G 6. Promoting informed decisions by involved family members.

ART
E
➔ assisted reproductive technology
N
➔ medical procedures used primarily to address infertility
E ➔ procedures sometimes use donor eggs, donor sperm, or
T previously frozen embryos.
I ➔ surrogate
◆ a woman who becomes pregnant with sperm from
C
the male partner of the couple
& ➔ gestational carrier
G ◆ becomes pregnant with an egg from the female
E partner and sperm from the male partner
➔ TYPES OF ART:
N
IVF
E
➔ in vitro fertilization
T ➔ a method of assisted reproduction in which a man’s sperm
I and a woman’s eggs are combined outside of the body in a
laboratory dish.
C ➔ used to treat many causes of infertility:
C ◆ advanced maternal age
◆ damaged or blocked FT
O
➔ One or more oocytes are aspirated from the woman and are
U fertilized by a sperm under laboratory conditions but outside
N the woman’s body.
➔ The woman is given an ovulation stimulating agent before
S the procedure
E ➔ ovaries are examined daily through ultrasound beginning at
the 10th day of the menstrual cycle to check the development
L of the ovarian follicles.
I ➔ Once a follicle has matured, hCG is injected to cause
ovulation within 39 to 42 hours
N
➔ 40 hrs after fertilization, the first cell division occurs
G ➔ Initially, IVF was used to treat women with blocked, damaged,
or absent fallopian tubes.
➔ Today, IVF is used to treat many causes of infertility
GENETIC COUNSELOR ➔ steps:
➔ help identify families at possible risk of a genetic condition by ◆ ovarian stimulation
gathering and analyzing family history and inheritance ◆ egg retrieval
patterns and calculating chances of recurrence. ◆ embryo culture
➔ they provide information about genetic testing and related ◆ embryo transfer
procedures ➔ One cycle of IVF takes about two months.
➔ trained to present complex and difficult-to-comprehend ➔ Women younger than age 35 will get pregnant and have a
information about genetic risks, testing, and diagnosis to baby with their first IVF egg retrieval and subsequent embryo
families and patients. transfer(s) about half the time.
➔ help families understand the significance of genetic ➔ VARIATIONS:
conditions in relation to cultural, personal, and familial ◆ GAMETE INTRAFALLOPIAN TRANSFER (GIFT)
contexts ● gametes are transferred to the FT rather
➔ can serve as a central resource of information about genetic than uterus
conditions ● fertilization takes place in the tubes
GENETIC COUNSELING ● laparoscopy- transfer sperm & egg
◆ ZYGOTE INTRAFALLOPIAN TRANSFER (ZIFT)
➔ client or relatives at risk for an inherited disorder are advised
of the consequences and nature of the disorder, the ➔ Donor sperm is frozen and quarantined for six months
probability of transmitting it, and the options open to them in ➔ the use of frozen sperm in IVF cycles does not lower the
management and family planning chance of pregnancy.
➔ Involves gathering information ➔ SUBFERTILITY- the couple could not create a child for a year
◆ birth history ◆ PRIMARY SUBFERTILITY- no previous
◆ past medical hx conceptions
◆ current health status ◆ SECONDARY SUBFERTILITY- couple was able to
◆ family hx conceive in the past but could not do so at the
GOALS OF GENETIC COUNSELING present
1. Preventing birth defects. ➔ MALE SUBFERTILITY FACTORS
2. Improved psychological well-being in client adaptation to a genetic ◆ inadequate sperm count
condition or risk. ● number of sperm every ejaculation
3. Explaining alternatives to reduce the risk of genetic disorders ● 20 mil/mL- normal amount
4. Decreasing the incidence of genetic disorders. ● 50 mil sperms in single ejaculation
5.. Clarifying the family’s options for available treatment and prognosis. ● 50% of the sperm- motile
 ● 30% must be in good form
◆ obstruction
● Inflammation of the pathway of the
spermatozoa
● Pressure from tumors of those
with benign prostatic hypertrophy
◆ ejaculation problems
● psychological problems leads to erectile
dysfunction or impotence
○ inability to achieve an erection
○ premature ejaculation- before
penetration affects the
deposition of the sperm
➔ FEMALE SUBFERTILITY FACTORS
◆ ANOVULATION
- hypogonadism or Turner’s syndrome - no ovaries
that can produce egg cells
- hypothyroidism- interfere with the interaction
between the ovaries, hypothalamus, and the
pituitary gland, causing the inability of the ovaries
to produce egg cells.
- overall nutrition of women:
● affects ovulation- increased blood
glucose levels that disturb the FSH and
LH production and lead to ovulation
failure
- food (easy to digest carbs, too much protein &
saturated fats)- decreases fertility
- stress
● interferes with the secretion of GnRH
and lowers the production of LH and FSH
POLYCYSTIC OVARY SYNDROME
➔ most common cause of anovulation
➔ condition that enables the ovary to produce excess
testosterone thereby reducing the production of FSH and LH
➔ women ovulate only a few times for the entire year
➔ a common condition that affects how a woman’s ovaries work
➔ 3 main features:
◆ irregular periods - do not regularly release eggs
(ovulation)
◆ excess androgen - high levels of "male" hormones
in your body, which may cause physical signs such
as excess facial or body hair
◆ polycystic ovaries- ovaries become enlarged and
contain many fluid-filled sacs (follicles) that
surround the eggs
SYMPTOMS OF PCOS
1. irregular periods/ amenorrhea
2. difficulty getting pregnant (as a result of no or irregular
ovulation)
3. excessive hair growth/ hirsutism
4. weight gain
5. thinning hair & hair loss from the head
6. oily skin or acne
(female subfertility factors cont.)
❖ TUBAL TRANSPORT PROBLEMS
- Adhesion or scarring of the fallopian tubes
- one of the main causes of transport problems in
females who have undergone tubal ligation or
salpingitis.
- infection of the pelvic organs or pelvic inflammatory disease
- causes scarring of the tube w/c can furthermore
constrict them if left untreated
❖ UTERINE PROBLEMS
- tumors in the uterus
- rare condition that affects woman’s fertility
- might block thee implantation site of the embryo
- endometriosis
- implantation of the uterine endometrium
- it causes subfertility when the particles of the
endometrium regurgitate & proliferate, which
impedes the implantation site of the embryo
- Decrease secretion of estrogen and progesterone
from the ovary results in inadequate formation of
the endometrium, which also results in interference
in the growth of the embryo
❖ CERVICAL PROBLEMS
- When the cervix becomes infected, the cervical mucus
becomes too thick to allow penetration of the
spermatozoa, thus impeding fertilization.
- Scar tissues in the cervix caused by a previous D and C
also cause problems in the fertility of the woman.
❖ VAGINAL PROBLEMS
- infection of the vagina - pH level increases
- destructs the motility of the sperm
- sperm agglutinating antibodies
- destroy the sperm's ability to survive in th
vagina
- causes immobilization of sperm
- Vaginitis (inflammation of vagina)
- S/Sx: vaginal discharge, odor, itching, & pain
- common types: bacterial, yeast &
trichomoniasis
- Doderlein’s bacillus- large, Gram-positive bacterium
found in vaginal secretions.
- Albert Doderlein (German obstetrician &
gynecologist) - “founders of gynecological
bacteriology”
❖ DIAGNOSIS:
⮚ SEMEN ANALYSIS
- After 2 to 4 days sexual abstinence, the male must
ejaculate through masturbation into a clean and dry
specimen cup.
- The time it takes to examine the specimen is at least 1
hour while the sperm are being counted.
- The normal amount of sperm in every ejaculation should
reach 20 million spermatozoa in every milliliter of
seminal fluid.
- After 2 to 3 months, the analysis is repeated because
spermatogenesis is a process that goes on and on, and
the new sperm would reach its maturity after 30 to 90
days.
⮚ OVULATION MONITORING
- most inexpensive test for fertility
- the woman is instructed to monitor and record her BBT
daily for four months.
- BBT is determined by taking the temperature of a
woman before she gets up in the morning and before
performing any activity.
- The woman should record her daily temperature and
take note of any conditions that affect the rise and fall of
her temperature.
- During ovulation, the temperature level dips slightly then
rises but not more than the normal level of temperature
and remains at this level for almost 10 days, or 3 to 4
days before the next menstrual flow.
 - When the temperature rise did not last for the
approximated time, a defect in the luteal phase was
diagnosed.
⮚ OVULATION DETERMINATION TEST KIT
- OTC commercial test kits to assess ovulation
- determines the upsurge of LH just before the ovulation
- The kit contains a strip that the woman should dip into
her midmorning urine.
- According to each individual manufacturer’s instructions,
the strip would change color, and the woman should see
the indication of the color on the kit’s manual or
instructions.
⮚ TUBAL PATENCY
- Sonohysterography
- imaging tests that are used to determine the
patency of the fallopian tubes.
- This is an ultrasound that specifically views
the uterus.
- The uterus is filled with sterile saline solution,
then the vaginal transducer is inserted into the
vagina to inspect the uterus.
- This procedure can be done anytime during
the menstrual cycle because it is only
minimally invasive.
- hysterosalpingography
- the inspection of the fallopian tubes using a
radiopaque medium.
- This procedure is done after the menstrual
flow to avoid the regurgitation of the debris
from menstruation up the tube.
- Contraindications: vagina infections, cervical
infections, and uterine infections.
➔ CORRECTION OF THE UNDERLYING PROBLEM
◆ man must refrain from coitus for 7-10 days
● to increase sperm count & improve
motility
◆ changes in lifestyle (avoiding prolonged sitting; hot
baths & wearing loose clothing)
➔ REDUCTION OF THE PRESENCE OF INFECTION
◆ The infection present must be treated according to
the microorganism obtained from culture reports.
◆ Metronidazole, for trichomonal infection might be
teratogenic early in the pregnancy, so the woman
must be cautioned of this if the couple is suspecting
a pregnancy.
➔ HORMONE THERAPY
◆ GnRH- for disturbance of ovulation
◆ Clomiphene citrate- stimulate ovulation
◆ Administration of Human Menopausal
Gonadotropins- stimulates ovarian follicular growth
➔ SURGERY
◆ Intrauterine insemination - most likely result in
viable pregnancy
◆ myomectomy - removes a myoma
◆ Diathermy
● or steroid administration
● to correct a tubal insufficiency due to
inflammation
◆ Laparoscopy
● laser surgery
● removing peritoneal adhesions or
nodules
➔ THERAPEUTIC INSEMINATION
◆ instillation of the sperm into the reproductive tract
so that the woman can conceive.
◆ intracervical insemination - the sperm is instilled in
the cervix.
◆ intrauterine insemination- the sperm is instilled
directly into the uterus.
◆ Therapeutic insemination by husband uses the
sperm of the husband and is instilled into the
reproductive tract of the wife.
◆ Therapeutic donor insemination uses the sperm of
a donor, and this is instilled into the reproductive
tract of the woman.
◆ A male who has low sperm count or problems in
sperm motility or a woman who has reproductive
factors that interfere with fertility typically use
therapeutic insemination.
◆ Before the procedure, the woman determines her
ovulation day first through BBT, or the cervical
mucus, or an ovulation test kit.
◆ Once ovulation day is determined, a day after that,
the sperm are injected into the cervix using a
device that looks like a cervical cap, or it is instilled
directly into the uterus.
ABORTION
➔ The expulsion of the products of conception before the
embryo or fetus is viable
➔ any interruption of human pregnancy prior to the 20 to 24
weeks of gestation or the delivery of a fetus weighing less
than 500 grams.
