Complications during pregnancy
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Complications During Pregnancy. Objectives. At the end of this lesson, the SPN will be able to: Define indications of high risk pregnancies Explain the etiology, pathophysiology, treatment and nursing management for the patient experiencing complications while pregnant. OB Diagnostic Tests.

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Complications during pregnancy

Complications During Pregnancy


Objectives

Objectives

  • At the end of this lesson, the SPN will be able to:

  • Define indications of high risk pregnancies

  • Explain the etiology, pathophysiology, treatment and nursing management for the patient experiencing complications while pregnant


Ob diagnostic tests

OB Diagnostic Tests

  • Ultrasound

  • NST- Non Stress Test

  • Fetal Movements or kick counts

  • MSAFP

  • Amniocentesis

  • Gestational Diabetes Screen

  • ***Let us look at the handout from your packet.


Danger signs during pregnancy

Danger Signs During Pregnancy

  • The pregnant woman should immediately report any of the following S&S:

    • Any vaginal bleeding

    • Sudden gush or constant trickle of fluid from vagina

    • Persistent vomiting

    • Severe persistent headache

    • Edema of feet, hands, face upon arising

    • Blurred or double vision, spots before the eyes

    • Dizziness


Danger signs during pregnancy1

Danger Signs During Pregnancy

  • Fever > 100

  • Abdominal pain or cramps

  • Epigastric pain

  • Irritating vaginal discharge

  • Dysuria

  • Oliguria

  • Absence or marked decrease in fetal movements


Infections

Infections

  • Any infection is a risk factor during pregnancy and should be diagnosed and treated promptly.

  • TORCH Group- These include:

  • Toxoplasmosis

  • Rubella

  • Cytomegalovirus

  • Herpes Virus Type 2


Toxoplasmosis

Toxoplasmosis

  • Caused by a protozoan. This disease goes almost unnoticed by adults because the s/s are mild, vague and flu-like. The organism may be picked up by eating raw or partially cooked meat or from feces of an infected cat. Incubation period is 10 days.

  • Effects on Fetus- risk of aborting, preterm birth, and death. Other s/s include: microcephaly, hydrocephaly, and seizures. Many infants die after birth. Those that survive may be blind, deaf, or severely retarded.


Toxoplasmosis con t

Toxoplasmosis Con’t.

  • Mom’s s/s- malaise, myalgia, rash, splenomegaly, enlarged cervical lymph nodes

  • Rx- Sulfonamide used in combination with Daraprim (anti- protozoan)

  • Diet- No raw or partially cooked meats. Fruits and veggies should be thoroughly washed before they are eaten.


Rubella german measles

Rubella (German Measles)

  • Highly contagious. Spread by airborne droplets. Incubation period of 14-21 days.

  • Effects on Fetus- Cataracts, deafness, patent ductus arteriosis, IUGR, MR, hyperbilirubinemia and occasionally, a petechial rash

  • Mom’s s/s-A maculopapular rash appears and vanishes in 3 days. Muscle aches, joint pain, slightly elevated temp, and lymphadenopathy. **On the first prenatal visit, a blood titer will be drawn to determine if mom is immune to rubella.


Cytomegalovirus cmv

Cytomegalovirus- (CMV)

  • Is a member of the herpes virus group

  • More than half of all adults have antibodies for CMV.

  • CMV is found in saliva, breast milk, cervical mucus, urine and semen

  • It spreads by close contact

  • It is asymptomatic in adults and children but can affect the fetus in utero or during delivery

  • The fetus may have extensive damage leading to death


Cytomegalovirus cmv con t

Cytomegalovirus (CMV) Con’t.

  • However, the fetus may survive with hydrocephaly, microcephaly, MR, cerebral palsy, or with no noticeable damage

  • An infected newborn is usually small for gestational age

  • MR, auditory deficits, or learning disabilities may not be noticed right away

  • There is no treatment for mom or neonate


Genital herpes herpes simplex virus type 2

Genital Herpes (Herpes Simplex Virus Type 2)

  • Causes painful, vesicular genital lesions

  • Women who have their first infection close to the time of delivery have a greater chance of neonatal infection

  • After the membranes rupture, the virus ascends from active lesions to the fetus, or the fetus comes in contact with the lesions during a vaginal delivery


Genital herpes con t

Genital Herpes Con’t.

