High-risk pregnancy – is one in which a concurrent disorder (comorbidities such as heart disease, diabetes mellitus) pregnancy-

related complication, or external factor jeopardizes the health of the mother, the fetus, or both.

FACTORS IN HIGH RISK

• 2 or more premature deliveries (less than 37 weeks)

• 1 or more stillbirths
• CPD (cephalo pelvic disproportion) – a disproportion of the fetal head and mother’s pelvic
 Causes:
o Increased fetal weight
o Fetal position
o Problems with the pelvis
o Problems with the genital tract
 S/S:
o The delivery of the baby is obstructed
o The labor is prolonged

• Cervical incompetency (lumalambot or dilation occurs due to cervix weakness) within 16 – 22 weeks that is abnormal)
 The inability of the cervix to support a pregnancy to term due to structural and or functional weakness
 Painless and bloodless cervical dilation
 Premature cervical dilation between 16-22 weeks
Note:
• Uterine structural anomalies (uterus hindi competent)
• Multiple pregnancies, placental anomalies, AF abnormalities, Hemorrhage, retained placenta
• PN check-up inadequate (at least 4 times prenatal check-up if pregnant)
• Substance abuse (alcoholic, cigarettes)
• Malnutrition – can cause abortion due to lack of nutrition of the mother that contributes to the fetus
NOTE:
 CAUSE OF DEATH OF MOTHER (MORTALITY)
 Hemorrhage – loss of blood in the body that can lead to death
 PRE-ECLAMPSIA – due to an increase in blood pressure during pregnancy
 INFECTION – due to an increase in body temp (if severe)

HYPEREMESIS GRAVIDARUM (abnormal in pregnancy)

• Severe unremitting nausea and vomiting persisting after/beyond 1st trimester
• Due to high HCG (human chorionic gonadotropin hormone) levels = 1M to 2M IU (estimated)
 Normal HCG is 400,000 iu
• May result in weight loss, starvation with ketosis, F&E imbalance, malnutrition, dehydration
• Dehydration with Fluid & Electrolytes imbalance
MANAGEMENT
 May need hospitalization
 IVF 3L in 24h (to prevent dehydration with F and E imbalance)
 NPO for 24h
 May give Metoclopramide (antiemetics) – it’s used to help stop you from feeling or being sick (nausea or vomiting)
 ant
 Diet initiated as:
- Clear liquid – full liquid diet, soft diet, full diet but given in small frequent feedings
- Midnight snacks
- Parenteral vitamins and electrolytes
NURSING INTERVENTION
 Give IVF as ordered
 Monitor I & O
 Provide oral care
 Instruct patient to remain upright after meals to decrease reflux
 Dry crackers before arising
 Teach the client to conserve energy and promote rest
NURSING DIAGNOSIS OF HYPEREMESIS GRAVIDARUM
  Actual/potential fluid volume deficit
 Imbalance nutrition; less than body requirements
 Fatigue
 Ineffective coping
 Anxiety

TERATOGENIC MATERNAL INFECTIONS

 Teratogen (harmful to the fetus)
 Any factor, chemical or physical that adversely affects the fertilized ovum, embryo, or fetus
 Can involve either sexually transmitted or systematic infection
o T - Toxoplasmosis
o O - Other infection (syphilis, hepa B, HIV)
o R – Rubella > skin virus (tigdas hangin)
o C – cytomegalovirus (CMV)
o H – herpes simplex virus
TOXOPLASMOSIS
 CA (causative agent) – Toxoplasma Gondii found in animals (mice, sheep)
Note: pregnant woman cannot clean a garden with poops of cat or dog, because possible that poops have toxoplasmosis
 transmitted in the feces of cats who have consumed infected mice, & in meat from infected animals.
SAFETY ALERT: Prenatal teaching: do not handle cat litter, wash hands after handling cats, avoid raw & undercooked meats
 May be asymptomatic in humans or may cause influenza-like signs: fatigue, sore throat, rash, fever & eye pain
 May cause spontaneous abortion, intrauterine growth retardation & premature delivery
 TREATMENT: Antibiotics if diagnosed early, however, the neonatal disease may still occur

OTHERS
 The sexually transmitted disease will be discussed in gynecologic disturbances

