NRG 204: 3RD WEEK
GESTATIONAL CONDITIONS
PREGNANCY-INDUCED HYPERTENSION
What is Blood Pressure?
 Blood Pressure is the force that a person's
blood exerts against the walls of their blood
vessels.
 This pressure depends on the resistance of the
blood vessels and how hard the heart has to
work.
 Blood pressure is determined both by the
amount of blood your heart pumpsand the
amount of resistance to blood flow in your
arteries. The more blood your heart pumps and
the narrower your arteries, the higher your
blood pressure.
What is HYPERTENSION (HTN)
 High blood pressure, also called hypertension,
is dangerous because it makes the heart work
harder to pump blood out to the body.
 Uncontrolled high blood pressure increases
your risk of serious health problems, including
heart attack and stroke.
Risk Factors:
 Family history –genetic
 Being overweight or obese. The more you
weigh the more blood you need to supply
oxygen and nutrients to your tissues. As the
volume of blood circulated through your blood
vessels increases, so does the pressure on your
artery walls.
 Using tobacco. A chemicals in tobacco can
damage the lining of your artery walls. This can
cause your arteries to narrow and increase your
risk of heart disease. Secondhand smoke also
can increase your heart disease risk.
 Not being physically active. People who are
inactive tend to have higher heart rates. The
higher your heart rate, the harder your heart
must work with each contraction and the
stronger the force on your arteries. Lack of
physical activity also increases the risk of being
overweight.
 Too much salt (sodium) in your diet. Too much
sodium in your diet can cause your body to
retain fluid, which increases blood pressure.
 Certain chronic conditions. Certain chronic
conditions also may increase your risk of high
blood pressure, such as kidney disease, diabetes
 Diet (high fat/cholesterol intake; elevated
serum cholesterol) - plaques hardened &
narrowed arteries makes the heart work harder
to pump blood to the body
 Age –As you get older, fats, cholesterol, and
calcium can collect in your arteries and form
plaque.
 Pathophysiology

Hypertension gradually increases the pressure of blood
flowing through your arteries. As a result, you might
have:
 Damaged and narrowed arteries. High blood
pressure can damage the cells of your arteries'
inner lining. When fats from your diet enter
your bloodstream, they can collect in the
damaged arteries. Eventually, your artery walls
become less elastic, limiting blood flow
throughout your body.
 Aneurysm. Over time, the constant pressure of
blood moving through a weakened artery can
cause a section of its wall to enlarge and form a
bulge (aneurysm). An aneurysm can potentially
rupture and cause life-threatening internal
bleeding. Aneurysms can form in any artery, but
they're most common in your body's largest
artery (aorta).
Normal Blood Pressure: Systolic = 90-120 mmHg
Diastolic = 60-80 mmHg
Types of Hypertension
1. Primary (essential) hypertension
 There’s no identifiable cause of high
blood pressure& not related to medical
condition.
2. Secondary Hypertension
 Has a known cause
 Another medical condition that causes
high blood pressure, usually occurring
in the kidneys, arteries, heart, or
endocrine system.
Pregnancy-Induced Hypertension (PIH)
 Is a vascular disease of unknown cause which
occurs anytime after the 20th week of
gestation up to 2 weeks postpartum.
 Pregnancy-induced hypertension — which may
also be called pre-eclampsia, eclampsia, or
toxemia of pregnancy — is a pregnancy
complication characterized by high blood
pressure, swelling due to fluid retention, and
protein in the urine.
 Also called hypertension of pregnancy or
gestational hypertensive disorder
 A potentially life-threatening disorder that
usually develops after the 20th week of
pregnancy
Two categories of PIH:
Classified as:
A. Preeclampsia
B. Eclampsia
Preeclampsia
 Nonconvulsive form of the disorder
 Develops in about 7% of pregnancies and may
be mild or severe
 Marked by the onset of hypertension after 20
weeks gestation
 The incidence is significantly higher in low
socioeconomic groups
  Blood pressure 140/90mmHg or an increase of
30mmHg systolic or 15mmHg diastolic with
proteinuria.
Eclampsia
 Convulsive form of the disorder
 Occurs between 24 weeks’ gestation and the
end of the first postpartum week
 Incidence increases among women who are
pregnant for the first time, have multiple
fetuses, and have a history of vascular disease.
 Severe classification of PIH. When cerebral
(Extensive) edema occurs onset of seizure or
coma will be observe in patient.
 180/110 mmHg or more
Pathophysiology
 Exact cause is unknown
 Systemic peripheral vasospasm occurs, affecting
every organ system
 nutritional, immunologic, and familial factors
may contribute to its occurrence
 Age is also a factor, adolescents younger
 than age 19 and primiparas older than age
 35 are at highest risk
What happen in PIH?
