High risk pregnancy

‫الرحيم‬ ‫الرمحن‬ ‫هللا‬ ‫بسم‬
َ‫ل‬ َ‫ك‬َ‫ن‬‫ا‬َ‫ح‬ْ‫ب‬ُ‫س‬ ْ‫ا‬‫و‬ُ‫ل‬‫ا‬َ‫ق‬‫آ‬َ‫ن‬َ‫ل‬ َ‫م‬ْ‫ل‬ِ‫ع‬ّ‫ل‬ِ‫إ‬
ُ‫م‬‫ي‬ِ‫ل‬َ‫ع‬ْ‫ال‬ َ‫ت‬ْ‫ن‬َ‫أ‬ َ‫ك‬ّ‫ن‬ِ‫إ‬ ‫آ‬َ‫ن‬َ‫ت‬ْ‫م‬ّ‫َل‬‫ع‬ ‫ا‬َ‫م‬
ُ‫م‬‫ي‬ِ‫ك‬َ‫ح‬ْ‫ال‬
‫العظيم‬ ‫اهلل‬ ‫صدق‬
‫سورة‬‫البقرة‬‫أية‬32
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 1

High risk pregnancy
Thursday, April 5, 2018
Dr. Soad Abd El salam Ramdan 2

3
• Chairman of obstetrics &woman health
nursing department
• Pre. Vice of dean for students &Education
Affair
Faculty of nursing
Benha University
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan

Learning objectives:-
 Describe causes of bleeding in early pregnancy.
 Apply nursing care plan for woman with
bleeding in late pregnancy.
 Enumerate types of associated medical
problems during pregnancy.
 Describe the nurses responsibilities in relation
to various types of associated medical problems
during pregnancy.

Bleeding during pregnancy
Bleeding
Late
pregnancy
Accidental
hge.
Placenta
previa
Early
pregnancy
Abortion
Ectopic
pregnancy
Vesicular
mole

1- Bleeding
in early pregnancy

1-Bleeding In Early Pregnancy
(Before 20 weeks Gestation)
Causes:-
 Abortion.
 Vesicular mole.
 Ectopic pregnancy.

Related to pregnant state
 Abortion
 Ectopic pregnancy
 Molar pregnancy
Bleeding in early pregnancy
abortion ectopic Vesicular
mole

1- Abortion

1- Abortion :-
Definition
It is the termination
of pregnancy before
24 weeks, or products
of conception
weighing below
500 grams.

Causes
Fetal
 Chromoso
mal
anomalies.
 Diseases of
the
fertilized
ovum.
 Hypoxia.
Maternal
General conditions:
►Infections acute febrile conditions e.g. influenza, malaria.
►Disease such as chronic nephritis.
►Drug intake during pregnancy.
►Rh and ABO incompatibility.
Local conditions:
►Conditions that interfere with embedding, development and
nutrition of the ovum.
►Implantation of the ovum in the lower uterine segment.
►Incompetent cervix.
►Uterine malformation.
►Trauma - criminal interference, accidents, violent exercises,
uterine stimulation.
►Endocrine dysfunction

Types of
Abortion
Spontaneous induced
Therapeutic
Criminal

Spontaneous
Abortion
Threatened
Pregnancy
Progresses
Birth of
Viable Infant
Missed
Carneous
Mole
Inevitable
Incomplete
Septic
Complete

Types of Abortion:-
A- Spontaneous abortion: It means
termination of pregnancy through natural causes.
 ◘ Threatened abortion: It is one of the
subdivisions of spontaneous abortion. It may go to
term, or it may become inevitable.
 ◘ Missed abortion: Occurs when the fetus dies
and is not expelled but it is retained in utero for
two months or longer.

Cont.
◘ Inevitable abortion: Persistent bleeding and
cramps with dilatation of the cervix. Complete
abortion:All the products of conception are expelled.
◘ Incomplete abortion: Some parts of the
products of conception have been expelled, while
others (placenta and membranes) remain within the
uterus.
◘ Septic abortion: Incomplete abortion
complicated by infection of the uterine cavity.
◘ Habitual abortion: The patient has had three or
more successive, spontaneous abortions.

