High Risk Pregnancy

Autosomal Dominant Disorder:

1. Tuberous Sclerosis
2. Achondroplasia
3. Brittle Bone Disease
4. Huntington’s Disease
5. Marfan Syndrome
6. Neurofibromatosis 1 (NF 1)

Autosomal Recessive Disorder:

1. Sickle Cell Anemia
2. Cystic Fibrosis

X-linked Recessive Conditions

1. Red - Green Color Blindness
2. Hemophilia A
3. Fragile X syndrome
4. Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency

Y-linked Inheritance
1. Hypertrichosis
2. Syndactly
3. Ichythyosis Hystrix

Multifactorial (Polygenic) Inheritance

 Congenital Malformations
 Cleft lip/palate
 Congenital dislocation of the hip
 Congenital heart defects
 Neural tube defects
 Pyloric Stenosis
 Talipes (Clubfoot)
 Acquired Diseases (Childhood and Adult life)
 Asthma
 Autism
 Diabetes Mellitus
 Epilepsy
 Glaucoma
 Hypertension
 Ischemic heart disease
 Manic depression
 Parkinson’s disease
 Psoriasis
 Rheumatoid arthritis
 Schizophrenia

Mitochondrial Inheritance
1. Kearns-Sayre Syndrome

Chromosomal Disorders
1. Trisomy 13 syndrome
 47 XY 13 + / 47 XX 13 +
2. Trisomy 18 syndrome
 47 XY 18 + / 47 XX 18 +
3. CRI-DU-CHAT Syndrome
 46 XX 5p - / 46 XY 5p -
 4. Turner Syndrome
 45 X0 (affects female; gonadal dysgenesis)
5. Klinefelter Syndrome
 47 XXY (affects male)
6. Fragile X Syndrome
 46 XY 23q -
7. Trisomy 21/ Down Syndrome
 47 XY 21 + / 47 XX 21 +

Cardiovascular disease and pregnancy

 Valves damages
 Rheumatic fever
 Kawasaki disease
 Congenital anomalies
 Coronary Artery Disease
 Varicosities
 Peripartum heart disease - occurs during pregnancy
 Cardiac output > 30%
 Edema (3rd trimester)
 Transient murmurs - disappear after pregnancy
 Heart palpitations
 Pulses: Bounding, Weak, Absent
 Disappear after pregnancy

 Pulmonary Edema
 Orthopnea - cannot sleep when head and chest not elevated
 Paroxysmal nocturnal dyspnea
 Mitral stenosis
 Coarctation of the aorta
 Orthophic Position
 Pharmacotherapy
 Antihypertensive - control blood pressure
 Diuretics - reduce blood volume
 Beta-blockers - improve ventricular filling

Complications in pregnancy
 Impaired blood flow to the uterus
 Poor placental perfusion
 Intrauterine growth restriction
 Fetal mortality
 SGA (small for gestational age) - if baby survives

Thrombosis
 Anticoagulant
 Heparin - drug of choice; does not have tetratogenic effect
 Sodium Warfarin

 Edema
 Accumulation of fluids in extrimities; swelling
 Evident to pt w/ cardiac problems
 Peripartum heart disease
 Not normal in 1st and 2nd trimester (means not physiologic)

 Peripartal cardiomyopathy
 Peripartum cardiomyopathy (PPCM)
  AKA postpartum cardiomyopathy, is an uncommon form of heart failure that happens
during the last month of pregnancy up to 5 months after giving birth
 Cardiomyotpathy - means heart muscle disease
 Myocardial failure - shortness of breath, chest pain and edema
 Cardiomegaly - heart increase in size
 Cough - pulmonary edema
 Fatigue
 Tachycardia
 Poor fetal heart tone (PFHT)
 Increased respiratory rate from poor tissue perfusion
 Edema from poor venous return
 Decreased amniotic fluid from intrauterine growth restriction

 Chronic hypertensive vascular disease

 Chronic hypertensive disease - pregnancy with elevated blood pressure (140/90 mmHg)
 Normal: 90/60-120/80
 Chronic hypertension - woman and fetus at risk because fetal well-being can be
compromised by poor placental perfusion during pregnancy
 Management:
 Beta-blocker and ACE inhibitors - to reduce blood pressure by peripheral dilation to
safe level but not reduce below threshold that allows good placental circulation
 Methyldopa

 Venous thromboembolic disease

 Deep Vein Thrombosis (DVT) - lead to pulmonary emboli increases for women 30 years or
older because increased age is yet another risk factor for thrombosis formation
 Pain and redness usually in the calf of a leg
 Management:
 Avoid use of constrictive knee-high stockings
 Not sitting with legs crossed at knee
 Avoid standing in one position for long period
 Thromboplebitis
 Chief danger is pulmonary artery and blocking circulation to the lungs and heart
 Symptoms of pulmonary embolism:
 Chest pain
 Sudden onset of dyspnea
 Cough with hemoptysis - coughing with blood
 Tachycardia - missed beat
 Severe dizziness or fainting from low blood pressure

Hematologic problems
 Pseudo-anemia - drop in hematocrit
 True anemia - hemoglobin level is < 11 g/dL (hematocrit 33%) in 1 st and 3rd trimester or
hemoglobin concentration is < 10.5 g/dL (hematocrit 32%) in 2 nd trimester
 Normal hemoglobin:
 Men: 13.5 - 17.5 g/dL
 Women: 12.0 - 15.5 g/dL
 Iron deficiency Anemia
 Folic Acid Deficiency Anemia
 Sickle Cell Anemia
 Malaria
 Coagulation Disorders and Pregnancy
 Hematocrit - concentration to RBC (gives color)
 Hemoglobin - carries oxygen

Renal and Urinary problems

 UTI
  Frequent and pain on urination
 Pain in lumbar region (pylonephritis) right side that radiates downwards
 Area is tender upon palpitation
 Nausea and vomiting
 Malaise - discomfort or weakness
 Elevated temperature
 Premature rupture of membrane - preterm labor
 Low gestational age
 Abortion
 Amoxicillin, ampicillin, cephalosporin (safe; does not cross placenta)
 Sulfonamides, tetracycline (not safe)
 Chronic Kidney disease
 Kidneys are damaged and can’t filter blood the way they should
 Damage cause wastes to buildup in the body
 Need to be monitored because pt w/ CDK does not produce Erythopoeitin
 Erythropoeitin - hormone produced by kidney that plays role in production of RBC
 Given IM (erythropoeitin supplement)
 Increase creatinine level indicates problem with kidney
 Normal: 0.8 - 1.2 mg/dL
 Serum creatinine slightly below normal in normal pregnancy
 In CDK creatinine is high

