Nursing Care of Women With Complications During Pregnancy PDF

Nursing Care of Women With Complications During Pregnancy OBJECTIVES 1. Define each key term listed. 2. Explain the use of fetal diagnostic tests in women with complicated pregnancies. 3. Identify methods to reduce a woman’s risk for antepartum complications. Describe antepartum complications, their...

Nursing Care of Women With Complications During Pregnancy OBJECTIVES 1. Define each key term listed. 2. Explain the use of fetal diagnostic tests in women with complicated pregnancies. 3. Identify methods to reduce a woman’s risk for antepartum complications. Describe antepartum complications, their treatment, and their nursing care. 4. Discuss the management of concurrent medical conditions during pregnancy. 5. Describe environmental hazards that may adversely affect the outcome of pregnancy. 6. Describe how pregnancy affects care of the trauma victim. 7. Describe psychosocial nursing interventions for the woman who has a high-risk pregnancy and for her family. KEY TERMS abortion (p. 88) age of viability (p. 90) cerclage (sĕr-KLĂHZH, p. 90) disseminated intravascular coagulation (DIC) (p. 96) eclampsia (ĕ-KLĂMP-sē-ă, p. 97) erythroblastosis fetalis (ĕ-rĭth-rō-blăs-Ō-sĭs fĕ-TĂ-lĭs, p. 101) gestational diabetes mellitus (GDM) (p. 102) hydramnios (hī-DRĂM-nē-ŏs, p. 103) incompetent cervix (ĭn-KŎM-pă-tănt SŬR-vĭkz, p. 90) isoimmunization (ī-sō-ĭm-myū-nĭ-ZĀ-shŭn, p. 101) macrosomia (măk-rō-SŌ-mē-ă, p. 103) preeclampsia (prē-ĕ-KLĂMP-sē-ă, p. 97) preterm labor (p. 90) products of conception (POC) (p. 93) teratogen (TĔR-ă-tō-jĕn, p. 113) tonic-clonic seizures (p. 99) 198 http://evolve.elsevier.com/Leifer Most women have uneventful pregnancies that are free of complications. However, some women have complications that threaten their well-being and that of their babies. Many problems can be anticipated in the course of prenatal care and thus prevented or made less severe. Others occur without warning. Women who have no prenatal care or begin care late in pregnancy may have complications that are severe because the problems were not identified early. Danger signs that should be taught to every pregnant woman and reinforced at each prenatal visit are listed in the Patient Teaching box. The woman should be taught to notify her health care provider if any of these danger signs occur. A high-risk pregnancy is defined as one in which the health of the mother or fetus is in jeopardy. The causes of high-risk pregnancies usually include the following characteristics: • Relate to the pregnancy itself • Occur because the woman has a medical condition or injury that complicates the pregnancy • Result from environmental hazards that affect the mother or her fetus • Arise from maternal behaviors or lifestyles that have a negative effect on the mother or fetus Early and consistent assessment for risk factors during prenatal visits is essential for a positive outcome for the mother and the fetus. 199 Assessment of fetal health Extraordinary technical advances have enabled the management of high-risk pregnancies so that both the mother and the fetus have positive outcomes. Various tests can be used prenatally to assess the well-being of the fetus. Nursing responsibilities during the assessment of fetal health include preparing the patient properly, explaining the reason for the test, and clarifying and interpreting results in collaboration with other health care providers. The nurse can provide the psychosocial support that will allay or reduce parental anxiety. Amniocentesis is shown in Fig. 5.1, and Table 5.1 reviews common diagnostic tests that assess the status of the fetus. Fetal assessment techniques used during labor are discussed in Chapter 6. FIG. 5.1 Amniocentesis. An ultrasound transducer on the abdomen ensures needle placement away from the body of the fetus and the placenta. A needle is inserted into the amniotic cavity, and a sample of amniotic fluid is collected for laboratory examination and fetal assessment. (From Moore KL, Persaud TVN, Torchia MG: The developing human: clinically oriented embryology, ed 10, Philadelphia, 2016, Saunders.) Table 5.1 Fetal Diagnostic Tests Test Ultrasound examination Description Uses high-frequency sound waves to visualize structures within body; examination may use a transvaginal probe or an abdominal transducer. Abdominal ultrasound during early pregnancy requires a full bladder for proper visualization (have the woman drink 1–2 quarts of water before examination). Transvaginal ultrasound requires an empty bladder. 200 Uses during pregnancy Visualize gestational sac in early pregnancy to confirm pregnancy. Identify site of implantation (uterine or ectopic). Verify fetal viability or death. A targeted comprehensive ultrasound detects specific anomalies. Identify multifetal pregnancy such as twins or triplets. First-trimester combined screen of ultrasound for nuchal translucency and maternal blood test for cellfree DNA can detect a heart defect or chromosomal anomalies at 11–14 weeks. Echo or Doppler scan detects fetal heart activity at 6– 10 weeks. Three- or four-dimensional imaging produces clear detail and features. Transvaginal ultrasound in third trimester is used to determine cervix length to detect risk of preterm birth. Diagnose some fetal structural abnormalities. Guide procedures such as chorionic villus sampling, amniocentesis, or percutaneous umbilical blood sampling. Determine gestational age of embryo or fetus. Locate placenta. Determine amount of amniotic fluid. Observe fetal movements. Determine EDD. Amniotic fluid volume Ultrasound scan measures amniotic fluid pockets in From 5–19 cm is considered normal. Measurement < 5 cm is all four quadrants surrounding the mother’s known as oligohydramnios (insufficient amniotic fluid) and is umbilicus and produces AFI. associated with growth restriction and fetal distress during labor because of “kinking” of the cord. Measurement > 30 cm is polyhydramnios (excess amniotic fluid) and is associated with neural tube defects, gastrointestinal obstruction, and fetal hydrops. Estimation of Ultrasound examination at 8 weeks gestation can Between 7 and 14 weeks the crown–rump length can gestational age measure gestational sac. Ultrasound is more accurate indicate fetal age. After 12 weeks the biparietal diameter of than LNMP if used before 22 weeks gestation in the fetus and the femur length provide an accurate determining fetal age (Gabbe et al, 2017). estimation of fetal age. Biparietal diameter of the fetus at 36 weeks is 8.7 cm and at term is 9.8 cm. MRI MRI provides a noninvasive radiological view of Used when there is a high suspicion of an anomaly. fetal structures including the placenta. Kick count Maternal assessment of fetal movement While lying on her side, 1 hour after a meal, the pregnant woman counts fetal movements. Less than 3 kicks in 30 minutes or less than 10 kicks in 3 hours indicates the need for evaluation. A daily fetal movement record is kept at home once a day, and findings are evaluated during prenatal visits to ensure fetal health. The sleep cycle of the fetus should be considered when selecting a time to evaluate fetal movement. Doppler ultrasound Assessment uses high-frequency sound waves to Determine adequacy of blood flow through the placenta and blood flow assessment study blood flow through vessels; color Doppler can umbilical cord vessels in women in whom it is likely to