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BLEEDING COMPLICATIONS: EARLY PREGNANCY Spontaneous Abortion

Abortion describes the loss of pregnancy prior to fetal viability, which is typically defined as greater than 20 weeks’ gestation or fetal size greater than 500 gm. Abortion can be either spontaneous or induced. Spontaneous abortion, often called a miscarriage, occurs without inter ention from the patient or another person.

TYPES
Spontaneous abortion affects !5"20# of recognized pregnancies $%uscheck, 20!0&. Spontaneous abortions can be caused by a number of factors, including chromosomal abnormalities, maternal infection, maternal endocrine disorders $e.g., hypothyroidism, uncontrolled diabetes&, reproducti e system abnormalities $e.g., an incompetent cer i'&, and maternal in(ury. )iterature suggests that drug use and en ironmental factors may also be linked to the occurrence of spontaneous abortion. Spontaneous abortions are classified according to symptoms and the outcome of the products of conception. Spontaneous abortions are considered threatened, ine itable, incomplete, complete, missed, or recurrent.

Threatened abortions are diagnosed when there is aginal bleeding and, possibly, uterine cramping. %atients suffering from a threatened abortion may or may not lose the fetus. *owe er, careful monitoring and appropriate inter ention are necessary. +ypically, patients are instructed to a oid se'ual acti ity, tampons, and douches, as well as strenuous e'ercise. %atients are also encouraged to note and report bleeding to their healthcare pro ider.

Inevitable abortions occur when amniotic membranes rupture and the cer i' dilates. ,n this case, abortion or miscarriage is considered ine itable. %atients typically ha e cramping. +he products of conception are commonly e'pelled without inter ention. *owe er, a dilation and curettage $-./& may be performed if necessary.

Incomplete abortions occur when some, but not all, of the products of conception are e'pelled from the uterus. +he retained products pre ent the uterus from contracting completely, which results in bleeding from uterine blood essels. %atients generally e'perience se ere cramping and profuse bleeding, and recei e intra enous $,0& fluids and possibly blood products. 1enerally, a -./ is performed to remo e the retained products of conception. Additionally, patients may recei e medications such as o'ytocin $%itocin& or methylergono ine $2ethergine& to contract the uterus and stop the bleeding.

Complete abortions occur when all of the products of conception including the fetus and placenta are e'pelled from the uterus. +he cer i' closes, and cramping and bleeding stop. 3urther inter ention is typically not necessary. *owe er, the patient is ad ised to notify her healthcare pro ider of any additional bleeding, pain or symptoms of infection, such as fe er or foul"smelling aginal discharge.

Missed abortions occur when the fetus e'pires during the first half of pregnancy, but is retained in the uterus. ,f there are no ob ious signs of infection present, the patient may carry the fetus until spontaneous e'pulsion occurs. +his may take se eral weeks. *owe er, a -./ may be performed.

+he term recurrent $or habitual& spontaneous abortion, refers to three or more consecuti e spontaneous abortions. ,t is belie ed that genetic defects and reproducti e system abnormalities are the primary causes of recurrent abortions. %atients are screened and e'amined for reproducti e system abnormalities, such as recurrent premature dilation of the cer i', also known as incompetent cervix. ,n the case of the premature dilation of the cer i', a suturing procedure, known as a cerclage, may be performed to pre ent the cer i' from opening until deli ery.

NURSING CARE
4ursing care for patients e'periencing a spontaneous abortion aries depending on the type of abortion. *owe er, the primary nursing inter ention for all types of spontaneous abortion is to ensure patient safety by identifying and controlling bleeding and hypo olemic shock. Symptoms of hypo olemic shock include an increased heart rate, decreased blood

feelings of guilt are often significant emotional challenges that many patients must deal with while grie ing their loss. and eggs pro ide needed iron. . intake and output.n addition. and confusion.or antibiotics to treat or pre ent infection. lightheadedness. foul"smelling aginal discharge. 9'periencing a spontaneous abortion is challenging for patients both physically and emotionally and they need to rest for a few days after discharge. +he nurse monitors ital signs. +he nurse should anticipate the need for o'ygen therapy and fluid and blood replacement.pressure. significant bright red aginal bleeding. dried foods. 2any patients feel that their actions somehow led to the spontaneous abortion5 therefore. o'ygen saturation. %atients should be blood"typed and cross"matched in case a blood transfusion is necessary. 3oods such as li er. and pel ic pain. +hey may be re:uired to take iron supplements as a result of significant blood loss and.f a patient e'periences a threatened abortion but the fetus does not die. +he nurse may also be responsible for administering medications5 for e'ample. +he nurse should administer prescribed 6hogam to 6h"negati e patients within 72 hours to pre ent isoimmunization. Additional fluid intake is recommended. tampons. cool and clammy skin. PATIENT TEACHING 8arning signs include fe er. . o'ytocin $%itocin& may be used to help in e'pelling the products of conception or to control bleeding. patients are encouraged to a oid se'ual acti ity. and laboratory results according to institutional policies. green leafy egetables. +he nurse caring for a patient e'periencing spontaneous abortion will also need to help the patient e'plore her feelings regarding an actual or potential loss. the nurse may be responsible for monitoring fetal heart sounds and the o erall well"being of the fetus depending on gestational age. . or douches.

