Part III: Pregnancy (Normal &Complicated)

Outlines

Development & physiology of fetus.

Normal pregnancy (Physiological& psychological changes) Prenatal care.

Nursing care during complications of pregnancy(APH, PIH, GD, UTI,

&anemia).

Learning Objectives

At the end of this chapter, the student should be able to:

1. Explain mitosis and meiosis and differentiate between the two.

2. Describe the processes of spermatogenesis and oogenesis, and how they

differ.

3. Explain how the sex of the conceptus is determined.

4. Describe the three developmental stages of pregnancy with regard to

beginning and ending periods and major events occurring during each stage.

5. Describe the development of support structures during pregnancy.

6. Name four major functions of amniotic fluid.

7. Discuss three functions of the placenta.

8. List the steps in the process of the exchange of nutrients and wastes between

the maternal and fetal bloodstreams.

9. Trace the path of fetal circulation, including the three fetal shunts.

10. Name three categories of teratogens and list examples of each kind.

11. Discuss the threat to pregnancy that occurs with ectopic pregnancy.

12. Differentiate between the types of multifetal pregnancies.

DEVELOPMENT OF FOETUS

INTRODUCTION:

Life begins at the time fertilization of the ovum

The zygote formed is a single cell which develops into fully formed adult

Prenatal development is the process in which an embryo or fetus gestates

during pregnancy, from fertilization until birth.

Gestation Period

The gestation period of

a) Germinal Period - This begins at fertilization and extends till the third week.

b) Embryonic period – This extend from 4th

~ 8th

week, involving changes in

shape and external appearance.

c) Fetal period – This extends from 3rd

month up to termination of pregnancy.

Development of supportive structures of fetus & Major Events

Fertilization

o Cleavage Division – The process of repeated mitotic division results in

increase of number of cells known as Cleavage give rise to blastomere.

o Formation of morula and blastocyst -blastomere form compact ball called

morula. The centre of morula is inner cell mass.

Blastocyst – The cells of morula continue to divide and forms blastocele.

At this stage zygote is blastocyst. Outer cell is trophoblast and inner cell mass

is embryoblast.

o Implantation of blastocyst – Blastocyst attaches to endometrium and

implantation takes place on 6th ~ 7

th day after fertilization. Now Endometrium

is ready to support the pregnancy, and is now referred as the decidua.

The

Decidua

The corpus luteum continues to produce progesterone which stimulates

secretery activity of endometrial glands and increase the size of blood vessel

and form soft spongy bed.

The layers of Decidua

Basal Layer – Lies above the biometrium. It contains basal portion of glands

Functional Layer – It is through this layer that the cleavage of placental

separation occur

Superficial compact layer – This forms surface of decidua.

After implantation of the blastocyst the decidua is renamed as :

i. Basal decidua – The decidua underneath the blastocyst.

ii. Caspular decidua – It thin superficial layer covering the ovum.

iii. Parietal decidua – the rest of decidua lining the uterine cavity outside the site

of implantation.

Functions

Provides bed for implantation

Supplies nutrition to early stage of growing ovum

Protective function

Formation of germ layer

This is first major event after implantation.

Three layers are formed –

Ectoderm – layer forms skin and nervous system.

Mesoderm – Layer forms bone, muscle, heart and blood vessel.

Endoderm – Forms mucus membrane and glands

The three layer together are known as embryonic plates.

Development of Placenta:

Placenta develops from two sources

- Fetal part from chorionicfrondsumand,

- Maternal part from dduabasalis.

STAGES

Implantation.

Changes to decidua.

Trophoblastic forms chorion.

Chorionic villi are formed i.e. finger like projection.

Villi becomes profuse in the basal decidua and eventually develops into

placenta .

Villi under capsular decidua being less nourished degenerate and forms

chorionic laeve which is origin of chorionic membrane.

Chorionic villus center consist of mesoderm and fetal blood vessel and

branches of umbilical arteries and vein.

Placental Circulation:

Maternal Placental circulation:

The maternal blood through spiral arteries comes to placental bed and

surrounds the inter villus space and from there enters the veins and is drained

by them.

Fetal Placental Circulation:

Fetal blood comes to placenta through umbilical Arteries and enters the

chorionic villi.

Veins from chorionic villi drain into umbilical vein which carries the blood

from fetus to placenta.

Functions of Fetal Placental Circulation

Respiration – Oxygen is obtained and carbon dioxide is excreted through

placenta.

Nutrition - Placenta provides proteins as amino acids, carbohydrates and fats

as fatty acids.

Storage – It stores glucose as glycogen.

Excretion – It gives out carbon dioxide bilirubin urea uric acid

Protection – Prevents entry of microorganism and noxious agent but not drugs

and virus.

Endocrine – Produces human Chorionic Gonadotropin, Estrogen

&Progesterone.

Anatomic Variations

Succenturate Lobe of placenta , Small extra lobe is present.

Circumvallate placenta – in this an opaque ring is seen on fetus surface.

Battle dore insertion of cord – in this umbilical cord is attached closed to

margin of placenta

Velamentous insertion of chord – Chord is inserted into membrane some

distance away from edge of placenta.

Placenta preavia- Implantation in the lower part of uterine cavity.

Bipartite Placenta – to complete and separate lobes are present

Tripartrite Placenta – Three lobes are present

Umbilical Cord

The umbilical cord or funis forms the connecting link between the fetus and

placenta.

It has two arteries and one vein.

It is protected by Wharton's jelly average length 50 cm

If cord is long may become wrapped around the neck or body of fetus

Amniotic Fluid

The source is through both fetal and maternal

It is secreted by amnion

Some fluid is oozed from maternal vessel and some from fetal vessel

Fetal urine also contributes after 10th week of gestation

It is clear, pale, straw colored fluid consisting 99% of water.

Functions of Amniotic Fluid

1. Provides protection for embryo against shock, blow or pressure.

2. Embryo floats in the fluid.

3. It equalizes pressure

4. Allows fetal movement

5. Maintains constant temperature

6. Aids in effacement of cervix and dilation of uterine os.

7. Provides small amount of nutrient

The Fetal Membrane:

It has two layers

Chorion– It is thick opaque membrane derived from trophoblast.

Amnion – It is inner layer, it is smooth, tough, translucent membrane derived

from inner cell mass.

Changes by weeks of gestational age

Germinal period (0~3 Weeks)

1st week

- Cleavage division

- formation of morula& blastocyst

- Implantation of Blastocyst

2nd

week

- Implantation is complete

- Formation of biliminar embryonic disc.

- Amniotic cavity

- Amnion

- Yolk sac

- Connecting stalk

- Chorionic sac

3rd

week

- formation of trilaminar germ disc.

- Primitive streak.

- Notochord.

Gastrulation

This is a process by which bilaminar germ disc is converted into trilaminar

embryonic disc.

Primitive streak appears at the 15th day. It is narrow median groove formed by

ectodermal cell.

A neural groove (future spinal cord forms over the notochord with brain bulge

at one end).

Somites, the division of future vertebra forms. It is formed by proliferation of

mesoderm into paired cuboidal bodies called somites.

Primitive heart tube is forming. Vasculature begins to develop

Embryonic Period (4th

-8th

week)

week -4

• Three Germ layer appears.

• Folding of the embryo (Begins to curve into C- shape).

• Heart further develops.

• Brachial arches, grooves will form.

• Neural tube closes.

• Ear begins to form as otic pit.

• Arm buds and tails are visible.

• Pulmonary primordium appears.

• Hepatic plate appears.

• Cystic diverticulum, which will become gall bladder and pancreatic bud will

appear.

• Urorectal septum begins to form.

• Anterior and posterior horn differentiate into spinal cord.

• Spleen appears.

• Uretric buds appears.

Week-5

Embryo measures 8 mm in length.

Lens pits and optic cups form.

Nasal pit forms.

The brain develops.

