Complications During Pregnancy

• The content provided discusses complications in pregnancy, their management, and related information.

The Patient's Perspective in Complicated Pregnancies

• Fear, anger, guilt, failure, self-blame, and feeling helpless are common emotions.

Extra Appointments and Testing

• NST (Non-Stress Test) with ultrasound is commonly used.
• The ultrasound involves fetal surveillance, assessing amniotic fluid volume, placental maturity, estimated fetal weight, and fetal presentation.

Bleeding in Pregnancy

• First Trimester: SAB (Spontaneous Abortion) before 20 weeks, ectopic pregnancy, and gestational trophoblastic disease.
• Second and Third Trimesters: Placenta previa, placenta abruption, vaso previa, and adherent placenta (accreta).

Early 1st Trimester Spontaneous Abortion

• Etiology is often mal-development.
• Types direct care, including threatened vs Imminent, incomplete, complete, missed, recurrent, and septic.

Nursing Management of Spontaneous Abortion

• Assess blood loss via pad count/weigh and monitor Fetal Heart Tones (FHTs) and Vital Signs (VS).
• Hospital-based care may involve the Emergency Department (ED) and Dilation & Curettage (D&C).
• Provide psychological support and self-care teaching about future pregnancies.

Cervical Incompetence

• The cervix's inability to retain the fetus
• May be due to a functional or structural defect, absence of uterine contractions, or labor.
• Typically occurs from the early second to early third trimester.
• Congenital or Acquired factors include Ehlers-Danlos & Marfan syndrome (collagen deficiency), cervical trauma, and infection/inflammation.

Medical Management of Cervical Incompetence

• Prophylactic cerclage (before 16 weeks).
• Rescue cerclage (16-23 weeks).
• Transabdominal cerclage is used for severe anatomical defects or previous transvaginal cerclage failure.

Ectopic Pregnancy

• Occurs in 1 in every 50 pregnancies.
• It can become a medical emergency if ruptured.
• 10% maternal mortality rate.
• Occurs the majority of the time in the fallopian tube.

Ectopic Pregnancy Details

• Assessment includes menstrual history, history of pelvic infection, Beta-hCG lab test, transvaginal ultrasound for size and location.
• Examination reveals abdominal pain, amenorrhea, vaginal bleeding (spotting at 6-8 weeks), tender abdomen, painful vaginal exam, and cervical tenderness.

Ectopic Pregnancy Treatment

• Intravenous (IV) fluids and Methotrexate IM if less than 4 cm in size.
• Chemotherapy medication with chemo precautions.
• Follow up with weekly Beta-hCG tests for monitoring and delay pregnancy for three months post-treatment.
• Surgery can include linear salpingostomy (to preserve fertility) versus salpingectomy.
• Signs of complications/rupture include hypovolemic shock, infection/sepsis, and DIC (Disseminated Intravascular Coagulation).

Gestational Trophoblastic Disease: Molar Pregnancy

• Signs and Symptoms: vaginal bleeding, anemia, uterine enlargement, hydropic vesicles, elevated hCG, hyperemesis, preeclampsia, and low MSAFP.
• Treatment: early evacuation and curettage with extensive follow-up for malignant GTD.

Molar Pregnancy Management

• No pregnancy for at least one year.
• Repeated hCG level checks.

Bleeding in the 3rd Trimester

• Previa presents with bright red bleeding, no pain, and normal coagulation.
• Abruption presents with dark, old blood, pain, and can lead to DIC.
• Previa: life-threatening amount of bleeding.
• Abruption: minimal to moderate amount of bleeding.

Clinical Management: Previa

• Greater than 37 weeks: plan Cesarean birth.
• Less than 37 weeks: expectant management, saline lock, hospitalize if bleeding, tolerate small gushes, and type and crossmatch every 72 hours.

Abruptio Placentae

• Mild: 10-20%
• Moderate: 20-50%
• Severe: >50%
• Two types: concealed and revealed.

Accreta, Increta, Percreta

• Accreta: all or part of the placenta attaches abnormally to the myometrium.
• Chorionic villi attach to the myometrium instead of remaining in the decidua basalis.
• Increta: chorionic villi grow into the myometrium.
• Percreta: chorionic villi grow through the perimetrium (uterine serosa).

Risk Factors

• Previous Cesarean Section (C/S)
• Placenta previa in the presence of a uterine scar.
• Management: delivery by cesarean and potential abdominal hysterectomy.

Hyperemesis Gravidarum

• Nausea & Vomiting: 70-90% experience begins at 4-6 weeks, peaks 8-12 weeks, and hyperemesis incidence is 0.5-2%.
• Hyperemesis Gravidarum: intractable vomiting, usually resolves by 20 weeks, 10% persist until delivery, and cause unclear.

Clinical Treatment for Hyperemesis

• Controlling vomiting with medications like promethazine, pyridoxine & doxylamine, and ondansetron.
• Correct dehydration with fluids and medications.
• Restore electrolyte balance.
• Possible Total Parenteral Nutrition (TPN).
• Can be treated outpatient or inpatient.

Additional Complications/Disorders in Pregnancy

• Clotting disorders (DIC), Sexually Transmitted Diseases (STDs), Urinary Tract Infections (UTIs).
• Appendicitis, Cholethiasis/Cholecystitis, Trauma and Perimortem care.

Preterm Labor (PTL)

• Labor between 20 and 36 6/7 weeks.
• Regular contractions and cervical change.