RUBELLA/ GERMAN MEASLES

 CA: Rubella virus
 The maternal infection is mild but its effects on the fetus are severe.
Note: the first target of this disease is the heart that’s why the fetus has a fetal defect – kaya kapag nilabas bingi in 1 st tri.
Note: MMR was given at 18 months but in another country 12 months is ok.
Note: hindi pwedeng mabuntis ang babae kapag na injeckan na ng rubella vaccine for 3 months. Kasi kapag nabuntis
while she is not 3 months pedeng magkaroon ng congenital defect sa fetus na dadalhin nya.
 First Trimester Exposure:
 Deafness
 Eye defects (congenital cataracts & blindness)
 Cardiac malformation (PDA)
 Microcephaly, MR,
 Second /Third Trimester:
 premature labor, IUFD, DM, thyroid problems, neurologic defects
 S/s; pink maculopapular rash; starts on the face, caudal spread, slight fever, malaise, nasal catarrh, anorexia, arthralgia
may develop especially in adults
 TREATMENT: symptomatic/supportive
Cytomegalovirus (CMV)
 CA – herpes virus
 Droplet transmission from person to person
 Effects on the infant include:
 Neurological challenge (hydrocephalus “fluid in the head cavity”, microcephalus “small head”, spasticity,) with eye
damage (optic atrophy, deafness, liver disease
 Kaya kapag nilabas mahina ang utak or also called “bobo”
 As many as 75% of adult women have antibodies to CMV
 No tx

HERPES SIMPLEX VIRUS (Genital Herpes Infection)

 Systemic involvement (Viremia) and crossing the placenta to the fetus.
  1st tri-severe congenital anomalies or spontaneous miscarriage
 2nd tri & 3rd tri-premature birth, IUG retardation, and continuing infection of the newborn at birth
 Tx; IV or oral Acyclovir (Zovirax) during pregnancy

 Management:
 Antiviral agents – Acyclovir 200mg PO q 4 hrs for 5 days
 Sitz bath
 Analgesics

DANGER SIGNS OF PREGNANCY

1. Vaginal bleeding = vaginal bleeding should be reported immediately for further evaluation
 Mx: should be reported STAT > ask for LMP
2. Persistent vomiting (hyperemesis gravidarum) = nausea and vomiting that continue past the 12 weeks of pregnancy is
extended vomiting. It depletes the nutritional supply available to the fetus
 Mx: need to hospitalize
3. Chills and fever = may be evidence of intrauterine infection which is a serious complication for both the mother and fetus
 Hindi pwedeng mag high fever si pt. kasi can cause an infection that can lead to death and mortality
4. Sudden escape of fluid from the vagina = means that the membranes have ruptured. both the mother & the fetus are
threatened because the uterine cavity is no longer sealed against infection.
 Note: if the fetus is small & his head does not fit into the cervix, the umbilical cord may prolapse with the ruptured
membrane, and the head may be compressed against the cord. another dangerous complication is ascending infection.
o Ascending infection = urine from the outside goes to the inside which can lead to infection
5. Abdominal or chest pains = abdominal pains may mean tubal pregnancy that have ruptured, separation of the placenta
“abruption of the placenta”, preterm labor while chest pains may indicate pulmonary embolus that follows thrombophlebitis.

6. Absence of fetal heart sounds after they have initially been auscultated on the 4th & 5th month (may indicate intrauterine
fetal death - IUFD)
 Sepsis = infection sa dugo

7. Swelling of the face & fingers = edema, digital edema

 Cerebral edema = can cause seizures in the pt.
o NOTE: if the pregnant woman complaint epigastric pain, it is a warning sign for SEIZURE if she has edema
or swelling
o Mx: If the pregnant woman was in the bed, up the side rails to prevent falls that can lead to injury
 Lagyan din ng mga unan at tuwalya ang gilid.

