Complications of Pregnancy
Ana H. Corona, MSN, FNP-C
Nursing Instructor
February 2009
Assessment Fetal Well Being
Ultrasound
Nonstress test
Fetal acoustic stimulation test and
vibroacoustic stimulation test
Fetal biophysical profile
Fetal movements
Biochemical assessments
Assessment Fetal Well Being
Amniocentesis
Chorionic villi sampling
Contraction stress test
External fetal monitoring
Internal fetal monitoring
Nonstress Test (NST)
Procedure used to monitor fetal response
to movement.
FHR acceleration with fetal movement is
reassuring and a sign of fetal well being
Semi-Fowler's or side-lying position
Baseline fetal heart rate recorded
FHR pattern for monitored 20–30
minutes
Patient marks paper with each perceived
fetal movement
Nonstress Test (NST)
Result Criteria
Reactive (normal) In a 20-minute period,
two or more fetal heart rate accelerations
of at least 15 beats per minute above the
baseline heart rate
Nonreactive (abnormal) No fetal heart
rate accelerations over a 40-minute
period.
Contraction Stress Test
 High Risk Patient: Diabetic Patient
 Method of externally monitoring the fetus.
 Measures the ability of the placenta to provide
enough oxygen to the fetus during contractions.
 Oxytocin IV or nipple stimulation will be used to
induce contractions.
 Oxytocin Challenge Test: IV until 3 uterine
contractions are observed, lasting 40 - 60
seconds, over a 10-minute period.
Electrical Fetal Heart Monitoring
Accelerations: common - normal
Early Decelerations: vagal stimulation to
the fetal head during a contraction which
push the head toward the pelvis - normal
Late Decelerations: Utero-Placental
insufficiency (fetal blood flow compromised,
less oxygen!!! - abnormal
Variable Decelerations: cord compression
nuchal cord, knot, decreased amniotic fluid abnormal
Alpha-Fetoprotein (AFP)
Multipe Marker Screening: Genetic Test
Spina-Bifida
Anencephaly
Omphalocele
Tetralogy of
Duodenal atresia
Turner Syndrome
Intrauterine death
Done between 15 – <20 weeks gestation
BPP
Includes 5 components:
Fetal breathing movements
Gross body movements
Fetal tone
AFI
NST - reactive
AFI
Polyhydramnios – too much amniotic fluid
AFI of more than 24 cm
Oligohydramnios – too little amniotic fluid
AFI less than 7 cm
Studies show that oral hydration, by having the
women drink 2 liters of water, increases the AFI
by 30%.
Abruptio Placenta
 Premature separation from wall of uterus of a normally
implanted placenta.
 Abnormally short umbilical cord
 Abdominal Injury
 Sudden loss in amniotic fluid
Abruptio Placenta





Abdominal pain
Vaginal bleeding
Back pain
Symptoms include a rigid, painful abdomen.
Irreversible brain damage or fetal death may occur if
hypoxia is not reversed quickly.
Placenta Previa
 Implantation is in
lower uterine segment
with placenta lying
over or very near the
internal cervical os.
 Symptoms include
painless bleeding in
the last half of
pregnancy.
 Treat to maintain the
pregnancy until fetus
mature enough to
survive outside uterus
Ectopic
Pregnancy
 Abnormal pregnancy
that occurs outside the
uterus.
 Symptoms include:
 Missed menstrual
period
 Pelvic/Abdominal pain
 Spotty vaginal bleeding
 Pain in the shoulder
 Fainting
 nausea
Hyperemesis Gravidarum
Excessive vomiting during pregnancy.
Physiological and psychological factors
may be involved.
Treatment goals: control vomiting, correct
dehydration, restore electrolyte balance,
and maintain adequate nutrition.
Hydatidiform Mole
 Gestational Trophoblastic
Disease or molar pregnancy
 Abnormality of placenta–
chorionic villi become fluidfilled, grapelike clusters.
