ANTENATAL COMPLICATIONS

Abortion

• Interruption of pregnancy before the age of VIABILITY (20 weeks)

Spontaneous Abortion

• Causes
• Abnormal fetal formation
• Low progesterone levels
• Implantation abnormalities
• Infection
• Teratogens
• Signs and Symptoms
• VAGINAL SPOTTING

Threatened Abortion

• Unexplained scant bright red vaginal bleeding
• No cervical dilatation
• Most common cause of 1st trimester bleeding
• Nursing Care
• Avoid strenuous activity
• No coitus for 2 weeks

Imminent/Inevitable Abortion

• Bleeding with cervical dilation and uterine contractions
• Treatment
• Save any tissue fragments discharged for later examination
• If no FHT is detected, D&C is performed to remove conceptus

Complete Abortion

• All of conceptus is expelled without any assistance; profuse bleeding which stops after a few days
• Treatment
• Go directly to hospital for assistance
• Fragments of conceptus may be checked to prevent further bleeding
• Oxytocin or methergine to stop bleeding

Incomplete Abortion

• Part of the conceptus is expelled, usually the fetus, and the placenta and membranes are left
• Treatment
• Dilatation and Curettage (D&C)
• Make sure the woman knows that the pregnancy is already lost

Missed Abortion

• The fetus dies but is not expelled
• Treatment
• Dilatation and Curettage (D&C)
• Make sure the woman knows that the pregnancy is already lost
• MISOPROSTOL (Cytotec) - to dilate cervix and stop bleeding

Habitual Abortion

• Also known as Recurrent Pregnancy Loss; 3 spontaneous miscarriages at roughly the same gestational age
• Causes
• Defective sperm or ova
• Endocrine disorders
• Uterine defects
• Infections
• Autoimmune disorders

Induced Abortion

• Artificial induction of abortion via mechanical or chemical means

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Ectopic Pregnancy

• Implantation of the zygote outside the uterine cavity; most commonly on the ampullar region of the Fallopian tube
• Causes
• Salpingitis - may cause scarring of Fallopian tube and subsequent blockage
• PID
• Use of IUD
• Smokers
• Uterine tumors
• Signs and Symptoms
• Bleeding during 6-12 weeks
• SHARP STABBING PAIN
• CULLEN’S SIGN – bluish tinge on the umbilicus
• Falling hCG
• Shock
• Treatment
• Ligation of bleeding vessels
• Unilateral salpingectomy
• METHOTREXATE FOLLOWED BY LEUCOVORIN - to destroy remaining tissue
• Mifepristone - to induce labor

Abdominal Pregnancy (Ectopic)

• Growth of the fetus outside of the uterus
• Signs and Symptoms
• Fetal outline easily palpable directly below the abdominal wall and not inside the uterus

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Hydatidiform Mole / Gestational Trophoblastic Disease

• the abnormal proliferation and degeneration of trophoblastic villi
• Most common cause of 2nd trimester bleeding
• Complete Mole - trophoblastic villi swell and become cystic, “empty ovum” was fertilized; usually lead to choriocarcinoma
• Partial Mole - some of the trophoblastic villi form normally but is swollen and misshapen, has 69 chromosomes; usually doesn’t lead to choriocarcinoma
• Causes
• Asians
• Low protein intake
• Older than 35 years of age
• Signs and Symptoms
• Elevated hCG
• High weight gain for gestational age
• No FHT
• Discharge of clear fluid filled vesicles
• Treatment
• No pregnancy for 12 months
• Let mother express concerns, feelings and emotions
• o METHOTREXATE FOLLOWED BY LEUCOVORIN - to destroy remaining tissue
• o Dactinomycin - alternative to methotrexate

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Hyperemesis Gravidarum

• Projectile vomiting during pregnancy
• Causes
• Increased levels of hCG
• Treatment
• Monitor I&O
• TPN
• IV fluid replacement
• Soft diet
• Antiemetics – METOCLOPRAMIDE (Plasil, Reglan)

	Hyperemesis Gravidarum	Morning Sickness
Skin Color	yellow, jaundiced	normal
Duration	Exceeds 1st trimester	1st-2nd trimester
Skin Turgor	dehydrated	hydrated
Electrolytes	abnormal	normal

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Incompetent Cervix

• Also known as Premature Cervical Dilation
• Signs and Symptoms
• Pink show
• Painless dilation
• Treatment
• CERVICAL CERCLAGE – MCDONALD (taped) & SHIRODKAR (sutured) TECHNIQUE
• Modified Trendelenburg position

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Placenta Previa & Abruptio Placenta

• Types of Placenta Previa
• Low - placenta is in close proximity to the cervical os
• Partial - placenta covers a portion of the cervical os
• Total - placenta completely covers cervical os
• Degrees of Separation (Abruptio Placenta)
• 0 - no separation
• 1 - minimal separation, no fetal distress, vaginal bleeding
• 2 - moderate separation, fetal distress, uterus is tense and painful
• 3 - extreme separation, no immediate intervention, shock, death
• Treatment
• NO VAGINAL EXAMS
• Amniocentesis to assess fetal lung maturity
• BETAMETHASONE – to improve lecithin:sphingomyelin ratio of lung surfactants

