Ectopic Pregnancy Diagnostic Test:

An ectopic pregnancy occurs when a fertilized egg Urine pregnancy test

implants and grows outside the main cavity of the If (+) pregnancy test – quantitative HCG test →
uterus. An ectopic pregnancy most often occurs in a to know the fetal age
fallopian tube, which carries eggs from the ovaries to Pelvic exam
the uterus Ultrasound
Culdocentesis
> occurs when gestation is located outside the
uterine cavity/tubal pregnancies Treatment:

Causes: Vary depending on its size and location

Injection of methotrexate
>Fallopian tube damage often from infection-
Surgery
can block the fertilized egg’s path to the uterus
Laparoscopy
causing it to implant and grow in the tube
>Surgery Future Pregnancies:
>Endometriosis
>Smoking ➢ 30% who have had ectopic pregnancy will have
>Previous ectopic pregnancy difficulty becoming pregnant again.
>Pelvic infection – chlamydia or gonorrhea
>Fertility drugs that increase egg production ➢ If the fallopian tube has been spared, the
>Pelvic or abdominal surgery chances of a future successful pregnancy are
60%. Even if one fallopian tube has been
Risks: removed, the chances of having a successful
>Can damage the fallopian tube pregnancy with the other tube can be greater
Signs and Symptoms: than 40%.

Normal signs of pregnancy High Risk Women:

Pain- first red flag sign Age – 35 and 44 y/o
Other Signs and Symptoms: With PID – Pelvic Inflammatory
Disease
Vaginal spotting or bleeding Previous Ectopic Pregnancy
Dizziness or fainting (caused by blood loss) Surgery on fallopian tube
Low blood pressure (caused by blood loss) Infertility problems or medication to
Lower back pain stimulate ovulation

Nursing Care:
Unruptured Tubal Ruptured
Vital Signs
▪ missed period ▪ sudden sharp
Administer IVF
▪ abdominal pain severe pain
Monitor vaginal bleeding
within 3-5 ▪ shoulder pain
Monitor I&O
weeks (indicative of
Prepare for Culdocentesis
▪ scant, dark intraperitoneal
brown vaginal bleeding that
bleeding extends to Culdocentesis - is a procedure in which peritoneal fluid
▪ vague diaphragm and is obtained from the cul de sac of a female patient. It
discomfort Phrenic nerve) involves the introduction of a spinal needle through the
▪ + Cullen’s sign –
vaginal wall into the peritoneal space of the pouch of
bluish tinged
Douglas
umbilicus
Result: to determine if clotting or nonclotting

➢ If clotting – negative for ectopic pregnancy

➢ If non – clotting – positive for ectopic

pregnancy
INDUCED ABORTION consisting of avoidance of sexual intercourse,
1.THERAPEUTIC douching, inserting tampons.
2. ILLEGAL ➢ Teach sign of infection like fever , pelvic pain,
increased bleeding and advise to report them
➢ Is the termination of pregnancy before fetal to health care provider immediately.
viability for the purpose of safeguarding the ➢ Arrange for follow-up appointment and
womans health. counselling if necessary.

➢ Elective abortion is the termination of B. BLEEDING DISORDER DURING THE SECOND

pregnancy before fetal viability as a choice of TRIMESTER OF BLEEDING
the woman
1. Hydatidiform Mole ( H-Mole)

- an abnormal proliferation and degeneration of the

THERAPEUTIC OR VOLUNTARY ABORTION trophoblastic villi
PROCEDURE: Molar pregnancy
1. First trimester abortion can be managed by Gestational Trophoblastic Disease
Bunch of Grapes
dilatation and curettage or Dilatation and
Hydatid – means drop of water; mole – means
Suction.
spot
2. Second trimester abortion can be managed
Types:
using:
a) Prostaglandin E2, a. Partial Molar – pregnancy that includes an abnormal
b) Vaginal suppositories or IM injection of embryo (a fertilized egg that has begun to grow) but
F2 analogs. does not survive
c) Laminaria or Magnesium Sulfate tents
b. Complete Molar –pregnancy in which there is small
- may be used before prostaglandin
cluster of clear blisters or pouches that don’t contain
induction – to soften the cervix and
an embryo
assist with dilation.
3. Late second trimester abortion can be done
using intra amniotic saline injection,
hysterotomy or hysterectomy

NURSING CONSIDERATIONS:

➢ Review the woman knowledge of her choice

and the options available in regard to
childbearing to allow for informed decision
making.
➢ Ensure that patient understands the possible
benefits and risk of a therapeutic or voluntary
abortion Drug of Choice: Methotrexate
➢ Encourage patient to have support person
accompany her and drive her at home after the Etiology: Unknown
procedure
Other Causes:
➢ Teach that cramping and bleeding, similar to a
regular menstrual period, can be expected. Problems with the chromosome
Length of bleeding varies but usually subside in Problem with the nutrition – low protein intake
3 to 4 days Problem with the ovaries and uterus
➢ Discuss the need for contraception and advise Mole sometimes can develop from a placental
when to begin again tissue that is left behind in the uterus after a
➢ Inform that normal menstrual cycle should miscarriage or childbirth
resume in 4 to 6 weeks.
➢ Discuss the needs of pelvic rest, as ordered ,
usually 2 to 3 weeks to prevent infection,
Signs and Symptoms Treatment

