Complications of Pregnancy

Ana H. Corona, MSN, FNP-CNursing Instructor

February 2009

Assessment Fetal Well Being

UltrasoundNonstress testFetal acoustic stimulation test and

vibroacoustic stimulation testFetal biophysical profileFetal movementsBiochemical assessments

Assessment Fetal Well Being

AmniocentesisChorionic villi samplingContraction stress testExternal fetal monitoringInternal fetal monitoring

Nonstress Test (NST)

Procedure used to monitor fetal response to movement.

FHR acceleration with fetal movement is reassuring and a sign of fetal well being

Semi-Fowler's or side-lying position Baseline fetal heart rate recordedFHR pattern for monitored 20–30

minutesPatient marks paper with each perceived

fetal movement

Nonstress Test (NST)

Result Criteria Reactive (normal) In a 20-minute period,

two or more fetal heart rate accelerations of at least 15 beats per minute above the baseline heart rate

Nonreactive (abnormal) No fetal heart rate accelerations over a 40-minute period.

Contraction Stress Test

High Risk Patient: Diabetic Patient Method of externally monitoring the fetus. Measures the ability of the placenta to provide

enough oxygen to the fetus during contractions. Oxytocin IV or nipple stimulation will be used to

induce contractions. Oxytocin Challenge Test: IV until 3 uterine

contractions are observed, lasting 40 - 60 seconds, over a 10-minute period.

Electrical Fetal Heart Monitoring

Accelerations: common - normalEarly Decelerations: vagal stimulation to

the fetal head during a contraction which push the head toward the pelvis - normal

Late Decelerations: Utero-Placental insufficiency (fetal blood flow compromised, less oxygen!!! - abnormal

Variable Decelerations: cord compression nuchal cord, knot, decreased amniotic fluid - abnormal

Alpha-Fetoprotein (AFP)Multipe Marker Screening: Genetic TestSpina-BifidaAnencephaly Omphalocele Tetralogy of Duodenal atresiaTurner SyndromeIntrauterine deathDone between 15 – <20 weeks gestation

BPP

Includes 5 components: Fetal breathing movements Gross body movements Fetal tone AFI NST - reactive

AFI

Polyhydramnios – too much amniotic fluid AFI of more than 24 cm

Oligohydramnios – too little amniotic fluid AFI less than 7 cm Studies show that oral hydration, by having the

women drink 2 liters of water, increases the AFI by 30%.

Abruptio Placenta Premature separation from wall of uterus of a normally

implanted placenta. Abnormally short umbilical cord Abdominal Injury Sudden loss in amniotic fluid

Abruptio Placenta Abdominal pain Vaginal bleeding Back pain Symptoms include a rigid, painful abdomen. Irreversible brain damage or fetal death may occur if

hypoxia is not reversed quickly.

Placenta Previa Implantation is in

lower uterine segment with placenta lying over or very near the internal cervical os.

Symptoms include painless bleeding in the last half of pregnancy.

Treat to maintain the pregnancy until fetus mature enough to survive outside uterus

Ectopic Pregnancy

Abnormal pregnancy that occurs outside the uterus.

Symptoms include: Missed menstrual

period Pelvic/Abdominal pain Spotty vaginal bleeding Pain in the shoulder Fainting nausea

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.

Hydatidiform Mole

Gestational Trophoblastic Disease or molar pregnancy

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 PIH appear before 24 weeks.

Choriocarcinomas are highly malignant tumours may follow a molar pregnancy.

Hydatidiform Mole

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.

Pregnancy Induced Hypertension (PIH)

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.

May be asymptomatic

PIH

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.

PIH

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+.

PIH

Other symptoms: continuous headache, blurred vision, scotomata, nausea, vomiting, irritability, hyperreflexia, and epigastric pain.

Epigastric pain often last symptom identified before client moves into eclampsia.

Eclampsia

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.

Magnesium SulfateRespirations must be at least 14/minute.Toxicity: Respiratory depression to

paralysisDeep tendon reflexes must be kept at

normal response.Urine output must be at least 30 cc/hr.Monitor serum magnesium level.

1.5 – 3mEq/LCalcium gluconate is antidote for

magnesium sulfate–keep at bedside.

Disseminated Intravascular Coagulation

Over stimulation of normal clotting process, occurs as complication of a primary problem.

Pregnancy Induced HypertensionIt can cause fetal death.Symptom onset sudden: dyspnea, chest

pain, restlessness, cyanosis, and spitting frothy, blood-tinged mucous.

Disseminated Intravascular Coagulation

Underlying cause must be identified and corrected.

