HIGH RISK PREGNANCY
Definitions
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Maternal Mortality – The death of a woman during pregnancy and up to 6 weeks PP.
Newborn Mortality –The death of a newborn within 28 days of birth
DIC – Clotting & bleeding disorder that can occur 2o to abruptio placenta, missed SAB and HELLP.
Occurrence of bleeding
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Why does it happen?
o 1st half of pregnancy: Usually due to genetic or structural abnormalities
o 2nd half of pregnancy: Often related to maternal disease (HTN, DM)
Rule of thumb is that if the cervix stays closed, the pregnancy continues. If it opens, it will be lost.
Fetal risk = Hemorrhage  Uteroplacental Insufficiency  Fetal Distress, Bradycardia/Late Decels
Time
Complication
Signs/Symptoms
First Trimester
SAB
Bleeding, cramping, and partial or complete
expulsion of fetal products
Abrupt one-sided lower abdominal pain, with
or without vaginal bleeding.
Uterus size > Dates. Very high hCG (n/v)
No fetus on u/s, prune juice bleeding
Painless vaginal bleeding
May be profuse or scant
Painful bleeding (sharp abdominal pain and
tender board-like uterus)
Ectopic Pregnancy
Second Trimester
GTD
Third Trimester
Placenta Previa
Abruptio Placenta
Nursing interventions
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If bleeding, cramping or low back pain, she must be seen ASAP
o Instruct her to save any tissue or clots found on pads and bring with her to be examined.
At the facility, assess:
o VS – Any signs of hemorrhage or infection?
o Bleeding – Color, ODOR, amount (count and weigh pads… 1g=1mL), has she passed clots?
o Pain – Is there tenderness, cramping or contractions (backache?)
o Changes – Is there dilation of the cervix, and has there been a ROM?
o FWB – FHR, Kicks, EDC/LMP, NST & Biophysical Profile
Lab tests: hCG, H/H, clotting factors, fibrin split products, CBC w/diff (% Neutrophils)
Prepare for procedures:
o Ultrasound to determine fetal viability and the presence of tissues
o Surgery to evacuate the uterus
 D&C – Dilate, scrape uterine walls to remove tissues (inevitable or incomplete)
 D&E – Dilate and evacuate contents after 16 weeks of gestation
Possible medications
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Prostaglandins (Misoprostol) or Pitocin: Stimulates uterine contractions to evacuate the uterus
If the woman is Rh -, administer RhoGAM within 72 hrs after the abortion.
EARLY BLEEDING: SAB
Definitions
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Spontaneous Abortion – When a pregnancy is terminated before the 20th week of gestation
CATEGORY
CRAMPS
BLEEDING
CERVIX Pass POC? RESULT
Threatened
Mild
Slight
Closed
No
Pregnancy continues
Inevitable
Strong
Mild to moderate
Open
Not yet..
Might need D&C
Incomplete
Intense
Heavy, continued
Open
Some
Needs D&C
Complete
Decreasing
Decreasing
Open
All
No intervention needed
Missed Abortion
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What is it?: The unviable fetus is retained instead of aborted—No POC passed at all
Symptoms: Reversal of pregnancy signs (her uterus shrinks, hCG drops, etc), cervix will be closed
(not trying to abort), she may have brownish discharge
Major Complications = Infection & DIC
o DIC: Retained fragments cause release of clotting factors, eventually woman bleeds to
death.
Habitual/Recurrent Pregnancy Loss
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What has it? – History of three or more consecutive spontaneous abortions
Possible causes AND their treatments:
o Incompetent/premature cervical dilation – Cerclage after week 12 (tightening of the cervix)
o Luteal Phase Defect – A lack of progesterone, easy fix = Administer Progesterone!
o Vascular Disorder – Administer Aspirin
Discharge Teaching
1.
2.
3.
4.
5.
Activity: Bed rest, pelvic rest (NPV)
Pad count -- Save any tissue and bring it in to be examined
Follow up appointments should be made, and patient should know EME contact numbers
Realistic reassurance, never say “it will be okay”
Discuss contraception PRN
ECTOPIC PREGNANCY
What is it?