Gastrointestinal disorders
 Hyperemesis Gravidarum
 Vomitting
 Exceeds after 6 months
 Normal in 1st trimester
 Appendicitis
 RLQ
 Continuous, intense
 Pain; sharp; Right lower abdomen
 Peristaltic pain - feels like running
 No pain upon palpation; bounding pain when palpation is relased
 McBurney’s point - RLQ; halfway between umbilicus and iliac crest
 Ectopic pregnancy
 Scattered pain
 Diffuse pain or sharp
 LQ, fades instantly
 Vaginal bleeding
 GER - Gastroesophageal Reflux Disease; Hiatal Hernia GERD
 Cholecystitis - gallbladder inflamamtion
 Cholelithiasis - galstone formation
 Hepatitis
 A - fecal and oral
 B & C - discharge, blood, body fluids
 D & E - similar to B and C but rare

Seizure Disorder - anti-seizure medications

Myasthemia Gravis
 New born will develop limp and manifest symptoms of myasthemia gravis because of
transfer of antibodies

Multiple Sclerosis
 Degenerative disease
 Corticosteroids (from pregnancy) - inflammatory
Scoliosis
 Lateral curvature of spins
 Thoracic
 Lumbar
 Thoracic-lumbar
 Combined (lordosis + scoliosis)

Endocrine
 Hypothyroidism - underproduction of thyroid hormones
 Hyperthyroidism - overproduction of thyroid hormones
 Diabetes Mellitus
 Gestational Diabetes Mellitus
 Pancreas cannot produce adequate insulin to regulate body glucose levels
 Woman w/ this disorder is in controlling balance between insulin and blood
 Fetal heart anomalies
 Hydramnios - Polyhydramnios
 Caudal regression
 Most common in pregnancy

Bleeding during pregnancy

 Vaginal bleeding is always a deviation from normal in pregnancy
 May occur at any point during pregnancy
 Impair outcome of pregnancy and woman’s life and health

First trimester
 Threatened miscarriage : <16 weeks (early); 16-24 weeks (late)
 Imminent miscarriage
 Missed miscarriage
 Complete miscarriage
 Incomplete miscarriage
 Ectopic (tubal) pregnancy

Second trimester
 Hydatidiform mole (gestational trophoblastic disease)
 Premature cervical dilation

Third trimester
 Placenta previa (PP)
 Premature separation of placenta (abruptio placenta) (AP)
 Pre-term labor

Blood loss
 Cold extremities
 Decrease uterine production
 Hypotension - no good blood perfusion
 Decrease renal, uterine and brain perfusion
 Lethargy, coma, decreased renal output
 Renal failure
 Maternal and fetal death

Hypovolemic shock
 Confusion
 Pallor
 Tachypnea
 Increased pulse/ tachycardia
  Hypotension
 Decrease urine output
 Fetal bradycardia/ fetal distress
 Decreased cardiac output

Signs and Symptoms of Hypovolemic shock

 Increased pulse rate
 Decreased blood pressure
 Increased respiratory rate
 Cold, clammy skin
 Decreased urine output
 Dizziness or decreased level of consciousness
 Decreased central venous pressure

Management:
 IV fluid - D5LR
 O2 - 2 L/min (independent intervention (0.5 - 1 L/min - pedia)
 02 - 6 - 10 L/min (dependent) for bleeding
 Vital signs
 FHT: 120 - 160 bpm
 Do not do (omit) vaginal IE (internal Examination)
 NPO - for anticipation of OR
 Order 2 units of blood (w/ typing and cross matching) for blood transfusion
 Monitor I and O - 30 ml/ h

Abortion - interruption of a pregnancy before a fetus is viable

Elective abortion - voluntary abortion; planned; request for non-medical reasons

Miscarriage - a spontaneous abortion and pregnancy loss, is the natural death of an embryo or fetus
before it is able to survive independently

Cause of abortion/miscarriage
 Tetratogenic factor
 Chromosomal aberration
 Implantation abnormalities
 Decrease progesterone level
 Systematic infection
 Urinary tract infection
 Ingestion of tetratogenic drug

Assessment: symptoms of spontaneous miscarriage is vaginal spotting

Types of Abortion/ miscarriage

1. Spontaneous miscarriage
 unexpected
2. Threatened miscarriage
 Spotting with abdominal cramping
 Lumbar/back pain
 Ok if cervix is close; if cervix is open it can cause abortion
 Signs and symptoms:
 Vaginal bleeding
 Mild cramps; back ache
 Close cervix
 Treatment:
 Bed rest
 Avoid stress
  Avoid intercourse
 Progesterone therapy
3. Imminent miscarriage
 Abortion that has progressed to a stage where termination of the pregnancy
cannot be avoided
 Abortion cannot be avoided
 Signs and symptoms:
 Severe abdominal pain from strong uterine contractions
 Vaginal bleeding, often massive
 Cervical dilation (open)
4. Complete miscarriage
 When all fetal tissues are expelled
5. Incomplete miscarriage
 When parts of the products of conception are retained in the uterus
 Products: placenta, umbilicus
 Not expelled products
 Signs and symptoms:
 Heavy vaginal bleeding
 Abdominal cramps
 Cervical dilation - because products are still not expelled
6. Missed miscarriage
 Retention of dead products of conception in utero for more than 8 weeks
 Still born; fetus is dead inside
 Septic abortion - abortion associated with serious infection of the products of
conception and endometrial lining of the uterus, leading to generalized infection
 Usually caused by pathogenic organisms of the bowel or vagina
 No increased fundal; no fetas movements; no fetal sounds
7. Recurrent miscarriage
 “habitual abortion”
 Used to describe this miscarriage patterns
 Miscarriage of 3 or more consecutive pregnancies
 The abortion of 3 or more miscarriages (spontaneous abortions) with no
intervening pregnancies is also termed recurrent abortion
 Habitual or recurrent abortion is a form of infertility

Complications of Miscarriage
 Hemorrhage
 Monitor to detect hypovolemic shock
 Position flat
 Massage uterine fundus to aid contraction
 D&C
 Transfusion for blood loss
 Direct replacement of fibrinogen or another clotting factor
 Methergine
 Group of drugs called ergot alkaloids
 It affects the smooth muscle of a woman’s uterus improving the
muscle tone as well as the strength and timing of uterine contractions
 This medication is used after childbirth to help stop bleeding from
uterus
 Uterine atony - uterus fails to contract after delivery
Health teachings
 Amount
 > 1 sanitary pad/ hour is excessive
 Color
  Gradually changing to dark color to color of serous fluid as it does w/ the
postpartum women
 Odor
 Unusual odor or passing of large clots is also abnormal
 Medication
 Oral methylergonovine maleate (Methergine) to aid uterine contraction, be
certain she understands why it is being prescribed and the importance of taking
it

Ectopic pregnancy
 Implantation occurs outside the uterine cavity
 Sites:
 Interstitial
 Tubal (isthmus)
 Tubal (ampullar)
 Infundibular (ostial)
 Ovarian
 Peritoneal
 Cervical
 Abdominal
 Signs and symptoms:
 If internal bleeding progress to acute hemorrhage, a woman may experience
lightheadedness and rapid pulse, signs of impending shock
 Often asymptomatic
 Radiating pain (ruptured)/ shoulder tip pain
 Nausea
 Faint
 Severe abdominal pain
 Ammenorrhagia
 Vaginal bleeding

