Complications of Pregnancy

1. Complications of Pregnancy Ana H. Corona, MSN, FNP-C Nursing Instructor February 2009

2. Assessment Fetal Well Being • Ultrasound • Nonstress test • Fetal acoustic stimulation test and vibroacoustic stimulation test • Fetal biophysical profile • Fetal movements • Biochemical assessments

3. Assessment Fetal Well Being • Amniocentesis • Chorionic villi sampling • Contraction stress test • External fetal monitoring • Internal fetal monitoring

4. Nonstress Test (NST) • Procedure used to monitor fetal response to movement. • FHR acceleration with fetal movement is reassuring and a sign of fetal well being • Semi-Fowler's or side-lying position  • Baseline fetal heart rate recorded • FHR pattern for monitored 20–30 minutes • Patient marks paper with each perceived fetal movement

5. Nonstress Test (NST) • Result Criteria • Reactive(normal) In a 20-minute period, two or more fetal heart rate accelerations of at least 15 beats per minute above the baseline heart rate • Nonreactive(abnormal) No fetal heart rate accelerations over a 40-minute period.

6. Contraction Stress Test • High Risk Patient: Diabetic Patient • Method of externally monitoring the fetus. • Measures the ability of the placenta to provide enough oxygen to the fetus during contractions. • Oxytocin IV or nipple stimulation will be used to induce contractions. • Oxytocin Challenge Test: IV until 3 uterine contractions are observed, lasting 40 - 60 seconds, over a 10-minute period.

7. Electrical Fetal Heart Monitoring • Accelerations: common - normal • Early Decelerations: vagal stimulation to the fetal head during a contraction which push the head toward the pelvis - normal • Late Decelerations: Utero-Placental insufficiency (fetal blood flow compromised, less oxygen!!! - abnormal • Variable Decelerations: cord compression nuchal cord, knot, decreased amniotic fluid - abnormal

8. Alpha-Fetoprotein (AFP) • Multipe Marker Screening: Genetic Test • Spina-Bifida • Anencephaly • Omphalocele • Tetralogy of • Duodenal atresia • Turner Syndrome • Intrauterine death • Done between 15 – <20 weeks gestation

9. BPP • Includes 5 components: • Fetal breathing movements • Gross body movements • Fetal tone • AFI • NST - reactive

10. AFI • Polyhydramnios – too much amniotic fluid • AFI of more than 24 cm • Oligohydramnios – too little amniotic fluid • AFI less than 7 cm • Studies show that oral hydration, by having the women drink 2 liters of water, increases the AFI by 30%.

11. Abruptio Placenta • Premature separation from wall of uterus of a normally implanted placenta. • Abnormally short umbilical cord • Abdominal Injury • Sudden loss in amniotic fluid

12. Abruptio Placenta • Abdominal pain • Vaginal bleeding • Back pain • Symptoms include a rigid, painful abdomen. • Irreversible brain damage or fetal death may occur if hypoxia is not reversed quickly.

13. Placenta Previa • Implantation is in lower uterine segment with placenta lying over or very near the internal cervical os. • Symptoms include painless bleeding in the last half of pregnancy. • Treat to maintain the pregnancy until fetus mature enough to survive outside uterus

14. Ectopic Pregnancy • Abnormal pregnancy that occurs outside the uterus. • Symptoms include: • Missed menstrual period • Pelvic/Abdominal pain • Spotty vaginal bleeding • Pain in the shoulder • Fainting • nausea

15. Hyperemesis Gravidarum • Excessive vomiting during pregnancy. • Physiological and psychological factors may be involved. • Treatment goals: control vomiting, correct dehydration, restore electrolyte balance, and maintain adequate nutrition.

16. Hydatidiform Mole • Gestational Trophoblastic Disease or molar pregnancy • Abnormality of placenta–chorionic villi become fluid-filled, grapelike clusters. • Classic signs are bleeding, uterine enlargement, no fetal heart tones, hyperemesis gravidarum, or symptoms of PIH appear before 24 weeks. • Choriocarcinomas are highly malignant tumours may follow a molar pregnancy.

17. Hydatidiform Mole • The primary diagnostic tool is ultrasound. • The mole is removed surgically. • The client must be followed for 1 to 2 years to monitor for metastasis.

