Care of High-Risk Pregnant Women

From Ma'am Baccay's PPT and Lecture Discussion

High-risk Pregnancy

A situation in which a mother, her fetus, or both are at higher risk for problems during pregnancy, delivery, and postpartum than in a typical pregnancy

• Maternal age

• Weight

• Substance/alcohol abuse

• Abused/battered women

• Existing/pre-existing medical condition

What are the risk factors of a high-risk pregnancy?

FALSE; Both are risk factors of a high-risk pregnancy

TRUE or FALSE; Advanced maternal age is a risk factor of a high-risk pregnancy and adolescent pregnancy is not

TRUE

TRUE or FALSE: Both overweight and underweight women are at risk for high risk pregnancy.

• Physical development is not yet complete

• Developmental task is not yet fulfilled

• Emotional maturity not yet been achieved

In adolescent pregnancy, what aspects of their growth are not yet achieved/fulfilled making them risky?

35 years old

What age is considered elderly primigravid?

9 years old

According to Ma’am Ken, what age is the recorded youngest mother (idk lang if here in the PH lang or worldwide)?

TRUE; It is under '“Existing/pre-existing medical condition”

TRUE or FALSE; Mental health problems are considered risk factors for high risk pregnancy

Identity vs. Role Confusion

What developmental task do adolescents need to fulfill?

Having an idealistic concept of love

Give an example of a manifestation that an adolescent’s emotional maturity has not yet been achieved

• Lack of knowledge about conception and contraception

• Indulgence in risk-taking behavior

• Early sexual initiation

• Inadequate coping mechanism

• Lack of concern for long-term consequences

• Need for immediate gratification

• Increase in dysfunctional families

Give at least 3 contributing factors of adolescent pregnancy.

Drinking alcohol and smoking (they are also at higher risk for early sexual initiation)

What is an example of a risk-taking behavior of adolescents?

Early marriage to escape poverty (they are also at higher risk for early sexual initiation)

What is an example of an inadequate coping mechanism as a contributing factor to adolescent pregnancy?

TRUE; This is under “Lack of concern for long-term consequences”

TRUE or FALSE; Once you pop, you can’t stop

FALSE; First 15 years of life

TRUE or FALSE; Those who have father absence for the first 10 years of lives are at risk for adolescent pregnancy

• PIH (Pregnancy induced hypertension)

  • May nabasa ako na the cause remains unknown daw, pero feeling ko dahil underdeveloped pa yung cardiovascular system nila so pag dumami yung blood volume due to pregnancy, mas sensitive sila sa complications

• IDA (Iron deficiency anemia

  • Double requirements of iron (from 60 to 120 ang demand)

• Premature labor

  • Weak pelvic muscles; kapag hindi na kaya, doon magcocontract

• Low birth weight infants

  • ‘Di nila kayang i-hold yung appropriate infant weight kaya naglalabor agad

• Cephalopelvic disproportion

  • Hindi possible ang vaginal birth

• Intimate partner abuse

  • No confidence to decide for themselves

  • Highly dependent on their partners (risk for statutory rape

Give at least 3 complications of adolescent pregnancy and a rationale for each.

• Detailed health history

• Privacy during abdominal assessment and pelvic exam

  • PGH: may dedicated schedule for check up

• Look for danger signs in pregnancy

• Assess the nutritional status

Give at least 3 parameters that you need to take or keep in mind in the prenatal assessment of adolescent pregnancy

• Prenatal education (physiologic changes, birth plan, newborn care)

  • Saan pwede manganak? Bawal sa lying-in clinic

• Teach them about good nutrition

• Assess their activity and ensure adequate rest periods

  • Because pwedeng nasa school pa

  • Pwedeng magkaroon ng activity intolerance r/t Iron deficiency anemia

• Identify support system

• Postpartum family planning

  • Use contraceptive right after pregnancy

  • Finish their education

How do you manage adolescent pregnancy?

1. Abortion

2. Ectopic Pregnancy

What are the two (2) first trimester bleeding conditions?

0 to 13 weeks

When is the first trimester?

Abortion

This is defined as the Expulsion of the product of conception or termination of pregnancy before the fetus is viable

1. Before the 20th week of gestation

2. Less than 500 g birth weight

Give 2 criteria to consider that a fetus is not viable

1. Spontaneous Abortion

2. Recurrent Abortion

3. Induced Abortion

What are the three classifications of abortion?