◆ early abortion - before 12 weeks
◆ late abortion - 12 weeks onwards
1. SPONTANEOUS ABORTION
- occur without medical or mechanical intervention
2. THREATENED ABORTION
- occurs before the 20th week of gestation
- pt experiences vaginal bleeding w/ or w/o cramps
and the cervix is closed
- MANAGEMENT:
● bed rest & reassurance until bleeding
stops
● avoid sexual intercourse
● ultrasound
● hormone therapy- 400 mg natural
progesterone
3. INEVITABLE ABORTION
- the bleeding continues and becomes heavy, the
cervix is dilating and the contents of the uterus are
being expelled
- MANAGEMENT:
● immediate evacuation
○ <12 wks - suction evacuation
○ >12 wks- oxytocin infusion
● shock-resuscitation w/ IV fluids & blood transfusion
4. COMPLETE ABORTION
- all the products of conception are expelled
- MANAGEMENT:
● Conservative Treatment
5. INCOMPLETE ABORTION
- the uterus retains part or all of the placenta
 - bleeding may occur ● mild cases
- part of the placenta may adhere to the ○ broad spectrum antibiotics
uterine wall and the uterus does not ○ uterus evacuated
contract to seal the large blood vessels ● severe cases
- MANAGEMENT: ○ maintenance of perfusion & ventilation
● resuscitation if patient is in shock & evacuation by ● blood transfusion
suction evacuation ● oxygen through nasal catheter
○ <12 wks - suction evacuation ● ampicillin, gentamicin & metronidazole/ 3rd
○ >12 wks- oxytocin infusion generation cephalosporin (cefuroxime w/
● if the opening is closed progesterone tablets are metronidazole or clindamycin)
kept in vagina for ripening the cervix ● evacuation of uterus after infection is controlled
○ Misoprostol
○ Cytotec 8. INDUCED ABORTION
● RhoGAM- immunoglobulin w/c suppresses Anti-D - uses drugs or instruments to stop the normal
antibody formation in an Rh- mother w/ a confirmed course of pregnancy
Rh+ infant 9. RECURRENT/ HABITUAL PREGNANCY
- 3 consecutive spontaneous abortions
6. MISSED ABORTION - MANAGEMENT:
- intrauterine pregnancy is present but is no longer ● due to cervical incompetence:
developing normally ○ cervical cerclage
- disappearance of the signs of pregnancy except for ○ sonography- to confirm live fetus
amenorrhea ○ if there i an infection, it should be treated
- “early pregnancy failure” and sexual intercourse should be
- drugs for uterine contractions & birth: avoided
● misoprostol ● MCDONALD’S CERCLAGE
● mifepristone - The patient is in a lithotomy position and
- SIGNS: the cervix is exposed with sim’s
● absence of FHT speculum. the cervical lips are held with
● signs of pregnancy disappear sponge holding forceps and a purse
○ no enlargement of uterus string suture with a non absorbable
○ no fht material like black silk is taken all around
○ negative HCG the cervix
○ utz shows no cardiac activity ● MODIFIED SHIRODKAR’S CERCLAGE
- MANAGEMENT: - Small transverse incision is made on the
● uterus evacuation anterior lip of the cervix at cervicovaginal
● i uterine size is <12 wks of gestation progesterone junction 2 cm above the external os.
tablets kept in vagina - Bladder is then pushed up and a suture
- NSG Interventions: of black silk or mersilene tape is passed
● no bathroom privilege from anterior to posterior submucosally
● After bedpan use, inspect contents carefully for using Shirodkar’s or any curve bodied
intrauterine material needle.
● Note the amount, color, and odor of vaginal
bleeding. CAUSES OF ABORTION
● Assess vital signs every 4 hours for 24 hours or
more frequency, depending on the extent of A. FETAL
bleeding. 1. Chromosomal Anomalies
● Monitor urine output closely. - 50% to 80% of abortions in the first 12
● Check the patient’s blood type and administer
weeks
RhoGAM as ordered.
● Provide emotional support and counseling during 2. Diseases from fertilized ovum
the grieving process. 3. Hypoxia
● Encourage the patient and her partner to express B. MATERNAL
their feelings.
● Proper perineal wash front to back to avoid bacteria 1. infections
like enterococci, staphylococci 2. disease (chronic nephritis, TB)
3. drug intake during pregnancy
7. SEPTIC ABORTION 4. RHO & ABO incompatibility
- a spontaneous or therapeutic abortion complicated 5. incompetent cervix
by a pelvic infection 6. uterine malformation
- S/SX: 7. acquired uterine defect as uterine fibroid or
● foul smelling vaginal discharge adhesions
● uterine cramp 8. Trauma- criminal interference
● fever, chills, peritonitis 9. Endocrine disorder (hypothyroidism, DM)
● leukocytosis- high WBC 10. Severe malnutrition
● signs of septic shock
- MANAGEMENT: SIGNS OF ABORTION
 1. Vaginal Bleeding or spotting ◆ 2 sets of paternal haploid genes
2. Uterine or abdominal cramps ◆ 1 set of maternal haploid genes
3. passage of tissues or products of conception 1. They occur in almost all cases, following dispermic fertilization
4. signs related to blood loss (tachycardia, pallor) of an ovum.
2. There is usually evidence of a fetus or fetal red blood cells
COMPLICATIONS 3. The normal finding is a triploid karyotype , 69 chromosomes
1. hemorrhage instead of normal 46.
2. infection 4. The most common mechanism appears to be fertilization of a
3. disseminated intravascular coagulation (missed abortion) normal egg by two sperm, giving a complement of 69 XXY.
5. The partial mole shows a less clear -cut picture ,with the
APAS formation of vesicles usually focal
➔ Antiphospholipid Antibody Syndrome 6. Fetus and membranes may present.
➔ syndrome is a condition in which the immune system 7. The vesicles have a degree of vascularity.
mistakenly creates antibodies that attack tissues in the body. 8. Vesicular degeneration of the chorionic villi which affects only
➔ These antibodies can cause blood clots to form in arteries and the part of the placenta.
veins. Blood clots can form in the legs, lungs and other 9. Fetal parts and normal placenta villi are present along with
organs, such as the kidneys and spleen.
abnormal trophoblastic tissue
ABO INCOMPATIBILITY
➔ the most common maternal-fetal blood group incompatibility COMPLETE MOLE
and the most common cause of hemolytic disease of the
1. One of the most remarkable discoveries about hydatidiform
newborn (HDN).
moles has been the demonstration that complete moles have
➔ the most common reasons of bilirubin encephalopathy
chromosomes exclusively from the paternal side, and the
➔ A-B-O incompatibility occurs when:
karyotype is nearly always 46XX and only rarely is 46 XY
◆ the mother is type O and the baby is B, A, or AB.
◆ the mother is type A and their baby is B or AB. observed.
◆ the mother is type B and their baby is A or AB. 2. The normal mechanism is for a haploid sperm, 23X to fertilize
an empty egg, and to duplicate itself to form a 46XX
DILATATION & CURETTAGE complement. Much less commonly, two spermatozoa, one
➔ a minor surgical procedure to remove tissue from your uterus. being 23X, and the other 23Y, can fertilize an empty egg to
◆ A miscarriage. give a karyotype of 46 XY.
◆ Leftover tissue in your uterus after an abortion.
3. Microscopically, there are large oedematous enlarged villi, a
◆ Unexplained bleeding between menstrual periods.
➔ steps vascular , with variable degree of trophoblastic hyperplasia.
◆ dilate your cervix using a laminaria stick. 4. Carries greater risk of malignancy and requires longer follow
◆ may give you medication to relax and sedate you, up than the partial mole.
◆ suction D&C 5. No normal placenta
◆ During the procedure, you lie on a table with your 6. Bulky mass which can fill the uterine cavity
feet in stirrups, like during a gynecologic exam. 7. No fetal parts or normal placenta villi
Your provider will:
◆ Insert a speculum into your vagina. This smooth
device, shaped like a duck’s bill, helps open your RISK FACTORS:
cervix. ❖ Increased or decreased maternal age
◆ Use a clamp to hold your cervix in place.
❖ Low socio-economic status
◆ Make sure your cervix is sufficiently dilated, using
a series of rods to open it slowly. ❖ History of abortion
◆ Use a curette, a type of suction or scraping device, ❖ Clomiphene/Clomid therapy
to clean out tissue from your uterus.
H-MOLE CLINICAL FEATURES
❖ Brownish or reddish, intermittent or profuse vaginal bleeding
➔ hydatidiform mole/ gestational trophoblastic disease by 12 weeks
➔ an abnormal development of the placenta & the trophoblastic ❖ Spontaneous expulsion of molar cyst usually at 16th to 18th
tissue proliferates weeks
➔ subdivided into: ❖ Rapid uterine enlargement inconsistent with the age of
◆ partial mole gestation
◆ complete mole ❖ Hyperemesis gravidarum occurs in 25% of cases of moles
and appears more common when the uterus is much
➔ Incidence- 1 in every 1000 pregnancy enlarged and hCG levels are very high.
➔ common at: ❖ Symptoms of PIH before 20 weeks
◆ low animal fat ❖ The fetal parts are not palpable, and fetal heart tones are
◆ older than 35 or younger than 15 absent.
TROPHOBLASTIC TISSUE ❖ Positive pregnancy test
❖ Abdominal pain
➔ thin layer of cells that helps a developing embryo attach to the
wall of the uterus, protects the embryo, and forms a part of DIAGNOSIS OF H MOLE/ CLINICAL SIGNS:
the placenta ● history of amenorrhea, passage of vesicles vaginally with
bleeding
PARTIAL MOLE ● Triad Signs:
➔ triploid in origin ○ size & consistency of uterus
 ○ very high levels of serum hCG ❖ previous surgery, blocked fallopian tube
○ vaginal bleeding of brownish (prune juice) color ❖ ENDOSALPINGITIS- causes folds of the tubal mucosa to
● Anemia agglutinate, narrowing tube
● Ultrasound in early pregnancy has probably led to the earlier
diagnosis of molar pregnancy TRANSMIGRATION OF THE OVUM
● Hydropic vesicles (grape-shape; cluster) - from one ovary to the opposite causing delayed implantation
DIVERTICULA
● Uterine enlargement
- the formation of blind pouches that causes tubal
● Absence of fetal heart sounds abnormalities
TYPES OF ECTOPIC PREGNANCY
TREATMENT 1. Tubal
● Evacuation by D&C or hysterectomy if no spontaneous a. 80% ampullary
evacuation b. 12% isthmic
● hysterectomy c. 6% fiimbral
○ if above 45 years old d. 2% interstitial
○ no future pregnancy is desired a 2. Cervical, intraperitoneal, ovarian
○ ↑ HCG after D&C
ASSESSMENT FINDINGS/MANIFESTATIONS:
● HCG titer monitoring for 1 year (no pregnancy for 1 year) CLASSIC SIGNS OF ECTOPIC
● medical replacement of blood, fluid & plasma
● Chemotherapy for malignancy (methotrexate) 1. Amenorrhea or abnormal menstrual period
● chest x ray to detect early lung metastasis 2. vaginal Spotting
3. positive pregnancy test
PROGNOSIS 4. Abdominal Pain
80% of remission after D&C which may progress to
Choriocarcinoma SIGNS OF TUBAL RUPTURE
● sudden, acute low abdominal pain radiating to the shoulder
- cancer of the chorion
(kehr’s sign or referred shoulder pain) or neck pain
● nausea and vomiting
COMPLICATIONS ● Cullen’s sign- bluish navel because of blood in peritoneal
1. Choriocarcinoma cavity
2. Hemorrhage ● Rectal pressure because of blood in the cul-de-sac
3. Uterine perforation ● positive pregnancy test in many omen (50%)
4. Infection ● sharp localized pain when cervix is touched
● signs of shock:
NURSING IMPLEMENTATION ○ profuse bleeding
○ rapid pulse, lightheadedness, hypotension
1.) Advice bedrest
2.) Monitor V/S, blood loss, molar/tissue passage, I&O DIAGNOSIS
3.) Maintain fluid and electrolytes balance, plasma and blood ● TRANSVAGINAL ULTRASOUND reveal extrauterine
volume through replacement pregnancy
4.) Prepare for D&C or hysterectomy ● SERIAL HCG DETERMINATIONS
5. ) Provide for psychological support ● CULDOCENTESIS- aspiration of non-clotting blood from the
a. fear related to potential development of cancer cul-de-sac of douglas (positive tubal rupture)
b. disturbance in self-esteem for carrying an ● SERUM PROGESTERONE LEVEL
abnormal pregnancy
THERAPEUTIC MANAGEMENT
6. ) For discharge
1. METHOTREXATE chemotherapeutic followed by
a. emphasize the need for follow up HCG titer leucovorin (UNRUPTURED)
determination for 1 year 2. HYSTEROSALPINGOGRAM OR UTZ
b. Reinforce instruction on no pregnancy for 1 year 3. MIFEPRISTONE
ECTOPIC PREGNANCY 4. LAPAROSCOPY
5. SALPINGECTOMY OF RUPTURED TUBE
- significant cause of death due to hemorrhage 6. BLOOD REPLACEMENT FOR SHOCK
- 2nd most cause of vaginal bleeding during pregnancy 7. ANTIBIOTICS
- a condition where implantation of the fertilized ovum develops
outside the uterine cavity.
