1. Hyperemesis Gravidarum/ Pernicious Vomiting
Definition: Excessive nausea and vomiting during pregnancy, extending beyond week 12 or causing dehydration, ketonuria, and significant weight loss within the first 12 weeks.
Incidence: 1 in 200-300 women
Cause: Unknown, but may be associated with increased thyroid function and Helicobacter pylori infection.
Signs and Symptoms:
• Decreased urine output
• Weight loss
• Ketonuria
• Dry mucous membranes
• Poor skin turgor
• Elevated hematocrit
• Decreased sodium, potassium, and chloride levels
• Polyneuritis (in some cases)
Assessment:
• Hemoglobin: Elevated hematocrit concentration (hemoconcentration) due to inability to retain fluids.
• Electrolytes: Decreased sodium, potassium, and chloride levels due to low intake.
• Acid-base Balance: Hypokalemic alkalosis (severe vomiting, prolonged period).
• Neurological Examination: Polyneuritis due to B vitamin deficiency.
Effects (if left untreated):
• Intrauterine Growth Restriction (IUGR): Dehydration and inability to provide nutrients for fetal growth.
• Preterm birth: Due to complications caused by the condition.
• Prolonged hospitalization/home care: Resulting in social isolation.
Therapeutic Management:
• Fluid and Electrolyte Management: Monitor input and output, blood chemistry to prevent dehydration.
• Nutritional Support: Withhold oral food and fluids (usually) and administer total parenteral nutrition (TPN).
• Intravenous Fluid Replacement: 3000 ml Ringer's lactate with added vitamin B to increase hydration.
• Antiemetic Medication: Metoclopramide (Reglan) to control vomiting.
2. Ectopic Pregnancy
Definition: Implantation of a fertilized egg outside the uterine cavity (ovary, cervix, fallopian tube - most common).
Incidence: Second most frequent cause of bleeding during the first trimester.
Causes:
• Obstruction of the fallopian tube:
◦ Adhesions (from previous infection like chronic salpingitis or pelvic inflammatory disease).
◦ Congenital malformations.
◦ Scars from tubal surgery.
◦ Uterine tumor pressing on the proximal end of the tube.
◦ Current use of an intrauterine device (IUD).
Signs and Symptoms:
• Missed period/amenorrhea.
• Positive hCG test.
• Sharp, stabbing pain in the lower abdominal quadrants and pelvic pain (at time of rupture).
• Scant vaginal spotting/bleeding.
• Rigid abdomen (from peritoneal irritation).
• Leukocytosis (increased WBC count due to trauma).
• Decreased blood pressure and increased pulse rate (signs of shock).
• Cullen's sign (bluish tinge around the umbilicus).
• Tender mass palpable in the cul-de-sac of Douglas (vaginal exam).
• Falling hCG or serum progesterone level (suggesting the pregnancy has ended).
• No gestational sac on ultrasound.
Therapeutic Management:
• Non-ruptured Ectopic Pregnancy: Oral administration of methotrexate followed by leucovorin.
• Ruptured Ectopic Pregnancy (emergency): Laparoscopy to ligate bleeding vessels and remove or repair the damaged fallopian tube.
3. Hydatidiform Mole (H-mole)/ Gestational Trophoblastic Disease/ Molar Pregnancy
Definition: A gestational anomaly of the placenta consisting of a bunch of clear vesicles resembling grapes. This neoplasm is formed from the swelling of the chorionic villi, resulting from a fertilized egg whose nucleus is lost, and the sperm nucleus duplicates, producing a diploid number 46XX.
Incidence: Approximately 1 in every 1500 pregnancies.
Risk Factors:
• Low socioeconomic group (decreased protein intake).
• Women under 18 or over 35 years old.
• Women of Asian heritage.
• Receiving clomiphene citrate (Clomid) for induced ovulation.
Types of Molar Growth:
• Complete/Classic H-mole: All trophoblastic villi swell and become cystic. No embryonic or fetal tissue present. High risk for malignancy.
• Partial/Incomplete H-mole: Some of the villi form normally. Presence of fetal or embryonic tissue. Low risk for malignancy.
Signs and Symptoms:
• Uterus expands faster than normal.
• No fetal heart sounds heard.
• Serum or urine test for hCG strongly positive.
• Early signs of preeclampsia.
• Vaginal bleeding (dark-brown spotting or profuse fresh flow).
• Discharge of fluid-filled vesicles.
Diagnosis:
• Ultrasound.
• Chest x-ray (lung metastasis).
• Amniocentesis (no fluid).
• Hysteroscopy (via cervix).
Management:
• Evacuation of the mole: Dilation and curettage (D&C).
• Blood transfusion.
• Hysterectomy (in some cases).
• Monitoring hCG levels: Every 2 weeks until normal.
• Contraception: Reliable method for 12 months to prevent confusion with a new pregnancy.
4. Premature Cervical Dilatation/ Incompetent Cervix
Definition: Premature dilation of the cervix, usually occurring around week 20, when the fetus is too immature to survive.
Incidence: About 1% of pregnancies.
Causes:
• Increased maternal age.
• Congenital structural defects.
• Trauma to the cervix (cone biopsy, repeated D&C).
Signs and Symptoms:
• Painless dilation of the cervix.
• Pink-stained vaginal discharge.
• Increased pelvic pressure.
• Rupture of membranes and discharge of amniotic fluid.
Therapeutic Management:
• Cervical cerclage: Surgical procedure to prevent loss of the child due to premature dilation.
• Bed rest: After cerclage surgery, to decrease pressure on the sutures.
5. Abortion
Definition: Termination of pregnancy before the fetus is viable (400-500 grams or 20-24 weeks gestation).
