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Maternal Newborn Nursing

12.2 Conditions Limited to Pregnancy

Maternal Newborn Nursing12.2 Conditions Limited to Pregnancy

Learning Objectives

By the end of this section, you will be able to:

  • Explain the pathophysiology and management of conditions limited to pregnancy occurring in the first trimester of pregnancy
  • Explain the pathophysiology and management of various conditions limited to pregnancy that occur throughout pregnancy
  • Explain the pathophysiology and management of conditions limited to pregnancy occurring in the second trimester of pregnancy
  • Explain the pathophysiology and management of conditions limited to pregnancy occurring in the third trimester of pregnancy

In addition to preexisting conditions, certain other conditions can develop during pregnancy that increase the risk for adverse maternal-fetal outcomes. Conditions can range from mild to severe and can have a lifelong impact on the parent and the baby. This chapter outlines these conditions through discussion of their pathophysiology and management. Examples of conditions that arise during pregnancy include preeclampsia, gestational diabetes, abortion, placenta previa, and infection. Through increased understanding and awareness of these conditions, nurses can identify patients at risk and develop patient care plans to minimize adverse outcomes.

First Trimester

The first trimester, which spans the first 12 weeks of pregnancy, is critical to embryonic and fetal development. Conditions that arise during this time may lead to early pregnancy loss. Spontaneous abortions, or miscarriages, are more common during this trimester. First prenatal visits often occur during this time to identify and evaluate risk factors.

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.

Complete

Abortions can be classified into different categories including complete, incomplete, threatened, missed, recurrent, and inevitable. A complete abortion occurs when a pregnancy terminates and all products of conception are expelled from the uterus, such as the fetus, placenta, and other tissue. Because the uterus is empty, no additional intervention is indicated.

Incomplete

In contrast, an incomplete abortion occurs when some of the products of conception are still present in the uterus after the pregnancy terminates. These contents can include parts of the fetus, placenta, and other tissues. An incomplete abortion is one complication of a medically induced abortion, spontaneous abortion, or surgical abortion. Once the pregnancy is terminated, the uterus does not completely contract to expel all its contents. As a result, the patient may experience persistent bleeding, cramping, or abdominal pain afterward and is at increased risk of infection. Because of the risk of complications, patients who experience an incomplete abortion often require medical intervention, by taking a medication called misoprostol (Cytotec), or surgical intervention, by undergoing a cervical dilation and curettage (D&C) (England, 2023). A D&C is a surgical procedure in which the contents of the uterus are removed by dilating the cervix and using a surgical instrument (curette) to evacuate the uterine tissue and lining.

Threatened

A threatened abortion occurs when bleeding is present with no cervical dilation during the first trimester or before 20 weeks’ gestation. This term may be used synonymously with threatened miscarriage because the patient experiences signs and symptoms similar to a miscarriage, also known as a spontaneous abortion. Signs and symptoms include vaginal bleeding, abdominal cramping, and back pain. While vaginal bleeding during the first trimester occurs in approximately 25 percent of pregnancies, only about half of those patients actually experience a spontaneous abortion; however, this incidence increases to approximately 80 percent if cramping coincides with bleeding (Sapra et al., 2016).

Missed

A missed abortion, also referred to as a missed miscarriage, is a type of abortion with no expulsion of the products of conception and a closed cervix. The patient may experience minimal to no signs or symptoms of miscarriage (Cunningham et al., 2018). Instead, the pregnant person could continue to experience pregnancy signs and symptoms such as breast tenderness and morning sickness. The diagnosis often occurs during routine ultrasound when results reveal no fetal heart rate or growth. Because of the risk of complications, such as infection and prolonged bleeding, the patient may need medical or surgical intervention to remove all the products of conception from the uterus.

Recurrent

A recurrent abortion, also known as a recurrent pregnancy loss, refers to two or more consecutive spontaneous abortions that occur before 20 weeks’ gestation. While the exact pathogenesis is unclear, suspected causes of recurrent pregnancy loss include genetic abnormalities, uterine defects, endometrial problems, infection, autoimmune disorders, hormone imbalances, and unhealthy lifestyle habits (Dimitriadis et al., 2020). Diagnosis and management involve a thorough medical history and physical assessment with additional testing to evaluate for underlying etiology.

Inevitable

An inevitable pregnancy loss occurs when the cervix dilates or the membranes rupture without delivery of the fetus or placenta (Arendt & Long, 2020). Usually, these circumstances lead to vaginal bleeding and imminent spontaneous abortion. Signs and symptoms are similar to those of a spontaneous abortion, which include vaginal bleeding, abdominal cramping, and back pain. Often, medical or surgical interventions may be indicated to ensure complete removal of all uterine contents.

