Transcript Chapter 14

Chapter 13
Health Problems Complicating
Pregnancy
1
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Elsevier Inc.
Complications
of Pregnancy
2
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Elsevier Inc.
3
Objectives
– Define key terms listed.
– Discuss three causes of spontaneous abortion.
– Describe ectopic pregnancy.
– Describe placenta previa and state the characteristic
symptom.
– Explain five nursing measures for the care of a woman who
is hemorrhaging.
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4
Objectives (cont.)
– Compare two types of abruptio placentae.
– Review the cause of coagulation defects in pregnancy.
– List five causes of high-risk pregnancies and three leading
causes of maternal death.
– Recognize four factors that increase the risk for gestational
hypertension.
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5
Effects of a High-Risk
Pregnancy
on the Family
– Disruption of usual roles
– May require strict bed rest
– May have to find alternate child care
– Financial difficulties
– Delayed attachment to infant
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6
Bleeding Disorders
– Abnormal in pregnancy and should be investigated
– Maternal blood loss decreases oxygen-carrying capacity to
fetus
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Causes of Bleeding
in Early Pregnancy
– Spontaneous abortion
– Cervical polyps
– Uterine fibroids
– Ectopic pregnancy
– Hydatidiform mole
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Abortion
– Intentional or unintentional ending of a pregnancy before
20 weeks gestation
– Miscarriage is a lay term for spontaneous abortion
– Artificial or mechanical means for therapeutic or elective
reasons can also be performed
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Classification and Management
of Abortions
– Causes of spontaneous abortion
– Genetic defects
– Defective ovum or sperm
– Defective implantation
– Uterine fibroids
– Maternal factors
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Maternal Factors
– Chronic conditions
– Acute infections
– Nutritional deficiencies
– Abnormalities of maternal reproductive organs
– Endocrine deficiencies
– Blood group dyscrasias (ABO incompatibility)
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Nursing Interventions
– Monitor vital signs
– Observe for signs of shock
– Weigh perineal pads
– Prepare for IV therapy
– Assess fetal heart rate
– Provide supplemental oxygen
– Obtain history and laboratory results
– Provide emotional support for woman and partner
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Incompetent Cervix
– Cervix dilates without perceivable contractions
– Internal os dilates
– Incapable of supporting increasing weight and pressure of
growing fetus
– Cervix may need to be reinforced through a cerclage
procedure
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Ectopic Pregnancy
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– Abnormal implantation of
fertilized ovum outside
uterine cavity
– Most common site is fallopian
tube
– Tubal rupture can cause
hemorrhage
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Assessment of Tubal
Pregnancy
– Transvaginal ultrasound
– Serum hormone levels
– Progesterone
– β-hCG (beta-human chorionic gonadotropin)
– Shoulder pain
– Signs of shock out of proportion with visible blood loss
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Management of Tubal
Pregnancy
– Preserve fallopian for chance of future pregnancies
– Depends on status of tube: ruptured or unruptured
– Methotrexate
– Interferes with cell reproduction
– Surgical interventions
– salpingectomy
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Gestational Trophoblastic
Disease
– Hydatidiform mole
– Trophoblastic tissue proliferates
– Chorionic villi of placenta swell with fluid; can look like grapes
– Invasive mole
– Choriocarcinoma
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Gestational Trophoblastic
Disease (cont.)
– Two types
– Complete
– Chromosome banding and enzyme analysis show all genetic material
is paternally derived
– No inner cell mass develops
– No fetal vascularization
– Partial
– Genetic material maintained
– Fetus abnormal, usually aborts
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Assessment of Molar
Pregnancy
– Uterus grows more rapidly than in a normal pregnancy
– Brown vaginal bleeding (looks like prune juice)
– Hyperemesis gravidarum
– If gestational hypertension occurs before 24 weeks
gestation, strongly suggests molar pregnancy
– Serial β-hCG levels and ultrasound
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Management of Molar
Pregnancy
– Evacuation by suction aspiration
– Follow-up is essential due to increased risk of developing
choriocarcinoma
– Serum hCG levels monitored for 1 year until serum titers
return to normal
– Should delay pregnancy until hCG has returned to normal
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Bleeding in Late Pregnancy
– May be from increased vascularization of cervix, cervical
polyps, or cervicitis
– If in second or third trimester, may be caused by
– Placenta previa
– Abruptio placentae
– Disseminated intravascular coagulation (DIC)
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Placenta Previa
– Placenta abnormally implants near or over cervical os
– Increased risk of occurrence if
– Defective vascularity of decidua
– Previous infection in upper uterine segment
– Uterine scarring
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Placenta Previa (cont.)
