EXISTING DISORDERS COMPLICATING PREGNANCY
Some pregnant women have existing conditions that may complicate pregnancy and that require special attention. Such conditions include diabetes mellitus and cardiac disorders. Chemical dependency is another existing condition that requires special considerations to protect both the woman and the fetus.
Diabetes Mellitus
Diabetes mellitus is an endocrine disorder in which the pancreas fails to produce sufficient insulin for proper use of glucose.A diabetic woman needs special care and monitoring during pregnancy because insulin requirements fluctuate. Even when diabetes is monitored carefully, the pregnant woman and her developing fetus are at risk. Women with diabetes ideally should receive optimal care and client education before conception to prevent interrupted pregnancy and congenital malformations in their babies. Tight metabolic control can be achieved with intensive self-management and preparation for pregnancy.
In practice Educating the Client 68-1
THE PREGNANT WOMAN WITH DIABETES
Client and family teaching for the pregnant woman with diabetes includes the following:
• Method for self-testing blood for glucose several times per day
• Insulin and diet adjustments based on glucose level
• Method for insulin injections if the woman has not used insulin previously
• Signs of hyperglycemia and hypoglycemia
• Actions to take if hyperglycemia or hypoglycemia occurs
• Signs and symptoms of beginning preeclampsia
Potential problems during pregnancy include fetal death, macrosomia (oversized fetus), a fetus with a respiratory disorder, difficult labor, preeclampsia or eclampsia, polyhydramnios, and congenital malformations.
Diabetes is usually more difficult to control during pregnancy. The woman may become hyperglycemic, with resulting acidosis or diabetic coma. She also may become hypoglycemic, with resulting fetal hypoxia. The pregnant woman with insulindependent diabetes will need to learn to administer her own insulin injections during the pregnancy. Depending on the condition of the woman and fetus, diabetic women may deliver early (36-38 weeks) by induction or cesarean delivery.
Nursing Alert A reaction to too little or too much insulin is a danger to the woman, especially during labor and immediately after delivery The woman’s body reacts to the trauma of birth, and her glucose level is easily upset.
Blood glucose testing, dietary adjustments, and danger signs that must be reported are necessary teaching for the diabetic woman and her family. Family teaching is important because the woman may be unable to recognize these signs in time to be able to take action (In Practice: Educating the Client 68-1).
Diabetic women should be under the care of an internist and an obstetrician during pregnancy. Frequent antepartal visits are essential. Careful fetal monitoring is necessary during labor, and the newborn must be assessed carefully. Generally, these newborns are treated as premature babies.
An increasing number of pregnant women develop diabetes for the first time during pregnancy, a condition called gestational diabetes. Although management of gestational diabetes through diet alone works for some women, others will require insulin. Most women will return to prepregnancy glucose levels following delivery. Women with gestational diabetes mellitus and women who have delivered a baby weighing more than 9 pounds are known to develop type 1 or 2 diabetes in later years. These women should be advised that they are at higher risk than others.
Cardiac Disorders
Pregnancy places additional strain on the heart. Because of the increased blood volume, the greatest dangers are during the last trimester, labor, and delivery. During labor, women with a history of cardiac problems should be assessed for dyspnea, chest pain, and pulmonary edema.
During pregnancy, the woman with a cardiac condition should get plenty of rest and avoid activities that result in shortness of breath. She should maintain a diet that will prevent excessive weight gain and water retention. Usually sodium (salt) is restricted. The woman’s prognosis depends on her age and the severity and type of heart disease.
Women with cardiac disorders often successfully deliver their babies. Current belief is that a vaginal delivery is safer for the woman than a cesarean delivery because of the added strain of surgery. However, induced labor and early delivery may prevent a difficult labor.
Chemical Dependency
The addicted pregnant woman may be malnourished. Her addiction may result in a failure to seek antepartal care. Drug use may account for a stillbirth, spontaneous abortion, abruptio placentae, and numerous congenital defects. The chemically dependent mother often lacks parenting skills. Child protection authorities should be involved early in the pregnancy of a chemically dependent woman.
DISORDERS AFFECTING THE FETUS
Some disorders present special concerns for fetal health and well-being. Infections, including sexually transmitted infections (STIs; also referred to as sexually transmitted diseases [STDs]), not only require careful maternal treatment but also can compromise fetal health.Hemolytic conditions, such as Rh sensitization and AbO incompatibility, also warrant careful evaluation.
