Hyperemesis Gravidarum / Pernicious Vomiting

- the condition is associated with intrauterine growth restriction

Signs and Symptoms
• Severe nausea and vomiting
• Elevated hematocrit
• Reduce serum levels of sodium, potassium and chloride
• Polyneuritis
• Weight loss
• Urine positive for ketones
Nursing Implications:
• Women may need to be hospitalized for about 24 hours to document and monitor intake and output, and
blood chemistries and to restore hydration.
• All oral food and fluids are withheld for the first 24 hours.
• Intravenous fluids of 3,000 ml Ringer’s Lactate with added vitamin B1 may be administered to increase
hydration.
• An antiemetic, such as metoclopramide (Reglan, pregnancy class B), may be prescribed to control
vomiting.
• Intake and output is carefully measured, including the amount of vomitus.
• If there is no vomiting after the first 24 hours of oral restriction, small amounts of clear fluid can be
started.

Rh Incompatibility
Description:
• Rh incompatibility or isoimmunization during pregnancy occurs when an Rh-negative mother is carrying a fetus
with an Rh-positive blood type.
• When the Rh-positive fetus begins to grow inside an Rh-negative mother, it is as though her body is being
invaded by a foreign agent, or antigen, and her body begins to form antibodies against the invading substance.
• The invading maternal antibodies formed cross the placenta and cause red blood cell destruction (hemolysis)
of fetal red blood cells.
• Rhₒ (D) immune globulin (RHIG) is a commercial preparation of passive antibodies against the Rh factor that
can be administered to the mother at 28 weeks of pregnancy.
• RHIG can be administered again within 72 hours following delivery of an Rh-positive infant to attain passive
antibody protection for future pregnancies.

Nursing Implications:
• Instruct the client about Rh incompatibility.
• Arrange for antibody titers at the first prenatal visit.
• Monitor titers every 2 weeks during the remainder of pregnancy if maternal anti-D antibody is elevated.
• Assist with amniocentesis at least every 2 weeks to monitor fetal well-being.
• Prepare to administer RHIG to the client at 28 weeks.
• Obtain cord blood samples after delivery.

Anti-D antibody titer

Spectrophotometer readings are made to the amniotic fluid to reveal the fluid density.
If the fluid density remains low, the fetus either is in no distress.
If the reading is moderate, preterm delivery by induction of labor at fetal maturity is indicated.
If the reading is high, the fetus is in imminent danger and immediate delivery will be carried out or intrauterine
transfusion may be initiated.

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 Intrauterine Transfusion – done by injecting RBC directly into a vessel in the fetal cord.

Pregnancy-Induced Hypertension
Description
⚫ PIH, a systemic disorder affecting almost all organs, is a complication of pregnancy that places the mother and
fetus at high risk for problems.
⚫ In PIH, the symptoms result from peripheral vascular spasm, but why this vascular spasm occurs is difficult to
establish.
⚫ With PIH, there is a loss in the reduced responsiveness to blood pressure changes, resulting in vasoconstriction
and poor organ perfusion which leads to increased blood pressure.
⚫ The vascular effects of vasospasm include vasoconstriction and dramatic increases in blood pressure.
⚫ The kidney effects of vasospasm include decreased glomeruli filtration rate, increased permeability of glomeruli
membrane, increased serum blood urea nitrogen, uric acid creatine which leads to decreased urine output and
proteinuria.
⚫ The interstitial effects include diffusion of fluid from the blood stream into interstitial tissue which leads to edema.
⚫ Blood supply to organs is reduced; this is followed by tissue hypoxia in the maternal vital organs leading to poor
placental perfusion, possibly reducing the fetal nutrient and oxygen supply.
Predisposing Factors:
⚫ Primiparas younger than age 20 years or older than 40 years
⚫ Women from a low socioeconomic background
⚫ Women who have had five or more pregnancies
⚫ Women of color
⚫ Women with multiple pregnancy
⚫ Women with underlying disease
⚫ May be associated with poor calcium or magnesium intake
Classification with Signs and Symptoms
A. Gestational Hypertension
⚫ Blood pressure of 140/90 mmHg
⚫ No proteinuria

