MANIFESTING: PASAR SA MIDTERM MCN LEC! 3.

Ampullary Pregnancy- in the ampullary

department (70%)
BLEEDING DURING PREGNANCY
4. Abdominal Pregnancy- in the abdomen (1%)
COMMON CAUSES: 5. Cervical Pregnancy – in the cervix (1%)
6. Ovarian Pregnancy – in the ovary (3%)
 CERVICITIS -inflammation of the cervix, caused by infections
From STIS like chlamydia, gonorrhea or NON-STDS like 7. Fimbrial Pregnancy – in the fimbrae (11%)
bacterial vaginosis.
 CERVICAL POLYPS. – are growths on the passage that
connects the womb to the vagina. Polyps may form due to an
abnormal response to an increase in estrogen levels, or
congestion of blood vessels in the cervical canal during
pregnancy. As a result, contact with this area through
gynecological exam or sexual intercourse may cause bleeding.

 ECTOPIC PREGNANCY – a medical emergency which occurs

when a fertilized egg attaches itself outside the womb. Light to
heavy vaginal bleeding or spotting could be a symptom of
ectopic pregnancy. Other symptoms include weak- ness and
dizziness, sharp abdominal or pelvic pain and rectal pressure.

 IMPLANTATION SPOTTING – occurs as a fertilized egg

attaches itself to the womb around 10 days after ovulation. This
usually occurs during the first trimester. In fact, the spotting
could even occur before a woman knows she is pregnant and
might be mistaken for a period.

 MISCARRIAGE – occurs mostly during the first 12 weeks

Pregnancy, one of biggest concerns with First trimester.
Signs and symptoms
1. Vaginal Discharge
2. Abdominal cramping
3. Pinkish Vaginal Discharge
4. Passing Clots
5. Sudden loss of pregnancy symptoms

TYPES/STAGES OF ABORTION
ASSESSMENT
 STAGE 1 – THREATENED
-Spotting, cervix closed, viable pregnancy  Corpus luteum of the ovary continues to function as
 STAGE 2 – INEVITABLE if the implantation were in the uterus so no
-Vaginal bleeding, cervix open, mild cramps menstrual flow occurs
 STAGE 3 – INCOMPLETE
-Heavy abdominal bleeding, cervix open, lower abdomen pain, foetal  nausea and vomiting, +Pregnancy test for hCG
tissue in canal
 STAGE 4 – COMPLETE  diagnosed by ultrasound/MRI 6 to 12 weeks of
-Cervix closed, No foetal tissue present pregnancy
 Zygote grows large enough. That it ruptures the
slender fallopian tube
 Interstitial-rupture can cause severe intraperitoneal
bleeding
 Ampullar-the distal third), where the blood vessels
are smaller and hemorrhage is less
 serious continued bleeding in ruptured ectopic
pregnancy regardless of site
 Scant vaginal spotting, sharp, stabbing pain in one of
her lower abdominal quadrants at the time of
rupture
 Products of conception from the ruptured tube +
ECTOPIC PREGNANCY blood expelled into the pelvic cavity rather than into
the uterus
Types:
 progesterone secretion will stop
1. Interstitial Pregnancy – embryo in the interstitial
department (2-3%)  uterine decidua will begin to slough,
2. Isthmic Pregnancy – in the isthmic department  more vaginal bleeding
(12%)  -hypotensive from blood loss, light-headedness and
 a rapid pulse, signs of hypovolemic shock. ruptures during pregnancy

THERAPEUTIC MANAGEMENT
 Oral administration of methotrexate -advantage tube ASSESSMENT/MANAGEMENT
is left intact, no surgical scarring that could cause a • Fetal outline palpable through the abdomen; directly below
second ectopic implantation; treated until a negative the abdominal wall, not inside the uterus.
hCG titer
•Woman not be as aware of movements
 hysterosalpingogram or ultrasound to assess that
the pregnancy is no longer present and also whether - experience painful fetal movements and
the tube appears fully patent abdominal cramping with fetal movements.

 Hemoglobin level, typing and cross-matching, and - sudden lower quadrant pain earlier in the
possibly the hCG level pregnancy, no external bleeding.

 IVF using a large-gauge catheter to restore • An ultrasound or MRI will reveal the fetus outside the
intravascular volume uterus.

 Blood transfusion through this same line as soon as • Dangers:

it is matched. - Placenta could infiltrate and erode a major
blood vessel in the abdomen, leading to
 Laparoscopy to ligate the bleeding vessels and to
hemorrhage.
remove or repair the damaged fallopian tube.
- Implanted on the intestine, it may erode so
 Either the tube will be removed or suturing on the
deeply it causes bowel perforation, leaking
tube will be done with microsurgical technique
of intestinal contents, and peritonitis. Or
 50% fertile, sperm should not be able to reach the growth restriction
ovum on that side. Translocation of ova can occur-
•The fetus is also at high risk (only about 60% come to term)
that is, an ovum released from the right ovary can
because without a good uterine blood supply nutrients may
pass through the pelvic cavity to the opposite (left)
not reach the fetus in adequate amounts leading to the threat
fallopian tube and become fertilized and vice versa
of fetal deformity
 Rh-negative blood should receive Rh (D) immune •Infant must be born through laparotomy.
globulin (RhIG)/RhoGAM after an ectopic pregnancy
for isoimmunization protection in future • Placenta is difficult to remove -has implanted onto an
childbearing. abdominal organ/intestine.
• Left in place and allowed to absorb spontaneously in 2 or 3
months.
ABDOMINAL PREGNANCY
•follow-up ultrasound can be used to detect whether this has
-After an ectopic pregnancy ruptures- the products of occurred.
conception are expelled into the pelvic cavity with a
minimum of bleeding.
-Placenta continues to grow in the fallopian tube, spreading HYDATIDIFORM MOLE
into the uterus for a better blood supply; -It is an abnormal placenta due to excess of paternal (from
-Escape into the pelvic cavity and implant on an organ such father) genes.
as an intestine. -is caused by abnormal gametogenesis and fertilization.
-Fetus will grow in the pelvic cavity (an abdominal - It is the most common form of gestational trophoblastic
pregnancy). disease; occurs in 1/1,000-2,000 pregnancies
-Occur if a uterus ruptures because an old uterine scar -It results in the formation of enlarged and odematous
placental villi, which fill the lumen of the uterus.
-Passage of tissue fragments, which appear as small
grapelike masses, is common. The serum HCG concentration
is markedly elevated, and are rapidly increasing.
Risk factors:
 maternal age: girls younger than 15 years of age and
women over 40 are at higher risk.
 Ethnic background: incidence higher in Asian
women
 Women with a prior hydatidiform mole have a 20-
fold greater risk of a subsequent molar pregnancy
than the general population.
 until term
There are 2 types of hydatidiform mole (HM): -Painlessly, first symptom is show (a pink-stained vaginal
1. COMPLETE HM discharge) or increased pelvic pressure, ROM and discharge
of the amniotic fluid.
 Fertilization an empty egg by
- Uterine contractions begin and, after a short labor, the fetus
 One sperm. is born- occurs at 20 AOG the fetus is still too immature to
 All placental villa swollen. survive.

