High Risk Pregnancy Woman With Complications

7/31/2019 High Risk Pregnancy Woman With Complications

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HIGH RISK PREGNANCY:

WOMAN WHO DEVELOPS COMPLICATION DURING PREGNANCY

Bleeding and Development of Hypovolemic Shock

Any degree of bleeding during pregnancy is serious because the amount visualized mayonly be a fraction of the actual blood loss because an undilated cervix and intact

membranes can contain blood within uterus (internal bleeding). Evaluate for possible

Hypovolemic Shock.

Danger to Fetal Blood Supply occurs iftheres decrease blood flow to peripheral organs. Position: LeftSide Lying to improve Placental CirculationProcess of Hypovolemic Shock (Chronological Order)

1. Blood Loss2. Intravascular Volume3. Venous Return, Cardiac Output, Blood Pressure4. Body compensating by Heart Rateto circulate blood volume faster; vasoconstriction

of peripheral vessels to save blood vital organs; RR; feeling of apprehension at body

changes

5. Cold, clammy skin, uterine perfusion in the face of continued blood loss, althoughbody shifts fluid from interstitial spaces into intravascular spaces, blood pressure

continuously

6. Renal, Uterine, and Brain perfusion7. Lethargy, Coma, Renal output8. Renal Failure9. Maternal and Fetal DeathSigns and Symptoms of Hypovolemic Shock

Position: Trendelenburg

1. Pulse Rate (Tachycardia) heart is attempting to circulate blood volume faster.2. Blood Pressure (Hypotension) less peripheral resistance b/c of blood volume3. Respiratory Rate(Tachypnea) gas exchange to better oxygenate a RBC volume.4. Cold, Clammy Skin, Pallor vasoconstriction to maintain blood volume in central

body core

5. Urine Output inadequate blood is entering the kidney6. Dizziness / LOC / Confusion inadequate blood is reaching cerebrum7. Central Venous Pressure blood is returning to heart


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Two Conditions Associated with 1stTrimester bleeding (1st 3rd month)

1. Abortion or Miscarriage2. Ectopic Pregnancy

Abortion Any interruption of a pregnancy before a fetus becomes viable; < 20 weeks

AOG; spontaneously or electively

Age of Viability 20 24 weeks AOG; Fetus weighs at least 500g; Fetus can survive outside

uterus if born at that time

Miscarriage interruption of pregnancy occurs spontaneously during age of viability; >20-

24 weeks AOG

Elective Abortion - planned medical termination of pregnancy

Spontaneous Abortion or Spontaneous Miscarriage

Occurs from natural causes Early miscarriage before week 16 Late miscarriage between weeks 16 24 During first 6 weeks, placenta is tentatively attached to decidua, during weeks 6 12,

moderate attachment to myometrium. After week 12, attachment is penetrating and

deep. Bleeding before week 6 is rarely severe; bleeding after week 12 can be profuse.

Assessment: Vaginal SpottingCauses of Spontaneous Abortion

1. Abnormal Fetal Formation due to uterine abnormalities and chromosomal aberration.2. Immunologic Factors/ Rejection of embryo thru immune response3. Implantation Abnormalities Poor implantation results from inadequate endometrial formation or inappropriate

site of implantation

Placental circulation cant function adequately and fetal nutrition will be inadequate.4. Corpus Luteum fails to produce enough progesterone to maintain Decidua Basalis5. Infection crosses placenta causing fetal death

T oxoplasmosis (from cats feces, raw meat)O thers (Syphilis, Varicella (Chicken Pox) or Shingles, Hepa B, HIV)

R ubella (causes small children or SGA)

C ytomegalo Virus (affects CNS)

H Herpes Simplex Virus, Meningitis, Encephalitis

6. Ingestion of Teratogenic Drug (causes adverse effect to the fetus)7. Ingestion of Alcohol


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Threatened Abortion or Miscarriage

a. S/S: Bright Red Scant Vaginal bleeding, slight cramping, and no cervical dilatationb. Management Avoid strenuous activity for 24 48 hours. Complete bed rest is usually not

indicated. It may stop bleeding for blood is pooling vaginally. During ambulation,

bleeding will recur.

