HIGH RISK

PREGNANCY
High Risk
Pregnancy
◦ 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
Causes
• Defective ovum/ congenital defects
• Unknown causes

MATERNAL FACTORS
• Viral infection
• Malnutrition
• Trauma Kapag naaksidente
• Congenital defects of the reproductive tract Hindi pa matured
• Incompetent cervix Pwedeng malalaglag
• Hormonal Less hormones, less kapit
• Increased temperature Fever can cause miscarriage
• Systemic diseases in the mother Hypertension=Vasocon=Lessened O2 and Nutrients
• Environmental hazards Smoking envi
• Rh incompatibility
Types
Interruption of preg before the
fetus is viable
◦Spontaneous abortion
◦ Without medical or
mechanical intervention
Before 16 up to 20wks

◦Induced abortion Sinadya

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

INDUCED • Severe hemorrhage Dinudugo

ABORTIONS w/c may lead to
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
Bright Red/Scanty be present
Inevitable Moderate Moderate Open None No
Complete Small to Moderate Close or Complete No
negative partially open placenta with
dahil bagong
labas lang 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
Hindi lumabas yung dead fetus 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
Odorous Discharge with or discharge
without tissue
Signs
• 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
– Hypotension
– Air hunger
 Treatment
• Surgery For incomplete, missed and septic abortion
• 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
Stops contraction
Threatened Bed rest Tocolytics (Ritodrine,
Isoxsuprine, Terbutaline)
Inevitable IVF (LR/ PNSS) Oxytocin (>12) Vacuum aspiration Bld. Typing/
(<12) Cross-matching
Completion
Currettage Kinakayod
Incomplete IVF (LR/ PNSS) Oxytocin (>12) Vacuum aspiration Bld. Typing/
Antibiotics (Ampicilin/ (<12) Cross-matching
metronidazole) Completion
Analgesics Currettage Kinakayod
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/
Measure blood
Antibiotics (Cephalosporins, rization Cross-matching
loss
Ampicilin/metronidazole) Currettage
Hematinics Prevent blood loss
 70-95%

◦ 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
Surgery of the
narrowing or Inflammatory postpartal
fallopian tubes
constriction Disease (PID) sepsis

Congenital
anomalies of Adhesions,
IUD usage
the fallopian spasms, 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 collapse
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 administration, blood
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 16th to 18th
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-
McDonald surgery)
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
separation. 3. Severe/complete separation
Assessment
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 20th week and
before 37th week of gestation
Etiology
◦ 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)
◦ Cause: UNKNOWN
◦ Associated with
infection of the
membranes
(Chorioamnionitis)
◦ Occurs in 5-10% of
pregnancies
Assessment
findings
◦ Maternal report of passage
of fluid per vagina
◦ Determination of alkaline
amniotic fluid and not
acidic urine or vaginal
discharge
Diagnosis
◦ Nitrazine test
◦ Change in color of Nitrazine paper from
yellow (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
 ◦ Initial Assessment - objectives of the
initial assessment are:
- Confirm the diagnosis of PROM
Management - To determine the gestation of the
of PROM fetus
- 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 !!!