(+) pregnancy test often, the tissue is naturally expelled by the

Symptoms for the first 3-4 months fourth month of pregnancy.
Uterus grow abnormally fast In some instances, the physician will give the
End of 3rd month-woman will experience woman a drug called oxytocin to trigger the
vaginal bleeding ranging from scant spotting to release of the mole that is not spontaneously
excessive bleeding aborted
If this does not happen, a vacuum aspiration
can be performed to remove the mole
May predispose the:

➢ Presence of hyperthyroidism (overproduction D&C

of thyroid hormone) leads to:
Weight loss woman is given anesthetic
Increase appetite Cervix is dilated and the contents of the uterus
Intolerance to heat is gently suctioned out.
Grapelike cluster of cells itself will be shed with After the mole has been mostly removed,
the blood during this time gentle scraping of the uterus lining is usually
Nausea and vomiting due to increase HCG and performed.
progesterone If the woman is older and does not want any
(-) fetal movement
more children, the uterus can be surgically
(-)fetal heart rate
removed (hysterectomy) instead of a vacuum
Early Signs: aspiration because of the higher risk of
Vesicles passed thru the vagina cancerous moles in this age group
Hyperemesis gravidarum Monitoring the patient for at least 2 months
Fundal height – rapidly increases after the end of a molar pregnancy for HCG
Vaginal bleeding (scant or profuse) level
Pre-eclampsia at about 12 weeks Hcg level will be checked every 2 weeks – if
Late Signs don’t return to normal by that time, the mole
HPN before 20th week may have become cancerous
Vesicles look like a ‘snowstorm” on sonogram If HCG level is normal, the woman’s HCG will be
Anemia tested each month for 6 months and every 2
Abdominal cramping months for a year
Serious Late Complications
If mole become cancerous, treatment includes
Hyperthyroidism
removal of the cancerous tissue and
Pulmonary embolus
chemotherapy
Diagnosis: If cancer spread to other parts of the body,
radiation will be added
suspect until 3rd month or later if fetal Woman should not be pregnant within a year
heartbeat is present with bleeding and severe after HCG levels have returned to normal
nausea and vomiting If woman got pregnant within that time, it is
Physician will examine the woman’s abdomen difficult to tell whether the resulting high levels
feeling for any strange humps or abnormalities of HCG were caused by the pregnancy or as a
in the uterus cancer from the mole
Tubal pregnancy will be ruled out
Abnormally increased HCG level with vaginal C. BLEEDING DISORDERS DURING THE THIRD
bleeding; TRIMESTER OF PREGNANCY
(-) FHB 1. Placenta Previa – occurs when the placenta is
unusually large uterus will indicate a molar improperly implanted in the lower uterine segment,
pregnancy sometimes covering the cervical os.
Signs and Symptoms 7. Vaginal delivery may attempted in marginal
previa if without active bleeding
Frank, bright red, painless vaginal bleeding 8. Pediatric team is need at delivery time due to
Engagement (usually has not occurred) prematurity and neonatal complication,
Fetal distress
Presentation (usually abnormal) – baby is COMPLICATION
breech or in transverse position
Uterus measures larger than it should Fetal mortality resulting from hypoxia in utero
and prematurity
according to gestational age
Immediate hemorrhage, with possible shock
and maternal death
Postpartum hemorrhage resulting from
decreased contractility of uterine muscle.

NURSING ASSESSMENT

Determine the amount and type of bleeding

Inquire the presence or absence of pain in
association with bleeding.

Record maternal and fetal vital signs

Palpate for the presence of uterine

contraction.

Evaluate laboratory data on hemoglobin and

hematocrit status.
Types:
Assess fetal status with fetal monitoring.
a. Partial Placenta Previa – a portion of the cervix
is covered by the placenta NURSING INTERVENTION
b. Complete Placental Previa/Total – cervical 1. PROMOTING TISSUE PERFUSION
opening is completely covered b. Frequently monitor mother and fetus
c. Marginal Placenta Previa – extends just to the c. Administer IV fluids as prescribed
edge of the cervix d. Position on side to promote placental
perfusion.
DIAGNOSTIC EVALUATION:
e. Administer Oxygen by face mask as indicated
1. Trans-abdominal ultrasound- is the method of f. Prepare for an emergency delivery as needed
choice to show location of the placenta.
2. Sterile speculum examination- can also 2. MAINTAINING FLUID VOLUME
confirm placenta previa a. Establish and maintain a large-bore IV line as
prescribed
MANAGEMENT
b. Position in sitting position to allow the weight
1. Bed rest and hospitalization until fetus is of fetus to compress the placenta and decrease
mature and delivery can be accomplished as bleeding.
usual. c. Maintain strict bed rest during any bleeding
2. Needs immediate transport to the hospital for episode
recurrent of bleeding if patient is at home. d. If bleeding is profuse and delivery cannot be
3. IV access and at least 2 units of blood should delayed, prepare the woman physically and
be available. emotionally for the cesarean section.
4. Amniocentesis may be done to determine fetal e. Administer blood or blood products protocol
lung maturity for possible delivery. per institution policy
5. Continuous maternal and fetal monitoring
6. Immediate Cesarean section is often indicated
if degree of previa is above 30% excessive
bleeding
3. PREVENTING INFECTION Surgical Management:

a. Use aseptic technique when providing care C/S with blood transfusion based on blood loss
b. Evaluate temperature every 4 hours unless
2. Abruptio Placenta
elevated
c. Evaluate white blood cell and different count. > Premature separation of the placenta from the
d. Teach perenial care and handwashing implantation site. It usually occurs after the 20th week
technique of pregnancy
e. Assess odor of all vaginal bleeding or lochia > Bleeding into the deciduas basalis (the layer between
the placenta and myometrium) compresses and
4. DECREASING ANXIETY compromises the function of adjacent placenta
a. Explain all treatment and procedure and
Other Names:
answer all related question.
> Premature Separation of Placenta
b. Encourage verbalization of feelings by patient > Accidental Hemorrhage
and family > Ablatio Placenta
c. Provide information of cesarean delivery and > Placental Abruption
prepare patient emotionally.
d. Discuss the long term hospitalization or
e. prolonged bd rest.

5. COMMUNITY AND HOME CARE CONSIDERATION

a. Can care placenta previa with no active

bleeding, no sign of preterm labor, home close
to medical facility and emergency support
readily available.
b. Teach woman the sign and symptoms of
hemorrhage
c. Monitor vaginal discharges and bleeding after
each urination and bowel movement.
d. Instruct woman on doing home uterine activity
monitoring daily by way of palpation.
e. Instruct woman on fetal movement count to be
performed daily. Signs and Symptoms:
f. Perform daily or twice a week a nonstress test.
g. Instruct woman to have support person readily > Painful vaginal bleeding
available. > Severe abdominal pain
h. Instruct woman that there is to be nothing in > Concealed bleeding (retroplacental)
the vagina. Discuss alternative methods of > Rigid abdomen
sexual gratification. > Couvelaire uterus (caused by bleeding into the
6. PATIENT EDUCATION AND HEALTH MAINTENANCE myometrium)
> Dropping Coagulation factor (a potential for DIC)
a. Educate woman and her family about the
etiology and treatment of placenta previa.
b. Educate woman to inform medical personnel
about her diagnosis and not to have vaginal
examination.
c. Educate woman who discharged from hospital
to avoid intercourse or anything in the vagina,
to limit physical activity, to have an accessible
person in the event of emergency.
Predisposing Factors:

> Old Age

> Smoking
> Intake of alcoholic beverages
> history of placenta previa in the past pregnancy
Signs and Symptoms: Treatment and Management:
Couvelaire uterus (also known as
uteroplacental apoplexy) is a life-threatening IVF
condition in which loosening of the placenta Blood Transfusion
(abruptio placentae) causes bleeding that Check for presence of shock and fetal distress
penetrates into the uterine myometrium Emergency C/S – for fetal distress or maternal
forcing its way into the peritoneal cavity bleeding
Immature fetus with small placental separation
Other Signs and Symptoms: – hospitalization – for observation – release
after several days if no evidence of progressing
Uterine hypertonous contractions with a abruption occurs
duration lasting more than 2 minutes If mature fetus – vaginal delivery if maternal
Back pain and fetal distress is minimal
Preterm labor C/S – to protect the mother and child
Hypovolemic shock
Non reassuring fetal heart tracking and fetal General Nursing Care
demise
Infuse IVF, prepare to administer blood
Severe Cases: Type and cross match blood components
(PRBC)
➢ Maternal hypotension
Monitor FHR
➢ Uterine hypertonicity Insert foley catheter
➢ Fetal distress Measure blood loss – count pads
➢ Death Report signs and symptoms of DIC
➢ Clotting abnormalities Monitor V/S
Cause: unknown Strict I & O

Predisposing Factors: DIAGNOSTIC EVALUATION

Mechanical factors such as: abdominal trauma 1. Evaluate woman base history, physical
– car accident of fall examination laboratory studies and sign and
Sudden loss in uterine volume as occurs with symptoms, vaginal bleeding, abdominal pain,
rapid loss of amniotic fluid or the delivery of a uterine contraction, uterine tenderness, fetal
first twin distress.
Abnormally short umbilical cord 2. Ultrasound is done.
Hypertension 3. Laboratory screening on mother’s blood to
Pre-eclampsia check for fetal hemoglobin.
Multiparity
Rupture of membranes more than 24H MANAGEMENT

