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PREGNANCY AT RISK: GESTATIONAL ONSET

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Abortions are either spontaneous or induced ... Assess amount and character of emesis. Monitor I & O. Assess client's emotional state ... – PowerPoint PPT presentation

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Title: PREGNANCY AT RISK: GESTATIONAL ONSET


1
PREGNANCY AT RISK GESTATIONAL ONSET
  • CHAPTER 15

2
CARE OF THE WOMAN WITH A BLEEDING DISORDER
  • Major cause of bleeding during 1st and 2nd
    trimester is abortion
  • Abortions are either spontaneous or induced
  • Abortion defined expulsion of the fetus prior to
    viability, (20 weeks gestation or less or less
    than 500 g)

3
General Principles of Nursing Interventions
  • Assess type and amt of bleeding by Hx
  • Monitor vital signs often
  • Observe for shock
  • Count and weigh pads to assess bleeding save all
    clots.
  • Assess for FHT
  • Start IV

4
  • Have O2 ready if needed
  • Assess coping and give emotional support

5
Etiology of Spontaneous Abortions
  • Chromosomal abnormalities
  • Teratogneic drugs
  • Faulty implantation
  • Weakened cervix
  • Placental disorders
  • Maternal conditions
  • Chronic disease
  • Endocrine imbalances
  • Infections

6
Subcategories for Spontaneous Abortions
  • Threatened abortion
  • Imminent abortion
  • Complete abortion
  • Incomplete abortion
  • Missed abortion
  • Recurrent pregnancy loss
  • Septic abortion

7
Medical Therapy for Spontaneous Abortions
  • Ultrasound to detect gestational sax or cardiac
    activity
  • Bed rest
  • Intravenous fluids
  • Possible blood transfusions
  • DAC
  • RhoGAM if Rh neg within 72 hours

8
Causative Factors of Ectopic Pregnancy
  • Previous tubal damage or tubal surgery
  • Congenital abnormalities
  • Endometriosis
  • Presence of an IUD
  • Uterine exposure to diethylstilbestrol (DES)

9
Medical treatment for Ectopic Pregnancy
  • Administer methotrexate IM
  • Surgical treatment- Salpingootomy via laporaoscope

10
Gestational Trophoblastic Disease
  • Defined pathologic proliferation of
    trophoblastic cells
  • GTD includes
  • hydatiform mole complete and partial grapelike
    clusters of hydropic vesicles (fluid filled cysts
    grow from chorionic villa of placenta)
  • Invasive mole (chorioadenoma)
  • choriocarcinoma

11
Medical therapy for Hydatiform Mole
  • Suction evacuation of the mole
  • Curettage of the uterus

12
Nursing care for Hydatiform Mole
  • Assess vaginal bleeding
  • Monitor vital signs
  • Administer oxygen
  • Assess for anemia
  • Instruct on Follow up
  • Labs needed
  • Chest x-ray
  • Birth control for 1 year
  • Chemotherapy if mole is cancerous

13
Incompetent Cervix
  • Cervix dilates when fetus about 15 20 weeks
    gestation
  • History of spontaneous abortions
  • Sterile speculum exam reveals effacement and
    dilatation of cervix and bulging membranes

14
Medical treatment
  • vaginal ultrasound to detect dilation of the
    internal cervical os
  • Cerclage (Shirodkar-Barter) operation
  • Birth
  • C-section
  • Vaginal birth with sutures removed before term

15
Hyperemesis Gravidarum
  • Excessive vomiting during pregnancy
  • Cause may be increased levels of hCG
  • Medical treatment
  • Antiemetics
  • IV fluids
  • Restore electrolyte balance ( potassium,
    thiamine, vit B12
  • TPN

16
Nursing Care for Hyperemesis
  • Assess amount and character of emesis
  • Monitor I O
  • Assess clients emotional state
  • Provide a relaxed and quiet environment
  • Minimize food odors
  • Provide oral hygiene
  • Monitor weight

