Complications of
Pregnancy
Chapters 32, 33, 34
Categories of Spontaneous
Abortion
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Complete
Incomplete
Threatened
Missed
Habitual
SPONTANEOUS ABORTION
The naturally occurring termination of a
pregnancy before viability, which is
usually defined as either before 20 wks
gestation or weight less than 500 g.
 Incidence is approx. 15%.
 Threatened AB = occurrence of any
vaginal bleeding or spotting before 20
weeks gestation (slight & dark brownred in color).
 Inevitable AB = occurs with gross ROM
& the presence of cervical dilation.

Complete AB = the cessation of pain
and bleeding after the entire conceptus
has been passed.
 Missed AB = occurs when the
conceptus dies but is not aborted before
20 weeks gestation.
 Recurrent or habitual AB = three or
more consecutive 1st trimester Abs.
 ALL women should contact their
provider if they have any spotting,
bleeding, or increased temperature.
 A pregnancy loss @ any point, can
precipitate a grieving process.
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Placental Abnormalities
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Placenta previa
Abruptio placentae
INCOMPETENT CERVIX
A cervix that begins to dilate in the 2nd
or 3rd trimester without uterine
contractions. The result, if untreated, is
usually a spontaneous abortion.
 Pelvic exams reveal progressive
cervical effacement & dilation along with
bulging membranes (a characteristic
hour-glass shape).
 Cervical cerclage is a procedure usedd
to prevent dilation when the cervix is
incompetent.

HYDATIFORM MOLE
Abnormal development of the placenta
in which the fetal part of the pregnancy
fails to develop; the chorionic villi of the
placenta become a mass of clear
vesicles that hang in clusters,
resembling a bunch of grapes.
 Occurs in the presence of an abnormal
chromosomal makeup of the zygote.
 Occurs 1/1500-2000 deliveries.
 Choriocarcinoma occurs after 3-4% of
all moles, but is more commonon after a
complete mole.

Labor Disorders
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Incompetent cervix
Preterm labor and premature rupture of
membranes
Postterm pregnancy
Disorders of Amniotic Fluid
Volume
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Polyhydramnios
Oligohydramnios
High-Risk Fetal Conditions
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Multiple gestation
Rh immunization and ABO
incompatibility
Nonimmune hydrops fetalis
Endocrine Disorders
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Diabetes
Hypothyroidism
Hyperthyroidism
DIABETES MELLITUS:
A group of metabolic diseases
characterized by hyperglycemia
resulting from defects in insulin
secretion, insulin action or both.
 Hyperglycemia causes hyperosmolarity
of the blood, which attracts intracellular
fluid into the vascular system, resulting
in cellular dehydration & expanded
blood volume.

 The
kidneys function to excrete
large volumes of urine (polyuria) in
an attempt to regulate excess
vascular volume and to excrete the
unusuable glucose (glycosuria).
 Polyuria along with cellular
dehydration, causes excessive
thirst.
 The body compensates for its
inability to convert carbohydrate
(glucose) into energy by burning
proteins (muscle) and fats.
 Diabetes
causes significant
changes in both the microvascular
& macrovascular circulations.
 Structural changes affect a variety
of organ systems, particularly the
heart, eyes, kidneys, and nerves.
 Complications resulting from
diabetes include premature
atherosclerosis, retinopathy,
nephropathy, and neuropathy.
Diabetes Classification:

Type 1 diabetes:
– An absolute insulin deficiency.
– Currently thought to be caused by an
autoimmune process, as well as those for
which the cause is unknown.

Type 2 diabetes:
– Insulin resistance & usually relative (rather
than absolute) insulin deficiency.
– Develops gradually. Many people are
obese or have an increased amt. of body
fat distributed primarily in the abd.area.
Pregestational Diabetes Mellitus:
 Label given to Type 1 or Type 2
diabetes that existed before
pregnancy.
Gestational Diabetes Mellitus (GDM):
 Any degree of glucose intolerance
with the onset or first recognition
during pregnancy.
 Insulin or noninsulin dependent.
Effects of Pregnancy:
Adjustments in maternal metabolism
allow for adequate nutrition for both the
mother and the developing fetus.
 Glucose is the primary fuel used by the
fetus. It is transported across the
placenta.
 Insulin does not cross the placenta.
 As maternal glucose levels rise, fetal
glucose levels are increased, resulting
in increased fetal insulin secretion.

