PREGNANCY COMPLICATIONS Hemorrhagic conditions Early Hemorrhagic Conditions <20 weeks

1. Spontaneousloss of pregnancy BEFORE VIABILITY (spontaneous or induced/D&C)

Leading cause of pregnancy loss Inc. with parental age (35 or over BY CONCEPTION) 1st 12 weeks Etiology: Severe congenital anomalies Maternal infections/endocrine disorders Immunologicalfa fetal protein problems Uterine or cervial defects (e.g.: Bicornuate uterus makes increased risk miscarriage; cervical insufficiency)

A b o r t i o n

2. Threatened
Presentation: Vaginal bleeding cramps, back-ache (uterine contractions), pelvic pressure B-hCG levels rise/increase uterine size if embryonic growth (*if B-hCG levels arent doubling q 3 days it is likely the pregnancy will NOT last) Transvaginal US (at 7 weeks a heartbeat seen) Mgt: Assessment: last period; how much bleeding pad count; odor (infection S/S: tachycardia/pain/inc. RR & HR) Teaching: NO VAGINAL INTERCOURSE: NO SEX, TOYS, DOUCHING Emotional support

3. Inevitablewill happen
+ROM Cervical dilation HEAVY bleeding (shock? Infection?) Mgt: natural expulsion; dilatation & vacuum curettage (D&C)

4. Incompleteactive bleeding; abd cramping; VERY CONCERNING

BEFORE 14 wks: CV stabilization curettage uterotonic drugs (synth. Oxytocin) AFTER 14 wks: Oxytocin (stimulates uterine contraction) or prostaglandin; possible hemorrhage: r/o D&C

5. CompleteAll POC expelled from uterus 6. MissedFetus dies 1st half of pregnancy
Early symptoms pregnancy disappear Uterine growth halts & reduces size Mgt.: 1st trimester: D&C; 2nd trimester: prostaglandins (go home & return for f/u after fetus passes)

7. Recurrent spontaneous3+ CONSECUTIVE spontaneous abortions

Etiology: Genetic/chromosomal abnormalities or reproductive tract anomolies Hormones/immunologic factors Sytstemic diseases (e.g., LUPUS)

Ectopic pregnancy

o Risks: decreased. cilia; fallopian tube scarring; pelvic inflammation; previous surgery o <20 wks = GYN; >20 wks = OB o Methotrexate (cancer/chemo drug) ends pregnancy: acts on rapidly dividing cells like fetal cells Distal: If embryo dies early, may be Proximal: SUDDEN severe pain BLQ reabsorbed by body Intra-abd hemorrhage Usual signs pregnancy:
Missed period Intermittent abd/pelvic pain Vaginal spotting

Kehrs sign (intern. bleeding hits nerve; very painful) Hypovolemic shockno visible external bleeding

Early Hemorrhagic Conditions <20 weeks (contd) Late Hemorrhagic Conditions >20 weeks

Hydatidaform

Trophoblasts develop abnormally (+placenta; -fetal development) Develop VERY fast (CANCER big fear with this) Complete (no fetal tissue) or Partial Dx: US and B hCG S/S: Vag bleeding; large uterus; excessive N/V Tx: Chest imaging/labs; vacuum aspiration; f/u malignant changes 1-2 months; chemo if + choriocarcinoma

Placenta Previa
Sudden onset of PAINLESS uterine bleeding >20wks IUP

1. Marginal: >3cm from cervical OS 2. Partial: <3cm from cervical OS 3. Total: covers OS
Mgt.: CV stability (fluid replacement?); FHT pattern; Delay birth until 35-36 weeks to get fetal lung maturity (dexa- or betamethasone given) Nsg Rspns.: Assess bleeding, fetal movement (count 10 movements in one hour), UCs; no sexual intercourse that might cause bleeding or bimanual exams; previa in first trimester, usually placenta will move up Presentation: Vaginal bleeding vs. concealed Abd & low back pain & UCs High resting tone & uterine tenderness Mgt.: CV stabilityblood, fluid, large bore IV FHTsresting tone = between contractions (5-10 mmHg) RhoGAM(Rh- mom and Rh+ fetus)

