High Risk Pregnancy PDF

HIGH RISK PREGNANCY I. Bleeding in Pregnancy - never normal Intervention: 1. Restoring blood volume - IV fluid replacement  Large-gauge angiocath is used for rapid fluid expansion - Obtain hemoglobin and hct levels and sec...

HIGH RISK PREGNANCY I. Bleeding in Pregnancy - never normal Intervention: 1. Restoring blood volume - IV fluid replacement  Large-gauge angiocath is used for rapid fluid expansion - Obtain hemoglobin and hct levels and securing sample for typing or cross-matching 2. Administering O2 by mask if respiration is rapid 3. Assess of signs of hypovolemic shock (↓Bp, ↑PR, ↑ RR, ↓UO, restlessness) 4. Monitor FHR 5. Complete Bed rest: lateral position 6. restrict sexual intercourse 7. Ultrasound to assess for integrity of sac A. FIRST-TRIMESTER BLEEDING ABORTION – any interruption of a pregnancy before the fetus is viable. CAUSES OF SPONTANEOUS ABORTION 1. Abnormal fetal formation – due to teratogenic factor or chromosomal aberration 2. Implantation abnormalities - Inadequate endometrial formation - inappropriate site of implantation 3. Inadequate production of progesterone by corpus luteum 4. Infection rubella, syphilis, poliomyelitis, cytomegalovirus, toxoplasmosis, UTI 5. ingestion of teratogenic drug (eg, isotretinion (Accutane) 6. severe maternal malnutrition  Presenting symptom : painless vaginal bleeding TYPES OF ABORTION/MISCARRIAGE 1. Threatened miscarriage  Manifestations: - Bright red vaginal bleeding (initially scanty) - Slight cramping - No cervical dilatation  Diagnostic procedures  - ultrasound – to evaluate the viability of the fetus - Human chorionic gonnadotropin (hCG) – drawn at the start of bleeding then after 48 hours  Intervention - Limiting activities for 24 to 48 hours - Normal activity is resumed when bleeding stops - Coitus is restricted for 2 weeks after the bleeding episodes - Complete bed rest is usually not indicated because blood may pool vaginally. - Emotional support 2. Imminent (Inevitable Miscarriage) - there is uterine contractions and cervical dilataion - the loss of the products of conception cannot be halted  Diagnostic procedures - Ultrasound – could reveal empty uterus or nonviable fetus.  Client should be instructed to save any tissue fragments she has passed A. Complete Miscarriage - the entire products of conception are expelled spontaneously without any assistance. - Bleeding usually slows within 2 hours and ceases after a few days B. Incomplete Miscarriage - part of the conceptus (usually fetus) is expelled but the membranes or placenta is retained in the uterus. - Danger : hemorrhage Retained conceptus in the uterus Uterus cannot contract effectively hemorrhage  Management: - Dilatation and Curettage (D &C) - to evacuate the remainder of pregnancy from the uterus. - After D&C, vaginal bleeding is assessed by recording the number of pads used. C. Missed Miscarriage – “early pregnancy failure” - The fetus dies in the utero but is not expelled.   Manifestation: - painless vaginal bleeding or - no prior clinical symptoms  Diagnostic procedures - prenatal examination - no increase in the fundal height - no fetal heart tone previously heard - Ultrasound – can establish that the fetus is dead  Management: - D&C - If pregnancy is over 14 weeks, labor may be induced - prostaglandin suppository or misiprostol (Cytotec) - Used to dilate cervix - If not done, spontaneous miscarriage usually occurs within 2 weeks.  Complication: Disseminated intravascular coagulation (DIC) Septic Abortion – infection accompanies abortion  Recurrent pregnancy loss - three spontaneous miscarriages that occurred at the same gestational age. - Previously termed as “habitual aborters” - Causes 1. defective spermatozoa or ova 2. endocrine factors (eg thyroid problems) 3. Deviations of the uterus 4. Infection 5. Autoimmune disorders COMPLICATIONS OF MISCARRIAGE 1. Hemorrhage - common with incomplete miscarriage or to those who develops DIC  Management: - D&C - Methylergonovine maleate (Methergine ) – to aid with uterine contraction - assess Bp prior to administration - SE: hypertension - Notify physician if Bp rises > 25mmHg (systolic) >20mmHg (diastolic) over the baseline  Intervention: - Position woman flat and massage the uterine fundus to aid contraction  - Discharge instructions:  Monitoring bleeding by counting the number of pads used  What color changes she should expect  Any unusual odor or passing of large clots is abnormal 2. Infection - usually due to Escherichia Coli (spreads from rectum to vagina)  Danger signs a. fever - transient reaction to  fluid intake that preceded the miscarriage - systemic reaction to infection b. abdominal pain c. foul vaginal discharge  Intervention: - Prevention: Proper perineal hygiene. - Caution her not to use tampoons to control vaginal secretions 3. Septic Abortion - an abortion is complicated by infection - can happen after spontaneous abortion - more common in those who tried to self- abort  Manifestation: a. Fever b. Crampy abdominal pain c. Uterus feels tender on palpation  Management: a. High dose broad-spectrum antibiotics (combination of penicillin and clindamycin is commonly used) b. Indwelling catheter – to monitor urine output c. D&C – to remove all infected or necrotic tissue from the uterus d. tetanus toxoid or tetanus immune globulin for prophylaxis againt tetanus.  Complication: a. Toxic shock syndrome b. Septicemia c. Kidney failure d. Future infertility (due to uterine scarring or fibrotic scarring of the fallopian tube) 4. Isoimmunization Placenta dislodged (birth, D&C) Woman is Rh (-) Fetal blood enters maternal circulation Fetus is Rh (+) Production of antibodies against the Rh(+) blood If next child is Rh (+), antibodies would attempt to destroy RBC of the next child Hemolytic disease of the newborn / erythroblastosis fetalis Diagnostic procedure: - Rh (-) woman have anti- D titer  Management: - If wowan have high anti-D titer (1:16 or greater)- titer is monitiored approximately q 2 weeks - If woman is Rh (-) : - Adminstration of Rh immune globulin (RhoGAM)= To prevent the build up of antibodies in case the fetus is Rh (+) a. miscarriage b. 28 Weeks of pregnancy (can not cross placenta) c. within 72 hours after delivery (if fetus is Rh +/ Coombs (-) d. passive antibodies are transient - BT in utero - Exchange transfusion after birth B. ECTOPIC PREGNANCY - ONE IN WHICH IMPLANTATION OCCURS OUTSIDE THE UTERINE CAVITY - may occur on the surface of ovary, in the cervix, or in the fallopian tube. Possible Causes: 1. congenital defects of reproductive tract 2. diverticular disease  3. endosalphingitis 4. progestin-only hormonal contraceptive pills 5. sexually transmitted tubal infection 6. transmigration of ovum from one ovary to the opposite tube resulting in delayed implantation 7. tubal damage from pelvic inflammatory disease 8. Previous pelvic or tubal surgery 9. tumors pressing against the tube 10. use of intrauterine device (IUD)  Manifestations: No unusual symptoms at the time of implantation a. Signs of pregnancy - amenorrhea - nausea and vomiting - +hCG on pregnancy test b. Early signs: - Dull unilateral lower quadrant (pelvic or abdominal) pain - Irregular vaginal bleeding c. If ruptures: - sudden severe abdominal pain, - referred shoulder or neck pain (abdomen fills with blood) - signs of shock - Cullen’s sign – bluish tinged umbilicus - Syncope (fainting)  Diagnostic procedure: - Transvaginal ultrasound – will demonstrate 1. ruptured tube 2. collecting fluid in the pelvis - falling hCG or serum progesterone (the pregnancy has ended) - Culdocentesis (aspiration of fluid from vaginal cul-de-sac) detects free blood in the peritoneum  Management: - Laparoscopy - Purposes 1. to ligate the bleeding vessels 2. to remove or repair the damaged fallopian tube. - Rh immune globulin in patient who is Rh (-) - Methotrexate - a folic acid antagonist chemotherapeutic agent - attacks and destroys fast-growing cells - the drug is drawn to the site of the ectopic pregnancy - Mifepristone - An abortifacient  - Causes sloughing of the tubal implantation - Advantage : the tube is left intact, no scarring on the FT - Surgery: oophorectomy, hysterectomy, salphingectomy II. SECOND-TRIMESTER BLEEDING A. GESTATIONAL TROPHOBLASTIC DISEASE (Hydatidiorm Mole, molar pregnancy) - a proliferation and degeneration of the trophoblastic villi - abnormal pregnancy that results