HIGH RISK

PREGNANC
Y
High Risk
Pregnanc
y◦ Threatens the health or life of
the mother or her fetus.
◦ Concurrent disorder,
pregnancy-related
complication, or external
factor that jeopardizes
the health of the mother,
the fetus, or both.
◦ Requires specialized care
from specially trained
providers.
Factor Maternal Implications Fetal or Neonatal Implications
Social and Personal Poor antenatal care Low birth weight
Low income level and/or low educational level Poor nutrition Intrauterine growth restriction
risk preeclampsia
Poor diet Inadequate nutrition Fetal malnutrition
risk anemia Prematurity
risk of preeclampsia
Living at high altitude hemoglobin Prematurity
IUGR
hemoglobin (polycythemia)
Multiparity > 3 risk antepartum or postpartum hemorrhage Anemia
Fetal death
Weight < 45.5 kg (100 lbs) Poor nutrition IUGR
Cephalopelvic disproportion Hypoxia associated with difficult labor and birth
Prolonged labor
Weight >91 kg (200 lb) risk hypertension ↓ fetal nutrition
risk cephalopelvic disproportion risk macrosomia
risk diabetes
Age < 16 Poor nutrition Low birth weight
Poor antenatal care fetal demise
risk preeclampsia
risk cephalopelvic disproportion
Age > 35 risk preeclampsia congenital anomalies
risk cesarean birth chromosomal aberrations
Smoking one pack/day or more risk hypertension ↓ placental perfusion → ↓O2 and nutrients available low birth weight
risk cancer IUGR
Preterm birth

Use of addicting drugs risk poor nutrition risk congenital anomalies

risk of infection with IV drugs risk low birth weight
risk HIV, hepatitis C neonatal withdrawal
lower serum bilirubin
Excessive alcohol consumption poor nutrition risk fetal alcohol syndrome
Possible hepatic effects with long term consumption
Screening Procedures
◦ Ultrasonography
◦ Biparietal Diameter
◦ Doppler Umbilical Velocimetry
(Doppler US)
◦ Placental grading
◦ Amniotic Fluid
volume Assessment
◦ Electrocardiography
◦ Magnetic Resonance
Imaging
Screening Procedures
◦ Maternal Serum
Alpha- Fetoprotein
◦ Triple Screening
◦ Chorionic villus
sampling
◦ Amniocentesis
◦ Percutaneous umbilical
cord blood sampling
◦ Amnioscopy
◦ Fetoscopy
◦ Biophysical profile
 BLEEDING
DISORDERS
ABORTION
◦ Termination of
pregnancy before
the age of
viability usually
before 20 – 24
weeks
◦ Miscarriage
Cause
s•• Defective ovum/ congenital defects
Unknown causes

MATERNAL FACTORS
• Viral infection
• Malnutrition
• Trauma
• Congenital defects of the reproductive tract
• Incompetent cervix
• Hormonal
• Increased temperature
• Systemic diseases in the mother
• Environmental hazards
• Rh incompatibility
Type
s
◦ Spontaneous abortion
◦ Without medical or
mechanical intervention

◦ Induced abortion
◦ With medical or
mechanical intervention
 • Only allowed for
medical indications
• If continuation of
INDUCED pregnancy is risk to
life of the woman
ABORTIO • At least two medical
N doctors should reach
the decision and sign
Legal • Elective abortions –
are unlawful,
Aspects considered a criminal
act
 • Perforation of uterus,
intestines, urinary
bladder

