High risk pregnancy المخاطر التي تراجهها الام اثناء الحمل

 ❖ Outlines:  

 Indications  

 Definition  

 Risk factors that put mother in high risk  

 High risk factor 

 

 

 

 

 

❖ Introduction: 

▪ A high-risk pregnancy is one of greater risk to the mother or her fetus than an uncomplicated pregnancy. Pregnancy places additional physical and emotional stress on a woman’s body. Health problems that occur before a woman becomes pregnant or during pregnancy may also increase the likelihood for a high-risk pregnancy. 

▪ Definition: A high-risk pregnancy is one that threatens the health or life of the mother or her fetus. It often requires specialized care from specially trained providers. 

❖ Risk factors: o Several factors can make pregnancy high risk including: 

▪ physical factors; 

✓ Age: Under 17 or above 35 that high risk of genetic defects. 

✓ weight: Overweight or obesity (body mass index more than 30 ) high risk of birth defects and heart diseases. 

✓ height: Women shorter than 5 feet are more likely to have small pelvis ( difficult movement of fetus) and high risk of preterm labor. 

✓ Reproductive abnormalities: Structural abnormalities in the uterus or cervix. 

▪ social (lifestyle): 

✓ Smoking  

✓ drinking alcohol 

 

imbalanced of nitrition 

 

▪ medical factors before a woman becomes pregnant: 

✓ High blood pressure: can damage of blood vessels in kidney and cause preeclampsia. 

✓ Diabetes: can cause birth defect. 

✓ Kidney diseases: can cause preterm delivery and preeclampsia. 

✓ Autoimmune disease: such as lupus and multiple sclerosis can cause preterm birth and still birth. 

✓ thyroid disease: cause problems of metabolism. 

✓ Sexually transmitted disease such as (HIV). 

✓ Anemia. 

✓ Heart diseases. 

✓ Liver diseases. 

▪ Disorders during pregnancy:  

✓ Hepatitis B 

✓ Hepatitis Care transmitted blood to blood  

✓ Placenata previa: implantation of placenta in lower segment. 

✓ placenta abruption: can cause bleeding from the vagina. 

✓ Problems with amniotic fluid: polyhydraminous and overdistention. 

✓ cervical insufficiency: weak cervix. 

▪ Obstetrical history factor: 

✓ multiple pregnancy 

Caesarean section and any surgery of abdominal. ❖ Bleeding in early pregnancy: 

 Abortion:- 

▪ Definition : expulsion of the fetus and uterine contents before the 20th week of gestation. Mostly occur during the first trimester before the placenta is matured. 

▪ classification : 

1) Spontaneous abortion 

2) Induced abortion  

3) complete abortion  

4) Inevitable abortion 

5) Missed abortion  

6) Incomplete abortion  

7) Septic abortion 

1. Spontaneous Abortion: It is defined as the involuntary loss of the products of conception prior to 20 weeks of gestation. It can devided into 4 stages : 

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

o Threatened abortion: any vaginal bleeding in the first half ( 20 weeks ) of pregnancy (usually first trimester). 

Usually associated with mild abdominal cramping. It differs from inevitable abortion that cervix is closed and bleeding is minimal. 

✓ Can progress to an complete abortion or may subside. 

▪ Missed abortion :retention of product of conception in uterus after abortion for 2 months or more. 

✓ The fetus dies during the first 20 weeks of gestation but remains in utero. 

▪ Incomplete abortion: abortion where parts of product of conception remains inside uterus. 

2. Complete abortion : All products of conception are expelled and the embryo is dead. The cervix is dilated, and there is mild bleeding. 

3. Septic abortion:Any abortion associated with clinical evidences of infection of the uterus and its contents. 

4. Induced abortion:  

▪ Induced abortion Indication: 

-Continuation of pregnancy may threaten the life of women or seriously   impair her health  

- Persistent heart disease after cardiac decompensation 

- Advanced hypertensive vascular disease 

- Invasive carcinoma of the cervix,  

- Continuation of pregnancy is likely to result in the birth of child with severe physical deformities or mental retardation.it devided into legal and illegal 

 

▪Causes: 

✓ Abnormal genes or chromosomes: Most miscarriages occur because the fetus isn't developing normally. About 50 percent of miscarriages are associated with extra or missing chromosomes.  

• Chromosomal abnormalities might lead to: 

Blighted ovum: Blighted ovum occurs when no embryo forms. 

✓ Intrauterine fetal demise. In this situation, an embryo forms but stops developing and dies before any symptoms of pregnancy loss occur. 

✓ Maternal health conditions: 

• In a few cases, a mother's health condition might lead to miscarriage. 

Examples include: 

- Uncontrolled diabetes 

- Infections 

- Hormonal problems 

- Uterus or cervix problems 

- Thyroid disease ▪ Risk factors: 

✓ Age: Women older than age 35 have a higher risk of miscarriage than do younger women. Previous miscarriage:Women who have had two or more consecutive miscarriages are at higher risk of miscarriage. 

✓ Chronic conditions:Women who have a chronic condition, such as uncontrolled diabetes, have a higher risk of miscarriage. 

✓ Uterine or cervical problems:Certain uterine abnormalities or weak cervical tissues (incompetent cervix) might increase the risk of miscarriage. 

✓ Smoking:alcohol and illicit drugs. Women who smoke during pregnancy have a greater risk of miscarriage than do nonsmokers.  

✓ Weight:Being underweight or being overweight has been linked with an increased risk of miscarriage. 

✓ Invasive prenatal tests: Some invasive prenatal genetic tests, such as chorionic villus sampling and amniocentesis, carry a slight risk of miscarriage. 

• Symptoms of a miscarriage include: 

- Bleeding that progresses from light to heavy. 

- Cramps. 

- Abdominal pain. 

- Low back ache that may range from mild to severe. 

▪ Complications: 

- Excessive Bleeding 

- Recurrent Miscarriages 

- Infection After Miscarriage 

- Asherman Syndrome:Asherman syndrome is a rare complication of a dilation and curettage (D&C) procedure. This syndrome can develop for nfection. 

With this condition, scar tissue called adhesions form in the uterus. These adhesions can cause fertility problems and further miscarriage 

▪ Diagnostic Tests 

- Pregnancy test: Ultrasound.  

