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Chapter 25 Complication of Pregnancy1. Hemorrhagic conditions of early pregnancy

a. Abortion- The loss of a fetus before it is viable. The medical consensus today is that afetus of less than 20 weeks of gestation or one weighing less than 500g is not viable.

i. Spontaneous abortion1. Occur without action from anyone2. Most occur within 12 weeks3. Common cause: severe congenital abnormalities

ii. Threatened abortion1. 1st sign is vaginal bleeding2. Uterine cramping, persistent backache, pelvic pressure3. Advise the woman to limit physical activity and sex, count the pads she

uses.

iii. Inevitable abortion1. Cannot be stopped2. Membrane ruptures and the cervix dilates3. Natural expulsion, D&C, or vacuum to remove fetus4. Uterus shrinks5. Bleeding (may) occur6. D&C is performed for early pregnancy less than 12 weeks7. D&E for later pregnancy8. Infection is the primary concern

iv.

Incomplete abortion1. Not all product of conception are expelled2. Uterine cramping and heavy bleeding3. Cervix is open and fetal and placental tissue is passed4. Stabilize womans cardiovascular state5. D&C performed and oxytocin is administered to control bleeding6. *D&Cs cannot be performed past 14 weeks due to excessive bleeding

v. Complete abortion1. All products are expelled2. Hormone levels fall3. Negative pregnancy test4. Uterus shrink

vi. Missed abortion1. Fetus dies during the 1st of the pregnancy but is retained in the uterus2. Early symptoms of pregnancy disappear3. D&C performed and oxytocin is administered to control bleeding4. *D&Cs cannot be performed past 14 weeks due to excessive bleeding

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vii. Recurrent and spontaneous abortion1. 3 or more spontaneous abortions2. Primary cause is genetics or an incompetent uterus

b. Ectopic pregnancyi. Implantation of the of a fertilized ovum in an area outside the uterine cavity

ii. 98% occur in the fallopian tubeiii. disasterof reproduction

1. Significant cause of maternal death from hemorrhage2. Reduces the chance of subsequent pregnancies due to fallopian tube

damage

iv. Most common is Ampularv. Risk factors

1. STD2. Pelvic inflammatory disease3. Failed tubal ligation4. Intrauterine device5. Multiple induced abortions6. 35 y/o and older

vi. Hypovolemic shock is a major concernvii. Diagnosed through transvaginal ultrasound and human chorionic gonadatropianviii. Common signs

1. bluish swelling of the fallopian tube2. missed periods3. positive pregnancy test4. abdominal pain5. vaginal spotting

ix. Nursing care focuses on1. Early detection/prevention of hypovolemic shock2. Pain control3. Psychological support

x. When methotrexate is used note that1. Abdominal cramping is common2. Woman should avoid alcohol, sex, folic acid

c. Gestational Trophoblastic Disease (Hydatidiform Mole)i. Complete mole- ovum is fertilized by sperm that duplicates its own

chromosomes while the maternal chromosomes in the ovum are

inactivated(has NO fetal tissue)

ii. Partial mole- maternal contribution is usually present but the paternalcontribution is doubled and therefore the karyotype is triploid (69, XXY, or 69

XYY) (has SOME fetal tissue)

1. Peripheral cells attach the fertilized ovum to the uterine wall developabnormally

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2. Placenta develops but usually not any part of the fetus3. Grapelike cluster form4. More common among Asian5. Diagnosed through routine ultrasound6. Can become malignant and spread7. The woman should use birth control for at least 1 year.

2. Hemorrhagic conditions of late pregnancya. After 20 weeks of pregnancy the 2 major causes of hemorrhage are

i. Placenta Previa1. Implantation of the uterus in the lower uterus

a. Marginal-implanted in the lower uterus further than 3cm fromthe internal cervical OS

b. Partial- implanted in the lower uterus within 3cm of the internalcervical OS

c. Total- implantation completely covers the cervical OS2. Signs

a. Painless spontaneous bleeding at the end of pregnancyi. Painless because it is not enclosed and there isnt

additional pressure

b. Corticosteroids speed lung developmentii. Abruptio Placentae

1. Marginal abruption with external bleeding2. Partial abruption with concealed bleeding3. Complete abruption with concealed bleeding4. Maternal risks

a. Hemorrhageb. Hypovolemic shock

5. Fetal risksa. Asphyxiab. excessive blood lossc. prematurity

3. Hyperemesis Gravidarum (HEG)a. Persistent uncontrollable vomiting that begins in the 1st weeks and may last throughout

the entire pregnancy

b. Severity usually lessens over timec. Cause is unknownd. Woman should eat every 2-3 hourse. Salt helps replace lost chloride

4. Hypertensive disordersa. Gestational hypertension

i. Elevated BP after 20 weeks of pregnancy unaccompanied by proteinuria. Canprogress to preeclampsia

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b. Preeclampsiai. A systolic BP of greater than 140mm Hg or a diastolic BP greater than 90mm Hg

occurring after 20 weeks.

c. Eclampsiai. Progression of preeclampsia to generalized seizures that cannot be attributed to

other causes. Seizures may occur postpartum

d. Chronic hypertensioni. Systolic BP greater than 140mm Hg or diastolic greater than 90mm Hg that

existed before pregnancy or developed before 20 weeks of gestation

e. Preeclampsia superimposed on chronic hypertensioni. Development if new-onset proteinuria greater than 0.3g in a 24hr urine

collection in a woman who has had chronic hypertension

5. Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome6. Incompatibility between maternal and fetal blood

a. Rhesus factor occurs when the mother is Rh-negative and the fetus is Rh-positivei. Rh negative is an autosomal recessive trait

1. The gene must be inherited from both parentsb. When the mother is exposed she develops antibodies

i. The first child is usually not effected however the second isc. The mother needs to receive Rh (D) immune globulind. Blood type and Rh testing occur at the 1st prenatal visite. Coombs test determines if the woman has been exposed to Rh negative blood

7. ABO incompatibilitya. Occurs when the mother is type O and the fetus is type A, B, or ABb. Less severe than Rh incompatibilitiesc. Cord blood is tested (Direct coombs test)d. No extra prenatal care is needed