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Chapter 5Nursing Care of Women with Complications During PregnancyKey termsAbortionCerclageEclampsiaGestational diabetesIncompetent cervixpreeclampsiaCharacteristic Causes of High-Risk PregnanciesCan relate to the pregnancy itselfCan occur because the woman has a medical condition or injury that complicates the pregnancyCan result from environmental hazards that affect the mother or her fetusCan arise from maternal behaviors or lifestyles that have a negative effect on the mother or fetusAssessment of Fetal HealthAmniocentesisDanger Signs in PregnancySudden gush of fluid from the vaginaVaginal bleedingAbdominal painPersistent vomitingEpigastric painEdema of face and handsSevere, persistent headacheBlurred vision or dizzinessChills with fever over 38.0° C (100.4° F)Painful urination or reduced urine outputPregnancy-Related ComplicationsHyperemesis gravidarumBleeding disordersHypertensionBlood incompatibility between woman and fetusHyperemesis GravidarumManifestationsExcessive nausea and vomitingCan impact fetal growthDehydration Reduced delivery of blood, oxygen, and nutrients to the fetusHyperemesis Gravidarum (cont.)TreatmentCorrect dehydration and electrolyte or acid-base imbalanceAntiemetic drugs may be prescribedIn extreme cases TPN may be required HospitalizationBleeding Disorders of Early PregnancyTypes of AbortionsSpontaneous (nonintentional)ThreatenedInevitableIncompleteCompleteMissedRecurrent InducedTherapeuticElectiveNursing Care of Early Pregnancy Bleeding DisordersDocument amount and character of bleedingSave anything that looks like clots or tissue for evaluation by a pathologistPerineal pad count with estimated amount of blood per pad (i.e., 50%)Monitor vital signsIf actively bleeding, woman should be kept NPO in case surgical intervention is neededPost-Abortion TeachingReport increased bleedingTake temperature every 8 hours for 3 daysTake an oral iron supplement if prescribedResume sexual activity as recommended by the health care providerReturn to health care provider at the recommended time for a checkup and contraception informationPregnancy can occur before the first menstrual period returns after the abortion procedureEmotional CareSpiritual support of the family’s choice and community support groups may help the family work through the grief of any pregnancy lossEctopic Pregnancy95% occur in fallopian tubeScarring or tubal deformity may result fromHormonal abnormalitiesInflammationInfectionAdhesionsCongenital defectsEndometriosisMost Common Sitesfor Ectopic PregnanciesEctopic Pregnancy (cont.)ManifestationsLower abdominal pain and may have light vaginal bleedingIf tube rupturesMay have sudden severe lower abdominal painVaginal bleedingSigns of hypovolemic shockShoulder pain may also be feltTreatmentPregnancy testTransvaginal ultrasoundLaparoscopic examinationPriority is to control bleedingThree actions can be takenNo actionTreatment with methotrexate to inhibit cell divisionSurgery to remove pregnancy from the tubeNursing TipSupporting and encouraging the grieving process in families who suffer a pregnancy loss, such as a spontaneous abortion or ectopic pregnancy, allows them to resolve their griefSigns and Symptoms of Hypovolemic ShockFetal heart rate changes (increased, decreased, less fluctuation) Rising, weak pulse (tachycardia)Rising respiratory rate (tachypnea)Shallow, irregular respirations; air hungerFalling blood pressure (hypotension)Decreased or absent urinary output (usually less than 30 mL/hr)Pale skin or mucous membranesCold, clammy skinFaintnessThirstHydatidiform MoleAlso known as gestational trophoblastic disease or molar pregnancyOccurs when chorionic villi abnormally increase and develop vesiclesMay cause hemorrhage, clotting abnormalities, hypertension, and later development of cancerMore likely to occur in women at age extremes of the reproductive lifeHydatidiform Mole (cont.)ManifestationsBleedingRapid uterine growthFailure to detect fetal heart activitySigns of hyperemesis gravidarumUnusually early development of GHHigher-than-expected levels of hCGA distinct “snowstorm” pattern on ultrasound with no evidence of a developing fetusTreatmentUterine evacuationDilation and evacuationBleeding Disorders of Late PregnancyPlacenta previaAbnormal implantation of placentaBright red bleeding occurs when cervix dilates, resulting in painless bleedingThree degreesMarginalPartialTotal Bleeding Disorders of Late Pregnancy (cont.)Complications or RisksPlacenta previaInfection because of vaginal organismsPostpartum hemorrhage, because if lower segment of uterus was site of attachment, there are fewer muscle fibers, so weaker contractions may occurAbruptio