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COMPLICATIONS OF PREGNANCY

COMPLICATIONS OF PREGNANCY. Jeanie Ward. Risk Factors. Age – under 17 over 35 Gravida and Parity Socioeconomic status Psychological well-being Predisposing chronic illness – diabetes, heart conditions, renal, etc.

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COMPLICATIONS OF PREGNANCY

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  1. COMPLICATIONS OF PREGNANCY Jeanie Ward

  2. Risk Factors • Age – under 17 over 35 • Gravida and Parity • Socioeconomic status • Psychological well-being • Predisposing chronic illness – diabetes, heart conditions, renal, etc. • Pregnancy related conditions – hyperemesis gravidarum, PIH, etc.

  3. High Risk Pregnancy Goals of Care • Provide with optimum care for the mother and the fetus • Assist the patient and her family to understand and cope with the variations in a High Risk Pregnancy and cope with her feelings

  4. Bleeding Disorders

  5. Abortions • Termination of pregnancy at any time before the fetus has reached the age of viability • Either: • spontaneous – occurring naturally • induced – artificial

  6. Etiology / Predisposing Factors • Faulty germ plasm -- imperfect ova or sperm, faulty implantation, genetic make-up (chromosomal disorders), congenital abnormalities • Decrease in the production of progesterone • Drugs or radiation • Maternal causes -- infections, endocrine disorders, malnutrition, hypertension

  7. Assessment Types of Abortions Threatened • Signs and Symptoms • vaginal bleeding, spotting • Mild cramps, backache • Cervix remains CLOSED • Treatment and Nursing Care • Bed rest, sedation, • Avoid stress and intercourse • Progesterone therapy • A period of “watchful waiting”

  8. Inevitable Abortion • Signs and Symptoms • Loss is certain • Bleeding is more profuse • Painful uterine contractions • Cervix DILATES • Treatment and Nursing Care • Assess all bleeding. Save all pads. (May need to weigh the pads) • Use the bedpan to assess all products expelled • Treated by evacuation of the uterus usually be a D & C or suction • Provide Psychological Support

  9. Complete Abortion • All products of conception are expelled • No treatment is needed, but may do a D & C

  10. Incomplete Abortion • Parts of the products of conception are expelled, with placenta and membranes retained • Treated with a D & C or suction evacuation • Provide support to the family

  11. Missed Abortion • The fetus dies in-utero and is not expelled • Uterine growth ceases • Breast changes regress • Maceration occurs • Treatment: • D & C • Hysterotomy

  12. Missed AbortionCritical Thinking Exercise • The woman who has a missed abortion is at risk for what 2 conditions?

  13. Habitual Abortion / Premature Cervical Dilation • Abortion occurs consecutively in three or more pregnancies • Usually due to an Incompetent Cervical Os, that results from cervical trauma, cervical lacerations, repeated D & C, or conization. • Occurs most often about 18-20 weeks gestation.

  14. Habitual Abortion • Treatment • Cerclage procedure -- purse-string suture placed around the internal os to hold the cervix in a normal state

  15. Nursing Care • Bedrest in a slight trendlenburg position to decrease the pressure on the new sutures • Teach: • Assess for leakage of fluid, bleeding • Assess for contractions • Assess fetal movement and report decrease movement (if old enough) • Assess temperature for elevations

  16. Delivery • When time for delivery there are several options: • physician will clip suture and allow patient to go into labor on her own • induce labor • cesarean delivery

  17. Mrs. B. had a cerclage procedure done at 14 weeks gestation. She is now 39 weeks gestation and admitted to labor and delivery because she is in labor. • What is theMOST important assessment to make at this time?

  18. Key Concepts to Remember!! • If a woman is Rh-, RhoGam is given within 72 hours • Provide emotional support. Feelings of shock or disbelief are normal • Encourage to talk about their feelings. It begins the grief process

  19. Bleeding Disorders Ectopic Pregnancy • Implantation of the blastocyst in ANY site other than the endometrial lining of the uterus ovary (5) Cervical

  20. Etiology / Contributing Factors • Salpingitis • Pelvic Inflammatory Disease, PID • Endometriosis • Tubal atony or spasms • Imperfect genetic development

  21. Assessment Ectopic Pregnancy • Early: • Missed menstruation followed by vaginal bleeding (scant to profuse) • Unilateral pelvic pain, sharp abdominal pain • Referred shoulder pain • Cul-de-sac mass • Acute: • Shock – blood loss poor indicator • Cullen’s sign -- bluish discoloration around umbilicus • Nausea, Vomiting • Faintness

  22. Diagnostic Tests Ectopic Pregnancy • Diagnosis: • Ultrasound • Culdocentesis • Laparoscopy

  23. Interventions / Nursing Care • Combat shock / stabilize cardiovascular • Draw blood for type and cross match • Give blood replacements • IV’s. • Laparotomy • Psychological support • Linear salpingostomy • Methotrexate – used prior to rupture. Destroys fast growing cells

  24. Hydatiform Mole Etiology • A DEVELOPMENTAL ANOMALY OF THE PLACENTA WITH DEGENERATION OF THE CHORIONIC VILLI • As cells degenerate, they become filled with fluid and appear as fluid filled grape-size vessicles.

