Download Pregnancy at Risk: Pregnancy-Related Complications

Pregnancy at Risk: PregnancyRelated Complications
Chapter 17
Objectives
1. Choose appropriate nursing interventions for the woman with hyperemesis
gravidarum.
2. Describe clinical manifestations of ectopic pregnancy.
3. Compare and contrast the six types of spontaneous abortion.
4. Discuss the treatment for cervical insufficiency.
5. Explain treatment and nursing care for the woman experiencing a
hydatidiform mole.
6. Compare and contrast placenta previa and abruptio placentae according to
characteristics of bleeding and other clinical manifestations.
7. Apply the nursing process to the care of a pregnant woman with a bleeding
disorder.
8. Differentiate four categories of hypertensive disorders in pregnancy.
9. Discuss treatment and nursing interventions for the woman with
preeclampsia-eclampsia.
10. Contrast the management of a multiple gestation pregnancy with that of a
singleton gestation.
11. Explain the threat to pregnancy posed by ABO and Rh incompatibilities.
Pregnancy at Risk: Pregnancy-Related
Complications

The licensed practical or vocational
nurse’s (LPN’s) role includes
◦ Identification of risk factors for pregnancyrelated complications through
 Patient interview
 Data collection

You must be able to identify signs of
complications and know what problems
need prompt intervention
Hyperemesis Gravidarum
Disorder of early pregnancy
 Characterized by severe nausea and vomiting
 Results in weight loss, nutritional
deficiencies, and/or electrolyte (esp. K+) and
acid/base imbalance
 Most often appears between 8 and 12
weeks’ gestation and usually resolves by
week 20
 Exact cause is unclear (association with high
levels of hCG)

Hyperemesis Gravidarum (cont.)

Risk of hyperemesis is increased with
◦ A multiple gestation
◦ Molar pregnancy
◦ When there is a history of hyperemesis
gravidarum

Stress and psychological factors can
contribute to the condition
Hyperemesis Gravidarum (cont.)

Clinical manifestations
◦
◦
◦
◦
Distinguished from “morning sickness”
Acid/base imbalances may occur
Ultrasound is helpful (R/O molar pregnancy)
Clinical features
 Symptoms of dehydration
 Postural hypotension
 Elevated hematocrit
Hyperemesis Gravidarum (cont.)

Treatment
◦ Emergency treatment is directed toward correcting
fluid, electrolyte, and acid/base imbalances
◦ Nothing by mouth (NPO) for the first 24 hours or
until the vomiting stops
◦ Pyridoxine (vitamin B6) with or without doxylamine
is the recommended first-line therapy
Hyperemesis Gravidarum (cont.)

Treatment (cont.)
◦ Antiemetics may be added
 many of these medications are in pregnancy
Category C
 Antiemetics usually more effective when given on a
regular, around-the-clock schedule versus as-needed
(PRN) dosing
 Given by parenteral injection or via rectal
suppository until the vomiting is under control
Hyperemesis Gravidarum (cont.)

Treatment (cont.)
◦ Once the vomiting has stopped
 A clear liquid diet is given and then advanced, as
tolerated, to a bland diet
 Thiamine supplements
Hyperemesis Gravidarum (cont.)

Nursing care
◦ Assess the woman for nausea and administer
pyridoxine/antiemetics, as ordered
◦ Record intake and output
◦ Assess for signs of dehydration
◦ Monitor laboratory values
◦ Monitor the fetal heart
Hyperemesis Gravidarum (cont.)

Nursing care (cont.)
◦ After the vomiting has stopped
 Implement measures to promote intake
 Provide mouth care before and after meals
 Observe family dynamics
Question
Although there is not a clear understanding
of what causes hyperemisis gravidarum,
several conditions have been linked with
it. What is one condition that has been
linked with hyperemisis gravidarum?
a. Single pregnancies
b. Older mother
c. Molar pregnancy
d. Obesity
Answer
c. Molar pregnancy
Rationale: The risk of hyperemesis is increased
with a multiple gestation (pregnancy with
more than one fetus), molar pregnancy, or
when there is a history of hyperemesis
gravidarum.
Bleeding Disorders

Can occur during early, mid-, or late pregnancy
◦ Early pregnancy
 Ectopic pregnancy and spontaneous abortion
 Molar pregnancy
◦ Mid-pregnancy
 Cervical insufficiency
◦ Late pregnancy
 Placenta previa and abruptio placentae
Ectopic Pregnancy

A pregnancy that occurs outside of the uterus
◦ Common term for this condition is “tubal” pregnancy
Leading cause of pregnancy-related death in the
first trimester
 Any condition or surgical procedure that can
injure a fallopian tube increases the risk

Ectopic Pregnancy (cont.)