be detect speed and direction of blood flow within fetal impaired (such as women with pregnancy-induced vessels. hypertension or diabetes mellitus). AFP testing Test determines level of AFP in the pregnant Identify high levels, which are associated with open defects woman’s serum or in a sample of amniotic fluid. such as spina bifida (open spine), anencephaly (incomplete development of skull and brain), or gastroschisis (open abdominal cavity). Correct interpretation requires an accurate Identify low levels, which are associated with chromosome gestational age. abnormalities or gestational trophoblastic disease (hydatidiform mole). AFP measurement of high hCG and low unconjugated estriol in maternal blood at 18 weeks gestation is a marker for trisomies 18 and 21 and indicates need for follow-up. Chorionic villus Sampling consists of obtaining a small part of the Identify chromosome abnormalities or other defects that can sampling developing placenta to analyze fetal cells at 10–12 be determined by analysis of cells. Results of chromosome weeks gestation. studies are available 24–48 hours later. Cannot be used to determine spina bifida or anencephaly (see AFP testing). Higher rate of spontaneous abortion after procedure than after amniocentesis. Reports of limb reduction defects in newborns. Rh0(D) immune globulin (RhoGAM) is given to the Rh-negative woman. Cell-free DNA Test of maternal blood. Identify chromosomal anomaly if there is evidence of high risk. Maternal use of anticoagulants and/or aspirin can decrease availability of cell-free DNA in maternal circulation (Nitsche et al, 2017). Amniocentesis This procedure consists of insertion of a thin needle Early pregnancy: Identify chromosome abnormalities, through abdominal and uterine walls to obtain a biochemical disorders (such as Tay-Sachs disease), and level sample of amniotic fluid, which contains cast-off fetal of AFP; a fetus cannot be tested for every possible disorder. cells and various other fetal products (see Fig. 5.1). Amniocentesis after 15 weeks gestation carries a 1:400 risk of complication (Gabbe et al, 2017). Standard genetic amniocentesis is done at 15–17 Late pregnancy: Identify severity of maternal–fetal blood weeks gestation. incompatibility and assess fetal lung maturity. Rh0(D) immune globulin is given to the Rh-negative woman. Amniocentesis before 15 weeks gestation is not recommended because of risk of clubfoot (Gabbe et al, 2017). NST Test comprises evaluation with electronic fetal Identify fetal compromise in conditions associated with monitor of FHR for accelerations of at least 15 poor placental function, such as hypertension, diabetes beats/min lasting 15 seconds in a 20-minute period. mellitus, or postterm gestation. Adequate accelerations of Fetal movements do not have to accompany FHR are reassuring that placenta is functioning properly 201 Vibroacoustic stimulation test CST BPP accelerations. This procedure is similar to NST; in addition, an artificial larynx device is used to stimulate the fetus with sound. Expected response is acceleration of FHR, as in NST. Test is evaluation of FHR response to mild uterine contractions by using an electronic fetal monitor; contractions may be induced by self-stimulation of the nipples, which causes the woman’s pituitary gland to release oxytocin, or by intravenous oxytocin (Pitocin) infusion. The woman must have at least three contractions at least 40 seconds in duration in a 10-minute period for interpretation of CST. Profile consists of five fetal assessments: FHR and reactivity (NST), fetal breathing movements, fetal body movements, fetal tone (closure of the hand), and volume of amniotic fluid (AFI). Some centers omit NST, and others assess only NST and AFI. and the fetus is well oxygenated. Clarify (if NST is questionable) whether the fetus is well oxygenated, reducing the need for more complex testing. Clarify (during labor) questionable FHR patterns. Purposes are the same as for NST; CST may be done if NST results are nonreassuring (the fetal heart does not accelerate) or if they are questionable. Late decelerations after a contraction can indicate that fetus may not tolerate labor. Normal or negative CST results mean there are no late decelerations and the fetus can probably tolerate labor. Identify reduced fetal oxygenation in conditions associated with poor placental function but with greater precision than NST alone. As fetal hypoxia gradually increases, FHR changes occur first, followed by cessation of fetal breathing movement, gross body movements, and finally loss of fetal tone. Amniotic fluid volume is reduced when placental function is poor (shows pockets of low or absent amniotic fluid). Percutaneous umbilical Procedure obtains a fetal blood sample from a Identify fetal conditions that can be diagnosed only with a blood sampling placental vessel or from the umbilical cord. This may blood sample. be used to give a blood transfusion to an anemic fetus. Blood transfusion may be necessary for fetal anemia caused by maternal–fetal blood incompatibility, placenta previa, or abruptio placentae. Tests of fetal lung These tests use a sample of amniotic fluid (obtained Evaluate whether fetus is likely to have respiratory maturity by amniocentesis or from pool of fluid in the vagina) complications in adapting to extrauterine life. May be done to determine substances that indicate fetal lungs are to determine whether fetal lungs are mature before mature enough to adapt to extrauterine life. performing an elective cesarean birth or inducing labor if gestational age is questionable. Also used to evaluate whether fetus should be promptly delivered or allowed to mature further when the membranes rupture and the gestation is at < 37 weeks or if the gestational age is questionable. Lecithin/sphingomyelin A 2:1 ratio indicates fetal lung maturity (3:1 ratio ratio desirable for diabetic mother); fluid usually obtained by amniocentesis. Foam stability index Presence of phosphatidylglycerol and (“shake test”) phosphatidylinositol; persistence of a ring of bubbles for 15 minutes after shaking together equal amounts of 95% ethanol, isotonic saline, and amniotic fluid. AFI, Amniotic fluid index; AFP, alpha-fetoprotein; BPP, biophysical profile; CST, contraction stress test; EDD, estimated date of delivery; FHR, fetal heart rate; hCG, human chorionic gonadotropin; LNMP, last normal menstrual period; MRI, magnetic resonance imaging; NST, non–stress test. The future of fetal assessment lies in the continued development of new ultrasound technologies and hand-held receivers. Ultrasound pictures taken by a portable instrument can be transmitted via the Internet to be interpreted by experts in medical centers. Telemedicine, a growing field, is a specialized technology used in “virtual prenatal care” (see Chapter 4). Noninvasive fetal assessment technologies that reduce risks to the fetus and increase accurate assessments and interventions for a positive birth outcome continue to be researched and developed. Patient Teaching Danger Signs in Pregnancy The nurse should teach the woman to report promptly any danger signs that occur during pregnancy, including the following: • A sudden gush of fluid from vagina • Vaginal bleeding • Abdominal pain • Abnormal “kick count” 202 • Persistent vomiting • Epigastric pain • Edema of face and hands • Severe, persistent headache • Blurred vision or dizziness • Chills with fever greater than 