High Risk PregnancyHigh Risk Pregnancy

IntroductionIntroduction

Many complications can occurs during Many complications can occurs during pregnancy and affect health of mother and pregnancy and affect health of mother and fetus as well as outcomesfetus as well as outcomes

Hemorrhage is the first ten causes of Hemorrhage is the first ten causes of maternal mortality and morbidity affect maternal mortality and morbidity affect about 32% of all maternal death. Abortion about 32% of all maternal death. Abortion represent 4.5% of all maternal death represent 4.5% of all maternal death

Many women do not understand the Many women do not understand the bleeding is abnormal and dangerous signs bleeding is abnormal and dangerous signs and come late to health care facilities and come late to health care facilities

High Risk ConditionHigh Risk Condition

Bleeding in early pregnancy.Bleeding in early pregnancy.Bleeding in late pregnancy ( ante Bleeding in late pregnancy ( ante

partum hemorrhage). partum hemorrhage). Pregnancy induced hypertension.Pregnancy induced hypertension.Diabetes Mellitus.Diabetes Mellitus.

11--Bleeding In Early Bleeding In Early Pregnancy Pregnancy

(Before 20 weeks Gestation)(Before 20 weeks Gestation)

CausesCausesAbortion.Abortion.Vesicular mole.Vesicular mole.Ectopic pregnancy.Ectopic pregnancy.Local lesions — cervical polyps — Local lesions — cervical polyps —

cervical cancer.cervical cancer.

AbortionAbortion

It is the termination of pregnancy It is the termination of pregnancy before 24 weeks, or products of before 24 weeks, or products of conception weighing below 500 conception weighing below 500 grams. grams.

The termination is either spontaneous The termination is either spontaneous or induced,befor the fetus develops or induced,befor the fetus develops sufficiently to survivesufficiently to survive

IncidenceIncidence

Spontaneous abortion occurs in 10-Spontaneous abortion occurs in 10-15% of pregnancy , 80% of them 15% of pregnancy , 80% of them occur in the first trimester.occur in the first trimester.

CausesCauses

50%-80% of abortions in the first 50%-80% of abortions in the first 12 weeks of pregnanacy result 12 weeks of pregnanacy result from Chromosomal anomalies.from Chromosomal anomalies.

FetalFetal Chromosomal anomalies.Chromosomal anomalies. Diseases of the fertilized Diseases of the fertilized

ovum.ovum. Hypoxia.Hypoxia.

MaternalMaternal Infections e.g. influenza, Infections e.g. influenza,

malaria, syphilis ,HIV.malaria, syphilis ,HIV. Disease such as chronic Disease such as chronic

nephritis,TB.nephritis,TB.

Drug intake during Drug intake during pregnancy.pregnancy.

Rh and ABO Rh and ABO incompatibility.incompatibility.

Incompetent cervix.Incompetent cervix. Uterine malformation.Uterine malformation. Aquired uteine defect as Aquired uteine defect as

uterine fibroid or uterine fibroid or adhesionsadhesions

Trauma - criminal Trauma - criminal interference,interference,

Endocrinal disorder as Endocrinal disorder as hypothyrodism , daibetes hypothyrodism , daibetes mellitus mellitus

Pathology of abortion Pathology of abortion

First 8 weeks gestation First 8 weeks gestation Separation of decidua basalies and expulsion of the ovumSeparation of decidua basalies and expulsion of the ovum

If retained within the uterus, the ovum becomes surrounded If retained within the uterus, the ovum becomes surrounded by decidua and blood clot by decidua and blood clot

8-12 weeks of gestation8-12 weeks of gestation

Rupture of decidua capsularis and explusion of the product of Rupture of decidua capsularis and explusion of the product of conception conception

After 12 weeksAfter 12 weeksRupture of membernes followed explusion of the product of Rupture of membernes followed explusion of the product of

fetus and the placenta retained in uterus fetus and the placenta retained in uterus

Types of AbortionTypes of Abortion

Spontaneous Spontaneous abortionabortion

Threatened Threatened abortion: abortion:

Missed abortionMissed abortion Inevitable abortion Inevitable abortion Complete abortion Complete abortion

Incomplete Incomplete abortionabortion

Habitual abortionHabitual abortion Therapeutic Therapeutic

abortion abortion Criminal abortion Criminal abortion Septic abortion Septic abortion

Signs and Symptoms of Signs and Symptoms of AbortionAbortion

Threatened abortion:Threatened abortion: Cervical os is closed.Cervical os is closed. Membranes are intact.Membranes are intact. Pain and backache may or may not be Pain and backache may or may not be

presentpresent..

