Week 5 Content
Complications in Pregnancy
Chapter 7
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Spontaneous Abortion (Miscarriage)
• Incidence:
Any pregnancy loss before 20 weeks gestation
Threatened SAB
Inevitable SAB
Incomplete SAB
Complete SAB
Missed SAB
Septic SAB
Recurrent (Habitual) SAB
Therapeutic Abortion (TAB)
Signs and symptoms of a miscarriage include:
Possible causes:
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Drug and Alcohol abuse
Overweight
Systemic Diseases
Uncontrolled diabetes
Increased maternal and paternal age
Endocrine abnormalities (diabetes or luteal phase)
Drug or environmental toxins
Autoimmune disease
Infections
Uterine or cervical abnormalities
Generic factors
Systemic disorders
Management:
Medical termination: Mifepristone and Misoprostol are 95% to 98% effective
Surgical termination: D&C (dilation and curettage) dilation through the cervix, then evacuation such as
scrapping all contents
Nursing actions (Related to care after early pregnancy loss): pg.
186-187
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Monitor B/P
Monitor bleeding
Review labs
Give RhoGAM
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Follow agency guidelines, support the family’s decision about disposition of the products of
conception
Acknowledge feeling of sadness, distress, or relief toward pregnancy loss
Give parent choices and opportunities for decision making
Etc…
Ectopic Pregnancy
Most likely place of implantation
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Blastocyst implantation ANYWHERE other than the endometrial lining of the uterus
NONVIABLE (the baby won’t survive!)
Risk factors (refer to information in textbook) pg. 187
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50% of all ectopic pregnancies occur in women without risk factors
Uterine Fibroids
Pelvic inflammatory
Previous ectopic pregnancy
Cigarette smoking
Increased age
Endometriosis
Women w/ abnormal fallopian tubes
Infertility
Pelvic or abdominal surgery
Sexually transmitted diseases
Prior tubal surgery
Exposure to the drug diethylstilbestrol
Tubal surgery
Signs and symptoms
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Pelvic or abdominal pain
Light or heavy bleeding, meaning is not your normal menstrual period (Abnormal vaginal
bleeding)
Nausea/Vomiting/Vertigo
Sudden/sharp and severe pain in ruptured fallopian tube
It may occur only in one side
Pain in the shoulders
Pain in the lower back
Weakness, dizziness, or fainting
Changes in vital signs become unstable, indicating hypovolemia in ruptured fallopian tube
Diagnostic Findings
Vaginal bleeding or spotting
Abnormally rising beta hCG levels
Cullen’s Sign: Superficial edema and bruising around the umbilicus indicating retroperitoneal or
intraabdominal bleeding
Visualization of empty uterus or presence of ectopic pregnancy on ultrasound
Changes in vital signs and symptoms of shock in ruptured fallopian tube
3 different types of management (Ectopic Management OPTIONS)
Ø Expectant management
Ø Medical management with methotrexate It’s also a (Immunosuppressive drug/chemotherapy
Folic Acid Antagonist)
Ø Surgical management
Nursing actions:
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provide emotional support and guidance what to expect.
Start IV, labs, prepare for surgery
Powerlessness related to early loss of pregnancy ( ectopic pregnancy)
Risk for Deficient Fluid Volume related to bleeding from a ruptured ectopic pregnancy.