Clinical manifestations
◦ Symptoms usually appear 4–8 weeks after the
last menstrual period (LMP)
◦ Most commonly reported symptoms are
pelvic pain and/or vaginal spotting
 Late signs, such as shoulder pain or hypovolemic
shock – these signs are associated with tubal
rupture
◦ Diagnosis is not always immediately apparent
Ectopic Pregnancy (cont.)

Clinical manifestations (cont.)
◦
◦
◦
◦
Serum or urine pregnancy test is done
Transvaginal ultrasound
Culdocentesis
Laparoscopy
Culdocentesis
Ectopic Pregnancy (cont.)

Treatment
◦ Management depends on the condition of the woman
 Shock requires emergency treatment
 May need blood expanders or transfusion
◦ Non-emergent diagnosed cases of tubal pregnancy
 Laparoscopic surgery is the most common
 Salpingectomy
 Intramuscular injections of methotrexate
◦ Rh-non-sensitized women require RhoGam
Ectopic Pregnancy (cont.)

Nursing care
◦ Measure and record vital signs
◦ Monitor the amount and appearance of
vaginal bleeding
◦ Report immediately heavy bleeding or signs
and symptoms of shock
◦ Assist the RN to prepare the patient for
surgery
Ectopic Pregnancy (cont.)

Nursing care (cont.)
◦ Once the patient is in stable condition,
emotional issues become the focus of nursing
care
◦ Before discharge, instruct the woman
regarding danger signs she should report
Early Pregnancy Loss
Another name is spontaneous abortion
 Most common complication of pregnancy
 Loss is before the age of viability (less
than 20 weeks of gestation or fetal size of
less than 350–500 grams)
 Common name for early pregnancy loss is
miscarriage
 Usually occur during the first trimester

Early Pregnancy Loss (cont.)

Factors that increase the risk for spontaneous
abortion
◦
◦
◦
◦
◦
◦
◦
Advancing maternal age
History of previous spontaneous abortion
Smoking, alcohol and substance abuse
Increasing gravidity
Uterine defects and tumors
Active maternal infection
Chronic maternal health factors, such as diabetes
mellitus, renal disease, etc.
Early Pregnancy Loss (cont.)
Difficult to determine the exact cause
 There are three overall categories of
causation:

◦ Fetal – usually genetic
◦ Maternal – multiple factors
◦ Environmental – poor nutrition, exposure to
chemicals, etc.
Early Pregnancy Loss (cont.)

Early abortion
◦ Occurs before 12 weeks
◦ Usually fetal cause

Late abortion
◦ Occurs between 12 and 20 weeks
◦ Usually maternal cause
Early Pregnancy Loss (cont.)

Clinical manifestations
◦ Typical symptoms of spontaneous abortion
include cramping and spotting or frank
bleeding
◦ Occurs along a continuum: threatened,
inevitable, incomplete, complete, and missed
◦ hCG levels drawn
◦ Transvaginal ultrasound
Early Pregnancy Loss (cont.)

Treatment
◦ Depends on which type of early pregnancy loss is
occurring
 Threatened abortion – conservative treatment
 All other types
‒May use prostaglandin misoprostol (Cytotec) given by
mouth
‒Vacuum aspiration or dilatation and curettage (D&C)
are the most common surgical methods used to clear
the uterus
Early Pregnancy Loss (cont.)
Treatment (cont.)
◦ After uterine evacuation
 Intravenous oxytocin (Pitocin)
 Oral methylergonovine maleate
(Methergine)
 Nursing care
◦ Assess vital signs, amount and appearance of
vaginal bleeding, and pain level
◦ Report a falling blood pressure and rising
pulse
◦ Save all expelled tissue

Early Pregnancy Loss (cont.)

Nursing Care (cont.)
◦ Provide analgesics as ordered
◦ Grief reactions are to be expected
◦ Accept and support the woman’s emotions
Question
Early pregnancy loss, commonly known as
“miscarriage” can occur for a variety of
reasons. What is one of these reasons?
a. First pregnancy
b. Active maternal infection
c.Young age of mother
d. Multiple pregnancy
Answer
b. Active maternal infection
Rationale: Factors that increase the risk for
spontaneous abortion include advancing
maternal age, history of previous
spontaneous abortion, smoking, alcohol
and substance abuse, increasing gravidity,
uterine defects and tumors, active
maternal infection, and chronic maternal
health factors, such as diabetes mellitus,
renal disease, etc.
Cervical Insufficiency

