HIGH RISK PREGNANCY: WOMAN WHO DEVELOPS COMPLICATION DURING PREGNANCY Bleeding and Development of Hypovolemic Shock Any

y degree of bleeding during pregnancy is serious because the amount visualized may only be a fraction of the actual blood loss because an undilated cervix and intact membranes can contain blood within uterus (internal bleeding). Evaluate for possible Hypovolemic Shock. Danger to Fetal Blood Supply occurs if theres decrease blood flow to peripheral organs. Position: Left Side Lying to improve Placental Circulation Process of Hypovolemic Shock (Chronological Order) 1. Blood Loss 2. Intravascular Volume 3. Venous Return, Cardiac Output, Blood Pressure 4. Body compensating by Heart Rate to circulate blood volume faster; vasoconstriction of peripheral vessels to save blood vital organs; RR; feeling of apprehension at body changes 5. Cold, clammy skin, uterine perfusion in the face of continued blood loss, although body shifts fluid from interstitial spaces into intravascular spaces, blood pressure continuously 6. Renal, Uterine, and Brain perfusion 7. Lethargy, Coma, Renal output 8. Renal Failure 9. Maternal and Fetal Death Signs and Symptoms of Hypovolemic Shock Position: Trendelenburg 1. 2. 3. 4. Pulse Rate (Tachycardia) heart is attempting to circulate blood volume faster. Blood Pressure (Hypotension) less peripheral resistance b/c of blood volume Respiratory Rate (Tachypnea) gas exchange to better oxygenate a RBC volume. Cold, Clammy Skin, Pallor vasoconstriction to maintain blood volume in central body core 5. Urine Output inadequate blood is entering the kidney 6. Dizziness / LOC / Confusion inadequate blood is reaching cerebrum 7. Central Venous Pressure blood is returning to heart

Two Conditions Associated with 1st Trimester bleeding (1st 3rd month) 1. Abortion or Miscarriage 2. Ectopic Pregnancy Abortion Any interruption of a pregnancy before a fetus becomes viable; < 20 weeks AOG; spontaneously or electively Age of Viability 20 24 weeks AOG; Fetus weighs at least 500g; Fetus can survive outside uterus if born at that time Miscarriage interruption of pregnancy occurs spontaneously during age of viability; >2024 weeks AOG Elective Abortion - planned medical termination of pregnancy Spontaneous Abortion or Spontaneous Miscarriage Occurs from natural causes Early miscarriage before week 16 Late miscarriage between weeks 16 24 During first 6 weeks, placenta is tentatively attached to decidua, during weeks 6 12, moderate attachment to myometrium. After week 12, attachment is penetrating and deep. Bleeding before week 6 is rarely severe; bleeding after week 12 can be profuse. Assessment: Vaginal Spotting Causes of Spontaneous Abortion 1. Abnormal Fetal Formation due to uterine abnormalities and chromosomal aberration. 2. Immunologic Factors / Rejection of embryo thru immune response 3. Implantation Abnormalities Poor implantation results from inadequate endometrial formation or inappropriate site of implantation Placental circulation cant function adequately and fetal nutrition will be inadequate. 4. Corpus Luteum fails to produce enough progesterone to maintain Decidua Basalis 5. Infection crosses placenta causing fetal death T oxoplasmosis (from cats feces, raw meat) O thers (Syphilis, Varicella (Chicken Pox) or Shingles, Hepa B, HIV) R ubella (causes small children or SGA) C ytomegalo Virus (affects CNS) H Herpes Simplex Virus, Meningitis, Encephalitis 6. Ingestion of Teratogenic Drug (causes adverse effect to the fetus) 7. Ingestion of Alcohol

Threatened Abortion or Miscarriage a. S/S: Bright Red Scant Vaginal bleeding, slight cramping, and no cervical dilatation b. Management Avoid strenuous activity for 24 48 hours. Complete bed rest is usually not indicated. It may stop bleeding for blood is pooling vaginally. During ambulation, bleeding will recur. No Coitus for 2 weeks after bleeding to prevent infection & further bleeding. Drugs: a. Duvadilan (IM, ORAL, Parenteral) b. Ritrodine Hydrochloride c. Terbatuline Sulfate Imminent or Inevitable Abortion a. S/S: Threatened Abortion becomes imminent when theres uterine contractions (cramping) and cervical dilatation. b. Management Save tissue fragments for examination D&C if FHT is absent and fetus is not viable, to prevent infection, and hemmorhage. After procedure, assess bleeding by recording no. of pad (> 1 pad/ hour is considered heavy bleeding) Complete Abortion All products of conception (fetus, membranes, placenta) are expelled spontaneously without any assistance. Management: Emotional Support no need for D&C Incomplete Miscarriage Usually fetus is expelled, but membrane or placenta is retained in the uterus. Management: D&C to evacuate remaining parts to prevent hemorrhage and infection. Missed Miscarriage or Early Pregnancy Failure Fetus dies inside utero but not expelled Assessment a. Fundal height doesnt increase in size b. Absent Fetal Heart Sounds c. (-) Pregnancy Test d. Painless vaginal bleeding (Threatened Miscarriage) or no prior clinical symptoms Management a. Sonogram to check if fetus is dead

