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

pressure, cool and clammy skin, lightheadedness, and confusion. +he nurse should anticipate the need for o'ygen therapy and fluid and blood replacement. +he nurse may also be responsible for administering medications5 for e'ample, o'ytocin $%itocin& may be used to help in e'pelling the products of conception or to control bleeding. %atients should be blood"typed and cross"matched in case a blood transfusion is necessary.

+he nurse monitors ital signs, o'ygen saturation, intake and output, and laboratory results according to institutional policies. ,f a patient e'periences a threatened abortion but the fetus does not die, the nurse may be responsible for monitoring fetal heart sounds and the o erall well"being of the fetus depending on gestational age. +he nurse should administer prescribed 6hogam to 6h"negati e patients within 72 hours to pre ent isoimmunization.

+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. 2any patients feel that their actions somehow led to the spontaneous abortion5 therefore, feelings of guilt are often significant emotional challenges that many patients must deal with while grie ing their loss.

PATIENT TEACHING 8arning signs include fe er, foul"smelling aginal discharge, significant bright red aginal bleeding, and pel ic pain. ,n addition, patients are encouraged to a oid se'ual acti ity, tampons, or douches. 9'periencing a spontaneous abortion is challenging for patients both physically and emotionally and they need to rest for a few days after discharge. +hey may be re:uired to take iron supplements as a result of significant blood loss and;or antibiotics to treat or pre ent infection. 3oods such as li er, green leafy egetables, dried foods, and eggs pro ide needed iron. Additional fluid intake is recommended.

Ectopic Pre nanc!

9ctopic pregnancies occur when the o um is fertilized by the sperm but implants outside the uterus in the fallopian tubes, cer i', o ary, or abdominal ca ity. 2ost ectopic pregnancies occur in the fallopian tubes $3igure !&.

SIGNS AND SYMPTOMS

Signs and symptoms of an ectopic pregnancy include aginal bleeding, lack of menstruation $amenorrhea&, and abdominal pain. *owe er, other disease processes $e.g., spontaneous abortion& may be responsible for such symptoms. <ltrasound and laboratory testing are necessary to diagnose an ectopic pregnancy.

+he outcome of an ectopic pregnancy depends on the location of implantation. +he o um may naturally reabsorb into the body, or the structure supporting the o um may rupture. ,f the implantation site is a fallopian tube, the tube may rupture and cause internal hemorrhaging and hypo olemic shock, which is a life"threatening e ent for the patient.

Signs and symptoms of a ruptured fallopian tube include aginal bleeding, se ere abdominal pain or pel ic, shoulder or neck pain $as a result of blood leaking out of the fallopian tube and irritating the diaphragm&, weakness, dizziness, decreased blood pressure, and increased pulse. ,t is important to note that o er 50# of patients e'periencing an ectopic pregnancy are asymptomatic prior to tubal rupture $/han . =ohnson, 200>&.

MEDICAL MANAGEMENT
An ectopic pregnancy implanted in a fallopian tube re:uires either pharmacologic or surgical management. %harmacologic management with methotre'ate is indicated if the tube is unruptured, the ectopic pregnancy is less than ?.5 cm, the fetus is not li ing, and the patient is stable hemodynamically. @ften, patients re:uire more than one dose of methotre'ate for effecti e treatment. 2ethotre'ate treatment is usually performed on an outpatient basis.

,f the fallopian tube is ruptured as a result of an ectopic pregnancy and the patient wants to become pregnant in the future, a surgical procedure called a linear salpingostomy is performed to protect the tube. A linear salpingostomy re:uires a small linear incision in the tube to remo e the products of conception. +he tube is then allowed to heal without suturing to pre ent significant scarring. 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 tube is ruptured and the patient does not desire a future pregnancy, a laparoscopic salpingectomy is performed. +his procedure in ol es the actual remo al of the affected fallopian tube.

N"RSING CARE
+he nurse caring for a patient e'periencing an ectopic pregnancy looks for changes in the patients blood pressure and pulse, which could indicate hypo olemic shock resulting from hemorrhage. 6egular assessment of aginal bleeding is also essential. 6h"negati e patients re:uire administration of prescribed 6hogam to pre ent isoimmunization. 3inally, the nurse is responsible for monitoring and controlling pain le els.

,f a linear salpingostomy or salpingectomy is performed, the nurse monitors ital signs, o'ygen saturation, intake and output, and laboratory results according to institutional policies. As with all patients e'periencing a pregnancy loss, 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.