Termination

Termination during the first trimester of pregnancy is a procedure that can be performed medically or surgically. It is generally considered safe and effective. Medical termination of pregnancy typically involves taking two pills: mifepristone (Mifeprex) followed by misoprostol (Cytotec). Mifepristone blocks the action of progesterone, a hormone needed to sustain a pregnancy. Misoprostol causes uterine contractions and cervical dilation, which induce labor to expel the products of conception. The recommended method of surgical termination of pregnancy is cervical dilation and curettage through electric vacuum suction or manual aspiration. Antibiotics may be prescribed before the procedure to reduce the risk of infection (Lui & Ho, 2020). Table 12.6 summarizes the different types of abortions and their symptoms.

Type Symptoms
Complete Heavy bleeding or cramping, passing of tissue, loss of pregnancy symptoms
Incomplete Persistent bleeding, cramping, abdominal pain, signs of infection
Threatened Vaginal bleeding, abdominal cramping, and back pain
Missed No symptoms, but may still experience symptoms of pregnancy
Recurrent Vaginal bleeding, cramping, passing of tissue, loss of pregnancy symptoms, emotional distress in two or more consecutive pregnancies
Inevitable Vaginal bleeding, abdominal cramping, and back pain
Termination Vaginal bleeding, cramping, pain after the procedure, nausea and vomiting from medications, emotional distress
Table 12.6 Types of Abortions and Symptoms

Nursing care for all types of abortion is the same and involves the following:

  • Assessment: severity of bleeding, symptoms of pregnancy, signs of infection, emotional and psychologic state, pain level
  • Medications: administration of medications for pain, infection, or to assist with termination
  • Monitoring: monitor for complications such as significant blood loss or infection
  • Support: emotional and psychologic support as needed; refer to grief counseling or mental health services
  • Referral: refer based on underlying etiology; patient may require fertility specialist or multidisciplinary approach due to comorbid conditions
  • Education: teach patients how to monitor for complications at home and when to seek medical attention

Medical Management

Management of abortion during the first trimester of pregnancy begins with evaluation of the underlying etiology through identification of risk factors. Patients with recurrent pregnancy loss may undergo additional testing to identify potential causes, such as chromosomal testing, ultrasound for uterine anomalies, thyroid functions, antiphospholipid antibodies, and inherited thrombophilia (van Dijk et al., 2020). Patients who experience abortion may also experience emotional and psychologic stress. Nurses can provide emotional support and education regarding reproductive technology and referral to a grief counselor to assist with the current loss or to a fertility specialist for future pregnancies.

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.

Diagram showing locations of an ectopic pregnancy: infundibular, isthmus, interstitial, abdominal, ampullar, ovarian, and cervical.
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.

Conditions Occurring Throughout the Pregnancy

Certain conditions can occur throughout pregnancy and result in a high-risk pregnancy. These conditions include multiple gestation, intrauterine fetal demise, and infection.

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.

Diagram showing types of twins. Dizygotic twins start as two embryos that implant into the uterus, resulting in a dichorionic diamniotic pregnancy. Monozygotic twins are formed when the morula splits, resulting in a dichorionic diamniotic pregnancy; when the blastocyst splits before implantation, resulting in a monochorionic diamniotic pregnancy; and when the blastocyst splits after implantation, resulting in a monochorionic monoamniotic pregnancy.
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.

Toxoplasmosis gondii

Toxoplasmosis gondii is a protozoan parasite that infects domestic and nondomestic cats. It can be spread through contact with cat feces or through contaminated food, such as uncooked meat or raw vegetables. When a patient becomes infected, the parasite can cross the placenta to infect the fetus. Treatment depends on gestational age. For pregnancies less than 18 weeks, spiramycin (Selectomycin) is recommended and must be obtained from the U.S. Food and Drug Administration (CDC, 2022e). To reduce the risk of infection, patients who are pregnant or planning to become pregnant should be instructed to avoid handling cat feces and raw meat, to perform proper hand hygiene, and to thoroughly cook foods.

Other (Syphilis)

Syphilis is a bacterial infection caused by Treponema pallidum that can lead to intrauterine fetal demise, preterm birth, neonatal death, or congenital syphilis. Syphilis is spread through sexual contact or exposure to infected blood, as with infected needles. Vertical transmission also occurs from pregnant person to fetus. One sign of primary syphilis is the presence of a painless lesion (chancre) at the infection site that may be accompanied by lymphadenopathy. If untreated, primary syphilis can progress into secondary syphilis and cause more systemic effects. Patients are routinely screened for syphilis early in pregnancy during the first prenatal visit. Nontreponemal tests used to detect antibodies to the bacterium are the Venereal Disease Research Laboratory (VDRL) test or the rapid plasma reagin (RPR) test. If either test is positive, a treponemal test, such as the fluorescent treponemal antibody absorption (FTA-ABS) test, may be ordered to detect the presence of bacteria (U.S. Preventive Services Task Force, 2018). Patients with positive screening tests often undergo additional testing in addition to treatment with penicillin. Both the pregnant person and the fetus are closely monitored during pregnancy to assess for additional complications.

