2. Selected Pregnancy Complications



Selected Pregnancy Complications


Early Pregnancy Bleeding


Miscarriage (Spontaneous Abortion)


Miscarriage is a pregnancy that ends as a result of natural causes before 20 weeks of gestation. A fetal weight less than 500 g also may be used to define a miscarriage.


Incidence



Etiology


Early (Before 12 Weeks of Gestation)


Late (Between 12 and 20 Weeks of Gestation)


Types of Miscarriage


Table 2-1 lists types of miscarriage and describes signs and symptoms associated with each type.



TABLE 2-1


Miscarriage: Assessment and Usual Management





























































Type of Miscarriage Amount of Bleeding Uterine Cramping Passage of Tissue Cervical Dilation Management
Threatened Slight, spotting Mild No No
Inevitable Moderate Mild to severe No Yes
Incomplete Heavy, profuse Severe Yes Yes, with tissue in cervix
Complete Slight Mild Yes No (cervix has already closed after tissue passed)
Missed None, spotting None No No
Septic Varies, usually malodorous Varies Varies Yes, usually
Recurrent (generally defined as three or more consecutive miscarriages) Varies Varies Yes Yes, usually


Image


hCG: Human chorionic gonadotropin.


Sources: Cunningham, F., Leveno, K., Bloom, S., Hauth, J., Rouse, D., & Spong, C. (2010), Williams obstetrics (23rd ed.). New York: McGraw-Hill; Gilbert, E. (2011). Manual of high risk pregnancy & delivery (5th ed.). St. Louis: Mosby.


Management


Management depends on the classification of the miscarriage and on signs and symptoms (see Table 2-1).



ent Traditionally, threatened miscarriages have been managed expectantly with supportive care. Follow-up treatment depends on whether the threatened miscarriage progresses to actual miscarriage or symptoms subside and the pregnancy remains intact. If bleeding and infection do not occur, expectant management is a reasonable option. In approximately half of all threatened miscarriages managed in this way, the pregnancy continues.


ent Medical management is another treatment option if bleeding and infection are not present. Prostaglandin medications (e.g., misoprostol [Cytotec]) may be given orally or vaginally and are usually effective in completing the miscarriage within 7 days. If the products of conception are not passed completely, the woman may be prepared for manual or surgical evacuation of the uterus.


ent Surgical management consists of dilation and curettage (D&C), a procedure in which the cervix is dilated and a curette is inserted to scrape the uterine walls and remove uterine contents. Before a D&C is performed, a full history should be obtained and general and pelvic examinations performed. General preoperative and postoperative care is appropriate for the woman requiring surgical intervention for miscarriage.


Postprocedure Care (Applies to Medical and Surgical Management)



Ectopic Pregnancy


An ectopic pregnancy is a pregnancy in which the fertilized ovum is implanted outside the uterine cavity. The most common site of implantation is the uterine (fallopian) tube, where approximately 95% of ectopic pregnancies occur. Other much less common implantation sites include the abdominal cavity, ovary, and cervix. Ectopic pregnancy is the leading cause of first-trimester maternal mortality and a leading cause of infertility.


Incidence


The reported incidence of ectopic pregnancy rose through 1990 in the United States. Since then, because more cases are managed medically, reliable data on the actual number of ectopic pregnancies have not been available. Improved diagnostic techniques, however, have likely resulted in the identification of more cases.


Etiology



Signs and Symptoms



Diagnosis



Management



ent Surgical management depends on the location and cause of the ectopic pregnancy, the extent of tissue involvement, and the woman’s desires regarding future fertility. Options include:


ent Salpingectomy


ent Salpingostomy


ent General preoperative and postoperative care is appropriate


ent Preoperative laboratory tests include determination of blood type and Rh factor, complete blood count (CBC), and serum quantitative β-hCG level.


ent Ultrasonography is used to confirm an extrauterine pregnancy.


ent Blood replacement may be necessary.


ent Administer Rho(D) immunoglobulin if appropriate.


ent A contraceptive method should be used for at least three menstrual cycles to allow time for the woman’s body to heal.


ent Medical management involves giving methotrexate to dissolve the tubal pregnancy. Methotrexate is an antimetabolite and folic acid antagonist that destroys rapidly dividing cells.


ent The woman must be hemodynamically stable to be eligible for medical management.


ent The best results following methotrexate therapy are usually obtained if the mass is unruptured and measures less than 3.5 cm in diameter by ultrasound, if no fetal cardiac activity is noted on ultrasound, and if the serum β-hCG level is less than 5000 milli-International Units/ml.


ent The woman must also be willing and able to comply with posttreatment monitoring.


ent See Box 2-1 for information regarding administration, patient and family teaching, and follow-up when ectopic pregnancy is treated with methotrexate.




