Nursing Management of Pregnancy Related Complications PDF

Nursing Management of Pregnancy Related Complications Dr. Nadia Bassuoni Elsharkawy  Objectives At the end of this lecture, each student will be able to: Evaluate the term “high-risk pregnancy.” Differentiate between different types of early and late pregnancy bleeding. Outline nu...

Nursing Management of Pregnancy Related Complications Dr. Nadia Bassuoni Elsharkawy  Objectives At the end of this lecture, each student will be able to: Evaluate the term “high-risk pregnancy.” Differentiate between different types of early and late pregnancy bleeding. Outline nursing assessment and management for the pregnant woman experiencing vaginal bleeding. Discuss the assessment & and management of pregnancy-related bleeding Identify the classification of hypertension in pregnancy. Differentiate between mild and severe preeclampsia. Discuss eclampsia and HELLP syndrome. Explain the management of preeclampsia, eclampsia, and HELLP syndrome  High-Risk pregnancy Is one in which a condition exists that jeopardizes the health of the mother, her fetus, or both. The condition may result from the pregnancy, or it may be a condition that was present before the woman became pregnant.  1- Early Bleeding during Pregnancy Spontaneous abortion Ectopic pregnancy Gestational trophoblastic disease Cervical insufficiency  Abortion/ Miscarriage It is a termination of pregnancy before viability of the fetus (A fetus of less than 20 weeks of gestation and weighing less than 500 g is not considered viable). Early abortion: 80% occurs before 12 weeks. Late abortion: occurs between the 13th and 24th week of gestation. Incidence:15-20% of pregnancies total reproductive losses are much higher if one considers losses that occur prior to clinical recognition. Classification: 1. Spontaneous: occurs without medical or mechanical means. 2. Induced abortion: legal and illegal / criminal  Abortion/ Miscarriage Causes of Spontaneous abortion The most common cause for first- trimester abortions is fetal genetic abnormalities and Chromosomal abnormalities Environmental factors : Smoking, alcoholism, X-ray, Radiation, Chemotherapy. Infections :Viral as rubella, cytomegalovirus, herpes simplex and toxoplasmosis , Bacterial or Parasitic. Malformation of uterus, uterine fibroid, intrauterine adhesions , retroverted uterus, and cervical incompetence Inherited Thrombophilia, uteroplacental ischemia, progesterone deficiency, diabetes, polycystic ovary syndrome, and hypothyroidism.  Types of Spontaneous Abortion 1. Threatened 2. Inevitable 3. Incomplete 4. Complete 5. Missed 6. Habitual  Nursing Assessment and Management 1. Assess Vital signs 2. Monitor the amount of vaginal bleeding through pad counts and observe for passage of products of conception tissue. 3. Assess the woman’s pain and provide appropriate pain management. 4. Assist in preparing the woman for procedures and treatments such as surgery to evacuate the uterus or medications such as misoprostol 5. If the woman is Rh-negative and not sensitized, expect to administer RhoGam within 72 hours after the abortion.  Ectopic Pregnancy Is one in which the fertilized ovum implants in a location other than the endometrial cavity of the uterus. This abnormally implanted gestation grows and draws its blood supply from the site of abnormal implantation. The Fallopian Tube is the most common site. The risk of an ectopic pregnancy increases with STIs and with increased age(35-45) Ectopic pregnancy is a significant cause of first-trimester maternal deaths.  Ectopic Pregnancy Cont. Predisposing Factors: - Pelvic inflammatory disease (PID). - Previous ectopic pregnancy - Congenital anomalies. - Stimulation of ovulation. - Contraceptive failure. - Intrauterine device (IUD). Sites: - The fallopian tube 95%. - Ovary, Cervix , and Abdominal Cavity 5%. Ectopic Pregnancy Cont.  Ectopic Pregnancy Cont. Clinical manifestations: Before Rupture of tube : - intermittent dark Mild vaginal bleeding. - Abdominal pain(dull – unilateral or bilateral). - Abdominal tenderness - Signs of blood loss Ruptured tube: exacerbation of pain occurs during rupture in an ectopic pregnancy. Ectopic Pregnancy pain Cont.  