RLE FINALS:

ABORTION

Questions:
1. What is the definition of abortion?
Abortion is the termination or the end of pregnancy before fetus is viable at 20 weeks
gestation or when the fetus is delivered at less than 500 grams.
2. Different types of abortion?
There are two types of abortion these are:
1. Spontaneous Abortion
This type of abortion is an ending of pregnancy that is not associated which the use of
interventions made by the mother or any medical practitioner and this type of abortion
occurs naturally. Spontaneous abortion occurs because of:
 Abnormal fetal position
 Maternal age above 35 years old and below 18 years old
 Abnormal embryonic development
 Viral infections (ex. Varicella, rubella, Cytomegalovirus)
 Immune response
 Trauma and accidents
 Exposure to teratogenic substances (ex. (T)oxoplasmosis, (O)ther Agents,
(R)ubella (also known as German Measles), (C)ytomegalovirus, and (H)erpes
Simplex.)
 Too much sexual activity
 Incompetent cervix
There are different types of spontaneous abortions such as:
 Threatened
 Inevitable
 Complete
 Incomplete
 Missed
 Habitual
 Septic
2. Induced or Elective Abortion
This type of abortion is done for therapeutic purposes in order to preserve or protect
the health of the mother. The pregnant mother could be induced at roughly about 20
weeks of gestation and this is done in cases such as where the fetus could endanger
the life of the mother such as genetic disease and anomalies.
3. What are the causes and risk factors of abortion?
Miscarriage or abortion goes along with different causes and risk that could affect
maternal health.
There are different factors for miscarriage that parents, fetus or both that could
partake.
Lifestyle factors such as:
 Smoking
 Drinking of alcohol
 Using of illegal drugs
 Consuming too much caffeine

 Not maintain a healthy weight

 Not having proper nutrition
 Exposure to low levels of radiation
 Strenuous/ or high impact exercise
 Chronic stress and anxiety
The mother could experience different complications would not be resolved
immediately; this includes:
 Damage to the womb or the cervix
 Excessive bleeding
 Incomplete abortion that surgical abortion
 Infection of the uterus or the fallopian tube
 Sepsis or septic shock
 Uterine perforation
 Death
Abortion could also cause future risk
 Premature births
4. What are the symptoms of abortion?
The most common and first sign of miscarriage or abortion is vaginal bleeding at the
first trimester whether it may be heavy or a light spotting should not be neglected.
Although this may not necessarily mean a woman is having a miscarriage if vaginal
bleeding persist medical health provider should be contacted immediately. Other
symptoms may include cramps, a discharge of tissues and fluids from the vagina,
abdominal pain and lower backache that may range from mild to severe.
5. What are the diagnostic procedure to confirm abortion.
In early pregnancy especially approximately at 20 weeks of gestation it is hard to
detect the fetus via ultrasound because the fetus is too small. In order to confirm
miscarriage hCG test is done and the only available tool in order to confirm
miscarriage. During the early weeks of pregnancy, the level of the pregnant mother’s
hCG can double up every 2 to 3 days and when not increasing appropriately or
accordingly this may indicate miscarriage and to confirm at least 2 hCG levels are
taken at least two days apart for the results to be useful.
Ultrasound scans is also one way of detecting miscarriage and transvaginal ultrasound
is use at about 8 weeks of gestation. Miscarriage may be detected if there are visible
abnormalities like the lack of development of the mother’s gestational sac. Lack of
fetal heartbeat that was previously seen and the embryo does not have a heartbeat
when larger than 5millimeters in size.
Other doctors may conduct pelvic examination to check whether the cervix is dilating.
A dilated cervix is a strong indication that the pregnant woman is having miscarriage.
In cases when the cervix is not dilating but there is a spotting or light vaginal bleeding
this may suggest threatened abortion pelvic exam may also reveal ectopic pregnancy.
Fetal Heart Monitor or fetal dopplers can solely detect the sound of the baby’s heart
through the woman abdomen. The fetal heart beat can be audible between 7-12
weeks of gestation and after 12 weeks that there is still no fetal heart beat noted this
can strongly indication pregnancy loss.
1. Explain the anatomy and physiology of female reproductive organ.