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. 2ore specifically, if the patient e'periences pain, significant bleeding, or a fe er and chills, she needs to notify her healthcare pro ider. ,f methotre'ate is used for the treatment of an ectopic pregnancy, the patient should be educated about the unpleasant side effects $nausea and omiting& of methotre'ate. +he patient should ha e a clear understanding of the feelings of anger, sadness, 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.

Gestationa# Trop$ob#astic Disease %GTD&

1estational trophoblastic disease, also known as a hydatidiform mole or a molar pregnancy, occurs when the chorionic illi of the placenta increase as a result of genetic abnormalities. +he illi swell, forming fluid"filled sacs, which appear as tiny clusters of grapes within the uterus. 2olar pregnancies are classified as complete or partial based on whether a fetus is present. A partial mole occurs when a fetus or an amniotic sac is present, whereas a complete mole only contains the fluid"filled sacs. +he fetus is usually non iable in a molar pregnancy. *owe er, according to -ente $2007&, although it is uncommon, AtwinningB has been reported with a complete CmoleD plus a sur i ing fetus with a normal placenta.B

INCIDENCE AND RIS' (ACTORS

1+- pregnancies are rare and occur in appro'imately ! in !000 pregnancies in the <nited States and 9urope $/unningham et al., 2005&. %atients of ad anced maternal age and of Asian descent ha e a higher risk of ha ing a molar pregnancy. Additionally, patients who e'perienced a pre ious molar pregnancy ha e a higher risk of ha ing a molar pregnancy in the future.

SIGNS AND SYMPTOMS

%atients with a 1+- e'hibit light to hea y bleeding and e en hemorrhage. Eleeding can be bright red or brown, appearing similar to prune (uice. Anemia may result due to bleeding. Additionally, as a result of the proliferation of tissues and the presence of clotted blood, the uterus may appear larger than e'pected for gestational age. -espite an enlarged uterus, fetal heart tones and mo ement are absent. Serum h/1 le els are also increased and patients may e'perience hyperemesis. Symptoms of gestational hypertension before 2> weeks gestation are a strong indication of gestational trophoblastic disease.

MEDICAL MANAGEMENT
2olar tissues are remo ed by acuum aspiration. ,ntra enous o'ytocin is usually administered to contract the uterus after the acuum aspiration. ,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., 2005&. 1entle

curettage, or scraping of the uterus, is performed to ensure that the uterus is emptied of all affected tissue.

N"RSING CARE
,t is ital that the nurse monitoring patients e'periencing molar pregnancies assess for signs and symptoms of bleeding and shock, including changes in heart rate, blood pressure and urinary output. ,f a patient has hyperemesis resulting from the molar pregnancy, the nurse should assist the patient with mouth care and any additional inter entions that are appropriate. 4ursing care also includes pre" and post"operati e care. )aboratory work, including a complete blood count, blood typing and crossmatching, and serum h/1 le els is re:uired prior to acuum aspiration and curettage.

6h"negati e patients should recei e 6hogam to pre ent isoimmunization. As with all pregnancy losses, patients may e'hibit grief in response to the loss. %atients should be informed that this is a normal response to a pregnancy loss5 therefore, nursing care includes referring patients to appropriate pro iders or support groups as needed.

PATIENT TEACHING
-ue to the risk of choriocarcinoma, it is ital that patients understand the need for regular follow"up to test serum h/1 le els. %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. ,t is important that patients are aware of the signs and symptoms of complications following a molar pregnancy and acuum aspiration, including e'cessi e bleeding, foul"smelling aginal discharge, and fe er.

%atients should a oid tampons, douches, and se'ual acti ity until the healthcare pro ider indicates that these acti ities can be performed safely. As a result of bleeding, patients may be anemic and re:uire increased iron intake or possibly iron supplementation. 3oods such as li er, green leafy egetables, dried foods, and eggs can pro ide needed iron. +he patient should also be encouraged to increase fluid intake.

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. %re ias are classified according to the degree to which they co er the os. Specifically, if the lower border of the placenta is close to, but does not :uite reach, the internal cer ical os, the pre ia is considered marginal. ,f the placenta partly co ers the internal os, the pre ia is considered a partial placenta pre ia. +he pre ia is considered a total pre ia if the placenta completely co ers the internal cer ical os $3igure 2&. As the pregnancy nears term and the cer i' dilates, the placenta implanted near or o er the internal cer ical os is disrupted and bleeding can occur. +he bleeding places the patient and her unborn child at"risk.

RISK FACTORS FOR

!AC"#TA

R"$IA

Ad anced maternal age /esarean section Smoking or drug use $e.g., cocaine& %re ious placenta pre ia <terine scarring $e.g., endometriosis& ,nduced or spontaneous abortion SIGNS AND SYMPTOMS
+he most significantly recognized symptom of placenta pre ia is painless, bright red aginal bleeding or hemorrhage during late pregnancy. ,t is imperati e that aginal e'aminations be a oided because stimulation of the placenta may cause hemorrhage. *owe er, bleeding may not occur until labor begins.