Ectopic Pregnancy Cont. Clinical manifestations: After Rupture of the tube : - Faintness (dizziness during bleeding). - Unilateral abdominal pain. - Referred shoulder pain caused or related to diaphragmatic irritation from blood in the peritoneal cavity. - Signs of shock. - A febrile state. Diagnosis: - Beta subunit in blood. - Ultrasound will confirm an extra-uterine pregnancy  Management of the Ectopic Pregnancy 1. Surgical involves laparoscopy or laparotomy for salpingectomy with the partial or complete removal of the fallopian tube or removal of the ectopic pregnancy from other sites. 2. An alternate method to surgery is to administer of Methotrexate Only if the fetus is under 2.5-3.5 cm. Single dose Follow-up with ultrasounds and beta-HCG.  Ectopic Pregnancy Cont. 3. IV as soon as possible- be prepare to give blood 4. Provide emotional support to the client 5. If client is Rh-negative administer RhoGam 6. Monitor client for hemorrhage and infection Discharge Instructions : Teach client to report signs of infection and/or blood loss to the health provider Anemic clients should take iron supplements Importance of follow up care. Gestational Trophoblastic Disease  Gestational Trophoblastic Disease Is also known as Hydatidiform Mole or Molar pregnancy. It is a benign proliferative growth of trophoblast in which chorionic villi develop into edematous, cystic transparent vesicles that hang in grape-like clusters. It occurs in about 1 in every 1000 pregnancies. Risk Factors: Clients of Southeast Asia- Japanese or Taiwan descent Mothers over 40 Possibly Vitamin A and protein deficiency Previous GTD.  Gestational Trophoblastic Disease Clinical Manifestations: - Vaginal Bleeding- red to prune color - Severe nausea and vomiting - Uterine size greater than dates - Passing on grape-like vesicles - No fetal parts were palpated and no FHR was heard - Hyperthyroidism. - Abnormal labs : - Very high hCG levels - Possible low RBCs, Hct, and Hb.  Gestational Trophoblastic Disease o Diagnosis : - Serial Beta – subunit for HCG - Ultrasound (snow –storm) Complications: - Hemorrhage - Infection - Choriocarcinoma, a virulent cancer with metastasis to other organs - DIC  Management of Gestational Trophoblastic Disease Evaluate for coexisting conditions: - History and medical condition - CBC, coagulation profile, serum chemistry - thyroid function - blood type and cross-match - chest radiography - pelvic ultrasonography Evacuation of mole - Suction curettage - Hysterectomy if completed childbearing  Management Gestational of Trophoblastic Disease If Rh is negative, give RhoGam Follow-Up Care - 80% of patients cured by evacuation - Follow B-hCG levels every two weeks until 3 consecutive tests negative - Then monthly B-hCG every month for 6-12 months - More than half of patients will have complete regression of hCG to normal within 2 months of evacuation. - Avoid pregnancy for at least 6 months -1 year after the first normal B-hCG (oral contraceptive pills are preferable). - Prophylactic chemotherapy.  Cervical Insufficiency Cervical Insufficiency is also called premature dilation of the cervix or cervical incompetence Is a medical condition of pregnancy in which a weak, structurally defective cervix spontaneously dilates in the absence of contractions in the second trimester or in the early third trimester, resulting in the loss of the pregnancy. Cervical cerclage.  Cervical Insufficiency Therapeutic management Bed rest, pelvic rest, avoidance of heavy lifting Cervical cerclage Nursing assessment Risk factors Pink-tinged vaginal discharge or pelvic pressure Cervical shortening via transvaginal ultrasound Nursing management Continuing surveillance; close monitoring for preterm labor Emotional support Education  2-Late Bleeding during pregnancy (Antepartum) Bleeding from the genital tract after the 28th week of pregnancy OR during the 1st stage of labor. 1- Placental site bleeding (95%) Placenta Previa Abruption Life-Threatening Ruptured vasa Previa Uterine scar disruption 2- Extra-placental bleeding (5%): Cervical polyp Cervicitis or cervical ectropion Vaginal trauma Cervical cancer Rupture of varicose veins in the cervix.  Placenta Previa A placenta is implanted partially or completely in the lower segment of the uterus. Incidence: Approximately 1 in 200 pregnancies, or a 0.5% risk. Bleeding results from small disruptions in the placental attachment during normal development and thinning of the lower uterine segment The exact cause of placenta previa is unknown.  