M 102

HIGH RISK PREGNANCY

Prepared by: RUBY V. DE LUNA RM,RN,MAN

Identifying potential risk of a pregnancy is an important part of prenatal care. When risk factor are known early in pregnancy,
timely
preventive measures can be instituted and early treatment can be provided for disease conditions to ensure successful
pregnancy
outcome and prevent complications

HIGH RISK PREGNANCY - One in which a concurrent disorder, pregnancy – related complication, or external factor
jeopardizes the health of the mother, the fetus, or both.

HIGH RISK FACTORS

1. Biophysical and Socio-demographic Factors
a. Genetic considerations
b. Age
 Adolescent / early pregnancy
 Mature / multiparous mothers
c. Nutritional status
 Diet
 Height
 Weight

d. Medical and Obstetric disorders

e. Marital Status
f. Race and Ethnicity
g. Income
h. Residence

2. Behavioral and Psychosocial Factors

a. Teratogens
b. Smoking
c. Caffeine
d. Alcohol
e. Drugs
f. Dental hygiene
g. Abuse and violence
h. Psychological status

3. Environmental Factors
a. Infections
b. Radiation
c. Chemicals
d. Pollution (smoking)
e. Stress
f. Occupational hazard
 Prolonged shift
 Extreme heat
 Exposure to radiation

GOALS OF NURSING CARE

 1. Identify risk factors and estimate the potential effect of the pregnancy outcome.
2. Promote the wellbeing of the mother and the fetus / baby.
3. Prevent development or worsening of complications.
4. Educate pregnant clients on how to maintain a safe, healthy and enjoyable pregnancy.

BLEEDING DISORDERS

Hemorrhage- rapid loss of more than 1% of body weight in blood.

Hypovolemic Shock- occurs bleeding results in blood loss amounting to 1.5-2L
Perinatal Hemorrhage- hemorrhage occurs during pregnancy labor and delivery.
1. Antepartum hemorrhage- hemorrhage occur anytime during pregnancy, labor and delivery
Early – before 20 weeks
Late- after 20 weeks
2. Intrapartum hemorrhage- hemorrhage occurs during labor and is most commonly due to:
- Placental abruption
- Uterine rupture
- Uterine inversion
- Abnormal adhesions of the placenta
- CS complications
3. Postpartum Hemorrhage- blood loss greater than 500 ml in a vaginal delivery or 1000ml in a CS
birth. Early- first 24 hours after delivery
Uterine atony and lacerations
Late- occurs during 24 hours after delivery

General management:
- Complete Bed rest
- Avoid sexual contact
- Approximation or assess for bleeding
o Counting pads
o Saturation: fully saturated, 30-40 cc.(60-100ml) it is more accurate to monitor blood loss by weighing
perineal pad before and after use.
o Weight 1 gm=1cc
o Assess for complications, hypovelemic shock
o Save discharges for histopathology to determine if the product of conception has been expelled.
o Prepare the mother for sonography or UTZ to determine the integrity of the sac.
 HEMORRHAGIC COMPLICATIONS OF
PREGNANCY

First Trimester Bleeding Second Trimester Bleeding Third Trimester Bleeding

1. Abortion 1. Hydatidiform Mole 1. Placenta previa
2. Ectopic Pregnancy 2. Premature Cervical Dilatation
2. Abruptio placenta
ABORTION
– any interruption in pregnancy before the age of viability (20 weeks AOG).

TYPES:
1. Spontaneous miscarriage - nature‟s way of expelling a defective fetus.
- Common to mothers age > 35 y/o.
- Early abortion occurs before 16th week AOG while late abortion occurs between 16th and 24th week AOG.
- Severity of bleeding depends on degree of attachment of the fetus to the endometrium.
- There is mild bleeding if abortion occurs on 1st to 6th week, moderate after 6th week to 12th week and severe on 12th
week and onwards.
INCIDENCE: 15 – 30 % of all pregnancies
CAUSES:
. Fetal Causes
a. Abnormal fetal formation
b. Immunologic factors/Immune response (rejection)
c. Implantation abnormalities

. Maternal Factors
a. Increases with advancing maternal age, especially after 35 years of age
- Structural abnormalities of the reproductive tract.
b. Inadequate progesterone production (Corpus luteum fails to produce enough estrogen)
-
- Maternal infections
- Chronic and systematic maternal disease

SUBTYPES:
a. Threatened Abortion – the fetus survives after bleeding
S/S:
 Moderate bright red vaginal bleeding, slight uterine cramping, no cervical
dilatation Management:
 Complete bedrest w/o bathroom privileges on the first 48 hours
 No coitus for 2 weeks after bleeding stops
 Count used pads to estimate amount of bleeding (1ml = 1 gm)
 Instruct to report increase in bleeding and passage of tissue.
b. Imminent/ Inevitable Abortion – the fetus dies after the bleeding. May be complete (all products of
conception are expelled without any assistance, bleeding usually slows within 2 hours), incomplete (placenta
and membranes are retained), missed/IUFD (fetus dies in utero but is not expelled; the fetal skin
undergoes maceration, leathery
appearance then stony appearance/Lithopedion, may lead to coagulopathy).
S/S:
 Bright red vaginal bleeding, cervical dilatation and uterine contractions
 Asymptomatic, painless vaginal bleeding, no increase in fundic height and no FHT