B- Induced abortion
 Therapeutic abortion: It means
artificial legal termination of pregnancy by
a physician due to medical indication.
 ◘ Criminal abortion: The illegal
termination of pregnancy.There are no
medical or obstetrical indications.

pes Types of abortion

Signs and Symptoms of
Abortion
1-Threatened abortion:
Cervical os is closed.
Membranes are intact.
Pain and backache may or may
not be present.

2- Incomplete abortion:
 Parts of the products of conception are
expelled (fetus is expelled from uterus,
placenta and membranes are still inside).
 Severe bleeding.
 Cervical os partly closed.
 No uterine involution.
 Pain may or may not be present.
 Uterus is soft and smaller than the
expected period of pregnancy

3- Septic abortion:
 Tender and painful uterus.
 Offensive vaginal bleeding.
 High temperature.
 Rapid pulse.
 Chills.
 Unstable blood pressure.
 Shock.

4- Inevitable abortion:
 Bleeding is excessive (more than 10 days).
 Blood is red in color with clots.
 Severe colicky lower abdominal pain.
 Cervical os is dilated and rupture of
membranes has occurred.
 Uterus will be firm.
 There is severe blood loss and the woman
becomes shocked.

5- Missed abortion:
 Fetus dies and is retained in the uterus.
 Some signs of pregnancy disappear.
 Pregnancy test will be negative.
 Fundal height does not increase in size.
 The breasts may secrete milk due to
hormonal changes/(Prolactin). FHR are
absent.
 No fetal movement.
 A sonar test confirms fetal death.
 Some brownish vaginal discharge.
 Cervix os is closed.
Thursday, April 5, 2018
Dr. Soad Abd El salam Ramdan 23

Treatment
◘Threatened abortion:
 Complete bed rest.
 All vaginal pads and stained linen should
be kept to estimate the amount of blood
loss.
 Good personal hygienic care.
 Sedatives such as phenobarbital 60 mg. is
usually ordered, for pain, pethidine 30-60
mg is ordered.
 Checking ofTPR and BP twice daily, or
every 4 hours according to the condition
of the mother.

Cont. :-
 Avoid enema and purgatives.
 Avoid constipation and diarrhea.
 Rich protein diet with supplementary iron
and vitamin should be provided.
 Advise no sexual intercourse.
 Administration of prescribed drugs.
 Accurate observation of blood loss, color,
odor, amount and content.
 Intake and output chart should be kept.

Treatment of incomplete abortion:
 Go to hospital for assessment and proper
intervention.
 If no heart beats are detected a dilute
solution of oxcytocin may be given as the
doctor orders to help in the expulsion of
the contents of the uterus.
 Dilatation and curettage should be done.

Treatment of Septic abortion:
 Isolation.
 Clinical bacteriological and hematological investigation
to identify the infectious organisms.
 Administration of antibiotics as doctor orders.
Electrolyte control.
 Accurate observation of renal functions.
 Intake and output chart should be kept.
 General hygienic care.
 The soiled pads should be properly collected and
burned.
 Accurate observation of TPR and BP.
 Understanding and supporting.

6- Recurrent (Habitual)
Abortion
 Definition:
Three (two by some authors) or
more consecutive abortions.
Dr. Soad Abd El salam RamdanThursday, April 5, 2018 28

Recurrent (Habitual)
Abortion>Aetiology:
 1. Chromosomal abnormalities: Can be
detected in
o Foetus: e.g. autosomal trisomy, sex
chromosome monosomy (X), and
polyploidy.
o Parents: e.g. balanced translocation.

Abortion>Aetiology:
 2.Uterine abnormalities:
o Congenital anomalies: e.g. hypoplasia, bicornuate, septate
and subseptate uterus.
o Intrauterine synechiae (Asherman’s syndrome).
o Cervical incompetence: whether congenital or acquired.
o Uterine myomas.
o Deficiency of endometrial oestradiol and progesterone
receptors: leads to failure of implantation or early abortion
o Divided uterine artery: uterus with two ascending uterine
arteries may fail to provide adequate blood flow to the
developing placenta and the growing foetus.

