The Pregnant Woman with Complications Chapter 26 The Pregnant Woman with Complications Khulod Barqawi

Hemorrhagic conditions of early pregnancy 1- during early pregnancy (less than 20 weeks of pregnancy), most common causes are: Abortion Ectopic pregnancy Hydatidiform mole. 2- during late pregnancy (more than 20 weeks of pregnancy), most common causes are: Placeta previa Abruptio placenta Khulod Barqawi

Spontaneous abortion: Abortion is defined loss of pregnancy before the fetus is viable i.e. less than 20 weeks gestation or one weighing less than 500g. Abortion can be either: Spontaneous: denotes termination of a pregnancy without action taken by the woman or any other person. Induced * Miscarriage: spontaneous abortion less than 16G Khulod Barqawi

Common causes of spontaneous abortion: - Chromosomal abnormalities, - Severe congenital abnormalities, - Chromosomal abnormalities, - Maternal infections (syphilis, rubella,…) Intraabdominal infections, Maternal endocrine disorders, Abnormalities of the reproductive organ, Immunologic factors, Anatomic defects of the uterus or cervix Khulod Barqawi

Spontaneous abortion is divided into six subgroups: Threatened abortion Inevitable abortion Incomplete abortion Complete abortion Missed abortion Recurrent spontaneous abortion Khulod Barqawi

Threatened abortion: Manifestations: Vaginal bleeding, Uterine cramping mild) Persistent backache, Feeling of pelvic pressure, Closed cervix, Rising levels of beta- human chorionic gonadotropin (β-hCG) Increase in uterine size. Khulod Barqawi

Therapeutic management: LMP onset, duration, amount of bleeding Accompanying discomforts Fever or uterine tenderness suggest infection Ultrasound examination, HCG level Reduce activity Instruct the woman to count the perineal pads to note the quantity and color of blood Avoid sexual activity until bleeding ceased Khulod Barqawi

Inevitable abortion Manifestations: Cannot be stopped The membranes rupture and the cervix dilates, Active bleeding. Therapeutic management: - Natural expulsion of the uterine content is common, if not occurred Dilatation and curettage is done Khulod Barqawi

Two Types of Spontaneous Abortion Fig. 26-1a Khulod Barqawi

Active uterine bleeding, Severe abdominal cramping, *Incomplete abortion: It occurs when some but not all of the products of conception are expelled from the uterus. *Manifestations: Active uterine bleeding, Severe abdominal cramping, The cervix is open and the fetal and placental tissue is passed, The products may remain in the vagina but expelled from uterus *Therapeutic management: -Insure cardiovascular stabilization, Iv line for blood, fluid replacement and drugs, D&C if pregnancy less than 14GW IF pregnancy > 14 GW Oxytocin or Prostaglandin used to induce labor(expulsion of content) Khulod Barqawi

Incomplete Spontaneous Abortion Fig. 26-1c Khulod Barqawi

*Complete abortion: all products are expelled from the uterus. *Manifestations: Uterine contractions and bleeding abate and the cervix closes after all products are passed. *Therapeutic management: .No additional intervention is needed until excessive bleeding or infection develops. . Woman advised to rest .Should abstain from intercourse until a follow up visit Khulod Barqawi

*Missed abortion: occurs when the fetus dies during the first half of pregnancy but is retained in the uterus. *Manifestations: Early signs and symptoms of pregnancy ends spontaneously after fetal death, decrease in uterine size *Therapeutic management D&C if pregnancy in first trimester Prostaglandin compounds to induce contractions during the second trimester. Complications: 1.infection 2. Disseminated intravascular coagulopathy(DIC) Khulod Barqawi

Recurrent Spontaneous Abortion (habitual abortion): three or more consecutive spontaneous abortions. Causes: Genetic or chromosomal abnormalities Anomalies of the woman’s reproductive tract, Systemic diseases e.g. DM and SLE Reproductive infections and some sexually transmitted diseases Immunologic Factors Khulod Barqawi