b. Dilatation and Evacuation c. If > 14 weeks, induce labor by the ff drugs: Prostaglandin suppository or Misoprostol (Cytotec) to dilate cervix Oxytocin or Mifespristone d. If not terminated can cause DIC if dead fetus remains too long in utero. Recurrent Pregnancy Loss or Habitual Abortion 3 or more consecutive spontaneous miscarriages that occurred at the same gestational age; Women are called Habitual Aborters Causes a. Incompetent Cervix (Premature Cervical Dilatation) b. Defective spermatozoa or ova c. Deviations of uterus (septate or bicornuate) d. Infection e. Endocrine Factors f. Autoimmune disorders (lupus anticoagulant and antiphospholipid antibodies) Complications of Miscarriage 1. Hemorrhage a. Monitor V/S to detect Hypovolemic Shock b. Position: Flat on bed and massage fundus to stimulate contraction c. D&C and Suction Curettage to empty uterus which prevent it from contracting d. Blood Transfusion to replace blood loss e. Direct replacement of fibrinogen or other clotting factor to aid coagulation f. Drug: Methylergonovine Maleate (Methergine) to aid with contraction (if patient is not Hypertensive; of hypertensive give Oxy instead) 2. Infection Danger signs a. Fever - may be systemic reaction; >38 C requires careful evaluation to avoid infection. b. Abdominal Pain or Tenderness c. Foul Vaginal Discharge Usual Causative Agent: E.Coli Management: Teach Client Perineal Hygiene (wipe front to back)

3. Septic Abortion

 Complicated by infection which occurs in women who have tried to self abort or aborted illegally using unsterile instrument such as knitting needle. If untreated can lead to TSS, Septicimia, Kidney Failure, Death If treated can lead to infertility d/t uterine scarring or fibrotic scarring of fallopian tubes. Symptoms a. Fever b. Crampy Abdominal Pain c. Tender Uterus upon palpation Management a. Obtain CBC, Serum Electrolytes, Serum Creatinine, Blood Type, Cross Match b. Obtain Cervical, Vaginal, and Urine Cultures c. Indwelling Catheter to monitor urine output hourly to asses kidney function. d. D&C or D&E to remove infected and necrotic tissue from uterus e. Tetanus Toxoid or Tetanus Immune Globulin IM for prophylaxis against tetanus. f. High Broad Spectrum Antibiotic Drugs: PENICILLIN (gram+), GENTAMICIN (gram -), and CLINDAMYCIN(gram-) 4. Isoimmunization If fetus was RH (+) and mother is RH (-), RH (+) fetal blood may enter maternal circulation to cause ISOIMMUNIZATION Production of antibodies against RH (+) blood. If next child has RH (+) blood, these antibodies will destroy RBCS of next infant inside utero. After miscarriage, women with RH (-) should receive RH (D antigen) and Immune globulin (RhIG) to prevent build-up of antibodies if the fetus was RH (+). 5. Powerlessness and Anxiety Assess adjustment. Sadness and grief over the loss is to be expected.

ECTOPIC PREGNANCY

 Pregnancy Implantation outside uterus, usually in Fallopian Tube Fallopian Tube Sites of Implantation a. 80% in Ampulla (distal 3rd; actual site of fertilization) b. 12% in Isthmus c. 8% in Interstitial or Fimbrial (where tube joins the uterus; most dangerous site) After fertilization, zygote begins to divide and grow. Because obstruction is present, such as adhesion of tube from previous infection such as Chronic Salpingitis or PID, Congenital Malformation, Scars from Tubal Surgery or Uterine Tumor, zygote cant travel along the tube and is implanted there instead in uterus. Assessment 1. No unusual symptoms during implantation 2. No menstrual flow 3. Nausea and Vomiting 4. (+) Pregnancy Test Ruptured Ectopic Pregnancy During 6 12 weeks, zygote grows large to rupture fallopian tube and tears blood vessels. If implantation is in interstitial, Intraperitoneal bleeding may occur Signs and Symptoms a. Sharp, stabbing lower abdominal pain followed by scant vaginal spotting b. Severe Shock (rapid thready pulse, rapid RR, falling BP) c. Leukocytosis from trauma not from infection d. Abdominal Rigidity due to peritoneal irritation e. + Cullens Sign (bluish tinge umbilicus) f. Movement of cervix causes pain during pelvic examination g. Shoulder pain from blood in peritoneal cavity causing phrenic nerve irritation h. Tender mass palpable in Douglas cul-de-sac on vaginal examination. Management 1. Transvaginal Sonogram to see ruptured tube and blood collecting in peritoneum 2. Laparoscopy or Culdoscopy to visualize fallopian tube 3. If discovered before rupture, it can be treated with the ff drugs a. Oral Methotrexate folic acid antagonist chemotherapeutic agent; destroys fast growing cells Continuous until HCG becomes