Before 16 weeks

In spontaneous abortion, when is it considered an early miscarriage?

Between 16 to 20 weeks

In spontaneous abortion, when is it considered a late miscarriage?

Threatened Abortion

Assessment: closed cervix, scanty to bright red vaginal bleeding, (+) uterine contractions

(A type of Spontaneous Abortion)

Threatened Abortion

Suggests an increased risk of miscarriage (50%)

• Notify physician

• FHT is assessed and TV UTZ exam is done

• Limit sexual activity or avoid strenuous activity

• Count number of perineal pads used

• Observe for drainage with foul odor

What are included in the therapeutic management of threatened abortion?

Imminent or Inevitable Abortion

Assessment: Profuse vaginal bleeding, open cervix, (+) ruptured BOW (bag of water), (+) contractions

(A type of Spontaneous Abortion)

Imminent or Inevitable Abortion

In this type of spontaneous abortion, abortion is almost certain.

• Natural expulsion of uterine content

• Dilation and evacuation

What are included in the Therapeutic Management of Imminent/Inevitable Abortion?

Vacuum curettage [aka Vacuum Aspiration Abortion or Suction Curettage (?) ]

How do you perform dilation and evacuation in imminent abortion?

Complete Abortion

Type of Spontaneous Abortion: Products of conception are expelled spontaneously

Complete Abortion

Type of Spontaneous Abortion: All fetal and placental material is expelled from the uterus before 20 weeks of gestation

• Observe the mother for signs of bleeding

• Provision of emotional support

How do you manage complete abortion?

Incomplete Abortion

Type of Spontaneous Abortion: Clinical manifestations include active uterine bleeding and severe abdominal cramping

Incomplete Abortion

Type of Spontaneous Abortion: Some products of pregnancy are still in the uterus

Dilation and curettage (suction curettage)

What is the treatment for Incomplete Abortion?

Missed Abortion

A type of Spontaneous Abortion: Early pregnancy failure - fetus died in utero but is not expelled

Missed Abortion

Assessment: closed cervix, (+) spotting
(A type of Spontaneous Abortion)

Blighted ovum

What do you call it when the pregnancy sac is empty? (Missed Abortion)

UTZ will reveal that the fetus has died

How do you diagnose Missed Abortion?

• Labor induction

• Provision of emotional support

How do you treat/manage Missed Abortion?

Recurrent Abortion

Type of Abortion: Three or more consecutive spontaneous abortion

Discover the cause of Abortion

How do you manage Recurrent Abortion?

• Chromosomal anomaly

• Endocrinal or autoimmune disorder

  • Antiphospholipid Antibody Syndrome (APAS)

• Altered immune system

• Deviations of the uterus

  • Involving septum in the uterus (may septum sa gitna kaya na-didivide eon into two separate parts) — A congenital anomaly among women

What are the possible causes of Recurrent Abortion? (CEAD)

Induced Abortion

A Type of Abortion: Elective termination of pregnancy

Induced Abortion

A Type of Abortion: Voluntary method to end a pregnancy at the request of the woman but not for reasons of impaired maternal health or fetal disease

• Mifepristone

• Misoprostol

• Methotrexate

• Vacuum aspiration with curettage

• Dilation and curettage

* They can be done orally or through the vagina

* They induce contraction

Give 3 methods of pregnancy termination in Induced Abortion

• Hemorrhage

• Sepsis

What are the complications of Induced Abortion relating to Maternal Mortality?

• Ectopic pregnancy

  • pinilit mo kasing paalisin yung nauna eh, edi yung sumunod tatakas/magtatago

• Spontaneous abortion

• Low birth weight infants

• Fertility

  • Baka hindi na magbuntis kahit gusto pa

What are the complications of Induced Abortion relating to Impact on future pregnancies?

TRUE po

TRUE or FALSE: An induced abortion of more than 20 weeks AOG is considered murder

FALSE: Government hospitals

TRUE or FALSE: When induced abortion has been documented, especially in private hospitals, a police report should be made

• Monitor vital signs, amount and type of bleeding, pain, emotional response to loss

• Complete bed rest

• Facilitate diagnostic tests

• Assist and support during dilatation and curettage 

• Institute measures to alleviate fear and anxiety 

• WOF: hypovolemic shock, infection

• Administer oxygen support if necessary

• Maintain fluid and electrolyte balance

• Monitor condition of uterus

• Administer Rho-gam to Rh negative client after abortion

• Facilitate physiologic reality but allow to undergo grieving process

• Educate on follow-up care

What are included in the nursing management for Induced Abortion?