Abortion>Aetiology:
 3.Infections:
oToxoplasma.
o Mycoplasma hominis.
o Ureaplasma urealyticum.
o Listeria monocytogenes.
o Brucella.
o Chlamydia.
o Syphilis.
Dr. Soad Abd El salam Ramdan
Thursday, April 5, 2018 31

Abortion>Aetiology:
 4. Hormonal:
o Hypothyrodism,
o Diabetes.
o Luteal phase deficiency.
Dr. Soad Abd El salam Ramdan
Thursday, April 5, 2018 32

Abortion>Aetiology:
 5. Immunological:
o Human leukocyte antigens (HLA): the
difference in HLA between both parents
stimulates the maternal production of the
"blocking factors" which prevent rejection of
the conception. More sharing in HLA
between the parents causes recurrent
abortions. So the incidence of recurrent
abortions is higher if there is positive
consanguinity between the two partners.

Abortion>Aetiology:
 5. Immunological:
o Antiphospholipid antibodies:These
antibodies cause placental vessels
thrombosis resulting in infarction and
placental insufficiency.
o Systemic lupus erythematosus.

Abortion>Aetiology:
 6. Miscellaneous:
o Chronic malnutrition.
o Chronic anaemia.
o Chronic cardiac and renal diseases.
o Cigarette smoking and alcohol
abuse.

Abortion>:Treatment
 Medical treatment:
 Treatment of the cause as:
o anaemia and malnutrition,
o diabetes,
o renal diseases,

Abortion>:Treatment
 o infections as chlamydia and
mycoplasma (tetracycline or doxycycline)
and toxoplasma (spiramycin) which may
need another coarse(s) of treatment
during pregnancy.

Abortion>:Treatment
 Luteal phase defect treated by
progesterone or progestogens in the
secretory phase and up to 16th week of
pregnancy.

Abortion>:Treatment
* Surgical treatment:
Cervical cerclage:
Ultrasonography is done before operation to:
# confirm foetal viability,
# exclude congenital
anomalies,
# measure the internal os.

Abortion>:Treatment
 o Cervical cerclage:
+ It means encircling the cervix at
or as near as possible to the internal os by a
non-absorbable suture.
+ The best time for the operation
is about 12-14 weeks, so that the placenta is
formed and there is no possibility of
abortion due to congenital anomalies of the
early embryo.
+ The suture is removed at 38
weeks or if labour started at any time.

Abortion>:Treatment
Vaginal cerclage:
# Shirodkar operation:
* Two incisions at the reflection of the
vaginal wall on the cervix are done
anteriorly and posteriorly and bladder is
dissected upwards.A nylon or silk suture
or a dacron (mersilene) tape is applied
around the internal os under the cervical
mucosa.

Abortion>:Treatment
 Vaginal cerclage:
 # Mc Donald operation:
* It is the commonest operation.
* The cervix is surrounded from outside by
a nylon or silk purse- string suture.The
suture takes bites of cervical tissue at
3,6,9 and 12 o'clock then tied anteriorly
or posteriorly.
* This operation is easier and gives nearly
the same results as Shirodkar.

Abortion>:Treatment
 + Abdominal cerclage:
# In case of previous high
amputation of the cervix extensive
cervical laceration or repeated failure of
vaginal cerclage.
# The isthmus uteri is
encircled by a non-absorbable suture and
the patient should be delivered by
caesarean section.

2-Vesicular mole

Hydatidiform Mole (Vesicular
Mole)
Hydatidiform mole is a gross
malformation of the trophoblast
in which the chorionic villi
proliferate and become avascular.
The villi are filled with fluid forming
vesicles, which look like a bunch of
grapes.
It is an abnormal development of
the chorionic villi of conceptus.

Causes:-
 The exact cause is unknown
◘ Risk factors are:-
 age ; old than 45 years or younger than
20 years
 Parity ;more with high parity
 Socioeconomic ;more in poor
 Previous obstetric performance
;common with one or more abortion .

Types:
Partial molar pregnancy:
This is where a baby starts to develop, but is
unable to survive, often being absorbed into
the vesicles that continue to multiply.
Complete molar pregnancy:
This is where a baby never develops, but the
placenta implants and grows many small
cysts, like sacs filled with fluid.

