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Ectopic pregnancy

Symptoms include lower abdominal and pelvic pain; amenorrhea, possibly followed by vaginal
spotting or bleeding; and a palpable adnexal mass on pelvic examination. An ectopic pregnancy
may implant in one of many locations outside the uterine cavity, including the fallopian tubes,
ovaries, or abdominal cavity.
As the ectopic pregnancy outgrows its environment, it may rupture, causing life-threatening
maternal hemorrhage.
Symptoms indicative of a ruptured ectopic pregnancy include hypotension,
tachycardia, dizziness, and referred shoulder pain. Shoulder pain results from irritation of the
diaphragm by intraabdominal blood.
A ruptured ectopic pregnancy is a surgical emergency and requires immediate intervention.

Important preconception education topics


Folic acid supplementation at least 400 mcg per day reduce the incidence of neural tube
defects. fortified grain products (eg, cereals, bread, pasta) and green, leafy vegetables. alternate
sources include beans, rice, peanut butter
Appropriate dental care and vaccinations. Periodontal disease is associated with adverse
pregnancy outcomes, including preterm birth and low birth weight
Avoidance of alcohol, smoking, and illicit drugs. Smoking is associated with fetal growth
restriction
Clients who are not immune to rubella should be vaccinated and avoid pregnancy for at least 4
weeks after vaccination
Clients should also attempt to achieve normal weight (BMI of 18.5-24.9 kg/m2) before
conceiving to improve outcomes. Obesity (BMI >30 kg/m2) during pregnancy is associated with
increased risk for fetal/maternal complications (eg, birth defects, gestational diabetes, pregnancy-
related hypertension, fetal macrosomia).

Normal laboratory values during third trimester


Hemoglobin >11 g/dL (110 g/L)
Hematocrit >33% (0.33)
Red blood cells 5.00-6.25 x 106/mm3
White blood cells 5,000-15,000/mm3
Platelets 150,000-400,000/mm3

Pregnant women experience an increase in total blood volume to meet the increased oxygen
demand and nutritional needs of the growing fetus and maternal tissues. The increase in plasma
volume is greater than the increase in red blood cells, creating a hemodiluted state termed
physiologic anemia of pregnancy

Placenta previa
an abnormal implantation of the placenta resulting in partial or complete covering of the cervical
os (opening). The condition is diagnosed by ultrasound. In clients reporting painless vaginal
bleeding after 20 weeks gestation, placenta previa should be suspected. Placenta previa found
early in pregnancy may resolve by the third trimester
As pregnancy progresses, the placenta grows in size and can potentially migrate away from the
cervical opening, resulting in complete resolution of the previa. Therefore, an additional
ultrasound is usually performed around 36 weeks gestation to assess placental location
persistent placenta previa or hemorrhage require cesarean birth.
The nurse should initiate electronic fetal monitoring and pad counts, draw a type and screen, and
initiate large-bore IV access. Digital vaginal examinations are contraindicated.
at risk for hemorrhage. Vaginal examinations are contraindicated, and pelvic rest is
recommended to prevent disruption of placental vessels. A cesarean birth is planned prior to
onset of labor.

Hyperemesis gravidarum (HG)


severe, persistent nausea and vomiting during pregnancy. Excessive loss of gastric contents leads
to fluid and electrolyte imbalances (eg, hypokalemia, hyponatremia), metabolic alkalosis,
nutritional deficiencies, ketonuria, and weight loss
expect signs and symptoms of dehydration (eg, dry mucous membranes, poor skin turgor,
decreased urine output, tachycardia)
Urine is concentrated with dehydration, indicated by increased specific gravity
(>1.030). Ketonuria indicates that the body is breaking down fat to use for energy due to the
client's starvation state
low blood pressure would be expected due to hypovolemia.

Indirect Coombs testing


screens for Rh sensitization in Rh-negative mothers. If the test results are positive, the fetus and
subsequent pregnancies are at risk for serious complications. Rh immune globulin (eg,
RhoGAM) is given at 28 weeks gestation and within 72 hours postpartum as well as any time
there is maternal trauma. RhoGAM is not effective once sensitization has occurred.