Management:
 Complete: rest, no need for D & C, Indirect Coomb‟s Test, alleviation of guilt
 Incomplete: Suction Curettage or D & C, Indirect Coomb‟s Test, alleviation of guilt
 Missed: D & C, induction of labor if more than 14 weeks AOG, Indirect Coomb‟s Test, alleviation of
guilt

c. Habitual Abortion – often related to incompetent cervix

S/S:
  3 or more consecutive abortions with unidentified cause
Management:
 If incompetent cervix is its cause, cervical cerclage maybe done
Management:
1. The cause of abortion must be identified in order to determine the most effective treatment to achieve a
successful pregnancy
2. Surgery of the cervix or cervical cerclage (suturing the cervix)
. A. Mc Donald Operation- temporary cerclage of the incompetent cervical os
. Suturing is done around the cervix in a simple purse-string fashion to hold growing fetus and is removed
by 36 weeks gestations to allow the mothe to deliver via normal spontaneous delivery.
. Shirodkhar Procedure
. The suture is buried beneath the cervical mucosa and is often left in place (permanent cerclage)
. Delivery via cs only.
3. Fertility drugs- stimulate estrogen and progesterone production to create a better nourished uterine lining, which is
more suitable for implantation of an embryo.
o Drugs used: clomiphene, pergonal

4. Aspirin or Mini heparin

o Prevented blood clots
o The first tissue changes that occur in the placenta before the loss of pregnancy is the formation of hyaline
fibrinogen blood clots within the small blood vessels which impede blood flow resulting to tissue necrotic changes
in the placenta and disruption of normal blood supply leading to fetal death

5. Luteal phase progesterone support

o Progesterone maintains the deciduas where embryo implants.
6. Correction of uterine abnormalities
7. Treatment of medical illness such as DM hyperthyroidism,STDs

2. Induced Abortion
 Legal / Planned/ Medical/ Therapeutic Abortion – performed by a doctor in a controlled hospital as a clinic
for a medical or legal reason.
 Illegal Abortion – never allowed in the Philippines
- INFECTED ABORTION
- infection involving the products of conception and the matenal reproductive organs

- SEPTIC ABORTION
- Dissemination of bacteria into the maternal circulatory system
- signs and symptoms of infection and of threatened or incomplete abortion
- associated with induced abortion performed by untrained persons using nonsterile techniques or criminal abortions.

Causative Organisms
- Escherichia coli- most common pathogenic agent
- Enterobacter aerogenes
- Proteus Vulgaris
- Hemolytic streptococci
- Staphylococci

Signs and Symptoms

1. Foul smelling discharge
2. Uterine cramping
3. Fever, chills,and peritonitis
4. Leukocytosis- WBC count 16,000 to 22000
5. Critically ill patients may evidence sepsis or endotoxic, shock with vasomotor collapse, hypothermia, hypotension,
oliguria or anuria and respiratory distress.

Management
1. Treat abortion
2. High dose antibiotic therapy: penicillin, clindamycin
3. D & C if accompanied by incomplete abortion
4. Infertility may occur after recovery due to scarring of uterus and fallopian tubes, scarring can interfere with
fertilization and proper implementation.

ECTOPIC PREGNANCY
– Fertilized ovum is implanted in any tissue other than the uterine wall.

TYPES:
1. Tubal Implantation – 95 %
a. Ampulla – 80 %
b. Isthmus – 12 %
c. Interstitial – 8 % (most dangerous)
2. Ovarian Implantation
3. Cervical Implantation
4. Abdominal Implantation

PREVALENCE: 14:1000 pregnancies

CAUSES: Main cause is obstruction or scarring in the fallopian tube

1. Lesser risk
a. Previous abdominal or pelvic surgery c. Frequent vaginal douching
b. Cigarette smoking d. Age of first intercourse is less < 18 years old
2.
3. Greater risk
a. Previous genital infection/PID c. Multiple sexual partners
b. Infertility
4. Greatest risk
a. Previous ectopic pregnancy d. Use of DES
b. Previous tubal surgery/sterilization e. Prolonged use of IUD
c. Documented tubal scarring

S/S:
1. Unruptured
a. Missed period
b. Abdominal pain within 3 – 5 weeks missed periods (generalized/one sided)
c. Scanty dark brown vaginal bleeding
d. Vague discomfort
2. Ruptured
a. Sharp, stabbing pain in either lower quadrant of the abdomen
b. Unilateral shoulder pain
c. Excruciating pain during IE
d. (+) Cullen‟s sign
e. Rigid abdomen
f. s/sof shock
MANAGEMENT:
1. Culdocentesis – determines hemoperitoneum.
2. Oral Methotrexate (Actinomycin D) - an antimetabolite and folic acid antagonist that suppresses cell growth/division.
May cause bone marrow suppression.
3. Oral Leucovorin – a folic acid derivative given in conjunction with methotrexate to decrease methotrexate toxicity
and its side effect.
4. Salphingotomy – cutting of fallopian tube which is saved or preserved but pregnancy is terminated.
5. Salphingectomy – removal of fallopian tube
6. Exploratory Laparotomy

