ABNORMAL OB
1st TRIMESTER BLEEDING
ABORTION
- termination of pregnancy before 20 weeks (age of
viability)
- Fetal Causes:
1. Rejection of ovum
2. Defective embryonic development: 5th to 8th week;
organogenesis or formation of the different organ
Structure
- Maternal Causes:
1. Infection
2. Malnutrition
3. Drug Ingestion
4. DEHYDRATION- Trigger the Posterior Pituitary
Gland to produce anti-diuretic hormone- to retain
water; PPG is also responsible in the production of
oxytocin that can lead to pre-term contractions that
will lead to abortion.
- Types of Abortion:
1. Induced- artificially done through medical
intervention; elective/voluntary; therapeutic
**Progesterone- hormone of pregnancy; responsible in
thickening of the endometrium.
Mifepristone- anti-progesterone medication
Misoprostol- prostaglandin medication; soften and
dilate the cervix (Decrease Progesterone and Increase
Prostaglandin= Abortion)
2. Spontaneous- naturally occurring, “miscarriage”
- Threatened: cervix is closed
- Inevitable: cervix is open
- Complete: all of products of conception are expelled
- Incomplete: some are retained
- Missed: all are retained; intrauterine fetal death
(Mifepristone and Misoprostol are given for incomplete
and missed abortion; if not effective proceed to dilation
and curettage or raspa--->monitor for vaginal bleeding)
- Recurrent Pregnancy Loss: 3 successive miscarriage
- Septic: complicated by infection--->E.coli
- General Interventions for Abortion:
1. Bed rest “as prescribed”
- strict bed rest is not required- can cause pooling of
blood in the uterine cavity
2. NPO immediately
- for possible emergency surgery
3. IV fluids
- to maintain hydration
4. Cervical Examination
- to check for cervical dilation by using vaginal
speculum
5. NO TO INTERNAL/MANUAL/VAGINAL
EXAMINATION
- can cause another injury
- use vaginal speculum
6. Monitor amount of bleeding
- save all pads (1gm-1ml)
BEST PREVENTION: Adequate prenatal care and
education
ECTOPIC PREGNANCY
- Occurs when a fertilized egg implants and grows outside
the main cavity of the uterus.
- Ovaries has a thousand of Graafian follicle that contains
ovum- Process of ovulation
- Ovum will travel along the fallopian tube (ampulla)Site of fertilization
- Fertilize ovum will travel along the fallopian tube and
will reach the uterus that will be planted to
endometrium. – Normal Pregnancy
- Ampulla: most common site of ectopic pregnancy
- Most common risk factor: Pelvic Inflammatory Disease
(PID)- inflammation of the reproductive organs;
narrowing of the fallopian tube
- Interstitial: most dangerous site of ectopic pregnancy;
connection between uterus and fallopian tube
- Pain Characteristics: unilateral lower abdominal
discomfort relating to back and shoulder
***Left or right ovary? Either, it depends what ovary
ovulate the ectopic pregnancy. (alternate ovulation
between right and left ovary)
- Diagnosis: UTZ- procedure; Sonogram- result
- Medical Management: Mifepristone, Misoprostol,
Methotrexate (anti-neoplastic; mitotic inhibitor)
- Surgical Management: laparoscopic salpingostomy- the
ectopic pregnancy is removed and the tube left to heal
on its own.
- Human Chorionic Gonadotropin (HCG) Assessment:
every 2 weeks until negative
*Which of the following instructions are you going
to give a woman who have undergone laparoscopic
salpingostomy after a diagnosis of ectopic pregnancy?
Instruct the woman to avoid pregnancy for one year or
use contraceptive to prevent pregnancy for one
year.
- Most Common Time: 5th-8th week of pregnancy
(embryonic stage; organ formation
- Pain Characteristics: sudden knife-like pain
- Manifestations: bleeding-->shock-->hypotension—
>tachycardia-->tachy (Cullen’s sign- bluish discoloration
or internal bleeding)
- MOST IMPORTANT assessment: Pulse Rate
2ND TRIMESTER BLEEDING
HYATIDIFORM MOLE/ GESTATIONAL TROPHOBLASTIC
DISEASE
- is a growing mass of tissue inside the womb (uterus)
that will not develop into a baby.