in grapelike clusters of vesicles - highest incidence among 40y/o Two types: a. complete mole – there is neither an embryo nor amniotic sac b. partial mole – there is an embryo (usually with multiple anomaly) and an amniotic sac Possible Causes: a. chromosomal abnormalities b. hormonal imbalances c. protein and folic acid deficiency d. previous molar, ectopic and normal pregnancy or spontaneous or induced abortion  Diagnostic procedures: - Ultrasound - shows dense growth - no fetal outline  Manifestations: - uterus expands faster than normallly - no fetal heart sounds - strongly positive serum or urine test of hCG for pregnancy - marked nausea and vomiting - symptoms of hypertension prior week 20 of pregnancy - at week 16 of pregnancy – vaginal bleeding - vaginal spotting of dark-brown blood or profuse fresh flow - clear-fluid-filled vesicles Fluid-filled, grape-sized vesicles  Complication: choriocarcinoma  Management: Suction curettage – to evacuate the mole - After mole extraction 1. Baseline pelvic examination, 2. Chest x-ray (to check for lung metastasis) 3. Serum test for beta subunit of hCG a. every 2 weeks x 6 months b. then every 2 months for 6 months.  gradually declining hCG titer = no complication  plateau for 3x or increase = suggests malignancy - Client teaching: - avoid pregnancy for at least a year - do not use contraceptive with estrogen because estrogen promotes regrowth of chorionic villi - Methotrexate - drug of choice - causes leukopenia – decrease WBC B. PREMATURE CERVICAL DILATATION - previously termed “incompetent cervix” - refers to a cervix that dilates prematurely and therefore cannot hold a fetus until term. - Commonly occurs at week 20 of pregnancy  Manifestations: - painless dilatation of the cervix - show (pink-tinged vaginal discharge) - increased pelvic pressure - rupture of the membrane - discharge of amniotic fluid - uterine contractions  Risk factors: - increased maternal age - congenital structural defects – short cervix - trauma to cervix (cone biopsy or repeated D&C)  Management: - Cervical cerclage – suturing of cervix at around 14 weeks a. Mc Donald – temporary; vaginal approach b. Shirodkar - permanent; transabdominal Prerequisites: 1. cervix is not dilated beyond 3 cm 2. intact membrane  3.no vaginal bleeding or uterine cramping - Ultrasound confirms that the fetus is healthy. - Regional anesthesia is used - After procedure, client remains on bed rest (slight or modified Trendelenburg) for a few days to decrease the pressure on the suture. - Restrict activities (coitus) III. THIRD-TRIMESTER BLEEDING A. PLACENTA PREVIA – LOW IMPLANTATION OF THE PLACENTA  Four degrees: a. Low-lying – placenta implants near the internal os with its margin located about 2-5 cm from the os b. Marginal – the edge of the placenta is lying at the margin of the internal os c. Partial – placenta partially covers the internal os d. Total – placenta completely covers the internal os when the cervix is fully dilated Risk factors: - advanced maternal age - past ceasarean section - past uterine curettage - multiple gestation Placenta forced to spread to find adequate exchange surface Placenta previa Late in pregnancy: Lower uterine segment starts to differentiate from the upper segment Placenta unable to stretch to accommodate the differing shape of the uterus Bleeding  Manifestations: - Bleeding - abrupt - painless - bright red  Danger: - maternal hemorrhage  - fetal oxygen may be compromised  Management: - Immediate Care a. Bed rest on side-lying position. b. Assess for hypovolemia c. Monitor fetal heart rate d. No IE, or rectal exam (if necessary : done only in an OR with double set up) e. Keep IV line and make blood available (blood typed/ cross matched) f. Position: marginal or low lying - semi-fowler’s Partial or total - trendelenburg - Continuing care measures a. If bleeding stops, client may be sent home with a referral for bed rest. b. Restrict activities (heavy lifting/standing for long periods) c. Coitus is contraindicated d. Diet: high iron, high fiber (to prevent constipation/ straining) a. Client is more prone to hemorrhage because 1. lower uterine segment does not contract as effectively as the upper segment 2. larger denuded surface area - Birth : CS B. PREMATURE SEPARATION OF THE PLACENTA (ABRUPTIO PLACENTA) - the placenta which have been implanted correctly suddenly begins to separate and bleeding results. - Occurs late in pregnancy - May occur during the first and second stage of labor.  