university of Gondar

College of medicine and health science

Obstetrics and Gynecology nursing
Abnormal pregnancy
For comprehensive Nursing Students
BY: Agumas E. (BSc, MSc)

4/15/2021 Agumas E. UOG 1

 Hyperemesis graviderum
Objectives
At the end of this secession the students will be able to:-
1. Define Hyperemesis gravidarum.
2. List risk factors of HG.
3. Diagnose/ identify HG.
4. Describe complications of HG.
5. Manage HG

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 HEG
Definition:-
Derived From Greek words :
Hyper - excessive
Emesis – vomiting
And from Latin word:
Gravida - pregnant
❖ Is excessive vomiting during pregnancy
❖ Is sever form of nausea and vomiting during pregnancy
result in dehydration and weight loos

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Sign and symptoms
❖Weight loss 5% or greater body weight
❖Dehydration
❖Takycardia
❖Metabolic imbalance
❖Sensitivity of brain to motion
❖Ptyalism
❖Some what earlier to morning sickness….etc

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Diagnosis
HEG: Common criteria's for diagnosis are:
❖ Persistent nausea and vomiting ( >3x /day),
❖ Weight loss >5% of prepregnancy body weight
(>3 kg ) and
❖ Ketonuria unrelated to other causes

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The mean onset of symptoms is:
⮚ At 5 to 6 weeks of gestation,
⮚ Peaking at about 9 weeks, and
⮚ Usually abating by 16 to 20 weeks ; however,
⮚ May continue until 3rd trimester in 15 to 20% of cases
and until delivery in 5%.
⮚ If persists beyond a few days postpartum , other
etiologies should be investigated.

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Risk factors
•Multiple gestations,
•Hydatidiform mole
•Women who did not take multivitamins prior to 6
weeks of gestation and
•Female fetuses
•Genetic factors appear to play a role
•Alcohol use and cigarette smoking (perhaps due to
the effect of nicotine) appear to be protective factors
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Differential diagnosis:
• Gastroenteritis
• cholecystitis
• hepatitis
• pyelonephritis
• intestinal parasites,
• PUD and drug induced vomiting should be ruled out by
history, physical examination and laboratory investigations.

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Standard initial evaluation includes measurement of:
• Weight
• Vital signs
• Serum electrolytes,
• Urine ketones and specific gravity
• An obstetrical ultrasound and
• Ruling out other possible differentials

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General Management:
⮚ Exclude - Other disease, identify obstetrics condition
⮚ Adequate fluid, electrolyte and calorie replacement
⮚ Arrest the vomiting with potent anti-emetics
⮚ NPO until vomiting stopped and NPO for at least 24-48 hours after
vomiting have ceased,
⮚ Encourage small frequent meals once vomiting has subsided after 48
hours.
⮚ Avoid noxious stimuli such as unpleasant odors.
⮚ Reassurance and emotional support, and psychological
counseling
⮚ Therapeutic abortion – very rarely
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Treatment
■ Rehydrate with N/S, ringer lactate
■ Add 40% glucose
■ vit. B complex
■ Chlorpromazine, 12.5-25 mg IM BID until vomiting is
controlled & then PO or
■ Promethazine, 25mg IM/IV BID, followed by 25 mg PO
BID
■ Metoclopromide 10 mg IM/IV BID

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Potential complication
■ Fluid and electrolyte imbalance
■ Renal failuer

■ Malnutrition
■ IUGR and LBW
■ Vitamin deficiency

■ Anemia
■ Death

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PREGNANCY-INDUCEDHYPERTENSION (PIH)

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 Objectives
At the end of this session students will be
able to:
✔ Define PIH
✔ Classify PIH
✔ List types of preeclampsia
✔ Describe characteristics of preeclampsia
✔ Analyze pathophysiology of preeclampsia
✔ Diagnose and manage PIH

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 Definition
HTN during px Is defined as:-

⮚ single BP of 160/110 mmhg or more or

⮚ Two consecutive Bp 140/90mmhg or more at least two

occasion 6hrs or more apart .