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A MEDICAL EMERGENCY in which a fertilized ovum implants outside the uterine cavity.
Most common site = fallopian tubes, but may implant in the ovary, cervix, or abdominal cavity.
o Once implanted, the embryo grows.
o Risk for rupture increases, b/c only the uterus is designed to adjust to fetal development.
Risk factors include:
o Tubal scarring from PID, IUD, Failed tubal ligation, previous ectopic
o Chlamydia, Gonorrhea
o Maternal age over 35
Complications: Can lead to massive hemorrhage, infertility, or death.
Symptoms and diagnosis
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Symptoms = Normal pregnancy signs, which makes diagnosis challenging because most women are
fine until rupture occurs. Some may have spotting and abdominal pains.
Diagnostic procedures include:
o Ultrasound to visualize location
o HCG – If levels decrease or do not double q 48 hrs, pregnancy failing & intervention
needed
o Aspiration of blood from cul-de-sac indicates peritoneal bleeding & rupture
Signs of Rupture
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Increasing sharp abdominal/pelvic pain.
Profuse hemorrhage -- severe hypovolemic shock
Referred shoulder pain
Treatment
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If unruptured: Methotrexate or Linear Salpingostomy
METHOTREXATE IM (Single Dose)
What is it?
Action
Indications
Side effects
Teaching
Follow up
Chemotherapy agent and folic acid antagonist
Stops embryo growth and salvages tube
If the tube is intact and patient is stable (no active bleeds)
Spotting, nausea, abdominal pain, dizziness
No alcohol or folic acid, sun exposure, NPV
Baseline bloodwork and then testing every 2-3 days until normal
o Linear Salpingostomy: Incision & removal, preserves tube and future fertility
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If ruptured – Tube removal (unilateral) is necessary d/t possible uncontrolled hemorrhage.
 Interventions: Control bleeding, stabilize, prepare for removal of tube
 Follow up: Monitor hCG levels until undetectable administer RhoGAM, if indicated
GTD – HYDATIDIFORM MOLE
What is it?
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Hydatidiform Mole (Molar pregnancy)
o Trophoblasts “gone wild” – become fluid filled cells and attach to the uterine wall
 “Empty egg” is fertilized by sperm. The embryo is not viable and dies.
 The placenta is present, but NO fetus is found – bloodflow to “fetus” causes
hemorrhage into the uterine cavity
o Risk factors include: Advanced age, protein deficiency
Symptoms and diagnosis:
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Clinical Manifestations
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o Scant Prune Juice vaginal bleeding.
o Extremely elevated hCG levels which cause excessive severe nausea and vomiting
o Rapid uterine growth  uterine size > dates
PC’s: Can develop into choriocarcinoma, a highly virulent cancer with metastasis.
Testing: Ultrasound shows growth but no fetus
Treatment
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Procedure: Suction D&C is done to aspirate and evacuate the mole
PREOP
POSTOP
FOLLOW UP
Obtain…
Administer…
Monitor hCG levels
• CXR
• IV Pitocin
weekly for a year
• CBC
• RhoGAM PRN
• Blood type
Obtain baseline….
• Clotting factors
• Pelvic exam
• Abdominal u/s
TEACH
RELIABLE PO or
barrier contraceptive
for one year
pregnancy will throw
off hCG level
Long-term follow-up d/t risk of Choriocarcinoma!!!
o Why?? --- Remaining trophoblastic tissue might become malignant.
o Monitor hCG levels weekly for several weeks, then monthly for a year
 If they do not return to baseline: Methotrexate!!
PLACENTA PREVIA VS ABUPTIO PLACENTAE
Placenta Previa
Abruptio Placentae
Definition
The placenta implants in the lower
uterus, near or over the cervical os
instead of the fundus
The placenta separates before birth,
depriving the baby of nutrients and O2 and
causing hemorrhage of mother and child.
