High risk pregnancy

By: ShenellD
Bleeding Disorders of
pregnancy
• First Trimester bleeding- Abortion and
ectopic pregnancy
• Second trimester bleeding-
Hydatidiform mole and incompetent
cervix
• Third trimester bleeding- Placenta
previa and abruption placenta
abortion
• Abortion- is the most common bleeding disorder of
early pregnancy. Abortion is the termination of
pregnancy before viability,that is, before 20 weeks.
• Abortus- a fetus that is aborted before it is 500 gms in
weight.
• Blighted ovum- a small macerated fetus, sometimes
there is no fetus, surrounded by a fluid inside the sac.
• Maceration- a dead fetus undergoing necrosis.
• Early abortion- termination of pregnancy before 16
weeks.
• Late abortion- abortion that occurs between 16 to 20
weeks.
 Causes of abortion:
• FETAL CAUSES-
• The most common cause of early
spontaneous abortion is abnormal
development of the zygote, embryo, and
fetus.
• This abnormalities are incompatible with
life and would have resulted to severe
congenital anomalies if pregnancy has not
been aborted.
 Causes of abortion:
• MATERNAL CAUSES-
• These are congenital or acquired conditions
of the mother and environmental factors
that had adversely affected the pregnancy
outcome and led to abortion.
• Such conditions include DM, incompetent
cervix, exposure to radiation and infection.
 Types of abortion:
• Threatened abortion
• Inevitable abortion
• Incomplete Abortion
• Complete Abortion
• Missed Abortion
• Habitual Abortion
• Septic abortion
Threatened abortion- possible loss of
product of conception
• Light vaginal bleeding
• None to mild uterine cramping
• Vaginal examination at this stage
usually reveals a closed cervix. 25%
to 50% of threatened abortion
eventually result in loss of the
pregnancy.
 The development of abortion is as follows:

continuing
threatened pregnancy
•
abortion complete
inevitable abortion
abortion

incomplete
abortion
• Inevitable abortion- the loss of the
products of conception cannot be
prevented
• Moderate to profuse bleeding,
moderate to severe uterine cramping
• Open cervix
• Rupture of membrane
• Complete abortion- spontaneous
expulsion of the products of
conception after the fetus has died
in utero
• Light bleeding
• Mild uterine cramping
• Passage of tissue
• Closed cervix
• Incomplete abortion- expulsion of
some parts and retention of other
parts of conceptus in uterus
• Heavy vaginal bleeding
• Severe uterine cramping
• Open cervix
• Passage of tissue
• Missed abortion- retention of all
products of conception after the
death of the fetus in the uterus
• No FHT
• Signs of pregnancy disappear
• Habitual abortion- abortion occurring
in 3 or more successive pregnancies
• The most common cause is a
significant genetic abnormality of the
conceptus.
• Septic abortion- abortion
complicated by infection
• Foul smelling vaginal discharge
• Uterine cramping
• Fever
 Nursing
responsibilities
• Save all tissue passed (histopathology
examination)
• Strict bed rest and monitor bleeding
• Increased fluid PO or IV as ordered
• Prepare client for surgical intervention
(D & C or suction evacuation) if needed
ECTOPIC PREGNANCY
• Ectopic pregnancy is any gestation
located outside the uterine cavity.
• extra uterine pregnancy is the second
leading cause of bleeding in early
pregnancy.
Causes of Ectopic pregnancy
• Mechanical Factors- factors that delay the
passage of ovum in the oviducts and
prevent it from reaching the uterus in time
for implantation.
• Salphingitis
• Peritubal adhesions- kinking and
narrowing
• Previous ectopic pregnancy
• Tumors that distort the tube
Causes of Ectopic pregnancy

• Functional and failed contraception

factors
– External migration of the ovum
– IUD
– Oral contraception
– Tubal ligation- 15-50 %
– Hysterectomy
Causes of Ectopic pregnancy

