COMPLICATIONS of PREGNANCY

COMPLICATIONS of PREGNANCYComplications of Pregnancy:Abortion termination or expulsion of pregnancy from the uterus of fetus or embryo prior to viability Types of Abortion:Induced pregnancy intentionally aborted 1.1 Therapeutic abortion when performed to save the life of the pregnant woman, prevent harm to the womans physical or mental health, if the child will have increased chance of prematurity ,or disabled. 1.2 Elective or voluntary abortion- when performed at the request of the woman or non-medical reasons.2. Spontaneous also known as miscarriage is untentional expulsion of an embryo or fetus before the 20th or 22th week of gestation.Complications of Pregnancy:2. Ectopic pregnancy - abnormal pregnancy that occurs outside the uterus - embryo implants outside the uterine cavitySites of ectopic pregnancy:2.1 tubal pregnancy occurs in the fallopian tube2.2 non tubal pregnancy ovary, cervix, intraabdominal

Signs & symptoms of ectopic pregnancy:1.Pain in the lower abdomen, inflammation ( pain maybe with strong stomach pain, may also like a strong cramp pain2. Pain while urinating3. Mild pain & discomfort4. Mild abnormal vaginal bleeding 5. Low back pain 6. Mild cramping pain on one side of the pelvis 7. Nausea8. Pain in the lower abdomen or pelvic area

Ectopic pregnancy is often caused by a condition that blocks or slows the movement of a fertilized egg through the fallopian tube to the uterus. This can be caused by a physical blockage in the tube or by hormonal factors .Cause is unknownMost cases are caused by:SmokingAlcohol drinkingPast ectopic pregnancyPast infection on of the fallopian tubeSurgery of the fallopian tubes

50% of women with ectopic pregnancy:Birth defects in the fallopian tubesComplications of ruptured appendixEndometriosis occurs when cells from the lining of the uterus grow in other areas of the bodyScarring caused by previous pelvic surgeryRisk factors of ectopic pregnancy:Age over 35Having had many sexual partnersInvitrofetilization

Diagnostic tests:1. Culdocentesis procedure that check abnormal fluid in the space just behind the vagina (cul-de-sac)

Diagnostic tets2. Hematocrit 3. Pregnancy tets4. Serum progesterone level5. White blood count6. Transvaginal ultrasound or pregnancy ultrasound7. Qunatitative HCG blood testOther tests to confirm ectopic pregnancy:D & CLaparoscopy look directly at the contents of a patients abdomen or pelvis, fallopian tubes, ovaries, uterus, small bowel, large bowel, appendix, liver & gallbladderLaparotomy abdominal surgery to examine the contents of the abdomenManagement:Blod transfusionIVF administrationOxygenWarmRaising the legsIf there is a rupture, surgery is done:Confirm an ectopic pregnancyRemove the abdominal pregnancyRepair any tissue damageMost cases remove the fallopian tubePrevention:Avoid risk factors for pelvic inflammatory disease sexual partners, sex with out condom, getting STDEarly diagnosis & treatment of STDsStopping smokingComplication of Pregnancy3. H-Mole/Hydatidiform mole abnormal form of pregnancy wherein a non viable fertilized egg implants in the uterus characterized by hydatidiform (hydatid mole) Rare mass or growth that forms inside the uterus at the beginning of pregnancy Type of gestational trophoblastic diseaseTrophoblastic disease group of abnormalities in which tumor grow inside a womans uterus.- The abnormal cells wil start in the tissue that would normally become the placenta, the organ that develops during pregnancyCause of H-mole results over production of the tissue that is supposed to develop into the placenta . The placenta feeds a fetus during the pregnancy . In this condition, the tissues develop into an abnormal growth called a mass.

Types of H-mole:Partial molar H-mole there is an abnormal placenta & some fetal developmentComplete molar pregnancy abnormal placenta but no fetus

Both forms are due to problems during fertilizaton.Exact cause of fertilization problems still unknown

Symptoms of H-mole:Abnormal growth of the womb (uterus)-excessive growthNausea & vomiting that maybe severeVaginal bleeding during pregnancy frist 3 months of pregnancyHyperthyroidism: heat intolerance, loose stools, rapid heart rate, nervousness, trembling hands, unexpected weight loss

Signs of H-mole5. Symptoms similar to eclampsia: 1st or nearly 2nd trimester almost always a sign of H-mole because pre eclampsia is rare this early in the normal pregnancy : hypertension & swllin gin feet, ankles & feetExams & Tests:Pelvic exam may show sign of normal pregnancy but the size of the womb maybe abnormalPregnancy ultrasound will show an abnormal placenta without some development of a babyChest x ray

