High-Risk Pregnancy & Hemorrhagic Disorders

High-Risk Pregnancy

• High-risk pregnancies arise from conditions due to pregnancy or pre-existing conditions, putting both the woman and fetus at risk
• Risk assessment is ongoing throughout pregnancy and the post-partum period

Hemorrhagic Disorders

• Hemorrhagic disorders in pregnancy are medical emergencies
• Maternal blood loss decreases oxygen-carrying capacity and can result in hypovolemia, anemia, infection, preterm labor, and preterm birth
• Hemorrhage adversely affects oxygen delivery to the fetus
• Fetal risks from hemorrhage include: blood loss, anemia, hypoxemia, hypoxia, anoxia, and preterm birth

Early Pregnancy Bleeding

• Early pregnancy bleeding can be due to matermal complications in the second and third trimesters
• Miscarriage (spontaneous abortion) is pregnancy loss before 20 weeks and most common
• The cause of miscarriage is unknown and highly variable

Early Pregnancy Bleeding: Nursing Assessment and Interventions:

• Monitor vital signs, pain level
• Monitor vaginal bleeding an cramping or contractions
• Prescribe Misoprostol (Cytotec) & Oxytocin (Pitocin)
• Administer Rh(D) immunoglobulin (RhoGam) if Rh negative
• Provide client understanding and psychological support

Cervical Insufficiency

• Cervical Insufficiency is premature dilation of the cervix
• The cervix dilates without uterine contractions, resulting in pregnancy loss
• Cause is unknown, but associated with a history of cervical damage or preterm labor

Cervical Insufficiency: Management

• Management includes ultrasound to check cervical length
• Treatments involve bed rest, avoiding heavy lifting, and progesterone
• Surgical intervention may involve cervical cerclage as treatment
• Monitor Rhogam if Rh negative
• Close monitoring for preterm labor is essential

Bleeding During Early Pregnancy: Ectopic Pregnancy

• Implantation of fertilized ovum occurs outside the uterine cavity (90% in fallopian tubes)
• Obstruction or slowing passage of ovum through the tube to the uterus can cause ectopic pregnancy
• Increased risk if there is a history of pelvic inflammatory disease
• Risk to the woman includes hemorrhage related to rupture and decreased fertility that may be related to the removal of the fallopian tube or ovary

Assessment for Ectopic Pregnancy:

• Classic clinical signs involve abdominal pain (within 7-8 weeks after last menses)
• Other classic signs include amenorrhea and vaginal bleeding
• Dull colicky pain, often unilateral, and referred shoulder pain can also occur
• Also assess for signs of hemorrhage and shock

Management of Bleeding During Early Pregnancy: Ectopic Pregnancy

• Diagnostic testing involves transvaginal ultrasound and serum hCG
• Methotrexate dissolves the fertilized ovum
• Surgery (salpingectomy) may remove fallopian tubes if there are ruptures
• RhoGam is administered if the woman is Rh negative

Bleeding During Early Pregnancy: Ectopic Pregnancy: Nursing Actions

• Nursing action includes assessing appearance and amount of vaginal bleeding, monitoring vital signs, and fluid replacement
• Provide pre and postoperative care
• Assess maternal psyche and provide referral for pregnancy loss support group
• Discuss future fertility and contraception, considering the higher risk of having fertility issues

Gestational Trophoblastic Disease (Hydatidiform Mole)

• Gestational Trophoblastic Disease (GTD) involves rapid deterioration of trophoblastic villi in the placenta, gestational tissue present, and a non-viable pregnancy
• The 2 most common types of GTD are Partial-may be fetal tissue, embryo fails to develop early, no viable pregnancy and Complete- no fetal tissue, no embryo, no amniotic sac
• Choriocarcinoma is a chorionic malignancy

Assessment and Diagnosis of Gestational Trophoblastic Disease

• Rapid uterine growth, no fetal heart rate, vaginal bleeding, and blood loss
• Symptoms of preeclampsia before 24 weeks gestation
• Persistently elevated or increasing hCG levels past 10-12 weeks
• Diagnosis through ultrasound, high hCG levels

Gestational Trophoblastic Disease: Therapeutic Management

• Evacuation of uterine contents via D&C
• Monitor baseline hCG level, chest x-ray and pelvic ultrasound
• Monitor serial hCG levels weekly until normal
• Continue monitoring monthly for 12 months
• Monitor for signs of anemia
• Monitor Chest x-ray every 6 months detect pulmonary metastasis
• Stress reliable contraception for 1 year

