Transcript Complications of Pregnancy

Complications of
Pregnancy
Pre-Eclampsia/Eclampsia
Diabetes in Pregnancy
Perinatal Infections
Abortion & Others
ACOG (American Academy of Obstetricians
and Gynecologists) created a task force of
experts in the management of hypertension
in pregnancy
 Reviewed
available data
 Published evidence based recommendations
http://www.acog.org/Resources-And-Publications/Task-Force-andWork-Group-Reports/Hypertension-in-Pregnancy
4 Categories Used By The Task
Force
 Chronic
Hypertension (of any
cause)
 Chronic Hypertension with
superimposed preeclampsia
 Gestational Hypertension
 Preeclampsia/Eclampsia
Chronic Hypertension
High blood pressure known to predate
conception or detected BEFORE 20
weeks gestation
Chronic Hypertension with
Superimposed Preeclampsia


(Maternal prognosis is worse than either condition alone)
HTN with proteinuria that develops after the 20th week OR
HTN and proteinuria before the 20th week WITH (At least
one):
 Sudden increase in BP
 Sudden manifestation of other s/s ( i.e. increase in liver
enzymes to abnormal levels)
 Platelets below 100,000/microliter
 Additional symptoms like RUQ pain & Severe headache
 Pulmonary congestion or edema
 Renal insufficiency
 Sudden and sustained increase in protein excretion
Gestational Hypertension
 Transient—
BP that occurs without proteinuria
late in pregnancy or in the early pp period, but
returns to normal by 12 weeks pp.
 Chronic—
BP that occurs without proteinuria
late in pregnancy or in the early pp period, but
remains  after 12 wks pp.
Pre-eclampsia/Eclampsia
(Pregnancy-specific, multi-system syndrome)
Hypertension that develops after the 20th week gestation
AND
 Proteinuria
OR
 Thrombocytopenia
 Renal insufficiency
 Impaired liver function
 Pulmonary edema
 Cerebral or visual symptoms

Blood Pressure

> or = 140 systolic OR > or = to 90 diastolic on two
occasions AT LEAST 4 hours apart in a woman with
previously normal BP
>
or = 160 systolic OR > or = 110 diastolic can be
confirmed within a short interval to facilitate timely
treatment.
 Increase
occurs AFTER the 20th week gestation
Proteinuria

> or = 300 mg per 24 hour urine collection (GOLD
STANDARD)
OR
 Protein/creatinine
 Dipstick
ratio > or = to 0.3 mg/dL
reading of 1+ (used only if other quantitative
methods are not available)
Trombocytopenia
 Platelet count less than 100,000/microliter
Renal Insufficiency
 Protein/creatinine ratio > or = to 0.3 mg/dL
Impaired liver function
 Elevated blood concentrations > 1.1 mg/dL or a doubling of
the serum creatinine concentration in the absence of other
renal disease
Pulmonary Edema
Cerebral or Visual Symptoms
Eclampsia
The Presence of new-onset grand mal
seizure in a woman with preeclampsia
Cannot
cause
be attributed to any other
Predisposing Factors to
Preeclampsia
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Primiparity
Previous preeclamptic pregnancy
Chronic hypertension or chronic renal disease
History of thrombophilia
Multigestational pregnancies
In vitro fertilization
Family Hx of preeclampsia
Type I DM or Type II DM
Obesity
Systemic lupus erythematosus
Maternal age <19 or >40
Changes in Normal Pregnancy
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 Cardiac output by 50%
 Blood volume by 1500ml
 Peripheral vascular resistance
 BP
 Renin
 GFR
 ECF
Aldosterone effects blocked
Changes in Preeclampsia (pg382; 10
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th
ed)
Generalized Vasospasm 
 Hypertension

Intravascular volume   placental perfusion
 IUGR of fetus, fetal distress
  renal perfusion   GFR  urine output
(oliguria)
  BUN & Creatinine & uric acid
  proteinuria   serum albumin
  Extravascular fluid (edema)  Pulmonary,
retinal, & cerebral edema 
 Dyspnea, scotomata, CNS irritability/
hyperreflexia, HA, N& V, convulsions
  Hepatic perfusion   Liver function tests,
epigastric pain (RUQ)
Preeclampsia without severe
features