Exams & tests:4. MRI of the abdomen or CT scan5. Blood clotting tetst6. Kidney & liver function tests7. HCG blood test (human chorionic gonadotropin) - will check if there is HCG in the blood. HCG is normally produced during pregnancyTreatment:If suspect of H-mole suction curettage is done - surgical abortion done that ends pregnancy by removing the fetus & placenta from the mothers womb2. HysterectomyAfter treatment serum HCG will be followedIt is important to avoid pregnancy & use a reliable contraceptive for 6-12 months after treatment for a molar pregnancy-to allow correct testing to be sure that the abnormal tissue does not returnWomen who got pregnant too soon after a molar pregnancy have a greater risk of having another one.Prognosis:More than 80% of H-mole are benignThe outcome after treatment is usually excellentAfter treatment use very effective contraception for at least 6-12 monthsIn some cases, H-moles may develop into invasive moles which may grow far into the uterine wall that may cause bleedingPrognosis:Few cases, H-mole may develop into choriocarcinoma fast growing form of gestational gestational trophoblastic form Choriocarcinoma- fast growing cancer in a womans uterus ,abnormal cells start in the uterus that would normally become the placenta the organ that develops placentaPossible Complications:Pre eclampsiaThyroid problems

Complications of Pregnancy4. Incompetent Cervix medical condition in which a pregnant womans cervix begins to dilate & efface (thin) before pregnancy has reached its term. This may cause miscarriage or preterm birth.During pregnancy as the babys grows & gets heavier presses on the cervix, this pressure cause the cervix to start to open.Causes of incompetent or weakened cervix:Previuos surgery on the cervixDamage during a difficult birthMalformed cervix or uterus from a birth defectPrevious trauma to the cervix such as D & C from a termination or a miscarriageDES exposure - DietheylstilbestrolWomen can be evaluated before pregnancy or in early pregnancy through pelvic exam Ultrasound should be used to measure the cervical opening or the length of the cervixHow often an incompetent cervix happen-It happens in about 1-2& of pregnancies .Almost 25% or babies miscarried in the 2nd trimester are due to incompetent cervix

Treatment:1.Cervical cerclage surgical procedure in which the cervix is sewn during pregnancy.The cervix is the lowest part of the uterus & extends into the vagina.WHY IS CERVICAL CERCLAGE IS USED: IF A WOMANS CERVIX IS AT RISK OF OPENING UNDER THE PRESSURE OF THE GROWING PREGNANCY.When is cervical used: best time is the 3rd month (12-14 weeks) of pregnancyHowever there are women may need cervical cerclage later in pregnancy ( emergent cerclage) A WEAK CERVIX MAYBE THERESULT OF:History of 2nd trimester miscariagePreviuos cone biopsy Damaged cervix by pregnancy termination

Benefits of the cerclage:Prevents miscarriagePrevents premature labor casued by cervical incompetenceWhat to do before the cerclage:Medical historyTh0rough exam of the cervixGeneral anesthesia, spinal or epidural anesthesia

Nursing care after the procedure:Advise to stay in the hospital for a few hours or overnightInform that immediately after he procedure may experience light bleeding & mild cramping which stop after a few days.Explain that there will be an increased thick vaginal discharge 4. For 2-3 days plan to relax at home avoid unnecessary physical activity5. Abstinence from sex for one week before & at least one week after the procedure.POSSIBLE RISKS OF CERVIAL CERCLAGE:1.Premature contractions2. Cervical dystocia- inability of the cervix to dilate normally in the course of labor3. Rupture of membranes4. Cervical laceration if labor happens before the cerclage is removed5. Some risks associated with general anesthesia include vomiting & nauseaSigns to look for after cerclage:Contractions or crampingLower abdominal or back pain that comes and goes like labor painVaginal bleedingA fever over 37.8 or chillsNausea & vomitingFoul smell vaginal dischargeBag of water breaking or leaking

Complication of Pregnancy:5. Placenta previa placenta grows in the lowest part of the uterus & covers all or part of the opening to the cervix.Previa placenta partly or completely covers the cervixTypes of Placenta previa:Marginal placenta is next to the cervix but does not cover the openingPartial placenta covers the part of the cervical openingComplete placenta covers all the cervical openingPlacenta Previa is common in women who have:Abnormally develop uterusLarge or abnormal placentaMany previous pregnanciesMultiple pregnanciesScarring on the lining of the uterus due to surgery, c-section, previous pregnancy, aboriton