No Coitus for 2 weeks after bleeding to prevent infection & further bleeding. Drugs:

a. Duvadilan (IM, ORAL, Parenteral)b. Ritrodine Hydrochloridec. Terbatuline Sulfate

Imminent or Inevitable Abortion

a. S/S: Threatened Abortion becomes imminent when theres uterine contractions(cramping) and cervical dilatation.

b. Management Save tissue fragments for examination D&C if FHT is absent and fetus is not viable, to prevent infection, and hemmorhage.

After procedure, assess bleeding by recording no. of pad (> 1 pad/ hour is

considered heavy bleeding)

Complete Abortion

All products of conception (fetus, membranes, placenta) are expelled spontaneouslywithout any assistance.

Management: Emotional Support no need for D&CIncomplete Miscarriage

Usually fetus is expelled, but membrane or placenta is retained in the uterus. Management:D&C to evacuate remaining parts to prevent hemorrhage and infection.Missed Miscarriage or Early Pregnancy Failure

Fetus dies inside utero but not expelled Assessment

a. Fundal height doesnt increase in sizeb. Absent Fetal Heart Soundsc. (-) Pregnancy Testd. Painless vaginal bleeding (Threatened Miscarriage) or no prior clinical symptoms

Managementa. Sonogram to check if fetus is dead


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b. Dilatation and Evacuationc. If > 14 weeks, induce labor by the ff drugs: Prostaglandin suppository or Misoprostol (Cytotec) to dilate cervix Oxytocin or Mifespristone

d. If not terminated can cause DIC if dead fetus remains too long in utero.Recurrent Pregnancy Loss or Habitual Abortion

3 or more consecutive spontaneous miscarriages that occurred at the same gestationalage; Women are called Habitual Aborters

Causesa. Incompetent Cervix (Premature Cervical Dilatation)b. Defective spermatozoa or ovac. Deviations of uterus (septate or bicornuate)d. Infectione. Endocrine Factorsf. Autoimmune disorders (lupus anticoagulant and antiphospholipid antibodies)

Complications of Miscarriage

1. Hemorrhagea. Monitor V/S to detect Hypovolemic Shockb. Position: Flat on bed and massage fundus to stimulate contractionc. D&C and Suction Curettage to empty uterus which prevent it from contractingd. Blood Transfusion to replace blood losse. Direct replacement of fibrinogen or other clotting factor to aid coagulationf. Drug: Methylergonovine Maleate (Methergine) to aid with contraction (if patient

is not Hypertensive; of hypertensive give Oxy instead)

2. Infection Danger signs

a. Fever - may be systemic reaction; >38 C requires careful evaluation to avoidinfection.

b. Abdominal Pain or Tendernessc. Foul Vaginal Discharge

Usual Causative Agent: E.Coli Management: Teach Client Perineal Hygiene (wipe front to back)

3. Septic Abortion


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Complicated by infection which occurs in women who have tried to self abort oraborted illegally using unsterile instrument such as knitting needle.

If untreated can lead to TSS, Septicimia, Kidney Failure, Death If treated can lead to infertility d/t uterine scarring or fibrotic scarring of

fallopian tubes.

Symptomsa. Feverb. Crampy Abdominal Painc. Tender Uterus upon palpation

Managementa. Obtain CBC, Serum Electrolytes, Serum Creatinine, Blood Type, Cross Matchb. Obtain Cervical, Vaginal, and Urine Culturesc. Indwelling Catheter to monitor urine output hourly to asses kidney function.d. D&C or D&E to remove infected and necrotic tissue from uteruse. Tetanus Toxoid or Tetanus Immune Globulin IM for prophylaxis against tetanus.f. High Broad Spectrum Antibiotic Drugs: PENICILLIN (gram+), GENTAMICIN

(gram -), and CLINDAMYCIN(gram-)

4. Isoimmunization If fetus was RH (+) and mother is RH (-), RH (+) fetal blood may enter maternal

circulation to cause ISOIMMUNIZATION

Production of antibodies against RH (+) blood. If next child has RH (+) blood, theseantibodies will destroy RBCS of next infant inside utero.