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Assessment and
Management
– Ultrasound can detect presence
– Suspect if onset of painless bleeding occurs after 24 weeks
gestation
– Bleeding occurs most often in third trimester as cervix
prepares for delivery
– Monitor vital signs and amount of blood loss, including
fetal heart rate
– Do not perform vaginal examination
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Home Management
– If following criteria are met, woman can be sent home
– Maintain strict bed rest and no coitus
– Must have around-the-clock transportation and communication
available
– Compliant with oral tocolytic therapy
– Hematocrit above 30%
– Can be followed closely (e.g., ultrasound, nonstress test,
biophysical profiles)
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Potential Complications
– Hemorrhage for woman
– Hypoxia or death of fetus
– Hypovolemic shock and death of mother
– Postpartum infection
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Abruptio Placentae
– Premature separation of placenta
– Partial or total detachment
– Occurs after 20 weeks gestation
– Bleeding is painful
– Risks include
– Maternal hypertension
– Prior abruption
– High parity
– Degree of compromise depends on extent of separation and
blood loss
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Types of Abruptio Placentae
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Complications
– Inability of uterus to contract
– Trapping of blood may release thromboplastin into
maternal circulation
– Can lead to DIC
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Assessment and
Management
– Dark red vaginal bleeding
– Uterine rigidity
– Severe abdominal pain
– Maternal hypovolemia
– Signs of fetal distress
– Excessive bleeding
– Coagulation profile
– Prepare for cesarean delivery if hemorrhage severe or fetal
distress evident
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Disseminated Intravascular
Coagulation (DIC)
– Blood cannot clot
– Overstimulation of normal coagulation process
– Massive, rapid fibrin formation
– Depleted platelets and clotting factors
– Does not occur as primary disorder but secondary to
another complication
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Assessment and
Management
– Monitor coagulation studies closely
– Correct underlying cause
– Terminate pregnancy
– Administer blood products
– Do not give heparin
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Blood Incompatibility
(Isoimmunization)
– Placenta can allow maternal and fetal blood to mix due to
small “leaks”
– If maternal and fetal blood compatible, no issues
– If not compatible, mother’s body produces antibodies to
destroy foreign fetal RBCs
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Rh Incompatibility
– Rh-positive blood type is dominant trait
– If father is Rh positive and mother is Rh negative, good
chance fetus will be Rh positive
– If leakage occurs, mother starts making antibodies to
destroy the Rh-positive erythrocytes, which also destroy
fetal RBCs
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ABO Incompatibility
– Woman has group O blood
– Fetus has group A, B, or AB blood
– Anti-A and anti-B antibodies
– Few cross placenta, so treatment not required during
pregnancy
– First pregnancy most often affected
– Newborn may develop jaundice within 24 hours of birth
– Provide phototherapy
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Audience Response System
Question 1
In the presence of Rh incompatibility, an amniocentesis can be done to
determine if what is present?
A.
Fetal hemolysis
B.
A congenital anomaly
C.
Alpha-fetoprotein levels
D.
Genetic disorders
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Cardiovascular
and Endocrine
Complications
44
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Elsevier Inc.
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Objectives
– Discuss three signs that a pregnant hypertensive woman
should report immediately to her physician.
– Identify the antihypertensive drug most commonly given to
women with gestational hypertension and its antidote.
– Compare the effects of the physiologic changes in
pregnancy related to thromboembolic disease.
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Objectives (cont.)
– Discuss heart disease in pregnancy.
– Explain hyperemesis gravidarum.
– Explain three ways diabetes mellitus affects pregnancy.
– Review four aspects of self-care for the diabetic woman.
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Cardiovascular
Disorders
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Elsevier Inc.
