Chapter 55- Complications of Pregnancy

CHAPTER 55- COMPLICATIONS OF PREGNANCY

Introduction:
Most pregnant women don’t have complications, but if they do, they and their partners are often guilt-ridden and frightened.
To identify those at risk regular prenatal care is important in order to detect complications as early as possible
See high risk factors table

Ways to assess fetal well-being:
Ultrasound
Uses sound waves to visualize contents
Can be used to detect:
More than one fetus
Ectopic pregnancy
Do measurements of biparietal diameter, femur and overall length of fetus
Gestational age
IUGR
Fetal anomalies
Amniotic fluid amount and if there is normal, too much or not enough
Fetal position and presentation
Fetal death
Two types:
Transabdominal:
Need full bladder
Lie on back
Endovaginal
Vaginal probe
Lithotomy position
Empty bladder

Non-stress test (NST):
Use electronic fetal monitor
Records fetal movement and heart rate (FHR)
Reclines in chair or in bed
Semi-fowler’s or side-lying position
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
Test nonreactive if above criterion not met- could mean fetus sleeping or is having a problem
Heart rate increases with fetal movement

Fetal Acoustic Stimulation Test (FAST) and Vibroacoustic Stimulation Test (VST):
Use with NST if nonreactive test
Vibrator/buzzer placed over fetal head on abdominal to stimulate fetus.
Reactive test is 2 FHR increases of 15 beats/min. lasting 15 secs in a 10 min. period

Fetal Biophysical Profile (FBPP) assesses:
Fetal breathing movement
Fetal movements of body or limbs
Fetal tone –extension/flexion of extremities
Amniotic fluid volume
Reactive NST
See table- if score of 8 or more shows probable fetal well-being

Fetal movement- “quickening”
Occurs at 16-20 weeks
2 ways to assess:
Count fetal movement daily for 10 minutes 3x a day
Cardiff method:
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

movements

Biochemical Assessments:
Maternal serum alpha-fetoprotein (MSAFP):
Identifies birth defects and chromosomal anomalies
Done between 16-18 weeks
If result hi- can be:
Neural tube defect
Multiple gestation
Maternal diabetes
Fetal distress
Fetal death
If low can be:
Down syndrome
Maternal hypertensive state
Estriol:
Indicates fetoplacental function
If gradually increases means placenta functioning properly

Human Placental Lactogen (PL):
As fetal weight increases, hPL should increase

Amniocentesis:
Needle inserted into amniotic sac thru abdomen and amniotic fluid is withdrawn
Never before 14 weeks- do between 14 to 16 weeks
Diagnoses genetic diseases and birth defects
Can also detect fetal lung maturity
See safety- amniocentesis
Tests done on amniotic fluid:
Lecithin/sphingomyelin ratio- determines lung maturity; by 35 weeks if lungs are mature (surfactant present) should be 2:1 ratio
Phosphatidylglycerol determines lung maturity
Bilirubin- done to see if fetal anemia exists
Sex determination

Chorionic Villi sampling:
Detects genetic disorders
Done at 8-10 weeks gestation

Contraction Stress Test (CST):
Evaluates respiratory function of placenta
Test done by stimulating uterine contractions by IV oxytocin or nipple stimulation
During contractions, O2 of fetus is normally decreased, if healthy fetus, this is tolerated without problems
If placenta is not functioning properly, will see fetal hypoxia, myocardial depression and a decreased FHR
Not to be used in placenta previa, abruption placenta, PROM, history of preterm labor, previous C/S
Desired result is a negative CST meaning no late decelerations (decreases in FHR) with uterine contractions
Not desired is a positive CST with late decelerations that occur with more than half of the contractions

Electronic Fetal Monitoring (EFM):
Visual record of FHR in relation to uterine contractions- it shows you what happens to the fetal heart rate when a contraction occurs
2 types:
External (indirect) monitoring:
A tocodynamometer is placed on mother’s abdomen near the fundus to monitor uterine contractions
A Doppler transducer (an ultrasonic device) is placed on the mother’s abdomen to monitor FHR
Both held on with an elastic band
Internal (direct) monitoring:
More reliable- directly monitors FHR
EKG electrode is directly attached to fetal presenting part (usually the head)
4 conditions must be met:
Ruptured membranes
2cm dilated cervix
Presenting part needs to be down near cervix
Sterile technique
Interpretations:
Baseline rate: average FHR during a 10 minute period; normal rate 110-160; if rate above 160-tachycardia, below 110- bradycardia
Accelerations- short-term increases in FHR usually caused by fetal movement; is normal
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
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
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

HYPEREMESIS GRAVIDARUM:

Excessive vomiting during pregnancy
Cause: unknown but may be hormonal or have a psychological component
Can come and go or last entire pregnancy
Leads to:
Dehydration
Electrolyte and fluid imbalances
Alkalosis
Protein and vitamin deficiencies
Cardiac arrhythmias
Death of both mother and baby
Sxs:
Tachycardia
Hypovolemia
Increased Hct and BUN
Decreased urine output
Treatment:
Hospitalize
IV fluids
Psychotherapy
Minimal meds (teratogenic to fetus)
NPO , then dry foods, then regular diet
Bedrest
Emotional support
Encourage ventilation of feelings
Quiet environment
Good oral hygiene
Antiemetic as ordered
Assess:
Skin turgor, mucous membranes
I&O
Emotional state
What triggers it
Amount and characteristics of emesis
FHR
For jaundice
For vaginal bleeding

BLEEDING:

A.Abortion:
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

ECTOPIC PREGNANCY:

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

iv.bedrest

v.analgesics

vi.vital signs

HYDATIDIFORM MOLE (TROPHOBLASTIC DISEASE):