Postpartum hemorrhage
defined as maternal blood loss of >500 mL after a vaginal birth or >1000 mL after a cesarean
birth.
A potentially life-threatening condition that should be addressed immediately.
Saturating a peripad in 1-2 hours could indicate hemorrhage, a life-threatening condition.
characterized by a soft, "boggy," and poorly contracted uterus, is the most common cause of early
PPH (occurring ≤24 hours after birth). Delayed PPH (>24 hours after birth) usually results from
retained placental fragments associated with a long third stage of labor (ie, time from birth of
baby to expulsion of placenta, lasting >30 minutes).
The nurse should first assess the fundus and massage it if boggy. The nurse should also assess
the client's vital signs and should never leave the client alone.
Risk factors for PPH include:
 History of PPH in prior pregnancy
 Uterine distension due to:
o Multiple gestation
o Polyhydramnios (ie, excessive amniotic fluid)
o Macrosomic infant (≥8 lb 13 oz [4000 g])
 Uterine fatigue (labor lasting >24 hours)
 High parity
 Use of certain medications:
o Magnesium sulfate
o Prolonged use of oxytocin during labor
o Inhaled anesthesia (ie, general anesthesia)
Uterine atony
Excessive postpartum bleeding is most commonly caused by uterine atony. fundus is elevated
above the umbilicus and deviated to the right, indicating a distended bladder.
Bladder distension prevents the uterus from contracting sufficiently to control bleeding at the
previous placental site. The client should be assisted to void to correct the bladder distension.
then perform fundal massage.
Signs of pregnancy
Subjective (presumptive)
Are self-reported by a client. This client's symptoms could originate from pathologic causes (eg,
urinary tract infection [UTI], sexually transmitted infection), but collectively these symptoms
may be indicative of early pregnancy. Any client with possible signs/symptoms of early
pregnancy should be asked about menstrual history
Subjective (self-reported) signs of pregnancy may include leucorrhea (white discharge), breast
tenderness, and urinary frequency, amenorrhea, n/v, quickening, excessive fatigue.
Objective (probable)
 Uterine & cervical changes
o Goodell sign
o Chadwick sign
o Hegar sign
o Uterine enlargement
 Braxton Hicks contractions
 Ballottement
 Fetal outline palpation
 Uterine & funic souffle
 Skin pigmentation changes
o Chloasma
o Linea nigra
o Areola darkening
 Striae gravidarum
 Positive pregnancy tests
Positive (diagnostic)
 Fetal heartbeat heard with Doppler device
 Fetal movement palpated by health care provider or visible fetal movements
 Visualization of fetus by use of ultrasound
Iron deficiency anemia
common complication during pregnancy.
diagnosed with anemia when hemoglobin is <11 g/dL (110 g/L) in the first or third trimesters, or
<10.5 g/dL (105 g/L) in the second trimester.

Discomfort of pregnancy
Constipation is a common. It is best treated with 10-12 cups of fluid daily, a high-fiber
diet/supplementation, and regular exercise. Clients should not take laxatives without first
discussing this with the health care provider.
dairy products should be consumed at least 2 hours before or 1 hour after iron supplements as
they bind to iron and decrease absorption.
Pyrosis, or heartburn. Lifestyle changes to reduce symptoms include maintaining an upright
position after meals, eating small meals, drinking fluids between meals, and avoiding trigger
foods (fried fatty food, caffeine, chocolate, citrus, peppermint, tomato, spicy, carbonated drinks).
Avoid tight fitting clothes.
Morning sickness- characterized by nausea with or without vomiting, is a common problem
during the first trimester. can happen anytime throughout the day.
Relieved through lifestyle and dietary changes, including eating small and frequent meals,
drinking cold fluids between meals, having a high-protein snack before bedtime and on
awakening, and consuming foods/drinks containing ginger and vitamin B6.
Prescriptions are contraindicated in pregnancy
Doxycycline- can impair bone mineralization in the fetus
Isotretinoin (Accutane)- causes severe birth defects
ACE inhibitors (pril).- affect kidney development in the fetus.
angiotensin II receptor blockers (sartan) -teratogenic, leading to fetal renal and cardiac
abnormalities
NSAIDs (Ibuprofen, indomethacin, naproxen) should be avoided in the third trimester due to risk
of premature closure of the fetal ductus arteriosus. NSAIDs should be taken only under the
direction and supervision of a health care provider during the first and second trimesters.