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Gestational Hypertension
– Types
– Gestational hypertension
– Preeclampsia
– Eclampsia
– Chronic hypertension
– Preeclampsia with superimposed chronic hypertension
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Classification and Risk
Factors
– Preeclampsia—renal involvement leads to proteinuria
– Eclampsia—CNS involvement leads to seizures and chronic
HTN with superimposed eclampsia
– HELLP syndrome—disease is dominated by hematologic
and hepatic clinical manifestations
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Pathophysiology of
Preeclampsia
– Thought to start with placental implantation
– May not be evident until 20 weeks gestation
– Loss of resistance to angiotensin II
– Prostacyclin (vasodilator) decreases
– Thromboxane (vasoconstrictor) increases
– Leads to increased vasospasms
– Condition reverses once placenta is delivered
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Effects on the Mother and
Fetus
– Mother
– Fetus
– DIC
– Uteroplacental perfusion
– Immunologic response may trigger
preeclampsia
– Increased risk of abruptio placentae
– HELLP
– Fetal distress from hypoxia
– Nausea, vomiting, malaise
– Preterm birth
– Intrauterine growth restriction
– Later: hematuria, jaundice,
generalized abdominal pain
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Assessment and Management
– If occurs before 34 weeks gestation, screen for presence of
antiphospholipid antibodies
– If present, increases risk of recurrent severe gestational hypertension in future
pregnancies
– Closely monitor blood pressure, proteinuria, renal and hepatic function
– If severe, may have to terminate pregnancy/deliver
– Should not go beyond 40 weeks gestation due to placental insufficiency
– Magnesium sulfate infusion
– Toxicity treated with calcium gluconate
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Clinical Manifestations of
Gestational Hypertension (GH)
– Expedient delivery if
– Maternal oliguria
– Renal failure
– HELLP syndrome
– Magnesium sulfate therapy should be stopped if
– Loss of deep tendon reflexes (DTRs)
– Respiratory rate < 12/min
– Decreased urine output of < 30 mL/hr
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Prenatal Nursing
Assessment and Management
– If mother received magnesium sulfate, can cause
respiratory depression in newborn
– Evaluate deep tendon reflexes
– A mild form of preeclampsia may rapidly progress to a
severe form, including seizures
– Management depends on symptoms, aggressiveness of
physician, and understanding and compliance of the
patient
– Calcium gluconate is used to treat magnesium sulfate
toxicity
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Education, Self-Care, Home
Management
– Important to know baseline blood pressure
– Increases in systolic by 30 mm Hg and diastolic by 15 mm Hg above baseline
places woman in high-risk category
– Careful teaching, guidance, and compliance are critical to the woman,
the developing fetus, and family
– If on home management, woman must have a means of
communication and transportation
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Hospitalization and
Management
of Preeclampsia and Eclampsia
– Quiet room
– Left side-lying
– To optimize placental blood flow
– Frequent monitoring of blood pressure
– Urine evaluated every 4 hours for protein and specific
gravity
– Accurate I&O
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Emergency Care
– Equipment to have readily
available
– Symptoms that may
precede seizures
– Oral airway
– Ambu bag
– Rise in blood pressure
– Oxygen
– Epigastric pain
– Suction equipment
– Severe headache
– Ophthalmoscope
– Apprehension
– Medications
– Pulse oximetry
– Electrocardiography
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– Twitching
– Hyperirritability of
muscles
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Chronic Hypertensive
Disease
– Blood pressure of 140/90 mm Hg or higher before
pregnancy or before 20 weeks gestation
– Goal is to prevent preeclampsia, ensure normal fetal
growth and development
– Antihypertensive may be prescribed for blood pressure
over 160/100 mm Hg
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Chronic Hypertension
with Superimposed
Preeclampsia
– First 48 hours after delivery require careful monitoring
– After 48 hours, assessments may be decreased
– Monitor uterine tones and fundus to prevent postpartum
bleeding
– Baseline blood pressure usually returns within 2 weeks
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Thromboembolic Disease
– Pregnancy increases risk of superficial thrombophlebitis, deep vein
thrombosis, and pulmonary embolism (PE)
– PE leading cause of maternal death
– Risk factors
– Venous stasis
– Normal changes in coagulability and fibrinolysis during pregnancy
– Use of oral contraceptives before pregnancy
– Sitting for extended periods
– Over 30
– Obese
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Assessment
– May complain of sudden pain with swelling in affected
extremity
– May be warmth and redness at site
– On passive dorsiflexion, pain in calf of leg (Homans’ sign)
– Diagnosed via Doppler scanning, MRI
– If develops a PE, may have dyspnea, chest pain,
hemoptysis, and tachycardia
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Heart Disease:
Effects During Pregnancy
– Pregnancy results in increased cardiac output, heart rate,
blood volume, and stroke volume
– Some drugs to help treat are contraindicated in pregnancy