Follow-up



β-hCG, Beta-human chorionic gonadotropin.Sources: Gilbert, E. (2011). Manual of high risk pregnancy & delivery (5th ed.). St. Louis: Mosby; Murray, H., Baakdah, H., Bardell, T., & Tulandi, T. (2005). Diagnosis and treatment of ectopic pregnancy. Canadian Medical Association Journal, 173(8), 905-912.



NURSING ALERT


A woman receiving methotrexate therapy who drinks alcohol and takes vitamins containing folic acid (e.g., prenatal vitamins) increases her risk of experiencing side effects of the drug or exacerbating the ectopic rupture.


Nursing Considerations



ent Encourage expression of feelings related to the pregnancy loss.


ent Refer to community resources for grief or infertility support.


ent Inform the woman that vaginal intercourse must be avoided until β-hCG levels indicate that the ectopic pregnancy has completely dissolved. This could require abstaining from sexual activity for several months.


ent There is a small risk that the pelvic pressure associated with vaginal intercourse could rupture the mass. In addition, intercourse will cause pain similar to that experienced with impending or actual tubal rupture, making it difficult to easily identify the source of the pain.


ent For future reference, instruct the woman to contact her health care provider immediately if she suspects that she might be pregnant, because of the increased risk for recurrent ectopic pregnancy.


Late Pregnancy Bleeding


Placenta Previa


Placenta previa is the implantation of the placenta in the lower uterine segment such that it completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces.


Types of Placenta Previa


When transvaginal ultrasound is used placenta previa is classified as:



Risk Factors



Signs and Symptoms



Risks Associated with Placenta Previa


Maternal


Fetal


Diagnosis


All women with painless vaginal bleeding after 20 weeks of gestation should be assumed to have a placenta previa until proven otherwise.



Management


The woman will be managed either actively or expectantly, depending on gestational age, amount of bleeding, and fetal condition.


Active Management

Cesarean birth is indicated in all women with ultrasound evidence of placenta previa.



Expectant Management


ent Purpose is to allow the fetus time to mature


ent Generally the treatment of choice if:


ent Less than 36 weeks of gestation


ent FHR tracing is normal (reassuring)


ent Bleeding is mild (<250 ml) and stops


ent Not in labor


ent Initial management


ent Admit to a labor and birth unit for continuous FHR and contraction monitoring.


ent Initiate large-bore (16- to 18-gauge) IV access.


ent Initial laboratory tests: hemoglobin, hematocrit, platelet count, coagulation studies


ent Maintain a “type and screen” sample at all times in the hospital’s transfusion services department.


ent Administer antenatal corticosteroids if the woman is less than 34 weeks of gestation.


ent Management after bleeding stops


ent Bed rest with bathroom privileges and limited activity


ent Assess bleeding by checking the amount of bleeding on perineal pads, bed pads, and linens.


ent Monitor for signs of preterm labor.


ent Ultrasound every 2 to 3 weeks


ent Fetal surveillance: nonstress test (NST) or biophysical profile (BPP) once or twice weekly


ent Serial laboratory assessments for decreasing hemoglobin and hematocrit levels and changes in coagulation values


ent No vaginal or rectal examinations


ent Pelvic rest (nothing inserted in the vagina)


ent The woman’s condition should always be considered a potential emergency because massive blood loss with resulting hypovolemic shock can occur quickly if bleeding resumes. The possibility always exists that she may require an emergency cesarean birth.


ent Criteria for home care


ent Stable condition with no vaginal bleeding for at least 48 hours before discharge


ent Willing and able to comply with activity restrictions (bed rest with bathroom privileges and pelvic rest)


ent Telephone access


ent Close supervision by family and friends at home


ent Constant access to transportation


ent Able to keep all appointments for fetal testing, laboratory assessments, and prenatal care


ent Discharge teaching for home care


ent How to assess uterine activity and bleeding


ent Pelvic rest and activity limitations


ent Importance of keeping appointments


Abruptio Placentae (Placental Abruption)


Placental abruption (abruptio placentae) is the detachment of part or all of a normally implanted placenta from the uterus. The separation may be partial, marginal, or complete. Bleeding from the placental site may dissect (separate) the membranes from the decidua basalis and flow out through the vagina (70% to 80%), it may remain concealed (retroplacental hemorrhage) (10% to 20%), or both.


Risk Factors



Signs and Symptoms


See Table 2-2 for assessment of placental abruption.




Diagnosis



Risks Associated with Placental Abruption


Maternal


Fetal/Neonatal


Management


The woman will be managed either actively or expectantly, depending on the severity of blood loss and fetal maturity and status.


