The Woman Who Develops a

Complication of Pregnancy
 Nursing care for the well, pregnant woman focuses on
preventing illness by promoting an especially healthy
lifestyle.
 When accidents and illness occurs despite these
safeguards, nursing care focuses on:

a. Preventing such disorders from affecting the

health of the fetus.
b. Helping a woman regain her health as quickly as
possible so she can continue a healthy pregnancy
and prepare herself psychologically and physically
for labor and birth and the arrival of her newborn.
c. Helping a woman learn more about her chronic
illness so she can continue to safeguard her health
during her childrearing years
Nursing Process Overview
Assessment:
 Objective Data

 Subjective Data
Nursing Diagnosis:
 Anxiety related to guarded pregnancy
outcome

 Deficient fluid volume related to third-

trimester bleeding
 Risk for infection related to incomplete
miscarriage

 Ineffective tissue perfusion related to

hypertension of pregnancy

 Deficient knowledge related to signs &

symptoms of possible complications
Outcome Identification & Planning
Emergency: short time frame

 Address fetal, maternal, & family

welfare
Once condition stabilizes: long term
objectives

 Pregnancy should come to term

 Prevent new complications
Implementation:
Interventions should maintain:
 Healthy fetal growth
 Maternal physical health
 Woman’s & family’s psychological
health
 Pregnancy duration as long as possible
Outcome evaluation:
Outcome should be evaluated
throughout pregnancy.

 Evaluate woman’s psychological

attitude & physical status at each visit
 IDENTIFYING A HIGH RISK PREGNANCY

A high risk pregnancy is one in which a

concurrent disorder, pregnancy related
complication, or external factor jeopardizes the
health of the woman, the fetus or both.
Factors that categorize a pregnancy
as High Risk
 A. Psychological – hx of intimate partner abuse, mental
illness, loss of support system, lack of preparation for
labor.
 B. Social
Occupation – handling toxic substances; radiation;
anesthesia gases, low economic level, neglected
prenatal care, lack of access to emergency
personnel or equipment and continued health
care.
 C. Physical – pelvic inadequacy, poor obstetric history,
PIH, infection, Amniotic Fluid abnormality,
hemorrhage, laceration, CPD.
Antepartum Hemorrhage
 refers to hemorrhage that occurs anytime
during pregnancy.

 Early antepartum hemorrhage

 Late antepartum hemorrhage

Intapartum Hemorrhage – hemorrhage that occurs
during labor and is commonly due to:

Placental abruption, uterine rupture, uterine

inversion, abnormal adhesions of the
placenta and CS complications.

Postpartum Hemorrhage – defined as blood loss greater

than 500ml in vaginal delivery or 1000ml in CS birth.
Primary causes of Bleeding
First trimester :
 Abortion
 Ectopic (tubal) Pregnancy
Second trimester
 Hydatidiform mole (Gestational
Trophoblastic disease)
 Premature cervical dilatation or
Incompetent cervix
Third trimester
 Placenta previa
 Abruptio placenta
 HEMORRHAGE
 Rapid loss of more than 1% of body weight in blood.
 Rapid loss results in:
> inadequate tissue perfusion
> deprivation of glucose and oxygen in the tissues
> build up of waste products
 HYPOVOLEMIC SHOCK occurs when bleeding
results in blood loss amounting to 1.5 to 2 liters.
Process of hypovolemic shock :
↓
Blood Loss intravascular
volume

↓ venous return ↑ HR,

vasoconstriction,
↓ cardiac output
↑ RR, feeling of
↓ BP apprehension
 Cold, clammy ↓ renal, uterine,
skin, ↓ uterine & brain
perfusion , ↓ BP perfusion

Lethargy,
coma, ↓ renal Renal failure
output

Maternal &
Fetal death
Signs of Hypovolemic Shock:
 ↑ HR – heart attempting to circulate ↓
blood volume

 ↓ BP – less peripheral resistance because

of ↓ blood volume
 ↑ RR - ↑ gas exchange to better oxygenate
↓ red blood cell volume.

 Cold, clammy skin – vasoconstriction

occurs to maintain blood volume in
central body core.
 ↓ urine output – inadequate blood
entering kidney due to ↓ blood volume.

 Dizziness or ↓ level of consciousness –

inadequate blood is reaching cerebrum
due to ↓ blood volume.
 ↓ central venous pressure - ↓ blood is
returning to heart due to reduced blood
volume.
Therapy: aimed at restoring blood
volume & halting source of
hemorrhage.
Conditions Associated with
First-Trimester Bleeding
ABORTION
Abortion
 Medical term for any
interruption of pregnancy
before fetus is viable.
 A viable fetus is usually defined
as a fetus of >20-24wks AOG or
one that weighs at least 500g.
Abortion

 Occurs in 15% to 30% of all

pregnancies & from natural causes.
Early Abortion Late Abortion

 Occurs before 12  Occurs between

weeks of 12 to 20 weeks of
pregnancy pregnancy
Types of Abortion:
 Elective abortion or therapeutic abortion
>planned medical termination of pregnancy as
recommended by the HCP to protect the mothers
physical or mental health
>initiated by personal choice