Ectopic Pregnancy

Occurs when a fertilized ovum becomes implanted on any tissue other than the uterine lining

scanty; sharp, stabbing

Ectopic pregnancy is characterized by _________ bleeding with ________, ___________ pain

Ampulla part of the oviduct

Common site of ectopic pregnancy

Interstitial part of the oviduct

• pinaka-nakakatakot kasi maraming blood vessels

Most dangerous site of ectopic pregnancy

• Salphingitis

• Peritubal adhesions

• Structural abnormalities of the fallopian tube

• Previous ectopic pregnancy

• Previous tubal surgery, pelvic, and abdominal

• Multiple previous induced abortions

• Tumors distorting the tube

• IUD

• Smoking

• STI

Give at least 3 Risk Factors of Ectopic Pregnancy

FALLS (woosh woosh)

TRUE or FALSE; IUD is recommended for nulligravid in relation to ectopic pregnancy

Antibiotics for both mother and father

How is STI managed in Ectopic Pregnancy

• Sharp, stabbing pain in lower abdomen

• Radiating pain in the scapula

• Vaginal spotting or bleeding (konti lang; hindi ganon kalakas)

• Dizziness

• Lightheadedness

• Fainting

• Nausea and vomiting

• S/Sx of hypovolemic shock (bleeding sa loob)

Give at least 3 clinical manifestations of Ectopic Pregnancy

• Sonography

• HCG level

• Serum progesterone level (>25ng/mL)

• Laparoscopy

What are the diagnostic tests for Ectopic Pregnancy?

• Menstrual pattern

• Vaginal bleeding pattern, nature, and amount

• Pain

• Vital signs

• LOC

What should you assess in the management of Ectopic Pregnancy?

• Adequate pain management

• Identification and prevention of hypovolemic shock

• Acceptance and resolution of grief and pregnancy loss

• Increased knowledge on ectopic pregnancy

• Perioperative care

What are the goals of care in the management of Ectopic Pregnancy?

FIRST TRIMESTER BLEEDING CONDITIONS

• Abortion

  • Spontaneous Abortion

    • Threatened

    • Imminent

    • Complete

    • Incomplete

    • Missed

  • Recurrent Abortion

  • Induced Abortion

• Ectopic Pregnancy

BONUS: Click to see the whole outline of the first trimester bleeding conditions

No, dapat UTZ pa rin ang gamit to confirm

Is Beta HCG a reliable indication of pregnancy?

1. Hydatidiform Mole (Molar Pregnancy)

2. Premature Cervical Dilatation

What are the second trimester bleeding conditions?

14 to 26 weeks

When is the second trimester of pregnancy?

Hydatidiform Mole (Molar Pregnancy)

Abnormal conceptions with excessive placental, and little or no fetal development

Hydatidiform Mole (Molar Pregnancy)

Placenta contains grape-like vesicles

Hydatidiform Mole (Molar Pregnancy)

Can lead to gestational trophoblastic neoplasia

Partial Mole

Type of Molar Pregnancy: Includes some fetal tissues and membranes

Complete Mole

Type of Hydatidiform Mole: Composed only of enlarged villi

FALSE; There are more chances that a cancer will develop in partial mole than in complete mole

TRUE or FALSE: There are more chances that a cancer will develop in complete mole than in partial mole

• Maternal age

• Paternal age

• Prior molar pregnancy

• Prior miscarriage

• Family history

• Racial factors: 17.5/1000 women

• Diet and nutrition: decrease carotene and animal fat

What are the factors affecting Hydatidiform Mole conception?

35 years old

What maternal age is considered at risk for Hydatidiform Mole conception?

45 years old

What paternal age is considered at risk for Hydatidiform Mole conception?

