High risk pregnancy
High risk pregnancy
Introduction
Most of the time having a baby is a natural
process. After a full-term pregnancy, women go into labor on or near their due
date and give birth to a healthy baby. A day or two later they leave the
hospital to begin day-to-day life with their growing family. But not allence what doctors refer to as a
high-risk pregnancy.
Definition
A pregnancy is considered high-risk when
there are potential complications that could affect the mother, the baby, or
both.
High-risk pregnancies require management by
a specialist to help ensure the best outcome for the mother and baby.
Risk factors
Many factors can
increase the possibility of woman to be in a high risk pregnancy, It’s
classified to:
a)
Physical factors
b)
Social factors
c)
Pre- pregnancy medical
factors
d)
Medical disorders during
pregnancy
e)
Obstetrical history
factors
f)
Psychological factors Physical factors
•
Age: Under 17 or above 35
that high risk of genetic defects.
•
weight: Overweight or
obesity 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
nutrition
Pre-
pregnancy medical factors:
•
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.
Medical
disorders during pregnancy:
•
Hepatitis B
•
Hepatitis Care transmitted
blood to blood
•
Placenta previa:
implantation of placenta in lower segment.
•
placenta abruption: can
cause bleeding from the vagina.
•
Problems with amniotic
fluid: polyhydraminous and over distention.
•
cervical insufficiency:
weak cervix.
Obstetrical history factor:
•
multiple pregnancy
•
Caesarean section and any
surgery of abdominal.
High risk conditions:
Bleeding in early pregnancy
Early pregnancy bleeding refers to
vaginal bleeding before 24 weeks of gestational age (during the first and
second trimester).
Causes:- Abortion.
• Vesicular mole.
• Ectopic pregnancy.
• Rarely Gynecological lower tract pathway.(local lesions,
cervical cancer, polyp)
Abortion
It's a termination of pregnancy before 24
weeks , or products of conception weighing below 500 gram .
It occur 10 - 15% of Pregnancy , 80% of them occur in the
first trimester.
Causes:-
Fetal:
•
Chromosomal anomalies.
•
Disease of the fertilized
ovum
•
Hypoxia.
Maternal: o infection
e.g. influenza , malaria, syphilis , HIV. o Disease such as chronic nephritis. o Drug
intake during pregnancy. o RH and ABO incompatibility. o Incompetent cervix. o uterine
malformations.
o Acquired uterine defect as uterine fibroid or adhesion s o Trauma
, criminal interference.
o Endocrinal disorder as hypothyroidism, diabetes mellitus.
Types of abortion:
ü spontaneous abortion
ü Threatened abortion
ü missed abortion
ü Inevitable abortion.
ü Complete abortion
ü incomplete abortion
ü habitual abortion
ü Therapeutic abortion.
ü Criminal abortion.
ü septic abortion.
Threatened abortion
It's an attempt of uterus to get rid of its contents.
Sign
and symptoms:- o Vaginal
bleeding mild and bright red in color.
o Abnormal pain and backache may or may not be present. o cervical
os is closed.
o Membrane are intact.
Nursing
management:- • Complete
bed rest .
•
Avoid heavy work, enema and
constipation.
•
no sexual intercourse.
•
Administration of
prescribed medication.
Inevitable abortion
Sign and symptoms:-
•
Bleeding is excessive (more
than 10 Day)
•
blood is red in color with
clots.
•
sever colicky lower
abdominal pain.
•
Cervical os is dilated and
rupture of membranes has occurred.
•
There is sever blood loss
and the women become shocked.
Nursing management:
•
Hospitalization
•
Anti shock measure
•
fluid infusion.
•
Blood transfusion if
indicated .
•
O2 mask 6 - 8 L /m
•
Warmth
•
sedative: morphine
•
If no heart beats are
detected a dilute solution of oxytocin may be given as the doctor order to help
in the expulsion of the contents of the uterus.
•
D&C should be done Missed
abortion fetus is dead and retained inside the uterus.
Sign and symptoms:-
•
Some signs of pregnancy
disappear
•
fundal height doesn’t
increase in size
•
The breast may be secreted
milk due to hormonal changes
•
Fetal heart rate are absent
.