Rubella

Rubella, a viral infection also known as German measles, is primarily transmitted through respiratory droplets. When a patient becomes infected during pregnancy, the virus can cross the placenta and cause congenital rubella syndrome. Infection during the first trimester carries the greatest risk. Infections that occur later in pregnancy have a lower risk of adverse fetal outcomes. Congenital abnormalities associated with rubella infection include congenital heart defects, cataracts, deafness, and central nervous system (CNS) abnormalities. Other abnormalities include fetal growth restriction, hepatosplenomegaly, and thrombocytopenia. Management centers on prevention through vaccination prior to pregnancy, since there is currently no treatment. In cases of rubella infection during pregnancy, the fetus should be closely monitored for complications, such as growth restriction. Postnatal management includes supportive care with engagement of a multidisciplinary team.

Cytomegalovirus

Cytomegalovirus (CMV) is a virus in the herpesvirus family. When contracted during pregnancy, it can lead to congenital CMV infection. Transmission occurs through contact with body fluids, including breast milk, saliva, urine, and feces. Patients at the greatest risk of infection are childcare providers such as day care workers and teachers, patients who are immunosuppressed or have a history of transplant, patients located in high-risk areas, and nurses. Patients may be asymptomatic or have flu-like symptoms, although patients who are immunosuppressed can develop signs of severe systemic infection. Fetal complications of congenital CMV include hearing loss, thrombocytopenia, fetal growth restriction, ventriculomegaly, chorioretinitis, hepatosplenomegaly, and developmental delay (March of Dimes, 2021). There is no routine screening during pregnancy for congenital CMV; however, the patient may undergo additional testing based on ultrasound findings and a high-risk history of infection. Like many viral infections, management primarily involves supportive care. Prevention should focus on proper hand hygiene and minimizing exposure to infected persons.

Herpes Simplex Virus

Herpes simplex is a viral infection caused by herpesvirus HSV-1 or HSV-2 and is spread through sexual contact. It can also affect the mouth, lips, and oral cavity. Infection is commonly characterized by vesicular lesions around the mouth or genital areas. Patients may also exhibit signs of fever, lymphadenopathy, malaise, and meningitis. There is no cure for the virus, but treatment with antiviral therapy can reduce symptoms, shedding, and possibly transmission. Neonatal herpes infection can result from the transmission of herpes during pregnancy or childbirth and can lead to significant complications, such as blisters on the skin, eyes, or mouth (SEM), CNS effects such as seizures, and disseminated effects such as organ failure and death. Patients should be monitored during pregnancy for outbreaks and treated with antiviral therapy accordingly. The administration of antiviral suppressive therapy, such as acyclovir (Zovirax), is recommended starting at 36 weeks’ gestation for patients with primary outbreaks or a history of genital herpes (Urato, 2020). If active lesions are present on the perineum, labia, or cervix at the onset of labor or rupture of membranes, a cesarean birth is recommended to reduce the risk of transmission.

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.

Infection Complications
Hepatitis Preterm delivery, cholestasis of pregnancy, gestational diabetes, low-birth-weight infant, preeclampsia, transmission to fetus
HIV Infection, side effects of antiretroviral therapy, gestational diabetes, preeclampsia, transmission to fetus, preterm delivery, low-birth-weight infant
Toxoplasmosis Spontaneous abortion or intrauterine fetal demise, congenital toxoplasmosis (fetal hearing loss, blindness, developmental delay)
Syphilis Intrauterine fetal demise, preterm birth, neonatal death, congenital syphilis (fever, hepatosplenomegaly, neurologic impairment, bone and joint problems, anemia)
Rubella Congenital rubella syndrome (congenital heart defects, cataracts, deafness, CNS abnormalities, fetal growth restriction, hepatosplenomegaly, thrombocytopenia)
Cytomegalovirus (CMV) Flu-like symptoms, congenital CMV (hearing loss, thrombocytopenia, fetal growth restriction, ventriculomegaly, chorioretinitis, hepatosplenomegaly, developmental delay)
Herpes Fever, lymphadenopathy, malaise, meningitis, congenital herpes (SEM disease, disseminated disease, or CNS disease)
Varicella Intrauterine fetal demise, congenital varicella (skin scarring, eye, limb, or neurologic abnormalities, anemia, thrombocytopenia, low birth weight)
Group B streptococcus (GBS) Neonatal meningitis, pneumonia, and sepsis
Table 12.7 Infections and Pregnancy Complications (CDC, 2021b)

Second Trimester

Conditions specific to the second trimester include abortion, cervical insufficiency, and Rh isoimmunization. Abortion during the second trimester can be spontaneous or induced. Cervical insufficiency can result in preterm delivery around the edge of viability. Rh isoimmunization can lead to severe fetal anemia, which may result in fetal death.

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.

