High risk pregnancy

By: ShenellD

Bleeding Disorders of pregnancy

• First Trimester bleeding- Abortion and ectopic pregnancy

• Second trimester bleeding- Hydatidiform mole and incompetent cervix

• Third trimester bleeding- Placenta previa and abruption placenta

abortion

• Abortion- is the most common bleeding disorder of early pregnancy. Abortion is the termination of pregnancy before viability,that is, before 20 weeks.

• Abortus- a fetus that is aborted before it is 500 gms in weight.

• Blighted ovum- a small macerated fetus, sometimes there is no fetus, surrounded by a fluid inside the sac.

• Maceration- a dead fetus undergoing necrosis.

• Early abortion- termination of pregnancy before 16 weeks.

• Late abortion- abortion that occurs between 16 to 20 weeks.

Causes of abortion:• FETAL CAUSES- • The most common cause of early

spontaneous abortion is abnormal development of the zygote, embryo, and fetus.

• This abnormalities are incompatible with life and would have resulted to severe congenital anomalies if pregnancy has not been aborted.

Causes of abortion:• MATERNAL CAUSES- • These are congenital or acquired

conditions of the mother and environmental factors that had adversely affected the pregnancy outcome and led to abortion.

• Such conditions include DM, incompetent cervix, exposure to radiation and infection.

Types of abortion:

• Threatened abortion• Inevitable abortion• Incomplete Abortion • Complete Abortion• Missed Abortion• Habitual Abortion• Septic abortion

Threatened abortion- possible loss of product of conception

• Light vaginal bleeding• None to mild uterine

cramping• Vaginal examination at this

stage usually reveals a closed cervix. 25% to 50% of threatened abortion eventually result in loss of the pregnancy.

The development of abortion is as follows:

continuing

pregnancy •

complete inevitable

abortion abortion

incomplete

abortion

threatened abortion

• Inevitable abortion- the loss of the products of conception cannot be prevented

• Moderate to profuse bleeding, moderate to severe uterine cramping

• Open cervix• Rupture of membrane

• Complete abortion- spontaneous expulsion of the products of conception after the fetus has died in utero

• Light bleeding• Mild uterine cramping• Passage of tissue• Closed cervix

• Incomplete abortion- expulsion of some parts and retention of other parts of conceptus in uterus

• Heavy vaginal bleeding• Severe uterine cramping• Open cervix• Passage of tissue

• Missed abortion- retention of all products of conception after the death of the fetus in the uterus

• No FHT• Signs of pregnancy disappear

• Habitual abortion- abortion occurring in 3 or more successive pregnancies

• The most common cause is a significant genetic abnormality of the conceptus.

• Septic abortion- abortion complicated by infection

• Foul smelling vaginal discharge

• Uterine cramping• Fever

Nursing responsibiliti

es

• Save all tissue passed (histopathology examination)

• Strict bed rest and monitor bleeding

• Increased fluid PO or IV as ordered

• Prepare client for surgical intervention (D & C or suction evacuation) if needed

ECTOPIC PREGNANCY

• Ectopic pregnancy is any gestation located outside the uterine cavity.

• extra uterine pregnancy is the second leading cause of bleeding in early pregnancy.

Causes of Ectopic pregnancy• Mechanical Factors- factors that

delay the passage of ovum in the oviducts and prevent it from reaching the uterus in time for implantation.

• Salphingitis • Peritubal adhesions- kinking and

narrowing• Previous ectopic pregnancy• Tumors that distort the tube

Causes of Ectopic pregnancy

• Functional and failed contraception factors– External migration of the

ovum– IUD– Oral contraception– Tubal ligation- 15-50 % – Hysterectomy

Causes of Ectopic pregnancy

• Assisted reproduction– Ovulation induction- clomid– Gamete intrafallopian transfer– In vitro fertilization– Ovum transfer

siteS OF ECTOPIC PREGNANCY

Most frequent site is in the fallopian tube, so rupture of the site usually

occurs before 12 weeks

• Ectopic pregnancy usually occurs 99% of cases in the uterine tube. It can be found in

• 1.      The ampulla (64%)• 2.      The Isthmus (25%)• 3.      The infundibulum (9%)• 4.      The intramural junction

(2%)• 5.      Ovarian (0.5%)• 6.      Cervical (0.4%)• 7.      Abdominal (0.1%)• 8.      Intraligamental (0.05%)

•The classic symptom triad: amenorrhea,

vaginal bleeding,

abdominal pain.

