A WOMAN WITH DIABETES MELLITUS
-Diabetes mellitus is an endocrine disorder in which the pancreas cannot
produce adequate insulin to regulate body glucose levels
-It is increasing in incidence as more and more obese adolescents develop
type 2 diabetes
-Reproductive planning may be a fourth concern, as women with diabetes
may not be good candidates for oral contraceptives because progesterone
interferes with insulin activity and therefore increases blood glucose levels.
-The primary concern for any woman with this disorder is controlling the
balance between insulin and blood glucose levels to prevent hyperglycemia
or hypoglycemia.
-If a woman’s insulin production is insufficient, glucose cannot be used by
body cells. The cells register the need for glucose, and the liver quickly
converts stored glycogen to glucose to increase the serum glucose level.
Because insulin is still not available, however, the body cells still cannot use
the glucose, so the serum glucose levels rise (i.e., hyperglycemia).
-Long-term effects are vascular narrowing that leads to kidney, heart, and
retinal dysfunction.
Diabetes During Pregnancy
- type 1 diabetes
is probably an autoimmune disorder because marker antibodies are
present, the pancreas fails to produce adequate insulin for body
requirements
type 2 diabetes
is a gradual loss of insulin production, but some ability to produce
insulin will still be present.
- apt to develop less-than-optimal control during pregnancy because all
women experience several changes in the glucose– insulin regulatory system
as pregnancy progresses
- The rate of insulin secretion is increased, and the fasting blood sugar level
is lowered
-It causes difficulty for a pregnant woman with diabetes because she must
then increase her insulin dosage beginning at about week 24 of pregnancy to
prevent hyperglycemia.
-she must guard against hypoglycemia (i.e., lowered serum glucose levels)
and ketoacidosis caused by the constant use of glucose by the fetus.
-Infants of women with poorly controlled diabetes tend to be large (>10 lb)
because the increased insulin the fetus must produce to counteract the
overload of glucose he or she receives acts as a growth stimulant.
-Hydramnios may develop because a high glucose concentration causes
extra fluid to shift and enlarge the amount of amniotic fluid
- infants of women with diabetes to be born by cesarean birth.
-There is also a high incidence of congenital anomaly
caudal regression syndrome (failure of the lower extremities to
develop)
spontaneous miscarriage, and stillbirth in women with uncontrolled
diabetes.
-The first trimester of pregnancy is the most important time for fetal
development
Risk factors for developing gestational diabetes include: • Obesity • Age
over 25 years • History of large babies (10 lb or more) • History of
unexplained fetal or perinatal loss • History of congenital anomalies in
previous pregnancies • History of polycystic ovary syndrome • Family history
of diabetes (one close relative or two distant ones) • Member of a population
with a high risk for diabetes (Native American, Hispanic, Asian)
-all pregnant women receive a 50-g glucose challenge test between 24 and
28 weeks gestation to determine if they are at risk for gestational diabetes.
all pregnant women receive a 50-g glucose challenge test between 24
and 28 weeks gestation to determine if they are at risk for gestational
diabetes.
-the woman drinks an oral 100-g glucose solution; a venous blood sample is
then taken for glucose determination at 1, 2, and 3 hours later. If two of the
four blood samples collected for this test are abnormal or the fasting value is
above 95 mg/dl, a diagnosis of diabetes is made.
SPONTANEOUS MISCARRIAGE
-Abortion is a medical term for any interruption of a pregnancy before a
fetus is viable (i.e., able to survive outside the uterus if born at that time),
but it is better to speak of these early pregnancy losses as spontaneous
miscarriages to avoid confusion with intentional terminations of pregnancies.
- as a fetus of more than 20 to 24 weeks of gestation or one that
weighs at least 500 g.
is considered a miscarriage or is termed a premature or immature
birth
-The most frequent cause of miscarriage in the first trimester of pregnancy
is abnormal fetal development, due either to a teratogenic factor or to a
chromosomal aberration.
