Life or health of mom or fetus is in jeopardy because of a problem that has occured b/c of the pregnancy or independently of the prgnancy (i.e. preexisting conditions)

Timeframe extends through first 30 days PP (maternal complications possible)

• Age (<15 or >35)
• Lack of prenatal care
• Low level of education
• Unmarried status (single mom)
• Nonwhite race (AA maternal mortality rates are 3x higher than caucasian women)
• Biophysical, psychosocial, sociodemographic, & environmental factors (see chart pg 634)

• Fetal death-- prevention of antepartum fetal deaths relates to responding appropriately to abnormalities of late pregnancy and labor
• Neonatal death--in first 28 days of life
• Perinatal death (fetal or neonatal)

• Congenital anomalies-- leading cause of death in neonatal period !
• Preterm delivery and LBW
• Respiratory distress syndrome (meconium aspiration, infection)
• Effects of maternal complications

• Smoking
• Caffeine
• Alcohol (ETOH)
• Drugs
• Psychologic status
• Eating disorders

• Genetic factors (defective genes, inherited disorder, chromosomal abnormalities, multi-gestation, ABO incompatibility, large fetal size)
• Medical and obstetric disorders
• Nutritonal/ general health status

• Low income
• Lack of prenatal care
• Age (<15, >35)
• Marital status
• Residence (rural at higher risk)
• Ethnicity (nonwhite moms 3x as likely to die from complications)

• Hazards in workplace and general environment
• Radiation
• Chemicals
• Drugs
• Pollutants
• Stress
• Diet

• Sociodemographic: age (<15, >35), low socioeconomic status
• Psychosocial: smoking, drug/alcohol use
• Biophysical: maternal weight <50kg, poor nutrition, hx of preterm births, incompetent cervix, iterine abnormalities, pneumonia, multiple gestation, anemia, abnormal fetal presentation, preterm ROM, placental abnormalities, infection

Too much amniotic fluid (>2L)

• Risk factors:
• Diabetes mellitus
• Multiple gestation
• Fetal congenital abnormalities
• Isoimmunization (Rh/ ABO)
• Abnormal fetal presentation

Too little amniotic fluid (<300mL)

• Risk factors:
• Renal agenesis (kidneys don't develop correctly)
• Prolonged ROM
• Intrauterine growth restriction (IUGR)
• Intrauterine fetal death (IUFD) 

• Maternal issues: cyanotic heart disease, hx of pregnancy with IUGR, poor nutrition, collagen diseases, chronic HTN, PIH, hemoglobinopathy, recurrent antepartum hemorrhage, smoking, drug/etoh abuse
• Fetal issues: infection, CV anomalies, congenital anomalies, multiple gestation

• AKA prenatal testing
• Any testing done to check on the status of the fetus
• Identifies fetal compromise before fetal asphyxia occurs
• Allows time for appropriate interventions to be implemented to save the fetus
• Tests are selected based on needs of woman

• AKA kick counts
• Used to monitor fetus when there may be hypoxia (PIH, chronic HTN, DM, etc. are risk factors)
• Done at home, noninvasive
• Usually move about 30 times in 40 minutes
• Exact protocol depends on facility

• Basic/ limited
• Performed by ultrasonographers, nurses, HCPs, etc.
• Comprehensive
• Performd by highly trained and specialized personnel
• Provides more detail and specific info

• Detect fetal viability
• Determine fetal presentatin
• Assess GA
• Locate placenta
• Examine fetal anatomy for malformations
• Determine amniotic fluid volume

• Non-invasive
• Evaluates blood flow in fetus and placenta
• Used to assess pregnancies complicated by things that can impact uteroplacental blood flow, such as:
• HTN, PIH, DM, multi-gestation, and preterm labor

• Used when there is risk of placental insufficnecy
• Noninvasive
• Real-time sono assesses:
• Fetal breathing movements, fetal muscle tone, FHR patterns, amniotic fluid volume (AFV)
• Non-stress test (NST) also included

• Scored 2 for each normal finding, 0 for abnormal
• 8-10 is normal, 6 is equivocal, and <4 is abnormal
• Normal score = fetus is not hypoxic and CNS is functioning

