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M6 13-005

Exam 9: Common Complications of Pregnancy

Pregnancy Complications Unique to pregnancy. Can occur at any time, but are complications when in conjunction with pregnancy.
Danger Signals in Pregnancy Vaginal Bleeding. Fluid from vagina. Swelling of fingers or puffiness of face & eyes. Persistent headache. Visual disturbances. Severe ABD or epigastric pain. Chills or fever. Pain or burning with urination. Persistent vomiting. Change in fetal
S/S of Preterm Labor Uterine contractions or Cramps. Constant or irregular low backaches. Pelvic Pressure. Watery Vaginal Discharge.
What are the two categories of pregnancy complications? Those unique to the pregnancy and those that could occur at any time, but when they occur concurrently with pregnancy complicate its course.
Assessment of Fetal Health: Purpose of Dx testing To detect congenital anomalies. To evaluate the condition of the fetus. NO Dx test can guarantee the birth of a healthy baby.
Assessment of Fetal Health: Dx Testing Ultrasound examination Doppler ultrasound blood flow Alpha-fetoprotein Chorionic villus sampling Amniocentesis Non-stress test Vibroacoustic stimulation test Contractions stress test Biophysical profile Percutaneous umbilical blood (kicks count)
Ultrasound Examination Use of high frequency sound waves to visualize structures within the body Transvaginal or Transabdominal
Ultrasound Examination: Uses Confirm pregnancy. Verify (Uterine/Ectopic). Verify Fetal Viability. Growth in multi-fetal gestations. Fetal abnormalities. Needle placement. Gestational age. Determine location of uterus, cervix and placenta. Determine amount of amniotic fluid.
Transvaginal ultrasound: used in 1st trimester. Full bladder not required.
Transabdominal ultrasound: used in 2nd and 3rd trimesters
Doppler Ultrasound Blood Flow Assessment Determines adequacy of blood flow through the placenta and umbilical cord Used for complications of: Hypertension Fetal growth restriction
Alpha-Fetoprotein Screening Predominate protein in fetal plasma AFP screening determines protein level in pregnant woman's serum or sample of amniotic fluid
Alpha-Fetoprotein Screening Use Elevated levels: spina bifida (open spine) anencephaly (incomplete development of the skull and brain) gastroschisis (open abdominal cavity) Low Levels: Down Syndrome or trisomy 21 Gestational trophoblastic disease (hydatidiform mole)
Alpha-Fetoprotein Patient Teaching Many factors may influence the level of AFP This is a screening test and further tests may be offered to explain abnormal levels. Normal levels of AFP do not guarantee a perfect baby.
Chorionic Villus Sampling Fetal tissue is analyzed to diagnose chromosomal, metabolic, or DNA abnormalities Performed 10-12 weeks gestation
Types of Choronic Villus Sampling Techniques Transabdominal Transcervical
Amniocentesis: Procedure A hollow needle is inserted through the mother's ABD into the uterus, and amniotic fluid is drawn for analysis.
Amniocentesis Amniotic fluid contains cast-off fetal cells and various other fetal products Best performed between 15 and 20 weeks’ gestation. Ultrasonography used to guide procedure Rh immune globulin given to Rh-neg women Patient teaching
Amniocentesis: Midtrimester Uses Identify chromosomal abnormalities Fetal condition in women sensitized to Rh + Diagnose intrauterine infections Investigate AFP
Amniocentesis: Third Trimester Uses Assess fetal lung maturity Test for fetal hemolytic diseases when Rh incompatibility is suspected
Non-Stress Test Noninvasive, 40 min test Identifies how fetal heart rate responds to fetal movement Identifies fetal compromise Adequate accelerations are reassuring
Vibroacoustic Stimulation Test Noninvasive, similar to NST Fetus stimulated with sound; expected response is acceleration of fetal heart rate, as in NST Used to confirm a nonreactive NST and shorten time required to obtain high-quality NST data
Contraction Stress Test Evaluation of the fetal heart rate response to mild uterine contractions Use: Purposes are the same as the NST May be done if the NST results are abnormal or questionable. Done after 32 weeks gestation.
Biophysical Profile A group of five fetal assessments: Fetal heart rate and reactivity (interpreted from the NST) Fetal breathing movements. Gross fetal body movements Fetal muscle tone (closure of the hand) Volume of amniotic fluid 
Biophysical Profile: Use Used to determine how the fetal central nervous system reacts to hypoxemia and fetal acidosis.
