1. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. COMPLICATIONS OF PREGNANCY CHAPTER 51

2. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. ASSESSMENT OF FETAL WELL-BEING Ultrasound Nonstress test Fetal acoustic stimulation test and vibroacoustic stimulation test Fetal biophysical profile Fetal movements Biochemical assessments

3. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. ASSESSMENT OF FETAL WELL-BEING (continued) Amniocentesis Chorionic villi sampling Contraction stress test External fetal monitoring- see professional tip block page 1455 Internal fetal monitoring

4. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. HYPEREMESIS GRAVIDARUM Excessive vomiting during pregnancy. Physiological and psychological factors may be involved. Treatment goals: control vomiting, correct dehydration, restore electrolyte balance, and maintain adequate nutrition.

5. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. ABORTION Spontaneous or induced. Termination of a pregnancy before viability. Spontaneous abortion: miscarriage. May be classified as threatened, inevitable, incomplete, complete, missed, or habitual.

6. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. ABORTION (continued) Symptoms of spontaneous abortion are abdominal cramping, vaginal bleeding, and feelings of fear and guilt. Bed rest for threatened abortions. A D & C (dilatation and curettage) is performed to remove products of conception from the uterus.

7. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. ECTOPIC PREGNANCY Occurs when a fertilized ovum implants outside the uterine cavity. The most common site is fallopian tube. Symptoms begin 3-5 weeks after first missed menstrual cycle. Pain is noted as the tube stretches with the growing embryo, eventually rupturing. Rapid surgical treatment is generally necessary to control bleeding. See professional tip pg 1461

8. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. HYDATIDIFORM MOLE Abnormality of placenta–chorionic villi become fluid-filled, grapelike clusters. Classic signs are bleeding, uterine enlargement, no fetal heart tones, hyperemesis gravidarum, or symptoms of pregnancy-induced hypertension appear before 24 weeks. READ CARE PLAN PG 1463

9. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. HYDATIDIFORM MOLE (continued) The primary diagnostic tool is ultrasound. The mole is removed surgically. The client must be followed for 1 to 2 years to monitor for metastasis.

10. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. PLACENTA PREVIA Implantation is in lower uterine segment with placenta lying over or very near the internal cervical os.(Marginal, Partial, Complete) Symptoms include painless bleeding in the last half of pregnancy. (If happens early, is serious) Medical treatment is to maintain the pregnancy until fetus mature enough to survive outside uterus. Surgical-Csection if fetal distress or profuse vaginal bleeding develops Pharmacological-Celestone to accelerate fetal lung development Activity-Bedrest with bathroom privileges if no bleeding. Complete bedrest if has bleeding. Nursing-Bedrest, monitor vitals & FHR, prepare for ultrasound, maintain calm environment, assess for uterine contractions

11. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. ABRUPTIO PLACENTA Premature separation from wall of uterus of a normally implanted placenta. (Central, Marginal, Complete) ***CLASSIC SYMPTOM include a rigid, painful abdomen.*** Irreversible brain damage or fetal death may occur if hypoxia is not reversed quickly.

12. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. DISSEMINATED INTRAVASCULAR COAGULATION (DIC) Overstimulation of normal clotting process, occurs as complication of a primary problem. Obstertrical problems that may precipitate DIC include abruptio placenta, placenta previa, hydatidiform mole, PIH, retained products of conception, amniotic fluid embolism, and infections. It can cause fetal death. Symptom onset sudden: dyspnea, chest pain, restlessness, cyanosis, and spitting frothy, blood-tinged mucous.

13. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. DISSEMINATED INTRAVASCULAR COAGULATION (continued) Underlying cause must be identified and corrected. The fetus must be delivered. IV administration of blood, fibrinogen, or cryoprecipitate is begun. Heparin is given continuously. Oxygen therapy is begun.

14. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. PREGNANCY-INDUCED HYPERTENSION Most common hypertensive disorder in pregnancy, after 20 weeks’ gestation. Only cure is delivery of the baby. Mild preeclampsia–blood pressure increases 30 mm Hg systolic or 15 mm Hg diastolic over baseline on two occasions at least 6 hours apart.

15. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. PREGNANCY-INDUCED HYPERTENSION (continued) Edema noted in face and hands. Objectively defined as weight gain of more than 1 pound a week. Urine may show 1+ or 2+ albumin. Proteinuria usually the last of the three classic symptoms to appear.

16. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. PREGNANCY-INDUCED HYPERTENSION (continued) Severe preeclampsia–blood pressure increases to 160/110 or higher. Generalized edema in face, hands, sacral area, lower extremities, abdomen. Weight gain may be 2 pounds a week. Urinary albumin may be 3+ or 4+.

17. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. PREGNANCY-INDUCED HYPERTENSION (continued) Other symptoms: continuous headache, blurred vision, scotomata, nausea, vomiting, irritability, hyperreflexia, and epigastric pain. EPIGASTRIC PAIN is often LAST symptom identified before client moves into ECLAMPSIA.

18. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. PREGNANCY-INDUCED HYPERTENSION (continued) Eclampsia–grand mal seizures. Without treatment, the client may die. Treat to lower blood pressure, prevent convulsions, and deliver a healthy baby. Magnesium sulfate given to prevent convulsions.

19. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. MAGNESIUM SULFATE ADMINISTRATION Respirations must be at least 14/minute. Deep tendon reflexes must be kept at normal response. Urine output must be at least 30 cc/hr. Monitor serum magnesium level.(4.0-8.0) Common SE-flushing, sweating, hypotension, hypothermia, muscle weakness, constipation, nausea, vomitting Calcium gluconate is antidote for magnesium sulfate–keep at bedside.

20. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. DIABETES MELLITUS Diabetic clients: disease under control. Gestational diabetes mellitus appears only during pregnancy. Effects on pregnancy-high risk Hydraminios Preterm labor, premature rupture of membranes Hyperglycemia, ketoacidosis, maternal or fetal death Pregnancy in a diabetic client has a higher risk of complications. Macrosomia, excessive fetal growth, results from maternal hyperglycemia.

21. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. CHRONIC HYPERTENSION BP 140/90 or higher before pregnancy or before the 20th week of gestation that lasts longer than 6 weeks after delivery. Clients with moderate to severe chronic hypertension are most at risk to develop PIH.

22. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. HEART DISEASE Normal physiological changes of pregnancy may cause problems in client with heart disease. Many clients are cared for by both their cardiologist and obstetrician. Prenatal care appointments may be increased to two or three per week between 28 and 32 weeks’ gestation. Antibiotics often used as a prophylaxis for all pregnant women with heart disease.

23. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. MATERNAL PHENYLKETONURIA When woman with PKU keeps her phenylalanine level less than 2.0 mg/dL while pregnant, outcome of pregnancy better. Poorly regulated maternal PKU casues increase in incidence of IUGR, mental retardation, microcephaly, and heart defects. The mother’s blood phenylalanine level should be checked throughout pregnancy. Client to maintain phenylalanine-free diet.

24. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. TORCH GROUP OF INFECTIONS Toxoplasmosis (TO) Rubella (R) Cytomegalovirus (C) Herpes genitalis (H) When active lesions are visible at the time of delivery, a cesarean birth is best. If untreated: abortion, congenital anomalies, fetal infections, IUGR, preterm labor, mental retardation, or death.

25. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. HIV/AIDS Weight gain is a challenge for pregnant HIV-infected client. HIV may be transmitted to fetus through placenta, during birth, or during breast feeding. Nutritional counseling and support may be necessary.

26. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. HEMOLYTIC DISEASES Rh incompatibility–can only happen when mother is Rh negative and fetus is Rh positive. ABO incompatibility–problem occurs when maternal blood enters fetal circulation.

27. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. MULTIPLE PREGNANCY First trimester proceeds much the same as with a single fetus. Fundal height greater than expected for the weeks of gestation is often the first clue of a multiple pregnancy. As uterus grows, greater pressure on and displacement of the internal organs. Greater risk of fetal anomalies, abnormal presentations, and preterm birth.

28. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. SUBSTANCE ABUSE Substance abusers may not seek prenatal care until late in pregnancy. Most do not voluntarily admit addiction. These mothers have an increased rate of complications. They often use available money for drugs instead of food.

29. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. PRETERM LABOR Labor that begins after viability but before 38 weeks’ gestation. Causes maternal, fetal, or placental. Preterm labor may produce a neonate not able to cope well with extrauterine life. The process of stopping labor with medications is called tocolysis.

30. Copyright 2005 Thomson Delmar Learning. Thomson and Delmar Learning are trademarks used herein under license. PRETERM LABOR No attempt is made to stop labor if : The cervix is dilated 4 cm or more Severe PIH Prolonged rupture of membranes Hemorrhage Abruptio placenta Fetal complications Fetal death