Chapter 55- Complications of Pregnancy

Chapter 55- Complications of Pregnancy


  1. Introduction:
  2. Most pregnant women don’t have complications, but if they do, they and their partners are often guilt-ridden and frightened.
  3. To identify those at risk regular prenatal care is important in order to detect complications as early as possible
  4. See high risk factors table
  1. Ways to assess fetal well-being:
  2. Ultrasound
  3. Uses sound waves to visualize contents
  4. Can be used to detect:
  5. More than one fetus
  6. Ectopic pregnancy
  7. Do measurements of biparietal diameter, femur and overall length of fetus
  8. Gestational age
  9. IUGR
  10. Fetal anomalies
  11. Amniotic fluid amount and if there is normal, too much or not enough
  12. Fetal position and presentation
  13. Fetal death
  14. Two types:
  15. Transabdominal:
  16. Need full bladder
  17. Lie on back
  18. Endovaginal
  19. Vaginal probe
  20. Lithotomy position
  21. Empty bladder
  1. Non-stress test (NST):
  2. Use electronic fetal monitor
  3. Records fetal movement and heart rate (FHR)
  4. Reclines in chair or in bed
  5. Semi-fowler’s or side-lying position
  6. Test reactive if 2 accelerations (increases) of 15 beats/min. lasting 15 seconds in a 20 min. period- means fetus has adequate O2 and intact CNS
  7. Test nonreactive if above criterion not met- could mean fetus sleeping or is having a problem
  8. Heart rate increases with fetal movement
  1. Fetal Acoustic Stimulation Test (FAST) and Vibroacoustic Stimulation Test (VST):
  2. Use with NST if nonreactive test
  3. Vibrator/buzzer placed over fetal head on abdominal to stimulate fetus.
  4. Reactive test is 2 FHR increases of 15 beats/min. lasting 15 secs in a 10 min. period
  1. Fetal Biophysical Profile (FBPP) assesses:
  2. Fetal breathing movement
  3. Fetal movements of body or limbs
  4. Fetal tone –extension/flexion of extremities
  5. Amniotic fluid volume
  6. Reactive NST
  7. See table- if score of 8 or more shows probable fetal well-being
  1. Fetal movement- “quickening”
  2. Occurs at 16-20 weeks
  3. 2 ways to assess:
  4. Count fetal movement daily for 10 minutes 3x a day
  5. Cardiff method:
  6. Count fetal movements at the same time each day until 10 movements are felt (note start and stop times)

3.Notify dr. if:

a. fewer than 10 movements in 12 hours

b. no movements for 8 hours

c. sudden, violent movements followed by reduced


  1. Biochemical Assessments:
  2. Maternal serum alpha-fetoprotein (MSAFP):
  3. Identifies birth defects and chromosomal anomalies
  4. Done between 16-18 weeks
  5. If result hi- can be:
  6. Neural tube defect
  7. Multiple gestation
  8. Maternal diabetes
  9. Fetal distress
  10. Fetal death
  11. If low can be:
  12. Down syndrome
  13. Maternal hypertensive state
  14. Estriol:
  15. Indicates fetoplacental function
  16. If gradually increases means placenta functioning properly
  1. Human Placental Lactogen (PL):
  2. As fetal weight increases, hPL should increase
  1. Amniocentesis:
  2. Needle inserted into amniotic sac thru abdomen and amniotic fluid is withdrawn
  3. Never before 14 weeks- do between 14 to 16 weeks
  4. Diagnoses genetic diseases and birth defects
  5. Can also detect fetal lung maturity
  6. See safety- amniocentesis
  7. Tests done on amniotic fluid:
  8. Lecithin/sphingomyelin ratio- determines lung maturity; by 35 weeks if lungs are mature (surfactant present) should be 2:1 ratio
  9. Phosphatidylglycerol determines lung maturity
  10. Bilirubin- done to see if fetal anemia exists
  11. Sex determination
  1. Chorionic Villi sampling:
  2. Detects genetic disorders
  3. Done at 8-10 weeks gestation
  1. Contraction Stress Test (CST):
  2. Evaluates respiratory function of placenta
  3. Test done by stimulating uterine contractions by IV oxytocin or nipple stimulation
  4. During contractions, O2 of fetus is normally decreased, if healthy fetus, this is tolerated without problems
  5. If placenta is not functioning properly, will see fetal hypoxia, myocardial depression and a decreased FHR
  6. Not to be used in placenta previa, abruption placenta, PROM, history of preterm labor, previous C/S
  7. Desired result is a negative CST meaning no late decelerations (decreases in FHR) with uterine contractions
  8. Not desired is a positive CST with late decelerations that occur with more than half of the contractions
  1. Electronic Fetal Monitoring (EFM):
  2. Visual record of FHR in relation to uterine contractions- it shows you what happens to the fetal heart rate when a contraction occurs
  3. 2 types:
  4. External (indirect) monitoring:
  5. A tocodynamometer is placed on mother’s abdomen near the fundus to monitor uterine contractions
  6. A Doppler transducer (an ultrasonic device) is placed on the mother’s abdomen to monitor FHR
  7. Both held on with an elastic band
  8. Internal (direct) monitoring:
  9. More reliable- directly monitors FHR
  10. EKG electrode is directly attached to fetal presenting part (usually the head)
  11. 4 conditions must be met:
  12. Ruptured membranes
  13. 2cm dilated cervix
  14. Presenting part needs to be down near cervix
  15. Sterile technique
  16. Interpretations:
  17. Baseline rate: average FHR during a 10 minute period; normal rate 110-160; if rate above 160-tachycardia, below 110- bradycardia
  18. Accelerations- short-term increases in FHR usually caused by fetal movement; is normal
  19. Early decelerations- reductions in FHR that begin early with the contraction and typically mirror the contraction, caused by head compression during contractions, no intervention needed
  20. Late decelerations- reductions in FHR that begin at peak of contraction and increase to baseline level after the contraction has finished, caused by uteroplacental insufficiency (poor blood flow), is abnormal, report STAT, give mother some O2
  21. Variable decelerations- reductions in FHR that have no relationship to the contractions, caused by compression of the umbilical cord leading to decreased blood flow to the fetus, is abnormal, report STAT, change mother’s position- to lie on either side, preferably the left