 Classic signs are bleeding,
uterine enlargement, no fetal
heart tones, hyperemesis
gravidarum, or symptoms of
PIH appear before 24 weeks.
 Choriocarcinomas are highly
malignant tumours may follow
a molar pregnancy.
Hydatidiform Mole
 The primary
diagnostic tool is
ultrasound.
 The mole is removed
surgically.
 The client must be
followed for 1 to 2
years to monitor for
metastasis.
Pregnancy Induced Hypertension (PIH)
Most common hypertensive disorder in
pregnancy, after 20 weeks’ gestation.
Only cure is delivery of the baby.
Mild preeclampsia–blood pressure
increases 30 mm Hg systolic or 15 mm Hg
diastolic over baseline on two occasions at
least 6 hours apart.
May be asymptomatic
PIH
Edema noted in face and hands.
Objectively defined as weight gain of more
than 1 pound a week.
Urine may show 1+ or 2+ albumin.
Proteinuria usually the last of the three
classic symptoms to appear.
PIH
Severe preeclampsia–blood pressure
increases to 160/110 or higher.
Generalized edema in face, hands, sacral
area, lower extremities, abdomen.
Weight gain may be 2 pounds a week.
Urinary albumin may be 3+ or 4+.
PIH
Other symptoms: continuous headache,
blurred vision, scotomata, nausea,
vomiting, irritability, hyperreflexia, and
epigastric pain.
Epigastric pain often last symptom
identified before client moves into
eclampsia.
Eclampsia
Eclampsia–grand mal seizures.
Without treatment, the client may die.
Treat to lower blood pressure, prevent
convulsions, and deliver a healthy baby.
Magnesium sulfate given to prevent
convulsions.
Magnesium Sulfate
Respirations must be at least 14/minute.
Toxicity: Respiratory depression to
paralysis
Deep tendon reflexes must be kept at
normal response.
Urine output must be at least 30 cc/hr.
Monitor serum magnesium level.
1.5 – 3mEq/L
Calcium gluconate is antidote for
magnesium sulfate–keep at bedside.
Disseminated Intravascular Coagulation
Over stimulation of normal clotting
process, occurs as complication of a
primary problem.
Pregnancy Induced Hypertension
It can cause fetal death.
Symptom onset sudden: dyspnea, chest
pain, restlessness, cyanosis, and spitting
frothy, blood-tinged mucous.
Disseminated Intravascular Coagulation
Underlying cause must be identified and
corrected.
The fetus must be delivered.
IV administration of blood, and other blood
products
Heparin is given continuously.
Oxygen therapy
Pregnancy and Diabetes
 Hyperglycemia
 May be due to inadequate insulin action or due to
impaired insulin secretion
 Type 1 – insulin deficiency
 Type 2 – insulin resistance
 GDM – glucose intolerance during pregnancy
 10th week fetus produces it own insulin
 Insulin does not cross the placental barrier
 Glucose levels in the fetus and directly proportional to
the mother
 2nd and 3rd trimesters – decreased tolerance to glucose,
increased insulin resistance, increased hepatic function
of glucose
Diabetic Neuropathy
Increased risks for:
Preeclampsia
IUGR
PTL
Fetal distress
IUFD
Neonatal death
DM
Poor glycemic control is associated with
increased risks of miscarriage at time of
conception
Poor glycemic control in later part of
pregnancy is assoc. with fetal macrosomia
and polyhydramnios
May compress on the vena cava and aorta
causing hypotension, PROM, PP
hemorrhage, maternal dyspnea
DM
Disproportionate increase in shoulder and
trunk size
4000-4500gms or greater
Fetus will have excess stores of glycogen
Increased risks of
Shoulder dystocia
C/S
Assisted deliveries
Neonatal Hypoglycemia
 Usually 30-60 minutes after birth
 Due to high glucose levels during pregnancy
and rapid use of glucose after birth
 Related to mothers level of glucose control
 Neonates normal glucose level: 40-65mg/dl
 Premature infants: 20-60mg/dl
IUGR
 Compromised uteroplacental insufficiency
 02 available to the fetus is decreased
Fetal Surveillance
NSTs done around 26 weeks, weekly
At 32 weeks done biweekly with NST/BPP
What complications should the nurse be alert
for when the mother is experiencing gestational
diabetes?