Gestational Trophoblastic Disease - (Hydatidiform Mole) / H-mole

 Abnormal proliferation and then degeneration of trophoblastic villi
 + HCG (Human Chorionic Gonadotropin) - detected by pregnancy test
 Proliferation of trophoblastic villi, looks pregnant but not
 2 types of molar pregnancy:
 Complete Hydatidiform mole
 Caused by a single (90% of time) sperm or two (10% of the time) combing with an
egg which has lost its DNA
 Partial hydatidiform mole
 Impede growth of fetus
 Abnormal pregnancy which an embryo (the fertilized egg) either develops
incompletely or doesn’t develop at all
 Instead, a cluster of grape-like cysts (known as a hydatidiform mole) grows in
uterus

Premature Cervical Dilatation

 “Incompetent cervix”
 “Incompetent cervical os” (os - opening)
 Cervix that dilates prematurely and therefore cannot hold a fetus until term
 Dilatation is usually painless
 Term - 37 to 42 weeks (viable)

Goodell’s sign - softening/ ripening of cervix

Chadwick’s sign - change color

Placenta Previa
  Placenta is implanted abnormally in the uterus
 Most common cause of painless bleeding in the third trimester of pregnancy
 Low
 Partial
 Total - placenta in cervix
 Signs and symptoms:
 Bright red bleeding from vagina during second half of your pregnancy - it can range
from light to heavy, and it’s often painless
 Contractions along w/ bleeding - patient might feel cramping or tightening that comes
with contractions or feel pressure in the back
 Immediate Care Measures
 Place the woman immediately on bed rest in a side-lying position
 Be sure to assess:
 Duration of the pregnancy AOG (Age of Gestation)
 Time the bleeding began
 Woman’s estimation of the amount of blood - ask her to estimate in terms of
cups or tablespoons - cup: 240mL ; tablespoon: 15mL
 Whether there was accompanying pain
 Color of the blood - red blood indicated bleeding is fresh or is continuing

Premature Separation of the Placenta / Abruptio Placenta / Abruption Placenta

 Abruption placenta
 The placenta appears to have been implanted correctly
 Suddenly, however, it begins to separate and bleeding results
 Premature separation of placenta
 Bleeding with pain
 Cause:
 Chorioamnionitis - an infection of the fetal membranes and fluid
 Assessment:
 A sharp, stabbing pain high in the uterine fundus
 If labor begins with the separation, each contraction will be accompanied by pain over
and above the pain of the contraction
 Heavy bleeding
 Uterus becomes tense and feels rigid to the touch (internal bleeding)
 Predisposing factors:
 High parity
 Advanced maternal age
 A short umbilical cord
 Chronic hypertensive disease
 Pregnancy-induced hypertension
 Direct trauma (as from an automobile accident or intimate partner abuse)
 Vasoconstriction from cocaine or cigarette use
 And thrombophilitic conditions that lead to thrombosis such as autoimmune
antibodies, protein C and factor V Leiden

Couvelaire Uterus/ Uteroplacental Apoplexy

 If blood infiltrates the uterine musculature, couvelaire uterus or uteroplacental apoplexy
 Forming a hard (uterus)
 Boardlike uterus w/ no apparent, or minimally apparent, bleeding present occurs

Assess: (In ER)

 Time bleeding began
 Whether pain accompanied it
 Amount and kind of bleeding, and
 Her actions to detect if trauma could have led the placental separation
 Labworks: hemoglobin level, typing and cross-matching, and a fibrinogen level and fibrin
breakdown products to detect DIC
Therapeutic Management:
 Fluid Replacement (IVF) - D5LR
 Oxygen by mask to limit fetal anoxia
 Monitor fetal heart sounds externally
 Record maternal vital signs every 5 to 15 minutes to establish baseline and observe
progress
 Keep woman in a lateral, not supine, position to prevent pressure on the vena cava and
additional interference with fetal circulation
 Do not perform any abdominal, vaginal or pelvic examination on a woman w/ a diagnosed
or suspected placental separation

Disseminated Intravascular Coagulation (DIC)

 DIC is an acquired disorder of blood clotting in which the fibrinogen level falls to below
effective limits
 Easy bruising or bleeding from an intravenous site
 Occurs when there is such extreme bleeding and so many platelets and fibrin from the
general circulation rush to the site that not enough are left in the rest of the body
 Results in a paradox at one point in the circulatory system, the person has increased
coagulation, but throughout the rest of the system, a bleeding defect exists
 DIC is an emergency because it can result in extreme blood loss. Goals should reflect the
presence of the emergency

Normal occurrence of blood clotting mechanism

 Normally, platelets quickly form a seal over a point of bleeding to prevent further loss of
blood
 Intrinsic and extrinsic clotting pathways then activate and strengthen this plug by fibrin
threads to produce a firm, fixed structure
 To prevent too much clotting from occurring, at the same time the clot is being formed,
thrombin activates fibrinolysin, a proteolytic enzyme, to begin to digest excess fibrin
threads (anticoagulation)
 This lysis results in the release of the fibrin degradation products

Preterm Labor
 Labor occurs before the end week of 37 of gestation
 False labor: intermittent pain
 True labor: persistent pain
 Systems:
 Persistent, dull, low backache
 Vaginal spotting
 A feeling of pelvic pressure or abdominal tightening
 Menstrual-like cramping
 Increased vaginal discharge
 Uterine contractions
 Intestinal cramping
 Medical management, can halt when…
 Fetal membranes are intact
 Fetal distress is absent
 No evidence of bleeding
 Cervix is not dilated more than 4-5 cm (10 cm for labor)
 Effacement is not more than 50%
 Intervention:
 Bed rest side-lying position
 Relieves pressure of fetus on the cervix
 Enhance uterine perfusion
 Uterine and fetal monitoring provides evidences of fetal well-being
  Monitor vital signs closely
 Every 15 minutes during adjustment of flow rate then
 Every 30 minutes until contractions cease
 37. 5 C - TSB
 38 C -Medication
 Normal:
 T: 36.5 C - 37.3 C
 P: 60 - 100 bpm
 R: 16 - 20 cpm
 BP: 90/60 - 120/80 mmHg
 Monitor fetal heart rates and patterns every 15 to 30 minutes
 Through dopler by quadrants depending on position of fetus
 Breech - head (up) leg (down) - LUQ
 Cepalic - head (down) leg (up) - RLQ
 120 - 160 bpm
 Assist with using relaxation techniques
 Muscle relaxation
 Breathing
 Music
 Provide frequent updates about progress
 Allow client to verbalize feeling and concerns
 Administer betamethasone to aid fetal lung maturity and an antibiotic for urinary tract
infection as prescribed
 Administer terbutaline as ordered, as an IV
 Continue infusion for 12-24 hrs after cessation of contraction
 Act as uterine relaxant helping to halt contraction (preterm contraction)
 “Ter” - terminates
 B2 agonist - bronchodilator and terminates
 “Uterine” contraction
 Tocolytic agent
 Uterine relaxants (Tocolytics)
 Indomethecin (NSAID)
 Nifedipine (Ca channel blocker)
 Magnesium Sulfate
 Terbutaline (adrenergic agonist)

