NSG210 Exam 2 Reading Outline - Durham Ch. 7: Complications of Pregnancy (High-Risk Antepartum Nursing Care)

Source: Durham & Chapman, Davis Advantage for Maternal-Newborn Nursing, Chapter 7 (~/Documents/texts/nursing/NSG210/exam02/DURHAM_OB_CH07.pdf). Part of nsg210-exam-2-readings-outline. See also the lecture notes in raw/nsg210_wk05_ComplicationsInPregnancy.md.

Learning Outcomes

1. Describe the primary complications of pregnancy and related nursing and medical care.
2. Identify clinical features and tests used to predict, screen for, diagnose, and manage complications.
3. Identify potential complications for the woman, fetus, and newborn.
4. Plan care for physical, emotional, and psychosocial needs.
5. Describe key teaching for antenatal complications.
6. Understand preexisting medical conditions that affect pregnancy.

Nursing diagnoses: risk for disturbed maternal-fetal dyad, risk of maternal injury, risk for ineffective family coping, interrupted family process, powerlessness, risk of fetal injury, caregiver role strain.

I. Risk Assessment and Health Equity

• High-risk pregnancy - greater risk to mother or fetus than an uncomplicated pregnancy
• Risk factors (Box 7-1): existing conditions (hypertension, diabetes, HIV), prior pregnancy complications, complications arising in pregnancy (GDM, preeclampsia), overweight or obesity, multiples, age 18 or younger or over 35
• Risk tools have poor predictive value; up to a third of women with complications have no identifiable risk factor
• Racial and ethnic disparities persist in preterm birth, growth restriction, fetal demise, and maternal mortality and are not explained by patient characteristics
• Social determinants of health (SDOH) - conditions where people are born, live, work, and age
• Birth equity - addresses structural racism and SDOH at the systems level
• Weathering - cumulative stress of inequity over time raises risk of adverse outcomes; toxic stress is proposed as a driver of higher preterm birth in Black women
• Preterm birth is about 50% higher in Black women than White women; group prenatal care can reduce it
• Council on Patient Safety in Women’s Health Care publishes safety bundles, including one on reducing peripartum racial and ethnic disparities

Nursing activities to promote adaptation (Critical Component):

• Responses: stress and anxiety, threats to self-esteem and self-blame, disappointment, conflict, crisis
• Actions: time to express feelings, active listening, repeat information in lay terms, explain causes to reduce guilt, referrals (social work, chaplain), shared decision-making, flexible visiting, read the emotional “temperature,” advocate for access and against disparities

II. Preterm Labor (PTL) and Birth

A. Definitions

• PTL - regular contractions causing cervical change before 37 weeks
• Preterm birth (PTB) - birth between 20 0/7 and 36 6/7 weeks
• Late preterm - 34 0/7 to 36 6/7 weeks
• Very preterm - before 32 weeks
• Periviable birth - 20 0/7 to 25 6/7 weeks
• Diagnosis: regular contractions with cervical change, or regular contractions with dilation of at least 2 cm; under 10% of women diagnosed with PTL deliver within 7 days

B. Significance

• About 10% of US births are preterm (10.02% in 2018); 14.13% in Black mothers vs 8.57% in Asian mothers
• PTB is the leading cause of neonatal mortality and most common reason for antenatal hospitalization; accounts for about 70% of neonatal deaths, 36% of infant deaths, 25-50% of long-term neurologic impairment
• Long-term sequelae: cerebral palsy, hearing and vision impairment, chronic lung disease, learning problems
• Three-quarters of PTBs are spontaneous; 25% are medically indicated (preeclampsia, hemorrhage, IUGR)
• Types: spontaneous, medically indicated, non-medically indicated (elective - not recommended before 39 weeks)
• Healthy People 2030 goal: PTB rate of 9.4%

C. Pathophysiology (Figure 7-2)

Multiple factors interact to start the labor cascade early. Four major pathways:

1. Excessive uterine stretch or distention (multiples, polyhydramnios, uterine anomalies) - releases prostaglandins
2. Decidual hemorrhage (abruption) - thrombin activation
3. Intrauterine infection and inflammation - cytokines and endotoxins trigger prostaglandins, cervical ripening, contractions, ROM
4. Maternal or fetal stress - activation of the HPA axis, corticotropin-releasing hormone (CRH)

Also: uteroplacental vascular insufficiency, hormonal factors, cervical insufficiency, genetics.

D. Risk Factors

• 50% of women who deliver preterm have no risk factors; 70% of those “at risk” deliver at term
• Three most common:
  1. Prior PTB - single most important factor (recurrence up to 40%; 16% after one, 47% after two, 57% after three early PTBs)
  2. Multiple gestation - 50% of twins and 90% or more of higher multiples deliver preterm
  3. Uterine or cervical abnormalities, short cervix, DES exposure
• Others: fetal anomalies, prior second-trimester loss, cervical insufficiency, IVF, hydramnios or oligohydramnios, infection (genitourinary, periodontal), PROM, interpregnancy interval under 9 months, hypertension, diabetes, bleeding, chronic disease, poor nutrition or low BMI, age under 17 or over 35, late or no prenatal care, obesity, long work hours and standing, genetics, Black race, unmarried status, IPV, mental illness, substance use, smoking, low education and income

Prevention teaching (MOD): healthy weight, no smoking, alcohol, or drugs, early and regular prenatal care, treat chronic conditions and depression, prevent infection (vaccines, handwashing, no raw meat or cat litter, safe sex), reduce stress, wait at least 18 months between birth and next pregnancy.

E. Prediction and Assessment

• No screening method is consistently effective
• Transvaginal cervical length (symptomatic women): over 30 mm reliably excludes PTL; under 25 mm has strong positive predictive value
• Fetal fibronectin (fFN) - low positive, high negative predictive value; useful to identify who will NOT deliver preterm
• PAMG-1 (PartoSure) - high accuracy predicting PTB within 7 and 14 days
• Signs and symptoms: change or increase in vaginal discharge (watery, mucus, bloody), pelvic pressure, constant low dull backache, mild cramps with or without diarrhea, regular often painless contractions, possible ROM

F. Medical Management

• Bedrest, pelvic rest, and hydration are no longer recommended (no evidence, possible harm)
• About 30% of PTL resolves on its own; 50% of women hospitalized for PTL deliver at term
• Goal: delay delivery 48-72 hours to give antenatal steroids
• Tocolytics - suppress contractions; effective up to 48 hours; typically used at 24-34 weeks; not for contractions without cervical change or under 2 cm dilation; maintenance tocolysis is ineffective
• Antibiotics should not be used to prolong pregnancy with intact membranes (different from PPROM and GBS)
• Progesterone:
  • 17-alpha-hydroxyprogesterone caproate 250 mg weekly from 16 to 36 weeks for prior spontaneous PTB; not for multiples
  • Vaginal progesterone for cervical length under 20 mm at or before 24 weeks
• Cerclage before 24 weeks for singleton with prior PTB and short cervix
• Magnesium sulfate for fetal neuroprotection when birth is expected before 32 weeks - reduces cerebral palsy risk and severity
• Antenatal corticosteroids - single course at 24-34 weeks if delivery is likely within 7 days (including ROM and multiples); one repeat course if under 34 weeks and prior course more than 14 days ago (rescue as early as 7 days)

Tocolytic agents (Table 7-1):

Contraindications to tocolysis: fetal demise, lethal anomaly, nonreassuring fetal status, severe preeclampsia or eclampsia, maternal bleeding with instability, chorioamnionitis, PPROM without infection (except for transport or steroids), agent-specific contraindications, placental abruption, pulmonary hypertension, fetal maturity.

Antenatal corticosteroids (Understanding Medication):

• Most beneficial intervention for neonatal outcomes in PTB
• Action: stimulate fetal surfactant production; reduce RDS, intracranial hemorrhage, NEC, and death
• Betamethasone 12 mg IM every 24 hours x 2 doses, or dexamethasone 6 mg IM every 12 hours x 4 doses
• Optimal benefit: delivery 2-7 days after the first dose; give the first dose even if the second is unlikely
• Raises blood glucose (may need insulin in diabetics); raises WBC (not a sign of infection)

G. Nursing Actions

Immediate care:

• Review prenatal record; confirm gestational age (early ultrasound most reliable)
• Assess for infection, ROM (sterile speculum, ferning), bleeding, dehydration
• Assess FHR and contractions; report fetal tachycardia
• Obtain cultures and fFN or PAMG-1 before any vaginal exam (not if ROM, bleeding, intercourse, or collected in last 24 hours)
• Strict I&O; hydration; fluid limit may be 3,000 mL/24 hr on tocolytics
• Give tocolytics and steroids as ordered; side-lying position
• Report BP over 140/90 or under 90/50, HR over 120, temperature over 100.4 F (38 C)
• Auscultate lungs for pulmonary edema; sterile vaginal exam unless ROM or bleeding

Continuing care:

• Emotional support (guilt, fear, loss of a “normal” pregnancy), shared decision-making, neonatology consult and NICU tour
• Monitor for pulmonary edema: dyspnea, chest tightness, cough, SpO2 under 95%, rising RR and HR, apprehension, restlessness
• Clinical judgment: RR under 12 or over 24 is a warning; untreated respiratory arrest leads to cardiac arrest
• Short-term goals (each week gained), flexible visiting, journaling, support groups, sibling responses

Discharge (Box 7-2 warning signs): water breaks, decreased fetal movement, more than the set number of contractions per hour, low backache, cramps, pelvic pressure, intestinal cramps with or without diarrhea, increased discharge, fever over 100.4 F, feeling that something isn’t right.