TreatmentTreatment Complete bed rest Complete bed rest Avoid enema Avoid enema & &constipation constipation no sexual intercourse no sexual intercourse Administration of prescribed drugs Administration of prescribed drugs

Incomplete abortionIncomplete abortion Severe bleeding.Severe bleeding. Cervical os partly closed.Cervical os partly closed. No uterine involution.No uterine involution. Pain may or may not be present.Pain may or may not be present. Uterus is soft and smaller than the expected Uterus is soft and smaller than the expected

period of pregnancy.period of pregnancy.

Septic abortionSeptic abortion:: Tender and painful uterus.Tender and painful uterus. Offensive vaginal bleeding.Offensive vaginal bleeding. High temperature.Rapid pulse. .Unstable blood pressure.High temperature.Rapid pulse. .Unstable blood pressure. Shock.Shock.

TreatmentTreatment Isolation.Isolation. Clinical bacteriological to identify the infectious organisms.Clinical bacteriological to identify the infectious organisms. Administration of antibiotics as doctor orders.Administration of antibiotics as doctor orders. Intake and output chart should be kept.Intake and output chart should be kept. The soiled pads should be properly collected and burned The soiled pads should be properly collected and burned

Inevitable abortionInevitable abortion Bleeding is excessive (more than 10 days).Bleeding is excessive (more than 10 days). Blood is red in color with clots.Blood is red in color with clots. Severe colicky lower abdominal pain.Severe colicky lower abdominal pain. Cervical os is dilated and rupture of membranes has Cervical os is dilated and rupture of membranes has

occurred.occurred.

There is severe blood loss and the woman becomes shockedThere is severe blood loss and the woman becomes shocked ..

TreatmentTreatment Hospitalization Hospitalization If no heart beats are detected a dilute solution of oxcytocin may 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 be given as the doctor orders to help in the expulsion of the contents of the uterus.contents of the uterus.

Dilatation and curettage should be done.Dilatation and curettage should be done.

Missed abortionMissed abortion Some signs of pregnancy disappear.Some signs of pregnancy disappear. Pregnancy test will be negative.Pregnancy test will be negative. Fundal height does not increase in size.Fundal height does not increase in size. The breasts may secrete milk due to hormonal The breasts may secrete milk due to hormonal

changeschanges FHR are absent.FHR are absent. No fetal movement.No fetal movement. A sonar test confirms fetal death.A sonar test confirms fetal death. Some brownish vaginal discharge Some brownish vaginal discharge

Complication of missed abortionComplication of missed abortion 1- Hypofibrinogenemia(DIc)1- Hypofibrinogenemia(DIc)2- Infection leads to septic abortion, septicemia, 2- Infection leads to septic abortion, septicemia,

septic shock and death septic shock and death

Habitual abortionHabitual abortion::May be due to:May be due to: Cervical incompetence.Cervical incompetence. Poor nutritional status.Poor nutritional status. Hormonal disturbance.Hormonal disturbance. Defective ova or spermatozoa.Defective ova or spermatozoa. Rh incompatibility.Rh incompatibility.

Chronic nephritisChronic nephritis..

Treatment of the cause such as cervical Treatment of the cause such as cervical incompetence or treatment of incompetence or treatment of causative diseases as syphilis, DM, etc.causative diseases as syphilis, DM, etc.

Complete abortion:Complete abortion:

There is minimal bleeding.There is minimal bleeding.Pain stops.Pain stops.Uterus is hard and much smaller Uterus is hard and much smaller The cervix is closed The cervix is closed

Nursing Management of Nursing Management of AbortionAbortion

Prevention measures should be taken to Prevention measures should be taken to avoid risk of a spontaneous abortionavoid risk of a spontaneous abortion. .

A nutritional diet.A nutritional diet.Avoiding smoking or drinking.Avoiding smoking or drinking.Receiving available immunizations Receiving available immunizations

against infectious diseases.against infectious diseases.Treatment of vaginal or pelvic Treatment of vaginal or pelvic

infections.infections.

Hydatidiform Mole (Vesicular Hydatidiform Mole (Vesicular Mole)Mole)

Hydatidiform mole is a gross malformation of the Hydatidiform mole is a gross malformation of the trophoblast in which the chorionic villi proliferate trophoblast in which the chorionic villi proliferate

and become avascularand become avascular..