  • Effects on the fetus/neonate: If there is an infection in the first trimester, about ½ will end in spontaneous abortion or stillbirth. Most infected infants have no symptoms at birth. Symptoms of poor feeding, jaundice, and seizures develop after a 2-12 day incubation period. Many of these infants will also have the vesicular lesions

  • Diagnosis: is made by culturing active lesions. Rx. Is mainly to relieve pain. When no lesions are visible at the time of delivery, a cesarean birth is best to prevent fetal contact with the lesions

  • Rx: Acyclovir (Zovirax) reduces healing time and the time the lesions contain the live virus.


Hiv aids

HIV/AIDS

  • HIV is the causative organism of acquired immunodeficiency syndrome(AIDS). The virus eventually cripples the immune system, making the person susceptible to infections that eventually can result in death.


Hiv con t

HIV Con’t.

  • There is no treatment or cure for AIDS. HIV infection is acquired one of the following ways:

    • 1. Sexual contact (anal or vaginal) with an infected person

    • 2. Parenteral or mucus membrane exposure to infected body fluids

    • 3. Perinatal exposure (infants)

    • The infant may be infected in one of the following ways:

      • 1. Transplacentally

      • 2. Through contact with infected maternal secretions at birth

      • 3. Through breast milk


Hiv con t1

HIV Con’t.

  • The infected woman has a 20 to 40% chance of transmitting the virus to her fetus.

  • Infants often have a positive antibody titer for as long as 15 months after birth due to the transfer of maternal antibodies

  • Those infants who are not infected with HIV will seroconvert to a negative antibody titer


Group b streptococcus infection

Group B Streptococcus Infection

  • Group B strep is a leading cause of perinatal infections that have a high neonatal mortality rate

  • The organism can be found in the woman’s rectum, vagina, cervix, throat, or skin

  • Although she is colonized with the organism, the woman is usually asymptomatic, but the infant may be infected through contact at birth with vaginal secretions

  • The risk is greater if the woman has a long labor or premature rupture of membranes

  • GBS is a significant cause of maternal PP infection; especially after a c-section

  • Diagnosis of GBS is confirmed by vaginal or rectal culture


Bleeding disorders in pregnancy

Bleeding Disorders in Pregnancy

  • Abortion/miscarriage: spontaneous termination of a pregnancy before the fetus has become viable, 24 weeks of gestation and 500 gm. of weight

  • Occurs most often in the first trimester

  • Classification of Spontaneous Abortions:

    • Threatened- may or may not abort, no cervical dilation

    • Inevitable- definitely will abort, cervical dilation

    • Complete-Passage of all products of conception; cervix closes; bleeding stops

    • Incomplete- most but not all products of conception expelled

    • Missed- fetal death occurs but is not expelled

    • Habitual or Recurrent- Spontaneous abortions that occurr 2 consecutive times or more


Abortion miscarriage con t

Abortion/ Miscarriage Con’t.

  • S&S: vaginal bleeding, uterine cramping, bachache

  • Rx: For threatened- bedrest, avoidance of stress, strenuous activity, and intercourse. Bleeding usually stops within 48 hours.

  • For inevitable, or incomplete, a D&C to remove products of conception

  • For missed-D&C or induction if more than 12 weeks gestation

  • For habitual- cerclage (purse string suture into cervix)


Abortion miscarriage

Abortion/Miscarriage

  • Induced Abortion- The intentional termination of a pregnancy before the age of viability. There are 2 types:

    • 1. Therapeutic- Intentional termination to preserve the health of the mother

    • 2. Elective- Intentional termination for reasons other than the health of the mother


Ectopic pregnancy

Ectopic Pregnancy

  • Fertilized egg implants outside the uterus

  • Most often in the distal fallopian tubes

  • Patients at risk are those with PID and those who use IUD’s

  • There are 2 types:

    • 1. Unruptured- occur 3-5 weeks after missed menstrual period. Abdominal cramps on one side, tenderness, low grade fever, vaginal spotting which may be brown in color. There may be no outward sign of bleeding

    • 2. Ruptured- sudden, acute abdominal pain, hemorrhage, nausea, low BP, rapid pulse, thirst, apprehension, pallor, cool, moist skin, weakness, air hunger. Acute rupture is an emergency and requires surgical removal of gestational products and reconstruction of the fallopian tube


