"HIGH-RISK"

PREGNANCY
 LEARNING OBJECTIVES

• After hour of lecture, the students will be able to:

1. Identify and discuss the different factors to be considered why pregnant woman and her baby
is considered at risk.
2. Assess pregnant woman who is at risk.
3. Differentiate common discomforts of pregnancy with conditions that cause pregnancy to be
at risk.
4. Create / Develop a nursing care plan for pregnant woman who is at risk.
 • A "high-risk" pregnancy means that the
"HIGH-RISK" mother, fetus, or newborn has one or more
PREGNANCY things / factors that makes her, or her baby
at increased risk of morbidity or mortality
before (antepartum), during (intrapartum),
or after delivery (postpartum).
• These risk factors include:
✓ Certain physical characteristics, such as age,
and social characteristics of women
✓ Problems in a previous pregnancy

✓ Certain disorders present before pregnancy

✓ Exposures that can harm the fetus

✓Other problems that increase risk can

develop during pregnancy or during labor and
delivery.
 PHYSICAL CHARACTERISTICS

REPRODUCTIVE
ABNORMALITIES
AGE

WEIGHT
HEIGHT

Common Risk / Problems during Antepartum Period

 "HIGH-RISK" PREGNANCY
WOMEN UNDER AGE 20
Women under age 20 or • Women under the age of 20 have a significantly higher risk of serious
Women 17 years old and medical complications related to pregnancy than those over 20.
• Teenage mothers are more likely to:
under ✓ deliver prematurely
✓ have a baby with low birth weight
✓ experience pregnancy-induced hypertension
✓ develop preeclampsia (a type of high blood pressure that develops during
pregnancy / with BP > 140/90 mm Hg plus new unexplained proteinuria)
• Some risk factors connected to young age include the following:
• Underdeveloped pelvis. Young women’s bodies are still growing and
changing. An underdeveloped pelvis can lead to difficulties during
childbirth.
• Nutritional deficiencies. Young women are more likely to have poor eating
habits. Nutritional deficiency can lead to extra strain on the body that
causes more complications for both the mother and child.
• High blood pressure. Developing high blood pressure in pregnancy can
trigger premature labor. This can lead to premature or underweight babies
who require specialized care to survive.
 "HIGH-RISK" PREGNANCY WOMEN OVER AGE 35
• As woman age, their chances of conceiving begin to decline.
• An older woman who becomes pregnant is also less likely to have a problem-free pregnancy.
Women over age 35 Common issues include the following:
1. Underlying conditions
• Older women are more likely to have conditions like high blood pressure, diabetes, or
cardiovascular disease that can complicate pregnancy. When these conditions aren’t well
controlled, they can contribute to miscarriage, poor fetal growth, and birth defects.
2. Chromosomal problems
• A woman over 35 has a higher risk of having a child with birth defects due to chromosomal
issues.
• Down syndrome is the most common birth defect related to chromosomes. It causes varying
degrees of intellectual disability and physical abnormalities. Prenatal screening and tests can help
determine the likelihood of chromosomal complications.
3. Miscarriage
• According to the Mayo Clinic, the risk of miscarriage increases for women who are over the age of
35.
• While the reason for this is unclear, it’s believed to be due to an increased risk of preexisting
medical conditions combined with a decrease in the quality of a woman’s eggs as she ages.
• One study even found that paternal age can have an effect on miscarriage — if the father is over
40 and the mother is over 35, the risk for miscarriage is much greater than if just the woman is
over 35.
4. Other complications
• Women over 35 are more likely to have complications commonly associated with pregnancy
regardless of age, including:
• an increased risk of developing high blood pressure or gestational diabetes while pregnant
• being more likely to have a multiple pregnancy (twins or triplets)higher likelihood of low birth weight
• needing a cesarean delivery
 "HIGH-RISK" PREGNANCY
WEIGHT
• Being either overweight or underweight can lead to complications
WEIGHT during pregnancy.
Overweight or Underweight ❑ Obesity
• Women who are obese are at a higher risk than normal-weight
women of having babies with certain birth defects, including:
✓ spina bifida
✓ heart problems
✓ hydrocephaly
✓ cleft palate and lip
• Obese women are also more likely to be diagnosed with gestational
diabetes during the pregnancy or to have high blood pressure.
• This can lead to a smaller than expected baby as well as increase the
risk for preeclampsia.
❑ Underweight
• Women who are very thin—with a body mass index (BMI) of less than
19.8 or weigh less than 100 pounds before becoming pregnant are
more likely to have
• Small, underweight babies
 HEIGHT
"HIGH-RISK" PREGNANCY
• Women shorter than 5 feet are more likely to have a small
pelvis, which may make movement of the fetus through the
HEIGHT pelvis and vagina (birth canal) difficult during labor.
• For example, the fetus's shoulder is more likely to lodge against
the pubic bone. This complication is called shoulder dystocia.
• Also, short women are more likely to have preterm labor and a
baby who is born underweight (small-for-gestational age).
 REPRODUCTIVE ABNORMALITIES
• Structural abnormalities in the uterus or cervix increase the risk
"HIGH-RISK" PREGNANCY
of the following:
REPRODUCTIVE • A difficult labor
A miscarriage during the 2nd trimester and preterm labor
ABNORMALITIES •

• A fetus in an abnormal position

• Preterm labor or a premature baby
• Need for a cesarean delivery
• Structural abnormalities include a double uterus, fibroids in the
uterus, and a weak (incompetent) cervix (cervical insufficiency)
that tends to open (dilate) as the fetus grows.
• Fibroids occasionally cause the placenta to be mislocated
(called placenta previa), labor to begin too early (preterm labor),
and miscarriages to occur.
• Cervical insufficiency increases the risk that a baby will be
delivered too soon (preterm delivery).
 STRUCTURAL
ABNORMALITIES OF THE
UTERUS
• There are several types of uterine
malformations:
• Absent Uterus. The uterus is not present, vagina
only rudimentary or may be absent.
• Arcuate (shaped like a bow; curved) Uterus
• Bicornuate Uterus (Uterus with two horns) - uterus in
heart-shaped
• Septated Uterus (Uterine septum or partition)
• Didelphys Uterus (Double Uterus)
• Unicornate Uterus (One-sided uterus)
• Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a disorder that occurs in
females and mainly affects the reproductive system.
• This condition causes the vagina and uterus to be underdeveloped or absent,
although external genitalia are normal.
Other names for this condition
are:
• Affected women usually do not have menstrual periods due to the absent uterus. •Congenital absence of the uterus
• Often, the first noticeable sign of MRKH syndrome is that menstruation does not and vagina (CAUV)
begin by age 16 (primary amenorrhea). •Genital renal ear syndrome (GRES)
• Women with MRKH syndrome have a female chromosome pattern (46,XX) and •MRKH syndrome
normally functioning ovaries. •Mullerian agenesis
•Mullerian aplasia
• They also have normal breast and pubic hair development.
•Mullerian dysgenesis
• Although women with this condition are usually unable to carry a pregnancy, they •Rokitansky Kuster Hauser
may be able to have children through assisted reproduction. syndrome
•Rokitansky syndrome

• When only reproductive organs are
affected, the condition is classified as
MRKH syndrome type 1.
• Some women with MRKH syndrome
also have abnormalities in other parts of
the body; in these cases, the condition is
classified as MRKH syndrome type 2.
Females with MRKH syndrome type 2
may also have hearing loss or heart
defects.
❑ The reproductive abnormalities of MRKH
syndrome are due to incomplete
development of the Müllerian duct.
❑ This structure in the embryo develops into
the uterus, fallopian tubes, cervix, and the
upper part of the vagina.
❑ The cause of the abnormal development of
the Müllerian duct in affected individuals is
unknown.
❑ Originally, researchers suspected that MRKH
syndrome was caused by environmental
factors during pregnancy, such as
medication or maternal illness.
❑ However, subsequent studies have not
identified an association with any specific
maternal drug use, illness, or other factor.
❑ Researchers now suggest that in
combination, genetic and environmental
factors contribute to the development of
MRKH syndrome, although the specific
factors are often unknown.

Clinical description
• MRKH syndrome is most often diagnosed in adolescence as the
first symptom is usually a primary amenorrhea in young women
presenting otherwise with normal development of secondary
sexual characteristics and normal external genitalia.
• MRKH syndrome type 1 and 2 patients lack the uterus and the
upper 2/3 of the vagina leading to difficulties with sexual
intercourse in some.
• Pelvic pain can be reported in those with uterine remnants.
• As the uterus is missing or not functional, women cannot bear
children, but ovaries are normal and functional.
• Other associated malformations seen in MRKH type 2 include
kidney abnormalities (40% of cases), skeletal abnormalities (20-
25%), hearing impairment (10%), and, more rarely, heart defects.
Etiology
✓ The exact etiology is largely unknown
✓ MRKH syndrome has a genetic origin
✓ These reveal several chromosomal
abnormalities associated with the disease
Diagnostic methods
✓ The karyotype of MRKH patients is always
46, XX.
✓ Hormone levels are normal, showing
normal and functional ovaries without
hyperandrogenism.
✓ Transabdominal ultrasonography must be
the first investigation in evaluating patients
with suspected utero-vaginal aplasia.
✓ MRI can be performed to clearly visualize
the malformation.
✓ A full check-up (renal ultrasonography,
spine radiography, heart echography,
audiogram) must be undertaken to search
for any associated malformations.
• An arcuate uterus is a mildly variant shape of the uterus.
There is an indentation at the top of the uterus
• It is technically one of the Müllerian duct anomalies but is
often classified as a normal variant.
• Arcuate uterus can be characterized with high-quality
ultrasound scan with good three-dimensional or MRI.
• Many patients with an arcuate uterus will not experience
any reproductive problems
• Having surgery is not required when woman have an
arcuate uterus as there are no disadvantages of having an
arcuate uterus.