Signs and Tests: 1. Vaginal delivery is accomplished if cervix

dilates
➢ During a physical examination, uterine 2. Cesaren section if fetal and maternal status will
tenderness and or increased uterine tone deteriorates and blood loss is excessive.
may be noticed 3. IV and Blood transfusion replacement.
➢ CBC – decreased hematocrit and hemoglobin 4. Availablity of pediatric team for any
and platelets prematurity and neonital complication.
➢ Prothrombin time test COMPLICATIONS
➢ Partial thromboplastin time test
1. Maternal shock
➢ Fibrinogen level test 2. Amniotic fluid embolism (AFE)
➢ Ultrasound 3. Postpartum hemorrhage
4. Prematurity
5. Maternal/ fetal death
6. Adult respiratory syndrome ( ARDS)
7. Renal tubular necroses
8. Rapid labor and delivery
NURSING ASSESSMENT DISSEMINATED INTRAVASCULAR COAGULATION
1. Determine the amount and type of bleeding (DIC)
and presence and absence of pain
2. Monitor maternal and fetal vital signs DISSEMINATED INTRAVASCULAR COAGULATION
especially maternal blood pressure, pulse , (DIC)- IS AN ACQUIRED DISORDER OF BLOOD CLOTTING
FHR. IN WHICH THE FIBROGEN LEVEL FALLS TO BELOW
3. Palpate abdomen –note the presence of EFFECTIVE LIMITS.
contraction and relaxation and assess the
abdomen for firmness.
4. Measure and record fundic height – to EARLY SYMPTOMS
evaluate the presence of concealed bleeding • BRUISING OR BLEEDING FROM THE
5. Prepare possible delivery.
INTRAVENOUS SITE.
NURSING INTERVENTIONS CAUSES:
1. MAINTAINING TISSUE PERFUSION
b. Evaluate amount of bleeding by weighing all a. Premature separation of the placenta
pads. b. Pregnancy – induced Hypertension
c. Monitor CBC results and vital signs. c. Amniotic fluid embolism
d. Position patient on lateral position with head d. Placental retention
elevated to enhance placental perfusion. e. Septic abortion
e. Administer Oxygen through face mask at 8 to f. Retention of a dead fetus
12L
f. Evaluate fetal status with continuous external Medical Management:
fetal monitoring
• Give anticoagulant- to prevent to much
g. Encourage relaxation technique.
clotting
h. Prepare for possible cesarean section delivery.
• Rapid Fetal fibronectin test –
2. MAINTAINING FLUID VOLUME
a. Establish and maintain large-bore IV line for Preterm Labor
fluids and blood products as prescribed
• Labor that occurs before the end of week 37
b. Evaluate coagulation studies
c. Monitor maternal vital signs and contraction of gestation
d. Monitor vaginal bleeding and evaluate fundal • Danger: Infant is immature
height to detect an increase in bleeding.
3. DECREASING FEAR Assessment:
a. Inform woman and her family about the status
of both herself and the fetus > Any pregnant woman having persistent
b. Explain all procedures in advance when uterine contractions, mild and widely spaced
possible to perform should be considered to be in labor, if
c. Answer question in a calm manner, using contractions have caused cervical effacement
simple terms or dilatation over 1 cm
d. Encourage the presence of a support person.
4. PATIENT EDUCATION AND HEALTH Measures on How to Prevent Preterm Labor:
MAINTENANCE 1. Remain on bed rest except to use on
a. Provide woman an information about the bathroom. 2. Drink 8 to 10 glasses of fluids
causes and treatment of abruptio placentae.
daily
b. Encourage involvement from neonatal team
2. Keep mentally active by reading or working on
c. Teach the sign and symptoms and increased
uterine activity a project to prevent boredom
d. Instruct woman to report immediately if 3. Avoid activities that could stimulate labor
excessive bleeding and pain occur at home. 4. Consult your primary care giver whether sexual
e. Instruct woman to emergency plan for relations should be restricted
transport to medical facility. 6. Immediately report signs of ruptured
membranes and sudden gush of fluid from the
vagina) or vaginal bleeding
 7. Report signs of urinary tract infections or CLINICAL MANIFESTATION
vaginal infection (burning or frequency of 1. Uterine cramps
urination, vaginal itching or pain) 2. Uterine contraction every 10 to 15 minutes
8. Keep appointments for prenatal care. 3. Low abdominal pressure
9. Empty bladder to prevent pressure on the 4. Low back pain
uterus 5. Vaginal bleeding
6. Increased vaginal discharge of clear or tan fluid
10. Lie down on your left or right side to
7. Feeling that something on her vagina
encourage blood return to the fetus
8. Abdominal cramping with nausea and vomiting
Diagnosis: 9. Persistent thigh pain