• Assisted reproduction
– Ovulation induction- clomid
– Gamete intrafallopian transfer
– In vitro fertilization
– Ovum transfer
siteS OF ECTOPIC
PREGNANCY
Most frequent site is in the fallopian tube, so
rupture of the site usually occurs before 12
weeks
• Ectopic pregnancy usually occurs 99% of
cases in the uterine tube. It can be found
in
• 1.      The ampulla (64%)
• 2.      The Isthmus (25%)
• 3.      The infundibulum (9%)
• 4.      The intramural junction (2%)
• 5.      Ovarian (0.5%)
• 6.      Cervical (0.4%)
• 7.      Abdominal (0.1%)
• 8.      Intraligamental (0.05%)
• The classic symptom
triad: amenorrhea,
vaginal bleeding,
abdominal pain.
 Assessment findings:
• History of missed periods & symptoms of early
pregnancy.
• Abdominal pain, may be localized on one side
• Rigid. Tender abdomen; sometimes abnormal
pelvic mass
• Bleeding: if severe may lead to shock
• Low Hgb & Hct, rising white cell count
• Pelvic pain- sudden knife like pain is the
most common symptom when the tube
ruptures
• Signs of hemorrhage:
– Cullen’s sign- bluish discoloration of the
umbilicus due to the presence of blood in the
peritoneal cavity
– Hard rigid board like abdomen due to presence
of blood in the peritoneal cavity.
– Signs of shock- cyanosis, pallor, cold clammy
skin, rapid pulse, dec BP
 Blood loss

dec. intravascular volume

dec. venous return, cardiac output & BP

Vasoconstriction of peripheral blood vessels & inc. respiratory rate.

Cold, clammy skin, dec. uterine perfusion

Reduced renal, uterine & brain perfusion The

process of
Lethargy, coma, dec. renal output shock due
to blood
Renal failure loss