There is arteriolar vasoconstriction, systemic
vasospasms, and vascular changes that occur.
 Vasospasms result in fluid volume excess
resulting in fluid retention.
 Vasoconstriction will causes poor organ
perfusion, so the heart increases its demand to
fill into the blood vessels & other organs
(increases blood pressure).
Who is at risk of developing PIH?
A woman is more likely to develop PIH if she:
 Has a history of chronic hypertension
 Has a previous history of PIH
 Has diabetes before becoming pregnant
 Has kidney disease –can’t remove waste, build
up fluid, raise BP
 Has a history of alcohol, drug, or tobacco use
 Is expecting twins or triplets
Assessment Findings
 BP over 140/90 mmHg or 160/110 or an
increase of 30 mmHg systolic and 15 mmHg
diastolic over baseline obtained on two
occasions at least 4 -6 hours apart
 Increase in generalized edema associated with a
sudden weight gain of more than 5 lbs. (2.3 kg)
per week
 Rapid or sudden weight gain, high blood
pressure, protein in the urine, and swelling (in
the hands, feet, and face).
 Abdominal pain, severe headaches, a change in
reflexes, spots before your eyes, reduced
output of urine or no urine, blood in the urine,
dizziness, or excessive vomiting and nausea.
Triad Symptoms:
1. hypertension
2. Edema/swelling (face, hands, lower extremity)
3. Proteinuria (protein in urine)]
Severe preeclampsia include:
 increase blood urea nitrogen
 creatinine and uric acid levels
 frontal headaches
 blurred vision
 hyperreflexia
 nausea and vomiting
  Irritability
 cerebral disturbances
 epigastric pain
 Epigastric/abdominal pain (aura to the
development of convulsion/seizures)
 Visual disturbances –warning sign for
preeclampsia
Diagnostic test:
 routine prenatal tests, your weight gain, blood
pressure and protein in urine are monitored
Diagnostic Test Findings
 Proteinuria
o Mild preeclampsia: 1-2+
o Severe preeclampsia
o 3+ -4+
o In eclampsia: 5+ or more
Management of Hypertension:
 Monitor Blood Pressure
 Urine testing to check for protein. This is a sign
that your kidneys aren’t working well.
 Checking for swelling
 Checking your weight more often
 Liver and kidney function tests
 Blood clotting tests
 High protein, low-salt diet
 Adequate fluid intake
 Bed rest in lateral position
 Close observance of BP, FHR, edema,
 proteinuria, and signs of pending eclampsia
 Administration of antihypertensive, such as
 methyldopa and hydralazine
 Administration of Magnesium sulfate
 Nonstress tests every one to two times per
 week; biophysical profile every 3 weeks
Medications
 Diuretics – helps in elimination of build up fluid
 Hydralazine - vasodilator. It works by relaxing
blood vessels so blood can flow through the
body more easily.
 Methyldopa (Aldomet) –oral
 Magnesium Sulfate (MgSO4) –CNS depressant,
given to control seizures (anticonvulsant). Mg
SO4 acts as vasodilator which decreases BP.
Antedote for MgSO4 toxicity is Calcium Gluconate.
Magnesium Sulfate Toxicity
 CNS depressant may cause MgSO4 toxicity
Symptoms of Magnesium toxicity:
 Loss of knee jerk reflexes (DTR)
 Respiratory depression (below 12cpm)
 Oliguria (small amtof urine; not below 30ml/hr)
 later: respiratory arrest & cardiac arrest
Mgt: VS every 15 mins.
 check DTR
 Foley Catheter –monitor hourly urine output
Nursing Interventions
 Monitor the patient regularly for changes in
 BP, PR, RR, FHR, vision, level of consciousness,
and deep tendon reflexes and for headache.
 Close monitor the results of stress and non-
stress tests.
 Keep emergency resuscitative equipment and
an anticonvulsant readily available
 Maintain patent airway and have oxygen readily
available.
 Fetal monitoring (NST) –FHT, fetal movement,
uterine contractions, Doppler study, biophysical
profile (check fetal well-being)
 Restrict activity ( complete bed rest w/out BRP)
 Implement seizure precautions such as
minimize stimuli, raised bedside rails, turning to
side to drain secretions, maintenance of patent
airway (O2), suction machine
 Continue to monitor 24-48 hrs post delivery of
baby.
 Prepare for emergency cesarean delivery, if
indicated
 If the woman is receving MgSO4 IV, administer
the loading dose over 15-30 minutes and then
maintain the infusion at a rate of 1 to 2g/hour.
 Monitor for MgSO4 toxicity: Monitor UO, DTR ,
RR and LOC
 Prepare antidote for MgSO4: Calcium gluconate
 Monitor the extent and location of edema.
