HIGH RISK PREGNANCY

PREGNANCY RISK FACTORS

 Age
 Weight

 Nutritional status

 Income

 Multiparity

 Obstetrical history

 Family history of genetic disease or previous baby with a

birth defect
 Substance use

 Pre-existing medical conditions

 Infertility

 External risk factors

BLEEDING DISORDERS OF PREGNANCY
 Hemorrhage > rapid loss of more than 1% of
body weight in blood

 Rapid blood loss results in:

a) inadequate tissue perfusion
b) deprivation of glucose & oxygen in the
tissue
c) build up of waste products
PERINATAL HEMORRHAGE
 Hemorrhage that occurs during pregnancy,
labor, & delivery

1. Antepartum hemorrhage
> occurs anytime during pregnancy
a) early antepartum hemorrhage
b) late antepartum hemorrhage
2. Intrapartum hemorrhage > occurs
during labor and is most commonly due
to:
a) abruptio placenta
b) uterine rupture
c) uterine inversion
d) CS complications
3. Postpartum hemorrhage > blood loss
greater than 500 ml in a vaginal
delivery or 1,000 ml in a CS
a) early postpartum hemorrhage
b) late postpartum hemorrhage
DIFFERENT BLEEDING DISORDERS OF
PREGNANCY
 FirstTrimester
> abortion & ectopic pregnancy
 Second Trimester

> H-mole & incompetent cervix

 Third Trimester

> placenta previa & abruptio placenta

ABORTION
 The termination of pregnancy before
viability.
 Spontaneous abortion occurs in 15-20% of
recognized pregnancy.
 Early abortion > before 12 weeks
 Late abortion > between 12-20 weeks
TERMS RELATED TO ABORTION
 Abortus > fetus that is aborted
weighing less than 500g
 Occult pregnancy > zygotes that

were aborted before pregnancy

is diagnosed
 Blighted ovum > a small macerated

fetus, sometimes there is no

fetus, surrounded by a fluid
inside an open sac
 Carneous mole > a zygote that is
surrounded by a capsule of clotted blood
 Fetus compressus > a fetus compressed
upon itself & desiccated with dried
amniotic fluid
 Fetus papyraceous > a fetus that is so dry
that it resembles a parchment
 Lithopedion > calcified embryo
 Immature infant > an infant having a birth
weight between 500-1,000 g.
TYPES OF ABORTION
 Elective Abortionor Therapeutic Abortion
> deliberate termination of a pregnancy

 Spontaneous Abortion

> the loss of a fetus during pregnancy due

to natural causes
CAUSES OF SPONTANEOUS ABORTION
 Fetalcauses
1. developmental anomalies
2. chromosomal abnormalities

 Maternal Causes > congenital or acquired

conditions of the mother, including
environmental factors
1. advancing maternal age
2. structural abnormalities
3. inadequate progesterone
production
4. maternal infections/viral infection
5. chronic and systemic maternal
disease
6. exogenous factors
SIGNS OF SPONTANEOUS ABORTION
 Bleeding
 Uterinecramps
 Passage of products

 Frequency of spontaneous abortion

increases further with maternal age.
 Late implantation is also associated with a
higher incidence of abortion.
 The frequency of miscarriage decreases
with an increasing gestational age.
 A woman who has a history of abortion
has a higher chance of having another
abortion than a woman who has not had an
abortion.
COMPLICATIONS OF ABORTION
 Hemorrhage
 Disseminated intravascular coagulation
(DIC)
SPONTANEOUS ABORTION
4 Stages
a) Threatened
b) Inevitable
c) Incomplete
d) Complete
 TYPES OF SPONTANEOUS ABORTION
A. Threatened Abortion
 Possible loss of the products of conception.

 All vaginal bleeding in early pregnancy

without cervical changes is considered
threatened abortion.

