Maternity

CHAPTER 6

Caring for the Woman Experiencing Complications During Pregnancy

 CONCEPTS

Female reproduction

Pregnancy

Nursing

Family

 KEY WORDS

salpingectomy

laparotomy

laparoscopy

salpingostomy

complete abortion

incomplete abortion

inevitable abortion

threatened abortion

missed abortion

septic abortion

recurrent abortion

elective or therapeutic abortion

cerclage

complete (total) placenta previa

partial placenta previa

marginal placenta previa

Kleihauer–Betke

abruptio placentae

tocolysis

oligohydramnios

pre-eclampsia

eclampsia

scotomata

disseminated intravascular coagulopathy

erythroblastosis fetalis

direct Coombs’

indirect Coombs’

glycosylated hemoglobin A1c

biophysical profile

contraction stress test (CST)

 LEARNING OBJECTIVES

At the completion of this chapter, the student will be able to:

■ Plan nursing assessments and interventions for the woman experiencing complications of pregnancy.

■ Discuss the importance of complete and accurate documentation in caring for the patient experiencing an obstetric emergency.

■ Identify complications of pregnancy that require fetal and/or maternal surveillance.

 PICO(T)Questions

Use these PICO(T) questions to spark your thinking as you read the chapter.

1. Are (P) women with multifetal pregnancies (I) at greater risk for (O) gestational diabetes than (C) women who are pregnant with a single fetus?

2. Are (P) women who have a miscarriage with their first pregnancy (I) more likely to (O) have another miscarriage (C) than women who have a miscarriage with their second pregnancy?

INTRODUCTION

Complications during pregnancy can arise during any gestational age. Some complications occur early on and others arise in the later stages of pregnancy. Understanding complications allows nurses to provide care that can optimize health outcomes for both the woman and fetus. The nurse must apply skills, knowledge, and expertise combined with the nursing process to identify the pregnant patient at risk and then formulate, implement, and evaluate an appropriate, holistic plan of care. Identification and activation of appropriate community resources are also essential components of the care plan. Throughout the entire process, the nurse must remain cognizant of the unique individuality of the patient and her family and deliver care that is respectful of their diversity and culture. This chapter describes pregnancy complications and how nurses can deliver appropriate care.

BLEEDING COMPLICATIONS IN PREGNANCY

Early Pregnancy Complications

Three of the most common pregnancy complications in the first trimester are ectopic pregnancy, gestational trophoblastic disease, and spontaneous abortion (miscarriage). Outcomes of these complications can affect the health of the woman and pregnancy. Not all bleeding in early pregnancy indicates a complication; however, women who have this symptom must be evaluated and, depending on the diagnosis, may require extensive work-up, treatment, and follow-up throughout the pregnancy.

Ectopic Pregnancy

An ectopic pregnancy occurs when the fertilized egg implants outside the uterine cavity. Implantation may occur in the fallopian tube (99%), on the ovary, on the cervix, on the outside of the fallopian tube, on the abdominal wall, or on the bowel ( Fig. 6-1). Patients who present with unilateral abdominal pain, vaginal bleeding, a missed period, or abdominal tenderness should always be evaluated for an ectopic pregnancy. The hallmark sign of an ectopic pregnancy is unilateral stabbing pain in the lower quadrant, caused by the growing pregnancy in the fallopian tube. Referred pain can also occur in the shoulder due to a rupture ectopic pregnancy and the diaphragmatic irritation of the phrenic nerve caused by blood in the peritoneal cavity. Ectopic pregnancy, especially a ruptured ectopic pregnancy, can lead to extreme blood loss, shock, and death. All women who have shock symptoms, including tachycardia, hypotension, faintness, and dizziness, should be thoroughly assessed. Significant vaginal bleeding may or may not occur, as the woman may experience a large volume of internal bleeding.

A number of factors place a woman at risk for experiencing an ectopic pregnancy. These include past and current medical and gynecological problems such as:

■ History of sexually transmitted infections or pelvic inflammatory disease

■ Prior ectopic pregnancy

■ Previous tubal, pelvic, or abdominal surgery

■ Endometriosis

■ Current use of exogenous hormones (e.g., estrogen and progesterone)

■ Use of an intrauterine device

■ In-vitro fertilization or other method of assisted reproduction

■ In-utero diethylstilbestrol (DES) exposure with abnormalities of the reproductive organs

A ruptured ectopic pregnancy is an emergency and must be diagnosed before the onset of hypotension, bleeding, pain, and overt rupture to prevent major morbidity and death. The patient’s history can often indicate signs of an ectopic pregnancy that warrant immediate evaluation, such as unilateral, bilateral, or diffuse abdominal pain and missed period. During the physical examination, a palpable mass is present on bimanual examination in approximately 50% of women. Active bleeding is associated with rupture; other symptoms of this complication may include hypotension, tachycardia, vertigo, unilateral lower abdominal pain, and shoulder pain. Women may also have referred shoulder pain on the side of the ectopic pregnancy due to irritation of the phrenic nerve.

FIGURE 6-1 Ectopic pregnancy.

  Labs

Work-Up for Ectopic Pregnancy

Women receiving blood work for ectopic pregnancy will need repeated labs in subsequent days to monitor for worsening of the condition.

• Beta-human chorionic gonadotropin (β-hCG) that is low for gestational age should be monitored. (Because an ectopic pregnancy has a poorly implanted placenta, the level of β-hCG does not double every 48 hours as in normal implantation.) β-hCG will be taken every 2 days to monitor for effectiveness of treatment.

• Type is completed in cases of rupture, ectopic, and/or need for operative surgical removal or a blood transfusion.

• Rh is completed to determine Rh factor and the woman will need Rhogam if she is Rh-negative.

• Complete blood count is performed to assess the degree of vaginal bleeding or internal bleeding and level of hemorrhage and a white blood count (WBC) that can range from normal to 15,000/mm3.

 Diagnostic Tools

Diagnosis of an ectopic pregnancy is typically performed by ultrasound that will indicate where the pregnancy has implanted.

• Transvaginal ultrasonography should be performed to confirm intrauterine or tubal pregnancy. Ultrasonographic identification of an intrauterine pregnancy rules out the presence of an ectopic pregnancy in most women. Location of the pregnancy outside the uterus is considered ectopic.

• In cases where ultrasound is inconclusive, serial BhCG will be conducted. The woman may need a later follow-up ultrasound.

• In the early work-up stage the woman may undergo a pelvic examination to confirm an adnexal mass. If an ectopic pregnancy is suspected the examination should be conducted gently so as not to rupture the mass. Once a mass or ectopic pregnancy is diagnosed, pelvic examinations are avoided due to the risk of rupture.

MANAGEMENT

Salpingectomy (removal of the ruptured fallopian tube) by  laparotomyinvolves abdominal surgery with a traditional incision (Venes, 2021). Current clinical emphasis is not only preventing maternal death but also promptly restoring health through a rapid recovery with preservation of fertility. To achieve this goal,  laparoscopy (visualization of the reproductive organs using a laparoscope inserted into the pelvic cavity through a small incision in the abdomen),  salpingostomy (incision into the fallopian tube to remove the pregnancy), and partial salpingectomy are replacing laparotomy as the treatment modes of choice. At present, laparotomy is performed only when a laparoscopic approach is too difficult, the surgeon is not trained in operative laparoscopy, or the patient is hemodynamically unstable.

Methotrexate is a chemotherapeutic drug and folic acid inhibitor that stops all rapid cell production, inhibiting the growth of the embryo and destroying remaining trophoblastic tissue. Methotrexate treatment is used in the management of uncomplicated, non-life-threatening ectopic pregnancies. Patients are considered eligible for methotrexate therapy if the ectopic mass is unruptured and measures 1.6 in. (4 cm) or less on ultrasound examination. Patients with larger ectopic masses, embryonic cardiac activity, or clinical evidence of acute intra-abdominal bleeding (acute tender abdomen, hypotension, or falling hematocrit) are not eligible for this mode of treatment.

  Patient Education

Methotrexate

Patients receiving methotrexate should have comprehensive patient education on the chemotherapeutic medication so that the patient and family members can stay safe and healthy. Educational points include:

• Information on side effects such as nausea and vomiting

• Discontinuation of prenatal vitamins and other folic acid supplements, which can act as antagonists

• The need for alcohol abstinence

• Avoidance of NSAIDs, which can precipitate gastric bleeding

• The need for sunscreen and protective clothing to prevent photosensitivity

• Required follow-up laboratory work to monitor hCG levels and other side effects

Ectopic pregnancy can be a life-threatening complication of pregnancy. Depending on the type of treatment, patients should have a low threshold for returning to their healthcare providers. If a woman exhibits additional or worsening symptoms such as abdominal pain or vaginal bleeding, she should seek immediate emergency treatment in case of ruptured ectopic pregnancy. The women and family may benefit from psychosocial support and/or therapy due to the loss of a pregnancy. In addition, depending on the extent of the ectopic pregnancy and treatment, future pregnancies may also be compromised, resulting in further grieving, which the woman may experience at a later time.

Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD), otherwise known as hydatidiform mole or molar pregnancy, can have different pathologies including locally invasive mole, metastatic mole, and choriocarcinoma. GTD is characterized by an abnormal placental development that results in the production of fluid-filled grapelike clusters (instead of normal placental tissue) and a vast proliferation of trophoblastic tissue ( Fig. 6-2). It is associated with loss of the pregnancy and, rarely, the development of cancer. GTD occurs in 1 in 1,000 pregnancies. The incidence of hydatidiform mole increases with maternal age (especially in women 45 or older) and in those with a history of a previous molar pregnancy. Other risk factors include blood types A and AB and becoming pregnant accidentally while on birth control. Women with a history of a molar pregnancy have a 1% to 2% risk for a second molar pregnancy in subsequent pregnancies (American Cancer Society, 2017).

Figure 6-2 A hydatidiform mole pregnancy is one in which the chorionic villi degenerate into a mass of fluid-filled grapelike clusters.

PATHOPHYSIOLOGY

The cause of molar pregnancy is unknown, but it is thought that complete moles result from the fertilization of an empty ovum (one whose nucleus is missing or nonfunctional) by a normal sperm. A complete mole is characterized by trophoblastic proliferation and the absence of fetal parts. Incomplete moles often appear with a coexistent fetus that has a triploid genotype (69 chromosomes) and multiple anomalies. Incomplete moles are almost always benign and have a much lower malignancy potential than complete moles. An invasive mole is similar to a complete mole but has invaded the myometrium layer of the uterus. Invasive moles rarely metastasize. Choriocarcinoma is an invasive, malignant trophoblastic disease that is usually metastatic and can be fatal (American Cancer Society, 2017).

SIGNS AND SYMPTOMS

Clinical and laboratory findings include an absence of fetal heart sounds, a markedly elevated quantitative serum hCG (may be greater than 100,000 mIU/mL), and very low levels of maternal serum α-fetoprotein (MSAFP). More than 95% of patients experience vaginal bleeding that may be scant or profuse and ranges in color from dark brown to bright red. Some women may pass part of the molar pregnancy with tissue that resembles grapes. In early pregnancy, there is often a discrepancy between uterine size and dates with larger than expected size. The patient may complain of excessive nausea and vomiting (hyperemesis gravidarum) and abdominal pain caused by uterine distention. Pre-eclampsia may occur earlier in pregnancy, usually between 9 and 12 weeks of gestation, but any symptoms of gestational hypertension before 24 weeks of gestation may be indicative of hydatidiform mole (American Cancer Society, 2017).

MANAGEMENT

Clinical management involves removal of the uterine contents with meticulous follow-up. If the GTD is in the early stages, then suction dilation and curettage may be the first option. Depending on the size and invasiveness of the GTD, some women may need hysterectomy. Chemotherapy is initiated immediately if the hCG titer rises or plateaus during follow-up or if metastases (movement of cancer cells from the original site to another site) are detected at any time. Surgery may be indicated if chemotherapy is not successful or for patients who have completed their childbearing. Radiation therapy is usually reserved for treating brain and liver metastases (American Cancer Society, 2017).

Follow-up will include serial hCG levels. A sensitive marker, hCG is secreted by the molar cells. The amount of this hormone measured in maternal serum is directly related to the number of molar cells. The hCG levels should be assessed every 1 to 2 weeks until hCG is undetectable on two consecutive determinations. Thereafter, hCG should be measured every 1 to 2 months for at least a year.

PATIENT EDUCATION

Patient education must include the need to avoid pregnancy for at least 1 year following GTD.

Effective contraception is needed during this time to prevent pregnancy and the resulting confusion about the cause of changes in the hCG levels. In addition, pregnancy could mask an hCG rise associated with malignant GTD. The nurse should carefully counsel the patient about different methods of contraception and stress the importance of avoiding pregnancy for a year. During a subsequent pregnancy, first trimester sonography should be performed to confirm that the pregnancy is normal.

Spontaneous Abortions

A spontaneous abortion (SAB) or miscarriage is the loss of a pregnancy before age of viability or fetus less than 500 g (Venes, 2021). Of all clinically recognized pregnancies, approximately 10% result in SAB, with 80% occurring within the first trimester (American College of Obstetricians and Gynecologists, 2018a). These percentages underestimate the exact number due to undiagnosed SAB, and very early miscarriages can be mistaken for menses. By definition, an early pregnancy loss occurs before 12 weeks of gestation; a late pregnancy loss occurs between 12 and 20 weeks of gestation. First-trimester SABs are associated with chromosomal abnormalities due to a faulty embryo development or placenta. Infections (e.g., listeriosis, toxoplasmosis, and C trachomatis), maternal anatomical defects, and immunological and endocrine factors have also been identified as causes of early pregnancy loss, although many have no obvious cause. Second-trimester SABs (12 to 20 weeks) have been linked to chronic infection, recreational drug use, maternal uterine or cervical anatomical defects, maternal systemic disease, exposure to fetotoxic agents, and trauma and shock.

The type of SAB that occurs is defined by whether any or all products of conception (POC) have been passed and whether the cervix is dilated.

Terminology/classifications associated with SABs include the following:

■  Complete abortion: Complete expulsion of all POC before 20 weeks of gestation.

■  Incomplete abortion: Partial expulsion of some but not all POC before 20 weeks of gestation.

■  Inevitable abortion: No expulsion of products, but bleeding and dilation of the cervix has occurred and expulsion of POC cannot be halted.  Threatened abortion: Signs of SAB are present with intrauterine bleeding before 20 weeks of gestation, without dilation of the cervix; fetus is still alive and attached to the uterus.

■  Missed abortion: Death of the embryo or fetus before 20 weeks of gestation with complete retention of the POC; these often proceed to a complete abortion within 1 to 3 weeks, but occasionally they are retained up to 8 weeks.

■  Septic abortion: POC and/or uterus become infected during the abortion process.

■  Recurrent abortion: Three or more pregnancies that have ended in SAB, often due to genetic, chromosomal, or anatomical irregularities.

■  Elective or therapeutic abortion: The POC are removed for medical reasons in which the fetus has a condition incompatible with life, when the woman’s health is in danger, or for personal reasons.

A woman experiencing an SAB usually presents with bleeding and may also complain of cramping, abdominal pain, and decreased symptoms of pregnancy; cervical changes (dilation) may be present on vaginal examination. An ultrasound is performed for placental evaluation and to determine fetal viability and/or degree of retained POC. Laboratory tests include a quantitative level of ß-hCG, which should show a lower value than when associated with a viable pregnancy ( Fig. 6-3); hemoglobin and hematocrit levels; blood type and Rh status determination; and indirect Coombs’ screen. A progesterone level may also be warranted in some cases to help determine the viability of pregnancy, especially in cases of threatened abortions.

MANAGEMENT

Management of SAB starts with an assessment and history taking. Assessment includes obtaining vital signs, gestational age, and Rh status. Symptom assessment should include time of onset of vaginal bleeding or pain, character and amount of vaginal bleeding, and the passing of tissue (any tissue should be preserved and sent to the laboratory for examination). Assessment should also include evaluation for serious complications such as shock, sepsis, and disseminated intravascular coagulations (DIC). Mental health assessment should also be a priority as the patient may experience a range of emotions including grief, anger, guilt, sadness, depression, relief, and sometimes happiness in cases of unwanted pregnancies (Venes, 2021).

Incomplete, inevitable, and missed abortions are usually managed via a dilation and curettage (D and C). With this procedure, the cervix is dilated and a curette is inserted to scrape the uterine walls and remove the uterine contents. In the case of an incompetent cervix, an emergent  cerclage(placement of ligature to close the cervix) may be performed. An unsensitized, Rh(D)-negative woman should be given Rho(D)-immune globulin (RhoGAM) to prevent antibody formation. (See discussion later in this chapter.) Another option may be expectant management for women who prefer to allow for the natural progression of the abortion and expulsion of uterine contents. Candidates include women who have inevitable abortion, complete abortion, and sometimes missed abortion depending on how far along the pregnancy is and when the abortion occurred.

FIGURE 6-3 hCG levels.

Depending on the circumstances, the nurse can provide counseling or make an appropriate referral. Not all women who suffer a pregnancy loss require formal assessment, but all women should be offered an evaluation after several losses. The nurse should also allow the family to express as much grief as they are feeling at the moment and are willing to share; allow them to talk freely of what their hopes and expectations had been for this new life, and acknowledge that this is a very difficult time for them. The nurse may offer to enlist the assistance of social services, a chaplain, a rabbi, or appropriate support groups if they so desire.

 Optimizing Outcomes

Follow-up for Habitual SAB

Habitual (three or more) abortions may occur due to medical or genetic conditions. Women affected often benefit from genetic counseling and further testing to include:

• A karyotype obtained from the POC and from both parents

• Examination of maternal anatomy, beginning with a hysterosalpingogram; if abnormal, hysteroscopy or laparoscopy. Assessment of the reproductive tract to determine anomalies such as a bicornuate uterus, which is a congenital condition resulting in abnormal uterus shape often appearing as two separate horns

• Screening tests for endocrine disorders as well as hypothyroidism, diabetes mellitus, antiphospholipid syndrome (APS; an acquired hypercoagulable state that involves venous and arteriole thrombosis) and systemic lupus erythematosus (SLE)

• Serum progesterone level during the luteal phase of the menstrual cycle

• Cultures of the cervix, vagina, and endometrium

Cervical Insufficiency

Cervical insufficiency is the structural inability of the uterine cervix to remain closed and support a growing pregnancy in the absence of preterm labor (PTL). Cervical insufficiency is associated with recurrent abortions and/or preterm births and is often seen in women who have experienced cervical trauma, had cervical procedures such as a loop electrosurgical excision procedure (LEEP), or have a family history of DES exposure (Venes, 2021). Approximately 1% of women have cervical insufficiency (Brown et al, 2019).

MANAGEMENT

Management may include placement of a cerclage, or purse string suture, beneath the cervical mucosa either at the cervical-vaginal junction (a McDonald cerclage) ( Fig. 6-4) or at the internal cervical os (a Shirodkar cerclage). The intent of the cerclage is to close the cervix. Sometimes a cerclage is placed via an abdominal incision. It may be placed electively before pregnancy, at 12 to 14 weeks of gestation, or as an emergency procedure. The cerclage is usually removed in the office or clinic at 37 weeks of gestation to facilitate vaginal birth. A new cerclage will need to be placed with subsequent pregnancies. The cerclage may also be left in place, necessitating a cesarean delivery.

FIGURE 6-4 Cerclage.

Hyperemesis Gravidarum

Hyperemesis gravidarum is characterized by extreme persistent, continuous nausea and vomiting in pregnancy. This is one of the most common reasons for hospitalizations in pregnancy, occurring in 2 out of every 1,000 pregnant women. Adverse outcomes of hyperemesis gravidarum include electrolyte imbalance, dehydration, alkalosis, ketonuria, and some discrete weight loss, most often 5% of the prepregnancy weight. Many women also experience a mental health effect and can develop symptoms of post-traumatic stress disorder (London et al, 2017). Risk to the fetus includes growth restriction in cases that are persistent and severe as well as risk of PTL.

