Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication

❖ BLEEDING DURING PREGNANCY

- Never normal, more blood loss may be hidden.
- Hypovolemic shock occurs with 10% or 2 units of blood are lost.
- Fetal distress occurs when 25% of blood volume is lost.
- May occur at any point - frightening.
- Bleeding may be innocent, but any degree of bleeding should be evaluated.
- Week 6: not severe
- Week 12: severe (placenta has implanted deeply)

• Primary Cause of Bleeding During Pregnancy

First and Second Trimester

1. Threatened Spontaneous Miscarriage
Early: under 16 weeks
Late: 16 – 24 weeks
2. Imminent Miscarriage
3. Missed Miscarriage
4. Incomplete Spontaneous Miscarriage
5. Complete Spontaneous Miscarriage
6. Ectopic (Tubal) Pregnancy

Second Trimester
1. Gestational Trophoblastic Disease (Hydatidiform mole)
2. Premature Cervical Dilatation

Third Trimester
1. Placenta previa
2. Premature Separation of the Placenta (Abruption Placentae)
3. Preterm Labor

• S/S of Hypovolemic Shock

- Pallor Normal values:
- Confusion (Dizziness or decreased level of consciousness)
- Decreased BP BP: above 100/60 mmHg
- Increased resp rate and pulse rate PR: below 100 bpm
- Cold, clammy skin/extremities
FHR: 120 – 160 bpm
- Decreased urine output
- Peripheral vasoconstriction (placental insufficiency will occur) Maternal Urine Output:
- Fetal bradycardia greater than 30ml/hr.

• Related Interventions for Bleeding

- Monitor urine output
- Monitor hemoglobin and hematocrit
- Secure blood sample for cross-matching of blood (blood replacement)
- IV Ringer’s lactate with 16 or 18 gauge
- Oxygen by mask
- Monitor oxygen saturation levels by pulse oximetry
- Rest in side-lying position (left lateral) *if not possible, position her on her back*
- Central venous pressure catheter measures the right atrial
pressure or the pressure of blood within the vena cava) or a pulmonary capillary wedge
catheter (measures the pressure in the left atrium or the filling pressure in the left ventricle)
inserted after bleeding is halted.
- Central venous pressure: 1 – 6 mmHg
- Pulmonary capillary wedge pressure: 6 – 12 mmHg

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 • Emergency Interventions for Bleeding
- Place on side, flat in bed
- IV Ringer's lactate with 16-18gauge Angiocath
- Oxygen 6-10L/min by face mask
- Monitor uterine contractions and FHR by external monitor
- No oral fluids or vaginal exams
- Order type and cross match of 2 units of whole blood
- Measure intake and output
- Assess vital signs
- Assist with placement of central venous pressure or pulmonary artery catheter and blood
determinations
- Measure/weigh pads to assess blood loss (saturating more than 1/hour is heavy loss)
- Assist with ultrasound examination
- Maintain a positive attitude about fetal outcome.
- Support woman’s self-esteem; provide emotional support to woman and her support person

• SPONTANEOUS MISCARRIAGE

Abortion
- Interruption of a pregnancy before fetus is viable (less than 20-24 weeks, under 500 g)

Miscarriage
- Fetus born before viability
- Early: under 16 weeks
- Late: 16 – 24 weeks

Spontaneous Miscarriage
- Pregnancy ends because of natural causes

• Common Causes
- Abnormal fetal development (due to teratogenic factor or chromosomal aberration)
- Immunologic factors
- Rejection of embryo (immune response)
- Implantation abnormalities
- Ovary fails to produce enough progesterone
✓ Tx: Progesterone therapy
- Ingestion of alcohol = abnormal fetal growth
- Urinary tract infections
- Systemic infections (rubella, syphilis, poliomyelitis, cytomegalovirus, and toxoplasmosis)

• Symptoms / Assessment
- Vaginal spotting
- Slight cramping

• Diagnosis: Types of Miscarriages

1. Threatened miscarriage
- Cause: chromosomal or uterine abnormalities
- Assessment:
o Vaginal spotting
o Slight cramping
o No cervical dilatation
- Caution: Do not use tampons to stop bleeding (can lead to infection)
- Management:
✓ Assess fetal heart sounds.
✓ Ultrasound
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 ✓ Blood to test hCG.
✓ Avoid strenuous activity for 24 – 28 hrs.
✓ Restrict coitus for 2 weeks.