S/Sx 1. light vaginal bleeding

2. none to mild uterine
cramping
Management
1. Assess for

a) ask LMP
b) instruct the client to save all
pads for examination
c) ask for presence of clots
d) ask if there is pain/abdominal
pain
2. Conservative Management
 In any mild bleeding episode that occurs during
the first trimester:
a) instruct client to have bedrest until 3 days
after bleeding has stopped
 b) coitus should be avoided up to
2 wks after bleeding stopped
3. Provide reassurance
B. INEVITABLE OR IMMINENT
ABORTION
 Refersto the loss of the products of conception
that can not be prevented

S/Sx: 1. moderate profuse bleeding

2. moderate to severe uterine
cramping
3. open cervix or dilatation of the
cervix
4. rupture of membrane
5. no tissue has passed yet
 Management

1. hospitalization
2. D & C
3. oxytocin after D & C
4. sympathetic understanding & emotional
support
C. COMPLETE ABORTION
 Refers to the spontaneous expulsion of the products of
conception after the fetus has died in utero

S/Sx: 1. vaginal bleeding

abdominal pain
passage of tissue
2. on examination on the clinic/hospital
a) light bleeding or some blood in the
vaginal vault
b) no tenderness in the cervix, uterus or
abdomen
 c) none to mild uterine cramping
d) closed cervix
e) empty uterus on ultrasound

Management:
1. Usually needs no further medical or surgical treatment.

2. Observe closely for continued bleeding or signs of

infection.
3. Regular diet

4. Advise patient to rest for a few days to 2 weeks and

refrain from intercourse and douching for 2 weeks.
5. Tell patient that she may experience intermittent
menstrual like flow and cramps during the following
week. The next menstrual period usually occurs in 4-5
weeks.
6. It is important that the expelled products of conception
are evaluated by a physician and confirmed to be intact
and truly products of conception.
7. Reassure patient that her next pregnancy is likely to last
to term if she is young and has no other risk factors.
8. Advise the patient to return to the emergency department
if any of the following symptoms occur:
- profuse vaginal bleeding
- severe pelvic pain
- temperature greater than 100°F
D. INCOMPLETE ABORTION
 expulsion of some parts and retention of other parts of
conceptus in utero

S/Sx: 1. heavy vaginal bleeding

2. severe uterine cramping
3. open cervix
4. passage of tissue
5. ultrasound shows that some of the
products of conception are still inside the
uterus
Management
*goal of intervention is prompt evacuation of the uterus to
prevent hemorrhage or infection
1. D & C

2. Monitor blood loss in patient’s who have inevitable and

incomplete abortion.
3. Sympathetic understanding and emotional support.
COMPARISON OF COMPLETE &
INCOMPLETE ABORTION
Complete Abortion Incomplete Abortion
1. No abdominal distension There is rebound tenderness & or
no rebound tenderness a distended uterus
2. Normal bowel sounds
3. Only mild suprapubic
tenderness
4. IE may show IE will reveal
- some blood on the vagina but - active bleeding from internal os
- cervix is dilated
limited active bleeding
- cervix is nontender to - clots & tissues may also be
minimally tender present in the vagina or
- uterus is smaller than what is cervical canal
expected for dates, & it is
nontender to mildly tender
E. MISSED ABORTION
 Retention of all products of conception after the death of
fetus in the uterus

S/Sx: 1. absence of FHT

2. signs of pregnancy disappear

Missed abortion should be suspected when the

> uterus fails to enlarge
> fetal heart sounds are not heard at the appropriate time
or disappears after it has been initially heard
> serum or uterine test for HCG becomes negative earlier
than expected or does not double within 48-72 hours

Management
1. Depending in the AOG, the products of conception has
to be removed from the uterus to prevent DIC.
2. Up to 28 weeks gestation, missed abortion is frequently
managed by inserting a 20 mg suppository into the
vagina every 3 or 4 hours as necessary to produce
contractions
3. Late missed abortion may be completed with a dilute IV
infusion of oxytocin which causes contraction of the
uterus and delivery of the products of conception
F. HABITUAL ABORTION
 Abortion occurring in 3 or more successive pregnancies

Management
1. Treating the cause

2. Specific treatment according to the cause of abortion:

a) cervical cerclage
b) fertility drugs
c) aspirin or mini-heparin
d) luteal phase progesterone support
e) correction of defects before pregnancy
f) treatment of medical illness to ensure
successful gestation
G. INFECTED ABORTION
 Infection
involving the products of conception
and the maternal reproductive organs
H. SEPTIC ABORTION
 Dissemination of bacteria/toxins into the
maternal circulatory and organ system.