According to Erick et al (2018) and London et al (2017), risk factors include:

■ Increased placental mass

■ Multiple fetus pregnancy

■ Increase in hormones, including serum hCG, progesterone, and estrogen

■ History of hyperemesis in previous pregnancy

■ Pregnancy complications including multiple gestation and molar pregnancy

■ Deficiency in thiamine and vitamin B1

■ Familial history of hyperemesis gravidarum, including daughters and sisters; women who are pregnant with a female child are also considered to be at risk

■ Fetus with chromosomal abnormality

MANAGEMENT

Women with a history of nausea and vomiting in a previous pregnancy are advised to regularly take multivitamins before the next conception. Rest is encouraged. The nurse should counsel the woman to avoid foods and sensory stimuli

that provoke symptoms (e.g., some women become nauseous when they smell certain foods being prepared). She should eat small frequent meals of dry, bland foods, and high-protein snacks. Spicy foods should be avoided. Eating crackers before arising in the morning may help alleviate symptoms. Nonpharmacological management can include ginger capsules 250 mg four times daily and the use of P6 acupressure with wrist bands (Erick et al, 2018). If the patient requires hospitalization, IV fluids containing dextrose and vitamins are given, and the patient is placed on a nothing by mouth status and treated with antiemetics ( Box 6-1). Parenteral or enteral feedings may be ordered if the patient is unable to take oral nourishment and if normal weight gain parameters for the gestation of pregnancy are not being achieved (Erick et al, 2018).

Bleeding Disorders Later in Pregnancy

Hemorrhagic disorders constitute an obstetric emergency and are a leading cause of maternal death in the United States. Third-trimester vaginal bleeding occurs in 3% to 4% of all pregnancies and may be obstetric or nonobstetric in nature (Cunningham et al, 2018). Examples of nonobstetric causes include severe cervicitis, benign and malignant neoplasms, lacerations, and varices.

 Clinical Judgment Alert

Early Identification of Maternal Hemorrhage

During pregnancy, the woman’s blood volume increases 50%, and in the case of multiple gestation, it increases as much as 100%. Because of this expanded blood volume, the patient may be asymptomatic and exhibit vital signs that remain within normal parameters despite a large amount of blood loss. Blood pressure is a very poor indicator of blood volume deficit. The maternal pulse (tachycardia) and/or fetal heart rate (FHR; bradycardia or tachycardia) may be the first indicators of maternal instability.

BOX 6-1

Common Medications for Nausea and Vomiting of Pregnancy

Pyridoxine (vitamin B6), 25–75 mg (orally) per day, used alone or in combination with doxylamine (Unisom), 25 mg (orally) per day

*Doxylamine succinate and pyridoxine hydrochloride (Diclegis) delayed release tablets 10 mg/10 mg; 2 tablets (orally) at bedtime (day 1); may be increased as needed to maximum recommended dose of 4 tablets/day. (Note: The medication is taken as a daily prescription and not on an as-needed basis to help control symptoms throughout the day.)

Promethazine (Phenergan) 12.5–25 mg (IV, intramuscularly, orally, or rectally) every 4 hours

Dimenhydrinate (Dramamine) 50–100 mg (orally or rectally) every 4–6 hours or 50 mg IV (in 50 mL of saline run over 20 minutes) every 4–6 hours

Metoclopramide (Reglan) 5–10 mg (IV, intramuscularly, or orally) every 8 hours

*FDA-approved in 2013

Placental Causes of Vaginal Bleeding

PLACENTA PREVIA

Placenta previa is an implantation of the placenta in the lower uterine segment, near or over the internal cervical os. This condition occurs in 1 of every 200 pregnancies. There are three recognized variations of placenta previa. With a  complete (total) placenta previa, the placenta covers the entire cervical os. Because it is associated with the greatest amount of blood loss, a complete placenta previa presents the most serious risk. A  partial placenta previa describes a placenta that partially occludes the cervical os. A  marginal placenta previa is characterized by the encroachment of the placenta to the margin of the cervical os, and a low-lying placenta is one that is implanted in the lower uterine segment in proximity to the internal cervical os ( Fig. 6-5).

Placenta previa may be associated with conditions that cause scarring of the uterus, such as a prior cesarean birth or previous abortions with curettage. A placenta previa may also occur with a large placental mass as seen in multiple gestations, diabetes, and erythroblastosis fetalis. Other risk factors include smoking, cocaine use, a prior history of placenta previa, previous abortion, closely spaced pregnancies, grand multiparity, and maternal age greater than 40 years (Abduljabbar et al, 2016). Abnormal placental adherence often occurs with placenta previa in which the placenta abnormally attaches to the uterine wall. Placenta accreta, placenta percreta, and placenta increta are the most common placenta abnormalities involving adhesion, each invading different uterine layers of the muscles. There is a high risk of bleeding in labor, and treatment often involves a hysterectomy.

Signs and Symptoms

The most common symptom is painless bright red vaginal bleeding, believed to occur from small disruptions in the placental attachment during normal development and the subsequent stretching and thinning of the lower uterine segment during the third trimester. Initially, the bleeding is usually a small amount that stops as the uterus contracts to close the open blood vessels. However, bleeding can reoccur at any time and may be associated with profuse hemorrhage especially if the cervix is dilating and the placental is pulling away from the uterine wall cervix.

VASA PREVIA

With vasa previa, the umbilical vessels are not supported by the cord and the vessels traverse within the membranes and cross the cervical os before reaching the placenta. The umbilical blood vessels are at risk for laceration, which can cause significant hemorrhage. The appearance of bright red blood at the time of rupture of the membranes (ROM) should alert the nurse to the possibility of a vasa previa. Maternal risks associated with vasa previa are in vitro fertilization (IVF), placenta previa, fetal anomalies (spina bifida, single umbilical artery, exomphalos, prematurity, antepartum hemorrhage, and fetal growth restriction (Gagnon, 2017).

Today most cases of placenta previa are detected antenatally before the onset of significant bleeding. Although diagnosis typically occurs in the second trimester, these cases tend to resolve as the uterus enlarges. The placenta can shift with the uterus and can migrate upward and off the cervix.

Management of the pregnant woman who is experiencing active bleeding associated with placenta previa requires astute assessment skills to avoid a delay in treatment. Delay can mean the difference between an optimal or poor outcome for the patient and her fetus. Stabilization involves the administration of IV fluids and a laboratory work-up that includes a complete blood count, prothrombin time, partial thromboplastin time, fibrin split products, and fibrinogen. A blood type and crossmatch should be obtained in anticipation of the need for a transfusion. A maternal  Kleihauer-Betke blood test may be ordered to determine whether there has been a transfer of fetal blood cells into the maternal circulation and treatment with RhoGam should be administered. The patient is placed on bedrest and the fetus is continuously assessed by electronic fetal monitoring (EFM). If time permits, betamethasone (a long-acting corticosteroid) may be administered to promote fetal lung maturity if the woman is preterm. Vaginal examinations should be avoided at all times, and if labor cannot be halted, fetal compromise, and life-threatening maternal hemorrhage are indications for immediate delivery (often by c-section) regardless of gestational age.

PLACENTAL ABRUPTION

Placental abruption  (abruptio placentae) is the premature separation (partial or complete) of a normally implanted placenta from the decidual lining of the uterus. This condition occurs in 0.3–1 in every 100 births (Venes, 2021) (Ananth et al, 2015).

Risk Factors and Classifications

Bleeding can be either concealed (internal) or revealed (apparent vaginal bleeding). A concealed hemorrhage occurs in 20% of cases and describes an abruption in which the bleeding is confined within the uterine cavity. The most common abruption is associated with a revealed or external hemorrhage, in which the blood dissects downward toward the cervix ( Fig. 6-6).

FIGURE 6-5 Placenta previa.  A, Complete (Total).  B, Partial.  C,Marginal/Low lying.

Experiencing domestic violence in pregnancy is a major risk factor for placental abruption. Other risk factors include maternal hypertension (chronic, gestational, pre-eclampsia/eclampsia), cigarette smoking, multiparity, abortions (spontaneous, elective), illicit drug use (cocaine, methamphetamine), short fetal umbilical cord, maternal abdominal trauma, ROM, and uterine leiomyoma (fibroids) located behind the placenta. Placental abruption may be broadly classified into three grades that correlate with clinical and laboratory findings ( Box 6-2).

Perinatal and Maternal Morbidity and Mortality

Maternal mortality from abruptio placentae varies from 0.5% to 5%. The degree of hemorrhage that results from the torn placental vessels can vary from maternal anemia in mild cases to shock, acute renal failure, and maternal death in severe cases. Thirty-five percent of infants whose mothers require an antepartal transfusion will themselves be anemic and require a transfusion after birth. Fetal mortality occurs in about 35% of all placental abruptions and can be as high as 50% to 80% when associated with severe placental abruption. Death results from hypoxia that is related to the decreased placental surface area and maternal hemorrhage (Cunningham et al, 2018).

Signs and Symptoms

The classic presenting sign is third-trimester bleeding associated with severe abdominal pain. Other signs include uterine tenderness and abdominal or back pain, a board-like abdomen and no vaginal bleeding, abnormal contractions and increased uterine tone, fetal compromise as evidenced by late FHR decelerations, bradycardia and lack of variability on the electronic fetal monitor, and fetal demise.

Vaginal bleeding in the third trimester of pregnancy is the hallmark of placental abruption or placenta previa and should always prompt an investigation to determine its etiology. Diagnosis is made by clinical findings and, when available, ultrasound examination. However, during the acute phase of placental abruption, ultrasound findings may not be reliable, so a thorough clinical evaluation of any pregnant woman who presents with bleeding or acute abdominal pain is always indicated (Cunningham et al, 2018).

Management will depend on the degree of the placenta abruption. The potential for rapid deterioration (hemorrhage, DIC, fetal hypoxia) necessitates delivery in some cases of placental abruption. However, most abruptions are small and noncatastrophic and therefore do not necessitate immediate delivery. Certain actions, including hospitalization, laboratory studies, continuous monitoring, and ongoing patient support should be initiated when placental abruption is suspected ( Box 6-3).

FIGURE 6-6 Abruptio placentae.

BOX 6-2

Classifications of Abruptio Placentae

Grade 1: Slight vaginal bleeding and some uterine irritability are usually present. Maternal blood pressure is unaffected, and the maternal fibrinogen level is normal. The fetal heart rate pattern is normal.

Grade 2: External uterine bleeding is absent to moderate. The uterus is irritable and tetanic, or very frequent contractions may be present. Maternal blood pressure is maintained, but the pulse rate may be elevated and postural blood volume deficits may be present. 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 is frequently present, and fetal death has occurred. Fibrinogen levels are often reduced or are less than 150 mg/dL; other coagulation abnormalities (e.g., thrombocytopenia and factor depletion) are present.

Source: Cunningham et al. (2018).

BOX 6-3

Care for the Patient Experiencing an Abruptio Placentae

• Hospitalization.

• IV placement with a large-bore catheter (16-gauge).

• Labwork: Includes CBC, coagulation studies (fibrinogen, PT, PTT, platelet count, and fibrin degradation products), type and screen for 4 units of blood, Kleihauer-Betke for Rh(D)-negative patients. A “clot test” may be performed: A red top tube of blood is drawn, set aside, and checked for clotting. If a clot does not form within 6 minutes or if it forms and lyses within 30 minutes, a coagulation defect is probably present and the fibrinogen level is less than 150 mg/dL.

• Betamethasone may be given to the woman to promote fetal lung maturity when delivery is not imminent.

• Rh(D)-negative patients should receive RhoGAM to prevent isoimmunization.

• Continuous evaluation of intake and output.

• Continuous electronic fetal monitoring.

• Delivery (cesarean or vaginal birth) may be initiated depending on the status of the mother and the fetus.

• Nursing care is centered on continuous maternal-fetal assessment with ongoing information and emotional support for the patient and her family.

Source: Cunningham et al. (2018).

PRETERM LABOR

Preterm labor is defined as cervical changes and regular uterine contractions occurring between 20 and 37 weeks of pregnancy. Many patients present with preterm contractions, but only those who demonstrate changes in the cervix are diagnosed with PTL (Venes, 2021). Preterm birth, the number one complication of PTL, is considered a significant acute health problem in maternal-child health. ( Fig. 6-7). The sequelae of preterm birth have a profound effect on the survival and health of about 1 in every 10 infants born in the United States (Centers for Disease Control and Prevention, 2019b)

FIGURE 6-7 Premature infant in the neonatal intensive care unit (NICU).

Morbidity and Mortality

As a result of high-tech neonatal intensive care, advanced technology, and improved medications, the morbidity of babies born after 34 to 35 weeks has decreased. With appropriate medical care, neonatal survival dramatically improves as gestational age increases. Short-term neonatal morbidities associated with preterm birth are numerous and include respiratory distress syndrome, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, and patent ductus arteriosus. Long-term morbidities include cerebral palsy, intellectual and developmental disabilities, and retinopathy of prematurity. The risk of these morbidities is directly related to the infant’s gestational age and birth weight.

Etiology and Risk Factors

The defining physiological mechanism that triggers the onset of PTL is largely unknown but may include decidual hemorrhage (abruption), mechanical factors (uterine overdistention or cervical incompetence), hormonal changes (perhaps mediated by fetal or maternal stress), and bacterial infections (American College of Obstetricians and Gynecologists, 2020a). However, a number of risk factors have been associated with PTL ( Box 6-4).

  Labs

Fetal Fibronectin Testing

Fetal fibronectin (fFN) is a glycoprotein produced by the fetal membranes. It is normally present in the cervicovaginal fluid until 16 to 20 weeks of gestation. Fetal fibronectin may be described as the “glue” that attaches the fetal membranes to the underlying uterine decidua and not present again in vaginal secretion until just before delivery. Negative results predict that pregnancy will continue for another 14 days. However, positive results indicate that labor may start within 7 to 14 days. Keep in mind that this test must be interpreted with caution as a positive test can also be caused by other factors, such as vaginal bleeding or infection. Fetal fibronectin testing is done when the membranes are not ruptured, and the patient is not bleeding. The patient should not have had a pelvic examination, vaginal ultrasound, or vaginal intercourse within the 24 hours before collection. To test for the presence of fFN, a sterile cotton-tipped swab is placed in the posterior vaginal fornix or in the ectocervical region of the external cervical os for a minimum of 10 seconds. The collection swab is then removed, placed in a manufacturer-supplied medium, and sent to a laboratory that performs the test with results reported in 24 to 48 hours (Van Leeuwen & Bladh, 2021).

Assessment of Cervical Length and Funneling

Determining the cervical length (CL) can play a crucial part in the prevention of PTL as there is an association of cervical shortening of less than 25 mm with preterm birth (Butt et al, 2019). Average CL at term is 35–40 mm (Venes, 2021). Cervical length measurements are performed, preferably with transvaginal ultrasound (TVU) or with the FDA-approved CervilLenz CL measuring device. The risk of preterm delivery increases as the CL in the second trimester declines. When a short CL is detected during transabdominal ultrasound scanning of the lower uterine segment, a subsequent transvaginal confirmatory ultrasound examination should be performed. If short CL is present, the patient’s risk factors for preterm birth should be reviewed to determine appropriate clinical management.

BOX 6-4

Various Risk Factors Associated With Preterm Labor and Birth

SOCIAL, PERSONAL, AND ECONOMIC CHARACTERISTICS

•  Maternal age extremes (i.e., less than 16 years or greater than 40 years)

•  Teens and women over age 35

•  Black race

•  Women with low socioeconomic status

•  Women in intimate partner violence relationships

PREGNANCY AND MEDICAL CONDITIONS

•  Prior preterm birth

•  Preterm premature rupture of the membranes (PPROM)

•  Shorten cervical length

•  Infections of the urinary or reproductive tract

•  Placenta previa or abruptio placenta

•  Uterine or cervical anomalies

•  Bacterial infections (e.g., sexually transmitted infections, asymptomatic bacteriuria)

•  Hypertensive disorders of pregnancy

•  Diabetes mellitus

•  Thyroid disease

•  Clotting disorders

•  Periodontal disease

FETAL CONDITIONS

•  Fetal anomalies

•  Multiple pregnancy (twins, triplets, or more)

BEHAVIORAL

•  Tobacco use

•  Alcohol or substance use

•  Stress

•  Later or lack of adequate prenatal care

•  Poor nutrition

•  Low prepregnancy weight

Sources: American College of Obstetricians and Gynecologists (2016); Butt et al (2019); Centers for Disease Control and Prevention (2019b); Cunningham et al. (2018).

In addition to CL assessment, other lower uterine segment and cervical characteristics can be assessed by midtrimester ultrasound. One of these is the presence of cervical funnel, defined as protrusion of the amniotic membranes greater than 5 mm into the internal os. It has been demonstrated that the presence of funneling is a significant risk factor for an adverse perinatal outcome, and it is best measured as either “present” or “absent.” Methods of cervical funneling assessment include observation of the shape of the funnel (U or V), percentage of funneling, and the depth and width of the funnel. In high-risk women with a prior spontaneous preterm birth and short cervix, the progression to a U-shaped funnel has been associated with an increased risk of preterm delivery.

 Optimizing Outcomes

Interventions to Prevent Preterm Labor

Research has demonstrated that the following interventions appear to be beneficial in decreasing the risk of PTL: preconception control of chronic medical conditions (e.g., diabetes, seizures, asthma, and hypertension); smoking cessation; routine prenatal screening and treatment for asymptomatic bacteriuria; and the use of laminaria for women undergoing second trimester pregnancy termination via dilation and evacuation. Progesterone supplements have been also shown to decrease the risk of PTL. Women at risk for PTL may benefit from progesterone supplementation. Micronized progesterone vaginal gel or suppositories (every night from weeks 16 to 20 through 36) may reduce PTL, especially in women with a history of preterm birth and a short CL. Oral progesterone has shown to significantly reduce the risk of PTL and improve infant morbidity and mortality (Boelig et al, 2019). Weekly injections of 17-α-hydroxyprogesterone caproate (17P) significantly reduced the risk of preterm birth before 32 weeks.

The diagnosis of PTL can be very challenging because many of the symptoms are subtle and common during pregnancy. For example, women experiencing PTL may complain of backache, pelvic aching, menstrual-like cramps, increased vaginal discharge, pelvic pressure, urinary frequency, and intestinal cramping with or without diarrhea.

A diagnosis of PTL is made when findings include regular uterine contraction and cervical dilation or regular contractions and at least 2 cm dilation upon presentation for evaluation (American College of Obstetricians and Gynecologists, 2020a).

Infection has been implicated as a contributing factor in PTL. Prostaglandin production by the amnion, chorion, and decidua is stimulated by cytokines (extracellular factors) that are released by activated macrophages. Group B streptococci, chlamydia, and gonorrhea have been associated with PTL and preterm premature ROM (PROM) (Cunningham et al, 2018). It is always prudent for the nurse to obtain a clean-catch, midstream, or catheterized urine specimen to identify and treat infection if the patient presents with signs of PTL or preterm PROM.

Signs of PTL include:

■ Contractions that may be painful or painless

■ Lower back pain

■ Gastrointestinal (GI) upset, cramping, or diarrhea

■ Pelvic pressure or fullness

■ Vaginal discharge/bloody show

■ Vaginal discomfort pressure

Management

The two major goals in the management of PTL are to inhibit or reduce the strength and frequency of contractions, thus delaying the time of delivery, and to optimize the fetal status before preterm delivery (American College of Obstetricians and Gynecologists, 2020a).

Tocolysis is the use of medications (tocolytics) to inhibit uterine contractions. It is important to note that no medication has been identified to effectively stop PTL, and no one drug is approved in the United States or has been proven superior as a tocolytic agent. Medication selection is individualized based on efficacy, risks, contraindications ( Box 6-5), and side effects. Tocolytic therapy generally is effective for up to 48 hours, and only women whose fetuses would benefit from a 48-hour delay in delivery should receive tocolytic therapy. In general, tocolytics are not indicated for use before neonatal viability (the upper limit for use is 34 weeks of gestation), fetal demise, severe pre-eclampsia, preterm premature rupture of membranes (PPROM), nonreassuring fetal status, and maternal contraindications (American College of Obstetricians and Gynecologists, 2020a).

 Optimizing Outcomes

Antenatal Corticosteroids to Improve Neonatal Outcomes

The administration of antenatal corticosteroids is the most beneficial intervention for improvement of neonatal outcomes among women who give birth preterm. A single course of corticosteroids is recommended for pregnant women between 24 and 34 weeks of gestation who are at risk of preterm delivery within 7 days. A single course of antenatal corticosteroids should also be administered to women with PROM before 32 weeks of gestation. Neonates whose mothers receive antenatal corticosteroids have significantly lower severity, frequency, or both, of respiratory distress syndrome, intracranial hemorrhage, necrotizing enterocolitis, and death.

