Complications of Pregnancy：妊娠并发症

Complications of Pregnancy：妊娠并发症 Complication of Pregnancy , Places a burden on the woman and family. , Hospitalization may be necessary. , Leading causes of maternal death during pregnancy are thromboembolism, hemorrhage, infection, hypertension, anesthesia complications, ectopic pregnancy and heart disease. , Nursing Process: , Nurses discover complications. , Outcomes address fetal and maternal welfare. Bleeding During Pregnancy , Vaginal bleeding is never normal and is frightening. , Bleeding and the Development of Shock: , Serious because the amount visualized may only be a fraction of the actual loss. , Hypovolemic shock , Process of shock , Uterus is a nonessential organ, danger to fetal blood supply occurs when the woman’s body decreases blood flow to peripheral organs. , 10% of blood volume, 2 units of blood lost. , Fetal distress occurs when 25% of blood volume is lost. , ER interventions. , Restore blood volume and halt the source of bleeding. , First Trimester Bleeding , Spontaneous Miscarriage: , Abortion-interruption of a pregnancy before the fetus is viable. Medical or surgical interrupted. , Nonviable fetus is a fetus of 20 to 24 weeks of gestation or weighing 500 g or less. , Miscarriage-interruption occurs spontaneously. Occurs in 15% to 30% of all pregnancies and occurs from natural causes. , Bleeding before week 6 is rarely severe. , Bleeding after week 12 can be profuse because the placenta is implanted deeply. , Between weeks 6 to 12 the stage of attachment can be the most severe bleeding and a threat to their lives. , Causes: , 1st trimester-abnormal fetal formation due to teratogenic factor or chromosomal aberration. 60% structural abnormalities. , Implantation abnormalities. 50% , Corpus luteum fails to produce enough progesterone to maintain decidua basalis. , Infection-rubella, syphilis, UTI , Teratogenic drugs. , Assessment: , Vaginal spotting. Ask about self abort. , Threatened Miscarriage: , Vaginal bleeding scant then bright red. , Light cramping, no cervical dilatation. , Sonogram, hCG at start of bleeding and 48 hours. Will double if placenta is intact. , Limit activity to no strenuous activity for 24 to 48 hours is key intervention. , Support and reassurance. May resolve in 24 to 48 hours, no sex for 2 weeks. , Imminent (Inevitable) Miscarriage: , If uterine contractions and cervical dilation occur. Ash to go to hospital or office for an exam. , Bring tissue fragments, may do sonogram. , D&C, bleeding more than 1 per hour is abnormally heavy bleeding. , Complete Miscarriage: , Entire products of conception (fetus, membranes, and placenta) are expelled spontaneously without assistance. , Incomplete Miscarriage: , Part of conceptus (usually the fetus) is expelled, but membranes or placenta is retained in the uterus. , Danger of maternal hemorrhage because uterus can not contract. , D&C or suction curettage. , Be sure woman knows the pregnancy is already lost. , Missed Miscarriage: , Early pregnancy failure, fetus dies in utero but is not expelled. , Discovered at prenatal visit-fundal height not increased, no fetal heart. , Sonogram, D&C, over 14 weeks labor induced by prostaglandin suppository or Cytotec to dilate the cervix, followed by oxytocin. If not actively terminated, miscarriage occurs in 2 weeks. , Danger of DIC , Support. , Recurrent Pregnancy Loss: , 3 spontaneous miscarriages at same gestational age-habitual aborters. , Cause: , Defective spermatozoa or ova , Endocrine factor , Deviations of the uterus , Infection , Autoimmune disorders , Complications of Miscarriage: , Hemorrhage: , With complete spontaneous miscarriage, serious or fatal hemorrhage is rare. , DIC-position woman flat and massage fundus, may need D&C. , 1 pad per hour , Unusual odor or passing large clots is abnormal. , Methergine , Repression , Infection: , Teach danger signs of infection. (100.4) , Organism-Escherichia coli , Avoid tampons-stasis of blood. , Endometritis usually occur. , Septic Abortion: , An abortion that is complicated by infection. , Happens after spontaneous miscarriage, self abort or illegal abortion, nonsterile. , SS-fever, crampy abdominal pain, uterus feels tender to palpation. , Toxic shock, septicemia, kidney failure and death. , Tx.