 Hysterosalpingogram - performed after chemotherapy to assess if tube is fully patent b. Mifepristone - abortifacient; sloughs tubal implantation site c. Advantage : tube left intact w/o scarring that may cause 2nd ectopic implantation 4. IV Fluid using large gauge catheter 5. Laparoscopy to ligate and remove bleeding vessels and repair damaged fallopian tube. Surgery: a. Fallopian Salphingectomy b. Abdominal Exploratory Laparotomy c. Uterus Hysterectomy

ABDOMINAL PREGNANCY
Fetus grows inside abdominal cavity such as in the Intestine Magnetic Resonance Imaging (MRI) to reveal fetus outside uterus Signs and Symptoms a. Fetal Outline easily palpable b. Woman not aware of movements or has painful fetal movements and abdominal cramping with movements c. Sudden lower quadrant pain Placenta will penetrate and erode a major blood vessel inside abdomen. If implanted on intestine, it may erode deeply that causes bowel perforation and peritonitis. High fetal risk because w/o good uterine supply, nutrients may not reach fetus. In infants who survived, theres threat of fetal deformity or growth restriction. At term, infant must be delivered by Laparotomy Placenta is difficult to remove in intestine. It may be left in place and allowed to absorb in 2 or 3 months or may be treated w/ Methotrexate to help absorb placenta

Conditions associated with 2nd trimester bleeding (4 6 mos)

1. Gestational Trophoblastic Disease (Hydatidiform mole) Abnormal proliferation and degeneration of trophoblastic villi Abnormal overgrowth of trophoblastic tissue Appear as clear fluid filled, grape sized vesicles Embryo fails to develop Associated with Choriocarcinoma (rapidly metastizing malignancy) Woman who have one incidence of Hmole have high risk of 2nd Hmole. Tends to occur in women a. Low protein intake b. 35 y/o and above c. Asian Heritage a. Complete Mole All trophoblastic villi swell and become cystic If embryo forms, it dies early at 1 2 mm in size with no fetal blood supply. Chromosome was duplicated (46 XX or 46 XY) and contributed by the father or an empty ovum. b. Partial Mole Some villi form normally and Syncytiotrophoblastic layer of villi is swollen and misshapen. Macerated embryo of 9 weeks AOG Fetal blood supply present Has 69 chromosomes (triploid formation; 3 chromosomes instead of 2 for each pair) Rarely lead to choriocarcinoma HcG lower than complete mole and return to a normal faster mole evacuation. Assessment 1. Uterus expands faster 2. Absent Fetal Heart Sounds 3. (+) HcG in Serum or Urine test ( produced by trophoblast cells that are ; 1 2 million IU compared with normal pregnancy of 400,000 IU) 4. Nausea and Vomiting because of HcG level 5. PIH Symptoms arent present before week 20 (Hypertension, Proteinura, Edema) 6. Snowflake pattern in sonogram 7. If not identified by sonogram, during WEEK 16: Vaginal spotting of DARK BROWN BLOOD with clear fluid filled grapelike vesicles Interventions

1. Suction Curettage to evacuate mole. 2. Assess HcG level every 2 weeks until levels are again normal. Thereafter, levels are assessed every 4 weeks for 6 12 months. Gradually declining hCG suggest no complication. Levels that plateu for three times or increase suggest malignancy. 3. Woman cant be pregnant for a year and should use reliable contraceptive for 12 months. After 6 months if hCG still (-), theres no malignancy. By 12 months, she could plan 2nd pregnancy. 4. Drug for Choriocarcinoma: Methotrexate

PREMATURE CERVICAL DILATATION (INCOMPETENT CERVIX) Cervix dilates prematurely approximately during week 20 Signs and Symptoms 1. Painless Dilatation 2. Pink stained vaginal discharge or increased pelvic pressure ROM Discharge of Amniotic Fluid Uterine Contractions Preterm Birth Associated with: 1. Increased Maternal Age 2. Congenital Structural Defects 3. Trauma to cervix (biopsy or repeated D&Cs) Management 1. Cervical Cerclage Surgical operation to prevent cervix from dilating prematurely during 2nd pregnancy. If sonogram confirms 2nd pregnancy is healthy, at 12 14 weeks purse string sutures are placed inside cervix under regional anesthesia to strengthen cervix and prevent it from dilating. Sutures are removed at 37 38 weeks so fetus can be born vaginally. a. Mc Donald nylon sutures placed horizontally & vertically across cervix to reduce cervical canal to a few millimetres in diameter. b. Shirodkar Sterile tape threaded in a purse string manner under submucous layer of cervix to achieve a closed cervix. Post Surgery Intervention: Bed rest in slight or modified Trendelenburg to decrease pressure on new sutures. Conditions Associated with Third Trimester Bleeding (7 9 months)

