ABNORMAL PREGNANCY

Prepared by Yeshi Assefa

(MSC,BSC,R/N)
March/2021
 OUTLINES:
 Minor disorders of pregnancy
 Hyper emesis gravidram
 Hypertensive disease during pregnancy
 Ante partum hemorrhage
 Amniotic fluid disorder
 Premature rapture of membranes
 Fetal growth abnormality
o Intra uterine fetal death
 Preterm labor
 Prolonged pregnancy
 Multiple pregnancy and associated complication
 RH incompatibility
 MINOR DISORDERS OF PREGNANCY
• Minor disorders are only disorders that occur during pregnancy
and are not life threatening.
1. Nausea and vomiting- This presents between 4 and 12 weeks of
gestation.
- Hormonal influences are the most likely causes. -
usually occurs in the morning but can occur any time during the
day, aggravated by smelling of food.
 Management: -
- Reassure the mother
- Small frequent meals (dry meals)
- Reduce fatty and fried containing foods.
- Rest
.
 Cont…
2. Heart burn: - is a burning sensation in the mid chest
region.
Progesterone relaxes the cardiac sphincter of the
stomach and allows reflex of gastric contents into
esophagus.
Heart burn is most troublesome at 30-40 weeks
gestation due to the pressure from the growing uterus
• Management:
- Small and frequent meal, sleeping with more
pillows than usual.
- For persistence/sever case/ prescribe antacids
3. Pica: - This is the term used when mother craves
certain foods of unnatural substances such as
coal, soil...etc.
The cause is unknown but hormones and changes
in metabolism are blamed.
 Management: - Seek medical advice if the
substance craved is potentially harmful to the
unborn baby.
 Cont…
4. Constipation: -
Progesterone causes relaxation and decreased
peristaltic activity of the gut, which is also
displaced by the growing uterus.
 Management: -
Increase the intake of water, fresh fruit,
vegetables and roughages in the diet.
- Exercise is helpful especially walking
5. Backache - The hormones sometime soften
the segments to such a degree that some
support is needed.
 Management:
- Advice the mother to sleep on firm bed.
- Advice support mechanisms of the back.
6. Fainting: -
• In early pregnancy fainting may be due to the
vasodilatation occurs under the influence of
progesterone before there has been a compensatory
increase in blood volume.
• The weight of the uterine contents presses on the
inferior venacava and slows the return of blood to the
heart.
 Management:
- Avoid long period of standing
- Sit or lie down when she feels slight dizziness
- Advice not to lie on her back except during
abdominal examination
7. Varicosities- Progesterone relaxes the smooth muscles of
the veins and result in sluggish circulation.
The valves of the dilated veins become insufficient and
varicosities result.
It occurs in legs, anus (hemorrhoids) and vulva.
 Management:
- Exercising the calf muscles by rising on the toes
- Elevate the leg and rest on the table
- Support thighs and legs
- Avoid constipation and advise adequate fluid intake.
- Sanitary pad give support for vulva varicositis
 Cont…
• Most minor disorders can be advanced into a more serious
complication of pregnancy.
The disorders require immediate actions are as follows (Danger
signals of pregnancy)

