Understanding Multiple Pregnancy and Complications: A Comprehensive Guide

1. Chapter 20Conditions Occurring During Pregnancy

2. Multiple Pregnancy #1 • Approximately 3% of births are twins. • When two eggs are fertilized, the result is dizygotic or fraternal twins. • Risks for dizygotic twinning rates include the use of fertility drugs, certain ethnicity, or a family history of twinning. • Monozygotic twins are identical and occur after the fertilization of one ovum. • Monozygotic twinning is considered a random, spontaneous event. • Multi-fetal pregnancies increase maternal and fetal risk. • Risks include preeclampsia, pulmonary embolism, preterm birth, placenta previa, fetal anomalies, stillbirth, and twin-to-twin transfusion.

3. Multiple Pregnancy#2

4. Question #1 Is the following statement true or false? In monozygotic twinning, the earlier an ovum is cleaved, the higher the risk.

5. Answer #1 False. In monozygotic twinning, the earlier an ovum is cleaved, the less likely the twins will share any structures. Therefore, there will be less risk to the twins. The later cleavage occurs, the more structures will be shared and the greater the risk to the twins.

6. Hyperemesis Gravidarum #1 • Hyperemesis gravidarum (HG) is characterized by unusually acute nausea and vomiting. • HG may lead to weight loss, malnutrition, dehydration, ketonuria, and electrolyte imbalances. • Nurses must evaluate for signs of dehydration, malnutrition, and laboratory tests. • Treatment may include antiemetics (although some have known teratogenic effects), intravenous (IV) rehydration, and the administration of parenteral electrolytes.

7. Hyperemesis Gravidarum#2

8. Bleeding in Pregnancy: Miscarriage #1 • Up to 20% of women report vaginal bleeding in early pregnancy. • For a subset of women, vaginal bleeding may indicate a miscarriage, ectopic pregnancy, or gestational trophoblastic disease. • A miscarriage, also known as a spontaneous abortion or spontaneous pregnancy loss, occurs before 20 weeks gestation. • Majority of miscarriages occur between weeks 5 and 8 and are thought to be the result of chromosomal abnormalities. • If a pregnancy loss is suspected, the woman should be evaluated for symptoms of bleeding, cramping, and the passage of tissue. An ultrasound may be ordered to evaluate the pregnancy as well as beta hCG levels.

9. Bleeding in Pregnancy: Miscarriage#2

10. Bleeding in Pregnancy: Ectopic Pregnancy • A pregnancy that occurs outside the uterus, often occurs in the fallopian tube. • Ectopic pregnancies are considered life-threatening for the mother and must not be continued. • Signs of an ectopic pregnancy include pelvic pain that may be unilateral and bleeding. • Risk factors for an ectopic pregnancy include: • History of pelvic infection or previous ectopic pregnancy. • Treatment may be managed medically or surgically, depending on time of discovery. • Nurses should be prepared to support the patient physically and emotionally.

11. Bleeding in Pregnancy: Gestational Trophoblastic Disease • Gestational trophoblastic disease (GDP), also known as a molar pregnancy, is a nonviable mass of trophoblastic tissue. • A molar pregnancy grows at an abnormally high rate, produces abnormally high levels of beta hCG, and may spread beyond the uterus (gestational trophoblastic invasive mole or gestational choriocarcinoma). • Diagnosed on ultrasound. • Treatment includes hysterectomy or dilation and curettage, possible prophylactic chemotherapy, serial serum hCG levels for one year, and avoiding subsequent pregnancy for one year.

12. Hypertensive Disorders: Gestational Hypertension • Gestational hypertension is diagnosed by systolic blood pressure greater than 140 mm Hg or higher and/or a diastolic blood pressure of 90 mm Hg or higher without protein in the urine or signs of end-organ dysfunction after 20 weeks of pregnancy. • As many as half of the women diagnosed with gestational hypertension go on to develop preeclampsia. • Complications of gestational hypertension include preterm birth, small for gestational age (SGA) infants, and placental abruption.

13. Preeclampsiaand Eclampsia #1 • Preeclampsia occurs in 3% to 5% of pregnancies. Can cause oligohydramnios, placental abruption, and intrauterine growth restriction for the fetus. Can impact maternal organ systems causing renal damage, pulmonary edema, impaired liver function, cerebral edema, and thrombocytopenia. • Preeclampsia diagnosed when a patient has hypertension (≥ 140/90 mm Hg) on two occasions at least 4 hours apart and has proteinuria. Or • The patient has hypertension with or without proteinuria and a platelet count <100,000, serum creatine liver >1.1 mg/dL, elevated liver enzymes, pulmonary edema, or new-onset visual or cerebral symptoms. • Eclampsia is preeclampsia with tonic-clonic seizure activity.

