Out lines:

1- Changes of Reproductive System:

a- Uterus. b- Cervix.
c- Ovaries and Fallopian Tubes. d- Vagina.

2- Changes of Gastrointestinal System:

A-Oral Cavity. B-Gastrointestinal motility.
C- Stomach and Esophagus. D- Metabolism.
E - Gall Bladder. F- Liver.
3- Changes Urinary System:
A- Renal Cavity.
B- Bladder.
4- Changes of Hematologic System:
A - Blood Volume.
B- Red Blood Cells.
C- I Ron.
E- Clotting Factors.
5- Changes of Cardio Vascular System:
A - Position and Size of Heart.
B- Cardiac Output.
C - Blood Pressure.
6- Changes of Respiratory System :
A - Lung Volumes and Capacities.
7- Changes of the Skin:

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 A - Cholosma.

B - Linea Nigra.

C - Striae Gravidarum.

8- Changes of Musculo Skeletal System .

9- Changes of Endocrine System:

A - Pituitary Gland.

B- Thyroid.

C- Parathyoid.

D - Adrenal Glands.

E- Pancreas.

General objective:
To differentiate between physiological changes that

associated with pregnancy.

Phys iol ogi cal Change s

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 Associated with Pregnancy
The physiologic, biochemical,and anatomic changes
(adaptation) that occur during pregnancy are extensive and may
be sistemic or local. For mantaina healthy enviroment of the fetus
without compromising the mother`s health. Although , sometimes
determine small disconfort to the mother.

Reproductive system

a. Uterus

(1) Size: increases from 7.5 x 5 x 2.5 cm to 35 x 25 x 20 cm at

term due to

Hypertrophy of the muscle fibers (estrogen effect)&

Hyperplasia (progesterone effect)

(2) Weight: increases form 50 gm to 1000gm., at term.

(3) Capacity: increases form 4 ml to 4000 at term.

(4) Contractions: Braxton hicks Contractions which are

Irregular, painless& Begin during the first trimester.

(5) Shape: changes form that of an inverted pear to a soft

globular.

(6) Formation of lower uterine segment: after 12 weekks, the

isthmus (0.5cm) starts to expand gradually to form lower
uterine segment, which measures 10 cm length at term.

b. Cervix

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 (1) Softening related to increased vascularity and slight
hypertrophy (Goodell’s sig).

(2) cervical glands :

Mucous plug formed from the thick mucus produced by

endocervical glands.

c. Ovaries and fallopian tubes

(1) Anovulation results from the suppression of follicle-

stimulating hormone (FSH) and luteinizing hormone (LH)
related to high levels of estrogen and progesterone.

(2) Corpus luteum remains active for 8 to 10 weeks into

pregnancy, producing progesterone and estrogen to maintain
pregnancy. After 9 to 10 weeks’ gestation, the placenta will
produce the progesterone and estrogen to maintain
pregnancy.

d. Vagina

(1) Increased vascularity.

(2) Bluish violet discoloration (Chadwick’s sign).

(3) Hypertrophy and hyperplasia of epithelium and elastic

tissues.

(4) Leukorrhea, acid pH 3.5 to 6.

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 The Breast

(1) Increased vascularity

(2) Hypertrophy of mammary alveloi (because of high

estrogen and progesterone levels) :

Size increases.

Breasts become nodular

(3) Areola and nipples:

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 Pigmentation drakens (begins during the first trimester)
Montgomery’s glands become more prominent.

Secondary areola may develop.

Nipples enlarge and become more erectile (second trimester)

(4) Colostrum from mammary glands:

Precolostrum secreted in early second trimester.

Colostrum secreted in third trimester.

Gastrointestinal System
During pregnancy, nutritional requirements,including those
for vitamins and minerals, are increased, and several maternal
alterations occur to meet this demand,.The mother`s appetite
usually increases, some women have a decreased appetite or
experience nausea and vomiting.These symptoms may be
related to relative levels of human chorionic
gonadotrophin(hCG).

Oral Cavity: Salivation may seem to increase due to

swallowing difficulty associated with nausea, and, if the pH
of the oral cavity decreases, tooth decay may occur.

The gums may become hipertrofic, hiperemic and friable;

this maybe due to increased systemic estrogen. Vitamin C
deficiency also can cause tenderness and bleeding of the
gums. Gastointestinal Motility

Gastrointestinal motility may be reduced during pregnancy

due to increased levels of progesterone, which in turn

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 decrease the production of motilin, ahormonal peptide that
is known to stimulate smooth muscle in the gut. Transit
time of food throughout the gastrointestinal tract may be
so much slower that more water than normal is reabsorbed,
leading to constipation. Stomach and Esophagus

Gastric production of hidrocloric acid is variable and

sometimes exaggrated, especially during the first trimester. More
commonly, gastric acidity is reduced. Production of the hormone
gastin increases significantly, resulting in increased sthomac
volume and decreased stomach pH.

Gastric production of mucus may be increased. Esophageal

peristalses is decreased, accompanid by gastric reflux because of
the slower emptying time and dilatation or relaxation of the
cardiac sphincter. Gastric reflux is more prevalent in later
pregnancy lead to elevation of the stomach by the enlarged
uterus. Leading to heartburn, all of these alterations as well as
lying in the supine lithotomy position make the use of anesthesia
more hazardous because of the increased possibility of
regurgitation and aspiration.

Metabolism

As the fetus and placenta grow and place increasing

demands on the mother, phenomenal alterations in metabolism
occur. The most obvious physical changes are weight gain and
altered body shape. Weight gain is due not only to the uterus and
its contents but also to increase breast tissue, blood and water
volume in the form of extravascular and extracellular fluid.
Deposition of fat and protein and increased cellular water are

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added to the maternal stores. The average weight gain during
pregnancy is 12,5Kg.

Total body fat incresas during pregnancy, but the amount

varies with total weight gain. During the second half of
pregnancy, plasma lipids increase.

Gallblader

Function is also altered during pregnancy because of the

hypotonia of the smooth muscle wall. Emptying time is slowed
and often ncomplete. Bile can become thick, and bile stasis may
lead to gallstone formation.

Liver
There are no apparent morphologic changes in the liver during
normal pregnancy, but there are functional alterations,

Serum alkaline phosphatase activity can double, probably

because of inceased placental alkaline phosphatase isoenzimes.
Thus, a decrease in the albumin/globulin ratio occurs normally
in pregnancy.

Urinary System
During pregnancy, each kidney increases in leagth by 1-
1,5cm, with a concomitant increase in weight. The renal pelvis is
dilated.The ureters are dilated above the brim of the bony
pelvis.The ureters also elongate, widen, and become more
curved.Thus there is an increase in urinary stasis, this may lead to
infection ,The absolute cause of hydonephrosis and hydroureter
in pregnancy is unknown, there may be several contributing

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factors : 1-Elevated progesterone levels may contribute to
hypotonia of the smooth muscle in the ureter.

2-Dextorotation of the uterus during pregnancy may

explain why the right ureter is usually more dilated than the left.

Renal Function

The glomerular filtration rate(GFR) increases during

pregnancy by about 50% .The renal plasma flow rate increases
by as much as 25-50%. Urinary flow and sodium excretion rates
in late pregnancy can be alterated by posture, being twice as
great in the lateral recumbent position as in the supine position.

With the increase in GFR, there is an incease in endogenous

clearence of creatinine. The concentration of creatinine in serum
is reduced in proportion to increase in GFR, and concentration of
blood urea nitrogen is similarly reduced.

