PREGNANCY AT RISK: GESTATIONAL ONSET

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PREGNANCY AT RISK GESTATIONAL ONSET

• CHAPTER 15

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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)

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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

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

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Etiology of Spontaneous Abortions

• Chromosomal abnormalities
• Teratogneic drugs
• Faulty implantation
• Weakened cervix
• Placental disorders
• Maternal conditions
• Chronic disease
• Endocrine imbalances
• Infections

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Subcategories for Spontaneous Abortions

• Threatened abortion
• Imminent abortion
• Complete abortion
• Incomplete abortion
• Missed abortion
• Recurrent pregnancy loss
• Septic abortion

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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

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Causative Factors of Ectopic Pregnancy

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

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Medical treatment for Ectopic Pregnancy

• Administer methotrexate IM
• Surgical treatment- Salpingootomy via laporaoscope

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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

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Medical therapy for Hydatiform Mole

• Suction evacuation of the mole
• Curettage of the uterus

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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

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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

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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

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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

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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

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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

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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

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• 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

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

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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

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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

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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

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• 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

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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

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

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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

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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

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• 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

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ABO Incompatibility

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

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Care of Woman requiring Surgery during Pregnancy

• Pregnancy risk
• Preterm labor
• IUGR
• Fetal mortality
• Spontaneous abortion

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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

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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

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Maternal-Fetal complications

• Uterine rupture
• Placenta abruption
• Premature rupture of membranes
• Preterm labor
• Spontaneous abortion

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

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Battered Pregnant Woman

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

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

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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

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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

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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

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• 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

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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

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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

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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

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• 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