First heart beat begins and four chambers are functioning.

Leg buds form and hands form as flat paddles on the arms.

Umbilical cord develops

Week-6

Embryo measures 13-mm.

Lungs begins to form

Arms and legs have lengthened.

Hands and feet have digits.

Gonadal ridge begins to perceptible.

Lymphatic system begins to develop.

Nostrils forms.

Intestine and pancreas grow

Week-7

Embryo measures 18 mm.

Nipples & hair follicles begin to form.

Location of elbow & toes are visible.

Teeth begin to develop.

All essential organs have at least begun formation.

Week-8

Cartilage & bones begins to form.

The tongue begins to develop.

Intestine moves out of the umbilical cord in to the abdomen.

Facial features continue to develop.

Sex differentiation begins.

Embryo measures 30 mm and weight is 1 gm.

Fetal period

The fetal period is extending from the beginning of the third month(9th

week)

up to the termination of pregnancy.

Associated with complete development of placenta, umbilical cord & fetal

membranes.

Developing organism is called fetus.

Week-9

Fetus is about 50 mm long and weight is 8 gms.

Head constitutes half the crown heel length of fetus.

Face is broad, eyes get widely separated, ears are low set and eye lids gets

fused.

Movement begins.

Most of the joints are formed.

Week 10

Face has human profile.

Placenta begins to function.

Genitalia have male or female characterstics but still not fully formed.

Week 11

Genitals appear well differentiated.

Hair and nails begins to grow.

Fingers and toes are separated.

Amniotic fluid begins to accumulate as the kidneys begins to function.

Week-12

Length is about 8 cm and weight is 25 gms.

Eyes are widely spaced.

Vocal cords begin to form.

Heart beat is audible by droppler.

Pancreas is active.

RBCs are produced in liver.

Week-13

Growth is rapid.

Inhaling and exhaling have started.

Neck is getting longer and hands becoming more functional.

Week-14

Fetal skin is almost transparent.

More muscle tissues and bones have developed.

Thyroid gland has matured and fetus begins to produce hormones in boys

prostate gland and in females the ovaries move from abdomen to pelvis.

Fine hair called lanugo develops.

Week-15-16

Sucking motions are made by mouth.

Fetus makes active movements.

Tiny bones in the middle ear begin to harden.

Ovaries are differentiated and contain primary ovarian follicles.

Meconium is made in intestinal tract.

Liver and pancreas are functioning.

By end of 16th week sucking, swallowing and blinking are evident.

Week 17-20

Lanugo covers the entire body.

Eyebrows & eyelashes appear.

Mother feels fetal movements, known as quickening.

Nails appear on fingers & toes.

Skin is covered with vernixcaseosa.

Brown fat is formed & is site of heat production.

By 18th

week, uterus is formed & canalization has begun.

By 20th

week testes begins to descend.

Fetal heart beat can be heard with stethoscope.

Immunities are transferred from mother to fetus.

Week 21-25

21 Week

Shows substantial gain in weight.

Rapid eye movement begins.

WBCs are under production.

More amniotic fluid is swallowed.

22 Week

Eye lids & eye brows are fully formed.

Liver breaks down bilirubin.

23 Week

Proportion of body is quite similar to a new born.

Fetus is able to hear.

24 eek

Baby is officially considered viable.

By end of this week fetus has grown 28-36 cm & weighs 550 gms.

Pupils react to light.

Taste buds begin to form.

Production of lung surfactant begins.

25 Week

Structure of spine begins to form the joints, ligaments and rings.

Blood vessels of lungs develop.

Nostrils begin to open.

Week 26-29

26 Week

Fetus touches to a length of about 35-38cm & weighs about 1200gms

Brain develops rapidly.

Retina begins to form.

Air sacs in lungs forms now.

Eye lids open in 26th week

27 Week

Response to sound grows.

The central nervous system matures.

Lungs continue to grow & are ready to function outside of the womb.

Retina has formed.

28 eek

Eyelids open & close.

Fetal body is getting plump & rounded.

Muscle tone is improving.

29 Week

Fetal head is in proportion with body now.

Fat accumulate under the skin.

Movement is increased.

Fetal spleen is important site of hematopoiesis.

Male testes descend inscortum& female clitoris is prominent.

Week 30-34

Length is about 38-43 cm weight is about 1,600 gms.

As fetus continues to grow the amniotic fluid will decrease.

Early lanugo disappears slowly & owns hair may begin to appear.

Bone marrow produces RBCs.

30 Week

Physical growth slows down.

Fetus gains weight.

Bones are fully developed, but are still soft and pliable.

31 Week

Movements are bit reduced because of increased size.

All five senses are working as thalamic brain connections which mediate

sensory input form.

32 Week

Active mores reflex is present.

The skull is quite pliable & not completely joined.

33 Week

In male fetus the testicles descend into the scortum.

Eyes are opened wide when awake & closed while sleeping.

Fetus has already turned to a head down position.

Week 35-40

Fetus reaches a length of about 40-46 cm & weight is around 1,800-1,900

gms.

Lanugo disappears.

Fetus takes up the space in most of uterus & mother may feel like chut has run

out of room.

36 Week

Fetus reaches a length of about 40-46 cm & weight is around 1,800-1,900

gms.

Lanugo disappears.

Fetus takes up the space in most of uterus & mother may feel like chut has run

out of room.

37 Week

Fetus is official full term.

Length reaches up to 42-48 cm & may weigh 1,800-2,700 gms.

Grasp reflex is firmly established.

38 Week

Birth position is usually assumed.

Fetal intestines are accumulating lots meconium.

Hairs are thick.

Circumference of head & abdomen are about same size.

39 Week

Lanugo has gone except on the upper arm & shoulders.

Lungs are matured and surfactant production is increased.

Fat stores are more that will help to regulate the body temperature after birth.

Fetus is around 50 cm in length & weighs about 3288 gms.

40 Week

Much of vernixhas disappeared.

15 % of baby's body is fat.

Breast buds are present.

Lungs will continue to develop until birth.

Fetus is 51cm &weight is around 3400 grams.

Any time & any day the fetus is delivered now and the development continues

postnatal with child development stages.

Pregnancy at Risk: Conditions That Complicate Pregnancy

Learning Objectives

At the end of this chapter, the student should be able to:

1. Compare and contrast the pathophysiology of the three major classifications

of diabetes in the pregnant woman.

2. Explain treatment goals for the pregnant woman with diabetes.

3. Differentiate between the care of the pregnant woman with pregestational

diabetes and one with gestational diabetes.

4. Describe typical nursing concerns for the pregnant woman with diabetes.

5. Differentiate between pregnancy concerns for the woman with iron-deficiency

anemia and one with sickle cell anemia.

6. Compare and contrast placenta previa and abruptio placentae according to

characteristics of bleeding and other clinical manifestations.

7. Apply the nursing process to the care of a pregnant woman with a bleeding

disorder.

8. Differentiate four categories of hypertensive disorders in pregnancy.

9. Discuss treatment and nursing interventions for the woman with

preeclampsia-eclampsia.

10. Contrast the management of a multiple gestation pregnancy with that of a

singleton gestation.

Prenatal care

Pre-natal care includes:

1. Medical & nursing care

2. Taking history

3. Physical exam.

4. Obstetrical exam.

5. Nutrition during pregnancy

6. General hygiene during pregnancy

7. Minor discomforts during pregnancy

8. Preparation for labor & delivery

Importantof Antenatal care

1. Maintaining mother in best possible health condition.

2. Detecting complications earlier.

3. Maternal education: for diet, general health,vaccination, psychological

support.

