PREGNANCY COMPLICATIONS

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PREGNANCY COMPLICATIONS

• SFC WARD

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Premature Labor

• 10 - 15 of all pregnancies
• 20 - 30 follow premature rupture of membranes
• Maternal medical problems
• Placental or fetal abnormalities
• Assessment-regular contractions every 10 min X 30
  min with cervical dilation
• Prevention is key to management

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Abnormal Labor (Dystocia)

• Passage through the pelvis
• Presentation of passenger
• Power of uterine contraction

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Pelvic Adequacy-basic shapes

• Gynecoid - easiest for delivery
• Platypelloid - wide hipped female
• Android - normal male shape
• Anthropoid - prevalent in blacks difficult
  delivery

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Pelvic Adequacy

• Small portals lead to dystocia

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Pelvic Adequacy

• Determined by pelvic exam
• Managed by surgical delivery (Cesarean Section)

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Abnormal Presentation

• Occiput posterior - 4.9 of births
• 70 of time will rotate into OA
• Transverse - fatal
• Must be rotated manually or surgically delivered
• Face - 1 in 500 births
• Assess by vaginal exam
• Carefully monitor cord position and fetal
  respiration

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Abnormal Presentation

• Breech - buttocks or feet presented instead of
  head
• 5.5 times greater infant mortality due to cord
  prolapse
• Types
• Frank (knees extended, feet near head
• Complete (knees bent, feet near buttocks
• Incomplete (knees bent, foot presenting before
  buttocks

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Breech Presentation

• Assessed by vaginal/abdominal exam
• Management
• Prevention is preferred. Attempt external version
  with extreme caution
• Delivery is slow process of clearing one
  extremity at a time
• Keep constantly aware of status of umbilical cord

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Abnormal Uterine Action

• Inadequate contractions
• Reassure patient, maintain fluids, have patient
  walk if possible, enema, nipple stimulation
• If uterus is atonic try to correct with massage,
  Oxytocin IV under physicians supervision

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Cord Accident

• Prolapsed cord
• Assessed by vaginal exam
• Management
• Reposition fetus and cord if possible
• Keep airway open
• Meconium staining shows fetal distress

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Multiple Pregnancies

• Normal delivery of one fetus followed by delivery
  of second no later than 20 minutes afterwards

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Uterine rupture

• 1 in 1500 deliveries
• Usually occurs during labor
• Contributing factors are high parity, obstructed
  labor, intrauterine maneuvers, previous surgery,
  MVA with lap seat belt
• Sudden lower abdominal pain and shock
• Manage shock

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Vaginal and Perineal Lacerations

• 1st Degree
• Slight laceration
• No need for suturing

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Vaginal and Perineal Lacerations

• 2nd Degree
• Into perineum without entering into anal
  sphincter or rectal mucosa
• Mange with simple suture repair

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Vaginal and Perineal Lacerations

• 3rd Degree
• Into anal sphincter and/or rectal mucosa
• Mange with carefully placed sutures (layers)

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Uterine Inversion (prolapse)

• Profuse bleeding after delivery
• Abdominal pain
• Uterus descended into vagina
• Possibly as a result of traction placed on cord
  during 3rd stage of labor
• Manually reposition with fist or fingers
• Carefully monitor for shock and blood loss

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Abortion (Miscarriage)--Termination of pregnancy
before viability

• Incidence--15 of all pregnancies abort
  spontaneously. These abortions seem to be a
  natural rejection of mal-developing fetus 85
  occur in the first trimester and are related to
  fetal causes
• Categories threatened, inevitable, incomplete,
  complete, or induced abortions

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Threatened Abortion--any vaginal bleeding in the
first 20 weeks of pregnancy - 20 -30 of pregnant
women have some bleeding in early months.
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Threatened Abortion--Signs and symptoms

• Vaginal bleeding--varies from brownish to bright
  red, may occur repeatedly for many days
• Mild cramps
• Tenderness over the uterus, low back pain, sense
  of pelvic pressure