or abdominal ca ity. dizziness. MEDICAL MANAGEMENT An ectopic pregnancy implanted in a fallopian tube re:uires either pharmacologic or surgical management. weakness. Signs and symptoms of a ruptured fallopian tube include aginal bleeding.Ectopic Pre nanc! 9ctopic pregnancies occur when the o um is fertilized by the sperm but implants outside the uterus in the fallopian tubes. 200>&. . .f the implantation site is a fallopian tube. @ften. other disease processes $e. . %harmacologic management with methotre'ate is indicated if the tube is unruptured.g. o ary. the tube may rupture and cause internal hemorrhaging and hypo olemic shock. and abdominal pain. and increased pulse. 2ost ectopic pregnancies occur in the fallopian tubes $3igure !&. which is a life"threatening e ent for the patient. and the patient is stable hemodynamically. or the structure supporting the o um may rupture. lack of menstruation $amenorrhea&. the ectopic pregnancy is less than ?. 2ethotre'ate treatment is usually performed on an outpatient basis. SIGNS AND SYMPTOMS Signs and symptoms of an ectopic pregnancy include aginal bleeding. *owe er.t is important to note that o er 50# of patients e'periencing an ectopic pregnancy are asymptomatic prior to tubal rupture $/han . shoulder or neck pain $as a result of blood leaking out of the fallopian tube and irritating the diaphragm&. =ohnson. decreased blood pressure.. the fetus is not li ing. cer i'. <ltrasound and laboratory testing are necessary to diagnose an ectopic pregnancy. +he o um may naturally reabsorb into the body. se ere abdominal pain or pel ic. patients re:uire more than one dose of methotre'ate for effecti e treatment. +he outcome of an ectopic pregnancy depends on the location of implantation. spontaneous abortion& may be responsible for such symptoms.5 cm.

or guilt that may arise following an ectopic pregnancy and that these feelings are a normal part of the grie ing process for someone e'periencing the loss of a pregnancy. As with all patients e'periencing a pregnancy loss. 6egular assessment of aginal bleeding is also essential. 2ore specifically. N"RSING CARE +he nurse caring for a patient e'periencing an ectopic pregnancy looks for changes in the patient’s blood pressure and pulse. if the patient e'periences pain. which could indicate hypo olemic shock resulting from hemorrhage. the nurse monitors ital signs.. the nurse is responsible for monitoring and controlling pain le els. +his procedure in ol es the actual remo al of the affected fallopian tube. and laboratory results according to institutional policies.f methotre'ate is used for the treatment of an ectopic pregnancy. sadness. a laparoscopic salpingectomy is performed. . A linear salpingostomy re:uires a small linear incision in the tube to remo e the products of conception. PATIENT TEACHING 4urses are responsible for ensuring that the patient is aware of signs and symptoms that re:uire a call to the healthcare pro ider or a return isit to the emergency room following hospital discharge. or a fe er and chills. Significant scarring in the fallopian tube could potentially affect the ability of the patient to ha e a successful pregnancy in the future.f the fallopian tube is ruptured as a result of an ectopic pregnancy and the patient wants to become pregnant in the future.f the tube is ruptured and the patient does not desire a future pregnancy.f a linear salpingostomy or salpingectomy is performed. a surgical procedure called a linear salpingostomy is performed to protect the tube. . . +he tube is then allowed to heal without suturing to pre ent significant scarring. 3inally. . significant bleeding. she needs to notify her healthcare pro ider. intake and output. it is important for the nurse to recognize the loss and to pro ide resources to assist the patient in coping with the emotions that accompany the e'perience of an ectopic pregnancy. the patient should be educated about the unpleasant side effects $nausea and omiting& of methotre'ate. o'ygen saturation. +he patient should ha e a clear understanding of the feelings of anger. 6h"negati e patients re:uire administration of prescribed 6hogam to pre ent isoimmunization.

%atients of ad anced maternal age and of Asian descent ha e a higher risk of ha ing a molar pregnancy. which appear as tiny clusters of grapes within the uterus. fetal heart tones and mo ement are absent.pregnancies are rare and occur in appro'imately ! in !000 pregnancies in the <nited States and 9urope $/unningham et al. patients who e'perienced a pre ious molar pregnancy ha e a higher risk of ha ing a molar pregnancy in the future. +he illi swell. Anemia may result due to bleeding.B INCIDENCE AND RIS' (ACTORS 1+. . Additionally. Additionally. appearing similar to prune (uice. forming fluid"filled sacs. *owe er. although it is uncommon. SIGNS AND SYMPTOMS %atients with a 1+.ntra enous o'ytocin is usually administered to contract the uterus after the acuum aspiration. occurs when the chorionic illi of the placenta increase as a result of genetic abnormalities. also known as a hydatidiform mole or a molar pregnancy. as a result of the proliferation of tissues and the presence of clotted blood.. Eleeding can be bright red or brown. according to -ente $2007&. A partial mole occurs when a fetus or an amniotic sac is present.Gestationa# Trop$ob#astic Disease %GTD& 1estational trophoblastic disease. 1entle . the uterus may appear larger than e'pected for gestational age. Serum h/1 le els are also increased and patients may e'perience hyperemesis.t is important to note that o'ytocin should not be administered prior to acuum aspiration to a oid tissue being forced into enous circulation and subse:uent embolization $2cFinney et al. . whereas a complete mole only contains the fluid"filled sacs.e'hibit light to hea y bleeding and e en hemorrhage.. 2005&. AtwinningB has been reported with a complete CmoleD plus a sur i ing fetus with a normal placenta. 2olar pregnancies are classified as complete or partial based on whether a fetus is present. 2005&. MEDICAL MANAGEMENT 2olar tissues are remo ed by acuum aspiration. +he fetus is usually non iable in a molar pregnancy. -espite an enlarged uterus. Symptoms of gestational hypertension before 2> weeks’ gestation are a strong indication of gestational trophoblastic disease.

is performed to ensure that the uterus is emptied of all affected tissue.f a patient has hyperemesis resulting from the molar pregnancy. 6h"negati e patients should recei e 6hogam to pre ent isoimmunization.t is important that patients are aware of the signs and symptoms of complications following a molar pregnancy and acuum aspiration. PATIENT TEACHING -ue to the risk of choriocarcinoma. and eggs can pro ide needed iron.curettage. or scraping of the uterus. %atients should a oid tampons. douches. and serum h/1 le els is re:uired prior to acuum aspiration and curettage. blood typing and crossmatching. 3oods such as li er. As with all pregnancy losses. foul"smelling aginal discharge. nursing care includes referring patients to appropriate pro iders or support groups as needed. 4ursing care also includes pre" and post"operati e care. As a result of bleeding. N"RSING CARE . %atients should also understand that another pregnancy immediately following a molar pregnancy should be a oided in order to monitor h/1 le els without the interference of h/1 from pregnancy. . and se'ual acti ity until the healthcare pro ider indicates that these acti ities can be performed safely. blood pressure and urinary output. including e'cessi e bleeding. it is ital that patients understand the need for regular follow"up to test serum h/1 le els. the nurse should assist the patient with mouth care and any additional inter entions that are appropriate. including changes in heart rate. patients may e'hibit grief in response to the loss. )aboratory work.t is ital that the nurse monitoring patients e'periencing molar pregnancies assess for signs and symptoms of bleeding and shock. patients may be anemic and re:uire increased iron intake or possibly iron supplementation. and fe er. . green leafy egetables. %atients should be informed that this is a normal response to a pregnancy loss5 therefore. including a complete blood count. . +he patient should also be encouraged to increase fluid intake. dried foods.