Infection
Maternal infections can harm the fetus. For instance, a severe respiratory disease, such as viral pneumonia, can cause fetal anoxia. If the woman contracts rubella early in pregnancy, fetal malformation is a strong possibility. A woman whose rubella titer is low (< 1:10) does not have the antibodies to fight rubella. If this woman is exposed to rubella, gamma globulin may be given. An abortion may be an option. After the pregnancy, the mother is immunized for rubella. She should be cautioned not to become pregnant for at least 3 months after this immunization to avoid harm to the next fetus.
Maternal STIs are often transmitted to the fetus. Maternal/fetal circulation transmits syphilis, gonorrhea, herpesvirus 2, and human immunodeficiency virus or acquired immunodeficiency syndrome.
Rh Sensitization
Rh sensitization is preventable in most cases. In Rh sensitization, the mother is Rh negative, but Rh-positive red blood cells from the fetus cross the placental barrier and enter the maternal circulation. Because the Rh-positive cells become antigens in the Rh-negative woman, they stimulate the formation of antibodies within the woman’s circulatory system. These antibodies return to the fetus, destroying the fetal erythrocytes. An Rh-negative woman who has produced these antibodies is said to be sensitized. The newborn in this situation is born with a condition known as erythroblastosis fetalis.
The sensitization of the woman in erythroblastosis fetalis usually occurs at or near the delivery, so the antibodies do not always affect the fetus being carried at that time. However, in subsequent pregnancies with Rh-positive fetuses, the already sensitized woman usually produces large numbers of antibodies. Some newborns are only mildly affected, whereas others are severely affected. Efforts to save the fetus may include intrauterine transfusion (exchange of fetal blood in utero) if the pregnancy is less than 32 weeks’ duration, or early delivery at 34 to 38 weeks.
Administering anti-D gamma globulin, also known as Rh0(D) immune globulin (RhoGAM, Gamulin Rh), to the Rh-negative woman can prevent erythroblastosis fetalis. This drug should be administered at 28 weeks of gestation and again after 72 hours: or after the birth of an Rh-positive baby, any abortion, or any invasive procedure, such as an amniocentesis. RhoGAM prevents the woman’s body from building up anti-Rh-positive antibodies. Erythroblastosis fetalis is thus prevented, even in Rh-positive fetuses. RhoGAM’s availability has made this disorder rare in the United States.
Nursing Alert Each time an Rh-negative woman delivers or aborts, RhoGAM must be administered again.
ABO Incompatibility
ABO incompatibility, a type of hemolytic disease of the newborn, can arise if the woman’s blood type is A and the fetus’s is B or AB; if the mother is B and the fetus is A or AB; and if the mother is O and the fetus is A, B, or AB.
ABO incompatibility is not detectable before birth. It can occur in a first pregnancy and does not increase in severity with subsequent pregnancies. It is usually clinically milder than Rh sensitization. The problem is indicated by jaundice in the newborn within the first 24 to 36 hours. Phototherapy is often initiated to treat jaundice.
PLACENTAL AND AMNIOTIC DISORDERS
Placental disorders include placenta previa and abruptio placentae. Placenta previa means that the placenta implants in the wrong place within the woman’s uterus. Abruptio placentae is a condition in which the placenta tears abruptly and prematurely from the uterus. Both conditions can be life threatening to the woman and fetus. Polyhydramnios, or excessive amniotic fluid, presents serious dangers to the fetus.
Placenta Previa
Placenta previa is a serious condition that occurs when the placenta implants in the lower segment of the uterus, rather than in the upper wall (Fig. 68-2). Low implantation is placental attachment at the opening or border of the cervical os, but not covering it. If the placenta partially obliterates the cervical os, it is a partial placenta previa. Placenta that totally covers the cervical os is called total placenta previa.
Predisposing factors for placenta previa are numerous and include closely spaced pregnancies, abnormalities in uterine structure, late fertilization, and old cesarean scars. Painless vaginal bleeding during the later months of pregnancy, the primary symptom, is caused by the placenta separating from the uterine wall.
If undetected before labor begins, placenta previa will result in hemorrhage because the cervical dilation causes increased tearing of the placental tissue. The severity of hemorrhage in relation to the progress of labor determines the method of delivery to be used. In total placenta previa, cesarean delivery is performed. In partial placenta previa, the amount of cervical involvement dictates the method of delivery, although cesarean delivery is usually performed if the placenta previa covers more than 30% of the cervical os when the cervix is fully dilated. A woman may be hospitalized several times before hemorrhaging becomes severe enough to warrant cesarean birth.