Assessment findings:• History of missed periods &

symptoms of early pregnancy.• Abdominal pain, may be localized on

one side• Rigid. Tender abdomen; sometimes

abnormal pelvic mass• Bleeding: if severe may lead to

shock• Low Hgb & Hct, rising white cell count

• Pelvic pain- sudden knife like pain is the most common symptom when the tube ruptures

• Signs of hemorrhage:– Cullen’s sign- bluish discoloration of

the umbilicus due to the presence of blood in the peritoneal cavity

– Hard rigid board like abdomen due to presence of blood in the peritoneal cavity.

– Signs of shock- cyanosis, pallor, cold clammy skin, rapid pulse, dec BP

Blood loss

dec. intravascular volume

dec. venous return, cardiac output & BP

Vasoconstriction of peripheral blood vessels & inc. respiratory rate.

Cold, clammy skin, dec. uterine perfusion

Reduced renal, uterine & brain perfusion

Lethargy, coma, dec. renal output

Renal failure

Matenal and fetal death

The process of shock due to blood

loss

Management:

ectopic pregnancy.flv

• If not yet ruptured, therapeutic abortion is performed.

• If ruptured, removal or repair of ruptured tube. Many physician choose to remove the ruptured tube because the presence of scar if the tube repaired and left can lead to another tubal pregnancy.

• Prevent and treat hemorrhage which is the main danger of ectopic pregnancy.

• Prevent infection as the woman who lost so much blood is susceptible to infection

• Prepare client for surgery• Institute measures to control?

Treat shock if hemorrhage is severe; continue to monitor postoperatively.

• Allow client to express feelings about loss of pregnancy & concern about future pregnancies.

HYDATIDIFORM MOLEh-mole

• A benign disorder characterized by degeneration of the chorion and death of the embryo. The chorionic villi rapidly proliferate and become grape like vesicles that produce large amount of HCG.

• Gestational trophoblastic disease

• Cause essentially unknown

Risk factors:• A molar pregnancy creates a

20-40 times higher risk of having it again.

• Increased incidence with advanced maternal age.

• Unusual chromosomal patterns seen. ( either no genetic material in ovum or 69 chromosomes)

Diagnostics:

• Ultrasonography reveals no fetal skeleton

• Elevated HCG level

Signs and symptoms• excessive vomiting due to elevated

HCG levels• passage of grape like vesicles around

the 4th month (dark red to brownish vaginal bleeding)

• rapid increase of uterine size which is out of proportion to the actual age of gestation.

• absence of FHT and fetal skeleton• ultrasound reveal a mass of fluid filled

vesicles instead of a developing fetus.

Management:– D and C to remove the mole. If the

woman is more than 40 years old, hysterectomy since she has a higher chance of developing choriocarcinoma

– Anticancer drug prescribed to the woman for one year to prevent development of malignant or cancer cells in the uterus.

Nursing responsibilities:• Provide pre-postoperative care for

evacuation of uterus (usually suction curettage).

• Teach contraceptive use so that pregnancy is delayed for at least a year.

• Teach client’s need for follow-up lab work to detect rising HCG levels indicative of choriocarcinoma.

Hyper emesis gravidarum

Hyper emesis gravidarum

• -is intractable vomiting during pregnancy that results in dehydration and electrolyte imbalance.

• It occurs in one of every 1000 pregnancies; the cause is uncertain

• Risk factors: unknown• Diagnostics: by symptoms• Sign and symptoms:1. Severe, persistent vomiting

that leads to dehydration or nutritional deficiency

2. Progresses to fluid electrolyte imbalance and alkalosis from loss of hydrochloric acid.

Management:• Medical: replacement of fluids,

electrolytes, and vitamins, along with tranquilizer or antiemetic

• NPO for 48 hours, after condition improves, six small feedings are alternated with liquid nourishment in small amount every 1-2 hours.

• If vomiting recurs, NPO status is resumed and administration of IV is restarted.

PLACENTA PREVIA

• Placenta previa is the abnormal implantation of placental near or over the internal os.

• It is the most common bleeding disorder of the third trimester.

Causes of Placenta previa:• Multiparity• Multiple pregnancy• Advance maternal age- over

35 years old• Smoking• Previous cesarean section

and abortion

• Sign and symptoms:• Painless bright red vaginal

bleeding is the most significant sign near the end of early of the 3rd trimester.

• Ultrasound revealed placenta implanted over or near the cervix.

Nursing intervention:• Ensure complete bed rest.• Maintain sterile conditions for

any invasive procedure.• Make provisions for emergency

cesarean birth• Continue to monitor

maternal/fetal vital signs

Management:• Cesarian is the delivery of

choice for all kinds of placenta previa.

• Manage bleeding episodes• Watchful waiting- delay

delivery until fetus is mature enough

• No IE is performed in diagnosed placenta previa

ABRUPTIO PLACENTA

• Abruptio placenta is the premature separation of placenta from part or all normal implantation site, usually accompanied by pain.