Causative Agent
- escherichia coli
- enterobacter aerogenes
- proteus vulgaris
- hemolytic streptococci
- staphylococci
S/Sx: 1. foul smelling vaginal discharge
2. uterine cramping
3. fever, chills, & peritonitis
4. leukocytosis
5. critically ill patients may evidence septic
or endotoxic shock

Management
1. Treat abortion

2. High dose IV antibiotic therapy

3. D & C if accompanied by incomplete abortion

B. ECTOPIC PREGNANCY
 Implantation of the zygote outside the uterine cavity or
in an abnormal location inside the uterus
 As much as 50% of women who have experienced
ectopic pregnancy will ever carry pregnancy to term and
7.7% to 20% will suffer a repeat ectopic pregnancy.

Causes:
1. Mechanical Factors > conditions that delay the passage
of the ovum in the oviducts and prevent it from reaching
the uterus in time for implantation
2. Functional Factors
- external migration of the ovum
- menstrual reflux
- altered tubal motility associated with the
use of IUD, etc.
3. Assisted Reproduction
- ovulation induction associated with fertility drugs
- gamette intrafallopian transfer
- in vitro fertilization
- ovum transfer
4. Failed Contraception
TYPES OF ECTOPIC PREGNANCY
1. Tubal
2. Ovarian
3. Abdominal
4. Cervical
Signs:
1. highly vascularized, bleeding & enlarged cervix
2. tight internal os & dilated external os
3. thin walled cervix
4. painless vaginal bleeding
5. seldom goes beyond 20 weeks gestation
5. Heterotypic pregnancy
> a tubal pregnancy accompanied by intrauterine
pregnancy
6. Tubo-uterine
> results from the gradual extension into the uterine
cavity of products of conception that originally
implanted in the interstitial portion of the tube
7. Tubo-abdominal
> a zygote that originally implanted in the fimbriated end
of the fallopian tube gradually extends into the peritoneal
cavity
8. Tubo-ovarian
> a zygote that is partly imparted in the tube and partly
in the ovary
SIGNS AND SYMPTOMS
 Most common: missed menstrual period
unilateral lower abdominal pain
irregular vaginal bleeding
1. Normal pregnancy signs appear during the first weeks
after fertilization
2. Before the rupture
> brief amenorrhea occurs but some spotting & bleeding
may occur
> pelvic & abdominal pain on the side of the affected tube
> Arias-Stella Reaction – uterus will not enlarge as in
normal pregnancy, decidua will be formed but no
trophoblast development
3. Rupturing or ruptured ectopic pregnancy
> isthmic pregnancy usually ruptures early at 6 weeks
> ampullary EP ruptures at around 8-12 weeks
> abdominal pregnancy may terminate anytime
> if fetus dies without extensive bleeding, it may
become infected, calcified or an adipocere

 Pain is sudden, severe, & knife-like

>Can radiate to the neck and shoulder
>Cervical pain during IE

 Spotting or bleeding
> amount of bleeding may not reflect the actual amount
of blood loss
 Cullen’s sign
> bluish discoloration of the umbilicus due to the
presence of blood in the peritoneal cavity
 hard or boardlike abdomen
 Signs of shock
DIAGNOSIS
1. Transvaginal UTZ
> can reveal an extrauterine pregnancy
> should be repeated after 3 days if the first is not diagnostic
for further examination
2. Serial HCG determination
> HCG level is lower than expected for gestational time and
usually does not double normally
3. Pregnancy Tests
4. Serum Progesterone Levels
5. Colpotomy
6. Laparoscopy
7. Laboratory Findings: ↓Hgb, Hct, HCG; ↑ WBC
TREATMENT
1. Salpingectomy > in ruptured EP
2. Hysterectomy > in ruptured interstitial or
cervical pregnancy
3. Oophorectomy > in ovarian pregnancy
NURSING INTERVENTION
1. Care of a woman with bleeding, possible shock.
2. Pain relief
3. Post operative care
4. Meet emotional needs of patient
5. Provide information
C. HYDATIDIFORM MOLE
 A benign disorder of the placenta characterized
by degeneration of the chorion and death of the
embryo
 Chorion proliferate and become grapelike
vesicles that produce large amounts of HCG
 Spontaneous expulsion occurs between 16 & 18
weeks
TYPES OF H-MOLE
1. Complete Molar Pregnancy
> have only placental parts and form when the sperm
fertilizes an empty egg
> all of the fertilized egg’s chromosomes come from the
father and are duplicated
> chorionic villi develop and proliferate rapidly for
unknown reasons causing a rapid enlargement of the
uterus
> villi produce large amounts of HCG resulting in
excessive nausea & vomiting
2. Partial Molar Pregnancy
> embryo has 69 chromosomes
> 2 sperm cells fertilize an egg or an ovum
fertilized by one sperm in which meiosis or
reduction division did not occur
> placenta and fetus are formed but development
is not completed
Cause: Unknown

