Transcript Complications of Pregnancy Module B

Complications of Pregnancy
Module B
NUR 106
Spring, 2005
Assessment of Fetal Well-being
Detect physical abnormalities
Monitor fetal condition
Fetal movement
Complex diagnostic testing
Risks and benefits
Amniocentesis
Aspiration of amniotic fluid
Determine genetic disorders
Sex of fetus
Fetal lung maturity
Risks
Nursing management
Amniocentesis
Chorionic Villus Sampling
Aspiration of small sample of
chorionic villus tissue
8 to 12 weeks gestation
Detects genetic abnormalities
Risks and benefits
Nursing management
Hormone Levels
Estriol
Human chorionic gonadotropin
Maternal serum—alpha fetoprotein
Alfa-Fetoprotein Screening
MSAFP
AFAFP
Time sensitive
Low MSAFP levels associated with
Down syndrome
High MSAFP levels associated with
neural tube defects
Triple Marker Screening
Alpha-fetoprotein
Human chorionic gonadotropin
Unconjugated estriol
High Risk Assessment
Daily fetal movement count
Nonstress test
Biophysical profile
Contraction stress test
Daily Fetal Movement Count
Begin at 27th week
Consider
Fetal sleep-wake cycles
Maternal food intake
Drug-nicotine use
Environmental stimuli
Maternal position
Procedure
Fetal Monitor
Fetal Monitoring
Normal fetal heart rate
Baseline
Baseline FHR
Rate
Variability
Assesses average rate for at least 2
minutes within a 10 minute window
Normal: 110 to 160 bpm
Bradycardia: < 110 bpm for 10 minutes
Tachycardia: > 160 bpm for 10 minutes
Variability
Normal irregularity of fetal cardiac
rhythm
Short-term
Beat-to-beat changes
Need fetal scalp electrode
Long-term
Rhythmic changes (waves) from
the baseline value
Usually 3 to 5 beats
Reduced Variability
Accelerations
Bradycardia
Tachycardia
Deceleration
Nonstress Test
Assess response of FHR to periods of
fetal movement
After 27th to 30th week
Frequency depends on condition of
maternal-fetal unit
Indications
Procedure
Perform test during a time of activity
Maternal preparation
Maternal vital signs
Attach monitor
Monitor fetal movement
Interpretation
Reactive result
Nonreactive result
Unsatisfactory result
Reactive NST
Nonreactive Test
Contraction Stress Test
Assess ability of fetus to withstand
the stress of uterine contractions
Assesses placental oxygenation and
function
Determines fetal well being
Performed if NST is abnormal
Interpretation
Negative CST
Positive CST
Equivocal
Unsatisfactory
Negative CST; Reactive NST
Positive CST
Biophysical Profile
Assess fetal status
NST
Fetal breathing movements
Fetal body movements
Fetal muscle tone
Amniotic fluid volume
Placental grading
Biophysical Profile Scoring
Lung Maturity Testing
Lecithin to sphingomyelin ratio
Phosphatidylglycerol
Fibronectin
Test for preterm delivery
Negative test result highly reliable
Reassures that risk of preterm
delivery is low
Presence of fFN in symptomatic
women during weeks 22 – 34 of
gestation = increased risk of preterm
delivery
Hyperemesis Gravidarum
Intractable nausea and vomiting that
persists beyond the first trimester
and causes disturbances in nutrition,
electrolytes, and fluid balance
Assessment
Nausea most pronounced on arising
Persistent vomiting
Weight loss
Signs of dehydration
Electrolyte imbalances
Ketonuria
Increased hematocrit levels
Nursing Interventions
Monitor vital signs
Monitor FHR, fetal activity and fetal
growth
Monitor for dehydration and
electrolyte imbalance
Daily weight, I&O, calorie count
Monitor urine for ketones
Administer IV fluids, antiemetics
Bleeding Disorders of Early
Pregnancy
Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole
Abortion
Threatened
Imminent
Complete
Incomplete
Missed
Habitual
Elective
Threatened Abortion
Imminent Abortion
Incomplete Abortion
A 22 year old gravida i, para 0, is
11 weeks pregnant. She was
admitted to the hospital with
moderate vaginal bleeding and some
abdominal cramping. Vaginal
examination reveals that the cervix is
dilated 2 cm. She is diagnosed as
having an imminent abortion. What
nursing interventions are indicated
when caring for this patient?
Nursing Interventions
Save perineal pads / tissue
Emotional support
Observe for shock
Bed rest / diversional activity
RhoGAM
Possible surgery
Medication / Blood
Ectopic pregnancy is often
difficult to diagnose because
its symptoms are similar to
those of abdominal conditions.
Identify at least five signs or
symptoms of ectopic pregnancy
and briefly explain why each
occurs.