 Maternal complications – infections, difficult labor
related to increased fetal size, vascular complications
(retinopathy) azotemia, ketoacidosis, increased
incidence of hypertensive disorders (preeclampsia and
c-section)
 Fetal complications: stillbirth, spontaneous abortion,
hydraminos, large placenta, Macrosomia, congenital
anomalies, neonatal hypoglycemia, neonatal
hyperbilirubinemia, increase incidence of respiratory
distress syndrome and fetal or neonatal death
Chronic hypertension
BP 140/90 or higher before pregnancy or
before the 20th week of gestation that
lasts longer than 6 weeks after delivery.
Clients with moderate to severe chronic
hypertension are most at risk to develop
PIH.
Maternal Heart Disease
 The heart must compensate for the normal blood volume
increase and workload
 If the cardiac changes are not well tolerated than cardiac
failure can develop
 1% of pregnancies are complicated by heart disease
 Cardiac output is increased
 Peak of the increase 28-32 weeks gestation.
 Prenatal care visits should be more often than usual.
 Cardiac problems should be managed with cardiologist
 Mortality with pulmonary hypertension and pregnancy is
more than 50%
 Diet: low sodium
 Avoiding anemia
 Avoid strenuous activity
 Monitor for: cardiac failure (CHF) and pulmonary
congestion
Nursing Care during labor
 Side lying position
 Prophylactic antibiotic
 Epidural
 Attempt vaginal
delivery
 If anticoagulant
therapy is needed:
Heparin
Lovenox
Phenylketonuria
 Individuals with PKU cannot process a part of
protein called phenylalanine present in most
foods.
 phenylalanine builds up in the bloodstream and
causes brain damage and mental retardation.
 The characteristic features of maternal PKU
syndrome include mental retardation,
microcephaly, (IUGR)intrauterine growth
retardation, and congenital heart defects
 When woman with PKU keeps her phenylalanine
level less than 2.0 mg/dL while pregnant,
outcome of pregnancy better.
TORCH: acronym for maternal infections
Toxoplasmosis (TO) - protozoan infection,
neonatal effects – jaundice, hydrocephalus,
microcephaly
Rubella (R) - congenital deformities
Cytomegalovirus (C) - CNS damage to fetus
Herpes genitalis (H) - Perinatal loss. Fetus
may pick up virus if present in the vagina
during labor
If untreated: abortion, congenital anomalies,
fetal infections, IUGR, preterm labor, mental
retardation, or death.
TORCH RESULTS
HIV/AIDS
Weight gain is a challenge for pregnant
HIV-infected client.
HIV may be transmitted to fetus through
placenta, during birth, or during breast
feeding.
Nutritional counseling and support may be
necessary.
Congenital defects such as microcephaly
(abnormal smallness of the head) and
facial deformities.
Hemolytic Diseases
 Rh incompatibility–
can only happen
when mother is Rh
negative and fetus is
Rh positive.
 ABO incompatibility–
problem occurs when
maternal blood enters
fetal circulation.
Hemolytic Disease
 Basic incompatibility of
blood, such as ABO
incompatibility, or from
transfer of antibodies
through the placenta
 Erythroblastosis fetalis is
a type of hemolytic
anemia that occurs in
newborns as a result of
maternal fetal blood
group incompatibility,
especially involving the
Rh factor and ABO blood
groups
RhoGam
RhoGam 300mcg IM given at 28 weeks
of pregnancy and 72 hrs of delivery (Rh
negative, abortion, ectopic pregnancy
and amniocentesis).