Severe HTN in Px:- is a single DBP of 120mmhg or more or

DBP 110mmhg or more on two occasions 4hrs or more apart.

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 Definition…

Significant proteinuria in px:-

o urinary protein excretion of 300mg or more per

24hrs or (quantitative)

o 1+ or more protein on dipstick of two clean-catch

midstream specimens of urine collected 4hrs or more

apart. (qualitative)
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 Definition…

Pathologic edema

-Dependent edema that persist after night rest or

-Any time of non- dependent edema that involve the

face, the hand or whole body or

-Abnormal wt gain of more than one kg per wk.

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 Classification of PIH
Pre-eclampsia - New onset of HTN and protenuria after 20
wks of gestation in a previously normotensive woman and
resolves within 6wks postpartum.

Chronic HTN

HTN that antedates Px or first detected before 20wks of

gestation and persists after 12wks postpartum.

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 Classification of PIH…
Gestational or transient hypertension:

❑ Recurrent mild HTN without protinuria that develop

after 20 wk gestation in previously normotensive woman

with out sign of sever pre-eclampsia.

❑ Resolve within 10 days of post partum.

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 Classification of PIH…
• Superimposed pre-eclampcia:

– Pre-eclampsia or eclampsia that occurs in a woman with

pre-existing chronic HTN .

– Is new onset of proteinuria with or with out pathologic

edema after 20wks

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 Types of Pre-eclampsia

Mild pre-eclampsia/ pre-eclampsia without

severity feature
• Two readings of diastolic blood pressure 90-110
mm Hg 4 hours apart after 20 weeks gestation
• Proteinuria up to 2+
• No other signs/symptoms of severe pre-eclampsia

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 Types of Pre-eclampsia…
Preeclampsia with severity feature
severe HTN (DBPis110mmhg or more
protein uria 500mg or more in 24hr or 3+ or more on
dipstick on two random specimens

Oligo- uria(<400ml/24hrs)
Right upper quadrant pain

Thrombocytopenia

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 Types of Pre-eclampsia…
-Cerebral symptom like persistent frontal or occipital
headache, blurring of vision

-IUGR
-Pulmonary edema -DIC

-HELLP syndrome(hemolysis, elevated liver enzyme &

low platelet count)
Lab changes:- increased Hct, platelet<100,000

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 Types of Pre-eclampsia…
Eclampsia: This is defined as the new onset of
convulsions during pregnancy or postpartum,
unrelated to other cerebral pathological conditions, in
a woman with pre-eclampsia.

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 Etiology of pre- eclampsia

• The exact cause is unknown

Risk factor for pre-enclampsia

• Null parity (age less than 20 and greater than 35 years)
• multiple pregnancy
• Molar pregnancy
• Family history of pre-eclampsia.
• Black race and low socioeconomic status.

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 Complications of preeclampsia
• Eclampsia
• Abruption placenta
• Acute renal failure
• Hepatic failure
• HELLP syndrome & DIC
• Cerebral hemorrhage & pulmonary edema
• Heart failure
• Intrauterine growth restriction
• IUFD

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 Management of Pre-eclampsia

• Termination of pregnancy is the definitive & curative

treatment for pre-eclampsia resulting in resolution of
the condition with in 48 hrs.
• It is the most important treatment for the mother.
• Factors that determine whether to follow aggressive
(delivery) or conservative management are
❖The gestational age
❖The severity of the disease
❖The fetal maturity & fetal condition

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 Management of pre-eclampsia will be:
Ambulatory management in patient with:-
1. In women with DBP b/n 90-109 mmHg or SBP 140-
160 mmHg.
2. Proteinuria 1+ or less dipstick or 24 hrs urine protein
less than 5gm.
3. No fetal jeopardy/threat
• Follow up
• Random urine protein twice/ week
• Bp measurement twice/ week
• Daily fetal movement counting
• Weekly ANC follow up
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 The patient should report immediately if:

– Sudden increase in wt
– Generalized edema including the upper limb & face
– Decrease in urine output
– Persistent headache
– Blurring of vision
– Right upper quadrant or epigastric pain
– Decreased fetal movement
– Vaginal bleeding
– Convulsion or loss of consciousness occur

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 Hospital management

Maternal- Close follows up of mother

✔Daily weight measure.
✔No salt restriction
✔BP every 6 hrs.
✔Urine protein every 48 hrs.
.
Fetal -Growth by ultrasound
✔Fetal well being (biophysical profile 2x (week)
✔Daily FHR auscultation
✔Daily fetal movement counting (kick chart)
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 1. Anticonvulsant Drugs
1. MgSo4 (magnesium sulfate)-the best drug of choice.
• Magnesium sulfate is indicated for:-
a) Sever preeclampsia
b) Preeclampsia intrapartum and postpartum (regardless of severity)
c) Eclampsia
• Dosage
• Loading dose
• 4 gm as 20% solution IV given over 5 minutes
(mix 8ml of 50% Magnesium sulfate solution with 12 ml of 5%DW or
0.9% NS to make 20 % solution )
• followed by 10 gm as 50% solution IM divided into 5gm (10ml) given
in each buttock
(add 2ml lidocaine 1% solution to syringe prior to administration)

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Maintenance dose
• Administer maintenance dose of magnesium sulfate
every 4hrs until 24hrs after delivery or last seizure.
• Dose: 5 gm MgSo4 as 50% solution IM given in
alternative buttocks. (Add 1ml/2ml lidocaine prior to administration)
• Reduce dose by ½ if signs of renal impairment (oliguria or
elevated creatinine)
If convulsions recur after 15 minutes, give 2 g magnesium
sulfate (20% solution) IV over 5 minutes.

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 Keep antidote ready
• In case of respiratory arrest:
• Assist ventilation (mask and bag, anaesthesia
apparatus, intubation).
• Give calcium gluconate 1 g (10 mL of 10%
solution) IV slowly until respiration begins to
antagonize the effects of magnesium sulfate.

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Monitoring for Mgso4 toxicity
• Check RR every 1 hr. ( should be > 12/min. )
• Check patellar deep tendon reflexes every 1 hr. (it should be
present)
• Measure urine output every 4 hrs. (should be >100ml/4hrs)
Management of MgSo4 toxicity
• If deep tendon reflexes are depressed, discontinue MgSo4 and
monitor patient closely.
• If RR < 12, give calcium gluconate 1gm as 10% solution (10
ml) IV over 2 minutes and monitor patient for bradycardia
(HR< 60/min. )
• If sever respiratory depression is present, transfer patient to
ICU for mechanical ventilation.
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2. Diazepam

• 10mg IV bolus over 2 minutes

• 40mg/500ml 5% D/w 30 drop/min
• Repeat 10mg IV bolus, if convulsion recurs.
3. Phenytoin
• Used for prevention of convulsion /recurrent
convulsion
• Loading dose 1gm IV over 20min &
maintenance 200mg every 6 hrs after 12hrs of
initial dose.

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2. Antihypertensive

• Indication - For sever hypertension & to keep DBP < 110

mmHg.
• Emergency treatment to control raised BP.
Drugs
a. Haydralzine (vasodilator) : Dose - 5mg Iv stat, repeat every
20min until diastolic Bp is < 110 mmHg. ( not more than
30mg)
b. Nifedipine (Ca++ channel blocker)
– Dose - 10mg sublingual, repeat same dose in 30 min until DBP is
110mm Hg.
c. Labetalol (B- Blocker)
– Dose - 5-15 mg IV push, every 10-20 min
– Double the dose (maximum, 300mg) & then 600 mg po six hrly if
conservative management is planned.
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 Delivery

• All patient with sever pre-eclampsia & GA 34 week

termination of pregnancy should be by:-
• Cesarean section - for obstetric indications
• Induction if :
– Term
– Favorable Cx,
– No contra indication for vaginal delivery
– Controlled maternal - fetal condition

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Intrapartum care
✔FHB monitoring every 15 min
✔Maternal vital sign every 30 min-1 hr
✔Urine output every 4 hrs
✔Shorten the second stage of labor
✔Prevent PPH (mange third stage actively using
oxytocin)

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Post partum care

• Continue anti-convulsant for 24 hrs post partum

• Closely monitor BP & If hypertension persists
beyond 6 weeks post partum the patient needs further
follow up.

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 Antepartum hemorrhage( APH)

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 OBJECTIVES:-
By the end of this lesson students will be able to:
❑ Define APH
❑ Describe possible causes of APH and there typical
characterstics
❑ List classifications of Placenta previa and Abruptio
placenta
❑ Manage APH

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 Definition
APH is bleeding from genital tract in late pregnancy, after the 28 week
of gestation till the end of second stage of labor.
Effect on the fetus
• Fetal mortality and morbidity are increased as a result of severe
vaginal bleeding in pregnancy.
• Still birth or perinatal or neonatal death may occur.
• Premature placental separation and consequent hypoxia may result in
the birth of a child who is mentally and physically handicapped.
Effect on the mother
• If bleeding is severe, it may be accompanied by shock, disseminated
intravascular coagulation and renal failure.
• The mother may die or be left with permanent ill-health.

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 Causes of APH
The causes could broadly be grouped in to two;
1. Obstetric causes
▪ Placental
–placenta praevia
most commonest cause
-Abruptio placentae
–Vasa previa
▪Ruptured uterus
.

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 Causes…
2. Non-obstetric (local or incidental causes)
–Cervicitis -traumatic lesions
–cervical cancer -cervical polyp
3. Undetermined causes: not identified even after
delivery and examining the placenta
N.B. Vaginal bleeding in late pregnancy is mainly due
to placenta praevia or placental abruption

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 Placental Abruption

• Placental abruption is premature separation of a normally

situated placenta occurring after the 28th week of
pregnancy.
• The etiology of this type of hemorrhage is not always clear,
but it is often associated with pregnancy induced
hypertension or with a sudden reduction in uterine size.
• Rarely, direct trauma to the abdomen may partially dislodge
the placenta.
• Placental abruption is an accidental occurrence of
hemorrhage in 2% of all pregnancies.
• Further bleeding continues to separate the placenta to a
greater
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or lesser degree. 45
Types of placental abruption based on condition of bleeding
• The blood loss from a placenta abruption may be
– Revealed,
– concealed or
– mixed hemorrhage.
An alternative classification, based on the severity of
abruption.
– Mild (10-20 %)
– Moderate and ( 20-50%)
– Sever hemorrhage.(> 50%)
• Bleeding type in PA is dark red.

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4/15/2021 47
 ABRUPTIO PLACENTA

CONCEALED
REVEALED

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 Abruptio Placenta

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49
Concealed hemorrhage is:
• Blood is retained behind the placenta.
• The mother will have all the s/s of hypovolemic shock.
• Causes uterine enlargement and extreme pain.
• The uterus has a hard consistency and there is a guarding on
palpation of the abdomen
• Fetal parts may not be palpable; the fetal heart is unlikely to
be heard with a fetal stethoscope.
• The uterus appears bruised & edematous

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Revealed hemorrhage
• Blood flow to the external and no blood is accumulated behind
the placenta.
Mixed hemorrhage
A combination of these two situations where some of the blood
drains via the vagina and some is retained behind the placenta.
Assessment of the mother’s condition
• There may be history of pregnancy induced HTN, ECV.
• If there is placental separation after the birth of a first twin or loss
of copious amounts of amniotic fluid during rupture of amniotic
membrane the probability of placenta abruption also high.

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 Management

• Any woman with a history suggestive of placenta abruption needs

urgent medical attention.
• She should be transferred urgently to a consultant obstetric unit after
securing intravenous infusion.
• Pain exacerbates shock and pain must be alleviated
Observation
• Vital sign should be recorded
• Urinary output is accurately assessed
• Fluid intake must also be recorded accurately
• If the fetus is alive, the fetal heart rate should be monitored
continuously
• Any deterioration in the maternal or fetal condition must be
immediately reported to the obstetrician.
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• If the mother is not in labor and the gestation is less than 37
weeks she may be cared for a few days and assessed for the
risks.
• Mothers who have passed the 37th week of pregnancy will
have an amniotomy to induce labor.
• Further bleeding or evidence of fetal distress may indicate
that a caesarean section is necessary.
• Moderate separation of the placenta up to 1000ml of blood
may be lost and in severe separation of the placenta about
2000ml of blood or more are lost from the circulation.

