High Risk Pregnancy Disorders

High Risk Pregnancy

1. Hemorrhagic Disorders

General Management

1.)     CBR

2.)     Avoid sex

3.)     Assess for bleeding (per pad 30 – 40cc) (wt – 1gm =1cc)

4.)     Ultrasound to determine integrity of sac

5.)     Signs of Hypovolemic shock

6.)     Save discharges – for histopathology – to determine if product of conception has been expelled or not

First Trimester Bleeding – abortion or eptopic

A. Abortions – termination of pregnancy before age of viability (before 20 weeks)

Spontaneous Abortion- miscarriage

Cause:   1.) chromosomal alterations

2.) blighted ovum

3.) plasma germ defect

Classifications:

1. Threatened – pregnancy is jeopardized by bleeding and cramping but the cervix is closed
2. Inevitable – moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)

Types:

1.)     Complete – all products of conception are expelled. No mgt just emotional support!

2.)     Incomplete – Placental and membranes retained. Mgt: D&C

Incompetent cervix – abortion

McDonalds procedure – temporary circlage on cervix

S/E; infection. During delivery, circlage is removed. NSD

Sheridan – permanent surgery cervix. CS

c.    Habitual – 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix. Present 2^nd trimester

d.    Missed – fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy cease. (-) preg test, scanty dark brown bleeding

Mgt:  induced labor with oxytocin or vacuum extraction

      5.)    Induced Abortion – therapeutic abortion to save life of mom. Double effect choose between lesser evil.

1. Ectopic Pregnancy – occurs when gestation is located outside the uterine cavity. common site: tubal or ampular

Dangerous site - interstitial

Unruptured	Tubal rupture
-          missed period -          abdominal pain within 3 -5 weeks of missed period (maybe generalized or one sided) -          scant, dark brown, vaginal bleeding Nursing care: Vital signs Administer IV fluids Monitor for vaginal bleeding Monitor I & O	-          sudden , sharp, severe pain. Unilateral radiating to shoulder. shoulder pain (indicative of intraperitoneal bleeding that extends to diaphragm and phrenic nerve) + Cullen’s Sign – bluish tinged umbilicus – signifies intra peritoneal bleeding syncope (fainting) Mgt: Surgery depending on side Ovary: oophrectomy Uterus : hysterectomy

Second trimester bleeding

C. Hydatidiform Mole “bunch or grapes” or gestational trophoblastic disease. – with fertilization. Progressive degeneration of chorionic villi. Recurs.

- gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed form the selling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46 XX, it grows & enlarges the uterus vary rapidly.

Use: methotrexate to prevent choriocarcinoma

Assessment:

Early signs             -               vesicles passed thru the vagina

                                        Hyperemesis gravidarium increase HCG

                                        Fundal height

Vaginal bleeding( scant or profuse)

Early in pregnancy

                                High levels of HCG

                                Preeclampsia at about 12 weeks

Late signs              hypertension before 20^th week

                                Vesicles look like a “ snowstorm” on sonogram

                                Anemia

                                Abdominal cramping

Serious complications                         hyperthyroidism

                                                                Pulmonary embolus

Nursing care:

                Prepare D&C

                Do not give oxytoxic drugs

                Teachings:

a.       Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus and rising titer could indicative of choriocarcinoma

b.       Avoid pregnancy for at least one year

 

Third Trimester Bleeding “Placenta Anomalies”

1. Placenta Previa – it occurs when the placenta is improperly implanted in the lower uterine segment, sometimes covering the cervical os. Abnormal lower implantation of placenta.

-          candidate for CS

Sx: frank

Bright red

Painless bleeding

Dx:

Ultrasound

Avoid: sex, IE, enema – may lead to sudden fetal blood loss

Double set up: delivery room may be converted to OR

Assessment:

Engagement (usually has not occurred)

Fetal distress

Presentation ( usually abnormal)

                Surgeon – in charge of sign consent, RN as witness

-          MD explain to patient

complication: sudden fetal blood loss

Nursing Care

                NPO

Bed rest   

Prepare to induce labor if cervix is ripe

Administer IV

2. Abruptio Placenta – it is the premature separation of the placenta form the implantation site. It usually occurs after the twentieth week of pregnancy.

Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.

Assessment:

Concealed bleeding (retroplacental)

Couvelaire uterus (caused by bleeding into the myometrium)-inability of uterus to contract due to hemorrhage.

Severe abdominal pain

Dropping coagulation factor (a potential for DIC)

Complications:

Sudden fetal blood loss

-placenta previa & vasa previa

Nursing Care:

Infuse IV, prepare to administer blood

Type and crossmatch

Monitor FHR

Insert Foley

Measure blood loss; count pads

Report s/sx of DIC

Monitor v/s for shock

Strict I&O

3. Placenta succenturiata – 1 or 2 more lobes connected to the placenta by a blood vessel may lead to retained placental fragments if vessel is cut.
4. Placenta Circumvalata – fetal side of placenta covered by chorion
5. Placenta Marginata – fold side of chorion reaches just to the edge of placenta
6. Battledore Placenta – cord inserted marginally rather then centrally
7. Placenta Bipartita – placenta divides into 2 lobes
8. Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta
9. Vasa Previa – velamentous insertion of cord has implanted in cervical OS

2. Hypertensive Disorders

I. Pregnancy Induced Hypertension (PIH)- HPN after 24 wks of pregnancy, solved 6 weeks post partum.

1.)     Gestational hypertension - HPN without edema & protenuria    H without EP

2.)     Pre-eclampsia – HPN with edema & protenuria or albuminuria    HE P/A

3.)     HELLP syndrome – hemolysis with elevated liver enzymes & low platelet count

II. Transissional Hypertension – HPN between 20 – 24 weeks

III. Chronic or pre-existing Hypertension –HPN before 20 weeks not solved 6 weeks post partum.

Three types of pre-eclampsia

1.) Mild preeclampsia – earliest sign of preeclampsia   

a.) increase wt due to edema

b.) BP 140/90

c.) protenuria +1 - +2

2.) Severe preeclampsia

Signs present: cerebral and visual disturbances, epigastric pain due to liver edema and oliguria usually indicates an impending convulsion. BP 160/110  ,  protenuria +3 - +4

3.) Eclampsia – with seizure! Increase BUN – glomerular damage. Provide safety.

Cause of preeclampsia

1.)     idiopathic or unknown common in primi due to 1^st exposure to chorionic villi

2.)     common in multiple pre (twins) increase exposure to chorionic villi

3.)     common to mom with low socioeconomic status due to decrease intake of CHON

Nursing care:

P – romote bed rest to decrease O2 demand, facilitate, sodium excretion, water immersion will cause to urinate.

P- prevent convulsions by nursing measures or seizure precaution

1.) dimly lit room . quiet calm environment

                                                2.) minimal handling – planning procedure

                                                3.) avoid jarring bed

P- prepare the following at bedside

                                - tongue depressor

                                - turning to side done AFTER seizure! Observe only! for safely.

E – ensure high protein intake ( 1g/kg/day)

                                - Na – in moderation

A – anti-hypertensive drug Hydralazine ( Apresoline)

C – convulsion, prevent – Mg So4 – CNS depressant

                 E – valuate physical parameters for Magnesium sulfate

                            Magnesium SO4 Toxicity:

1.       BP decrease

2.       Urine output decrease

3.       Resp < 12

4.       Patella reflex absent – 1^st sigh Mg SO4 toxicity.  antidote – Ca gluconate

3.Diabetes Mellitus -  absence of insufficient insulin (Islet of Langerhans of pancreas)

Function: of insulin – facilitates transport of glucose to cell

Dx: 1 hr 50gr  glucose tolerance test   GTT

Normal glucose – 80 – 120 mg/dl                    < 80 – hypoclycemic

                                   ( euglycemia)                     > 120 - hyperglycemia

3 degrees GTT of > 130 mg/dL

maternal effect DM

1.)     Hypo or hyperglycemia – 1^st trimester hypo, 2^nd – 3^rd trim – hyperglycemic

2.)     Frequent infection- moniliasis

3.)     Polyhydramnios

4.)     Dystocia-difficult birth due to abnormalities in fetus or mom.

