High Risk Pregnancy

Complication of Pregnancy

n  Places a burden on the woman and family.

n  Hospitalization may be necessary.

n  Leading causes of maternal death during pregnancy are thromboembolism, hemorrhage, infection, hypertension, anesthesia complications, ectopic pregnancy and heart disease.

n  Nursing Process:

n  Nurses discover complications.

n  Outcomes address fetal and maternal welfare.

Bleeding During Pregnancy

n  Vaginal bleeding is never normal and is frightening.

n  Bleeding and the Development of Shock:

n  Serious because the amount visualized may only be a fraction of the actual loss.

n  Hypovolemic shock

n  Process of shock

n  Uterus is a nonessential organ, danger to fetal blood supply occurs when the woman’s body decreases blood flow to peripheral organs.

n  10% of blood volume, 2 units of blood lost.

n  Fetal distress occurs when 25% of blood volume is lost.

n  ER interventions.

n  Restore blood volume and halt the source of bleeding.

n  First Trimester Bleeding

n  Spontaneous Miscarriage:

n  Abortion-interruption of a pregnancy before the fetus is viable. Medical or surgical interrupted.

n  Nonviable fetus is a fetus of 20 to 24 weeks of gestation or weighing 500 g or less.

n  Miscarriage-interruption occurs spontaneously. Occurs in 15% to 30% of all pregnancies and occurs from natural causes.

n  Bleeding before week 6 is rarely severe.

n  Bleeding after week 12 can be profuse because the placenta is implanted deeply.

n  Between weeks 6 to 12 the stage of attachment can be the most severe bleeding and a threat to their lives.

n  Causes:

n  1st trimester-abnormal fetal formation due to teratogenic factor or chromosomal aberration. 60% structural abnormalities.

n  Implantation abnormalities. 50%

n  Corpus luteum fails to produce enough progesterone to maintain decidua basalis.

n  Infection-rubella, syphilis, UTI

n  Teratogenic drugs.

n  Assessment:

n  Vaginal spotting. Ask about self abort.

n  Threatened Miscarriage:

n  Vaginal bleeding scant then bright red.

n  Light cramping, no cervical dilatation.

n  Sonogram, hCG at start of bleeding and 48 hours. Will double if placenta is intact.

n  Limit activity to no strenuous activity for 24 to 48 hours is key intervention.

n  Support and reassurance. May resolve in 24 to 48 hours, no sex for 2 weeks.

n  Imminent (Inevitable) Miscarriage:

n  If uterine contractions and cervical dilation occur. Ash to go to hospital or office for an exam.

n  Bring tissue fragments, may do sonogram.

n  D&C, bleeding more than 1 per hour is abnormally heavy bleeding.

n  Complete Miscarriage:

n  Entire products of conception (fetus, membranes, and placenta) are expelled spontaneously without assistance.

n  Incomplete Miscarriage:

n  Part of conceptus (usually the fetus) is expelled, but membranes or placenta is retained in the uterus.

n  Danger of maternal hemorrhage because uterus can not contract.

n  D&C or suction curettage.

n  Be sure woman knows the pregnancy is already lost.

n  Missed Miscarriage:

n  Early pregnancy failure, fetus dies in utero but is not expelled.

n  Discovered at prenatal visit-fundal height not increased, no fetal heart.

n  Sonogram, D&C, over 14 weeks labor induced by prostaglandin suppository or Cytotec to dilate the cervix, followed by oxytocin. If not actively terminated, miscarriage occurs in 2 weeks.

n  Danger of DIC

n  Support.

n  Recurrent Pregnancy Loss:

n  3 spontaneous miscarriages at same gestational age-habitual aborters.

n  Cause:

n  Defective spermatozoa or ova

n  Endocrine factor

n  Deviations of the uterus

n  Infection

n  Autoimmune disorders

n  Complications of Miscarriage:

n  Hemorrhage:

n  With complete spontaneous miscarriage, serious or fatal hemorrhage is rare.

n  DIC-position woman flat and massage fundus, may need D&C.

n  1 pad per hour

n  Unusual odor or passing large clots is abnormal.

n  Methergine

n  Repression

n  Infection:

n  Teach danger signs of infection. (100.4)

n  Organism-Escherichia coli

n  Avoid tampons-stasis of blood.

n  Endometritis usually occur.

n  Septic Abortion:

n  An abortion that is complicated by infection.

n  Happens after spontaneous miscarriage, self abort or illegal abortion, nonsterile.

n  SS-fever, crampy abdominal pain, uterus feels tender to palpation.

n  Toxic shock, septicemia, kidney failure and death.

n  Tx.-Labs, cultures, catheter, IV, antibiotic-penicillin, gentamicin, clindamycin.

n  D&C, tetanus toxoid,

n  ICU, Dopamine and digitalis, O2

n  Infertility due to scaring.

n  Isoimmunization:

n  Production of antibodies against Rh-positive blood by her immunologic system.

n  When placenta is dislodged, some blood from placental villi may enter the maternal circulation. Woman is Rh-negative.

n  Receive Rh (D antigen) immune globulin (RhIG) to prevent buildup of antibodies.

n  Powerlessness:

n  Sadness, grief, loss of control.

