1. Chapter 21 Sudden Pregnancy Complication

2. Bleeding  Development of shock  Blood pressure  Pulse  Fetal heart rate  Treatment

5. Disseminated Intravascular Coagulation (DIC)  Disorder of blood clotting  Fibrinogen levels fall below effective limits  Symptoms  Bruising or bleeding  Causes

6. 1 st Trimester Bleeding  Spontaneous miscarriage (Abortion)  Threatened  Imminent  Complete  Missed  Recurrent pregnancy loss

7. Complications of Miscarriage  Hemorrhage  Infection  Septic abortion  Isoimmunization  Powerlessness or anxiety

8. 1 st Trimester Bleeding  Ectopic pregnancy  Implantation occurs outside of the uterine cavity  Abdominal pregnancy

10. 2 nd Trimester Bleeding  Gestational trophoblastic disease (hydatidform mole)  Abnormal proliferation and degeneration of the trophoblastic villi

13. Assessment  HCG  Ultrasound  Fundal height  NauseaManagement D&CD&C CXRCXR HCG Beta q 4 weeks for 12 monthsHCG Beta q 4 weeks for 12 months ContraceptionContraception No pregnancy 1 yearNo pregnancy 1 year

14.  Premature cervical dilatation  Cannot hold the fetus until term  Cervical cerclage

16. 3 nd Trimester Bleeding  Placenta previa  Low implantation of placenta, Partial previa, complete previa  Risk factors  Assessment: Painless vaginal bleeding  Management  Immediate care  Continuing care

18. 3 nd Trimester Bleeding  Abruptio Placentae  Premature separation of placenta  Occurs suddenly  Most frequent cause of perinatal death  Risk factors  Assessment: Painful  Management

20. Preterm Labor Labor before the end of 37 weeks gestation. Occurs in 9 to 11% of all pregnancies. Persistent uterine contractions 4 in 20 min. Actual labor is if uterine contractions that cause effacement over 80% and dilation over 1 cm. Preterm births are 2/3 of all infant deaths. Cause unknown, dehydration, UTI, chorioamnionitis (infection of fetal membranes and fluid), strenuous jobs, extreme fatigue.

21. Preterm Labor SS-persistent, dull, low backache, vaginal spotting, feeling of pelvic pressure or abdominal tightening, menstrual like cramping, increased vaginal discharge, uterine contraction, intestinal cramping. Management: Analyze changes in vaginal mucus (fetal fibronectine), short cervix, sonogram. May try to stop labor if not beyond 4 to 5 cm or 50% effacement Admit to hospital, bedrest, IV, cultures,

22. Preterm Labor UA, oral tocolytic agent-terbutaline, good nutrition and no smoking. Antibiotic for strep B prophylaxis, corticosteroid (lung surfactant) Pregnancy <34 weeks betamethasone 2 doses 12 mg IM 24 hours apart, effect lasts 7 days. Magnesium sulfate 4 to 6 g IV bolus to halt contractions (CNS depressant) p. 399. Terbutaline (Brethine)-relaxes uterine muscles, blood vessels and bronchi.

23. Preterm Labor Monitor: VS, I&O, labs, lungs for edema, daily wt., FHR. Fetal assessment: Count fetal movement-10 in 1 hour (lt. side) Labor: ROM, cervix > 50% effaced or 3 to 4 cm dilated it is unlikely it can be halted. Fetus immature – cesarean birth Use caution giving analgesics (demerol) due to immaturity of fetus. Epidural is best. Episotomy is needed to decrease risk of hemorrhage of fetus. May be larger and forceps may be used.

24. Preterm Labor Support, she needs to rebuild her self esteem. Preterm Rupture of Membranes Associated with infection of membranes. Occurs in 2% to 18% of pregnancies. If early it is a threat to the fetus, infection and pressure on cord or prolapse. Non fluid environment > Potter like syndrome of distorted facial features and pulmonary hypoplasia from pressure.

25. Preterm Labor Assessment: Labor will not be halted if ROM. Sudden gush clear fluid, test with nitrazine paper (alkaline reaction-blue), ferning (high estrogen), sonogram, cultures, labs. Management: Bedrest, antibiotic, may apply fibrin-based sealant to ruptured membranes, amniotic fluid is always being formed.

