1. The Pregnant Woman with Complications
Chapter 26
The Pregnant Woman with Complications
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2. 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
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3. 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
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4. 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
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5. Spontaneous abortion is divided into six subgroups:
Threatened abortion
Inevitable abortion
Incomplete abortion
Complete abortion
Missed abortion
Recurrent spontaneous abortion
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6. 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.
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7. 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
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8. 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
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9. Two Types of Spontaneous Abortion
Fig. 26-1a
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10. 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)
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11. Incomplete Spontaneous Abortion
Fig. 26-1c
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12. *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
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13. *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)
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14. 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
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15. 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
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16. 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
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17. 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
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18. 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
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19. Three Classifications of Placenta Previa
Fig. 26-4
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20. 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.
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21. 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
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22. 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.
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23. 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.
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24. 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
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25. 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.
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26. 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
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27. 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.
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28. 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
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29. 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
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30. 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
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31. 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)
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32. 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
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33. Additional signs Back pain Nonreassuring FHR patterns
Signs of hypovolemic shock
Fetal death
Port wine color of aminiotic fluid
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34. 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.
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35. 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
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36. Khulod Barqawi

37. 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
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38. 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
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39. 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.
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40. 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.
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41. 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
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42. 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)
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43. 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
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