High risk pregnancy
one in which a condition exists that jeopardizes the health of the mother, her baby, or both
When do risk assessments begin and how long do they last?
Begin at the first antepartal visit and continue w/ each subsequent visit
Why are risk assessments continued through out the pregnancy?
Because risk factors may be identified in later visits that were not apparent during earlier visits
What is the biggest killer of mom and baby during pregnancy?
What conditions are associated with early bleeding during pregnancy?
- Spontaneous abortion
- Ectopic pregnancy
- Gestational trophoblastic disease
- Cervical insufficiency
What conditions are associated with late bleeding during pregnancy?
After 20th week of gestation
What is the most common complication of early pregnancy?
loss of a pregnancy before 20 weeks gestation
loss of a fetus after 20 weeks gestation
What is the most common cause of spontaneous abortion in the first trimester?
fetal genetic/chromosomal abnormalities
What are common causes of spontaneous abortion in the second trimester?
Maternal conditions: cervical insufficiencies, congenital or acquired anomaly of the uterine cavity (fibroids), hypothyroidism, diabetes mellitus, chronic nephritis, cocaine use, PCOS, HSV, hypertension, etc…
If the mother is Rh- how long after the completion of the abortion will she need Rhogam?
within 72 hours after completion
- slight bleeding
- NO cervical dilation
- mild cramping
- NO passage of fetal tissue
- vaginal bleeding
- cervical dilation
- strong cramping
- possible passage of tissue
- intense abdominal cramping
- heavy vaginal bleeding
- cervical dilation
- passage of some tissue
- passage of ALL tissue
- history of vaginal bleeding and abdominal pain
- passing of tissue w/ subsequent decrease in pain and significant decrease in vaginal bleeding
- nonviable embryo retained in utero for at least 6 weeks
- absent uterine contractions
- irregular spotting
- possible progression to inevitable abortion
history of three of more consecutive spontaneous abortions
not carrying the pregnancy to viability or term
How long after an abortion will mom need Rhogam?
within 72 hours
stimulates uterine contractions to terminate a pregnancy; evacuate the uterus after an abortion to ensure passage of all the products of conception
acts as progesterone antagonist, allowing prostaglandins to stimulate uterine contractions; causes the endometrium to slough; may be followed by administration of misoprostol within 48 hours
stimulates uterine contractions, causing expulsion of uterine contents; to expel uterine contents in fetal death or missed abortion during second trimester, or to efface and dilate cervix at term
suppresses immune response of non-sensitized Rh-clients who are exposed to Rh+ blood after abortions, miscarriages, or pregnancies
any pregnancy in which the fertilized ovum implants outside the uterine cavity
where can ectopic pregnancies occur
fallopian tubes, cervix, ovaries, and the abdominal cavity
where is the most common place of an ectopic pregnancy
what is the most common cause of maternal death
ectopic pregnancy can lead to what?
massive hemorrhage, infertility, or death
ectopic pregnancies usually result from what conditions?
conditions that obstruct or slow the passage of the fertilized ovum through the fallopian tube to the uterus
most common cause of ectopic pregnancy
pelvic inflammatory disease (PID)
risk factors for ectopic pregnancy
STI's - chlamydia and gonorrhea PID previous tubal surgery previous pregnancy loss oral contraceptives previous ectopic pregnancy fibroids sterilization smoking multiple sex partners douching
Why is the diagnosis of ectopic pregnancy sometimes challenging?
Because many women are asymptomatic until rupture
What is the classic triad of ectopic pregnancy?
What diagnostic procedures are used for ectopic pregnancy?
Uterine pregnancy test to confirm pregnancy
Beta-hCG to rule out false negative
Transvaginal ultrasound to visualize misplaced pregnancy
What medication is often used to treat ectopic pregnancies with an early diagnosis?
What are contraindications for medical intervention of ectopic pregnancies?
unstable patient severe abdominal cramps pulmonary, renal, or liver disease peptic ulcer suspected intrauterine pregnancy immunodeficiency poor client compliance
folic acid antagonist that inhibits cell division in a developing embryo
What other medications may be used for ectopic pregnancy?
prostaglandins, misoprostol, and actinomycin
What are adverse effects of methotrexate?
nausea, vomiting, stomatitis, diarrhea, gastric upset, increased abdominal pain, and dizziness
What surgical intervention might be performed for unruptured fallopian tube with ectopic pregnancy?