Types of Placenta Previa Total placenta previa: The internal cervical os is covered completely by the placenta, cesarean delivery is likely. Partial placenta previa: The internal os is partially covered by the placenta, vaginal delivery might be possible but preferable Marginal placenta previa: The edge of the placenta is at the margin of the internal os, vaginal delivery is likely. Low-lying placenta: The placenta is implanted in the lower uterine segment such that the placenta edge actually does not reach the internal os but is in close proximity to it, Vaginal delivery is likely. Placenta Previa  Management of Placenta Previa A- Expectant Management The gestational age is less than 36 weeks. The bleeding is mild (less than 250ml). The patient is not in labor. The goal is to obtain the maximum fetal maturity without risk to the mother or fetus through the following 1- Hospitalization with complete bed rest for 72 hours. 2- Close observation for bleeding. 3- Continuous fetal monitoring to facilitate early detection of fetal distress during bleeding. Otherwise, assess every 4 hours with a Doppler FHR device or fetoscope. 4- I.V. infusion unless bleeding is minimal.  Management of Placenta Previa 5- Have a maternal blood sample available at all times in the blood bank for immediate type and cross-match for blood transfusion. 6-Betamethasone to enhance fetal pulmonary maturity may be ordered. 7- Amniocentesis is usually performed between 34 and 36 weeks of gestation to determine fetal lung maturity. 8- Monitor for signs of preterm uterine contractions stimulated by prostaglandin release from placental separation 9- Tocolytic therapy, preferably magnesium sulfate. 10- If the patient is allowed to return home after stabilization, she should be instructed to: Limit her activity- Avoid enemas- Avoid coitus-Avoid douching.  Management of Placenta Previa B- Delivery: Immediate delivery should be implemented under the following conditions, regardless of gestational age (36 or more weeks): The fetus is mature. Excessive bleeding occurs. Active labor begins unresponsive to Tocolysis. Intra-amniotic infection. A coagulation defect (DIC) Fetal distress with a viable fetus Fetal demise or anomalies that are incompatible with life Cesarean birth is indicated if the patient has a partial or complete placenta previa  Nursing Interventions The patient should be placed on complete bed rest with no bathroom privileges. A quiet environment will improve the outcome by decreasing sensory stimulation. NO VAGINAL EXAMINATION IV access Assess Bleeding, Hypovolemic Shock Lab Tests Vital Signs Intake and Output Emotional Interventions  Abruptio Placentae It is the premature separation of a normally located placenta after the 20th week of gestation and prior to birth that leads to hemorrhage. The etiology of this condition is unknown; however, it has been proposed that abruption starts with degenerative changes in the small maternal arterioles, resulting in thrombosis, degeneration of the decidua, and possible rupture of a vessel. Bleeding from the vessel forms a retro-placental clot. The bleeding causes increased pressure behind the placenta and results in separation Fetal blood supply is compromised and fetal distress develops in proportion to the degree of placental separation.  Types of Abruptio Placentae Revealed: Marginal (peripheral) detachment of placenta. External hemorrhage. Concealed Central separation with adherence of edge. Retroplacental hematoma provoke more separation. Blood may dissect through the myometrium between muscle fibers to reach peritoneal cavity (couvelaire’s uterus) Mixed. Concealed Mixed Revealed couvelaire’s uterus  Abruptio Placentae Therapeutic management: assessment, control, and restoration of blood loss; positive outcome; prevention of DIC Nursing assessment Risk factors Bleeding (dark red) Pain (knife-like), uterine tenderness, contractions Fetal movement and activity (decreased) Fetal heart rate Laboratory and diagnostic testing: CBC, fibrinogen levels, PT/PTT, type and cross-match, Nonstress test, biophysical profile  Abruptio Placentae Nursing management To improve tissue perfusion: 1. left lateral position, 2. strict bed rest, 3. oxygen therapy, 4. vital signs, 