High Risk Conditions.rtu.Intro

7/23/2019 High Risk Conditions.rtu.Intro

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High Risk Conditions: Bleeding Disorders of Pregnancy

1st Trimester• Abortion

• Ectopic

pregnancy

nd Trimester

• Hydatidiformmole

• !ncompetentcer"i#

3rd Trimester

PlacentaPrevia

AbruptionPlacenta



• $olic AcidDe%ciency Anemia

• !ron de%ciency

Anemia• !soimm&ni'ation

• (estational HT)

–

Pre*eclampsia+Eclampsia

• Hyperemesisgra"idar&m

• Pica• Pse&docyesis

Multiplepregnancy

HELLP

Syndrome

CardiacDiseases

HIDiabetes

Mellitus

STD!sDIC



Risk $actorsAge , &nder 1- o"er ./

0eight

)&tritional stat&s

(ra"ida and Parity

ocioeconomic stat&s

2B score

$amily history of genetic disorders

&bstance &se + !nfertility medication

Psychological 3ell*being

Predisposing chronic illness , diabetes4 heart conditions4renal4 etc5

Pregnancy related conditions , hyperemesis gra"idar&m4

P!H4 etc5



High Risk Pregnancy

(oals of Care

Pro"ide 3ith optim&m carefor the mother and the fet&s

Assist the patient and herfamily to &nderstand and

cope 3ith the "ariations in aHigh Risk Pregnancy andcope 3ith her feelings



• Co&"ade syndrome , dade#periences 3hat mom goesthro&gh , lihi6 *sympathy pain 7

psychosomatic condition



THE CHED89E 2$

PRE)ATA9 CHEC*8P

;onthly , <=6 Pregnant to > 3eeks

<1st - months 6

E"ery 3eeks , from > 3eeks to

.? 3eeks <> , @ months 6

E"ery 3eek , from .? 3eeks &ntildeli"ery



SI"# P$SSI%LE CA&SE

3elling of face and %nger HT) of pregnancy4thromboplebitis <for

s3elling of legs6

HA <contin&o&s andse"ere6

HT) of pregnancy

Abdominal 7 chest pain Ectopic pregnancy4 &teriner&pt&re4 p&lmonary

embolismaginal bleeding Placenta problems

< placenta pre"ia4 abr&ptioof placenta4

omiting persistent !nfection <3+ fe"er 7 chills64

hyperemesis gra"idar&mis&al changes HT) pregnancy

Escape of "aginal &ids Premat&re r&pt&re ofmembrane

3elling of face4 %nger4

legs

HT) of pregnancy

S

H

A

S

DA#"E' SI"#S $( P'E"#A#C)



• aginal Bleeding , it sho&ld bereported no matter ho3 slight4beca&se some serio&s bleedingbegins 3ith spotting

• Persistent omiting , once or# a day is not &ncommon

d&ring 1st trimester ho3e"erfre&ent episodes are notnormal5



•

Chills and $e"er , may indicateintra&terine infection4 a serio&scomplication for both mother andfet&s

• &dden Escape of $l&id from theagina , this may indicate that themembranes may ha"e r&pt&red5

Altho&gh this may be one of the %rstsigns of labor4 mother and fet&s areno3 both threatened4 beca&se itincreases the risk of infection



• Abdominal or Chest Pains , thissignals that something is abnormal5 !tco&ld be an ectopic pregnancy4 a

premat&re separation of the placentapreterm labor or something &nrelatedto pregnancy as appendicitis4 &lcer orpancreatitis5 Chest pain may indicate

a p&lmonary embol&s secondary tothrombophlebitis5



• Pregnancy !nd&cedHypertension , increase BPd&ring pregnancy

• !ncrease or Decrease $etal;o"ement , this may indicatethat the fet&s is responding tothe need of o#ygen