Cause: Unknown  Predisposing Factors: - high parity - short umbilical cord - chronic hypertensive disease - hypertension of pregnancy - vasoconsriction from cocaine use - direct trauma - smoking  Manifestations: - sharp, stabbing pain high in the uterine fundus - pain during contraction is over and above the pain of contraction  Excessive bleeding - tenderness on uterine palpation - with or without vaginal bleeding - heavy bleeding a. external bleeding – if placenta separates on the edge first b. internal bleeding – if placenta separates on the center first - couveliare uterus or uteroplacental apoplexy - blood infiltrate the uterine musculature - uterus is tense and rigid, board-like  Classifications: According to separation 1. partial 2. marginal 3. complete  Classification: According to hemorrhage 1. Occult hemorrhage – placenta separates centrally and a large amount of blood is accumulated under the placenta 2. Apparent hemorrhage – separation along the placental margin and blood flows under the membranes and through the cervix  Degrees of Separation: Grade 0 - No symptoms of separation were apparent from fetal and maternal VS - Diagnosis is made after placental delivery 1 - Minimal separation - + Vaginal bleeding - + changes in maternal VS - no fetal distress - no shock 2 - Moderate separation - + fetal distress - uterus is tense - painful on palpation 3 - extreme separation - maternal shock and fetal death will result if no immediate intervention is done  Complication: DIC Body attempts to halt bleeding through clot formation Woman’s reserve of blood fibrinogen is used up Disseminated Intravascular Coagulation  Management: 1. Fluid replacement 2. O2 administration to limit fetal anoxia 3. Monitor fetal heart rate and maternal VS q 5 to 15 minutes 4. Fibrinogen determination up to the time of delivery 5. Position: lateral 6. Do not perform vaginal and pelvic examinations or give enema 7. If happened during the active labor, a. membranes can be ruptured (amniotomy) b. labor augmented with IV oxytocin 8. If birth is not imminent, CS is delivery method of choice A. PRETERM LABOR - LABOR THAT OCCURS BEFORE THE END OF THE WEEK 37 OF GESTATION - if it occurs before 20th week, it is abortion  Cause: Unknown  Associated with: - dehydration - UTI - Chorioamnionitis (infection of the fetal membranes and fluid)  Risk Factors - African-American women - Adolescents - Those who receive inadequate prenatal care - Those who continue strenuous activity during pregnancy - Those who perform shift work  Manifestations - persistent, dull low backache - vaginal spotting - a feeling of pelvic pressure or abdominal tightening - menstrual cramping - increased vaginal discharge - uterine contractions - intestinal cramping - progressive cervical dilatation - effacement  Management: If - Fetal membranes are intact - there is no sign of fetal distress - No evidence of bleeding - Cervix is not dilated >4-5 cm  - Effacement is not more than 50% Halt labor a. Women is placed on bed rest b. IVF therapy dehydration Pituitary gland activated to release ADH Pituitary gland may also release oxytocin Oxytocin strengthens uterine contractions c. Rule out infection – vaginal and cervical cultures, urinalysis d. Maintain adequate nutrition e. Client advised not to smoke f. Administration of Tocolytic agents (drugs that halt labor) 1. beta-symphatomimetic drugs - beta –2 receptors found in a. uterine smooth muscle b. broncial smooth muscle c. blood vessels - acts by coupling with adrenegic receptors on the outer surface of the membrane of the myometrial cells. a. Ritodrine HCl (Yutopar) side effects: - nausea - vomiting - Most Common SE: headache (cerebral blood vessels dilation) Adverse effects - causes mild hypotension - mild tachycardia - hypokalemia - pulmonary edema - hyperglycemia - hypotension Nursing Consideration: 1. Before administration, obtain baseline blood data (hct, hgt, K, NaCl, CO2), and ECG 2. An external uterine and fetal monitor should be in place if possible.  