Glucosuria during pregnancy is not necessarily abnormal,

may be explained by the increase in GFR with impairment of
tubular reabsortion capacity for filtered glucose. Increased levels
of urinary glucose also contribute to increased susceptibility of
pregnant women to urinary tract infection.

Proteinuria changes litlle during pregnancy and if more than

500mg/24h is lost.

Blader

As the uterus enlarges, the urinary blader is displaced

upward and flattened in the anterior-posterior or diameter.
Pressure from the uterus leads to inceased in urinary frequency .

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 Blader vascularity increases and muscle tone decreases, incresin
capacity up to 1500ml.

Hematologic System
Blood Volume

Maternal physiologic alteration occurring during pregnancy

is the increase in the blood volume, The increases varies
according to the size of woman, the number of pregnancies she
has had, the number of infants she has delivered, and whether
there is one or multiple fetuses.

The increases in blood volume progress until term;the

average increase in volume at term is 45-50%. The increase is
needed for extra blood flow to the uterus, extra metabolic needs
of fetus, and increased perfusion of others organs, especially
kidneys.

Red Blood Cells

The increase in red blood cell mass is about 33%. Since

plasma volume increases early in pregnancy and faster than red
blood cell volume, the hematocrit falls until the end of the second
trimester, when the increase in the red blood cells is synchronized
with the plasma volume increase. The hematocrit then stabilizes
or may increase slightly near term.

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 Iron

With the increase in red blood cells, the need for iron for the
production of hemoglobin naturally increases. If supplemental
iron is not added to the diet, iron deficiency anemia will result.

Maternal requiriments can reach 5-6mg/d in the latter half

of pregnancy. If iron is not readly available, the fetus uses iron
from maternal stores. Thus, the production of fetal hemoglobin is
usually adequate even if the mother is serely iron deficient.

Therefore anemia in the newborn is rarely a problem;

instead, maternal iron deficiency more commonly may cause
preterm labour and late spontaneus abortion, incresing the
incidence of infant wastage and morbidity.

White Blood Cells

The total blood leukocyte count increases during pregnancy

from a prepregnancy level of 4300-4500/mL to 5000-12000/mL
in the last trimester, althought counts as hight as 16000/mL have
been observed in the last trimester. Counts as hight as 25000-
30000/mL has been noted in anormal patient during labor.
Lymphocite and monocyte numbers stay the same throughout
pregnancy.

Clotting Factors

During pregnancy, levels of several essential coagulation

factors are increase. Thereare marked increases in fibrinogen and
coagulation factors.

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 The placenta may be partially responsible for this alteration
in fibrinolytic status. Plasminogen levels increase with
fibrinogens levels, causing an equilibrationof clotting and lysing
activity.

Clearly, coagolation and fibrinolytic systems undergo major

alterations during pregnancy. Understanding these physiologic

Changes are necessary to manange two of the more serious

problems of pregnancy: hemorrage and thromboembolic disease,
both caused by disorders in the mechanism of hemostasis.

Cardiovascular System
Position and Size of Heart :

As the uterus enlarges and the diaphragm becomes elevated,

the heart is displaced upward and somewhat to the left with
rotation on its long axis, so that the apex beat is moved laterally .

Cardiac capacity increases by 70-80mL; this may be due to

increased volume or hyperthophy of cardiac muscle. The size of
the heart appears to increase by about 12%

Cardiac Output :

Cardiac output increases approximately 40% during

pregnancy, reaching its maximum at 20-24 week’s gestation and
continuing at this level until term. The increase in output can be
as much as1, 5L/min over the non-pregnant level.

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 Cardiac output is very sensitive to changes in body
position, this sesitivity increases because the uterus impinges
upon the inferior vena cava, thereby decreasing blood return to
the heart.

Blood Pressure :

Systemic blood pressure declines slightly during pregnancy.

There is a little change in systolic blood pressure, but diastolic
pressure is reduced (5-10mmHg) from about 12-26 weeks.
Diastolic pressure increases thereafter to prepregnancy levels by
about 36 weeks.

The obstruction caused by the uterus on the inferior vena

cava and the pressure of fetal presentig part on the commom
illiac vein can result in decreased blood return to the heart. This
decreases cardiac output, leads to a fall in blood pressure, and
causes edema in the lower extremities.

Respiratory System :
Hormonal changes to the mucosal vasculature of the respiratory
tract lead to capillary engorgement and swelling of the lining in
the nose, oropharynx, larynx, and trachea. Symptoms of nasal
congestion, voice change and upper respiratory tract infection
may prevail throughout gestation. These symptoms increased y
fluid overload or oedema associated with pregnancy-induced
hypertension (PIH) or pre-eclampsia.

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 In such cases, manipulation of the airway can result in profuse
bleeding from the nose or oropharynx through the larynx.
Airway resistance is reduced, probably due to the progesterone-
mediated relaxation of the bronchial musculature.

Lung Volumes and Capacities

Alterations occurring in lung volumes and capacities during

pregnancy include the following:

Increases owing to relaxation of the musculature of

conducting airways. volumes increases gradually(35-50%)as
pregnancy progesses. Total lung capacity is reduced (4-5%) by
the elevation of the diaphragm.

Functional respiratore changes include a slight increase in

respiratory rate,a 50% increase in minute ventilation, a 40%
increase in tidal volume, and a progressive increase in oxigen
consuption of up to 15-20% above nonpregnant levels by term.

- “Hiperventilayion of pregnancy”occurs, causing a decrease in

alveolar CO2. This decrease lowers the maternal blood CO2
tension however alveolar oxigen tension is maintened within
normal limits. Maternal hyperventilation is considered a
protective measure that prevents the fetus from the exposure to
excessive levels of CO2.

The Skin

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 1-The Skin undergoes hyperpigmentation

Which is due to increased production of melanocyte stimulating

hormone :

(a)Chloasma is the blotchy,brownish, maskof pregnancy”

(b) Lineanigra (abdomen)

(c) Areolae (nipples)

(d) Other area : a xillae, vulva, and perineum all darken.

2- Striae gravidarum (breasts and abdomen)

3- Secreations: increase in sweat and sebaceous glands activity

4- Skin disorders and skin problems associated with pregnancy :

May include noninflammatory pruritis and acne vulgaris
(especially in the first trimester).

Musculoskeletal system
a. Alterations in posture can result in lordosis.

b. Relaxation and steroid sex hormones.

c. Diastasis recti, a separation of the rectus muscles of the

abdominal wall, is associated with the enlarging uterus in some

. Endocrine system
a. Pituitary gland

(1) Anterior lobe: slight increase in size

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 (a) Follicle-stimulating hormone and luteininzing
hormone production is supperssed

(b) Thyrotropin and adrenocorticotropic hormone may

increase slightly.

(c) Melanotropin production is increased.

(d) Human placental lactogen production is suppressed.

(e) Prolactin (PRL) production is increased.

(2) Posterior lobe: oxytocin production gradually increase

as the fetus matures.

b. Thyroid

- Gland enlarges, resulting in increased iodine metabolism.

- Thyroxine (T4) level, unbound to plasma proteins, remains

unchanged (T3 (triiodothyronine) and T4 increase but are
bound to thyroxinebinding globulin).

c. Parathyroid gland-activity increases and blood levels of

parathyroid hormone are elevated.

d. Adrenal glands: little change in function.

e. Pancreas: insulin production is increased throughout

pregnancy to compensate for placental hormone insuli
antagonism.

(1) Insulin antagonists (human placental lactogen hormones,

estrogen, progesterone, and adrenal cortisol) cause
decreased tissue sensitivity.

