Pregnancy review

1
Pregnancyreview

• N. Petrenko, MD, PhD

2
Signs of pregnancy

• Presumptive (generally subjective)
• Probable (objective)
• Positive (diagnostic)

3
Presumptive symptoms of pregnancy (felt by
woman)

• Cessation of menses
• Nausea with or without vomiting
• Morning sickness
• Frequent urination
• Fatigue
• Breast tenderness, fullness, tingling
• Maternal perception of fetal movement
  (Quickening) 18-20w, 16 w

4
Presumptive signs of pregnancy

• Increased skin pigmentation chloasma, linea
  nigra
• Appearance of striae on abdomen and breasts

5
Probable signs of pregnancy (observed by
examiner)

• Changes in the size, shape, and consistency of
  the uterus (Hegar sign-softening of the cervix )
• Enlargement of the abdomen
• Changes in the cervix (Goodell sign-softening of
  the cervix )

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Probable signs of pregnancy (observed by
examiner)

• Bluish or purplish coloration of the vaginal
  mucosa and cervix (Chadwicks sign-a dark blue to
  purplish-red congested appearance of the vaginal
  mucosa )
• Palpation of Braxton-Hicks contractions
• Outlining the fetus manually
• Endocrine tests of pregnancy

7
Positive signs of pregnancy(noted by examiner,
confirm pregnancy)

• Identification of the fetal heart beat separately
  and distinctly from that of the mother (10-12 w)
• Perception of fetal movements by the examiner
  (18-20 w)
• Visualization of pregnancy on ultrasound
• Fetal recognition on X-ray

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Gravida and Para

• Gravida means a woman who has been, or currently
  is, pregnant
• Para means a woman who has given birth
• Nulligravida never been pregnant
• Primigravida pregnant for the first time
• Primipara has delivered once
• Multipara has delivered more than once

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G T P A L

• G GRAVIDA (how many pregnancies)
• T TERM (how many term deliveries)
• P PRETERM (how many preterm deliveries)
• A ABORTIONS (how many abortions, spontaneous
  or induced)
• L LIVING how many children currently living

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Term, Preterm, Abortion

• TERM means delivery occurring in weeks 38-42
• PRETERM means delivery occurring in weeks 20-37
• ABORTION means delivery occurring before 20 weeks
• POSTTERM means delivery occurring after week 42

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• Duration 280 days 40 weeks 10 lunar months 9
  calendar month
• 1st Trimester 1-13 weeks
• Accepting reality of pregnancy
• 2nd Trimester 14-26 weeks
• Resolving feelings about her own mother defining
  herself as a mother
• 3rd Trimester 27-40 weeks
• Active preparation for childbirth and baby

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Assessment of Gestational Age

• By LMP
• By physical exam
• By ultrasound

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Nageles Rule

• Subtract 3 months from that date then add 7 days
• 1st day of LNMP (last normal menstrual period)
• Example LNMP September 10, 2006
• Expected Due Date (EDD) June 17, 2007

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Uterine Sizing

• 6 weeks globular with softening of the isthmus,
  size of a tangerine
• 8 weeks globular, size of a baseball
• 10 weeks globular with irregularity around one
  cornua (Piskaceks sign), size of a softball
• 12 weeks globular, size of a grapefruit

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Uterine Sizing

• Uterine enlargement
• 12 weeks At Symphysis
• 16 weeks Midway between symphysis and
  umbilicus
• 20 weeks At the umbilicus
• 36 weeks - Near xyphoid process

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Uterine Sizing
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Accuracy of Dating by Ultrasound
Gestational Age weeks) Ultrasound Measurements Range of Accuracy
lt 8 Sac size 10 days
8-12 CRL 7 days
12-15 CRL, BPD 14 days
15-20 BPD, HC, FL, AC 10 days
20-28 BPD, HC, FL, AC 2 weeks
gt 28 BPD, HC, FL, AC 3 weeks
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Nausea with or without Vomiting

• Starts at 4-6 weeks, peaks at 8-12 weeks,
  resolves by 14-16 weeks
• Causes unknown may be rapidly increasing and
  high levels of estrogen, hCG, thyroxine may have
  a psychological component
• Rule out hyperemesis gravidarum

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Nausea and vomiting in early
pregnancy

• Most cases of nausea and vomiting in pregnancy
  will resolve spontaneously within 16 to 20 weeks
  of gestation.
• Nausea and vomiting are not usually associated
  with a poor pregnancy outcome.

A
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Nausea and vomiting in early pregnancy

• If a woman requests or would like to consider
  treatment, the following interventions appear to
  be effective in reducing symptoms
• non-pharmacological
• ginger
• P6 acupressure
• pharmacological
• antihistamines.

A
21
Ptyalism

• Excessive salivation accompanied by nausea and
  inability to swallow saliva
• Cause unknown may be related to increased
  acidity in the mouth

22
Fatigue

• Causes unknown may be related to gradual
  increase in BMR
• Rule out anemia, thyroid disease

23
Backache

• Women should be informed that exercising in
  water, massage therapy might help to ease
  backache during pregnancy.