-Labs, cultures, catheter, IV, antibiotic-penicillin, gentamicin, clindamycin. , D&C, tetanus toxoid, , ICU, Dopamine and digitalis, O2 , Infertility due to scaring. , Isoimmunization: , Production of antibodies against Rh-positive blood by her immunologic system. , When placenta is dislodged, some blood from placental villi may enter the maternal circulation. Woman is Rh-negative. , Receive Rh (D antigen) immune globulin (RhIG) to prevent buildup of antibodies. , Powerlessness: , Sadness, grief, loss of control. Ectopic Pregnancy , Implantation occurs outside the uterine cavity. , 95% occur in fallopian tube. , 2nd most frequent cause of bleeding early in pregnancy. , Oral contraceptives may reduce the possibility. , Assessment: , N&V, hCG positive, no menstrual flow. , 6 to 12 weeks zygote grows large enough to rupture fallopian tube. Tearing and destruction of blood vessels in tube. , Experience sharp, stabbing pain in lower abdominal quadrants, followed by scant vaginal spotting. , Blood may be expelled into pelvic cavity. , SS-lightheadedness, rapid pulse and shock. Leukocytosis from trauma, falling hCG, rigid abdomen, bluish tinge umbilicus. , Sonogram, laparoscopy or culdoscopy. , Movement of cervix causes extreme pain, pain in shoulder, tender mass in Douglas. , Management: , Emergency situation when it ruptures. , Labs, IV,laparoscopy to ligate bleeding vessels and remove or repair damaged fallopian tube, Rh type. , If not ruptured-oral Methotrexate followed by leucovorin. Mifepristone causes sloughing of the tubal implantation site. , Abdominal Pregnancy: , May implant on an organ such as intestines. Abdominal Pregnancy , Fetus will grow in the pelvic cavity. , Fetal outline is easily palpable because it is directly below the abdominal wall, not in the uterus. , Sonogram or MRI , Placenta will infiltrate and erode a major blood vessel in abdomen and lead to hemorrhage. , Bowel perforation, peritonitis, poor nutrient supply, 60% survival. , At term the infant is born by laparotomy. , Placenta difficult to remove, implanted on an abdominal organ. , May be left in place and allow to be absorbed spontaneously in 2 to 3 months. , Follow up sonogram. , Second Trimester Bleeding , Gestational Trophoblastic Disease , Hydatidiform Mole , Proliferation and degeneration of the trophoblastic villi. Gestational Trophoblastic Disease , As cells degenerate, they become filled with fluid and appear as fluid filled grape sized vesicles. , Embryo fails to develop beyond a primitive start. , Associated with coriocarcinoma a rapidly metastasizing malignancy. , 1 in 2000 pregnancies. , Occurs in women under 18 or over 35, low protein intake, Asian heritage. , Types: , Complete mole-all trophoblastic villi swell and become cystic. If embryo forms it dies at 1-2 mm with no fetal blood present. , Sperm-empty ovum + duplication = 46 , Partial mole-some villi form normally. No embryo is present, fetal blood may be present in the villi. Has 69 chromosomes. Rarely leads to Ca. , Assessment: , Uterus expands faster than normal. , No fetal heart, hCG for pregnancy is positive beyond 100 days, hypertension. , Sonogram shows dense growth (snowflake pattern) no fetal growth in uterus. , At 16 weeks, vaginal bleeding, spotting or fresh flow. Discharge of clear fluid filled vesicles (bring clots or tissue to hospital). , Management: , Suction curettage to evacuate the mole. , Pelvic exam, chest X-Ray, serum hCG every 1-2 weeks for 6 months. , Levels that plateau for 3 times or increase suggest malignancy. , Methotrexate 15 to 30mg PO or IM qd x 5 interferes with white cell formation. , After 6 months, hCG still negative risk free. , Loss of false pregnancy, malignancy, postponed pregnancy. , Risk 4 to 5 times for 2nd molar pregnancy. , US early in 2nd pregnancy to screen for occurrence. Premature Cervical Dilatation , Incompetent cervix-cervix dilates prematurely and cannot hold a fetus until term. , SS-show, pink stained vaginal discharge, increased pelvic pressure which may be followed by ROM and loss of amniotic fluid, contractions begin, short labor and fetus is born. , Occurs at 20 weeks and fetus is too immature to survive. , Increased maternal age, defects, trauma to cervix (biopsy, D&C) , Cervical cerclage – at week 12 to 14, purse string sutures are placed in cervix under regional