Complications of pregnancy are the symptoms and problems that are associated with pregnancy.

There are both routine problems and serious, even potentially fatal problems. The routine problems are normal complications, and pose no significant danger to either the woman or the fetus. Serious problems can cause both maternal death and fetal death if untreated.

ABORTION ECTOPIC PREGNANCY GESTATIONAL TROPHOBLASTIC DISEASE INCOMPETENT CERVIX PREGNANCY INDUCED HYPERTENSION PLACENTA PREVIA ABRUPTIO PLACENTA PROLAPSED OF THE UMBILICAL CORD HYDRAMNIOS OLIGOHYDRAMNIOS PREMATURE RUPTURE OF MEMBRANE PRETERM LABOR

ABORTION

Abortion is defined as the termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo prior to viability. An abortion can occur spontaneously, in which case it is usually called a miscarriage, or it can be purposely induced. The term abortion most commonly refers to the induced abortion of a human pregnancy. Abortion, when induced in the developed world in accordance with local law, is among the safest procedures in medicine. However, unsafe abortions(those performed by persons without proper training or outside of a medical environment) result in approximately 70 thousand maternal deaths and 5 million disabilities per year globally. An estimated 42 million abortions are performed globally each year, with 20 million of those performed unsafely. The incidence of abortion has declined worldwide as access to family planning education and contraceptive services has increased. Forty percent of the world's women have access to induced abortions (within gestational limits). Induced abortion has a long history and has been facilitated by various methods including herbal abortifacients, the use of sharpened tools, physical trauma, and other traditional methods. Contemporary medicine utilizes medications and surgical procedures to induce abortion. The legality, prevalence, cultural and religious status of abortion vary substantially around the world. In many parts of the world there is prominent and divisive public controversy over the ethical and legal issues of abortion.

TYPES:

Induced Approximately 205 million pregnancies occur each year worldwide. Over a third are unintended and about a fifth end in induced abortion. Most abortions result from unintended pregnancies. A pregnancy can be intentionally aborted in several ways. The manner selected often depends upon the gestational age of the embryo or fetus, which increases in size as the pregnancy progresses. Specific procedures may also be selected due to legality, regional availability, and doctor or patient preference. Reasons for procuring induced abortions are typically characterized as either therapeutic or elective. An abortion is medically referred to as a therapeutic abortion when it is performed to save the life of the pregnant woman; prevent harm to the woman's physical or mental health; terminate a pregnancy where indications are that the child will have a significantly increased chance of premature morbidity or mortality or be otherwise disabled; or to selectively reduce the number of fetuses to lessen health risks associated with multiple pregnancy. An abortion is referred to as an elective or voluntary abortion when it is performed at the request of the woman for non-medical reasons.

Spontaneous Spontaneous abortion, also known as miscarriage, is the unintentional expulsion of an embryo or fetus before the 20th to 22nd week of gestation. A pregnancy that ends before 37 weeks of gestation resulting in a live-born infant is known as a "premature birth" or a "preterm birth". When a fetus dies in utero after viability, or during delivery, it is usually termed "stillborn".[12] Premature births and stillbirths are generally not considered to be miscarriages although usage of these terms can sometimes overlap.

Only 30 to 50% of conceptions progress past the first trimester. The vast majority of those that do not progress are lost before the woman is aware of the conception, and many pregnancies are lost before medical practitioners have the ability to detect the presence of an embryo. Between 15% and 30% of known pregnancies end in clinically apparent miscarriage, depending upon the age and health of the pregnant woman. The most common cause of spontaneous abortion during the first trimester is chromosomal abnormalities of the embryo/fetus, accounting for at least 50% of sampled early pregnancy losses. Other causes include vascular disease (such as lupus), diabetes, other hormonal problems, infection, and abnormalities of the uterus. Advancing maternal age and a patient history of previous spontaneous abortions are the two leading factors associated with a greater risk of spontaneous abortion. A spontaneous abortion can also be caused by accidental trauma; intentional trauma or stress to cause miscarriage is considered induced abortion or feticide. Medical abortions are those induced by abortifacient pharmaceuticals. Medical abortion became an alternative method of abortion with the availability of prostaglandin analogs in the early 1970s and the antiprogestogen mifepristone in the 1980s. The most common early first-trimester medical abortion regimens use mifepristone in combination with a prostaglandin analog (misoprostol or gemeprost) up to 9 weeks gestational age, methotrexate in combination with a prostaglandin analog up to 7 weeks gestation, or a prostaglandin analog alone. Mifepristonemisoprostol combination regimens work faster and are more effective at later gestational ages than methotrexatemisoprostol combination regimens, and combination regimens are more effective than misoprostol alone. In very early abortions, up to 7 weeks gestation, medical abortion using a mifepristonemisoprostol combination regimen is considered to be more effective than surgical abortion (vacuum aspiration), especially when clinical practice does not include detailed inspection of aspirated tissue. Early medical abortion regimens using 200 mg of mifepristone, followed 2448 hours later by 800 mcg of buccal or vaginal misoprostol are 98% effective up to 9 weeks gestational age. In cases of failure of medical abortion, surgical abortion must be used to complete the procedure. Early medical abortions account for the majority of abortions before 9 weeks gestation in Britain, France, Switzerland, and the Nordic countries. In the United States, the percentage of early medical abortions is far lower. Medical abortion regimens using mifepristone in combination with a prostaglandin analog are the most common methods used for second-trimester abortions in Canada, most of Europe, China and India,[22] in contrast to the United States where 96% of second-trimester abortions are performed surgically by dilation and evacuation. Surgical