NURSING CARE:
1. Prepare for surgery – rupturedectopic pregnancy is and emergency.
2. Monitor vital signs, I & Ostrictly.
3. Administer IVF as ordered.
4. Common Lab result – Low HCG, Hgb, Hct, High WBC

GESTATIONAL TROPHOBLASTIC DISEASE/HYDATIDIFORM MOLE

– Abnormal proliferation and degeneration of the trophoblastic villi. As the cells degenerate, they become fluid – filled and
appear
as “grapes-sized vesicles” and embryo fails to develop beyond a primitive start.

TYPES:
1. Complete mole – results from fertilization of an egg with a lost or inactivated nucleus. No fetus, placenta,
amniotic fluid, membranes. 20 % develop to choriocarcinoma.
2. Partial mole – fertilized egg has embryonic or fetal parts and amniotic sac. Congenital anomalies are present. <
6 % develops to choriocarcinoma.

PREVALENCE: 1: 1000 pregnancies, common to women with low socio-economic status

S/S:
1. Very high levels of HCG – 1-2 M IU that persists even after day 100 of
pregnancy. Normal is 400, 000 IU and
decreases after day 100.
2. Marked nausea and vomiting
3. Greater than standard fundic height
4. Absence of FHT
5. Dense growth pattern “snowstorm/snowflake” in UTZ
6. If undetected beyond 16th week AOG – vaginal bleeding that starts as dark brown spotting then profuse fresh flow
with clear, fluid-filled vesicles.

COMPLICATIONS:
1. Hyperthyroidism
2. Pulmonary Embolism
3. Choriocarcinoma

MANAGEMENT:
1. Suction and curettage to evacuate mole
2. No oxytocin after S & C – may cause pulmonary embolism
3. After surgery:
a. Serum HCG test for 1 year (every 4 weeks for 0-6 months and every 8 weeks 7-12
months) b. No pregnancy for 1 year – NO to pills, may increase HCG levels
c. Prophylactic Methotrexate to prevent choriocarcinoma

PREMATURE CERVICAL DILATATION / INCOMPETENT CERVIX

– cervical effacement and dilatation in early 2nd trimester, therefore, cannot hold the fetus „til term.
PREVALENCE: 1:1000 pregnancies
CAUSES: Exact cause is Unknown
1. Associated with advanced maternal age
2. Congenital structural defects
3. Repeated trauma to cervix (D & C)
S/S:
1. Pink stained vaginal discharge (show) c. Rupture of membranes
2. Uterine contractions d. Painless cervical dilatation
MANAGEMENT: “CERVICAL CERCLAGE”
1. McDonald Operation – temporary, insoluble ribbon/suture is tied around the cervix in a purse string manner. This
is done at 2 -3 months AOG and removed before vaginal delivery
2. Shirodkar Procedure – permanent, insoluble ribbon/suture is place beneath the cervical mucosa. The woman
delivers through CS.

PLACENTA PREVIA
– Low implantation of the placenta.
TYPES:
1. Low lying/marginal Placenta previa - 30 %, 2 – 3 cm away from cervical os
2. Partial Placenta previa – 70 %, covers some parts of the cervical os
3. Total Placenta previa – 100 %, covers the whole cervical os

PREVALENCE: 5:1000 pregnancies

CAUSES:
1. Increased parity
2. Advanced maternal age
3. Multiple pregnancy
S/S:
1. Frank, bright red, painless vaginal bleeding
2. Not associated with increase inactivity or participation in sports
3. Bleeding stops as abruptly as it began
MANAGEMENT:
1. Bed rest
2. Monitor bleeding and progress of labor
3. NO IE, prepare for double set up

ABRUPTIO PLACENTA
- Premature partial or complete separation of a normally implanted placenta.
TYPES:
1. Partial Separation with Concealed Hemorrhage
2. Partial Separation with External Hemorrhage
3. Complete Separation with Concealed Hemorrhage
PREVALENCE: 1:200 pregnancies
CAUSES: Exact cause is unknown
1. Short umbilical cord
2. Chronic hypertension
3. PIH
4. Direct trauma
5. Multifetal gestation
6. Smoking and cocaine use
S/S:
1. Dark red, painful bleeding
2. Severe, sharp stabbing, knife-like pain high in fundus
3. Hard, board like abdomen
4. Couvelaire uterus – copper colored uterus most common with concealed bleeding
COMPLICATIONS: DIC

MANAGEMENT:
1. Administer fluid replacement (IVF/BT) as ordered
2. Administer oxygen
3. Monitor FHT every 5 to 15 minutes
4. Position Left lateral
5. Monitor for blood loss and s/sof shock
6. Prepare for CS if birth does not seem imminent

INFECTIONS AFFECTING
PREGNANCY
1. Toxoplasmosis
2. Others
 Hepatitis
A
Hepatitis B 
HIV
 Syphilis
3. Rubella
4. Cytomegalovirus
5. Herpes simplex virus
6. Gonorrhea
7. Urinary Tract Infection

MECHANISM OF INFECTIONS
1. Crosses placenta through pinocytosis.
 Causes release of Prostaglandins.
 Premature uterine contractions – labor.
 Directly affect fetus and cause developmental anomalies
2. Ascend through the birth canal.
 Affect fetus during vaginal delivery.

