Complications of the Childbearing Experience

Complications of the Childbearing Experience

OBSTETRIC COMPLICATIONS

 

ECTOPIC PREGNANCY

Ectopic pregnancy is gestation located outside the uterine cavity (ie, implantation occurs at a site other than the endometrium). Because about 96% of ectopic pregnancies occur in the fallopian tubes, the term “tubal” pregnancy is commonly used.

Pathophysiology and Etiology

• The fertilized ovum implants outside the uterus

• Most tubal pregnancies occur in the distal (ampullary) two-thirds of the tube.

• Some are located in the proximal portion of the extrauterine part of the tube (isthmic).

• Rarely, intrauterine and extrauterine gestations can exist as the same time (heterotopic pregnancy).

• Structural factors that prevent or delay the passage of the fertilized ovum include adhesions of the tube, salpingitis, congenital and developmental anomalies of the fallopian or uterine tube, previous ectopic pregnancy, use of an intrauterine device for more than 2 years, and multiple induced elective abortions.

• Functional factors include menstrual reflux and decreased tubal motility.

• Contributing factors may include:

• History of pelvic inflammatory disease (PID).

• Endometriosis.

• Previous tubal surgery.

• Uterine curettage.

• Maternal age and race.

• Renal disease or transplant.

• Improved treatment for PID, which prevents total blockage of tubes, but may cause partial blockage.

• Surgical corrections of fallopian tube occlusions.

• Elective sterilizations being reversed at a later date.

Clinical Manifestations

• Abdominal or pelvic pain (most common).

• Irregular vaginal bleeding — usually scanty and dark (most common).

• Amenorrhea—in 75% of the cases.

• Uterine size is usually similar to what it would be in a normally implanted pregnancy.

• Abdominal tenderness on palpation.

• Shoulder pain.

• Increased pulse and anxiety.

• Nausea, vomiting, faintness, or vertigo and syncope with abdominal pain may develop.

• Pelvic examination reveals a pelvic mass, posterior or lateral to the uterus, adnexal tenderness, and cervical pain on movement of the cervix.

Diagnostic Evaluation

• Serum progesterone—reflects production of progesterone by the corpus luteum, which is stimulated by a viable pregnancy; diagnostic with 97.5% sensitivity if serum progesterone levels are greater than or equal to 25 ng/mL (greater than or equal to 79.5 nmol/L), which would negate need for further testing.

• Serum ОІ-human chorionic gonadotropin (ОІ-hCG) (produced by trophoblastic cells)—when done serially, will not show characteristic rise as in intrauterine pregnancy

• Transvaginal ultrasound—may identify tubal mass and absence of gestational sac within the uterus

• Culdocentesis—bloody aspirate from the cul-de-sac of Douglas indicates intraperitoneal bleeding from tubal rupture

• Laparoscopy—visualization of tubal pregnancy (considered the diagnostic gold standard)

• Laparotomy—indication for surgery if there is any question about the diagnosis

Management

Conservative Therapy

• Conservative therapy is chosen should the patient desire future childbearing. Treatment with methotrexate is fast becoming the standard of care for ectopic therapy.

• Methotrexate is given to hemodynamically stable patients who are eligible for treatment and meet the criteria listed below.

• Single-dose methotrexate (50 mg/m²) I.M.

• Multiple-dose methotrexate (1 mg/kg) I.M. every other day (days 1, 3, etc.), accompanied with Leucovorin (0.1 mg/kg) I.M. every other day (days 2, 4, 6, etc.). Regimen is followed until the ОІ-hCG drops 15% or more in 48 hours or four doses of methotrexate have been given.

• Goal of treatment is to remove ectopic pregnancy and preserve productive function.

OR

• Usually given on outpatient basis. Must meet criteria as set forth by the American College of Obstetrics and Gynecology (ACOG):

• Ectopic size 4 cm or less.

• Desire for future fertility.

• Stable or rising hCG levels with peak values below 15,000 mIU/mL.

• Tubal serosa intact.

• No active bleeding.

• Ectopic pregnancy fully visualized at laparoscopy and unruptured.

• Selected cases of cervical and cornual pregnancy.

• Advantages of single-dose treatment

• Eliminates adverse effects caused by multiple dosing: gastritis, stomatitis, increased hepatic transaminase levels, leukopenia, and thrombocytopenia.

• Increased safety and patient acceptance.

• Requires less medication, thus decreases patient follow-up and cost of treatment.

• Contraindications to methotrexate therapy:

• Mass greater than 4 cm.

• Evidence of acute intra-abdominal bleeding (acute abdomen, hypotension, or falling hematocrit).

• Poor patient compliance.

• History of active herpes or renal disease.

• Presence of fetal cardiac activity.

• Abnormal serum creatinine or aspartate aminotransferase (AST).

• Active peptic ulcer disease.

• Blood leukocyte count of less than 3,000 or a platelet count of less than 100,000.

Surgical Treatment

• If woman does not consent to or meet criteria for methotrexate, surgical intervention is instituted. The surgical procedure depends on the extent of tubal involvement and if rupture has occurred.

• The surgery of choice used to preserve future fertility is a salpingostomy.

• Should a womaot desire future fertility, the surgery of choice is salpingectomy.

• Other surgeries range from removal of ectopic pregnancy with tubal resection, salpingostomy (removes conceptus leaving tube intact, yet scarred), and possibly salpingo-oophorectomy.

• Treat shock and hemorrhage if necessary.

• Administer RhIG (immune globulin) per your facility’s policy if woman is Rh negative.

Complications

• Infertility

• Hemorrhage and death

Nursing Assessment

Evaluate the following to determine pregnancy and to monitor for changes in patient’s status, such as rupture or hemorrhage:

• Maternal vital signs

• Presence and amount of vaginal bleeding

• Amount and type of pain

• Presence of abdominal tenderness on palpation/shoulder pain

• Date of last menstrual period

• Presence of positive pregnancy test

• Rh type

Nursing Diagnoses

• Risk for Deficient Fluid Volume related to blood loss from ruptured tube

• Acute Pain related to ectopic pregnancy or rupture and bleeding into the peritoneal cavity

• Anticipatory Grieving related to loss of pregnancy and potential loss of childbearing capacity

Nursing Interventions

Maintaining Fluid Volume

• Establish an I.V. line with a large-bore catheter, and infuse fluids and packed RBCs as prescribed.

• Obtain blood samples for complete blood count (CBC) and type and screen for whole blood, as directed.

• Monitor vital signs and urine output frequently, depending on condition.

Promoting Comfort

• Administer analgesics as needed and prescribed.

• Encourage the use of relaxation techniques.

Providing Support through the Grieving Process

• Be available to patient and provide emotional support.

• Listen to concerns of patient and significant others.

• Be aware that family may be experiencing denial or other stage of grieving.

• Suggest referrals such as social worker, psychiatrist, and clergy, as appropriate. Suggest grief counseling.

• Teach signs and symptoms related to ectopic pregnancy to women at risk including increased vaginal bleeding, severe abdominal pain, shoulder pain, nausea, and vomiting.

• Instruct woman to report to her primary care provider should signs and symptoms be present or to emergency department if condition is severe.

• Instruct woman to bring support persons with her when she comes to the facility.

• Encourage grief counseling and supportive care at home.

• Teach signs of postoperative infection, including fever, abdominal pain, and increased or malodorous vaginal discharge.

• Reinforce that chances of another ectopic pregnancy are increased and that subsequent conception potential may be decreased, based on health care provider’s explanation.

• Discuss contraception.

• Teach signs of recurrent ectopic pregnancy—abnormal vaginal bleeding, abdominal pain, menstrual irregularity.