- Process of fetal development: Ovum (blastocyst)-->Zygote
(implanted in the endometrium)-->Embryo-->FetusNORMAL
- In H. mole: Only ovum will fertilized, it does not form to
zygote, embryo, and fetus
- Blastocyst: will form a green-like structure which is h.
mole; composed of thousands trophoblastic cells-->
producing HCG-->Nausea and Vomiting
- Predisposing factors: late pregnancy (more than 40
y/o)-->old ovum (unhealthy development)
- Assessment:
1. Hyperemesis Gravidarum
2. Absence of fetal heart tone and fetal outline
3. Rapid increase in uterine size
4. Dark brown vaginal discharge
Management: Mifepristone, Misoprostol,
Methotrexate, dilation and curettage, No to pregnancy
for one year, HCG assessment until negative
***More than 40 y/o- HYTERECTOMY- to prevent
Choriocarcinoma
PREMATURE CERVICAL DILATATION/ INCOMPETENT CERVIX
- opening of the cervix more than 20 weeks
- Initial Sign: SHOW (pink-tinged vaginal discharge)
- Management: Cerclage
1. Shirodkar- suturing of the cervix
2. McDonalds- tying of the cervix
- Position after:
1. Trendelenburg- to reduce the tension on the cervix
2. Modified Trendelenburg
- Removal of Sutures: 37 weeks (term)
3rd TRIMESTER BLEEDING
PLACENTA PREVIA
- a problem during pregnancy when the placenta
completely or partially covers the opening of the uterus
(cervix).
- Types of Placenta Previa:
1. Low lying placenta
2. Marginal placenta
3. Partial previa
4. Complete previa
- Common cause: can lead to scarring of the
endometrium causing placenta previa
1. Multiparity
2. Previous Cesarean Section
3. Previous dilatation and curettage (raspa)
- Definition: abnormal implantation of the placenta
- Risk factors: D&C, CS, multiparity
- Fundic Height Assessment: higher than normal
pregnancy
- MOST important sign: Painless, bright reed, vaginal
Bleeding--> immediate deliver the baby
- Confirmatory Diagnosis: UTZ
- MOST common cause if fetal loss: Prematurity
MOST common complication after delivery:
Hemorrhage
- Goals of Management:
1. Maintain Adequate Circulation
Position: left side lying position
Vaginal Examination: Speculum
IV Fluids: Ringer’s lactate solution
Monitor blood loss: save all pads; tissue passed
***BED REST
2. Increase fetal maturity- betamethasone-->
“corticosteroid”
ABRUPTIO PLACENTA
- premature separation of normally implanted placenta
- Types of Abruptio Placenta:
1. Marginal separation
2. Partial separation
3. Complete separation, concealed hemorrhage
- Primary Cause: unknown
- Predisposing Factors: anything that can cause in blood
pressure of a pregnant woman Ex. Pregnancy Induced
Hypertension, Cocaine/shabu, smoking, emotions,
trauma
- MOST important sign: Painful, dark red vaginal bleeding
- Management: No IE, left side lying position, save all
pads and tissues, and ringer’s lactate (same with
placenta previa)
- Complications: Couvelaire uterus- purplish board-like
uterus
DISSEMINATED INTRVASCULAR COAGULATION
- anything that can cause injury of the uterus
- Associated Conditions: Placenta previa, abruptio
placenta, abortion, PIH, intrauterine fetal death
- Physiology: injury or bleeding-->producing fibrin (for
blood clotting)-->increase production of fibrinolysis
(destroy the fibrin)-->paradoxical bleeding-->platelets
will rush to the site of the injury-->abnormal
distribution of platelet-->paradoxical bleedingnosebleed, gum bleeding, hematochezia, purpura,
petechiae, ecchymosis
- Management: Heparin (anticoagulant- immediate
effect)
HYPEREMESIS GRAVIDARUM
- extreme, persistent nausea and vomiting during
pregnancy
- Peak: end of the 1st trimester
- Manifestations:
1. Weight loss
2. Oliguria
3. Rapid pulse
4. Low-grade fever
5. Dehydration
- Complication: metabolic alkalosis
- PRIORITY: electrolyte and hydration
- Management:
1. Anti-emetic (plasil)
2. Vitamin B (pyridoxine)
3. Ginger/peppermint
4. Avoid spicy and fatty foods
5. Acupressure-->neiguan point
RH ISOIMMUNIZATION/SENSITIZATION
- Rh incompatibility occurs when a woman who is Rhnegative becomes pregnant with a baby with Rhpositive blood. With Rh incompatibility, the woman's
immune system reacts and creates Rh antibodies. These
antibodies help drive an immune system attack against
the baby, which the mother's body views as a foreign
object. *Mom (Rh-) & Dad (Rh+) = Baby (Rh+)
- Blood type:
1. Type A- antigen A
2. Type B- antigen B
3. Type O- no antigen A&B
4. Type AB- both antigen A&B
5. B+ & AB+: (+: Resus factor; Antigen D)
6. B- & AB- Erythroblastosis fetalis: is hemolytic anemia in the
fetus (or neonate, as erythroblastosis neonatorum)
caused by transplacental transmission of maternal
antibodies to fetal red blood cells. The disorder usually
results from incompatibility between maternal and
fetal blood groups, often Rho(D) antigens.