Diagram showing cervical cerclage: dilated cervical canal with sutures; narrowed cervical canal.
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.

Conditions Occurring in Second and Third Trimesters

Conditions that arise during the second and third trimesters may relate to complications within the intrauterine environment and pregnancy-induced medical conditions. Complications within the intrauterine environment include amniotic fluid and placental abnormalities. Preterm labor and preterm rupture of membranes can also occur. Pregnancy-induced disorders, such as gestational hypertension, preeclampsia, and gestational diabetes, are diagnosed during this time. Prompt identification and diagnosis can lead to timely treatment.

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.

Diagram showing placenta previa: (a) normal placental location, (b) low lying placenta, (c) marginal previa, (d) partial previa, (e) complete placenta previa.
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.

Diagram showing classifications of placental abruption: (a) partial abruption, concealed hemorrhage; (b) partial abruption, apparent hemorrhage; (c) complete abruption, concealed hemorrhage.
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)
Disorder Signs and Symptoms
Placenta previa Vaginal bleeding, painless
May cause fetal distress
Cramping, uterine contractions
Placental abruption Vaginal bleeding, painful
May cause maternal and fetal distress
Signs of maternal and fetal hemorrhage
Abdominal pain
Cramping, uterine contractions
Back pain
Table 12.8 Signs and Symptoms of Placenta Previa versus Placental Abruption

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.

Pharmacology Connections

Medications Prescribed for Preterm Labor

Tocolytic Medications

Tocolytic medications are administered to prevent or inhibit preterm labor by suppressing uterine contractions. By stopping or slowing preterm labor, tocolytic medications create time for fetal growth, additional interventions, and maternal transfer for specialized care.

Terbutaline (Brethine)

  • Indication: used to stop preterm labor (tocolysis)
  • Mechanism of Action: causes uterine smooth muscle relaxation
  • Adverse Effects: restlessness, tremors, hypokalemia, hyperglycemia, hypertension, tachycardia, dizziness, headache, nausea and vomiting, diaphoresis, insomnia, chest pain, arrhythmia, pulmonary edema, neonatal hypoglycemia, increased fetal heart rate
  • Contraindications: prolonged tocolytic therapy for more than 72 hours, receiving maintenance tocolytic therapy, history of hypersensitivity or allergy; hold medication if the pulse of the pregnant person is > 120.
  • High Alert/Black Box Warning: The use of terbutaline for the treatment of preterm labor for more than 48 to 72 hours is associated with maternal cardiac problems and death.
  • Patient Education: discussion of adverse effects
  • Classification: beta 2 agonist
  • Dose: IV 2.5 to 5 mcg/minute; may gradually increase to a maximum of 25 mcg/minute or 0.25 mg every 20 to 30 minutes up to three doses in 4 hours

Magnesium Sulfate

  • Indication: used to stop preterm labor (tocolysis)
  • Mechanism of Action: precise mechanism of action unknown, suspected to be related to relaxation of smooth muscle of the uterus by decreasing the release of acetylcholine
  • Adverse Effects: flushing, sweating, nausea, vomiting, headache, blurred vision, muscle weakness, respiratory depression, cardiac arrest
  • Contraindications: renal dysfunction, myasthenia gravis, cardiac disease
  • Patient Education: Educate patients about adverse effects and when to seek medical attention.
  • Classification: antiseizure agent, electrolyte, tocolytic
  • Dose: loading dose of 4 to 6 grams administered IV over 20 to 30 minutes, followed by a maintenance dose of 1 to 4 grams per hour

Nifedipine (Procardia)

  • Indication: used to stop preterm labor (tocolysis)
  • Mechanism of action: blocks calcium ions from entering the cell membrane, which ultimately results in uterine wall relaxation
  • Adverse Effects: nausea, vomiting, flushing, headache, dizziness, palpitations, hypotension, peripheral edema
  • Contraindications: Hypotension, heart failure, liver dysfunction, hypersensitivity
  • Patient Education: Discuss adverse effects and when to notify the health-care provider.
  • Classification: calcium channel blocker
  • Dose: 10 to 20 mg every 4 to 6 hours up to 48 hours

Indomethacin (Indocin)

  • Indication: used to stop preterm labor (tocolysis)
  • Mechanism of Action: inhibits prostaglandins that are released during labor
  • Adverse Effects: gastrointestinal upset (nausea, vomiting, reflux, abdominal pain), thrombocytopenia, oligohydramnios, renal dysfunction, hypertension, neonatal complications (chronic lung disease, patent ductus arteriosus, intraventricular hemorrhage)
  • Contraindications: low platelets, renal impairment, hypersensitivity to NSAIDs or aspirin, gastrointestinal bleeding, > 32 weeks’ gestation
  • Patient Education: Discuss adverse fetal and neonatal effects.
  • Classification: cyclooxygenase inhibitor (COX inhibitor), nonsteroidal anti-inflammatory (NSAID)
  • Dose: 50 to 100 mg loading dose orally or rectally, then 25 mg every 4 to 6 hours for only 72 hours

Corticosteroid Medications

Corticosteroids are administered to patients in preterm labor before 34 weeks’ gestation because these medications promote fetal lung development and decrease the risk of respiratory distress syndrome of the newborn. When administered 2 to 7 days prior to preterm birth, corticosteroid administration has a significant impact on the reduction of adverse severe neonatal outcomes.