H. Periviable Birth

• 20 0/7 to 25 6/7 weeks; about 0.5% of births but most neonatal deaths
• Resuscitation recommended at 24-26 weeks, can be considered at 22-24 weeks, not recommended before 22 weeks
• If life-sustaining treatment is withheld: comfort care (warmth, minimal discomfort, time with family) and bereavement support

III. PROM and PPROM

• PROM (prelabor rupture of membranes) - rupture before labor onset, at term
• PPROM - rupture before labor and before 37 weeks; about 3% of pregnancies but 30-40% of PTBs
• Prolonged ROM - more than 24 hours
• Latency - time from rupture to delivery; most deliver within 1 week
• Previable (under 23-24 weeks), remote from term (24-32 weeks), near term (32-36 weeks)
• Spontaneous PPROM usually from ascending infection; iatrogenic after CVS, amniocentesis, fetoscopy
• Risk factors: prior PPROM or PTB, bleeding, short cervix, hydramnios, multiples, STIs, low BMI, low income, smoking and drugs
• Maternal risks: chorioamnionitis (15-35%), endometritis (15-25%), abruption, retained placenta, cesarean
• Fetal risks: sepsis (earlier rupture = higher risk), prematurity complications, cord compression and hypoxia, deformities if before 26 weeks
• Diagnosis: confirmed gestational age, speculum exam with positive ferning; oligohydramnios supports but does not diagnose
• Management by gestational age (ACOG):
  • 34 0/7 to 36 6/7 weeks: expectant management or delivery; single course of steroids if not given and delivery in 24 hours to 7 days; GBS prophylaxis; treat infection and deliver
  • 24 0/7 to 33 6/7 weeks: expectant management; 7-day latency antibiotics (IV ampicillin and erythromycin, then oral amoxicillin and erythromycin); single course of steroids; GBS swab and prophylaxis; magnesium for neuroprotection under 32 weeks; treat infection and deliver
  • Under 23-24 weeks (periviable): counseling, expectant management or induction; antibiotics may be considered from 20 weeks; no GBS prophylaxis, steroids, tocolysis, or magnesium before viability
• Delivery indicated for nonreassuring fetal status, chorioamnionitis, significant abruption
• Nursing: FHR and contractions; infection signs - maternal or fetal tachycardia, fever 100.4 F or higher, uterine tenderness, foul fluid; WBC not useful after steroids; NST and BPP; vaginal bleeding raises concern for abruption; tocolysis is controversial

IV. Cervical Insufficiency

• Inability of the cervix to retain a pregnancy without contractions or labor, in the mid-second or early third trimester
• Diagnosis based on history: painless dilation after the first trimester with second-trimester loss (usually before 24 weeks) without contractions, bleeding, infection, or ROM
• Short cervix on ultrasound raises PTB risk but is not sufficient to diagnose insufficiency
• Causes: congenital (collagen or developmental defect) or acquired (cervical trauma - lacerations, conization, LEEP, forced dilation during D&C or D&E); infection and inflammation often involved
• Risks: repeated second-trimester births; cerclage complications (ROM, chorioamnionitis, lacerations, suture displacement)
• Symptoms usually absent or nonspecific: backache, contractions, spotting, pelvic pressure, mucoid discharge
• Activity restriction, bedrest, and pelvic rest are not effective; pessary evidence limited
• Cerclage - purse-string suture (McDonald or Shirodkar)
  • Indications (singleton): one or more painless second-trimester losses; prior cerclage for painless dilation; painless dilation now; prior spontaneous PTB under 34 weeks plus cervix under 25 mm before 24 weeks
  • History-indicated (prophylactic) - placed at about 12-16 weeks (text also cites 13-14)
  • Exam-indicated (rescue, emergency) - for dilation without contractions, up to about 24 weeks
  • Not recommended for twins with short cervix (may increase PTB)
  • McDonald removed at 36-37 weeks; removed early for labor, infection, progressive change, bleeding
• Serial transvaginal ultrasounds from 16 to 24 weeks; cervical cultures
• Post-op nursing: palpate for contractions; monitor bleeding, leaking, infection (fever, uterine tenderness); teach warning signs; modified activity and pelvic rest for a week

V. Multiple Gestation

• Monozygotic (one egg splits in the first week; identical; same sex) about one-third of twins; dizygotic (two eggs; same or different sex; always dichorionic diamniotic) about two-thirds
• Different-sex twins are dizygotic and therefore dichorionic
• Placentation: 30% dichorionic/diamniotic; 70% monochorionic/diamniotic (of monozygotic); about 1% monochorionic/monoamniotic
• Monozygotic twins have 3-10 times the morbidity and mortality of dizygotic; conjoined twins from incomplete splitting
• Multiples are about 3% of births; twin rate peaked in 2014 (older maternal age and ART), now declining
• Five-fold stillbirth and seven-fold neonatal death risk; preterm delivery six times more likely
• Multifetal pregnancy reduction - reducing the number of fetuses in the first or early second trimester; patient autonomy must be respected

Maternal risks: GDM, hemorrhage, abruption, previa, dilutional anemia, peripartum cardiomyopathy, pulmonary edema, PE, cholestasis, acute fatty liver, cesarean, PTL, earlier and more severe hypertensive disorders (proportional to number of fetuses).

Fetal risks: threefold perinatal mortality; death of one twin after 20 weeks threatens the survivor; IVH and periventricular leukomalacia under 32 weeks; LBW; IUGR and discordant growth (25% or more weight difference); TTTS (blood shunts from donor to recipient through placental anastomoses - recipient overloaded, donor anemic); twin anemia-polycythemia sequence; cord entanglement (monoamniotic); anomalies; vanishing twin.

Assessment findings: diagnosed by ultrasound; higher hCG and AFP (more nausea); fundal height greater than dates; extra fetal parts on Leopold’s; blood volume up 50-60% (extra 500 mL); cardiac output up an extra 20%; plasma volume up 50-100%; uterine contents up to 10 L and over 20 lb (back pain, supine hypotension, dyspnea); anemia; dermatoses.

Antepartal management: serial ultrasound for growth, placentas, membranes; genetic testing; monitor for PTL, anemia, preeclampsia, hydramnios, hemorrhage, fetal demise; steroids if preterm delivery expected; NST and BPP; nutrition consult; GDM screening; perinatologist. Prophylactic cerclage, tocolytics, pessary, progesterone, routine hospitalization, and bedrest are not effective.

Recommended delivery timing (Table 7-2):

• Dichorionic-diamniotic: 38 0/7 to 38 6/7 weeks
• Monochorionic-diamniotic: 34 0/7 to 37 6/7 weeks
• Monochorionic-monoamniotic: 32 0/7 to 34 0/7 weeks
• Triplets and higher: individualized

Intrapartum: type and crossmatch; ultrasound for positions; continuous EFM of all fetuses; immediate cesarean capability; hemorrhage medications and blood; 1:1 nursing; neonatal team for each infant; triplets and higher delivered by cesarean. Complications include uterine dysfunction, malpresentation, cord prolapse, abruption, PPH.

Nursing: PTL is harder to detect with multiples; watch for hypertension and hemorrhage; NST, AFI, BPP; teach PTL and preeclampsia signs; nutrition (iron, calcium, magnesium); emotional support; support groups; referrals.

VI. Hyperemesis Gravidarum

• Vomiting severe enough to cause dehydration, electrolyte and acid-base imbalance, starvation ketosis, and weight loss (usually 5% or more of pre-pregnancy weight); a diagnosis of exclusion
• Incidence 0.3-3%; most common reason for hospitalization in early pregnancy; second only to PTL overall
• Hyponatremia, hypokalemia, low serum urea; ptyalism common
• Peaks around 9 weeks, subsides by about 20 weeks
• Risk factors: prior hyperemesis, multiples, migraines, motion sickness, family history
• Linked to rapidly rising hCG, progesterone, estrogen; psychological theories are “questionable at best”
• Associated with LBW, SGA, and preterm infants
• Assessment: prolonged severe vomiting; weight loss; ketonuria; dehydration (lightheadedness, tachycardia, unable to keep food or fluid down for over 12 hours, dry mucous membranes, poor turgor, malaise, low BP)
• Medical management:
  • Prenatal vitamins for 1 month before conception may reduce NVP
  • Treat NVP early to prevent progression
  • First line: vitamin B6 or B6 plus doxylamine
  • IV hydration if unable to tolerate oral fluids or dehydrated
  • Refractory: H1 antihistamines, phenothiazines, benzamides
  • Monitor kidney and liver function
  • Correct ketosis and vitamin deficiency - dextrose and vitamins, especially thiamine
  • Enteral tube feeding before parenteral nutrition (TPN has life-threatening complications)
• Nursing: identify and reduce triggers (odors, stuffy rooms); ginger; antiemetics; emotional support; oral hygiene; IV fluids with vitamins and electrolytes; daily weight; I&O and urine specific gravity; fluids 30 minutes before or after solids; NPO until vomiting controlled then advance slowly; dietitian; prenatal vitamins at bedtime with a snack; preferred foods; complementary therapies (evidence limited)

VII. Intrahepatic Cholestasis of Pregnancy (ICP)

• Most common pregnancy-specific liver disease; defect in bile salt excretion leads to high serum bile acids deposited in the skin
• Late second or third trimester; about 1% in the US; up to 15% in Latin America; higher with multiples and hepatitis C
• Hallmark: generalized pruritus, especially palms and soles, worse at night, no rash
• Labs: bile acids over 10 micromol/L; elevated transaminases in up to 60%; elevated direct bilirubin in 20%; may have dark urine, pale stools, rarely jaundice
• Fetal risks: preterm delivery, meconium, abnormal FHR, stillbirth (under 5%); risk rises with bile acids over 40 micromol/L; fetal death can occur despite reassuring testing
• Maternal: increased intrapartum and postpartum hemorrhage
• Treatment: ursodeoxycholic acid (UDCA) 300 mg twice daily, up to 600 mg twice daily; antihistamines usually ineffective
• Twice-weekly NST; late preterm delivery may be based on bile acid levels
• Nursing: monitor labs; menthol cream, emollients, moisturizing, hydration; watch excoriations for infection; itching resolves within days of delivery; recheck liver function and bile acids 6-8 weeks postpartum

VIII. Diabetes in Pregnancy

A. Overview

• Complicates about 7% of pregnancies; most common metabolic disease of pregnancy; linked to the obesity epidemic (about 47% of GDM attributed to overweight or obesity)
• Type 1 - autoimmune beta-cell destruction, absolute insulin deficiency (5-10%)
• Type 2 - insulin resistance and inadequate production (90-95%); often needs insulin in pregnancy
• About 90% of diabetes in pregnancy is GDM
• Pregnancy is insulin resistant: placental hPL, progesterone, growth hormone, CRH antagonize insulin and shift energy to ketones and fatty acids
• Goals for both types: euglycemia, minimize complications, prevent prematurity
• Preconception goal: lowest HbA1c without hypoglycemia