▪ Medical management: 

o Administration of intravenous fluids. Such as Lactated Ringer’s, IV therapy should be anticipated by the nurse as well as administration of oxygen regulated at 6-10L/minute by a face mask to replace intravascular fluid loss and provide adequate fetal oxygenation. 

o Avoid vaginal examinations. The physician would also avoid further vaginal examinations to avoid disturbing the products of conception or triggering cervical dilatation. 

o The physician might also order an ultrasound examination to glean more information about the fetal and also maternal well-being 

▪ Nursing Management  1) Nursing Assessment:  

o The presenting symptom of an abortion is always vaginal spotting, and once this is noticed by the pregnant woman, she should immediately notify  healthcare provider 

o Ask of the pregnant woman’s actions before the spotting or bleeding occurred and identifies the measures she did when she first noticed the bleeding. 

o Inquire of the duration and intensity of the bleeding or pain felt. 

o Lastly, identify the client’s blood type for cases of Rh incompatibility. 2) Nursing Interventions: 

• If bleeding is profuse, place the woman flat in bed on her side and monitor uterine contractions and fetal heart rate through an external monitor. 

• Also measure intake and output to establish renal function and assess the woman’s vital signs to establish maternal response to blood loss. 

• Measure the maternal blood loss by saving and weighing the used pads. 

• Save any tissue found in the pads because this might be a part of the products of conception. 

3) Evaluation: 

✓ The aim for evaluation is inclined towards restoring the maternal blood volume and stopping the source of the bleeding. 

4) Prevention: 

✓ Often, there's nothing you can do to prevent a miscarriage. Simply focus on taking good care of mother and her fetus: Seek regular prenatal care. 

✓ Avoid known miscarriage risk factors — such as smoking, drinking alcohol and illicit drug use. 

✓ Take a daily multivitamin. 

✓ Limit your caffeine intake. 

 What Is Ectopic Pregnancy? 

o Ectopic pregnancy, also called extrauterine pregnancy, is when a fertilized egg grows outside a woman’s uterus, somewhere else in their belly.the egg implants in a fallopian tube . this is called atubal pregnancy 

▪ Early signs of ectopic pregnancy: 

- Light vaginal bleeding and pelvic pain 

- Upset stomach and vomiting 

- Sharp abdominal cramps 

- Pain on one side of your body 

- Dizziness or weakness 

- Pain in your shoulder, neck, or rectum 

- An ectopic pregnancy can cause your fallopian tube to burst or rupture.  

- Emergency symptoms include major pain, with or without severe bleeding. Call your doctor right away if you have heavy vaginal bleeding with lightheadedness, fainting, or shoulder pain, or if you have severe belly pain, especially on one side. 

▪ Causes of ectopic pregnancy:  

✓ inflammation and scarring of the fallopian tubes from a previous medical condition, infection, or surgery 

✓ hormonal factors 

✓ genetic abnormalities 

✓ birth defects 

✓ medical conditions that affect the shape and condition of the fallopian tubes and reproductive organs 

▪Who is at risk for an ectopic pregnancy:  

o All sexually active women are at some risk for an ectopic pregnancy. 

o Risk factors increase with any of the following: 

- maternal age of 35 years or older. 

- history of pelvic surgery, abdominal surgery, or multiple abortions and history of pelvic inflammatory disease (PID). 

- history of endometriosis. 

- conception occurred despite tubal ligation or intrauterine device (IUD). 

- conception aided by fertility drugs or procedures. 

- Smoking 

- history of ectopic pregnancy 

- history of sexually transmitted diseases (STDs), such as gonorrhea or chlamydia 

- having structural abnormalities in the fallopian tubes that make it hard for the egg to travel ▪ Types of Ectopic Pregnancy: o An ectopic pregnancy is classified according to where exactly the fertilized egg implants. 

• Tubal pregnancy: A tubal pregnancy occurs when the egg has implanted in the fallopian tube. This is the most common type of ectopic pregnancy. 

• A pregnancy grows in the fimbrial end in around five percent of all cases. 

• A pregnancy grows in the ampullary section in around 80% of all cases. 

• A pregnancy in the isthmus of the fallopian tube is seen in around 12% of all cases.  

• A pregnancy in the cornual and interstitial part of the fallopian tube is seen in around two percent of cases . 

▪ Expectant management:  

o Mother will have regular blood tests to check that the level of hCG in blood is going down – these will be needed until the hormone is no longer found. 

o Mother may need further treatment if her hormone level doesn't go down or it increases. 

o If mother have some vaginal bleeding – use sanitary pads or towels, rather than tampons, until this stops. 

o may experience some tummy pain – take paracetamol to relieve this. 

• Medication o If an ectopic pregnancy is diagnosed early but active monitoring isn't suitable, treatment with a medicine called methotrexate may be recommended.. 

✓ regular blood tests will be carried out to check if the treatment is working. 

✓ A second dose is sometimes needed and surgery may be necessary if it doesn't work. 

✓ You need to use reliable contraception for at least 3 months after treatment. 

✓ There's also a chance of your fallopian tube rupturing after treatment.  

• Surgery 

✓ In most cases, keyhole surgery (laparoscopy) will be carried out to remove the pregnancy . 

✓ If your fallopian tube has already ruptured, you'll need emergency surgery. 

✓ After either type of surgery, a treatment called anti-D rhesus prophylaxis will be given if your blood type is RhD negative.  

 Vascular mole : 

▪ Definition : Hydatidiform mole (HM) is a rare mass or growth that forms inside the womb (uterus) at the beginning of a pregnancy. It is a type of gestational trophoblastic disease (GTD) ▪ Symptoms :  

✓ Women who have a hydatidiform mole feel as if they are pregnant. But because hydatidiform moles grow much faster than a fetus,the abdomen becomes larger much faster than it does in a normal pregnancy. 

✓ Severe nausea and vomiting and vaginal bleeding are common.  

▪Causes : 

o molar pregnancy can happen to women of all ethnicities, ages, and backgrounds. 

o It sometimes happens because of a mix-up at the genetic — DNA — level. Most women carry hundreds of thousands of eggs. Some of these might not form correctly. They’re usually absorbed by the body and put out of commission. 

o But once in a while an imperfect (empty) egg happens to get fertilized by a sperm. It ends up with genes from the father, but none from the mother. This can lead to a molar pregnancy. 

o In the same way, an imperfect sperm — or more than one sperm — may fertilize a good egg. This can also cause a mole. 

▪ Types: 

1. Complete mole: The whole conceptus is transformed into a mass of vesicles. No embryo is present. It is the result of fertilisation of anucleated ovum (has no chromosomes) with a sperm which will duplicate giving rise to 46 chromosomes of paternal origin only. 