Betamethasone (Celestone) or Dexamethasone (Decadron)

  • Indication: promotes fetal lung maturity in the setting of anticipated preterm delivery before 34 weeks’ gestation
  • Mechanism of action: stimulates the development of pneumocytes and the production of surfactant
  • Adverse effects: hyperglycemia, hypertension, uterine irritability, fetal heart rate changes, fluid retention, gastrointestinal upset
  • Contraindications: hypersensitivity to corticosteroids
  • Patient education: discussion of adverse effects and the positive impact on fetal lung outcomes
  • Classification: corticosteroid
  • Dose: ideally should be given more than 24 hours before birth to see the full benefits
    • Betamethasone: 2 doses of 12 mg given IM 24 hours apart
    • Dexamethasone: 4 doses of 6 mg given IM 12 hours apart

(Nursing 2024 Drug Handbook, 2024)

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.

Clinical Safety and Procedures (QSEN)

Confirmation of Preterm Rupture of Membranes Using Amnisure

Confirming preterm premature rupture of membranes requires the nurse to insert a sterile swab into the vaginal discharge and place it into a tube containing the solvent vial for a minimum of 1 minute. After removing the swab, the solvent fluid is tested and if positive, confirms rupture of membranes.

Nursing Actions to Prevent Infection

Prior to and after confirmation of preterm rupture of membranes, a major goal is prevention of maternal and fetal infection while awaiting delivery. Nursing actions include:

  • handwashing
  • perineal hygiene
  • frequent changing of perineal pad
  • monitoring temperature
  • monitoring uterus for irritability and pain
  • monitoring the fetal heart rate (FHR) for evidence of stress

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.

Unfolding Case Study

12.1: Prenatal Care: Part 2

See Prenatal Care: Part 1 for a review of the patient data.

Flow Chart 28 Weeks’ Gestation
BP: 124/74
Fundal Height: 29 cm
FHR: 136
Lab Results 28 Weeks’ Gestation
3-hour GTT
FBS: 110 mg/dL
1-hour glucose: 185 mg/dL
2-hour glucose: 149 mg/dL
3-hour glucose: 128 mg/dL
Provider’s orders 28 Weeks’ Gestation
Provide glucose monitoring education
Instruct in daily fetal movement counts
1.

The nurse discusses the results of the test with Brianne and Trey. Brianne asks the nurse what caused her blood sugar to be abnormal and whether this means she will need insulin. Select the most appropriate option to complete the statement.

The nurse identifies the priority problem at this time as         .

  1. knowledge deficit regarding gestational diabetes
  2. increased risk for genetic congenital condition
  3. knowledge deficit regarding labor and birth
2.

The nurse prepares to discuss the importance of glucose control and possible complications regarding gestational diabetes with Brianne and Trey. What topics should the nurse include in the discussion at this time? Select all that apply.

  1. nutrition
  2. how to monitor her blood glucose
  3. relaxation techniques
  4. the expected range of the 2-hour postprandial glucose reading
  5. importance of daily fetal movement counts (FMC)
  6. preparing for a planned cesarean birth
  7. increased risk for genetic anomalies
  8. increased risk for pregnancy-induced hypertension (HTN)
  9. importance of exercise to regulate glucose

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).

Pharmacology Connections

Medication Prescribed for Gestational Diabetes

Insulin is the preferred medication for the management of hyperglycemia in gestational diabetes. Because insulin does not cross the placenta, it can safely lower maternal glucose levels with minimal risks to the fetus. Metformin may be prescribed for patients who cannot take insulin or who refuse insulin, but it has limited use because it crosses the placenta. Glyburide (DiaBeta) is not recommended, as it is linked with congenital defects. The nurse should counsel patients on hypoglycemic agents as well as collaborate with a nutritionist to provide education on lifestyles modifications, such as improving diet and exercise.