According to ACOG (2020), evidence supports the use of first-line tocolytic treatment with beta-adrenergic receptor agonists, nonsteroidal anti-inflammatory drugs (e.g., indomethacin), and calcium channel blockers within 48 hours of pregnancy, with the goal to delay birth and for the woman to receive corticosteroids to accelerate fetal lung maturity. This is to help prevent respiratory complication of the newborn born with fetal lungs not fully developed. In addition, delaying the birth provides an opportunity of time for the safe transfer of the woman to a facility equipped with a neonatal intensive care unit.

BOX 6-5

Contraindications to the Use of Tocolytics in Preterm Labor

• Pre-eclampsia with severe features or eclampsia

• Maternal bleeding with hemodynamic instability

• Maternal contraindications to tocolysis (agent specific)

• Nonreassuring fetal status

• Fetal demise or lethal anomaly

• Chorioamnionitis

• Preterm premature rupture of the membranes

• In the absence of infection, tocolytics may be considered for the purposes of maternal transport, steroid administration, or both

Sources: American College of Obstetricians and Gynecologists (2020); Cunningham et al (2018).

Magnesium sulfate (MgSO4), a central nervous system depressant, is often used in PTL. Magnesium sulfate has limited effect as a tocolytic agent and is associated with severe maternal risk factors including pulmonary edema and cardiovascular problems. However, MgSO4 may exert a neuroprotective benefit, protecting the brain of the very preterm infant by possibly reducing the risk of cerebral palsy (ACOG, 2020). Long-term maintenance therapy with any tocolytic medication is ineffective for preventing preterm birth and improving neonatal outcomes and is not recommended for this purpose. Caring for the patient receiving tocolytic therapy requires the nurse to be cognizant of not only the safety aspects of administering the medication to the pregnant woman but also to the emotional needs of the patient as attempts to halt the PTL are being made ( Box 6-6).

 Clinical Judgment Alert

Nifedipine Medication Interactions

Nifedipine, a calcium channel blocker used to inhibit PTL, works primarily by blocking the flow of calcium ions through the cell membrane (thereby decreasing the activation of smooth muscle contractile proteins). If nifedipine is given with magnesium sulfate or erythromycin, sudden cardiac arrest can occur (Vallerand & Sanoski, 2021).

  Patient Education

Preventing Preterm Birth

Perinatal nurses must be proactive by educating women and their families about PTL, teaching them to recognize warning signs and symptoms, and explaining actions to take if symptoms occur. Nurses should take time to ensure that patients have information on concerning symptoms that may indicate PTL:

• Uterine contractions (can be mild), cramping, or low-back pain

• Painless contractions with regular abdominal tightening

• Ruptured membranes

• A feeling of pelvic fullness, pressure, or pain

• A change in the amount or character of vaginal discharge (such as bloody or mucus discharge)

• GI symptoms: nausea, vomiting, diarrhea

• A general sense of discomfort or unease

If patients believe they are having PTL, they should call the health-care provider or go to the hospital for further evaluation of symptoms.

BOX 6-6

Nursing Care of the Patient Receiving Tocolytic Therapy

• Explore the woman’s understanding of what is taking place.

• Include the woman’s partner in all discussions about medications and their effects.

• Provide anticipatory guidance regarding what is likely to happen during medication administration.

• Position the woman on her side for better placental perfusion.

• Explain the side effects and contraindications of the medication(s).

• Assess blood pressure, pulse, and respirations regularly according to hospital policies (in many institutions every 15 minutes).

• Notify the health-care provider if systolic blood pressure is greater than 140 mm Hg or less than 90 mm Hg.

• Notify the health-care provider if diastolic blood pressure is greater than 90 mm Hg or less than 50 mm Hg.

• Assess for signs of pulmonary edema (chest pain and shortness of breath).

• Assess for the presence of DTRs.

• Monitor intake and output; avoid volume overload.

• Provide continuous external fetal monitoring for FHR pattern and frequency, duration, and approximate intensity of uterine contractions.

• Palpate the maternal abdomen to assess strength of uterine contractions.

• Provide psychosocial support and opportunities for the patient to express anxiety.

• Administer tocolytic therapy as ordered to delay delivery long enough to administer therapy: corticosteroids to accelerate fetal lung maturity; complete maternal transport to a Level III center before delivery; maternal antibiotic therapy to prevent neonatal Group B streptococcus (GBS) infection.

Source: Gilbert (2011)

PREMATURE RUPTURE OF THE MEMBRANES

To facilitate an understanding of premature rupture of the membranes (PROM), it is helpful to first define the various terms used:

■ Premature rupture of the membranes is defined as rupture of the membranes before the onset of labor at any gestational age.

■ Preterm ROM is defined as rupture of the membranes before 37 completed weeks of gestation and is a common cause of PTL, preterm delivery, and chorioamnionitis.

■ Preterm premature rupture of the membranes is defined as a combination of both terms. Rupture occurs before the 37th completed week of gestation and in the absence of labor.

One of the most common causes of PROM is infection or bacteria in the genital tract that causes an inflammatory process, enabling the weakening of the amnionic sac. Most often, the patient reports a gush or leakage of fluid from the vagina. However, any increased vaginal discharge should be evaluated. The diagnosis is based on the patient’s history of leaking vaginal fluid and the finding of a pooling of fluid on sterile speculum examination. The nitrazine, AmniSure, or fern test can confirm the diagnosis of PROM. Easily performed, these tests discriminate between vaginal discharge and amniotic fluid. Ultrasound examination of amniotic fluid volume may be useful in documenting  oligohydramnios (decreased amniotic fluid) but is not considered diagnostic.

Management

The risk of perinatal complications changes dramatically according to the gestational age when ROM occurs. Clinical practice varies and, at present, considerable controversy exists concerning the optimal management of PPROM. However, there is consensus about the following factors:

■ Gestational age should be established based on clinical history and prior ultrasound assessment when available.

■ Ultrasound should be performed to assess fetal growth, position, and residual amniotic fluid.

■ The woman should be assessed for evidence of advanced labor, chorioamnionitis (intrauterine infection), abruptio placentae, and fetal distress.

■ Patients with advanced labor, intrauterine infection, significant vaginal bleeding, or nonreassuring fetal testing are best delivered promptly, regardless of gestational age.

Conservative management includes inpatient observation unless the membranes reseal and the leakage of fluid stops. This approach initially consists of prolonged continuous fetal and maternal monitoring combined with modified bedrest to promote amniotic fluid reaccumulation and spontaneous membrane sealing. Delivery of the fetus should be accomplished if signs of infection are present: maternal temperature of 100.4°F (38°C) or greater, foul-smelling vaginal discharge, elevated WBC, uterine tenderness, and maternal and/or fetal tachycardia.

Without intervention, approximately 50% of patients who have ROM will go into labor within 33 hours, and up to 95% will do so within 94–107 hours (American College of Obstetricians and Gynecologists, 2020c). Although maintaining the pregnancy to gain further fetal maturity can be beneficial, prolonged PPROM has been correlated with an increased risk of chorioamnionitis, placental abruption, and cord prolapse.

The nurse’s role in caring for the patient with PPROM includes explaining to the patient that she will be on full or modified bedrest and her vital signs will be checked at least every 4 hours to detect early signs of a developing infection. If the patient does not exhibit signs of labor, intermittent fetal monitoring is appropriate. Frequent ultrasound examinations are performed to assess amniotic fluid levels. An important component of the nursing care plan centers on providing emotional support to the patient who is understandably worried about the outcome for her baby. The nurse should encourage the woman and her family members to ask questions and express fears and concerns.

Patient Education

For the woman with uncomplicated PROM, discharge home may be appropriate with close follow-up. The nurse should provide education on staying hydrated, monitor temperature, monitor vaginal discharge. The woman will also need to abstain from intercourse, inserting any items into the vagina, avoid taking baths, and should abstain from smoking or using other substances. Routine fetal kick counts should be conducted on a daily basis and promptly report any concerning changes or worsening symptoms to the health-care provider.

HYPERTENSIVE DISORDERS OF PREGNANCY

Hypertensive disorders is one of the common medical complications, the second leading cause of death in pregnancy, and has been identified as a preventable condition in pregnancy (Centers for Disease Control and Prevention, 2018). The incidence of hypertensive disorders is between 8% and 10% of pregnancies (U.S. National Library of Medicine, 2018; Webster et al, 2019). Hypertensive disorders contribute significantly to adverse outcomes for the pregnancy including placental abruption, preterm birth, and results in adverse infant outcomes including low birth weight, poor fetal growth, and even increasing the risk for stillbirth (U.S. National Library of Medicine, 2018). For the mother, hypertension can result in cerebral hemorrhage, HELLP syndrome, DIC, hepatic failure, acute renal failure, and a higher risk of cardiovascular disease later in life (U.S. National Library of Medicine, 2018; Webster et al., 2019).

Classifications and Definitions

The terminology used to describe hypertensive disorders covers an array of different types of disorders from the following classifications:

■ Chronic hypertension is present and observable before pregnancy or diagnosed before the 20th week of gestation. Hypertension is defined as a systolic pressure greater than or equal to 140 mm Hg and a diastolic pressure greater than or equal to 90 mm Hg.

■ Gestational hypertension is the development of new onset of hypertension after 20 weeks of gestation without proteinuria.

■  Pre-eclampsia is a pregnancy-specific systemic syndrome clinically defined as an increase in blood pressure (i.e., systolic and diastolic blood pressures greater than or equal to 140 and greater than or equal to 90 mm Hg, respectively, occurring twice, 4 hours apart) after 20 weeks’ gestation accompanied by proteinuria (excretion of greater than or equal to 300 mg protein/24 hours or 1 + dipstick).

■  Eclampsia is the presence of new-onset grand mal seizures in a woman with pre-eclampsia who has no other cause for seizure (Centers for Disease Control and Prevention, 2018; Croke, 2019; U.S. National Library of Medicine, 2018; Webster et al, 2019).

Pre-eclampsia

Pathophysiology

The normal physiological adaptations to pregnancy are altered in the woman who develops pre-eclampsia. Pre-eclampsia is a multisystem, vasopressive disease process that targets the cardiovascular, hematological, hepatic, renal, and central nervous systems.

Pre-eclampsia is associated with a clinical spectrum of events that range from mild to severe with a potential endpoint of eclampsia. Patients do not suddenly “catch” severe pre-eclampsia or develop eclampsia but rather progress in a predictable course through the clinical spectrum. In most cases, the progression is relatively slow, and the disorder may remain mild. In other situations, the disease can progress more rapidly and change from a mild to a severe form in a matter of days or weeks. In the most serious cases, the progression can be rapid: Mild disease at the time of diagnosis evolves to pre-eclampsia with severe features or eclampsia over hours or days (Lavallee, 2015). Hence, the nurse must alert the patient to signs and symptoms that signal a worsening condition and continuously assess the patient for any change.

Although the pathophysiology is poorly understood, it is clear that the blueprint for its development is laid down early in pregnancy. Pre-eclampsia is a disease of the placenta because it has been documented in pregnancies that involve trophoblastic tissue but no fetus (i.e., a molar pregnancy). In a normal pregnancy, the endovascular trophoblast cells of the placenta transform uterine spiral arteries to accommodate an increased blood flow. In the presence of pre-eclampsia, the arterial transformation is incomplete. Women with preeclampsia have a distinctive lesion in the placenta termed acute atherosis (fat accumulation in the placental arteries). Their placentas also exhibit a greater degree of infarction (necrosis related to decreased blood supply) than is found in placentas of normotensive women. These pathological changes can lead to decreased placental perfusion and placental hypoxia (Lavallee, 2015; Cunningham et al, 2018).

Vasospasm and endothelial cell damage are the major underlying pathophysiological events in pre-eclampsia. Vasospasm may be associated with an elevation in arterial blood pressure and resistance to blood flow. It is unclear whether vasospasm produces damage to the vessels or if damage to the vessels produces vasospasm. Regardless, the restriction of blood flow is associated with endothelial cell damage, and this tissue insult prompts the systemic utilization of platelets and fibrinogen. The widespread vascular changes alter blood flow and result in hypoxic damage to vulnerable organs. Over time, the alterations produce widespread maternal vasospasm that results in decreased perfusion to virtually all organs, including the placenta. Associated physiological events include decreased plasma volume, activation of the coagulation cascade, and alterations in the glomerular endothelium. The increased platelet activation and markers of endothelial activation can predate clinically evident pre-eclampsia by weeks or even months and can lead to HELLP syndrome (Lavallee, 2015; Cunningham et al, 2018) ( Fig. 6-8).

 Assessment Tools

SPASMS: A Memory Enhancer When Caring for a Pre-eclampsia Patient

S Significant blood pressure changes may occur without warning.

P Proteinuria is a serious sign of renal involvement.

A Arterioles are affected by vasospasms that result in endothelial damage and leakage of intravascular fluid into the interstitial spaces. Edema results.

S Significant laboratory changes (most notably, liver function tests [LFTs] and the platelet count) signal worsening of the disease.

M Multiple organ systems can be involved: cardiovascular, hematological, hepatic, renal, and central nervous system.

S Symptoms appear after 20 weeks of gestation.

Risk Factors

In the United States, the incidence of pre-eclampsia is rising, most likely caused by an increased prevalence of predisposing disorders such as obesity, diabetes, and chronic hypertension.

Risk factors associated with pre-eclampsia are presented in  Box 6-7.

Classification of Pre-eclampsia and Maternal and Fetal Morbidity and Mortality

A number of maternal and fetal complications are likely to develop as the condition worsens. Signs of severe disease include any of the following:

■ Systolic BP greater than or equal to 160 mm Hg or diastolic BP greater than or equal to 110 mm Hg on two occasions at least 4 hours apart while the patient is on bedrest

■ Thrombocytopenia (platelets less than 100 × 109/L)

■ Impaired liver function, as indicated by abnormally elevated blood concentrations of liver enzymes (to twice normal concentration) and/or severe, persistent right upper quadrant (RUQ) or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses

BOX 6-7

Risk Factors for Pre-eclampsia

• Primigravida (6–8 times greater risk)

• Age extremes (less than 19 years and greater than 40 years)

• Pregestational diabetes

• Pre-existing hypertension, renal disease, or collagen disease

• Multiple gestation (5 times greater risk)

• Fetal hydrops (10 times greater risk)

• Hydatidiform mole (10 times greater risk)

• Pre-eclampsia in a previous pregnancy

• Family history

• Obesity

• Periodontal disease

• Antiphospholipid antibody syndrome

• Rh incompatibility

• African American ethnicity

• Pregnancies that result from donor insemination, oocyte donation, or embryo donation

CDC (2018), Croke (2019), Cunningham et al (2018)

■ Progressive renal insufficiency (serum creatinine concentration greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease

■ Pulmonary edema

■ New-onset visual or central nervous system (CNS) disturbances

FIGURE 6-8 Pathophysiological changes of pre-eclampsia.

The maternal complications associated with pre-eclampsia are related to the widespread arteriolar vasoconstriction that affects the brain (seizure and stroke), kidneys (oliguria and renal failure), liver (edema and subcapsular hematoma), and small blood vessels (small ruptures within the walls of the vessels use up large amounts of platelets in an effort to correct the bleeding). This results in thrombocytopenia and DIC.

The perinatal outcome in pre-eclampsia is dependent on one or more of the following factors: the gestational age at the onset of the disease process, the presence of a multiple gestation, and the presence of underlying maternal hypertension or renal disease. In patients with pre-eclampsia without severe features at term, the perinatal mortality, incidence of fetal growth restriction, and neonatal morbidity are similar to those associated with normotensive pregnancies. In contrast, both perinatal and maternal morbidity are increased when the disease is severe, particularly when disease develops in the second trimester, and the fetus is quite immature. Maternal death and severe complication rates from pre-eclampsia are also lowest among women who receive regular prenatal care and are managed by experienced physicians in tertiary centers (Croke, 2019).

Management of Pre-eclampsia/Eclampsia

Once the diagnosis of pre-eclampsia has been made, delivery of the fetus is the only cure. The primary considerations of therapy must always be the safety of the patient and the delivery of a live, mature newborn who will not require intensive and prolonged neonatal care. According to ACOG, preeclampsia without severe features, which presents as a maternal blood pressure of greater than or equal to 140 mm Hg systolic or greater than or equal to 90 mm Hg diastolic (on two occasions at least 4 hours apart after 20 weeks of gestation) and proteinuria (greater than or equal to 300 mg/24 hours  or protein/creatinine ratio greater than or equal to 0.3  or dipstick reading greater than or equal to 1 +), can often be managed at home after the patient has had a careful assessment of her signs and symptoms, a physical examination, laboratory tests, and evaluation of fetal well-being (Croke, 2019).

For patients with new-onset pre-eclampsia, the initial examination must be performed in the hospital. Ongoing education (e.g., rationales for various tests and instructions for fetal activity monitoring) and the provision of a supportive environment are important nursing interventions at this time. If the woman’s blood pressure and laboratory test results indicate that her care may be safely managed at home, the nurse must make certain that the patient fully understands the signs and symptoms associated with a worsening of the condition and report promptly to their health-care provider ( Fig. 6-9).

  Patient Education

Home Management of the Pregnant Patient With a Hypertensive Disorder

Before discharge, it is important to ascertain that the home environment is conducive to recovery and the patient will be able to rest frequently throughout the day. It is essential that the patient can verbalize understanding of the importance of keeping all prenatal appointments and that she must immediately notify her physician or midwife at the first appearance of:

• Blood pressure values greater than those at the time of hospital discharge—MD or certified nurse-midwife should provide parameters

• Visual changes

• Epigastric pain

• Nausea and vomiting

• Bleeding gums

• Headaches

• Increasing edema, especially of the hands and face

• Decreasing urinary output

• Decreased fetal movement

• “Just not feeling right”

 Collaboration in Caring

Promoting Rest at Home

Obtaining an adequate amount of rest is not always easy, especially for women who have other children at home and no extended family to help. The nurse may offer suggestions for getting adequate rest, such as lying down and resting while the other children nap, bringing young children into bed and reading them a story, or asking a neighbor to watch the children. The woman’s partner should also be involved in formulating a plan to help facilitate rest. Church groups may be able to help out with child care, running errands, or preparing meals for the family. When friends ask what they can do to help, suggest that the woman have a prepared list of specific actions that would make it easier for her to maintain a calm, restful home environment. The hospital’s social services department should also be contacted and asked for assistance. They are a useful resource that can share information about organizations that can be called on to help.

FIGURE 6-9 Nurse provides discharge teaching to a patient with pre-eclampsia.

Because lying in the lateral side position decreases pressure on the vena cava, the woman is instructed to maintain this position as much as possible. This position also increases venous return, circulatory volume, and placental and renal perfusion. Improving renal blood flow helps decrease angiotensin II levels, promotes diuresis, and lowers blood pressure. Antihypertensive medications have not been shown to improve perinatal outcomes in pre-eclampsia without severe features and should not be routinely prescribed.

The clinical course of pre-eclampsia with severe features may be characterized by a progressive deterioration in both maternal and fetal conditions. Pregnancies complicated by pre-eclampsia with severe features have been associated with increased rates of perinatal mortality and significant risks for maternal morbidity and mortality. Because of this, there is universal agreement that delivery should be prompt if the disease develops after 34 weeks’ gestation or earlier if there is evidence of maternal or fetal compromise. Management of pre-eclampsia with severe features includes the following clinical actions:

1. Seizure prophylaxis with magnesium sulfate, which has been universally accepted as the drug of choice because of its CNS-depressant action.

2. Antihypertensive medications ( Table 6-1 and 6-2). The use of antihypertensive agents in severe pre-eclampsia is generally indicated when diastolic blood pressures reach or exceed 110 mm Hg. The goal of therapy is to reduce the risk of cerebral vascular accident while maintaining uteroplacental perfusion. A decrease in the diastolic pressure to less than 90 mm Hg in the patient with severe hypertension will decrease placental blood flow, often with a decrease in the FHR. Management is directed at reducing the diastolic blood pressure to a value of less than 110 mm Hg but greater than 95 to 100 mm Hg.

