Developed by D. Ann Currie, R.N., M.S.N.

Begins prior to pregnancy for those women with disease processes or conditions such as Cardiac disease, Diabetes Mellitus, Systemic Lupus Erythematosus, etc.

It may also will begin with the first prenatal visit and will continue throughout the pregnancy, into the intrapartum , and postpartum periods.

Many factors may influence the Outcome of a Pregnancy.

The nurse should be able to assess and identify those factors that place the the Antepartum Client at risk.

Age-under 17 or over 30-35 Lower Socioenomic Race-Afro-American or Hispanic Nutritional Status Environmental Factors Pregestational Conditions Substance Abuse Infections-STI’s, TORCH, and other No Prenatal Care See text for complete list

Pregnancy –induced Hypertension disorders:PreeclampsiaEclampsiaHELLP syndromePregnancy-induced

hypertension( Gestational Hypertension Chronic Hypertension

A hypertension condition which may occur in pregnancy starting in the third trimester of pregnancy, and/or the intrapartum, and/or postpartum periods.

The clinical manifestations include: Hypertension- B/P over 140/90 Proteinuria ? Edema( if client has generalized edema

with other clinical manifestations Others …. Depending on severity Types- mild, moderate, and severe

Risk Factors:NulliparityMaternal age-teens under 19 or over 30Race-Afro-American and HispanicsLower Socioeconomic statusFamily history of preeclampsiaChronic hypertensionDiabetes mellitusSystemic Lupus ErythematosusMultigestationGestational Trophoblastic diseaseFetal hydrops

Complications of Preeclampsia Hypertensive Crisis Pulmonary edema Renal Failure HELLP DIC Eclampsia Cerebral Vascular

Accident Blindness Hepatic Failure Hepatic Rupture

Abruptio placenta Uteroplacental

insuffiency IUGR Preterm delivery Fetal Death Maternal Death-3th leading cause of

maternal mortality in USA

Mild Preeclampsia:Hypertension over 140-/90 –MAP-over 105Proteinuria( over 1+)0.3grams/liter in a 24

hour urine collectionWeight gain(2-2.5 pounds/week)?edemaOther

Moderate Preeclampsia:B/P-160/100Proteinuria-+3Edema facial and fingerVisual Problems

Severe Preeclampsia:: B/P – Over 180/110 ,MAP- Proteinuria- 3+to4+ or more than 500grams

in a 24 hour specimen. Oliguria-less 400-500ml/day or less than 30

ml/hour Sudden large weight gain Generalize edema-facial, lung may have

crackles Central nervous system irritability:

Headaches Hyperreflexia-DTR’s greater than +3-+4 with

clonus Visual disturbances-scotomata or burred vision

Cont-Severe PreeclampsiaHepatic involvement- upper right quadrant

pain or epigastric pain.Pulmonary edemaothers

Nursing Assessment guidelines for the client with preeclampsia:• Obtain a thorough history

• Past medical history-check risk factors• Past Obstetrical history• Current pregnancy history

• Assessment of the various systems• Cardiovascular assessment:• Vital signs and B/P frequency will depend of severe of

preeclampsia• Ausculate heart sounds and lung sounds• Assess for edema-generalized pitting and pulmonary

edema• Daily weight-A.M. same scale• Check capillary refill

CONT. -Nsg. Assessment• Respiratory Assessment:• Assess respiratory rate, quality, and pattern • Ausculate lung sounds• Assess skin color.• Monitor oxygenation with pulse oximetry if

indicated• Renal Assessment:• Assess Strict Urinary Output- frequency will

depend on severity of preeclampsia maybe as often as every hour.

• Assess for Protienuria-dipstick• Maintain 24 hour urine collect• Monitor laboratory valves-Electrolytes, BUN,

Creatine, Serum protein, Uric acid

Cont. Nsg. Assessment-• Hematologic-• Monitor Laboratory Studies

• CBC-RBC, PLT, Hg, and Hct • Coagulation profile-fibrogen, fibrin split products,

coagulation factors, PT ,and PTT• Monitor client for bleeding-in urine, bruises, etc.