1. Placenta Previa (Unavoidable Hemmorhage) Low implantation of placenta so that it crosses cervical os Occurs in 4 degrees and estimated in % a. Low lying implantation in lower portion of uterus b. Marginal implantation placenta edge approaches cervical os c. Partial placenta previa implantation in a portion of cervical os d. Total Placenta previa implantation that totally obstructs cervical os Bleeding occurs when lower uterine segment differentiates from upper uterine segment approximately during week 30 and cervix begins to dilate Bleeding results from placentas inability to stretch to accommodate differing shape of lower uterine segment or cervix. Site of bleeding is uterine deciduas (maternal blood), that places mother at risk for hemmorhage and because placenta is loosened, fetal oxygen may be compromised and preterm birth can occur. Predisposing Factors a. Increased Parity b. Advanced Maternal Age c. Past CS births d. Past Uterine Curettage e. Multiple Gestation f. Male Fetus Assessment a. Abrupt, Painless, Bright Red Bleeding b. Soft Fundus upon palpation Nursing Management (Immediate Care) a. Position: Side Lying b. Assess the ff: Duration of pregnancy, time of bleeding began, estimation of blood loss in terms of cups or tablespoon (1 cup is 240 ml and 1 teaspoon is 15ml) Presence of Pain Color of blood (redder blood indicates bleeding is fresher or continuing) What she has done for bleeding (if tampon is inserted to halt bleeding) Prior episodes of bleeding Prior cervical surgery for premature cervical dilatation c. Inspect perineum for bleeding and estimate blood loss rate. d. Weigh perineal pads before and after use and calculating the difference by subtraction.

e. f. g. h. i. j.

APT or KLEIHAUER BETKE TEST test strip to detect if blood is fetal or maternal NEVER attempt pelvic or rectal exam may initiate massive hemmorhage. Monitor V/S to determine presence of shock and assess BP every 5 15 mins IV Fluid using large gauge catheter Monitor urine output every hour External fetal monitoring, record fetal heart sounds and uterine contractions. Internal monitor is contraindicated. k. Determine placenta location accurately in a hope for its position will make vaginal birth possible. If placenta is under 30%, it may be possible for fetus to be born past it. If 30% and fetus is mature, safest birth method is CS. l. Abdominal Exam reveals fetal head isnt engaged b/c of interfering placenta. m. Ready oxygen in case of fetal distress CONTINUING CARE a. Bed rest for 48 hours b. Assess fetal heart sounds c. Assess Hgb & Hct d. BETAMETHASONE, a steroid to encourage maturity of fetal lungs if fetus is < 34 weeks PREMATURE SEPARATION OF PLACENTA (ABRUPTIO PLACENTA) Accidental Hemmorhage, Concealed Hemmorhage, and Utero Placental Apoplexy Placenta separates from uterus during 1st or 2nd stage of labor and bleeding occurs. This separation immediately cuts off blood supply to the fetus. Predisposing factors: a. High parity b. Advanced Maternal Age c. Short Umbilical Cord d. Chronic Hypertensive Disease (Hypertension) e. Acute Infection f. Fibrin Defects g. PIH h. Trauma or Injury (automobile accident or intimate partner abuse) i. Vasoconstriction from cocaine or cigarette use j. Thromboplitic conditions that lead to thrombosis such as Autoimmune antibodies, Protein C, & Factor V Leiden (inherited thrombophilia)

Assessment 1. Sudden Sharp, Stabbing pain high in uterine fundus as initial separation occurs. 2. External Bleeding placenta separates first at the edges 3. Internal Bleeding - placenta separates first at the center, blood pools under placenta and is hidden and may infiltrate Uterine Musculature (COUVELAIRE UTERUS or UTEROPLACENTAL APOPLEXY), forming a Hard, Board like Uterus without apparent or minimally apparent bleeding. 4. Uterus becomes tense and feels rigid to touch (Abdominal Rigidity) Management 1. Position: Left Lateral to prevent uterine pressure on vena cava and interference with fetal circulation. 2. Large gauge IV Catheter for fluid replacement 3. Oxygen by mask to limit fetal anoxia (absence of oxygen) 4. External Fetal Monitoring of FHT 5. Monitor Maternal V/S every 5 15 mins 6. Do not perform vaginal or pelvic exam and dont give enema

DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

Acquired Blood Clotting Disorder w/c fibrinogen level falls below effective limits. Early Symptoms: early bruising, petechiae, and bleeding from IV Site Associated with the ff: a. Abruptio Placenta b. PIH c. Septic Abortion d. Placental Retention e. Retention of Dead Fetus f. Amniotic Fluid Embolism Drug: HEPARIN to stop local coagulation and free clotting factors for systemic use.