Uterotonic drugs
eg, oxytocin [Pitocin]) are used to induce or augment labor and to stop postpartum hemorrhage by
promoting uterine contractions. Oxytocin must be administered via infusion pump and
requires continuous electronic fetal monitoring as it is a high-alert medication. The nurse
assesses and documents the fetal heart rate and contraction pattern every 15 minutes during the
first stage of labor with oxytocin. Most oxytocin protocols dictate gradual titration to achieve
contractions every 2-3 minutes.
Tachysystole (ie, ≥5 contractions in 10 minutes) is a potential adverse effect of
oxytocin. Excessive uterine contractions can decrease placental blood flow and compromise fetal
oxygenation. Treatment of tachysystole may include decreasing or stopping oxytocin infusion
and administering IV fluid bolus and/or tocolytic drugs (eg, terbutaline)
Preterm birth
defined as birth before 37 weeks and 0 days gestation. Infection (eg, periodontal disease, urinary
tract infection) is strongly associated with preterm labor, particularly when untreated. risk factors
include history of preterm birth, previous cervical surgery, tobacco/illicit drug use, Maternal
undernutrition, and maternal age <17 or >35.

Zika infection
in a pregnant woman can cause birth defects and developmental dysfunction. Current guidelines
recommend that pregnant women avoid travel to Zika-affected areas.
transmitted via mosquitoes, sexual contact, and infected bodily fluids. Zika causes viral
symptoms (eg, low-grade fever, arthralgias) and has been shown to
cause microcephaly, developmental dysfunction, and encephalitis
living in a Zika-affected area, proper mosquito precautions (eg, insect repellant containing
DEET) and safe sex practices (eg, barrier methods) should be utilized, and routine Zika testing
may be provided.

Naegele's rule
Provides a quick determination of the estimated date of birth (EDB).
EDB = (LMP - 3 months) + 7 days.

Urinary tract infection (UTI)


Most common bacterial infection during pregnancy
Symptoms include frequency, dysuria, urgency, foul-smelling urine, sediment/pus/blood in the
urine, or sensation of bladder fullness.
Diagnosis is made on signs/symptoms and urinalysis.
The prescribed antibiotic course must be completed to treat the infection appropriately.
The priority is to deal with the current infection. If the UTI is untreated, the infection can lead to
pyelonephritis or premature labor.
Postpartum endometritis
Fever >100.4, chills, tachycardia, uterine tenderness, and foul-smelling lochia
usually caused by polymicrobial infection and is treated with broad-spectrum antibiotics. If the
health care provider prescribes blood cultures
they must be obtained prior to initiating antibiotic therapy as the medication may alter laboratory
results

Oligohydramnios
a condition characterized by low amniotic fluid volume
Amniotic fluid is produced by the fetal kidney and serves 2 major purposes - to prevent cord
compression and promote lung development.
Fluid volume also declines gradually after 41 weeks. Small uterine size for gestational age or a
fetal outline that is easily palpated through the maternal abdomen should raise suspicion for
oligohydramnios. Ultrasound confirms the diagnosis.
Major complications of oligohydramnios are:
1. Pulmonary hypoplasia - due to the lack of normal alveolar distension by aspirated
amniotic fluid. Therefore, additional neonatal personnel should attend the birth in
anticipation of possible resuscitation
2. Umbilical cord compression - continuous (not intermittent) fetal monitoring should be
applied to monitor for variable decelerations
Pulmonary embolism (PE)
Pregnancy is a hypercoagulable state that provides protection from hemorrhage after birth, but
also greatly augments risk of thrombus formation.
Women who give birth by cesarean section are at particularly increased risk for deep venous
thrombosis (DVT). Additional risk factors for DVT include obesity, smoking, and genetic
predisposition.
Signs and symptoms of PE include anxiety/restlessness, pleuritic chest pain/tightness, shortness
of breath, tachycardia, hypoxemia, and hemoptysis.
The nurse's priority is rapidly identifying symptoms, assessing respiratory status, administering
supplemental oxygen, and notifying the health care provider (HCP)

Measles-mumps-rubella (MMR)
is a live attenuated vaccine. Live vaccines are contraindicated in pregnancy due to the
theoretical risk of contracting the disease from the vaccine. Maternal rubella infection can
be teratogenic for the fetus. The fetal effects of congenital rubella syndrome include congenital
cataracts, deafness, heart defects (patent ductus arteriosus), and cerebral palsy. The best time to
administer an MMR vaccine to a nonimmune client is in the postpartum period just prior to
discharge
can safely be administered to breastfeeding clients.
Pregnancy should be avoided for at least 1-3 months after immunization.

HIV infection
Transmission of HIV infection from mother to baby can occur during antepartum, intrapartum, or
postpartum periods. Maternal antiretroviral therapy (ART) during pregnancy is imperative for
decreasing the risk of perinatal transmission. Pregnant clients who are HIV positive should
receive recommended inactivated vaccines. Newborns born to HIV-positive clients should not
breastfeed and should receive 4-6 weeks of ART after birth.