B. Pregestational Diabetes

• Fivefold increase in major anomalies (heart and CNS) from hyperglycemia during organogenesis (first 6-8 weeks)
• Maternal risks: DKA (1%, especially second trimester), hypertensive disorders, hyperemesis-related metabolic problems, PTL (25%), spontaneous abortion (30% or more), polyhydramnios (20%) or oligohydramnios, cesarean, shoulder dystocia, worsening heart disease, retinopathy, nephropathy, neuropathy, infection (80% - UTI, chorioamnionitis, endometritis), induction, PPH
• Fetal and newborn risks: congenital defects, macrosomia (fetal hyperinsulinemia), hypoglycemia, hypocalcemia, hypomagnesemia, polyhydramnios, IUGR (maternal vascular disease), asphyxia, RDS (delayed lung maturity), polycythemia, hyperbilirubinemia, prematurity, cardiomyopathy, birth injury, stillbirth (especially after 36 weeks)
• Long-term for offspring: metabolic syndrome, type 2 diabetes, impaired development, epigenetic changes
• Self-management:
  • SMBG 4-8 times daily (before and after meals and at bedtime)
  • Urine ketones on first void when glucose over 200, during illness, or with poor control; moderate to large ketones mean inadequate intake
  • Records of glucose, food, insulin, activity
  • Exercise at least 20 minutes three times weekly (unless hypertension or preeclampsia)
  • Always carry fast-acting carbohydrate
• Glucose targets in pregnancy with diabetes (Table 7-3): fasting 95 or less; premeal under 100; 1 hour after meals under 140; 2 hours after meals under 120; mean 100; A1C under 6%
• Medical management: HbA1c under 7% for 1-2 months before conception; team of perinatologist, diabetes educator, dietitian; kidney, heart, thyroid, eye exams; insulin needs may reach 2-3 times prepregnancy by term
• Medical nutrition therapy: at least 1,800 kcal/day; 40% carbohydrate, 20% protein, 30-40% fat; individualized and culturally sensitive
• Intrapartum: phosphatidylglycerol (not L/S ratio) for lung maturity under 38 weeks; glucose 70-110 in labor; IV insulin as needed; steroids raise insulin needs
• Timing of delivery is challenging (stillbirth and macrosomia vs failed induction); diabetes alone is not an indication for cesarean; infants of diabetic mothers have delayed lung maturity (RDS, TTN)
• Nursing: teach pregnancy’s effect on diabetes and changing insulin needs; dietitian; SMBG and insulin technique; records to every visit
  • Hypoglycemia (under 70): diaphoresis, tachycardia, shakiness, cold clammy skin, blurred vision, fatigue, confusion, irritability, pallor; treat with 15 g carbohydrate, recheck in 15 minutes
  • DKA signs: abdominal pain, nausea and vomiting, polyuria, polydipsia, fruity breath, leg cramps, altered mental status, rapid respirations; ICU and OB care (fluids, electrolytes, insulin, treat cause); Black women more affected by ketosis-prone type 2
  • Call provider for glucose over 200, moderate ketones, persistent vomiting, decreased fetal movement
  • During illness: glucose every 1-2 hours on insulin drip, ketones every 4 hours; keep taking insulin even when vomiting
  • Antenatal testing (NST, BPP) usually from 24-28 weeks; plan for assisted birth or shoulder dystocia; diabetes educator referral

C. Gestational Diabetes (GDM)

• Glucose intolerance first recognized in pregnancy, regardless of treatment or persistence
• Insulin resistance from growth hormone, cortisol, hPL (human chorionic somatomammotropin), insulinase, estrogen, progesterone, plus maternal adiposity; worsens as the placenta grows
• Maternal insulin does not cross the placenta; the fetus makes more insulin in response to maternal hyperglycemia, which drives growth and macrosomia
• Screening at 24-28 weeks, two-step:
  • 1-hour 50 g nonfasting glucose challenge; positive at 135-140 mg/dL
  • 3-hour 100 g GTT after 8-12 hour fast; GDM if 2 or more values at or above: fasting 95, 1 hour 180, 2 hours 155, 3 hours 140
• Women with GDM have 30-50% chance of type 2 diabetes within 20 years (up to 70% overall; 60% of Latin American women)
• GDM A1 - diet controlled; GDM A2 - insulin controlled (up to 40% need insulin)
• Higher prevalence in Hispanic, Black, American Indian, Asian, and Pacific Islander women
• Risk factors: prior macrosomia, strong family history, obesity, inactivity, prior GDM, PCOS, hypertension; 50% have no known risk factor
• Maternal risks: hypoglycemia, DKA, preeclampsia, hypertensive disorders, cesarean (wound problems), later diabetes
• Fetal and newborn risks: same as pregestational except no increase in congenital anomalies - macrosomia (over 90th percentile or 4,000-4,500 g), brachial plexus injury, shoulder dystocia, IUGR, neonatal hypoglycemia in first hours, hyperbilirubinemia, RDS, assisted delivery, birth trauma, stillbirth; cesarean recommended for estimated fetal weight over 4,500 g
• Symptoms of uncontrolled hyperglycemia: polyuria, polydipsia, polyphagia, blurred vision, frequent UTIs, fatigue, recurrent candidiasis, sudden weight loss
• Management: diet and exercise for most; insulin as needed; oral agents without firm consensus
• Nursing:
  • Glucose checks: fasting plus three postprandial daily; targets fasting under 95, 1 hour under 140, 2 hours under 120; teach-back
  • Morning fasting ketones
  • Insulin self-administration (often new for GDM - major lifestyle change)
  • Diet plan helps 75-80% become normoglycemic; include whoever cooks
  • Walk 10-15 minutes after meals; 30-60 minutes daily brisk walking
  • Kick counts and prenatal visits
  • Assess stress, eating disorders, self-esteem, support
  • Screen for type 2 diabetes after birth and for comorbidities

Key concepts (Critical Component): strict control before and during pregnancy improves outcomes; fetal risk is relative to glycemic control; preconception euglycemia reduces miscarriage and anomalies; assess GDM risk early; GDM raises lifetime type 2 risk.

IX. Hypertensive Disorders in Pregnancy

A. Classification

• Hypertension: systolic 140 or more or diastolic 90 or more (either one)
• Affects 12-22% of pregnancies; second leading cause of maternal death
• Chronic hypertension - before pregnancy or before 20 weeks, or persisting beyond 12 weeks postpartum
• Chronic hypertension with superimposed preeclampsia - new proteinuria after 20 weeks, or sudden worsening proteinuria, liver enzymes, creatinine, thrombocytopenia, RUQ pain, headache, visual symptoms, pulmonary edema
• Gestational hypertension - new BP 140/90 or more after 20 weeks without preeclampsia findings; normal by 12 weeks postpartum; progresses to preeclampsia in 25%
• Preeclampsia - hypertension plus proteinuria (or systemic findings) after 20 weeks
• Preeclampsia with severe features - plus any of: SBP 160 or DBP 110 or more; creatinine over 1.1 or doubled; platelets under 100,000; liver enzymes twice normal; new cerebral or visual disturbances; persistent epigastric pain (also pulmonary edema)
• Eclampsia - seizures not attributable to another cause in a woman with preeclampsia
• HELLP syndrome - hemolysis, elevated liver enzymes, low platelets; complicates severe preeclampsia

B. Preeclampsia

Definition and criteria (Critical Component):

• New BP 140/90 or more on two readings at least 4 hours apart after 20 weeks, plus:
• Proteinuria: 300 mg or more in 24 hours, protein/creatinine ratio 0.3 or more, or dipstick 2+ (only if others unavailable)
• Or, without proteinuria, new: platelets under 100,000; creatinine over 1.1 or doubled; liver transaminases twice normal; pulmonary edema; new headache unresponsive to medication; visual symptoms
• Severe features add SBP 160 or DBP 110 or more (can be confirmed within minutes to allow prompt treatment), severe persistent RUQ or epigastric pain
• Proteinuria is no longer required; amount of protein doesn’t predict severity
• “Mild preeclampsia” is no longer used - the disease is progressive
• Early-onset (before 34 weeks) - more severe; poor placentation, abnormal uterine artery Doppler, IUGR, PTB; late-onset (after 34 weeks) - better outcomes, thought to be immune-triggered; postpartum preeclampsia is its own presentation
• Complicates 2-8% of pregnancies; rate rose 25% from 1987 to 2004; no consensus on cause

Pathophysiology:

• Normal pregnancy is vasodilated (PVR down 25%, BP falls, blood volume up 50%, cardiac output up 30-50%, GFR up)
• Preeclampsia is reduced organ perfusion from vasospasm and endothelial activation
• Proposed mechanisms: abnormal trophoblast invasion of uterine vessels; immune maladaptation between maternal, paternal, and fetal tissue; maternal maladaptation to cardiovascular or inflammatory changes; genetics
• Stage 1 - abnormal placentation: normally at 8-10 weeks trophoblasts remodel the spiral arteries into wide, low-resistance vessels; in preeclampsia invasion is shallow (decidual only), leaving narrow, high-resistance vessels and poor placental perfusion; acute atherosis adds infarcts and hypoxia; leads to IUGR, decelerations, acidemia, fetal death; the placenta is the root cause
• Stage 2 - maternal systemic disease: the underperfused placenta releases inflammatory factors (soluble Flt-1, soluble endoglin, CRP, IL-6) causing endothelial damage, vasospasm, altered hemostasis, coagulation activation
• Organ effects (Figure 7-7):
  • Liver - fat deposition, periportal hemorrhagic necrosis, subcapsular hematoma; epigastric or RUQ pain, nausea, vomiting; may progress to HELLP
  • Kidney (70%) - glomerular endothelial damage, fibrin, ischemia; lower renal flow and GFR; proteinuria; lower uric acid, creatinine, and calcium clearance; oliguria signals severe disease
  • Coagulation - platelet aggregation at damaged endothelium; thrombocytopenia under 100,000 is severe
  • Brain - fibrin, edema, hemorrhage; headache, hyperreflexia, progression to eclampsia
  • Eyes - retinal arteriolar spasm; blurred or double vision, photophobia, scotoma
  • Capillary leak - protein loss, low albumin, tissue edema
  • Lungs - pulmonary edema, usually from left ventricular failure due to very high vascular resistance
  • Placenta - decreased uteroplacental perfusion

Risk factors: nulliparity, age over 35, BMI over 30, multiples, family history, chronic hypertension, kidney disease, lupus, thrombophilia, antiphospholipid syndrome, pregestational diabetes, prior preeclampsia or eclampsia, GDM, assisted reproduction.

Maternal risks: cerebral edema, hemorrhage, stroke; DIC; pulmonary edema; heart failure; renal and hepatic failure; HELLP; eclampsia; abruption; 1.5-2 times higher lifetime heart disease risk and five times higher hypertension risk.

Fetal risks: uteroplacental ischemia leads to growth restriction, oligohydramnios, abruption, nonreassuring status, poor tolerance of labor, stillbirth, preterm delivery; IUGR programs adult metabolic and cardiovascular disease.