Evaluation: Expected Outcomes

• Vital signs stable

• Verbalizes pain relief

• Patient and support person express sorrow over their loss

 

HYDATIDIFORM MOLE

Hydatidiform mole (gestational trophoblastic disease) is an abnormal pregnancy resulting from a developmental anomaly of the placenta. It is characterized by the conversion of the chorionic villi into a mass of clear vesicles. There may be no fetus, or a degenerating fetus may be present.

 

Pathophysiology and Etiology

• It is believed to be derived from genetic abnormalities as the paternal haploid, X-carrying set of chromosomes that reaches 46 XX by its own duplication. Not all moles have the 46 XX chromosomal makeup.

• It arises in fetal rather than maternal tissue.

• Large amounts of ОІ-hCG are present secondary to the proliferation of chorionic tissue. Assay values of ОІ-hCG are elevated in the condition.

• Contributing factors may include chromosomal abnormalities, malnutrition, hormonal imbalance, age under 20 or over 40, and low economic status.

Clinical Manifestations

• First trimester vaginal bleeding

• Absence of fetal heart tones and fetal structures

• Rapid enlargement of the uterus; size greater than dates

• ОІ-hCG titers greater than expected for gestational age

• Expulsion of the vesicles

• Hyperemesis (severe nausea and vomiting)

• Signs of preeclampsia before 24 weeks’ gestation

Diagnostic Evaluation

• ОІ-hCG levels—elevated

• Ultrasound—shows a characteristic picture of the mole in most cases

Management

• Suction curettage is the method of choice for immediate evacuation of the mole with possibility of laparotomy.

• Follow-up for detection of malignant changes because a complication is the development of choriocarcinoma of the endometrium.

• Administer RhIG (RhoGAM) per your facility’s policy if woman is Rh negative.

Complications

Significant blood loss

Nursing Assessment

• Monitor maternal vital signs; note presence of hypertension.

• Assess the amount and type of vaginal bleeding; note the presence of any other vaginal discharge.

• Assess the urine for the presence of protein.

• Palpate uterine height; if above the umbilicus, measure the fundal height.

• Determine date of last menstrual period and date of positive pregnancy test.

• Evaluate CBC results and Rh type.

Nursing Diagnoses

• Risk for Deficient Fluid Volume related to maternal hemorrhage

• Anxiety related to loss of pregnancy and medical interventions

Nursing Interventions

Maintaining Fluid Volume

• Obtain blood samples for type and screen, and have 2 to 4 units of whole blood available for possible replacement.

• Establish and maintain I.V. line; start with a large needle to accommodate possible transfusion and large quantities of fluid.

• Assess maternal vital signs, and evaluate bleeding.

• Monitor laboratory results to evaluate patient’s status.

Decreasing Anxiety

• Prepare the patient for surgery. Explain preoperative and postoperative care along with intraoperative procedures.

• Educate patient and family on the disease process.

• Allow the family to grieve over the loss of the pregnancy.

Patient Education and Health Maintenance

• Advise the woman on the need for continuous follow-up care.

• Provide reinforcement of follow-up procedures:

• Measure ОІ-hCG levels every 1 to 2 weeks until normal — then begin monthly testing for 6 months, then every 2 months for a total of 1 year.

• Consider chemotherapy or hysterectomy if ОІ-hCG levels rise or begin to plateau or there is evidence of metastasis.

• Encourage ongoing discussion of care with health care provider.

Evaluation: Expected Outcomes

• Vital signs stable; laboratory work withiormal limits

• Verbalizes concerns about self and related procedures; describes follow-up care and its importance

SPONTANEOUS ABORTION

 

Spontaneous abortion is the unintended termination of pregnancy at any time before the fetus has attained viability (20 weeks’ gestation or fetal weight of more than 500 g). Intended termination of a pregnancy is known as therapeutic or voluntary abortion and is accomplished through medical or, in most cases, surgical intervention.

TABLE 39-1 Types of Spontaneous Abortions

CLASSIFICATION CLINICAL MANIFESTATIONS MANAGEMENT Threatened Vaginal bleeding or spotting Mild cramps Tenderness over uterus, simulates mild labor or persistent lower backache with feeling of pelvic pressure Cervix closed or slightly dilated Symptoms subside or develop into inevitable abortion Vaginal examination Bed rest (some clinicians will not limit activity in belief that the embryo will be aborted anyway) Pad count Inevitable Bleeding more profuse Cervix dilated Membranes rupture Painful uterine contractions Embryo delivered, followed by dilatation and evacuation (D&E) Habitual Spontaneous abortion occurs in successive pregnancies (three or more) D&E Treatment of possible causes: hormonal imbalance, tumors, thyroid dysfunction, abnormal uterus, incompetent cervix; with treatment, 70% to 80% carry a pregnancy successfully Hysterogram to rule out uterine abnormalities, infections Surgical suturing of the cervix if incompetent cervix is a causative factor Incomplete Fetus usually expelled Placenta and membranes retained D&E Missed Fetus dies in utero and is retained Maceration No symptoms of abortion, but symptoms of pregnancy regress (uterine size, breast changes) Real-time ultrasound, and if second trimester, fetal monitoring to determine if fetus is dead If fetus is not passed after diagnosis, oxytocin induction may be used. Retained dead fetus may lead to development of disseminated intravascular coagulation or infection Fibrinogen concentrations should be measured weekly

 

Pathophysiology and Etiology

• Cause frequently unknown, but 50% are due to chromosomal anomalies

• Exposure or contact with teratogenic agents.

• Poor maternal nutritional status.

• Maternal illness with virus, such as rubella, cytomegalovirus, active herpes, and toxoplasmosis, or specific bacterial microorganisms that put the pregnancy at risk.

• History of diabetes, thyroid disease, anticardiolipin antibodies, or lupus erythematosus.

• Smoking or drug abuse or both.

• Immunologic factor by which the mother and father are genetically similar, with similar major antigens that cause the maternal immune system to reject the embryo.

• Luteal phase defect.

• Postmature sperm or ova.

• Abnormal uterine development or structural defect in the maternal reproductive system (including an incompetent cervix).

• Imperfect sperm or ova.

• Environmental factors such as drugs, radiation, or trauma.

Clinical Manifestations

• Uterine cramping, lower back pain.

• Vaginal bleeding usually begins as dark spotting, then progresses to frank bleeding as the embryo separates from the uterus.

• ОІ-hCG levels may be elevated for as long as 2 weeks after loss of the embryo.

Diagnostic Evaluation

• Ultrasonic evaluation of the gestational sac or embryo

• Visualization of the cervix; presence of dilation or tissue evaluated

Complications

• Hemorrhage

• Uterine infection

• Septicemia

• Disseminated intravascular coagulation (DIC) in a missed abortion

Nursing Assessment

• Evaluate the amount and color of blood that is present; determine the time the bleeding began and any precipitating factors.

• Determine whether a positive pregnancy test has previously been obtained, also the date of the last menstrual period.

• Monitor maternal vital signs for indications of complications, such as hemorrhage, infection.

• Evaluate any blood or clot tissue for the presence of fetal membranes, placenta, or fetus.

Nursing Diagnoses

• Risk for Deficient Fluid Volume related to maternal bleeding

• Anticipatory Grieving related to loss of pregnancy, cause of the abortion, future childbearing

• Risk for Infection related to dilated cervix and open uterine vessels

• Acute Pain related to uterine cramping and possible procedures

Nursing Interventions

Maintaining Fluid Volume

• Report tachycardia, hypotension, diaphoresis, or pallor, indicating hemorrhage and shock.