 Spontaneous Abortion refers to the loss of a fetus

during pregnancy due to natural
causes.(MedlinePlus Medical Encyclopedia, 2002)
Causes of Spontaneous Abortion :
Fetal causes:
> abnormal fetal formation due to
either teratogenic factor or to a
chromosomal aberration. (50-90%)
Maternal causes:
1. advanced maternal age, especially after 35 years of
age.
 below 35 yo, 15% abortion rate
 between 35-39 yo, 20-25% abortion rate
Between 40-42 yo, about 35% abortion rate
Above 42 yo, about 50% abortion rate.
2. Structural abnormalities of the reproductive tract
such as:

>congenital uterine defects particularly uterine

septum
>Fibroids
>cervical incompetence
3. Insufficient production of
progesterone

4. Maternal Infections: Rubella virus,

Syphylis, cytomegalovirus and
toxoplasmosies, UTI.

[Link] of teratogenic drug

(isotretinoin, accutane)
5. Chronic and systemic maternal diseases:

> polystic ovary syndrome

> poorly controlled diabetes mellitus
> renal diasease
> Systemic Lupus Erythematosus (SLE)
> untreated thyroid disease
> severe hypertension
6. Exogenous factors include the following:

> Tobacco
> Alcohol
> Cocaine
> Caffeine (high doses)
> Radiation
Assessment
 Vaginal spotting – presenting symptom
of abortion.

 Inform woman to call her HCP at first

sign of vaginal spotting.
Assessment factor:
 Confirmation of pregnancy
 Pregnancy length
 Duration of bleeding
 Intensity of blood flow
 Description of type of blood
Therapeutic management:
 Physician or nurse- midwife will
decide, depending on symptoms &
description of bleeding.
Types of Spontaneous
Abortion
[Link] Abortion
Threatened Abortion
Symptoms
 Vaginal spotting
 Initially scant & usually bright red.
 Perhaps slight cramping, but no
cervical dilatation
Diagnosis
 FHT / UTZ test is done to check
viability of fetus.

 hCG hormone blood test

Management
 Avoidance of strenuous activity for 24
to 48 hours

 Complete bed rest

 Provide emotional support

 Provide counseling

 Coitus is restricted for 2 weeks after

bleeding episode
 50% continue pregnancy

 50% proceed to imminent / inevitable

2. Imminent (Inevitable) Abortion
Imminent or inevitable Abortion
 Uterine
contractions

 Cervical
dilatation
occur
Diagnosis
 FHT / UTS test

 Examine tissue fragments brought by

pt from home & passed from labor
room ( D&E)
Management
 D & E (Dilatation & Evacuation)
 Inform pt about procedure & its
rationale
After D&E
 Assess vaginal bleeding

“1 pad / hour = abnormally heavy

bleeding”
3. Complete Abortion
 Entire POC are expelled spontaneously
w/o assistance
 Bleeding usually slows w/n 2 hours
 Ceases w/n few days after POC passage
4. Incomplete abortion
Incomplete Abortion
 Part of POC is expelled
 Membrane or placenta is retained in
uterus
 Maternal hemorrhage may happen
Management
 Dilatation & Curettage (D&C) / suction
curettage
 Inform woman about procedure & its
rationale
5. Missed Abortion
Missed Abortion
 Retention of all POC after the death of
fetus in the uterus.
 Signs of pregnancy disappears.
May have painless vaginal bleeding or
no symptoms at all.
Diagnosis
 Fundal ht is not increasing in size
 FHT cannot be heard
 UTS
Management
 D&E
 Induced labor (> 14 wks)
 Provide emotional support &
counseling
Induced labor (> 14 wks)
 Prostaglandin suppository or
misoprostol (cytotec) - dilate cervix.
 Oxytocin stimulation or administration
of mifepristone techniques
 If not actively terminated – miscarriage
spontaneuosly occurs w/n 2 weeks

 DIC – if dead fetus remains too long in

utero
[Link] or Habitual Abortion
 3 or more successive spontaneous
abortions

 Occurs 1% of pregnancies
Possible causes:
 Defective spermatozoa or ova
 Endocrine factors
 Deviation of uterus
 Chorioamnionitis or uterine infection
 Complication of Abortion
 Hemorrhage
 Infection
 Rh isoimmunization
 Woman’s psychological state
Hemorrhage
Serious or fatal
 Rare w/ complete spontaneous
abortion

 Possible for incomplete abortion & pt

w/ coagulation defect
Management
 Monitor v/s changes
 D&C
 BT may be necessary
 Oral Methergine can be prescribed
Instruct woman about normal:
 amount of bleeding
 change of blood color
 Odor & appearance
Infection
 Minimal – loss occurs over a short
time, bleeding is self limiting, &
instrumentation is limited

 May happen in pt who lost lots of

blood
Management
Teach woman about s/sx of infection:
 Fever (>38°C)
 Abdominal pain
 Tenderness
 Foul vaginal discharge
Advise woman to:
 Wipe perineal area from front to back
after voiding & defecation

 Not use tampons to control vaginal

discharge
Infection that may occur:
 Endometritis
 Parametritis
 Peritonitis
 Thrombophlebitis
 Septicemia
Septic Abortion
 An abortion that is complicated by
infection
 Dissemination of bacteria/toxins into
the maternal circulatory and organ
system.
Occurs frequently on self-abortion or
illegal abortion using a nonsterile
instrument or performed by untrained
persons.
 Infectious organism grow rapidly in
uterus esp if POC remains.

