Pregnancy-Related Complications Flashcards
___ ___
- Leading cause of pregnancy loss
- Most commonly due to chromosomal abnormalities incompatible with life
- Rate increases with age (over 35)
Spontaneous abortion
- Common term we hear = miscarriage
- 1 in 4 experience this loss
- Textbook notes as “unexpected”
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
Types of Spontaneous Abortions (can overlap, be interrelated)
* Threatened
* Inevitable
* Incomplete
* Complete
* Missed
* Recurrent
* Habitual Abortion
?
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
Inevitable abortion
?
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
Threatened abortion
?
When all products of conception are expelled from the uterus and the cervix closes after the products pass
Complete abortion
?
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)
Incomplete abortion
- 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
?
- 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)
Recurrent and habitual abortions
?
Occurs when the fetus dies during the 1st half of pregnancy but is retained in the uterus
- Risk for infection and D&C
Missed abortion
___ abortion
Some products of conception have been expelled, but some remain
Incomplete
___ abortion
Vaginal bleeding occurs
Threatened
___ abortion
Membranes rupture, and cervix dilates
Inevitable
?
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
Disseminated Intravascular Coagulation (DIC)
?
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
Ectopic pregnancy
pelvic inflammation
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
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
Methotrexate
salpingostomy
salpingectomy
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
interstitial
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
* Intrauterine device (IUD)
* Multiple induced abortions (therapeutic abortion, scar tissue formation)
* Maternal age > 35
* Use of assisted reproductive technologies
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)
- Provide emotional support
- Surveillance for cancer
- Can spread rapidly
- Watch hCG level
- Patient may need chemotherapy
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
- 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
?
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
Placenta Previa
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
___ 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
Partial
___ Placenta Previa
Placenta completely covers internal cervical os
Hemorrhage from mother and baby
Total
___ Placenta Previa
Diagnosed at ~ 20 weeks with transvaginal US/anatomy scan
! Can go on to have a normal pregnancy and delivery
Marginal
?
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
Abruptio Placentae
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
- 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
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
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
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
* 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
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
___ ___
Persistent, uncontrollable vomiting that begins in the first weeks of pregnancy and may continue throughout
Common and worsens in each pregnancy
Give Zofran (ondansetron)
Hyperemesis Gravidarum (HG)
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
Hypertension During Pregnancy
* Gestational Hypertension
* Preeclampsia
* Eclampsia
* Chronic hypertension (preexisting)
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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
Gestational Hypertension
≥ 140 (systolic) or ≥ 90 (diastolic) over 2 readings
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
* Chronic renal disease
* Obesity
* Diabetes
* Multifetal pregnancy
* Pregnancy from assisted reproductive technology
?
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
Preeclampsia
140/90
proteinuria (in a 24 hour urine sample [most accurate] ratio > 0.3; in a single dipstick urine = 0.1)
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
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
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”)
Preeclampsia - Management cont’d
* Give magnesium sulfate
Can give rx’s like hydralazine, also nifedipine and labetalol
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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
Eclampsia
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)
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
Hemolysis
Elevated Liver Enzymes
Low Platelets
Hemolysis occurs as a result of the fragmentation and distortion of the erythrocytes during the passage through damaged blood vessels
Liver enzymes increase because hepatic blood flow gets obstructed by the fibrin deposits and low platelets are caused by vascular damage resulting from vasospasm
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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
Chronic Hypertension
preeclampsia
proteinuria
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 ?
Rh<span>o</span>(D) Immunoglobulin (RhoGAM)
ABO Incompatability
___ blood type woman with naturally occurring anti-A and anti-B antibodies
May result in ___ in the infant
O
hyperbilirubinemia
