L3

• High risk pregnancy


  One in which a concurrent disorder, pregnancy related complications or external factor jeopardize the health of the woman, the fetus or both
• Risk factors for high risk pregnancy

  • Physiological
  • Sociodemographic
  • Psychological
  • Environmental
• Physiological risk factors


  • Concurrent illness
  • Malnutrition
  • Physically challenged
  • Frequent pregnancies
• Sociodemographic risk factors


  • Poverty
  • Unemployment
  • Lack of education
  • Age
  • Poor access to transportation for care
  • Lack of support people
• Psychological risk factors


  • Cognitively challenged
  • Single / Separated mothers
  • Victims of Abuse, domestic violence, rape, incest
  • Mental Retardation
• Environmental risk factors


  • Exposure to Teratogens due to employment
  • Environmental contaminants at home
  • Poor Housing
• Caring for a woman who develops a complication of pregnancy

  1. Assessment

  2. Implementation

  3. Evaluation
• Common nursing diagnoses for women with pregnancy complications

  • Anxiety related to guarded pregnancy outcome
  • Risk for infection related to incomplete miscarriage
  • Deficient knowledge related to signs and symptoms of possible complications
  • Risk for ineffective tissue perfusion related to pregnancy-induced hypertension
  • Ineffective role performance related to increasing level of daily restrictions secondary to chronic illness and pregnancy
• Sudden pregnancy complications


  • Bleeding during pregnancy
  • Ectopic pregnancy
  • Gestational trophoblastic disease
  • Premature cervical dilatation
  • Placenta previa
  • Abruptio placenta
  • Disseminated intravascular coagulation
  • Preterm labor
  • Preterm rupture of membranes
  • Pregnancy induced hypertension
  • HELLP Syndrome
  • Multiple pregnancy
  • Abnormal amniotic fluid volume
  • Isoimmunization

  
• Abortion


  Medical term for any interruption of a pregnancy before a fetus is viable
• Types of miscarriage


  • Spontaneous miscarriage
  • Threatened miscarriage
  • Imminent (inevitable) miscarriage
  • Complete miscarriage
  • Incomplete miscarriage
  • Recurrent pregnancy loss
• Causes of miscarriage


  • Teratogenic factor
  • Chromosomal aberrations/abnormal fetal development
  • Implantation abnormalities
  • Failure to produce enough progesterone
  • Infection
• Complications of miscarriage


  • Hemorrhage
  • Infection
  • Risk for isoimmunization
• Ectopic pregnancy


  Implantation occurs outside the uterine cavity
• Ruptured ectopic pregnancy


  Sharp stabbing pain in lower abdominal quadrant, vaginal spotting, may lead to shock, falling hCG level
• Gestational trophoblastic disease (hydatidiform mole)


  Abnormal proliferation and then degeneration of the trophoblastic villi
• Types of gestational trophoblastic disease

  • Complete mole
  • Partial mole
• Premature cervical dilatation


  Cervix that dilate prematurely, cannot hold a fetus until term
• Placenta previa


  Placenta is implanted abnormally in the uterus, most common cause of painless bleeding in the third trimester of pregnancy
• Degrees of placenta previa

  • Low lying
  • Marginal
  • Partial
  • Total placenta previa
• Premature separation of the placenta (abruptio placenta)

  Placenta appears to be implanted correctly but begins to separate and bleeding results
• Predisposing factors for abruptio placenta

  • High parity
  • Advanced maternal age
  • Short umbilical cord
  • Chronic hypertensive disease
  • Pregnancy induced hypertension
  • Direct trauma
  • Vasoconstriction
  • Autoimmune antibodies
  • Chorioamnionitis
• Predisposing factors for cause unknown placental abruption

  • High parity
  • Advanced maternal age
  • Short umbilical cord
  • Chronic hypertensive disease
  • Pregnancy induced hypertension
  • Direct trauma
  • Vasoconstriction
  • Autoimmune antibodies
  • Chorioamnionitis
• Assessment of placental abruption

  • Sharp stabbing pain high in the uterine fundus
  • If labor begins, each contraction will be accompanied by pain over and above the pain of contraction
  • Heavy bleeding – evident if separation occurs at the edges
  • Couvelaire uterus (uteroplacental apoplexy) – hard board like uterus with no apparent or minimally apparent bleeding
  • Disseminated Intravascular Coagulation (DIC) may occur
• Therapeutic management of placental abruption

  1. Emergency situation

  2. Large gauge IV catheter

  3. Oxygen by mask

  4. FHT and maternal VS monitoring

  5. Lateral position

  6. No abdominal, pelvic or vaginal examination

  7. Unless separation is minimal, pregnancy must be TERMINATED
• Disseminated Intravascular Coagulation (DIC)

  Acquired disorder of blood clotting, fibrinogen level falls to below effective limits
• Conditions associated with DIC development

  • Premature separation of placenta
  • PIH
  • Amniotic fluid embolism
  • Placental retention
  • Septic abortion
  • Retention of dead fetus

  
• DIC


  Extreme bleeding causes many platelets and fibrin from the general circulation rush to the site, not enough are left for the rest of the body
• Tests for DIC


  • Test tube – clot must form
  • Platelet assessment – less than or equal to 100,000/uL
  • Prothrombin – low
  • Thrombin – elevated
  • Fibrinogen – less than 150 mg/dL
• Management of DIC


  1. Halt the underlying insult

  2. IV administration of Heparin

  3. Blood or platelet transfusion
• Preterm labor


  Labor that occurs before the end of the 37 weeks of gestation
• Preterm labor


  • Persistent uterine contractions, cervical effacement over 80% and dilation over 1cm
  • Unknown cause

  
• Conditions associated with preterm labor

  • Dehydration
  • UTI
  • Periodontal disease
  • Chorioamnionitis
  • Inadequate prenatal care
• Assessment of preterm labor


  • Persistent, dull, low backache
  • Vaginal spotting
  • Pelvic pressure or abdominal tightening
  • Menstrual like cramping
• Fetal fibronectin


  Protein produced by trophoblast cells, presence indicates preterm contractions are ready to occur, absence indicates labor will not occur at least 14 days
• Therapeutic management of preterm labor

  1. Woman usually admitted

  2. Bed rest

  3. IV fluids – hydration may stop contractions

  4. Tocolytic agent – halt labor (terbutaline)

  5. Advise to limit strenuous activities

  6. Fetal assessment – count to 10 test
• Administration of terbutaline


  1. Mixed with lactated Ringer's (not given purely)

  2. Piggy back

  3. Microdrip

  4. Check blood pressure and pulse rate

  5. If contractions are halt, oral terbutaline may be given
• Drug administration in preterm labor

  1. Steroid (betamethasone) – to hasten lung maturity

  2. Effects after 24 hours and lasts 7 days
• Preterm labor that cannot be halted


  • Membranes have ruptured
  • Cervix more than 50% effaced and 3-4 cm dilated
  • If fetus is very immature – CS

  
• Method of delivery for preterm labor

  1. If very immature – CS delivery to reduce pressure on the fetal head

  2. Cord is clamped immediately – extra amount of blood could overburden the circulatory system