HIGH RISK PREGNANCY

Definitions
 Maternal Mortality – The death of a woman during pregnancy and up to 6 weeks PP.
 Newborn Mortality –The death of a newborn within 28 days of birth
 DIC – Clotting & bleeding disorder that can occur 2o to abruptio placenta, missed SAB and HELLP.

Occurrence of bleeding
 Why does it happen?
o 1st half of pregnancy: Usually due to genetic or structural abnormalities
o 2nd half of pregnancy: Often related to maternal disease (HTN, DM)
 Rule of thumb is that if the cervix stays closed, the pregnancy continues. If it opens, it will be lost.
 Fetal risk = Hemorrhage  Uteroplacental Insufficiency  Fetal Distress, Bradycardia/Late Decels

Time Complication Signs/Symptoms

First Trimester SAB Bleeding, cramping, and partial or complete
expulsion of fetal products
Ectopic Pregnancy Abrupt one-sided lower abdominal pain, with
or without vaginal bleeding.
Second Trimester GTD Uterus size > Dates. Very high hCG (n/v)
No fetus on u/s, prune juice bleeding
Third Trimester Placenta Previa Painless vaginal bleeding
May be profuse or scant
Abruptio Placenta Painful bleeding (sharp abdominal pain and
tender board-like uterus)

Nursing interventions
 If bleeding, cramping or low back pain, she must be seen ASAP
o Instruct her to save any tissue or clots found on pads and bring with her to be examined.
 At the facility, assess:
o VS – Any signs of hemorrhage or infection?
o Bleeding – Color, ODOR, amount (count and weigh pads… 1g=1mL), has she passed clots?
o Pain – Is there tenderness, cramping or contractions (backache?)
o Changes – Is there dilation of the cervix, and has there been a ROM?
o FWB – FHR, Kicks, EDC/LMP, NST & Biophysical Profile
 Lab tests: hCG, H/H, clotting factors, fibrin split products, CBC w/diff (% Neutrophils)
 Prepare for procedures:
o Ultrasound to determine fetal viability and the presence of tissues
o Surgery to evacuate the uterus
 D&C – Dilate, scrape uterine walls to remove tissues (inevitable or incomplete)
 D&E – Dilate and evacuate contents after 16 weeks of gestation

Possible medications
 Prostaglandins (Misoprostol) or Pitocin: Stimulates uterine contractions to evacuate the uterus
 If the woman is Rh -, administer RhoGAM within 72 hrs after the abortion.
 EARLY BLEEDING: SAB
Definitions
 Spontaneous Abortion – When a pregnancy is terminated before the 20th week of gestation
CATEGORY CRAMPS BLEEDING CERVIX Pass POC? RESULT
Threatened Mild Slight Closed No Pregnancy continues
Inevitable Strong Mild to moderate Open Not yet.. Might need D&C
Incomplete Intense Heavy, continued Open Some Needs D&C
Complete Decreasing Decreasing Open All No intervention needed

Missed Abortion
 What is it?: The unviable fetus is retained instead of aborted—No POC passed at all
 Symptoms: Reversal of pregnancy signs (her uterus shrinks, hCG drops, etc), cervix will be closed (not
trying to abort), she may have brownish discharge
 Major Complications = Infection & DIC
o DIC: Retained fragments cause release of clotting factors, eventually woman bleeds to death.

Habitual/Recurrent Pregnancy Loss

 What has it? – History of three or more consecutive spontaneous abortions
 Possible causes AND their treatments:
o Incompetent/premature cervical dilation – Cerclage after week 12 (tightening of the cervix)
o Luteal Phase Defect – A lack of progesterone, easy fix = Administer Progesterone!
o Vascular Disorder – Administer Aspirin