• Bicornuate uterus - “heart-shaped” womb because it ✓ A bicornuate uterus raises woman’s risk of having a
actually looks like a heart miscarriage later in her pregnancy and delivering the baby
• Some women with a bicornuate uterus report the early.
following symptoms:
•irregular vaginal bleeding ✓ The baby may settle in a breech position
•repeated miscarriages
•painful periods Treatment for Bicornuate Uterus
•abdominal discomfort ✓ Surgery, called a Strassman metroplasty,
•pain during intercourse ✓ The Strassman metroplasty joins the two narrow uterine corpora
into one and tries to reconstruct the normal anatomical structure.
Both abdominal and laparoscopic metroplasty can improve uterine
morphology, enlarge cavity volume, reduce intrauterine pressure,
and increase blood flow to the endometrium and muscle.
• A double uterus is a rare abnormality that develops
when a baby girl is in her mother’s womb.
• Every uterus starts out as two small tubes called
Mullerian ducts.
▪ No known cause
• As they begin to develop, they usually fuse together to
▪ Can be diagnosed with ultrasound, MRI.
form one uterus. But in rare cases, the tubes remain
Hysterosalpingography (HSG) - During
separate and become two uteri. this test, a dye is inserted into the uterus via the
• Sometimes there is only one cervix for both wombs, cervix. As the dye travels through, X-rays allow a
other times each womb has a cervix. doctor to see the size and shape of the uterus.
Sonohysterogram the images are taken after
• Often the vagina in women with a double uterus is a fluid is inserted into the uterus through a thin
divided into two separate openings by a thin membrane. tube that is put into the vagina. This allows the
doctor to see any abnormalities in the shape of
• It’s entirely possible for women with a double uterus to
the uterus that may be present.
carry a baby to term. However, the condition does come
▪ No treatment
with an increased risk of miscarriage or premature labor.
▪ Surgery is possible to correct a double uterus,
but it’s rarely needed
• A septate uterus is when a girl's uterus has a wall of tissue
running vertically up and down the middle of it, separating the
uterus into two cavities.

• The septate uterus happens when the septum doesn’t get

absorbed by the body after the fallopian tubes and uterus are
formed. The septate uterus is a genetic abnormality and has
no known cause.

• Women with a septate uterus have higher chances of

pregnancy loss or miscarriage, preterm birth, and fetal
malpresentation.
• A septate uterus can cause a more painful period but often doesn’t
get diagnosed until the woman has multiple pregnancy losses.

Septate uteruses are divided into three types:

• Partial septate uterus. When the septum tissue doesn’t

include the cervix. Treatment
• Complete septate uterus. When the septum also includes Hysteroscopic surgery can be used to cut or shave
the cervix, which is the opening of the womb. off the septum.
• Septate uterus and vagina. When the septum extends into
By cutting the septum, the uterus is no longer
the vagina. divided into two parts.
• Unicornuate uterus is a rare condition in which the uterus is only partially
developed.
• People with a unicornuate uterus may only have one fallopian tube. Their
uterus is smaller and differently shaped than a typical uterus.
• Having a unicornuate uterus can be a concern during menstruation and ▪ No known cause;
pregnancy, but woman can still have children despite the condition. ▪ no way to prevent it and no
• In the case of a unicornuate uterus, there may be two Mullerian ducts, but known risk factors for it
one is underdeveloped. Instead of connecting into a single organ, one duct happening
▪ More often, the unicornuate uterus is
develops into a banana-shaped partial uterus with one fallopian tube. diagnosed when a teenager has pain or
• Some people with a unicornuate uterus may also have a remnant uterus discomfort with menstruation, if there is a
hemi-uterus alongside the unicornuate
called a hemi-uterus that may separate from the more fully formed uterus. uterus.
• A hemi-uterus may have its own cervix but it probably won't connect to the ▪ Other people discover they have a
unicornuate uterus when they want to have
vagina. It might develop a uterine lining for menstruation, but it cannot a baby.
release the lining out of the body. This can lead to severe pain during ▪ They may have difficulty conceiving due to
menstruation. the unusual shape of their uterus.
▪ Once they do get pregnant, they might
discover their unicornuate uterus during
a routine ultrasound.
• An incompetent cervix, also called a cervical insufficiency,
occurs when weak cervical tissue causes or contributes to premature
birth or the loss of an otherwise healthy pregnancy
• Some women have mild discomfort or spotting over the course of several
days or weeks starting between 14 and 20 weeks of pregnancy.
• Signs and Symptoms: Risk Factors
▪ A sensation of pelvic pressure Cervical Trauma
• A new backache Race
• Mild abdominal cramps Congenital conditions
• A change in vaginal discharge
• Light vaginal bleeding
Complications
An incompetent cervix poses risks the woman’s pregnancy — particularly
during the second trimester — including:
• Premature birth
• Pregnancy loss
Prevention
• It can’t be prevented but there's much a woman can do to promote a
healthy, full-term pregnancy such as:
• Seek regular prenatal care
• Eat a healthy diet.
• Gain weight wisely
• Avoid risky substances

The doctor might recommend preventive medication during pregnancy,

frequent ultrasounds or a procedure that closes the cervix with strong
sutures (cervical cerclage).
• Placenta previa occurs when a baby's placenta partially or
totally covers the mother's cervix — the outlet for the
uterus.
Complications - Placenta previa can cause severe bleeding
during pregnancy and delivery; Preterm birth.
Symptoms
• Bright red vaginal bleeding without pain during the second
half of pregnancy is the main sign of placenta previa.
Some women also have contractions.
 Diagnosis
• Placenta previa is diagnosed through
ultrasound, either during a routine prenatal
appointment or after an episode of vaginal
bleeding.
Causes • Most cases of placenta previa are
• The exact cause of placenta previa is unknown. diagnosed during a second trimester
Risk factors ultrasound exam.
• Avoid routine vaginal exams to reduce
Placenta previa is more common among women who:
the risk of heavy bleeding
• Have had a baby
• Have scars on the uterus, such as from previous surgery,
Treatment
▪ There is no medical or surgical treatment
including cesarean deliveries, uterine fibroid removal, and dilation Management of the bleeding depends on various
and curettage factors, including:
• Had placenta previa with a previous pregnancy ▪ The amount of bleeding
• Are carrying more than one fetus ▪ Whether the bleeding has stopped
▪ How far along the pregnancy is
• Are age 35 or older ▪ Woman’s health
• Are of a race other than white ▪ Woman’s baby's health
• Smoke ▪ The position of the placenta and the baby
• Use cocaine
If placenta previa doesn't resolve during the
pregnancy, the goal of treatment is to help woman
get as close to her due date as possible.
Almost all women with unresolved placenta previa
require a cesarean delivery.
• Placenta accreta is a serious pregnancy condition that occurs
when the placenta grows too deeply into the uterine wall.
• Typically, the placenta detaches from the uterine wall after
childbirth. With placenta accreta, part or all of the placenta
remains attached. This can cause severe blood loss after delivery.
• It's also possible for the placenta to invade the muscles of the
uterus (placenta increta) or grow through the uterine wall
(placenta percreta).
• Placenta accreta is considered a high-risk pregnancy
complication. If the condition is diagnosed during pregnancy, you'll
likely need an early C-section delivery followed by the surgical
removal of your uterus (hysterectomy).
Symptoms There are three types of this condition. The type is
▪ Placenta accreta often causes no signs or symptoms during determined by how deeply the placenta is attached
pregnancy — although vaginal bleeding during the third to the uterus.
trimester might occur. •Placenta accreta: The placenta firmly attaches to
▪ Occasionally, placenta accreta is detected during a routine the wall of the uterus. It does not pass through the
ultrasound. wall of the uterus or impact the muscles of the
Causes uterus. This is the most common type of the
▪ Placenta accreta is thought to be related to abnormalities in
condition.
the lining of the uterus, typically due to scarring after a C-
section or other uterine surgery. •Placenta increta: This type of the condition sees
▪ Sometimes, however, placenta accreta occurs without a the placenta more deeply imbedded in the wall of
history of uterine surgery. the uterus. It still does not pass through the wall, but
Risk factors is firmly attached to the muscle of the uterus.
▪ Previous uterine surgery. •Placenta percreta: The most severe of the types,
▪ Placenta position placenta percreta happens when the placenta
▪ Maternal age passes through the wall of the uterus. The placenta
▪ Previous childbirth.
might grow through the uterus and impact other
Complications - severe blood loss after delivery and premature organs, such as the bladder or intestines.
birth
▪ It can require a blood transfusion and
even hysterectomy (removal of the uterus).
• Placental abruption (abruptio placentae) is an uncommon
yet serious complication of pregnancy.
• Placental abruption occurs when the placenta partly or
completely separates from the inner wall of the uterus
before delivery. This can decrease or block the baby's
supply of oxygen and nutrients and cause heavy bleeding
in the mother.
• Placental abruption often happens suddenly.
• Left untreated, it endangers both the mother and the baby.

Symptoms
• Placental abruption is most likely to occur in the last trimester of pregnancy,
especially in the last few weeks before birth.
Signs and symptoms of placental abruption include:
• Vaginal bleeding, although there might not be any
• Abdominal pain
• Back pain
• Uterine tenderness or rigidity
• Uterine contractions, often coming one right after another
• Abdominal pain and back pain often begin suddenly. The amount of vaginal
bleeding can vary greatly and doesn't necessarily indicate how much of the
placenta has separated from the uterus.
• It's possible for the blood to become trapped inside the uterus, so even with
a severe placental abruption, there might be no visible bleeding.
• In some cases, placental abruption develops slowly (chronic abruption), which
can cause light, intermittent vaginal bleeding.
• the baby might not grow as quickly as expected, and the mother might have
low amniotic fluid or other complications.
Causes
➢ often unknown.
➢ Possible causes include trauma or injury to the
abdomen — from an auto accident or fall, for example
— or rapid loss of the fluid that surrounds and cushions
the baby in the uterus (amniotic fluid).
Risk factors
•Placental abruption in a previous pregnancy that wasn't
caused by abdominal trauma
•Chronic high blood pressure (hypertension)
•Hypertension-related problems during pregnancy,
including preeclampsia, HELLP syndrome or eclampsia
•A fall or other type of blow to the abdomen
•Smoking
•Cocaine use during pregnancy
•Early rupture of membranes, which causes leaking
amniotic fluid before the end of pregnancy
•Infection inside of the uterus during pregnancy
(chorioamnionitis)
•Being older, especially older than 40
 Diagnosis
➢ physical exam to check for uterine tenderness or
rigidity.
➢ To help identify possible sources of vaginal bleeding -
Complications
blood and urine tests and ultrasound.
• Placental abruption can cause life-threatening problems for both mother and
baby. During an ultrasound, high-frequency sound waves
create an image of the uterus on a monitor. It's not
For the mother, placental abruption can lead to: always possible to see a placental abruption on an
• Shock due to blood loss ultrasound, however.