38.0°C (100.4°F) • Painful urination or reduced urine output 203 Pregnancy-related complications Hyperemesis gravidarum Mild nausea and vomiting are easily managed during pregnancy (see Chapter 4). In contrast, the woman with hyperemesis gravidarum has excessive nausea and vomiting that can significantly interfere with her food intake and fluid balance. Fetal growth may be restricted, resulting in a lowbirth-weight infant. Dehydration impairs perfusion of the placenta, reducing the delivery of blood oxygen and nutrients to the fetus. Manifestations Hyperemesis gravidarum differs from “morning sickness” of pregnancy in one or more of the following ways: • Persistent nausea and vomiting, often with complete inability to retain food and fluids • Significant weight loss (more than 5% of prepregnant weight) • Dehydration as evidenced by a dry tongue and mucous membranes, decreased turgor (elasticity) of the skin, scant and concentrated urine, and a high serum hematocrit level • Electrolyte and acid-base imbalances • Ketonuria • Psychological factors such as unusual stress, emotional immaturity, passivity, or ambivalence about the pregnancy Treatment The health care provider will rule out other causes for excessive nausea and vomiting, such as gastroenteritis or liver, gallbladder, or pancreatic disorders, before making this diagnosis. The medical treatment for hyperemesis gravidarum is to correct dehydration and electrolyte or acidbase imbalances with oral or intravenous fluids. Antiemetic drugs such as Diclegis (doxylamine succinate and pyridoxine hydrochloride) at bedtime, transdermal clonidine, and oral ondansetron may be prescribed for more severe symptoms in the outpatient setting. Occasionally, severe cases necessitate hospitalization and total parenteral nutrition. The woman may need hospital admission to correct dehydration and inadequate nutrition if home measures are unsuccessful. Thiamine is often administered before intravenous dextrose to prevent Wernicke’s syndrome, which is characterized by double vision and ataxia (Gabbe et al, 2017). The condition is self-limiting in most women, although it is quite distressing to the woman and her family. Nursing care Nursing care focuses on patient teaching because most care occurs in the home. The woman should be taught how to reduce factors that trigger nausea and vomiting. She should avoid food odors, which may abound in meal preparation areas and tray carts if she is hospitalized. If she becomes nauseated when her food is served, the tray should be removed promptly and offered again later. Accurate intake and output and daily weight records are kept to assess fluid balance. Frequent, small amounts of food and fluid keep the stomach from becoming too full, which can trigger vomiting. Easily digested carbohydrates, such as crackers or baked potatoes, are tolerated best. Foods with strong odors should be eliminated from the diet. Taking liquids between solid meals helps to reduce gastric distention. Sitting upright after meals reduces gastric reflux (backflow) into the esophagus. The emesis basin is kept out of sight so that it is not a visual reminder of vomiting. It should be emptied at once if the woman vomits, and the amount should be documented on the intake and output record. Stress may contribute to hyperemesis gravidarum; stress may also result from this complication. The nurse should provide support by listening to the woman’s feelings about pregnancy, child rearing, and living with constant nausea. Although psychological factors may play a role in some cases of hyperemesis gravidarum, the nurse should not assume that every woman with this complication is adjusting poorly to her pregnancy. 204 Bleeding disorders of early pregnancy Several bleeding disorders can complicate early pregnancy, including spontaneous abortion (miscarriage) (Fig. 5.2), ectopic pregnancy (Fig. 5.3), and hydatidiform mole (Fig. 5.4). Maternal blood loss decreases the oxygen-carrying capacity of the blood, resulting in fetal hypoxia, and places the fetus at risk. FIG. 5.2 Three types of spontaneous abortion. 205 FIG. 5.3 The ovary (H), uterus, and fallopian tubes, illustrating various abnormal implantation sites. A to F are tubal pregnancies (the most common); G is an abdominal pregnancy; and X indicates the wall of the uterus where normal implantation should occur. (From Moore KL, Persaud TVN, Torchia MG: The developing human: clinically oriented embryology, ed 10, Philadelphia, 2016, Saunders.) 206 FIG. 5.4 A hydatidiform mole (gestational trophoblastic disease). Abortion Abortion is the spontaneous (miscarriage) or intentional termination of a pregnancy before the age of viability (20 weeks gestation). Table 5.2 differentiates types of abortions. Table 5.2 Types of Abortions 207 D&E, Dilation and evacuation. a Elective abortions are embedded in political debate concerning timing and legality of the procedure. The nurse must be aware of the current state and national laws related to this procedure. Treatment When a threatened abortion occurs, efforts are made to keep the fetus in utero until the age of viability. In recurrent pregnancy loss, causes are investigated; these can include genetic, immunological, anatomical, endocrine, or infectious factors. Cerclage, or suturing an incompetent cervix that opens when the growing fetus presses against it, is successful in most cases. A low human chorionic gonadotropin (hCG) level or low fetal heart rate by 8 weeks gestation may be an ominous sign. Termination of pregnancy after 20 weeks of gestation (age of viability) is called preterm labor and is discussed in Chapter 8. Table 5.3 describes procedures used in pregnancy termination. In all cases of pregnancy loss, counseling of the parents is essential. Even when the mother elects to terminate pregnancy, there are emotional responses that should be recognized and addressed. Table 5.3 Procedures Used in Early Pregnancy Termination Procedure and description Vacuum aspiration (vacuum curettage): Cervical dilation with metal rods or laminaria (a substance that absorbs water and swells, enlarging the cervical opening) followed by controlled suction through a plastic cannula to remove all POC D&E: Dilation of the cervix as in vacuum curettage followed by gentle scraping of the uterine walls to remove POC Mifepristone (Mifeprex; antiprogestin) followed by misoprostol (Cytotec; prostaglandin analogue)a Comments Used up to 12 weeks gestation; also used to remove remaining POC after spontaneous abortion; may be followed by curettage (see D&E); paracervical block (local anesthesia of the cervix) or general anesthesia needed; conscious sedation with midazolam (Versed) may be used. Used for first-trimester or early second-trimester abortions and to remove all POC after a spontaneous abortion; greater risk of cervical or uterine trauma and excessive blood loss than with vacuum curettage; paracervical block or general anesthesia can be used. An oral medication that may be taken up to 70 days gestation; often used with a prostaglandin agent. The antiprogestin agent is followed by the prostaglandin analogue that causes muscle contraction and termination of pregnancy. Follow-up in 1–2 weeks with health care provider is recommended. D&E, Dilation and evacuation; POC, products of conception. a Data from U.S. Food and Drug Administration. https://www.fda.gov/Drugs/DrugSafety/ucm111323.htm. Accessed August 2017. Oxytocin (Pitocin) controls