12.2 Conditions Limited to Pregnancy

Abortion

The term abortion refers to any pregnancy loss during the first trimester or before 20 weeks’ gestation. An abortion may be spontaneous, as in cases of miscarriage, or induced, as through medical or surgical intervention. In early pregnancy loss, there is an empty gestational sac or absent fetal heart rate before 13 weeks of pregnancy (ACOG, 2018b). More recently, the term early pregnancy loss has been used for unexpected losses during the first trimester, and the term abortion is reserved for terminated pregnancies that are induced (Arendt & Long, 2020). For the sake of simplicity, this chapter will use the term abortion to refer to any pregnancy that terminates or is terminated during the first trimester.

According to the World Health Organization (2021), patients seek an induced abortion in six out of 10 unintended pregnancies. Further, approximately 45% of all abortions are unsafe, nearly all of which occur in developing countries (WHO, 2021). In the United States, the number of induced abortions reported in 2021 was 625,978, with an abortion rate of 11.6 per 1,000 pregnancies for patients 15 to 44 years old (CDC, 2022d). Unsafe abortion is a leading preventable cause of maternal morbidity and mortality and can negatively impact a patient’s health, social circumstances, and finances, while also creating additional strain for the community (WHO, 2021). While increasing access to health care through policy change can promote opportunities to perform safe abortion care, nurses must advocate and care for patients on an individual level.

Blighted Ovum

A blighted ovum is also referred to as an anembryonic pregnancy because a fertilized egg implants into the uterus, but an embryo does not form. The exact pathophysiology is unknown but is likely related to underlying genetic or chromosomal abnormalities. Other risk factors include obesity, advanced maternal age, uterine defects, hormone imbalances, or immune disorders (Chaudhry et al., 2023). Diagnosis occurs with ultrasound when there is evidence of a gestational sac but no formation of an embryo. The patient may experience symptoms such as spotting, bleeding, or cramping. Management includes serial monitoring of human chorionic gonadotropin (hCG) levels, serial ultrasound scans, administration of misoprostol, or surgical treatment with vacuum aspiration (Chaudhry et al., 2023). Complications of treatment may include infection, heavy bleeding, or perforation of the uterus.

Ectopic Pregnancy

An ectopic pregnancy occurs when a fertilized egg becomes implanted outside the uterus. Common sites of extrauterine implantation are shown in Figure 12.6. Key risk factors include prior ectopic pregnancy, pelvic infection, infertility treatment, and tubal surgery (ACOG, 2018c). Patients may present with signs or symptoms such as vaginal bleeding, abdominal or pelvic pain, syncope, or shock; however, a patient may be asymptomatic until rupture occurs. Transvaginal ultrasound and serial hCG levels are used to rule out an intrauterine pregnancy and diagnose an ectopic pregnancy.

Figure 12.6 Locations of an Ectopic Pregnancy An ectopic pregnancy occurs when a fertilized egg implants outside the uterus. This image demonstrates the many different locations where an ectopic pregnancy can occur. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

An ectopic pregnancy may be managed medically or surgically. Medical or surgical intervention is indicated in the presence of worsening abdominal or pelvic pain, increasing hCG levels, or evidence of tubal rupture (ACOG, 2019). A medication called methotrexate (Trexall) can be prescribed to medically manage an ectopic pregnancy, but the patient must meet specific criteria, such as hemodynamic stability with sonographic evidence of a small gestational sac outside the uterus. Patients who are unstable require emergent surgical intervention due to the risk of rupture of the ectopic pregnancy, which can result in significant internal bleeding and maternal death. Surgery can be performed laparoscopically to remove the ectopic pregnancy, and removal of the fallopian tube may be needed if a tubal pregnancy is present. The nurse should monitor the patient for signs of shock and be prepared to administer rapid fluid resuscitation, blood products, and oxygen.

Gestational Trophoblastic Disease

Patients below 20 years or above 40 years of age are at increased risk for abnormal growth of placental trophoblastic tissue during pregnancy. This abnormal growth occurs inside the uterus after conception and results in a group of rare conditions termed gestational trophoblastic disease. Gestational trophoblastic disease can be categorized as molar pregnancies or gestational trophoblastic tumors. In a molar pregnancy, tissue in the uterus that would have formed the placenta instead grows abnormally as trophoblastic tissue. There is no viable fetus in a molar pregnancy. Patients with a molar pregnancy may experience irregular vaginal bleeding, enlarged uterus, elevated hCG levels, and hyperemesis (Ngan et al., 2021). Diagnosis is most often made by ultrasound during the first trimester. If left untreated, the trophoblasts and abnormal tissue in a molar pregnancy (or even normal pregnancy) can develop into gestational trophoblastic tumors, which can be benign or malignant. Treatment is a D&C and a follow-up series of serum quantitative hCG tests to ensure that all trophoblastic tissue was removed and that no malignant gestational trophoblastic neoplasms develop. It is recommended that the patient not conceive for up to 1 year to decrease the risk of developing a malignancy.