	Abruptio Placenta	Placenta Previa
Skin Color	painful	painless
Blood Color	dark	bright red
Amount of Bleeding	profuse	scant
Palpation	board-like, rigid, tender	soft, boggy, not tender

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Pregnancy-Induced Hypertension (PIH)

• Signs and Symptoms
• HYPERTENSION
• EDEMA
• PROTEINURIA
• Treatment
• Bed rest
• Nutritious Diet
• Care During Seizures
• Place pillow under head
• Raise side rails
• Side-lying position
• No sudden stimuli
• NPO
• MAINTAIN PATENT AIRWAY

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Mild Preeclampsia (PIH)

• Signs and Symptoms
• BP 140/90
• Proteinuria +1 to +2
• Edema on face and upper extremities

Severe Preeclampsia (PIH)

• Signs and Symptoms
• BP 160/110
• Proteinuria +3 to +4
• Extreme edema on face and hands
• Hyperreflexia and ankle clonus

Eclampsia (PIH)

• Signs and Symptoms
• Seizures
• Signs and symptoms of preeclampsia
• Stages of Tonic-Clonic Seizures
• Tonus – muscles of the body contract and stiffen
• Clonus – muscles contract and relax repeatedly and limbs flail wildly
• Post-ictal state – in a semicomatose state
• Drug of Choice
• MAGNESIUM SULFATE

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HELLP Syndrome

• Hemolysis, Elevated Liver enzymes, Low Platelet
• Signs and Symptoms
• Nausea
• Epigastric pain
• General malaise
• Right upper quadrant tenderness
• Thrombocytopenia
• Treatment
• Platelet transfusion
• IV Dextrose

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Multiparity

• Signs and Symptoms
• Elevated alpha-fetoprotein
• Faster rate of increase in size of uterus
• Multiple FHT
• Nursing Care
• Bed rest
• Cesarean section upon delivery

Fetal Death

• No FHT
• MISOPROSTOL w/ OXYTOCIN - to induce labor and stop bleeding

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Hydramnios

• Amniotic fluid more than 2000mL
• Normal amount: 500-1000mL
• Signs and Symptoms
• Unusual rapid enlargement of uterus
• Shortness of breath
• Weight gain
• Varicosities
• Tx
• Bed rest
• Stool softeners
• Amniocentesis

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Post Term Pregnancy

• Exceeds 42 weeks of gestation
• Treatment
• Cesarean section
• Assessment of maturity
• Labor induction
• Treatment
• MISOPROSTOL - induces labor
• PROSTAGLANDIN E1 - induces labor
• Oxytocin - induces labor

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Preterm Labor

• Labor before the 37th week of gestation
• Causes
• Chorioamnionitis
• Other infections
• Incompetent cervix
• Signs and Symptoms
• Early uterine contractions
• Rx
• Tocolytics - MAGNESIUM SULFATE - halts contractions
• BETAMETHASONE IM q24h 12mg - improves lung surfactant ratio
• DEXAMETHASONE IM q12h 6mg - improves lung surfactant ratio
• β-sympathomimetic drugs - TERBUTALINE & RITODRINE - halts contractions

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TORCH Complex

• Toxoplasmosis, Other infections, Rubella, Cytomegalovirus, Herpes Simplex
• Vaccination, Antibiotics, and Cesarean Section

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PROM (Premature Rupture of Membranes)

• Rupture of fetal membranes with loss of amniotic fluid during pregnancy before 37 weeks
• Signs and Symptoms
• Blue Nitrazine test result
• Sudden gush of clear fluid
• Treatment
• FIBRIN-BASED SEALANT - glues membranes
• AMNIOINFUSION - infusion of fluid into amniotic sac
• Bed rest - reduces fluid loss
• Antibiotics - prophylactic measure for infection

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Rh Incompatibility

• Also known as Isoimmunization
• Develops when Rh- mother with Rh+ baby
• Baby may develop erythroblastosis fetalis - maternal antibodies destroy the Rh+ fetal RBC
• The destruction of red blood cells from erythroblastosis fetalis releases large amounts of unconjugated bilirubin leading to a condition known as kernicterus, wherein the unconjugated bilirubin is deposited in the brain and damages it
• Caused when the father is Rh+
• Appears as Coombs’ Test Negative
• Treated with RhoGam

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DIC (Disseminated Intravascular Coagulation)

• Fibrinogen levels fall below effective limits
• Extreme bleeding at one site because most of the fibrin and platelets rush to another area; not enough is left for the rest of the body especially at the site of implantation
• Signs and Symptoms
• Easily bruised
• Treatment
• HEPARIN