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(2) Women with poor pancreatic function may develop true
diabetes during pregnancy.

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 DIA GNOS IS OF PR EGN AN CY
Out lines:
1- Diagnosis in the First Trimester:
• Symptoms such as:
a. Amenorrhea .
b. Morning sickness.
c. Frequency of micturation .
d. Breast symptoms.
• Signs such as:
a. Breast Signs.
b. Uterine Signs.
c. Cervical and Vaginal Signs.
2- Diagnosis in the Second Trimester.
3- Diagnosis in the Third Trimester.
4- Importance of Fetal Heart Sound (F.H.S).
5- Identification of Minor Discomfort of Normal
Pregnancy.

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 DIA GNOS IS OF PR EGN AN CY
Diagnosis in the first trimester

Symptoms:
1. Amenorrhea: (Missed period):

Cessation of menstruation, however it may be absent in cases

of:

• pregnancy during lactation amenorrhea.

• Threatened abortion.

• Slight bleeding at the expected time of menstruation may

occur only in the 1st – 3 months (Hartman’s sign).

N.B. Amenorrhea is due to increased estrogen and pregesterone

production by the corps luteum.

2. Morning sickness:

• Nausea, vomiting especially in the morning.

• Usually disapears after the 3rd month.

• May be due to allergy to hCG.

3. Frequancy of micturition

• Due to congestion, irritation of the bladder by the

pregnant uterus.

• Usually disappears after the 3rd months.

4. Breast symptoms

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 Enlargement, tenderness discomfort and tingfing sensation.

5. Appetite changes

Craving for certain types of food and refusal of other types.

Signs

1. Breast signs: (evident in a primigravida)

• Increased size and vascularity.

• Dilated visible veins.

• Increased pigmentation of the nipple and 1st areola.

• Appears of 2nd areola.

• Appearance of Montgomery tubercles in the areola (dilated

sebaceous glands). Expression of colostrum.

2. Uterine signs:

• Size: enlarged

• Consistency: soft

• Shape: globular.

• Hegar sign: (between 6-10 weeks) two fingers in the

anterior fornix, the fingers of the other hand over the
abomen behind the uterus the fingers of both hands can be

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 •

Approximated, as the lower part of the uterine body is soft

and empty.

• Plamer sign:

Uterine contractions detected by bimanual examination.

3. Cervical and vaginal signs:

• Leucorrhea: increased vaginal discharge.

• Chadwick’s sign:

Bluish discoloration of the vegina and cervix.

• Goodell’s sign:

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 Cyanosis and softening of the cervix at 4 weeks.

Investigations
1. Pregnancy tests:

All depend on the detection of hCG either in urine or in serum:

a. Immunologic pregnancy tests:

• Detect hCG in urine by an antigen antibody reaction.

• Chorionic gonadotrophins in the urine of pregnant females

prevent agglutination of hCG coated particles mixed with
an anti-hCG serum

• The urine is added to a solution containing an anti-hCG

(antibody).

• Antigen antibody reaction takes place.

• Another solution containing hCG coated particles (latex

particles or RBCs) is added. Now the antibody is not free
and will not cause agglutination or recipitation of the
particles ie:

- no agglutination: + ve pregnancy test.

- Agglutination: - ve pregnancy test.

The sensitivity of these tests ranges between 25-250 mlU/ml.

positive from few days to 2 weeks after the missed period.

Uses of pregnacy tests:

• Diagnosis of normal pregnancy.

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 • Diagnosis of missed abortion.

• Diagnosis of entopic pregnancy.

• Diagnosis and follow-up of vesicular mole and

choriocarcinoma.

• Diagnosis of intrauterine fetal death.

2. Ultrasonography:

Abdominal:

Gestational saC: 5 weeks. One fetal pole: 6 weeks.

Two fetal poles: 7 weeks. Fetal heart activity: 8 weeks.

Vaginal:

The previous findings can be detected one week earlier.

3. Auscultation of FHS: using the Doptone (Sonicaid starting

from 10 weeks.

4. Hormone withdrawal bleeding:

Progesterone is given.

• If there is no pregnancy: withdrawal bleeding occurs

within a week.

• If there is pregnancy: no bleeding.

• However, this test is not relible, and synthetic progesterone

carries the risk of virilization of the female fetus.

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 DIA NGO NS IS IN TH E SEC ON D
TR IME STE R
13-28 WEE KS
A. Symptoms:
1. Amenorrhea.

2. Morning sickness and urinary symptoms gradually decrease.

3. “Quickening”: perception of fetal movements by the

pregnant woman:

• 18-20 weeks in primigravida.

• 16-18 weeks in multipara.

4. Abdominal enlargement.

B. Signs:
1. Breast changes become more evident.

2. The uterus is abdominally felt.

3. Braxton Hicks contractions;intermittent painless contractions

detected by abdominal examination.

4. Internal ballotement: at 16 weeks.

It can be demonstrated by pushing the fetus through the

anterior fornix using 2 fingers.

5. External ballottement: at 20 weeks through abdominal

examination.

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6. Palpation of the fetal parts and palpation of fetal
movements by the obstetrician at 20 weeks.

7. Auscultation of the F.H.S. at 20-24 weeks by the pinard’s

fetal stethoscope.

8. Stria gravidarum are detected in the 2nd half of pregnancy.

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-86 -
Diagnostic in the 3rd trimester
All the signs of pregnancy become very evident, sonography is
diagnostic.

Sure evidence of pregnancy

1. Palpation of fetal parts.

2. Palpation of fetal movements.

3. Auscultation of FHS.

4. Auscultation of umbilical souffle.

5. Visualization of fetal parts, fetal movements and fetal heart

movements by ultrasonography.

6. Visualization of fetal skeleton by x-ray.

Important of F.H.S.
1. Sure sign of pregnancy.

2. Diagnosis of presentation and position.

3. Diagnosis of multiple pregnancy (Twins).

4. Diagnosis of fetal viability.

5. Detection of fetal distress.

6. Detection of progress during labour.

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-88 -
 MINOR DISCOMFORTS OF NORMAL
PREGNANCY
-Nousea & vomiting (Morning sickness):-

About half of all pregnant woman has neusea and

vomiting. Most commonly occurs during the first 10 weeks,
related to higher levels of (HCG). About 1/1000 gravidas with
sever morning sickness devlop intractable vomiting (hyperemesis
gravidarum) in such cases, psychiatric consultation may be most
usefull. Hospitalization may betocorrect fluid and electrolyte
imblance or to remove the gravida from a stress full environment.
In this sever cases weight; nitrogen balance, liver enzymes and
fetal growth must be monitored.

The addition of intravenous vitamins decrease the

possibility of hypovitaminosis usually explanation, reassurance
dietary changes are helpful eating dry toast and jelly immediately
on rising.

-Back ache:-

Fatigue, muscle spasm, postural back strain or relaxation

of the pelvic joints is responsible for backache.

Back ache often can be relived by the following measure:-

Prescribe back exercises under the supervision sleep on the

firm matters. Apply local heat & light massage to relax tense.
When sitting use support, arm rests, & pillow behind your back.

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-Heart Burn: -

Results from gastroesophageal regurgitation in almost 10%

of all gravidas in late pregnancy. *Relived by the following
measures:

Eat several small meals daily and avoid fatty food, avoid
smoking, coffee , tea drink which stimulate acid formation in the
stomach.

-Leukorrhea: -

A gradual increase in the amount of non irritating vignal

dischange due to estrogen stimulation of cervical mucous is
normal during pregnancy.

