Complications Antepartum Period

Risk Factors

•      compromise health of mother and fetus

•      excellent assessment skills competent nursing care

•      identify potential problems

•      interventions

•      goals for desired outcome

Risk factors

•      multiple pregnancy

•      hyperemesis gravidarum

•      infections

•      bleeding disorders

•      PIH

•      Anemia

•      diabetes

Multiple Pregnancy

•      higher risk of other complications

•      higher incidence of Preterm labor - enlarge uterus

•      more likely for surgical intervention

Diagnosis of Multiple Pregnancy

•      fundal height grows rapidly

•      rapid weight gain

•      more than one heart beat on doppler

•      definitive diagnosis made by ultrasound

 Hyperemesis Gravidarum

•      persistent and frequent nausea and vomiting

•      usually after the first trimester

•      accompanied by sleep loss, restlessness, exhaustion and weight loss

•      lead to dehydration and electrolyte imbalance

Assessment

•      good assessment

•      daily weights, skin turgor, mucous membranes, lab values

•      identify triggers for N/V

•      food and odors common

Treatment

•      hospitalization if severe

•      clear liquid

•      when solids introduced - small frequent meals

•      restful environment

Infections

•      mother and fetus at risk

•      consider immunosuppressed state

•      decreased ability to fight infection

•      susceptible to many different types of infections

Types of Infections

•      UTI’s - urinary tract infections

•      vaginal infections

•      rubella

•      STD’s

UTI’s - Urinary Tract Infections

•      caused by anatomic changes in urinary tract

•      enlarging uterus compresses ureters

•      decreased flow to bladder

•      urinary stasis

•      stagnant urine great medium of growth

Types of UTI’s

•      Bacteriuria- (ASB) asymptomatic lower tract inflammation of bladder

•      acute cystitis- inflammation of bladder

•      pyelonephritis - inflammation of kidney

•      causative organism - escherichia coli

Signs and Symptoms

•      depends on type

•      lower - frequency, urgency , dysuria, lower abd. Pain

•      upper - sever - elevated temp, chills, lower back pain, N/V

Diagnosis

•      history

•      symptoms

•      midstream urine + bacteria

•      C&S of urine - identify causative organism

Treatment

•      antibiotics

•      increased fluid intake

•      rest cranberry juice

Vaginal Infections

•      most common organism - candida albicans

•      normally found in intestines

•      parasite

Signs & Symptoms

•      thick white cheesy discharge

•      intense itching

•      burning

Treatment

•      seek medical attention

•      not use O.T.C unless directed by M.D

•      antifungal

•      treatment of male partner

Rubella

•      German measles

•      serious if contracted by pregnant women

•      cause major anomalies in fetus

•      L.B.W, deafness, mental retardation, congenital heart, hepatitis

•      prenatal antigen testing is done

•      if titer is less than 1:8 needs to avoid exposure

•      vaccine cannot be given during pregnancy

•      wait 3 months before getting pregnant

Bleeding disorders

•      hemorrhage remains one of the number one causes of maternal death

•      any bleeding potential threat to mother and infant

•      encourage  mother to report any bleeding

•      bleeding classified as early, or late according to trimester

Causes of Bleeding in Early Pregnancy

•      ectopic pregnancy

•      abortion

•      incompetent cervix

•      gestation trophoblastic disease GTD

Ectopic Pregnancy

•      blastocyst implants in place other than endometrium

•      95% in fallopian tubes - other in cervix, ovaries & abdomen

•      almost 100% lead to fetal death

•      leading cause of maternal death in first trimester

•      incidence is 1 in 44 pregnancies in U.S

Causative Factors

•      most common cause - PID

•      other  causes

–   tubal surgery, tubal anomalies, previous ectopic, endometriosis, hormonal imbalances

–   defective embryo, use of IUD

–   higher rates in later prenatal care and smokers

Problems

•      rupture of tube

•      bleeding in abdominal cavity

•      hypovolemic shock results from hemorrhage

•      slow bleeding causes board hard abdomen

•      peritonitis

Treatment

•      removal of affected tube - salpingectomy

•      usually with laparoscopy

•      may repair if wants further pregnancies

•      higher incidence of future ectopic pregnancies

Assessment

•      s/s of normal pregnancy

•      symptoms appear in 6-12 weeks

•      early symptoms

–   faintness, dizziness, sharp stabbing abdominal pain, referred shoulder pain

–   scant, dark brown vaginal bleeding

–   some cases no symptoms but enlarged uterus and adnexal mass tenderness

•      diagnosis

–   client history

–   sono-abdominal or trans-vaginal

–   HCG is less

Interventions

•      vital signs, monitor bleeding  and pain

•      bleeding may be scant

•      look for symptoms of peritonitis

•      fluid/electrolyte replacement

•      blood transfusions

•      Rhogam if RH negative

Abortion

•      termination of pregnancy before age of viability

•      varies from state to state - 20-24 weeks

•      types - spontaneous  or elective

•      spontaneous - involuntary and has variety of natural causes

•      electives- intentional termination for medical or personal reasons

Spontaneous

•      classified - early or late

•      early - before 12 weeks

•      late - between 16-20 weeks

•      15% of all pregnancies end in spontaneous AB

Causes of Spontaneous Abortions

•      maternal

–   structural problems, incompetent cervix, infection, poor nutrition, trauma, substance abuse, exposure to teratogens