Pregestational Diabetes Mellitus:
 During the 1st trimester, maternal
blood glucose levels are normally
reduced & the insulin response to
glucose is enhanced, glycemic
control is improved.
 Insulin requirements steadily
increase after the 1st trimester,
insulin dosage must be adjusted
accordingly to avoid hyperglycemia.
Pulmonary Disorders
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Asthma
Tuberculosis
Hematologic Disorders
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Immune thrombocytopenic purpura
Sickle cell disease
Fetal & Neonatal Risks /
Complications:

Sudden & unexplained stillbirth: a major
concern. Usually after 36 weeks in women
with vascular disease or poor glycemic
control. (may be associated with
preeclampsia, DKA, hydramnios, or
macrosomia; or chronic intrauterine hypoxia).
 Congenital Malformations: with insulin
dependent women, risk is 2-4 X greater. Up
to 50% of all perinatal deaths among IDM are
a result of cong.malformations. Related to
severity & duration of diabetes.
 Anomalies
commonly seen affect:
– The central nervous system.
– The cardiovascular system.
– The urinary system.
– The gastrointestinal system.
 Macrosomia:
excessive growth;
weight > 4000-4500 gm. LGA.
The infant is at risk for:
– Fractured clavicle.
– A liver or spleen laceration.
– A brachial plexus injury.
– Facial palsy.
– Phrenic nerve injury.
– Subdural hemorrhage.
 IUGR:
may be seen in infants of
diabetic mothers with vascular
disease.
– Related to compromised
uteroplacental circulation.
– May be worsened in the presence of
ketoacidosis & preeclampsia.
– The amount of O2 available to the
fetus is decreased as a result of
maternal vascular changes.
 Respiratory
Distress Syndrome
(RDS): hyperglycemia &
hyperinsulinemia may be
instrumental in delaying pulmonary
maturation in the fetus of a diabetic
mother.
 Metabolic abnormalities (30-60 min
after birth):
– Neonatal hypoglycemia.
– Hypocalcemia.
– Hypomagnesemia.
– Hyperbilirubinemia.
– Polycythemia.
Plan of Care & Interventions
Monitor frequently & thoroughly.
 Prenatal visits q 1-2 weeks during 1st &
2nd trimesters.
 Prenatal visits 1-2 X q week, during 3rd
trimester.
 Goal = achieving & maintaining
constant euglycemia, with blood
glucose levels in the range of 60-120
mg/dl.
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Diet:
– Dietary mgt is based on blood glucose (not urine)
– Energy needs are calculated on the basis of 30-35
calories per kilogram of ideal body weight, with
average diet including 2200 (1st trimester) to 2500
calories (2nd & 3rd trimesters).
– 50-60% calories should be carbohydrates
(minimum or 250 gm/day).
– 12-20% proteins.
– 20-30% fat (no more than 10% saturated fats)
– Weight gain for most women should be about
12kg during pregnancy.
 Exercise:
– Need not be vigorous to be beneficial.
– The best time for exercise is after
meals, when blood glucose level is
rising.
– Hypoglycemia may result: if exercise
is done when insulin is peaking or
engages in prolonged exercise
without carbohydrate intake.
– Exercise should stop if uterine
contractions are detected.
 Insulin
therapy:
– During 1st trimester: little or no
change in prepregnancy insulin needs
(may need to be decreased d/t
hypoglycemia).
– During 2nd & 3rd trimester: insulin
dosage must be increased to
amintain target glucose level, d/t
insulin resistance.
– Usually managed with 2-3 injections
per day.