5. fundal height, 6. continuous fetal monitoring Support and education: empathy, understanding, explanations, possible loss of fetus, reduction of recurrence  Hypertensive Disorders during Pregnancy Hypertensive disorders during pregnancy are still one of the most common causes of maternal and prenatal mortality and morbidity. It is characterized by vasospasm that leads to poor perfusion of many vital organs including the fetoplacental unit. The classification of hypertensive disorders in pregnancy currently consists of five categories: 1. Gestational hypertension (replaces term of PIH) 2. Preeclampsia 3. Eclampsia 4. Preeclampsia superimposed on chronic hypertension 5. Chronic hypertension  Classification of hypertension in pregnancy Gestational hypertension (replaces term of PIH): Elevation of blood pressure after 20 weeks of pregnancy that is not accompanied by proteinuria Preeclampsia: Elevation of blood pressure after 20 weeks of pregnancy that is accompanied by significant proteinuria Eclampsia: Progression of preeclampsia to generalized seizures that cannot be attributed to other causes. Seizures may occur postpartum.  Classification of hypertension in pregnancy Cont. Preeclampsia superimposed on chronic hypertension: Development of proteinuria in a woman who has chronic hypertension Chronic hypertension The elevated blood pressure that was known to exist before pregnancy or develops before 20 weeks of gestation Clinical manifestations of preeclampsia: Subjective signs: Headache Visual changes such as blurred vision Rapid onset edema of the face or abdomen or pitting edema in the leg after 12 hours of bed rest Oliguria less than 500 ml / 24 hrs Hyperreflexia Nausea and vomiting Epigastric or right upper quadrant pain.  Complications Abruptio placentae DIC HELLP syndrome Pulmonary edema; cerebral edema Oliguria; acute renal failure Thrombocytopenia Hemorrhage; stroke Blindness; Retinal detachment Hypoglycemia Hepatocellular dysfunction; hepatic rupture Prematurity, IUGR from decreased placental perfusion, and fetal death HELLP Syndrome Is a severe sequel of preeclampsia; occurs in 2-12 % of cases. It is an acronym for: H: Hemolysis: red blood cell (RBC) breakdown in vessels in vasospasm. EL: elevated liver enzymes: LP: low platelet count (Thrombocytopenia).  Therapeutic management for preeclampsia The goal of management is to prevent seizures and to maintain the pregnancy until it is safe to deliver the fetus Delivery is the only definitive treatment but not be ideal if the preeclampsia is mild or the fetus is immature If the fetus is >34 weeks, steroids to accelerate fetal lung maturity are given, and an attempt is made to delay delivery for 48hours If maternal or fetal condition deteriorates; the woman is delivered regardless of fetal age or administration of steroids Bed rest in a quiet environment  Therapeutic management for preeclampsia cont. Anticonvulsant therapy: Magnesium sulphate MgSO4 is the drug of choice in preeclampsia which acts as a central nervous system depressant to prevent seizures Calcium gluconate is the antidote of MgSO4 Antihypertensive medications: Hydralazine (aprisoline) is commonly used if systolic blood pressure is ≥ 160 or diastolic is ≥ 110mmHg. Intrapartum management: Oxytocin to stimulate uterine contractions and MgSO4 to prevent seizures are often administered simultaneously during labor Continuous electronic fetal monitoring should be used to identify any fetal compromise Postpartum management: MgSO4 may be continued to prevent seizures  Nursing Assessment and interventions for Preeclampsia Identification of risk factors through interviews at the first prenatal visit and subsequent visits. Monitoring and reporting of BP, proteinuria, urinary output, hematological values, and neuralgic signs/ status. Implementation of prescribed medical intervention to: Control hypertension Prevent seizures Prevent fluid overload. Fetal Status monitoring Fetal movement counts should be recorded daily. Inactivity is indicated when there are less than 3 movements/ hour or less than 10 movements/12 hours  Room should be prepared to any emergency Patients room should be closed to staff, & emergency drugs, supplies and equipment should be available. Noise and external stimuli must be minimized, and seizures precautions should be taken.