• Blood clotting problems Treatment

• The need for a blood transfusion
• Failure of the kidneys or other organs resulting from blood loss
• Rarely, the need for hysterectomy, if uterine bleeding can't be controlled
For the baby, placental abruption can lead to:
• Restricted growth from not getting enough nutrients
• Not getting enough oxygen
• Premature birth
• Stillbirth
It isn't possible to reattach a placenta that's separated from
the wall of the uterus.
Treatment options for placental abruption depend on the
circumstances:
The baby isn't close to full term. If the abruption seems
mild - hospitalized for close monitoring. If the bleeding
stops and the baby's condition is stable, mother might be
able to rest at home.
Given medication to help the baby's lungs mature and to
protect the baby's brain, in case early delivery becomes
necessary.
The baby is close to full term. Generally, after 34 weeks
of pregnancy, if the placental abruption seems minimal, a
closely monitored vaginal delivery might be possible. If the
abruption worsens or jeopardizes the baby's health,
delivery by C-section.
• Premature labor is also called preterm labor. It’s when the
woman’s body starts getting ready for birth too early in her
pregnancy.
• Labor is premature if it starts more than 3 weeks before
the woman’s due date.
• Premature labor can lead to an early birth. But the good
news is that doctors can do a lot to delay an early delivery.
The longer the baby gets to grow inside right up to the due
date -- the less likely they are to have problems after birth.
 Risk factors
Preterm labor can affect any pregnancy. Many factors
have been associated with an increased risk of preterm
labor, however, including:
•Previous preterm labor or premature birth,
particularly in the most recent pregnancy or in
more than one previous pregnancy
Signs and symptoms of preterm labor include: •Pregnancy with twins, triplets or other multiples
• Regular or frequent sensations of abdominal tightening (contractions) •Shortened cervix
•Problems with the uterus or placenta
• Constant low, dull backache •Smoking cigarettes or using illicit drugs
• A sensation of pelvic or lower abdominal pressure •Certain infections, particularly of the amniotic fluid
and lower genital tract
• Mild abdominal cramps
•Some chronic conditions, such as high blood
• Vaginal spotting or light bleeding pressure, diabetes, autoimmune disease and
• Preterm rupture of membranes — in a gush or a continuous trickle of depression
fluid after the membrane around the baby breaks or tears •Stressful life events, such as the death of a loved
one
• A change in type of vaginal discharge — watery, mucus-like or bloody
•Too much amniotic fluid (polyhydramnios)
•Vaginal bleeding during pregnancy
•Presence of a fetal birth defect
•An interval of less than 12 months — or of more
than 59 months — between pregnancies
•Age of mother, both young and older

Prevention
❑ Seek regular prenatal care. Prenatal visits can help monitor woman’s
health and baby's health..
❑ Eat a healthy diet. Healthy pregnancy outcomes are generally associated
with good nutrition. In addition, some research suggests that a diet high
in polyunsaturated fatty acids (PUFAs) is associated with a lower risk of
premature birth. PUFAs are found in nuts, seeds, fish and seed oils.
❑ Avoid risky substances. Quit smoking. Avoid illicit drugs and alcohol
❑ Consider pregnancy spacing. Some research suggests a link between
pregnancies spaced less than six months apart, or more than 59 months
apart, and an increased risk of premature birth.
❑ Manage chronic conditions. Certain conditions, such as diabetes, high
blood pressure and obesity, increase the risk of preterm labor.
Diagnostic Tests and procedures to diagnose
preterm labor include:
•Pelvic exam.
•Ultrasound. A transvaginal ultrasound might be used to
measure the length of your cervix. An ultrasound might
also be done to check for problems with the baby or
placenta, confirm the baby's position, assess the volume
of amniotic fluid, and estimate the baby's weight.
•Uterine monitoring. Lab tests.
• swab of your vaginal secretions to check for the
presence of certain infections and fetal fibronectin — a
substance that acts like a glue between the fetal sac and
the lining of the uterus and is discharged during labor.
These results will be reviewed in combination with other
risk factors.
•urine sample, which will be tested for the presence of
certain bacteria.
Treatment
• Medications
• Corticosteroids. Corticosteroids can help promote the
baby's lung maturity. If mother is between 23 and 34
weeks, corticosteroids is recommended because of
increased risk of delivery in the next one to seven days.
• Steroids for at risk of delivery between 34 weeks and 37
weeks.
• Woman might be given a repeat course of corticosteroids if
they are less than 34 weeks pregnant, at risk of delivering
within seven days, and they had a prior course of
corticosteroids more than 14 days previously.
• Magnesium sulfate. to reduce the risk of a specific type of
damage to the brain (cerebral palsy) for babies born before
32 weeks of gestation.
•Tocolytics. To temporarily slow your contractions.
•Tocolytics may be used for 48 hours to delay
preterm labor to allow corticosteroids to provide
the maximum benefit or, if necessary, for mother
to be transported to a hospital that can provide
specialized care for the premature baby.
•Tocolytics don't address the underlying cause of
preterm labor and overall have not been shown
to improve babies' outcomes. It won’t be
recommended if mother have certain conditions,
such as pregnancy-induced high blood pressure
(preeclampsia).
 SOCIAL CHARACTERISTICS
❑ Being unmarried or in a lower
socioeconomic group increases the
risk of problems during pregnancy.
❑ The reason these characteristics
increase risk is unclear but is
probably related to other
characteristics that are more
common among these women.
❑ For example, these women may be
more likely to smoke, less likely to
consume a healthy diet, more likely
to have unprotected sexual
intercourse, and less likely to obtain
appropriate medical care.

Common Risk / Problems during Antepartum Period

 PROBLEMS IN A PREVIOUS PREGNANCY
❑ When women have had a problem in one
pregnancy, they are more likely to have a
problem, often the same one, in subsequent
pregnancies.
❑ Such problems include having had any of the
following:
• A premature baby
• An underweight baby (small-for-gestational
age)
• A baby that weighed more than 10 pounds
(large-for-gestational age)
• A baby with birth defects
• A previous miscarriage
• A late (postterm) delivery (after 42 weeks of
pregnancy)
• Rh incompatibility that required a blood
transfusion to the fetus
Common Risk / Problems during Antepartum Period
• Labor that required a cesarean delivery
• A baby who died shortly before or after birth (stillbirth)
• Too much amniotic fluid in the uterus (polyhydramnios)
• Too little amniotic fluid in the uterus (oligohydramnios)
• A fetus in an abnormal position, such as buttocks first
(breech)
• A baby whose shoulder gets caught in the birth canal
(shoulder dystocia)
• A baby with an injury that stretched the nerves in the baby's
shoulder (brachial plexus injury) during delivery
• A previous pregnancy with more than one fetus (multiple
births)
• A seizure disorder
• A baby with cerebral palsy
DISORDERS PRESENT BEFORE PREGNANCY

❑ Before becoming pregnant, women may have a disorder

that can increase the risk of problems during pregnancy.
❑ These disorders include
• High blood pressure
• Diabetes
• Kidney disorders
• Kidney infections
• Heart failure
• Sickle cell disease
• Sexually transmitted diseases
• Women who have one of these disorders should talk with a
doctor and try to get in the best physical condition possible
before they become pregnant.
• After they become pregnant, they may need special care,
often from an interdisciplinary team.
• The team may include an obstetrician (who may also be a
specialist in the disorder), a specialist in the disorder, and
other health care practitioners (such as nutritionists).

Common Risk / Problems during Antepartum Period

 "HIGH-RISK" PREGNANCY
WOMEN WITH HIGH
BLOOD PRESSURE
Hypertension increases risk of the following:
• Fetal growth restriction (by decreasing
uteroplacental blood flow)
• Preeclampsia and eclampsia
• Adverse fetal and maternal outcomes
WOMEN WITH HIGH BLOOD PRESSURE
Hypertensive disorders are classified as
• Chronic hypertension: Present before the pregnancy or
developing before 20 weeks of pregnancy
• Gestational hypertension: New onset of high systolic and/or
diastolic blood pressure (BP) > 140/> 90 mm Hg with no
proteinuria and no signs of preeclampsia
• Preeclampsia: New-onset hypertension (BP > 140/90 mm Hg)
plus new unexplained proteinuria (> 300 mg/24 hours or urine
protein/creatinine ratio ≥ 0.3) after 20 weeks or other signs of
end-organ damage (eg, thrombocytopenia [platelets <
100,000/mcL], impaired liver function, renal insufficiency,
pulmonary edema, or cerebral or visual symptoms).
• Chronic hypertension plus superimposed preeclampsia:
New or worsening proteinuria or other signs of end-organ damage
after 20 weeks in a woman with preexisting hypertension
• Severe preeclampsia or HELLP syndrome (hemolysis,
elevated liver enzymes, and low platelet count)
• Chronic hypertension is differentiated from gestational
hypertension, which develops after 20 weeks of pregnancy. In
either case, hypertension is defined as systolic BP > 140 mm Hg or
diastolic BP > 90 mm Hg on 2 occasions > 24 hours apart.
 "HIGH-RISK" PREGNANCY
▪ Mild preeclampsia: high blood pressure, water retention, and protein in the
urine.
WOMEN WITH HIGH ▪ Severe preeclampsia: headaches, blurred vision, inability to tolerate bright
light, fatigue, nausea/vomiting, urinating small amounts, pain in the upper
BLOOD PRESSURE right abdomen, shortness of breath, and tendency to bruise easily.
▪ There is no cure for preeclampsia except for the delivery of the baby.
• Women with mild preeclampsia may be treated conservatively to allow the
❑ Gestational hypertension is diagnosed
baby to mature, as long as they are closely monitored. They may be
when blood pressure readings are
given corticosteroids to help the baby's lungs mature and magnesium
higher than 140/90 mm Hg in a
sulfate to prevent seizures. Sometimes, medications to lower blood
woman who had normal blood
pressure are needed.
pressure prior to 20 weeks and has no
• Fetal complications of preeclampsia include the risk of preterm delivery,
proteinuria (excess protein in the
oligohydramnios (low fluid volume within the uterus), and sub-optimal fetal
urine).
growth.
❑ Preeclampsia is diagnosed when a
woman with gestational hypertension
also has increased protein in her urine.
❑ Eclampsia is the development of seizures in a woman with severe
❑ Preeclampsia usually occurs after the
preeclampsia. It has a 2% mortality (death) rate.
34th week of gestation, but it can
• Maternal complications of preeclampsia and eclampsia
develop after the infant is delivered.
include liver and kidney failure, bleeding and clotting disorders, and HELLP
syndrome (hemolysis, elevated liver enzymes, and low platelet count)
 "HIGH-RISK" PREGNANCY
HIGH BLOOD PRESSURE DURING PREGNANCY POSES VARIOUS RISKS,
WOMEN WITH HIGH INCLUDING:
• Decreased blood flow to the placenta. If the placenta doesn't get enough
BLOOD PRESSURE blood, the baby might receive less oxygen and fewer nutrients. This can lead
to slow growth (intrauterine growth restriction), low birth weight or premature
birth. Prematurity can lead to breathing problems, increased risk of infection
and other complications for the baby.
• Placental abruption. Preeclampsia increases the risk of this condition in
which the placenta separates from the inner wall of the uterus before delivery.
Severe abruption can cause heavy bleeding, which can be life-threatening for
mother and baby.
• Intrauterine growth restriction. Hypertension might result in slowed or
decreased growth of baby (intrauterine growth restriction).
• Injury to the other organs. Poorly controlled hypertension can result in injury
to the brain, heart, lungs, kidneys, liver and other major organs. In severe
cases, it can be life-threatening.
• Premature delivery. Sometimes an early delivery is needed to prevent
potentially life-threatening complications when woman have high blood
pressure during pregnancy.
• Future cardiovascular disease. Having preeclampsia might increase
woman’s risk of future heart and blood vessel (cardiovascular) disease.