Risk Factors/Incidence:
1. Geography

2. Age

3. Socioeconomic status

4. History of molar pregnancy

Diagnosis: UTZ
SIGNS AND SYMPTOMS
1. Excessive nausea & vomiting
2. Vaginal bleeding
3. Passage of grapelike vesicles around the 4th mo.
4. Extra large uterus
5. Signs of PIH before 20 weeks
6. Absence of FHT, quickening, outline, skeleton
Treatment: careful D&C or hysterectomy; HCG
monitoring for 1 year

Complications:
1. Hemorrhage

2. Infection

3. Uterine perforation

4. Gestational trophoblastic tumors

a) choriocarcinoma > most severe malignant

complication that involve the transformation of chorionic
villi into cancer cells that invade & erode blood vessels
& uterine muscle
b) Invasive mole > characterized by excessive formation
of trophoblastic villi that penetrates the myometrium
c) Placental Site Trophoblastic Tumor > arises
from the site of the placenta
> these cells produce both prolactin &HCG
> main symptom is bleeding and may follow an
abortion, normal pregnancy and H-Mole
NURSING RESPONSIBILITIES
1. Care of a woman with bleeding
2. Give instructions on need for

a) follow up care for 1 year

b) follow up HCG titer monitoring for 1 year to rule out
choriocarcinoma
> HCG level is monitored every 2 weeks until
normal then monthly for 6 months then every 2 months
for another 6 months
> chest x-ray every 3 months for 6 months
3. Provide psychological support
D. INCOMPETENT CERVIX
 Mechanical defect of the cervix where in
there occurs
a. painless cervical dilatation in the 2 nd
trimester or early in the 3rd trimester
b. prolapse & ballooning of the
membranes in the vagina
c. eventually leads to membrane rupture &
expulsion of the products of conception
DIAGNOSIS
1. Manually by pelvic exam or IE to assess the degree of
dilatation & effeacement
2. UTZ to view the cervical os & canal

Predisposing Factors
3. Cervical trauma

4. Hormonal influences

5. Congenitally short cervix

6. Forced D&C

7. Uterine anomalies
SIGNS & SYMPTOMS
1. Painless vaginal bleeding or pinkish
show accompanied by cervical dilatation
2. Rupture of membranes & passage of
amniotic fluid with subsequent loss of the
products of conception
MANAGEMENT
1. Cervical cerclage at around 14 weeks gestation.
Prerequisites of cervical cerclage
a. cervix not dilated beyond 3 cm
b. intact membranes
c. no vaginal bleeding & uterine cramping

Types of Cervical Cerclage

2. Shirodkar suture
3. Mc Donald suture
After Suturing the Cervix
1. Place the woman on bedrest for 24hrs to several days
after the procedure.
2. Observe for bleeding, uterine contractions & rupture of
bag of water.
3. Report passage of fluids or signs or ruptured BOW.

4. It uterine contractions occur, ritodrine may be

administered to stop the contractions.
5. Restrict activities after application of suture for the
next 2 weeks.
E. PLACENTA PREVIA
 Is the abnormal implantation of placenta near or over the
internal os
 In the 3rd trimester, the lower uterine segment begins to
stretch and shorten in preparation for labor
→gradual thinning of the uterine segment causes the
placental villi attached to the lower uterine wall to tear &
eventually separate from its attachment
→detachment of the portion of the placenta over the
cervix results in bleeding
TYPES OF PLACENTA PREVIA
1. Complete or Total
> placenta completely covers the internal os when the
cervix is fully dilated
2. Partial Placenta Previa
> placenta partially covers the internal os
3. Marginal Placenta Previa
> edge of the placenta is lying at the margin of the
internal os
4. Low Lying Placenta Previa
> placenta implants near the internal os with its margin
located about 2cm to 5cm from the internal os.
CAUSES
1. Conditions that make implantation to the upper segment
undesirable due to decreased blood supply or scarring:
a) multiparity
b) previous molar pregnancy
c) endometritis
d) previous C/S
e) abortion
f) repeated D&C

