Complications Caused by Pregnancy

1. Complications Caused by Pregnancy Prepared by : Ayda khader April.2017

2. Introduction • Pregnancy is a normal function of the body, not a disease.Several factors can complicate pregnancy. However including preexisting conditions and those that develop during pregnancy. • Pregnancy (s) that threaten the health of the fetus or the mother need special care (before, during and after delivery).

3. High Risk pregnancies : □ Complications of previous pregnancies: • - Prolonged labor. - Cesarean birth -PIH • - Bleeding - Abnormal fetal position. □ Anatomical abnormalities: • - Small pelvis. - Incompetent cervix. □ Metabolic and endocrine disorders: • - Diabetes. - Thyroid disorders. □ Cardiovascular disorders: • - Hypertension - Congenital heart disease. □ Kidney disorders: • - Acute pyelonephritis. - Acute cystitis.

4. □ Hematological disorders: • - Anemia. - Sickle cell anemia. □ other factors : • - Age: under 16 or over 35 years. • - Weight: less than 45 kg or over 90 kg. • - Syphilis. • - Smoking. • - Drug addiction.

5. Preexisting medical conditions Diabetes mellitus • Diabetes is an endocrine disorder characterized by high blood levels of glucose in the urine. Diabetes results from inadequate production or use of insulin. Pregnancy imposes an additional physiological stress on a diabetic woman. Successful delivery of a healthy infant requires much teaching, support, adherence to dietary control and work of the entire health care team.

6. Effects of pregnancy on diabetes: • Pregnancy is an insulin-resistant state. • Placental hormones (HPLHuman placental lactogen) , Placental insulinase) have anti-insulin effect result in increasing the incidence of ketoacidosis {Spare glucose for fetal use while mobilizing lipids for maternal energy use}. • Insulin dose increases (except in first trimester). • Oral hypoglycemic must not be used. • During labor and early postpartum period, insulin should be stopped since HPL is decreased. • Glucosuria is common during pregnancy because of decreased renal threshold or nephropathy

7. Effects of Diabetes on Pregnancy: • Gestational diabetes mellitus (GDM): is a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy) may develop during pregnancy. • When it is well controlled its effect in pregnancy many be minimal. If the control is inadequate they may be have the following complications

8. Maternal Effects: • Hypoglycemia: usually occurs in the first half of pregnancy and needs to adjust insulin dose based on caloric intake and hyperglycemia tends to occur in second half of pregnancy. • Urinary tract, other infections and anemia • Hypertension: diabetic women are at higher risk for hypertensive disorders of pregnancy. • Polyhydramnios: May occur in 10-20% of diabetic pregnancies probably result of fetal polyuria resulting from fetal glucosuria. • Retinopathy and postpartum hemorrhage.

9. Fetal Effects: • There is an increased risk of spontaneous abortion, stillbirth and fetal abnormality • Macrosomia: usually defined as infants greater than 4500g. High incidence of birth trauma. • Perinatal mortality is 2 or 3 times higher for diabetic mother • The main four neonatal effects are: hypoglycemia, hypocalcemia, hyperbillirubinemia and respiratory distress.

10. Screening Examination: • 50 g oral glucose load, plasma glucose checked 1 hour later. • •Less than 140mg/dl →normal. • •Greater than 140mg/dl → perform oral glucose tolerance test (GTT). • •Greater than 200mg/dl → probably doesn't need GTT → (positive). • •Glucose Tolerance Test: • •Begins after 3 days of good diet. (250 calories of carbohydrate daily). • •Fast for 10 hours prior to test is ingested. • •100 g oral glucose solution. • •Perform blood level tests at fasting, 1, 2 and 3 hours after drinking solutions.

11. Interventions: • Diabetic woman needs continuous medical and nursing supervision during pregnancy, therefore prenatal visits are scheduled every 1-2 weeks for the first 32 weeks, then weekly until delivery. • interventions are based on Identifying Problems as follow: • Dietary Regulation Need: • Recommended diet is 35 calories/ kg of ideal body weight. • 250 g of carbohydrates, 125 g protein , 60-80 g fat. Mother should not gain more than 1.3-1.6 kg /month

12. Insulin Need: • Insulin dosage is based on blood and urine glucose levels. • Oral hypoglycemics are not used because they are fetotoxic (teratogenic) and don't provide adequate control. • Mothers need to learn how to test for glucose and administer correct amount of insulin. • They need to know the symptoms of hypoglycemia and hyperglycemia and appropriate emergency management of each.

13. Monitor blood pressure frequently. • There is a potential susceptibility to PIH. • If signs of PIH appear, treatment is begun at once so Preeclampsia potential. Infection potential: • vaginitis and UTI are common. • If symptoms appear, diagnosis and medical treatment are begun at once. Inadequate rest: Mothers need to lie down and rest frequently during the day. Hydramnios: • Size of mother's uterus and signs of respiratory distress are evaluated. • Sometimes amniotony may be performed to remove excessive fluid.