Percutaneous Umbilical Blood Sampling Aspiration of fetal blood from the umbilical cord for prenatal diagnosis or therapy
Percutaneous Umbilical Blood Sampling: Use Management of Rh disease Diagnosis of abnormal blood clotting factors Acid-base status of the fetus Clarify questionable results of genetic testing Treat blood diseases and deliver therapeutic drugs that cannot be delivered to the fetus in another way
Maternal Assessment of Fetal Movement (Kick Counts) Mother counts fetal movements in a prescribed period of time Daily evaluation of movement provides way of evaluating fetus
Why is an ultrasound useful in pregnancy? It has many uses. It can visualize structures in the body, and confirm pregnancy and most fetal anomalies.
What is it called when the mother counts the number of fetal movements in a prescribed period of time? Maternal Assessment of Fetal Movement (Kick Counts)
What is the most common indication for an amniocentesis during the third trimester? Assess if fetal lungs are mature enough to adapt to extrauterine life.
Psychosocial Nursing Interventions: Woman/Family Provide information about the test and clear instructions for the procedure Encourage the woman and her family to express their concerns
How can a nurse facilitate communication with a client undergoing fetal diagnostic procedures? By providing clear, simple explanations of what the test measures and its purposes.
How can we help families cope? By helping them set realistic goals and encouraging them to express their concerns.
Hyperemesis Gravidarum Persistent, uncontrollable vomiting Begins in first weeks of pregnancy HEG can have serious consequences
Hyperemesis Gravidarum Manifestations Loss of 5% or more of prepregnancy weight Dehydration Metabolic imbalances Elevated ketones Vitamin K &Thiamine deficiency
Hyperemesis Gravidarum Therapeutic Management Exclude other causes Lab studies Home therapy (first) Drug therapy Correct dehydration and imbalances IV fluids TPN if severe Enteral nutrition
Hyperemesis Gravidarum Nursing Considerations I&O Lab data. Daily weights. Urine for ketones. Frequent small amounts of food & fluids: -Q2-3 hrs -Salting -K & Mg rich foods Bland low fat diet/easily digested carbs. Sitting upright after meals. emotional Support
What is it called when a female is pregnant has excessive nausea and vomiting, which significantly hinders nutritional status and causes electrolyte and metabolic imbalances? Hyperemesis gravidarum
Name a nursing intervention that can be provided to a person with hyperemesis gravidarum? Encourage bland, low fat diet; intake & output; daily weights; Monitor urine for ketones; meals every 2-3 hours
Abortion: Loss of pregnancy before the fetus is viable, or capable of living outside the uterus. Fetus less than 20 weeks gestation or one weighing less than 500 g is not viable
Spontaneous abortion termination of pregnancy without action by the woman or another person
Spontaneous Abortion Causes Most common cause is severe congenital abnormalities incompatible with life Maternal infections Maternal endocrine disorders Abnormalities of the reproductive organs.
Spontaneous Abortions Six Subgroups Threatened Inevitable Incomplete Complete Missed Recurrent
Types of Spontaneous Abortion Threatened Inevitable Incomplete
Threatened Abortion Vaginal bleeding occurs
Inevitable Abortion Membrane rupture and cervix dilates.
Incomplete Abortion Some products of conception have been expelled but some remain.
Spontaneous Abortion Therapeutic Management Varies depending on type of abortion D&C may be indicated to remove retained placental tissue Iron supplementation if significant blood loss
Ectopic Pregnancy: definition Implantation of a fertilized ovum outside the uterus.