 Assess fluid balance.
  Hyperemesis gravidarum (HG) is an extreme
form of morning sickness that causes severe
Severe Complications of Eclampsia nausea and vomiting during pregnancy.
 Cerebral Edema
 Stroke
 Abruptio placenta  Severe and unremitting nausea and vomiting
 Fetal death that persists after the first trimester.
 Usually occurs with the first pregnancy and
HELLP Syndrome commonly affects pregnant women with
conditions that produce high levels of Human
A variation of the gestational hypertensive process
Chorionic Gonadotropin (hCG), such as
named for the common symptoms that occur:
gestational trophoblastic disease or multiple
 Hemolysis leads to anemia gestations.
 Elevated liver enzymes lead to epigastric pain
Possible causes or contributing factors include the
 Low Platelets lead to abnormal
following:
bleeding/clotting
 Rising levels of hormones, such as human
Assessment Findings:
chorionic gonadotropin (HCG), estrogen, and
 Headache. progesterone early in pregnancy.
 Vision problems.  Abnormal tissue growth in the uterus, called a
 Pain in the upper right abdomen (liver). hydatidiform mole
 Shoulder, neck, and other upper body pain (this Pathophysiology
pain also originates in the liver).
 Fatigue.  Exact cause is unknown, but it is linked to
 Nausea and vomiting. trophoblastic activity, gonadotropin
 Seizure. production, and psychological factors
 Various possible causes
Treatment o decreased secretion of free
 Requires emergency medical treatment. hydrochloric acid in the stomach
 Vaginal delivery is often possible, but a o decreased gastric motility
caesarean is used if the mother or fetus is not o Drug toxicity
medically stable. o Inflammatory obstructive bowel disease
 Prevent seizures, known as eclampsia o Vitamin deficiency (especially of B6)
(magnesium sulfate prevents seizures). o Psychological factors
 Control severe high blood pressure.
Trophoblastic disease - abnormal growth of cells inside
 Develop the fetus's lungs if the pregnancy is less the uterus (trophoblastcells produce hCG).
than 34 weeks along (corticosteroid injections
are given to the mother). HCG is released by the placenta.
HYPEREMESIS GRAVIDARUM  hormonal changes in pregnancy → increased
hcG levels →→ excessive hCG stimulates
secretions of electrolytes causes distention and
activity GIT
Assessment findings

 Unremitting nausea and vomiting (cardinal sign)

 Substantial weight loss
 Thirst
 Oliguria
 Electrolyte imbalance
 Dehydration
 Metabolic acidosis
  It is an unsuccessful pregnancy that occurs after
a man's sperm has fertilized a woman's egg and
when tissue that would normally develop into
the placenta to nourish the developing fetus
forms an abnormal growth, or mass, containing
Diagnostic test findings hundreds of grape-sized cysts (fluid-filled sacs).
 Decreased serum protein, sodium, and  A tumor develops inside the uterus from tissue
potassium levels that forms after conception.
 Increased blood urea nitrogen levels  Normal level of hcg:
 Elevated white blood cell count o In most normal pregnancies with hCG
 Ketonuria levels below 1,200 mIU/ml, the hCG
usually doubles every 48-72 hours and
Management increases by at least 60% every two
days.
 Restore fluid and electrolyte balance with IV
fluid therapy
 Administer antiemetic to control vomiting
 Maintain adequate nutrition and rest
 Progress to oral feedings as tolerated
Nursing Interventions
 Administer IV fluids as ordered.
 Monitor intake and output, vital signs, skin
turgor, daily weight, serum electrolyte levels,
and urine ketone levels.
 Suggest decreased liquid intake at meal time
 Instruct the patient to remain upright for 45
mins. after eating.
 Suggest that the patient eat two or three dry
crackers on awakening.
 Encourage the patient to discuss her feelings.  Gestational trophoblastic disease is a major
 Help the patient develop effective coping cause of second trimester bleeding.
strategies.  Early detection is necessary because it is
 Teach the patient measures to conserve energy. associated with choriocarcinoma, a fast
growing, and highly invasive malignancy.
Possible complications:  Hydatidiform moles (H Mole), are the most
common GTD.
 Substantial weight loss
 In HMs a basic test will
 Starvation, with ketosis
show that you’re
 Dehydration, with subsequent fluid and
pregnant and you may
electrolyte imbalances (hypokalemia)
even feel that way, but
 Acid-base imbalances (acidosis and alkalosis)
there’s no baby
 Renal damage
growing.
GESTATIONAL TROPHOBLASTIC DISEASE
Pathophysiology
 Anomaly of the placenta that converts the  Exact cause is unknown
chorionic villi into a mass of clear vesicles.