Late Pregnancy Bleeding: Placenta Previa

• Bleeding typically happens during the 2nd or 3rd trimesters
• The cause is unknown; but it involves placental implantation in the lower uterine segment near or over internal cervical os
• A total/complete placenta previa obstructs the internal cervical os, whereas a low-lying placenta is close to the internal cervical os
• Monitor via ultrasound

Late Pregnancy Bleeding: Placenta Previa:Risk Factors

• Placenta previa/uterine scarring can be risk factors
• Advanced maternal age and smoking
• Multifetal gestation and/or closely spaced pregnancies
• Hypertension or diabetes

Assessment for Placenta Previa:

• This condition involves painless vaginal bleeding that is bright red in the 2nd or 3rd trimester
• The bleeding has spontaneous cessation then recurrence
• Bleeding is usually identified at 27-32 weeks' gestation
• Vital signs are initially stable
• Uterine is relaxed, soft, and nontender
• Initially, the fetal heart rate is reassuring
• Do not do vaginal/rectal examinations

Late Pregnancy Bleeding: Placenta Previa Con’t: Diagnostic and Laboratory Tests

• Perform ultrasound for placenta placement via transvaginal approach
• Obtain blood samples (labs) perform a complete blood count (CBC)
• Assess Hemoglobin (Hgb) & Hematocrit (Hct)
• Determine blood type and Rh status, as it can be a possible candidates for blood transfusion
• Do the Kleihauer-Betke (KB) test to look for the presence of fetal cells in maternal circulation.

Late Pregnancy Bleeding: Placenta Previa Con't: Therapeutic Management

• Management depends on: bleeding, location of placenta, gestational age, labor signs & symptoms
• Assess vaginal bleeding and contractions
• Perform Leopold's maneuvers and monitor FHR
• Monitor maternal vital signs
• Administer IV fluids and blood products as prescribed
• Anticipate order for corticosteroids if early delivery by cesarean section
• Help with fetal lung development
• Expected management: observation and bedrest

Late Pregnancy Bleeding: Abruptio Placentae

• Abruptio Placentae is a painful occurrence when the placenta separates from the uterine wall prematurely, compromising fetal blood supply
• Occurs after 20 weeks gestation, usually 3rd trimester
• Separation can be partial or complete
• Abruptio Placentae's is a significant cause of 3rd-trimester bleeding
• Can be high maternal and fetal morbidity and mortality

Late Pregnancy Bleeding: Abruptio Placentae: Risk Factors

• Maternal hypertension is a risk factor
• Also involves Blunt external abdominal trauma (MVA)
• Cocaine use and smoking are strong risk factors
• Multifetal pregnancy
• Premature rupture of membranes (PROM)

Late Pregnancy Bleeding: Abruptio Placentae: Assessment Findings

• Sudden onset
• Vaginal bleeding may or may not be observed - dark red
• Sharp, stabbing pain, abdomen unusually firm
• Contractions with increased uterine tone
• Fetal distress or absent FHR
• Signs of hypovolemic shock
• Need to plan for emergent delivery

Late Pregnancy Bleeding: Abruptio Placentae: Diagnostic and Lab Tests

• Diagnostic and lab tests include CBC, fibrinogen levels, clotting studies, type&cross-match
• Perform Ultrasound and biophysical profile

Late Pregnancy Bleeding: Abruptio Placentae: Nursing Management

• Rapid assessment and intervention is key when dealing with Abruptio Placentae
• Provide Tissue perfusion: via left lateral position, bedrest, oxygen therapy, monitor vital signs, fundal height, continuous fetal monitoring
• To stabilize and determine severity if fetal distress cesarean section
• Administer corticosteroids
• Monitor urinary output and fluid balance

Late Pregnancy Bleeding: Abruptio Placentae: Maternal Risks

• Hemorrhagic shock can occur
• Disseminated intravascular coagulation (DIC) and Postpartum hemorrhage

Late Pregnancy Bleeding: Abruptio Placentae: Fetal and Neonate Risks with Occurrence

• Premature birth
• Hypoxia, anoxia, neurological injury
• Intrauterine growth restriction
• Neonatal death

Late Pregnancy Bleeding: Cord Insertion and Placental Variations

• Cord insertion and placental variations can cause Late Pregnancy Bleeding Velamentous insertion is one of such causes