The fetus must be delivered.IV administration of blood, and other blood

products Heparin is given continuously. Oxygen therapy

Pregnancy and Diabetes

Hyperglycemia May be due to inadequate insulin action or due to

impaired insulin secretion Type 1 – insulin deficiency Type 2 – insulin resistance GDM – glucose intolerance during pregnancy 10th week fetus produces it own insulin Insulin does not cross the placental barrier Glucose levels in the fetus and directly proportional to

the mother 2nd and 3rd trimesters – decreased tolerance to glucose,

increased insulin resistance, increased hepatic function of glucose

Diabetic Neuropathy

Increased risks for: Preeclampsia IUGR PTL Fetal distress IUFD Neonatal death

DM

Poor glycemic control is associated with increased risks of miscarriage at time of conception

Poor glycemic control in later part of pregnancy is assoc. with fetal macrosomia and polyhydramnios

May compress on the vena cava and aorta causing hypotension, PROM, PP hemorrhage, maternal dyspnea

DM

Disproportionate increase in shoulder and trunk size

4000-4500gms or greaterFetus will have excess stores of glycogenIncreased risks of

Shoulder dystocia C/S Assisted deliveries

Neonatal Hypoglycemia Usually 30-60 minutes after birth Due to high glucose levels during pregnancy and

rapid use of glucose after birth Related to mothers level of glucose control Neonates normal glucose level: 40-65mg/dl Premature infants: 20-60mg/dl

IUGR Compromised uteroplacental insufficiency 02 available to the fetus is decreased

Fetal Surveillance

NSTs done around 26 weeks, weekly

At 32 weeks done biweekly with NST/BPP

What complications should the nurse be alert for when the mother is experiencing gestational diabetes?

Maternal complications – infections, difficult labor related to increased fetal size, vascular complications (retinopathy) azotemia, ketoacidosis, increased incidence of hypertensive disorders (preeclampsia and c-section)

Fetal complications: stillbirth, spontaneous abortion, hydraminos, large placenta, Macrosomia, congenital anomalies, neonatal hypoglycemia, neonatal hyperbilirubinemia, increase incidence of respiratory distress syndrome and fetal or neonatal death

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.

Maternal Heart Disease The heart must compensate for the normal blood volume

increase and workload If the cardiac changes are not well tolerated than cardiac

failure can develop 1% of pregnancies are complicated by heart disease Cardiac output is increased Peak of the increase 28-32 weeks gestation. Prenatal care visits should be more often than usual. Cardiac problems should be managed with cardiologist Mortality with pulmonary hypertension and pregnancy is

more than 50% Diet: low sodium Avoiding anemia Avoid strenuous activity Monitor for: cardiac failure (CHF) and pulmonary

congestion

Nursing Care during labor

Side lying position Prophylactic antibiotic Epidural Attempt vaginal

delivery If anticoagulant

therapy is needed: Heparin Lovenox

Phenylketonuria Individuals with PKU cannot process a part of

protein called phenylalanine present in most foods.

phenylalanine builds up in the bloodstream and causes brain damage and mental retardation.

The characteristic features of maternal PKU syndrome include mental retardation, microcephaly, (IUGR)intrauterine growth retardation, and congenital heart defects

When woman with PKU keeps her phenylalanine level less than 2.0 mg/dL while pregnant, outcome of pregnancy better.

TORCH: acronym for maternal infections

Toxoplasmosis (TO) - protozoan infection, neonatal effects – jaundice, hydrocephalus, microcephaly

Rubella (R) - congenital deformitiesCytomegalovirus (C) - CNS damage to fetusHerpes genitalis (H) - Perinatal loss. Fetus

may pick up virus if present in the vagina during labor

If untreated: abortion, congenital anomalies, fetal infections, IUGR, preterm labor, mental retardation, or death.

TORCH RESULTS

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.

Congenital defects such as microcephaly (abnormal smallness of the head) and facial deformities.

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.

Hemolytic Disease

Basic incompatibility of blood, such as ABO incompatibility, or from transfer of antibodies through the placenta

Erythroblastosis fetalis is a type of hemolytic anemia that occurs in newborns as a result of maternal fetal blood group incompatibility, especially involving the Rh factor and ABO blood groups

RhoGam

RhoGam 300mcg IM given at 28 weeks of pregnancy and 72 hrs of delivery (Rh negative, abortion, ectopic pregnancy and amniocentesis).

A card is givenMom needs to carry card with her at all

timesPhototherapy – bilirubin levels reach 12

to 15 mg/dl

Hemolytic Disease

Blood Typing Indirect Coomb’s test of maternal blood –

measures the number of maternal antibodies Antibody titer test – level of maternal antibodies,

if exceeds 1:16 amniocentesis may be performed

Optical density studies – measure bilirubin level, fetal condition

After delivery – direct Coomb’s test (infant blood to determine the presence of antibody coated RBCs (bilirubin)

Multiple pregnancy

First trimester proceeds much the same as with a single fetus.

As uterus grows, greater pressure on and displacement of the internal organs.

Greater risk of fetal anomalies, abnormal presentations, and preterm birth.

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.

