COMPLICATIONS

OF
PREGNANCY
Jeanie Ward

Risk Factors
Age under 17 over 35
Gravida and Parity
Socioeconomic status
Psychological well-being
Predisposing chronic illness
diabetes, heart conditions, renal, etc.
Pregnancy related conditions
hyperemesis gravidarum, PIH, etc.

High Risk Pregnancy

Goals of Care
Provide with optimum care
for the mother and the fetus
Assist the patient and her
family to understand and
cope with the variations in a
High Risk Pregnancy and cope
with her feelings

Bleeding Disorders

Abortions

Termination of pregnancy at any

time before the fetus has reached
the age of viability

Either:
spontaneous occurring
naturally
induced artificial

Etiology / Predisposing
Factors
Faulty germ plasm -- imperfect ova or
sperm, faulty implantation, genetic make-up
(chromosomal disorders), congenital
abnormalities
Decrease in the production of progesterone
Drugs or radiation
Maternal causes -- infections, endocrine
disorders, malnutrition, hypertension

Assessment
Types of Abortions
Threatened

Signs and Symptoms

vaginal bleeding, spotting

Mild cramps, backache
Cervix remains CLOSED

Treatment and Nursing Care

Bed rest, sedation,
Avoid stress and intercourse
Progesterone therapy
A period of watchful waiting

Inevitable Abortion
Signs and Symptoms
Loss is certain
Bleeding is more profuse
Painful uterine contractions
Cervix DILATES

Treatment and Nursing Care

Assess all bleeding. Save all pads. (May
need to weigh the pads)
Use the bedpan to assess all products
expelled
Treated by evacuation of the uterus
usually be a D & C or suction

Provide Psychological Support

Complete Abortion
All products of conception are
expelled
No treatment is needed, but may
do a D & C

Incomplete Abortion
Parts of the products
of conception are
expelled, with
placenta and
membranes retained
Treated with a D & C
or suction evacuation
Provide support to
the family

Missed Abortion
The fetus dies in-utero and is not
expelled
Uterine growth ceases
Breast changes regress
Maceration occurs
Treatment:
D & C
Hysterotomy

Missed Abortion
Critical Thinking Exercise
The woman who has a missed
abortion is at risk for what 2
conditions?

Habitual Abortion /
Premature Cervical
Dilation

Abortion occurs consecutively in three

or more pregnancies
Usually due to an Incompetent
Cervical Os, that results from cervical
trauma, cervical lacerations, repeated
D & C, or conization.
Occurs most often about 18-20 weeks
gestation.

Habitual Abortion
Treatment

Cerclage procedure -- pursestring suture placed around

the internal os to hold the
cervix in a normal state

Nursing Care
Bedrest in a slight trendlenburg
position to decrease the pressure
on the new sutures
Teach:
Assess for leakage of fluid, bleeding
Assess for contractions
Assess fetal movement and report
decrease movement (if old enough)
Assess temperature for elevations

Delivery
When time for delivery there are
several options:
physician will clip suture and allow
patient to go into labor on her own
induce labor
cesarean delivery

 Mrs. B. had a cerclage procedure

done at 14 weeks gestation. She is
now 39 weeks gestation and
admitted to labor and delivery
because she is in labor.
What is the MOST important
assessment to make at this time?

Key Concepts to
Remember!!

If a woman is Rh-, RhoGam is given

within 72 hours
Provide emotional support. Feelings
of shock or disbelief are normal
Encourage to talk about their
feelings. It begins the grief process

Bleeding
Disorders
Implantation of Ectopic
the blastocyst in
Pregnancy
ANY
site other than the
endometrial lining of the uterus

ovary

(5) Cervical

Etiology / Contributing
Factors

Salpingitis
Pelvic Inflammatory Disease, PID
Endometriosis
Tubal atony or spasms
Imperfect genetic development

Assessment
Ectopic Pregnancy
Early:
Missed menstruation followed by vaginal
bleeding (scant to profuse)
Unilateral pelvic pain, sharp abdominal
pain
Referred shoulder pain
Cul-de-sac mass

Acute:
Shock blood loss poor indicator
Cullens sign -- bluish discoloration
around umbilicus
Nausea, Vomiting
Faintness

Diagnostic Tests
Ectopic Pregnancy
Diagnosis:
Ultrasound
Culdocentesis
Laparoscopy

Interventions / Nursing
Care

Combat shock / stabilize cardiovascular

Draw blood for type and cross match
Give blood replacements
IVs.

Laparotomy
Psychological support
Linear salpingostomy
Methotrexate used prior to rupture.
Destroys fast growing cells

Hydatiform Mole
Etiology
A DEVELOPMENTAL ANOMALY OF
THE PLACENTA WITH
DEGENERATION OF THE CHORIONIC
VILLI
As cells degenerate, they become
filled with fluid and appear as fluid
filled grape-size vessicles.