"HIGH-RISK" PREGNANCY
WOMEN WITH HIGH BLOOD
PRESSURE
MANAGEMENT
• Regardless of the hypertensive disorder of pregnancy, BP requires
urgent treatment in a monitored setting when severe (>160/110
mm Hg); acceptable agents for this include oral nifedipine or
intravenous labetalol or hydralazine. Oral labetalol may be used if
these treatments are unavailable.
• Regardless of the hypertensive disorder of pregnancy, BPs
consistently at or >140/90 mm Hg in clinic or office (or ≥135/85
mm Hg at home) should be treated, aiming for a target diastolic BP
of 85 mm Hg in the office (and systolic BP of 110–140 mm Hg) to
reduce the likelihood of developing severe maternal hypertension
and other complications, such as low platelets and elevated liver
enzymes with symptoms. Antihypertensive drugs should be reduced
or ceased if diastolic BP falls <80 mm Hg. Acceptable agents include
oral methyldopa, labetalol, oxprenolol, and nifedipine, and second
or third line agents include hydralazine and prazosin.
❑ Women with preeclampsia should be assessed in hospital when first diagnosed;
thereafter, some may be managed as outpatients once it is established that their
condition is stable and they can be relied on to report problems and monitor their
BP.
❑ Women with preeclampsia who have proteinuria and severe hypertension, or
hypertension with neurological signs or symptoms, should receive magnesium
sulfate (MgSO4) for convulsion prophylaxis.
❑ Fetal monitoring in preeclampsia should include an initial assessment to confirm
fetal well-being. In the presence of fetal growth restriction, a recommended
schedule for serial fetal surveillance with ultrasound is detailed within these
recommendations.
❑ Maternal monitoring in preeclampsia should include BP monitoring, repeated
assessments for proteinuria if it is not already present, clinical assessment including
clonus, and a minimum of twice weekly blood tests for hemoglobin, platelet count,
and tests of liver and renal function, including uric acid, the latter being associated
with worse maternal and fetal outcomes.
❑ Women with preeclampsia should be delivered if they have reached 37 weeks’ (and
zero days) gestation or if they develop any of the following:
✓ Repeated episodes of severe hypertension despite maintenance treatment
with 3 classes of antihypertensive agents;
✓ Progressive thrombocytopenia;
✓ Progressively abnormal renal or liver enzyme tests;
✓ Pulmonary edema;
✓ Abnormal neurological features, such as severe intractable headache,
repeated visual scotomata, or convulsions;
✓ Non-reassuring fetal status.
 "HIGH-RISK" PREGNANCY

WOMEN WITH HIGH BLOOD PRESSURE

 "HIGH-RISK" PREGNANCY WOMEN WITH DIABETES
• Women with both type 1 and type 2 diabetes may experience
complications during pregnancy.
WOMEN WITH DIABETES • Women with preexisting diabetes are more likely to require
preterm delivery for obstetric or medical indications.
• Poor control of diabetes can increase the chances of birth
defects in the baby and can cause health concerns for the
mother.
• Being diagnosed with diabetic symptoms during pregnancy is
called gestational diabetes > much higher risk for developing
diabetes after their pregnancy is over.
• Women with diabetes are more likely to have babies that weigh
more than 10 pounds at birth.

❑ Gestational diabetes is routinely screened for at 24 to 28 weeks

and, if women have risk factors, during the 1st trimester.

❑ Risk factors include the following:

✓• Previous gestational diabetes
✓• A macrosomic infant in a previous pregnancy
✓• Family history of non- insulin–dependent diabetes
✓• Unexplained fetal losses
✓• Body mass index (BMI) > 30 kg/m2
 "HIGH-RISK" PREGNANCY ❑ Optimal treatment of gestational diabetes (with
dietary modification, exercise, and close
monitoring of blood glucose levels
WOMEN WITH DIABETES and insulin when necessary) reduces risk of
adverse maternal, fetal, and neonatal outcomes.

❑ Women with gestational diabetes are at a higher

lifetime risk of cardiovascular events and, after
delivery, should be referred for appropriate
cardiovascular risk assessment and follow-up.

❑ Women with gestational diabetes mellitus may

have had undiagnosed diabetes mellitus before
pregnancy. Thus, they should be screened for
diabetes mellitus 6 to 12 weeks postpartum, using
the same testing and criteria used for patients who
are not pregnant.
 "HIGH-RISK" PREGNANCY

WOMEN WITH HIGH KIDNEY DISORDERS

WOMEN WITH KIDNEY DISORDERS

• Women who have a kidney disorder that regularly requires hemodialysis are
often at high risk of pregnancy complications, including miscarriage, stillbirth,
preterm birth, and preeclampsia.
• But because of advances in dialysis treatment, up to 90% of babies born to
these women survive.
• In women with moderate to severe kidney disease (stages 3-5), the risk of
complications is much greater.
• For some women, the risk to mother and child is high enough that they should
consider avoiding pregnancy.
 "HIGH-RISK" PREGNANCY
WOMEN WITH HIGH
KIDNEY DISORDERS
WOMEN WITH KIDNEY DISORDERS
• Women who have a kidney disorder
that regularly requires hemodialysis
are often at high risk of pregnancy
complications, including miscarriage,
stillbirth, preterm birth, and
preeclampsia. But because of
advances in dialysis treatment, up to
90% of babies born to these women
survive.
• In women with moderate to severe
kidney disease (stages 3-5), the risk
of complications is much greater.
• For some women, the risk to mother
and child is high enough that they
should consider avoiding pregnancy.
"HIGH-RISK" PREGNANCY
WOMEN WITH HIGH KIDNEY INFECTIONS
❑ The hormonal changes in pregnancy as well as the physical changes exerted by the enlarging
uterus can lead to a slowdown of the passage of urine through the urinary tract and even to
vesicouteral reflux, a condition in which urine in the bladder backs up, or refluxes, back into the
ureters (the tubes that carry urine from the kidneys to the bladder).
❑ The hormone progesterone is responsible for changes in action of the smooth muscle walls of the
ureters, and the weight of the uterus itself can lead to urinary retention.
❑ There is further an expansion of blood volume and increased load on the kidneys in pregnant
women, resulting in increased urine output in the face of decreased mobility of the ureters.
❑ Finally, pregnant women tend to have higher urinary levels of glucose than nonpregnant women.
❑ All of these changes predispose to infection within the urinary tract.
❑ Fortunately, urinary infections in pregnancy are readily treatable.
❑ Cephalexin, ampicillin, and nitrofurantoin are examples of antibiotics that may be used to treat
lower urinary tract infections and cystitis in pregnant women. These medications are taken in pill
or tablet form.
❑ Infections of the kidney (pyelonephritis) require more intensive treatment with hospitalization and
intravenous antibiotics.
As with any illness, it is important for the mother to maintain adequate hydration to avoid reducing
❑
blood flow to the uterus during a urinary tract infection.
❑ If pyelonephritis (kidney infection) goes untreated, maternal and fetal complications may develop
including premature labor and low birth weight, so it is important to seek medical care when
symptoms of a urinary infection are present.
❑ Pregnant women should not wait until the urinary tract infection becomes “worse” or rely on
alternative treatments to “treat” an infection; they should call their doctor as soon as symptoms
occur.
"HIGH-RISK" PREGNANCY
WOMEN WITH HEART FAILURE
Pregnancy stresses the heart and circulatory system, but many women who
have heart conditions deliver healthy babies
WOMEN WITH
The risks depend on the nature and severity of your heart condition.
HEART FAILURE For example:

• Heart rhythm issues. Minor abnormalities in heart rhythm are common

during pregnancy. They're not usually cause for concern.
• Heart valve issues.
• Having an artificial heart valve or scarring or malformation of the heart or
valves can increase the risk of complications during pregnancy. If the valves
aren't working properly, the woman might have trouble tolerating the
increased blood flow that occurs during pregnancy.
• In addition, artificial or abnormal valves carry an increased risk of a
potentially life-threatening infection of the lining of the heart (endocarditis)
and heart valves.
• Mechanical artificial heart valves also pose serious risks during pregnancy due
to the need to adjust use of blood thinners, the potential for life-threatening
clotting (thrombosis) of heart valves.
• Taking blood thinners can also put the developing baby at risk.
• Congestive heart failure. As blood volume increases, congestive heart
failure can worsen.
• Congenital heart defect. Causes the baby for a greater risk of developing
some type of heart defect, too. Woman might also be at risk for heart
problems occurring during pregnancy and of premature birth.
"HIGH-RISK" PREGNANCY
WOMEN WITH HEART FAILURE
• Certain heart conditions, especially narrowing of the mitral valve or aortic valve, can
WOMEN WITH pose life-threatening risks for mother or baby.
• Depending on the circumstances, some heart conditions require major treatments
HEART FAILURE — such as heart surgery — before the woman try to conceive.
• Pregnancy isn't recommended for women who have the rare congenital condition

Medication for Heart Problems during Pregnancy

✓ Medication taken during pregnancy can affect the baby.
✓ Often the benefits outweigh the risks, however. If the mother need medication to
control her heart condition, the health care provider will prescribe the safest
medication at the most appropriate dose.
✓ Woman must take the medication exactly as prescribed. They should not stop
taking the medication or adjust the dose on their own.