Classification
Marginal: NVD is possible
Partial: C-Section
Total: C-Section
Concealed– Blood stays internal
Apparent– Blood is evacuated vaginally
Causes
Previous SAB, C/B, Previa
HTN, Substance abuse, trauma
Vital Signs
WNL
Signs of hemorrhage
Diagnosis
U/S to confirm placental location
NO VAGINAL EXAMS
U/S for FWB
Bleeding
Bright, light & painless
Dark & painful
Visibility
Always visible
Can be concealed and lead to shock
Uterus
Soft and relaxed
Hypertonic
Abdomen
Normal
Rigid, tender, board-like
Occurrence
After 20 weeks
After 20 weeks
EFM
Reassuring
Fetal distress, late decels
Homecare, bed rest, pelvic rest (NPV)
Emergency Plan, VNA referral
Monitor Kick Counts at home
Bed rest
Tocolytic meds
Management
-If mild
-If unstable Wait and see
May deliver early, if indicated
Complications PP Hemorrhage d/t lower uterus
inability to contract like fundus
PREPARE FOR EMERGENCY C SECTION
RhoGAM
Before birth if indicated
At birth if indicated
Hemorrhage, hypovolemic shock
DIC, Thrombocytopenia
Fetal anoxia, preterm birth, death
RH INCOMPATIBILITY
What’s happening?
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A mother is pregnant with a fetus who’s blood type is incompatible with her own
Although maternal-fetal blood theoretically does not mix, certain events allow contamination.
o As little as 0.5 ml will cause sensitization, in which maternal antibodies are produced.
Other incompatibility disorders:
o ABO incompatibility: A type O mother is pregnant with a type A, B, or AB fetus
Blood exchange and Rh sensitization
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90% of cases occur during delivery:
o Luckily, it is too late to have negative effect the firstborn infant with Rh+ blood type
o Subsequent pregnancies are at risk if the fetus is Rh+
10% of cases occur before delivery:
o Antenatal testing – i.e. Amniocentesis
o ANY of the above pregnancy bleeding disorders
o Abdominal trauma, such as MVA, fall
Possible fetal effects in subsequent pregnancies
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Erythroblastosis fetalis where mom’s antibodies destroy all of their RBC’s
Icterus gravis = Very high levels of Bilirubin in less than 24 hrs
o This is PATHOLOGICAL jaundice, not physiological --- this is FATAL
o Bilirubin encephalopathy, or “nicteris” which leads to mental retardation
Hydros fetalis = abundance of extra fluid  Generalized edema or fetal CHF
Nursing Care
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Goal: All Rh- unimmunized woman receive RhoGAM at 28 weeks, and again within 72hrs of birth
Initial Prenatal visit:
o If mother is Rh- perform an indirect Coombs
 If Positive = Mom has antibodies. It is too late to intervene, fetus is at risk
 If Negative = Mom does not have antibodies and she should receive RhoGAM
28 Week visit
o RhoGAM is given to Rh- women to protect them for the rest of the pregnancy
o Another Coombs test done to assess whether blood has mixed since first visit
 Increasing titers signify fetal jeopardy
 Amniocentesis may be performed to check fetal bilirubin
o If bilirubin low, fetus is probably Rh o If bilirubin high, Intrauterine transfusion, then delivery
 Ultrasound may be done to detect ascites, edema, enlarged heart, hydramnios
Birth and Delivery
o DIRECT Coombs performed using blood from the cord:
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If blood type is –, antibodies absent
If blood type is + RhoGAM MUST BE given to the mom within 72 hours of birth
 Newborn may have antibodies and develop pathological jaundice
HYPERTENSION IN PREGNANCY
Hypertensive conditions:
Hypertension:
Chronic HTN:
Gestational HTN:
Preeclampsia:
Eclampsia:
HELLP:
Blood pressure which exceeds 140/90
HTN that is present before pregnancy, or before 20 weeks. Treated with ALOMET.
HTN after 20 wks gestation in previously normotensive pt. Resolves by 12 wks PP.
