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Davis Advantage for Maternal-Child Nursing Care, Third Edition.

Chapter 6

Caring for the Woman Experiencing Complications During Pregnancy

Ectopic Pregnancy

Fertilized egg implants outside the uterine cavity

Unilateral stabbing pain in lower quadrant

Ruptured ectopic pregnancy can lead to extreme blood loss, shock, and death

Risk factors for experiencing an ectopic pregnancy

Diagnostic Tools

Transvaginal ultrasonography

Used to confirm intrauterine or tubal pregnancy

If ultrasound is inconclusive, serial BhCG will be performed

Pelvic examination to confirm mass

Lab Values

Beta-human chorionic gonadotropin

Type

Needed in cases of rupture, ectopic, or for operative surgery

Determine need to Rhogam

Complete blood count

White blood count

Management

Salpingectomy

Removal of fallopian tube

Salpingostomy

Incision into the fallopian tube to remove the pregnancy

Methotrexate

Chemotherapeutic drug and folic acid inhibitor that stops all rapid cell production

Gestational Trophoblastic Disease

Hydatiform mole or molar pregnancy

Abnormal placental development that results in the production of fluid-filled grapelike clusters

Proliferation of trophoblastic tissue

Associated with loss of pregnancy

In rare cases, associated with the development of cancer

Pathophysiology of Molar Pregnancy

Fertilization of an empty ovum

Complete mole

Trophoblastic proliferation and the absence of fetal parts

Incomplete mole

Coexistent fetus that has a triploid genotype and multiple abnormalities

Invasive mole

Invades myometrium layers of the fetus

Signs and Symptoms of Molar Pregnancy

Absence of fetal heart sounds

Markedly elevated quantitative serum hCG

Very low levels of maternal serum α-fetoprotein

Vaginal bleeding that may be scant or profuse

May pass part of the molar pregnancy

Discrepancy between uterine size and dates

Excessive nausea and vomiting

Management of Molar Pregnancy

Removal of uterine contents

Early stages: suction dilation and curettage

Some women may need a hysterectomy

Chemotherapy if hCG titer rises or plateaus

Surgery if chemotherapy not successful

Radiation therapy reserved for brain and liver metastases

Spontaneous Abortions

Complete abortion (complete expulsion)

Incomplete abortion (partial expulsion)

Inevitable abortion: bleeding & dilation occur but no expulsion

Threatened abortion: intrauterine bleeding before 20 wks, fetus is still alive

Missed abortion: death of embryo with expulsion within 1 to 3 wks (up to 8wks)

Septic abortion

Recurrent abortion

Elective or therapeutic abortion: medical condition, etc

Hyperemesis Gravidarum

Extreme persistent, continuous nausea and vomiting in pregnancy

Most common reason for hospitalizations

Concerns include:

Electrolyte imbalance

Dehydration

Alkalosis

Ketonuria

Discrete weight loss

Cervical Insufficiency

Due to multiple abortions/ D&C

Cervical cerclage may be placed to retain pregnancy

Bleeding Disorders Later in Pregnancy

Hemorrhagic disorders constitute an obstetric emergency

A leading cause of maternal health in the United States

Early identification of maternal hemorrhage

Placental causes of vaginal bleeding

First indicators:

Tachycardia (Maternal)

Bradycardia or tachycardia (Fetal)

Placenta Previa

Associated w/: hx C/S, abortions,, mutli gestation, diabetes

Complete placenta previa

Partial placenta previa

Marginal placental previa

Signs and symptoms: painless, bright red bleeding

Vasa previa: unprotected umbilical vessels run through the amniotic membranes, and pass over the cervix = significant hemorrhage

Bright red blood at the ROM

Placental Abruption

Premature separation of a normally implanted placenta

Risk factors and classifications: HTN, multiparity, abortions, etc

Perinatal and maternal morbidity and mortality

Signs and symptoms: SEVERE Abd pain, board like abd & no vaginal bleeding, vaginal bleeding ( 3rd trimester)is the HALLMARK sign of placenta abruption/placenta previa.

Placental Abruption Treatment

Pg. 152 Box 6-3

Hospitalization

IV placement Large bore needle (16g)

Labs:

CBC, PT, Platelet count, fibrinogen, clot test

Betamethasone: given to maternal to aid in fetal lung development

Rh negative patients receive RhoGAm

Intake/Output

Electrical Fetal Monitoring

Delivery: depending on mother and baby status

Pg. 152 BOX 6-2

Classifications of Abruptio Placentae

Grade 1: Slight vaginal bleeding and some uterine irritability are usually present. The fetal heart rate pattern is normal.

Grade 2: External uterine bleeding is absent to moderate. The fibrinogen level may be decreased. The fetal heart rate pattern often shows signs of fetal compromise.

Grade 3: Bleeding is moderate to severe but may be concealed. The uterus is tetanic and painful. Maternal hypotension and fetal death has occurred. Fibrinogen levels are often reduced or are less than 150 mg/dL;

Preterm Labor Pg. 153 Box 6-4

Morbidity and mortality

Etiology and risk factors: hemorrhage, uterine overdistention, hormonal changes, etc

Fetal fibronectin testing: predicts risk of PRL

Assessment of cervical length and funneling: Average Cervical Lengthening (CL): 35-40mm.

