chapter 13 health problems complicating pregnancy copyright © 2012, 2008 by saunders, an imprint of...

Chapter 13

Health Problems Complicating Pregnancy

Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1

Complications of Pregnancy


Objectives

Define key terms listed. Discuss three causes of spontaneous

abortion. Describe ectopic pregnancy. Describe placenta previa and state the

characteristic symptom. Explain five nursing measures for the care of

a woman who is hemorrhaging.


Objectives (cont.)

Compare two types of abruptio placentae. Review the cause of coagulation defects in

pregnancy. List five causes of high-risk pregnancies and

three leading causes of maternal death. Recognize four factors that increase the risk

for gestational hypertension.


Effects of a High-Risk Pregnancy

on the Family Disruption of usual roles

May require strict bed rest May have to find alternate child care

Financial difficulties Delayed attachment to infant


Bleeding Disorders

Abnormal in pregnancy and should be investigated

Maternal blood loss decreases oxygen-carrying capacity to fetus


Causes of Bleeding in Early Pregnancy

Spontaneous abortion Cervical polyps Uterine fibroids Ectopic pregnancy Hydatidiform mole


Abortion

Intentional or unintentional ending of a pregnancy before 20 weeks gestation

Miscarriage is a lay term for spontaneous abortion

Artificial or mechanical means for therapeutic or elective reasons can also be performed


Classification and Management of Abortions

Causes of spontaneous abortion Genetic defects Defective ovum or sperm Defective implantation Uterine fibroids Maternal factors


Maternal Factors

Chronic conditions Acute infections Nutritional deficiencies Abnormalities of maternal reproductive

organs Endocrine deficiencies Blood group dyscrasias (ABO incompatibility)


Nursing Interventions

Monitor vital signs Observe for signs of shock

Weigh perineal pads Prepare for IV therapy Assess fetal heart rate Provide supplemental oxygen Obtain history and laboratory results Provide emotional support for woman and

partner


Incompetent Cervix

Cervix dilates without perceivable contractions

Internal os dilates Incapable of supporting increasing weight and

pressure of growing fetus Cervix may need to be reinforced through a

cerclage procedure


Ectopic Pregnancy

Abnormal implantation of fertilized ovum outside uterine cavity Most common site

is fallopian tube Tubal rupture can

cause hemorrhage


Assessment of Tubal Pregnancy

Transvaginal ultrasound Serum hormone levels

Progesterone β-hCG (beta-human chorionic gonadotropin)

Shoulder pain Signs of shock out of proportion with visible

blood loss


Management of Tubal Pregnancy

Preserve fallopian for chance of future pregnancies Depends on status of tube: ruptured or unruptured

Methotrexate Interferes with cell reproduction

Surgical interventions salpingectomy


Gestational Trophoblastic Disease

Hydatidiform mole Trophoblastic tissue proliferates Chorionic villi of placenta swell with fluid; can look

like grapes Invasive mole Choriocarcinoma


Gestational Trophoblastic Disease (cont.)

Two types Complete

• Chromosome banding and enzyme analysis show all genetic material is paternally derived

• No inner cell mass develops

• No fetal vascularization

Partial • Genetic material maintained

• Fetus abnormal, usually aborts


Assessment of Molar Pregnancy

Uterus grows more rapidly than in a normal pregnancy

Brown vaginal bleeding (looks like prune juice)

Hyperemesis gravidarum If gestational hypertension occurs before 24

weeks gestation, strongly suggests molar pregnancy

Serial β-hCG levels and ultrasound


Management of Molar Pregnancy

Evacuation by suction aspiration Follow-up is essential due to increased risk of

developing choriocarcinoma Serum hCG levels monitored for 1 year until

serum titers return to normal Should delay pregnancy until hCG has

returned to normal


Bleeding in Late Pregnancy

May be from increased vascularization of cervix, cervical polyps, or cervicitis

If in second or third trimester, may be caused by Placenta previa Abruptio placentae Disseminated intravascular coagulation (DIC)


Placenta Previa

Placenta abnormally implants near or over cervical os

Increased risk of occurrence if Defective vascularity of decidua Previous infection in upper uterine segment Uterine scarring


Placenta Previa (cont.)