PREVENTION
❑ Taking good care of self is the best way to take care of the baby.
For example:

✓ Keep prenatal appointments. Visit health care provider regularly throughout

the pregnancy.
✓ Take medication as prescribed.
✓ Get plenty of rest. Take a daily nap, if possible, and avoid strenuous physical
activities.
✓ Monitor weight gain. Gaining the right amount of weight supports the baby's
growth and development. Gaining too much weight places additional stress
on the heart.
✓ Manage anxiety.
✓ Know what's off-limits. Avoid smoking, alcohol, caffeine and illegal drugs.
 "HIGH-RISK" PREGNANCY WOMEN WITH SICKLE CELL DISEASE
❑ Sickle cell disease is a blood disorder passed down from parent to child.
People with sickle cell disease have abnormal hemoglobin. Hemoglobin is
WOMEN WITH a protein in red blood cells that carries oxygen to the body.
❑ The abnormal hemoglobin in sickle cell disease makes the red blood cells
SICKLE CELL DISEASE stiff and sticky. They form into the shape of a sickle, or the letter "C."
❑ These sickle cells tend to clump together and can’t easily move through
the blood vessels. The clumps block the flow of healthy, oxygen-carrying
blood. This causes pain and damages tissues.
❑ A pregnant woman with SCD is at a higher risk of preterm labor, having a
low-birth-weight baby or other complications. However, with early
prenatal care and careful monitoring throughout pregnancy, a woman
with SCD can have a healthy pregnancy.
❑ Some women with sickle cell disease have no change in their disease
during pregnancy. In others, the disease may get worse. Painful events
called sickle cell crises may still occur in pregnancy. These events may be
treated with medicines that are safe to use during pregnancy.
❑ Generally, women with sickle cell trait do not have problems from the
disorder. But they may have a lot of urinary tract infections during
pregnancy.
❑ Pregnant women with sickle cell trait can also have a kind of anemia
caused by not having enough iron in their blood.
❑ In pregnancy, it is important for blood cells to be able to carry oxygen.
With sickle cell anemia, the abnormal red blood cells and anemia may
result in lower amounts of oxygen going to the developing baby. This can
slow down the baby’s growth.
 "HIGH-RISK" PREGNANCY WOMEN WITH SICKLE CELL DISEASE
TREATMENT:
• Pregnant women with sickle cell trait may not have any
WOMEN WITH complications. But the baby may be affected if the father also
SICKLE CELL DISEASE carries the trait.
• Partner should be tested before woman become pregnant. Or he
Complications and increased risks may should be tested at the first prenatal visit. If the baby's father has
include:
✓ Infections, including infection in the urinary sickle cell trait, amniocentesis or other tests is needed to see if
tract, kidneys, and lungs the developing baby has the trait or the disease.
✓ Gallbladder problems, including gallstones
✓ Heart enlargement and heart failure from • Early and regular prenatal care is important. It allows healthcare
anemia provider to keep a close watch on the disease and on the health
✓ Miscarriage
✓ Death
of developing baby.
Complications and increased risks for • Some women may need blood transfusions to replace the sickle
developing baby may include: cells with fresh blood. These may be done several times during
✓ Severe anemia
✓ Poor fetal growth the pregnancy. Blood transfusions can help the blood carry
✓ Preterm birth. This means before 37 weeks of oxygen and lower the number of sickle cells.
pregnancy.
✓ Low birth weight. This means less than 5.5
• During blood transfusions, mother is screened for antibodies
pounds. that may have been transferred in the blood and that may affect
✓ Stillbirth and newborn death the baby. The most common antibodies are to the blood factor
Rh.
 WOMEN WITH STDs
"HIGH-RISK" PREGNANCY
• During pregnancy, bacterial vaginosis, gonorrhea, and genital
WOMEN WITH chlamydial infection increase risk of preterm labor and premature
rupture of the membranes.
SEXUALLY TRANSMITTED • Routine prenatal care includes screening tests for HIV infection,
DISEASES hepatitis B, and syphilis and, if < 25 years, for chlamydial
infection and gonorrhea at the first prenatal visit.
• Syphilis testing is repeated during pregnancy if risk continues
and at delivery for all women.
• Pregnant women who have any of these infections are treated
with antimicrobials.
• Treatment of bacterial vaginosis, gonorrhea, or chlamydial
infection may prolong the interval from rupture of the membranes
to delivery and may improve fetal outcome by decreasing fetal
inflammation.

• Fetal syphilis in utero can cause fetal death, congenital

malformations, and severe disability.
• Without treatment, risk of transmission of HIV from woman to
offspring is about 30% prepartum and about 25% intrapartum.
• Neonates are given antiretroviral treatment within 6 hours of birth
to minimize risk of transmission intrapartum.
 "HIGH-RISK" PREGNANCY
WOMEN WITH
PREEXISTING MEDICAL CONDITIONS
Some preexisting medical conditions can make
the woman more susceptible to complications
during pregnancy.
❑ Some examples include:
• Polycystic ovary syndrome (PCOS)
• Polycystic ovary syndrome (PCOS) is a hormonal
disorder that can cause irregular periods and your
ovaries to not function properly.
• Pregnant women with PCOS have a higher risk of
miscarriage, premature delivery, gestational diabetes,
and preeclampsia.
• Autoimmune disease
• Examples of autoimmune diseases include conditions
like multiple sclerosis (MS) and lupus.
• Women with an autoimmune disease may be at a risk
for premature delivery or stillbirth.
• Additionally, some medication that’s used to treat
autoimmune disease may harm the developing fetus.
• Thyroid disease
• Hyperthyroidism (overactive thyroid) or hypothyroidism (underactive thyroid)
that isn’t controlled can lead to heart failure or poor weight gain in the fetus
as well as birth defects.
• Asthma
• Asthma that’s not controlled can lead to an increased risk of poor fetal
weight gain and premature delivery.
• Uterine fibroids
• While uterine fibroids can be relatively common, they can cause miscarriage
and premature delivery in rare cases.
• A cesarean delivery may be required when a fibroid is blocking the birth
canal.
• Multiple pregnancies
• If the woman had five or more previous pregnancies, she is more susceptible
to abnormally quick labor and accompanying excessive blood loss during
future labors.
• Multiple-birth pregnancies
• Complications arise in multiple-birth pregnancies because more than one
baby is growing in the womb.
• Because of the limited amount of space and the additional strain multiple
fetuses put on a woman, these babies are more likely to arrive prematurely.
• Many pregnancy complications, like high blood pressure and diabetes, are
more common in multiple pregnancies.
 DISORDERS DURING PREGNANCY

❑ During pregnancy, a problem may occur or a disorder may develop to

make the pregnancy high risk.
❑ Some disorders that occur during pregnancy are related to (are
complications of) pregnancy. Other disorders are not directly related to
pregnancy.
❑ Certain disorders are more likely to occur during pregnancy because of
the many changes pregnancy causes in a woman's body.
❑ Pregnancy complications are problems that occur during pregnancy.
They may affect the woman, the fetus, or both and may occur at
different times during the pregnancy.
❑ For example, complications such as a mislocated placenta (placenta
previa) or premature detachment of the placenta from the uterus
(placental abruption) can cause bleeding from the vagina during
pregnancy.
❑ Women who have heavy bleeding are at risk of losing the baby or of
going into shock and, if not promptly treated, of dying during labor and
delivery.

Common Risk / Problems during Intrapartum Period

 DISORDERS DURING PREGNANCY
❑ Placenta previa is the most
common cause of painless
bleeding after the 20th
week.
❑ Placenta previa is a
complication that results
from the placenta
implanting either near to, or
overlying, the outlet of the
uterus (the opening of the
uterus, the cervix).
❑ Because the placenta is rich
in blood vessels, if it is
implanted near the outlet of
the uterus, bleeding can
occur when the cervix
dilates or stretches
The types of placenta previa include:
•Complete placenta previa occurs when the placenta
completely covers the opening from the womb to the cervix.
•Partial placenta previa occurs when the placenta partially
covers the cervical opening
•Marginal placenta previa occurs when the placenta is located
adjacent to, but not covering, the cervical opening.
The term low-lying placenta or low placenta has been used to
refer both to placenta previa and marginal placenta previa.
Sometimes, the terms anterior placenta previa and posterior
placenta previa are used to further define the exact position of
the placenta within the uterus, as defined by ultrasound
examinations.
Common Risk / Problems during Intrapartum Period
Treatment of placenta previa depends upon
the:
•extent and severity of bleeding,
•gestational age and condition of the fetus,
•position of the placenta and fetus, and
•whether the bleeding has stopped.
❑ Cesarean delivery (C-section) is required for
complete placenta previa and may be necessary for
other types of placenta previa.
❑ Women who are actively bleeding or who have
bleeding that cannot be stopped will be admitted to
the hospital for further care.
❑ If there has been little or no bleeding or the bleeding
has stopped, bed rest at home may be prescribed.
❑ Home care is not always appropriate, and women
who remain at home must be able to access medical
care immediately should bleeding resume.
❑ Women with placenta previa in the 3rd trimester of
pregnancy are advised to avoid sexual intercourse
and exercise and to reduce their activity level.
❑ Women with placenta previa who experience heavy
bleeding may require blood transfusions and
intravenous fluids.
❑ In some cases, tocolytic drugs (medications that slow
down or inhibit labor), such as magnesium sulfate
or terbutaline are necessary.
❑ Corticosteroids may be given to enhance lung
development in the fetus prior to Cesarean delivery.

DISORDERS DURING PREGNANCY
❑ Placental abruption
(abruptio placentae) is an
uncommon yet serious
complication of pregnancy.
❑ Placental abruption occurs
when the placenta partly or
completely separates from the
inner wall of the uterus before
delivery.
❑ This can decrease or block the
baby's supply of oxygen and
nutrients and cause heavy
bleeding in the mother.
❑ Placental abruption often
happens suddenly.
❑ Left untreated, it endangers
both the mother and the baby.
Prevention
It cannot be prevented but it can be
decrease by avoiding certain risk
factors. For example, don't smoke
or use illegal drugs, such as
cocaine.
Diagnosis
❑ If health care provider suspects placental abruption,
physical exam is done to check for uterine
tenderness or rigidity.
❑ Then identify possible sources of vaginal bleeding;
blood and urine tests and ultrasound is also done.
Treatment
❑ It isn't possible to reattach a placenta that's
separated from the wall of the uterus.
❑ Treatment options for placental abruption depend on
Symptoms
❑ Placental abruption is most likely to occur in the last trimester of the circumstances:
pregnancy, especially in the last few weeks before birth. ❑ hospitalization for close monitoring
Signs and symptoms of placental abruption include: ❑ medication to help baby's lungs mature and to
❑ Vaginal bleeding, although there might not be any protect the baby's brain, in case early delivery
❑ Abdominal pain becomes necessary
❑ Back pain ❑ mmediate delivery — usually by C-section
❑ Uterine tenderness or rigidity
❑ Uterine contractions, often coming one right after another
❑ Abdominal pain and back pain often begin suddenly.
❑ The amount of vaginal bleeding can vary greatly and doesn't necessarily
indicate how much of the placenta has separated from the uterus.
❑ It's possible for the blood to become trapped inside the uterus, so even
with a severe placental abruption, there might be no visible bleeding.
Risk factors
Factors that can increase the risk of placental abruption include:
•Placental abruption in a previous pregnancy that wasn't caused by abdominal trauma
•Chronic high blood pressure (hypertension)
•Hypertension-related problems during pregnancy, including preeclampsia, HELLP
syndrome or eclampsia
•A fall or other type of blow to the abdomen
•Smoking
•Cocaine use during pregnancy
•Early rupture of membranes, which causes leaking amniotic fluid before the end of
pregnancy
•Infection inside of the uterus during pregnancy (chorioamnionitis)
•Being older, especially older than 40
Common Risk / Problems during Intrapartum Period
 DISORDERS DURING PREGNANCY
Problems With Amniotic Fluid (the fluid that surrounds the fetus in the uterus)
(POLYHYDRAMNIOS; HYDRAMNIOS; OLIGOHYDRAMNIOS)

❑ Amniotic fluid is the fluid that surrounds the fetus

in the uterus. The fluid and fetus are contained in
membranes called the amniotic sac.
❑ Problems with amniotic fluid include
❑ Too much amniotic fluid
❑ Too little amniotic fluid
❑ Infection of the fluid, amniotic sac, and/or
placenta (called an intra-amniotic infection)
❑ Pregnancy complications, such as too much or
too little amniotic fluid, are problems that occur
only during pregnancy. They may affect the
woman, the fetus, or both and may occur at
different times during the pregnancy. However,
most pregnancy complications can be effectively
treated.