PRETERM LABOR
Labor after 20 weeks and before the end of 37th week of pregnancy Persistent uterine contractions every 10 minutes for 1 hour and dilatation begin. Associated with: a. Dehydration b. Urinary Tract Infection (UTI) c. Chorioamnionitis (infection of the fetal membranes and fluid) d. Inadequate prenatal care e. Strenuous jobs or perform shift work that leads to extreme fatigue Management a. Analyze vaginal mucus changes FETAL FIBRONECTIN, a protein produced by Trophoblast Cells that predicts preterm contractions will occur; absence predicts labor will not occur for at least 14 days b. Bed rest to relieve pressure of fetus on the cervix c. IV Therapy because hydration help stop contractions. If dehydrated, pituitary gland is activated and may release oxytocin, which strengthen uterine contractions. d. Drink enough fluids e. Administration of Drugs as Ordered a. Oral Tocolytic Agent such as ORAL TERBUTALINE to halt labor Can administer if cervix is <4cm dilated, <50% effaced, membranes are intact. b. Magnesium Sulfate Drug of choice to halt contractions. Classified as CATHARTIC Has CNS depressant action that slows and halts contractions. c. Ritodine Hydrochloride (Yutopar) d. Beta sympathomimetic e. Antibiotic for Group B Streptococcus prophylaxis. f. Corticosteroids accelerate formation of lung surfactant such as BETAMETHASONE to attempt to hasten fetal lung maturity.

Labor that cannot be halted

1. If membranes are ruptured or cervix is >50% effaced and >3-4%cm dilated, labor cant be halted. The rupturing of the membranes can be thought as the point of no return 2. If fetus is very immature, CS may be planned to reduce pressure on fetal head and possibility of subdural or intraventricular hemmorhage from vaginal birth 3. Because of the increased risk of Prolapse of the Cord around a small head, Amniotomy (artificial ruputure of membranes) is not done until head is firmly engaged. 4. ANALGESICS ADMINISTERED WITH CAUTION because of the immaturity of fetus. Fetus will have difficulty breathing at birth. For pain relief, use EPIDURAL ANESTHESIA. 5. Delaying rupture of the membranes is another factor that prolong first stage of labor. 6. Woman may need episiotomy incision larger than usual because excessive pressure can result in subdural or intraventricular hemmorhage. 7. Cord is clamped asap rather waiting for the pulsation to stop because immature infant has difficult time to excrete large amounts of Bilirubin that will be formed if this extra blood is added to circulation and could overburden circulatory system.

Premature Rupture of Membranes (PROM)

Rupture of fetal membranes with loss of amniotic fluid before 37th week. (First Stage of Labor in Active Phase) Cause is unknown but associated with Chorioamnionitis EPROM (Early Rupture of Membranes which occurs earlier than Active Phase) Complications: a. Uterine and fetal infection b. Increased pressure on the cord from loss of Amniotic Fluid, inhibiting Fetal Nutrition c. Cord prolapsed Extension of cord out of the uterine cavity into the vagina Most apt to occur when fetal head is still so small to fit cervix d. Potter Like Syndrome or Distorted Facial Features e. Pulmonary Hypoplasia from pressure f. Preterm labor may follow ROM Assessment 1. Sudden gush of clear fluid from vagina, usually mistaken as urinary incontinence 2. Amniotic Fluid cant be differentiated from urine by appearance, so sterile vaginal speculum is done to observe for vaginal pooling of fluid. Tests:

a. Nitrazine Paper Amniotic fluid has alkaline reaction and remains blue Urine has acidic reaction and remains yellow b. Fern test to differentiate amniotic fluid to urine 3. Associated with Vaginal Infection, so culture of Neiserriae Gonnorhea, Streptococcus P., and Chlamydia are taken. Management: 1. Avoid routine vaginal exam because of the risk of infection rises when digital examinations are performed after PROM. 2. If fetus is estimated to be mature enough to survive during rupture and labor doesnt begin within 24 hours, labor contractions are induced by IV administration of oxyctocin. 3. Positions: a. Trendelenburg b. Knee chest position c. Lithotomy (8-9cm dilatation) 4. Bed Rest if labor doesnt begin and fetus is near at point of viability. 5. Administration of Drugs as ordered: a. Betamethasone - Corticosteroid to hasten fetal lung maturity b. Prophylactic administration of broad spectrum antibiotics may delay onset of labor and reduce risk of infection enough to allow corticosteroid to effect. 6. Endoscopic intrauterine procedures, membranes can be resealed by the use of FIBRIN based commercial sealant so they are intact again.