B. Mild Preeclampsia
⚫ Blood pressure of 140/90 mmHg
⚫ Proteinuria 1+ to 2+ on a random sample
⚫ Weight gain more than 2 lb/week in the second trimester and 1 lb/week in the third trimester
⚫ Mild edema in upper extremities or face
C. Severe Preeclampsia
⚫ Blood pressure of 160/110 mmHg
⚫ Proteinuria 3+ to 4+ on a random sample & 5 g on a 24-hour urine sample
⚫ Oliguria (500ml or less in 24 hours)
⚫ Cerebral or visual disturbances
⚫ Pulmonary edema with shortness of breath
⚫ Extensive peripheral edema
⚫ Hepatic dysfunction
⚫ Thrombocytopenia
⚫ Epigastric pain, nausea and vomiting
⚫ Marked hyperreflexia
D. Eclampsia
⚫ Blood pressure greater than 160/110 mm Hg
⚫ Tonic-clonic seizure
Management:
⚫ Obtain a thorough antepartal history and physical examination
⚫ Assess the client’s blood pressure

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⚫ Monitor the client’s weight gain
⚫ Assess the client’s deep tendon reflexes
⚫ Instruct the client to eat a high-protein, moderate sodium diet
⚫ Encourage bed rest in the left lateral recumbent position
For Mild Preeclampsia
⚫ Instruct the client regarding need for follow-up visits every 2 weeks; inform physician immediately if symptoms
worsen
For Severe Preeclampsia
⚫ Anticipate the need for the client to be hospitalized
⚫ Prepare for amniocentesis or induction of labor
⚫ Place the client in a private room
⚫ Darken the room
⚫ Monitor the client’s blood pressure every 4 hours
⚫ Obtain blood studies – CBC, platelet count, liver function test, BUN, creatinine and fibrin degradation products to
assess for renal and liver function and development of DIC
⚫ Anticipate obtaining a type and cross match blood
⚫ Insert and indwelling urinary catheter
⚫ Obtain urine specimens for urinary proteins and specific gravity
⚫ Monitor daily weights
⚫ Assess fetal status every 4 hours
⚫ Prepare the client for non-stress test or biophysical profile
⚫ Administer oxygen as prescribed
⚫ Institute safety measures
⚫ Administer IV fluids
⚫ Administer hydralazine (Apresoline) to reduce blood pressure
⚫ Prepare to administer magnesium sulfate; before administering , check to make sure that urine output is above
25 to 30 ml/hr, respirations are above 12/minute, the client can answer questions, ankle clonus is minimal, and
deep tendon reflexes are present.
⚫ Monitor serum blood levels and maintain at 4 to 7 mg/100 ml.
⚫ Keep a solution of 10 ml of 10% calcium gluconate at the bedside as antidote for magnesium sulfate therapy.

For Eclampsia
⚫ Monitor the client for signs of impending seizure
⚫ Administer oxygen to protect the fetus
⚫ Turn the client on left side
⚫ Evaluate the fetus
⚫ Administer magnesium sulfate or diazepam
⚫ Monitor the client’s level of consciousness
⚫ Assess for the possibility of abruptio placenta and uterine contractions
⚫ Allow nothing by mouth (NPO)

MATERNAL HEART FAILURE (Gravido Cardiac)

Description
• Maternal heart failure is a preexisting condition that places the pregnant woman at risk during
pregnancy.
• Heart failure can be left-sided or right-sided.
• Left-sided heart failure occurs with conditions such as mitral stenosis, mitral insufficiency, and aortic
coarctation.
- Left-sided heart failure occurs when the left ventricle is unable to move forward the volume of
blood received by the left atrium from the pulmonary circulation; the reason is often at the level
of the mitral valve.
- The normal physiologic tachycardia of pregnancy shortens diastole and decreases the time
available for blood to flow across this valve, causing back pressure on the pulmonary circulation
resulting in distention and interference with gas exchange at the alveoli.
- If mitral stenosis is present, it is so difficult for blood to leave the left atrium that a secondary
problem of thrombus formation can occur.
- If coarctation is causing the difficulty, dissection of the aorta and thrombus formation can be
secondary problems.
• Right-sided heart failure may result from congenital heart defects, such as pulmonary valve stenosis
and atrial and ventricular septal defects.