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 Complications
• DIC ( Disseminated intravascular coagulation)
• PPH due to DIC. Inj. Ergometrine 5mg IV at
delivery
• Renal failure as a result of Hypovolaemia
• Pituitary necrosis due to severe Hypotension.

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 Placenta praevia

• The placenta is partially or wholly implanted in the lower

uterine segment on either the anterior or posterior wall.
• The lower uterine segment grows and stretches
progressively often the 12th week of pregnancy.
• In late weeks this may cause the placenta to separate and
sever bleeding can occur.
• Incidence: placenta praevia occurs in 0.5% of all
pregnancies.

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 Classifications of PP
Type 1 placenta praevia (low-lying placenta)
• The majority of the placenta is in the upper uterine segment
• Vaginal delivery is possible
• Blood loss is usually mild
• The mother and the fetus remains in good condition
Type 2 placenta praevia (placenta previa marginalis)
• The placenta is partially located in the lower uterine segment near the
internal cervical os (marginal placenta praevia).
• Vaginal delivery is possible particularly if the placenta is implanted
anteriorly
• Blood loss is usually moderate
• Fetal hypoxia is likely to be present
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Type 3 placenta praevia (placenta previa partialis)
• The placenta covers the internal os but only partially.
• Bleeding is likely to be sever particularly when the lower segment
stretches and the cervix begins to efface and dilate in late pregnancy
• Vaginal delivery is inappropriate.
Type 4 placenta praevia(placenta previa totalis)
• The placenta is located centrally over the internal cervical os and
sever haemorrhage is very likely
• Vaginal delivery should not be considered
• Caesarean section is essential in order to save the life of the mother
and fetus.

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 Type 1 Type 2 Type 3 Type 4

Types of placenta praevia and relation of implantation with

cervical os.
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Predisposing factors
The exact cause is unknown, but there are a number of
predisposing factors.
• Any uterine scar secondary to previous vigorous curettage,
C/S, myomectomy
• Multiparty
• Bulky placental tissue as in multiple pregnancy and
erythroblastosis fetalis
• Others include high altitude, smoking, previous Hx of APH.

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Sign and symptom of placenta praevia
• Painless , bright red and recurrent bleeding per vagina
• Mostly occurs at night
• The fetal head remains unengaged
• There is malpresentation
• The lie is oblique or transverse
• The lie is unstable, usually in a multigravida.

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Diagnosis
• Using ultrasonic scanning will confirm the existence of
placenta praevia and establish its degree.
• The color of the blood is bright red, denoting fresh
bleeding.
• Can be diagnosed by pv exam if double setup available
(double setup eaxamination) ,if no pv is contraindicated.

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Assessment
• If the hemorrhage is slight, the mother’s blood pressure,
respiratory rate and pulse rate may be normal
• In severe hemorrhage;
– The blood pressure will be low and the pulse rate raised
– Respiration is also rapid
– The mother’s skin color will be pale and her skin will be
cold and moist
– Vaginal examination should not be attempted

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Assessing the fetal condition:
• The mother should be asked whether fetal activity has been
normal.
• Excessive or cessation of fetal movement is another
indication of sever fetal hypoxia.

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Management of placenta praevia
The managements of placenta praevia depend on:
• the amount of bleeding
• the conditions of mother and fetus
• the stage of the previa
Conservative management: it is appropriate if bleeding is slight and
mother and fetus are well.
• The woman will be kept in hospital at rest until bleeding has stopped.
• A speculum examination will have ruled out incidental causes.
• Ultrasound scans are repeated at intervals in order to observe the
position of the placenta in relation to the cervical os.

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• If bleeding should occur or when the fetus is mature, an
examination per vagina will be carried out under general
anesthetic at operation room.
• If the placenta is felt, caesarean section will be performed
without delay.
Active management
• Sever vaginal bleeding will necessitate immediate delivery
by caesarean section.
• This should take place in a unit with facilities for special
area of the new born especially if the baby will be preterm.

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Complications
• PPH
Mgt.
⮚ Oxytocin drugs should be given as the baby is delivered.
⮚ Occasionally uncontrolled hemorrhage may continue and a
caesarean hysterectomy may be required.
• Maternal shock
• Maternal death
• Fetal hypoxia due to placental separation, and
• Fetal death

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 RH, ABO blood group incompatibility

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Definitions:
• Rh incompatibility: is the presence of different Rh types, in a
woman and her fetus. In obstetrics, the significant incompatibility
is when the woman is Rh negative and the fetus is Rh positive.
• Rh Isoimmunization (Rh sensitization): is production of
antibody against the Rh factor by an Rh negative woman
following exposure to Rh-positive cells.
• Erythroblastosis fetalis: is the condition in which large numbers
of nucleated red cells are seen in the fetal circulation, occurring in
response to excessive destruction of fetal red blood cells.
• Hemolytic disease of the newborn: is occurrence of progressive
anemia and Hyperbilirubinaemia in a newborn caused by
hemolysis of red blood cells, in most cases antibody mediated.

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 RH ISOIMMUNIZATION
• Next to the ABO system, the Rh system is the second most
important blood group system.
• The Rh antigens are found on red blood cell membrane protein.
• The D antigen, also called the Rh factor is the most powerful
and important of the Rh antigens.
• An individual who possess it is labeled as Rh positive and who
lack it as Rh negative.
• The incidence of Rh negative people varies from population to
population (15% in Caucasians and 4% in African blacks).
• Exposure of these Rh-negative people to even small amounts
of Rh-positive cells, by either transfusion or pregnancy, can
result in the production of anti-D alloantibody, a condition
called Rh sensitization or Isoimmunization.

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Pathogenesis
• For Rh isoimmunization to occur, the following prerequisites must
be fulfilled:
a. Rh negative mother carrying Rh positive fetus, having inherited
the gene for the Rhesus factor from his father.
b. Entry of the fetal Rh positive red blood cells into maternal
circulation
• This occur more commonly following feto-maternal hemorrhage
(through leaks in the placenta).
• Conditions that aggravate feto-matemal hemorrhage are
spontaneous or induced abortion, ectopic gestation, APH especially
abruptio placenta, amniocentesis, abdominal trauma, and ECV.
• Conditions that worsen fetomaternal bleeding during labor are
manual removal of placenta, twin delivery and cesarean section.
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C. Development of Rh antibodies by the mother

• The maternal immune system responds by producing antibodies

which are initially of IgM type (big immunoglobulin that cannot
pass the placental barrier).
• Feto-maternal bleeding in the subsequent pregnancies results in
IgG type of antibody (small antibody that can pass the placental
barrier).
⮚ Factors that affect this maternal response are:-
✔ inborn responsiveness of the mother (30% are non responders),
✔ volume and rate of hemorrhage (as little as 0.1 ml is enough),
✔ presence of ABO incompatibility (reduces risk by 50 -75%).

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⮚ Effects on the fetus and the newborn
• Hemolytic anemia develops, the extent of which depends on the
amount of antibody.
• To compensate for the ensuing anemia the fetal bone marrow and
later the extra-medullary sites that produce RBC (liver, spleen and
placenta) are called to produce red blood cells at fast rate.
• This results in the appearance of young nucleated cells in the b/d
stream.
• In severe cases even extra-medullary hematopoiesis cannot cope
with the degree of destruction.
• This results in progressive anemia which eventually leads to
congestive heart failure and tissue hypoxia.
• Serum albumin falls, and generalized edema of the fetus called
hydrops fetalis. Eventually fetal death occurs.

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Management
a. Identification of pregnancies at risk at the initial ANC visit
• Determine blood group & Rh factor and indirect Coomb's test for
antibody screening for all pregnant mothers.
The possible outcomes are:
• Rh +ve with negative antibody screen - no further testing needed
• Rh -ve with +ve antibody screen-manage as sensitized pregnancy
• Rh -ve with -ve antibody screen-manage as unsensitized pregnancy
b. Management of unsensitized pregnancy
• Determine the blood group and Rh factor of the partner.
• Repeat indirect Coomb's test at 28 weeks and at 36 weeks.
• If negative consider antepartum prophylaxis with 300
micrograms of anti D gamma globulin at 28 weeks.
• If positive manage as sensitized pregnancy.
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• Anti D immunoglobulin will coat the fetal red cells that contain
Ag & destroy them before the woman’s immune system has time
to recognize the foreign protein & react to it.
• Provide anti D prophylaxis in cases with amniocentesis, APH,
external cephalic version.
• Following delivery, determine blood group of the newborn and
antibody screening.
• If the newborn is Rh negative no further treatment is needed.
• If antibody screen is positive monitor the newborn for hemolysis
and manage next pregnancy as sensitized.
• If newborn is Rh positive and antibody screen is negative provide
anti D gamma globulin within 72 hours.
• The usual dose is 300 micrograms but for abortion of less than 12
weeks gestation the dose is 50 micrograms.
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Management of sensitized mother
• These women need specialized care with measurement of
antibody levels in titers at regular intervals, amniocentesis for
bilirubin levels, serial ultrasound for detection of hydrops and
management of neonatal anemia and hyperbilirubinaemia.
• Therefore, early referral of these women is the correct
approach at health center level.

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ABO incompatibility
• It occurs when the mother has group O blood (with anti-A and
anti-B antibodies in her serum) and fetus is group A, B or AB.
• Unlike Rh isoimmunization, 40-50% of ABO incompatibilities
occur in the first-born infant.
• ABO hemolytic disease primarily manifest following birth,
when the infant becomes jaundiced within the first 24 hours
with a variable amount of anemia and hyperbilirubinaemia
which is usually mild. Serious complications almost never
occur.
• The management consists of measurement of bilirubin serially
and provision of phototherapy to the newborn.

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 Pre mature rupture of membrane

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PROM
• Membrane rupture physiologically occurs in the
2nd stage of labor as the descending fetal
presentation puts considerable pressure on them
• PROM:- is rupture of membranes (ROM) before the onset
of labor (regular uterine contractions)
Latency period: - is the interval between the rupture of
membranes & the onset of labor
Prolonged PROM is rupture of membranes for> 12 hrs

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Term PROM is rupture of membranes after 37 completed
weeks of gestation
Pre term PROM: - is rupture of membranes before 37
completed weeks of gestation
Causes of PROM
• Subclinical chorioamnionitis due to ascending
infections from the cervix ( STIs)
• Past history of PROM
• Collagen synthesis defects – genetic defects leading
to weak collagen variants
• Cervical incompetence
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• Polyhydramnios
• CPD
• Malpresentations
• Multiple pregnancy – higher risk than singl
• Amniocentesis
• External cephalic version

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 Diagnosis of PROM
• Most cases can be diagnosed on the basis of
the history & physical examination.
• Digital examination should be avoided as it
increases the risk of ascending infection
History:
✔ A large gush of fluid from the vagina
followed by persistent uncontrolled leakage .
✔Some patients have only small, intermittent
leakage
✔ May soak clothing or bedding
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✔Fluid may be seen on clothing or on sanitary
pads
✔ Fluid can usually be seen at the introits
Physical examination:
❑General examination- to rule the presences of
maternal and fetal infection

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❑ Speculum examination - using high level
disinfected or sterile instruments may help to
confirm the diagnosis, & may reveal:
✔Glistening, washed out vagina
✔ Fluid pooling in posterior fornix
✔Free flow of fluid from cervix! presence of
meconium/vernix
✔Ask the women to cough' this may cause a
gush of fluid
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 NB During speculum examination note the
following:
• Rule out the presence of a cord prolapse
• Asses the state of the cervix (effacement and dilatation
Laboratory Testes:
1. Ferns test: Obtain fluid by swabbing the posterior
fornix, avoiding cervical mucus.
• Spread some fluid on a slide & let it dry. Examine it with a
microscope
• Amniotic fluid crystallizes & may leave a fern-leaf pattern
(Arborization), which suggests membrane rupture