17
PREMATURE RUPTURE OF MEMBRANES
  • Spontaneous rupture of the membranes prior to the
    onset of labor
  • PPROM preterm ROM before 37 weeks
  • Maternal risk is r/t chorioamnionitis (infection
    intra-amniotic- before birth and endometritis
    (postpartal infection)
  • Fetal-newborn risk of respiratory distress
    syndrome, fetal sepsis, malpresentation, prolapse
    of the cord and increase perinatal morbidity and
    mortality

18
PROM Assessment
  • Nitrazine swabs and microscopic exam for ferning
    test.
  • Nursing Care with infection
  • Monitor vital signs esp. temperature
  • IV antibiotics usually
  • Delivery of fetus

19
  • Nursing care without infection
  • Monitor maternal status
  • vital signs
  • Uterine activity
  • Peri-pad count
  • Avoid vaginal exams
  • Rest on left side
  • Report signs of infection

20
  • Monitor fetal status
  • Nonstress test
  • Biophysical profile electronic fetal monitoring
    as necessary

21
Pre-term Labor
  • Labor that occurs between 20 and 37 completed
    weeks of pregnancy
  • Nursing Care of preterm labor
  • Maintain good uterine blood flow (side)
  • EFM to assess contractions
  • Administer corticosteroids (celestone)
  • IV infusion to hydrate
  • Administer tocolytic medication to suppress
    uterine contractions (terbutaline, procardia or
    magnesium sulfate)
  • Teach self-care measures to prevent preterm labor

22
PREECLAMPSIA (PIH) AND ECLAMPSIA
  • Increased blood pressure after 20 weeks gestation
    accompanied with proteinuria are the classic
    signs
  • Eclampsia is the most severe form of preeclampsia
    and is accompanied by seizures or coma

23
Vascular changes with preeclampsia
  • Gradual loss of resistance to angiotensin II
  • Blood pressure rises
  • Imbalance between prostacyclin and thromboxane
  • Thromboxane dominates
  • Vasoconstriction and platelet-aggregation occur

24
  • Loss of normal vasodilation of uterine arterioles
  • Maternal vasospasm with decreased placental
    perfusion
  • Renal changes decreased renal perfusion, urine
    output decreases retention of sodium causes
    increased extra cellular volume

25
Treatment of preeclampsia
  • Hospitalization- monitor maternal and fetal
    status
  • Delivery if condition worsens
  • Nursing care
  • Mild bed rest on left side, diet alterations
  • Severe bed rest, anticonvulsant medication,
    fluid and electrolyte replacement, steroids,
    antihypertensive medication

26
  • HELLP syndrome can be associated with severe
    preeclampsia. Stands for hemolysis of red blood
    cells, elevated liver enzymes, and low platelet
    count

27
Chronic Hypertension
  • Elevated blood pressure before 20 weeks gestation
  • Persists 42 days after birth
  • Can have superimposed preelampsia with
    proteinuria and edema in upper body
  • Gestational hypertension elevation of BP with
    occurs for first time in pregnancy and has no
    signs of proteinuria

28
Rh Alloimmunization (sensitization)
  • Rh negative woman carries an Rh-positive fetus
  • Mothers system produced anti-Rh positive
    antibodies if fetus blood enters the mother's
    blood.
  • Subsequent pregnancies Rh antibodies cross the
    placenta and enter the fetal circulation

29
  • Red blood cells of the fetus are attacked by the
    mothers anti-Rh positive antibodies, causing
    hemolysis of fetal red blood cells
  • Hydrops fetalis marked fetal edema
  • Prevention
  • Screening with blood test antibody screen
    (indirect coombs)
  • Administration of Rh immune globulin (RhoGam) at
    28 weeks gestation and after birth if infant is
    RH positive