Discharge Teaching
1. Activity: Bed rest, pelvic rest (NPV)
2. Pad count -- Save any tissue and bring it in to be examined
3. Follow up appointments should be made, and patient should know EME contact numbers
4. Realistic reassurance, never say “it will be okay”
5. Discuss contraception PRN
 ECTOPIC PREGNANCY
What is it?
 A MEDICAL EMERGENCY in which a fertilized ovum implants outside the uterine cavity.
 Most common site = fallopian tubes, but may implant in the ovary, cervix, or abdominal cavity.
o Once implanted, the embryo grows.
o Risk for rupture increases, b/c only the uterus is designed to adjust to fetal development.
 Risk factors include:
o Tubal scarring from PID, IUD, Failed tubal ligation, previous ectopic
o Chlamydia, Gonorrhea
o Maternal age over 35
 Complications: Can lead to massive hemorrhage, infertility, or death.

Symptoms and diagnosis

 Symptoms = Normal pregnancy signs, which makes diagnosis challenging because most women are
fine until rupture occurs. Some may have spotting and abdominal pains.
 Diagnostic procedures include:
o Ultrasound to visualize location
o HCG – If levels decrease or do not double q 48 hrs, pregnancy failing & intervention needed
o Aspiration of blood from cul-de-sac indicates peritoneal bleeding & rupture

Signs of Rupture
 Increasing sharp abdominal/pelvic pain.
 Profuse hemorrhage -- severe hypovolemic shock
 Referred shoulder pain

Treatment
 If unruptured: Methotrexate or Linear Salpingostomy
METHOTREXATE IM (Single Dose)
What is it? Chemotherapy agent and folic acid antagonist
Action Stops embryo growth and salvages tube
Indications If the tube is intact and patient is stable (no active bleeds)
Side effects Spotting, nausea, abdominal pain, dizziness
Teaching No alcohol or folic acid, sun exposure, NPV
Follow up Baseline bloodwork and then testing every 2-3 days until normal
o Linear Salpingostomy: Incision & removal, preserves tube and future fertility

 If ruptured – Tube removal (unilateral) is necessary d/t possible uncontrolled hemorrhage.

 Interventions: Control bleeding, stabilize, prepare for removal of tube
 Follow up: Monitor hCG levels until undetectable administer RhoGAM, if indicated
 GTD – HYDATIDIFORM MOLE
What is it?
 Hydatidiform Mole (Molar pregnancy)
o Trophoblasts “gone wild” – become fluid filled cells and attach to the uterine wall
 “Empty egg” is fertilized by sperm. The embryo is not viable and dies.
 The placenta is present, but NO fetus is found – bloodflow to “fetus” causes
hemorrhage into the uterine cavity
o Risk factors include: Advanced age, protein deficiency

Symptoms and diagnosis:

 Clinical Manifestations
o Scant Prune Juice vaginal bleeding.
o Extremely elevated hCG levels which cause excessive severe nausea and vomiting
o Rapid uterine growth  uterine size > dates
 PC’s: Can develop into choriocarcinoma, a highly virulent cancer with metastasis.
 Testing: Ultrasound shows growth but no fetus

Treatment
 Procedure: Suction D&C is done to aspirate and evacuate the mole
PREOP POSTOP FOLLOW UP TEACH
Obtain… Administer… Monitor hCG levels RELIABLE PO or
• CXR • IV Pitocin weekly for a year barrier contraceptive
• CBC • RhoGAM PRN for one year
• Blood type Obtain baseline…. pregnancy will throw
• Clotting factors • Pelvic exam off hCG level
• Abdominal u/s

 Long-term follow-up d/t risk of Choriocarcinoma!!!

o Why?? --- Remaining trophoblastic tissue might become malignant.
o Monitor hCG levels weekly for several weeks, then monthly for a year
 If they do not return to baseline: Methotrexate!!
 PLACENTA PREVIA VS ABUPTIO PLACENTAE
Placenta Previa Abruptio Placentae
Definition The placenta implants in the lower The placenta separates before birth,
uterus, near or over the cervical os depriving the baby of nutrients and O2 and
instead of the fundus causing hemorrhage of mother and child.