The first visit called booking. This includes the followings

1. History taking

2. General exam.

3. Obstetric exam. → scheduled visits

4. Investigations → GUE , Hb%, Blood group & Rh

Maintaining general health during pregnant

1. Rest, sleep (10 hrs.)

2. Exercise.

3. Employment activity.

4. Breast care.

5. Cloths (wide, clean).

6. Shoes (low healed).

7. Teeth care.

8. Bowel habit.

9. Douches& vaginal hygiene.

10. Avoid smoking and alcohol, and drug abuse.

11. Diet intake (adequate, frequent, carbohydrates).

12. Psychologicalsupport .

Constipation: caused by ↓ peristalsis, iron support & pressure of uterus.

Management: drink water, eat vegetables, laxative is contraindicated.

Piles: nursing care by pushing them upward with use of lubricants & ice bag

(vasoconstriction).

Vaginal douches: nurse advise the mother for washing clothes , deodorant

spray is contraindicated , vaginal douching is limited.

Smoking: cause IUGR , LBW infants & prematurity, stillbirth, placenta

previa → nurse should discuss hazards of smoking

Alcohol: lead to fetal –alcohol syndrome . Nurse advise the mother to stop

taking alcohol

History taking

The nurse should receive mother in pleasant manner, good relationship, able

to answer all questions

1. Demographic data: name, age, race, occupation, religion.

2. Chief complaint: what makes the patient come to the clinic &duration.

3. History of present illness: details of chief complaints.

4. Medical history : includes :

a. Infectious diseases → Measles, Mumps, Hepatitis, T.B.

b. Chronic diseases → D.M, HT, Thyroid disorder,lung, kidney disorders,

seizures.

c. adult injuries , hospitalization, blood transfusion

5. Present health status :

a. allergy , medications, previous transfusion

b. immunization: Tetanus, Measles, Mumps ,Rubella(MMR), Hepatitis B , last

T.B skin test

c. Screeningtest: Pap smear, mammography, CXR, Hb% , GUE, Blood group

& Rh , dental exam.

d. Environmental / chemical hazards: home exposure to heat / cold,noise,

industrial toxins e.g. asbestoses, lead, diethylstilbestrolDES, radiation

exposure, cat feces, cigarette smoke.

6. Surgical history : type, date, reason, any complications

7. Family history : D.M , HT, respiratory or renal, thyroid disorders, bleeding

disorders, hepatitis , epilepsy

8. Social history : habits , living accommodations

9. Review of systems : respiratory, cardiac, GIT, genitourinary , neurological

10. Obstetric history: parity, gestational age , sex, wt. of baby …………

11. Gynecological history : gynecological infection , operations , contraceptive

use

12. Menstrual history : menarche, regular , amount of blood loss, dysmenorrhea

, LMP

General examination / physical examination.

1. Vital signs: Blood pressure , Temp. , PR, Respiratory rate, height , wt. lymph

nodes , goiter , teeth , throat, breast , skin, signs of infection or disorders

2. Abdominal exam. : fundal height, fundal grips , lateral grip, pelvic grip

3. Pelvic exam. : Bimanual exam. for confirming pregnancy , any infection ,

adequacy of pelvic cavity

4. Investigations : Hb% , Blood group & Rh , GUE

5. Subsequent visits → scheduled as follows :

Monthly during 1- 6 months of pregnancy.

Twice monthly( every two weeks ) during 7th& 8

th month of pregnancy.

Weekly during 9th

month of pregnancy till labor

Nutrition during pregnancy

Studies show direct relationship between maternal diet & pregnancy outcome.

Bad nutrition leads to difficulties in pregnancy, labor &delivery: ↑ perinatal

mortality, LBW, ↑ infant morbidity.

Possible effects of poor nutrition on reproductive cycle:

1. infertility

2. abortion , stillbirth, neonatal death

3. PET, eclampsia

4. placental abnormalities

5. LBW babies

6. slow postpartum recovery

7. difficulties in lactation

Nutritional assessment

1. Assess dietary intake : nurse ask for amount of food intake , type , method of

preparation

2. Assess nutritional status : by :

a. measuring height & wt. ( BMI ) to identify under wt. mother

b. doing investigations Hb%, S. level of folic acid used as indicator

c. Sometime, do total protein, Albumin, Vit. B12

Nutritional risk factors

1. LBW, ↑ perinatal mortality,prematurity.

2. Gestational diabetes, anemia,, neonatal death.

Minor discomforts during pregnancy:

1. Morning sickness

Nausea & vomiting in 1st 6-12 week .( ↑ HCG, Progesterone )

Hyperemesis gravidarum : exaggerated morning sickness

Management

Exclude other causes (pyelonephritis, intestinal obstruction, infective

hepatitis, cerebral tumor); occur in multiple pregnancy and hydatidiform

mole.

By reassurance, giving antiemetic(Meclizine 25 mg,Cyclizine 50 mg or

Promethazine 25 mg TDS), I.V fluid with sedative & sometime Vit. B12

(10mg)supplement.

Check for weight gain & urinary output , vital signs .

Eating fluid & semisolid diet .Frequent small meals, ↓ fat , ↑ carbohydrates &

protein diet .

Psychotherapy is needed.

2. Heart burn: due to decrease peristalsis.

Treatment by reducing fattydiet.

Eat solid carbohydrates,frequent meals, drink fluid, milk, and water.

Coffee & smoking prohibited.

Antacids, bicarbonate drinks sometime given.

3. Flatulence: eating small well masticated food. Avoid gas forming food (

beans )

4. Frequency of urination: due to uterine pressure in the first trimester &

engaged head in third trimester. Exclude UTI.

5. Backache: changing woman posture in relation to growing uterus. Shoulders

pushed backward, abdomen protruded, relaxation of sacroiliac joints, in

addition to postural changes cause backache.

6. Dyspnea: from pressure on diaphragm, sleeping in semi sitting position,

differentiate it from heart failure where the onset is acute.

7. Varicosity: due to progesterone, pressure of uterus on pelvic veins.

Treated by:

Wearing elastic stockings.

Prevent constipation.

Avoid standing for long time.

Varicose vein may rupture & cause vulval hematoma.

8. Cramps

Painful spasm of muscles of legs.

Commonly occur in later months of pregnancy due to pressure effect of uterus

on nerves or due to decreased ofcalcium.

Immediate relief is by force toes upward & presses on knee to straighten the

leg, elevate legs, keep them warm, warm both before sleeping, massage with

hot pads.

9. Edema: physiological edema, especially in hot weather.

Treated by:

Elevatinglegs,rest.

Provide high salt diet, eating high protein.

Avoid tight clothing.

10. Vaginal discharge: physiological increase of secretion.

a. If yellow discharge → gonorrhea , trichomonasvaginalis

Itchingoccur, burning sensation, urinary signs → treated by givingflagyl 200

mg TDS for 10 days.

b. Ifwhite, cheese like discharge → candida albicans → treated by sodium

bicarbonate, antifungal drugs.

Preparation of pregnant woman for labor & delivery

1. Education during antenatal care. Explain what will happen

2. Psychological support

3. Advise to have bath, clean cloths

4. Evacuate the bowel , catheterization for urination

5. Clean vagina by shaving hair

6. Measuring vital signs frequently

7. Checking her investigations

8. Thorough exam. ( general& obstetrical exam.)

9. Position in the theatre , isolation of the patient

10. Detect signs & symptoms of maternal & fetal distress

Mental health during pregnancy

Mental health during pregnancyincludes:

1. Psychological changes during all trimesters of pregnancy.

2. The nurse's role in mental health.

Sources of stress

1. Concern about health of baby.

2. Labor.

3. Change in sexual interest.

4. Loss of attractiveness.

5. Changes about symptoms of nausea,vomiting, morning sickness, heartburn &

backache.

The impact of them depends on personality,attitude, belief about childbearing,

social circumstances & inherited psychological illness.

Minor psychological problems

1. Anxiety: presented as headache, tremor, ↑ sweating, palpitation, ↑ systolic

B.p ,epigastria discomfort , nausea , dry mouth, frequent micturition or

defecation , difficulty in falling asleep.

