Chapter 22

Complications of Pregnancy

•2•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Embryonic Development

3 to 8 weeks after fertilizationOrganogenesis—formation of basic functional elements of organ systemsCritical time in development of all organs and structuresBy end of 8 weeks, all organs are formedExposure of the embryo to teratogens

Can cause serious congenital abnormalities

•3•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Teratogen

Any substance or situation that causes a developmental abnormalityVirusesSmoking or exposure of mother to second-hand smoke

Child with low birth weightIncreased irritabilityPossible stillbirth

•4•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Teratogen (Cont.)

AlcoholRisk throughout pregnancyFetal Alcohol syndrome

• Impairs child’s neurological and intellectual developmentRadiation Certain medications, including herbal remedies

•5•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Development

Most organs have completed formation.Teratogens have less effect on development.

Functional impairment can still result.This is particularly true in the central nervous system

Elementary functions can be observed.Fetus gains weightOrgans such as lungs mature

•6•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Pregnancy

Pregnancy is divided into three trimesters.Approximately 3 months each

Laboratory diagnosisPresence of human chorionic gonadotropin (hCG) in mother’s plasma or urine

Absolute signsLater in pregnancyInclude heartbeat

• By auscultation or ultrasound

•7•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Pregnancy (Cont.)

Estimated date of delivery (EDD) or estimated date of birth (EDB)

Calculated using Nägele’s ruleFor women with longer cycles or irregular cycles—formula must be adjusted

Gestational age (2 weeks longer than biological age)

Length of time since the first day of the last menstrual period (LMP)280 days (40 weeks)

•8•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Pregnancy (Cont.)

Gravidity and parityWoman’s history of pregnancy and childbirthGravidity

• Number of pregnanciesPrimigravida

• Pregnant for the first timeParity

• Number of pregnancies in which the fetus has reached viability

Multipara• Completed two or more pregnancies with viability

•9•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Pregnancy (Cont.)

Amniocentesis Withdrawal of small amount of amniotic fluid

• After 14 weeks• Fluid checked for chemical contents• Cells cultured for chromosome analysis

Chorionic villi sampling (CVS)• Alternative process• Earlier in pregnancy• Useful for chromosomal examination• Diagnosis in high-risk clients

•10•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Hormonal Changes

Estrogen and progesterone blood levels increase.

Essential to the development of the uterusMaintenance of pregnancyPreparation for lactation

Hyperplasia of thyroidIncreased thyroxine production

• Increases mother’s metabolism and may be cause of heat intolerance

•11•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Reproductive System Changes

Increase in size of the uterusHypertrophy of muscle cells

Increased vascularity of the cervix and vaginaSoftening of the tissueMore abundant cervical mucus—cervical plug

• Protection of uterine contentMore acidic vaginal secretions

• Deterrent to some infectious organismsBreasts enlarge

Increased glandular tissue

•12•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Sagittal Section of Pregnant Woman: Effects of Expanding Uterus

Pressure of expanding uterusCan interfere with digestive functionReduces vital capacityIncreases pressure on bladder and rectumChanges center of gravity

•13•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Weight Gain and Nutrition

Average weight gain: 25-30 pounds (11-13 kg)Increased size of uterus and contentsEnlarged breastsAdditional blood volume

Increased demand for protein, carbohydrates, fat, vitamins, mineralsAdequate calcium for bones and teethIncreased iron needs as maternal blood volume increases

•14•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Extra Weight

Baby—~8 poundsPlacenta—2-3 poundsAmniotic fluid—2-3 poundsBreast tissue—2-3 poundsBlood supply—4 poundsStored fat for delivery and breastfeeding—5-9 poundsLarger uterus—2-5 poundsTotal—25-35 poundsThese numbers are the normal average figures.

•15•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Digestive System Changes

Nausea and vomitingCommon in first trimester

• Not just in the morningChange in eating pattern often reduces discomfort

Decreased motility in the digestive tractRelaxation of smooth muscle by progesteroneSlower emptying of the stomach

• Reflux of stomach contents (heartburn)• Constipation

•16•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Musculoskeletal Changes

Marked postural changesPelvic joints relax or loosen

• Hormones prepare for delivery• Loss of stability—waddling gait

Increased abdominal weight• Tendency toward lordosis • Balance and coordination may be impaired.

