High Risk Pregnancy

High Risk Pregnancy

Bleeding in Early Pregnancy (before 20 weeks Gestation)

Causes

** Abortion.
** Vesicular mole (molar pregnancy )
** Ectopic pregnancy
** Local lesions

Abortion

It is termination of pregnancy before the fetus is capable to living outside the uterus prior 20 weeks gestation or with fetal weight less than 500 gm .

Types of abortion:

1-Spontaneous abortion
(occurring naturally )
2-Induced abortion
(artificial or mechanical interruption )

Miscarriage (Spontaneous Abortion)
Miscarriage is the another term for spontaneous abortion .

Causes of abortion

1-Fetal Causes .

2-Maternal causes .

Fetal Causes
1- Chromosomal abnormalities .
2- Diseases of fertilized ovum .
3- Hypoxia .

Maternal causes :

1-Drugs .
2-Weakened cervix .
3-Placental abnormalities .
4-Maternal infection .
5-Chronic Maternal disease .
6-Endocrine imbalances .

Classification of spontaneous abortion

Nursing Care

1- Complete bed rest.

2- IV line & IV fluid as doctor order .
3- All vaginal pads and linen should be kept to estimate the amount of blood loss.
4- Good personal hygienic care.
5- Checking of TPR and BP every 4 hours.
6- Avoid enema .

7- Take blood Sample for blood grouping, cross matching and hemoglobin.
8-pain killer according to the doctor order .
9- No sexual intercourse.
10- Observation of blood loss, odor, amount and content.

Nursing Care Plan :

**Nursing Assessment

1-Assess amount &characteristics of vaginal bleeding .

2-Monitor vital signs .

3-Assess FHS by Doppler 10-12 weeks .

4-Blood type .

5-Needs for anti D immune globulin

***Nursing Diagnosis

-Fears related to the risk of pregnancy loss .

-Pain related to abdominal cramping .

- Fluid volume deficit related to excessive bleeding .

***Implementation
1-Emotional support .
2- give her analgesic as doctor order .
3-Supplying women &her family with information about causes of abortion .

4-If she had D&C some one remain with her 12-24h .

5-Teaching the women to report

(episodes of heavy bleeding or tenderness )

6-Teach the women to report characteristics of bleeding (color –odor –amount)

7-Established and maintain intervenes line for fluid and blood products as prescribed .

8- monitor maternal vital signs every 4 hours .

9- monitor vaginal bleeding and evaluate fundal height to detect an increased in bleeding .

Surgical intervention

D&C, dilatation & curettage

This prevents delayed hemorrhage and infection related to retention of necrotic tissue.

Ectopic pregnancy

Definition

Implantation of a fertilized ovum outside uterine cavity.

The majority of ectopic pregnancies (96%-98%) are occur in the Fallopian tube so called tubal pregnancies .

Incidence

*0.5-1% of all pregnancies

Sites of Implantation

1-Uterine tube (most common) .

2-Ovary .

3-Cervix .

4-Abdomen .

causes

1.Anatomic ( scarring that blocks transport of the egg )

- Pelvic inflammatory disease (PID).
- Previous ectopic pregnancy
- Previous tubal surgery
- Previous pelvic surgery
- Endometriosis

2.Functional

- impaired tubal mobility .

Sings and Symptoms

1-Delay in menstruation from 1-2 weeks followed by slight vaginal bleeding 2-Abdominal tenderness on palpation.

3-Sharp , colicky pain on the affected side .

4-Nausea , vomiting .

5- Abdominal pain (usually result from stretching of the peritoneum , Once the tube ruptured, pain usually decreases or disappears).

6-Dizziness .

7- shoulder pain is late signs .

Management

-Management depend on whether the tube intact or ruptured .

-If the tube is intact and human chorionic gonadotrophin levels are declining it is indicates regression of the tubal pregnancy .

Medical

- Early treatment of an ectopic pregnancy with methotrexate.

-If administered early in the pregnancy, methotrexate terminates the growth of the developing embryo; this may cause an abortion, or the tissue may then be either resorbed by the woman's body or pass with a menstrual period.

Surgical

- If hemorrhage has already occurred, surgical intervention may be necessary.

- Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy ) .

-Replacement of fluid loss and maintenance of electrolyte are essential aspect of treatment .

Nursing care plan :

Assessment :

Maternal vital signs.

Presence and amount of vaginal bleeding.

Amount and type of pain.

Presence of abdominal tenderness on palpation/shoulder pain.

Blood grouping type.

Nursing diagnosis :

1-Acute pain R/T abdominal bleeding secondary to tube rupture .

2-Fluid volume deficits R/T blood loss

3-Grieving related to the loss of pregnancy and affect on future pregnancies .

4-Knowledge deficit related to the treatment and effect on future .

Ante partum Hemorrhage

Definition

Bleeding from the genital tract in the late pregnancy .

( Third trimester bleeding )

Causes of ante partum hemorrhage

Placental site bleeding:

1/ Placenta previa.

2/ Abruptio placentae.

Non-placental site bleeding:

1/Trauma.

2/ Rupture uterus

Placenta Previa

Definition:

Placenta previa occurs when the placenta develops in the lower part of the uterus rather than in the upper part .

Causes

1- Implantation of the zygote low down in the uterine cavity.

2- Placenta of large size ( twins pregnancy ).

Degrees of the placenta previa

-First degree (placenta previa lateralis )

The lower part of the placenta is implanted over the lower uterine segment, but does not reach the internal os.

-second degree ( placenta previa marginalis)

Part of the placenta is implanted over the lower uterine segment and its margin, reaches the internal os, but does not cover it completely

-third degree (Complete central Placenta previa)

The placenta covers the internal os completely even when it is fully dilated.