8. flashes of lights or dots (scotoma) = imaginary vision

IN CASE: if there’s a person who was a seizure all
9. blurring of vision you need to do is “place his/her head to the
10. severe headache & dizziness ground until it stops to prevent head injury” and
** may mean signs of pregnancy-induced hypertension
at the same time “position him/her side lateral to
prevent stock secretion to his/her throat that
leads to aspiration”.
RISK FACTORS ASSOCIATED WITH PREGNANCY

A bleeding complication in pregnancy

First trimester (1-3 months)  abortion
 ectopic pregnancy
 Second trimester (4-6 months)  hydatidiform mole
 incompetent cervix – soft
Third trimester (7-9 months)  placenta previa > abruption placenta
 preterm labor (below 37 weeks)
 if there’s a bleeding complaint in prenatal check-up
 Mx:
o (1) Ask her LMP
o (2) How painful it is?
 If nag di-dysmenorrhea validate the cause by depending on the trimester

HYPERTENSIVE DISORDERS IN PREGNANCY

 Gestational hypertension
 Chronic hypertension
 Pregnancy induced hypertension
 Pre-eclampsia
 Eclampsia
 HeLLP syndrome
METABOLIC DISORDER IN PREGNANCY
 Gestational diabetes mellitus

MEDICAL CONDITIONS COMPLICATING PREGNANCY

 Heart disease

RISK FACTORS ASSOCIATED WITH PREGNANCY

 Advanced age of 35 yrs and above is a high-risk pregnancy
 Teenage pregnancy of 16 years and below is considered a high-risk pregnancy
Parity
o First pregnancy – is the period of highest risk
o Second / Third and Fourth pregnancy – the risk of death for the mother is at its lowest
o Fifth pregnancy – marked increase especially when the pregnant mother is over 40 years of age.

COMPLICATIONS OF PREGNANCY

A. FIRST TRIMESTER BLEEDING

1. Abortion
 the expulsion of the products of conception before the age of viability (fetus can survive extrauterine life)
 a fetus is less than 20 weeks (24 weeks in the us) or less than 500 grams

CAUSES OF ABORTION:

1. Abnormality in the germ plasma (defective ovum/ congenital defects)

2. Abnormality in the implantation process

3. Trauma – psychological, physical

4. Hormonal imbalance (low progesterone) =purpose of PROGESTERONE pang-pakapit, pang parelax, to maintain well
pregnancy

5. Intake of drugs – Cytotec = pangpalaglag

6. Infectious diseases – German measles, PTB, herpes

7. Presence of venereal diseases

8. Abnormality in the reproductive system

8. Severe malnutrition

early abortion – happens before 16 weeks

 late abortion – happens between 16 – 20 weeks

 TYPES OF ABORTION:
 Spontaneous (hindi inaasahan)= unintended termination of pregnancy at any time before the fetus has attained
viability.

 threatened = possible loss of the products of conception

S/SX: slight bleeding; mild uterine cramping but no cervical dilatation on vaginal examination; no passage of tissue
Mx: rest
o Management:
 Advise on complete bedrest for 24 to 48 hours > health teaching is to take rest
 Teach to save all blood clots passed & perineal pad used > walking can cause bleeding, so that’s why it
must be avoided
 Advise prompt reporting to the hospital if bleeding persists or increases
 Prevention of abortion: Avoid coitus (sexual intercourse) or orgasm (can cause contraction of the uterus
that can lead to abortion)

 INEVITABLE OR IMMINENT ABORTION – is a loss of a pregnancy that cannot be prevented

Clinical manifestation:
 Moderate to profuse bleeding
 Moderate to severe uterine cramping
 Cervix dilated = within <37 weeks of gestation
 Membrane rupture > BOW
 TYPES OF INEVITABLE ABORTION:
1. Complete – all products of conception are expelled (lumalabas) = no need to RASPA (D and C)

S/XS of complete abortion:

o Small negative bleeding

o Moderate cramping
o Close or partially open cervix
o Passage of complete placenta with the fetus

2. Incomplete – not all products of conception are expelled from the uterus. = RASPA needed

Signs and S/XS:

o Profuse vaginal bleeding (bleeds the most)

o Severe uterine cramping
o Open cervix
o Passage of fetus or incomplete placental tissue
o Other products are retained

 MISSED MISCARRIAGE
o Retention of all products of conception after the death of the fetus in the uterus

S/SX:

o No FHT w/ ultrasound
o Signs of pregnancy disappear

MX:

o Dilatation and Curettage = RASPA

SEPTIC ABORTION

 Abortion complicated by infection

S/XS:
 - Mild to severe bleeding
- Foul smelling vaginal discharge
- Severe uterine cramping
- Presence of fever

MX:

- Treat abortion
- antibiotics

HABITUAL OR RECURRENT PREGNANCY LOSS = spontaneous abortion in three or more successive pregnancies usually due to
incompetent cervix > it must not be incompetent the cervix during 1st tri and 2nd tri.