-other miscarriages, immunologic factors may be present or rejection of the
embryo through an immune response may occur
- common cause of early miscarriage involves implantation abnormalities, as
up to 50% of zygotes probably never implant securely because of
inadequate endometrial formation or from an inappropriate site of
implantation.
- Miscarriage may also occur if the corpus luteum on the ovary fails to
produce enough progesterone to maintain the decidua basalis.
-Systemic infections such as rubella, syphilis, poliomyelitis, cytomegalovirus,
and toxoplasmosis readily cross the placenta and so may also be responsible
- if the fetus fails to grow, estrogen and progesterone production by the
placenta falls and leads to endometrial sloughing. With the sloughing,
prostaglandins are released; uterine contractions and cervical dilatation
along with expulsion of the products of the pregnancy begin.
Diagnosis
-Threatened Miscarriage
begin as vaginal bleeding, initially only scant and usually bright red
slight cramping, but no cervical dilatation is present on vaginal
examination.
to have fetal heart sounds assessed or an ultrasound performed to
evaluate the viability of the fetus.
Blood may be drawn to test for human chorionic gonadotropin (hCG)
hormone at the start of bleeding and again in 48 hours (if the placenta is still
intact, the level in the bloodstream should double in this time).
Avoidance of strenuous activity for 24 to 48 hours is the key
intervention, assuming the threatened miscarriage involves a live fetus and
presumed placental bleeding.
Complete bed rest is usually not necessary as this may appear to stop
the vaginal bleeding but only because blood pools vaginally.
CERVICAL INSUFFICIENCY (PREMATURE CERVICAL DILATATION)
- termed an incompetent cervix
-cervix that dilates prematurely and therefore cannot retain a fetus until
term
- the first symptom is show (a pink-stained vaginal discharge) or increased
pelvic pressure, which then is followed by rupture of the membranes and
discharge of the amniotic fluid
- this commonly occurs at approximately week 20 of pregnancy
- it is associated with increased maternal age, congenital structural defects,
and trauma to the cervix, such as might have occurred with a cone biopsy or
repeated D&Cs
- diagnosed by an early ultrasound before symptoms occur, it is usually
diagnosed only after the pregnancy is lost.
-a surgical operation termed cervical cerclage can be performed to
prevent this from happening in a second pregnancy
-approximately weeks 12 to 14, purse-string sutures are placed in the cervix
by the vaginal route under regional anesthesia.
-This procedure is called a McDonald or a Shirodkar procedure after the
surgeons who perfected the technique.
-n a McDonald procedure, nylon sutures are placed horizontally and
vertically across the cervix and pulled tight to reduce the cervical canal to a
few millimeters in diameter
- a Shirodkar technique, sterile tape is threaded in a purse- string manner
under the submucous layer of the cervix and sutured in place to achieve a
closed cervix. Although routinely accomplished by a vaginal route, sutures
may be placed by a transabdominal route.
-women remain on bed rest (perhaps in a slight or modified Trendelenburg
position) for a few days to decrease pressure on the new sutures
-the sutures are removed at weeks 37 to 38 of pregnancy so the fetus can
be born vaginally
-Be certain to ask women who are reporting painless bleeding (also the
symptoms of spontaneous miscarriage) whether they have had past cervical
operations to remind them they may have sutures in place.
PLACENTA PREVIA
-the placenta is implanted abnormally in the lower part of the uterus, is the
most common cause of painless bleeding in the third trimester of pregnancy
It occurs in four degrees
implantation in the lower rather than in the upper portion of the uterus
(low-lying placenta)
marginal implantation (the placenta edge approaches that of the
cervical os)
implantation that occludes a portion of the cervical os (partial
placenta previa),
implantation that totally obstructs the cervical os (total placenta
previa).
-Increased parity, advanced maternal age, past cesarean births, past uterine
curettage, multiple gestation, and perhaps a male fetus are all associated
with placenta previa.