A vacuum aspiration abortion at eight weeks gestational age (six weeks after fertilization). 1: Amniotic sac 2: Embryo 3: Uterine lining 4: Speculum 5: Vacurette 6: Attached to a suction pump In the first 15 weeks, suction-aspiration or vacuum abortion is the most common surgical method. Manual vacuum aspiration (MVA) abortion consists of removing the fetus or embryo, placenta and membranes by suction using a manual syringe, while electric vacuum aspiration (EVA) abortion uses an electric pump. These techniques are comparable, and differ in the mechanism used to apply suction, how early in pregnancy they can be used, and whether cervical dilation is necessary. MVA, also known as "mini-suction" and "menstrual extraction", can be used in very early pregnancy, and does not require cervical dilation. Dilation and curettage (D&C), the second most common method of surgical abortion, is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal bleeding, and abortion. Curettage refers to cleaning the walls of the uterus with a curette. The World Health Organization recommends this procedure, also called sharp curettage, only when MVA is unavailable. From the 15th week until approximately the 26th, other techniques must be used. Dilation and evacuation (D&E) consists of opening the cervix of the uterus and emptying it using surgical instruments and suction. Premature labor and delivery can be induced with prostaglandin; this can be coupled with injecting theamniotic fluid with hypertonic solutions containing saline or urea. After the 16th week of gestation, abortions can also be induced by intact dilation and extraction (IDX) (also called intrauterine cranial decompression), which requires surgical decompression of the fetus's head before evacuation. IDX is sometimes called "partial-birth abortion," which has been federally banned in the United States. In the third trimester of pregnancy, abortion may be performed by IDX as described above, induction of labor, or by hysterotomy. Hysterotomy abortion is a procedure similar to a caesarean section and is performed under general anesthesia. It requires a smaller incision than a caesarean section and is used during later stages of pregnancy. First-trimester procedures can generally be performed using local anesthesia, while second-trimester methods may require deep sedation or general anesthesia. Other methods

Bas-relief at Angkor Wat, Cambodia, c. 1150, depicting a demon inducing an abortion by pounding the abdomen of a pregnant woman with a pestle. Historically, a number of herbs reputed to possess abortifacient properties have been used in folk medicine: tansy, pennyroyal, black cohosh, and the now-extinct silphium (see history of abortion). The use of herbs in such a manner can cause seriouseven lethalside effects, such as multiple organ failure, and is not recommended by physicians. Abortion is sometimes attempted by causing trauma to the abdomen. The degree of force, if severe, can cause serious internal injuries without necessarily succeeding in inducing miscarriage. In Southeast Asia, there is an ancient tradition of attempting abortion through forceful abdominal massage. One of the bas reliefs decorating the temple of Angkor Wat in Cambodia depicts a demon performing such an abortion upon a woman who has been sent to theunderworld. Reported methods of unsafe, self-induced abortion include misuse of misoprostol, and insertion of non-surgical implements such as knitting needles and clothes hangers into the uterus. These methods are rarely seen in developed countries where surgical abortion is legal and available.

ECTOPIC PREGNANCY

An ectopic pregnancy, or eccysis , is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the parent, since internal haemorrhage is a life threatening complication. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen. An ectopic pregnancy is a potential medical emergency, and, if not treated properly, can lead to death. In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine lining where it has plenty of room to divide and grow. About 1% of pregnancies are in an ectopic location with implantation not occurring inside of the womb, and of these 98% occur in the Fallopian tubes. Detection of ectopic pregnancy in early gestation has been achieved mainly due to enhanced diagnostic capability. Despite all these notable successes in diagnostics and detection techniques ectopic pregnancy remains a source of serious maternal morbidity and mortality worldwide, especially in countries with poor prenatal care. In a typical ectopic pregnancy, the embryo adheres to the lining of the fallopian tube and burrows into the tubal lining. Most commonly this invades vessels and will cause bleeding. This intratubal bleeding hematosalpinx expels the implantation out of the tubal end as a tubal abortion. Tubal abortion is a common type of miscarriage. There is no inflammation of the tube in ectopic pregnancy. The pain is caused by prostaglandins released at the implantation site, and by free blood in the peritoneal cavity, which is a local irritant. Sometimes the bleeding might be heavy enough to threaten the health or life of the woman. Usually this degree of bleeding is due to delay in diagnosis, but sometimes, especially if the implantation is in the proximal tube (just before it enters the uterus), it may invade into the nearby Sampson artery, causing heavy bleeding earlier than usual. If left untreated, about half of ectopic pregnancies will resolve without treatment. These are the tubal abortions. The advent of methotrexate treatment for ectopic pregnancy has reduced the need for surgery; however, surgical intervention is still required in cases where the Fallopian tube has ruptured or is in danger of doing so. This intervention may be laparoscopic or through a larger incision, known as a laparotomy.

