High risk pregnancy delfin 202Presentation 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- 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.
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.
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 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.
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 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 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.
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
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
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 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+