GENERAL SIGNS and SYMPTOMS

1. Vague influenza-like symptoms
2. Rashes and lesions
3. Enlarged lymph nodes
4. Jaundice (hepatic involvement)

TOXOPLASMOSIS
Cause: Protozoa “Toxoplasma gondii” from infected cat‟s feces, raw goat‟s milk, raw or undercooked infected vegetables or
meat. 1st trimester: risk is low, s/sare serious/lethal (abortion)
3rd trimester: risk is high,asymptomatic
Fetal Effects: Choriorenitis, IUGR, fetal hydrops, microcephaly, intracranial calcifications
Neonatal Effects: Seizures, hepatosplenomegaly, thrombocytopenia
Treatment: Pyrimethamine, Sulfadiazine, Clindamycin, Spiramycin.

OTHERS: HEPATITIS A
Cause: DNA virus, transmitted via fecal-oral route, oral-anal sex.
Maternal Effects: liver failure during pregnancy, fever, malaise, nausea and abdominal discomfort
Fetal Effects: Miscarriage, fetal anomalies, fetal or neonatal hepatitis, preterm birth, IUFD.
Tx: Administration of Gamma globulin
Prevention: Handwashing

OTHERS: HEPATITIS B
Cause: DNA virus, transmitted via blood or blood products, sexual contact, break in the skin or mucous membrane.
Fetal Effects: Transfer of infection during birth
Tx: Administration of Hepatitis B Immune globulin
Prevention: Standard precaution

OTHERS: HIV
Cause: RNA retrovirus, transmitted via infected body secretions like blood or blood products, sexual contact, sharing
contaminated needles, contact with genital secretions during vaginal delivery and HIV – infected breastmilk.
Tx: Administration of Antiretrovirals like Zidovudine IV.
Prevention: Standard precaution

OTHERS: SYPHILIS
(Leusvenerea, Morbus gallicus, French pox)
Cause: Spirochete bacteria, “Treponema pallidum” transmitted via sexual contact, or transplacentally.
S/S:
1. Primary - 1 to 6 wks, painless lesions (chancre) for 4-6 weeks, leaving scars.
2. Secondary – influenza – like symptoms, maculopapular skin rash, mucous patches, alopecia.
4. Latent syphilis
5. Tertiary/Late syphilis – gummas: cardiovascular, musculoskeletal, ophthalmic and CNS involvement.
6. Congenital Syphilis

Fetal Effects: Hydrops fetalis, Fetal demise, stillbirth, premature birth.

Neonatal Effects: Jaundice (@ 2nd week), Rhinitis, mucocutaneous eruptions, hepatosplenomegaly,
osteochondritis. Treatment:
1. Newborn – Benzanthine Penicillin G, 6 – 100, 000 Units/Kg, single dose IM. Another dose after 1 – 2 weeks if
symptoms persist. Erythromycin 15 mg/Kg IM @ 12th – 15th day of life.
2. Mother – Pen – G, 2-4 Million Units, single dose IM. (Jarisch Herxcheimer Reaction: hypotension, fever,
tachycardia, weakness). If infections is > 1 yr, Pen G 2.4 MU, IM once a week x 3 weeks. Tetracycline HCl, 500 mg
PO QIDx 14 days. (Yellowish teeth) Not for < 8 y/o.

RUBELLA: 3-Day Measles, German Measles

Cause: Highly contagious RNA virus, transmitted via respiratory droplets.
S/S:
1. Low grade fever
2. Mild catarrhal symptoms
3. Onset w/ malaise, headache, mild conjunctivitis, sore throat, stiff neck, anorexia
4. Swelling of sub-occipital lymph nodes
5. White patches/lesions in soft palate – “Forcheimer spots”
6. Retroauricularmaculopapular rashes
7. Spread of rash from face to neck to extremities

Fetal Effects: Teratogenic @ 1st trimester, spontaneous abortion, stillbirth, cleft lip, cleft palate, Congenital Heart
disease, clubbed foot, IUGR
Prevention: Isolation Precaution
Management:
1. Immediate - prophylactic 20 ml Immune serum globulin IM. (passive antibodies)
2. After delivery – Rubella vaccine, avoid pregnancy for 3 months.

CYTOMEGALOVIRUS
Cause: Herpesviridae group of virus transmitted by sexual contact, respiratory droplets and contaminated body secretions
like breast milk.
Fetal Effects: Congenital malformations, hydro/microcephaly, or fetal death.
Neonatal Effects: Pneumonia, hepatosplenomegaly, jaundice, hemolytic anemia, deafness, severe dental caries.
 Management: Gancyclovir for infected infants

HERPES GENITALIS
Cause: HSV 2, transmitted by contact with contaminated genital secretions.
Fetal Effects: Symmetric IUGR, spontaneous abortion, microcephaly, cerebral calcifications.
Neonatal Effects: MR, pneumonia, hepatosplenomegaly, jaundice, petechiae, meningoencephalitis
Management: Not curable. Acyclovir (rarely used in pregnants), Analgesic, Anesthetics, CS.