•
A sonar test confirms fetal
death .
•
some brownish vaginal
discharge. Management:- - Evacuation. Septic abortion any type
of abortion completed by infection e.g. missed or criminal abortion. Sign and
symptoms:-
•
Tender and painful
uterus
•
offensive vaginal bleeding.
•
High temperature , rapid
pulse , unstable blood pressure.
•
Shock
Nursing management:-
•
isolation
•
complete bed rest, in
folwer position.
•
monitoring for vital signs
and fluid chart.
•
Fluid infusion (5% Glucos+
saline ) to maintain uterine flow >30ml/hr
•
Clinical bacteriological to
identify the infection organism.
•
Administration of
antibiotics , antipyretic and analgesic as doctor order.
•
To soild pads should be
properly collected and burned.
Incomplete abortion Signs &
symptoms:
•
Severe bleeding • Cervical
is partly closed.
•
No uterine involution.
•
Pain may or may not be
present.
•
Uterus is soft and smaller
than the expected period of pregnancy.
Complete abortion:
Signs & symptoms:
•
There is minimal bleeding.
•
Pain stops.
•
Uterus is hard and much
smaller
•
The cervix is closed Treatment:
of the cause such as cervical incompetence or treatment of causative
diseases as syphilis, DM, etc.
Nursing
Management of Abortion
•
Prevention measures should
be taken to avoid risk of a spontaneous abortion:
•
A nutritional diet.
•
Avoiding smoking or thinking alcohol.
•
Receiving available
immunizations against infectious diseases.
•
Treatment of vaginal or
pelvic infections.
Hydatidiform Mole !Vesicular mole)
It is a gross malformation of the
trophoblastic in which the chorionic villi proliferate and become avascular.
Causes:
The exact cause is unknown.
Risk factors are:
•
Maternal age above 40 years
or below 19 years.
•
Malnutrition Types
•
partial mole
•
complete mole
Signs and Symptoms
•
Excessive frequent vomiting.
•
Over distension of the
uterus and larger than expected for weeks of
•
gestation.
•
Some vaginal bleeding may
occur plus vesicles.
•
No fetal movements, No
fetal parts
•
Positive pregnancy test
result in highly diluted urine 1:500.
Complications:
- Hemorrhage
- shock
-perforation
-Uterine sepsis -Choriocarcinoma
Nursing management:
-Admit the woman into hospital.
-Evacuation of the uterus under general anesthesia.
• Health education on the following:
• Need for monitoring HCG levels for two years (monthly for the
first 3 months, then every three months for one year).
Birth spacing methods to prevent pregnancy for two years.
- If HCG levels remain more than five international units per
liter eight weeks postpartum , prophylactic chemotherapy is indicated.
3-Ectopis Pregnancy pregnancy
occurring outside the normal uterine cavity.it usually occurs 99% of cases in
the uterine tube.
Tubal Pregnancy
Causes
- Impaired tubal cilliary action.
- Impaired tubal contractility.*
- Decreased sperm mobility
- The use of intrauterine contraceptive device.
Risk Factors:
• Pelvic inflammatory disease.
History of previous pelvic operations such as D and C,
ovarian surgery.
Signs and Symptoms
-Short periods of amenorrhea.
-
Sudden/recurrent severe,
colicky abdominal pain in one iliac fossa or entire lower abdomen
-
Blood stained vaginal
discharge.
-
Signs of shock.
-
Dyspareunia.
Management:
Surgical
-
-Especially in undisturbed
ectopic.
-
-Evacuated immediately.
-
-Salpingectomy is
performed.
-
-Provide emotional support.
-
Follow-up is needed.
Medical.
When undisturbed
B-HCG less than 1000
Bleeding in Late Pregnancy (Antepartum Hemorrhage)
It is bleeding from the genital tract
after the 28th week of pregnancy and before the end of the second stage of
labor. Classification
•
Placental site bleeding:
(62%)
•
Placenta praevia (22%):
Bleeding from separation of a placenta wholly or partially implanted in the
lower uterine segment.
•
Abruption placentae (30%):
Premature separation of a normally implanted placenta.