So close attention to bodily cleanliness. Frequent change

of prneal pads.

1- Excessive leukorrhea accompanied by pruritus,

discoloration of the secretion, fouloder requires lab
investigation and treatment.

-Constipation:-

Constipation due to suluggish bowel function in pregnancy

may be due to progesterone effect & bowel displacement it also
aside effect of injecting iron supplements or due to physical in
activity.
The following measure to relives:-

A dequet fluid intake 6-8 glasses / day diet rich in

roughage, such as whole grain cereals vegetables, fruits , good

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powel habits help full encourage exercise walk at least one mile
per day.

-Hemorrhoids

May cause considerable discomfort strainging at stool

especially in woman prone to varicosities symptomatic is usually
suffient treat constipation.

- Sitz bathes, rectal ointments, suppositories & mild

laxatives are indicated postoperatively or
postdelivery.

- Gently push the hemorrhoids backinto the rectum,

put gloves & lubricate your index finger.

-Ankle swelling:-

Edema of the lower extremities (not assiocated with

preeclampsia-eclampsia) devolping in late pregnancy edema is
due to water retention and increased venous pressure in the leg.
Generalized edema, always serious must be investigated.

The following measure for relif:-

The patient should be elevate her legs frequently. Restrict

excessive salt intake. Provide elastic support for varicose veins.
Maintain good posture, avoid prolonged standing or sitting.

Varicose veins:-

Varicostities may develop in the legs or in the vulva

varices are due to smooth muscle relaxation, weakness of the
vascular walls and incompletent valves pressure on the venous
return from the legs by the enlarging uterus.

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The following measure for relif:

The patient should elevate her legs above the level of her
body, control excessive weight gain. Wear elastic stretch
stockings.

-Legcramps: -

Cramping of the muscles of the calf, thigh or buttocks may

occur suddenly after sleep or recumbency in many women after
the first timester of pregnancy. Leg cramps may due to areduced
level of diffusible serum calcium or. Excessive dietary intake of
phosphorus in milk, cheese, meat or calcium phosphate or
diminished intake or impaired absorption of calcium may
predispose in leg cramps.

Treatment shold be include:

Decrease phosphat intake. Systematic treatment consists

leg massage, gentle flexing of the feet and local heat. General
exercise and use of good body mechanics to improve circulation.

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 ANT EP AR TU M C ARE
Out lines:
1- History.
2- Physical examinations.
3- Ante partum management.
4- Nursing actions for first visit and follow up
visits.

General objective of prenatal care: is the delivery of a

healthy infant and maintenance of the health of the mother.

Specific objectives:
At the end of this lecture the student should be able to:
1- Prevent and manage of those conditions that
cause poor pregnancy outcomes such as
premature labor, hypertension, diabetes and
intrauterine growth retardation.
2- Keep the pregnant women in good physical and
emotional health.
3- List complication during pregnancy

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 ANT EP AR TU M C ARE
Components of antepartum care

1- Periodic assessment, which begins with a

comprehensive history and physical examination to
identify risk factors and abnormalities, should continue
at regular intervals.

2- Patient education fosters optimal health, good dietary

habits, and proper hygiene.

3- Psychosocial support is very important during an

emotional experience as profound as pregnancy.

I-History

1-Personal History

Name.

Age.

Job and level of education (both for her and for her
husband).

Duration of marriage.

Number of living children.

Smoking habits.

2-Obstetric History

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 Number of (previous pregnancies, previous pregnancy
living children and children who died).

Mode of previous deliveries.

Date of last delivery.

Number of abortions and its types (Spontaneous or

induced).

3-Contraceptive history

• Has the woman used any previous contraceptive

method?

• If yes, what is it?

• Has the woman suffered any side effects with it?

• Has pregnancy occurred during its use?

• Has she stopped using it and what are the causes?

• Is she now using any method and what is it?

4-Menstrual History:

Are the cycles regular?

What is the amount and duration of bleeding during the

cycle?

Is there any irregular bleeding between the cycles?

Are the cycles associated with dysmensorrhoea & what is

its relation to the beginning of the cycle and its duration?

6-Past medical history: Ask for

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 • Any previous medical disease specially hypertension,
diabetes, heart disease or renal disease.

• Previous surgical operations and its results.

• Any serious previous disease and any treatment for it.

7-Family History:

Any family disease specially in partners such as

hypertension or diabetes.

II-Physical examination
A-General examination

A general examination should include an evaluation of

height, weight, blood pressure, eye fundus, breasts, heart, lungs,
abdomen, rectum, extremities, and current nutritional status (e.g.,
obesity or malnutrition).

B-Pelvic examination

a- The speculum examination permits

visualization of the vagina and the cervix.

1- The blue-red passive hyperemia

(Chadwick’s sign) of the cervix is
characteristic of pregnancy.

2- A dilated cervix may reveal membranes

at the internal os.

b-Evaluation of cervical and vaginal lesions can

be accomplished by performing a pap smear

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 (Papanicolaou’s test), biopsy, or culdoscopic
examination.

c- Bimanual examination permits the evaluation

of the pelvis and the uterus.

So configuration and capcity of the bony pelvis should be

evaluated.

a- Abdominal examination allows the ongoing evaluation

of the growth and status of the fetus.

1- Esimating weeks of gestation. Between 18

and 30 weeks, there is an excellent
correlation between the size of the uterus
and the gestation by weeks. The
measurement in centimeters from the
symphysis pubis to the top of the fundus
should approximate the weeks of gestation.
At midpregnancy (20 weeks’ gestation), the
fundus of the uterus is at the level of the
umbilicus.

2- Fetal heart tones can be identified by a

Doppler (Sonar) device at 12-14 weeks and
by a fetoscope at 18-20 weeks.

3- Use of real-time ultrasonorgaphy:

a- The vaginal probe can detect fetal

viability at human choroni
gonadotropin (hCG) levels of 1500-

-97 -
 2000 mIU/ml, or 5-6 weeks from the
LMP.

b- Fetal heart activity can be seen by the

abdominal proble at hCG levels of
5000-6000 ml-U/ml, or 6-7 weeks

c- From the LMP.

III-Antepartum management
A-Laboratory tests

1-Initial screening should include the following studies:

a- Hemoglobin.

b- Urinalysis for protein and glucose.

c- Blood group and Rh type.

d- Irregular antibody screening.

e- Cervical cytology.

f- Serologic testing for syphilis.

2- In third-trimester routine testing should

include the following studies:

a- Repeat hemoglobin or hematocrit level.

b- Repeat antibody testing in unsensitized Rh-negative

patients at 28-32 weeks dence of Rh
isoimmunization in an Rh-negative woman when
her antibody screen is negative and the father of the
fetus is Rh-positive.

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b-Routne Visits

1-Frequency

a- In an uncomplicated pregnancy, a woman should

be seen every 4 weeks for the first 28-30 weeks
of pregnancy, every 2 weeks until 36 weeks, and
weekly thereafter until delivery.

b- High-risk pregnancies. Women with medical or

obstertric problems require close surveillance at
intervals determined by the nature and severity of
the problems.

2-Monitoring

a-Mother

1- Blood pressure and weight with notation of any change.

2- Presence of headache, altered vision, abdominal pain,

nausea, vomiting, bleeding, fluid from the vagina, and
dysuria.

3- Height of the uterine fundus above the symplysis pubis.

4- Position, consistency, effacement, and dilatation of the

cervix (late in pregnancy).

b-Fetus

Fetal heart rate. Size of fetus. Amount of amniotic fluid.

