Nursing Management of Pregnancy At Risk: Pregnancy –Related Complications - PowerPoint Presentation

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Nursing Management of Pregnancy At Risk: Pregnancy –Related Complications

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HIGH RISK PREGNANCY

Healthy People 2020 Goals: REDUCTIONS

MICH-6: Reduce maternal illness and complications due to pregnancy (complications during hospitalized labor and delivery)

Nursing Significance: Will reduce perinatal morbidity and mortality and optimize pregnancy outcomes.

MICH-9: Reduce Preterm births

Nursing Significance:

Will help to preserve the health and well-being of the growing fetus if the pregnancy goes to term.

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MATERNAL DEATHS

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The leading causes of maternal deaths during pregnancy are:

THROMBOEMBOLISM

HEMORRHAGE

INFECTION

HYPERTENSION OF PREGNANCY

ANESTHESIA RELATED COMPLICATIONS

ECTOPIC PREGNANCYHEART DISEASE

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COMPLICATIONS OF BLEEDING

Vaginal Bleeding: deviation from normal that may occur at any time during pregnancy.

1st trimester: threatened, missed, incomplete, or complete abortion /miscarriage.

Cause: Unknown, possible chromosomal or uterine abnormalities.

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REFER to table 19.1 p. 629

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PREGNANCY COMPLICATIONS

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Abortion: is defined as any interruption of a pregnancy before the fetus is viable, whether done by medical or surgical means.

Miscarriage: interruption of pregnancy that occurs spontaneously.

Nonviable pregnancy: fetuses of 20-24 weeks gestation or weighing 500gms or less.

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COMPLICATIONS OF ABORTIONS

DICHEMORRHAGE

INFECTION (Endometritis)

SEPTIC ABORTION

ISOIMMUNIZATION

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ABNORMAL IMPLANTATION

Ectopic Pregnancy

Ectopic: Implantation of zygote at a site other than in the uterus.

Fallopian Tubes

Abdomen

Symptoms: Sudden unilateral lower abdominal pain, minimal vaginal bleeding, signs of shock or hemorrhage.

Treatment: Surgery or Pharmacological with Methotrexate.

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Ectopic

Nursing AssessmentHealth history and Physical exam.Laboratory

Serum Beta-hCG

CBC/Type & RH

Urinalysis

Diagnostic testing

Transvaginal ultrasound

Nursing Management:

Preparation for treatmentVital SignsObserve S/S of hypovolemic shockAnalgesicsSurgical Prep

Emotional SupportEducation

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HYDATIDIFORM MOLE

Gestational Trophoblastic Disease (GTD): Abnormal proliferation of trophoblast tissue; fertilization or division defect

Partial (rarely cancerous)

Complete(associated with Choriocarcinoma.

Assessment: Overgrowth of uterus, highly positive HCG test, no fetus present, bleeding, cyst formation.

Treatment: D&C, HCG weekly until non-detectable (3weeks) then levels monthly for 12 months. Chest x-ray q 6 months, regular pelvic exams

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PREGNANCY: MORBIDITY & MORTALITY DATA

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GTD

Nursing Assessment

S/S pregnancy

Discharge

Anemia

No fetal heart

Ovarian enlargement

Severe morning sickness

Fluid retention/swellingEnlarged uterine sizehCG levels greatly increasedEarly development of preeclampsiaExpulsion of grapelike vesicles

Nursing ManagementPreparing the clientSurgical Intervention

Providing Emotional Support

Pregnancy loss

Potential Life Threatening condition

Spiritual/Cultural Care

Educating the Client

Simple explanations regarding cause of GTD

Follow-up care including hCG levels weekly, need to prevent pregnancy for more than 1 year, contraceptive methods.

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PREMATURE CERVICAL DILATATION

Cervical Insufficiency: Cervix that dilates prematurely and therefore, cannot hold a fetus until term. Pregnancy loss usually occurs at 20 wks gestation.

Cause generally unknown, but may be related to cervical trauma.

Nursing Assessment: H/O Painless bleeding leading to expulsion of fetus, cervical damage, previous loss of pregnancy around 20 wks gestation, vaginal discharge

Treatment: Cerclage: sutures inserted into the cervix (McDonald procedure). Or Shirodkar normally performed at 12-14 wks gestation

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CERVICAL CHANGES

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Shirodkar Procedure/McDonalds

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Nursing Management

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Monitoring for s/s preterm labor

Backache, increase in vaginal discharge, SROM, and uterine contractions.

Emotional Support

Allay anxiety regarding fetal status

Pre-operative teaching

Discuss cerclage

Discharge teachingInclude family in s/s of preterm laborImportance of reporting changes immediatelyImportance of continued follow-up antepartal care

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Placenta Previa

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Bleeding condition that occurs during the last two trimesters of pregnancy.

