Dr. Areefa Al Bahri

1. Dr. Areefa Al Bahri Chapter 3Complications During Pregnancy Complications that arise during pregnancy are often challenging and demand the perinatal nurse’s skills, knowledge, and expertise, combined with the nursing process, to fi rst identify the pregnant patient at risk and then formulate, implement, and evaluate an appropriate, holistic plan of care.

2. Early Pregnancy Complications • Hyperemesis gravidarum • Spontaneous abortion/ miscarriage • Gestational trophoblastic disease • Ectopic pregnancy • Perinatal loss- Fetal death Less than perfect child

3. Miscellaneous Complications • Multiple gestation • Premature rupture of membranes • Preterm labor • Incompetent cervix

4. Endocrine Complication • Diabetes Type I & II • Hyper/hypothyroid Cardiovascular/Hematological • cardiomyopathy • Hematological • • Sickle cell anemia • • Thalassemia

5. Hypertensive disorders • Chronic hypertension • Preeclampsia/eclampsiaProteinuria, edema, CNS alterations, HELLP • Chronic hypertension with preeclampsia • Gestational hypertension

7. Ectopic Pregnancy An ectopic pregnancy is one that implants outside of the uterine cavity. Implantation may occur in the fallopian tube (99%), on the ovary, the cervix, on the outside of the fallopian tube, the abdominal wall, or on the bowel. Patients who present with vaginal bleeding, a missed period, and abdominal tenderness or pain should

8. A number of factors of ectopic pregnancy which include: • • History of STI or pelvic inflammatory disease • • Prior ectopic pregnancy • • Previous tubal, pelvic, or abdominal surgery • • Endometriosis • • In vitro fertilization or other method of assisted reproduction • • Use of an intrauterine device

9. Diagnosis ectopic pregnancy should be diagnosed before the onset of hypotension, bleeding, pain, and overt rupture. The patient’s history (e.g., unilateral, bilateral or diffuse abdominal pain, missed period) and physical exam (a palpable mass is present on bimanual examination in approximately 50% of women) should alert the health care professional to the possible presence of an ectopic pregnancy.Diagnostic laboratory tests include a beta-human chorionic gonadotropin (hCG) . Transvaginalultrasonographyshould be performed to confirm intrauterine or tubal pregnancy (Farquhar, 2005). Ultrasonographic identification of an intrauterine pregnancy rules out the presence of an ectopic pregnancy in most women (Murray, Baakdah, Bardell, & Tulandi, 2005).

10. Management Salpingectomy(removal of the ruptured fallopian tube) by laparotomy (surgical procedure in which the abdomen is opened to visualize the abdominal organs) has long offered an almost 100% cure for the treatment of an ectopic pregnancy. using a laparoscope inserted into the pelvic cavity through a small incision in the abdomen),salpingostomy(incision into the fallopian tube to remove the pregnancy) and partial salpingectomy are replacing laparotomy as the treatment mode of choice.

11. GESTATIONAL TROPHOBLASTIC DISEASE Gestational trophoblastic disease (GTD) is a clinical diagnosis that includes the histologic diagnoses of hydatidiform mole (“molar pregnancy”), locally invasive mole, metastatic mole, and choriocarcinoma. It is a disease characterized by an abnormal placental development that results in the production of fluid-filled grapelike clusters (instead of normal placental tissue) and a vast proliferation of trophoblastic tissue. It is associated with loss of the pregnancy and rarely, the development of cancer. GTD occurs in 1 in 1200 pregnancies (Berman, DiSaia, & Tewari, 2004).

12. Pathophysiology The cause is unknown, but it is thought that complete moles result from the fertilization of an empty ovum (one whose nucleus is missing or nonfunctional) by a normal sperm. Since the ovum contains no maternal genetic material. A complete mole is characterized by trophoblastic proliferation and the absence of fetal parts. Most fetuses associated with incomplete moles being spontaneously aborted. Incomplete moles are almost always benign and have a much lower malignancy potential than complete moles. Choriocarcinomais invasive, malignanttrophoblasticdisease that is usually metastatic and can be fatal (Berman et al., 2004).