Fetal activity. Presenting part and station (late in pregnancy).

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C-Special instructions. Patients are instructed about the following
danger signals, which should be reported immediately
whenever they occur

1- Any vaginal bleeding.

2- Swelling of the face or fingers.

3- Sever or continuous headache.

4- Blurring of vision.

5- Abdominal pain.

6- Persistent vomiting.

7- Chills or fever.

8- Dysuria.

9- Escape of fluid from the vagina.

Nursing actions of first visit and follow

upvisits:-

Assessment strategies

I-Interview

A-Physcial data

1- Family history.

2- Medical history.

3- Obstetric.

a- Prior pregnancies.

b- Present pregnancy.

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 B-Sexual history

C-Review of women’s physical systems

D-Social profile

1- Biographic data.

2- Perceptions (woman and family) of pregnancy.

3- Coping mechanisms.

a- Knowledge and understanding of process of

pregnancy, danger signals.

b- Desire to participate in care.

4- Support systems

Therapeutic and educational measures

I- Establish caring relationship with woman (or

couple).

II- Prepare for physical examination and discuss

findings of physical examination.

III- Review plan of care with woman and family.

1- Schedule: check for convenience of timing

problems in transportation, and care of other
children provide written copy of schedule.

2- Need for continuity of care: check for

woman’s understanding of reasons for
periodic reassessment.

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3- Physical examinations: describe routine
physical examinations, including instructions
for obtaining clean-catch urine specimens for
routine analysis.

-102 -
IV - Instruct woman on general health care.

a- Personal hygiene.

b- Diet.

c- Rest and exercise.

d- Dental care.

e- Use of medications.

f- Sexual counseling.

V- Discuss current problems.

Lifestyle adaptations during pregnancy:

-

a- Exercise. It is not necessary for a pregnant woman to

limit her exercise, provided she does not become
excessively tried. Severe restrictions may be necessary
in such situations as suspected or actud cervical
incompetence, pregnancy induced hypertension,
premature labor, and multiple gestition.

b- Travel. No harmful effects have been ascribed to travel;

pressurized aricuraft present no risk. A pregnant woman
should move around every 2 hours to guard against
lower extermit venous statsis and thrombophlebitis.

c- Bowel habits. Bowel habits during pregnancy tend to

become irregular because of the progesterone induced
gastrointestinal smooth tuscle relaxation and the

-103 -
 pressure of the enlarginauterine Mass. A woman may
avoid constipation with fluid intake, exercises.

d- Coitus. Sexual intercourse does no harm at any time

during pregnancy unless there is a pregnancy
complication, such as ruptured membranes, premature
labor, or cervical incompetence. Prostaglandin’s in the
seminal plasma and female orgasm may be responsible
for the occasional transient contractions that occur with
coitus.

e- Smoking. Mothers who smoke often have smaller (by

an average of 250 g) infants with increased prenatal
mortality. Mothers should be encouraged to quit
smoking completely during pregnancy.

f- Alcohol. The current recommendation is that no alcohol

be consumed during pregnancy. The fetal abnormalities
associated with heavy drinking during pregnancy are
known as fetal alcohol syndrome and include
craniofacial defects, limb and cardiovascular defects,
prenatal and postnatal growth retardation, and mental
retardation.

g- Medication. Any drug administered during pregnancy

will cross the placenta and reach the fetus; therefore, if
a drug must be used, its advantages must outweigh the
risks.

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 Ble edi ng in pr egn ancy

Ou t li ne s:
A-Bleeding in early pregnancy

Causes:

1. Abortion.

2. Ectopic pregnancy.

3. Vesicular mole.

4. Cervical lesions

5. Implantation bleeding (when the blast cyst erodes the

endometrium during the process of embedding

B-Bleeding in late pregnancy

Causes:

1-Placenta previa. 2-Abruption placenta.

-105 -
General objective:
To provide the students with knowledge about bleeding in
pregnancy and how to cope with it .
Specific objectives:
At the end of this lecture the students should be able to:
1- Differentiate between bleeding in early and late
pregnancy.
2- Identify causes of bleeding in early and late
pregnancy.
3- List Complications that result from bleeding
in pregnancy.

4- Guide the students with proper Nursing

management for mother with bleeding in
pregnancy.

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 Abortion

Definition:

Termination of pregnancy before viability of the fetus < 28

week

Causes:

 Fetal causes:

Mal development or disease of the fertilized ovum and in

30 to 40% of spontaneous, first trimester abortions
chromosomal anomalies are present.

 Maternal causes:

 Infections: acute febrile conditions such as influenza

may cause death of the fetus.

 Diseases: such as chronic nephritis.

 Drugs: such as quinine or ergot.

 Endocrine dysfunction: progesterone deficiency is

the secondary effect of fetal damage,not the cause.

 RH incompatibility: between mother and embryo.

 Psychological stress

 Local conditions:

-107 -
  Trauma: accidents, violent exercise or truma
during abdominal operation.

 Uterine malformation, fibroid tumors.

 Incompetent cervix (congenital)

 Excessive dilatation of the cervix: forceps or

breech extraction before full cervical dilatation.
(Acquired)

Signs and symptoms:

Vaginal bleeding, the earliest sign, is due to partial

detachment of the embedded ovum.

Pain, which is usually felt in the abdomen & intermittent .

Types of abortion

1. Threatened abortion – when a pregnant patient bleeds or

threatens to lose the products of conception.

2. Inevitable abortion – bleeding with continuous and

progressive dilation of the cervix and the inevitable
expulsion of the products of conception:

a) Incomplete abortion – only part of the products of

conception have been expelled.

b) Complete abortion – all the products of the complete

abortion – all the products of the conceptus have
been expelled.

c) Missed abortion – abortion where expulsion of the

dead embryo and placenta has failed to occur and

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 the products of conception remain in utero for 8
weeks or more.

d) Spetic abortion – an infected abortion – most

frequently after induced, incomplete abortion.

3. Therapeutic abortion – the interruption of pregnancy for

medically approved indications.

4. Induced abortion – the deliberate interruption of

pregnancy by any means before the 28th week of gestation.

5. Habitual abortion – the occurrence of spontaneous

abortion on three or more consecutive occasions.

Type, Signs & symptoms and management :

Type Signs & symptoms Management

1.Threatened • Painless bleeding • Bed-rest and sedation
abortion:
• Only slight uterine • Progesterone; ritodrine
contractions

• Closed cervix

• Uterus is expected size

for dates

2. Inevitable • Bleeding. • Treat bleeding or

abortion: shock, if any
• Dilated cervix
• Treat pain – i.m.
• Visible products of
pethidine 100 mg
conception
• Evacuate uterus
• Regular uterine
oxytocic drugs i.v. and

-109 -
 contractions and pain curettage if possibility
of retained placental
tissue

3. Complete • History of bleeding and • No treatment if

abortion: pain and passage of diagnosis certains
products of conception

• Presently asymptomatic

• Uterus contracted to
normal size

-110 -
 Type, Signs & symptoms and management:
Type Type Signs & symptoms
4. Incomplete • Persistent bleeding after
abortion: passage of products of
conception
5. Missed • Uterus small for dates
abortion:
• Pregnancy symptoms
subside
• Pregnancy tests negative
and ultrasound scan
confirms diagnosis
• May be brown baginal
discharge but cerbical os
is usually closed
6. Septic • Pyrexia patient feels
abortion: weak and very ill
• Painful enlarged uterus
with or without
peritoneal involvement
• Septic discharge
• Retained products of
conception
7. Habitual • An abortion sequence of
abortion: not less than three
• Commonest treatable
cause: incompetent
internal cervical os
-111 -
Management
• Treat bleeding or shock,
if any
• Check maternal
fibrinogen levels and
clotting studies before
evacuation
• Evacuate uterus suction
curettage
• If uterus greater than 12
weeks for size, expulsion
of contents of uterus
induced by
prostaglandins or
oxytocin infusion
• Intravenous broad-
spectrum antibiotics and
hydrocortisone
• Evacuate uterus
promptly by suction
curettage
• Blood transfusion
• Shirodkar suture a suture
around the cervical
veginal mucosa at the
level of the internal os
 Com pl icat ion s
1) Blood loss.