2. Partial mole: A part of trophoblastic tissue only shows molar changes. There is a foetus or at least an amniotic sac. It is the result of fertilisation of an ovum by 2 sperms so the chromosomal number is 69 chromosomes ▪ Risk factor : 

o Some factors increase a woman’s chance of having. Vascular mole Very young and very old women have a higher risk. 

✓ Women who have had one molar pregnancy already 

✓ have a 6-fold increased risk of having a recurrence, and those who have had more than two previous  

✓ molar pregnancies have a 120-fold increased risk. 

▪ Complication :  

- Infection of the uterus. 

- A widespread infection of the blood (sepsis). 

- Dangerously low blood pressure (shock). 

- Very high blood pressure with increased protein in the urine (preeclampsia) 

▪ Management  

✓ Insert an IV line (16-18G catheter) and administer Ringer lactate. 

✓ Closely monitor: heart rate, blood pressure and bleeding. 

✓ Prepare for a possible transfusion, determine the patient’s blood type, select potential donors or ensure that blood is available. If transfusion is necessary, only use blood that has been screened (HIV-1, HIV-2, hepatitis B, hepatitis C, syphilis, and malaria in endemic areas). 

✓ Evacuate the mole using aspiration, or if not available, digital curettage or careful instrumental curettage   

✓ Provide effective contraception for at least one year, or perform tubal ligation if desired 

▪Treatment:  

o To prevent complications, the abnormal placental tissue must be removed. 

o Treatment usually : 

✓ Dilation and curettage (D&C): To treat a molar pregnancy( remove the molar tissue). 

✓ Hysterectomy: Rarely, if there is increased risk of gestational trophoblastic neoplasia (GTN) and there's no desire for future pregnancies, 

❖ Bleeding In Late Pregnancy : 

 Placenta previa :Placenta previa is an obstetric complication that presents as painless vaginal bleeding in the third trimester secondary to an abnormal placentation near or covering the internal cervical os. 

▪ What causes placenta previa : 

1. Past pregnancy. 

2. Tumors (fibroids) in the uterus. ... 

3. Past uterine surgeries  

4. cesarean deliveries. 

5. Woman who is older than 35. 

6. Cigarette smoking.  

▪ Placenta Previa Symptoms : 

1. Bright red bleeding from the vagina 

2. Contractions along with the bleeding. (cramping) 

3. pressure in your back. 

▪ Types(grade): 

o (grade II) marginal previa : placental tissue reaches the margin of the Internal cervical os, but does not cover it. – (grade III) partial previa: 

Placenta partially covers the internal cervical os o (grade IV) complete previa: placenta completely ▪ Diagnosis:  

o Through ultrasound during a second trimester ▪ Treatment : 

✓ bed rest and limitation of activity. 

✓ Tocolytic medications. 

✓ intravenous fluids, and blood transfusions may be required depending Upon the severity of the condition. 

✓ A Cesarean delivery is required for complete placenta previa. 

 placenta Abruption: 

▪ Definition :Placental abruption occurs when the placenta separates from the wall of the uterus prior to the birth of the baby. This can result in severe, uncontrollable bleeding.  

  

▪ Causes : 

- smoking  

- trauma 

- cocaine use  

- Hypertension 

- pre eclampsia  -  rupture of membranes ▪ sings and symptoms : o Placental abruption is most common in third trimester.  

1. vaginal bleeding  

2. pain in abdomen and back 

3. uterine tenderness  4. uterine contraction ▪ management : 

o surgical management: 

✓ Surgical management put on action when condition is danger.  

o Nursing Management : 

- Vital signs  

- Bleeding 

- Signs of shock-rapid pulse, pallor, cold and most skin 

- Decreasing urine output 

- Never perform a vaginal or rectal examination or take any action that would stimulate uterine activity. 

- Monitor the FHR externally and measure 6-maternal vital signs every 5 to 15 minutes Administer oxygen to the mother by mask. 

- Prepare for cesarean section, which is the method of choice for the birth. 

- Provide client and family teaching ▪ Nursing Interventions : 

✓ Assess and monitor vaginal bleeding. 

✓ Obtain history from patient. 

 Cervical polyp: 

▪ Definition:A cervical polyp is a growth that develops on the cervix, which is the canal connecting the uterus to the vagina. Sperm must pass through this canal to fertilize an egg. Cervical polyps are tumors, but they are usually non-cancerous, or benign. 

▪ Causes: 

✓ The cause of cervical polyps is not entirely understood. 

✓ They may result from infection. They can also result from long-term (chronic) inflammation, an abnormal response to an increase in estrogen levels, or congestion of blood vessels in the cervical canal. 

▪ Symptoms: o The common symptoms of cervical polyps are: 

✓ Unusual vaginal bleeding such as bleeding after sexual intercourse. 

✓ Bleeding between your menstrual periods. 

✓ Bleeding after you have had your menopause. 

✓ White or yellow mucous or discharge from the vagina. 

▪ Types: 

o The two types of cervical polyps are ectocervical and endocervical. Ectocervical polyps arise from the outer surface layer of cells on the cervix. Endocervical polyps arise from the cervical glands, and they’re the most common type of cervical polyp. 

▪ Complications: 

o Cervical polyps are benign growths protruding from the inner surface of the cervix. 

o Complications of a polypectomy are rare, but include: 

✓ Infection. 

✓ Haemorrhage. 

✓ Uterine perforation (very rare) – to reduce this risk only polyps that are visible easily should be removed in the outpatient setting. 

▪ Treatment: It is recommended that cervical polyps are removed. If the polyp is small, then it can often be removed by the  doctor. To remove, the polyp is gently twisted using an instrument called polyp forceps, until the polyp tissue comes away from the cervix and is removed ❖ Preclamsia: 

▪ Definition: Preeclampsia, formerly called toxemia, is when pregnant women have high blood pressure, protein in their urine, and swelling in their legs, feet, and hands. It can range from mild to severe. It usually happens late in pregnancy, though it can come earlier or just after delivery. 

▪ Preeclampsia Causes: o Many experts think preeclampsia and eclampsia happen when a woman’s placenta doesn’t work the way it should, but they don’t know exactly why. Some think poor nutrition or high body fat might contribute. A lack of blood flow to the uterus could play a role. Genes are also a factor. 

o Other High Blood Pressure Disorders in Pregnancy 

o Preeclampsia is one of four blood pressure disorders in pregnant women. The other three are: 

1. Gestational hypertension.  

2. Chronic hypertension which is:high blood pressure that starts before a woman gets pregnant or before the 20th week of pregnancy. 

3. Chronic hypertension with superimposed preeclampsia. This is chronic high blood pressure that gets worse as pregnancy goes on, causing more protein in urine and other complications. 

