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COMPLICATIONS OF PREGNANCY

COMPLICATIONS OF PREGNANCY. Revised October 2009 Debbie Perez RN, MSN, CNS. Risk Factors. Age – under 17 over 35 Gravida and Parity Socioeconomic status Psychological well-being Predisposing chronic illness – diabetes, heart conditions, renal, etc.

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COMPLICATIONS OF PREGNANCY

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  1. COMPLICATIONS OF PREGNANCY Revised October 2009 Debbie Perez RN, MSN, CNS

  2. Risk Factors • Age – under 17 over 35 • Gravida and Parity • Socioeconomic status • Psychological well-being • Predisposing chronic illness – diabetes, heart conditions, renal, etc. • Pregnancy related conditions – hyperemesis gravidarum, PIH

  3. Goals of Care for High Risk Pregnancy • Provide optimum care for the mother and the fetus • Assist the client and her family to understand and cope through education

  4. Gestational Onset Disorders

  5. Take report: Mrs. R. admitted to L&D • Initial Data • Chief complaint: moderate amount vaginal bleeding • Vital Signs: T. 98.4; P. 100, R. 22, B/P 100/66 • G 1 P 0 • Last menstrual period: 8/12; EDC: May 19 • Allergies: none known • Nauseated • Mild pain • HCG levels – WNL for pregnancy

  6. Bleeding Disorders

  7. Abortions • Termination of pregnancy at any time before the fetus has reached the age of viability • Either: • spontaneous – occurring naturally • induced – artificial

  8. Etiology / Predisposing Factors • Chromosomal abnormalities - Faulty germ plasm -- imperfect ova or sperm, genetic make-up (chromosomal disorders), congenital abnormalities • Faulty implantation • Decrease in the production of progesterone • Drugs or radiation • Maternal causes -- infections, endocrine disorders, malnutrition, hypertension, cervix disorder

  9. Assessment Types of Abortions Threatened • Signs and Symptoms • vaginal bleeding, spotting • Mild cramps, backache • Cervix remains CLOSED • Intact membranes • Treatment and Nursing Care • Bed rest, sedation, • Avoid stress and intercourse • Progesterone therapy • A period of “watchful waiting”

  10. Imminent Abortion • Signs and Symptoms • Loss is certain • Bleeding is more profuse • Painful uterine contractions • Cervix DILATES • Treatment and Nursing Care • Assess all bleeding. Save all pads. (May need to weigh the pads) • Use the bedpan to assess all products expelled • Treated by evacuation of the uterus usually be a D & C or suction • Provide Psychological Support

  11. Complete Abortion • All products of conception are expelled • No treatment is needed, but may do a D & C

  12. Incomplete Abortion • Parts of the products of conception are expelled, placenta and membranes retained and intact • Treated with a D & C or suction evacuation • Provide support to the family

  13. Missed Abortion • The fetus dies in-utero and is not expelled • Uterine growth ceases • Breast changes regress • Maceration occurs • Treatment: • D & C • Hysterotomy

  14. Question??? • What are two main complications related to a missed abortion? • 1. • 2.

  15. Recurrent / Habitual Abortion Premature Cervical Dilation • Abortion occurs consecutively in _____ or more pregnancies • Usually due to an Incompetent Cervical Os • Occurs most often about 18-20 weeks gestation.

  16. Habitual Abortion • Treatment • Cerclage procedure -- purse-string suture placed around the internal os to hold the cervix in a normal state

  17. Nursing Care post cerclage • Bedrest in a slight trendelenburg position • Teach: • Assess for leakage of fluid, bleeding • Assess for contractions • Assess fetal movement and report decrease movement • Assess temperature for elevations

  18. Delivery options: • When time for delivery there are several options: • physician will clip suture and allow patient to go into labor on her own • induce labor • cesarean delivery

  19. Key Concepts to Remember!! • If a woman is Rh-, RhoGam is given within 72 hours • Provide emotional support. Feelings of shock or disbelief are normal • Encourage to talk about their feelings. It begins the grief process