13. Signs and Symptoms • vaginal bleeding More than 95% of patients experience • which may be scant or profuse • Uterine enlargement results from the rapidly proliferating trophoblastic tissue and the large accumulation of clotted blood. • excessive nausea and vomiting (hyperemesis gravidarum) and abdominal pain caused by uterine distention. • Preeclampsia may occur, usually between 9 and 12 weeks of gestation but any symptoms of gestational hypertension before 24 weeks of gestation may be indicative of hydatidiform mole. Clinical and laboratory • findings include an absence of fetal heart sounds. • a markedly elevated quantitative serum hCG (may be 100,000 mIU/mL), and very low levels of maternal serum -fetoprotein (MSAFP).

14. Management • removal of the uterine contents • The hCG levels should be assessed every 1 to 2 weeks until hCG is undetectable on two consecutive • hCG should be measured every 1 to 2 months for at least a year • Effective contraception is needed. • counsel the patient about different methods of contraception • avoiding pregnancy for a year

15. Prognosis Invasive moles are generally not metastatic and respond well to single-agent chemotherapy. Choriocarcinoma spreads to the lungs, vagina, pelvis, brain, liver, intestines, and kidneys. Since choriocarcinoma can occur weeks to years after any type of gestation, patients usually present with signs and symptoms of active metastases. The long term prognosis depends on the degree of metastases and the patient’s response to the chemotherapy.

16. SPONTANEOUS ABORTION Not all conceptions result in a live-born infant. Of all clinically recognized pregnancies, 10% to 20% are lost, and approximately 22% of pregnancies detected on the basis of hCG assays are lost before the appearance of any clinical signs or symptoms (White & Bouvier, 2005). By definition, an early pregnancy loss occurs before 12 weeks of gestation; a late pregnancy loss is one that occurs between 12 and 20 weeks of gestation.

17. Spontaneous abortions may be classified as the following: • Abortus: Fetus lost before 20 weeks of gestation, wt. less than 500 g) • Complete abortion: Complete expulsion before 20 weeks of gestation • Incomplete abortion: Partial expulsion of some but not all before 20 weeks of gestation • Inevitable abortion: No expulsion of products, but bleeding and dilation of the cervix such that a pregnancy is unlikely • Threatened abortion: Any intrauterine bleeding before 20 weeks of gestation, without dilation of the cervix or expulsion • Missed abortion: Death of the embryo or fetus before 20 weeks with complete retention these often proceed to a complete abortion within 1 to 3 weeks but occasionally they are retained much longer.

18. Etiology It is estimated that 60% to 80% of all SABs in the first trimester are associated with chromosomal abnormalities Infections (e.g., bacteriuria and Chlamydia trachomatis), maternalanatomical defects, and immunological and endocrine factors have also been identified as causes of early pregnancy loss, although many have no obvious cause. Second trimester spontaneous abortions (12 to 20 weeks) have been linked to chronic infection, recreational drug use, maternal uterine or cervical anatomical defects, maternal systemic disease, exposure to fetotoxic agents, and trauma (Cunningham et al., 2005).

19. Diagnosis A woman who is experiencing a spontaneous abortion usually presents with bleeding and may also complain of cramping, abdominal pain, and decreased symptoms of pregnancy; cervical changes (dilation) may be present on vaginal examination. An ultrasound is performed for placental evaluation and to determine fetal viability. Laboratory tests include a quantitative level of -hCG, which should show a lower value than when associated with a viable pregnancy. hemoglobin and hematocrit, blood type and Rh status determination, and indirect Coombs’ screen (Cunningham et al., 2005).

20. Management Incomplete, inevitable, and missed abortions are usually managed via a dilatation and curettage (D & C: the cervix is dilated and a curette is inserted and used to scrape the uterine walls and remove the uterine contents). In the case of an incompetent cervix, an emergent cerclage (placement of ligature to close the cervix) may be performed. An unsensitized, Rh-negative woman should be given Rho(D) immune globulin (RhoGAM) to prevent

21. INCOMPETENT CERVIX Patients with cervical incompetence usually present with painless dilation and effacement of the cervix, often during the second trimester of pregnancy. They frequently give a history of repeated second trimester losses with no apparent etiology. Incompetent cervix is estimated to cause approximately 15% of all second trimester losses (Cunningham et al., 2005).