The reproductive system of the female consists of two main parts these are the uterus
and the ovaries which produce the woman’s egg cells. A female’s internal productive
organs consist of the vagina, uterus, fallopian tubes, cervix and the ovary. While the
mons pubis, pudendal cleft, labia majora and minora, vulva, Bartholin’s gland and
clitoris.
Uterus
 Produces vaginal and uterine secretions
 Hosts the developing fetus
 Passes the anatomically male sperm through the fallopian tubes
Ovaries
  Produces the anatomically female egg cells
 Produce and secrete estrogen and progesterone
Ovaries
 The ovum producing organs of the internal female reproductive system.
 Secretes estrogen and progesterone
 Attached to the uterus via ovarian ligament (which runs in the broad ligament)
 There are two extremities to the ovary, the tubal extremity and the uterine
extremity.
 Endocrine organs and produce hormones that act during the female menstrual
cycle and pregnancy.
 Locates in the lateral wall of the pelvis in a region called the ovarian fossa.
 Ovaries takes turns releasing the eggs every moth, however if one is absent or
dysfunctional then the other ovary releases egg every month.
Uterus
 The body of the uterus is connected to the ovaries via the fallopian tubes, and
opens into the vagina via the cervix.
 Two Mullerian ducts: usually form initially in a female fetus, but I humans they
completely fuse into a single uterus during gestation.
 Essential in sexual response by directing blood flow to the pelvis and to the
external genitalia, including the ovaries, vagina, labia and the clitoris.
 Its function is to accept a fertilized ovum which passes through the utero-tubal
junction from the fallopian tube.
 The lining of the uterine cavity is called the endometrium.
Female Duct System
 The fallopian tubes, or oviducts, connects the ovaries to the fetus.
 The fallopian tube allows passage of the egg from the ovary to the uterus.
 The lining of the fallopian tube is ciliated and have several segments, including
the infundibulum, ampullary, isthmus, and interstitial regions.
 Interspersed between the ciliated cells are peg cells, which contains apical
granules and produce the tubular fluid that contains nutrients for spermatozoa,
oocytes and zygotes.
 Sometimes the embryo implants into the fallopian tube instead of the uterus
creating an ectopic pregnancy.
Vagina
 Female reproductive tract that has two primary functions: sexual intercourse and
childbirth
  Situated between the cervix of the uterus and the external genitalia, primarily
the vulva
 The length of the aroused vagina of a woman of childbearing age is
approximately 6 to 7.5 cm (2.5 to 3 inches) across the interior wall (front) and 9
cm (3.5 inches) long across the posterior wall (rear)
 During sexual arousal the vagina expands both length and width
 Vaginal lubrication is provided by the Bartholin’s glands near the vaginal opening
and the cervix
 Hymen is a membrane of tissue that surrounds or partially covers the external
opening.
Vulva
 External genitalia of the female reproductive tract, situated immediately external
to the genital orifice
 Rich in nerves that are stimulated during sexual activity and arousal
 Contains the opening of the female urethra and thus serves the vital function of
passing urine.
Perineum
 Region between the genitals and the anus, including the perineal body and
surrounding structures
 Refer to both external and deep structures
 An erogenous zone for both males and females
Mammary Glands
 An organ in female mammals that produces milk to feed young offspring.
 Not associated with female reproductive tract, but develop as secondary sex
characteristics in reproductive-age females.
 Basic component are alveoli, hollow cavities, a few millimeters large lined with
milk-secreting cuboidal cells and surrounded by myoepithelial cells
ECTOPIC PREGNANCY
1. What is ectopic pregnancy?
In anormal pregnancy the fertilized egg is attached to the lining of the uterus.
While an ectopic pregnancy or tubal pregnancy occurs when the fertilized egg is
implanted and grows outside the main cavity of the uterus. Ectopic pregnancy
often occurs in the fallopian tube, which carries the eggs from the ovaries to the
uterus. Sometimes, ectopic pregnancy may also occur in areas such as ovary,
and abdominal cavity or the lower part of the uterus which is the cervix.
2. Enumerate the sites of ectopic pregnancy. What is the most common?
1. Fallopian tube – most common
2. Cervix
3. Abdomen
4. Ovaries
3. What are the early signs of ectopic pregnancy. What are the life-threatening
symptoms?
Early signs of ectopic pregnancy:
 Kehr’s sign – a severe lower quadrant pain radiating to the shoulders that
causes inflammation.
 Pain when urinating
 Vaginal bleeding that is slightly dark red
 Internal bleeding where the hemorrhage is only on the affected site
 Cullen’s sign- internal bleeding that will cause bluish navel
Life threatening symptoms of ectopic pregnancy:
 Severe abdominal pain or pelvic pain accompanied by vaginal bleeding- heavy
bleeding inside the abdomen likely occurred
 Extreme lightheadedness or fainting
 Shoulder pain