PREGNANCY INDUCED HYPERTENSION (TOXEMIA)

 Vasospasm occurs during pregnancy in small and large arteries (spastic arteries) The cause is still unknown Originally called TOXEMIA, because researchers pictured a toxin produced by woman in response to foreign protein produced by fetus which leads to the typical symptoms. 3 Triads or Signs 1. Hypertension 2. Proteinuria 3. Edema Associated with the ff: 1. Multiple Pregnancy 2. Primiparas younger than 20 years old or older than 40 years old. 3. From low socio economic backgrounds (because of poor nutrition) 4. Hydramnios (>2,000ml of Amniotic Fluid or above 24cm index) 5. Heart disease, diabetes with vessel or renal involvement, and hypertension (without history) 6. Chronic Hypertensive Disease (when theres history of hypertension) Pathophysiology The symptoms affect almost all organs. Vascular spasm may be caused by INCREASED CARDIAC OUTPUT that INJURES ENDOTHELIAL CELLS of the arteries and the action of prostaglandins. Vascular Spasms causes 1. Vascular Effect Vasoconstriction Poor Organ Perfusion Hypertension 2. Kidney Effects Decreased Glomerular Filtration Rate (GFR) and Increased Permeability of Glomerular Membranes Increased BUN, Uric Acid and Creatinine Oliguria and Proteinuria 3. Interstitial Effects Diffusion of fluid from blood stream to interstitial tissue edema

1. Gestational Hypertension

a. b. c. d.

Elevated BP of 140/90 mmHg OR Elevated Systolic pressure of 30 mmHg OR Elevated Diastolic pressure of 15mmHg above pre- pregnancy level NO PROTEINURIA AND EDEMA

Management: Monitor V/S; BP returns to normal after birth. No drug therapy is necessary. Mild Preeclampsia 1. Elevated BP of 140/90 mmHg taken on 2 occasions 6 hours apart OR 2. Systolic pressure elevated 30 mmHg OR 3. Diastolic elevated 15mmHg above prepregnancy level 4. PROTEINURIA of 1 2+ on Reagan Test strip on random sample. ORTHOSTATIC PROTEINURIA in long periods of standing they excrete protein at bed rest they dont. 5. MILD EDEMA b/c of protein loss, sodium retention, and GFR; accumulation in the upper part of body or facial edema 6. Weight gain > 2lbs per week in 2nd trimester and > 1 lb per week in 3rd trimester indicates abnormal tissue fluid retention. Nursing Interventions with Mild PreEclampsia 1. Promote Bed Rest: Lateral Recumbent Sodium is excreted at a faster rate than during activity Avoids uterine pressure on vena cava & prevent supine hypotension 2. Promote Good Nutrition Continue usual pregnancy diet. Sodium restriction no longer true may result in renin-angiotensin aldosterone system and result in increased BP 3. Promote Emotional Support

Severe Preeclampsia

1. Elevated BP of 160/110 above on 2 occasions 6 hours apart at BED REST (position in which blood pressure is lowest) OR 2. Diastolic pressure is 30mmHg above pre-pregnancy level. 3. PROTEINURIA of 3 4+ on a random sample and 5g on a 24 hour sample 4. OLIGURIA(<600ml in 24 hours or <30ml per hour; Normal Urine: 1,200 ml in 24 hours) 5. EXTREME EDEMA in face and hands and can be palpated over bony prominences: a. tibia on anterior leg b. ulnar surface of forearm c. cheekbones Grading of Edema a. Non pitting: fingers are not indented with pressure b. 1+ - slight (pedal edema) c. 2+ - moderate (anasarca) d. 3+ - deep e. 4+ - indentation is so deep it remains after removal of finger (pitting edema) 6. Pulmonary Edema causes shortness of breath 7. Cerebral Edema causes a. visual disturbances (blurring of vision and spots) b. severe headache c. hyperflexia d. Ankle clonus 8. Abdominal Edema or Ischemia of Liver or Pancreas causes a. Severe Epigastric Pain b. Nausea and Vomiting 9. Hepatic Dysfunction 10. Thrombocytopenia (<100,000 /mm3 of Platelet count) Nursing Intervions with Severe Pre-eclampsia 1. Bed Rest Woman should be undisturbed (admitted in private room and visitors restricted to support people to avoid loud noise that can trigger seizure) Raise Side Rails to prevent injury if seizure should occur. Darken the room (dim light) for bright light can trigger seizures. Not so dark that flashlight will be used to make assessments. Shining a flashlight into womans eyes is the sudden stimulation to be avoided. Avoid Stress which increases BP and stimulate seizures 2. Monitor Maternal V/S

 Monitor BP at least every 4 hours; An increase indicates condition is worsening. Obtain Blood Studies CBC, Platelet Count, BUN, Creatinine to assess liver and renal function and development of DIC, which often accompanies severe vasospasm; Because shes at risk of Abruptio Placenta and resulting hemmorhage, blood type and cross match is drawn; daily hematocrit level to monitor blood concentration. Weigh client daily at same time each day to evaluate tissue fluid retention (ensure woman is wearing same weight of clothing as before) Indwelling Urinary Catheter (Folly) to monitor urine output and compare with input (should be >600ml in 24 hours or >30ml in an hour) 24 hour urine sample for protein and creatinine to evaluate kidney function. 3. Monitor Fetal Well Being External Monitoring of FHB or FHT Oxygen administration to mother to maintain fetal oxygenation. 4. Nutritious Diet Diet high in protein and moderate in sodium 5. Administer Medications to Prevent Eclampsia Drug Hydralazine (Apresoline) Pregnancy Risk Catergory C Indication Antihypertensive (peripheral vasodilator) to decrease BP Dosage 5 10 mg/IV Nsg Implication Administer slowly to avoid sudden fall of BP. They can cause Tachycardia (Increase Heart Rate) Maintain Diastolic over 90 mmHg to ensure adequate placental filling Given in loading or Administer as IV bolus dose. PIGGYBACK Loading dose: 4 6g/h IV Maintenance Dose: 1 2 g/h IV Given in loading dose for 15 30 minutes. Drug acts asap but effect is only 30 60