- the placenta appears to have been implanted correctly. Suddenly,
however, it begins to separate and bleeding results. This occurs in about 10
out of 1,000 pregnancies and, because it can lead to extensive bleeding, is
the most frequent cause of perinatal death
-
Assessment
- sonogram done to date the pregnancy
-bleeding with placenta previa doesn’t usually begin, however, until the
lower uterine segment starts to differentiate from the upper segment late in
pregnancy (approximately week 30) and the cervix begins to dilate.
-The bleeding is usually abrupt, painless, bright red, and sudden enough to
frighten a woman.
Therapeutic Management
-Immediate Care Measures
-place the woman immediately on bed rest in a side-lying position.
-Inspect the perineum for bleeding and estimate the present rate of blood
loss.
- (test strip procedures) can be used to detect whether the blood is of fetal
or maternal origin.
-Obtain baseline vital signs to determine whether symptoms of hypovolemic
shock are present
-Continue to assess blood pressure every 5 to 15 minutes or continuously
with an electronic cuff
-record fetal heart sounds and uterine contractions (an internal monitor for
either fetal or uterine assessment is contraindicated).
- Hemoglobin, hematocrit, prothrombin time, partial thromboplastin time,
fibrinogen, platelet count, type and cross-match, and antibody screen will be
assessed to establish baselines, detect a possible clotting disorder, and
ready blood for replacement if necessary
-Monitor urine output frequently, as often as every hour,
-Administer intravenous fluid as prescribed, preferably with a large-gauge
catheter to allow for blood replacement through the same line.
-the safest birth method for both mother and baby is often a cesarean birth
- careful speculum examination of the vagina and cervix to establish the
degree of fetal engagement and to rule out another cause for bleeding, such
as ruptured varices or cervical trauma.
- oxygen equipment available in case the fetal heart sounds indicate fetal
distress, such as bradycardia or tachycardia, late deceleration, or variable
decelerations during the exam.
-. Betamethasone, a steroid that hastens fetal lung maturity, may be
prescribed for the mother to encourage the maturity of fetal lungs if the
fetus is less than 34 weeks gestation
-: Fear related to outcome of pregnancy after episode of placenta previa
bleeding
PREMATURE SEPARATION OF THE PLACENTA (ABRUPTIO PLACENTAE)
- the placenta appears to have been implanted correctly. Suddenly,
however, it begins to separate and bleeding results. This occurs in about 10
out of 1,000 pregnancies and, because it can lead to extensive bleeding, is
the most frequent cause of perinatal death
-The separation generally occurs late in pregnancy; even as late as during
the first or second stage of labor.
-The primary cause of premature separation is unknown, but certain
predisposing factors are high parity, advanced maternal age, a short
umbilical cord, chronic hypertensive disease, hypertension of pregnancy,
direct trauma (as from an automobile accident or intimate partner violence),
vasoconstriction from cocaine or cigarette use, and thrombophilic conditions
that lead to thrombosis formation
-It also may be caused by chorioamnionitis or infection of the fetal
membranes and fluid
-Yet another possible cause is a rapid decrease in uterine volume, such as
occurs with sudden release of amniotic fluid as can happen with
polyhydramnios
Assessment
- experiences a sharp, stabbing pain high in the uterine fundus as the initial
separation occurs.
- If labor begins with the separation, each contraction will be accompanied
by pain over and above the pain of the contraction. Tenderness can be felt
on uterine palpation.
-Heavy bleeding usually accompanies premature separation of the placenta,
although it may not be readily apparent
- signs of hypovolemic shock usually follow quickly
- The uterus becomes tense and feels rigid to the touch
-assess when the time the bleeding began, whether pain accompanied it, the
amount and kind of bleeding, and her actions to detect if trauma could have
led to the placental separation
- Initial blood work should include hemoglobin level, typing and cross-
matching, and a fibrinogen level and fibrin breakdown products to detect
DIC.
Therapeutic Management
- A woman needs a large-gauge intravenous catheter inserted for fluid
replacement and oxygen by mask to limit fetal anoxia
-Monitor fetal heart sounds externally and record maternal vital signs every
5 to 15 minutes to establish baselines and observe progress.