Insulin

  • Indication: decrease high blood glucose levels
  • Mechanism of Action: Insulin is a hormone produced by the pancreas that helps regulate the amount of glucose in the blood. During pregnancy, the placenta produces hormones that can interfere with insulin’s ability to lower blood glucose levels. Insulin therapy can help overcome this resistance and maintain blood glucose levels within a normal range.
  • Side Effects/Adverse Reactions: hypoglycemia, signs of allergic reaction
  • Contraindications: none, but use caution if there is concern for an allergy
  • Patient Education: Discuss how to perform proper injection technique, identify signs of hypoglycemia, monitor blood glucose levels, follow a healthy diet and exercise routine, and take medication as prescribed.
  • Classification: hormone and antidiabetic agent
  • Dose: varies by individual patient

Metformin

  • Indication: decrease high blood glucose levels, only used when patient refuses or cannot take insulin
  • Mechanism of Action: decreases glucose production in the liver, decreases absorption of glucose from gastrointestinal tract, increases insulin sensitivity
  • Boxed Warning: may cause lactic acidosis leading to death, hypotension, arrhythmias, and hypothermia
  • Side Effects/Adverse Reactions: hypoglycemia, signs of allergic reaction, gastrointestinal effects (nausea, vomiting, flatulence, diarrhea, abdominal pain), lactic acidosis, vitamin B12 deficiency, chest discomfort, palpitations, myalgia, headache
  • Contraindications: hypersensitivity to metformin, signs of renal dysfunction or metabolic acidosis
  • Patient Education: Inform the patient that metformin crosses the placenta, and there are limited data to support safe use during pregnancy. Counsel the patient on how to identify signs of hypoglycemia, monitor blood glucose levels, follow a healthy diet and exercise routine, and take medication as prescribed.
  • Classification: antidiabetic agent
  • Dose: oral route, 500 mg once or twice daily, taken with meals to minimize GI upset

(Nursing 2024 Drug Handbook, 2024)

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.

Gestational Hypertension

Gestational hypertension is hypertension that occurs after 20 weeks’ gestation and may also be termed preeclampsia. Risk factors for gestational hypertension include obesity, nulliparity, history of preeclampsia, preexisting diabetes, renal disease, and multiple gestation pregnancy (Shen et al., 2017). A formal diagnosis can be made when systolic blood pressure exceeds 140 mm Hg or diastolic blood pressure exceeds 90 mm Hg on more than one occasion. Gestational hypertension carries increased risk to both the pregnant person and the fetus. Antihypertensive therapy is often prescribed to prevent severe hypertension. Patients who develop severe gestational hypertension may need to be admitted to the hospital with close blood pressure and maternal-fetal monitoring. Delivery may be indicated at 37 weeks or before, depending on clinical status and lab findings.

Pharmacology Connections

Medications Prescribed for Hypertensive Disorders of Pregnancy

A number of medications can be safely prescribed to treat hypertensive disorders of pregnancy.

Labetalol hydrochloride (Trandate)

  • Indication: treatment of hypertensive disorders, such as gestational hypertension and preeclampsia, that develop during pregnancy
  • Mechanism of Action: blocks alpha and beta receptors, which reduces the effects of catecholamines that increase blood pressure, dilates blood vessels to decrease blood pressure
  • Adverse Effects: hypotension, bradycardia, shortness of breath, dizziness, headache, nausea, edema, flushing, drowsiness
  • Contraindications: COPD, asthma, heart failure, heart block, history of hypotension or bradycardia, hypersensitivity
  • Patient Education: Discuss how to take blood pressure and monitor adverse effects.
  • Classification: antihypertensive, beta blocker
  • Dose: starting dose is 100 mg twice daily; higher doses indicated for hypertensive emergency in pregnancy

Nifedipine (Procardia)

  • Indication: treatment of hypertensive disorders in pregnancy, such as gestational hypertension and preeclampsia, that develop during pregnancy
  • Mechanism of Action: blocks calcium ions from entering the cell membrane, which ultimately results in relaxation of coronary vasculature and decreases peripheral vascular resistance
  • Adverse Effects: nausea, vomiting, flushing, peripheral edema, headache, dizziness, palpitations, hypotension
  • Contraindications: hypotension, heart failure, liver dysfunction, hypersensitivity
  • Patient Education: Discuss adverse effects and when to notify the health-care provider.
  • Classification: antihypertensive, calcium channel blocker
  • Dose: varies depending on the patient, with starting dose of 10 to 30 mg orally and increased as indicated to target blood pressure

Magnesium Sulfate

  • Indication: treatment of hypertensive disorders in pregnancy, such as gestational hypertension, preeclampsia, and eclampsia, that develop during pregnancy
  • Mechanism of Action: decreases neuromuscular transmission
  • Adverse Effects: flushing, sweating, nausea, vomiting, headache, blurred vision, muscle weakness, respiratory depression, cardiac arrest
  • Contraindications: renal dysfunction, myasthenia gravis, cardiac disease
  • Patient Education: Educate patients about adverse effects and when to seek medical attention.
  • Classification: antiseizure agent, electrolyte, tocolytic
  • Dose: loading dose of 4 to 6 grams administered IV over 20 to 30 minutes, followed by a maintenance dose of 1 to 4 grams per hour

Hydralazine hydrochloride (Apresoline)

  • Indication: treatment of hypertensive disorders in pregnancy, such as gestational hypertension
  • Mechanism of action: causes vasodilation and decreases systemic resistance to lower blood pressure
  • Adverse Effects: headache, nausea, dizziness, flushing, hypotension, lupus-like syndrome, acute myocardial infarction, palpitations, tachycardia, gastrointestinal upset
  • Contraindications: mitral valve rheumatic heart disease, coronary artery disease, cerebral artery disease, hypersensitivity
  • Patient Education: Instruct patients to take medication as prescribed, monitor blood pressure, and identify adverse effects.
  • Classification: antihypertensive, vasodilator
  • Dose: depends on the patient’s needs; may be started orally at 10 to 20 mg every 4 to 6 hours. IV dosing may involve more frequent dosing to achieve target blood pressure.