Placenta implants over the cervical os

Exact cause is unknown

Classified according to the degree of coverage or proximity to cervical os

Total: internal os is completely covered

Partial: internal os is partially covered

Marginal: the placenta is at the margin or edge of the internal osLow-lying: the placenta is implanted in the lower uterine segment, near but not reaching the cervical os.

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PLACENTAL ABNORMALITIES

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Frequently associated with:

Increased parity

Advanced maternal age

Past cesarean births

Past uterine curettage

Multiple gestation

Cocaine usePrior

previa

Smoking

Infertility treatment

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PREVIA ASSESSMENT

Painless bleeding

Duration

Amount

Presence of pain

Previous bleeds

Fetal Heart Rate

Management:

Diagnostic ultrasound

Kleihauer Betke test (used to detect fetal blood in maternal circulation)Bed Rest

No Vaginal Exams

Administer Betamethasone (Celestone) 12mg IM stat and repeated in 24 hrs. and 1-2wks.

Rhig Workup

Cesarean Birth

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Nursing Management

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Thorough history and physical

VS

FHR/Contractions

Laboratory

Support

Education

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ABRUPTIO PLACENTA

Premature separation of placenta

Partial

Complete

Causes: Unknown, associated with hypertension, high parity, short cord, PIH, trauma, drugs and cigarettes.

Assessment:

Sharp abdominal pain

uterine tenderness

Vaginal Bleeding Couvelaire Uterus (concealed hemorrhage)

Maternal shockFetal distress

DIC

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ABRUPTIO MANAGEMENT/Obstetrical

Emergency

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Vital Signs

Fetal Heart Rate

Routine Labs

DIC workup

IV Therapy

Vaginal Delivery or Cesarean Section

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Nursing Management

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Ensuring adequate tissue perfusion

VS, pulse ox, FHR, Contractions

IV therapy

Strict bed rest

Left lateral position (to prevent vena cava compression)

Oxygen therapyIndwelling foley cath

Observe for hypovolemic shock, DICSupport and Education

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PLACENTAL ABRUPTION

PLACENTAL PREVIA

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Placenta Accreta

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Condition in which the placenta attaches itself too deeply into the wall of the uterus but does not penetrate the uterine muscle.

Diagnosed after birth when placenta does not separate from the uterine wall.

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Hyperemesis Gravidarum

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Occurs in 5 out of1000 pregnancies

Defined as persistent vomiting unresponsive to outpatient treatment and is severe enough to cause weight loss and disturbed nutritional status.

Related to increasing level of hCG.

Lasts beyond 12 weeks gestation.

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Symptoms Hyperemesis

Electrolyte imbalanceDehydration

Weight loss

Acidosis

Alkalosis

Ketonuria

Hypokalemia

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Therapeutic Management

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Dietary and lifestyle alterations

Hospitalization/ NPO status (24-36 hours)

Oral nutritional supplementation

Pharmacologic preparations

Promethazine (Phenergan)

Prochlorperazine (Compazine)

Ondansetron (Zofran)

IV vitamin-mineral therapy

Parenteral nutrition

Enteral tube feedings

Supportive psychotherapy

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Nursing Management

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Health History and Physical Examination

Review of antepartal record

Lab testing review (LFT’s, CBC, BUN, serum electrolytes, urinalysis, urine specific gravity, ketones, and ultrasound results)

Promote Comfort and Nutrition

Support and Education

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Umbrella of Hypertensive Disorders In Pregnancy

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Chronic

Gestationa

l

Preeclampsia

Eclampsia

HELLP

Hypertensive Disorders

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CLASSIFICATION OF HYPERTENSION IN PREGNANCY

BP > 140/90 mm Hg

Chronic Hypertension

Onset before 20 weeks gestation, persists after pregnancy, may be essential or secondary

No Proteinuria or edema

Gestational Hypertension

Onset in the 3

rd

trimester, subsides by 3

rd

month postpartum, no evidence of organ dysfunction

Preeclampsia

HTN after 20 weeks

Proteinuria1-2+

Edema, Organ dysfunction,

Hyperreflexia

Eclampsia

Severe BP elevations, proteinuria, 3-4 + hyperreflexia, clonus, seizures

Major organ dysfunction

HELLP Syndrome can occur as a complication of all classifications of hypertension

Hemolysis

Elevated Liver Enzymes

Low Platelets

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Chronic Hypertension

Existence of high BP prior to pregnancy or before the 20

th

week of gestation

Persists beyond 12 weeks postpartum

Preconception counseling

Antihypertensive agents reserved for severe hypertension Systolic > 160mmHg or Diastolic >100mm/Hg

Medication Therapy: Methyldopa (Aldomet)

Labetalol (Transdate)

Atenolol (Tenormin)

Nifedipine (Procardia

)

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GESTATIONAL

HYPERTENSION

PIH is a condition in which vasospasm occurs during pregnancy.