  1. Excessive vomiting during pregnancy
  2. Cause: unknown but may be hormonal or have a psychological component
  3. Can come and go or last entire pregnancy
  4. Leads to:
  5. Dehydration
  6. Electrolyte and fluid imbalances
  7. Alkalosis
  8. Protein and vitamin deficiencies
  9. Cardiac arrhythmias
  10. Death of both mother and baby
  11. Sxs:
  12. Tachycardia
  13. Hypovolemia
  14. Increased Hct and BUN
  15. Decreased urine output
  16. Treatment:
  17. Hospitalize
  18. IV fluids
  19. Psychotherapy
  20. Minimal meds (teratogenic to fetus)
  21. NPO , then dry foods, then regular diet
  22. Bedrest
  23. Emotional support
  24. Encourage ventilation of feelings
  25. Quiet environment
  26. Good oral hygiene
  27. Antiemetic as ordered
  28. Assess:
  29. Skin turgor, mucous membranes
  30. I&O
  31. Emotional state
  32. What triggers it
  33. Amount and characteristics of emesis
  34. FHR
  35. For jaundice
  36. For vaginal bleeding


a. induced (purposeful) or spontaneous (natural) termination of pregnancy before 24 weeks of gestation (viability of fetus)

b. spontaneous:

i. a miscarriage

ii. related to:

A. chromosomal abnormalities

B. faulty implantation

C. teratogenic substances

D. placental abnormalities

E. incompetent cervix

F. chronic maternal disease

G. maternal infections

H. endocrine imbalances

iii. TYPES:

A. threatened- unexplained bleeding and cramping; cervix closed and membranes intact; treat: bedrest 24-48 hours, avoid stress, strenuous activity, sexual intercourse.

B. inevitable- increased bleeding and cramping, cervix begins to dilate, membranes can rupture; treat: D&C or suction evacuation, blood transfusion if needed

C. incomplete- some of the products of conception are expelled, bleeding heavy, cramping severe; treat: same as inevitable

D. complete- all parts of conception are expelled

E. missed- fetus dies but is retained, cervix closed, if not expelled within 6 weeks and fetus is < 12 weeks a D&C is done, if fetus is > 12 weeks induction of labor with oxytocin is used

F. habitual- any of the above occurring in 3 consecutive pregnancies, cervix begins to dilate in 2nd trimester- incompetent cervix; treat: cerlage-Shirodkar procedure is done, internal mouth of cervix is sutured shut, done at 16 weeks of gestation

iv. assess:

A. amount of bleeding, cramping, presence of clots, for expelled tissue

B. do vital signs

C. have a calm environment

D. provide active listening

E. patient may have feelings of guilt/fear


A. Fertilized ovum implants outside the uterus, most often the fallopian tube but can be other sites

B. Risk factors: PID, Diethylstilbesterol, STDs, medication for infertility, endometriosis

C. Ages: 15-45 year old mostly

D. Pregnancy appears normal at first, then 3 to 5 weeks after missed period pain starts due to increasing size of fallopian tube, tube ruptures with severe pain then bleeding intrabdominal or vaginal can occur

E. Sxs:

i. amenorrhea

ii. nausea

iii.breast tenderness

iv.dull ache on one side of pelvis becoming more severe

v.when tube ruptures, pt. experiences a single excruciating pain in abdomen- may have referred shoulder pain

vi.decreased Hgb, Hct and RBC

vii. increased WBC, sed rate

viii.slowly rising hCG level

ix.rigid, tender abdomen

F.Surgical management:

i. surgery so bleeding can be controlled

ii. NPO

iii.Pre and post op care



vi.vital signs


A.abnormality of the placenta

B.can be partial or complete

C. uterus fills with fluid filled grapelike clusters called vesicles FHTs

E. if partial, fetus is present but not viable

F. may have hyperemesis gravidarum

G. sxs:

i. severe nausea and vomiting

ii. brownish vaginal drainage but may be bright red

iii.characteristic molar pattern on ultrasound is a snowy appearance

iv.PIH sxs

H.suspected if PIH occurs before 24 weeks gestation

I.diagnose by ultrasound

J. medical management:

i. follow-up for 1-2 years afterwards due to risk of developing choriocarcinoma

ii. do chest x-rays to detect metastasis pelvic exams weekly hCG levels NOT become pregnant during this time

K.surgical management:


ii.if older, hysterectomy


i. if hCG remains high or rises after uterus evacuated- methotrexate is given

ii.oxytocin is used to keep uterus contracted to control bleeding

iii.blood transfusions if needed


A.fertilized ovum is implanted in lower uterine segment with placenta lying over or very near the internal cervical mouth

B. cause is unknown

C.risk factors:


ii.D&C, C/s scarring

iii.maternal advancing age


D. sxs:

i. PAINLESS bleeding in last half of pregnancy

ii. relaxed, nontender uterus

iii.bleeding-spotting to profuse

iv.usually FHR stable

E. classified as:

i. low-lying or marginal-placenta near internal cervical mouth and not covering any part of the opening

ii.partial-placenta covers part of the internal cervical mouth opening

iii.complete/total- placenta completely covers internal cervical mouth

iv.diagnose by ultrasound cervix thins during labor, placenta pulls away from cervix and bleeding occurs

G. effects on fetus/neonate:

i. if profuse bleeding, hypoxia to fetus occurs

ii. neonate should be checked for anemia

H.medical management:

i. maintain pregnancy until fetus is viable

ii.determine lung maturity by the L/S ratio H&H q 12 hrs.

iv.blood transfusions if needed vaginal exams once diagnosed

I. surgical management:

i. C/S STAT if fetal duistress or maternal condition worsens

J. pharmacological:

i. Betamethasone (Celestone) is given to mom to accelerate fetal lung maturity

K. treatment:

i. bedrest with BRP if no bleeding; bedrest if bleeding

ii.monitor vital signs and FHR

iii.calm environment

iv.Monitor uterine contractions


1. premature separation from the wall of the uterus of a normally implanted placenta

2. cause: unknown

3. risk factors:

i. mom has hypertension

ii.multiple pregnancies

iii.abdomen trauma

iv.smoking,alcohol or cocaine use

4. Occurs late in pregnancy or during labor

5. types:

i. central- center of placenta separates, blood is trapped between placenta and uterine wall, no apparent bleeding, bleeding is hidden

ii.marginal- edge of placenta separates and bright red bleeding vaginally

iii.complete- entire placenta separates with profuse bleeding vaginally

6. moderate to severe PAIN, rigid, painful uterus

7. after delivery of the fetus and placenta the uterus contracts poorly with much bleeding