Common Risk / Problems during Intrapartum Period

 DISORDERS DURING PREGNANCY
Problems With Amniotic Fluid (the fluid that surrounds the fetus in the uterus)
(POLYHYDRAMNIOS; HYDRAMNIOS; OLIGOHYDRAMNIOS)

❑ Too much amniotic fluid (polyhydramnios or hydramnios) stretches the uterus and puts pressure on the diaphragm
of pregnant women.

❑ Too much fluid may accumulate because of the following:

✓ Diabetes in the pregnant woman
✓ More than one fetus (multiple births)
✓ Anemia in the fetus, such as that caused by Rh antibodies to the fetus’s blood produced by the pregnant woman (Rh
incompatibility)
✓ Birth defects in the fetus, especially a blockage in the esophagus or urinary tract
✓ Other disorders in the fetus, such as infections or a genetic disorder
✓ However, about half the time, the cause is unknown.
❑ Too much amniotic fluid can lead to several problems:
❑ The woman may have severe breathing problems.
❑ The uterus become stretched out and not be able to contract normally (a condition called uterine atony).
❑ The woman may have bleeding from the vagina after delivery.
❑ Labor may begin early—before 37 weeks of pregnancy (preterm labor).
❑ The membranes around the fetus may rupture too soon (called premature rupture of the membranes).
❑ The fetus may be in an abnormal position or presentation, sometimes requiring cesarean delivery.
❑ The umbilical cord may come out of the vagina before the baby (called a prolapsed umbilical cord).
❑ The fetus may die.
❑ The placenta may detach from the wall of the uterus too soon (called placental abruption) if premature rupture of the
membranes occurs.
❑ Having too much amniotic fluid may cause no symptoms.

Common Risk / Problems during Intrapartum Period

 DISORDERS DURING PREGNANCY

❑ An incompetent cervix, also called a cervical insufficiency, occurs when weak cervical
tissue causes or contributes to premature birth or the loss of an otherwise healthy pregnancy.
❑ Before pregnancy, the cervix (the lower part of the uterus that opens to the vagina) is normally
closed and firm.
❑ As pregnancy progresses and the womb prepare to give birth, the cervix gradually softens,
decreases in length (effaces) and opens (dilates).
❑ In an incompetent cervix, the cervix might begin to open too soon, causing the pregnant
mother to give birth too early.

SYMPTOMS
❑ With incompetent cervix, the woman may not have any signs or symptoms during early
pregnancy.
❑ Some women have mild discomfort or spotting over the course of several days or weeks
starting between 14 and 20 weeks of pregnancy.
❑ The patient pregnant mother should lookout for:
•A sensation of pelvic pressure
•A new backache
•Mild abdominal cramps
•A change in vaginal discharge
•Light vaginal bleeding

Common Risk / Problems during Intrapartum Period

 DISORDERS DURING PREGNANCY

DIAGNOSIS
❑An incompetent cervix can only be detected during pregnancy.
❑Even then diagnosis can be difficult, particularly during a first pregnancy.

Tests and procedures to help diagnose an incompetent cervix during the second trimester
include:
•Transvaginal ultrasound. To evaluate the length of the cervix and to check if membranes are
protruding through the cervix. During this type of ultrasound, a slender transducer is placed in the
vagina to send out sound waves that generate images on a monitor.
•Pelvic exam. To examine the cervix to see if the amniotic sac has begun to protrude through
the opening (prolapsed fetal membranes). If the fetal membranes are in the cervical canal or
vagina, this indicates cervical insufficiency. Also used to check for contractions and, if necessary,
monitor them.
•Lab tests. If fetal membranes are visible and an ultrasound shows signs of inflammation, but
don't have symptoms of an infection, a sample of amniotic fluid (amniocentesis) will be tested to
diagnose or rule out an infection of the amniotic sac and fluid (chorioamnionitis).

There aren't any tests that can be done before pregnancy to reliably predict an incompetent
cervix. However, certain tests done before pregnancy, such as an MRI or an ultrasound, can help
detect uterine abnormalities that might cause an incompetent cervix

Common Risk / Problems during Intrapartum Period

 DISORDERS DURING PREGNANCY

TREATMENTS for or approaches to managing an incompetent cervix might include:

•Progesterone supplementation. If there is a history of premature birth, weekly shots of a form

of the hormone progesterone called hydroxyprogesterone caproate (Makena) during second
and third trimester is done. However, further research is needed to determine the best use of
progesterone in cervical insufficiency.
•Repeated ultrasounds. If there is a history of early premature birth or have a history that may
increase the risk of cervical insufficiency, careful monitoring of the length of the cervix by having
ultrasounds every two weeks from week 16 through week 24 of pregnancy is done. If cervix
begins to open or becomes shorter than a certain length, doctor might recommend cervical
cerclage.
•Cervical cerclage. If less than 24 weeks pregnant or have a history of early premature birth
and an ultrasound shows that the cervix is opening, a surgical procedure known as cervical
cerclage might help prevent premature birth.
•During this procedure, the cervix is stitched closed with strong sutures.
•The sutures will be removed during the last month of pregnancy or during labor.

Common Risk / Problems during Intrapartum Period

 DISORDERS DURING PREGNANCY

❑ An ectopic pregnancy occurs when a fertilized egg implants and grows outside the main
cavity of the uterus.
❑ An ectopic pregnancy most often occurs in a fallopian tube, which carries eggs from the
ovaries to the uterus. This type of ectopic pregnancy is called a tubal pregnancy.
❑ Sometimes, an ectopic pregnancy occurs in other areas of the body, such as the ovary,
abdominal cavity or the lower part of the uterus (cervix), which connects to the vagina.
❑ An ectopic pregnancy can't proceed normally. The fertilized egg can't survive, and the growing
tissue may cause life-threatening bleeding, if left untreated.

SYMPTOMS
Unnoticeable symptoms at first.
Some women have the usual early signs or symptoms of pregnancy — a missed period, breast tenderness and nausea.
Pregnancy test result is positive; but cannot continue as normal.
As the fertilized egg grows in the improper place, signs and symptoms become more noticeable.

Early warning of ectopic pregnancy

Often, the first warning signs are light vaginal bleeding and pelvic pain.
If blood leaks from the fallopian tube, shoulder pain or an urge to have a bowel movement.
The specific symptoms depend on where the blood collects and which nerves are irritated.
Emergency symptoms
If the fertilized egg continues to grow in the fallopian tube, it can cause the tube to rupture.
Heavy bleeding inside the abdomen is likely.
Symptoms of this life-threatening event include extreme lightheadedness, fainting and shock.
Seek emergency medical help if there is presence of:
• Severe abdominal or pelvic pain accompanied by vaginal bleeding
• Extreme lightheadedness or fainting
• Shoulder pain

Common Risk / Problems during Intrapartum Period

 DISORDERS DURING
PREGNANCY
COMPLICATIONS
❑ An ectopic pregnancy can cause the fallopian tube to burst open.
Without treatment, the ruptured tube can lead to life-threatening
bleeding.
PREVENTION
CAUSES ❑ There's no way to prevent an ectopic pregnancy, but here are some ways
❑ A tubal pregnancy — the most common type of ectopic pregnancy — happens when a fertilized egg to decrease the risk:
gets stuck on its way to the uterus, often because the fallopian tube is damaged by inflammation or is ❑ Limiting the number of sexual partners and using a condom during sex
misshapen. helps to prevent sexually transmitted infections and may reduce the risk
❑ Hormonal imbalances or abnormal development of the fertilized egg also might play a role.
of pelvic inflammatory disease.
RISK FACTORS ❑ No smoking.
Some things that make you more likely to have an ectopic pregnancy are: DIAGNOSIS
✓ Pregnancy Test - human chorionic gonadotropin (HCG) blood
❑ Previous ectopic pregnancy. test to confirm that you're pregnant
❑ Inflammation or infection. Sexually transmitted infections, such as gonorrhea or chlamydia, can
✓ Pelvic Exam – to identify areas of pain, tenderness, or a mass
cause inflammation in the tubes and other nearby organs, and increase the risk of an ectopic
pregnancy. in the fallopian tube or ovary
❑ Fertility treatments. Some research suggests that women who have in vitro fertilization (IVF) or ✓ Transvaginal ultrasound - to see the exact location of
similar treatments are more likely to have an ectopic pregnancy. Infertility itself may also raise the pregnancy
risk. TREATMENT
❑ Tubal surgery. Surgery to correct a closed or damaged fallopian tube can increase the risk of an
❑ A fertilized egg can't develop normally outside the uterus.
ectopic pregnancy.
❑ Choice of birth control. The chance of getting pregnant while using an intrauterine device (IUD) ❑ To prevent life-threatening complications, the ectopic tissue needs to be
is rare. However, if you do get pregnant with an IUD in place, it's more likely to be ectopic. Tubal removed.
ligation, a permanent method of birth control commonly known as "having your tubes tied," also ❑ Depending on the symptoms and when the ectopic pregnancy is
raises the risk, if woman become pregnant after this procedure. discovered, this may be done using medication, laparoscopic surgery or
❑ Smoking. Cigarette smoking just before getting pregnant can increase the risk of an ectopic
abdominal surgery.
pregnancy. The more the woman smoke, the greater the risk.

Common Risk / Problems during Intrapartum Period

 DISORDERS DURING PREGNANCY

HYPEREMESIS GRAVIDARUM (HG) is an extreme form of morning sickness that causes

severe nausea and vomiting during pregnancy.