Classification Marginal: NVD is possible Concealed– Blood stays internal

Partial: C-Section Apparent– Blood is evacuated vaginally
Total: C-Section

Causes Previous SAB, C/B, Previa HTN, Substance abuse, trauma

Vital Signs WNL Signs of hemorrhage

U/S to confirm placental location

Diagnosis U/S for FWB
NO VAGINAL EXAMS

Bleeding Bright, light & painless Dark & painful

Visibility Always visible Can be concealed and lead to shock

Uterus Soft and relaxed Hypertonic

Abdomen Normal Rigid, tender, board-like

Occurrence After 20 weeks After 20 weeks

EFM Reassuring Fetal distress, late decels

Management

-If mild Homecare, bed rest, pelvic rest (NPV) Bed rest
Emergency Plan, VNA referral Tocolytic meds
Monitor Kick Counts at home

-If unstable Wait and see PREPARE FOR EMERGENCY C SECTION

May deliver early, if indicated
Complications PP Hemorrhage d/t lower uterus Hemorrhage, hypovolemic shock
inability to contract like fundus DIC, Thrombocytopenia
Fetal anoxia, preterm birth, death

RhoGAM At birth if indicated Before birth if indicated

 RH INCOMPATIBILITY
What’s happening?
 A mother is pregnant with a fetus who’s blood type is incompatible with her own
 Although maternal-fetal blood theoretically does not mix, certain events allow contamination.
o As little as 0.5 ml will cause sensitization, in which maternal antibodies are produced.
 Other incompatibility disorders:
o ABO incompatibility: A type O mother is pregnant with a type A, B, or AB fetus

Blood exchange and Rh sensitization

 90% of cases occur during delivery:
o Luckily, it is too late to have negative effect the firstborn infant with Rh+ blood type
o Subsequent pregnancies are at risk if the fetus is Rh+
 10% of cases occur before delivery:
o Antenatal testing – i.e. Amniocentesis
o ANY of the above pregnancy bleeding disorders
o Abdominal trauma, such as MVA, fall

Possible fetal effects in subsequent pregnancies

 Erythroblastosis fetalis where mom’s antibodies destroy all of their RBC’s
 Icterus gravis = Very high levels of Bilirubin in less than 24 hrs
o This is PATHOLOGICAL jaundice, not physiological --- this is FATAL
o Bilirubin encephalopathy, or “nicteris” which leads to mental retardation
 Hydros fetalis = abundance of extra fluid  Generalized edema or fetal CHF

Nursing Care
 Goal: All Rh- unimmunized woman receive RhoGAM at 28 weeks, and again within 72hrs of birth
 Initial Prenatal visit:
o If mother is Rh- perform an indirect Coombs
 If Positive = Mom has antibodies. It is too late to intervene, fetus is at risk
 If Negative = Mom does not have antibodies and she should receive RhoGAM
 28 Week visit
o RhoGAM is given to Rh- women to protect them for the rest of the pregnancy
o Another Coombs test done to assess whether blood has mixed since first visit
 Increasing titers signify fetal jeopardy
 Amniocentesis may be performed to check fetal bilirubin
o If bilirubin low, fetus is probably Rh -
o If bilirubin high, Intrauterine transfusion, then delivery
 Ultrasound may be done to detect ascites, edema, enlarged heart, hydramnios
 Birth and Delivery
o DIRECT Coombs performed using blood from the cord:
 If blood type is –, antibodies absent
 If blood type is + RhoGAM MUST BE given to the mom within 72 hours of birth
 Newborn may have antibodies and develop pathological jaundice
 HYPERTENSION IN PREGNANCY
Hypertensive conditions:
Hypertension: Blood pressure which exceeds 140/90
Chronic HTN: HTN that is present before pregnancy, or before 20 weeks. Treated with ALOMET.
Gestational HTN: HTN after 20 wks gestation in previously normotensive pt. Resolves by 12 wks PP.
Preeclampsia: HTN present after 20 weeks gestation along with proteinuria (mild or severe).
Eclampsia: Occurrence of Grand Mal seizures in a woman with preeclampsia.
HELLP: Hemolysis, Elevated liver enzymes, Low Platelets