Hyperemesis Gravidarum

Severe nausea and vomiting during the first trimester, leading to electrolyte imbalances, weight loss, malnutrition, and dehydration, is a condition called hyperemesis gravidarum. The specific pathophysiology behind hyperemesis gravidarum is unknown; however, suspected underlying factors include hormonal changes due to elevated hCG levels, decreased gastric motility, genetic predisposition, and psychologic factors, such as stress and anxiety. While nausea and vomiting commonly occur during the first trimester, hyperemesis gravidarum is the most severe form and may require hospitalization for fluid and electrolyte replacement. Complications related to hyperemesis gravidarum can negatively impact fetal outcomes and lead to low birth weight and preterm birth (Fejzo et al., 2019). Patients may be prescribed antiemetic medications. Patients may be directed to take thiamine (vitamin B1) to reduce the risk of refeeding syndrome and Wernicke encephalopathy related to thiamine deficiency (Fejzo et al., 2019). Recent studies have identified specific placental proteins and hormone receptors that link the placenta to the underlying etiology of hyperemesis gravidarum (Fejzo et al., 2019).

Diagnosis is often made by exclusion. The health-care provider evaluates for all causes of severe nausea and vomiting in a patient during the first trimester. Other conditions with a similar presentation that must be ruled out include gastrointestinal problems (appendicitis, cholecystitis, pancreatitis, and gastroenteritis), endocrine abnormalities (hyperthyroidism, diabetic ketoacidosis), neurologic conditions (brain tumors, migraines, hydrocephalus), drug withdrawal, urinary tract infection, or molar pregnancy (Fejzo et al., 2019). Once diagnosis is confirmed, management focuses on optimizing the patient’s fluid and nutritional status and often follows an algorithm.

During the first trimester, nausea and vomiting are common symptoms and can be managed on an outpatient basis. With appropriate intervention, the symptoms can be reduced to a tolerable level to improve the patient’s quality of life. The nurse’s role in managing nausea and vomiting during the first trimester includes the following (Fejzo et al., 2019):

1. Assessment: The nurse should assess the severity of symptoms to determine the level of intervention.
2. Support: The nurse can provide emotional support as indicated to promote an improved quality of life. The nurse can provide the patient with resources to ensure the patient receives the care they need.
3. Education: Mild symptoms may require diet and lifestyle modifications. The nurse can educate patients to eat small frequent meals, avoid spicy foods, drink fluids, and rest.
4. Medication administration and education: Moderate symptoms may require additional intervention, such as through complementary or pharmacologic treatments. The nurse may administer or recommend treatments based on patient assessment and should educate the patient on potential side effects. Examples of complementary treatments include ginger and acupuncture. Pharmacologic treatments include pyridoxine (vitamin B6), doxylamine (Unisom), diphenhydramine (Benadryl), metoclopramide (Reglan), promethazine (Phenergan), or ondansetron (Zofran).
5. Outpatient or inpatient care: Severe symptoms may require hospitalization for management of dehydration and electrolyte imbalances such as decreased potassium. In cases of malnutrition, patients may be prescribed parenteral nutrition or enteral tube feedings. The nurse may be caring for the patient on an inpatient basis.

Multiple Gestation

A multiple gestation pregnancy is one in which there is more than one fetus. A twin pregnancy can be dizygotic (fraternal), where there are two separate fertilized eggs, or monozygotic (identical), where a single fertilized egg splits during development. Twin pregnancies can be further classified as monochorionic or dichorionic and monoamniotic or diamniotic. The chorion refers to the placenta, so a monochorionic twin pregnancy has one placenta, and a dichorionic pregnancy has two placentas. The amnion refers to the number of amniotic sacs, so a monoamniotic pregnancy has one amniotic sac, and a diamniotic pregnancy has two. Depending on development in the first trimester, a twin pregnancy may be categorized as monochorionic-monoamniotic, monochorionic-diamniotic, or dichorionic-diamniotic. Figure 12.7 shows the development of these different categories.