TERATOGENIC

MATERNAL INFECTIONS



• 5 T2RCH: To#oplasmosis4 2ther4 R&bella4Cytomegalo "ir&s4 Herpes simples "ir&s5

T , to#oplasmosis , mom takes care of

cats5 $eces of cat go to ra3 "egetables ormeat

2 , others5 Hepa A or infectio&s heap ,oral+ fecal <hand 3ashing6

Hepa B4 H! , blood 7 body &ids 4yphilis R , r&bella , (erman measles ,

congenital heart disease <1st month6normal r&bella titer 1:1

F1:1 , less imm&nity to r&bella4 afterdeli"ery4 mom 3ill be gi"en r&bella"accine5 DonGt get pregnant for .months5 accine is terratogenic

C , cytomegalo "ir&s

H , her es sim le# "ir&s



• T2RCH <Teratogenic6 !nfections , "ir&ses – CHARACTER!T!C: gro&p of infections

ca&sed by organisms that can cross the

placenta or ascend thro&gh birth canal andad"ersely aect fetal gro3th andde"elopment5

T2I2P9A;2! *proto'oan to#oplasmagondii

Eating ra3 foods or poorly cook or contact 3+feces of infected animals

+: myalgia4 malaise4 rashes4 splenomegaly4posterior cer"ical lypmphadenopathy

Diagnostic : serologic test s&ch as abin*$eldmandye test

T2I2P9A;2



T2I2P9A;2!



• To#oplasmosis , a proto'oaninfection4 is spread most

commonly thro&gh contact 3ithcat stool in soil or cat litter4 mayalso be contacted by eating&ndercooked meats5

• The 3oman 3ill e#periencealmost no symptoms of thedisease e#cept for fe3 days of

malaise and posterior cer"icallymphadenopathy5

•

0ith this an infant may be born3ith C) damage4





'&%ELLA



'&%ELLAD&ring 1st trimester <greatest risk6 4 .rd 7 nd 3k

<death fet&s64 nd trimester : permanent hearingimpairment5 9e&kemia in childhood has been noted7 die early in infancy5

Best pre"ention <not pregnant6 , li"e atten&ated"accine

Pregnant , tested 3ith imm&nity



• R&bella <(erman ;easles6 , ca&sesonly mild systemic illness to motherb&t the eect on

• $et&s is de"astating 3hich incl&desdeafness4 mental and motor

retardation4 cataracts4 cardiacdefects <most fre&ently the PDA andP&lmonary tenosis64 retarded

intra&terine gro3th4 dental and facial



CJT2;E(A92!R8



CJT2;E(A92!R8

Belongs to herpes gro&p 7 ca&ses

both congenital 7 ac&ired infectionsreferred to as cytomegalic incl&siondisease

ir&s be transmitted by asymptomatic

3oman across the placenta orcer"ical ro&te d&ring deli"ery5 ir&scan be fo&nd in &rine4 sali"a4 cer"icalm&c&s4 semen 7 breast milk

Principal organ 7tiss&e aected:blood4 brain 7 li"er res&lts tohemolysis leads to anemia 7

hyperbilir&binemia4 thrombocytopenia



17



17 Herpes imple# ir&s <(enital Herpes

!nfection6(enital irritation or itching4"aginal &rethraldischarge<copio&s4 fo&lsmelling64 enlarged tender

lymph nodes 7 dys&ria5Begins 3ith reddened pap&les3+c becomes itchy p&st&lar"esicles that may break 7

form painf&l 3et &lcers 3hichthen dry 7 de"elop cr&sts

*/K sponteneo&s abortion<1st trimester64 premat&re

birth <3ks64 s&r"i"ors has



• yphilis , this can place thefet&s at risk for congenital

syphilis5 The ca&sati"espirochete4 TreponemaPallid&m4 can

• E#tensi"ely damage thefet&s after 1?th to 1>th

3eek of intra&terine life5 !fleft &ntreated beyond the1>th 3eek of gestation4deafness4 cogniti"eim airment osteochondritis