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Threatened Abortion--Signs and symptoms

• Cervix closed or slightly dilated, no tissue loss
• Symptoms subside or it becomes an inevitable
  abortion

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Threatened Abortion Management--conservative

• Vaginal exam, make sure cervix is closed
• Pad count, to monitor bleeding
• Bed rest

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Inevitable Abortion--Intolerable pain or bleeding
that threatens the mother's well being
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Inevitable Abortion-- Signs and symptoms

• Bleeding more profuse threatens mother
• Cervix dilated
• Membrane rupture
• Painful uterine contractions

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Inevitable Abortion--Treatment

• Embryo delivered
• D C after delivery

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Incomplete Abortion--some products of conception
partially passed from uterine cavity
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Incomplete Abortion--Signs and symptoms

• Vaginal bleeding--varies from brownish to bright
  red, may occur repeatedly for many days
• Mild cramps
• Tenderness over the uterus, low back pain, sense
  of pelvic pressure
• Cervix closed or slightly dilated, no tissue loss

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Incomplete Abortion--Management

• Complete the abortion promptly with suction
• Monitor vital signs and amount of bleeding, treat
  symptomatically (IVs, blood, bedrest)
• Psychological assistance/reduce anxiety
• Pain meds PRN, vitamin and iron supplement
• Watch for infection

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Complete Abortion--all products of conception are
expelled
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Complete Abortion--Signs and symptoms

• Same as incomplete except all POC are passed
• Positive pregnancy test prior to abortion
• Symptoms of pregnancy no longer exist (cervix
  closes, uterus contracts to normal size).

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Complete Abortion--Management

• Bedrest for three days
• Monitor vital signs and bleeding, replace blood
  PRN, keep pad count
• Vitamin and iron supplements
• DC if bleeding continues
• Follow up visit to ensure return to proper
  menstruation and no evidence of infection for
  approximately 6 weeks
• Pain meds PRN

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Missed abortion--Fetus has died but has been
retained in utero 4 weeks or longer
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Missed abortion--Signs and symptoms

• Uterus fails to grow
• Fetal heart sound is not heard at appropriate
  time with doppler
• Fetal heart sound was present previously and now
  is absent
• Ultrasound no longer shows cardiac activity

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Missed abortion--Treatment

• If the fetus is not passed oxytoxin induction may
  be used
• DC may be used to remove fragments of the
  placenta

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Ectopic Pregnancies--implantation of fertilized
egg in any site other than the uterine cavity
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Ectopic Pregnancies--Incidence

• One in 150 pregnancies
• Incidence is rising and higher in non whites
• Increases with prior tubal diseases, ectopic
  pregnancies and induced abortions

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Ectopic Pregnancies

• 95 occur in fallopian tube ("tubal pregnancy"),
  more than half are on the right side ectopic
  pregnancy may also occur in ovary, abdomen, or
  cervix
• Most common cause of maternal mortality in first
  trimester.

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Ectopic Pregnancies--Causes--delayed passage of
eggs due to decreased lumen size

• PID chandelier sign
• Congenital deformities in mother
• Use of IUD (4 x greater in IUD users)
• Adhesions of the tube
• Anything leading to tubal sterilization.

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Ectopic Pregnancies--Signs and symptoms

• Abdominal/pelvic pain early in pregnancy
  "tearing" type of pain. (Abdominal pain occurs
  in 90)
• Amenorrhea, spotty or irregular vaginal bleeding
  is present in 75
• Positive pregnancy test--50
• Abdominal tenderness
• Pelvic exam may or may not reveal tender adnexal
  mass.