• Draw blood for CBC as well as type and screen for possible blood administration.

• Establish and maintain an I.V. with large-bore catheter for possible transfusion and large quantities of fluid replacement.

• Inspect all tissue passed for completeness.

Providing Support through the Grieving Process

• Assess the reaction of patient and support person, and provide information regarding current status, as needed.

• Encourage the patient to discuss feelings about the loss of the pregnancy; include effects on relationship with the father.

• Do not minimize the loss by focusing on future childbearing; rather acknowledge the loss and allow grieving.

• Provide time alone for the couple to discuss their feelings.

• Discuss the prognosis of future pregnancies with the couple.

• If the fetus is aborted intact, provide an opportunity for viewing, if parents desire.

• Refer to chaplain or social worker if indicated or requested.

Preventing Infection

• Evaluate temperature every 4 hours if normal, and every 1 to 2 hours if elevated.

• Check vaginal drainage for increased amount and odor, which may indicate infection.

• Instruct on and encourage perineal care after each urination and defecation to prevent contamination.

Promoting Comfort

• Instruct patient on the cause of pain to decrease anxiety.

• Instruct and encourage the use of relaxation techniques to augment analgesics.

• Administer pain medications as needed and as prescribed.

Community and Home Care Considerations

• Teach patient with threatened abortion signs and symptoms of hemorrhage.

• Discuss emergency access to care with patient and support personnel.

• If the woman should pass anything through her vagina, instruct her not to discard it, but to bring it to the facility with her for evaluation.

• Explain to woman to bring her support persons with her to the facility.

Patient Education and Health Maintenance

• Provide the names of local support groups for couples who have experienced an early pregnancy loss. Resolve Through Sharing groups may be available through a local hospital.

• Discuss with the couple the methods of contraception to be used.

• Explain the need to wait at least 3 to 6 months before attempting another pregnancy.

• Teach the woman to observe for signs of infection (fever, pelvic pain, change in character and amount of vaginal discharge), and advise to report them to provider immediately.

• Provide information regarding genetic testing of the products of conception if indicated; send the specimen according to policy.

Evaluation: Expected Outcomes

• Vital signs remaiormal; minimal blood loss

• Expresses feelings regarding the loss of the pregnancy by demonstrating normal signs of grief

• No signs of infection, temperature normal, performs perineal care

• Verbalizes relief of pain

HYPEREMESIS GRAVIDARUM

Hyperemesis gravidarum is exaggerated nausea and vomiting that persists during pregnancy. Hyperemesis gravidarum can be experienced with or without food intake at any time of the day.

 

Pathophysiology and Etiology

• Occurs during the first 16 weeks’ gestation. Cause unknown but may possibly result from high levels of beta-hCG or estrogen.

• Accompanied by appetite disturbances that are intractable iature.

• Psychological factors including neurosis or altered self-concept may be contributory.

• Seen in molar pregnancies, multiple gestation, and history of hyperemesis in previous pregnancies.

• Slowed gastric motility occurs.

• The persistent vomiting may result in fluid and electrolyte imbalances, dehydration, jaundice, and elevation of serum transaminase.

Clinical Manifestations

• Persistent vomiting; inability to tolerate anything by mouth.

• Dehydration—fever, dry skin, decreased urine output.

• Weight loss (up to 5% to 10% of body weight).

• Severity of symptoms increases as the disease progresses.

Diagnostic Evaluation

• Tests may be done to rule out other conditions causing vomiting (cholecystitis, appendicitis, pancreatitis, thyroid disease, or hepatitis).

• Liver function studies—elevated alanine aminotransferase (ALT) and AST up to four times normal in severe cases.

• Prothrombin time (PT), partial thromboplastin time (PTT) usually normal.

• Blood urea nitrogen (BUN) and creatinine—may be slightly elevated.

• Serum electrolytes—may be hypokalemia, hyponatremia or hypernatremia; loss of hydrogen and chloride.

• Ketones in blood and urine.

Management

• Try withholding food and fluid for 24 to 48 hours, or until vomiting stops and appetite returns; then restart small feedings.

• Control of vomiting may require antiemetics (if benefit to therapy outweighs the risks of drugs), such as:

• The phenothiazines—prochlorperazine (Compazine, injectable or rectal suppository); promethazine (Phenergan); or chlorpromazine (Thorazine).

• Droperidol (Inapsine).

• Metoclopramide (Reglan)—do not give in combination with phenothiazines.

• Meclizine (Antivert).

• Methylprednisolone (recently found to more helpful than promethazine; 16 mg three times per day for 3 days then tapered over 2 weeks).

• Control of dehydration through I.V. fluids—typically 1 to 3 L of dextrose solution with electrolytes and vitamins, as needed. Bicarbonate may be given for acidosis.

• Most women respond quickly to restricting oral intake and giving I.V. fluids, but repeated episodes may occur.

• Rarely, total parenteral nutrition is needed.

• Rarely, complications of hepatic or renal failure or coma could result from disease progression.

Complications

• Hypovolemia and renal insufficiency

• Electrolyte imbalance

Nursing Assessment

• Evaluate weight gain or loss pattern. Compare the prepregnant weight with the current weight.

• Evaluate 24- or 48-hour dietary recall.

• Evaluate environment for factors that may affect the woman’s appetite. Determine if woman is ingesting nonfood substances (known as pica), such as starch, clay, or toothpaste.

• Monitor vital signs for tachycardia, hypotension, and fever due to dehydration.

• Assess skin turgor and mucous membranes for signs of dehydration.

Nursing Diagnoses

• Risk for Deficient Fluid Volume related to prolonged vomiting

• Imbalanced Nutrition: Less Than Body Requirements related to prolonged vomiting

• Ineffective Coping related to stress of pregnancy and illness

• Fear related to concerns for fetal well-being

Nursing Interventions

Maintaining Fluid Volume

• Establish an I.V. line, and administer I.V. fluids as prescribed.

• Monitor serum electrolytes, and report abnormalities.

• Medicate with antiemetics as prescribed.

• Maintaiothing-by-mouth (NPO) status except for ice chips until vomiting has stopped.

• Assess intake and output, urine specific gravity and ketones, vital signs, skin turgor, and fetal heart rate (FHR) as indicated by condition.

Encouraging Adequate Nutrition

• Advise the woman that oral intake can be restarted when emesis has stopped and appetite returns.

• Begin small feedings. Suggest or provide bland solid foods; serve hot foods hot and cold foods cold; do not serve lukewarm.

• Avoid greasy, gassy, and spicy foods.

• Provide liquids at times other than mealtimes.

• Suggest or provide an environment conducive to eating.

• Avoid strong food odors that may trigger vomiting.

• Keep room cool and quiet before and after meals.

• Keep emesis pan handy, yet out of sight.

• Administer parenteral calorie replacement if multiple antiemetic treatments and enteral tube feeding have been unsuccessful.

• Consult with a dietitian as indicated.

Strengthening Coping Mechanisms

• Allow patient to verbalize feelings regarding this pregnancy.

• Encourage patient to discuss any personal stress that may have a negative effect on this pregnancy.

• Refer the patient to social service and counseling services as needed.

Allaying Fears

• Explain the effects of all medications and procedures on maternal as well as fetal health.

• Accentuate the positive signs of fetal well-being.

• Praise mother for attempts at following nutritious diet and healthy lifestyle.

Patient Education and Health Maintenance

• Educate the woman about proper diet and nutrition.

• Educate the woman about healthy weight gain.

• Educate the woman on the need for child care during the periods of severe nausea and vomiting.