After miscarriage, women with RH (-) should receive RH (D antigen) and Immuneglobulin (RhIG) to prevent build-up of antibodies if the fetus was RH (+).

5. Powerlessness and Anxiety Assess adjustment. Sadness and grief over the loss is to be expected.

ECTOPIC PREGNANCY


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Hysterosalpingogram - performed after chemotherapy to assess if tube is fullypatent

b. Mifepristone - abortifacient; sloughs tubal implantation sitec. Advantage : tube left intact w/o scarring that may cause 2nd ectopic implantation

4. IV Fluid using large gauge catheter5. Laparoscopy to ligate and remove bleeding vessels and repair damaged fallopian tube.Surgery:

a. Fallopian Salphingectomyb. Abdominal Exploratory Laparotomyc. Uterus Hysterectomy

ABDOMINAL PREGNANCY

Fetus grows inside abdominal cavity such as in the Intestine Magnetic Resonance Imaging (MRI) to reveal fetus outside uterusSigns and Symptoms

a. Fetal Outline easily palpableb. Woman not aware of movements or has painful fetal movements and abdominal

cramping with movements

c. Sudden lower quadrant pain Placenta will penetrate and erode a major blood vessel inside abdomen. If implanted on

intestine, it may erode deeply that causes bowel perforation and peritonitis.

High fetal risk because w/o good uterine supply, nutrients may not reach fetus. Ininfants who survived, theres threat of fetal deformity or growth restriction. At term,

infant must be delivered by Laparotomy

Placenta is difficult to remove in intestine. It may be left in place and allowed to absorbin 2 or 3 months or may be treated w/ Methotrexate to help absorb placenta

Conditions associated with 2nd trimester bleeding (4 6 mos)


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1. Suction Curettage to evacuate mole.2. Assess HcG levelevery 2 weeks until levels are again normal . Thereafter, levels are

assessed every 4 weeks for 6 12 months. Gradually declining hCG suggest no

complication. Levels that plateu for three times or increase suggest malignancy.

3. Woman cant be pregnant for a year and should use reliable contraceptive for 12months. After 6 months if hCG still (-), theres no malignancy. By 12 months, she could

plan 2nd pregnancy.

4. Drug for Choriocarcinoma:Methotrexate

PREMATURE CERVICAL DILATATION (INCOMPETENT CERVIX)

Cervix dilates prematurely approximately during week 20Signs and Symptoms

1. Painless Dilatation2. Pink stained vaginal dischargeor increased pelvic pressure ROM Discharge

of Amniotic Fluid Uterine Contractions Preterm Birth

Associated with:

1. Increased Maternal Age2. Congenital Structural Defects3. Trauma to cervix (biopsy or repeated D&Cs)Management

1. Cervical Cerclage Surgical operation to prevent cervix from dilating prematurely during 2nd

pregnancy.

If sonogram confirms 2nd pregnancy is healthy, at 12 14 weeks purse stringsutures are placed inside cervix under regional anesthesia to strengthen cervix and

prevent it from dilating.

Sutures are removed at 37 38 weeks so fetus can be born vaginally.a. Mc Donald nylon sutures placed horizontally & vertically across cervix to reduce

cervical canal to a few millimetres in diameter.

b. Shirodkar Sterile tape threaded in a purse string manner under submucouslayer of cervix to achieve a closed cervix.

Post Surgery Intervention: Bed rest in slight or modified Trendelenburg to decrease

pressure on new sutures.

