Complications of Pregnancy

1. Complications of Pregnancy Author: Evelyn M. Hickson, RN, MSN, CNS, WCC

2. Objectives Describe and define the following complications of pregnancy; discuss predisposing factors, and management of: • Preterm Labor • Premature Rupture of Membranes • Diabetes • Thrombophelias • Pulmonary Edema • Bleeding Complications of Pregnancy (Placenta previa, Abruption, DIC)

3. Preterm Labor Definition: Persistent uterine contractions that are accompanied by dilatation and/or effacement as detected by digital exam (Gonik and Creasy 1986)

4. Preterm Labor • One of the most common complications during pregnancy • Issue is the appropriate diagnosis and monitoring • Treatment modalities still have not been proven to work

5. Definitions: Preterm Delivery • Any birth, regardless of birth weight, that occurs before 37 completed weeks from the first day of the last menstrual period • Beginning at 20 weeks and ending at 36 6/7 weeks (Creasy and Resnik, 2004)

6. Hypertension Systemic infections Pyelonephritis Drug abuse Maternal race Previous preterm birth Low prepregnancy weight Absent or inadequate PNC <18yrs >35yrs Strenuous work High personal stress Anemia Smoking Bacteriuria Genital colonization or infection Cervical injury or abnormality Uterine anomaly Low socioeconomic status Risk Factors Contributing to Preterm Delivery

7. Risk Factors Contributing to Preterm Delivery • Preterm labor • Ruptured membranes • Multiple gestation • Preeclampsia • Abrupto placenta • Placenta previa • Vaginal bleeding • Growth restriction • Oligo, polyhydramnios • Fetal anomalies • Uterine anomalies • Chorioamnionitis • Incompetent cervix • Diabetes • Connective tissue disorders • Poor nutrition • Peridonal disease • Fibroids

8. Spontaneous Preterm Labor • Risk factors • preterm rupture of membranes • incompetent cervix • amnionitis • genital tract infection • nonwhite race • multiple gestation • second trimester bleeding • low prepregnancy weight • previous preterm birth • About 75% of preterm births fall into the spontaneous category (Creasy and Resnik)

9. Epidemiology • Poorly understood • Recent Studies have theorized: • Response to chronic intrauterine inflammatory insult • Influenced by fetal and maternal immune response • Infection induced activation for the fetal hypothalamic-pituitary-adrenal axis, the fetal membranes and decidua produce cytokines which initiate labor or rupture of membranes.

10. Signs and Symptoms -Nonspecific and not necessarily those of labor at term -Pelvic pressure -Increased vaginal discharge -Backache -Menstrual-like cramps -Painful or painless contractions, different from Braxton-Hicks only in their persistence

11. Difficulty with Accurate Diagnosis • Fetal fibronectin test – can improve accuracy of diagnosis—negative • Predictive value with dilatation <3cm and effacement <80% for delivery • Within 7-14 days good, positive predictive value not good

12. Difficulty with Accurate Diagnosis • High prevalence of S&S among healthy women not in preterm labor • Imprecision of digital exam • Contraction frequency (4 or more per hour ) has low sensitivity and low positive predictive value • Endovaginal ultrasonography cervical length of 30mm or greater has very high negative predictive value in symptomatic women

13. Diagnosis • Cervical effacement of 80% or greater • Dilation of more than 2 cm • Change in dilation of 1 cm or more • Sonographic cervical length under 30mm or a positive fetal fibronectin

14. Management Variety of drugs available-no clear first line drug-clinical situation and physician preference Antibiotics do not appear to prolong gestation, should be used for GBS prophylaxis if delivery is imminent Maintenance or repeated acute tocolysis doesn’t improve perinatal outcome used generally

15. Managment • Tocolytic drugs may prolong pregnancy 2-7 days which may allow for steroids to improve lung maturity, and transport to a tertiary center • Antenatal corticosteroids significantly reduce the incidence and severity of neonatal RDS. Also reduce incidence of IVH and necrotizing enterocolitis. • Decrease neonatal mortality.