  20. Bleeding Disorders Ectopic Pregnancy • Implantation of the blastocyst in ANY site other than the endometrial lining of the uterus ovary (5) Cervical

  21. Etiology / Contributing Factors • Salpingitis • Pelvic Inflammatory Disease, PID • Endometriosis • Tubal atony or spasms • Imperfect genetic development

  22. Assessment Ectopic Pregnancy • Early: • Missed menstruation followed by vaginal bleeding (scant to profuse) • Unilateral pelvic pain, sharp abdominal pain • Referred shoulder pain • Cul-de-sac mass • Acute: • Shock – blood loss poor indicator • Cullen’s sign -- bluish discoloration around umbilicus • Nausea, Vomiting • Faintness

  23. Diagnostic Tests Ectopic Pregnancy • Diagnosis: • Ultrasound • Culdocentesis • Laparoscopy

  24. Treatment Options / Nursing Care • Combat shock / stabilize cardiovascular • Type and cross match • Administer blood replacement • IV access and fluids • Laparotomy • Psychological support • Linear salpingostomy • Methotrexate – used prior to rupture. Destroys fast growing cells Question 4

  25. Gestational Trophoblastic DiseaseHydatiform Molar PregnancyEtiology • A DEVELOPMENTAL ANOMALY OF THE PLACENTA WITH DEGENERATION OF THE CHORIONIC VILLI • As cells degenerate, they become filled with fluid and appear as fluid filled grape-size vessicles.

  26. Assessment: • Vaginal Bleeding -- scant to profuse, brownish in color (prune juice) • Possible anemia due to blood loss • Enlargement of the uterus out of proportion to the duration of the pregnancy • Vaginal discharge of grape-like vesicles • May display signs of pre-eclampsia early • Hyperemesis gravidarium • No Fetal heart tone or Quickening • Abnormally elevated level of HCG Question 6

  27. Interventions and Follow-Up • Empty the Uterus by D & C or Hysterotomy • Extensive Follow-Up for One Year • Assess for the development of choriocarcinoma • Blood tests for levels of HCG frequently • Chest X-rays • Placed on oral contraceptives • If the levels rise, then chemotherapy started usually Methotrexate

  28. Critical Thinking Exercise • A woman who just had an evacuation of a hydatiform mole tells the nurse that she doesn’t believe in birth control and does not intend to take the oral contraceptives that were prescribed for her. • How should the nurse respond?

  29. Placenta Previa • Low implantation of the placenta in the uterus • Etiology • Usually due to reduced vascularity in the upper uterine segment from an old cesarean scar or fibroid tumors • Three Major Types: • Low or Marginal • Partial • Complete Question 8

  30. Abruptio Placenta • Premature separation of the placenta from the implantation site in the uterus • Etiology: • Chronic Hypertension • Sudden decompression of an over-distended uterus • Trauma • Injudicious use of Pitocin • Smoking / Caffeine / Cocaine • Vascular problems

  31. Placenta Previa PAINLESS vaginal bleeding Bright red bleeding First episode of bleeding is slight then becomes profuse Signs of blood loss comparable to extent of bleeding Uterus soft, non-tender Fetal parts palpable; FHT’s countable Blood clotting defect absent Abruptio Placenta Bleeding accompanied Abruptio by PAIN Dark red bleeding First episode of bleeding usually profuse Signs of blood loss out of proportion to visible amount Uterus board-like, painful Fetal parts non-palpable, FHT’s non-countable Blood clotting defect (DIC) likely

  32. Signs of Concealed Hemorrhage • Increase in fundal height • Hard, board-like abdomen • High uterine baseline tone on electronic fetal monitoring • Persistent abdominal pain • Systemic signs of hemorrhage

  33. Interventions and Nursing Care • Placenta Previa • Bed-rest • Assessment of bleeding • Electronic fetal monitoring • If it is low lying, then may allow to deliver vaginally • Cesarean delivery for All other types of previa

  34. Treatment and Nursing Care • Abruptio Placenta • Cesarean delivery immediately • Combat shock – blood replacement / fluid replacement • Blood work – assessment for complication of DIC