Smoking Alcohol

Risks: SAB SGA Bleeding IUFD Prematurity SIDS

Risks: LBW Mental retardation Learning and

physical deficits With FAS – severe

facial deformities

OPIATES IN PREGNANCY

Drugs include: heroin, Demerol, morphine, codeine, methadone

Methadone is used to treat addiction to other opiates

Possible effects on pregnancy and heroin use are: Preeclampsia, PROM, infections, PTL

Tx: Methadone and psychotherapyGoal: prevent withdrawal symptoms

COCAINE DURING PREGNANCY

Maternal effects: Cardiovascular stress Tachycardia HTN Dysrhythmias MI Liver damage Sz Pulmonary disease Death

Fetal Complications: Abruptio placentae PTL Precipitous labor Risks for abdominal

pregnancy Fetal complications after

delivery

Questions

The acronym for maternal infections is:

1. TORCH

2. LATCH

3. MEALS

4. HELLP

Answer is 1

TORCH

• Rho (D) immune globulin (RhoGAM) is prescribed for a woman following delivery of a newborn infant and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from

which of the following?

1. Being affected by Rh incompatibility

2. Having Rh positive blood

3. Developing a rubella infection

4. Developing physiological jaundice

Answer is 1

1. Administration of Rho (D) immune globulin prevents the woman from developing antibodies against Rh positive blood by providing passive antibody protection against the Rh antigen.

A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium therapy is effective if:

1. Ankle clonus in noted

2. The blood pressure decreases

3. Seizures do not occur 4. Scotoma’s are present

Answer is 3

For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures).

Magnesium sulfate is an anticonvulsant, not an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient.

A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client.

1. Monitor maternal vital signs every 2 hours

2. Notify the physician if respirations are less than 18 per minute.

3. Monitor renal function and cardiac function closely

4. Keep calcium gluconate on hand in case of a magnesium sulfate overdose

5. Monitor deep tendon reflexes hourly

6. Monitor I and O’s hourly

7. Notify the physician if urinary output is less than 30 ml per hour.

Answers: 3, 4, 5, 6, 7

When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, every 30-60 minutes and notify the physician if respirations are less than 12.

Calcium gluconate is kept on hand in case of magnesium sulfate overdose.

Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys.

A 21-year old client, 6 weeks’ pregnant is diagnosed with hyperemesis gravidarum. This excessive vomiting during pregnancy will often result in which of the following conditions?

1. Bowel perforation

2. Electrolyte imbalance

3. Miscarriage

4. Pregnancy induced hypertension (PIH)

Answer is 2

Excessive vomiting in clients with

hyperemesis gravidarum often causes

weight loss and fluid, electrolyte, and acid-

base imbalances.

A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present?

1. Absence of abdominal pain 2. A soft abdomen 3. Uterine tenderness/pain 4. Painless, bright red vaginal bleeding

Answer is 3

In abruptio placenta, acute abdominal pain is present. Uterine tenderness and pain accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability.

A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician’s orders and would question which order?

1. Prepare the client for an ultrasound

2. Obtain equipment for external electronic fetal heart monitoring

3. Obtain equipment for a manual pelvic examination

4. Prepare to draw a Hgb and Hct blood sample

Answer is 3

Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and placental previa is ruled out.

Digital examination of the cervix can lead to maternal and fetal hemorrhage.

An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for:

1. Complete bed rest for the remainder of the pregnancy

2. Delivery of the fetus

3. Strict monitoring of intake and output

4. The need for weekly monitoring of coagulation studies until the time of delivery

Answer is 2

2. The goal of management in abruptio placenta is to control the hemorrhage and deliver the fetus as soon as possible.

Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy.

The nurse is caring for a woman who is 37-weeks gestation diagnosed with PIH. The nurse would be MOST concerned by which of the following findings?

1. B/P 150/95

2. 4+ proteinuria.

3. The patient c/o right quadrant pain.

4. 3+ pitting edema of the ankles

Answer is C

Explanation of Answer:This indicates impaired liver function, sign of impending eclampsia.

WHICH OF THE FOLLOWING IS A CHARACTERISTIC OF A REASSURING FETAL HEART RATE PATTERN?

1. A FHR OF 170–180 bpm

2. A BASELINE VARIABILITY OF 25–35BPM

3. OMINOUS PERIODIC CHANGES

4. ACCELERATION OF FHR WITH FETAL MOVEMENTS

Answer is D

Accelerations with movement are normal.

Which of the following matches the definition:  abnormal placenta development covering the cervix?

1. Placenta Previa

2. Abruptio Placentae

3. Multigravida

4. Proliferative phase

Answer is 1

The right answer was Placenta Previa.

Which of these is not considered a T.O.R.C.H. infection?

1. Rubella

2. Herpes

3. Cytomegalovirus

4. HIV

Answer is 4

The right answer was HIV