Tubal pregnancy The vast majority of ectopic pregnancies implant in the Fallopian tube. Pregnancies can grow in the fimbrial end (5% of all ectopics), the ampullary section (80%), the isthmus (12%), and the cornual and interstitial part of the tube (2%). Mortality of a tubal pregnancy at the isthmus or within the uterus (interstitial pregnancy) is higher as there is increased vascularity that may result more likely in sudden major internal hemorrhage. A review published in 2010 supports the hypothesis that tubal ectopic pregnancy is caused by a combination of retention of the embryo within the

fallopian tube due to impaired embryo-tubal transport and alterations in the tubal environment allowing early implantation to occur. Nontubal ectopic pregnancy Two percent of ectopic pregnancies occur in the ovary, cervix, or are intraabdominal. Transvaginal ultrasound examination is usually able to detect a cervical pregnancy. An ovarian pregnancy is differentiated from a tubal pregnancy by the Spiegelberg criteria. While a fetus of ectopic pregnancy is typically not viable, very rarely, a live baby has been delivered from an abdominal pregnancy. In such a situation the placenta sits on the intraabdominal organs or the peritoneum and has found sufficient blood supply. This is generally bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic (liver) artery or even aorta have been described. Support to near viability has occasionally been described, but even in third world countries, the diagnosis is most commonly made at 16 to 20 weeks gestation. Such a fetus would have to be delivered by laparotomy. Maternal morbidity and mortality from extrauterine pregnancy is high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. If the organ to which the placenta is attached is removable, such as a section of bowel, then the placenta should be removed together with that organ. This is such a rare occurrence that true data are unavailable and reliance must be made on anecdotal reports. However, the vast majority of abdominal pregnancies require intervention well before fetal viabilitybecause of the risk of hemorrhage.

Heterotopic pregnancy In rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the uterus and the other inside. This is called a heterotopic pregnancy. Often the intrauterine pregnancy is discovered later than the ectopic, mainly because of the painful emergency nature of ectopic pregnancies. Since ectopic pregnancies are normally discovered and removed very early in the pregnancy, an ultrasound may not find the additional pregnancy inside the uterus. When hCG levels continue to rise after the removal of the ectopic pregnancy, there is the chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound. Although rare, heterotopic pregnancies are becoming more common, likely due to increased use of IVF. The survival rate of the uterine fetus of an ectopic pregnancy is around 70%. Successful pregnancies have been reported from ruptured tubal pregnancy continuing by the placenta implanting on abdominal organs or on the outside of the uterus.

Persistent ectopic pregnancy A persistent ectopic pregnancy refers to the continuation of trophoplastic growth after a surgical intervention to remove an ectopic pregnancy. After a conservative procedure that attempts to preserve the affected fallopian tube such as a salpingotomy, in about 15-20% the major portion of the ectopic growth may have been removed, but some trophoblastic tissue, perhaps deeply embedded, has escaped removal and continues to grow, generating a new rise in hCG levels. After weeks this may lead to new clinical symptoms including bleeding. For this reason hCG levels may have to be monitored after removal of an ectopic to assure their decline, also methotrexate can be given at the time of surgery prophylactically.

Signs and symptoms Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 5 to 8 weeks. Later presentations are more common in communities deprived of modern diagnostic ability. Early signs include:

Pain in the lower abdomen, and inflammation (Pain may be confused with a strong stomach pain, it may also feel like a strong cramp) Pain while urinating Pain and discomfort, usually mild. A corpus luteum on the ovary in a normal pregnancy may give very similar symptoms. Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. This can be indistinguishable from an early miscarriage or the 'implantation bleed' of a normal early pregnancy. Pain while having a bowel movement

Patients with a late ectopic pregnancy typically experience pain and bleeding. This bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanisms:

External bleeding is due to the falling progesterone levels. Internal bleeding (hematoperitoneum) is due to hemorrhage from the affected tube.

The differential diagnosis at this point is between miscarriage, ectopic pregnancy, and early normal pregnancy. The presence of a positive pregnancy test virtually rules out pelvic infection as it is rare indeed to find pregnancy with an active Pelvic Inflammatory Disease (PID). The most common misdiagnosis assigned to early ectopic pregnancy is PID. More severe internal bleeding may cause:

Lower back, abdominal, or pelvic pain. Shoulder pain. This is caused by free blood tracking up the abdominal cavity and irritating the diaphragm, and is an ominous sign. There may be cramping or even tenderness on one side of the pelvis. The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse.

Ectopic pregnancy can mimic symptoms of other diseases such as appendicitis, other gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory disease and other gynaecologic problems. Causes There are a number of risk factors for ectopic pregnancies. However, in as many as one third[11] to one half[12] of ectopic pregnancies, no risk factors can be identified. Risk factors include: pelvic inflammatory disease, infertility, use of an intrauterine device (IUD), previous exposure to DES, tubal surgery, intrauterine surgery (e.g. D&C), smoking, previous ectopic pregnancy, and tubal ligation. Although older texts suggests an association between endometriosis and ectopic pregnancy this is not evidence based and current research suggests no association between endometriosis and ectopic pregnancy.

