Pregnancy related complications

• Health disparities

  • A particular type of health difference that is closely linked with social, economic and/or environmental disadvantage
• Health equity

  • The state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance.
• Social determinants of health

  • Conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.
• Health literacy

  • The degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.
• Pre-term labor/Pre-term Birth

  • Labor occurring from 20-36 6/7 weeks of gestation
  • Uterine activity/cx's with cervical change
  • Situations where it may occur: 1)*Spontaneous*, 2) Medically indicated inductions-preeclampsia, prolonged ROM, diabetes, IUGR and 3) Non-medically indicated aka elective
• Etiologies/Risk Factors PTL/PTB

  • HX of pre-term labor and delivery - strongest indicator
  • Maternal disorders: infection, anemia, HTN, diabetes, mx gestation, obesity and abruption
  • Psychosocial factors STRESS!, substance use, domestic violence, lack of social support, age (young or old), low socioeconomic status, low educational level, and systemic racism
• Patho behind PTL/PTB

  1. Premature activation of the fetal or maternal HPA axis (stress response)
  2. Placental abruption (decidual bleeding-thrombin activation, inflammation)
  3. Exaggerated inflammatory response/infection- UTI, abnormal vaginal flora, periodontal disease, chorioamnionitis
  4. Pathological uterine distention

  May lead to cervical shortening, dilation, effacement (cervical insufficiency), membrane weakening and contractions
• Signs & Symptoms of Pre-term Labor

  • Menstrual like cramping
  • Pelvic pressure
  • Intestinal cramping/diarrhea
  • Low backache
  • Change in or increase of vaginal discharge
  • Cervical changes (dilation, effacement)
• Other assessment components

  • Cultures for infection
  • Fetal fibronectin test
  • Vaginal exam to check for cervical change/ROM
  • Electronic fetal monitoring for ctx and FHR
  • Ultrasound for cervical length: 25-35 mm normal length, less than 20 (strong positive predictor value), and more than 30 (excludes PTL)
• Fetal fibronectin (fFN)

  • Biochemical marker/test used to predict who will/will not deliver preterm
  • A protein found in cervical/vaginal secretions detected by immunoassay
  • Normally not found in vaginal-cervical secretions between 22-24 weeks
  • fFN has a 95% negative predictive value (95% chance of NOT having PTB)
  • Has a poor positive predictive value (25-40%) only that percentage will develop PTB
• Problems associated with prematurity

  • Respiratory/Feeding problems
  • Thermoregulation
  • Necrotizing enterocolitis
  • Sepsis
  • Hyperbilirubinemia
  • CNS damage
  • Developmental delays
  • Vision/hearing
  • Patent ductus arteriosus
  • Intracranial bleeding
• Nursing management of PTL

  • LEAST invasive: decreased activity/side-lying position, good hydration, I&O, empty bladder, monitor uterine activity & FHR, teaching
• Nursing management of PTL (More invasive)

  • IV fluids
  • Antibiotics for GBS +
  • Steroids (betamethasone/dexamethasone, stimulates surfactant production in fetus to speed lung maturity)
  • Tocolytics: Terbutaline, calcium channel blockers, NSAIDs/prostaglandin inhibitors
  • MgSo4: fetal neuroprotective as well as some tocolytic action (preterm labor & preeclampsia)
  • Progesterone: preventative for high risk women
  • Low dose aspirin: prevention for nulliparous women
• Terbutaline

  • Beta adrenergic agonist: causes relaxation of uterine smooth muscle
  • Prevention and reversal of bronchospasm-bronchodilator
  • Side effects: tachycardia, palpitations, nervousness, tremors, pulmonary edema-strict I&O
  • Only used short term- 24 to 72 hrs
• Nursing actions Terbutaline

  • Check pulse before administration- tachycardia
  • Check lung sounds (for fluid)
  • Monitor FHR, UCs
  • Use infusion pump if giving IV
  • Monitor I&O's
• Nifedipine (Procardia)

  • Calcium channel blocker which leads to myometrial relaxation, also a peripheral vasodilator
  • Given PO
  • Side effects: hypotension, palpitations, flushing, HA and nausea
• Magnesium sulfate

  • Calcium antagonist- decreases uterine contractility
  • A weak tocolytic
  • Protects fetal brain against micro-capillary brain hemorrhage (neuroprotective)
  • Also used in pre-eclampsia (PreE) to prevent seizures
  • Side effects: respiratory depression, lethargy, weakness, N/V, DTR depression
• MgSo4 nursing actions

  • Given in PTL and pre-eclampsia
  • Loading dose of 4-6 grams (over 30 min) then continuous (1-4 g/hr)
  • If for pre-eclampsia, continue for 24 hours post delivery
  • For PTL, give up to 48 hours
  • Calcium gluconate= antagonist/antidote
  • Always administer with an infusion pump
  • Monitor VS, RR every 1-2 hr
  • Monitor magnesium levels (therapeutic level is 5-8 mg/dL)
  • S/S of toxicity: more than 10-12 mg/dL- respiratory depression, loss of DTRs, oliguria, SOB
  • Monitor deep tendon reflexes/clonus
  • Lung sounds for fluid overload
• Hyporeflexia 


  MgSo4
• Hyperreflexia


  Pre-eclampsia
• PROM: leakage of amniotic fluid before the onset of labor at term (37 weeks and above)