Clinical manifestation of placenta previa

The main symptoms of the placenta previa is:

- painless and recurrent bright- red vaginal bleeding.

- lower abdominal discomfort.

- Pale .

- cold sweat .
- Drowsiness .

- lowered BP .

On Abdominal examination:

-the uterus soft not tender .

-the fetal parts and heart sound (FHS) can be easily detected .

-malpresentation is common .

-Lie: usually oblique or transfer.
- Presenting part is not engaged.

Diagnosis of placenta previa:

1-clinical findings painless bleeding occurs suddenly and tends to be recurrent.

2-Abdominal examination .

3-Diagnostic procedures by transabdominal ultrasound , transvaginal ultrasound.

Management

The management of placenta previa depend on :-

-The amount of bleeding .

-The condition of mother and fetus.

-The location of the placenta .

-The stage of the pregnancy .

-If Sever vaginal bleeding Immediate delivery by cesarean section regardless of the location of the placenta .

-blood sample for blood grouping and cross matching .

-intravenous line .

If the bleeding is slight , or moderate correct anemia by blood transfusion and look to the gestational age:

I- if completed 37 weeks or more is terminated by induction of labor or caesarean section.

II- If less than 37 weeks , conservative treatment is indicated till the end of the 37 weeks ..

Vaginal delivery is allowed if the following findings are fulfilled:

I- Placenta previa is lateralis

II- Bleeding is slight.

III- Vertex presentation.

IV- Adequate pelvis with no soft tissue obstruction.

V- Partially dilated cervix to allow amniotomy.

Precautions before delivery:

1/ Blood volume one or two liters should be ready.

2/Equipment for resuscitation should be ready.

Precaution during delivery:

-Ergometrine should be given Intravenous with the delivery of anterior shoulder to prevent post partum hemorrhage.

Caesarean section is indicated if:

I- placenta previa centralis .

III- Severe bleeding

Complications of placenta previa:

A- maternal:

1- Preterm labor .

2- Postpartum hemorrhage .

B- fetal:

1- prematurity .

2- Asphyxia .

Nursing Management

1- History taking.

2- Immediate referral according to

the amount of blood loss.
3- Bed rest and restriction of physical activity for 72 hours after admission.
4- check vital signs especially BP .

5- Avoid infection by frequent care .
6- Observe signs of shock.
7- Listening for FHR every 4h.
8- Record intake and output.

9- Palpate uterus for tenderness and tone.

10-Monitor bleeding amount and colour of bleeding .

11-Do not perform vaginal examination because it may stimulate further bleeding

Abruptio placentae

Definition :

It is bleeding during the late months of pregnancy, due to premature separation of normally situated placenta.

Etiology

1.External trauma from fall or automobile accident .

2. Sudden drop of intrauterine pressure as rupture of membranes in polyhydramnios.

Predisposing factors

-Blood clotting disorders .

-Smoking .
-Previous history .
-Advanced maternal age .
-Short cord .

Classification according to separation of placenta :

Partial :

Detachment of part of the placenta .

Total :

Complete detachment of the placenta

marginal :

Detachment at the edge of the placenta .

Central :

detachment of the central surface of the placenta , edges stay attached .

Classification (according to hemorrhage) :

-Revealed hemorrhage .
-Concealed hemorrhage .
-Combined hemorrhage .

1.Revealed:
All the blood expelled through the cervix.

2.Concealed:
All the blood is retained inside the uterus.

- Occurs between the placenta and the uterine wall .

- The fundal size appears larger than the gestational age .

- pain and shock are common features.

- The uterus may become rigid and tender.

3.Combined:
some of the blood is retained inside the uterus and some is expelled through the cervix.

Clinical Manifestation:

These depend on the type of haemorrhage present .

1.Revealed:
    .Vaginal bleeding .
   . Present signs of blood loss.
   . Painful contraction
   . Felt fetal parts.
   . FHS heard.

2.Concealed:

. Sever abdominal pain

. Systolic BP decrease while diastolic remain increased.

. The abdomen is tender and rigid.

Diagnosis:
-History.

-Clinical examination .

-U/S helps in the diagnosis .

Management

When bleeding is slight(small placenta separation ) ,conservative treatment is given this include :

1/ bed rest and relaxation.

2/ Anemia should be corrected if present.

3/ The perineal pad should be inspected and perineal care done .

4/ patient must be kept under close observation .

5/ Drugs such as , folic acid and ferrous sulphate are given to prevent anemia.

6/ A gentle abdominal examination noting tenderness .

7-IV fluids and blood transfusions.

8-The mother will be carefully monitored for symptoms of shock.

9- The fetus condition will be monitor which includes an abnormal heart rate.

- If sever bleeding an emergency cesarean section may be needed.

-If the fetus is developed enough, vaginal delivery may be done if it is safe for the mother and child.

-Otherwise, a cesarean section may be done.

Complication :

-Acute renal failure.
- Postpartum hemorrhage .

–shock (hypovolemic ).

-hysterectomy (removal of the uterus) if bleeding not control .

Nursing management

-Immediate referral .
-Continuous observation of patient's general condition , vital signs , bleeding and signs of shock.

-Continuous observation of fetal condition.

-IV fluids and blood transfusions.
- Regular urine analysis for proteinuria .

- Recording of intake and output.
- Provide pre and post operative care.
- Advise the patient about importance of follow up for hypertension , anemia or any disorders . other disorder .

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نشرت فى 2 مارس 2012 بواسطة DlMuntasirM

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د/منتصر محمد عبدالله صالح / نهر النيل / شندى

High Risk Pregnancy

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