Assessment and Management

Ultrasound can detect presence Suspect if onset of painless bleeding occurs

after 24 weeks gestation Bleeding occurs most often in third trimester

as cervix prepares for delivery Monitor vital signs and amount of blood loss,

including fetal heart rate Do not perform vaginal examination


Home Management

If following criteria are met, woman can be sent home Maintain strict bed rest and no coitus Must have around-the-clock transportation and

communication available Compliant with oral tocolytic therapy Hematocrit above 30% Can be followed closely (e.g., ultrasound,

nonstress test, biophysical profiles)


Potential Complications

Hemorrhage for woman Hypoxia or death of fetus Hypovolemic shock and death of mother Postpartum infection


Abruptio Placentae

Premature separation of placenta Partial or total detachment Occurs after 20 weeks gestation

Bleeding is painful Risks include

Maternal hypertension Prior abruption High parity

Degree of compromise depends on extent of separation and blood loss


Types of Abruptio Placentae


Complications

Inability of uterus to contract Trapping of blood may release

thromboplastin into maternal circulation Can lead to DIC



Dark red vaginal bleeding Uterine rigidity Severe abdominal pain Maternal hypovolemia Signs of fetal distress Excessive bleeding Coagulation profile Prepare for cesarean delivery if hemorrhage

severe or fetal distress evident


Disseminated Intravascular Coagulation (DIC)

Blood cannot clot Overstimulation of normal coagulation

process Massive, rapid fibrin formation Depleted platelets and clotting factors Does not occur as primary disorder but

secondary to another complication



Monitor coagulation studies closely Correct underlying cause Terminate pregnancy Administer blood products Do not give heparin


Blood Incompatibility (Isoimmunization)

Placenta can allow maternal and fetal blood to mix due to small “leaks”

If maternal and fetal blood compatible, no issues

If not compatible, mother’s body produces antibodies to destroy foreign fetal RBCs


Rh Incompatibility

Rh-positive blood type is dominant trait If father is Rh positive and mother is Rh

negative, good chance fetus will be Rh positive

If leakage occurs, mother starts making antibodies to destroy the Rh-positive erythrocytes, which also destroy fetal RBCs


ABO Incompatibility

Woman has group O blood Fetus has group A, B, or AB blood Anti-A and anti-B antibodies

Few cross placenta, so treatment not required during pregnancy

First pregnancy most often affected Newborn may develop jaundice within 24

hours of birth Provide phototherapy


Audience Response SystemQuestion 1

In the presence of Rh incompatibility, an amniocentesis can be done to determine if what is present?

A.Fetal hemolysis

B.A congenital anomaly

C.Alpha-fetoprotein levels

D.Genetic disorders


Cardiovascular and Endocrine Complications


Objectives

Discuss three signs that a pregnant hypertensive woman should report immediately to her physician.

Identify the antihypertensive drug most commonly given to women with gestational hypertension and its antidote.

Compare the effects of the physiologic changes in pregnancy related to thromboembolic disease.


Objectives (cont.)

Discuss heart disease in pregnancy. Explain hyperemesis gravidarum. Explain three ways diabetes mellitus affects

pregnancy. Review four aspects of self-care for the

diabetic woman.


Cardiovascular Disorders


Gestational Hypertension

Types Gestational hypertension Preeclampsia Eclampsia Chronic hypertension Preeclampsia with superimposed chronic

hypertension


Classification and Risk Factors

Preeclampsia—renal involvement leads to proteinuria

Eclampsia—CNS involvement leads to seizures and chronic HTN with superimposed eclampsia

HELLP syndrome—disease is dominated by hematologic and hepatic clinical manifestations


Pathophysiology of Preeclampsia

Thought to start with placental implantation May not be evident until 20 weeks gestation

Loss of resistance to angiotensin II Prostacyclin (vasodilator) decreases Thromboxane (vasoconstrictor) increases

Leads to increased vasospasms Condition reverses once placenta is delivered


Effects on the Mother and Fetus

Mother DIC Immunologic response

may trigger preeclampsia

HELLP Nausea, vomiting,

malaise Later: hematuria,

jaundice, generalized abdominal pain

Fetus Uteroplacental

perfusion Increased risk of

abruptio placentae Intrauterine growth

restriction Fetal distress from

hypoxia Preterm birth



If occurs before 34 weeks gestation, screen for presence of antiphospholipid antibodies If present, increases risk of recurrent severe

gestational hypertension in future pregnancies Closely monitor blood pressure, proteinuria,

renal and hepatic function If severe, may have to terminate pregnancy/deliver Should not go beyond 40 weeks gestation due to

placental insufficiency Magnesium sulfate infusion

Toxicity treated with calcium gluconateCopyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 44

Clinical Manifestations of Gestational Hypertension (GH)

Expedient delivery if Maternal oliguria Renal failure HELLP syndrome

Magnesium sulfate therapy should be stopped if Loss of deep tendon reflexes (DTRs) Respiratory rate < 12/min Decreased urine output of < 30 mL/hr


Prenatal Nursing Assessment and Management

If mother received magnesium sulfate, can cause respiratory depression in newborn

Evaluate deep tendon reflexes A mild form of preeclampsia may rapidly

progress to a severe form, including seizures Management depends on symptoms,

aggressiveness of physician, and understanding and compliance of the patient

Calcium gluconate is used to treat magnesium sulfate toxicity


Education, Self-Care, Home Management

Important to know baseline blood pressure Increases in systolic by 30 mm Hg and diastolic by