Therapeutic management: - Examine the woman’s reproductive organs, Genetic screening, Cervical suture (cerclage) If the woman have cervical incompetence Prophylactic antibiotic. Treatment according to cause Khulod Barqawi

Nursing considerations - Prevention, or identification and treatment of hypovolemic shock are the nursing priorities. - Observe for tachycardia, falling blood pressure, pale skin and mucus membranes, confusion, restlessness, and cool and clammy skin. Fluid and blood replacement as ordered, Family support Iron supplement, Anti-D for RH negative Khulod Barqawi

Nursing Diagnosis for a client experiencing spontaneous abortion Anxiety/fear Fluid volume deficit Acute pain Situational low self esteem related to inability to successfully carry a pregnancy to term gestation Khulod Barqawi

Hemorrhagic conditions of late pregnancy: Placenta previa: it is the implantation of the placenta in the lower uterus, near the fetal presenting part. Classifications of placenta previa: Marginal Partial Total Khulod Barqawi

Three Classifications of Placenta Previa Fig. 26-4 Khulod Barqawi

Total, the placenta is completely covers the internal cervical os. Marginal (low lying) the placenta is planted in the lower uterus but its lower border is more than 3 cm from the internal cervical os. Partial, the lower border of the placenta is within 3 cm of the internal cervical os but does not completely cover the os. Total, the placenta is completely covers the internal cervical os. Khulod Barqawi

Incidence and etiology: More common in older women Multiparas Woman who had cesarean birth Woman who had suction curettage for induced or spontaneous abortion Woman who had previous placenta previa Ethnicity( Asian or African Ethnicity) Smoking and cocaine use It is more likely to occur if the fetus is male Khulod Barqawi

Manifestations: Sudden onset of painless uterine bleeding in the latter half of pregnancy The main cause of the bleeding is the torn of the placental villi from the uterine wall, resulting in hemorrhage from uterine vessels. Khulod Barqawi

May be scanty or profuse. May cease spontaneously and recur later the bleeding is: Painless bleeding because it does not occur in a closed cavity and so not causing a pressure in adjacent tissues. May be scanty or profuse. May cease spontaneously and recur later Caution: Manual examinations and administration of oxytocin to stimulate labor should be avoided. Manual vaginal examination or contraction stimulation can interrupt connections between maternal and placental vessels if the placenta is attached low in the uterus. Khulod Barqawi

Therapeutic managements: Mainly based on the condition of the mother and the fetus. We evaluate the mother and fetus by: Amount of bleeding External electronic fetal monitoring Fetal gestational age Khulod Barqawi

Management Conservative management : if the mother's cardiovascular system is stable and the fetus is immature and has a reassuring FHR monitoring and US. Delaying birth is necessary in this case to increase birth weight and allowing administration of corticosteroid to speed maturation of fetal lung. Khulod Barqawi

Options of management Home care: we have to make sure that The woman is clinically stable ,no evidence of active bleeding The woman can remain in bed rest Home is within a reasonable distance from the hospital Emergency transportation is available 24 hrs Teaching (mother, family) to assess bleeding, kick count, uterine activity, omit sexual intercourse. Instruct family to report : decreased fetal movement, uterine contractions or increased vaginal bleeding Khulod Barqawi

Nursing assessment for: Bleeding Signs of preterm labor 2. Inpatient care: needed if the woman not met the criteria for home care Nursing assessment for: Bleeding Signs of preterm labor Rupture of membrane Fetal condition (NST) If the fetus is 36 weeks and the lungs are mature, C/S birth is scheduled. Immediate delivery of an immature fetus may be necessary if bleeding is excessive and does not stop, or there are signs of fetal compromise. Khulod Barqawi

Nursing Diagnosis for a client experiencing placenta previa Decreased cardiac out put Fluid volume deficit Altered peripheral tissue perfusion Risk for fetal injury Risk for injury (mother) Anxiety/fear Altered family process Risk for infection Khulod Barqawi

Abruptio placenta Definition: separation of normally implanted placenta before the fetus is born. Occurs when there is a bleeding and formation of hematoma in the maternal side of placenta Khulod Barqawi