2. Depression

In depressive neurosis the mood is not constant, difficulty in sleep.

The prevalence of neurosis of all women in childbearing age is 10-15 %.

In first trimester the rate is higher & probably is lower in rest of pregnancy.

History of past psychological illness, marital tension, past termination of

pregnancy is important in anxiety development.

3. Psychosis: is 50 times less common than neurosis. It is more severe

psychiatric

Types of psychosis

a. Affective illness

Change in mood, the commonest illness is depression (hopeless of future,

depression since morning & ↓at evening.

Disturbedappetite& sleep.

Loss of interest in life, impaired concentration.

Slow speech &thought, in severe cases voice hallucination, risk of suicide.

b. Hypomania: less common than depression.

Patient is elated, more confident & even grandiose.

incoherent of speech & thought , over active ,

Increase appetite, change in mood, interest in lifeincrease .

c.Schizophrenia: had abnormal perceptual experiences, hear hallucinatory

voices, changeable emotional reaction.One- third of patients recover & other

show chronic illness.

Pregnancy at Risk: Conditions That Complicate Pregnancy

PREGNANCY COMPLICATED BY MEDICAL CONDITION.

Anemia during pregnancy

Is the reduce ability of the blood to carry oxygen to the cell. Hemoglobin

level H.B lower than 10.5g/dl in the second trimester. And below 11g/dl in

first and third trimester indicate anemia during pregnancy

Types of anemia

1. Anemia during pregnancy

Nutritional anemia

Iron deficiency anemia

Folic acid anemia

2. genetic anemia

Sickle cell anemia

Thalassemia

Anemia is onset of the most common medical problem occur during

pregnancy.

Nutritional anemia

Most woman with anemia have vague symptoms the woman may be:

Fatigue easily

Have little energy

Her skin and mucus membrane are pale

Shortness of breath

Pounding heart and rapid pulse occur with severe anemia

Iron deficiency anemia

Pregnant woman need additional iron for their own increase blood volume for

transfer to the fetus and for cushion against the blood loss expected at birth.

The RBCs or small (microcytic) and pale (hypo chromic) in iron deficiency

anemia

Approximately 200 mg of iron will be conserved due to the functional

amenorrhea of pregnancy

Pregnant woman needs approximately 1000 mg more iron intake during

pregnancy

1.300_400 mg transferred to the fetus

2.500 mg is needed for the increase red blood cell. mass in the woman’s own

increased circulating blood volume

3. 100 mg is needed for the placenta

4. 280 mg is needed to replace the 1mg of iron lost daily through feces , urine

and sweat

Maternal risks of deficiency anemia

1. low birth weight

2. post-partum complication (infection)

3. Poor wound healing

4. HB lower than 6 gm\dl will cause cardiac failure

Fetal new-natal risk of iron deficiency anemia

1. low birth weight

2. prematurity labor

3. still birth

4. neonatal death

High hemoglobin level associated with

-growth restriction

-preterm delivery

-prenatal death

Prevention

Iron supplements are commonly used to meet the need of pregnancy and

maintain iron stores

Vitamin C may be enhance absorption of iron

Iron should not be taken with milk or antacids because calcium impairs

absorption

Treatment

Woman with iron deficiency anemia need extra iron for correct anemia and

replenish her stores. She is treated with oral doses of elemental iron and

continuous this therapy for about 3 months after the anemia has been

corrected

Folic acid anemia:

Folic acid deficiency is characterized by large immature RBCs (megaloblastic

anemia) iron deficiency anemia is often present at the same time

(anticonvulsantdrug, sulfa drugs, and alcohol) can decrease absorption of the

folic acid from food

Folic acid is needed for DNA and RNA synthesis and cell duplication. Even

more significantly an inadequate intake of folic acid has been

associated(NTDs) neural defect (spinabifida, an encephalopathy,

menningomyelocele) in the fetus or newborn

Daily folate 400_800 gm\day

Prevention

Folic acid is essential for normal growth and development of fetus

A dailysupplement of folic acid (0.4 g) ensures adequate folic acidic now

recommended for all women of child bearing age

Treatment

Treatment of folic acid deficiency is with folic acid supplementation 1gm/day

the preventive dosage supplementary folic acid may be higher for woman

who have had previous child with natural tub defect

Genetic anemia

1.Sickle cell disease: people with sickle cell disease have abnormal

hemoglobin that causes their erythrocytes to become distorted into sickle

shape during episodes of hypoxia or acidosis (it is autosomal recessive

disorder) meaning that affected person receive an abnormal gene from each

parent. Pregnancy may cause a sickle crisis with massive erythrocyte

destruction and occlusion of blood vessels. homozygous it is manifested

disease by(abdominal pain, fever, joint pain)

Maternal risk

Urinary tract infection

Pulmonary infection

Congestive heart failure & renal failure

Preeclampsia

Fetal- neonatal risk

Fetal death

Prenatal mortality

Prematurity labor

Low birth weight

Treatment

The woman should be frequent treatment and evaluation for anemia during

prenatal care

Fetal evaluations concentrate on fetal growth and placental function

Fluids are given continuously during labor to prevent sickle cell crisis

Genetic counseling should be effort

2.Thalassemia

Thalassemia is genetic trait that causes an abnormality in one of tow chains of

hemoglobin the( alpha) or( beta) chains. The beta chain verity is most often

encountered in the world. The person can inherit an abnormal gene from each

parent. Causing B- thalassemia major or coolly anemia of only one abnormal

gene is inherited. B- thalassemia minor not effect in pregnancy and treated by

folic acid supplement

Symptoms are causal by the shortened life span of the red blood cell which

result in active erythropoiesis in the liver, spleen, &bones this produces

hepatosplenomegaly and sometime bony malformation

Maternal and neonatal risks

Preeclampsia

Intrauterine growth retardation

Fetal distress

Low birth weight baby

Patient may die from chronic infection

cardiac failure

hepatic failure

Nursing care for anemia during pregnancy

1. the woman is taught which foods are high in iron and folic acid to help her

Prevent or treat anemia

2. the nurse explains for pregnant how to take the supplements e.g. Milk is

good during pregnancy but should not take at the same time as iron

supplement because iron will not absorbed easily because calcium

3. the nurse treat all woman's appropriate foods sources of those nutrients

4. the nurse thought the women when take iron her stools will be dark , green

to black and that mailed gestational discomfort may occur

5. foods contain high vitamin C may enhance absorption

6. should not take antacids with iron

7. the woman with sickle cell disease require close medical and nursing care.

she should be teach to prevent dehydrations and activities cause hypoxia

8. the woman with beta thalassemia is teach to avoid situations in which

exposure to infection (e.g.: avoid crowd during flu season)

Nursing process for anemia

1. Assessment

Fatigue

Greater need for sleep and rest

Dizziness and headache

Vital sings

T:36.9

P:75

R:18

BP:100/80

2. Diagnosis Activity intolerance related to imbalance between

oxygen supply (delivery) and demand

3. Planning

Prognosis with patient including activities that the

patient views essential increase level of activities as

tolerated

Identify or implements energy saving technique like

sitting while doing a task.

Monitor laboratory studies HB and RBCs count,

arterial blood gases(ABGs)

4. implementation

Assess patient ability perform normal task or

activities of daily living

Note changes in balance/gait disturbance, muscle

weakness

Recommend quite atmosphere and bed rest

Elevate the head of the bed as tolerated

5.evaluation Patient reveals an increase in activity tolerance

demonstrating reduction in physiological sings of

intolerance and laboratory values within normal

range

Bleeding in late pregnancy

Vaginal bleeding if sing may be caused by the increased vascularization of the

cervix, cervical prolapsed, or cervix inflammation. however the major cause

of bleeding in the second and third trimesters are placenta previa, abruption

placenta.