Ectopic Pregnancy

n  Implantation occurs outside the uterine cavity.

n  95% occur in fallopian tube.

n  2nd most frequent cause of bleeding early in pregnancy.

n  Oral contraceptives may reduce the possibility.

n  Assessment:

n  N&V, hCG positive, no menstrual flow.

n  6 to 12 weeks zygote grows large enough to rupture fallopian tube. Tearing and destruction of blood vessels in tube.

n  Experience sharp, stabbing pain in lower abdominal quadrants, followed by scant vaginal spotting.

n  Blood may be expelled into pelvic cavity.

n  SS-lightheadedness, rapid pulse and shock. Leukocytosis from trauma, falling hCG, rigid abdomen, bluish tinge umbilicus.

n  Sonogram, laparoscopy or culdoscopy.

n  Movement of cervix causes extreme pain, pain in shoulder, tender mass in Douglas.

n  Management:

n  Emergency situation when it ruptures.

n  Labs, IV,laparoscopy to ligate bleeding vessels and remove or repair damaged fallopian tube, Rh type.

n  If not ruptured-oral Methotrexate followed by leucovorin. Mifepristone causes sloughing of the tubal implantation site.

n  Abdominal Pregnancy:

n  May implant on an organ such as intestines.

Abdominal Pregnancy

n  Fetus will grow in the pelvic cavity.

n  Fetal outline is easily palpable because it is directly below the abdominal wall, not in the uterus.

n  Sonogram or MRI

n  Placenta will infiltrate and erode a major blood vessel in abdomen and lead to hemorrhage.

n  Bowel perforation, peritonitis, poor nutrient supply, 60% survival.

n  At term the infant is born by laparotomy.

n  Placenta difficult to remove, implanted on an abdominal organ.

n  May be left in place and allow to be absorbed spontaneously in 2 to 3 months.

n  Follow up sonogram.

n  Second Trimester Bleeding

n  Gestational Trophoblastic Disease

n  Hydatidiform Mole

n  Proliferation and degeneration of the trophoblastic villi.

Gestational Trophoblastic Disease

n  As cells degenerate, they become filled with fluid and appear as fluid filled grape sized vesicles.

n  Embryo fails to develop beyond a primitive start.

n  Associated with coriocarcinoma a rapidly metastasizing malignancy.

n  1 in 2000 pregnancies.

n  Occurs in women under 18 or over 35, low protein intake, Asian heritage.

n  Types:

n  Complete mole-all trophoblastic villi swell and become cystic. If embryo forms it dies at 1-2 mm with no fetal blood present.

n  Sperm-empty ovum + duplication = 46

n  Partial mole-some villi form normally. No embryo is present, fetal blood may be present in the villi. Has 69 chromosomes. Rarely leads to Ca.

n  Assessment:

n  Uterus expands faster than normal.

n  No fetal heart, hCG for pregnancy is positive beyond 100 days, hypertension.

n  Sonogram shows dense growth (snowflake pattern) no fetal growth in uterus.

n  At 16 weeks, vaginal bleeding, spotting or fresh flow. Discharge of clear fluid filled vesicles (bring clots or tissue to hospital).

n  Management:

n  Suction curettage to evacuate the mole.

n  Pelvic exam, chest X-Ray, serum hCG every 1-2 weeks for 6 months.

n  Levels that plateau for 3 times or increase suggest malignancy.

n  Methotrexate 15 to 30mg PO or IM qd x 5 interferes with white cell formation.

n  After 6 months, hCG still negative risk free.

n  Loss of false pregnancy, malignancy, postponed pregnancy.

n  Risk 4 to 5 times for 2nd molar pregnancy.

n  US early in 2nd pregnancy to screen for occurrence.

Premature Cervical Dilatation

n  Incompetent cervix-cervix dilates prematurely and cannot hold a fetus until term.

n  SS-show, pink stained vaginal discharge, increased pelvic pressure which may be followed by ROM and loss of amniotic fluid, contractions begin, short labor and fetus is born.

n  Occurs at 20 weeks and fetus is too immature to survive.

n  Increased maternal age, defects, trauma to cervix (biopsy, D&C)

n  Cervical cerclage – at week 12 to 14, purse string sutures are placed in cervix under regional anesthesia. McDonald or a Shirodkar procedure. Prevents it from dilating.

n  Bedrest for few days, slight or modified Trendelenburg position.

n  Removed at 37 to 38 weeks to deliver vaginally.

n  May leave in place and do cesarean birth.