Conditions Associated with Third Trimester Bleeding (7 9 months)


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1. Placenta Previa (Unavoidable Hemmorhage) Low implantation of placenta so that it crosses cervical os Occurs in 4 degrees and estimated in %

a. Low lying implantation in lower portion of uterusb. Marginal implantation placenta edge approaches cervical osc. Partial placenta previa implantation in a portion of cervical osd. Total Placenta previa implantation that totally obstructs cervical os

Bleeding occurs when lower uterine segment differentiates from upperuterine segment approximately during week 30 and cervix begins to dilate

Bleeding results from placentas inability to stretch to accommodate differingshape of lower uterine segment or cervix.

Site of bleeding is uterine deciduas (maternal blood), that places mother at riskfor hemmorhage and because placenta is loosened, fetal oxygen may be

compromised and preterm birth can occur.

Predisposing Factors

a. Increased Parityb. Advanced Maternal Agec. Past CS birthsd. Past Uterine Curettagee. Multiple Gestationf. Male Fetus

Assessment

a. Abrupt, Painless, Bright Red Bleedingb. Soft Fundus upon palpationNursing Management (Immediate Care)

a. Position: Side Lyingb. Assess the ff: Duration of pregnancy, time of bleeding began, estimation of blood loss in terms of

cups or tablespoon (1 cup is 240 ml and 1 teaspoon is 15ml)

Presence of Pain Color of blood (redder blood indicates bleeding is fresher or continuing) What she has done for bleeding (if tampon is inserted to halt bleeding) Prior episodes of bleeding Prior cervical surgery for premature cervical dilatation

c. Inspect perineum for bleeding and estimate blood loss rate.d. Weigh perineal pads before and after use and calculating the difference by subtraction.


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e. APT or KLEIHAUER BETKE TEST test strip to detect if blood is fetal or maternalf. NEVER attempt pelvic or rectal exam may initiate massive hemmorhage.g. Monitor V/S to determine presence of shockand assess BP every 5 15 minsh. IV Fluid using large gauge catheteri. Monitor urine output every hourj. External fetal monitoring, record fetal heart sounds and uterine contractions.

Internal monitor is contraindicated.

k. Determine placenta location accurately in a hope for its position will make vaginalbirth possible. If placenta is under 30%, it may be possible for fetus to be born past it. If

30% and fetus is mature, safest birth method is CS.

l. Abdominal Exam reveals fetal head isntengaged b/c of interfering placenta.m. Ready oxygen in case of fetal distressCONTINUING CARE

a. Bed rest for 48 hoursb. Assess fetal heart soundsc. Assess Hgb & Hctd. BETAMETHASONE, a steroid to encourage maturity of fetal lungs if fetus is < 34 weeks

PREMATURE SEPARATION OF PLACENTA

(ABRUPTIO PLACENTA)

Accidental Hemmorhage, Concealed Hemmorhage, and Utero PlacentalApoplexy

Placenta separates from uterus during 1stor 2nd stage of labor and bleeding occurs. This separation immediately cuts off blood supply to the fetus.Predisposing factors:

a. High parityb. Advanced Maternal Agec. Short Umbilical Cordd. Chronic Hypertensive Disease (Hypertension)e. Acute Infectionf. Fibrin Defectsg. PIHh. Trauma or Injury (automobile accident or intimate partner abuse)i. Vasoconstriction from cocaine or cigarette usej. Thromboplitic conditions that lead to thrombosis such as Autoimmune antibodies, Protein C, & Factor V Leiden (inherited thrombophilia)


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Assessment

1. Sudden Sharp, Stabbing pain high in uterine fundus as initial separation occurs.2. External Bleeding placenta separates first at the edges3. Internal Bleeding - placenta separates first at the center, blood pools under placenta

and is hidden and may infiltrate Uterine Musculature (COUVELAIRE UTERUS or

UTEROPLACENTAL APOPLEXY), forming a Hard, Board like Uterus without

apparent or minimally apparent bleeding.