- Keep a woman in a lateral, not supine, position to prevent pressure on the
vena cava and additional interference with fetal cerculation
- do not perform any abdominal, vaginal, or pelvic examination on a woman
with a diagnosed or suspected placental separation.
- If DIC has developed, cesarean birth may pose a grave risk because of the
possibility of hemorrhage during the surgery and later from the surgical
incision
-Intravenous administration of fibrinogen or cryoprecipitate (which contains
fibrinogen) can be used to elevate a woman’s fibrinogen level prior to and
concurrently with surgery
- a hysterectomy might be necessary to prevent exsanguination.
-Death can occur from massive hemorrhage leading to shock and circulatory
collapse or renal failure from circulatory collapse.
Preterm Labor
- is labor that occurs before the end of week 37 of gestation
- it results in the infant’s birth, the infant will be immature
- Maintaining general health during pregnancy is the best preventive
measure to avoid preterm birth
- they diagnose back pain or contractions as nothing more than extremely
hard Braxton Hicks contractions
- with dehydration, urinary tract infection, periodontal disease,
chorioamnionitis, and perhaps large fetal size
- Women who continue to work at strenuous jobs during pregnancy or
perform shift work that leads to extreme fatigue
-trauma this causes may be yet another cause
Common symptoms of early preterm labor
persistent, dull, and low backache; vaginal spotting; a feeling of pelvic
pressure or abdominal tightening; menstrual-like cramping; increased
vaginal discharge; uterine contractions; and intestinal cramping.
THERAPEUTIC MANAGEMENT
-A woman who is in preterm labor is usually first admitted to the hospital
and placed on bed rest to relieve the pressure of the fetus on the cervix.
-External fetal and uterine contraction monitors are attached to monitor FHR
and the intensity of contractions
-Intravenous fluid therapy to keep her well hydrated is begun because
although not well documented, hydration may help stop contractions
-Vaginal and cervical cultures and a clean-catch urine sample are prescribed
to rule out infection
DRUG ADMINISTRATION
-Terbutaline is a drug approved to prevent and treat bronchospasm (i.e.,
narrowing of airways) but may be used, off-label, as a tocolytic agent (i.e.,
an agent to halt labor)
- it should not be used for over 48 to 72 hours of therapy because of a
potential for serious maternal heart problems.
-Magnesium sulfate, given intravenously, is used primarily to treat
preeclampsia and prevent eclamptic seizures. It was traditionally given to
prevent preterm labor as well.
-Magnesium sulfate for fetal neuroprotection is used prior to 32 weeks to
help prevent cerebral palsy in premature infants
-During the time labor is being chemically halted, therefore, if the pregnancy
is under 34 weeks, a woman may be given two doses of 12 mg
betamethasone intramuscularly 24 hours apart or four doses of 6 mg
dexamethasone intramuscularly 12 hours apart.
FETAL ASSESSMENT
- assess overall fetal welfare in the woman who is trying to delay or prevent
preterm labor by assessing the FHR and activity
Preterm Rupture of Membranes
-is rupture of fetal membranes with loss of amniotic fluid before 37 weeks of
pregnancy
-The cause of preterm rupture is unknown, but it is strongly associated with
infection of the membranes (i.e., chorioamnionitis)
- second complication that can result is increased pressure on the umbilical
cord from the loss of amniotic fluid (thus, inhibiting the fetal nutrient supply)
or cord prolapse (extension of the cord out of the uterine cavity into the
vagina past the small fetus), a condition that could also interfere with fetal
circulation.
-the development of a Potter-like syndrome (i.e., distorted facial features
and pulmonary hypoplasia from uterine pressure)
ASSESSMENT
-suggested by the history
-sudden gush of clear fluid from her vagina, with continued minimal leakage.
-sterile vaginal speculum examination is done to observe for vaginal pooling
of fluid
- ultrasound can be used to assess the amniotic fluid index.