Therapeutic management
 Best rest to relieve the pressure of the fetus on the cervix
 Intravenous fluid therapy to keep her well hydrated is began because hydration may help
stop contractions
 Vaginal and cervical cultures and a clean-catch urine sample are obtained to rule out
infection
 Tocolytic agent - to halt labor, such as terbutaline may be prescribed
 Strict best rest prevents preterm labor
 Limit strenous activities

Preterm Rupture of Membranes (PROM)

 Membrane ruptures before the onset of labor (before 37 week’s gestation)
 With loss amniotic fluid
 Danger:
 Seal to the fetus is lost and uterine and fetal infection may occur
 Mucus plug - protect from infection
 Increased pressure on the umbilical cord from the loss of the amniotic fluid, inhibiting
the fetal nutrient supply
 Cord prolapse (extension of the cord out of the uterine cavity into the vagina), a
condition that could also interfere w/ fetal circulation
 Cord comes out first
Pregnancy Induced Hypertension
 PIH, 20-24th week of gestation
 High blood pressure in pregnancy
 7 to 10 % of all pregnancy
 Chronic hypertension
 The blood pressure that is present before pregnancy begins
 Disappears after 10th day postpartum
 Risk:
 Pre-existing hypertension (high blood pressure)
 Kidney disease
 Diabetes
 PIH with a previous pregnancy
 Mother’s age younger than 20 or older than 40
 Multiple fetuses - twins, triplets
 Signs of PIH:
 Proteinuria
 Rising blood pressure / Hypertension
 Edema
 Signs and symptoms:
 Increased blood pressure
 Protein in the urine
 Edema (swelling)
 Sudden weight gain
 Visual changes (blurred or double vision)
 Nausea and vomiting
 Right-sided upper abdominal pain or stomach ache
 Urinating small amounts
 Changes in liver and kidney function test
 SGPT (liver)
 Creatinine test (kidney)
 Therapeutic Management
 Bedrest
 Hospitalization (specialized personnel and equipment may be necessary)
 Magnesium sulfate (or other antihypertensive medications for PIH)
 Fetal monitoring (to check health of fetus)
 Fetal movement counting (to keep track of fetal kicks and movements (if there is
change in the number or frequency, it may mean the fetus is under stress)
 Nonstress testing - a test that measures the fetal heart rate in response in the fetus
movements
 Biophysical profile - a test that combines nonstress test w/ ultrasound to observe the
fetus
 Doppler flow studies - type of ultrasound that uses sound waves to measure the flow
of blood through a blood vessel
 Continued laboratory testing of urine and blood (for changes that may signal
worsening of PIH)
 Medications, called corticosteroids, that may help mature the lungs of the fetus (lung
immaturity is a major problem of premature babies)
 Delivery of the baby (if treatments do not control PIH or if fetus or mother is in
danger). Caesarean delivery may be recommended, in some cases

HELLP Syndrome
 Syndrome collection of signs and symptoms
 Hemolysis, Elevated Liver enzymes, Low Platelet count
 Begins during last three months of pregnancy or shortly after childbirth
 Severe form of preeclampsia
 Severe form of gestational hypertension
 Hemolysis - breakdown of red blood cells these, these cells carry 02 from your lungs to
your body
 Elevated liver enzymes - when levels are high, it could mean there’s a problem with the
liver
 Low platelet count - platelets help your blood count; prone to hemorrhage > hypovolemic
shock
 Cause problems w/ blood, liver and blood pressure
 Major complications:
 Seizures
 Stroke
 Liver rupture
 Placental abruption (premature separation of the placenta from the wall of the uterus)
 Signs and symptoms:
 Fatigue
 Severe headache
 Excess weight gain
 Nausea and vomiting - hyperemesis gravidarum
 Nosebleed
 Pain in the abdomen - pain in upper right quadrant, the lower right chest or the
midepigastric area
 General malaise (fatigue)
 Right upper quadrant tenderness because of liver distention and inflammation
 Severe edema - “pitting”; indention when pressed or put pressure
 Laboratory studies:
 Hemolysis of RBC
 RBC appear fragment on a peripheral blood smear
 Thrombocytopenia
 Platelet count < 100,000/ mm3
 Normal: 150,000 - 400,000/ mm3
 Elevated liver enzyme levels such as alanine aminotransferase (AST)
 Nursing management:
 Assist the client to a setting with intensive care facilities available
 Administer magnesium sulfate per doctor’s order to control seizures
 To control the blood pressure, give Hydralazine as ordered
 Avoid traumatizing the liver by abdominal pressure
 A sudden increase in the intraabdominal pressure, including seizure, could lead
to the rupture of a subcapsular hematoma that could result to internal bleeding
and hypovolemic shock. Events such as this could result to hepatic rupture
leading to maternal and fetal mortality
 Manage prescribed fluid replacement accurately to avoid worsening the woman’s
reduced intravascular tone.Excessive fluid administration could lead to pulmonary
edema or ascites
 Check IV to prevent cardiac overload, fluid intake
 If the gestation is at 34 weeks, cervical ripening with labor induction is usually done.
Delivery may be delayed if the gestation is less than 34 weeks and the woman’s
condition is stable to give steroids for stimulating fetal maturation.
 Transfuse fresh-frozen plasma or platelets as ordered to improve the platelet count
 Use care when when transporting the woman
 Give psychosocial support
 Drugs for stimulating fetal lung maturation:
 Betamethasone
 Dexamethasone
 Terbutaline
 Treatments:
 Blood transfusion
 Bedrest
 Continuous monitoring of mother and baby
  Magnesium sulfates for seizure
 Blood pressure medications
 Corticosteroids for fetal lung development

Polyhydramnios - increased amniotic fluid

Oligohydramnios - decreased amniotic fluid

Polyhydramnios
 Excessive accumulation of amniotic fluid
 Symptoms:
 Shortness of breath or the inability to breathe
 Swelling in the lower extremities and abdominal wall
 Uterine discomfort or contractions
 Braxton Hicks
 Intermittent
 7 - 8 months
 Fetal malposition, such as breech position
 The condition can occur with:
 Multiple pregnancies
 Congenital anomalies (problems that exist when the baby is born)
 Gestational diabetes
 Complications:
 Premature birth
 Premature rupture of membranes - when water breaks early
 Placental abruption - when the placenta peels away from the inner wall of the uterus
before delivery
 C-section delivery
 Still birth - dead during delivery
 Heavy bleeding due to lack of uterine muscle tone after delivery
 Relax - continue bleeding X
 Contraction - stop bleeding