• Done in office over 20-30 minute period
• Noninvasive, no side effects
• High rate of false positives (non-reactive)
• Use external monitors:
• Doppler transducer records FHR 
• Toco transducer records fetal movement 
• Mom presses button when she feels baby move

• Reactive (good, 2 on BPP)
• 2 or more accelerations from baseline of 15 bpm, lasting for 15 seconds
• Non-reactive (bad, 0 on BPP)
• <2 accelerations in 40 minutes
• Caused by hypoxia, acidosis, drugs (esp. pain meds and beta blockers)
• False positives caused by fetal sleep cycles, smoking meds, and fetal immaturity

Abnormalities in AFV--> fetal disorders

• Amniotic fluid index (AFI) calculated w/ AFV values:
• <5 cm = oligohydramnios
• 5-19 cm = normal
• >20 cm = polyhydramnios

• Maternal blood test, 4 components:
• AFP (alpha fetoprotein), hCG, UE₃ (unconjugated estriol), Diameric Inhibin-A
• Screening test for Down syndrome, Trisomy 18, and NTDs
• Done at 14-22 weeks gestation
• Does NOT diagnose or rule out-- need amniocentesis

Amniocentesis

• Obtains amniotic fluid, done after 14 weeks
• Diagnoses genetic disorders and congenital anomalies
• NTDs, fetal metabolic disorders, etc.
• Also assesses fetal lung maturity and fetal hemolytic disease
• Can determine if meconium has been passed in utero 

• Lecithin/sphingomyelin ratio-- assesses lung maturity
• Early pregnancy: S > L
• About 32 weeks: L > S
• 35+ weeks: ratio is 2:1 (L:S)
• Indicates lungs are mature enough to prevent RDS (respiratory distress syndrome) 

• Used for rapid chromosomal diagnosis, genetic studies, or transfusion for RH isoimmunization or hydrops fetalis
• Done in 2nd and 3rd trimesters to access fetal blood
• Needle inserted into fetal umbilical fessel (guided by ultrasound); monitor fetus for 1 hr after !
• Shows fetal blood type, maternal antibodies, and level of anemia (may indicate transfusion)

• Performed b/w 10-12 weeks gestation
• Allows for earlier diagnosis than amniocentesis but w/ higher risk to fetus (genetic studies)
• Removes tissue specimen from fetal portion of placenta
• If mom is Rh negative, she needs Rhogam after CVS
• Complications: vaginal spotting, miscarriage, ROM, cramping

• Maternal blood test, done at 15-22 weeks
• Screening for NTDs and abdominal wall defects 
• NTDs = spina bifida, anencephaly
• Abdominal wall defects = omphalocele and gastroschisis
• Recommended for all pregnant women (catches 80-85% of defects)
• If results positive--> amniocentesis to diagnose

• Maternal blood test used for Rh neg women
• Tests for Rh incompatibility (see if fetus is Rh pos) 
• If maternal titer for Rh antibodies is > 1:8 --> amniocentesis to look for bilirubin in amniotic fluid
• Level of bilirubin determines severity of fetal hemolytic anemia

• Assesses fetal well-being
• In 1st and 2nd trimester:
• Detects fetal anomalies
• In 3rd trimester:
• Determines whether intrauterine environment (placenta and uterus) support fetal growth
• Also measures fetal response to hypoxia
• Done if uteroplacental insufficency suspected

• When hypoxia or asphyxia occurs, blood flow is shunted to vital organs
• Allows fetus to survive for 30 minutes in acute episodes
• Longer periods--> decreased CO--> decreased blood flow to brain

• Stress
• Anxiety
• Low self-esteem, guilt
• Frustration
• Inability to function

• Negative impacts on:
• Parental attachment
• Accomplishment of the tasks of pregnancy
• Family adaptation to the pregnancy

Systolic pressure > 140 OR increase 30 over baseline
Diastolic pressure > 90 OR increase 15 over baseline
MAP > 105 

(only needs to reach one of these to quality as hypertensive)

• Prehypertensive
• 120-139 systolic, 80-89 diastolic
• Stage 1 HTN
• 140-159 systolic, 90-99 diastolic
• Stage 2 HTN
• >160 systolic, >100 diastolic

1. Chronic HTN
2. Gestational HTN (PIH)
3. Preeclampsia
4. Severe Preeclampsia
5. Eclampsia
6. Preeclampsia Superimposed on Chronic HTN

• HTN that develops after 20 weeks
• No previous history of HTN
• No proteinuria
• Final diagnosis made PP (if still present after 12 weeks PP, it is considered chronic)
• Increased risk for developing chronic HTN in the future !