+he pre ia is considered a total pre ia if the placenta completely co ers the internal cer ical os $3igure 2&. the pre ia is considered a partial placenta pre ia. the placenta implanted near or o er the internal cer ical os is disrupted and bleeding can occur. but does not :uite reach. . bleeding may not occur until labor begins. As the pregnancy nears term and the cer i' dilates. the internal cer ical os. Specifically.f the placenta partly co ers the internal os. bright red aginal bleeding or hemorrhage during late pregnancy.g. *owe er. +he fetus may also e'perience hypo'ia and possibly death from maternal bleeding.BLEEDING COMPLICATIONS: LATE PREGNANCY P#acenta Pre)ia %lacenta pre ia occurs when the placenta implants in the lower portion of the uterus by the internal cer ical os.. endometriosis& .nduced or spontaneous abortion SIGNS AND SYMPTOMS +he most significantly recognized symptom of placenta pre ia is painless. the fetus is often in a trans erse or breech position. +he patient may go into shock as a result of hemorrhage. the pre ia is considered marginal. which may be noted during fundal e'amination.t is imperati e that aginal e'aminations be a oided because stimulation of the placenta may cause hemorrhage. +he bleeding places the patient and her unborn child at"risk. if the lower border of the placenta is close to. cocaine& %re ious placenta pre ia <terine scarring $e. RISK FACTORS FOR • • • • • • !AC"#TA R"$IA Ad anced maternal age /esarean section Smoking or drug use $e.. . %re ias are classified according to the degree to which they co er the os. MATERNAL AND (ETAL IMPLICATIONS As a result of the abnormally implanted uterus. .g.

the cer i' is ripe.t is important to note that pregnant patients can e'perience significant blood loss $appro'imately >0#& without a change in ital signs $)owdermilk . while intermittent fetal heart tones are obtained according to medical orders or institutional policy. Some patients may deli er aginally if they are near term. %atients should be blood"typed and cross"matched in case a blood transfusion is necessary. . fetal status. or a complete pre ia is present. 6egular assessment of fetal heart rate and mo ement is necessary. Significant bleeding or hemorrhage should be reported immediately to the appropriate healthcare pro ider. %erry. and there is minimal bleeding. %atients with a placenta pre ia should remain on bed rest. a cesarean section is usually necessary.MEDICAL MANAGEMENT As pre iously mentioned. N"RSING CARE 4ursing care for patients with a placenta pre ia in ol es close monitoring of bleeding as well as fetal and maternal status. PATIENT TEACHING . 4on"reassuring fetal heart rate patterns should be reported to the healthcare pro ider immediately. 4on"stress testing to e aluate fetal status is performed during bleeding episodes. 6hogam is gi en to 6h negati e patients during each bleeding episode to pre ent isoimmunization.ntra enous access should be maintained for prompt administration of fluids or blood products. +herefore. and type of pre ia. A transabdominal ultrasound can be performed to diagnose the pre ia. if there is a non" reassuring fetal heart tracing. aginal e'amination must be a oided if a patient presents with painless. the fetal heart tracing is reassuring. or hemorrhage. 2edical management of a placenta pre ia is largely determined by gestational age. A Fleihauer"Eetke test is usually performed on 6h"negati e patients to determine if the fetal blood has entered the maternal circulation as a result of fetal"maternal hemorrhage $Flossner. *owe er. . significant bleeding. careful monitoring of bleeding is imperati e as ital sign changes may not be initially e ident. 200G&. 200G&. amount of bleeding. bright red aginal bleeding because hemorrhage may occur.

often referred to as an abruption or placenta abruption.g. cocaine& Alcohol abuse /igarette smoking *ypertension -iabetes mellitus Ad anced maternal age 2ultiparity and multiple pregnancy *istory of abruptio placentae +hromboembolic disorders . with apparent or concealed hemorrhage $3igure ?&. RISK FACTORS FOR A%R& TIO • • • • • • • • • !AC"#TA" -rug use $e. Apparent hemorrhage refers to bleeding that is e ident. is the premature separation of the normally implanted placenta from the uterine wall before labor and deli ery of the newborn. An abruption is partial if a section of the placenta separates from the uterine wall but the margins of the placenta remain intact. Eleeding occurs between the uterine wall and the placenta.. Abruptio P#acentae Abruptio placentae.. . A complete abruption occurs when the entire placenta detaches from the uterine wall. patients should be instructed to maintain pel ic rest by abstaining from se'ual intercourse or using tampons or douches. 9ncourage the patient to prohibit aginal e'aminations. An abruption can be partial or complete.n addition. while a concealed hemorrhage denotes bleeding that is obscured. Abruptio placentae is classified according to the degree of placental separation and subse:uent hemorrhage.t is e'tremely important that patients with a placenta pre ia understand the need to maintain bed rest to pre ent unnecessary pressure on the internal cer ical area where the placenta is implanted.