(Nursing 2024 Drug Handbook, 2024)

HELLP Syndrome

HELLP syndrome is an acronym that stands for Hemolysis, Elevated Liver enzymes, and Low Platelet count. Patients often experience signs and symptoms of preeclampsia, such as epigastric pain, headache, and vision changes, but the patient may not necessarily develop hypertension or proteinuria (Alese et al., 2021). Signs and symptoms specific to HELLP syndrome include fatigue and abnormal bruising (related to hemolysis), abdominal pain (often right upper quadrant [RUQ]), edema, nausea, and vomiting (related to elevated liver enzymes), and petechiae or prolonged bleeding time (related to low platelets) (Khalid et al., 2023). Diagnosis is based on low platelets and lab values that indicate liver involvement. HELLP syndrome can be life-threatening to both the pregnant person and the fetus, so close monitoring and prompt evaluation are necessary. Treatment options include anticipated delivery if > 34 weeks’ gestation based on lab values, supportive care, and management of possible hemorrhage (Khalid et al., 2023). The nurse’s role includes close monitoring of vital signs, assessing for worsening symptoms, and promptly notifying the health-care team of any changes to clinical status. The nurse administers medications and monitors fetal status using electronic fetal monitoring. Patient education should include discussion of the maternal-fetal risks of HELLP and the possibility of preterm delivery. The nurse can prepare the patient for preterm birth by discussing what to expect after delivery and by collaborating with a multidisciplinary team, including the NICU team, to discuss the neonatal risks related to prematurity.

Preeclampsia

The multisystem disorder preeclampsia can occur after 20 weeks’ gestation and up to 6 weeks postpartum and, if untreated, can lead to damage of the vital organs and seizures. Compared with gestational hypertension, preeclampsia has a greater risk of adverse outcomes, such as cesarean delivery, preterm birth, low Apgar scores, placental abruption, and small-for-gestational-age infants (Shen et al., 2017). The exact etiology of preeclampsia is unknown, but it is thought to be related to vascular changes in the placenta and uterus. The vascular changes damage the endothelial cells of the blood vessels, increasing vascular permeability leading to edema and increased glomerular damage leading to proteinuria. Risk factors for preeclampsia include nulliparity, extremes in maternal age, obesity, multiple gestation pregnancy, kidney disease, chronic hypertension, diabetes, and a personal or family history of preeclampsia. Signs of preeclampsia are high blood pressure, proteinuria, edema, headaches, vision changes, epigastric pain, and nausea or vomiting. Patients should be instructed to immediately see their health-care provider if they experience any of these signs or symptoms.

Risk reduction is the first step toward management of preeclampsia. Daily low-dose aspirin beginning early in the second trimester is recommended for patients who are at risk (ACOG, 2020c). The most effective treatment of preeclampsia is delivery. However, prior to delivery, hypertension can be managed with antihypertensive therapy. In cases of preeclampsia with severe features, the patient may be started on magnesium sulfate to prevent the progression of preeclampsia to seizures. Therefore, the patient with severe symptoms will need to be hospitalized for monitoring until stabilization of blood pressures or until delivery. Delivery will depend on the severity of preeclampsia.

During hospitalization, the nurse closely monitors for signs of worsening preeclampsia, which can lead to the onset of eclampsia. Hyperreflexia and the presence of clonus are warning signs for seizure risk. In addition to vital sign monitoring, the nurse should regularly assess the patient’s neurologic status, including level of consciousness, reflexes, and signs of magnesium toxicity (loss of deep tendon reflexes, respiratory depression, and decreased urine output). Continuous electronic fetal monitoring may be ordered to evaluate fetal heart rate and uterine contractions. Additional monitoring of serial lab tests, such as magnesium levels and liver and renal function tests, may be indicated. Any significant change to maternal clinical status or fetal heart rate should be immediately reported to the health-care team.

Clinical Safety and Procedures (QSEN)

Safe Administration and Monitoring of Magnesium Sulfate during Pregnancy

Disclaimer: Always follow the agency’s policy for medication administration.

Definition: Safely administer and closely monitor patients to reduce risks of side effects and magnesium toxicity.

