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Chapter 13
Health Problems Complicating
Pregnancy
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
1
Complications of Pregnancy
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
2
Objectives





Define key terms listed.
Discuss three causes of spontaneous
abortion.
Describe ectopic pregnancy.
Describe placenta previa and state the
characteristic symptom.
Explain five nursing measures for the care of
a woman who is hemorrhaging.
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3
Objectives (cont.)




Compare two types of abruptio placentae.
Review the cause of coagulation defects in
pregnancy.
List five causes of high-risk pregnancies and
three leading causes of maternal death.
Recognize four factors that increase the risk
for gestational hypertension.
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4
Effects of a High-Risk Pregnancy
on the Family

Disruption of usual roles




May require strict bed rest
May have to find alternate child care
Financial difficulties
Delayed attachment to infant
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5
Bleeding Disorders


Abnormal in pregnancy and should be
investigated
Maternal blood loss decreases oxygencarrying capacity to fetus
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6
Causes of Bleeding
in Early Pregnancy





Spontaneous abortion
Cervical polyps
Uterine fibroids
Ectopic pregnancy
Hydatidiform mole
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7
Abortion



Intentional or unintentional ending of a
pregnancy before 20 weeks gestation
Miscarriage is a lay term for spontaneous
abortion
Artificial or mechanical means for therapeutic
or elective reasons can also be performed
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8
Classification and Management
of Abortions

Causes of spontaneous abortion





Genetic defects
Defective ovum or sperm
Defective implantation
Uterine fibroids
Maternal factors
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9
Maternal Factors


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Chronic conditions
Acute infections
Nutritional deficiencies
Abnormalities of maternal reproductive
organs
Endocrine deficiencies
Blood group dyscrasias (ABO incompatibility)
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10
Nursing Interventions

Monitor vital signs


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
Observe for signs of shock
Weigh perineal pads
Prepare for IV therapy
Assess fetal heart rate
Provide supplemental oxygen
Obtain history and laboratory results
Provide emotional support for woman and
partner
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11
Incompetent Cervix


Cervix dilates without perceivable
contractions
Internal os dilates


Incapable of supporting increasing weight and
pressure of growing fetus
Cervix may need to be reinforced through a
cerclage procedure
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12
Ectopic Pregnancy

Abnormal
implantation of
fertilized ovum
outside uterine
cavity


Most common site
is fallopian tube
Tubal rupture can
cause hemorrhage
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13
Assessment of Tubal Pregnancy


Transvaginal ultrasound
Serum hormone levels
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Progesterone
β-hCG (beta-human chorionic gonadotropin)
Shoulder pain
Signs of shock out of proportion with visible
blood loss
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14
Management of Tubal Pregnancy

Preserve fallopian for chance of future
pregnancies


Methotrexate


Depends on status of tube: ruptured or unruptured
Interferes with cell reproduction
Surgical interventions

salpingectomy
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15
Gestational Trophoblastic
Disease

Hydatidiform mole

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
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Trophoblastic tissue proliferates
Chorionic villi of placenta swell with fluid; can look
like grapes
Invasive mole
Choriocarcinoma
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16
Gestational Trophoblastic
Disease (cont.)

Two types

Complete
• Chromosome banding and enzyme analysis show all
genetic material is paternally derived
• No inner cell mass develops
• No fetal vascularization

Partial
• Genetic material maintained
• Fetus abnormal, usually aborts
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17
Assessment of Molar Pregnancy


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Uterus grows more rapidly than in a normal
pregnancy
Brown vaginal bleeding (looks like prune
juice)
Hyperemesis gravidarum
If gestational hypertension occurs before 24
weeks gestation, strongly suggests molar
pregnancy
Serial β-hCG levels and ultrasound
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18
Management of Molar Pregnancy



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Evacuation by suction aspiration
Follow-up is essential due to increased risk of
developing choriocarcinoma
Serum hCG levels monitored for 1 year until
serum titers return to normal
Should delay pregnancy until hCG has
returned to normal
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19
Bleeding in Late Pregnancy


May be from increased vascularization of
cervix, cervical polyps, or cervicitis
If in second or third trimester, may be caused
by

