Complications of Pregnancy

SISKA HELINA
MIDWIFERY DEPARTMENT
Hyperemesis Gravidarum

Intractable nausea and vomiting that

persists beyond the first trimester
and causes disturbances in nutrition,
electrolytes, and fluid balance
 Assessment

Nausea most pronounced on arising

Persistent vomiting
Weight loss
Signs of dehydration
Electrolyte imbalances
Ketonuria
Increased hematocrit levels
 Midwife Interventions

Monitor vital signs

Monitor FHR, fetal activity and fetal
growth
Monitor for dehydration and
electrolyte imbalance
Daily weight, I&O, calorie count
Monitor urine for ketones
Administer IV fluids, antiemetics
Bleeding Disorders of Early
Pregnancy

Spontaneous abortion

Ectopic pregnancy

Hydatidiform mole
 Abortion

Threatened
Imminent
Complete
Incomplete
Missed
Habitual
Elective
Threatened Abortion
Imminent Abortion
Incomplete Abortion
A 22 year old gravida i, para 0, is
11 weeks pregnant. She was
admitted to the hospital with
moderate vaginal bleeding and some
abdominal cramping. Vaginal
examination reveals that the cervix is
dilated 2 cm. She is diagnosed as
having an imminent abortion. What
nursing interventions are indicated
when caring for this patient?
 Midwife Interventions

Save perineal pads / tissue

Emotional support
Observe for shock
Bed rest / diversional activity
RhoGAM
Possible surgery
Medication / Blood
Ectopic pregnancy is often
difficult to diagnose because
its symptoms are similar to
those of abdominal conditions.
Identify at least five signs or
symptoms of ectopic pregnancy
and briefly explain why each
occurs.
 Ectopic Sites

l
 Ectopic Pregnancy

Fertilized ovum implants outside the

uterus
Symptoms at 6 to 12 weeks of gestation
Severe unilateral pelvic-abdominal pain
Pain may refer to shoulder
Tender abdominal mass
Nausea, faintness
Bleeding – frank or occult
 Nursing Interventions

Monitor vital signs

Administer intravenous fluids
Provide oxygen when needed
Medicate for pain
Assess lab results
Prepare for possible surgery
Provide emotional support
 Incompetent Cervix

Premature dilation of cervix

Occurs in 4th or 5th month of pregnancy
Associated with cervical trauma
Vaginal bleeding at 18 to 28 weeks
Fetal membranes visible through cervix
Treatment is surgical
Hydatidiform Mole

Gestational trophoblastic disease

Developmental anomaly of placenta
Changes chorionic villi into a mass of
clear vesicles
Edematous grapelike cluster
May develop into choriocarcionoma
Hydatidiform Mole
 Assessment

FHR not detectable

Vaginal bleeding
Symptoms of PIH
Fundal height > expected for date
Elevated hCG
Ultrasound shows characteristic
snowstorm pattern
Bleeding Disorders of Late
Pregnancy

Placenta previa

Abruption placenta
 Placenta Previa

Painless
Spotting or heavy bleeding
Bright-red bleeding
Soft, non-tender, relaxed uterus with
normal tone
Shock in proportion to observed blood
loss
Signs of fetal distress usually not
present
Placenta Previa
 Assessment

Episodic painless vaginal bleeding

after 20th week of pregnancy without
contractions
Each successive bleeding episode
heavier than the last
Profuse hemorrhage
Ultrasound shows location of placenta
 Nursing Interventions

No vaginal exams
Bedrest
Monitor vital signs and fetal well-
being
Assess blood loss
IV access
Provide adequate nutrition
Provide emotional support
Abruptio Placenta

Severely painful
Heavy bleeding may be partially or
completely hidden
Usually dark-brown bleeding
Rigid, board-like, tender uterus
possibly with contractions
Shock seeming to be out of
proportion to blood loss
Signs of fetal distress
Abruptio Placenta
 Assessment