8. may need hysterectomy

9. Can lead to DIC

10. effects on fetus/neonate:

i. 1/3rd of cases lead to fetal death


  1. Preterm labor
  2. Hypoxia
  3. Anemia
  4. Irreversible brain damage
  5. Fetal death

11.medical management:

i. blood tests to include: H&H, PTT, protime, clotting factors, platelets

ii.blood transfusions if needed

iii.foley catheter

iv.if a small separation and near term- induce and deliver vaginally

v.if moderate or severe separation, C/S

vi.hysterectomy may have to be done to control bleeding

12. medications:

i.Rhogam to nonsensitized Rh negative mothers



13.nursing management:

i. NPO if surgery


iii.assess bleeding, pain, vital signs, FHR, fetal activity

iv.blood transfusions ineeded


vi.pre&post-op teaching if C/S

vii.lie on left side, not back

viii.foley cath care


  1. Condition in which there is overstimulation of normal clotting process leading to small blood clots (thrombin) forming throughout the circulatory system. In addition, platelets and clotting factors are depleted leading to generalized bleeding causing anemia and ischemia to vital organs.
  2. Is a complication of a primary problem
  3. Can occur to anyone, not just a pregnant woman
  4. Risk factors:
  5. Abruption placenta
  6. Placenta previa
  7. Haydatidiform mole,
  8. PIH,
  9. retained products of conception,
  10. amniotic fluid embolism,
  11. infections
  12. Sxs:
  13. Onset sudden
  14. c/o dyspnea/chest pain
  15. restlessness
  16. cyanosis
  17. spitting up frothy blood-tinged mucus
  18. bleeding gums
  19. epistaxis
  20. petechiae under blood pressure cuff
  21. bleeding from injection sites
  22. Effects on fetus/neonate:
  23. STAT delivery even if preterm
  24. Fetal hypoxia
  25. Fetal death
  26. Medical management:
  28. Deliver fetus
  29. Diagnostic blood work includes: H&H, fibrinogen level, PT, PTT, platelets
  30. Medications:
  31. IV of blood, fibrinogen or cryoprecipitate is started
  32. Heparin drip on IV pump to prevent microemboli
  33. O2
  34. Nursing management:
  35. Have a calm manner
  36. IV fluids, blood
  37. Heparin
  38. O2
  39. Vital signs


  1. Also called toxemia, preeclampsia
  2. Appears after 20 weeks gestation
  3. Classic sxs:
  4. Hypertension
  5. Edema
  6. Proteinuria
  7. Usually with 1st babies of mothers <20 or > 35 and poor and with poor nutrition
  8. Risk factors:
  9. Diabetes
  10. Multiparity
  11. Family history of PIH
  1. SXS:
  2. Increased BP
  3. Decreased blood flow to uterus and placenta
  4. Cerebral edema leading to headaches and visual disturbances
  5. Liver increase in size leading to epigastric pain
  6. Cause: unknown
  7. CURE: deliver baby
  8. Effects on fetus/neonate:
  9. Abruption placenta
  10. Placental infarction
  11. Acute hypoxia
  12. Intrauterine death
  13. Preterm baby
  14. Types:
  15. Mild preeclampsia:
  16. BP is increased 30 points systolically or 15 points diastolically over baseline on 2 occasions at least 6 hours apart or mother has a BP of 140/90
  17. Facial and hand edema leading to weight gain of >1lb./wk.
  18. +1 or +2 albumin in urine
  19. Severe preeclampsia:
  20. BP of 160/110 or > on 2 occasions at least 6 hours apart
  21. Generalized edema of face, hands, sacral area, lower extremities, abdomen
  22. Wt. gain 2 lbs. or more in a few days/wk.
  23. +3 or +4 proteinuria
  24. Urine output < 500ml in 24 hours
  25. Hct, uric acid, and creatinine levels increase
  26. Other sxs: continuous headache, blurred vision, scotomata (spots before eyes), N&V, irritability, etc.
  27. Epigastric pain usually last sx seen before goes into full blown eclampsia
  28. Eclampsia:
  29. Seizures tonic clonic- grand mal
  30. Coma for few minutes to hours
  31. Without treatment- death
  32. Seizure activity may trigger uterine contractions
  33. HELLP syndrome:
  34. Complication of preeclampsia/eclampsia with liver damage occurring
  35. Hemolysis of RBCs
  36. Increased liver enzymes- AST/ALT
  37. Ischemia of liver
  38. Platelets decrease to less than 100,000
  39. Causes ischemia, tissue damage, hypoglycemia
  40. If blood sugar < 40, maternal mortality high
  41. 20% of PIH patients develop HELLP
  42. Medical management:
  43. Goals of treatment:
  44. Decrease BP
  45. Prevent convulsions
  46. Deliver healthy baby
  47. If mild preeclampsia- bedrest with lying on either side
  48. Lab tests: Hct, Plt, lytes, liver enzymes, estriol level, 24 hour urine for protein and creatinine, serum creatinine
  49. Surgical management:
  50. C/S if mother’s condition deteriorates or fetal distress
  51. Medications:
  52. Magnesium Sulfate (MgSO4):
  53. A CNS depressant
  54. Decrease possibility of convulsions and BP
  55. IV or IM (Z-Track)
  56. Excreted by kidneys- so if pt. has poor renal function can be toxic and lead to cardiac arrhythmia and arrest
  57. Given for 24-48 hrs. post-delivery
  58. Conditions that MUST be met in order to give MgSO4:
  59. Respirations must be 14/min or more
  60. Deep tendon reflexes (DTR) have normal response when checked
  61. Have at least 30cc urine/hr. output
  62. Mag levels need to be monitored- therapeutic level is 4-8
  63. Side effects of toxicity are: flushing, sweating, hypotension, hypothermia, muscle weakness, constipation, N&V
  64. Foley catheter inserted
  65. Mag toxicity antidote is calcium gluconate- keep at bedside for emergency injection
  66. Antihypertensive- Apresoline except if cardiac disease then Normadyne
  67. Valium/Phenobarbitol to help rest
  68. Oxytocin to induce labor- may be used along with MgSO4
  69. Diet:
  70. Well-balanced, hi protein, moderate sodium
  71. If nauseated or has convulsions, keep NPO
  72. Activity:
  73. Bedrest, left-side lying position, no lying on back
  74. Nursing managment:
  75. Check vs, FHR, edema, weight, for irritability, hyperreflexia (DTR), dyspnea, Proteinuria, headache, blurred vision, cyanosis, nausea, and epigastric pain
  76. Include family in decisions
  77. Encourage ventilation of feelings
  78. Assess for toxicity if MgSO4 is being used
  79. I&O