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 - Right-sided heart failure occurs when the output of the right ventricle is less than the blood volume
the heart receives at the right atrium from the vena cava or venous circulation.
- Back pressure results in congestion of the systemic venous circulation and decreases cardiac
output to the lungs.
- The congenital anomaly that is most apt to cause right-sided heart failure in women of
reproductive age is Eisenmenger’s syndrome (a right-to-left atrial or ventricular septal defect with
an accompanying pulmonary stenosis). These women, if the anomaly is not corrected, have a 50%
chance of dying during pregnancy.
• Regardless of the type of heart failure, the fetus is at risk because of decreased placental perfusion
leading to intrauterine growth retardation, fetal distress, or prematurity.
Classification and Description
1. Class I – uncompromised. no limitation of physical activity
2. Class II – slightly compromised. slight limitation; ordinary activity causes fatigue, palpitation,
dyspnea or chest pain
3. Class III – markedly compromise. moderate to marked limitation; less than ordinary activity causes
fatigue
4. Class IV – severely compromised. unable to carry on any activity without experiencing discomfort
Assessment Findings
Left-sided heart failure
Signs and Symptoms
▪ Decreased cardiac output
▪ Pulmonary hypertension
▪ Pulmonary edema
▪ Productive cough with blood-speckled sputum
▪ Increased respiratory rate
▪ Fatigue
▪ Weakness
▪ Dizziness
▪ Increased heart rate
▪ Increased blood pressure
▪ Sodium and water retention
▪ Difficulty in sleeping in any position
▪ Paroxysmal nocturnal dyspnea
Right-sided heart failure
Signs and Symptoms
▪ Decreased cardiac output
▪ Jugular venous distention
▪ Enlarged liver and spleen
▪ Ascites
▪ Peripheral edema
▪ Dyspnea and pain
Nursing Implications
• Obtain a thorough antepartal history and physical examination to establish a baseline and ongoing to
identify changes.
• Classify the client’s heart failure based on her symptoms.
• Continually assess the clients for signs and symptoms indicating a worsening of her condition.
• Provide education regarding the need for close follow-up throughout pregnancy to prevent possible
complications.
• Encourage the client to take frequent rest periods to minimize oxygen demands, lessen the strain of the
increased burden on her heart, and prevent fatigue.
• Instruct the client to rest in the left lateral recumbent position to prevent hypotension and increase heart
effort.
• Discuss activity level and instruct the client in specific activities that are allowed and that are to be avoided.
• Suggest that the client sleep with her head and chest elevated to aid in her breathing.
• Be aware that many physicians prefer that women with heart disease remain on complete bed rest after
week 30 of the pregnancy to ensure that the pregnancy will be carried to term or at least past week 36 so
that fetal maturity can be assumed.
• Develop a sound nutritional program with the client to ensure adequate weight gain without excessive
weight gain that could overburden the heart and circulatory system.
• If the client was following a sodium-restricted diet before pregnancy, encourage her to continue it during
pregnancy.