Painful, rigid, board-like abdomen

with vaginal bleeding
Central abruption
Marginal abruption
Fetal outcome
 Midwife Interventions

Monitor vital signs

Continuous EFM
Assess for bleeding, uterine activity,
abdominal pain
Measure abdominal girth
Review lab values
IV access
Provide oxygen
 Hypertensive Disorders

Pregnancy induced hypertension

Preeclampsia and eclampsia
Chronic hypertension
Superimposed preeclampsia
Transient hypertension
 Pathophysiology

Vasospasm reduces blood flow to

mother’s organs and placenta
Vascular endothelial damage
Hypertension
Edema
Proteinuria
 PIH - Assessment

Mild preeclampsia

Severe preeclampsia

Systemic responses

Lab values
 Midwife Interventions
Bedrest -- left lateral position
Monitor B/P and weight
Monitor neurological status
Monitor DTRs
Provide adequate fluids
Monitor I & O
Increase dietary protein
Administer medications as prescribed
Magnesium Sulfate ( Mg SO4 )

Mg++ causes vasodilation

Therapeutic levels = 4 to 8 mg/dL

 Mg SO4 Therapy

Monitor blood pressure closely

Monitor maternal serum Mg SO4
levels every 6 - 8 hours
Monitor respirations closely
Assess patellar tendon reflex
Determine urinary output
Monitor FHR continuously
Continue Mg SO4 infusion for
approximately 24 hours after birth
Maternal Side Effects

Vasodilation
Flushing
Headaches
“Hot Flashes”
Blurred vision
Nasal Congestion
Decreased peripheral vascular
resistance
 Maternal Side Effects

Neuromuscular depression
Respiratory depression
Myocardial depression
Gastrointestinal system
nausea
vomiting
 Neonatal Side Effects

Hypocalcemia

Hypermagnesemia

Respiratory depression
 Chronic Hypertension

Occurs before pregnancy

Diagnosed before 20th week of gestation

Diagnosed during pregnancy and persists

beyond the 42 day postpartum
 Assessment

Headaches
Visual changes
Blood pressure 140/90 mm Hg or >
Delayed fetal growth
Oligohydramnios
 Antihypertensives

Given for diastolic blood pressure of

105 to 110 or above
Methyldopa
Hydralazine
Labetalol
Nifedipine
Diabetes

Pregnancy places demands on

carbohydrate metabolism
Insulin requirements increase in 2nd
and 3rd trimester
Insulin-dependent diabetes
Diabetes in pregnancy
 Assessment

Risk factors
Classic symptoms
Frequent UTIs and yeast infections
Screening at 24-28 weeks gestation
 Midwife Interventions

Prenatal visits bimonthly for 6 months than

weekly
Maintain blood glucose between 65-130
mg/dL
Monitor for hypoglycemia / hyperglycemia
Glucose control
Monitor for infection, PIH, ketoacidosis
Reinforce diet instructions
 Gestational Diabetes

Occurs during 2nd and 3rd trimesters

No prior diagnosis
Screened during 26th week
Glucose = 105 mg/dL
Diet
Medications
“Normal” after delivery
 Anemia

Decrease in RBCs
Types
Iron deficiency
Folic acid
Hemoglobinopathies
Sickle cell disease
Thalassemia
 Assessment

Fatigue
Headache
Pallor
Tachycardia
Diagnostic test: H & H
Treatment: Iron and folic acid
 Midwife Interventions

Monitor H & H every 2 weeks

Iron and folic acid supplements
Take iron with vitamin C
Foods high in iron, folic acid and protein
Monitor for infection
May use parenteral iron / transfusions
 Position, posture and presentation of the fetus
(in the uterus)
Position of the fetus (situs fetus) is defined as a relation of its longitudinal
axis to the longitudinal axis of the uterus
3 positions are distinguished:
- longitudinal position - both axes run parallel - in 99,5 per cent
- transverse position - both axes are rectangle
- oblique position - axes are passing (instable position)
The longitudinal position:
by head (96,5 %) or
by breech (pelvic end of the fetus) - 3 %.
The back of the fetus is most often oriented to the left edge of the uterus

