for mera

1. High risk pregnancy
By: ShenellD

2. 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

3. abortion

4. • 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.

5. 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.

6. 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.

7. Types of abortion:
• Threatened abortion
• Inevitable abortion
• Incomplete Abortion
• Complete Abortion
• Missed Abortion
• Habitual Abortion
• Septic abortion

8. 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.

9. The development of abortion is as follows:
continuing
pregnancy
• complete
inevitable abortion
abortion
incomplete
abortion
threatened
abortion

10. • 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

11. • 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

12. • 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

13. • Missed abortion- retention of all
products of conception after the
death of the fetus in the uterus
• No FHT
• Signs of pregnancy disappear

14. • Habitual abortion- abortion
occurring in 3 or more successive
pregnancies
• The most common cause is a
significant genetic abnormality of
the conceptus.

15. • Septic abortion- abortion
complicated by infection
• Foul smelling vaginal discharge
• Uterine cramping
• Fever

16. Nursing
responsibilities

17. • 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

18. ECTOPIC PREGNANCY

19. • Ectopic pregnancy is any gestation
located outside the uterine cavity.
• extra uterine pregnancy is the
second leading cause of bleeding in
early pregnancy.

20. 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

21. Causes of Ectopic pregnancy
• Functional and failed
contraception factors
– External migration of the ovum
– IUD
– Oral contraception
– Tubal ligation- 15-50 %
– Hysterectomy

22. Causes of Ectopic pregnancy
• Assisted reproduction
– Ovulation induction- clomid
– Gamete intrafallopian transfer
– In vitro fertilization
– Ovum transfer

23. siteS OF ECTOPIC
PREGNANCY

24. Most frequent site is in the fallopian tube,
so rupture of the site usually occurs
before 12 weeks

25. • 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%)

26. • The classic
symptom triad:
amenorrhea,
vaginal bleeding,
abdominal pain.

27. 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

28. • 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

29. 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
Lethargy, coma, dec. renal output
Renal failure
Matenal and fetal death
The
process of
shock due
to blood
loss

30. Management:
ectopic pregnancy.flv

31. • 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.

32. • 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

33. • 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.

34. HYDATIDIFORM MOLE
h-mole

35. • 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

37. 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)

38. Diagnostics:
• Ultrasonography reveals no
fetal skeleton
• Elevated HCG level

39. 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.

40. 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.

41. 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.

42. Hyper emesis gravidarum

43. 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

44. • 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.

45. 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.

46. PLACENTA PREVIA

47. • 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.

49. Causes of Placenta previa:
• Multiparity
• Multiple pregnancy
• Advance maternal age- over 35
years old
• Smoking
• Previous cesarean section and
abortion

50. • 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.

51. 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

52. 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

53. ABRUPTIO PLACENTA

54. • 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

57. Causes of abruptio placenta:
• Maternal hypertension
• Advance maternal age
• Multiparity
• Trauma to the uterus
• Short umbilical cord
• Cigarette smoking and cocaine
abuse

58. 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.

59. 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.

60. 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.

61. 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.

62. 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.

64. hydramnios
Polyhydramnios: (More than
2L of fluid). Excess of amniotic
fluid.

66. Causes:
• Fetal abnormalities- excessive
urination of fetus
• Esophageal atresia- fetus cannot
swallow amniotic fluid.
• Multiple pregnancy
• Diabetes mellitus

67. Complications:
• Premature labor & delivery
• Abruptio placenta
• Postpartum hemorrhage due to
over distension of uterus
• Cord prolapsed
• malpresentation

68. oligohydramnios
Oligohydramnios: (Less than
500 ml of fluid) ↓ of the
amniotic fluid.

70. Causes:
• Fetal renal anomalies that
results in anuria
• Premature rupture of
membranes

71. Complications:
• Club foot
• Amputation- due to adhesion of
fetal parts to the amnion
• Abortion
• Stillbirth
• Fetal growth retardation
• Abruptio placenta

72. Complication during labor and
delivery
• Cord compression
• Fetal hypoxia as a result of
cord compression
• Prolonged labor

73. Pregnancy induced
hypertension- PIH

74. • 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.

75. • 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

76. vasospasm
Vascular effect Kidney effect Interstitial effects
vasoconstriction
Poor organ
perfusion
Inc. BP
Dec. glomeruli
filtration rate &
inc. permeability of
glomeruli
membranes
Inc. serum blood urea
nitrogen, uric acid, &
creatinine
Dec. urine output &
protenuria
Diffusion of
fluid from
blood stream
into interstitial
tissue
edema

77. –Danger Signs of Pregnancy-
Induced Hypertension
• Swelling of the face or fingers
• Flashes of light or dots
• Blurring of vision
• Severe continuous headache

78. 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

79. 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.

80. 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+

81. 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

82. • Nursing responsibilities:
mgs04
• Monitor client’s respirations,
blood pressure and reflexes,
as well as urinary output
• Adm.med. Either IV or IM

83. 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

84. 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

85. 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.

86. 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.

87. 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.

88. 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

89. Gestational diabetes

90. • 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.

91. RISK FACTORS
• Age over 30
• Family Hx of DM
• Prior macrosomic,
malformed or stillborn infant
• Obesity
• Hypertension

93. TWO TYPES OF DIABETES

95. 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

96. 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

97. 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.

98. 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

99. 99
MACROSOMIA
Pathogenesis

101. 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

103. Heart disease

104. 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)

105. 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

106. Prenatal period assessment:
• Evidenced of cardiac decompensation
especially when blood volume peaks (
weeks 28-32)
• Cough & dyspnea
• Edema
• Heart murmur
• Palpitations
• rales

107. 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+