MATERNAL AND (ETAL IMPLICATIONS

As a result of the abnormally implanted uterus, the fetus is often in a trans erse or breech position, which may be noted during fundal e'amination. +he fetus may also e'perience hypo'ia and possibly death from maternal bleeding. +he patient may go into shock as a result of hemorrhage.

MEDICAL MANAGEMENT
As pre iously mentioned, aginal e'amination must be a oided if a patient presents with painless, bright red aginal bleeding because hemorrhage may occur. A transabdominal ultrasound can be performed to diagnose the pre ia. 2edical management of a placenta pre ia is largely determined by gestational age, fetal status, amount of bleeding, and type of pre ia. Some patients may deli er aginally if they are near term, the cer i' is ripe, the fetal heart tracing is reassuring, and there is minimal bleeding. *owe er, if there is a non" reassuring fetal heart tracing, significant bleeding, or hemorrhage, or a complete pre ia is present, a cesarean section is usually necessary.

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. Significant bleeding or hemorrhage should be reported immediately to the appropriate healthcare pro ider. 6egular assessment of fetal heart rate and mo ement is necessary. 4on"reassuring fetal heart rate patterns should be reported to the healthcare pro ider immediately. ,t is important to note that pregnant patients can e'perience significant blood loss $appro'imately >0#& without a change in ital signs $)owdermilk . %erry, 200G&. +herefore, careful monitoring of bleeding is imperati e as ital sign changes may not be initially e ident.

%atients with a placenta pre ia should remain on bed rest. 4on"stress testing to e aluate fetal status is performed during bleeding episodes, while intermittent fetal heart tones are obtained according to medical orders or institutional policy. %atients should be blood"typed and cross"matched in case a blood transfusion is necessary. ,ntra enous access should be maintained for prompt administration of fluids or blood products.

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, 200G&. 6hogam is gi en to 6h negati e patients during each bleeding episode to pre ent isoimmunization.

PATIENT TEACHING

,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. ,n addition, 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.

Abruptio P#acentae
Abruptio placentae, often referred to as an abruption or placenta abruption, is the premature separation of the normally implanted placenta from the uterine wall before labor and deli ery of the newborn. Eleeding occurs between the uterine wall and the placenta.

Abruptio placentae is classified according to the degree of placental separation and subse:uent hemorrhage. An abruption can be partial or complete, with apparent or concealed hemorrhage $3igure ?&. An abruption is partial if a section of the placenta separates from the uterine wall but the margins of the placenta remain intact. A complete abruption occurs when the entire placenta detaches from the uterine wall. Apparent hemorrhage refers to bleeding that is e ident, while a concealed hemorrhage denotes bleeding that is obscured.

RISK FACTORS FOR A%R& TIO

!AC"#TA"

-rug use $e.g., cocaine& Alcohol abuse /igarette smoking *ypertension -iabetes mellitus Ad anced maternal age 2ultiparity and multiple pregnancy *istory of abruptio placentae +hromboembolic disorders

%remature rupture of membranes $%6@2& Abdominal trauma $e.g., accident, iolence& SIGNS AND SYMPTOMS
+he classic signs and symptoms of abruption placentae include aginal bleeding, which may be dark red due to old blood from a concealed abruption, uterine tenderness, and a board"like abdomen. %atients often complain of an aching or dull pain in the abdomen or lower back. Additionally, uterine irritability with poor uterine resting tone is fre:uently noted.

MATERNAL AND (ETAL IMPLICATIONS

Abruptio placentae is a life"threatening e ent for the patient and the fetus. %atients with an abruption are at risk for de eloping hypo olemic shock, disseminated intra ascular coagulation $-,/&, and possibly death. %atients may also suffer from postpartum hemorrhage after deli ery due to poor contractility of the uterus following an abruption. Since the placenta is the source of o'ygenation for the unborn fetus, premature separation of the placenta from the uterine wall can place the fetus at great risk for hypo'ia and death.

MEDICAL TREATMENT
Abruptio placentae is usually diagnosed by abdominal ultrasound, in addition to the presenting signs and symptoms. +reatment is based on the degree of placental separation and subse:uent hemorrhage, as well as the status of the patient and fetus. ,n the presence of se ere abruption and hemorrhage, emergency cesarean section is performed. *owe er, in some cases, the abrupted area is small and emergency deli ery is not necessary. 0aginal deli ery can be safely performed if the patient and fetus are hemodynamically stable $-a idson, )adewig . )ondon, 200H&.