5.)     Insulin requirement, decrease in insulin by 33% in 1^st tri; 50% increase insulin at 2nd – 3^rd trimester.

Post partum decrease 25% due placenta out.

Fetal effect

1.)     hyper & hypoglycemia

2.)     macrosomia – large gestational age – baby delivered > 400g or 4kg

3.)     preterm birth to prevent stillbirth

Newborn Effect : DM

1.)     hyperinsulinism

2.)     hypoglycemia

normal glucose in newborn 45 – 55 mg/dL

hypoglycemic < 40 mg/dL

Heel stick test – get blood at heel

Sx:

Hypoglycemia high pitch shrill cry tremors, administer dextrose

3.)     hypocalcemia - < 7mg%

Sx:

Calcemia tetany

Trousseau sign

Give calcium gluconate if decrease calcium

Recommendation

Therapeutic abortion

If  push through with pregnancy

1.)     antibiotic therapy- to prevent sub acute bacterial endocarditis

2.)     anticoagulant – heparin doesn’t cross placenta

Class I & II- good progress for vaginal delivery

Class  III & IV- poor prognosis, for vaginal delivery, not CS!

NOT lithotomy! High semi-fowlers during delivery. No valsalva maneuver

Regional anesthesia!

Low forcep delivery due to inability to push. It will shorten 2^nd stage of labor.

Heart disease

Moms with RHD at childhood

Class I – no limit to physical activity

Class II – slight limitation of activity. Ordinary activity causes fatigue & discomfort.

Recommendation of class I & II

1.)     sleep 10 hrs a day

2.)     rest 30 minutes & after meal

Class III - moderate limitation of physical activity. Ordinary activity causes discomfort

Recommendation:

1.) early hospitalization by 7 months

Class IV. marked limitation of physical activity. Even at rest there is fatigue & discomfort.

Recommendation: Therapeutic abortion

XII. Intrapartal complications

1. Cesarean Delivery  Indications:

a.             Multiple gestation

b.             Diabetes

c.              Active herpes II

d.             Severe toxemia

e.              Placenta previa

f.              Abruptio placenta

g.              Prolapse of the cord

h.             CPD primary indication

i.               Breech presentation

j.               Transverse lie

Procedure:

1. classical – vertical insertion. Once classical always classical
2. Low segment – bikini line type – aesthetic use

VBAC – vaginal birth after CS

INFERTILITY -  inability to achieve pregnancy. Within a year of attempting it

-          Manageable

STERILITY - irreversible

Impotency – inability to have an erection

2 types of infertility

1.) primary – no pregnancy at all

2.) Secondary – 1^st pregnancy, no more next preg

test male 1^st

-          more practical & less complicated

-          need: sperm only

-          sterile bottle container ( not plastic has chem.)

-          Sims Huhner test – or post coital test. Procedure: sex 2 hours before test                                                                            mom – remains supine 15 min after ejaculation

Normal: cervical mucus must be stretchable 8 – 10 cm with 15 – 20 sperm. If >15 – low sperm count

Best criteria- sperm motility for impotency

Factors: low sperm count

1.)     occupation- truck driver

2.)     chain smoker

administer: clomid ( chomephine citrate) to induce spermatogenesis

Mgt: GIFT= Gamete Intra Fallopian Transfer  for low sperm count

Implant sperm in ampula

1.) Mom: anovulation – no ovulation. Due to increase prolactin – hyperprolactinemia

Administer; parlodel ( Bromocryptice Mesylate)

Action; antihyper prolactineuria

Give mom clomid: action: to induce oogenesis or ovulation

S/E: multiple pregnancy

2.) Tubal Occlusion – tubal blockage – Hx of PID that has scarred tubes

-          use of IUD

-          appendicitis (burst) & scarring

= dx: hysterosalphingography – used to determine tubal patency with use of radiopaque material

Mgt: IVF – invitrofertilization (test tube baby)

England 1^st test tube baby

To shorten 2^nd stage of labor!

1.)     fundal pressure

2.)     episiotomy

3.)     forcep delivery