Placenta previa

Placenta Previa

  • Placenta Previa is the abnormal implantation of the placenta in the lower portion of the uterus. There are 3 types:

    • 1.marginal-the placenta is near the internal cervical os but does not cover it

    • 2.partial- the placenta covers the internal cervical os partially

    • 3. complete or total- the placenta covers the cervical os completely

  • S&S: PAINLESSvaginal bleeding in the last half of pregnancy. Bleeding may be gushing or intermittent


Placenta previa con t

Placenta Previa Con’t.

  • Rx: depends on the S&S- if bleeding is severe, a emergency C-section is performed.

    • For less serious bleeding, CBR and scheduled C-section

    • Mother is at risk for hemorrhage and the fetus is at risk for premature birth and hypoxia


Abruptio placentae

Abruptio Placentae

  • Premature separation of a normally implanted placenta late in pregnancy

  • The cause is unknown

  • There are 3 types:

    • 1. central-center of the placenta separates with blood trapped between placenta and uterine wall- edges of placenta remain attached to uterine wall- no visible bleeding

    • 2. partial separation- a placental edge separates and blood flows between the placenta and uterine wall escaping through the cervix. Visible bleeding

    • 3. complete separation- entire placenta separates- profuse bleeding


Abruptio placentae1

Abruptio Placentae

  • S&S: bleeding depending upon amount of separation, uterine tenderness, abdominal pain

  • Dx: hx, physical assessment, ultrasound

  • Rx: delivery by C-section


Diabetes

Diabetes

  • Diabetes=hyperglycemia- insulin is absent or ineffective in taking glucose out of blood and letting it into the cell

  • Pregnant women can have type I-IDDM, Type II-NIDDM, or Gestational Diabetes

  • Risk factors for developing GD:

    • Family history

    • Advanced maternal age

  • Gestational Diabetes: elevated blood glucose only during pregnancy

  • May be managed by diet and exercise alone

  • Insulin may be needed to control blood glucose

  • Most oral hypoglycemics are contraindicated during pregnancy because they cross the placenta and cause hypoglycemia in the fetus


Diabetes con t

Diabetes Con’t.

  • Risks for fetus:

    • Premature birth

    • Congenital defects

    • Macrosomia- excessive fetal growth

  • Risk for Infant:

    • Respiratory distress syndrome

    • Neonatal hypoglycemia

    • Hyperbilirubinemia


Diabetes con t1

Diabetes Con’t.

  • Risks for Mother:

    • PIH

    • Difficult delivery

    • UTI

    • Uncontrolled hyperglycemia

    • High risk for developing diabetes later in life

    • All women are screened for GD at 24-28 weeks of gestation with a 1 hr. glucose screening test. Values above 140 mg/dl after 1 hr. indicates the need for a 3 hr. GTT for confirmation

    • Blood glucose returns to normal after delivery


Diabetes con t2

Diabetes Con’t.

  • Nursing Care: same as for all types of diabetes, except that GD mother may need more education regarding: diet, exercise, insulin, injections, S&S of hypoglycemia, hyperglycemia, etc.


Pregnancy induced hypertension pih or gestational hypertension

Pregnancy Induced Hypertension (PIH) or Gestational Hypertension

  • Risk Factors for PIH include:

    • 1. first pregnancies

    • 2. under age 20 and over 35

    • 3. multiple pregnancy

    • 4. diabetes

    • 5. family history of PIH

    • 6. poor nutrition

    • 7. Obesity


Pih con t

PIH Con’t.

  • There are 3 cardinal signs of PIH which include;

    • HYPERTENSION, EDEMA, AND PROTEINURIA

  • PIH can be divided into 3 categories which include:

  • 1. Mild Preeclampsia-usual onset > 20 weeks gestation.

    • S&S include: BP > 140/90, 1+ proteinuria, weight gain of 2 lbs/week

    • Rx: managed at home, bedrest, left lateral position, daily weights, high protein diet. Mom is to report any visual disturbances, headache, or decreased output


Pih con t1

PIH Con’t.

  • 2. Severe Preeclampsia-

    • S&S: BP > 160/110, 3-4+ proteinuria, edema of hands and face, visual disturbances, oliguria of < 400cc/24hrs.