Amniotic Fluid Index

 Standardized way to assess the sufficiency of amniotic fluid quantity in pregnancy
 8 - 25 cm
 Ultrasound
 Normal AFI: 5 - 24 cm
 Oligohydramnios: AFI < 5 cm
 Polyhydramnios: > 24 cm

Amniotic fluid volume

 > 1500 mL (Poly)
 Amount/ volume of amniotic fluid is greatest about 34 weeks (gestation) into the
pregnancy when it averages 800 mL
 About 600 mL of the amniotic fluid surrounds the baby at full term (40 weeks gestation)

Clinical features
 Smaller uterine size
 Less fetal movement
 Uterus is “full of fetus” - when palpated there’s a lot of curves
 Malpresentation
 Evidences of IUGR - Intrauterine Growth Restriction

Causes of Oligohydramnios
 Demise (fetal)
 Renal abnormalities (decreased urine output)
  IUGR (Intrauterine Growth Restriction)
 Premature rupture of membranes
 Post dates
 Chromosomal abnormalities
 Occur with:
 Late pregnancies
 Ruptured membranes
 Placental dysfunction
 Fetal abnormalities

“term” : 37 - 42 weeks
“preterm” : < 37 weeks
“post-term” : > 42 weeks
“early term” : 37 - 38 weeks
“full term” : 39 - 40 weeks
“late term” : 41 weeks - 41 weeks & 6 days

Post-term pregnancy
 > 42 weeks or 294 days from first day of LMP
 Prolonged pregnancy
 Infant is considered post mature or dysmature, especially if placental insufficiency as
interfered with fetal growth
 Prolonged pregnancy may occur w/ high intake of salicylates, which interferes w/ the
synthesis of prostaglandins and may be responsible for the initiation of labor
 Meconium aspiration would likely occur as fetal intestinal contents are more likely to reach
the rectum
 Meconium - first stool of fetus
 Macrosomia is also another problem if the fetus continues to grow
 The fetus is exposed to decreased blood perfusion as the placenta only has adequate
functioning ability for 40 - 42 weeks
 The fetus might also suffer from lack of oxygen, fluid and nutrients

Salicylates
 Acetaminophen
 Dictofenac
 Diflunisal
 Etodolac
 Fenoprofen
 Floctafenine
 Flubriprofen oral
 Ibuprofen

Meconium
 Thick, green, tar-like substance that lines fetus’ intestines during pregnancy
 Typically this substance is not released in your baby’s bowel movements until after birth
 However, sometimes a baby will have bowel movement prior to birth, excreting the
meconium into the amniotic fluid
 Meconium staining (AF with meconium)
 Greenish color
 Amniotic fluid
 Clear; color like urine
 Meconium Aspiration Syndrome (MAS)

What to do? (Post-term)

 Prostaglandin gel or misoprostol may be applied to the cervix to initiate ripening or
stripping of membranes followed by an oxytocin infusion can be used
  Caesarean birth will be necessary if all measures are ineffective
 Monitor fetal heart rate closely, during labor to be certain placental insufficiency would not
occur

Anomalies of the placenta and cord

1. Placenta Succenturiata
 Is a morphological abnormality of the placenta where one or more of the lobes are present
outside the placental body
 These can have different sizes and are connected by blood vessels to the main placenta
 No problem unless large - can entail uterine restriction growth

Schultze - shiny, fetus

Duncan - dirty, mother

2. Placenta Circumvallata
 Circumvallata placenta is an abnormality of the placenta
 Causes the membranes of the placenta to fold back around its edges (murag 2 ka placenta)
 It can increases the chance of complications
 Preterm delivery
 Placental abruption
 Neonatal death
 An emergency cesarean
 Circummarginate placenta
 A flattened edge w/ a ridge of fibrin demarking the edge of the vascular plate. It often only
involves a portion of the circumference
 Circumvallate placenta
 A peripheral cuplike insertion of the membranes at the placental surface

3. Battledore Placenta
 (Marginal Cord Insertion) is a condition in which the umbilical cord is inserted at or near the
placental margin rather than in the center
 This anomaly is rare and has no known clinical significance either

4. Placenta Accreta
 Unusually deep attachment of the placenta to the uterine myometrium so deeply the
placenta will not loosen and deliver
 Attempts to remove it manually may lead to extreme hemorrhage because of the deep
attachment

5. Velamentous Insertion of the cord

 Is an abnormal cord insertion (CI) in which the umbilical vessels diverge as they transverse
between the amnion and chorion (fetal membrane) before reaching the placenta
 It is characterized by membranous umbilical vessels at the placental insertion site, the
remainder of the cord is usally normal

6. Vasa Previa
 The fetal umbilical cord blood vessels run across or very close to the internal opening of the
cervix
 These vessels are inside the membranes, unprotected by the umbilical cord or the placenta
 As such, they are at risk of rupturing when the membranes break

Anomalies of the Cord

1. Umbilical cord
  Responsible for transporting oxygen-rich blood to a baby and taking away oxygen-poor
blood and waste products from the baby
 Umbilical vein - carries oxygen-rich blood to the baby
 Umbilical arteries - carry oxygen-poor blood away from the baby and the placenta
 The placenta then returns the waste to the mother’s blood and the kidneys eliminate
 Normal:
 2 arteries (red)
 1 vein (blue)
 Two-vessel cord:
 1 artery and vein
 Single umbilical artery (SUA)

Unusual cord length

 Normal cord - 50 to 60 cm (55 cm average)
 Short cord
 < 35 cm
 May lead to fetal distress, placenta abruptio, prolonged labor
 Long cord
 > 80 cm
 Higher occurrence of cord around neck (nuchal cord/ CAN Cord-Around-the-
Neck); cord around the body, cord knot, cord prolapse and cord
compression

Nursing care for of Family experiencing complication of Labor and Birth

 4p’s
 Power (Force of labor)
 Passenger (Fetus)
 Passage (Pelvis)
 Psyche/ Psychology

 Dystocia
 Difficult labor
 4 main components of the labor process
 The power - the force that propels the fetus (uterine contraction)
 The passenger - the fetus
 The passage - the birth canal
 The psyche - the woman’s and family’s perception of the event

Common cause of dysfunctional labor

 Inappropriate use of analgesia (excessive or too early administration)
 Pelvic bone contraction that has narrowed the pelvic diameter so that a fetus cannot pass,
such as could occur in a woman with rickets
 Poor fetal position (posterior rather than anterior position)
 Extension rather than flexion of the fetal head
 Woman becoming exhausted from labor
 Primigravida status
 Overdistention of the uterus, as w/ multiple pregnancy, hydramnios or excessive oversized
fetus
 Cervical rigidity (unripe)
 Presence of a full rectum or urinary bladder that impede fetal descent

Complications Associated with Power (force of labor)

 Ineffective Urine Force
 Hypotonic contractions
 Hypertonic contractions
  Uncoordinated contractions
 Dysfunctional labor and associated stages of labor
 Contraction rings
 Bandl’s Contraction Ring / Bandl’s Ring
 Hard band that forms across the uterus at the junction of the upper and lower uterine
segments and interferes with fetal descent
 “pathologic retraction ring”

