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Chapter 21
Sudden Pregnancy Complication
Bleeding
Development of shock
 Blood pressure
 Pulse
 Fetal heart rate
 Treatment
Disseminated Intravascular
Coagulation (DIC)
Disorder of blood clotting
 Fibrinogen levels fall below effective limits
Symptoms
 Bruising or bleeding
Causes
1st Trimester Bleeding
Spontaneous miscarriage (Abortion)
 Threatened
 Imminent
 Complete
 Missed
 Recurrent pregnancy loss
Complications of Miscarriage
Hemorrhage
Infection
Septic abortion
Isoimmunization
Powerlessness or anxiety
1st Trimester Bleeding
Ectopic pregnancy
 Implantation occurs outside of the uterine
cavity
Abdominal pregnancy
2nd Trimester Bleeding
Gestational trophoblastic disease
(hydatidform mole)
 Abnormal proliferation and degeneration
of the trophoblastic villi
Assessment
 HCG
 Ultrasound
 Fundal height
 Nausea
Management
• D&C
• CXR
• HCG Beta q 4 weeks for 12 months
• Contraception
• No pregnancy 1 year
Premature cervical dilatation
 Cannot hold the fetus until term
 Cervical cerclage
3nd Trimester Bleeding
Placenta previa
 Low implantation of placenta, Partial
previa, complete previa
 Risk factors
 Assessment: Painless vaginal bleeding
 Management
Immediate care
Continuing care
3nd Trimester Bleeding
Abruptio Placentae
 Premature separation of placenta
 Occurs suddenly
 Most frequent cause of perinatal death
 Risk factors
 Assessment: Painful
 Management
Preterm Labor
• Labor before the end of 37 weeks gestation.
• Occurs in 9 to 11% of all pregnancies.
• Persistent uterine contractions 4 in 20 min.
• Actual labor is if uterine contractions that cause
effacement over 80% and dilation over 1 cm.
• Preterm births are 2/3 of all infant deaths.
• Cause unknown, dehydration, UTI, chorioamnionitis
(infection of fetal membranes and fluid), strenuous
jobs, extreme fatigue.
Preterm Labor
• SS-persistent, dull, low backache, vaginal spotting,
feeling of pelvic pressure or abdominal tightening,
menstrual like cramping, increased vaginal
discharge, uterine contraction, intestinal cramping.
Management:
• Analyze changes in vaginal mucus (fetal
fibronectine), short cervix, sonogram.
• May try to stop labor if not beyond 4 to 5 cm or
50% effacement
• Admit to hospital, bedrest, IV, cultures,
Preterm Labor
UA, oral tocolytic agent-terbutaline, good nutrition
and no smoking.
• Antibiotic for strep B prophylaxis, corticosteroid
(lung surfactant)
• Pregnancy <34 weeks betamethasone 2 doses 12
mg IM 24 hours apart, effect lasts 7 days.
• Magnesium sulfate 4 to 6 g IV bolus to halt
contractions (CNS depressant) p. 399.
• Terbutaline (Brethine)-relaxes uterine muscles,
blood vessels and bronchi.
Preterm Labor
• Monitor: VS, I&O, labs, lungs for edema, daily wt.,
FHR.
Fetal assessment:
• Count fetal movement-10 in 1 hour (lt. side)
Labor:
• ROM, cervix > 50% effaced or 3 to 4 cm dilated it
is unlikely it can be halted.
• Fetus immature – cesarean birth
• Use caution giving analgesics (demerol) due to
immaturity of fetus. Epidural is best.
• Episotomy is needed to decrease risk of
hemorrhage of fetus. May be larger and forceps
may be used.
Preterm Labor
• Support, she needs to rebuild her self esteem.
Preterm Rupture of Membranes
Associated with infection of membranes.
Occurs in 2% to 18% of pregnancies.
If early it is a threat to the fetus, infection and
pressure on cord or prolapse. Non fluid
environment > Potter like syndrome of distorted
facial features and pulmonary hypoplasia from
pressure.
Preterm Labor
Assessment:
• Labor will not be halted if ROM.
• Sudden gush clear fluid, test with nitrazine paper
(alkaline reaction-blue), ferning (high estrogen),
sonogram, cultures, labs.
Management:
• Bedrest, antibiotic, may apply fibrin-based sealant
to ruptured membranes, amniotic fluid is always
being formed.
Preterm Rupture of Membranes
Rupture of fetal membranes with a loss
of amniotic fluid
 Before 37 weeks’ gestation
 Associated with chorioamnioitis
 Complications
 Assessment
 Management
Pregnancy Induced
Hypertension
PIH
• Vasospasm occurs during pregnancy.
• Occurs in 5% to 10% of pregnancies.
