COMPLICATIONSCOMPLICATIONS

OFOF

PREGNANCYPREGNANCY

Revised October 2009Revised October 2009Debbie Perez RN, MSN, CNSDebbie Perez RN, MSN, CNS

Risk Factors

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

diabetes, heart conditions, renal, etc.

Pregnancy related conditions – hyperemesis gravidarum, PIH

Goals of Care for High Risk Pregnancy

Provide optimum care for the mother and the fetus

Assist the client and her family to understand and cope through education

Gestational Onset Disorders

Take report: Mrs. R. admitted to L&D• Initial Data

– Chief complaint: moderate amount vaginal bleeding

– Vital Signs: T. 98.4; P. 100, R. 22, B/P 100/66– G 1 P 0– Last menstrual period: 8/12; EDC: May 19– Allergies: none known– Nauseated– Mild pain– HCG levels – WNL for pregnancy

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

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

• Faulty implantation

• Decrease in the production of progesterone

• Drugs or radiation

• Maternal causes -- infections, endocrine disorders, malnutrition, hypertension, cervix disorder

Assessment Types of Abortions Threatened

Assessment Types of Abortions Threatened

• Signs and Symptoms– vaginal bleeding, spotting– Mild cramps, backache– Cervix remains CLOSED– Intact membranes

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

Imminent Abortion Imminent 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, placenta and membranes retained and intact

• 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

Question???

• What are two main complications related to a missed abortion?

• 1.

• 2.

Recurrent / Habitual Abortion Premature Cervical Dilation

Recurrent / Habitual Abortion Premature Cervical Dilation

• Abortion occurs consecutively in _____ or more pregnancies

• Usually due to an Incompetent Cervical Os

• 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 Care post cerclage

• Bedrest in a slight trendelenburg position

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

decrease movement– Assess temperature for elevations

Delivery options:

• 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

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

Treatment Options / Nursing Care• Combat shock / stabilize cardiovascular

• Type and cross match • Administer blood replacement • IV access and fluids

• Laparotomy

• Psychological support

• Linear salpingostomy

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

Question 4

Gestational Trophoblastic DiseaseHydatiform Molar Pregnancy

Etiology

Gestational Trophoblastic DiseaseHydatiform Molar Pregnancy

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)

• Possible anemia due to blood loss• 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 level of HCG

Question 6

Interventions and Follow-UpInterventions and Follow-Up

• Empty the Uterus by D & C or Hysterotomy

• Extensive 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 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

Question 8

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 bleeding First episode of bleeding

usually profuseusually profuse

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

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

Signs 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

Treatment and Nursing Care

Abruptio Placenta Cesarean delivery immediately Combat shock – blood replacement /

fluid replacement Blood work – assessment for

complication 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 Amniotic embolism Maternal liver disease Septic abortion HELLP and preeclampsia

Assessment Signs and Symptoms Assessment Signs and Symptoms

Spontaneous bleeding -- from gums and Epistaxis, 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

Altered LOC if brain affected.

Diagnostic 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

Question 9-D: E

HYPEREMESIS GRAVIDARIUMHYPEREMESIS GRAVIDARIUM

**Pernicious vomiting during **Pernicious vomiting during PregnancyPregnancy

Hyperemesis GravidariumHyperemesis Gravidarium

EtiologyEtiology

Increased levels of HCGIncreased levels of HCG

AssessmentAssessment

Persistent nausea and vomitingWeight loss from 5 - 20 poundsMay become severely dehydrated with

oliguria AEB increased specific gravity, and dry skin

Depletion of essential electrolytesMetabolic alkalosis -- Metabolic

acidosisStarvation

Nursing Care / InterventionsHyperemesis GravidariumNursing Care / InterventionsHyperemesis Gravidarium

Control vomiting

Maintain adequate nutrition and electrolyte balance Allow patient to eat whatever she wants If unable to eat – Total Parenteral Nutrition

Combat emotional component – provide emotional support. Mouth care

Weigh daily

Check urine for output, ketones

PREGNANCY INDUCED HYPERTENSION

A hypertensive disease of pregnancy. Known as pre-eclampsia and eclampsia.