GONORRHEA
Causes: “Neisseria gonorrheae” transmitted through sexual contact.
Effects: preterm labor, abortion, sepsis, neonatal conjunctivitis, postpartum endometriosis.
Management:
1. Mother – Ceftriaxone 125 mg IM SD, Cefixime 400 mg POSD, Doxycycline 100 mg PO BID for 7 days,
Spectinomycin 2 gms IM
2. Infant – 1 % Silver nitrate, Ophthalmic erythromycin or tetracycline ointment within 1 hour afterbirth.

UTI
Causes: different bacteria “E. Coli, Klebsiella, Proteus, Pseudomonas, Enterobacter”.
Effects: preterm labor discomforts.
Prevention:
1. Proper hygiene
2. Use of cotton underwear
3. Do not delay urination
4. Increase OFI
5. Acidophilus milk or yogurt
6. Avoid tub,bubble baths or use of bath oils.
7. Urinate right after intercourse.
Management: Antibiotics

COMPLICATED
PREGNANCY

1. Hyperemesis Gravidarum / Pernicious vomiting

2. Oligohydramnios
3. Polyhydramnios
4. Multiple Gestation
5. Pregnancy Induced Hypertension (PIH)
6. Pregnant Client with Cardiac Problems
7. Diabetes Mellitus
8. Rh Incompatibility / Isoimmunization
9. ABO Incompatibility

> HYPEREMESIS GRAVIDARUM (PERNICIOUS VOMITING)

> Excessive nausea and vomiting that start between 4 and 10 (8-12 wks. Sia) weeks gestation, and resolve before
16- 20 weeks, requiring intervention
> Associated with dehydration, electrolyte imbalance and weight loss, acidosis from starvation
> Because of these complications, many women who suffer from HG require hospitalization at some point for treatment
and although rare.

Causes:
 1. Unknown
2. Elevated HCG
- HCG disrupts the normal activity of the GIT by causing reverse peristalsis that result in nausea and vomtiting
- Higher HCG levels has been found in women pregnant with female fetuses than male fetuses
3. Thyroid dysfunction
- Thyroxine hormone has been found to be elevated in as many as 70% of women suffering from Hyper
emesis gravidarum
4. Psychological stress
- Some studies point out an increased incidence of depression, anxiety and interpersonal problem in women with
hyper emesis.
Signs and symptoms
1. Excessive nausea and vomiting not relieved by ordinary remedies persisting beyond 12 weeks
2. Sign of dehydration; thirst, dry skin,increased pulse rate, weight loss, concentrated and scanty urine.

MANAGEMENT:
1. Hospitalization in severe cases
2. NPOfor 24 – 48 hours
3. IV therapy (D5LR) with Vit. B
4. Monitor Blood Chemistry
5. Antiemetics – B6 (25-75 mg daily), Doxylamine (Unisom 25 mg), Promethazine (Phenergan), Metoclopramide
(Reglan).
6. If (-) vomiting for 24 hours – clear liquid – dry bland foods like crackers, toast, baked chicken – small frequent
feedings of cereals, low fat, high protein, potassium rich foods.
7. If vomiting is persistent – TPN
8. Adequate rest

1. Conservative management

- When a patient report excessive nausea and vomiting but she does not suffer from dehydration, the initial
intervention would be carried ot at home.
- Ff: health instructions

a. Have dry, low fat, high carbohydrate and bland diet

- Take dry crackers
- Small frequent feedings and sips of water to avoid gastric distention which could trigger vomiting reflex
- Avoid very hot or very cold beverages

b. Avoid stimuli that may precipitate nausea

- Motion and pressure around the stomach such as tight waistband
- Temporary cessation of iron supplements if it contributes to gastric upset
- Avoid highly seasonded and spicy foods
- Avoid strong odors such as perfumes
- Avoid loud noises, brigth and blinking lights
- Excessive vomiting after 12th week or 1st trimester of pregnancy leading to loss of 5 % of pre-pregnancy
weight. Normal n/v is confined in 1st trimester 16 – 20 weeks, begins @ 4 – 6 weeks, peaks @ 8 –
12 weeks.