blood loss before and after curettage, much as the drugs do after term birth. Rh0(D) immune globulin (RhoGAM [300 mcg] or the lower-dose MICRhoGAM [50 mcg]) is given to Rh-negative women after any abortion to prevent the development of antibodies that might harm the fetus during a subsequent pregnancy. Nursing care 208 Physical care The nurse documents the amount and character of bleeding and saves anything that looks like clots or tissue for evaluation by a pathologist. A pad count and an estimate of how saturated each is (e.g., 50%, 75%) documents blood loss most accurately. A woman with threatened abortion who remains at home is taught to report increased bleeding or passage of tissue. The nurse should check the hospitalized woman’s bleeding and vital signs to identify hypovolemic shock resulting from blood loss. She should not eat (nothing by mouth [NPO] status) if she has active bleeding to prevent aspiration if anesthesia is required for dilation and evacuation treatment. Laboratory tests such as a hemoglobin level and hematocrit are ordered. After vacuum aspiration or curettage, the amount of vaginal bleeding is observed. Blood pressure, pulse, and respirations are checked every 15 minutes for 1 hour, then every 30 minutes until discharge from the postanesthesia care unit. The woman’s temperature is checked on admission to the recovery area and every 4 hours until discharge to monitor for infection. Most women are discharged directly from the recovery unit to their home after curettage. Guidelines for self-care at home include the following: • Report increased bleeding. Do not use tampons, which may cause infection. • Take temperature every 8 hours for 3 days. Report signs of infection (temperature of 38°C [100.4°F] or higher; foul odor or brownish color of vaginal drainage). • Take an oral iron supplement if prescribed. • Resume sexual activity as recommended by the health care provider (usually after the bleeding has stopped). • Return to the health care provider at the recommended time for a checkup and contraception information. • Pregnancy can occur before the first menstrual period returns after the abortion procedure. Emotional care Society often underestimates the emotional distress spontaneous abortion causes the woman and her family. Even if the pregnancy was not planned or not suspected, they often grieve for what might have been. Their grief may last longer and be deeper than they or other people expect. The nurse listens to the woman and acknowledges the grief she and her partner feel. The Communication box gives examples of effective and ineffective techniques for communicating with the family experiencing pregnancy loss. Spiritual support of the family’s choice and community support groups may help the family work through the grief of any pregnancy loss. Nursing Care Plan 5.1 suggests interventions for families experiencing early pregnancy loss. Nursing Care Plan 5.1 The Family Experiencing Early Pregnancy Loss Patient data A woman is admitted at 18 weeks gestation and within a few hours delivers a fetus that does not survive. The woman asks what she has done wrong to cause this loss. Selected Nursing Diagnosis: Grief as a result of loss of anticipated infant 209 Critical thinking questions 1. What steps should the nurse take to assist the woman in coping with the loss of her pregnancy? 2. How should questions be formulated to foster communication with the patient? Communication The Family Experiencing Pregnancy Loss Examples of effective communication techniques Keep the family together. Wait quietly with family (i.e., “be there”). Say, “I’m sorry” or “I’m here if you need to talk.” Touch (may not be appreciated by some people or in some cultures). Refer to spontaneous abortion as “miscarriage” rather than the harsher-sounding “abortion.” Provide mementos as appropriate (lock of hair, photograph, footprint); save keepsakes for later retrieval if the family does not want them immediately. 210 Alert other hospital personnel to the family’s loss to prevent hurtful comments or questions. Allow the family to see the fetus if they wish; prepare them for the appearance of the fetus. Reduce the number of staff with whom the family must interact. Summon a hospital chaplain such as a minister or rabbi. Make referrals to support groups in the area. Examples of ineffective communication techniques Do not give the woman or family any information. Separate family members. Discourage expressions of sadness; for example, expect the father to be strong for the mother’s sake. Avoid interacting with the family and talking about their loss. Act uncomfortable with the family’s expressions of grief. Minimize the importance of the pregnancy by comments such as “You’re young—you can always have more children”; “At least you didn’t lose a real baby”; “It was for the best; the baby was abnormal”; or “You have another healthy child at home.” Say, “I know how you feel”; self-disclosure of your similar experience must be used carefully and only if it is likely to be therapeutic to the patient. Encourage the family not to cry. Ectopic Pregnancy Ectopic pregnancy occurs when the fertilized ovum (zygote) is implanted outside the uterine cavity (see Fig. 5.3). Of all ectopic pregnancies, 95% occur in the fallopian tube (tubal pregnancy). An obstruction or other abnormality of the tube prevents the zygote from being transported into the uterus. Scarring from a previous pelvic infection or deformity of the fallopian tubes or inhibition of normal tubal motion to propel the zygote into the uterus may result from the following: • Hormonal abnormalities • Inflammation • Infection • Adhesions • Congenital defects • Endometriosis (uterine lining occurring outside the uterus) Use of an intrauterine device for contraception may contribute to ectopic pregnancy because these devices promote inflammation within the uterus. A woman who has had a previous tubal pregnancy or a failed tubal ligation is also more likely to have an ectopic pregnancy. A zygote that is implanted in a fallopian tube cannot survive for long because the blood supply and size of the tube are inadequate. The zygote or embryo may die and be resorbed by the woman’s body, or the tube may rupture with bleeding into the abdominal cavity, creating a surgical emergency. Manifestations The woman has a history of a missed menstrual period and often complains of lower abdominal pain, sometimes accompanied by light vaginal bleeding. If the tube ruptures, she may have sudden severe lower abdominal pain, vaginal bleeding, and signs of hypovolemic shock (Box 5.1). The amount of vaginal bleeding may be minimal, because most blood is lost into the abdomen rather than externally through the vagina. Shoulder pain is a symptom that often accompanies bleeding into the abdomen (referred pain). Box 5.1 Signs and Symptoms of Hypovolemic Shock 211 • • • • • • • • • • Fetal heart rate changes (increased, decreased, less fluctuation) Rising, weak pulse (tachycardia) Rising respiratory rate (tachypnea) Shallow, irregular respirations; air hunger Falling blood pressure (hypotension) Decreased (usually less than 30 mL/h) or absent urine output Pale skin or mucous membranes Cold, clammy skin Faintness Thirst Treatment A sensitive pregnancy test for hCG is done to determine if the woman is pregnant. Transvaginal ultrasound examination determines whether the embryo is growing within the uterine cavity. Culdocentesis (puncture of the upper posterior vaginal wall with removal of peritoneal fluid) may occasionally be performed to identify blood in the woman’s pelvis, which suggests tubal rupture. A laparoscopic examination may be done to view the damaged tube with an endoscope (lighted instrument for viewing internal organs). The physician attempts to preserve the tube if the woman wants other children, but this is not always possible. The priority medical treatment is to control blood loss. Blood transfusion may be required for massive hemorrhage. Depending on the gestation and the amount of damage to the fallopian tube, one of the following three courses of treatment is chosen: 1. No action is taken if the woman’s body is resorbing the pregnancy. 