HIGH-RISK PREGNANCY - Diabetes Mellitus

- A concurrent disorder that threatens the health of the - Cardiac Diseases

woman, the fetus, or both. FETAL COMPLICATION
- Risk factors are categorized into three: 1. Folic Acid deficiency = Neural tube defects
o Minimal 2. Protein deficiency = Poor development of the fetus
o Moderate and growth restriction
o Extensive 3. Iron deficiency = low fetal birth weight and
preterm birth
Factors that categorize a Pregnancy as High Risk 4. Sickle cell Anemia = inherited form of anemia,
1. Psychological insufficient amount of RBC
- Hx of drug - Poor acceptance of 5. Tay-Sachs Disease = genetic disorder, destruction
dependence pregnancy of nerve cells in the brain and spinal cord
- Hx of abuse - Hx of complicated
PREGNANCY INDUCED HYPERTENSION
(sexual) pregnancy
(PIH)
- Hx mental illness - Seperation to infant
- A condition which vasospasm (constriction of blood
- Loss of support - Lack of preparation
vessels) occurs during pregnancy in both small and
person
large arteries.
- Illness of a family - Illness in newborn
- Also known as “Toxemia of Pregnancy”
mem.
- Most common complication in pregnancy
- Decreased self- - Disappointing infant
esteem birth Chronic Hypertension: elevated blood pressure before
pregnancy
2. Social
- Occupation w/ - Conception gap is short  Cause of PIH is unknown but it may be related to
toxic substance (one year) pre-existing hypertension & kidney disease
- Environmental - Lack of support person CARDINAL SIGNS
Contaminants 1. Hypertension
- Low economic - Inadequate home for  Poor organ perfusion
level NB care
 Elevated blood pressure
- Poor access to - Unplanned cesarean
2. Proteinuria
transportation birth
 Increased serum blood urea nitrogen, uric acid,
- Poor housing - Exposure to
and creatinine
- Disruptive family environmental
incident teratogens  Protein from blood flows to the urine
3. Edema
3. Physical  Diffusion of fluid from bloodstream into
- Pelvic misshape - Possible blood interstitial tissue
- Fluid imbalance incompatibility
 Occult – marked increased in weight
- Uterine - 17 below/ 35 above of
 Clinical – mild/severe in nature; severity is
incompetency age
related to worsened preeclampsia
- Secondary major - Smoker/ substance
illness abuse  Facial – puffiness of eyelids
- Poor gynecologic/ - Subject to trauma PIH CLASSIFICATIONS
obstetric hx - Bleeding disruption 1. Gestational Hypertension
- Cephalopelvic - Poor placenta form  Elevated blood pressure (140/90 mm Hg)
disproportion - Retained placenta without proteinuria or edema
- Obesity, - Nutritional deficiency  New hypertension developed by a pregnant
underweight - Gestational diabetes woman
- PID & PIH - Hemorrhage &  Occurs 20 weeks of gestation; blood pressure
- Dystocia Infection returns after birth
- Post maturity - Lacerations 2. Pre-eclampsia
- AF abnormality - Multiple gestation  Elevated blood pressure with proteinuria and
edema; No seizures
 17 below/ 35 above of age are at risk for:  Occurs 20 weeks of gestation
o Low birth weight of newborn  With 2 classification:
o Preterm neonate o Mild Pre-eclampsia
o Anemia  Blood pressure: 140/90 mm Hg
o Labor dysfunction  Proteinuria: 1+ or more
o Cephalopelvic disproportion  Mild Edema: upper body extremities or
COMPLICATIONS: face
First Trimester o Severe Pre-eclampsia
- Abortion  Blood pressure: 160/110 mm Hg
- Ectopic Pregnancy  Proteinuria: 3+ or 4+
- Hydatidiform Mole  Extensive Edema: palpated over bony
- Hyperemesis Gravidarum surfaces, such as over the tibia on the
Second Trimester & Third Semester anterior leg, the ulnar surface of the
- Placenta Previa forearm, and the cheekbones
- Placenta Abruption
- Pregnancy-induced Hypertension (PIH) 3. Eclampsia
- Preeclampsia  Most severe PIH