b. Terbutaline (Brethrine) - dose is calculated, increased q 10 minutes until contractions is halted - After contractions is halted, infusion continued x 12 to 24 h - Oral dose is begun 30 minutes before the IV med is stopped Nursing Consideration: 1. Mix drug with LR rather than D5W (to prevent hyperglycemia) 2. Assess Bp q 15 minutes while the flow rate is being increased and q 30 minutes thereafter 3. Assess for crackles, chest pain and dyspnea 4. Promptly report PR > 120 bpm Bp < 90/60 mmHg 5. Monitor I/O (risk for fluid overload) 6. Daily weights 7. Observe FHR, late decelerations, variable deceleration (suggest possible uterine bleeding) 8. Instructions to patient discharge with oral med. - Take her pulse before taking med. - If she forget a dose, take it as soon as she remembers it but do not double the dose t make up for the missed dose. 2. Steriod (eg betamethasone) - hasten fetal lung maturity - usually 2 doses IM, 24 hr apart - Takes about 24 hours to take effect - Effect lasts for approx 7 days. LABOR CAN NOT BE HALTED IF a. membranes have ruptured b. cervix is 50 % effaced c. 5-6cm dilated Delivery: 1. CS – if the fetus is too immature - to prevent pressure on the fetal head - to reduce the possibility of subdural and intraventricular hemorrhages. - 2. Epidural anesthesia is preferable. 3. If NSD, episiotomy is done to reduce pressure on the fetal head. 4. After delivery, cord is immediately clamped. - to prevent extra blood to be transferred to the baby  - to prevent extra load of bilirubin B. PRETERM RUPTURE OF MEMBRANE - rupture of the fetal membranes with the loss of amniotic fluid during pregnancy.  Cause: unknown, but associated with infection of the membrane  Complications: - Fetal and uterine infection - Cord prolapse - Increase pressure on the umbilical cord inadequate fetal nutrients.  Manifestation: - sudden gush of clear fluid form vagina  Diagnostic procedures: 1. Nitrazine paper test: a. Amniotic fluid is alkaline = nitrazine paper turns blue b. urine is acidic = nitrazine paper remains yellow 2. fluid is tested for ferning (swabbing and drying on a slide and viewing in the microscope) = typical appearance of high estrogen fluid on microscopic examination. 3. Ultrasound done to assess amniotic fluid index 4. Cultures for vaginal infection (Neisseria gonorrhea, beta- streptoccoci, Chlamydia)  Management: 1. Labor does not begin and fetus is too young to survive, the client is put on strict bed rest (home or hospital) 2. Administration of antibiotics 3. Vaginal examinations are avoided 4. If the fetus is mature enough to survive extrauterine life, and labor does not occur in 24 hours = IV administration of oxytocin 5. monitor for signs of infection (temp  100.4F) 6. No coitus or douching IV. PREGNANCY-INDUCED HYPERTENSION - a condition in which vasospasm occurs during pregnancy - previously termed ”Toxemia”  Risk factors: 1. primipara younger than 20 y/o 2. primipara older than 40 y/o 3. low socioeconomic background ( poor nutrition) 4. women with multiple pregnancy 5. women with hydramnios 6. women with undelying diseases (heart disease, DM, essential HPN) Pathophysiology  Systemic peripheral vascular spasm Vascular effects Endothe Kidney effects damage Vasoconstriction thrombocytope  Bp Poor Organ  GFR &  perfusion permeability of Pancreas Placenta glomeruli Epigastric pain  OU  serum BUN, Reduced fetal O2 & creatinine, uric a nutrient proteinuria supply  reabsorption of Na Diffusion of fluid from IVC to interstitial space Pulmonary Retinal edema Cerebral edema edema edema Vision Headache changes seizure **If retinal hemorrhage occurs, blindness can result Classic signs: HPN, proteinuria, edema  Classifications: 1. gestational HPN – elevated Bp (140/90mmHg) - no proteinuria nor edema  Management: low dose aspirin – because of anti platelet function 2. Mild preeclampsia  Manifestations: - Bp = 140/90mmHg on two occasions at least 6 hours apart - Or systolic pressure is 30 mmHg / diastolic pressure is 15mmHg above baseline - Proteinuria (1+ or 2+) random sample (1+ is 1 g/li) - Edema that accumulates in the upper part of the body - Weight gain: >2lb/week in the second trimester >1lb/week in the third trimester  Nursing Intervention: 1. Promote bed rest - in lateral position, Na tends to be excreted at the faster rate than during activity. 