High Risk Pregnancy PDF

HIGH RISK PREGNANCY  Definitions:  A high-risk pregnancy defined as: - Any condition put the mother or fetus or both in problems.  1-Past obstetrical history: *Contracted pelvis or cephalopelvic disproportion *Pregnancy-induced hypertension *kidney disease...

HIGH RISK PREGNANCY  Definitions:  A high-risk pregnancy defined as: - Any condition put the mother or fetus or both in problems.  1-Past obstetrical history: *Contracted pelvis or cephalopelvic disproportion *Pregnancy-induced hypertension *kidney disease *Preterm labor * Anemia or hemorrhage *History of prolonged, obstructed or instrumental delivery. * Two or more breech. *Previous operative births (e.g. cesarean birth) * Genital tract infecti0n.  2- Current obstetrical history : Nullipara 35 years or over or less than 14 years *Multipara 40 years or over. *High parity. *Gestational diabetes. * Hyper-emesis gravidarium. *Pregnancy induced hypertension * Bleeding in early or in late pregnancy  Medical history: *Thyroid disease (hypo or hyperthyroidism). *Malnutrition or extreme obesity. *Heart disease *Diabetes mellitus *Tuberculosis or other serious pulmonary condition (asthma). * Malignant or premalignant tumors. *Psychiatric disease or epilepsy. * Mental retardation.  Fetal factors: Multifetal pregnancy. Malposition &/or malpresentation Previous low birth weight History of macrosomia (large infant; over 4kg). Two or more spontaneous preterm births. One or more stillbirths at term gestation. One or more gross anomalies. Rh- incompatibility.  Bleeding during pregnancy Early late Two Content Layout with Table First bullet point here Class Group A Group B Second bullet point here Class 1 82 95 Third bullet point here Class 2 76 88 Class 3 84 90  I. ABORTION Incidence 10—20% Aetiology 1.Chromosomal abnormalities: cause at least 50% of early abortions e.g. trisomy. 2.Blighted ovum (anembryonic gestational sac). 3. Trauma: external to the abdomen or during abdominal or.pelvic operations. 4. Endocrine causes: Progesterone deficiency,Diabetes mellitus, Hyperthyroidism. 5. Over distension of the uterus: e.g. acute hydramnios.. 7-Immunological causes: Systemic lupus erythematosus, Antiphospholipid antibodies that are directed against platelets and vascular endothelium leading to thrombosis, placental destruction and abortion. 8-Uterine defects Septum, Asherman's syndrome (intrauterine adhesions). 9-Idiopathic. Septic abortion * Anti D for Rh -ve patient Add a slide title – 4  Treatment – Stabilize vitals and Suction evacuation / curettage  After 12 weeks – IV oxytocin drip TTT N0 ACTIVE INTERVENTION  Treatment: The dead conceptus is expelled spontaneously in the majority of cases. Evacuation of the uterus is indicated in the following conditions: spontaneous expulsion does not occur within four weeks, there is bleeding, infection or DIC developed or, patient is anxious.  Evacuation is carried out as following: If the uterine size is less than 12 weeks’ gestation vaginal or suction evacuation is done If the uterine size is more than 12 weeks' gestation: evacuation can be done by Prostaglandins OR Oxytocin infusion. Hysterotomy: is rarely indicated in 2nd trimester missed abortion if the medical induction fails  Recurrent (Habitual) abortion: Recurrent abortion (more than 2 consecutive spontaneous abortions) Signs & Symptoms of Recurrent (Habitual) abortion: Pain and bleeding are usually absent or minimal. Treatment of Recurrent (Habitual) abortion: -Treatment of the cause such as cervical cerclage for cervical incompetence or treatment of causative diseases as syphilis, DM, etc. II-ECTOPIC PREGNANCY  INCIDENCE >1 in 100 pregnancies. Recurrence rate - 15% after 1, 25% after 2 ectopics  Signs and Symptoms 1. Short periods of amenorrhea. 2. History of infertility, tubal surgery, induced abortion 3. Sudden/recurrent severe, colicky abdominal pain in one iliac fosse or entire lower abdomen. 4. Dizziness and fainting attacks. 5. Blood stained vaginal discharge. 6. Diffuse tenderness on lower abdomen. 7. Signs of shock. 8. Dyspareunia  MEDICAL TREATMENT Methtrexate – Ectopic pregnancy size should be < 3.5 cm. IV/IM/Oral, usually along with Folinic acid.  