• Usually occurs after 20 weeks of gestation and before delivery of the fetus

Causes of abruptio placenta:• Maternal hypertension• Advance maternal age• Multiparity• Trauma to the uterus• Short umbilical cord• Cigarette smoking and

cocaine abuse

Signs and symptoms: • Painful Vaginal bleeding• Board-like abdomen caused

by accumulation of blood behind the placenta with fetal parts hard to palpate

• Sharp pain over the fundus as the placenta separates

• Signs of shock and fetal distress if bleeding is severe.

Nursing interventions:• Ensure bed rest • Check maternal/fetal vital signs

frequently• Vaginal delivery if there is no

sign of fetal distress, CS if bleeding is severe and fetus cannot be delivered with vaginal method.

 

Incompetent cervix• Premature dilation of the

cervix• Is a defect related

trauma of the cervix or a congenitally short cervix, which leads to habitual abortion and premature labor.

Risk factors: cervical trauma related to D&C, cervical lacerations from previous deliveries

Sign & symptoms:• Dilated cervix without painful

uterine contractions.• Rupture membranes, labor

begins and premature fetus is delivered.

Surgical treatment:• Reinforcement of the weakened

cervix by a purse string suture, which encircles the internal os.

• Shidorkar-barter cerclage; permanent suture that allows the cervix to remain closed for all pregnancies; cesarian delivery is required.

• McDonald cerclage; left in place until term, then remove before labor.

hydramnios

Polyhydramnios: (More than 2L of fluid). Excess

of amniotic fluid.

Causes:

• Fetal abnormalities- excessive urination of fetus

• Esophageal atresia- fetus cannot swallow amniotic fluid.

• Multiple pregnancy• Diabetes mellitus

Complications:

• Premature labor & delivery• Abruptio placenta• Postpartum hemorrhage due to

over distension of uterus• Cord prolapsed• malpresentation

oligohydramniosOligohydramnios: (Less

than 500 ml of fluid) ↓ of the amniotic fluid.

Causes:

• Fetal renal anomalies that results in anuria

• Premature rupture of membranes

Complications:

• Club foot• Amputation- due to

adhesion of fetal parts to the amnion

• Abortion• Stillbirth• Fetal growth retardation• Abruptio placenta

Complication during labor and delivery

• Cord compression• Fetal hypoxia as a result

of cord compression• Prolonged labor

Pregnancy induced hypertension- PIH

• Gestational hypertension replaces the term PIH and is used for hypertensive disorders that are specifically associated with pregnancy, preeclampsia, and eclampsia.

Incidence:• Occur in 5-7% of all pregnancies• Seen more often to primigravidas,

teenagers of low socioeconomic class.

• May be related to decreased production of some vasodilating prostaglandins, vasospasm occurs.

• Onset after 20th week of pregnancy, may appear in labor or up to 48 hours postpartum.

• Cause essentially unknown

vasospasm

Vascular effect Kidney effect Interstitial effects

vasoconstriction

Poor organ perfusion

Inc. BP

Dec. glomeruli filtration rate &

inc. permeability of glomeruli

membranes

Inc. serum blood urea nitrogen, uric acid, &

creatinine

Dec. urine output & protenuria

Diffusion of fluid from blood stream into interstitial tissue

edema

–Danger Signs of Pregnancy- Induced Hypertension• Swelling of the face or fingers

• Flashes of light or dots• Blurring of vision• Severe continuous headache

Mild preeclampsia• Bp of 140/90 or +30/+15

mmhg on two consecutive occasions at least 6 hours apart.

• Sudden weight gain• Proteinuria of 300 mg/l in 24

hour urine collection

Nursing intervention:

• Promote bed rest as long as signs of edema or proteinuria are minimal, preferably side lying.

• Provide well-balanced diet with adequate protein.

• Explain need for close follow-up, weekly or twice-weekly visits to physician.

Severe preeclampsia• Headaches, epigastric pain,

nausea and vomiting, visual disturbances, irritability

• Bp of 150-160/100-110 mmhg• Increased edema and weight

gain• Proteinuria (5g/24hrs) 4+

Management:• Magnesium sulfate- acts upon the

myoneural junction, diminishing neuromuscular transmission

• It promotes maternal vasodilatation, better tissue perfusion and has anticonvulsant effect.