Factors that increase risk for multiple gestation include a family history of multiples, older age, high parity, and being African American. Advances in assisted reproductive technology increase the risk of multiple gestation, as through the implantation of multiple embryos or the fertilization of multiple eggs. Patients with multiple gestation pregnancies require increased monitoring due to increased risk of complications. These complications include hyperemesis gravidarum, anemia, gestational diabetes, hypertensive disorders, placental insufficiency, increased size of the uterus, preterm labor, preterm delivery, and twin-to-twin transfusion (D’Alton & Breslin, 2020). Management includes ultrasound monitoring, nutritional support, bed rest, and pharmacologic therapies. Serial ultrasound scans may be used to detect abnormalities in amniotic fluid volume, cervical length, and fetal growth (D’Alton & Breslin, 2020). When a placenta is shared during a monochorionic pregnancy, both fetuses are at risk for a twin-to-twin transfusion caused by an imbalance in fetal blood flow. Serial ultrasound scans can detect this complication to determine the need for additional intervention. Patients with multiple gestation pregnancies may require nutritional counseling because of increased nutritional needs. Bed rest may be ordered in cases of impending preterm delivery. Medications may be prescribed to manage problems such as preeclampsia, gestational diabetes, preterm labor, and urinary tract infection. The method of delivery depends on a variety of factors and the presence of complications.

Figure 12.7 Development of Twin Pregnancy Twin pregnancies are classified by the number of placentas (chorions) and the number of amniotic sacs (amnions). This image displays how each type develops during the first trimester.
(attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Intrauterine Fetal Demise

The death of a fetus that occurs after 20 weeks’ gestation is called intrauterine fetal demise, or intrauterine fetal death (ACOG, 2020b). An intrauterine fetal demise will be diagnosed when there is no fetal heart rate detected on ultrasound (ACOG, 2020b; Maslovich & Burke, 2022). This diagnosis may occur during a routine prenatal visit or during labor. Patients may experience decreased or absent fetal movement prior to diagnosis, which is one sign of impending fetal demise. According to ACOG, risk factors associated with fetal demise include non-Hispanic Black race, advanced maternal age, multiple gestation, male sex of fetus, maternal obesity, nulliparous pregnancy, smoking and alcohol use, history of prior fetal demise, pregnancy through reproductive technology, and comorbid conditions (ACOG, 2020b). Specific comorbid conditions that increase the risk include hypertension, diabetes, renal disease, autoimmune disorders, cholestasis of pregnancy, and antiphospholipid syndrome; specific causes may include placental and umbilical cord abnormalities, fetal growth restriction, genetic and chromosomal conditions, and infection; many times, no cause is found (ACOG, 2020b).

One complication of fetal demise is disseminated intravascular coagulation (DIC), which increases in likelihood when the fetal demise is undiagnosed for several weeks. DIC is a serious condition categorized by widespread coagulopathy and tiny blood clots that form throughout the body. It often follows placental abruption or sepsis, and management involves fluid resuscitation, blood product replacement, antibiotic administration, frequent lab monitoring, and close clinical evaluation (Maslovich & Burke, 2022). When intrauterine fetal demise or spontaneous abortion occurs, fetal resorption may occur. During fetal resorption, fetal tissues are broken down into simple molecules, which are absorbed by the body of the pregnant person. This is an unusual phenomenon, and there are typically no signs of pregnancy. In the event of signs of bleeding or cramping, the patient should seek medical attention for further evaluation and monitoring. Nurses play a key role in providing support to both the patient and the support person, as well as monitoring the patient’s status.

Infections

Patients can develop infection at any time during pregnancy. Infections that occur early in pregnancy typically have more detrimental effects on the fetus due to organogenesis and critical fetal development that occurs during that time. Infections can be vertically transmitted across the placenta, as with TORCH infections and COVID-19, or the fetus can be exposed during the labor and delivery process, as with group B streptococcus. Screening for infection during the first trimester can many times lead to identification and treatment to minimize risk to the pregnant person and the fetus.

The nurse’s role in caring for patients who are impacted by infection during pregnancy includes education, prevention, assessment, screening, collaboration, referral, treatment and medication administration, and counseling and support. Education and prevention involve discussing safe sex practices, discussing the maternal-fetal risks related to infection, administering vaccinations, and promoting consistent prenatal care. The nurse assesses for signs and symptoms of infections and performs routine screenings, such as for group B streptococcus and sexually transmitted infections. The nurse collaborates with the health-care team to develop a multidisciplinary care plan, then administers treatments and medications accordingly. Throughout the patient’s pregnancy, the nurse provides counseling and support to optimize maternal-fetal health and minimize risks.

