High Risk Gestational Conditions Lecture 2020 PDF

Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications (Ch.19) Dr. Rebecca M. Thomas, WHNP-BC Objectives Differentiate among causes, signs/symptoms, and management of ectopic pregnancy, gestational trophoblastic disease (hydatiform mole), and cervical...

Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications (Ch.19) Dr. Rebecca M. Thomas, WHNP-BC Objectives Differentiate among causes, signs/symptoms, and management of ectopic pregnancy, gestational trophoblastic disease (hydatiform mole), and cervical insufficiency. Compare and contrast placenta previa and abruptio placentae (placental abruption) in relation to signs and symptoms, complications, and management. Explain the effects of hyperemesis gravidarum on maternal and fetal well-being. Explain the effects of ABO and Rh incompatibility on fetal well- being. Understand amniotic fluid imbalances such as polyhydramnios and oligohydramnios. Copyright © 2017 Wolters Kluwer · All Rights Reserved Objectives Recognize the risks associated with multiple gestation pregnancies and explain management. Differentiate among chronic hypertension, gestational hypertension, and preeclampsia. Describe etiologic theories and pathophysiology of preeclampsia. Compare care management of women with mild gestational hypertension or preeclampsia versus severe gestational hypertension or preeclampsia. Discuss the preconception, antepartum, intrapartum, and postpartum management of the woman with chronic hypertension. Copyright © 2017 Wolters Kluwer · All Rights Reserved High-Risk Pregnancy What is considered a “high-risk pregnancy”? – Condition due to pregnancy or result of condition present before pregnancy that may cause jeopardy to mother, fetus, or both – Higher morbidity and mortality Risk assessment with first antepartal visit; ongoing throughout pregnancy Diverse factors – Genetic/Hereditary – Environmental – Lifestyle – Diet/Nutrition – Medical/Medications Copyright © 2017 Wolters Kluwer · All Rights Reserved Bleeding During Pregnancy Bleeding During Pregnancy Can jeopardize maternal and fetal well-being – Maternal Risks: hypovolemia, anemia, infection, and PTL – Fetal Risks: Blood loss or anemia, hypoxemia, hypoxia, anoxia, and preterm birth Early Pregnancy Bleeding (before 20 weeks) – Spontaneous abortion (miscarriage) – Ectopic pregnancy – Gestational trophoblastic disease (hydatiform mole) – Cervical insufficiency Late Pregnancy Bleeding (after 20 weeks) – Placenta previa – Abruptio placentae (placental abruption) Ruptured ectopic pregnancy and abruptio placentae have the highest incidence of maternal mortality Copyright © 2017 Wolters Kluwer · All Rights Reserved Early Pregnancy Bleeding Early Pregnancy Bleeding: Spontaneous Abortion (Miscarriage) A pregnancy that ends without medical or surgical methods before 20 weeks of gestation or fetal weight of less than 500g Cause unknown and highly variable – 1st trimester commonly due to genetic abnormalities of fetus – 2nd trimester likely r/t maternal conditions Types – Threatened (A) – Inevitable (B) – Incomplete (C) – Complete (D) – Missed (E) – Recurrent (habitual) Copyright © 2017 Wolters Kluwer · All Rights Reserved Early Pregnancy Bleeding: Spontaneous Abortion (Miscarriage) Nursing Assessment – Vaginal bleeding (pad count, POC) – Cramping or contractions – Vital signs, pain level Nursing Management – Depends on the classification and S/S Threatened: Bedrest, repetitive transvaginal U/S, hCG and progesterone levels Inevitable/Complete: Expectant management Incomplete/Missed: monitor vaginal bleeding/pad count, passage of products of conception, pain level, preparation for procedures (D&C), medications (misoprostol) – Other medications: Pitocin then methergine or hemabate if excessive bleeding occurs, RhoGAM, NSAIDs, antibiotics Copyright © 2017 Wolters Kluwer · All Rights Reserved Early Pregnancy Bleeding: Spontaneous Abortion (Miscarriage) Psychosocial Support – physical and emotional – stress that woman is not the cause of the loss – verbalization of feelings – grief support – referral to community support group Copyright © 2017 Wolters Kluwer · All Rights Reserved Early Pregnancy Bleeding: Ectopic Pregnancy Ovum implantation outside the uterus – Obstruction to or slowing passage of ovum through tube to uterus Accounts for 2% of pregnancies in the U.S. and 9% of all pregnancy related deaths Often called tubal pregnancies because 95% occur in the fallopian tubes – Can occur in the abdominal cavity, on an ovary, or on the cervix Copyright © 2017 Wolters Kluwer · All Rights Reserved Ectopic Pregnancy: Risk Factors Previous ectopic pregnancy History of sexually transmitted infections (STI’s) Fallopian tube scarring from pelvic inflammatory disease (PID) Endometriosis Previous tubal or pelvic surgery Treatment for infertility Uterine fibroids Previous intrauterine contraception (IUD) Copyright © 2017 Wolters Kluwer · All Rights Reserved Ectopic Pregnancy: Manifestations Before Rupture – Abdominal pain: dull, lower quadrant pain on one side – Delayed menses – *Abnormal vaginal bleeding (spotting) that occurs approximately 6 to 8 weeks after the last normal menstrual period – Mild to moderate