TABLE 6-1

Medications Used to Treat Chronic Severe Hypertension in Pregnancy
AGENT (TRADE NAME)	CLASS	DOSE	MATERNAL ADVERSE EFFECTS	BREASTFEEDING
Alpha-methyldopa	Central alpha-adrenergic inhibitor	0.5–3.0 g PO per day in 2–3 divided doses	Sedation, elevated liver function tests, depression, dry mouth, lethargy, hemolytic anemia	Safe
Labetalol (Trandate)	Alpha-/beta-adrenergic blocker	200–2,400 mg PO per day in 2–3 divided doses	Headache, dizziness, orthostatic hypotension, nausea/vomiting, sweating, bronchospasm, dyspnea, scalp tingling, tremulousness, flushing	Safe
Nifedipine (Adalat, Procardia)	Calcium channel blocker	30–120 mg PO per day of a slow-release preparation	Headache, orthostatic hypotension, flushing, tachycardia	Safe
Adjunctive Agents
Hydralazine hydrochloride	Peripheral arteriolar vasodilator	50–300 mg PO per day in 2–4 divided doses	Tachycardia, dizziness, headache, palpitations. Use with methyldopa or labetalol to prevent reflex tachycardia; risk of neonatal thrombocytopenia	Safe
Hydrochlorothiazide	Loop diuretic	12.5–50 mg PO per day	Dizziness, drowsiness, lethargy, weakness, hypotension, volume depletion, electrolyte disorders (e.g., hypokalemia, hypercalcemia, hypomagnesemia, hyponatremia, hypophosphatemia)	Risk is remote, but there are concerns about potential thrombocytopenia in infants

Sources: Vallerand & Sanoski (2021), King et al (2016), Webster et al (2019), Cunningham et al (2018)

TABLE 6-2

Medications Used for Urgent Control of Severe Acute Hypertension in Pregnancy
AGENT (TRADE NAME)	CLASS	DOSAGE	MATERNAL ADVERSE EFFECTS
Labetalol hydrochloride (Normodyne, Trandate)	Alpha-/beta-adrenergic blocker	20 mg IV, then 20–80 mg every 5–15 minutes, up to a maximum of 300 mg; or constant infusion of 1–2 mg/min	Lower risk of tachycardia and arrhythmia than with other vasodilators; increasingly preferred as first-line agent. May cause neonatal bradycardia and should be avoided in women with asthma or heart failure.
Hydralazine	Peripheral/arterial vasodilator	5 mg IV or IM, then 5–10 mg every 20–40 minutes; or constant infusion of 0.5–10 mg/hr	Long experience of safety and efficacy; risk of delayed maternal hypotension (systolic BP ≤ 90 mm Hg) and fetal bradycardia. Considered a first-line agent.
Nifedipine (Adalat, Procardia)	Calcium channel blocker	10–30 mg PO, repeat in 45 minutes if needed	See hydralazine. Possible interference with labor; use caution if the patient is also receiving magnesium sulfate.
Sodium nitroprusside (Nitropress)	Vasodilator	0.25 mcg/kg/min (increase by 0.25 mcg/kg/min every 5 minutes) to a maximum of 5 mcg/kg/min	Should be reserved for extreme emergencies and used for the shortest amount of time possible because of concerns about cyanide and thiocyanate toxicity in the mother and fetus or newborn and of cerebral edema in the mother.

Source: Vallerand & Sanoski (2021).

3. Invasive hemodynamic monitoring may be required if any of the following are present:

■ Oliguria unresponsive to a fluid challenge

■ Pulmonary edema

■ Hypertensive crisis refractory to conventional therapy

■ Cerebral edema

■ DIC

■ Multisystem organ failure

Nursing Assessments

Nursing care centers on extremely accurate, astute observations and assessments. An in-depth understanding of the pharmacological regimens, management plans, and potential complications associated with this disease is also essential. The clinical manifestations of pre-eclampsia are directly related to the presence of vascular vasospasms. Vasospasms cause endothelial injury, red blood cell (RBC) destruction, platelet aggregation, increased capillary permeability, increased systemic vascular resistance, and renal and hepatic dysfunction.

  MEDICATION:  Magnesium Sulfate (mag -nee-zhum  sul-fate)

Pregnancy Category:  D

Indications:  Anticonvulsant in severe pre-eclampsia or eclampsia

Unlabeled Use:  Preterm labor

(Note: Magnesium sulfate is not FDA-approved for the treatment of PTL)

Actions:  Plays an important role in neurotransmission and muscular excitability

Therapeutic Effects:  Resolution of eclampsia

Pharmacokinetics:

ABSORPTION: IV administration results in complete bioavailability; well absorbed from IM sites

DISTRIBUTION: Widely distributed; crosses the placenta and is present in breast milk

METABOLISM AND EXCRETION: Excreted primarily by the kidneys

HALF-LIFE: Unknown

Contraindications and Precautions:

CONTRAINDICATED IN: Hypermagnesemia/hypocalcemia/anuria/heart block/active labor or within 2 hours of labor (unless used for pre-eclampsia or eclampsia)

USE CAUTIOUSLY IN: Any degree of renal insufficiency

Adverse Reactions and Side Effects:

Central nervous system: Drowsiness

Respiratory system: Decreased respirations

Cardiovascular system: Arrhythmias, hypotension, bradycardia

Gastrointestinal system: Diarrhea

Dermatology system: Flushing, sweating

Metabolic: Hypothermia

Interactions:  Potentiates neuromuscular blocking agents

Route and Dosage (Eclampsia/Pre-eclampsia):

Piggyback a solution of 40 g of magnesium sulfate in 1,000 mL of lactated Ringer’s solution—use an infusion control device at the ordered rates: loading dose, initial bolus of 4 to 6 g over 15 to 30 min; maintenance dose, 1 to 3 g/hr.

IM: 4 to 5 g given in each buttock; can be repeated at 4-hour intervals; use Z-track technique. (Note: IM route rarely used because the absorption rate cannot be controlled and injections are painful and may result in tissue necrosis.)

Time/Action Profile for Anticonvulsant Effect:

IM: Onset is 60 minutes with peak unknown, and duration is 3 to 4 hours; IV: Onset is immediate with peak unknown and duration is 30 minutes.

Nursing Implications:  Remember that this is a very potent, high-alert drug!

1. Explain purpose and side effects of the medication to the patient and her companion.

2. Explain that she may feel very warm, become flushed, and experience nausea and vomiting, visual blurring, and headaches.

3. Magnesium sulfate must never be abbreviated and requires a written order by the physician for administration.

4. Always use an infusion pump for administration and run the medication piggyback, not as the main line.

5. Monitor pulse, blood pressure, respirations, and ECG frequently throughout parenteral administration. Respirations should be at least 16/min before each dose.

6. Monitor neurological status before and throughout therapy.

7. Institute seizure precautions.

8. Keep the room quiet and darkened to decrease the likelihood of triggering seizure activity.

9. Patellar reflexes should be tested before each parenteral dose of magnesium sulfate. If absent, no additional dose should be administered until a positive response returns.

10. Monitor intake and output. Urine output should be maintained at a level of at least 100 mL/4 hr.

11. Serum magnesium levels and renal function should be monitored periodically throughout administration of parenteral magnesium sulfate ( Box 6-8).

12. Have 10% calcium gluconate available should toxicity occur. Administer 10 mL IV over 1 to 3 minutes until signs and symptoms are reversed.

13. After delivery, monitor the newborn for hypotension, hyporeflexia, and respiratory depression.

Source: Data from Vallerand, A. H., & Sanoski, C. A. (2021). Davis’s drug guide for nurses (17th ed.). Philadelphia: F.A. Davis.

 Clinical Judgment Alert

Preventing Magnesium Sulfate Accidents

Accidental overdose of magnesium sulfate administration can pose a significant risk to both mother and newborn. Current recommendations to prevent magnesium sulfate accidents include the following:

• A standardized unit protocol should be consistent and include standing orders addressing the initial bolus and maintenance dose to be administered, how the pump should be programmed, the maintenance IV solutions that will be used, and the frequency that the fetus and mother will be assessed.

• Administer IV magnesium sulfate (including the initial bolus) only through a controlled infusion device with free-flow protection.

• Use universal standardized dose prepackaged magnesium sulfate.

• Have a second nurse check the initial magnesium sulfate IV bag and pump settings (and every magnesium sulfate IV bag that is added and each subsequent rate change).

• Use a 100-mL (4 g) or 150-mL (6 g) IV piggyback for the initial bolus instead of bolusing from the main bag with a rate change on the pump.

• Use color-coded tags on the lines as they go into the pumps and into the IV ports.

• Provide 1:1 nursing care for women in labor who are receiving magnesium sulfate.

• When care is transferred to another nurse, have both nurses together at the bedside to review the pump settings for both the magnesium sulfate and mainline IV fluids and to review written physician orders for magnesium sulfate infusion orders.

• Implement periodic magnesium sulfate overdose drills with airway management and calcium administration with the physician and nurse team members participating together.

• Maintain the calcium antidote in the patient’s room in a locked box.

 Optimizing Outcomes

Daily Assessment for Patients Who Have Pre-eclampsia

During the assessment, the nurse should include the following parameters:

• Auscultation of heart sounds, lungs, and breath sounds

• Presence and degree of edema

• Early signs or symptoms of pulmonary edema, such as tachycardia and tachypnea

• Daily weight taken at the same time of the day and on the same scale

• Skin color, temperature, and turgor

• Capillary refill, which may indicate decreased perfusion or vasoconstriction if greater than 3 seconds

BOX 6-8

Serum Magnesium Levels

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

Sources: Vallerand & Sanoski (2021).

SIGNIFICANCE OF PROTEINURIA

Proteinuria is defined as the excretion of 300 mg or more of protein every 24 hours. If 24-hour urine samples are not available, proteinuria is defined as a protein concentration of 300 mg/L or more (greater than or equal to 1 + on dipstick) in at least two random urine samples taken at least 4 to 6 hours apart and no more than 7 days apart. As an important component of hospital care, the nurse assesses urine output every 1 to 4 hours to confirm adequate renal perfusion and oxygenation. A urine output of 25 to 30 mL/hr or 100 mL/4 hr is normal; a downward trend in output should be reported immediately. A urimeter attached to the Foley catheter tubing is useful in the accurate assessment of the hourly urine output. A 24-hour urine test for total protein may be ordered to monitor for an increase in the excretion of protein, a finding indicative of increasing kidney impairment. The nurse should be aware that if the 24-hour urine specimen (for total protein) shows the presence of protein, a dipstick is not appropriate. Once protein is evident in a 24-hour urine collection, protein will always be present when the urine is tested by the dipstick. Therefore, no new information is obtained. The 24-hour urine sample yields more accurate information because it shows whether or not the urine protein is increasing, decreasing, or remaining the same. When indicated, a high-protein diet may be needed to replace the protein excreted in the urine.

ASSESSING EDEMA

At one time, edema was an important component of the triad considered along with hypertension and proteinuria to diagnose pre-eclampsia. However, edema is a common finding in pregnancy. Dependent edema in the absence of hypertension or proteinuria is generally related to changes in the interstitial and intravascular hydrostatic pressures that facilitate the movement of intravascular fluid into the tissues. When pre-eclampsia is present, continuous capillary leakage combined with a decreased colloidal pressure can lead to pulmonary edema. In this situation, intravascular fluid leaks out through holes (caused by vasospasms) in the endothelial lining of the blood vessels. Pulmonary edema can occur very suddenly, especially if the patient receives an overload of IV fluid. Because of the potential for rapid development of this life-threatening complication, the nurse must frequently perform a careful assessment of the patient’s pulmonary status and meticulously monitor the total intake and output.

CENTRAL NERVOUS SYSTEM ALTERATIONS

Pre-eclampsia may quickly develop into eclampsia, the convulsive phase of pre-eclampsia. Before the onset of seizure activity, the patient may complain of headaches, visual disturbances, blurred vision,  scotomata(blind spots, specks or spots in the vision), and in rare cases, cortical blindness. These symptoms can be indicators of increased CNS irritability that precedes the onset of seizures. A retinal examination often reveals vascular constriction and narrowing of the small arteries. These changes are reflective of the widespread vasoconstriction occurring throughout the body. Deep tendon reflexes (DTRs) are also routinely assessed for evidence of irritability and clonus (rapidly alternating muscle contraction and relaxation), two additional signs of increased CNS irritability with pre-eclampsia, and there will be reflexes on the brisker side (Sommers, 2019). Other nursing interventions include maintaining a quiet, darkened environment, reducing stimuli that may result in hypertension and seizures. Ensure that seizure precautions (e.g., suction equipment, oxygen administration equipment, and emergency medication tray) are in place (Figs. 6-10 and 6-11).

 Optimizing Outcomes

Grading Reflexes and Checking for Clonus

During the assessment, grade maternal reflexes on a 0 to 4 + scale:

4 + Very brisk, hyperactive; often indicative of disease; often associated with clonus

3 + Brisker than average; possibly but not necessarily indicative of disease

2 + Average; normal

1 + Somewhat diminished

0 No response

Procedure

If the reflexes are hyperactive, test for ankle clonus. Clonus is a spasmodic reaction to the stretching of a muscle. Support the knee in a partly flexed position. With your other hand, dorsiflex and plantar flex the foot a few times while encouraging the patient to relax, and then sharply dorsiflex the foot and maintain it in dorsiflexion. Look and feel for rhythmic oscillations between dorsiflexion and plantar flexion. Normal is no reaction to this stimulus. Sustained clonus indicates upper motor neuron disease. The ankle plantar flexes and dorsiflexes repetitively and rhythmically (see  Fig. 6-11) (Sommers, 2019). Clonus is usually noted as “absent” or “present” but it may be rated as:

• Mild (2 movements)

• Moderate (3 to 5 movements)

• Severe (6 or more movements)

FIGURE 6-10 Assessing deep tendon reflexes.

FIGURE 6-11 Testing for clonus.

Eclampsia

Eclampsia is the occurrence of grand mal seizures in women who have either gestational hypertension or pre-eclampsia and is considered an obstetrical emergency (Lavallee, 2015). It is the most common CNS complication of hypertension, and most maternal deaths attributable to hypertension occur in women with eclampsia. Although patients with severe pre-eclampsia are at the greatest risk for developing seizures, eclampsia-related seizures have been reported in women with pre-eclampsia without severe features. Women developing eclampsia exhibit a wide spectrum of signs and symptoms, ranging from extremely high blood pressure, 4 + proteinuria, generalized edema, and 4 + patellar reflexes to minimal blood pressure elevation, no proteinuria or edema, and normal reflexes.

Maternal complications of eclampsia include cerebral hemorrhage, aspiration pneumonia, hypoxic encephalopathy, coma, thromboembolic events, and maternal death (incidence 0.4% to 14%). The perinatal death rate in pregnancies complicated by eclampsia is 9% to 23%. Perinatal deaths are closely related to gestational age and most often result from premature delivery, abruptio placentae, and intrauterine asphyxia (Cunningham et al, 2018). Eclampsia is a serious condition, and anyone who is pregnant and having a seizure must be considered eclamptic until proven otherwise.

 FOCUS ON SAFETY

Care of the Seizing Pregnant Patient

Seizures are an obstetrical emergency. Nurses caring for a patient who is having a seizure or is postseizure must activate the code team and call for help. Patient safety is paramount and a nurse must stay with the patient during the seizure. Actions to take include the following:

• Do not attempt to shorten or abolish the initial seizure.

• Secure the patient airway, maintain adequate oxygenation; administer oxygen via face mask at 10 L/min.

• Minimize the risk of aspiration. Suction equipment should be ready and working.

• Assess circulation and for pulse. Activate an arrest code if no pulse.

• Place patient on left side to prevent aortic compression.

• Monitor vital signs frequently.

• Obtain intravenous access.

• Obtain blood work and pre-eclampsia panel for monitoring.

• Give adequate magnesium sulfate to control seizures. As soon as possible following the seizure, venous access should be secured with a 4- to 6-g loading bolus of magnesium sulfate given over 15 to 20 minutes. If the patient seizes following the loading dose, another 2-g bolus may be given IV over 3 to 5 minutes.

• Correct maternal acidemia. Blood gas analysis allows monitoring of oxygenation and pH status. Respiratory acidemia is possible after a seizure.

• Avoid polytherapy. Maternal respiratory depression, respiratory arrest, or cardiopulmonary arrest is more likely in women who receive polytherapy to arrest a seizure. Remember that anticonvulsants are respiratory depressants and may interact.

• Monitor the fetus after a seizure. Fetal monitor tracing may show loss of FHR variability and bradycardia.

• Assess for ruptured membranes, contractions, cervical dilation, and signs of placental abruption.

• Prepare for delivery as indicated.

• Support the patient and her family. This is a very frightening event for them, and they will need reassurance and to be kept aware of the plan of care and the well-being of their baby (Lavallee, 2015; Phillips & Boyd, 2016).

 CASE STUDY

Rosa Garcia

Rosa Garcia is a 25-year-old married Mexican immigrant who is pregnant with her first child. Rosa’s family practice physician has been caring for her since her first prenatal visit at 114/7 weeks’ gestation. During the initial prenatal visit, the following data were obtained:

Vital signs: temperature: 98.6°F (37.0°C); pulse: 78 beats/min; respirations: 20 breaths/min; blood pressure: 110/70; weight: 146 lb (66.4 kg)

A complete physical examination was performed with normal findings, and prenatal labs including a thyroid-stimulating hormone level (TSH; because of a positive family history for hypothyroidism) were drawn. During the interview, the nurse inquired about any other family medical problems. Rosa reported that both her sister and her mother had experienced pre-eclampsia during pregnancy.

An ultrasound was ordered for pregnancy dating because Rosa had experienced irregular menstrual periods since discontinuing oral contraceptives.

Rosa kept her regular prenatal appointments every 4 weeks and the pregnancy progressed uneventfully until 4 months later, when she presented to the office with increased blood pressure and swollen legs. Rosa had noticed an increased swelling that extended up to the knees of both legs. She denied hand or facial swelling, headaches, visual problems, or RUQ pain. Her sister, a chiropractor, had been checking her blood pressure and noted it to be as high as 160 to 170/100 to 110 mm Hg. At this prenatal visit, the following data were obtained:

Blood pressure: 144/96 (sitting). Repeat on left side: 140/90. Weight: 172.5 lb (78.4 kg)

Urine dipstick reading: 1 +

Physical examination: General—in no acute distress; abdomen: nontender fundus at 28–11.8 in. (30 cm) above the symphysis pubis; FHR 150 bpm; cardiovascular: 1 + pedal edema; neurological: reflexes 3 + with no clonus.

Assessment: Pre-eclampsia without severe features.

The following laboratory tests were ordered: CBC with platelet count, liver enzyme determination (AST, ALT, LDH), alkaline phosphatase (ALP), prothrombin time (PT), a chemistry panel (electrolytes: Na+, K+, Cl–, HCO3–, Ca2+, Mg2+), blood urea nitrogen (BUN), creatinine (Cr), uric acid, and a 24-hour urine collection for protein and creatinine clearance. A sonogram (ultrasound) was also ordered to monitor the status of the fetus.

Rosa was instructed to go home, rest on her left side as much as possible, and call the nurse if she experienced increased edema, headaches, visual disturbances, or RUQ pain. She was told to continue with fetal kick counts and twice daily blood pressure monitoring, record all findings and symptoms, and return to the office in 1 week.

On her next office visit 8 days later, Rosa reported that she had been adhering to frequent rest periods at home and had noticed that her leg edema was improved. She exclaimed: “I can see my ankle bones again!” Her sister had continued to monitor the blood pressure. According to the blood pressure log, Rosa’s systolic blood pressure measurements had been in the 160s and the diastolic measurements were in the 80 to 90 range. Rosa denied headaches, visual disturbances, or abdominal pain and remarked that the fetus had been active. At this visit, the following data were obtained:

Blood pressure: 160/98 (sitting); 162/100 (left side); weight: 160 lb (72.7 kg); fundal height: 27 cm; FHR: 150 to 170 bpm; reflexes: 3 to 4 + with no clonus; urinary protein: 4 + (2,000 + mg/dL) on dipstick

Assessment: Pre-eclampsia with severe features at 294/7 weeks’ gestational age

At this point, Rosa’s physician consulted with a maternal fetal medicine specialist, who advised transferring Rosa to a tertiary care center 50 miles away. Rosa was promptly transferred to the tertiary care center and admitted to the obstetric service.