Magnesium Sulfate (MgSo4)

Muscle Relaxant Prevents Seizure

Pregnancy Category Classified as B cathartic that reduces edema CNS depressant to

prevent seizures

minutes so continuous administration is needed Assess Toxicity Always prepare when administering MgS04

Calcium Gluconate MgSo4 Toxicity Pregnancy Category C

10ml of 10% Calcium Gluconate Solution 1g/ hour IV

Symptoms of Magnesium Sulfate Toxicity 1. Decreased urine output (<30ml per hour or <600ml in 24 hours) 2. Decreased Respirations (<12 cpm) 3. Reduced Level of Consciousness 4. Decreased Deep Tendon Reflexes Before administration ensure the ff: 1. Urine output > 30ml/hour with a specific gravity of 1.010 or lower 2. Respirations >12cpm 3. Can answer questions asked to her 4. Minimal Ankle Clonus (continued motion of foot) 5. Deep Tendon Reflexes by assessing Patellar Reflex (kneejerk)

Eliciting Patellar Reflex

Position woman in supine and ask to bend knee slightly. Place your hand under her knee to support the leg. Locate patellar tendon in the midline just below knee cap. Strike using a percussion or reflex hammer. If the leg and foot move, pattelar reflex is present. Scoring a. 0 = no response; hypoactive; abnormal b. 1+ = somewhat diminished response but not abnormal c. 2+ = average response d. 3+ = brisker than average but not abnormal e. 4+ = hyperactive; very brisk; abnormal

Eliciting Ankle Clonus

In supine, dorsiflex foot 3x in rapid succession. As you take your hand away, observe the foot. If no further motion is present, no ankle clonus is present. Usually rated as absent or present, Scoring: a. Mild 2 movements b. Moderate 3 5 movements c. Severe more than 6 movements Eclampsia Seizure or coma accompanied by S/S of preeclampsia Usually happens late in pregnancy up to 48 hours after birth. Goal: a. To be free from injury b. To regain homeostasis c. To maintain fetal oxygenation Implementation a. Maintain Patent Airway b. Suction to prevent aspiration c. Protect Mother from injury d. Monitor Signs of Abruptio Placenta e. Monitor FHT f. Note Nature, Onset, and Progression of seizure g. Administer Medications as ordered 1. Oxygen Administration

Stages of Eclampsia
Stage Aura (Momentary Sensation) Time Appearance of Mother Woman senses convulsion (something is happening) by seeing bright stars, smells sharp foul odor, and epigastric pain due to ischemia of pancreas Muscles contract Back Arches Intervention

Tonic

20 seconds

Maintain Patent Airway. Dont put anything inside

Woman appears stiff (arms and legs are stiff) Jaw closes abruptly and may bite tongue Respirations halted causing client to be cyanotic (d/t contraction of Thoracic Muscles)

mouth or tongue depressor. May cause broken teeth that can be aspirated Position on Left Lateral to drain secretions and prevent aspiration O2 Administration thru face mask to maintain fetal oxygenation Monitor womans oxygen saturation by pulse oximeter External Fetal Monitoring Needs continuous oxygenation of mother to maintain fetal oxygenation Administer as ordered: MgS04 to halt seizures OR Diazepam Valium UV

Clonic

20 secs 1 min

All muscles contract and relax rhythmically Inhales and exhales irregularly and respirations are noisy and uneven Saliva can be aspirated if not positioned on the left side Bowel and Bladder muscles contract and relax and incontinence of urine and feces occurs

Postictal

Still halted respirations and remain cyanotic 1 min to 1 Semi Comatose 4 hours Aroused only by a painful

Monitor FHB Monitor Uterine

stimuli

Contractions Monitor Vaginal Bleeding every 15 mins Monitor Signs of Abruptio Placenta (for woman may not feel contractions) Position on left side to drain secretions NPO Avoid stimuli may initiate another seizure Hearing is the sense that is lost and regained first

BIRTH If pregnancy is >24 weeks, birth decision will be made as soon as womans condition stabilizes, usually 12 24 hours after seizure. There is evidence that fetus doesnt continue to grow after eclpamsia, so terminating pregnancy at this time is appropriate for both mother and child. For an unexplained reason, fetal lung maturity appears to be advanced rapidly, so even the fetus is <36 weeks, lecithin sphingomyelin may indicate fetal lung maturity CS birth is not recommended because of association of retained lung fluid. Woman is not a good candidate for surgery. Because her intravascular blood volume is low, she may become hypotensive with regional anesthesia such as epidural block. Preferred method is NSVD. If labor doesnt begin spontaneously, rupture of membranes or induction of labor with IV oxytocin may be given. If this is ineffective, and the fetus appears imminent danger, CS is indicated. Postpartum Hypotension Usually occurs 48 hours after birth up to 10 14 days after birth. Mgt: Monitor blood pressure to detect residual hypertension or renal disease.