A card is given
Mom needs to carry card with her at all
times
Phototherapy – bilirubin levels reach 12
to 15 mg/dl
Hemolytic Disease
 Blood Typing
 Indirect Coomb’s test of maternal blood –
measures the number of maternal antibodies
 Antibody titer test – level of maternal antibodies,
if exceeds 1:16 amniocentesis may be
performed
 Optical density studies – measure bilirubin level,
fetal condition
 After delivery – direct Coomb’s test (infant blood
to determine the presence of antibody coated
RBCs (bilirubin)
Multiple pregnancy
First trimester proceeds much the same as
with a single fetus.
As uterus grows, greater pressure on and
displacement of the internal organs.
Greater risk of fetal anomalies, abnormal
presentations, and preterm birth.
Substance Abuse
Substance abusers may not seek prenatal
care until late in pregnancy.
Most do not voluntarily admit addiction.
These mothers have an increased rate of
complications.
They often use available money for drugs
instead of food.
Smoking
 Risks:
SAB
SGA
Bleeding
IUFD
Prematurity
SIDS
Alcohol
 Risks:
LBW
Mental retardation
Learning and
physical deficits
With FAS – severe
facial deformities
OPIATES IN PREGNANCY
Drugs include: heroin, Demerol, morphine,
codeine, methadone
Methadone is used to treat addiction to
other opiates
Possible effects on pregnancy and heroin
use are: Preeclampsia, PROM, infections,
PTL
Tx: Methadone and psychotherapy
Goal: prevent withdrawal symptoms
COCAINE DURING PREGNANCY
 Maternal effects:
 Cardiovascular stress
 Tachycardia
 HTN
 Dysrhythmias
 MI
 Liver damage
 Sz
 Pulmonary disease
 Death
 Fetal Complications:
 Abruptio placentae
 PTL
 Precipitous labor
 Risks for abdominal
pregnancy
 Fetal complications after
delivery
Questions
 The acronym for maternal infections is:
1.
2.
3.
4.
TORCH
LATCH
MEALS
HELLP
Answer is 1
T
O
R
C
H
•
Rho (D) immune globulin (RhoGAM) is prescribed for a
woman following delivery of a newborn infant and the
nurse provides information to the woman about the
purpose of the medication. The nurse determines that
the woman understands the purpose of the medication if
the woman states that it will protect her next baby from
which of the following?
1.
2.
3.
4.
Being affected by Rh incompatibility
Having Rh positive blood
Developing a rubella infection
Developing physiological jaundice
Answer is 1
1. Administration of Rho (D) immune
globulin prevents the woman from
developing antibodies against Rh
positive blood by providing passive
antibody protection against the Rh
antigen.
 A woman with preeclampsia is
receiving magnesium sulfate. The
nurse assigned to care for the client
determines that the magnesium
therapy is effective if:
1. Ankle clonus in noted
2. The blood pressure decreases
3. Seizures do not occur
4. Scotoma’s are present
Answer is 3
For a client with preeclampsia, the goal of
care is directed at preventing eclampsia
(seizures).
Magnesium sulfate is an anticonvulsant, not
an antihypertensive agent. Although a
decrease in blood pressure may be
noted initially, this effect is usually
transient.
A nurse is caring for a pregnant client with severe
preeclampsia who is receiving IV magnesium sulfate. Select
all nursing interventions that apply in the care for the client.
1. Monitor maternal vital signs every 2 hours
2. Notify the physician if respirations are less than 18 per
minute.
3. Monitor renal function and cardiac function closely
4. Keep calcium gluconate on hand in case of a
magnesium sulfate overdose
5. Monitor deep tendon reflexes hourly
6. Monitor I and O’s hourly
7. Notify the physician if urinary output is less than 30 ml
per hour.
Answers: 3, 4, 5, 6, 7
 When caring for a client receiving magnesium
sulfate therapy, the nurse would monitor
maternal vital signs, every 30-60 minutes and
notify the physician if respirations are less than
12.
 Calcium gluconate is kept on hand in case of
magnesium sulfate overdose.