Hepatitis

Hepatitis during pregnancy can lead to significant morbidity and mortality for both the pregnant person and the fetus. Hepatitis B and hepatitis C viruses can be vertically transmitted to the fetus. Therefore, patients are routinely screened during initial prenatal visits to minimize risk and initiate treatment. The initial screening test for hepatitis B will detect the presence of hepatitis B antigen (HBsAg). If the test is positive, additional testing is performed, and antivirals may be started, depending on viral load (Chilaka & Konje, 2021). Newborns of hepatitis B seropositive birthing parents should receive the hepatitis B vaccine and hepatitis B immune globulin (HBIG) in the first 12 hours of life. The initial screening test for hepatitis C detects antibodies to the hepatitis C virus that are present in the blood. Patients positive for hepatitis C will undergo additional testing to assess viral load and liver function. Antiviral therapy is generally deferred until the postpartum period because of the limited safety profile of the medication and risks to the fetus (CDC, 2021a).

Patients infected with hepatitis may be at risk for complications such as preterm delivery, cholestasis of pregnancy, gestational diabetes, and delivering infants of low birth weight (Nwaohiri et al., 2018). Additional complications include preeclampsia, liver failure, and spontaneous abortion. Risk of vertical transmission increases in the presence of HIV co-infection. Depending on the facility, patients may be screened universally or only in cases of high risk (Nwaohiri et al., 2018). Antiviral therapy may be considered on an individual basis. Breast-feeding is not contraindicated unless nipples are cracked and bleeding, which could lead to viral transmission. After birth, newborns will need to be screened and monitored for the hepatitis C virus and be treated accordingly.

HIV

Patients with HIV are at risk for transmitting the virus to the fetus during pregnancy, during delivery, or following birth through breast-feeding. (See HIV/AIDS earlier in this chapter.)

TORCH

TORCH infections can be vertically transmitted to the fetus from the pregnant person and significantly impair fetal development. Nurses provide education on the signs and symptoms of the different infections and the perinatal complications.

Varicella

Varicella, or chickenpox, is a highly contagious disease caused by the varicella zoster virus that is spread through airborne particles or direct contact with infected persons. Infection during pregnancy can lead to intrauterine fetal demise. Congenital varicella may result in skin scarring; eye, limb, or neurologic abnormalities; anemia; thrombocytopenia; and low birth weight. Patients who are pregnant and have never been infected with the virus or received the vaccine are at greatest risk. The greatest risk of newborns contracting neonatal varicella occurs when the mother contracts varicella and develops a rash 5 days before or 2 days after delivery (CDC, 2022f). Management includes supportive care, antiviral therapy, and close monitoring.

GBS

The bacterium group B streptococcus (GBS) is commonly found in the vagina or rectum of healthy patients. When transmitted during delivery, it can lead to significant neonatal complications, including meningitis, pneumonia, and sepsis. Screening for GBS occurs between 36 and 38 weeks’ gestation to evaluate neonatal risk at delivery. Risk factors for early-onset neonatal sepsis caused by GBS include prolonged rupture of membranes, low birth weight, history of GBS, preterm labor, and chorioamnionitis. To prevent transmission during birth, patients are treated prophylactically with IV antibiotics, such as penicillin, during labor. Neonates who are at risk for GBS infection are closely monitored after birth. Table 12.7 summarizes the pregnancy risks associated with infections.

Abortion

Abortion during the second trimester (14 to 27 weeks’ gestation) can occur spontaneously or through medical induction. Pregnancy complications that can lead to spontaneous abortion during the second trimester include placental abnormalities, infection, fetal anomalies, and maternal medical conditions. Placental abnormalities include placenta previa or placental abruption. Infection can be from prolonged rupture of membranes and chorioamnionitis. Fetal anomalies may include chromosomal abnormalities, congenital heart defects, or neural tube defects. Maternal medical conditions such as autoimmune disease, hypertension, diabetes, and other problems can lead to preterm birth or abortion (Wilson & Kahn, 2018). Patients experiencing vaginal bleeding, abdominal cramping, decreased fetal movement, or signs of infection should immediately be evaluated by a health-care provider to assess maternal-fetal status.