Placenta previa
 Abruptio placentae
 Disseminated intravascular coagulation (DIC)
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20
Placenta Previa


Placenta abnormally implants near or over
cervical os
Increased risk of occurrence if



Defective vascularity of decidua
Previous infection in upper uterine segment
Uterine scarring
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21
Placenta Previa (cont.)
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Assessment and Management

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Ultrasound can detect presence
Suspect if onset of painless bleeding occurs
after 24 weeks gestation
Bleeding occurs most often in third trimester
as cervix prepares for delivery
Monitor vital signs and amount of blood loss,
including fetal heart rate
Do not perform vaginal examination
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23
Home Management

If following criteria are met, woman can be
sent home

Maintain strict bed rest and no coitus
 Must have around-the-clock transportation and
communication available
 Compliant with oral tocolytic therapy
 Hematocrit above 30%
 Can be followed closely (e.g., ultrasound,
nonstress test, biophysical profiles)
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Potential Complications




Hemorrhage for woman
Hypoxia or death of fetus
Hypovolemic shock and death of mother
Postpartum infection
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Abruptio Placentae

Premature separation of placenta




Bleeding is painful
Risks include




Partial or total detachment
Occurs after 20 weeks gestation
Maternal hypertension
Prior abruption
High parity
Degree of compromise depends on extent of
separation and blood loss
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Types of Abruptio Placentae
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Complications



Inability of uterus to contract
Trapping of blood may release
thromboplastin into maternal circulation
Can lead to DIC
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Assessment and Management
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Dark red vaginal bleeding
Uterine rigidity
Severe abdominal pain
Maternal hypovolemia
Signs of fetal distress
Excessive bleeding
Coagulation profile
Prepare for cesarean delivery if hemorrhage
severe or fetal distress evident
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Disseminated Intravascular
Coagulation (DIC)
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
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Blood cannot clot
Overstimulation of normal coagulation
process
Massive, rapid fibrin formation
Depleted platelets and clotting factors
Does not occur as primary disorder but
secondary to another complication
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30
Assessment and Management





Monitor coagulation studies closely
Correct underlying cause
Terminate pregnancy
Administer blood products
Do not give heparin
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31
Blood Incompatibility
(Isoimmunization)



Placenta can allow maternal and fetal blood
to mix due to small “leaks”
If maternal and fetal blood compatible, no
issues
If not compatible, mother’s body produces
antibodies to destroy foreign fetal RBCs
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32
Rh Incompatibility



Rh-positive blood type is dominant trait
If father is Rh positive and mother is Rh
negative, good chance fetus will be Rh
positive
If leakage occurs, mother starts making
antibodies to destroy the Rh-positive
erythrocytes, which also destroy fetal RBCs
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33
ABO Incompatibility



Woman has group O blood
Fetus has group A, B, or AB blood
Anti-A and anti-B antibodies



Few cross placenta, so treatment not required
during pregnancy
First pregnancy most often affected
Newborn may develop jaundice within 24
hours of birth

Provide phototherapy
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34
Audience Response System
Question 1
In the presence of Rh incompatibility, an
amniocentesis can be done to determine if what is
present?
A. Fetal hemolysis
B. A congenital anomaly
C. Alpha-fetoprotein levels
D. Genetic disorders
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35
Cardiovascular and Endocrine
Complications
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Objectives



Discuss three signs that a pregnant
hypertensive woman should report
immediately to her physician.
Identify the antihypertensive drug most
commonly given to women with gestational
hypertension and its antidote.
Compare the effects of the physiologic
changes in pregnancy related to
thromboembolic disease.
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Objectives (cont.)




