High-Risk Pregnancy & Hemorrhagic Disorders

High-Risk Pregnancy

• High-risk pregnancy conditions can originate from the pregnancy itself, or result from a condition that was already present before pregnancy
• These conditions put the woman and/or the fetus at risk and can include:
  • Hypertension
  • Hyperemesis gravidarum
  • Hemorrhagic conditions
  • Trauma or surgery during pregnancy
  • Urinary tract infections
• Risk assessment is ongoing throughout pregnancy and the postpartum period

Hemorrhagic Disorders

• Hemorrhagic disorders in pregnancy are medical emergencies because they decrease the oxygen-carrying capacity of the mother
• They can also increase the risk for:
  • Hypovolemia
  • Anemia
  • Infection
  • Preterm labor
  • Preterm birth
• Hemorrhagic disorders may have an adverse effect on oxygen delivery to the fetus
• Fetal risks include:
  • Blood loss
  • Anemia
  • Hypoxemia
  • Hypoxia
  • Anoxia
  • Preterm birth

Early Pregnancy Bleeding

• Miscarriage, or spontaneous abortion, is pregnancy loss before 20 weeks and is the most common complication in early pregnancy
• The cause is usually unknown and is highly variable
• Nursing assessments and interventions include assessing:
  • vaginal bleeding
  • cramping/contractions
  • vital signs and pain level
• Medications that may be needed include:
  • Misoprostol (Cytotec)
  • Oxytocin (Pitocin)
  • Rh(D) immunoglobulin (RhoGam) for any Rh-negative woman
• Client understanding and psychological support is also necessary

Cervical Insufficiency

• Cervical insufficiency is the premature dilation of the cervix
• The cervix dilates without uterine contractions, resulting in loss of pregnancy
• The cause is unknown, but it may be related to a history of cervical damage or preterm labor
• Management techniques include:
  • Ultrasound to check cervical length
  • Bed rest
  • Avoiding heavy lifting
  • Progesterone
  • Cervical cerclage
  • RhoGAM if Rh negative
  • Close monitoring for preterm labor

Bleeding During Early Pregnancy: Ectopic

• An ectopic pregnancy involves implantation of a fertilized ovum outside the uterine cavity
• 90% occur in the fallopian tubes
• Obstruction or slowing of the ovum's passage through the tube to the uterus can cause this
• Increased risk can be associated with a history of pelvic inflammatory disease
• Risks for the woman include:
  • Hemorrhage related to rupture
  • Decreased fertility related to removal of fallopian tube or ovary
• Classic clinical signs include abdominal pain within 7 to 8 weeks after the last menses, amenorrhea, and vaginal bleeding
• Rupture may manifest as dull, colicky pain, often unilateral, with referred shoulder pain
• Signs of hemorrhage and shock
• Therapeutic management involves:
  • Lab/diagnostic testing: transvaginal ultrasound, serum hCG
  • Medical management using the drug methotrexate
  • Surgery if rupture occurs, salpingectomy
  • RhoGam if the woman is Rh negative
• Nursing actions include:
  • Assessing the appearance and amount of vaginal bleeding
  • Monitoring vital signs and fluid replacement
  • Providing pre- and postoperative care
  • Assessing the maternal psyche and provide referral for pregnancy loss support group
  • Future fertility and contraception should be discussed

Gestational Trophoblastic Disease (Hydatidiform Mole)

• Gestational trophoblastic disease refers to rapid deterioration of trophoblastic villi in the placenta
• Gestational tissue is present, but the pregnancy is not viable
• Two common types of GTD include:
  • Partial: There may be fetal tissue, the embryo fails to develop past the early stage and has no viable pregnancy
  • Complete: No fetal tissue, embryo, or amniotic sac
  • Choriocarcinoma: A chorionic malignancy
• Assessment findings may include:
  • Rapid uterine growth
  • No fetal heart rate
  • Vaginal bleeding
  • Blood loss
  • Symptoms of preeclampsia before 24 weeks gestation
  • Persistently elevated or increasing hCG levels past 10-12 weeks
• Diagnosis can be done through ultrasound and revealing high hCG levels
• Therapeutic management includes:
  • Evacuation of uterine contents (D&C)
  • Check baseline hCG level, chest x-ray, and pelvic ultrasound
  • Monitor serial hCG levels weekly until they return to normal baseline levels
  • Continue monitoring monthly for 12 months
  • Monitor for signs of anemia
  • Conduct a chest x-ray every 6 months to detect pulmonary metastasis
  • Stress reliable contraception for 1 year