14. Labor Induction: • At about 37 weeks if fetal lungs are mature enough, labor may be induced. • Blood glucose levels and fetal conditions are monitored closely. • To evaluate the fetal status, observe how FHR varies in relation to fetal movement. • Observation for 30 minutes by continuous F.H.M. after ingestion of 30 g glucose.

15. Postpartum Considerations: • The mother's insulin need is monitored closely after delivery. • watched carefully for signs of hemorrhage caused by uterine relaxation, which often follows hydramnios. • Postpartum Family Planning: • Usually recommend barrier contraception, IUD may also be a good choice in selected patients. Low-dose oral contraception pills may be used.

16. Heart disease • Every pregnancy places extra demands on the cardiovascular system especially on the heart. • Blood volume and cardiac output are increased 40-50% and the rate is accelerated. • The normal heart is well able to compensate for the added work but the damaged or diseased one may not. The Signs of cardiac decompensation are: • Increasing fatigue and breathlessness with usual exertion. • Episodes of murmurs, palpitation and tachycardia. • Haemoptysis and progressive generalized oedema

17. Classification: • Women with heart disease are classified into 4 groups according to the level of activity tolerated without symptoms. Medical and nursing care is adjusted accordingly. • Patients classified as I and II generally do well during pregnancy, but those classified as III or IV have a significantly increased risk of morbidity and mortality with pregnancy.

18. Class 1: No limitation of physical activity, no symptoms of cardiac insufficiency or anginal pain with ordinary physical activity. Class 2: Slight limitation of physical activity, comfortable at rest, excessive fatigue, palpitation, dyspnoea or anginal pain with ordinary physical activity. Class3:Marked limitation of physical activity, comfortable at rest, excessive fatigue, palpitation, dyspnoea or anginal pain with less than ordinary physical activity. Class 4: Inability to perform any physical activity without discomfort, signs of cardiac insufficiency possible at rest, discomfort increased with physical activity.

19. Effects of pregnancy on heart disease: • Increase volume of circulation 40-45%. • Increase cardiac output. Increase body weight (edema). • Increase coagulation tendency. • Salt and water retention. Effects of heart disease on pregnancy: • Prematurity. • IUGR. • Placental insufficiency. • Intrauterine fetal death.

20. Assessment: • History. • Cardiac status of women should be evaluated very early in pregnancy if not before {chest X-ray, ECG}. • Cardiac status and functional capacity are monitored carefully throughout pregnancy. • Monitor for signs of cardiac decompensation {cyanosis, dyspnea, tachycardia, edema, hemoptysis, and cough…}.

21. Interventions: • Rest is most important; 10 hours sleep per night and rest throughout the day. • stress is to be avoided. • Infection must be avoided. • A well balanced diet, high in protein, iron, vitamins and minerals to prevent anemia. • Hospitalization prior to delivery is usual for women with classes 1 or 2 cardiac disease.

22. For classes 3 and 4 therapeutic abortion may be indicated, sterilization surgery may be recommended for those who attempt pregnancy of the 4th class, • absolute bed rest, hospitalization During labor and delivery: • The woman`s vital signs and fetal heart tones are monitor. • The woman may receive oxygen during the course of labor. • Regional anesthesia may be used to reduce pain. • To avoid having the mother push, forceps delivery may be used. • Cesarean delivery is avoided because of (grater blood loss, risk of infection, risk of thromboemboism ). • Second stage of labor is shortened to reduce stress on the mother`s heart as much as possible

23. During postpartum: • Monitor carefully for postpartum hemorrhage, infection or thromboemboism.

24. Hypertensive Disorders of Pregnancy • Hypertension is defined as Hypertension is identified as systolic pressure 140 mm Hg or greater and/or diastolic pressure 90 mm Hg or greater. In pregnant woman blood pressure usually falls during the first and second trimester • Hypertensive disorders are classified into four categories by National High Blood Pressure Education Working Group [NHBPEP]: 1.Chronic hypertension:Hypertension before conception or before the 20th week of gestation; may put the woman at high risk for developing preeclampsia.