18. Pregnancy Induced Hypertension (PIH) • Most common hypertensive disorder in pregnancy, after 20 weeks’ gestation. • Only cure is delivery of the baby. • Mild preeclampsia–blood pressure increases 30 mm Hg systolic or 15 mm Hg diastolic over baseline on two occasions at least 6 hours apart. • May be asymptomatic

19. PIH • Edema noted in face and hands. • Objectively defined as weight gain of more than 1 pound a week. • Urine may show 1+ or 2+ albumin. • Proteinuria usually the last of the three classic symptoms to appear.

20. PIH • Severe preeclampsia–blood pressure increases to 160/110 or higher. • Generalized edema in face, hands, sacral area, lower extremities, abdomen. • Weight gain may be 2 pounds a week. • Urinary albumin may be 3+ or 4+.

21. PIH • Other symptoms: continuous headache, blurred vision, scotomata, nausea, vomiting, irritability, hyperreflexia, and epigastric pain. • Epigastric pain often last symptom identified before client moves into eclampsia.

22. Eclampsia • Eclampsia–grand mal seizures. • Without treatment, the client may die. • Treat to lower blood pressure, prevent convulsions, and deliver a healthy baby. • Magnesium sulfate given to prevent convulsions.

23. Magnesium Sulfate • Respirations must be at least 14/minute. • Toxicity: Respiratory depression to paralysis • Deep tendon reflexes must be kept at normal response. • Urine output must be at least 30 cc/hr. • Monitor serum magnesium level. 1.5 – 3mEq/L • Calcium gluconate is antidote for magnesium sulfate–keep at bedside.

24. Disseminated Intravascular Coagulation • Over stimulation of normal clotting process, occurs as complication of a primary problem. • Pregnancy Induced Hypertension • It can cause fetal death. • Symptom onset sudden: dyspnea, chest pain, restlessness, cyanosis, and spitting frothy, blood-tinged mucous.

25. Disseminated Intravascular Coagulation • Underlying cause must be identified and corrected. • The fetus must be delivered. • IV administration of blood, and other blood products • Heparin is given continuously. • Oxygen therapy

26. Pregnancy and Diabetes • Hyperglycemia • May be due to inadequate insulin action or due to impaired insulin secretion • Type 1 – insulin deficiency • Type 2 – insulin resistance • GDM – glucose intolerance during pregnancy • 10th week fetus produces it own insulin • Insulin does not cross the placental barrier • Glucose levels in the fetus and directly proportional to the mother • 2nd and 3rd trimesters – decreased tolerance to glucose, increased insulin resistance, increased hepatic function of glucose

27. Diabetic Neuropathy • Increased risks for: • Preeclampsia • IUGR • PTL • Fetal distress • IUFD • Neonatal death

28. DM • Poor glycemic control is associated with increased risks of miscarriage at time of conception • Poor glycemic control in later part of pregnancy is assoc. with fetal macrosomia and polyhydramnios • May compress on the vena cava and aorta causing hypotension, PROM, PP hemorrhage, maternal dyspnea

29. DM • Disproportionate increase in shoulder and trunk size • 4000-4500gms or greater • Fetus will have excess stores of glycogen • Increased risks of • Shoulder dystocia • C/S • Assisted deliveries

30. Neonatal Hypoglycemia • Usually 30-60 minutes after birth • Due to high glucose levels during pregnancy and rapid use of glucose after birth • Related to mothers level of glucose control • Neonates normal glucose level: 40-65mg/dl • Premature infants: 20-60mg/dl IUGR • Compromised uteroplacental insufficiency • 02 available to the fetus is decreased

31. Fetal Surveillance • NSTs done around 26 weeks, weekly • At 32 weeks done biweekly with NST/BPP

32. What complications should the nurse be alert for when the mother is experiencing gestational diabetes? • Maternal complications – infections, difficult labor related to increased fetal size, vascular complications (retinopathy) azotemia, ketoacidosis, increased incidence of hypertensive disorders (preeclampsia and c-section) • Fetal complications: stillbirth, spontaneous abortion, hydraminos, large placenta, Macrosomia, congenital anomalies, neonatal hypoglycemia, neonatal hyperbilirubinemia, increase incidence of respiratory distress syndrome and fetal or neonatal death

33. Chronic hypertension • BP 140/90 or higher before pregnancy or before the 20th week of gestation that lasts longer than 6 weeks after delivery. • Clients with moderate to severe chronic hypertension are most at risk to develop PIH.

