Pregnancy Complications - 1

Vaginal Bleeding (before 20 weeks’ gestation)
It may be related to spontaneous abortion, ectopic pregnancy, or gestational trophoblastic disease.

Spontaneous Abortion
It is a loss of pregnancy before viability, clinical Findings:

• Vaginal spotting (may pass clots)
• Abdominal cramping
• Cervical changes
• Fetal heartbeat may be present or absent

Ectopic Pregnancy
It is a product of conception implant outside the uterus, clinical findings:

• Vaginal spotting
• hCG lower than expected for dates
• Lower abdominal pain
• Ultrasound findings: absence of intrauterine gestational sac
• If rupture occurs, it would be: Positive Cullen’s sign (periumbilical bluish hue), Shoulder pain, and Signs of shock

Gestational Trophoblastic Disease
It is an abnormal proliferation of trophoblastic cells without viable fetus, Clinical Findings:

• Vaginal spotting (dark brown)
• Fundal height greater than expected for dates
• hCG greater than expected for dates
• Excessive nausea and vomiting
• Absence of fetal heart tones
• Ultrasound findings: Snowflake-like clusters, absence of fetus

Nursing Care (vaginal bleeding/early pregnancy)

1. Monitor amount of bleeding
2. Assess vital signs
3. Observe for signs of shock
4. Auscultate for fetal heart tones (FHTs)
5. Collect passed tissue/clots
6. Monitor patient comfort
7. Check blood type and Rh factor
8. Administer Rh(D) immunoglobulin if indicated
9. Initiate IV fluids as ordered
10. Report lab/ultrasound findings
11. Attend to patient’s emotional needs

Diabetes in Pregnancy

Client with diabetes and their infants are at risk for complication during pregnancy. Infants of diabetic mother tent to be large for gestational age. It is caused by glucose that crosses the placenta, whereas insulin does not, these infants tend to gain weight. The problem is that high glucose environment impedes lung development and although the infants are large for gestational age, they are often premature.

Complication of infants from maternal diabetes:

• Patent ductus arteriosus (PDA)
• Polyhydramnions
• Premature delivery
• Respiratory distress syndrome

Complications of mother with diabetes pregnancy:

• Hypertension
• Renal disease
• Ketoacidosis
• Vascular compromise
• Seizure activity related to hypoglycemia

Another problem in diabetes pregnancies is that the fluctuations in maternal blood sugar can result in fetal brain damage or sudden fetal death due to ketosis. That's why the client should be taught to check their blood glucose levels frequently during the day. Level over 120 mg/dL should be reported to the doctor for treatment.

Infants born to diabetic mothers might be delivered by cesarean section because of their large sizes and they should be assessed immediately after delivery for hypoglycemia by performing a dextrostix. The glucose level of 40 mg/dL or lower indicates hypoglycemia in the infant.

The blood is usually drawn from a heel stick and should be stuck on the lateral aspect of the heel. Blood test should be performed to detect hypocalcemia, hypokalemia and acidosis status.

COMPLICATION OF PREGNANCY

ABRUPTIO PLACENTAE
Abruptio Placentae is premature detachment of a normally situated placenta. Patient with abruption placentae will have bleeding, abdominal pain, boardlike uterus, maternal hypotension and tachycardia and fetal distress. Nursing managements will include: bed rest, monitor bleeding and shock, monitor fetal heart rate continuously.

ECLAMPSIA
Complication with seizures between 20th week of pregnancy and first postpartal week. Eclampsia can be happened with or following pregnancy-induced hypertension. Management of eclampsia will include giving magnesium sulfate, frequently assess vital signs, restrict fluid intake hourly to a total of 125 mL/h, and urinary output should be at least 30 mL/h.

