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Pfeil 1 Obstetrics Complications Lecture 1 Kristi Pfeil MSN, RN 2 Today’s Topics 1. Hemorrhagic disorders 2. Gestational Diabetes mellitus 3. Hyperemesis gravidarum...

Pfeil 1 Obstetrics Complications Lecture 1 Kristi Pfeil MSN, RN 2 Today’s Topics 1. Hemorrhagic disorders 2. Gestational Diabetes mellitus 3. Hyperemesis gravidarum 4. Pregnancy infections 5. Loss and Grief a. Imperfect baby b. fetal death 6. 3 Potential Causes of Hemorrhage Spontaneous abortion types Incompetent cervix Ectopic pregnancy Hydatidiform mole Placenta previa Abruptio placentae Polyhydramnios Disseminated intravascular coagulation (DIC) 4 Loss of Pregnancy Definitions Miscarriage: Loss of an intrauterine pregnancy before viability (20 weeks) Spontaneous abortion: Nonviable, intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus without fetal heart activity within the first 12 6⁄7 weeks of gestation Early pregnancy loss: Spontaneous pregnancy demise before 10 weeks of gestational age Still Birth according to the CDC (May ’24) Early is the loss of a baby between 20 and 27 weeks of pregnancy. Late is the loss of a baby between 28 and 36 weeks of pregnancy. Term is the loss of a baby at 37 or more weeks of pregnancy. 5 Spontaneous Abortion (Miscarriage) Types: Threatened Inevitable Incomplete Complete 1  Pfeil Missed Septic Recurrent habitual 6 Spontaneous Abortions Assessment: Pain: Backache, cramps, bleeding, abdominal tenderness? Rupture of membranes, tissue passed? dilation of cervix? Fever? VS: are there signs & symptoms of hemorrhage? What is the Emotional status & needs of patient & family? 7 Spontaneous Abortions Collaborative Management Monitor VS, LOC, & amount of bleeding (count pads) Maintain bed rest Prepare patient for lab work, diagnostics, and procedures Dilation, curettage, and/or evacuation (vacuum) of uterine contents Administer meds & blood products as ordered If patient is Rh negative, give RhoGAM 8 Spontaneous Abortions Discharge teaching: Patient shoud report: Report bright red clots Bleeding that lasts longer than 7 days Signs of infection temperature of greater than 100° F (37.8° C) foul-smelling vaginal discharge severe uterine cramping nausea or vomiting 9 Clinical Judgment case study A 25 y/o Primigravida had an incomplete abortion at 12 weeks’ gestation. She has B negative blood. After initial stabilization on admission to the hospital, a vacuum extraction with curettage was performed to remove retained placental tissue. 10 Clinical Judgment Thinking exercise Prior to the procedure, the patient had questions about the loss of her fetus and the procedure. how should the nurse therapeutically and truthfully respond? Indicate each response as therapeutic or nontherapeutic: 1. “Spontaneous abortions are for the best and you are lucky it happened early.” 2. “You can always have other children.” 2  Pfeil 3. “We will be monitoring your bleeding for your safety.” 4. “Fluid replacement and nutrition are important for your physical healing.” 5. “Talking to someone you trust is vital for your mental healing.” 6. “Who can I call to be with you during this time?” 11 Clinical Judgment Thinking exercise continued A 25 y/o Primigravida had an incomplete abortion at 12 weeks’ gestation. She has B negative blood. After initial stabilization on admission to the hospital, a vacuum extraction with curettage (AKA D&C) was performed to remove retained placental tissue. Discuss the causes, signs & symptoms, possible complications, & management of this spontaneous abortion 12 Cervical Insufficiency/Incompetent Cervix https://www.youtube.com/watch?v=SPBWlBqnsnc (3 min) Definition- Passive & painless dilation of the cervix Risk factors- history of cervical trauma, short labors, or previous pregnancy loss; exposure to diethylstilbestrol (DES), a synthetic form of estrogen Management Assess for vaginal discharge, bleeding, contractions Activity restriction or bed rest may be prescribed Increased Hydration to promote a relaxed uterus Avoid intercourse Prepare for possible cervical cerclage 13 14 Incompetent Cervix Cervical cerclage procedure purse-string suture placed around the internal os to hold the cervix in a normal state suturing is usually done between 12 and 14 weeks gestation to reinforce an incompetent cervix and maintain pregnancy the suturing is typically removed around 36-37 weeks gestation (video stated 35) 15 Incompetent Cervix Monitoring and Assessment: Vital Signs, Pain Management, Uterine Activity, Fetal Monitoring Education and Instructions: Activity Restrictions, Pelvic Rest, Hygiene, Signs of Complications Follow-Up Care: Visits, US, Suture removal Emotional Support Documentation 16 Ectopic Pregnancy 