22. Obstetric Causes of Vaginal Bleeding PLACENTA PREVIA Placenta previa is an implantation of the placenta in the lower uterine segment, near or over the internal cervical os. This condition accounts for 20% of all antepartal hemorrhages. There are three recognized variations of placenta previa. With a complete (total) placenta previa, the placenta covers the entire cervical os. a complete placenta previa presents the most serious risk. A partial previa describes a placenta that partially occludes the cervical os. A marginal previa is characterized by the encroachment of the placenta to the margin of the cervical os. Placenta accreta, percreta, and increta are placentas with abnormally fi rm attachments to the uterine wall. Unusual placental adherence may accompany a placenta previa.

24. Placenta previa may be associated with conditions that cause scarring of the uterus such as a prior cesarean section, multiparity, or increased maternal age. A previa may also occur with a large placental mass as seen in multiple gestations and erythroblastosis. Other risk factors include smoking, cocaine use, a prior history of placenta previa, closely spaced pregnancies, African or Asian ethnicity, and maternal age greater than 35 years (Clark, 2004).

25. Signs and Symptoms The most common symptom is painless vaginal bleeding. This is believed to occur from small disruptions in the placental attachment during normal development and the subsequent stretching and thinning of the lower uterine segment during the third trimester. Initially, the bleeding is usually a small amount that stops as the uterus contracts to close the open blood vessels. However, bleeding can reoccur at any time and may be associated with profuse hemorrhage and shock that leads to signifi cant maternal and fetal mortality and morbidity. The blood is bright red (Cunningham et al., 2005).

26. Diagnosis The timing of the diagnosis of placenta previa has undergone significant change in the last decade. Although thirdtrimester bleeding was often the first indicator of placenta previa, today, most cases of placenta previa are detected ante-natally before the onset of significant bleeding. The common practice of second-trimester abdominal ultrasound for the detection of fetal anomalies has led to this change. However, because most cases of placenta previa diagnosed in the second trimester tend to resolve as the uterus enlarges, management of placenta previa diagnosed in the second trimester differs from that for the same diagnosis made during the third trimester.

27. In patients diagnosed before 24 weeks’ gestation, a repeat ultrasound should be scheduled between 24 and 28 weeks’ gestation to confirm the diagnosis of placenta previa. However, if patients experience vaginal bleeding during this interval, they should be managed as presumed cases of placenta previa. Placenta previa should be suspected in all patients who present with bleeding

28. PLACENTAL ABRUPTION Placenta abruption (abruptio placenta) is the premature separation of a normally implanted placenta from the uterine wall. An abruption results in hemorrhage between the uterine wall and the placenta. 15% occur during labor, and 30% are identified only on inspection of the placenta after delivery (Cunningham et al., 2005).

30. Etiology and Classifications At the initial point of placental separation, non clotted blood courses from the site of injury. The enlarging collection of blood may cause further separation of the placenta. Bleeding can be either concealed or revealed (apparent). A concealed hemorrhage occurs in 20% of cases and describes an abruption in which the bleeding is confined within the uterine cavity. The most common abruption is associated with a revealed or external hemorrhage, where the blood dissects downward toward the cervix (Fig. 11-5). Placental abruption may be broadly classified into three grades that correlate with clinical and laboratory findings (Box 11-2).