Other potential complications of placenta previa are loss of uterine muscle tone (atony), uterine rupture, retention of placental tissue, and air embolism, a serious complication caused by exposure of uterine sinuses and blood vessels to the air. The fetus is at considerable risk, and fetal shock and maternal or fetal death are possible.
FIGURE 68-2 · Placenta previa. (A) Normal placenta. (B) Low implantation. (C) Partial placenta previa. (D) Total placenta previa.
Diagnosis and Management
If vaginal bleeding occurs, the client should be hospitalized immediately and placed on bed rest. The need for fetal monitoring, IV and blood administration, possible cesarean delivery, vaginal packing, and emergency infant resuscitation should be anticipated.
Diagnosis is most often obtained by ultrasonography (Doppler ultrasound), which can usually identify the exact placental location. In some situations, x-rays may be used (including placentography) to visualize the placenta.
If the fetus is diagnosed as viable, a sterile vaginal examination (SVE) may be done (by the physician only) in the operating room. The operating room should be prepared with a double setup to allow for an emergency cesarean delivery if necessary.
Vaginal birth is not usually considered unless the previa is minimal. If the fetus is under 36 weeks’ gestation, the mother is put on strict bed rest either in the healthcare facility or at home. If no bleeding occurs, ultrasound scanning may be done every 2 to 3 weeks along with nonstress testing and biophysical profile. If bleeding is found, a cesarean delivery is anticipated.
Although placenta previa is still considered serious, modern surgical methods and the use of blood transfusions have greatly reduced maternal mortality. The prognosis for the fetus depends on the effect of maternal hemorrhage on fetal circulation and oxygenation.
Nursing Considerations
Observe the mother carefully for hemorrhage following a placenta previa delivery. If bleeding continues to be severe and attempts at control are unsuccessful, an emergency hysterectomy may be performed.
Abruptio Placentae
Abruptio placentae, the abrupt premature separation of the normally implanted placenta from the uterine wall, is a grave complication of late pregnancy (Fig. 68-3). It usually develops after the 20th week of gestation and it often occurs without labor.
Nursing Alert Abruptio placentae is an emer gency that may require immediate cesarean delivery. Report vaginal bleeding, signs of shock, or a rising uterus (which becomes very hard without contractions) immediately Rationale: Blood may be trapped inside the uterus.
Some predisposing factors are hypertension, preeclampsia, poor placental circulation, substance abuse, grand multiparity, and numerous abortions or stillbirths. Physical trauma, such as a motor vehicle accident, also can cause immediate placental separation. The extent of the separation determines the amount of danger to the fetus. Abruptio placentae is a common cause of stillbirth.
Diagnosis and Management
Abruptio placentae can occur any time in pregnancy before the birth, giving rise to fetal distress. The bleeding that results from the separation may be apparent or hidden. If bleeding is externally visible, it is often dark. The uterus becomes tender and rigid, and symptoms of maternal shock may occur. Fetal movement may increase or decrease. If the woman experiences extreme pain or the uterine fundus rises, it may indicate bleeding and pooling behind the placenta (retroplacental hemorrhage).
Other possible maternal complications include bleeding into the uterine muscle, precipitous labor (fast and uncontrolled), loss of uterine tone (atony), and oliguria leading to acute renal failure. Disseminated intravascular coagulation (DIC) and maternal death may occur .Dangers to the fetus include anemia, anoxia, and death.
Nursing Considerations
The diagnosis of abruptio placentae is based on the client’s history, physical examination, and laboratory studies. Sonograms are used to rule out placenta previa, but they are not diagnostic for placental abruption. The amount of vaginal bleeding seen can be misleading because blood may be trapped behind the placenta. The nurse must be aware of changes in vital signs and indicators, such as sudden extreme pain or aberrations in uterine shape.
Treatment depends on the severity of maternal blood loss, determined by laboratory findings, fetal maturity, and the biophysical condition of both the woman and the fetus. Continuously monitor the fetus if a fetal heart rate is present. Identify the upper limit of the fundus and mark it on the woman’s abdomen with a felt-tip pen. Observe the fundus for changes in shape or movement upward. Measure abdominal girth (the distance around) with a flexible tape measure. If the abdomen increases in girth or moves upward, blood may be collecting within the uterus; this dangerous situation usually calls for immediate cesarean delivery.
FIGURE 68-3 · Premature separation and abruptio placentae.(A) Separation is low and incomplete; vaginal hemorrhage is evident. (B) Separation is high, causing fundus of uterus to rise. Fetus is in grave danger. External hemorrhage is not present, but amniotic fluid is port-wine color. (C) Complete abruption, with fetus in grave danger. External hemorrhage is prevented because fetus’s head is in cervical os.