2. Imminent (Inevitable) miscarriage

- Cause: poor placental attachment
- Assessment:
o Vaginal spotting
o Cramping or uterine contractions
o Cervical dilatation and effacement
- Management:
✓ Medications
✓ Dilatation and curettage (D&C) or dilation and evacuation (D&E) *to ensure all
products of conception are removed*
✓ Assess amount of vaginal bleeding.

3. Complete spontaneous miscarriage

- Cause: chromosomal or uterine abnormalities
- Assessment:
o Vaginal spotting
o Cramping
o Cervical dilatation
o Complete expulsion of uterine contents
- Management:
✓ Advise to report heavy bleeding.

4. Incomplete Spontaneous miscarriage

- Cause: chromosomal or uterine abnormalities
- Assessment:
o Vaginal spotting
o Cramping
o Cervical dilatation
o Incomplete expulsion of uterine contents (membranes or placenta are retained in
uterus)
- Caution: High risk for uterine infection and hemorrhage
- Management:
✓ Dilatation and curettage (D&C)
✓ Suction curettage

5. Missed Miscarriage (Early pregnancy failure)

- Assessment:
o Vaginal spotting
o Slight cramping
o No apparent loss of pregnancy
o Products of conception are retained in utero after fetal death.
- Cautions: Associated with Disseminated intravascular coagulation (DIC) if the fetus
remains too long in the utero.
- Management:
✓ Assess fundal height (no increase in size)
✓ Assess FHR (no sounds can be heard)
✓ Ultrasound
✓ D&C or D&E
✓ If over 14 weeks, labor can be induced by prostaglandin suppository or
misoprostol (Cytotec) followed by oxytocin stimulation or administration of
mifepristone techniques for elective termination of pregnancy.

6. Recurrent Pregnancy Loss (Habitual)

- Cause:
 Defective spermatozoa or ova
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  Endocrine factors
 Deviations of the uterus (septate or bicornuate uterus)
 Resistance to uterine artery blood flow
 Chorioamnionitis or uterine infection
 Autoimmune disorders (lupus anticoagulant and antiphospholipid antibodies)
- Assessment:
o Recurrent pregnancy losses that occur in 3 or more successions

• Nursing Interventions For Abortion

1. Maintain bed rest.
2. Monitor vs cramping and bleeding.
3. Count perineal pads to evaluate. Save expelled tissue and clots.
4. Maintain IV fluids as prescribed. Monitor for signs of hemorrhage or shock.
5. Prepare the client for D & C, as prescribed, for incomplete abortion.
6. Prepare to administer Rh (D) immune globulin (RhoGAM) to a Rh-negative woman.

• Surgical Management
1. Dilatation and evacuation. This is to make sure that all products of conception would be removed
from the uterus.
2. Dilation and curettage. This is most performed for incomplete abortions to remove the remainder
of the products of conception from the uterus.

• Complications of Miscarriage
• Hemorrhage
- Management:
✓ Monitor vital signs to detect hypovolemic shock.
✓ If excessive vaginal bleeding occurs, immediately position a woman flat and
massage the uterine fundus to try to aid contraction.
✓ Apply pneumatic antishock garments to maintain blood pressure.
✓ If bleeding doesn’t halt, a woman may need a D&C or suction curettage to empty
the uterus of the material that is preventing it from contracting and achieving
hemostasis.
✓ Blood transfusion
✓ Prescribed an oral medication such as methylergonovine maleate (Methergine) to
aid uterine contraction.

• Infection
- Reason for excessive blood loss.
- Assessment:
o Fever higher than 100.4°F (38.0°C)
o Abdominal pain or tenderness
o Foul-smelling vaginal discharge
- Management:
✓ Wipe perineal area from front to back after voiding and defecation
✓ Advise not to use tampons.

• Septic Abortion
- Abortion complicated by infection.
- Occur after spontaneous miscarriage, self-abort, illegal abortion w/ nonsterile instrument.
- Left untreated; toxic shock syndrome, septicemia, kidney failure, and death.
- Assessment:
o Fever
o Crampy abdominal pain
o Uterus tender to palpate
- Management:
✓ Complete blood count
✓ Serum electrolytes and serum creatinine
✓ Blood type and cross-match
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 ✓ Cervical, vaginal, and urine culture
✓ Indwelling urinary (Foley) catheter to monitor urine output
✓ IV fluid
✓ Antibiotic therapy; penicillin, gentamicin, clindamycin
✓ Central venous pressure or pulmonary artery catheter
✓ D&C and D&E
✓ Tetanus toxoid SUBQ / tetanus immune globulin IM
✓ Dopamine and digitalis to maintain cardiac output
✓ Oxygen and ventilatory support

• Isoimmunization
- Production of antibodies against Rh-positive blood.
- Management:
✓ Women with Rh-negative blood should receive Rh (D antigen) immune
✓ globulin (RhIG) to prevent the buildup of antibodies in the event the conceptus was
Rh positive.