-cultures for Neisseria gonorrhoeae, group B streptococcus, and chlamydia
are usually obtained
-Blood is drawn for white blood cell count and C- reactive protein, both of
which increase with membrane rupture
-. Avoid doing routine vaginal examinations because the risk of infection
rises s
THERAPEUTIC MANAGEMENT
- if labor does not begin within 24 hours and the fetus is estimated to be
mature enough by amniocentesis to survive in an extrauterine environment,
labor contractions may be induced by intravenous administration of oxytocin
so the infant can be born before infection can occur.
-if she declines delivery, she is placed on bed rest either in the hospital or at
home.
- If she reaches viability, a corticosteroid is administered to hasten fetal lung
maturity
-A woman with no signs of infection may be administered a tocolytic agent if
labor contractions begin.
-Although its effectiveness is not well documented, a woman might be given
an amnioinfusion
to reduce pressure on the fetus or cord and to allow a safer term birth
Hypertensive Disorders in Pregnancy
-Gestational hypertension is a condition in which vasospasm occurs in both
small and large arteries during pregnancy, causing increased blood pressure
-Preeclampsia is a pregnancy-related disease process evidenced by
increased blood pressure and proteinuria
- women with antiphospholipid syndrome (APS) or the presence of
antiphospholipid antibodies in maternal blood are much more likely to
develop preeclampsia
ASSESSMENT
-l symptoms such as vision changes, typically hypertension, proteinuria, and
edema are considered the classic signs of preeclampsia.
SYMPTOMS OF GESTATIONAL HYPERTENSION
-Gestational hypertension
-Blood pressure is 140/90 mmHg or systolic pressure elevated 30
mmHg or diastolic pressure elevated 15 mmHg above prepregnancy level;
no proteinuria or edema; blood pressure
-Preeclampsia without severe features
-Blood pressure is 140/90 mmHg or systolic pressure elevated 30
mmHg or diastolic pressure elevated 15 mmHg above prepregnancy level;
proteinuria of 1+ to 2+ on a random sample; weight gain over 2 lb/week in
second trimester and 1 lb/week in third trimester; mild edema in upper
extremities or face
-Preeclampsia with severe features
-Blood pressure is 160/110 mmHg; proteinuria 3+ to 4+ on a random
sample and 5 g on a 24-hour sample; oliguria (500 ml or less in 24 hours or
altered renal function tests; elevated serum creatinine more than 1.2
mg/dl); cerebral or visual disturbances (headache, blurred vision);
pulmonary or cardiac involvement; extensive peripheral edema; hepatic
dysfunction; thrombocytopenia; epigastric pain
-Eclampsia
-Either seizure or coma accompanied by signs and symptoms of
preeclampsia are present.
Polyhydramnios
- the amniotic fluid volume at term is 500 to 1,000 ml. Polyhydramnios
occurs when there is excess fluid of more than 2,000 ml or an amniotic fluid
index above 24 cm
-Polyhydramnios can cause fetal malpresentation because the additional
uterine space can allow the fetus to turn to a transverse lie
- It also can lead to premature rupture of the membranes from the increased
pressure, which then leads to the additional risks of infection, prolapsed
cord, and preterm birth.
ASSESSMENT
-Amniotic fluid is formed by a combination of the cells of the amniotic
membrane and from fetal urine. It is evacuated by being swallowed by the
fetus, absorbed across the intestinal membrane into the fetal bloodstream,
and transferred across the placenta.
- Excessive urine output occurs in the fetuses of diabetic women
(hyperglycemia in the fetus causes increased urine production).
-The first sign of polyhydramnios may be unusually rapid enlargement of the
uterus.
-The small parts of the fetus become difficult to palpate because the uterus
is unusually tense.
- Auscultating the FHR can be difficult because of the depth of the increased
amount of fluid surrounding the fetus
- extreme shortness of breath as the overly distended uterus pushes up
against her diaphragm.
- extreme shortness of breath as the overly distended uterus pushes up
against her diaphragm.