Cilial damage and tube occlusion Hair-like cilia located on the internal surface of the Fallopian tubes carry the fertilized egg to the uterus. Fallopian cilia are sometimes seen in reduced numbers subsequent to an ectopic pregnancy, leading to a hypothesis that cilia damage in the Fallopian tubes is likely to lead to an ectopic pregnancy.[15] Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy.[16] This results from the build-up of scar tissue in the Fallopian tubes, causing damage to cilia.[3] If however both tubes were completely blocked, so that sperm and egg were physically unable to meet, then fertilization of the egg would naturally be impossible, and neither normal pregnancy nor ectopic pregnancy could occur. Tubal surgery for damaged tubes might remove this protection and increase the risk of ectopic pregnancy[citation needed]. Intrauterine adhesions (IUA) present in Asherman's syndrome can cause ectopic cervical pregnancy or, if adhesions partially block access to the tubes via the ostia, ectopic tubal pregnancy.[17] [18] [19] Asherman's syndrome usually occurs from intrauterine surgery, most commonly after D&C.[17] Endometrial/pelvic/genitaltuberculosis, another cause of Asherman's syndrome, can also lead to ectopic pregnancy as infection may lead to tubal adhesions in addition to intrauterine adhesions. Tubal ligation can predispose to ectopic pregnancy. Seventy percent of pregnancies after tubal cautery are ectopic, while 70% of pregnancies after tubal clips are intrauterine[citation needed]. Reversal of tubal sterilization (Tubal reversal) carries a risk for ectopic pregnancy. This is higher if more destructive methods of tubal ligation (tubal cautery, partial removal of the tubes) have been used than less destructive methods (tubal clipping). A history of a tubal pregnancy increases the risk of future occurrences to about 10%.This risk is not reduced by removing the affected tube, even if the other tube appears normal. The best method for diagnosing this is to do an early ultrasound. Other Although some investigations have shown that patients may be at higher risk for ectopic pregnancy with advancing age, it is believed that age is a variable which could act as a surrogate for other risk factors. Also, it has been noted that smoking is associated with ectopic risk. Vaginal douching is thought by some to increase ectopic pregnancies.[3] Women exposed to diethylstilbestrol (DES) in utero (also known as "DES Daughters") also have an elevated risk of ectopic pregnancy, up to 3 times the risk of unexposed women[citation needed]. It has also been suggested that pathologic generation of nitric oxide through increased iNOS production may decrease tubal ciliary beats and smooth muscle contractions and thus affect embryo transport, which may consequently result in ectopic pregnancy.

Diagnosis

An opened oviduct with an ectopic pregnancy at about 7 weeks gestational age. An ectopic pregnancy should be considered in any woman with abdominal pain or vaginal bleeding who has a positive pregnancy test. An ultrasound showing a gestational sac with fetal heart in the fallopian tube is clear evidence of ectopic pregnancy. An abnormal rise in blood -human chorionic gonadotropin (-hCG) levels may indicate an ectopic pregnancy. The threshold of discrimination of intrauterine pregnancy is around 1500 IU/ml of -hCG. A high resolution, transvaginal ultrasound showing no intrauterine pregnancy is presumptive evidence that an ectopic pregnancy is present if the threshold of discrimination for -hCG has been reached. An empty uterus with levels higher than 1500 IU/ml may be evidence of an ectopic pregnancy, but may also be consistent with an intrauterine pregnancy which is simply too small to be seen on ultrasound. If the diagnosis is uncertain, it may be necessary to wait a few days and repeat the blood work. This can be done by measuring the -hCG level approximately 48 hours later and repeating the ultrasound. If the -hCG falls on repeat examination, this strongly suggests a spontaneous abortion or rupture. A laparoscopy or laparotomy can also be performed to visually confirm an ectopic pregnancy. Often if a tubal abortion or tubal rupture has occurred, it is difficult to find the pregnancy tissue. A laparoscopy in very early ectopic pregnancy rarely shows a normal looking fallopian tube. Culdocentesis, in which fluid is retrieved from the space separating the vagina and rectum, is a less commonly performed test that 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 and in front of the rectum. Any blood or fluid found may have been derived from a ruptured ectopic pregnancy. Cullen's sign can indicate a ruptured ectopic pregnancy.

Treatment

Medical Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical treatment since at least 1993. If administered early in the pregnancy, methotrexate terminates the growth of the developing embryo; this may cause an abortion, or the tissue may then be either resorbed by the woman's body or pass with a menstrual period. Contraindications include liver, kidney, or blood disease, as well as an ectopic mass > 3.5 cm. Surgical If hemorrhage has already occurred, surgical intervention may be necessary. However, whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of blood clot on ultrasound. Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy). The first successful surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883.

GESTATIONAL TROPHPBLASTIC DISEASE Molar pregnancy is an abnormal form of pregnancy, wherein a non-viable, fertilized egg implants in the uterus, and thereby converts normal pregnancy processes into pathological ones. It is characterized by the presence of a hydatidiform mole (or hydatid mole, mola hydatidosa). Molar pregnancies are categorized into partial and complete moles. A complete mole is caused by a single (90%) or two (10%) sperm combining with an egg which has lost its DNA (the sperm then reduplicates forming a "complete" 46 chromosome set) The genotype is typically 46,XX (diploid) due to subsequent mitosis of the fertilizing sperm, but can also be 46,XY (diploid). In contrast, a partial mole occurs when an egg is fertilized by two sperm or by one sperm which reduplicates itself yielding the genotypes of 69,XXY (triploid) or 92,XXXY (quadraploid).[2] Complete hydatidiform moles have a higher risk of developing into choriocarcinoma a malignant tumor oftrophoblast cells than do partial moles. The etymology is derived from hydatisia (Greek "a drop of water"), referring to the watery contents of the cysts, and mole (from Latin mola = millstone/false conception). The term, however, comes from the similar appearance of the cyst to a hydatid cyst in an Echinococcosis. A hydatidiform mole conception may be categorized in medical terms as one type of non-induced (natural) "missed abortion". - referred to colloquially as a "missed miscarriage", because the pregnancy has become non-viable (miscarried) but was not immediately expelled (therefore was "missed").