• Powerlessness or Anxiety
- Assess a woman’s adjustment to a spontaneous miscarriage.
- Sadness and grief over the loss or the feeling that a woman has lost control of her life is to
be expected.
- Assess a partner’s or the extended family’s feelings as well

• ECTOPIC PREGNANCY
- Pregnancy that occurs in a site other than a uterine site, with implantation usually occurring in
the fallopian tube.
- Risk factors:
- Damage to the fallopian tube causing blockage or narrowing so the eggs cannot move
into the uterus.
- Previous pelvic infection.
- Damage to the fallopian tube causing blockage or narrowing so the eggs cannot move
into the uterus.
- Previous pelvic infection.
- Chlamydia.
- Previous appendicitis.
- Women with a history of infertility (Stabile, 1996);
- Caesarean section.
- Women aged 35 or older.
- Smoking
- Assessment:
o Missed period
o Seems normal pregnancy
o Sharp, stabbing pain in lower abdominal quadrant with vaginal spotting (round ligament
pain)
o Hypotension
o Light-headedness
o Rapid, thready pulse
o Rapid respirations
o Signs of hypovolemic shock
o Umbilicus may develop bluish-tinged hue (Cullen sign)
o Continuing extensive or dull vaginal and abdominal pain
o Tender mass is palpable in Douglas cul-de-sac on vaginal examination.
- Management:
✓ If ruptured ectopic prepare for surgery via laparoscopy to ligate the bleeding vessels and
remove/repair the fallopian tube.
✓ Obtain blood for Hgb level, type and cross match.
✓ Start (16 gauge - pink) large bore IV for fluids and blood administration.
✓ Monitor VS, bleeding and for shock.

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 ✓ An ectopic pregnancy can be visualized via ultrasound and caught before any serious
complications.
✓ After agreement with mom that therapy could be lifesaving, Methotrexate is given.
(Chemo drug that will destroy cells) *oral or IM*
✓ Tube is left intact, no surgery needed.
✓ Women with Rh-negative blood should receive RhIG/RhoGAM after an ectopic
pregnancy for isoimmunization protection in future childbearing.

• ABDOMINAL PREGNANCY
- Fetus grows in the pelvic cavity.
- Occur if a uterus ruptures because an old uterine scar ruptures during pregnancy.
- Assessment:
o Fetal outline is easily palpable in abdomen.
o Painful fetal movements
o Abdominal cramping with fetal movements
o Sudden lower quadrant pain early in pregnancy
- Management:
✓ At term, infant must be born through laparotomy.
✓ Placenta left in place and allowed to absorb spontaneously in 2-3 months.
✓ Ultrasound
✓ Methoxetrate

• GESTATIONAL TROPHOBLASTIC DISEASE (HYDATIDIFORM MOLE)

- Abnormal proliferation and the, degeneration of the trophoblastic villi
- Appear as clear fluid-filled, grape sized vesicle
- Associated with choriocarcinoma
- Risk factors:
- Low protein intake
- Women older than 35 years of age
- Women of Asian heritage
- Blood group A women who marry blood group O men
- Assessment:
o No FHR
o Vaginal bleeding
o Signs of gestational HTN (increased BP, edema, and proteinuria)
o Fundal height greater than expected.
o Elevated HCG levels
o Ultrasound shows dense growth but no fetal growth - "clumps of abnormal cells."
o Nausea and vomiting at early pregnancy
- Management:
✓ Suction curettage to evacuate abnormal trophoblast cells
✓ Methotrexate and dactinomycin
✓ HCG is analyzed every 2 weeks until levels are normal again, then every 4 weeks for the
next 6-12 months.
✓ A woman should use reliable contraception for this 12 month period of evaluation then
after this period of time may plan for another pregnancy. This is to rule out malignancy.

• CERVICAL INSUFFICIENCY (PREMATURE CERVICAL DILATATION)

- “Incompetent cervix”
- Cervix dilate prematurely and cannot retain fetus until term.
- Occurs most often in 4th or 5th month of pregnancy.
- Assessment:
o Pink stained vaginal discharge
o Increased pelvic pressure
- Management:
✓ Cervical cerclage at weeks 12-14 to prevent this case in 2nd pregnancy.
✓ Sutures are placed in the cervix to strengthen it and prevent it from opening.
✓ Sutures are removed at weeks 37-38 so the fetus can be born vaginally.