Symptoms:

Elevated BP

No Proteinuria

No Edema

Occurrence: Primiparas <20yrs or >40yrs

Low Socioeconomic backgroundGrand Multipara’s

African American’sMultiple pregnancyHydraminos,

Underlying conditions

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ASSESSMENT & CLASSIFICATION OF PIH

Visual changes

Hypertension

Proteinuria

Edema

Rarely occurs before 20 wks. gestation

Mild Preeclampsia: BP 140/90 X’s2 6hrs apart, Proteinuria 1-2+, edema

Eclampsia: Most severe, cerebral edema, seizures or

coma

Severe: BP 160/100 or higher X’s 2 6hr apart, marked protein 3-4+ Pitting edema. Epigastric pain, N/V

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PIH NURSING INTERVENTIONS

BEDREST

GOOD NUTRITION

EMOTIONAL SUPPORT

MONITOR FETAL-MATERNAL WELL-BEING

DRUG THERAPY

Magnesium Sulfate

Seizure prevention

Apresoline

LabetalolProcardia

Sodium Nitroprusside

Lasix

IV Sedation

Calcium Gluconate For Magnesium Toxicity

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Nursing Management Magnesium Sulfate

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Hourly assessments for the following:

Blood pressure

Deep Tendon Reflexes (DTR)

Respiratory Rate: > 12/min

Urine output: > 30mL/hr

Magnesium Sulfate levels4-7mEq/L are considered therapeutic

>8mEq/L are considered toxic10mEq/L: loss of DTR’s15mEq/L: respiratory depression

25mEq/L: cardiac arrest

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HELLP SYNDROME

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A variation of PIH named for the common symptoms that occur.

H

-Hemolysis

E

-Elevated

Liver Enzymes

L-Low Platelets

Maternal Mortality 24%

Infant Mortality 35%

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HELLP SYMPTOMS

NauseaEpigastric Pain

General Malaise

Right Upper Quadrant tenderness.

Lab Values:

RBC’s-Thrombocytopenia, platelet count <100,000

Elevated liver enzymes: ALT/AST

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TREATMENT OF HELLP

SUPPORTATIVE THERAPYVital Signs

Maternal/Fetal Assessments

TRANSFUSIONS OF:

Fresh Frozen Plasma

Platelets

DELIVERY OF FETUS

Vaginal

Cesarean Section

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ISOIMMUNIZATION

Rh Incompatibility- a blood incompatibility between mother and fetus. Only the fetus is affected. A mixing of maternal and fetal blood. Usually only affects 2nd or greater pregnancies.

Causes:

Amniocentesis

Percutaneous Umbilical Blood sampling

Placental separation

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ISOIMMUNIZATION

Testing and Treatment

Antenatal testing

Anti-D Antibody Titer (Indirect Coombs)

Normal results:

Repeat at 28 wks gestation

Abnormal results:

1:16 or greater shows sensitization

Monitor q2 weeks

Treatment:

RhoGAM administered at 28-32 wks gestation for abnormal Anti-D results &

within 72 hours of birth for a Rh positive infant.

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ABO INCOMPATIBILITY

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Occurs in 20 to 25% of pregnancies

Rarely causes significant hemolysis

Type 0 Mother with a type A or B fetus

Incompatibility results from the interaction of antibodies present in maternal serum and the antigen sites on the fetal RBC’s

No Antepartal treatment necessary

Newborn can develop hyperbilirubinemia

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Amniotic fluid Imbalances

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Amniotic fluid develops from several maternal and fetal structures, including the amnion, chorion, maternal blood, fetal lungs, GI tract, kidneys and skin.

Hydraminos (Polyhydraminos)

Excessive

Oligohydramnios

Decreased

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HYDRAMINOS

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Excessive amniotic fluid formation.

Normal: 500-1000 ml at term

Abnormal:

>

2000 ml at term

Amniotic Fluid Index: AFI >24cm

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SYMPTOMS & TREATMENT OF HYDRAMINOS

Rapid enlargement of the uterus

Fetal small parts are difficult to palpate

Extreme SOB

Varicosities

Hemorrhoids

Extensive uterine pressure

Rapid excessive weight gain

Bed restSymptomatic treatment of Pre-term labor and PROM

Delivery if fetus viablePost Delivery assessment of infant for possible GI & GU anomalies