MIFEPRISTONE
CAUSES/ PREDISPOSING FACTORS: - RU 486
1. any factor that leads to a reduction in tubal motility. - cause an abortion during the early part of pregnancy
a. history of infertility - used up to week 10 of pregnancy (up to 70 days after the first
b. pelvic inflammatory disease ( STD) day of your last menstrual period)
c. pelvic operations (tubal, appendix ) - blocks a natural substance (progesterone) that is needed for
d. failed tubal sterilization your pregnancy to continue
e. previous tubal pregnancy
F. assisted conception - particularly IVF if tubes are patent METHOTREXATE
and damaged - stops cells from dividing
g. Failed contraceptive methods - to treat a pregnancy that is implanted outside uterus
h. Presence of an intrauterine device (ectopic)
i. Surgery of the fallopian tubes - given by injection usually 1 dose
j. Congenital anomalies of the fallopian tubes - To avoid after drinking methotrexate:
k. Adhesions, spasms, tumors - do not drink alcohol
2. FALLOPIAN TUBE DISEASES - do not take folic acid supplements including
❖ ENDOMETRIOSIS- tissue normally shed during menstruation prenatal vitamins
adheres to the fallopian tube - avoid folic acid rich foods
❖ uterine fibroids - do not have intercourse
❖ benign fallopian tube carcinoma
NSG INTERVENTIONS:
❖ birth defects resulting in abnormal fallopian tubes or an 1. Upon arrival at the emergency room, place the woman flat in
abnormal uterus bed.
 2. Assess the vital signs to establish baseline data and ● Serum electrolytes
determine if the patient is under shock.
3. Maintain accurate intake and output to establish the patient's MANAGEMENT
renal function 1. Goal→ control nausea and vomiting
4. Determine the amount of bleeding, description, location and
severity of pain 2. Antiemetic
5. Assess the bleeding by weighing the linen or periods. a. Metoclopramide (Reglan)
6. Check laboratory values for 3. Small frequent feedings
a. Hemoglobin is the protein in red blood cells that 4. Adequate hydration
carries oxygen. 5. Ice chips
b. Hematocrit describes the concentration of red 6. Reassurance
blood cells in your blood
7. Assess for fever, elevated pulse, malaise, prolonged and NORMAL SALINE
malodorous vaginal discharge
➔ 1st choice for fluid replacement
◆ aids in hyponatremia
MALE (AGES 15+): 13.0 - 17.0 G/DL
◆ with vitamins 24-36 hrs oral foods and
FEMALE (AGES 15+): 11.5 - 15.5 G/DL fluids are withheld
HEMATOCRIT NORMAL RANGE: ◆ GI rest/ GUT rest
MALE: 40 - 55%
FEMALE: 36 - 48% MEDICATIONS
PLATELET COUNT NORMAL RANGE: ➢ Promethazine (Phenergan)
➢ Prochlorperazine ( Compazine)
ADULT: 150,000 - 400,000/ML
➢ Ondansetron ( Zofran)
WHITE BLOOD CELL (WBC) NORMAL RANGE:
ADULT: 5,000-10,000/ML MANAGEMENT
● 1st line fails
HYPEREMESIS GRAVIDARUM ●
●
Hospitalization
Dehydration
➔ pernicious/ persistent vomiting, NVP ● Ketosis
➔ most severe form of nausea and vomiting ● Electrolyte deficits
➔ characterized by: ● Acid base imbalance
◆ persistent nausea and vomiting leading to
dehydration, starvation, and death
NURSING DIAGNOSIS
◆ volume depletion
1. Risk for deficient fluid volume related to vomiting secondary
◆ ketosis
to hyperemesis gravidarum
◆ electrolyte disturbances
◆ weight loss 2. Imbalanced nutrition, less than body requirements, related to
➔ would cause: prolonged vomiting.
◆ weight loss
◆ dehydration NURSING INTERVENTIONS
◆ alkalosis 1. Taking a dry piece of toast or a cracker
◆ hypokalemia ( dry carbohydrate foods ) a half hour before getting out of
➔ Incidence is at 8-12 weeks of pregnancy and last significantly bed may produce relief.
longer ( peak), resolved by 20 weeks 2. Sip hot water ( plain or lemon juice), hot tea, clear coffee, hot
milk.
➔ 70-85% of pregnant patients experience nausea & vomiting
3. Discourage intake of greasy foods.
➔ 2-5 % of these women experience HG 4. Advise small frequent feedings of 5-6 times a day.
➔ NVP (nausea vomiting of pregnancy) 5. Advise a high-protein meals (cheese, eggs, meat),fruit, fruit
◆ KETOSIS- high ketones acid; low carbs juices
◆ METABOLIC ALKALOSIS - excess base 6. Avoid lying down after eating
● NORMAL pH - 7.35 to 7.45 avoid tight waistbands to minimize pressure on abdomen
◆ METABOLIC ACIDOSIS- decrease in pH below 7. Avoid noxious stimuli- strong flavors, strong odors
normal range Eat foods that settle the stomach- dry crackers, toast, soda
◆ ALKALOSIS- increase in normal 8. Administer IVF as ordered until the patient can tolerate oral
feedings
CAUSE/ ETIOLOGY
1. Unknown- ↑ thyroid function- ↑ HCG, estrogen, progesterone, 9. Start with clear liquid diet to full liquid, small frequent to full
prolactin diet high Chon less grease
2. Maybe associated with Helicobacter pylori (peptic ulcer) 10. Monitor fluid I&O, VS, skin turgor, daily wt, serum electrolyte
3. Psychological component levels, urine ketone levels, anticipate the need for electrolyte
replacement therapy
S/SX
1. Gastrointestinal in nature include nausea and vomiting. (↑ 11. Provide frequent mouth care
hematocrit, ↓ Na, K, Cl)
2. Signs of dehydration such as low blood pressure, ↑ PR, COMPLICATIONS
scanty urine 1. Dehydration
3. Other common symptoms include weight loss, ptyalism 2. Electrolyte imbalance
(excessive salivation), fatigue, weakness, and dizziness, 3. Renal failure
headache, lethargy or confusion. 4. Wernicke’s Encephalopathy (Thiamine deficiency)
5. Vitamin K deficiency : maternal coagulopathy or fetal
DIAGNOSIS intracranial hemorrhage
● History/ PE 6. Mallory Weiss tears- characterized by upper gastro-intestinal
● CBC bleeding secondary to longitudinal mucosal lacerations at the
● Urinalysis gastroesophageal junction or gastric cardia.
 7. Boerhaave syndrome- characterized by upper 6.Monitor uterine contractions and FHR by external monitor
gastrointestinal bleeding secondary to transmural perforation 7.Monitor amount of blood loss, pain level, and uterine
of the esophagus. contractility
8. Assess maternal vital signs
9. Monitor the lab results
PLACENTA PREVIA 10. Emotional support
11. Prepare for CS
➔ the development of the placenta in the lower uterine segment, 12. Monitor tocolytic agents
partially or completely covering the internal cervical os. LABORATORY FINDINGS
➔ an obstetric complication in which the placenta is attached to
the uterine wall close to or covering the cervix.
➢ TRANS ABDOMINAL ULTRASONOGRAPHY
- confirms suspicion of placenta previa
➔ Can sometimes occur in the later part of the first trimester, but
➢ CBC
usually during the second or third
➔ leading cause of ante-partum hemorrhage. It affects - decreased Hgb and HCT levels if bleeding is
approximately 0.5% of all labors. present
TREATMENT
TYPES: ● Immediate delivery in a pregnancy of 36 weeks or greater with
documented fetal lung maturity, the neonate should be
1. TOTAL PLACENTA PREVIA delivered by cesarean delivery.
● In the case of marginal placenta previa, with documented fetal
- occurs when the internal cervical os is completely lung maturity, double-setup examination should be performed
covered by the placenta. to determine whether the patient is a candidate for a trial of
2. PARTIAL PLACENTA PREVIA vaginal delivery.
● Low vertical uterine incision is probably safer in patients with
- occurs when the internal os is partially covered by an anterior placenta previa.
the placenta. ● Cesarean delivery may be performed regardless of
3. MARGINAL PLACENTA PREVIA gestational age if hemorrhage is severe and jeopardizes the
- occurs when the placenta is at the margin/edge of mother or fetus.
the internal os. POSSIBLE COMPLICATIONS
4. LOW- LYING PLACENTA PREVIA ❖ Death
- the placenta is implanted in the lower uterine
❖ Major bleeding (hemorrhage)
segment
- the edge of the placenta is near the internal os but ❖ shock
does not reach it.
CAUSES OTHER RISK FACTORS
● The cause of placenta previa is unknown 1. Previous placenta previa, cesarean delivery, or D&C
● Endometrial damage from previous pregnancies and 2. Women who have had previous pregnancies, especially a
defective decidual vascularization have been postulated as large number of closely spaced pregnancies, are at higher
possible mechanisms. risk.
3. Women who are younger than 20 are at higher risk and
PLACENTA ACCRETA women older than 30 are at increasing risk as they get older.
- abnormally adherent into the uterine wall 4. Women with large placenta from twins or erythroblastosis are
at higher risk.
PLACENTA INCRETA 5. Women who smoke or use cocaine may be at higher risk.
- placenta extends into the uterine muscles 6. Race is a controversial risk factor, with some studies finding
PLACENTA PERCRETA that people from
- placenta perforates through uterine muscles 7. Asia and Africa are at higher risk and others find no
difference.
EFFECTS OF PLACENTA PREVIA ON PREGNANCY AND LABOR
ASSOCIATED CONDITIONS ❖ Abnormal presentation and position
1. Maternal age. Placenta previa is three times more common at ❖ Premature labor
age 35 than at age 25 ❖ Prolonged labor
2. Increasing parity ❖ More chance of surgical intervention
3. Previous uterine scar
4. Prior placenta previa ❖ Placenta may be adherent
5. Tobacco and cocaine use ❖ Postpartum hemorrhage
6. Multiple gestation ❖ Fetal malformation
7. Previous myomectomy to remove fibroid ❖ High incidence of fetal hypoxia and mortality
SIGNS AND SYMPTOMS
● painless bleeding ❖ Maternal shock
● premature contractions ❖ Maternal death
●
●
baby is breech or in transverse presentation
uterus measures larger than it should acc. to gestational age ABRUPTIO PLACENTA
NSG MANAGEMENT 🡪 premature separation of the normally implanted placenta after
● Ensure the physiologic well being of the client and fetus. the 20th week of pregnancy, typically with severe hemorrhage.
● Provide client and family teaching 🡪 separation of the placenta (the organ that nourishes the fetus)
● Address emotional and psychosocial needs from the site of uterine implantation before delivery of the
● Health Teaching fetus.
○ Maintain a bed rest TYPES OF ABRUPTIO PLACENTA
○ Maintain a 8 glasses of water ● CONCEALED HEMORRHAGE
NSG INTERVENTIONS o the placenta separation centrally, and a large
1. Assess vital signs amount of blood is accumulated under the
2. Maintain bed rest or chair rest when indicated placenta.
3. Monitor amount and time of sleeping ● EXTERNAL HEMORRHAGE
4. Position mother on her left side o separation is along the placental margin, and blood
5. Restrict vaginal examination flows under the membranes and through cervix.
GRADE 1 ⮚ Placental abruption may cause preterm labor.
■ (mild, 10- 20% marginal separation)
■ small amount of vaginal bleeding and some uterine NURSING MANAGEMENT
contractions, no signs of fetal distress or low blood pressure o Continuous evaluation of maternal and fetal physiologic
in the mother. status.
o Vaginal bleeding is slight or absent (<500 ml). o Asses the need for immediate delivery
o Uterine tenderness.
o No fetal heart rate abnormalities are present. o Provide appropriate management.
o There is no evidence of shock or coagulopathy. o Provide client and family teaching.
GRADE 2 o Address emotional and psychosocial needs.
■ (Moderate, 20-50%) o Continuous observation of patient’s general condition, blood
■ mild to moderate amount of bleeding, uterine contractions, pressure, vital signs, bleeding and signs of shock.
the FHR may show signs of distress. o Continuous observation of fetal condition.
o External bleeding may be absent to moderate
o Initiation and continuous observation of IV transfusion.
(1000-1500 ml).
o Uterine tone may be increased. Tetanic uterine o Give medications accurately, especially for hypotension and
contractions and uterine tenderness may be shock if present.
present. o Regular urine analysis for proteinuria.
o Fetal heart tones may be absent and, when o Assessment and recording of intake and output.
present, often show evidence of fetal distress. o Assist in vaginal delivery.
o Maternal tachycardia, narrowed pulse pressure, o Provide pre-operative care.
and orthostatic hypotension may be present.
o Early evidence of coagulopathy NURSING INTERVENTION
GRADE 3 INDEPENDENT
■ (severe, >50%)
❖ Monitor amount of bleeding by weighing all pads.
