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Transcript of Chapter 21 Sudden Pregnancy Complication. Bleeding Development of shock Blood pressure Pulse ...
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Chapter 21 Sudden Pregnancy ComplicationChapter 21 Sudden Pregnancy Complication
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BleedingBleeding
Development of shock
Blood pressure
Pulse
Fetal heart rate
Treatment
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Disseminated Intravascular Coagulation (DIC)
Disseminated Intravascular Coagulation (DIC)
Disorder of blood clotting
Fibrinogen levels fall below effective limits
Symptoms
Bruising or bleeding
Causes
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1st Trimester Bleeding1st Trimester Bleeding
Spontaneous miscarriage (Abortion)
Threatened
Imminent
Complete
Missed
Recurrent pregnancy loss
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Complications of MiscarriageComplications of Miscarriage
Hemorrhage
Infection
Septic abortion
Isoimmunization
Powerlessness or anxiety
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1st Trimester Bleeding1st Trimester Bleeding
Ectopic pregnancy
Implantation occurs outside of the uterine cavity
Abdominal pregnancy
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2nd Trimester Bleeding2nd Trimester Bleeding
Gestational trophoblastic disease (hydatidform mole)
Abnormal proliferation and degeneration of the trophoblastic villi
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Assessment Assessment
HCG
Ultrasound
Fundal height
Nausea
ManagementManagement• D&CD&C
• CXRCXR
• HCG Beta q 4 weeks for 12 monthsHCG Beta q 4 weeks for 12 months
• ContraceptionContraception
• No pregnancy 1 yearNo pregnancy 1 year
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Premature cervical dilatation
Cannot hold the fetus until term
Cervical cerclage
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3nd Trimester Bleeding3nd Trimester BleedingPlacenta previa
Low implantation of placenta, Partial previa, complete previa
Risk factors
Assessment: Painless vaginal bleeding
Management
Immediate care
Continuing care
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3nd Trimester Bleeding3nd Trimester BleedingAbruptio Placentae
Premature separation of placenta
Occurs suddenly
Most frequent cause of perinatal death
Risk factors
Assessment: Painful
Management
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Preterm LaborPreterm Labor• Labor before the end of 37 weeks gestation.
• Occurs in 9 to 11% of all pregnancies.
• Persistent uterine contractions 4 in 20 min.
• Actual labor is if uterine contractions that cause effacement over 80% and dilation over 1 cm.
• Preterm births are 2/3 of all infant deaths.
• Cause unknown, dehydration, UTI, chorioamnionitis (infection of fetal membranes and fluid), strenuous jobs, extreme fatigue.
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Preterm LaborPreterm Labor• SS-persistent, dull, low backache, vaginal spotting,
feeling of pelvic pressure or abdominal tightening, menstrual like cramping, increased vaginal discharge, uterine contraction, intestinal cramping.
Management:
• Analyze changes in vaginal mucus (fetal fibronectine), short cervix, sonogram.
• May try to stop labor if not beyond 4 to 5 cm or 50% effacement
• Admit to hospital, bedrest, IV, cultures,
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Preterm LaborPreterm LaborUA, oral tocolytic agent-terbutaline, good nutrition and no smoking.
• Antibiotic for strep B prophylaxis, corticosteroid (lung surfactant)
• Pregnancy <34 weeks betamethasone 2 doses 12 mg IM 24 hours apart, effect lasts 7 days.
• Magnesium sulfate 4 to 6 g IV bolus to halt contractions (CNS depressant) p. 399.
• Terbutaline (Brethine)-relaxes uterine muscles, blood vessels and bronchi.
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Preterm LaborPreterm Labor• Monitor: VS, I&O, labs, lungs for edema, daily wt.,
FHR.
Fetal assessment:
• Count fetal movement-10 in 1 hour (lt. side)
Labor:
• ROM, cervix > 50% effaced or 3 to 4 cm dilated it is unlikely it can be halted.
• Fetus immature – cesarean birth
• Use caution giving analgesics (demerol) due to immaturity of fetus. Epidural is best.
• Episotomy is needed to decrease risk of hemorrhage of fetus. May be larger and forceps may be used.
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Preterm LaborPreterm Labor
• Support, she needs to rebuild her self esteem.
Preterm Rupture of Membranes
Associated with infection of membranes.
Occurs in 2% to 18% of pregnancies.
If early it is a threat to the fetus, infection and pressure on cord or prolapse. Non fluid environment > Potter like syndrome of distorted facial features and pulmonary hypoplasia from pressure.
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Preterm LaborPreterm Labor
Assessment:
• Labor will not be halted if ROM.
• Sudden gush clear fluid, test with nitrazine paper (alkaline reaction-blue), ferning (high estrogen), sonogram, cultures, labs.
Management:
• Bedrest, antibiotic, may apply fibrin-based sealant to ruptured membranes, amniotic fluid is always being formed.
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Preterm Rupture of MembranesPreterm Rupture of MembranesRupture of fetal membranes with a loss
of amniotic fluid
Before 37 weeks’ gestation
Associated with chorioamnioitis
Complications
Assessment
Management
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Pregnancy Induced HypertensionPregnancy Induced HypertensionPIH
• Vasospasm occurs during pregnancy.