• - Vaginal bleeding - ---

Reduced fetal movements -
Frontal or recurring headaches - Sudden
swelling - Rupture of the
membrane - Premature
onset of contractions - Maternal
anxiety for whatever reason
HYPEREMESIS GRAVIDARUM
 Definition
 Hyper emesis gravidarium is a complication of
pregnancy characterized by persistent, uncontrollable
nausea and vomiting that begins in the first trimester
and causes dehydration, ketosis, and weight loss of
more than 5% of prepregnancy body weight.
 occurs in approximately 5 out of 1,000 pregnancies.
• The prevalence increases in molar pregnancies and
multiple gestations.
• The peak incidence is at 8 to 12 weeks of pregnancy,
and symptoms usually resolve by 20th week
 Etiology
• The exact cause is unknown. but it is known to be associated
with:
- Multiple pregnancies,
- Hydatidiform mole,
- A history of women who experience this condition will have a
recurrence in subsequent pregnancies
• A few theories that have been proposed to explain its etiology
include:
• Endocrine theory—high levels of HCG and estrogen
during pregnancy
• Metabolic theory—vitamin B6 deficiency
• Psychological theory—psychological stress increases
the symptoms
 Pathophysiology
• Elevated levels of HCG are present in all pregnant women
during early pregnancy, usually declining after 12 weeks.
This corresponds to the usual duration of morning
sickness.
• In hyper emesis gravidarium, the HCG levels are often
higher and extend beyond the first trimester.
Symptoms exacerbate the disease.
• Decreased fluid intake and prolonged vomiting cause
dehydration;
- Dehydration increases the serum concentration of
HCG, which in turn exacerbates nausea and vomiting—a
vicious cycle.
 Cont…
its effects :–
- Decreased placental blood flow,
- Decreased maternal blood flow and
- Acidosis—can threaten the health of the
mother and fetus.
- Dehydration can lead to preterm labor
 Assessing the mother’s condition
- Ask the woman whether normal diet has been resumed and
tolerated.
- Identify any events producing stress or anxiety, as these may
exacerbate any vomiting.
- Ascertain whether the nausea and vomiting are accompanied by
pain; the location of any pain should be elicited.
- Dryness or inelasticity of the skin
- The mother’s weight will be less than expected for gestation.
- The pulse rate will be weak and rapid and B/P becomes low.
- Urine- becomes scanty and dark in colour and smells of acetone
- It is usual for a mother suffering from hyper emesis gravidarum
to be admitted to hospital.
 Diagnosis
• CBC
• Urine ketones—positive when the body
breaks down fat to provide energy in
the absence of adequate intake
• Blood urea nitrogen (BUN)—increased in the
presence of salt and water depletion
 Cont…
 Urine specific gravity—greater than 1.025,
indicating concentrated urine linked to inadequate
fluid intake or excessive fluid loss
- ketonuria
 Serum electrolytes—decreased levels of potassium,
sodium, and chloride resulting from excessive
vomiting and loss of hydrochloric acid in stomach
 Ultrasound—evaluation for molar pregnancy or
multiple gestation
 Therapeutic Management
• Hyper emesis gravidarium is a diagnosis of exclusion.
Careful consideration of other conditions must be
assessed
• when a client experiences nausea and vomiting for the
first time after 9 weeks’ gestation, Conservative
management at home is the first line of treatment.
• This usually focuses on dietary and lifestyle changes.
• If it fails to alleviate the symptoms , hospitalization is
necessary to reverse the effects of severe nausea and
vomiting.
• On admission to the hospital,
- blood tests to assess the severity of the client’s
condition electrolyte imbalance, ketosis, and
malnutrition.
- Parenteral fluids and drugs are ordered for
rehydration
- The first choice 5% dextrose in Ringer’s lactated
solution with vitamins (pyridoxine [B6]) and
electrolytes.
- Oral food and fluids are withheld for the first 24 to 36
hours to allow rest to GI tract .
- Antiemetic administered rectally or intravenously to
control nausea and vomiting
 Cont….
• Once her condition stabilizes medications
administered orally.
• if tolerated a light diet may follow.
• Normal food is gradually introduced and intravenous
therapy discontinued.
• Vitamin B12 and C, folic acid and iron required to
correct anemia
• If there is no improvement after several days of bed
rest, “gut rest,” IV fluids, and antiemetic, total
parenteral nutrition or feeding to prevent malnutrition
• Most drugs are given parenterally or rectally
• If it is untreated, it may cause
- Neurologic disturbances,
- Renal damage,
- Retinal hemorrhage, or death.
• Note! Every pregnant woman needs to be
instructed to report any episodes of severe
nausea and vomiting or episodes that extend
beyond the first trimester
 Midwifery Assessment