Assessment:

• BP at rest, seated, arm supported at heart level, cuff bladder encircling at least 80% of the upper arm; left lateral position no longer recommended for BP (reads falsely low)
• Labs: liver function, kidney function, coagulation

Medical management:

• Expectant or expedited delivery depending on severity, gestational age, fetal status
• Low-dose aspirin for high-risk women
• Under 34 weeks: corticosteroids, possibly magnesium
• Weekly monitoring once diagnosed; can present abruptly
• Magnesium sulfate for prevention and treatment of seizures in gestational hypertension, preeclampsia with severe features, eclampsia
• Antihypertensives for severe range
• Outpatient management possible for preeclampsia without severe features if adherent
• Induced birth for severe features under 34 weeks or instability at any gestation
• Without severe features: serial ultrasound, weekly testing, BP monitoring, weekly labs

Nursing actions (hospitalized):

• Accurate assessment; progression to severe can happen within days
• Antihypertensives as ordered (usually for BP over 160/110)
• Magnesium sulfate; CNS checks (headache, visual changes, DTRs, clonus)
• Lung sounds and RR; pulmonary edema signs
• Epigastric or RUQ pain (liver)
• Daily weight and edema
• Urine protein (24-hour collection) and specific gravity
• Labs: creatinine over 1.1, hematocrit over 35, platelets under 100,000, AST and ALT over twice normal
• NST and BPP; adequate calories and protein
• Strict I&O; fluid limit may be 2,000 mL/24 hr
• Quiet environment; bedrest lateral recumbent; teach family; report deterioration
• Preeclampsia Early Recognition Tool (PERT) - maternal deaths show failures to recognize and respond to warning signs

DTR grading (Box 7-3): 0 absent; 1 sluggish or dull; 2 active, normal; 3 brisk; 4 brisk with transient or sustained clonus. Clonus - dorsiflex the foot sharply and release; beats of clonus are foot taps against the examiner’s hand.

Medications (Table 7-4):

• Magnesium sulfate: IV load 4-6 g of 10% solution in 100 mL over 20 minutes, then 1-2 g/hr; without IV access 10 g of 50% IM (5 g each buttock); contraindicated in pulmonary edema, renal failure, myasthenia gravis
• For SBP over 160 or DBP over 110:
  • Labetalol IV 10-20 mg, then 40, then 80 mg over 2 minutes every 10 minutes; max 300 mg/24 hr; onset 1-2 minutes; avoid in asthma or heart failure; can cause neonatal bradycardia
  • Hydralazine IV 5-10 mg over 2 minutes every 20 minutes; max 20 mg/24 hr; onset 10-20 minutes; caution mitral valve disease; may cause maternal hypotension
  • Nifedipine immediate-release oral 10-20 mg, may repeat in 20 minutes; can raise HR and overshoot hypotension
  • None require cardiac monitoring (the magnesium Critical Component says patients on IV labetalol should have cardiac monitoring)
• Anticonvulsants for recurrent seizures or when magnesium is contraindicated: lorazepam 2-4 mg IV, repeat once after 10-15 minutes; diazepam 5-10 mg IV every 5-10 minutes to max 30 mg

Care of the woman on magnesium sulfate (Critical Component):

• Action: cerebral vasodilation (less vasospasm ischemia), slows neuromuscular conduction, depresses vasomotor center and CNS irritability
• Always IV piggyback on an infusion pump; loading dose 4-6 g over 15-20 minutes, then 1-2 g/hr
• Serum level at 4-6 hours; therapeutic 4.8-9.6 mg/dL (4-8 mEq/L)
• Continue 24-48 hours postdelivery (text wording)
• Toxicity progression: DTRs lost at 9 mg/dL (7 mEq/L); respiratory depression at 12 mg/dL (10 mEq/L); cardiac arrest at 30 mg/dL (25 mEq/L) - if DTRs are present, serious toxicity is avoided
• Antidote: calcium gluconate 1 g of 10% IV slowly over 5-10 minutes
• Maternal side effects: nausea, flushing, diaphoresis, blurred vision, lethargy, hypocalcemia, depressed reflexes, respiratory depression and arrest, dysrhythmias, decreased platelet aggregation, circulatory collapse
• Nursing: baseline vitals, DTRs, neuro, urine output; every 5-15 minutes during load, then every 30-60 minutes until stable; DTRs every 2 hours (use brachial if epidural); cool environment; strict I&O with Foley and urimeter (intake under 125 mL/hr); oliguria or renal disease raises toxicity risk
• Toxicity signs: loss of DTRs, RR under 12-14, urine under 30 mL/hr, shortness of breath or chest pain, ECG changes; if suspected, stop the infusion and notify the provider
• Report: urine under 30 mL/hr, RR under 12, SpO2 under 95%, persistent hypotension, absent DTRs, altered LOC, abnormal labs
• Seizure precautions, resuscitation equipment, continuous FHR
• Fetal and neonatal effects: decreased FHR variability, respiratory depression, hypotonia, decreased suck - alert the neonatal team

Emergent therapy for acute severe hypertension (Clinical Judgment):

• SBP 160 or more or DBP 110 or more, antepartum, intrapartum, or postpartum
• Treat within 30-60 minutes of confirmation to reduce stroke risk
• Goal 140-150/90-100, not normal - prevent loss of cerebral autoregulation
• Stabilize the mother before delivery even in urgent circumstances
• BP every 5-15 minutes

Fetal assessment in preeclampsia:

• Report of decreased fetal movement always investigated
• BPP: normal 8 (without NST) to 10; 4 or less abnormal
• Oligohydramnios concerning (reflects poor renal perfusion)
• Umbilical artery Doppler S/D ratio normally falls as pregnancy progresses; over 3-4 suggests growth restriction before other signs; absent or reversed end-diastolic flow means placental dysfunction

C. Eclampsia

• Seizure in the presence of preeclampsia; can occur ante-, intra-, or postpartum (about 50% antepartum)
• Triggers: cerebral vasospasm, hemorrhage, ischemia, edema
• 78-83% preceded by warning signs: severe persistent occipital or frontal headache, blurred vision, photophobia, altered mental status - but can occur without warning
• During seizure: prolonged FHR decelerations or bradycardia, increased uterine activity; after: recurrent decelerations, tachycardia, reduced variability from maternal hypoxia and hypercarbia
• Deliver only after maternal stabilization
• Care during a seizure: stay with the patient; call for help; lower head of bed and turn head to the side; anticipate suction (aspiration is the leading cause of maternal mortality in eclampsia); padded side rails; record time, length, and type of seizure; notify physician
• After: assess mother and fetus; airway and suction; oxygen 10 L/min by mask (100% nonrebreather); IV access; magnesium sulfate; quiet environment
• Consequences: hypoxia, trauma, aspiration pneumonia; residual neurologic damage uncommon (possible memory and cognitive effects; white matter loss on MRI in up to a quarter without major deficits)

Eclampsia protocol (Box 7-4):

• Notify for: SBP under 90 or over 160; DBP over 100; HR under 50 or over 120; RR under 10 or over 30; SpO2 under 95%; urine under 35 mL/hr for 2 hours; agitation, confusion, unresponsiveness; blurred vision; proteinuria; nonremitting headache or shortness of breath
• Tests: pulse oximetry, CBC, CMP, urinalysis, type and screen, magnesium level, ECG, CT angiogram for chest pain, chest x-ray for dyspnea, echocardiogram
• Interventions: call the team, assign leader, recorder, primary RN; lateral position; protect airway; 100% nonrebreather; suction and bag-mask available; pulse oximetry; record seizure; monitor BP, RR, SpO2, fetus, contractions, cervix; IV and labs; magnesium; antihypertensives; delivery plan; communicate with family
• OB evaluates within 10 minutes; huddle; rapid response if worsening

D. HELLP Syndrome

• Severe form of preeclampsia with increased maternal morbidity and mortality
• H - hemolysis: RBCs destroyed traveling through constricted vessels
• EL - elevated liver enzymes: decreased blood flow and liver damage
• LP - low platelets: platelets aggregate at damaged endothelium and are consumed
• 7-24% of severe preeclampsia; can occur without cardinal signs of severe preeclampsia
• 70% during pregnancy, 30% immediately postpartum; may worsen over the first 48 hours postpartum
• Partial HELLP - only some lab changes
• Diagnostic labs: abnormal peripheral smear, LDH over 600 U/L, total bilirubin 1.2 mg/dL or more (the PDF scan reads “0.2”; 1.2 is the standard criterion), AST 70 U/L or more, platelets under 100,000
• Maternal risks: abruption, renal failure, liver hematoma and rupture, death
• Fetal risks: PTB, death
• Presenting symptoms: RUQ pain and malaise (up to 90%), nausea and vomiting (50%); unexplained bruising, mucosal bleeding, petechiae, bleeding at IV and injection sites
• Only definitive cure: delivery of fetus and placenta; resolves about 48 hours postpartum; platelets as needed; otherwise managed like severe preeclampsia
• Nursing: thorough assessment, evaluate labs, notify immediately if suspected or worsening, give platelets, education, emotional support

Hypertension safety bundle (Clinical Judgment): four domains - Readiness, Recognition and Prevention, Response, Reporting and Systems Learning. Postpartum: notify for SBP 160 or DBP 110 or more twice within 15 minutes; treat within 60 minutes of the second reading; follow-up within 7-14 days postpartum; patient education; support plans for ICU admissions.