Late Pregnancy Bleeding: Placenta Previa

• Placenta previa is bleeding that occurs during the second and third trimesters
• The cause is unknown and is diagnosed by transvaginal ultrasound
• Occurs when the placenta implants in the lower uterine segment near or over the internal cervical os
• The two types include:
  • Total/complete: The placenta totally obstructs the internal cervical os
  • Low-lying: The placenta implants in the lower segment of the uterus, close to the internal cervical os
• Risk factors include:
  • Previous placenta previa
  • Uterine scarring
  • Advanced maternal age
  • Smoking
  • Multifetal gestation
  • Closely spaced pregnancies
  • Hypertension or diabetes
• Assessment findings:
  • Painless vaginal bleeding (bright red) in the second or third trimester
  • Spontaneous cessation, then recurrence, usually at 27-32 weeks gestation
  • Vital signs that initially appear stable
  • Uterine relaxation, soft and nontender
  • Fetal heart rate (reassuring)
• No vaginal or rectal examinations should be performed
• Diagnostic and laboratory tests:
  • Ultrasound for placenta placement (transvaginal)
  • Labs: Complete blood count (CBC), Hemoglobin (Hgb) & Hematocrit (Hct), blood type and Rh status, Kleihauer-Betke (KB) test
• Therapeutic management depends on:
  • Bleeding levels
  • the placental location
  • Gestational age
  • Labor signs and symptoms
• Assessments:
  • Vaginal bleeding and contractions
  • Leopold's maneuvers and monitoring fetal heart rate
  • Monitor maternal vital signs
  • Administer IV fluids and blood products as prescribed
• Anticipate an order for corticosteroids if early delivery by cesarean section is needed
• Expected management includes observation and bed rest

Late Pregnancy Bleeding: Abruptio Placentae

• Abruptio placentae is when the placenta separates from the uterine wall prematurely
• This compromises the fetal blood supply and occurs after 20 weeks gestation, usually in the third trimester
• Separation can be partial or complete and is a significant cause of third-trimester bleeding
• This condition can result in high maternal and fetal morbidity and mortality
• Risk factors include:
  • Maternal hypertension
  • Blunt external abdominal trauma (MVA)
  • Cocaine and smoking
  • Multifetal pregnancy
  • Premature rupture of membranes (PROM)
• 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
• A plan for emergent delivery may be needed
• Diagnostics and lab tests include a CBC, fibrinogen levels, clotting studies, type & cross-match, ultrasound, and biophysical profile
• Rapid assessment and treatment intervention is key
• Nursing management:
  • To ensure tissue perfusion: left lateral position, bedrest, oxygen therapy, monitor vital signs, fundal height, continuous fetal monitoring
  • Stabilize and determine severity: If fetal distress, cesarean section, administer corticosteroids
  • Monitor urinary output and fluid balance
• Maternal risks include:
  • Hemorrhagic shock
  • Disseminated intravascular coagulation (DIC)
  • Postpartum hemorrhage
• Fetal and neonate risks include:
  • Premature birth
  • Hypoxia, anoxia, neurological injury
  • Intrauterine growth restriction
  • Neonatal death

Late Pregnancy Bleeding

• Cord insertion and placental variations include velamentous insertion

Hypertension in Pregnancy

• Preeclampsia complicates about 5% to 10% of all pregnancies
• Hypertensive disorders of pregnancy are the most common medical complication reported during pregnancy
• Hypertension is a significant contributor to maternal and perinatal morbidity and mortality
• Hypertensive disorders in pregnancy include:
  • Gestational hypertension
  • Preeclampsia
  • Severe preeclampsia
  • Eclampsia
  • Chronic hypertension
  • Preeclampsia superimposed on chronic hypertension