Anti-partum hemorrhage: it means bleeding occurs after 20 weeks of

pregnancy cause by:

Placenta previa.

abruption placenta

placenta previa

Occurs when the placenta develops in the lower part of the uterus rather than

upper. there are three types of placenta previa:

1.Marginal: placenta reaches within 2 to 3 cm of the cervical opening

2.Partial :placenta partly covers the cervical opening

3.Total :placenta completely cover the cervical opening

4.Placenta low lying: implanted in the lower segment but not reach the os

although it's in close proximity of it.

Causes of placenta previa

Placenta previa occurs approximately 1 in 200 live birth

1. Pravious infection in the upper uterine segment

2. Pravious cesarean section

3. Pravious placenta previa

4.Endometritis

5. Multi fetal gestation or multi birth

6. Large placenta &woman smoking

7. Increase maternal age and delay development implantation of fertilized

ovum

8.Definitive vascularity of the deciduas

Sign and Symptoms of placenta previa

1.painless vaginal bleeding occurs after 24 weeks

2.usually bright red (is the main characteristic of placenta previa)

3.soft abdomen with presenting part ball table above the pubic area

4.the cervix being to effect (thin) and dilate (open)

Diagnosis

1. Placenta prevail can be diagnosed before bleeding occurs in third trimester

2. Ultra sound for detection of fatal anomalies

3. Bleeding may be intermittent or gushes

4.Degital examination(PV exam) but may be leading to sever hemorrhage

(fetal)

Management

Management depend on the classification of previa and gestational age of the

fetus

1. woman hospitalized for observation placed on bed rest and closely

monitored

2. blood count type and cross match for blood and Rh factor

3 . Give magnesium sulfate or other tocolytic drugs(a tocolytic is drug that

stops labor contractions)

4. Vital signs are taken frequently

5. Intravenous fluid may be given once the bleeding has subsided

Management at home

Woman understand her condition and that she must remain on bed rest and

avoid coitus

Woman complete tocolytic therapy

Woman has around the clock transportation and communication available.

Complication

1. The main complications are hemorrhage for the woman and prematurity

hypoxia or death fetus

2. Hemorrhage can cause hypovolemic shock and death

3. Sever hemorrhage

4.Embolesim

5. Infection and endomatritis

Nursing process for placenta previa

1.Assesment Change in fetal heart rate or fetal activity

Release of me conium

Vital signs is:

T:36.9

P:96

R:22

BP:100/80

2.Diagnosis Impaired fetal gas exchange related to altered blood flow and

decreased surface area of gas exchange at sit of placenta

detachment

3.planning Provide objective evidence of bleeding to promote placental

perfusion

Prevent tearing of placenta if placenta previa is cause of

bleeding

Assess whether labor is present and fetal status and external

system avoids cervical trauma

Support the mother&child bonding

Provide adequate oxygenation despite of lowered maternal

circulating volume.

4.implementation Asses vital signs every 15 minutes

Maintain bed rest

Monitor amount type of bleeding

Monitor uterine contractions and fetal heart rate by external

monitor

Administer O2 as indicated

5.Evaluation After 8 hours of nursing intervention the patient was able to

verbalize understanding of causative factors and appropriate

interventions.

Abruption placenta

Is the premature separation of the placenta from the uterine wall can be partial

or total. it occur after (20th

)twentieth week of pregnancy during third trimester

Causes of abruption placenta:

1.Multifetal gestation.

2.Drug use that cause vasoconstriction.

3.Cigarette smoking and alcohol constipation.

4.Short umbilical cord.

5.May be result from degenerative changes in the small arteries that supply

the inter villous space(causing retro placental hematoma).

6.Increas maternal age

7.Blunt abdominal trauma

Types of abruption placenta

Abruption placenta are sub dividable in the following three types

1.Marginal: This type usually has external drainage of blood through the

cervix

2.Complete: allows blood to be trapped behind the placenta and bleeding may

or may not evident

3. Central: the placenta separates centrally .and the blood trapped between

the placenta and uterine wall

Sign and Symptoms

1. Bleeding with abdominal pain or back pain

2. Dark-red vaginal bleeding

3. The woman uterus tender and usually firm(beardlike)

4. Cramplike uterine contractions(uterine irritability)

5. The fetus or neonate may have anemia or hypovolemic shock

Management

1.Give i.v fluids(lactate ringer) and blood replacement.

2.Checking by ultrasound.

3.Cesarean section delivery is done because of the risk for maternal shock,

clotting disorder and fetal death.

4.Hysterectomy may be required some cases.

5. Coagulation test is performed to rule or DIC(disseminated intravascular

coagulate).

Nursing care

1.preparation for cesarean section and close monitoring of vital signs

2.signs of shock and bleeding from nose, the gums

3.monitor intravenous infusion

4.monitor laboratory results (HB, platelets, blood group, Rh)

5. administer oxygen by mask

6.monitor fetal heart rate and uterine contraction

7.psychological support

Complication of abruption placenta

1.hemorrhage can cause hypovolemic shock

2.past partum hemorrhage

3.DIC (Disseminated intravascular coagulation)

4.preterm labor

5.intrauterin asphyxia

6.Anemic baby and irreversible brain damage

Nursing process for abruption placenta:

1.Assesment Abdominal pain and abdominal guarding

Muscle tension

Irritability

Vital signs:

T:37.3

P:95

R:22

BP:100/70

2.Diagnosis Acute pain related to collection of blood between

uterine wall and placenta

3.planning Change in the location or intensity are not

uncommon but may reflect developing complication

Provide oxygenation

Preparation woman for cesarean/s

4.implementation Monitor amount of bleeding by weighing all pads

Monitor maternal vital signs and fetal heart rate

through continuous monitoring

Measure and record fundal high

Position mother in the left lateral position with the

head of bed elevated

Administer O2 as indicated

5.evaluation After 8 hours of nursing interventions the patient

was able to demonstrate use of relaxation skills

other methods to promote comfort

Differentiation Between placenta prevail and abruption placenta:

Sings Placenta prevail Abruption placenta

Placenta

location

Lower third of uterus; detected by

transvaginal ultrasound

Normal

Onset Frequently “quit “for first episode

of bleeding

“stormy “in moderate to

sever absorptions

Placenta palpable No palpable

Pain Painless bleeding(most significant

sign)

May be cramp like to

severe

abdomen and

uterus

Soft, not tender ;may be

contracting normally

May be tender to rigid

Bleeding External, bright red bleeding

;shock with excessive bleeding

External and/or internal,

either bright or dark

blood ;may be signs of

shock that are out of

proportion to bleeding

Abdomen&

uterus

Soft. not tender may be contracting

normally

May be tender to rigid

Blood

pressure

Usually normal; with excessive

bleeding hypovolemic shock can

occur

History of hypertension

&toxemia; post

abruption hypovolemic

shock can occur.

Fetal death Depends on fetal maturity and

amount of blood loss

Fetal distress or fetal

death may occur

Coagulation

defect

Not usually problem Coagulation

disorder(DIC) with

moderate to severe

abruption can be

complication

Diabetes mellitus

Diabetes is a condition where the body fails to utilize the ingested glucose

properly. This could be due to lack of the hormoneinsulin or because the

insulin that is available is not working effectively.

Classified based on disease etiology:

1. Type 1 diabetes absolute insulin deficiency:

Diabetes mellitus type 1 (Type 1 diabetes, IDDM, juvenile diabetes) is an

autoimmune disease that results in destruction of insulin-producing beta cells

of the pancreas. Lack of insulin causes an increase of fasting blood glucose

(around 70-120 mg/dL in non-diabetic people) that begins to appear in the

urine above the renal threshold (about 190-200 mg/dl in most people), thus

connecting to the symptom by which the disease was identified in antiquity,

sweet urine. Glycosuria or glucose in the urine causes the patients to urinate

more frequently, and drink more than normal (polydipsia). Classically, these

were the characteristic symptoms which prompted discovery of the disease.