Signs & Symptoms
 BP
> 140/90
 Proteinuria (Mild)
Treatment of Preeclampsia w/o
Severe Features
 Daily
kick counts
 Ultrasound for fetal growth q 3 weeks
 Amniotic fluid assessment at least 1/week
 NST twice a week (non-reactive = BPP)
 Monitor daily wt for gain
 Monitor BP daily
 Lab tests: CBC, liver enzyme & serum
creatinine level at least once a week.
 Regular diet w/ no salt restrictions
 Instructed to go to hospital w/worsening sx
Hospital care of mild preeclampsia
left lateral recumbent position to  renal
perfusion which promotes diuresis and lowers BP
 Bedrest,
balanced, nutritious, moderate  protein
to replenish what is spilled by kidneys
 Diet—well
Hospital care of mild preeclampsia (Cont’d)
 Assessment
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of fetal well-being
DFMC, BPP, NST, Amniocentesis
 Assessment
of maternal well-being
BP assessed qid or q4hr
 Daily wt, and assessment of worsening edema
 Assessment of HA, visual changes, epigastric
pain, hyperreflexia
 Lab tests: daily urine dipstick for protein, 24 hr
protein, CBC w/ platelet count q 2 days, serum
creatinine, uric acic, & liver function tests (AST,
ALT, LDH, Bili)
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Severe Preeclampsia
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Signs and symptoms
 BP
of 160/110 or higher on 2 occasions at least 4 hr
apart while on bedrest
 Proteinuria  5g/L in 24 hr or 3+ or > on 2 random
urine samples 4 hrs apart
 Oliguria: urine output <500ml/24hr
 Cerebral or visual disturbances—HA, scotomata or
blurred vision
 Pulmonary edema or cyanosis
 Epigastric or RUQ pain
 Impaired liver function ( AST, APT)
 Thrombocytopenia
Treatment of Severe
Preeclampsia
Absolute
bedrest
Quiet environment to reduce
stimuli
Delivery > 34 weeks gestation
Management of Severe Preeclampsia <34
weeks
Medications used in treatment
Seizure Prophylaxis
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Magnesium Sulfate: a 4-6 gm bolus is given
IV over 20 minutes, then a continuous
infusion of 2gm/hr is generally advocated.
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CNS depressant
 Needs to be maintained at a therapeutic level as
determined by each laboratory
 Excessive levels lead to respiratory paralysis and
cardiac arrest
 Calcium gluconate given to reverse
Case Study
A 35 year old G1P0 patient is admitted to L&D with severe
preeclampsia. Her most recent blood pressure readings have
been 172/108 & 176/112. She complains of seeing spots and a
severe headache. You have received orders for a 4gm IV bolus
of Magnesium over 20 minutes followed by a 2gm/hr
maintenance dose.
 If 40 grams are added to 1000mls of LR, at what rate would
you set the IV pump to administer 4gm in 20 minutes?
 What amount would you put in the VTBI on the pump?
 If you are to continue to infuse at 2gm/hr, at what rate would
you set the pump?
 What side effects can you educate your patient on?
 What are the nursing implications?
 What should you have available in case of Mag Sulfate
toxicity?
See p. 572 Davidson 10th ed. for more info
Medications used in treatment
Anti-hypertensives
Given for sustained BP’s >160/110
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First Line for Acute Hypertension
 Labetalol: 20 mg IV over 2 min, can give
q10 min if needed (max 300mg) – avoid
with asthma or CHF
 Hydralazine: 5mg IV over 1-2 min, can give
q20 min if needed (max 30mg)
Expectant management
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Oral Labetalol, Nifedipine, or Methyldopa
NO diuretics or ACE inhibitors
Eclampsia—
occurs in 1 in 1600 pregnancies
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Symptoms of impending seizure:
 Persistent
occipital or frontal headaches
 Blurred vision
 Photophobia
 Epigastric or right upper quadrant pain
 Altered mental status
 Hyperreflexia— 4+
 Scotomata—dark spots or flashing lights
 Vomiting
 Neurologic hyperactivity
 Pulmonary edema
 Cyanosis
Safety precautions
 Quiet
environment—no phone calls, TV,
lights, pulled shades, etc.
 Padded side rails in bed
 O2 ready and available
 Suction ready and available
Refer to Nursing Care Plan
pp. 389-391 Davidson et al, 10th ed.
Note importance of careful monitoring of
mother and fetus throughout
hospitalization with severe pre-eclampsia
 Prevention of complications is key to
healthy management
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HELLP Syndrome
Hemolysis
 Elevated Liver Enzymes
 Low Platelets (< 100,000/mm3)
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 Sometimes
associated with severe preeclampsia
 Sx: N & V, malaise, flu-like sx, or epigastric pain with
or without HTN
 Persons presenting with these sx should have CBC
with platelets and liver enzymes drawn
 These pts should be managed at tertiary care centers
 Corticosteroids: while usually given to foster fetal
maturity, they have been found to stabilize platelet
counts and hepatic enzymes and LDH levels.
Dexamethasone is often chosen for HELLP syndrome.
Diabetes In Pregnancy
Did it exist BEFORE Pregnancy?