Pre-eclampsia = hypertension, edema

proteinuria, Eclampsia = other signs plus

convulsions

It develops between the 20th and 24th week of gestation and resolves after the tenth day postpartum

PREDISPOSING FACTORSPREDISPOSING FACTORS

PRIMIGRAVIDA MULTIPLE PREGNANCY

VASCULAR DISEASE

UNDER 17 AND OVER 35

LOWER SOCIOECONOMIC STATUSSevere malnutrition, decrease Protein intake

Inadequate or late prenatal care

FAMILY HISTORY

HYDATIFORM MOLE

Diabetes, renal

PATHOLOGICAL CHANGESPIH is due to:

GENERALIZED ARTERIOLAR

CYCLICVASOSPASMS

INCREASED PERIPHERAL RESISTANCE; IMPEDED BLOOD FLOW( in blood pressure)

Endothelial CELL DAMAGE

Intravascular Fluid Redistribution

(decrease in diameter of blood vessel)

Decreased Organ Perfusion

Multi-system failure DiseaseMulti-system failure Disease

Clinical Manifestation

HYPERTENSIONHYPERTENSION

Earliest and The Most Earliest and The Most Dependable IndicatorDependable Indicator of PIHof PIH

Hypertension

B/P = 140 / 90 if have no baseline. 1. 30 mm. Hg. systolic increase or a 15 mm. Hg. diastolic increase (two occasions four to six hours apart)

2. Increase in MAP > 20 mm.Hg over baseline or >105 mm. Hg. with no baseline

Rationale for HYPERTENSIONThe blood pressure rises due to: ARTERIOLAR VASOSPASMS AND

VASOCONSTRICTION causing

(Narrowing of the blood vessels)

an increase in peripheral resistance

fluid forced out of vessels

HEMOCONCENTRATION

Increased blood viscosity = Increased hematocrit

Key Point to Remember !

HEMOCONCENTRATION develops because:

Vessels became narrowed forcing fluid to shift

Fluid leaves the intracellular spaces and moves to extracellular spaces

Now the blood viscosity is increased (Hemocrit is increased)

**Very difficult to circulate thick blood

Test Yourself !

Which of these readings indicates hypertension in the patient whose blood pressure normally is 100 / 60 and MAP of 77?

a. 120 / 76; MAP 96 b. 110 / 70; MAP 83 c. 130 / 80; MAP 98 d. 125 / 70; MAP 88

Proteinuria With Renal vasospasms, narrowing of

glomular capillaries which leads to decreased renal perfusion and decreased glomerular filtration rate (damage to glomeruli)

PROTEINURIA

Spilling of 1+ of protein is significant to begin treatment

Oliguria and tubular necrosis may precipitate acute renal failure

Significant Lab WorkChanges in Serum Chemistry

• Decreased urine creatinine clearance (80-130 mL/ min)

• Increased BUN (12-30 mg./dl.)

• Increased serum creatinine (0.5 - 1.5 mg./dl)

• Increased serum uric acid (3.5 - 6 mg./dl.)

Weight Gain and Edema

• Clinical Manifestation:

– Edema may appear rapidly– Begins in lower extremities and

moves upward– Pitting edema and facial edema are

late signs

– Weight gain is directly related to accumulation of fluid

WEIGHT GAIN AND EDEMA

Rationale:• Albumin is lost due to the damage to the

tubules allowing larger solutes to pass in the urine

• This leads to a decreased colloid osmotic pressure

• A in COP allows fluid to shift from from intravascular to extravascular by osmosis

• Fluid accumulates in the extravascular space• Increased angiotensin and aldostersone

triggers retention of sodium and water

The difference between dependent edema and generalized edema is important.

The patient with PIH has generalized edema because fluid is in all tissues.

The Nurse Must Know

Placenta

Due to Vasospasms and Vasoconstriction of the vessels in the placenta.

Decreased Placental Perfusion and Placental Aging

Fetal Growth is retarded - IUGR, SGA

Positive OCT / __________Decelerations

With Prolonged decreased Placental Perfusion:

Condition is

Worsening

Condition is

Worsening

•Oliguria – 100ml./4 hrs or less than 30 cc. / hour

•Edema moves upward and becomes generalized (face, periorbital, sacral)

•Excessive weight gain – greater than 2 pounds per week

Central Nervous System Changes

• Cerebral edema -- forcing of fluids to extracellular

–Headaches -- severe, continuous

–Hyper-reflexia–Level of Consciousness changes – changes in affect

–Convulsions / seizures

Visual Changes

Retinal Edema and spasms leads to:

• Blurred vision

• Double vision

• Retinal detachment

• Scotoma (areas of absent or depressed vision)