Expectant Management


Active Management


ent Treatment of choice in the following situations:


ent Term gestation


ent Moderate to severe bleeding


ent Woman or fetus is in jeopardy


ent Vaginal birth is usually feasible and especially desirable in cases of fetal death.


ent Cesarean birth should be reserved for cases of fetal distress or other obstetric indications.


ent Surgery should not be attempted when the woman has severe and uncorrected coagulopathy because it may result in uncontrollable bleeding.


ent At least one large-bore (16- to 18-gauge) IV line


ent Frequent vital signs


ent Serial lab tests to monitor hemoglobin, hematocrit, and clotting status


ent Continuous electronic fetal monitoring


ent Indwelling (Foley) catheter


ent Intake and output measurement


ent Blood and fluid volume replacement


ent Educate woman and family on cause, treatment, and expected outcomes.


ent Provide emotional support because the woman and her family may be experiencing fetal loss in addition to the woman’s critical illness.


Endocrine and Metabolic Disorders


Pregestational Diabetes Mellitus


Diabetes mellitus refers to a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. There are four types of diabetes mellitus: type 1, type 2, other specific types (e.g., diabetes caused by genetic defects in B-cell function or insulin action, disease or injury of the pancreas, or drug-induced diabetes), and gestational diabetes. Type 1 or type 2 diabetes that existed before pregnancy is often referred to as pregestational diabetes. Of the women with pregestational diabetes, the majority (65%) have type 2 diabetes.


Etiology


Type 1 Diabetes


Type 2 Diabetes


White’s Classification System for Diabetes in Pregnancy




Risks Associated with Pregestational Diabetes


Risks increase with the duration and severity of the diabetic condition. Also pregnancy may contribute to the vascular changes associated with diabetes.


Maternal


Fetal/Neonatal


Management


Medical goal of care: Achieving and maintaining constant euglycemia through a combination of diet, insulin, and exercise. The key to an optimal pregnancy outcome is strict maternal glucose control before conception as well as throughout pregnancy. See Table 2-4 for desired blood glucose levels during pregnancy.



Pregnancy


ent Assess current health status.


ent Perform routine prenatal examination.


ent Determine effects of diabetes on pregnancy:


ent Perform a baseline electrocardiogram to assess cardiovascular status.


ent Evaluate for retinopathy with follow-up as needed by an ophthalmologist each trimester and more often if retinopathy is diagnosed.


ent Monitor blood pressure.


ent Monitor weight gain.


ent Assess fundal height.


ent Laboratory tests


ent Glycosylated hemoglobin (hemoglobin A1c) (should be ≤6%)


ent 24-hour urine collection for total protein and creatinine clearance


ent Urinalysis and culture: initial prenatal visit and throughout the pregnancy


ent Urine dipstick for ketones


ent Thyroid function tests


ent Diet


ent Average diet includes 2200 to 2500 calories per day, distributed among three meals and an evening snack or (more commonly) three meals and two or three snacks.


ent Ideally, 55% of total calories should be carbohydrates.


ent Simple carbohydrates are limited; complex carbohydrates that are high in fiber content are recommended.


ent Large bedtime snack (at least 25 g of carbohydrate with some protein) is recommended.


ent Exercise


ent Must be prescribed by the health care provider


ent Best type of exercise is aerobic exercise with resistance training for at least 30 minutes most days of the week. Non–weight-bearing activities may also be recommended.


ent Best time for exercise is after meals.


ent Regular exercise may be contraindicated in women with diabetes who also have uncontrolled hypertension, advanced retinopathy, or severe autonomic or peripheral neuropathy.


ent Insulin


ent Insulin requirements in general increase as the pregnancy progresses. However, they normally plateau after 35 weeks of gestation and often drop significantly after 38 weeks.


ent Several types of insulin preparations are available. They differ in onset, peak, and duration of action. See Table 2-5 for further information on common insulin preparations.


ent Most women are managed with two or three injections per day, although continuous subcutaneous insulin infusion systems (e.g., the insulin pump) are increasingly being used during pregnancy.


ent Blood glucose testing


ent Done several times each day, using a glucose reflectance meter or biosensor monitor


ent Now considered standard of care for monitoring blood glucose levels during pregnancy


ent Most of the newer reflectance meters are calibrated to provide plasma (rather than whole blood) glucose values. Plasma glucose values are 10% to 15% lower than those measured in whole blood from the same sample.



SAFETY ALERT


The nurse must be knowledgeable about the specific glucose reflectance meter that the woman uses because target glucose values depend on the type of meter used.

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Related posts:

  1. 8. Selected Newborn Complications
  2. 7. The Newborn
  3. 1. Pregnancy
  4. 3. Intrapartum

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Jul 18, 2016 | Posted by in NURSING | Comments Off on 2. Selected Pregnancy Complications

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