Discuss heart disease in pregnancy.
Explain hyperemesis gravidarum.
Explain three ways diabetes mellitus affects
pregnancy.
Review four aspects of self-care for the
diabetic woman.
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38
Cardiovascular Disorders
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39
Gestational Hypertension

Types

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Gestational hypertension
Preeclampsia
Eclampsia
Chronic hypertension
Preeclampsia with superimposed chronic
hypertension
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40
Classification and Risk Factors



Preeclampsia—renal involvement leads to
proteinuria
Eclampsia—CNS involvement leads to
seizures and chronic HTN with superimposed
eclampsia
HELLP syndrome—disease is dominated by
hematologic and hepatic clinical
manifestations
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41
Pathophysiology of Preeclampsia

Thought to start with placental implantation




Loss of resistance to angiotensin II
Prostacyclin (vasodilator) decreases
Thromboxane (vasoconstrictor) increases


May not be evident until 20 weeks gestation
Leads to increased vasospasms
Condition reverses once placenta is delivered
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42
Effects on the Mother and Fetus

Mother






DIC
Immunologic response
may trigger
preeclampsia
HELLP
Nausea, vomiting,
malaise
Later: hematuria,
jaundice, generalized
abdominal pain
Fetus





Uteroplacental
perfusion
Increased risk of
abruptio placentae
Intrauterine growth
restriction
Fetal distress from
hypoxia
Preterm birth
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43
Assessment and Management

If occurs before 34 weeks gestation, screen for
presence of antiphospholipid antibodies


Closely monitor blood pressure, proteinuria,
renal and hepatic function



If present, increases risk of recurrent severe
gestational hypertension in future pregnancies
If severe, may have to terminate pregnancy/deliver
Should not go beyond 40 weeks gestation due to
placental insufficiency
Magnesium sulfate infusion

Toxicity treated with calcium gluconate
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44
Clinical Manifestations of
Gestational Hypertension (GH)

Expedient delivery if




Maternal oliguria
Renal failure
HELLP syndrome
Magnesium sulfate therapy should be
stopped if



Loss of deep tendon reflexes (DTRs)
Respiratory rate < 12/min
Decreased urine output of < 30 mL/hr
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45
Prenatal Nursing
Assessment and Management





If mother received magnesium sulfate, can
cause respiratory depression in newborn
Evaluate deep tendon reflexes
A mild form of preeclampsia may rapidly
progress to a severe form, including seizures
Management depends on symptoms,
aggressiveness of physician, and
understanding and compliance of the patient
Calcium gluconate is used to treat
magnesium sulfate toxicity
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46
Education, Self-Care, Home
Management

Important to know baseline blood pressure



Increases in systolic by 30 mm Hg and diastolic by
15 mm Hg above baseline places woman in highrisk category
Careful teaching, guidance, and compliance
are critical to the woman, the developing
fetus, and family
If on home management, woman must have
a means of communication and transportation
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47
Hospitalization and Management
of Preeclampsia and Eclampsia


Quiet room
Left side-lying




To optimize placental blood flow
Frequent monitoring of blood pressure
Urine evaluated every 4 hours for protein and
specific gravity
Accurate I&O
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48
Emergency Care

Equipment to have
readily available

Oral airway
 Ambu bag
 Oxygen
 Suction equipment
 Ophthalmoscope
 Medications
 Pulse oximetry
 Electrocardiography

Symptoms that may
precede seizures

Rise in blood
pressure
 Epigastric pain
 Severe headache
 Apprehension
 Twitching
 Hyperirritability of
muscles
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49
Chronic Hypertensive Disease



Blood pressure of 140/90 mm Hg or higher
before pregnancy or before 20 weeks
gestation
Goal is to prevent preeclampsia, ensure
normal fetal growth and development
Antihypertensive may be prescribed for blood
pressure over 160/100 mm Hg
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50
Chronic Hypertension
with Superimposed Preeclampsia

First 48 hours after delivery require careful
monitoring



After 48 hours, assessments may be decreased
Monitor uterine tones and fundus to prevent
postpartum bleeding
Baseline blood pressure usually returns
within 2 weeks
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51
Thromboembolic Disease



Pregnancy increases risk of superficial
thrombophlebitis, deep vein thrombosis, and
pulmonary embolism (PE)
PE leading cause of maternal death
Risk factors






Venous stasis
Normal changes in coagulability and fibrinolysis during
pregnancy
Use of oral contraceptives before pregnancy
Sitting for extended periods
Over 30
Obese
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52
Assessment