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 ✓ McDonald or Shirodkar procedure to strengthen cervix and prevent it from dilating until
end of pregnancy.

• Interventions For Incompetent Cervix

- Remain on bed rest for a few days after cerclage to decrease pressure on the new sutures.
- Avoid prolonged standing or heavy lifting.
- Usual activity and sexual relations can continue after this rest period.
- Instruct her to report post vaginal bleeding/ctx.
- The prognosis is favorable - success rate is 80-90%.

• Nursing Care
- Maintain bed rest for 24 hours after cerclage.
- Monitor for rupture of membranes or bleeding.

• PLACENTA PREVIA
- The placenta is improperly implanted in the lower uterine segment near or over the internal
cervical os.
- Most common cause of painless bleeding in third trimester of pregnancy
- 4 degrees of placenta:
1. Low-lying Placenta = implantation in the lower rather than upper portion of the uterus.
2. Marginal Implantation = the placenta edge approaches the cervical os.
3. Partial Placenta Previa = Implantation that occludes a portion of the cervical os.
4. Total Placenta Previa = Implantation that totally obstructs the cervical os.
- The degree to which the placenta covers the internal cervical os is generally estimated in
percentages: 100%, 75%, 30%, and so forth.

- Risk factors:
- Increased parity
- Advanced maternal age
- Past cesarean births
- Past uterine curettage
- Multiple gestation
- Male fetus
- Assessment:
o Placenta Previa is usually detected during pregnancy through routine ultrasound.
o Lower uterine segment or cervix
o Small portion loosens and damaged blood vessels begin to bleed.
o Sudden onset of painless, bright red, vaginal bleeding during the last half of pregnancy.
o May also cause pre-term labor.
- Management:
✓ Inspect perineum for bleeding, estimate blood loss.
✓ Obtain vital signs and determine if hypovolemia is present.
✓ Monitor BP every 5-15 mins
✓ *Vaginal exams or any other activity that would stimulate the uterus or further damage
placenta are AVOIDED.***
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 ✓ Maintain bedrest on the left side.
✓ Attach external monitors to record FHR and uterine contraction.
✓ Obtain labs for hemoglobin and hematocrit, type and cross match.
✓ Monitor urinary output, administer IV fluids.
✓ Obtain ultrasound to determine if vaginal delivery is possible. (Vaginal birth is safest for
the infant)
✓ Under 30% = vaginal birth,
✓ Over 30 % = cesarean section
✓ Complete placenta previa = C-SECTION

• Immediate Care Measures

- Place the woman immediately in side-lying position.
- Assess:
- Duration of the pregnancy
- Time the bleeding began
- Woman’s estimation of the amount of blood
- Whether there was accompanying pain
- Color of the blood (red blood indicates bleeding is fresh or is continuing)
- What she has done, if anything, for the bleeding (if she inserted a tampon to halt the
bleeding, there may be hidden bleeding)
- Whether there were prior episodes of bleeding during the pregnancy
- Whether she had prior cervical surgery for premature cervical dilatation

• Continuing Care Measures

- If labor has begun or bleeding is continuous, or fetus is compromised, birth MUST OCCUR
regardless of gestational age.
- If bleeding has stopped, and fetus and VS are stable, a woman is monitored for 24-48 hours in the
hospital. She is sent home on bed rest.
- Betamethasone (12-24 hours before birth) may be given to encourage fetal lung maturity if fetus
is less than 34 weeks gestation and help prevent respiratory distress syndrome.
- After delivery, mom is more prone to postpartum hemorrhage b/c the lower uterine segment does
not contract as well.