- Management:
1. RhoGAM (RH Immunoglobulin)
- weakens the existing antibodies and prevent the
formation of new antibodies.
- give Rhogam as soon as pregnancy is confirm; 28th
weeks; after invasive procedure (amniocentesis);
after delivery (within 72 hrs.); after abortion to
protect the second baby
2. Coomb’s test: to determine the presence of
antibodies
QUESTIONS:
1. The mother is RH+ and the baby is RH-, are you going
to give RhoGAM? ANSWER: NO
2. The mother is RH-, the baby is RH- and the
father is RH-, are you going to give RhoGAM?
ANSWER: NO
3. The mother is RH-, father is RH+, and the baby is
unknown, are you going to give RhoGAM?
ANSWER: YES
4. The mother is RH- and the baby is RH+, are you
going to give RhoGAM? ANSWER: YES
5. The mother is Coomb’s negative, and the baby is
RH- are you going to give RhoGAM? ANSWER: NO
6. The mother is Coomb’s positive, and the baby is
RH+, are you going to give RhoGAM? ANSWER: YES
7. The mother is Coomb’s negative and the baby is
RH+ are you going to give RhoGAM? ANSWER: YES
8. The mother is Coomb’s positive and the baby is
RH+, are you going to give RhoGAM? ANSWER: YES
9. The mother is RH+ and the baby is RH- are you going
to give RhoGAM? ANSWER: IMPOSSIBLE
10. The mother is RH-, the father is RH-, and the baby
is RH+, are you going to give RhoGAM? ANSWER:
YES
CONCLUSION: When the baby is RH+ always give RhoGAM
GESTATIONAL DIABETES MELLITUS
- Gestational diabetes occurs when your body can't
make enough insulin during your pregnancy. Insulin is a
hormone made by your pancreas that acts like a key to
let blood sugar into the cells in your body for use as
energy.
- Risk Factors: age, genetics, obesity
- Possible Cause: Human placental lactogen (HPL)- main
antagonist of insulin during pregnancy can cause
- decrease in insulin-->could not convert glucose to
energy so the mother will use fats to gain energy
- Lipolysis: obtain energy from fats-->byproduct:
ketones-->maternal ketoacidosis-->decrease
placental oxygenation-->fetal hypoxia; & due to
decrease insulin
- Glucose will not be transported from the blood of
the mother to the maternal cells-->maternal
hyperglycemia (cause polyuria)-->glucose will
pass through the placenta-->fetal hyperglycemia
(cause fetal polyuria)-->increase glucose in cells
Polyhydramnios (amniotic fluid more than 1,200ml)
*How are you going to characterized the infant born of
the pregnant woman with gestational diabetes
mellitus? ANSWER: Large for gestational age (LGA) or
macrosomia-->more than 4,000 grams or 4kg.