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• The test accurately confirms PROM in 85-98%
of cases
• False positive test can result from the
collection of cervical mucus
• The test is not affected by, meconium,
changes in vaginal PH & blood:

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 Ferns test

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 2. Nitrazine paper test
• Depends upon the fact that vaginal secretions
& urine are acid while amniotic fluid is
alkaline
• Hold a piece of nitrazine paper in a hemostat
& touch it against the fluid pooled on the
speculum blade.
• A change from yellow to blue indicates
alkalinity

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• The test is accurate in 90-98% of cases
• False positive results of nitrazine testing, may
occur in the presence of
• Blood or semen contamination
• Alkaline antiseptics, or
• Bacterial vaginosis
• False negative results occur with prolonged
leakage & minimal residual fluid

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 Additional test to confirm diagnosis

Pad test -can be helpful when there is no pooling & no

leakage from cervix .
• Place a vaginal pad over the vulva & examine it an
hour later visually & by odor
• Wetting with no urine and no vaginal discharge
(vaginitis) may suggest PROM

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 Management of PROM

General Management
▪ Confirm the diagnosis, & once the diagnosis is confirmed
admit the woman to a hospital.
▪ Assess -maternal & fetal well being & check for signs of labor
▪ History, physical examination and different testes should be
done

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 Check for signs of intra-amniotic infection
(chorioamnionitis) including
• Maternal fever
• Fetal tachycardia ((FHB > 180 beats per minutes)
• Tender uterus
• Purulent cervical discharge
• Leukocytosis

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❑If there are signs of uterine infection
1. Start treatment with broad-spectrum, high
dose, IV antibiotics
Ampicillin 2gm IV QID
Gentamycin 80mg IV TID
Metronidazole 500mg IV TID

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 Alternatives for Metronidazole could be
• Clindamycin 900mg IV Q 8hrs (best, if available)
• Chlorapmhenicol 1gm IV Q 6hrs
❖Single agent treatment with Ceftriazone 1gm IV
Bid/10 days
2. Induce labor & speed up delivery, without any delay
despite the GA;

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PROM without evidence for infection, depends
upon the gestational age
1. Management of Term PROM (>37wks GA)
• At term, PROM complicates approximately
8% of pregnancies & is generally followed by
onset of labor & delivery.

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Expedite delivery with out delay; in presence of suspected or
evident intrauterine infection, abruption placenta, or evidence
of fetal compromise.
Route of delivery depends on other obstetric conditions
⮚ If the cervix is favorable (on speculum examination)
• Consider induction, especially if duration of ROM is > 8hrs
(Without onset of labor}
• Initiate prophylactic anti-biotic when the duration of ROM>
12hrs
⮚ If the cervix is unfavorable (in absence of other needs for
immediate delivery)
• Start on expectant management & consider prostaglandin for
cervical ripening (if possible)

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2. Management of near term PROM (34-37 wks
GA)
• In this gestational age range, induction or expectant
management are acceptable management options
depending on local resoures
• Consider antenatal steroids & prostaglandin for
cervical ripening, if possible, before induction ( while
on expectant management)

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Management of Pre term PROM( under 34 wks)
• At this gestational age , expectant management is
preferred (in absence of chorioamnionitis), because
of the significant risks associated with pre- maturity;
Expectant management:-
✔ Avoid digital cervical (pelvic ) examination
✔ Advise bed-rest
✔ Complete pelvic rest
✔ Prophylactic antibiotics
- Ampicillin 2gm. IV QID for 48 hr. followed by
Amoxicillin 500mg PO TID for five days and
- erythromicine 500mg IV for 48 hr. and PO for five days
✔ Use of steroid - dexamethasone 6mg IM BID for 48 hr. or
betamethasone 12mg IM one per day for 48hr.
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Indications for delivery (i.e. termination of
expectant Management) include:
1. Onset of labor
2. Gestation age ≥ 37wks
3. Evidence for fetal distress
4. Evidence for intra uterine infection

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 Assignment
• Medical disorder during pregnancy
- Anemia
- DM
- Cardiac disease
- Malaria

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 THANK YOU!

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