Monitoring blood glucose levels:
– Blood sugar testing at home is the most
important tool, for determining degree of
glycemic control.
– Target levels of blood glucose during
pregnancy are lower than nonpregnant
values. 60-90mg/dl, and 3 hour
postprandial levels between 90-120mg/dl.

Urine testing: urine testing for ketones,
identifies onset of DKA. If ketones
appear at the same time each day,
some adjustment in diet may be
needed.

Fetal surveillance:
– Done for fetal growth and wellbeing.
– Done primarily in the 3rd trimester, when
the risk of fetal compromise is greatest.
– Baseline sonogram to determine EDC,
done in 1st trimester. Then q 4-6 weeks to
monitor fetal growth, estimate fetal weight,
and detect hydramnios, macrosomia, and
congenital anomalies.
– Maternal serum alpha-fetoprotein is done
at 16-18 weeks (d/t greater risk for neural
tube defects).
– Fetal echocardiography between 1822 weeks to detect cardiac
anomalies. (repeated @ 34 weeks).
– Fetal movement counts as a
sdcreening technique in fetal
surveillance.
– Non-stress test beginning at 28-30
weeks. After 32 weeks cone 2 X
week.
– Biophysical prophiile, to evaluate fetal
well-being.
– Amniocentesis to test for fetal lung
maturity. (for delivery)
 Complications
requiring
hospitalization:
– Failure to maintain acceptable blood
glucose levels, may lead to
hospitalization.
– 3rd trimester hospitalization for
women with vasculopathy (increased
risk for renal impairment,
hypertensive disorders, & fetal
compromise.
 Mode
of Birth:
– A controversy among practitioners.
– Elective labor induction btw.38-40
weeks.
– C/Section rate is around 45%. Often
performed when antepartum testing
suggests fetal distress or the
estimated fetal weight is 40004500gm.
– C/S when induction of labor is desired
and the cervix fails to respond.
Pregnancy in Special
Populations
Negative Infant Outcomes
Related to Adolescent
Pregnancy
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Prematurity
Low birth weight
Infant death
Serious respiratory problems
Negative Infant Outcomes in
Adolescent Pregnancy
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Blindness/deafness
Cerebral palsy
Mental retardation
Negative Child Outcomes in
Adolescent Pregnancy
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Neglect and abuse
Chronic cognitive defects
Developmental delays
Chronic behavioral problems
Negative Child Outcomes in
Adolescent Pregnancy (cont.)
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School failure/withdrawal
Chronic runaway
Foster/alternative placement
Effects of Smoking During
Pregnancy
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Possible perinatal loss
Small for gestational age babies
Increased premature rupture of
membranes
Increase in sudden infant death
syndrome
Contraception Methods
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Condoms with spermicides, foam,
cream, or suppositories
Oral contraceptives
Injectable progestin, Depo-Provera
and Norplant
Postcoital or morning-after pill
Women at Risk for HIV/AIDS
Infection
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History of drug use, especially
intravenous
History of prostitution
Frequent sexual intercourse with
multiple partners
Sexual intercourse with men who have
sex with other men
Women at Risk for HIV/AIDS
Infection (cont.)
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Residence in an area of the
country with high prevalence of
HIV and AIDS
Received a blood transfusion or
blood products prior to 1985
Having sex with someone with
any of the above risk factors
Signs of HIV Infection in
Infants
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Opportunistic infections such as
PCP and interstitial lymphocytic
pneumonia
Candida diaper rash, thrush, and
diarrhea
Recurrent bacterial infections
Growth failure, neurologic
problems, and developmental
delays
Antiretroviral Drug Therapy
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Nucleoside reverse transcriptase
inhibitors: zidovudine, didanosine,
salcitabine
Nonnucleoside reverse
transcriptase inhibitors:
nevirapine, delavirdine, lovirdine
Protease inhibitors: saquinavir,
indinivir, ritonavir, nelfinavir
Anticipatory Guidance for
Mothers Over 35 Years Old
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Counseling related to genetic
testing, amniocentesis, and
chorionic villus sampling
Identification of appropriate social
support
Potential medical problems