2. Type 2 diabetes insulin resistance or deficiency:

This was earlier termed non-insulin dependent diabetes mellitus (NIDDM)

or maturity-onset diabetes mellitus. In type 2 diabetes, not enough insulin is

produced or the insulin that is made by the body is insufficient to meet the

needs of the body. Obesity or being overweight predisposes to type 2

diabetes.

3. Gestational diabetes mellitus

Glucose intolerance with its onset during pregnancy normal range(70-110)

Diabetes during pregnancy divided into two groups:

1. Pre-gestational(before conception)

Alteration in carbohydrate metabolism

2. Gestational(during pregnancy)

3. Gestational diabetes

Gestational diabetes occurs in pregnant women who have never had diabetes

before but who have high blood sugar levels during pregnancy. Gestational

diabetes affects about 4% of all pregnant women. After childbirth the mother

may go on to develop type 2 diabetes. GD may associated with neonatal

complication(e.g. microsomal, hypoglycemia ,birth trauma)

Pathophysiology:

Pancreas produce insulin which is demands to maintain normal glucose level

throughout pregnancy with D.M lead to alteration in the metabolism support

growth and development of fetus supplying adequate nutrition

placenta hormones increase secretion to growth placenta tissue

1. hormone placenta tissue.

2. growth hormone(somatotropin)

Rising throughout last 20 week of pregnancy and causing insulin resistance

Risk factors of diabetes mellitus:

In the mother:

1. Family history of diabetes.

2. Age 35 or older.

3. Maternal obesity.

4. Hypertension.

5. Recurrent monila infection that cannot respond to treatment.

6. Sign and symptoms of glucose.

intolerance(polyuria,polyphagia,polydipsia,fatigue)

7. Presence of glycosuria or proteinuria.

In the fetal:

1.previous infant with congenital abnormalities(skeletal ,renal,CNS,cardiac).

2. previous infant weight more than 4 kg(macrocosmic baby: birth

injury,metabolicproblems,respiratory distress syndrome)

3.previous unexplained fetal or neonatal death

4.spontaneous abortion 25_45%

5.small for prematurity & predisposition to diabetes

Negative Maternal Health Outcomes

Greater increase in cesarean delivery rates - 22 to 30% for mothers with GDM

and 17% forthose without GDM.

Higher risk of third or fourth-degree laceration in women with GDM.

Polyhydramnios (an excess of amniotic fluid).

Pregnancy induced hypertension.

Increased risk of gestational diabetes in subsequent pregnancies.

Possible increased risk for pre-eclampsia.

Higher risk for development of type 2 diabetes

Negative Neonatal Health Outcomes

Macrosomia (birth weight greater than 8 lbs).

Brachial plexus injury.

Clavicular factures.

Hypoglycemia.

Increased possibility of a preterm birth.

Hypocalcemia.

Polycythemia.

Hyperbilirubinemia

Diagnostic Criteria for 100-g glucose Challenge Test

Two or more of the following indicates diagnosis of gestational diabetes

mellitus:

95 mg/dl or higher fasting blood glucose.

180 mg/dl or higher at 1-hour postprandial blood glucose.

155 mg/dl or higher at 2-hour postprandial blood glucose.

140 mg/dl or higher at 3-hour postprandial blood glucose

Medical surgical management

Medical

1. Maintain normal blood glucose level between 70mg\dl and 105 mg\dl and

to have healthy mother and baby.

2. Monitor blood glucose level and give themselves insulin according to

sliding scale.

3.Fetal status is evaluate throughout the pregnancy

4.gestational age is established by ultrasound at about 18 week gestation and

repeated every 4-6 week to monitor fetal growth and assess for congenital

abnormalities.

5.the mother monitors fetal activity delay beginning about 28 week gestation

Surgical

If fetal wellbeing is deteriorating, a cesarean birth is often performed.

Nursing care of DM

Assess the woman techniques for monitoring blood glucose level. and

administering insulin if order.

ensure food intake and avoid weight loss.

assess any changes needed if glucose level are not controlled.

sending urine specium for laboratory for checking glucose-protein.

discuss dietary measure related to blood glucose control.

Nursing care in pre or gestational diabetes:

intravenous flow regular insulin.

monitor blood glucose every 1-2 hours.

monitor FHR.

monitor intake and output.

assess maternal vital signs every hour.

during C\S monitor woman's blood glucose hourly and give short acting

insulin.

EncourageBrest feeding after birth tom maintain good glucose control.

Nursing process:

Assessment

Subjective data

Ask question regarding a family history of diabetes congenital abnormality,

neonatal death or an explained still birth.at each prenatal visit ,ask about diet,

activity and medication.

Objective data

Check blood sugar per finger stick as ordered, and also measure vital signs

and weight.

Nursing diagnoses

Deficient knowledge related to disease process of diabetes and implication of

pregnancy.

Risk for injury fetus related to decrease utero-placenta function

Noncompliance related to need for close monitoring and extra prenatal visit.

Nursing intervention

1. Present to or review with the client the pathophysiology of diabetes and

clarify client misconception

2. Teach how to monitor blood glucose level

3. Teach self-administration of insulin

4. Review effects of diabetes on client and fetus

5. Teach danger signs and home to notify

6. Refer to diabetic support group in the community

Evaluation

1. The client will verbalize an understanding of the disease process of

diabetes, control of diabetes and implication for the pregnancy

2. The client will perform blood glucose testing on schedule prenatal visit.

Gestational hypertension:

• Characterized by increase blood pressure without proteinuria after 20 weeks.

of gestational and return to abnormal blood pressure after birth Clinically

characterized by BP 140\90 or more or toxemic pregnancy

• The difference between gestational and chronic hypertension that is appear 20

wks .before pregnancy or before current the pregnancy and continues after

birth.

Classification of hypertension disorders in pregnancy

1.gestational hypertension or(transient hypertension)

2.chronic hypertension

3.preeclampsia_eclampsia

4.chronic hypertension with superimposed preeclampsia

Diagnostic testing &laboratory testing

1.HB%

2.clotting factors& platelet concentration

3.plasma fibrinogen

4.liver function test: SGOT,SGPT ,serum bilirubin

5.blood urea, serum creatinine, uric acid ,protein in urea

classified of Gestational diabetes

Preeclampsia –characterized by hypertension with proteinuria or edema.

Facial edema.

Blood pressure > 160/110.

Decreased urine output.

Increased proteinuria.

Headaches.

Epigastric pain.

Nausea and vomiting

Eclampsia –a progression of preeclampsia

Epigastric pain.

Grand mal seizures.

Coma

Nursing care of preeclampsia:

1. Bed rest at home if BP increased& encourage rat as possible in lateral

position

2. Reduce her blood pressure &promote dieresis & diagnostic test in antenatal

visits

3. Monitoring blood pressure daily(every 4_6 hr)&daily weighting to check

edema

4. Measure amount of protein in urine

5. Assess women with pulmonary disorder

6. Monitoring intake _ output and give fluid and electrolyte

7. Monitor respiratory depression ,hypocalcaemia

8. Stabilize the mother &fetus dyad and prepare for birth

eclampsia: occur when central nervous system involvement lead to seizure

and chronic hypertension with superimposed eclampsia.

Complication of eclampsia

1. Maternal death due to intracranial bleeding and central function

2. Fetal death due to premature labor ,fetal asphyxia

3. Accidental hemorrhage.

Nursing care of eclampsia

1.IV fluids

2. Monitoring of FHR &give magnesium sulfate(I.V)

3. Controlled hypertension by anti-hypertension medication

4. Suction to remove secretion from mouth after seizure

5. Clear air way and administer adequate oxygen

HELLP syndrome:A syndrome featuring a combination of:

"H" for hemolysis (breakage of red blood cells).

"EL" for elevated liver enzymes, and ,

"LP" for low platelet count (an essential blood clotting element).