26. Preterm Rupture of Membranes  Rupture of fetal membranes with a loss of amniotic fluid  Before 37 weeks’ gestation  Associated with chorioamnioitis  Complications  Assessment  Management

27. Pregnancy Induced Hypertension PIH Vasospasm occurs during pregnancy. Occurs in 5% to 10% of pregnancies. Cause unknown, in primiparas 40 yrs., low socioeconomic background, 5 or more pregnancies, women of color, multiple hydraminios, heart disease, diabetes, essential hypertension, poor calcium or magnesium intake. Patho: Normally blood vessels are resistant to the effects of pressor substances such as angiotensin and norepinephrine.

28. Pregnancy Induced Hypertension With PIH vasoconstriction occurs and B/P increases dramatically. Cardiac system becomes overwhelmed, reduction of blood supply to kidney, pancreas, liver, brain and placenta. Hypoxia in maternal vital organs, poor placental perfusion reduce fetal nutrients and O2. Ischemia in pancreas; epigastric pain and amylase- creatinine ratio, retinal hemorrhages – blindness, proteinuria, edema.

29. Pregnancy Induced Hypertension Extreme edema can lead to cerebral and pulmonary edema and seizures (eclampsia) Assessment: Classic signs: hypertension, proteinuria, and edema. Symptoms rarely occur before 20 weeks. Classified as: gestational hypertension, mild eclampsia, severe preeclampsia &eclampsia

30. Pregnancy Induced Hypertension  Vasospasm, hypoperfusion, and endothelial injury occurs during pregnancy  Symptoms  Hypertension  Proteinuria  Edema  Causes

31. Physiologic changes

32. Gestational Hypertension Elevated BP Without Edema or Proteinuria No Drug Therapy or Low Dose ASA May develop Hypertension in later life

33. Pre Eclampsia  Above gestational hypertension and below point of seizures (Eclampsia)  Mild preeclampsia  Severe preeclampsia

35. Mild Pre-eclampsia BP 30mm systolic and 15mm diastolic above pre- pregnancy values. BP > 140/90 Proteinuria 1+ to 2+ that is not orthostatic Sodium Retention Lower Glomerular filtration rate Edema upper body Weight gain 1-2 lb week

36. Severe Pre-Eclampsia BP at REST: –30mm diastolic above pre pregnancy –160/110 Marked Proteinuria 3+ to 4+ –Or > 5gm in 24 hour sample Edema –Pitting or non pitting over bony surfaces –4+ is indentation that remains after removal of finger –Extensive edema face and hands Epigastric Pain: Liver swelling Ankle Clonus: Cerebral Edema Urine output 400 to 600 mL/24 hours. SS-severe epigastric pain, nausea, vomiting, SOB, blurred vision, seeing spots, headache, marked hyperreflexia and muscle clonus. Review Patellar reflex and ankle clonus assessment

37. Eclampsia Severe cerebral edema to cause SEIZURE or COMA Poor fetal prognosis: anoxia, acidity, and potential for premature separation of placenta

38. Management of PIH Nursing Interventions for Mild Hypertension Can be managed at home with frequent follow up care. Promote bedrest, lateral recumbent position. Promote Good Nutrition Provide emotional support-SS are vague, no meds., works, other children. Seen weekly.

39. Nursing Intervention for Severe Hypertension: B/P > 160/110 after on bedrest, extensive edema, proteinuria 3+-4+ Support Bedrest, hospital, private room, side rails up if seizure, darken room, restrict visitors, less stress, explain everything. Monitor Maternal Well-Being –VS, labs, DIC, high risk for premature separation of placenta and hemorrhage, cathether (>600 mL/24h or 30mL/h), daily weight, Monitor Fetal Well-Being: –FHR, non stress test or biophysical profile daily, O2 to mother. Support Nutritional Diet: Moderate to high protein, moderate sodium diet, IV TKO.

40. Nursing Intervention for Severe Hypertension: Administer Medications to Prevent Eclampsia Table 21.7 pg. 580 drugs Magnesium sulfate, Apresoline or Normodyne, Valium Review treatment with Magnesium sulfate pg.581 Calcium Gluconate

41. Nursing Intervention with Eclampsia: Cerebral irritation from increased cerebral edema and seizure results. Late in pregnancy or 48 hours after birth. SS-B/P increases, temp increases to 103-104, burning of vision, headache, reflexes hyperactive, “something is happening,” epigastric pain, nausea and decreased urinary output. Seizure. Tonic-Clonic Seizures: Occurs in stages Maintain patent airway, O2 by face mask, pulse ox, FHR, turn on side, incontinent of urine and bowel, (valium, mag sulfate),third stage-semicomatose 1 to 4 hours.