• Most common complication of pregnancy (12-20%)
• Occurs after 20 weeks
• HTN with proteinuria !
• Can progress slowly or have sudden onset
• Often also have edema, but this is not diagnostic
• Cure: delivery of fetus and placenta

• Arteriolar vasospasm--> poor perfusion--> decreased diameter of blood vessels--> decreased blood flow--> increased BP--> decreased organ functionn--> fetal compromise (see chart slide 38)
• Decreases organ function up to 40-60%
• Multi-system disease (placenta, kidney, liver, brain)
• Placental insufficiency can cause fetal morbidity & mortality

• 1st pregnancy (primigravida)
• Age >40 years
• Obesity
• Preeclampsia in previous pregnancy
• Mutli-gestation
• Rh incompatability
• Pre-existing medical conditions: chronic HTN, DM, renal disease

• Presence of one of these in a preeclamptic woman:
• Systolic BP 160 of diastolic 110
• Proteinuria >2g on 24 hour urine or 2-3+ on dipstick
• Oliguria (<400-500mL over 24 hours)
• Cerebral or visual disturbances (LOC, h/a, etc.)
• Hepatic involvement (epigastric pain, elevated LFTs)
• Thrombocytopenia (platelets <100,000)
• Pulmonary or cardiac involvement
• Development of eclampsia or HELLP syndrome
• Increased serum creatinine (>1.2 mg/dL)
• Some cases of fetal growth retardation

• Not diagnostic, but used as marker for development of preeclampsia (raises suspicion !)
• What makes it pathologic not phsyiologic:
• Generalized edema in the face, hands, and abdomen that doesn't improve with bedrest OR
• 2 kg (4.4 lb) weight gain in 1 week

• Normal in pregnancy !
• Caused by fluid moving from intravascular to extravascular spaces
• Most common in feet
• Disappears after 8-12 hours of bed rest
• Does NOT indicate preeclampsia

• 1+ = 2 mm
• 2+ = 4 mm
• 3+ = 6 mm
• 4+ = 8 mm

• Onset of seizure activity or coma in a woman diagnosed with preeclampsia, but with no preexisting condition to cause the seizures
• Preeclampsia has turned into eclampsia if the woman begins to have seizures
• Presenting sign in some cases of eclampsia

• Severe preeclampsia with hepatic dysfunction
• Laboratory diagnosis
• H = hemolysis (see burr cells on a smear)
• Disruption of RBC membranes--> release of hemoglobin
• EL = elevated liver enzymes (AST & ALT)
• LP = low platelet count (<100,000) 
• Thrombocytopenia

• Extension of the patho of severe preeclampsia and eclampsia
• Arises form changes associated w/ preeclampsia (arteriolar vasospasm, endothelial damage, and platelet aggregation w/ tissue hypoxia)

• Often have NO s/s of preeclampsia (increased BP or proteinuria)
• 90% report malaise for a few days prior
• 65% have RUQ or epigastric pain w/ possible nausea and vomiting
• Complications:
• Renal failure, pulmonary edema, ruptured liver hematoma, DIC, and abruptio placenta

• Life threatening to mom and fetus !!
• Occurs in 2-12% of severely preeclamptic women (1/1000 pregnancies)
• More common in older, Caucasian, multipara

• Prompt diagnosis
• BP control
• Prevention of seizures
• Optimization of placental perfusion
• Delivery of the fetus ("the only cure")
• Close observation for complications

• Home care
• Increased visits to OB HCP
• Bed rest (mainly on left side)
• Diet:
• High protein
• Monitor sodium intake (don't restrict)
• Increased fluids

• Hospitalize if 1 or more of these occur:
• BP 160 systolic or 110 diastolic (2 readings, 6 hrs apart)
• Pronounced proteinuria or oliguria <30 mL/hr
• Cerebral or visual disturbances
• Brisk deep tendon reflexes (3+ or 4+)
• Pulmonary edema or cyanosis
• Epigastric pain
• Increased edema
• Persistent or severe headache
• N/V
• Abnormal Dopppler findings of FHR