Bleeding Disorders



• Hemorrhage , rapid loss of morethan 1K of body 3eight in blood

3hich res&lt to inade&ate tiss&eperf&sion4 depri"e gl&cose 7 2in tiss&e 7 b&ild &p of 3asteprod&cts5

– Hypo"olemic shock , bleedingres&lts in blood loss amo&nting to

15/ , li5

• Perinatal hemorrhage , d&ring

pregnancy4 labor 7 deli"ery



– !ntrapart&m hemorrhage: d&ring labor3hich are placental abr&ption4 &teriner&pt&re4 &terine in"ersion4 abnormaladhesion of placenta4 C complication

– Post part&m ,blood loss more than/ml )D or 1 ml C : Early:

&terine atony 7 laceration <d&ring 1st

Lhrs6 3hile late post part&m :retained placental fragment 7s&bin"ol&ntion of &ter&s5

RE!E0



RE!E0 :• D)A , carries genetic code

• Chromosomes , threadlike strands composed of

hereditary material , D)A• )ormal amo&nt of eMac&lated sperm . , / ml54 1 tsp

• 2"&m is capable of being fertili'ed 3ith in L , .?hrs after o"&lation

• perm is "iable 3ithin L> , - hrs4 *. days• Reprod&cti"e cells di"ides by the process of

meiosis <haploid6

• permatogenesis , mat&ration of sperm

• 2ogenesis , process * mat&ration of o"&m

• (ematogenesis , formation of haploid into diploid. = . N L? or diploid

•

Age of Reprod&cti"ity , 1/ , LLyo



Estrogen OHormone of the 0oman,

•

Primary f&nction: de"elopment secondaryse#&al characteristic female5

• 2thers:

15 inhibit prod&ction of $H < mat&ration of

o"&m65 hypertrophy of myometri&m

.5 pinnbarkeit 7 $erning < billings method+cer"ical6

L5 de"elopment d&ctile str&ct&re of breast/5 increase osteoblast acti"ities of long bones

?5 increase in height in female

-5 ca&ses early clos&re of epiphysis of long

bones

Progestin O Hormone of the ;other



Progestin Hormone of the ;other

• Primary f&nction: preparesendometri&m for implantation offertili'ed o"&m making it thick 7torto&s <t3isted6

• econdary $&nction: &terine

contractility <fa"ors pregnancy6

• 2thers:

15inhibit prod of 9H <hormone for

o"&lation6

5inhibit motility of (!T

.5 mammary gland de"elopment

• 9&teini'ing hormone <9H also kno3n



• 9&teini'ing hormone <9H4 also kno3nas l&tropin and sometimes l&trophin6is a hormone prod&ced by

gonadotroph cells in the anteriorpit&itary gland5 !n females4 an ac&terise of 9H <Q9H s&rgeQ6 triggers

o"&lation and de"elopment of thecorp&s l&te&m

• H&man chorionic gonadotropininteracts o"ary and promotes themaintenance of the corp&s

l&te&md&ring the beginning of







tages of $etal (ro3th and



tages of $etal (ro3th andDe"elopment

• .*L days tra"el of 'ygote , mitoticcell di"ision begins

• Pre*embryonic tage

a5 Sygote* fertili'ed o"&m5 9ifespan of'ygote , from fertili'ation to months

b5 ;or&la , m&lberry*like ball 3ith 1? ,

/ cells4 L days free oating 7m&ltiplication

c5 Blastocyst , enlarging cells that

forms a ca"ity that later becomes

• L phases of ;enstr&al Cycle



• L phases of ;enstr&al Cycle

15 Proliferati"e

5 ecretory

.5 !schemic

L5 ;enses

•

Parts of body responsible for mens: – hypothalam&s

– anterior pit&itary gland , master clock ofbody

– o"aries

– &ter&s

• !nitial phase , .rd day , decreased

estrogen



• igns of implantation:

• 15 slight pain

• 5 slight "aginal spotting

• * if 3ith fertili'ation , corp&sl&te&m contin&es to f&nction 7

become so&rce of estrogen 7progesterone 3hile placenta is notde"eloped5

. processes of !mplantation

15 Apposition

5 Adhesion



Abortions Termination of pregnancy at any

time before the fet&s has reachedthe age of "iability <1* 3eeksA2(6

2cc&lt pregnancy , 'ygotes that3ere aborted before pregnancy isdiagnosed or recogni'ed

Either: spontaneo&s , occ&rring nat&rally

ind&ced , arti%cial



pontaneo&s Abortion

• Threatened ;iscarriage

•!ne"itable ;iscarriage

!mplantation Bleeding

Decid&al Bleeding

Ectopic Pregnancy

EA'L) P'E"#A#C)%LEEDI#"



• Abortion* is the most commonbleeding disorder of early

pregnancy5 Abortion is thetermination of pregnancy before"iability4that is4 before 3eeks5

• Abort&s* a fet&s that is abortedbefore it is / gms in 3eight5

• Early abortion* termination ofpregnancy before 1? 3eeks5



%lig*ted ovum+ a small macerated

fet&s4 sometimes there is no fet&s4s&rro&nded by a &id inside the sac5

Maceration* a dead fet&s&ndergoing necrosis5



Ca&ses of abortion:

$ETA9 CA8E*

• The most common ca&se of earlyspontaneo&s abortion is abnormalde"elopment of the 'ygote4embryo4 and fet&s5

• This abnormalities areincompatible 3ith life and 3o&ld

ha"e res&lted to se"ere congenitalanomalies if pregnancy has notbeen aborted5

f b i



Ca&ses of abortion:;ATER)A9 CA8E*

• These are congenital or ac&iredconditions of the mother anden"ironmental factors that had

ad"ersely aected the pregnancyo&tcome and led to abortion5

• &ch conditions incl&de D;4

incompetent cer"i#4 e#pos&re toradiation and infection5

Spontaneous AbortionT*reatened



Spontaneous AbortionT*reatened

Etiology + Predisposing



Etiology + Predisposing$actors

• $a&lty germ plasm ** imperfect o"a or sperm4fa&lty implantation4 genetic make*&p <chromosomaldisorders64 congenital abnormalities

• Decrease in the prod&ction of progesterone

• Dr&gs or radiation

• ;aternal ca&ses ** infections4 endocrine disorders4maln&trition4 hypertension

Assessment



Assessment Types of Abortions

Threatened• igns and ymptoms – "aginal bleeding4 spotting

– ;ild cramps4 backache4 softening&ter&s

– Cer"i# remains C92ED• )o "aginal assessment as may pro"oke &terine acti"ity

• A pregnancy test is carried o&t and &ltraso&nd performed to assess

"iability• Hea"y or increased amo&nt of bleeding in an omino&s sign and may

precede ine"itable abortion

• Treatment and )&rsing Care –

Bed rest4 sedation





!ne"itable Abortion

• igns and ymptoms – 9oss is certain

– Bleeding is more prof&se

– Painf&l &terine contractions

– Cer"i# D!9ATE

• Treatment and )&rsing Care – Assess all bleeding5 a"e all pads5

<;ay need to 3eigh the pads6 – 8se the bedpan to assess all prod&cts

e#pelled

–

Treated by e"ac&ation of the &ter&s



The de"elopment of abortion is asfollo3s:

contin&ing

pregnancy

• complete

ine"itable abortion

abortion

incomplete

abortion

threatenedabortion



Complete Abortion

• All prod&cts of conception aree#pelled

• )o treatment is needed4 b&t may doa D 7 C

l b i



!ncomplete Abortion

• Parts of theprod&cts ofconception aree#pelled4 3ith

placenta andmembranesretained

• Treated 3ith a D 7C or s&ction

e"ac&ation

l b i



!ncomplete Abortion

• (estational sac is incompletelye#pelled4 3ith &s&ally the placentaltiss&e retained

• tatic or slo3ly falling HC( le"els

• E"ac&ation of retained prod&cts ofconception from the &ter&s carriedo&t

• !f s&rgical e"ac&ation re&ired43oman sho&ld be screened forchlamydial infection