2. Multiple Pregnancy
3. Maternal age over 35 years
4. Decreased blood supply to the endometrial lining
5. Short umbilical cord
6. Abnormal placentas > placenta increta & accreta
7. Large placenta

Complications:
1. DIC

2. Infection

3. Abnormal adhesion of placenta

4. Renal failure R/T shock caused from hemorrhage or

DIC
5. Anemia

6. Postpartum hemorrhage

7. More lacerations
8. Fetal of neonatal effects
a) fetal death
b) prematurity
c) C/S
d) fetal hemorrhage
e) neonatal anemias
f) small for gestational age
g) brain damage or neurological abnormalities
SIGNS & SYMPTOMS
1. Sudden painless vaginal bleeding
2. Intermittent/gushes of bright red vaginal bleeding & is
rarely continuous
3. The placement of the placenta in the lower segment
often prevents the fetal head from entering the true
pelvis
4. Decreased urinary output

UTZ is the earliest and safest diagnostic tool for placenta

previa
MANAGEMENT
1. Internal exam by the physician only under Double Set-
Up
> indicated when
a) UTZ is not available
b) when the patient presents with ongoing,
but not life-threatening vaginal bleeding
in labor
c) the mother has marginal previa and is in
well-established labor
2. Assess extent of blood loss
a) visual estimates
b) V/S
c) tilt test
d) urine flow
3. If pregnancy is below 36 wks
Watchful waiting > delaying delivery until fetus
has achieved lung maturity
> first choice of treatment if:
a) bleeding is minimal or less than 250 cc
b) fetus is too immature to be delivered or
below 36 weeks
c) there is no evidence of fetal compromise
NURSING INTERVENTION
a) Monitor
1. FHR & activity
2. vaginal bleeding
3. uterine contractions
4. maternal vital signs
5. maternal I & O
b) Woman is placed on CBR
c) Manage bleeding episodes
1. keep woman on NPO
2. monitor V/S, FHR, & vaginal bleeding
3. maintain on absolute bed rest
4. start IVF & BT as necessary
d) If woman is in active labor, tocolytics are administered
to the mother
e) If the patient has a complete or partial placenta previa,
an amniocentesis is generally performed weekly

Outpatient Management
a) Important requirements for outpatient management:
1. patient lives close to the hospital
2. transportation is available 24 hours
b) Restrict activities at home
1. be in bed rest for most part of the day
2. no heavy lifting
3. no standing for long periods of time
4. sexual arousal, intercourse, or orgasm may
initiate contractions
5. avoid enema & douche
6. stop working
7. provide diversional activities
c) Inform patient & family to be observant for danger signs
1. any vaginal bleeding
2. uterine contractions
3. decreased fetal activity
d) Diet
1. ↑ iron
2. prenatal vitamins
3. ↑ fiber
e) Clinic visit
1. UTZ
2. nonstress test
3. biophysical profile
Labor & Delivery
a) Delivery is implemented when:
1. fetus is mature
2. there is persistent hemorrhage
3. intrauterine infection
4. rupture of membranes
5. persistent uterine contractions
unresponsive to tocolytics
6. mother develops coagulation defects
7. fetal distress occurs
8. fetal/congenital abnormalities that are
incompatible with life
Method of Delivery > C/S

Nursing Care:
1. Anticipate doctor’s order for

a) UTZ
b) IVF
2. In case of profuse bleeding
a) CBR w/o bathroom privileges
b) NPO
c) administer oxygen
d) discourage bearing dow
3. Position: T-Burg
Semi-Fowler’s
F. ABRUPTIO PLACENTA
 Premature separation of a normally implanted placenta
after 20 weeks of gestation & before delivery of the
fetus.