INDUCED • Severe hemorrhage

ABORTION w/c may lead to
S hypovolemic shock
COMPLICATIONS

• Sepsis and its

associated
complications
,
Types of Spontaneous abortion
Types Bleeding Abdominal Cervical Tissue Fever
cramps dilation passage
Threatened Slight May or may not None None No
be present
Inevitable Moderate Moderate Open None No
Complete Small to Moderate Close or Complete No
partially open placenta with
negative fetus
Incomplete Severe (bleeds Severe Open with Fetal or, No
the most) tissue in incomplete
cervix placental
tissue
Missed None to severe None None None No
No FHT
Habitual: 3 or more May represent signs of any of the above; usually detected in the threatened
consecutive phase; cervical closure may be employed
Septic Mild to severe Severe Close or open Possibly, foul Yes
with or discharge
without tissue
Sign
s• Vaginal bleeding
or spotting,
mild to severe
• Uterine/
abdominal cramps
• Passage of tissues
or products of
conception
• Signs related to
blood loss/ shock:
– Pallor
– Tachycardia
– Tachypnea
– Cold
clammy
skin
– Restlessness
– Oliguria
– Hypotensio
n
– Air hunger
 Treatment
• Surgery
• Antibiotics
• Blood, plasma,
fluid replacement
• Habitual abortion:
• Determine etiology
• Treatment of underlying
causes
• Cerclage operation/ cervical
closure for incompetent cervix
(McDonald surgery, Shirodkar-
Barter surgery)
• Blood tests
 Management of Abortion
Types Activity Fluid Medications Procedure/ surgery Blood tests
replacement
Threatened Bed rest Tocolytics (Ritodrine,
Isoxsuprine, Terbutaline)
Inevitable IVF (LR/ PNSS) Oxytocin (>12) Vacuum aspiration Bld. Typing/
(<12) Cross-matching
Completion
Currettage
Incomplete IVF (LR/ PNSS) Oxytocin (>12) Vacuum aspiration Bld. Typing/
Antibiotics (Ampicilin/ (<12) Cross-matching
metronidazole) Completion
Analgesics Currettage
Missed Oxytocin (>12) If no spontaneous
Prostaglandin expulsion (4 weeks),
Dilation & Evacuation

Habitual Tocolytics Counselling

Oxytocin, Prosta-glandin, D&C
Misoprostol
RhoGam
Septic IVF (LR/ PNSS) Oxytocin (>12) Urethral Cathete- Bld. Typing/
Antibiotics (Cephalosporins, rization Cross-matching
Ampicilin/metronidazole) Currettage
Hematinics
◦A condition where pregnancy
develops outside the uterine cavity

◦ Types:
◦ Tubal (Fallopian tube -
interstitial, isthmic, ampulla,
infundibulum & fimbrial
portion)
◦ Cervical
◦ Abdominal
◦ Ovarian
Fallopian tube Pelvic Puerperal and
narrowing or Inflammatory postpartal Surgery of the
constriction Disease sepsis fallopian
(PID) tubes

Congenital
anomalies of Adhesions,
the IUD usage
spasms,
fallopian tumors
tubes
◦ Amenorrhea or abnormal
menstrual period/ spotting
◦ Early signs of pregnancy
◦ Tubal rupture signs
◦ Sudden, acute low
abdominal pain
radiating to the
shoulder (Kehr’s sign) or
neck pain
◦ Nausea and vomiting
◦ Bluish navel (Cullen’s sign)
◦ Rectal pressure
◦ Positive pregnancy test (50%)
◦ Sharp localized pain when cervix
is
touched
◦ Signs of shock/ circulatory
Ultrasonography

Culdocentesis

Laparoscopy

Serial testing of HCG

beta- subunit
Low hemoglobin and hematocrit

Low HCG (normal value at its peak: 400,000 IU/

24 hours)

Elevated WBC
(Unruptured) Methotrexate,
Leucovorin

Surgical removal of ruptured

tube (Salphingectomy)

Management of profound
shock if ruptured (Blood
replacement)

