MAAM YBOA DISCUSSION LP1

High Risk Pregnancy

- A high risk pregnancy is one in which a woman and her fetus face a
higher-than-normal chance of experiencing problem. These risks may be due to
factors in the pregnancy itself, or they may stem from pre existing maternal medical
conditions, such as cancer, diabetes, or lupus.
- Problems during the term of pregnancy
- Over 40 yrs old and under 18 yrs old have high risk pregnancy
Identifying and/or Monitoring High Risk Pregnancy
1. Alpha Fetoprotein (AFP)
- enzyme blood test, elevated levels may identify the pregnant woman carrying a baby
with neural tube defects (spina bifida and anencephaly); may also indicate twins.
- Anencephaly- absence of brain and skull
2. Ultrasonography
- High frequency sound wave testing discerns placental location and gestational age by
measurement of biparietal diameters.
3. Chorionic Villi Sampling (CVS)
- Supplies same data as amniocentesis but can be done earlier and quicker results can
be obtained.
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4. Amniocentesis
- Aspiration of amniotic fluid used to detect sex chromosomal and biochemical
defects, fetal age, 1/5 ratio (2/7 ratio indicates lung maturity), increased bilirubin
level associated with Rh diseases and phosphaldy (glycerol PG), which appears in
amniotic fluid after thirty-fifth week, indicating lung maturity.
5. Non-Stress Test (NST)
- To observe for accelerations of FHR in response to fetal movement.
- Patient is advised to fast before the test. Must explain to the patient of the procedure
to relieve anxiety or anxiousness.
- It is done after ultrasound.
Classifcation of Results
- Reactive (Positive Sound) 2 or more acceleration of FHR of of 50 beats per minute
lasting 15 seconds (no intervention needed)
- Nonreactive (No sound heard) No FHR acceleration
- Unsatisfactory (Sound is unclear)
 6. Contraction Stress Test (CST)
- To demonstrate whether a healthy fetus can withstand a decreased oxygen supply
during the stress of a contraction produced by exogenous oxytocin (Pitocin); if late
decelerations appear, the fetus may be compromised because of uteroplacental
insufficiency.
- Deceleration: temporary but distinct decrease of FHR.
- Late deceleration: lowest point after peak of contraction
- Early Deceleration: lowest point of same time as peak of contraction.
Classification of Results
a. Negative
- No late decelerations with a minimum of three contractions in 10 minutes, indicates
that the fetus has good chance of surviving labor.
b. Positive
- Persistent and late decelerations occurring more than half the contractions; indicates
need for consideration of premature intervention
c. Suspicious
- Late decelerations occurring in less than half; indicates contraction test should be
appealed in 24 hours.
7. Biophysical Profile (BFP)
- Assesses breathing movements, body, movements, tones, amniotic fluid volume, and
FHR reactivity (HG), and score of 2 is assigned to each finding with a score of 8 to
10 indicating a health fetus.
8. Maternal Assessment of Fetal Activity
- Need to contact physician or nurse midwife when there are fewer than 10 fetal
movements in a 12-hour period, fewer than three fetal movements in an 8- hour
period, or no fetal movements in the morning.
9. Fetal scalp pH sampling
- May be done during labor when fetal heart patterns begin to indicate distress;
capillary blood samples are found from fetal scalp in utero.
Hemorrhagic Complications of Early Pregnancy
2 categories
- Complications related to the pregnancy itself and not seen at other times
- Diseases that are not pregnancy induced but occur coincidentally. (e.g diabetes,
hypertension)
Abortion
- The termination of pregnancy at any time before the fetus has attained a stage of
viability, (i.e. before it is capable of extra uterine existence).
- Miscarriage is commonly used by lay persons to denote an abortion that has occurred
spontaneously rather than one which has been induced.
- 10 – 20 percent of abortions are spontaneous abortion.
- Abortion is the accepted medical term. Miscarriage is rarely used.
Causes
- May be caused by the presence of embryonic defects, external mechanical force
(legal abortion in states), or trauma (accident). Or sickness.
Types of Abortions
Spontaneous Abortion
- Is one in which the process starts at its own accord due to natural causes. Induced
abortion is one that is artificially induced whether for therapeutic or other reasons.
- Happens usually during 2nd or 3rd month of pregnancy.
- This condition is very common.