4. Explain briefly the causes of extrauterine pregnancy.

Ectopic pregnancy is caused by pelvic infection or infection or inflammation such
as chlamydia or Neisseria gonorrhea. Delayed or premature ovulations which
altered the motility and mobility which delays the production if estrogen and
progesterone. Multiple abortions and salpingitis or the infection of the fallopian
tube also cause extrauterine pregnancy, narrowing of the tubes and issue with
the fibrine.
 Anything that blocks or impedes the safe passage of a fertilized egg through the
fallopian tube increases the risk that the egg will implant in the fallopian tube.
5. Identify some risk factors contributing to incidence of ectopic pregnancy.
Some things that make you more likely to have an ectopic pregnancy are:
 Previous ectopic pregnancy. If you've had this type of pregnancy before, you're
more likely to have another.
 Inflammation or infection. Sexually transmitted infections, such as gonorrhea or
chlamydia, can cause inflammation in the tubes and other nearby organs, and
increase your risk of an ectopic pregnancy.
 Fertility treatments. Some research suggests that women who have in vitro
fertilization (IVF) or similar treatments are more likely to have an ectopic
pregnancy. Infertility itself may also raise your risk.
 Tubal surgery. Surgery to correct a closed or damaged fallopian tube can
increase the risk of an ectopic pregnancy.
 Choice of birth control. The chance of getting pregnant while using an
intrauterine device (IUD) is rare. However, if you do get pregnant with an IUD in
place, it's more likely to be ectopic. Tubal ligation, a permanent method of birth
control commonly known as "having your tubes tied," also raises your risk, if you
become pregnant after this procedure.
 Smoking. Cigarette smoking just before you get pregnant can increase the risk of
an ectopic pregnancy. The more you smoke, the greater the risk.
6. What are the diagnostic tests done to rule out ectopic pregnancy and its location.
In order to confirm ectopic pregnancy diagnostic tests are done such as hCG,
ultrasound, laparoscopy and salpingectomy is done. An hCG result of 600
M.U.M.L hCG confirms pregnancy and if the hCG levels rises slower or it does not
double up in every two to three days there is a possibility of ectopic pregnancy
but HCG alone cannot confirm ectopic pregnancy.
Ultrasound can help determine the location or the site of the gestational sac or
the embryo outside the uterus this diagnostic test is reliable and accurate.
Laparoscopy is needed to confirm the diagnosis of ectopic pregnancy. It is a
surgical procedure in which a small telescope called laparoscope is placed in the
abdominal cavity through a small incision.
Pelvic exam can also help the doctors identify the areas of pain, tenderness or a
mass in the fallopian tube or the ovary.
7. What is/are the recommended treatment for ectopic pregnancy.
 Treatment of ectopic pregnancy depends on the gestational age, symptoms and
location of the gestational sac. Advance ectopic pregnancy usually presents with
rupture, pain or severe bleeding and when this happens surgical treatments are
often indicated to surgically remove the pregnancy to control the bleeding and
protect the mother. If ectopic pregnancy is detected and diagnosed early and
before the onset of the symptoms other healthcare providers suggest of using
medication called methotrexate in order to stop the growth of pregnancy. In
cases of tubal pregnancy, surgical treatments including laparoscopic surgery is
done to remove the ectopic tissue and repair the mother’s fallopian tube. When
the fallopian tube is damaged, it might be removed.
8. Could the woman still get pregnant after an ectopic pregnancy?
Yes, the woman who previously had an ectopic pregnancy could be pregnant
again and could deliver a healthy and full-term baby.
9. Could the fetus survive in an ectopic pregnancy?
Ectopic pregnancy is very fetal to the fetus and it cannot survive outside of the
uterus. Ectopic pregnancy should be treated in order to protect the life of the mother.
9. What is the treatment of choice for Incomplete Abortion? Explain.
The treatment of choice for Incomplete abortion is Dilation and Curettage which
is a surgical procedure in which the cervix is dilated to be able to scrape the
uterine lining with a curette to remove abnormal tissues. A D&C is also important
for your health after a miscarriage or abortion. It removes any leftover tissue to
prevent heavy bleeding and infection.
10. What will be the Going Home choice for Incomplete Abortion? Explain.
DISCHARGE INSTRUCTIONS:
Return to the emergency department if:
 You have foul-smelling drainage or pus coming from your vagina.
 You have heavy vaginal bleeding and soak 1 pad or more in an hour.
 You have severe abdominal pain.
 You feel like your heart is beating faster than normal.
 You feel extremely weak or dizzy.
Contact your healthcare provider if:
 You have a fever greater than 100.4°F or chills.
 You have extreme sadness, grief, or feel unable to cope with what has
happened.
 You have questions or concerns about your condition or care.
 Self-care:
 Do not put anything in your vagina for 2 weeks or as directed. Do not use
tampons, douche, or have sex. These actions can cause infection and
pain.
 Use sanitary pads as needed. You may have light bleeding or spotting for
2 weeks.
 Do not take a bath or go swimming for 2 weeks or as directed. These
actions may increase your risk for an infection. Take showers only.
 Rest as needed. Slowly start to do more each day. Return to your daily
activities as directed.
 Talk to your healthcare provider about birth control. If you would like to
prevent another pregnancy, ask your healthcare provider which type of
birth control is best for you.
 Join a support group or therapy to help you cope. A miscarriage may be
very difficult for you, your partner, and other members of your family.
There is no right way to feel after a miscarriage. You may feel
overwhelming grief or other emotions. It may be helpful to talk to a
friend, family member, or counselor about your feelings.
11. What are the complications of Abortion?
 Damage to the womb or cervix
 Excessive bleeding
 Incomplete abortion, requiring a (additional) surgical abortion procedure
 Infection of the uterus or fallopian tubes
 Scarring of the inside of the uterus
 Sepsis or Septic shock
 Uterine perforation
 Death
ABRUPTIO PLACENTA
QUESTIONS:
1. What is Abruptio Placenta?
Abruptio placenta is a complication of late pregnancy or labor that is
characterized by premature partial or complete separation of a normally
implanted placenta. It is also termed as a accidental hemorrhage and ablatio
placenta. Abruptio placenta is also the second leading cause of bleeding in the 3 rd
trimester.
2. What are the different types of Placental Abruption? Describe each type.
 Revealed – bleeding tracks down from the site of placental separation and drains
through the cervix. This results in vaginal bleeding.
 Concealed – the bleeding remains within the uterus, and typically forms a clot
retroplacentally. This bleeding is not visible, but can be severe enough to cause
systemic shock.
 A partial placental abruption occurs when the placenta does not completely
detach from the uterine wall.
 A complete or total placental abruption occurs when the placenta completely
detaches from the uterine wall. There is usually more vaginal bleeding associated
with this type of abruption.
3. What are the risk factors for Placental Abruption?
The major risk factors for placental abruption include:
 Advanced maternal age – older mothers are at increased risk of a range of
pregnancy complications, including placental abruption.
 Prior pregnancy – the risk increases the more pregnancies a woman has had.
 Multiple fetuses – carrying twins, triplets, quads or more increases the risk of
placental abruption compared to carrying a single fetus.
 Prior placental abruption – if a woman has had the condition before, she is at
high risk of having it again.
 Hypertension – high blood pressure increases the risk of abnormal bleeding
between the placenta and the wall of the uterus. In nearly half of placenta
abruption cases (44%), the pregnant mother is hypertensive. One of the most
common causes of hypertension during pregnancy is a condition known as pre-
eclampsia.
 Excessive amniotic fluid (polyhydramnious) – more fluid than normal increases
the risk of bleeding between the placenta and the uterus wall.
 Substance use – cigarette smoking, alcohol use and taking drugs such as
methamphetamine or cocaine during pregnancy increase the risk of placenta
 abruption as well as a range of other serious health problems for both mother
and unborn baby.
 Some blood conditions – particularly any condition that affects the blood’s ability
to clot.
 Amniocentesis – a prenatal test that involves a needle inserted through the
mother’s abdomen and into the uterus to withdraw amniotic fluid. Very rarely,
the needle puncture causes bleeding.
 Amnioreduction – the prenatal condition of too much amniotic fluid is called
polyhydramnious. Amnioreduction is a procedure to remove excess amniotic fluid
using a needle inserted through the mother’s abdomen into the uterus. This
procedure uncommonly causes bleeding.

 External cephalic version – the doctor uses ultrasound imaging and external
massage on the mother’s abdomen to try to turn the baby from a head-up
position (breech) to a head-down position in readiness for childbirth. This
procedure can occasionally (rarely) dislodge the placenta.
4. What are the effects of Placental Abruption on the mother?
Placental abruption is life-threatening to the mother and these complications
includes:
 Blood loss.
 Blood clotting issues.
 Blood transfusion.
 Hemorrhage.
 Kidney failure.
5. What are the effects of Placental Abruption on the baby?
Placental abruption is life-threatening to the baby and these complications
includes:
 Premature birth.
 Low birth weight.
 Growth problems.
 Brain injury from lack of oxygen.
 Stillbirth.
6. What are the signs and symptoms of Placental Abruption?
 Couvelaire uterus – forming a hard board like uterus
 Uterus is enlarged due to concealed bleeding
 Painful vaginal bleeding in the 3rd trimester
 Sharp-like stabbing pain that radiates in the back
  Heavy dark red bleeding
 Labor pains (uterine contractions) that do not relax
7. What is the difference between Abruptio placenta and placenta previa?
Abruptio placenta is when the placenta is partially or completely detaches itself
from the uterine wall before the delivery of the fetus. While placenta previa
refers to placenta which is implanted partially or completely over the lower
uterine segment.
8. What diagnostic test is done to confirm Abruptio Placenta?
Abruptio placenta could be diagnosed by conducting a physical examination and
ultrasound.
10. Formulate at least 2 nursing diagnoses.
 Fear r/t threat to self and fetus
 Acute Pain: abdominal/back r/t premature separation of placenta before
deliver
 Acute Pain r/t surgical incision
 impaired Tissue integrity: maternal r/t possible uterine rupture
PREGNANCY INDUCED HYPERTENSION

Questions:

Case 4:

1. What is the meaning of PIH?

PHI means Pregnancy Induced Hypertension it is a form of high blood pressure in

pregnancy the occurs in about 7-10% of all pregnancies. It is a condition wherein
vasospasm occur during pregnancy in both small or large arteries in the body, with high
blood pressure there is an increase in the resistance of blood vessels. This can result to
a hindrance in the blood flow in many different organ systems of the mother that
includes the liver, kidney, brain, uterus and placenta.

2. What are the classification of PIH?

Gestational hypertension
Blood pressure 140/90 or systolic pressure elevated 30 mm Hg or diastolic pressure
elevated 15 mm Hg above prepregnancy level; no proteinuria or edema; blood pressure
returns to normal after birth.

Mild pre-eclampsia
Blood pressure 140/90 or systolic pressure elevated 30 mm Hg or diastolic pressure
elevated 15 mm Hg above prepregnancy level; proteinuria of 1–2% on a random
sample; weight gain over 2 lb per wk in second trimester and 1 lb per week in third
trimester; mild edema in upper extremities or face.

Severe pre-eclampsia
Blood pressure of 160/110; proteinuria 3–4% on a random sample and 5 g on a 24-hour
sample; oliguria (500 mL or less in 24 hours or altered renal function tests; elevated
serum creatinine more than 1.2 mg/dL); cerebral or visual disturbances (headache,
blurred vision); pulmonary or cardiac involvement; extensive peripheral edema; hepatic
dysfunction; thrombocytopenia; epigastric pain

Eclampsia
Seizure or coma accompanied by signs and symptoms of pre-eclampsia

HELLP syndrome is a variation of PIH named for the common symptoms that occur:
hemolysis that leads to anemia, elevated liver enzymes that lead to epigastric pain, and
low platelets that lead to abnormal bleeding/clotting and petechial (Guberman,
Greenspon, & Goodwin, 2007).
The syndrome occurs in 4% to 12% of patients with PIH. It is a serious syndrome
because it results in a maternal mortality rate as high as 24% and an infant mortality
rate as high as 35%.
3. What are the contributing factors that lead to the development of this condition?
The cause of PIH is unknown. Some conditions may increase the risk of developing PIH,
including the following:
  pre-existing hypertension (high blood pressure)
 kidney disease
 diabetes
 PIH with a previous pregnancy
 mother's age younger than 20 or older than 40
 multiple fetuses (twins, triplets)

4. What are the significant laboratory findings results presented that confirm the diagnosis?

Correlate with the case of the patient.

 blood pressure measurement

 urine testing
 assessment of edema
 frequent weight measurements
 eye examination to check for retinal changes
 liver and kidney function tests
 blood clotting tests.

Through this test we are able to identify that is patient is experiencing PIH.

Her platelet count and Hb is abnormal. Biochemistry results mostly shows abnormal results such
as the urea, bilirubin, bilirubin direct, SGOT, SGPT, LDH.

5. What are the signs and symptoms of PIH and at what age in weeks does it appear?
A serious medical condition that can occur about midway through pregnancy (after 20
weeks). Most common symptoms of high blood pressure in pregnancy. However, each
woman may experience symptoms differently. Symptoms may include:
 increased blood pressure
 protein in the urine
 edema (swelling)
 sudden weight gain
 visual changes such as blurred or double vision
 nausea, vomiting
 right-sided upper abdominal pain or pain around the stomach
 urinating small amounts
 changes in liver or kidney function tests
6. Discuss the pathophysiology of the disease. Make a schematic diagram
7.What are the complication of PIH?

There are other problems that may develop as a result of PIH. Placental abruption (premature
detachment of the placenta from the uterus) may occur in some pregnancies. PIH can also lead
to fetal problems including intrauterine growth restriction (poor fetal growth) and stillbirth. If
untreated, severe PIH may cause dangerous seizures and even death in the mother and fetus.
Because of these risks, it may be necessary for the baby to be delivered early, before 37 weeks
gestation.

8. What is HELLP Syndrome?

HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) syndrome is a life-threatening
pregnancy complication usually considered to be a variant of preeclampsia. Both conditions
usually occur during the later stages of pregnancy, or soon after childbirth.

HELLP syndrome was named by Dr. Louis Weinstein in 1982 after its characteristics:

H (hemolysis, which is the breaking down of red blood cells)

EL (elevated liver enzymes)

LP (low platelet count)

HELLP syndrome can be difficult to diagnose, because all of the typical signs of preeclampsia
may not be apparent, such as high blood pressure and protein in the urine. Its symptoms are
sometimes mistaken for gastritis, flu, acute hepatitis, acute fatty liver disease, gall bladder
disease, or other conditions. While some of these conditions may also be present, there is no
evidence they are related. Early diagnosis is critical because serious illness and even death can
occur in about 25% of cases. As a result, patient awareness of HELLP syndrome, and how it
relates to preeclampsia, is helpful to ensure the best medical care for mother and baby.

9. E.L. is advised for induction of labour. What does it mean?

Labor induction — also known as inducing labor — is the stimulation of uterine contractions
during pregnancy before labor begins on its own to achieve a vaginal birth. A health care
provider might recommend labor induction for various reasons, primarily when there's concern
for a mother's health or a baby's health. One of the most important factors in predicting the
likelihood of a successful labor induction is how soft and distended your cervix is (cervical
ripening)

10. What is the significance of Bishop Score in pregnancy?

The Bishop score is a scale used by medical professionals to assess how ready your cervix is for
labor. Your healthcare provider can use the score to estimate the likelihood of a vaginal birth if
you need to be induced. The higher the score, the more likely you will have a successful
induction.

11. The patient verbalize her feelings “I am worried to loss my baby”. What would be your
response?

Listen actively to the patient and show empathy make sure to share hope to the patient like “I
believe you can get through this and the baby will be safe because we are doing our best to
improve your situation and save you and your baby from harm. I need you to remain clam and
be strong because everything will be fine.”

12. What the recommended treatment for PIH?

Specific treatment for pregnancy-induced hypertension will be determined by your physician

based on:

 your pregnancy
 overall health and medical history
 extent of the disease
 your tolerance for specific medications, procedures, or therapies
 expectations for the course of the disease
 your opinion or preference

The goal of treatment is to prevent the condition from becoming worse and to prevent it from
causing other complications. Treatment for pregnancy-induced hypertension (PIH) may include:

 bedrest (either at home or in the hospital may be recommended).

 hospitalization (as specialized personnel and equipment may be necessary).
  magnesium sulfate (or other antihypertensive medications for PIH).
 fetal monitoring (to check the health of the fetus when the mother has PIH) may
include:
 fetal movement counting - keeping track of fetal kicks and movements. A change in the
number or frequency may mean the fetus is under stress.
 nonstress testing - a test that measures the fetal heart rate in response to the fetus'
movements.
 biophysical profile - a test that combines nonstress test with ultrasound to observe the
fetus.
 Doppler flow studies - type of ultrasound that uses sound waves to measure the flow of
blood through a blood vessel.
 continued laboratory testing of urine and blood (for changes that may signal worsening
of PIH).
 medications, called corticosteroids, that may help mature the lungs of the fetus (lung
immaturity is a major problem of premature babies).
 delivery of the baby (if treatments do not control PIH or if the fetus or mother is in
danger). Cesarean delivery may be recommended, in some cases.

13. What are the nursing management for PIH?

Nurses also have a role in reducing the blood pressure of the patient. These are just simple
interventions but could create a dramatic effect when applied properly.

 Assess vital signs, especially blood pressure. An elevated blood pressure of 140/90
mmHg and above would indicate hypertension.
 Presence of protein could be determined through urine tests.
 Assess patient for the presence of edema on the face, fingers, and upper extremities.
 Promote bed rest in a recumbent position to aid in the secretion of sodium.
 Promote good nutrition, since the woman has still to continue her usual pregnancy
nutrition.
 Provide emotional support to establish a trusting relationship and let the woman voice
out her fears.

14. Identify at least two nursing diagnosis and make a nursing care plan.
POST PARTUM HEMORRHAGE

1. What is Postpone Hemorrhage?

Postpartum hemorrhage (PPH) is severe bleeding after giving birth. It's a serious and
dangerous condition. PPH usually occurs within 24 hours of childbirth, but it can happen up to
12 weeks postpartum. When the bleeding is caught early and treated quickly, it leads to more
successful outcomes. Postpartum hemorrhage is when the total blood loss is greater than 32
fluid ounces after delivery, regardless of whether it’s a vaginal delivery or a Cesarian section, or
C-section, or when bleeding is severe enough to cause symptoms of too much blood loss or a
significant change in heart rate or blood pressure.

2. What is the most common cause of postpartum hemorrhage?

The causes of postpartum hemorrhage are called the four Ts (tone, trauma, tissue and
thrombin). The most common causes of PPH are:

 Uterine atony: Uterine atony (or uterine tone) refers to a soft and weak uterus after
delivery. This is when your uterine muscles don’t contract enough to clamp the placental
blood vessels shut. This leads to a steady loss of blood after delivery.
 Uterine trauma: Damage to your vagina, cervix, uterus or perineum (area between your
genitals and anus) causes bleeding. Using instruments like forceps or vacuum extraction
during delivery can increase your risk of uterine trauma. Sometimes, a hematoma
(collection of blood) can form in a concealed area and cause bleeding hours or days
after delivery.
 Retained placental tissue: This is when the entire placenta doesn't separate from your
uterine wall. It’s usually caused by conditions of the placenta that affect your uterus’s
ability to contract after delivery.
 Blood clotting condition (thrombin): If you have a coagulation disorder or pregnancy
condition like eclampsia, it can interfere with your body’s clotting ability. This can make
even a tiny bleed uncontrollable. 
3. Who is at risk for postpartum hemorrhage?

Some women are at greater risk for postpartum hemorrhage than others. Conditions that may
increase the risk include:

 Placental abruption. This is the early detachment of the placenta from the uterus.
 Placenta previa. This is when the placenta covers or is near the opening of the cervix.
 Overdistended uterus. This is when the uterus is larger than normal because of too
much amniotic fluid or a large baby.
 Multiple-baby pregnancy
 High blood pressure disorders of pregnancy
 Having many previous births
 Prolonged labor
 Infection
 Obesity
 Use of forceps or vacuum-assisted delivery
 Being of Asian or Hispanic ethnic background
  What are the symptoms of postpartum hemorrhage?
 These are the most common symptoms of postpartum hemorrhage:
 Uncontrolled bleeding
 Decreased blood pressure
 Increased heart rate
 Decrease in the red blood cell count
 Swelling and pain in the vagina and nearby area if bleeding is from a hematoma
4. Can low iron cause postpartum hemorrhage?

Anemia in pregnancy is common and linked to postpartum hemorrhage in terms of uterine

atony. The more severe the anemia, the more likely the greater blood loss and adverse
outcome.

5. What are the symptoms of hemorrhage?

 Uncontrolled bleeding.
 Increased heart rate.
 Decrease in the red blood cell count (hematocrit)
 Swelling and pain in tissues in the vaginal and perineal area, if bleeding is due to a
hematoma.
 Symptoms of a drop in blood pressure like dizziness blurred vision or feeling faint.
 Worsening abdominal or pelvic pain.
 Nausea or vomiting.
 Pale or clammy skin.
 Life-threatening conditions that can happen after giving birth include infections, blood clots,
postpartum depression and postpartum hemorrhage. Warning signs to watch out for
include chest pain, trouble breathing, heavy bleeding, severe headache and extreme pain.
6. What medications and used for prevention and treatment of postpartum hemorrhage?
 Oxytocin (Pitocin)
 Carboprost (Hemabate), a prostaglandin F 2-alpha analogue
 Methylergonovine (Methergine)
 Misoprostol (Cytotec),† a prostaglandin E1 analogue
 Tranexamic acid (Cyklokapron)†

9. What are the indications for a diagnostic dilatation and curettage?

Indications for the D&C in the pregnant patient include elective termination of pregnancy, early
pregnancy failure, evacuation of a molar pregnancy, or suspected retention of products of
conception. The pregnant D&C is usually performed with either manual or electric vacuum
aspiration.

10. What is a dilatation and curettage used for?

A dilation and curettage procedure, also called a D&C, is a surgical procedure in which the
cervix (lower, narrow part of the uterus) is dilated (expanded) so that the uterine lining
(endometrium) can be scraped with a curette (spoon-shaped instrument) to remove abnormal
tissues.
CESAREAN SECTION

1. Discuss the difference between elective and scheduled Caesarean section.

Scheduled Cesarean Birth are planned which means there is time for thorough preparation for
the experience throughout the antepartal period.

Emergent Cesarean Birth are done for reasons that arise suddenly in labor, such as placenta
previa, premature separation of placenta, fetal distress or failure to progress

2. What are the following indication or reasons for the need of caesarean section?
 Labor fails to progress
 Compressed umbilical cord Umbilical cord compression happens when the
umbilical cord, the tube-like structure that connects the placenta to the fetus,
becomes compressed or flattened, restricting the flow of blood, oxygen, and
nutrients to the baby.
 Abnormal fetal heart rate 
 Pregnancy of multiples
 Placenta previa (the placenta lies over the cervix)
 Placenta accrete (the placenta grows too deeply into the uterine wall)
 A fetus that is too big to be born vaginally
 A fetus in an unfavorable position (breech or transverse  lie)
 HIV infection
 Active herpes infection
 Diabetes
 High blood pressure / Incompatible Pelvic outlet…( PELVIMETRY)
3. What are the major risk or complication in caesarean birth?
FOR THE MOTHER
 Infection
 Blood loss
 Blood clots A blood clot, also called a thrombus, is blood that has coagulated
or clotted.
 Injury to bowel or bladder
 Amniotic fluid embolism can cause potentially life-threatening breathing and
heart issues, as well as uncontrolled bleeding. It is an often-fatal emergency that
requires immediate medical care for both the pregnant person and the baby.
 Reaction to anesthesia
 Amniotic fluid embolism is a rare but serious condition that occurs when amniotic
fluid — the fluid that surrounds a baby in the uterus during pregnancy — or fetal
material, such as fetal cells, enters the mother's bloodstream.
FOR THE BABY
 Altered immune development
 Increased likelihood of developing allergies and asthma
 Reduced gut microbiome diversity -The gut flora (also referred to as the
microbiome, microbiota, or microflora) make up a world of microorganisms that
 populate our gastrointestinal tract. It is estimated there are about 100 trillion of
these microorganisms, called microbes.
4. What are the different type of anesthesia used in caesarean section described and
discuss each procedure.

There are two main types of anesthesia typically used: regional anesthesia, which makes an
area of your body numb, like a spinal block, combined spinal-epidural anesthesia (CSE) or
epidural anesthesia; and general anesthesia, where you go to "sleep" for the surgery.

 The regional anesthesias, like an epidural, will block pain sensation in your
abdomen and nearby parts.3 You will be wide awake during the surgery and
aware of everything. You will feel pushing, pulling and tugging, but not pain.
One of the regional anesthesia choices is the most common type of anesthesia
for an elective cesarean section. Additional medications can be given if you are
experiencing nausea, anxiety, etc.
 General anesthesia is used when your medical history or an emergency dictates
that regional anesthesia is too risky or not possible.
5. Reason for indwelling catheter insertion before surgery in C- section. What are the
possible complication in prolong Foley catheter insertion?

Kidney damage (usually only with long-term, indwelling catheter use) Urethral injury. Urinary
tract or kidney infections. Bladder cancer (only after long-term indwelling catheter)

6. Explain how important is breast feeding to both mother and the baby and skin to skin
contact soon after delivery of the baby

Weight gain improves because your baby doesn’t use as much energy to regulate body
temperature. Instead, that energy can go toward growing. Improved breastfeeding also
contributes to healthier weight gain. Newborns that have skin-to-skin contact immediately after
birth are twice as likely to breastfeed within the first hour. Mom’s prolactin level rises as a result
—this is a hormone that is critical in maintaining a strong milk supply.

7. When can the mother start having sex again after caesarean section and what should I
be doing for birth control?

Sexual activity after a cesarean delivery, but many women will wait between four and six weeks
before resuming intercourse.