In most complete moles, all nuclear genes are inherited from the father only (androgenesis). In approximately 80% of these androgenetic moles, the most probable mechanism is that an empty egg is fertilized by a single sperm, followed by a duplication of all chromosomes/genes (a process called "endoreduplication"). In approximately 20% of complete moles the most probable mechanism is that an empty egg is fertilised by two sperm. In both cases, the moles are diploid (i.e. there are two copies of every chromosome). In all these cases, the mitochondrial genes are inherited from the mother, as usual. Most partial moles are triploid (three chromosome sets). The nucleus contains one maternal set of genes and two paternal sets. The mechanism is usually the reduplication of the paternal haploid set from a single sperm, but may also be the consequence of dispermic (two sperm) fertilization of the egg. In rare cases, hydatidiform moles are tetraploid (four chromosome sets) or have other chromosome abnormalities. A small percentage of hydatidiform moles have biparental diploid genomes, as in normal living persons; they have two sets of chromosomes, one inherited from each biological parent. Some of these moles occur in women who carry mutations in the gene NLRP7, predisposing them towards molar pregnancy. These rare variants of hydatidiform mole may be complete or partial

CLINICAL PRESENTATION and DIAGNOSIS Molar pregnancies usually present with painless vaginal bleeding in the fourth to fifth month of pregnancy. The uterus may be larger than expected, or the ovaries may be enlarged. There may also be more vomiting than would be expected (hyperemesis). Sometimes there is an increase in blood pressure along with protein in the urine. Blood tests will show very high levels of human chorionic gonadotropin (hCG).

The diagnosis is strongly suggested by ultrasound (sonogram), but definitive diagnosis requires histopathological examination. On ultrasound, the mole resembles a bunch of grapes ("cluster of grapes" or "honeycombed uterus" or "snow-storm". There is increased trophoblast proliferation and enlarging of the chorionic villi. Angiogenesis in the trophoblasts is impaired as well. Sometimes symptoms of hyperthyroidism are seen, due to the extremely high levels of hCG, which can mimic the normal Thyroid-stimulating hormone (TSH)

TREATMENT Hydatidiform moles should be treated by evacuating the uterus by uterine suction or by surgical curettage as soon as possible after diagnosis, in order to avoid the risks of choriocarcinoma.[17] Patients are followed up until their serum human chorionic gonadotrophin (hCG) level has fallen to an undetectable level. Invasive or metastatic moles (cancer) may require chemotherapy and often respond well to methotrexate. The response to treatment is nearly 100%. Patients are advised not to conceive for one year after a molar pregnancy. The chances of having another molar pregnancy are approximately 1%. Management is more complicated when the mole occurs together with one or more normal fetuses. Carboprost medication may be used to contract the uterus.

More than 80% of hydatidiform moles are benign. The outcome after treatment is usually excellent. Close follow-up is essential. Highly effective means of contraception are recommended to avoid pregnancy for at least 6 to 12 months. In 10 to 15% of cases, hydatidiform moles may develop into invasive moles. This condition is named persistent trophoblastic disease (PTD). The moles may intrude so far into the uterine wall thathemorrhage or other complications develop. It is for this reason that a post-operative full abdominal and chest x-ray will often be requested. In 2 to 3% of cases, hydatidiform moles may develop into choriocarcinoma, which is a malignant, rapidly-growing, and metastatic (spreading) form of cancer. Despite these factors which normally indicate a poor prognosis, the rate of cure after treatment with chemotherapy is high. Over 90% of women with malignant, non-spreading cancer are able to survive and retain their ability to conceive and bear children. In those with metastatic (spreading) cancer, remission remains at 75 to 85%, although their childbearing ability is usually lost.

FOLLOW UP Follow up is necessary in all women with gestational trophoblastic disease, because of the possibility of persistent disease, or because of the risk of developing malignant uterine invasion or malignant metastatic disease even after treatment in some women with certain risk factors. The use of a reliable contraception method is very important during the entire follow up period, because the follow-up depends on measuring hCG. If a reliable contraception method is not used during the follow-up, there can be great confusion if hCG rises: Why did it rise? Because the patient became pregnant again? Or because the gestational

trophoblastic disease is still present? Therefore, during the prescribed follow up period, the patients must not become pregnant. In women who have a malignant form of GTD, hCG concentrations stay the same (plateau) or they rise. Persistent elevation of serum hCG levels after a non molar pregnancy (i.e., normal pregnancy [term pregnancy], or preterm pregnancy, or ectopic pregnancy [pregnancy taking place in the wrong place, usually in the fallopian tube], or abortion) always indicate persistent GTD (very frequently due to choriocarcinoma or placental site trophoblastic tumour), but this is not common, because treatment mostly is successful. In rare cases, a previous GTD may be reactivated after a subsequent pregnancy, even after several years. Therefore, the hCG tests should be performed also after any subsequent pregnancy in all women who had had a previous GTD (6 and 10 weeks after the end of any subsequent pregnancy).

INCOMPETENT CERVIX Cervical incompetence is a medical condition in which a pregnant woman's cervix begins to dilate (widen) and efface (thin) before her pregnancy has reached term. Internal os opening more than 1 cm is abnormal and cervical length less than 2 cm is considered diagnostic. Cervical incompetence may cause miscarriage or preterm birth during the second and third trimesters. In a woman with cervical incompetence, dilation and effacement of the cervix may occur without pain or uterine contractions. In a normal pregnancy, dilation and effacement occurs in response to uterine contractions. Cervical incompetence occurs because of weakness of the cervix, which is made to open by the growing pressure in the uterus as pregnancy progresses. If the responses are not halted, rupture of the membranes and birth of a premature baby can result.

Risk factors for premature birth or stillbirth due to cervical incompetence include:[1]

diagnosis of cervical incompetence in a previous pregnancy, previous preterm premature rupture of membranes, history of conization (cervical biopsy), diethylstilbestrol exposure, which can cause anatomical defects, and uterine anomalies.

Repeated procedures (such as mechanical dilation, especially during late pregnancy) appear to create a risk. Additionally, any significant trauma to the cervix can weaken the tissues involved.

TREATMENT Cervical incompetence is not generally treated except when it appears to threaten a pregnancy. Cervical incompetence can be treated using cervical cerclage, a surgical technique that reinforces the cervical muscle by placing sutures above the opening of the cervix to narrow the cervical canal. Cerclage procedures usually entail closing the cervix through the vagina with the aid of a speculum. Another approach involves performing the cerclage through an abdominal incision. Transabdominal cerclage of the cervix makes it possible to place the stitch exactly at the level that is needed. It can be carried out when the cervix is very short, effaced or totally distorted. Cerclages are usually performed between weeks 14 and 16 of the pregnancy. The sutures are removed between weeks 36 and 38 to avoid problems during labor. The complications described in the literature have been rare:hemorrhage from damage to the veins at the time of the procedure; and fetal death due to uterine vessels occlusion. No significant differences in pregnancy outcomes were found in the study where performing cerclage was compared to not having it performed. As cerclage can induce preterm contractions without preventing premature delivery,[4] makes the recommendation that it be used sparingly in women with a history of conization.

UMBILICAL CORD PROPLAPSE

Umbilical cord prolapse happens when the umbilical cord precedes the fetus' exit from the uterus. It is an obstetric emergency during pregnancy or labor that imminently endangers the life of the fetus. Cord prolapse is rare.[1] Statistics on cord prolapse vary, but the range is between 0.14% and 0.62% of all births in most studies.

Cord prolapse is often concurrent with the rupture of the amniotic sac. After this happens the fetus moves downward into the pelvis and puts pressure on the cord. As a result, oxygen and blood supplies to the fetus are diminished or cut-off and the baby must be delivered quickly.

TREATMENT Some practitioners will attempt to reduce pressure on the cord and deliver vaginally right away. Frequently the attempt to resolve the prolapsed cord and deliver the baby vaginally fails, and an emergency caesarean section must be performed immediately.[3] While the patient is being prepared for a caesarean, the woman is placed in the Trendelenburg position or the knee-elbow position, and an attendant reaches into the vagina and pushes the presenting part out of the pelvic inlet and back into the pelvis to remove the pressure from the umbilical cord. If

attempts to deliver the baby prompty fail, the fetus' oxygen and blood supply are occluded and brain damage or death will occur. The mortality rate for the fetus is given as 1117%.[6] This applies to hospital births or very quick transfers in a first world environment. One series is reported where there was no mortality in 24 cases with the novel intervention of infusing 500ml of fluid by catheter into the woman's bladder, in order to displace the presenting part of the fetus upward, and to reduce compression on the prolapsed cord[citation needed]; however a recent trial comparing manual support alone (n=29) versus manual support plus bladder-filling (n=15) showed no added benefit in terms of neonatal outcome Potential predisposing risk factors include:

Premature rupture of the amniotic sac polyhydramnios (having a large volume of amniotic fluid). The cord may be forced out with the more forceful gush of waters. long umbilical cord fetal malpresentation multiparity multiple gestation

PREMATURE RUPTURE OF MEMBRANE Premature rupture of membranes (PROM) is a condition that occurs in pregnancy when there is rupture of the membranes (rupture of the amniotic sacand chorion) more than an hour before the onset of labor. PROM is prolonged when it occurs more than 18 hours before labor. PROM is preterm(PPROM) when it occurs before 37 weeks gestation.[1] Risk factors for PROM can be a bacterial infection, smoking, or anatomic defect in the structure of the amniotic sac, uterus, or cervix. In some cases, the rupture can spontaneously heal, but in most cases of PROM, labor begins within 48 hours. When this occurs, it is necessary that the mother receives treatment to avoid possible infection in the newborn

RISK FACTORS Maternal risk factors for a premature rupture of membranes include chorioamnionitis or sepsis. Association has been found between emotional states of fear in a population and prelabor rupture of membranes at term.[3] Fetal factors include prematurity, infection, cord prolapse, or malpresentation.

ASSESSMENT Assessment of a rupture of membranes involves taking a proper medical history, a gynecological exam using a speculum, nitrazine, cytologic (ferning) tests, and ultrasound. Amniotic fluid, when dried for 10 minutes on a slide and then viewed under a microscope, shows a characteristic fernlike pattern. Cervical mucus can also show ferning, but the fern-like shapes are usually smaller. Assessment for rupture of membranes can also involve a test called "Amnisure".

MANAGEMENT In a term pregnancy where premature rupture of membranes has occurred, spontaneous labor can be permitted. Current obstetrical management includes an induction of labor at approximately 12 hours if it has not already begun though many physicians believe it to be safe to induce labor immediately, and consideration of Group B Streptococcal prophylaxis at 18 hours. In light of evidence linking increased risk of cesarean births to inductions, some hospitals, birth centers and midwives do not induce labor at any point after PROM, but rather watch carefully for any signs of infection and ensure that nothing is introduced into the vagina after the PROM, including sterile vaginal exams.