Pregestational
Diabetes Mellitus
 Type
1
 Type 2
 1/2000 pregnancies

Gestational Diabetes
 Any
degree of glucose
intolerance with the onset or
first recognition occurring
during pregnancy
 2-5% of all pregnancies
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90% of all cases of diabetes in
pregnancy
25% of these women will
develop Type 2 diabetes later in
life
Normal CHO Metabolism in PG
Goal of changes is to provide adequate
glucose to fetus for growth
 Maternal glucose crosses the placenta
 Maternal insulin does NOT
 KEY CONCEPT TO UNDERSTAND

CHO Metabolism—1st Trimester
 in E & P stimulate Beta cells of
Pancreas to  Insulin production
 =  use of glucose  in serum glucose
levels (FBS
)
  in tissue glycogen stores

in liver glycogen production
 = Pregestational Diabetics  Hypoglycemia
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CHO Metabolism-2nd & 3rd Trimester
Pregnancy is a “diabetogenic” state
 Hormones levels lead to
tolerance to
glucose
  insulin resistance
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 HPL-Human

Insulin antagonist—Won’t let insulin work
 Placental
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Placental Lactogen
Insulinases
Breakdown insulin at placental site
Net Result = Changes in Insulin
Needs for Mother during Pregnancy

need for insulin
 insulin production, N&V,
 transfer to fetus
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1st trimester =


food intake,
2nd Trimester = Gradual 
 3rd Trimester = 2-4 times higher need for
insulin by 36 week, then levels off til labor
 After delivery =
;
glucose/insulin balance OK by 7-10 days
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
Risks to Mother

Pregestational Diab.
 If
poor control very early
in PG Miscarriage
 Macrosomic babyC/S
 Pre-eclampsia
 PTL
 Infections (UTI’s, Vag)
 Polyhydramnios
 Ketoacidosis /
Hypogylecemia
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Gestational-Onset
 2X
likely to have preeclampsia
 Macrosomic baby  C/S
Risks to Baby

Pregestational
 Congenital

Defects
Heart, Skeletal, CNS
 Same
as Gestational

Gestational
 MacrosomiaBirth
Trauma
 Hypoglycemia
 RDS
 Hypocalcemia
 Hyperbilirubinemia
 Thrombocytopenia
 Polycythemia
Management of
Pre-gestational Diabetes

Pre-conceptual Counseling
 Establish
glycemic control BEFORE PG
 Understand the VERY close monitoring
Blood glucose levels 4-8 times a day.
 Frequent MD visits
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 If
Type 2—Some oral hypoglycemic agents
are teratogenic Insulin SQ during
pregnancy
Management of
Pre-gestational Diabetes

Hgn A1c
 Good
control = 2.5% to 5.9 %
 Fair Control = 6% - 8%
 Poor Control = > 8%
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Diet VERY CAREFULLY BALANCED
 Should

be followed by Registered Dietician
Exercise
 Not
vigorous, Best time is after meals
Management of
Pre-gestational Diabetes-Insulin

Multiple daily injections needed
 Mixed
of longer-acting and rapid-acting in AM
and PM
Humulin or Novolin, NOT pork or beef
insulins
 Humalog, if newly diagnosed
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Management of
Pre-gestational Diabetes-Insulin

GOAL—keep blood sugar in narrow margin
 Fasting
= 60-90 mg/dl
 2-hour postprandial = 90-120 mg/dl
Management of
Pre-gestational Diabetes-Delivery
Careful determination of ACTUAL due date
 Amniocentesis Fetal lung maturity
 Induce 39-40 wks-NO LATER THAN 40 WKS
 If estimated fetal weight > 4000-4500 Gms 
C/S
 In L&D- Watch maternal glucose levels every
2 hours
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Gestational Diabetes-Screening

