Chapter 15 HIGH RISK Conditions associated w/ First Trimester Bleeding 1) Abortion – interruption of a pregnancy before a fetus is viable (20-24 weeks
/ weighs 500g) Spontaneous Miscarriage -Occurs before week 16 – 24 of pregnancy -First 6 weeks – the developing placenta is tentatively attached to the deciduas of the uterus -6-12 a moderate degree of attachment to the myometrium is accomplished -After week 12 attachments is penetrating and deep -occur most often in women who have a low Causes: - Abnormal fetal formation due to teratogenic/ chromosomal aberration (5080%) - Immunologic reaction rejection of the embryo - implantation abnormalities (50%) zygote are propbabaly never implanted - corpus luteum fails to produce enough progesterone to maintain the deciduas basalis -rubella, syphilis, poliomyelitis, cmv and toxoplasmosis, uti, isotretinoin (accunate), alcohol - w/ an infection, if the fetus fails to grow, estrogen and progesterone production by the placenta falls lead to endometrial sloughing prostaglandin releases leading to uterine contraction and cervical dilatation along w/ expulsion of the products of pregnancy -vaginal spotting Threatened Miscarriage -Manifested by painless vaginal bleeding, -symptoms of PIH occur before week 20 of -hCG (+) 1-2 million IU compared w/ a normal pregnancy level of 400,000 IU) N: after 100 days decline -uterus tends to expand (just over the symphisis brim at 12 weeks, at the umbilicus at 20-24 weeks Two types: 1)Complete mole – all trophoblasts villi swell and become cystic 2)Partial Mole – some of the villi form normally, the synctiotrophoblastic layer of villi, however is swollen and misshapen -has 69 chromosomes -a macerated embryo of approximately 9weeks may be present and fetal blood may be present in the villi protein intake, older than 35yrs old, asian heritage Cause: choriocarcinoma -as the cells degenerate, they become filled w/fluid and appear as clear fluid-filled, grapesized vesicles, the embryo fails to develop Conditions associated w/ Second Trimester Bleeding 1) Gestational Trophoblastic Disease (Hydatidiform Mole) -abnormal proliferation and degeneration of the trophoblastic villi (anomaly of the placents converting chorionic villi into a mass of clear vesicles
initially scant bleeding and bright red. but membrane/placenta is retained in the uterus Missed Miscarriage -early pregnancy failure -fetus dies in the utero but not expelled -painless vaginal bleeding/ asymptomatic Recurrent Pregnancy Loss -habitual aborters if a woman whoa had 3 spontaneous miscarriage at the same gestational age Isoimmunization – the production of antibodies against Rh positive blood by her immunologic system Causes: -increased maternal age. a woman is theoretically free of the risk of a malignancy developing) -prophylactic course of methotrexate for choriocarcinoma (SE: luekopeneia) -avoid pregnancy for atleast one year
Complete Miscarriage -fetus. membranes. the loss of the products of conception cannot be halted -saturating more than one pad per hour is abnormally heavy bleeding
pregnancy -week 16 (vaginal bleeding present). slight cramping w/ no cervical dilatation -Avoiding strenuous activity for 24-48 hours (once bleeding stops can resume normal activities) -Coitus is restricted for 2 weeks Imminent (inevitable) Miscarriage -If uterine contractions and cervical dilatation occur -4-6 weeks embryo died before the onset of miscarriage or failure of growth was noted -Over 14 weeks labor may induced by prostaglandin suppository or cytotec to dilate the cervix followed by oxytocin stimulation or administration of mifepristone -w/ cervical dilatation. and placenta are expelled Incomplete Miscarriage -part of the conceptus (usually fetus) is expelled. if hCG levels are still negative. refers to a cervix that dilates prematurely and therefore cannot hold a fetus until term -dilatation usually painless -often first symptom is show ( a pink-stained vaginal discharge) or increased pelvic pressure w/c may be followed by rupture of the membranes and discharge of the amniotic fluid that may lead to contraction and premature labor occur
. after surgey. positive reading at 3 weeks – 40 days (analyzed every 2 weeks until levels are normal) and assessed every 4 weeks for 6-12 months -after 6 months. congenital structural -commonly occurs at approximately 20 weeks of pregnancy 2) Premature cervical Dilatation -incompetent cervix. begin w/ vaginal spotting of dark-brown blood or profuse fresh flow) progresses w/ clear-fluidfilled vesicles -D&C. hCG levels eremain high.