•
Marginal separation(10%)ý:
Bleeding from the edge of a normally implanted placenta.
•
Non-placental site
bleeding: (28%)
•
Vasa praevia: Bleeding from
ruptured foetal vessels.
•
Rupture uterus.
•
Bloody show.
•
Cervical ectopy, polyp or
cancer.
•
Vaginal varicosity.
Placenta Pravia
The placenta is partially or totally attached to the lower
uterine segment.
Incidence
0.5% of pregnancies . It is more common
in multiparas and in twin pregnancy due to the large size of the placenta.
Causes
Not well known but may be due to:
Low implantation of the blastocyst.
Development of the chorionic villi in the
decidua capsularis leading to attachment to the lower uterine segment.
Large placenta as in twin pregnancy.
Mechanism of bleeding
Progressive stretching of the lower
uterine segment normally occurs during the 3rd trimester and labour, but the
inelastic placenta cannot stretch with it. This leads to inevitable separation
of a part of the placenta with unavoidable bleeding. The closer to term, the
greater is the amount of bleeding.
Diagnosis
Symptoms:
• Causeless, painless and recurrent bright-red vaginal bleeding;
• It is causeless, but may follow sexual intercourse or vaginal
examination.
• It is painless, but may be associated with labour pains .
• It is recurrent, but may occur once in slight placenta praevia
lateralis. Fortunately, the first attack usually not severe Signs:
• General examination:
The general condition of the patient
depends upon the amount of blood loss. Shock develops if there is acute severe
blood loss and anemia develops if there is recurrent slight blood loss.
• Abdominal examination:
The uterus is corresponding to the period
of amenorrhea, relaxed and not tender.
The fetal parts and heart sound (FHS) can
be easily detected. Malpresentations, particularly transverse and oblique lie
and breech presentation are more common as well as non-engagement of the head.
This is because the lower uterine segment is occupied by the placenta.
• Vaginal examination
Speculum examination to exclude local
lesions is only permissible when placenta praevia has been excluded by
ultrasound.
P/V is indicated only if active treatment
is initiated. This may provoke a severe attack of bleeding so it should be done
with the following precautions: In the operating room, under general
anesthesia, cross- matched blood is in hand, operating theatre is ready for
immediate caesarean section.
If the index finger is introduced
gently through the dilated cervix, the placenta can be felt as a tough fibrous
mass. Placental abruption (abruption
placentae) is an uncommon yet
serious complication of pregnancy. Placental abruption occurs when the placenta
partly or completely separates from the inner wall of the uterus before
delivery. This can decrease or block the baby's supply of oxygen and nutrients
and cause heavy bleeding in the mother.
Signs and symptoms
• Vaginal bleeding, although there might not be any
• Abdominal pain
• Back pain
• Uterine tenderness or rigidity
• Uterine contractions, often coming one right after another The cause of placental abruption is often unknown. Possible causes include:
• trauma or injury to the abdomen — from an auto accident or fall,
for example —
• Rapid loss of the fluid that surrounds and cushions the baby in
the uterus (amniotic fluid). Risk Factors
• Placental abruption in a previous pregnancy that wasn't caused
by abdominal trauma
• Chronic high blood pressure (hypertension)
• Hypertension-related problems during pregnancy, including
preeclampsia, HELLP syndrome or eclampsia
• A fall or other type of blow to the abdomen
• Smoking
• Cocaine use during pregnancy
• Early rupture of membranes, which causes leaking amniotic fluid
before the end of pregnancy
• Infection inside of the uterus during pregnancy
(chorioamnionitis) Being
older, especially older than 40
Complications for the mother
•
Shock due to blood loss
•
Blood clotting problems
•
The need for a blood
transfusion
•
Failure of the kidneys or
other organs resulting from blood loss
•
Rarely, the need for
hysterectomy, if uterine bleeding can't be controlled Complications for the fetus
•
Restricted growth from not getting
enough nutrients
•
Not getting enough oxygen
•
Premature birth
•
Stillbirth
Prevention
We can't prevent placental abruption, but we can decrease
certain risk factors.
For example, mother should not smoke or
use illegal drugs, such as cocaine. If she have high blood pressure, then she
must work with her health care provider to monitor the condition.