Low-risk
<
25 y/o
 No family Hx
 Normal BMI
 Not in High-Risk group
 No Hx of Abnormal GTT
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Hi-Risk
 Hx
of gestational Diabetes
 Overweight/Obese BMI
 High-risk group
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African-American
Native-American
Latina
Pacific-Islander
Gestational Diabetes-Screening

First pre-natal visit
 50
gm glucose load -> draw serum 1 hour later
Negative < 140 mg/dl
 Positive > 140 mg/dl
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Screen again 24-28 weeks gestation
Gestational Diabetes-Screening
If positive do 3-hour GTT (100g of glucose)
 Positive for GDM = 2 or more levels are met
or exceeded

 Fasting
 1-hr
 2-hr
 3-hr
< 95 mg/dl
< 180 mg/dl
< 155 mg/dl
< 140 mg/dl
Gestational Diabetes Management
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GOAL Keep blood sugars within levels for Pregestational diabetes
Diet—Main course of treatment;
3 meals and 3 snacks
Exercise
Insulin—20% will need insulin during PG; safest
Glyburide (oral hypoglycemic agent) is being used
with caution but not yet approved by ACOG
Blood glucose monitoring
 Frequently
done in MD office or at home
Gestational Diabetes Management

Delivery
 Frequent
NST/BPP in last 2 months of
pregnancy
 Deliver by 40 weeks
Excellent resource link from the
National Diabetes Education Program with
handouts in various languages and lots of
resources.
 Another great resource with tables from
Merck Manual

Perinatal Infections

Group-B Hemolytic Streptococcus
 Major
cause of perinatal infections
 Found in Vagina and Urine
 Increase fetal mortality and morbidity
 Screen 35-37 wks (CDC Recommendations)

If Positive –Treat in Labor
Penicillin: 5 million Units IV x 1; 2.5-3 million units every 4
hours
 Ampicillin: 2 GMs IV x1; 1 GM every 4 hours
 Clindamycin 900mg IV q 8 hr OR Erythromycin 500mg IV
q 6hr till delivery if allergic to Penicillin.

Perinatal Infections

If GBS status unknown—Prophylactic trx
is indicated if:
 Previous
infant with GBS
 GBS bacturia during this pregnancy
 PTL
 Temp in labor > 100.4 F
 Membranes ruptured > 18 hours
Other Perinatal infections
Syphyllis
 Gonorrhea
 Chlamydia
 TORCH p.394-400; 10th ed.

 Toxoplasmosis
 Rubella
 Cytomegalovirus
 Herpes,
Human B19 Parvovirus
Hemorrhagic Complications
Abortion = loss of pregnancy BEFORE 20
weeks gestation
 spontaneous (miscarriage) or induced
 10% of all pregnancies end in a
miscarriage
 Most in 1st Trimester

Hemorrhagic Complications

Types of Abortions (know the differences)
 Threatened
 Imminent
 Incomplete
 Missed
 Habitual
Other Hemorrhagic Complications

Ectopic Pregnancy
 Egg

implants outside of
uterus
 Lots of pain and internal
bleeding –manifested by
sx of shock—lifethreatening
 Surgical intervention
needed
 Link with photos
Hydatidiform Mole
 No
fetus, Fluid filled
vesicles
 N&V, No FHT’s,
2nd trimester bleeding—
Prune-juice
 D&C
 Not get pregnant for 1 year
 Choriocarcinoma,
if HCG elevated
Gestational Trophoblastic Dz
Other Pregnancy Complications

Incompetent Cervix
premature delivery
 Cerclage— McDonald’s or Shirodkar procedure
10-14 weeks gestation
 NO Intercourse, Prolonged standing, heavy lifting
 On bedrest as much as possible
 Teach signs of Preterm Labor
 Take tocolytics as ordered
 Home uterine monitoring

suture at 37 weeks  vaginal
 Leave suture in  C/Sec
 Remove
Shirodkar Procedure for Incompetent Cervix
Other Complication of Pregnancy
Hyperemesis Gravidarum
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Intractable Vomiting in Pregnancy
5% loss of body weight, dehydration, ketosis, metabolic
alkalosis,
Rule out Gestational Trophoblastic Dz by ultrasound
Medical Management/Nursing Care
 If doesn’t respond to small, frequent meals, then
needs hospitalization: NPO, IV fluids with KCl to
prevent hypokalemia, B-vitamin replacement (B1 and
B6 especially)
 If still unable to eat, may need TPN temporarily
There you have it!
Refer to other supplement for more detail
on these complications