X. Bleeding in Pregnancy (Placental Abnormalities and Hemorrhage)

A. General

• Hemorrhage leads to hypovolemia, anemia, infection, PTB, maternal death; decreased placental perfusion leads to fetal hypoxemia, hypoxia, asphyxia, death
• Up to 20% of maternal cardiac output (up to 1,000 mL/min) flows through the placental bed at term; uncontrolled bleeding can exsanguinate the mother in 8-10 minutes
• Main causes of antepartum hemorrhage: placenta previa and abruption
• Rates of previa and accreta are rising with cesarean rate, maternal age, and ART; ultrasound allows antenatal diagnosis
• Critical Component: sterile vaginal exam is contraindicated in any pregnant woman with extensive bleeding until the source is known - with previa it can cause torrential bleeding

B. Placenta Previa

• Placenta attached to the lower uterine segment near or over the internal os; about 1 in 200 at term; cause unknown; tenfold increased risk of antepartum bleeding
• Bleeding from separation as the lower segment develops, with contractions, effacement, dilation, or vaginal exam
• Classification: “previa” if it covers the os to any degree; “low-lying” if near but not over; terms partial and marginal eliminated
• Risk factors: endometrial scarring (prior previa, prior cesarean, suction curettage), impaired vascularization (multiparity, short interval, age over 35, diabetes, hypertension, smoking, uterine anomalies, fibroids, endometritis), increased placental mass (large placenta, multiples)
• Maternal risks: hemorrhagic shock, transfusion, hysterectomy, ICU; exsanguination in 8-10 minutes; Rh sensitization; septicemia, thrombophlebitis, death
• Fetal risks: IUGR; deterioration related to maternal blood loss; hypoxia, death (under 10%); anemia; prematurity
• Assessment: classic painless bright red bleeding in the third trimester (may have pain or contractions); usually late second or third trimester; first episode rarely life-threatening; FHR changes with maternal blood loss; ultrasound confirms; only 10-20% of previas seen at 20 weeks persist to the late third trimester (placenta “moves away”); vaginal exam contraindicated
• Emergency management: cesarean when mother or fetus compromised; cesarean needed in nearly all previas; vaginal trial possible with low-lying placenta if emergency cesarean is available; may be associated with accreta spectrum; increased PPH risk
• Stable (bleeding under 250 mL): expectant management to allow lung maturity; outpatient for asymptomatic previa; benefits of bedrest, pelvic rest, reduced activity unproven
• Delivery for stable previa without bleeding: 36 0/7 to 37 6/7 weeks
• Nursing:
  • Assess color, character, and amount of bleeding (weigh pads); ultrasound; fetal status and gestational age
  • Continuous FHR - abnormal pattern may be the first sign of compromise
  • Vitals every 5-15 minutes if actively bleeding; up to 40% blood loss before BP and pulse change
  • Skin color, temperature, SpO2, mentation
  • Notify for: new or increased bleeding; BP under 90/60; pulse under 60 or over 120; RR under 14 or over 26; temperature over 100.4 F; urine under 30 mL/hr; SpO2 under 95%; decreased LOC; increased uterine activity; Category II or III FHR
  • Pain, tenderness, contractions; bedrest with bathroom privileges; large-bore IV; oxygen 8-10 L/min by mask
  • Type and crossmatch; massive transfusion protocol as needed
  • Steroids if indicated (including late preterm 34 0/7 to 36 6/7 if not previously given and delivery likely within 7 days); CBC, platelets, clotting studies
  • Inform and reassure; anticipate cesarean; RhoGAM if Rh-negative

C. Placental Abruption (Abruptio Placentae)

• Bleeding at the decidual-placental interface causing partial or complete detachment before delivery, after 20 weeks
• Starts with hemorrhage into the decidua basalis, forming a hematoma that destroys adjacent placenta; spiral arterioles may rupture
• Suspected with sudden, intense, often localized uterine pain or tenderness with or without bleeding; may present as preterm contractions, irritability, back pain
• About 1% of pregnancies; two-thirds severe; bleeding is almost always maternal; most have chronic etiology
• Grades (Figure 7-11): grade 1 mild (under 15% separated, concealed hemorrhage); grade 2 moderate (up to 50%, apparent hemorrhage); grade 3 severe (over 50%, concealed hemorrhage)
• Concealed hemorrhage in about 10% - uterine tenderness and abdominal pain
• About half occur before 37 weeks, 14% before 32 weeks
• Risk factors: previous abruption (up to 15% recurrence); hypertension (chronic, gestational, preeclampsia); prior cesarean, age, multiples, uterine anomalies or fibroids; PPROM under 34 weeks; abdominal trauma, motor vehicle crash; cocaine, methamphetamine, smoking; thrombophilias; early bleeding with subchorionic hemorrhage
• Maternal risks: hemorrhage, transfusion, hysterectomy, DIC, renal failure; death rare but seven times the overall maternal mortality rate
• Fetal risks: LBW, PTB, asphyxia, stillbirth; about 10% of PTBs and 10-20% of perinatal deaths
• Assessment:
  • Vaginal bleeding in up to 80% (can be concealed)
  • Shock signs: hypotension, oliguria, thready pulse, shallow irregular respirations, pallor, cold clammy skin, anxiety
  • Severe abdominal pain, tense abdomen, or continuous dull back pain
  • Contractions, tenderness, hypertonus, increasing uterine distention
  • Nausea and vomiting, decreased urine output
  • Signs of shock in pregnancy usually not present until 25-30% blood loss
  • Kleihauer-Betke may be positive (fetal RBCs in maternal blood)
  • Ultrasound misses 50% of abruptions
  • FHR tachycardia or bradycardia, Category II or III patterns (loss of variability, lates, decreasing baseline, sinusoidal)
  • Fear and anxiety
• Emergency management: cesarean for unstable or deteriorating status; monitor volume and coagulation; correct coagulopathy; restore blood; assess fetus; expedite delivery
• Stable and immature fetus: hospitalization and close monitoring of bleeding, uterine activity, hypertonus, pain, labs and coagulation; steroids; tocolysis may be considered
• Nursing: palpate uterus; monitor for shock; large-bore IV; oxygen 8-10 L/min; I&O; continuous FHR; emotional support; measure blood loss; massive transfusion protocol; anticipate cesarean; RhoGAM if Rh-negative and undelivered; steroids as indicated

D. Placenta Accreta Spectrum (PAS, morbidly adherent placenta)

• Defect of the endometrial-myometrial interface - failure of normal decidualization over a uterine scar lets villi anchor too deeply
• Complete (entire placenta), partial (one or more cotyledons), focal
• Placenta accreta - trophoblast invades beyond the normal boundary; villi attach to the myometrium without invading it (80%)
• Placenta increta - into the myometrium (15%)
• Placenta percreta - through the myometrium and serosa, can adhere to other organs such as the bladder (5%)
• Placenta does not separate after delivery, leading to massive hemorrhage (average blood loss 3,000-5,000 mL), DIC, hysterectomy, surgical injury (ureters, bladder, bowel), ARDS, transfusion reaction, renal failure; up to 90% need transfusion, 40% need more than 10 units; maternal mortality up to 7%
• Incidence parallels the cesarean rate
• Risk factors: previous cesarean with anterior or posterior previa over the scar (greatest risk); risk with previa by number of prior cesareans - 3%, 11%, 40%, 61%, 67% for first through fifth or more; previa without surgery 1-5%; IVF, age, multiparity, smoking, short interval
• Maternal risks: hemorrhagic shock; 25-50% ICU admission; infection, thromboembolism, pyelonephritis, pneumonia, ARDS, renal failure
• Fetal: average delivery at 34-36 weeks (medically indicated PTB); at term not a fetal risk
• Diagnosis: obstetric ultrasound (supplemented by MRI); absence of ultrasound findings doesn’t rule it out
• Antenatal diagnosis significantly reduces morbidity and mortality and allows planning
• Management: planned preterm cesarean hysterectomy with the placenta left in place, at a level III or IV center before labor or bleeding, with a multidisciplinary team and massive transfusion capability; delivery at 34-37 weeks for stable women; steroids; conservative or expectant management (leaving placenta, preserving uterus) is rare and individualized
• Complications of treatment: loss of fertility, hemorrhage, pelvic organ injury
• Nursing: counseling and preparation (cesarean, hysterectomy, loss of fertility); emotional support; information on timing; during hospitalization large-bore IV, type and hold 4 units PRBCs, CBC and clotting studies; massive transfusion protocol as needed

Labs for bleeding pregnant women (Clinical Judgment): CBC, fibrinogen, fibrin degradation products, platelets, blood type, whole blood clotting time, PT, aPTT.

XI. Pregnancy Loss

A. Abortion

• Abortion - spontaneous or elective termination before 20 weeks
• Induced (procedure or medication), elective (at the woman’s request before viability, not for maternal or fetal health), therapeutic (serious maternal illness or fetal anomaly); legal vs illegal
• About half of pregnancies are unplanned and half of those end in abortion; 1 in 4 US women will have an abortion; ACOG considers all terminations medically indicated
• 88% in the first trimester (up to 13 weeks), when safest; 60% at or before 10 weeks; medication abortion 39%
• Medication abortion: up to 70 days; mifepristone plus misoprostol preferred; can be taken at home; heavy bleeding and cramping; can take days to weeks; not for ectopic, IUD in place, long-term steroids, adrenal failure, coagulopathy or anticoagulants, porphyria, allergy; asthma and twins are not contraindications
• Surgical: suction curettage (most common, first trimester); dilation and evacuation (D&E) after 13 weeks (fewer complications than medical in second trimester)
• Call provider for: severe abdominal or back pain; soaking two maxi pads per hour for 2 consecutive hours; foul discharge; fever over 100.4 F
• Access barriers: insurance restrictions, waiting periods, parental involvement laws, stigma; disproportionate effect on adolescents, people of color, rural, low-income, incarcerated people
• AWHONN supports informed women making reproductive decisions with their provider; nurses should examine their own attitudes

B. Early Pregnancy Loss and Miscarriage

• Miscarriage - loss of an intrauterine pregnancy before viability; spontaneous abortion - nonviable intrauterine pregnancy (empty sac or no heart activity) within 12 6/7 weeks; early pregnancy loss - before 10 weeks
• About 10% of pregnancies; 80% in the first 12 weeks; about 50% from fetal chromosomal abnormalities; late losses at 12-20 weeks
• Risk by age: 9-17% at 20-30; 20% at 35; 40% at 40; 80% at 45
• Risk by history: 11% with no prior miscarriage, rising about 10% with each, 42% after three or more
• Graded model of care: after one - evaluate and inform; after two - miscarriage clinic, CBC, thyroid tests, early scans; after three - genetic testing and pelvic ultrasound
• Recurrent miscarriage is a marker for future PTB, FGR, abruption, stillbirth, cardiovascular disease, VTE
• Risk factors: prior loss, advanced age, diabetes or luteal phase defects, drugs or toxins, autoimmune disease, infection, systemic disorders, genetics, uterine or cervical abnormalities, Black women
• Assessment: bleeding first, then cramping hours to days later; ultrasound confirms; single hCG or ultrasound may not be enough
• Management: expectant, medical (misoprostol 800 mcg vaginally, repeat as needed), or surgical evacuation
• Rh-negative unsensitized: 50 mcg Rh immune globulin after surgical management or within 72 hours of diagnosis with medical or expectant management in the first trimester
• Call for changing more than two maxi pads per hour for 2 hours; surgery may be needed if expulsion is incomplete
• Vaginal micronized progesterone may increase live births in women with bleeding and prior miscarriage
• Families often report poor communication and lack of compassion - communication and patient-centered care matter
• Nursing: vitals, bleeding, labs, RhoGAM; support decisions about products of conception; acknowledge sadness, distress, or relief; choices; support groups; psychological effects (anxiety, depression, PTSD, suicide); follow-up; teach pericare, pelvic rest (no tampons, douching, intercourse for several weeks), excess bleeding and infection signs, iron and protein diet; confirm complete expulsion by ultrasound or serial hCG