Although you may experience slightly less bleeding with a cesarean section, it will still take
about six weeks for your cervix to close completely. Some women may feel ready to resume
intercourse sooner than others, but you should only have sex again once given the ok by your
obstetrician and when you feel comfortable.

Combined hormonal methods increase the risk of DVT even further. If you have no additional
risk factors for DVT and you are not breastfeeding, you can start using these methods 3 weeks
after childbirth. There is a very small risk that the estrogen in these methods can affect your
milk supply if you are breastfeeding.
 8. What is the meaning of postpartum depression and its management? Discuss.

Postpartum depression (PPD) is a complex mix of physical, emotional, and behavioral changes
that happen in some women after giving birth. According to the DSM-5, a manual used to
diagnose mental disorders, PPD is a form of major depression that begins within 4 weeks after
delivery. The diagnosis of postpartum depression is based not only on the length of time
between delivery and onset but on the severity of the depression.

 Get as much rest as you can.

 Accept help from family and friends.
 Connect with other new moms.
 Create time to take care of yourself.
 Avoid alcohol and recreational drugs, which can make mood swings worse.
9. Why [s caesarean section indicated to the client base in the scenario?

Cesarean section is indicated and the best for the client in the case scenario because the baby’s
cord is possibly wrapping around the baby’s neck and this is great risk for the life of the fetus,
the placenta is transverse and the baby in is breech presentation-footling

10. Formulate 2 nursing diagnosis and nursing intervention post caesarean section.
11. Mrs L. is receiving IV fluids of D5 LRS 1 Li.x 8 hours. Calculate how many gtts. / Min.
and cc. / hour will the patient received. Show formulas.
12. Oxytocin was incorporated to 2nd bottle of IVF. Discuss the rationale of giving oxytocin
to patient postpartum

Antepartum: Induction of labor in pts with medical indication (e.g., at or near term), to
stimulate reinforcement of labor, as adjunct in managing incomplete or inevitable abortion.
Postpartum: To produce uterine contractions during third stage of labor and to control
postpartum bleeding/hemorrhage.
Abortion
Abortion is the expulsion or extraction of an embryo or fetus weighing 500 g or less from its
mother when it is not capable of independent survival (i.e. before the period of viability)

Incidence
• 10–20% of all clinical pregnancies
• 75% abortions occur before the 16th week
• Rates vary with maternal age; also high in women with past miscarriages

Abortion
 Spontaneous
o Isolated
 Threatened
 Inevitable
 Incomplete Complete
 Missed Septic
o Recurrent
 Induced
o MTP
o Illegal

Etiology
• Fetal Factors
• Maternal Factors
Fetal Factors
• Genetic
– 50% of early miscarriage is due to chromosomal abnormalities
– Numerical defects like Trisomy, Polyploidy, Monosomy
– Structural defects like translocation, deletion, inversion
• Multiple Pregnancies
• Degeneration of villi
Maternal Factors
• ENDOCRINE AND METABOLIC FACTORS (10–15%):
– Luteal Phase Defect
– Thyroid abnormalities
– Diabetes mellitus
• Anatomical abnormalities (10–15%)
Cervicouterine factors
– Cervical incompetence & insufficiency
– Congenital malformation of the uterus
– Uterine Fibroid
– Intrauterine adhesions
• Infections (5%)
– Viral: rubella, cytomegalo, HIV,..
– Parasitic: toxoplasma, malaria,..
– Bacterial: ureaplasma, chlamydia,..
• IMMUNOLOGICAL DISORDERS (5–10%)
– Autoimmune disease
– Alloimmune disease
– Antifetal antibodies
• Environmental Factors
– Cigarette smoking
– Alcohol consumption
– Contraceptive agents
• Maternal medical illness
– Cyanotic heart disease
– Hemoglobinopathies
• Unexplained (40-60%)
– In majority, the exact cause is not known.
Threatened Abortion
• Condition in which miscarriage has started but has not progressed to a state from which
recovery is impossible
CLINICAL FEATURES:
• The patient, having amenorrhea, complains of:
(1) Slight bleeding per vagina
(2) Pain: Usually painless; there may be mild backache or dull pain in lower abdomen
• The uterus and cervix feel soft.
• Digital examination reveals closed external os
• Differential diagnosis includes
– cervical ectopy
– polyps or carcinoma
– ectopic pregnancy
– molar pregnancy

• Ultrasound is diagnostic; Pelvic examination is avoided when USG is available

Management & Prognosis

 Rest: Patient should be in bed for few days until bleeding stops
 Relief of pain: Diazepam 5 mg BD
 80% of pregnancies with threatened abortions go on until term
 If a live fetus is seen on USG, pregnancy is likely to continue in over 95% cases.
 If pregnancy continues, there is increased frequency of preterm labor, placenta previa &
IUGR

Inevitable Abortion
It is the clinical type of abortion where the changes have progressed to a state from
where continuation of pregnancy is impossible.

CLINICAL FEATURES:
• The patient, having the features of threatened miscarriage, presents with
– vaginal bleeding
– Aggravation of colicky pain in the lower abdomen
• Sometimes, the features may develop quickly without prior clinical evidence of threatened
miscarriage
• Internal examination reveals dilated internal os through which the products of conception are
felt

Management
• Management is aimed:
– To accelerate the process of expulsion
– To maintain strict asepsis
• If pregnancy < 12 weeks, suction evacuation is done
• If pregnancy > 12 weeks, expulsion by oxytocin infusion
• General measures:
– Excessive bleeding is controlled by administering methergine 0.2 mg
– Blood loss is corrected by IV fluid therapy and blood transfusion

Incomplete abortion
The process of abortion has already taken place, but the entire products of conception are not
expelled & a part of it is left inside the uterine cavity