N"RSING CARE
Although aginal deli ery is preferred to cesarean section for patients who are hemodynamically stable, the nurse must be prepared to deal with the possibility of se ere hemorrhage and hypo olemic shock, as well as the resulting fetal distress. %atients should ha e intra enous access with a large bore catheter to accommodate the administration of fluid and blood products.

,t is necessary to monitor carefully the status of the patient and fetus. 3re:uent ital signs and fetal heart tones, as well as monitoring and documentation of blood loss, is essential. Abnormal ital signs, bleeding, or non"reassuring fetal heart patterns should be reported immediately to the appropriate healthcare pro ider. @bser ation and documentation of the patients intake and output, and pain and comfort le els, is also essential. %atients should be blood typed and cross"matched in case a blood transfusion is necessary. 6hogam is indicated for 6h negati e patients.

Eecause the potential for patient and fetal in(ury is high in the presence of abruptio placentae, it is important to address the emotional needs of the patient. %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.

PATIENT TEACHING
%atients should be instructed to report bleeding and se ere abdominal pain immediately. ,t is important to inform patients with abruptio placentae that emergency deli ery may be necessary. ,f a patient must ha e an emergency cesarean section, it is important for the nurse to :uickly communicate to the patient and her family what will occur before and during the procedure. 4urses should remember that hemorrhage and emergency surgery can be ery frightening5 therefore, clear and honest information must be gi en to the patient and her family as fre:uently as possible.

!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, 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, formerly known as pregnancy-induced hypertension, refers to hypertension occurring for the first time during pregnancy. -iagnosis of gestational hypertension re:uires a blood pressure that is greater than or e:ual to !>0;I0 mm *g. +he blood pressure should be ele ated on at least two occasions > to G hours apart. +he diagnosis is made after 20 weeks gestation and is characterized by a blood pressure that returns to normal by !2 weeks postpartum. %atients with gestational hypertension do not present with proteinuria, which is a characteristic of preeclampsia. *owe er, gestational hypertension may progress to preeclampsia.

%reeclampsia is identified by a blood pressure that is greater than or e:ual to !>0;I0 mm *g, in the presence of protein in the urine $proteinuria&. %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.

"clampsia is the occurrence of seizures in the presence of preeclampsia. <sually, seizures are related to gestational hypertension and not to other causes. Seizures can occur anytime before, during, or after deli ery of the fetus.

Preeclampsia Superimposed on Chronic Hypertension

%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, or a platelet count less than !00,000 mm? in patients with hypertension and proteinuria before 20 weeks gestation $/unningham et al., 2005&. 2edical treatment and nursing care for patients with preeclampsia superimposed on chronic hypertension is similar to that of gestational hypertension and preeclampsia. %atient with preeclampsia superimposed on chronic hypertension are often treated with antihypertensi e agents.

INCIDENCE AND RIS' (ACTORS

According to the 4ational 0ital Statistics 6eports $20!0&, ?H.H# of !000 pregnancies were affected by pregnancy"related hypertensi e complications in 2007. Additionally, pregnancy" related hypertension is a significant contributor to maternal and fetal mortality rates. 1ibson and /arson $20!0& indicate that gestational hypertension occurs in appro'imately 2# to ?# of pregnancies in the <nited States, while )eifer $2005& indicates that eclampsia occurs in 5# of pregnancies.

%rimagra idas, African Americans, diabetics, patients of either young or ad anced maternal age, and patients pregnant with multiples are at a greater risk for de eloping pregnancy" related hypertension. A family history of pregnancy"related hypertension is also a significant risk factor.

PATHOPHYSIOLOGY
0asospasm in the arterioles of patients with gestational hypertension causes increased blood pressure and a decrease in placenta and uterine perfusion. 6enal blood flow is reduced, along with the renal glomerular filtration rate, which produces proteinuria. *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. )i er enlargement is the result of hepatic changes that lead to epigastric pain. 1eneralized asospasm causes endothelial cell damage, which triggers coagulation pathways and, subse:uently, abnormalities in bleeding and clotting can occur $)eifer, 2005&.

SIGNS AND SYMPTOMS

Signs and symptoms of pregnancy"related hypertension ary depending on the se erity of the hypertension. *owe er, the common signs and symptoms of pregnancy"related hypertension include headache, blurred ision, epigastric pain, weight gain $K2 pounds per week&, oliguria, and proteinuria. Although no longer considered diagnostic of pregnancy" related hypertension $/unningham et al., 2005&, edema may still be noted in these patients.