Threatened Abortion
- As abortion is regarded as threatened (vaginal bleeding or spotting occurs in early
pregnancy). This may or may not be associated with mild cramps. The cervix is
closed.
- Some threatened abortion may proceed to actual abortion.
- Some instances happens where one of the fetus is aborted while the other stays.
Inevitable Abortion
- Inevitable abortion is so called because of the process has gone so far that termination
of the pregnancy cannot be prevented. Bleeding is copious, and the pains are severe.
Incomplete Abortion
- Is one in which part of the products of conception has been passed, but part (usually
the placenta) is retained in the uterus.
Complete Abortion
- Is the expulsion of all the products of conception.
Missed Abortion
- The fetus dies in the uterus but is retained.
- Subject to surgical removal of the fetus.
 -
Habitual Abortion
- Is a condition in which spontaneous abortion occurs in successive pregnancies (three
or more)
- Have history of 3 or more abortion.
- Most distressing to the woman.
Illegal Abortion
- Is the termination of pregnancy outside of appropriate medical facilities (hospital or
clinic), generally by non-physician abortionists, regardless of the validity of the
indication.
-
Causes
Problems with the genes or chromosomes
- Blighted ovum
- Intrauterine fetal demise
- Molar pregnancy and partial molar pregnancy
- 50 percent of miscarriage is because there is a defect in fertilized eggs.
- Partial molar pregnancy: occurs when the mother’s chromosomes remain while the
father provides two sets of chromosomes.
Maternal Health Conditions
- Uncontrolled diabetes
- Infections
- Hormonal problems
- Uterus or cervix problems
- Thyroid diseases
Risk Factors
- Age (35 yrs old is ok especially if its your first pregnancy)
o ( 35 yrs old has 25% risk; 40 yrs old has about 40% risk; 45 yrs old has about
85% risk)
- Previous Miscarriages
- Chronic Conditions
- Uterine or cervical problems (e.g incompetent cervix - dilating of cervix in the early
months)
- Smoking, alcohol and illicit drugs
- Weight (underweight/overweight)
- Invasive prenatal tests (E.g CVS, Amniocentesis)
Diagnosis
 - Pelvic Exam
- Ultrasound (Fetal Heart Beat, Embryo)
- Blood Tests (If progesterone is maintained or not)
- Tissue Tests (spotting)
- Chromosomal tests (2 or more previous miscarriage: both partners should take the
test)
Treatment
- For a threatened miscarriage, recommended resting until the bleeding or pain
subsides
- Miscarriage
-Expectant Management
- Medical Treatment
- Surgical Treatment
Assessment
- Vital signs; amount of bleeding pad/hr (abstinence to sexual blahblah)
-Administer oxytocin, if not effective, surgical removal is needed.
- Pain
- Emotional Response to loss
Nursing Diagnoses
- Anticipatory grieving related to loss of expected infant
- Pain related to uterine contractions
Evaluation/Outcomes
- Remains free from complications such as hemorrhage and infection.
- Expresses feelings
Incompetent Cervix
- An incompetent cervix also called as cervix insufficiency, occurs when the cervix
causes or contributes to premature birth or the loss of an otherwise healthy pregnancy.
- Cervical Cerclage (Suture)
Symptoms
- A sensation of pelvic pressure
- A new backache
- Mild abdominal cramps
- A change in vaginal discharge
Risk Factors
- Cervical trauma
- Race
 - Congenital Conditions
Complications
- Premature Birth
- Pregnancy Loss
Prevention
- Seek regular prenatal care
- Eat a healthy diet
- Gain weight wisely
- Avoid risky substances
Treatment
- Progesterone supplementation (hydroxyprogesterone caproate)
- Repeated ultrasounds
- Cervical Cerclage
-McDonald’s Cervical Cerclage (Nylon; horizontal and vertical)
- Shirodkar Cervical Cerclage (Sterile Tape)
Nursing Assessment
- As the woman is reporting for painless bleeding if she is feeling an intense pressure
on her pelvis
- Inspect and save pads used by the woman during bleeding to determine any clots or
tissues that already passed out.
- Determine of the woman is experiencing true contractions to prepare for the birth of
the fetus
Nursing Diagnosis
- Anticipatory grieving related to potential loss of expected infant
- Situational low self-esteem related to inability to complete pregnancy without
intervention
- Anxiety related to impeding loss of pregnancy as evidenced by premature dilation of
the cervix
Nursing Interventions
- Determine any factors that further contribute to the anxiety of the woman so it could
be avoided.
- Monitor vital signs to determine any physical responses of the patient that could
affect her condition.
- Convey empathy and establish a therapeutic relationship to encourage client to
express her feelings.
- Provide accurate information about the situation to help client back into reality.
Evaluation
- Patient would appear relaxed and report anxiety has been reduced
- Verbalize awareness of feelings of anxiety
- Enumerate ways to deal with anxiety
- Use resources or support systems effectively.