– During labor, woman requires careful monitoring due to
blood shifts of 300 to 500 mL
– This leads to increased cardiac output by 15% to 20%; could
trigger congestive heart failure
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Assessment and
Management
– May complain of shortness of breath with activity, weight
gain, edema; may hear cardiac murmur
– Contraindications to planned pregnancy include pulmonary
hypertension, aortic coarctation, history of myocardial
infarction, and uncorrected tetralogy of Fallot
– Goal is to minimize stress on heart
– Symptoms of cardiac decompensation can occur slowly
during pregnancy
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Anemia
– Reduced ability of blood to carry oxygen to cells
– In pregnancy, defined by hemoglobin (Hgb) levels less than
10 g/dL and hematocrit (Hct) levels below 30%
– More susceptible to infection, increased risk of complications
during pregnancy
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Anemia (cont.)
– Iron deficiency anemia—serum iron of less than 60 mg/dL
with less than 16% transferrin saturation
– Folic acid deficiency—may result from inadequate intake,
poor absorption or drug interactions; seen in women with
vitamin B12 deficiency
– Thalassemia—genetic defect; abnormal Hgb; results in
hemolysis and anemia
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Sickle Cell Anemia
– Inherited disorder; presence of abnormal Hgb that causes
sickling of RBCs
– During labor
– Oxygen supplementation to mother
– Administration of IV fluids
– Fetal monitoring
– Maternal Hgb monitoring
– Administration of prophylactic antibiotics if operative delivery
is necessary or urinary tract infection is present
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GI Disorders:
Hyperemesis Gravidarum
– Nausea and vomiting that can lead to severe dehydration,
electrolyte imbalance, starvation, and excessive weight loss
before the 20th week of gestation
– Occurs most often with first pregnancy, multifetal
pregnancy, hydatidiform mole, and sometimes with
psychiatric disorders
– Fetus at risk for intrauterine growth restriction (IUGR)
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Assessment and Management
– Any specific “triggers” for nausea or vomiting?
– Correct fluid and electrolyte imbalance
– Parenteral nutrition may be indicated
– Record I&O, including weight
– Ketonuria suggests fat stores are being used to nourish fetus and meet
woman’s energy needs
– Low-fat frequent feedings
– Positioning and other techniques to reduce nausea and vomiting
– Drugs such as pyridoxine, meclizine
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Endocrine Disorders:
Diabetes Mellitus (DM)
– Affects carbohydrate metabolism
– Hyperglycemia; inadequate production or ineffective use of
insulin
– Pregestational DM: type 1 or 2
– Gestational DM: glucose intolerance first recognized during
pregnancy; usually resolves after delivery
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Effect of Pregnancy on
Diabetes
– Increased need for glucose creates a resistance to insulin
– Maternal insulin does not cross placenta
– By 10th week of gestation, fetus is obligated to secrete own insulin to
use glucose obtained from mother
– Hormone concentration higher in second and third trimesters, which
increases insulin resistance
– Allows more maternal glucose to be available to fetus; leads to
macrosomia
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Pregestational Diabetes
Mellitus
– Known diabetic before pregnancy
– Once pregnant, glycemic control affected
– Oral hypoglycemics cannot be taken during pregnancy
– First trimester maternal blood glucose usually reduced;
need less insulin
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Risk and Complications
– First trimester: hyperglycemia can cause fetal anomalies
– Second and third trimesters: glucose crosses placenta,
increases fetal secretion of insulin
– Can lead to macrosomia and impaired fetal lung function
– At birth, newborn at risk for hypoglycemia
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Preconceptional Counseling,
Assessment, and Management
– Woman should normalize blood glucose
– Some medications may need to be changed
– Close monitoring throughout pregnancy may be needed for
both mother and fetus
– Management depends on woman’s adherence to
treatment plan
– Diet: 30 to 35 kcal/kg/day in first trimester, 35 kcal/kg/day
in second and third trimesters
– Exercise
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Gestational Diabetes
Mellitus
– Carbohydrate intolerance of variable severity, with first
recognition during pregnancy
– May have only impaired tolerance to glucose or classic
signs of DM (polyuria, polyphagia, polydipsia)
– Risk of congenital malformation and spontaneous abortion
is less with GDM
– Diet often controls blood sugars
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Screening During Pregnancy
– Glucose challenge test
– Usually between 24 and 28 weeks gestation
– Renal threshold lower in pregnancy, causes glucose to spill into
urine
– Glycosuria is not considered diagnostic for DM but does
indicate need for further evaluation
– Glucose monitoring daily and with a blood test called
HbA1c
– Fetal surveillance: biophysical profile, alpha-fetoprotein,
kick count
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Audience Response System
Question 2
At what approximate week of development is the fetus
obligated to secrete its own insulin?