INCIDENCE: 3 – 10 / 1000
 POLYHYDRAMNIOS
- Amniotic fluid is more than 2,000 ml. Normal is 500 – 1,000 ml.
CAUSES:
1. Anencephaly
2. Tracheoesophageal fistula
3. Intestinal obstruction
4. Related to – DM, Multiple gestation, Isoimmunization, Non-immune hydrops, abnormal fetal presentation

S/S:
1. Rapid increase in fundic height
2. Edema and varicosities of vulva and lower extremities
3. SOB
4. Tense abdominal wall – difficult palpation of fetal parts, muffled FHT
5. Complications – umbilical cord prolapsed (unengaged head ), malpresentation (fetus moves freely), PROM
(excessive pressure), postpartum hemorrhage (overstretched uterus)

MANAGEMENT:
1. Amniocentesis/amniotomy (reduce pressure, size of uterus, have effective u.contraction)

OLIGOHYDRAMNIOS
- Amniotic fluid is less than 500 ml.
CAUSES:
1. Uteroplacental insufficiency
2. Congenital absence of fetal kidneys
3. PROM
4. Postmaturity
S/S:
1. Fundic height is 3 cm lower than AOG
2. Easily palpated fetal parts
3. Dry and leathery fetal skin
4. IUGR
5. Complications – Clubbed foot (d/t pressure), Amputation of limbs (adhesion)
MANAGEMENT:
1. Amnioinfusion – pre-warmed Saline or LR through Intrauterine Pressure Catheter (IUPC)

MULTIPLE GESTATION
- Presence of 2 or more fetuses inside the uterus. This is considered a complication because the woman‟s body must adjust
to the effect of more than 1 fetus.
INCIDENCE: 1:250, Twins = 1:40, Triplets = 1:1,340
CAUSES:
1. Genes – hereditary
2. Associated with – multiparity, advanced maternal age, use of fertility pills
S/S:
1. Rapid increase in fundic height
2. Quickening in several parts of the abdomen
3. 2 or more sets of FHT heard
4. Marked wt. gain not d/t pre-eclampsia or obesity
5. Complications – PIH, Hydramnios, anemia, Placenta previa, Premature labor, CS, Post partum hemorrhage

TYPES:
1. Monozygotic/Identical – one fertilized ovum which then divides, same sex, same genotype
 . Diamniotic, dichorionic: Early division (w/in 72 hours after fertilization) = 2 embryos, 2 amnions, 2
chorions, 2 placentas
. Diamniotic, monochorionic: Division w/in 4-8 days after fertilization = 2 embryos, 2 amnions, 1 chorion, 1
placenta
. Monoamniotic, monochorionic: Late division = 2 embryos, 1 amnion, 1 chorion, 1 placenta
. Conjoined or Siamese twins: Very late division = incomplete cleavage or separation
2. Dizygotic/Fraternal – two separate ova fertilized by two separate sperms, may or may not be of the same sex,
genetically different.
. 2 embryos, 2 amnion, 2 chorion, 2 placentas
3. Triplets and other multifetal pregnancy – associated with use of fertility drugs
. Identical triplets = 1 zygote – divides to 2 – 1 divides to 2 again
. 2 Identical, 1 Fraternal = 2 zygotes, 1 divides to 2 identical, 1 remains as fraternal
. Three zygotes

MANAGEMENT:
1. Close monitoring
2. Adequate nutrition
3. Bed rest for last trimester
4. No coitus or nipple stimulation on last trimester to prevent PROM
5. Prepare for CSor induction of labor
6. Provision of emotional support
7. Post partum check – up and counselling

DISEASES IN PREGNANCY

PREGNANCY INDUCED HYPERTENSION (PIH)

- Avascular disease (vasospasm) with unknown cause which occur anytime after the 24th week of gestation up to 6 weeks
post
partum.
INCIDENCE: 6-8 % of all pregnancies

CAUSES:
1. Unknown
2. Associated with multigravida, primiparas < 20 y/o and > 35 y/o, Chronic HPN, DM, Heart disease, Multiple gestation

S/S: H-E-P
1. Hypertension
2. Edema
3. Proteinuria

TYPES:
1. Gestational HPN – BP of 140/90 mmHg, (-) edema, (-) proteinuria, no drugs needed
2. Preeclampsia
. Mild – BP of 140/90 mmHg on 2 occasions taken 6 hours apart, Increase systolic of 30 mmHg, Increase diastolic of
15 mmHg,sudden wt. gain of 1-5 lbs/week, edema is persistent in upper half of the body, proteinuria of (+) 1.
. Severe - BP of 160/110 mmHg on 2 occasions taken 6 hours apart, edema, proteinuria of (+) 4, oliguria,
epigastric pain (aura), cerebral and visual disturbances, cyanosis
3. Eclampsia
. Most severe. Affects major organs like liver, lungs, heart, brain
. Triad symptoms (HEP)
. Unexplained grand mal seizure
. Increased BUN, Uric Acid,Oliguria
. Complications: HELLP, Intracerebral hemorrhage, death

MANAGEMENT: PPP-EE-A-C-E
1. Promote CBR w/out BP, side-lying position– decrease O2 demand and facilitate sodium excretion
 2. Prevent convulsions – dimly lit room, quiet/calmenv‟t, and minimize patient handling, Mg SO4 IM or IV
(anticonvulsant, CNS depressant, laxative/cathartic). Signs of toxicity:
. Blood pressure decreased
. Urine output decreased
. RR < 12 cpm
. Patellar reflex is absent – 1st sign
. Antidote is 10 % Calcium gluconate.
3. Prepare equipment at bedside – padded tonguedep (before seizure), side rails, O2, suction machine
4. Ensure safety during seizure – No restraints, side lying position (after), keep airway open
5. Ensure adequate protein intake of 1g/kg/day, Sodium in moderation
6. Antihypertensive drugs: Hydralazine (Apresoline)
7. Check FHR
8. Emergency CS or induction of labor

PREGNANT CLIENTS WITH HEART DISEASE (GRAVIDOCARDIACS)

- Increase in circulating blood volume during pregnancy challenges the diseased heart hemodynamically which may cause
cardiac decompensation or cardiac failure. Increase in blood volume peaks @ 28 – 32 weeks of gestation.

