High-Risk Pregnancy: Maternal & Fetal Complications

• Complications of pregnancy can categorize most births as low risk; however, maternal or fetal complications can classify some as high risk.
• Identification of risks along with appropriate, timely interventions, prevents morbidity and mortality of mothers and infants.
• Individuals with mental health issues or have a hard time using prenatal care are at risk.
• The health of the mother or fetus can be jeopardized.
• At-risk status extends through the entire postpartum period (approximately 6 weeks after childbirth).
• At-risk diagnosis poses a situational crisis on family
• The fear of pregnancy loss happens before the anticipated due date
• Fetal or maternal diagnosis may require a decision to continue or interrupt the pregnancy or birth of a newborn who does not meet cultural, societal, or familial norms

RPN Scope of Practice

• Identifying pregnancy risk factors through health assessment and interviewing
• RPNs cannot care for antenatal patients with pregnancy complications because it is considered too unstable
• RPNs can care for postpartum patients who have had complications during pregnancy and are now delivered and considered stable
• RPNs have to identify if the postpartum patient is decompensating, like uncontrolled BP, postpartum hemorrhage, and uncontrolled blood sugars

Maternal Morbidity

• The 3 major causes of maternal deaths include hemorrhage, infection and high blood pressure
• Factors related to maternal deaths includes being <20, >35 years, lack of prenatal care, low education level, mental health concerns, intimate partner violence and low to middle-low socioeconomic status

Gestational Conditions

• Disorders that did not exist before pregnancy may put the woman and fetus at risk such as hyperemesis gravidarum, hypertension in pregnancy, gestational diabetes mellitus, Rh incompatibility, and hemorrhagic complications

Warning Signs in Pregnancy

• Sudden gush or leaking of fluid from the vagina (<37 weeks)
• Vaginal bleeding
• Abdominal Pain
• Decreased or absent fetal movements
• Persistent Vomiting
• Epigastric Pain
• Edema of face and hands
• Severe, persistent headache
• Blurred vision/dizziness
• Chills with fever over 38.0 C
• Painful Urination

Hyperemesis Gravidarum (HG)

• Nausea and vomiting is the most common medical condition in pregnancy and affects 50-90% of women
• Hyperemesis Gravidarum is a potentially life-threatening condition that affects 0.5 to 2% of pregnancies and requires hospitalization

Hypertension in Pregnancy

• Hypertensive disorders of pregnancy are becoming more common, involving 5 to 10% of pregnancies
• Women over 40 years of age are at the highest risk
• Hypertension is the leading cause of maternal and perinatal morbidity and mortality worldwide

Gestational Diabetes Mellitus (GDM)

• Hyperglycemia that is identified first in pregnancy
• The prevalence is 3.8 to 6.5% in the overall population, and is higher among Indigenous, Latin American, South Asian, Asian, and African people
• Standardized screening is for all pregnant women at 24-28 weeks gestation
• The normal glucose range is 7.8-11.0 mmol/L

Rh and ABO Incompatibility

• Rh and ABO incompatibilities are abnormal reactions that occur when a pregnant woman's blood type does not match the fetus blood type
• This may result in the destruction of the baby's red blood cells
• Antibodies cross the placenta and destroy fetal red blood cells, and anemia will then occur; this is known as Hemolytic disease of the newborn
• Rh incompatibility involves a mother who is Rh negative and the fetus is Rh positive
• ABO incompatibility includes a mother who is O blood type with a baby who is either type A or B

Hemorrhagic Disorders

• Hemorrhagic disorders in pregnancy are medical emergencies
• 50% of bleeding in the third trimester is due to placenta previa or placental abruption
• Maternal blood loss decreases oxygen-carrying capacity
• There’s an increased risk for hypovolemia, anemia, infection, preterm labor, and preterm birth

Early Pregnancy Bleeding

• Early pregnancy bleeding is up to and before 20 weeks of gestation
• Early pregnancy bleeding can be a spontaneous miscarriage (loss of products of conception; bleeding and dilation of the cervix), threatened abortion (bleeding but pregnancy remains viable and cervix is closed), or incomplete abortion (bleeding, pregnancy not viable but products of conception are not passed)
• Common cramping and bleeding are associated with early pregnancy
• 1 in 4 women will experience a miscarriage in their lifetime

Early Pregnancy Bleeding: Nursing Care

• Patients require emotional and supportive care
• Pad counts and the estimation of pad saturation
• Assess patient's vital signs
• Observe for signs of hypovolemia and hypovolemic shock
• Monitor any tissues passed onto pads
• The patient has to remain NPO
• Prepare for surgery if and when needed
• Have post-surgical care whenever needed
• Teach warning signs surrounding excessive bleeding, signs and symptoms of infection, and plan for a follow-up appointment before discharging a patient

Early Pregnancy Bleeding: Ectopic Pregnancy

• Ectopic Pregnancy involves a fertilized ovum that implants outside the uterine cavity
• 95% of the cases happen in the fallopian tube, in other words, a tubal pregnancy
• An ectopic pregnancy manifests in a missed period, positive pregnancy test which yields low HCG or levels that do not rise, lower abdominal cramping and light bleeding
• Ectopic pregnancies may rupture, which causes severe abdominal pain, vaginal bleeding

Early Pregnancy Bleeding: Ectopic Pregnancy Treatment and Nursing Care

• Treatment involves surgical removal of the products of conception, typically done laparoscopically; although may result in the loss of the fallopian tube if there's severe damage
• Treatment includes an injection of methotrexate if the tube is not ruptured which inhibits cell division in the embryo and body can reabsorb
• Supportive and emotional care is required for pregnancy loss
• Post surgical care is required
• Have appropriate counselling regarding post pregnancy options

Late Pregnancy Bleeding

• Placenta Previa
• Placental Abruption
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Placenta Previa

• Placenta Previa is commonly painless bleeding and bright red in color
• Uterus is soft
• Bed rest is essential
• Can result in C/S
• Post-partum complications may include an infection, hemorrhage, and fetal anemia
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Placental Abruption

• Placental detaches
• Dark bleeding
• Abdominal pain
• At times there may be a concealed hemorrhage
• Uterus is firm
• Post partum complications are the same as in previa
• Placental Abruption is the premature separation of the placenta as part or all of the placenta detaches from the wall of the uterus
• Placental abruption should be suspected in the woman who has a sudden onset of intense, usually localized, uterine pain, with or without vaginal bleeding