34. Maternal Heart Disease • The heart must compensate for the normal blood volume increase and workload • If the cardiac changes are not well tolerated than cardiac failure can develop • 1% of pregnancies are complicated by heart disease • Cardiac output is increased • Peak of the increase 28-32 weeks gestation. • Prenatal care visits should be more often than usual. • Cardiac problems should be managed with cardiologist • Mortality with pulmonary hypertension and pregnancy is more than 50% • Diet: low sodium • Avoiding anemia • Avoid strenuous activity • Monitor for: cardiac failure (CHF) and pulmonary congestion

35. Nursing Care during labor • Side lying position • Prophylactic antibiotic • Epidural • Attempt vaginal delivery • If anticoagulant therapy is needed: • Heparin • Lovenox

36. Phenylketonuria • Individuals with PKU cannot process a part of protein called phenylalanine present in most foods. • phenylalanine builds up in the bloodstream and causes brain damage and mental retardation. • The characteristic features of maternal PKU syndrome include mental retardation, microcephaly, (IUGR)intrauterine growth retardation, and congenital heart defects • When woman with PKU keeps her phenylalanine level less than 2.0 mg/dL while pregnant, outcome of pregnancy better.

37. TORCH: acronym for maternal infections • Toxoplasmosis (TO) - protozoan infection, neonatal effects – jaundice, hydrocephalus, microcephaly • Rubella (R) - congenital deformities • Cytomegalovirus (C) - CNS damage to fetus • Herpes genitalis (H) - Perinatal loss. Fetus may pick up virus if present in the vagina during labor • If untreated: abortion, congenital anomalies, fetal infections, IUGR, preterm labor, mental retardation, or death.

38. TORCH RESULTS

39. HIV/AIDS • Weight gain is a challenge for pregnant HIV-infected client. • HIV may be transmitted to fetus through placenta, during birth, or during breast feeding. • Nutritional counseling and support may be necessary. • Congenital defects such as microcephaly (abnormal smallness of the head) and facial deformities.

40. Hemolytic Diseases • Rh incompatibility–can only happen when mother is Rh negative and fetus is Rh positive. • ABO incompatibility–problem occurs when maternal blood enters fetal circulation.

41. Hemolytic Disease • Basic incompatibility of blood, such as ABO incompatibility, or from transfer of antibodies through the placenta • Erythroblastosis fetalis is a type of hemolytic anemia that occurs in newborns as a result of maternal fetal blood group incompatibility, especially involving the Rh factor and ABO blood groups

42. RhoGam • RhoGam 300mcg IM given at 28 weeks of pregnancy and 72 hrs of delivery (Rh negative, abortion, ectopic pregnancy and amniocentesis). • A card is given • Mom needs to carry card with her at all times • Phototherapy – bilirubin levels reach 12 to 15 mg/dl

43. Hemolytic Disease • Blood Typing • Indirect Coomb’s test of maternal blood – measures the number of maternal antibodies • Antibody titer test – level of maternal antibodies, if exceeds 1:16 amniocentesis may be performed • Optical density studies – measure bilirubin level, fetal condition • After delivery – direct Coomb’s test (infant blood to determine the presence of antibody coated RBCs (bilirubin)

44. Multiple pregnancy • First trimester proceeds much the same as with a single fetus. • As uterus grows, greater pressure on and displacement of the internal organs. • Greater risk of fetal anomalies, abnormal presentations, and preterm birth.

45. Substance Abuse • Substance abusers may not seek prenatal care until late in pregnancy. • Most do not voluntarily admit addiction. • These mothers have an increased rate of complications. • They often use available money for drugs instead of food.

46. Risks: SAB SGA Bleeding IUFD Prematurity SIDS Risks: LBW Mental retardation Learning and physical deficits With FAS – severe facial deformities Smoking Alcohol

47. OPIATES IN PREGNANCY • Drugs include: heroin, Demerol, morphine, codeine, methadone • Methadone is used to treat addiction to other opiates • Possible effects on pregnancy and heroin use are: Preeclampsia, PROM, infections, PTL • Tx: Methadone and psychotherapy • Goal: prevent withdrawal symptoms

48. Maternal effects: Cardiovascular stress Tachycardia HTN Dysrhythmias MI Liver damage Sz Pulmonary disease Death Fetal Complications: Abruptio placentae PTL Precipitous labor Risks for abdominal pregnancy Fetal complications after delivery COCAINE DURING PREGNANCY

49. Questions • The acronym for maternal infections is: • TORCH • LATCH • MEALS • HELLP

50. Answer is 1 • T • O • R • C • H