Causes
◘ The exact cause is unknown.
◘ Risk factors are:
Maternal age above 40 years
or below 19 years.
Malnutrition (deficiency of
proteins).

Signs and Symptoms
◘ Signs and symptoms of early pregnancy are
present.
◘ Excessive frequent vomiting.
◘ Over distension of the uterus and larger than
expected for weeks of gestation.
◘ vaginal bleeding with passage of vesicles.
◘ No fetal movements are reported by the mother.
◘ No fetal parts can be palpated and no fetal
heartbeats can be detected.
◘ On palpation the uterus may have an elastic
consistency or it may be doughy.
◘ There is an increased incidence of pre-eclampsia.
◘ Positive pregnancy test result in highly diluted
urine 1:500.

Investigations:-
◦ Pregnancy test is +ve in high dilution.
◦ Ultrasound.
◦ X-ray (no fetal skeleton.
◦ If 1/200 is +ve it is highly suggestive.
◦ If 1/500 is +ve  it is surely diagnostic
Complications:-
◘ Hemorrhage.
◘ Uterine sepsis.
◘ Choriocarcinoma

Management:-
 ◘ Admit the woman into hospital.
 ◘ Fluid replacement and packed RBCs.
 ◘Prepare the woman for evacuation of the uterus
under general anesthesia.
 ◘ HCG levels should be checked periodically.
 ◘ Health education on the following:
 Need for monitoring HCG levels for two years
(monthly for the first 3 months, then every three
months for one year).
 Birth spacing methods to prevent pregnancy for
two years.
 If HCG levels remain more than five international
units per liter eight weeks postpartum,
prophylactic chemotherapy is indicated.

3- Ectopic Pregnancy

Ectopic Pregnancy:-
 Ectopic pregnancy is defined as
pregnancy occurring outside the
normal uterine cavity.
 ◘ It is an abnormal implantation
of the fertilized ovum that occurs
outside the uterine cavity.
 Approximately 2% of
pregnancies are ectopic.
 Second most frequent cause of
bleeding.

Sites of ectopic pregnancy
implantation:
1. The surface of the ovary
2. Cervix
3. Fallopian tube (95% ): 80% occur in the
ampullar

Ectopic Pregnancy Incidence
increase with:
 Smoking.
 Intrauterine devices (IUDs).
 In vitro fertilization.
 History of ectopic pregnancy (10%-20%).
 Pelvic inflammatory disease.
 History of previous pelvic operations such as
D and C, tuboplasty, tubal sterilization,
ovarian surgery.

Causes:-
 Obstruction, such as an adhesion of the fallopian
tube.
Causes of adhesions:
1. Previous infection.
2. Congenital malformations.
3. Scars from tubal surgery.
4. Uterine tumor.
 Impaired tubal ciliary action.
 Impaired tubal contractility.
 Decreased sperm mobility.
 The use of intrauterine contraceptive device.

Signs and Symptoms :-
 Short periods of amenorrhea.
 History of infertility, tubal surgery, induced
abortion.
 Sudden/recurrent severe, colicky abdominal
pain in one iliac fossa or entire lower
abdomen.
 Dizziness and fainting attacks.
 Blood stained vaginal discharge.
 Diffuse tenderness on lower abdomen.
 Signs of shock.
 Dyspareunia.

 Management
 Once the diagnosis of ectopic pregnancy has
been made, the pregnancy should be evacuated
immediately.
 Salpingectomy is preformed.
 Provide emotional support to the patient.
 Prepare for emergency surgery.
 Monitor the patient for shock. Follow-up is
needed.
 Family planning should be discussed.

THANKYOU
Thank you

Bleeding in late
pregnancy

2- Ante partum Hemorrhage:
Bleeding in late pregnancy
(After 20 weeks Gestation)
 Definition
 Antepartum hemorrhage is defined as
bleeding occurring from the genital tract
after the 24th week of pregnancy, and
before the birth of the infant.

Classification
 ◘ Placenta previa: –
Inevitable hemorrhage occurs from separation of an
abnormally situated placenta.The placenta lies partly
or wholly in the lower uterine segment.
 ◘ Abruptio placenta: –
bleeding occurs from the premature separation of a
normally situated placenta.
 ◘ Extraplacental bleeding: –
is vaginal bleeding from some other part of the
birth canal e.g. cervical polyp, varicose veins of the
vulva, etc.