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Ectopic Pregnancies--Management

• If left untreated usually results in death
• Culdocentesis to confirm diagnosis--aspirate
  blood from cul-de-sac. (blood indicates
  intraperitoneal bleeding.)
• Surgery for definitive management--even if
  diagnosed before rupture

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Ectopic Pregnancies--Management

• Principles guiding management include
• Preserve maternal life
• Terminate the pregnancy with surgery
• Supportive care of mother (blood, fluid, monitor
  vital signs, psychological support)

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Ectopic Pregnancies--Complications--catastrophic
sequence

• Tubal rupture
• Severe internal hemorrhage
• Shock
• Death

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Differential assessment--history very important

• PID
• Spontaneous abortions--miscarriage
• Ruptured ovarian cyst
• Torsion of the ovarian cyst
• Appendicitis
• Pyelonephritis
• Pancreatitis

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Abruptio Placentae--premature separation of the
normally implanted placenta after 20 weeks
gestation
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Abruptio Placentae

• External hemorrhage--retroplacental bleeding
  occurs and the blood may pass behind the
  membranes and through the cervix
• Internal hemorrhage--the placenta separates
  centrally and the blood accumulates under the
  placenta.

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Abruptio Placentae--Incidence

• 1/90 pregnancies

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Abruptio Placentae--contributing factors

• Hypertension
• Trauma
• Alcoholism
• Cocaine use
• Previous history of same problem.

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Abruptio Placentae--Signs and symptoms--depends
on degree of separation

• Concealed hemorrhage
• Sharp pain
• Change in vital signs--no external bleeding
• Tender uterus--can progress to board-like
• Evidence of fetal heart rate drop, fetal
  distress, or death
• External same signs and symptoms except
  bleeding occurs

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Abruptio Placentae--Management

• NO VAGINAL EXAM if even suspect, as it may
  precipitate hemorrhage
• IV fluids and oxygen
• Type and crossmatch blood for possible
  transfusion
• Prepare for possible immediate delivery of the
  fetus
• Frequent fetal monitoring
• Psychological support for the mother

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Placenta Previa--implantation of the placenta in
the lower uterine segment such that at least a
portion of a fully dilated cervix would be covered
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Placenta Previa

• Incidence
• One in two hundred pregnancies
• Multiparous greater than primiparous
• More common in patients with abnormalities of
  uterus (e.g., fibroids)
• Perinatal mortality is 20

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Placenta Previa--Signs and symptoms

• Sudden painless vaginal bleeding
• Lower abdominal cramps are possible
• Uterus is soft
• Fetal exam is usually normal--depends on the
  amount of bleeding when it occurs
• Usually not shocky as in abruptio placenta

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Placenta Previa-- Management

• NO VAGINAL EXAM if suspect, as it may precipitate
  hemorrhage
• IV fluids and oxygen
• Type and crossmatch blood
• Bed rest

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Placenta Previa-- Management

• Monitor maternal and fetal V/S
• Monitor amount of bleeding
• Position for comfort and provide psychological
  support
• When bleeding stops, the patient can ambulate

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Placenta Previa-- Management

• Prepare for possible delivery of the
  fetus--dependent upon the fetus size and the
  amount of bleeding once delivery is decided on,
  a C-section is usually preferred

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Toxemia of Pregnancy

• Preeclampsia--development of hypertension with
  proteinuria, edema, or both due to pregnancy
  between 20 weeks of pregnancy and first
  postpartum day

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Preeclampsia--Incidence

• 5 of all pregnancies
• Increased in primapara
• Increased in women with hypertension or other
  vascular disorders.

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Preeclampsia--Signs and symptoms

• Rise in BP over 140/90 or a 30/15 increase during
  pregnancy
• Edema--face, hands and feet, peripheral that can
  cause possible headache, diplopia. It is
  important to note that edema persists even during
  bedrest.
• Proteinuria 0.3g/liter in 24 hr sample
• Weight exceeds normal for patient

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Preeclampsia--Management

• Bedrest--preferably on the left side as this
  enhances tissue perfusion
• Frequent weight and BP measurements UA for
  protein
• Correct dietary deficiencies manage underlying
  medical conditions

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Preeclampsia--Management

• Ensure proper fluid and electrolyte
  intake--encourage fluids but avoid high sodium
  fluids
• Delivery of baby is the cure.