MATERNAL AND (ETAL IMPLICATIONS

*ypertension in pregnancy places patients and their fetuses at great risk for a ariety of complications. Some of the most significant maternal complications of hypertension in pregnancy include cerebral ascular accident $/0A&, disseminated intra ascular coagulation $-,/&, and placental abruption from the ele ated blood pressure. Additionally, patients are at risk for the de elopment of *9))% syndrome in the presence of gestational hypertension. =ust as its name implies, *9))% syndrome causes great dysfunction within the body that re:uires immediate inter ention. ,t is characterized byL

)emolysis of red blood cells, which leads to anemia "le ated li er enzymes leading to epigastric pain !ow platelets, 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, aspiration pneumonia, hypo'ic encephalopathy, and thromboembolic disorders $/allahan et al., 200>&. 3etal complications include intrauterine growth retardation and premature deli ery resulting from decreased placenta perfusion.

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, as well as the potential risk to the patient and fetus. -uring early pregnancy, outpatient management is usually appropriate5 these patients are monitored at home for blood pressure and proteinuria. 6egular fetal monitoring is necessary to e aluate fetal well"being. ,n addition, placental

perfusion tests can also be performed to assess and monitor uteroplacental sufficiency. %atients with e idence of ad anced dysfunction, such as oliguria, renal failure, or *9))% syndrome, are usually deli ered immediately $)eifer, 2005&.

Since deli ery is the only known cure for pregnancy"related hypertension, 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, if the healthcare pro ider determines that the fetus is too premature for deli ery, antihypertensi e medications may be administered to decrease blood pressure, thereby prolonging fetal growth in utero. 1lucocorticoids are administered to enhance fetal lung maturity $/unningham et al., 2005&.

*ealthcare pro iders may prescribe magnesium sulfate $2gS@ >& during labor and deli ery to pre ent seizures. 2agnesium sulfate is not used to control hypertension. 2agnesium sulfate is administered intra enously ia an infusion deli ery de ice during deli ery and for 2> hours post deli ery. Since 2gS@>can cause fetal respiratory depression following deli ery, arrangements should be made for specialized neonatal care.

N"RSING CARE
%regnancy"related hypertension presents a great risk to patients and their unborn fetuses. +herefore, it is the responsibility of the nurse to monitor the patient carefully for signs of a decline in health status. +he nurse should immediately report increases in blood pressure, isual disturbance changes, se ere headaches, epigastric pain, and oliguria to the appropriate healthcare pro ider.

8hile patients are hospitalized for pregnancy"related hypertension, the nurse will monitor blood pressure and the well"being of the fetus. ,f magnesium sulfate $2gS@>& is prescribed for preeclampsia or eclampsia, a 3oley catheter is usually inserted to monitor urine output and to obtain regular urine specimens. +he nurse is responsible for administering 2gS@> and for monitoring its to'icity. 2agnesium sulfate to'icity can be pre ented by ensuring that urine output is ade:uate $at least ?0 ml;hr&, deep tendon refle'es are present, and the respiratory rate is greater than !2 breaths per minute. ,f 2gS@ > to'icity is noted, the healthcare pro ider must be notified immediately and the infusion discontinued. /alcium gluconate can be administered when prescribed to re erse the effects of magnesium

2gS@> to'icity. +he serum magnesium le el for patients recei ing 2gS@ > should be > to 7 mg;dl $/unningham et al., 2005&.

,n the presence of eclampsia, the nurse must be prepared to pre ent in(ury to the patient during seizures and to monitor seizure acti ity. Eed side rails should be up and padded. 9mergency e:uipment should be readily a ailable, including an oral airway, o'ygen, a bag" al e"mask $E02&, and emergency medication. ,n the e ent of a seizure, patients should be protected from in(ury. +he nurse should note the beginning and ending of the seizure and ensure ade:uate o'ygenation after seizure acti ity has ceased. +he nurse should not attempt to insert an oral airway or other ob(ect into the mouth during a seizure. +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, 2005&. +he nurse obtains ital signs and monitors the fetus following the 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. Specifically, patients are taught to notify their healthcare pro ider if they e'perience headaches, isual disturbances, epigastric pain, or sudden weight gain. %atients may be taught to monitor their weight, blood pressure, and urine protein at home. +hey are instructed to notify the appropriate healthcare pro ider of ele ated blood pressures or protein in the urine. +hey should also be instructed to perform daily fetal kick counts to monitor fetal well"being, as well as to increase protein intake because proteinuria decreases the amount of a ailable protein.