 Fetus, cord, amniotic membrane are absent. -Weeks 12 to 14, purse-string sutures are placed in the
cervix by the vaginal route under regional anesthesia;
 Paternal chromosomes only. 46 XX. McDonald or a Shirodkar procedure the sutures serve to
 diploidy strengthen the cervix and prevent it from dilating until the
end of pregnancy
2. PARTIAL HM
 Fertilization of an egg by two sperms
PLACENTA PREVIA
 Some placental villa swollen
 Fetus, cord, amniotic membrane are present
 Paternal and maternal 69XXY
 Triploid

ASSESSMENT/THERAPY

•Uterus tends to expand faster than usual or the uterus

reaches its landmarks (just over the symphysis brim at 12
weeks, at the umbilicus at 20 to 24 weeks) a serum or urine
test of hCG strongly positive (1 to 2 million IU compared
with a normal pregnancy level of 400,000
•Marked Nausea & vomiting
•Symptoms of gestational hypertension, such as increased
blood pressure, edema, and proteinuria
•ultrasound will show dense growth (typically a snowflake
pattern); no fetal growth; no FHT; no viable fetus.
•16 week vaginal bleeding, spotting of dark-brown blood
resembling prune juice or as a profuse fresh flow; discharge
of the dear fluid-filled vesicles
•Therapy is suction curettage to evacuate the abnormal -Abnormal placement of placenta so that it partially covers
trophoblast cells. the cervix; dilatation results in bleeding, which can be of
•baseline pelvic examination and a serum test for the beta hemorrhagic proportions.
subunit of hCG-is then analyzed every 2 weeks until levels -The placenta is located over or very near the internal
are again normal. cervical os.
•After 6 months, if hCG levels are still negative, a woman is -Severe hemorrhage can result from digital palpation of the
theoretically free of the risk of a malignancy. By 12 months, internal os.
she could begin to plan a second pregnancy
-Previa is a serious but uncommon complication, occurring
•hCG level increases, a malignant transformation in .3-.5% of pregnancies.
choriocarcinoma
•prophylactic course of methotrexate-interferes with WBC
formation (i.e., leukopenia) COMPLICATIONS
• If malignant-methotrexate; second agent dactinomycin can -During pregnancy
be added to the regimen if metastasis occurs.  Antepartum hemorrhage with varying degrees of
shock
CERVICAL INSUFFICIENCY ( PREMATURE CERVICAL  Malpresentation
DILATATION)  Premature lahor
-Premature cervical dilatation, an incompetent cervix, refers  Death due to massive hemorrhage during the ante-
to a cervix that dilates prematurely and cannot retain a fetus partum, intrapartum or postpartum period
 •Never attempt a pelvic or rectal examination with
-During labor painless bleeding late in pregnancy because any
agitation of the cervix when there is a placenta
 Early rupture of the membranes previa might tear the placenta further and initiate
 Cond prolapse due to abricrmal attachment of the massive hemorrhage, possibly fatal to both mother
cord and child.

 Slow dilatation
 Attach external monitoring equipment to record
 Intrapartum hemorrhage fetal heart sounds and uterine contractions – an
 Increased incidence of operative interference internal monitor for either fetal or uterine
assessment is contraindicated
 Postpartum hemorrhage
 Hemoglobin, hematocrit, prothrombin time, partial
thromboplastin time, fibrinogen, platelet count, type
ASSESSMENT and cross-match, and antibody screen will be
P – Painless bright red bleeding assessed to establish baselines, detect a possible
clotting disorder, and ready blood for replacement if
R- Replace blood loss necessary.
E- Evident in lower segment  Monitor urine output frequently, as often as every
V-Vitals indicate shock hour, as an indicator her blood volume is remaining
adequate to perfuse her kidneys. Administer
I-Inspect FHR
intravenous IVF as prescribed, preferably with a
A-Avoid vaginal exams large-gauge catheter to allow for blood replacement
through the same line.

IMMEDIATE CARE MEASURES  If the previa is < 30% by abdominal or intravaginal

ultrasound, it may be possible vaginal birth; If
•To ensure an adequate blood supply to a woman and fetus, >30%, and the fetus is mature, CS
place the woman immediately on bed rest in a side-lying
position. Be certain to assess:  If minimum previa, may attempt a careful speculum
examination of the vagina and cervix to establish the
 Duration of the pregnancy degree of fetal engagement and to rule out another
 Time the bleeding began cause for bleeding, such as ruptured varices or
cervical trauma; done in OR
 Woman’ s estimation of the amount of blood-cups –
is 240 ml; a tablespoon is 15 ml)  If CS, have 02 equipment available in case the fetal
heart sounds indicate fetal distress, such as
 Whether there was accompanying pain
bradycardia or tachycardia, late deceleration, or
 Color of the blood (red blood indicates bleeding is variable decelerations during the exam
fresh or is continuing) CONTINUING CARE
 What she has done, if anything, for the bleeding (if  If labor has begun, bleeding is continuing, or the
she inserted a tampon to halt the bleeding, there fetus is being compromised (measured by the
may be hidden bleeding) response of the fetal heart rate to contractions),
 Whether there were prior episodes of bleeding birth must be accomplished regardless of
during the pregnancy gestational age.
 Whether she had prior cervical surgery for  If the bleeding has stopped, the fetal heart sounds of
premature cervical dilatation good quality, maternal vital signs are good, and fetus
is not yet 36 weeks of age, a woman is usually
•Inspect the perineum for bleeding and estimate the present
managed by expectant watching – a woman remains
rate of blood loss.
in the hospital on bed rest for close observation for
 Weighing perineal pads before and after use and 24 To 48 hours.
calculating the difference by subtraction is a good
 If the bleeding stops, she can be sent home with a
method to determine vaginal blood loss.
referral for bed rest and home care.
 An Apt or Kleihauer- Betke test (test strip
 Assessments of fetal heart sounds and laboratory
procedures) to detect whether the blood is of fetal
Tests, such as hemoglobin or hematocrit, are
or maternal origin.
obtained frequently.
 Obtain baseline vital signs to determine symptoms
 Betamethasone, a steroid that hastens fetal lung
hypovolemic shock are present.
maturity, may be prescribed for the mother to
 Continue to assess blood pressure every 5 to 15 encourage the maturity of fetal lungs if the fetus is
mins with an electronic cuff. less than 34 weeks gestation
  Betamethasone is a corticosteroid that acts as an are
anti-inflammatory and immunosuppressive agent.
- given to pregnant women 12 to 24 hours
before birth to hasten fetal lung maturity if
a fetus is less than 34 weeks gestation and
help prevent respiratory 24 distress
syndrome in the newborn

ABRUPTIO PLACENTA
•Placenta prematurely separates from uterine wall
- Partial or complete tear
•Excessive pain
•Rigid abdominal wall
•Attached placenta
•Minimal vaginal blood flow; dark

THERAPEUTIC MANAGEMENT
TYPES OF PLACENTAL ABRUPTION
•EMERGENCY SITUATION
1. Partial – Placenta does not completely detach from
the uterus - Large-gauge IV catheter inserted for fluid
replacement.
2. Complete or Total – Placenta completely detaches
from the uterine wall - oxygen by mask to limit fetal anoxia.

3. Revealed – Vaginal bleeding is visible - Monitor fetal heart sounds externally

4. Concealed – Little to no visible vaginal bleeding - record maternal vital signs every 5 to 15
minutes to establish baselines and observe
progress.
- The baseline fibrinogen determination will
be followed by additional determinations
up to the time of birth
• POSITIONING – Lateral Position and surgical wounds, and organs
- prevent pressure on the vena cava and
additional interference with fetal
circulation.
- Not to disturb the injured placenta any
further.
•do not perform any abdominal, vaginal, or pelvic
examination
• pregnancy must be terminated fetus cannot obtain
adequate oxygen and nutrients.
•If vaginal birth does not seem imminent, cesarean birth is
the birth method of choice