    • Rx: hospitalization, CBR, sedation, high protein, low NA diet, fetal monitoring, daily weights, VS q4hr, DTR’s and ankle clonus q4h, I&O, seizure precautions, antihypertensive medication, MGSO4 to prevent seizures, induction of labor if fetus is viable


Pih con t2

PIH Con’t.

  • 3. Eclampsia-degeneration of a woman’s condition from severe preeclampsia to eclampsia is marked by the occurrence of SEIZURES due to cerebral irritation caused by cerebral edema

    • S&S- BP > 160/110, 3-4+ proteinuria, increased edema, oliguria, epigastric pain due to liver ischemia, anuria, headache, visual disturbances, confusion, disorientation, increased reflexes, tremors, tonic-clonic seizures

    • Rx-same as severe preeclampsia, fetus will be delivered by induction or C-section. TREATMENT WITH ANTICONVULSANT, MGSO4, SHOULD BE CONTINUED FOR 24-48 HOURS AFTER DELIVERY!


Pih con t3

PIH Con’t.

  • PIH has specific effects on major organs. These effects are caused by decreased blood flow and hypoxia to the specific organ. They include:

    • Kidney- hypertension causes proteinuria, NA retention- weight gain, edema

    • Liver- ischemia causes epigastric pain, nausea and vomiting

    • Placenta- decreased blood flow to the placenta causes fetal hypoxia

    • Brain- vasospasms cause headache, irritability, behavior changes, hyperreflexia, and seizures due to cerebral irritation caused by cerebral edema

    • Retina- vasospasm of microvessels causes visual changes


Pih con t4

PIH Con’t.

  • Complications from PIH include: CVA, pulmonary edema, renal failure, grand mal seizures, abruptio placentae, and death

  • HELLP syndrome is a variant of PIH:

    • Hemolysis(breakage of erythrocytes) as they pass through small vessels

    • Elevated Liver enzymes- due to obstruction of hepatic blood flow

    • Low Platelets- gather at the site of blood vessel damage, recycling the number available in the general circulation. Low platelet levels cause abnormal clotting

  • Effects on fetus: hypoxia due to abruptio placentae or placental infarction, IUGR, preterm birth


Rh factor

Rh Factor

  • Some human red blood cells have a protein antigen (D) called the “Rh factor”

  • People who have the protein antigen (D) are termed Rh+(positive)

  • People who do not have the protein antigen (D) are termed Rh- (negative)

  • Problems occur in pregnancy when the mother is Rh- and the fetus is Rh+

  • Normally fetal blood does not mix with mom’s blood

  • However, during certain procedures such as amniocentesis, or during a normal delivery, small amounts of fetal blood enter the mom’s blood through tears and lacerations in the uterus, vagina, etc.


Rh factor con t

Rh factor Con’t.

  • Rh+ blood from the fetus is recognized as an invader by mom’s immune system

  • Mom’s immune system produces antibodies to destroy the Rh+ red blood cells from the fetus

  • These antibodies destroy fetal RBC’s

  • It takes about 72 hours for mom to make antibodies against Rh+ red blood cells

  • If the fetus is delivered before antibodies are formed no problems will occur with that fetus

  • If mom becomes pregnant again, the next fetus is in danger because of the antibodies mom has produced before


Rh factor con t1

Rh Factor Con’t.

  • The formation of antibodies can be prevented by an injection of RhoGAM within 72 hours of contact with Rh + cells

  • Prevention of Rh disease:

    • At 28 weeks of gestation and 72 hours after delivery all Rh- Moms receive injections of RhoGAM prophylactically

    • Moms are also given RhoGAM after any invasive procedure such as amniocentesis

  • RhoGam attaches to and coats any Rh+ fetal cells in the mother’s bloodstream. As a result, the mother’s body does not recognize them as foreign and does not produce antibodies against them.


Rh factor con t2

Rh Factor Con’t.