CAUSES
✓ Rapidly rising serum levels of hormones such as HCG (human chorionic gonadotropin) and
estrogen.
✓ Might indicate a multiple pregnancy or hydatidiform mole (abnormal tissue growth that is not
a true pregnancy).
SYMPTOMS
Hyperemesis gravidarum usually occurs during the first trimester of your pregnancy
•Have Vomiting more than three to four times per day that pregnant woman:
•lose more than 10 pounds.
•feel dizzy and lightheaded.
•become dehydrated.
In the case of hyperemesis gravidarum, the following are
RISK FACTORS:
•Hyperemesis gravidarum during an earlier pregnancy.
•Being overweight.
•Having a multiple pregnancy.
•Being a first-time mother.
•The presence of trophoblastic disease, which involves the abnormal growth of cells inside the
uterus.
DIAGNOSIS:
✓ Medical history and perform a physical exam; Lab tests;

Common Risk / Problems during Intrapartum Period

 DISORDERS DURING PREGNANCY

PREVENTION
•Eating small, frequent meals.
•Eating bland foods.
•Waiting until nausea has improved before taking iron supplements.
•Using a pressure-point wrist band, vitamin B6 and/or ginger, as recommended by a healthcare provider.
TREATMENT
The type of treatment that is required depends on how ill the pregnant woman become. Possible treatments might include:
•Preventive measures: These might include a pressure-point wristband — like those used for motion sickness — vitamin B6
and/or ginger.
•Small frequent meals: Nausea and vomiting might be treated with dry foods (such as crackers) and small, frequent meals.
•Intravenous fluids: It is important for a pregnant woman to maintain her fluid intake.
• Intravenous (IV) fluids might be needed if a woman continues to vomit throughout pregnancy.
• In severe cases, the woman might require hospitalization and given IV fluids.
• IV fluids might be discontinued when a woman is able to take in fluids by mouth.
•Total parenteral nutrition: The most severe cases of hyperemesis gravidarum might require that complex, balanced solutions
of nutrients be given through an IV throughout pregnancy.
•This is called total parenteral nutrition (TPN).
•Medicines: Medicine to prevent nausea is used when vomiting is persistent and poses possible risks to the mother or baby. If a
woman cannot take medicines by mouth, the drugs might be administered through an IV or a suppository.
•Medicines used to prevent nausea include Promethazine, Meclizine and Droperidol.

Common Risk / Problems during Intrapartum Period

 DISORDERS DURING PREGNANCY

INTRA-AMNIOTIC INFECTION
❑ Intra-amniotic infection is Intra-amniotic infection typically results
infection of the chorion, from an infection that ascends through
amnion, amniotic fluid, the genital tract.
placenta, or a combination.
RISK FACTORS
❑ Infection increases risk of Risk factors for intra-amniotic infection
obstetric complications and include the following:
problems in the fetus and •Preterm labor
neonate. •Meconium-stained amniotic fluid
•Internal fetal or uterine monitoring
SYMPTOMS include fever, uterine •Presence of genital tract pathogens
tenderness, foul-smelling (eg, group B streptococci)
amniotic fluid, purulent cervical •Multiple digital examinations during
discharge, and maternal or fetal labor in women with ruptured
tachycardia. membranes
•Long labor
DIAGNOSIS is by specific clinical •Premature rupture of
criteria or, for subclinical membranes (PROM)
infection, analysis of amniotic •Prolonged rupture of membranes (a
fluid. delay of ≥ 18 to 24 hours between
rupture and delivery)
TREATMENT includes broad-
spectrum antibiotics, antipyretics,
and delivery.
Common Risk / Problems during Intrapartum Period
 DISORDERS DURING PREGNANCY
MISCARRIAGE – occurs if a be prevented because it is the result
pregnancy ends before 24 weeks
CAUSES
▪ problems with the structure of the uterus.
▪ blood clotting disorders in the mother, such as
antiphospholipid syndrome.
▪ smoking or drug use.
▪ maternal health problems like uncontrolled high
blood pressure, diabetes, or autoimmune diseases.
▪ infection in the mother.
▪ trauma (for example, physical abuse)
CAUSES OF RECURRENT MISCARRIAGES
▪ Problems with the structure of the uterus
▪ Blood clotting disorders, such as antiphospholipid
syndrome
▪ Other maternal health conditions, like diabetes
mellitus or polycystic ovarian syndrome
▪ Certain chromosomal conditions, such
as balanced translocation
Common Risk / Problems during Intrapartum Period
❑ In most cases, a miscarriage cannot
TYPES OF MISCARRIAGE
❑ If a pregnant woman has bleeding, little or no pain, a
of a chromosomal abnormality or
problem with the development of the
closed cervix, and is found to still have a fetus with a
heartbeat in her uterus, she may have had a threatened
fetus. Still, certain factors — such as
miscarriage. Most pregnancies with early bleeding but
age, smoking, drinking, and a history of
with a detectable heartbeat turn out fine.
miscarriage — put a woman at a higher
❑ An inevitable miscarriage is when bleeding and
risk for losing a pregnancy.
cramping happen during pregnancy, with an open cervix.
❑ While miscarriages usually cannot be
❑ An incomplete miscarriage is when a miscarriage has
prevented, taking care of self and
happened, but the body does not expel all the tissue from
following health care provider's
the pregnancy.
recommendations, can increase the
❑ A complete miscarriage is when all of the tissue from
chances that the mother and baby will
the pregnancy is expelled by the body.
be healthy throughout the pregnancy.
❑ If a woman have miscarried, the doctor may say they
have a blighted ovum, which is a miscarriage that has
STILLBIRTHS
- The death of a baby after the 20th week happened so early that no clearly defined fetal tissues
of pregnancy, can happen before have formed.
delivery or during labor or delivery. ❑ A missed miscarriage is when the fetus has died or
- It is rare and happens in less than 1% of all has not developed, but the body does not discharge the
births.
fetus or tissues from the pregnancy. Sometimes women
- A stillbirth also is sometimes referred to as
intrauterine fetal death or antenatal with missed miscarriages notice that they no longer "feel
death. pregnant."
 DISORDERS DURING PREGNANCY
STILLBIRTH is further classified as
either early, late, or term.
•An early stillbirth is a fetal death
occurring between 20 and 27
completed weeks of pregnancy.
•A late stillbirth occurs between 28
and 36 completed pregnancy weeks.
•A term stillbirth occurs between
37 or more completed pregnancy
weeks..
RISK FACTORS
•are 35 years of age or older
•are of low socioeconomic status
•smoke cigarettes during pregnancy
•have certain medical conditions, such as
high blood pressure, diabetes and obesity
•have multiple pregnancies such as triplets
or quadruplets
•have had a previous pregnancy loss
Common Risk / Problems during Intrapartum Period
PREVENTION:
✓ Eat a proper diet with plenty of folic acid and calcium.
✓ Take prenatal vitamins daily.
✓ Exercise regularly (as instructed by the physician)
✓ Maintain a healthy weight (women who are overweight or
too thin may be more likely to have miscarriages).
✓ Avoid drugs and alcohol.
✓ Avoid deli meats and unpasteurized soft cheeses such as
feta and other foods that could carry listeriosis.
✓ Limit caffeine intake.
✓ Quit smoking
✓ Talk to doctor about all medications currently taking.
Unless doctor tells otherwise, many prescription and
over-the-counter medicines should be avoided during
pregnancy.
✓ Avoid activities that could cause abdominal trauma.
✓ Get immunized against communicable diseases and know
family medical and genetic history.
✓ Commit to scheduled prenatal appointments and discuss
any concerns with doctor.
✓ Call doctor right away if there is fever, feel ill, notice
decreased fetal movements, or are having bleeding,
spotting, or cramping.
 DISORDERS DURING PREGNANCY

PREECLAMPSIA is a pregnancy SYMPTOMS

complication characterized by high ❑ Preeclampsia sometimes develops without any symptoms.
blood pressure and signs of ❑ High blood pressure may develop slowly, or it may have a sudden onset.
❑ Monitoring the blood pressure is an important part of prenatal care because the first
damage to another organ system, sign of preeclampsia is commonly a rise in blood pressure.
most often the liver and kidneys. ❑ Blood pressure that exceeds 140/90 millimeters of mercury (mm Hg) or greater —
Preeclampsia usually begins after documented on two occasions, at least four hours apart — is abnormal.
20 weeks of pregnancy in women ❑ Other signs and symptoms of preeclampsia may include:
whose blood pressure had been ▪ Excess protein in the urine (proteinuria) or additional signs of kidney problems
normal. ▪ Severe headaches
▪ Changes in vision, including temporary loss of vision, blurred vision or light
sensitivity
CAUSES: ▪ Upper abdominal pain, usually under the ribs on the right side
▪ Nausea or vomiting
✓ Insufficient blood flow to the ▪ Decreased urine output
uterus ▪ Decreased levels of platelets in the blood (thrombocytopenia)
✓ Damage to the blood vessels ▪ Impaired liver function
✓ A problem with the immune ▪ Shortness of breath, caused by fluid in their lungs
system ▪ Sudden weight gain and swelling (edema) — particularly in the face and hands
— may occur with preeclampsia. But these also occur in many normal
✓ Certain genes pregnancies, so they're not considered reliable signs of preeclampsia.

Common Risk / Problems during Intrapartum Period

 DISORDERS DURING PREGNANCY
RISK FACTORS
Preeclampsia develops only as a complication of pregnancy.

Risk factors include:

➢ History of preeclampsia. A personal or family history of
preeclampsia significantly raises the risk of preeclampsia.
➢ Chronic hypertension. If the woman already have chronic
hypertension, she have a higher risk of developing preeclampsia.
➢ First pregnancy. The risk of developing preeclampsia is highest
during the first pregnancy.
➢ New paternity. Each pregnancy with a new partner increases the
risk of preeclampsia more than does a second or third pregnancy
with the same partner.
➢ Age. The risk of preeclampsia is higher for very young pregnant
women as well as pregnant women older than 35.
➢ Race. Black women have a higher risk of developing
preeclampsia than women of other races.
➢ Obesity. The risk of preeclampsia is higher if the woman is
obese.
➢ Multiple pregnancy. Preeclampsia is more common in women
who are carrying twins, triplets or other multiples.
➢ Interval between pregnancies. Having babies less than two
years or more than 10 years apart leads to a higher risk of
preeclampsia.
➢ History of certain conditions. Having certain conditions before
the woman become pregnant — such as chronic high blood
pressure, migraines, type 1 or type 2 diabetes, kidney disease, a
tendency to develop blood clots, or lupus — increases their risk
of preeclampsia.
➢ In vitro fertilization. The risk of preeclampsia is increased if the
woman’s baby was conceived with in vitro fertilization.
COMPLICATIONS OF PREECLAMPSIA
❑ FETAL GROWTH RESTRICTION. Preeclampsia affects the arteries carrying blood to the
placenta. If the placenta doesn't get enough blood, the baby may receive inadequate blood and
oxygen and fewer nutrients. This can lead to slow growth known as fetal growth restriction, low
birth weight or preterm birth.
❑ PRETERM BIRTH. If the woman have preeclampsia with severe features, she may need to be
delivered early, to save her life and her baby. Prematurity can lead to breathing and other
problems for the baby.
❑ PLACENTAL ABRUPTION. Preeclampsia increases the risk of placental abruption, a
condition in which the placenta separates from the inner wall of the uterus before delivery.
Severe abruption can cause heavy bleeding, which can be life-threatening for both mother and
baby.
❑ HELLP SYNDROME. HELLP — which stands for hemolysis (the destruction of red blood
cells), elevated liver enzymes and low platelet count — syndrome is a more severe form of
preeclampsia and can rapidly become life-threatening for both mother and baby.
❑ Symptoms of HELLP syndrome include nausea and vomiting, headache, and upper right
abdominal pain.
❑ HELLP syndrome is particularly dangerous because it represents damage to several organ
systems.
❑ On occasion, it may develop suddenly, even before high blood pressure is detected or it may
develop without any symptoms at all.