■ moderate to severe bleeding or concealed bleeding, uterine
contractions that do not relax, abdominal pain, low blood ❖ Investigate pain reports, noting location, duration,
pressure, fetal death. intensity (0-10 scale), and characteristics.
o External bleeding may be moderate or excessive ❖ Monitor maternal V/S and FHR through continuous
(>1500 ml) but may be concealed. monitoring.
o The uterus is tetanic and tender to palpation. COLLABORATIVE
o Fetal death is common. ❖ Administer oxygen as indicated.
o Maternal shock is usually present.
o Coagulopathy is frequently present. LABORATORY STUDIES
CAUSES: ● CBC count
❖ Pre-eclampsia and hypertensive disorders ● Fibrinogen
❖ History of placental abruption (recurrence rate approximately ● Prothrombin time
10%) ● Blood urea nitrogen
● Kleihauer- Betke Test
❖ High multiparity
● Blood type
❖ Extremes of age (<20 y/o or > 35 years old) ● Rh type
❖ Trauma ● Ultrasonography
❖ Cigarette smoking, Cocaine use
❖ Excessive alcohol consumption ABRUPTIO PLACENTA
❖ Preterm, premature rupture of the membranes ● Pathology: Sudden separation of normally implanted
❖ Rapid uterine decompression after delivery of the first fetus in placenta.
a twin gestation, or rupture of membranes with ● Vaginal Bleeding: may not be obvious; concealed behind
polyhydramnios placenta. If visible, will be dark. Bleeding into uterine cavity.
● Pain: Sharp, stabbing pain in abd.
SIGNS & SYMPTOMS: ● Uterus: hard boardlike abd.
⮚ Placental abruption can begin any time after 20 weeks. Signs PLACENTA PREVIA
● Pathology: Abnormal implantation of placenta; lower in
and symptoms of placental abruption include:
uterine cavity.
⮚ Vaginal bleeding ● Vaginal Bleeding: Abrupt onset; bright red.
⮚ Abdominal pain Completely painless.
⮚ Back pain ● Uterus: Soft, unless uterine contraction is present.
⮚ Uterine tenderness
⮚ Rapid uterine contractions, often coming one right after
DISSEMINATED INTRAVASCULAR COAGULATION
another. 🡪 “consumptive coagulopathy”
⮚ Vaginal bleeding is present in 80% of patients and concealed 🡪 a life-threatening defect in coagulation that may occur with
in 20%. several complications of pregnancy like;
⮚ Pain is present in most cases of placental abruption and is o placental abruption
usually of sudden onset, constant, and localized to the uterus PLASMA FACTORS
and lower back. • Platelets
⮚ Localized or generalized uterine tenderness and increased • Fibrinogen
uterine tone. • Prothrombin
• Factor V
⮚ The uterus may increase in size with placental abruption
• Factor VIII
when the bleeding is concealed.
⮚ Amniotic fluid may be bloody. DISEASES THAT CAUSES DIC TO FALL INTO 3 GROUPS:
⮚ Shock is variably present. ● Infusion of thromboplastin into the circulation, which
⮚ Fetal compromise is variably present. consumes or uses up other clotting factor such as fibrinogen
 and platelets.
Placental abruption and prolonged retention of the
dead fetus can cause this because the placenta is
a rich source of thromboplastin.
● Endothelial damage – Severe preeclampsia and HELLP
(hemolysis, elevated levels of liver enzymes and low platelet
levels) syndrome are characterized by endothelial damage.
● Non-specific effects of some diseases. Diseases such as
maternal sepsis or amniotic fluid embolism are in this
category.
DIC allows excess bleeding to occur from the
vulnerable area such as IV sits, incisions, gums, or
the nose and from expected sites such as Placental
attachment during the postpartum period.
TREATMENT
❖ MISSED ABORTION
o delivery of the placenta and fetus to ends
production of thromboplastin which is fueling
the process
❖ Blood replacement products such as whole blood,
packed blood cells (RBC)
❖ Cryoprecipitate
o administered as needed to maintain the
circulating volume and to transport oxygen to
body cells.
NURSING CONSIDERATIONS
o Observe the bleeding from unexpected sites like IV insertion
and venipuncture for laboratory works.
o Nosebleeds and spontaneous bruising maybe early indicators
of DIC and shld be reported.
o Additonal IV line to prepare for additional crystalloids, colloids
or blood products.
o Administer Oxygen at 10 litters P/M be facemask due to blood
loss
o Monitor VS
o Monitor IO
o Weigh all blood soak materials to obtain accurate output.
o 1grm = 1 ml
■ If blood clots form in the deep veins of leg—
o Pain, redness, warmth, and swelling in the lower leg
■ If blood clot forms in the blood vessels in the brain—
o Headaches, speech changes, paralysis (an inability to
move), dizziness, and trouble speaking and
understanding
ACUTE DIC
• blood clotting in the blood vessels usually occurs first,
followed by bleeding.
• bleeding may be the first obvious sign.
• Serious bleeding can occur very quickly after developing
acute DIC.
• Thus, emergency treatment in a hospital is needed.
CHRONIC DIC
o Blood clotting occurs but doesn’t lead to bleeding
S/SX OF EXCESSIVE BLOOD CLOTTING
• Chest pain and shortness of breath if blood clots form in the
blood vessels in your lungs and heart.
• Pain, redness, warmth, and swelling in the lower leg if blood
clots form in the deep veins of your leg.
• Headaches, speech changes, paralysis (an inability to move),
dizziness, and trouble speaking and understanding if blood
clots form in the blood vessels in your brain. These signs and
symptoms may indicate a stroke.
• Heart attack and lung and kidney problems if blood clots
lodge in your heart, lungs, or kidneys. These organs may
even begin to fail.
INTERNAL BLEEDING
🡪 Can occur in kidneys, intestines & brain
🡪 Life threatening
🡪 S/SX
o Blood in your urine from bleeding in your kidneys or
bladder.
o Blood in your stools from bleeding in your intestines
or stomach. Blood in your stools can appear red or
as a dark, tarry color. (Taking iron supplements
also can cause dark, tarry stools.)
o Headaches, double vision, seizures, and other
symptoms from bleeding in your brain.
EXTERNAL BLEEDING
🡪 can occur underneath or from the skin, such as at the site of
cuts or an intravenous (IV) needle
🡪 also can occur from the mucosa.
o mucosa is the tissue that lines some organs and
body cavities, such as your nose and mouth.
🡪 may cause purpura or petechiae
o Purpura- purple, brown, and red bruises. This
bruising may happen easily and often.
o Petechiae-- small red or purple dots on your skin.
HEART DISEASES
🡪 disease-involves a variety of heart conditions both congenital
and acquired that complicate pregnancy
🡪 complicates approx. 1 % of all pregnancies
🡪 responsible for 5% of maternal deaths during pregnancy
o 75% -- valvular (often result of rheumatic fever)
▪ Underlying problem depends on location and severity of
defect
▪ Valve stenosis decrease blood flow
▪ Workload on heart chambers increases
▪ Regurgitation occurs through incompletely closed heart
chambers
▪ Workload on heart chambers increases
CONGENITAL HEART DEFECT
❖ Atrial septal defect
❖ Pulmonary stenosis
❖ Coarctataion of the aorta
❖ Ventricular septal defect
PHYSIOLOGIC CHANGES (LABOR & PUERPERIUM)
First stage
❖ cardiac output increases by15%. Uterine contractions
increases venous return , causing increase in cardiac output
& can cause reflex bradycardia.
Second stage
❖ increase in intra-abdominal pressure (valsalva’s) causes
increase in venous return and cardiac output
Third stage
❖ normal blood loss during delivery leads to
a. Decrease blood volume
b. Decrease cardiac output.
CAUSES FOR INCREASED CARDIAC OUTPUT DURING
PREGNANCY
❖ Cardiac output begins to rise in the first trimester and
continues as steady increase to peak at 32 weeks gestation
by 30% to 50% of pre pregnancy level.
⮚ Increases in stroke volume (early pregnancy)
⮚ Increase in heart rate (late pregnancy)
⮚ Decreased peripheral resistance
⮚ Decreased blood viscosity
CAUSES FOR FALL IN PERIPHERAL RESISTANCE o The end of the lung wet rales persisted
- 20-30% at 21-24 weeks & returns to normal at DIAGNOSIS
term ❖ ECG
⮚ Due to the trophoblastic erosion of endometrial vessels, the o severe arrhythmias, atrial fibrillation, atrial flutter,
placental bed serves as a large arteriovenous shunt causing Ⅲ degree atrioventricular block, ST segment and
lowered systemic vascular resistance T wave abnormalities and changes
⮚ Physiological vasodilation- secondary to endothelial ❖ Chest radiograph
prostacyclin & circulating progesterone o the heart was significantly expanded
CLINICAL FEATURES THAT MIMICS A CARDIAC DISEASE ❖ Echocardiogram
❖ Dyspnea - due to hyperventilation, elevated diaphragm. a. expansion of the heart chamber
❖ Pedal edema b. myocardial hypertrophy
❖ Cardiac impulse c. valvular motion abnormalities
o Diffused and shifted laterally from elevated d. cardiac structural abnormalities
diaphragm. FUNCTIONAL CLASSIFICATION OF CARDIAC DISEASE
❖ Jugular veins may be distended. CLASS I
❖ Systolic ejection murmurs along the left sternal border ⮚ No functional limitation of activity.
o occur in 96% of pregnant women ⮚ No symptoms of cardiac decompensation with activity.
o caused by increased flow across the aortic and ⮚ Patients have no limitation of physical activity. Ordinary
pulmonary valves. physical activity does not cause undue fatigue, palpitations,
dyspnea or anginal pain.
NORMAL HEMODYNAMIC CHANGES DURING PREGNANCY CLASS II
⮚ Mild amount of functional limitation.
⮚ Patients are asymptomatic at rest. Ordinary physical activity
results in symptoms.
⮚ Patients have slight limitation of physical activity. Ordinary
physical activity results in fatigue, palpitations, dyspnea or
anginal pain
CLASS III
⮚ Limitation of most physical activity.
⮚ Asymptomatic at rest
⮚ Minimal physical activity results in symptoms.
Patients have marked limitation of physical activity. Less than
ordinary activity causes fatigue, palpitations, dyspnea or
anginal pain.
CLASS IV
⮚ Severe limitation of physical activity results in symptoms.
⮚ Patients may be symptomatic at rest/heart failure at any point
of pregnancy.
⮚ Patients have inability to carry out any physical activity without
discomfort. Symptoms of cardiac insufficiency or of anginal
S/SX OF CARDIAC DISEASE syndrome may be present, even at rest. If any physical activity
❖ Progressive dyspnea is undertaken, discomfort is increased.
❖ Cyanosis MORTALITY ASSOCIATED WITH SPECIFIC CARDIAC LESIONS
❖ Irregular pulse Group I. Low risk of maternal mortality (less than 1%).
❖ Edema a) Septal defects
❖ Rapid or difficult respiration b) New York Heart Association classes I and II.
c) Patent ductus arteriosus.
❖ Syncope
d) Pulmonary / tricuspid lesions.
❖ Chest pain Group II. Moderate risk of maternal mortality (5-15%).
❖ Tachycardia a) NYHA classes III and IV mitral stenosis
❖ Left parasternal heave b) Aortic stenosis.
❖ Palpitations c) Marfan’s syndrome with normal aorta
❖ Any diastolic murmurs d) Uncomplicated coarctation of aorta
❖ Cough e) Past history of myocardial infarction
SIGNS OF CARDIAC DETERIORATION Group III. High risk of maternal mortality (25-50%).
● Weak pulse a) Eisenmenger's syndrome.
● Irregular pulse b) Pulmonary hypertension.
● Sweating c) Marfan’s syndrome with abnormal aortic root
● Weakness d) Peripartum cardiomyopathy.
● Cough
● Chest pain EISENMENGER SYNDROME
● Palpitations 🡪 there is irregular blood flow in the heart and lungs
● Dyspnea (shortness of breath) 🡪 This causes the blood vessels in the lungs to become stiff and
● Rales (crackling at base of the lungs) narrow.
EARLY SIGNS OF HEART FAILURE
🡪 Blood pressure rises in the lungs' arteries (pulmonary arterial
o Chest tightness, palpitations, shortness of breath after mild
hypertension).
activity
o Resting heart rate> 110 beats / min 🡪 permanently damages the blood vessels in the lungs.
o Respiration> 20 times / min MARFAN SYNDROME
o Paroxysmal nocturnal dyspnea 🡪 an inherited disorder that affects connective tissue — the
 fibers that support and anchor your organs and other
structures in your body
🡪 most commonly affects the heart, eyes, blood vessels and
skeleton
🡪 If your aorta — the large blood vessel that carries blood from
your heart to the rest of your body — is affected, the condition
can become life-threatening
MANAGEMENT OF VARIOUS CARDIOVASCULAR DISORDERS IN
PREGNANT WOMAN
❖ Peripartum Cardiomyopathy
o treatment of diuretics, sodium restriction, afterload-
reducing agents, anticoagulants, digoxin. ACE
inhibitor only postpartum because it is teratogenic
agent
❖ Rheumatic heart disease
o the AHA recommends prophylaxis to prevent
infective endocarditis only in those who are highest
risk.