Nursing Care in Hosptial

Moderate/ Severe Preeclampsic Patient

• Quiet, non-stimulating environment
• Side-lying position
• Seizure precautions (padded side rails, suction, O2)
• Administer meds
• Continuous external fetal monitoring (FHR)
• Monitor BP, proteinura (dipstick), I&O's, deep tendon reflexes, presence of h/a, n/v, epigastric pain, visual disturbances, lung sounds, edema

• Indicated when diastolic BP is at or >110 mmHg
• Goal of meds: decrease risk of maternal CVA while maintaining uteroplacental perfusion
• Vasodilators most common
• Labetalol (beta blocker)
• Hydralazine (direct acting smooth muscle relaxant; vasodilator)

• DOC in US to prevent seizures in pts w/ severe PIH
• Inorganic salt that blocks amount of acetylcholine released, causing CNS depression
• Purpose: protect the brain from seizing, sometimes lowers BP too (side effect)
• Prevents uterine vasoconstriction--> increased uterine blood flow
• Mostly IV administration (4-6 g load over 30 min, then continuous infusion 1-3 g/hr)

• Educate pt that initial dose will make them feel:
• Sedated, flush, and hot (esp. bolus)
• Sedation continues after bolus 
• Maternal hypotension is commmon side effect (preload with bolus 1-2 L IV fluids)
• Serum Mg levels drawn after 4-6 hrs
• Therapeutic level = 4-8 mg/dl

• Toxicity serum levels:
• Loss of DTR's @ 9-12 mg/dl
• Respiratory arrest @ >15 mg/dl
• Cardiac arrest @ >25-30 mg/dl
• S/S of toxicity:
• Decreased respirations, slurred speech, drowsiness, extreme weakness, nausea, increased thirst, diminished/ absent DTRs

• Emergent situation !!
• Administer antidote: 10% Calcium Gluconate, 10 mL IV
• Keep vial at bedside while pt on therapy !
• Turn off magnesium sulfate
• Draw serum Mag level

• Labs:
• CBC
• Platelets
• Coags (PT/PTT)
• Liver function tests (SGOT)
• BUN/ creatinine (kidney specific)

• Delivery of fetus and placenta !
• Must weigh the risk vs benefit of delivery or continuing the pregnancy
• Fetal maturity (most concerned w/ viability and lung maturity)
• Maternal morbitity and mortality risk
• Continue Magnesium Sulfate for 24 hrs PP

• Bleeding puts mom and fetus at risk !
• Maternal blood loss decreases O2-carrying capacity and increases risk for:
• Hypovolemia, anemia, infection, preterm labor, adverse O2 delivery
• Vaginal bleeding indicates:
• 1st trimester-- miscarriage
• 2nd/3rd trimesters-- abnormal placental location

• Total blood volume increases by up to 40%
• Plasma volume and RBCs increase to:
• Meet metabolic demands of mom and fetus
• Protect against (potentially harmful) decrease in venous return
• Protect mom against the effects of blood loss during birth

1. Miscarriage (spontaneous abortion)
2. Incompetent cervix (recurrent premature dilation of cervix)
3. Ectopic pregnancy
4. Hydatidiform molar pregnancy

A pregnancy that ends before 20 weeks d/t natural causes

AKA spontaneous abortion (miscarriage is more sensitive to pts)

• Before 12 weeks GA
•  >90% of miscarriages are before 8 weeks GA
•  Causesd by:
• Chromosomal abnormalities (50%), endocrine imbalance, immunologic factors, infections 

• Between 12-20 weeks GA
• Causes are usually maternal:
• AMA, chronic infections, anomalies of cervix and reproductive tract, chronic debilitating diseases

• Possible loss of pregnancy
• Cervix is closed, placenta still attached
• Some bleeding occurs, possible cramping or backache
• Management:
• Bed rest, sedation, avoidance of stress and orgasm

• Loss of pregnancy cannot be prevented
• Placenta has separated from uterine wall and cervix has dilated
• Moderate amount of bleeding with mild to severe cramps
• Membranes may rupture
• Management: D&C 

• When not all of the products of conception are expelled from the uterus
• Profuse bleeding and severe pain may occur
• Some tissue is passed but some retained; cervix is dilated
• Most often, part of the placenta is retained
• Management: D&C