- Eclampsia  Seizures (Convulsions) or coma accompanied
- Hemolysis elevated liver enzyme and low platelet by signs and symptoms of (severe) pre-
(HELLP) syndrome eclampsia
Other:  Epigastric pain
  Tonic-clonic seizures -
Twin to twin transfusion syndrome (TTTS)
STAGES OF ECLAMPSIA FIT -
Rarely, Rh- Isoimmunization
1. Premonitory Stage (lasts 10 – 20 sec.) -
Complications to FHT
 Rapid eye movements -
Fetus has infection
 Head is drawn to one side & twitching of the -
Esophageal atresia to fetus; Trancheo-
facial muscles esophageal fistula
 No perception of the impending fit & show - Open neural tube defect of fetus
altered awareness o Encephalocele
2. Tonic Stage (lasts 10 – 20 sec.) o Anencephaly
 Body muscles go into spasm and become o Spina bifida
rigid, back may arched - Multipara especially w/ monozygotic twins
 Teeth is tightly clenched & eyes are staring - Diabetes mellitus
3. Clonic stage (lasts 60 – 90 sec.) - Chorioangioma, tumor in placenta
 Violent contraction & intermittent relaxation SIGNS:
of muscles producing conversions - Breathlessness & discomfort
movements - Abdominal pain (acute)
 Salivation and foaming at the mouth - Indigestions, heartburn, constipation
 Face is congested and bloated, features are - Edema & varicosities of vulva and lower limbs
distorted (Due to inadequate blood flow)
COMPLICATIONS:
 Unconscious, dexterous breathing, full and
- Fetal malpresentation
bounding pulse; convulsions subside
- Premature rupture of membranes
gradually
- Risk for infection
4. Stage of Coma
- Prolapsed cord
 Stertorous breathing continues
- Preterm birth
 Convulsions may occur before the returning - Postpartum hemorrhage
of consciousness
COMPLICATIONS OLIGOHYDRAMNIOS
 Cerebral = hemorrhage, thrombosis, mental - Amniotic fluid is less than 1500 mL
confusion - Amniotic Fluid Index is less than 5 – 6 cm
 Renal = acute renal failure - Suggests renal disorder to the fetus
 Hepatic = liver necrosis  ESOPHAGEAL ATRESIA
 Cardiac = myocardial failure o Birth defect in which baby’s esophagus does not
 Respiratory = asphyxia, pulmonary edema, develop properly
bronchopneumonia o Stomach and esophagus are not connected
 Visual = temporary blindness o Correlated w/ tracheoesophageal fistula (TEF)
 Injuries = bitten tongue, fractures  OPEN NEURAL TUBE DEFECTS (ONTDs)
 Fetal = hypoxia, still birth o Problems w/ brain, spinal cord, spine forms while
a baby is growing in the womb, has three types;
HELLP SYNDROME i. Spina bifida – at the lower back; prone
- Hemolysis Elevated liver enzyme and Low Platelet position
(HELLP) syndrome ii. Anencephaly -
- A variation of PIH; named from the common iii. Encephalocele – prone position
symptoms that occur:
o Hemolysis = Anemia (breakdown of RBC) DIAGNOSIS & ASSESSMENT:
o Elevated liver enzymes = Epigastric pain 1. Ultrasonic scan – reveals multiple pregnancy and
(changes in liver) fetal anomaly
o Low platelet = Abnormal bleeding /clotting and 2. Fetal echocardiogram – can see fetus’ circulatory
petechial system
- Complication of severe pre-eclampsia and eclampsia 3. Non-stress test – checks for FHT abnormalities
4. Biophysical profile – checks for fetus’ tone,
AMNIOTIC FLUID movement, and breathing motions
- Surrounds the fetus 5. Amniocentesis – for congenital disorders
- Provides warmth 6. Glucose challenge test – gestational diabetes
- Allows movement for the fetus
- Median level of Amniotic fluid Index: 14 cm from ISOIMMUNIZATION (RH
week 20 – 35 INCOMPATIBILITY)
- Normal amniotic fluid volume: 500 to 1000 mL - Mother = Rh negative : Fetus = Rh positive

POLYHYDRAMNIOS
- Amniotic fluid exceeds 1500 mL ANTEPARTUM HEMORRHAGE
- Amniotic Fluid Index of 5 – 25 cm - Bleeding from the genital tract in late pregnancy.