Gestational Trophoblastic Disease: Hydatidiform Mole
Definition (Pathophysiology)
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Benign proliferating growth of the trophoblast
Chorionic Villi develop into clear, cystic, vascular vesicles that look like grape clusters
No viable fetus
Signs and symptoms
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Increase hCG levels
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Nausea & Vomiting
Expulsion of vesicles (grape-like vesicles)
No fetal heart tone/ quickening (since there is no developing fetus)
Increase fundal height for dates
Brownish vaginal bleeding (prune juice) & discharge of grape-like vesicles
Vaginal bleeding
Excessive urine enlargement
Pelvic pain or sensation of pressure
Anemia
Hyperemesis gravidarum
Hyperthyroidism
Preeclampsia early in pregnancy
Amenorrhea
Abnormal uterine bleeding ranges from spotting to profuse hemorrhage
Enlarged uterus
Abdominal cramping
Management
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Immediate evacuation of mole with aspiration/suction D&C
Post-op: Assess uterus & monitor for s/s of hemorrhage
Offer support for pregnancy loss
Follow-up of hCG levels for 6 months to detect trophoblastic neoplasia
Pregnancy not recommended for 6-12 months
Chemo needed if choriocarcinoma diagnosis
May require more combination chemotherapy, sometimes together with radiation and/ or
surgery
Nursing actions
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Monitor for s/s of hemorrhage
Assess uterus
Offer explanation and reassurance related to the plan of care
Offer emotional support related to pregnancy loss
Assess response to diagnosis and treatment plan related to anxiety, fear, guilt
Provide support related to the pregnancy loss
Give RhoGAM is needed
Assess significance of loss to woman and family
Give parents choices and opportunities for decision making
Discharge teaching
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Teach patient to monitor for severe abdominal pain, excessive bleeding, and signs and symptoms
of infection such as a fever
Review plan for follow up with care provider and courage adherence to follow up regime
Teach patient appropriate pain management
Discuss contraception options and reason to prevent pregnancy for one year
Follow up care
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Emphasize importance of medical follow up with regular HCG levels because of the risk of
malignant trophoblastic disease and choriocarcinoma.
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Prophylactic chemotherapy is not routinely recommended
Premature Cervical Dilatation: Incompetent Cervix
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Key word is “painless”. Her cervix is changing (funneling and possibly dilating) WITHOUT
her feeling contractions. Has to do with the matrix of the tissue in the lower uterine
segment/cervix. If it progresses, it can cause contractions and preterm labor.
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Painless: dilation of cervix without contractions due to structural or functional defect of
cervix
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Associated with: Advance Maternal Age (AMA), congenital structural defects, trauma to
the cervix
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Diagnosed w/ ultrasound: findings short cervix and funneling
Imcompetent Cervix: S/S
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Pinkish vaginal discharge
Increase pelvic pressure
Can progress to: premature spontaneous of membranes (PSROM), contractions, labor
and birth
Imcompetent Cervix: Treatment
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Activity restriction
Bed rest
Pelvic rest
Cerclage with the next pregnancy
Cerclage
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A type of purse-string suture placed cervically to reinforce a weak cervix.
Transvaginal McDonald and Shirodkar techniques used
Typically, are placed at approx. 13 to 14 wks.
Associated w/ significant decreased in pre-term outcomes
Keep it on at least 37 wks.
Nursing actions:
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Monitor for uterine activity with palpation
Monitor for vaginal bleeding and leaking of fluid/rupture of membranes
Monitor for infection
Maternal fever
Uterine tenderness
Discharge teaching:
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Monitor for signs and symptoms of uterine activity, rupture of membranes, bleeding,
infection
Modify activity and pelvic rest for a week
Transvaginal McDonald cerclage removal is recommended at 36 to 37 wks of gestation
SEXUALLY TRANSMITTED INFECTIONS (STI’S)
Bacterial Vaginosis
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Overgrowth of bacteria in vaginal microbiome
Treatment: metronidazole (Flagyl) or clindamycin
Effects of mother: 50% of women are asymptomatic, A fishy odor or vaginal discharge, can result
in preterm labor/premature rupture of membranes
Fetal effects: premature rupture of membranes, chorioamnionitis, pre-term birth
Chlamydia/Gonorrhea
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Needs to be treated before they have a baby
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Can lead to PretermPROM, preterm labor
Infections in the neonate
Maternal effects: women experience no symptoms, “silent killer” disease, burning on urination,
abnormal vaginal discharge
Fetal effects: contact at delivery may cause conjunctivitis or preterm birth
Treatment with antibiotics: erythromycin (given in the eye), amoxicillin, azithromycin
(need for partner treatment) or can lead to pelvic inflammatory
• Gonorrhea
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women experience no symptoms
burning on urination
yellow-green vaginal discharge or bleeding between periods
Treatment with antibiotic: cephalosporin or erythromycin
• Trichomoniasis
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Protozoan Parasite
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Maternal effects: Malodorous yellow green vaginal discharge and vulvar irritation
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Can lead to PPROM, preterm labor, low birth weight, respiratory and genital infection in
newborn
Fetal effects: Can lead to premature rupture of membrane, preterm labor, low birth
weight, respiratory and genital infection in newborn
Treatment: metronidazole (Fragyl) (debate on partner treatment)
Herpes Simplex Virus (HSV)
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Known by history of outbreak or by positive HSV1 or HSV 2 IgG antibodies
Suppressive therapy given (typically acycolvir) starting at 36 weeks to PREVENT
an outbreak
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ANY lesion or active outbreak at time of delivery is an indication for immediate CSECTION
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Mortality of 50-60% if neonatal exposure to active primary lesion is related to massive
infection sepsis and neurological complications
Provide emotional support
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Instruct woman on treatment plan.
