COMPLICATIONSCOMPLICATIONS

OFOF

PREGNANCYPREGNANCY

Jeanie WardJeanie Ward

Risk FactorsRisk Factors

Age – under 17 over 35Gravida and ParitySocioeconomic statusPsychological well-beingPredisposing chronic illness –

diabetes, heart conditions, renal, etc.

Pregnancy related conditions – hyperemesis gravidarum, PIH, etc.

High Risk Pregnancy Goals of Care

Provide with optimum care for the mother and the fetus

Assist the patient and her family to understand and cope with the variations in a High Risk Pregnancy and cope with her feelings

Bleeding DisordersBleeding Disorders

AbortionsAbortions

Termination of pregnancy at any time before the fetus has reached the age of viability

Either: spontaneous – occurring

naturally induced – artificial

Etiology / Predisposing FactorsEtiology / Predisposing Factors

Faulty germ plasm -- imperfect ova or sperm, faulty implantation, genetic make-up (chromosomal disorders), congenital abnormalities

Decrease in the production of progesterone

Drugs or radiation

Maternal causes -- infections, endocrine disorders, malnutrition, hypertension

Assessment Types of Abortions Threatened

Assessment Types of Abortions Threatened

Signs and Symptoms vaginal bleeding, spotting Mild cramps, backache Cervix remains CLOSED

Treatment and Nursing Care Bed rest, sedation, Avoid stress and intercourse Progesterone therapy A period of “watchful waiting”

Inevitable Abortion Inevitable Abortion Signs and Symptoms

Loss is certain Bleeding is more profuse Painful uterine contractions Cervix DILATES

Treatment and Nursing Care Assess all bleeding. Save all pads. (May

need to weigh the pads) Use the bedpan to assess all products

expelled Treated by evacuation of the uterus

usually be a D & C or suction

Provide Psychological Support

Complete AbortionComplete Abortion

All products of conception are expelled

No treatment is needed, but may do a D & C

Incomplete Abortion Incomplete Abortion Parts of the products

of conception are expelled, with placenta and membranes retained

Treated with a D & C or suction evacuation

Provide support to the family

Missed Abortion Missed Abortion

The fetus dies in-utero and is not expelled

Uterine growth ceases Breast changes regress Maceration occurs Treatment:

D & C Hysterotomy

Missed AbortionCritical Thinking ExerciseMissed AbortionCritical Thinking Exercise

The woman who has a missed abortion is at risk for what 2 conditions?

Habitual Abortion / Premature Cervical Dilation

Habitual Abortion / Premature Cervical Dilation

Abortion occurs consecutively in three or more pregnancies

Usually due to an Incompetent Cervical Os, that results from cervical trauma, cervical lacerations, repeated D & C, or conization.

Occurs most often about 18-20 weeks gestation.

Habitual Abortion Habitual Abortion

Treatment Cerclage procedure -- purse-

string suture placed around the internal os to hold the cervix in a normal state

Nursing CareNursing Care

Bedrest in a slight trendlenburg position to decrease the pressure on the new sutures

Teach: Assess for leakage of fluid, bleeding Assess for contractions Assess fetal movement and report

decrease movement (if old enough) Assess temperature for elevations

DeliveryDelivery

When time for delivery there are several options: physician will clip suture and allow

patient to go into labor on her own induce labor cesarean delivery

Mrs. B. had a cerclage procedure done at 14 weeks gestation. She is now 39 weeks gestation and admitted to labor and delivery because she is in labor.

What is the MOST important assessment to make at this time?

Key Concepts to Remember!!

Key Concepts to Remember!!