scars from tubal surgery or a uterine tumor -occurs frequently in women who smoke -IUDs -oral contraceptives may reduce the possibility of ectopic pregnancy -no menstrual flow occurs -n/v -(+) pregnancy test Weeks 6-12 of pregnancy (2-8 weeks of missed menstrual period) the zygote grows large enough to rupture the slender fallopian tube or the trophoblasts cells break through the narrow base -sharp stabbing pain in one (unilateral) of her lower abdominal quadrants at time of rupture
defect. and trauma to the cervix. terbutaline (Brethine) and Mg S -cervical cerclage performed -week 12-14 Mcdonald procedure (nylon sutures are placed horizontally and vertically across the cervix and pulled tight to reduce the cervical canal to a few millimeters in diameter) and Shirodkar technique ( a sterile tape is threaded in a purse string manner under sub mucous layer of the cervix and sutured in place to achieved a close cervix -removed after 37-38 weeks -remain on bedrest/trendelenburg position for a few days to decrease pressure on the sutures -can resumed sexual relations after this rest
. a cone biopsy& repeated D&Cs -observed for rupture of bag of water (BOW) -avoid coitus & vaginal douche -administer Tocolytics: Ritodrine HCL (Yutopar). adhesion from infection (chronic salpingitis/PID) -congenital malformations. cervix. & most common in the fallopian tube) -80% ampulla (distal third of the fallopian tube) -12% isthmus -8% interstitial/fimbrial (rupture can cause severe intarperitoneal bleeding) -second most frequent cause of bleeding early in pregnancy Causes: -obstruction.-all women w/ Rh negative blood should receive Rh (Dantigen) immne globulin (RhIG) to prevent the buildup of antibodies in the event the conceptus was Rh positive 2) Ectopic Pregnancy -implantation occurs outside the uterine cavity (surface of the ovary.
is also effective at causing sloughing of tubal implantataion -as w/ miscarriage.followed by scant vaginal spotting -either a falling hcg or serum progesterone level suggests that the pregnancy has ended -Presence of body fluid from culdocentecis (aspiration from cul-de-sac of Douglas) – non clotting blood -Bluish-tinge (cullen’s sign) umbilicus due to peritoneal irritation -pain on shoulders from blood in the peritoneal cavity causing irritation to the phrenic nerve -can be treated medically by oral administration of Methotrexate (a folic acid antagonists chemotherapeutic agent. attacks and destros fast-growing cells) followed by leucovorin -hysterosalpingogram/sonogram is usually performed after the chemotherapy to assess whether the tube is fully patent -Mifepristone an arbotifacient. women w/ Rh-negative blood should receive Rh (D) immune globulin (RhIG) after an ectopic pregnancy for isoimmunization protection in future childbearing)
Conditions associated w/ Third Trimester Bleeding 1) PLACENTA PREVIA -low implantation of the placenta 4 degrees: a)implantation in the lower uterine rather than in the upper portion of the uterus (low-lying
placenta) b)marginal implantation (placenta edge approaches that of the cervical os) c) implantation that occludes a portion of cervical os (partial placenta previa) d) implantation that totally obstructs the cervical os (total placenta previa) Causes: -increased parity -advanced maternal age -past CS & curettage -multiple gestation -male fetus -bleeding at week 30 and cervix become to dilate -abrupt. headache. dizziness. increased risk for infection in long ter used -more prone to postpartum hemorrhage because the placental site is in the lower uterine segment. swelling. tachycardia. painless. -larger denuded surface area when placenta is removed because it grows larger than normal -2nd complication is endometritis because the placental site is close to the cervix 2)Premature Separation of the Placenta (Abruptio Placenta)
. bright red and a sudden enough to frighten a woman -does not allow optimal fetal nutrition or oxygenation -bed rest side lying position -Apt or Kleihauer-Betke test (test strip procedures) –used to detect whether blood is of fetal/maternal origin -never attempt a pelvic/rectal examination – may initiate massive hemorrhage -if the previa is under 30% (vaginal birth feasible) over 30% and fetus ids mature (CS) -Bethamethasone. itching. a steroid that hastens fetal lung maturity if the fetus is less than 34 weeks gestation -acts as an anti-inflammatory & immunosuppressive agent -given to pregy 12-24 hours before birth -IM. sodium & fluid retention. repeat dosing w/in 24 hours and again in 1 to 2 weeks SE: burning. wt gain. & irritation the injection site. w/c does not contract as efficiently as the upper segment.