• PREMATURE SEPARATION OF THE PLACENTA (ABRUPTIO PLACENTAE)

- Premature separation of the placenta from the uterine wall after 20 weeks gestation and before
the birth of the baby.
- Most frequent cause of perinatal death.
- Risk factors:
- High parity
- Advanced maternal age
- Short umbilical cord
- Chronic hypertensive disease
- Hypertension in pregnancy
- Direct trauma
- Vasoconstriction from cocaine
- Thrombophilic conditions
- Cause: chorioamnionitis/ infection of fetal membranes and fluid
- Assessment:
o Heavy dark red bleeding usually occurs (if placenta separates at the edges). If it separates
at the center, blood may not be evident.
o Hypovolemic shock follows quickly.
o Uterus becomes tense/rigid and tender.
o Sharp, stabbing pain high in uterine fundus
o Pain over and above pain of contraction
o Couvelaire uterus or uteroplacental apoplexy, forming a hard, boardlike uterus occurs.
- Management:

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 ✓ Assess when bleeding started, if pain is present, and trauma could have led to placental
separation.
✓ EMERGENCY SITUATION FOR MOM AND FETUS.
✓ Large-gauge (20 gauge) intravenous catheter for fluid replacement.
✓ Oxygen by mask.
✓ Keep woman lateral to prevent pressure on vena cava and interference
✓ of fetal circulation
✓ Do not perform abdominal, vaginal and pelvic examination
✓ Cesarean birth of method
✓ Intravenous administration of fibrinogen or cryoprecipitate.
✓ Monitor for DIC in postpartum period.
✓ If a woman has bleeding before birth, she is more prone to infection after birth.
- Degrees of separation:
- 0 = No symptoms of separation are apparent from maternal or fetal signs; the diagnosis is
made after birth, when the placenta is examined and a segment of the placenta shows a
recent adherent clot on the maternal surface.
- 1 = Minimal separation, but enough to cause vaginal bleeding and changes in the maternal
vital signs; no fetal distress or hemorrhagic shock occurs, however.
- 2 = Moderate separation; there is evidence of fetal distress; the uterus is tense and painful
on palpation.
- 3 = Extreme separation; without immediate interventions, maternal hypovolemic shock and
fetal death will result.

• DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

- Acquire disorder of blood clotting which fibrinogen level falls to below effective limit.
- Causes:
- Easy bruising or bleeding from intravenous site.
- Abruptio placentae
- Amniotic fluid embolism
- Gestational hypertension
- Placental retention
- Intrauterine fetal death
- Septic abortion
- Assessment:
o Uncontrolled; bleeding, bruising, petechiae/ecchymosis
o Occult blood in excretions (stool)
o Hematuria/hematemesis/vaginal bleeding
o Decrease in fibrinogen level, platelet count and hct level.
o Increase PT PTT, clotting time and fibrin degradation products
- DIC creates a paradox
- One part of the circulatory system may experience increased coagulation.
- The other part may experience a bleeding defect.
- Management:
✓ Draw blood for; platelet count, prothrombin, thrombin time, fibrinogen
✓ Treat underlying cause of DIC
✓ Increased coagulation must be stopped so normal clotting function can be restored - give
heparin.
✓ Heparin must be given cautiously close to birth d/t/ risk of postpartum hemorrhage.
✓ Kidneys can be affected - monitor for appropriate urinary output - 30 mL/hr
✓ Monitor labs to determine if blood coagulation studies are returning to normal.
✓ Blood or platelet transfusion
✓ Antithrombin III factor, fibrinogen, or cryoprecipitate
✓ If not available that listed above, fresh frozen plasma or platelets to aid in restoring
clotting function.

❖ PRETERM LABOR
- Labor that occurs before the end of week 37 of gestation
- Infant will be immature.
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 - Risk factors:
- Dehydration
- UTI
- Periodontal disease
- Chorioamnionitis
- Being adolescent or African-Amer.
- Lack of prenatal care
- Past OB conditions
- Substance abuse
- Assessment:
o Persistent dull and low backache
o Vaginal spotting
o Pelvic pressure or abdominal lightening
o Menstrual like cramping
o Increased vaginal discharge
o Uterine cramping/contractions
o Intestinal cramping
o Rupture of membranes
- Management:
✓ Focus on stopping labor if membranes are still intact, fetal distress, no bleeding and cervix is
not dilated more than 4-5 cm.
✓ Maintain bed rest on left side
✓ Monitor fetal activity and FHR, and contractions
✓ Administer fluids per physician orders for hydration
✓ Obtain clean catch urine to rule out UTI/infection

• Drug Administration
• Terbutaline
- Prevent and treat bronchospasm
- Cannot be used more than 48-72 hours of therapy d/t serious potential for maternal heart
problems and death.
- Can also be used as tocolytic (agent to halt labor)
- If woman is 4-5 cm or membranes have ruptured, terbutaline CANNOT BE USED.