2) Shock.

3) Infection that may lead to death or infertility.

4) Disseminated intravascular coagulation (DIC)

5) Depression; hysteria; grief

6) Pituitary necrosis (very rare – Sheehan’s disease).

Nursing management:

. Institute measures to alleviate fear and anxiety

assist with grieving process.

. Point out physiologic reality, but encourage client to work

through feelings of guilt.

. Monitor amount and type fo bleeding :

1. Save and count number of pads.

2. Distinguish between dark clotted blood and frank

bleeding, which is bright red.

. Monitor vital sings; assess for hypovlemia and shock.

. Monitor laboratory work; prepare for administration of

blood.

. Monitor fetal heart if pregnancy is beyond twentieth

weeks.

-112 -
 . Administer oxygen if necessary.

. Maintain fluid and electroyte balance.

. Administer RhoGAM to Rh-negative client after

abortion.

. Educate about necessity for follow-up care.

. Be aware of own fellings about abortion (essential if the

nurse is to intervene therapeutically with women having
abortions).

. Encourage the client's expression of frustration, fear,

anger, or guilt.

Be objective and support the client's decision about

abortion.

. Make certain that a complete history and physical

examination, complete laboratory workup, pelvic
examination and a pregnancy test, and a pregnancy test are
done prior to induced abortion.

. Counsel concerning contraceptive methods if requested.

. Administer RhoGAM when client's blood is Rh negative

and negative for antibodies.

ASSESSMENT

1. Clinical presentation

a. Signs and symptoms

i. Vaginal bleeding.

-113 -
ii. Pelvic carmping and backache may be present.

iii. Membrances may rupture.

b. History

i. Previous episodes of vaginal bleeding or pelvic

camping with current pregnancy; passage of
tissue or clots; EDC; LMP; previous abortions.

2. Biopsychosocial assessment

a. Monitor vital signs: TPR and BP

b. If greater than 14 weeks gestation monitor FHR with

Doppler

iii. If bleeding is heavy Blood replacement

(a) Observer patient for symptoms may be

necessary if

bleeding is excessive and signs of shock

(b) Start IV with large bore catheter

(c) Place patient in Trendelenburg’s position

(d) Blood: CBC, Rh type and cross mach immediately,

blood clotting.

(e) Palpate for uterus, measure funds if uterus is

palpable; palpate for consistency and tenderness.
External blood loss may

deceiving and uterus may be filling with blood.

To assess psychological state

-114 -
 II. Allow father or significant other to remain with
mother

III. Provide emotional support to mother. Mother and

father should not be separated at this time.

IV. Allow ans encourage ventilation of fears and

fellings.

To provide educative information. Complete bed

rest, avoid stress & coitus in threaten abortion.

Prepare for possible surgery. (D&C) in

inevitable and incomplete. In septic
abortion culture & sensitivity and board
spectrum antibiotic.

Prepare patient for possible fetal loss.

Assist the parents to begin grieving if fetal loss is
inevitable.

-115 -
 Acci de ntal H em orr ha ge
P lac enta A bru ptio
Alternate Names : Ablatio Placentae, Abruptio Placentae,
Accidental Hemorrhage, Placental Abruption, Premature
Separation of Placenta

Overview

Placenta abruptio during pregnancy is a condition in which

the placenta, also known as the afterbirth, separates from the
womb before the fetus is born. The placenta is a disc-shaped
organ that provides nourishment and blood to a fetus. This
most common form of this condition occurs in about 1 out
of 150 deliveries. The severe form occurs in only 1 out of
500 to 750 births.

Going on in the body:

In the normal birthing process, the placenta does not detach

from the womb until after the infant is born. In placenta
abruptio, blood vessels rupture and create a mass of blood,
also called a hematoma. This hematoma shears off the blood
vessels next to it, creating further bleeding and separation of
the placenta.

-116 -
kinds of placenta abruptio:

Relating to where the bleeding occurs:

A- Concealed. This form means that bleeding occurs

within the uterus and does not leave the cervix.

B- External. In this form, blood drains through the cervix

and out of the body.

causes :

(rare) may include:

Abdominal trauma from an automobile accident or a fall

Sudden loss in size of the uterus, due to loss of amniotic

fluid, or delivery of a first twin

-117 -
 Abnormally short umbilical cord

Risks of the disease:

a woman is more at risk for this condition if she:

Has had this condition before

Has pre eclampsia, which is a condition that develops

during pregnancy as a result of hypertension

Has eclampsia, which is toxemia during pregnancy that

becomes severe

Has chronic high blood pressure

Is older

Has uterine distension from multiple pregnancies, or an

excess of amniotic fluid

Have had more than four children

Has diabetes

Has other medical condition, such as systemic lupus

erythematosus

Smokes cigarettes

Have more than 14 alcoholic drinks per week

Uses cocaine

Has a history of an attempted internal version, a

procedure in which the obstetrician tries changing the baby's
position from breech to headfirst

-118 -
Symptoms & Signs: Symptoms may vary, depending on:

How much of the placenta has detached

During which stage of pregnancy it occurs

Thirty percent of placenta abruptios are small and produce

no symptoms. When the case is severe, symptoms may
include:

Vaginal bleeding

Severe abdominal pain, which is different from uterine

contractions

Uterus is tender and contracted tightly

Fetal distress, detected by fetal monitoring

Constant contractions, called uterine tetany

Back pain

Uterine tenderness

Maternal shock, with low blood pressure and inadequate

blood flow to vital organs .

Diagnosis & Tests

Medical history and consider any symptoms. signs of fetal

distress and for tenderness or increased tightness over the
uterus. Based on this information, the provider may suspect
placenta abruptio.

The diagnosis can be confirmed if:

A pregnancy ultrasound shows a clot behind the placenta

-119 -
 A complete blood count, called CBC, shows decreased
hemoglobin, hematocrit, and platelets

A bleeding tendency is found with clotting tests such as a

prothrombin time, or PT

The baby's heart rate or rhythm is abnormal

Prevention:

Women can reduce their risk factors by:

Avoiding general pregnancy risk factors, such as cocaine,

alcohol, or smoking

Treating chronic high blood pressure or other conditions,

such as diabetes

Good prenatal care will help to identify pregnancy risk

factors and possibly allow for early detection of placenta
problems. This will mean that treatment can be started right
away.

Long-term effects of the disease:

The death of the mother

The death of the fetus

Excessive bleeding leading to shock

A serious generalized bleeding problem called

disseminated intravascular coagulopathy, or DIC

Kidney failure, also known as renal failure

A liver disease called transfusion hepatitis

-120 -
 Low muscle tone, called uterine atony, with continued
bleeding

Premature delivery, birth trauma, and risks associated

with prematurity however, these results are rare. Maternal
death occurs in less than 5 out of 100 women who have
placenta abruptio. Fetal death rates are higher. The infant
may die in as many as 20 to 35 percent of cases.