• Encourage the woman to move slowly, avoiding quick changes of position. Quick changes of position can cause vertigo and theausea and vomiting.

• Educate the woman on the need to take antiemetics during the nausea phase, before vomiting occurs.

• Educate the woman on tips to assist with hyperemesis gravidarum.

• Eat dry toast or crackers before rising from bed or anytime nausea begins.

• Get fresh, outside air daily.

• Lie down in a semiprone position.

• Drink spearmint or peppermint tea.

• Take 50 to 100 mg of vitamin B₆ daily.

• Avoid food odors.

• Eat smaller, frequent meals.

• Educate the woman that if all interventions fail, she should contact her primary care provider.

Evaluation: Expected Outcomes

• Demonstrates signs of normal hydration with no ketosis 6 hours after treatment initiated. Urine output adequate; urine specific gravity withiormal limits; blood pressure (BP) stable

• Tolerates small, bland feedings without vomiting

• Verbalizes concerns and stresses related to pregnancy

• Mother expresses confidence in infant’s well-being

PLACENTA PREVIA

 

Placenta previa is the abnormal implantation of the placenta in the lower uterine segment, partially or completely covering the internal cervical os (see Figure 39-2, see page 1266). Classification may change during labor as the cervix dilates. Placenta previa occurs in 1 in 200 live births.

Pathophysiology and Etiology

• Classified as:

• Total placenta previa—the placenta totally covers the cervical os.

• Partial placenta previa—the placenta partially covers the cervical os.

• Marginal placenta previa—the placenta lies within 2 to 3 cm of the internal os, but does not cover it.

• Low-lying placenta—the exact relationship of the placenta to the os has yet to be determined, or placenta previa is suspected before the third trimester. In cases of low-lying placenta previa, the placenta may migrate upward as the uterus stretches and grows.

• The cause is unknown, but risk factors include:

• Previous myomectomy.

• Endometritis.

• Scarred uterus or vaginal birth after cesarean delivery (VBAC).

• Multiparity.

• Previous abortion.

• Multiple births.

• Erythroblastosis.

• Rh isoimmunization.

• Previous placenta previa.

• As the uterus enlarges during pregnancy, additional risks include hemorrhage and increased likelihood of cesarean delivery.

• One possible etiologic theory states that the embryo will implant in the lower uterine segment if the decidua in the uterine fundus is not favorable or if implantation is delayed.

• About 80% of placenta previa episodes occur in multiparas.

• Incidence increases after age 35, and further increases after age 40.

Clinical Manifestations

• The cardinal sign is sudden onset of painless vaginal bleeding, typically near the end of the second trimester or later. Bleeding occurs in 80% of cases and appears without warning.

• Initial episode is rarely fatal and usually stops spontaneously, with subsequent bleeding episodes occurring spontaneously; each episode is more profuse than the previous one.

• Bleeding from placenta previa may not occur until cervical dilation occurs and the placenta is loosened from the uterus.

• With a complete placenta previa, the bleeding will occur earlier in the pregnancy and be more profuse.

Diagnostic Evaluation

• Transabdominal ultrasound is the method of choice to show location of the placenta.

• If findings are questionable, transvaginal ultrasound can improve the accuracy of diagnosis. Due to bleeding tendencies, however, this must be done by a highly skilled technician.

• Sterile speculum examination can also confirm placenta previa.

Management

• If bleeding is minimal and stops, conservative management with bed rest and hospitalization until fetus is mature and term delivery can be accomplished.

• If woman is discharged, she needs availability of immediate transport to the hospital for recurrent bleeding.

• If bleeding is heavy, I.V. access should be established immediately, along with CBC and type and crossmatching for at least 4 units of blood.

• Continuous maternal and fetal monitoring.

• Amniocentesis may be done, if time permits, to determine fetal lung maturity for possible delivery.

• Cesarean delivery is usually indicated if the degree of previa is more than 30% or if there is excessive bleeding. The cesarean delivery may be performed immediately.

• Vaginal delivery may occasionally be attempted in marginal previa or low-lying placenta without active bleeding. In these cases, the operating room staff and anesthesia personnel may be present in the operating room or delivery room to facilitate either vaginal or cesarean delivery as indicated.

• A neonatal specialty team is needed at delivery due to prematurity or other neonatal complications.

Complications

• Placenta accreta (abnormally adherent to uterine wall), especially if placenta previa exists with maternal history of uterine surgery.

• Immediate hemorrhage, with possible shock and maternal death

• Postpartum hemorrhage resulting from decreased contractility of uterine muscle

• Increased risk for anemia secondary to increased blood loss and infection secondary to invasive procedures to resolve bleeding.

• Intrauterine growth restriction (IUGR), especially with maternal history of multiple antepartum bleeding episodes.

• Congenital anomalies, ie, neurodevelopmental abnormalities, especially with maternal history of multiple antepartum bleeding episodes, due to subtle degrees of fetal hypoxia.

• Fetal mortality resulting from hypoxia in utero and prematurity

Nursing Assessment

• Determine the amount and type of bleeding; also, review any history of bleeding throughout this pregnancy.

• Inquire as to the presence or absence of pain in association with the bleeding.

• Record maternal and fetal vital signs.

• Palpate for the presence of uterine contractions.

• Evaluate laboratory data on hemoglobin and hematocrit status.

• Assess fetal status with continuous fetal monitoring.

Nursing Diagnoses

• Ineffective Tissue Perfusion, Placental, related to excessive bleeding causing fetal compromise

• Deficient Fluid Volume related to excessive bleeding

• Risk for Infection related to excessive blood loss and open vessels near cervix

• Anxiety related to excessive bleeding, procedures, and possible maternal-fetal complications

Nursing Interventions

Promoting Tissue Perfusion

• Frequently monitor mother and fetus. Pulse, respirations, and BP should be taken every 5 to 15 minutes in the presence of active bleeding or if the patient is unstable. After stabilization, vital signs should be taken every 30 to 60 minutes and every 4 hours during expectant management phase.

• Administer I.V. fluids, as prescribed.

• Position patient on her side to promote placental perfusion.

• Administer oxygen by face mask, as indicated.

• Prepare for emergency delivery and neonatal resuscitation, as needed.

Maintaining Fluid Volume

• Establish and maintain a large-bore I.V. line, as prescribed, and draw blood for type and screen/cross for blood replacement. Repeat type and screen every 72 hours while hospitalized—will depend upon patient’s condition.

• Draw blood for CBC, platelets, PT/PTT, fibrinogen, and type and cross for 4 units packed red blood cells (PRBCs), as directed, if profuse bleeding occurs or delivery is scheduled.

• Assist the patient to a sitting position to allow the weight of fetus to compress the placenta and decrease bleeding. Inspect bleeding every 1 to 2 hours when stable, or more frequently as indicated. Note character, color, and estimated amount of bleeding.

• Maintain strict bed rest during any bleeding episode.

• If bleeding is profuse and delivery cannot be delayed, prepare the woman physically and emotionally for a cesarean delivery.

• Administer blood or blood products protocol per your facility’s policy.

Preventing Infection

• Use aseptic technique when providing care.

• Evaluate temperature every 4 hours if membranes are intact; if ruptured membranes, hypothermia, or hyperthermia, evaluate temperature every 1 to 2 hours.

• Evaluate white blood cell (WBC) and differential count.

• Teach perineal care and hand-washing techniques.

• Assess odor of all vaginal bleeding or lochia.

Decreasing Anxiety

• Explain all treatments and procedures, and answer all related questions.

• Encourage verbalization of feelings by patient and family.

• Provide information on a cesarean delivery, and prepare patient emotionally.

