COMPLICATIONS
OF
PREGNANCY
Jeanie Ward
Risk Factors
Age – under 17 over 35
Gravida and Parity
Socioeconomic status
Psychological well-being
Predisposing chronic illness – diabetes,
heart conditions, renal, etc.
Pregnancy related conditions – hyperemesis
gravidarum, PIH, etc.
High Risk Pregnancy
Goals of Care
Provide with optimum care for the
mother and the fetus
Assist the patient and her family to
understand and cope with the
variations in a High Risk Pregnancy
and cope with her feelings
Bleeding Disorders
Abortions
Termination of pregnancy at any time
before the fetus has reached the age of
viability
Either:
spontaneous – occurring naturally
induced – artificial
Etiology / Predisposing Factors
Faulty germ plasm -- imperfect ova or sperm, faulty
implantation, genetic make-up (chromosomal disorders),
congenital abnormalities
Decrease in the production of progesterone
Drugs or radiation
Maternal causes -- infections, endocrine disorders,
malnutrition, hypertension
Assessment
Types of Abortions
Threatened
Signs and Symptoms
vaginal bleeding, spotting
Mild cramps, backache
Cervix remains CLOSED
Treatment and Nursing Care
Bed rest, sedation,
Avoid stress and intercourse
Progesterone therapy
A period of “watchful waiting”
Inevitable Abortion
Signs and Symptoms
Loss is certain
Bleeding is more profuse
Painful uterine contractions
Cervix DILATES
Treatment and Nursing Care
Assess all bleeding. Save all pads. (May need to
weigh the pads)
Use the bedpan to assess all products expelled
Treated by evacuation of the uterus usually be a
D & C or suction
Provide Psychological Support
Complete Abortion
All products of conception are expelled
No treatment is needed, but may do a D & C
Incomplete Abortion
Parts of the products of
conception are expelled,
with placenta and
membranes retained
Treated with a D & C or
suction evacuation
Provide support to the
family
Missed Abortion
The fetus dies in-utero and is not expelled
Uterine growth ceases
Breast changes regress
Maceration occurs
Treatment:
D&C
Hysterotomy
Missed Abortion
Critical Thinking Exercise
The woman who has a missed
abortion is at risk for what 2
conditions?
Habitual Abortion /
Premature Cervical Dilation
Abortion occurs consecutively in three or
more pregnancies
Usually due to an Incompetent Cervical Os,
that results from cervical trauma, cervical
lacerations, repeated D & C, or conization.
Occurs most often about 18-20 weeks
gestation.
Habitual Abortion
Treatment
Cerclage procedure -- purse-string
suture placed around the internal os to
hold the cervix in a normal state
Nursing Care
Bedrest in a slight trendlenburg position to
decrease the pressure on the new sutures
Teach:
Assess for leakage of fluid, bleeding
Assess for contractions
Assess fetal movement and report decrease
movement (if old enough)
Assess temperature for elevations
Delivery
When time for delivery there are several
options:
physician will clip suture and allow patient to
go into labor on her own
induce labor
cesarean delivery
Mrs. B. had a cerclage procedure done at 14
weeks gestation. She is now 39 weeks
gestation and admitted to labor and delivery
because she is in labor.
What is the MOST important assessment to
make at this time?
Key Concepts to
Remember!!
If a woman is Rh-, RhoGam is given within
72 hours
Provide emotional support. Feelings of
shock or disbelief are normal
Encourage to talk about their feelings. It
begins the grief process
Bleeding Disorders
Ectopic Pregnancy
• Implantation of the blastocyst in ANY site
other than the endometrial lining of the
uterus
ovary (5) Cervical
Etiology / Contributing Factors
• Salpingitis
• Pelvic Inflammatory Disease, PID
• Endometriosis
• Tubal atony or spasms
• Imperfect genetic development
Assessment
Ectopic Pregnancy
• Early:
• Missed menstruation followed by vaginal
bleeding (scant to profuse)
• Unilateral pelvic pain, sharp abdominal pain
• Referred shoulder pain
• Cul-de-sac mass
• Acute:
• Shock – blood loss poor indicator
• Cullen’s sign -- bluish discoloration around
umbilicus
• Nausea, Vomiting
• Faintness
Diagnostic Tests
Ectopic Pregnancy
• Diagnosis:
• Ultrasound
• Culdocentesis
• Laparoscopy
Interventions / Nursing Care
• Combat shock / stabilize cardiovascular
• Draw blood for type and cross match
• Give blood replacements
• IV’s.
• Laparotomy
• Psychological support
• Linear salpingostomy
• Methotrexate – used prior to rupture. Destroys fast
growing cells
Hydatiform Mole
Etiology
A DEVELOPMENTAL ANOMALY OF THE
PLACENTA WITH DEGENERATION OF
THE CHORIONIC VILLI
As cells degenerate, they become filled with
fluid and appear as fluid filled grape-size
vessicles.