CausesCauses

The exact cause is unknown.The exact cause is unknown.Risk factors are:Risk factors are:Maternal age above 40 years or Maternal age above 40 years or

below 19 years.below 19 years.Malnutrition Malnutrition

Types Types 1- partial mole 1- partial mole 2- complete mole 2- complete mole

Signs and SymptomsSigns and Symptoms

Excessive frequent vomiting.Excessive frequent vomiting.Over distension of the uterus and Over distension of the uterus and

larger than expected for weeks of larger than expected for weeks of gestation.gestation.

Some vaginal bleeding may occur plus Some vaginal bleeding may occur plus vesicles.vesicles.

No fetal movements ,No fetal parts No fetal movements ,No fetal parts Positive pregnancy test result in highly Positive pregnancy test result in highly

diluted urine 1:500.diluted urine 1:500.

ComplicationsComplications

Hemorrhage.Hemorrhage.shockshock perforationperforationUterine sepsis.Uterine sepsis.Choriocarcinoma Choriocarcinoma

ManagementManagement

Admit the woman into hospital.Admit the woman into hospital. evacuation of the uterus under general anesthesia.evacuation of the uterus under general anesthesia.

Health education on the followingHealth education on the following:: Need for monitoring HCG levels for two years (monthly for Need for monitoring HCG levels for two years (monthly for

the first 3 months, then every three months for one year).the first 3 months, then every three months for one year). Birth spacing methods to prevent pregnancy for two years.Birth spacing methods to prevent pregnancy for two years. If HCG levels remain more than five international units per If HCG levels remain more than five international units per

liter eight weeks postpartum, prophylactic chemotherapy is liter eight weeks postpartum, prophylactic chemotherapy is indicated.indicated.

Ectopic PregnancyEctopic Pregnancy

pregnancy occurring outside the pregnancy occurring outside the normal uterine cavity normal uterine cavity

Ectopic pregnancy usually occurs Ectopic pregnancy usually occurs 99% of cases in the uterine tube. 99% of cases in the uterine tube.

Tubal PregnancyTubal Pregnancy

CausesCauses Impaired tubal ciliary action.Impaired tubal ciliary action. Impaired tubal contractility.Impaired tubal contractility.Decreased sperm mobility.Decreased sperm mobility.The use of intrauterine contraceptive The use of intrauterine contraceptive

device.device.

Risk FactorsRisk Factors

Pelvic inflammatory disease.Pelvic inflammatory disease.History of previous pelvic operations History of previous pelvic operations

such as D and C, ovarian surgery.such as D and C, ovarian surgery.

Signs and SymptomsSigns and Symptoms

Short periods of amenorrhea.Short periods of amenorrhea.Sudden/recurrent severe, colicky Sudden/recurrent severe, colicky

abdominal pain in one iliac fossa or abdominal pain in one iliac fossa or entire lower abdomen.entire lower abdomen.

Blood stained vaginal discharge.Blood stained vaginal discharge.Signs of shock.Signs of shock.Dyspareunia.Dyspareunia.

Possible Outcomes of Tubal Possible Outcomes of Tubal PregnancyPregnancy

Tubal abortion.Tubal abortion.Tubal mole.Tubal mole.Tubal rupture.Tubal rupture.

ManagementManagement

Evacuated immediately.Evacuated immediately.Salpingectomy is preformed.Salpingectomy is preformed.Provide emotional support.Provide emotional support.Follow-up is needed.Follow-up is needed.Family planning should be discussed.Family planning should be discussed.

Bleeding in late Bleeding in late pregnancypregnancy

Antepartum hemorrhage is defined as Antepartum hemorrhage is defined as bleeding from the genital tract between bleeding from the genital tract between 28th week of pregnancy and onset of 28th week of pregnancy and onset of laborlabor..

ClassificationClassification Placenta previa Placenta previa Abruptio placenta Abruptio placenta Extraplacental bleeding (cervical Extraplacental bleeding (cervical

polyp) polyp)

Placenta PreviaPlacenta Previa

placenta is partly or totally implanted placenta is partly or totally implanted over the lower uterine segment.over the lower uterine segment.

CausesCauses

No specific cause can be detected No specific cause can be detected for most of the cases, while the for most of the cases, while the predisposing factors are:predisposing factors are:

Large placentaLarge placentaprevious uterine scarringprevious uterine scarringMultiparaMultipara

IncidenceIncidenceOccurs in 5% of all pregnancies.Occurs in 5% of all pregnancies.

DegreesDegrees

Placenta previa lateralisPlacenta previa lateralis Placenta previa marginalisPlacenta previa marginalis Incomplete central placenta previa:Incomplete central placenta previa: Complete central placenta previaComplete central placenta previa

Effects of Placenta Previa on Effects of Placenta Previa on Pregnancy and LaborPregnancy and Labor

Abnormal Abnormal presentation and presentation and position.position.