Late Pregnancy Bleeding: Succenturiate Lobe Placenta

• Succenturiate lobe placenta, where there is an extra placenta lobe, and Placenta variations can cause Late Pregnancy Bleeding

Hypertension in Pregnancy

• Preeclampsia complicates approximately 5% to 10% of all pregnancies
• Hypertensive disorders of pregnancy are the most common medical complication reported during pregnancy
• Also a significant contributor to maternal and perinatal morbidity and mortality

Hypertension in Pregnancy: Types

• Gestational hypertension
• Preeclampsia- Severe Preeclampsia
• Eclampsia
• Chronic hypertension
• Preeclampsia superimposed on chronic hypertension

Gestational Hypertension

• Gestational hypertension is diagnosed after 20 weeks, with previous BP normal
• The BP reading is > BP 140/90 mmHg
• Measurement is taken at least 4 apart
• There is no proteinuria
• BP returns to normal by 12 weeks postpartum, usually resolves first week

Preeclampsia: Etiology

• Signs and symptoms develop only during pregnancy and disappear after birth
• Includes risk Factors Family history, Multifetal pregnancy, Black race, Obesity, Diabetes, Before 19 and after 40 years old, and Preexisting medical or genetic conditions

Preeclampsia

• It's a pregnancy specific syndrome
• New onset hypertension and proteinuria after 20 weeks gestation in previous normotensive women
• It involves vasospasm and poor tissue perfusion, and can be mild or severe
• Diagnosis through Elevated BP > or equal to 140/90- 2 measurements that are at least 4 hours apart, and Proteinuria

Preeclampsia: Nursing Assessments & Interventions

• Nursing assessments and interventions involve: Daily Blood pressures, V/S and more frequent as indicated
• Assess fluid balance: monitor I&O and daily weight and watch if unitary output decrease
• Visual changes, headache and level of consciousness (LOC)
• Assess for right upper quadrant pain/assess deep tendon reflexes (DTRs)
• Clonus-4+ can lead to CNS impairment, which leads to high risk for seizures

Preeclampsia: Nursing Assessment: Additional Interventions

• Left lateral position - activity restrictions
• Labs: CBC, Liver enzymes and creatinine, Uric acid, urine for proteinuria and Kidney function
• Administer medication as ordered (antihypertensive medication prn)
• Assess fetus by external monitor: includes Fetal movement counts, Nonstress test and Biophysical profile, Amniotic fluid index (AFI)

Severe Preeclampsia

• It can develop suddenly and immediate intervention is required
• BP reading is 160mmHg systolic or110mmHg diastolic or greater X 2, 4 hours apart
• Proteinuria is 5 gm in 24 hours or 4+
• Oliguria: less than 400 ml in 24 hours
• Visual or cerebral disturbances.
• Ankle clonus

Preeclampsia: Medications

• Antihypertensive medications to control Blood pressure: give Hydralazine hydrochloride- vasodilator, and/or Labetalol hydrochloride- beta blocker or Nifedipine- Calcium channel blocker
• Use Magnesium Sulfate which is a Central Nervous System depressant
• Dosage: 4-6 gm administered over 20 minutes, then 1-2 gm per hour and monitor levels of Magnesium Sulfate
• Calcium gluconate is the antidote for magnesium toxicity, typically 5-10 mEq IV over 5-10 minutes if there is magnesium toxicity

Magnesium Sulfate: Nursing management

• Note for Magnesium sulfate: Client may feel flushing initially
• Monitor BP, pulse, respirations, DTR, LOC, epigastric pain or headache, visual changes
• Monitor urine out put for 30mL or greater per hour, and fluid restrictions 100-125/mL/hour
• Assess fetal heart rate
• Monitor signs of magnesium toxicity Decreased DTR, urine output; Decreased Respirations, decreased LOC
• If assess above discontinue Magnesium sulfate and administer antidote

Eclampsia

• Preeclampsia progresses to Eclampsia when seizure activity is present
• Eclampsia is similar to Preeclampsia, more severe, and requires immediate care
• Can take place during antepartum or postpartum and, there is no history of previous pathology or seizure before diagnosis

Warning Signs of Impending Seizure

• Severe persistent headache
• Visual disturbances
• Epigastric pain
• Nausea and vomiting
• Hyperreflexia with clonus