Postpartum depression
May feel intense and persistent irritability, anxiety, anger, guilt, and sadness. Such feelings
may affect the ability to care for the newborn or themselves. A client showing irritability and
disinterest in caring for the newborn should be further assessed for postpartum depression and
offered a referral for follow-up care.

Postpartum blues ("baby blues")


is a common, milder form of depression characterized by emotional lability, sadness, anxiety, and
difficulty sleeping. However, the client's ability to function properly is not affected, and
symptoms subside within 2 weeks without treatment. If symptoms persist after 2 weeks, further
assessment may be necessary.

Nutrition
Pregnant clients should avoid deli meats and hot dogs (unless steaming hot), liver, unpasteurized
milk products, unwashed fruits and vegetables, raw fish, and fish high in mercury (eg, shark,
swordfish, king mackerel, tilefish).

Supine hypotensive syndrome


usually seen in the third trimester of pregnancy when the weight of the uterine contents
compresses the inferior vena cava. The resultant maternal hypotension (and reflex tachycardia) is
best treated initially by turning the client to the right or left side to relieve pressure on the vena
cava.
Manifestations include dizziness, pallor, and cold and clammy skin.

Preeclampsia Complications
Hydralazine (Apresoline), methyldopa (Aldomet), or labetalol (Trandate) is used to lower blood
pressure (BP) if needed (typically when BP is >160/110 mm Hg).

- Placental abruption is a possible complication


can be life-threatening to mother and baby. It occurs when the placenta tears away from the wall
of the uterus due to stress, causing significant bleeding to the mother and depriving the baby of
oxygen. Bleeding can be concealed inside the uterus. This may require immediate delivery of
the baby.
manifests with high blood pressure and protein in the urine. Edema is expected, although it is not
part of the criteria.
Symptoms and their severity depend on extent of abruption and include abdominal and/or back
pain, uterine contractions, uterine rigidity, and dark red vaginal bleeding. Tachysystole (ie,
excessive uterine contractions), with or without fetal distress, is often present, and continuous
fetal monitoring is necessary
Although blood loss is maternal, the loss of functional placental surface area can result
in decreased placental perfusion, impaired fetal oxygenation, and fetal death. In severe cases,
emergent cesarean birth is indicated

- HELLP
a more serious condition indicated by elevated liver enzymes
(Hemolysis, Elevated Liver enzymes, Low Platelets). This client will need additional laboratory
work. If diagnosed, the only treatment is delivery.
Right upper quadrant (RUQ) or epigastric pain can be an indicator
Clients may have nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and
hypertension may or may not be present.

severe complications (eg, placental abruption, liver failure, stroke) and/or maternal/fetal death

- Eclampsia
Seizures are a potential complication of worsening preeclampsia, also known as eclampsia
Seizure precautions should be in place for all clients with preeclampsia. Side rails should be
padded and the bed kept in the lowest position to prevent trauma during a seizure. Functioning
suction equipment and supplemental oxygen should be available at the bedside
During a seizure, the nurse should turn the client to the left side to prevent aspiration and promote
uteroplacental blood flow. After the seizure subsides, the nurse should suction any oral secretions
and apply oxygen 8-10 L/min by facemask.
Deep tendon reflexes should be assessed hourly during administration. Hyperreflexia or clonus
may indicate impending seizure activity, whereas hyporeflexia may indicate magnesium
toxicity. Calcium gluconate is the reversal agent administered in the event of magnesium toxicity
and should be immediately available.
Environmental stimuli should be minimized to decrease risk for seizures. This may include
limiting visitors and the number of caregivers entering/exiting the client's room.
Severe preeclampsia is associated with CNS irritability, and excessive stimulation should be
avoided. Lights should be lowered to decrease visual stimuli and risk for seizures.

Magnesium sulfate
a central nervous system depressant used to prevent/control seizure activity in
preeclampsia/eclampsia clients.
Normal blood level of magnesium is 1.5-2.5 mEq/L.
A therapeutic magnesium level of 4-7 mEq/L is necessary to prevent seizures in a preeclamptic
client
earliest sign of magnesium toxicity- Absent or decreased deep-tendon reflexes (DTRs)
progress to respiratory depression, decreased urine output (<30 mL/hr), and cardiac arrest
Assessments (including vital signs) should be performed every 5-15 minutes during the loading
dose, followed by 30- to 60-minute intervals until the client stabilizes, then every 2
hours. Treatment for magnesium toxicity is immediate discontinuation of the
infusion. Administration of calcium gluconate (antidote) is recommended only in the event of
cardiorespiratory compromise.