 Deep tendon reflexes are assessed hourly.
Cardiac and renal function is monitored closely.
The urine output should be maintained at 30 ml
per hour because the medication is eliminated
through the kidneys.
 A 21-year old client, 6 weeks’ pregnant is
diagnosed with hyperemesis gravidarum.
This excessive vomiting during
pregnancy will often result in which of the
following conditions?
1.
2.
3.
4.
Bowel perforation
Electrolyte imbalance
Miscarriage
Pregnancy induced hypertension (PIH)
Answer is 2
Excessive vomiting in clients with
hyperemesis gravidarum often causes
weight loss and fluid, electrolyte, and acidbase imbalances.
 A nurse is assessing a pregnant client in
the 2nd trimester of pregnancy who was
admitted to the maternity unit with a
suspected diagnosis of abruptio
placentae. Which of the following
assessment findings would the nurse
expect to note if this condition is
present?
1.
2.
3.
4.
Absence of abdominal pain
A soft abdomen
Uterine tenderness/pain
Painless, bright red vaginal bleeding
Answer is 3
In abruptio placenta, acute abdominal pain
is present. Uterine tenderness and pain
accompanies placental abruption,
especially with a central abruption and
trapped blood behind the placenta. The
abdomen will feel hard and boardlike on
palpation as the blood penetrates the
myometrium and causes uterine irritability.
 A maternity nurse is preparing for the admission
of a client in the 3rd trimester of pregnancy that
is experiencing vaginal bleeding and has a
suspected diagnosis of placenta previa. The
nurse reviews the physician’s orders and would
question which order?
1. Prepare the client for an ultrasound
2. Obtain equipment for external electronic fetal
heart monitoring
3. Obtain equipment for a manual pelvic
examination
4. Prepare to draw a Hgb and Hct blood sample
Answer is 3
Manual pelvic examinations are
contraindicated when vaginal bleeding is
apparent in the 3rd trimester until a
diagnosis is made and placental previa is
ruled out.
Digital examination of the cervix can lead
to maternal and fetal hemorrhage.
 An ultrasound is performed on a client at term
gestation that is experiencing moderate vaginal
bleeding. The results of the ultrasound indicate
that an abruptio placenta is present. Based on
these findings, the nurse would prepare the
client for:
1.
2.
3.
4.
Complete bed rest for the remainder of the pregnancy
Delivery of the fetus
Strict monitoring of intake and output
The need for weekly monitoring of coagulation studies
until the time of delivery
Answer is 2
2. The goal of management in abruptio
placenta is to control the hemorrhage and
deliver the fetus as soon as possible.
Delivery is the treatment of choice if the
fetus is at term gestation or if the bleeding
is moderate to severe and the mother or
fetus is in jeopardy.
 The nurse is caring for a woman who
is 37-weeks gestation diagnosed with
PIH. The nurse would be MOST
concerned by which of the following
findings?
1. B/P 150/95
2. 4+ proteinuria.
3. The patient c/o right quadrant pain.
4. 3+ pitting edema of the ankles
Answer is C
Explanation of Answer:
This indicates impaired liver function, sign
of impending eclampsia.
 WHICH OF THE FOLLOWING IS A
CHARACTERISTIC OF A REASSURING
FETAL HEART RATE PATTERN?
1. A FHR OF 170–180 bpm
2. A BASELINE VARIABILITY OF 25–
35BPM
3. OMINOUS PERIODIC CHANGES
4. ACCELERATION OF FHR WITH FETAL
MOVEMENTS
Answer is D
Accelerations with movement are normal.
 Which of the following matches the
definition: abnormal placenta
development covering the cervix?
1. Placenta Previa
2. Abruptio Placentae
3. Multigravida
4. Proliferative phase
Answer is 1
The right answer was Placenta Previa.
 Which of these is not considered a
T.O.R.C.H. infection?
1. Rubella
2. Herpes
3. Cytomegalovirus
4. HIV
Answer is 4
The right answer was HIV