A
24
Upper Backache

• Cause increase in size and weight of the breasts
• Relief well-fitting, supportive bra

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Low Backache

• Cause weight of the enlarging uterus causing
  exaggerated lumbar lordosis
• Rule out pyelonephritis (CVAT)

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Leukorrhea

• Definition a profuse, thin or thick white
  vaginal discharge consisting of white blood
  cells, vaginal epithelial cells, and bacilli
  acidic due to conversion of an increased amount
  of glycogen in vaginal epithelial cells into
  lactic acid by Doderleins bacilli
• Rule out vaginitis, STI, ruptured membranes

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Urinary Frequency

• 1st trimester increased weight, softening of the
  isthmus, anteflexion of the uterus
• 3rd trimester pressure of the presenting part
• Rule out UTI

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Heartburn

• Relaxation of the cardiac sphincter due to
  progesterone
• Decreased GI motility due to smooth muscle
  relaxation (progesterone)
• Lack of functional room for the stomach because
  of its displacement and compression by the
  enlarging uterus
• Rule out GI disease

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Heartburn

• Women who present with symptoms of heartburn in
  pregnancy should be offered information regarding
  lifestyle and diet modification.
• Antacids may be offered to women whose heartburn
  remains troublesome

GPP
A
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Constipation

• Decreased peristalsis due to relaxation of the
  smooth muscle of the large bowel under the
  influence of progesterone
• Displacement of the bowel by the enlarging uterus
• Administration of iron supplements

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Constipation

• Women who present with constipation in pregnancy
  should be offered information regarding diet
  modification, such as bran or wheat fibre
  supplementation.

A
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Hemorrhoids

• Relaxation of vein walls and smooth muscle of
  large bowel under influence of progesterone
• Enlarging uterus causes increased pressure,
  impeding circulation and causing congestion in
  pelvic veins
• Constipation

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Hemorrhoids

• Women should be offered information concerning
  diet modification.
• If clinical symptoms remain troublesome, standard
  hemorrhoids creams should be considered.

GPP
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Leg Cramps

• Cause unknown. ? inadequate calcium, ?
  Imbalance in calcium-phosphorus ratio
• Relief straighten the leg and dorsiflex the foot

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Dependent Edema

• Cause impaired venous circulation and increased
  venous pressure in the lower extremities
• Rule out preeclampsia

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Varicosities

• Impaired venous circulation and increased venous
  pressure in lower extremities
• Relaxation of vein walls and surrounding smooth
  muscle under the influence of progesterone
• Increased blood volume
• Familial predisposition

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Varicose veins

• Varicose veins are a common symptom of pregnancy
  that will not cause harm and
• Compression stockings can improve the symptoms
  but will not prevent varicose veins from emerging.

A
38
Insomnia

• Discomfort of the enlarged uterus
• Any of the common discomforts of pregnancy
• Fetal activity
• Psychological causes

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Round Ligament Pain

• Round ligaments attach on either side of the
  uterus just below and in front of insertion of
  fallopian tubes, cross the broad ligament in a
  fold of peritoneum, pass through the inguinal
  canal, insert in the anterior portion of the
  labia majora
• When stretched, they hurt!

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Supine Hypotensive Syndrome
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Screening for fetal anomalies
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Screening for structural
anomalies

• Pregnant women should be offered an ultrasound
  scan to screen for
  structural anomalies, ideally between 18 and 20
  weeks gestation, by an appropriately trained
  sonographer and with equipment of an appropriate
  standard.

A
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Screening for Downs syndrome

• Pregnant women should be offered screening for
  Downs syndrome with a test which provides the
  current standard of a detection rate above 60
  and a false-positive rate of less than 5.

B
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• The following tests meet this standard
• from 11 to 14 weeks
• nuchal translucency (NT)
• the combined test (NT, hCG and PAPP-A)
• from 14 to 20 weeks
• the triple test (hCG, AFP and uE3)
• the quadruple test (hCG, AFP, uE3, inhibin A)

B
45
Early pregnancy bleeding
Spontaneous abortionIncompetent cervixEctopic
pregnancyHydatiform mole
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Abortion
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Abortion miscarriage

• End of pregnancy before 20 weeks
• Fetal weight less than 500 mg
• Result of natural cause

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miscarriage

• 10-15 of recognize pregnancy end in miscarriage
• Early (till 12 weeks)
• before 8 weeks
• 50 - result from chromosomal abnormalities
• endocrine imbalance (luteal phase defects,
  insulin-dependent diabetes mellitus with high
  blood glucose levels in the first trimester),
• immunologic factors (antiphospholipid
  antibodies),
• Infections (bacteriuria and Chlamydia
  trachomatis),
• Systemic disorders (lupus erythematosus),
• genetic factors

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miscarriage

• Late 12 - 20 weeks
• Result from maternal causes
• advancing maternal age and parity,
• chronic infections,
• premature dilation of the cervix and other
  anomalies of the reproductive tract,
• chronic debilitating diseases,
• nutrition, and recreational drug use

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miscarriage

• Little can be done to avoid genetically caused
  pregnancy loss, but correction of maternal
  disorders, immunization against infectious
  diseases, adequate early prenatal care, and
  treatment of pregnancy complications can do much
  to prevent miscarriage.

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miscarriage

• Types of miscarriage
• threatened,
• inevitable,
• incomplete,
• complete,
• missed.

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miscarriage

• threatened

incomplete

• inevitable

• missed.

complete
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miscarriage

• Clinical manifestation
• uterine bleeding,
• uterine contractions,
• uterine pain are ominous
• before the sixth week - a heavy menstrual flow.
• between the sixth and twelfth weeks - moderate
  discomfort and blood loss.
• After the twelfth week more severe pain,
  similar to that of labor, because the fetus must
• be expelled.