➢ Analyzing changes in the length of the cervix by 1. CONSERVATIVE TREATMENT

ultrasound
a. Bed rest in a lateral position
➢ Analysis of vaginal mucus for the presence of b. Hydration with IV fluids and continuous
fetal fibronectin, a protein produced by monitoring of fetus status
trophoblast cells 2. TOCOLYTIC THERAPY
a. Betamimetic agents such as - Ritodrine and
▪ If this is present in vaginal mucus, preterm terbutaline
labor occurs, labor will not occur if the protein 1. Frequent monitoring to observe for the side
is absent for at least 14 days effects of increased blood pressure,
▪ Risk factor are divided into three categories hypervolemia.
like: 2. Have laboratory test request of the following
test: ECG, CBC, ELECTROLYTE, GLUCOSE, BUN,
1. Medical/ obstetrical predating the pregnancy CREATININE, PROTHOMBIN TIME.
a. Miscarriage b. Magnesium Sulfate - interfere with smooth muscle
b. Cervical incompetence contractility.
c. Uterine /cervical abnormalities
d. Hypertension c. Indomethacin (Indocin) - is a prostaglandin inhibitor
e. Diethylstilbestrol exposure that inhibits contraction.

d. Nifedipine - is a channel blocker that relaxes smooth

2. Current pregnancy related:
muscle by inhibiting the transport of calcium.
a. Anemia
b. Multiple gestation e. Oxytocin antagonists - is the receptor and inhibits
c. Placenta previa uterine contractions.
d. Abruptio placenta
e. Fetal anomaly NURSING ASSESSMENT:
f. Hydramnios
g. Abdominal surgery ▪ Assess fetal status by way of electronic fetal
h. Maternal infection monitoring.
i. Maternal bleeding ▪ Assess uterine activity pattern.
j. Previous PTL ▪ Assess respiratory status
k. Uterine distention ▪ Assess muscular tremors
l. Cervical incompetence ▪ Palpitations
3. Demographic and behavioral ▪ Dizziness/ light headache
a. Maternal age below 20 or above 35 years old ▪ Urinary output
b. Low socioeconomic status ▪ Assess the s/s of PTL
c. Single parent ▪ Assess the s/s of infection
d. Smoker
e. Chemical drug use or dependent NURSING INTERVENTION:
f. Pre-pregnancy weight below 100lbs ▪ Provide accurate information on the status of the
g. Poor weight gain fetus and labor
h. Inadequate prenatal care ▪ Determine quiet craft activities that can be done in
i. Psychological stress bed.
▪ Monitor fetal status and progress of labor.
▪ Maintain accurate intake and output
▪ Encourage private time for woman and partner.
Premature Rupture of Membranes 4. Do handwashing technique and hygiene after
urination and defecation
PREMATURE RUPTURE OF MEMBRANES 5. Monitor FHT and fetal activity every 4 hour.
(PROM)- Is a rupture of the membranes after 6. Monitor maternal vital sign and uterine
37 completed week’s gestation before the tenderness every 4 hours.
onset of spontaneous labor.
PROM occurs in 2 of 18 pregnancies. Preterm Premature Rupture of Membranes