• Nausea and Vomiting

• Epigastric pain –often sign of impending coma

Pre-Eclampsia Mild Severe

B/P 140/90 160/110Protein 1+ 2+ 3+ 4+Edema 1+, lower legs 3+ 4+Weight <1 lb. / week >2lb. / week Reflexes 1+ 2+ brisk 3+ 4+ (Hyperreflexia) Clonus presentRetina 0 Blurred vision, Scotoma

Retinal detachmentGI, Hepatic 0 N & V, Epigastric pain, changes in liver enzymesCNS 0 Headache, LOC changes

Fetus 0 Premature aging of placenta IUGR; late decelerations

Interventions and Nursing Care• Home Management

– Decrease activities and promote bed rest • Sedative drugs• Lie in left lateral position• Remain quiet and calm – restrict visitors and phone calls

– Dietary modifications • increase protein intake to 70 - 80 g/day• maintain sodium intake• Caffeine avoidance

– Weigh daily at the same time

– Keep record of fetal movement - kick counts

– Check urine for Protein

Hospitalization• If symptoms do not get better, patient

needs to be hospitalized for further evaluation

• Common lab studies:– CBC, platelets; type and cross

match– Renal blood studies -- BUN,

creatinine, uric acid– Liver studies -- AST, LDH, Bilirubin– DIC profile -- platelets, fibrinogen,

FSP, D-Dimer

Hospital ManagementNursing Care Goal

1. Decrease CNS Irritability

2. Control Blood Pressure

3. Promote Diuresis

4. Monitor Fetal Well-Being

5. Deliver the Infant

Decrease CNS Irritability Provide for a Quiet Environment and

Rest 1. MONITOR EXTERNAL STIMULI

Explain plans and provide Emotional Support

Administer Medications1. Anticonvulsant -- Magnesium Sulfate2. Sedative -- Diazepam (Valium)3. Apresoline (hydralazine)

Assess Reflexes Assess Subjective Symptoms Keep Emergency Supplies Available

Magnesium SulfateACTION

CNS Depressant, reduces CNS irritability Calcium channel blocker- inhibits cerebral neurotransmitter release

ROUTE IV effect is immediate and lasts 30 min. IM onset in 1 hour and lasts 3-4 hours

• Prior to administration:– Insert a foley catheter with urimeter

for assessment of hourly output

Magnesium SulfateNURSING IMPLICATIONS 1. Monitor respirations > 14-16; < 12 is critical

2. Assess reflexes for hyporeflexia -- D/C for hyporeflexia

3. Measure Urinary Output >100cc in 4 hrs.

4. Measure Magnesium levels – normal is 1.5-2.5 mg/dl Therapeutic is 4-8mg/dl.; Toxicity - >9mg/dl; Absence of reflexes is >10 mg/dl; Respiratory arrest is 12-15 mg/dl; Cardiac arrest is > 15 mg/dl.

• Have Calcium Gluconate available as antagonist

Test Yourself !

A Woman taking Magnesium Sulfate has a

respiratory rate of 10. In addition to discontinuing the medication, the nurse should:

a. Vigorously stimulate the woman b. Administer Calcium gluconate c. Instruct her to take deep breaths d. Increase her IV fluids

Nursing Care: Hospital Management

1. Decrease CNS Irritability

2. Control Blood Pressure

3. Promote Diuresis

4. Monitor Fetal Well-Being

5. Deliver the Infant

Control Blood Pressure• Check B / P frequently.

• Give Antihypertensive Drugs– Hydralzine ( apresoline)– Labetalol – Aldomet– Procardia

• Check Hemocrit

•Do NOT want to decrease the B/P too low or too rapidly. Best Do NOT want to decrease the B/P too low or too rapidly. Best to keep diastolic ~90. to keep diastolic ~90.

•WHY?WHY?

Nursing Care: Hospital Management

1. Decrease CNS Irritability

2. Control Blood Pressure

3. Promote Diuresis

4. Monitor Fetal Well-Being

5. Deliver the Infant

Promote Diuresis

**Don’t give Diuretic, masks the symptoms of PIH

• Bed rest in left or right lateral position

• Check hourly output -- foley cath with urimeter

• Dipstick for Protein

• Weigh daily -- same time, same scale

Nursing Care: Hospital Management1. Decrease CNS Irritability

2. Control Blood Pressure

3. Promote Diuresis

4. Monitor Fetal Well-Being

5. Deliver the Infant

Monitor Fetal Well-Being

FETAL MONITORING-- assessing for late decelerations.