If the tube has ruptured because of ectopic pregnancy what surgery will be performed?
laparotomy with salpingectomy
Why is the woman’s beta-hCG level still monitored until it is undetectable after treatment?
to ensure that any residual trophoblastic tissue that forms the placenta is gone
What is the hallmark sign of ectopic pregnancy?
abdominal pain with spotting 6-8 weeks after missed menses
How long should you encourage the patient to use contraceptives after ectopic pregnancy?
What are the two most common types of Gestational Trophoblastic Disease (GTD)?
gestational tissue is present but the pregnancy is not viable
a benign neoplasm of the chorion which the chorionic villi degenerate and become transparent vesicles containing clear vesicle fluid
-complete or partial
An “Empty Egg”
Signs and symptoms of complete mole
vaginal bleeding, anemia, excessively enlarged uterus, preeclampsia, and hyperemesis
Signs and symptoms of partial mole
missed or incomplete abortion, vaginal bleeding, small or normal size for date uterus
chorionic malignancy with metastasis to other organs
What are the signs and symptoms of choriocarcinoma?
shortness of breath indicating metastasis to lungs
What is the treatment for GTD?
immediate evacuation of the uterine contents as soon as the diagnosis is made and long term follow up to detect any tissue that might become malignant
How long are serial levels of hCG used to detect residual trophoblastic tissue?
every 3 weeks for 1 year
How long is the client advised to receive extensive follow up therapy?
How long should the patient avoid pregnancy after experiencing GTD?
Use contraceptives for 1 year
Signs and symptoms of GTD
reports of early signs of pregnancy brownish vaginal discharge anemia no fetal heart rate preeclampsia uterine size larger than expected fluid retention and swelling
Nursing Management for GTD
- preparing for D&C
- emotional support
- educating about the risk of cancer
- educating on strict adherence for follow-ups
premature dilation of the cervix
-a weak, structurally defective cervix that spontaneously dilates in the absence of uterine contractions in the second trimester or early third trimester resulting in loss of pregnancy
Therapeutic management for cervical insufficiency
bedrest, pelvic rest, avoid heavy lifting, progesterone supplements, cervical pessary, or surgically via cervical cleavage
using a heavy purse-string suture to secure and reinforce the internal os of the cervix
Risk Factors for cervical insufficiency
previous cervical trauma
fetal loss in second trimester
previous surgeries or procedures
Signs and Symptoms of Cervical Insufficiency
pink-tinged vaginal discharge or pelvic pressure, cramping w/ vaginal bleeding, and loss of amniotic fluid
When is a transvaginal ultrasound performed to asses for cervical insufficiency?
B/t 16 and 24 weeks to determine cervical length, evaluate for shortening, and attempt to predict preterm labor
Cervical Shortening w/ insufficiency
Can be viewed on ultrasound as funneling between 16-24 weeks
bleeding condition that occurs during the last 2 trimesters
-the placenta implants over the cervical os
What can increase the risk of placenta previa
history of cesarean births
How is placenta previa classified?
By amount of coverage Total Partial Marginal Low-lying
What does the therapeutic management of placenta previa depend on?
- extent of bleeding
- amount of coverage
- fetal development
- position of the fetus
- mother’s parity
- presence or absence of labor
Risk Factors for Placenta Previa
- older than 35 years of age
- previous c/s
- uterine injury
- cocaine use
- prior placenta previa
- infertility treatment
- multiple gestations
- surgical abortions
- hypertension or diabetes
How is the position of the placenta validated for placenta previa?
Nursing Management for Placenta Previa
- focuses on maternal health status
- assessing s/s of vaginal bleeding and fetal distress
- avoidance of vaginal exams
premature separation of a normally implanted placenta after the 20th week of gestation prior to birth which leads to hemorrhage
How is abruptio placentae classified?
According to extent of separation and amount of blood loss from maternal circulation Mild-grade 1 Moderate-grade 2 Severe-grade 3 -complete or incomplete
Mild-Grade 1 AP
minimal bleeding, marginal separation, tender uterus, no coagulopathy, no signs of shock, no fetal distress
Moderate Grade 2 AP
moderate bleeding, moderate separation, continuous abdominal pain, mild shock, normal maternal BP, maternal tachycardia
Severe Grade 3 AP
absent to moderate bleeding, severe separation, dark vaginal bleeding, agonizing abdominal pain, decreased maternal BP, significant maternal tachycardia, development of DIC
Therapeutic Management for Abruptio Placentae
Assess, control, and restore amount of blood loss; provide positive outcome; prevent coagulation disorders (DIC)
What emergency measures will be taken for Abruptio Placentae?
Starting 2 large-bore IV lines with normal saline or lactated ringers solution