31. What causes placental abruption? • The causes of placental abruption are not completely known. However, women are more at risk for this condition if they: • Smoke • Use cocaine during pregnancy • Age over 35 y • Have preeclampsia or hypertension • Are pregnant with twins or triplets • Have had a previous placental abruption • Experience trauma to the abdomen • Have abnormalities in the uterus

32. Signs and Symptoms Vaginal bleeding (although about 20% of cases will have no bleeding) Uterine tenderness Rapid contractions Abdominal pain Fetal heart rate abnormalities

33. Diagnosis Vaginal bleeding in the third trimester of pregnancy is the hallmark of placental abruption or placenta previa and should always prompt an investigation to determine its etiology. Diagnosis is made by clinical findings and, when available, ultrasound examination. Recent advances in ultrasound imaging and interpretation have greatly

34. Classifications of Abruptio Placenta Grade 1: Slight vaginal bleeding and some uterine irritability are usually present. Grade 2: External uterine bleeding is absent to moderate. The uterus is irritable and tetanic or very frequent contractions may be present. Grade 3: Bleeding is moderate to severe but may be concealed. The uterus is tetanic and painful. Maternal hypotension is frequently present and fetal death has occurred.

35. Management The potential for rapid deterioration (hemorrhage, disseminated intravascular coagulation [DIC], fetal hypoxia) necessitates delivery in some cases of placental abruption. However, most abruptions are small and noncatastrophic, and therefore do not necessitate immediate delivery. Certain actions, including hospitalization, laboratory studies, continuous monitoring, and ongoing patient support should be initiated when placental abruption is suspected

36. Care for the Patient Experiencing an Abruptio Placentae • Hospitalization • Intravenous placement with a large-bore catheter (16-gauge) • Labwork: Includes CBC, coagulation studies (fibrinogen, PT, PTT, platelet count, fibrin degradation products), type and screen for 4 units of blood Betamethasone may be given to the woman to promote fetal lung maturity when delivery is not imminent. • Rh(D)-negative patients should receive RhoGAM to prevent isoimmunization. • Continuous evaluation of intake and output • Continuous electronic fetal monitoring • Delivery (cesarean or vaginal birth) may be initiated depending on the status of the mother and the fetus. • Nursing care is centered on continuous maternal–fetal assessment, with on-going information and emotional support for the patient and her family.

37. Preterm Labor Preterm labor (PTL) is defined as cervical changes and regular uterine contractions occurring between 20 and 37 weeks of pregnancy. Many patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with preterm labor (ACOG, 2001).

38. Various Risk Factors Associated with Preterm Labor and Birth • History of preterm birth • Uterine or cervical anomalies • Multiple gestation • Hypertension • Diabetes • Obesity • Clotting disorders • Infection, especially urinary tract infections • Fetal anomalies • Premature rupture of membranes

39. • Vaginal bleeding • Late or no prenatal care • Smoking • Alcohol • Domestic violence • Age 17 years or 35 years • Low socioeconomic status • Stress • Long working hours with long periods of standing

40. Contraindications to the Use of Tocolytics in Preterm Labor • Significant maternal hypertension (eclampsia, severe preeclampsia, chronic hypertension) • Antepartum hemorrhage • Cardiac disease • Any medical or obstetric condition • Hypersensitivity to a specific tocolytic agent • Advanced cervical dilation • Fetal demise or lethal anomaly • Chorioamnionitis • In utero compromise • Acute: nonreassuring fetal heart rate pattern • Chronic: IUGR or substance abuse

41. Family Teaching Guidelines Preventing Prematurity Freda and Patterson (2004) suggest that nurses be proactive by educating women about preterm labor and teaching them how to recognize the warning signs and symptoms. ◆ Encourage all pregnant women to obtain prenatal care. ◆ Educate all pregnant women as to the signs and symptoms of preterm labor. ◆ Eliminate the term “Braxton-Hicks” from teaching (women may delay seeking treatment if they believe they are only experiencing Braxton-Hicks contractions). ◆ Ask all pregnant women if they have had any symptoms of preterm labor.

42. ◆ Screen for vaginal and urogenital infections and treat appropriately. ◆ Teach women about the dangers of douching. ◆ Assess all pregnant women for intimate partner violence and intervene. ◆ Discuss stress levels early in pregnancy. ◆ Assess all pregnant women for nutritional status and weight gain in pregnancy and intervene as necessary. ◆ Assess for illicit drug use, and help the woman get into treatment. ◆ Encourage women who have preterm labor symptoms to drink fl uids, lie down for 1 hour, and go to the hospital for a vaginal exam if symptoms continue. ◆ Remind the woman with symptoms that she should not hesitate to call her provider repeatedly if her symptoms recur.

