- Patho: the most severe class of gestational
hypertension
NURSING CARE OF THE FAMILY EXPERIENCING A
SUDDEN PREGNANCY COMPLICATION
By: Ms. Marvie Joy B. Cabioc, MAN, RN, PhD
RISK FACTORS FOR GESTATIONAL HYPERTENSION
• Affects central nervous system
• Eyes
• Urinary tract
• Respiratory system
• Gastrointestinal and liver
Management of gestational hypertension
• Depends on severity of the hypertension and on
the maturity of the fetus
Treatment of gestational hypertension focuses on:
• Maintain blood flow to the woman’s vital
organs and to the placenta
• Preventing convulsions
• Magnesium sulfate in gestational HTN/HPN
- Action: CNS depressant that blocks
acetylcholine. Halts convulsions and halts
premature labor by relaxing smooth muscle.
- Dose: 2-6 g IV over 20 min
- Therapeutic range: 5-8 mg/100 ml
- 8-10 mg: patellar reflex gone
- 15-20 mg: lungs fail
- 20 mg: cardiac issues occur
- Adverse effects:
➢ Absence of deep tendon reflexes,
respiratory depression in neonate
➢ Cardiac issues
➢ Decreased UO
Nursing Responsibilities on Gestational hypertension
- Assess patellar reflex q1-4 h
- Monitor intake and output
- Monitor serum magnesium level
- Run in a separate IV line
- Keep calcium gluconate as antidote
Magnesium sulfate toxicity
- Absence of patellar deep tendon reflexes
- Respiratory rate less than 12/min
- Cardiac dysrhythmia
- Urine output less than 30 ml/hour
- Decreased LOC
How often should magnesium level be drawn?
1. Before therapy
2. Every 6-8 hours
ECLAMPSIA
- Cerebra edema is so acute that grand mal
or coma occurs
- Occurs up to 2 weeks after delivery, mostly
2 days after
SYMPTOMS OF ECLAMPSIA
- Coma or grand-mal seizure
- Includes other signs and symptoms of pre-
eclampsia
- Sharp rise of temperature
- Aura
NURSING RESPONSIBILITIES FOR ECLAMPSIA
- Maintain airway (turn on side)
- Assess for uterine contractions
- Decision about birth will be made 12-24
hours after seizure (vaginal always
preferred)
Conservative treatment
- Activity restriction
- Maternal assessment of fetal activity
- Blood pressure monitoring
- Daily weight
- Checking urine for protein
Drug therapy
- Magnesium sulfate
• Calcium gluconate reverses effects
of magnesium sulfate
- Antihypertensive
BLEEDING INCOMPATIBILITIES
- Rh-negative blood type is an autosomal
recessive trait
- Rh-positive blood type is a dominant trait
- Rh incompatibility can only occur if the
woman is Rh-negative and the fetus if Rh-
positive.
HELLP SYNDROME
- Patho: variation of gestational HTN named
after its symptoms
- Caused by high BP
H – Hemolysis
EL – increase liver enzymes
LP – decrease platelet count
• 10-20% of severe pre-eclampsia and
eclampsia
• 1-2/1000 normal pregnancies
• Fatigue
• Fluid retention and excess weight
gain
• Headache
 • Worsening nausea and vomiting
• Upper right abdomen pain
• Blurry vision
• Nosebleed or other bleeding that
most stop easily
• Seizures or convulsions
WHO GETS IT?
- Antiphospholipid syndrome or presence of
anti-phospholipid AB
ISOIMMUNIZATION
- The leaking of fetal Rh-positive blood into
the Rh-negative mother’s circulation,
causing her body to respond by making
antibodies to destroy the Rh-positive
erythrocytes
- With subsequent pregnancy, the woman’s
antibodies against Rh-positive blood cross
the placenta and destroy the fetal Rh-
positive erythrocytes before the infant is
born.
ERYTHROBLASTOSIS FETALIS
- Occurs when the maternal anti-Rh
antibodies cross the placenta and destroy
fetal erythrocytes
- Requires RhoGAM to be given at 28 weeks
and within 72 hours of delivery to the
mother
- Fetal assessment tests must be done
throughout pregnancy
- An intrauterine transfusion may be done for
the severely anemic fetus
PREGNANCY COMPLICATED BY MEDICAL CONDITION
- Diabetes mellitus (DM)
- Classifies if preceded pregnancy
- Type 1: pathologic disorder
- Type 2: insulin resistance; genetic
predisposition
- Pregestational DM: type 1 or 2 DM
- Gestational Diabetes (GDM)
- Glucose intolerance with onset during
pregnancy
- In true Gestational diabetes, glucose usually
returns to normal by 6 weeks postpartum
EFFECTS OF PREGNANCY ON GLUCOSE METABOLISM
- Hormones (estrogen and progesterone),
insulinase (an enzyme) and increased
prolactin levels have two effects:
➢ Increase resistance of cells to
insulin
➢ Increased speed of insulin
breakdown
- Gestational diabetes mellitus (GDM)
➢ If woman cannot increase her insulin
production she will have periods of
hyperglycemia
➢ Because fetus is continuously drawing
glucose from the mother, she will also
experience hypoglycemia between
meals and during the night
➢ During the second and third trimesters,
fetus is at risk for organ damage from
hyperglycemia because fetal tissue has
increased tissue resistance to maternal
insulin action
- Pregestational diabetes mellitus
➢ Major risk for congenital anomalies
to occur from maternal
hyperglycemia during the
embryonic period of development
FACTORS LINKED TO GDM
- Maternal obesity (>90 kg or 198 lbs.)