❖ Mitral and Aortic Valve Stenosis
o reducing activity, sodium restriction, diuretic
therapy, B-blocking medication to lower HR, and
increased bed rest
❖ Mitral Valve Prolapse (MVP)
o specific tx is not necessary except for symptomatic
tachyarrythmias. Antibiotic prophylaxis may be
given for invasive procedures
❖ Eisenmenger's Syndrome
o physical activity is strictly limited and prophylactic
anticoagulation. intensive care monitoring
❖ Atrial and Ventricular Septal Defects
o like eisenmenger syndrome
❖ Tetralogy of Fallot
o Surgical correction, anticoagulant therapy, high
concentration oxygen administration,
hemodynamic monitoring during labor and birth as
well as prophylactic antibiotics
❖ Marfan syndrome
o limiting physical activity, preventing hypertensive or
hypotensive complications and administering B-
blockers as needed
❖ Heart Transplantation
o B-blocking agent during labor to prevent
tachycardia. After birth the neonate may exhibit
immunosuppresive effects in the first week life.
Mother taking cyclosporine should not breast feed
NURSING MANAGEMENT DURING PREGNANCY
▪ Nursing assessment (history)
▪ history of dyspnea ,palpitations , easy fatigability
▪ Identify other factors that would increase strain on heart
e.g anemia , infection , anxiety
▪ Family history of heart disease
▪ Determine the functional capacity of the heart by taking
the woman's pulse, respiration and blood pressure
NURSING CARE DURING ANTENATAL PERIOD
⮚ Assess cardiac status
⮚ Assess if symptoms of cardiac decompensation occur
o irregular, weak, rapid pulse (>100 bpm)
o progressive, generalized edema
o crackles that don't clear after coughing
o orthopnea; increasing dyspnea
o rapid respirations (> 26 breaths/min)
o moist, frequent cough
o cyanosis of lips and nail beds
o increase fatigue or difficulty breathing
o palpitations; feeling that her heart is "racing"
⮚ Teach signs and symptoms of deteriorating cardiac status
such as dyspnea, orthopnea, cough and hemoptysis and how
to report them
⮚ Decrease exertion reduces fatigue and promotes adequate
ventilation
⮚ Protection from infection
o inform the woman about the importance of the
protection from infection especially upper
respiratory infection
o teach patient to report signs and symptoms of
infection
⮚ Promotion of adequate nutrition
o a diet should be rich in iron, protein and essential
nutrition
o low in sodium
⮚ Promotion of rest
o rest is necessary to reduce the work load on heart
o 8-10 hrs. of sleep are essential with daily rest
period
o the patient should be instructed to rest on the left
side
o lateral recumbent position to facilitate blood flow to
the fetus
⮚ The woman should understand her condition
o signs of decompensation
o any medication she is taking and how to use it
o reason for the need to decrease activity if
symptoms occur
⮚ When therapy is being initiated the nurse must assist the
patient by;
o providing oxygenation
o providing skin care
o ensuring that constipation is avoided, stool sofener
o promoting good nutrition, low Na intake
⮚ Implementation of supportive therapy
o Use of prophylactic antibiotic on doctors order
o Oxygen by mask if dyspnea occur
o Administration of diuretics to reduce the venous
return to the heart and thereby decrease the
pulmonary and left atrial blood pressure so
reducing pulmonary congestion
o Sedative to help to alleviate anxiety and decrease
the voluntary muscles activity during the second
stage of labor
NURSING MANAGEMENT DURING LABOR AND DELIVERY
● Encourage relaxation and sleep between contractions
● Support the woman emotionally to be less anxious
● The nurse guards the woman against over exertion during
pushing by coaching her to use shorter more moderate open
glottis pushes with complete relaxation between pushes
● Monitor vital signs closely every 10 minutes during the second
stage
● Oxytocin is contraindicated for heart disease in first and
second stage
● Blood loss during 3rd and 4th stage of labor is kept to a
minimum by promoting delivery of the placenta and oxytocin
administration
NURSING CARE DURING POST PARTUM PERIOD
⮚ Promotion of recovery
o Monitor vital signs regularly
o Maintain the woman in semi- fowler's positions
o Facilitate bowel elimination by controlling the diet
o The woman resumes activity gradually and
progressively
COMPLICATIONS
▪ Myoccardial infarction
▪ Cardiomyopathy
▪ IUGR
▪ Pre- maturity
DIABETES MILLETUS
🡪 a metabolic disorder caused by defects in insulin secretion or
action, which lead to abnormalities in the metabolism of
carbohydrates, lipids and protein.
🡪 Chronic hyperglycemia associated with diabetes causes
 tissue damage in all organ systems
🡪 most common endocrine disorder affecting pregnancy
complicating approx. 4 % of all pregnancy
INSULIN
o hormone produced by the beta cells of pancreas that is
released when stimulated by elevated glucose levels.
o decreases blood sugar levels by accelerating the transport of
glucose into the body cells where it is oxidized for energy or
converted to glycogen or fat for storage.
o the key to the cell to let glucose inside the cell
GLUCOSE
o a form of sugar that circulates in the blood and provides the
major source of energy for body tissues
o Physiologic Role of Glucose
o Essential source of energy for the body's cells
o Main source of energy for the brain/neural cells
o Digestion converts carbohydrates to sugars (mainly
glucose). The glucose enters the portal circulation
and stimulates the pancreas to release insulin so it
may enter the cells
TYPES OF DM
❖ Type 1 DM (insulin-dependent or juvenile onset diabetes)
o immune-mediated disorder
o characterized by destruction of the beta cells of the
pancreas, which leads to an absolute insulin
deficiency
❖ Type 2 DM (non-insulin dependent or adult onset diabetes)
o individuals who are insulin resistant and usually
relative insulin deficiency
o the most prevalent form of diabetes, accounting for
90 percent to 95 percent of cases
o Can be controlled with lifestyle modification and
oral medications
o Classic signs of polyuria, polydipsia, and
polyphagia
o Most are obese or have an increase of fat in the
abdominal area
o Other risk factors are aging, sedentary lifestyle,
HTN, and prior gestational diabetes
❖ Pregestational diabetes
o is the label sometimes given to type 1 or 2 diabetes
that existed before pregnancy
❖ Gestational Diabetes Mellitus
o is any degree of glucose intolerance with its onset
or first recognition during pregnancy
GESTATIONAL DIABETES MELLITUS
🡪 occurs only during pregnancy
🡪 affects the way the body uses blood sugar (glucose)
🡪 As a result, the blood sugar level is too high.
🡪 If untreated or uncontrolled, gestational diabetes can result in
a variety of health problems to fetus and mother
🡪 Occurs: 20th- 24th week
🡪 Measured: 24th- 28th week
🡪 After the baby is born and placental hormones disappear from
the bloodstream, blood sugar levels should quickly return to
normal
NORMAL METABOLISM/ CAUSE OF GDM:
⮚ During digestion, body breaks carbohydrates into simple
sugar molecules that it can eventually use for energy
⮚ One of these sugar molecules is glucose, the main energy
source for the body
⮚ Glucose is absorbed directly into the bloodstream after
eating, but it can't enter the cells without the help of insulin
⮚ Pancreas – a gland located just behind the stomach produces
insulin continuously
⮚ The insulin escorts sugar into the cells, providing the body
with energy while maintaining a normal level of sugar in the
blood
⮚ Liver also plays a key role in maintaining a normal blood sugar
level.
o If presence of more glucose than the cells need for
energy, the body can remove that excess from the
bloodstream and store it in the liver as glycogen.
⮚ When runs low glucose – for example, if not eaten for a while
– body can tap into that stored glucose and release it into the
bloodstream.
⮚ The amount of glucose in the blood fluctuates in response to
a number of factors, including the food eaten, exercise, stress
and infections.
⮚ Yet the complex relationship among insulin, glucose and the
liver ensures that the blood sugar stays within set limits.
⮚ During pregnancy, the placenta – the organ that supplies the
baby with nutrients through the umbilical cord – produces
hormones that prevent insulin from doing its job
⮚ These hormones, which include estrogen, cortisol and human
placental lactogen, are vital to preserving the pregnancy.
o Yet they also make the cells more resistant to
insulin.
⮚ As placenta grows larger in the second and third trimesters, it
secretes even more of these hormones, further increasing
insulin resistance
⮚ Normally, the pancreas responds by producing enough extra
insulin to overcome this resistance
⮚ But may need up to three times as much insulin as normal,
and sometimes the pancreas simply can't keep up
⮚ When this happens, too little glucose gets into the cells and
too much stays in the blood resulting to hyperglycemia
RISK FACTORS FOR GDM:
● Age
o women older than age 25
● Family or personal history
o if a close family member, such as a parent or
sibling, has type 2 diabetes
● Gestational diabetes if present in a previous pregnancy
● Weight/obesity
o being overweight before pregnancy
● Race
o Native American, Hispanic, Asian
● Previous complicated pregnancy
o unexplained stillbirth or a baby who weighed more
than 9 pounds
● Glycosuria
COMMON S/SX
❖ Hyperglycemia (extreme thirst, frequent urination, dry skin,
hunger, blurred vision, drowsiness, nausea)
❖ Glycosuria
❖ Polyuria
❖ Polydipsia
❖ Increased hunger
❖ Weight loss
INSULIN REQUIREMENTS DURING PREGNANCY, POSTPARTUM
PERIOD, AND LACTATION
✔ First trimester
o insulin need is reduced because of increased
insulin production by the pancreas and increased
peripheral sensitivity; nausea, vomiting, and
decreased food intake by mother and glucose
transfer to embryo/fetus contributes to
hypoglycemia.
✔ Second trimester
o insulin need increases as placental hormones,
cortisol, and insulinase act as insulin antagonists,
decreasing the effectiveness of insulin
✔ Third trimester
o insulin requirements gradually increase until about
36 wks of gestation
✔ Day of delivery
o maternal insulin requirement drop drastically to
 approach pre-pregnancy levels.
✔ Breastfeeding mother maintains lower insulin requirements,
as much as 25% less than prepregnancy; insulin need of
nonbreastfeeding mother returns to prepregnancy levels in 7
to 10 days
✔ At weaning of breastfeeding infant, mother's insulin need
returns to pre-pregnancy levels
MATERNAL RISKS OR COMPLICATIONS ASSOCIATED WITH
DIABETES IN PREGNANCY
▪ There is a 28% increase in early pregnancy loss
▪ Cesarean birth
o failure to progress or failure of descent
▪ Preterm birth and labor
o ketoacidosis in 2nd and 3rd trimesters (nausea,
vomiting, dehydration, abdominal pain, low serum
bicarb, hypergylcemia, elevated ketones)
▪ Hypoglycemia occurs during sleep early in pregnancy when
hepatic production of glucose is dimished and peripheral use
of glucose is enhanced
▪ Hydramnios - 10x more likely
▪ Hypertensive disorders - preeclampsia, eclampsia
▪ UTI and severe diabetes
FETAL RISKS OR COMPLICATIONS ASSOCIATED WITH
DIABETES IN PREGNANCY
❖ Stillbirth
❖ Congenital anomalies, 6% - 10% increase
❖ CNS defects
o anencephaly, open spina bifida
❖ Cardiac defects
o ventricular septal defects (VSD) & transposition of
the great vessels
❖ Caudal regression
o 200 to 400x due to diabetic mothers
❖ Macrosomia, hypoglycemia. respiratory distress syndrome,
polycythemia and hyperbilirubinemia.
MACROSOMIA
🡪 a baby who is considerably larger than normal
🡪 If the maternal blood has too much glucose, the
pancreas of the fetus senses the high glucose
levels and produces more insulin in an attempt to
use this glucose
🡪 The fetus converts the extra glucose to fat.
🡪 The combination of high blood glucose levels from
the mother and high insulin levels in the fetus
results in large deposits of fat which causes the
fetus to grow excessively large.
HYPOGLYCEMIA
🡪 low blood sugar in the baby immediately after
delivery
🡪 This problem occurs if the mother's blood sugar
levels have been consistently high, causing the
fetus to have a high level of insulin in its circulation.