dark red or brown intermittent vaginal bleeding After Rupture – *Referred shoulder pain: diaphragmatic irritation caused by blood in the peritoneal cavity – Generalized, one sided or deep lower quadrant acute abdominal pain – Faintness, dizziness related to the amount of bleeding in the abdominal cavity – Cullen sign: ecchymotic blueness around the umbilicus Copyright © 2017 Wolters Kluwer · All Rights Reserved *Hallmark signs Ectopic Pregnancy: Management Laboratory and Diagnostic Testing – Transvaginal ultrasound – Serial serum beta hCG levels Medications – Methotrexate IM 3.5 cm size or less No fetal cardiac activity Unruptured and in stable condition – Prostaglandins, misoprostol – Rh immunoglobulin if woman Rh negative Surgery – Salpingectomy: removal of tube – Salpingostomy: incision made for removal of products of conception Copyright © 2017 Wolters Kluwer · All Rights Reserved Early Pregnancy Bleeding: Gestational Trophoblastic Disease (GTD) GTD is a group of pregnancy-related trophoblastic proliferative disorders without a viable fetus that are caused by abnormal fertilization – Rare: 1 in 1000 pregnancies Two Types – Hydatidiform mole Benign proliferative growth of the placental trophoblast in which the chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in a grapelike cluster – Choriocarcinoma Cancerous form – May be partial or complete Copyright © 2017 Wolters Kluwer · All Rights Reserved Hydatiform Mole: Risk Factors and S&S Cause/Risk Factors – Exact cause unknown; may be related to an ovular defect or a nutritional deficiency – Increased risk for women who have had a previous molar pregnancy, early teens or older than 40 years of age Manifestations (S&S) – Dark brown (resembling prune juice) or bright red vaginal bleeding either scant or profuse – Excessive N/V – Abdominal cramps – Signs of preeclampsia before 24 weeks gestation – Excessively enlarged uterus Copyright © 2017 Wolters Kluwer · All Rights Reserved Hydatiform Mole: Management Medical Management – Immediate evacuation of uterine contents (D&C) – Long-term follow-up and monitoring of serial hCG levels A rising titer and enlarged uterus may indicate choriocarcinoma – Rhogam if patient Rh negative Nursing Management – Preoperative preparation – Emotional support – Education Treatment and serial hCG monitoring Prophylactic chemotherapy Avoid pregnancy for next year due to increased risk of cancer Copyright © 2017 Wolters Kluwer · All Rights Reserved Early Pregnancy Bleeding: Cervical Insufficiency Passive and painless dilation of the cervix during the second trimester (AKA incompetent cervix) Etiology – Cause unknown, but possibly due to cervical damage from: Lacerations during childbirth Excessive cervical dilation for curettage or biopsy Exposure to DES (diethylstilbestrol) Manifestations/Diagnosis – Pink-tinged vaginal discharge or pelvic pressure – Short labors – Recurring loss of the pregnancy at progressively earlier gestational ages – Advanced cervical dilation at the time of first presentation for care – Cervical shortening (noted with transvaginal ultrasound) Copyright © 2017 Wolters Kluwer · All Rights Reserved Cervical Insufficiency: Management Medical Management – Bedrest – Pessaries – Antibiotics – Antiinflammatory drugs – Progesterone supplementation Surgical Management – Cerclage: a suture is placed around the cervix beneath the mucosa to constrict the internal os of the cervix – May be placed prophylactically (11 to 15 weeks) or as a rescue procedure once the cervix has been found to be effaced or dilated Copyright © 2017 Wolters Kluwer · All Rights Reserved Cervical Insufficiency: Cerclage Risks of Cerclage Placement – Preterm Labor (PTL) – Premature Rupture of Membranes (PROM) – Chorioamnionitis Follow-Up Care – Bedrest – Avoid sexual intercourse – Importance of initial activity restriction and close observation Patient Education – Signs of preterm labor-cramping, regular ctx, back pain, PROM – Signs of Chorioamnionitis-diffuse abdominal pain – Signs of imminent delivery-Severe perineal pressure, urge to push Removal Copyright © 2017 Wolters Kluwer · All Rights Reserved Late Pregnancy Bleeding Late Pregnancy Bleeding: Placenta Previa Placenta implants in lower uterine segment completely or partially covering cervical os or close enough to cervix to cause bleeding when dilation or effacement occurs Classifications – Low-Lying (A) – Marginal (B) – Partial (C) – Complete (D) Copyright © 2017 Wolters Kluwer · All Rights Reserved Placenta Previa: Risk Factors Previous C/S Previous placenta previa D&C for miscarriage/ induced abortion Multiple gestation Multiparity Maternal age 2,000 mL Risk Factors: maternal diabetes, fetal genetic disorders or gastrointestinal obstructions, multiples Therapeutic Management: close monitoring; removal of fluid, indomethacin (decreases fluid by decreasing fetal urinary output) Nursing Assessment: risk factors, fundal height, abdominal discomfort, difficulty palpating fetal parts, or obtaining FHR Nursing Management: ongoing assessment and monitoring; assisting with therapeutic amniocentesis Copyright © 2017 Wolters Kluwer · All Rights Reserved Oligohydramnios When total amniotic fluid /= 1+ on dipstick – Urine output