A.
20 weeks
B.
30 weeks
C.
10 weeks
D.
40 weeks
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Effects of
Toxins and
Pregnancy
Loss
77
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Elsevier Inc.
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Objectives
– Describe rubella and its consequences in pregnancy.
– Identify the changes that occur in pregnancy that predispose the
woman to urinary tract infections.
– Discuss the cause and prevention of toxoplasmosis.
– Describe three self-care measures for a pregnant woman with a
urinary tract infection.
– Describe how the use of nicotine, alcohol, and recreational drugs can
affect the fetus.
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Objectives (cont.)
– Discuss the effects of substance abuse on women’s health.
– Relate the impact of pregnancy on the woman’s response to bioterrorist
agent exposure and treatment protocols.
– Recognize the effects of drugs used to treat bioterrorist infections on the
developing fetus.
– Identify signs of fetal demise.
– Recognize stages of grieving and nursing interventions that can assist
parents in dealing with fetal loss.
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Infections
– TORCH
– Can be used to help identify congenital risks
– Urinary tract infection (UTI)
– Can have asymptomatic infection, cystitis, or pyelonephritis
– Symptoms vary
– Bacteriuria
– Group B streptococci
– Bacterial vaginosis
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Substance Abuse
– Use of illegal drugs, tobacco, and alcohol can cause serious
complications in the developing fetus
– IV and intranasal administration crosses placenta more
often than other methods
– Prenatal care may not occur until late into pregnancy, if at
all
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Accidents During Pregnancy
– Motor vehicle accidents most common cause of trauma
during pregnancy
– Blunt trauma can lead to abruptio placentae and fetal
demise
– Blunt trauma or penetrating wounds can cause shock,
preterm labor, spontaneous abortion
– ABCs (airway, breathing, circulation)
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Bioterrorism Exposure
and Pregnancy
– Metabolism and elimination of drugs altered in pregnancy
– Protecting life of mother is priority
– Vaccines may be needed regardless of pregnancy status
– Pregnancy increases susceptibility to infections
– Countermeasures include antibiotics, antivirals, antitoxins
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Loss of Expected Birth
Experience
– Allow parents to remain together in privacy
– Accept behaviors related to grieving
– Develop care plan to provide support to family
– Offer memento and opportunity to hold infant, if parents
choose
– Prepare parents for infant’s appearance
– Discuss wishes concerning religious and cultural rituals
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Pregnancy Loss:
Grief and Bereavement
– Perinatal loss after 20 weeks gestation in United States is 6.8
per 1000 total births
– 50% occur before 28 weeks
– Causes: physiologic, maladaptation, birth defects, teratogen
exposure
– Loss includes abortion, fetal or neonatal death, SIDS, and fetal
anomalies
– Denial, anger, bargaining, depression, acceptance are steps in
grieving process
– Nurse plays important role
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Audience Response System
Question 3
In preeclampsia, the most likely cause of serious end-organ
effects or alterations in function during pregnancy is:
A.
Hemorrhage
B.
Medications
C.
Vasospasms
D.
Hypervolemia
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Review Key
Points
87
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Elsevier Inc.