CRITICAL THINKING QUESTIONS

1. What are Rosa’s risk factors for developing pre-eclampsia?

2. Why did the nurse ask Rosa about headaches, blurred vision, and RUQ pain?

3. What signs and symptoms prompted Rosa’s physician to consult with the maternal–fetal specialist and arrange for a transfer to a tertiary care center?

HELLP Syndrome

HELLP is an acronym for  Hemolysis and  Elevated  Liver enzymes and  Low  Platelet levels. As a result of the arteriolar vasospasms in the cardiovascular system that occur in pre-eclampsia, the circulating RBCs are destroyed as they try to navigate through the constricted vessels  (Hemolysis). Vasospasms decrease blood flow to the liver, resulting in tissue ischemia and hemorrhagic necrosis  (Elevated  Liver enzyme level). In response to the endothelial damage caused by the vasospasms (small openings develop in the vessels), platelets aggregate at the site and a fibrin network is set up, leading to a decrease in the circulating platelets  (Low  Platelet level).

HELLP syndrome is a rare and life-threatening condition that arises as a serious complication of pre-eclampsia in approximately 1 to 2 of every 1,000 pregnancies (Sommers, 2019; Venes, 2021). It can manifest itself at any time during pregnancy and the puerperium, but like pre-eclampsia, it is rare before 20 weeks’ gestation.

HELLP syndrome consists of a combination of laboratory anomalies. The primary presentation of patients often have pre-eclampsia symptoms of nausea, vomiting, epigastric pain, headache, vision problems, hepatic dysfunction leading to liver failure, acute renal failure, DIC, respiratory failure, and/multiple organ failure (Sommers, 2019).

Therapy for HELLP syndrome centers on improving the platelet count by transfusion of fresh-frozen plasma or platelets and delivery as soon as feasible by vaginal or cesarean birth. Intrapartum nursing care involves continuous maternal-fetal monitoring. Measurement of central venous pressure or pulmonary arterial wedge pressure (Swan-Ganz catheter) may be required to monitor fluid status accurately when pulmonary edema or acute renal failure is present.

DISSEMINATED INTRAVASCULAR COAGULOPATHY

Disseminated intravascular coagulopathy (DIC) is a hematological disorder characterized by a pathological form of clotting that is diffuse and consumes large amounts of clotting factors. DIC causes widespread external or internal bleeding or both (Cunningham et al, 2018). The most common causes of DIC in pregnancy are excessive blood loss with inadequate blood component replacement, placental abruption, amniotic fluid embolism, and severe pre-eclampsia/HELLP syndrome. DIC is a consumptive coagulopathy that results in depletion of the platelets and clotting factors. Early diagnosis and prompt and appropriate management are critical in reducing maternal and perinatal death and complication rates (Sommers, 2019).

Nursing Care

Nursing care includes continued meticulous assessment for signs of bleeding (e.g., petechiae, oozing from injection sites, and hematuria). Amount of blood loss should be calculated in cases of vaginal bleeding and detailed assessments of any bruises or hematomas in terms of size, shape, color, and assessment time to monitor for worsening bleeding. Use of an indwelling catheter for monitoring urinary output and assessment of hematuria is essential because renal failure is a potential consequence of DIC. Vital signs and fetal assessments are monitored frequently, and the patient is maintained in a side-lying tilt to enhance blood flow to the uterus. Oxygen may be administered through a rebreathing mask at 8 to 10 L/min, and blood and blood products are administered according to physician orders (Sommers, 2019). The patient and her family are emotionally supported and kept informed about the maternal-fetal status.

MULTIPLE GESTATION

Multiple gestation refers to a pregnancy in which two or more fetuses are present in the uterus, most commonly twins. In 2018 there were 123,536 twin births, 3,400 triplet births, and 115 quadruplet births (Centers for Disease Control and Prevention, 2019e). Twinning occurs when ovulation produces two separate ova and each is fertilized (dizygotic, or fraternal twins), or if a single fertilized ovum (zygote) splits early in pregnancy and develops into two fetuses (monozygotic or identical twins) ( Fig. 6-12). Assisted reproductive technologies such as assisted embryo hatching and intracytoplasmic sperm injection have resulted in increased monozygotic twinning by as much as eightfold; monozygotic pregnancies account for only 30% of spontaneously conceived twins.

■ Dichorionic/diamniotic: Two chorions (outer membrane) and two amnions (inner membrane); division of the embryo takes place during the first 3 days of development; occurs in approximately 25% to 30% of monozygotic twins.

■ Monochorionic/diamniotic: One chorion (outer membrane) and two amnions (inner membrane) and a single, shared placenta. Division of the embryo takes place between 4 to 8 days of development; occurs in approximately 70% to 75% of monozygotic twins. Each twin has its own amnion, but the fetuses are surrounded by one chorion.

■ Monochorionic/monoamniotic: One chorion and one amnion—the fetuses share the same living quarters. The zygotic division occurs later than the first week of development. Associated with a very high (40% to 60%) mortality rate as a result of cord accidents from entanglement.

■ Conjoined twins: Conjoined twins are identical twins, whose bodies are joined in utero. The twins share a common chorion, amnion, and placenta. The level of degree they can be conjoined can be a small shared area to a large shared area, which can affect survival.

FIGURE 6-12 Multiple gestations.  A, Monozygotic twins with one placenta, one chorion, and two amnions.  B, Dizygotic twins with two placentas, two chorions, and two amnions.

Associated Complications

Multiple gestations are high-risk pregnancies associated with a number of maternal and fetal complications. Complications may occur during the antepartal, intrapartal, or postpartal period. Preterm labor often results from uterine overdistention and frequently necessitates an early operative delivery. Other complications include PTL, gestational diabetes, increased urinary tract infections (UTIs), pre-eclampsia/eclampsia, acute fatty liver, pulmonary embolism, placenta previa, fetal intrauterine growth restriction (IUGR), abnormal presentation, and umbilical cord prolapse (Cunningham et al, 2018).

Determination of Chorionicity

A positive diagnosis of a multiple gestation can be confirmed by ultrasound examination. Sonography reveals multiple gestational sacs with yolk sacs by 5 weeks of gestation and multiple embryos with cardiac activity by 6 weeks of gestation. Rapid uterine growth, excessive maternal weight gain, or palpation of three or more fetal large parts (cranium and breech) on Leopold maneuvers are clinical findings suggestive of multiple gestation. Laboratory tests show elevated levels of human chorionic gonadotropin (hCG), human placental lactogen (hPL), and MSAFP (Cunningham et al, 2018).

Ultrasound determination of chorionicity (an examination of the chorion), best performed around 10 to 13 weeks’ gestation, constitutes an important component of modern management. The presence of placental tissue between the layers of the intervening twin membrane near the placenta is indicative of a dichorionic/diamniotic (DC/DA) gestation, whereas the absence of intervening placental tissue between the membranes is indicative of a single chorion (a monochorionic/diamniotic [MC/DA] twin gestation). As a group, twins contribute disproportionately to the overall perinatal morbidity/mortality rate, and MC/DA twins demonstrate higher mortality rates than DC/DA twins.

Twin-to-twin transfusion syndrome, a complication of monochorionic twins, results from vascular connections or anastomoses (i.e., artery-to-vein, artery-to-artery, vein-to-vein) within the single, monochorionic placenta. In most cases, the vessels carry blood from one fetus to the other without creating an imbalance of flow. However, if an imbalance of blood flow occurs, one fetus receives a reduced blood volume (eventually leading to oligohydramnios) while the other twin receives an increased blood volume (eventually leading to polyhydramnios). Without intervention, fetal death occurs 90% of the time in one or both fetuses (Stagnati et al, 2017). Selective IUGR and twin-reversed arterial perfusion sequence are other complications that may affect monochorionic twins; management depends on the underlying cause and the gestational age at the time of diagnosis.

Multiple gestation pregnancies are considered high risk; ideally an appropriately trained specialist should manage the obstetric care. Delivery should be planned to take place at a Level III facility that has trained personnel who are prepared to deal with maternal or neonatal complications. When a pregnancy is complicated by a multiple gestation, the normal maternal physiological adaptations to pregnancy are heightened. Complications that are associated with these changes help to guide the clinical management. Consideration of maternal-fetal physiological parameters along with ongoing surveillance is essential in developing an appropriate plan of care.

Nursing Implications

Caring for the patient with a multiple gestation pregnancy can be challenging, especially when complications arise. Hospitalization may be needed because of the increased risk of complications, and the nurse needs to remain cognizant of this. There is an increased risk of pulmonary edema caused by the expanded plasma volume and increased cardiac output. Also, nutritional requirements are increased. Maternal caloric needs increase; in a singleton pregnancy a woman needs to increase their caloric intake by 300 calories, but with twins and triplets they need to increase by 600 and 900 per day (American College of Obstetricians and Gynecologists, 2020b). Early in the pregnancy, the patient may suffer from severe hyperemesis gravidarum as a result of higher levels of pregnancy hormones found in multiple pregnancies compared with singleton pregnancies. This condition can lead to dehydration and poor nutrient intake and require hospitalization for rehydration. At this time, the nurse can refer the patient to a nutritionist and also review foods that might be more appealing to the patient. Providing ongoing counseling about the importance of regular prenatal care and the identification of signs and symptoms of PTL and other complications constitutes a critical nursing action throughout the pregnancy.

The nurse must also remain aware that the patients being cared for are the woman (the primary patient) as well as each individual fetus. Serial ultrasounds, nonstress tests (NSTs), and biophysical profiles (BPPs) will be part of the ongoing assessment for fetal well-being and growth. Fetal surveillance with EFM may be difficult, especially with more than two fetuses. Triplet monitors are available that allow for the tracing of three separate FHRs on a single channel, or two heart rate tracings and a digital readout for the third fetus. It is best to monitor all fetuses simultaneously, and the nurse should label which line corresponds to which ultrasound transducer so that it is clear which fetus is being monitored. The presenting twin is always “A,” with the remaining fetuses (“B,” “C,” etc.) identified by relative ascending positions. Although not common, late pregnancy changes in fetal positions (e.g., male fetus B now in the position of female fetus A) should be noted in the patient record. If no recent ultrasound has been obtained, the nurse should identify each FHR by the appropriate abdominal quadrant.

A multifetal pregnancy can cause many concerns for the family. They often fear for the well-being of the babies, especially because PTL is a major complication with multiples. The thought of the everyday rigors of caring for several newborns at one time can constitute another major cause of stress. If there are other children in the household, the expectant couple may question how they are going to be able to give the older siblings the care and time they will also need. Family finances can be a great concern as well as the affordability of child care when it is necessary for the mother to return to work. The nurse can be supportive in encouraging families to voice their concerns and address them as appropriately as possible. Helping the family to prepare for the birth of the babies can be of great benefit. The nurse may offer suggestions that include giving the older children household chores appropriate for their age; alerting the partner’s employer of a potential need to adjust the work schedule to help out at home; or finding someone to help with housekeeping, grocery shopping, laundry, cleaning, and/or child care. Other team members such as social services can also provide valuable solutions to these concerns. Referring the couple to a support group may also be appropriate and welcomed.

INFECTIONS

Urinary Tract Infection

Urinary tract infection is the most common bacterial infection in pregnancy. The three most common clinical syndromes associated with UTI are asymptomatic bacteriuria, acute cystitis, and acute pyelonephritis.

The physiological dilation of the urinary collecting system that occurs normally during pregnancy is associated with an increase in ascending urinary infections. Mechanical and hormonal changes may lead to hydroureter, decreased peristalsis, bladder distention, and incomplete emptying. These events can result in urine stasis or reflux in the bladder and ureters (Cunningham et al, 2018).

The most common infecting organism is  Escherichia coli (E coli); other bacteria include Staphylococcus aureus,  Klebsiella, Proteus, Pseudomonas, Chlamydia, Enterobacter, Group B streptococcus (GBS), and coagulase-negative staphylococci (Derese et al, 2016). Bacteriuria in pregnancy predisposes the patient to the development of acute pyelonephritis, a condition that poses significant risk to the woman and her fetus. Asymptomatic and untreated bacteriuria has been associated with a number of complications during pregnancy including low birthweight, intrauterine death, pre-eclampsia, and maternal anemia.

Asymptomatic bacteriuria is defined as the presence of at least 105colony-forming units of bacteria per milliliter of clean, voided, midstream urine in specimens obtained on two separate occasions. As the name implies, the patient does not express any symptoms of a UTI. Asymptomatic bacteriuria occurs in 2% to 11% of pregnancies (T. L. King et al, 2018). Screening women for asymptomatic bacteriuria on the first prenatal visit constitutes a standard of obstetric care (Derese et al, 2016)). Treatment should be based on culture sensitivity so that the correct antibiotic therapy can be initiated.

 Optimizing Outcomes

When Caring for the Patient With an UTI

During pregnancy, a urine specimen is more likely to be contaminated by bacteria that originate in the urethra, vagina, or perineum. This occurs because of a change in pH during pregnancy. The urine becomes more alkaline as a result of the maternal excretion of bicarbonate; the vagina also becomes alkaline and the vaginal secretions have increased glycogen content, which aids bacterial growth. Before collecting a midstream specimen, the nurse should instruct the patient about the importance of proper cleansing.

A urinalysis and urine culture and sensitivity should be obtained on all patients who present with signs of PTL, and the nurse must remember that signs of UTI often mimic normal pregnancy complaints (i.e., urgency, frequency). It is important to remind the patient to take  all the medication that has been prescribed, even if the symptoms subside and she feels better. A repeat urine test to evaluate whether bacteria are still present should be obtained once the treatment has been completed.

Group B Streptococcal Infection

Group B streptococcus is a common infection in which many women do not show an active infection and have no symptoms. Women harbor GBS as part of the normal fecal and vaginal flora and typically remain asymptomatic and infection-free (Centers for Disease Control and Prevention, 2019a). However, they can still colonize these bacteria in the reproductive tract, frequently causing UTIs and chorioamnionitis during pregnancy as well as endometritis postpartum. Unfortunately, GBS can cause significant infections including sepsis and 4% to 6% of newborns who have GBS infection will die. Newborns are at risk of coming into contact of GBS when there is a vaginal birth and the woman is GBS positive. The newborn will come in direct contact with GBS, which can lead to early onset GBS infection. Late-onset GBS is community acquired (the route of transmission is less clear and can be nosocomial [acquired while in the hospital], environmental, or maternal) and presents more than a week after birth.

To protect infants from GBS infections, recommended screening is universal for maternal GBS infection. This includes obtaining vaginal and rectal cultures from all pregnant women between 36 and 37 weeks of pregnancy (American College of Nurse Midwives, 2019). Women with positive cultures and those with unknown GBS status at the onset of labor and any of the following: delivery at less than 37 weeks of gestation; ruptured membranes greater than or equal to 18 hours; or an intrapartum temperature greater than or equal to 100.4°F (38.0°C) are treated with a penicillin-based anti-infective agent.

TORCH Infections

TORCH refers to a group of maternal infectious diseases that cause harm to the embryo-fetus ( Table 6-3). The TORCH acronym stands for  Toxoplasmosis,  Rubella,  Cytomegalovirus (CMV), and  Herpes simplex virus type 2 (HSV-2). Some sources identify the “O” as “other” infections, such as hepatitis B, syphilis, and HIV. Maternal exposure to the TORCH infections during the first 12 weeks of gestation is associated with fetal developmental anomalies.

HIV and AIDS

HIV infection causes a slow but relentless destruction of the immune system that ultimately results in AIDS. HIV is an increasing problem among women of childbearing age as it can be transmitted in pregnancy to the newborn, known as perinatal transmission. The risk of perinatal transmission can be reduced if the woman complies with their antiviral medication and the newborn completes a 4-6 week course of postexposure HIV antiviral medications (Centers for Disease Control and Prevention, 2020b).

Ideally, universal HIV screening should be offered before conception; if not, testing should take place as early in the pregnancy as possible. Women with HIV should be counseled in the preconceptional, prenatal, and postpartum periods about appropriate antiviral medications and risks (American College of Nurse Midwives, 2017). Screening with a rapid HIV test is recommended for women who present in labor with an unknown HIV status; if reactive, immediate antiretroviral prophylaxis should be recommended.

TABLE 6-3

TORCH Infections
INFECTION/AGENT/TRANSMISSION	DETECTION	MATERNAL EFFECTS
Toxoplasmosis Toxoplasma gondii Single-celled protozoan parasite. Transmitted transplacentally.	Serological antibody testing IgM-specific antibody IgG seroconversion from negative to positive. Active infection indicated by a rise in IgG titer in two appropriately spaced tests. After 20 weeks of gestation, fetal blood samples can be tested for the presence of specific IgM. Ultrasonography can demonstrate severe congenital toxoplasmosis (e.g., ventriculomegaly, intracranial calcifications, microcephaly, ascites, hepatosplenomegaly, intrauterine growth restriction).	Most infections are asymptomatic but may cause fatigue, muscle pains, pneumonitis, myocarditis, and lymphadenopathy.
Other Hepatitis B DNA virus Transmitted via direct contact with blood or body fluids from an infected person.	HBsAG identified 7–14 days after exposure; HBsAb present with HBsAG indicates noninfectious stage	Course of the disease is not altered during the pregnancy, and 30%–50% of infected women are asymptomatic. When present, symptoms include low-grade fever, nausea, anorexia, jaundice, hepatomegaly, malaise, preterm labor, and preterm birth.
Rubella (German measles) Caused by the rubella virus. Transmitted via nasopharyngeal secretions; also transplacentally	Rubella-specific IgM antibodies Rubella antibody titer of 1:8 or more indicates immune status	Erythematous maculopapular rash on face, neck, arms, and legs lasting 3 days. Also, lymph node enlargement, slight fever, malaise, headache, and arthralgia.
Cytomegalovirus DNA virus of the herpes group. Transmitted by droplet infection and contact with infected secretions (saliva, urine, breast milk, cervical mucus, semen); also transplacentally	Serology of CMV-specific IgM antibody	Most infections are asymptomatic, but when present (15% of adults) include a mononucleosis-like syndrome (e.g., fever, pharyngitis, lymphadenopathy, polyarthritis).
Severity varies with gestational age (i.e., the earlier the fetus is infected, the more severe the disease); congenital infection can result if acute toxoplasmosis occurs during pregnancy (especially likely in third trimester). Can cause spontaneous abortion, low birth weight, hepatosplenomegaly, icterus, anemia, neurological disease, and chorioretinitis	Pregnant women who acquire toxoplasmosis should be treated with spiramycin. If fetal infection is established, treatment consists of a combination of pyrimethamine, sulfadiazine, and folinic acid, alternating with spiramycin to eradicate parasites in the placenta and in the fetus.	Teach women: avoid consuming raw or poorly cooked meat, especially pork, lamb, or venison and do not touch the hands or mouth after handling undercooked meat; avoid contact with cat feces; peel or thoroughly wash fruits and vegetables. Approximately 50% of adults have an antibody to this organism.
Stillbirth Neonates may be infected following exposure to maternal blood, genital secretions at birth. 1 in 1,000–8,000 infants have a 90% chance of becoming chronically infected, HBV carrier and a 25% risk of developing significant liver disease; 95% can be prevented with prophylaxis at birth; 90%–95% of those infected are symptomatic and become chronic hepatitis B carriers	Mother: No specific treatment, but may include bedrest and a high-protein, low-fat diet Infant: HBIG HBV vaccine recommended (three doses)	Women at risk include: Pregnant women from China, Southeast Asia, Africa, Philippines, and Indonesia Eskimos Prostitutes Homosexuals IV drug users Hemophiliacs Transfusion recipients People with other sexually transmitted diseases or multiple sex partners CDC recommends universal screening of all prenatal patients. Hepatitis B vaccine can be safely given in pregnancy at 0, 1, and 6 months (standard schedule), or at 0, 1, and 4 months (accelerated schedule). Mother-to-child transmission of HBV occurs in 10%–20% of women who are seropositive for HBsAG and in 90% of women who are seropositive for both HBsAG and HBcAg.
Overall risk of congenital rubella syndrome is 20% for primary maternal infection in the first trimester; 50% if maternal infection occurs during the first 4 weeks of gestation; and 25% if the infection occurs in the 2nd 4-week period after conception. Congenital spectrum anomalies include: Deafness (60%–75%) Eye defects (10%–30%) CNS anomalies (10%–25%) Cardiac malformation (10%–20%)	Women with rubella require no special therapy other than mild analgesics and rest. Infants born with congenital rubella may shed virus for many months and thus be a threat to other infants, as well as to susceptible adults.	Occurs most often in the springtime, and an estimated 6%-25% of women are susceptible. Inquire about history of exposure 3 weeks earlier. Vaccine is contraindicated during pregnancy. Patient counseling: If nonimmune (i.e., absence of rubella antibody), she should be vaccinated immediately postpartum and use contraception for a minimum of 1 month after vaccination.
Infection to fetus most likely with primary maternal infection and timing: first and second trimester exposure associated with more severe effects: low birth weight, IUGR, microcephaly CNS abnormalities, mental and motor retardation, intracranial calcifications, sensorineural deafness, blindness with chorioretinitis, intellectual and developmental disabilities, hepatosplenomegaly, jaundice	Mother: treat symptoms Infant: no satisfactory treatment is available; isolate the infant. Ganciclovir may prevent hearing loss and developmental outcomes in infants born with symptomatic congenital CMV infection with CNS involvement, but this antiviral medication has serious side effects.	Factors associated with increased risk of maternal infection include history of abnormal cervical cytology, lower socioeconomic status, birth outside North America, first pregnancy at younger than 15 years, and history of STI. Day care centers can be a common source of infection. Counsel patients at high risk (e.g., those with young children or who work with young children): carefully handle potentially infected articles (e.g., diapers), practice safe-handling techniques such as rigorous hand washing and the use of latex gloves, avoid high risk behaviors (e.g., IV drug use, sharing of needles), use condoms. Maternal immunity does not eliminate the possibility of fetal infection. Vaccine is available but more research is needed. Counsel patients: maintain rigorous personal hygiene throughout pregnancy.
Herpes simplex virus (HSV) Double-stranded DNA virus, associated with chronic infection. Transmitted via viral exposure at time of birth and ascending infection, also transplacental transmission is possible if initial infection occurs during pregnancy.	Tissue culture (swab specimen from vesicles) Immunofluorescent staining of the cell can differentiate HSV-1 from HSV-2	Painful genital vesicle lesions (may be present on the cervix, vagina, or external genitalia). The primary infection is commonly associated with fever, malaise and myalgia, numbness, tingling, burning, itching, and pain. May also have lymphadenopathy and urinary retention.