• Magnesium Sulphate
- Treat preeclampsia and prevent eclamptic seizures.
- DOC for gestational hypertension but can be used to reduce uterine ctx.
- Administered IV until contractions have slowed/dilation has stopped. Mom needs monitored
for respiratory depression!
- Antidote: Calcium gluconate

• Betamethasone
- Reducing respiratory distress syndrome or bronchopulmonary dysplasia.
- Is used in 2 doses, 24 hours apart to help surfactant production if pregnancy is less than 34
weeks.

• Fetal Assessment
- Assess overall welfare in women
- Asked to record daily fetal “kick” or “count to 10”test

• Labor that cannot be halted

- Cesarean birth to reduce pressure on fetal head and reduce possibility of subdural or
intraventricular hemorrhage from vaginal birth
- Cord of preterm birth should not clamped immediately.

❖ PRETERM RUPTURE OF MEMBRANES

- Rupture of fetal membranes with loss of amniotic fluid before 37 weeks of pregnancy.

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 - When rupture of membranes is before term and delivery will be delayed, infection becomes a risk.
- Complications:
- Lost fetal
- Uterine and fetal infection
- Increased pressure on umbilical cord
- Cord prolapse
- Assessment:
o Sudden gush of clear fluid from vagina, with minimal leakage
o Vaginal infection
o If fluid pools in the vagina, this is an indication of ROM. The Nitrazine test or Fern test
positive to confirm.
o Amount/color/consistency/odor of fluid needs to be assessed.
o Preterm rupture is associated with infection, so cultures are obtained vaginally for
gonorrhea, group B strep and chlamydia.
o FHR - tachycardia may indicate infection
- Management:
✓ Assist with tests to assess gestational age.
✓ If labor does not begin within 24 hours and the fetus is mature enough to survive, oxytocin
will be administered IV to start labor.
✓ If the fetus is not viable, a woman is placed on bedrest and administered corticosteroid
(betamethasone).
✓ Prophylactic ATB will be given to delay labor and reduce risk of infection.
✓ If contractions begin and no infection is present, mom will be given a tocolytic agent to stop
labor.
✓ Avoid vaginal exam because of risk of infection.
✓ Age of viability is 24 but if ruptured membranes hold off as long as possible.
✓ Bed rest.
✓ Stem cell engineering to repair ruptured membrane

❖ HYPERTENSIVE DISORDERS IN PREGNANCY

• GESTATIONAL DIABETES
- Vasospasm occurs in both small and large arteries during pregnancy, causing increased BP,
proteinuria and edema.
- Risk factors:
- Women of color
- Multiple pregnancies
- Primiparas under 20 years old or older than 40
- Low socioeconomic backgrounds
- Those who has had 5 pregnancies or more
- Those with underlying disease such as heart disease, DM or primary HTN
- Complications:
- Abruptio placentae
- DIC
- Thrombocytopenia
- Placental insufficiency
- Intrauterine growth restriction
- Intrauterine fetal death
- Classifications:
- Gestational hypertension
- Mild pre-eclampsia
- Severe pre-eclampsia
- Eclampsia
- HELLP
- BP elevation is detected for the first time after a woman has REACHED 20 WEEKS of
pregnancy = mid pregnancy
- Assessment:
o BP 140/90 with no proteinuria or edema
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 - Further BP evaluation:
- a systolic increase of 30 mmHG or diastolic increase of 15 mmHG above pre-pregnancy
level = gestational hypertension.
- Management:
✓ Monitor BP
✓ Fetal activity and growth.
✓ Perinatal mortality is not increased with simple gestational hypertension, so observe
carefully, and no drug therapy is necessary
✓ BP returns to normal after birth.

• PRE-ECLAMPSIA
- Pregnancy related disease process evidenced by increased blood pressure and proteinuria.
- Occurs after 20 weeks of gestation
- Pathophysiologic Events:
- Affect almost organs
- Poor placental perfusion
- Ischemia in pancreas
- Vision change
- Edema
- Vasospasm in kidney

• Mild Pre-eclampsia
- Assessment:
o BP increases to 140/90 mmHg, taken on 2 occasions at least 6 hours apart.
o Proteinuria: random urine sample shows +1 to 2+ protein on a reagent strip (dip stick)
o Weight gain over 2 lbs./week in second trimester and 1 lbs. in third trimester.
o Mild edema begins to accumulate in the upper extremities or face
- Management:
✓ Monitor antiplatelet therapy
✓ increased risk for platelet aggregation
✓ OTC baby aspirin may be recommended by PCP
✓ Promote bed rest
✓ this helps secrete sodium.
✓ Left side best position.
✓ Provide good nutrition.
✓ Provide emotional support.
✓ Monitor BP, weight, and urine for protein as is routine for every visit.