  35. Critical Thinking • Mrs. A., G3 P2, 38 weeks gestation is admitted to L & D with bleeding. What is the priority nursing intervention at this time? • Assess the fundal height for a decrease • Place a hand on the abdomen to assess if hard, board-like, tetanic • Place a clean pad under the patient to assess the amount of bleeding • Prepare for an emergency cesarean delivery

  36. Disseminated Intravascular Coagulation (DIC) Anti-coagulation and Pro-coagulation effects existing at the same time.

  37. EtiologyDefect in the Clotting Cascade • An abnormal overstimulation of the coagulation process Activation of Coagulation with release of thromboplastin ê Thrombin (powerful anticoagulant) is produced ê Fibrinogen fibrin which enhances platelet aggregation • ê • Widespread fibrin and platelet deposition in capillaries and arterioles

  38. Resulting in Thrombosis (multiple small clots) • Excessive clotting activates the fibrinolytic system • Lysis of the new formed clots create fibrin split products • These products have anticoagulant properties and inhibit normal blood clotting • A stable clot cannot be formed at injury sites • Hemorrhage occurs • Ischemia of organs follows from vascular occlusion of numerous fibrin thrombi • Multisite hemorrhage results in shock and can result in death

  39. Disseminated Intravascular Coagulation (DIC) • Precipating Factors: • Abruptio placenta • PIH • Sepsis • Retained fetus (fetal demise) • Fetal placenta fragments • Amniotic embolism • Maternal liver disease • Septic abortion • HELLP and preeclampsia

  40. Assessment Signs and Symptoms • Spontaneous bleeding -- from gums and Epistaxis, and injection and IV sites, incisions • Excessive bleeding -- Petechiae at site of blood pressure cuff, pulse points. Ecchymosis • Tachycardia, diaphoresis, restlessness, hypotension • Hematuria, oliguria, occult blood in stool • Altered LOC if brain affected.

  41. Diagnostic Tests • Lab work reveals: • PT – Prothrombin time is prolonged • PTT – Partial Thromboplastin Time increased • D-Dimer – increased Product that results from fibrin degradation. More specific marker of the degree of fibrinolysis • Platelets -- decreased • Fibrin Split Products – increase An increase in both FSP and D-Dimer are indicative of DIC

  42. DICInterventions and Nursing Care • Remove Cause • Evaluate vital signs • Replace blood and blood products • Fluid replacement • May give Heparin Question 9-D: E

  43. Hyperemesis Gravidarum

  44. HYPEREMESIS GRAVIDARIUM **Pernicious vomiting during Pregnancy

  45. Hyperemesis Gravidarium Etiology Increased levels of HCG

  46. Assessment • Persistent nausea and vomiting • Weight loss from 5 - 20 pounds • May become severely dehydrated with oliguria AEB increased specific gravity, and dry skin • Depletion of essential electrolytes • Metabolic alkalosis -- Metabolic acidosis • Starvation

  47. Nursing Care / InterventionsHyperemesis Gravidarium • Control vomiting • Maintain adequate nutrition and electrolyte balance • Allow patient to eat whatever she wants • If unable to eat – Total Parenteral Nutrition • Combat emotional component – provide emotional support. Mouth care • Weigh daily • Check urine for output, ketones

  48. Pregnancy Induced Hypertension

  49. PREGNANCY INDUCED HYPERTENSION A hypertensive disease of pregnancy. Known as pre-eclampsia and eclampsia. Pre-eclampsia = hypertension, edema proteinuria, Eclampsia = other signs plus convulsions It develops between the 20th and 24th week of gestation and resolves after the tenth day postpartum

  50. MULTIPLE PREGNANCY PRIMIGRAVIDA UNDER 17 AND OVER 35 HYDATIFORM MOLE PREDISPOSING FACTORS FAMILY HISTORY VASCULAR DISEASE Diabetes, renal LOWER SOCIOECONOMIC STATUS Severe malnutrition, decrease Protein intake Inadequate or late prenatal care

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