 Poor maternal nutrition, specifically an
 Gestational trophoblastic disease is a group of insufficient intake of CHON and folic acid,
rare diseases in which abnormal defective ovum, chromosomal abnormalities, or
trophoblastcells grow inside the uterus after hormonal imbalances.
conception.
 With this disorder, the trophoblastic villi cells
 Also called molar pregnancy (H mole) rapidly increase in size and fill with fluid
Types of H. Moles
1. Complete Hydatidiform mole -have no embryo or
normal placental tissue and amniotic sac.
 Occurs because a woman's egg lacks maternal
chromosomes (the mother's chromosomes are
either lost or inactivated), and the egg is
fertilized by one or two sperm cells. This results
in a fertilized egg that only contains
chromosomes from the father, or 46
chromosomes. (An ultrasound will show that
there is no fetus only placental tissue.)
2. Partial Hydatidiform Mole- may have some normal
placental tissue, but the embryo rarely survives to term
(embryo usually with multiple abnormalities).
 Occurs when a woman releases a normal egg,
but two sperm fertilize the egg instead of one.
This leads to an abnormal embryo that contains
too many chromosomes: one set of
chromosomes from the mother and two sets of
chromosomes from the father, or 69
chromosomes instead of the normal 46 (23
from the mother and 23 from the father).
Assessment Findings
 Disproportionate enlargement of the uterus;
possible grapelike clusters noted in vagina on
pelvic examination.
 Excessive nausea and vomiting
 Intermittent or continuous bright red or
brownish vaginal bleeding by the 12th week of
gestation
 Passage of tissue resembling grapelike clusters
 Symptoms of PIH before the 20th week of
gestation
 Absence of fetal heart tones
 Abnormal growth of the uterus. For a complete
mole, the size of the uterus is larger than
normal during early pregnancy. For a partial
mole, the size of the uterus is smaller than
usual.
 High blood pressure during the first trimester
or early second trimester of pregnancy.
 Enlarged ovaries. High levels of hCG (human
chorionic gonadotropin), a hormone produced
during the early phase of pregnancy, may cause
the ovaries to be larger than normal during
pregnancy.
 Severe nausea and vomiting.
 Absence of Fetal heart tones
Diagnostic test findings:
A. Abdominal ultrasound
 Which can show the presence of cysts in the
uterus.
 A complete mole pregnancy may be easier to
detect by ultrasound than a partial mole
pregnancy.
 Ultrasonography performed after the 3rd
month revealing grapelike clusters rather than a
fetus, no skeleton detected and evidence of a
snowflake-like pattern.
B. Radioimmunoassay of hCG levels extremely
elevated for early pregnancy.
 In women with a complete mole pregnancy,
levels of hCGmay be higher than expected.
Rapidly growing placenta tissue triggers the
release of hCG.
C. Histologic examination of possible vesicles helps
confirm diagnosis.
D. Imaging, such as X-ray, CT scan, MRI, or PET scan to
check if GTD has spread.
E. Hemoglobin level, hematocrit, red blood cell count, to prevent pregnancy for at least one year after
prothrombin time, partial thromboplastin and renal hCG levels return to normal.
function finding are all abnormal
ECTOPIC PREGNANCY
 White blood cell count and erythrocyte
 Implantation of the fertilized ovum outside the
sedimentation rate increased
uterine cavity
Management  Most occurs in fallopian tube, other sites
include the cervix, ovary, or abdominal cavity
 Induced abortion if a spontaneous one doesn't
 Second most common cause of vaginal bleeding
occur
during pregnancy
 Follow-up care vital because of increased risk of
 Significant cause of maternal death due to
choriocarcinoma
hemorrhage
 Weekly monitoring of hcg levels until they
remain normal for three consecutive weeks
 Periodic follow-up for 1-2 years
 Pelvic examinations and chest x-rays at regular
intervals
 Removal of the embryo and placenta from a
woman's uterus by a procedure known as
dilation and curettage (D&C).
 A woman who is older and not planning to
become pregnant again may elect to have a
hysterectomy, a surgery to remove the uterus,
instead of undergoing a D&C.
 Follow-up care vital because of increased risk of
choriocarcinoma
 Weekly monitoring of hcg levels until they
remain normal for three consecutive weeks
 Periodic follow-up for 1-2 years with –normal
chorionic gonadotropin level
 Pelvic examinations and chest x-rays at regular
intervals
 Emotional support for the couple who are
grieving for the lost pregnancy and an unsure
obstetric and medical future
 Avoidance of pregnancy until hCG levels are
normal (may take up to one year)
Nursing Interventions
 Assess patient's vital signs to obtain a baseline.