• Severe Pre-eclampsia
- Assessment:
o BP rises to 160/110 or above on 2 occasions 6 hours apart after a woman has been on bed rest.
o Proteinuria is present +3 to 4+ on a random urine sample or more than 5 g in a 24 hour urine
sample.
o Oliguria (less than 500 mL urine in 24 hours or altered renal function tests; elevated serum
creatinine more than 1.2 mg/dL)
o Cerebral edema - severe headache, blurred vision, seeing spots, confusion. May have
pulmonary edema (will feel short of breath)
o Extensive peripheral edema
o Hepatic dysfunction
o Thrombocytopenia
o Epigastric pain
- Key Assessment:
- Severe Pre-eclampsia Additional Assessment
- Assess the extent of edema - 1+, 2+, 3+, 4+
- Cerebral edema causes marked hyperreflexia and possible ankle clonus (pulsed motion of
the foot after flexion).

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 - Check patellar reflex - place mom in supine and have her bend her knee. Use reflex hammer
to strike patellar tendon. Reflex is scored as 0 (none), 1+ (diminished), 2+ (normal), 3+
9brisker than average, 4+ (hyperreactive) - stronger than normal.
- Eliciting Ankle Clonus:
- Check ankle clonus by dorsiflexing the feet 3 times. Once you take your hand away, observe
foot. If the foot continues to move involuntarily, clonus is present.
- No motion - no clonus
- Mild = 2 movements
- Moderate = 3-5 movements
- Severe = over 6 movements
- Eliciting Patellar Reflex
- With the woman in a supine position, ask her to bend her knee slightly. Locate the patellar
tendon, and strike it firmly and quickly with a reflex hammer or the side of your hand. If the
leg and foot move, a patellar reflex is present.
- 0 = No response; hypoactive; abnormal
- 1+ = Somewhat diminished response but not
- abnormal
- 2+ = Average response
- 3+ = Brisker than average but not abnormal
- 4+ = Hyperactive; very brisk; abnormal
- Management:
✓ If a woman has reached 39 weeks, labor is induced/C-section performed.
✓ If less than 39 weeks:
- Maintain bed rest, room is darkened, stress should be decreased.
- Take BP frequently, q 4h.
- Obtain blood studies: CBC, platelets, liver function, obtain daily weights and strict I&O.
- 24-hour urine: check for protein and creatinine clearance.
- Monitor fetal well-being: doppler q 4h, nonstress test or biophysical profile.
- Support nutritious intake: high protein and moderate sodium.
- Provide emotional support because of possibly changing birthing plans.

• Eclampsia
- Seizure or coma accompanied by signs and symptoms of pre-eclampsia.
- Cerebral edema that is so severe that either a seizure or coma has occurred.
- It can happen in late pregnancy or up to 2 weeks after birth.
- With eclampsia one can have tonic-clonic seizures
- Assessment (Eclamptic seizure: Tonic-clonic)
o Body becomes rigid in a state of tonic muscular contractions that last 15-20 seconds.
o Facial muscles and then all body muscles alternately contract and relax in rapid succession
(clonic phase may last about 1 minute)
o Respirations ceases during seizure b/c diaphragm tends to remain fixed; resumes shortly
after it is over
o Postictal sleep occurs (woman cannot tell you if she’s in labor)
- Management:
✓ Maintain patent airway
✓ Magnesium sulfate or diazepam (IV)
✓ Oxygen saturation and administration by mask (8-10 L)
✓ External fetal heart monitor
✓ Check vaginal bleeding
✓ Remain with client and call for help
✓ Assess uterine contractions
- "Cure" for eclampsia - baby needs delivered after patient has become stable. Labor is
induced if fetus has reached viability
- Labor and delivery:
- Depends on woman’s condition
- Vaginal birth rather than Cs

NCM 109: TILLES

 - Minimum of anesthesia
- Postpartum:
- Monitor BP
- Healthcare visit
- Medications to prevent eclampsia
- Antihypertensive: Hydralazine (Apresoline), labetalol (Normodyne), or nifidipine may be
given to reduce hypertension.
- May cause tachycardia, so assess pulse as well as BP before administration.
- Magnesium sulfate may be ordered to prevent seizures.
- Blood levels should be maintained at 5-8 mg/dL. Higher than 8 is toxicity.
- Signs of Magnesium sulphate toxicity:
- Flushing
- Sweating
- Hypotension
- Depressed tendon reflexes
- Decreased resp
- Decreased urine output
- Reduce consciousness
- ANTIDOTE: Calcium gluconate