C. Ectopic Pregnancy

• Pregnancy outside the uterine cavity; blastocyst implants outside the endometrium; nonviable
• 95% in the fallopian tube; also ovary, cervix, abdomen; about 2% of pregnancies
• The tube cannot support the trophoblast and can rupture, causing life-threatening internal bleeding
• Ruptured ectopic caused 2.7% of pregnancy-related deaths and was the leading cause of hemorrhage-related death
• Risk factors: up to 50% have none; prior ectopic (5-25% recurrence, up to 10 times baseline); abnormal tubes from PID, infertility, pelvic or abdominal surgery, endometriosis, STDs, tubal surgery or sterilization; smoking; DES exposure; increased age
• Maternal risks: hemorrhage from rupture; decreased fertility from tube removal
• Assessment: pelvic or abdominal pain (sudden, sharp, may be one-sided, may come and go); abnormal vaginal bleeding; shoulder pain from blood under the diaphragm; weakness, dizziness, fainting; unstable vitals if hemorrhage
• Diagnosis: clinical signs, serial hCG, transvaginal ultrasound, serum progesterone
• Management:
  • Stable, unruptured: laparoscopic surgery or IM methotrexate (folic acid antagonist that dissolves the mass and preserves the tube)
  • Unstable or hemorrhaging: immediate surgery
  • Salpingostomy vs salpingectomy guided by clinical status, desire for fertility, tube damage
• Nursing: stabilize cardiovascular status; explain and reassure; address anxiety, fear, guilt; grief support; follow-up plan; RhoGAM; teach warning signs (severe pain, bleeding, fever), iron-rich diet, pain management
• Methotrexate teaching: GI effects (nausea, vomiting, stomatitis); avoid alcohol and NSAIDs; abdominal pain 2-3 days after is common

D. Gestational Trophoblastic Disease (GTD) - Hydatidiform Mole

• GTD - spectrum of placental tumors from abnormal trophoblast growth; molar and nonmolar; gestational trophoblastic neoplasia (GTN) is almost always malignant
• Hydatidiform mole (molar pregnancy) - benign proliferation of trophoblast; chorionic villi become fluid-filled, grape-like clusters without a viable fetus; complete mole has no fetus; partial mole may have abnormal fetal tissue that never matures
• 1-2 per 1,000 US pregnancies
• Risk factors: age under 18 or over 40; previous molar pregnancy
• Maternal risk: choriocarcinoma
• Signs: vaginal bleeding (spotting to hemorrhage); uterus large for dates; pelvic pain or pressure; anemia; hyperemesis; hyperthyroidism (hCG has TSH-like activity); gestational hypertension or preeclampsia early in pregnancy; amenorrhea; nausea and vomiting; cramping and passing vesicles
• Diagnosis: early ultrasound, hCG, transvaginal ultrasound
• Management: immediate evacuation by suction D&C; serial hCG to detect malignancy; oral contraceptives are safe during monitoring; single-agent chemotherapy for nonmetastatic GTD; hCG follow-up for at least 6 months; pregnancy may be considered after hCG is normal for 6 months; prophylactic chemotherapy not routine
• Nursing: monitor for hemorrhage; assess uterus; support for loss and cancer fear; explain serial hCG; RhoGAM; grief support; discharge teaching (pain, bleeding, infection signs, follow-up, contraception and avoiding pregnancy for 1 year)

Psychosocial considerations (Critical Component): hospitalization means loss of routine and control; financial hardship; fear of death or fetal loss; anxiety about future pregnancies; separation from NICU infants (powerlessness, breastfeeding barrier - needs lactation support).

XII. Infections

Infections can reach the fetus transplacentally (HIV), by ascending the birth canal, or by contact during vaginal birth (herpes). All women are screened for STIs at the first prenatal visit; high-risk women rescreened in the third trimester.

A. HIV/AIDS

• Retrovirus attacking CD4 cells; spread by blood and sexual contact; perinatally by transplacental, intrapartum, and breast milk exposure
• About 5,000 births per year to women with HIV in the US
• Transmission 20-25% without treatment, as low as 2% with antepartum antiretrovirals
• Fetal risks: preterm delivery, PPROM, IUGR
• Findings: fever, fatigue, GI symptoms, weight loss, lymphadenopathy, neuro changes, opportunistic infections; anxiety, stigma, lack of support
• Management: screen at first visit; CD4 at first visit and every 3 months; viral load at 36-38 weeks to decide delivery mode; at least three antiretrovirals
• Factors increasing transmission: maternal AIDS, preterm delivery, low CD4, high viral load (cesarean recommended), chorioamnionitis, blood exposure (episiotomy, lacerations, forceps)
• Antepartum nursing: education, sleep, nutrition (protein, zinc, vitamin A), infection avoidance, emotional support
• Intrapartum nursing: avoid instruments, keep membranes intact, no fetal scalp electrode, no episiotomy or assisted delivery; avoid breastfeeding; avoid Methergine with antiretrovirals (exaggerated vasoconstriction)

B. Hepatitis C

• Most common bloodborne infection in the US; injection drug use is the main risk; rates doubled among women with live births 2009-2014
• 1-2.5% of pregnant women; about 5% vertical transmission; linked to FGR and LBW
• Direct-acting antivirals cure 90% but are not approved in pregnancy - treat postpartum
• Screen at-risk women at the first visit (anti-HCV), repeat if ongoing risk; counsel to avoid alcohol
• Cesarean not indicated for HCV alone; avoid internal monitoring, prolonged ROM, episiotomy; breastfeeding not discouraged

C. Sexually Transmitted Infections (Table 7-5)

• About 20% of the US population had an STI in 2018; half of new STIs in ages 15-24
• Routine prenatal testing: syphilis, hepatitis B, HIV, HPV; HSV screening if history or symptoms

• Risks: PID (infertility), PTL, PROM, uterine infection; fetal PTB, LBW, sepsis, neurologic damage
• Prevention: risk assessment and counseling, vaccination (hepatitis B, HPV), identify asymptomatic infections, treat partners, know partners, condoms, avoid high-risk practices
• Nursing: information, support, correct medication use and completion, warning signs, abstain until both partners are free of infection, treat partner, STIs spread by oral and anal sex too

D. TORCH Infections (Table 7-6)

TORCH - Toxoplasmosis, Other (hepatitis B), Rubella, Cytomegalovirus, Herpes simplex virus. Each can cross the placenta; effects depend on timing.

E. Urinary Tract Infection and Pyelonephritis

• Most common bacterial infection in pregnancy; linked to PTL, LBW, pyelonephritis, perinatal mortality; can be asymptomatic
• Causes: ascending colonization; urinary stasis from uterine pressure and hormones; E. coli 80-90%
• Risks: prior UTI, age, low income, chronic illness (sickle cell trait, diabetes, hypertension), poor hygiene, frequent intercourse, catheterization, trauma or surgery
• Symptoms: frequency, dysuria, hematuria, fever, chills, malaise, nocturia, malodorous urine, flank pain, nausea, vomiting, lower abdominal tenderness
• Diagnosis: over 100,000 colonies/mL on clean-catch midstream urine
• Management: urine culture at first visit for all; shortest effective antibiotic course; sulfonamides and nitrofurantoin are first-line in the second and third trimesters (first trimester only if no alternative); follow-up cultures; prophylaxis for recurrent UTI
• Nursing: prevention and symptom teaching; complete antibiotics; PTL precautions; hygiene, wiping, prompt voiding, hydration

F. Group B Streptococcus (GBS)

• Colonizes genital tract and rectum in 30-50% of pregnant women; leading cause of newborn infection (sepsis, meningitis, pneumonia)
• Transmission 50-75% mother to infant at birth; neonatal prevalence 0.5 per 1,000
• Maternal: UTI, pyelonephritis, chorioamnionitis, PTL, endometritis, wound infection; intrapartum fever with ROM over 12 hours
• Screening: vaginal-rectal culture at 36-37 weeks (text; Ch. 4 says 35-37)
• Treatment in labor: penicillin or ampicillin; penicillin allergy low anaphylaxis risk - cefazolin; high risk - clindamycin
• Unknown status in labor: treat if prior GBS history or risk factors
• Prelabor cesarean does not need prophylaxis even if positive
• Nursing: teach importance of intrapartum antibiotics; assess for fever and sepsis

G. Zika Virus

• Flavivirus spread mainly by mosquitoes, also sexually; high vertical transmission
• Risks: birth defects (microcephaly), PTB, IUGR, miscarriage, stillbirth
• Symptoms: fever, rash, arthralgia, conjunctivitis; ultrasound for fetal abnormalities
• No vaccine; prevent exposure
• If the woman tests positive: condoms or abstinence for 8 weeks; if the man or both: 3 months
• Nursing: travel screening; limit travel; cover skin, insect repellent

H. COVID-19

• Pregnant patients at higher risk of severe illness, ICU, ventilation, preterm birth, VTE; diabetes and obesity raise risk further
• ACOG and SMFM recommend COVID-19 vaccination for all pregnant people
• Disparities: disproportionate burden in Black, Latino, American Indian communities
• Symptoms 2-14 days after exposure: fever, cough, dyspnea, fatigue, aches, headache, loss of taste or smell, sore throat, congestion, GI symptoms
• Care: single or isolation room, airborne and droplet precautions, PPE; isolation ends at least 10 days after symptom onset and 24 hours fever-free
• Newborn: tested and isolated from other infants; no required separation from mother; hand hygiene, 6 feet when possible, mask while breastfeeding; breastfeeding not contraindicated
• Nursing: infection prevention teaching, EFM, manage anxiety, symptom and testing teaching, vaccines (flu, pneumonia, COVID-19), emotional support

I. Sepsis

• Life-threatening organ dysfunction from a dysregulated host response to infection
• Watch trends: temperature, BP, HR, RR, breath sounds, SaO2, urine output, skin, capillary refill, mental status
• Fetal tachycardia is often one of the first signs of maternal infection; decreased variability and late decelerations with poor perfusion
• Treatment: fluid resuscitation and antibiotics within the first hour; goal is cardiac output and oxygen transport

XIII. Trauma in Pregnancy

• Leading cause of maternal death; most common fatal injuries are abdominal (hemorrhagic shock) and head injury
• Blunt trauma mostly from motor vehicle crashes; penetrating from gunshots; IPV is a major cause
• The woman’s interests are paramount; optimizing the mother optimizes the fetus
• 15% of cardiac output (750-1,000 mL/min) goes to the placental bed at term; exsanguination possible in 8-10 minutes
• Pregnancy masks hemorrhage: plasma volume up 50%, RBC volume up 30%; up to 1,500 mL can be lost without vital sign changes
• Maternal hypotension causes uterine artery vasoconstriction, shunting blood away from the fetus to maintain maternal BP
• Decreased oxygen reserve and buffering capacity - vulnerable to hypoxemia and acidemia
• Catastrophic events after blunt abdominal trauma: placental abruption and uterine rupture
• Assessment: ATLS protocols; maternal evaluation and resuscitation first; contractions more often than every 10 minutes or uterine irritability may mean abruption; FHR changes may signal maternal deterioration
• Management: over 20 weeks, monitor at least 4 hours for uterine activity; Kleihauer-Betke for all major trauma; consider ultrasound; screen for IPV; monitoring 24-48 hours is common with abdominal injury
• Nursing: maternal stabilization first; uterine activity and fetal status; watch for bleeding, tenderness, contractions, fluid loss; during CPR, left lateral uterine displacement by tilting the body 25-30 degrees

XIV. Pregestational (Preexisting) Conditions

Patient-centered care (Critical Component): elicit and communicate values and preferences; value the patient’s expertise about her own body; respect preferred level of involvement. Maternal safety is the prime consideration.