Assessment:
• Vaginal Bleeding -- scant to profuse,
brownish in color (prune juice)
• Enlargement of the uterus out of proportion
to the duration of the pregnancy
• Vaginal discharge of grape-like vesicles
• May display signs of pre-eclampsia early
• Hyperemesis gravidarium
• No Fetal heart tone or Quickening
• Abnormally elevated levels of HCG
Interventions and Follow-Up
• Empty the Uterus by D & C or Hysterotomy
• Follow-Up for One Year
• Assess for the development of choriocarcinoma
• Blood tests for levels of HCG frequently
• Chest X-rays
• Placed on oral contraceptives
• If the levels rise, then chemotherapy started
usually Methotrexate
Critical Thinking Exercise
A woman who just had an evacuation of a
hydatiform mole tells the nurse that she
doesn’t believe in birth control and does not
intend to take the oral contraceptives that
were prescribed for her.
How should the nurse respond?
Placenta Previa
• Low implantation of the placenta in the
uterus
• Etiology
• Usually due to reduced vascularity in the upper
uterine segment from an old cesarean scar or
fibroid tumors
• Three Major Types:
• Low or Marginal
• Partial
• Complete
Abruptio Placenta
Premature separation of the placenta from
the implantation site in the uterus
Etiology:
Chronic Hypertension
Sudden decompression of an over-distended
uterus
Trauma
Injudicious use of Pitocin
Smoking / Caffeine / Cocaine
Vascular problems
Placenta Previa Abruptio Placenta
• PAINLESS vaginal Bleeding accompanied
bleeding Abruptio by PAIN
• Bright red bleeding Dark red bleeding
• First episode of First episode of bleeding
bleeding is slight then usually profuse
becomes profuse
• Signs of blood loss Signs of blood loss out of
comparable to extent of proportion to visible
bleeding amount
• Uterus soft, non-tender Uterus board-like, painful
• Fetal parts palpable; Fetal parts non-palpable,
FHT’s countable FHT’s non-countable
• Blood clotting defect Blood clotting defect (DIC)
absent likely
Signs of Concealed Hemorrhage
Increase in fundal height
Hard, board-like abdomen
High uterine baseline tone on electronic
fetal monitoring
Persistent abdominal pain
Systemic signs of hemorrhage
Interventions and Nursing Care
Placenta Previa
Bed-rest
Assessment of bleeding
Electronic fetal monitoring
If it is low lying, then may allow to deliver
vaginally
Cesarean delivery for All other types of previa
Abruptio Placenta
Deliver by cesarean delivery immediately
Combat shock – blood replacement / fluid
replacement
Blood work – assessment of DIC
Critical Thinking
Mrs. A. , G3 P2, 38 weeks gestation is
admitted to L & D with bleeding. What is
the priority nursing intervention at this
time?
A. Assess the fundal height for a decrease
B. Place a hand on the abdomen to assess if hard,
board-like, tetanic
C. Place a clean pad under the patient to assess the
amount of bleeding
D. Prepare for an emergency cesarean delivery
Disseminated Intravascular
Coagulation (DIC)
Anti-coagulation and Pro-coagulation
effects existing at the same time.
Etiology
Defect in the Clotting Cascade
An abnormal overstimulation of the
coagulation process
Activation of Coagulation with
release of thromboplastin
Thrombin (powerful anticoagulant) is produced
Fibrinogen fibrin which enhances platelet aggregation
Widespread fibrin and platelet deposition in
capillaries and arterioles
Resulting in Thrombosis (multiple small clots)
Excessive clotting activates the fibrinolytic system
Lysis of the new formed clots create fibrin split
products
These products have anticoagulant properties and
inhibit normal blood clotting
A stable clot cannot be formed at injury sites
Hemorrhage occurs
Ischemia of organs follows from vascular occlusion
of numerous fibrin thrombi
Multisite hemorrhage results in shock and can
result in death
Disseminated Intravascular
Coagulation (DIC)
Precipating Factors:
Abruptio placenta
PIH
Sepsis
Retained fetus (fetal demise)
Fetal placenta fragments
Assessment
Signs and Symptoms
Spontaneous bleeding -- from gums and Epistasis,
and injection and IV sites, incisions
Excessive bleeding -- Petechiae at site of blood
pressure cuff, pulse points. Ecchymosis
Tachycardia, diaphoresis, restlessness, hypotension
Hematuria, oliguria, occult blood in stool
Mental changes if brain affected.
Diagnostic Tests
Lab work reveals:
PT – Prothrombin time is prolonged
PTT – Partial Thromboplastin Time increased
D-Dimer – increased Product that results from
fibrin degradation. More specific marker of the
degree of fibrinolysis
Platelets -- decreased
Fibrin Split Products – increase
An increase in both FSP and D-Dimer are
indicative of DIC
DIC
Interventions and Nursing Care
Remove Cause
Evaluate vital signs
Replace blood and blood products
Fluid replacement
May give Heparin -- interrupt the clotting
cascade and prevent triggering the
fibrinolytic system.
Structural Disorders
Fetal Demise / Intrauterine Fetal Death
DEFINITION:
Death of a fetus after the age of viability
Assessment:
1. First indication is usually NO fetal
movement
2. NO fetal heart tones
Confirmed by ultrasound
3. Decrease in the signs and symptoms of
pregnancy
Interventions and Nursing Care
• Allow patient to decide when she wants to
deliver
• Most women go into labor on their own in 2
weeks, so may wait for labor to begin
spontaneously
• Induce labor
• Prostaglandin (Prostin E) causes smooth
muscles to contract: Side effects - nausea,
vomiting, diarrhea
• Cytogel
• Provide with Emotional Support, allow to hold
baby
The End