Preterm birth:

Tocolysis is also sometimes used, though its use in this context is controversial. The mother should be admitted to hospital and put under careful surveillance for preterm labor andchorioamnionitis. Induction of labor should happen at around 34 weeks.

antenatal steroids if the gestational age is less than 32 weeks.

Infection

Maternal: If chorioamnionitis is present at the time of PPROM, antibiotic therapy is usually given to avoid sepsis, and delivery is indicated. If chorioamnionitis is not present, prompt antibiotic therapy can significantly delay delivery, giving the fetus crucial additional time to mature.[4] In preterm premature rupture of membranes (PPROM), antibiotic therapy should be given to decrease the risk of sepsis. Ampicillin or erythromycin should be administered for 7 days

Fetal: If the GBS status of the mother is not known, Penicillin or other antibiotics may be administered for prophylaxis against vertical transmission of Group B streptococcal infection.

Abortion Types

Characteristics

Management

Threatened Abortion

occurring before the 20th week of 1. Bedrest gestation 2. No coitus up to 2 weeks after bleeding characterized by cramping and stopped vaginal bleeding with no cervical dilation. it may subside or an incomplete abortion may follow. membranes rupture and the cervix dilates characterized by lower abdominal cramping and bleeding. is characterized by expulsion of only part of the products of conception (usually the fetus). severe uterine cramping bleeding occur with cervical dilation. characterized by complete expulsion of all products of conception light bleeding mild uterine cramping passage of tissue closed cervix 1. 2. 3. 4. 5. 1. 2. 3. 4. Hospitalization D and C Oxytocin after D and C Sympathetic Understanding and emotional support D and C Oxytocin after D and C Sympathetic Understanding and emotional support

Imminent or Inevitable Abortion

Incomplete Abortion

Complete Abortion

1. There is no treatment other than rest is usually needed. 2. All of the tissues that came out should be saved for examination by a doctor to make sure that the abortion is complete. 3. The laboratory examination of the saved tissue may determine the cause of abortion.

Missed Abortion

intrauterine pregnancy is present 1. Usually treated by induction of labor by but is no longer developing dilation (or dilatation) and curettage (D & C). normally the cervix is closed, and the client may report dark brown vaginal discharge. pregnancy test findings are negative. characterized by spontaneous abortion of three or more consecutive pregnancies abortion complicated by infection foul smelling vaginal discharge uterine cramping fever 1. Trace the cause of recurrent abortion

Recurrent orHabitual Abortion Septic Abortion

1. Antibiotics as prescribed by your Obstetrician

ABRUPTIO PLACENTA

Placental abruption (also known as abruptio placentae) is a complication of pregnancy, wherein the placental lining has separated from the uterus of the mother. It is the most common pathological cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth. It occurs in 1% of pregnancies world wide with a fetal mortality rate of 2040% depending on the degree of separation. Placental abruption is also a significant contributor to maternal mortality. The heart rate of the fetus can be associated with the severity.

On the mother:

A large loss of blood or hemorrhage may require blood transfusions and intensive care after delivery. 'APH weakens for PPH to kill'. The uterus may not contract properly after delivery so the mother may need medication to help her uterus contract. The mother may have problems with blood clotting for a few days. If the mother's blood does not clot (particularly during a caesarean section) and too many transfusions could put the mother into disseminated intravascular coagulation (DIC) due to increased thromboplastin, the doctor may consider a hysterectomy. A severe case of shock may affect other organs, such as the liver, kidney, and pituitary gland. Diffuse cortical necrosis in the kidney is a serious and often fatal complication. In some cases where the abruption is high up in the uterus, or is slight, there is no bleeding, though extreme pain is felt and reported.

On the baby:

If a large amount of the placenta separates from the uterus, the baby will probably be in distress until delivery and may die in utero, thus resulting in a stillbirth. The baby may be premature and need to be placed in the newborn intensive care unit. He or she might have problems with breathing and feeding. If the baby is in distress in the uterus, he or she may have a low level of oxygen in the blood after birth. The newborn may have low blood pressure or a low blood count. If the separation is severe enough, the baby could suffer brain damage or die before or shortly after birth.

SYMPTOMS

contractions that don't stop (and may follow one another so rapidly as to seem continuous) pain in the uterus tenderness in the abdomen vaginal bleeding (sometimes) uterus may be disproportionately enlarged pallor

CLINICAL MANIFESTATION

Class 0: asymptomatic. Diagnosis is made retrospectively by finding an organized blood clot or a depressed area on a delivered placenta. Class 1: mild and represents approximately 48% of all cases. Characteristics include the following:

No vaginal bleeding to mild vaginal bleeding

Slightly tender uterus Normal maternal BP and heart rate No coagulopathy

No fetal distress Class 2: moderate and represents approximately 27% of all cases. Characteristics include the following: No vaginal bleeding to moderate vaginal bleeding Moderate-to-severe uterine tenderness with possible tetanic contractions Maternal tachycardia with orthostatic changes in BP and heart rate Fetal distress

Hypofibrinogenemia (i.e., 50250 mg/dL) Class 3: severe and represents approximately 24% of all cases. Characteristics include the following: No vaginal bleeding to heavy vaginal bleeding Very painful tetanic uterus Maternal shock Hypofibrinogenemia (i.e., <150 mg/dL) Coagulopathy Fetal death