1 https://www.youtube.com/watch?v=aMrRR3Igslk (5.5 min) Implantation of the fertilized ovum in any site other than the endometrial lining of the uterus 17 Risk Factors for Ectopic Pregnancy 3  Pfeil Previous Ectopic Pregnancy Pelvic Inflammatory Disease (PID) Pelvic Surgery Assisted Reproductive Techniques (ART) Tubal Abnormalities Intrauterine Device (IUD) Use Smoking Age (35-44) Contraceptive Failure History of Tubal Surgery Progestin-Only Contraceptives 18 Ectopic Pregnancy: Diagnostics, Treatment Options, Nursing Care Transvaginal ultrasound shows an empty uterus Monitor hemodynamic status, IV fluid/blood administration Methotrexate to inhibit cell division & embryo enlargement Prepare for surgery Laparoscopic salpingectomy Linear salpingostomy Psychological support 19 Ectopic Pregnancy Assessment: Signs & Symptoms A patient with a ruptured ectopic pregnancy commonly has sharp pain in the lower abdomen, with spotting and cramping She may have abdominal rigidity, rapid, shallow respirations, tachycardia, and shock Cullen’s sign -- bluish discoloration around umbilicus 20 Gestational trophoblastic disease (GTD) A developmental anomaly of the placenta with proliferation & degeneration of trophoblastic villi that become swollen, fluid-filled, & have an appearance of grape-like clusters Embryo fails to develop beyond a primitive state, which is associated with choriocarcinoma 21 Hydatidiform Mole (Molar Pregnancy) is a result of abnormal cell growth the placenta develops but not the fetus Also called Gestational trophoblastic mole 22 Manifestations of Molar Pregnancy 4  Pfeil Vaginal Bleeding - scant to profuse, brownish in color Enlargement of uterus - out of proportion to the duration of the pregnancy May show S/S of preeclampsia: HTN, edema to legs, ankles, & feet N/V due to  hCG levels No fetal heart tones 23 Management of Molar Pregnancy Treat HTN, N/V Ultrasound reveals dense growth, but no fetus Suction curettage to evacuate the mole Post-surgery, Rh-negative women are given Rho(D) immune globulin (RhoGAM) 24 Follow Up of Molar Pregnancy Lab work – monitor serum hCG levels weekly for 3 weeks, then monthly for 6 months up to 1 year to detect GTD Provide patient education & emotional support Offer referral for patients & partners to pregnancy loss support groups Instruct the patient to use reliable contraception as a component of follow-up care due to increased risk of choriocarcinoma 25 Placenta Previa (4 min) https://www.youtube.com/watch?v=xnRIF8SDYf8 26 Placenta Previa: Manifestation When a pregnant patient has undiagnosed painless vaginal bleeding, vaginal examination should be avoided until ultrasonography rules out placenta previa Digital exams when placenta previa is present  can cause additional placental separation OR  can tear the placenta itself, causing severe maternal and fetal bleeding 27 Placenta Previa: Interventions and Nursing Care Goal is to prevent preterm birth Positioning on left side for maximum fetal perfusion Monitoring fetal heart tones Administering I.V. fluids and oxygen, as ordered Maintain bed rest, if ordered Pelvic rest Assessment of bleeding How will the patient deliver? Vaginally for marginal/low previa C-Section for partial & total previa 28 Abruptio Placentae (6 min) 5  Pfeil https://www.youtube.com/watch?v=lvT3Q79zxZ4 29 Abruptio Placentae: Manifestations FIVE classic signs and symptoms 1. Vaginal bleeding, which may not reflect true amount of blood loss 2. Abdominal/Low back pain 3. Uterine irritability 4. High uterine resting tone 5. Uterine tenderness 30 Abruptio Placentae: Treatment and Nursing Care Hospitalization & evaluation Palpate uterus for tenderness & tone Assess FHR pattern, continuous fetal monitoring If signs of fetal compromise, then Cesarean delivery immediately: Apply oxygen 8-10 L/min via facemask, Monitor VS, fluid & blood replacement, assess urinary output & monitor fluid balance Lab work – CBC, blood type & screen, clotting factors 31 Comparison 32 Polyhydramnios Excessive accumulation of amniotic fluid Increased risk for developing : Abruptio placentae Preterm contractions/preterm labor Premature rupture of membranes Fetal malposition Maternal respiratory compromise Umbilical cord prolapse Uterine atony 33 Disseminated Intravascular Coagulation (DIC) https://www.youtube.com/watch?v=Gmh01S0msfY (6 min) Risk factors for DIC in pregnancy (Potential Complication)  Abruptio placentae  Severe preeclampsia  Sepsis  Fetal demise (intrauterine death)  HELLP Syndrome  Liver disease  Amniotic fluid embolism  Gestational hypertension 6  Pfeil 34 Lab Findings In DIC 35 DIC TREATMENT 1. Remove the underlying pathological cause – deliver fetus & placenta 2. Maintain the blood volume and hemostatic