Cervical Insufficiency

Painless dilation of the cervix during pregnancy that often results in the inability to carry the fetus beyond the second trimester is called cervical insufficiency. Cervical insufficiency may also be referred to as an incompetent cervix or shortened cervix. The presence of cervical insufficiency may be associated with low back pain, pelvic pressure, and vaginal bleeding or discharge. If left untreated, abrupt delivery of the fetus can occur at a very early gestational age. A history of prior cervical surgery or pregnancy losses increases a patient’s risk; however, the exact etiology remains unknown. To prevent preterm delivery, a cerclage may be placed, which involves a surgical procedure in which sutures are placed around the cervix to prevent it from dilating. See Figure 12.8 for suture placement. The sutures are then removed as the pregnancy approaches term.

Figure 12.8 Cervical Cerclage A cervical cerclage can be placed to prevent preterm delivery. This surgical procedure involves the placement of sutures around the cervix to prevent cervical dilation. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Rh Isoimmunization

Rhesus (Rh) incompatibility between the pregnant person and the fetus is the leading cause of Rh isoimmunization during pregnancy. When a patient’s blood type is Rh negative, antibodies form against Rh-positive fetal blood. This sensitization occurs during a first pregnancy with an Rh-positive fetus (regardless of outcome) and the formation of IgM antibodies, which do not cross the placenta. When the patient is exposed to Rh-positive fetal blood during a subsequent pregnancy, additional antibodies are formed that cross the placenta and cause hemolysis in the fetus. This leads to hemolytic disease of the newborn and potentially hydrops fetalis and fetal or neonatal death (ACOG, 2022b). Prevention of Rh isoimmunization includes the administration of Rh immune globulin (RhoGAM) to Rh-negative pregnant persons during pregnancy when there is any chance of maternal exposure to fetal blood, as with a spontaneous abortion, invasive procedure, trauma, termination of pregnancy, at 28 weeks’ gestation, or prior to delivery (ACOG, 2022b). Rh immune globulin may be given again within 72 hours after birth to Rh-negative patients to neutralize any fetal red blood cells that entered the patient’s bloodstream during birth. Rh immune globulin will cause the antibody screen to be falsely positive for 12 weeks. The nurse should educate the patient who is Rh negative on the routine administration of RhoGAM and discuss its role in the prevention of hemolytic disease of the newborn.

Oligohydramnios

In oligohydramnios, an abnormally low volume of amniotic fluid is present. During the second and third trimesters, amniotic fluid is primarily comprised of fetal urine, fetal lung and gastrointestinal secretions, and fluid from the placenta and umbilical cord (Keilman & Shanks, 2024). When the production or secretion of amniotic fluid is interrupted—such as from congenital renal and urinary tract anomalies, placental dysfunction, fetal growth restriction, or ruptured membranes—a decreased volume in amniotic fluid results. Management includes close monitoring of the amniotic fluid volume as well as fetal status and hydration of the pregnant person using IV or oral fluids (Keilman & Shanks, 2024). In cases of nonreassuring fetal status or fetal distress, induction of labor or emergent delivery may be performed.

Polyhydramnios

In contrast, polyhydramnios refers to an abnormally high volume of amniotic fluid present during pregnancy. Certain maternal conditions can lead to polyhydramnios, such as maternal diabetes, anemia, or autoimmune disorders (Hwang & Mahdy, 2023). Because the fetus swallows amniotic fluid, congenital anomalies that impair fetal swallowing (such as a tracheoesophageal fistula) lead to polyhydramnios (Hwang & Mahdy, 2023). Multiple gestation pregnancies can also cause polyhydramnios due to the overproduction of amniotic fluid caused by two or more fetuses. Complications of polyhydramnios include preterm birth, placental abruption, premature rupture of membranes, umbilical cord prolapse, or fetal malpresentation (Hwang & Mahdy, 2023). Management includes close monitoring of maternal-fetus status to identify and minimize complications. An amnioreduction may be ordered in cases of severe polyhydramnios. During this procedure, an amniocentesis is done to remove some of the excess amniotic fluid. (See Chapter 13 Prenatal Testing for a full discussion.) The nurse will monitor the patient after the withdrawal of amniotic fluid for signs of complications, specifically placental abruption.