Premature labor.Premature labor. Prolonged labor.Prolonged labor. More chance of More chance of

surgical surgical intervention.intervention.

Placenta may be Placenta may be adherent adherent

Postpartum Postpartum hemorrhage.hemorrhage.

Fetal Fetal malformation.malformation.

High incidence of High incidence of fetal hypoxia and fetal hypoxia and mortality.mortality.

Maternal shock.Maternal shock. Maternal death. Maternal death.

Management in HospitalManagement in Hospital

Conservative Conservative treatment If bleeding is slight, treatment If bleeding is slight, observe carefully and correct anemia)observe carefully and correct anemia)

Active treatment if Active treatment if Bleeding is slight.Bleeding is slight. The placenta is of the first or second The placenta is of the first or second

degree.degree. The fetus lies longitudinally.The fetus lies longitudinally. The patient is in labor, with good uterine The patient is in labor, with good uterine

contraction.contraction.

Cesarean section is indicated if:Cesarean section is indicated if:The patient has lost a large amount The patient has lost a large amount

of blood.of blood.Placenta of third and fourth degrees.Placenta of third and fourth degrees.Old primigravida or multipara.Old primigravida or multipara. Posterior placenta prevla.Posterior placenta prevla.

Role of the NurseRole of the Nurse

Bed rest and restriction of physical activity Bed rest and restriction of physical activity for at least 24 hours after admission.for at least 24 hours after admission.

Avoid constipation, enemas, and vaginal Avoid constipation, enemas, and vaginal and rectal examinationsand rectal examinations

Follow strict aseptic technique to avoid Follow strict aseptic technique to avoid infection.infection.

Continuous observation of bleeding and Continuous observation of bleeding and signs of shock.signs of shock.

listening FHR every 4 hours.listening FHR every 4 hours. accurate recording of intake and output.accurate recording of intake and output.

Abruptio Placenta Abruptio Placenta (Accidental Hemorrhage)(Accidental Hemorrhage)

bleeding during the last three bleeding during the last three months of pregnancy, the first or months of pregnancy, the first or second stage of labor, due to second stage of labor, due to premature separation of a normally premature separation of a normally situated placenta situated placenta

CausesCauses

The most important cause is The most important cause is hypertension.hypertension.

The second most common cause is The second most common cause is traumatrauma

deficiencies in vitamins C and K.deficiencies in vitamins C and K.Traction on a short umbilical cord.Traction on a short umbilical cord.Sudden reduction of the size of the Sudden reduction of the size of the

uterus. uterus.

TypesTypes

Revealed:Revealed: almost all the blood almost all the blood expelled through the cervix.expelled through the cervix.

Concealed:Concealed: almost all the blood is almost all the blood is retained inside the uterus.retained inside the uterus.

Combined:Combined: some blood is retained some blood is retained inside the uterus and some is inside the uterus and some is expelled through the cervix.expelled through the cervix.

ComplicationsComplications

Shock.Shock.Acute renal failure.Acute renal failure.Postpartum hemorrhage.Postpartum hemorrhage.Consumption coagulopathy Consumption coagulopathy

ManagementManagement Treatment of toxemia.Treatment of toxemia. Replacement of blood loss.Replacement of blood loss. Treatment for shock.Treatment for shock.Obstetric treatment:Obstetric treatment: In the presence of painful uterine In the presence of painful uterine

contractions: artificial rupture of membranes.contractions: artificial rupture of membranes. In the absence of labor pain: IV syntocin drip.In the absence of labor pain: IV syntocin drip. When labor pains are established: the When labor pains are established: the

treatment is continued as above.treatment is continued as above. When the drip is a failure, a cesarean section When the drip is a failure, a cesarean section

must be done must be done

Role of the NurseRole of the Nurse

Continuous observation of patient’s general Continuous observation of patient’s general condition, blood pressure, vital signs, bleeding and condition, blood pressure, vital signs, bleeding and signs of shock.signs of shock.

Continuous observation of fetal condition.Continuous observation of fetal condition. Initiation and continuous observation of IV Initiation and continuous observation of IV

transfusion.transfusion. Give medications accurately, especially for Give medications accurately, especially for

hypotension and shock if present.hypotension and shock if present. Regular urine analysis for proteinuria.Regular urine analysis for proteinuria. Assessment and recording of intake and output.Assessment and recording of intake and output. Assist in vaginal delivery, ◘ Provide pre-operative Assist in vaginal delivery, ◘ Provide pre-operative

carecare Provide post-operative care.Provide post-operative care.