anesthesia. McDonald or a Shirodkar procedure. Prevents it from dilating. , Bedrest for few days, slight or modified Trendelenburg position. , Removed at 37 to 38 weeks to deliver vaginally. , May leave in place and do cesarean birth. Third Trimester Bleeding , Placenta Previa: , Low implantation of the placenta. , Four degrees: , Implantation in lower rather than upper portion of uterus (low-lying placenta). , Marginal implantation (placenta edge approaches that of the cervical os) , Implantation that occludes a portion of the cervical os (partial placenta previa) , Implantation that totally obstructs the cervical os (total placenta previa) , Causes: Increased parity, advanced maternal age, past cesarean births, past uterine curettage, and multiple gestation. , 5 in 1000 pregnancies. , Thought to occur whenever the placenta is forced to spread to find an adequate exchange surface. , Increase in congenital fetal anomalies may occur if low implantation does not allow optimal fetal nutrition or oxygenation. , Assessment: , Sonogram done routinely and diagnosis is made early. , Call if SS of bleeding, lower uterine segment begins to differentiate from the upper segment around week 30 and cervix begins to dilate. , Placenta’s inability to stretch to accommodate the differing shape of the lower uterine segment of the cervix. , Abrupt, painless, bright red, sudden. , Frightening to her. , Management: , Emergency situation, site is uterine decidua so the mother is at risk for hemorrhage. , Placenta is loosened, fetal O2 is at risk. , Immediate care measures: , Bedrest, side lying position, duration of pregnancy, time bleeding started, amount of blood, pain, color of blood, what she has done for the bleeding, prior episodes, prior cervical surgery for cervical dilatation. , Inspect perineum for bleeding, weigh pads, no pelvic or rectal exam, VS, B/P q 5-15 min, IV, I&O, fetal heart monitor, Labs, , Vaginal birth safest for infant, if 30% or less. If over 30% -cesarean birth. , Continuing Car Measures: , Gestation, point of placenta previa, fetal heart rate, watch carefully in hospital, bedrest for 48 hours. If stops she may go home on bedrest. , Betamethasone-steroid-hastens lung maturity if < 34 weeks. , Mother is worried, emotional stress. , Birth: , At 37 weeks amniocentesis analysis for lung maturity shows a positive result, if bleeding occurs, labor begins of distress with the fetus it will be delivered, cesarean. , Incision transverse then vertical in uterus above the implantation site. , More prone to hemorrhage, postpartum. , More likely to develop endometritis because placental site is close to the cervix. , Premature Separation of the Placenta , Abrupto Placenta , Placenta appears to have implanted correctly. Suddenly it begins to separate and bleeding results. , Occurs late in pregnancy even during the 1st or 2nd stage of labor. , Know the amount and kind of vaginal discharge. Kind of pain. , Occurs in 10% of pregnancies and most frequent cause of perinatal death. , Cause: unknown, high parity, short umbilical cord, chronic hypertensive disease, hypertension of pregnancy, direct trauma, vasoconstriction from cocaine use, cigarette smoking. , May follow a rapid decrease in uterine volume. , Assessment: , Woman experiences a sharp, stabbing pain high in uterine fundus as the initial separation occurs. , If in labor each contraction will be accompanied by pain over and above the pain of the contraction. , Tenderness is felt on uterine palpation, heavy bleeding, may not be readily apparent. Pooling of blood, or infiltrate uterine musculature (hard board like uterus). , Shock, uterus becomes tense and rigid to touch, may have DIC. , Time the bleeding began, pain, womans actions. Labs, type and cross match, fibrinogen level and fibrin breakdown products to detect occurrence of DIC. , Quick assess of blood clotting draw 5 mL of blood and set aside for 5 minutes (Clot). , Management: , IV large gauge, O2, monitor fetal heart, VS q 5 to 15 min., lateral position, no vag or pelvic exam, no enema, degree of placental separation is graded, if above 0 to 1 the pregnancy must be terminated. , If premature separation occurs during active labor, ROM or IV oxytocin to hasten birth. , ROM prevents large amounts of blood from being trapped in the