▪ Symptoms: 

o Preeclampsia sometimes develops without any symptoms. High blood pressure may develop slowly, or it may have a sudden onset. Monitoring your blood pressure is an important part of prenatal care because the first sign of preeclampsia is commonly a rise in blood pressure. Blood pressure that exceeds 140/90 millimeters of mercury (mm Hg) or greater 

— documented on two occasions, at least four hours apart — is abnormal. 

o Other signs and symptoms of preeclampsia may include: 

• Excess protein in your urine (proteinuria) or additional signs of kidney problems. 

• Severe headaches. 

• Changes in vision, including temporary loss of vision, blurred vision or light sensitivity 

• Upper abdominal pain, usually under your ribs on the right side 

• Nausea or vomiting 

• Decreased urine output 

• Decreased levels of platelets in your blood (thrombocytopenia) 

• Impaired liver function 

• Shortness of breath, caused by fluid in your lungs 

• Sudden weight gain and swelling (edema) — particularly in your face and hands — may occur with preeclampsia. But these also occur in many normal pregnancies, so they're not considered reliable signs of preeclampsia. 

▪ Risk factors: o Preeclampsia develops only as a complication of pregnancy. Risk factors include: 

1. History of preeclampsia: A personal or family history of preeclampsia significantly raises your risk of preeclampsia. 

2. Chronic hypertension: If you already have chronic hypertension, you have a higher risk of developing preeclampsia. 

3. First pregnancy: The risk of developing preeclampsia is highest during your first pregnancy. 

4. New paternity: Each pregnancy with a new partner increases the risk of preeclampsia more than does a second or third pregnancy with the same partner. 

5. Age: The risk of preeclampsia is higher for very young pregnant women as well as pregnant women older than 35. 

6. Race: Black women have a higher risk of developing preeclampsia than women of other races. 

7. Obesity: The risk of preeclampsia is higher if you're obese. 

8. Multiple pregnancy: Preeclampsia is more common in women who are carrying twins, triplets or other multiples. 

9. Interval between pregnancies: Having babies less than two years or more than 10 years apart leads to a higher risk of preeclampsia. 

10. History of certain condition:Having certain conditions before you become pregnant — such as chronic high blood pressure, migraines, type 1 or type 2 diabetes, kidney disease, a tendency to develop blood clots, or lupus — increases your risk of preeclampsia. 

11. In vitro fertilization:Your risk of preeclampsia is increased if your baby was conceived with in vitro fertilization. 

▪ Prevention: 

o magnesium sulfate: 

The only treatment to stop progression and lead to resolution of preeclampsia is delivery of the baby and placenta. Waiting to deliver can increase risk of complications but delivering too early in the pregnancy increases the risk for preterm birth.minimize those risks.Depending on the severity of the disease and gestational age, doctors may recommend women with preeclampsia come in more often for outpatient prenatal visits, or possibly be admitted to the hospital. They’ll likely perform more frequent blood and urine tests. They may also prescribe: 

✓ medications to lower blood pressure 

✓ corticosteroids to help mature the baby’s lungs and improve the mother’s health 

✓ In severe cases of preeclampsia, doctors often recommend antiseizure medications, such as magnesium sulfate. Magnesium sulfate is a mineral that reduces seizure risks in women with preeclampsia. A healthcare provider will give the medication intravenously. 

✓ Sometimes, it’s also used to prolong pregnancy for up to two days. This allows time for corticosteroid drugs to improve the baby’s lung function. 

✓ Magnesium sulfate usually takes effect immediately. It’s normally given until about 24 hours after delivery of the baby. 

✓ Women receiving magnesium sulfate are hospitalized for close monitoringof the treatment. o Magnesium sulfate can be beneficial to some with preeclampsia. But there’s a risk of magnesium overdose, called magnesium toxicity. Taking too much magnesium can be life-threatening to both mother and child. In women, the most common symptoms include:nausea, diarrhea, or vomiting ,large drops in blood pressureslow or irregular heart rate and breathing problems. 

o Treatment of magnesium toxicity: Doctors treat magnesium toxicity with:giving an antidote , fluids , breathing support , dialysis 

 

To prevent magnesium toxicity from happening in the first place, your doctor should closely monitor your intake. They may also ask how you’re feeling, monitor your breathing, and check your reflexes often. The risk of toxicity from magnesium sulfate is low if you’re dosed appropriately and have normal kidney function. 

▪ Nursing roles: 

o Patients with preeclampsia require close monitoring. A thorough initial assessment of the woman with possible preeclampsia should include a complete history, a complete physical exam with close attention to preeclampsia symptoms including unremitting headaches, edema, visual changes, and epigastric pain, fetal activity, and vaginal bleeding. The RN should review baseline BPs throughout pregnancy, medications and/or drugs throughout pregnancy (illicit & OTC). The patient should have current vital signs, including O2 saturation. The RN should also review current and past fetal assessment: FHR monitoring results estimated fetal weight and recent biophysical profile. Labs that should be drawn are CBC, platelets, LDH, liver function tests, electrolytes, BUN and creatinine, and a urine sample sent for a protein/creatinine ratio. 

o The nursing assessments needed vary depending on the diagnosis. Women with preeclampsia without severe features need vital signs, including pulse ox, and lung sounds every 4 hours. Level of consciousness, edema, and assessment for headache, visual disturbances, epigastric pain should occur every 8 hours. Intake and output should be monitored hourly. Fetal monitoring should be done as ordered. 

o Women with preeclampsia with severe features OR women on magnesium sulfate need vital signs, including pulse ox every 30 minutes (should be done every 5 minutes during loading dose of magnesium sulfate). These women need lung sounds assessed every 2 hours. Level of consciousness, edema, and assessment for headache, visual disturbances, epigastric pain should occur every 8 hours. Strict (hourly) intake and output should be monitored, and intake should be ≤ 125 mL/hour. Fetal monitoring should be continuous as ordered.4 Once the woman is stable without severe features and not on magnesium sulfate, she may be monitored as a patient with preeclampsia without severe features. 

❖ Eclampsia: 

▪ Definition:Eclampsia is a severe complication of preeclampsia. It’s a rare but serious condition in which their large amount of protein in urine and high blood pressure results in seizures (convulsions ) during pregnancy. 

▪ causes: o Doctors don’t know for sure what causes preeclampsia, but it’s thought to result from abnormal formation and function of the placenta.  

o They can explain how the symptoms of preeclampsia may lead to eclampsia. 