Matenal and fetal death

Management:
ectopic pregnancy.flv
• If not yet ruptured, therapeutic
abortion is performed.
• If ruptured, removal or repair of
ruptured tube. Many physician choose
to remove the ruptured tube because
the presence of scar if the tube
repaired and left can lead to another
tubal pregnancy.
• Prevent and treat hemorrhage which
is the main danger of ectopic
pregnancy.
• Prevent infection as the woman who
lost so much blood is susceptible to
infection
• Prepare client for surgery
• Institute measures to control? Treat
shock if hemorrhage is severe;
continue to monitor postoperatively.
• Allow client to express feelings about
loss of pregnancy & concern about
future pregnancies.
HYDATIDIFORM MOLE
h-mole
• A benign disorder characterized by
degeneration of the chorion and death
of the embryo. The chorionic villi
rapidly proliferate and become grape
like vesicles that produce large amount
of HCG.
• Gestational trophoblastic disease
• Cause essentially unknown
 Risk factors:
• A molar pregnancy creates a 20-40
times higher risk of having it again.
• Increased incidence with advanced
maternal age.
• Unusual chromosomal patterns seen. (
either no genetic material in ovum or
69 chromosomes)
 Diagnostics:
• Ultrasonography reveals no fetal
skeleton
• Elevated HCG level
 Signs and symptoms
• excessive vomiting due to elevated HCG levels
• passage of grape like vesicles around the 4th
month (dark red to brownish vaginal bleeding)
• rapid increase of uterine size which is out of
proportion to the actual age of gestation.
• absence of FHT and fetal skeleton
• ultrasound reveal a mass of fluid filled vesicles
instead of a developing fetus.
 Management:
– D and C to remove the mole. If the woman is
more than 40 years old, hysterectomy since
she has a higher chance of developing
choriocarcinoma
– Anticancer drug prescribed to the woman for
one year to prevent development of
malignant or cancer cells in the uterus.
 Nursing responsibilities:
• Provide pre-postoperative care for
evacuation of uterus (usually suction
curettage).
• Teach contraceptive use so that pregnancy
is delayed for at least a year.
• Teach client’s need for follow-up lab work
to detect rising HCG levels indicative of
choriocarcinoma.
Hyper emesis gravidarum
Hyper emesis gravidarum
• -is intractable vomiting during
pregnancy that results in
dehydration and electrolyte
imbalance.
• It occurs in one of every 1000
pregnancies; the cause is uncertain
• Risk factors: unknown
• Diagnostics: by symptoms
• Sign and symptoms:
1. Severe, persistent vomiting that leads
to dehydration or nutritional
deficiency
2. Progresses to fluid electrolyte
imbalance and alkalosis from loss of
hydrochloric acid.
 Management:
• Medical: replacement of fluids, electrolytes,
and vitamins, along with tranquilizer or
antiemetic
• NPO for 48 hours, after condition improves,
six small feedings are alternated with liquid
nourishment in small amount every 1-2
hours.
• If vomiting recurs, NPO status is resumed
and administration of IV is restarted.
PLACENTA PREVIA
• Placenta previa is the abnormal
implantation of placental near or
over the internal os.
• It is the most common bleeding
disorder of the third trimester.
Causes of Placenta previa:
• Multiparity
• Multiple pregnancy
• Advance maternal age- over 35
years old
• Smoking
• Previous cesarean section and
abortion
• Sign and symptoms:
• Painless bright red vaginal bleeding is
the most significant sign near the end
of early of the 3rd trimester.
• Ultrasound revealed placenta
implanted over or near the cervix.
 Nursing intervention:
• Ensure complete bed rest.
• Maintain sterile conditions for any
invasive procedure.
• Make provisions for emergency cesarean
birth
• Continue to monitor maternal/fetal vital
signs
Management:
• Cesarian is the delivery of choice
for all kinds of placenta previa.
• Manage bleeding episodes
• Watchful waiting- delay delivery
until fetus is mature enough
• No IE is performed in diagnosed
placenta previa
ABRUPTIO PLACENTA
• Abruptio placenta is the premature
separation of placenta from part or
all normal implantation site, usually
accompanied by pain.
• Usually occurs after 20 weeks of
gestation and before delivery of the
fetus
Causes of abruptio placenta:
• Maternal hypertension
• Advance maternal age
• Multiparity
• Trauma to the uterus
• Short umbilical cord
• Cigarette smoking and cocaine
abuse
Signs and symptoms:
• Painful Vaginal bleeding
• Board-like abdomen caused by
accumulation of blood behind the
placenta with fetal parts hard to
palpate
• Sharp pain over the fundus as the
placenta separates
• Signs of shock and fetal distress if
bleeding is severe.
Nursing interventions:
• Ensure bed rest
• Check maternal/fetal vital signs
frequently
• Vaginal delivery if there is no sign of
fetal distress, CS if bleeding is severe
and fetus cannot be delivered with
vaginal method.
 
Incompetent cervix
• Premature dilation of the
cervix
• Is a defect related trauma of
the cervix or a congenitally
short cervix, which leads to
habitual abortion and
premature labor.
Risk factors: cervical trauma related to
D&C, cervical lacerations from
previous deliveries
Sign & symptoms:
• Dilated cervix without painful uterine
contractions.
• Rupture membranes, labor begins and
premature fetus is delivered.
 Surgical treatment:
• Reinforcement of the weakened cervix by a
purse string suture, which encircles the
internal os.
• Shidorkar-barter cerclage; permanent suture
that allows the cervix to remain closed for all
pregnancies; cesarian delivery is required.
• McDonald cerclage; left in place until term,
then remove before labor.
 hydramnios
Polyhydramnios: (More than
2L of fluid). Excess of amniotic
fluid.
 Causes:
• Fetal abnormalities- excessive
urination of fetus
• Esophageal atresia- fetus cannot
swallow amniotic fluid.
• Multiple pregnancy
• Diabetes mellitus
 Complications:
• Premature labor & delivery
• Abruptio placenta
• Postpartum hemorrhage due to over
distension of uterus
• Cord prolapsed
• malpresentation
 oligohydramnios
Oligohydramnios: (Less than
500 ml of fluid) ↓ of the amniotic
fluid.
 Causes:

• Fetal renal anomalies that results in

anuria
• Premature rupture of membranes
 Complications:
• Club foot
• Amputation- due to adhesion of
fetal parts to the amnion
• Abortion
• Stillbirth
• Fetal growth retardation
• Abruptio placenta
Complication during labor and
delivery

• Cord compression
• Fetal hypoxia as a result of cord
compression
• Prolonged labor
Pregnancy induced hypertension-
PIH
• Gestational hypertension replaces the term
PIH and is used for hypertensive disorders
that are specifically associated with
pregnancy, preeclampsia, and eclampsia.
Incidence:
• Occur in 5-7% of all pregnancies
• Seen more often to primigravidas,
teenagers of low socioeconomic class.
• May be related to decreased production of
some vasodilating prostaglandins,
vasospasm occurs.
• Onset after 20th week of pregnancy, may
appear in labor or up to 48 hours
postpartum.
• Cause essentially unknown
 vasospasm

Vascular effect Kidney effect Interstitial effects

Dec. glomeruli
vasoconstriction filtration rate &
inc. permeability of
glomeruli
Diffusion of
membranes
fluid from
blood stream
Poor organ Inc. serum blood urea into interstitial
perfusion nitrogen, uric acid, & tissue
creatinine

Dec. urine output &

Inc. BP protenuria edema
– Danger Signs of Pregnancy-
Induced Hypertension
• Swelling of the face or fingers
• Flashes of light or dots
• Blurring of vision
• Severe continuous headache
Mild preeclampsia
• Bp of 140/90 or +30/+15 mmhg on
two consecutive occasions at least 6
hours apart.
• Sudden weight gain
• Proteinuria of 300 mg/l in 24 hour
urine collection
 Nursing intervention:
• Promote bed rest as long as signs of edema
or proteinuria are minimal, preferably side
lying.
• Provide well-balanced diet with adequate
protein.
• Explain need for close follow-up, weekly or
twice-weekly visits to physician.
Severe preeclampsia
• Headaches, epigastric pain, nausea and
vomiting, visual disturbances, irritability
• Bp of 150-160/100-110 mmhg
• Increased edema and weight gain
• Proteinuria (5g/24hrs) 4+
 Management:
• Magnesium sulfate- acts upon the
myoneural junction, diminishing
neuromuscular transmission
• It promotes maternal vasodilatation, better
tissue perfusion and has anticonvulsant
effect.
• Antidote: calcium gluconate
• Nursing responsibilities: mgs04
• Monitor client’s respirations,
blood pressure and reflexes, as
well as urinary output
• Adm.med. Either IV or IM
 Nursing interventions:
• Bed rest, side lying
• Carefully monitor maternal/fetal vital
signs
• Monitor I&O, results of laboratory test
• Take daily weights
• Institute seizure precautions
• Continue to monitor 24-48 hours post
delivery
 eclampsia
• Increased HPN precede convulsion
followed by hypotension and collapse
• Coma may ensue
• Labor may begin, putting fetus in great
jeopardy
• Convulsion may occur
Medical mgt. same with severe
preeclampsia
Nursing intervention:
• Minimize all stimuli
• Have airway, oxygen and suction
equipment available
• Administer medication as ordered
• Prepare for C-section with seizures
stabilized
• Continue observations 24-48 hours
postpartum.
 Complication of PIH:
• Maternal complications:
• Inc. intraocular pressure leading to
retinal detachment.
• HELLP (Hemolysis, Elevated Liver
function test, Low platelet count)
syndrome has been associated with
severe preeclampsia.
Fetal complications:
• Usually small for gestational age
• May be born prematurely
• Newborn maybe born over sedated because
of medications given to mother
• May have hypermagnesemia because of
maternal treatment with mgs04.
 Danger signs of pregnancy
SIGN POSSIBLE CAUSE