  • SUMMARY:

  • Rh+ mother/Rh+ fetus= no problems

  • Rh+ mother/Rh- fetus= no problems

  • Rh- mother/Rh- fetus= no problems

  • Rh- mother/ Rh+ fetus= PROBLEMS


Abo incompatibility

ABO Incompatibility

  • Pregnant mom has type “O” blood

  • Fetus has type “A, B, or AB” blood from dad

  • Antibodies are formed against invader RBC’s

  • Causes less severe problems in fetus and newborn

  • Hyperbilirubinemia occurs in 1st 24 hours of life

  • Dx: Indirect Coomb’s= test done on mom’s blood to determine if there are maternal antibodies present that will destroy fetal RBC’s

  • Direct Coomb’s test done on cord blood

  • Rx: Phototherapy


Heart disease

Heart Disease

  • Damaged heart may not be able to withstand the increased cardiac workload of pregnancy, labor and delivery

  • Most common forms of heart disease in pregnant women are rheumatic heart disease or a congenital lesion

  • Heart disease increases the risk for:

    • Low birth weight

    • Premature labor

    • Intrauterine fetal hypoxia


Heart disease1

Heart Disease

  • There are 4 classifications of heart disease(S&S: SOB, dyspnea, edema, chest pain)

  • Class I- Class IV

  • Class I involves no physical symptoms and no limitation of activity

  • Class IV involves the inability to perform any activity without severe S&S, and activity is dramatically limited

  • Moms with class III and IV are advised NOT to become pregnant (sterilization may be advised)


Heart disease2

Heart Disease

  • Rx: includes frequent monitoring

  • Adequate rest and avoidance of activities that cause symptoms

  • Additional sleep and rest periods

  • Diet modifications, excessive weight gain is also discouraged

  • Teaching S&S of heart failure- dyspnea, paroxysmal nocturnal dyspnea, orthopnea, nocturia, and peripheral edema

  • Laboring woman with heart disease must be relieved of discomfort, anxiety and fatigue


Heart disease con t

Heart Disease Con’t.

  • Rx Con’t.

    • Will have a systemic analgesic and sedative

    • O2 will be administered

    • Side-lying position with head and shoulders elevated

    • In the second stage of labor, forceps are used to avoid maternal pushing

    • C section if indicated


Complications during pregnancy

UTI

  • Most common renal problem in pregnancy is urinary tract infection

  • Anatomic changes and hormonal effects cause dilation of the ureters leading to urinary stasis, delayed emptying and increased risk of infection

  • Pregnant women with bacteriuria (100,000 organisms) should be treated to prevent UTI which can increase the risk of premature labor

  • Rx: C&S, antibiotics


Complications during pregnancy

UTI

  • Nursing Care:

    • Eight 8oz. glasses of fluids daily

    • Void frequently

    • Void before and after intercourse

    • Cotton underpants

    • Good personal hygiene

    • Teach S&S of UTI


Hyperemesis gravidarum

Hyperemesis Gravidarum

  • Frequent uncontrollable vomiting in early pregnancy

  • Cause is not definite but may be attributed to hormones that slow gastric emptying, or psychological problem

  • Rx: fluid and electrolyte replacement, antiemetic meds such as promethazine(phenergan), prochlorperazine (compazine), metoclopramide(reglan)


Gtd gestational trophoblastic disease

GTD- Gestational Trophoblastic Disease

  • Formerly hydatidiform mole or molar pregnancy

  • GTD is a tumor that develops from trophoblastic cells that formed the chorion and villi

  • Tumors may be benign or malignant and fill the uterus with grape-like clusters of vesicles

  • No embryo present because it has been absorbed by the tumor

  • S&S: severe nausea and vomiting in 1st trimester, persistent vaginal bleeding, lack of fetal heart tones and movement, increased levels of HCG

  • Rx: hysterectomy or D&C. mom is at risk of developing choriocarcinoma after a molar pregnancy.


Substance abuse while pregnant

Substance Abuse while Pregnant

  • Drugs commonly abused include: ETOH, cocaine, crack, marijuana and heroin

  • The use of any of these substances is a threat to pregnancy

  • Substance abusers may not seek prenatal care, or they seek prenatal care late in pregnancy

  • Most substance abusers do not voluntarily admit their addiction

  • These mothers may have an increased rate of PIH, abruptio placenta, poor nutrition, and STD’s

  • They often use available money for the drug habit instead of food

  • We need to make sure that we try to provide a safe labor and delivery


Substance abuse while pregnant con t

Substance Abuse While Pregnant Con’t.