  25. Assessment: • Vaginal Bleeding -- scant to profuse, brownish in color (prune juice) • Enlargement of the uterus out of proportion to the duration of the pregnancy • Vaginal discharge of grape-like vesicles • May display signs of pre-eclampsia early • Hyperemesis gravidarium • No Fetal heart tone or Quickening • Abnormally elevated levels of HCG

  26. Interventions and Follow-Up • Empty the Uterus by D & C or Hysterotomy • Follow-Up for One Year • Assess for the development of choriocarcinoma • Blood tests for levels of HCG frequently • Chest X-rays • Placed on oral contraceptives • If the levels rise, then chemotherapy started usually Methotrexate

  27. Critical Thinking Exercise • A woman who just had an evacuation of a hydatiform mole tells the nurse that she doesn’t believe in birth control and does not intend to take the oral contraceptives that were prescribed for her. • How should the nurse respond?

  28. Placenta Previa • Low implantation of the placenta in the uterus • Etiology • Usually due to reduced vascularity in the upper uterine segment from an old cesarean scar or fibroid tumors • Three Major Types: • Low or Marginal • Partial • Complete

  29. Abruptio Placenta • Premature separation of the placenta from the implantation site in the uterus • Etiology: • Chronic Hypertension • Sudden decompression of an over-distended uterus • Trauma • Injudicious use of Pitocin • Smoking / Caffeine / Cocaine • Vascular problems

  30. Placenta Previa PAINLESS vaginal bleeding Bright red bleeding First episode of bleeding is slight then becomes profuse Signs of blood loss comparable to extent of bleeding Uterus soft, non-tender Fetal parts palpable; FHT’s countable Blood clotting defect absent Abruptio Placenta Bleeding accompanied Abruptio by PAIN Dark red bleeding First episode of bleeding usually profuse Signs of blood loss out of proportion to visible amount Uterus board-like, painful Fetal parts non-palpable, FHT’s non-countable Blood clotting defect (DIC) likely

  31. Signs of Concealed Hemorrhage • Increase in fundal height • Hard, board-like abdomen • High uterine baseline tone on electronic fetal monitoring • Persistent abdominal pain • Systemic signs of hemorrhage

  32. Interventions and Nursing Care • Placenta Previa • Bed-rest • Assessment of bleeding • Electronic fetal monitoring • If it is low lying, then may allow to deliver vaginally • Cesarean delivery for All other types of previa • Abruptio Placenta • Deliver by cesarean delivery immediately • Combat shock – blood replacement / fluid replacement • Blood work – assessment of DIC

  33. Critical Thinking • Mrs. A. , G3 P2, 38 weeks gestation is admitted to L & D with bleeding. What is the priority nursing intervention at this time? • Assess the fundal height for a decrease • Place a hand on the abdomen to assess if hard, board-like, tetanic • Place a clean pad under the patient to assess the amount of bleeding • Prepare for an emergency cesarean delivery

  34. Disseminated Intravascular Coagulation (DIC) Anti-coagulation and Pro-coagulation effects existing at the same time.

  35. EtiologyDefect in the Clotting Cascade • An abnormal overstimulation of the coagulation process Activation of Coagulation with release of thromboplastin ê Thrombin (powerful anticoagulant) is produced ê Fibrinogen fibrin which enhances platelet aggregation • ê • Widespread fibrin and platelet deposition in capillaries and arterioles

  36. Resulting in Thrombosis (multiple small clots) • Excessive clotting activates the fibrinolytic system • Lysis of the new formed clots create fibrin split products • These products have anticoagulant properties and inhibit normal blood clotting • A stable clot cannot be formed at injury sites • Hemorrhage occurs • Ischemia of organs follows from vascular occlusion of numerous fibrin thrombi • Multisite hemorrhage results in shock and can result in death

  37. Disseminated Intravascular Coagulation (DIC) • Precipating Factors: • Abruptio placenta • PIH • Sepsis • Retained fetus (fetal demise) • Fetal placenta fragments

  38. Assessment Signs and Symptoms • Spontaneous bleeding -- from gums and Epistasis, and injection and IV sites, incisions • Excessive bleeding -- Petechiae at site of blood pressure cuff, pulse points. Ecchymosis • Tachycardia, diaphoresis, restlessness, hypotension • Hematuria, oliguria, occult blood in stool • Mental changes if brain affected.

  39. Diagnostic Tests • Lab work reveals: • PT – Prothrombin time is prolonged • PTT – Partial Thromboplastin Time increased • D-Dimer – increased Product that results from fibrin degradation. More specific marker of the degree of fibrinolysis • Platelets -- decreased • Fibrin Split Products – increase An increase in both FSP and D-Dimer are indicative of DIC

  40. DICInterventions and Nursing Care • Remove Cause • Evaluate vital signs • Replace blood and blood products • Fluid replacement • May give Heparin -- interrupt the clotting cascade and prevent triggering the fibrinolytic system.

  41. Structural DisordersFetal Demise / Intrauterine Fetal Death DEFINITION: Death of a fetus after the age of viability

  42. Assessment: 1. First indication is usually NO fetal movement 2. NO fetal heart tones Confirmed by ultrasound 3. Decrease in the signs and symptoms of pregnancy

  43. Interventions and Nursing Care • Allow patient to decide when she wants to deliver • Most women go into labor on their own in 2 weeks, so may wait for labor to begin spontaneously • Induce labor • Prostaglandin (Prostin E) causes smooth muscles to contract: Side effects - nausea, vomiting, diarrhea • Cytogel • Provide with Emotional Support, allow to hold baby

  44. The End

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