 Observe the patient for signs of complications
(hemorrhage, uterine infection, vaginal passage
of vesicles).  Implantation of the fertilized ovum outside the
 Encourage patient and her family to express uterine cavity
their feelings, and offer support.  Most occurs in fallopian tube, other sites
 Help the patient and her family develop include the cervix, ovary, or abdominal cavity
effective coping strategies.  Second most common cause of vaginal bleeding
 Help obtain baseline information (pelvic during pregnancy
examination, CXR, serum hCG levels).  Significant cause of maternal death due to
 Stress the need for regular monitoring of hCG hemorrhage
levels.
 Instruct the patient to promptly report any new In a normal pregnancy, your ovary releases an egg into
signs and symptoms and to use contraceptives your fallopian tube. If the egg meets with a sperm, the
fertilized egg moves into your uterus to attach to its
lining and continues to grow for the next 9 months.
But in up to 1 of every 50 pregnancies, the fertilized egg
stays in your fallopian tube. In that case, it's called an
ectopic pregnancy or a tubal pregnancy.
Pathophysiology
 Results from any condition that prevents or
retards the passage of the fertilized ovum
through the fallopian tube, as a hormonal
factors, previous pelvic or tubal surgery,
damage from PID, tubal atony, and malformed
fallopian tubes
 previous surgery (tubal ligation or resection, or
adhesions from previous abdominal or pelvic
surgery
 Transmigration of the ovum
What causes an ectopic pregnancy?
 inflammation and scarring of the fallopian tubes
from a previous medical condition, infection, or
surgery
 genetic abnormalities
 birth defects
 medical conditions that affect the shape and
condition of the fallopian tubes and
reproductive organs
Who are at risk?
 maternal age of 35 years or older
 history of pelvic surgery, abdominal surgery, or
multiple abortions
 conception occurred despite tubal ligation or
intrauterine device (IUD)
 conception aided by fertility drugs or
procedures
 history of ectopic pregnancy
 having structural abnormalities in the fallopian
tubes that make it hard for the egg to travel
What are the symptoms of an ectopic pregnancy?
 Nausea and breast soreness are common
symptoms in both ectopic and uterine
pregnancies.
The following symptoms are more common in an
ectopic pregnancy and can indicate a medical
emergency:
 sharp waves of pain in the abdomen, pelvis
 severe pain that occurs on one side of the
abdomen
 light to heavy vaginal spotting or bleeding
 dizziness or fainting
 rectal pressure
Diagnostic findings
1. Ultrasound – transvaginal, allows your doctor
to see the exact location of your pregnancy.
2. Pregnancy test
 Human chorionic gonadotropin (hCG) blood test
to confirm that you're pregnant.
3. Abdominal ultrasound, in which an ultrasound
wand is moved over your belly, also may be
used to confirm your pregnancy or evaluate for
internal bleeding.
4. Complete Blood Count - will be done to check
for anemia or other signs of blood loss
Serum pregnancy (hCG) test result shows an abnormally
low level of hCG, when repeated in 48hrs, the level
remains lower than the levels found in a normal
intrauterine pregnancy
Real-time ultrasonography determination of
intrauterine pregnancy or ovarian cyst (performed if
serum pregnancy test results are posititve)
Culdocentesis (aspiration of fluid from the vaginal cul-
de-sac) detects free blood in the peritoneum
Laparoscopy may reveal pregnancy outside the uterus
(performed if culdocentesisis positive)
Assessment Findings
 normal pregnancy
symptoms other than
mild abdominal pain
 amenorrhea or abnormal menses
 slight vaginal bleeding and unilateral pelvic pain
over the mass
 abnormally low hCG
Management
1. Emergency surgery
 If the ectopic pregnancy is causing heavy
bleeding, you might need emergency
surgery through an abdominal incision
(laparotomy).
 Laparoscopic surgery or abdominal surgery
 The ectopic pregnancy is removed and the
tube is either repaired (salpingostomy) or
removed
(salpingec tomy).
2. Medication
 An early ectopic pregnancy without
unstable bleeding is most often treated
with a medication called methotrexate,
which stops cell growth and dissolves
existing cells. The medication is given by
injection.
