation \> Hypertension (\_\_\_/\_\_\_ or greater) WITH ___ ? Management \> Activity restrictions, fetal monitoring, BP monitoring, weight measurements, urinalysis, sodium-free diet

Answer 37

Preeclampsia 140/90 proteinuria (in a 24 hour urine sample [most accurate] ratio \> 0.3; in a single dipstick urine = 0.1)

Question 38

Preeclampsia - Occurs in 5-8% of US pregnancies annually - 1 of the major causes of perinatal death - Black Americans at a greater risk of and complications from due to systemic racism within the healthcare system - Black women are at a 3-4x higher rate of maternal death than white women

Answer 38

Preeclampsia - Risk Factors - Have chronic hypertension - Are overweight, obese, or have a history of diabetes - Most likely to occur in the 1st pregnancy - With a new partner - Happened in a prior pregnancy - Very young or older - In multifetal pregnancies

Question 39

Preeclampsia - Symptoms - Hyperreflexia - Alterations in bloodwork (liver, renal) - Headaches, vision changes, epigastric pain (under the right breast) [distended hepatic capsule] \> a sign that seizures may be imminent - Could have edema (hard to tell) ! Facial edema as a tell-tale sign (a "pig nose")

Answer 39

Preeclampsia - Management cont'd \* Give magnesium sulfate Can give rx's like hydralazine, also nifedipine and labetalol

Question 40

? Progression of preeclampsia to generalized seizures Magnesium sulfate [a smooth muscle relaxer] is used to prevent seizures in preeclampsia ! Watch for respiratory depression - Monitor O₂ sats, lung sounds, frequently check DTRs \> We could see hyporeflexia or absent reflexes → Indicates that a woman could experience respiratory depression

Answer 40

Eclampsia

Question 41

Interventions & Care for Seizures - Initiate preventative measures \> Padding on side rails; low and locked bed position; place side-lying until seizure ends - Monitor for signs of impending seizure activity - note timing - Prevent seizure-related injury - Protect the woman during a seizure - Support the family - Monitor for S/S of magnesium toxicity (hyporeflexia or absent DTRs as well as S/S of respiratory depression)

Answer 41

Question 42

HELLP Syndrome \_\_\_, ___ \_\_\_ \_\_\_, and ___ \_\_\_ - Presentation with severe pain in RUQ (at liver) ! Delivery helps treat this - Likely BP issues in the setting of preeclampsia and eclampsia - Bedrest (continuous monitoring of mom and baby) - Blood transfusions (treats anemia) - Corticosteroids (for fetal lung development) if only at PRETERM to help surfactant production

Answer 42

**H**emolysis **E**levated **L**iver Enzymes **L**ow **P**latelets

Question 43

_Hemolysis_ occurs as a result of the fragmentation and distortion of the erythrocytes during the passage through damaged blood vessels

Answer 43

_Liver enzymes increase_ because hepatic blood flow gets obstructed by the fibrin deposits and _low platelets_ are caused by vascular damage resulting from vasospasm

Question 44

? Hypertension that precedes the pregnancy or developed at less than 20 weeks gestation Increased risk for \_\_\_ Monitor closely for \_\_\_ Antihypertensive medications should be initiated if diastolic BP is higher than 100 mmHg

Answer 44

Chronic Hypertension preeclampsia proteinuria

Question 45

Incompatability Between Maternal and Fetal Blood *Rh Incompatability* Rh-negative woman conceives an Rh-positive baby (due to father being Rh+) Maternal antibodies develop after exposure to fetal Rh-positive blood Administration of ?

Answer 45

Rh_o(D) Immunoglobulin (RhoGAM)

Question 46

*ABO Incompatability* \_\_\_ blood type woman with naturally occurring anti-A and anti-B antibodies May result in ___ in the infant

Answer 46

O hyperbilirubinemia