Interventions to prevent preterm labor

Patient education

Medications: Tocolytics

Nifedipine (CCB) decreases smooth muscle contraction (nifedipine & magnesium  may lead to sudden cardiac arrest

Premature Rupture of the Membranes

Occurs before the 37th completed week of gestation

Absence of labor

Most common cause is infection or bacteria in the genital tract: monitor maternal temperature

Patient reports a gush or leakage of fluid from the vagina  may lead to oligohydramnios

Any increased vaginal discharge should be evaluated

Pat. Education: Bedrest, VS/4 hrs, Hydration, NO sexual intercourse/orgasm

Hypertensive Disorders of Pregnancy

Pre-eclampsia

Eclampsia

Pathophysiology

Management

HELLP Syndrome

Hemolysis, Elevated Liver enzymes, Low Platelet

Patient education

Medication: labetalol, hydralazine, etc. Pg. 159 Table 6-1

Significance of proteinuria

Magnesium Sulfate

Very potent, HIGH Alert Drug!

Causes: decrease Respirations/drowsiness

Educate Pt: flushed/warmth effect, blurring, headaches, etc.

Monitor: BP, HR, RR (16bpm before dose)

Monitor Patellar Reflexes for toxicity & clonus (2+ is Normal)

Monitor: Mag Serum Levels

Calcium Gluconate ready!

Serum Magnesium Levels	(mEq/L)
Normal	1.5–2
Therapeutic	4–7
ECG changes	5–10
Loss of reflexes	8–12
Respiratory distress	15
Cardiac arrest	25

Patient w/ Seizure Activity

DO NOT attempt to shorten/abolish sz

Secure Airway, administer O2 face mask 10L/min, Suction equipment

Assess pulse/circulation (Call code if no pulse), ROM

LEFT side lying (prevent aortic compression)

Monitor VS, IV access, give Mag Sulfate,

Disseminated Intravascular Coagulopathy

Depletion of platelets & clotting factors

Signs: hematuria, petechiae, oozing from injections

Causes widespread external or internal bleeding

Most common causes of DIC in pregnancy:

Excessive blood loss with inadequate component replacement

Placental abruption

Amniotic fluid embolism

Severe pre-eclampsia

Multiple Gestation

Associated complications

PRL, IUGR, Gest Diabetes, UTIs, preclampsia/eclampsia

High-Risk Pregnancy

Delivery planned in Level III Facility

Ultrasounds, Bio Physical Profiles, Non Stress Tests

Twin-to-Twin Transfusion

Vascular connections (A-A, A-V, V-V)

Infections

Urinary tract infection

Group B streptococcal infection

Normal vaginal/fecal flora

May cause sepsin in Newborn

Maternal screening 36-37 weeks, Abx (penicillin, erythromycin if needed

Torch infections

Associated with congenital anomalies if exposed during first 12 wks

HIV and AIDS

Systemic Lupus Erythematosus

Chronic multisystem inflammatory disorder

Autoimmune antibody production

Inflammation of connective tissue

Body fails to recognize its own proteins

Inflammation of multiple organ systems

Adverse pregnancy outcomes more common in SLE

Rho(D) Isoimmunization

Hemolytic disease of the fetus and newborn

Maternal antibodies against antigens present on the fetal and neonatal RBCs

Antigens provoke an immune reaction if an incompatible blood cell enters the circulation

Administered deltoid within 3-72 hrs after delivery, abortion, miscarriage , transfusion

Special consideration Jehovah's contains human plasma

Respiratory Complications

Asthma

Management

Goals of therapy include:

Optimal control of asthma symptoms

Attainment of normal pulmonary function

Prevention and reversal of asthma attacks

Prevention of maternal and fetal complications

Diabetes in Pregnancy

Definition and classification of diabetes mellitus

Pregestational

Gestational

Maternal and perinatal morbidity and mortality

Management

Continuous blood glucose monitors

Insulin and oral hypoglycemic therapy

The Thyroid Gland and Pregnancy

Hyperthyroidism

Excessive levels of thyroid hormone:

Heat intolerance, diaphoresis, fatigue, anxiety, tachycardia, insomnia, wide pulse pressure

Treatment:

Propyl-thiouracil (PTU) drug of choice

Patient education

Hypothyroidism

Inadequate production of thyroid hormone:

Cold intolerance, lethargy, hair loss, brittle nails, dry skin

Treatment:

Levothyroxine

Venous Thrombosis and Pulmonary Embolism

Venous thromboembolic diseases

Superficial and deep vein thrombophlebitis

Pulmonary embolism:

S/S: tachypnea, dyspnea, heart murmur, anxiety, etc

Thrombosis

Pain tenderness/ warmth, swelling , color change, etc

Risk Factors: obesity, limited mobility, preeclampsia, multiple gestation

Doppler, MRI, CT to confirm Thrombosis

Psychiatric Complications During Pregnancy

Depression

Bipolar disorder

Schizophrenia

Anxiety disorders

Eating disorders

Assessment and Diagnostic Tools

Doppler ultrasound blood flow studies

Fetal biophysical profile (Pg. 178 Table 6-4)

Nonstress test Play

20 -40 mins

Contraction stress test

Electronic fetal heart rate monitoring

maternity

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