Backache caused by these changes

•17•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Cardiovascular Changes

Increased blood volumeBoth fluid and erythrocytesIncreased production of red blood cells for fetus

• Requires increased iron intake by the motherHeart rate may increase slightlyBlood pressure

Frequently drops slightly in first two trimestersRises to normal levels in last trimester

Varicose veinsFrequently develop during pregnancy

•18•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Ectopic Pregnancy

Tubal pregnancyZygote is implanted outside the uterus

Usually in the fallopian tubesSpontaneous abortion may follow.Embryo may continue to develop.

Eventually causes tubal ruptureSevere hemorrhage leading to shockDeathConsidered a surgical emergency

•19•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Pregnancy-Induced Hypertension

Persistently elevated blood pressure>140/90 mm HgDevelops after 20 weeks of gestationMay lead to stroke or damage to retinaReturns to normal after delivery

•20•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Pregnancy-Induced Hypertension (Cont.)

Pre-eclampsiaProgressively higher BPKidney dysfunction, weight gain, generalized edemaComplication—HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)

Eclampsia Extremely high blood pressure—seizures or comaHigh risk of strokeMay require cesarean section delivery to reduce maternal risk

•21•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Gestational Diabetes Mellitus

Develops in 2% to 5% of womenMay lead to developmental abnormalities if blood glucose level is high in first trimesterNewborn is large for gestational age and may experience hypoglycemia after birthGlucose levels should be closely monitored in:

Women with family history of diabetesPreviously high-birth-weight infants

•22•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Gestational Diabetes Mellitus (Cont.)

Dietary managementAppropriate exercise programInsulin may be necessary to reduce the blood glucose level.

Oral hypoglycemics are teratogenic and are not used.

•23•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Placental Problems

Placenta previaPlacenta is implanted in the lower uterus or over cervical osPlacenta may tear at end of pregnancyBright red bleeding—painless

•24•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Placental Problems (Cont.)

Abruptio placentaeMay occur following motor vehicle accident or spontaneouslyPremature separation of the placenta from the uterine wall, usually causing bleedingBlood may be trapped between placenta and uterine wallAbdominal pain is common.

•25•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Blood-Clotting Problems

ThromboembolismBlood clots, common after childbirthUsually develop in veins of legs or pelvis

ThrombophlebitisClot forms over an inflamed area in the vein wall

Embolus If a piece of the thrombus breaks away:

• Will flow with venous blood• May result in a pulmonary embolus

•26•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Blood-Clotting Problems (Cont.)

Disseminated intravascular coagulationSerious complication of other conditions

• Examples :abruptio placentae, pre-eclampsiaIncreased activation of clotting mechanisms

• Results in multiple blood clots throughout circulationDiagnosis confirmed by low serum levels of clotting factorsHemorrhage, shock, and tissue ischemia

•27•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Rh Incompatibility

Results when the mother is Rh-negative and the fetus is Rh-positiveUsually not a problem during first pregnancyRh-positive blood enters maternal circulation because of placental tears.Formation of maternal antibodies to Rh-positive bloodSubsequent pregnancies—maternal antibodies destroy red blood cells.

•28•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Rh Incompatibility (Cont.)

•29•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Rh Incompatibility (Cont.)

Hemolysis of red blood cellsSevere anemia, low hemoglobinJaundice may be severe.Possible heart failure and death

Early delivery or intrauterine transfusion may be recommended.Exchange transfusion after birth may be required.

•30•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Rh Incompatibility (Cont.)

Prevention Prenatal blood testing of woman and, if Rh-negative, of her partnerMonitoring for Rh antibodies in maternal bloodAdministration of Rh antibodies within 48 hours of delivery or termination of pregnancy to neutralize Rh-positive cells in maternal blood—thus, no immunological memory to Rh-positive cells

•31•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Maternal Infection

The healing uterus and perineal tissues are vulnerable to infection during the postpartum period.May lead to septic shock or peritonitis if untreatedIncreased risk of infection:

Retained placentaInadequate hygieneAbortion in nonsterile conditions

•32•Copyright © 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Adolescent Pregnancy

Teenagers have increased nutritional needs to meet demands of their own growth. Pregnancy at this time has increased risk of complications. Anemia is a common problem.Babies born to adolescent mothers frequently weigh less than normal or are preterm.Labor and delivery difficult—immature pelvisPregnancy-induced hypertension is common.