Common Risk / Problems during Intrapartum Period

DISORDERS DURING PREGNANCY
COMPLICATIONS OF PREECLAMPSIA
❑ ECLAMPSIA. When preeclampsia isn't controlled,
eclampsia — which is essentially preeclampsia
plus seizures — can develop. It is very difficult to
predict which patients will have preeclampsia that is
severe enough to result in eclampsia.
❑ Often, there are no symptoms or warning signs to
predict eclampsia. Because eclampsia can have serious
consequences for both mom and baby, delivery becomes
necessary, regardless of how far along the pregnancy is.
❑ OTHER ORGAN DAMAGE. Preeclampsia may result
in damage to the kidneys, liver, lung, heart, or eyes, and
may cause a stroke or other brain injury. The amount of
injury to other organs depends on the severity of
preeclampsia.
❑ CARDIOVASCULAR DISEASE. Having
preeclampsia may increase the risk of future heart and
blood vessel the woman had preeclampsia more than
once or they had a preterm delivery. To minimize this
risk, after delivery they must try to maintain ideal
weight, eat a variety of fruits and vegetables, exercise
regularly, and don't smoke.
Common Risk / Problems during Intrapartum Period
PREVENTION
Reduce the risk of preeclampsia with:
1. Low-dose aspirin. If the mother meets certain risk factors — including a history of preeclampsia, a
multiple pregnancy, chronic high blood pressure, kidney disease, diabetes or autoimmune disease —
doctor may recommend a daily low-dose aspirin (81 milligrams) beginning after 12 weeks of pregnancy.
2. Calcium supplements. In some populations, women who have calcium deficiency before pregnancy
— and who do not get enough calcium during pregnancy through their diets — might benefit from
calcium supplements to prevent preeclampsia.
3. Do not take any medications, vitamins or supplements without doctors advise.
4. Mother should be healthy; they must lose weight as needed, if with diabetes – it should be well-
managed.
5. While pregnant, mother should take care of self and baby, through early and regular prenatal care. If
preeclampsia is detected early, the doctor and the mother can talk on how to prevent complications and
make the best choices for self and her baby.
DIAGNOSIS TREATMENT
To diagnose preeclampsia, there should be ❑ The most effective treatment for
presence of high blood pressure and one or preeclampsia is bed rest and delivery.
more of the following complications after ❑ Medications to lower blood pressure
the 20th week of pregnancy: ❑ Corticosteroid medications can
✓ Protein in urine (proteinuria) temporarily improve liver and platelet
✓ A low platelet count function to help prolong the pregnancy.
✓ Impaired liver function Corticosteroids can also help the baby's
✓ Signs of kidney problems other than lungs become more mature in as little as
protein in the urine 48 hours — an important step in preparing
✓ Fluid in the lungs (pulmonary edema) a premature baby for life outside the
✓ New-onset headaches or visual womb.
disturbances ❑ Anticonvulsant medications for severe
cases

❑ Rh incompatibility is a condition
that occurs during pregnancy if a
woman has Rh-negative blood
and her baby has Rh-positive
blood.
❑ "Rh-negative" and "Rh-positive"
refer to whether the mother’s
blood has Rh factor.
❑ Rh factor is a protein on red blood
cells.
❑ If the mother have Rh factor, she
is Rh-positive.
❑ This can make the baby's red blood
cells swell and rupture. This is known
as hemolytic or Rh disease of the
newborn. It can make a baby's blood
count get very low.
DISORDERS DURING PREGNANCY
What's an Rh Factor?
❑ An Rh factor is a protein
found on some red blood
cells (RBCs).
❑ Not everyone carries this
protein, though most do.
They are Rh-positive.
❑ People who don't carry the
protein are Rh-negative.
❑ Rh-negative pregnant
women can be exposed to the
Rh protein that might cause
antibody production in other
ways too.
These include:
•blood transfusions with
Rh-positive blood
•Miscarriage
•ectopic pregnancy
Common Risk / Problems during Intrapartum Period
CAUSES
❑ During pregnancy, red blood cells from the unborn baby
can cross into the mother's blood through the placenta.
❑ If the mother is Rh-negative, her immune system treats
Rh-positive fetal cells as if they were a foreign substance.
❑ The mother's body makes antibodies against the fetal blood
cells. These antibodies may cross back through the placenta
into the developing baby. They destroy the baby's
circulating red blood cells.
❑ When red blood cells are broken down, they
make bilirubin. This causes an infant to become yellow
(jaundiced). The level of bilirubin in the infant's blood may
range from mild to dangerously high.
❑ Firstborn infants are often not affected unless the mother
had past miscarriages or abortions. This would sensitize
her immune system. This is because it takes time for the
mother to develop antibodies.
❑ All children she has later who are also Rh-positive may be
affected.
❑ Rh incompatibility develops only when the mother is Rh-
negative and the infant is Rh-positive.
❑ This problem has become less common in places that
provide good prenatal care. This is because special immune
globulins called RhoGAM are routinely used.
TREATMENT:
❑ If a pregnant woman has the potential to
develop Rh incompatibility, a series of
two Rh immune-globulin shots during
her first pregnancy will be given.
❑ She'll get:
✓ the first shot around the 28th week of
pregnancy
✓ the second shot within 72 hours of giving
birth
❑ Rh immune-globulin acts like a vaccine.
It prevents the mother's body from
making any Rh antibodies that could
cause serious health problems in the
newborn or affect a future pregnancy.
❑ A woman also might get a dose of Rh
immune-globulin if she has a
miscarriage, an amniocentesis, or any
bleeding during pregnancy.
❑ If a woman has already developed Rh
antibodies, her pregnancy must be
closely watched to make sure that those
levels are not too high.
❑ In rare cases, if the incompatibility is
severe and a baby is in danger, the baby
can get special blood transfusions called
exchange transfusions either before birth
(intrauterine fetal transfusions) or after
delivery.
❑ Exchange transfusions replace the baby's
blood with blood with Rh-negative blood
cells.
❑ This stabilizes the level of red blood cells
and minimizes damage from Rh
antibodies already in the baby's
bloodstream.
 Exposure to Teratogens
❑ Environmental variables can also play a major
role in prenatal development. Harmful
environmental elements that can affect the fetus
are known as teratogens
❑ Common teratogens (agents that cause fetal
malformation) include infections, drugs, and
physical agents.
❑ Malformations are most likely to result if
exposure occurs between the 2nd and 8th week
after conception (the 4th to 10th week after the
last menstrual period), when organs are
forming.
❑ Other adverse pregnancy outcomes are also
more likely.
❑ Pregnant women exposed to teratogens are
counseled about increased risks and referred for
detailed ultrasound evaluation to detect
malformations.
Commonly used drugs that
may be teratogenic include
• Alcohol
• Tobacco
• Cocaine
❑ The use of substances by the mother can
have devastating consequences to the fetus.
Smoking is linked to low birth weight,
which can result in a weakened immune
system, poor respiration, and neurological
impairment.
❑ Alcohol use can lead to fetal alcohol
syndrome, which is linked to heart defects,
body malformations, and intellectual
disability.
❑ The use of illicit psychoactive drugs such
as cocaine and methamphetamine is also
linked to low birth weight and neurological
impairment.
 Exposure to Teratogens
❑ A number of maternal diseases can
negatively impact the fetus.
❑ Herpes virus is one of the most
common maternal diseases and can be
transmitted to the fetus, leading to
deafness, brain swelling, or intellectual
disability.
❑ Women with herpes virus are often
encouraged to deliver via cesarean to
avoid transmission of the virus.
❑ Common infections that may be
teratogenic include
❑ Herpes simplex
❑ Viral hepatitis
❑ Rubella
❑ Varicella
❑ Syphilis
❑ Toxoplasmosis
❑ Cytomegalovirus infection
❑ Coxsackievirus infection
❑ Zika infection
❑ HIV/AIDS
HIV Mercury in seafood can
be toxic to the fetus.
✓ Not only is there a risk that these infections can
be passed from mother to child, but they can also • Avoiding tilefish from the Gulf
cause serious complications during pregnancy. of Mexico, shark, swordfish,
✓ Pregnant women who have HIV can transmit the big-eye tuna, marlin, orange
virus to their child during pregnancy, childbirth, roughly, and king mackerel
or breastfeeding. • Limiting albacore tuna to 4
✓ In order to prevent this, mothers with HIV should ounces (one average
take medications for treating HIV. meal)/week
✓ Babies born to mothers living with HIV may • Before eating fish caught in
receive such medication for several weeks after local lakes, rivers, and
birth. coastal areas, checking
local advisories about the
safety of such fish and, if
levels of mercury are not
known to be low, limiting
consumption to 4
ounces/week while avoiding
other seafood that week
 REFERENCES

1. Hoyert DL, Gregory ECW. Cause of fetal death: Data from the fetal death report, 2014. National vital statistics reports;
vol 65 no 7. Hyattsville, MD: National Center for Health Statistics. 2016
2. Xu JQ, Kochanek KD, Murphy SL, Arias E. Mortality in the United States, 2012. NCHS data brief, no 168. Hyattsville, MD:
National Center for Health Statistics. 2014.
3. MacDorman MF, Kirmeyer SE, Wilson EC. Fetal and perinatal mortality, United States, 2006. National vital statistics
reports; vol 60 no 8. Hyattsville, MD: National Center for Health Statistics. 2012
4. Artal R: Exercise: The alternative therapeutic intervention for gestational diabetes. Clinical Obstetrics and Gynecology 46 (2):479–487, 2003.

5. Artal R: The role of exercise in reducing the risks of gestational diabetes mellitus in obese women. Best Pract Res Clin Obstet Gynaecol 29
(1):123–4132, 2015.

6. Artal R, Lockwood CJ, Brown HL: Weight gain recommendations in pregnancy and the obesity epidemic. Obstet Gynecol 115 (1):152–155, 2010.
doi: 10.1097/AOG.0b013e3181c51908

7. Mottola MF, Davenport MH, Ruchat SM, et al: 2019 Canadian guideline for physical activity throughout pregnancy. Br J Sports Med 52 (21):1339–
1346, 2018. doi: 10.1136/bjsports-2018-100056