Swelling of face, fingers & legs HPN of pregnancy

Headache, continuous & severe HPN of pregnancy

Abdominal/ chest pain Ectopic pregnancy, uterine rupture,

pulmonary embolism

Vaginal bleeding Placental problems , abortion

Vomiting, persistent Infection, hyperemesis gravidarum

Visual changes HPN of pregnancy

Escape of vaginal fluids PROM

Gestational diabetes
• disorder of late gestation
• disorder induced by pregnancy: from
exaggerated physiological changes in
glucose metabolism
• Reversal after termination of
pregnancy with 20-50% chances of
developing type 2 diabetes later in life.
RISK FACTORS
• Age over 30
• Family Hx of DM
• Prior macrosomic, malformed
or stillborn infant
• Obesity
• Hypertension
TWO TYPES OF DIABETES
 Assessment for gestational diabetes
• 3 P’s (polyphagia, polyuria, polydipsia)
• Dizziness, if hypoglycemic
• Confusion, if hyperglycemic
• Congenital anomalies
• Inc.risk of PIH
• Macrosomia
• Poor tissue perfusion of fetus
• Glycosoria
• Hyperglycemia
• Hydramios
• Possibility of inc. monilial infection
 Diagnostic Tests for DM
Glycosylated hemoglobin
 Provides information about blood
glucose level during the previous 3
months
 because glucose in the bloodstream
attaches to some of the hemoglobin and
stay attached during the 120-day
lifespan of the RBC
 Diagnostic Tests for DM
Oral glucose challenge test values for
pregnancy:
Test type pregnancy glucose level
Fasting 95
1 hour 180
2 hours 155
3 hours 140
Following a 100g glucose load. Rate is abnormal
if two values are exceeded.
GDM - ADVERSE EFFECTS
MACROSOMIA
• Excessive fat deposition on shoulders/trunk
• Predisposes to shoulder dystocia
• Maternal hyperglycemia  transfer of excess
glucose to fetus  stimulate fetal insulin
secretion which is a potent growth factor

HYPOGLYCEMIA at birth
MACROSOMIA
Pathogenesis

99
 D-I-A-B-E-T-E-S
• D- DIET: 50-60% CHO, 20-30% FATS, 10-
20% CHON
• I- INSULIN– TYPE 1
• A- ANTIDIABETIC AGENTS– TYPE 2
• B- BLOOD SUGAR MONITORING
• E- EXERCISE
• T- TRANSPLANT OF PANCREAS
• E- ENSURE ADEQUATE FOOD INTAKE
• S- SCRUPULOUS FOOT CARE
Heart disease
 HEART DISEASE
Normal hemodynamic of pregnancy that
adversely affect the client with heart
disease
1.      Oxygen consumption increased 10% to
20% ; related to needs of growing fetus
2.     Plasma level and blood volume
increase; RBCs remain the same
(physiologic anemia)
Functional or therapeutic classification of heart
disease during pregnancy
1.      Class I: no limitation of physical activity; no
symptoms of cardiac insufficiency or angina
2.     Class II: slight limitation of physical
activity; may experience excessive fatigue,
palpitation, angina, or dyspnea; slight limitation
as indicated
3.     Class III: moderate to marked limitation of
physical activity; dyspnea, angina, and fatigue
occur with slight activity, and bed rest is
indicated during most pregnancy
4.     Class IV; marked limitation of physical
activity; angina, dyspnea, and discomfort occur
at rest; pregnancy should be avoided; indication
for termination of pregnancy
Prenatal period assessment:
• Evidenced of cardiac decompensation
especially when blood volume peaks ( weeks
28-32)
• Cough & dyspnea
• Edema
• Heart murmur
• Palpitations
• rales
 Nursing intervention
prenatal period:
• Teach client to recognize & report signs of
infection, importance of prophylactic
antibiotics
• Compare vital signs to baseline
• Instruct in diet to limit weight gain to 15
lbs, low na+