Incompetent cervix
◦ Painless cervical dilatation with bulging of fetal
membranes and parts through the external os
in the second trimester
◦ Pregnancy loss is frequently inevitable
◦ Risk factors
◦ Standard treatment is cervical cerclage
 Performed between 14 and 26 weeks of gestation
Cerclage
Gestational Trophoblastic Disease

Encompasses two related diseases of
trophoblastic tissue
◦ Hydatidiform mole or molar pregnancy-benign
growth of placental tissue
◦ Gestational trophoblastic neoplasia – malignancy
of uterine lining

Two types of molar pregnancies: partial (fetal
tissue) and complete (no fetus)
◦ Both types involve errors in chromosomal
duplication during fertilization
◦ Some features of a malignancy
Gestational Trophoblastic Disease (cont.)

Molar pregnancy (cont.)
◦ Risk factors: history of previous gestational
trophoblastic disease; extremes of age; young
women in their early teens and older women
who are near the end of their reproductive
lives are at highest risk
Gestational Trophoblastic Disease (cont.)

Clinical manifestations

Treatment
◦ Most common presenting sign for both partial and
complete moles is vaginal bleeding
◦ hCG level is usually higher than expected for
gestational age
◦ Transvaginal ultrasound
◦ Evacuation of the uterus
◦ Continued follow-up for 1 year is extremely
important
Gestational Trophoblastic Disease (cont.)

Nursing care
◦ Woman is at risk for several complications
Monitor frequently for vaginal bleeding
Check the condition of the uterine fundus
Administer oxytocin as ordered
Disseminated intravascular coagulation (DIC)
Trophoblastic embolus or pulmonary edema secondary to
fluid overload
 Emotional support





Placenta Previa
A condition in which the placenta is
implanted close to or covers the cervical
os
 Exact cause is not known
 Conditions that increase risk

◦ History of elective abortions, multiparity,
advanced maternal age (older than 35 years),
previous cesarean birth or uterine incisions,
maternal smoking, and prior placenta previa
Placenta Previa (cont.)

Classified according to the degree to
which the placenta covers the cervix
◦ Total placenta previa – rarely resolves
◦ Partial placenta previa – sometimes resolves
◦ Marginal placenta previa – sometimes resolves
Placenta Previa (cont.)

Clinical manifestations
◦ Painless, bright red bleeding
◦ The first bleeding episode occurs on average between
27 and 32 weeks’ gestation
◦ Digital examination of the cervix is deferred until
placenta previa has been excluded
◦ Diagnostic test of choice is transvaginal ultrasound
◦ Usually, first bleeding episode does not harm the fetus
◦ Total placenta previa is associated with atypical fetal
presentations
Placenta Previa (cont.)

Treatment
◦ If massive bleeding occurs, immediate cesarean delivery is
a life-saving measure for the woman and her fetus
◦ Kleihauer-Betke test (if woman is Rh(D) negative –
determine if fetal blood cells are in maternal circulation
◦ Anti-D immunoglobulin (RhoGam)
◦ Serial nonstress tests (NSTs) – monitors fetal well-being
◦ A cesarean delivery is necessary in all cases of total
placenta previa
Placenta Previa (cont.)

Nursing care
◦
◦
◦
◦
Requires careful nursing observation
IV access at all times
Assess for signs of shock
Listen to the fetal heart rate at least every 4
hours
◦ Postpartum care
 Normal
 Assess for signs of infection and hemorrhage
Question
A young woman has delivered a molar
pregnancy.You are giving her discharge
instructions when she asks you why she has
to have blood drawn every 1–2 weeks by
her primary caregiver. What is your best
response?
a. To detect malignancy, which is treatable
if caught early
b. To make sure you don’t develop
ovarian cancer
c. Most women with a molar pregnancy
get cancer
during the following year.
d. To detect any precursors to a
malignancy
Answer
a. To detect malignancy, which is treatable if
caught early
Rationale: Continued follow-up for 1 year is
extremely important. The woman returns to
the doctor’s office every 1–2 weeks to have
hCG levels drawn. This monitoring is
necessary to detect malignancy, which is
highly treatable if caught early.
Abruptio Placentae
Premature separation of a normally implanted
placenta
 Cause of abruptio placentae is unknown
 Associated risk factors:

◦ Conditions characterized by elevated blood pressure
 Preeclampsia and pre-existing chronic hypertension
◦ Advanced maternal age (greater than 35 years);
multiparity and history of cesarean delivery
◦ Trauma (e.g., motor vehicle collisions or domestic
violence), cigarette smoking, alcohol consumption,
cocaine use, and preterm premature rupture of the
membranes
Abruptio Placentae (cont.)