placentaePredisposing factorsHypertensionCocaine or alcohol useCigarette smoking and poor nutritionBlows to the abdomenPrior history of abruptio placentaeFolate deficiencyNursing TipPain is an important symptom that distinguishes abruptio placentae from placenta previaCare of the Pregnant Woman with Excessive BleedingDocument blood lossClosely monitor vital signs, including I&OObserve forPainUterine rigidity or tendernessVerify that orders for blood typing and cross-match have been carried outMonitor intravenous infusionPrepare for surgery, if indicatedMonitor fetal heart rate and contractionsMonitor laboratory results, including coagulation studiesAdminister oxygen by maskPrepare for newborn resuscitationHypertension During PregnancyGestational hypertension (GH)PreeclampsiaEclampsiaChronic hypertensionPreeclampsia with superimposed chronic hypertensionPresent 20 weeks before pregnancyNew occurrence of proteinuria or thrombocytopeniaHypertension During Pregnancy (cont.)An increase over baseline blood pressure of 30 mm Hg or more systolic15 mm Hg diastolic will place the woman in a high-risk category for GHRisk Factors for GHFirst pregnancyObesityFamily history of GHAge over 40 years or under 19 yearsMultifetal pregnancyChronic hypertensionChronic renal diseaseDiabetes mellitusManifestations of and Systems Affected by GHHypertensionEdemaProteinuriaBlood clottingCentral nervous systemEyesUrinary tractRespiratory systemGastrointestinal system and liverManagement of GHDepends on severity of the hypertension and on the maturity of the fetusTreatment focuses onMaintaining blood flow to the woman’s vital organs and to the placentaPreventing convulsionsConservative TreatmentActivity restrictionMaternal assessment of fetal activityBlood pressure monitoringDaily weightChecking urine for proteinDrug therapyMagnesium sulfateCalcium gluconate reverses effects of magnesium sulfateAntihypertensivesBleeding IncompatibilitiesRh-negative blood type is an autosomal recessive traitRh-positive blood type is a dominant traitRh incompatibility can only occur if the woman is Rh-negative and the fetus is Rh-positiveIsoimmunizationThe leaking of fetal Rh-positive blood into the Rh-negative mother’s circulation, causing her body to respond by making antibodies to destroy the Rh-positive erythrocytesWith subsequent pregnancy, the woman’s antibodies against Rh-positive blood cross the placenta and destroy the fetal Rh-positive erythrocytes before the infant is bornErythroblastosis FetalisErythroblastosis Fetalis (cont.)Occurs when the maternal anti-Rh antibodies cross the placenta and destroy fetal erythrocytesRequires RhoGAM to be given at 28 weeks and within 72 hours of delivery to the motherAlso given after amniocentesis, woman who experiences bleeding during pregnancyFetal assessment tests must be done throughout pregnancyAn intrauterine transfusion may be done for the severely anemic fetusPregnancy Complicated by Medical ConditionsDiabetes Mellitus (DM)Classified if preceded pregnancyType 1: pathologic disorderType 2: insulin resistance; genetic predispositionPregestational DM: Type 1 or 2 DMGestational DM (GDM)Glucose intolerance with onset during pregnancyIn true GDM, glucose usually returns to normal by 6 weeks postpartumEffects of Pregnancy on Glucose MetabolismHormones (estrogen and progesterone), insulinase (an enzyme), and increased prolactin levels have two effectsIncreased resistance of cells to insulinIncreased speed of insulin breakdownGestational Diabetes Mellitus (GDM)If woman cannot increase her insulin production, she will have periods of hyperglycemiaBecause fetus is continuously drawing glucose from the mother, she will also experience hypoglycemia between meals and during the nightDuring the second and third trimesters, fetus is at risk for organ damage from hyperglycemia because fetal tissue has increased tissue resistance to maternal insulin actionPregestational Diabetes MellitusMajor risk for congenital anomalies to occur from maternal hyperglycemia during the embryonic period of developmentFactors Linked to GDMMaternal obesity (>90 kg or 198 lbs)Large infant (>4000 g or about 9 lbs)Maternal age older than 25 yearsPrevious unexplained stillbirth or infant having congenital abnormalitiesHistory of GDM in a previous pregnancyFamily history of DMFasting glucose over 126 mg/dL or postmeal glucose over 200 mg/dLMacrosomic InfantTreatmentDietMonitoring blood glucose levelsKetone monitoringExerciseFetal assessmentCare During Labor of the Woman with GDMIntravenous infusion of dextrose may be neededRegular insulinAssess blood glucose levels hourly and adjust insulin administration accordinglyCare of the Neonate Whose Mother Has GDMMay have the