Gestational Hypertension

• Diagnosis occurs after 20 weeks, with a previous normal BP
• Considered a temporary diagnosis
• Blood pressure is > 140/90 mmHg taken at least 4 hours apart
• No proteinuria is present
• Nursing management involves assessing frequent blood pressure and checking for proteinuria or other systemic findings
• BP usually returns to normal by 12 weeks postpartum, most resolving the first week
• A definitive diagnosis can be made once the blood pressure returns to normal

Preeclampsia: Etiology & Pathophysiology

• Signs and symptoms develop only during pregnancy and disappear after birth
• Associated high-risk factors include:
  • Family history
  • Multifetal pregnancy
  • Black race
  • Obesity
  • Diabetes
  • Being younger than 19 or older than 40 years old
  • Preexisting medical/genetic conditions
• Pathophysiology involves a pregnancy-specific syndrome
• New onset hypertension and proteinuria after 20 weeks gestation in previously normotensive women
• Involves vasospasm and poor tissue perfusion (can be mild or severe)
• Can cause reduced kidney function which can develop postpartum
• Diagnosis includes:
  • Elevated BP > or equal to 140/90 at least twice, measured 4 hours apart
  • Proteinuria >/= 3 g protein (1+) or more in a 24-hour urine collection
• Nursing assessments and interventions include:
  • Monitoring daily BP and VS (more frequently as indicated)
  • Assess fluid balance by monitoring Input/output and daily weight
  • Check for visual changes, headache, and level of consciousness (LOC)
  • Assess for right upper quadrant pain
  • Assess deep tendon reflexes (DTRs)
  • Check for clonus and pitting edema
• Further nursing assessments and interventions include:
  • Left lateral position-activity restrictions
  • Labs: CBC, liver enzymes/creatinine/uric acid, urine for proteinuria
  • Administer medication as ordered
  • Antihypertensive medication prn
• Assess fetus by external monitor:
  • Fetal movement counts
  • Nonstress test
  • Biophysical profile
  • Amniotic fluid index (AFI)

Severe Preeclampsia

• Can develop suddenly-requires immediate intervention
• Blood pressure of 160mmHg systolic or 110mmHg diastolic or greater X2, 4 hours apart
• Proteinuria is 5 gm in 24 hours, or 4+
• Oliguria: less than 400 ml in 24 hours
• Possible visual or cerebral disturbances
• Deep tendon (DTR) hyperreflexia
• Possible ankle clonus
• Right upper quadrant pain
• Monitor for clonus

Medications for Preeclampsia

• Antihypertensive medications to control blood pressure:
  • Hydralazine hydrochloride (vasodilator)
  • Labetalol hydrochloride (beta blocker)
  • Nifedipine (calcium channel blocker)
• Magnesium Sulfate (Central Nervous System depressant)
  • 4-6 gm dosage administered over 20 minutes, then 1-2 gm per hour and monitor levels
• Calcium gluconate
• A magnesium toxicity antidote with a dosage of 5-10 mEq IV over 5-10 minutes
• Calcium chloride may be administered
• Nursing care for Magnesium sulfate:
  • Client may feel flushing initially
  • Monitor BP, pulse, respirations, DTR, LOC, epigastric pain or headache, visual changes
  • Monitor urine output for 30mL or greater per hour; fluid restrictions 100-125/mL/hour
  • Assess fetal heart rate
  • Monitor for signs of magnesium toxicity
  • Decreased DTR and urine output
  • Decreased respirations or LOC
  • If assessed, discontinue magnesium sulfate and administer antidote