The other risks

This condition can be harmful to the fetus. The woman also

has a higher risk of developing this condition during future
pregnancies.

Treatment & Monitoring :

This condition is usually an emergency and requires

treatment right away. Measures will be taken to keep the
mother and infant healthy. This might include:

Immediate and continuous internal fetal monitoring of

the infant

IV fluids

Monitoring of vital signs, such as blood pressure, heart

rate, and urine output

"Watchful management" if the fetus is not in distress, the

mother's vital signs are stable, and labor is not in motion.
Some small abruptios will stop bleeding on their own.

Vaginal delivery if the infant and mother are stable

-121 -
 Cesarean section if the mother and infant are unstable

Blood transfusion if signs of shock are present

Side effects of the treatments

Because the treatments for this condition may be life-saving,

the potential side effects should be weighed against the loss
of life. It may take longer for a woman to recover from
major abdominal surgery involved in a cesarean section.
Risks for any surgery include bleeding, infection, and
allergic reaction to the anesthesia.

After treatment for the condition:

After delivery, the woman will be watched closely for signs

of continued bleeding. This entails monitoring frequent
CBCs, evaluating clotting times, and watching vital signs.
The surviving infant will likewise be observed in the
intensive care unit.

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 Pla centa p re vi a
Placenta previa occurs in about 1:200 pregnancies.
Implantation occurs along the lower uterine segment over
the cervix leading to an inability to deliver vaginally. While
there are no specific etiologies, placenta previa is associated
with grand multiparity, previous uterine surgery, including
previous Caesarean section or suction curettage, smoking. It
can be complicated by abnormal lie, postpartum

haemorrhage and hysterectomy.

Definition:

-123 -
 Painless, causeless, recurrent bleeding due to abnormal
situated placenta,(placenta implanted in the lower part of
the uterus).

Classifications:

1. Central or complete previa:

The placenta covers the internal os.

2. Marginal previa:

The lower placental edge lies within 2 cm of the internal os

but does not cover it. If present at term there is an increased
risk of intrapartum bleeding.

3. Low lying placenta:

Apparent placenta previa before the third trimester. With

follow-up ultrasound in 90% of those cases the placenta will
be clear of the cervical os at term.

Symptoms:

* Painless vaginal bleeding

* Typically this occurs without warning or labour, however,

labour may ensue or have initiated the bleeding, or there
may be an associated abruption, in which case pain may be a
feature.

*There may be malpresentation, or a high presenting part

* Initial bleeding is usually a warning bleed

(Not enough to cause hypovolemic shock, but awoman with

placenta previa will inevitably bleed again).

-124 -
Diagnosis:

1. Ultrasound – transvaginal and translabial ultrasound are

very useful following the initial transabdominal scan) in
accurately diagnosing placenta previa, and measuring the
distance, in centimeters, from the internal os to the placental
edge.

2. No digital vaginal or rectal examinations until the

placenta is localized and placenta previa is ruled out.

3. If patient needs delivery for fetal or maternal reasons,

double set-up may be required.

• Double set-up: refers to a digital exam being done to

determine placental location, in the operating room with the
anaesthetist present, assistants scrubbed and instruments
prepared for immediate Caesarean section.

Management:

Role of nurse:-( Assessment):

With the client’s admission to the hospital, the nurse

begins with an assessement of the bleeding. Necesseary
history data include gravidity, parity, EDD, general status,
bleeding (quantity, precipitating event, associated pain),
vital signs and fetal status. Abdominal assessement reveals a
soft relaxed, nontender uterus with normal tone. Laboratory
studies include CBC, determination of blood type,
coagulation profile and possible type .

-125 -
*If bleeding is severe, it may be necessary to deliver the
infant and call for the neonatal transport team.

* Remember that the woman with placenta previa will

inevitably bleed again.

* Stabilization and transfer will be necessary for level (I)

units or centres with inadequate surgical and blood bank
backup, or inadequate neonatal facilities.

* Full discussion regarding possible need for blood products

is necessary.

* Assess maternal and fetal health

* Start intravenous infusion of saline or Ringer’s lactate

using a large bore needle

* Blood replacement as deemed necessary (based on amount

of bleeding and maternal vital signs)

*Monitor intake and output. Insert urinary catheter if

bleeding is severe Perinatal Outreach Program of
Southwestern Ontario

* Monitor maternal vital signs and fetal heart rate every 15

minutes while actively bleeding, and hourly once stable

* Continuous fetal heart rate monitoring until active

bleeding has stopped.

* Assess the colour and amount of blood loss

• Pad count

• Weighing pads

-126 -
• Blood clots, number and size

• Sequential CBC’s and coagulation status

* Lab assessment

• CBC, Hgb

• Coagulation screen

• Electrolytes, creatinine

• Group and cross match 2-4 units packed red cells (take
blood

during transfer)

* Assess uterine tone and presence of contractions

* Strict bedrest in the lateral position

* Communicate with staff at receiving hospital if patient

being transferred

*Nursing care with nurse accompaniment during transport

If the woman is retained in a level II centre, the

following is also recommended:

1. Bedrest until active bleeding has stopped for 2 – 3 days

2. Assess and treat anemia

3. Consider steroid (betamethasone) administration.

4. Daily fetal movement counts and non-stress testing

5. Delivery at 37-38 weeks, unless indicated earlier for

maternal or fetal reasons .

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 Ect op ic p re gnan cy
Definition:

Ectopic means "out of place." Ectopic pregnancy is the

implantation of a pregnancy outside the normal utero decidual
area. In an ectopic pregnancy, a fertilized egg has implanted
outside the uterus. The egg settles in the fallopian tubes more
than 95% of the time. So ectopic pregnancies are commonly
called "tubal pregnancies." The egg can also implant in the ovary,
abdomen, or the cervix, so these referred to as cervical or
abdominal pregnancies.

None of these areas has as much space or nurturing tissue as a

uterus for a pregnancy to develop. As the fetus grows, it will

eventually burst the organ that contains it. This can cause severe
bleeding and endanger the mother's life. A classical ectopic
pregnancy never develops into a live birth.

-128 -
Signs and Symptoms:

Ectopic pregnancy can be difficult to diagnose because

symptoms often mirror those of a normal early pregnancy. These
can include :

* Missed periods, breast tenderness, nausea, vomiting,

or frequent urination.

* Vaginal spotting or bleeding.

* Dizziness or fainting (caused by blood loss).

* Low blood pressure (also caused by blood loss).

* Lower back pain{ Pain is the first sign}. Pain as sharp and
stabbing. It may concentrate on one side of the pelvis, and it may
come and go or vary in intensity. , Abdomen, or in extreme cases,
even shoulder or neck (if blood from a ruptured ectopic
pregnancy builds up and irritates certain nerves)

Causes:

An ectopic pregnancy results from a fertilized egg's inability to

work its way quickly enough down the fallopian tube into the
uterus. An infection or inflammation of the tube may have
partially or entirely blocked it. Pelvic inflammatory disease (PID)
is the most common of these infections.

Endometriosis (when cells from the lining of the uterus detach

and grow elsewhere in the body) or scar tissue from previous
abdominal or fallopian surgeries can also cause blockages. More
rarely, birth defects or abnormal growths can alter the shape of
the tube and disrupt the egg's progress.