- May occur as early as 16 weeks After the 28th week of gestation until 2nd stage of
- Pt. w/ polyhydramnios must be placed in upright labor
position to relieve dyspnea PRIMARY CAUSES OF ANTEPARTUM
TYPES: BLEEDING
1. Chronic Polyhydramnios 1. First trimester
o 30th weeks - Threatened miscarriage
o Common type; gradual in overt - Imminent miscarriage
2. Acute Polyhydramnios - Incomplete miscarriage
o 20th weeks - Complete miscarriage
o Sudden occurrence, rare - Ectopic pregnancy
RISK FACTORS: 2. Second trimester
- Increased blood glucose level - Hydatidiform mole
- Premature cervical dilatation
 3. Third Trimester  Separation cuts off blood supply to the fetus
- Placenta previa SIGNS AND SYMPTOMS
- Placenta abruption  Sudden, sharp fundal pain
- Preterm labor  Heavy vaginal bleeding
EFFECTS  Uterus is tense & rigid (Convelaire uterus)
 Hypovolemic shock  Dark venous blood
 Disseminated intravascular coagulation TYPES
o blood disorder that may occur with/by trauma 1. Revealed hemorrhage
 Renal failure  Blood flow to the external
 Still birth  No blood is accumulated behind the placenta
 A low-lying placenta is susceptible for hemorrhage 2. Concealed
due to mild trauma, may be caused by vaginal  blood is retained behind the placenta
examination  signs and symptoms of hypovolemic shock is
present
TYPES  enlarged & painful uterus that appears bruised
1. PLACENTA PREVIA and edematous
 Placenta is in low implantation that crosses the 3. Mixed
cervical os (near the cervix)  Blood drains thru vagina and some is retained
 Most dangerous behind the placenta
SIGNS AND SYMPTOMS: RISK FACTORS
 Painless vaginal bleeding o PIH
 Soft uterus (not tender) o High parity
 Fetal head remains unengaged o Multigravida
 Malpresentation o Drug abuse (cocaine)
 Lie is oblique or transverse, unstable in o Short umbilical cord
multipara o Advanced maternal age (35 yrs. old)
 Bright red blood
 Kehr’s Sign – collection of blood under the
2 MAIN TYPES diaphragm; shoulder referred pain
1. Minor Placenta Previa Normal hemoglobin
 Low but does not cover the internal cervical Men : 13.5 – 17.5 g/dl
os Women : 12.0 – 15.5 g/dl
2. Major Placenta Previa  Fibrinogen – soluble protein in the plasma that is
 Lies over the internal cervical os broken down to fibrin by the enzyme thrombin to
 Covers the cervical os form clots
TYPES ACCORDING TO DEGREE OF Fibrinogen level
EXTENSION Adult : 200 – 400 mg/dL or 2 – 4 g/L (SI units)
 Type 1 – Low lying Newborn : 125 – 300 mg/dL
o Majority of placenta is in the upper uterine  Oxytocin – induce and augment contractions/ labor
segment OBSTRUCTED LABOR MANAGEMENT
o Vaginal delivery is possible - also known as labor dystocia
o Blood loss is mild - When baby does not exit the pelvis during
 Type 2 – Marginal childbirth due to being physically blocked,
o Placenta is partially located in the lower despite the uterus contracting normally
segment near the internal os CAUSES:
o NSD is possible if placenta is placed 1. Cephalopelvic disproportion (CPD)