METHOTREXATE
 Medication will cause symptoms that are
similar to that of a miscarriage. These
include:
 cramping
 bleeding
 the passing of tissue
Nursing Interventions
 Ask the patient the date of her last menses and
obtain serum hCG levels as ordered
 Assess vs and monitor vaginal bleeding for
extent of fluid loss
 Check the amount, color and odor of vaginal
bleeding, monitor pad count
 NPO in anticipation of possible surgery; prepare
the patient for surgery, as indicated
 Assess the patient for signs and symptoms of
hypovolemic shock secondary to blood loss
from tubal rupture, and monitor urine output
closely for a decrease suggesting fluid volume
deficit
 Administer blood transfusions for replacement
as ordered and provide emotional support
 Record the location and character of the pain,
and administer an analgesic as ordered
  Determine if the patient is Rh-negative; if she is,
administer Rho (D) immune globulin (RhoGAM)
as ordered after treatment or surgery
 Maintain IV infusion for admin. of plasma, Assessment Findings
blood, antibiotics, or other required
medications  Cervical dilation in the absence of contractions
 Prepare client for surgery or pain
 Support grieving  Pink-stained vaginal discharge
 POST OP: VS, I&O, promote relaxation  Increased pelvic pressure with possible
 Provide a quiet, relaxing environment, offer the ruptured membranes and release of amniotic
patient emotional support fluid
 encourage her and her partner to express their Diagnostic test findings
feelings of fear, loss, and grief
 refer her to a mental health professional for  Ultrasound revealing defect
additional counseling, if necessary  Nitrazine test result indicates rupture of
 To prevent recurrent ectopic pregnancy, urge membranes (if occured)
the patient to have pelvic infections treated
Management
promptly to prevent diseases of the fallopian
tube  Placement of cerclage in the cervix on 12th-
14thwk-helps keep the cervix closed until term
Possible Complications
or the patient goes into labor:
 Rupture of the tube causes life-threatening  McDonald procedure
complications, including hemorrhage, shock,
and peritonitis
 Infertility results in the uterus or either fallopian
tubes or both ovaries are removed.
INCOMPETENT CERVIX

McDonald procedure using nylon sutures horizontally

and vertically to close off cervix to only a few mm.

 Also called Premature Cervical dilatation

 Refers to a painless premature dilatation of the
cervix
 It generally occurs in the 4th to 5th month of
gestation, most commonly around the 20th
week of gestation
Pathophysiology
 This condition is associated with congenital
structural defects or previous cervical trauma
resulting from surgery or delivery.
 Abnormally formed uterus or cervix.
Management
 Bed rest after surgery
 Removal of sutures at 37 to 39 weeks' gestation
 Emotional support
Nursing Interventions
 Assess complaints of vaginal drainage and
investigate history for previous cervical
surgeries.
 Prepare woman for cervical cerclage under
regional anesthesia as indicated; monitor
maternal vital signs and fetal heart rate patterns
closely.
 Instruct woman in signs and symptoms of labor
with the need to notify health care provider if
any occur.
 Maintain bed rest after surgery as ordered; if
necessary, place woman in a slight or
 Modified Trendelenburg position to alleviate
pressure of the uterus on the sutured area.
 Encourage follow-up to evaluate progress of
pregnancy.
 Advise the woman that the sutures will be
removed around the 37th to 39th week of
pregnancy.
Possible complication
 Rupture (sudden bursting) of the uterus.
 Laceration (cut or tear) on the cervix.
 Infection.
 Preterm birth
 Spontaneous abortion
ABORTION
 Termination of pregnancybefore viability.
 Occurs when pregnancy is lost before viability
 is the ending of pregnancy by the removal or
forcing out from the womb of a fetus or embryo
before it is able to survive on its own.
 Non-viable fetus
 below 20-22 weeks AOG
Fetal Viability-ability to survive outside the uterus.
SPONTANEOUS ABORTION
 •Spontaneous expulsion of the products of
conception from the uterus before fetal viability
(fetal wt less than 17 ½ oz or 496 g and
gestational age of less than 20 wks)
 A.k.a. Miscarriage
Types of Spontaneous Abortion
1. Complete – Uterus passes all products of conception.
Minimal bleeding usually accompanies complete
abortion because the uterus contracts and compresses
the maternal blood vessels that fed the placenta.
2. Habitual - spontaneous loss of three or more
consecutive pregnancies constitutes habitual abortion
3. Incomplete – uterus retains part or all of the
placenta. Before 10 weeks gestation, the fetus and
placenta are usually expelled together; after 10th week,
they’re expelled separately.
 Because part of the placenta may adhere to the
uterine wall, bleeding continues. Hemorrhage is
possible because the uterus does not contract
and seal the large vessels that fed the placenta.