- Large infant (>4000 g or about 9 lbs.)
- Maternal age older than 25 years
- Previous unexplained stillbirth or infant
having congenital abnormalities
- History of GDM in previous pregnancy
- Family history of DM
- Fasting glucose over 126 mg/dl or post meal
glucose overdose
- Macrosomic infant
TREATMENT
- Diet
- Monitoring blood glucose levels
- Ketone monitoring
- Exercise
- Fetal assessment
- Care during labor of the woman with GDM
- Intravenous infusion of dextrose may be
needed
- Regular insulin
- Assess blood glucose levels hourly and
adjust insulin administration accordingly
- Care of the neonate who mother had GDM
may have the following:
o Hypoglycemia
o Respiratory distress
- Injury related to macrosomia
- Blood glucose monitored closely for at least
the first 24 hours after birth
- Breastfeeding should be encouraged
- Heart disease
MANIFESTATIONS
- Increased levels of clotting factors
- Increased risk for thrombosis
• If woman’s heart cannot handle
• Increased workload, congestive
heart failure (CHF results)
 • Fetus suffers from reduced Treatment
placental blood flow
- Oral doses of elemental iron
SIGNS OF CHF (CONGESTIVE HEART FAILURE) DURING - Continue therapy for about 3 months after
PREGNANCY anemia has been corrected

- Signs of CHF during pregnancy Folic-acid deficiency anemia

- Persistent cough
- Large, immature RBCs (megaloblastic
- Moist lung sounds
anemia)
- Fatigues or fainting on exertion
- Anticonvulsants, oral contraceptives, sulfa
- Difficulty breathing on exertion
drugs, and alcohol can decrease absorption
- Orthopnea
of folate from meals
- Severe pitting edema of the lower
- Folate essential for normal growth and
extremities or generalized edema
development
- Palpations
- Prevention
- Changes in fetal heart rate
o Daily supplement 400 mcg (0.4 mg)
o Indicating hypoxia or growth
per day
restrictions
Treatment
TREATMENT
- Folate deficiency is treated with folic acid
- Under care of both obstetrician and
supplementation
cardiologists
- 1 mg/day (over twice the amount of the
- Priority care is limiting physical activity
preventive supplement)
• Drug therapy
- Dose may be higher for women who have
• May include beta-adrenergic
had a previous child with a neural tube
blockers, anticoagulants, diuretics
defect
- Vaginal birth is preferred as it carries less
• Genetic anemias
risk for infection or respiratory
• Sickle cell disease
complications
• Autosomal recessive disorder
- Anemia
• Abnormal hemoglobin
- The reduced ability of the blood to carry
- Causes erythrocytes to become distorted
oxygen to the heart
sickle (crescent) shaped during hypoxic or
- Nutritional anemias
acidotic episodes
Four types are significant during pregnancy - Abnormally shaped blood cells do not flow
smoothly
- Two are nutritional
- Can clog small blood vessels
• Iron deficiency
• Pregnancy can cause a crisis
• Folic acid deficiency
• Massive erythrocyte destruction and vessel
- Two are genetic disorders
occlusion
• Sickle cell disease
- Risk to fetus is occlusion that supply the
• Thalassemia
placenta
Symptoms • Can lead to preterm birth, growth restriction,
and fetal demise
- Easily fatigued
• Oxygen and fluids are given continuously
- Skin mucous membranes are pale
through labor
- Shortness of breath
• Thalassemia
- Pounding heart
• Genetic trait causes abnormality in one of two
- Rapid pulse (with severe anemia)
chain of hemoglobin
Iron deficiency anemia
BETA CHAIN SEEN MOST OFTEN IN U.S.