15 mm Hg above baseline places woman in high-risk category

Careful teaching, guidance, and compliance are critical to the woman, the developing fetus, and family

If on home management, woman must have a means of communication and transportation


Hospitalization and Managementof Preeclampsia and Eclampsia

Quiet room Left side-lying

To optimize placental blood flow Frequent monitoring of blood pressure Urine evaluated every 4 hours for protein and

specific gravity Accurate I&O


Emergency Care

Equipment to have readily available Oral airway Ambu bag Oxygen Suction equipment Ophthalmoscope Medications Pulse oximetry Electrocardiography

Symptoms that may precede seizures Rise in blood

pressure Epigastric pain Severe headache Apprehension Twitching Hyperirritability of

muscles


Chronic Hypertensive Disease

Blood pressure of 140/90 mm Hg or higher before pregnancy or before 20 weeks gestation

Goal is to prevent preeclampsia, ensure normal fetal growth and development

Antihypertensive may be prescribed for blood pressure over 160/100 mm Hg


Chronic Hypertension with Superimposed Preeclampsia First 48 hours after delivery require careful

monitoring After 48 hours, assessments may be decreased

Monitor uterine tones and fundus to prevent postpartum bleeding

Baseline blood pressure usually returns within 2 weeks


Thromboembolic Disease Pregnancy increases risk of superficial

thrombophlebitis, deep vein thrombosis, and pulmonary embolism (PE)

PE leading cause of maternal death Risk factors

Venous stasis Normal changes in coagulability and fibrinolysis during

pregnancy Use of oral contraceptives before pregnancy Sitting for extended periods Over 30 Obese


Assessment

May complain of sudden pain with swelling in affected extremity May be warmth and redness at site On passive dorsiflexion, pain in calf of leg

(Homans’ sign) Diagnosed via Doppler scanning, MRI If develops a PE, may have dyspnea, chest

pain, hemoptysis, and tachycardia


Heart Disease: Effects During Pregnancy

Pregnancy results in increased cardiac output, heart rate, blood volume, and stroke volume Some drugs to help treat are contraindicated in

pregnancy During labor, woman requires careful

monitoring due to blood shifts of 300 to 500 mL This leads to increased cardiac output by 15% to

20%; could trigger congestive heart failure



May complain of shortness of breath with activity, weight gain, edema; may hear cardiac murmur

Contraindications to planned pregnancy include pulmonary hypertension, aortic coarctation, history of myocardial infarction, and uncorrected tetralogy of Fallot

Goal is to minimize stress on heart Symptoms of cardiac decompensation can

occur slowly during pregnancy


Anemia

Reduced ability of blood to carry oxygen to cells

In pregnancy, defined by hemoglobin (Hgb) levels less than 10 g/dL and hematocrit (Hct) levels below 30% More susceptible to infection, increased risk of

complications during pregnancy


Anemia (cont.)

Iron deficiency anemia—serum iron of less than 60 mg/dL with less than 16% transferrin saturation

Folic acid deficiency—may result from inadequate intake, poor absorption or drug interactions; seen in women with vitamin B12 deficiency

Thalassemia—genetic defect; abnormal Hgb; results in hemolysis and anemia


Sickle Cell Anemia

Inherited disorder; presence of abnormal Hgb that causes sickling of RBCs

During labor Oxygen supplementation to mother Administration of IV fluids Fetal monitoring Maternal Hgb monitoring Administration of prophylactic antibiotics if

operative delivery is necessary or urinary tract infection is present


GI Disorders:Hyperemesis Gravidarum

Nausea and vomiting that can lead to severe dehydration, electrolyte imbalance, starvation, and excessive weight loss before the 20th week of gestation

Occurs most often with first pregnancy, multifetal pregnancy, hydatidiform mole, and sometimes with psychiatric disorders

Fetus at risk for intrauterine growth restriction (IUGR)


Assessment and Management Any specific “triggers” for nausea or vomiting? Correct fluid and electrolyte imbalance Parenteral nutrition may be indicated Record I&O, including weight Ketonuria suggests fat stores are being used to

nourish fetus and meet woman’s energy needs Low-fat frequent feedings Positioning and other techniques to reduce

nausea and vomiting Drugs such as pyridoxine, meclizine


Endocrine Disorders:Diabetes Mellitus (DM)

Affects carbohydrate metabolism Hyperglycemia; inadequate production or

ineffective use of insulin Pregestational DM: type 1 or 2 Gestational DM: glucose intolerance first

recognized during pregnancy; usually resolves after delivery


Effect of Pregnancy on Diabetes Increased need for glucose creates a

resistance to insulin Maternal insulin does not cross placenta By 10th week of gestation, fetus is obligated

to secrete own insulin to use glucose obtained from mother

Hormone concentration higher in second and third trimesters, which increases insulin resistance