4. Uterus becomes tense and feels rigid to touch (Abdominal Rigidity)Management

1. Position:Left Lateral to prevent uterine pressure on vena cava and interference withfetal circulation.

2. Large gauge IV Catheter for fluid replacement3. Oxygen by mask to limit fetal anoxia (absence of oxygen)4. External Fetal Monitoring of FHT5. Monitor Maternal V/S every 5 15 mins6. Do not perform vaginal or pelvic exam and dont give enemaDISSEMINATED INTRAVASCULAR COAGULATION (DIC)

Acquired Blood Clotting Disorder w/c fibrinogen level falls below effective limits. Early Symptoms: early bruising, petechiae, and bleeding from IV Site Associated with the ff:

a. Abruptio Placentab. PIHc. Septic Abortiond. Placental Retentione. Retention of Dead Fetusf. Amniotic Fluid Embolism

Drug: HEPARIN to stop local coagulation and free clotting factors for systemic use.


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PRETERM LABOR

Labor after 20 weeks and before the end of 37th week of pregnancy Persistent uterine contractions every 10 minutes for 1 hour and dilatation begin.

Associated with:

a. Dehydrationb. Urinary Tract Infection (UTI)c. Chorioamnionitis (infection of the fetal membranes and fluid)d. Inadequate prenatal caree. Strenuous jobs or perform shift work that leads to extreme fatigueManagement

a.

Analyze vaginal mucus changes FETAL FIBRONECTIN, a protein produced byTrophoblast Cells that predicts preterm contractions will occur; absence predicts labor

will not occur for at least 14 days

b. Bed rest to relieve pressure of fetus on the cervixc. IV Therapy because hydration help stop contractions. If dehydrated, pituitary gland

is activated and may release oxytocin, which strengthen uterine contractions.

d. Drink enough fluidse. Administration of Drugs as Ordered

a. Oral Tocolytic Agentsuch as ORAL TERBUTALINE to halt labor Can administer if cervix is


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1. If membranes are ruptured or cervix is >50% effaced and >3-4%cm dilated, labor cantbe halted. The rupturing of the membranes can be thought as the point of no return

2. If fetus is very immature, CS may be planned to reduce pressure on fetal head andpossibility of subdural or intraventricular hemmorhage from vaginal birth

3. Because of the increased risk of Prolapse of the Cord around a small head, Amniotomy(artificial ruputure of membranes) is not done until head is firmly engaged.

4. ANALGESICS ADMINISTERED WITH CAUTION because of the immaturity of fetus. Fetuswill have difficulty breathing at birth. For pain relief, use EPIDURAL ANESTHESIA.

5. Delaying rupture of the membranes is another factor that prolong first stage of labor.6. Woman may need episiotomy incision larger than usual because excessive pressure can

result in subdural or intraventricular hemmorhage.

7. Cord is clamped asap rather waiting for the pulsation to stop because immature infanthas difficult time to excrete large amounts of Bilirubin that will be formed if this extra

blood is added to circulation and could overburden circulatory system.

Premature Rupture of Membranes (PROM)

Rupture of fetal membranes with loss of amniotic fluid before 37th week. (First Stage ofLabor in Active Phase)

Cause is unknown but associated with Chorioamnionitis EPROM (Early Rupture of Membranes which occurs earlier than Active Phase)Complications:

a. Uterine and fetal infectionb. Increased pressure on the cord from loss of Amniotic Fluid, inhibiting Fetal

Nutrition

c. Cord prolapsed Extension of cord out of the uterine cavity into the vagina Most apt to occur when fetal head is still so small to fit cervix

d. Potter Like Syndrome or Distorted Facial Featurese. Pulmonary Hypoplasia from pressuref. Preterm labor may follow ROM

Assessment

1. Sudden gush of clear fluid from vagina, usually mistaken as urinary incontinence2. Amniotic Fluid cant be differentiated from urine by appearance, so sterile vaginal

speculum is done to observe for vaginal pooling of fluid.

Tests:


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a. Nitrazine Paper Amniotic fluid has alkaline reaction and remains blue Urine has acidic reaction and remains yellow

b. Fern test to differentiate amniotic fluid to urine3. Associated with Vaginal Infection, so culture of Neiserriae Gonnorhea, Streptococcus P.,

and Chlamydia are taken.