Mother should always wear her seatbelt
when in a motor vehicle. If she have had abdominal trauma — from an auto
accident, fall or other injury — seek immediate medical help.
If she have had a placental abruption,
and are planning another pregnancy, she should talk to her health care provider
before she conceive to see if there are
ways to reduce the risk of another abruption.
Medical treatment
The treatment for placental abruption
depends upon the severity of the abruption. Your doctor will determine if your
placental abruption is mild, moderate, or severe. Mild placental abruption is
when blood loss has occurred, but the bleeding has slowed and you and your baby
are stable. Treatments will also depend on how far along you are in your
pregnancy. If you’ve lost a significant amount of blood, you may need a blood
transfusion. Mild placental abruption at 24 to 34 weeks. If you and your baby
are doing well, your doctor may give you medications to try and speed up your
baby’s lung development and allow them to keep developing. If your bleeding
seems to have stopped or slowed, your doctor may send you home. Otherwise, you
may need to remain in the hospital for close monitoring.
Mild placental abruption at 34 weeks or
greater. If you’re near full-term, your doctor may induce labor or perform a
cesarean delivery. If your baby has had time to develop, an earlier delivery
can reduce the risks for further complications.
Moderate to severe placental abruption.
This degree of placental abruption — marked by significant blood loss and
complications to you and your baby — usually requires immediate delivery, often
by cesarean.
In rare instances, if your doctor can’t
stop your bleeding, you may need a hysterectomy. This is the surgical removal
of the uterus. Again, this is in rare instances of severe bleeding.
Nursing management
1. Place the woman in a lateral, not supine position to avoid
pressure in the vena cava.
2. Monitor fetal heart sounds.
3. Monitor maternal vital signs to establish baseline data.
4. Avoid performing any vaginal or abdominal examinations to
prevent further injury to the placenta.
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:
• poor nutrition or high body fat
• A lack of blood flow to the uterus
• Genes
• High Blood Pressure Disorders in Pregnancy
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.
-
Blood pressure that exceeds
140/90 millimeters of mercury (mm Hg) or greater
-
documented on two
occasions, at least four hours apart is abnormal.
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 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:
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:
a. 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 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 Monitoring of 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 pressure slow or irregular heart rate and breathing problem 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:
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.
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, epigastria pain should occur
every 8 hours. Intake and output should
be monitored hourly. Fetal monitoring should be done as ordered.
-
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 fever. Eclampsia
Eclampsia is a severe complication
of preeclampsia. It’s a rare but serious condition where high blood pressure
results in seizures during pregnancy. Definition are periods of disturbed brain
activity that can cause episodes of staring, decreased alertness, and
convulsions (violent shaking)
Signs and symptoms :-
Patients with eclampsia can have the same
symptoms of preeclampsia or may even
present with no symptoms prior to the onset of eclampsia. The following are
common symptoms of eclampsia:
• seizures
• loss of consciousness
• agitation causes:-
• Doctors don’t know for sure what causes preeclampsia, but it’s
thought to result from abnormal formation and function of the placenta. They
can explain how the symptoms of preeclampsia may lead to eclampsia.
• High blood pressure
• Proteinuria
Who is at risk for eclampsia?
• Previous history of
preeclampsia
Other risk factors
for developing eclampsia during pregnancy include:
• gestational or chronic hypertension (high blood pressure)
• being older than 35 years or younger than 20 years
• pregnancy with twins or triplets
• first-time pregnancy
• diabetes
• kidney disease
• Women who have long term high blood pressure before becoming
pregnant have a greater risk of pre-eclampsia.
• women with other pre-existing vascular diseases (diabetes or
nephropathy) or thrombophilic diseases such as the antiphospholipid syndrome
are at higher risk to develop pre-eclampsia and eclampsia.
• Having a large placenta (multiple gestation, hydatidiform mole)
also predisposes women to eclampsia.
• In addition, there is a genetic component: a woman whose mother
or sister had the condition is at higher risk than otherwise.
• Women who have experienced eclampsia are at increased risk for
preeclampsia/eclampsia in a later pregnancy.
Complications
The development of complications depends on a number of
factors, including the degree of vulnerability, susceptibility, age, health
status, and immune system condition.