• HELLP SYNDROME
- Variation of gestational hypertension, common symptoms:
- Hemolysis (leads to anemia)
- Elevated Liver (leads to epigastric pain)
- Low Platelets (abnormal bleeding/clotting)
- Petechiae (red dots)
- Occur primi and multigravida
- Assessment:
o Proteinuria
o Edema
o Increased blood pressure
o Epigastric pain
o Malaise
o Right upper quadrant tenderness
o Liver inflammation
- Management:
✓ Transfusion of fresh frozen plasma or platelets; if hypoglycemic (glucose).
✓ Infant needs to be born as soon as possible. (Vaginal or CS)
✓ Have to monitor platelets.
- Complications:
- Spontaneous abortion
- Anemia
- Congenital anomalies
- Hyperemesis gravidarum
- Intrauterine growth restriction
- Gestational HTN
- Polyhydramnios
- Postpartum hemorrhage
- Premature rupture of membranes
- Preterm labor/delivery

• MULTIPLE PREGNANCY
- Caused by in vitro fertilization
- Assessment:
o Excessive fetal activity: uterus large gestational age
o Palpation of 3-4 fetal arts in the uterus
o Auscultate more than one FHR
o Excessive weight gain
NCM 109: TILLES
 o Ultrasound reveals multiple sacs early in pregnancy.

• HYDRAMNIOS or POLYHYRAMNIOS
- Excess fluid of more than 2,000 ml or an amniotic fluid index above 24 cm
- Occurs because fetus has issues swallowing (transesophageal fistula) or absorbing fluid, or has
excess UO (ie fetus of diabetic)
- Assessment:
o Uterus enlargement
o Extreme shortness of breath
o Weight gain, hemorrhoids
- Management:
✓ Bed rest (prevent preterm labor and increase circulation)
✓ High fiber diet and stool softeners (avoid constipation)
✓ Amniocentesis removes extra fluid
✓ Needled membrane rupture

• OLIGOHYDRAMNIOS
- Less than average amount of amniotic fluid (less than 500ml-1000ml)
- Caused by a bladder or renal disorder in the fetus (growth restriction or fetus not voiding as
usual)
- Severe growth restriction
- Breast tenderness
- Management:
✓ Careful inspection of infant at birth to rule out kidney disease and compromised lung
development.

• POST TERM PREGNANCY

- A pregnancy that goes beyond 38 to 42 weeks.
- Meconium aspiration happens and macrosomia
- Diagnosis:
- Nonstress test/ biophysical profile
- Prostaglandin gel or misoprostol
- Fetal heart rate monitoring

• ISOIMMUNIZATION (RH INCOMPATIBILITY)

- Rh negative mother and Rh-positive fetus.
- Maternal AB are formed 72 hours after first birth, can cross placenta in the second pregnancy,
and destroy fetal RBCs causing hemolytic disease of the newborn.
- Hemolytic disease of newborn or erythroblastosis fetalis: deficient in red blood cells
- Diagnosis:
- Amniocentesis
- Percutaneous umbilical cord sampling
- Anti-D titer at 1st visit and week 28.
- Titier is 1:16 or greater.
- Doppler velocity is high in fetal middle cerebral artery
- Management:
✓ At 28 weeks: RhoGaM given, and 72 after birth in event of positive COOMBS test
✓ In utero blood transfusion
✓ Phototherapy for fetus to reduce bilirubin released from injured RBC's
- What is the function of RHOGAM?
- Given at 28 weeks and 72 hours after birth.
- Within 2 weeks - 2 months, will destroy passive antibodies
- What is the meaning of a negative COOMBS test?
- Cord blood sample from fetus is Rh+, thus the RhoGAM injection is given to the mother.
- How is fetal maturity determined?
- Mature lecithin/sphingomyelin ratio has been reached.

NCM 109: TILLES

• FETAL DEATH
- Causes:
- Chromosomal abnormalities, congenital, Hep B, immunologic, complications of maternal
disease
- Assessment:
o Painless spotting
o Lack of fetal movement
o Confirmation by Ultrasound
- Management:
✓ Misoprostol (Cytotec) to being uterine contractions if labor does not begin spontaneously
✓ Observe for excess bleeding (sign of DIC)
✓ Swaddle as if it were a newborn.
✓ Wait 6 months before starting another pregnancy.

NCM 109: TILLES