30
ABO Incompatibility
  • Pregnant mother has different blood type than
    fetus
  • Rarely causes hemolysis
  • Newborn assessed closely for hyperbilirubinemia

31
Care of Woman requiring Surgery during Pregnancy
  • Pregnancy risk
  • Preterm labor
  • IUGR
  • Fetal mortality
  • Spontaneous abortion

32
Physiological changes of pregnancy that
complicate surgery
  • Decreased intestinal motility
  • Delayed gastric emptying
  • Increases respiration secretions
  • Bladder distention
  • Postoperative teaching
  • Diet modifications
  • Physical activity level
  • Warning signs

33
Care of Woman suffering trauma from an Accident
  • Traumas causing concerns during pregnancy
  • Blunt trauma (auto accidents)
  • Penetration abdominal injuries (gunshot or knife
    wound)
  • Maternal shock

34
Maternal-Fetal complications
  • Uterine rupture
  • Placenta abruption
  • Premature rupture of membranes
  • Preterm labor
  • Spontaneous abortion

35
  • Nursing care
  • Maintain airway
  • Control bleeding
  • Administer intravenous fluids
  • Assess uterine irritability
  • Monitor FHT
  • Possible surgery
  • Possible cesarean birth

36
Battered Pregnant Woman
  • Complications related to the abused pregnant
    woman
  • Anemia
  • Infection
  • Low weight gain
  • Bleeding problems
  • Loss of pregnancy

37
  • Complications related to the fetus
  • Low birth weight infants
  • Preterm labor
  • Fetal death

38
Signs of Maternal Physical Abuse
  • Bruising and/or injury breast, abdomen,
    genitalia
  • Decreased eye contact
  • Silence when around partner
  • Nervousness, insomnia
  • Drug overdose, alcohol problems

39
Nursing Care and Community Resources
  • Identify clients at risk
  • Promote decision-making skills
  • Decrease potential for future abuse
  • Secure a safe environment
  • Refer to community resources
  • Emergency shelters
  • Police
  • Legal services, social services, counseling

40
Perinatal Infections affecting the Fetus
  • TORCH toxoplasmosis, rubella, cytomegalovirus,
    herpes
  • Effects on newborns with
  • Toxoplasmosis convulsions, coma, microcephaly,
    hydrocephalus, infant death
  • Rubella congenital cataracts, sensorineural
    deafness, heart defects, mental retardation
  • Cerebral palsy

41
  • Effects on newborn continued
  • Cytomegalovirus fetal death, severe neurological
    problems, eye abnormalities, hearing loss, mental
    retardation
  • Herpes simplex virus (type 2 or genital)
    microcephaly, mental retardation seizures,
    retinal dysplasia apnea, coma

42
Other Infections That can cause Complications in
the Newborn
  • Group B Streptococcal infections
  • Bacteria found in GI tract and urogenital tracts
    in women
  • Major cause of early-onset neonatal infections
    (1-2 per 1000 live births)
  • Early onset in fetus causes serious illness
    including pneumonia and overwhelming septicemia
  • Late onset 1 week or more later meningitis or
    pneumonia

43
GBS Preventative Treatment
  • Screen all pregnant women at 35 to 37 weeks
    gestation
  • GBS carriers should receive antibiotic
    prophylaxis at the onset of labor or the rupture
    of membranes
  • GBS status unknown treat intrapartally
  • Observe infant for ss and keep in hospital for
    at least 48 hours

44
Other Infections of significance
  • Acute pyelonephritis risk of premature birth and
    IUGR
  • Vulvovaginal candidiasis newborn thrush
  • Trichomoniasis PROM, preterm birth, low birth
    weight infants
  • chlamydial infection Newborn conjunctivitis and
    pneumonia

45
  • Gonorrhea ophthalmia neonatorum in infant
    leading to possible blindness
  • Syphilis can be passed transplacentally to the
    fetus. If untreated, can cause second trimester
    abortion, stillborn infant at term, congenitally
    infected infant
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