Sources: CDC (2018), CDC (2020b), Croke (2019), Cunningham et al (2018), King et al (2018)

The risk of perinatal transmission (vertical transmission) to the fetus or newborn is proportional to the concentration of virus in maternal plasma (viral load). Vertical transmission occurs antepartally when the virus crosses the placenta, intrapartally when it travels (via the bloodstream) from the vagina up into the uterus during labor or following ROM, or postpartally through transfer in the breast milk. Transmission of HIV to the fetus or infant is believed to most often occur late in pregnancy or during labor and birth. Increased rates of transmission also occur with advanced maternal disease and ruptured membranes and after events during labor and delivery that increase fetal exposure to maternal blood.

SYSTEMIC LUPUS ERYTHEMATOSUS

Systemic lupus erythematosus is a chronic multisystem inflammatory disorder. It is characterized by an autoimmune antibody production that results in an inflammation of the connective tissue in various organs or systems in the body. The disease tends to affect young women in the second, third, and fourth decades of life but may occur in any age-group. The prevalence of SLE is approximately 1 per 1,000 in the general population, and 90% of cases.

The immune system is composed of specialized cells that destroy invading organisms by phagocytosis and antibody and lymphocyte production. When a foreign organism or antigen enters the body, it is consumed by macrophages and then passed on to lymphokines, which present the antigens to the T and B lymphocytes. The B lymphocytes are activated, resulting in the production of an increased number of circulating antibodies that target their specific antigen. The antigen-antibody complex either promotes destruction of the antigen or activates the normal inactive proteins in the complement system. With SLE, the body fails to recognize its own proteins. The clinical manifestations result from inflammation of multiple organ systems, especially the joints, skin, kidneys, nervous system, and serous membranes.

Adverse pregnancy outcomes are more common in SLE than in any other rheumatic disease. In the presteroid era, it was common practice to terminate pregnancy in patients with active SLE. However, with successful treatment of active disease with corticosteroids, this practice has become less frequent. Patients are more likely to have inactive SLE at the onset of pregnancy because of earlier disease diagnosis and more effective prepregnancy therapy, as well as appropriate prepregnancy counseling. Recommendations for pregnancy include inactive disease state for at least 6 months depending on the degree of known organ damage (Petri, 2020). Pregnancy outcome is improved in the following circumstances: SLE has been in remission for at least 6 months; there is no active renal involvement; superimposed pre-eclampsia does not develop; and there is no evidence of antiphospholipid antibody activity (Cunningham et al, 2018).

The patient with SLE should be seen frequently by both an internist-rheumatologist and a perinatologist specializing in high-risk cases. Assessment of the signs and symptoms of an impending SLE flare-up should be elicited on the patient’s history and physical examination, and blood samples should be obtained for serological evaluation. A rise in the anti-dsDNA antibody titer and a decrease in complement may be predictive of an exacerbation of SLE. The onset of edema and hypertension in pregnancy in these patients is characteristic of both pre-eclampsia and active SLE-associated nephritis. Because the treatment of these conditions is very different, the importance of an accurate diagnosis is essential. When SLE complicates the pregnancy, there is an increased risk of SAB, PROM, PTL, preterm birth, intrauterine growth restriction (IUGR), stillbirth, neonatal lupus, and neonatal death (Petri, 2020).

Management of SLE is aggressive and includes immunosuppression of lupus flare with corticosteroid therapy, nonsteroidal anti-inflammatory drugs, antimalarial agents, azathioprine, and careful fetal surveillance. If the disease flares during the pregnancy, treatment must be implemented as quickly as possible. The physician assesses the manifestations and extent of the disease exacerbation and selects the safest, most effective therapy. The patient’s health must be deemed the first priority, and the treatment is planned accordingly. When caring for patients with SLE, nurses should offer support and remain alert for early indicators of SLE exacerbation and pregnancy complications. Patients and their families should be educated about the plan of care, the need for close surveillance, and the importance of effective family planning after the birth.

RHO(D) ISOIMMUNIZATION

Hemolytic disease of the fetus and newborn is a condition in which the life span of the fetal or neonatal RBCs is shortened by the action of maternal antibodies against antigens present on the fetal and neonatal RBCs. Antigens provoke an immune reaction if an incompatible blood cell enters the circulation. The RBCs are agglutinated and destroyed. The two most problematic types are those of the rhesus (Rh) system and the ABO system. Maternal antibodies form in the Rh(D)-negative mother after exposure to Rh(D)-positive fetal blood. Theoretically, no mixing of fetal and maternal blood occurs during pregnancy and childbirth. In reality, however, drops of fetal blood most likely enter the maternal circulation after small placental “accidents.” The development of maternal antibodies, which destroy the fetus’ Rh(D)-positive blood, is termed isoimmunization, alloimmunization, or sensitization. In addition to the Rh system, there are more than 400 different antigens found on the surface of RBCs. The incidence of hemolytic disease in the newborn has dramatically declined with the advent of Rho(D) immune globulin (RhoGAM).

Pathophysiology

For Rh(D) maternal isoimmunization to occur, at least three circumstances must exist:

■ The fetus must have Rh(D)-positive erythrocytes, and the mother must have Rh(D)-negative erythrocytes.

■ A sufficient number of fetal erythrocytes must gain access to the maternal circulation. This amount can be as little as 0.1 mL.

■ The mother must have the immunogenic capacity to produce antibodies directed against the D antigen.

Fetal RBCs gain access to the maternal circulation during pregnancy, childbirth, and in the immediate postpartum period. Clinical factors such as cesarean birth, multiple gestation, bleeding placenta previa or abruption, manual removal of the placenta, and intrauterine manipulation may increase the chance of substantial hemorrhage.

Rho(D) immune globulin (such as RhoGAM) works by coating and destroying fetal cells in the maternal circulation. Rho(D) immune globulin  must be given within 72 hours, and its effects last for 3 months. To ensure that the correct amount of Rho(D) immune globulin (sometimes more than one 300-mcg vial is required) is given to the patient, a fetal screen or Kleihauer-Betke blood test is performed on the woman’s blood after it has been determined that the baby is Rh(D)-positive. This test estimates the number of fetal RBCs in the mother’s circulation. In most situations, exposure of maternal blood to fetal blood occurs during the third stage of labor at the time of placental separation. The woman’s first child is usually unaffected because the maternal antibodies form after the infant’s birth. However, subsequent Rh(D)-positive fetuses may be affected unless the woman receives Rho(D) immune globulin to prevent antibody formation. Rho(D) immune globulin must be given after the birth of  every Rh(D)-positive infant ( Fig. 6-13). The information presented in  Box 6-9 helps to simplify what can be a very confusing clinical situation.

When antibodies to the Rh factor are present in the pregnant patient’s blood (i.e., the woman is sensitized), they freely cross the placenta and destroy the RBCs of the Rh(D)-positive fetus. Over time, the fetus develops an RBC deficiency, the fetal bilirubin levels rise (“icterus gravis”), and severe neurological disease (“bilirubin encephalopathy”) may result. In the fetus, this pathological process triggers a rapid production of erythroblasts (immature RBCs) that are unable to carry oxygen. The syndrome associated with this hemolytic process is termed  erythroblastosis fetalis. Fetal anemia and generalized edema (“hydrops fetalis”) develop and lead to fetal congestive heart failure.

Figure 6-13 The Rh isoimmunization sequence. Rh+ father and Rh- mother; Rh+ fetus. During pregnancy or childbirth, a small amount of fetal blood enters the mother’s circulation. The mother’s immune system produces anti-Rho(D) antibodies (triangles). In subsequent pregnancies with an Rh+ fetus, the antibodies cross the placenta, enter the fetal circulation, and attack the fetal red blood cells, causing hemolysis.

BOX 6-9

Simplifying and Understanding the Rh Factor

RH FACTOR

Rh(D)-positive: Persons who have the D genotype: The Rh antigen is present on their erythrocytes

Rh(D)-negative: Persons who DO NOT possess the antigen on their RBCs

Anti-Rh antibodies do not spontaneously occur and are only formed if there is sensitization by Rh(D)-positive cells entering the circulation of the Rh(D)-negative person. The Rh(D)-negative person develops antibodies against the Rh(D)-positive cells. This is why the first pregnancy is not affected, UNLESS the mother was previously sensitized during a miscarriage, amniocentesis, or antepartum hemorrhage.

EXAMPLE

Rh(D)-negative mother gives birth to an Rh(D)-positive baby and some of the baby’s blood enters the mother’s system at the time of delivery. (It takes only 0.1 mL.) Mother develops antibodies against any future Rh(D)-positive babies.

During the prenatal period, all Rh(D)-negative women receive an antibody titer (indirect Coombs’ test) to determine whether they are sensitized from a previous exposure to Rh(D)-positive blood. If the test is negative, another antibody titer is obtained at 28 weeks of gestation to rule out sensitization that may have occurred later in the pregnancy. If the woman remains unsensitized, Rho(D) immune globulin is given as a preventive measure to prevent formation of active antibodies during the remainder of pregnancy. After birth, if the infant is Rh(D)-positive, another dose of Rho(D) immune globulin is administered. If the infant is Rh(D)-negative, no Rho(D) immune globulin is necessary.

If the prenatal patient’s indirect Coombs’ test is positive, sensitization has occurred and antibodies against Rh(D)-positive erythrocytes are present in the maternal circulation. In this situation, the patient’s antibody titer is repeated frequently throughout pregnancy to identify a rising level. A rise in the maternal antibody titer is indicative of ongoing antibody formation and an increased likelihood of fetal erythrocyte destruction.

  MEDICATION: Rho(D) Immune Globulin (RhoGAM, HypRho-D, BayRho-D, Gamulin Rh, Rhophylac)

(arr aych oh dee im -yoon glob-yoo-lin)

Pregnancy Category:  C

Indications:  Administered to Rh(D)-negative women who have been exposed to Rh(D)-positive blood by:

Delivering an Rh(D)-positive infant

Aborting an Rh(D)-positive fetus

Having chorionic villus sampling (CVS), amniocentesis, or intra-abdominal trauma while carrying an Rh(D)-positive fetus

Accidental transfusion of Rh(D)-positive blood

Action:  Prevents production of anti-Rho(D) antibodies in Rh(D)-negative patients who were exposed to Rh(D)-positive blood by suppressing the immune reaction of the Rh(D)-negative woman to the antigen in the Rh(D)-positive blood.

Therapeutic Effects:  Prevents antibody response and subsequently prevents hemolytic disease of the newborn (erythroblastosis fetalis) in future pregnancies of women who have conceived an Rh(D)-positive fetus. Prevention of Rho(D) sensitization following transfusion accident.

Pharmacokinetics:

ABSORPTION: Well absorbed from IM sites.

Contraindications and Precautions:

CONTRAINDICATED IN: Rho(D)- or Du-positive patients; patients previously sensitized to Rho(D) or Du.

Adverse Reactions and Side Effects: Pain at IM site

Route and Dosage:  One vial standard dose (300 mcg) administered IM:

• At 28 weeks of pregnancy and within 72 hours of delivery.

• Within 72 hours after the termination of a pregnancy of 13 weeks or more of gestation.

• After an accidental transfusion, dosage is calculated based on the volume of blood that was erroneously administered.

    One vial MICRhoGAM (microdose) (50 mcg) within 72 hours after CVS or the termination of a pregnancy of less than 13 weeks of gestation.

    Note: (l) More than 300 mcg of RhoGAM may be indicated after a large transplacental hemorrhage or after a mismatched blood transfusion; (2) Rhophylac can be given IM or IV (prefilled syringes are available).

Nursing Implications:

1. Do not give to infant, to Rh(D)-positive individual, or to Rh(D)-negative individual previously sensitized to the Rho(D) antigen. Note: There is no more risk than when given to a woman who is not sensitized—if in doubt, administer Rho(D) immune globulin.

2. Administer into the deltoid muscle. Should be given within 3 hours but may be given up to 72 hours after delivery, miscarriage, abortion, or transfusion.

3. Explain to the patient the purpose of this medication to protect future Rh(D)-positive infants; before administering, obtain a signed consent form if required by the agency.

4. Special considerations may be indicated for women who are members of Jehovah’s Witnesses because this medication is made from human plasma.

Source: Data from Vallerand, A. H., & Sanoski, C. A. (2021). Davis’s drug guide for nurses (17th ed.). Philadelphia, PA: F.A. Davis.

Management

Prevention of isoimmunization (a rising anti-Rh antibody titer in an Rh(D)-negative woman) is the goal throughout pregnancy. All pregnant women should be tested for ABO and Rho(D) type along with an antibody screen during their first prenatal visit. It is essential that these determinations be made during each subsequent pregnancy, as previous maternal antibody screening is not an adequate assessment. Rho(D) immune globulin (RhoGAM) should also be given at any time during the pregnancy when a possibility exists that a patient may be exposed to fetal blood (e.g., CVS, amniocentesis, miscarriage, vaginal bleeding, abortion, and ectopic pregnancy).

 Optimizing Outcomes

Safe Administration of Rh (D) Immune Globulin (RhoGAM)

In an Rh(D)-negative woman who is nonsensitized, RhoGAM should be given after delivery of an Rh(D)-positive infant. In the United States, the standard dose is 300 mcg given within 72 hours of delivery. Remember to educate your patient as to the reason she is receiving RhoGAM.

Be sure to give your patient documentation that she has received RhoGAM.

Never give RhoGAM to:

• An Rh(D)-positive woman

• A sensitized Rh(D)-negative woman

• An Rh(D)-negative woman who has given birth to an Rh(D)-negative baby

• The baby or father of the baby

ABO

In this condition the  mother is blood group O, and the  baby is either A or B. This form of blood incompatibility is unrelated to the Rh factor. It is important for nurses to remember that blood group O carries no antigens; group A carries A antigen, and group B carries B antigen. Because the mother already has anti-A and anti-B antibodies present during the first pregnancy, the first child may be affected. IgG antibodies (immunoglobulins that respond to a specific antigen, in this case, A or B) can cross the placenta and cause hemolysis of the fetal RBCs.

The Coombs’ test is performed on the baby’s cord blood obtained at the time of birth. A  direct Coombs’ test identifies the presence of maternal antibodies in the neonate’s blood and hemolysis or lysis of RBCs, whereas the  indirect Coombs’ test detects antibodies against RBCs in the maternal serum. The results are reported as either positive or negative. A positive direct Coombs’ test must be reported to the pediatrician.

RESPIRATORY COMPLICATIONS

Pulmonary diseases have become more prevalent in the general population and therefore in pregnant women. The normal physiological changes of pregnancy can cause a woman with a history of compromised respirations to develop significant problems. The outcome for a pregnant woman with respiratory complications depends on the adequacy of ventilation and oxygenation and the early detection of respiratory compromise. Hypoxia poses a major threat to the fetus.

Asthma

Asthma is the most common form of lung disease that affects pregnancy, characterized by limited airflow that is generally more marked during expiration than during inspiration. Asthma exacerbations occur in approximately 45% of pregnant women with asthma (Murphy, 2015). Asthma is associated with significant risks for both the fetus. There is little risk to the fetus with well-controlled maternal asthma, and it is safer for pregnant asthmatics to be treated with appropriate medications than to have asthma symptoms and exacerbations. Exacerbations that cause hypoxia and decreased uterine blood flow increase the incidence of IUGR, preterm birth, and neonatal mortality.

Management

Careful monitoring and appropriate adjustments in therapy may be required to maintain maternal lung function and ensure an adequate oxygen supply to the fetus. Guidelines for asthma management have been developed to help ensure maternal-fetal safety and well-being during pregnancy. Goals of therapy include optimal control of asthma symptoms, attainment of normal pulmonary function, prevention and reversal of asthma attacks, and prevention of maternal and fetal complications. Asthma therapy is based on a stepwise classification system designed to control symptoms, avoid acute attacks, and help patients achieve unhampered lifestyles (Murphy, 2015).

Medications currently used for asthma are generally well tolerated during pregnancy and appear to be safe for the fetus. Therefore, the management of asthma in the pregnant woman differs little from management in the nonpregnant patient. It is also widely accepted that the fetal risk is higher with poorly controlled maternal asthma than with medications necessary to gain optimal symptom control. Research has shown poor compliance with medications, making patient education regarding the need for adherence a critical aspect in controlling and preventing asthma exacerbations (Murphy, 2015)

DIABETES IN PREGNANCY

Diabetes during pregnancy encompasses a range of disease entities, including gestational diabetes mellitus (GDM) and overt diabetes mellitus. Diabetes complicates approximately 2% to 10% of all pregnancies each year in the United States (Centers for Disease Control and Prevention, 2020a). Diabetes is a complex health-care problem that requires a comprehensive, multidisciplinary approach to ensure positive outcomes for both the patient and her infant. When working with this population, perinatal nurses are challenged to provide care and education that incorporates diabetes management principles into obstetric care during all phases of childbearing, from preconception through the postpartum period.

Definition and Classification of Diabetes Mellitus

Pregestational Diabetes Mellitus

Pregestational diabetes mellitus is a chronic metabolic disease characterized by hyperglycemia that results from limited or absent insulin production, deficient insulin action, or a combination of the two. Diabetes is divided into two broad categories—type 1 and type 2—that are differentiated according to the primary underlying etiology. Type 1 diabetes (formerly termed “insulin-dependent diabetes mellitus”) is characterized by an autoimmunity directed at the pancreatic beta cells. With type 1 diabetes, there is an absolute insulin deficiency, requiring the patient to have insulin treatment and management.