🡪 After delivery, the baby continues to have a high
insulin level, but there is no longer a high level of
sugar from its mother, resulting in the newborn's
blood sugar level becoming very low
DX OF GDM
▪ Fasting blood sugar-
o fasting plasma glucose of 126 mg/dl (NV 70-110
ave. 95 mg/dL)
▪ Random plasma glucose of 200 mg/dl
▪ Oral glucose challenge test
o is usually done between 24 and 28 weeks of
pregnancy. The client will be asked to drink a
glucose solution that tastes like extra-sweet soda
pop. A blood sample is drawn to determine the
blood sugar level.
o Normal: 140 mg/dL
o Blood sugar levels are checked every hour for a
period of 3hrs
o Having at least two instances of abnormally high
blood sugar levels confirms the diagnosis of
gestational diabetes
o 1 hr. plasma glucose- 180 mg/dL
2 hr. plasma glucose- 155 mg/dL
3 hr. plasma glucose- 140 mg/dL
▪ HBA1C or A1C
o Glucosated hemoglobin in percentage of total
hemoglobin - tells how much glucose is attached to
hemoglobin. Goal is < 7%.
MANAGEMENT
GOAL: maintain maternal glycemic control to reduce the risks
associated with the disease and promote fetal development
✔ GLYCEMIC GOALS
o Preprandial plasma glucose- 90 mg/dL -130 mg/Dl
o Peak postprandial- below 180 mg/L
o HbA1c Glycosylated hemoglobin measures the
amountt of glucose level of the person over the last
2 months. Results of more than 7 % of total hgb is
abnormal.
✔ Diet of 1800-2400 cal/day composed of 40% carbohydrates,
40% fat, 20% protein divided into 3 meals a day with 2-3
snacks per day.
✔ Self-monitoring of blood glucose at least 3 times a day with
the desired values of;
o before meal- 95 mg/dL
o 1 hr. after meal- < 140 mg/dL
o 2 hr. after meal- < 120 mg/dL
✔ Exercise may be beneficial for women with diabetes for
metabolic control and well-being.
Before exercising, the woman should check blood glucose
and urine ketones:
o If blood sugar is ≥250 mg/dl and if ketones are
positive, she should delay exercise.
o If blood sugar is <250 and ketones are moderate,
she should call her provider.
o If blood sugar is >250 and ketones are negative,
she can exercise
✔ Insulin therapy
o Patients who do not meet metabolic goals within
one week or show signs of excessive fetal growth,
insulin has been the usual first choice.
o Sulfonylureas (glyburide) may be used in selected
patients
o Other diabetes medications are not recommended
in GDM
o Diabetics taking oral hypoglycemic agents before
pregnancy should stop taking and change to insulin
▪ Category B - Aspart, Lispro, NPH, Lispro
protamine (used in pregnancy)
▪ All other insulins are Category C
ANTENATAL CARE
❖ First trimester: a ultrasound is obtained for viability, routine
labs, urine culture.
❖ 2nd trimester: fetal ultrasound for anatomy, or congenital
anomalies.
❖ 3rd trimester:
o ultrasound for fetal growth,
o surveillance of fetal well being (32-34 weeks) twice
a week.
o BPP (biophysical profile), Nonstress test
If an indication of preeclampsia or baby fetal heart
tones non-reassuring baby should be delivered.
❖ Preterm labor is more frequent among patients with diabetes.
o Tocolysis- given to delay delivery so that
glucocorticoid therapy can be given to mature the
babies lungs
o Magnesium sulfate- used to stop contractions
o Terbutaline should be avoided because it may
cause hyperglycemia
POSTNATAL MANAGEMENT
 ⮚ Blood glucose testing first few days after delivery ⮚ Weakness.
⮚ Fasting glucose rechecked 6-12 weeks following delivery ⮚ Pale or yellowish skin.
⮚ Every 6-12 months thereafter to be screened for Type 2 ⮚ Irregular heartbeats.
Diabetes-high risk of developing Type 2 Diabetes ⮚ Shortness of breath.
⮚ Dizziness or lightheadedness.
HEMATOLOGIC DISORDERS OF PREGNANCY ⮚ Chest pain.
IRON DEFICIENCY ANEMIA ⮚ Cold hands and feet.
• Disorder of oxygen transport DIET RICH IN IRON
• Associate wd low birth wt and preterm ❖ Meat
• Considered microcytic – small sized RBC ❖ Green leafy vegetables
• Hypochromic – less hgb than average RBC anemia, pale ❖ Legumes
• When iron intake is inadequate its
❖ Dark chocolate
available for incorporation into RBC
• As a result cells aren’t as large or as rich ❖ Oyster
in hgb as they are ❖ Soybeans
• Pseudo anemia – blood volume expands during pregnancy ❖ Fish
• True anemia – hgb less than 11 g/dl ❖ chicken
• Iron deficiency anemia – most common during pregnancy NURSING INTERVENTIONS
• low iron in the diet, heavy menstruation ✔ Instruct all pregnant mothers to take vitamins as prescribed
• 1000 mg of iron needed for pregnancy ✔ Take iron wd orange juice or vit c for better absorption
• MATERNAL EFFECTS: ✔ Monitor CBC, serum iron and ferritin - Ferritin is a blood
• s/s – pallor, lethargy, fatigue, headache protein that contains iron
• Inflammation of lips and tongue
✔ Assess family dietary habits
• PICA – consuming nonfood substances such as clay,
dirt, ice, and starch ✔ Take iron with meals though less absorption but no GI
• Laboratory findings discomfort
• RBC Microcytic (small) ✔ If anemia is severe O2 administration to reduce hypoxia
• Hypochromic (pale) ✔ Use Z tract when IM injection to avoid skin discoloration,
• Daily oral iron and folic acid supplementation with 30 mg to scarring, and irritating iron deposits in the skin
60 mg of elemental iron and 400 g (0.4 mg) of folic acid is ✔ If IV watch for signs of Allergic reaction
recommended for pregnant women to prevent maternal ✔ Watch for dizziness, headache, and thrombophlebitis around
anemia, puerperal sepsis, low birth weight, and preterm birth the IV site
ANEMIA ✔ Therapy for 6 months
🡪 a low red blood cell count, a low hematocrit, or a low NURSING MGT
hemoglobin concentration ● Encourage frequent rest period
🡪 In pregnancy, a hemoglobin concentration of less than ● Asses FHT
11.0 g/dL in the first trimester and less than 10.5 or 11.0 ● Iron best absorbs wd acid medium
g/dL in the second or third trimester (depending on the ● Causes gastric irritation
guideline used) is considered anemia. ● Constipation, encourage high fiber diet
🡪 most common hematologic abnormality in pregnancy ● Black stool and tarry
🡪 MATERNAL ANEMIA FOLIC ACID DEFICIENCY
o associated with adverse fetal, neonatal and
childhood outcomes, but causality is not 🡪 FOLIC ACID
established o a form of folate (a B vitamin) that everyone needs
o increases the likelihood of transfusion at o protects unborn babies against serious birth
delivery defects (Neural tube defects and abdominal wall
o Besides hemodilution, iron deficiency is the defects in fetus)
most common cause of anemia in pregnancy 🡪 Maternal needs for a folic acid double during pregnancy in
allergic reactions are rare. response to the demand for greater production of erythrocyte
• screening for anemia with a complete blood count in the first and fetal and placental growth
trimester and again at 24 0/7 to 28 6/7 weeks of gestation 🡪 Deficiency in folic acid-- results in a reduction in the rate of
(American College of Obstetricians and Gynecologists) DNA synthesis and mitotic activity of individuals cells resulting
• Mild anemia, with a hemoglobin of 10.0 g/dL or higher and a in the presence of large immature erythrocytes (Megaloblast)
mildly low or normal mean corpuscular volume (MCV) is likely
iron deficiency anemia. MEGALOBLASTIC ANEMIA
• A trial of oral iron can be both diagnostic and therapeutic. 🡪 Enlarge red blood cells
o Mild anemia with a very low MCV, macrocytic o due to size, the MCV mean corpuscular volume will
anemia, moderate anemia (hemoglobin 7.0–9.9 be elevated in contrast to the lowered level seen in
g/dL) iron def. anemia.
o severe anemia (hemoglobin 4.0–6.9 g/dL) 🡪 Folic acid or folacin is one of the vitamins important for the
o Oral Iron normal formation of RBC and the synthesis of DNA
▪ First-line of treatment o Water soluble and easily destroyed cooking, heat-
o New evidence suggests that intermittent dosing is labile
as effective as daily or twice-daily dosing with fewer o Seen in women who have an underlying hemolytic
side effects. For patients with iron deficiency illness that results from the destruction and
anemia who cannot tolerate, cannot absorb, or do distribution of RBC
not respond to oral iron, intravenous iron is AFFECTS FOLIC ABSORPTION
preferred • Hydantoin – anticonvulsant
SYMPTOMS • Contraceptives
⮚ Fatigue. • Sources of folic acid
 • Fortified grains
• Beans, black beans, lentils, peanuts, fresh dark green leafy
vegetables
ASSESSMENT FINDINGS
• Severe progressive fatigue – a hallmark of folic acid
deficiency
• Pallor or jaundice
• Shortness of breath
• Palpitations
• Diarrhea
• Nausea or anorexia
• Headache, weakness or lightheadedness
• Forgetfulness
• Irritability
MGT
• Folic acid supplement, orally or parenterally
• Diet high in folic acid - vitamins and fortified foods, such as
bread, pasta and cereals. Folate is found naturally in foods
such as leafy green vegetables, oranges, and dried beans,
peanut butter and liver.
• Encourage to eat rich in vit C to absorb folic acid
• Monitor pulse often – if tachycardia minimize work
• Asses maternal VS and FHT
• Monitor pts CBC, platelet count and serum folate.
DIAGNOSTIC FINDINGS
• Macrocytic RBC
• Macrocytosis is a term used to describe red blood
cells that are larger than normal. Also known as
megalocytosis or macrocythemia, this condition
typically causes no signs or symptoms and is
usually detected incidentally on routine blood tests.
• Decrease reticulocyte count
• Reticulocytes are slightly immature red blood
cells. A reticulocyte count is a blood test that
measures the amount of these cells in the blood. In
the presence of some anemias, the body increases
production of red blood cells (RBCs), and sends
these cells into the bloodstream before they are
mature.
• Increase mean corpuscular volume
• High MCV means that the RBC are too
large and indicates macrocytic anemia.
This condition can be caused by several
factors including low folate or vitamin
B12 levels or chemotherapy
• Abnormal platelet count
• Decreased serum folate level below 4 mg/ml
POSSIBLE COMPLICATONS
• Early spontaneous abortion
• Premature separation of placenta
• Fetal neural defect
SICKLE CELL ANEMIA
🡪 Common to black people
🡪 Recessively inherited hemolytic anemia by an abnormal
amino acid in the beta chain of hemoglobin.
🡪 If the abnormal amino acid replaces the amino acids valine,
sickling HbS results, if it is substituted for the amino acid
lysine, non-sickling hemoglobin HbC results
🡪 A healthy red blood cell is round like a jelly donut. These cells
are made of a substance called hemoglobin A, which helps
carry oxygen to the tissues of the body. For most people, the
blood is composed almost entirely of hemoglobin A.
🡪 If you inherited the mutation from one of your parents, you are
a carrier. Your blood likely is mostly composed of hemoglobin
A with some hemoglobin S. You typically don’t have
symptoms but can be at risk for some pregnancy
complications.
🡪 If you inherited a mutation from both of your parents, you have
sickle cell disease. Your blood is mostly composed of
hemoglobin S. You likely have noticeable symptoms, which
can increase during pregnancy.
MANIFESTATIONS
❖ Anemia
❖ Fatigue
❖ Complaints of burning and pain on urination
❖ Pooling of blood in lower extremities
❖ Severe pain if crisis develops
NURSING MGT
⮚ Periodically collect clean catch urine, prone to bacteriumia9
vascular stasis
⮚ Monitor nutritional intake of sufficient folic acid being
consumed
⮚ Sufficient intake of folic acid
⮚ Should not take a routine iron supplement
⮚ Ensure 8 glasses of water consumption, unless
contraindicated like nausea
⮚ Assess for varicosities (blood cell destruction)
⮚ UTZ for IUGR
INTERVENTIONS TO PREVENT SICKLE CELL CRISIS
• BT
• Controlling pain
• O2 administration
• Watch for s/s of infection fever ,chills
• Blood flow velocity test – gto determine blood flow to the
uterus and placenta, reduce blood flow indicates IUGR
• Percutaneous umbilical blood sampling – determine if the
fetus has the dse. sample for RBC electrophoresis
• Electrophoresis is a laboratory technique used to separate
DNA, RNA or protein molecules based on their size and
electrical charge.
MULTIPLE PREGNANCY
● Increase use of fertility drugs
o doubling of the incidence of multiple gestations.
o 2 to 3 %. Of all births.