• Inform the woman and her support persons that long-term hospitalization or prolonged bed rest may be necessary and inform them of the effects.

Community and Home Care Considerations

• Home care for patients with placenta previa and other antenatal bleeding disorders can occur if the following criteria are met:

• No active bleeding.

• No signs and symptoms of preterm labor (PTL).

• Home close to medical facility—maximum of 15 to 20 minutes away.

• Emergency support readily available.

• Teach the woman signs and symptoms of hemorrhage. Woman is to report to Labor and Delivery immediately if bleeding occurs.

• Monitor vaginal discharge and bleeding after each urination and bowel movement.

• Instruct the woman on doing home uterine activity monitoring (HUAM) daily by palpation or electronic telemetry units, if applicable.

• Instruct the woman on fetal movement counts (kick counts) to be performed on daily basis.

• Perform daily or twice weekly nonstress test (NST) or home visits and daily provider contact.

• Instruct the woman to have support persons readily available.

• Instruct the woman that there is to be nothing in the vagina. Discuss alternative methods of sexual gratification.

Patient Education and Health Maintenance

• Educate the woman and her family about the etiology and treatment of placenta previa.

• Educate the woman to inform medical personnel about her diagnosis and not to have vaginal examinations.

• Educate the woman who is discharged from the hospital with a placenta previa to avoid intercourse or anything per vagina, to limit physical activity, to have an accessible person in the event of an emergency, and to go to the hospital immediately for repeat bleeding or more that 6 uterine contractions per hour.

Evaluation: Expected Outcomes

• Fetal condition stable

• Absence of shock, stable vital signs, absence of bleeding

• Does not develop symptoms of an infection

• Verbalizes concerns and understanding of procedures and treatments

 

ABRUPTIO PLACENTAE

Abruptio placentae is premature separation of the normally implanted placenta before the birth of the fetus. It may be classified as partial, complete, or marginal. Hemorrhage can be either occult or apparent. With an occult hemorrhage, the placenta usually separates centrally, and a large amount of blood is accumulated under the placenta. When an apparent hemorrhage is present, the separation is along the placental margin, and blood flows under the membranes and through the cervix

Pathophysiology and Etiology

• Frequently, the etiology is unknown, but risks include:

• History of abdominal trauma.

• Maternal hypertension.

• Umbilical cord anomaly (eg, short umbilical cord); presence of a uterine anomaly or tumor.

• Increased parity (> 6).

• Advanced maternal age.

• Cigarette smoking.

• Cocaine or amphetamine abuse.

• Additional risks include multiple gestation, preterm premature rupture of membranes (PPROM) at less than 34 weeks’ gestation, uterine fibroids, previous abruptio placentae, and supine hypotension.

• Hemorrhage occurs into the decidua basalis, which then forms a hematoma. This hematoma can expand as the bleeding increases; the enlarged size of the hematoma further detaches the placenta from the uterine wall.

Clinical Manifestations

• Sudden onset, intense, localized, uterine pain/tenderness with (external) or without (occult) vaginal bleeding; however, approximately 10% of women present with only concealed hemorrhage.

• Uterine contractions may be low amplitude and high frequency. Uterine baseline resting tone may be elevated, making assessment of uterine activity difficult.

• Changes in the FHR may commonly be the first sign of maternal hemodynamic imbalance. The FHR may be increased (tachycardia) or decreased (bradycardia), or may demonstrate repetitive late decelerations or decreased or absent variability. Fetal response depends on the amount of blood loss and the extent of uteroplacental insufficiency present.

• Abdominal pain is commonly present due to increased uterine activity, although it is a less constant symptom than vaginal bleeding. Pain in mild cases may be difficult to distinguish from pain of labor contractions.

• Nausea and vomiting.

• Patient may exhibit signs and symptoms of rapid labor progress and delivery.

Diagnostic Evaluation

• Based on woman’s history, physical examination, laboratory studies, and signs and symptoms, including vaginal bleeding, abdominal pain, uterine contractions, uterine tenderness, fetal distress. Not all may be seen in every case.

• Ultrasound is done to exclude placenta previa, but is not always sensitive enough to either diagnose or rule out abruptio placentae.

• Laboratory screen for erythrocyte rosette on mother’s blood to check for fetal cells in the maternal circulation. Kleihauer-Betke acid elution tests have also been recommended to determine maternal-fetal hemorrhage by assessing maternal blood for the presence of fetal hemoglobin; however, the test has been found to be of little value in the general workup of patients with abruptio placentae.

Management

• Management depends on the maternal and fetal status and degree of bleeding; however, any patient with suspected abruptio placentae should be admitted immediately.

• Depends on maternal and fetal status.

• In fetal compromise, severe hemorrhage, coagulopathy, poor labor progress, or increasing uterine resting tone, emergent cesarean delivery is highly recommended.

• If the mother is hemodynamically stable and the fetus is stable (reassuring FHR tracing) or has already died in utero (intrauterine fetal demise), vaginal delivery may be recommended.

• If mother is not hemodynamically stable, she may need stabilization with I.V./blood/blood products replacement to maintain urine output at 30 to 60 mL/hour and hematocrit at least 30%. With rapid infusion of fluids, monitor woman for signs/symptoms of pulmonary edema.

• A neonatal specialty team is necessary at delivery due to prematurity and neonatal complications.

Complications

• Maternal shock

• DIC

• Anaphylactoid syndrome of pregnancy (formerly amniotic fluid embolism)

• Postpartum hemorrhage

• Acute respiratory distress syndrome

• Sheehan’s syndrome (postpartum pituitary necrosis)

• Renal tubular necroses

• Rapid labor and delivery

• Maternal death

• Prematurity

• Fetal death

Nursing Assessment

 

TABLE 39-2 Characteristics of Abruptio Placentae and Placenta Previa

CHARACTERISTIC ABRUPTIO PLACENTAE PLACENTA PREVIA Onset Third trimester Third trimester (commonly at 32-36 weeks) Bleeding May be concealed, external dark hemorrhage, or bloody amniotic fluid Mostly external, small to profuse in amount, bright red Pain and uterine tenderness Usually present; irritable uterus, progresses to boardlike consistency Usually absent; uterus soft Fetal heart tone May be irregular or absent Usually normal Presenting part May be engaged Usually not engaged Shock Moderate to severe depending on extent of concealed and external hemorrhage Usually not present unless bleeding is excessive Delivery Immediate delivery, usually by cesarean section Delivery may be delayed, depending on size of fetus and amount of bleeding

• Determine the amount and type of bleeding and the presence or absence of pain.

• Monitor maternal and fetal vital signs, especially maternal BP, pulse, FHR, and FHR variability.

• Palpate the abdomen

·       

 

• Note the presence of contractions and relaxation between contractions (if contractions are present).

• If contractions are not present, assess the abdomen for firmness.

• Measure and record fundal height to evaluate the presence of concealed bleeding.

• Prepare for possible delivery.

Nursing Diagnoses

• Ineffective Tissue Perfusion: Placental related to excessive bleeding, hypotension, and decreased cardiac output, causing fetal compromise

• Deficient Fluid Volume related to excessive bleeding

• Fear related to excessive bleeding, procedures, and unknown outcome

Nursing Interventions

Maintaining Tissue Perfusion

• Evaluate amount of bleeding by weighing all pads. Monitor CBC results and vital signs.

• Position in the left lateral position, with the head elevated to enhance placental perfusion.

• Administer oxygen through a snug face mask at 8 to 12 L/minute. Maintain oxygen saturation level above 90% by using pulse oximetry monitoring.