Placenta Previa

In placenta previa, the placenta is located on the lower aspect of the uterus near the internal cervical os. Risk factors for the development of a placenta previa include a history of placenta previa, multiple gestation pregnancy, multiparity, history of prior uterine surgeries (including C-sections), uterine abnormalities, advanced maternal age, use of assisted reproductive technology, and smoking. Severity ranges from the placenta lying near the internal cervical os to the placenta completely covering the os and lower uterine segment (Jauniaux et al., 2019). The term low lying placenta is often used to signify a placenta that does not entirely cover the internal os, reserving the term placenta previa for when the os is completely covered (Jauniaux et al., 2019). See Figure 12.9 to contrast low lying placenta with placenta previa. Diagnosis is often made during the second trimester through ultrasound. The biggest risk of a placenta previa is hemorrhage. This can occur during pregnancy or labor. The signs include bright red vaginal bleeding with or without pain. Close monitoring for signs of bleeding and maternal-fetal status should occur during the second and third trimesters. Patients with placenta previa must undergo a cesarean birth. Vaginal delivery is contraindicated in cases of partial and complete placenta previa due to risk of bleeding and placental tearing. Similarly, vaginal exams should be avoided to prevent additional injury in the presence of a known placenta previa or other incidences of vaginal bleeding. A hysterectomy may be performed if hemorrhage occurs. The nurse should counsel patients to monitor for any signs of bleeding and to seek medical attention immediately if it occurs. Additionally, the nurse should educate the patient about what to expect in a cesarean birth. Physical activity may be restricted once placenta previa is diagnosed. In cases of high risk for hemorrhage, patients may be placed on bed rest and pelvic rest until delivery.

Figure 12.9 Placenta Previa Placenta previa occurs when the placenta is located on the lower aspect of the uterus near the internal cervical os. The severity and maternal-fetal risk of a placenta previa can range from low lying placenta to complete previa. (modification of work from Anatomy and Physiology 2e. attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Placental Abruption

A placental abruption occurs when the placenta or part of the placenta separates from the uterine lining, which may lead to significant maternal-fetal blood loss, intrauterine fetal demise, or maternal death. Risk factors for placental abruption include hypertension, smoking, cocaine use, and abdominal trauma during pregnancy. Signs of abruption of the placenta include sudden onset of severe abdominal pain with or without dark red bleeding. Diagnosis is made based on clinical assessment and recent history. The signs the nurse may see include prolonged uterine contractions or a uterus that remains contracted without achieving a resting tone and changes in the fetal heart rate pattern. An ultrasound can also provide additional information. Management includes close fetal monitoring with imminent delivery based on the severity of maternal or fetal distress. Hemodynamic monitoring (pulse, urine output, blood pressure) of both the pregnant person and the fetus is imperative. Fluid replacement with blood products or other fluids may be indicated in cases of significant blood loss with hemodynamic instability. For more about different presentations of abruption, see Figure 12.10. To compare and contrast the signs and symptoms of placenta previa and placental abruption, see Table 12.8.

Figure 12.10 Placental Abruption A placental abruption is an emergent situation because the placenta separates from the uterine lining, which can lead to significant maternal-fetal blood loss, intrauterine fetal demise, or maternal death. The severity of a placental abruption ranges from (a and b) partial to (c) complete abruption. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Placenta Accreta

In placenta accreta, the placenta grows into the uterine wall beyond the endometrium and may invade other nearby organs. Growth occurs on a spectrum from mild abnormal tissue growth to significant invasion of vital organs. Risk factors include history of cesarean delivery, placenta accreta, or uterine surgery (ACOG, 2018d). Diagnosis can be made through imaging, such as ultrasound or magnetic resonance imaging (MRI), or the condition may go undiagnosed until the third stage of labor. If diagnosed prenatally, patients must be monitored closely throughout pregnancy using a multidisciplinary approach. A cesarean birth is performed to reduce risks to the pregnant person and the fetus, but a hysterectomy is typically indicated because of the life-threatening nature of the accreta (ACOG, 2018d). Blood is made available, and the patient will often have more than one IV access because of the high risk of hemorrhage. A multidisciplinary team is often present during the cesarean delivery to assess invasion of nearby tissues and perform additional surgery if indicated, such as a hysterectomy.

Preterm Labor

The onset of labor before term gestation, which occurs at 37 weeks’ gestation, is considered preterm labor. Preterm labor can be diagnosed by obtaining a detailed history, performing a thorough assessment, implementing diagnostic tools, and monitoring contractions. Diagnostic tools include a fetal fibronectin test and transvaginal ultrasound. A fetal fibronectin test detects a protein called fetal fibronectin that exists between the uterine lining and the amniotic sac. A negative fetal fibronectin test provides strong predictive value against preterm labor and delivery within 7 to 10 days (Berghella & Saccone, 2019). A transvaginal ultrasound can detect cervical length, where a shortened cervical length of less than 25 mm indicates preterm labor, but it is not a strong diagnostic tool. The nurse’s primary role is to monitor the patient for contractions that are increasing in frequency and severity, which, along with cervical change, indicate impending preterm delivery.