anteriorly 2. Fetal malformation (Hydrocephaly)
o Moderate blood loss 3. Pelvic tumor; pelvic bone contour
o Fetal hypoxia is more likely 4. Problems in the ‘Ps’ (Power, Passenger,
 Type 3 – Incomplete or partial central Passage, Psyche)
o Placenta is located centrally over the internal THE Ps
os 1. Power
o Bleeding is likely to be severe  Sluggishness of contractions
o NSD inappropriate  Three types:
 Type 4 - Central or total o Hypotonic contractions – low /
o Placenta is located centrally over the internal infrequent contractions
cervical os o Hypertonic contractions – frequent
o Severe bleeding contractions
o NSD not considered, cesarean section is o Uncoordinated contractions – more than
used one pacemaker is initiating the
COMPLICATIONS contraction
- Intrauterine hypoxia (may lead to DIC) 2. Passenger
- Intrauterine Fetal death (IUFD)  Large fetal head (big for the pelvis)
- Postpartum hemorrhage  Hydrocephalus (brain surrounded by fluid,
- Maternal shock/death which makes the skull swell)
- Low birth weight  Twin pregnancy (locked at the neck)
- Fetal hypoxia (low oxygen level)  Conjoined twins (fused together w/ some
shared organs)
2. PLACENTA ABRUPTION
3. Passage
 Premature separation of a normal situated
 Birth canal
placenta from the uterus occurring after 28 th
 Pelvis is too small or has an abnormal shape
weeks, before the fetus is born.
  Presence of tumor or other physical GROWTH – physical increase in size or amount that is
obstruction in the pelvis easily observed.
 Bony pelvis, may be: TYPES:
o Contracted due to malnutrition - Physical growth (Ht, Wt, head & chest
o Deformed due to trauma, polio circumference)
4. Psyche - Physiological growth (vital signs)
 Pain, stress/anxiety, fatigue DEVELOPMENT – ability of a person to things that
SIGNS are complex and difficult; growth in psychomotor
(Early signs) capacity
 Cervix dilates slowly; edematous TYPES:
 Presenting part does not enter pelvis - Motor development
 Early membrane rupture - Cognitive development
(Late signs) - Emotional development
 Maternal & fetal distress - Social development
 Abdomen is tense & hard to palpate Stages of human growth
 Contractions are long, strong with little or no
1. Fetus
relaxation between
o Dependent on the maternal body
 Bandl’s Ring (Pathologic Retraction Ring) is
2. Infancy (Up to 1 year)
seen
o Dependent to the parents
o A shallow depth in the middle of the
o Learns to cry and make sounds
abdomen
3. Toddler (1 to 5 years)
o Depression between the upper & lower
o Cognitive & emotional development begins
halves of uterus, at above level of
4. Childhood (3 to 11 years)
umbilicus
o Motor skills are developed
 Lower uterine segment is very thin & ready to
5. Adolescence (12 to 19 years)
rupture
o Physical changes are visible (hair growth, breast
 Low vital signs
growth, voice change)
o ↑ PR, above 100 bpm
6. Adulthood (20 years to death)
o ↓ BP
o Can reproduce
o ↑ RR, above 30 bpm
NORMAL NEWBORN INFANT
o ↑ Temp.
