2
11/8/2023
1
Pregnancy Related Complications
3
Ricci Chapter 19
ATI Chapters 7 & 9
NUR 212
•Dr. Baker Stein DNP, RN, CNE
2
3
Healthy People 2030 Objectives
• Reduce severe maternal complications of pregnancy identified during labor and
delivery hospitalizations.
4
• Reduce preterm births.
4
Common Causes of Hemorrhage
1st half of Pregnancy
• Abortion
• Ectopic Pregnancy
3
5
• Gestational Trophoblastic
5
6
Abortion
6
4
1
Spontaneous Abortion
1 • “Miscarriage”
• SAB
• Most occur before 12 weeks
•
2 Causes:
• Congenital Abnormalities
5
• Maternal Infection
• Maternal Endocrine Disorders
6
• Defects in cervix or uterus
1
7
•
2
7
8
Types of Abortions
8
9
Dilation & Vacuum Curettage (D & C )
10
9
10
11
11
7
Dilation & Evacuation
2 (D & E)
Ectopic Pregnancy
(out of place)
1
10
9
11/8/2023
10
11
11
Ectopic Pregnancy
(out of place)
• I in every 50 pregnancies
• 2% of all pregnancies
12
• Risk Factors?
12
Gestational Trophoblastic Disease
13
“Hydatidiform Mole” “Choriocarcinoma”
• Abnormal cell growth ~ placenta develops but not the fetus
• 110-120 / 100,000 pregnancies
• Management
• Evacuation of molar pregnancy
• Regular follow-up for 1 year to detect malignant changes
13
14
Cervical Insufficiency
14
• Premature dilation of cervix
• Cause unknown; possibly due to cervical damage
15
15
Therapeutic Management
• Bed rest, pelvic rest, avoidance of heavy lifting
• Cervical Cerclage
16
16
Hemorrhagic Conditions of Late Pregnancy
• Placenta Previa
• Abruptio Placentae
17
17
Placenta Previa
Implantation of the placenta in the lower uterus
Stats:
• 1st pregnancy: 1:400
• After PCB: 1:160
• After 2nd RCB: 1:60
• After 3rd RCB: 1:30
• After 4th RCB: 1:10
18
Classifications of Placenta Previa
18
19
19
20
2
11/8/2023
18
18
19
Classifications of Placenta Previa
19
Placenta Previa
20
20
21
Vaginal bleeding (painless, bright red in second or third trimester, spontaneous
cessation then recurrence)
Placenta Previa
Monitoring of maternal–fetal status
• Vaginal bleeding; pad count
• Avoidance of vaginal exams
• FHR
Support and education: fetal movement counts, effects of prolonged bed rest (if
necessary); signs and symptoms to report
21
Risk factors
22
• AMA
• Prior Previa
• Smoking
• Cocaine use
• HTN, DM
• Multiparity
• RCB
• Previous Myomectomy
•
•
22
23
Marginal “Low – lying”
23
• Placenta implanted in lower uterus
• Appears to move ~ drawn upward as myometrium beneath it develops with
pregnancy
24
24
25
25
Total Previa
Delivery?
Abruptio Placentae
• Separation of a normally implanted placenta before the fetus is born
• Bleeding and formation of a hematoma on the maternal side of the placenta
• Bleeding may be visible or concealed.
• 10% of preterm births
• 10-20% of perinatal deaths
• Abruptio placentae is accompanied by pain, uterine tenderness, and uterine
hyperactivity.
26
26
27
3
11/8/2023
26
27
26
28
26
27
29
27
28
30
28
29
29
30
30
31
31
31
32
32
33
• Abruptio placentae is accompanied by pain, uterine tenderness, and uterine
hyperactivity.
•
5 Classic Signs
Risk Factors
Risk Factors
Intrapartum Emergencies
Placental abnormalities
• Placenta accreta
• Placenta increta
• Placenta percreta
Placenta Abnormalities
All or part of the placenta attaches abnormally to the myometrium Three grades
defined according to the depth of invasion
Accreta – chorionic villi attach to the myometrium, rather than being restricted within
the decidua basalis.
Increta – chorionic villi invade into the myometrium.
Percreta – chorionic villi invade through the perimetrium (uterine serosa).
Hyperemesis Gravidarum
33
• Severe form of nausea and vomiting
• Symptoms usually resolve by week 20
• Weight loss >5% of prepregnancy body weight
• Dehydration, metabolic acidosis, alkalosis, and hypokalemia
•
•
34
Laboratory and Diagnostics
32
33
• Liver enzymes r/o Hepatitis, Pancreatitis, Cholestasis
34
34
• CBC r/o dehydration(increase RBC & hematocrit)
• Electrolytes (decrease K, Na) *vomiting loss of hydrochloric acid
• Ultrasound r/o “molar” pregnancy
•
35
Therapeutic Management
36
35
37
35
36
37
36
4
11/8/2023
35
Therapeutic Management
38
36
Weight Loss or Electrolyte Imbalance
37
Hypertension During Pregnancy
39
38
Gestational Hypertension (PIH)
• Blood pressure elevation after 20 weeks of pregnancy
• Not accompanied by proteinuria
• Resolves 12 weeks PP
• If it persists chronic hypertension may be diagnosed
39
Preeclampsia
• Generalized vasospasm decreases circulation to ALL organs of the body including the
placenta.
40
• Hypertension with proteinuria (*current research)
41
42
• Systolic greater than 140 mm Hg
• Diastolic greater than 90 mm Hg
43
____________
•Cure???
PreEclampsia
40
44
41
42
43
44
Symptoms / Diagnostics / Assessments
• Cardiovascular
•
• Central Nervous System
•
• Renal
• Hepatic
• Placenta
45
Eclampsia
Progression of preeclampsia to generalized seizures
• Facial twitching …. Rigid body
Med to prevent seizure?
45
46
5
11/8/2023
Med to prevent seizure?
46
Magnesium Sulfate
• Action?
• How does patient “feel” with this med?
• Adverse Reactions?
•
• Antidote: Calcium gluconate (slow IVP)
47
HELLP Syndrome
48
• Hemolysis ~ fragmentation and distortion of erythrocytes during passage through
damaged blood vessels.
• Liver enzyme levels increase ~ hepatic blood flow is obstructed by fibrin deposits.
• Low platelet levels ~ vascular damage resulting from vasospasm.
49
Disseminated intravascular coagulation (DIC)
• Pro-coagulation and anti-coagulation factors are simultaneously activated.
• Thromboplastin activates widespread clotting
• “Uses up” other clotting factors ~ platelets
• in clotting factors &
anticoagulants = BLEEDING
50
Progression
51
Incompatibility Between Maternal and Fetal Blood
• Rh incompatibility (reviewed with PP)
• Rh– woman conceives an Rh+ child
• Maternal antibodies may then develop after exposure to fetal Rh+ blood
• Administration of RhoGAM
52
53
6
11/8/2023
52
53
ABO incompatibility
• Mother: O blood type
• Fetus: A, B, AB (antigens not present in O)
• May cause hemolysis of fetal RBC
•
•
•
• May result in hyperbilirubinemia of the infant
• Direct Coombs test
•
54
Polyhydramnios
• Amniotic fluid >2,000 mL 32-36 weeks
• 2% of all pregnancies
• Fetal anomalies ~ upper GI, neural tube, impaired swallowing
• 18% w/maternal DM,
• increased cesarean delivery, low 5-minute APGAR
•
55
Oligohydramnios
Amniotic fluid <500 mL
• US
• NST
• Amnioinfusion
56
7