INCIDENCE: 1 – 4 % of pregnancies

CAUSES: Pre-existing heart problem:

1. Rheumatic Heart Disease
2. Mitral Valve Stenosis
3. Mitral Valve Prolapse
4. Atrial Septal Defect
5. Tetralogy of Fallot
6. Marfan Syndrome
7. Eisenmenger Syndrome
8. Peripartum Cardiomyopathy
9. Heart Transplant
 S/S:
1. Heart murmurs
2. Decreased cardiac output
3. Hypertension and pulmonary edema
4. Congestive Heart Failure

TYPES/CLASSIFICATIONS:

Class Description Remarks

I Asymptomatic. No limitations in physical Can experience normal pregnancy
Uncompromised activities. and delivery.
II Minor s/s with increased activity, Can experience normal pregnancy
Slightly excessive fatigue, palpitations or dyspnea and delivery.
Compromised in the last trimester. Slight limitations in
physical activity.
III Symptomatic with ordinary activities: Needs more attention during the
Markedly Compromised excessive fatigue, palpitation, and dyspnea. last trimester, labor and delivery.
Moderate to marked limitation in physical Poor candidate for NSVD.
activities. Bed rest on most parts of pregnancy.
IV Symptomatic even at rest. Unable to carry on Very poor candidate for
Severely Compromised any physical activity. Marked limitation of NSVD. Pregnancy should be
physical activities. avoided. May be an indication
for termination of pregnancy.

MANAGEMENT: “Limit Stress”

1. Antepartum: Adequate rest – Position in side lying. I & II: 8-10 hours of sleep, 30 minutes nap, III: bed rest for
much of each day, hospitalization on last trimester, IV: No activity bed rest throughout the pregnancy.
2. Adequate nutrition – “enough but not too much” High CHON, Iron, Folic Acid, Fiber (prevent Valsalva Maneuver),
Potassium (prevent digitalis toxicity & hypokalemia from diuretics, LSLF
3. Medications – Diuretics (Lasix), Digitalis (Deslanoside), Iron/Folic acid supplement, Anticoagulant (Heparin),
Prophylactic antibiotics (Benzanthine Pen G/Erythromycin), Beta/Calcium channel Blockers, Syntocinon. NO TO:
Vitamin K, Beta adrenergic agents like Ritodrine and Terbutaline
4. Regular use of elastic stocking and periodic elevation of legs
5. Intrapartum: Delivery: Semi – Fowlers (Sitting) or Left Lateral Position, Open glottis minimal pushing, Epidural
(Caudal) anesthesia, Low Forceps delivery. NOTOCS.
6. Postpartum: Early Ambulation, antPostpartum: Early Ambulation, antiembolic stockings, prophylactic antibiotics, rest
and monitoring, Methergin with caution (HPN), NO exercise except Kegel, Stool softener, follow – up check up.
Prepare for CPR.

DIABETES MELLITUS
- Group of metabolic disorders characterized by hyperglycemia resulting from defects in insulin secretion, action or both.
Hyperglycemia - > 130 mg/dl. Euglycemia 70 – 120 mg/dl (adults), 45 – 55 mg/dl (newborn).
Hypoglycemia - < 70 mg/dl (adult), < 40 mg/dl (newborn).
INCIDENCE: 2:1000

CAUSES:
1. Type I – Unknown or autoimmune
2. Type II – Genetic predisposition
3. Gestational DM – pregnancy-related insulin resistance etralogy of Fallot

S/S:
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Weight loss

TYPES/CLASSIFICATIONS:
Class Description
I Beta Cell destruction with absolute insulin deficiency. Results to
Insulin Dependent Ketoacidosis. Before age 40
II Insulin resistance. Hyperglycemia develops gradually. Affects obese people
Non Insulin Dependent more than age 40.
III Any degree of glucose intolerance with the onset or first recognition
Gestational DM occurring during pregnancy.