function: transfuse packed red blood cells Give fresh frozen plasma Give platelets concentrate Replace missing blood coagulation factors (components) 3. The main goal of the DIC treatment is balancing function to restore the body’s ability to coagulate normally 36 Gestational Diabetes Mellitus (GDm) Diagnosed during pregnancy; controlled by either diet/exercise alone or diet/exercise and medication Diabetes in Pregnancy (8 min) https://www.youtube.com/watch?v=N3jnRuzseoM Gestational Diabetes - Overview (signs and symptoms, pathophysiology, diagnosis, treatment - 12 min) https://www.youtube.com/watch?v=T09oiyoy6ek 37 Gestational Diabetes Mellitus  Risk factors  Overweight or obesity (BMI > 25)  Maternal age older than 25 years  Gestational diabetes in previous pregnancy  History of abnormal glucose tolerance level  History of diabetes in close relative  Member of high-risk ethnic group 38 Effects of Pregnancy on Glucose Metabolism  Early pregnancy Metabolic and energy needs change little Insulin releases in response to serum glucose increases  Late pregnancy Hormones of pregnancy create insulin resistance Human placental lactogen (hpl), cortisol, growth hormone, progesterone Hormones cause Insufficient insulin sensitivity and periods of hyperglycemia 39 Major Effects of Diabetes Mellitus on Pregnancy Maternal effects Preeclampsia Urinary tract infections Ketoacidosis 7  Pfeil Labor dystocia (large fetal size) Birth injury to maternal tissue 40 Major Effects of Diabetes Mellitus on Pregnancy Increased fetal & neonatal risks Congenital malformation Perinatal death Variations in fetal size (macrosomia > 4000g) Intrauterine fetal growth restriction Preterm labor, premature rupture of membranes, preterm birth Birth injury Hypoglycemia Polycythemia Hyperbilirubinemia Hypocalcemia Respiratory distress syndrome (RDS) 41 Identifying Gestational Diabetes Mellitus 1. All pregnant women should be screened at 24-28 weeks gestation 2. Routine urinalysis with glycosuria 3. Glucose challenge test, screening (fasting not necessary) 1-hr glucose tolerance test performed 50 gram oral glucose load, followed by plasma glucose analysis 1-hr later If 140 mg/dL or higher, then do 3 hour OGTT 42 Identifying Gestational Diabetes Mellitus continued 4. 3-hr oral glucose tolerance test (OGTT) Overnight fasting required, avoid caffeine & smoking for 12 hrs prior to test A fasting glucose is obtained 100 gram glucose load given Serum glucose levels obtained at 1, 2, & 3 hrs after glucose ingestion  Gestational diabetes if 2 or more occur: Fasting – 95 mg/dl 1 hour - 180 mg/dl 2 hour - 155 mg/dl 3 hour – 140 mg/dl 43 Gestational Diabetes Treatment Diet - diabetic educator or dietician should determine dietary needs Exercise - Improves glucose metabolism Self-monitoring blood glucose (finger sticks) – 6 times a day Fasting & 2 hours post breakfast 1 hour before lunch & 2 hours post lunch 1 hour before dinner & bedtime Medication - Insulin use for each trimester First Trimester-- may drop slightly 8  Pfeil Second Trimester-- Rise in the requirements Third Trimester-- double to quadruple by the end of pregnancy 44 Clinical Judgment Thinking exercise During a prenatal visit, the nurse is explaining dietary management to a woman with pregestational diabetes. The nurse evaluates that teaching has been effective when the woman states: A. “I will need to eat 600 more calories per day because I am pregnant.” B. “I can continue with the same diet as before pregnancy as long as it is well balanced.” C. “Diet and insulin needs change during pregnancy.” D. “I will plan my diet based on results of urine glucose testing.” 45 Clinical Judgment Thinking exercise Your patient had a 3 hour glucose tolerance test, the results are as follows: Fasting- 100 mg/dl 1 hour- 205 mg/dl 2 Hour- 183 mg/dl 3 Hour- 158 mg/dl Does your patient have GDM? Explain the rationale for these post-procedure prescriptions: 1. Dietary modifications 2. Moderate exercise program 3. Instructions for self-monitoring of glucose 4. Daily dietary log & record of all blood glucose levels; bring these to next appointment 46 Pregnancy Infections  TORCH Infections caused by one of the following: Toxoplasma gondii Other agents (syphilis, varicella-zoster virus, Human Immunodeficiency virus (hiv), parvovirus B19) Rubella (German measles) Cytomegalovirus (cmv) Herpes simplex virus (hsv) These infections can cross the placenta & cause physical malformations, miscarriage or stillbirth  47 Toxoplasmosis Caused by Toxoplasma gondii, a protozoan parasite that is transmitted from handling infected cat feces or eating undercooked meat Toxoplasmosis may present as fever and fatigue in the mother The infection is carried to the infant through the