• Transf&sion ma be i"en if blood



;issed Abortion

• The fet&s dies in*&tero and is note#pelled <no $HT6

• 8terine gro3th ceases

• Breast changes regress

• ;aceration occ&rs

• Treatment: – D 7 C

– Hysterotomy

Habit&al Abortion +



Habit&al Abortion +Premat&re Cer"ical Dilation• Abortion occ&rs consec&ti"ely in

three or more pregnancies

• 8s&ally d&e to an !ncompetentCer"ical 2s4 that res&lts from cer"icaltra&ma4 cer"ical lacerations4

repeated D 7 C4 or coni'ation5

• 2cc&rs most often abo&t 1>*3eeks gestation5

H bit l Ab ti



Habit&al Abortion

•

Treatment –Cerclage proced&re ** p&rse*

string s&t&re placed aro&nd theinternal os to hold the cer"i# in anormal state:

• hirodkar 7 ;cDonald techni&e



Electi"e



Electi"eAbortions+Therape&tic

Abortions Electi"e Abortion is the intentional termination ofpregnancy before *L3eeks5

Therape&tic Abortion is the termination of the

pregnancy for medical reasons5 The termination of the pregnancy is done by

s&rgery , Dilatation and C&rettage <D7C6 or 3ithmedications called abortifacts

The n&rse sho&ld be a3are of the stateGsspeci%c reg&lations go"erning abortions5

Abortions ha"e many ethical iss&es5 The n&rsesho&ld kno3 beliefs concerning this iss&e5

$ETA9 92



$ETA9 92• !f client spontaneo&s loses baby r it

is an intra&terine death and if theclient+family 3o&ld like to "ie3and+or "isit 3ith baby4 Pro"ide the

opport&nity in a pri"ate area• Allo3 the client to name the baby

• Take pict&res

• (i"e something for the client to takehome

• Clean the baby 3ith soft cloth or

cotton



)&rsing Care

• Bedrest in a slight trendlenb&rgposition to decrease the press&re

on the ne3 s&t&res• Teach:

– Assess for leakage of &id4 bleeding

– Assess for contractions

– Assess fetal mo"ement and reportdecrease mo"ement <if old eno&gh6

– Assess temperat&re for ele"ations



Deli"ery

• 0hen time for deli"ery there arese"eral options: – physician 3ill clip s&t&re and allo3

patient to go into labor on her o3n – ind&ce labor

– cesarean deli"ery



Complication of Abortion

• Hemorrhage

• !nfection or septic abortion

• Disseminated intra"asc&larcoag&lation <D!C6 , if retained 3ithin a month

ey Concepts to



ey Concepts toRememberUU

• !f a 3oman is Rh*4 Rho(am is gi"en3ithin - ho&rs

• Pro"ide emotional s&pport5 $eelingsof shock or disbelief are normal

• Enco&rage to talk abo&t theirfeelings5 !t begins the grief process





• Abortion , termination of labor before age of "iability

P2)TA)E28 AA i i



P2)TA)E28 AA miscarriage

• Ca&ses Chromosomal aberrations d&e to ad"anced

maternal age 7 Blighted o"&m and Plasma germ defect

– )at&res 3ay of e#pelling defecti"e babiesClassi%cations :

• Threatened

• pregnancy is Meopardi'ed by bleeding and cramping b&t the cer"i#is closed and can be sa"ed5

• !ne"itable * can )2T be pre"ented

• moderate bleeding4 cramping4 tiss&e protr&des from the cer"i# and

the cer"i# is open5 Types :

Complete * all prod&cts of conception are e#pelled5 ;gt : emotional s&pport!ncomplete * placenta and membranes retained5 ;gt : D7C

;issed abortion , $et&s die in &ter&s4 b&t it is not e#pelled

Habit&al abortion , . , ? abortions

!)D8CED

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High Risk Conditions.rtu.Intro