Classified in several ways

Maternal complications

Severity and type of fetal complications relate to
the degree of placental separation and maturity of
the fetus
◦ Bleeding is either concealed (hidden) or apparent
◦ Degree of abruption is either partial or complete
◦ Hemorrhagic shock, DIC, uterine rupture, renal failure,
and death
◦ Hypoxia, anemia, growth retardation, and even fetal death
may occur
Abruptio Placentae (cont.)

Clinical manifestations
◦ Preliminary diagnosis based on signs and
symptoms of the patient
◦ Pain has a sudden onset and is constant
◦ Ultrasound

Treatment
◦ Vaginal delivery is preferred to cesarean birth
for small abruptions
Abruptio Placentae (cont.)

Nursing care
◦ Requires careful monitoring
◦ Assess for signs of shock
◦ Continuous EFM is necessary
◦ Be prepared for an emergency cesarean birth
if ordered
◦ After delivery requires close monitoring for
postpartum hemorrhage
◦ Continue to observe for signs of DIC
Nursing Process for the Woman With a
Bleeding Disorder

Assessment
◦
◦
◦
◦


A thorough obstetric history
Acute bleeding episode
Obtain the fetal heart rate (FHR) and apply the EFM
Evaluate the woman’s pain
Selected nursing diagnosis
Outcome identification and planning
◦ Maintaining the safety of the pregnant woman and her
fetus is the primary goal
Nursing Process for the Woman With a
Bleeding Disorder (cont.)

Implementation
◦
◦
◦
◦
◦
◦

Maintaining placental perfusion and fluid volume
Avoiding fetal injury
Preventing Maternal injury
Preventing infection
Managing pain
Reducing anxiety
Evaluation: goals and expected outcomes
HYPERTENSIVE DISORDERS IN
PREGNANCY



Second leading cause of maternal morbidity and
mortality
Not only dangerous for the pregnant woman, but
also significantly increase the risk for the fetus
Four basic categories
◦
◦
◦
◦
1. Gestational hypertension
2. Preeclampsia/eclampsia
3. Chronic hypertension
4. Preeclampsia superimposed on chronic
hypertension
HYPERTENSIVE DISORDERS IN
PREGNANCY (cont.)

Gestational Hypertension
◦ Current term used to describe elevated blood
pressure (greater than or equal to 140/90 mmHg)
that develops for the first time during pregnancy
◦ Can be transient or chronic (if not resolved after
delivery)
◦ Concern for developing into preeclampsia-eclampsia
syndrome

Preeclampsia-Eclampsia
◦ Preeclampsia is a serious condition of pregnancy in
which the blood pressure rises to 140/90 mmHg or
higher accompanied by proteinuria
HYPERTENSIVE DISORDERS IN
PREGNANCY (cont.)

Preeclampsia-Eclampsia (cont.)
◦ May develop into eclampsia
 Presence of seizure activity or coma in a woman with
preeclampsia
◦ Exposure to trophoblastic tissue appears to be the
triggering factor
◦ No diagnostic tests available (regular prenatal checks)
◦ African-American women are more likely to develop
preeclampsia and are 2–3 times more likely to die of
preeclampsia or eclampsia than white women
HYPERTENSIVE DISORDERS IN
PREGNANCY (cont.)

Preeclampsia-Eclampsia (cont.)
◦ Primary problem underlying the development
of preeclampsia is generalized vasospasm
◦ Edema is significant if it is nondependent or if
it involves the face and hands
◦ Categorized as mild or severe
◦ Seizures are generalized tonic-clonic in nature
and only rarely progress to status epilepticus
HYPERTENSIVE DISORDERS IN
PREGNANCY (cont.)

HELLP syndrome

Treatment
◦ Severe form of preeclampsia-eclampsia
◦ Acronym for hemolysis, elevated liver enzymes, and
low platelets
◦ Greatly increases the mortality associated with
preeclampsia
◦ Primary goals of therapy are to deliver a healthy baby
and restore the woman to a healthy state
◦ Timing of delivery
HYPERTENSIVE DISORDERS IN
PREGNANCY (cont.)

Treatment (cont.)
◦ Preventing maternal seizures
◦ Magnesium sulfate
 Therapeutic level of magnesium sulfate is 4 to 8 mg/dL
 Monitor the reflexes and respiratory rate of the woman
receiving magnesium sulfate at frequent intervals
◦ Calcium gluconate is the antidote to magnesium
sulfate
HYPERTENSIVE DISORDERS IN
PREGNANCY (cont.)