HTN present after 20 weeks gestation along with proteinuria (mild or severe).
Occurrence of Grand Mal seizures in a woman with preeclampsia.
Hemolysis, Elevated liver enzymes, Low Platelets
Preeclampsia/Eclampsia
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What is happening?  Vasoconstriction  VASOSPASM  hypoperfusion to organs.
Blood Testing
o CBC, Plt, Glucose, Clotting studies
o Kidney panel: (BUN, Creatinine, Uric Acid), Liver panel: (ALT, LDH, AST / SGOT, SGPT)
Systemic effects and dangers of Preeclampsia
Kidneys
Brain
Liver
Placenta
Decreased GFR, Increased Hct, + Proteinuria
Kidneys hold fluid b/c it thinks the body is dehydrated  third spacing, weight gain
ACT/electrical impulses are excitable. CNS and reflexes are hyper responsive.
If not treated, at risk for seizure!
Impaired function, edema, increased LFT’s, epigastric pain
If not treated at risk for liver rupture which is FATAL
Fetal is not getting oxygen (hypoxemia), becomes acidotic.
At risk for mental retardation, IUGR, or death.
Classifications
Parameters
Diagnosable
Proteinuria
Oliguria
Potential sxs:
Activity
Position
Mild Preeclampsia
Severe Preeclampsia
>140/90
After 20 weeks gestation
300 mg
+1
No
Edema of face and hands
Headache
Drowsiness, irritability
Marked weight gain
>160/110
Twice while on bed rest
5 grams
+3
< 500ml in 24 hours
Pulmonary edema, cyanosis
Blurred vision
RUQ pain
Thrombocytopenia
Fetal growth restriction
Hospital, bed rest no stim.
Left lateral
Home, bed rest no stim.
Left lateral
Eclampsia
>160/110
Tonic Clonic convulsion
Marked
Renal failure
Respirations STOP during
Deep & stertorous after
Cerebral hemorrhage
Onset of labor
ROM
Left lateral
Actions
Precautions
Teach to self monitor
(BP, dipstick, DW, kick
counts)
None
Monitor BP, Fetal well being
Proteinuria
DW
Seizure – suction, oxygen
Stay with patient
Call for help
Apply 10L oxygen
Seizure – suction, oxygen
Nursing care during and after delivery
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During delivery: Monitor fetal status constantly, keep mom in Left Lateral position
Postpartum: Still HTN for the first few days, which can  intracerebral hemorrhage  death
o Continue on Magnesium Sulfate for 24h, then antihypertensives for 2-6weeks
o Observe for: HTN, h/a, visual disturbances, epigastric pain, edema, proteinuria
o Recovery Signs =
 Massive urinary output 4-6 Liters/ 24 hours (decreased proteinuria)
 BP normal within 2-6 weeks
Development of HELLP syndrome
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What is it? LIFE THREATENING complication of preeclampsia
o HEMOLYSIS: Fragmentation of RBC’s as they pass through damaged small blood vessels
o ELEVATED LIVER ENZYMES: Hepatic blood flow is obstructed by fibrin deposits
 AST: 0-30 Units/L
 ALT: 5-35 Units/L
o LOW PLATELETS: Thrombocytopenia d/t platelets aggregating at damaged vessels
 Normal: 150,000- 400,000
 Concern: 100,000
 Critical: 50,000
Symptoms: Chest and epigastric pain, n/v, edema, malaise
Complications: Renal Failure, Pulmonary Edema, Ruptured Liver, Hematoma, DIC, Placental abruption
Treatment: ICU, C/Birth likely, Magnesium Sulfate
Seizure prevention in hypertensive disorders
 MAGNESIUM SULFATE: CNS DEPRESSANT
o Action: Relaxes smooth muscle, decreasing vasoconstriction and ACT release
o Administration: IV piggyback on pump (to control administration so it can be stopped quickly)
1. Initial Bolus/Loading dose = 4-6g over 15-30 minutes
2. Maintenance dose = 1-2g per hour IV Drip
o Have antidote (Calcium Gloconate) nearby and premixed in a 1 gram injection IV push
o Nursing: Monitor serum levels, HR, BP, RR, Foley catheter, FHR, reflexes, Clonus