Ectopic Sites
l
Ectopic Pregnancy
Fertilized ovum implants outside the
uterus
Symptoms at 6 to 12 weeks of gestation
Severe unilateral pelvic-abdominal pain
Pain may refer to shoulder
Tender abdominal mass
Nausea, faintness
Bleeding – frank or occult
Nursing Interventions
Monitor vital signs
Administer intravenous fluids
Provide oxygen when needed
Medicate for pain
Assess lab results
Prepare for possible surgery
Provide emotional support
Incompetent Cervix
Premature dilation of cervix
Occurs in 4th or 5th month of pregnancy
Associated with cervical trauma
Vaginal bleeding at 18 to 28 weeks
Fetal membranes visible through cervix
Treatment is surgical
Hydatidiform Mole
Gestational trophoblastic disease
Developmental anomaly of placenta
Changes chorionic villi into a mass of
clear vesicles
Edematous grapelike cluster
May develop into choriocarcionoma
Hydatidiform Mole
Assessment
FHR not detectable
Vaginal bleeding
Symptoms of PIH
Fundal height > expected for date
Elevated hCG
Ultrasound shows characteristic
snowstorm pattern
Bleeding Disorders of Late
Pregnancy
Placenta previa
Abruption placenta
Placenta Previa
Painless
Spotting or heavy bleeding
Bright-red bleeding
Soft, non-tender, relaxed uterus with
normal tone
Shock in proportion to observed blood
loss
Signs of fetal distress usually not
present
Placenta Previa
Assessment
Episodic painless vaginal bleeding
after 20th week of pregnancy without
contractions
Each successive bleeding episode
heavier than the last
Profuse hemorrhage
Ultrasound shows location of placenta
Nursing Interventions
No vaginal exams
Bedrest
Monitor vital signs and fetal wellbeing
Assess blood loss
IV access
Provide adequate nutrition
Provide emotional support
Abruptio Placenta
Severely painful
Heavy bleeding may be partially or
completely hidden
Usually dark-brown bleeding
Rigid, board-like, tender uterus
possibly with contractions
Shock seeming to be out of
proportion to blood loss
Signs of fetal distress
Abruptio Placenta
Assessment
Painful, rigid, board-like abdomen
with vaginal bleeding
Central abruption
Marginal abruption
Fetal outcome
Nursing Interventions
Monitor vital signs
Continuous EFM
Assess for bleeding, uterine activity,
abdominal pain
Measure abdominal girth
Review lab values
IV access
Provide oxygen
Hypertensive Disorders
Pregnancy induced hypertension
Preeclampsia and eclampsia
Chronic hypertension
Superimposed preeclampsia
Transient hypertension
Pathophysiology
Vasospasm reduces blood flow to
mother’s organs and placenta
Vascular endothelial damage
Hypertension
Edema
Proteinuria
PIH - Assessment
Mild preeclampsia
Severe preeclampsia
Systemic responses
Lab values
Nursing Interventions
Bedrest -- left lateral position
Monitor B/P and weight
Monitor neurological status
Monitor DTRs
Provide adequate fluids
Monitor I & O
Increase dietary protein
Administer medications as prescribed
Magnesium Sulfate ( Mg SO4 )
Mg++ causes vasodilation
Therapeutic levels = 4 to 8 mg/dL
Mg SO4 Therapy
Monitor blood pressure closely
Monitor maternal serum Mg SO4
levels every 6 - 8 hours
Monitor respirations closely
Assess patellar tendon reflex
Determine urinary output
Monitor FHR continuously
Continue Mg SO4 infusion for
approximately 24 hours after birth
Maternal Side Effects
Vasodilation
Flushing
Headaches
“Hot Flashes”
Blurred vision
Nasal Congestion
Decreased peripheral vascular
resistance
Maternal Side Effects
Neuromuscular depression
Respiratory depression
Myocardial depression
Gastrointestinal system
nausea
vomiting
Neonatal Side Effects
Hypocalcemia
Hypermagnesemia
Respiratory depression
Chronic Hypertension
Occurs before pregnancy
Diagnosed before 20th week of gestation
Diagnosed during pregnancy and persists
beyond the 42 day postpartum
Assessment
Headaches
Visual changes
Blood pressure 140/90 mm Hg or >
Delayed fetal growth
Oligohydramnios
Antihypertensives
Given for diastolic blood pressure of
105 to 110 or above
Methyldopa
Hydralazine
Labetalol
Nifedipine
Diabetes
Pregnancy places demands on
carbohydrate metabolism
Insulin requirements increase in 2nd
and 3rd trimester
Insulin-dependent diabetes
Diabetes in pregnancy
Assessment
Risk factors
Classic symptoms
Frequent UTIs and yeast infections
Screening at 24-28 weeks gestation