Eclampsia

• Preeclampsia progresses to eclampsia when seizure activity is present
• Similar to preeclampsia: More severe and requires immediate care
  • Can occur during antepartum or postpartum
  • No history of previous pathology
• Seizures can occur during labor
  • Stabilize mother- birth once seizures are controlled
  • Magnesium Sulfate to prevent further seizure
  • Antihypertensive agents
• Warning signs of an impending seizure:
  • Severe persistent headache, visual disturbances, epigastric pain, nausea, and vomiting
  • Hyperreflexia with clonus

Preeclampsia: HELLP Syndrome

• A complication of severe preeclampsia that involves hepatic dysfunction
• Diagnosed with changes in 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, and ALT elevated > 50 units/L, LDH elevated > 600 units/L -Result from decreased blood flow and damage to the liver
  • Low Platelets (LP) < 100,000/mm
  • Result from platelets collecting at the site of damaged vascular endothelium
• HELLP Signs and Symptoms:
  • Similar to severe preeclampsia
  • Review lab values for HELLP
    • Nausea and vomiting
    • Malaise
    • Right upper quadrant/epigastric pain
    • Edema
    • Gastrointestinal bleeding
  • Anticipate orders for platelets
  • Only cure is delivery, and the disease should resolve within 48 hours
  • Associated with increased risk of:
  • Pulmonary edema and Acute renal failure
  • Liver hemorrhage or failure
  • Disseminated intravascular coagulation (DIC)
  • Placental abruption
  • Acute respiratory distress syndrome
  • Sepsis or stroke
  • Fetal and maternal death

Hypertensive Disorders: Chronic

• Chronic hypertensive disorders are present before the pregnancy
• The diagnosis is initial during pregnancy and lasts >12 weeks after birth
• Can occur in Chronic hypertension with superimposed preeclampsia
  • Difficult to diagnose
  • Associated with adverse outcomes

Hyperemesis Gravidarum

• Defined by severe nausea and vomiting past 12 weeks gestation
• Risk factors include:
  • Obesity; Diabetes
  • Multifetal gestation or first pregnancy
  • Risk for fetus with intrauterine growth restriction (IUGR) or preterm birth
  • May be associated with increased hCG and estrogen levels
• Psychosocial concerns, high stress levels
• Assessment findings include:
  • Vomiting that is excessive for prolonged periods
  • Weight loss
  • Signs/symptoms of dehydration -Urinalysis ketones and acetone present
  • Liver enzymes, CBC, electrolytes present
  • Ultrasound and hCG levels
• Management:
  • IV hydration with LR
  • May be prescribed pyridoxine (Vitamin B12)
  • Monitor I&O; NPO 24 hours, clear liquids until no N/V
  • Monitor lab values for fluid and electrolyte imbalances
  • Daily weights
  • Antiemetic as ordered, such as ondansetron or metoclopramide
  • Advance diet slowly as tolerated (small, frequent meals) before advancing to soft, then regular, as tolerated
  • Explore complementary therapies

Multiple Gestations

• Pregnancy with two or more fetuses
• Two types: monozygotic and dizygotic
• Therapeutic management: Confirmed by ultrasound, close monitoring during labor
• Operative delivery (cesarean section) is common with increased risk of preterm labor and birth
• Nursing assessments:
  • Uterus is larger than expected or the estimated date of birth (done by ultrasound)
  • Anemia is a common finding
• Nursing management includes:
  • Education and support antepartum
  • Nutrition support
  • Close surveillance during labor with perinatal team on stand by
  • Postpartum assessment for possible hemorrhage

Gestational Diabetes Mellitus

• Glucose intolerance that was not present prior to pregnancy
• Placental hormones change insulin resistance
• Effects on the fetus
• Care management
  • Screening for gestational diabetes mellitus
  • Early pregnancy screening
  • Screening at 24 to 28 weeks
• Interventions:
  • Intrapartum
    • Glucose monitoring hourly
    • Insulin infusion
    • Avoid dextrose solutions
  • after birth
    • Most return to normal
    • High risk for future GDM in pregnancy
    • increased risk of type 2 diabetes
    • Reassess at 6-12 weeks

Summary

• Pregestational gestational complications pose risk to mother and fetus and require astute assessment and specialized care to optimize maternal and fetal outcomes