• Cause unknown, in primiparas <20 yrs. or > 40
yrs., low socioeconomic background, 5 or more
pregnancies, women of color, multiple hydraminios,
heart disease, diabetes, essential hypertension,
poor calcium or magnesium intake.
Patho:
• Normally blood vessels are resistant to the effects
of pressor substances such as angiotensin and
norepinephrine.
Pregnancy Induced
Hypertension
• With PIH vasoconstriction occurs and B/P increases
dramatically.
• Cardiac system becomes overwhelmed, reduction
of blood supply to kidney, pancreas, liver, brain
and placenta.
• Hypoxia in maternal vital organs, poor placental
perfusion reduce fetal nutrients and O2.
• Ischemia in pancreas; epigastric pain and amylasecreatinine ratio, retinal hemorrhages – blindness,
proteinuria, edema.
Pregnancy Induced
Hypertension
Extreme edema can lead to cerebral and pulmonary
edema and seizures (eclampsia)
Assessment:
• Classic signs: hypertension, proteinuria, and
edema.
• Symptoms rarely occur before 20 weeks.
Classified as: gestational hypertension, mild
eclampsia, severe preeclampsia &eclampsia
Pregnancy Induced Hypertension
Vasospasm, hypoperfusion, and
endothelial injury occurs during
pregnancy
Symptoms
 Hypertension
 Proteinuria
 Edema
Causes
Physiologic changes
Gestational Hypertension
Elevated BP
Without
Edema or Proteinuria
No Drug Therapy or Low Dose ASA
May develop Hypertension in later life
Pre Eclampsia
 Above gestational hypertension and
below point of seizures (Eclampsia)
Mild preeclampsia
Severe preeclampsia
Mild Pre-eclampsia
• BP 30mm systolic and 15mm diastolic above prepregnancy values.
• BP > 140/90
• Proteinuria 1+ to 2+ that is not orthostatic
• Sodium Retention
• Lower Glomerular filtration rate
• Edema upper body
• Weight gain 1-2 lb week
Severe Pre-Eclampsia
• BP at REST:
–
30mm diastolic above pre pregnancy
–
160/110
• Marked Proteinuria 3+ to 4+
–
Or > 5gm in 24 hour sample
• Edema
–
Pitting or non pitting over bony surfaces
–
4+ is indentation that remains after removal of finger
–
Extensive edema face and hands
• Epigastric Pain: Liver swelling
• Ankle Clonus: Cerebral Edema
• Urine output 400 to 600 mL/24 hours.
• SS-severe epigastric pain, nausea, vomiting, SOB, blurred vision,
seeing spots, headache, marked hyperreflexia and muscle clonus.
• Review Patellar reflex and ankle clonus assessment
Eclampsia
• Severe cerebral edema to cause SEIZURE or COMA
• Poor fetal prognosis: anoxia, acidity, and potential for
premature separation of placenta
Management of PIH
Nursing Interventions for Mild Hypertension
• Can be managed at home with frequent follow up care.
• Promote bedrest, lateral recumbent position.
• Promote Good Nutrition
• Provide emotional support-SS are vague, no meds.,
works, other children. Seen weekly.
Nursing Intervention for Severe
Hypertension:
• B/P > 160/110 after on bedrest, extensive edema,
proteinuria 3+-4+
• Support Bedrest, hospital, private room, side rails up if
seizure, darken room, restrict visitors, less stress,
explain everything.
• Monitor Maternal Well-Being
– VS, labs, DIC, high risk for premature separation of
placenta and hemorrhage, cathether (>600 mL/24h
or 30mL/h), daily weight,
• Monitor Fetal Well-Being:
– FHR, non stress test or biophysical profile daily, O2
to mother.
Support Nutritional Diet:
• Moderate to high protein, moderate sodium diet, IV TKO.
Nursing Intervention for Severe
Hypertension:
Administer Medications to Prevent Eclampsia
• Table 21.7
pg. 580 drugs
• Magnesium sulfate, Apresoline or Normodyne, Valium
• Review treatment with Magnesium sulfate pg.581
• Calcium Gluconate
Nursing Intervention with Eclampsia:
• Cerebral irritation from increased cerebral edema and
seizure results. Late in pregnancy or 48 hours after birth.
• SS-B/P increases, temp increases to 103-104, burning of
vision, headache, reflexes hyperactive, “something is
happening,” epigastric pain, nausea and decreased
urinary output. Seizure.
Tonic-Clonic Seizures:
• Occurs in stages
• Maintain patent airway, O2 by face mask, pulse ox, FHR,
turn on side, incontinent of urine and bowel, (valium,
mag sulfate),third stage-semicomatose 1 to 4 hours.