MAGNESIUM SULFATE TOXICITY
INTERVENTIONS FOR TOXICITY
1. SERUM LEVEL OF 8 OR MORE!!
1. D/C immediately, switch to IV fluids
2. Decrease in RR, HR, BP, DTR’s
2. Call for assistance, notify HCP STAT
3. Hyporeflexia or absent reflexes
3. Administer CALCIUM GLUCONATE
4. U/O less than 30 ml/hr.
4. Monitor return of DTR’s, RR, BP, U/O
5. Fetal stress, changes in FHR
5. Monitor drug level (Thx = 4-7mEq)
GESTATIONAL DIABETES
What is it?
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Screening for ALL pregnant woman is done at 24-28 weeks, earlier if indicated (high risk)
o 1 hour non-fasting GTT is performed
o If she fails  3 hour GTT is performed if the result is >140 mg/dL
o If 2 out of 4 tests are abnormal, she is classified as a Gestational Diabetic
Effects on size of infant may vary
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If vasculature is weakened form years of DM, baby will likely be SGA (poor perfusion to placenta)
If no diet control and new diagnosis, baby will likely be LGA (hyperglycemic, hyperinsulinemic)
Normal, Gestational DM, and Pre-gestational DM
TIME
NORMAL CHANGES
GESTATIONAL DM
1st Trim.
BG = siphoned by fetus
Lowers maternal BG
Body’s insulin needs decrease
BG = siphoned by fetus
Lowers maternal BG
Body’s insulin needs decrease
2nd Trim.
hPL & lactase begin to destroy
insulin, body readjusts as
needed – No problem!
Insulin production by the body
is adequate for needs
After 18-20 weeks, pancreas
can’t keep up with insulin
resistance
Need DIET (and maybe insulin)
TEACH: Diet/exercise as 50%
will go on to have DM w/in 5y
BS hourly
Sc Insulin
3rd Trim.
Delivery
No precautions
Postpartum
No precautions
Baby:
Normal PP interventions
TYPE 1 DM
Reduced insulin needs
compared with usual
maintenance
(Baby is unloading BG off mom!)
After 20 weeks the insulin needs
start to increase again due to
increasing resistance
Insulin requirements increase
50-75% of previous dose!!
BS hourly
Reg Insulin/NS on IV pump
Additional IV for D5%
BS may fluctuate for 24-48 hrs, Return to pre-pregnant regime
insulin may continue; most
return to normal postpartum
BS check at 6 wk F/U
1. Monitor for hypoglycemia initially (3 BG checks)
2. Monitor BS hourly, then at meal time
3. Watch for jitteriness, irritability
4. Monitor bilirubin (Yellowish skin tone)
5. Ensure adequate feedings or IV with Dextrose
Treatment: Nutrition and diet
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90% of GDM cases are treated by diet ALONE!
ADA Daily requirements:
o 3 Meals & 3 Snacks, Don’t SKIP MEALS
o 2,200-2,500 kcals per day
 Limit simple sugars (cake, candy, cookies)
 Increase complex: starch, bread, potato
 1 protein & 1 complex CHO before bed
Treatment: Insulin
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10-20% of GDM patients will require insulin therapy
Daily requirements are not a focus, patients must achieve TIGHT control
Insulin teaching
o Administer the correct dose of insulin at the correct time every day.
o Eat breakfast within 30 minutes after injecting regular insulin to prevent a reaction.
Blood Glucose Monitoring
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Hgb A1c – Every 4-6 wks to monitor risk for abnormalities.
SMBG before meals & at bedtime, between 4-10x/day.
Test
Glycosylated Hgb (Hgb A1c)
Fasting Blood Sugar
2 hour Postprandial
Goal
< 6%
< 95
< 120
Important teaching
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Exercising: After meals, while BS is up, avoid extreme temps. Have ID and hard candy on hand.