Precipitate Labor
 Precipitate labor and birth occur when uterine contractions are so strong that a woman
gives birth with only a few, rapidly occurring contractions
 It is often defined as a labor that is completed in fewer than 3 hours
 Precipitate dilatation is cervical dilatation that occurs at a rate of 5 cm or more per hour in
a primipara or 10 cm or more per hour in a multipara

Induction and Augmentation of Laor

 Induction of Labor
 When the mother and fetus is at risk
 Labor is started artificially (ex. Oxytocin)
 Augmentation of Labor
 Assisting labor that has started spontaneously but is not effective

Uterine Rupture
 When uterus undergoes more strain than it is capable of sustaining
 Rupture occurs most commonly when a vertical scar from a previous cesarean birth or
hysterectomy repair tears
 Contributing factors:
 Prolonged labor
 Abnormal presentation
 Multiple gestation
 Unwise use of oxytocin
 Obstructed labor
 Traumatic maneuvers of forceps or traction

Inversion of the uterus

 A potentially life-threatening complication of childbirth
 Normally, the placenta detaches from the uterus and exits the vagina around half an hour
after the baby is delivered
 The uterine inversion means the placenta remains attached, and its exit pulls the uterus
inside-out

Amniotic Fluid Embolism

 Occurs when amniotic fluid (the fluid that surrounds the baby in the uterus during
pregnancy), or fetal material, such as fetal cells, enters the mother’s bloodstreams

Nursing care of postpartum client

 Puerperium - 6th weeks after child birth
 Postpartum - after giving birth

Normal postpartum
 Contracted uterus preventing hemorrhage; uterus should not be relaxed after birth

Uterine Atony
 Failure of uterus to contract causing hemorrhage; relax uterus
Postpartum hemorrhage
 More bleeding than normal after the birth of a baby
 Causes:
 Tear in the cervix or tissue of vagina
 Tear in blood vessel in the uterus - (Fundal push X)
 Bleeding into a hidden tissue area or space in pelvis. This mass of blood is called
hematoma. It is usually in the vulva or vagina
 Blood clotting disorders
 Placenta problems

4 T’s (causes)
 Tone - uterine atony
 Tissue - retained placenta
 Trauma - laceration, uterine rupture
 Clotting (cloTTing) - coagulopathy

Who is at risk?
 Placenta abruption
 Early detachment of placenta from uterus
 Placenta previa
 When placenta covers or is near the opening of the cervix
 Multiple baby pregnancy
 High blood pressure disorders of pregnancy
 Prolonged labor
 Overdistended uterus - Uterus is larger than normal
 Macrosomia - baby is too large
 Polyhydramnios - too much fluid
 Infection
 Obesity
 Use of forceps or vacuum - assisted delivery
 Asian or Hispanic ethnic background - small build, pelvis
 Multigravida - many previous births

(Cephalo-pelvis disproportion
 Baby’s head is too large to fit through the mother’s pelvis)

Symptoms:
 Uncontrolled bleeding
 Decreased blood pressure
 Increased heart rate
 Decrease in the red blood cell count
 Swelling and pain in the vagina and nearby area if bleeding is from hematoma

Perineum
 Space between anus and genital
 Episiotomy: slanting slit

Treatment
 Aim: find and stop the cause of bleeding ASAP
 Medicine or uterine massage to stimulate uterine contractions:
 Oxytocin
 Massage fundus or abdomen
 Removing pieces of placenta remain in the uterus (D & C: Dilatation & Curettage)
 Exam of the uterus and other pelvic tissues, vagina and vulva to look for areas that may
need repair
 Laparotomy - surgery to open the abdomen to find cause of bleeding
  Tying off or sealing bleeding blood vessels. This is done using uterine compression sutures,
special gel, glue or coils. The surgery is done during laparotomy
 Hysterectomy - surgery to remove the uterus; last resort
 Replacing lost blood and fluids is important in treating
 Quickly give IV fluids, blood and blood products to prevent shock
 Oxygen may also help

Possible complications
 Losing lots of blood quickly can cause a severe drop in blood pressure
 This may lead to shock and death if not treated

Puerperal infections/ puerperal sepsis

 Puerperium
 6th weeks after childbirth during which the mother’s reproductive organs return to
their original non-pregnant condition
 Body tissues (genital and pelvic organ) return to the condition into pre-pregnancy
state of the women
 Breast don’t come to the previous state
 Sepsis
 Systematic infect (not local infection)
 Presence in tissues of harmful bacteria and their toxins, typically through infection of a
wound
 Life-threatening condition that arises when the body’s response to infection causes
injury to its own tissues and organs
 Puerperal sepsis
 Infection of genital tract occurring at labor or within 42 days (6 weeks) of the
postpartum period
 Infection occurs as a complication of delivery or miscarriage is termed as puerperal
sepsis (DC DUTTA’s textbook)
 Primary sites:
 Perineum
 Vagina
 Cervix
 Uterus

Endometritis
 Inflammation and infection of the endometrium (lining of uterus)

Difference (Puerperal sepsis vs Reproductive tract infection)

 Puerperal sepsis
 Complication of delivery or miscarriage within 6 weeks
 Reproductive tract infection
 Happens even if you’re not pregnant or did not gave birth

Local infection (wound infection) - certain area

 Rise of temperature
 Generalized malaise
 Headache
 Local wound becomes red and Swollen (PRISH)
 Pus
 Chills and rigor (shivering)
 Seropurulent discharge - milky

Five (5) cardinal signs of inflammation (PRISH)

 Pain
  Redness
 Immobility
 Swelling
 Heat

Uterine infection
 Mild
 > temperature (> 100.4 F)
 > pulse rate (> 90) - always in infection
 Lochial discharge become offensive (foul smelling) and copious (abundant quantity)
 Uterus is subinvoluted and tender - may be due to lochiostasis and lochiometra
 Subinvoluted - uterus did not return to normal size after childbirth
 Severe
 High rise of temperature
 Chills and rigor
 Pulse is rapid
 Breathlessness
 Abdominal pain
 Dysuria
 Lochiorrhea, green color, foul odor
 Uterus may be subinvoluted, tender

Normal Lochial discharge:

 Lochia rubra - dark red (3-4 days postpartum)
 Lochia serosa - pinkish brown (3 weeks postpartum)
 Lochia alba - whitish yellow (10 days - 6 weeks postpartum)

Measure lochia
 Scant: < 2.5 cm (1 inch) stain
 Light: 2.5 - 10 cm ( 1 to 4 inches) stain
 Moderate: 10 - 15 cm (4 to 6 inches) stain
 Heavy: Saturated in 1 hour

