Post on 24-Dec-2015
Chapter 21 Sudden Pregnancy ComplicationChapter 21 Sudden Pregnancy Complication
BleedingBleeding
Development of shock
Blood pressure
Pulse
Fetal heart rate
Treatment
Disseminated Intravascular Coagulation (DIC)
Disseminated Intravascular Coagulation (DIC)
Disorder of blood clotting
Fibrinogen levels fall below effective limits
Symptoms
Bruising or bleeding
Causes
1st Trimester Bleeding1st Trimester Bleeding
Spontaneous miscarriage (Abortion)
Threatened
Imminent
Complete
Missed
Recurrent pregnancy loss
Complications of MiscarriageComplications of Miscarriage
Hemorrhage
Infection
Septic abortion
Isoimmunization
Powerlessness or anxiety
1st Trimester Bleeding1st Trimester Bleeding
Ectopic pregnancy
Implantation occurs outside of the uterine cavity
Abdominal pregnancy
2nd Trimester Bleeding2nd Trimester Bleeding
Gestational trophoblastic disease (hydatidform mole)
Abnormal proliferation and degeneration of the trophoblastic villi
Assessment Assessment
HCG
Ultrasound
Fundal height
Nausea
ManagementManagement• 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
Premature cervical dilatation
Cannot hold the fetus until term
Cervical cerclage
3nd Trimester Bleeding3nd Trimester BleedingPlacenta previa
Low implantation of placenta, Partial previa, complete previa
Risk factors
Assessment: Painless vaginal bleeding
Management
Immediate care
Continuing care
3nd Trimester Bleeding3nd Trimester BleedingAbruptio Placentae
Premature separation of placenta
Occurs suddenly
Most frequent cause of perinatal death
Risk factors
Assessment: Painful
Management
Preterm LaborPreterm 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.
Preterm LaborPreterm 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,
Preterm LaborPreterm LaborUA, 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.
Preterm LaborPreterm 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.
Preterm LaborPreterm 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.
Preterm LaborPreterm 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.
Preterm Rupture of MembranesPreterm Rupture of MembranesRupture of fetal membranes with a loss
of amniotic fluid
Before 37 weeks’ gestation
Associated with chorioamnioitis
Complications
Assessment
Management
Pregnancy Induced HypertensionPregnancy Induced HypertensionPIH
• Vasospasm occurs during pregnancy.
• Occurs in 5% to 10% of pregnancies.
• Cause unknown, in primiparas <20 yrs. or > 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.
Pregnancy Induced HypertensionPregnancy 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.
Pregnancy Induced HypertensionPregnancy 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
Pregnancy Induced HypertensionPregnancy Induced HypertensionVasospasm, hypoperfusion, and endothelial
injury occurs during pregnancy
Symptoms
Hypertension
Proteinuria
Edema
Causes
Physiologic changesPhysiologic changes
Gestational HypertensionGestational Hypertension
Elevated BP
Without
Edema or Proteinuria
No Drug Therapy or Low Dose ASA
May develop Hypertension in later life
Pre EclampsiaPre Eclampsia
Above gestational hypertension and below point of seizures (Eclampsia)
Mild preeclampsia
Severe preeclampsia
Mild Pre-eclampsiaMild 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
Severe Pre-EclampsiaSevere 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
EclampsiaEclampsia
• Severe cerebral edema to cause SEIZURE or COMA
• Poor fetal prognosis: anoxia, acidity, and potential for premature separation of placenta
Management of PIHManagement of PIH
Nursing Interventions for Mild HypertensionNursing 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.
Nursing Intervention for Severe Hypertension: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.
Nursing Intervention for Severe Hypertension: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
Nursing Intervention with Eclampsia: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.
Continued: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:Postpartal Hypertension:
• Up to 10 to 14 days after birth. (48 hours) monitor B/P closely.
Hemolysis
Elevated Liver Enzymes
Low Platelets
Causes
Symptoms
HELLP SyndromeHELLP Syndrome
•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.
Multiple PregnancyMultiple 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
Identical (monozygotic) twins:Identical (monozygotic) twins:
• Begin with single ovum and spermatozoon
• Fusion or 1st cell division, zygote divides into 2 identical individuals.
• Usually have 1 placenta, 1 corion, 2 amnions, and 2 umbilical cords.
• Always same sex.
Fraternal (dizygotic, non-identical) twins: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.
Assessment: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.
ManagementManagement• 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.
Hydramnios (Poly)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
Hydramnios cont’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.
OligohydramniosOligohydramnios
• Less than average amount amniotic fluid
• Bladder or renal disorder interferes with fetal voiding
• Muscles weak, lungs fail to develop
• Uterine slow growth
• Amnioinfusion
Post Term PregnancyPost 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.
PseudocyesisPseudocyesis
•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.
Isoimmunization (Rh Incompatibility)Isoimmunization
(Rh Incompatibility)Rh-negative mother is carrying a fetus
with Rh-positive blood
Hemolytic disease of the newborn
Assessment
Management
Fetal DeathFetal Death
Most severe complication
Assessment
Nursing care