Additionally. as well as the status of the patient and fetus. as well as the resulting fetal distress. MEDICAL TREATMENT Abruptio placentae is usually diagnosed by abdominal ultrasound. 200H&. +reatment is based on the degree of placental separation and subse:uent hemorrhage./&. disseminated intra ascular coagulation $-. )ondon.g. %atients may also suffer from postpartum hemorrhage after deli ery due to poor contractility of the uterus following an abruption. emergency cesarean section is performed.n the presence of se ere abruption and hemorrhage. Since the placenta is the source of o'ygenation for the unborn fetus. which may be dark red due to old blood from a concealed abruption. the abrupted area is small and emergency deli ery is not necessary. . uterine tenderness.. premature separation of the placenta from the uterine wall can place the fetus at great risk for hypo'ia and death. . in some cases. uterine irritability with poor uterine resting tone is fre:uently noted. %atients with an abruption are at risk for de eloping hypo olemic shock. the nurse must be prepared to deal with the possibility of se ere hemorrhage and hypo olemic shock.• • %remature rupture of membranes $%6@2& Abdominal trauma $e. accident. %atients should ha e intra enous access with a large bore catheter to accommodate the administration of fluid and blood products. and a board"like abdomen. *owe er. iolence& SIGNS AND SYMPTOMS +he classic signs and symptoms of abruption placentae include aginal bleeding. MATERNAL AND (ETAL IMPLICATIONS Abruptio placentae is a life"threatening e ent for the patient and the fetus. %atients often complain of an aching or dull pain in the abdomen or lower back. N"RSING CARE Although aginal deli ery is preferred to cesarean section for patients who are hemodynamically stable. and possibly death. )adewig . 0aginal deli ery can be safely performed if the patient and fetus are hemodynamically stable $-a idson. in addition to the presenting signs and symptoms.

t is important to inform patients with abruptio placentae that emergency deli ery may be necessary. is also essential. . %atients should be kept informed of the status of the fetus and the nurse should be a ailable and ready to answer any :uestions that patients or their families may ha e. !AC"#TA Assessment R"$IA vs' A%R& TIO lacenta revia !AC"#TA" Abruptio lacentae %ain %ainless <terine tenderness5 se ere abdominal pain and possibly aching or dull pain in the lower back 2ay be concealed5 if noted. and pain and comfort le els. 6hogam is indicated for 6h negati e patients. 3re:uent ital signs and fetal heart tones. bleeding. PATIENT TEACHING %atients should be instructed to report bleeding and se ere abdominal pain immediately. Abnormal ital signs. Eecause the potential for patient and fetal in(ury is high in the presence of abruptio placentae. . or non"reassuring fetal heart patterns should be reported immediately to the appropriate healthcare pro ider. is essential. 4urses should remember that hemorrhage and emergency surgery can be ery frightening5 therefore. it is important to address the emotional needs of the patient. clear and honest information must be gi en to the patient and her family as fre:uently as possible.t is necessary to monitor carefully the status of the patient and fetus.f a patient must ha e an emergency cesarean section.. @bser ation and documentation of the patient’s intake and output. as well as monitoring and documentation of blood loss. %atients should be blood typed and cross"matched in case a blood transfusion is necessary. it is important for the nurse to :uickly communicate to the patient and her family what will occur before and during the procedure. it is often dark red Eleeding <terus Eright red 4o unusual contractions or AEoard"likeB abdomen5 irritability uterine irritability with poor resting tone .

!AC"#TA Assessment R"$IA vs' A%R& TIO lacenta revia !AC"#TA" Abruptio lacentae 6isk for postpartum hemorrhage *igh risk5 due to low placement of the placenta there is limited uterine contraction *igh risk5 due to poor contractility of the uterus following an abruption PREGNANCY*RELATED HYPERTENSI+E COMPLICATIONS (estational hypertension.I0 mm *g. +he blood pressure should be ele ated on at least two occasions > to G hours apart. Preeclampsia Superimposed on Chronic Hypertension . %atients with gestational hypertension do not present with proteinuria. gestational hypertension may progress to preeclampsia. *owe er. <sually. seizures are related to gestational hypertension and not to other causes.I0 mm *g. refers to hypertension occurring for the first time during pregnancy. "clampsia is the occurrence of seizures in the presence of preeclampsia. which is a characteristic of preeclampsia. -iagnosis of gestational hypertension re:uires a blood pressure that is greater than or e:ual to !>0. formerly known as pregnancy-induced hypertension. during. %reeclampsia is identified by a blood pressure that is greater than or e:ual to !>0. Seizures can occur anytime before. %reeclampsia is indicated when there is a finding of ?00 mg of protein in a 2>"hour urine test or ! to 2J protein or greater ia urine dipstick. +he diagnosis is made after 20 weeks’ gestation and is characterized by a blood pressure that returns to normal by !2 weeks postpartum. in the presence of protein in the urine $proteinuria&. or after deli ery of the fetus.

and patients pregnant with multiples are at a greater risk for de eloping pregnancy" related hypertension. while )eifer $2005& indicates that eclampsia occurs in 5# of pregnancies..H# of !000 pregnancies were affected by pregnancy"related hypertensi e complications in 2007. which produces proteinuria. Additionally. 2edical treatment and nursing care for patients with preeclampsia superimposed on chronic hypertension is similar to that of gestational hypertension and preeclampsia. PATHOPHYSIOLOGY 0asospasm in the arterioles of patients with gestational hypertension causes increased blood pressure and a decrease in placenta and uterine perfusion. INCIDENCE AND RIS' (ACTORS According to the 4ational 0ital Statistics 6eports $20!0&. %rimagra idas. subse:uently. which triggers coagulation pathways and. pregnancy" related hypertension is a significant contributor to maternal and fetal mortality rates. ?H. or a platelet count less than !00. 1ibson and /arson $20!0& indicate that gestational hypertension occurs in appro'imately 2# to ?# of pregnancies in the <nited States. 2005&. . diabetics. 2005&. *eadaches and isual disturbances are the result of cellular damage and cerebral edema caused by central ner ous system changes in the presence of hypertension. 6enal blood flow is reduced. 1eneralized asospasm causes endothelial cell damage. )i er enlargement is the result of hepatic changes that lead to epigastric pain. African Americans. %atient with preeclampsia superimposed on chronic hypertension are often treated with antihypertensi e agents.%reeclampsia superimposed on chronic hypertension refers to chronic hypertension with a new onset of proteinuria in hypertensi e patients without proteinuria before 20 weeks’ gestation or a sudden increase in proteinuria or blood pressure. A family history of pregnancy"related hypertension is also a significant risk factor.000 mm? in patients with hypertension and proteinuria before 20 weeks’ gestation $/unningham et al. along with the renal glomerular filtration rate. patients of either young or ad anced maternal age. abnormalities in bleeding and clotting can occur $)eifer.