Clinical features:
• History of expulsion of a fleshy mass per vaginam;
– Continuation of pain in lower abdomen
– Persistence of vaginal bleeding
• Internal examination reveals
– uterus smaller than the period of amenorrhea
– Open internal os
– varying amount of bleeding
• On examination, the expelled mass is found incomplete Complications:
• The retained products may cause:
(a) bleeding
(b) sepsis or
(c) placental polyp.
MANAGEMENT:
• Evacuation of the retained products of conception (ERCP)
• Early abortion: Dilatation and evacuation under analgesia or general anesthesia is to be done.
• Late abortion: Uterus is evacuated under general anesthesia and the products are removed by
ovum forceps or by blunt curette. In late cases, D&C is to be done to remove the bits of tissues
left behind.
• Prophylactic antibiotics are given; removed materials are subjected to a histological
examination.
• Medical management
- Tab. Misoprostol 200 μg is used vaginally every 4 hours

Complete Abortion
• When the products of conception are completely expelled from the uterus, it is called
complete miscarriage.
Clinical features
• There is history of expulsion of a fleshy mass per vaginam followed by
– Subsidence of abdominal pain
– Vaginal bleeeding becomes trace or absent
• Internal examination reveals:
– Uterus smaller than the period of amenorrhea
– Cervical os is closed
– Bleeding is trace.
• Transvaginal sonography confirms that uterus is empty

Missed Abortion
• The fetus is dead and retained passively inside the uterus for a variable period
• It is diagnosed when there is a fetus with a crown rump length of 5mm without a fetal heart.
CLINICAL FEATURES:
The patient usually presents with features of threatened miscarriage followed by:
– Subsidence of pregnancy symptoms
– Uterus becomes smaller in size
– Cervix feels firm with closed internal os
– Nonaudibility of the fetal heart sound even with Doppler ultrasound
– Immunological test for pregnancy becomes negative
Complications
• Retaining the products for long time can lead to sepsis
• DIC [Disseminated Intravascular Coagulation]
– (very rare) in gestations exceeding 16 weeks
Management Uterus is less than 12 weeks:
• Prostaglandin E1 (Misoprostol) 800 mg is given vaginally and repeated after 24 hours if
needed. Expulsion usually occurs within 48 hours
• Suction evacuation is done when the medical method fails Uterus more than 12 weeks
• 6th or 12th hourly misoprostol tablets given vaginally
• If this fails, extra amniotic instillation of ethacridine lactate is used
• Antibiotics are given

Septic Abortion
• Any abortion associated with clinical evidences of infection of the uterus and its contents
• Most common cause
– Attempt at induced abortion by an untrained person without the use of aseptic precautions
Clinical Grading:
• Grade–I: The infection is localized in the uterus.
• Grade–II: The infection spreads beyond the uterus to the parametrium, tubes and ovaries or
pelvic peritoneum.
• Grade–III: Generalized peritonitis and/or endotoxic shock or jaundice or acute renal failure.
Grade-I is the commonest and is usually associated with spontaneous abortion
Clinical Features
• Fever, abdominal pain and vomiting or diarrhea
• A rising pulse rate of 100–120/min or more is a significant finding than even pyrexia. It
indicates spread of infection beyond the uterus.
• Examination shows abdominal tenderness, guarding, rigidity
• Internal examination reveals:
– offensive purulent vaginal discharge
– tender uterus usually with patulous os or a boggy feel
– Soft cervix with open internal os
Investigations
• CBC
• Serum urea, creatinine, electrolytes
• High vaginal swab
• Blood culture in suspected septicaemia
• Pelvic USG to detect retained products of conception
• X-ray abdomen in suspected bowel injury
• X-ray chest if there is difficulty in respiration
Complications Immediate:
• Hemorrhage
• Injury may to uterus & adjacent structures
• Spread of infection leads to:
– Generalized peritonitis
– Endotoxic shock
—mostly due to E. Coli
– DIC
– Acute renal failure
– Thrombophlebitis.
• All these lead to increased maternal deaths
Management
• Mild cases
– Broad spectrum antibiotics started
– Uterus is evacuated
• Severe Cases
– Vigorous IV infusion with crystalloid
– Oxygen given by nasal catheter
– Broad spectrum antibiotics
– combination of ampicillin, gentamicin, metronidazole is started
– Uterus is evacuated in 4-6 hrs of commencing therapy.
Recurrent Miscarriage/ Pregnancy loss
Recurrent Abortion
• Recurrent miscarriage is defined as a sequence of three or more consecutive spontaneous
abortion
• Seen in ~ 1% of all women
• Risk increases with each successive abortion
• No underlying cause is found for 50% of recurrent pregnancy loss
Etiology FIRST TRIMESTER ABORTION:
• Genetic factors (3–5%):
Parental chromosomal abnormalities
The most common abnormality is a balanced translocation.
This leads to unbalanced translocation in the fetus, causing early miscarriage or a live birth with
congenital malformations
Risk of miscarriage in couples with a balanced translocation is > 25%.
This is the most common cause for 1st trimester loss
Endocrine and Metabolic:
– Poorly controlled diabetic patients
– Presence of thyroid autoantibodies
– Luteal phase defect
– Hypersecretion of luteinizing hormone (e.g. in PCOS).
• Infection:
– Infection in the genital tract - (Transplacental fetal infection)
– Syphilis
• Inherited thrombophilia
– Protein C deficiency, Protein S deficiency, factor V Leiden mutation, prothrombin gene
mutation
• Immunological cause:
Autoimmunity – Antiphospholipid antibody syndrome(15%). – Antiphospholipid antibodies
present in mother produce adverse fetal outcome – Diagnosis by presence of lupus
anticoagulant/IgG/IgM anticardiolipin antibodies Alloimmune factors – Immune response
against paternal antigens in the fetus – This is a result of lack of production of blocking
antibodies by the mother due to failure of recognition of TLX
37. SECOND TRIMESTER MISCARRIAGE: • Anatomic abnormalities - responsible for 10– 15% of
recurrent abortion. • Causes may be (a) Congenital - defects in the mullerian duct fusion (e.g.
unicornuate, bicornuate, septate or double uterus) (b) Acquired - intrauterine adhesions,
uterine fibroids and endometriosis, cervical incompetence