• Evaluate fetal status with continuous external fetal monitoring.

• Encourage relaxation techniques.

• Prepare for possible cesarean delivery if maternal or fetal compromise is evident.

Maintaining Fluid Volume

• Establish and maintain large-bore I.V. line for fluids and blood products as prescribed.

• Evaluate coagulation studies.

• Monitor maternal vital signs and contractions.

• Monitor vaginal bleeding, and evaluate fundal height to detect an increase in bleeding.

Decreasing Fear

• Inform the woman and her family about the status of herself and the fetus.

• Explain all procedures in advance when possible or as they are performed.

• Answer questions in a calm manner, using simple terms.

• Encourage the presence of a support person.

Patient Education and Health Maintenance

• Provide information to the woman and her family regarding etiology and treatment for abruptio placentae.

• Encourage involvement from the neonatal team regarding education related to fetal/neonatal outcome.

• Teach high-risk women the signs and symptoms of placental abruption and increased uterine activity.

• Instruct woman to report to Labor and Delivery immediately should excessive bleeding or pain occur at home.

• Instruct woman to have emergency plan in place for transport to medical facility expediently. It is important to have support persons aware of procedures as well.

Evaluation: Expected Outcomes

• FHR withiormal range, without a loss of variability

• Absence of shock, demonstrated by stable maternal vital signs after initiation of treatment

• Demonstrates concern; asks questions

HYPERTENSIVE DISORDERS OF PREGNANCY

Hypertensive disorders of pregnancy, which affect the placenta, are considered the most common medical complications of pregnancy, affecting 12% to 22% of all pregnancies.

 

Classification

Chronic Hypertension

 

Hypertension that is present and observable before pregnancy or that is diagnosed before the 20th week of gestation.

Preeclampsia and Eclampsia

• Preeclampsia—diagnosis is determined by increased BP accompanied by proteinuria.

• BP increases are either systolic BP greater than or equal to 140 mm Hg or diastolic BP greater than or equal to 90 mm Hg.

• Diastolic BP is determined as Korotkoff V (disappearance of sounds).

• Gestational hypertension is confirmed based on two determinations of no more than 1 week apart.

• Proteinuria is urinary excretion of greater than or equal to 0.3 g protein in a 24-hour specimen. A random test usually indicates greater than or equal to 30 mg/dL (1+ on dipstick); however, it is recommended that the diagnosis of proteinuria be determined by the 24-hour urine specimen method rather than the random test.

• Preeclampsia is categorized as mild or severe. Severe preeclampsia criteria include:

• Systolic BP of greater than or equal to 160 mm Hg or diastolic BP of greater than or equal to 110 mm Hg differentiate between mild and severe forms.

• Proteinuria of greater than or equal to 2 g in 24 hours (2+ to 3+ on qualitative examination).

• Increased serum creatinine (greater than 1.2 mg/dL).

• Persistent headache or cerebral or vision disturbances.

• Persistent epigastric pain.

• Platelet count less than 100,000/mm³ or evidence of microangiopathic hemolytic anemia (with increased lactic acid dehydrogenase).

• HELLP syndrome—

• Eclampsia—hypertension with seizures in a preeclamptic patient that cannot be contributed to an underlying neurologic condition. Note: Eclampsia was previously referred to as toxemia because it was thought to be caused by toxins. The term eclampsia is more commonly used.

Preeclampsia/Eclampsia Superimposed on Chronic Hypertension

• In women with hypertension and no proteinuria early in pregnancy (prior to 20 weeks’ gestation) and new-onset proteinuria, defined as greater than or equal to 0.3 g protein in a 24-hour specimen.

• In women with hypertension and proteinuria before 20 weeks’ gestation

• Sudden increase in proteinuria—greater than or equal to 0.3 g protein in 24-hour specimen, or two dipstick tests of 2+ (100 g/dL), with values recorded at least 4 hours apart, with no evidence of urinary tract infection (UTI).

• Sudden increase in BP in a woman whose BP was previously well controlled.

• Thrombocytopenia (platelet count less than 100,000/mm³).

• Increase in ALT or AST to abnormal levels.

Gestational Hypertension

• BP elevation detected for first time in pregnancy, without proteinuria. This classification includes:

• Women with preeclampsia syndrome who have not yet manifested proteinuria

• Women who do not have the syndrome

• Final differentiation as to whether the woman had preeclampsia syndrome is determined postpartum.

• If she does not develop preeclampsia and her BP has returned to normal by 12 weeks postpartum, the woman is given the diagnosis of transient hypertension of pregnancy.

• However, if her BP remains elevated after 12 weeks’ postpartum, the woman is given the diagnosis of chronic hypertension.

Therefore, the diagnosis of gestational hypertension is used during pregnancy only until a more definitive and specific diagnosis can be made during the postpartum period.

 

Pathophysiology and Etiology

• Actual cause is unknown.

• Theories of the etiology include the exposure to chorionic villi for the first time, or in large amounts, along with immunologic, genetic, and endocrine factors.

• The disease is more commonly seen in primigravidas.

• Chronic hypertension, hydatidiform mole, multiple gestation, polyhydramnios, preexisting vascular disease, obesity, and diabetes mellitus may predispose a patient to preeclampsia.

• Adolescents (younger than age 17) and women older than age 35 are at higher risk.

• Multisystem disease with widespread vasospasms occur and result in increased resistance in vascular flow, increasing the arterial BP and causing endothelial damage. Stimulates platelet and fibrinogen use, causing hypoxic damage to vulnerable organ systems.

• Increased sensitivity to angiotensin II occurs before the onset of hypertension.

• Hemoconcentration occurs due to the vasoconstriction or as a result of increased vascular permeability or a combination of both. Will see increased hematocrit (not consistent with normal pathophysiology of pregnancy where hematocrit decreases).

• Decreased placental production of prostacyclin and increased thromboxane A₂.

HELLP Syndrome

HELLP syndrome—consisting of Hemolysis of RBCs, Elevated Liver enzymes, and Low Platelets (<100,000 mm³)—is a severe complication of pregnancy-induced hypertension.

• These findings are frequently associated with disseminated intravascular coagulation (DIC) and, in fact, may be diagnosed as DIC.

• The hemolysis of erythrocytes is seen in the abnormal morphology of the cells.

• The elevated liver enzyme measurement is associated with the decreased blood flow to the liver as a result of fibrin thrombi.

• The low platelet count is related to vasospasm and platelet adhesions.

• Treatment is similar to treatment for preeclampsia with close monitoring of liver function and bleeding.

• These women are at increased risk for postpartum hemorrhage.

• Complaints range from malaise, epigastric pain, and nausea and vomiting to nonspecific viral syndromelike symptoms

Clinical Manifestations

• Elevated BP

• Mild preeclampsia—systolic BP greater than 140 mm Hg or diastolic BP greater than 90 mm Hg.

• Severe preeclampsia—systolic BP greater than 160 mm Hg or diastolic BP greater than 110 mm Hg.

• Proteinuria

• Mild preeclampsia—greater than 0.3 g/24 hour specimen (1+ on qualitative assessment [urine dipstick]).

• Severe preeclampsia proteinuria—2 g in 24 hours (2+ to 3+ on qualitative examination).

• Other symptoms in severe preeclampsia:

• Increased serum creatinine (> 1.2 mg/dL)

• Persistent headache or cerebral or visual disturbances (altered level of consciousness [LOC], headache, scotomata, or blurred vision).

• Hyperreflexia—deep tendon reflexes (DTRs) increased (3+ to 4+)/clonus (> 2 beats).