16. Tocolytics

17. Tocolytics

18. Nursing Care: Evaluation for Preterm Labor • History (risk factors) • S&S of preterm labor • S&S UTI • S&S vaginitis/cervicitis/STDs • S&S viral or bacterial infection • S&S PROM • Physical Exam • VS • Evaluate gestational age • Electronic monitor and palpate contractions • Electronic monitor of FHR and pattern • Abdominal palpation for presentation, position, multiple gestation, EFW, pain • Costovertebral angle tenderness • Low back or suprapubic pain

19. Evaluation for Preterm Labor • Pelvic Exam • Speculum exam for vaginitis,cervicitis,STDs,PROM, bloody show, meconium • Digital exam for cervical changes (not done if PROM found on spec exam) • Lab tests • UA, urine culture and sensitivity • Wet mount for Bacterial Vaginosis or Trichomonas • GBS cultures and cultures of any lesions • GC and chlamydia cultures • CBC with differential • Nitrazine and ferning if appropriate

20. Nursing Care of Woman in Preterm Labor • Bedrest, lateral position • IV, hydration has not been shown to be effective in stopping labor and increases risk of pulmonary edema • Continuous uterine and fetal monitoring • Medications as ordered • Arrange for transport if planned • Arrange for care of infant, staffing, pediatrician, respiratory therapy, equipment

21. Premature Rupture of Membranes (PROM) • Definition: Rupture of membranes before the onset of labor • Preterm premature rupture of membranes (PPROM)is rupture of membranes before the onset of labor at <37 weeks gestation

22. Term PROM • Complicates 8% of pregnancies • Generally followed by onset of labor and delivery • In a large randomized study, with expectant management, and ½ of women with PROM delivered within 5 hours, and 95% delivered within 28 hours. • Risks—intrauterine infection—increases with duration of membrane rupture, umbilical cord compression (ACOG practice bulletin)

23. Etiology of Membrane Rupture at Term • Combination of stretching with uterine growth, strain from uterine contractions and fetal movement • Biochemical changes, including a decrease in collagen content

24. Management PROM • May induce labor immediately • Observe for the onset of spontaneous labor for up to 24-72 hours (if observing need to avoid digital exams which increase the risk of infection) • Antibiotics if GBS positive or if rupture >18 hours

25. Risk Factors • Smoking • Multiple gestation • Abruptio placenta • Cocaine use • Previous PPROM • Previous cervical operations or lacerations • Occupational fatigue, long working hours • Vitamin C and E deficiencies

26. Management • Antibiotics—prolongs latency period and improve perinatal outcome with expectant management prior to 35 weeks • Administration of corticosteroids if <32 weeks (some recommend <34 weeks*) • Avoid digital exams if not in labor and immediate induction is not planned

27. Nursing Care • Accurate history: time, amt, color, odor, intercourse • Physical Exam: VS,FHR, contractions, abdominal palpation • Sterile Speculum Exam: vulva, vaginal pooling, fluid from os, cord, fetal part, nitrazine, fFN, amnitoic protein, cervical cultures, GBS

28. Nursing Care continued • In labor assess temp q2 hrs, otherwise q 4 hrs • Monitor FHR, cord compression or tachycardia • Avoid unnecessary vaginal exams • Watch hydration, dehydration can cause a temp elevation

29. Diabetes Mellitus • Definition: Gestational Diabetes is the presence of carbohydrate intolerance of varying degrees of severity with an onset or first recognition during pregnancy. (Varney) • Incidence: Averages about 7%, varies with ethnicity • Increased in Hispanic, African, Native American, South or Eastern Asian, or Pacific Islander • Pregestational Diabetes: Diabetes which antedates the pregnancy

30. Pre-Gestational Diabetes • Type I or Type II • Type I: True insulin-dependent, typically develops prior to adolescence, usually diagnosed prior to pregnancy.White classification of B,C,D,F and above • Type II: Not necessarily insulin dependent and usually begins after age 40

31. Risk Factors • Marked obesity • Hx GDM prior pregnancy • Strong family Hx • Previous infant >4000 gm • Hx unexplained stillbirth • Poor OB Hx, SABs, congenital anomalies • Recurrent glycosuria (2 positive tests) unexplained by diet

32. Physiology Gestational Diabetes • Similar to type II Diabetes: Insulin is available • Hormonal changes alter receptivity to insulin • <20 weeks cells more responsive to insulin • >20 weeks, as placenta grows, production of human placental lactogen (HPL) increases

33. Physiology of Gestational Diabetes • HPL increases cellular resistance to insulin • When production of insulin cannot keep up with rising need hyperglycemia results • Peak effect of HPL 26 to 28 weeks

34. Risks of Diabetes • Pregestational Diabetes: Congenital anomalies,spontaneous AB, stillbirth, IUGR, HTN, preeclampsia • Gestational Diabetes: If early pregnancy blood sugars not elevated, no increase in anomalies, but increase in macrosomic infants, protracted labor, shoulder dystocia, operative delivery HTN and preeclampsia, Type II Diabetes later in life