May complain of sudden pain with swelling in
affected extremity




May be warmth and redness at site
On passive dorsiflexion, pain in calf of leg
(Homans’ sign)
Diagnosed via Doppler scanning, MRI
If develops a PE, may have dyspnea, chest
pain, hemoptysis, and tachycardia
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53
Heart Disease:
Effects During Pregnancy

Pregnancy results in increased cardiac
output, heart rate, blood volume, and stroke
volume


Some drugs to help treat are contraindicated in
pregnancy
During labor, woman requires careful
monitoring due to blood shifts of 300 to 500
mL

This leads to increased cardiac output by 15% to
20%; could trigger congestive heart failure
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54
Assessment and Management




May complain of shortness of breath with
activity, weight gain, edema; may hear
cardiac murmur
Contraindications to planned pregnancy
include pulmonary hypertension, aortic
coarctation, history of myocardial infarction,
and uncorrected tetralogy of Fallot
Goal is to minimize stress on heart
Symptoms of cardiac decompensation can
occur slowly during pregnancy
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55
Anemia


Reduced ability of blood to carry oxygen to
cells
In pregnancy, defined by hemoglobin (Hgb)
levels less than 10 g/dL and hematocrit (Hct)
levels below 30%

More susceptible to infection, increased risk of
complications during pregnancy
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56
Anemia (cont.)



Iron deficiency anemia—serum iron of less
than 60 mg/dL with less than 16% transferrin
saturation
Folic acid deficiency—may result from
inadequate intake, poor absorption or drug
interactions; seen in women with vitamin B12
deficiency
Thalassemia—genetic defect; abnormal Hgb;
results in hemolysis and anemia
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57
Sickle Cell Anemia


Inherited disorder; presence of abnormal Hgb
that causes sickling of RBCs
During labor

Oxygen supplementation to mother
 Administration of IV fluids
 Fetal monitoring
 Maternal Hgb monitoring
 Administration of prophylactic antibiotics if
operative delivery is necessary or urinary tract
infection is present
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58
GI Disorders:
Hyperemesis Gravidarum



Nausea and vomiting that can lead to severe
dehydration, electrolyte imbalance,
starvation, and excessive weight loss before
the 20th week of gestation
Occurs most often with first pregnancy,
multifetal pregnancy, hydatidiform mole, and
sometimes with psychiatric disorders
Fetus at risk for intrauterine growth restriction
(IUGR)
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Assessment and Management








Any specific “triggers” for nausea or vomiting?
Correct fluid and electrolyte imbalance
Parenteral nutrition may be indicated
Record I&O, including weight
Ketonuria suggests fat stores are being used to
nourish fetus and meet woman’s energy needs
Low-fat frequent feedings
Positioning and other techniques to reduce
nausea and vomiting
Drugs such as pyridoxine, meclizine
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Endocrine Disorders:
Diabetes Mellitus (DM)




Affects carbohydrate metabolism
Hyperglycemia; inadequate production or
ineffective use of insulin
Pregestational DM: type 1 or 2
Gestational DM: glucose intolerance first
recognized during pregnancy; usually
resolves after delivery
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Effect of Pregnancy on Diabetes





Increased need for glucose creates a
resistance to insulin
Maternal insulin does not cross placenta
By 10th week of gestation, fetus is obligated
to secrete own insulin to use glucose
obtained from mother
Hormone concentration higher in second and
third trimesters, which increases insulin
resistance
Allows more maternal glucose to be available
to fetus; leads to macrosomia
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62
Pregestational Diabetes Mellitus




Known diabetic before pregnancy
Once pregnant, glycemic control affected
Oral hypoglycemics cannot be taken during
pregnancy
First trimester maternal blood glucose usually
reduced; need less insulin
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63
Risk and Complications




First trimester: hyperglycemia can cause fetal
anomalies
Second and third trimesters: glucose crosses
placenta, increases fetal secretion of insulin
Can lead to macrosomia and impaired fetal
lung function
At birth, newborn at risk for hypoglycemia
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64
Preconceptional Counseling,
Assessment, and Management