Causes:
1. Maternal HPN

2. Advanced maternal age

3. Grand multiparity

4. Trauma to the uterus

5. Short umbilical cord

6. Uterine fibroids
7. Behavioral risk factors
a. cigarette smoking, cocaine abuse
b. maternal alcohol consumption

 Believed to be caused by degenerative changes in the

spiral arterioles that consequently decrease blood supply
to the decidua
TYPES OF ABRUPTIO PLACENTA
1. Accdg. To Placental Separation
a) covert/Central A.P.
>separation begins at the center of placental
attachment
b) Overt or Marginal
> separation begins at the edges of the placenta
2. Accdg to S/Sx
a) Grade 0
> no symptoms, diagnosed after delivery when
placenta is examined & found to have retroplacental
clot
 b) Grade 1 > some external bleeding, uterine tetany
& tenderness may or may not be noted, absence of fetal
distress & shock
c) Grade 2 > external bleeding, uterine tetany, uterine
tenderness, & fetal distress
d) Grade 3 > internal & external bleeding, uterine
tetany, maternal shock, probably fetal death &DIC

3. Accdg. To Extent of Separation

a) Mild > less than 1/6 of the placenta is separated from
the uterus
> bleeding may or may not be present
> some uterine irritability w/ no fetal distress
 > there may or may not be vaginal bleeding
> there may be some uterine tenderness & vague back
ache
b) Moderate > 1/6 – 2/3 of the placenta is separated from
the uterus
> dark vaginal bleeding may be absent or present
> uterine tetany & tenderness
> fetus will exhibit distress due to uteroplacental
insufficiency
c) Severe > more than 2/3 of the placenta is separated from
the uterus causing uterine tenderness & rigidity along
with severe pain
> dark vaginal bleeding, or may be absent
> entire separation will cause maternal shock, fetal death,
severe pain & possible DIC
SIGNS & SYMPTOMS
1. Vaginal bleeding
2. Abdominal pain

* mild > mother may complain of labor pains with

slight uterine irritation
* moderate > pain can develop gradually or abruptly
* severe > sudden & knifelike/sharp
3. Board like abdomen
4. Signs of shock & fetal distress if bleeding is severe
MANAGEMENT
1. Hospitalization
2. If fetus is below 36 wks

a) prolonging the pregnancy if:

1. bleeding is not life threatening
2. fetal heart sounds are normal
3. mother is not in active labor
b) manage bleeding episode
c) monitor fetal condition
3. Delivery: C/S
vaginal
G. PREGNANCY INDUCED
HYPERTENSION
HPN > a BP reading in 2 occasions of at least 140/90 or a
rise of 30mmHg systolic & 15mmHg diastolic
Gestational HPN > BP of 140/90mmHg develops for the
first time during pregnancy, but there is no proteinuria &
with in 12 weeks postpartum the BP is normal
PIH > HPN that develops after the 20th week of gestation to
a previously normotensive woman
Preeclampsia > HPN of BP 140/90 that develops after 20
weeks of gestation accompanied by proteinuria
Eclampsia > all the signs and symptoms of
preeclampsia accompanied by convulsions or
coma that is not caused by other conditions
Superimposed Eclampsia & Preeclampsia > occurs
when a woman having chronic HPN develops
preeclampsia nor eclampsia during pregnancy
Chronic HPN > the presence of HPN before
pregnancy or HPN that develop before 20 weeks
gestation in the absence of H-mole that persists
after 12th week postpartum
PREDISPOSING FACTORS
1. Disease of primiparas > ↑ incidence in primis below 20
& above 35 y/o
2. Preexisting diseases > diabetes, chronic HPN, chronic
renal disease
3. Low socioeconomic status & inadequate prenatal care
4. Poor nutrition
5. Pregnancy complications
6. Herediatary
7. Black race
Causes ofS/Sx PIH Mild P/E Severe P/E

1.BP No definite cause140/90 or diastolic BP

is known Diastolic is 100 or ↑
is more than 100
Genetic predisposition
2.Proteinuria 300mg/24hr urine 5g/24hr urine collection
S/Sx of Preeclampsiacollection
Edema Digital edema Pitting, generalized
edema
Weight gain 2lb/wk More rapid wt gain
Urinary output Not less than Less than 400ml/24hrs
400ml/24hrs
Cerebral disturbance Occasional headache Severe frontal
headache, photophobia,
blurring spots before the
eyes, nausea, vomiting
Epigastric pain Absent RUQ pain due to
swelling of hepatic
capsule
Sign of Eclampsia
1. All S/Sx of preeclampsia