+he nurse encourages patients with pregnancy"related hypertension to rest in the left side" lying position as much as possible, whether at home or in the hospital. +his position pre ents unnecessary pressure on the ena ca a, which decreases renal and placental blood flow and leads to increased blood pressure $)eifer, 2005&. +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. 4ursing care should be performed in a manner that pre ents unnecessary disturbances to

the patients en ironment while hospitalized. Stress and an'iety is a ma(or concern in patients with pregnancy"related hypertension, as it can lead to increased blood pressure. +herefore, the nurse should discuss stress and an'iety management with patients.

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. *owe er, gestational diabetes often resol es after deli ery. +he cause of gestational diabetes is largely unknown. *owe er, it is belie ed that, as the fetus grows, glucose demands increase for the pregnant patient. ,n addition, the Ainsulin"antagonisticB properties of placental hormones affect the patient by causing insulin resistance $)owdermilk . %erry, 200G&. As a result, the pregnant patient is unable to process glucose in the body and hyperglycemia occurs.

INCIDENCE AND RIS' (ACTORS

According to the American -iabetes Association $n.d.&, gestational diabetes affects 7# of pregnancies in the <nited States. Se eral factors that place patients at risk for de eloping gestational diabetes mellitus are listed below.

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. %atients ha e a significant chance of deli ering ia cesarean section due to the

large size of infants born to patients with gestational diabetes. %atients also ha e an increased fre:uency of hypertension $/unningham et al., 2005&.

,nfants born to patients with gestational diabetes mellitus are usually macrosomic $birthweight K>500 grams&. +his occurs due to fetal hyperinsulinemia as a result of maternal hyperglycemia, 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. ,f aginal deli ery is attempted, the infant is at risk for shoulder dystocia or other birth in(uries. After deli ery, the newborn infants blood glucose must be monitored regularly due to the sharp decrease in a ailable glucose after the umbilical cord is cut. +he newborns pancreas continues to produce insulin after deli ery despite the decrease in serum glucose. +his adds to the potential instability of the infants blood glucose. ,nfants are also at risk for hypocalcemia, hyperbilirubinemia, and respiratory distress syndrome as a result of gestational diabetes.

MEDICAL TREATMENT
%regnant patients are routinely screened for gestational diabetes mellitus between 2> and 2I weeks gestation. ,n order to diagnose gestational diabetes, patients drink 50 grams of oral glucose solution. After one hour, a blood sample is obtained and tested for glucose tolerance. A glucose le el of !?5 to !>0 mg;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., as cited in )owdermilk . %erry, 200G&.

2ost patients with gestational diabetes are treated through diet. +hey are encouraged to consume a proper diet and obtain ade:uate e'ercise. According to the American -iabetes Association $as cited in /unningham, et al., 2005&, patients with gestational diabetes should consume a diet that pro ides ?0"kcal;kg;d. 3urthermore, they indicate that patients with a body mass inde' greater than ?0 kg;m2 may benefit from a ?0# to ??# caloric restriction. Eesides proper diet and e'ercise, some patients may re:uire insulin or oral hypoglycemia agents to manage gestational diabetes mellitus.

NURSE ALERT: Resistance Exercise and Gestational Diabetes

Brankston and associates (as cited in Cunningham, et al., 2005), indicate that resistance exercise can help overweight patients with gestational diabetes avoid insulin therap .

N"RSING CARE
,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. A referral to a dietician may also be necessary. +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.

-uring labor, 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. Elood glucose may be monitored as often as e ery hour.

After deli ery, the nurse is responsible for monitoring the infants blood glucose le els, as glucose instability is common in newborns born to patients with gestational diabetes mellitus. ,f the newborns blood glucose le el is below acceptable national or institutional standards, usually M>0 mg;d), treatment with intra enous fluids, intra enous or oral glucose, or early feedings is necessary. 4urses must be aware of signs and symptoms of hypoglycemia in the newborn, including (itteriness, tremors, irritability, lethargy, seizures, tachypnea, temperature instability, and;or poor feeding and take appropriate action to assist in the treatment of hypoglycemia.

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. ,n addition, the nurse can teach patients about proper diet and safe e'ercise during pregnancy. -uring prenatal isits, the nurse re iews the blood glucose and diet logs to make recommendations about monitoring, medication administration, and diet. %atients may also need to learn how to self"administer insulin. +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.

,t is imperati e that the nurse teach patients with gestational diabetes the signs and symptoms of hypoglycemia. +hese signs and symptoms include shakiness, an'iety, headache, hunger, cold, clammy skin, and tingling around the mouth. +he patient should be

taught to closely monitor for hypoglycemia and to notify their healthcare pro ider immediately if signs and symptoms are noted. +he patient can drink milk or (uice or eat fruit to correct hypoglycemia $)eifer, 2007&.