• Central Nervous System Assessment• Assess DTR’s• Assess level of consciousness• Pain- headaches• Visual changes• Assess for clinical manifestation of ICP-H/A, N/V, etc.• Change in behavior

Liver Assessment Assess for pain-epigastric or upper right quadrant pain Monitor Liver Functions:

LDHSGOTSGPTAlkaline phosphateBilirubin

Assess Skin Color Fetal Assessment

Fetal movement NST Biophysical Profile

Uterine Assessment Monitor for uterine contractions Assess for Uterine bleeding-Placental abruption. Assess for clinical manifestations of

uteroplacental insufficiency- AFI under 5cm or Decrease FM

Nursing Diagnoses:Alt.Tissue Perfusion-Cerebral, Uterine, Renal

, etc relate to VasospasmsRisk for InjuryFluid Volume Deficient

Nursing Care for the client who has Preeclampsia: depends on the severity of the disorder. Mild Preeclampsia:

Bedrest at home-BRP- Bed exercises Frequent rest periods or naps Diet high in protein-70grams-100grams and no added salt/ no salty foods-2-4grams of

sodium Daily Weights- A.M. Assessment of B/P , dipstick urine for protein. Fetal movement counts Teach client/family signs to report to health care

provider that may indicate complications Client will frequent visits will the doctor-discuss the

importance of these visits Provide support for client’s/family’s concerns and

fears.

Moderate Preeclampsia:The client with moderate and severe

Preeclampsia will be admitted to the hospital.

SEVERE PREECLAMPSIA: Bed rest Decrease CNS stimulation:

A quiet calm environment:Lights lowLimit visitors

Prepare Room/equipment for emergencies : Pad side rails Oxygen and suction setups IV equipment that can handle several kind of medications

or lines Dinomap and pulse oximeter Fetal Monitor for continuous monitoring Foley catheter Preeclampsia tray:

Emergency equipment and drugs including : Calcium gluconate Valium

SEVERE PREECLAMPSIA:Complete initial and continuous assessment( see

guideline for assessment)Diet – maybe high in protein or NPOVital signs- B/P, HR, RR, and FHR every 15 minutes Intake and output every hour-strictDeep tendon reflexes every 15 minutesDaily WeightsPosition client in lateral position Monitor IV infusionsMonitor laboratory tests

SEVERE PREECLAMPSIA: Medications Magnesium Sulfate-Antidote-Calcium

gluconate Hypertensive agents:

Methyldopa-Aldomet Hydralazine- Apresoline Labetalol-Normodyne Nifedipine-Procardiac xl Nitroprusside sodium-Nitropride

Glucorticosteriods-solu-medrol Diazepam-Valium and/ or Phenytoin- Dilantin Diuretics- Lasix-only with CHF or pulmonary

edema

ECLAMPSIA is the development of: Convulsions(seizures) Tonic-Clonic seizures Coma

in the client who has clinical manifestations of preeclampsia.

It can occur in the antepartum, intrapartum, or postpartum periods.

Nursing Care: Seizure care- refer to med-surg. text Monitor fetal status and prepare for delivery Prevent complications Administer Medications

HELLP Syndrome is a multisystem condition, a severe form of preeclampsia in which the client may present with a variety of clinical manifestations.

Exhibits common laboratory markers:H: Hemolysis.-Low RBC, present of burr cellsEL: Elevated Liver enzymes .- All liver

functions will be highLP: Low Platelets.-PLT.-less than 100,000The progression from severe preeclampsia

to the development of multiple organ involvement and damage leads to HELLP.

The client may complain of malaise, epigastric or upper right quadrant pain, nausea and vomiting, or vague symptoms ( not feeling well). She may be pale or jaundice.

Nursing Care- Assessments and management of care is the

same as severe preeclampsia. Monitor laboratory values:

CBC Liver Function Tests Coagulation Studies Type and Crossmatch

Possible Blood Transfusions and /or Platelet

Cont. NSG. Care:Prepare for deliveryNotify Charge nurse ,Anesthesia staff, and

INCClient will go to a Intensive Care UnitClint will have a Central line placed. Medical or surgerical physicians maybe

called in.Equipment maybe needed from the surgery

unit.

Pregestational Hypertension Maintain B/P within normal limitsObserve for complicationsMedications:

The pregnant client should not take ACE Inhibitors or Beta Blockers for antihypertension agents.

Also Diuretics are usually not given except with the client will CHF

Monitor Fetal Well BeingAssist client to use non- pharmacological

methods to help to control blood pressure.

ECTOPIC PREGNANCYGESTATIONAL TROPHOBLASTIC DISORDER ABORTIONSPLACENTA PREVIAABRUPTIO PLACENTA

ECTOPIC PREGNANCY is one in which the fertilized ovum implants in a location other than the endometrial cavity of the uterus.

The Fallopian Tube is the most common site.

