Download Additional Complications of Pregnancy

MENNONITE COLLEGE OF NURSING
at Illinois State University
Maternal Infant Nursing - 316
ADDITIONALCOMPLICATIONS OF PREGNANCY
Cardiac Disease (p. 363-366 Davidson et al 10th ed.)
The usual causes of heart disease associated with pregnancy are congenital heart disease and rheumatic fever.
Although heart disease remains the major non-obstetric cause of maternal death, the majority of expectant
women are able to complete a pregnancy successfully. The normal heart has adequate cardiac reserve to adjust
to the increased demands of pregnancy with little difficulty. Blood volume normally increases 40% by the 30th
week of gestation. The client with cardiac disease has decreased cardiac reserve because her heart already has
a higher workload. The heart compensates by ventricular dilatation, ventricular hypertrophy and tachycardia.
Symptoms of decompensation are: cough, dyspnea, edema, heart murmurs, palpitations and rales. Fetal risks
depend upon the severity of the maternal condition. Cardiac failure may lead to perinatal mortality. Severe heart
disease may lead to abortion or retardation of intrauterine growth. Heart disease is classified into four categories
(Class I to Class IV) based on the limitation of physical activities required and the severity of the symptoms
exhibited. There is an increased incidence of congestive heart failure in pregnant women with heart disease.
Peripartum Cardiomyopathy usually occurs at the end of the pregnancy or the 1st 5 months pp. Sx are CHF and
may have high mortality.
Anemia - Iron Deficiency Anemia (p.350- Davidson et al 10th ed.)
Anemias in pregnancy may be due specifically to the pregnancy, or they may exist coincidentally with the
pregnancy. Iron deficiency anemia is the most common medical complication of pregnancy and 77% of anemias
in pregnancy are the iron deficiency type. The woman with iron deficiency anemia is more susceptible to infection,
tires easily, has an increased chance of postpartal hemorrhage, and tolerates poorly even minimal blood loss
during delivery. If the anemia is severe (Hbg less than 6 g/dl), cardiac failure may occur. With severe anemia the
incidence of stillbirth and SGA neonates is increased. Abortion and prematurity rates are increased and the
neonate may be dysmature. Fetal iron stores are not significantly impaired. The fetus may be hypoxic during labor
due to impaired uteroplacental oxygenation. Iron supplements are essential during pregnancy because dietary
sources alone cannot meet the extra gestational requirements. Iron supplements of 30mg/day is recommended,
then  to 60-120mg/day, but this may also increase the woman’s nausea as well as constipation.
Hyperemesis Gravidarum (p.379-380 Davidson et al 10th ed.))
Hyperemesis gravidarum has been defined as a condition in which intractable vomiting and disturbed nutrition
lead to an alteration of electrolyte balance, loss of weight (5% or more), ketosis and acetonuria, leading ultimately
to neurological damage, retinal hemorrhage, and renal disease. The cause is unknown, but probably related to
trophoblastic activity of the gonadotropin production (^ HCG levels) and is stimulated or exaggerated by
physiologic factors. Nursing care should be supportive and directed at maintaining a relaxed, quiet environment.
Signs and symptoms include: metabolic alkalosis initially then moving to acidosis, hypotension, decreased urine
output & increased specific gravity, decreased weight, and increased Hct and BUN. Medical tx may include
NPO, IV fluids with vitamin replacement, especially thiamine and pyroxidine (vitamin B6 ) and electrolyte
replacement, especially Potassium Chloride, and phenothiazines or antihistamines to control nausea. Herbal teas
like ginger, spearmint, etc. may be helpful, or acupuncture or hypnosis. (IV Phenergan has been effective).
Central Lines for TPN may also be indicated if vomiting cannot be controlled and fetus is in jeopardy.
Spontaneous Abortion (p.373-376 Davidson et al 10th ed.) )
During the first and second trimesters of pregnancy, the major cause of bleeding is abortion. Abortions may be
either spontaneous or induced. Miscarriage is a lay term for abortion. Spontaneous abortions are further classified
into: threatened (cervix closed, may be stopped), imminent (cervix open, certain to occur), incomplete (all or
part of conceptus retained, bleeding continues), missed (fetus dies in utero, but not expelled until months later),
and Recurrent Pregnancy Loss (formerly habitual) (three or more consecutive abortions). 75% of all
spontaneous abortions occur during the first 2 to 3 months of pregnancy. Treatment is restriction of activities, bed
rest and perhaps sedation. If bleeding persists, hospitalization with IV's and blood transfusions may be required.
Dilatation and curettage may be required to remove the remainder of the products of conception. Nursing care
focuses on Fear, Pain, and possible Fluid Volume Deficit.