NST -- Non-stress test

OCT --oxytocin challenge test

If all else fails ---- Deliver the baby

Key Point to Remember !

SEVERE COMPLICATIONS OF PIH:PLACENTAL SEPARATION - ABRUPTIO PLACENTA;

DIC

PULMONARY EDEMA

RENAL FAILURE

CARDIOVASCULAR ACCIDENT

IUGR; FETAL DEATH

HELLP SYNDROME

HELLP Syndrome

•A multisystem condition that is a form of severe preeclampsia - eclampsia

•H = hemolysis of RBC

•EL = elevated liver enzymes

•LP = low platelets <100,000mm (thrombocytopenia)

Etiology of HELLP

Hemolysis occurs from destruction of RBC’s

Release of bilirubin

Elevated liver enzymes occur from blood flow that is obstructed in the liver due to fibrin deposits

Vascular vasoconstriction endothelial damage platelet aggregation at the sites of damage low platelets.

HELLP Syndrome Assessment:1. Right upper quadrant pain and tenderness2. Nausea and vomiting3. Edema4. Flu like symptoms5. Lab work reveals – a.  anemia – low Hemoglobin b.  thrombocytopenia – low platelets. < 100,000. c.  elevated liver enzymes:    -AST asparatate aminotransferase (formerly SGOT) exists within the liver cells and with damage to liver cells, the AST levels rise > 20 u/L.   - LDH – when cells of the liver are lysed, they spill into the bloodstream and there is an increase in serum > 90 u/L/

HELLP

• Intervention:• 1. Bed rest – any trauma or increase in

intra- abdominal pressure could lead to rupture of the liver capsule hematoma.

• 2. Volume expanders

• 3. Antithrombic medications

Urinary Tract Infection

Most common infection complicating Pregnancy

EtiologyPressure on ureters and bladder

causing Stasis with compression of ureters

RefluxHormonal effects cause decrease tone

of bladder Assessment

Dysuria, frequency, urgency lower abdominal pain; costal

vertebral pain fever

InterventionsMonthly culturesOral Sulfonamides; Amoxicillin,

Ampicillin, Cephalosporins, NO tetracyclines

Increase fluid intake to 3 – 4 liters / day

Knee chest positionComplication

Premature labor

T O R C H A Infections

T = ToxoplasmosisO = Other Syphilis, Gonorrhea, Chlamydial,Hepatitis A or B

R = RubellaC = CytomegalovirusH = HerpesA = Aids

ToxoplasmosisEtiology

Protozoan infection. Raw meat and cat litter

Maternal and Fetal Effects Mom - flu-like symptoms,

lymphadenopathy Fetus – stillborn, premature birth,

microcephaly; mental retardationInterventions / Nursing Care

* Instruct to cook meat thoroughly* Avoid changing cat litter* Advise to wear gloves when working in the garden Treatment: Sulfa drugs

Syphilis

• Etiology•Spirochete – Treponema Pallium

• Maternal and Fetal Effects• May pass across the placenta to fetus

causing spontaneous abortion. Major cause of late,second trimester abortions

• Infant born with congenital anomalies

Syphilis

• Intervention:•1. Penicillin

•2. Advise to return for prenatal visits monthly to assess for reinfection.

•3. Advise that if treated early, fetus may not be infected

GonorrheaEtiology – Neisseria GonorrhoeaeMaternal and Fetal Effects:

May get infected during vaginal delivery causing Ophthalmia neonatorium (blindness) in the infant

Mom will experience dysuria, frequency, urgency

Major cause Pelvic Inflammatory Disease which leads to infertility.

Treated with RocephinSpectinomycin

Treat partner!!Treat partner!!

Chlamydia Three times more common than

gonorrhea. Etiology - Chlamydia trachomatis Maternal and Fetal Effects

Mom – pelvic inflammatory disease, dysuria, abortions, pre-term labor

Fetus -- Stillbirth, Chylamydial pneumonia

Interventions Erythromycin, doxycycline, zithromax Advise treatment of both partners is

very important

Hepatitis A or B

• Highly contagious when transmitted by direct contact with blood or body fluids

• Maternal and Fetal Effects:• All moms should be tested for Hep B during

pregnancy• Fetus may be born with low birth weight and

liver changes\• May be infected through placenta, at time of

birth, or breast milk

• Intervention:• Recommend Hepatitis B vaccination to both

mother and baby after delivery.