Congenital syphilis
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If mom has syphilis
Fetal effects: transplacental transmission
Congenital syphilis may cause preterm birth, physical deformity (bone deformity),
neurological complications, stillbirth or neonatal death
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Treatment: Penicillin
Increasing in the United States
Perinatal Transmission of HIV and AIDS
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Transmission of HIV perinatally happens through transplacental, intrapartal, and
breast milk exposure
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Before use of antiviral therapy in pregnancy, risk of vertical transmission from HIV
seropositive mother to neonate was ~25%
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Today, most pregnant women are on regular treatment with antiretroviral
medications, decreasing viral load to almost undetectable. Current transmission
rate <2%
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Even though she may get pregnant and not be on antivirals, you can start her on them
and if she gets 3 doses, her risk will be significantly decreased.
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In the US you can’t Breastfeed the baby … but in other countries where there is no clean
water and the baby is at risk for other diseases/infections, they may tell moms to
breastfeed.
Hyperemesis Gravidarum
Signs, symptoms
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0.5-2% of pregnancies
Severe nausea and vomiting
Dehydration, ketonuria, significant weight loss in first trimester, or
Continues after 12 weeks
Carbohydrate depletion/ketonuria
Unable to maintain usual nutrition
Dehydration/electrolyte imbalances
Low sodium, potassium, chloride
Nursing Actions***
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Therapeutic management
Hospitalization
NPO
IV hydration LR, NS, D5LR (KCl if hypokalemic)
Vitamin replacement
Parental nutrition
Medication: Antinausea (Phenergan, Zofran, Reglan)
Proton Pump Inhibitors
Possible use of steroids
Gradual reintroduction of food
Labs CMP
Treatments
Vitamin B6 or Vitamin B6 plus doxylamine
DIABETES!!!!!
Gestational diabetes
A form of diabetes mellitus that occur during some pregnancies
-can disappear after delivery
-managed by diet & exercise
Gestational diabetes: ideal bg level
• 60-90 before meals
• Less than or 120 mg 2 hr after meal
Gestational diabetes: hypoglycemia
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Clammy pale skin
Weakness
Tremors
Irritability
Lightheadedness
Gestational diabetes: hyperglycemia
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flushed dry skin
fruity breath
rapid breathing
increased thirst and urination
headache
Pregestational Diabetes: type 1 or type 2 diabetes
Goal: Reach steady glucose levels
Therapeutic goals include:
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Maintaining glycemia control
Minimizing complications
Preventing prematurity
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Insulin needs ↓ in 1st trimester BUT ↑ in 2nd & 3rd trimester--may be 2 to 4 x greater by end of
pregnancy
Glycosylated hemoglobin (HbA1c) measures control: normal: 4.5%-5.2%
Target blood glucose for pregnant women with diabetes: <6%
10% associated with 20-25% rate of fetal anomaly
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Risks to pregnancy:
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Diabetic ketoacidosis
Hypertensive disorders and preeclampsia
Metabolic disturbances related to hyperemesis, nausea, and vomiting
Preterm labor
Spontaneous abortion
Polyhydramnios/Oligohydramnios
C-section
Infection
Postpartum hemorrhage
Effects of Diabetes Mellitus for Mother
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Hydramnios
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Preeclampsia
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Ketoacidosis
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Difficult labor (dystocia)
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Retinopathy
Effects on Pregestational Diabetes for Baby:
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In 2010, pre-GDM had a 2x risk of congenital anomalies
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Stillbirth
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Birth trauma
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Macrosomia
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Hypoglycemia
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Respiratory distress syndrome (RDS)
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Polycythemia
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Hyperbilirubinemia
Gestational diabetes Mellitus (diabetic during their pregnancy)
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Risk of Type 2 DM later in life as high as 50%
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Patients work with a diabetic educator and nutritionist to control and record glucose levels
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Diet-controlled versus use of insulin depends on glycemic control and recommendation of
OB/Gyn physician and perinatologist
Gestational diabetes Mellitus Symptoms:
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Extreme thirst.