• Persistent epigastric pain. May have impaired liver function of unclear etiology (may be due to decreased hepatic function).

• Platelet count less than 100,000/mm³ or evidence of microangiopathic hemolytic anemia (with increased lactic acid dehydrogenase)

• Eclampsia—seizures or coma without neurologic or febrile origin in patient with preeclampsia; third trimester and 48 hours postpartum are most common times for occurrence

Diagnostic Evaluation

• A 24-hour urine for protein of more than 0.3 g (mild); more than 2.0 g (severe).

• Serum BUN, serum creatinine, and serum uric acid to evaluate renal function and glomerular filtration capability, specifically creatinine clearance, uric acid clearance, and urea clearance.

• Liver function tests (AST, ALT).

• Coagulation studies, specifically platelets, antithrombin III, and factor VIII levels.

• Lipid panel to assess high-density lipoprotein (HDL) and low-density lipoprotein (LDL); HDL levels are decreased in preeclamptic women whereas LDL levels are elevated.

• Sonogram, NST to evaluate placenta and fetus

• DTRs and clonus evaluation to assess level of disease process

• BP changes meeting criteria for diagnosis

Management

Directed toward decreasing the maternal BP through the use of inpatient hospitalization or conservative management and antihypertensive medications along with increase in dietary protein and an increase in calories, if indicated. Delivery is appropriate therapy; however, delivery may endanger the fetus due to fetal lung immaturity.

• Expectant management (wait and watch) can be considered if the following maternal and fetal factors are present:

• Controlled hypertension

• Urinary protein of any amount

• Oliguria (< 0.5 mL/kg/hour) that resolves with routine fluid/food intake

• AST or ALT greater than 2 times upper limit of normal without epigastric pain or right upper quadrant (RUQ) tenderness

• Biophysical profile (BPP) more than 6

• Amniotic fluid index (AFI) more than 2 cm

• Ultrasound fetal weight more than 5th percentile

• Delivery should be achieved within 72 hours if any of the following occur:

• Uncontrolled hypertension

• Eclampsia

• Platelet count less than 100,000/mm³

• AST or ALT more than two times upper limit of normal with epigastric or RUQ tenderness

• Pulmonary edema

• Compromised renal function

• Abruptio placentae

• Persistent severe headache or visual changes

• Repetitive late or nonreassuring variable decelerations

• BPP less than 4 on two occasions 4 hours apart

• AFI less than 2 cm

• Ultrasound estimated fetal weight < 5th percentile

• Reverse umbilical artery diastolic flow

Pharmacologic Therapies

• Magnesium sulfate (MgSO₄) may be given either I.V. or I.M. The I.V. route is preferred; I.M. administration is reserved for eclamptic patients without I.V. access.

• A 4- to 6-g loading dose of 50% MgSO₄ is usually given I.V. over 15 to 30 minutes followed by a maintenance dose (secondary infusion) of 2 to 3 g/hour.

• The therapeutic level for magnesium sulfate is a serum level of 4 to 7 mEq/dL).

• Actions: decreases neuromuscular irritability and blocks the release of acetylcholine at the neuromuscular junction; depresses vasomotor center; depresses central nervous system (CNS) irritability.

• Phenytoin (Dilantin), although proposed for eclampsia prophylaxis, is not a first-line therapy in the United States.

• If seizures develop and the patient is not on MgSO₄, 2 g may be given I.V. every 15 minutes to a maximum of 6 g. If the patient is already on MgSO₄, then give 1 to 2 g I.V. and continue to check magnesium levels to assess toxicity/therapeutic levels.

• If seizures continue, paralytic agents may be necessary and the patient may require mechanical ventilation.

• Calcium gluconate is kept at bedside (but must remain secure) as a reversal agent for magnesium toxicity.

• Dosage is 1 g (10 mL of 10% solution) by slow I.V. push.

• Signs of MgSO₄ toxicity include loss of deep tendon reflexes, including knee-jerk reflex, respiratory depression, oliguria, respiratory arrest, and cardiac arrest.

Antihypertensive Drug Therapy

 

May be used when the diastolic pressure reaches or exceeds 105 mm Hg or when cerebrovascular accident is impending. The goal of antihypertensive therapy is to reduce the BP to a level that will provide the mother with a margin of safety (95 to 100 mm Hg) without compromising adequate uterine perfusion.

• Hydralazine (Apresoline) is the drug of choice.

• Hydralazine relaxes the arterioles and stimulates cardiac output via direct peripheral vasodilation.

•  

• Dosage: 5 mg I.V. push followed by 5 mg I.V. or 10 mg I.M., given 5 to 10 mg every 20 to 30 minutes to a maximum dose of 20 mg (I.V.) to 30 mg (I.M.).

• Onset of action can occur in 10 to 20 minutes, with peak action in 20 minutes after administration; duration of the drug can last from 3 to 8 hours.

• If desired response not obtained after 20 to 30 mg, change agents and consider hemodynamic monitoring.

• Adverse effects of hydralazine include flushing, headache, maternal and fetal tachycardia, palpitations, uteroplacental insufficiency with subsequent fetal tachycardia, late decelerations, and worsening hypertension (if hypertension due to elevated cardiac output). Rebound hypotension is possible if drug given too rapidly.

• Labetalol (Normodyne)—used in place of hydralazine.

• Contraindicated in women with asthma, heart failure and/or second- or third-degree heart block.

• Alpha/beta-adrenergic blocker that decreases systemic vascular resistance without reflex tachycardia; it slows the maternal heart rate. Cardiac monitoring is required.

• Administered either I.V. bolus or titrated drip.

• If I.V. bolus: initial dose 20 mg; if effect is suboptimal after 10 minutes, give 40 mg I.V.; if effect is still suboptimal after a subsequent 10 minutes, then give 80 mg I.V. for two additional doses.

• Maximum dose is 220 mg.

• Onset of action is 1 to 2 minutes, with peak of action at 10 minutes, and duration of drug effect lasting 6 to 16 hours.

• Adverse effects of labetalol include transient fetal and neonatal hypotension, bradycardia, and hypoglycemia. Small doses excreted in breast milk.

• Alpha-methyldopa (Aldomet)

• Safe and well tested; however, it has a delayed onset of 4 to 6 hours even with I.V. administration, limiting its usefulness for hypertensive emergencies.

• Can cause somnolence (sleepiness) in some patients.

• Nifedipine (Procardia)

• Calcium channel blocker that decreases BP by blocking the intracellular pathways of calcium movement causing smooth muscle relaxation and vasodilatation.

• Onset of action occurs in 5 to 19 minutes, with peak action occurring in 10 to 20 minutes, and duration of effect lasting 4 to 8 hours.

• Adverse effects include hypotension, palpitations, nausea, headache, fetal acidosis related to uteroplacental insufficiency.

• Sodium nitroprusside (Nipride)—potent, short-acting, direct vasodilator; used only when all other agents have failed and the patient has life-threatening hypertension.

• Given in titrated drip only with onset of action occurring in 15 to 30 seconds.

• Initial dose started at 0.25 mcg/kg/minute and titrate to desired effect.

• Maintenance dose is increased by 0.25 mcg/kg/minute every 5 minutes.

• Average dose is 3 mcg/kg/minute with the range being 0.5 to 10 mcg/kg/minute.

• Onset of action occurs in 30 seconds to 2 minutes, with peak action occurring in 1 to 2 minutes and duration of effect lasting 3 to 5 minutes.

• Actions: potent vasodilator with direct effect on arterial and venous smooth muscle.