4. Inevitable – membranes rupture and the cervix
dilates. As labor continues, the uterus expels the
products of conception
5. Missed abortion – uterus retains the product of
conception for 2 months or more after the fetus has
died. Uterine growth ceases; uterine size may even
seem to decrease. Prolonged retention of the dead
products of conception may cause coagulation defects
such as DIC
Pathophysiology
 More than 50% are caused by abnormalities in
fetoplacental development
 Fetal factors usually cause such abortions at 6
to 10 weeks’ gestation
 defective embryologic development from
abnormal chromosome division (the 2nd most
common cause of death)
 faulty implantation of fertilized ovum
 Placental factors usually cause spontaneous
abortion around the 14thweek, when the
placenta takes over the hormone production
necessary to maintain the pregnancy
 premature separation of the normally
implanted placenta
 abnormal placental implantation
 abnormal platelet function
 Maternal factors usually cause spontaneous
abortion between 11 and 19 wks.
 maternal infection
 severe malnutrition
 abnormalities of the reproductive organs
(especially incompetent cervix, in which the
 cervix dilates painlessly and without blood in
the 2nd trimester)
 Other maternal factors that can cause
spontaneous abortion
 trauma, including any type of surgery that
necessitates manipulation of the pelvic organs
 blood group incompatibility and Rh isoimmunization
 drug ingestion
Diagnostic exam: preg test to assess HcG level
Risk Factors:
 defects in ovum or sperm,
 defective implantation, abnormalities of the
uterus
 placental developmental defects
 Incompetent cervix
 maternal diseases that predispose to abortion
such as infection, diabetes, vascular disease,
hormonal deficiencies,
Assessment Findings
 Symptom severity depends on the gestational
age at the time of spontaneous abortion
 S/S include uterine cramping and vaginal
bleeding
Sign and Symptoms:
 Abdominal/uterine cramping
 Vaginal spotting or bleeding
 Low backache
 Eventual rupture of membranes and dilatation
of the cervix
Management:
 Record onset, duration, amount & character of
bleeding
 Monitor VS
 Threatened abortion -limitation of the pt’s
activities for 24 to 48 hrs
 Bed rest, pad count, restriction of coitus for
about 2 wks
 Complete abortion-rest, monitoring for
temperature elevation and bleeding, if the
uterus emptied on its own and the pt has no
signs of infection, no further intervention is
needed
 Provide emotional support
 Prepare for a Dilation & curettage (D&C)
 Provide complete bedrest
 Instruct to avoid intercourse until the bleeding
stops.
 recognize SHOCK: paleness, profuse sweating,
hypotension, tachycardia
Complications:
Hemorrhage, infection
Nursing Interventions
 CBR without BRP, after bedpan use, inspect
contents for intrauterine material
 Note the amount, color and odor of vaginal
bleeding
 Assess VS for 24 hrs or more frequently,
depending on the extent of bleeding
 Monitor urine output closely
 Provide good perineal care
 Check the pt’s bld type and administer RhoGAM
as ordered
 Provide emotional support and counseling
during the grieving process
 Encourage the ptto express her feelings
 Monitor for bleeding –pads use, saturation
 Listen for concern, loss and grieving of patient
 Administer pain reliever, antibiotics as ordered
 Health teaching –complete bed rest
 Help the pt and her partner to develop effective
coping strategies
 Explain all procedures and treatments to the pt
and provide teaching about aftercare and ff up
 Watch for signs of infections, such as fever,
(higher than 37.8 C) and foul-smelling vaginal
discharge
DISORDERS OF AMNIOTIC FLUID
 Amniotic fluid - is a clear, slightly yellowish
(pale-straw) liquid that surrounds the unborn
baby (fetus) during pregnancy. It is contained in
the amniotic sac.
The amniotic fluid helps:
 The developing baby to move in the womb,
which allows for proper bone growth
 The lungs to develop properly
 Prevents pressure on the umbilical cord
 Keep a constant temperature around the baby,
protecting from heat loss
 Protect the baby from outside injury by
cushioning sudden blows or movements
 Aids dilatation of the cervix during labor.
  Amniotic fluid also contains nutrients,
hormones (chemicals made by the body) and
antibodies (cells in the body that fight off
infection).

Using the AFI the following definitions apply:

Oligohydramnios: 0 to <5cm.
Normal: 5 to 25cm
Polyhydramnios: greater than 25cm.

POLYHYDRAMNIOS
 Polyhydramniosis where there is too much
amniotic fluid around the baby.
 Amniotic fluid is 900 ml or more
AMNIOTIC FLUID INDEX
 Amniotic Fluid Index
 The amniotic fluid index (AFI) measurement is
calculated by first dividing the uterus into four
quadrants using the linea nigra for the right and
left divisions and the umbilicus for the upper
and lower quadrants.
 The maximum vertical amniotic fluid pocket
diameter in each quadrant is measured in
centimetres; the sum of these measurements is
the AFI.

What causes Polyhydramnios?