25. 2. Preeclampsia–eclampsia: Preeclampsia, a systemic disease with hypertension accompanied by proteinuria after the 20th week of gestation; eclampsia, a convulsive stage of the disease. Ten percent of all first pregnancies are affected by preeclampsia–eclampsia. The term preeclampsia has replaced the term toxemia. 3. Preeclampsia superimposed on chronic hypertension: Hypertensive women who develop new-onset proteinuria; proteinuria before the 20th week gestation; or sudden uncontrolled hypertension. Up to 25% of women with chronic hypertension develop preeclampsia

26. 4. Gestational hypertension: High blood pressure detected for the first time after mid-pregnancy, without proteinuria. The NHBPEP Working Group has recommended that “gestational hypertension” replace the term “pregnancy-induced hypertension. It is a provisional diagnosis used for a heterogeneous group of women

27. Pregnancy Induced Hypertension(PIH)=Gestational hypertension • Pregnancy-induced hypertension is defined as the development of new arterial hypertension in a pregnant woman after 20 weeks gestation • Delay of treatment can lead to significant maternal morbidity and mortality. Also it’s associated with intrauterine fetal growth restriction (IUGR). Fetal death with preeclampsia is about 10% and with Eclampsia 20%.

28. (PIH) has two stages: Preeclampsia and Eclampsia. • In Preeclampsia hypertension, proteinuria and excessive fluid retention develop with resultant edema and weight gain. Symptoms may be mild or severe. • In Eclampsia, convulsive seizures and coma develop. The only cure for PIH is termination of pregnancy

29. Etiology: • Unknown: described in 1916 as “a disease of theories" and still true today. • Theories include: Uterine ischemia, Autoimmune disease. • Deficiency of dietary protein. • Organism called "hydatoxi Lualba".

30. Risk Factors: 1.Primigravida (6–8 times greater risk) 2.Age extremes (17 years (less than 20 y. ) and over 35 years) 3.Diabetes 4.Preexisting hypertension 5.Multiple gestation (5 times greater risk) 6.Hydatidiform mole (10 times greater risk) 7.Preeclampsia in a previous pregnancy 8.Family history 9.Obesity

31. 10.Immunological factors 11.Chronic renal disease 12.Rh incompatibility 13.African-American ethnicity 14.embryo donation

32. The incidence: • PIH develops in the last 10 weeks of gestation, during labor or in the first 12-48 hours after delivery. • It occurs in 5% of all pregnancies. • Adolescents, younger primiparas and low income women have 10%-30% risk. • Women who have had PIH or those who have chronic hypertension have a chance of 25%-35%. • In those who develop Preeclampsia, 5% go on to develop Eclampsia. • Fetal death with Preeclampsia is about 10% and with Eclampsia 20%.

33. Pathophysiology • In normotensive pregnancies, the spiral arteries of the uterus are remodeled by invasion of endovascular trophoblast cells, which allows them to widen to accommodate a 10-fold increase in blood flow. • In a preeclamptic woman, this remodeling is incomplete and the spiral arteries remain thick walled, resulting in suboptimal placental perfusion • Resulting in epithelial cell dysfunction that leads to generalized vasospasm and so uteroplacent perfusion are reduced. • Placental ischemia is going to cause a widespread activation/dysfunction of the maternal vascular endothelium that results in an increase ratio of vasoconstrictor as thromboxane to vasodilators such as nitric oxide and prostacyclinwhich leading to hypertension, increase peripheral resistance and impending blood flow to vital organs.

35. Preeclampsia • Preeclampsia defined as an increase in blood pressure (140/90) after 20 weeks’ gestation accompanied by proteinuria. • Syndrome of PIH accompanied by 1. proteinuria, 2. edema and 3. frequently other organ system disturbances. • Preeclampsia is a multisystem, vasopressive disease process that targets the cardiovascular, hematologic, hepatic, renal, and • central nervous systems. Patients do not suddenly “catch” severe preeclampsia or develop eclampsia but rather progress in a fairly predictable course through the clinical spectrum.

36. In most cases, the progression is relatively slow, and the disorder may never proceed beyond mild preeclampsia. In other situations, the disease can progress more rapidly. In the most serious cases, the progression can be rapid: mild preeclampsia evolves to severe preeclampsia or eclampsia over hours or days

37. Mild Preeclampsia Is characterized by: • Hypertension: a rise of 30 mmHg systolic and 15 mmHg diastolic, blood pressure : 140/90 mmHg • Proteinuria: of +2 or 1 g/L. • Edema: generalized, facial, hands and fingers reflecting weight gain of over than 0,7 kg/week. • Assessment: In each prenatal visit, blood pressure and other signs of hypertension are assessed. Assessment includes urine testing for proteinuria. Weighting on the same scale. Assessing for edema, headache, epigastric pain… Assessment of fetal movement, non stress test and U/S.