ü
Renal insufficiency and
acute renal failure.
ü
Fetal changes – IUGR,
abruption placentae, oligohydramnios.
ü
Hepatic damage and rarely
hepatic rupture.
ü
Hematologic compromise and
DIC How is eclampsia diagnosed?
If you already have a preeclampsia
diagnosis or have a history of it, your doctor will order tests to determine if
your preeclampsia has happened again or gotten worse. If you don’t have
preeclampsia, your doctor will order tests for preeclampsia as well as others
to determine why you’re having seizures. These tests can include:
CBC
Creatinine test
Urine tests for protein
What are the
treatments for eclampsia?
-
Delivering your baby and
placenta are the recommended treatment for preeclampsia and eclampsia.
-
doctor will consider the
severity of the disease and how mature baby is when recommending timing of
delivery.
-
If diagnoses with mild
preeclampsia, they may monitor your condition and treat you with medication to
prevent it from turning into eclampsia. Medications and monitoring will help
keep your blood pressure within a safer range until the baby is mature enough
to deliver.
-
If you do develop severe
preeclampsia or eclampsia, your doctor may deliver your baby early. Your care
plan will depend on how far along you are in your pregnancy and the severity of
your disease. You will need to be hospitalized for monitoring until you deliver
your baby.
Medications
Medications to prevent seizures, called anticonvulsants
drugs, may
be necessary. You may need medication to lower blood pressure if you have high
blood pressure. You may also receive steroids, which can help your baby’s lungs
mature prior to delivery. Gestational
hypertension
To remember: Physiological blood pressure changes During
pregnancy
Early in the first trimester there is a
fall in blood pressure caused by active vasodilatation,
After this, there is a gradual increase in
blood pressure until term when prepregnancy levels are attained.
Immediately after delivery blood pressure
usually falls Definition having a HTN(
higher than 140/90measured on two separate occasions, more than 6 hours apart)
alone (without protein in urine) after 20 weeks of gestation and returning to
normal postpartum. The difference between it and preeclampsia
chronic HTN: occur
before conception or before 20 week's gestation
Pre-eclampsia: presence of protein in
urine Causes
•
Unknown but risk factors of
•
having previous HTN before
pregnancy
•
Having kidney disease.
•
Having diabetes.
•
Being younger than 20 years
of age or older than 40 years of age.
•
Bring pregnant with
multiples, such as twins or triplets.
Symptoms
Symptoms can occur but sometimes no
The main symptoms is high blood pressure
•
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
•
Checking for swelling
•
Checking weight gain
•
Blood pressure readings
•
Urine testing to check for
protein. This is a sign that kidneys aren’t working well
•
Liver and kidney function
tests
•
Blood clot test
Compilation
a. decrease blood flow in mother's liver, kidneys, brain, uterus,
and placenta
b. Placental abruption. This is when the placenta pulls away from
the uterus too early.
c. Poor fetal growth (intrauterine growth restriction)
d. Stillbirth
e. can lead to pre-eclampsia or Seizures (eclampsia)
f. Death of the mother and baby
Treatment
•
Blood pressure monitoring
•
Fetal monitoring to check the health of the baby may
include Fetal movement counting
Mother will keep track of her baby’s kicks and movements.
A change in the number of kicks or how often
baby kicks may mean baby is under
stress.
•
Non stress testing.
measure baby’s heart rate in response
to his movements. Biophysical profile.
combines a
non-stress test with an ultrasound to watch the baby.
•
Doppler flow studies
A type of ultrasound that uses sound
waves to measure the flow of baby’s blood through a blood testing
•
Lab testing
Such as urine and blood test to make sure
that mother's conditions isn't getting worse
•
Medicine
corticosteroids can
help baby’s lungs form.
Combination of
Prazosin & Captopril as antihypertensive drugs
•
Nursing care
Nursing care for PIH involves providing
adequate nutrition, good prenatal care, and control of pre-existing
hypertension during pregnancy decrease the incidence and severity of
preeclampsia. Early recognition and prompt treatment of preeclampsia can
prevent progression to eclampsia.