Monitor fetal wellbeing: Perform daily “kick counts.”
Most pregnancies are allowed to go to term with tight control and satisfactory assessment of FWB
Know symptoms and treatment of hypoglycemia & hyperglycemia:
Symptoms
Treatment
Hypoglycemia: Cold, clammy, hungry, disoriented Glucose tablets, lifesavers, milk
Hyperglycemia: Hot, dry skin/mouth, thirsty,
Call doctor! May need treatment!
Surveillance
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Maternal surveillance may include:
o Urine check for protein and ketones (may indicate the need for evaluation of eating habits)
o Kidney function evaluation every trimester
o Eye examination in the first trimester to evaluate the retina for vascular changes
o HbA1c every 4 - 6 weeks to monitor glucose trends
Fetal surveillance may include:
o U/S, AFP, BPP
o NST are performed weekly after 28 weeks’ gestation to evaluate FWB.
o Amniocentesis in the 3rd trimester to determine fetal lung maturity
 Phosphatidylglycerol: Present or absent
 L/S ratio: Goal = greater than 2:1
MULTIFETAL PREGNANCY
Types of twins
A. Dizygotic/Fraternal -66%
• Formed when two separate sperms fertilize two separate ova at the same time
• Separate amnions, chorions, and placentas
• Is hereditary, babies can be same sex or opposite
B. Monozygotic/Identical -33%
• Formed when a single fertilized ovum splits during the first 2 weeks after conception
• Always the same sex
Symptoms and diagnosis
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Assessment: Fundal height = much > dates, 2 FHR, Ultrasound typically confirms the diagnosis
Effects on the Mother
o Increased blood volume causes increased workload of CV system – HTN?
 Greater fetal Fe+ demand --- Marked anemia
o Increased uterine distention from added pressure on vessels and adjacent structures
 Can lead to Diastasis abdominal recti muscles
Potential Complications
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•
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Maternal Complications: Risk of Placenta Previa, Placenta Abruptio, Preterm delivery/SROM
Fetal Complications: Tangled cords, Fetal-to-Fetal transfusion (one twin takes most of the nutrients)
Ethical/Medical Issues d/t poor outcome
o Selective reduction – Reduce the number of fetuses so that success if more likely.
Helps to avoid: Conjoined/Siamese, Cerebral Palsy, neurological deficits, learning disabilities
Nursing Interventions:
•
•
•
Prenatal visits
o Teaching points: Need more iron, required more weight gain, NPV
o 2nd trimester: Every two weeks
o 3rd trimester: Weekly
Nutritional counseling
o Iron & Vitamin supplements
o Expected weight gain = 35- 44lb (twins)
Resources and referrals
o “Mothers of Multiples” or “Parents of Twins”
o Support Groups
HYPEREMESIS GRAVIDARUM
What is it?
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
A complication of pregnancy characterized by persistent, uncontrollable nausea and vomiting that
begins in the 1st trimester and causes dehydration, ketosis, and weight loss of more than 5%.
o NOT “Morning sickness”! -- Teach all woman to report any episodes of severe n/v, or episodes
that extend beyond the 1st trimester.
Potential causes:
o Endocrine theory—high levels of hCG and estrogen during pregnancy
o Metabolic theory—vitamin B6 deficiency
o Psychological theory—psychological stress increases the symptoms
Symptoms and diagnosis
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Signs & Symptoms:
o Loss = 5% of pre-pregnancy weight
o Dehydration, fluid/electrolyte imbalance, tenting, dry mucous membranes, hypokalemia
o Woman cannot tolerate sips of fluid, food, strong smells
Management:
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•
•
Medications:
• Pyridoxine- Vitamin B6 & Unisom
• Zofran/Ondansetron
• Reglan
Non-Pharm: Ginger, Hypnosis
Interventions
• RULE OUT Gall bladder attack
• Diet: Clear liquids, crackers, TPN