myometrium which could prevent contractions. , Cesarean birth may be best choice. , If DIC has developed, surgery is big risk for hemorrhage, IV fibrinogen used to elevate the fibrinogen level. , Fetal prognosis depends on extent of placental separation and hypoxia. , Maternal prognosis depends on prompt Tx. , Monitor for infection. , Disseminated Intravascular Coagulation: , Acquired disorder of blood clotting. , SS-bruising or bleeding from IV site. , Causes:premature separation of the placenta, hypertension of pregnancy, amniotic fluid embolism, placental retention, septic abortion, retention of a dead fetus. , DIC occurs when there is extreme bleeding and so many platelets and fibrin from general circulation rush to the site that there is not enough left for further clotting. , High thrombin level continues to encourage anticoagulation, , Person has increased coagulation but throughout the rest of the system, a bleeding defect exists. ER , To stop DIC the underlying insult must be halted. , Next, marked coagulation must be stopped so that coagulation factors can be freed and restore normal clotting function. , IV heparin, blood or platelet transfusion to replace loss, antithrombin III factor, fibrinogen, or cryoprecipitate can restore clotting, fresh frozen plasma or platelets can restore clotting function. , Evaluation- if labs return to normal, if any anoxia in renal or brain cells from occluded coagulated capillaries. Preterm Labor , Labor before the end of 37 weeks gestation. , Occurs in 9 to 10 % of all pregnancies. , Persistent uterine contractions 4 in 20 min. , Actual labor is if uterine contractions that cause effacement over 80% and dilation over 1 cm. , Preterm births are 2/3 of all infant deaths. , Cause unknown, dehydration, UTI, chorioamnionitis (infection of fetal membranes and fluid), strenuous jobs, extreme fatigue. , SS-persistent, dull, low backache, vaginal spotting, feeling of pelvic pressure or abdominal tightening, menstrual like cramping, increased vaginal discharge, uterine contraction, intestinal cramping. , Management: , Analyze changes in vaginal mucus (fetal fibronectine), short cervix, sonogram. , May try to stop labor if not beyond 4 to 5 cm or 50% effacement , Admit to hospital, bedrest, IV, cultures, UA, oral tocolytic agent-terbutaline, good nutrition and no smoking. , Antibiotic for strep B prophylaxis, corticosteroid (lung surfactant) , Pregnancy <34 weeks betamethasone 2 doses 12 mg IM 24 hours apart, effect lasts 7 days. , Magnesium sulfate 4 to 6 g IV bolus to halt contractions (CNS depressant) p. 399. , Terbutaline (Brethine)-relaxes uterine muscles, blood vessels and bronchi. , Monitor: VS, I&O, labs, lungs for edema, daily wt., FHR. , Fetal assessment: , Count fetal movement-10 in 1 hour (lt. side) , Labor: , ROM, cervix > 50% effaced or 3 to 4 cm dilated it is unlikely it can be halted. , Fetus immature – cesarean birth , Use caution giving analgesics (demerol) due to immaturity of fetus. Epidural is best. , Episotomy is needed to decrease risk of hemorrhage of fetus. May be larger and forceps may be used. , Support, she needs to rebuild her self esteem. , Preterm Rupture of Membranes , Associated with infection of membranes. , Occurs in 2% to 18% of pregnancies. , If early it is a threat to the fetus, infection and pressure on cord or prolapse. Non fluid environment > Potter like syndrome of distorted facial features and pulmonary hypoplasia from pressure. , Assessment: , Labor will not be halted if ROM. , Sudden gush clear fluid, test with nitrazine paper (alkaline reaction-blue), ferning (high estrogen), sonogram, cultures, labs. , Management: , Bedrest, antibiotic, may apply fibrin-based sealant to ruptured membranes, amniotic fluid is always being formed. Pregnancy Induced Hypertension , PIH , Vasospasm occurs during pregnancy. , Occurs in 5% to 10% of pregnancies. , Cause unknown, in primiparas <20 yrs. or > 40 yrs., low socioeconomic background, 5 or more pregnancies, women of color, multiple hydraminios, heart disease, diabetes, essential hypertension, poor calcium or magnesium intake. , Patho: , Normally blood vessels are resistant to the effects of pressor substances such as angiotensin and norepinephrine. , With PIH vasoconstriction occurs and B/P increases dramatically. , Cardiac