complications of of pregnancy pregnancy jeanie ward
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Risk FactorsRisk Factors
Age – under 17 over 35Gravida and ParitySocioeconomic statusPsychological well-beingPredisposing chronic illness –
diabetes, heart conditions, renal, etc.
Pregnancy related conditions – hyperemesis gravidarum, PIH, etc.
High Risk Pregnancy Goals of Care
Provide with optimum care for the mother and the fetus
Assist the patient and her family to understand and cope with the variations in a High Risk Pregnancy and cope with her feelings
AbortionsAbortions
Termination of pregnancy at any time before the fetus has reached the age of viability
Either: spontaneous – occurring
naturally induced – artificial
Etiology / Predisposing FactorsEtiology / Predisposing Factors
Faulty germ plasm -- imperfect ova or sperm, faulty implantation, genetic make-up (chromosomal disorders), congenital abnormalities
Decrease in the production of progesterone
Drugs or radiation
Maternal causes -- infections, endocrine disorders, malnutrition, hypertension
Assessment Types of Abortions Threatened
Assessment Types of Abortions Threatened
Signs and Symptoms vaginal bleeding, spotting Mild cramps, backache Cervix remains CLOSED
Treatment and Nursing Care Bed rest, sedation, Avoid stress and intercourse Progesterone therapy A period of “watchful waiting”
Inevitable Abortion Inevitable Abortion Signs and Symptoms
Loss is certain Bleeding is more profuse Painful uterine contractions Cervix DILATES
Treatment and Nursing Care Assess all bleeding. Save all pads. (May
need to weigh the pads) Use the bedpan to assess all products
expelled Treated by evacuation of the uterus
usually be a D & C or suction
Provide Psychological Support
Complete AbortionComplete Abortion
All products of conception are expelled
No treatment is needed, but may do a D & C
Incomplete Abortion Incomplete Abortion Parts of the products
of conception are expelled, with placenta and membranes retained
Treated with a D & C or suction evacuation
Provide support to the family
Missed Abortion Missed Abortion
The fetus dies in-utero and is not expelled
Uterine growth ceases Breast changes regress Maceration occurs Treatment:
D & C Hysterotomy
Missed AbortionCritical Thinking ExerciseMissed AbortionCritical Thinking Exercise
The woman who has a missed abortion is at risk for what 2 conditions?
Habitual Abortion / Premature Cervical Dilation
Habitual Abortion / Premature Cervical Dilation
Abortion occurs consecutively in three or more pregnancies
Usually due to an Incompetent Cervical Os, that results from cervical trauma, cervical lacerations, repeated D & C, or conization.
Occurs most often about 18-20 weeks gestation.
Habitual Abortion Habitual Abortion
Treatment Cerclage procedure -- purse-
string suture placed around the internal os to hold the cervix in a normal state
Nursing CareNursing Care
Bedrest in a slight trendlenburg position to decrease the pressure on the new sutures
Teach: Assess for leakage of fluid, bleeding Assess for contractions Assess fetal movement and report
decrease movement (if old enough) Assess temperature for elevations
DeliveryDelivery
When time for delivery there are several options: physician will clip suture and allow
patient to go into labor on her own induce labor cesarean delivery
Mrs. B. had a cerclage procedure done at 14 weeks gestation. She is now 39 weeks gestation and admitted to labor and delivery because she is in labor.
What is the MOST important assessment to make at this time?
Key Concepts to Remember!!
Key Concepts to Remember!!