May develop for this reasons:
 GDM mother
 multiple pregnancies
 the fetus having difficulty swallowing the
amniotic fluid
 the fetus producing an increased amount of
urine
 congenital malformations, such as a blockage of
the fetus’s gastrointestinal or urinary tract, or
 an abnormal development of the brain and
spinal cord
 problems affecting the fetus’s genetic makeup,
lungs, or nervous system
Assessment Findings:
 Breathing problem
 Swollen feet and ankle
 heartburn
 Uterine distention
Diagnostic Test:
 Ultrasound
 Size of fundic height
 Blood test for maternal diabetes
 Biophysical profile. This test uses an ultrasound
to provide more information about your baby's
breathing, tone and movement.
Treatment:
 Reduction amniocentesis, also called
amnioreduction. (fluid is removed & tested)
Medication:
 Indomethacin (Indocin) to help reduce fetal
urine production and amniotic fluid volume.
 Diabetic mother medication –insulin
 CS method is necessary if risk noted for both
mother & fetus.
Complication of Polyhydramnios
 your waters breaking early -Preterm
labor/Preterm birth
 dangerous positioning of the umbilical cord,
which can cause the cord to become trapped
against the fetus, limiting the oxygen supply
 heavy bleeding after your baby is born because
your womb has stretched (bleeding after labor)
OLIGOHYDRAMNIOS
 Oligohydramniosis when there is reduced
amniotic fluid around a fetusin the uterus
(womb). It can affect the baby’s ability to turn
to the correct position for birth or cause
umbilical cord compression.
 Amniotic fluid is below 500ml or lesser
Factors that are associated with
oligohydramniosinclude the following:
 Premature rupture of membranes (before
labor)
 Intrauterine growth restriction (poor fetal
growth)
 Post-term pregnancy
 Birth defects, especially kidney and urinary tract
malformations of fetus
Diagnostic findings
 Ultrasound. Pockets of amniotic fluid can be
measured and the total amount estimated.
 Ultrasound can also show fetal growth, the
structure of the kidneys and urinary tract, and
detect urine in the fetal bladder.
 Measure the symphysis fundal height.
Treatment for oligohydramniosmay include:
 Closely monitoring the amount of amniotic fluid
and frequent follow-up visits with the doctor
 Amnioinfusion--instilling a special fluid into the
amniotic sac to replace lost or low levels of
amniotic fluid. Amnioinfusion may be given in a
woman in labor whose membranes have
ruptured. Amnioinfusion will not be given if the
woman is not in labor.
 Hydration –oral and IV
 Delivery (if oligohydramnios endangers the
well-being of the fetus, then an early delivery
may be necessary)
What is the danger of oligohydramniosin Pregnancy?
 Amniotic fluid is important in the development
of fetal organs, especially the lungs. Too little
fluid for long periods may cause abnormal or
incomplete development of the lungs called
pulmonary hypoplasia.
 Oligohydramnios increases the risk of
miscarriage or stillbirth. It can also cause the
baby to be born with severe abnormalities,
including under developed lungs.
Premature Rupture of Membrane
 PROM - is a rupture (breaking open) of the
membranes (amniotic sac) before labor begins.
 PPROM – Preterm Premature Rupture of
Membrane –refers to if PROM occurs before 37
weeks of pregnancy.
What causes premature rupture of membranes?
  Rupture of the membranes near the end of Healthcare provider will monitor:
pregnancy (term) may be caused by a natural
 Signs of labor or contractions
weakening of the membranes or from the force
of contractions.  Your baby’s movement, heart rate, and other
 Before term, Unknown causes tests
 Other factors that may be linked to PROM  Symptoms of infection. These can include a
fever and pain.
include the following: Previous preterm birth,
less likely to receive proper prenatal care,
Sexually transmitted infections, such as
chlamydia and gonorrhea, Cigarette smoking
during pregnancy
Assessment Findings:
 Leaking or a gush of watery fluid from the
vagina
 A sudden gush of fluid from your vagina
 Constant wetness in underwear
Diagnostic test:
 An examination of the cervix (may show fluid
leaking from the cervical opening)
 Looking at the dried fluid under a microscope
(may show a characteristic fern-like pattern)
 Ultrasound
 pH (acid-base) balance testing. The pH balance
of amniotic fluid is different from vaginal fluid
and urine.
Treatment:
MEDICATIONS
 Corticosteroids (dexamethasone) - help your
baby’s lungs grow and mature. If your baby is
born early, his or her lungs may not be able to
work on their own.
 Antibiotics-to prevent or treat an infection.
 Tocolytic medicines-used to stop preterm labor.
 CCB (nifedipine) work by preventing calcium
from moving into the muscle cells of the uterus,
making it less able to contract.
 Hospitalization and Complete bed rest
What are possible complications of PPROM?
 Infection, such as infections of the amniotic
fluid and membranes
 Separation of the placenta from the uterus –
placental abruption
 Problems with the umbilical cord -compression
 serious infection of the placental tissues called
chorioamnionitis
Nursing Interventions