Preeclampsia/Eclampsia
 What is happening?  Vasoconstriction  VASOSPASM  hypoperfusion to organs.
 Blood Testing
o CBC, Plt, Glucose, Clotting studies
o Kidney panel: (BUN, Creatinine, Uric Acid), Liver panel: (ALT, LDH, AST / SGOT, SGPT)

Systemic effects and dangers of Preeclampsia

Kidneys Decreased GFR, Increased Hct, + Proteinuria
Kidneys hold fluid b/c it thinks the body is dehydrated  third spacing, weight gain
Brain ACT/electrical impulses are excitable. CNS and reflexes are hyper responsive.
If not treated, at risk for seizure!
Liver Impaired function, edema, increased LFT’s, epigastric pain
If not treated at risk for liver rupture which is FATAL
Placenta Fetal is not getting oxygen (hypoxemia), becomes acidotic.
At risk for mental retardation, IUGR, or death.

Classifications
Mild Preeclampsia Severe Preeclampsia Eclampsia
Parameters >140/90 >160/110 >160/110
Diagnosable After 20 weeks gestation Twice while on bed rest Tonic Clonic convulsion
Proteinuria 300 mg 5 grams Marked
+1 +3
Oliguria No < 500ml in 24 hours Renal failure
Potential sxs: Edema of face and hands Pulmonary edema, cyanosis Respirations STOP during
Headache Blurred vision Deep & stertorous after
Drowsiness, irritability RUQ pain Cerebral hemorrhage
Marked weight gain Thrombocytopenia Onset of labor
Fetal growth restriction ROM
Activity Home, bed rest no stim. Hospital, bed rest no stim.
Position Left lateral Left lateral Left lateral
Actions Teach to self monitor Monitor BP, Fetal well being Stay with patient
(BP, dipstick, DW, kick Proteinuria Call for help
counts) DW Apply 10L oxygen
Precautions None Seizure – suction, oxygen Seizure – suction, oxygen
Nursing care during and after delivery
 During delivery: Monitor fetal status constantly, keep mom in Left Lateral position
 Postpartum: Still HTN for the first few days, which can  intracerebral hemorrhage  death
o Continue on Magnesium Sulfate for 24h, then antihypertensives for 2-6weeks
o Observe for: HTN, h/a, visual disturbances, epigastric pain, edema, proteinuria
o Recovery Signs =
 Massive urinary output 4-6 Liters/ 24 hours (decreased proteinuria)
 BP normal within 2-6 weeks

Development of HELLP syndrome

 What is it? LIFE THREATENING complication of preeclampsia
o HEMOLYSIS: Fragmentation of RBC’s as they pass through damaged small blood vessels
o ELEVATED LIVER ENZYMES: Hepatic blood flow is obstructed by fibrin deposits
 AST: 0-30 Units/L
 ALT: 5-35 Units/L
o LOW PLATELETS: Thrombocytopenia d/t platelets aggregating at damaged vessels
 Normal: 150,000- 400,000
 Concern: 100,000
 Critical: 50,000
 Symptoms: Chest and epigastric pain, n/v, edema, malaise
 Complications: Renal Failure, Pulmonary Edema, Ruptured Liver, Hematoma, DIC, Placental abruption
 Treatment: ICU, C/Birth likely, Magnesium Sulfate

Seizure prevention in hypertensive disorders

 MAGNESIUM SULFATE: CNS DEPRESSANT
o Action: Relaxes smooth muscle, decreasing vasoconstriction and ACT release
o Administration: IV piggyback on pump (to control administration so it can be stopped quickly)
1. Initial Bolus/Loading dose = 4-6g over 15-30 minutes
2. Maintenance dose = 1-2g per hour IV Drip
o Have antidote (Calcium Gloconate) nearby and premixed in a 1 gram injection IV push
o Nursing: Monitor serum levels, HR, BP, RR, Foley catheter, FHR, reflexes, Clonus