Antibiotics
 Carry out an ongoing assessment for shock
 Implement promptly shock treatment
 Position on modified Trendelenburg
 Infuse D5LR for plasma blood
administration, transfusion or drug
administration as ordered
 Monitor VS, bleeding, I & O
 Provide physical and psychological support.
 Rh
Hemorrhage Infection
sensitization
• Abnormal proliferation
and then degeneration of
the trophoblastic villi.
• As the cells degenerate,
they become filled with
fluid and appear as clear
fluid-filled, grape-sized
vesicles
• Cause: unknown
◦ Low protein intake.
◦ Women older than 35 years old.
◦ Asian women.
◦ Women with a blood group of A who marry
men with blood group O.
◦ Fertilization occurs as the sperm enters the ovum.
In instances of a partial mole, two sperms might
fertilize a single ovum.
◦ Reduction division or meiosis was not able to
occur in a partial mole. In a complete mole, the
chromosome undergoes duplication.
◦ The embryo fails to develop completely. There are
69 chromosomes that develop for the partial
mole, and 46 chromosomes for the complete
mole.
◦ The trophoblastic villi start to proliferate rapidly
and
become fluid-filled grape-like vesicles.
◦ Brownish or reddish, intermittent or
profuse vaginal bleeding by 12
weeks
◦ Expulsion, spontaneous, of molar cyst
usually occurs between the 16 t h to
18 t h weeks of pregnancy
◦ Rapid uterine enlargement inconsistent
with the age of gestation
◦ Symptoms of PIH before 20 weeks
◦ Excessive nausea and vomiting because
of excessive HCG (1 to 2 million
IU/L/24 hours)
◦ Positive pregnancy test
◦ No fetal signs – heart tones, parts,
movements
◦ Abdominal pain
◦ Passage of vesicles – 1st sign that
aids to diagnosis
◦ TRIAD signs:
◦ Big uterus
◦ Vaginal bleeding
◦ HCG greater than 1 million
◦ Ultrasound
◦ Flat plate of the abdomen
done after 15 weeks

◦ 80% remission after D &

C; may progress to cancer
of the chorion:
Choriocarcinoma
◦ Evacuation by Suction D & C or hysterectomy if
no spontaneous evacuation
◦ Hysterectomy if above 45 years old and no
future pregnancy is desired or with increased
chorionic gonadotropin levels after D & C
◦ HCG titer monitoring for one year (no pregnancy
for
1 year)
◦ Medical replacement: blood, fluid, plasma
◦ Chemotherapy for malignancy: Methotrexate is
drug of choice
◦ Chest X-ray
◦ Advise bed rest
◦ Monitor VS, blood loss, molar/ tissue passage, I & O
◦ Maintain fluid and electrolyte balance, plasma, and blood volume
through replacements as ordered
◦ Prepare for suction D & C, hysterotomy or hysterectomy as
indicated
◦ Provide psychological support
◦ Prepare for discharge
◦ Emphasize need for follow-up HCG titer determination for 1 year
◦ Reinforce instructions on NO PREGNANCY FOR ONE YEAR; give instructions
related to contraceptions
◦ Choriocarcinoma
◦ Hemorrhage
◦ Uterine perforation
◦ Infection
A condition characterized
by a mechanical defect in
the cervixcausing cervical
effacement and dilation
and expulsion of the POC.
◦ CONGENITAL INCOMPETENCE
◦ Diethylstilbestrol (DES) exposure
in- utero
◦ Women with a bicornuate uterus
◦ ACQUIRED INCOMPETENCE
◦ Inflammation
◦ Infection
◦ Subclinical uterine activity
◦ Cervical trauma
◦ Increased uterine volume
• Painless contractions
resulting in delivery
of a dead or non-
viable fetus

• History of abortions

• Relaxed cervical os
on pelvic
examination
CONSERVATIVE
MANAGEMENT
:
• Bed rest; avoidance of
heavy lifting; no coitus