system becomes overwhelmed, reduction of blood supply to kidney, pancreas, liver, brain and placenta. , Hypoxia in maternal vital organs, poor placental perfusion reduce fetal nutrients and O2. , Ischemia in pancreas; epigastric pain and amylase-creatinine ratio, retinal hemorrhages – blindness, proteinuria, edema. , Extreme edema can lead to cerebral and pulmonary edema and seizures (eclampsia) , Assessment: , Classic signs: hypertension, proteinuria, and edema. , Symptoms rarely occur before 20 weeks. , Classified as: gestational hypertension, mild eclampsia, severe preeclampsia & eclampsia , SS of PIH. , Gestational Hypertension: , Develops an elevated B/P 140/90 but has no proteinuria or edema. , Low dose aspirin, chronic hypertension may develop later in life. , Mild Preeclampsia: , Any status before a woman has a seizure from hypertension of pregnancy. , B/P 140/90 on 2 occasions 6 hours apart. , Diastolic indicates degree of peripheral arterial spasm present. , Systolic > 30 mm hg and diastolic > 15 mm hg above prepregnancy values. , Proteinuria- 1+ or 2+ on reagent test strip. , Edema- protein loss, sodium retention, lowered glomerular filtration rate. , Edema upper part of body, wt. gain > 2lbs/wk in 2nd trimester, or 1lb/wk in 3rd trimester. , Severe Preeclampsia: , B/P > 160/110 mm Hg or above on 2 occasions 6 hours apart at bedrest. , Or diastolic 30 mmHg above prepregnancy level. , Proteinuria- 3+ or 4+ on random urine sample or more than 5g in 24 hour sample , And extensive edema face and hands. , Urine output 400 to 600 mL/24 hours. , SS-severe epigastric pain, nausea, vomiting, SOB, blurred vision, seeing spots, headache marked hyperreflexia and muscle clonus. , Eclampsia: , Most severe hypertension. , Seizures, coma due to cerebral edema. , 20% mortality, prognosis is poor because of hypoxia and consequent fetal acidosis. , If premature separation of placenta from vasospasm occurs-prognosis grave. , Nursing Interventions for Mild Hypertension , Can be managed at home with frequent follow up care. , Promote bedrest, lateral recumbent position. , Promote Good Nutrition , Provide emotional support-SS are vague, no meds., works, other children. Seen weekly. , Nursing Intervention for Severe Hypertension: , B/P > 160/110 after on bedrest, extensive edema, proteinuria 3+-4+ , Support Bedrest, hospital, private room, side rails up if seizure, darken room, restrict visitors, less stress, explain everything. , Monitor Maternal Well-Being , VS, labs, DIC, high risk for premature separation of placenta and hemorrhage, cathether (>600 mL/24h or 30mL/h), daily weight, , Monitor Fetal Well-Being: , FHR, non stress test or biophysical profile daily, O2 to mother. , Support Nutritional Diet: , Moderate to high protein, moderate sodium diet, IV TKO. , Administer Medications to Prevent Eclampsia , drugs , Magnesium sulfate, Apresoline or Normodyne, Valium , Review treatment with Magnesium sulfate p. 409. , Nursing Intervention with Eclampsia: , Cerebral irritation from increased cerebral edema and seizure results. Late in pregnancy or 48 hours after birth. , SS-B/P increases, temp increases to 103-104, burning of vision, headache, reflexes hyperactive, “something is happening,” epigastric pain, nausea and decreased urinary output. Seizure. , Tonic-Clonic Seizures: , Occurs in stages , Maintain patent airway, O2 by face mask, pulse ox, FHR, turn on side, incontinent of urine and bowel, (valium, mag sulfate),third stage-semicomatose 1 to 4 hours. , Unable to report contractions if placenta has separated. Check for vaginal bleeding. , Birth: , Pregnancy > 24 weeks, decide about delivery, fetus may not grow after eclampsia occurs. , Vaginal birth preferred, vascular system is low in volume. , Postpartal Hypertension: , Up to 10 to 14 days after birth. (48 hours) monitor B/P closely. HELLP Syndrome , Is a variation of PIH , Hemolysis, elevated liver enzymes, and low platelets. , 4% to 12% of PIH patients (1 in 150 births). , Cause is unknown, SS-nausea, epigastric pain, general malaise and rt. upper quadrant tenderness. , Labs, monitor for bleeding. , Tx. Transfusion fresh-frozen plasma or platelets. IV dextrose if hypoglycemic. , Deliver as soon as fetus is viable. Multiple Pregnancy , Considered a complication of pregnancy. , Account