Since the potential for de eloping diabetes is significant in patients with gestational diabetes, it is important that patients understand the need for follow"up e aluation after deli ery. %atients should continue to watch for signs and symptoms of hypoglycemia and notify their healthcare pro ider if seen.

AMNIOTIC MEMBRANE COMPLICATIONS

remature rupture of membranes $%6@2& refers to the rupture of membranes ! hour or more before the onset of labor, whereas preterm premature rupture of membranes $%%6@2& refers to the rupture of membranes prior to ?7 weeks gestation. %reterm premature rupture of membranes and %6@2 are often associated with preterm labor and birth.

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 . *ill, 200G&. %remature rupture of membranes $%6@2& occurs in ?#" to !H# of all pregnancies $Erown, 2000&. 6isk factors for preterm premature and premature rupture of membranes include infections such as S+,s, a prematurely dilated cer i', hydramnios, multiple pregnancy, fetal malpresentation, maternal nutritional deficiencies, and stress. African American patients ha e a higher risk of de eloping early rupture of membranes $Erown, 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, )ondon . )adewig, 200H&.

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 )*+, through bacteremia and increased levels o(

proin(lammator c tokines- (p. ."0). /(ter conducting a stud o( the deliver data (or more than 01 million women, the (ound that $o( the acute respirator conditions, acute upper respirator disease and viral and bacterial pneumonia were associated with )*+,, but not acute bronchitis. +( the chronic respirator conditions, asthma was associated with )*+,, but chronic bronchitis was not- (p. ."1).
MATERNAL AND (ETAL IMPLICATIONS
%reterm premature rupture of membranes can cause a ariety of problems, especially for the unborn fetus. 8ithout the protecti e barrier of the amniotic membrane, the fetus is at a greater risk for the de elopment of infection and preterm deli ery. +he fetus is also at risk for becoming septic after deli ery. Additionally, without the cushioning of the amniotic fluid there is a higher probability of umbilical cord compression as well as cord prolapse.

%atients with %%6@2 or %6@2 ha e a risk of de eloping chorioamnionitis, which is an infection of the chorion and amnion of the placenta that can be life"threatening for the patient and fetus.

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. +he healthcare pro ider will then perform a sterile speculum e'amination to look for pooling of amniotic fluid near the cer i'. 3luid is tested using nitrazine paper as well as ia microscopic e'amination for the presence of Aferning.B <ltrasound e'amination may be performed to determine the amount of a ailable amniotic fluid after the rupture of membranes.

2edical treatment for patients with %%6@2 or %6@2 depends on a ariety of factors. 1estational age, fetal lung maturity, a ailable amniotic fluid, and etiology must be considered before deciding on treatment. %atients near term whose labor does not begin spontaneously following the rupture of membranes may be induced if the cer i' is ripe. 3or preterm patients, healthcare pro iders and patients may desire to prolong the pregnancy to

promote fetal lung maturity. %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.

+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. Antibiotics are often administered to treat any infection and to pre ent chorioamnionitis. ,f there is a significant loss of amniotic fluid rather than a slow leak, there is a stronger possibility of the need to induce labor. *owe er, in preterm gestation, an amniotic sac with a slow leak of amniotic fluid may form a seal and the amniotic fluid may reestablish itself $2cFinney et al., 2005&.

N"RSING CARE
As with medical treatment, nursing care greatly depends on whether the medical diagnosis is %%6@2 or %6@2. *owe er, nursing care typically in ol es assisting the healthcare pro ider to confirm the rupture of membranes, monitoring the patient for infection and for the presence of uterine contractions, and monitoring the status of the fetus. ,t is imperati e that the nurse change patient underpads fre:uently and a oid unnecessary aginal e'aminations to pre ent infection.

@ften, patients with %%6@2 who are considered stable are initially monitored on an inpatient basis and then discharged to home. 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. 4ursing care for patients whose labor is induced in ol es administering induction agents and monitoring the status of the patient, fetus, and uterine contractions. As with all complications in pregnancy, the nurse should be a ailable to answer :uestions and assist in relie ing the patients an'iety about her diagnosis.