Preeclampsia: HELLP Syndrome

• HELLP Syndrome is a complication of Severe Preeclampsia that involves hepatic dysfunction
• It's diagnosed with changes in Lab values

Preeclampsia: HELLP Syndrome: Lab Values

• Hemolysis (H): Increased bilirubin (indirect) elevated > 1.2mg/dl
• Result of red blood cell destruction
• Elevated Liver enzymes (EL): AST > 70 units/L, ALT > 50 units/L, LDH > 600 units/L
• This occurs because of decreased blood flow and damage to the liver
• Low Platelets (LP) < 100,000/mm; which as a result of Platelets collect at the site of damaged vascular endothelium

HELLP: Signs and Symptoms:

• Nursing Assessments are similar to severe preeclampsia; and include reviewing lab values for HELLP
• Nausea and vomiting
• Malaise
• Right upper quadrant or epigastric pain
• Edema
• Gastrointestinal bleeding
• Anticipate orders for platelets

Preeclampsia: HELLP Syndrome: Complications

• Associated with increased risk for: Pulmonary edema and Acute renal failure
• Liver hemorrhage or failure often take place
• Disseminated intravascular coagulation (DIC) and Placental abruption
• Acute respiratory distress syndrome
• Can cause Sepsis or stroke
• Fetal and maternal death

Hypertensive Disorders- Chronic

• Present before the pregnancy
• Initial diagnosis during pregnancy and lasting >12 weeks after birth
• Can also be identified as Chronic hypertension with superimposed preeclampsia
• Difficult to diagnose and associated with adverse outcomes

Hyperemesis Gravidarum

• Defined by severe nausea and vomiting persisting past 12 weeks gestation
• Obseity, Diabetes, Multifetal gestation or first pregnancy are risk factors
• It can also lead to Intrauterine growth restriction (IUGR) and preterm birth
• Can be associated with increased HCG and Estrogen levels and Psychosocial concerns, high stress levels

Hyperemesis Gravidarum: Assessment and Diagnostics

• Excessive vomiting for prolonged periods, which leads to weight loss
• Sign of dehydration, Urinalysis and ketones, and electrolyte imbalances
• Monitor Liver enzymes, CBC (Complete Blood Count), and Electrolytes levels
• Perform Ultrasound, assess HCG levels

Hyperemesis Gravidarum: Management

• Management involve implementing IV hydration with LR
• May be prescribed pyridoxine (Vitamin B12), and to monitor
• Monitor I&O; NPO 24 hours-clear liquids if no N/V
• Monitor lab values for fluid and electrolyte imbalances
• Monitor Daily weights and administer Antiemetic as ordered-ondansetron, metoclopramide
• Advance diet slow as tolerated, small frequent meals, then advance soft to regular as tolerated
• Explore complementary therapies

Multiple Gestations

• Multiple gestations are pregnancies involving two or more fetuses
• The two types are monozygotic and dizygotic twins

Multiple Gestations: Therapeutic Management

• Confirmed by ultrasound, close monitoring during labor, operative delivery-cesarean section (common)
• Increased risk for preterm labor and birth

Multiple Gestations-Nursing Assessments

• Uterus larger than expected for estimated date of birth, ultrasound confirmation
• Anemia- common finding

Multiple Gestations-Nursing Management

• Education and support antepartum
• Nutrition support
• Close surveillance (during labor) with perinatal team on stand by
• Postpartum assessment- possible hemorrhage due to uterine expansion

Gestational Diabetes Mellitus

• It is glucose intolerance that was not present prior to pregnancy
• Placental hormones change in insulin resistance
• Monitor for effects on the fetus

Care Management for Gestational Diabetes Mellitus

• Care management screens for gestational diabetes mellitus
• Screening in early pregnancy and for all other women by 24-28 weeks in pregnancy

Gestational Diabetes Mellitus Interventions:

• In intrapartum: Monitor Glucose hourly and Insulin Infusion; but avoid dextrose solutions
• After birth: Most return to normal in after birth but there is still High risk for future GDM in pregnancy

Gestational Diabetes Mellitus: Additional Interventions

• Watch for Increased risk of type 2 diabetes
• Do Reassess at 6-12 weeks

Antepartum Summary

• Pre-gestational and gestational complications will pose risks to mom and fetus
• High risk pregnancy requires astute, assessment, and specialized care to optimize maternal and fetal outcomes