 High blood pressure: 

o Preeclampsia is when your blood pressure, or the force of blood against the walls of your arteries, becomes high enough to damage your arteries and other blood vessels. Damage to your arteries may restrict blood flow. It can produce swelling in the blood vessels in your brain and to your growing baby. If this abnormal blood flow through vessels interferes with your brain’s ability to function, seizures may occur.  Proteinuria: 

o Preeclampsia: commonly affects kidney function. Protein in your urine, also known as proteinuria, is a common sign of the condition. Each time you have a doctor’s appointment, your urine may be tested for protein. 

 Typically, your kidneys filter waste from your blood and create urine from these wastes. However, the kidneys try to retain nutrients in the blood, such as protein, for redistribution to your body. If the kidneys’ filters, called glomeruli, are damaged, protein can leak through them and excrete into your urine 

▪Signs and symptoms of eclampsia : 

✓ Eclampsia is a disorder of pregnancy characterized by seizures in the setting of pre-eclampsia. 

✓ Typically the pregnant woman develops hypertension and proteinuria before the onset of a convulsion (seizure). 

✓ Long-lasting (persistent) headaches 

✓ Blurred vision 

✓ Photophobia (i.e. bright light causes discomfort) 

✓ Abdominal pain 

✓ Either in the epigastric region (the center of the abdomen above the navel, or belly-button) 

✓ And/or in the right upper quadrant of the abdomen (below the right side of the rib cage) 

✓ Altered mental status (confusion) 

✓ Any of these symptoms may present before or after a seizure occurs. It is also possible that none of these symptoms will develop. 

✓ Other cerebral signs may immediately precede the convulsion, such as nausea, vomiting, headaches, and cortical blindness. If the complication of multi-organ failure ensues, signs and symptoms of those failing organs will appear, such as abdominal pain, jaundice, shortness of breath, anddiminished urine output. 

▪ Diagnosis: 

o Vital signs : One of the core features of pre-eclampsia is high blood pressure. Blood pressure is a measurement of two numbers. If either the top number (systolic blood pressure) is greater than 140 mmHg or the bottom number (diastolic blood pressure) is greater than 90 mmHg, then the blood pressure is higher than the normal range and the person has high blood pressure. If the systolic blood pressure is greater than 160 or the diastolic pressure is greater than 110, the hypertension is considered to be severe 

o Laboratory testing: 

✓ Another core feature of pre-eclampsia is proteinuria, which is the presence of excess protein in the urine. To determine if proteinuria is present, the urine can be collected and tested for protein; if there is 0.3 grams of protein or more in the urine of a pregnant woman collected over 24 hours, this is one of the diagnostic criteria for pre-eclampsia and raises the suspicion that a seizure is due to eclampsia. 

✓ In cases of severe eclampsia or pre-eclampsia, the level of platelets in the blood can be low in a condition termed thrombocytopenia. 

✓ A complete blood count, or CBC, is a test of the blood that can be performed to check platelet levels. 

✓ Other investigations include: kidney function test, liver function tests (LFT), coagulation screen, 24-hour urine creatinine, and fetal/placental ultrasound ▪ Treatment : 

o The four goals of the treatment of eclampsia are to stop and prevent further convulsions, to control the elevated blood pressure, to deliver the baby as promptly as possible, and to monitor closely for the onset of multi-organ failure. 

o Convulsions : 

✓ Convulsions are prevented and treated using magnesium sulfate. The study demonstrating the effectiveness of magnesium sulfate for the management of eclampsia was first published in 1955.  

✓ Serum magnesium concentrations associated with maternal toxicity as well as neonatal respiratory depression, low muscle tone, and low Apgar scores are: 

7.0–10.0 mEq/L: loss of patellar reflex 

10.0–13.0 mEq/L: respiratory depression 

15.0–25.0 mEq/L: altered atrioventricular conduction and (further) complete heart block >25.0 mEq/L: cardiac arrest 

✓ With intravenous administration, the onset of anticonvulsant action is fast and lasts about 30 minutes. Following intramuscular administration the onset of action is about one hour and lasts for three to four hours.  

✓ Effective anticonvulsant serum levels range from 2.5 to 7.5 mEq/liter.  

✓ Magnesium is excreted solely by the kidneys at a rate proportional to the plasma concentration and glomerular filtration. 

✓ Even with therapeutic serum magnesium concentrations, recurrent convulsions may occur, and additional magnesium may be needed, but with close monitoring for respiratory, cardiac, and neurological depression.  

✓ If magnesium administration with resultant high serum concentrations fail to control convulsions, the addition of other intravenous anticonvulsants may be used, facilitate intubation and mechanical ventilation, and to avoid magnesium toxicity including maternal thoracic muscle paralysis. 

✓ Magnesium sulfate results in better outcomes than diazepam, phenytoin or a combination of chlorpromazine, promethazine, and pethidine. 

o Blood pressure management : 

Blood pressure control is used to prevent stroke, which accounts for 15 to 20 percent of deaths in women with eclampsia. The agents of choice for blood pressure control during eclampsia are hydralazine or labetalol. This is because of their effectiveness, lack of negative effects on the fetus, and mechanism of action. Blood pressure management is indicated with a diastolic blood pressure above 105–110 mm Hg. o Delivery : 

If the baby has not yet been delivered, steps need to be taken to stabilize the woman and deliver her speedily. This needs to be done even if the baby is immature, as the eclamptic condition is unsafe for both baby and mother. As eclampsia is a manifestation of a type of non-infectious multiorgan dysfunction or failure, other organs (liver, kidney, lungs, cardiovascular system, and coagulation system) need to be assessed in preparation for a delivery (often a caesarean section), unless the woman is already in advanced labor. Regional anesthesia for caesarean section is contraindicated when a coagulopathy has developed. 

There is limited to no evidence in favor of a particular delivery method for women with eclampsia. Therefore, the delivery method of choice is an individualized decision. 

o Monitoring:  

Invasive hemodynamic monitoring may be elected in an eclamptic woman at risk for or with heart disease, kidney disease, refractory hypertension, pulmonary edema, or poor urine output. 

❖ Gestational hypertension: 

 Defination: Gestational hypertension is high blood pressure in pregnancy. It occurs in about 3 in 50 pregnancies.  

o This condition is different from chronic hypertension. Chronic hypertension happens when a woman has high blood pressure before she gets pregnant. It’s also different from preeclampsia and eclampsia.  