for 2% due to fertility drugs. , Identical (monozygotic) twins: , Begin with single ovum and spermatozoon , Fusion or 1st cell division, zygote divides into 2 identical individuals. , Usually have 1 placenta, 1 corion, 2 amnions, and 2 umbilical cords. , Always same sex. , Fraternal (dizygotic, non-identical) twins: , Fertilization of 2 separate ova by 2 separate spermatozoa (possible not from the same sexual partner). , 2 placentas, 2 chorions, 2 amnions and 2 umbilical cords. , May be same or different sex. , 2/3 of twins are dizygotic. , Multiples may be any combination. , Occurs more frequently in non whites, high parity and age, multiple gestation, inherited , Assessment: , Uterus increases in size at a rate faster than usual. , Elevated alpha-fetoprotein levels , Sonogram reveals multiples. , Quickening woman reports flurries of action , If fetus has back toward woman’s back only one fetal heart sound may be heard. , Management; , Monitor for complications-PIH, hydramnios placenta previa, preterm labor, anemia. , Prone to postpartal bleeding. , Delivery early, immaturity of fetus. , High risk for congenital anomalies, spinal cord defect and cord inserted into fetal membranes. , Shared circulation, overgrowth of 1 fetus, knotting or twisting of cord. , Encourage rest especially last 2 to 3 months, eat 6 small meals a day, take vitamin supplements, monthly US , Prepare for role changes , Worries of premature labor and survival of the infants. , Hydramnios , Excessive amniotic fluid formation. , Usual-500 to 1000 mL. , 2000mL or index > 24 cm. , Can cause fetal malpresentation due to extra space for fetus to turn. , Premature ROM and preterm labor from increased pressure and prostaglandin release , Assessment: , Suggests difficulty with fetus’ ability to swallow or absorb or excessive urine production. , SS-rapid enlargement of uterus, tense uterus, fetal heart is difficult to hear, SOB, lower extremity varicosities and hemorrhoids, increased weight gain. , Sonogram , Management: , Admit to hospital for bed rest or rest at home. , Educate on ROM, contractions, avoid constipation. , VS, edema, may do amniocentesis to remove extra fluid, Indomethacin to reduce total volume, Magnesium sulfate to halt preterm labor, “needled” to allow slow controlled release of fluid. , Post-Term Pregnancy: , Term is 38 to 42 weeks , Ovulation period may be longer so EDD will be 12 to 17 days later. , Trigger did not turn on for labor. , High dose of salicylates interferes with synthesis prostaglandins, which initiate labor. , 2 weeks beyond term are at risk for meconium aspiration, macrosomia, lack of growth. , Placenta functions for 40 to 42 weeks. , At 41 weeks; nonstress test,maternal fibronectin level, and biophysical profile to document state of placental perfusion and amniotic fluid. May induce. , Cytotec to initiate ripening, ROM,oxytocin. , Pseudocyesis: , False pregnancy can also be seen in men; N&V, amenorrhea enlarged abdomen. , Occurs: wish fulfillment or fear of pregnancy, depression. , Sonogram , Refer for psychological counseling. Isoimmunization , RH incompatibility , Missing Rh (D) factor in their blood or have Rh-negative blood type. , Rh negative and Rh positive fetus. , Rh positive blood has a protein factor (D antigen) that Rh negative people do not. , Body reacts as if it is being invaded by a foreign agent, or antigen. Forms antibodies against invading substance. Crosses the placenta. , Antibodies form 1st 72 hours after birth. , Assessment: , Rh neg woman should have anti-D antibody titer (1:8 or below) , Monitor q 2 weeks, , Management: , RhIG passive antibodies against Rh factor at 28 weeks. Does not cross placenta. , Intrauterine Transfusion: , High Rh antibody titer in the woman suggests rapid destruction of fetalRBC. , Give high dose of gamma globulin (IVIG) , Blood transfusion on fetus in utero. RBC directly into fetal cord or depositing them in fetal abdomen using amniocentesis. (26) , Fetal Death: , Causes: chromosomal abnormalities, congenital malformations, hepatitis B, immunologic cause, complications of maternal disease. , May have miscarriage, monitor for DIC. , Sonogram , Induce labor. Fetal Death , Support, grief process, let her see the baby, prepare if anomaly, autopsy, clergy. , Recommend to wait 6 months.