• Occurs in 5% to 10% of pregnancies.
• Cause unknown, in primiparas <20 yrs. or > 40 yrs., low socioeconomic background, 5 or more pregnancies, women of color, multiple hydraminios, heart disease, diabetes, essential hypertension, poor calcium or magnesium intake.
Patho:
• Normally blood vessels are resistant to the effects of pressor substances such as angiotensin and norepinephrine.
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Pregnancy Induced HypertensionPregnancy Induced Hypertension
• With PIH vasoconstriction occurs and B/P increases dramatically.
• Cardiac system becomes overwhelmed, reduction of blood supply to kidney, pancreas, liver, brain and placenta.
• Hypoxia in maternal vital organs, poor placental perfusion reduce fetal nutrients and O2.
• Ischemia in pancreas; epigastric pain and amylase-creatinine ratio, retinal hemorrhages – blindness, proteinuria, edema.
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Pregnancy Induced HypertensionPregnancy Induced Hypertension
Extreme edema can lead to cerebral and pulmonary edema and seizures (eclampsia)
Assessment:
• Classic signs: hypertension, proteinuria, and edema.
• Symptoms rarely occur before 20 weeks.
Classified as: gestational hypertension, mild eclampsia, severe preeclampsia &eclampsia
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Pregnancy Induced HypertensionPregnancy Induced HypertensionVasospasm, hypoperfusion, and endothelial
injury occurs during pregnancy
Symptoms
Hypertension
Proteinuria
Edema
Causes
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Physiologic changesPhysiologic changes
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Gestational HypertensionGestational Hypertension
Elevated BP
Without
Edema or Proteinuria
No Drug Therapy or Low Dose ASA
May develop Hypertension in later life
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Pre EclampsiaPre Eclampsia
Above gestational hypertension and below point of seizures (Eclampsia)
Mild preeclampsia
Severe preeclampsia
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Mild Pre-eclampsiaMild Pre-eclampsia
• BP 30mm systolic and 15mm diastolic above pre-pregnancy values.
• BP > 140/90
• Proteinuria 1+ to 2+ that is not orthostatic
• Sodium Retention
• Lower Glomerular filtration rate
• Edema upper body
• Weight gain 1-2 lb week
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Severe Pre-EclampsiaSevere Pre-Eclampsia• BP at REST:
– 30mm diastolic above pre pregnancy
– 160/110
• Marked Proteinuria 3+ to 4+
– Or > 5gm in 24 hour sample
• Edema
– Pitting or non pitting over bony surfaces
– 4+ is indentation that remains after removal of finger
– Extensive edema face and hands
• Epigastric Pain: Liver swelling
• Ankle Clonus: Cerebral Edema
• Urine output 400 to 600 mL/24 hours.
• SS-severe epigastric pain, nausea, vomiting, SOB, blurred vision, seeing spots, headache, marked hyperreflexia and muscle clonus.
• Review Patellar reflex and ankle clonus assessment
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EclampsiaEclampsia
• Severe cerebral edema to cause SEIZURE or COMA
• Poor fetal prognosis: anoxia, acidity, and potential for premature separation of placenta
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Management of PIHManagement of PIH
Nursing Interventions for Mild HypertensionNursing Interventions for Mild Hypertension
• Can be managed at home with frequent follow up care.
• Promote bedrest, lateral recumbent position.
• Promote Good Nutrition
• Provide emotional support-SS are vague, no meds., works, other children. Seen weekly.
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Nursing Intervention for Severe Hypertension:Nursing Intervention for Severe Hypertension:• B/P > 160/110 after on bedrest, extensive edema,
proteinuria 3+-4+
• Support Bedrest, hospital, private room, side rails up if seizure, darken room, restrict visitors, less stress, explain everything.
• Monitor Maternal Well-Being
– VS, labs, DIC, high risk for premature separation of placenta and hemorrhage, cathether (>600 mL/24h or 30mL/h), daily weight,
• Monitor Fetal Well-Being:
– FHR, non stress test or biophysical profile daily, O2 to mother.
Support Nutritional Diet:
• Moderate to high protein, moderate sodium diet, IV TKO.
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Nursing Intervention for Severe Hypertension:Nursing Intervention for Severe Hypertension:
Administer Medications to Prevent Eclampsia
• Table 21.7 pg. 580 drugs
• Magnesium sulfate, Apresoline or Normodyne, Valium
• Review treatment with Magnesium sulfate pg.581
• Calcium Gluconate
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Nursing Intervention with Eclampsia:Nursing Intervention with Eclampsia:
• Cerebral irritation from increased cerebral edema and seizure results. Late in pregnancy or 48 hours after birth.
• SS-B/P increases, temp increases to 103-104, burning of vision, headache, reflexes hyperactive, “something is happening,” epigastric pain, nausea and decreased urinary output. Seizure.
Tonic-Clonic Seizures:
• Occurs in stages
• Maintain patent airway, O2 by face mask, pulse ox, FHR, turn on side, incontinent of urine and bowel, (valium, mag sulfate),third stage-semicomatose 1 to 4 hours.