and thromboembolic disorders $/allahan et al. MATERNAL AND (ETAL IMPLICATIONS *ypertension in pregnancy places patients and their fetuses at great risk for a ariety of complications. blurred ision.n addition. placental . MEDICAL TREATMENT 2edical treatment for patients with pregnancy"related hypertension greatly depends on the se erity of hypertension and the gestational age of the fetus. edema may still be noted in these patients. epigastric pain. Additionally./&. . aspiration pneumonia.. which leads to anemia "le ated li er enzymes leading to epigastric pain !ow platelets. and placental abruption from the ele ated blood pressure.. Although no longer considered diagnostic of pregnancy" related hypertension $/unningham et al. 6egular fetal monitoring is necessary to e aluate fetal well"being. as well as the potential risk to the patient and fetus. disseminated intra ascular coagulation $-.SIGNS AND SYMPTOMS Signs and symptoms of pregnancy"related hypertension ary depending on the se erity of the hypertension. -uring early pregnancy. *9))% syndrome causes great dysfunction within the body that re:uires immediate inter ention. 3etal complications include intrauterine growth retardation and premature deli ery resulting from decreased placenta perfusion. 200>&. weight gain $K2 pounds per week&.t is characterized byL • • • )emolysis of red blood cells. and proteinuria. Some of the most significant maternal complications of hypertension in pregnancy include cerebral ascular accident $/0A&. the common signs and symptoms of pregnancy"related hypertension include headache. patients are at risk for the de elopment of *9))% syndrome in the presence of gestational hypertension. hypo'ic encephalopathy. . which cause abnormal bleeding and clotting as well as petechiae %atients whose function continues to decline without inter ention can de elop eclampsia and are at risk for cerebral hemorrhage. =ust as its’ name implies. *owe er. oliguria. outpatient management is usually appropriate5 these patients are monitored at home for blood pressure and proteinuria. 2005&.

+he nurse should immediately report increases in blood pressure. renal failure. +herefore. it is the responsibility of the nurse to monitor the patient carefully for signs of a decline in health status. se ere headaches. and oliguria to the appropriate healthcare pro ider. arrangements should be made for specialized neonatal care. *ealthcare pro iders may prescribe magnesium sulfate $2gS@ >& during labor and deli ery to pre ent seizures. 2agnesium sulfate is administered intra enously ia an infusion deli ery de ice during deli ery and for 2> hours post deli ery. if the healthcare pro ider determines that the fetus is too premature for deli ery. a 3oley catheter is usually inserted to monitor urine output and to obtain regular urine specimens. are usually deli ered immediately $)eifer. thereby prolonging fetal growth in utero. . 2005&. the nurse will monitor blood pressure and the well"being of the fetus. 1lucocorticoids are administered to enhance fetal lung maturity $/unningham et al.perfusion tests can also be performed to assess and monitor uteroplacental sufficiency. 2agnesium sulfate is not used to control hypertension. 8hile patients are hospitalized for pregnancy"related hypertension. deep tendon refle'es are present.. antihypertensi e medications may be administered to decrease blood pressure. %atients with e idence of ad anced dysfunction. or *9))% syndrome. isual disturbance changes. N"RSING CARE %regnancy"related hypertension presents a great risk to patients and their unborn fetuses. such as oliguria. 2agnesium sulfate to'icity can be pre ented by ensuring that urine output is ade:uate $at least ?0 ml. /alcium gluconate can be administered when prescribed to re erse the effects of magnesium . Since deli ery is the only known cure for pregnancy"related hypertension.f 2gS@ > to'icity is noted. +he nurse is responsible for administering 2gS@> and for monitoring its to'icity. 2005&. and the respiratory rate is greater than !2 breaths per minute. many healthcare pro iders will recommend immediate induction and deli ery if the patient is near"term and shows signs of se ere preeclampsia or eclampsia. *owe er. Since 2gS@>can cause fetal respiratory depression following deli ery. the healthcare pro ider must be notified immediately and the infusion discontinued.hr&. . epigastric pain.f magnesium sulfate $2gS@>& is prescribed for preeclampsia or eclampsia.

+he nurse should note the beginning and ending of the seizure and ensure ade:uate o'ygenation after seizure acti ity has ceased. o'ygen. patients should be protected from in(ury. 9mergency e:uipment should be readily a ailable. blood pressure. +he nurse encourages patients with pregnancy"related hypertension to rest in the left side" lying position as much as possible. +he patient should also be instructed to decrease en ironmental stimuli by lowering or turning off lights and by decreasing the olume on radios or tele isions as well as decreasing the number of isitors. isual disturbances. a bag" al e"mask $E02&.dl $/unningham et al.n the e ent of a seizure. PATIENT TEACHING %atients suffering from pregnancy"related hypertension who are being treated on an outpatient basis are taught to monitor themsel es and their unborn child for a decline in health status. 2005&. +he serum magnesium le el for patients recei ing 2gS@ > should be > to 7 mg. and urine protein at home. the nurse must be prepared to pre ent in(ury to the patient during seizures and to monitor seizure acti ity. as well as to increase protein intake because proteinuria decreases the amount of a ailable protein. .2gS@> to'icity. including an oral airway. and emergency medication. Eed side rails should be up and padded. or sudden weight gain. +his position pre ents unnecessary pressure on the ena ca a. Specifically. +hey should also be instructed to perform daily fetal kick counts to monitor fetal well"being. 4ursing care should be performed in a manner that pre ents unnecessary disturbances to . whether at home or in the hospital. +hey are instructed to notify the appropriate healthcare pro ider of ele ated blood pressures or protein in the urine. %atients may be taught to monitor their weight. 2005&.n the presence of eclampsia. . +he nurse should not attempt to insert an oral airway or other ob(ect into the mouth during a seizure. 2005&. +he head can be gently turned to the side to pre ent the aspiration of mucus and omitus into the lungs during seizure acti ity $)eifer. which decreases renal and placental blood flow and leads to increased blood pressure $)eifer. patients are taught to notify their healthcare pro ider if they e'perience headaches.. +he nurse obtains ital signs and monitors the fetus following the seizure. epigastric pain.