Risk factors for preterm labor include previous preterm birth, infection, cervical abnormalities, chronic medical conditions, multiple gestation pregnancy, and certain lifestyle factors, such as substance use, smoking, poor diet, stress, and limited access to health care (Griggs et al., 2020). Although risk factors have been identified, the exact underlying etiology remains unknown. Management for preterm labor aims to prolong pregnancy to allow the fetus to mature while minimizing maternal-fetal complications. Tocolytic medications may be administered to decrease contractions by causing relaxation of the uterus. Tocolytic medications include indomethacin (Indocin), nifedipine (Procardia), and magnesium sulfate (Mayer & Apodaca-Ramos, 2023). Corticosteroids, such as betamethasone (Celestone), may be given if preterm delivery is anticipated and the pregnant person is at less than 34 weeks’ gestation. This medication helps to promote fetal lung maturity and reduce the neonate’s risk of chronic lung disease. Magnesium sulfate can also be used for neuroprotection (protecting the brain from a hemorrhage) of the fetus. If there is concern for infection, antibiotics may be initiated to minimize transmission to the fetus and prevent sepsis. Close monitoring of preterm labor often occurs in a hospital setting, where both the pregnant person and the fetus can be closely observed until contractions cease and imminent delivery is no longer anticipated. In addition to frequent patient monitoring and assessment, the nurse administers tocolytics and other medications while collaborating with the health-care team to prepare for or delay preterm delivery long enough for the antenatal corticosteroids to be effective in improving fetal lung maturity.

Preterm Premature Rupture of Membranes

Rupture of the amniotic sac before term gestation at 37 weeks, with leakage of amniotic fluid and concern for imminent delivery, is called preterm premature rupture of membranes (PPROM). Risk factors include infection, multiple gestation, and a history of prior preterm birth. Leakage of amniotic fluid from the vagina is the primary sign. Complications of preterm premature rupture of membranes are infection, oligohydramnios, cord prolapse, and preterm labor. In cases of unstable pregnant person or fetal status, induction of labor or cesarean delivery may be performed. If the rupture of membranes occurs at a very early gestational age, the patient may remain as an inpatient to allow the fetus time to mature. Nursing care includes monitoring for signs and symptoms of infection and preparing for a preterm birth.

Gestational Diabetes

Gestational diabetes is diagnosed when high maternal glucose levels are present during the second or third trimester. Gestational diabetes occurs secondary to hormonal changes during pregnancy that lead to increased insulin resistance with insufficient insulin secretion to meet pregnancy needs, and genetic factors may also play a role. Preexisting diabetes can be ruled out during the first trimester through a glucose challenge test (GCT) in patients at high risk (ACOG, 2020c). In patients who are not at increased risk, the 1-hour glucose challenge test may be administered during the second trimester at 24 to 28 weeks’ gestation.

If the test results reveal concern for gestational diabetes, a 3-hour glucose tolerance test is administered to confirm a diagnosis (ACOG, 2020c). Like preexisting diabetes, gestational diabetes can be associated with adverse maternal and fetal outcomes when blood glucose levels are not well controlled. Because of the risks of hyperglycemia, treatment targets normalizing blood glucose levels. Management of blood glucose levels can occur through dietary and lifestyle modifications, frequent glucose monitoring, and insulin therapy (Johns et al., 2018).

Hypertensive Disorders of Pregnancy

Hypertensive disorders during pregnancy place the fetus at increased risk for complications due to impaired blood flow to the placenta. Management of hypertension aims to reduce blood pressure to normal ranges while monitoring for adverse maternal conditions, such as HELLP syndrome and eclampsia, uteroplacental insufficiency, fetal growth restriction, and intrauterine fetal demise.