43. Premature Rupture of the Membranes To facilitate an understanding of premature rupture of the membranes (PROM), it is helpful to first define the various terms used: • Premature rupture of the membranes (PROM) is defi ned as rupture of the membranes before the onset of labor at any gestational age. • Preterm rupture of membranes is defined as rupture of the membranes before 37 completed weeks of gestation. It is a common cause of preterm labor, preterm delivery, and chorioamnionitis. • Preterm premature rupture of the membranes (PPROM) is defined as a combination of both terms— rupture occurs before the 37th completed week of gestation and in the absence of labor. PPROM accounts for 25% of all cases of premature rupture of the amniotic membranes and is respon sible for 30% to 40% of all preterm deliveries (Cunningham et al., 2005).

44. PATHOPHYSIOLOGY Premature rupture of the membranes is multifactorial. Choriodecidual infection or inflammation appears to play an important role in the etiology of PPROM, especially at early gestational ages. Other factors include decreased amniotic membrane collagen, lower socioeconomic status, cigarette smoking, sexually transmitted infections, prior preterm delivery, prior preterm labor during the current pregnancy, uterine distention (e.g., multiple gestation, hydramnios), cervical cerclage, amniocentesis, and vaginal bleeding in pregnancy (Mercer, 2003). In many cases, the cause is not known.

45. DIAGNOSIS The diagnosis is based on the patient’s history of leaking vaginal fluid and the finding of a pooling of fluid on sterile speculum examination. Nitrazine and fern tests confirm the diagnosis of PROM. The level of amniotic fluid in the uterus may also be checked via an abdominal ultrasound examination. Leakage of amniotic fl uid is consistent with findings of oligohydramnios (decreased amniotic fluid).

46. MANAGEMENT • Gestational age should be established based on clinical history and prior ultrasound assessment when available. • Ultrasound should be performed to assess fetal growth, position, and residual amniotic fluid. The woman should be assessed for evidence of advanced labor, chorioamnionitis (intrauterine infection), abruptio placentae, and fetal distress.

47. • Patients with advanced labor, intrauterine infection, significant vaginal bleeding, or nonreassuring fetal testing are best delivered promptly, regardless of gestational age. There is further debate over the use of tocolytics, corticosteroids, and antibiotics in patients with PPROM. Tocolysis appears to be of little benefit in PPROM and may be harmful when chorioamnionitis is present. However, in many hospitals, tocolytic therapy is instituted for 48 hours, especially with earlier gestational ages, in order to administer a course of corticosteroids to enhance fetal lung maturity (Cunningham et al., 2005).

48. Conservative management includes in patient observationunless the membranes reseal and the leakage of fluid stops. This approach initially consists of prolonged continuous fetal and maternal monitoring combined with modified bed rest to promote amniotic fluid accumulation and spontaneous membrane sealing. Delivery of the fetus should be accomplished if signs of infection are present: maternal temperature of 100.4°F (38°C) or greater, foul-smelling vaginal discharge, elevated white blood count, uterine tenderness, and maternal and/or fetal tachycardia.

49. Without intervention, approximately 50% of patients who have ROM will go into labor within 24 hours. • maintaining the pregnancy to gain further fetal maturity can be beneficial, prolonged PPROM has been correlated with an increased risk of • Chorioamnionitis • placental abruption • cord prolapse

50. Nursing interventions • explaining to the patient that she will be on: • full or modified bed rest • vital signs will be checked at least every 4 hours to detect early signs of a developing infection • intermittent fetal monitoring is appropriate • Frequent ultrasound examinations are performed to assess amniotic • providing emotional support to the patient • encourage the woman and her family members to ask questions and express fears and concerns. • The woman should be assessed for evidence of advanced labor, chorioamnionitis (intrauterine infection), abruptio placentae, and fetal distress.