the Ainsulin"antagonisticB properties of placental hormones affect the patient by causing insulin resistance $)owdermilk . %erry. as the fetus grows.&. Se eral factors that place patients at risk for de eloping gestational diabetes mellitus are listed below. GESTATIONAL DIABETES MELLIT"S 1estational diabetes mellitus occurs with the onset of pregnancy and is characterized by the inability of the pregnant patient to tolerate glucose. %atients who de elop gestational diabetes may de elop diabetes later in life. +herefore. glucose demands increase for the pregnant patient.n addition. *owe er. As a result. 200G&. INCIDENCE AND RIS' (ACTORS According to the American -iabetes Association $n. the pregnant patient is unable to process glucose in the body and hyperglycemia occurs. +he cause of gestational diabetes is largely unknown. %atients ha e a significant chance of deli ering ia cesarean section due to the . Stress and an'iety is a ma(or concern in patients with pregnancy"related hypertension.the patient’s en ironment while hospitalized. it is belie ed that. as it can lead to increased blood pressure. . gestational diabetes affects 7# of pregnancies in the <nited States. gestational diabetes often resol es after deli ery.d. RISK FACTORS FOR ("STATIO#A! *IA%"T"S M"!!IT&S • • • • • • • • 2aternal obesity Ad anced maternal age 2ember of a minority population 1-2 in pre ious pregnancies %resence of glycosuria *istory of a macrosomic infant$s& $birthweight K>500 g& *istory of spontaneous abortion or fetal demise 3amily history of diabetes mellitus or 1-2 MATERNAL AND (ETAL COMPLICATIONS A ariety of maternal and fetal complications are associated with gestational diabetes mellitus. the nurse should discuss stress and an'iety management with patients. *owe er.

200G&.d) is considered a positi e screen and further in estigation is warranted5 A 2"hour or ?"hour glucose tolerance test is then typically performed $/unningham et al. +he newborn’s pancreas continues to produce insulin after deli ery despite the decrease in serum glucose. patients drink 50 grams of oral glucose solution. patients with gestational diabetes should consume a diet that pro ides ?0"kcal... According to the American -iabetes Association $as cited in /unningham.large size of infants born to patients with gestational diabetes. as cited in )owdermilk . MEDICAL TREATMENT %regnant patients are routinely screened for gestational diabetes mellitus between 2> and 2I weeks’ gestation. . Eesides proper diet and e'ercise. . they indicate that patients with a body mass inde' greater than ?0 kg. 2ost patients with gestational diabetes are treated through diet. NURSE ALERT: Resistance Exercise and Gestational Diabetes Brankston and associates (as cited in Cunningham..f aginal deli ery is attempted. After one hour. 2005&. et al. 2005&. the newborn infant’s blood glucose must be monitored regularly due to the sharp decrease in a ailable glucose after the umbilical cord is cut.n order to diagnose gestational diabetes. hyperbilirubinemia. +his occurs due to fetal hyperinsulinemia as a result of maternal hyperglycemia.nfants are also at risk for hypocalcemia. . and respiratory distress syndrome as a result of gestational diabetes. 3urthermore. %erry.m2 may benefit from a ?0# to ??# caloric restriction. indicate that resistance exercise can help overweight patients with gestational diabetes avoid insulin therap . which stimulates e'cessi e growth. +hese large infants may ha e difficulty maneu ering the birth canal and a cesarean section may be re:uired. . +hey are encouraged to consume a proper diet and obtain ade:uate e'ercise. +his adds to the potential instability of the infant’s blood glucose. the infant is at risk for shoulder dystocia or other birth in(uries.nfants born to patients with gestational diabetes mellitus are usually macrosomic $birthweight K>500 grams&.d. some patients may re:uire insulin or oral hypoglycemia agents to manage gestational diabetes mellitus. After deli ery. 2005). . %atients also ha e an increased fre:uency of hypertension $/unningham et al. A glucose le el of !?5 to !>0 mg.kg.. et al. a blood sample is obtained and tested for glucose tolerance.

d). usually M>0 mg. treatment with intra enous fluids. irritability.f the newborn’s blood glucose le el is below acceptable national or institutional standards. lethargy. temperature instability. medication administration. A referral to a dietician may also be necessary. or early feedings is necessary. intra enous or oral glucose.t is imperati e that the nurse teach patients with gestational diabetes the signs and symptoms of hypoglycemia. clammy skin. including (itteriness. -uring labor. the nurse re iews the blood glucose and diet logs to make recommendations about monitoring. PATIENT TEACHING +he nurse working with patients who are diagnosed with gestational diabetes mellitus is often responsible for teaching the patient how to self"monitor and record glucose and ketones at home. cold. as glucose instability is common in newborns born to patients with gestational diabetes mellitus.n addition. -uring prenatal isits. seizures. and diet. +hese signs and symptoms include shakiness. 4urses must be aware of signs and symptoms of hypoglycemia in the newborn. headache.t is important for the nurse to monitor serum glucose le els as well as ketones and glucose in the urine throughout the pregnancy of patients with gestational diabetes mellitus. +he nurse may also conduct regular fetal sur eillance including non"stress tests $4S+& or biophysical profiles $E%%& starting from ?2 to ?G weeks’ gestation and until deli ery. . the nurse can teach patients about proper diet and safe e'ercise during pregnancy. +he patient should be . Elood glucose may be monitored as often as e ery hour.N"RSING CARE . tremors. the patient with gestational diabetes mellitus may need to be on intra enous insulin and glucose5 blood glucose le els will be monitored regularly according to medical orders or institutional policies. %atients may also need to learn how to self"administer insulin. After deli ery. .or poor feeding and take appropriate action to assist in the treatment of hypoglycemia. the nurse is responsible for monitoring the infant’s blood glucose le els. an'iety. and. +he nurse should make sure the patient can comfortably and appropriately check blood glucose le els and administer insulin by re:uesting a return demonstration. hunger. tachypnea. . and tingling around the mouth.