2. Medical therapy with methotrexate (if the tube is not ruptured) inhibits cell division in the embryo and allows it to be resorbed. 3. Surgery to remove the products of conception (POC) from the tube is performed if damage is minimal; severe damage requires removal of the entire tube and occasionally the uterus. Nursing care Nursing care includes observing for hypovolemic shock as in spontaneous abortion. Vaginal bleeding is assessed, although most lost blood may remain in the abdomen. The nurse should report increasing pain, particularly shoulder pain, to the physician. If the woman has surgery, preoperative and postoperative care is similar to that for other abdominal surgery, as follows: • Measurement of vital signs to identify hypovolemic shock and temperature to identify infection • Assessment of lung and bowel sounds • Intravenous fluid; blood replacement may be ordered if the loss was substantial • Antibiotics as ordered • Pain medication, often with patient-controlled analgesia after surgery • NPO status preoperatively; oral intake usually resumes after surgery, beginning with ice chips and then clear liquids, and is advanced as bowel sounds resume • Indwelling Foley catheter as ordered; urine output is a significant indicator of fluid balance and will fall or stop if the woman hemorrhages; minimum acceptable urine output is 30 mL/h • Bed rest before surgery; progressive ambulation postoperatively; the nurse should have adequate assistance when the woman first ambulates because she is more likely to faint if she lost a significant amount of blood In addition to physical preoperative and postoperative care, the nurse provides emotional support, because the woman and her family may experience grieving similar to that accompanying spontaneous abortion. Loss of a fallopian tube threatens future fertility and is another source of 212 grief. However, future pregnancies are possible if the remaining fallopian tube is normal. Nursing Tip Supporting and encouraging the grieving process in families who experience a pregnancy loss, such as a spontaneous abortion or ectopic pregnancy, allow them to resolve their grief. Hydatidiform Mole Hydatidiform mole (gestational trophoblastic disease; also known as a molar pregnancy) occurs when the chorionic villi (fringelike structures that form the placenta) increase abnormally and develop vesicles (small sacs) that resemble tiny grapes (see Fig. 5.4). The mole may be complete, with no fetus present, or partial, in which only part of the placenta has the characteristic vesicles. Hydatidiform mole may result in hemorrhage, clotting abnormalities, hypertension, and a possibility of later development of cancer (choriocarcinoma). Chromosome abnormalities are found in many cases of hydatidiform mole. It is more likely to occur in women at the age extremes of reproductive life, and a woman who has had one molar pregnancy has a 1% chance of another molar pregnancy in the future (Eagles et al, 2015). Manifestations Signs associated with hydatidiform mole appear early in pregnancy and can include the following: • Bleeding, which may range from spotting to profuse hemorrhage and may be brown in color; cramping may be present • Rapid uterine growth and a uterine size that is larger than expected for the gestation • Failure to detect fetal heart activity • Signs of hyperemesis gravidarum (see earlier section Hyperemesis Gravidarum) • Unusually early development of gestational hypertension (see later section Hypertension During Pregnancy) • Higher than expected levels of hCG • A distinctive “snowstorm” pattern on ultrasound but no evidence of a developing fetus in the uterus Nursing Tip The nurse should teach the woman to report promptly any danger signs that occur during pregnancy. Treatment Transvaginal ultrasound verifies the diagnosis. The uterus is evacuated by vacuum aspiration and dilation and evacuation. The level of hCG is tested and retested until it is undetectable, and the levels are followed for at least 1 year. Persistent or rising levels suggest that vesicles remain or that malignant change has occurred. The woman should delay conceiving until follow-up care is complete because a new pregnancy would confuse tests for hCG. Rh0(D) immune globulin is prescribed for the Rh-negative woman. Nursing care The nurse observes for bleeding and shock; care is similar to that given in spontaneous abortion and ectopic pregnancy. If the woman also experiences hyperemesis or preeclampsia, the nurse incorporates care related to those conditions. The woman has also lost a pregnancy, so the nurse 213 should provide care related to grieving, similar to that for a spontaneous abortion. The need to delay another pregnancy may be a concern if the woman is nearing the end of her reproductive life and wants a child; therefore the need for follow-up examinations is reinforced. The woman is encouraged and taught how to use contraception (see Chapter 11). Bleeding disorders of late pregnancy Placenta previa or abruptio placentae often cause bleeding in late pregnancy (Table 5.4). Table 5.4 Comparison of Placenta Previa and Abruptio Placentae Presenting signs and symptoms Placenta previa Abruptio placentae Abnormal implantation of placenta in the lower Premature separation of normally implanted placenta uterus Marginal: Approaches, but does not reach, cervical opening (≤ 3 cm) Partial: Partially covers cervical opening Total: Completely covers cervical opening Bleeding Obvious vaginal bleeding, usually bright; may be profuse Pain None, other than from normal uterine contractions if in labor Uterus soft; no abnormal contractions or irritability Fetus may be in an abnormal presentation such as breech or transverse lie (see Chapter 8) Normal Uterine consistency Fetus Blood clotting Postpartum complications Infection: Placental site is near the nonsterile vagina Hemorrhage: Lower uterine segment does not contract as effectively to compress bleeding vessels Signs of fetal compromise if maternal shock or extensive placental detachment occur Fetal or neonatal anemia may occur because of blood loss Partial: Detachment of part of placenta Marginal: Detachment at the edge of placenta Central: Detachment of the center surface of placenta; edges stay attached Total: Complete detachment of placenta Visible dark vaginal bleeding or concealed bleeding within uterus; enlargement of uterus suggests that blood is accumulating within the cavity Gradual or abrupt onset of pain and uterine tenderness; possibly low back pain Uterus firm and boardlike; may be irritable, with frequent, brief contractions Fetal presentation usually normal Often accompanied by impaired blood clotting More likely to occur if the