FOR WOMEN WITH

PREVIOUS LOSSES: elective
cervical cerclage (late first
trimester or early second
trimester)
• Shirodkar procedure
• McDonald procedure
◦ Provide psychological support to client
who may have negative feelings
◦ Provide post-cerclage procedure care
◦ Advise limitation of physical
activities within 2 weeks after
treatment
◦ Maternal and fetal growth
monitoring
◦ Instruct to report promptly signs of
labor
◦ Assessment for signs of labor,
infection or premature rupture of
membranes
◦ In labor, prepare STITCH REMOVAL SET
in addition to delivery set (post-
ABRUPTIO
PLACENTA
Premature separation of the
implanted placenta before the birth
of the fetus
Predisposing factors
◦ Maternal hypertension: PIH, renal
disease
◦ Sudden uterine decompression (multiple
pregnancy, polyhydramnios)
◦ Advance maternal age
◦ Multiparity
◦ Short umbilical cord
◦ Trauma; fibrin defects
Types of Abruptio
Placenta
Type I: Concealed, Covert or Type II: Marginal, Overt or
Central type External bleeding type
 Types of 1. Marginal/low separation
2. Moderate/high separation
3. Severe/complete separation
separation
Assessmen
t findings
◦ Painful, vaginal bleeding
◦ Rigid, board-like, and painful
abdomen
◦ Enlarged uterus due to
concealed bleeding
◦ If in labor: tetanic
contractions with the absence
of alternating contraction and
relaxation of the uterus
Diagnosis
◦ Clinical diagnosis (signs and
symptoms)
◦ Ultrasound – detects the
retroplacental bleeding
◦ Clotting studies – reveal DIC,
clotting defects
◦ The thromboplastin from
retroplacental clot enters maternal
circulation and consumes
maternal free fibrinogen resulting
in:
◦ DIC: small fibrin clots in
circulation
◦ Hypofibrinogenemia: decrease
normal fibrinogen results in
absence of normal blood
coagulation
Complications
◦ Hemorrhagic shock
◦ Couvelaire uterus
◦ Disseminated intravascular
coagulation (DIC)
◦ Cerebrovascular accident (CVA)
from DIC
◦ Hypofibrinogenemia
◦ Renal failure
◦ Infection
◦ Prematurity, fetal distress/
demise (IUFD)
Nursing management
◦ Maintain bed rest, LLR
◦ Careful monitoring: Maternal VS, FHT, Labor onset/ progress, I &
O,
oliguria/ anuria, uterine pain, bleeding
◦ Administer IV fluids, plasma, or blood as ordered
◦ Prepare for diagnostic examinations
◦ Provide psychological support
◦ Prepare for emergency birth
◦ Observe for associated problems after delivery:
◦ Poorly contracting uterus
◦ Disseminated Intravascular Coagulation
◦ Hypofibrinogenemia
◦ Prematurity, neonatal distress
PRETERM
LABOR
Labor that occurs after the 20 week and
th

before 37 t h week of gestation

Etiolog
y◦ In >30% cases exact
cause of preterm labor
is not known
◦ Occurs approximately
9- 11% of all
pregnancies
◦ Any woman having
persistent uterine
contractions (4 every
20 minutes)
 Risk
◦factors
Maternal factors
◦ Maternal infection, illness or disease, DM
◦ Premature rupture of membranes (PROM)
◦ Bleeding
◦ Uterine abnormalities/ overdistention,
incompetent cervix
◦ Previous preterm labor, spontaneous or induced
abortion, preeclampsia, short interval (less than
1 year) between pregnancies
◦ Trauma, poor nutrition, no prenatal care, lack of
childbirth experience
◦ Extremes of age, decreased weight (<100 lbs)
and less height (<5 ft)lack of rest/ excessive
fatigue
◦ Smoking
◦ Extreme emotional stress
Risk
factors
◦ Fetal factors
◦ Multiple pregnancy
◦ Infections
◦ Polyhydramnios
◦ Congenital Adrenal Hyperplasia
◦ Fetal malformations
◦ Placental factors
◦ Placental separation
◦ Placental disorders
◦ Unknown factors
Complications
◦ Prematurity
◦ Fetal death
◦ Small-for-gestational
age (SGA)/ IUGR
◦ Increase perinatal
morbidity and
mortality
Treatment
(Hospitalization
)◦ Bed rest on LLR
◦ Adequate hydration
◦ Monitoring:
◦ Uterine contractions and irritability
(every 1-2 hours)
◦ VS
◦ I&O
◦ Signs of infection
◦ Cardiac and respiratory status
and distress signs
◦ Cervical consistency, dilatation, and
effacement
◦ Fetal well being
◦ Early signs of edema
Treatment
(Hospitalization
)
◦ Promotion of physical
and emotional comfort
◦ Administration of Tocolytics
(magnesium sulfate, Terbutaline,
Ritodrine)
◦ Contraindications:
◦ Advanced pregnancy
◦ Ruptured bag of waters
◦ Maternal distress
(bleeding complications,
PIH, cardiovascular
disease)
◦ Fetal distress
◦ Presence of fetal problems
(Rh isoimmunization)
Treatment
(Hospitalization
)
◦ Administration of
corticosteroids
◦ Betamethasone
(12mg IM every
24 hours x 2
doses)
◦ Dexamethasone (6mg IM every
12 hours x 4 doses)