A.abnormality of the placenta

B.can be partial or complete

C. uterus fills with fluid filled grapelike clusters called vesicles

D.no 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

iii.do pelvic exams

iv.do weekly hCG levels

v.do NOT become pregnant during this time

K.surgical management:

i.D&C

ii.if older, hysterectomy

L.pharmacological:

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

PLACENTA PREVIA:

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:

i.multiparity

ii.D&C, C/s scarring

iii.maternal advancing age

iv.smoking

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

F.as 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

iii.do H&H q 12 hrs.

iv.blood transfusions if needed

v.no 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

ABRUPTIO PLACENTA:

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

ii.complications:

Preterm labor
Hypoxia
Anemia
Irreversible brain damage
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

ii.plasma

iii.analgesics

13.nursing management:

i. NPO if surgery

ii.bedrest

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

iv.blood transfusions ineeded

v.O2

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

vii.lie on left side, not back

viii.foley cath care

DIC (DISSEMINATED INTRAVASCULAR COAGULATION):

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.
Is a complication of a primary problem
Can occur to anyone, not just a pregnant woman
Risk factors:
Abruption placenta
Placenta previa
Haydatidiform mole,
PIH,
retained products of conception,
amniotic fluid embolism,
infections
Sxs:
Onset sudden
c/o dyspnea/chest pain
restlessness
cyanosis
spitting up frothy blood-tinged mucus
bleeding gums
epistaxis
petechiae under blood pressure cuff
bleeding from injection sites
Effects on fetus/neonate:
STAT delivery even if preterm
Fetal hypoxia
Fetal death
Medical management:
MUST IDENTIFY AND TREAT UNDERLYING CAUSE
Deliver fetus
Diagnostic blood work includes: H&H, fibrinogen level, PT, PTT, platelets
Medications:
IV of blood, fibrinogen or cryoprecipitate is started
Heparin drip on IV pump to prevent microemboli
O2
Nursing management:
Have a calm manner
IV fluids, blood
Heparin
O2
Vital signs

PIH (PREGNANCY INDUCED HYPERTENSION):

Also called toxemia, preeclampsia
Appears after 20 weeks gestation
Classic sxs:
Hypertension
Edema
Proteinuria
Usually with 1st babies of mothers <20 or > 35 and poor and with poor nutrition
Risk factors:
Diabetes
Multiparity
Family history of PIH

SXS:
Increased BP
Decreased blood flow to uterus and placenta
Cerebral edema leading to headaches and visual disturbances
Liver increase in size leading to epigastric pain
Cause: unknown
CURE: deliver baby
Effects on fetus/neonate:
Abruption placenta
Placental infarction
Acute hypoxia
Intrauterine death
Preterm baby
Types:
Mild preeclampsia:
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
Facial and hand edema leading to weight gain of >1lb./wk.
+1 or +2 albumin in urine
Severe preeclampsia:
BP of 160/110 or > on 2 occasions at least 6 hours apart
Generalized edema of face, hands, sacral area, lower extremities, abdomen
Wt. gain 2 lbs. or more in a few days/wk.
+3 or +4 proteinuria
Urine output < 500ml in 24 hours
Hct, uric acid, and creatinine levels increase
Other sxs: continuous headache, blurred vision, scotomata (spots before eyes), N&V, irritability, etc.
Epigastric pain usually last sx seen before goes into full blown eclampsia
Eclampsia:
Seizures tonic clonic- grand mal
Coma for few minutes to hours
Without treatment- death
Seizure activity may trigger uterine contractions
HELLP syndrome:
Complication of preeclampsia/eclampsia with liver damage occurring
Hemolysis of RBCs
Increased liver enzymes- AST/ALT
Ischemia of liver
Platelets decrease to less than 100,000
Causes ischemia, tissue damage, hypoglycemia
If blood sugar < 40, maternal mortality high
20% of PIH patients develop HELLP
Medical management:
Goals of treatment:
Decrease BP
Prevent convulsions
Deliver healthy baby
If mild preeclampsia- bedrest with lying on either side
Lab tests: Hct, Plt, lytes, liver enzymes, estriol level, 24 hour urine for protein and creatinine, serum creatinine
Surgical management:
C/S if mother’s condition deteriorates or fetal distress
Medications:
Magnesium Sulfate (MgSO4):
A CNS depressant
Decrease possibility of convulsions and BP
IV or IM (Z-Track)
Excreted by kidneys- so if pt. has poor renal function can be toxic and lead to cardiac arrhythmia and arrest
Given for 24-48 hrs. post-delivery
Conditions that MUST be met in order to give MgSO4:
Respirations must be 14/min or more
Deep tendon reflexes (DTR) have normal response when checked
Have at least 30cc urine/hr. output
Mag levels need to be monitored- therapeutic level is 4-8
Side effects of toxicity are: flushing, sweating, hypotension, hypothermia, muscle weakness, constipation, N&V
Foley catheter inserted
Mag toxicity antidote is calcium gluconate- keep at bedside for emergency injection
Antihypertensive- Apresoline except if cardiac disease then Normadyne
Valium/Phenobarbitol to help rest
Oxytocin to induce labor- may be used along with MgSO4
Diet:
Well-balanced, hi protein, moderate sodium
If nauseated or has convulsions, keep NPO
Activity:
Bedrest, left-side lying position, no lying on back
Nursing managment:
Check vs, FHR, edema, weight, for irritability, hyperreflexia (DTR), dyspnea, Proteinuria, headache, blurred vision, cyanosis, nausea, and epigastric pain
Include family in decisions
Encourage ventilation of feelings
Assess for toxicity if MgSO4 is being used
I&O

CHRONIC MEDICAL PROBLEMS:

DIABETES MELLITUS:

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

CHRONIC HYPERTENSION: