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High Risk Pregnancy. Introduction Many complications can occurs during pregnancy and affect health of mother and fetus as well as outcomes Many complications.

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Presentation on theme: "High Risk Pregnancy. Introduction Many complications can occurs during pregnancy and affect health of mother and fetus as well as outcomes Many complications."— Presentation transcript:

1 High Risk Pregnancy

2 Introduction Many complications can occurs during pregnancy and affect health of mother and fetus as well as outcomes Many complications can occurs during pregnancy and affect health of mother and fetus as well as outcomes Hemorrhage is the first ten causes of maternal mortality and morbidity affect about 32% of all maternal death. Abortion represent 4.5% of all maternal death Hemorrhage is the first ten causes of maternal mortality and morbidity affect about 32% of all maternal death. Abortion represent 4.5% of all maternal death Many women do not understand the bleeding is abnormal and dangerous signs and come late to health care facilities Many women do not understand the bleeding is abnormal and dangerous signs and come late to health care facilities

3 High Risk Condition Bleeding in early pregnancy. Bleeding in early pregnancy. Bleeding in late pregnancy ( ante partum hemorrhage). Bleeding in late pregnancy ( ante partum hemorrhage). Pregnancy induced hypertension. Pregnancy induced hypertension. Diabetes Mellitus. Diabetes Mellitus.

4 1-Bleeding In Early Pregnancy (Before 20 weeks Gestation) Causes Abortion. Abortion. Vesicular mole. Vesicular mole. Ectopic pregnancy. Ectopic pregnancy. Local lesions — cervical polyps — cervical cancer. Local lesions — cervical polyps — cervical cancer.

5 Abortion It is the termination of pregnancy before 24 weeks, or products of conception weighing below 500 grams. It is the termination of pregnancy before 24 weeks, or products of conception weighing below 500 grams. The termination is either spontaneous or induced,befor the fetus develops sufficiently to survive The termination is either spontaneous or induced,befor the fetus develops sufficiently to survive

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

7 Causes 50%-80% of abortions in the first 12 weeks of pregnanacy result from Chromosomal anomalies. 50%-80% of abortions in the first 12 weeks of pregnanacy result from Chromosomal anomalies.Fetal Chromosomal anomalies. Chromosomal anomalies. Diseases of the fertilized ovum. Diseases of the fertilized ovum. Hypoxia. Hypoxia. Maternal Maternal Infections e.g. influenza, malaria, syphilis,HIV. Infections e.g. influenza, malaria, syphilis,HIV. Disease such as chronic nephritis,TB. Disease such as chronic nephritis,TB. Drug intake during pregnancy. Drug intake during pregnancy. Rh and ABO incompatibility. Rh and ABO incompatibility. Incompetent cervix. Incompetent cervix. Uterine malformation. Uterine malformation. Aquired uteine defect as uterine fibroid or adhesions Aquired uteine defect as uterine fibroid or adhesions Trauma - criminal interference, Trauma - criminal interference, Endocrinal disorder as hypothyrodism, daibetes mellitus Endocrinal disorder as hypothyrodism, daibetes mellitus

8 Pathology of abortion First 8 weeks gestation First 8 weeks gestation Separation of decidua basalies and expulsion of the ovum If retained within the uterus, the ovum becomes surrounded by decidua and blood clot 8-12 weeks of gestation 8-12 weeks of gestation Rupture of decidua capsularis and explusion of the product of conception After 12 weeks After 12 weeks Rupture of membernes followed explusion of the product of fetus and the placenta retained in uterus

9 Types of Abortion Spontaneous abortion Spontaneous abortion Threatened abortion: Threatened abortion: Missed abortion Missed abortion Inevitable abortion Inevitable abortion Complete abortion Complete abortion Incomplete abortion Incomplete abortion Habitual abortion Habitual abortion Therapeutic abortion Therapeutic abortion Criminal abortion Criminal abortion Septic abortion Septic abortion

10 Signs and Symptoms of 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 present. Pain and backache may or may not be present.Treatment Complete bed rest Complete bed rest Avoid enema &constipation Avoid enema &constipation no sexual intercourse no sexual intercourse Administration of prescribed drugs Administration of prescribed drugs

11 Incomplete 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 period of pregnancy. Uterus is soft and smaller than the expected period of pregnancy.

12 Septic 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.Treatment 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

13 Inevitable 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 occurred. Cervical os is dilated and rupture of membranes has occurred. There is severe blood loss and the woman becomes shocked. There is severe blood loss and the woman becomes shocked.Treatment Hospitalization Hospitalization 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. 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. Dilatation and curettage should be done.

14 Missed 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 changes The breasts may secrete milk due to hormonal changes 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 abortion 1- Hypofibrinogenemia(DIc) 2- Infection leads to septic abortion, septicemia, septic shock and death

15 Habitual abortion: 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 nephritis. Chronic nephritis. Treatment of the cause such as cervical incompetence or treatment of causative diseases as syphilis, DM, etc.

16 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

17 Nursing Management of Abortion Prevention measures should be taken to avoid risk of a spontaneous abortion. Prevention measures should be taken to avoid risk of a spontaneous abortion. A nutritional diet. A nutritional diet. Avoiding smoking or drinking. Avoiding smoking or drinking. Receiving available immunizations against infectious diseases. Receiving available immunizations against infectious diseases. Treatment of vaginal or pelvic infections. Treatment of vaginal or pelvic infections.

18 Hydatidiform Mole (Vesicular Mole) Hydatidiform mole is a gross malformation of the trophoblast in which the chorionic villi proliferate and become avascular. Hydatidiform mole is a gross malformation of the trophoblast in which the chorionic villi proliferate and become avascular.

19 Causes The exact cause is unknown. The exact cause is unknown. Risk factors are: Maternal age above 40 years or below 19 years. Maternal age above 40 years or below 19 years. Malnutrition MalnutritionTypes 1- partial mole 2- complete mole

20 Signs and Symptoms Excessive frequent vomiting. Excessive frequent vomiting. Over distension of the uterus and larger than expected for weeks of gestation. Over distension of the uterus and larger than expected for weeks of gestation. Some vaginal bleeding may occur plus vesicles. Some vaginal bleeding may occur plus vesicles. No fetal movements,No fetal parts No fetal movements,No fetal parts Positive pregnancy test result in highly diluted urine 1:500. Positive pregnancy test result in highly diluted urine 1:500.

21 Complications Hemorrhage. Hemorrhage. shock shock perforation perforation Uterine sepsis. Uterine sepsis. Choriocarcinoma Choriocarcinoma

22 Management 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 following: 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). 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. 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. If HCG levels remain more than five international units per liter eight weeks postpartum, prophylactic chemotherapy is indicated.

23 Ectopic Pregnancy pregnancy occurring outside the normal uterine cavity Ectopic pregnancy usually occurs 99% of cases in the uterine tube. Ectopic pregnancy usually occurs 99% of cases in the uterine tube.

24 Tubal Pregnancy Causes 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 device. The use of intrauterine contraceptive device.

25 Risk Factors Pelvic inflammatory disease. Pelvic inflammatory disease. History of previous pelvic operations such as D and C, ovarian surgery. History of previous pelvic operations such as D and C, ovarian surgery.

26 Signs and Symptoms Short periods of amenorrhea. Short periods of amenorrhea. Sudden/recurrent severe, colicky abdominal pain in one iliac fossa or entire lower abdomen. Sudden/recurrent severe, colicky abdominal pain in one iliac fossa or entire lower abdomen. Blood stained vaginal discharge. Blood stained vaginal discharge. Signs of shock. Signs of shock. Dyspareunia. Dyspareunia.

27 Possible Outcomes of Tubal Pregnancy Tubal abortion. Tubal abortion. Tubal mole. Tubal mole. Tubal rupture. Tubal rupture.