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Hunger
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Fatigue.
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Frequent, large-volume urination.
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Sugar in the urine.
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Numerous bladder, vaginal, or skin infections.
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Nausea.
Gestational Diabetes Mellitus Screening in Pregnancy Labs!!!!
1.) First step in the two-step process is a non-fasting: 1 hour 50 g oral glucose tolerance test
(positive test 135 mg/dL to 140 mg/dL) then do 3 hour test
2.) Women who test positive à Second step: 3-hour glucose tolerance test performed on a separate
day after 8 to 12 hrs of fasting
3.) The 3 hr test is done after the woman ingests a 100 g glucose load; plasma glucose levels are
drawn at 1,2, and 3 hours post glucose load.
4.) If two or more glucose levels are above the thresholds, a diagnosis of GDM is made
Diabetes Management in Pregnancy
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GDM may be managed by care providers w/ consultation & referral as appropriate
Well-balanced diet and exercise
40% women w/ GDM may need to be managed w/ insulin
Oral hypoglycemic agents may be used
C-section for estimated fetal weight >4,500 g
Women w/ GDM need to be monitored for type 2 diabetes after the birth
Placental functioning & fetal well-being testing:
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Fetal kick counts
NST and AFI (non-stress test/ amniotic fluid index)
Ultrasounds for growth scans, Estimated birth weight
Delivery at term or possibly 38 weeks: (For a women who has diabetes)
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Possible c-section if macrosomia (big ASS baby)
Cephalopelvic Disproportion (baby has trouble getting thru the birth canal, baby’s head is
big)
Risk factors for Gestational Diabetes Mellitus:
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No known risk factors are identified in 50% of patients w/ GDM
History of fetal macrosomia
Strong family history of diabetes
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Obesity
Patient Teaching on lifestyle changes
Maintain euglycemia throughout pregnancy
Glucose monitoring regularly
Encourage decision making
Teach mom to monitor fasting ketonuria levels in the morning
Proper self-administration of insulin (Insulin pump therapy)
Diet/Exercise
Patient teaching on monitoring fetal well-being
Reinforce plan of care related to self-management and fetal surveillance
Provide info on effects of elevated glucose on developing fetus
PRETERM LABOR!!!
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Incidence is high in the United States- significant cause of neonatal morbidity and mortality
Occurs before 37 weeks’ gestation
Risk factors:
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Prior preterm birth
Multiple gestation
Uterine/cervical abnormalities
Signs and symptoms:
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low backache, vaginal spotting, pelvic pressure, abdominal tightening, cramping
Associated with: Dehydration, UTI, Chorioamnionitis
Can attempt to stop if effacement < 50% and dilatation < 4-5 cm
Diagnosis: Clinical presentation and vaginal exam (evaluation with Urinalysis, CBC,
vaginal culture, test for rupture of membranes (SROM).