2. Convulsion followed by coma

3. Oliguria

4. Pulmonary edema

Screening & early diagnosis

Roll over test > given between 28-32 weeks
gestation
> an ↑ in 20mmHg or greater in diastolic BP
(+)
AMBULATORY MANAGEMENT
1. Home management is allowed only if
BP is 140/90 or below
↓proteinuria
no fetal growth retardation
good fetal movement
2. Bed rest
3. Consult clinic
4. Diet

• Magnesium sulfate is the drug of choice

• Calcium Gluconate is the antidote
H. CARDIAC DISEASE IN PREGNANCY
 The degree of disability experienced by the woman with
cardiac disease often is more important in the treatment
& prognosis during pregnancy than is the diagnosis of the
type of cardiovascular disease

Common Signs of Cardiac Disease

Left Sided
1. dyspnea, orthopnea

2. Rales, cough

3. Chest pain

4. Arrythmias, syncope

5. Extreme fatigue, pallor, cyanosis

 Right Sided
1. Edema
2. Neck vein engorgement
3. Hepatomegaly

Classifications of Cardiac Disease

Class I: asymptomatic without limitation of
physical activity
Class II: symptomatic with slight limitation of
activity
Class III: symptomatic with marked limitation of
activity
Class IV: symptomatic with inability to carry on any
physical activity without discomfort
NURSING INTERVENTIONS
A. Antepartum
 Therapy is focused on minimizing stress on the heart
which is greatest between 28-32 weeks as the
hemodynamic changes reach their maximum
 Health Teaching Topics
1. sleep & rest
2. activity restrictions
3. treatment of infections
4. diet
5. medications
B. Intrapartum
1. Positioning

2. Oxygen therapy as needed

C. Postpartum
3. Head of bed is elevated

4. Progressive ambulation may be permitted.

5. Stool softeners, ↑ fluid intake

6. breastfeeding is not C/I

DIABETES MELLITUS IN PREGNANCY
 Refers to a group of metabolic diseases characterized by
hyperglycemia resulting from defects in insulin
secretion, insulin action or both

Effect of Pregnancy on Diabetes

 During the course of pregnancy, the placenta produces:

1. HPL
2. estrogen & progesterone
3. placenta insulinase
Classifications:
Type I > includes those cases that are primarily caused by
pancreatic islet beta cell destruction & that are prone to
ketoacidosis
Type II > is the most prevalent form of the disease
> includes individuals who have insulin resistance &
usually relative insulin deficiency

Pregestational Diabetes > label sometimes given to type I

or type 2 diabetes that existed before pregnancy

Gestational Diabetes > any degree of glucose intolerance

with the onset or first recognition occurring during
pregnancy
PREGESTATIONAL DIABETES
 Women who have pregestational diabetes may have
either type I or type 2 diabetes which may or may not be
complicated by vascular disease, retinopathy,
nephropathy or other diabetic sequelae
 Insulin requirements steadily increase after the first
trimester
 Insulin resistance begins as early as 14-16 weeks of
gestation & continues to rise until it stabilizes during the
last few weeks of pregnancy
MATERNAL RISKS AND
COMPLICATIONS
1. Poor glycemic control
2. Hypertensive disorders
3. Infections
4. Ketoacidosis

Complications in Fetus
5. IUGR

6. RDS

7. Sudden and unexpected stillbirth

8. Risk of birth injuries R/T increased fetal size

GESTATIONAL DM
Risk Factors:
1. Maternal age

2. Obesity

3. Family history

4. Obstetric hx of an infant weighing more than 4,500g

5. Hydramnios

6. Unexplained stillbirth

7. Miscarriage

8. Infant with congenital anomalies

ANTEPARTUM CARE
>aimed at strict blood glucose control

Target Blood Glucose Levels During Pregnancy

Premeal >65 but <105
Postmeal(1 hr)<130 – 155
Postmeal(2 hrs) <130