Transcript Rx Con`t. - TeacherWeb

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
• 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
• The pregnant woman should immediately report any of the following
S&S:
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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 Pregnancy
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Fever > 100
Abdominal pain or cramps
Epigastric pain
Irritating vaginal discharge
Dysuria
Oliguria
Absence or marked decrease in fetal movements
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
• 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.
• 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)
• 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)
• 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.
• 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)
• 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.
• 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 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.
• There is no treatment or cure for AIDS. HIV infection is acquired one
of the following ways:
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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’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 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 csection
• Diagnosis of GBS is confirmed by vaginal or rectal culture
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:
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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.
• 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
• 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
• 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 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: PAINLESS vaginal bleeding in the last half of pregnancy.
Bleeding may be gushing or intermittent
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
• 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 wallno 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 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=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
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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.
• Risks for fetus:
• Premature birth
• Congenital defects
• Macrosomia- excessive fetal growth
• Risk for Infant:
• Respiratory distress syndrome
• Neonatal hypoglycemia
• Hyperbilirubinemia
Diabetes Con’t.
• Risks for Mother:
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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’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
• Risk Factors for PIH include:
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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.
• 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’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’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 Csection. TREATMENT WITH ANTICONVULSANT, MGSO4, SHOULD BE
CONTINUED FOR 24-48 HOURS AFTER DELIVERY!
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:
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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’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
• 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+ 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’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’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
• 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
• 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 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 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.
• Rx Con’t.
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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
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
UTI
• Nursing Care:
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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
• 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
• 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
• 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.
• 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 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 Labor
• Risk Factors:
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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 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.
• 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’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’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’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’t.
• Nursing Assessment during Tocolytic Therapy:
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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