MAGNESIUM SULFATE TOXICITY INTERVENTIONS FOR TOXICITY

1. SERUM LEVEL OF 8 OR MORE!!
2. Decrease in RR, HR, BP, DTR’s
3. Hyporeflexia or absent reflexes
4. U/O less than 30 ml/hr.
5. Fetal stress, changes in FHR
1. D/C immediately, switch to IV fluids
2. Call for assistance, notify HCP STAT
3. Administer CALCIUM GLUCONATE
4. Monitor return of DTR’s, RR, BP, U/O
5. Monitor drug level (Thx = 4-7mEq)
 GESTATIONAL DIABETES
What is it?
 Screening for ALL pregnant woman is done at 24-28 weeks, earlier if indicated (high risk)
o 1 hour non-fasting GTT is performed
o If she fails  3 hour GTT is performed if the result is >140 mg/dL
o If 2 out of 4 tests are abnormal, she is classified as a Gestational Diabetic

Effects on size of infant may vary

 If vasculature is weakened form years of DM, baby will likely be SGA (poor perfusion to placenta)
 If no diet control and new diagnosis, baby will likely be LGA (hyperglycemic, hyperinsulinemic)

Normal, Gestational DM, and Pre-gestational DM

TIME NORMAL CHANGES GESTATIONAL DM TYPE 1 DM
1st Trim. BG = siphoned by fetus BG = siphoned by fetus Reduced insulin needs
Lowers maternal BG Lowers maternal BG compared with usual
Body’s insulin needs decrease Body’s insulin needs decrease maintenance
(Baby is unloading BG off mom!)
2nd Trim. hPL & lactase begin to destroy After 18-20 weeks, pancreas After 20 weeks the insulin needs
insulin, body readjusts as can’t keep up with insulin start to increase again due to
needed – No problem! resistance increasing resistance
3rd Trim. Insulin production by the body Need DIET (and maybe insulin) Insulin requirements increase
is adequate for needs TEACH: Diet/exercise as 50% 50-75% of previous dose!!
will go on to have DM w/in 5y
Delivery No precautions BS hourly BS hourly
Sc Insulin Reg Insulin/NS on IV pump
Additional IV for D5%
Postpartum No precautions BS may fluctuate for 24-48 hrs, Return to pre-pregnant regime
insulin may continue; most
return to normal postpartum
BS check at 6 wk F/U
Baby: Normal PP interventions 1. Monitor for hypoglycemia initially (3 BG checks)
2. Monitor BS hourly, then at meal time
3. Watch for jitteriness, irritability
4. Monitor bilirubin (Yellowish skin tone)
5. Ensure adequate feedings or IV with Dextrose
Treatment: Nutrition and diet
 90% of GDM cases are treated by diet ALONE!
 ADA Daily requirements:
o 3 Meals & 3 Snacks, Don’t SKIP MEALS
o 2,200-2,500 kcals per day
 Limit simple sugars (cake, candy, cookies)
 Increase complex: starch, bread, potato
 1 protein & 1 complex CHO before bed

Treatment: Insulin
 10-20% of GDM patients will require insulin therapy
 Daily requirements are not a focus, patients must achieve TIGHT control
 Insulin teaching
o Administer the correct dose of insulin at the correct time every day.
o Eat breakfast within 30 minutes after injecting regular insulin to prevent a reaction.

