Second Trimester Complications

1. Complications affecting comfort, rest, mobility: Incompetent cervix
   • Pathophysiology - inability of cervix to support growing weight of pregnancy; associated with repeated spontaneous second trimester abortion.
   • Etiology:
     1. Unknown; exposure to DES.
     2. Congenital defect in cervical musculature.
     3. Cervical trauma during previous birth, abortion; aggressive, deep, or repeated dilation and curettage.
   • Assessment:
     1. History of habitual, second trimester abortions.
     2. Painless, progressive cervical effacement and dilation during second trimester.
     3. Signs of threatened abortion or (early third trimester) preterm labor.
   • Analysis/nursing diagnosis:
     1. Pain related to early dilation.
     2. Fear related to possible pregnancy loss.
   • Nursing care plan/implementation:
     1. Medical management
        • Cerclage surgical procedure (Shirodkar, McDonald).
     2. Preoperative nursing management
        • Goal: reduce physical stress on incompetent cervix. Bed rest, supportive care.
        • Goal: emotional support. Encourage verbalization of anxiety, fear, concerns.
        • Goal: health (preoperative) teaching. Explain procedure - purse-string suture encircles cervix and reinforces musculature.
        • Goal: preparation for surgery.
     3. Postoperative nursing management
        • Goal: maximize surgical result. Bed rest, supportive care.
        • Goal: health teaching.
          1. Avoid: strenuous physical activity; straining.
          2. Report promptly: signs of labor (vaginal bleeding, cramping).
          3. Need for continued, close health surveillance.
     4. Evaluation/outcome criterion: woman carries pregnancy to successful termination.
     
     
2. Complications affecting sensory/perceptual functions: pregnancy-induced hypertension (PIH); preedampsia/eclampsia
   • Pathophysiology
     1. Generalized arteriospasm —> increased peripheral resistance, decreased tissue perfusion, and hypertension.
     2. Kidney:
        • Reduced renal perfusion and vasospasm —> glomerular lesions.
        • Damage to membrane —> loss of serum protein (albuminuria). Note: Reduced serum albumin/globulin (A/G) ratio alters blood osmolarity —> edema.
        • Increased tubular reabsorption of sodium —> increased water retention (edema).
        • Release of angiotensin contributes to vasospasm and hypertension.
     3. Brain: decreased oxygenation, cerebral edema, and vasospasm —> visual disturbances and hyperirritability, convulsions, and coma.
     4. Uterus: decreased placental perfusion —> increased risk of SGA baby, abruptio placentae, oligohydramnios.
   • Etiology: unknown. Risk factors:
     1. Pregnancy - occurs only when a functioning trophoblast is present; more common in first pregnancies; develops after week 20 of gestation.
     2. Coexisting conditions - diabetes, multifetal gestation, polyhydramnios, renal disease.
     3. Angiotensin gene T235.
   • Assessment - types:
     1. Preeclampsia - mild
        • Hypertension - systolic increase of 30 mm Hg or more over baseline; diastolic rise of 15 mm Hg or more.
        • Proteinuria - 1 g/day.
        • Edema - digital and periorbital; weight gain over 0.45 kg (1 lb)/wk.
     2. Preeclampsia - severe
        • Increasing hypertension - systolic at or above 160 mm Hg or more than 50 mm Hg over baseline; diastolic, 110 mm Hg or more
        • Urine: proteinuria (5 grams or more in 24 hours); oliguria (400 mL or less in 24 hours).
        • Hemoconcentration, hypoproteinemia, hypernatremia, hypovolemic condition.
        • Nausea and vomiting.
        • Epigastric pain - due to edema of liver capsule.
        • Cerebral or visual disturbances (before convulsive state):
          1. Disorientation and somnolence.
          2. Severe frontal headache.
          3. Increased irritability; hyperreflexia.
          4. Blurred vision, halo vision, dimness, blind spots.
        • HELLP Syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets).
     3. Eclampsia
        • Tonic and clonic convulsions; coma.
        • Renal shutdown - oliguria, anuria.