• Antidote: calcium gluconate

• Nursing responsibilities: mgs04

• Monitor client’s respirations, blood pressure and reflexes, as well as urinary output

• Adm.med. Either IV or IM

Nursing interventions:• Bed rest, side lying• Carefully monitor maternal/fetal

vital signs• Monitor I&O, results of

laboratory test• Take daily weights• Institute seizure precautions• Continue to monitor 24-48

hours post delivery

eclampsia• Increased HPN precede

convulsion followed by hypotension and collapse

• Coma may ensue• Labor may begin, putting fetus

in great jeopardy• Convulsion may occurMedical mgt. same with severe

preeclampsia

Nursing intervention:• Minimize all stimuli• Have airway, oxygen and

suction equipment available• Administer medication as

ordered• Prepare for C-section with

seizures stabilized• Continue observations 24-48

hours postpartum.

Complication of PIH:• Maternal complications:• Inc. intraocular pressure leading

to retinal detachment.• HELLP (Hemolysis, Elevated

Liver function test, Low platelet count) syndrome has been associated with severe preeclampsia.

Fetal complications:• Usually small for gestational age• May be born prematurely• Newborn maybe born over sedated

because of medications given to mother

• May have hypermagnesemia because of maternal treatment with mgs04.

Danger signs of pregnancySIGN POSSIBLE CAUSE

Swelling of face, fingers & legs HPN of pregnancy

Headache, continuous & severe HPN of pregnancy

Abdominal/ chest pain Ectopic pregnancy, uterine rupture, pulmonary embolism

Vaginal bleeding Placental problems , abortion

Vomiting, persistent Infection, hyperemesis gravidarum

Visual changes HPN of pregnancy

Escape of vaginal fluids PROM

Gestational diabetes

• disorder of late gestation• disorder induced by

pregnancy: from exaggerated physiological changes in glucose metabolism

• Reversal after termination of pregnancy with 20-50% chances of developing type 2 diabetes later in life.

RISK FACTORS• Age over 30• Family Hx of DM• Prior macrosomic,

malformed or stillborn infant

• Obesity• Hypertension

TWO TYPES OF DIABETES

Assessment for gestational diabetes• 3 P’s (polyphagia, polyuria, polydipsia)

• Dizziness, if hypoglycemic• Confusion, if hyperglycemic• Congenital anomalies• Inc.risk of PIH• Macrosomia• Poor tissue perfusion of fetus• Glycosoria• Hyperglycemia• Hydramios• Possibility of inc. monilial infection

Diagnostic Tests for DM

Glycosylated hemoglobin Provides information about

blood glucose level during the previous 3 months

because glucose in the bloodstream attaches to some of the hemoglobin and stay attached during the 120-day lifespan of the RBC

Diagnostic Tests for DM

Oral glucose challenge test values for pregnancy:

Test type pregnancy glucose levelFasting 951 hour 1802 hours 1553 hours 140Following a 100g glucose load. Rate is

abnormal if two values are exceeded.

GDM - ADVERSE EFFECTSMACROSOMIA• Excessive fat deposition on

shoulders/trunk• Predisposes to shoulder dystocia• Maternal hyperglycemia transfer

of excess glucose to fetus stimulate fetal insulin secretion which is a potent growth factor

HYPOGLYCEMIA at birth

99

MACROSOMIAPathogenesis

D-I-A-B-E-T-E-S• D- DIET: 50-60% CHO, 20-30% FATS,

10-20% CHON• I- INSULIN– TYPE 1• A- ANTIDIABETIC AGENTS– TYPE 2• B- BLOOD SUGAR MONITORING• E- EXERCISE• T- TRANSPLANT OF PANCREAS• E- ENSURE ADEQUATE FOOD INTAKE• S- SCRUPULOUS FOOT CARE

Heart disease

HEART DISEASE Normal hemodynamic of pregnancy

that adversely affect the client with heart disease

1.      Oxygen consumption increased 10% to 20% ; related to needs of growing fetus

2.     Plasma level and blood volume increase; RBCs remain the same (physiologic anemia)

Functional or therapeutic classification of heart disease during pregnancy

1.      Class I: no limitation of physical activity; no symptoms of cardiac insufficiency or angina

2.     Class II: slight limitation of physical activity; may experience excessive fatigue, palpitation, angina, or dyspnea; slight limitation as indicated

3.     Class III: moderate to marked limitation of physical activity; dyspnea, angina, and fatigue occur with slight activity, and bed rest is indicated during most pregnancy

4.     Class IV; marked limitation of physical activity; angina, dyspnea, and discomfort occur at rest; pregnancy should be avoided; indication for termination of pregnancy

Prenatal period assessment:

• Evidenced of cardiac decompensation especially when blood volume peaks ( weeks 28-32)

• Cough & dyspnea• Edema• Heart murmur• Palpitations• rales

Nursing interventionprenatal period:

• Teach client to recognize & report signs of infection, importance of prophylactic antibiotics

• Compare vital signs to baseline• Instruct in diet to limit weight gain

to 15 lbs, low na+