COMPLICATIONS:
1. Infections – altered CHO metabolism, UTI, monilialvaginitis
2. Polyhydramnios
 3. PIH
4. Dystocia
5. Miscarriage, IUFD/Stillbirth (common 36 weeks AOG) - micro/macrovascular changes, fetal hypoxia, Ketoacidosis
6. Macrosomia - > 4500 grams, hyperinsulinism (10 – 14th week) – hyperglycemia
7. IUGR - micro/macrovascular changes, fetal hypoxia
8. Injuries at birth
9. Hyperinsulinism/Hypoglycemia/Hypocalcemia (< 7 mg/dl) at birth – high pitched, shrill cry , jittery, tremors

MANAGEMENT: “Maintain Euglycemia”

1. Insulin therapy – primary factor to maintain normoglycemia. NO ORAL HYPOGLYCEMICS (teratogenic)
. 1st trimester – small doses 33 %
. 2nd trimester – increase by 55 – 75 %
. 3rd trimester – increase by 55 – 75 %
. After delivery – decreased by 25 %
2. Diet – highly individualized, goals: promote weight gain consistent with normal pregnancy, prevent ketoacidosis,
prevent fluctuation in blood glucose. Adequate glucose intake 1, 800 – 2, 200 calories/day to prevent IUGR. 40 -
50 % of total calories from CHO, 30 – 40 % from Fats and CHON. Simple CHO is limited, Complex CHO is better.
Wear DM bracelet and bring insulin syringes or “glucose booster” always.
3. Exercise – best after meals. Usually 15 – 30 minutes walk 4 -6 times a week. Non – weight bearing exercises
like arm exercises, recumbent bicycle.
4. Monitor fetal well – being – Heel stick glucose test, Calcium gluconate for hypoglycaemia
5. Early delivery

Rh INCOMPATIBILITY (ISOIMMUNIZATION)
- Hemolytic disorder that occurs in an Rh (-) woman pregnant with an Rh (+)
baby who inherited the father‟sdominant Rh (+) gene. First-borns are not
affected.

INCIDENCE: 10 – 15 % of all Caucasians couples, 5 % of African-American couples, rare in Asians

CAUSES: “Maternal Sensitization”

1. Previous pregnancy with Rh (+) baby
2. Transfusion with Rh (+) blood
3. Miscarriage or abortion after 8th week of gestation
4. Amniocentesis
5. Premature separation of placenta/AP, PROM
6. Trauma

S/S:
1. Positive Indirect Coomb‟s Test
2. Positive Direct Coomb‟s Test
3. Anemic and edematous fetus
4. Fetal hyperbilirubinemia or jaundice
5. Edematous placenta

COMPLICATIONS:
1. Eryhtroblastosis Fetalis - (Hydrops fetalis): Anemia, cardiomegaly, hepatosplenomegaly, hypoxia
2. Kernicterus

MANAGEMENT: “Halt or minimize antibody (Ig M or IgG) production”

1. Coomb‟s Test and RhoGAM Therapy (Rho D Immune globulin) – passive antibody.
. 1st prenatal visit – Indirect Coomb‟s test (2-3 cc of maternal blood plus Rh + RBC)
o Negative – No action
o Positive – check titer level (Liley‟s graph), 1:8 not fatal, 1:16 needs amniocentesis to check hemolysis,
rising bilirubin may need intrauterine transfusion.
. 2 visit/28 weeks – Indirect Coomb‟s test
nd

o Negative – give RhoGAM IM

o Positive – repeat test after 4 – 6 weeks to monitor maternal antibody titer.
. After birth – Direct Coomb‟s test or Direct Antiglobulin Test/DAT (blood from umbilical cord tested for
maternal antibodies)
o Negative – no action
o Positive – 1:64 Exchange transfusion
2. Intrauterine transfusion – Rh (-) Type O blood to umbilical veni, as often as 2 weeks until fetus reaches
pulmonary maturity at 37 – 38 weeks AOG.
3. Exchange transfusion – 5 – 20 ml of newborn blood is removed at one time then replaced by Type O Rh (-). Total of
170 mg/kg body weight or 75 – 85 % of all blood. Calcium gluconate is given during BT because preservatives
lower the newborn‟s serum calcium.
4. Early Feeding with human milk of formula – to remove excess bilirubin
 5. Phototherapy with conventional lights and fiberoptic blankets – helps hasten liver maturity
6. Counselling – danger to next pregnancies

ABO INCOMPATIBILITY

- Hemolytic disorder that occurs in a pregnant woman with blood type O carrying a baby with blood type A, B or AB. It
occurs rarely on babies with Type B blood born to mothers with Type A blood. First borns are affected because preformed
antibodies may cross the placenta. More common than Rh incompatibility but has less severe effects.

MECHANISM: Transfer of Anti A or B antibodies through the placenta.

Hemolysis begins at birth after placental separation.
1. Agglutinogens – act as antigen that stimulates agglutination
2. Agglutinins – specific antibodies in the blood.
Bloodgroup Agglutinogens Agglutinins
O - - A&B
A A B
B B A
AB A&B - -

S/S:
1. Weakly positive Direct Coomb‟s Test
2. Cord bilirubin is less than 4 mg/dl
3. Hyperbilirubinemia and jaundice – accumulated unconjugated bilirubin, product of haemoglobin from hemolyzed
RBC.
4. Mild fetal or neonatal anemia

COMPLICATIONS:
1. Kernicterus

MANAGEMENT:
1. Early Feeding with human milk of formula – to remove excess bilirubin
2. Phototherapy with conventional lights and fiberoptic blankets – helps hasten liver maturity
3. Exchanged transfusion in some cases only