Bleeding Disorders of Pregnancy

Patients who have bleeding disorders during pregnancy must be closely monitored for signs of bleeding and/or blood clots prior to and after delivery. The nurse should monitor for signs such as prolonged bleeding time, easy bruising, petechiae, spontaneous bleeding, and frequent nosebleeds. Pale skin, tachycardia, and hypotension may indicate significant blood loss. Bleeding disorders that develop during pregnancy include immune thrombocytopenia purpura (ITP), disseminated intravascular coagulation (DIC), and antiphospholipid syndrome (APS). During ITP, the immune system mediates the destruction of platelets. Patients may develop severe thrombocytopenia with signs of bleeding and require a platelet transfusion. Additional treatments include immunoglobulin or steroids. DIC develops in response to organ dysfunction with interruption of the coagulation process. In these cases, DIC produces tiny blood clots that can lead to increased hemorrhage or further organ damage. DIC can occur secondary to severe preeclampsia, infection, or placental abruption. Antiphospholipid syndrome is an autoimmune condition that targets the phospholipids of the body’s cell membranes and leads to increased blood clotting. Because of the increased risk of blood clots, patients may be placed on anticoagulation therapy to reduce the risk of maternal-fetal morbidity and mortality.

Gallbladder and Liver Disease

Gallbladder disease during pregnancy includes the onset of biliary colic, cholestasis, acute cholecystitis, and choledocholithiasis. Hormonal changes and the increase in estrogen and progesterone can promote the formation of gallstones. Signs and symptoms vary by underlying condition, but patients generally experience different variations of right upper quadrant pain. Symptom management through dietary modifications and medications may help patients with mild to moderate symptoms. In more severe cases, surgery during or after pregnancy may be indicated to remove the gallbladder.

Liver disease during pregnancy can vary depending on underlying etiology. Conditions that lead to liver dysfunction during the third trimester include cholestasis, HELLP syndrome, cirrhosis, and acute fatty liver of pregnancy (AFLP). AFLP can be a life-threatening condition due to liver failure from an increased buildup of fat in the liver. AFLP may be difficult to differentiate from other conditions, such as cholestasis and preeclampsia, but ultrasound and computed tomography scans may be helpful. Prompt identification and management through supportive care and induction of labor can minimize adverse outcomes such as fetal demise.

Postdated Pregnancy

Postdated pregnancy, also referred to as postterm pregnancy, is a pregnancy that progresses past 42 weeks’ gestation. Potential adverse outcomes include placental insufficiency, oligohydramnios, fetal hypoxia, macrosomia, meconium aspiration, intrauterine fetal demise, and labor complications, such as shoulder dystocia (Lockwood, 2014). Because of these risks, health-care providers often prefer to deliver by induction of labor or cesarean section at 42 weeks (ACOG, 2014). Otherwise, patient and fetus status continue to be closely monitored as the pregnancy approaches 42 weeks.

Fetal surveillance may include a nonstress test (NST) or biophysical profile (BPP). A biophysical profile may be ordered to evaluate fetal status and well-being. A biophysical profile includes a fetal ultrasound and nonstress test. An ultrasound can assess fetal movements, breathing movements, amniotic fluid volume, muscle tone, and the fetal heart rate. An NST may be performed as part of the biophysical profile or independently to evaluate the fetal heart rate reactivity and responsiveness. A nonreactive NST may indicate fetal distress related to fetal hypoxemia.

Trauma during Pregnancy

Trauma during pregnancy can occur in the form of blunt force or penetrating trauma, emotional trauma, or intimate partner violence. Regardless of the type of trauma, the patient should be closely evaluated and hospitalized in cases of maternal-fetal instability. Blunt force or penetrating trauma can lead to significant physical and neurologic damage. Falls and motor vehicle accidents are a common type of blunt force or penetrating trauma that affects the pregnant population. Initial physical assessment establishes maternal stability, while an ultrasound can evaluate fetal status. The nurse’s role includes assessing physical injuries and vital signs, facilitating prompt evaluation from the health-care team, fetal monitoring, and administering prescribed treatments and comfort measures to alleviate pain and distress. Collaboration and consultation with other teams may be required; these include emergency response, intensive care, and surgery teams. The nurse should facilitate communication with these teams to ensure prompt patient care. Depending on the degree of injury, the patient may remain hospitalized until birth or until maternal-fetal stability is achieved.

Intimate partner violence (IPV) may cause psychologic distress in addition to physical injury. The incidence of IPV increases during pregnancy (Selwyn, 2020). The nurse should be able to identify signs and symptoms of IPV during routine prenatal visits, including observing for physical injuries, emotional distress, or unexplained delays in seeking care. The nurse should create a safe and nonjudgmental environment, actively listen to the patient, and ask questions to assess for possible IPV. Additional nursing interventions include assisting the patient with the development of a safety plan to prevent further IPV, providing emotional support, documenting injuries, educating the patient on maternal-fetal risks and ways to improve prenatal health, and providing information on community resources, such as a safe house. Collaboration with a psychologist and social worker may be necessary.