COMPLICATIONS OF PREGNANCY

1. COMPLICATIONS OF PREGNANCY Jeanie Ward

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, etc.

3. High Risk Pregnancy Goals of Care • Provide with optimum care for the mother and the fetus • Assist the patient and her family to understand and cope with the variations in a High Risk Pregnancy and cope with her feelings

4. Pregnancy- Related Complications

5. Bleeding Disorders

6. Abortions • Termination of pregnancy at any time before the fetus has reached viability Either: • spontaneous – occurring naturally • induced – artificial Question 1

7. What would cause a woman to abort a pregnancy ? • 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

8. Nursing Assessment • The nurse collects the following data from Mrs. X.: • Gravida 1, Para 0 • 14 weeks gestation • Had bright red vaginal bleeding • Experiencing abdominal pain • What is the appropriate action now?

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

10. The more blood loss, the more likely the woman is to progress from threatened to inevitable abortion. A = True B = False

11. Inevitable 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

12. Complete Abortion • All products of conception are expelled • No treatment is needed, but may do a D & C With speculum inserted into the vagina, first the os of cervix is dilated and then the curette device is used to empty the contents of the uterus.

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

14. A woman who is 12 weeks gestation comes to the ER complaining of vaginal bleeding. What is the Appropriate action(s) of the nurse? (select all that apply) • Save all clots or material passed • Perform a vaginal exam to assess dilation • Prep her for a D&C • Assess vital signs • Assess quickening • Prep for ultrasound

15. Missed Abortion • Fetus dies, but is retained in the uterus. • Symptoms of pregnancy disappear • Maceration occurs • Treatment: • D&C; Hysterotomy Question? • What are two main complications related to a missed abortion? • 1. • 2.

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

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

18. Nursing Care • Bedrest in a slight trendlenburg position to decrease the pressure on the new sutures • Teach: • Assess for leakage of fluid, bleeding • Assess for contractions • Assess fetal movement and report decrease movement (if old enough) • Assess temperature for elevations

19. 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

20. 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

21. Bleeding Disorders Ectopic Pregnancy • Implantation of the blastocyst in ANY site other than the endometrial lining of the uterus ovary (5) Cervical Question 2

22. Etiology / Contributing Factors • Salpingitis • Pelvic Inflammatory Disease, PID • Endometriosis • Tubal atony or spasms • Imperfect genetic development Question 3

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 • 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 • Draw blood for type and cross match • Give blood replacements • IV’s. • Laparotomy • Psychological support • Linear salpingostomy • Methotrexate – used prior to rupture Question 4

26. 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. Question 5

27. Assessment: • Vaginal Bleeding -- scant to profuse, brownish in color (prune juice) • 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 levels of HCG Question 6

28. Interventions and Follow-Up • Empty the Uterus by D & C or Hysterotomy • Prior to evacuation the following lab tests are done to develop a baseline: • Chest x-rays • Blood chemistry tests • Serum β-hCG Question 7

29. Hydatiform Molar Pregnancy Question 8 • 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

30. 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?

31. 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 9

32. 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

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 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

34. 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 Question 9-C

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 • Deliver by cesarean delivery immediately • Combat shock – blood replacement / fluid replacement • Blood work – assessment of DIC

37. 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

38. Disseminated Intravascular Coagulation (DIC) Anti-coagulation and Pro-coagulation effects existing at the same time. Question 10

39. 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

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 follows 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) • Fetal placenta fragments

42. Assessment Signs and Symptoms • Spontaneous bleeding -- from gums and Epistasis, 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 • Mental changes if brain affected. Question 10-C

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 Question 10-D: E

45. Which signs and symptoms would support the diagnosis of DIC? • Sudden onset of chest pain and frothy sputum • Foul smelling, concentrated urine • Oozing blood from the IV catheter site • A reddened inflamed central line catheter site

46. Try This! • C.M., 42y/o, comes into the Clinic complaining of: • vaginal bleeding and abdominal pain that is completely unlike her usual monthly cramping. She describes her pain as “very sharp” and an “11” on a scale of 0 to 10. • Her vital signs are T 98.8, P 102, R 24, and BP 102/64. She indicates that her blood pressure is “usually 130/90.” • She is unable to recall the date of her last menstrual period. Additionally, she has almost soaked an entire pad in the last hour. C.M. is very anxious and says, “I’ve never had any real female problems before, except for the little cramping I get on the first day of my period. She admits sheepishly to having gonorrhea five years ago.

47. How about this one? J.J. is a 40 y/o GiPo who is 22 weeks’ gestation, although her fundal height is consistent with 26 weeks’ gestation. She indicates that throughout the pregnancy she had periodic spotting that resembles prune juice. J.J. states: “I knew pregnancy would be difficult at my age in spite of what my grandmother says, but I am vomiting so much that my weight is down to 102 pounds. My pressure is up a little but I guess that’s because of my age too.” J.J.’s records indicate that her weight at the initial prenatal visit was 110 pounds. Her vital signs are T 98.6, P 86, R 20, and BP 142/90, but fetal heart tones and movement are not detected. She states, “It gets harder and harder to keep working in our restaurant.”

48. HyperemesisGravidarium

49. HYPEREMESIS GRAVIDARIUM **Pernicious vomiting during Pregnancy Question 11

50. Hyperemesis Gravidarium Etiology Increased levels of HCG