- Labor: give glucose solution and regular insulin
- 1st 24 hours after delivery: do not give insulin to
prevent hyperglycemia
- 24 hours after delivery: return to the usual dose of
insulin (no placenta – no HPL)
PREGNANCY INDUCED HYPERTENSION/GESTATIONAL
- Main Problem: Vasoconstriction- baroreceptor
(pressure receptors-->regulate the BP) but during
pregnancy baroreceptor are deactivated causing
vasoconstriction
- Predisposing factor: early and late pregnancy->adolescent (highest risk at developing PIH)
- Complication: decrease nutrient exchange; small for
gestational age (SGA) intrauterine growth retardation
- Types of PIH
1. Transient HNP- 140/90 BP; Systolic (increase
30mmHg) /Diastolic (increase 15mmHg) in 2
consecutive readings, 4 hours apart from regular BP
2. Pre-eclampsia- increase BP + Proteinuria + Edema
(face, hands) - protein responsible in oncotic
pressure (pulling pressure inside blood vessel)
Types of Pre-Eclampsia:
MILD (w/o
complication)
Blood
140/90
Pressure
Proteinuria +1,+2
SEVERE (w/
complication)
160/110
+3,+4
- Blood Test for Glucose:
1. 50-gram oral glucose test
- done in initial pre-natal visit
- no preparations needed
- after 1 hr. obtain blood specimen
- NORMAL: 140mg/dL--> 50-gram oral glucose test
- NORMAL: 70-110mg/dL-->general
2. 100-gram oral glucose tolerance test or 3hr. OGTT
- if higher than 140mg/dL
- Prepare for NPO post-midnight
- fasting blood sugar: <90mg/dL
- give 100-gram oral glucose solution
- after 1 hour: <180mg/dL
- after 2 hour: <160mg/dL
- after 3 hour: <140mg/dL
3. Glycosylated Hemoglobin or HbA1c
- irreversibly bound to glucose
- Implication: long term compliance to treatment->3
months-->lifespan of RBC
- NORMAL: less than 6%
Edema
+1,+2
+3,+4
Weight
gain
more than
1lb per week
more than
5lb per week
- Management for Gestational Diabetes Mellitus
- 1st trimester: glucose is needed for fetal brain
development; decrease dosage of insulin
- PRIORITY:
1. During seizure- safety
2. After seizure- airway
- 2nd trimester & 3rd trimester: increase HPL =
decrease insulin; need to increase dosage of insulin
to compensate the HPL
NORMAL RESULT IN PROTEINURIA: Negative and
traces of protein in urine
- Weight Gain:
1. 1st trimester- 1lb/month= 3 lbs.
2. 2nd trimester- 1lb/week= 12 lbs.
3. 3rd trimester- 1lb/week= 12 lbs.
= 27 lbs.
3. Eclampsia- increase BP + Proteinuria + Edema
(cerebral edema or edema in brain)--> seizure
- Management of PIH:
1. Positioning- Left side lying position to increase fetal
placental perfusion
2. Environment- less stimulus to prevent seizure
3. Company- same diagnosis; room across the nursing
station for close monitoring
- Medical Management: HYDRALAZINE- direct
Vasodilator
- DIET:
1. High protein diet
2. Moderate sodium (1,500 mg/day)
- If low sodium-->HYPONATREMIA-->increase
Aldosterone (to retain sodium)-->Angiotensin—
>Angiotensinogen 1--> Angiotensinogen 2
(vasocontraction)-->Renin (regulate
blood pressure)--> can cause high blood pressure
3. Dietary Approaches to Stop Hypertension (DASH)
- DRUG OF CHOICE FOR PREVENTION OF CONVULSIONS:
1. Magnesium Sulfate- both a neurologic and
respiratory depressant
- Assessment Parameters:
 RR- higher than 14bpm
 Patellar reflex/DTR must be positive
 Urine Output- more than 30ml/hour
- Normal Magnesium- 1.5-2.5mg/dL
- Therapeutic Level: 5-8mg/dL
- Toxicity Level: more than 8mg/dL
- Antidote: Calcium gluconate (Magnesium and
Calcium are irreversible)
- Long term complication: Osteoporosis
PREMATURE & PRETERM RUPTURE OF MEMBRANES
- Premature rupture of membranes (PROM) is a rupture
(breaking open) of the membranes (amniotic sac)
before labor begins.
- Usual time for ROM: early second stage of labor or
when the cervix is fully dilated
- Preterm: rupture before 37 weeks
- PROM: rupture before onset of labor
- Initial Nursing Action:
1. Rule out cord compression/cord prolapse
- cord compression-->decrease fetal heart rate->variable decelerations
- Normal Fetal Heart Rate: 120-160bpm
- Therapeutic Management:
1. Betamethasone- to increase fetal lung maturity
2. Ritodrine Hydrochloride (Yutopar)- to relax the
uterus
- Complication:
1. Potter-like syndrome
*There is no such thing as dry labor
2. Chorioamnionitis- In this condition, bacteria infects the chorion and
amnion (the membranes that surround the fetus)
and the amniotic fluid (in which the fetus floats).
This can lead to infections in both the mother and
fetus.
- Cause: PROM
- Manifestations:
1. Foul smelling amniotic fluid
2. Low grade fever
3. Leakage of amniotic fluid
4. Tachycardia
5. Elevated WBC
6. Uterine tenderness
- Nursing Intervention:
1. Increase oral fluid intake
2. Antibiotics- Ampicillin or Gentamycin