Ectopic Pregnancy (pp. 376-378 Davidson et al 10th ed.))
Ectopic pregnancy is an implantation of the blastocyst in a site other than the endometrial lining of the uterine
cavity. The most common type is a tubal pregnancy in which the implantation occurs in the fallopian tube. Signs
and symptoms include: pelvic pain - often described as "knife-like", vaginal bleeding, fainting or shock (rapid
thready pulse, tachypnea, decreased blood pressure). Hcg levels do not rise at the same rate as normal
pregnancy. Ultrasound can confirm the ectopic pregnancy. Surgical intervention is required with IV fluids and
blood transfusions as needed. Usually the tube is removed although in some instances the pregnancy is removed
and the tube is repaired. Emotional support is essential during this very difficult time.
Gestational Trophoblastic Disease -GTD (Hydatidiform Mole) (p.378-379 Davidson et al 10th ed.) )
An abnormal pregnancy resulting in a mass of cysts resembling a bunch of grapes. These cysts resemble fluid
filled vesicles. Usually no embryo is present. It is a pathologic proliferation of trophoblastic cells. The cause is
unknown. Initially the pregnancy appears normal but near the end of the first trimester vaginal bleeding occurs.
Uterine size usually is larger than expected for the duration of the pregnancy. Because of unusually high levels of
HCG, nausea and vomiting may be severe. Signs and symptoms include: abnormally high levels of HCG, uterine
enlargement > than expected for gestational age, no fetal heart tones, bleeding may be present in 2nd trimester
(dark in color). Transvaginal ultrasound confirms diagnosis. Treatment is by emptying the uterine cavity and
curettage for any remaining fragments. these patients are instructed not to become pregnant for at least one year.
Choriocarcinoma occurs in 20% of women following the evacuation of the molar pregnancy, and thus
necessitates close follow-up of these patients. The patient's urine is tested once a month for the next year to
check for presence of HCG. Pregnancy HCG rise could mask an HCG-associated with a malignant GTD.
Emotional support is essential.
Cervical Insufficiency (formerly Incompetent Cervix) (p. 586-587 Davidson et al 10th ed.)
Cervical insufficiency refers to a cervix that is abnormally prone to dilate before termination of the normal
gestational period, resulting in premature expulsion of the fetus often times as 2nd trimester spontaneous
abortion. It may be attributable to previous cervical trauma. Medical tx includes serial cervical ulstrasounds to
assess for ‘funneling’ of the cx, bed rest, progesterone supplementation, antibiotics, and anti-inflammatory drugs.
It is managed surgically by reinforcing the weak cervix at the level of the internal os with suture material. This
procedure is called cerclage. Once the suture is in place the delivery may be by cesarean section or the suture
may be cut and vaginal delivery permitted. Two types of suture techniques are used: a) Shirodkar, and b)
McDonald. Some spotting may be noted after the suturing procedure is performed.
Substance Abuse: Drug Addiction (pp. 353-357 Davidson et al 10th ed.) See p. 354 for helpful Tables.
Indiscriminate drug use during pregnancy may adversely affect the normal growth and development of the fetus.
Many drugs cross the placenta and adversely retard growth at crucial stages of organogenesis especially during
the first trimester. Drugs ingested at other times during the pregnancy may negatively influence the well-being of
the fetus as well as produce critical problems in the neonate. Commonly misused drugs are: alcohol,
amphetamines, barbiturates, hallucinogens and heroin and other narcotics. The effects of the drugs on the
newborn are severe and include withdrawal behaviors (eg. high-pitched cry, fetal position fully flexed), congenital
malformations and prematurity. Neonatal Abstinence Syndrome is a complication of excessive narcotic use in
mom.
Substance Abuse: Alcoholism (p. 353-355, Davidson et al, 10th ed.)
Alcohol is a drug, which has increased dramatically in the incidence of abuse. Chronic alcohol abuse can cause
malnutrition, especially folic acid and thiamine deficiencies, bone marrow suppression, increased incidence of
infections, and liver disease. Fetal alcohol syndrome has become well documented. Fetal alcohol syndrome is the
leading cause of stillbirth. It is recommended that all pregnant women abstain from alcohol consumption. Signs
and symptoms include characteristic facial abnormalities-- short palpebral fissures, midfacial and maxillary
hypoplasia, small lower jaw, hypoplastic upper lip, and diminished or absent philtrum(groove on upper lip); cardiac
defects-- primarily septal and valvular defects; limb and joint abnormalities, microcephaly, cleft palate, fine motor
dysfunction, and mental deficiency from borderline to severe.