35. Macrosomic Infant • Insulin similar to Human Growth Hormone • Glucose crosses the placenta • Fetus increases insulin production to metabolize glucose • Hyperplasia and hypertrophy of cells causing lifelong change increasing risk of obesity as well as diabetes

36. Screening tests • ADA recommends random nonfasting 1hour post 50 gram glucola <130-140 (early with risk factors, 24-28 weeks for everyone) • 3 hour glucose tolerance test

37. Management • ADA diet—same nutrition requirements as nondiabetic women —2000 to 2200k cal diet, may consider caloric restriction in obese women no more than 33% • Balance of calories from carbohydrate, fat and protein • Home glucose monitoring Fasting <95mg/dl, 1 hr <140, 2hr <120 • Careful evaluation of fetal size and fluid volume, ultrasound if necessary but poor predictor of EFW • Optimal antenatal testing for diet controlled GDM with no other risk factors not established • Usually recommend DFMC from 34 to 36 wks on at 40 weeks NST or BPP

38. Management • Mild to moderate exercise • If well controlled with diet alone, await spontaneous labor • Insulin or glyburide if poorly controlled with diet • Consider C-Section if EFW >4500 gm • 6 week postpartum glucose testing • Labor management the same as nondiabetic with higher level of suspicion for shoulder dystocia • IV fluids should not contain glucose

39. Nursing Care • Same as any woman in labor • Notify pediatrician of diabetic mom • Anticipate shoulder dystocia and be prepared to help • Avoid glucose containing IV fluids unless on insulin drip and NPO • If on insulin, periodic blood glucose checks and insulin as ordered • Anticipate postpartum uterine atony/hemorrhage if macrosomic infant • Watch vital signs closely and be aware of increased risk for HTN

40. Thrombophilia Definition: Tendency toward blood clot formation • Most common inherited are: • Factor V Leiden • Prothrombin G20210A mutation • Less common inherited are: • Deficiency of anticoagulants protein C, proteinS, and antithrombin III

41. Thrombophilia • Most common acquired: • Antiphospholipid antibody syndrome • Lupus Anticoagulant • Anticardiolipin antibodies • Less common acquired: • Lupus Anticoagulant • Anticardiolipin Antibodies

42. Risk Factors for Deep Vein Thrombosis and Thromboembolic Disorders • Hereditary thrombophilia • Acquired thrombophilia • Mechanical heart valve • Atrial fibrillation • Trauma/prolonged immobilization/major surgery • History of deep vein thrombosis • Strong family history of thrombosis or thromboembolic events • Pregnancy • Oral contraceptive use

43. Testing for Thrombophilias • History of thrombosis • First degree relative with thrombophilia • Recurrent fetal loss • History of early or severe preeclampsia • Severe unexplained IUGR

44. Signs and Symptoms - Superficial Thrombophlebitis • Leg pain • Localized heat, tenderness or inflammation at site • Palpation of knot or cord

45. Signs and Symptoms DVT • Slight temperature elevation • Mild tachycardia • Abrupt onset with severe leg pain worse with motion or standing • Edema of ankle,leg,thigh • Positive Homan’s sign • Pain with calf pressure • Tenderness along entire course of involved vessel with palpable cord

46. Signs and Symptoms of Pulmonary Embolism • Dyspnea • Tachycardia • Tachypnea • Breath sounds few rales or wheezes • Low PO2 and O2 saturation • Hemoptysis • Pleuritic chest pain

47. Signs and Symptoms of Pulmonary Embolism • Pleural friction rub or signs of effusion • Hypoxia • Hypotension • Cyanosis • Jugular venous distention • Right ventricular heave (lower left sternal border)

48. Management of Thrombophilias • Appropriate testing for thrombophilias • High index of suspicion with risk factors • Occasional prophylactic anticoagulation with sub q heparin injection • During labor, if anticoagulant therapy is required, IV heparin is used • Postpartum, switch back to sub q heparin overlapping with coumadin • With some anticoagulants neuraxial blocks should not be used for 24 hours after last injection

49. Nursing Care • Recognize increased risk for thromboembolic events and be prepared • If on anticoagulants, recognize increased risk for bleeding and be prepared

50. Pulmonary Edema • Usually due to excess capillary pressure as in cardiomyopathy, mitral stenosis or due to a disruption of alveolar capillary membrane integrity as in pneumonia, ARDS (Gabbe, Niebyl, Simpson, 2002) • Two general causes alveolar flooding: caused by heart failure or permeability edema from alveolar-capillary injury. In many OB cases both are present (Williams OB, 2001)