TRUE

• Prevalence rate in Japan = 16.5/1000 women

• Prevalence rate in the Philippines = 17.5/1000 women

TRUE or FALSE: Asians are at higher risk of developing molar pregnancy

• Beta-HCG: 1-2 Million U/mole

  • Normal HCG Factor: 50,000 U/mole

  • Soaper dami beh kaya nagcacause ng hyperemesis gravidarum (ikaw ba naman halos 20 to 40 times more than normal yung Beta-HCG, hindi ka ba naman magsuka nang magsuka)

• Ultrasound

  • Will confirm grape-like structures

What are the diagnostic studies for Hydatidiform Mole?

• Uterus larger than expected length of pregnancy

  • Like 12 weeks pa lang pero mukha nang 16 weeks

• No palpable fetal parts

  • Kapag nag-Leopold’s Maneuver ka, hindi mo ma-aappreciate yung buttocks and extremities

• Symptom of PIH and hyperemesis

  • Mataas yung BP (PIH)

  • Mataas din yung Beta-HCG (hyperemesis)

• Vaginal bleeding containing grape-like tissue

• Absence of fetal heart tones or activity

• Confirmation by ultrasonography

What are the clinical manifestations of Molar Pregnancy (Hydatidiform Mole)?

• Complete bedrest

• Facilitate diagnostic studies

• Assist and support during dilatation and curettage or total hysterectomy

• Monitor the amount and type of bleeding

• Institute measures to alleviate fear and anxiety

• Monitor for side effects of prophylactic methotrexate

• Monitor vital signs

• Maintain fluid and electrolyte balance

• Monitor the condition of the uterus

• Educate on follow-up care

• Support through loss of expected pregnancy

What are included in the nursing management for Hydatidiform Mole?

Methotrexate

• There is a high chance that the partial mole will develop into a neoplasia

• Gestational trophoblastic neoplasia: Mataas (pataas nang pataas) pa rin yung Beta-HCG na nagliliead to Neoplasia

• Binibigay sa mga feeling ng HCWs hindi na babalik sa hospital for monitoring

  • Usually 6 months minomonitor yung Beta-HCG

• Adverse effect: Leukopenia

  • Bumababa ang WBC that is why important ang Reverse Isolation

Why is Prophylactic Methotrexate indicated for Molar Pregnancy?

After D&C (Dilation and Curettage) aka “Raspa”

• Hindi pa pwedeng magbuntis agad kasi mataas pa ang Beta-HCG levels

• After 6 months na consistent within normal levels ang Beta-HCG, doon na pwede magbuntis

Explain the follow-up care for Hydatidiform Mole

Premature cervical dilatation

Also known as incompetent cervix or cervical insufficiency

Premature cervical dilatation

Weak cervical tissue causes or contributes to premature birth or loss of an otherwise healthy pregnancy

• Increased maternal age

• Congenital structural defects

• Trauma to the cervix

What are the risk factors of Premature cervical dilatation

• Painless contractions in mid-trimester

  • Sa third trimester ma-tetest if competent ang cervix

• Pink-stained vaginal discharge

• Ruptured BOW

  • Pregnancy can still progress

What are the clinical manifestations of Premature cervical dilatation or Dysfunctional/Incompetent Cervix or Cervical insufficiency?

• Bedrest in trendelenburg position

• Observe for rupture of membranes or bleeding

  • If still intact pa

• Monitor FHR with Doppler UTZ

• Assist with therapeutic intervention

  • Cerclage procedure

  • Cesarean birth or cutting of suture for vaginal birth

What are included in the nursing management for Dysfunctional Cervix?

14 to 16 weeks AOG

In Cerclage Procedure, on what week of AOG is the cervix typically sutured?

37 to 38 weeks

In Cerclage Procedure, on what week of AOG is the suture in the cervix typically removed?

• Placenta Previa

• Abnormal Placental Attachments

• Abruptio Placenta

What are the third trimester bleeding conditions?

27 weeks to the end of pregnancy or 27 to 38.5 weeks

When is the third trimester of pregnancy?

Placenta Previa

Implantation of the placenta at the lower uterine segment near the cervical os

Ultrasound

What is used to diagnose Placenta Previa?

1. Total

2. Partial

3. Marginal

4. Low-Lying

What are the classifications of Placenta Previa?

Total

Classification of Placenta Previa: Totally obstructs cervical os

Partial

Classification of Placenta Previa: Partially occludes cervical os

Marginal

Classification of Placenta Previa: Placental edge approaches cervical os

Low-lying

Classification of Placenta Previa: Lower portion of the uterus