 If untreated lead to toxic shock

syndrome, septicemia, kidney failure,
& death
Signs & Symptoms
 Fever
 Crampy abdominal pain
 Tender uterus upon palpation
Complication
 Infertility
 Infection
 hemorrhage
Isoimmunization
 Some fetal blood enter maternal
circulation
 If Fetus is Rh-positive & woman Rh-
negative = antibodies will be produced
 Next pregnancy, if child is Rh positive,
antibodies destroys RBC.
 Rh negative woman should receive Rh
(D antigen) immune globulin (RhIG)
Nursing diagnosis:
 Anxiety related to possible pregnancy loss

 Anticipatory grieving related to threatened abortion;

potential for infant with congenital anomalies.

 Risk for infection related to internal site for organism

invasion secondary to vaginal bleeding during
pregnancy.
 Risk for deficient fluid volume related to excessive
losses: vaginal bleeding during pregnancy.
END
Ectopic Pregnancy
 a complication of pregnancy in which
implantation occurs outside
the uterine cavity.

 2% of all pregnancies
Sites of Implantation:
 Surface of the ovary
 Cervix
 Abdominal cavity
 Tubal
 Fallopian tube (95% pregnancies)
 Ampullar (distal 3rd tube) – 80%
 Isthmus (proximal portion) – 12%
 Interstitial / Fimbrial – 8%
Risk Factors
 Previous infection
 Congenital malformations
 Scars from tubal surgery
 Uterine tumor
 Smoking
 Previous ectopic pregnancy
Pathophysiology
Zygote cannot It lodges at a
travel length stricture site along Implants
of tube the tube

Rupture fallopian
Tearing & 6 – 12 wks
tube or trophoblast
destruction of bld
cells break through Grows large
vessels
narrow base

Bleeding
Signs & Symptoms
 Missed menstrual period of 2wks
duration (68%)
 Unilateral lower abdominal pain (99%)
 Irregular vaginal bleeding (75%)
Before the rupture:
 Amenorrhea with some spotting and
bleeding
• Pelvic and abdominal pain on the
affected side due to distention. PAIN is
the most common sign (90%).
Rupturing or ruptured ectopic pregnancy:

 Isthmic pregnancy ruptures early at 6wks

 Ampullary EP ruptures later around 8-12 weeks.
 Abdominal pregnancy may terminate anytime
depending on the site of implantation.
Signs & symptoms of ruptured EP
 Pain - sudden severe and knife like pain.
 Pain radiating to the neck and shoulder as the blood
accumulates in the abdominal cavity.
 Lightheadedness and rapid pulse.
 Spotting or bleeding, blood usually dark brown
 Cullen’s sign or the bluish discoloration of the umbilicus
due to the presence of blood in the peritoneal cavity.
 Hard or boardlike abdomen
 Signs of shock: cyanosis, pallor, cold clammy skin, rapid
pulse, hypotension, oliguria
Diagnosis
 UTS
 MRI
 Falling hCG & serum progesterone level
 Laparoscopy or culdoscopy
Therapeutic Management
Unruptured
 Oral methotrexate - chemotherapeutic
agent, attacks & destroys fast growing
cells
 Leucovorin – reduce toxicity ff high
dose of methotrexate therapy.
 Mifepristone – abortifacient, causing
sloughing of implantation site
Ruptured
 Salpingostomy
 Salpingectomy
 First successful surgery for an ectopic
pregnancy was performed by Robert
Lawson Tait in 1883.
Nursing Interventions
Maintaining Fluid Volume
 IVF using large-gauge cath
 Blood samples (CBC, type & screen)
 BT
 Monitor vital signs
 Monitor urine output
 Promoting Comfort
 Administer analgesics as needed &
prescribed.
 Encourage use of relaxation
techniques.
Providing Support
 Be available & provide emotional
support
 Listen to concerns of pt & significant
others.
 Provide grief counseling
 Patient Education & Health
Maintenance
 Teach s/sx of ectopic pregnancy to
women at risk
 Instruct to report relative s/sx present
 Discuss contraception.
COMPLICATIONS
 50% Infertility
 Isoimmunization
 Hemorrhage & death
Nursing Diagnoses
 Risk for Deficient Fluid Volume r/to bld loss
from ruptured tube
 Acute Pain r/to ectopic pregnancy or
rupture & bleeding into peritoneal cavity
 Anticipatory Grieving related to loss of
pregnancy & potential loss of childbearing
capacity
END