followingHypoglycemiaRespiratory distressInjury related to macrosomiaBlood glucose monitored closely for at least the first 24 hours after birthBreastfeeding should be encouragedHeart DiseaseManifestationsIncreased levels of clotting factors Increased risk of thrombosisIf woman’s heart cannot handle increased workload, congestive heart failure (CHF) resultsFetus suffers from reduced placental blood flowSigns of CHF During PregnancyPersistent coughMoist lung soundsFatigue or fainting on exertionDifficulty breathing on exertionOrthopnea Severe pitting edema of the lower extremities or generalized edemaPalpitationsChanges in fetal heart rateIndicating hypoxia or growth restrictionTreatmentUnder care of both obstetrician and cardiologistPriority care is limiting physical activityDrug therapyMay include beta-adrenergic blockers, anticoagulants, diureticsVaginal birth is preferred as it carries less risk for infection or respiratory complicationsAnemiaThe reduced ability of the blood to carry oxygen to the cellsFour types are significant during pregnancyTwo are nutritionalIron deficiencyFolic acid deficiencyTwo are genetic disordersSickle cell diseaseThalassemia Nutritional AnemiasSymptomsEasily fatiguedSkin and mucous membranes are paleShortness of breathPounding heartRapid pulse (with severe anemia)Iron-Deficiency AnemiaRBCs are small (microcytic) and pale (hypochromic)PreventionIron supplementsVitamin C may enhance absorptionDo not take iron with milk or antacidsCalcium impairs absorptionTreatmentOral doses of elemental ironContinue therapy for about 3 months after anemia has been correctedFolic-Acid Deficiency AnemiaLarge, immature RBCs (megaloblastic anemia)Anticonvulsants, oral contraceptives, sulfa drugs, and alcohol can decrease absorption of folate from mealsFolate essential for normal growth and developmentPreventionDaily supplement of 400 mcg (0.4 mg) per dayTreatmentFolate deficiency is treated with folic acid supplementation1 mg/day (over twice the amount of the preventive supplement)Dose may be higher for women who have had a previous child with a neural tube defectGenetic AnemiasSickle Cell DiseaseAutosomal recessive disorderAbnormal hemoglobin Causes erythrocytes to become distorted sickle (crescent) shaped during hypoxic or acidotic episodesAbnormally shaped blood cells do not flow smoothlyCan clog small blood vesselsPregnancy can cause a crisisMassive erythrocyte destruction and vessel occlusionRisk to fetus is occlusion of vessels that supply the placentaCan lead to preterm birth, growth restriction, and fetal demiseOxygen and fluids are given continuously throughout laborThalassemiaGenetic trait causes abnormality in one of two chains of hemoglobin Beta chain seen most often in U.S.Can inherit abnormal gene from each parent, causing beta-thalassemia major If only one abnormal gene is inherited, infant will have beta-thalassemia minorWoman with beta-thalassemia minor has few problems, other than mild anemiaFetus does not appear affectedIron supplements may cause iron overloadBody absorbs and stores iron in higher-than-usual amountsNursing Care for Anemias During PregnancyTeach woman about foods that are high in iron and folic acidTeach how to take supplementsDo not take iron supplements with milkDo not take antacids with ironWhen taking iron, stools will be dark green to blackThe woman with sickle cell disease requires close medical and nursing careTaught to prevent dehydration and activities that cause hypoxiaAvoid situations where exposure to infection is more likelyReport any signs of infection promptlyInfectionsAcronym TORCH is used to describe infections that can be devastating to the fetus or newbornToxoplasmosisOtherRubellaCytomegalovirusHerpesViral InfectionsNo effective therapyImmunizations can prevent some infectionsCytomegalovirusInfected infant may haveMental retardationSeizuresBlindnessDeafnessDental abnormalitiesPetechiaeTreatmentNo effective treatment is knownTherapeutic abortion may be offered if CMV infection is discovered early in pregnancyRubellaMild viral diseaseLow fever and rashDestructive to developing fetusIf woman receives a rubella vaccine prior to pregnancy, she should not get pregnant for at least 1 monthNot given during pregnancy because vaccine is from a live virusEffects on embryo or fetusMicrocephaly (small head size)Mental retardationCongenital cataractsDeafnessCardiac effectsIntrauterine growth restriction (IUGR)HerpesvirusTwo typesType 1: likely to cause fever blisters or cold soresType 2: likely to cause genital herpesAfter primary infection, lies dormant in the nerves, can reactivate at any timeInitial infection during first half of pregnancy may cause spontaneous abortion, IUGR, and preterm laborInfant