high parity -advanced maternal age -short umbilical cord -chronic hypertensive disease -PIH -direct trauma -coacaine. not supine. suspect an interference w/ blood coagulation -keep a woman in a lateral. forming a hard. position to prevent pressure on the vena cava -do not perform vaginal/pelvic exam or an enema --DIC developed surgery may not good. uterus is tense and painful upon palpation 3 extreme separation – fetal death & maternal shock 3) Disseminated Intravascular Coagulation (DIC) -acquired disorder of blood clotting in w/c the fibrinogen level fall to below effective limits
. dry test tube. at the end of this time.-placenta is implanted incorrectly -most frequent cause of prenatal death Causes: -unknown . stabbing pain high in the uterine fundus as initial separation occurs -not evident on contraction but may be felt upon palpation -blood may infiltrate the uterine musculature (Couvelaire uterus or uteroplacental apoplexy). protein C and factor V Leiden ( a common inherited hemophilia) -sharp. stand it aside for 5 minutes. IV administration of fibrinogen or cryoprecipitate (w/c contains ibrinogen) may be used to elevates a woman’s fibrinogen level Degree of separation: 0 no sx of separation 1 minimal separation 2 moderate evidence of fetal distress. cigarette used -thrombolytic conditions that lead to thrombosis such as autoimmune antibodies. if a clot has not formed. board like uterus w/ no apparent or minimally apparent bleeding present -evidence of shock -fibrin breakdown products detect DIC (draw 5 ml and place it in a clean.
vaginal spotting.-early sx easy bleeding and bruising Causes: -PSP. PIH. presence of fetal fibronectin. septic abortion and retention of dead fetus -to prevent too much clotting-THROMBIN-ACTIVATES-FIBRINOLYSIN (a proteolytic enzyme. feeling of pelvic pressure or abdominal tightening. absence of protein predicts that labor will not occur for atleast 14 days -bedrest -IV fluid -Tocolytic (terbutaine)
. DIC is an emergency because it can result in extreme blood loss from lack of fibrinogen -heparin to halt the clotting cascade -blood or platelet transfusion may be necessary -antithrombin III factor. to begin to digest excess fibrin threads (anticoagulation) – lysis results in the release of fibrin degradation product -DIC occurs when there is such extreme bleeding and so many platelets and fibrin from general circulation rush to the site that not enough are left in the rest of the body for further clotting. a bleeding defect exists. a protein produced by trophoblasts cells. dull. The high thrombin level continues to encourage anticoagulation. If this present in vaginal mucus it predicts that preterm contraction are ready to occur. This result is a paradox: at one point. amniotic fluid embolism. the person has increased coagulation but throughout the rest of the system. inc vaginal discharge.a woman having persistent uterine contractions (4 every 20 minutes) should be considered in labor Causes: -UTI -chorioamnionitis (infection of the fetal membranes and fluid) -Dehydration – pituitary gland is activated to secrete ADH – release of oxytocin – contraction Sx: -persistent. fibrinogen. low backache. cryoprecipitate can all be used to restore blood clotting & frsh frozen plasma/platelets 4) PRETERM LABOR -occurs before the end of 37 weeks of gestation . uterine and intestinal cramping -analyzing vaginal mucus. menstrual like cramping. placental retention.