Rubella

EtiologySpread by droplet infection or through

direct contact with articles contaminated with nasopharyngeal secretions.

Crosses placenta Maternal and Fetal Effects

Mom– fever, general malaise, rashMost serious problem is to the fetus--

causes many congenital anomalies (cataracts, heart defects)

InterventionDetermine immune status of mother. If

titer is low, vaccine given in early postpartum period

CYTOMEGALOVIRUSEtiology -- Member of the Herpes virus

• Crosses the placenta to the fetus or contracted during delivery. Cannot breast feed because transmitted through breast milk

Effects on Mom and Fetus• Mom – no symptoms, not know until after

birth of the baby• Fetus -- Severe brain damage; Eye

damage

InterventionNo drug available at this timeTeach mom should not breast feed babyIsolate baby after birth

Herpes Simplex Type 2 Maternal and Fetal Effects

Painful lesions, blisters that may rupture and leave shallow lesions that crust over and disappear in 2-6 weeks

Culture lesions to detect if Herpes, No cure

If mom has an outbreak close to delivery, then cannot deliver vaginally. Must deliver by Cesarean birth

*Virus is lethal to fetus if inoculated at birth Intervention:

Zivorax

AIDS

• Etiology: Human Immunodeficiency Virus, HIV

• Transmission of HIV to the fetus occurs through:– The placenta; birth canal– Through breast milk

**The virus must enter the baby’s bloodstream to produce infection.

Maternal and Fetal Effects:

– Mom - brief febrile illness after exposure to with symptoms of fatigue and lymphadenopathy

– Fetus has a 2-5% chance of being infected. No symptoms until about 1 year of age

Diagnosis:• ELISA test – identifies antibodies specific to HIV. If

positive = person has been exposed and formed antibodies

• Western Blot – used to confirm seropositivity when ELISA is positive.

• Viral load - measures HIV RNA in plasma. It is used to predict severity – lower the load the longer survival.

• CD4 cell count – markers found on lymphocytes to indicate helper T4 cells. HIV kills CD4 cells which results in impaired immune system.

Goal: reduce viral load to below 50 copies /ml. and increase the CD4 cell count.

Nursing Care:

• **Provide Emotional Support

• **Teach measures to promote wellness AZT

oral during pregnancy IV during labor liquid to newborn for 6 weeks.

• **Provide information about resources

Fetal Demise / Intrauterine Fetal Fetal Demise / Intrauterine Fetal DeathDeath

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

Treatment:

• Deliver the fetus

• How???

Pre-Gestational Onset Disorders

Diabetes in Pregnancy

Diabetes creates special problems which affect pregnancy in a variety of ways.

Successful delivery requires work of the entire health care team

Endocrine Changes During

Pregnancy

There is an increase in activity of maternal pancreatic islets which result in increaseincrease production of insulin.

Counterbalanced by:a. Placenta’s production of Human

Chorionic Somatomammotropin (HCS)

b. Increased levels of progesterone and estrogen--antagonistic to insulin

c. Human placenta lactogen – reduces effectiveness of circulating insulin

d. Placenta enzyme-- insulinase

GESTATIONAL DIABETESDiabetes diagnosed during pregnancy,

but unidentifable in non-pregnant woman

Known as Type III Diabetes - intolerance to glucose during pregnancy with return to normal glucose tolerance within 24 hours after delivery

Glucose tolerance test:1 hr oral GTT – if elevated, do 3 hour GTTGestational diabetes if:

Fasting – 95 mg / dl1 hour - 180 mg/ dl2 hour - 155 mg/ dl3 hour – 140mg/dl

Treatment for the patient with Gestational Diabetes:•

• Treatment - controlled mainly by diet

• No use of oral hypoglycemics

Effects of Diabetes on the Pregnancy

MATERNAL Increase incidence of INFECTION

Fourfold greater incidence of Pre-eclampsia

Increase incidence of Polyhydramnios

Dystocia – large babies

Rapid Aging of Placenta

FETAL COMPLICATIONSFETAL COMPLICATIONS

Increase morbidity

Increase Congenital Anomalies neural tube defect (AFP)Cardiac anomalies

Spontaneous Abortions

Large for Gestation Baby, LGA

Increase risk of RDS

Effects of Pregnancy on the Diabetic

Insulin Requirements are AlteredFirst Trimester--may drop slightlySecond Trimester-- Rise in the

requirementsThird Trimester-- double to quadruple by

the end of pregnancy

Fluctuations harder to control; more prone to DKA

Possible acceleration of vascular diseases

Key Point to Remember!