Ectopic Pregnancy More than 98% occur in fallopian tube “Disaster of reproduction”
Ectopic Pregnancy: Causes Scarring/abnormality in tube Additional causes
Ectopic Pregnancy Manifestations Abdominal pain Vaginal spotting Missed period Ruptured tube symptoms Sudden, severe pain in one of the lower quadrants Profuse bleeding (hypovolemic shock) Radiating scapula pain
Ectopic Pregnancy Diagnosis Transvaginal Ultrasound Beta HCG : lower than normal
Ectopic Pregnancy Therapeutic Management: Unruptured tube Methotrexate Surgery
Ectopic Pregnancy Therapeutic Management: Ruptured tube Goal: control bleeding prevent hypovolemic shock Salpingectomy
Ectopic Pregnancy Nursing Considerations Prevention or early detection Monitor for signs of rupture or bleeding Pain management Patient teaching Rhogam given to Rh-negative mothers
Disseminated Intravascular Coagulation (DIC): definition A life-threatening defect in coagulation that may occur with several complications of pregnancy
DIC Clinical Manifestations Sudden onset Patient may complain of chest pain or dyspnea and become extremely restless and cyanotic, occasionally expectorating frothy, blood-tinged mucus Profound circulatory shock from hemorrhage may occur rapidly Fetal and maternal death may occu
DIC Clinical Diagnosis Lab studies show : Decreased fibrinogen and platelets Prolonged prothrombin (PT) and activated partial thromboplastin time (aPTT) Increased fibrin degradation products
DIC Treatment Priority is to correct the cause Administer blood products
List appropriate nursing care for a patient experiencing a bleeding disorder of early pregnancy. Assess for shock, pain control, and provide emotional support.
List signs and symptoms of hypovolemic shock. Fetal heart changes, rising weak pulse, rising respiratory rate, shallow irregular respirations, falling blood pressure, decreased urine output, pale skin, cold clammy skin, faintness and thirst
What is it called when all products of conception are expelled from the uterus? Complete abortion
What is it called when the fertilized ovum is implanted outside the uterus? Ectopic pregnancy
Hemorrhagic Conditions of Late Pregnancy Bleeding Disorders of Late Pregnancy: Placenta Previa Abruptio Placenta
Placenta Previa: Definition Implantation of the placenta in the lower uterus; as a result the placenta is closer to the internal cervical os than the presenting part of the fetus
Placenta Previa: Three types Marginal/low lying Partial Total
Placenta Previa: Manifestations Painless vaginal bleeding Bleeding results from tearing of the placental villi Bleeding may not occur until labor starts NO vaginal exam
Placenta Previa: Therapeutic Managment Determine the amount of hemorrhage Electronic monitoring Conservative if pt is stable and fetus is immature Home care may include Delivery may be scheduled Immediate delivery via stat C/section if hypovolemia or fetal compromise
Abruptio Placentae: Definition premature separation of a normally implanted placenta from the uterine wall
Abruptio Placentae: Predisposing factors/etiology Chronic HTN or PIH Cocain use (#1) Premature rupture of membranes. Blunt external ABD trauma. Short umbilical cord. Smoking. Prior Hx of abrupto placentae. Maternal age 3X greater risk of multigravida greater than 5.
Abruptio Placentae Manifestations Bleeding evident vs. concealed Uterine tenderness (board-like) Uterine irritability Abdominal or low back pain High uterine resting tone Additional signs hypovolemic shock fetal distress fetal death
Abruptio Placentae: Divided into two main types Concealed hemorrhage Apparent hemorrhage
Abruptio Placenta Therapeutic Management Immediate hospitalization and evaluation Conservative management may be initiated. Must evaluate CV status of mother and status of fetus Immediate delivery may be done
Abruptio Placenta Nursing Management Side lying position with wedge under right hip for uterine placental perfusion Preparation for immediate cesarean delivery Blood/fluid replacement: two large-bore IV lines should be placed Foley catheter Continuous external FHM
Abruptio Placenta Nursing Management Cont. Frequent monitoring of vital signs, hemodynamic status Oxygen via mask Emotional support for pt and family Patient/family teaching about medical treatment Provide support for grieving family if fetus dies
What is the premature separation of a placenta that is normally implanted? Abruptio placenta
What occurs when the placenta develops in the lower part of the uterus? Placenta previa
Name two nursing interventions used in both placenta previa and placenta abruptio? Standard vital signs and fetal monitoring
