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High risk pregnancy delfin 202

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    High risk pregnancy delfin 202 High risk pregnancy delfin 202 Presentation Transcript

    • 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
      pregnancy
      complete
      inevitable abortion
      abortion
      incomplete
      abortion
      threatened 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 shock due to blood loss
      Lethargy, coma, dec. renal output
      Renal failure
      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 MOLEh-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:
      Severe, persistent vomiting that leads to dehydration or nutritional deficiency
      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 filtration rate & inc. permeability of glomeruli membranes
      vasoconstriction
      Diffusion of fluid from blood stream into interstitial tissue
      Poor organ perfusion
      Inc. serum blood urea nitrogen, uric acid, & creatinine
      Dec. urine output & protenuria
      Inc. BP
      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
    • 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
    • 99
      MACROSOMIAPathogenesis
    • 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 interventionprenatal 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+
    • Thanks for Listening!