 Optimizing Outcomes

Preconception Care for Pregestational Diabetes Mellitus

Nurses who care for childbearing-age women with diabetes mellitus are perfectly positioned to offer preconceptional counseling during every patient contact. Women should be taught about the adverse obstetric and maternal outcomes that may result from poorly controlled diabetes and the importance of euglycemic control before pregnancy. Depending on the situation, testing to assess for vascular changes may include a retinal examination, 24-hour urine collection for protein excretion and creatinine clearance, and electrocardiography. Thyroid function studies may also be indicated, and all women who contemplate pregnancy should receive a multivitamin containing at least 400 mcg of folic acid, especially important in women with diabetes, who have an increased risk for offspring with neural tube defects (ACOG Practice Bulletin No. 201: Pregestational Diabetes Mellitus, 2018).

Gestational Diabetes Mellitus

Gestational diabetes mellitus is an impairment in carbohydrate metabolism that first manifests during pregnancy. Changes in carbohydrate, protein, and fat metabolism in normal pregnancy are profound, mediated in part by the developing fetus and the production of placental hormones. The first half of pregnancy is considered an anabolic phase. It is associated with an increased storage of fat and protein, along with an increase in the secretion of estrogen and progesterone. These physiological events lead to maternal hyperplasia and hyperinsulinemia. The increased insulin production prompts an increased tissue response to insulin and the increased uptake and storage of glycogen and fat in the liver and tissues.

The second half of pregnancy is characterized by a catabolic phase associated with the breakdown of protein and fat. During this time there is also an increased insulin resistance caused by the heightened production of placental hormones (insulinase and hPL), cortisol, and growth hormones. These hormones are diabetogenic and act as insulin antagonists. In women who cannot meet the increasing needs for insulin production, this change leads to an altered carbohydrate metabolism and progressive hyperglycemia.

During this time, the developing fetus continuously removes glucose and amino acids, substances that can easily cross the placenta, from the maternal circulation. Because insulin does not cross the placenta, the fetus must increase its own insulin production. Fetal hyperinsulinemia develops and acts as a growth hormone that contributes to an increase in fetal size (macrosomia) and a decrease in pulmonary surfactant production. Macrosomia occurs in 20% to 25% of diabetic pregnancies. When the pregnant woman’s blood glucose levels remain abnormally elevated, there is a constant transport of maternal glucose across the placenta. This “glucose load” prompts the fetus to produce insulin at a greater rate to use the glucose.

During the first trimester, maternal blood glucose levels are normally reduced and the insulin response to glucose is enhanced. The woman with well-controlled pregestational diabetes may need a decrease in her insulin dosage to avoid hypoglycemia. During the second and third trimesters, as the insulin requirements steadily increase, the insulin dosage must be adjusted to prevent hyperglycemia. Maternal insulin resistance begins around 14 weeks of gestation and continues to increase until it stabilizes during the final weeks of pregnancy.

These factors increase a woman’s risk of developing gestational diabetes:

■ Age older than 25

■ Obesity

■ Insulin resistance

■ Polycystic ovary syndrome

■ History of pregnancy-related diabetes mellitus

■ History of a large for gestational age infant

■ Hydramnios

■ Stillbirth, miscarriage, or an infant with congenital anomalies during a previous pregnancy

■ Family history of type 2 diabetes (first-degree relative)

■ Ethnicity

Maternal and Perinatal Morbidity and Mortality

The changes in the maternal milieu that characterize the diabetic state can have profound effects on the growth and development of the fetus, increase the risk of perinatal morbidity and mortality, and exert adverse effects throughout life. The physiological adaptations induced by pregnancy can unmask latent maternal diabetes or result in transient worsening of pre-existing vascular compromise. Diabetic women are four times more likely to develop pre-eclampsia or eclampsia, require a C-section, and develop diabetes later in life (American College of Obstetricians and Gynecologists, 2018b). The rates of infection, hydramnios, postpartum hemorrhage, and cesarean birth increase. In the long term, GDM is also associated with impaired insulin tolerance and the manifestation of diabetes in later life (Centers for Disease Control and Prevention, 2020a).

Major fetal effects associated with diabetes include a fivefold increase in perinatal death and a two- to threefold increase in the rate of congenital malformations. Early in pregnancy, the fetus is at risk for congenital malformations and poor fetal growth. Congenital defects result from the teratogenic effects of hyperglycemia during the time of organogenesis during the early gestational weeks. Late in pregnancy, the fetus is at risk for growth abnormalities and sudden intrauterine death. Macrosomia can also occur in the fetus, thereby increasing the risk of dystocia and hypoglycemia.

Control of maternal glucose levels is an important factor in determining fetal outcome. The  glycosylated hemoglobin A (HbA1c) level is commonly assessed to guide adjustments in the treatment plan throughout pregnancy. Because the maternal serum HbA1c reflects the degree of glycemic control during the preceding 5 to 6 weeks, the test is repeated every trimester. Good diabetic control is reflected by an HbA value of 2.5% to 5.9%; an HbA value greater than 8% is indicative of poor diabetic control. In the absence of prepregnancy and prenatal care, the rate of perinatal mortality for the diabetic patient and her fetus may be as high as 40%. However, with close, meticulous care, the perinatal mortality rate can be reduced.

  What to Say

Teaching Patients About Hypoglycemia

Hypoglycemia occurs more frequently in pregnancy than at other times, especially in patients with type 1 pregestational diabetes mellitus. When teaching about hypoglycemia, the nurse should include the following information:

• Hypoglycemia is a condition that occurs when your blood sugar levels decrease to less than 60 mg/dL.

• It is more common during pregnancy.

• Symptoms include light-headedness, shaking, headache, sweating, confusion, hot flashes, nervous and anxiety attacks, intense hunger, sudden irritability, and changes in vision.

• It is important that you and your family are able to immediately recognize and respond to hypoglycemia.

• Drinking a glass of milk is better than a glass of juice that contains high levels of glucose.

• Always keep glucagon on hand for severe hypoglycemia or loss of consciousness.

 Diagnostic Tools

Screening Pregnant Women for GDM

According to ACOG, all pregnant women should be screened for GDM, whether by patient history, clinical risk factors, or a 50-g, 1-hour loading test to determine blood glucose levels at 24 to 28 weeks of gestation. Women with high risk factors (previous medical history of GDM, known impaired glucose metabolism, obesity [body mass index greater than or equal to 30]) should be screened earlier in pregnancy; if diabetes mellitus is not diagnosed, blood glucose testing should be repeated at 24 to 28 weeks of gestation (American College of Obstetricians and Gynecologists, 2018b).

In the United States, most centers use the following diagnostic recommendations and criteria established by the National Diabetes Data Group:

• The Glucose Challenge Test (Glucola screening): A 50-g oral glucose solution is administered to the woman and a blood sample is taken 1 hour after it is consumed. Patients with a 1-hour plasma glucose value that exceeds 130 to 140 mg/dL (depending on the laboratory used) should be further evaluated with the formal 3-hour oral glucose tolerance test (OGTT).

• The 3-hour OGTT requires the fasting patient to ingest 100 g of glucose with blood drawn at 1-hour intervals. Before the test, the woman should avoid caffeine (it may increase glucose levels) and refrain from smoking at least 12 hours before and during the test. The diagnosis of GDM is made when two values or more of the threshold are above the norm. The normal plasma values are:

Fasting blood sugar	<95 mg/dL
1 hour	<180 mg/dL
2 hour	<155 mg/dL
3 hour	<140 mg/dL

Management

The goal of modern glycemic management during the diabetic pregnancy is to maintain blood glucose levels as close to normal (euglycemia) as possible. Metabolic monitoring during pregnancy is directed at detecting hyperglycemia and making all necessary pharmacological, dietary, or activity adjustments to minimize any adverse effects to the fetus. Home blood glucose monitoring with a glucose reflectance meter or biosensor monitor is a widely accepted method for monitoring blood glucose levels and an essential tool for helping the woman to assess her degree of blood glucose control ( Fig. 6-14). Patients monitor their blood glucose levels daily, record the findings, and bring their blood glucose logs with them to each prenatal appointment.

Continuous Blood Glucose Monitors

Self-monitoring of blood glucose (SMBG) via the intermittent monitoring of capillary blood has brought significant improvements to the care of patients with diabetes. Recently, continuous glucose monitoring (CGM) has become available. This modality, which provides real-time glucose data, offers patients and providers a tool to use along with SBGM to achieve a more complete picture of 24-hour blood glucose patterns. CGM can identify sudden blood glucose drops, hyperglycemia, and postprandial changes in glucose levels that cannot be identified with intermittent glucose monitoring. Pregnant women may especially benefit from this added information because glycemic goals during pregnancy are more stringent.

Figure 6-14 Blood glucose monitoring is an essential component of care for the pregnant patient with diabetes.

 Collaboration in Caring

Fetal Surveillance

Ongoing fetal surveillance is of utmost importance. Maternal care requires the cooperative efforts of a clinical team that includes the obstetrician, internist, endocrinologist, diabetes educator, neonatologist, dietitian, and nurse. Ultrasound examinations throughout the pregnancy are useful in determining viability and accurately establishing the gestational age early in pregnancy, diagnosing fetal complications and macrosomia. Patient education is essential to ensure that the woman understands her diabetic state and the need to adhere to treatment so that an optimal outcome is achieved. Social services, home nursing visitation, and spiritual support are often involved as well.

Insulin and Oral Hypoglycemic Therapy

Optimal glycemic goals for GDM include a fasting venous plasma glucose concentration less than or equal to 95 mg/dL and a 1-hour postprandial plasma glucose of less than or equal to 140 mg/dL. Blood glucose self-monitoring is recommended. Although diet and exercise are the mainstays of care for the woman with GDM, up to 20% will require insulin during pregnancy to maintain euglycemia. If fasting blood glucose levels exceed 105 mg/dL, insulin therapy is initiated.

Most insulin used to treat pregestational diabetes mellitus is biosynthetic human insulin such as lispro or aspart, which are short- or rapid-acting insulin analogs that mimic physiological insulin action. The analogs can be given closer to a meal (i.e., 5–10 minutes vs. 30–45 minutes) than regular insulin, but patients must be warned that significant hypoglycemia can occur if they do not eat promptly after administering the medication. Often, a four-dose regimen that combines a short-acting (preprandial) with a long-acting (bedtime dosing) insulin is used. Patients who are highly motivated and compliant may wish to use an insulin pump, which delivers a continuous subcutaneous infusion of a rapid-acting insulin such as lispro, which has been shown to be more effective in maintaining desired glucose levels and in reducing the risk of fetal macrosomia (ACOG, 2018; Hurst, 2011).

Oral hypoglycemic agents, which cross the placenta and have not been well studied in pregnancy, are generally not used. However, glyburide (Glynase, Micronase), a second generation oral sulfonylurea, does not cross the placenta and has been used to treat GDM. Glyburide has been found to be comparable to insulin in improving glucose control without evidence of adverse maternal and neonatal complications. According to ACOG (2018), the use of oral agents for the control of type 2 diabetes mellitus during pregnancy should be limited and individualized until the safety and efficacy of these medications have been confirmed.

THE THYROID GLAND AND PREGNANCY

Thyroid disorders are relatively common among pregnant women. The hormonal changes and increasing metabolic demands of pregnancy bring about complex compensatory alterations in maternal thyroid function. Human chorionic gonadotropin, which is at its highest levels in early pregnancy, possesses intrinsic, weak thyroid-stimulating activity. Thyroid-stimulating hormone levels fall during the first trimester, and this decrease parallels the rise in the production of hCG. Thyroid disease in pregnancy has serious adverse consequences, including increased risk of miscarriage, gestational hypertension, placental abruption, postpartum hemorrhage, low birth weight infants, and negative cognitive development (Gorringe, 2019).

Hyperthyroidism

Hyperthyroidism occurs when there is excessive levels of the thyroid hormone thyroxine (T4) and triiodothyronine (T3) (Venes, 2021). The signs and symptoms of mild to moderate hyperthyroidism are common during pregnancy (heat intolerance, diaphoresis, fatigue, anxiety, emotional lability, tachycardia, insomnia, and a wide pulse pressure). However, weight loss, tachycardia greater than 100 beats per minute, and diffuse goiter (enlargement of the thyroid gland) are clinical features suggestive of hyperthyroidism. Gastrointestinal symptoms (i.e., severe nausea, excessive vomiting, and diarrhea), cardiomyopathy, lymphadenopathy, and congestive heart failure can also accompany thyrotoxicosis (excessive thyroid activity) in pregnancy. Establishing a diagnosis of maternal hyperthyroidism can be challenging because of the myriad of metabolic and hormonal changes that normally take place during pregnancy. However, a depressed maternal serum TSH concentration and an elevated T4 and T3 level are useful in confirming the diagnosis. Early treatment of hyperthyroidism is imperative because of the potential for serious maternal and fetal complications including low birth weight infants, preterm delivery, and pre-eclampsia (King et al, 2016).

Treatment

Treatment for hyperthyroidism includes the use of antithyroid medications such as the thioamides, propyl-thiouracil (PTU—the drug of choice), or methimazole (Tapazole). Treatment often depends on the gestational age. In the first trimester the woman will receive PTU, changed to methimazole in the second trimester due to the hepatotoxicity of long-term PTU and avoidance of methimazole in the first trimester during organogenesis. Symptomatic improvement usually occurs within 2 weeks after the initiation of therapy and repeat laboratory work should be obtained to determine efficacy (King et al, 2016).

Patient Education

Patient education should focus on complications of antithyroid therapy (i.e., purpuric skin rash, pruritus, fever, and nausea) and dietary needs (i.e., increased calories and protein)

Hypothyroidism

Symptoms

Caused by an inadequate production of thyroid hormone, the symptoms of hypothyroidism are insidious and can be masked by the hypermetabolic state associated with pregnancy. Maternal symptoms can include modest weight gain, a decrease in exercise capacity, lethargy, cold intolerance, constipation, hoarseness, hair loss, brittle nails, and dry skin. Laboratory confirmation is made from an elevated TSH level and low to normal T3and T4 values.

Treatment

During early gestation, thyroid hormones cross the placenta in small amounts. The fetus is dependent on the hormones until fetal production begins at 12 weeks. Maternal hypothyroidism must be treated promptly, because there is an increased risk for pre-eclampsia, placental abruption, preterm birth, low birth weight, and stillbirth. Fetal neurological development can be severely affected by decreased levels of thyroid hormone. Treatment involves the use of a thyroid hormone supplement (e.g., levothyroxine [Synthroid]) with the dose adjusted every 4 weeks until the TSH level reaches the lower end of the normal range for pregnancy. Radioactive iodine (131I) is contraindicated in pregnancy (Cunningham, 2018).

VENOUS THROMBOSIS AND PULMONARY EMBOLISM

Venous thromboembolic diseases, which complicate approximately 1 to 2 in 1,000 births, include superficial and deep vein thrombophlebitis (DVT), pulmonary embolus (PE), septic pelvic thrombophlebitis, and thrombosis (Royal College of Obstetricians and Gynaecologists, 2015). These conditions account for one-half of all obstetric morbidity. Pulmonary embolism is the leading cause of maternal mortality. The most common form of thrombosis that occurs during pregnancy involves the veins of the calf, thigh, and pelvis. The most important aspect of lower extremity and pelvic venous thrombosis is that it can lead to pulmonary embolism, which poses a major threat to the pregnant woman.

Thrombosis is thought to result from alterations in the vessel wall, slowing of blood flow (or stasis), and changes in blood components. Pregnancy presents the ideal state in which all three of these components may exist. Trauma to the vessel wall may occur during childbirth with alterations in the clot-inhibiting endothelial surface. Blood flow from the legs and pelvic veins are slowed during pregnancy because of pressure exerted on the iliac veins by the gravid uterus and by the relaxation of the smooth muscles in response to increased progesterone.

The most important individual risk factor for venous thromboembolism in pregnancy is a personal history of thrombosis. Other factors include history of hemoglobinopathies, obesity, hypertension, overweight, smoking, advanced age, increased parity, sedentary or limited mobility, and pregnancy complications (e.g., pre-eclampsia and multiple gestation) (Royal College of Obstetricians and Gynaecologists, 2015).

When assessing the pregnant patient, the nurse must be aware of the characteristic signs associated with thromboembolic disease. The diagnosis can be very challenging because some of the symptoms are normal during pregnancy (e.g., lower extremity edema). Doppler ultrasound technique has become the diagnostic study of choice in cases of proximal vein occlusion. When results are negative and iliac vein thrombosis is suspected, confirmatory imaging with magnetic resonance imaging (MRI) is recommended. If there is a suspicion of PE, ventilation-perfusion scanning or computed tomographic (CT) angiography results in minimal radiation exposure to the fetus. Management involves a combination of strategies including medications (i.e., anticoagulant therapy with heparin), bedrest with elevation of the involved extremity, and the application of warm, moist heat.

During the examination, the nurse assesses for the presence of the following signs and symptoms that may be indicative of thromboembolism:

■ Pain, tenderness, and/or warmth.

■ Swelling of the lower extremity, which is asymmetric with a difference greater than 0.8 in. (2 cm) between the normal and affected leg. Swelling of the thigh is especially relevant because the risk of pulmonary embolism is associated with femoral or iliac phlebitis.

■ Color change, especially in the left leg.

■ A palpable cord underlying the region of pain and tenderness.

Symptoms of a pulmonary embolism:

■ Tachypnea

■ Dyspnea

■ Pleuritic chest pain

■ Atelectatic rales

■ Cough

■ Fever

■ Diaphoresis

■ Tachycardia

■ Hemoptysis

■ Cyanosis

■ Heart gallop or murmur

■ Anxiety

■ Apprehension

PSYCHIATRIC COMPLICATIONS DURING PREGNANCY

The recognition and management of depression and psychoses during pregnancy and the puerperium are of critical importance. Particularly in the United States, these disorders often are underrecognized and undertreated, and this factor potentially contributes to the likelihood of devastating effects on the child, the mother, the family, and society.

Consulting With the Pregnant Psychiatric Patient

Psychiatric complications during pregnancy can represent an exacerbation of an ongoing psychiatric disorder, a resurgence of previously remitted symptoms, or the onset of a new illness. Prenatal counseling should include a mental health history to determine any previous or past psychiatric disorders during pregnancy and the potential associated with fetal exposure to psychotropic agents and/or maternal mental illness.

Consultations with pregnant women who suffer from a psychiatric disorder should include discussion of the following:

■ Psychoactive medications readily cross the placenta.

■ Risks associated with untreated maternal psychiatric illness and exposure to psychotropic medications may include poor attention to prenatal care, substance abuse, and deliberate self-harm.

■ Risk of experiencing relapse or worsening symptoms if pharmacological treatment is not continued or instituted when necessary. Maternal anxiety and stress have been shown to have adverse effects on pregnancy outcome, infant/child neurodevelopment, and maternal postnatal mental health.

■ Use of a single medication at a higher dose is preferable to the use of multiple medications for the treatment of psychiatric illness during pregnancy. Changing medication increases the exposure to the fetus.

■ Patient care is optimized when provided by a multidisciplinary team composed of the obstetrician, mental health clinician, primary health-care provider, and pediatrician.

Depression

The incidence of depression during pregnancy is estimated to be 7% to 20% (Biaggi et al, 2016). Women at risk for antepartum depression are those with a personal or family history of affective disorders (unipolar and bipolar), depression in a previous pregnancy, unplanned pregnancy, young age, few social supports or isolation, high psychosocial stress, intimate partner violence (IPV), marital conflict, significant life events, and cessation of antidepressant medications. Signs and symptom of antenatal depression include:

■ Lack of interest in pregnancy

■ Lasting sadness, tearfulness, anxiety, or emotional detachment

■ Feelings of hopelessness or pessimism

■ Feelings of guilt, worthlessness, or helplessness

■ Feelings of irritability or restlessness

■ Loss of energy

■ Poor concentrating or memory

■ Difficulty making decisions

■ Difficulty falling asleep or sleeping too much

■ Overeating or loss of appetite

■ Suicidal thoughts or suicide attempts

■ Lack of interest in sex

Antenatal depression can have detrimental health outcomes including increase risk of preterm birth, low birth weight, and abnormal stress responses in offspring. Women with antenatal depression are also at risk for postpartum depression (Biaggi et al, 2016). Treatment for depression may include psychotherapeutic counseling, talk therapy, peer support groups as well as regular exercise for some women with mild depression symptoms (Centers for Disease Control and Prevention, 2019c; U.S. Department of Health & Human Services, 2018).