Management:

1. Avoid routine vaginal exam because of the risk of infection rises when digitalexaminations are performed after PROM.

2. If fetus is estimated to be mature enough to survive during rupture and labor doesntbegin within 24 hours, labor contractions are induced by IV administration of oxyctocin.

3. Positions:a. Trendelenburgb. Knee chest positionc. Lithotomy (8-9cm dilatation)

4. Bed Restif labor doesnt begin and fetus is near at point of viability.5. Administration of Drugs as ordered:

a. Betamethasone - Corticosteroid to hasten fetal lung maturityb. Prophylactic administration of broad spectrum antibiotics may delay onset of

labor and reduce risk of infection enough to allow corticosteroid to effect.

6. Endoscopic intrauterine procedures, membranes can be resealed by the use ofFIBRIN based commercial sealant so they are intact again.

PREGNANCY INDUCED HYPERTENSION (TOXEMIA)


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Vasospasm occurs during pregnancy in small and large arteries (spastic arteries) The cause is still unknown Originally called TOXEMIA, because researchers pictured a toxin produced by woman

in response to foreign protein produced by fetus which leads to the typical symptoms.

3 Triads or Signs

1. Hypertension2. Proteinuria3. Edema

Associated with the ff:

1. Multiple Pregnancy2. Primiparas younger than 20 years old or older than 40 years old.3. From low socio economic backgrounds (because of poor nutrition)4. Hydramnios (>2,000ml of Amniotic Fluid or above 24cm index)5. Heart disease, diabetes with vessel or renal involvement, and hypertension (without

history)

6. Chronic Hypertensive Disease (when theres history of hypertension)Pathophysiology

The symptoms affect almost all organs. Vascular spasm may be caused by INCREASED

CARDIAC OUTPUT that INJURES ENDOTHELIAL CELLS of the arteries and the action of

prostaglandins.

Vascular Spasms causes

1. Vascular Effect Vasoconstriction Poor Organ Perfusion Hypertension2. Kidney Effects Decreased Glomerular Filtration Rate (GFR) and Increased

Permeability of Glomerular Membranes Increased BUN, Uric Acid and Creatinine

Oliguria and Proteinuria

3. Interstitial Effects Diffusion of fluid from blood stream to interstitial tissue edema

1. Gestational Hypertension


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a. Elevated BP of 140/90 mmHg ORb. Elevated Systolic pressure of 30 mmHg ORc. Elevated Diastolic pressure of 15mmHg above prepregnancy leveld. NO PROTEINURIA AND EDEMAManagement: Monitor V/S; BP returns to normal after birth. No drug therapy is

necessary.

Mild Preeclampsia

1. Elevated BP of 140/90 mmHg taken on 2 occasions 6 hours apart OR2. Systolic pressure elevated 30 mmHg OR3. Diastolic elevated 15mmHg above prepregnancy level4. PROTEINURIA of 1 2+on Reagan Test stripon random sample. ORTHOSTATIC PROTEINURIA in long periods of standing they excrete protein at

bed rest they dont.5. MILD EDEMA b/c of protein loss, sodium retention, and GFR; accumulation in the

upper part of body or facial edema

6. Weight gain > 2lbs per week in 2nd trimester and > 1 lb per week in 3rd trimesterindicates abnormal tissue fluid retention.

Nursing Interventions with Mild PreEclampsia

1. Promote Bed Rest: Lateral Recumbent Sodium is excreted at a faster rate than during activity Avoids uterine pressure on vena cava & prevent supine hypotension

2. Promote Good Nutrition Continue usual pregnancy diet. Sodium restriction no longer true may result in

renin-angiotensin aldosterone system and result in increased BP

3. Promote Emotional Support

Severe Preeclampsia


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Monitor BP at least every 4 hours; An increase indicates condition is worsening. Obtain Blood Studies CBC, Platelet Count, BUN, Creatinine to assess liver and renal

function and development of DIC, which often accompanies severe vasospasm;

Because shes at risk of Abruptio Placenta and resulting hemmorhage, blood type

and cross match is drawn; daily hematocrit level to monitor blood concentration.