2. Promote good nutrition 3. Provide emotional support - usually seen approximately weekly or more frequent for the remainder of pregnancy 3. Severe preeclampsia  Manifestations: - Bp = 160/110mmHg or above on at least two occasions at least 6 hours apart at bed rest - Marked proteinuria (3+ or 4+) or more than 5g in a 24-hour urine sample - Extensive edema (face and hands are puffy) - UO =400 – 600ml/day - Severe epigastric pain - Visual changes - Cerebral edema - Ischemia of pancreas and liver  Nursing Intervention: 1. Support bed rest - private room - quiet environment - padded side rails - darkened - visitors are restricted - Avoid stress 2. Monitor Maternal well-being - Monitor Bp (at least q 4 h) - Obtain blood studies including typing and cross matching - Obtain daily hematocrit  - Daily assessment of the optic fundus - Accurate assessment of the IO (catheterized) - Obtain daily weights 3. Monitor Fetal well-being - Assessment of the FHR q h - Non-stress test or biophysical profile done - O2 administration to the mother 4. Support Nutritious Diet - Diet: moderate to high protein, moderate Na - IV line for emergency use 5. Administer Medication to prevent Eclampsia 1. Anti-hypertensive drugs: Hydralazine (Apresoline) - Assess Bp before administration. - Diastolic pressure should be at least 80 to 90 mmHg - Common SE: headache 2. Magnesium sulfate: drug of choice - cathartic - reduces edema by causing fluid shifting from ECS to intestine - has CNS depressant action - may halt uterine contraction Nursing implication: a. Withhold medication or stop infusion if 1. deep tendon reflex is depressed or absent 2. urine output is less than 30 ml/hr (catheterize for accurate measurement) 3. RR < 12 cpm 4. absent bowel sounds b. Assess for other signs of toxicity - Lethargy - Weakness - Diaphoresis - Flushing - Feeling of warmth - Nasal congestion c. Obtain serum magnesium level q 6 – 8 hrs d. Mg level should be 4-7mEq/Li e. Keep antidote: calcium gluconate readily available f. After delivery, assess child for respiratory depression if given (IV) within 2 hours of the birth g. assess for ankle clonus h. given until 12 to 24 h after delivery. 4. Eclampsia  Manifestations: - Manifestations of severe preeclampsia - seizures (due to severe cerebral edema)  Complications - cerebral hemorrhages - circulatory collapse - renal failure - fetal hypoxia and acidosis - premature separation of placenta  Nursing Intervention 1. Tonic- clonic seizures a. tonic phase – all muscles of the body contract. (back arches, arms and legs stiffens, her jaw closes, respirations halt) - lasts approx 20 seconds. Care: 1. Patent Airway 2. Administer O2 by mask 3. Assess O2 saturation by pulse oximetry 4. Apply an external fetal monitor 5. Turn woman to side b. Clonic phase - all body muscles contract and relax repeatedly. - breathing is irregular - may aspirate saliva - incontinence of urine and saliva may occur - may be cyanotic - may last up to 1 minute - Magnesium sulfate or diazepam may be given IV c. Postictal phase - woman may be semicomatose and can be roused only by painful stimuli - may last for 1 to 4 hrs - danger: premature separation of the placenta Care: - keep woman on her side - continuously assess for FHR - Check for vaginal bleeding q 15 min   Birth: 1. If AOG >24 weeks, delivery is made when the woman stabilizes (usually after12 to 24 h) 2. Fetal lung maturity appears to advance rapidly 3. Preferred method: vaginal delivery 4. If labor do not occur: rupture of the membrane or IV administration of oxytocin. 