If a woman is Rh-, RhoGam is given within 72 hours

Provide emotional support. Feelings of shock or disbelief are normal

Encourage to talk about their feelings. It begins the grief process

Bleeding Disorders Ectopic Pregnancy

Bleeding Disorders Ectopic Pregnancy• Implantation of the blastocyst in

ANY site other than the endometrial lining of the uterus

(5) Cervicalovary

Etiology / Contributing Factors Etiology / Contributing Factors

• Salpingitis• Pelvic Inflammatory Disease, PID• Endometriosis• Tubal atony or spasms• Imperfect genetic development

Assessment Ectopic Pregnancy Assessment Ectopic Pregnancy

• Early:• Missed menstruation followed by

vaginal bleeding (scant to profuse)• Unilateral pelvic pain, sharp abdominal

pain• Referred shoulder pain• Cul-de-sac mass

• Acute:• Shock – blood loss poor indicator• Cullen’s sign -- bluish discoloration

around umbilicus• Nausea, Vomiting• Faintness

Diagnostic Tests Ectopic Pregnancy Diagnostic Tests Ectopic Pregnancy

• Diagnosis:• Ultrasound• Culdocentesis• Laparoscopy

Interventions / Nursing CareInterventions / Nursing Care

• Combat shock / stabilize cardiovascular • Draw blood for type and cross match• Give blood replacements • IV’s.

• Laparotomy

• Psychological support

• Linear salpingostomy

• Methotrexate – used prior to rupture. Destroys fast growing cells

Hydatiform Mole

Etiology

Hydatiform Mole

Etiology

A DEVELOPMENTAL ANOMALY OF THE PLACENTA WITH DEGENERATION OF THE CHORIONIC VILLI

As cells degenerate, they become filled with fluid and appear as fluid filled grape-size vessicles.

Assessment: Assessment:

• Vaginal Bleeding -- scant to profuse, brownish in color (prune juice)

• Enlargement of the uterus out of proportion to the duration of the pregnancy

• Vaginal discharge of grape-like vesicles• May display signs of pre-eclampsia early• Hyperemesis gravidarium• No Fetal heart tone or Quickening• Abnormally elevated levels of HCG

Interventions and Follow-UpInterventions and Follow-Up

• Empty the Uterus by D & C or Hysterotomy

• Follow-Up for One Year• Assess for the development of

choriocarcinoma• Blood tests for levels of HCG frequently• Chest X-rays• Placed on oral contraceptives• If the levels rise, then chemotherapy started

usually Methotrexate

Critical Thinking ExerciseCritical Thinking Exercise

A woman who just had an evacuation of a hydatiform mole tells the nurse that she doesn’t believe in birth control and does not intend to take the oral contraceptives that were prescribed for her.

How should the nurse respond?

Placenta PreviaPlacenta Previa

• Low implantation of the placenta in the uterus

• Etiology• Usually due to reduced vascularity in

the upper uterine segment from an old cesarean scar or fibroid tumors

• Three Major Types:• Low or Marginal• Partial• Complete

Abruptio PlacentaAbruptio Placenta

Premature separation of the placenta from the implantation site in the uterus

Etiology: Chronic Hypertension Sudden decompression of an over-

distended uterus Trauma Injudicious use of Pitocin Smoking / Caffeine / Cocaine Vascular problems

Placenta PreviaPlacenta Previa• PAINLESS vaginal

bleeding• Bright red bleeding• First episode of

bleeding is slight then becomes profuse

• Signs of blood loss comparable to extent of bleeding

• Uterus soft, non-tender

• Fetal parts palpable; FHT’s countable

• Blood clotting defect absent

Abruptio PlacentaAbruptio Placenta Bleeding accompanied Bleeding accompanied

Abruptio by PAINAbruptio by PAIN Dark red bleedingDark red bleeding First episode of First episode of

bleeding usually bleeding usually profuseprofuse

Signs of blood loss out Signs of blood loss out of proportion to visible of proportion to visible amount amount

Uterus board-like, Uterus board-like, painfulpainful

Fetal parts non-Fetal parts non-palpable, FHT’s non-palpable, FHT’s non-countablecountable