III- Hydatidiform Mole (Vesicular Mole) Definition: Hydatidiform mole is abnormal development of the the chorionic villi in which the chorinic villi proliferate with formation of cluster of small cysts of varing sizes which look like a bunch of grapes. Causes: The exact cause is unknown.  Risk factors are: 1. Maternal age above 35 years or below 16 years. 2. Malnutrition (deficiency of proteins). 3. A hydatidiform mole in the prior pregnancy.  Signs and Symptoms: 1. Signs and symptos of early pregnancy are present 2. Excessive frequent vomiting. 3. The uterus is larger than expected for weeks of gestation. 4. Some vaginal bleeding may occur plus vesicles. 5. No fetal movements are reported by the mother. 6. No fetal parts can be palpated & fetal heartbeats not heard 7. On palpation the uterus is soft in consistency or it may be doughy. 8. There is an increased incidence of thyrotxicosis 9. Positive pregnancy test results in highly diluted urine up to 1/500.  Investigations  Pregnancy test of HCG level in urine.  Ultrasound scanning.  Complications  Hemorrhage.  Uterine sepsis.  Choriocarinoma.  Management Admit the woman into hospital. Prepare the woman for evacuation of the uterus under general anesthesia.  Bleeding In Late Pregnancy Third Trimester Bleeding Antepartum Hge  DIFFERENTIAL DIAGNOSIS Placental abruption Placenta previa Uterine Rupture Vasa previa  ACCIDENTAL HEMORRHAGE (ABRUPTIO PLACENTA)  ABRUPTIO PLACENTA Premature separation of the normally implanted placenta Occurs in approximately 1 in 120 births Accounts for 15% of perinatalmortality  RISK FACTORS Idiopathic Maternal hypertension (>140/90) Blunt abdominal trauma Chorioamnionitis Previous abruption Smoking  Types Revealed: (peripheral) detachment of placenta. External hemorrhage. Concealed Central separation with adherence of edge. Retroplacental hematoma provoke more separation. Mixed.  Clinical picture A- concealed accidental Hge. Severe abdominal pain. Shock ( hemorrhage & pain). Abdominal examination. Tender & rigid abdomen. Fundal level higher than period of amenorhea. B- Revealed accidental Hge. Vaginal bleeding. Mild abdominal pain. Signs hypovolemic shock.  Investigation. U/S: Exclude placenta previa. Viability of fetus. Retroplacental hematoma. Urine analysis: Proteinurea.  Complication of concealed type Fetal and maternal death. Acute renal failure. DIC Postpartum Hge.  Management A-Concealed & mixed types: Correction of shock. Termination usually by induction of labour or CS B- Revealed type: Severe hge: Correction of shock followed by CS. Mild Hge. Hospitalization. monitoring of maternal & fetal condition. Anti D for Rh -ve mother.  Role of the Nurse Immediate referral of patient to hospital on appearance of any signs or symptoms of abruption-placenta. Continuous observation of patient’s general condition, blood pressure, vital signs, bleeding and signs of shock. Continuous observation of fetal condition. Initiation and continuous observation of IV transfusion. Give medications accurately; (hypertension and  PLACENTA PREVIA Definition: Placenta located in the lower uterine segment after gestational age of viability. Incidence: 1:200  Etiology Unknown? Scarred uterus. High parity. Multiple pregnancy.  Degree 1 --st degree: The lower edge within 3 cm from internal os. 2 --nd degree: The lower edge of the placenta is just reaching the internal os but not covering it. 3 --rd degree: The placenta cover the closed internal os when closed and partially cover the os when dialated 4 --th degree: The placenta completely cover the internal os even when dilated.  Clinical picture Symptoms: Vaginal bleeding ( causeless, painless & recurrent) Signs: Vital signs Pallor No vaginal examination ( u/s first to exclude placenta previa)  Investigation U/S: ( Trans-abdominal versus Transvaginal ) HB level & HCT value. MRI or Doppler when placenta accreta is suspected.  Treatment Resuscitation: I.V. line & fluid, cross matched blood. Indication of termination: Mature fetus (after 37 w). Dead fetus Active labour pain. Attack of severe bleeding.  Methods of termination The role by CS except: st degree placenta previa. nd degree placenta previa (anterior)