Types of occurrence of PIH: 1. Antepartum convulsion and coma occurs before the onset of labor pains, most severe that increases risk of fetal and maternal mortality 2. Intrapartum occurs during labor, OB wasnt able to sedate patient 3. Post Partum occurs within 24 hours up to 10 14 days; mildest OTHER DRUGS USED IN PIH Diazepam (Valium) Halt seizures Pregnancy Risk Category D

5 10 mg/IV

Administer slowly Dose may be repeated every 5 10 min up to 30 mg /hr Observe Respiratory Depression or Hypotension in mother Observe Respiratory Depression and Hypotonia in infant at birth

HELLP SYNDROME
Variation of PIH named for the common symptoms that occur: a. Hemolysis of RBCS b. Elevated Liver enzymes (Alanine Aminotransferase (ALT); Serum Aspartate Amino Transferase (AST); due to hemmorhage and necrosis of liver) c. Low Platelet Count (Thrombocytopenia <100,000/mm3) Symptoms: a. Nausea b. Epigastric pain c. General Malaise d. RUQ tenderness from liver inflammation Associated with both Primigravida and Multigravida Management: IMPROVE PLATELET COUNT a. Transfusion of fresh frozen plasma or platelets b. Check maternal hemmorhage at birth because of poor clotting ability.

 Complications: a. Subcapsular Liver Hematoma b. Hyponatremia c. Renal Failure d. Hypoglycemia (corrected by IV dextrose infusion) Infant delivered via Vaginal or CS Maternal Hemmorhage may occur at birth b/c of poor clotting ability Epidural Anesthesia not possible b/c of low platelet count that can increases possible bleeding at epidural site.

HYDRAMNIOS (POLYHYDRAMNIOS)
2,000ml or amniotic fluid index above 24cm Normal Amniotic Fluid at term is 500 1,000 ml Complication: a. Fetal Malpresentation b/c of additional uterine space allows the fetus to turn. b. PROM d/t increased pressure and possible prostaglandin release. Assessment 1. Accumulation suggests difficulty of fetuss ability to swallow or absorb excessive urine production which occurs in infants who are anencephalic or who have tracheoesophageal fistula with stenosis or intestinal obstruction. Excessive urine output occurs in fetuses of diabetic women (hyperglycemia) 2. Rapid enlargement of uterus 3. Small parts of fetus are difficult to palpate because uterus is tense. 4. Auscultation of FHT is difficult 5. Extreme shortness of breath (overly distended uterus pushes up against diaphragm) 6. Lower extremity varicosities and hemmorhoids Management 1. Bed Rest to uteroplacental circulation & reduce cervix pressure to help prevent preterm labor. 2. Assess V/S 3. Assess Lower extremity edema 4. Possible Amniocentisis to remove some amniotic fluid

5. In most instances of hydramnios, there will be PROM due to excessive pressure, followed by preterm labor. To prevent sudden loss of fluid and danger of prolapsed cord, membranes can be needled to allow a slow, controlled release of fluid.

POST TERM PREGNANCY / POSTMATURE / POSTDATE

Pregnancy that exceeds the normal 38 42 weeks Placenta detoriates which causes inadequate nutrition to fetus. Infant is considered post mature or dysmature Assessment: 1. Meconium Aspiration 2. If fetus continues to grow, MACROSOMIA could create a birth problem. However the usual effect is lack of growth. 3. Lack of oxygen, fluid, and nutrients to the fetus. 4. Oligohydramnios (<Amniotic fluid from lessened urine production of fetus) can lead to variable decelerations from cord compression.

Drug: Prostaglandin Gel or Misoprostol (Cyototec) applied to cervix to initiate ripening or stripping of membranes followed by OXYTOCIN to begin labor. If ineffective, CS birth

PSEUDOCYESIS (FALSE PREGNANCY)

Womans body responds to physiologic symptoms such as breast tenderness, nausea and vomiting, amenorrhea, enlarging abdomen in non pregnant woman and can also be in men. Causes: a. Wish fulfilment theory: desire to be pregnant b. Conflict theory: fear of pregnancy c. Depression theory: attributes causes to major depression

MULTIPLE GESTATION
Puts additional strain to womans physical resources and may lead to preterm birth with immaturity of infant. Management: Help woman obtain adequate nutrition and rest during pregnancy