If the insulin requirements do not rise as pregnancy progresses that is an indication that the placenta is not functioning well.

Test Yourself?

Mrs. R.’s is 31 weeks gestation and her insulin requirements have dropped. What additional test could be performed to assess fetal well-being? a. L/S ratio b. Estriol levels c. Oxytocin Challenge Test

Interventions /Nursing Care

I. I. Diet TherapyDiet Therapy– dietary management must be based on

BLOOD GLUCOSE LEVELS – Pre-pregnant diet usually will not work– Need ~300kcal/day– Divide among three meals and three

snacks

II. Insulin RegulationII. Insulin Regulation– maintaining optimal blood glucose levels

require careful regulation of insulin. Sometimes placed on insulin pump.

III. Blood Glucose MonitoringIII. Blood Glucose Monitoring– teach how to keep a record of results of home

glucose monitoring

IV. EXERCISE– A consistent and structured exercise program is O.K.

V. MONITOR FETAL WELL-BEING– The objective is to deliver the infant as near to

term as possible and prevent unnecessary prematurityNSTUltrasoundL / S ratio

Heart Disease in

Pregnancy

Cardiac Response in All Pregnancies

Increase in Cardiac Output 30% - 50%

Expanded Plasma Volume

Increase in Blood (Intravascular) Volume

Every Pregnancy affects the cardiovascular system

A woman with a healthy heart can tolerate the stress of pregnancy,but a woman with a compromised heart is challenged Hemodynamically and will have complications

Effects of Heart Disease on Pregnancy

Growth Retarded Fetus

Spontaneous Abortion

Premature Labor and Delivery

Effects of Pregnancy onHeart Disease

The Stress of Pregnancy on an already weakened heart may lead to cardiac decompensation (failure).

The effect may be varied depending upon the classification of the disease

Classification of Heart Disease

Class 1 Uncompromised No alteration in activity No anginal pain, no symptoms with activity

Class 2 Slight limitation of physical activity Dyspnea, fatigue, palpitations on ordinary

exertion comfortable at rest p. 328

Class 3 Marked limitation of physical activity Excessive fatigue and dyspnea on minimal exertion Anginal pain with less than ordinary exertion

Class 4 Symptoms of cardiac insufficiency even at rest Inability to perform any activity without discomfort Anginal pain Maternal and fetal risks are high p. 328

Nursing Care - Antepartum

Decrease Stress– Teach the importance of REST! – watch weight– assess for infections - stay away from

crowds– assess for anemia– assess home responsibilities

Teach signs of cardiac decompenstion

Key Point to RememberSigns of Congestive Heart Failure

Cough (frequent, productive, hemoptysis)

Dyspnea, Shortness of breath, orthopnea

Palpitations of the heart

Generalized edema, pitting edema of legs and feet

Moist rales in lower lobes, indicating pulmonary edema

Teach about diet

high in iron, proteinlow in sodium and calories ( fat )

Watch weight gain

Teach how to take their medicine– Supplemental iron– Heparin, not coumarin – monitor lab work– Diuretics – very careful monitoring– Antiarrhythmics –Digoxin, quinidine, procainamide. *Beta-blockers are

associated with fetal defects.

Reinforce physicians care

Key point to remember !

Never eat foods high in Vitamin K while on

an anticoagulant!

( raw green leafy vegetables)

Nursing Care: Intrapartum

Labor in an upright or side lying position Restrict fluids On O2 per mask throughout labor and

cardiac monitoring. Sedation / epidural given early Report fetal distress or cardiac failure

Stage 2 - gentle pushing, high forceps delivery

Nursing Care Postpartum The immediate post delivery period is the

MOST significant and dangerous for the mom with cardiac problems

Following delivery, fluid shifts from extravascular spaces into the blood stream for excretion

Cardiac output increases, blood volume increases

Strain on the heart! Watch for cardiac failure

Test Yourself !• Mrs. B. has mitral valve prolapse.

During the second trimester of pregnancy, she reports fatigue and palpitations during routine housework. As a cardiac patient, what would her functional classification be at this time?

a. Class I b. Class II c. Class III d. Class IV

The End