Endometritis - inflammation of endometrium

Endometriosis - abnormal thickening of endometrial lining

Medical Management:
 Antibiotics - ideal antibiotic regimen should depend on the culture and sensitivity report
 Gentamicin (1.5 mg/kg 8 hourly) + Clindamycin (900 mg/8 hourly)
 Metronidazole (500 mg/12 hr) + Penticillin (5 million units/ 6 hr)
 Clindamycin + Aztreonam (2 gm/ 8 hr)
 Ampicillin (2 gm/ 6 hr) + Gentamycin
 Antibiotic Regimens - a combination of either Piperacillin-Tazobactam or Carbapenem
 Women with MRSA (Methicillin-resistant S. aureus) infection should be treated w/
Vancomycin or Teicoplanin

Surgical Management
 Hysterectomy
 Laparotomy
 Surgical evacuation

Nursing Management
 Isolation of patient
 Adequate fluid and calorie
 Correcting anemia
 Indwelling catheter
  A chart is maintained by recording pulse, respiration, temperature, lochial discharge and
fluid I and O
 Ensure that wound is cleaned w/ site bath several times a day and is dressed with an
antiseptic ointment
 Ex. bedpan commode as tub
 Dehiscence (wound separation) of episiotomy or abdominal wound following cesarean
section is managed by scrubbing the wound twice daily, debridement of all necrotic tissue
and then closing the wound w/ secondary suture

Prophylaxis
 Antenatal prophylaxis
 Includes improvement of nutritional status (to raise hemoglobin level) of the pregnant
woman and eradication of any septic focus (skin, throat, tonsils) in the body
 Intranatal phrophylaxis
 Includes full surgical asepsis during delivery
 Screening for group B streptococcus in a high risk patient
 Prophylactic use of antibiotic at the time of cesarean section has significantly reduced
the incidence of wound infection, endometritis, urinary tract infection and other
serious infections
 Postpartum phrophylaxis
 Includes aseptic precautions for at least 1 week, following delivery until the open
wounds in the uterus, perineum, vagina are healed up
 Too many visitors restricted
 Sterilized sanitary pads are to be used
 Infected babies and mothers should be in isolated room

Thrombophlebitis
 Associated with DVT (Deep Vein Thrombosis)
 Thrombo - blood clot
 Phleb - vein
 The risk of developing blood clots (thrombophlebitis) is increased for about 6 to 8 weeks
after delivery (Thromboembolic Disorders During Pregnancy)
 Blood clots that occur in the deep veins of the legs or pelvis (a disorder called deep vein
thrombosis)
 Signs and symptoms:
 Pain
 Swelling
 Tenderness
 Warmth
 Arm or leg is restless
How do you know if you have blood clot postpartum?
 Bright red bleeding beyond the third day after birth
 Blood clots bigger than a plum
 Bleeding that soaks more than one sanitary pad an hour and doesn’t slow down or stop
 (report only if pad is soak in an hour even if it’s still lochia rubra (3-4 days))

Deep Vein Thrombosis

 DVT is a serious condition that occurs when a blood clot forms in a vein located deep inside
your body
 A blood clot is a clump of blood that’s turned to a solid state
 Deep vein blood clots typically form in your thigh or lower leg, but they can also develop in
other areas of your body
 Signs and symptom during pregnancy and postpartum:
 Heavy or painful feeling in the leg ( a lot of people say that it feels like a really bad
pulled muscle that doesn’t go away)
 Tenderness, warmth and/or redness in the calf or thigh
 Slight to severe swelling
  If blood clot has moved to the lungs:
 Chest pain that gets worse when you take a deep breath or cough
 Unexplained shortness of breath
 Coughing up blood
 Rapid or irregular heartbeat

Pulmonary embolism
 Reaches the lungs
 Complication of DVT

Why DVT is common in pregnancy and postpartum?

 During pregnancy, the level of blood-clotting proteins increases, white anti-clotting protein
levels get lower
 Other factors that can contribute to DVT during pregnancy may include an enlarged uterus
which increases pressure on the veins that return the blood to the heart from the lower
body, as well as lack of movement due to bed rest

Mastitis
 Is an inflammation of breast tissue that sometimes involves an infection
 Signs and symptoms:
 Breast pain
 Swelling
 Warmth
 Redness
 Fever
 Chills
 Causes:
 Blocked milk duct
 If breast doesn’t completely empty at feedings, milk ducts can become clogged
 The blockage causes milk to back up, leading to breast infection
 Bacteria entering breast
 Bacteria from the skin’s surface and baby’s mouth can enter the milk ducts
through a crack in the skin of your nipple or through a milk duct opening
 Stagnant milk in a breast that isn’t emptied provides a breeding ground for the
bacteria
 Risk factors:
 Previous bout of mastitis while breast-feeding
 Sore or cracked nipples (although can develop w/o broken skin)
 Wearing a tight-fitting bra or putting pressure on your breast when using a seat belt or
carrying a heavy bag, which may restrict milk flow
 Improper nursing technique
 Becoming overly tired or stressed
 Poor nutrition
 Health teachings
 Fully drain the milk from breasts while breast-feeding
 Allow baby to completely empty one breast before switching to the other breast
during feeding
 Change the position of client use to breast-feed from one feeding to the next
 Make sure infant latches on properly during feedings

Post-partal preeclampsia
 Rare condition
 Occurs when client have high blood pressure and excess protein in the urine soon after
childbirth
Emotional and Psychosocial Complications of Puerperium

Postpartum Depression
 PPD
 Is a complex mix of physical, emotional and behavioral changes that happen in some
women after giving birth
 Facts:
 According to the DSM-5, a manual used to diagnose mental disorders, PPD is a form of
major depression that begins within 4 weeks after delivery
 The diagnosis of postpartum depression is based not only on the length of time
between delivery and onset but on the severity of the depression

Postpartum Psychosis
 Serious mental health illness that can affect someone soon after having a baby

Other manifestations:
 Being uninterested in your baby or feeling like you’re not bonding with them
 Crying all the time, often for no reason
 Depressed mood
 Severe anger and crankiness
 Loss of pleasure
 Feelings of worthlessness, hopelessness and helplessness
 Thoughts of death or suicide
 Thoughts of hurting someone else
 Trouble concentrating or making decisions

Cause:
 Hormones
 The dramatic drop in estrogen and progesterone after giving birth may play a role.
Other hormones produced by thyroid gland also may drop sharply and make you feel
tired, sluggish and depressed
 Lack of sleep
 When a client is sleep-derived and overwhelmed, may have trouble handling even
minor problems
 Anxiety
 Anxious about their ability to care for a newborn
 Self-image
 May feel less attractive, struggle with their sense of identity, or feel that they’ve lost
control over your life

Parricide - murder of family members

PP- postpartum
Nursing intervention depends on severity of conditions

When to get help?