● IDENTICAL TWINS
o Begins w/ a single ovum & spermatozoon
o During first division—zygote divides into two
identical individuals
o Single ovum twins one placenta, one chorion, two
amnion and two umbilical cords
S/Sx
✔ Increase in uterus size at a rate faster than usual.
✔ Quickening at different areas of the abdomen
✔ More fetal activity than expected
✔ Multiple sets of fetal heart sounds
✔ Increased fatigue and backache
✔ Elevated alpha-fetoprotein levels
✔ Evidence of multiple gestational sacs or amniotic sacs
❖ During pregnancy, if your AFP blood levels are higher or lower than
normal, it may be sign that:
• The baby has a high risk of having a genetic disorder,
such as:
• neural tube defect-- serious condition that
causes abnormal development of a
developing baby's brain and/or spine
❖ Maternal AFP levels in pregnancy
• start to rise from about the 14th week of gestation up
until about 32 weeks of gestation
• Between 15 and 20 weeks, AFP levels usually range
between 10 ng/ml to 150 ng/ml
PROBLEMS IN MULTIPLE PREGNANCY
1. Prematurity
a. Risk of pre term delivery twins increased 5-fold
b. And 10-fold for triplets
c. 14% twins and 41% triplets born very pre-term
2. Intrauterine growth restriction
 a. Often manifest as discordant growth • advised the mother abt her condition and Close frequent
3. Congenital malformations increased 2-fold follow-up.
In monochorionic twins only • Encourage frequent rest period to avoid fatigue
4. Increased rate of maternal pregnancy disorders • Rest in side lying to avoid supine hypotension syndrome
- Pre-eclampsia, gestational diabetes, APH etc • Monitor maternal v/s, wt gain, fundal ht, fht and position every
5. Overall PeriNatal mortality increased 2 – 3-fold visit
• Encourage UTZ
TYPES OF TWIN PREGNANCY • Urge the woman to take prenatal vitamins and balanced diet
⮚ Dizygotic and iron
o arise from two eggs. • Be cautious abt. the signs of preterm labor
o These are non-identical twins • Allow the woman to verbalize her concerns
⮚ Monozygotic
o one egg or embryo that splits COMPLICATIONS
o identical • Pregnancy-induced hypertension
But from a clinical perspective it is chorionicity that is important: • Polyhydramnios, (500-1000 ml normal), 2000 m polyhy- 24
o Dichorionic (two chorion, separate sacs and placentas) cm index
o Monochorionic (one chorion and a shared placenta) • Placenta previa
• Preterm labor
IDENTICAL TWINS • Anemia
o Develop from single fertilized ovum • Postpartum bleeding
o Of same sex and have same genotype • Preterm births
o Identical twins usually have common placenta; monozygosity • Velamatous cord insertion – happens when the umbilical cord
is not affected by environment, race, physical characteristics, that connects you and your fetus doesn't attach to the
or fertility placenta correctly,
o Both fetus are same sex with same characteristics • knotting n twisting of umbilical cords
o Single placenta • Twin -to -twin transfusion – an overgrowth of one fetus,
o Number of amnions and chorions present - depends on timing undergrowth of the second.
of division
o Division within 3 days of fertilization; two embryos, two POLYHYDRAMNIOS/ HYDRAMNIOS
amnions, and two chorions will develop • can cause fetal malpresentation due to space
o Division about 5 days after fertilization • Premature membrane rupture due to increased pressure
Two embryos develop with separate amniotic sacs. Sacs will leads to infection prolapse cord and preterm birth.
eventually be covered by a common chorion • Amniotic fluid (fetal urine, amniotic membrane)
o Monochorionic-diamniotic placenta • Difficulty of the fetus to swallow (anencephalic) or absorb or
o If amnion already developed, division approximately 7 to 13 excessive urine production
days after fertilization • diabetic mother
o Two embryos with common amniotic sac and common
chorion S/SX
o Monochorionic-monoamniotic placenta occurs about 1% of • Rapid enlargement of the uterus
the time • Difficulty to auscultate the FHT
• Extreme shortness of breath
SUPERFECUNDATION • Lower extremity varicosities n
✔ Fraternal twins are the result of hyper ovulation, • Hemorrhoids due to venous return from the lower extremities
o the release of multiple eggs in a single cycle. are blocked by extensive uterine pressure
• Wt gain
✔ Superfecundation describes a situation in which each of the
• EDEMA of the vulva, legs and abdomen
eggs are fertilized by sperm from different men, leading them
to have different biological fathers (making the twins half-
siblings). AMNIOTIC BAND SYNDROME
✔ The appropriate term to describe this situation is hetero 🡪 constriction ring syndrome
paternal superfecundation. 🡪 happens when fibrous bands of the amniotic sac (the lining
✔ One way hetero paternal superfecundation could occur is if a inside the uterus that contains a fetus) get tangled around a
woman has sexual intercourse with two different men within developing fetus.
the same timeframe that both embryos are conceived. 🡪 In rare cases, the bands wrap around the fetus' head or
FRATERNAL TWINS umbilical cord.
o Dizygotic NSG MGT
o Arise from two separate ova fertilized by two separate • High protein diet, low sodium
spermatozoa • Mild sedation
o Two placentas, two chorions, and two amnions • Indomethacin (Indocin)
o Sometimes placentas fuse and appear to be one • Amniocentesis
o No more similar to each other than singly mom siblings • Induction of labor if fetus is mature and symptoms are severe
o May be of same or different sex MGT
• Avoid constipation – straining might lead to uterine rupture
WHEN TO DELIVER? • Assess vs
NICE Recommendations: • Amniocentesis to remove excess extra fluid
✔ 35 completed weeks for monochorionic twins • Tocolysis to halt labor
✔ 37 completed weeks for dichorionic twins
OLIGOHYDRAMNIOS
✔ Because of the very poor prognosis associated with MCMA
• less than the average amniotic fluid highly concentrated
pregnancies many perinatologists recommend:
• due to bladder or renal problem that hinder normal voiding
Elective Caesarean at 32w after steroids
• due to iugr
• hypoplastic lungs
NSG INTERVENTIONS
 • potter syndrome and potter phenotype to a group of findings
associated with a lack of amniotic fluid and kidney failure in
an unborn infant. Amniotic fluid not only protects the fetus
from injury and temperature changes, it also is circulated by
the fetus every 3 hours.
PULMONARY HYPOPLASIA
🡪 is a condition in which the lungs are abnormally small, and do
not have enough tissue and blood flow to allow the baby to
breathe on his or her own. This can be a life-threatening
condition
POTTERS SYNDROME
NSG MGT
• Monitor vs, fht closely
• Monitor maternal wt gain pattern
• Emotional support
• Watch for continuous fluid drainage via the vagina, report any
sudden cessation of fluid flow. Which suggests fetal head
engagement leading to fluid retention within the uterus and
possible development of hydramnios.
COMPLICATIONS
• Dystocia
• Umbilical cord compression
• Abnormal fetal heart rate patterns
TEENAGE PREGNANCY
✔ affects about 6% of Filipino girls
✔ a teenage girl within the years of 13 - 19 becoming pregnant
✔ Teen Pregnancy Prevention is important to the health and
quality of life for youth
✔ Engaging in sexual risk behaviors such as having sex at an
early age, having more than one sex partner, and not using
condoms or contraceptives can lead to unintended
pregnancy, STD’s, and HIV infection
FACTORS CONTRIBUTING TO ADOLESCENT PREGNANCY
What causes teenage pregnancy?
► Lack of Approximately 90% of births to girls aged 15-19 in
developing countries occur within early marriage where there
is often an imbalance of power, no access to contraception
and pressure on girls to prove their fertility.
► Factors such as parental income and the extent of a girl’s
education also contribute. Girls who have received minimal
education are 5 times more likely to become a mother than
those with higher levels of education.
► Pregnant girls often drop out of school, limiting opportunities
for future employment and perpetuating the cycle of poverty.
In many cases, girls perceive pregnancy to be a better option
than continuing their education.
REASONS FOR HIGH NO. OF ADOLESENT PREGNANCY
► EARLIER AGE OF MENARCHE – 9y/O
► RATES OF SEXUAL ACTIVITY AMONG TEENAGERS
► LACK OF KNOWLEDGE ABT CONTRACEPTION AND
ABSTINENCE
► DESIRE OF YOUNG GIRLS TO HAVE A BABY
DEVELOPMENTAL TASKS
⮚ To establish a sense of self worth
⮚ To emancipate from parents
⮚ To adjust to a new body image
⮚ To choose a vocation
Adolescent pregnancies are a global issue but most often occur in
poorer and marginalized communities. Many girls face considerable
pressure to marry early and become mothers while they are still children
themselves.
Girls must be able to make their own decisions about their bodies
and futures, understand the effects of teenage pregnancy, and have
access to appropriate healthcare services and comprehensive sexuality
education
PREVENTION
▪ Abstinence
▪ Protected sex (condom use, birth control, IUD, etc.)
▪ Talking to teens about outcomes and risk factors of
pregnancy
▪ Comprehensive sex education
RISK FACTORS
● Low birth weight
● Premature birth
● Pregnancy induced high blood pressure (preeclampsia)
● Higher rate of infant death
● 38% of teen girls who have a child before 18 get a high school
diploma by age 22
● 30% of teen girls who have dropped out of high school say
pregnancy is a
reason
● 67% of teen mothers who moved out of their families’ house live
below the
poverty level
● Children born to teen mother score significantly worse on math
& reading tests
DIAGNOSIS
● Pregnancy urine tests
○ Detects if human chorionic gonadotropin (hCG) is present to
indicate pregnancy
○ Home pregnancy tests are more than 97% accurate
○ Always best to do with the first urination in the morning
○ If unsure, retest again!
● Blood tests
○ Also detects if human chorionic gonadotropin (hCG)
WHAT ARE THE EFFECTS OF TEENAGE PREGNANCY
► Adolescent pregnancy remains a major contributor to
maternal and child mortality. Complications relating to
pregnancy and childbirth are the leading cause of death for
girls aged 15-19 globally. Pregnant girls and adolescents also
face other health risks and complications due to their
immature bodies. Babies born to younger mothers are also at
greater risk.
► For many adolescents, pregnancy and childbirth are neither
planned, nor wanted. In countries where abortion is prohibited
or highly restricted, adolescents typically resort to unsafe
abortion, putting their health and lives at risk. Some 3.9 million
unsafe abortions occur each year to girls aged 15-19 in
developing regions.
► Adolescent pregnancy can also have negative social and
economic effects on girls, their families and communities.
Unmarried pregnant adolescents may face stigma or rejection
by parents and peers as well as threats of violence. Girls who
become pregnant before age 18 are also more likely to
experience violence within a marriage or partnership.
 • Low nasal bridge
• Epicanthal folds (eyes)
• Minor ear abnormalities
• Thin upper lip
• Receding jaw

POSITIVE PARENTING PRACTICES

● Stay informed about where your teen is getting information and
what health
messages they are learning
● Identify opportunities to have conversations about sex and
pregnancy and have frequent conversations
● Be relaxed and open
● Avoid overreacting
BEHAVIORAL EFFECTS ASSOCIATED WITH FAS
PARENTS TALKING ABOUT SEX WITH TEENS •Attention deficit/hyperactivity disorder (ADHD)
● Teens are influenced by their parents’ values, beliefs, and • Inability to foresee consequences
expectations of • Inability to learn from previous experience
appropriate behavior • Lack of organization
● Topics to be discussed: • Learning difficulties/poor abstract thinking
○ Healthy, respectful relationships • Poor reasoning and judgment skills
○ Communicate your own expectations for your teen about • Poor memory and impulse control
relationships and sex • Speech and language problems
○ Provide factual information about ways to prevent STD’s and • Poor judgment
pregnancy (abstinence, condoms,
birth control, testing) COCAINE IN PREGNANCY
○ Focus strongly on benefits of protecting oneself from pregnancy • Vasoconstriction, gestational hypertension, abruptio
○ Provide information on where your teen can receive sexual placenta, abortion, CNS defects, IUGR
health services • Cocaine causes the release of catecholamines which
causes:
COMPLICATIONS ⃰ Increase in HR & B/P (r/t vasoconstriction)
1. IRON DEFICIENCY ANEMIA, DUE TO MENSTRUAL FLOW ⃰ Increase in fetal B/P
2. Preterm labor - not fully grown uterus ⃰ Increased uterine activity-risk of preterm labor and birth
3. CPD – lack of engagement at the beginning of labor, prolonged ⃰ Decreased uterine blood flow-not good for fetus
first stage, and poor fetal descent (Partograph)
4. postpartum hemorrhage – girl’s uterus is not fully developed, it PERINATAL RISKS WITH COCAINE USE
becomes over-distended by pregnancy. Risk of spontaneous abortion = 40-50%
5. Overdistended did not fully contract Risk of preterm Labor = as high as 60%
6. deeper perineal n cervical lacerations - RT to size of infant and • After BP surges, the risk for placental abruption increases
body of mother adolescent muscle stretch more • Infants born to cocaine addicted mothers have additional risks:
7. Postpartum depression – inability to adapt postnatally ⃰ Increased risk for SIDS
8. Inability to breastfeed ⃰ Irritable & difficult to calm
⃰ Poor feeders with diarrhea, weak/absent abdominal muscles
⃰ Fetal anomalies: cardiac, neuro, GU, GI
SUBSTANCE ABUSE IN PREGNANCY ⃰ Learning disabilities & delayed language, motor & intellectual
Alcohol development
• No level is safe
Spontaneous abortion due to fetoplacental dysfunction, small for MARIJUANA IN PREGNANCY
gestational age ● Increases carbon monoxide levels in the mother's blood,
ADHD, oppositional defiant disorder, conduct disorder thereby reducing oxygen supply to fetus.