Medications prescribed for depression include selective serotonin reuptake inhibitors (SSRIs), such as fluvoxamine, sertraline, citalopram, and fluoxetine, and tricyclic antidepressants (TCAs) including amitriptyline, clomipramine, doxepin, and protriptyline. Presently, there are conflicting data regarding SSRI exposure and the risk for fetal malformations such as heart defects, encephalopathy, gastroschisis, and omphalocele. Health-care providers need to carefully discuss the risk and benefits of all treatments to patients so they can discuss what is best for their pregnancy (Centers for Disease Control and Prevention, 2019d).

Bipolar Disorder

Bipolar disorder is commonly characterized by distinct periods of abnormally and persistently elevated, expansive, or irritable mood and separate distinct periods of depressed mood or anhedonia (inability to gain pleasure from normally pleasurable experiences). The course of bipolar disorder is particularly unpredictable during pregnancy and some women can experience relief of symptoms during pregnancy (U.S. Department of Health & Human Services, 2018). However, despite relief of symptoms many women need to continue mood-stabilizer medications so that they don’t relapse. The health-care provider needs to work in collaboration with the mental health team to determine any at-risk behavior, such a noncompliance with medication, severity of disease, lack of support systems, and other compounding factors such as medical or living arrangement to help guide a plan of care.

Early prenatal exposure to mood stabilizers such as lithium and lamotrigine can cause congenital cardiac malformations. Anticonvulsants including valproate and carbamazepine are also used in the treatment of bipolar disorder; however, they are associated with significant adverse effects when used during pregnancy and should be avoided, especially during the first trimester (Boyce & Buist, 2016).

Schizophrenia

Schizophrenia is a psychotic disorder that consists of delusions, hallucinations, disorganized speech, grossly disorganized or bizarre behavior, and symptoms involving loss of behaviors, lack of motivation, empty verbal response, inappropriate affect, anhedonia, dysphoric mood, abnormal psychomotor activity, slow reaction time, dysfunctional interpersonal relations, and/or dysfunctional self-care (Venes, 2021). During pregnancy, women often experience worsening symptoms, and because of the potential teratogenic effects on the fetus, the prescribed psychotropic medication may need to be discontinued or changed. No significant teratogenic or toxic effects have been documented with typical antipsychotic drugs, including haloperidol, perphenazine, and chlorpromazine. However, reproductive safety data on the commonly used atypical antipsychotics such as olanzapine are extremely limited, and the routine use of the atypical antipsychotics should be used with caution during pregnancy (Teodorescu et al, 2017).

Maternal high-risk symptoms of schizophrenia include psychotic denial of pregnancy (the woman denies she is pregnant despite clear evidence that she is), self-mutilation, fetal abuse, and neonaticide. Nurses caring for pregnant women with schizophrenia should assess for delusions and coexisting health problems such as depression, eating disorders, sexually transmitted infections, alcohol or drug abuse, and compliance with treatment of coexisting chronic conditions, including diabetes mellitus and hypertension.

Anxiety Disorders

Anxiety disorders including panic disorder, generalized anxiety disorder, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD) are common during the childbearing years. Childbearing has been associated with the onset or worsening of panic disorder or OCD, and women are at greatest risk for exacerbation of both disorders during the postpartum period. Risk factors for anxiety disorders in pregnancy include history of depression or anxiety, use of alcohol or smoking, child abuse, parenting style that includes low care or high control, and lack of partner, marital, or social supports (Biaggi et al, 2016).

Eating Disorders

Eating disorders in pregnant women have both physiological and psychological effects on the outcome of the pregnancy and on subsequent infant development, including miscarriages, premature birth, and low birth weight. Anorexia nervosa has been associated with higher rates of perinatal mortality, obstetric complications, and congenital anomalies. Bulimia nervosa has been associated with extreme maternal weight gain, pre-eclampsia, and eclampsia. Women with a history of eating disorders need to be monitored for relapses so that intervention can occur in a timely manner (U.S. Department of Health & Human Services, 2018/2018).

Management

The importance of the detection of mental health disorders in the pregnant population cannot be overemphasized. The health and welfare of not only the mother but also that of the entire family is at stake. Nurses are often the first care providers to recognize indicators of psychiatric difficulties in their patients. Strategies to help identify mental health problems during pregnancy may include:

■ Placing psychoeducational materials throughout all patient areas

■ Routinely inquiring about the patient’s and her family’s psychiatric history during the initial interview

■ Using a standard screening tool to assess for depression at least once during the perinatal period

■ Assessing the woman’s access to social and family supports

■ Referring the woman to community resources such as home health visitation and the local mental health agency

ASSESSMENT AND DIAGNOSTIC TOOLS TO DETERMINE FETAL WELL-BEING

Doppler Ultrasound Blood Flow Studies (Velocimetry)

Doppler ultrasound is used to study blood flow in the umbilical vessels of the fetus, placental circulation, fetal cardiac motion, and maternal uterine circulation. This technology is useful in managing pregnancies at risk because of hypertension, diabetes mellitus, IUGR, multiple fetuses, or PTL. A noninvasive Doppler wave measures the velocity of RBC movement through the uterine and fetal vessels. Assessment of the blood flow through the uterine vessels is useful in determining vascular resistance in women at risk for developing placental insufficiency. Decreased velocity is associated with poor neonatal outcome.

Fetal Biophysical Profile

The fetal  biophysical profile is a noninvasive fetal physical examination that is more accurate in predicting fetal well-being than any single assessment. It combines electronic FHR monitoring with ultrasonography measures to evaluate fetal well-being. The fetus responds to central hypoxia by alterations in movement, muscle tone, breathing, and heart rate patterns. A finding of normal fetal biophysical parameters indicates that the CNS is functional and therefore the fetus is not hypoxemic. The BPP comprises the following five components and is based on a 30-minute time period ( Table 6-4). Findings on the BPP are scored with a normal finding receiving a 2 and anything abnormal receiving a 0. Scores of 8 to 10 with normal amniotic fluid volume and a reactive NST indicate satisfactory fetal status. A score of 6 with normal amniotic fluid volume requires reassessment of a preterm fetus within 24 hours of delivery. Scores of less than 6 or a nonreactive NST indicate fetal compromise and require prompt delivery (Venes, 2021).

Sonographic methods for determining amniotic fluid volume include subjective assessment, three-dimensional techniques with ultrasonography or MRI, and measurement of amniotic fluid pockets (known as amniotic fluid index [AFI]). Amniotic fluid index is calculated by summing the deepest vertical amniotic fluid pockets in each of four quadrants of the uterus. At term, an AFI less than 5 cm has been used as a common cutoff value to define oligohydramnios, and hydramnios occurs when there is an AFI of greater than 24 cm or maximal vertical pocket greater than 8 cm.

Each of the five BPP components is assigned a score of 2 (normal or present) or 0 (abnormal). A score of 8 to 10 is reassuring whereas a score of 6 is considered “equivocal,” and the test should be repeated within 24 hours in the case of a preterm infant; the term infant should be promptly delivered. A score of 0 to 4/10 strongly suggests fetal asphyxia and indicates a need for consideration for early or immediate delivery (Van Leeuwen & Bladh, 2021).

Nonstress Test

The NST is one of the most common methods of antenatal screening that assesses for fetal well-being (Venes, 2021). It involves the use of EFM for approximately 20 minutes. An NST monitors both the FHR and uterine activity or contractions. The NST is based on the premise that a normal fetus moves at various intervals and that the CNS and myocardium responds to movement. The response is demonstrated by an acceleration of the FHR. Loss of heart rate reactivity is associated most commonly with a fetal sleep cycle but may result from any cause of CNS depression, including fetal hypoxia, acidosis, and some congenital anomalies. Reactivity is also based on gestational age; 32 to 34 weeks is considered the appropriate age for reactivity to occur. Before this gestational age, a very large percentage of fetuses will not meet the acceptable criteria and results of the NST need to account for variations due to gestational age. Nonstress testing is performed once or twice weekly for women with certain risk factors ( Table 6-5).

TABLE 6-4

Fetal Biophysical Profile
COMPONENT	SCORE 2	SCORE 0
Nonstress test	At least 2 or more accelerations greater or equal to 15 bpm lasting for at least 15 or more seconds in a time frame of 20–40 minutes	0 or only 1 acceleration in a time frame of 20–40 minutes
Fetal breathing	1 or more episode of rhythmic breathing lasting 30 or more seconds in a time frame of 30 minute	Less than 30 seconds of rhythmic breathing in a time frame of 30 minutes
Fetal movement	3 or more discrete body or limb movements in a time frame of 30 minutes	Less than 3 discrete body or limb movements in a time frame of 30 minutes
Fetal tone	1 or more episode of extremity or extension and subsequent return to flexion	No movements of extension and flexion movements
Amniotic fluid volume	Single vertical pocket of at least 2 cm of fluid or more	Largest single vertical pockets less than 2 cm

Contraction Stress Test

The  contraction stress test (CST) evaluates the FHR response to uterine contractions. The CST is based on the premise that fetal oxygenation that is only marginally adequate with the uterus at rest is transiently worsened by uterine contractions. The nurse uses the electronic fetal monitor to obtain a baseline FHR tracing for 20 minutes. If spontaneous uterine contractions do not occur during this time, uterine stimulation is produced through IV oxytocin infusion (beginning with 0.5 milliunits/min and increasing the dose by 0.5 milliunits/min at 15- to 30-minute intervals) until three contractions of at least 40 seconds’ duration occur within a 10-minute time frame. CSTs are evaluated according to the presence or absence of late FHR decelerations. A late deceleration, associated with fetal hypoxia, is one that begins at the peak of the contraction and persists after the conclusion of the contraction. Episodic patterns (i.e., accelerations, variable decelerations, and prolonged decelerations) are FHR patterns that do not have a direct relation to uterine contractions (Venes, 2021).

The test is considered negative (normal) if there is no evidence of late or significant variable decelerations. A positive CST (abnormal) is one in which there are late decelerations with 50% of contractions, even if the frequency is less than three in 10 minutes. An equivocal/suspicious result indicates the presence of either intermittent late decelerations or significant (severe) variable decelerations (Venes, 2021).

Electronic Fetal Heart Rate Monitoring

Electronic fetal heart rate monitoring (EFM) uses electronic techniques to give an ongoing assessment of fetal well-being. EFM provides information related to the response of the FHR in the presence or absence of uterine contractions. Electronic monitoring of the FHR can be accomplished by either external or internal means.

TABLE 6-5

Selected Indications for Nonstress Testing/Biophysical Profile
MATERNAL	PREGNANCY-RELATED
Hyperthyroidism (poorly controlled)	Intrauterine growth restriction
Trauma/motor vehicle accident, improper seat belt use Injury/Intimate partner violence	Polyhydramnios
Gestational diabetes, or diabetes mellitus (type 1 or type 2)	Oligohydramnios
Chronic renal disease	Multiple gestation
Prior stillbirth or intrauterine fetal demise (IUFD)	Isoimmunization
Hemoglobinopathies (Hgb SS, SC, S-thalassemia) cyanotic heart disease	Post-term gestation (greater than 42 weeks)
Systemic lupus erythematosus	Decreased fetal movement
Hypertensive disorders Significant illness/septic shock	Placental abnormality Previous pregnancy loss/stillbirth Premature rupture of membraness Decreased fetal movement

  PROCEDURE ■  Performing an NST

To prepare the patient for an NST, the nurse explains the procedure and asks her to void. The patient is then assisted into a semi-Fowler’s or lateral tilt position, and the nurse performs Leopold maneuvers to determine fetal position and to guide proper placement of the external fetal heart ultrasound transducer (U/S) and tocodynamometer (toco), a pressure-sensitive device. Next, the nurse applies the external U/S and toco on the maternal abdomen ( Fig. 6-15) and obtains baseline maternal vital signs. The tracing is then observed for evidence of FHR accelerations of at least 15 bpm above the baseline heart rate. During this time, the patient may or may not be aware of fetal movement.

    In a term fetus, at least two FHR accelerations sustained for at least 15 seconds (from beginning to end of the acceleration) should occur over a 20-minute time period. If these criteria are met, the test is considered normal or reassuring and is termed a “reactive test.” The test may be extended for another 20 to 40 minutes if needed. If the reactive criteria are not met (i.e., no FHR accelerations or the accelerations do not reach 15 bpm or do not last for 15 seconds) over a 20- to 40-minute period in a term fetus, the test is considered to be “nonreactive.” Depending on the fetal age, a nonreactive NST result should be followed by another NST a few hours later or contraction stress test or a BPP (Venes, 2021).

FIGURE 6-15 Placement of the fetal heart ultrasound transducer and tocodynamometer for a nonstress test.

SPECIAL CONDITIONS AND CIRCUMSTANCES THAT MAY COMPLICATE PREGNANCY

The Pregnant Woman Who Requires Bedrest

The patient whose antenatal course is compromised by medical or obstetric complications that require bedrest faces even more challenges. Maloni has written extensively about the deleterious effects of bedrest on body systems and addresses problems such as muscle wasting, bone loss, failure to gain weight, and cardiovascular and psychological difficulties. Lack of weight-bearing and inactivity make muscles weak. Dizziness, difficulty regulating blood pressure, and fainting are common symptoms in the patient confined to bedrest.

In most situations, regular home visitation by a community health nurse is an important component of care ( Fig. 6-16). Referral to social services and other community resources may be helpful in assisting the couple with financial matters and other aspects of home care.

Nursing interventions that can be instituted to help the family adjust to the stress of a complicated pregnancy include the involvement of high-risk pregnancy or other specialty support groups, professional counseling when appropriate, and religious support when desired. The educational needs of the pregnant woman who is experiencing a high-risk pregnancy are essentially the same as those of any childbearing woman. Whenever possible, nurses should encourage their patients to participate in prenatal classes, seek lactation counseling, learn about infant care, and attend self-care classes. The nurse may arrange for the couple to attend childbirth education classes in either a group or private setting. For most, participating in a group promotes a feeling of normalcy. Family members, particularly the woman’s partner, should be included, because they can share infant care responsibilities and provide emotional support.

The recognition that high-risk couples may have depleted their coping skills as a result of perinatal complications constitutes an important nursing issue, especially during the intrapartal period. The nurse needs to be aware that the anxiety and stress of labor may be extremely difficult for the couple. The nurse can assist and empower the patient and her partner by encouraging them to express their emotional concerns, keeping them informed of changes in the woman’s condition, and encouraging them to ask questions.

FIGURE 6-16 Visiting patients confined to bedrest at home is an important nursing intervention.

The Adolescent Pregnant Patient

Although teen pregnancies have been decreasing steadily during the past decade, the United States still has one of the highest teen pregnancy rates among developed countries. Pregnancy complications are the leading cause of death for girls ages 15 to 19 years old (World Health Organization, 2020).

Prenatal medical and behavioral risk factors can severely complicate adolescent pregnancy and result in poor birth outcomes, particularly when late or inadequate prenatal care occurs. Prenatal medical and behavioral risks for the adolescent population include:

■ PTL and birth, especially when combined with low socioeconomic status, single parent, smoker, illicit drug use, prepregnant weight less than 100 lb (45.5 kg), poor weight gain during pregnancy, and inadequate prenatal care

■ Anemia

■ Pre-eclampsia/eclampsia

■ Repeated exposure to sexually transmitted infections

■ Chronic or asymptomatic UTIs

■ Acute pyelonephritis

■ IUGR/low birth weight infants (less than 2,500 g)

■ Social issues: poverty, unmarried status, low educational levels, smoking, and drug use

The nurse’s need for good communication skills when working with adolescents cannot be overstated, because these young women often lack trust in medical personnel and fear that their behaviors might be judged. Without good communication, the nurse is unable to make an accurate assessment of the adolescent’s knowledge about the importance of quality, consistent prenatal care.

The Advanced Age Pregnant Patient

Many women are now choosing to delay childbirth until later years. The implementation of infertility technology has broadened the boundaries of the reproductive age. Both socioeconomic circumstances and the nature of the older mother have changed with time. The older maternity patient today is at significantly lower risk than her contemporary of two decades ago, who tended to be the mother of many children, having commenced childbearing many years earlier. However, the nurse must be aware of special considerations such as an increased likelihood of chronic diseases (e.g., diabetes and hypertension) when planning care for the woman who has become pregnant after age 35.

The Pregnant Patient Who Has Suffered Trauma

Trauma is the fourth leading cause of death worldwide and the leading nonobstetric cause of maternal death during pregnancy. Motor vehicle accidents account for more than one-half of maternal trauma incidents. About 50% of fetal deaths result from maternal trauma, and most of these result from motor vehicle accidents with many of them related to improper seat belt use (Royal College of Obstetricians and Gynaecologists, 2015; Scannell, 2018a). Blunt trauma is caused by the following conditions:

■ Motor vehicle collisions in which force is applied to the abdomen from direct impact or as a result of secondary injury from abdominal organs. Abruption of the placenta and/or PTL may result from the trauma.

■ Accidental falls, usually more common in the third trimester as the woman’s center of gravity becomes increasingly displaced.

■ Assaults involving IPV (the incidence increases during pregnancy) and gunshot and stabbing wounds.

 Optimizing Outcomes

Considerations When Caring for the Obstetric Trauma Patient

Maternal stabilization is the initial goal in resuscitation. Resuscitation during pregnancy proceeds as with any other trauma. Trauma in pregnancy involves at least two patients (more in the case of multiple gestation). Minor injuries in the woman may cause significant or fatal injury to the fetus. Maternal outcome in trauma corresponds to the injury; fetal outcome depends on the injury and the maternal physiological response. The FHR is often the first vital sign to change. All pregnant trauma patients need continuous fetal monitoring. Risk factors predictive of fetal death include ejection during an automobile crash (preventable with proper seat belt use), motorcycle and pedestrian collisions, abnormal heart FHR patterns, maternal tachycardia, and maternal death (Scannell, 2018a).

Intimate Partner Violence During Pregnancy

Intimate partner violence, family violence, battering, and spousal abuse are all terms used to describe a pattern of assaultive and coercive behaviors. The effects of IPV during pregnancy can have serious consequences for the woman and the growing fetus. Pregnant women are likely to have more multiple injury sites than nonpregnant women, and the abuse is often directed to the breasts, genitalia, and abdomen. The risk of injury to the fetus is very high because of the chance of placental injury that can result in an abruption. Women in IPV relationships are also more often at risk for physical injuries, sexually transmitted infection, urinary infections, mental health disorders including suicide, and inadequate prenatal care. The effects on the pregnancy and fetus include PTL, placenta previa, miscarriages, IUGR, prenatal distress, and stillbirth (Scannell, 2018b). Pregnancy is often the trigger for the beginning or escalation of violence in a relationship, and many chronically abused women report an increase in violence directed at them during pregnancy.

Pregnant teenagers are particularly vulnerable because of their need to rely on others for the basics of life. Often those whom they rely on are their abusers. Incest, rape, child abuse, gang (group) fighting, stalking, and IPV from both male and female partners have been described. Nurses can help teenagers with violence only if they know that the teenagers are experiencing it. Thus, nurses need to be able to gain their young patients’ trust and confidence so that they feel comfortable sharing their problems. Assessment, safety planning, documentation, and follow-up are all essential components of providing care for women who are experiencing violence, no matter what their age. The medical record is often the source of information that can raise suspicions of abuse, and a number of assessment forms specifically designed to elicit information regarding patterns of abuse have been developed.

 SUMMARY POINTS

■ Complications that arise during pregnancy are often challenging and demand the perinatal nurse’s skills, knowledge, and expertise, combined with the nursing process, to first identify the pregnant patient at risk and then formulate, implement, and evaluate an appropriate, holistic plan of care.

■ Anticipatory nursing care is invaluable in preventing a complication from becoming a major health crisis.

■ Alterations of signs and symptoms from the expected clinical progression during pregnancy must be immediately conveyed to the primary health-care provider so that an appropriate management plan may be activated.

■ The nurse must always remain cognizant of the important role the patient’s family, culture, language, and religious beliefs play in her adjustment to motherhood and overall well-being.

■ By providing culturally competent care to childbearing families, many potential complications can be identified in a timely manner to allow for effective treatment and improved outcomes.

■ Meticulous documentation of the patient’s plan of care and response to the plan of care cannot be overemphasized.

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