• Products of conception die in utero but are not expelled
• No bleeding, but possible brownish discharge
• No cramping or pain; cervix is closed
• Uterine growth stops, hCG levels drop, pregnancy test is negative
• Confirm with ultrasound
• Management: D&C

• All fetal tissue has been expelled from the uterus
• Small amount of bleeding
• Mild cramps
• Uterus is contracted and cervix is closed
• May not need further interventions

• Dilation and curettage
• Method to manage miscarriage
• Cervix dilated and curette inserted to scrape the walls of the uterus/ remove uterine contents

• Method to manage miscarriage
• Wide cervical dilation and instrumental removal of uterine contents

Use of Prostaglandins in Miscarriage Management

• For late incomplete, inevitable, or missed miscarriages (16-20 wks)
• Ex: Cytotec
• Administer into amniotic sac or by vaginal suppository

• Recurrent, painless dilation of the cervical os in 2^nd/3^rd trimesters
• Causes:
• Hx of late abortions, cervical procedures in past, hx of traumatic birth, forceful D&C, congenitally short cervix or uterine anomalies, or mom’s ingestion of Diethylstilbestrol (DES)

• Bed rest, hydration
• Tocolytics if premature labor occurs (inhibit uterine contractions)
• Terbutaline (B2 adrenergic receptor agonist)
• McDonald Cerclage

• Band placed around the cervix to constrict the internal os
• Woman placed on bed rest and activity restrictions
• Left in place until close to term
• After removed, labor progresses spontaneously

• Fetus is implanted outside the uterine cavity
• Fallopian tube most common place (95% of ectopic occur here)
• Also in interstitium, fimbria, tuboovarian ligament, ovary (1%), abdominal cavity (3-4%), cervix (1%)

• Maternal mortality (leading cause in 1^st tri)
• Infertility—only 60% of women with ectopic hx are able to conceive, and 40% of those will be ectopic again
• Occurrence on the rise due to:
• STD’s, treatment for PID (pelvic inflammatory disease), tubal sterilizations

• Missed period
• Adnexal fullness and tenderness
• Colicky pain (unilateral, bilateral, or diffuse)
• Increased pain = tube rupture
• Referred shoulder pain possible
• Dark brown/red vaginal bleeding or internal bleeding (Cullen’s sign)
• Transvaginal sonogram diagnoses it earlier than ever

• Controlling bleeding is top priority !
• Before rupture of tube:
• Salpingostomy
• Methotrexate therapy
• After rupture of tube: 
• Salpingectomy (removal of entire tube)

• Surgical removal of the pregnancy from the fallopian tube
• Incision made in tube and contents of pregnancy removed
• Must be done before rupture
• Methotrexate given post-op to dissolve residual tissue (rapidly destroys dividing cells)

• Given as single shot or several injections
• Stops the growth of rapidly dividing cells (including embryonic, fetal, and early placenta cells)
• Low complication rate, high success rate, and preserves reproductive potential of tube
• If pregnancy persists after 2-3 doses, surgery must be done

• Molar pregnancy (1/1,200 pregnancies)
• Gestational trophoblastic disease
• Type of neoplasm
• Exact cause is unknown
• Risk higher for early teens, women over 40, women using drugs that stimulate ovulation (ex: clomid), or hx of previous molar pregnancy
• Can be complete or partial mole

• Classic form of molar pregnancy
• Fertilization of an ovum w/ a lost or inactivated nucleus (ovum has no genetic material)
• Sperm duplicates itself
• Contains no fetus, placenta, amniotic membranes, or fluid

• When 2 sperm fertilize a normal ovum
• May be some embryonic or fetal parts and an amniotic sac

• Degenerative process in the chorionic villià increased levels of hCG
• Multiple cysts grow rapidly in grapelike clustersà growth of uterus
• Uterus may rupture !
• 95% will have vaginal bleeding
• Risk for hemorrhage into uterine cavity b/c maternal blood has no placenta to receive it

• Vaginal bleeding w/ white, grapelike vesicles
• Blood may be dark brown or bright red
• Uterine size larger than expected for suspected GA
• PIH before 24 weeks
• Preeclampsia in 15% of cases, usually at 9-12 wks
• Anemia
• Hyperemesis gravidarum
• Abdominal cramps from uterine distention