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miscarriage

• threatened miscarriage - spotting of blood but
  with the cervical os closed, Mild uterine
  cramping
• Inevitable and incomplete - a moderate to heavy
  amount of bleeding with an open cervical os,
  Tissue may be present with the bleeding, Mild to
  severe uterine cramping
• An inevitable miscarriage is often accompanied
  by rupture of membranes (ROM) and cervical
  dilation passage of the products of conception
  is a certainty.
• An incomplete miscarriage involves the expulsion
  of the fetus with retention of the placenta

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miscarriage

• complete miscarriage all fetal tissue is passed,
  the cervix is closed,
• slight bleeding, mild uterine cramping
• missed miscarriage - fetus has died but the
  products of conception are retained in utero for
  several weeks.
• It may be diagnosed by ultrasonic examination
  after the uterus stops increasing in size or even
  decreases in size.
• no bleeding or cramping, and the cervical os
  remains closed.
• Recurrent early (habitual) miscarriage is the
  loss of three or more previable pregnancies.
  Women having three or more miscarriages are at
  increased risk for preterm birth, placenta
  previa, and fetal anomalies in subsequent
  pregnancies

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miscarriage

• Assessment
• Complain (pain, bleeding)
• LMP
• Vital sign (t, Ps, BP)
• Previous pregnancy
• hCG
• US
• CBC (Hb, Ht, WBC, ESR)
• Blood type Rh

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miscarriage

• Management
• Threatened bed rest supportive therapy
• inevitable, incomplete, complete, missed DC

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miscarriage

• Postoperative care
• Oxiticin 10-20 U in 1000 ml of fluid
• Antibiotics
• Analgetics
• Transfusion

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miscarriage

• Discharge
• Rest
• Iron supplementation
• Sexual behavior
• Emergency sign
• Contraception
• http//www.youtube.com/watch?v9LJESmC5-wA

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Incompetent cervix
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Incompetent cervix

• passive and painless dilation of the cervix
  during the second trimester.
• Etiology.
• a history of previous cervical lacerations during
  childbirth,
• excessive cervical dilation for curettage or
  biopsy,
• ingestion of diethylstilbestrol by the woman's
  mother while being pregnant with the woman.
• a congenitally short cervix or cervical or
  uterine anomalies.
• Clinical diagnosis based on
• history of short labors and recurring loss of
  pregnancy at progressively earlier gestational
  ages are characteristics of reduced cervical
  competence.
• Ultrasound cervix (less than 20 mm in length) is
  indicative of reduced cervical competence.
• Often, but not always, the short cervix is
  accompanied by cervical fanneling, or effacement
  of the internal cervical os

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Incompetent cervix
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Incompetent cervix

• Conservative management
• bed rest, hydration, and tocolysis (inhibition of
  uterine contractions).
• A cervical cerclage may be placed around the
  cervix beneath the mucosa to constrict the
  internal os of the cervix
• Prophylactic cerclage is placed at 10 to 14 weeks
  of gestation, after which the woman is told to
  refrain from intercourse, prolonged (more than 90
  minutes) standing, and heavy lifting. She is
  followed during the course of her pregnancy with
  ultrasound scans to assess for cervical
  shortening and funneling.
• The cerclage is electively removed (usually an
  office or a clinic procedure) when the woman
  reaches 37 weeks of gestation, or it may be left
  in place and a cesarean birth performed. If
  removed, cerclage placement must be repeated with
  each successive pregnancy.
• Risks r/t of the procedure
• premature rupture of membranes,
• preterm labor,
• chorioamnionitis.
• Because of these risks, and because bed rest and
  tocolytic therapy can be used to prolong the
  pregnancy cerclage is rarely performed after 25
  weeks of gestation

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Ectopic pregnancy
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Ectopic pregnancy

• Implantation of the fertilized ovum outside the
  uterine cavity
• uterine (fallopian) tube 95, with most located
  on the ampullar
• abdominal cavity (3 to 4),
• ovary (1),
• and cervix (1).

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Ectopic pregnancy
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Ectopic pregnancy

• Clinical manifestation assessment
• missed period,
• Adnexal fullness, and tenderness
• The tenderness can progress from a dull pain to a
  colicky pain when the tube stretches. Pain may be
  unilateral, bilateral, or diffuse over the
  abdomen.
• Abnormal vaginal bleeding that is dark red or
  brown occurs in 50 to 80 of women.
• If the ectopic pregnancy ruptures, pain
  increases. This pain may be generalized,
  unilateral, or acute deep lower quadrant pam
  caused by blood irritating the peritoneum.
  Referred shoulder pain can occur as a result of
  diaphragmatic irritation caused by blood in the
  peritoneal cavity.
• The woman may exhibit signs of shock related to
  the amount of bleeding in the abdominal cavity
  and not necessarily related to obvious vaginal
  bleeding.
• An ecchymotic blueness around the umbilicus
  (Cullen sign), indicating hematoperitoneum, may
  develop in a neglected ruptured intraabdominal
  ectopic pregnancy.
• hCG, US, CBC
• Ps, BP

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Ectopic pregnancy

• Differential diagnosis
• miscarriage, ruptured corpus luteum cyst,
  appendicitis, salpingitis, ovarian cysts, torsion
  of the ovary, and urinary tract infection

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Ectopic pregnancy

• Management
• Surgery (tubeectomy, remove ectopic pregnancy)
• Methotrexate
• Antibiotics
• Transfusion
• Contraception
• Restoring of fertility

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Ectopic pregnancy

• Nursing Interventions with Ectopic Pregnancy
• Prepare patient for surgery.
• Institute measures to control bleeding/treat
  shock if hemorrhage severe and continue to
  monitor postoperatively
• May be given methotrexate instead of surgery
• Allow patient to express feelings about loss of
  pregnancy and concerns about future pregnancies.