Ectopic Pregnancy
- An ectopic pregnancy most often occurs in fallopian tube, which carries eggs from
the ovaries to the uterus. This type of ectopic pregnancy is called a tubal pregnancy.
- Sometimes, an ectopic pregnancy occurs in other areas of the body, such as the ovary,
abdominal cavity or the lower part of the uterus (cervix), which connects to the
vagina.
Symptoms
- Sharp abdominal pain
- Vaginal Spotting
- Sharp stabbing pain of the lower quadrant
- Vaginal Bleeding
Risk Factors
- Previous ectopic pregnancy
- Inflammation or infection
- Fertility Treatments
- Tubal Surgery
- Choice of Birth Control (e.g IUD, Bilateral tubal ligation)
- Smoking
Complications
- An ectopic pregnancy can cause the fallopian tube to burst open. Without treatment,
the ruptured tube can lead to life-threatening bleeding.
Diagnosis
- Pelvic exam
- Blood tests
- Ultrasound
- Pregnancy test

Treatment
 - Medication (Methotrexate- a type of birth control that can induce abortion)
- Laparoscopic procedures
- Salpingostomy and salpingectomy
o In a salpingostomy, the ectopic pregnancy is removed and the tube left to heal
on its own. In a salpingectomy, the ectopic pregnancy and the tube are both
removed.
- Emergency Surgery
o Laparotomy
Nursing Assessment
- No unusual symptoms are usually present on the time of implantation of an ectopic
pregnancy
- The usual sign of pregnancy would occur, such as a positive pregnancy test, nausea
and vomiting and amenorrhea.
- At 6-12 weeks of pregnancy, the trophoblast would be large enough to rupture the
fallopian tube.
- Bleeding would follow and it would depend on the number and size of the affected
blood vessels the amount of bleeding that would occur.
- Sharp stabbing pain in the lower quadrant. It is likely to be felt by the woman once a
rupture has occurred followed by scant vaginal bleeding.
- Upon arrival at the hospital, a woman who has a ruptured ectopic pregnancy might
present signs of shock such as a rapid thread pulse, rapid respirations, and decreased
blood pressure.
- There would be a decreased hCg levels of progesterone levels that would indicate that
the pregnancy has ended.
Nursing Diagnosis
- Risk for Deficient fluid volume related to bleeding from a ruptured ectopic pregnancy
- Powerlessness related to early loss of pregnancy secondary to ectopic pregnancy.
Nursing Interventions
- Upon arrival at the emergency room, place the woman flat in bed.
- Assess the vital signs to establish baseline data and determine if the patient is under
shock.
- Maintain accurate intake and output to establish the patient’s renal function.
Evaluation
- The goal of the evaluation is to ensure that maternal blood loss is replaced and the
bleeding would stop.
- The patient must maintain adequate fluid volume of a functional level as evidenced
by normal urine output at 30-60ml/hr and a normal specific gravity between the
ranges of 1.010 to 1.021.
Hyatidiform Mole
- Hyatidiform mole (HM) is a rare mass or growth that forms inside the womb (uterus)
at the beginning of a pregnancy. It is a type of gestational trophoblastic disease
(GDT)
- Molar Pregnancy
o Complete molar Pregnancy ( 1 or 2 sperm fertilizes the egg)
o Partial Molar Pregnancy (abnormal chromosome in mother)
Risk Factor
- Earlier molar pregnancy
Complications
- Gestational Trophoblastic Neoplasia (GTN)
o Seen if the ECG is still high even after the removal of Molar Pregnancy.
Diagnosis of complete molar pregnancy
● Excess levels of hCG (100,000 mIU/mL)
● Associated with vaginal bleeding, uterine enlargement and abnormal ultrasound findings
(snowstorm-like appearance)
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