The major dangers are: For the woman: Bleeding Hypovolemic shock Clotting abnormalities e.g DIC (Dissemintal Intravascular Coagulation). 2. For the fetus: dangers are related to Anoxia Blood loss Preterm birth Khulod Barqawi

1. Maternal hypertension Maternal cigarette smoking Etiology: 1. Maternal hypertension Maternal cigarette smoking Multigravida status Short umbilical cord Abdominal trauma History of previous premature separation of the placenta Maternal use of cocaine 8. Auto immune antibodies( result in coagulopatheies) Khulod Barqawi

Manifestations: Classic sign Vaginal bleeding. Abdominal and low back pain (aching or dull). Uterine irritability with frequent low intensity contractions. High uterine resting tone identified by use of an intrauterine pressure catheter. Uterine tenderness that may be localizes to the site of the abruption Khulod Barqawi

Additional signs Back pain Nonreassuring FHR patterns Signs of hypovolemic shock Fetal death Port wine color of aminiotic fluid Khulod Barqawi

Concealed: occur behind the placenta while the margins remain intact. Bleeding might be: Concealed: occur behind the placenta while the margins remain intact. Apparent: blood flow out of vagina In both types the abruptions might be complete or partial. Khulod Barqawi

May be sudden and severe when there is bleeding into myometrium Abdominal pain May be sudden and severe when there is bleeding into myometrium Or intermittent and difficult to distinguish from labor contractions The abdomen may become exceedingly firm(board like) and tender Khulod Barqawi

Khulod Barqawi

Signs and Symptoms Suggesting Concealed Hemorrhage in Abruptio Placentae Increase in fundal height Hard, board-like abdomen High uterine baseline tone on electronic monitoring strip Persistent abdominal pain Systemic signs of early hemorrhage Persistent late deceleration of decreasing baseline variability in fetal heart rate Vaginal bleeding that may be slight or absent Khulod Barqawi

Therapeutic management Hospitalization Evaluation of mother and fetal condition Conservative management if fetus is immature and abruption is mild: 1. Tocolytic medication to decrease uterine activity 2. Bed rest 3. If the mother RH is negative , Ant D immune globulin is given to prevent sensitization Immediate delivery: if fetus is compromised or signs of excessive hemorrhage Khulod Barqawi

Nursing care: for late hemorrhage Assessment: Amount and nature of bleeding (time of onset, description of tissue or clots) Pain (type, location, onset, ..) Maternal vital signs (increase or decrease blood pressure, tachycardia) Fetal condition (monitor FHR) Uterine contractions, check ROM. Obstetric history (G T P A L). Length of gestation (LMP, Fundal Height,…) Lab tests (CBC, blood group, Rh factor,…) Emotional state of parents. Khulod Barqawi

Interventions: Monitor for signs of hypovolimic shock a. fetal tachycardia b. maternal tachycardia c. normal or slightly decreased blood pressure d. increased respiratory rate e. cool, pale skin and mucus membranes. Khulod Barqawi

Signs and Symptoms of Impending Hypovolemic Shock Due to Blood Loss Increased pulse rate, falling blood pressure, increased respiratory rate Weak, diminished, or “thready” peripheral pulses Cool, moist skin, pallor, or cyanosis (late sign) Decreased urinary output (<30 ml/hr) Decreased hemoglobin, hematocrit levels Change in mental status Khulod Barqawi

Interventions: cont. 2- Monitor the fetus: 3- promoting tissue oxygenation: Place the woman on lateral position with flat head of the bed. Restrict maternal movements to decrease the tissue demand for O2. Provide simple explanations, reassurance and emotional support. 4- fluid replacement with collaborating with the physician. 5- provide emotional support. 6- care related to surgery: (box 20-2 page 460 nursing care for C/S) Khulod Barqawi

Nursing Diagnosis for a client with Abruptio Placenta Pain related to bleeding between uterine wall and placenta secondary to premature separation of placenta Fluid volume deficit Risk for fetal injury Risk for injury (mother) Grieving related to actual or threatened loss of infant Powerlessness related to maternal condition Khulod Barqawi