A. Cardiovascular Disorders

• Cardiovascular disease is now the leading cause of death in pregnant and postpartum women (26.5% of pregnancy-related deaths); leading non-obstetric cause
• Affects 0.5-4% of pregnancies; congenital heart disease is now over half; ischemic disease rising with obesity, hypertension, diabetes, delayed childbearing
• Pregnancy changes that strain the heart: blood volume up 30-50%; cardiac output peaks at 28-32 weeks; plasma up 45%; RBC up 20%; heart rate up; diastolic BP down 10-15 mmHg at 24-32 weeks; heart enlarged and displaced; vena cava compression; estrogen vasodilation
• Can exceed the diseased heart’s capacity, causing pulmonary hypertension, pulmonary edema, heart failure, maternal or fetal death
• Risk factors for mortality: non-Hispanic Black race (3.4 times), age over 40 (30 times vs under 20), hypertension (13-fold MI, 8-fold heart failure), obesity (especially with sleep apnea)
• Maternal mortality 1-50% depending on the lesion; pulmonary edema, emboli, heart failure
• Labor: cardiac output up 50%, oxygen consumption tripled; vaginal birth generally preferred (less blood loss and surgical morbidity)
• Fetal: prematurity, SGA, IUGR, hypoxia and CNS damage, increased congenital heart disease if mother has it; neonatal death 3-50%
• Signs of deteriorating cardiac function: decreased ability to do ADLs, breathlessness, dyspnea limiting activity, progressive orthopnea, paroxysmal nocturnal dyspnea, exertional syncope, palpitations, chest pain, sustained arrhythmias, loud harsh systolic or any ventricular murmurs, pulmonary edema, fatigue, cyanosis, JVD, thromboembolism, fluid retention
• Management: collaborative team; discuss risks; renal labs; invasive hemodynamic monitoring as needed; lesion-specific drugs; vaginal delivery for most; preterm delivery for deterioration
• Nursing: prevent complications and detect deterioration; history and functional class; pregnancy heart team for complex disease; auscultation, vitals, capillary refill, RR and rhythm, weight, skin, edema; SpO2, 12-lead ECG, urine output, EFM; renal labs; fetal assessment reflects maternal cardiac function; discuss possible permanent cardiac decline and maternal and fetal risks; teach anticoagulant self-injection; thromboembolism and infection monitoring; diet and activity; follow-up; home health

B. Pulmonary Disorders

• Pregnancy leaves limited cardiopulmonary reserve: progesterone-driven hyperventilation and higher tidal volume; lower residual volume; higher oxygen consumption; estrogen-driven mucosal edema; tendency to respiratory alkalosis

Asthma:

• Most common lung disease in pregnancy (about 8%); airway obstruction, hyperresponsiveness, edema
• Poorly controlled asthma raises prematurity, cesarean, preeclampsia, growth restriction, maternal morbidity
• One-third worsen (usually 17-24 weeks), one-third improve, one-third unchanged; with aggressive management outcomes equal nonasthmatics
• Fetal: hypoxia (major complication), PTB, LBW, FGR
• Signs: cough, wheezing, chest tightness, dyspnea, RR over 20; hypoxia - cyanosis, lethargy, agitation, retractions, RR over 30
• Management: aggressive treatment (benefits outweigh medication risks); monthly pulmonary function; serial ultrasounds and testing for moderate to severe; bronchodilators, inhaled and oral steroids, allergy shots, antihistamines are safe; early steroids for severe acute asthma
• Nursing: history, PFTs, ABGs; for exacerbations oxygen to keep PaO2 over 95% (text), continuous pulse oximetry, beta-agonist inhalers; SpO2 at 95% to oxygenate the fetus; fetal assessment; avoid triggers; daily peak flow; medication teaching; action plan; report worsening

Pneumonia:

• Leading cause of maternal death among nonobstetric infections in the peripartum period
• Maternal risks: PTL, bacteremia or sepsis, pericardial tamponade, pneumothorax, atrial fibrillation, respiratory failure; fetal: hypoxia, PTB, SGA, death
• Signs: temperature 95 F or lower or 102.2 F or higher; RR 30 or more; hypotension; HR 120 or more; WBC under 4,000; anorexia; dry cough; dyspnea for weeks
• Management: antibiotics, oxygen 2-4 L by nasal cannula, antipyretics, hydration, pain control, chest x-ray
• Nursing: history, lung auscultation, continuous pulse oximetry (95% or higher), labs (WBC, lactate, sputum, ABGs, blood cultures), fetal monitoring, flu and pneumococcal vaccines, hypoxia signs, semi- or high-Fowler’s

Pulmonary edema:

• Fluid in interstitium and alveoli; hydrostatic (cardiogenic) or permeability (noncardiogenic)
• Signs: dyspnea, tachypnea, anxiety, tachycardia, crackles and wheezes, cough progressing to pink frothy sputum, nasal flaring, retractions, falling SpO2
• Causes to consider: preeclampsia, medications (tocolytics), fluid balance, anesthesia
• Tests: chest x-ray, ABGs, pulse oximetry, ECG, echocardiogram
• Treatment: maximize oxygenation; arterial line and ICU for severe; antihypertensives; small doses of morphine; diuretics (monitor potassium)
• Nursing: strict I&O; watch for worsening hypoxia; fetal status; high-Fowler’s or side-lying; pulse oximetry; medication teaching

C. Seizure Disorders (Epilepsy)

• 1.5 million US women of childbearing age; about 24,000 births per year
• Check antiepileptic drug levels before pregnancy and monthly (especially lamotrigine, carbamazepine, phenytoin)
• Seizure-free 9-12 months before pregnancy gives 84-92% chance of staying seizure-free
• Seizure risks: maternal injury and sudden unexpected death in epilepsy; fetal hypoxia, acidosis, decreased placental flow, FHR decelerations, trauma
• Antiepileptic drugs double to triple major malformation risk; highest with valproate, phenobarbital, topiramate, and polytherapy
• Ensure neurologist knows about the pregnancy

D. Gastrointestinal Disorders - Cholelithiasis

• Gallstones; acute cholecystitis is the second most common nonobstetric surgical indication in pregnancy (about 1 in 1,600)
• Estrogen raises cholesterol secretion; progesterone reduces bile acid secretion and slows gallbladder emptying
• Conservative management had high recurrence (40-90%), hospitalizations, PTL, and losses; early laparoscopic cholecystectomy after ERCP now preferred
• Signs: colicky RUQ pain, anorexia, nausea, vomiting, fever; stones on ultrasound
• Pregnancy is not a reason to deny necessary surgery; nonacute surgery may wait until postpartum; steroids for viable preterm fetus if PTL risk
• Nursing: pain and nausea management, antiemetics, comfort, explain plan and diet, EFM based on viability, monitor for PTL after surgery

XV. Venous Thromboembolic Disease

• Pregnant and postpartum women have 4-5 times the thromboembolism risk; VTE causes 9.3% of US maternal deaths
• DVT 75-80% and PE 20-25% of pregnancy VTE; half during pregnancy, half postpartum, but daily risk highest in the weeks after delivery
• Thigh clots more likely to embolize than lower leg clots
• Causes: hypercoagulability (more fibrin and clotting factors, less fibrinolysis), venous stasis, compression of vena cava and pelvic veins, reduced mobility; greatest DVT risk in the left leg
• Thrombophilia (inherited or acquired) - associated with severe preeclampsia, abruption, IUGR, fetal demise, PTB, recurrent miscarriage; antiphospholipid antibody syndrome is the most common acquired thrombophilia
• Other risks: cesarean (especially with PPH or infection), obesity, hypertension, autoimmune disease, heart disease, sickle cell disease, multiples, preeclampsia, smoking
• DVT signs: pain and swelling in an extremity (over 80%); calf circumference difference of 2 cm or more; dependent edema, sudden unilateral pain, erythema, low-grade fever, positive Homans’ sign
• PE signs: shortness of breath, tachypnea, tachycardia, dyspnea, pleuritic chest pain, fever, anxiety
• Diagnosis: Doppler ultrasound, MR venography, pulsed Doppler (DVT); chest x-ray, CT, ECG (PE)
• Management: prophylactic anticoagulation for prior VTE, thrombosis history, or high-risk thrombophilia; heparin compounds preferred (LMWH, unfractionated heparin); IV heparin to aPTT 1.5-2.5 times control for at least 5-7 days, then subcutaneous; LMWH safe in pregnancy; PE - stabilize, ICU, thrombolysis or embolectomy
• Nursing: ambulate once symptoms subside, elastic stockings, pain management, teach subcutaneous heparin injection in the abdomen, report bleeding gums, nosebleeds, easy bruising, injection-site problems
• VTE safety bundle (Readiness, Recognition, Response, Reporting) - risk assessment at the first prenatal visit, every antepartum admission, immediately postpartum, and at discharge

XVI. Maternal Obesity

• BMI 30 or greater; severe obesity BMI over 40; US obesity 42.4% (2017-2018); highest in non-Hispanic Black women
• Physiologic effects: cardiac output rises 30-50 mL/min per 100 g of fat, compounding pregnancy’s increase; cardiac hypertrophy and dilation; more sleep apnea; more reflux and hiatal hernia; added thrombosis risk; a large panniculus worsens vena cava compression
• Maternal risks: preeclampsia, DVT, UTI, GDM, PTB, cesarean, operative complications (longer surgery, blood loss, wound infection and dehiscence, thromboembolism, endometritis)
• Fetal risks: anomalies (NTDs, cardiac, diaphragmatic hernia, cleft lip and palate, anorectal atresia, hydrocephaly, limb reduction), IUGR, prematurity, macrosomia, fetal death, low Apgars, birth trauma, acidemia, NICU admission, respiratory complications, childhood and adult obesity
• Management: counsel on risks (NTDs, stillbirth); early GDM screening for BMI 30 or more; weight gain goal 11-20 lb; special nutrition after bariatric surgery
• Nursing: record height, weight, BMI; typical gain 3-6 lb in first trimester then 0.5-1 lb/week, but avoid exceeding goals; teach preeclampsia, diabetes, sleep apnea, vena cava syndrome signs; encourage walking and diet; frame obesity as a medical condition; small preconception weight loss helps; dietitian referral; caution moving the panniculus (vena cava compression); sleep sitting up; equipment rated for at least 400 lb; recognize and address weight bias