  • The patient may require hospitalization for detox

  • “Cold Turkey” withdrawal is not recommended during pregnancy because of possible fetal risks.

  • I will discuss the effects on the fetus/ baby during another lesson.


Preterm labor

Preterm Labor

  • Preterm labor is defined as uterine contractions after 19 weeks gestation and before 37 completed weeks of gestation. Contractions are less than 10 minutes apart, resulting in progressive cervical changes or cervical dilation of 2 cm or effacement of 75%.

  • Etiology- remains unknown. However, certain changes in the body occur with the onset of spontaneous labor. Cervical “ripening” occurs which includes softening and shortening of the cervix.


Preterm labor1

Preterm Labor

  • Risk Factors:

    • Multiple gestation

    • History of previous preterm labor or delivery

    • Abdominal surgery during current pregnancy

    • Uterine anomaly

    • History of cone biopsy

    • History of abortions

    • Fetal or placental malformation

    • Bleeding after the first trimester

    • Maternal age of less than 18 or greater than 35 years

    • Poor nutritional status

    • Poor, irregular, or no prenatal care

    • Emotional stress

    • More than 10 cigarettes smoked in a day

    • Recreational drug use


Preterm labor2

Preterm Labor

  • Treatment-

  • The focus of treatment is prevention of delivery of a preterm infant. The method depends on the cervical dilatation and contraction pattern. If contractions are detected early and treatment is begun early, there is a higher rate of stopping labor.

  • A. Conservative Treatment

    • 1. Treatment is begun early with the use of bed rest in a left lateral position

    • 2. Hydration with IV fluids and continuous monitoring of fetal status and uterine contraction pattern are instituted

    • 3. If this stops the contractions, tocolytic therapy is not needed


Preterm labor con t

Preterm Labor Con’t.

  • Tocolytic Therapy- If conservative therapy is not successful, tocolytic therapy is instituted. These drugs should be used only when the potential benefit to the fetus outweighs the potential risk. Tocolytic drugs include:

  • 1. Betamimetic Agents

  • 2. MgSO4

  • 3. Indocin

  • 4. Nifedipine

  • Let us look at each of these drugs individually.


Preterm labor con t1

Preterm Labor Con’t.

  • Betamimetic agents such as ritrodrine (Yutopar) and terbutaline (Bricanyl)

    • These drugs stimulate the Beta receptors, which causes uterine relaxation

    • Ritrodine is administered IV or orally; terbutaline may be administered IV, subcutaneously, or orally

    • Frequent monitoring is necessary to observe for side effects of increased pulse, shortness of breath, chest pain, decreased blood pressure, hypervolemia, decreased potassium concentration, hyperglycemia, and hyperinsulinemia

    • Before beginning administration of these medications the following lab tests should be done and a baseline ECG should be obtained: CBC with diff, electrolytes, glucose, BUN, creatinine, prothrombin time and partial prothrombin time


Preterm labor con t2

Preterm Labor Con’t.

  • MgSO4

    • MgSO4 interferes with smooth muscle contractility. The exact action is not clear.

    • Administration is IV on an infusion pump

    • During administration the woman is monitored for pulmonary edema, loss of deep tendon reflexes, decreased respirations, hypotension

    • Serum magnesium levels are monitored

    • Calcium gluconate is the antidote for MgSO4 and should be at the bedside


Preterm labor con t3

Preterm Labor Con’t.

  • Indomethacin (Indocin)

    • Indomethacin is a prostaglandin inhibitor that inhibits contractions

    • Administration is oral or rectal

    • It is usually well tolerated by the woman

  • Nifedipine (Procardia)

    • Nifedipine is a calcium channel blocker that relaxes smooth muscle

    • Administration is oral

    • Side effects include headache, nausea, and flushing from vasodilatation


Preterm labor con t4

Preterm Labor Con’t.

  • Nursing Assessment during Tocolytic Therapy:

    • Fetal status via electronic fetal monitoring

    • Contraction pattern

    • Respiratory status (pulmonary edema is a common side effect)

    • Muscular tremors

    • Palpations

    • Dizziness/ light-headedness

    • Urinary output

  • Complications of Preterm Labor:

    • Prematurity and associated neonatal complications, such as lung immaturity


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