◦ Assess effects of drugs on

labor and fetus
◦ Monitor for side effects
 Discharge
(premature labor
◦stopped)
Maintain bed rest, LLR preferred
◦ Well-balanced diet (high in iron,
vitamins, and important
minerals)
◦ Continuation of oral medications
◦ Frequent prenatal visit every
week
◦ Activity/ Lifestyle evaluated
and restricted as necessary
◦ Illnesses: Chronic –
monitored; Acute – treated
stat
◦ Provide client teaching
◦ Symptoms of preterm labor
◦ Prompt reporting to physician
 PREMATURE RUPTURE
OF MEMBRANES
(PROM)
Spontaneous rupture of fetal membrane any time
after
the period of viability but before the onset of labor
Premature Rupture
Of Membranes
(PROM)
◦ Defined as rupture of
the membrane before
the onset of
spontaneous labor
◦ Normally spontaneous
membranes
rupture(break) end of
1st stage or beginning
of second stage
Premature Rupture
Of Membranes
(PROM)
◦ Cause: UNKNOWN
◦ Associated with
infection of the
membranes
(Chorioamnionitis)
◦ Occurs in 5-10%
of pregnancies
Assessmen
t findings
◦ Maternal report of
passage of fluid per
vagina
◦ Determination of alkaline
amniotic fluid and not
acidic urine or vaginal
discharge
 RISK FACTORS
A. Infection
B. Previous history of PROM
C. Hydramnios
D. Incompetent cervix
E. Multiple gestation
F. Abruptio placentae
Diagnosis
◦ Nitrazine test
◦ Change in color of Nitrazine paper
from yellow-green (acidic vaginal pH
= 4-6) to blue color because of neutral
to slightly alkaline amniotic fluid (pH =
7-7.5)
◦ Ferning test
◦ Amniotic fluid, high in sodium
content, will assume a ferning pattern
when dried on the slide
◦ Sterile speculum examination
◦ Direct visualization of fluid from
cervical
os is the most reliable diagnosis
 ◦ Maternal infection-chorioamniotnitis
Complications ◦ Cord prolapse
◦ Premature labor
◦ Fetal/neonatal infection
 ◦ Initial Assessment - objectives of
the initial assessment are:
- Confirm the diagnosis of PROM
Manageme - To determine the gestation of
nt the
of fetus
PROM - To identify the women who
need to
deliver
 Management of
PROM
◦ If Pregnancy is >37 weeks and with presence
of:
◦ Congenital anomalies
◦ Fetal distress , cord prolapse
◦ Signs of chorioamnionitis

Then deliver....

◦ Induction of labor- if no contraindication

 Management of
PPROM
◦ Balance between risk of infection in expectant management &
Premature labor
◦ Shift the patient where the facility for neonatal care is available .
◦ If pregnancy is >34 and <37 weeks
- CBC, cervical swab c/s
- Antibiotics
- Careful watch on signs of chorioamnionitis
Maternal & fetal conditions
- If no spontaneous labor in 24-48hrs-induction
of labor
◦ If pregnancy <34 weeks

Expectant Management- The aim is to

prolong the pregnancy for fetal
maturity
- Bed rest
- CBC & Cervical swab c/s
- give corticosteroid & tocolytics
- Antibiotics
-Watch for signs of
chorioamnionitis,
Maternal & fetal
condition.
Thank
you !!!