Allows more maternal glucose to be available to fetus; leads to macrosomia


Pregestational Diabetes Mellitus

Known diabetic before pregnancy Once pregnant, glycemic control affected Oral hypoglycemics cannot be taken during

pregnancy First trimester maternal blood glucose usually

reduced; need less insulin


Risk and Complications

First trimester: hyperglycemia can cause fetal anomalies

Second and third trimesters: glucose crosses placenta, increases fetal secretion of insulin

Can lead to macrosomia and impaired fetal lung function

At birth, newborn at risk for hypoglycemia


Preconceptional Counseling,Assessment, and Management

Woman should normalize blood glucose Some medications may need to be changed Close monitoring throughout pregnancy may

be needed for both mother and fetus Management depends on woman’s

adherence to treatment plan Diet: 30 to 35 kcal/kg/day in first trimester, 35

kcal/kg/day in second and third trimesters Exercise


Gestational Diabetes Mellitus

Carbohydrate intolerance of variable severity, with first recognition during pregnancy

May have only impaired tolerance to glucose or classic signs of DM (polyuria, polyphagia, polydipsia)

Risk of congenital malformation and spontaneous abortion is less with GDM

Diet often controls blood sugars


Screening During Pregnancy

Glucose challenge test Usually between 24 and 28 weeks gestation Renal threshold lower in pregnancy, causes

glucose to spill into urine Glycosuria is not considered diagnostic for DM but

does indicate need for further evaluation Glucose monitoring daily and with a blood

test called HbA1c Fetal surveillance: biophysical profile, alpha-

fetoprotein, kick count


Audience Response SystemQuestion 2

At what approximate week of development is the fetus obligated to secrete its own insulin?A. 20 weeks

B. 30 weeks

C. 10 weeks

D. 40 weeks


Effects of Toxins and Pregnancy Loss


Objectives Describe rubella and its consequences in

pregnancy. Identify the changes that occur in pregnancy

that predispose the woman to urinary tract infections.

Discuss the cause and prevention of toxoplasmosis.

Describe three self-care measures for a pregnant woman with a urinary tract infection.

Describe how the use of nicotine, alcohol, and recreational drugs can affect the fetus.


Objectives (cont.) Discuss the effects of substance abuse on

women’s health. Relate the impact of pregnancy on the woman’s

response to bioterrorist agent exposure and treatment protocols.

Recognize the effects of drugs used to treat bioterrorist infections on the developing fetus.

Identify signs of fetal demise. Recognize stages of grieving and nursing

interventions that can assist parents in dealing with fetal loss.


Infections

TORCH Can be used to help identify congenital risks

Urinary tract infection (UTI) Can have asymptomatic infection, cystitis, or

pyelonephritis Symptoms vary

Bacteriuria Group B streptococci Bacterial vaginosis


Substance Abuse

Use of illegal drugs, tobacco, and alcohol can cause serious complications in the developing fetus

IV and intranasal administration crosses placenta more often than other methods

Prenatal care may not occur until late into pregnancy, if at all


Accidents During Pregnancy

Motor vehicle accidents most common cause of trauma during pregnancy

Blunt trauma can lead to abruptio placentae and fetal demise

Blunt trauma or penetrating wounds can cause shock, preterm labor, spontaneous abortion

ABCs (airway, breathing, circulation)


Bioterrorism Exposureand Pregnancy

Metabolism and elimination of drugs altered in pregnancy

Protecting life of mother is priority Vaccines may be needed regardless of

pregnancy status Pregnancy increases susceptibility to

infections Countermeasures include antibiotics,

antivirals, antitoxins


Loss of Expected Birth Experience

Allow parents to remain together in privacy Accept behaviors related to grieving Develop care plan to provide support to

family Offer memento and opportunity to hold infant, if

parents choose Prepare parents for infant’s appearance Discuss wishes concerning religious and cultural

rituals


Pregnancy Loss: Grief and Bereavement

Perinatal loss after 20 weeks gestation in United States is 6.8 per 1000 total births 50% occur before 28 weeks Causes: physiologic, maladaptation, birth defects,

teratogen exposure Loss includes abortion, fetal or neonatal death,

SIDS, and fetal anomalies Denial, anger, bargaining, depression,

acceptance are steps in grieving process Nurse plays important role


Audience Response System Question 3

In preeclampsia, the most likely cause of serious end-organ effects or alterations in function during pregnancy is:

A.Hemorrhage

B.Medications

C.Vasospasms

D.Hypervolemia


Review Key Points


chapter 13 health problems complicating pregnancy copyright © 2012, 2008 by saunders, an imprint of...

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