Gestational hypertension
new-onset high blood pressure (≥140/90 mm Hg) that occurs after 20 weeks gestation without
proteinuria. Signs of hypertensive disorders during pregnancy may include headache and facial
edema.

Mastitis
a common infection in postpartum women due to multiple risk factors leading to inadequate milk
duct drainage (eg, poor latch).
Symptoms of mastitis include fever, breast pain, and focal inflammation (redness, edema).
Treatment antistaphylococcal antibiotics (dicloxacillin or cephalexin) and analgesics (eg,
ibuprofen), treatment of lactational mastitis requires effective and frequent milk drainage. Milk
ducts are most efficiently drained by direct breastfeeding (every 2-3 hrs).
correct position for optimal milk intake involves the infant forming a tight seal around most of the
areola. a common cause of severe pain during latching occurs when the infant only suckles on the
nipple.

Pica
the constant craving for and consumption of nonfood and/or nonnutritive food substances that
may occur in pregnancy. Common substances include ice, cornstarch, chalk, clay, dirt, and paper.
It may be accompanied by iron deficiency anemia. Hemoglobin and hematocrit levels are useful
in these clients to screen for anemia.

GTPAL system
G - gravida indicates the number of pregnancies, delivered or undelivered
T - term deliveries are from 37 wk 0 days and beyond
P - preterm deliveries are from 20 wk 0 days to 36 wk 6 days gestation
A - abortions (spontaneous or elective) occur prior to 20 wk 0 days gestation
L - living children are counted individually regardless of multiple birth status.

Fetal tachycardia
is a baseline of >160 beats/min for >10 minutes. Tachycardia needs evaluation and continued
surveillance. The most sensitive indicators of fetus health are fetal movement and fetal heart rate.

Breast engorgement
often painful, and the following treatments are recommended to relieve discomfort:
 Apply ice packs to both breasts for 15-20 minutes every 3-4 hours. Ice causes
vasoconstriction and reduces blood flow and swelling.
 Apply chilled, fresh cabbage leaves to both breasts, replacing them with fresh leaves after
they wilt. The mechanism of action is unclear but may be related to the cool temperature
or to the phytoestrogens from the leaves themselves.
 Take an anti-inflammatory analgesic, such as ibuprofen, which is recommended for the
pain associated with breast engorgement.
 decrease stimulation by wearing a supportive bra (not tight, no underwire) at all times
until milk flow is diminished.

Genital herpes simplex virus (HSV)


Painful genital lesions can be indicative of an outbreak. are a priority assessment finding to report
to the health care provider.
Active herpes lesions that are present at the onset of labor indicate the need for cesarean birth.

The fundus
rises above the symphysis pubis at approximately 12 weeks gestation,
reaches the umbilicus at 20-22 weeks gestation,
reaches the xyphoid process at 36 weeks gestation.
After 20 weeks gestation, the fundal height in centimeters correlates closely to the weeks of
gestation.
Toxoplasmosis
A parasitic infection acquired by exposure to infected cat feces or ingestion of undercooked meat
or soil-contaminated fruits/vegetables. Pregnant clients who contract toxoplasmosis may transfer
the infection to the fetus and potentially cause serious fetal harm. Pregnant clients should take
precautions when gardening and thoroughly wash all produce to decrease exposure risk.

** Fetal heart tones can be detected by 7 weeks gestation.


Fetal sex may be determined on ultrasound as early as the end of 12 weeks gestation.
Fetal movements are typically felt at around 16-20 weeks gestation.

** 1-hour (50 g) oral glucose screen is considered abnormal if the result is ≥140 mg/dL (7.8
mmol/L).
** In clients with hydatidiform mole or "molar pregnancy," the fetus is replaced by edematous,
cystic chorionic villi. Clients experiencing molar pregnancy should anticipate intermittent, dark
brown vaginal discharge until the pregnancy is evacuated.

** Human chorionic gonadotropin is the hormone detected in a urine or serum pregnancy test to
determine if a client is pregnant.

** Mothers of Arabian ancestry value privacy and modesty; therefore, they may choose to bottle-
feed while in the hospital and begin breastfeeding once discharged home. Mothers of southern
Asia, sub-Saharan Africa, Pacific Island, Native American, and Hispanic ancestry may believe
colostrum is harmful.