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Pregnancy Related Complications 1 Hyperemesis Gravidarum A disorder of early pregnancy that is characterized by severe (excessive) nausea and vomiting Most often appears between 8 and 12 weeks gestation – resolves by 16 weeks Associated with high levels of human chorionic gonadotropin (hCG) or estrogen Increases with multiple pregnancies, molar pregnancies and stress 2 Hyperemesis Gravidarum Not “morning sickness” More severe and results in dehydration, weight loss and electrolyte imbalances Emergency Tx is correct fluid, electrolyte and acid-base imbalances Hospitalization is needed with IV fluid administration with dextrose added to prevent protein breakdown and antiemetics 3 Hyperemesis Gravidarum Pt. is kept NPO for the first 24 hours Ginger, and herbal remedy can significantly reduce nausea Pyridoxine (makes up vitamin B6) supplementation may be ordered because a deficiency in the B vitamin is associated with hyperemesis Encourage small frequent meals to decrease nausea 4 Ectopic Pregnancy Ectopic refers to an object that is located away from the expected site or position An ectopic pregnancy occurs outside of the uterus Adhesions, scarring and narrowing of the tubal lumen may block the zygote’s progress to the uterus Symptoms appear at 4 to 8 weeks after LMP 5 Ectopic Pregnancy The most common symptoms are pelvic pain and/or vaginal spotting If the tube ruptures, hemorrhage occurs into the abdominal cavity, which can lead to hypovolemic shock S/S of shock – rapid, thready pulse; rising respiratory rate; shallow, irregular respirations; falling BP; decreased/absent urine output; pale, cold, clammy skin; faintness; thirst 6 Ectopic Pregnancy Diagnosis not apparent A serum pregnancy test is done to detect the presence of hCG. Transvaginal ultrasound is used to locate gestational sac – may be diagnostic Surgery may be needed to remove the ectopic pregnancy Methotrexate (chemo drug) targets pregnancy for destruction, may avoid surgery 7 Early Pregnancy Loss Is the most common complication of pregnancy Occurs in approximately 75% of women who are trying to conceive Spontaneous abortion (miscarriage) – loss before 20 weeks gestation, early before 12 weeks, late between 12 and 20 weeks Most common cause is fetal chromosomal defects 8 Early Pregnancy Loss Treatment is conservative “wait and see” If pregnancy is lost, a D&C may be needed to clear uterus of products of conception, and may need pitocin or Methergine to prevent excessive bleeding If Rh negative, needs RhoGam Emotional response varies Needs ongoing grief support after discharge – make referrals at discharge 9 Incompetent Cervix Painless dilation occurs with bulging of fetal membranes and parts through the external os Usually results in the loss of the pregnancy Tx is placing a purse string type suture in the cervix to keep it from dilating = cerclage, done between 14 and 26 weeks Suture removed when term or in labor 10 Hydatidiform Mole Molar pregnancy is characterized by a benign growth of placental tissue Molar pregnancies have some features of a malignancy in that trophoblastic tissue proliferates out of control 20% of women with complete molar pregnancies develop choriocarcinoma malignancy of the uterine lining within 6 months to 1 year after a molar pregnancy 11 Hydatidiform Mole Continuous follow-up for 1 year is extremely important Return every 1 to 2 weeks to have hCG levels drawn Follow-up to detect choriocarcinoma which is highly treatable when caught early 12 Placenta Previa When the placenta is implanted close to or over the cervical os May be caused by scarring which causes the embryo to implant in a more favorable area Classified to the degree of which it covers the cervix Marginal, partial, or complete 13 Placenta Previa Strong indications of placenta previa is painless, bright red bleeding that begin with no warning, may be light or severe Presentation with painless bleeding = a digital exam is not done until placenta previa is ruled out – fingers could penetrate the placental tissue and cause massive hemorrhage 14 Placenta Previa Most require cesarean delivery Marginal placenta previas may