Nursing Care
◦
◦
◦
◦
◦
Woman and fetus require frequent monitoring
Important to auscultate the lungs every 2 hours
Weigh the woman daily
Report headache, visual changes, and epigastric pain
Assess deep tendon reflexes and determine if clonus
is present
◦ Implement seizure precautions
◦ Woman should remain on bed rest

HYPERTENSIVE DISORDERS IN
PREGNANCY (cont.)
Nursing Care (cont.)
◦
◦
◦
◦
Adequate nutrition
Psychosocial needs
NSTs
Postpartum care
 If magnesium sulfate was not administered, the woman may
be transferred to a postpartum unit
 If used receives care in the labor and delivery unit or a highrisk antepartum unit for the first 24 to 48 hours after
delivery
HYPERTENSIVE DISORDERS IN
PREGNANCY (cont.)

Chronic Hypertension and
Preeclampsia Superimposed on
Chronic Hypertension
◦ Chronic hypertension is high blood pressure that
is present before the woman becomes pregnant
◦ Clinical Manifestations
 If the blood pressure remains elevated after the
pregnancy, the woman has chronic hypertension
 Superimposed preeclampsia when she experiences
proteinuria
HYPERTENSIVE DISORDERS IN
PREGNANCY (cont.)

Chronic Hypertension and
Preeclampsia Superimposed on
Chronic Hypertension
◦ Treatment and Nursing Care
 Prenatal visits occur at more frequent intervals
 Fetal surveillance is an area of intense focus
 Methyldopa (Aldomet) is the antihypertensive of
choice for maintenance therapy
Question
Tell whether the following statement is true
or false.
One of the first signs of magnesium sulfate
toxicity is an absence of reflexes.
Answer
True
Rationale: Magnesium toxicity begins when
serum magnesium levels approach 9 mg/dL.
First the reflexes disappear, then as the levels
increase, respiratory depression and cardiac
arrest can follow.
MULTIPLE GESTATION
Refers to a pregnancy in which the woman is
carrying more than one fetus
 Twins

◦ Twin-to-twin transfusion syndrome (TTTS)

Multifetal pregnancy is at risk
◦ Mother - hyperemesis gravidarum, pyelonephritis,
preterm labor, placenta previa, and preeclampsiaeclampsia
◦ Twins - conjoined, experience growth restriction, or
be born prematurely
MULTIPLE GESTATION (cont.)
During the postpartum period the woman is at
risk for postpartum hemorrhage
 Increases fetal nutrient demands
 Maternal anemia

MULTIPLE GESTATION (cont.)

Clinical Manifestations
◦ A uterus that is large for dates

Treatment
◦ Increased emphasis on the woman’s diet,
multivitamin and iron supplements, and rest
◦ Practitioner must choose (or recommend) a
mode of delivery
MULTIPLE GESTATION (cont.)

Nursing Care
◦ Assist the physician to perform assessments
◦ Instruct the woman regarding symptoms of
preterm labor
◦ Perform fetal movement counts daily after 32
weeks gestation
◦ Encourage the woman to get adequate rest
and a well-balanced diet.
BLOOD INCOMPATIBILITIES
Incompatibilities between the woman’s
blood and the fetus’ blood can cause
problems for the fetus.
 Two types of blood incompatibilities are

◦ Rh incompatibility
◦ ABO incompatibility

BLOOD INCOMPATIBILITIES (cont.)

Rh Incompatibility
◦ Rho(D) factor (antigen found on the surface
of the blood)
 Isoimmunization.
◦ Fetus develops hemolytic anemia
◦ Anti-D immunoglobulin (RhoGam)
◦ Clinical Manifestations
 Woman will have no symptoms at all
 Fetus may be severely affected
BLOOD INCOMPATIBILITIES (cont.)

Rh Incompatibility (cont.)
◦ Treatment
 RhoGam
◦ Nursing Care
 Criteria for giving RhoGAM are as follows:
 The woman must be Rho(D) negative.
 The woman must not have anti-D antibodies (i.e.,
must not be sensitized).
 The infant must be Rho(D) positive (the fetus’
blood type is not checked after an abortion).
 A direct Coombs’ test (a test for antibodies
performed on cord blood at delivery) must be
weakly reactive or negative.
BLOOD INCOMPATIBILITIES (cont.)

ABO Incompatibility
◦ Another cause of hemolytic disease of the
newborn
◦ Most frequently arises when the woman’s
blood type is O and the fetus’ blood type is A,
B, or AB
◦ Much less severe form of hemolytic disease
than does Rh incompatibility
◦ Fetus rarely requires exchange transfusion
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