A. Induced abortion – is an intentional loss of pregnancy through direct stimulation either by chemical or mechanical means

Types of induced abortion:

1. Therapeutic abortion – to preserve the life of the mother > due to her condition kaya ayaw nyang magkaanak, like severe
hypertension during pregnancy
2. Elective abortion (ayaw nya talagang magkaanak) – to end a pregnancy because of a woman’s choice not to have a child yet

REASON FOR INDUCED ABORTION:

 Therapeutic – to end a pregnancy that life-threatening to the mother

 To end a pregnancy of a fetus found to have severe congenital abnormalities that may be incompatible with life
 To end an unwanted pregnancy that is a result of rape or incest (nabuntis ng family and relatives)

ECTOPIC PREGNANCY = “Kyawa”

- Any pregnancy that occurs outside the uterine cavity. Second leading cause of bleeding in early pregnancy

Types:

1. Ampular = most common type 90% - 95% (Fallopian tube)

2. Abdominal
3. Ovarian
4. Cervical

PREDISPOSING CAUSES:

 Salpingitis or Pelvic Inflammatory Disease

 Previous ectopic pregnancy

 Tumors that distort the tubes

 External migration of the ovum

 Intrauterine device (IUD)

 Adhesion of the fallopian tube from a previous infection

 Scars from tubal surgery

Signs and S/SXs:

 Vaginal spotting or bleeding

  Absence of amniotic sac

 Amenorrhea or abnormal menstruation -/ SPOTTING – most common sign

 Rectal pressure because of blood in the cul de sac

 Positive (+) pregnancy test in many women (50%)

Signs of hemorrhage:

 Cullen’s sign – bluish discoloration of the umbilicus due to the presence of blood in the peritoneal cavity

 Hard or rigid boardlike abdomen

Signs of hypovolemic shock:

 Falling Hgb, Hct

 Falling BP, rapid pulse, rapid RR
 Lightheadedness
 Pallor
 Cyanotic nail beds
 Cold clammy skin

DIAGNOSTIC AIDS

 Culdocentesis = aspiration of bloody fluid from cul de sac of Douglas indicating intraperitoneal bleeding from tubal
rupture

 Ultrasound = reveals presence of the gestational sac outside of the uterine cavity
 Laparoscopy = visualization of tubal pregnancy (considered the diagnostic GOLDEN standard)

Treatment and management:

 If not yet ruptured:

o Salpingotomy = removal of a conceptus less than 2 cm located at the distal portion of the fallopian tube by
performing a linear incision over the ectopic pregnancy. The conceptus will extrude from the incision and is
removed manually.
 If ruptured:
o Salpingectomy = Removal of the ruptured tube because the presence of a scar if tube is repaired and left can
lead to another tubal pregnancy.

NURSING CARE: prevent and treat hemorrhage which is the main danger of ectopic pregnancy.

 Blood transfusion
 Place patient flat in bed with legs elevated
 Monitor vital signs, I & O, & amount of blood loss
 Prevent infection as the woman who lost so much blood is susceptible to infection
 Contraception must be started upon discharge from hospital. Ovulation begins as early as 19 days or 3 weeks after resection
of ectopic pregnancy.
HETEROTOPIC PREGNANCY

 A tubal pregnancy with co-existing intrauterine pregnancy

SECOND TRIMESTER BLEEDING

1. GESTATIONAL TROPHOBLASTIC DISEASE (HYDATIDIFORM MOLE OR H-MOLE))- is a mass of abnormal rapidly growing
trophoblastic tissue in which avascular vesicles hang in grapelike clusters THAT PRODUCE LARGE AMOUNTS OF HCG.

 benign neoplasm of the chorion. The chorion fails to develop into a full-term placenta

Gestational trophoblastic disease

(hydatidiform mole)