14. Preeclampsia and Eclampsia#2

15. Preeclampsia and Eclampsia: Assessment • Frequent assessments of the preeclamptic patients should include: • Blood pressure • Headache • Blurred vision • Restlessness • Epigastric and right upper quadrant pain • Shortness of breath • Fetal movement • Urine output • Unusual vaginal bleeding or discharge • Reflexes • Clonus • Laboratory tests

16. Preeclampsia and Eclampsia: Treatment • To reduce the risk of preeclampsia, women at high risk may be advised to start taking an aspirin and calcium supplementation to decrease risk. • Women with mild preeclampsia and gestational hypertension may be monitored on an outpatient basis and do not require medication. • Women suspected of having progressed to severe preeclampsia may need to be induced and deliver early. • Magnesium sulfate is often given by IV to prevent seizures. • Magnesium sulfate reduces central nervous system irritability caused by cerebral edema and brings down the seizure activity by an estimated 50%. • Hypertension may be controlled by IV antihypertensives to protect from complications such as stroke, renal damage, and heart disease.

17. Preeclampsia and Eclampsia: Magnesium Sulfate #1

18. Preeclampsia and Eclampsia: Magnesium Sulfate#2 • Administered as a secondary infusion by pump with a loading dose of 4 to 6 g over 15 to 30 minutes. Then, a maintenance dose of 1 to 3 g/hour to maintain a serum magnesium level of 4 to 7 mEq/L. • Signs of magnesium include: • Respiratory depression • Absent reflexes • Lethargy • Slurred speech • Loss of consciousness • Interventions to address toxicity include: • Stop the infusion immediately. • Administer calcium gluconate as ordered (typically 1 g by slow IV push over 3 minutes).

19. Question #2 A patient diagnosed with preeclampsia had a severe headache, 2+ protein in the urine, hyperreflexes, and was started on magnesium sulfate. Current assessment findings include a severe headache, slurred speech, and hyporeflexes. What should the nurse do next? A. Reassess the patient in 1 hour. B. Notify the charge nurse immediately. C. Document current assessment findings. D. Turn off the magnesium sulfate infusion.

20. Answer #2 D. Turn off the magnesium sulfate infusion. Slurred speech and hyporeflexes are signs of magnesium sulfate toxicity. The nurse should first turn off the magnesium sulfate infusion. Then, the nurse should notify the charge nurse or health care provider, provide interventions as ordered, document assessment findings, and reassess the patient.

21. Gestational Diabetes #1 Gestational diabetes complicates 6% to 7% of pregnancies and is associated with insulin resistance and results in high blood glucose levels.

22. Gestational Diabetes#2 • Women at high risk may be screened at their first prenatal visit for preexisting diabetes. All patients are screened at 24 to 28 weeks of pregnancy. • Screening test for all women between 24 to 28 weeks: • Nonfasting 50 g glucose tolerance test. • If blood glucose is >130, diagnostic testing indicated. • Diagnostic testing: • Fasting 100 g glucose tolerance test. • Blood sugar evaluated fasting 1, 2, and 3 hours after ingesting. • If two or more values elevated, the patient has gestational diabetes. • Fasting ≥95 mg/dL • One hour ≥180 g/dL • Two hours ≥155 mg/dL • Three hours ≥140 mg/dL

23. Gestational Diabetes#3 • Gestation diabetes risks include stillbirth, fetal macrosomia, and postpartum hemorrhage. • Gestational diabetes is treated with diet, exercise, and sometimes medication (insulin). • Risks for developing gestational diabetes include: • Body mass index >25 (overweight or obese) • Prior history of gestational diabetes • Family history of type 2 diabetes • Previous unexplained fetal demise • Previous birth with macrosomia • Maternal age over 40 years • Hypertension • Hispanic, African American, Native American, Asian, or Pacific Islander ethnicity

24. Gestational Diabetes: Patient Teaching

25. Gestational Diabetes: Care Considerations • No current consensus regarding fetal monitoring for women with well-controlled gestational diabetes. • Women who require medications (metformin, glyburide, or insulin) may be monitored more closely. • Outcomes are optimized when blood sugars are controlled. • Fasting blood glucose should remain less than 95 mg/dL. • 1-hour postprandial levels should be less than 140 mg/dL. • 2-hour levels should be less than 120 mg/dL. • Spontaneous vaginal birth is the preferred method of delivery, but if suboptimal glucose control, patient may require induction of labor or cesarean birth.