Weigh client daily at same time each day to evaluate tissue fluid retention (ensurewoman is wearing same weight of clothing as before)

Indwelling Urinary Catheter (Folly) to monitor urine output and compare with input(should be >600ml in 24 hours or >30ml in an hour)

24 hour urine sample for protein and creatinine to evaluate kidney function.3. Monitor Fetal Well Being

External Monitoring of FHB or FHT Oxygen administration to mother to maintain fetal oxygenation.

4. Nutritious Diet Diet high in protein and moderate in sodium

5. Administer Medications to Prevent EclampsiaDrug Indication Dosage Nsg Implication

Hydralazine

(Apresoline)

Pregnancy RiskCatergory C

Antihypertensive

(peripheral

vasodilator)to decrease BP

5 10 mg/IV Administer slowly

to avoid sudden fall

of BP. They cancause Tachycardia

(Increase Heart

Rate)

Maintain Diastolic

over 90 mmHg to

ensure adequate

placental filling

Magnesium

Sulfate (MgSo4)

Pregnancy Category

B

Muscle Relaxant

Prevents Seizure

Classified as

cathartic that

reduces edema

CNS depressant to

Given in loading or

bolus dose.

Loading dose:

4 6g/h IV

Maintenance Dose:

1 2 g/h IV

Administer as IV

PIGGYBACK

Given in loading

dose for 15 30

minutes. Drug acts

asap but effect is

only 30 60


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prevent seizures minutes so

continuous

administration is

needed

Assess Toxicity

Calcium Gluconate

Pregnancy Category

C

MgSo4 Toxicity 10ml of 10%

Calcium Gluconate

Solution 1g/ hour

IV

Always prepare

when administering

MgS04

Symptoms of Magnesium Sulfate Toxicity

1. Decreased urine output (


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Eliciting Ankle Clonus In supine, dorsiflex foot 3x in rapid succession. As you take your hand away, observe

the foot. If no further motion is present, no ankle clonus is present. Usually rated as

absent or present,

Scoring:a. Mild 2 movementsb. Moderate 3 5 movementsc. Severe more than 6 movements

Eclampsia

Seizure or comaaccompanied by S/S of preeclampsia Usually happens late in pregnancy up to 48 hours after birth. Goal:

a. To be free from injuryb. To regain homeostasisc. To maintain fetal oxygenation

Implementationa. Maintain Patent Airwayb. Suction to prevent aspirationc. Protect Mother from injuryd. Monitor Signs of Abruptio Placentae. Monitor FHTf. Note Nature, Onset, and Progression of seizureg. Administer Medications as ordered1. Oxygen Administration

Stages of Eclampsia

Stage Time Appearance of Mother Intervention

Aura

(Momentary

Sensation)

Woman senses convulsion

(something is happening) by

seeing bright stars, smells

sharp foul odor, and epigastric

pain due to ischemia of

pancreas

Tonic 20 seconds Muscles contract

Back Arches

Maintain Patent Airway.

Dont put anything inside


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Woman appears stiff (arms

and legs are stiff)

Jaw closes abruptly and may

bite tongue

Respirations halted causing

client to be cyanotic (d/t

contraction of Thoracic

Muscles)

mouth or tongue

depressor. May cause

broken teeth that can be

aspirated

Position on Left Lateral

to drain secretions and

prevent aspiration

O2 Administration thru

face mask to maintain

fetal oxygenation

Monitor womans oxygen

saturation by pulseoximeter

External Fetal

Monitoring

Clonic 20 secs 1

min

All muscles contract and relax

rhythmically

Inhales and exhales irregularly

and respirations are noisy anduneven

Saliva can be aspirated if not

positioned on the left side

Bowel and Bladder muscles

contract and relax and

incontinence of urine and feces

occurs

Still halted respirations and

remain cyanotic

Needs continuous

oxygenation of mother to

maintain fetal

oxygenation

Administer as ordered:

MgS04 to halt seizures

OR Diazepam Valium UV

Postictal 1 min to 1

4 hours

Semi Comatose

Aroused only by a painful

Monitor FHB

Monitor Uterine


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stimuli Contractions

Monitor Vaginal

Bleeding every 15 mins

Monitor Signs of

Abruptio Placenta (for

woman may not feel

contractions)

Position on left side to

drain secretions

NPO

Avoid stimuli may

initiate another seizure

Hearing is the sense that

is lost and regained first

BIRTH

If pregnancy is >24 weeks, birth decision will be made as soon as womans conditionstabilizes, usually 12 24 hours after seizure. There is evidence that fetus doesntcontinue to grow after eclpamsia, so terminating pregnancy at this time is appropriate

for both mother and child.

For an unexplained reason, fetal lung maturity appears to be advanced rapidly, so eventhe fetus is


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Types of occurrence of PIH:

1. Antepartum convulsion and coma occurs before the onset of labor pains, most severethat increases risk of fetal and maternal mortality

2. Intrapartumoccurs during labor, OB wasnt able to sedate patient3. Post Partum occurs within 24 hours up to 10 14 days; mildestOTHER DRUGS USED IN PIH

Diazepam (Valium)

Pregnancy Risk

Category D

Halt seizures 5 10 mg/IV Administer slowly

Dose may be repeated

every 5 10 min up to 30

mg /hr

Observe Respiratory

Depression or Hypotensionin mother

Observe Respiratory

Depression and Hypotonia

in infant at birth

HELLP SYNDROME Variation of PIH named for the common symptoms that occur:

a. Hemolysis of RBCSb. Elevated Liver enzymes (Alanine Aminotransferase (ALT); Serum Aspartate

Amino Transferase (AST); due to hemmorhage and necrosis of liver)

c. Low Platelet Count(Thrombocytopenia


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Complications:a. Subcapsular Liver Hematomab. Hyponatremiac. Renal Failured. Hypoglycemia (corrected by IV dextrose infusion)

Infant delivered via Vaginal or CS Maternal Hemmorhage may occur at birth b/c of poor clotting ability Epidural Anesthesia not possible b/c of low platelet count that can increases possible

bleeding at epidural site.

HYDRAMNIOS (POLYHYDRAMNIOS)

2,000ml or amniotic fluid index above 24cm Normal Amniotic Fluid at term is 500 1,000 ml Complication:

a. Fetal Malpresentation b/c of additional uterine space allows the fetus to turn.b. PROM d/t increased pressure and possible prostaglandin release.

Assessment

1. Accumulation suggests difficulty offetuss ability to swallow or absorb excessiveurine production which occurs in infants who are anencephalic or who have

tracheoesophageal fistula with stenosis or intestinal obstruction. Excessive urine

output occurs in fetuses of diabetic women (hyperglycemia)

2. Rapid enlargement of uterus3. Small parts of fetus are difficult to palpate because uterus is tense.4. Auscultation of FHT is difficult5. Extreme shortness of breath (overly distended uterus pushes up against diaphragm)6. Lower extremity varicosities and hemmorhoidsManagement

1. Bed Rest to uteroplacental circulation & reduce cervix pressure to help preventpreterm labor.2. Assess V/S3. Assess Lower extremity edema4. PossibleAmniocentisis to remove some amniotic fluid


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5. In most instances of hydramnios, there will be PROM due to excessive pressure,followed by preterm labor. To prevent sudden loss of fluid and danger of prolapsed

cord, membranes can be needled to allow a slow, controlled release of fluid.

POST TERM PREGNANCY / POSTMATURE / POSTDATE Pregnancy that exceeds the normal 38 42 weeks Placenta detoriates which causes inadequate nutrition to fetus. Infant is considered post mature or dysmature Assessment:

1. Meconium Aspiration2. If fetus continues to grow, MACROSOMIA could create a birth problem. However the

usual effect is lack of growth.

3. Lack of oxygen, fluid, and nutrients to the fetus.4. Oligohydramnios (

High Risk Pregnancy Woman With Complications

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