If a woman is Rh-, RhoGam is given within 72 hours
Provide emotional support. Feelings of shock or disbelief are normal
Encourage to talk about their feelings. It begins the grief process
Bleeding Disorders Ectopic Pregnancy
Bleeding Disorders Ectopic Pregnancy• Implantation of the blastocyst in
ANY site other than the endometrial lining of the uterus
(5) Cervicalovary
Etiology / Contributing Factors Etiology / Contributing Factors
• Salpingitis• Pelvic Inflammatory Disease, PID• Endometriosis• Tubal atony or spasms• Imperfect genetic development
Assessment Ectopic Pregnancy Assessment Ectopic Pregnancy
• Early:• Missed menstruation followed by
vaginal bleeding (scant to profuse)• Unilateral pelvic pain, sharp abdominal
pain• Referred shoulder pain• Cul-de-sac mass
• Acute:• Shock – blood loss poor indicator• Cullen’s sign -- bluish discoloration
around umbilicus• Nausea, Vomiting• Faintness
Diagnostic Tests Ectopic Pregnancy Diagnostic Tests Ectopic Pregnancy
• Diagnosis:• Ultrasound• Culdocentesis• Laparoscopy
Interventions / Nursing CareInterventions / Nursing Care
• Combat shock / stabilize cardiovascular • Draw blood for type and cross match• Give blood replacements • IV’s.
• Laparotomy
• Psychological support
• Linear salpingostomy
• Methotrexate – used prior to rupture. Destroys fast growing cells
Hydatiform Mole
Etiology
Hydatiform Mole
Etiology
A DEVELOPMENTAL ANOMALY OF THE PLACENTA WITH DEGENERATION OF THE CHORIONIC VILLI
As cells degenerate, they become filled with fluid and appear as fluid filled grape-size vessicles.
Assessment: Assessment:
• Vaginal Bleeding -- scant to profuse, brownish in color (prune juice)
• Enlargement of the uterus out of proportion to the duration of the pregnancy
• Vaginal discharge of grape-like vesicles• May display signs of pre-eclampsia early• Hyperemesis gravidarium• No Fetal heart tone or Quickening• Abnormally elevated levels of HCG
Interventions and Follow-UpInterventions and Follow-Up
• Empty the Uterus by D & C or Hysterotomy
• Follow-Up for One Year• Assess for the development of
choriocarcinoma• Blood tests for levels of HCG frequently• Chest X-rays• Placed on oral contraceptives• If the levels rise, then chemotherapy started
usually Methotrexate
Critical Thinking ExerciseCritical Thinking Exercise
A woman who just had an evacuation of a hydatiform mole tells the nurse that she doesn’t believe in birth control and does not intend to take the oral contraceptives that were prescribed for her.
How should the nurse respond?
Placenta PreviaPlacenta Previa
• Low implantation of the placenta in the uterus
• Etiology• Usually due to reduced vascularity in
the upper uterine segment from an old cesarean scar or fibroid tumors
• Three Major Types:• Low or Marginal• Partial• Complete
Abruptio PlacentaAbruptio Placenta
Premature separation of the placenta from the implantation site in the uterus
Etiology: Chronic Hypertension Sudden decompression of an over-
distended uterus Trauma Injudicious use of Pitocin Smoking / Caffeine / Cocaine Vascular problems
Placenta PreviaPlacenta Previa• PAINLESS vaginal
bleeding• Bright red bleeding• First episode of
bleeding is slight then becomes profuse
• Signs of blood loss comparable to extent of bleeding
• Uterus soft, non-tender
• Fetal parts palpable; FHT’s countable
• Blood clotting defect absent
Abruptio PlacentaAbruptio Placenta Bleeding accompanied Bleeding accompanied
Abruptio by PAINAbruptio by PAIN Dark red bleedingDark red bleeding First episode of First episode of
bleeding usually bleeding usually profuseprofuse
Signs of blood loss out Signs of blood loss out of proportion to visible of proportion to visible amount amount
Uterus board-like, Uterus board-like, painfulpainful
Fetal parts non-Fetal parts non-palpable, FHT’s non-palpable, FHT’s non-countablecountable
Blood clotting defect Blood clotting defect (DIC) likely(DIC) likely
Signs of Concealed HemorrhageSigns of Concealed Hemorrhage
Increase in fundal heightHard, board-like abdomenHigh uterine baseline tone on
electronic fetal monitoringPersistent abdominal painSystemic signs of hemorrhage
Interventions and Nursing Care Interventions and Nursing Care
Placenta Previa Bed-rest Assessment of bleeding Electronic fetal monitoring If it is low lying, then may allow to
deliver vaginally Cesarean delivery for All other types of
previa Abruptio Placenta
Deliver by cesarean delivery immediately
Combat shock – blood replacement / fluid replacement
Blood work – assessment of DIC
Critical ThinkingCritical ThinkingCritical ThinkingCritical Thinking Mrs. A. , G3 P2, 38 weeks gestation
is admitted to L & D with bleeding. What is the priority nursing intervention at this time?A. Assess the fundal height for a decreaseB. Place a hand on the abdomen to assess
if hard, board-like, tetanicC. Place a clean pad under the patient to
assess the amount of bleedingD. Prepare for an emergency cesarean
delivery
Disseminated Intravascular Coagulation (DIC)
Disseminated Intravascular Coagulation (DIC)
Anti-coagulation and Pro-coagulation
effects existing at the same time.