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Complications of Hydramnios

Fetal MalpresentationPremature ROM

Preterm Labor

Fetal anomalies

Anencephaly

Tracheoesophageal

Fistula with stenosis

Intestinal obstruction

Hyperglycemia in fetus

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Nursing Management

Ongoing Assessment and monitoring forAbdominal painDyspnea

Uterine Contractions

Edema of lower extremities

Education regarding

Premature rupture of membranes (PROM)

S/S of worsening condition

Therapeutic amniocentesis

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Oligohydramnios

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Decreased amount of amniotic fluid <500 mL between 32 and 36 weeks’ gestation

Results from any condition that prevents the fetus from making urine or blocks fluid from going into the amniotic sac

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Therapeutic Management of Oligohydramnios

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Antepartal

Serial Ultrasounds

Non-stress Testing

Biophysical Profiles

Intrapartal

Continuous fetal monitoringAmnioinfusion (crystalloid fluid Normal Saline)Intrauterine resuscitation

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Nursing Assessment/Management

Uteroplacental Insufficiency

PROM

HTN of Pregnancy

Gestational Diabetes

IUGR

Post-Term Pregnancy

Fetal Renal Agenesis

Polycystic Kidneys Fetal Urinary Tract Obstructions Continuous monitoring for fetal well-beingNon-stress TestingIntrapartum: presence of variable decelerations indicating cord compression

AmnioinfusionComfort measures

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MULTIPLE GESTATIONS

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Woman’s body must adjust to the effects of more than one fetus.

Twinning – 12 per 1000 births

Triplets - 1 in 6400 births

4,5,6,7 - Fetus’s may be single ovum conception, multiple ova conception or a combination of both

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Monozygotic/Identical

Dizygotic/Fraterna

l

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RISK FACTORS MULTIPLE GESTATIONS

PIH

HYDRAMINOS

PLACENTA PREVIA

PRETERM LABOR

ANEMIA

POST PARTUM HEMORRHAGE

PREMATURITY IN NEWBORN

CONGENITAL ANOMALIESTWIN-TWIN TRANSFUSION (DISCORDANT INFANTS)CORD COMPLICATIONS

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Nursing Assessment/Management

Health history

Physical Exam

Severe nausea/vomiting

Fundal height

Lab results (usually anemia is present)

Ultrasound

Antenatal

EducationIncreased restS/S complicationsPre-term labor

PROMIncreased fetal surveillanceIntrapartalAssess fetal presentation

Continuous fetal monitoring

Multiple staff to care for neonates

Labor support

Postpartal

VS assessment

Uterine involution

Lochia assessment

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PREMATURE RUPTURE OF MEMBRANES

Rupture of fetal membranes with loss of amniotic fluid during pregnancy.

Cause: Unknown, but associated with:

infection

Fetal nutrition

Prolapse of cord

Non fluid filled environment

Fluid Assessment: Fern and nitrazine tests, AFI by ultrasound

Documentation of + ROM

ColorOdor

Fetal Assessment

Fetal Heart Rate

Cord

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Nursing Assessment/Management

Determine date, time and duration

Determine gestational age

History

Labor symptoms

Performing diagnostic tests

Assessing for s/s of infection

S/S of infected amniotic fluid include:

Temp elevationElevated pulseFetal tachycardia >160 bpmElevated white count and C-reactive protein

Cloudy, foul-smelling amniotic fluid

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PROM TREATMENT Based on Results of Assessment

Cultures- GBS, Gonorrhea, Chlamydia

Lab evaluation: esp. WBC’s

Vital Signs

FHR

Contractions

Temperature Q2hrs.

Broad spectrum antibiotics

+GBS/ Ampicillin or PenicillinBetamethasone (Celestone)Delivery if Infection is apparent

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Questions

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CLICKERS PLEASE!!!

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A patient, 32 weeks pregnant with severe headache,

is admitted to the hospital with preeclampsia. In addition

to obtaining baseline vital signs and placing the client

on bed rest, the physician ordered the following

items. Which of the orders should the nurse perform first?

Assess deep tendon reflexes

Obtain complete blood count

Assess baseline weight

Obtain routine urinalysis

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A

woman at 26-weeks-gestation is diagnosed

with

severe preeclampsia

with HELLP syndrome.

The

nurse will assess for

which of the following

signs/symptoms?

Low serum creatinine

High serum protein

Bloody stools

Epigastric pain

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Which of the following findings should the nurse

expect when assessing a client, 8 weeks’ gestation

with a gestational trophoblastic disease (hydatiform

mole)?

Protracted pain

Variable fetal heart decelerations

Dark brown vaginal bleeding

Suicidal ideations

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A woman has been diagnosed with a ruptured

ectopic pregnancy. Which of the following signs

and symptoms is characteristic of this diagnosis.

Dark brown rectal bleeding

Severe nausea and vomiting

Sharp unilateral abdominal pain

Marked hyperthermia

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