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Hydatidiform mole
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Hydatidiform mole

• is a gestational trophoblastic disease. There are
  two distinct types of hydatidiform moles
  complete (or classic) mole and partial mole.
• The etiology is
• unknown,
• may be
• an ovular defect or a nutritional deficiency.
• Using clomiphene (Clomid)
• early teens or older than 40 years of age.
• Chromosomal abnomalities
• Types. The complete mole results from
  fertilization of an egg whose nucleus has been
  lost or inactivated nucleus.
• The mole resembles a bunch of white grapes .
• The fluid-filled vesicles grow rapidly, causing
  the uterus to be Rupture of uterus

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Hydatidiform mole

• Clinical manifestations
• early stages same as normal pregnancy.
• Later, vaginal bleeding (dark brown (resembling
  prune juice) or bright red and either scant or
  profuse. It may continue for only a few days or
  intermittently for weeks.
• Early in pregnancy the uterus in approximately
  half of affected women is significantly larger
  than expected from menstrual dates.
• The percentage of women with an excessively
  enlarged uterus increases as length of time since
  LMP increases. Approximately 25 of affected
  women have a uterus smaller than would be
  expected from menstrual dates.
• Anemia from blood loss, excessive nausea and
  vomiting (hyperemesis gravidarum), and abdominal
  cramps caused by uterine distention are
  relatively common findings.
• Preeclampsia occurs in approximately 15 of
  cases, usually between 9 and 12 weeks of
  gestation, but any symptoms of PIH before 20
  weeks of gestation may suggest hydatidiform mole.
  
• Hyperthyroidism and pulmonary embolization of
  trophoblastic elements occur infrequently but are
  serious complications of hydatidiform mole.
  Partial moles cause few of these symptoms and may
  be mistaken for an incomplete or missed
  miscarriage.

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Hydatidiform mole

• Management
• US (snowstorm pattern)
• hCG
• Uterine height
• DC
• Induced labour
• Contraception
• hCG level control 1 year

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Late pregnancy bleeding
Placenta previaAbruptio placenta
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Placenta previa
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Placenta previa

• the placenta is implanted in the lower uterine
  segment near or over the internal cervical os.
• Total or complete placenta previa - if the
  internal os is entirely covered by the placenta
  when the cervix is fully dilated.
• Partial placenta previa implies incomplete
  coverage of the internal os.
• Marginal placenta previa indicates that only an
  edge of the placenta extends to the internal os
  but may extend onto the os during dilation of the
  cervix during labor.
• The term low-lying placenta is used when the
  placenta is implanted in the lower uterine
  segment but does not reach the os.

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Placenta Praevia
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Placenta Praevia

• Etiology / risk factors
• previous placenta previa,
• previous cesarean birth,
• induced abortion, possibly related to endometrial
  scarring
• multiple gestation (because of the larger
  placental area),
• advanced maternal age (older than 35 years),
• African or Asian ethnicity,
• smoking, and cocaine us

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Placenta Praevia

• painless vaginal bleeding
• vaginal bleeding associated with uterine
  activity.
• after 24 weeks of gestation.
• This bleeding is associated with the stretching
  and thinning of the lower uterine segment that
  occurs during the third trimester.
• It is bright red in color.
• Vital signs may be normal, even with heavyblood
  loss, because a pregnant woman can lose up to 40
  of blood volume without showing signs of shock.
• Clinical presentation and decreasing urinary
  output may be better indicators of acute blood
  loss than vital signs alone.
• The fetal heart rate is reassuring unless there
  is a major detachment of the placenta.
• Abdominal examination usually reveals a soft,
  relaxed, nontender uterus with normal tone. If
  the fetus is lying longitudinally, the fundal
  height is usually greater than expected for
  gestational age because the low placenta hinders
  descent of the presenting fetal part. Leopold's
  maneuvers may reveal a fetus in an oblique or
  breech position or lying transverse because of
  the abnormal site of placental implantation.

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Placenta Praevia

• Related risk mother
• premature ROM,
• preterm birth,
• surgery-related trauma to structures adjacent to
  the uterus, anesthesia complications, blood
  transfusion reactions, overinfusion of fluids,
  abnormal placental attachments to the uterine
  wall (e.g., placenta accreta), postpartum
  hemorrhage, thrombophlebitis, anemia, and
  infection.
• Fetus
• death is caused by preterm birth.
• hypoxia in utero
• Congenital anomalies.
• IUGR

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Placenta Previa

• Nursing Management Assess the amount and
  character of bleeding
• Monitor Fetal Heart Tones (FHT) and activity
  monitoring (kick count)
• Bedrest and no sexual activity
• Report signs of preterm labor
• Conservative management of pregnancy

84
Placenta Praevia

• Management based on
• Gestational age
• Amount of bleeding
• Fetal condition
• CS

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Management

• Hospitalize if actively bleeding if not minimal
  activity at home is OK---pelvic rest
• Check Hgb Hct routinely
• Transfusion may be necessary to maintain maternal
  and fetal stability (goal is to keep maternal Hct
  between 30-35)
• If bleeding is severe, delivery is indicated
  regardless of gestational age or fetal lung
  maturity
• Birth by cesarean if cervix is gt30 covered or if
  bleeding is excessive otherwise, attempt at
  vaginal delivery is indicated (double set-up)