•Disseminated Intravascular Coagulation has developed

-CS may pose a grave risk of hemorrhage during the surgery
and the surgical incision
-IV administration of fibrinogen or cryoprecipitate (which
contains fibrinogen) to elevate a woman’s fibrinogen level
prior to and concurrently with surgery.
-With the worst outcome, a hysterectomy might be
necessary to prevent exsanguination -DIC is an acquired disorder of blood clotting in which the
fibrinogen level falls to below effective limits
-Death can occur from massive hemorrhage leading to shock
and circulatory collapse or renal failure from circulatory -Early symptoms include easy bruising or bleeding from an
collapse intravenous site.
-Conditions such as premature separation of the placenta,
hypertension of pregnancy, amniotic fluid embolism,
placental retention, septic abortion, and retention of a dead
fetus are all associated with its development.
-DIC occurs when there is such extreme bleeding and so
many platelets and fibrin from the general circulation rush
to the site that there is not enough left in the rest of the body.
-At one point in the circulatory system, the person has
increased coagulation, but throughout the rest of the system,
a bleeding defect exists
-Premature separation of the placenta- ending the pregnancy
by birthing the fetus and delivering the placenta
 marked coagulation must be stopped so that
coagulation factors can be freed and normal clotting
function can be restored.
 accomplished by the administration of heparin to
halt the clotting cascade; first intravenously, then by
subcutaneous injection.
 Heparin must be cautiously given close to birth,
however, or postpartum hemorrhage could occur
DISSEMINATED INTRAVASCULAR COAGULATION from poor clotting after delivery of the placenta
• Pathological activation of coagulation (blood clotting) -A blood or platelet transfusion to replace blood or platelet
mechanisms that happens in response to a variety of loss is usually delayed until after heparin therapy so the new
diseases blood factors are also not consumed by the coagulation
process.
•Leads to the formation of small blood clots inside the blood
vessels throughout the body -Antithrombin III factor, fibrinogen, or cryoprecipitate
(which contains fibrinogen) can all be used in place of whole
• Small clots consume coagulation proteins and platelets,
blood for transfusion; if not available, fresh frozen plasma or
normal coagulation is disrupted and abnormal bleeding
platelets can also aid in restoring clotting function.
occurs.
-Heparin does not cross the placenta so a newborn will not
-From the skin, gastrointestinal tract, the respiratory tract,
be born with decreased clotting ability burning or frequency of urination, vaginal itching or pain).
Clinical findings: at risk of bleeding, thrombosis, organ
failure • Keep appointments for prenatal care.
Treatment of DIC If uterine contractions recur:
 Treatment of the underlying disorder. • Empty your bladder to relieve pressure on the uterus.
 Transfusion support of Red Blood Cells or Fresh • Lie down on your left or right side to encourage blood
Frozen Plasma (FFP) to replace coagulation factors return to the uterus.
• Drink two or three glasses of fluid to increase hydration.
PRETERM LABOR/BIRTH • Telephone your health care provider to report the incident
PRETERM LABOR - Regular contractions of the uterus and ask for further care measures.
resulting in changes in the cervix (dilation and effacement)
that starts before 37 weeks of pregnancy.
THERAPEUTIC MANAGEMENT
Warning signs of Preterm Labor:
ATTEMPT TO STOP LABOR IF NO:
-Abdominal pain, Low dull backache, Menstrual-like cramps,
Pelvic pressure, Contractions, Bleeding and spotting, Vaginal -ROM
discharge that is heavy. - FETAL DISTRESS
You may be at a higher risk of preterm labor if you: -BLEEDING
-Have had previous preterm deliveries, Have an infection, -cervix is not dilated more than 4 to 5 cm,
Are carrying more than one baby, Smoke or use alcohol or
- effacement is not more than 50%.
drugs, Were underveight before pregnancy, Have poor
nutrition
PRETERM BIRTH- When birth occurs any time after the start ADMITTED TO THE HOSPITAL
of the 20th week up to completion of the 37th week of -BED REST; relieve the pressure of the fetus on the cervix
gestation
-Monitor fetal heart rate and the intensity of contractions
Risk Factors for Preterm Labor/Delivery
-IVF therapy for hydration, stop contractions
•history of a previous preterm labor or delivery
-If DEHYDRATED, pituitary gland secrete antidiuretic
•pregnancy complicated by a multiple gestation hormone; release oxytocin – strengthening uterine
• uterine, cervical or placental abnormalities are contractions
•hypertension -Vaginal and cervical cultures and a clean-catch urine sample
are prescribed to rule out infection
• diabetes
-Record daily fetal 10 kick count
• maternal tobacco or illicit drug use
• obesity
DRUG ADMINISTRATION
• short intervals between pregnancies
-Terbutaline prevent and treat bronchospasm/narrowing of
• inadequate prenatal care
airways may be used as a tocolytic agent to halt labor
-Magnesium sulfate reduce uterine contraction
MEASURES TO HELP PREVENT A RECURRENCE OF
-If pregnancy is under 34 two doses of 12 mg betamethasone
PRETERM LABOR
intramuscularly 24 hours apart, or four doses of 6 mg
• Remain on bed rest (a lounge or couch) except to use the dexamethasone intramuscularly 12 hours apart
bathroom.
• Drink 8 to 10 glasses of fluids daily (keep a pitcher by your
PLACENTAL INSUFFICIENCY
bed so you do not have to get up).
• Keep mentally active by reading or working on a project to
prevent boredom.
• Avoid activities that could stimulate labor, such as nipple
stimulation.
• Consult your primary care provider regarding whether
sexual relations should be restricted.
• Immediately report signs of ruptured membranes (sudden
gush of vaginal fluid) or vaginal bleeding.
• Report signs of urinary tract or vaginal infection (e.g.,
 COMPLICATIONS
•PRETERM LABOR
•PRE-ECLAMPSIA
•INTRAUTERINE GROWTH RESTRICTION (IUGR)
•STILLBIRTH

HYPOVOLEMIC SHOCK
Signs and Symptoms

BACKGROUND EMERGENCY INTERVENTIONS FOR BEELDING IN

•OXYGEN & NUTRIENTS are NOT SUFFICIENTLY PREGNANCY
TRANSFERRED to FETUS via PLACENTA •Alert health care team of emergency situation – Provides
•Aka PLACENTAL DYSFUNCTION maximum coordination of care
•LEADS to FETAL HYPΟΧΕΜΙΑ & RESTRICTED FETAL •Place woman flat in bed on her side. – Maintains optimal
GROWTH placental and renal function
•AFFECTS ~ 10% OF PREGNANCIES •Begin intravenous fluid such as Ringer’s lactate with a 16-or
18-gauge angiocath.- Replaces intravascular fluid volume;
intravenous line is established if blood replacement will be
RISK FACTORS needed
•MATERNAL HYPERTENSIVE DISORDERS •Administer oxygen as necessary at 6-10 L/min by face
•SMOKING, ALCOHOL CONSUMPTION, & DRUG USE mask.- Provides adequate fetal oxygenation despite lowered
maternal circulating blood volume
•PRIMIPARITY
•Monitor uterine contractions and fetal heart rate by
•ADVANCED MATERNAL AGE external monitor. – Assesses whether labor is present and
•HISTORY of IUGR NEONATE fetal status; external system avoids cervical trauma
•USE of ANTINEOPLASTICS or ANTIEPILECTICS •Omit vaginal examination. – Prevents tearing of placenta if
placenta previa is cause of bleeding
•Withhold oral fluid. – Anticipates need for emergency
surgery
•Order type and cross-match of 2 units of whole blood. –
Allows for restoring circulating maternal blood volume if
needed
•Measure intake and output. – Enables assessment of renal
function (will decrease to under 30 ml/hr with massive
circulating volume loss)
•Assess vital signs (pulse, respirations, and blood pressure
every 15 min: apply pulse oximeter and automatic blood
pressure cuff as necessary). – Provides baseline data on
maternal response to blood loss
•Assist with placement of central venous pressure or
pulmonary artery catheter and blood determinations. -
Provides more accurate data on maternal hemodynamic
state
•Measure maternal blood loss by weighing perineal pads;
save any tissue passed. – Provides objective evidence of
amount of bleeding; saturating a sanitary pad in less than 1
hr is heavy blood loss; tissue may be abnormal trophoblast
tissue
•Assist with ultrasound examination. – Supplies information
on placental and fetal well-being
•Maintain a positive attitude about fetal outcome. – Supports
mother-child bonding
•Support woman’s self-esteem; provide emotional support HYPERTENSIVE DISORDERS DURING PREGNANCY
to woman and her support person – Assists problem solving,
 Chronic Hypertension
which is lessened by poor self-esteem.
 Gestational Hypertension
 Preeclampsia
PRETERM RUPTURE OF MEMBRANES
 Preeclampsia+
-The spontaneous rupture of the fetal membranes any time
beyond the 28th week of pregnancy but before the onset of  Eclampsia
labor.
 HELLP syndrome -Hemolysis , elevated liver
•After 37th wks – Term PROM enzymes, low platelets
•Before 37 wks – Preterm PROM  Chronic HTN+ Preeclampsia
•Rupture of membranes for > 24 hours before delivery is GESTATIONAL HYPERTENSION
called prolonged rupture of membranes
-Gestational hypertension is a condition in which vasospasm
occurs in both small and large arteries during pregnancy,
Risk factors for PROM: causing signs of increased blood pressure, proteinuria, and
edema.
• Increasing friabilty
-An older term for the condition was toxemia of pregnancy –
• Decreased tensile strength of membranes symptoms as being caused by women producing a toxin of
• Infections like bacterial vaginosis. some kind in response to the foreign protein of the growing
fetus.
• Polyhydrtamnios
-Develops an elevated blood pressure (140/90 mmHg) but
• Multiple pregnancy
has no proteinuria or edema.
• Cervical incompetence
-Careful observation but no drug therapy is necessary
• Previous H/O PROM

FACTORS
DIAGNOSIS:
•Occurs in 5% to 7% of pregnancies.
-Escape of watery discharge per vaginum
•Cause of the disorder is unknown,
-“A sterile per speculum examination to demonstrate
•Highly correlated with the antiphospholipid syndrome or
leaking”
the presence of antiphospholipid antibodies in maternal
blood
•Tends to occur most frequently in:
-Women of color,
-Those with a multiple pregnancy,
-Primiparas younger than 20 years or older than 40 years of
age,
-Low socioeconomic backgrounds (perhaps because of poor
nutrition),
-Have had five or more pregnancies,
-Have hydramnios, overproduction of amniotic fluid
-Have an underlying disease such as heart disease, diabetes
with vessel or renal involvement, and essential hypertension
•Vasospasm – sudden constriction of blood vessel reducing
its diameter and flow rate -Urine output should be over 30 ml/hr and respiratory rate
SYMPTOMS OF GESTATIONAL HYPERTENSION over 12 breaths/min. Serum magnesium level should remain
below 7.5 mEq/l.
-Observe for central nervous system (CNS) depression and
hypotonia in infant at birth and calcium deficit in the mother.

2. Hydralazine (Apresoline) (Pregnancy risk

category C)
Indication: Antihypertensive (peripheral vasodila- tor);
used to decrease hypertension
Dosage-5-10 mg IV
Comments:
- Administer slowly to avoid sudden fall in blood pressure.
-Maintain diastolic pressure over 90 mmHg to ensure
adequate placental filling

3. Diazepam (Valium) (Pregnancy risk category D)

Indication: Halt seizures
Dosage: 5-10 mg IV
Comments:
-Administer slowly. Dose may be repeated q 5-10 min (up to
30 mg/hr).
Gestational hypertension - Blood pressure is 140/90 -Observe for respiratory depression or hypoten- sion in
mmHg or systolic pressure elevated 30 mmHg or diastolic mother and respiratory depression and hypotonia in infant
pressure elevated 15 mmHg above prepregnancy level; no at birth
proteinuria or edema; blood pressure returns to normal
after birth.
Mild preeclampsia – Blood pressure is 140/90 mmHg or 4. Calcium gluconate (Pregnancy risk category C)
systolic pressure elevated 30 mmHg or diastolic pressure Indication: Antidote for magne- sium intoxication
elevated 15 mmHg above prepregnancy level; proteinuria of Dosage: 1 g IV (10 ml of a 10% solution)
1+-2+ on a random sample; weight gain over 2 lb/wk in
second trimester and 1 lb/wk in third trimester, mild edema Comments:
in upper extremities or face. -Have prepared at bedside as the antidote when
Severe preeclampsia -Blood pressure is 160/110 mmHg; administering magnesium sulfate. Administer at 5 ml/min
proteinuria 3+-4+ on a random sample and 5 g on a 24-hr
sample; oliguria (500 ml or less in 24 hr or altered renal
function tests; elevated serum creatinine more than 1.2 ELICITING A PATELLAR REFLEX AND ANKLE CLONUS
mg/dl); cerebral or visual disturbances (headache, blurred
vision); pulmonary or cardiac involvement; extensive
peripheral edema; hepatic dysfunction; thrombocytopenia,
epigastric pain.
Eclampsia- Either seizure or coma accompanied by signs
and symptoms of preeclampsia are present.

DRUGS USED IN GESTATIONAL HYPERTENSION

1. Magnesium Sulfate (Pregnancy risk category B)
Indication: Muscle relaxant; prevents seizures
Dosage: Loading dose 4-6 g, Maintenance dose 1-2 g/h IV
Comments:
- Infuse loading dose slowly over 15-30 min. Always
administer as a piggyback infusion.
-Assess respiratory rate, urine output, deep tendon reflexes,
and clonus every hour.
 2. Promote Bedrest
-And increased evacuation of sodium and encouraging
diuresis of edema fluid. rest in a lateral recumbent position
to avoid uterine pressure on the vena cava and prevent
supine hypotension syndrome
3. Promote Good Nutrition
PREECLAMPSIA -Continue usual pregnancy nutrition while on bedrest,
Nursing Interventions for a Woman With Mild sodium restriction may activate the renin-angiotensin-
Gestational Hypertension aldosterone system and actually result in increased blood
pressure
1. Antiplatelet therapy
4. Provide Emotional Support
-Low-dose aspirin, may prevent or delay the development of
preeclampsia, excessive cause maternal bleeding at the time -Clear information that, if these early: y symptoms are
of birth ignored, they could worsen to the point that they interfere
with both her health and that that of her fetus
5. Health Care Visits
-Weekly or more frequently for the remainder of pregnancy,
woman understands that if symptoms worsen before her
next health care visit, she should report them immediately.

Nursing Interventions for a Woman with Severe

Preeclampsia

1.Support Bed Rest

-restrict visitors, private rooms side rails up; darken rooms
avoid stress; allow to express feelings
2. Monitor Maternal Well-being
-BP q4, blood studies CBC, platelet count, liver function, BUN,
HCT; creatine and fibrin degradation prescribed to assess
renal and liver fien & development of DIC daily weight,
indwelling catheter
3. Monitor Fetal Well-being-Doppler auscultation at 4-
hour intervals;
- nonstress test or biophysical profile daily to assess
uteroplacental sufficiency, if fetal bradycardia occurs, 02
administration to the mother to maintain adequate fetal
oxygenation
4. Support a Nutritious intake
-mod to high CHON, mod Na to compensate for the CHON
lost in urine; IVF line to serve as an emergency route for
drug administration as well as to administer fluid to reduce
hemoconcentration and hypovolemia.
5. Administer Medications to Prevent Eclampsia ASSESSMENT OF ECLAMPSIA
- hypotensive drug such as hydralazine (Apresoline), -Degeneration of a woman's condition from severe
labetalol (Normodyne), or nifedipine; magnesium sulfate preeclampsia to eclampsia occurs when cerebral irritation
from increasing cerebral edema becomes so acute that a
seizure occurs.
MAGNESIUM SULFATE 💊 -Happens late in pregnancy but can happen up to 48 hours
after childbirth Immediately before a seizure, a woman's
-Maintain serum blood levels (for anticonvulsant use) at 5 to blood pressure rises suddenly from additional vasospasm.
8 mg/100 ml. If blood serum levels rise above this,
-The increased cerebral pressure causes her temperature to
respiratory depression, cardiac arrhythmias, and cardiac
rise sharply to 103" to 104° F (39.4° to 40° C).
arrest can occur.
-Blurring of vision or severe headache (from the increased
-Do not administer additional doses and stop infusion if deep
cerebral edema),
tendon reflexes are absent or if respiratory rate is less than
12- 14 breaths/min or urine output is less than 30 ml/hr. -Reflexes become hyperactive.
- Experience a premonition or aura that something is
happening."
This drug may cause respiratory depression in the newborn
if administered close to birth. Alert neonatal care personnel -Vascular congestion of the liver or pancreas can lead to
about this possibility. severe epigastric pain and nausea or vomiting.
-Magnesium sulfate may cause osteoporosis in the mother if -Urinary output may decrease abruptly to less than 30
given over a long time. ml/hr.
Action:
-a central nervous system depressant that acts to block -Eclamptic seizure is a tonic- clonic type occurs in stages:
neuromuscular transmission of acetylcholine to halt • TONIC PHASE preliminary signal or aura:
convulsions.
-All the muscles body contract.
-It also halts premature labor, as it relaxes smooth muscle
-Back arches,
Possible Adverse Effects:
-Her arms and legs stiffen,
-Flushing thirst with toxicity, absence of deep tendon
reflexes, respiratory depression, cardiac arrhythmias, -Her jaw closes so abruptly she may bite her tongue.
cardiac arrest, and decreased urine output. -Lasts approximately 20 seconds.
Nursing Implications: -Respirations halt because her thoracic muscles are held in
-Administer continuous infusion piggybacked into a main IV contraction.
line so it can be discontinued immediately without -It may seem longer because a woman may grow slightly
interfering with fluid administration cyanotic from the cessation of respirations.
-Always use an infusion control device to maintain a regular
flow rate.
-Assess maternal blood pressure and fetal heart rate
continuously with bolus IV administration
-Assess deep tendon reflexes every 1 to 4 hours during
continuous infusion. Use the patellar reflex. If patient has
received epidural anesthesia, use the biceps reflex.
-Monitor intake and output every hour during continuous
infusion. Urine output should be 30 ml/hr or greater. • second (clonic) stage:
-Assess client’s level of consciousness, including ability to -the woman's bladder and bowel muscles contract and relax;
respond to questions, every hour. Obtain serum magnesium incontinence of urine and feces may occur.
levels as indicated, usually every 6-8 hours
-begins to breathe during this stage, the breathing is not
-Keep calcium gluconate, the antidote for toxicity, readily entirely effective so she may remain cyanotic.
available at the bedside.

Eclampsia
-It is a disorder that pregnant women experience in which
blood pressure of the patient increases a lot and urine
contains protein.
- lasts up to 1 minute. placental separation has occurred will
probably appear first on the fetal heart
record; vaginal bleeding will strengthen the
presumption.
 During the postictal stage, a woman cannot be
roused except by painful stimuli for 1 to 4 hours.
-Extremely close observation to assess for uterine
contractions
-if labor begins during this period, the woman will
be unable to report the sensation of contractions.
-the painful stimulus of contractions may initiate
another seizure.
-Be certain to keep the woman on her side so
secretions can drain from her mouth
-Give her nothing to eat or drink.
-Remember that with coma, hearing is not
• Third postictal stage: necessarily lost, so be certain conversation is limited
-will enter an hour long unconscious to those things you would say if she were awake.
Continue to check for vaginal bleeding every 15
- cannot be roused except by painful stimuli for 1 to 4 hours.
minutes

Nursing Interventions for a Woman With Seizures

-The priority care for a woman with a tonic clonic seizure is:
 to maintain a patent airway.
 to prevent aspiration, turn her onto her side to allow
secretions to drain from her mouth.
 Magnesium sulfate or diazepam (Valium) may be
administered intravenously as emergency measures.
 Assess oxygen saturation via a pulse oximeter.
 Administer oxygen by face mask as needed to
protect fetal oxygenation. Apply an external fetal
heart monitor if one is not already in place to assess
the fetal heart rate.
 The seizure may announce the beginning of labor, so
assess as well for uterine contractions.
- Check for vaginal bleeding to detect
placental separation, although evidence
 Nursing Interventions for a Woman With Symptoms that occur:
Eclampsia During Birth and Post Partum • Hemolysis that leads to anemia,
Birth • Elevated Liver enzymes that lead to epigastric pain,
-If the fetus is viable, birth will be made as soon as a •Low platelets that lead to abnormal bleeding/clotting to
woman’s condition stabilizes, usually 12 to 24 hours
after the seizure •Petechia
-Because of the increased stress that has occurred, •HELLP SYNDROME SIGNS AND SYMPTOMS
fetal lung maturity appears to advance rapidly with -Occurs both primigravidas and multigravidas
gestational hypertension, so even though the fetus is
younger than 37 weeks, the -Associated with antiphospholipid syndrome (a condition
lecithin/sphingomyelin ratio may indicate fetal immune system mistakenly creates antibodies that attack
lung maturity. tissues in the body)or the presence of antiphospholipid
antibodies
-Cesarean birth is always more hazardous for the
fetus than vaginal birth because of the association of - In addition to proteinuria, edema, and increased blood
retained lung fluid pressure, additional symptoms of nausea, epigastric pain,
general malaise, and right upper quadrant tenderness from
-Woman with severe high blood pressure is not a liver inflammation occur.
good candidate for surgery.
- An additional problem arises: because her Vascular
system is low vin volume, she may become •LABORATORY STUDIES
hypotensive with regional anesthesia, such as an -Hemolysis of red blood cells (they appear fragmented on a
epidural block peripheral blood smear),
-preferred method for birth-vaginal with a minimum - thrombocytopenia (a platelet count 100,000/mm3)
of anesthesia; if labor does not begin spontaneously, -elevated liver enzyme levels (alanine aminotransferase
rupture of the membranes or induction of labor with [ALT] and serum aspartate aminotransferase [AST)
intravenous oxytocin maybe instituted.
-If fetus appears to be in imminent danger,
cesarean birth becomes the birth method of choice. ALL EFFECTS OF HEMORRHAGE AND NECROSIS OF THE
LIVER

POSTPARTUM
COMPLICATIONS
-Postpartum hypertension may occur up to 10 to 14 days
after birth, although it usually occurs within 48 hours after -subcapsular liver hematoma, hyponatremia, renal failure,
birth and hypoglycemia from poor liver function.
 monitor BP every health care visits -at risk for cerebral hemorrhages, aspiration pneumonia, and
hypoxic encephalopathy.
 being alert for eclampsia, which can occur as late as
2 weeks post birth, are essential to detect this - Fetal complications can include growth restriction and
residual hypertension preterm birth

HELLP SYNDROME MANAGEMENT

HELLP syndrome is a variation of gestational hypertension -Transfusion of fresh frozen plasma or platelets in order to
that is named for the common improve the platelet count.
- Hypoglycemia is present, corrected by an intravenous
glucose infusion.
- The infant is born as soon as feasible by either vaginal or
cesarean birth.

ISOIMMUNIZATION (RH INCOMPATIBILITY)

 -Occurs when an Rh-negative mother (one negative for a D
antigen or one with a dd genotype) carries a fetus with an
Rh-positive blood type (DD or Dd genotype)
-The father of the child must either be homozygous (DD) or
heterozygous (Dd) Rh positive.
-If the father of the child is homozygous (DD) for the factor,
100% of the couple’s children will be Rh positive (Dd).
-If the father is heterozygous for the trait, 50% of their
children can be expected to be Rh positive (Dd).
-The mother forms antibodies against the invading
substance.
-The Rh factor exists as a portion of the red blood cell, so
these maternal antibodies cross the placenta and cause
destruction (i.e., hemolysis) of fetal red blood cells
-When a woman and her unborn baby carry different Rhesus -Hemolytic disease of the newbom or erythroblastosis fetalis
(Rh) protein factors, their condition is called Rh
incompatibility.
-It occurs when a woman is Rh-negative and her baby is Rh-
positive.
-The Rh factor is a specific protein found on the surface of
your red blood cells.
-Like the blood type, inherit the Rh factor type from parents.
-Most people are Rh-positive, but a small percentage of
people are Rh-negative. This means they lack the Rh protein.
-Rh incompatibility occurs when the mother’s blood type is
Rh negative and her fetus’s blood type is Rh positive. An
alternative name is Rh disease. If a pregnant woman is Rh
negative and the baby’s father is Rh positive, then the baby
may inherit the father’s blood type, creating incompatibility
between the mother and the fetus
•No connection between fetal blood and maternal blood -Indirect: tests mother’s blood for number of Antibodies.
during pregnancy, so the mother should not be exposed to •RhoGAM
fetal blood
-IM injection of anti-Rh gamma globulin
•A small amount of fetal blood enter maternal circulation
during these procedures such as: -Given to Mom at 28 weeks and at 72 hours postpartum to
prevent antibody development
•amniocentesis or percutaneous umbilical blood sampling
-Also given if Rh-negative mom has abortion, ectopic
•As the placenta separates after birth of the first child, pregnancy or amniocentesis
•there is an active exchange of fetal and maternal blood from •Indirect Antiglobulin Test
damaged villi.
Aka: Indirect Coombs Test
•Causes most of the maternal antibodies formed against the
Rh-positive blood to be formed in the first 72 hours after Purpose:Detect antibodies that are directed against RBC
birth. antigens
•Become a threat in a second pregnancy Examples: Performed in patients about to undergo a blood
transfusion to detect the presence of antibodies to the RBCs
about to be transfused (mismatch)
Management -During pregnancy or at delivery for a woman who is Rh
•To reduce the number of maternal Rh (D) antibodies being negative
formed, RhIG, a commercial preparation of passive Rh (D) •Direct Coombs’ test (Baby)
antibodies against the Rh factor, is administered to women
who are Rh negative at 28 weeks of pregnancy-these cannot - to detect antibodies that are already bound to the surface of
cross the placenta and destroy fetal red blood cells red blood cells in the baby.
•RhIG (RhoGAM) is given again by injection to the mother in
the first 72 hours after birth of an Rh-positive child to Management:
further prevent the woman from forming natural antibodies.
• INTRAUTERINE TRANSFUSION PHOTOTHERAPY AFTER
•After birth, the infant’ s blood type will be determined from BIRTH – to reduce the level of bilirubin released from
a sample of the cord blood. destroyed red blood cells or an
•If it is Rh positive (i.e., Coombs test negative, indicating a •EXCHANGE TRANSFUSION – to remove hemolyzed red
large number of antibodies are not present in the mother), blood cells and replace them with healthy blood cells
the mother will receive the RhIG injection.
Intrauterine Transfusion (IUT)
•If the newborn’s blood type is Rh negative, no antibodies
have been formed in the mother’s circulation during -Given to the fetus to prevent hydrops fetalls and fetal death.
pregnancy and none will form, so passive antibody injection -Can be done as early as 17 weeks, although preferable to
is unnecessary wait until 20 weeks
-Severely affected fetus, transfusions done every 1 to 4
Rh immune globulin should be given to an Rh-negative weeks until the fetus is mature enough to be be delivered
woman to prevent sensitization: safely. Amniocentesis may be done to determine the
maturity of the fetus’s lungs before delivery is scheduled.
-After multiple IUTS, most of the baby’s blood will be D
1. After amniocentesis, fetal blood sampling or CVS… negative donor blood, therefore, the Direct Antiglobulin test
2. When bleeding occurs in the second or third will be negative, but the Indirect Antiglobulin Test will be
trimester of pregnancy. positive.
3. At 28 weeks of pregnancy. -After IUTS, the cord bilirubin is not an accurate indicator of
rate of hemolysis or of the likelihood of the need for post-
4. After an external cephalic version of a breech fetus. natal exchange transfusion.
5. After abdominal trauma during pregnancy.
6. Within 72 hours after delivery of an Rh-positive
infant.
7. After a threatened or complete miscarriage, or an
Induced abortion,
8. Before or immediately after treatment for ectopic
pregnancy or a partial molar pregnancy.

Rh incompatibility
•Coomb’s test
-Direct: tests infant’s blood for antibody-coated. RBCS
 spermatozoa (possibly not from the same sexual partner).
-Double-ova twins have two placentas, two chorions, two
amnions, and two umbilical cords.
-The twins may be of the same or a different sex It is
sometimes difficult to determine by ultrasound or at birth
whether twins are identical or fraternal because the two
fraternal placentas may fuse and appear as one large
placenta

MULTIPLE GESTATIONS
•Dizygotic twins showing two placentas, two chorions, and
two amnions.
•Monozygotic twins with one placenta, one chorion, and two
amnions.

-Identical (i.e., monozygotic) twins begin with a single ovum

and spermatozoon.
-In the process of fusion, or in one of the first cell divisions,
the zygote divides into two identical individuals.
-Single-ovum twins usually have one placenta, one chorion,
two amnions, and two umbilical cords.
-The twins are always of the same sex; they account for one
third of twin births.

Assessment
-Multiple gestation is suspected early in pregnancy, when the
uterus begins to increase in size at a rate
-Faster than usual. Elevated AFP levels.
-At the time of quickening, flurries of action at different
portions of abdomen rather than at one consistent spot (e. g.,
where the feet are located). On auscultation, multiple sets of
fetal heart sounds can be heard
-If one or more fetus has his or her back positioned toward a
woman’s back, only one fetal heart sound may be heard.
-An ultrasound can reveal multiple gestation sacs early in
•Multiple gestation is considered a complication of
pregnancy.
pregnancy – a woman’s body must adjust to the effects of
more than one fetus. -Early ultrasound examinations reveal multiple Amniotic
sacs
-Fraternal (ie, dizygotic, nonidentical), the result of the
fertilization of two separate ova by two separate
Complications •Increased amount of fluid will cause increased weight gain.
•Susceptible to complications of pregnancy such as MANAGEMENT
gestational hypertension, hydramnios, placenta previa, 1. BEDREST -Maintaining bed rest helps to increase
pretermlabor, and anemia uteroplacental circulation and reduces pressure on
•Following birth, they are more prone to postpartum the cervix, which may help prevent preterm labor
bleeding because of the additional uterine stretching that 2. STOOL SOFTENER -Straining to defecate could
occurred. Usually ends before term, 25% of LBW increase uterine pressure and cause a rupture of
•There is a higher incidence of velamentous cord insertion membranes constipation alone is ineffective
(the cord inserted into the fetal membranes) with twins-rick encouraging her to eat a high fiber diet. Suggest of
of bleeding at the time of birth from a torn cord is increased stool softener alone is ineffective
if monozygotic twins share a common vascular 3. VITAL SIGNS -Assess vital signs; lower extremity
communication, it can lead to overgrowth of one fetus and edema frequently (the extremely tense uterus puts
undergrowth of the second (a twin-to-twin transfusion) unusual pressure on both the diaphragm and the
resulting in discordant vessels of the pelvis
•If a single amnion is present, there can be knotting and 4. AMNIOCENTESIS/NEEDLING -Remove some of the
twisting of umbilical cords, causing fetal distress or difficulty extra fluid to prevent placental separation or
with birth. rupture of membranes; thin needle is inserted
•Twin pregnancy needs closer prenatal supervision than a vaginally to pierce to allow slow, controlled release
woman with a single gestation to detect these problems as of fluid to prevent prolapse of the cord.
early as possible. 5. LABOR AND NEWBORN- contractions begin,
•More than two fetuses is at greatest risk. tocolysis is may be necessary to prevent or haft
pretem labor. Infant in must be assessed carefully
for factors that may have interfered with the ability
HYDRAMINOS to swallowing utero, such as a gastrointestinal
-Amniotic fluid volume at term is 500to 1,000 ml blockage
Hydramnios occurs when there is excess fluid of more than
2,000 ml amniotic fluid index above 24
OLIGOHYDRAMNIOS
- Hydramnios can cause fetal malpresentation
-Refers to a pregnancy with less than the average amount of
 the additional uterine space can allow the fetus to amniotic fluid
turn to a transverse lie.
-Part of the volume of amniotic fluid is formed by
 lead to premature rupture of the membranes from
-The addition of fetal urine, this reduced amount of fluid is
the increased pressure leads to the additional risks
usually caused by a bladder or renal disorder in the fetus
of infection, prolapsed cord, and preterm birth.
that is interfering with voiding. Occur from severe growth
-Suggests difficulty with the fetus ability to swallow or restriction (because of the small size, a fetus is not voiding as
absorb, or excessive urine production. much as usual).
 Inability to swallow occurs in infants who are  Fetus is so cramped for space
anencephalic who have tracheoesophageal fistula
 muscles are left weak at Birth, lungs can fail to
with stenosis, or who have intestinal obstruction
develop (hypoplastic lungs)
-Excessive urine output occurs in the fetuses of diabetic
women (hyperglycemia in the fetus causes increased urine  Possibly leading to severe difficulty breathing After
production). birth
 distorted features of the face occur (termed Potter
syndrome)
Assessment
•First sign of hydramnios unusually rapid enlargement of the
uterus. ASSESSMENT

•The small parts of the fetus difficult to palpate, the uterus is •Oligohydramnios is suspected during pregnancy when the
unusually tense. uterus fails to meet its expected growth rate.

•Difficulty in auscultating the FHR-depth of the increased •Confirmed by ultrasound when the pockets of amniotic
amount of fluid surrounding the fetus. fluid are less than average.

•May begin to notice extreme shortness of breath as the

overly distended uterus pushes up against her diaphragm MANAGEMENT:
•may develop lower extremity varicosities and hemorrhoids- •Infants need careful inspection at birth to rule out kidney
venous return from the lower extremities is blocked by disease and compromised lung development.
extensive uterine pressure.
POSTTERM PREGNANCY
-Post-term pregnancy is a pregnancy that lasts more than 42
weeks of gestation from the last menstrual period (LMP)
-Other terms as postmature, postdate or dysmature.
-Evidence that placental insufficiency has occurred and
interfered with fetal growth.
-It is associated with risks for both the mother and the baby,
such as fetal malnutrition, meconium aspiration syndrome,
stillbirths, and problems with the placenta to 17 days.
-Healthcare provider may induce labor to deliver the baby if
tests show that it is no longer healthy for the baby to stay in
the uterus
-Also associated with: Women receiving a high dose of
salicylates (for severe sinus headaches or rheumatoid
arthritis) that interferes with the synthesis of
prostaglandins, which may be responsible for the initiation
of labor.
- Myometrial quiescence, or a uterus that (for unknown
reasons) does not respond to normal fabor stimulation
danger to a fetus for several reasons.
•Meconiumaspiration is more apt to occur as fetal intestinal
contents are more likely to reach the rectum
• if the fetus continues to grow, macrosomia could create a
Birth problem
•Usual effect of being posttermis lack of growth because a
placenta seems to have adequate functioning ability for only
40 to 42 weeks
-After that time, it acquires calcium deposits
- exposes a fetus to decreased blood perfusion and a lack of
oxygen, fluid, and nutrients

Goal of Management
•Overall health and medical history
•Extent of the condition
•Tolerance for specific medications, procedures or therapies
•Expectations for the course of the condition
•Opinion or preferences

Detect Potential problems

-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 watches the fetal heart rate
for increases with fetal movements, a sign of fetal well-being.
-Biophysical profile-a test that combines the nonstress test
-with an ultrasound to. Evaluate fetal well-being.
ULTRASOUND-a diagnostic imaging technique which uses
high-frequency sound waves and a computer to create
images of blood vessels, tissues, and organs. Ultrasounds are
used to view internal organs as they function, and to assess
blood flow through various vessels. Ultrasounds are used to
follow fetal growth. contractions
-DOPPLER FLOW STUDIES-a type of ultrasound which use -Observe woman-Blood for coagulation studies to detect DIC
sound waves to measure blood flow. must be obtained to rule out the possibility of this
developing.

If tests determine that it is no longer healthy for the fetus to

stay in the mother’s uterus, labor may be induced, to deliver
the baby.

Management
1. Continuous monitoring of FHR with an electronic
monitor to help identify changes in the heart rate
due to low oxygenation.
2. The baby may need suctioning and special care after
delivery, pass meconium (the first stool) during
labor, the risk of meconium aspiration is increased.
3. Amnioinfusion is sometimes used during labor if
there is very little amniotic fluid or the fetus is
compressing the umbilical cord sterile fluid is
instilled with a catheter (hollow tube) into the
broken amniotic sac to help replace the low levels of
fluid and cushion the fetus and cord.
4. CS-if labor does not progress or there is fetal
distress
5. Very large babies may have difficulty at delivery,
and forceps or vacuum-assisted delivery may be
needed

PSEUDOCYESIS
-Pseudocyesis (false pregnancy), nausea and vomiting,
amenorrhea, and enlargement of the abdomen occur in
either a nonpregnant woman or a man
-There are several theories regarding why the phenomenon
occurs:
 Wish-fulfillment theory suggests a woman’s desire
to be pregnant actually causes physiologic changes
to occur
 Conflict theory suggests a desire for and fear of Assessing the Pregnant Woman Over 40 Years of Age for
pregnancy create an internal conflict leading to Complications
physiologic changes, depression theory attributes
the cause to major depression.
FETAL DEATH
-On assessment, an ultrasound will confirm the absence of a
FHB.
-Fetus has died early in intrauterine life – miscarriage
-If a fetus dies in utero past the point of quickening, a woman
will be very aware that fetal movements are suddenly
absent.
-Begins painless spotting, gradually accompanied by uterine
contractions with cervical effacement and dilatation.
-fetus is born lifeless and emaciated
- induced through a combination of prostaglandin gel such as
misoprostol (Cytotec) applied to the cervix to effect cervical
ripening and oxytocin administration to begin uterine
 concern.
• Do not take medicine in the dark, so you can clearly read
the label.
• Avoid working to a point of fatigue, as fatigue lowers
judgment.
• Avoid long periods of standing, because this can lead to a
drop in your blood pressure, causing you to feel dizzy and
faint.
•Always use a seat belt while driving or as a passenger in an
automobile.
• Refuse to ride with anyone in an automobile who has been
drinking alcohol or whose judgment might be impaired in
some other way.

Assessing the Effects of Trauma in the Pregnant Woman

Pregnant Woman Over 40 Years of Age Complications

 Premature birth
 Birth by C-section
 Low birth weight
 Miscarriage
 Gestational diabetes
 Preeclampsia
 Miscarriage
 Preterm birth
 Preeclampsia
 Ectopic pregnancy

PREVENTIVE MEASURES TO REDUCE UNINTENTIONAL

INJURY DURING PREGNANCY
• Do not stand on stepstools or stepladders (it is difficult to TRAUMA IN PREGNANCY
maintain balance on a narrow base).
-Trauma complicates approximately 1 in 12 pregnancies
• Keep small items such as footstools out of pathways (late in
- It is the leading non-obstetrical cause of maternal death
pregnancy, it’s difficult to see your feet).
-Trauma has foetal complications as well, and has been
• Avoid throw rugs without a nonskid backing so you don’t
reported to increase the incidence of
slip on these.
• Use caution stepping in and out of a bathtub.  Spontaneous abortion (SAB)

