CHAPTER

12

High Risk Perinatal Care:

Gestational Conditions

KEY POINTS
Hypertensive disorders during pregnancy are a leading cause of
maternal and perinatal morbidity and mortality worldwide.
Gestational hypertension is the onset of hypertension without
proteinuria after week 20 of pregnancy. Hypertension is defined
as a systolic blood pressure (BP) greater than 140mmHg or a
diastolic BP greater than 90mmHg. This should be recorded on
at least two separate occasions at least 4 to 6 hours apart but
within a maximum of a 1-week period.
Preeclampsia is a pregnancy-specific condition in which hypertension and proteinuria develop after 20 weeks of gestation in a
woman who previously had neither condition. Preeclampsia is a
multisystem disease, and the pathologic changes are present long
before clinical manifestations such as hypertension are evident.
The cause of preeclampsia is unknown, and there are no known
reliable tests for predicting women at risk for developing
preeclampsia.
Eclampsia is the onset of seizure activity or coma in a woman
with preeclampsia who has no history of preexisting disease that
can result in seizure activity.
HELLP syndrome, which is usually diagnosed during the third
trimester, is a variant of severe preeclampsia, not a separate
illness.
At 37 weeks or more of gestation, the plan of care for a woman
with mild gestational hypertension or mild preeclampsia is most
likely to be the induction of labor, preceded, if necessary, by
cervical ripening. When mild gestational hypertension or mild
preeclampsia is suspected before 37 weeks of gestation, close
observation of maternal and fetal status is necessary.
Women diagnosed with severe gestational hypertension or severe
preeclampsia should be hospitalized immediately for a thorough
evaluation of maternal-fetal status. Magnesium sulfate, the anticonvulsant of choice for preventing or controlling eclamptic
seizures, requires careful monitoring of reflexes, respirations, and
renal function.
The intent of emergency interventions for eclampsia is to prevent
self-injury, enhance oxygenation, reduce aspiration risk, and
establish control with magnesium sulfate.
The woman with hyperemesis gravidarum may have significant
weight loss and dehydration; management focuses on restoring
fluid and electrolyte balance and preventing recurrence of nausea
and vomiting.

Some miscarriages occur for unknown reasons, but fetal or placental maldevelopment and maternal factors account for many
others.
The type of miscarriage and the signs and symptoms direct care
management.
The medical management for reduced cervical competence consists of bed rest, pessaries, antibiotics, antiinflammatory drugs,
and progesterone supplementation. Surgical management may
also be chosen with placement of a cervical cerclage. Ectopic
pregnancy is a significant cause of maternal morbidity and
mortality.
Hydatidiform mole occurs in 1 in 1000 pregnancies in the United
States. The cause is unknown, although it may be related to an
ovular defect or a nutritional deficiency. Women at increased risk
are those who have had a prior molar pregnancy and those who
are in their early teens or older than 40 years of age.
Placental abruption and placenta previa are differentiated by type
of bleeding, uterine tonicity, and presence or absence of pain.
In the obstetric population, disseminated intravascular coagulation (DIC) is most often triggered by the release of large amounts
of tissue thromboplastin, which occurs in placental abruption
(the most common cause of severe consumptive coagulopathy in
obstetrics), the retained dead fetus syndrome, and the amniotic
fluid embolus (anaphylactoid syndrome of pregnancy). Severe
preeclampsia, HELLP syndrome, and gram-negative sepsis are
examples of conditions that can trigger DIC because of widespread damage to vascular integrity
Pyelonephritis is a serious medical complication of pregnancy
and the second most common nondelivery reason for
hospitalization.
Perioperative care for a pregnant woman differs from that for a
nonpregnant woman in one significant aspect: the presence of at
least one other personthe fetus.
Most maternal trauma results from MVAs and falls. Most maternal deaths are caused by MVAs.
Fetal survival depends on maternal survival. After trauma, the
first priorities are resuscitation and stabilization of the mother
before consideration of the fetus.
Maternal trauma can be associated with major complications for
the pregnancy, including placental abruption, fetomaternal hemorrhage, preterm labor and birth, and fetal death.

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