Preterm Birth (PTB)

• Birth between 20 and 36 6/7 weeks.
• Low birth weight is equal to 2500g or less.
• Very low birth weight (VLBW) is less than 1500g.
• Indicates preterm birth rate rose 4% in 2021.
• Approximately 1.1 million prematurely born babies die annually.
• 15 million PTB in the US each year.
• The average cost per day is $3000.00.

Healthcare

• Monetary value related to the use of community health services.

Social Services

• Case management, counseling, respite care, and residential care.

Educational

• Higher incidence of learning disabilities.

Out-of-Pocket

• Includes co-pays, transportation costs, accommodation expenses.

Conditions Leading to Preterm Birth

• Inflammation/Infection: 40%
• Activation of the maternal-fetal hypothalamic-pituitary-adrenal (HPA) axis: 30%.
  • This axis controls the stress response system
• Hemorrhage: 20%
• Uterine distention: 10%

PPROM

• Accounts for 1/3 of all Preterm Birth.
• Fetal surveillance requiring NICU admit if viable.
• Steroids, Magnesium, and Antibiotics.
• No vaginal exams Sepsis screen.
• It requires Tocolytics and Time for antenatal steroids.
• Maternal transport to level 3/4 care may be necessary.

Importance of Intact Membranes

• Hydrostatic pressure of amniotic fluid expands the lungs and matures the lung buds.
• Barrier to infection allowing for movement and growth while protecting the fetus and cord.

PPROM and early stages of lung development

• Most critical time of 17-34 weeks.
• More susceptible to irreversible arrest of lung development and injury.

PPROM and later trimesters

• Effect growth and movement
• Skeletal deformities.
• Cord compression.

PPROM: Health History and Tests

• History: Assess for labor/UCs (Uterine Contractions), VS for signs of infection, Continuous FHR monitoring, no vaginal exam, observe amount/color/odor of fluid.
• Record time of leak/rupture.
• Tests: UA, CBC, GBS, Nitrazine paper for pH, vaginal secretions acidic (4.5), amniotic fluid (7.0), Fern test, and Ultrasound.

PPROM Risks

• 1/3 develop infection, cord prolapse, cord compression, increase in neonatal morbidity and mortality.
• Sepsis, Necrotizing Enterocolitis (NEC), and Intraventricular Hemorrhage (IVH) are all possible risks.
• Can reseal and fluid can re-accumulate.

Preventing Premature Birth: Modifiable Factors

• Lifestyle Changes: smoking, child spacing, nutrition, substance use, stress reduction, and management of medical conditions like hypertension, renal issues, asthma, and the flu can assist.
• Progesterone Therapy: start at 16 weeks and continue to 36 weeks.
• It can act by supplementing decreasing levels, or through anti-inflammatory effects.

Prevention: Early Recognition

• Requires knowing the subtle and non-specific signs.
• These include uterine activity (more frequent than 6/hr, lasting more than 1hr, even if painless).
• Lower abdominal cramping, dull intermittent backache, menstrual-like cramps, pelvic/suprapubic pressure/heaviness discomfort.
• Also change in vaginal discharge, or leaking fluid that isnt related to urination.

Fetal Fibronectin (FFN)

• Normally present in early and late pregnancy.
• Appearance between 24 and 34 weeks may predict PTL (Preterm Labor).
• It has low positive predictive value (46%) but high negative predictive value.
• Predicts who will NOT go into labor; false positives can result from recent VE (Vaginal Exam), sexual intercourse, or vaginal bleeding.

Cervical Length

• Measurement from internal cervical os to the external cervical os.
• Normal length is 30mm.

Risk Assessment

• < or = 20mm: high risk.
• < 15mm: 50% chance of PTB.

Management of Person at Risk for Preterm Birth

• Transport to a Level 3 or 4 Hospital.
• Hydrate; limit activity.
• Treat for infection and accelerate fetal lung maturity with antenatal steroids.
• Administer Suppression of uterine activity with tocolytics and Magnesium for neuro-protection.

Antenatal Steroids

• Promotes fetal lung maturity.
• Can use Betamethasone (2 doses, 24 hours apart) or Dexamethasone (4 doses, 12 hours apart).
• Requires 48 hours to work.
• NIH recommends for all women at risk for preterm birth.
• Not indicated in cord prolapse, chorioamnionitis, or abruptio placentae.
• Will Impact blood sugars for both mother and neonate.

Tocolytics

• Nifedipine: calcium antagonist that interrupts calcium channels in the myometrium to cause uterine relaxation.
• Side effects include hypotension, flushing, headache, dizziness, and nausea.
• Indocin: Prostaglandin inhibitor that interferes with the production of prostaglandins, thus interfering with uterine contractions, but has potential side-effects.
• Give 30mg orally (po), then 10-20mg every 4-6 hours.

Nursing Considerations

• Monitor Vital Signs (VS) prior to dose, then frequently, to notify provider for systolic blood pressure (BP) < 9, diastolic BP < 50.
• Requires continuous fetal and uterine monitoring until stable.
• Indocin can cause nausea, heartburn, potential renal toxicity, oligohydramnios, IVH, NEC, and constriction of the DA in the fetus.
• Administer 50 mg rectal or 50-100 mg PO load, then 25-50mg PO every 6 hours for 48 to 72 hours.
• Monitoring requires giving after meals and continuous fetal and uterine activity.