Diagnosis of Preterm Labor:
Fetal Fibronectin (fFn) test:
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High sensitivity (if negative, then 95% sure she WON’T deliver in next 2 weeks)
Medications Used in Treating Preterm Labor:
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IV Hydration Ringer’s lactate
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Antibiotics (ampicillin, clindamycin)
-Group B streptococcus prophylaxis, chorioamnionitis
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Corticosteroids (Betamethasone or Dexamethasone)
-24 to 37 weeks gestation
-To help accelerate the formation of lung surfactant (maturity)
Medications Used in Treating Preterm Labor
TOCOLYTICS (Stop Contractions)
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Terbutaline 1st line agent (Subcutaneous injection or PO)
Works on Beta-2 receptor sites in uterus
Side effects: tachycardia, arrhythmia, palpitations, hyperglycemia, hypokalemia
FDA now disallows use of Terbutaline for Preterm labor
Magnesium Sulfate (IV continuous infusion)
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Central nervous system depressant
4-6 g loading dose, 2 g maintenance
Procardia (nifedipine) (PO)
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Calcium channel blocker, relaxes smooth muscle
Side effects: hypotension, tachycardia, facial flushing, headache
*Becoming drug of choice ---evidence based practice
Patient Teaching
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Contractions, cramping, pelvic pressure, ROM, low dull backache, change in vaginal
discharge
Evaluation of UCs (uterine contractions)
Pelvic rest/activity level
Empty bladder, lie on side, hydrate with water or gatorade,
Palpate for contraction and time frequency, rest,
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notify MD or present to L&D triage if symptoms persist
PPROM (Can happen with or without preterm labor)
Premature rupture of membranes (PROM) is ruptured membranes
before the onset of labor.
Preterm premature rupture (PPROM) of membranes is rupture of
membranes with a premature gestation (< 37 weeks)
DIAGNOSIS
Ø Observe for vaginal leaking (sterile speculum exam for pooling)
Ø Nitrizine paper
Ø Ferning test
Ø Amnisure, ROM+
Ø Fetal distress, decreased AFI on ultrasound
Ø Symptoms of infection
Management of PPROM
Management and treatment PROM so
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hospitalization and bed rest
testing for infections
monitoring for progression to infection
brought a spectrum antibiotic
if between 24 to 27 weeks gives steroids collaborate care with high
risk OB GYN physician,perinatologist and NICU team (including
neonatologist)
Hypertensive Disorders of Pregnancy
1. Gestational hypertension
Symptom: blood pressure elevated >140/90 mm Hg
Onset: >20 weeks pregnancy
2. Preeclampsia
Symptom: blood pressure elevated > 140 / 90 mm Hg and +1 or greater proteinuria on
dipstick
Onset: >20 weeks pregnancy
3. Eclampsia
Symptom: preeclampsia with neurologic symptoms/seizures
Onset: >20 weeks pregnancy
4. Chronic hypertension
Symptom: pre-existing hypertension
Onset: Exists prior to pregnancy
5. Preeclampsia/eclampsia superimposed on chronic HTN
Symptom: Blood pressure increases >30 mm Hg systolic or >15 mm Hg diastolic from
base line with onset of significant proteinuria.
Onset: >20 weeks pregnancy
o Chronic hypertension and Gestational hypertension
§ Assessment, monitoring, patient teaching, lifestyle
interventions
§ Medical management
Management of hypertension in pregnancy:
Gestational Hypertension: Pregnancy Induced Hypertension (PIH)
Gestational Hypertension also referred to as Pregnancy-Induced Hypertension (PIH) is a condition
characterized by high blood pressure during pregnancy. Gestational Hypertension can lead to a serious
condition called Preeclampsia, also referred to as Toxemia. Hypertension during pregnancy affects
about 6-8% of pregnant women.
The different types of hypertension during pregnancy:
High blood pressure can present itself in a few different ways during pregnancy.
The following are the 3 common types of gestational hypertension:
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Chronic Hypertension– Women who have high blood pressure (over 140/90) before pregnancy,
early in pregnancy (before 20 weeks), or continue to have it after delivery.
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Gestational Hypertension– High blood pressure that develops after week 20 in pregnancy and
goes away after delivery.
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Preeclampsia – Both chronic hypertension and gestational hypertension can lead to this severe
condition after week 20 of pregnancy. Symptoms include high blood pressure and protein in the
urine. This can lead to serious complications for both mom and baby if not treated quickly.