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• Instruct the client in the need for prenatal vitamins and evaluate compliance.
• Warn the client taking cardiac medications before pregnancy that she may need to increase their
maintenance dose because of the expanded blood volume during pregnancy.
• Instruct the client in any newly prescribed medications, such as cardiac glycosides or prophylactic
antibiotics.
• Be aware that some physicians prescribe a course of prophylactic antibiotics for the client with valvular or
congenital heart disease close to the anticipated date of birth to prevent possible postpartum subacute
bacterial endocarditis.
• Educate the client regarding the need to avoid infection to prevent increased oxygen and cardiac demands.
• Assist the client with methods to reduce psychological stress; offer support and guidance throughout the
pregnancy.
• Keep in mind that a client with heart disease should not push with contractions; anticipate the use of
epidural anesthesia and low forceps delivery.
• During labor, closely monitor the client’s uterine contractions, fetal heart rate, and vital signs; report any
significant findings to the physician.
• Encourage the client to remain in the side-lying position during labor to reduce the possibility of supine
hypotension syndrome.
• Anticipate the need for decreased activity and possibly anticoagulant and digitalis therapy following the
birth to compensate for the dramatic rise in blood volume.
• Ambulate the client as soon as possible after birth and apply antiembolism stockings to prevent the
formation of emboli.
• Be aware that if the client was not on prophylactic antibiotic therapy before birth, she will be started on
them immediately postpartally to discourage subacute bacterial endocarditis caused by introduction of
microorganisms from the denuded uterus.
• Allow the client to see the baby immediately after birth to allay her fears and anxieties about possible fetal
problems.
• Be sure to point out that acrocyanosis is normal in newborns so that the client does not interpret this as
cardiac inadequacy.
• Postpartally, administer stool softener as prescribed to decrease straining.
• Provide education regarding the need for follow-up both for gynecologic health and cardiac status.

Gestational Diabetes Mellitus/Diabetes Mellitus (DM) in Pregnancy

Description
• Is a preexisting condition that places the client at high risk during pregnancy.
• Is an endocrine disorder in which the pancreas is unable to produce adequate insulin to regulate
body glucose.
• Even a woman who has successful regulation of glucose-insulin metabolism before pregnancy is apt
to develop less than optimum control during pregnancy because of the changes occurring in the
glucose-insulin regulatory system as pregnancy progresses.
- Decreased renal threshold for sugar because of increased estrogen
- Glomerular filtration of glucose is increased
- Rate of insulin secretion is increased but the sensitivity of the body to insulin is decreased
- Insulin resistance develops
- Increased production of hormones, which affect carbohydrate and lipid metabolism, thus,
increasing concentration of glucose in the serum.
- Continued use of glucose by the fetus leads to hypoglycemia
• The primary problem is control of the balance between insulin and blood glucose to prevent acidosis,
a threat to the fetus.
• Approximately 2% to 3% of all women who do not begin a pregnancy with DM become diabetic
during pregnancy, usually at the midpoint of the pregnancy, when insulin resistance becomes
noticeable; this is called gestational diabetes.
• It places the mother and fetus at risk for problems, including fetal growth retardation; asphyxia;
abortion; stillbirth; maternal pregnancy-induced hypertension; infection; large-for-gestational-age
infants; delivery problems; infants prone to congenital anomalies, hypoglycemia, respiratory distress
syndrome, hypocalcemia, and hyperbilirubinemia; and hydramnios.
Risk Factors:
▪ Obesity ▪ History of unexplained perinatal loss
▪ Age over 25 years ▪ History of congenital anomalies in previous
▪ History of large babies (10 lb or more) pregnancies
▪ History of unexplained fetal loss ▪ Family History of diabetes

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 ▪ Member of a population with a high risk for
diabetes
Signs and Symptoms
▪ Glycosuria ▪ Fasting serum glucose of 105 mg/dl or
▪ Thirst greater with 3-hour glucose tolerance test;
▪ Polyuria 1-hour serum glucose level of 190 mg/dl or
▪ Possible monilial infection greater with 3-hour glucose tolerance test;
▪ Ketonuria 2-hour serum glucose level of 165 mg/dl or
▪ Dizziness (if hypoglycemic) greater with 3-hour glucose tolerance test;
▪ Confusion (if hyperglycemic) 3-hour serum glucose level of 145 mg/dl or
▪ Serum glucose greater than 140 mg/dl with greater with 3-hour glucose tolerance test.
1-hour glucose screening test
Oral Glucose Tolerance Test (Plasma Values)
TEST TYPE Pregnant mg/dl Glucose
Fasting 95
1H 180
2H 155
3H 140
Nursing Implications
• Prepare the client for glucose screening test at 24 to 28 weeks of pregnancy.
• Keep in mind that those women at high-risk for developing DM should be screened earlier in pregnancy.
• Be aware that resistance to insulin during pregnancy requires the client to increase her insulin dosage at
about 24 weeks of pregnancy to prevent hyperglycemia.
• Warn the client that because of continued use of glucose by the fetus, she may experience hypoglycemia
between meals or overnight, especially common in the second and third trimesters of pregnancy.
• Educate the client about necessary dietary changes, including the adherence to 1800- to 2,200-calorie diet
(or one calculated at 35 Kcal/kg of ideal weight) divided into 3 meals with 3 snacks; urge the client to
make her final snack of the day one of protein and complex carbohydrate to prevent hypoglycemia at
night.
• Instruct the client about an appropriate exercise program, including the effect of exercise on insulin
requirements.
• Reinforce instructions about insulin administration and blood glucose monitoring.
- If hypoglycemia is present, instruct the client to drink a glass of milk and eat some crackers.
- If hyperglycemia is present, instruct the client to check her urine for acetone and report the findings
to the health care professional.
• Assist with arranging diagnostic tests for evaluation of fetal well-being, such as serum alpha-fetoprotein
levels, ultrasonography, nonstress test, and biophysical profile.
• Keep in mind that following delivery, with insulin resistance gone, the client often needs no insulin during
the immediate postpartum period.