Diabetes Mellitus
• describes a • metabolic (endocrine ) disorder resulting
from defects in insulin secretion, insulin action, or both classification Diabetes in
pregnancy 1) pre-existing
diabetes:
The
women has diabetes before pregnancy. And this can be subdivided to a)
pre-existing insulin dependent diabetes (IDDM) it encompasses the majority of cases
that are primarily due pancreatic is let beta-cell destruction and It is
characterized by absolute insulin deficiency,
b) pre-existing
non-insulin dependent diabetes (NIDDM) - is the major of diabetes, which
results from defects in insulin secretion, always with a • major contribution
from insulin resistance 2) Gestational
diabetes. the pregnant women develops
diabetes during the course of her pregnancy.
Risk factors for the development of diabetes
in pregnancy *Called potentially diabetics.
1- family history.
2- obesity.
3- previous baby>4.5kg.
4- previous unexplained stillbirth.
5- previous fetal congenital malformations
Influence of Diabetes on
Pregnancy During pregnancy :
• Mother:
a. Abortion.
b. Pre-eclampsia.
c. Polyhylramnios.
d. Increase Incidence of cesarean section.
• Fetus
a. TUGR.
b. TUFD.
a.
Congenital anomalies.
b.
Abnormal presentation During
Labor:
• Mother:
Obstructed labor.
• Fetus:
a. Prematurity.
b. Neonatal hypoglycemia.
c. Respiratory distress.
d. Macrosomia Postpartum
e. Infection.
f.
Postpartum hemorrhage
management Pre-pregnancy management
-
pre pregnancy glycemic
control should be optimal before pregnancy
-
-diabetic should be
educated regarding the need for tight control and screened and treated from
diabetic complications like retinopathy and nephropathy
-
general advice should be
given concerning diet and the need for folic acid before pregnancy and during the
first trimester - diet :
-
supply 30 to 35 kcal/kg/day
-
-avoid sugar, decrease fat
and increase fibers - insulin
:
• Dose is calculated based on body weight
- first trimester0.6
- second trimester 0.7 unit/kg
- third trimester 0.8 unit/kg
Multiple Short acting is given before meals and
intermediate acting insulin at bed time
Prevention
Maintain a healthy weight before pregnancy
If you have made a decision to try to
have a baby, try to maintain a healthy weight before becoming pregnant. If you
are overweight, that doesn’t necessarily mean you will develop gestational
diabetes, but it does increase the risk. Having a body mass index (BMI) of more
than 30 makes you three times more likely to develop gestational diabetes than
having a BMI of 25 or less. Diet :
•
measuring out smaller
portion sizes
•
avoiding packaged food and
―junk food‖
•
replacing candy with fruit
•
eating more lean protein,
such as fish and tofu, to stay fuller for longer
•
increasing fiber intake by
eating plenty of vegetables and whole grains
•
replacing juices,
dairy-laden coffee drinks, and sodas with herbal tea, black coffee, or
sparkling water with lemon or lime slices Exercise :
•
Exercise is a vital part of
maintaining a healthy weight. Both before and during pregnancy, exercise can
help prevent gestational diabetes. Exercise helps the body become more
sensitive to the insulin that the pancreas creates, which helps regulate blood
sugar levels.
Anemia
-Is a reduction in the number of RBCs and
haemoglobin content with a corresponding reduction in the oxygen carrying
capacity of the blood. -Anemia in pregnancy is defined as a hemoglobin
concentration of less than 110 g/L (less than 11 g/dL) in venous blood.
• Types
a. Iron-deficiency anemia.
b. Folate-deficiency anemia.
c. Vitamin B12 deficiency.
1-Iron-deficiency anemia
This
type of anemia occurs when the body doesn't have enough iron to produce
adequate amounts of hemoglobin. That's a protein in red blood cells.
It carries oxygen from the lungs to the rest of the body.
-In iron-deficiency anemia, the blood
cannot carry enough oxygen to tissues throughout the body.
-Iron deficiency is the most common cause of anemia in
pregnancy.
2-Folate-deficiency anemia.
Folate is the vitamin found naturally in certain
foods like green leafy vegetables A type of B vitamin, the body needs folate to
produce new cells, including healthy red blood cells.