38. Management: • Initial management consists of rest and observation if patient is not a candidate for delivery. Bed rest maximizes uteroplacental flow. • Delivery should done by 38th week or sooner if the fetus is mature. Nursing Interventions: • Diet: increase protein diet with moderate sodium intake. • Rest and activity: resting on the left lateral recumbent position is beneficial. Complete bed rest may not be necessary, reduced activity is beneficial. • Antenatal visits are scheduled every 2 weeks or less depending on the symptoms for assessment of signs of preeclampsia. • Mothers are instructed to report any sudden change in their condition such as generalized edema, headaches, fever, seizures and sudden increase of body weight

39. Severe Preeclampsia • Criteria for severe Preeclamosia 1. Blood pressure: consistently ≤ 160 mmHg systolic and ≤ (110 mmHg diastolic 2. Proteinuria: ≤ 5g in 24 hours urine collection or ≤ 3+ on randomly urine dipstick 3. Oliguria: (less than 500 ml/24 hours) or increasing serum creatinine levels (>1.2 mg/dl). 4. Edema: generalized, weight gain of 0.9 kg over a period of one week or less.

40. 5. Platelet count: less than 100,000 and increase in lactic acid dehydrogenase (LDH) and direct bilirubin levels. HELLP syndrome may be develop (Hemolysis (H): due to hypofibrogenemia, Elevated liver enzymes (EL) and Low Platelet Count (LP) 6. Headache, visual disturbances or other cerebral signs. 7. Epigastric or right upper quadrant pain. 8. Cardiac decompensation, pulmonary edema or cyanosis. 9. Fetal growth restriction: due to reduction of intervillous perfusion

41. Note: { HELLP variant (syndrome)}. • •Hemolysis (H): due to hypofibrogenemia. • •Elevated liver enzymes (EL). • •Low Platelet Count (LP).

42. Assessment: • Hospitalization is necessary. • The goal of care is to prevent seizures, lowering blood pressure, establishing an adequate renal function and to continue the pregnancy until fetal maturity. • If the pregnancy is at the 34th week or more, labor is induced or cesarean birth is performed. • Serial examinations recommended for Preeclamptic hospitalized patients include:

43. Mother: • 1. Blood pressure: four times daily. • 2. Assessment for proteinuria, edema, weight, hyperreflexia, headache, visual disturbance, epigastric pain (daily). Hematocrit, platelet count (every 2 days). Serum uric acid and creatinine levels, 24 hours urine for total protein and creatinine clearance (twice weekly). • 3. Liver function test (weekly). 4.Urinary output (at each voiding or by catheterization, should be more than 700 ml/24 hours or 30 ml/hr).

44. Fetus: • 1. Assess or ask the mother to observe Fetal movement (daily). • 2. Fetal heart rate (every 4 hours or continuously). • Placental separation (hourly in case of severe Preeclampsia). • 3. Ultrasound for fetal growth (every 2 weeks). • 4. Non stress test (twice weekly).

45. Management: The goal of therapy is to 1. reduce the risk of CVA , & maintaining uteroplacental perfusion. 2. reducing the diastolic blood pressure to a value of less than 110 mm Hg, 3. Delivery is always the appropriate maternal therapy. 4. Drug therapy: Hydralazine, aldomine, nefidipine. 5. Carefully monitor urinary output. 6. Preventing Convulsions: 7. Drug of choice is Magnesium Sulfate. 8. Treat all Preeclamptic patients during labor and 24 hours postpartum.

46. Magnesium Sulfate.:. • •4 g I.V. load then 2-3 g/ hour. • •Keep serum magnesium 4-8 mg/dl. • •IM doses more painful. • •10 g load IM, then 5 g IM every 4 hours. Magnesium Sulfate Toxicity: • -Loss of patellar reflex. • -Respiratory depression, respiratory rate is less than 12 breath/min. • -Defective cardiac conduction. • -Treatment of toxicity: antedote: Calcium Gluconate 10% (1 g I.V. over 3 min).

47. Nursing Care: • Maternal and fetal compromise related to edema, proteinuria, hypertension. • The goal: to minimize the effects of edema, proteinuria and hypertension. • Control amount of stimulation, place in quiet private room with dimmed lighting, no phone or visitors. • Maintain absolute bed rest with side rails up, disturb only for essential procedures. • Have the woman select the people she wishes to stay with her. • Explain rational for care.

48. Monitor: level of consciousness, headache, irritability and epigastric pain… • Send blood specimen for measurement of HCT, PLT and SGOT daily. • Check results against normal values and report variations immediately.

49. Possible Complications of Preeclampsia: • Eclampsia. • Abruptio placenta. • Pulmonary edema. • Congestive heart failure. • Cerebral edema. • Retinal detachment. • Renal damage.

50. EcIampsia • Severe form of Preeclarnpsia with seizure or coma. The occurrence of one or more convulsions not attributable to other cerebral disorders such as epilepsy or cerebral hemorrhage in a patient with Preeclampsia. • Women in whom eclampsia develops exhibit a wide spectrum of signs and symptoms, ranging from extremely high blood pressure, 4+ proteinuria, generalized edema, and 4+ patellar reflexes to minimal blood pressure elevation, no proteinuria or edema, and normal reflexes.