• Some moles abort spontaneously, some removed with suction curettage
• Should NOT conceive for 1 year, and test hCG often:
• Measure hCG 2x/ wk until normal for 3 wks, then monthly until 6 months, then every 2 months for 1 year
• Rising titer and enlarging uterusà choriocarcinoma

1. Placenta previa
2. Abruptio placenta
3. Variations in cord insertion and placental abnormalities

• Placenta abnormally implanted in lower uterine segment (near or over internal os)
• S/S: painless vaginal bleeding after 24 wks; soft, relaxed, nontender uterus w/ normal tone
• Bleeding associated w/ thinning and stretching of lower uterine segment in 3^rd trimester
• Placenta may separate from uterine wall

• Internal os is entirely covered by placenta when the cervix is fully dilated
• Can cause a lot of blood loss during labor
• Usually diagnosed with routine ultrasounds

Incomplete/ partial placenta previa

Incomplete or partial coverage of the internal os when cervix is dilated

Only an edge of the placenta extends to the internal os

May extend onto the os during labor w/ dilation

• Diagnosis—transabdominal ultrasonographic exam
• NO vaginal or rectal exam ! (increased bleeding risk)
• Vaginal speculum exam by HCP is postponed until fetal viability reached

• Term gestation: delivered by C-section, unless partial or marginal previa w/ minimal bleeding (vaginal birth may be attempted)
• Preterm gestation, not in labor:
• Bed rest and close observation
• Regular ultrasounds, nonstress testing, BPPs, labs (H&H)
• Betamethasone to promote fetal lung maturity in case of preterm delivery

• Premature separation of the placenta (all or part) from the uterine wall
• Usually occurs after 20 weeks and before delivery
• A woman w/ 2 previous abruptions is at 25% increased risk in next pregnancy
• Types: partial, concealed hemorrhage; partial, apparent hemorrhage; complete, concealed hemorrhage

• HTN
• Cocaine (increased HTN)
• Blunt trauma
• Smoking
• Poor nutrition
• Multi-gestation

Grade 1 (mild) Abruptio Placenta

• Minimal bleeding and uterine tenderness
• Mild or no hypertonicity
• Mom and baby in NO distress
• Placenta 10-20% detached; EBL 500 mL

Grade 2 (moderate) Abruptio Placenta

• Moderate bleeding and minimal uterine tenderness
• Moderate hypertonicity
• Mom not in shock but fetal distress present
• Mom at risk for coagulopathies
• Placenta 20-50% detached; EBL 1000-1500 mL

Grade 3 (severe) Abruptio Placenta

• Moderate bleeding, uterus is board-like
• Severe hypertonicity and agonizing pain
• Mom in shock, fetus usually dies
• Placenta >50% detached; EBL >1500 mL
• Women usually develop DIC
• Medical emergency !!

• Vary with degree of separation
• Vaginal bleeding (70-80%)
• Abdominal pain
• Uterine tenderness and contractions

• Depends on severity of EBL and fetal maturity/ status
• Vaginal delivery treatment of choice if:
• Abruption is mild & baby is 36 wks GA or less
• Fetus is at term or bleeding is moderate/ severe and mom or fetus is in jeopardy
• C-section for fetal distress or other indications; avoided if there is coagulopathy

Disseminated Intravascular Coagulation (DIC)

• Pathologic form of clotting that consumes large amounts of clotting factors and causes widespread bleeding
• Triggered by:
• HELLP syndrome, abruption placenta, retained dead fetus, gram negative sepsis, severe preeclampsia

• Endothelial injuryà diffuse activation of clotting cascadeà clot formation in small vessels (brain, heart, lungs, etc.) and consumption of large amounts of clotting factorsà ext. and int. bleeding
• Lab findings
• Decreased platelets, decreased fibrinogen, prolonged PT and PTT

• Rare, associated w/ placenta previa and multi-gestation
• Umbilical arteries & vein aren’t covered w/ Wharton’s jelly
• Risk for laceration of cord w/ ROM
• Bleeding or decreased FHR w/ ROM = immediate evaluation !

Gelatinous substance

Provides insulation and protection to umbilical cord