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Preeclampsia/Eclampsia
Signs and Symptoms & Severe Features:
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>160/110 mm Hg
Two readings taken 4 hours apart with bed rest
Persistent headache
Blurry vision (blurred or double, blind spots)
Epigastric pain
Proteinuria
Swelling (pitting edema) edema of face and hands
Nausea/Vomiting
Hyperreflexia
Restlessness
Oliguria
Abnormal liver function test
Low platelet count <100,000
Liver abnormalities
HELLP syndrome
Pulmonary edema
Hyperreflexia with ankle clonus
Risk factors
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Nulliparity (never has been pregnant)
Primiparity (first pregnancy)
Age younger than 20 or older than 35 years old
Obesity
multiple pregancy
family history of preeclampsia
chronic hypertension, kidney disease, lupus, or diabetes prior to pregnancy
previous preeclampsia or eclampsia
gestational diabetes (Type 1 diabetes
history of thrombophilia
Systemic lupus erythematosus
Nursing interventions:
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Darkened, quiet room
Seizure precautious
Pad the side rails
Have oxygen & suction equipment ready at bedside
Administer magnesium sulfate
Risks for mother:
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Cerebral edema/hemorrhage/stroke
Disseminated intravascular coagulation (DIC)
Pulmonary edema
Congestive heart failure
Organ damage HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)
Abruptio placenta
Risk for fetus/newborn:
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Fetal/neonatal morbidity and mortality are consequenses of intrauterine growth restriction (IUGR)
prematurity and placental abruption
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Fetal intolerance to labor due to decrease placental perfusion
Stillbirth
Diagnosis:
Hypertension in pregnancy: After 20 weeks of gestation with BP of >140/90 mmHg , 4 hours apart
Signs and symptoms of Mild preeclampsia
Elevated blood pressure
weight gain exceeding 2 lbs a week
elevated protein in the urine
water retention and swelling
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A woman with preeclampsia whose condition is worsening will develop other signs and symptoms
known as “severe features.” These include a low number of platelets in the blood, abnormal
kidney or liver function, pain over the upper abdomen, changes in vision, fluid in the lungs, or a
severe headache. A very high blood pressure reading also is considered a severe feature.
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Preeclampsia without severe features (what used to be called "mild preeclampsia") is
characterized by the following:
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Blood pressure of 140/90 or above
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Swelling, particularly of the arms, hands, or face that is reflected in greater than expected
weight gain, which is a result of retaining fluid. (Swelling in the ankle area is considered
normal during pregnancy.)
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Protein in the urine. Although uncommon, a woman can have preeclampsia without
protein in the urine.
Preeclampsia with severe features (formerly called "severe preeclampsia") is characterized by:
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Blood pressure of 160/110 mmHg or higher in more than one reading separated by at
least six hours and proteinuria
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OR
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Blood pressure of 140/90 mmHg or higher and symptoms or signs of ongoing damage to
internal organs, such as:
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Severe headache, changes in vision, reduced urine output, abdominal pain, fluid in the
lungs and pelvic pain
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Signs of the "HELLP" syndrome, which means the liver and blood-clotting systems are
not functioning properly. HELLP stands for Hemolysis (damaged red blood cells),
Elevated Liver enzymes (indicating ongoing liver cell damage) and Low latelets (cells that
help the blood to clot). It occurs in about 10% of patients with severe preeclampsia.
Eclampsia is diagnosed when a woman with preeclampsia has seizures. These seizures usually
happen in women who have severe preeclampsia, though they can occur with preeclampsia.
Eclampsia also can happen soon after a woman gives birth. Approximately 30% to 50% of
patients with eclampsia also have the HELLP syndrome.
3 uses for Magnesium Sulfate
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Preventing seizures in a woman with severe preeclampsia
Slowing or stopping premature labor
Protecting the brains of the premature babies
Management of preeclampsia
Preeclampsia Magnesium Sulfate
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Assess deep tendon reflexes, BP, RR, lung
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sounds, urine output, level of consciousness.
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Stop infusion if symptoms of toxicity occur.
Normal side effects with MgSO4:
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Warmth over body/flushing
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Burning at IV site
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Mild SOB, mild chest pain
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Congestion, headache, dizziness
Antidote: Calcium Gluconate
Side effects of Magnesium Sulfate Toxicity
• BP decrease
• Urine output decrease
• Respiratory Rate decrease
• Patellar reflex absent
• Nausea
• Flushing
• Diaphoresis
• Blurred vision
• Lethargy
• Hypocalcemia
• Depressed reflexes
• Respiratory depression arrest
• Cardiac dysrhythmias
• Decreased platelet aggregation
• Circulatory collapse
***(if they have any of these happen STOP magnesium sulfate & administer antidote: Calcium Gluconate)
Magnesium Sulfate therapeutic level: 4 to 8 mg/dL (above it means toxicity)
Plasma level of magnesium: 10-12 Respiratory depression (bad level)
Patient Teaching (nursing actions)
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Assess the VS before beginning infusion and every 5-15 mins during loading dose, after
30-60 mins ‘til patient stabilizes. Freq is then determined by patient status.