Blood Glucose Monitoring Test Goal

 Hgb A1c – Every 4-6 wks to monitor risk for abnormalities. Glycosylated Hgb (Hgb A1c) < 6%
 SMBG before meals & at bedtime, between 4-10x/day. Fasting Blood Sugar < 95
2 hour Postprandial < 120

Important teaching
 Exercising: After meals, while BS is up, avoid extreme temps. Have ID and hard candy on hand.
 Monitor fetal wellbeing: Perform daily “kick counts.”
 Most pregnancies are allowed to go to term with tight control and satisfactory assessment of FWB
 Know symptoms and treatment of hypoglycemia & hyperglycemia:
Symptoms Treatment
Hypoglycemia: Cold, clammy, hungry, disoriented Glucose tablets, lifesavers, milk
Hyperglycemia: Hot, dry skin/mouth, thirsty, Call doctor! May need treatment!

Surveillance
 Maternal surveillance may include:
o Urine check for protein and ketones (may indicate the need for evaluation of eating habits)
o Kidney function evaluation every trimester
o Eye examination in the first trimester to evaluate the retina for vascular changes
o HbA1c every 4 - 6 weeks to monitor glucose trends
 Fetal surveillance may include:
o U/S, AFP, BPP
o NST are performed weekly after 28 weeks’ gestation to evaluate FWB.
o Amniocentesis in the 3rd trimester to determine fetal lung maturity
 Phosphatidylglycerol: Present or absent
 L/S ratio: Goal = greater than 2:1
 MULTIFETAL PREGNANCY
Types of twins
A. Dizygotic/Fraternal -66%
• Formed when two separate sperms fertilize two separate ova at the same time
• Separate amnions, chorions, and placentas
• Is hereditary, babies can be same sex or opposite
B. Monozygotic/Identical -33%
• Formed when a single fertilized ovum splits during the first 2 weeks after conception
• Always the same sex

Symptoms and diagnosis

 Assessment: Fundal height = much > dates, 2 FHR, Ultrasound typically confirms the diagnosis
 Effects on the Mother
o Increased blood volume causes increased workload of CV system – HTN?
 Greater fetal Fe+ demand --- Marked anemia
o Increased uterine distention from added pressure on vessels and adjacent structures
 Can lead to Diastasis abdominal recti muscles

Potential Complications
 Maternal Complications: Risk of Placenta Previa, Placenta Abruptio, Preterm delivery/SROM
• Fetal Complications: Tangled cords, Fetal-to-Fetal transfusion (one twin takes most of the nutrients)
• Ethical/Medical Issues d/t poor outcome
o Selective reduction – Reduce the number of fetuses so that success if more likely.
Helps to avoid: Conjoined/Siamese, Cerebral Palsy, neurological deficits, learning disabilities

Nursing Interventions:
• Prenatal visits
o Teaching points: Need more iron, required more weight gain, NPV
o 2nd trimester: Every two weeks
o 3rd trimester: Weekly
• Nutritional counseling
o Iron & Vitamin supplements
o Expected weight gain = 35- 44lb (twins)
• Resources and referrals
o “Mothers of Multiples” or “Parents of Twins”
o Support Groups
 HYPEREMESIS GRAVIDARUM
What is it?
 A complication of pregnancy characterized by persistent, uncontrollable nausea and vomiting that
begins in the 1st trimester and causes dehydration, ketosis, and weight loss of more than 5%.
o NOT “Morning sickness”! -- Teach all woman to report any episodes of severe n/v, or episodes
that extend beyond the 1st trimester.
 Potential causes:
o Endocrine theory—high levels of hCG and estrogen during pregnancy
o Metabolic theory—vitamin B6 deficiency
o Psychological theory—psychological stress increases the symptoms

Symptoms and diagnosis

 Signs & Symptoms:
o Loss = 5% of pre-pregnancy weight
o Dehydration, fluid/electrolyte imbalance, tenting, dry mucous membranes, hypokalemia
o Woman cannot tolerate sips of fluid, food, strong smells

Management:
• Medications:
• Pyridoxine- Vitamin B6 & Unisom
• Zofran/Ondansetron
• Reglan
• Non-Pharm: Ginger, Hypnosis
• Interventions
• RULE OUT Gall bladder attack
• Diet: Clear liquids, crackers, TPN