86
Placenta Previa

• Nursing Care of the Patient Maintain IV access
• O2 PRN
• Continuous fetal monitoring if active bleeding
• Hourly pad count noting color and amount
• Digital cervical exams are contraindicated!!
• Evaluation of cervical dilatation is obtained
  visually with a speculum

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Placenta abruptio
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Placenta abruptio

• Risk factors
• Multiparity,
• PIH,
• Polyhydramnios,
• Trauma,
• Smoking,
• Malnutrition,
• Previous abruption,
• Idiopathic

89
Placenta abruptio

• Grades 1 (mild), vaginal bleeding with uterine
  tendeness, no distress, 10-20
• 2 (moderate), uterine tendeness and tetany with
  or with out external bleeding, fetal distress,
  20-50
• 3 (severe) severe uterine tetany, schock, fetal
  is dead, coagulopathy, greater than 50

90
Placenta abruptio

• Clinical symptoms
• Vaginal bleeding
• Abdominal pain
• Uterine tenderness
• Uterine contraction
• Couvelaire uterus

91
Placenta abruptio

• Outcomes
• Maternal mortality
• Renal failure
• pituitary necrosis
• Rh negative woman with Rh positive fetus can
  become sensitized if fetal-to-maternal hemorrhage
  
• fetal hypoxia,
• preterm birth,
• Risk for neurologic defects
• Perinatal mortality

92
Placental Abruption

• Expectant management- if small bleed, and
  maternal and fetal condition satisfactory.
  Monitor well-being and induce labour gt37weeks.
  Anti-D if indicated.
• Active Management- if severe abruption.
  Resuscitate and correct shock DIC. Perform ARM
  and deliver fetus asap. IV Oxytocics to prevent
  PPH. Anti-D as above.

93
Abruptio Placenta

• Complete of partial premature separation of the
  placenta from uterus
• Precipitating Factors
• Blunt trauma to abdomen
• Drug abuse, especially cocaine
• Hypertension
• Premature rupture of membrane
• Smoking

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Abruptio Placenta (continued)

• Medical emergency because of the risk of maternal
  hemorrhage and fetal demise
• May develop Disseminated Intravascular
  Coagulation (DIC)
• Bleeding may be obvious or concealed
• Concealed bleeding may lead to uterine tenderness
  and abdominal pain
• Monitoring may reveal elevated uterine resting
  tone and a rising FHT

95
Nursing Management of Abruptio Placenta

• Assess amount and character of bleeding
• Assess abdominal/uterine tenderness, contractions
  and resting
• Monitor for shock
• Assess FHT and activity
• Measure fundal height since concealed bleeding
  may be present
• Provide emotional support
• Prepare for possible C-Section

96
Clinical Manifestations

• Vaginal bleeding (external)
• May not be present in concealed abruptions
  (occult bleeding)
• Abdominal pain (sudden onset/often severe)
• Uterine tenderness
• Uterine CTXs/hypertonus/hyperactivity
• Hemorrhagic shock
• Ischemic necrosis of distant organs
• Fetal distress or death

97
Management

• Hospitalize
• Large-bore (16-guage) IV access (2 preferable)
• Assess Bleeding
• Hgb Hct monitoring
• Coagulation factor monitoring (fibrinogen,
  platelets, fibrin split products, PT, PTT)
• Transfuse if necessary
• Frequent VS
• O2 if necessary
• Continuous Fetal Monitoring
• Rhogam if necessary
• Rhogam covers ?30cc fetal whole blood

98
Managementcont.

• Identify appropriate timing of delivery
• Decision is based on condition of mother and
  fetus, gestational age of fetus, dilation of
  cervix
• Possibly use betamethasone to accelerate fetal
  lung maturity in preparation for delivery
• Type of delivery
• Vaginal delivery may be attempted if abruption is
  moderate (stable mother and no signs of fetal
  distress)
• Cesarean section if fetal distress is present

99
Hypertension in Pregnancy Classification

• Chronic hypertension
• Pregnancy-induced hypertension
• Gestational hypertension
• Preeclampsia
• Eclampsia
• Preeclampsia superimposed on chronic hypertension
• Standard definitions are not consistently used by
  health care providers

100
Chronic hypertension

• Present before the pregnancy or diagnosed before
  week 20 of gestation
• or continuing beyond 42 days postpartum

101
Gestational hypertension

• Onset of hypertension without proteinuria after
  the 20th week of pregnancy
• Systolic BP gt 140 mm Hg
• Diastolic BP gt90 mm Hg
• Diagnosis of onset during pregnancy based on two
  measurements that meet criteria for gestational
  BP elevation within a 1-week period

102
Preeclampsia

• Pregnancy-specific syndrome
• Hypertension develops after 20 weeks of gestation
  in previously normotensive woman
• Proteinuria may be present
• Multisystem, vasospastic disease process
  characterized by hemoconcentration, hypertension,
  and proteinuria
• Disease of reduced organ perfusion with presence
  of hypertension and proteinuria
• Complicates 3 to 7 of all pregnancies

103
Proteinuria

• is a concentration of 0.1 g/L (1 to 2 on
  dipstick measurement) or more in at least two
  random urine specimens collected at least 6 hours
  apart.
• In a 24-hour specimen, proteinuria is a
  concentration of 0.3 g/L per 24 hours

104
Edema

• Pathologic edema is clinically evident,
  generalized accumulation of fluid of the face,
  hands, or abdomen that is not responsive to 12
  hours of bed rest. It may also be manifested as a
  rapid weight gain of more than 2 kg in 1 week.
  The presence of edema is no longer considered
  necessary for the diagnosis of preeclampsia