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Assess the DTRs/2hr. DTR can be elicited by striking the tendon of a partially stretched
muscle briskly, using the flat or pointed surface of the reflex hammer.
Reflexes ate graded on a 0 to 4+, 0 being absent and +4 being hyperactive.
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Monitor strict intake and output patients with oliguria or renal disease are at risk for toxic
levels of magnesium.
Monitor serum magnesium levels 5-7 mg/dl
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Monitor for S/S of Magnesium toxicity:
o Decrease reflexes = respiratory depression
o Loss of DTRs
o Respiratory depression <14 breaths/min
o Oliguria <30 mL/hr
o Shortness of breath or chest pain
o EKG Changes
o Toxicity is suspected discontinue the infusion and notify health care pro.
12mEq/L
o Keep calcium gluconate available
o Maintain seizure precautions and keep resuscitation equipment nearby
o Receiving IV Labetalol for BP control should have cardiac monitoring
o Maintain continuous fetal heart rate monitoring
o Report abnormal findings: Urine output <30ml/hr., Respiratory <12breaths/min,
SpO2 <95%
o Persistent hypotension
o Absent deep tendon reflex
o Altered maternal levels of consciousness
o Abnormal laboratory test values
o Motor FHR, alert the neonatal team before delivery of use of magnesium sulfate
in labor.
Eclampsia
• Progression of preeclampsia to generalized seizures that cannot be
attributed to other causes
• Seizure may cause precipitous birth
• May occur postpartum
Eclampsia Interventions:
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Maintain airway
Position to side (Place in lateral position)
Administer O2
Suction as needed
Call for assistance
Ensure side rails are up and padded
Record time, length, and type of seizure activity
Notify the physician
Protect airway
Administer magnesium sulfate & antihypertensive therapy
Warning signs
o HELLP : (Hemolysis, elevated liver enzymes, low platelets)
A variant of gestation where hypertension where hematologic conditions coexist with severe
preeclampsia and hepatic dysfunction.
Signs and symptoms:
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Malaise
Nausea
Vomiting
Right upper gastric pain
Bruising
Mucosal bleeding
Petechiae
Bleeding from injection site
Normal levels Red Blood Cells:
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Non-pregnant: 3.91-5.11
Pregnant: 2.7-4.55
Newborn: 4.51-7.01
HELLP Syndrome: H
(Hemolysis): resulting in anemia & jaundice
HELLP Syndrome: EL
(Elevated liver enzymes)
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Elevated ALT: >2x upper limit of normal
Elevated AST: >2x upper limit of normal
**Her ALT/AST levels are 200-300 (That is HIGH)
HELLP Syndrome: LP
Normal levels of platelet count: **** To distinguish what a low platelet count is
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150,000-400,000
Low platelets: <100,000
Disseminated Intravascular Coagulation (DIC):
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DIC Is a Disorder of The "Clotting Cascade."
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Hypercoagulability in pregnancy is the propensity of pregnant women to develop thrombosis
(blood clots).
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Pregnancy itself is a factor of hypercoagulability (pregnancy-induced hypercoagulability), as
a physiologically adaptive mechanism to prevent post partum bleeding
It Results in Depletion of Clotting Factors In The Blood.
Pregnancy represents a state of accelerated but compensated intravascular coagulation
and the coagulation activity is increased relative to the fibrinolytic activity.
Possible Precursors to DIC:
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Hemorrhagic shock
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Transfusion reaction
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Sepsis
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Severe pre-eclampsia or HELLP syndrome
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Retained fetal demise
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Premature separation of the placenta
(placental abruption)
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Retained placenta
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Amniotic fluid embolism (usually not able to be determined until autopsy)
Pathophysiology of DIC:
v Coagulation process is abnormally stimulated
v Excessive amounts of thrombin are generated
v Fibrinolytic mechanisms are activated and cause extensive destruction of clotting factors
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Micro Blood clots form throughout the body, and eventually using up the blood clotting factors.