muscle contraction ineffective & uterine contractions halt BETA 1 ( adipose tissue. blood vessels) Ex. & gastrointestinal smooth muscle) BETA 2 (uterine smooth muscles. liver. -toxicity: absence of DTR. cardiac arrest.-empty bladder -left or right side lie down -pregnancy under 34 weeks Bethamethasone (2doses of 12 mg IM 24 hours apart). flushing. bronchial smooth muscle. decreased urinary output. w/ continued minimal leakage -used Nitrazine papae (it will turn blue (alkaline) para macheck kung amniotic fluid nga yun) -ferning also -membranes can be resealed by use of a fibrin-based commercial sealant so they are again intact
. pancreatic islet cells. uminom kaagad kapag naalala and space their doses according from that time. or (4 doses IM 12 hours apart) -effect last for 7 days Magnesium Sulfate -CNS depressant block ACH -SE: thirst. respi depression -assess DTR every 1-4 hrs used patellar kapg nakaepidral aesthesia sya used biceps reflex -Ca gluconate dapat katabi -nakakacause ng osteoporosis in long ter used -release adenecyclase –triggers the conversion of adenosine triphosphate into cyclic adenosine monophosphate – responsible for reducing the intracellular calcium concentration. Ritodrine hydrochloride (Yutopar) Terbutaline (Brethine) – cautiously used in DM and thyroid dysfunction -mix w/ Ringers lactate rather than a dextrose sol to prevent hyperglycemia -piggy back -after 12-24 hours of continuous infusion oral administration begun -first oral dose given 30 minutes before tanngalin ung IV na terbutaline -up to 37 weeks o kapag nagmature n ung lungs na madedect through amniocentecis -kapag nakalimutan inumin sa oras. wag doblehin ang pills cause severe tachycardia Normal fetal movements: 10-12 times per hour 5)Preterm Rupture of membranes -point of no return -sudden gush of clear-fluid from the vagina. heart.
a condition in w/ vasospasm occurs during pregnancy in both small & large arteries -Hypertension. inhibiting the fetal nutrient supply/cord prolapsed (interfere w/ fetal circulation) -Potter-like syndrome or distorted facial feature and pulmonary hypoplasia from pressure occur in nonfluid environment -if a woman want pain relief not meperidine (Demerol) epidural is preferable -following birth. The extra amount of blood can also overburden the circulatory system 6) Pregnancy Induced Hypertension (PIH) . sodium retention and lower glomerular filtration rate (usually on the upper part of the body)
. 5 or more pregy.cause unknown but mostly chorioamnionitis -infection may occur -increased pressure from the umbilical cord from the loss amniotic fluid. This is because an immature infant has a difficult time excreting the large amount of bilirubin that will be formed if this extra blood is added to the circulation. the cord of the preterm infant is usually clamped immediately rather than waiting for pulsation to stop. proteinuria. low socio status. because of the protein loss. toxemia -multiple pregy. edema -unknown. hydramnios.-a count more than 18k-20k/mm3 = infection -intrauterine amnioinfusion may be used to supply additional uterine fluid and help protect the umbilical cord from compression and the fetus from compression deformities & pulmonary hypoplasia . primaparas youger 20 and older 40. at bedrest they do not) -edema develops. heart & dm/renal underlying disease Gestational hypertension -elevated BP 140/90 -no proteinuria/edema present Mild Pre-eclampsia -BP 140/90 taken on two occasions atleast 6 hours apart -the diastolic value of blood pressure is extremely important to document because it is this pressure that best indicates the degree of peripheral arterial spasm present -second criterion systolic bp greater than 30 mmHg and a diastolic greater than 15 mmHg above pregnancy values -proteinuria (1+ or 2+) = 1g/L -occasionally women have orthostatic proteinuria (on long periods of standing they excrete protein.