26. Infections in Pregnancy #1 • Infection may be caused by sexually transmitted infections (STIs), TORCH infections, or urinary tract infections. • Chlamydia and gonorrhea may cause preterm labor, preterm rupture of membranes, or postpartum endometritis. Treated with antibiotics followed by retesting 3 months later. • Herpes can be transmitted to the fetus. Women with herpes are typically prescribed an antiviral medication the month before pregnancy due date and are delivered by cesarean if lesions are present. • Pregnancy is not contraindicated for women who are HIV positive. Women with HIV are often delivered by cesarean to reduce risk of transmission to fetus. • Infants born to hepatitis B-positive women should be given the hepatitis B vaccine and the hepatitis B immune globulin within 12 hours of birth.

27. Infections in Pregnancy#2 • TORCH infections are a group of infections that may cause fetal anomalies and are often asymptomatic for the mother. • TORCH infections include: • Toxoplasmosis • Other Infections • Rubella • Cytomegalovirus (CMV) • Herpes (HSV-1 and HSV-2). • Urinary tract infections are often asymptomatic and should be treated with antibiotics during pregnancy.

28. Cervical Insufficiency #1 • Painless, premature dilation of the cervix in the second trimester of pregnancy. • High risk for miscarriage or premature birth. • Diagnosed with history of second-trimester pregnancy losses and/or measurement of cervical length by ultrasound. • Treatment options include maternal progesterone supplementation and cervical cerclage.

29. Cervical Insufficiency#2

30. Trauma • Trauma in pregnancy may be related to motor vehicle accidents, falls, or intimate partner violence. • Care considerations for trauma treatment include: • Placing a wedge under the woman’s hip to minimize supine hypotension. • Understanding chest compressions may be more challenging and ineffective in a pregnant woman. • Oxygen consumption is increased and women should be monitored closely for hypoxia. • Abdominal trauma may result in placental abruption. • Trauma may be an indication for the administration of Rho (D) immune globulin to an Rh-negative woman. • The nurse should carefully assess the woman and the fetus for complications related to trauma.

31. Intrauterine Growth Restriction (IUGR) #1 • Condition that indicates there has been a complication of pregnancy. • IUGR is diagnosed in 20% of stillbirths. • The root cause of IUGR may be maternal, placental, or fetal in origin and should be evaluated. • Infants with IUGR are at high risk for hypoglycemia, problems with thermoregulation, and respiratory distress after birth.

32. Intrauterine Growth Restriction#2

33. Amniotic Fluid Volume Disorders: Polyhydramnios • Amniotic fluid serves as a protective buffer for the fetus and allows for fetal movement. • Polyhydramnios is excessive amniotic fluid. • Cause may be unknown or related to diabetes or twin-to-twin transfusion. • Associated with poor outcome including postpartum hemorrhage and placental abruption. • Polyhydramnios is diagnosed by ultrasound assessment of the four largest pockets of amniotic fluid. The amount of fluid in the four pockets are added together to obtain an amniotic fluid index (AFI). An AFI of 20 to 25 cm is abnormal. • Treatment includes amnioreduction, administration of indomethacin (prior to 34 weeks) to stabilize amniotic fluid, and induction of labor.

34. Amniotic Fluid Volume Disorders: Oligohydramnios • Oligohydramnios is decreased amniotic fluid that may be caused by fetal anomalies or premature rupture of membranes. • Oligohydramnios is associated with poor prognosis. • Diagnosed with ultrasound findings of decreased amniotic fluid index ≤ 5 cm fluid. • Treatment may include amnioinfusion of Ringer’s lactate into the amniotic sac.

35. Question #3 Risks of amniotic fluid volume disorders include which of the following? A. Preterm delivery B. Umbilical cord prolapse C. Variable decelerations in the fetal heart rate D. All of the above

36. Answer #3 D. All of the above Patients are at risk for preterm delivery with polyhydramnios because of overdistension of the uterus or with oligohydramnios because of fetal intolerance of labor. Umbilical cord prolapse is a risk in patients with polyhydramnios after rupture of membranes because excess fluid may push the cord through the cervix or the head may not be engaged in the pelvis due to excess fluid. Amniotic fluid helps cushion the umbilical cord in utero, variable decelerations are caused by cord compression and may be seen in patients with oligohydramnios.

37. Dermatoses of Late Pregnancy • Intrahepatic cholestasis: • Caused by impaired bile flow from liver. • Symptoms include pruritis, clay-colored stools, and fatigue. • Treatment goals include minimizing itching, reducing concentration of bile acid, and induced delivery at 36 to 37 weeks. • Resolves by the end of pregnancy. • Pruritic urticarial papules and plaques of pregnancy: • Highly pruritic papules that may be associated with an inflammatory process. • Treatments include oral topical corticosteroids and an antihistamine. • Resolves within a few weeks of delivery.