Anemia in Pregnancy
Iron Deficiency Anemia
▪ Many women enter pregnancy with an iron deficiency anemia resulting from poor diet, heavy menstrual
periods or unwise weight reduction programs.
▪ Iron deficiency anemia is associated with low fetal birth weight and preterm birth.
Signs and Symptoms
▪ Microcytic, hypochromic red blood cells
▪ Hematocrit below 33%
▪ Hemoglobin below 11 g/dl
▪ Serum ferritin below 10 µg/L
▪ Serum transferrin saturation level below 16%
▪ Serum iron level below 10 µg/L
▪ Mean corpuscular hemoglobin concentration
(MCHC) below 30
▪ Iron binding capacity over 400 µg/L
▪ Fatigue
▪ Poor exercise tolerance

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Nursing Implications
• Prepare the client for serum blood studies; evaluate results and notify physician of abnormal values.
• Keep in mind that some women develop pica, or the eating of substances, such as ice or starch.
• Instruct the client in use of prenatal vitamins containing an iron supplement as prophylactic therapy
against iron deficiency anemia.
• Encourage the client to take the supplement with orange juice to enhance absorption.
• Instruct the client in foods that are high in vitamins and iron.
• Instruct the client that stools may turn black and tarry; encourage client to eat foods high in fiber and
drink plenty of fluids to prevent constipation.
• If iron deficiency is severe, anticipate administering iron supplement intramuscularly or intravenously.

Urinary Tract Infection

▪ A urinary tract infection in a in a pregnant client occurs as a result of urinary stasis in ureters that are
dilated from the effect of progesterone.
▪ Glycosuria that occurs with pregnancy can contribute to the growth of organisms.
▪ The organisms most commonly responsible for urinary tract infections is Eschericia coli.
▪ An increase incidence of preterm labor, premature rupture of membranes, and fetal loss may be
associated with pyelonephritis.
Signs and Symptoms
▪ Pain in the lumbar area
▪ Nausea and vomiting
▪ Malaise
▪ Frequency in urination
▪ Fever
▪ Urine culture positive for over 100,000 organisms per ml of urine
Nursing Implications
▪ Obtain a clean-catch urine specimen for culture and sensitivity
▪ Instruct the client about ways to prevent UTI, such as voiding frequently, wiping from front to back after
bowel movements, wearing cotton not synthetic fiber underwear, and voiding after intercourse.
▪ Encourage the client who has a UTI to increase her intake of fluids by giving her a specific amount to drink
every day, up to 3 to 4 L per hours.
▪ Teach the client how to promote urine drainage by assuming a knee-chest position for 15 minutes
morning and evening to shift the weight of the uterus forward, freeing the ureter for drainage.
▪ Know that sulfonamides are used early in pregnancy to treat UTI but should not be used near term
because they interfere with protein binding of bilirubin, which could lead to hyperbilirubinemia in the
neonate.
▪ Remember that tetracyclines are contraindicated in pregnancy because they cause retardation of bone
growth and staining of fetal teeth.