-increased amount of fluid will cause increased weight gain
- ultrasound is done to document the presence of polyhydramnios and to
discover a reason for the excessive amount of fluid
THERAPEUTIC MANAGEMENT
- severe polyhydramnios may be admitted to a hospital for bed rest and
further evaluation or may be cared for at home.
-bed rest helps to increase uteroplacental circulation and reduces pressure
on the cervix, which may help prevent preterm labor
-report any sign of ruptured membranes or uterine contractions
-Assess vital signs as well as lower extremity edema frequently (the
extremely tense uterus puts unusual pressure on both the diaphragm and
the vessels of the pelvis)
-Amniocentesis can be performed to remove some of the extra fluid
-Polyhydramnios can also lead to placental separation or rupture of
membranes
- tocolysis may be necessary to prevent or halt preterm labor.
-membranes can be “needled” (a thin needle is inserted vaginally to pierce
them) to allow a slow, controlled release of fluid.
Oligohydramnios
- refers to a pregnancy with less than the average amount of amniotic fluid
-s reduced amount of fluid is usually caused by a bladder or renal disorder in
the fetus that is interfering with voiding
- It also can occur from severe growth restriction (because of the small size,
a fetus is not voiding as much as usual).
- the fetus is so cramped for space, muscles are left weak at birth, lungs can
fail to develop (hypoplastic lungs), possibly leading to severe difficulty
breathing after birth, and distorted features of the face occur (termed Potter
syndrome).
-Oligohydramnios is suspected during pregnancy when the uterus fails to
meet its expected growth rate
- It is confirmed by ultrasound when the pockets of amniotic fluid are less
than average. Infants need careful inspection at birth to rule out kidney
disease and compromised lung development.
Postterm Pregnancy
-A term pregnancy is 38 to 42 weeks long. A pregnancy that exceeds these
limits is prolonged (i.e., postterm pregnancy, postmature, or postdate).
- infant of such a pregnancy is considered postmature, or dysmature, if
there is evidence that placental insufficiency has occurred and interfered
with fetal growth.
-Such pregnancies can occur in women receiving a high dose of salicylates
(for severe sinus headaches or rheumatoid arthritis) that interferes with the
synthesis of prostaglandins, which may be responsible for the initiation of
labor.
-Remaining in utero for longer than 2 weeks beyond term creates a danger
to a fetus for several reasons.
- Meconium aspiration is more apt to occur as fetal intestinal contents are
more likely to reach the rectum.
-If the fetus continues to grow, macrosomia could create a birth problem.
-postterm is lack of growth because a placenta seems to have adequate
functioning ability for only 40 to 42 weeks
- it acquires calcium deposits. This exposes a fetus to decreased blood
perfusion and a lack of oxygen, fluid, and nutrients
-it can lead to variable decelerations in the FHR from cord compression.
-If labor has not begun by 41 weeks, a nonstress test, and/or a biophysical
profile may be done to document the state of placental perfusion and the
amount of amniotic
-Prostaglandin gel or misoprostol (Cytotec) applied to the vagina to initiate
cervical ripening followed by an oxytocin infusion are common methods used
to begin labor.
- If oxytocin is ineffective, cesarean birth may be necessary
- Monitor the FHR closely during labor to be certain placental insufficiency is
not occurring from aging of the placenta
Isoimmunization (Rh Incompatibility)
- occurs when an Rh-negative mother (one negative for a D antigen or one
with a dd genotype) carries a fetus with an Rh-positive blood type (DD or Dd
genotype). For such a situation to occur, the father of the child must either
be homozygous (DD) or heterozygous (Dd) Rh positive
- If the father of the child is homozygous (DD) for the factor, 100% of the
couple’s children will be Rh positive (Dd)
- If the father is heterozygous for the trait, 50% of their children can be
expected to be Rh positive (Dd)
-Because people who have Rh-positive blood have a protein factor (the D
antigen) that Rh-negative people do not, when an Rh-positive fetus begins
to grow inside an Rh- negative mother who is sensitized, her body reacts in
the same manner it would if the invading factor were a substance such as a
virus—she forms antibodies against the invading substance.