105
Preeclampsia
MILD PREECLAMPSIA SEVERE PREECLAMPSIA SEVERE PREECLAMPSIA
MATERNAL EFFECTS MATERNAL EFFECTS MATERNAL EFFECTS MATERNAL EFFECTS
Blood pressure BP reading of 140/90 mm Hg x2, 4-6 hr apart BP reading of 140/90 mm Hg x2, 4-6 hr apart Rise to gt160/110 mm Hg on two separate occasions 4-6 hr apart with pregnant woman on bed rest
Mean arterial pressure (MAP) gt105 mm Hg gt105 mm Hg gt105 mm Hg
Weight gain Weight gain of more than 0.5 kg/wk during the second and third trimesters or sudden weight gain of 2 kg/wk at any time Weight gain of more than 0.5 kg/wk during the second and third trimesters or sudden weight gain of 2 kg/wk at any time Same as mild preeclampsia
Proteinuria Qualitative dipstick Ouantitative 24 hr analysis Proteinuria of 0.3 g/L in a 24 hr specimen or gt0.1 g/L in a random day-time specimen on two or more occasions 6 hr apart (because protein loss is variable) with dipstick, values varying from 1 to 2 Proteinuria of 0.3 g/L in a 24 hr specimen or gt0.1 g/L in a random day-time specimen on two or more occasions 6 hr apart (because protein loss is variable) with dipstick, values varying from 1 to 2 Proteinuria of gt0.5 g/L in 24 hr or gt4 protein on dipstick
Edema Dependent edema, some puffiness of eyes, face, fingers pulmonary edema absent Dependent edema, some puffiness of eyes, face, fingers pulmonary edema absent Generalized edema, noticeable puffiness eyes, face, fingers pulmonary edema possibly present
Reflexes May be normal May be normal Hyperreflexia 3, possible ankle clonus
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Preeclampsia
MILD PREECLAMPSIA SEVERE PREECLAMPSIA SEVERE PREECLAMPSIA
MATERNAL EFFECTS MATERNAL EFFECTS MATERNAL EFFECTS MATERNAL EFFECTS
Reflexes May be normal May be normal Hyperreflexia 3, possible ankle clonus
Urine output Output matching intake, 30 ml/hr or lt650 ml/24 hr Output matching intake, 30 ml/hr or lt650 ml/24 hr lt20 ml/hr or lt400 ml to 500 ml/24 hr
Headache Absent/transient Absent/transient Severe
Visual problems Absent Absent Blurred, photophobia, blind spots on funduscopy
Irritability/changes in affect Transient Transient Severe
Epigastric pain Absent Absent Present
Serum creatinine Normal Normal Elevated
Thrombocytopenia Absent Absent Present
AST elevation Normal or minimal Normal or minimal Marked
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Preeclampsia
MILD PREECLAMPSIA SEVERE PREECLAMPSIA SEVERE PREECLAMPSIA
FETAL EFFECTS FETAL EFFECTS FETAL EFFECTS FETAL EFFECTS
Placental perfusion Reduced Reduced Decreased perfusion expressing as IUGR in fetus FHR late decelerations
Premature placental aging Not apparent Not apparent At birth placenta appearing smaller than normal for duration of pregnancy, premature aging apparent with numerous areas of broken syncytia, ischemic necroses (white infarcts) numerous, intervillous fibrin deposition (red infarcts)
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HELLP syndrome

• is a laboratory diagnosis for a variant of severe
  preeclampsia characterized by hemolysis (H),
  elevated liver enzymes (EL), and low platelets
  (LP)

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Eclampsia

• Seizure activity or coma in woman diagnosed with
  preeclampsia
• No history of previous seizure disorder
• Presentation varies
• One third in labor
• One third during delivery
• One third within 72 hours postpartum

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Chronic hypertension with superimposed
preeclampsia

• Women with chronic hypertension may acquire
  preeclampsia or eclampsia
• Increases morbidity for mother and fetus

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Etiology

• Unique to human pregnancies
• Signs and symptoms develop only during pregnancy
  and disappear after birth of the fetus and
  passage of placenta
• The cause is unknown
• Associated high risk factors
• Primigravidity
• Multifetal pregnancy
• Preexisting medical condition (Obesity, Chronic
  renal disease, Chronic hypertension, Diabetes)
• Preeclampsia in a prior pregnancy or Family
  history of PIH
• Maternal age lt19 years gt40 years
• Rh incompatibility

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Etiology

• Current theories
• Increase vasoconstrictor tone
• Abnormal prostaglandin action
• Endotelian cell activation
• Immunologic factor
• Genetic disposition
• diet

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Pathophysiology

• May be caused by disruptions in placental
  perfusion and endothelial cell dysfunction
• Main pathogenic factor is not an increase in BP,
  but poor perfusion resulting from vasospasm
• Arteriolar vasospasm diminishes diameter of blood
  vessels, which impedes blood flow to all organs
  and increases BP
• Significant decreases in placental, kidney,
  liver, and brain function

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Pathophysiology

• reflects alterations in the normal adaptations of
  pregnancy.
• Normal physiologic adaptations to pregnancy
  include increased blood plasma volume,
  vasodilatation, decreased systemic vascular
  resistance, elevated cardiac output, and
  decreased colloid osmotic pressure
• Pathologic changes in the endothelial cells of
  the glomeruli (glomeruloendotheliosis) are
  uniquely characteristic of preeclampsia,
  particularly in nulliparous women (85).
• The main pathogenic factor is not an increase in
  blood pressure but poor perfusion as a result of
  vasospasm. Arteriolar vasospasm diminishes the
  diameter of blood vessels, which impedes blood
  flow to all organs and raises blood pressure
• Function in organs such as the placenta,
  kidneys, liver, and brain is depressed by as much
  as 40 to 60