 Symptoms persist beyond 2 weeks
 They can’t function normally
 They can’t cope with everyday situations
 They have thoughts of harming themselves or their baby
 They’re feeling extremely anxious, scared and panicked most of the day

Symptoms of Postpartum Psychosis:

 Hallucinations
 Delusions
 Confusions
 Severe mood swings
 Suicidal thoughts
  Paranoia
 Insomnia

Nursing Care of Male and Female Clients w/ General and Specific Problems in Reproduction and
Sexuality

Conception - sperm deposited to the woman via vagina, cervix, uterus, ampulla

Ampulla - where fertilization happens

Infertility
 Term used to describe the inability to conceive a child or sustain a pregnancy to birth
 Subfertility

Subfertility
 Subfertility is said to exist when a pregnancy has not occurred after at least 1 year of
engaging in unprotected coitus (intercourse)
 Primary subfertility
 No previous conceptions
 Secondary subfertility
 Has previous viable pregnancy but the couple is unable to conceive at present
 Become pregnant but later on cannot conceive again
 May or may not know reason
 Sterility is the inability to conceive because of a known condition

Male Subferility factors:

1. Disturbance in spermatogenesis (production of sperm cells)
 Inadequate sperm count
2. Obstruction in the seminiferous tubules, ducts or vessels preventing movement of spermatozoa
3. Qualitative or quantitative changes in the seminal fluid (allows movement of sperm) preventing
sperm motility (movement of sperm)
4. Development of autoimmunity that immobilizes sperm
5. Problems in ejaculation or deposition preventing spermatozoa from being placed close enough to a
woman’s cervix to allow ready penetration and fertilization

Disturbances in spermatogenesis
 Sperm count is the number of sperm in a single ejaculation or in a millimeter of semen
 Minimum 20 million per ml of seminal fluid, or 50 million per ejaculation
 At least 50% of sperm should be motile, 30% should be normal in shape and form
A) Sperm count
B) Sperm morphology
C) Sperm motility

Facts:
 Average volume of semen per ejaculation: 2 to 6 ml
 Average number of times a man will ejaculate in his lifetime: 7,200
 Average total amount of lifetime ejaculation: 17 liters or 18 quarts
 Average number of calories in a teaspoon of semen: 7
 Average duration of orgasm: 4 seconds
 Average number of sperm cells in the ejaculate of healthy man: 40-600 million
 Distance sperm travels to fertilize an egg: 7.5 - 10 cm or 3-4 inches
 Sperm lifespan: 2.5 months from development to ejaculation

Sperm: From Production to Ejaculation

1. Sperm develop as tiny round cells in seminiferous tubules of testicles
2. Hormones from testicles and pituitary gland help sperm mature
3. They travel to epididymis and develop further for several weeks
4. Migrate to vas deferens
5. Travel to seminal gland, where nourished by semen fluid
6. Travel to prostate gland and mix with prostate fluids
7. Exit through urethra during ejaculation

 Spermatozoa must be produced and maintained at a temperature slightly lower than body
temperature to be fully motile
 Sperm is produced in seminiferous tubules of testicles

BPH / Benign Prostatic Hyperplasia

 Prostate gland enlargement
 Problem w/ urinating and ejaculation

Pathological reason:
1. Cryptorchidism
 Undescended testes
 Descend of testes in fetus: 28 weeks; 7 months
 Lead to lowered sperm count
 If surgical repair of this problem was not completed until after puberty or if the
spermatic cord become twisted after surgery
2. Varicocele
 Varicosity of spermatic vein
 Increase in temperature within the testes and slow and disrupt spermatogenesis
 Trauma to the testes
 Surgery on or near the testicles that results in impaired testicular circulation
 Endocrine imbalances, particularly of the thyroid, pancreas or pituitary glands
 Drug use or excessive alcohol use and
 Environmental factors such as exposure to x-rays or radioactive substances (ask for
lead shield to protect self from radiation)

Obstruction or Impaired Sperm Motility

 Obstruction in pathway of sperm (tubes)
 Mumps orchitis (testicular inflammation and scarring because of the mumps virus)
 Epididymitis (inflammation of the epididymis)
 And tubal infections such as gonorrhea or ascending urethral infection can result in this
type of obstruction because adhesions firm and occlude sperm transport
 Women are more prone for infection because their urethra is shorter
 Normal Ureter:
 Male: 20 cm
 Female: 4 cm

Ejaculation Problems
1. Erectile dysfunction
 Formerly called impotence or the inability to achieve an erection
 Primary
 If the man has never been able to achieve erection and ejaculation
 Secondary
 If the man has been able to achieve ejaculation in the past but now has
difficulty
 Inability to develop and maintain a full erection
 Psychological :
 Stress
 Performance anxiety
 Depression
 Organic causes:
 Vascular - inadequate blood supply
  Atherosclerosis
 Blood vessel damage from hypertension
 Diabetes mellitus
2. Premature ejaculation
 Ejaculation before penetration is another factor that may interfere with the
proper deposition of sperm
 Primary
 Since in younger years; problem since the time you become sexually
active and can be permanent; influenced by internal factors
 Secondary
 Acquired later in life and is temporary; influenced by external factors
(anxiety, stress)

Female Subfertility Factors:

1. Anovulation
 Absence of ovulation, the most common cause of subfertility in women, may
occur from a generic abnormality such as Turner’s syndrome (hypogonadism) in
which there are no ovaries to produce ova
 Causes:
 Hormonal imbalance
 Ovarian tumors
 Chronic or excessive exposure to x-rays or radioactive substances
 General ill health
 Poor diet (nutrition, body weight and exercise all influence the blood
glucose/ insulin balance

2. Tubal Transport Problems

 Chronic salpingitis (chronic pelvic inflammatory disease) - scarring develops in
the fallopian tubes
 Pelvic Inflammatory Disease (PID) - is infection of the pelvic organs: the uterus;
fallopian tubes; ovaries and their supporting structures
 The initial source of infection is usually a sexually transmitted disease
 Inflammations can cause scarring, obstructing the way of the sperm or egg
 TVS (Transvaginal Sonography) - to view internal reproductive organ of woman

3. Uterine Problems
 Endometriosis refers to the implantation of uterine endometrium or nodules,
that have spread from the interior of the uterus to locations outside the uterus
 Tumors
 Congenitally deformed uterine cavity:
 Didelphys
 Arcuate
 Unicornuate
 Bicornuate
 Septate

4. Cervical Problems
 Infection or inflammation of the cervix (erosion)
 Stenotic cervical os or obstruction of the os by a polyp

5. Vaginal Problems
 Acidotic vagina - kills sperm upon entry
 Spermimmobilizing or sperm-agglutinating antiboties

6. Tubal patency
 Sonohysterography
 Hysterosalpingography
  (utrasound transducer - to view uterus and cervix)

Fertility Assessment:
 Health history
 MOSCC
 Menstruation
 Obstetric
 Sexual history
 Contraceptives
 Cervical smear
 Physical Examination
 Fertility testing
 Semen’s analysis
 Sperm Penetration Assay and Antisperm Antibody Tetsing
 Ovulation monitoring
 Ovulation determination by test strip
 Tubal pregnancy

In vivo - done inside body; involves a life

In vitro - performed in the laboratory or test tube