mother's placenta, and can cause infections of the eyes or central nervous system The organism can invade brain and cause hydrocephalus, intracranial calcifications; can invade muscle tissue and form tissue cysts 48 Other (Syphilis) 9  Pfeil Caused by a spirochete (spiral- or coil-shaped bacterium), Treponema pallidum It is transmitted in the adult population by sexual intercourse Syphilis can cause early delivery, miscarriage, or stillbirth If the fetus survives, congenital syphilis may cause craniofacial malformations, rash, and deafness 49 Rubella Rubella spread through direct contact with infected saliva, mucus, or air droplets In the mother, rubella may present with mild symptoms: swollen lymph nodes, polyarthritis, or rashes rubella that is transmitted to a developing fetus during pregnancy can result in congenital rubella syndrome, which is characterized by deafness, clouding of the eyes (i.e., cataracts), rash, and heart defects problems may develop in later in childhood, including autism, hearing loss, brain syndromes, immune system disorders, or thyroid disease A rubella vaccine shouldn’t be given to a pregnant woman; the vaccine can be administered after delivery, but the patient should be instructed to avoid becoming pregnant for 3 months 50 Cytomegalovirus (CMV) CMV belongs to the herpes virus group of infections It can be transmitted through body secretions, as well as by sexual contact; some newborns acquire CMV through the mother's breast milk; in adults, it produces symptoms resembling those of mononucleosis a congenital CMV infection in a developing fetus can present with rashes, deafness, inflammation of the eye (chorioretinitis), seizures, an unusually small head (microcephaly), and intracranial calcifications A pregnant staff member should not be assigned to work with a patient who has cytomegalovirus infection because the virus can be transmitted through direct contact with infected bodily fluids 51 Herpes simplex virus (HSV) Can be spread by oral secretions (kissing, sharing utensils, sharing drinks, etc.) Can be spread by genital secretions (usually infects a newborn during passage through the birth canal) the virus enters the infant through its eyes, skin, mouth, and upper respiratory tract HSV can cause blisters and inflammation of the brain (meningoencephalitis) 52 Infections During Pregnancy (Cont.) Human immunodeficiency virus (HIV) A retrovirus that gradually causes a fall in the effectiveness of the maternal immunity HIV attacks & destroys T-lymphocytes, causing immunosuppression Maternal treatment with zidovudine (ZDV) along with other antiviral medications can substantially reduce infection of the fetus 10  Pfeil The newborn should be started on the ZDV within 6–12 hours after birth 53 Prevention of Perinatal HIV Infection of the Infant 54 Torch infections Treatment dependent on specific agent responsible for the infection Infants with toxoplasmosis can be treated with pyrimethamine, an antiparasitic medication, and sulfadiazine, which is an antibiotic In all suspected cases of HSV, infection may be treated aggressively with acyclovir While there is no specific antiviral therapy for rubella, supportive treatment may involve screening for hearing and vision issues, as well as surgery to correct any heart defects Because Treponema pallidum is a bacterium, penicillin can treat syphilis Fetuses with parvovirus B19 may need intrauterine blood transfusion 55 Hyperemesis gravidarum SEVERE uncontrollable vomiting A pregnant woman who has hyperemesis gravidarum may require hospitalization to treat dehydration and starvation 56 Hyperemesis Gravidarum: Assessment Persistent nausea and vomiting Weight loss 5% or more of body weight May become severely dehydrated Depletion of essential electrolytes Starvation 57 Hyperemesis Gravidarum: Nursing Care/Interventions Control nausea/vomiting Replace fluids and nutrition Emotional support http://www.helpher.org/ 58 Loss and Grief  Imperfect baby  Duck Dynasty Story (6 min 41 sec) https://youtu.be/THxrtd5Qf6Q 59 Critical Reflection You are the nurse caring for a family that has given birth to an infant with Down’s Syndrome. The mother and father were unaware of this diagnosis throughout the pregnancy and are very shocked to see their “imperfect” baby. What do you do or say? 11  Pfeil 60 Loss and Grief  Fetal Demise is death of the fetus after viability  Intrauterine Fetal Death In a stillbirth, the mother goes through L&D process & should be allowed to hold the neonate to help her come to terms with the death Typically rooms away from live births Look for sign on door signifying loss Labor & Delivery Nurse Experience w/IUFD (21 min 41 sec): https://www.youtube.com/watch?v=P5kcUzPi2C0 12