Before a cesarean birth, lost maternal blood must be replaced and circulating blood volume restored. During this time, constantly monitor maternal vital signs and fetal heart rate (if present). In a few cases, a hysterectomy may need to be performed to control the bleeding.
With modern treatment, abruptio placentae is rarely fatal to the woman. However, the outlook for the newborn’s survival depends on the severity of the separation and the degree to which his or her oxygen supply has been affected.
Polyhydramnios
Polyhydramnios (sometimes called hydramnios) means an excessive amount of amniotic fluid (>2 L or 2,000 mL). Seen in approximately 10% of pregnant diabetic women, polyhydramnios also accompanies neural tube defects, such as spina bifida and anencephaly. The woman’s abdomen is excessively large, producing dyspnea and difficulty with movement. The skin is stretched tightly, and excessive stretch marks (striae gravidarum) may be present. Uterine muscles also have been stretched, which may lead to ineffective contractions (dystocia) and failure of the uterus to contract following childbirth.
Placenta Accreta
A placenta that fails to separate, fails to be expelled within 20 to 30 minutes after delivery, or leaves remnants in the uterus is a danger to the woman. This condition is called placenta accreta or retained placenta. The tissue must be removed soon after delivery so that infection or hemorrhage does not develop. Retained placenta may result from partial separation of a normally attached placenta, entrapment of the separated placenta by uterine constriction, mismanagement of labor’s third stage, or abnormal adherence to the uterine wall.
The birth attendant may need to remove the placenta manually and may perform a postpartum uterine D&C. Vigorous attempts at removal may lead to hemorrhage, shock, or uterine rupture or inversion. If the uterus ruptures or bleeding is uncontrollable, a hysterectomy may be performed to save the mother’s life. Nursing measures include support and monitoring vital signs.
OTHER HIGH-RISK PREGNANCIES
Prolonged Pregnancy
A pregnancy continuing beyond 42 weeks is known as a prolonged (postdate or postterm) pregnancy. In this case, the obstetrician may induce labor or perform a cesarean delivery. The condition of the fetus is a determining factor. If any indication of fetal distress exists, a cesarean delivery is the most likely option. Risks to be considered include placental insufficiency, a condition in which the placenta deteriorates and uteroplacental circulation is compromised.
Multiple Pregnancy
A multiple pregnancy is one in which more than one fetus is developing in the uterus at the same time. If a multiple pregnancy is suspected, ultrasound is diagnostic. Labor is not ordinarily more difficult than in a normal pregnancy, although preterm and precipitate (sudden, progressing faster than normal) deliveries are relatively common.
Adolescent Pregnancy
More than 1.2 million adolescent women in the United States become pregnant each year, representing nearly 20% of births. Pregnancy in a girl younger than 16 years places a particular strain on her body; this adolescent is undergoing not only the normal changes of adolescence, but also those needed to sustain a pregnancy. Iron requirements are high for both adolescence and pregnancy, and anemia may result. The young woman may need special dietary instructions or vitamin supplements.
Complications of adolescent pregnancy often involve preeclampsia, eclampsia, and spontaneous abortion. Babies are often preterm and small for their gestational age. Perinatal mortality is increased, and newborns often develop slowly. Pregnant adolescents are at high risk for infections and STIs.
Childbirth preparation classes are offered through local public health departments or healthcare facilities. Pregnant clients, particularly adolescents, should attend these classes to understand their nutritional needs and the process of pregnancy.
The pregnant teen should also receive information about continuing her education. By law, public school education must be made available to pregnant teenagers. Counseling services should be offered because the girl may be afraid to go to her parents for help. Local church groups or clergy members, Planned Parenthood of America, local social service agencies, and the family physician may provide resources and counseling. Financial assistance also may be available.
Pregnancy in the Woman Older Than 40 Years
The pregnant woman older than 40 years encounters more risks than the woman between 16 and 40 years of age. Bodily changes in preparation for menopause may have begun. Primigravidas of this age have an increased incidence of complications in pregnancy (e.g., ectopic pregnancy, gestational diabetes, and hypertensive disorders) in addition to problems during labor and delivery, such as hypertonic or hypotonic dystocia (contractions too weak or too strong, respectively) and hemorrhage. They also face greater than normal chances of having cognitively impaired or malformed children. The older grand multipara may be more likely to have a precipitate delivery, placenta previa, hydram-nios, hypotonic dystocia, or hemorrhage because of an atonic uterus (one that does not contract following delivery).