Third Trimester Bleeding

n  Placenta Previa:

n  Low implantation of the placenta.

n  Four degrees:

n  Implantation in lower rather than upper portion of uterus (low-lying placenta).

n  Marginal implantation (placenta edge approaches that of the cervical os)

n  Implantation that occludes a portion of the cervical os (partial placenta previa)

n  Implantation that totally obstructs the cervical os (total placenta previa)

n  Causes: Increased parity, advanced maternal age, past cesarean births, past uterine curettage, and multiple gestation.

n  5 in 1000 pregnancies.

n  Thought to occur whenever the placenta is forced to spread to find an adequate exchange surface.

n  Increase in congenital fetal anomalies may occur if low implantation does not allow optimal fetal nutrition or oxygenation.

n  Assessment:

n  Sonogram done routinely and diagnosis is made early.

n  Call if SS of bleeding, lower uterine segment begins to differentiate from the upper segment around week 30 and cervix begins to dilate.

n  Placenta’s inability to stretch to accommodate the differing shape of the lower uterine segment of the cervix.

n  Abrupt, painless, bright red, sudden.

n  Frightening to her.

n  Management:

n  Emergency situation, site is uterine decidua so the mother is at risk for hemorrhage.

n  Placenta is loosened, fetal O2 is at risk.

n  Immediate care measures:

n  Bedrest, side lying position, duration of pregnancy, time bleeding started, amount of blood, pain, color of blood, what she has done for the bleeding, prior episodes, prior cervical surgery for cervical dilatation.

n  Inspect perineum for bleeding, weigh pads, no pelvic or rectal exam, VS, B/P q 5-15 min, IV, I&O, fetal heart monitor, Labs,

n  Vaginal birth safest for infant, if 30% or less. If over 30% -cesarean birth.

n  Continuing Car Measures:

n  Gestation, point of placenta previa, fetal heart rate, watch carefully in hospital, bedrest for 48 hours. If stops she may go home on bedrest.

n  Betamethasone-steroid-hastens lung maturity if < 34 weeks.

n  Mother is worried, emotional stress.

n  Birth:

n  At 37 weeks amniocentesis analysis for lung maturity shows a positive result, if bleeding occurs, labor begins of distress with the fetus it will be delivered, cesarean.

n  Incision transverse then vertical in uterus above the implantation site.

n  More prone to hemorrhage, postpartum.

n  More likely to develop endometritis because placental site is close to the cervix.

n  Premature Separation of the Placenta

n  Abrupto Placenta

n  Placenta appears to have implanted correctly. Suddenly it begins to separate and bleeding results.

n  Occurs late in pregnancy even during the 1st or 2nd stage of labor.

n  Know the amount and kind of vaginal discharge. Kind of pain.

n  Occurs in 10% of pregnancies and most frequent cause of perinatal death.

n  Cause: unknown, high parity, short umbilical cord, chronic hypertensive disease, hypertension of pregnancy, direct trauma, vasoconstriction from cocaine use, cigarette smoking.

n  May follow a rapid decrease in uterine volume.

n  Assessment:

n  Woman experiences a sharp, stabbing pain high in uterine fundus as the initial separation occurs.

n  If in labor each contraction will be accompanied by pain over and above the pain of the contraction.

n  Tenderness is felt on uterine palpation, heavy bleeding, may not be readily apparent. Pooling of blood, or infiltrate uterine musculature (hard board like uterus).

n  Shock, uterus becomes tense and rigid to touch, may have DIC.

n  Time the bleeding began, pain, womans actions. Labs, type and cross match, fibrinogen level and fibrin breakdown products to detect occurrence of DIC.

n  Quick assess of blood clotting draw 5 mL of blood and set aside for 5 minutes (Clot).

n  Management:

n  IV large gauge, O2, monitor fetal heart, VS q 5 to 15 min., lateral position, no vag or pelvic exam, no enema, degree of placental separation is graded, if above 0 to 1 the pregnancy must be terminated.

n  If premature separation occurs during active labor, ROM or IV oxytocin to hasten birth.

n  ROM prevents large amounts of blood from being trapped in the myometrium which could prevent contractions.

n  Cesarean birth may be best choice.

n  If DIC has developed, surgery is big risk for hemorrhage, IV fibrinogen used to elevate the fibrinogen level.

n  Fetal prognosis depends on extent of placental separation and hypoxia.

n  Maternal prognosis depends on prompt Tx.

n  Monitor for infection.

n  Disseminated Intravascular Coagulation:

n  Acquired disorder of blood clotting.

n  SS-bruising or bleeding from IV site.

n  Causes:premature separation of the placenta, hypertension of pregnancy, amniotic fluid embolism, placental retention, septic abortion, retention of a dead fetus.

n  DIC occurs when there is extreme bleeding and so many platelets and fibrin from general circulation rush to the site that there is not enough left for further clotting.

n  High thrombin level continues to encourage anticoagulation,

n  Person has increased coagulation but throughout the rest of the system, a bleeding defect exists. ER

n  To stop DIC the underlying insult must be halted.

n  Next, marked coagulation must be stopped so that coagulation factors can be freed and restore normal clotting function.

n  IV heparin, blood or platelet transfusion to replace loss, antithrombin III factor, fibrinogen, or cryoprecipitate can restore clotting, fresh frozen plasma or platelets can restore clotting function.

n  Evaluation- if labs return to normal, if any anoxia in renal or brain cells from occluded coagulated capillaries.