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HELLP syndrome

• Laboratory diagnostic variant (not clinical)
  variant of severe preeclampsia involves hepatic
  dysfunction, characterized by
• Hemolysis (H)
• Elevated liver enzymes (EL)
• Low platelets (LP)

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HELLP syndrome

• epigastric or right upper quadrant abdominal pain
  (possibly related to hepatic ischemia) 65
• nausea and vomiting 50

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Severe preeclampsia and HELLP-syndromeMagnesium
sulfate

• As prophylaxis against convulsion
• I/V as a secondary infusion to the main
  intravenous (IV) line by volumetric infusion pump
  
• An initial loading dose of 4 to 6 g of MgSO4 per
  protocol or physician's order is infused over 20
  to 30 minutes. This dose is followed by a
  maintenance dose of magnesium sulfate that is
  diluted in an IV solution per physician's order
  (e.g., 40 g of magnesium sulfate in 1000 ml of
  lactated Ringer's solution) and administered by
  infusion pump at 1 to 3 g/hr.
• This dose should maintain a therapeutic serum Mg
  level of 4 to 8 g/dl.
• Serum magnesium levels are obtained after the
  patient has received magnesium sulfate for 4 to 6
  hours.

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Severe preeclampsia and HELLP-syndrome Magnesium
sulfate

• Intramuscular (IM) MgSO4 is seldom used because
  absorption rate cannot be controlled, injections
  are painful, and tissue necrosis may occur.
• However, the IM route may be used with some women
  who are being transported to a tertiary care
  center.
• The IM dose is 4 to 5 g given in each buttock, a
  total of 10 g (with 1 procaine possibly being
  added to the solution to reduce injection pain),
  and can be repeated at 4-hour intervals.
• Z-track technique should be used for the deep IM
  injection, followed by gentle massage at the site.

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Severe preeclampsia and HELLP-syndrome Magnesium
sulfate

• Magnesium sulfate interferes with the release of
  acetylcholine at the synapses,
• decreasing neuromuscular irritability,
• depressing cardiac conduction,
• and decreasing CNS (central nervous system)
  irritability.
• Because magnesium circulates free and unbound to
  protein and is excreted in the urine, accurate
  recordings of maternal urine output must be
  obtained.
• Diuresis is an excellent prognostic sign
  however, if renal function declines, all of the
  magnesium sulfate will not be excreted and can
  cause magnesium toxicity.
• Serum magnesium levels are obtained on the basis
  of the woman's response and if any signs of
  toxicity are present.
• Early symptoms of toxicity include nausea, a
  feeling of warmth, flushing, muscle weakness,
  decreased reflexes, and slurred speech.

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Severe preeclampsia and HELLP-syndrome Magnesium
sulfate

• Deep tendon reflexes
• Urine output
• Respiration rate
• Consciousness
• If magnesium toxicity is suspected, the infusion
  should be discontinued immediately.
• Calcium gluconate, the antidote for magnesium
  sulfate, may also be ordered (10 ml of a 10
  solution, or 1 g) and given by slow IV push
  (usually by the physician) over at least 3
  minutes to avoid undesirable reactions such as
  arrhythmias, bradycardia, and ventricular
  fibrillation.
• Because magnesium sulfate is also a tocolytic
  agent, its use may increase the duration of
  labor. A preeclamptic woman receiving magnesium
  sulfate may need augmentation with oxytocin
  during labor. The amount of oxytocin needed to
  stimulate labor may be more than that needed for
  a woman who is not on magnesium sulfate.

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Severe preeclampsia and HELLP-syndrome
antihypertensive agent

• Starts if diastolic pressure is higher than 100
  to 110 mm Hg
• Order to decrease the diastolic blood pressure to
  90 to 100 mm Hg
• Prevent left ventricular failure and cerebral
  hemorrhage.
• decrease the arterial pressure too much or too
  rapidly
• agent of choice is
• hydralazine IV
• labetalol hydrochloride IV
• methyldopa orally
• Nifedipine orally

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Diabetes Mellitus Pathogenesis

• Group of metabolic diseases characterized by
  hyperglycemia resulting from defects in insulin
  secretion, insulin action, or both
• Insulin, produced by the beta cells in the islets
  of Langerhans in the pancreas, regulates blood
  glucose levels by enabling glucose to enter
  adipose and muscle cells, where it is used for
  energy.
• When insulin is insufficient or ineffective in
  promoting glucose uptake by the muscle and
  adipose cells, glucose accumulates in the
  bloodstream, and hyperglycemia results.
• Hyperglycemia causes hyperosmolarity of the
  blood, which attracts intracellular fluid into
  the vascular system, resulting in cellular
  dehydration and expanded blood volume.
• Consequently, the kidneys function to excrete
  large volumes of urine (polyuria) in an attempt
  to regulate excess vascular volume and to excrete
  the unusable glucose (glycosuria).
• Polyuria, along with cellular dehydration, causes
  excessive thirst (polydipsia).