The HELLP syndrome is a recognized complication of preeclampsia and

eclampsia (toxemia) of pregnancy, occurring in 25% of these pregnancies

Common symptoms in women with the HELLP syndrome include:

1. A general feeling of feeling unwell (malaise).

2. Nausea and/or vomiting, and

3. Pain in the upper abdomen.

4. Increased fluid in the tissues (edema) is also frequent.

5. Protein is measurable in the urine of most women with the HELLP syndrome.

6. Blood pressure may be elevated.

7. Occasionally, coma can result from seriously low blood sugar

(hypoglycemia).

Nursing process of gestational hypertension

Assessment

Subjective data:

Ask the client about headache visual disturbance epigastria pain ,swelling of

hands and face

Objective data:

Check vital signs and weight and compare to previous figures and check urine

for protein .edema may be found in the face, hands, sacral area ,lower

extremities or abdomen.

Nursing diagnosis:

1.interrupted family process related to illness &bed rest

2deficient knowledge related to lack of information about gestational

hypertension

3.deficient fluid volume related to shift in fluid from intravascular to

interstitial.

Planning:

1.the family will work together to maintain family function

2.the client will verbalize anunderstaning of gestational hypertension

3.the client will maintain intravascular fluid volume

Nursing intervention:

1. Encourage client and family to verbalize feelings about situation

2. Encourage family to visit client

3. Assist family in discussion regarding how they will manage

4. Help client and family identify sources of support

5. Assess BP and FHT every 1 to 4 hours &assess for edema

6. Weigh daily &test urine for protein as ordered

7. Monitor laboratory test.

Evaluation

Evaluate each outcome to determine how it has been met by the client.

Chronic hypertension

Exist when the blood pressure is 140\90 or higher before pregnancy or before

20 weeks of gestation or persist 42 days following child birth.

If diastolic BP is greater than 80mm\hg during the second trimester chronic

hypertension should be suspected.

Etiology of chronic hypertension

1. Essential hypertension

2. Secondary hypertension associated with

A . Neurogic increased intracranial pressure

b. Endocrine disease crushing syndrome

3. Systolic hypertension :thyrotoxicosis.

Complication of chronic hypertension

1. Maternal complication.

a .preeclampsia 30%

b. accidental hemorrhage(abruption placenta)

2. Fetal complication.

A . Intrauterine growth.

B . Preterm labor.

c. Fetal hypoxia &fetal acidosis.

Nursing care for hypertension

1. Nutrition: sodium is limited to about (2.4 g)per day ,the woman is advised

about recommended weight gain

2. Bed risk:- frequently rest period are advisable at minimum ,the woman

should rest twice a day for 1 hour period of time

3. Medication :-ant hypertension medication are not us used during pregnancy

methyldopa is the first choice using

4. Prenatal visits:-counseling regarding the importance of frequent prenatal

visits to reduce incidence of complication

5. BP monitoring: the woman & her partner can be taught how to monitor bp

pressure at home &maintain a record to be brought to each prenatal visits.

6. Fetal surveillance: starting at about (24)wks the woman should being to

keep fetal movement record &notify her care provider of any significant

decrease in fetal movement.

Nursing process

Assessment:

Subjective data:

Most clients have no symptoms of hypertension until it becomes severe .then

headaches or visual disturbances may occur

Objective data:

Blood pressure will be 140\90 mmH or higher.

Nursing diagnosis

Risk for injury ,fetus related to placental infarcts and poor placental perfusion.

Deficient knowledge related to disease process and effects on pregnancy.

Nursing intervention

1.Teach client the possible placental changes related to hypertension.

2. Assist client to plan for rest period throughout the day.

3. Administeranti-hypertensive medications as ordered.

4. Allow opportunity for client to ask questions.

Evaluation :evaluate each outcome to determine how it has been met by the

client

Abortion

Abortion: is defined as any interruption of a pregnancy before the fetus is

viable (a stage of development that will enable the fetus to survive outside the

uterus if born at that time) Anon viable fetus is usually defined as a fetus of

20 to 24 weeks gestation or weighting 500 g a fetus born at this point would

be considered a premature or immature birth.

Types of Abortion.

A. Spontaneous abortion ( miscarriage )

Is an early abortion if it occurs before week 16 of pregnancy and a late

abortion if it occurs between weeks 16 and 24.

Causes

1. During the first trimester, Chromosomal a abnormalities ( 50 % -60 % ).

2. During the Second trimester:

Drugs.

Placental abnormalities.

Endocrine imbalances.

Maternal infection.

Cervical in competence.

uterine abnormalities

Pathophysiology

Embryonic death occurs, which results in loss human chorionic gonadotropin

(HCG) and decreased progesterone and estrogen levels.

The uterine decidua is then ,

Sloughed off (vaginal bleeding) and usually expels the embryo / fetus .

Classification

Spontaneous abortions are subdivided in to the following categories so that

they can be differentiated clinically

1. Threatened abortion

Unexplained bleeding ,cramping , or backache indicate that the fetus may be

in jeopardy , bleeding persist for days the cervix is closed it may be followed

by partial or complete expulsion of pregnancy , or it may resolve without

threatening the fetus these will continue to term other will end by missed

abortion

2. Imminent abortion

Bleeding and cramping increase the internal cervical as dilates membranes

may rupture.

3. Incomplete abortion

All the products of conception are retained, most often the placenta the

internal cervical as is dilated.

4. Complete abortion

Cessation of pain and bleeding after all the products of conception are

expelled the uterus is contracted and the cervical os may be closed.

5. Missed abortion

The fetus dies in utero but is not expelled uterine growth ceases.

Breast changes regress and the women may report brownish vaginal

discharge.

Thecervix is closed on history, pelvic examination, and drops in (HCG) levels

or a negative pregnancy test and may be confirmed by ultrasound if

necessary.

If the fetus is retained beyond 4 weeks, fetal autolysis (break down of cells or

tissue) results in the release of thromboplastin , and disseminated

intravascular coagulation ( DIC ) may develop.

6. Recurrent or habitual abortion

Abortion occurs consecutively in three or more pregnancies.

Causes ofRecurrent or habitual abortion

fetal causes

Maternal causes, which include:

a. mechanical problem:

Uterine amoralities that do not give fetus enough space to grown or implant

e.g. uterine adhesion, uterine abnormalities.

Fibroid incompetent cervix.

Intra uterine device.

b. environmental exposure : exposure to

Infections agent such as neoplasm a which cause uterine infection

chemical agent such as anesthetic gases , benzene , tobacco ,alcohol

7. Septic abortion

Presence of infection septic abortion is less common since the availability of

legal abortion , may occur with prolonged , unrecognized rupture of the

membranes , pregnancy with intrauterine device (IUD ) in utero , or

pregnancy attempts by in adequately prepared individuals to terminate a

pregnancy.

Medical – surgical management

Medical

1. The client is usually told to limit activities for 24 to 48 hours. if the bleeding

is going to stop ,it will usually do so in 48 hours .

2. If the bleeding stops , the client is advised to avoid stress , fatigus , strenuous ,

activity and sexual intercourse , having one or two rest periods during the day

is also recommended until pregnancy seems to be progressing normally .

Surgical

When the products of conception, in a missed abortion are not expelled in 4 to

6 weeks, the client is hospitalized for 12 weeks gestation orless, a D&C is

performed if more than 12 weeks gestation induction of labor with oxytocin

may be used.

Nursing process for women with abortion.

Assessment

Subjective data

abdominal cramping and vaginal bleeding ,

Feelings of fear and guilt.

Objective data

amount of blooding , presence of clots , and any tissue expelled

Vital signs may indicate excessive blood loss (hypovolemic) .

Assess location, quality, and intensity of pain.

Nursing diagnoses

Situational low self- esteem related to feelings of guilt for doing something to

cause abortion.

Acute pain related to contractions (cramping) of uterine muscle.

Fear related to potential loss of pregnancy.

