Chapter 25 Complication of Pregnancy

1. Hemorrhagic conditions of early pregnancy a. Abortion- The loss of a fetus before it is viable. The medical consensus today is that a fetus of less than 20 weeks of gestation or one weighing less than 500g is not viable. i. Spontaneous abortion 1. Occur without action from anyone 2. Most occur within 12 weeks 3. Common cause: severe congenital abnormalities ii. Threatened abortion 1. 1st sign is vaginal bleeding 2. Uterine cramping, persistent backache, pelvic pressure 3. Advise the woman to limit physical activity and sex, count the pads she uses. iii. Inevitable abortion 1. Cannot be stopped 2. Membrane ruptures and the cervix dilates 3. Natural expulsion, D&C, or vacuum to remove fetus 4. Uterus shrinks 5. Bleeding (may) occur 6. D&C is performed for early pregnancy less than 12 weeks 7. D&E for later pregnancy 8. Infection is the primary concern iv. Incomplete abortion 1. Not all product of conception are expelled 2. Uterine cramping and heavy bleeding 3. Cervix is open and fetal and placental tissue is passed 4. Stabilize womans cardiovascular state 5. D&C performed and oxytocin is administered to control bleeding 6. *D&Cs cannot be performed past 14 weeks due to excessive bleeding v. Complete abortion 1. All products are expelled 2. Hormone levels fall 3. Negative pregnancy test 4. Uterus shrink vi. Missed abortion 1. Fetus dies during the 1st of the pregnancy but is retained in the uterus 2. Early symptoms of pregnancy disappear 3. D&C performed and oxytocin is administered to control bleeding 4. *D&Cs cannot be performed past 14 weeks due to excessive bleeding

vii. Recurrent and spontaneous abortion 1. 3 or more spontaneous abortions 2. Primary cause is genetics or an incompetent uterus b. Ectopic pregnancy i. Implantation of the of a fertilized ovum in an area outside the uterine cavity ii. 98% occur in the fallopian tube iii. disaster of reproduction 1. Significant cause of maternal death from hemorrhage 2. Reduces the chance of subsequent pregnancies due to fallopian tube damage iv. Most common is Ampular v. Risk factors 1. STD 2. Pelvic inflammatory disease 3. Failed tubal ligation 4. Intrauterine device 5. Multiple induced abortions 6. 35 y/o and older vi. Hypovolemic shock is a major concern vii. Diagnosed through transvaginal ultrasound and human chorionic gonadatropian viii. Common signs 1. bluish swelling of the fallopian tube 2. missed periods 3. positive pregnancy test 4. abdominal pain 5. vaginal spotting ix. Nursing care focuses on 1. Early detection/prevention of hypovolemic shock 2. Pain control 3. Psychological support x. When methotrexate is used note that 1. Abdominal cramping is common 2. Woman should avoid alcohol, sex, folic acid c. Gestational Trophoblastic Disease (Hydatidiform Mole) i. Complete mole- ovum is fertilized by sperm that duplicates its own chromosomes while the maternal chromosomes in the ovum are inactivated(has NO fetal tissue) ii. Partial mole- maternal contribution is usually present but the paternal contribution is doubled and therefore the karyotype is triploid (69, XXY, or 69 XYY) (has SOME fetal tissue) 1. Peripheral cells attach the fertilized ovum to the uterine wall develop abnormally

2. Placenta develops but usually not any part of the fetus 3. Grapelike cluster form 4. More common among Asian 5. Diagnosed through routine ultrasound 6. Can become malignant and spread 7. The woman should use birth control for at least 1 year. 2. Hemorrhagic conditions of late pregnancy a. After 20 weeks of pregnancy the 2 major causes of hemorrhage are i. Placenta Previa 1. Implantation of the uterus in the lower uterus a. Marginal-implanted in the lower uterus further than 3cm from the internal cervical OS b. Partial- implanted in the lower uterus within 3cm of the internal cervical OS c. Total- implantation completely covers the cervical OS 2. Signs a. Painless spontaneous bleeding at the end of pregnancy i. Painless because it is not enclosed and there isnt additional pressure b. Corticosteroids speed lung development ii. Abruptio Placentae 1. Marginal abruption with external bleeding 2. Partial abruption with concealed bleeding 3. Complete abruption with concealed bleeding 4. Maternal risks a. Hemorrhage b. Hypovolemic shock 5. Fetal risks a. Asphyxia b. excessive blood loss c. prematurity 3. Hyperemesis Gravidarum (HEG) a. Persistent uncontrollable vomiting that begins in the 1st weeks and may last throughout the entire pregnancy b. Severity usually lessens over time c. Cause is unknown d. Woman should eat every 2-3 hours e. Salt helps replace lost chloride 4. Hypertensive disorders a. Gestational hypertension i. Elevated BP after 20 weeks of pregnancy unaccompanied by proteinuria. Can progress to preeclampsia

b. Preeclampsia i. A systolic BP of greater than 140mm Hg or a diastolic BP greater than 90mm Hg occurring after 20 weeks. c. Eclampsia i. Progression of preeclampsia to generalized seizures that cannot be attributed to other causes. Seizures may occur postpartum d. Chronic hypertension i. Systolic BP greater than 140mm Hg or diastolic greater than 90mm Hg that existed before pregnancy or developed before 20 weeks of gestation e. Preeclampsia superimposed on chronic hypertension i. Development if new-onset proteinuria greater than 0.3g in a 24hr urine collection in a woman who has had chronic hypertension 5. Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome 6. Incompatibility between maternal and fetal blood a. Rhesus factor occurs when the mother is Rh-negative and the fetus is Rh-positive i. Rh negative is an autosomal recessive trait 1. The gene must be inherited from both parents b. When the mother is exposed she develops antibodies i. The first child is usually not effected however the second is c. The mother needs to receive Rh (D) immune globulin d. Blood type and Rh testing occur at the 1st prenatal visit e. Coombs test determines if the woman has been exposed to Rh negative blood 7. ABO incompatibility a. Occurs when the mother is type O and the fetus is type A, B, or AB b. Less severe than Rh incompatibilities c. Cord blood is tested (Direct coombs test) d. No extra prenatal care is needed