  1. If you have diabetes and want to get pregnant, it is important that your diabetes is well controlled prior to conception.
  2. Whether chronic or gestational diabetes, effects same
  3. Pregnancy and carbohydrate metabolism:
  4. Early pregnancy- insulin production increased
  5. Last half of pregnancy- increased tissue resistance to insulin
  6. If already a diabetic, pregnancy makes it harder to control it
  7. Effects of pregnancy on diabetes:
  8. 1st trimester, insulin need is decreased
  9. 2nd trimester insulin need is increased
  10. 3rd trimester has 4x the insulin need
  11. After delivery and placenta passed, insulin need decreases
  12. Effects of diabetes on pregnancy:
  13. Higher risk for complications
  14. Has higher risk for PIH if vascular problems
  15. Hydramnios (excessive amount of amniotic fluid) may occur
  16. Death of fetus and mother can occur
  17. Maternal complications directly related to degree of blood glucose control
  18. Effects on fetus/neonate:
  19. Macrosamia (excessive fetal growth)
  20. After birth, neonate develops hypoglycemia (2-4 hrs).
  21. If fetus has a high insulin level, surfactant can be inhibited and fetus can have respiratory distress syndrome
  22. Fetus also has polycythemia (excessive amount of RBCs) and increased bilirubin leading to hyperbilirubinemia
  23. Higher risk for fetal anomalies especially heart, CNS, skeletal system
  24. Medical management:
  25. Maintain maternal blood sugar between 70-120
  26. Mother seen by OB and endocrinologist monitors own blood sugar and gives self insulin according to sliding scale
  27. Fetal status:
  28. Assessed throughout pregnancy
  29. AFP screening done as there is a risk for neural tube defects
  30. Ultrasound done at 18 weeks then repeated q 4-6 weeks- to determine gestational age and look for congenital anomalies
  31. NST done weekly
  32. CST starting at 32 weeks and then weekly.
  33. Surgical management:
  34. If fetus having trouble, do C/S
  35. Medications:
  36. Humalin used as less allergic reaction
  37. Daily multiple injections using a sliding scale
  38. No oral hypoglycemic
  39. Diet:
  40. Increase calories by 300 daily when pregnant
  41. Divide total calories between 3 meals and 3 snacks
  42. Eat bedtime snack as late as possible to prevent nitetime hypoglycemia- include a carbohydrate and a protein
  43. Do no more than 10 hours between bedtime snack and breakfast
  44. Activity:
  45. Maintain unless contraindicated
  46. Nursing management:
  47. Listen actively to patient
  48. Answer questions
  49. Provide support
  50. Teach glucose monitoring and insulin use if needed
  51. Monitor fetal status
  52. Encourage compliance for prenatal visits and testing appointments
  53. Assess:
  54. Diet, activity, medication compliance
  55. Urine for sugar
  56. Vital signs
  57. Weight
  58. NST
  59. For infection
  60. After 28 weeks gestation, record maternal evaluation of fetal activity