deliver vaginally May require an emergency cesarean delivery if bleeding is excessive and the fetus and mother are compromised 15 Abruptio Placentae Placental abruption is the premature separation of a normally implanted placenta Risk factors – HTN, preeclampsia, advanced maternal age, multiparity, trauma, smoking, use of cocaine, premature rupture of membranes Bleeding is concealed or apparent 16 Abruptio Placentae Massive hemorrhage may occur Maternal complications include DIC, hemorrhagic shock, uterine rupture, renal failure and death Fetal complications include hypoxia, anemia, growth retardation and death Classic signs are pain, dark red vaginal bleeding, tender/rigid abdomen, blood y amniotic fluid 17 Abruptio Placentae Requires careful monitoring Large bore IV and IV fluid infusion Blood products immediately available Emergency cesarean delivery Strict I&O after delivery DIC may still develop after delivery 18 Gestational Hypertension Formerly called pregnancy induced hypertension Indicated when BP is greater than or equal to 140/90, develops for the first time in pregnancy, and is without the presence of protein in the urine May develop in to more severe preeclampsia-eclampsia 19 Preeclampsia-Eclampsia A serious condition of pregnancy Diagnosed when BP rises to 140/90 or higher and in accompanied by proteinuria Develops after 20 weeks The underlying cause of the disorder is unknown Risk factors – African-American, nulliparity, systemic lupus erythematosus, renal disease, diabetes 20 Preeclampsia-Eclampsia Underlying development os generalized vasospasm, which affects every organ of the body Vasospasm leads to endothelial damage which causes abnormal clotting CNS irritability results in hyperactive deep tendon reflexes and clonus May include HA, visual disturbances, elevated liver enzymes, low platelets 21 Preeclampsia-Eclampsia Advances to full blown eclampsia when there is seizure activity or coma Cerebral hemorrhage and stroke are complications of seizures in eclampsia HELLP syndrome is a severe form of preeclampsia-eclampsia (hemolysis, elevated liver enzymes and low platelets 22 Preeclampsia-Eclampsia Tx – includes activity restriction (bedrest, visitor restriction, stimulation restriction), IV magnesium sulfate infusion Magnesium infusion requires careful monitoring of VS, I&O, maternal ling sounds, FHR, and deep tendon reflexes Therapeutic magnesium level is 4 to 8 Calcium gluconate is magnesium sulfate antidote if toxicity occurs 23 Blood Incompatibilities Rh incompatibility Rh factor is an protein that is found on the surface of blood cells If the factor is present = Rh positive If the factor is missing = Rh negative Isoimmunization is when an Rh negative women’s body has produced antibodies to the Rh factor and she is sensitized to Rh positive blood 24 Blood incompatibilities If a pregnant Rh negative women who has been sensitized and produced antibodies to Rh positive blood, and she then carries a fetus who is Rh positive, the antibodies cross the placenta and attack the fetus’ blood cells, resulting in hemolytic anemia This hemolytic anemia often requires exchange transfusions in utero or after birth 25 Blood Incompatibilities Now, Rh negative women are given RhoGam at 28 weeks and 72 hours after the delivery of an Rh positive baby It is critical for a woman who is Rh negative to receive RhoGam after childbirth, miscarriage or abortion, ectopic pregnancy, or any invasive procedures If the baby is also Rh negative, no RhoGam is needed – only when they are Rh positive 26 Blood Incompatibilities ABO Incompatibility is another hemolytic disease of the newborn Arises when the woman’s blood type is O and the fetus is A, B, or AB O has naturally occurring antibodies to the other blood types, but these antibodies are large and don’t cross the placenta Only occurs if fetal blood leaks into maternal circulation 27 Blood Incompatibilities The woman’s immune system then produces antibodies to the fetal blood that can cross the placenta and work to destroy the fetal blood This incompatibility is much less severe The neonate may, but rarely needs an exchange transfusion Most likely will have problems with jaundice 28 29