Future drinking problems in adult offspring ● Babies born to women who use marijuana exhibit altered
• Fetal Alcohol Spectrum Disorder responses to visual stimuli, increased tremulousness, high-
Fetal Alcohol Syndrome (FAS) is now a classification under pitched cry, anemia, inadequate weight gain, hyperactive
the broader term of fetal alcohol spectrum disorder (FASD) startle reflex, prematurity, IUGR

Fetal Alcohol Syndrome TOBACCO IN PREGNANCY

CDC Diagnostic Criteria
1. Growth problems
3. Facial dysmorphia
• Smooth philtrum
• Thin vermillion border
• Short palpebral fissures
1.Impaired oxygen delivery, nicotine induced vasospasm,
2. CNS abnormalities carbon monoxide, other chemicals, chromosomal instability,
lung development
• Short nose 2. Preterm delivery, low birth weight, small for gestational
• Flat midface age, PPROM, placenta previa, abruptio placenta, IUFD
3. SIDS, asthma, otitis media
3. SIDS, asthma, otitis media
 4. Idiopathic mental retardation, ADHD 1. Mild Preeclampsia
5. Obesity and diabetes in adult offspring a. Previously normotensive woman
6. Smoking and use of nicotine substitutes in first 12weeks, b. SP of > 140 mmHg
slght risk of congenital malformation c. DP of > 90 mmHg
7. Pharmacotherapy for those who are unlikely to quit d. Proteinuria of > 300 mg in 24 hour collection
e. Nondependent edema
OPIATES AND NARCOTICS EFFECTS ON FETUS
Abruptio placenta, preterm labor, premature rupture of membranes, 2. Severe Preeclampsia
perinatal asphyxia, newborn sepsis and death, intellectual impairment, a. BP of > 160 systolic or >110 diastolic
malnutrition b. > 5 gr of protein in 24 hour urine or > 3+ on 2
dipstick urines greater than 4 hours apart
SEDATIVES EFFECTS ON FETUS c. Oliguria of < 500 mL in 24 hours
CNS depression, newborn withdrawal, maternal seizures in labor, d. Cerebral or visual disturbances (headache,
delayed lung maturity scotomata)
e. Pulmonary edema or cyanosis
HEROIN IN PREGNANCY f. Epigastric or RUQ pain
Pre-eclampsia, third trimester bleeding, IUGR, PROM, infections, g. Evidence of hepatic dysfunction
malpresentation, preterm labor (prematurity), nonreassring fetal status, h. Thrombocytopenia
IUFD i. Intrauterine growth restriction (IUGR)

CAFFEINE IN PREGNANCY General Signs of Preeclampsia

Vasoconstriction and mild diuresis in mother; fetal stimulation, but 1. Rapid weight gain; swelling of arms/face
teratogenic effects not documented via research 2. Headache; vision changes (blurred vision, seeing double,
seeing spots)
TOXEMIA OF PREGNANCY 3. Dizziness/faintness/ringing in ears/confusion
PREGNANCY-INDUCED HYPERTENSION 4. Abdominal pain
HYPERTENSIVE VASCULAR DISEASE 5. ↓ production of urine
6. nausea and vomiting
HYPERTENSIVE STATES OF PREGNANCY
Eclampsia- the most severe classification of PIH with occurrence of
🡪 Is the global cause of maternal and fetal morbidity and generalized convulsion and/or coma in the setting of preeclampsia, with
mortality which is responsible for about 76,000 deaths per no other neurological condition.
year. a.Diagnosis of preeclampsia
Major cause of maternal and perinatal morbidity and mortality b. Presence of convulsions not explained by a
🡪 Complicates up to 10% of pregnancies neurologic disorder
🡪 Second leading cause of maternal mortality in the developed c. Grand mal seizure activity
world. d. Occurs in 0.5 to 4% or patients with
🡪 1/3 of all maternal deaths are from hypertensive disorders preeclampsia
PREGNANCY-INDUCED HYPERTENSION e. Seizures or coma r/t hypertensive
encephalopathy; most serious complication.
🡪 is a hypertension that develops after the 20th weeks of
f. Major cause of maternal death r/t intracranial
gestation to a previously normotensive woman. It includes
hemorrhage
preeclampsia, eclampsia and gestational hypertension
g. Maternal mortality rate is 8-36%
h. Deliver by C/S ASAP
Thromboxane
– powerful vasoconstrictor and stimulant of platelet
3. Superimposed Preeclampsia on Chronic Hypertension
aggregation, antagonist prostaglandin.
a. Occurs when a woman having chronic HPN develops pre-
Endothelin
eclampsia during pregnancy.
- releases due to placental ischemia, toxic to endothelial cells.
b. Affects 10-25% of patients with chronic HTN
c. Preexisting Hypertension with new onset of proteinuria
CATEGORIES OF HYPERTENSION
and thrombocytopenia.
1. Chronic HTN/Preexisting HTN
a. Presence of HPN before pregnancy
4. Transient HTN/Gestational HTN
b. Systolic pressure of ≥ 140 mmHg
a. BP of >140 /90 without proteinuria or other signs of
c. Diastolic pressure of ≥90 mmHg, or both.
preeclampsia
d. Presents before 20th week of pregnancy or
b. Normotensive patient may become hypertensive late in
persists longer than 12 weeks postpartum.
pregnancy, during labor, or 24 hours postpartum.
e. Not associated w/ proteinuria
c. Develops in late pregnancy, after 20 weeks gestation.
2. Preeclampsia- is a new onset of hypertension and proteinuria after
d. Resolves by 12 weeks postpartum
20 weeks gestation.
e. Can progress into preeclampsia.
a. Systolic blood pressure of ≥140 mmHg or diastolic blood
f. Indications for and choice of antihypertensive therapy are
pressure of ≥90 mmHg
the same as for women with preeclampsia.
b. Blood pressure elevated on two occasions at least 6
hours apart
RISK FACTORS FOR HYPERTENSION IN PREGNANCY
c. Proteinuria of 0.3 g or greater in a 24-hour urine specimen
1.Molar pregnancy
d. Associated with proteinuria and edema e. Preeclampsia
2. Preexisting HTN, Diabetes mellitus
before 20 weeks, think of molar pregnancy
3. Renal or vascular disease
4. Prior history of preeclampsia/eclampsia
Categories of Preeclampsia
5. Nulliparity/ primagravida
1. Mild Preeclampsia
6. Preeclampsia in a previous pregnancy
2. Severe Preeclampsia
7. Age > 40 years or <20 years
8. Family history of pregnancy-induced hypertension
 9. Chronic hypertension Altered sensorium
10. Multifetal gestation Urine output < 25-30 cc/hour
11. High body mass index
12. Pregnancy Complications MAGNESIUM TOXICITY
(H-mole, DM) a. sharp drop in BP
13. Hereditary b. respiratory paralysis
c. disappearance of patellar reflex
Frequency: 5% of all pregnancies in US STOP infusion, give O2 & calcium gluconate ASAP.
Causes: Unknown Antidote: 10 ml of 10% solution of calcium gluconate IV over 3 minutes
Theories: Maternal immune reaction that leads to systemic peripheral
vascular spasm >leads to endothelial cell damage > vasoconstriction> Alternate Anticonvulsants
increased BP. Have not been shown to be as efficacious as magnesium sulfate and
Affects multiple organs >reduced blood supply to kidneys, liver, may result in sedation that makes evaluation of the patient more difficult
placenta, brain> can lead to placental abruption and fetal and maternal 1. Diazepam 5-10 mg IV
death. 2. Sodium Amytal 100 mg IV
3. Pentobarbital 125 mg IV
Management 4. Dilantin 500-1000 mg IV infusion
- Usually, only cure is delivery
- Depends on symptoms HELLP SYNDROME
a distinct clinical entity with:
Mild Preeclampsia • Hemolysis
1. Promote Bed Rest • Elevated Liver enzymes
2. Monitor @ home or hospital • Low Platelets
3. Deliver if close to EDC. • Occurs in 20% of patients with severe
4. Frequent BP’s, 24 hour urine, liver enzymes, FHR, and ultrasounds. preeclampsia
5.Monitor antiplatelet therapy-low dose aspirin may be given to prevent • Thrombocytopenia
or delay development of severe preeclampsia (50-150mg) • Hepatocellular dysfunction
6. Provide emotional support
🡪 HEELP syndrome happens when red blood cells become
Severe Preeclampsia fragmented as they pass through small, damaged blood
1. Goal is to prevent convulsions and control maternal BP. vessels. Due to elevated liver enzymes are the result of the
2. Support bed rest liver secondary to obstruction from fibrin deposits.
3. Monitor maternal well being 🡪 Syndrome-the target organ is the liver.
a. monitor BP at least q4 • Vasospasms cause vasoconstriction and lead to
b. obtain blood studies such as CBC, platelet count, liver function, reduction in blood flow to uterus/other organs.
BUN, creatinine • Leads to ↑ BP, visual disturbances, low UO, ↓
c. an IC maybe inserted to monitor I &O HCT
4. Monitor fetal well being • Anemia; Epigastric/RUQ pain & tenderness d/t
a. continuous monitoring of FHR liver swelling.
b. Nonstress test or biophysical profile-a simple procedure • Weakness, fatigue, jaundice.
that checks how often the baby moves and how much his • Hemolysis > destruction blood cells; + anemia.
heart rate increases with movement. ↑ liver enzymes > sign of liver damage.
It is done to make sure the fetus is getting enough oxygen • Low platelets - ↑ peripheral vascular destruction.
and nourishment • CBC, platelet count, PT, PTT, LFT’s, uric acid
c. Oxygen administration to mother to maintain adequate
fetal oxygenation DIC: DISSEMINATED INTRAVASCULAR COAGULATION
5. Support a nutritious diet • Blood begins to coagulate throughout the entire body.
a. moderate to high protein diet Widespread fibrin deposits in capillaries/arterioles. Body
b. moderate sodium restriction depleted of platelets and coagulation factors; ↑ risk of
6. Administer Medication to prevent eclampsia hemorrhage. Over activation of clotting cascade.
7. Give medical therapy • Results in decreased blood flow & ↑ tissue damage
a. Hydralazine-peripheral vasodilator, 5-10 mg every 20 • Always a secondary diagnosis
minutes
Side effects: headache, flushing, tachycardia, lupus like Causes: ↑ tissue thromboplastin d/t vascular damage
symptoms Triggers: amniotic fluid embolism, eclampsia, abruption, pre-
b. Labetalol - Alpha and Beta blocker, 20mg, then 40, then eclampsia, HELLP, trauma, sepsis
80 every 20 minutes, for a total of 220mg
Side effects: hypotension Both HEELP and Preeclampsia occur during the later stages of
c. Nifedipine- CA channel blocker,10 mg po, not sublingual pregnancy and sometimes after childbirth.
Side effects: chest pain, headache, tachycardia Therapeutic mgt.
d. Nitroprusside- direct vasodilator, 0.2 – 0.8 mg/min IV 1. lowering high blood pressure
Side effects: cyanide accumulation, hypotension a. labetalol
e. Clonidine- Alpha agonist, works centrally, b. hydralazine
1 mg po 2. magnesium sulfate
Side effects: unpredictable, avoid rapid withdrawal 3. Blood component therapy
Seizure Prophylaxis
Magnesium sulfate, 4-6 g bolus, 1-2 g/hr
Works as a centrally acting anticonvulsant
Monitor urine output
With renal dysfunction, may require a lower dose
Respiratory rate < 12