NURSE ALERT: Cord Prolapse

2hen dealing with ))*+, and )*+,, the nurse should be prepared to deal with cord prolapse and compression, which can occur as the umbilical cord slips down in the pelvis and is a li(e3threatening situation (or the (etus4 there(ore, the (etus must be monitored closel . 5n the event o( cord prolapse and compression, the nurse should attempt to relieve pressure on the umbilical cord and instruct the patient to

6uickl move into the knee3chest or 7rendelenburg position. +x gen should be administered and the healthcare provider noti(ied immediatel .
PATIENT TEACHING
,t is important for patients with %%6@2 to understand the signs and symptoms that suggest infection as well as preterm labor, which often follows %%6@2. %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.>N3 $?HN/& 3oul"smelling aginal discharge or other signs of infection <terine contractions or cramping $including tightening of the abdomen& -ecreased fetal mo ement

,n addition, 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. +hese include se'ual acti ity, orgasm, nipple stimulation, and tampons and douches. Some patients may be placed on bed rest and should be encouraged to follow this directi e to pre ent preterm labor.

PRETERM LABOR AND BIRTH

reterm labor refers to labor that occurs after 20 weeks, but before ?7 weeks, gestation. reterm birth, a conse:uence of preterm labor, refers to deli ery prior to ?7 weeks gestation.

INCIDENCE AND RIS' (ACTORS

%reterm labor is responsible for preterm birth, which affects the ability of the newborn to ad(ust to e'trauterine life. According to the 4ational 0ital Statistics 6eports $20!0&, the preterm birth rate in the <nited States in 200H was !2.?#, which was an increase from 2000 data. %reterm birth is a significant contributor to infant mortality rates. +he bo' below

presents a ariety of risk factors that predispose patients to preterm labor and subse:uent birth.

RISK FACTORS FOR

R"T"RM !A%OR A#* %IRT)

,nfection -ehydration %%6@2 <terine bleeding -iabetes Substance abuse Smoking ,ncompetent cer i' 2ultiple gestation %reeclampsia %oor nutrition %o erty $e.g., homelessness, low socioeconomic status& *istory of preterm labor and birth Ooung or ad anced maternal age ,ntimate partner iolence $,%0&

MATERNAL AND (ETAL IMPLICATIONS

%reterm labor and birth present a uni:ue challenge to patients and their fetuses. Although most of the implications apply to the fetus, patients may suffer from stress due to the diagnosis of preterm labor and birth as well as from the causati e agent. Specifically, patients may be e'periencing preterm labor and birth due to conditions such as sepsis or ,%0. +he fetus is at great risk for deli ering early as a result of preterm labor. +he effects of preterm labor and birth depend on the gestational age of the fetus at deli ery. *owe er, the immaturity of fetal lungs in the presence of preterm labor and birth is a significant concern for healthcare pro iders.

SIGNS AND SYMPTOMS

%atients presenting with preterm labor and birth often complain of feeling pressure in the pel ic area, abdominal and;or uterine cramping or contractions, painful or painless contractions, feeling as though the fetus is Aballing up,B and;or constant back pain. Amniotic membranes may rupture prematurely, therefore a sudden gush or constant trickle of aginal fluid may be noted.

MEDICAL TREATMENT
According to the American Academy of %ediatrics and the American /ollege of @bstetricians and 1ynecologists $as cited in /unningham et al., 2005&, in order for a diagnosis of preterm labor to be gi en, the following should be notedL > contractions in 20 minutes or H contractions in G0 minutes with a progressi e change in the cer i', cer ical dilation greater than ! cm and cer ical effacement of H0# or greater.

2edical treatment for preterm labor and birth is dependent upon the gestational age of the fetus. 1enerally, 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., 2005&. @ften healthcare pro iders prescribe antibiotics to treat infection, glucocorticoids to increase fetal lung maturity, intra enous therapy to maintain hydration, 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, glucocorticoids, intra enous fluids, and tocolytics, and preparing the patient for possible deli ery. 8hile hospitalized, patients should be monitored for signs and symptoms of infection, which can lead to preterm labor. 3etal tachycardia indicates possible infection and should be e aluated immediately. 0ital signs, contractions, and fetal status should be assessed as ordered or according to institutional policy. As patients are often permitted to remain at home once stable, nursing care for these patients include teaching patients pre enti e measures that will help them a oid early deli ery.

8hen patients are faced with the possibility of deli ering a preterm infant, the situation may :uickly become o erwhelming to them. Although preterm labor and birth can occur rapidly, it is imperati e that nurses address the emotional issues of the patient. 1enerally, this will

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.

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.

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.g., aginal e'ams, se'ual acti ity, orgasm, tampons, douches&. 6est in the left side"lying position to impro e blood flow to the uterus. /onsume ade:uate fluid to pre ent dehydration, which causes the release of o'ytocin. 9ncourage the patient to notify the healthcare pro ider immediately if any of the following signs and symptoms are notedL uterine contractions, cramping or irritability, constant back pain, a feeling that the fetus is Aballing up,B a gush or a constant trickle of aginal fluid, or fe er.