woman recently ingested cocaine Infection: Bleeding into uterine muscle fibers predisposes to bacterial invasion Hemorrhage: Bleeding into uterine muscle fibers damages them, inhibiting uterine contraction after birth Signs of fetal compromise, depending on amount and location of placental surface that is disrupted Fetal or neonatal anemia may occur because of blood loss Placenta Previa Placenta previa occurs when the placenta develops in the lower part of the uterus rather than the upper part. There are three degrees of placenta previa, depending on the location of the placenta in relation to the cervix (Fig. 5.5A), as follows: Marginal: Placenta reaches within 2 to 3 cm of the cervical opening Partial: Placenta partly covers the cervical opening Total: Placenta completely covers the cervical opening 214 FIG. 5.5 Placenta previa and abruptio placentae. (A) Placenta previa. The placenta (purple) is implanted low in the uterus. Detachment of the placenta from the uterine wall occurs as the cervix dilates, resulting in bleeding. (B) Abruptio placentae. The placenta (purple) is implanted normally in the uterus but separates from the uterine wall. If the fetal head is engaged, bleeding (red) may accumulate in the uterus instead of being expelled externally. (From Patton KT, Thibodeau GA: Anatomy & physiology, ed 9, St. Louis, 2015, Mosby.) A low-lying placenta is implanted near the cervix but does not cover any of the opening. This variation is not a true placenta previa and may or may not be accompanied by bleeding. The lowlying placenta may be discovered during a routine ultrasound examination in early pregnancy. It also may be diagnosed during late pregnancy because the woman has signs similar to those of a true placenta previa. Manifestations Painless vaginal bleeding, usually bright red, is the main characteristic of placenta previa. The woman’s risk of hemorrhage increases as term approaches and the cervix begins to efface (thin) and dilate (open). These normal prelabor changes disrupt the placental attachment. The fetus is often in an abnormal presentation (e.g., breech or transverse lie) because the placenta occupies the lower uterus, which often prevents the fetus from assuming the normal head-down presentation. The fetus or neonate may have anemia or hypovolemic shock because some of the blood lost may be fetal blood. Fetal hypoxia may occur if a large disruption of the placental surface reduces the transfer of oxygen and nutrients. A woman with placenta previa is more likely than others to experience an infection or hemorrhage after birth for the following reasons: • Infection is more likely to occur because vaginal organisms can easily reach the placental site, which is a good growth medium for microorganisms. • Postpartum hemorrhage may occur because the lower segment of the uterus, where the placenta was attached, has fewer muscle fibers than the upper uterus. The resulting weak contraction of the lower uterus does not compress the open blood vessels at the placental site as effectively as would the upper segment of the uterus. Treatment Medical care depends on the length of gestation and the amount of bleeding. The goal is to maintain the pregnancy until the fetal lungs are mature enough that respiratory distress is less likely. 215 Delivery will be done if bleeding is sufficient to jeopardize the mother or fetus, regardless of gestational age. The woman should lie on her side or have a pillow under one hip to avoid supine hypotension. If bleeding is extensive or the gestation is near term, a cesarean section is performed for partial or total placenta previa. The woman with a low-lying placenta or marginal placenta previa may be able to deliver vaginally unless the blood loss is excessive. Nursing care The priorities of nursing care include monitoring the fetal heart and the character of contractions. Documenting and reporting vaginal blood loss and signs and symptoms of shock are important. Vital signs are taken every 15 minutes if the woman is actively bleeding, and oxygen is often given to increase the amount delivered to the fetus. Vaginal examination is not done because it may precipitate bleeding if the placental attachment is disrupted. The fetal heart rate is monitored continuously. The nurse implements care for a cesarean delivery as needed (see Chapter 8). The parents of the infant are often fearful for their child, particularly if a preterm delivery is required. Supportive care should be provided. Nursing Tip If placenta previa is suspected, the physician will perform a vaginal examination with preparations for both vaginal and cesarean delivery (a double setup) in place. Abruptio Placentae An abruptio placenta is the premature separation of a placenta that is normally implanted. Predisposing factors include the following: • Hypertension • Cocaine (which causes vasoconstriction) • Cigarette smoking and poor nutrition • Blows to the abdomen, such as might occur in battering or accidental trauma • Previous history of abruptio placentae • Folate deficiency Abruptio placentae may be partial or total (see Fig. 5.5B); it may be marginal (separating at the edges) or central (separating in the middle). Bleeding may be visible or concealed behind the partially attached placenta. Nursing Tip Pain is an important symptom that distinguishes abruptio placentae from placenta previa. Manifestations Bleeding accompanied by abdominal or low back pain is the typical characteristic of abruptio placentae. In contrast to the bleeding in placenta previa, most or all of the bleeding may be concealed behind the placenta. Obvious dark red vaginal bleeding occurs when blood leaks past the edge of the placenta. The woman’s uterus is tender and unusually firm (boardlike) because blood leaks into its muscle fibers. Frequent, cramplike uterine contractions often occur (uterine irritability). The fetus may or may not have problems, depending on how much placental surface is 216 disrupted. As in placenta previa, some of the blood lost may be fetal, and the fetus or neonate may have anemia or hypovolemic shock. Disseminated intravascular coagulation (DIC) is a complex disorder that may complicate abruptio placentae. The large blood clot that forms behind the placenta consumes clotting factors, which leaves the rest of the mother’s body deficient in these factors. Clot formation and anticoagulation (destruction of clots) occur simultaneously throughout the body in the woman with DIC. She may bleed from her mouth, nose, incisions, or venipuncture sites because the clotting factors are depleted. Postpartum hemorrhage may also occur because the injured uterine muscle does not contract effectively to control blood loss. Infection is more likely to occur because the damaged tissue is susceptible to microbial invasion. Treatment The treatment of choice, immediate cesarean delivery, is performed because of the risk for maternal shock, clotting disorders, and fetal death. Blood and clotting factor replacement may be needed because of DIC. The mother’s clotting action quickly returns to normal after birth because the source of the abnormality is removed. Nursing care Preparation for cesarean section and close monitoring of vital signs and fetal heart are essential. Signs of shock and bleeding from the nose, the gums, or other unexpected sites should be promptly reported. Rapid increase in the size of the uterus suggests that blood is accumulating within