Complications of Antepartum
Hemorrhage
◘ Maternal Risks:
 Hemorrhagic shock.
 Acute renal failure.
 Disseminated intravascular
coagulation (DIC)
 Increased risk for
postpartum hemorrhage.
 Severe anemia.
◘ Fetal Risks:
 Prematurity and
birth asphyxia.
 Intrauterine fetal
death.

1- Placenta Previa

Placenta Previa
 Definition
 This is a condition in
which the placenta is
partly or totally
implanted over the
lower uterine
segment.

Prevalence of Placenta Previa
Occurs in 1/200 pregnancies that
reach 3rd trimester

Causes:-
No specific cause can be detected, but theories
1- Large placenta
 Placenta membrana (large and thin)
 Placenta of twins pregnancy
 Syphilis
 Some cases of D.M
 low implantation of placenta in L.U.S: due
to delayed development of trophoblast

Placenta previa Incidence
increase with:
Previous uterine instrumentation (D & C)
 Multiparty
 Maternal age over 40 years
 Multiple gestation as twins pregnancy
 Prior placenta previa
 Uterine fibroid

Degrees:-
◘ Placenta previa
lateralis: [type I]
 The lower part of
the placenta is
implanted over the
lower uterine
segment, but does
not reach the
internal os.
◘ Placenta previa
marginalis: [type II]
 Part of the placenta
is implanted over the
lower uterine
segment and its
margin reaches the
internal os, but does
not cover it
completely.

◘ Incomplete central
placenta previa: [type
III]
 The placenta covers the
closed or incompletely
dilated internal os
eccentrically, but with
further dilatation.The
placenta does not cover
it completely when it is
closed, but covers it
incompletely when the
os is dilated.
◘ Complete central
placenta previa: [type
IV]
 The whole placenta is
implanted over the
lower uterine segment,
with the internal os
located at the center of
the placenta.Thus, the
placenta covers the
internal os completely
even when it is fully
dilated.

Diagnosis 1- C/P – Placenta Previa
* Symptoms:
 Cardinal symptom is painless
,causeless and recurrent 2nd or 3rd
trimester vaginal bleeding

Signs:
acute: hgic. Shock
a. General Exam :blood loss chronic: anemia
 b.Abdominal Examination:
 1- uterus :
1- Fundal level equal to period of amenorrhea
2- Not tender , not hard
3- Easy palpable fetal parts
4- Audible F.H.S , malpresentaion
5- No engagement
6- Supra pubic fullness if placenta interior

 C- P.V contraindicated but if
necessary
 Under Precaution :
1- Available blood transfusion
2- In operating theatre
3 Under aseptic condition
4- Under general anesthesia
5-When active treatment is indicated

Investigation:
1- Laboratory
 Hematocrit or complete blood count
 Blood type and Rh
 Coagulation tests

Ultrasound – Placenta Previa
 it’s the most useful test to confirm
diagnosis
 Full bladder can create false appearance of
anterior previa
 MRI
 Test for fetal maturity and fetal well being

Effects of Placenta Previa on
Pregnancy and Labor
 ◘ It lowers the general
resistance of the patient.
 ◘ Abnormal
presentation and
position.
 ◘ Premature labor.
 ◘ Prolonged labor.
 ◘ More chance of
surgical intervention.
 ◘ Increased risk of
lacerations.
 ◘ Placenta may be
morbidly adherent.
 ◘ Postpartum
hemorrhage.
 ◘ Fetal malformation.
 ◘ High incidence of
fetal hypoxia and
mortality.
 ◘ Maternal shock.
 ◘ Maternal death.