Continued:
• Unable to report contractions if placenta has separated.
Check for vaginal bleeding.
Birth:
• Pregnancy > 24 weeks, decide about delivery, fetus may
not grow after eclampsia occurs.
• Vaginal birth preferred, vascular system is low in volume.
Postpartal Hypertension:
• Up to 10 to 14 days after birth. (48 hours) monitor B/P
closely.
HELLP Syndrome
 Hemolysis
 Elevated Liver Enzymes
 Low Platelets
Causes
Symptoms
• Is a variation of PIH
• 4% to 12% of PIH patients (1 in 150
births).
• Cause is unknown, SS-nausea,
epigastric pain, general malaise and rt.
upper quadrant tenderness.
• Labs, monitor for bleeding.
• Tx. Transfusion fresh-frozen plasma or
platelets. IV dextrose if hypoglycemic.
• Deliver as soon as fetus is viable.
Multiple Pregnancy
Considered a complication of pregnancy.
Account for 2% due to fertility drugs.
Multiples may be any combination.
Occurs more frequently in non whites,
high parity and age, multiple gestation,
inherited
Identical (monozygotic) twins:
• Begin with single ovum and spermatozoon
• Fusion or 1st cell division, zygote divides into 2 identical
individuals.
• Usually have 1 placenta, 1 corion, 2 amnions, and 2
umbilical cords.
• Always same sex.
Fraternal (dizygotic, non-identical) twins:
• Fertilization of 2 separate ova by 2 separate spermatozoa
(possible not from the same sexual partner).
• 2 placentas, 2 chorions, 2 amnions and 2 umbilical cords.
• May be same or different sex.
• 2/3 of twins are dizygotic.
Assessment:
• Uterus increases in size at a rate faster than usual.
• Elevated alpha-fetoprotein levels
• Sonogram reveals multiples.
• Quickening woman reports flurries of action
• If fetus has back toward woman’s back only one fetal
heart sound may be heard.
Management
• Monitor for complications-PIH, hydramnios placenta
previa, preterm labor, anemia.
• Prone to postpartal bleeding.
• Delivery early, immaturity of fetus.
• High risk for congenital anomalies, spinal cord defect and
cord inserted into fetal membranes.
• Shared circulation, overgrowth of 1 fetus, knotting or
twisting of cord.
• Encourage rest especially last 2 to 3 months, eat 6 small
meals a day, take vitamin supplements, monthly US
• Prepare for role changes
• Worries of premature labor and survival of the infants.
Hydramnios (Poly)
• Excessive amniotic fluid formation.
• Usual-500 to 1000 mL.
• 2000mL or index > 24 cm.
• Can cause fetal malpresentation due to extra space
for fetus to turn.
• Premature ROM and preterm labor from increased
pressure and prostaglandin release
Hydramnios cont’
Assessment:
• Suggests difficulty with fetus’ ability to swallow or absorb or
excessive urine production.
• SS-rapid enlargement of uterus, tense uterus, fetal heart is
difficult to hear, SOB, lower extremity varicosities and
hemorrhoids, increased weight gain.
• Sonogram
Management:
• Admit to hospital for bed rest or rest at home.
• Educate on ROM, contractions, avoid constipation.
• VS, edema, may do amniocentesis to remove extra fluid,
Indomethacin to reduce total volume, Magnesium sulfate to
halt preterm labor, “needled” to allow slow controlled release
of fluid.
Oligohydramnios
• Less than average amount amniotic fluid
• Bladder or renal disorder interferes with fetal voiding
• Muscles weak, lungs fail to develop
• Uterine slow growth
• Amnioinfusion
Post Term Pregnancy
• Term is 38 to 42 weeks
• Ovulation period may be longer so EDD will be 12 to 17
days later.
• Trigger did not turn on for labor.
• High dose of salicylates interferes with synthesis
prostaglandins, which initiate labor.
• 2 weeks beyond term are at risk for meconium
aspiration, macrosomia, lack of growth.
• Placenta functions for 40 to 42 weeks.
At 41 weeks; nonstress test,maternal fibronectin level, and
biophysical profile to document state of placental
perfusion and amniotic fluid. May induce.
• Cytotec to initiate ripening, ROM,oxytocin.
Pseudocyesis
• False pregnancy can also be seen in
men; N&V, amenorrhea enlarged
abdomen.
• Occurs: wish fulfillment or fear of
pregnancy, depression.
• Sonogram
• Refer for psychological counseling.
Isoimmunization
(Rh Incompatibility)
Rh-negative mother is carrying a fetus
with Rh-positive blood
Hemolytic disease of the newborn
Assessment
Management
Fetal Death
Most severe complication
Assessment
Nursing care