EtiologyDefect in the Clotting Cascade
EtiologyDefect in the Clotting Cascade
An abnormal overstimulation of the
coagulation process Activation of Coagulation with release of thromboplastin Thrombin (powerful anticoagulant) is produced
Fibrinogen fibrin which enhances platelet
aggregation Widespread fibrin and platelet deposition in
capillaries and arterioles
Resulting in Thrombosis (multiple small clots)
Excessive clotting activates the fibrinolytic system
Lysis of the new formed clots create fibrin split products
These products have anticoagulant properties and inhibit normal blood clotting
A stable clot cannot be formed at injury sites
Hemorrhage occurs Ischemia of organs follows from vascular
occlusion of numerous fibrin thrombi Multisite hemorrhage results in shock and
can result in death
Disseminated Intravascular Coagulation (DIC)
Disseminated Intravascular Coagulation (DIC)
Precipating Factors: Abruptio placenta PIH Sepsis Retained fetus (fetal demise) Fetal placenta fragments
Assessment Signs and Symptoms Assessment Signs and Symptoms
Spontaneous bleeding -- from gums and Epistasis, and injection and IV sites, incisions
Excessive bleeding -- Petechiae at site of blood pressure cuff, pulse points. Ecchymosis
Tachycardia, diaphoresis, restlessness, hypotension
Hematuria, oliguria, occult blood in stool
Mental changes if brain affected.
Diagnostic TestsDiagnostic Tests Lab work reveals:
PT – Prothrombin time is prolonged PTT – Partial Thromboplastin Time
increased D-Dimer – increased Product that results
from fibrin degradation. More specific marker of the degree of fibrinolysis
Platelets -- decreased Fibrin Split Products – increase
An increase in both FSP and D-Dimer are indicative of DIC
DICInterventions and Nursing Care
DICInterventions and Nursing Care
Remove Cause Evaluate vital signs Replace blood and blood products Fluid replacement
May give Heparin -- interrupt the clotting cascade and prevent triggering the fibrinolytic system.
Structural DisordersStructural Disorders
Fetal Demise / Intrauterine Fetal Fetal Demise / Intrauterine Fetal DeathDeath
Structural DisordersStructural Disorders
Fetal Demise / Intrauterine Fetal Fetal Demise / Intrauterine Fetal DeathDeath
DEFINITION: Death of a fetus after the age of
viability
Assessment: 1. First indication is usually NO
fetal movement
2. NO fetal heart tones Confirmed by ultrasound
3. Decrease in the signs and symptoms of
pregnancy
Interventions and Nursing Care
• Allow patient to decide when she wants to deliver
• Most women go into labor on their own in 2 weeks, so may wait for labor to begin spontaneously
• Induce labor • Prostaglandin (Prostin E) causes
smooth muscles to contract: Side effects - nausea, vomiting, diarrhea
• Cytogel
• Provide with Emotional Support, allow to hold baby