PATHOPHYSIOLOGY AND ETIOLOGY PRETERM PREMATURE RUPTURE OF MEMBRANES

• The exact etiology of PROM is not clearly (PPROM)- Is a rupture of membranes before 37
understood. PROM at term may result from completed weeks gestation with or without the onset
stretching of the membrane and fetal of spontaneous labor.
movements that cause the membrane to
weaken. PATHOPHYSIOLOGY
• PROM is manifested by a large gush of Exact cause is unknown
amniotic fluid per vagina, which usually
persists. Risk factor include:
Infection (amnionitis, group B beta
DIAGNOSTIC EVALUATION Streptococcus)
▪ Sterile speculum examination- Previous history of PROM or preterm birth
▪ Nitrazine test- positive test will change pH strip Hydramnios ( Poly or Oligo)
from yellow –green to blue in the presence of Incompetent cervix
amniotic fluid taken from vaginal opening. Nulliparity
▪ Fern test- positive test will reveal- a swab of Spontaneous labor with uterine contraction
the posterior vagnal fornix is taken to obtain every 5 min/ 100% effacement.
amniotic fluid. PROM within2 hours after admission
NURSING MANAGEMENT Induction of Oxytocin if no cervical change.
1. Once PROM is confirmed, the woman is
admitted to hospital and remain until delivery. BEFORE INDUCTION OF OXYTOCIN
2. Woman will be evaluated to rule out labor, • Obtain a 20 minute NST – to assess fetal well
fetal compromise and infection and to being.
establish gestational age. • Evaluate maternal vital sign
3. Vaginal examination are kept to a minimum to • Evaluate patency of the IV site.
prevent infection.
COMPLICATION: AFTER ADMINISTRATION OF OXYTOCIN:
1. PTL a. Continuous monitoring of FHR and uterine
2. Prematurity and associated complication activity especially the resting tone.
3. Maternal infection-chorioamnionitis b. Assess maternal vital sign every 2 to 4 hours.
4. Fetal or neonatal infection c. Limit vaginal examination especially after the
membrane have ruptured.
NURSING ASSESSMENT: d. Maintain intake and output and record and
1. Evaluate maternal vital sign every 2 hours. watch for intoxication – like dizziness,
2. Monitor amount and type of amniotic fluid headache, confusion, nausea and vomiting,
that is leaking, foul-smelling discharge. hypotension, tachycardia and decreased urine
3. Evaluate daily CBC differential – note the output.
immaturity of neutrophils. e. Evaluate IV site for patency.
4. Evaluate fetal status every 4 hours.
5. Determine if uterine tenderness occurs on NURSING INTERVENTION:
abdominal palpitation. 1. Teach to use relaxation technique and
distraction technique.
NURSING INTERVENTIONS: Preventing infection 2. Assess fetal status and uterine contraction
1. Evaluate amount and odor of amniotic fluid through auscultation and palpation.
leakage. 3. Encourage use of breathing techniques
2. Do not perform vaginal examination comfort measure.
3. Place patient in the disposable pad every 2
hours – to collect leaking fluid.
HYPERTENSIVE DISORDERS OF PREGNANCY PIH CLASSIFIED AS:
1. Preeclampsia = hypertension with proteinuria,
CLASSIFIED AS SUCH: edema or both. Further classified as mild or
1. PREGNANCY – INDUCED HYPERTENSION severe.
2. CHRONIC HYPERTENSION/ COINCIDENTAL 2. Eclampsia= hypertension with convulsion and
HYPERENSION coma occurs in the absence of an underlying
3. PREECLAMPSIA neurologic condition. Was also previously
4. GESTATIONAL HYPERTENSION referred as TOXEMIA because it was thought
5. SUPERIMPOSED ECLAMPSIA AND to be caused by toxin.
PREECLAMPSIA
6. TRANSIENT HYPERTENSION CAUSES OF PIH
1. No definite cause is known
A. PREGNANCY – INDUCED HYPERTENSION 2. Protein deficiency theory
- Is a disorder occurring during pregnancy after the 20th 3. Endothelin theory - endothelin are potent
week of gestation. It occurs in 15% to 10 % of all vasoconstrictor
pregnancies. 4. Uterine ischemia
5. Increased sensitivity to vasopressors.
B. CHRONIC HYPERTENSION/ COINCIDENT
HYPERTENSION EFFECTS OF PIH
- is the presence of hypertension before pregnancy or A. CARDIOVASCULAR CHANGES
hypertension that develop before 20 weeks gestation 1. Decreased cardiac output
in the absence of H-Mole and persist beyond the 2. Hemoconcentration
postpartum period. 3. Failure of blood volume to expand to
normotensive women
C. GESTATIONAL HYPERTENSION 4. Thrombocytopenia
- a hypertension that develops after 20 weeks gestation 5. Increased levels of clotting factor
accompanied by proteinuria and edema. 6. Abnormal formation of red blood cells.

D. SUPERIMPOSED ECLAMPSIA AND PREECLAMPSIA B. ENDOCRINE AND METABOLIC CHANGES

- occurs when a woman having chronic hypertension, 1. Increased of the following Hormone:
or vascular disease before pregnancy develops a. Renin
preeclampsia or eclampsia during pregnancy. b. Angiotensin II- elevates BP
c. Aldosterone- promote sodium absorption and
E. PREECLAMPSIA fluid retention
- hypertension that develop after 20 weeks gestation d. Antidiuritics hormone-decrease the amount of
accompanied by proteinuria and edema. urine
e. Chronic gonadotropin
F. TRANSIENT HYPERTENSION 2. Increased Extracellular fluid volume- edema.
- develop of mild elevated blood pressure during
pregnancy or in first 24 hours postpartum without any C. RENAL CHANGES
sign of chronic disease or preeclampsia. 1. Reduced renal perfusion and glomerular filtration
2. Elevated creatinine, uric acid and urea.
PREDISPOSING FACTOR: 3. Decreased excretion of calcium in the urine
1. Higher incidence in primiparas below 20 and 4. Decreased urine output
above 35 year old 5. Proteinuria
2. Low socioeconomic status
3. Previous hypertension of pregnancy, H-Mole, COMPLICATION OF PREECLAMPSIA AND ECLAMPSIA
diabetes disease, multiple pregnancy, 1. Abruptio placenta
polyhydramnios, renal disease, heart disease 2. Cerebral hemorrhage
4. Hereditary 3. Hepatic Failure
4. Acute renal Failure
A. PREGNANCY – INDUCED HYPERTENSION ( PIH) 5. Prematurity
• Is a disorder occurring during pregnancy after 6. Perinatal death
the 20th week of gestation. It occurs in 15% to 7. Maternal death
10 % of all pregnancies.
SIGN AND SYMPTOMS

a. Prevent convulsion

b. Reduce edema

c. Reduce Blood Pressure

Checked the following first before administering Mag

Sulfate:

RR should be above 14 cycles per minute

Urine output should be at least 100ml/4hours
Deep tendon reflexes are present ( knee-jerk
or patellar reflex)
MANAGEMENT OF PIH
A. AMBULATORY MANAGEMENT: MAGNESIUM SULFATE
1. Home management is allowed only if: If Mag Sulfate toxicity develops as shown by
a. BP is 140/90 or below
respiratory depression ( RR is below 14 per
b. there is no proteinuria
minute) and disappearance of deep tendon
c. there is no fetal growth retardation
d. the patient is not primipara reflex, give the antidote Calcium gluconate and
2. Bed rest- most part of the day notify physician.
3. Woman should consult the clinic as often as Mag Sulfate is given up to 24 hours after
necessary delivery or from the last convulsion if
4. Diet should be high in protein and carbohydrates convulsion occurred during the postpartum
with moderate sodium restriction. period.
5. Hospitalization is necessary if condition worsens If given during postpartum, monitor for uterine
6. Provide detailed instruction about warning sign of: atony as it can cause uterine relaxation.
a. epigastric pain
b. visual disturbances 3. Diuretics- are not given and IVF administration is
c. severe headache limited.
d. Nausea and vomiting
MANAGEMENT OF PIH- HOSPITAL MANAGEMENT
B. HOSPITAL MANAGEMENT g. Monitor patient closely
1. Need hospitalization if BP is above
140/90mmhg. Take vital signs and fetal heart tone
2. Bed rest to reduce BP and promote diuresis: continously
a. Rest in left lateral recumbent position-to Ask woman if she experiences blurring of
promote blood supply to the placenta and vision, severe headache, and epigastric pain.
fetus. Attach Indwelling catheter to monitor urinary
b. Room should be dim, away from areas of output accurately
activity, avoid bright lights such as flashlight Weigh daily- at the same time each day using
c. Restrict visitors to allow patient to rest
the same weighing scale
d. Leave BP cuff on patients arm so as not to
Laboratory tests for proteinuria, creatinine,
disturb the patient when placing it every time
BP checked. hematocrit
e. Diet should be high in protein and f. Fetal monitoring: to check the health of the fetus
carbohydrates but moderate sodium when the mother has PIH may include:
restriction to prevent more fluid retention.
f. Medication : Fetal movement counting- keeping track of
1. Hydralazine – antihypertensive drugs given fetal kicks and movements.
intravenously when diastolic pressure reaches Nonstress testing – a test that measure the
110mmhg or higher fetal heart rate
2. Magnesium Sulphate – drugs of choice to treat Biophysical profile – a test that combines
and prevent convulsion. The woman stops
nonstress test with ultrasound to observe the
convulsion after the initial dose.
fetus.
ACTION:
 Doppler flow studies – type of ultrasound that Watch for sign of abruptio placenta, vaginal
use sound waves to measure the flow of blood bleeding, abdominal pain, decreased fetal
through a blood vessel. activity.
Take vital sign and FHT after convulsion.
STAGES OF CONVULSION
Do not give anything by mouth unless woman
A. Stage of invasive – face twitching rolling of the is fully awake after convulsion.
eyes to one side, staring fixedly in space.
b. During delivery
B. Tonic phase – body become rigid as all muscle
1. The cure of PIH is termination of pregnancy or
so into violent spasms or contractions, eyes
delivery.
protrude, arms are flexed with legs inverted,
2. Sign and symptoms usually disappear once
hands are clenched, woman stops breathing,
pregnancy is terminated.
last for 15 to 20 second.
3. Physician waits until the fetus will be mature
C. Clonic phase- jaws and eyelids close and open before attempting delivery.
violently, foaming of the mouth, face becomes 4. In severe cases, labor induction is performed
congested and purple, muscle of the body irregardless of gestational age.
contact and relax alternately. The contraction 5. Preferred method of delivery is vaginal
are so violent that the woman may throw delivery. Labor is induced by amniotomy or
herself out of bed. Lasts for about one minute. oxytocin administration 24 hours after the last
convulsion and when the condition of the
D. Postal state- woman is semicomatose , no woman is stable.
more violent muscular contraction. The patient 6. If labor induction is unsuccessful and fetal
will not remember the convulsion and the distress is so severe that the fetus needs to be
events immediately before and after . delivered as soon as possible, ceasarean
j. Safety measures section is performed.