 Causes:  o Healthcare providers don't know what causes this condition. The following things may increase your risk: 

1. Having high blood pressure before pregnancy or with a past pregnancy 

2. Having kidney disease 

3. Having diabetes 

4. Being younger than 20 years of age or older than 40 years of age 

5. Bring pregnant with multiples, such as twins or triplets 

6. Being African American  Signs and Symptoms: 

o The main symptom is high blood pressure in the second half of pregnancy. But some women don’t have any symptoms. 

o High blood pressure in pregnancy can lead to other serious issues. 

These can include preeclampsia.  

o You should watch for signs of high blood pressure. They can include: 

- Headache that doesn’t go away 

- Edema (swelling) 

- Sudden weight gain 

- Vision changes, such as blurred or double vision 

- Nausea or vomiting 

- Pain in the upper right side of your belly, or pain around your stomach 

- Making small amounts of urine  Diagnosis of gestational hypertension: 

o If  blood pressure increases,  healthcare provider may diagnose you with this condition. And may also have the following tests to check for this issue: 

• Blood pressure readings 

• Urine testing to check for protein. This is a sign that your kidneys aren’t working well. 

• Checking for swelling 

• Checking your weight more often 

• Liver and kidney function tests 

• Blood clotting tests  Management:  

o Treatment: The goal of treatment is to stop this issue from getting worse and causing other problems. Treatment will depend on  symptoms, pregnancy, and general health. It will also depend on how severe the condition is.  

o treatment may include the following:  

✓ Blood pressure monitoring: healthcare provider may check  blood pressure more often. You should also tell  healthcare provider if you have any new symptoms. 

✓ Fetal monitoring:  healthcare provider  do tests to check the health of your baby. These tests may include: 

1. Fetal movement counting: You’ll keep track of your baby’s kicks and movements. A change in the number of kicks or how often your baby kicks may mean your baby is under stress. 

2. Nonstress testing. This test measures your baby’s heart rate in response to his or her movements. 

3. Biophysical profile:This test combines a nonstress test with an ultrasound to watch your baby. 

4. Doppler flow studies. This is a type of ultrasound that uses sound waves to measure the flow of your baby’s blood through a blood vessel. 

✓ Lab testing:  healthcare provider may test your urine and blood at every prenatal checkup. This will tell if your condition is getting worse. 

✓ Medicine:  healthcare provider may give  corticosteroids. These medicines can help your baby’s lungs form. You’ll get these medicines if it looks like your baby is going to be born early. 

 Complications: 

o High blood pressure can affect your blood vessels. This may decrease blood flow in your liver, kidneys, brain, uterus, and placenta.  

o This condition can get worse. It can lead to preeclampsia and eclampsia. These are serious blood pressure problems. These issues can cause the following problems: 

1. Placental abruption. This is when the placenta pulls away from the uterus too early. 

2. Poor fetal growth (intrauterine growth restriction) 

3. Stillbirth 

4. Seizures (eclampsia) 

5. Death of the mother and baby 

6. Delivery  may happen before 37 weeks of pregnancy. 

❖ Anemia:  

▪ INTRODUCTION: Anemia in pregnancy is a global health problem. While some degree of dilutional anemia is part of normal pregnancy physiology, iron deficiency anemia can have serious adverse health consequences for the mother and child. Thus, it is critical to distinguish iron deficiency anemia from physiologic anemia, as well as to identify other less common causes of anemia that may require treatment. 

▪ Definition of anemia: Anemia during pregnancy is a decrease in the total red blood cells or hemoglobin in the blood during pregnancy or in the post-pregnancy period.  It involves a decrease in the ability of oxygen to carry blood.  Anemia is an extremely common condition in pregnancy and after childbirth worldwide, which leads to a number of health risks for the mother and the baby. 

▪ Definition of physiological anemia: Physiologic anemia should be regarded as a developmental response of the infant's erythropoietic system due to the interaction of several factors: a relative decrease in marrow erythropoietic activity, a relative increase in the rate of hemolysis, and hemodilution due to a rapid expansion of the blood volume. 

▪ Who is at risk for anemia during pregnancy? 

o Women are more likely to get anemia during pregnancy if they: 

✓ Are strict vegetarians or vegans. They are at greater risk of having a vitamin B12 deficiency.  

✓ Have celiac disease or Crohn's disease, or have had weight loss surgery where the stomach or part of the stomach has been removed 

✓ Women are more likely to get iron-deficiency anemia in pregnancy if they: 

1- Have 2 pregnancies close together 

2- Are pregnant with twins or more 

3- Have vomiting often because of morning sickness 

4- Are not getting enough iron from their diet and prenatal vitamins 

5- Had heavy periods before pregnancy ▪ Effects of anemia in pregnancy: 

o Anemia increases perinatal risks for mothers and neonates; and increases overall infant mortality. The odds for fetal growth restriction and low birth weight are tripled. The odds for preterm delivery are more than doubled. Even a moderate hemorrhage in an anemic pregnant woman can be fatal. 

▪ Effects of anemia on fetus and neonate: 

o A basic principle of fetal/neonatal iron biology is that iron is prioritized to red blood cells at the expense of other tissues, including brain. When iron supply does not meet iron demand, the fetal brain may be at risk even if the infant is not anemic. Although dietary deficiency may be contributory, the etiology of the vast majority of cases of iron deficiency anemia in infancy and childhood is maternal iron deficiency anemia in pregnancy. Anemia adversely affects cognitive performance, behavior and physical growth of infants, preschool and school-aged children. Anemia depresses the immune status and increases the morbidity from infections in all age groups. It adversely impacts the use of energy sources by muscles and thus the physical capacity and work performance of adolescents and adults. 

▪ Classificiation of Anemia: 

1- physiological anemia.  

2- pathological anemia :iron, vitamin B12, folic acid deficiency. 

3- Hemorragic anemia :1_acute :following bleeding in early months. 

4- Chronic:hook worm infestation, bleeding piles. 

5- Hemolytic anemia: 

• familial :congental jaundice, sickel cell anemia.  

• aquired: malaria, severe infection.  

6- bone marrow insuficiency:hypo plasia, or aplasia. 

7- hemoglobinopathies: sickel cell anemia. 

▪ Causes of anemia in pregnancy according to type: 

1- Anemia of pregnancy: During pregnancy, the volume of blood increases. This means more iron and vitamins are needed to make more red blood cells. If you don't have enough iron, it can cause anemia. It's not considered abnormal unless your red blood cell count falls too low. 

2- Iron-deficiency anemia. During pregnancy, your baby uses your red blood cells for growth and development, especially in the last 3 months of pregnancy. If you have extra red blood cells stored in your bone marrow before you get pregnant, your body can use those stores during pregnancy. Women who don't have enough iron stores can get irondeficiency anemia. This is the most common type of anemia in pregnancy. Good nutrition before getting pregnant is important to help build up these stores. 