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Toxemia of Pregnancy

• Eclampsia--occurrence of one or more convulsions
  not attributed to other cerebral conditions in a
  patient with preeclampsia.

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Eclampsia --Signs and symptoms

• Same as preeclampsia with progression to seizures.

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Eclampsia

• Perinatal mortality with eclampsia 15
• Eclampsia develops in 1/200 pre-eclamptic
  patients and usually total if untreated.

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Eclampsia--Management

• Oxygen and airway management
• Monitor BP, pulse and respirations every 15 min.
  and urinary output and input recorded hourly.
  This should stabilize 4-6 hours when delivery
  must be accomplished.
• Magnesium sulfate--used to prevent and treat
  convulsions

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Eclampsia--Management

• Constant fetal monitoring
• Quiet, dark environment
• Hydration, balanced salt solution IV, usually 3-4
  liters over 24 hours
• Delivery of baby is the cure. Monitor post
  delivery closely as eclampsia can occur up to a
  week postpartum.

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Common Medical Complications Which Affect
Pregnancy

• Diabetes Mellitus
• Anemia
• Urinary tract infections
• Constipation
• Medication use/abuse
• Infections

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Diabetes Mellitus--pregnancy increases need for
glucose, Metabolic changes during pregnancy can
increase diabetes mellitus signs and symptoms,
and may cause problems.
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Diabetes Mellitus

• In most third world countries, the majority of
  such women will be sterile.
• Where signs of polyuria, polyphagia, and
  polydipsia appear--check the mother's blood
  glucose.
• Insulin replacement is critical along with the
  management of weight and diet. Type II diabetics
  along with type I always require insulin.

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Complications associated with diabetes mellitus

• Primary fetal hazard is anoxia as a result of
  maternal toxemia or ketoacidosis
• Toxemia appears in 20 of the cases
• Excessive weight gain, hydramnios, and fetal
  death are complications of the fetus
• Preeclampsia is also a common occurrence
• Pregnancy induced hypertension--25
• Premature labor.

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Anemia--follow the maternal hematocrit and give
only cross-matched blood if absolutely needed,
otherwise increase iron intake as RBC indicates.
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Urinary tract infections

• Always evaluate urine in prenatal care--there is
  a higher incidence of premature births and
  perinatal mortality in pregnant women with an
  unmanaged UTI.

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Urinary tract infections

• Asymptomatic bacteriuria indicates UTI--always
  manage despite being asymptomatic since 25 of
  these patients will develop acute pyelonephritis
  later in pregnancy.

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Urinary tract infections

• Assessment by visualizing WBCs/RBCs in urine.
• Almost always the result of gram-negative
  organisms--always gram-stain the urine to
  identify bacteria.
• Nearly all will respond well to ampicillin

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Constipation--single most common problem in
pregnancy

• Increase fiber in diet
• Add some mineral oil or stool softener
• Enema if unresolved
• Common reason for hemorrhoids--iron supplements
  compound the problem by increasing the firmness
  of the stool which causes constipation

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Medication use/abuse

• Careful dispensing of any medication to
  childbearing women must be exercised
• The use of drugs during the first trimester can
  result in teratogenic effects to the fetus
  therefore, education plays the most important part

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Medication use/abuse

• Each medication must be individually evaluated
• Stop all use of tobacco, alcohol, hallucinogens
• Review all pharmacologic substances before
  administering during pregnancy

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Immunizations

• Only tetanus and rabies should be given whenever
  there is an indication
• Smallpox and typhoid should only be given in the
  case of maternal exposure
• Never give mumps, measles, rubella

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Infections

• Malaria--manage mother with chloroquine
• Vaginal infections--venereal diseases must be
  managed prior to delivery to avoid fetal
  contraction of the disease.
• Some infections such as herpes merit delivery by
  C-section

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SUMMARY

• Premature Labor
• Abnormal Labor
• Cord Accidents
• Tears
• Abortion
• Ectopic Pregnancy
• Abruptio Placentae
• Placenta Previa
• Toxemia
• Medical Conditions

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