Posture of the fetus (habitus fetus) is defined as a relation of fetal body

parts to each other
may be regular and irregular
regular posture = the head is in flexion, the chin is in close contact with the
chest, upper and lower limbs are flexed in both articulations and are folded
Presentation of the fetus (praesentatio fetus) is defined as a relation of the
fetal body part to the pelvic aditus

cases that occur:

- cephalic presentation - is physiological or normal
- breech presentation - by pelvic end of the fetus - rare,
- foot or knee presentation - very rare,
- malpresentation - any abnormal presentation
Assessment of Fetal Well-being

Detect physical abnormalities

Monitor fetal condition
Fetal movement
Complex diagnostic testing
Risks and benefits
 Amniocentesis

Aspiration of amniotic fluid

Determine genetic disorders
Sex of fetus
Fetal lung maturity
Risks
Nursing management
Amniocentesis
Chorionic Villus Sampling

Aspiration of small sample of

chorionic villus tissue
8 to 12 weeks gestation
Detects genetic abnormalities
Risks and benefits
Nursing management
 Hormone Levels

Estriol

Human chorionic gonadotropin

Maternal serum—alpha fetoprotein

Alfa-Fetoprotein Screening

MSAFP
AFAFP
Time sensitive
Low MSAFP levels associated with
Down syndrome
High MSAFP levels associated with
neural tube defects
Triple Marker Screening

Alpha-fetoprotein

Human chorionic gonadotropin

Unconjugated estriol
High Risk Assessment

Daily fetal movement count

Nonstress test
Biophysical profile
Contraction stress test
Daily Fetal Movement Count
Begin at 27th week
Consider
Fetal sleep-wake cycles
Maternal food intake
Drug-nicotine use
Environmental stimuli
Maternal position
Procedure
Fetal Monitor
Fetal Monitoring

Normal fetal heart rate

Baseline
 Baseline FHR

Rate
Variability
Assesses average rate for at least 2
minutes within a 10 minute window
Normal: 110 to 160 bpm
Bradycardia: < 110 bpm for 10 minutes
Tachycardia: > 160 bpm for 10 minutes
 Variability

Normal irregularity of fetal cardiac

rhythm
Short-term
Beat-to-beat changes
Need fetal scalp electrode
Long-term
Rhythmic changes (waves) from
the baseline value
Usually 3 to 5 beats
Reduced Variability
Accelerations
Bradycardia
Tachycardia
Deceleration
Nonstress Test

Assess response of FHR to periods of

fetal movement
After 27th to 30th week
Frequency depends on condition of
maternal-fetal unit
Indications
 Procedure

Perform test during a time of activity

Maternal preparation
Maternal vital signs
Attach monitor
Monitor fetal movement
 Interpretation

Reactive result

Nonreactive result

Unsatisfactory result
Reactive NST
Nonreactive Test
Contraction Stress Test

Assess ability of fetus to withstand

the stress of uterine contractions
Assesses placental oxygenation and
function
Determines fetal well being
Performed if NST is abnormal
 Interpretation

Negative CST

Positive CST

Equivocal

Unsatisfactory
Negative CST; Reactive NST
Positive CST
 Biophysical Profile

Assess fetal status

NST
Fetal breathing movements
Fetal body movements
Fetal muscle tone
Amniotic fluid volume
Placental grading
Biophysical Profile Scoring
 Lung Maturity Testing

Lecithin to sphingomyelin ratio

Phosphatidylglycerol
 Fibronectin
Test for preterm delivery
Negative test result highly reliable
Reassures that risk of preterm
delivery is low
Presence of fFN in symptomatic
women during weeks 22 – 34 of
gestation = increased risk of preterm
delivery