it. The uterus is usually very tender and hard. Nursing care after delivery is similar to that with placenta previa. The fetus sometimes dies before delivery. See Nursing Care Plan 5.1 for nursing care related to fetal death (stillbirth) and support of the grieving family. Many therapeutic communication techniques outlined earlier in the Communication box The Family Experiencing Pregnancy Loss are appropriate. The care of a pregnant woman with excessive bleeding is summarized in Box 5.2. Box 5.2 Care of the Pregnant Woman With Excessive Bleeding Document blood loss. Closely monitor vital signs including intake and output. Observe for: • Pain • Uterine rigidity or tenderness Verify that orders for blood typing and crossmatch have been implemented. Monitor intravenous infusion. Prepare for surgery, if indicated. Monitor fetal heart rate and contractions. Monitor laboratory results including coagulation studies. Administer oxygen by mask. Prepare for newborn resuscitation. Hypertension during pregnancy Preeclampsia and Eclampsia Hypertension may exist before pregnancy; this is known as chronic hypertension. When hypertension develops as a complication during pregnancy, it is known as gestational hypertension (GH). GH is a transient form of hypertension during pregnancy but can become chronic hypertension later in life. Table 5.5 compares the different types of hypertension during pregnancy. The term preeclampsia is defined as an increase in blood pressure that occurs after 20 weeks gestation with proteinuria (protein in the urine) in a woman who had a normal blood pressure before pregnancy (Sibai, 2016). 217 Table 5.5 Hypertensive Disorders of Pregnancy Disorder Gestational hypertension Characteristics Development of hypertension (blood pressure > 140/90 mm Hg) in a previously normotensive woman after 20 weeks gestation Does not include proteinuria; blood pressure usually returns to normal 6–12 weeks postpartum Preeclampsia As above, with renal involvement leading to proteinuria Eclampsia As above, with CNS involvement causing seizures Liver and coagulation abnormalities dominate the clinical picture Chronic hypertension Presence of hypertension before 20 weeks gestation; usually hypertension lasts beyond 12 weeks postpartum Preeclampsia with superimposed Chronic hypertension that has new occurrence of proteinuria or occurrence of thrombocytopenia and chronic hypertension increased liver enzymes (formerly known as HELLP syndromea) CNS, Central nervous system. aHemolysis, elevated liver enzymes, low platelets. Data from Gabbe S, Niebyl J, Simpson J, et al: Obstetrics: normal and problem pregnancies, ed 7, Philadelphia, 2017, Elsevier; ACOG: Chronic hypertension in pregnancy: practice bulletin #29, Washington, D.C., 2010, ACOG; ACOG: Diagnosis and management of preeclampsia and eclampsia: practice bulletin #33, Washington, D.C., 2010, ACOG. Symptoms of mild preeclampsia are: • Systolic blood pressure greater than 140 mm Hg but less than 160 mm Hg • Diastolic blood pressure greater than 90 mm Hg but less than 110 mm Hg Blood pressure should be assessed on several visits between 1 and 7 days apart. Symptoms of severe preeclampsia are: • Sustained blood pressure of systolic 160 mm Hg and diastolic 110 mm Hg and greater • Proteinuria—urine dipstick results of 1 + or greater on two separate urine specimens Other symptoms include excess weight gain more than 1.8 kg (4 lb) in 1 week in the second or third trimester. Edema is not always present in preeclampsia. Preeclampsia progresses to eclampsia when convulsions occur. Convulsions as a result of eclampsia can occur antepartum, intrapartum, or postpartum (one sometimes hears the term toxemia, an old term for preeclampsia). The cause of GH is unknown, but birth is its cure. GH usually develops after 20 weeks gestation. Vasospasm (spasm of the arteries) is the main characteristic of GH. Although the cause is unknown, any of several risk factors increases a woman’s chance of developing GH (Box 5.3). Box 5.3 Risk Factors for Preeclampsia • • • • • • • • • First pregnancy Obesity Family history of preeclampsia Age more than 35 years or less than 19 years Multifetal pregnancy (e.g., twins) Chronic hypertension Chronic renal disease Diabetes mellitus Autoimmune disease 218 • History of a pregnancy interval more than 10 years Data from Creasy RK, Resnik R, Iams JD, et al: Creasy & Resnik’s Maternal-fetal medicine, ed 7, Philadelphia, 2014, Saunders; Gabbe S, Niebyl J, Simpson J, et al: Obstetrics: normal and problem pregnancies, ed 7, Philadelphia, 2017, Elsevier; Smith R: Netter’s obstetrics and gynecology, ed 3, Philadelphia, 2018, Elsevier. Chronic Hypertension During Pregnancy In pregnant patients with chronic hypertension, new-onset proteinuria, a sudden increase in blood pressure that was previously controlled, or a sign of kidney involvement is indicative of preeclampsia. Antihypertensives may not be given to women with mild hypertension, but frequent prenatal visits and fetal monitoring are scheduled. Medication is prescribed if the blood pressure exceeds the moderate range. Labetalol is the antihypertensive drug of choice during pregnancy, as angiotensin-converting enzyme inhibitors are contraindicated. However, labetalol should not be used in patients with asthma or heart failure (ACOG, 2015). Management of the pregnant patient with chronic hypertension who develops preeclampsia requires frequent fetal evaluations including ultrasound examinations and non–stress tests and possibly early delivery at 36 to 37 weeks gestation. Severe preeclampsia is defined as a blood pressure greater than 160/110 mm Hg on two occasions 4 or more hours apart, especially if the patient is on bed rest. The patient should be instructed to report symptoms such as headaches or visual changes, and the nurse will monitor laboratory tests for abnormal results. Nursing Tip When taking the blood pressure of a woman with preeclampsia, the woman should be in a sitting position or semireclining in the bed if hospitalized. The reading should be taken in the right arm, elevated horizontally at heart level. GH is closely related to the development of complications such as abruptio placentae, fetal growth restriction, preeclampsia, prematurity, and stillbirth, so special care of the pregnant woman with hypertension is essential. GH is associated with an increased risk of type 2 diabetes mellitus in the offspring as an adult (Kajantie et al, 2017). The U.S. Preventive Services Task Force (USPSTF) recommends blood pressure screening at each visit during pregnancy to detect GH (Sperling and Gassett, 2017). Manifestations of gestational hypertension Vasospasm impedes blood flow to the mother’s organs and placenta, resulting in one or more of these signs: (1) hypertension, (2) edema, and (3) proteinuria. Severe GH can also affect the central nervous system, eyes, urinary tract, liver, gastrointestinal system, and blood clotting function. Table 5.6 summarizes laboratory tests that aid in diagnosis. Table 5.6 Laboratory Tests for Patients With Gestational Hypertension Test Hemoglobin and hematocrit Platelets Urine for protein Serum creatinine Serum uric acid Serum transaminase Rationale Detects hemoconcentration for indication of severity of GH Thrombocytopenia suggests GH Proteinuria confirms preeclampsia Elevated creatinine and oliguria suggest preeclampsia Elevated uric acid suggests preeclampsia Elevated transaminase confirms liver