XVII. Thyroid Disorders

• Thyroid enlarges and makes more hormone in pregnancy; maternal TSH-receptor antibodies can cross the placenta
• Symptoms overlap normal pregnancy, making diagnosis hard; poor control leads to miscarriage, PTB, PTL, fetal loss, thyroid storm

Hyperthyroidism:

• Graves’ disease causes 90-95%; ophthalmopathy (lid lag, retraction) and dermopathy (pretibial myxedema)
• Untreated: preterm delivery, severe preeclampsia, heart failure, LBW, fetal loss
• Overlapping signs: heat intolerance, tachycardia, wide pulse pressure, vomiting
• Labs: low TSH, high free T4
• Treatment: thioamides - propylthiouracil or methimazole, chosen by trimester; radioactive iodine-131 contraindicated in pregnancy (destroys fetal thyroid)
• Monitor fetal growth, thyroid levels, liver enzymes, WBC (leukopenia)
• Nursing: teach signs and medications, lowest effective dose, extra calories, fetal and maternal risks

Hypothyroidism:

• Inadequate thyroid hormone; high TSH, low free T4; subclinical - high TSH with normal T4
• Maternal thyroid hormone is critical for fetal brain development early in pregnancy
• Untreated: miscarriage, preeclampsia, PTB, abruption, stillbirth, impaired fetal brain development
• Overlapping signs: fatigue, constipation, weight gain, cramps; also edema, dry skin, hair loss, slow DTR relaxation
• Treatment: levothyroxine 1-2 mcg/kg/day (about 100 mcg); TSH and T4 every 4-6 weeks
• Nursing: teach risks, signs, daily medication, follow-up

XVIII. Systemic Lupus Erythematosus (SLE)

• Autoimmune disease with overactive B lymphocytes affecting skin, joints, kidneys, serous membranes, nervous system, blood; 90% women
• Increased maternal mortality and morbidity (preeclampsia, GDM); miscarriage, fetal death, IUGR, PTB
• Best outcomes when quiescent for at least 6 months before pregnancy with stable renal function; lupus nephritis can worsen; pregnancy generally doesn’t cause flares
• Signs: malaise, fever, weight loss, arthritis, rash, pleuro-pericarditis, photosensitivity, anemia, cognitive dysfunction
• Management: no cure; monitor mother and fetus; low-dose aspirin; balance disease control against drug toxicity; corticosteroids or methylprednisolone for flares
• Nursing: identify flares; teaching; low-salt diet; calcium and vitamin D; stretching and aerobic exercise (22-45% also have fibromyalgia); avoid strenuous activity during flares

XIX. Substance Use in Pregnancy

A. Overview

• Substance use disorder - pathological pattern of use of any of 10 classes of substances
• First 8 weeks most critical for teratogenic effects
• 5.4% of pregnant women used illicit drugs in 2018; marijuana most common
• Many resume use soon after birth
• Polydrug use common; stillbirth risk: tobacco 1.8-2.8 times, marijuana 2.3, stimulants or opioids 2.2, passive smoke 2.1
• Commonly misused substances (Box 7-5): alcohol, cannabinoids, club drugs (MDMA, flunitrazepam, GHB), dissociatives (ketamine, PCP, dextromethorphan), hallucinogens, opioids, inhalants and anabolic steroids, prescription drugs, stimulants, tobacco
• Nursing interventions (Box 7-6): advocate for treatment referral; teach fetal risks; nonjudgmental, nonpunitive (addiction is a disease); facilitative (access to care) vs adversarial (prosecution) policies - AWHONN opposes punitive laws; dignity and therapeutic alliance; encourage prenatal visits; specific reduction strategies; written resources; know local resources; pain management for opioid-tolerant women; advocate for treatment over criminalization

B. Smoking and Tobacco

• Most important modifiable cause of poor pregnancy outcomes
• Doubles LBW risk; slows growth; increases PTB, spontaneous abortion, stillbirth; up to three times SIDS risk; doubles previa and abruption risk
• Children: asthma, colic, obesity
• 7.2% smoked during pregnancy (2016); about half of smokers quit around pregnancy; quitting before 15 weeks is best but any time helps
• Nicotine reduces uterine blood flow; carbon monoxide reduces oxygen-carrying capacity; effects dose-dependent
• Assessment: ask about all forms (cigarettes, e-cigarettes, vaping, hookah, snus, lozenges, patches, gum); cough, tobacco smell; denial, guilt, anxiety; ultrasound for IUGR
• Nursing: screen routinely, support reduction, alternative coping, teach risks (orofacial clefts, FGR, previa, abruption, PPROM, LBW, perinatal mortality, ectopic, low thyroid function), screen for other substances, refer (1-800-QUIT-NOW, smokefree.gov, SmokefreeTXT, QuitSTART app), motivational interviewing and CBT; nicotine replacement evidence mixed

C. Marijuana

• Most commonly used illicit drug in pregnancy; 3-7% report use; 34-60% of users continue in pregnancy, often believing it’s safe
• Tachycardia and low BP (orthostatic hypotension)
• THC crosses into the fetal brain and disrupts the endocannabinoid system
• Fetal: CNS abnormalities, IUGR, SGA, LBW, prematurity, stillbirth; neonates may show altered visual response, tremulousness, high-pitched cry

D. Alcohol

• Leading known preventable cause of birth defects; no safe amount or time; 1 in 9 pregnant women report use; binge drinking 3.9%
• At-risk use for pregnant women: any amount; binge: more than four drinks per occasion
• Pregnant teens 15-17: about 16% drank in past month
• Alcohol crosses the placenta quickly; fetal liver clears it slowly so levels stay high longer
• FASD - lifelong physical, behavioral, intellectual disabilities; FAS 2-7 per 1,000; FASD up to 5%; completely preventable
• Five criteria for FAS risk: drinking in pregnancy, birth defects, facial abnormalities, brain damage, growth restriction
• Four P’s screen: Have you ever used drugs or alcohol during pregnancy? Had a problem with drugs or alcohol in the past? Does your partner have a problem? Do you consider one of your parents to be an addict or alcoholic?
• Findings: poor nutrition or hygiene, tremors, edema, agitation, memory loss, hepatomegaly; depression, anxiety, denial, low self-esteem; blood alcohol level, STI tests, serial ultrasound
• Management: inpatient or outpatient treatment, written resources, case management, more prenatal visits
• Nursing: teach effects; stop drinking when stopping contraception; refer (AA, NA, NOFAS, SAMHSA 1-800-662-HELP)

E. Illicit Drugs

• Cocaine: vasoconstriction leads to abruption, PTB, PROM, precipitous delivery, meconium, LBW
• Methamphetamine: more potent than amphetamine; half-life about 12 hours (cocaine about 1 hour); hypertension, tachycardia, MI, dysrhythmias, subarachnoid hemorrhage, seizures, sudden death; fetal CNS, cardiac, GI, oral cleft, and limb defects, prematurity, SGA
• Opioids: use disorder quadrupled 1999-2014; tolerance and dependence; linked to poor fetal growth, PTB, stillbirth, birth defects, neonatal abstinence syndrome
  • Heroin: late prenatal care, FGR, abruption, fetal death, PTL, meconium; STI, hepatitis, HIV exposure; neonatal withdrawal, meconium aspiration, sepsis, IUGR, neurodevelopmental problems
  • Opioid agonist pharmacotherapy (methadone) is recommended over medically supervised withdrawal (high relapse); methadone maintenance is part of comprehensive care
  • Signs: late prenatal care, missed visits, poor weight gain, sedation, intoxication, withdrawal, erratic behavior
• Women who use illicit drugs are counseled to stop, except heroin users, for whom methadone is recommended

F. Assessment, Management, and Nursing for Substance Use Disorder

• Universal screening starting at the first visit, supportive and nonjudgmental (Ewing’s 4 P’s); urine toxicology only with consent and per state law
• Management: multispecialty clinics, treatment programs, screen for domestic violence, frequent urine toxicology, targeted ultrasound for anomalies, education, antepartum testing
• Maternal risks: PTL, PPROM, poor weight gain and nutrition, previa, abruption
• Nursing: pregnancy is a window of opportunity; long-term, family-focused, nonstigmatizing treatment; harm reduction when abstinence isn’t possible; know state reporting laws; counsel and refer; advocate; address stigma; social service needs; culturally specific public health campaigns

XX. Care Plan - Preeclampsia Concept Map

• CNS irritability - prevent seizures: monitor headache, dizziness, visual changes; seizure precautions; magnesium care; fluids to 125 mL/hr; I&O; DTRs; lateral bedrest; low stimulation; relaxation
• Altered cardiovascular function - BP below 140/90: BP hourly or more; antihypertensives; edema; lungs; left lateral bedrest
• Anxiety - calm, explain procedures and results, relaxation, encourage expression of feelings
• Altered renal function - strict I&O; report urine under 30 mL/hr; urine protein and specific gravity; kidney labs; edema
• Altered hepatic function - epigastric or RUQ pain, nausea, vomiting; AST and LDH; report changes
• Altered placental perfusion - FHR baseline and variability, Category II or III; intrauterine resuscitation (IV fluids, oxygen, lateral position); report; antenatal testing; kick counts

Case Study Themes (Mallory Polk, 42, G2 P0, IVF, 32 weeks)

• Presentation: backache, discharge, pelvic pressure, spotting, contractions every 5-7 minutes; risk factors for PTL (age, Black race, IVF, stress, long work hours)
• Treatment: IV LR bolus, CBC, urinalysis, fFN (positive), cervix 2 cm/75%/0 station, magnesium 4 g bolus then 2 g/hr, betamethasone 12 mg x 2, ultrasound
• Magnesium side effects (hot, flushed, burning at IV site, lethargy); magnesium level 5.6 mEq/L
• PPROM after a strong contraction; progression to 5 cm; magnesium stopped, vaginal birth anticipated
• Psychosocial: guilt, fear for the baby, not ready, work pressure; NICU tour and neonatal consult