3- Vitamin B12 deficiency. Vitamin B12 is important in making red blood cells and protein. Eating food that comes from animals, such as milk, eggs, meats, and poultry, can prevent vitamin B12 deficiency. Women who don't eat any foods that come from animals (vegans) are most likely to get vitamin B12 deficiency. Strict vegans often need to get vitamin B12 shots during pregnancy.  

4- Folate deficiency. Folate (folic acid) is a B vitamin that works with iron to help with cell growth. If you don't get enough folate during pregnancy, you could get iron deficiency. Folic acid helps cut the risk of having a baby with certain birth defects of the brain and spinal cord if it's taken before getting pregnant and in early pregnancy. 

▪ Symptoms of anemia: 

1- Central: Fatigue,  dizziness  

2- Eyes: yellowing 

3- Skin: paleness,  coldness,  yellowish  

4- Blood vessels: low blood pressure  

5- Respiratory: shortness of breath  

6- Heart: chest pain,  angina,  heart attack  

▪ How is anemia during pregnancy diagnosed? 

o healthcare provider will check for anemia during your prenatal exams. It's usually found during a routine blood test. Other ways to check for anemia may include other blood tests such as:  

✓ Hemoglobin: This is the part of blood that carries oxygen from the lungs to tissues in the body. 

✓ Hematocrit: This measures the portion of red blood cells found in a certain amount of blood. 

▪ Anemia prevention: 

o Good pre-pregnancy nutrition not only helps prevent anemia, but also helps build other nutritional stores in your body. Eating a healthy, balanced diet before and during pregnancy helps keep up your levels of iron and other important nutrients needed for your growing baby. 

o Good food sources of iron include: 

✓ Meats: Beef, pork, lamb, liver, and other organ meats. 

✓ Poultry:  Chicken, duck, turkey, and liver, especially dark meat. 

✓ Fish. 

✓ Leafy greens of the cabbage family. These include broccoli, kale, turnip greens, and collards. 

✓ Yeast-leavened whole-wheat bread and rolls 

✓ Iron-enriched white bread, pasta, rice, and cereals o Experts recommend all women of childbearing age and all women who are pregnant take vitamin supplements with at least 400 micrograms of folic acid. Folate is the form of folic acid found in food. Good sources are: 

✓ Leafy, dark green vegetables 

✓ Dried beans and peas 

✓ Citrus fruits and juices and most berries 

✓ Fortified breakfast cereals 

✓ Enriched grain products ❖ Gestational diabetes: 

▪ Definition : is a condition in which a woman without diabetes develops high blood sugar levels during pregnancy. 

▪ Couses: 

- Gestational diabetes can occur during pregnancy because of insulin resistance or reduced production of insulin. 

▪ Risk Factor: 

- Polycystic ovary syndrome. 

- A previous diagnosis of gestational diabetes or prediabetes, impaired glucose tolerance, or impaired fasting glycaemia. 

- A family history revealing a first-degree relative with type 2 diabetes 

- Maternal age – a woman's risk factor increases as she gets older (especially for women over 35 years ) 

- Paternal age – one study found that a father's age over 55 years was associated with GD 

- Being overweight, obese or severely obese  

- A previous pregnancy which resulted in a child with a macrosomia 

(high birth weight: >90th centile or >4000 g  

- Previous poor obstetric history 

o Other genetic risk factors: There are at least 10 genes where certain polymorphism are associated with an increased risk of gestational diabetes, About 40–60% of women with GDM have no demonstrable risk factor; for this reason many advocate to screen all women. Typically, women with GDM exhibit no symptoms (another reason for universal screening), but some women may demonstrate increased thirst, increased urination, fatigue, nausea and vomiting, bladder infection, yeast infections and blurred vision. 

▪ The Effect of GDM on mother and the Fetus: 

o Gestational diabetes generally resolves once the baby is born. Based on different studies, the chances of developing GDM in a second pregnancy, if a woman had GDM in her first pregnancy, are between 30 and 84%, depending on ethnic background. A second pregnancy within 1 year of the previous pregnancy has a large likelihood of GDM recurrence. 

1. Maternal: Women diagnosed with gestational diabetes have an increased risk of developing diabetes mellitus in the future. The risk is highest in women whoneeded insulin treatment, had antibodies associated with diabetes (such as antibodies against glutamate decarboxylase, women with more than two previous pregnancies, and women who were obese (in order of importance). Women requiring insulin to manage gestational diabetes have a 50% risk of developing diabetes within the next five years. 

2. Fetal:Children of women with GDM have an increased risk for childhood and adult obesity and an increased risk of glucose intolerance and type 2 diabetes later in life. 

 

This risk relates to increased maternal glucose values.[GDM poses a risk to mother and child. This risk is largely related to uncontrolled blood glucose levels and its consequences. The risk increases with higher blood glucose levels.] 

The two main risks GDM imposes on the baby are growth abnormalities and chemical imbalances after birth, which may require admission to a neonatal intensive care unit. Infants born to mothers with GDM are at risk of being both large for gestational age (macrosomic)[] in unmanaged GDM, and small for gestational age and Intrauterine growth retardation in managed GDM. Macrosomia in turn increases the risk of instrumental deliveries or problems during vaginal delivery (such as shoulder dystocia).  

 

Neonates born from women with consistently high blood sugar levels are also at an increased risk of low blood glucose (hypoglycemia), jaundice, high red blood cell mass (polycythemia) and low blood calcium (hypocalcemia) and magnesium (hypomagnesemia). 

 

Untreated GDM also interferes with maturation, causing dysmature babies prone to respiratory distress syndrome due to incomplete lung maturation and impaired surfactant synthesis. 

▪ Complications: 

Gestational diabetes that's not carefully managed can lead to high blood sugar levels. High blood sugar can cause problems for mother and baby, including an increased likelihood of needing a C-section to deliver. 

Complications that may affect the baby: 

✓ Excessive birth weight. Higher than normal  

✓ blood sugar in mothers can cause their babies to grow too large. Very large babies — those who weigh 9 pounds or more — are more likely to become wedged in the birth canal, have birth injuries or need a Csection birth. 

✓ Early (preterm) birth. High blood sugar may increase women's risk of early labor and delivery before the Expected date. Or early delivery may be recommended because the baby is large. 

✓ Serious breathing difficulties. Babies born early to mothers with gestational diabetes may experience respiratory distress syndrome — a condition that makes breathing difficult. 

