Complications of Pregnancy

1. Complications of Pregnancy Chapters 32, 33, 34

2. Categories of Spontaneous Abortion • Complete • Incomplete • Threatened • Missed • Habitual

3. SPONTANEOUS ABORTION • The naturally occurring termination of a pregnancy before viability, which is usually defined as either before 20 wks gestation or weight less than 500 g. • Incidence is approx. 15%. • Threatened AB = occurrence of any vaginal bleeding or spotting before 20 weeks gestation (slight & dark brown-red in color). • Inevitable AB = occurs with gross ROM & the presence of cervical dilation.

4. Complete AB = the cessation of pain and bleeding after the entire conceptus has been passed. • Missed AB = occurs when the conceptus dies but is not aborted before 20 weeks gestation. • Recurrent or habitual AB = three or more consecutive 1st trimester Abs. • ALL women should contact their provider if they have any spotting, bleeding, or increased temperature. • A pregnancy loss @ any point, can precipitate a grieving process.

5. Placental Abnormalities • Placenta previa • Abruptio placentae

6. INCOMPETENT CERVIX • A cervix that begins to dilate in the 2nd or 3rd trimester without uterine contractions. The result, if untreated, is usually a spontaneous abortion. • Pelvic exams reveal progressive cervical effacement & dilation along with bulging membranes (a characteristic hour-glass shape). • Cervical cerclage is a procedure usedd to prevent dilation when the cervix is incompetent.

7. HYDATIFORM MOLE • Abnormal development of the placenta in which the fetal part of the pregnancy fails to develop; the chorionic villi of the placenta become a mass of clear vesicles that hang in clusters, resembling a bunch of grapes. • Occurs in the presence of an abnormal chromosomal makeup of the zygote. • Occurs 1/1500-2000 deliveries. • Choriocarcinoma occurs after 3-4% of all moles, but is more commonon after a complete mole.

8. Labor Disorders • Incompetent cervix • Preterm labor and premature rupture of membranes • Postterm pregnancy

9. Disorders of Amniotic Fluid Volume • Polyhydramnios • Oligohydramnios

10. High-Risk Fetal Conditions • Multiple gestation • Rh immunization and ABO incompatibility • Nonimmune hydrops fetalis

11. Endocrine Disorders • Diabetes • Hypothyroidism • Hyperthyroidism

12. DIABETES MELLITUS: • A group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both. • Hyperglycemia causes hyperosmolarity of the blood, which attracts intracellular fluid into the vascular system, resulting in cellular dehydration & expanded blood volume.

13. The kidneys function to excrete large volumes of urine (polyuria) in an attempt to regulate excess vascular volume and to excrete the unusuable glucose (glycosuria). • Polyuria along with cellular dehydration, causes excessive thirst. • The body compensates for its inability to convert carbohydrate (glucose) into energy by burning proteins (muscle) and fats.

14. Diabetes causes significant changes in both the microvascular & macrovascular circulations. • Structural changes affect a variety of organ systems, particularly the heart, eyes, kidneys, and nerves. • Complications resulting from diabetes include premature atherosclerosis, retinopathy, nephropathy, and neuropathy.

15. Diabetes Classification: • Type 1 diabetes: • An absolute insulin deficiency. • Currently thought to be caused by an autoimmune process, as well as those for which the cause is unknown. • Type 2 diabetes: • Insulin resistance & usually relative (rather than absolute) insulin deficiency. • Develops gradually. Many people are obese or have an increased amt. of body fat distributed primarily in the abd.area.

16. Pregestational Diabetes Mellitus: • Label given to Type 1 or Type 2 diabetes that existed before pregnancy. Gestational Diabetes Mellitus (GDM): • Any degree of glucose intolerance with the onset or first recognition during pregnancy. • Insulin or noninsulin dependent.

17. Effects of Pregnancy: • Adjustments in maternal metabolism allow for adequate nutrition for both the mother and the developing fetus. • Glucose is the primary fuel used by the fetus. It is transported across the placenta. • Insulin does not cross the placenta. • As maternal glucose levels rise, fetal glucose levels are increased, resulting in increased fetal insulin secretion.

18. Pregestational Diabetes Mellitus: • During the 1st trimester, maternal blood glucose levels are normally reduced & the insulin response to glucose is enhanced, glycemic control is improved. • Insulin requirements steadily increase after the 1st trimester, insulin dosage must be adjusted accordingly to avoid hyperglycemia.

19. Pulmonary Disorders • Asthma • Tuberculosis

20. Hematologic Disorders • Immune thrombocytopenic purpura • Sickle cell disease

21. Fetal & Neonatal Risks / Complications: • Sudden & unexplained stillbirth: a major concern. Usually after 36 weeks in women with vascular disease or poor glycemic control. (may be associated with preeclampsia, DKA, hydramnios, or macrosomia; or chronic intrauterine hypoxia). • Congenital Malformations: with insulin dependent women, risk is 2-4 X greater. Up to 50% of all perinatal deaths among IDM are a result of cong.malformations. Related to severity & duration of diabetes.

22. Anomalies commonly seen affect: • The central nervous system. • The cardiovascular system. • The urinary system. • The gastrointestinal system. • Macrosomia: excessive growth; weight > 4000-4500 gm. LGA. The infant is at risk for: • Fractured clavicle. • A liver or spleen laceration. • A brachial plexus injury.

23. Facial palsy. • Phrenic nerve injury. • Subdural hemorrhage. • IUGR: may be seen in infants of diabetic mothers with vascular disease. • Related to compromised uteroplacental circulation. • May be worsened in the presence of ketoacidosis & preeclampsia. • The amount of O2 available to the fetus is decreased as a result of maternal vascular changes.

24. Respiratory Distress Syndrome (RDS): hyperglycemia & hyperinsulinemia may be instrumental in delaying pulmonary maturation in the fetus of a diabetic mother. • Metabolic abnormalities (30-60 min after birth): • Neonatal hypoglycemia. • Hypocalcemia.

25. Hypomagnesemia. • Hyperbilirubinemia. • Polycythemia.

26. Plan of Care & Interventions • Monitor frequently & thoroughly. • Prenatal visits q 1-2 weeks during 1st & 2nd trimesters. • Prenatal visits 1-2 X q week, during 3rd trimester. • Goal = achieving & maintaining constant euglycemia, withblood glucose levels in the range of 60-120 mg/dl.

27. Diet: • Dietary mgt is based on blood glucose (not urine) • Energy needs are calculated on the basis of 30-35 calories per kilogram of ideal body weight, with average diet including 2200 (1st trimester) to 2500 calories (2nd & 3rd trimesters). • 50-60% calories should be carbohydrates (minimum or 250 gm/day). • 12-20% proteins. • 20-30% fat (no more than 10% saturated fats) • Weight gain for most women should be about 12kg during pregnancy.

28. Exercise: • Need not be vigorous to be beneficial. • The best time for exercise is after meals, when blood glucose level is rising. • Hypoglycemia may result: if exercise is done when insulin is peaking or engages in prolonged exercise without carbohydrate intake. • Exercise should stop if uterine contractions are detected.

29. Insulin therapy: • During 1st trimester: little or no change in prepregnancy insulin needs (may need to be decreased d/t hypoglycemia). • During 2nd & 3rd trimester: insulin dosage must be increased to amintain target glucose level, d/t insulin resistance. • Usually managed with 2-3 injections per day.

30. Monitoring blood glucose levels: • Blood sugar testing at home is the most important tool, for determining degree of glycemic control. • Target levels of blood glucose during pregnancy are lower than nonpregnant values. 60-90mg/dl, and 3 hour postprandial levels between 90-120mg/dl. • Urine testing: urine testing for ketones, identifies onset of DKA. If ketones appear at the same time each day, some adjustment in diet may be needed.

31. Fetal surveillance: • Done for fetal growth and wellbeing. • Done primarily in the 3rd trimester, when the risk of fetal compromise is greatest. • Baseline sonogram to determine EDC, done in 1st trimester. Then q 4-6 weeks to monitor fetal growth, estimate fetal weight, and detect hydramnios, macrosomia, and congenital anomalies. • Maternal serum alpha-fetoprotein is done at 16-18 weeks (d/t greater risk for neural tube defects).

32. Fetal echocardiography between18-22 weeks to detect cardiac anomalies. (repeated @ 34 weeks). • Fetal movement counts as a sdcreening technique in fetal surveillance. • Non-stress test beginning at 28-30 weeks. After 32 weeks cone 2 X week. • Biophysical prophiile, to evaluate fetal well-being. • Amniocentesis to test for fetal lung maturity. (for delivery)

33. Complications requiring hospitalization: • Failure to maintain acceptable blood glucose levels, may lead to hospitalization. • 3rd trimester hospitalization for women with vasculopathy (increased risk for renal impairment, hypertensive disorders, & fetal compromise.

34. Mode of Birth: • A controversy among practitioners. • Elective labor induction btw.38-40 weeks. • C/Section rate is around 45%. Often performed when antepartum testing suggests fetal distress or the estimated fetal weight is 4000-4500gm. • C/S when induction of labor is desired and the cervix fails to respond.

35. Pregnancy in Special Populations

36. Negative Infant Outcomes Related to Adolescent Pregnancy • Prematurity • Low birth weight • Infant death • Serious respiratory problems

37. Negative Infant Outcomes in Adolescent Pregnancy • Blindness/deafness • Cerebral palsy • Mental retardation

38. Negative Child Outcomes in Adolescent Pregnancy • Neglect and abuse • Chronic cognitive defects • Developmental delays • Chronic behavioral problems

39. Negative Child Outcomes in Adolescent Pregnancy (cont.) • School failure/withdrawal • Chronic runaway • Foster/alternative placement

40. Effects of Smoking During Pregnancy • Possible perinatal loss • Small for gestational age babies • Increased premature rupture of membranes • Increase in sudden infant death syndrome

41. Contraception Methods • Condoms with spermicides, foam, cream, or suppositories • Oral contraceptives • Injectable progestin, Depo-Provera and Norplant • Postcoital or morning-after pill

42. Women at Risk for HIV/AIDS Infection • History of drug use, especially intravenous • History of prostitution • Frequent sexual intercourse with multiple partners • Sexual intercourse with men who have sex with other men

43. Women at Risk for HIV/AIDS Infection (cont.) • Residence in an area of the country with high prevalence of HIV and AIDS • Received a blood transfusion or blood products prior to 1985 • Having sex with someone with any of the above risk factors

44. Signs of HIV Infection in Infants • Opportunistic infections such as PCP and interstitial lymphocytic pneumonia • Candida diaper rash, thrush, and diarrhea • Recurrent bacterial infections • Growth failure, neurologic problems, and developmental delays

45. Antiretroviral Drug Therapy • Nucleoside reverse transcriptase inhibitors: zidovudine, didanosine, salcitabine • Nonnucleoside reverse transcriptase inhibitors: nevirapine, delavirdine, lovirdine • Protease inhibitors: saquinavir, indinivir, ritonavir, nelfinavir

46. Anticipatory Guidance for Mothers Over 35 Years Old • Counseling related to genetic testing, amniocentesis, and chorionic villus sampling • Identification of appropriate social support • Potential medical problems