  PPROM: occurs before 37 weeks

  Prolonged ROM: ruptured for more than 24 hours
• Predisposing factors for PROM

  • Multiple gestation
  • Infections (chorioamnionitis)
  • Hx of PROM
  • Polyhydramnios
  • Abruption
  • Insufficient cervix/short cervical length
  • STRESS
• Maternal risk related to infection of the membranes (chorioamnionitis)

  -Maternal/fetal tachycardia

  -Maternal fever higher than 100.4 F

  -Uterine tenderness

  -Foul smelling vaginal discharge/leaking

  Neonatal risk associated with:

  -Infection/sepsis

  -Prematurity

  -RDS

  -Hypoxia (umbilical cord compression)

  -Prolapsed cord
• PROM Assessment/Diagnosis

  -S/S: gush or slow steady leaking of fluid from the vagina

  -Confirmed by sterile speculum exam: looking for amniotic fluid at vaginal vault

  Check pH of vaginal fluid with nitrazine paper

  Check ferning

  Amnisure: most accurate
• Medical/Nursing Care PPROM more invasive/intensive:

  -Hospitalization: deliver at term or when s/s infection

  -Limit SVE

  -Vital signs q 1-2 hrs, if stable q 4 hrs

  -Activity restriction

  -Daily NSTs/fetal monitoring

  -Lab tests: WBC, C-reactive protein

  -Medications: administer antibiotics, administer corticosteroids if PPROM and 24-34 weeks, and MgSo4 for fetal neuroprotection
• Insufficient/incompetent cervix

  • Painless dilation and/or effacement (shortening) of the cervical os without uterine contractions
  • Commonly occurs in 2nd trimester
  • Diagnosed by ultrasound
  • Etiology is not well understood- connective tissue unable to maintain closure of cervical os during pregnancy
• Management of incompetent cervix

  • More than 25 mm= normal length
  • Less than or equal to 25 mm= short length
  • Education (report pink-tinged discharge, ROM, pelvic pressure)
  • More invasive: cerclage and birth
• Cerclage

  • Membranes cannot be ruptured
  • No s/s infection
  • No PTL
  • Regional or general anesthesia
  • Remove at 37 weeks gestation or upon onset of PTL
• Categories/Definitions of HTN

  1. Chronic/preexisting HTN
  2. Chronic/preexisting HTN with superimposed preeclampsia
  3. Gestational HTN
  4. Preeclampsia (PreE): early onset (symptoms before 34 weeks) & severe (eclampsia-seizures and HELLP syndrome)
• Preeclampsia-Diagnosis

  • Symptoms begin to be seen after 20th week
  • Multisystem disorder/syndrome
  • Elevated BP (more than 140/90) on 2 occasions, 4 hours apart
  • PLUS: *proteinuria*, low platelet count, elevated creatinine/liver enzymes, pulmonary edema, and visual symptoms (*HA, *blurred vision)
• Predisposing/Risk factors for preeclampsia

  • First pregnancy
  • Family hx
  • Pre-existing HTN or cardiac disease
  • Obesity
  • Excessive gestational weight gain
  • Higher rates among African American women
  • Prior preeclampsia
  • Older than 35
  • Multiple gestation
  • Diabetes
  • Kidney disease
  • Lupus
  • Gestational trophoblastic (placental tumor)
• Patho of preeclampsia

  • Stage 1: abnormal development of the placental vasculature early in pregnancy: maternal spiral arteries & fetal trophoblast cell invasion
  • Stage 2 (after 20th week): impaired placental perfusion/hypoxia/underperfusion of fetus AND altered maternal systemic endothelial function causing HTN
• Severe preeclampsia

  • BP more than 160/110
  • Proteinuria 2+ or greater
  • Headache, visual disturbances, upper abdominal pain and oliguria
  • Increased serum creatinine (1.2)
  • Thrombocytopenia (less than 100,000)
  • Elevated liver enzymes (ALT, AST)
  • Fetal growth restriction
  • Eclampsia
• Eclampsia Nursing Care

  • Get help!
  • Keep airway open
  • Suction to prevent aspiration
  • Pad side rails/put side rails up
  • Record length of seizure
  • Oxygen
  • Ensure IV access
  • Administer MgSo4, anticonvulsants
• Long Term maternal health problems

  • Cardiovascular disease
  • HTN
  • Stroke
  • Renal disease/failure
  • Liver damage
  • Diabetes
  • Fetal/Newborn: intolerance to labor, consequences of IUGR, prematurity and stillbirth
• Management of eclampsia

  • Low dose aspirin and calcium supplements : prior to 16 weeks gestations
  • Labs: CBC, platelets, BUN, creatinine, uric acid, & liver enzymes
  • Daily weights
  • DTR's: hyperreflexia/clonus
  • Assess for: headache, visual disturbance, epigastric pain, decrease LOC, vaginal bleeding, and signs of abruption
• Dizygotic twins will always be dichorionic/diamniotic
• Monozygotic twin separation:

  Days 1-3 days: Di, Di (Two chorions and two amnions)

  Days 4-8: Monochorionic, Diamniotic (One chorion and two amnions)

  Days 8-13: Monochorionic, Monoamniotic (Cords may become entangled, one chorion and one amnion)

  Days 13-18: Conjoined twins