GESTATIONAL DIABETES
Gestational diabetes occurs in 3–6% of all pregnancies, and although it typically resolves after delivery, it increases the risk of maternal pyelonephritis and of certain congenital anomalies, and is often associated with polyhydramnios and fetal macrosomia, with resultant dystocia. Patient will have polyuria, polydipsia and polyphagia. Gestational diabetes can be diagnosed with 3 hours Glucose Tolerance Test after 100 grams load. Management: exercise, dietary management, insulin (if needed), monitoring of weight, and teach and to assess glucose monitoring and diet.


PLACENTA PREVIA
Placenta previa is the condition in which the placenta is implanted in the lower segment of the uterus, extending to the margin of the internal os of the cervix or partially or completely obstructing the os. Clinical sign of placenta previa is painless vaginal bleeding. Management: monitor maternal vital signs, bed rest, monitor fetal heart rate, and not performing vaginal examination if placenta previa is suspected.

GROUP B STREPTOCOCCAL INFECTION
It would be 10-30% of pregnant women are colonized which are asymptomatic. It is recommended screening by rectovaginal swab at 37 weeks of gestation.

PREGNANCY-INDUCED HYPERTENSION (PIH)
PIH is a syndrome of hypertension, edema, and proteinuria that can occurs after 20th week of pregnancy. This patient will have headache, blood pressure of 140/90 or greater, or an increase of 30 mm Hg systolic or 15 mm Hg diastolic at two readings and edema that not relieved by bed rest, proteinuria, weight gain above 2 lb / weeks, visual disturbance, and epigastric pain. Patient who has pregnancy-induced hypertension will be managed by bed rest, control blood pressure, antihypertensive medicines, monitor intake and output, daily weight, and check urine for protein.

HELLP SYNDROME
This is a type of severe preeclampsia involving hemolysis, elevated liver function, and low platelets. Patient should delivery soon.

PRETERM LABOR
Preterm labor is a labor between 20 and 37 weeks of gestation.

Fundal Height Assessment - Prenatal Care

Fundal Height assessment is measured to evaluate the fetus's gestational age. Fundal height is measured from the top of the symphysis pubis to the top of the fundus. Height is assessed in centimeters.

At 16 weeks, the fundus can be found halfway between the symphysis pubis and the umbilicus. At 20 - 22 weeks, the fundus will be at the umbilicus, and at 36 weeks, the fundus is at xyphoid process. During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks plus or minus 2 centimeters.

Remember that picture as it maybe questioned in NCLEX - CGFNS test.

1. To Measure Fundal Height :
2. Place the pregnant woment in the supine position
3. Place the end of the tape measure at the level of the symphysis pubis.
4. Stretch the tape to the top of the uterine fundus, and
5. Record / document the measurement.

Maternity Nursing - Pregnancy, Signs and Symptoms

Here the explanation of these signs and symptoms of pregnancy.




PRESUMPTIVE SIGNS OF PREGNANCY

1. Amenorrhea, more than 10 days elapsed since the time of expected onset of menstruation
2. Nausea and vomiting
3. Increase of urinary frequency
4. Fatigue and drowsiness
5. Breast changes : feeling of fullness, tenterness, enlargement, darkening of areola, prominence of veins, enlargement of montgomery's tubercles (it is a small gland around nipple)
6. Vaginal changes: bluish color (chadwick's sign)
7. Skin Changes : striae (stretch marks), dark pigmented vertical lines on abdomen (linea nigra), pigment formation on face (facial chloasma), and mother's perception of fetal movement (quickening)

PROBABLE SIGNS OF PREGNANCY

1. Uterine changes : Hegar's sign (softening of lower uterus), Goodell's sign (softening of cervix), and Braxton Hicks' Contraction (false labor)
2. Palpation of fetal body
3. Positive of horman test for pregnancy
4. Ballottement (rebounding of fetus in amniotic fluid)

POSITIVE SIGNS OF PREGNANCY

1. Fetal movement (felt by examiner)
2. Fetal heartbeat
3. Radiograph of fetus
4. Sonogram of fetus

These signs and symptoms of pregnancy always appears in NCLEX-CGFNS questions.