During pregnancy, women need extra
folate. But sometimes they don't get enough from their diet. When that happens,
the body can't make enough normal red blood cells to transport oxygen to
tissues throughout the body.
Man-made supplements of folate are called folic acid.
Folate deficiency can directly contribute
to certain types of birth defects, such as neural tube abnormalities (spina
bifida) and low birth.
3-Vitamin B12 deficiency.
The body needs vitamin B12 to form
healthy red blood cells. When a pregnant woman doesn't get enough vitamin B12
from their diet, their body can't produce enough healthy red blood cells. Women
who don't eat meat, poultry, dairy products, and eggs have a greater risk of
developing vitamin B12 deficiency, which may contribute to birth defects, such
as neural tube abnormalities, and could lead to preterm labor.
• Causes
The cause of anemia truly comes down to
how many red blood cells are being produced in the body and how healthy they
are.
1- Nutritional deficiency
The most cases anemia is caused by not
having enough iron in diet before and/or during
pregnancy.
a lack of iron in the diet as a result of
not eating enough iron-rich foods or the body’s inability to absorb the iron
being consumed.
2- vitamin deficiency (B12 or folic acid).
3- Acute or chronic blood loss. bleeding due to an ulcer or polyp, or blood donation
causes red blood cells to be destroyed faster than they can be replenished.
•
Risk factors
ý pregnant with multiples
ý -have two or more pregnancies in quick succession
ý -aren’t eating enough foods rich in iron
ý -experienced heavy periods before becoming pregnant
ý -are routinely vomiting as a result of morning sickness
•
Symptoms
While mild cases of anemia may have no
symptoms at all, moderate to severe conditions may present themselves with the
following symptoms:
ü feeling excessively fatigued or weak
ü becoming pale
ü experiencing shortness of breath
ü heart palpitations
ü chest pain
ü feeling lightheaded
ü hands and feet become cold
ü having cravings for nonfood items like dirt, clay, or cornstarch
• Risks of Anemia during Pregnancy
“Complications”
(1) Severe
or untreated iron-deficiency anemia during pregnancy can increase risk of
having:
- A preterm or low-birth-weight baby
- A blood transfusion (if you lose a significant amount of blood
during delivery)
- Postpartum depression
- A baby with anemia
- A child with developmental delays
(2) Untreated folate deficiency can increase risk of
having a:
- Preterm or low-birth-weight baby
- Baby with a serious birth defect of the spine or brain (neural
tube defects)
(3)Untreated vitamin B12 deficiency can
also raise risk of having a baby with neural tube defects leading to spina
bifida.
Diagnosis
Tests for Anemia
ý Hemoglobin test.
ý Hematocrit test.
•Management
(1) Medical anemia during pregnancy, need to start taking an iron
supplement and/or folic acid supplement in addition to prenatal vitamins.
and add more foods that are high in iron
and folic acid to the diet.
(2) Nutritional
supplements.
-
Anemia during pregnancy can
easily be treated by adding iron or vitamin supplements to the daily routine.
-
Use of nutritional
supplements should be appropriately taught to the pregnant women and the family
because too much intake cannot improve anemia.
(3) Blood transfusion.
Patients with acute blood loss or severe
hemolysis may have decreased tissue perfusion from decreased blood volume or
reduced circulating erythrocytes, so transfusion of blood would be necessary.
(4) Intravenous fluids.
Intravenous fluids replace the lost volumes of
blood or electrolytes to restore them to normal levels.
N.B To treat vitamin B12 deficiency, doctor may
recommend take a vitamin B12 supplement
and may also recommend that diet includ meat eggs ,dairy products.
(5) Nursing Management
1- Take History
ý Family history.
Assessment of family history is important
because certain anemias are inherited
ý Health history and physical exam.
Both provide important data about the
type of anemia involved, the extent and type of symptoms it produces, and the impact
of those symptoms on the patient’s life.
ý Diet.
The nurse should encourage a healthy diet
that is packed with essential nutrients.
ý Provide client and family teaching.
Discuss using iron supplements and
increasing dietary sources of iron as indicated.
4- Blood transfusion monitoring.