Knowledge: The nurse will review current evidence-based practice standards and facility policies related to magnesium sulfate administration and monitoring, and will reflect on risks to unsafe nursing practices.

Skill: Demonstrate effective strategies to reduce the risk of magnesium toxicity. The nurse will do the following:

  • Identify indications and contraindications for magnesium administration.
  • Use standard drug packaging and preparation per pharmacy.
  • Follow the five rights of medication administration.
  • Utilize an infusion pump to set limits and ensure proper dose and infusion rate.
  • Implement standard parameters for administration as outlined by provider order and facility protocol.
  • Monitor and report magnesium levels per facility protocol and standing order.
  • Monitor for and respond promptly to signs of magnesium toxicity:
    • Recognize signs of magnesium toxicity that include muscle weakness with decreased deep tendon reflexes, nausea/vomiting/diarrhea, arrhythmia, hypotension, confusion, flushing, and respiratory depression.
    • Stop infusion immediately and notify health-care provider.
    • Draw sample for a magnesium level immediately.
    • Ensure accessibility of calcium gluconate (usually at bedside) as antidote; administer as ordered.
    • In cases of respiratory depression, be prepared to provide respiratory support and notify rapid response team.
  • Provide patients with education about side effects (flushing, feeling hot, drowsiness, muscle weakness), the risk of magnesium toxicity, and what signs and symptoms to monitor.

Attitude: The nurse will respect individual role in preventing errors by adhering to safe, evidence-based practice standards.

(AHRQ Safety Program for Perinatal Care, 2017)

Eclampsia

A diagnosis of eclampsia is made when signs of preeclampsia progress to seizure activity. Eclampsia can occur during pregnancy or after birth. Eclampsia is associated with increased risk of death to the pregnant or newly delivered person and the fetus. Maternal complications include pulmonary edema, acute renal failure, hemorrhage, placental abruption, preterm delivery, neurologic damage, and cardiac arrest (Laskowska, 2023). Management of eclampsia focuses on prevention by quickly identifying and treating preeclampsia. Magnesium sulfate may be prescribed to control seizure activity. An emergent cesarean delivery may be performed to prevent adverse outcomes, including maternal and fetal death.

Clinical Safety and Procedures (QSEN)

Nursing Care of Pregnant Person with Eclampsia

  • Recognition of Seizure Activity
    • There is sudden onset of tonic/clonic seizure activity.
    • Seizures are typically 60 to 70 seconds in length.
    • Seizures are followed by a postictal state.
  • Nursing Actions to Prevent Injury
    • Remove any objects from the patient’s bed.
    • Loosen anything tight around the neck and waist.
    • Lift side rails and cover with blankets.
    • Stay with the patient.
  • Nursing Actions to Maintain Open Airway
    • Lower the head of the bed to < 30 degrees.
    • Turn the patient to their side.

Superimposed Hypertensive Disorders of Pregnancy

Chronic hypertension can progress to superimposed preeclampsia during late pregnancy. Superimposed preeclampsia may be suspected if a patient diagnosed with chronic hypertension during the first trimester develops increasing blood pressures after 20 weeks’ gestation. Because of the similar presentation of elevated blood pressure and proteinuria in chronic hypertension and preeclampsia, superimposed preeclampsia may be difficult to differentiate. Management should focus on the administration of antihypertensives and the treatment of preeclampsia to reduce morbidity and mortality.

Renal and Cardiac Conditions

Physiologic changes during pregnancy can place additional stress on the heart and kidneys, which can worsen hypertension. Because the kidneys play a vital role in the regulation of blood pressure, damage to the kidneys often causes hypertension during pregnancy. Patients with chronic kidney disease are at increased risk of complications during pregnancy. These complications include preeclampsia, preterm delivery, and worsening kidney function (Hladunewich, 2017). Hypertensive disorders related to kidney disease can be managed with antihypertensive therapy and close collaboration with nephrology. Monitoring of proteinuria can reduce the risk of nephrotic syndrome. Prevention of hypertensive disorders during pregnancy in patients with renal disease may include low-dose aspirin and calcium supplementation. Cardiac conditions, such as aortic and coronary artery disease, that are present during pregnancy may place additional strain on the heart. Close collaboration with cardiology can ensure that cardiac function is adequate and that blood pressure is managed to minimize myocardial demand.

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.

Third Trimester

Conditions that place a pregnancy at risk during the third trimester (weeks 28 to 40) include gallbladder and liver disease, postdated pregnancy, and trauma. Because of the increase in size of the uterus and the physiologic changes that occur, gallbladder and liver disease may develop or be exacerbated during the third trimester, resulting in adverse effects for the pregnant person and the fetus. Postdated pregnancy (42 weeks and beyond) can lead to placental insufficiency or additional growth of the fetus, which can complicate delivery. Finally, trauma that occurs during the third trimester can cause physical and emotional stress that can compromise maternal and fetal health.

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.

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