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Continued:Continued:
• Unable to report contractions if placenta has separated. Check for vaginal bleeding.
Birth:
• Pregnancy > 24 weeks, decide about delivery, fetus may not grow after eclampsia occurs.
• Vaginal birth preferred, vascular system is low in volume.
Postpartal Hypertension:Postpartal Hypertension:
• Up to 10 to 14 days after birth. (48 hours) monitor B/P closely.
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Hemolysis
Elevated Liver Enzymes
Low Platelets
Causes
Symptoms
HELLP SyndromeHELLP Syndrome
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•Is a variation of PIH
•4% to 12% of PIH patients (1 in 150 births).
•Cause is unknown, SS-nausea, epigastric pain, general malaise and rt. upper quadrant tenderness.
•Labs, monitor for bleeding.
•Tx. Transfusion fresh-frozen plasma or platelets. IV dextrose if hypoglycemic.
•Deliver as soon as fetus is viable.
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Multiple PregnancyMultiple Pregnancy
Considered a complication of pregnancy.
Account for 2% due to fertility drugs.
Multiples may be any combination.
Occurs more frequently in non whites, high parity and age, multiple gestation, inherited
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Identical (monozygotic) twins:Identical (monozygotic) twins:
• Begin with single ovum and spermatozoon
• Fusion or 1st cell division, zygote divides into 2 identical individuals.
• Usually have 1 placenta, 1 corion, 2 amnions, and 2 umbilical cords.
• Always same sex.
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Fraternal (dizygotic, non-identical) twins:Fraternal (dizygotic, non-identical) twins:
• Fertilization of 2 separate ova by 2 separate spermatozoa (possible not from the same sexual partner).
• 2 placentas, 2 chorions, 2 amnions and 2 umbilical cords.
• May be same or different sex.
• 2/3 of twins are dizygotic.
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Assessment:Assessment:
• Uterus increases in size at a rate faster than usual.
• Elevated alpha-fetoprotein levels
• Sonogram reveals multiples.
• Quickening woman reports flurries of action
• If fetus has back toward woman’s back only one fetal heart sound may be heard.
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ManagementManagement• Monitor for complications-PIH, hydramnios placenta
previa, preterm labor, anemia.
• Prone to postpartal bleeding.
• Delivery early, immaturity of fetus.
• High risk for congenital anomalies, spinal cord defect and cord inserted into fetal membranes.
• Shared circulation, overgrowth of 1 fetus, knotting or twisting of cord.
• Encourage rest especially last 2 to 3 months, eat 6 small meals a day, take vitamin supplements, monthly US
• Prepare for role changes
• Worries of premature labor and survival of the infants.
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Hydramnios (Poly)Hydramnios (Poly)• Excessive amniotic fluid formation.
• Usual-500 to 1000 mL.
• 2000mL or index > 24 cm.
• Can cause fetal malpresentation due to extra space for fetus to turn.
• Premature ROM and preterm labor from increased pressure and prostaglandin release
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Hydramnios cont’Hydramnios cont’Assessment:
• Suggests difficulty with fetus’ ability to swallow or absorb or excessive urine production.
• SS-rapid enlargement of uterus, tense uterus, fetal heart is difficult to hear, SOB, lower extremity varicosities and hemorrhoids, increased weight gain.
• Sonogram
Management:
• Admit to hospital for bed rest or rest at home.
• Educate on ROM, contractions, avoid constipation.
• VS, edema, may do amniocentesis to remove extra fluid, Indomethacin to reduce total volume, Magnesium sulfate to halt preterm labor, “needled” to allow slow controlled release of fluid.
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OligohydramniosOligohydramnios
• Less than average amount amniotic fluid
• Bladder or renal disorder interferes with fetal voiding
• Muscles weak, lungs fail to develop
• Uterine slow growth
• Amnioinfusion
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Post Term PregnancyPost Term Pregnancy
• Term is 38 to 42 weeks
• Ovulation period may be longer so EDD will be 12 to 17 days later.
• Trigger did not turn on for labor.
• High dose of salicylates interferes with synthesis prostaglandins, which initiate labor.
• 2 weeks beyond term are at risk for meconium aspiration, macrosomia, lack of growth.
• Placenta functions for 40 to 42 weeks.
At 41 weeks; nonstress test,maternal fibronectin level, and biophysical profile to document state of placental perfusion and amniotic fluid. May induce.
• Cytotec to initiate ripening, ROM,oxytocin.
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PseudocyesisPseudocyesis
•False pregnancy can also be seen in men; N&V, amenorrhea enlarged abdomen.
•Occurs: wish fulfillment or fear of pregnancy, depression.
•Sonogram
•Refer for psychological counseling.
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Isoimmunization (Rh Incompatibility)Isoimmunization
(Rh Incompatibility)Rh-negative mother is carrying a fetus
with Rh-positive blood
Hemolytic disease of the newborn
Assessment
Management
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Fetal DeathFetal Death
Most severe complication
Assessment
Nursing care