Blood clotting defect Blood clotting defect (DIC) likely(DIC) likely

Signs of Concealed HemorrhageSigns of Concealed Hemorrhage

Increase in fundal heightHard, board-like abdomenHigh uterine baseline tone on

electronic fetal monitoringPersistent abdominal painSystemic signs of hemorrhage

Interventions and Nursing Care Interventions and Nursing Care

Placenta Previa Bed-rest Assessment of bleeding Electronic fetal monitoring If it is low lying, then may allow to

deliver vaginally Cesarean delivery for All other types of

previa Abruptio Placenta

Deliver by cesarean delivery immediately

Combat shock – blood replacement / fluid replacement

Blood work – assessment of DIC

Critical ThinkingCritical ThinkingCritical ThinkingCritical Thinking Mrs. A. , G3 P2, 38 weeks gestation

is admitted to L & D with bleeding. What is the priority nursing intervention at this time?A. Assess the fundal height for a decreaseB. Place a hand on the abdomen to assess

if hard, board-like, tetanicC. Place a clean pad under the patient to

assess the amount of bleedingD. Prepare for an emergency cesarean

delivery

Disseminated Intravascular Coagulation (DIC)

Disseminated Intravascular Coagulation (DIC)

Anti-coagulation and Pro-coagulation

effects existing at the same time.

EtiologyDefect in the Clotting Cascade

EtiologyDefect in the Clotting Cascade

An abnormal overstimulation of the

coagulation process Activation of Coagulation with release of thromboplastin Thrombin (powerful anticoagulant) is produced

Fibrinogen fibrin which enhances platelet

aggregation Widespread fibrin and platelet deposition in

capillaries and arterioles

Resulting in Thrombosis (multiple small clots)

Excessive clotting activates the fibrinolytic system

Lysis of the new formed clots create fibrin split products

These products have anticoagulant properties and inhibit normal blood clotting

A stable clot cannot be formed at injury sites

Hemorrhage occurs Ischemia of organs follows from vascular

occlusion of numerous fibrin thrombi Multisite hemorrhage results in shock and

can result in death

Disseminated Intravascular Coagulation (DIC)

Disseminated Intravascular Coagulation (DIC)

Precipating Factors: Abruptio placenta PIH Sepsis Retained fetus (fetal demise) Fetal placenta fragments

Assessment Signs and Symptoms Assessment Signs and Symptoms

Spontaneous bleeding -- from gums and Epistasis, and injection and IV sites, incisions

Excessive bleeding -- Petechiae at site of blood pressure cuff, pulse points. Ecchymosis

Tachycardia, diaphoresis, restlessness, hypotension

Hematuria, oliguria, occult blood in stool

Mental changes if brain affected.

Diagnostic TestsDiagnostic Tests Lab work reveals:

PT – Prothrombin time is prolonged PTT – Partial Thromboplastin Time

increased D-Dimer – increased Product that results

from fibrin degradation. More specific marker of the degree of fibrinolysis

Platelets -- decreased Fibrin Split Products – increase

An increase in both FSP and D-Dimer are indicative of DIC

DICInterventions and Nursing Care

DICInterventions and Nursing Care

Remove Cause Evaluate vital signs Replace blood and blood products Fluid replacement

May give Heparin -- interrupt the clotting cascade and prevent triggering the fibrinolytic system.

Structural DisordersStructural Disorders

Fetal Demise / Intrauterine Fetal Fetal Demise / Intrauterine Fetal DeathDeath

Structural DisordersStructural Disorders

Fetal Demise / Intrauterine Fetal Fetal Demise / Intrauterine Fetal DeathDeath

DEFINITION: Death of a fetus after the age of

viability

Assessment: 1. First indication is usually NO

fetal movement

2. NO fetal heart tones Confirmed by ultrasound

3. Decrease in the signs and symptoms of

pregnancy

Interventions and Nursing Care

• Allow patient to decide when she wants to deliver

• Most women go into labor on their own in 2 weeks, so may wait for labor to begin spontaneously

• Induce labor • Prostaglandin (Prostin E) causes

smooth muscles to contract: Side effects - nausea, vomiting, diarrhea

• Cytogel

• Provide with Emotional Support, allow to hold baby

The End The End