• Adverse effects include nausea, diaphoresis, anxiety, headache, bradycardia, electrocardiogram (ECG) changes, tachycardia, raised intracranial pressure, decreased reflexes, blurred vision, crosses placenta, and cyanide toxicity.

• Dilute in dextrose 5% in water (D₅W) only, and do not mix with any other drug.

• Continuous BP monitoring with arterial line and ECG monitoring, along with central hemodynamic monitoring should be considered.

• Arterial blood gas (ABG) levels need to be monitored for metabolic acidosis, which may be an early sign of cyanide toxicity.

• Nitroglycerin—indicated for hypertension refractory to conservative pharmacologic therapy.

• Dosage: initial dose is 5 to 10 mcg/min; subsequent doses titrated to the desired response by increasing the dose 5 mcg/min every 3 to 5 minutes.

• Actions: relaxes predominantly venous, but also arterial, vascular smooth muscle; decreases preload at low doses and afterload at high doses.

• Must be diluted before administration in D₅W or normal saline (NS).

• Requires central hemodynamic monitoring (central venous pressure [CVP], pulmonary artery pressure, and pulmonary artery wedge pressure).

• FHR variability may be decreased with this drug, and fetal stress may occur when mean arterial pressure (MAP) is greater than 106 mm Hg.

• Hypovolemia must be corrected before use.

• Adverse effects include hypotension, tachycardia, nausea, vomiting, pallor, sweating, headache, flushing of skin, methemoglobinemia (with I.V. doses greater than 7 mcg/kg/minute).

Correction of Hypovolemia

• Correct hypovolemia before initiation of antihypertensive therapy.

• Avoid abrupt and usually profound drops in BP.

• Maintain diastolic BP between 95 and 100 mm Hg diastolic to maintain uteroplacental perfusion.

Complications

Complications of preeclampsia affect many body systems, including cardiovascular, renal, hematologic, neurologic, hepatic, and uteroplacental systems.

• Abruptio placentae

• DIC

• HELLP syndrome

• Maternal or fetal death

• Hypertensive crisis

• Pulmonary edema; cerebral edema

• Oliguria; acute renal failure

• Thrombocytopenia

• Hemorrhage; stroke

• Blindness

• Fetal intolerance of labor

• Hypoglycemia

• Hepatocellular dysfunction; hepatic rupture

• Prematurity

• Intrauterine growth restriction (IUGR) from decreased placental perfusion

Nursing Assessment

• Evaluate BP using the correct size cuff and same arm for each measurement. The sitting position is recommended with the (preferably right) arm supported in a horizontal position at the level of the heart. In the side-lying position, the dependent arm should be used, but the patient should not be lying on it.

• Check the protein level of a spot urine specimen and initiate a 24-hour urine specimen.

• Measure weight daily when the patient is stable.

• Evaluate DTRs and clonus.

• Evaluate fetal status with NST, fetal movement (kick) counts, BPP, and contraction stress test (CST) via nipple stimulation or oxytocin challenge test (OCT).

• Evaluate uterine activity for high-frequency, low-intensity uterine contractions.

• Observe for signs and symptoms of disease escalation.

• Monitor for signs of MgSO₄ toxicity—absent knee-jerk reflex, respiratory depression, oliguria. Discontinue MgSO₄, and notify health care provider

• Serum magnesium level every 6 to 8 hours per your facility’s policy.

Nursing Diagnoses

• Excess Fluid Volume related to pathophysiologic changes of gestational hypertension and increased risk of fluid overload

• Ineffective Tissue Perfusion: Fetal Cardiac and Cerebral related to altered placental blood flow caused by vasospasm and thrombosis

• Risk for Injury related to seizures or to prolonged bed rest or other therapeutic regimens

• Anxiety related to diagnosis and concern for self and fetus

• Deficient Diversional Activity related to prolonged bed rest

• Decreased Cardiac Output related to decreased preload or antihypertensive therapy

Nursing Interventions

Maintaining Fluid Balance

• Control I.V. fluid intake using a continuous infusion pump.

• Monitor intake and output strictly; notify health care provider if urine output is less than 30 mL/hour.

• Monitor hematocrit levels to evaluate intravascular fluid status.

• Monitor vital signs every hour.

• Auscultate breath sounds every 2 hours, and report signs of pulmonary edema (wheezing, crackles, shortness of breath, increased pulse rate, increased respiratory rate).

Promoting Adequate Tissue Perfusion

• Position on side to promote placental perfusion.

• Monitor fetal activity.

• Evaluate NST to determine fetal status.

• Increase protein intake to replace protein lost through kidneys.

Preventing Injury

• Instruct on the importance of reporting headaches, visual changes, dizziness, and epigastric pain.

• Instruct to lie down on left side if symptoms are present.

• Keep the environment quiet and as calm as possible.

• If patient is hospitalized, side rails should be padded and remain up to prevent injury if seizure occurs.

• If patient is hospitalized, have oxygen and suction setup, along with a tongue blade and emergency medications, immediately available for treatment of seizures.

• Assess DTRs and clonus every 2 hours. Increase frequency of assessment as indicated by patient’s condition.

Decreasing Anxiety and Increasing Knowledge

• Explain the disease process and treatment plan including signs and symptoms of the disease process.

• Explain that preeclampsia does not lead to chronic hypertension.

• Discuss the effects of all medications on the mother and fetus.

• Allow time to ask questions and discuss feelings regarding the diagnosis and treatment plan.

Promoting Diversional Activities

• Explain the need for bed rest to the woman and her support persons.

• Explore woman’s hobbies/diversional activities.

• Instruct family to arrange for easy access to TV, phone, computer, and stereo to limit woman getting out of bed.

• Instruct family to arrange for community support (eg, church, women’s groups).

Maintaining Cardiac Output

• Control I.V. fluid intake using a continuous infusion pump.

• Monitor intake and output strictly; notify primary care provider if urine output is less than 30 mL per hour.

• Monitor maternal vital signs, especially mean BP and respirations.

• Assess edema status, and report pitting edema of ≥ +2 to primary care provider.

• Monitor oxygenation saturation levels with pulse oximetry. Report oxygenation saturation rate of less than 90% to primary care provider.

Community and Home Care Considerations

Mild preeclampsia may be treated at home.

• Ensure that patient meets criteria set forth by ACOG for home management:

• Gestational age more than 20 weeks.

• BP less than 150/100 mm Hg sitting position or less than 140/90 mm Hg lateral position.

• No headache or visual disturbances present.

• No epigastric pain, marked edema, clonus, or DTRs greater than +2.

• Must have available BP equipment.

• Ensure that patient has daily phone contact with primary care provider.

• Make periodic home visits, either daily or twice weekly.

• Teach woman signs and symptoms of disease progression.

• Teach woman at-home BP monitoring for two to four times daily in the same arm and the same physical position (eg, on left side, on right side).

• Obtain daily weights at the same time each day.

• Assess urine protein status daily on the first voided urine or obtain 24-hour urine each week.

• Teach woman to assess daily fetal movement (kick) counts; arrange for weekly NST.

Patient education and Health Maintenance

• Teach the woman the importance of bed rest in helping to control symptoms.

• Encourage the support of family and friends while on bed rest.

• Provide and suggest diversional activities while on bed rest.

• Provide information on tests and procedures to evaluate maternal-fetal status, such as laboratory tests, sonogram, NST.

• Include support of the neonatal team for discussion of fetal prognosis with the woman and her family.

Evaluation: Expected Outcomes

• No evidence of pulmonary edema; urine output adequate

• FHR withiormal range; reactivity present

• No seizure activity

• Expresses concern for self and the fetus

• Maintaining bed rest and pursuing diversional activities

• BP and other vital parameters stable