Nursing Interventions
Prenatal visits bimonthly for 6 months
than weekly
Maintain blood glucose between 65-130
mg/dL
Monitor for hypoglycemia / hyperglycemia
Glucose control
Monitor for infection, PIH, ketoacidosis
Reinforce diet instructions
Gestational Diabetes
Occurs during 2nd and 3rd trimesters
No prior diagnosis
Screened during 26th week
Glucose = 105 mg/dL
Diet
Medications
“Normal” after delivery
Cardiac Disease
Rheumatic fever
Congenital heart disease
Classification of Functional Capacity
Classification Functional Capacity
I
II
Uncompromised: No limitation on physical activity
due to angina or symptoms of cardiac
insufficiency
Slightly Compromised: Normal activity causes
fatigue, palpitation, dyspnea, or angina
III
Markedly Compromised: May be comfortable at
rest, but less than usual activity causes fatigue,
dyspnea, palpitations, or angina
IV
Severely Compromised: Cannot perform any
activity without increasing discomfort; may
experience angina and cardiac insufficiency while
at rest
Assessment
Dyspnea and fatigue
Cough
Peripheral edema
Anginal-type pain
Palpitations and tachycardia
Signs of pulmonary edema
Signs of respiratory infection
Nursing Interventions
Monitor VS, FHR, condition of fetus
Activity and rest
Encourage adequate nutrition
Maintain bed rest as ordered
Monitor for signs of respiratory infection
Encourage adequate nutrition
Administer cardiac medications
Anemia
Decrease in RBCs
Types
Iron deficiency
Folic acid
Hemoglobinopathies
Sickle cell disease
Thalassemia
Assessment
Fatigue
Headache
Pallor
Tachycardia
Diagnostic test: H & H
Treatment: Iron and folic acid
Nursing Interventions
Monitor H & H every 2 weeks
Iron and folic acid supplements
Take iron with vitamin C
Foods high in iron, folic acid and protein
Monitor for infection
May use parenteral iron / transfusions
Infection in Pregnancy
Immunological system suppressed
Genitourinary adaptations to pregnancy
Risk factors increase severity
Fever
Pneumonia
Direct infection of fetus
Systemic infection
TORCH Infections
T
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H
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Toxoplasmosis
Other infections
Rubella
Cytomegalovirus
Herpes
Group B Streptococcus
Bacterial infection found in the lower
GI and urogenital tracts
Screening cultures at 35-37 weeks
Leading infectious cause of neonatal
sepsis and mortality
Carriers often asymptomatic
Intrapartum prophylaxis
Sexually Transmitted Diseases
Syphilis
Gonorrhea
Chlamydia
Trichomoniasis
HPV
HIV
Vaginal Infections
Candidiasis
Bacterial vaginosis
Urinary Tract Infections
Cause preterm labor
Untreated may cause
pyelonephritis
Rh Incompatibility and
Sensitization
Determine maternal blood type and
Rh factor
Antibody screen (indirect Coombs’
test)
RhoGAM administration
Serial ultrasounds
Amniotic fluid analysis
Erythroblastosis fetalis
Nursing Interventions
Client education
RhoGAM protocol
Kleihauer-Betke test
Ultrasound
EFM, BPP
Intrauterine exchange transfusion
Rh + father; Rh - mother
Pregnancy: Rh + fetus
Sensitization
Sensitization
Subsequent Rh + Pregnancies
Multifetal Pregnancy
Monozygotic or dizygotic
Assisted reproductive techniques
Diagnosis
Interventions
Complications
Nursing Interventions
Monitor vital signs
Monitor FHR, fetal activity, fetal growth
Monitor cervical changes
Ultrasound
Monitor for anemia
Monitor and treat preterm labor
Prepare for possible cesarean section
Substance Abuse
Tobacco
Alcohol
Marijuana
Cocaine
Heroin
Preterm Labor
Occurs after the 20th week and
before the 37th week of gestation
Contractions every 10 minutes lasting
30 seconds or longer
Documented cervical change
Effacement of 80%
Dilation of 2 cm
Risk Factors
Previous history of preterm labor or birth
Demographic factors
Lifestyle factors
Health problems
Uterine factors
Assessment
Increased or bloody discharge
Leaking amniotic fluid
Backache
Pressure and cramping
Palpable uterine contractions
Diarrhea
Nursing Interventions
Maintain bedrest
Tocolytic agents
Betamethasone
Magnesium sulfate
Monitor fetal status
Trauma
MVAs
Homicide
Abuse
Domestic violence
Adolescent Pregnancy
Developmental tasks
Adolescence
Pregnancy
Special needs
Physical
Support
Role changes
Medications
Review drugs discussed
Dosage
Route
Nursing implications