INCIDENCE AND RIS' (ACTORS %reterm premature rupture of membranes $%%6@2& occurs in ?# of pregnancies and is the cause of one"third of preterm deli eries $2edina . African American patients ha e a higher risk of de eloping early rupture of membranes $Erown. Since the potential for de eloping diabetes is significant in patients with gestational diabetes. NURSE ALERT: Respiratory Diseases and PROM !etahun and colleagues (200") h pothesi#ed $% that acute and chronic respirator diseases &were' associated with &an' increased risk o( spontaneous )*+. 6isk factors for preterm premature and premature rupture of membranes include infections such as S+. it is important that patients understand the need for follow"up e aluation after deli ery.taught to closely monitor for hypoglycemia and to notify their healthcare pro ider immediately if signs and symptoms are noted. and stress. fetal malpresentation. maternal nutritional deficiencies. 200G&. a prematurely dilated cer i'. hydramnios.s. 200H&. whereas preterm premature rupture of membranes $%%6@2& refers to the rupture of membranes prior to ?7 weeks’ gestation. 2007&. %remature rupture of membranes $%6@2& occurs in ?#" to !H# of all pregnancies $Erown. )ondon . 2000&. AEetween H0# and I0# of those women who rupture membranes between 2H and ?> weeks CgestationD will gi e birth within 7 daysB $-a idson. through bacteremia and increased levels o( . +he patient can drink milk or (uice or eat fruit to correct hypoglycemia $)eifer. 2000&. %atients should continue to watch for signs and symptoms of hypoglycemia and notify their healthcare pro ider if seen. )adewig. %reterm premature rupture of membranes and %6@2 are often associated with preterm labor and birth. multiple pregnancy. AMNIOTIC MEMBRANE COMPLICATIONS remature rupture of membranes $%6@2& refers to the rupture of membranes ! hour or more before the onset of labor. *ill.

and etiology must be considered before deciding on treatment.B <ltrasound e'amination may be performed to determine the amount of a ailable amniotic fluid after the rupture of membranes. 1estational age. especially for the unborn fetus. MATERNAL AND (ETAL IMPLICATIONS %reterm premature rupture of membranes can cause a ariety of problems."1). which is an infection of the chorion and amnion of the placenta that can be life"threatening for the patient and fetus.(p. MEDICAL TREATMENT +he first step in determining the appropriate course of action for patients with %6@2 or %%6@2 in ol es distinguishing amniotic fluid from urine. . @ften patients complain of a Asudden gushB or a constant trickle of fluid from the agina once the membranes ha e actually ruptured. 8ithout the protecti e barrier of the amniotic membrane. 3or preterm patients. %atients with %%6@2 or %6@2 ha e a risk of de eloping chorioamnionitis. healthcare pro iders and patients may desire to prolong the pregnancy to . +( the chronic respirator conditions. +he healthcare pro ider will then perform a sterile speculum e'amination to look for pooling of amniotic fluid near the cer i'. but not acute bronchitis. Additionally. acute upper respirator disease and viral and bacterial pneumonia were associated with )*+. the (ound that $o( the acute respirator conditions. 3luid is tested using nitrazine paper as well as ia microscopic e'amination for the presence of Aferning. . but chronic bronchitis was not. fetal lung maturity. without the cushioning of the amniotic fluid there is a higher probability of umbilical cord compression as well as cord prolapse. /(ter conducting a stud o( the deliver data (or more than 01 million women."0). a ailable amniotic fluid. the fetus is at a greater risk for the de elopment of infection and preterm deli ery.(p.. 2edical treatment for patients with %%6@2 or %6@2 depends on a ariety of factors. +he fetus is also at risk for becoming septic after deli ery.. %atients near term whose labor does not begin spontaneously following the rupture of membranes may be induced if the cer i' is ripe.proin(lammator c tokines. asthma was associated with )*+.

. nursing care greatly depends on whether the medical diagnosis is %%6@2 or %6@2. the (etus must be monitored closel .promote fetal lung maturity. +he cause of early rupture of membranes as well as the degree of amniotic fluid loss must also be considered when determining the appropriate course of action for patients with %%6@2. As with all complications in pregnancy.t is imperati e that the nurse change patient underpads fre:uently and a oid unnecessary aginal e'aminations to pre ent infection. . and )*+.. *owe er. the nurse should be a ailable to answer :uestions and assist in relie ing the patient’s an'iety about her diagnosis. an amniotic sac with a slow leak of amniotic fluid may form a seal and the amniotic fluid may reestablish itself $2cFinney et al.f there is a significant loss of amniotic fluid rather than a slow leak. patients with %%6@2 who are considered stable are initially monitored on an inpatient basis and then discharged to home. 4ursing care for patients whose labor is induced in ol es administering induction agents and monitoring the status of the patient. 5n the event o( cord prolapse and compression. 4ursing care for these patients in ol es teaching about the signs and symptoms of preterm labor and when to call the healthcare pro ider. . @ften. the nurse should be prepared to deal with cord prolapse and compression. and monitoring the status of the fetus. there is a stronger possibility of the need to induce labor. monitoring the patient for infection and for the presence of uterine contractions. the nurse should attempt to relieve pressure on the umbilical cord and instruct the patient to . 2005&. fetus. *owe er. nursing care typically in ol es assisting the healthcare pro ider to confirm the rupture of membranes. N"RSING CARE As with medical treatment. %atients who are preterm may be prescribed corticosteroids to promote fetal lung maturity until deli ery occurs or until there is a need to induce labor. Antibiotics are often administered to treat any infection and to pre ent chorioamnionitis. which can occur as the umbilical cord slips down in the pelvis and is a li(e3threatening situation (or the (etus4 there(ore. NURSE ALERT: Cord Prolapse 2hen dealing with ))*+. in preterm gestation. and uterine contractions.