✓ Low blood sugar (hypoglycemia). Sometimes babies of mothers with gestational diabetes have low blood sugar (hypoglycemia) shortly after birth. Severe episodes of hypoglycemia may cause seizures in the baby. 

Prompt feedings and sometimes an intravenous glucose solution can return the baby's blood sugar level to normal. 

✓ Obesity and type 2 diabetes later in life. Babies of mothers who have gestational diabetes have a higher risk of developing obesity and type 2 diabetes later in life. 

✓ Stillbirth. Untreated gestational diabetes can result in a baby's death either before or shortly after birth. o Complications that may affect mother 

✓ High blood pressure and preeclampsia. Gestational diabetes raises risk of high blood pressure, as well as preeclampsia — a serious complication of pregnancy that causes high blood pressure and other symptoms that can threaten the lives of both mother and baby. 

✓ Having a surgical delivery (C-section). 

▪ Prevention: 

o There are no guarantees when it comes to preventing gestational diabetes — but the more healthy habits you can adopt before pregnancy, the better. If you've had gestational diabetes, these healthy choices may also reduce the risk of having it again in future pregnancies or developing type 2 diabetes in the future. 

• Eat healthy foods:Choose foods high in fiber and low in fat and calories. Focus on fruits, vegetables and whole grains. Strive for variety to help you achieve your goals without compromising taste or nutrition. Watch portion sizes. 

• Keep active:Exercising before and during pregnancy can help protect the mother from developing gestational diabetes. Aim for 30 minutes of moderate activity on most days of the week. Take a brisk daily walk. Ride your bike.Swim laps. Short bursts of activity — such as parking further away from the store when you run errands or taking a short walk break — all add up too. 

• Start pregnancy at a healthy weight:If you're planning to get pregnant, losing extra weight beforehand may help you have a healthier pregnancy. Focus on making lasting changes to your eating habits that can help you through pregnancy, such as eating more vegetables and fruits. 

• Don't gain more weight than recommended:Gaining some weight during pregnancy is normal and healthy. But gaining too much weight too quickly can up your risk of gestational diabetes. Ask your doctor what a reasonable amount of weight gain is for you ▪ Management: o Women with gestational diabetes are encouraged to: 

1. Eat small amounts often and maintain a healthy weightInclude some carbohydrate in every meal and snack. 

2. Choose foods that are varied and enjoyable that provide the nutrients you especially need during pregnancy.  

3. Avoid foods and drinks containing large amounts of sugar. 

4. Choose Basmati or Doongara rices – they have a lower glycaemic index and will help you to stay fuller for longer. 

5. See a dietitian who can provide expert advice on the proper nutrients for you and your baby, as well as helping you make healthy food choices. 

▪ Nursing roles: 

1. Monitoring blood sugar level (morning and after meals daily). 

2. explain to the mother effect of GDM on her and her fetus. 

3. demonstrate mother to do regulare exercises  (lowering blood sugar) such as walking. 

4. inform her about prescribed medications. 

5. insulin administration.  

6. emotional and educationalsupport to the mother. 

❖ Rh incompatibility: 

 Definition: Rh incompatibility is a condition that develops when a pregnant woman has Rh-negative blood and the baby in her womb has Rh-positive blood. 

▪ The Rh factor is a protein that can be found on the surface of red blood cells. If your blood cells have this protein, you are Rh positive. If your blood cells do not have this protein, you are Rh negative. During pregnancy, problems can occur if you are Rh negative and your fetus is Rh positive. Treatment can be given to prevent these problems. 

▪ The Rh factor is inherited, meaning it is passed from parent to child through genes. The fetus can inherit the Rh factor from the father or the mother. Most people are Rh positive, meaning they have inherited the Rh factor from either their mother or father. If a fetus does not inherit the Rh factor from either the mother or father, then he or she is Rh negative. When a woman is Rh negative and her fetus is Rh positive, it is called Rh incompatibility. 

▪ When the blood of an Rh-positive fetus gets into the bloodstream of an Rh-negative woman, her body will recognize that the Rh-positive blood is not hers. Her body will try to destroy it by making anti-Rh antibodies. 

These antibodies can cross the placenta and attack the fetus’s blood cells. This can lead to serious health problems, even death, for a fetus or a newborn. 

▪ During a pregnancy, Rh antibodies made in a woman’s body can cross the placenta and attack the Rh factor on fetal blood cells. This can cause a serious type of anemia in the fetus in which red blood cells are destroyed faster than the body can replace them.Red blood cells carry oxygen to all parts of the body. Without enough red blood cells, the fetus will not get enough oxygen. In some cases, a fetus or a newborn can die from anemia. Rh incompatibility also can cause jaundice in a newborn. 

 Prevention : 

problems during pregnancy caused by Rh incompatibility can be prevented. The goal of treatment is to stop an Rh-negative woman from making Rh antibodies in the first place. This is done by finding out if you are Rh negative early in pregnancy (or before pregnancy) and, if needed, giving you a medication to prevent antibodies from forming. ❖ Heart disease in pregnancy:  

 Pregnancy stresses the cardiovascular system, often worsening known heart disorders. Stresses include decreased hemoglobin and increased blood volume, stroke volume, and eventually heart rate. Cardiac output increases by 30 to 50%. These changes become maximal between 28 and 34 weak gestation. 

 During labor, cardiac output increases about 20% with each uterine contraction; other stresses include straining during the 2nd stage of labor and the increase in venous blood returning to the heart from the contracting uterus. Cardiovascular stresses do not return to prepregnancy levels until several weeks after delivery. 

▪ Incidence : 

o World Health Organization estimates cardio vascular disease accounts for 1 to4% in pregnant women globally. Maternal mortality in South Africa is rising, and heart conditions currently account for 41 per cent of indirect causes of deaths. Little is known about the burden of heart disease in pregnant South Africans.  

o The overall prevalence of pregnant women with heart disease was 9.3% in Egypt (Soliman et al., 2016).  In Egypt 16% of maternal deaths are due to heart diseases during pregnancy. This percentage means that heart disease during pregnancy is the fourth most common cause of maternal death (Soliman et al., 2016)  

o Cardiac disease is a leading cause of maternal death in pregnancy in many developed countries, including the UK. However, there is a lack of evidence-based guidelines to assist in planning the management of affected pregnancies. 

▪ Guidelines for management of heart disease during pregnancy: 

General Guidelines to management 

Activity restrictions 

Diet modifications 

Infection control 

Immunizations, prophylaxis against Rheumatic fever 

Interruption of pregnancy 

Counseling 

Contraception 

CV surgery 

CV drugs