Woman should normalize blood glucose
Some medications may need to be changed
Close monitoring throughout pregnancy may
be needed for both mother and fetus
Management depends on woman’s
adherence to treatment plan
Diet: 30 to 35 kcal/kg/day in first trimester, 35
kcal/kg/day in second and third trimesters
Exercise
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65
Gestational Diabetes Mellitus




Carbohydrate intolerance of variable severity,
with first recognition during pregnancy
May have only impaired tolerance to glucose
or classic signs of DM (polyuria, polyphagia,
polydipsia)
Risk of congenital malformation and
spontaneous abortion is less with GDM
Diet often controls blood sugars
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Screening During Pregnancy

Glucose challenge test





Usually between 24 and 28 weeks gestation
Renal threshold lower in pregnancy, causes
glucose to spill into urine
Glycosuria is not considered diagnostic for DM but
does indicate need for further evaluation
Glucose monitoring daily and with a blood
test called HbA1c
Fetal surveillance: biophysical profile, alphafetoprotein, kick count
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Audience Response System
Question 2
At what approximate week of development is
the fetus obligated to secrete its own insulin?
A.
B.
C.
D.
20 weeks
30 weeks
10 weeks
40 weeks
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68
Effects of Toxins and Pregnancy
Loss
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Objectives





Describe rubella and its consequences in
pregnancy.
Identify the changes that occur in pregnancy
that predispose the woman to urinary tract
infections.
Discuss the cause and prevention of
toxoplasmosis.
Describe three self-care measures for a
pregnant woman with a urinary tract infection.
Describe how the use of nicotine, alcohol,
and recreational drugs can affect the fetus.
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Objectives (cont.)





Discuss the effects of substance abuse on
women’s health.
Relate the impact of pregnancy on the woman’s
response to bioterrorist agent exposure and
treatment protocols.
Recognize the effects of drugs used to treat
bioterrorist infections on the developing fetus.
Identify signs of fetal demise.
Recognize stages of grieving and nursing
interventions that can assist parents in dealing
with fetal loss.
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71
Infections

TORCH


Urinary tract infection (UTI)





Can be used to help identify congenital risks
Can have asymptomatic infection, cystitis, or
pyelonephritis
Symptoms vary
Bacteriuria
Group B streptococci
Bacterial vaginosis
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72
Substance Abuse



Use of illegal drugs, tobacco, and alcohol can
cause serious complications in the
developing fetus
IV and intranasal administration crosses
placenta more often than other methods
Prenatal care may not occur until late into
pregnancy, if at all
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73
Accidents During Pregnancy




Motor vehicle accidents most common cause
of trauma during pregnancy
Blunt trauma can lead to abruptio placentae
and fetal demise
Blunt trauma or penetrating wounds can
cause shock, preterm labor, spontaneous
abortion
ABCs (airway, breathing, circulation)
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Bioterrorism Exposure
and Pregnancy
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Metabolism and elimination of drugs altered
in pregnancy
Protecting life of mother is priority
Vaccines may be needed regardless of
pregnancy status
Pregnancy increases susceptibility to
infections
Countermeasures include antibiotics,
antivirals, antitoxins
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
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Loss of Expected Birth
Experience
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Allow parents to remain together in privacy
Accept behaviors related to grieving
Develop care plan to provide support to
family
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Offer memento and opportunity to hold infant, if
parents choose
 Prepare parents for infant’s appearance
 Discuss wishes concerning religious and cultural
rituals
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
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Pregnancy Loss:
Grief and Bereavement
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Perinatal loss after 20 weeks gestation in
United States is 6.8 per 1000 total births
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50% occur before 28 weeks
Causes: physiologic, maladaptation, birth defects,
teratogen exposure
Loss includes abortion, fetal or neonatal death,
SIDS, and fetal anomalies
Denial, anger, bargaining, depression,
acceptance are steps in grieving process
Nurse plays important role
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
77
Audience Response System
Question 3
In preeclampsia, the most likely cause of
serious end-organ effects or alterations in
function during pregnancy is:
A. Hemorrhage
B. Medications
C. Vasospasms
D. Hypervolemia
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Review Key Points
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