Which disorder of pregnancy has painless, profuse, bright red bleeding? Placenta previa
Hypertensive Disorders of Pregnancy: Four Categories Gestational Hypertension Preeclampsia Eclampsia Chronic Hypertension
Gestational Hypertension BP elevation after 20 weeks that is NOT accompanied by proteinuria May progress to preeclampsia *HTN with NO protein in urine*
Preeclampsia SBP > or = 140 DBP > or = 90 Significant proteinuria *Occurring after 20 weeks of pregnancy
Eclampsia Progression of preeclampsia to generalized seizures Seizures CAN occur postpartum
Chronic hypertension High BP known to exist before pregnancy If gestational HTN persists after birth, then chronic HTN is diagnosed Relatively common Major cause of perinatal death Associated with IUGR
Hypertensive Disorders of Pregnancy: Risk Factors First pregnancy Age > 35 African American Anemia Family history of PIH Inadequate prenatal care Chronic HTN Chronic renal disease Obesity Diabetes mellitus Antiphospholipid Syndrome Multifetal pregnancy Mother or sister had preeclampsia
Hypertensive Disorders of Pregnancy: Classic signs Hypertension Proteinuria
Hypertensive Disorders of Pregnancy: Additional S/S Retinal changes Hyperreflexia Lab studies showing liver, renal, & hepatic dysfunction Symptoms of arterial vasospasm Continuous headache, drowsiness or mental confusion Epigastric pain or upset stomach Decreased urinary output
Therapeutic Management Mild Preeclampsia Only cure is delivery of the baby
Therapeutic Management Mild Preeclampsia: Home Care : Systolic BP > 140 but < 160; Diastolic BP > 90 but < 110; proteinuria 1+ Activity restrictions BP checked in same arm 2-4 times/day Daily weight: use same scale Urinalysis Fetal assessment
Therapeutic Management Severe Preeclampsia: Inpatient Management Systolic BP > 160 x two readings, 6 hours apart, while on bedrest; Diastolic BP > 110; Proteinuria 3+ or higher; elevated renal labs and liver enzymes, low platelets, headache, RUQ pain and visual disturbances may or may not be present.
Therapeutic Management Severe Preeclampsia: Antepartum goals Improve fetal blood flow &fetal oxygenation Prevent seizures
Therapeutic Management Severe Preeclampsia Bedrest Antihypertensive drugs Other medications
Antihypertensives given to decrease risk for stroke or CHF
Antihypertensives Hydralazine (Apresoline) Nifedipine (calcium channel blocker) Labetolol (beta-adrenergic blocker) 
Hydralazine (Apresoline): major advantage over other antihypertensives is that it is a vasodilator that increases cardiac output and blood flow to the placenta
Therapeutic Management Severe Preeclampsia: Caution When antihypertensive meds are given to a woman receiving magnesium sulfate, HYPOTENSION may result, reducing placental perfusion
Therapeutic Management Anticonvulsants Magnesium sulfate: most common -CNS depressant -Not an antihypertensive, but relaxes smooth muscle -Administer IVPB
Therapeutic Management Severe Preeclampsia: Intrapartum Management Most seizures occur during labor or the first 24 hrs after birth Monitor mother & fetus continuously Medical management
Therapeutic Management Severe Preeclampsia: Postpartum management watch for signs of shock -Aggravated blood loss during delivery -Assessment of preeclampsia must be continued for at least 48 hours -Magnesium sulfate is continued for at least 24 hours
Therapeutic Management Eclampsia Facial twitching, followed by rigidity of the body. Tonic-clonic movements. Breathing stops. Unlikely to recall event. FHR pattern. Magnesium sulfate is drug of choice.
HEELP Syndrome: Definition acronym that refers to a life-threatening occurrence that complicates about 10% of pregnancies.
HEELP Syndrome: HE Hemolysis
HEELP Syndrome: EL Elevated liver Enzyme
HEELP Syndrome: LP Low Platelet Count
Why is the patient placed on her left side while on bed rest? It helps improve the blood flow to the placenta and more effectively providing oxygen and nutrients to the fetus
What compound is present in urine with a person who has preeclampsia? Protein
Rh Incompatibility (Example/explanation) Rh-negative woman with Rh-Positive fetus. Cells from Rh-positive fetus enter mother's bloodstream. Woman becomes sensitized- antibodies form to fight Rh-positive blood cells. In the next Rh-positive pregnancy, antibodies attack fetal blood cells.
Rh Incompatibility: Manifestations Mother Fetus
ABO Incompatibility A common and generally mild type of haemolytic disease in babies.
What drug is administered to mom's who are RH negative? RhoGAM
What is the disease that occurs when anti-Rh antibodies cross the placenta and destroy fetal erythrocytes? Erythroblastosis fetalis
Created by: jtzuetrong