The nurse should monitor the patient’s
vital signs and pulse oximeter readings closely.
Prepare for blood-typing and
crossmatching, and for administering packed PBCs during labor if the client has
severe anemia.
•
Prevention during
pregnancy:make sure you get enough iron
،Eat well-balanced meals and add more foods that are high in iron to
your diet.
Aim for at least three servings a
day of iron-rich foods, such as: lean red meat, poultry, and fish leafy, dark
green vegetables (such as spinach, broccoli, and kale) iron-enriched cereals
and grains
beans, lentils, and tofu nuts and
seeds eggs
Foods that are high in vitamin C can help
your body absorb more iron. These include:
ü citrus fruits and juices
ü strawberries
ü kiwis
ü tomatoes
ü bell peppers
Try eating those foods at the same time
that you eat iron-rich foods. For example, you could drink a glass of orange
juice and eat an iron-fortified cereal for breakfast.
Also, choose foods that are high in folate to help prevent
folate deficiency.
These include:
ü leafy green vegetables
ü citrus fruits and juices
ü dried beans
ü breads and cereals fortified with folic acid
Follow your doctor's instructions for
taking a prenatal vitamin that contains a sufficient amount of iron and folic
acid.
Vegetarians and vegans should talk with
their doctor about whether they should take a vitamin B12 supplement when
they're pregnant and breastfeeding
Cardiac Disease in Pregnancy
ð Pregnancy stresses the cardiovascular system, often worsening
known heart disorders. Stresses include decreased hemoglobin and increased
blood volume, stroke volume, and eventually heart rate.
ð Cardiac output increases by 30 to 50%. These changes become
maximal between 28 and 34 weeks gestation.
ð 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.
v Incidence:
ü 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.
ü 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)
ü 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
ý Activity restrictions
ý Diet modifications
ý Infection control
ý Immunizations, prophylaxis against Rheumatic fever
ý Interruption of pregnancy
ý Counseling
ý Contraception
ý CV surgery
ý CV drugs
Rh ISO immunization
ISO immunization is defined as the
development of antibodies against the antigens of another individual of the
same species.
Rh iso immunization is when the blood from
the baby makes the mother's body create antibodies that can harm the baby's
blood cells.
Causes
Rh iso immunization can happen if the
baby's Rh positive blood enters the mother's blood flow. This may happen
during:
ü Miscarriage
ü Trauma
ü Ectopic pregnancy
ü Induced abortion
ü Amniocentesis or other pregnancy procedures—rare
Risk Factors
The risk of Rh incompatibility is higher in an Rh-negative
pregnant woman who:
-
Had a prior pregnancy with
a baby that was Rh positive.
-
Had a prior blood
transfusion or amniocentesis
-
Did not get an Rh
immunization during a prior pregnancy with an Rhpositive bab
Symptoms
Symptoms will only be in the baby. They can be mild to
severe, such as:
ü •Anemia —red blood cells are destroyed faster than they are made
ü •Jaundice —a buildup of a substance in the blood that causes the
skin to look yellow
ü •Swelling of the body, which can lead to heart failure or
breathing problems.
ü Diagnosis
A woman's Rh factor is tested at
routine visits.
1- Blood tests will be done to:
ü Find out if the mother is Rh positive or Rh negative
ü Look for Rh antibodies
ü Keep track of antibody levels
ý An amniocentesis may also be done. It removes and tests a small
amount of the fluid that surrounds the baby to find out if the baby is Rh
positive.
Management
There is a wide spectrum of severity of
neonatal Rh disease. A careful prenatal history, physical examination, and
laboratory studies are important in evaluating the neonate. Treatment of
hydrops fetalis is difficult. Phototherapy and exchange transfusion remain the
mainstays of therapy for hyperbilirubinemia. Additional therapies may include
phenobarbital, heme oxygenase inhibitors, intravenous immunoglobulin (IVIG),
and erythropoie-tin for late, hyporegenerative anemia.
Prevention
Rhesus disease
can largely be prevented by having an
injection of a medication called anti-D immunoglobulin. This can help to avoid
a process known as sensitization, which is when a woman with RhD negative blood
is exposed to RhD positive blood and develops an immune response to it.
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