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Diabetes Mellitus

• The body compensates for its inability to convert
  carbohydrate (glucose) into energy by burning
  proteins (muscle) and fats. However, the end
  products of this metabolism are ketones and fatty
  acids, which, in excess quantities, produce
  ketoacidosis and acetonuria. Weight loss occurs
  as a result of the breakdown of fat and muscle
  tissue. This tissue breakdown causes a state of
  starvation that compels the individual to eat
  excessive amounts of food (polyphagia).
• Over time, diabetes causes significant changes in
  both the microvascular and macrovascular
  circulations. These structural changes affect a
  variety of organ systems, particularly the heart,
  eyes, kidneys, and nerves. Complications
  resulting from diabetes include premature
  atherosclerosis, retinopathy, nephropathy, and
  neuropathy.
• Diabetes may be caused by either impaired insulin
  secretion, when the beta cells of the pancreas
  are destroyed by an autoimmune process, or by
  inadequate insulin action in target tissues at
  one or more points along the metabolic pathway.
  Both of these conditions are commonly present in
  the same person, and it is unclear which, if
  either, abnormality is the primary cause of the
  disease

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Diabetes Mellitus Classification

• Type 1 diabetes
• Absolute insulin deficiency
• Type 2 diabetes
• Relative insulin deficiency
• Pregestational diabetes mellitus
• Gestational diabetes mellitus (GDM)

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Diabetes Mellitus

• Metabolic changes associated with pregnancy
• Alterations in maternal glucose metabolism,
  insulin production, and metabolic homeostasis
• During normal pregnancy, adjustments in maternal
  metabolism allow for adequate nutrition for both
  the mother and the developing fetus. Glucose, the
  primary fuel used by the fetus, is transported
  across the placenta through the process of
  carrier-mediated facilitated diffusion. This
  means that the glucose levels in the fetus are
  directly proportional to maternal levels.
  Although glucose crosses the placenta, insulin
  does not.
• Around the tenth week of gestation the fetus
  begins to secrete its own insulin at levels
  adequate to use the glucose obtained from the
  mother. Thus, as maternal glucose levels rise,
  fetal glucose levels are increased, resulting in
  increased fetal insulin secretion.
• During the first trimester of pregnancy the
  pregnant woman's metabolic status is
  significantly influenced by the rising levels of
  estrogen and progesterone. These hormones
  stimulate the beta cells in the pancreas to
  increase insulin production, which promotes
  increased peripheral use of glucose and decreased
  blood glucose, with fasting levels being reduced
  by approximately 10
• There is a concomitant increase in tissue
  glycogen stores and a decrease in hepatic glucose
  production, which further encourage lower fasting
  glucose levels. As a result of these normal
  metabolic changes of pregnancy, women with
  insulin-dependent diabetes are prone to
  hypoglycemia during the first trimester.

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Diabetes Mellitus

• During the second and third trimesters, pregnancy
  exerts a "diabetogenic" effect on the maternal
  metabolic status. Because of the major hormonal
  changes, there is decreased tolerance to glucose,
  increased insulin resistance, decreased hepatic
  glycogen stores, and increased hepatic production
  of glucose. Rising levels of human estrogen,
  progesterone, chorionic somatomammotropin,
  prolactin, cortisol, and insulinase increase
  insulin resistance through their actions as
  insulin antagonists. Insulin resistance is a
  glucose-sparing mechanism that ensures an
  abundant supply of glucose for the fetus.
  Maternal insulin requirements may double or
  quadruple by the end of the pregnancy, usually
  leveling off or declining slightly after 36 weeks
• At birth, expulsion of the placenta prompts an
  abrupt drop in levels of circulating placental
  hormones, cortisol, and insulinase. Maternal
  tissues quickly regain their prepregnancy
  sensitivity to insulin. For the nonbreastfeeding
  mother the prepregnancy insulin-carbohydrate
  balance usually returns in approximately 7 to 10
  days.
• Lactation uses maternal glucose thus the
  breastfeeding mother's insulin requirements will
  remain low during lactation. On completion of
  weaning, the prepregnancy insulin requirement is
  reestablished

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Diabetes MellitusChanging insulin needs during
pregnancy
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Diabetes MellitusAntepartum care

• Routine visit
• every 1-2 weeks at I and II trim
• 1-2 times each week at last trim
• Hospitalization
• Insulin dose changes
• Maintain constant euglycemia

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Complications requiring Hospitalization

• Complete baseline cardiovascular, renal,
  ophtalmologic evaluations, balance diet and
  insulin regiment
• Inections
• Fail to maintain acceptable glucose level
• Before labour
• To confirm fetal lung maturity lecithin/
  sphingomyelin ratio

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Cesarean birth

• Fetal distress
• Estimate fetal weight is 4000-4500 kg

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Risk factors for GDM include

• maternal age over 30 years
• obesity
• family history of type 2 diabetes
• and an obstetric history of an infant weighing
  more than 4000 g,
• hydramnios,
• unexplained stillbirth,
• miscarriage, or an infant with congenital
  anomalies.
• Women at high risk for GDM are often screened at
  their initial prenatal visit and then rescreened
  later in pregnancy if the initial screen is
  negative

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Maternal-Fetal Risk

• of developing hypertensive disorders compared
  with normal pregnant women
• fetal macrosomia, which can lead to increased
  rates of perineal lacerations, episiotomy, and
  cesarean birth
• macrosomia with associated shoulder dystocia and
  birth trauma.
• hypoglycemia, hypocalcemia, hyperbilirubinemia,
  thrombocytopenia, polycythemia, and respiratory
  distress syndrome
• The overall incidence of congenital anomalies
  among infants of women with gestational diabetes
  approaches that of the general population because
  gestational diabetes usually develops after the
  twentieth week of pregnancyafter the critical
  period of organogenesis (first trimester) has
  passed.