28 Management 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.

29 Bleeding in late pregnancy Antepartum hemorrhage is defined as bleeding from the genital tract between 28th week of pregnancy and onset of labor. Antepartum hemorrhage is defined as bleeding from the genital tract between 28th week of pregnancy and onset of labor.Classification Placenta previa Placenta previa Abruptio placenta Abruptio placenta Extraplacental bleeding (cervical polyp) Extraplacental bleeding (cervical polyp)

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

31 Causes No specific cause can be detected for most of the cases, while the predisposing factors are: No specific cause can be detected for most of the cases, while the predisposing factors are: Large placenta Large placenta previous uterine scarring previous uterine scarring Multipara Multipara

32 Incidence Occurs in 5% of all pregnancies. Occurs in 5% of all pregnancies.

33 Degrees Placenta previa lateralis Placenta previa lateralis Placenta previa marginalis Placenta previa marginalis Incomplete central placenta previa: Incomplete central placenta previa: Complete central placenta previa Complete central placenta previa

34 Effects of Placenta Previa on Pregnancy and Labor Abnormal presentation and position. Abnormal presentation and position. Premature labor. Premature labor. Prolonged labor. Prolonged labor. More chance of surgical intervention. More chance of surgical intervention. Placenta may be adherent Placenta may be adherent Postpartum hemorrhage. Postpartum hemorrhage. Fetal malformation. Fetal malformation. High incidence of fetal hypoxia and mortality. High incidence of fetal hypoxia and mortality. Maternal shock. Maternal shock. Maternal death. Maternal death.

35 Management in Hospital Conservative treatment If bleeding is slight, observe carefully and correct anemia) Active treatment if Bleeding is slight. Bleeding is slight. The placenta is of the first or second degree. The placenta is of the first or second degree. The fetus lies longitudinally. The fetus lies longitudinally. The patient is in labor, with good uterine contraction. The patient is in labor, with good uterine contraction.

36 Cesarean section is indicated if: The patient has lost a large amount of blood. The patient has lost a large amount 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.

37 Role of the Nurse Bed rest and restriction of physical activity for at least 24 hours after admission. Bed rest and restriction of physical activity for at least 24 hours after admission. Avoid constipation, enemas, and vaginal and rectal examinations Avoid constipation, enemas, and vaginal and rectal examinations Follow strict aseptic technique to avoid infection. Follow strict aseptic technique to avoid infection. Continuous observation of bleeding and signs of shock. Continuous observation of bleeding and 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.

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

39 Causes The most important cause is hypertension. The most important cause is hypertension. The second most common cause is trauma The second most common cause is trauma 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 uterus. Sudden reduction of the size of the uterus.

40 Types Revealed: almost all the blood expelled through the cervix. Revealed: almost all the blood expelled through the cervix. Concealed: almost all the blood is retained inside the uterus. 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. Combined: some blood is retained inside the uterus and some is expelled through the cervix.

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

42 Management Treatment of toxemia. Treatment of toxemia. Replacement of blood loss. Replacement of blood loss. Treatment for shock. Treatment for shock. Obstetric treatment: In the presence of painful uterine contractions: artificial rupture of membranes. In the presence of painful uterine 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 treatment is continued as above. When labor pains are established: the treatment is continued as above. When the drip is a failure, a cesarean section must be done When the drip is a failure, a cesarean section must be done

43 Role of the Nurse Continuous observation of patient ’ s general condition, blood pressure, vital signs, bleeding and signs of shock. Continuous observation of patient ’ s general condition, blood pressure, vital signs, bleeding and signs of shock. Continuous observation of fetal condition. Continuous observation of fetal condition. Initiation and continuous observation of IV transfusion. Initiation and continuous observation of IV transfusion. Give medications accurately, especially for hypotension and shock if present. Give medications accurately, especially for 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 care Assist in vaginal delivery, ◘ Provide pre-operative care Provide post-operative care. Provide post-operative care.

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