42. Continued: Unable to report contractions if placenta has separated. Check for vaginal bleeding. Birth: Pregnancy > 24 weeks, decide about delivery, fetus may not grow after eclampsia occurs. Vaginal birth preferred, vascular system is low in volume. Postpartal Hypertension: Up to 10 to 14 days after birth. (48 hours) monitor B/P closely.

43.  Hemolysis  Elevated Liver Enzymes  Low Platelets  Causes  Symptoms HELLP Syndrome

44. Is a variation of PIH 4% to 12% of PIH patients (1 in 150 births). Cause is unknown, SS-nausea, epigastric pain, general malaise and rt. upper quadrant tenderness. Labs, monitor for bleeding. Tx. Transfusion fresh-frozen plasma or platelets. IV dextrose if hypoglycemic. Deliver as soon as fetus is viable.

45. Multiple Pregnancy Considered a complication of pregnancy. Account for 2% due to fertility drugs. Multiples may be any combination. Occurs more frequently in non whites, high parity and age, multiple gestation, inherited

46. Identical (monozygotic) twins: Begin with single ovum and spermatozoon Fusion or 1 st cell division, zygote divides into 2 identical individuals. Usually have 1 placenta, 1 corion, 2 amnions, and 2 umbilical cords. Always same sex.

47. Fraternal (dizygotic, non-identical) twins: Fertilization of 2 separate ova by 2 separate spermatozoa (possible not from the same sexual partner). 2 placentas, 2 chorions, 2 amnions and 2 umbilical cords. May be same or different sex. 2/3 of twins are dizygotic.

49. Assessment: Uterus increases in size at a rate faster than usual. Elevated alpha-fetoprotein levels Sonogram reveals multiples. Quickening woman reports flurries of action If fetus has back toward woman’s back only one fetal heart sound may be heard.

50. Management Monitor for complications-PIH, hydramnios placenta previa, preterm labor, anemia. Prone to postpartal bleeding. Delivery early, immaturity of fetus. High risk for congenital anomalies, spinal cord defect and cord inserted into fetal membranes. Shared circulation, overgrowth of 1 fetus, knotting or twisting of cord. Encourage rest especially last 2 to 3 months, eat 6 small meals a day, take vitamin supplements, monthly US Prepare for role changes Worries of premature labor and survival of the infants.

51. Hydramnios (Poly) Excessive amniotic fluid formation. Usual-500 to 1000 mL. 2000mL or index > 24 cm. Can cause fetal malpresentation due to extra space for fetus to turn. Premature ROM and preterm labor from increased pressure and prostaglandin release

52. Hydramnios cont’ Assessment: Suggests difficulty with fetus’ ability to swallow or absorb or excessive urine production. SS-rapid enlargement of uterus, tense uterus, fetal heart is difficult to hear, SOB, lower extremity varicosities and hemorrhoids, increased weight gain. Sonogram Management: Admit to hospital for bed rest or rest at home. Educate on ROM, contractions, avoid constipation. VS, edema, may do amniocentesis to remove extra fluid, Indomethacin to reduce total volume, Magnesium sulfate to halt preterm labor, “needled” to allow slow controlled release of fluid.

53. Oligohydramnios Less than average amount amniotic fluid Bladder or renal disorder interferes with fetal voiding Muscles weak, lungs fail to develop Uterine slow growth Amnioinfusion

54. Post Term Pregnancy Term is 38 to 42 weeks Ovulation period may be longer so EDD will be 12 to 17 days later. Trigger did not turn on for labor. High dose of salicylates interferes with synthesis prostaglandins, which initiate labor. 2 weeks beyond term are at risk for meconium aspiration, macrosomia, lack of growth. Placenta functions for 40 to 42 weeks. At 41 weeks; nonstress test,maternal fibronectin level, and biophysical profile to document state of placental perfusion and amniotic fluid. May induce. Cytotec to initiate ripening, ROM,oxytocin.

55. Pseudocyesis False pregnancy can also be seen in men; N&V, amenorrhea enlarged abdomen. Occurs: wish fulfillment or fear of pregnancy, depression. Sonogram Refer for psychological counseling.

56. Isoimmunization (Rh Incompatibility)  Rh-negative mother is carrying a fetus with Rh-positive blood  Hemolytic disease of the newborn  Assessment  Management

58. Fetal Death  Most severe complication  Assessment  Nursing care