Nursing interventions

1. Provide information about causes of a spontaneous abortion assist client to

identify personal strengths actively listen to the client.

2. Administer analgesic as ordered monitor effect of analgesic.

3. Provide opportunities for the client to express fears help client identify

sources of support show acceptance of clients 'perceptions.

Evaluation

1. Normal vital signs.

2. The woman free from any complication.

3. The woman verbalizes her concerns.

Ectopic pregnancy

It means the blast cyst does not implant within the uterine cavity, the most

common site of implantation is fallopian tube it can implant in numerous

place even to abdominal cavity.

Causes

1. Delay ovum transport is primary causes.

2. Tubal damage caused by pelvic inflammatory disease.

3. Previous pelvic or tubal surgery.

4. Endometriosis.

5. Previous ectopic pregnancy.

6. Presence of an intrauterine device (IUD).

7. High levels of progesterone, which can alter the mortality of the egg in the

fallopian tube.

8. Congenital anomalies of the tube.

9. Use of ovulation –inducing drugs.

10. Primary infertility.

11. Smoking.

12. Advanced maternal age.

Diagnosis

1. A careful assessment of menstrual history , particularly the last menstrual

period ( LMP ).

2. Careful pelvic exam to identify any abnormal pelvic masses and tenderness

3. Laboratory testing (pregnancytest).

4. Physical examination.

5. Ultrasonography.

6. Laparoscopy.

Management

Surgical for rupture either by laparoscopy or laparotomy to remove the

affected tube or to perform a salpingostom( incision in to the tube to terminate

the pregnancy ) .

Medical by methotrexate in case of early diagnosis when un-ruptured mass is

lass then 4 cm.

Complication of ectopic pregnancy

1. sever blood loss

2. residual trophoblastic tissues which cause infection and adhesion

3. future infertility

Nursing process: women with ectopic pregnancy.

Assessment

Subjective data

1. The client describes amenorrhea, and nausea.

2. Breast tenderness and a dull ache on one side that has increasingly become

more severe.

3. When the tube ruptures, the client will describe a single excruciating pain in

the abdomen and may also have referred shoulder pain.

Objective data

1. Some vaginal bleeding may appear.

2. Laboratory reports may show a low hemoglobin and hematocrit, a rising

leukocytelevel, and ,

3. a slowly rising HCH level the red blood count ( RBG) count is low and

sedimentation rate elevated the abdomen may be rigid and,

4. Vital signs may indicate hypovolemic shock.

Nursing diagnoses

Anticipatory grieving related to the loss of the pregnancy.

Impaired tissue integrity related to the rupture of a fallopian tube.

Acute pain related to tubal rupture and blood in the abdomen.

Nursing intervention

1. Encourage client and family to talk about feelings .allow them privacy to

grieve. Listen actively to concerns about this and future pregnancies provide

information about causes of ectopic pregnancy refer to other professionals for

help as needed.

2. Prepare client for surgery as ordered begin preoperative teaching .

3. Administer analgesics as ordered and evaluate its effectiveness provide

information about causes of pain.

4. Checking vital signs.

5. Psychological support.

6. After operation, nurse must be alert for the sign of infection and intra-

abdominal bleeding follow – up B.Hcg levels are essential to confirm that all

trophoblastic tissue was removed.

Evaluation: evaluate each outcome to determine how it has been met by the

client

Gestational trophoblastic disease

The trophoblast is the outer most layer of embryonic cells , and gives rise to

the chorion ( pathological proliferation )

Hydatidformal:

Is a pregnancy in which the placenta or trophoblast is abnormally developed

special the chorionic Villi degenerate in to amass of clear vesicles , giving the

placenta a characteristic appearance of a bunch of groups.

Type of hydatid formal

Hydatid formal subdivide in to

1. Complete hydatid formal

2. In complete hydatid formal

3. Invasive mole ( chorioadenomadestruens )

4. Choriocarcinoma

Signs and symptoms

1. Vaginal bleeding is almost universal with molar pregnancies and may occur

as early as the fourth week or as late as the second trimester. It is often

brownish like prune juice due to liquefaction of the uterine clot but it may be

bright red.

2. Anemia occurs frequently due to the loss of blood.

3. hydropic vesicles may be passed and if so , are diagnostic with a partial mole

the vesicles are often smaller and may not be notice by the women.

4. Uterine enragement greater than expected for gestational age is a classicsign

.enlargementis due to the proliferating trophoblasic tissue and to a large

amount of clotted blood.

5. Absence of fetal heart sounds in the presence of other signs of pregnancy is a

classic sign of molar pregnancy.

6. Markedly elevated serum HCG may be present due to continued secretion by

the proliferation trophoblastictissue.

7. Very low levels of maternalserum fetoprotein are found.

8. pre-eclampsia may be seen , especially in the molar pregnancy continues in to

the second trimester.

9. Rarely , hyperthyroidism results from production thyrotropin by molar tissue

It produced thyrotoxicosis

Diagnosis

1. Ultrasound.

2. High level of HCG.

3. Chest X- ray will done to exclude metastatic to the lung.

Management

Management of mal pregnancy is based on three principles

1. Diagnosis of the mole.

2. Evacuation of the uterus.

3. monitoring of HCG levels

Evacuation

Done by suction of uterus and tissue will send for histopathology.

Immediate hysterectomy will decrease the chancer of malignancy.

Complication of hydatidiform mole

1. Anemia.

2. Hyperthyroidism.

3. Infection .usually seen with late diagnosis and spontaneous abortion of the

mole.

4. Disseminated intravenous coagulation (DIC).

5. Tropholastic embolization of the lung, usually seen after molar evacuation of

a significantly enlarged uterus (this creates a cardio respiratory emergency).

6. Ovarian cysts, which may be small or large enough to displace the uterus.

Medical – surgical management

Medical

After surgery to remove the mole, the client must be followed for 1 to 2 years.

The care includes chest x- rays to detect metastases, physical examination

with a pelvic examination, and regular (usuallyweekly) laboratory

measurement of hCGlevel.

The client is advised not to become pregnant during the follow-up time.

Surgical

The desire of the client for future fertility influences the surgical procedure

used to empty the uterus.

AD& C may be performed, but it is difficult to make certain that no fragment

of the molar pregnancy is left in the uterus.

A hysterectomy, cutting the uterus open (like cesarean birth) allows visual

determination that the uterus is completely emptied, if the client is older and

no future pregnancy is desired or there is excessive bleeding, a hysterectomy

is performed.

Pharmacological

If the hCG level remains high or rises after the uterus is evacuated,

methotrexate ( maxate , folex ) is given .

Oxytocin is given to keep the uterus contracted to control bleeding .typed and

cross- matched blood must be available.

Nursing process

Assessment

Subjective data

1. The client may describe severe nausea and vomiting and,

2. May have some brownish vaginal discharge.

Objective data

1. There is vaginal bleeding, usually brownish but may be bright red.

2. Uterine enlargement is greater than expected for gestational age.

3. Ultrasoundreveals a characteristic molar pattern the client may have

symptoms of gestational hypertension (BP140 / 90mmHg or an increase of

30/15.

4. Proteinuria, and edema measured by sudden weight gain .

5. The lack of FHT when the client has other signs of pregnancy is a classic

symptom of a hydatidiformmole.

6. The client has very low level of serum alpha-fetoprotein.

Nursing diagnoses:

Fear and anxiety related to the possible development of choriocarcinoma.

Deficient knowledge related to lack of understanding for regular monitoring

of hCG level and delaying.

Nursing intervention

1. Provide opportunities for client to express fears.

2. .help client identify sources of support.

3. Refer to other professionals as needed.

4. Explain that the Hcg level indicates whether chorio carcionoma is developing.

5. Provide reasons for delaying another pregnancy.

6. Allow client to express feelings about regular laboratory test of blood.

Evaluation: evaluation each outcome to determine how it has been met by the

client.