-129 -
Diagnoses:

Complaining of abdominal pain, urine pregnancy test. if the urine

test comes back positive, be given a quantitative hCG test. This
blood test measures levels of the hormone human chorionic
gonadotropin (hCG), which is produced by the placenta. The
hormone hCG appears in the blood and urine as early as 10 days
after conception, and its levels double every 2 days for the first
10 weeks of pregnancy. If hCG levels are lower than expected for
the stage of pregnancy, doctors are one step closer to diagnosing
ectopic pregnancy.

a pelvic exam to locate the areas causing pain, to check for an

enlarged, pregnant uterus, or to find any masses in the abdomen.
Ultrasound examination, which shows whether the uterus
contains a developing fetus or if masses are present elsewhere in

The abdominal area . But the ultrasound may not be able to

detect every ectopic pregnancy.

A less commonly performed test, a culdocentesis, may be used

to look for internal bleeding. In this test, a needle is inserted
into the space at the very top of the vagina, behind the uterus

-130 -
and in front of the rectum. Any blood or fluid found there likely
comes from a ruptured ectopic pregnancy.

Even with the best equipment, it's hard to see a pregnancy that's
less than 6 weeks along. If can't diagnose ectopic pregnancy
return every 2 days to measure the hCG levels. If these levels
don't rise as quickly as they should, the doctor will continue to
monitor carefully until 6 weeks, when an ultrasound can be used.

Nursing Management:-

Provide preoperative care.

Assess continuously for sings of shock.

Administer analgesics as ordered for pain.

The nurse must monitor the amount of vaginal bleeding,

vital signs, and the woman’s general condition for signs of
overt hemorrhage and hypovolemic shock. Preparations for
surgery are the same as those for any abdominal procedure.
Rh-negative women who are not sensitized should receive
immune globulin (RhoGam) within 72 hours. The woman
with an ectopic pregnancy may experience feelings of grief
and loss so encourage patient to express her feelings &
emotional support is very important .

Treatment

Treatment of an ectopic pregnancy varies, depending on its size

and location and whether patient want the ability to conceive
again.

-131 -
An early ectopic pregnancy can sometimes be treated with an
injection of methotrexate, which dissolves the fertilized egg and
allows the body to reabsorb it. This nonsurgical approach
minimizes scarring of your pelvic organs.

If the pregnancy is further along, need surgery to remove the

abnormal pregnancy.

However, the pregnancy may sometimes be removed using

laparoscopy, a less invasive surgical procedure. The surgeon
makes a small incision in the lower abdomen and then inserts a
laparoscope. This long, hollow tube with a lighted end allows the
doctor to view internal organs and insert other instruments as
needed. Sometimes, a second small abdominal incision is made
for the instruments. The ectopic pregnancy is then surgically
removed and any damaged organs are repaired or removed.
General anesthesia may be used.

Whatever patient is treated ,the doctor should see patient

regularly afterward to make sure that hCG levels return to zero.
This may take up to 12 weeks. An elevated hCG could mean that
some ectopic tissue was missed. This tissue may have to be
removed using methotrexate or additional surgery.

Future Pregnancies

Approximately 30% of women who have had ectopic

pregnancies will have difficulty becoming pregnant again. The
prognosis depends mainly on the extent of the damage and the
surgery that was done.

-132 -
If the fallopian tube has been spared, the chances of a future
successful pregnancy are 60%. Even if one fallopian tube has
been removed, the chances of having a successful pregnancy
with the other tube can be greater than 40%.

The likelihood of a repeat ectopic pregnancy increases with each

subsequent ectopic pregnancy. Once patient have had one
ectopic pregnancy, patient face an approximate 15% chance of
having another.

Risk for Ectopic Pregnancy

The risk of ectopic pregnancy is highest for women who are

between 35 and 44 years old and have had:

• PID

• A previous ectopic pregnancy

• Surgery on a fallopian tube

• Infertility problems or medication to stimulate

ovulation

Some birth control methods can also increase the risk of ectopic
pregnancy. If patient get pregnant while using progesterone-only
oral contraceptives, progesterone intrauterine devices (IUDs), or
the morning-after pill, patient more likely to have an ectopic
pregnancy.

-133 -
 Mol ar pr eg nancy
Definition

A molar pregnancy is known medically as a 'Hydatidiform Mole'.

The word 'hydatidiform' derives from 'hydatid', meaning 'water-
filled cysts'. Other terms used to describe a molar pregnancy are
'vesicular mole' or 'trophoblastic disease'. Molar pregnancies are
very rare, resulting from the abnormal development of the
placenta.
A hydatidiform mole starts at the time the egg is fertilised, The
woman usually misses her period and experiences the normal
physical signs of pregnancy. However she may be more severely
nauseated and vomit frequently. At some stage during the
pregnancy (usually in the first 3 to 4 weeks), part of the placenta
(known as the 'chorionic villi', or 'trophoblast') starts to produce
fluid filled cysts, or vesicles that multiply rapidly. The vesicles
can range in size from a pinhead to a small grape. The woman
may then start to experience some vaginal bleeding (often around
12 weeks).

There are 2 types of molar pregnancies:

A complete mole: This is where a baby never develops, but the

placenta implants and grows many small cysts, like sacs filled
with fluid.

A partial mole: This is where a baby starts to develop, but is

unable to survive, often being absorbed into the vesicles that
cotinue to multiply.

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 The chance of a molar pregnancy recurring in the same
woman is about 1:80 (or 1.25%).

Diagnosis:

Symptoms

1. Short period of amenorrhea

2. Vaginal bleeding.

3. Prune juice.

4. Expulsion of the vesicles.

5. hyperemsis ,edema and headache.

6. Pain if present, is due to it is excessive distension by the

mole or starting expulsion.

Signs

1. Hypertension, edema and albuminuria (toxemia of

pregnancy before 20weeks gestation)

2. Pallor is due to repeated attacks of bleeding.

3. Undue enlargement of the uterus.(a woman with

12weeks,amenorrhea may have a uterus the size of
a24weeks).

4. Fetal movement will not have been felt.

5. fetal heartbeat is not heard.

6. Fetal parts will not be felt by palpation.

7. Vaginal bleeding with passage of vesicles.

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 8. Palpable cystic ovaries.

Investigations:

1. Pregnancy test is +ve in high dilution.

2. Ultrasound.

3. X-ray (no fetal skeleton.

4. If 1/200 is +ve it is highly suggestive.

5. If 1/500 is +ve  it is surely diagnostic.

Dangers:

1. Hemorrhage.

2. Sepsis.

3. Erosion of the uterine wall ( invasive mole) and may

erforate the uterus causing internal hemorrhage.

4. Choriocarcinoma.

Treatment:

A- Vaginal evacuation (suction evacuation):

1. Suction curettage:

it is the most effective and safest method.

• Pre-intra and most operative oxytocin drip.

• Dilatation of the cervix to accommodate the suction

curette under general anesthesia.

• Fluid replacement and packed RBCs.

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 • Curettage after evacuation of the mole.

2-medical evacuation:

it is apparatus for suction evacuation is not

available.we give pitocin drip 500glucose 5% +10-20 units
pitocin to initiate uterine contraction and cervical dilatation , then
expulsion starts. We may use, prostaglandin.

B-abdominal hysterotomy:

It is induced only in cases of excessive bleeding from

alarge-sized uterus and the cervix is closed.

C-abdominal hysterectomy:

it is indicated in :

-Invasive mole.

-Women over 40years or complete her family and desires

sterilization.

Follow up:

• No regnancy for 2years:

The method of contraception used is mechanical method

or pills.

• Follow up at monthly interval for one year:

And 3 monthly interval for another year.

• Follow u for vaginal bleeding, haemptysis, and

involution of uterus, pregnancy test return –ve after 4
weeks.

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