These are then not available to form clots at the local sites of real tissue injury. (microthrombi)
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Clot dissolving mechanisms are also increased-fibrinolysis
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Signs and symptoms
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Excessive bleeding from orifices
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Petechiae, purpura, and hypotension
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Multi-organ failure
Disseminated Intravascular Coagulation (DIC):
Risk factors:
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Abruptio placenta, the primary cause DIC
HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome
Anaphylactoid syndrome of pregnancy
Hemorrhage
Assessment Finding:
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Prolonged, uncontrolled uterine bleeding
Bleeding from the IV site, incision site, gums, and bladder
Purpuric areas at pressure cuff site
Abnormal clotting study results, such as low platelets and activated partial thromboplastin time
Increased anxiety
S/S shocked related blood loss: pale skin, tachycardia, tachypnea, hypotension
Medical Management:
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Lab tests (fibrinogen levels, prothrombin time, partial thromboplastin time and platelet count) to
assess for abnormal clotting
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Identify the primary cause of bleeding and intervention based on this knowledge
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IV therapy
Blood replacement
Platelet infusion
Fresh frozen plasma
Cryoprecipitate
Oxygen therapy
Nursing Actions:
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Reduce risk of DIC
o Review prenatal and labor records for risk factors.
o Monitor women more frequently who are at risk for DIC
o Assess for PPH and intervene appropriately. Early intervention can decrease the risk of
DIC
o Monitor VS and immediately report to the MD or CNM abnormal findings, such as an
increase in heart rate, a decrease in blood pressure, and a change in quality of
respiration.
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Obtain IV site with large-bore intracatherer as per orders
Administer IV fluids as ordered.
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Facilitate transfer to ICU
Administer oxygen as ordered
Obtain lab results specimens as ordered
Review lab results and notify the physician
Start blood infusion as order
Provide emotional support and information to the woman and her family to decrease level of
anxiety
Nursing Actions
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Reduce risk of DIC
Obtain IV (large bore)
Administer O2
Obtain Lab specimens as ordered
Review labs results and notify
Anaphylactoid Syndrome:
Pathophysiology:
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Also referred to as Amniotic Fluid Embolism. A rare but often fatal complication that can occur
during pregnancy, labor and birth, or the first 24 hours postbirth. 2 stage process that occurs
when amniotic fluid contains fetal cells, lanugo, and vernix enters the maternal vascular system.
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Amniotic fluid within the vascular system initiates a cascading process that leads to
cardiorespiratioy collapse and DIC. Women usually die withim a few hours of symptom onset.
The cervix following rupture of amniotic membranes
Site of plancenta separation
Site of uterine trauma laceration
Risk factors:
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Induction of labor
Abruptio placenta
Placenta previa
No reliable risk factors that predict AFE.
Assessment Finding:
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Dyspnea
Seizures
Hypotension
Cyanosis
Cardiopulmonary arrest
Uterine atony that causes massive hemorrhage and leads to DIC
Cardiac and respiratory arrest
Medical Management:
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No scientific date exists to support any intervention that improves maternal prognosis with
anaphylactoid syndrome of pregnancy
Focus is on maintaining cardiac and respiratory function, stopping the hemorrhage and correcting
blood loss
Complete blood count CBC, platelet count, arterial blood gases, fibrinogen and prothrombin time
are a few of the lab tests that might be ordered.
Blood type and screen for possible transfusion
Transfer to the critical care unit
Chest xray
Blood replacement, packed red blood cells, and platelets
A heart lung bypass machine can be used to help stabilize
Nursing Actions:
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Monitor for signs and anaphylactoid syndrome of pregnancy
Notify the physician immediately of assessment data so that early interventions can be initiated.
Administer oxygen
Establish 2 IV sites with large bore intracatheres: one for IV fluid replacement
Obtain lab specimens are ordered
Administer blood replacement as ordered.
Provide emotional support to the women and her family
Call code and initiate CPR when indicated
Facilitate transfer to ICU
• Amniotic Fluid Embolism
o Understand basic pathophysiology
o Assessment findings, signs and symptoms
o Nursing care