Women at risk: smokes, have children at older age Symptoms:Sudden bleeding from the vagina.cramps, bleeding may start near the end of the 2nd trimester or beginning of the 3rd trmesterSevere bleeding on & offLabor starts after several days of severe bleedingTreatment depends on :The amount of bleedingWether the baby is developed enough to survive if deliveredHow much of the cervix is coveredThe babys positionThe number of previous birthsWether the woman is in laborIf the lpacenta is near or covering a part of the cervix, the doctor will recommend:Reducing the activitiesBed restPelvic rest no sex, no tampons & no douchingNothing should be placed in the vaginaTreatment:Blood transfusion if lots of blood is lostMedicines to prevent early laborMedcines to help pregnancy to continue to at least 36 weeksShot of special medicine Rhogam if blood type Rh negativeSteroids shots to help the babys lungs to mature6. After 36 weeks delivery of the baby maybe the best treatment7. Emergency c- section maybe done if there is severe bleedingRisks to the mother:Major bleedingShockdeathOther risks include: blood clots, infection, need for blood transfusion

Risks to the baby: blood loss in the baby, deathMOST INFANT DEATH DUE TO PLACENTA PREVIA OCCUR WHEN THE BABY DELIVERED BEFORE 36 WEEKS OF PREGNANCY

Complication of pregnancy:6. Abruptio Placenta - premature separation of the placenta from the uterus. -also called placental abruption, typically present with bleeding, uterine contractions, and fetal -placental abruption must be considered whenever bleeding is encountered in the second half of pregnancy. Complications:Hemorrhage into the decidua basalis occurs as the placenta separates from the uterus.Hematoma formation further separates the placenta from the uterine wall, causing compression of these structures and compromise of blood supply to the fetus.

Classification of placental abruption is based on extent of separation (ie, partial vs complete) and location of separation (ie, marginal vs central). (See Clinical.) Clinical classification is as follows:Class 0 AsymptomaticClass 1 - Mild (represents approximately 48% of all cases3. Class 2 - Moderate (represents approximately 27% of all cases)4. Class 3 - Severe (represents approximately 24% of all cases)Class 1 characteristics include the following:No vaginal bleeding to mild vaginal bleedingSlightly tender uterusNormal maternal BP and heart rateNo coagulopathyNo fetal distress

Class 2 characteristics include the following:No vaginal bleeding to moderate vaginal bleedingModerate to severe uterine tenderness with possible tetanic contractionsMaternal tachycardia with orthostatic changes in BP and heart rateFetal distressHypofibrinogenemia (ie, 50-250 mg/dL)

Class 3 characteristics include the following:No vaginal bleeding to heavy vaginal bleedingVery painful tetanic uterusMaternal shockHypofibrinogenemia (ie, < 150 mg/dL)CoagulopathyFetal death

Risk factors in abruptio placentae include the following:Maternal hypertension - Most common cause of abruption, occurring in approximately 44% of all casesMaternal trauma (eg, motor vehicle collision [MVC], assaults, falls) - Causes 1.5-9.4% of all casesCigarette smokingAlcohol consumption

Cocaine useShort umbilical cordSudden decompression of the uterus (eg, premature rupture of membranes, delivery of first twin)Retroplacental fibromyomaRetroplacental bleeding from needle puncture (ie, postamniocentesis)Idiopathic (proba

Previous placental abruptionChorioamnionitisProlonged rupture of membranes (24 h or longer)Maternal age 35 years or olderMaternal age younger than 20 yearsMale fetal sexLow socioeconomic statusAn increased risk of placental abruption has been demonstrated in patients younger than 20 years and those older than 35 years

Placental abruption is more common in African American women than in white or Latin American women. However, whether this is the result of socioeconomic, genetic, or combined factors remains unclear. Prognosis If the bleeding continues, fetal and maternal distress may develop. Fetal and maternal death may occur if appropriate interventions are not undertaken. The severity of fetal distress correlates with the degree of placental separation. In near-complete or complete abruption, fetal death is inevitable unless an immediate caesarian delivery is performed.

Maternal morbidity may include the following:Transfusion-related morbidityClassic cesarean delivery with need for repeat cesarean deliveriesHysterectomy

Maternal and fetal complications include issues related to (1) cesarean delivery, (2) hemorrhage/coagulopathy, and (3) prema

Patient Education Educate patients about reversible risk factors, especially smoking, before further pregnancies.Question the patient regarding possible trauma from abuse.