- RBCs are small (microcytic) and pale
- Can inherit abnormal gene from each
(hypochromic)
parent, causing beta-thalassemia major
Prevention:
- If only one abnormal gene is inherited,
- Iron supplements
infant will have beta-thalassemia minor
- Vitamin C may enhance absorption
• Woman with beta-thalassemia minor has few
- Do not take iron with milk or antacid
problems, other than mild anemia
- Calcium impairs absorption
• Fetus does not appear affected
• Iron supplements may cause iron overload
 - Body absorbs and stores iron in higher- - Deafness
than-usual amount - Cardiac effects
- Intrauterine growth restriction (IUGR)
NURSING CARE FOR ANEMIAS DURING PREGNANCY
- Herpesvirus
• Teach woman about foods that are high in iron - Two types:
and folic acid o Type 1: likely to cause fever blisters
• Teach how to take supplements or cold sores
• Do not take iron supplements with milk o Type 2: likely to cause genital
• Do not take antacids with iron herpes
• When taking iron, stools will be dark green to - After primary infection, lies dormant in the
black nerves, can reactivate at any time
• The woman with sickle cell disease requires - Initial infection during first half of
close medical and nursing care pregnancy may cause spontaneous
abortion, IUGR, and preterm labor
• Taught to prevent dehydration and activities
- Infant can be infected in one of two ways
that cause hypoxia
• Neonatal herpes can be
• Avoid situations where exposure to infections is
- Localized
more likely
- Disseminated (widespread)
• Report any signs of infection promptly
- High mortality rate
• Acronym TORCH is used to describe infections
• Treatment and nursing care
that can be devastating to the fetus or newborn
- Avoid contact with lesions
• TORCH
- Mother and infant do not need to be
- Toxoplasmosis
isolated as long as direct contact with lesion
- Other
is avoided
- Rubella
- Breastfeeding is possible if no lesions are
- Cytomegalovirus
present on the breasts
- Herpes
• Infections HEPATITIS B
• Viral infections
- Transmitted by blood, saliva, vaginal
• No effective therapy
secretions, semen, and breast milk; can also
• Immunizations can prevent some infections
cross the placenta
• Cytomegalovirus
- Fetus may be infected trans placentally or
Infected infant may have: by contact with blood or vaginal secretions
during delivery
- Mental retardation - Upon delivery, the neonate should receive a
- Seizures single dose of hepatitis B immune globulin,
- Blindness followed by the hepatitis B vaccine
- Deafness - Risk for hepatitis B
- Dental abnormalities ➢ Intravenous drug use
- Petechiae ➢ Multiple sexual partners
Treatment - Repeated infection with STI
- Occupational exposure to blood products
- No effective treatment is known and needle sticks
- Therapeutic abortion may be offered if CMV - Hemodialysis
infection is discovered early in pregnancy - Multiple blood transfusions or other blood
- Rubella products
- Mild viral disease - Household contact with hepatitis carrier or
- Low fever and rash hemodialysis patient
- Destructive to developing fetus - Contact with persons arriving from
- If woman receives a rubella vaccine prior to countries where there is a higher incidence
pregnancy, she should not get pregnant for of the disease.
at least 1 month - Human immunodeficiency virus
- Not given during pregnancy because - Virus that causes AIDS
vaccine is from a liver virus - Cripples immune system
Effects of embryo or fetus - No known immunization or curative
treatment
- Microcephaly (small head size) - Acquired in one of three ways
- Mental retardation ➢ Sexual contact
- Congenital cataracts
 ➢ Parenteral or mucous membrane
exposure to infected body fluids
➢ Perinatal exposure
- Infant may be infected
➢ Trans placentally
➢ Through contact with infected
maternal secretions
➢ Through breast milk
NURSING CARE
• Educate the HIV-positive woman on methods to
reduce the risk of transmission to her
developing fetus/infant
• Pregnant women with HIV/AIDS are more
susceptible to infection
• Breastfeeding is absolutely contraindicated for
mothers who are HIV-positive
• Nonviral infections
• Toxoplasmosis
• Parasite acquired by contact with cat feces or
raw meat
• Transmitted through placenta
Congenital toxoplasmosis includes the following
possible signs:
- Low birthweight
- Enlarged liver and spleen
- Jaundice
- Anemia
- Inflammation of eye structures
- Neurological damage
PREVENTIVE MEASURES
- Cook all meat thoroughly
- Wash hands and all kitchen surfaces after
handling raw meat
- Avoid uncooked eggs and unpasteurized
milk
- Wash fresh fruits and vegetables with water
- Avoid materials contaminated with feces
- Group B Streptococcus (GBS) infection
- Leading cause of perinatal infection with
high mortality rate
- Organism found in woman’s rectum, vagina,
cervix, throat, or skin
- The risk of exposure to the infant is greater
if the labor is long or the woman
experiences premature rupture of
membranes
- GBS significant cause of maternal
postpartum infection
➢ Symptoms include elevated
temperature within 12 hours after
delivery, rapid heart rate,
abdominal distention
- Can be deadly to the infant
- Penicillin
- Tuberculosis
- Increasing incidence in the U.S.
