Complications of Pregnancy

1. Complications of Pregnancy Fall 2011

2. Risk Factors • Age – under 17 over 35 • Gravida and Parity • Socioeconomic status • Psychological well-being • Predisposing chronic illness – diabetes, heart conditions, renal • 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. 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 Related to Bleeding Disorders • If a woman is Rh-, RhoGam is given within 72 hours of abortion • 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 • History of sexually transmitted disease

22. Contributing Factors • Failed tubal ligation • Intrauterine device • Multiple induced abortions • Maternal age > 35 years • History of previous ectopic

23. 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

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

25. 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

26. Gestational Trophoblastic DiseaseHydatiform Molar Pregnancy • 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.

27. 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

28. 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

29. 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?

30. 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

31. Abruptio Placenta • Premature separation of the placenta from the implantation site in the uterus • Etiology: • Chronic Maternal Hypertension • Short umbilical cord • Trauma • History of previous delivery with separation • Smoking / Caffeine / Cocaine • Vascular problems such as with diabetes • Multigravida status • Defined as marginal, partial or complete

32. Recently Identified Risk Factor • Autoimmune antibodies including resulting in various coagulopathies: • Anticardiolipin • Lupus anticoagulant

33. 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 and uterus is not hypertonic • Blood clotting defect absent Abruptio Placenta • Bleeding accompanied 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 and low back pain • Fetal parts non-palpable, FHT’s non-countable and high uterine resting tone (noted with IUPC) • Blood clotting defect (DIC) likely

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

35. 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

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

37. Critical Thinking • Mrs. A., G3 P2, 38 weeks gestation is admitted to L & D with scant amoutn of dark red 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

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

39. Etiology Defect in the Clotting Cascade • An abnormal overstimulation of the coagulation process Activation of Coagulation with release of thromboplastin into maternal bloodstream ê Thrombin (powerful anticoagulant) is produced ê Fibrinogen fibrin which enhances platelet aggregation and clot formation • ê • Widespread fibrin and platelet deposition in capillaries and arterioles

40. 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 from vascular occlusion of numerous fibrin thrombi • Multisite hemorrhage results in shock and can result in death

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

42. Assessment Signs and Symptoms • Spontaneous bleeding -- from gums and nose (Epistaxis), 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 cerebral bleeding or significant blood loss

43. 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

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

45. Hyperemesis Gravidarum

46. HYPEREMESIS GRAVIDARIUM **Pernicious vomiting during Pregnancy

47. Hyperemesis Gravidarium Etiology Increased levels of HCG

48. 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

49. Nursing Care / InterventionsHyperemesisGravidarium • 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 and outlet for sharing feelings • Mouth care • Weigh daily • Check urine for output, ketones

50. Hypertenison during pregnancy