High-Risk Pregnancy: Complications and LPN Response

High-Risk Pregnancy: Complications and LPN Response

High-risk pregnancies require close monitoring, early recognition of warning signs, and rapid, coordinated responses. As an LPN, your role centers on accurate assessment, timely reporting, and supporting the care plan directed by the RN or provider. This lesson covers five major antepartum complications: gestational hypertension, preeclampsia, gestational diabetes, placenta previa, and placental abruption.

Gestational Hypertension and Preeclampsia

Gestational hypertension is defined as a sustained blood pressure of 140/90 mmHg or higher on two occasions at least four hours apart, arising after 20 weeks of gestation in a woman who had normal blood pressure before pregnancy, with no protein in the urine and no other systemic signs.

Preeclampsia meets the same blood-pressure threshold but adds evidence of end-organ involvement. The classic additional finding is proteinuria, but current clinical criteria also recognize thrombocytopenia, impaired liver function, new-onset renal insufficiency, pulmonary edema, or new-onset headache unresponsive to medication as qualifying features even without proteinuria.

Preeclampsia with severe features is present when systolic BP reaches 160 mmHg or diastolic reaches 110 mmHg on two readings, or when end-organ damage is significant (e.g., right upper-quadrant pain, severe persistent headache, visual disturbances, markedly elevated liver enzymes, oliguria).

Eclampsia is the onset of grand-mal seizures in a woman with preeclampsia when no other cause can be identified. It is a life-threatening emergency.

LPN priority actions for hypertensive disorders:

• Monitor blood pressure per protocol and report readings that meet or exceed facility thresholds immediately.
• Assess for headache, visual changes, epigastric or right upper-quadrant pain, and edema at every encounter.
• Measure and document urine output; report oliguria (less than 30 mL/hour) promptly.
• Keep the environment calm and low-stimulus; reduce unnecessary noise and lighting.
• Have emergency equipment accessible (oxygen, suction, seizure precaution padding).
• Do not leave the patient alone if severe features are present.
• The RN and provider manage magnesium sulfate therapy and antihypertensives; the LPN monitors for toxicity signs (loss of deep-tendon reflexes, respiratory depression, decreased urine output) and reports them immediately.

Gestational Diabetes

Gestational diabetes mellitus (GDM) is glucose intolerance that is first recognized during pregnancy. Hormones produced by the placenta cause insulin resistance. Risks to the fetus include macrosomia (large for gestational age), hypoglycemia after birth, shoulder dystocia at delivery, and long-term metabolic risk for both mother and child.

Signs and symptoms are often absent; GDM is typically detected by screening (oral glucose challenge test followed by a diagnostic glucose tolerance test if the screen is positive).

LPN priority actions:

• Reinforce dietary counseling (consistent carbohydrate intake as instructed by the dietitian and provider).
• Teach and support blood glucose monitoring as ordered; document and report values outside the target range set by the provider.
• Reinforce foot care and skin inspection.
• Educate about signs of hypoglycemia (shakiness, diaphoresis, confusion) and hyperglycemia (polyuria, polydipsia, blurred vision).
• Prepare the patient for increased fetal surveillance appointments (non-stress tests, biophysical profiles).

Placenta Previa

Placenta previa occurs when the placenta implants over or very near the internal cervical os. As the lower uterine segment develops and the cervix begins to efface or dilate, placental sinuses tear, causing bleeding.

Classic presentation: sudden, painless, bright-red vaginal bleeding in the second or third trimester. The uterus is typically soft and non-tender. The fetus may or may not be in a normal lie.

Critical safety point: Vaginal or rectal examinations are strictly contraindicated in any patient with unexplained vaginal bleeding until placenta previa has been ruled out by ultrasound. A digital exam can provoke catastrophic hemorrhage.

LPN priority actions:

• Do NOT perform a vaginal or rectal exam.
• Position the patient on her left side or as ordered to optimize uteroplacental blood flow.
• Apply oxygen per protocol; establish IV access if ordered.
• Continuously monitor maternal vital signs and fetal heart tones.
• Quantify and document blood loss (pad counts, pad weights if ordered).
• Notify the RN and provider immediately.
• Prepare for possible emergency cesarean section.

Placental Abruption

Placental abruption is the premature separation of a normally implanted placenta from the uterine wall before delivery. Separation disrupts the maternal-fetal blood exchange and can cause severe hemorrhage that may be concealed behind the placenta.

Classic presentation: sudden onset of dark-red vaginal bleeding (though bleeding may be concealed), a rigid or board-like abdomen, severe uterine pain and tenderness, and uterine hypertonicity. Fetal distress (abnormal fetal heart rate pattern) is common.

Contrast with placenta previa: Abruption is typically painful with a firm uterus; previa is typically painless with a soft uterus.

LPN priority actions:

• Notify the RN and provider immediately — this is an obstetric emergency.
• Do not perform a vaginal exam.
• Position the patient laterally; administer oxygen as ordered.
• Monitor maternal vital signs frequently for signs of hypovolemic shock (falling BP, rising pulse, pallor, decreased level of consciousness).
• Maintain IV access; be prepared for rapid fluid resuscitation or blood product administration as ordered.
• Continuously monitor fetal heart tones.

Escalation and SBAR Communication

Recognize the findings that require immediate provider notification: BP at or above severe-range thresholds, seizure activity, loss of deep-tendon reflexes, sudden heavy vaginal bleeding, signs of maternal shock, absent or abnormal fetal heart tones, or any abrupt change in the patient's level of consciousness.

Use SBAR (Situation, Background, Assessment, Recommendation) for all urgent verbal reports. State what is happening, relevant history, your objective findings, and what you believe is needed. Clear, organized handoff protects the patient and demonstrates professional accountability.

Scope reminder: LPNs in most states work under the supervision of RNs or providers in obstetric settings. Know your facility's policies. When in doubt, report and document.