-The Rh factor exists as a portion of the red blood cell, so these maternal
antibodies cross the placenta and cause destruction (i.e., hemolysis) of fetal
red blood cells
- A fetus can become so deficient in red blood cells from this that a sufficient
oxygen transport to body cells cannot be maintained. This condition is
termed hemolytic disease of the newborn or erythroblastosis fetalis.
-Procedures such as amniocentesis or percutaneous umbilical blood sampling
can allow this to occur.
ASSESSMENT
All women with Rh-negative blood should have an anti-D antibody titer done
at a first pregnancy visit
- normal or the titer is minimal (normal is 0; a ratio below 1:8 is
minimal), the test is repeated at week 28 of pregnancy. If this is also
normal, no therapy is needed.
- anti-D antibody titer is elevated at a first assessment (1:16 or greater),
showing Rh sensitization, the well-being of the fetus in this potentially toxic
environment will be monitored every 2 weeks (or more often) by Doppler
velocity of the fetal middle cerebral artery
a technique that can predict when anemia is present or fetal red cells
are being destroyed
-If the artery velocity remains high, a fetus is not developing anemia and
most likely is an Rh-negative fetus.
- If the reading is low, it means a fetus is in danger, and immediate
birth will be carried out providing the fetus is near term
THERAPEUTIC MANAGEMENT
-To reduce the number of maternal Rh (D) antibodies being formed, RhIG, a
commercial preparation of passive Rh (D) antibodies against the Rh factor, is
administered to women who are Rh negative at 28 weeks of pregnancy.
- RhIG (RhoGAM) is given again by injection to the mother in the first 72
hours after birth of an Rh-positive child to further prevent the woman from
forming natural antibodies.
- Because RhIG is passive antibody protection, it is transient, and in 2 weeks
to 2 months, the passive antibodies are destroyed. Only those few
antibodies that were formed during pregnancy are left.
-After birth, the infant’s blood type will be determined from a sample of the
cord blood. If it is Rh positive, the mother will receive the RhIG injection. If
the newborn’s blood type is Rh negative, no antibodies have been formed in
the mother’s circulation during pregnancy and none will form, so passive
antibody injection (RhIG) is unnecessary.
Fetal Death
-Obviously, one of the most severe complications of pregnancy is fetal death
-The most likely causes of this include chromosomal abnormalities,
congenital malformations, infections such as hepatitis B, immunologic
causes, and complications of maternal disease.
- If fetal death occurs before the time of quickening, a woman will not be
aware the fetus has died because she is not able to feel fetal movements.
This type of fetal death may be discovered at a routine prenatal visit when
no fetal heartbeat can be heard. An ultrasound will reveal that no fetal
heartbeat is present.
-That a fetus has died early in intrauterine life may also be revealed first by
the miscarriage that occurs
- a woman begins painless spotting, gradually accompanied by uterine
contractions with cervical effacement and dilatation.
-If a fetus dies in utero past the point of quickening, a woman will be very
aware that fetal movements are suddenly absent.
-She may lie down or sit in a position that she knows usually causes
fetal movement
-Unable to believe something could have happened, she may attribute the
lack of movement to “sleeping” or “saving enough strength to be born.”
Because she is denying what is happening, it may be a full 24 hours
before she calls her healthcare facility to report the apparent lack of fetal
movement.
- On assessment, no fetal heartbeat can be heard
- An ultrasound will confirm the absence of a fetal heartbeat.
- a combination of prostaglandin gel or misoprostol (Cytotec) applied to the
vagina to effect cervical ripening and oxytocin administration to begin
uterine contractions
-Blood for coagulation studies to detect DIC must be obtained to rule out the
possibility of this developing.
Nursing Diagnoses and Related Interventions
-Nursing Diagnosis: Powerlessness related to fetal death
-Outcome Evaluation: Patient and support person express meaning of
pregnancy loss; identify support people/family with whom they can share
grief.