Assessment:
Vaginal Bleeding -- scant to profuse,
brownish in color (prune juice)
Enlargement of the uterus out of
proportion to the duration of the
pregnancy
Vaginal discharge of grape-like vesicles
May display signs of pre-eclampsia early
Hyperemesis gravidarium
No Fetal heart tone or Quickening
Abnormally elevated levels of HCG

Interventions and FollowUp

Empty the Uterus by D & C or Hysterotomy
Follow-Up for One Year

Assess for the development of choriocarcinoma

Blood tests for levels of HCG frequently
Chest X-rays
Placed on oral contraceptives
If the levels rise, then chemotherapy started
usually Methotrexate

Critical Thinking Exercise

A woman who just had an
evacuation of a hydatiform mole
tells the nurse that she doesnt
believe in birth control and does
not intend to take the oral
contraceptives that were
prescribed for her.
How should the nurse respond?

Placenta Previa
Low implantation of the placenta
in the uterus
Etiology
Usually due to reduced vascularity in
the upper uterine segment from an old
cesarean scar or fibroid tumors

Three Major Types:

Low or Marginal
Partial
Complete

Abruptio Placenta
Premature separation of the placenta
from the implantation site in the
uterus
Etiology:
Chronic Hypertension
Sudden decompression of an over

distended uterus
Trauma
Injudicious use of Pitocin
Smoking / Caffeine / Cocaine
Vascular problems

Placenta Previa
PAINLESS vaginal
bleeding
Bright red bleeding
First episode of
bleeding is slight
then becomes
profuse
Signs of blood loss
comparable to extent
of bleeding
Uterus soft, nontender
Fetal parts palpable;
FHTs countable
Blood clotting defect
absent

Abruptio Placenta
Bleeding accompanied
Abruptio by PAIN
Dark red bleeding
First episode of
bleeding usually
profuse
Signs of blood loss out
of proportion to visible
amount
Uterus board-like,
painful
Fetal parts nonpalpable, FHTs noncountable
Blood clotting defect
(DIC) likely

Signs of Concealed
Hemorrhage
Increase in fundal height
Hard, board-like abdomen
High uterine baseline tone on
electronic fetal monitoring
Persistent abdominal pain
Systemic signs of hemorrhage

Interventions and
Nursing Care

Placenta Previa
Bed-rest

Assessment of bleeding
Electronic fetal monitoring
If it is low lying, then may allow to deliver

vaginally
Cesarean delivery for All other types of
previa
Abruptio Placenta
Deliver by cesarean delivery immediately
Combat shock blood replacement / fluid
replacement
Blood work assessment of DIC

Critical Thinking

Mrs. A. , G3 P2, 38 weeks gestation

is admitted to L & D with bleeding.
What is the priority nursing
intervention at this time?
A. Assess the fundal height for a decrease
B. Place a hand on the abdomen to assess
if hard, board-like, tetanic
C. Place a clean pad under the patient to
assess the amount of bleeding
D. Prepare for an emergency cesarean
delivery

Disseminated
Intravascular Coagulation
(DIC)
Anti-coagulation and Procoagulation
effects existing at the same time.

Etiology
Defect in the Clotting
Cascade

An abnormal overstimulation of the

coagulation process
Activation of Coagulation with
release of thromboplastin

Thrombin (powerful anticoagulant) is produced

Fibrinogen fibrin which enhances platelet

aggregation

Widespread fibrin and platelet deposition in
capillaries and arterioles

 Resulting in Thrombosis (multiple small

clots)
Excessive clotting activates the fibrinolytic
system
Lysis of the new formed clots create fibrin
split products
These products have anticoagulant
properties and inhibit normal blood clotting
A stable clot cannot be formed at injury sites
Hemorrhage occurs
Ischemia of organs follows from vascular
occlusion of numerous fibrin thrombi
Multisite hemorrhage results in shock and
can result in death

Disseminated
Intravascular Coagulation
(DIC)
Precipating Factors:

Abruptio placenta
PIH
Sepsis
Retained fetus (fetal demise)
Fetal placenta fragments

Assessment
Signs and Symptoms
Spontaneous bleeding -- from gums and
Epistasis, and injection and IV sites, incisions
Excessive bleeding -- Petechiae at site of
blood pressure cuff, pulse points. Ecchymosis
Tachycardia, diaphoresis, restlessness,
hypotension
Hematuria, oliguria, occult blood in stool
Mental changes if brain affected.

Diagnostic Tests
Lab work reveals:
PT Prothrombin time is prolonged
PTT Partial Thromboplastin Time
increased
D-Dimer increased Product that results
from fibrin degradation. More specific
marker of the degree of fibrinolysis
Platelets -- decreased
Fibrin Split Products increase
An increase in both FSP and D-Dimer are
indicative of DIC

DIC
Interventions and Nursing
Care

Remove Cause
Evaluate vital signs
Replace blood and blood products
Fluid replacement

May give Heparin -- interrupt the

clotting cascade and prevent
triggering the fibrinolytic system.

Structural Disorders
Fetal Demise / Intrauterine Fetal
Death

DEFINITION:
Death of a fetus after the age of
viability

Assessment:
1. First indication is usually NO
fetal
movement
2. NO fetal heart tones
Confirmed by ultrasound
3. Decrease in the signs and
symptoms of
pregnancy

Interventions and Nursing Care

Allow patient to decide when she wants
to deliver
Most women go into labor on their own
in 2 weeks, so may wait for labor to
begin spontaneously
Induce labor
Prostaglandin (Prostin E) causes
smooth muscles to contract: Side
effects - nausea, vomiting, diarrhea
Cytogel
Provide with Emotional Support, allow
to hold baby

The End