Management of Placenta
Praevia
 Management of placenta praevia depends
on:
◦ The amount of bleeding
◦ The condition of mother and fetus
◦ The degree of the placenta
◦ The duration of pregnancy

Therapeutic Management:
❖Birth must be accomplished regardless of
gestational age;
▪ if labor has begun,
▪ bleeding is continuing,
▪ fetus in distress
❖Managed by expectant watching:
 If the bleeding has stopped,
• the fetal heart sounds are of good quality,
• maternal vital signs are good,
• and the fetus is not yet 36 weeks of age

Complication of Placenta Previa
 Maternal complication
1- Abnormal presentation and position.
2- Premature labor.
3- Prolonged labor.
4- More chance of surgical intervention.
5- Placenta may be adherent: Placenta accreta,
increta, or percreta
6- Postpartum hemorrhage
7- Maternal shock and maternal death

Fetal complication
 Fetal malformation.
 High incidence of fetal hypoxia
 Increase incidences of perinatal
mortality and morbidity.
 Increase incidences of prematurity

Nursing care
 1- Assessment:
With the client’s admission to the hospital, the nurse
begins with an assessment of the bleeding. Necessary
history data include gravidity, parity, EDD, general status,
bleeding (quantity, precipitating event, and associated
pain), vital signs and fetal status. Abdominal assessment
reveals a soft relaxed, non tender uterus with normal
tone. Laboratory studies include CBC, determination of
blood type and Rh factor, coagulation profile and
possible type and cross match for 2 packed red blood
cells.

2- Nursing diagnosis:
Nursing diagnosis for placenta
previa include focus on alterations
in hemodynamic status, knowledge
deficits, fears and anxiety of the
woman and her significant others,
and fetal status

3- Planning:
The plan must relate specifically to the
client’s clinical and nursing diagnosis
* The woman will identify and use available
support systems.
* The woman will not develop
complications.
* The woman will carry her pregnancy to
term or near term.
* The woman will give birth to healthy
infant.

 4- Implementation:
If conservative management is used, nursing
care focuses on accurate assessments and
appropriate referrals. The client is instructed on
the importance of bed rest and the need to report
any further spotting or bleeding. Maternal vital
signs will be assessed as indicated by the woman’s
condition. Serial laboratory values will be evaluated
for the presence of falling hemoglobin and
hematocrit levels and changes in coagulation
studies. Fetal well-being will be evaluated Any
indication of fetal compromise will be reported
immediately to the physician.

 If active management is under taken, the nurse
will continuously assess maternal and fetal status
while preparing the client for surgery. Laboratory
studies will include CBC, DIC profile, and
possible type and cross matching for packed red
blood cells maternal vital signs will be assessed
frequently for decreasing blood pressure, rising
pulse rate, changes in level of consciousness
(L.O.C) and /or oliguria. Fetal assessment will be
maintained by continuous electronic fetal
monitoring (E.F.M) to assess for signs of hypoxia.

5- Evaluation:
The nurse can be assured that care was effective
to the degree that goals for care have been met.
* She does not develop complications.
* She carries her pregnancy to term or near term.
* She gives birth to a healthy infant.

2- Abruptio Placenta
(Accidental
Hemorrhage)

Abruptio Placenta
(Accidental Hemorrhage)
Definition
It is bleeding during the last
three months of pregnancy, the
first or second stage of labor,
due to premature separation
of a normally situated placenta.

Causes &Types
 ◘ The most important
cause is hypertension
due to toxemia of
pregnancy.
 ◘ The second most
common cause is trauma.
 ◘ Some deficiencies in
vitamins C and K.
 ◘ Torsion of the
pregnant uterus.
 ◘ Traction on a short
umbilical cord.
 ◘ Sudden reduction of
the size of the uterus.
 ◘Revealed: almost all
the blood expelled
through the cervix.
 ◘Concealed: almost
all the blood is retained
inside the uterus.
 ◘Combined: some
blood is retained inside
the uterus and some is
expelled through the
cervix.

Causes of Premature Separation
 The primary cause is unknown.
 Incidence increase with:
1. High parity.
2. Advanced maternal age.
3. Short umbilical cord.
4. Chronic hypertensive disease.
5. Pregnancy-induced hypertension.
6. Direct trauma.
7. Vasoconstriction from cocaine or cigarette use.
8. Thrombophilitic conditions that lead to thrombosis.
9. Follow a rapid decrease in uterine volume, such as occurs with
sudden release of amniotic fluid.