involvement in preeclampsia GH, Gestational hypertension. Data from Gabbe S, Niebyl J, Simpson J, et al: Obstetrics: normal and problem pregnancies, ed 7, 219 Philadelphia, 2017, Elsevier. Hypertension Despite an increase in blood volume and cardiac output, most pregnant women do not experience a rise in blood pressure because they have a resistance to factors that cause vasoconstriction. In addition, the resistance to blood flow in their vessels (peripheral vascular resistance) decreases because of the effects of hormonal changes. A blood pressure of 140/90 mm Hg or greater is considered to constitute hypertension in pregnancy. Edema Edema can occur because fluid leaves the blood vessels and enters the tissues. Edema is not essential to the diagnosis, as many pregnant women experience edema that is not related to blood pressure. The woman may notice facial swelling or may stop wearing rings because they are hard to remove. Edema is severe if a depression remains after the tissue is compressed briefly with the finger (pitting edema). Edema resolves quickly after birth as excess tissue fluid returns to the circulation and is excreted in the urine. Urine output may reach 6 L/day and often exceeds fluid intake. Safety Alert! Sudden excess weight gain of 1.8 kg (3.5 lb) in 1 week in the second or third trimester may be indicative of preeclampsia. Related edema may or may not be present. Proteinuria Proteinuria develops as reduced blood flow damages the kidneys. This damage allows protein to leak into the urine. A clean-catch (midstream) or catheterized urine specimen is used to check for proteinuria because vaginal secretions might lead to a false-positive result. Other manifestations of preeclampsia Other signs and symptoms occur with severe preeclampsia. All are related to decreased blood flow and edema of the organs involved. Central nervous system A severe, unrelenting headache may occur because of brain edema and small cerebral hemorrhages. The severe headache often precedes a convulsion. Deep tendon reflexes become hyperactive because of central nervous system irritability. Eyes Visual disturbances such as blurred or double vision or “spots before the eyes” occur because of arterial spasm and edema surrounding the retina. Visual disturbances often precede a convulsion. Urinary tract Decreased blood flow to the kidneys reduces urine production (oliguria) and worsens hypertension. Respiratory system Pulmonary edema (accumulation of fluid in the lungs) may occur with severe preeclampsia. Gastrointestinal system and liver Epigastric pain or nausea occurs because of liver edema, ischemia, and necrosis and often precedes a convulsion. Liver enzyme levels are elevated because of reduced circulation, edema, and small hemorrhages. 220 Blood clotting HELLP syndrome is a variant of GH that involves hemolysis (breakage of erythrocytes), elevated liver enzymes, and low platelets. Hemolysis occurs as erythrocytes break up when passing through small blood vessels damaged by hypertension. Obstruction of hepatic blood flow causes the liver enzyme levels to become elevated. Low platelet levels occur when the platelets gather at the site of blood vessel damage, reducing the number available in the general circulation. Low platelet levels cause abnormal blood clotting. HELLP syndrome is more common in preeclamptic women conservatively managed but may occur in women without hypertension and proteinuria (Sibai, 2016). RUQ or epigastric pain, nausea, vomiting, and malaise may signal that HELLP syndrome is developing. Liver enzyme laboratory reports should be monitored. HELLP syndrome can also develop postpartum, and all patients with hypertension should be closely monitored during the postpartum period. The patient with severe HELLP syndrome is monitored in the intensive care unit and given magnesium sulfate to prevent convulsions and antihypertensive medications. The need for delivery of the fetus after steroid therapy to improve fetal lung function is evaluated, and the woman is monitored closely for bleeding. Postpartum, the mother is evaluated for fluid intake and output, laboratory values, and pulse oximetry for at least 48 hours. Most patients improve after delivery. Eclampsia Progression to eclampsia occurs when the woman has one or more generalized tonic-clonic seizures. Facial muscles twitch; this sign is followed by generalized contraction of all muscles (tonic phase), then alternate contraction and relaxation of the muscles (clonic phase). An eclamptic seizure may result in cerebral hemorrhage, abruptio placentae, fetal compromise, or death of the mother or fetus. Responsibilities of the nurse include administration of magnesium to control seizures, close fetal monitoring as well as monitoring of uterine contractions, and measures to prevent aspiration. Delivery may be expedited. Effects on the fetus Preeclampsia reduces maternal blood and nutrition flow through the placenta and decreases the oxygen available to the fetus. Fetal hypoxia may result in meconium (first stool) passage into the amniotic fluid or fetal distress. The fetus may have intrauterine growth restriction (IUGR) and at birth may be long and thin with peeling skin if the reduced placental blood flow has been prolonged. Fetal death sometimes occurs. Treatment Medical care focuses on prevention and early detection of GH. Drugs are sometimes needed to prevent convulsions and to reduce blood pressure that is dangerously high. Prevention Correction of some risk factors reduces the risk for preeclampsia. For example, improving the diet, particularly of the pregnant adolescent, may prevent preeclampsia and promote normal fetal growth. Other risk factors, such as family history, cannot be changed. Early and regular prenatal care allows preeclampsia to be diagnosed promptly so that it is more effectively managed. USPSTF recommends administration of low-dose aspirin starting between 12 and 14 weeks gestation to patients with high risk of developing eclampsia (USPSTF, 2017). Management Treatment of preeclampsia depends on the severity of hypertension and on the maturity of the fetus. Treatment focuses on (1) maintaining blood flow to the woman’s vital organs and the placenta and (2) preventing convulsions. Birth is the cure for preeclampsia. If the fetus is mature, pregnancy is ended by labor induction or cesarean birth. If preeclampsia is severe, the fetus is often in greater danger from being in the uterus than from being born prematurely. Some women with mild preeclampsia can be managed at home if they can comply with treatment and if home nursing visits are possible. If the woman has severe preeclampsia or cannot comply with treatment or if home nursing visits are not available, the woman is usually admitted to the hospital. Conservative treatment, whether at home or in the hospital, includes the following: 221 • Activity restriction to allow blood that would be circulated to skeletal muscles to be conserved for circulation to the mother’s vital organs and the placenta. The woman should remain on reduced activity with frequent rest periods lying on her side to improve blood flow to the placenta. • Maternal assessment of fetal activity (“kick counts”) (see Chapter 4). The woman should report a decrease in movements or if none occur during a 3-hour period (see Table 5.1). • Blood pressure monitoring two to four times per day in the same arm and in the same position. A family member must be tau