The risk of an ectopic pregnancy increases with STI’s and with increase age(35-45)

Ectopic pregnancy is a significant cause of first trimester maternal deaths.

Clinical manifestations:Mild vaginal bleedingAbdominal painPalpable massSigns of blood lossUltrasound will confirm an extrauterine

pregnancy Management of the ectopic pregnancy:

Surgerical involves laparoscopy or laparotomy for salingectomy with the partial or complete removal of the fallopian tube or removal of the ectopic pregnancy from other sites. –Prep for surgery

Alternate method to surgery is administer of Methotrexate Only if the fetus is under 2.5-3.5 cm. Single dose Follow-up with ultrasounds and beta-hCG

Start IV as soon possible- be prepare to give blood

Provide emotional support to the client If client is Rh-negative administer RhoGam Monitor client for hemorrhage and infection Discharge Instructions :

Teach client to report signs of infection and/or blood loss to the health provider

Anemic clients should take iron supplements Importance of follow up care.

GESTATIONAL TROPHOBLASTIC DISEASE is also know as Hydatidiform Mole or Molar pregnancy.

It is an abnormal growth of the trophoblasitc tissue including the placenta and chorion.

Risk Factors: Clients of Southeast Asia- Japanese or Taiwan

descent Mothers over 40 Possibly Vitamin A deficiency Previous GTD.

Complications: Hemorrhage Infection Choriocarcinoma DIC

Clinical Manifestations:Vaginal Bleeding- red to prune colorSevere nausea and vomitingUterine size greater than datesPassing on grape-like vesiclesNo fetal parts palpated and no FHR heardAbnormal labs :

Very high hCG levels Very low MSAFP Possible low Rbc, Hct, and Hg

Clinical Manifestations:Preeclampsia prior than 20 weeksUltrasound will have characteristic “snow storm”

pattern with no fetus Nursing Care for client who has GTD:

Monitor Vital Signs Insert IV catheter and maintain IV infusionPrepare the client for surgery-suction uterine

evacuation of mole.Administer RhoGam is client is Rh-negative.Administer chemotherapy as order- Methotrexate

Cont. NSG. Care:Teach client:

About the disease process, and treatment The need for follow up care for a year Weekly hCG testing at first, than every 3monthsfor a

year No pregnancies for at least one year and the use of

contraception Signs of problems to report to the health care provider About the Medications being used

Acknowledge and support the need to grieve the loss of the pregnancy

• An ABORTION is the termination of a pregnancy prior to 20 weeks. In Texas a fetus must have two of the three criteria’s; be under 20 weeks, or under 500 grams, or under 14 inches, to be considered an abortion.

• Types of Abortions: • Spontaneous- lay term is Miscarriage• Elective or Therapic-surgically or medically induce

termination of the pregnancy.

TYPES of SPONTANEOUS ABORTIONS:Threatened Abortion Inevitable Abortion Incomplete AbortionComplete AbortionMissed AbortionReoccurring Abortions (Habitual Abortion)Septic Abortion

Risk Factors: vary

Clinical manifestations: May vary Vaginal bleeding Cramping May have cervical dilation May pass tissue and/or clots Dull backache Regression of signs of pregnancy Falling hCG levels No fetal heart tone Smaller uterine size Signs of infection in infection is present

Nursing Care: Depends on the type of spontaneous abortion Bedrest and no sexual activity if threaten abortion Save any tissue pass Prepare for surgery: dilatation and curettage(D&C)

Assess client Insert IV catheter and maintain IV infusion Obtain lab specimens and sent to lab:

CBCType and Rh- Type and cross matchSerum beta-hCGPossible coagulation studies

Prepare for ultrasound Administer RhoGam if client is Rh-negative Provide emotional support remember this a loss Refer to pregnancy –loss or grief support groups

If client spontaneous loses baby 0r it is an intrauterine death and if the client/family would like to view and/or visit with baby, Provide the opportunity in a private area

Allow the client to name the baby Take pictures Give something for the client to take home Clean the baby with soft cloth or cotton Never give a cold baby…Wrap in warm blankets Allow family to visit Provide the opportunity for religion beliefs

Elective Abortion is the intentional termination of pregnancy before 20-24weeks.

Therapeutic Abortion is the termination of the pregnancy for medical reasons.

The termination of the pregnancy is done by surgery – Dilatation and Curettage (D&C) or with medications called abortifacts

The nurse should be aware of the state’s specific regulations governing abortions.

Abortions have many ethical issues. The nurse should know beliefs concerning this issue.