can be infected in one of two waysNeonatal herpes can beLocalizedDisseminated (widespread)High mortality rateTreatment and nursing careAvoid contact with lesionsMother and infant do not need to be isolated as long as direct contact with lesions is avoidedBreastfeeding is possible IF no lesions are present on the breastsHepatitis BTransmitted by blood, saliva, vaginal secretions, semen, and breast milk; can also cross the placentaFetus may be infected transplacentally or by contact with blood or vaginal secretions during deliveryUpon delivery, the neonate should receive a single dose of hepatitis B immune globulin, followed by the hepatitis B vaccineRisk for hepatitis BIntravenous drug useMultiple sexual partnersRepeated infection with STIOccupational exposure to blood products and needle sticksHemodialysisMultiple blood transfusions or other blood productsHousehold contact with hepatitis carrier or hemodialysis patientContact with persons arriving from countries where there is a higher incidence of the diseaseHuman Immunodeficiency VirusVirus that causes AIDSCripples immune systemNo known immunization or curative treatmentAcquired in one of three waysSexual contactParenteral or mucous membrane exposure to infected body fluidsPerinatal exposureInfant may be infectedTransplacentallyThrough contact with infected maternal secretions at birthThrough breast milkNursing CareEducate the HIV-positive woman on methods to reduce the risk of transmission to her developing fetus/infantPregnant women with HIV/AIDS are more susceptible to infectionBreastfeeding is absolutely contraindicated for mothers who are HIV-positiveNonviral InfectionsToxoplasmosisParasite acquired by contact with cat feces or raw meatTransmitted through placentaCongenital toxoplasmosis includes the following possible signsLow birthweightEnlarged liver and spleenJaundiceAnemiaInflammation of eye structuresNeurological damageTreatmentTherapeutic abortionPreventive measuresCook all meat thoroughlyWash hands and all kitchen surfaces after handling raw meatAvoid uncooked eggs and unpasteurized milkWash fresh fruits and vegetables wellAvoid materials contaminated with cat fecesGroup B Streptococcus (GBS) InfectionLeading cause of perinatal infection with high mortality rateOrganism found in woman’s rectum, vagina, cervix, throat, or skinThe risk of exposure to the infant is greater if the labor is long or the woman experiences premature rupture of membranesGBS significant cause of maternal postpartum infectionSymptoms include elevated temperature within 12 hours after delivery, rapid heart rate, abdominal distentionCan be deadly to the infantTreatmentPenicillinTuberculosisIncreasing incidence in the U.S.Multidrug-resistant strains also increasingMother can be tested via PPD skin test or serum Quantiferon Gold? If positive, chest x-ray and possibly sputum specimens will be neededReport to local public health department (PHD) if active pulmonary TB is suspectedIf mother active, infant must be kept away from mother until she has been cleared by the PHDSexually Transmitted Infections (STIs)Common mode of transmission is sexual intercourseInfections that can be transmittedSyphilis, gonorrhea, Chlamydia, trichomoniasis, and Condylomata acuminata Vaginal changes during pregnancy increase the risk of transmissionUrinary Tract InfectionsPregnancy alters self-cleaning action due to pressure on urinary structuresPrevents bladder from emptying completelyRetained urine becomes more alkalineMay develop cystitisBurning with urinationIncreased frequency and urgency of urinationNormal or slightly elevated temperaturePyelonephritisHigh feverChillsFlank pain or tendernessNausea and vomitingEnvironmental Hazards During Pregnancy Bioterrorism and the pregnant womanThree basic categoriesA—can be easily transmitted from person to personB—Can be spread via food and waterC—Can be spread via manufactured weapons designed to spread diseaseSubstance abuseQuestions should focus on how the information will help nurses and physicians provide the safest and most appropriate care to the pregnant woman and her infantAlcoholA single episode of consuming two alcoholic drinks can lead to the loss of some fetal brain cellsTrauma During PregnancyThree leading causes of traumatic deathAutomobile accidentsHomicideSuicide BatteringBruises in various stages of healingNursing TipIf a woman confides that she is being abused during pregnancy, this information must be kept absolutely confidential. Her life may be in danger if her abuser learns that she has told anyone. She should be referred to local shelters, but the decision to leave her abuser is hers alone. ................
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