nipple stimulation. and tampons and douches.t is important for patients with %%6@2 to understand the signs and symptoms that suggest infection as well as preterm labor. gestation. +hese include se'ual acti ity. %atients should be instructed to call their healthcare pro ider or report to the hospital immediately if the following signs and symptoms are notedL • • • • 3e er greater than !00.?#. which affects the ability of the newborn to ad(ust to e'trauterine life. orgasm. the preterm birth rate in the <nited States in 200H was !2. PRETERM LABOR AND BIRTH reterm labor refers to labor that occurs after 20 weeks’. but before ?7 weeks’. which often follows %%6@2. +x gen should be administered and the healthcare provider noti(ied immediatel . Some patients may be placed on bed rest and should be encouraged to follow this directi e to pre ent preterm labor. which was an increase from 2000 data. refers to deli ery prior to ?7 weeks’ gestation.>N3 $?HN/& 3oul"smelling aginal discharge or other signs of infection <terine contractions or cramping $including tightening of the abdomen& -ecreased fetal mo ement . patients should be encouraged to a oid acti ities or ob(ects that might induce labor or cause infection by e'posing the cer i' to bacteria.6uickl move into the knee3chest or 7rendelenburg position. %reterm birth is a significant contributor to infant mortality rates. reterm birth. a conse:uence of preterm labor.n addition. According to the 4ational 0ital Statistics 6eports $20!0&. INCIDENCE AND RIS' (ACTORS %reterm labor is responsible for preterm birth. PATIENT TEACHING . +he bo' below .

%0& MATERNAL AND (ETAL IMPLICATIONS %reterm labor and birth present a uni:ue challenge to patients and their fetuses. +he effects of preterm labor and birth depend on the gestational age of the fetus at deli ery.. SIGNS AND SYMPTOMS .presents a ariety of risk factors that predispose patients to preterm labor and subse:uent birth.g. RISK FACTORS FOR • • • • • • • • • • • • • • • R"T"RM !A%OR A#* %IRT) .ntimate partner iolence $. patients may be e'periencing preterm labor and birth due to conditions such as sepsis or . *owe er.ncompetent cer i' 2ultiple gestation %reeclampsia %oor nutrition %o erty $e.%0. +he fetus is at great risk for deli ering early as a result of preterm labor. low socioeconomic status& *istory of preterm labor and birth Ooung or ad anced maternal age . the immaturity of fetal lungs in the presence of preterm labor and birth is a significant concern for healthcare pro iders. homelessness. Specifically. Although most of the implications apply to the fetus.nfection -ehydration %%6@2 <terine bleeding -iabetes Substance abuse Smoking . patients may suffer from stress due to the diagnosis of preterm labor and birth as well as from the causati e agent.

therefore a sudden gush or constant trickle of aginal fluid may be noted. abdominal and. glucocorticoids.%atients presenting with preterm labor and birth often complain of feeling pressure in the pel ic area. the following should be notedL > contractions in 20 minutes or H contractions in G0 minutes with a progressi e change in the cer i'. this will .B and.or constant back pain. 8hen patients are faced with the possibility of deli ering a preterm infant. MEDICAL TREATMENT According to the American Academy of %ediatrics and the American /ollege of @bstetricians and 1ynecologists $as cited in /unningham et al.. 2edical treatment for preterm labor and birth is dependent upon the gestational age of the fetus. 2005&. contractions. intra enous fluids. patients should be monitored for signs and symptoms of infection. intra enous therapy to maintain hydration. healthcare pro iders seek to a oid deli ery of patients prior to ?> weeks’ gestation to allow further maturation of the fetal lungs $/unningham et al. and preparing the patient for possible deli ery. Although preterm labor and birth can occur rapidly. painful or painless contractions. Amniotic membranes may rupture prematurely. glucocorticoids to increase fetal lung maturity. As patients are often permitted to remain at home once stable. 1enerally. nursing care for these patients include teaching patients pre enti e measures that will help them a oid early deli ery. and tocolytics. 0ital signs.or uterine cramping or contractions.. 8hile hospitalized. which can lead to preterm labor. 3etal tachycardia indicates possible infection and should be e aluated immediately. it is imperati e that nurses address the emotional issues of the patient. feeling as though the fetus is Aballing up. 2005&. 1enerally. cer ical dilation greater than ! cm and cer ical effacement of H0# or greater. in order for a diagnosis of preterm labor to be gi en. the situation may :uickly become o erwhelming to them. and fetal status should be assessed as ordered or according to institutional policy. and tocolytics to control uterine contractions in patients with preterm labor. N"RSING CARE 4ursing care for patients e'periencing preterm labor include administering prescribed medications such as antibiotics. @ften healthcare pro iders prescribe antibiotics to treat infection.

orgasm.in ol e answering patient :uestions about the status of the fetus and preparing the patient for the care re:uired to pre ent deli ery or the necessary preparation for preterm deli ery. aginal e'ams. 6est in the left side"lying position to impro e blood flow to the uterus. PATIENT TEACHING +he ma(or goal of teaching patients with preterm labor is to help them become aware of factors that may cause premature labor and deli ery.. 9ncourage the patient to notify the healthcare pro ider immediately if any of the following signs and symptoms are notedL uterine contractions. se'ual acti ity.g. douches&. a feeling that the fetus is Aballing up. or fe er. tampons. constant back pain.B a gush or a constant trickle of aginal fluid. • • • . which causes the release of o'ytocin. /onsume ade:uate fluid to pre ent dehydration. cramping or irritability. T"AC)I#( • ATI"#TS "+ "RI"#CI#( R"T"RM !A%OR A oid acti ities that may disturb the cer i' and cause labor or infection $e.