•      placental

–   abnormal placental implantation, premature separation

•      fetal

–   abnormal genetics, implantation problems

Assessment

•      vaginal bleeding and lower abdominal cramping

•      longer the gestation the heavier the bleeding

•      other s/s

•      diagnosis based on symptoms and ultrasound

Classifications of Spontaneous Abortions

•      threatened - completion of pregnancy in doubt

•      inevitable- unable to prevent

•      incomplete- all products are not expelled

•      missed- fetal death without expulsion

•      septic- products become infected

•      habitual - three or more AB’s

Interventions

•      depends on whether AB has already occurred

•      threatened care directed at decreasing risk

–   bed rest , reduce stress factors, sedatives, refrain from sexual intercourse, cont. assessment

•      has occurred

–   bleeding and pain level, intravenous fluid replacement , blood transfusion & Rhogam

Incompetent Cervix

•      premature dilation of cervix before the end of pregnancy

•      dilation occurs when cervix not able to support increased weight

•      cause unknown

•      congenital factors- bicornate uterus, short cervix , congenital malformations related to maternal ingestion of DES

Treatment

•      circlage - ribbon band of suture around the cervix

•      called McDonald stitch

•      bed rest if contractions start

•      remove stitch at 37 weeks

GTD - Gestational Trophoblastic Disease

•      development anomaly of placenta when the ovum doesn’t develop normally

•      also known as a hydatiform mole

•      degenerative process of chorionic villi causing multiple  cyst to grow rapidly

•      described as clusters or bunches of grapes

Incidence

•      1 in every 1200-1500 pregnancies

•      increased with maternal age and parity

•      increase in women on clomiphene - clomid

•      women with previous GTD

Diagnosis

•      objective and subjective data

•      history and physical exam

•      ultrasound will reveal no fetus - just mass of tissue

•      tissue may be benign or malignant

•      choriocarcinoma occurs in 20% of all cases

Treatment

•      surgical removal of molar mass

•      hysterectomy may be performed to reduce risk of malignancy

•      chemo if mole is malignant

Assessment

•      intermittent or continuous dark red or brown vaginal bleeding

•      anemia

•      uterus enlarges rapidly - larger than for gestation

•      no fetal heart tones - no movement

Bleeding in Late Pregnancy

•      placenta previa

•      placenta abruptio

Placenta Previa

•      most common cause of bleeding in second half of pregnancy

•      placenta attached in the lower uterine segment

•      occurs 1 in every 200-300 pregnancies

•      contractions may loosen placenta and cause bleeding

Classification

•      depends  on the degree with which the placenta covers the cervical os

•      three types

•      total or complete - covers internal os

•      partial or incomplete - partial covers os

•      marginal or low lying - near cervical opening

Cause

•      unknown

•      incidence increases in multigravidas and advance maternal age

•      previous C/S

•      multiple pregnancy

Diagnosis

•      history and physical

•      symptom - painless uterine bleeding- bright red

•      breech position

•      presenting part remains unengaged

Treatment

•      fetus less than 37 weeks and bleeding mild - conservative

•      immediate C/S if hemorrhaging

Assessment

•      classic sign- painless bright red uterine bleeding

•      abdomen is soft

Placenta Abruptio

•      premature separation of placenta during second half of pregnancy

•      1 out of 250 pregnancies

•      three types based on degree of separation

•      partial separation with concealed hemorrhage

•      complete separation with concealed hemorrhage

•      partial  separation with external hemorrhage

Cause

•      unknown

•      contributing factors

–   hypertension

–   nutritional

Signs and Symptoms

•      uterus hard and painful

•      bleeding if present - dark red

•      ultrasound is definitive

Disseminated Intravascular Coagulation - DIC

•      over-stimulation of coagulation process

•      not a primary disease results from other conditions

•      results in depletion of coagulation factors and fibrinogen

•      diagnosis made based on bleeding tendencies and lab values

•      decreased platelets and antithrombin III

•      prolonged PT and PTT

•      goal of treatment to prevent shock

PIH

•      leading cause maternal mortality

•      develops after twenty weeks gestation

•      causes CVA, cerebral hemorrhage, pulmonary edema, renal failure, hepatic rupture, cardiac failure, abruptio placenta, DIC, IUGR

Cause

•      unknown

•      theories

•      decreased blood supply to uterus

•      hormonal

•      autoimmune responses

•      genetic factors

Classic Signs

•      elevated blood pressure

•      edema

•      proteinuria

Classifications of PIH

•      gestational Hypertension

•      preeclampsia

•      eclampsia

Gestational Hypertension

•      significant blood pressure increase after 20 weeks

•      no proteinuria

•      systolic >30 mmhg

•      diastolic >15 mmhg

•      important baseline before pregnancy

Preeclampsia

•      hypertension with proteinuria and /or edema after 20 weeks

•      classified as mild or severe

•      mild

•      severe

Mild Preeclampsia

•      B.P similar to gest. Hypertension

•      protein in urine 1-2+

•      edema feet

Severe Preeclampsia

•      B.P > 160/110 mmhg

•      proteinuria 3 to 4+

•      oliguria

•      headache, blurred vision , spots

•      pitting edema of legs

•      dyspnea, hyperreflexia, anxiety, irritability

•      nausea and vomiting

•      epigastric pain

Eclampsia

•      seizing

•      kidney failure

Chronic Hypertension

•      prior to 20 weeks

•      preexisting condition

•      treatment variable

•      depends on cause

Anemia

•      diagnosis

•      hgb & hct

•      iron supplement depending on severity

•      ferrous sulphate and folic acid

•      blood transfusion

Diabetes

•      gestational >after 20 weeks

•      preexisting < 20 weeks

Gestational Diabetes

•      assessment

•      diagnosis

•      treatment