Types of Abortion:
• Spontaneous Abortion: Pregnancy interruption due to natural causes.
◦ Threatened: Mild cramping, vaginal spotting.
◦ Inevitable/Imminent: Profuse bleeding, uterine contractions, cervical dilation.
◦ Complete: All products of conception expelled spontaneously.
◦ Incomplete: Part of the conceptus expelled, some retained in the uterus.
◦ Missed: Fetus dies in utero but is not expelled.
◦ Habitual: 3 or more consecutive spontaneous abortions.
• Induced Abortion: Deliberate termination of pregnancy in a controlled setting.
Complications of Abortion:
• Hemorrhage.
• Infection (endometritis, parametritis, peritonitis, thrombophlebitis, septicemia).
Management:
• Bed rest.
• Emotional support.
• Sedation.
• D&C: Surgical removal of retained products of conception.
• Antibiotics.
• Blood transfusion.
6. Placenta Previa
Definition: The placenta is implanted in the lower uterine segment, covering the cervical os, obstructing the birth canal.
Incidence: 5 per 1000 pregnancies.
Signs and Symptoms:
• Abrupt, painless vaginal bleeding (bright red).
• Bleeding may stop or slow after the initial hemorrhage, but continue as spotting.
Types:
• Total: Placenta completely obstructs the cervical os.
• Partial: Placenta partially obstructs the cervical os.
• Marginal: Placenta edge approaches the cervical os.
• Low-lying: Placenta implanted in the lower rather than the upper portion of the uterus.
Therapeutic Management:
• Immediate Care: Bed rest in a side-lying position.
• Assessment: Monitor vital signs, bleeding, and fetal heart sounds.
• Intravenous Therapy: Fluid replacement with large gauge catheter.
• Delivery: Vaginal birth (safe for infant if previa is less than 30%). Cesarean section (safest for both mother and infant if previa is over 30%).
7. Abruptio Placenta/ Premature Separation of Placenta/ Accidental Hemorrhage/ Placental Abruption
Definition: Separation of a normally implanted placenta after the 20th week of pregnancy, before birth of the fetus.
Incidence: Most frequent cause of perinatal death.
Causes:
• Unknown.
• Predisposing Factors:
◦ High parity.
◦ Advanced maternal age.
◦ Short umbilical cord.
◦ Chronic hypertensive disease.
◦ PIH.
◦ Trauma (automobile accident, intimate partner abuse).
◦ Cocaine or cigarette use.
◦ Thrombophilitic conditions (autoimmune antibodies).
Classification:
• Total/Complete: Concealed hemorrhage.
• Partial: Concealed or apparent hemorrhage.
Signs and Symptoms:
• Sharp, stabbing pain in the uterine fundus.
• Contractions accompanied by pain.
• Uterine tenderness on palpation.
• Heavy vaginal bleeding (may be concealed).
• Signs of shock.
• Tense, rigid uterus.
• Disseminated Intravascular Coagulation (DIC).
Therapeutic Management:
• Fluid Replacement: IV fluids.
• Oxygen: Limit fetal hypoxia.
• Fetal Monitoring: External fetal heart rate monitoring.
• Fibrinogen Determination: IV fibrinogen or cryoprecipitate.
• Lateral Position: Prevent pressure on the vena cava.
• Delivery: CS is the method of choice if birth is not imminent.
8. Premature Rupture of Membranes
Definition: Rupture of the fetal membranes with loss of amniotic fluid during pregnancy before 37 weeks.
Incidence: 5%-10% of pregnancies.
Causes:
• Unknown.
• Associated with: Infection of the membranes (chorioamnionitis), vaginal infections (gonorrhea, streptococcus B, Chlamydia).
Signs and Symptoms:
• Sudden gush of clear fluid from the vagina with continued minimal leakage.
• Nitrazine paper test: Amniotic fluid turns the paper blue (alkaline), urine remains yellow (acidic).
• Microscopic examination: Amniotic fluid shows ferning, urine does not.
• Ultrasound: Assess amniotic fluid index.
• Signs of infection (increased WBC count, C-reactive protein, temperature, tenderness, odorous vaginal discharge).
Therapeutic Management:
• Bed Rest: To prevent further leakage and risk of infection.
• Corticosteroids: To hasten fetal lung maturity.
• Prophylactic Antibiotics: To reduce risk of infection.
• Intravenous Penicillin/Ampicillin: If (+) for streptococcus B.
• Induction of Labor: If fetus is mature and labor does not begin within 24 hours.
9. Pregnancy-Induced Hypertension (PIH)/ Toxemia
Definition: Vasospasm occurring in both small and large arteries during pregnancy, causing elevated blood pressure, proteinuria, and edema.
Incidence: Rarely occurs before 20 weeks of pregnancy.
Risk Factors:
• Multiple pregnancy.
• Primiparas younger than 20 or older than 40.
• Low socioeconomic background.
• Five or more pregnancies.
• Hydramnios.
• Underlying diseases (heart disease, diabetes).
• Rh incompatibility.
• History of H-mole.
Categories:
• Gestational Hypertension: Blood pressure 140/90 or greater, without proteinuria or edema.
• Preeclampsia: Blood pressure 140/90 or greater, with proteinuria and edema.
• Eclampsia: Seizures or coma accompanied by preeclampsia.
Therapeutic Management:
• Preeclampsia: Bed rest, balanced diet, left lateral position.
• Severe Preeclampsia: Hospitalization, diazepam, hydralazine, magnesium sulfate.
• Eclampsia: Magnesium sulfate, diazepam, oxygen therapy, left lateral position
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