• History and physical examination to identify

signs and symptoms associated with this
disorder.
- The client is extremely uncomfortable.
- She may experience many hours of lost
work productivity and sleep,
- hyper emesis may damage family
relationships.
 Health History and Physical Examination
• take history fromthe client about:-
• The onset, duration, and course of her nausea and vomiting.
• Any medications or treatments used and its effectiveness
• Diet history , including a dietary recall in the past week.
• Note the client’s knowledge of nutrition and need for
appropriate nutritional intake.
• Be alert for patterns that may contribute /cause her distress.
• Ask about any complaints of ptyalism (excessive salivation),
anorexia, indigestion, and abdominal pain or distention.
• Ask if she has noticed any blood or mucus in her stool.
 Cont…
• Review the client’s history for possible risk factors,
such as young age, nausea and vomiting with
previous pregnancy
• History of intolerance of oral contraceptives,
- trophoblastic disease, multiple gestation
- emotional or psychological stress,
- gastro esophageal reflux disease,
- primigravida status, obesity, hyperthyroidism,
- helicobacter pylori seropositivity .
• Weigh the client and compare with the weight
before experiencing symptoms
 Cont…
• Inspect the mucous membranes for dryness
• Check skin turgor for fluid loss and dehydration.
• Assess B/P for hypotension, that may suggest a fluid volume
deficit.
• Note any complaints of weakness, fatigue, activity,
intolerance, dizziness, or sleep disturbances.
• Assess client’s perception of the situation.
• Note any evidence of depression, anxiety, irritability, mood
changes, and decreased ability to concentrate, which can
add to her emotional distress .
• Determine woman’s support systems available for help.
• Check lab results
 Midwifery Management
• Management focuses on
 promoting comfort and adequate nutrition.
 providing support and educating the client
and her family
 Promoting Comfort and Nutrition

• During the initial period, expect to withhold all oral food

and fluids, maintaining NPO status to allow the GI tract to
rest.
• Administer prescribed drugs and IV fluids .
• Monitor the rate of infusion to prevent overload
• Assess IV insertion site to prevent infiltration or infection.
• Administer electrolyte replacement therapy as ordered to
correct any imbalances
• Observe the B/P, pulse rate and temperature 4/hourly.
• periodically check serum electrolyte levels to evaluate the
effectiveness of therapy
 Cont...
• Provide physical comfort measures such as
hygiene measures and oral care.
• Pay special attention to the environment, making
sure to keep the area free of pungent odors.
• As the client’s nausea and vomiting subside,
gradually introduce oral fluids and foods in small
amounts.
• Monitor intake and output and assess the
client’s tolerance to the increase in intake
 Providing Support and Education
• Women with hyper emesis gravidarium commonly are fatigued
physically and emotionally. exhausted, frustrated, and
anxious.
• Reassure the mother that all interventions are directed toward
promoting positive pregnancy outcomes
• Inform about the expected plan of care to alleviate anxiety.
• Listen to her concerns and feelings, answer all questions
honestly.
• Educate the woman & her family about the condition and
treatment options
• Teach the client about therapeutic lifestyle changes, such as
avoiding stressors and fatigue that trigger nausea and
vomiting
Educate the mother to :-
Avoid noxious stimuli—such as strong flavors, perfumes, or
strong odors such as frying that might trigger nausea
and vomiting.
• Avoid tight waistbands to minimize pressure on
abdomen.
• Eat small, frequent meals throughout the day
( six small meals).
• Separate fluids from solids by consuming fluids in
between meals.
• Avoid lying down for at least 2 hours after eating.
• Use high-protein supplement drinks.
• Avoid foods high in fat.
 Cont….
• Increase intake of carbonated beverages.
• Increase exposure to fresh air to improve symptoms.
• Eat when hungry, regardless of normal mealtimes.
• Drink herbal teas containing peppermint or ginger.
• Avoid fatigue and learn how to manage stress in life.
• Schedule daily rest periods to avoid becoming
overtired.
• Eat foods that settle the stomach, such as dry
crackers, toast, or soda.
THANKYOU