5. Post partal HPN may occur 10 to 14 days after delivery. V. HELLP SYNDROME - a variation of PIH - Hemolysis, Elevated Liver enzymes, Low Platelets  First symptoms: nausea Epigastric pain General malaise Right upper quadrant tenderness  Laboratory results: hemolysis of the RBC Thrombocytopenia (>100,000/cu mm) Elevated liver enzyme (ALT, AST)  Management: 1. BT – fresh-frozen plasma or platelet  Complications: - liver hematoma - renal failure - hypoglycemia C. MULTIPLE PREGNANCY Single ovum and sperm Two ova, two spermatozoa Zygote divides into two Two placenta, two identical individuals chorion, two amnions, two umbilical cords One placenta, one chorion, two amnions, two umbilical cords Fraternal (dizygotic, non-identical) Identical (monzygotic) twins   Higher incidence among: - non whites - High parity - Older woman - Inheritance (familial maternal pattern of occurrence)  Manifestations: - uterus grows larger on a faster rate - woman reports flurries of action at different spot - multiple FHT on auscultation  Diagnostic procedures - Alpha-feto protein is elevated - Ultrasound  Management: - prevent postpartal bleeding - prevent/assess complcations : - PIH - Hydramnios - Placenta previa - Preterm labor - Anemia - twin to twin transfusion - if fetuses share vascular communication - overgrowth of one , undergrowth of the second - spinal cord defect on the fetus VI. HYDRAMNIOS - excessive amniotic fluid formation - (normally: 500 to 1000ml at term) - more than 2000 ml  Complications - fetal malpresentation ( extra uterine space where the fetus can turn) - premature rupture of membrane  Causes: - inability of the fetus to swallow (anencephalic, tracheoesophageal fistula with stenosis, intestinal obstruction) - excessive urine output of the fetus (fetus of diabetic mother)   Manifestations: - unusually rapid growth of the uterus - small parts of the fetus is difficult to palpate - auscultating the FHT is difficult - woman experiences : SOB - lower extremity varicosities, hemorrhoids - increased weight gain  Diagnostic procedure: Ultrasound  Management: - if severe- admitted to the hospital for bed rest rationale: bedrest helps to increase uteroplacental circulation and reduces pressure on the cervix - Educate woman on signs of premature rupture of the membrane. - Help prevent constipation (prevents increase in uterine pressure during straining) - Assess lower extremity for edema - Amniocentesis - After birth, assess newborn for factors that may have interferred with the ability to swallow VII. HYPEREMESIS GRAVIDARUM - persistent, uncontrolled vomiting that begins in the first weeks of pregnancy and may continue throughout pregnancy - results to dehydration, electrolyte imbalances, jaundice Manifestations: - continuous, severe nausea and vomiting - dry, coated tongue - dry skin, mucous membrane - nonelastic skin turgor - oliguria - rapid pulse - weight loss - fetid, fruity tongue - metabolic acidosis/alkalosis - jaundice Diagnostic evaluation: - ABG - Hct, hgb, elevated - Hypokalemia  - Decreased protein, chloride and sodium levels - Increased BUN - Urine: ketones are elevated - Urine specific gravity is increased Nursing Interventions: - IVF therapy - small frequent meals; bland solid foods - serve hot food hot and cold foods cold - avoid greasy and spicy foods - encourage liquids between meals - recommend upright position for 1-2 hr after eating (to prevent reflux) - frequent mouth care - suggest eating 2 or 3 crackers before getting out of bed - monitor weight VIII. GESTATIONAL DIABETES - diabetes that occurs during pregnancy (2-3%) - client may have a preexisting DM or may develop gestational diabetes while she’s pregnant Possible causes: - heredity - environment (infection, diet, exposure to toxins and stress) - lifestyle in genetically susceptible persons Risk factors: - obesity - history of delivering large neonates (>10 lbs) unexplained fetal loss, congenital anomalies in previous pregnancy - age older than 35 - family history Diagnostic Evaluation: - Glucose tolerance test - routinely done at 24- 28 weeks’ gestation (repeated at 32 weeks’ if woman is obese or over 40y/o) - if at high risk: done at the first prenatal visit, repeated between weeks 24-28 Glucose Screening Test Three Hour Glucose Glycosylated hemoglobin Tolerance Test (HbA)  8 hour fasting for FBS  ingest 100g glucose * measures glucose  Given 50g glucose  blood sugar level taken attached to hemoglobin load after 1, 2,3 hours  Blood sugar level *reflects average glucose  taken after 1 hour level over the past 4-6 fasting - 95 mg/dl months - If FBS is more than 1 hr -