Hydatidiform mole

PREDIPOSING FACTORS: - cause is unknown

 17 years old below and 35 years above

 Low protein intake
 Previous mole
 Higher incidence in Asian women

Types:

1. Complete mole = lacks an embryo or fetus (no fetal blood)

2. Partial mole = involves a chromosomally abnormal embryo or fetus (with fetal blood) = 69 XXX or 69 XXY

COMPLETE MOLE PARTIAL MOLE

• there is total hydatidiform change with no evidence of • associated with a fetus
fetal circulation • hydatidiform change is variable
• More common • trophoblast proliferation is of moderate degree
• proliferation of the trophoblast cells is marked • karyotype is either normal, trisomic or triploid 69xxx
• the karyotype is 46xx derived from paternal or xxy
 contribution • less likely to develop malignant change
• fertilization is by haploid (23x) sperm which duplicates
its chromosomes without cell division
• more likely to develop malignant change

CAUSES:

Signs and SXS:

 Rapid increase in uterine size greater than gestational age of the fetus

 Marked increase HCG titer; NV:400,00 iu

 Excessive nausea and vomiting due to elevated HCG

 Brownish vaginal discharge around 4th month containing grapelike vesicles

 No FHT is detected after 10 to 12 weeks, no fetal movement after 18-20 weeks

 No fetal parts/ no fetal skeleton

 Bleeding which may vary from spotting to profuse hemorrhage and is usually brownish but may be bright red

 Positive (+ ) pregnancy test

 Hypertension & other sx of preeclampsia

 Symptoms of PIH before 20th week gestation

**difference bet.H-mole & pre-eclampsia

- before 20 weeks =H mole

- after 20 weeks up to 2 weeks post-partum = preeclampsia

DX: = Passage of vesicles – first sign that aids in diagnosis

Triad signs:

1. Vaginal bleeding
2. Big uterus
3. HCG greater than 1 million
 Ultrasound will identify the characteristics of vesicles

Treatment and management:

  Evacuation by D and C or S and C to remove the mole. (if the woman is more than 40 years old, hysterectomy is done since
she has a higher change of developing CHORIOCARCINOMA
 Monitor HCG for 1 year (HCG should be negative 2- 6 weeks after removal of H-mole)
 Chest X ray every 3 mos for 6 mos. The lungs are the most common site of metastasis of choriocarcinoma
 Chemotherapy (Methotrexate) if:
-HCG titers are increased for 3 consecutive weeks or double at anytime
-HCG titers remain elevated 3-4 mos. after delivery
 The woman is advised not to get pregnant for 1-year, contraceptive method should NOT be the pills. Pills contain estrogen
which promote regrowth of the chorionic villi.
 Use mechanical equipment’s against pregnancy
Ex. Condom

Complications:

1. Choriocarcinoma= most dreaded complication

2. Hemorrhage – most serious during tyhe early tx phase
3. Uterine perforation
4. Infection

PROGNOSIS: - 80% remission after D&C; may progress to cancer of the chorion: CHORIOCARCINOMA

INCOMPETENT CERVIX OR PREMATURE CERVICAL DILATION:

 Painless cervical effacement and dilation in early mid trimester resulting in expulsion of the products of conception
 Most common cause of habitual abortion

CAUSES;

1. Increase maternal age

2. Congenital mal development of the cervix – short cervix
3. Trauma to the cervix (hx of repeated D & C’s; cervical lacerations with previous pregnancies)

Signs and Sxs:

 Presence of uterine contractions in mid trimester

 Rupture of the bag of waters

 Expulsion of the conceptus

 Presence of painless cervical dilatation

 Relaxed cervical os on pelvic examination

Mx:

1. CERVICAL CERCLAGE – medical management wherein the physician sutures a certain part of the cervix between 14- and 16-
weeks’ gestation to prevent cervical dilatation.
a. MCDONALD’S – (temporary) nylon sutures are placed horizontally & vertically across the cervix & pulled tight to
reduce the cervical canal to a few millimeters in diameter.

b. SHIRODKAR – (permanent) Sterile tape is threaded in a purse-string manner under the submucus layer of the
cervix & sutured in place to achieve a closed cervix.

Prerequisites of cervical cerclage

 Cervix not dilated

 Intact membranes
 No vaginal bleeding & uterine cramping