 Meconium drain in vagina Physical growth
 Concentrated (meconium/blood) urine Weight : 2.7 – 4 kg
 Edema of vulva & cervix Height : 47.5 – 53.75 cm
PROLONGED LABOR Girls ave. Ht. : 49 cm Boys ave. Ht. : 50 cm
1. Latent = > 8 hours Head circumference : 33 – 35 cm
2. Active = > 12 hours Chest circumference : 30.5 – 33 cm
PROLONGED SECOND STAGE OF LABOR Abdominal circumference : 31 – 33 cm
 Multipara = > 1 hour Length : 19 – 20 inch / 49 - 50 cm
 Primipara = > 2 hours  Weight loss of 5% - 10% by 3 – 4 days after birth,
due to:
MATERNAL COMPLICATIONS o Withdrawal of hormones from mother
 Post partum Hemorrhage o Loss of excessive fluid
 Fistula o Passage of meconium and urine
o Abnormal opening (due to ruptured o Limited food intake
tissue) between the;  Weight gain by 10th day; ¾ kg weight gain for 1st
 Vagina & urinary bladder month
 Vagina & rectum  Head is ¼ of the total body length
 Vagina & urethra/ureter  Head has 2 fontanel (anterior & posterior):
 Slow return of uterus to pre-pregnancy size o Anterior
 Shock (low blood pressure & high pulse rate)  diamond in shape
 Paralytic ileus  junction of the sagittal, corneal, frontal
o Small intestine is paralyzed sutures
o Stops movement  between 2 frontal & 2 parietal bones
 Sepsis  3 – 4 cm in length & 2 – 3 cm in width
o Widespread infection throughout the  Closes at 12 – 18 months
body o Posterior
 Death  Triangular in shape
NEONATE COMPLICATIONS  Between occipital & 2 parietal bones
 Neonatal sepsis  Closes by 1st month of age
 Convulsions Physiological growth
 Facial injury Temperature : 36.3 - 37.2 C
 Severe asphyxia Pulse : 120 – 160 bpm
o Life threatening lack of oxygen Respiration : 35 – 50 bpm
 Death
NEWBORN SENSES
 AMNIOTOMY – artificial rupture of the
1. Touch
membranes, intentional rupture of the amniotic sac
o Most highly developed sense
o Lips, tongue, ears, & forehead
GROWTH AND DEVELOPMENT o
 2. Vision SPEECH MILESTONES
o Pupils react to light - 1 – 2 months: coos
o Follows object in line of vision - 2 – 6 months: laughs & squeals
o Binocular vision – ability to fuse two images into - 8 – 9 months: babbles mama/dada as sounds
one - 10 – 12 months: mama/dada specific
3. Hearing - 18 – 20 months: 20 to 30 words – 50%
o Ordinary sounds are heard well before 10 th day of understood by strangers
life - 22 – 24 months: two word sentences, >75%
o Reacts thru cry, eye movement, cessation of understood by strangers
activity, startle reactions - 30 – 36 months: almost all speech understood
4. Taste by strangers
o Bitter and sour are resisted
o Sweet fluids are accepted
5. Smell
o Used when searching for the nipple & breast milk

GROSS MOTOR DEVELOPMENT

- Movements are random, diffuse, and
uncoordinated
- Reflexes carry out bodily functions and
responses to external stimuli
- Assessed through ventral suspension position,
prone, sitting, and standing position
FINE MOTOR DEVELOPMENT
- Movements are more focused and fixed
REFLEXES
- Rooting reflex (4 months)
- Palmar grasp reflex (5 – 6 months)
- Moro reflex (2 months)
- Tonic neck reflex (5 – 7 months)
- Crawl reflex
- Step reflex
- Landau reflex – in ventral position, head, legs,
and spine extend
- Extrusion reflex – food placed on an infant’s
tongue is thrust forward and out of the mouth
- Neck-righting reflex – head, shoulders, trunk,
and pelvis turns to side
- Thumb opposition – ability to bring the thumb
and fingers together
COGNITIVE DEVELOPMENT
- Ability to learn or understand from
experience, to acquire and retain knowledge,
to respond to a new situation and to solve
problems
EMOTIONAL DEVELOPMENT
- Socialization, or learning how to interact with
others
- Social smile – a definite response to
interaction in 6 weeks old to 2 months
- Eight-month anxiety / stranger anxiety – fear
of strangers
ERUPTION PATTERN OF DECIDUOUS TEETH
UPPER JAW LOWER JAW
Central incisor: Central incisor:
8-12 months 6-10 months
Lateral incisor: Lateral incisor:
9-13 months 10-16 months
Cuspid: Cuspid:
16-22 months 17-23 months
First molar: First molar:
13-19 months 14-18 months
Second molar: Second molar:
25-33 months 23-31 months

Natal teeth – teeth that newborns are born with

Neonatal teeth – teeth that erupt in the first 4 weeks of
life.
Deciduous teeth – temporary or baby (milky) teeth,
essential for protecting the growth of the dental arch.
Occurs from 5 to 6 months of age.