Raise padded side rails at all times to keep i. Postpartum care:

the woman from falling if convulsion occur 1. If the danger of convulsion exists until 24 hour
Put bed at lowest position after delivery, Magnesium Sulfate Therapy is
Have emergency equipment available for continued until the immediate 24 hour
immediate use: postpartum.
a. Padded tongue blade
b. Suction apparatus 2. Watch for urine relaxation and increased
c. Magnesium sulfate lochial flow if the woman is receiving
d. Calcium gluconate Magnesium sulfate.
e. Oxygen
3. Two years should be elapse before another
h. Care of the woman during convulsion pregnancy is attempted to decrease the
likelihood that PIH will recur on the
RESPONSIBILITIES DURING CONVULSION subsequent pregnancy.
airway and safety HELLP SYNDROME
Always monitor patient for impending sign of Is a serious complication of severe
convulsion, epigastric pain, severe headache, pregnancy –induced hypertension.
severe nausea and vomiting. It occurs in about 10% of women with high
Maintain patient airway and protection of blood pressure of pregnancy.
patient from safe injury. It usually develops before delivery, but
Insert a padded mouth gag or tongue blade may occur postpartum or after delivery as
only before convulsion. well.
Turn patient on her side to allow drainage of
saliva and prevent aspiration. HELLP SYNDROME CONSISTS OF THE FF:
Never leave an eclamptic patient alone.
✓ HEMOLYSIS- break down of red blood cells
Do not restrict movement during convulsion as
this could result to fracture.
 ✓ ELEVATED LIVER ENZYMES – damage to liver 7. Medication of Corticosteroids – that may help
cells cause changes in liver function lab tests. mature the lungs of the fetus

✓ LOW PLATELETS –cells found in the blood that 8. Delivery – if HELLP syndrome worsen and
are needed to help the blood to clot in order to endanger the well being of the mother or
control bleeding. fetus, then an early delivery may be necessary.

HELLP CAUSES TO OTHER PROBLEM:

1. ANEMIA – breakdown of red blood cells may

cause anemia.

2. DISSEMINATED INTRAVASCULAR
COAGULATION (DIC) -may lead to severe
bleeding or hemorrhage

3. PLACENTAL ABRUPTIO - early detachment of

the placenta may also occur.

4. PULMONARY EDEMA- ( fluid build up in the MULTIPLE GESTATION

lungs) is also a serious complication. -RESULT WHEN TWO OR MORE FETUSES ARE
SYMPTOMS OF HELLP SYNDROME: PRESENT IN THE UTERUS AT THE SAME TIME.

1. Right – sided upper abdominal pain or pain TYPES OF TWINNING

around the stomach. A. Dizygotic twin
2. Nausea and vomiting occurs when two separates ova are fertilized.
3. Headache twins that do not have the same genetic make
4. Increase blood pressure up and are as similar as other brothers
and sister.
5. Protein in the urine
have two placenta and two chorions and two
6. Edema amnions.
HOW HELLP SYNDROME DIAGNOSED? B. Monozygotic twin
1. Blood pressure measurement occurs when one ovum divides early in
2. Red blood cells count gestation and two embryos develop.

3. Bilirubin level test Are identical in genetic make up. Etiology is

unclear for spontaneous monozygotics.
4. Liver count
with one placenta, one chorion and one
5. Platelet count amnion.
6. Urine test for protein CLINICAL MANIFESTATION:
TREATMENT FOR HELLP: UTERUS IS LARGE FOR GESTATIONAL AGE
DURING THE SECOND TRIMESTER.
1. Bed rest
AUSCULTATION OF TWO DISTINCT AND
2. Hospitalization as needed SEPARATE FETAL HEARTS MAY OCCUR WITH A
DOPPLER late in the first trimester.
3. Blood transfusion – for severe anemia.
Ultrasound is the best screening test at
4. Magnesium sulfate – to prevent seizure present. It may identify separate gestation sac.

5. Antihypertensive medication COMPLICATION:

6. Laboratory testing of liver, urine and blood 1. SPONTANEOUS ABORTION

2. POLYHYDRAMNIOS, OLIGOHYDRAMNIOS
WITH TWIN COMMON
3. PIH
4. UMBILICAL CORD PROBLEMS CORD
PROLAPSE OR VAS PREVIA.
5. PLACENTA ACCIDENT SUCH AS ABRUPTIO
PLACENTA OR PLACENTA PREVIA.

MANAGEMENT AND NURSING

INTERVENTION:

1. Nutritional Counseling = increased

caloric and protein intake as well as
vitamins supplements.
2. Fetal evaluation
3. Evaluate woman for sign and
symptoms of PIH
4. Cesarean section.
5. Intrapartum management like:
6. Establish IV access to prepare for
emergency birth or other
complication.
7. Provide for electric fetal monitoring
8. Double set – up is recommended for
delivery
9. Postpartum hemorrhage may occur
due to uterine atony.

6. Emotional support = encourage the family to

discuss feeling about multiple birth and
identity ways in which they will need help.

HYDRAMNIOS OR POLYHYDRAMNIOS