CriteriaGrade
No symptoms of separation were apparent from maternal or
fetal signs; the diagnosis that a slight separation did occur is
made after birth, when the placenta is examined and a
segment of the placenta shows a recent adherent clot on the
maternal surface.
0
Minimal separation, but enough to cause vaginal bleeding
and changes in the maternal vital signs; no fetal distress or
hemorrhagic shock occurs, however.
1
Moderate separation; there is evidence of fetal distress; the
uterus is tense and painful on palpation.
2
Extreme separation; without immediate interventions,
maternal shock and fetal death will result.
3
Degrees of Separation

Premature separation of the placenta

Signs and Symptoms
 ◘ Revealed accidental
hemorrhage:
 Vaginal bleeding.
 Signs of blood loss are
present (pale, irritable,
air hunger, increased
pulse). Blood pressure is
usually not affected.
 If there is shock and
painful contractions are
present.
 Laxed uterus between
contractions.
 Fetal parts are easily felt.
 Fetal head may be fixed
or engaged in the pelvis.
 FHS are heard if less
than half of the placenta
is separated.

Concealed accidental hemorrhage:
 Sudden, severe
abdominal pain followed
by fainting and vomiting.
 Shock is always present.
 Patient becomes pale
and irritable.
 Systolic pressure
decreases while diastolic
remain increased.
 The abdomen is very
tender and rigid.The
uterus is very hard and
larger than expected.
 If severe shock, no
uterine contractions are
felt.
 Some scanty dark
bleeding.
 Edema of lower limbs.
 Heavy albuminuria.

Combined accidental
hemorrhage:
The blood is partially revealed
and partly concealed.
Signs and symptoms depend on
the amount of blood loss and
whether it is more revealed or
concealed.

Complications
 ◘ Hemorrhage.
 ◘ Acute renal failure.
 ◘ Postpartum
hemorrhage.
 ◘ Pituitary necrosis.
Prognosis
 ◘ A mild case has a
good prognosis, while
a severe case has
serious
consequences for the
mother and fetus.

Treatment:-
 Treatment of concealed A.H
 1- Correction of shock
 2-T.O.P : divided into:
a- Dead fetus :
ARM+ syntocinon C.S if have
contraindicated of normalV.D
B- living fetus :C.S
Treatment of complication: DIC and PPH

Prevention:
Avoiding general pregnancy risk factors, such
as cocaine, alcohol, or smoking
 Treating chronic high blood pressure or
other conditions, such as diabetes
 Good antenatal care will help to identify
pregnancy risk factors and possibly allow
for early detection of placenta problems.

Nursing care
1- Assessment:
Nursing assessments include all
components described for clients with
spontaneous abortions and placenta
previa.Additional assessments are
necessary to identify an increasing
fundal height, which indicates
concealed bleeding.

 2- Nursing diagnosis:
Nursing diagnosis related to the care of the client with
abruption placenta focus on alterations in homodynamic
status, knowledge deficits, fears and anxiety of the woman
and fetal status. Many of the potential nursing diagnosis are
the same as for placenta previa. Additional potential nursing
diagnosis includes the following:
* Pain related to bleeding between the uterine wall and the
placenta secondary to premature separation of the
placenta.
* Grieving related to actual or threatened loss of infant.
* Power lessens related to maternal condition and
hospitalization.

3- Planning:
* The woman will identify and use
available support systems.
* The woman will express relief of
pain.
* She will not develop complications.
* She will give birth to healthy infant

 4- Implementation:
Careful assessments are mandatory. Information
is given to the client and her family about
abruption placenta including cause, treatment and
expected out come. Vital signs are assessed
frequently to observe for signs of declining
homodynamic status. Fetal status is continuously
monitored if the fetus has survived the initial
result. Preparations are made for the birth, but it
should be kept in mind that an emergency
cesarean birth is always a possibility.

5- Evaluation:
The nurse can be reasonably assured
that care was effective to the extent
that the goals for care have been met.
That is, the woman identifies and uses
available support systems, expresses
relief of pain does not develop
complications, and gives birth to
a healthy infant who has not
experienced fetal compromise.

High risk pregnancy

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to High risk pregnancy

Similar to High risk pregnancy (20)

Recently uploaded

Recently uploaded (20)

High risk pregnancy