Abruptio Placenta
Placental separation before birth; hematoma forms between placenta and uterus & contractions occur

Hyperemesis gravidarum:
persistent uncontrollable vomitting

5% LOSS of PRE-pregnancy weight Risk for low birth weightfetus losing nutrition (starving = acidotic) Prevent dehydrationvomiting loses K+ & Na; dehydration means non-perfused kidneys I&Os, labs, IVF/TPN, & daily weights Medications: B6, Ginger, Zofran, methylprednisolone

Preeclempsia Hypertensive disorders:

Danger signs: o During last 3 mos of pregnancy o Face and hands swell (feet swelling not a sign) o HA/vision trouble S/S: HTN; proteinuria; hyperreflexia (DTRs); HA; drowsiness Generalized vasospasm: decreased circulation to kidneys, liver, brain, & placenta

Eclempsia
ALREADY HAD SEIZURE; (preventable extension of preeclampsia) Onset of 1 or more seizures Mgt.: Pregnancy, intrapartum or postpartum BS q hr (pulmoary edema?), O2 sat, high flow O2, UO (should have EXCESS UO) Fluid shift causes hypovolemia Lasix & Digitalis Monitor ROM, FHT, UC, & abruption Seizure precautions Aspiration pneumonia (onto left side) Hemolysis Elevated liver Enzymes Low Platelets HEELP Life-threatening complication of severe HTN Syndrome Symptoms:
RUQ, lower chest or epigastric pain (DO NOT palpate: liver could be damaged), tenderness d/t liver distention N/V and severe edema

Chronic HTN:

Treatment: same as preeclampsia or ecclampsia Occurs PREpregnancy or <20 weeks High protein diet (losing a lot) Methyldopa if DBP >100 CONSISTENTLY Hypertensive crisis: HYDRALAZINE

Gestational Diabetes:
Goalgood glucose control before getting pregnant (mothers blood brings extra gluc. to fetus; fetus releases inc. insulin; excess glucose stored in fetus as fat)

Maternal effects: Fetal effects: Neonatal effects:

Preeclempsia UTI Hydramnios Shoulder dystociababy delivered with shoulder first Congenital malformation IUGRintrauterine growth restriction <90% other fetuses at same GA MacrosomicLARGE birth weight (4000g) Hypoglycemia, hypocalcemia, hyperbilirubinemia, RESP. distress syndrome

Cardiac Disease:

Goal: Prevent CHF (restrict activity; limit weight gain; prevent anemia/infection) Classifications: I/IIPrevention; III/IVTreatment Teaching: CHF prevention Avoid temperature extremes Decrease emotional stress No smoking or drug use Breastfeeding advisement (increased demand on the heart)

DIC Disseminated Intravascular Coagulation: Goal: GET BABY OUT! Anemias:

Iron deficiency Folic acid deficiency Sickle cell Thalassemias

Anticoagulation & procoagulation

Common occurrences: missed abortion; abruptio placentae; HTN Diagnosis via labs Decreased fibrinogen & platelets PROLONGED PT/PTT +D-dimer Mgt.: Delivery of fetus & placenta stops thromboplastin Blood products IRON DEFICIENCY ANEMIA: Insufficient iron to meet demands of pregnancy (adequate fetal iron stores at cost of moms iron levels) S/S: Pallor Fatigue Lethargy HA Treatment: Ferrous sulfate 325 mg 3-4x daily High iron diet FOLIC ACID DEFICIENCY ANEMIA: Maternal folic acid needs to double in pregnancy: Greater erythrocyte production Fetal & placental growth Fetal effects: spontaneous abortion, abruption and neural tube (1 st 12 weeks) Treatment: Folic acid 600 mcg 4x daily Diet