lessens possibility of seizures -last for 30-60 min -blood serum level should be remained 5-8 mg/100ml -Ca gluconate (1g) -If it is given iv w/in 2 hrs of the baby’s birth. marked hyperreflexia. the baby may be born w/ Respiratory depression
.2 mg/dL -cerebral/visual disturbances (headache. blurred vision. sodium tends to be excreted at a faster rate than during activity -stringent sodium restriction may no longer true because it may activate the RAAS
Severe pre-eclampsia -BP 160/110 mmHg or above on atleast 2 occasions 6 hours apart at bed rest -marked proteinuria 3+ or 4+ on a random urine sample or more than 5g in a 24 hour sample -puffiness in a woman’s face & hands -more readily palpated over the bony surfaces (over the tibia on the anterior leg. extensive peripheral edema. When the body is in lateral recumbent position. ulnar surface of the forearm. hepatic dysfx. ankle clonus). thrombocytopenia. pulmonary/cardiac involvement. cheekbones) -oliguria (500 ml/less in 24 hour) -elevated serum creatinine >1. epigastric pain -bed rest -restricted visitors -darken the room -shining a flashlight beam into a woman’s eyes is a kind of a sudden stimulation to be avoided -raise siderails -UO should be more than 600ml/24hr -moderate high protein and sodium diet -hydralazine (Apresoline) or labetalol – hypotensive drug -lower bp by peripheral dilatation and thus not interfere w/ placental circulation. can cause tachycardia.-a weight gain of more than 2lb/week in the 2nd tri and 1lb/week on the 3rd tri is usually indicates abnormal tissue fluid retention .promote bed rest. should not be given to diastolic pres below 80/90mmHg -Mg S reduces edema by causing a shift in fluid from extracellular spaces into the intestines.
elevated liver enzymes.because the drug crosses thae placenta -after birth it may continued for 12-24 hours -BF is delayed until it is d/c -severe oliguria may be treated by iv infusion of salt-poor albumin Eclampsia -seizure or coma accompanied by s/sx of preeclampsia -happens late in pregy but can happen up to 48 hours after childbirth -ankle clonus – drosiflexing the clients foot 3x in a rapid succession. hyonatremia. low platelets)
unknown first sx: nausea. Inability to swallow occurs in infants who are anencephalic or who have tracheoesophageal fistula w/ stenosis or intestinal obstruction -bed rest Post-term pregnancy -exceeds to 42 weeks long -infant is considered postmaure/dysmature -prolonged pregnanacy can occur in a woman receiving a high dose of salicylates (for severe headaches/rheumatoid arthritis) because salicylates interferes w/ the synthesis of prostaglandins. & hypoglycemia 7) Hydramnios -excess fluid more than 2000ml or an amniotic index above 24 cm) [N: 500-1000 ml] -too much amniotic fluid can cause fetal malpresentation because additional uterine space allows the fetus to turn -PROM from the increased pressure and possible release of prostaglandin -accumulation of amniotic fluid suggests difficulty w/ the fetus ability to swallow or absorb or else excessive urine production. AST) Complications: subcapsular liver hematoma. w/c may be responsible for the initiation of labor
. general malaise.00/mm3) elevated liver enzymes (ALT. observe the foot used to move in involuntary movements -vaginal birth is preferable -postpartum hypertension may occur up to 10-14 days after birth -fetal lung maturity appears to advance rapidly w/ PIH
HELLP (hemolysis. R. epigastric pain. renal failure. upper quadrant tenderness from lver inflammation thrombocytopenia (<100.
-it is also associated w/ myometrial quiescence or a uterus that does not respond to normal stimulation -meconium aspiration& macrosomia apt to occur -prostaglandin gel or misoprostol (Cytotec) applied to the cervix to initiate ripening. or stripping of membranes followed by an oxytocin infusion is a common method to begin labor Pseudocyesis (false pregnancy) -wish-fulfillment theory -conflict theory -depression theory