- Multidrug-resistant strains also increasing
- Mother can be tested via PPD skin or serum
QuantiFERON Gold
- If positive, chest x-ray and possibly sputum
specimens will be needed
- Report to local public health department
(PHD) if active pulmonary TB is suspected
- If mother active, infant must be kept away
from mother until she has been cleared by
the PHD
- Sexually transmitted infections (STIs)
- Common mode of transmission is sexual
intercourse
- Infections that can be transmitted
➢ Syphilis, gonorrhea, chlamydia,
trichomoniasis, and condylomata
acuminata
- Vaginal changes during pregnancy increase
the risk of transmission
- Urinary tract infections
- Pregnancy alters self-cleaning action due to
pressure on urinary structures
- Prevents bladder from emptying completely
- Retained urine becomes more alkaline
- May develop
➢ Burning with urination
➢ Increased frequency and urgency of
urination
➢ Normal or slightly elevated
temperature
- Pyelonephritis
- High fever
- Chills
- Flank pain or tenderness
- Nausea and vomiting
- Environmental hazards
DURING PREGNANCY
- Bioterrorism and the pregnant women
- Three basic categories
➢ A- can be easily transmitted from
person to person
➢ B- can be spread via food and
water
➢ C- can be spread via manufactured
weapons designed to spread
diseases.
Substance abuse
- Questions should focus on how the
information will help nurses and physicians
provide the safest and most appropriate
care to the pregnant woman and her infant
Alcohol
- A single episode of consuming two alcoholic
drinks can lead to the loss of some fetal
brain cells
 TRAUMA DURING PREGNANCY
- Three leading cause if traumatic death
➢ Automobile accidents
➢ Homicide
➢ Suicide
Battering
- Bruises in various stages of healing
Nursing tips
- If a woman confides that she is being
abused during pregnancy, this information
must be kept absolutely confidential
- Her life may be in danger if her abuser
learns that she has told anyone
- She should be referred to local shelters, but
the decisions leave her abuser is hers alone.
HYDRAMNIOS
- Patho:
➢ Amniotic fluid is 200 ml or more.
Occurs because fetus has issues
swallowing (transesophageal
fistula) or absorbing fluid or has
excess UO (i.e. fetus of diabetic).
- Symptoms:
➢ Rapid enlargement of uterus
➢ Extreme SOB weight gain,
hemorrhoids
- Treatment
➢ Bed rest to prevent preterm labor,
increase circulation
➢ High fiber diet and stool softener
➢ Amniocentesis removes extra fluid
➢ Needled membrane rupture
OLIGOHYDRAMNIOS
- Patho:
➢ Less than normal (less than 500 ml-
1000 ml)
➢ Amniotic fluid caused by growth
restriction or fetus not voiding as
usual (bladder or renal disorder)
- Treatment
➢ Careful inspection of infant at birth
to rule out kidney disease and
compromised lung development
PSEUDOCYECIS
- False pregnancy caused by wish-fulfillment,
conflict, or depression
- Treatment
➢ Careful inspection of infant at birth
to rule out kidney disease and
compromised lung development
ISOIMMUNIZATION (Rh incompatibility)
- Patho:
➢ Rh- mother carries a Rh+ fetus
➢ Maternal AB are formed 72 hours
after first birth, can cross placenta
in the second pregnancy, and
destroy fetal RBCs causing
hemolytic disease of the newborn.
- Dx:
➢ Anti-D titer at 1st visit and week 28
➢ Titer is 1:16 or greater
➢ Doppler velocity is high in fetal
middle cerebral artery
- Tx:
➢ At 28 weeks: RhoGAM given, and 72
after birth in event of positive
Coombs rest
➢ In utero blood transfusion
➢ Phototherapy for fetus to reduce
bilirubin released from injured
RBC’s
What is the function of RhoGAM
- Given at 28 weeks and 72 hours after birth
- Within 2 weeks- 2 months, will destroy
passive antibodies.
What is the meaning of negative Coombs test?
- Cord blood sample from fetus id Rh+, thus
the RhoGAM injection is given to the
mother
How is fetal maturity determined?
- Mature lecithin/sphingomyelin ratio has
been reached
Fetal death
- Causes: chromosomal abnormalities,
congenital, hepatitis B, immunologic,
complications of maternal disease
- Symptoms: painless spotting, lack of fetal
movement
- Confirmation by US
- Treatment: misoprostol (Cytotec) to being
uterine contractions if labor dies not begin
spontaneously
- Nursing management: observe for excess
bleeding (sign of DIC)
- Swaddle as if it were a newborn
- Wait 6 months before starting another
pregnancy