• Do not overload electrical circuits (it is difficult for a  Preterm premature rupture of membranes
pregnant woman to escape a fire because of poor mobility).  Preterm birth (PTB)
• Do not smoke, so falling asleep with a cigarette will not be a  Uterine rupture
  Cesarean delivery -Preventing you from seeing your family or friends or from
going to school or work
 Placental abruption
5. CRITICISM
 Stillbirth
-Calling you OVERWEIGHT, UGLY, STUPID OR CRAZY
-Ridiculing your beliefs ambitions or friends
- Placental abruption is major contributing factor in foetal
death -TELLING you he or she IS the only one who really care
about you
-Usually 1 in 3 pregnant women admitted to the hospital for
trauma will deliver during her hospitalization. -BRAINWASHING you to Feel worthless
6. SABOTAGE
FACTORS FOR TRAUMA IN PREGNANCY -Making you MISS work, school or interview,
1. IMPROPER SEAT BELT USE -test or competition by starting a fight
2. DOMESTIC VIOLENCE -Having a MELTDOWN or getting sick
3. DRUG USE -Breaking up with you or hiding your keys, wallet, textbooks
or phone STEALING your belongings.
7. BLAME
KNOW THE EIGHT BEFORE ITS TOO LATE
-Making you feel GUILTY for his or her behavior
-Blaming the world or you for his PROBLEMS
1. INTENSITY
-Emotional manipulation always saying this is your FAULT”
-Excessive charm
8. ANGER
-LYING to cover up insecurities
-OVERREACTING to small problems
-Needing to win you over your friends and family
-Frequently losing control violent OUTBURST
- OVER THE TOP gestures that seem too much too soon
-Having severe mood swings
-BOMBARDING you with too much text and emails in a short
time -Drinking or partying
-Behaving obsessively insisting that you get serious -Excessively when upset Making THREATS, picking
IMMEDIATELY -FIGHTS Having a history of violent behavior and making
you feel AFRAID
1. JEALOUSY
-Responding IRRATIONALLY when you interact with other PUNCTURED WOUND
people •Results from the penetration of a sharp object such as a nail,
- becoming ANGRY when. You speak with the opposite sex splinter, nail file, or knife.
-Persistently ACCUSING you of flirting/cheating Resenting •Puncture wounds bleed little an advantage in terms of
your time with friends and family minimizing blood loss but not in terms of wound cleaning
-DEMANDING to know private details of your life •not sutured because suturing would create a sealed,
unoxygenated cavity below the sutures or a space where a
tetanus bacilli infection could grow.
2. CONTROL
•If a woman has had a tetanus immunization within the past
-TELLING how to wear your hair, when to speak and what to 10 years, tetanus toxoid (Tdap) is administered.
think
•If a woman has not had a tetanus immunization within 10
-Showing up UNINVITED in your home/school/job years (the usual condition), both tetanus toxoid (Tdap) and
-CHECKING your cellphone, emails, facebook immune tetanus globulin (Tig) are administered.

-Following you •Both of these are safe to administer during pregnancy

-Sexually coercing you •Puncture wounds are usually frightening because it’s
difficult to tell how deep they Are; associated with of
- Making you FEEL BAD about yourself violence.
-Going through your belongings •Knife wounds cause deep penetration puncture wounds
and are often directed into the abdomen.
3. ISOLATION •Paring knife may easily reach the depth of the uterus,
possibly directly cutting the fetus.
-INSISTING you only spend time with him or her making you
emotionally and psychologically DEPENDENT •Most stab wounds of the abdomen, occur in the upper
quadrants of the abdomen above the uterus, and are more
apt to strike the liver or pancreas

LACERATION Gunshot Wounds

-Assessment inspection for the paint where the bullet
entered the body as well as the point where it exited (the
entry w1ound is smaller than the exit wound because, as a
bullet slows, it begins to tumble, enlarging the space it
occupies)
-The uterine wall is so thick during pregnancy that it may
trap a bullet, so there may be no exit point from a woman’s
body if the uterus was punctured.
-If the bullet entered high in the abdomen, the intestines will
surely be injured because so many loops of these are
compressed above the uterus.

POISONING
•Laceration (e.g., a jagged cut) may involve only the skin •Can occur unintentionally, from inadequately refrigerated
layer or may penetrate to deeper subcutaneous tissue and or Undercooked foods or if a woman wakes at night and
even tendons. attempts to take medicine in the dark
-Generally bleed profusely; halt bleeding by putting pressure •also the possibility a woman might poison herself as a self-
on the edges of the laceration; harm attempt.
-This may be difficult to achieve in the lower extremities •Managed the same as in a nonpregnant woman
because venous pressure is so greatly increased in the legs
during pregnancy. • state she is pregnant and what she unintentionally
swallowed oral activated charcoal is safe during pregnancy
-After cleaning, the area is then sutured through each layer and so is the drug of choice to neutralize stomach poison
of tissue involved to approximate the edges – local
anesthetic such as lidocaine (Xylocaine) is necessary for
suturing. Choking

If a pregnant woman chokes on a piece of food or a foreign

ANIMAL BITES object blocks her airway, attempting to dislodge the object
with a sudden upward thrust to the upper abdomen can be
•Animal bites produce a form of puncture wound, so if the difficult because there is a lack of space between the uterus
rabies immunization status of the dog is known to be up to and the end of the sternum.
date, the wound is washed and treated as a puncture
•If the dog cannot be located or is proved to be rabid after 48
hours of observation-must be administered rabies immune
globulin and vaccine.
•Pregnancy is not a contraindication to rabies immunization
because contracting the disease would be fatal.

Blunt Abdominal Trauma

•Occurs from automobile accidents, when a women
abdomen strikes the steering wheel or dashboard or occurs
from someone kicking or punching her abdomen. Orthopedic Injuries
•No visible break is present in the skin, the underlying tissue -Apply ice to the area to decrease swelling as an immediate
becomes edematous broken underlying blood vessels ooze first-aid measure.
and Form ecchymoses or a hematoma at the - X-ray may be necessary to determine whether a fracture is
•If the bruise is over the abdomen, to assess if there is present
internal bleeding, a diagnostic peritoneal lavage may be -Assess injury and manage accordingly
done by introducing a small amount of normal saline by
syringe into the peritoneum and then withdrawing it to see if - Analgesics to relieve pain
blood is evident. Ultrasound may also be used to detect this - Good calcium food sources if with a fracture so both she
•Careful assessment of pregnancy and the fetus can obtain adequate calcium for new bone
growth.
 is no longer used that way because, although it creates a
sense of euphoria, it also causes irritation and possibly long-
term hallucinations (i.e., flashback episodes), and it is now
Marijuana seen most frequently as part of polydrug use by the” rave”
•Marijuana and hashish are obtained from the hemp plant, culture.
cannabis •Because the drug tends to leave the maternal circulation
•Using merijuana during pregnancy can cause LBW and and concentrate in fetal cells, it may be particularly injurious
abnormal neurological development to a fetus.
•Secondhand marijuana smoke contains many of the same
toxic and cancer-causing chemicals found in tobacco smoke. Opioids are a class of drugs used to manage pain
•THC, the psychoactive or mind-altering compound in •Serious negative health outcomes for pregnant women and
marijuana, may also be passed to infants through developing babies, including:
secondhand smoke
- Preterm, still birth, maternal mortality
neonatal abstinence syndrome (NAS)
TOBACCO •Used for the relief of pain, such as morphine, oxycodone,
•Smoking during pregnancy increases the risk of health meperidine (Demerol), and codeine
problems for developing babies, including posterm birth, low •Can be obtained by prescription and they have a dramatic
birth weight, and birth defects of the mouth.and.lip. euphoric effect
•Smoking during and after pregnancy also increases the risk
of sudden infant death syndrome (SIDS).
Opioids – Heroin
•Raw illicit opiate administered intradermally (i.e.,” skin
Alcohol popping” ), through inhalation (i.e., snorting” ), or
•No known safe amount of alcohol use during pregnancy or intravenously (i.e.,” shooting” ).
while trying to get pregnant. •It produces an immediate and short lived feeling of
•No safe time during pregnancy to drink euphoria immediately followed by sedation.
•All types of alcohol are equally harmful, including all wines •Pregnancy complications related to its use include
and beer. gestational hypertension and- because the drug is often
injected with shared needles- phlebitis, subacute bacterial
•Effect fetal alcohol spectrum disorders endocarditis, and hepatitis B and HIV infection may occur.

COCAINE
•Exceptionally harmful during pregnancy extreme
vasoconstriction can severely compromise placental
circulation, leading to PREMATURE separation of the
placenta which then results in preterm labor or fetal death
• Infants born to cocaine-dependent women can suffer the
immediate effects of intracranial hemorrhage and an
abstinence syndrome of tremulousness, irritability, and
muscle rigidity.
•Learning and social interaction defects are suspected

Amphetamines
•Methamphetamine (ie, speed) is a cheaper neurostimulant
and neurotoxin that has a effect similar to cocaine
•ice, a rock type of methamphetamine that is smoked, can
produce high concentrations of the drug in the maternal
circulation.
•Women develop blackened and infected teeth.
•Newborns whose mothers used the drug show jitteriness
and poor feeding at birth and may be growth restricted

Phencyclidine (PCP)
-Was developed in the 1950s as an intravenous anesthetic; it