PATHOPHYSIOLOGY Trauma, hypertension, or coagulopathy contributes to the avulsion of the anchoring placental villi from the expanding lower uterine segment, which in turn, leads to bleeding into the decidua basalis. This can push the placenta away from the uterus and cause further bleeding. Bleeding through the vagina, called overt or external bleeding, occurs 80% of the time, though sometimes the blood will pool behind the placenta, known as concealed or internal placental abruption. Women may present with vaginal bleeding, abdominal or back pain, abnormal or premature contractions, fetal distress or death. Abruptions are classified according to severity in the following manner:

Grade 0: Asymptomatic and only diagnosed through post partum examination of the placenta. Grade 1: The mother may have vaginal bleeding with mild uterine tenderness or tetany, but there is no distress of mother or fetus. Grade 2: The mother is symptomatic but not in shock. There is some evidence of fetal distress can be found with fetal heart rate monitoring.

Grade 3: Severe bleeding (which may be occult) leads to maternal shock and fetal death. There may be maternal disseminated intravascular coagulation. Blood may force its way through the uterine wall into the serosa, a condition known as Couvelaire uterus.

RISK FACTORS

Maternal hypertension is a factor in 44% of all abruptions. Maternal smoking is associated with up to 90% increased risk. Maternal drinking of alcoholic beverages within a year before conception and during pregnancy can increase the risk by a factor 3 to 4 Maternal trauma, such as motor vehicle accidents, assaults, falls or nosocomial infection. Short umbilical cord Prolonged rupture of membranes (>24 hours) Retroplacental fibromyoma Maternal age: pregnant women who are younger than 20 or older than 35 are at greater risk. Previous abruption: Women who have had an abruption in previous pregnancies are at greater risk. some infections are also diagnosed as a cause cocaine intoxication

The risk of placental abruption can be reduced by maintaining a good diet including taking folic acid, regular sleep patterns and correction of pregnancy-induced hypertension.

OLIGOHYDRAMNIOS

Oligohydramnios is a condition in pregnancy characterized by a deficiency of amniotic fluid. It is the opposite of polyhydramnios. Diagnosis is made by ultrasound measurement of the amniotic fluid index (AFI) <5cm. Several different methods exist for calculating AFI, that produce different index numbers below which oligohydramnios is said to be present. It is typically caused by fetal urinary tract abnormalities such as bilateral renal agenesis ( Potter's syndrome ), fetal polycystic kidneys, or genitourinary obstruction. Uteroplacental insufficiency is another common cause. Most of these abnormalities can also be detected by obstetric ultrasound. It may also occur simply due to dehydration of the mother, maternal use of angiotensin converting enzyme inhibitors, or without a determinable cause (idiopathic). Complications may include cord compression, musculoskeletal abnormalities such as facial distortion and clubfoot, pulmonary hypoplasia and intrauterine growth restriction. Amnion nodosum is frequently also present (nodules on the fetal surface of the amnion). The use of oligohydramnios as a predictor of gestational complications is controversial What is oligohydramnios? Oligohydramnios is the condition of having too little amniotic fluid. Doctors can measure the amount of fluid through a few different methods, most commonly through amniotic fluid index (AFI) evaluation or deep pocket measurements. If an AFI shows a fluid level of less than 5 centimeters (or less than the 5th percentile), the absence of a fluid pocket 2-3 cm in depth, or a fluid volume of less than 500mL at 32-36 weeks gestation, then a diagnosis of oligohydramnios would be suspected. About 8% of pregnant women can have low levels of amniotic fluid, with about 4% being diagnosed with oligohydramnios. It can occur at any time during pregnancy, but it is most common during the last trimester. If a woman is past her due date by two weeks or more, she may be at risk for low amniotic fluid levels since fluids can decrease by half once she reaches 42 weeks gestation. Oligohydramnios can cause complications in about 12% of pregnancies that go past 41 weeks. What causes low amniotic fluid? Birth defects Problems with the development of the kidneys or urinary tract which could cause little urine production, leading to low levels of amniotic fluid. Placental problems If the placenta is not providing enough blood and nutrients to the baby, then the baby may stop recycling fluid. Leaking or rupture of membranes This may be a gush of fluid or a slow constant trickle of fluid. This is due to a tear in the membrane. Premature rupture of membranes (PROM) can also result in low amniotic fluid levels. Post Date Pregnancy- A post date pregnancy (one that goes over 42 weeks) can have low levels of amniotic fluid, which could be a result of declining placental function. Maternal Complications- Factors such as maternal dehydration,hypertension, preeclampsia, diabetes, and chronic hypoxia can have an effect on amniotic fluid levels.

What are the risks of having low amniotic fluid? The risks associated with oligohydramnios often depend on the gestation of the pregnancy. The amniotic fluid is essential for the development of muscles, limbs, lungs, and the digestive system. In the second trimester, the baby begins to breathe and swallow the fluid to help their lungs grow and mature. The amniotic fluid also helps the baby develop muscles and limbs by providing plenty of room to move around. If oligohydramnios is detected in the first half of pregnancy, the complications can be more serious and include:

Compression of fetal organs resulting in birth defects

Increased chance of miscarriage or stillbirth If oligohydramnios is detected in the second half of pregnancy, complications can include:

Intrauterine Growth Restriction (IUGR) Preterm birth Labor complications such as cord compression, meconium stained fluid and cesarean delivery

What treatments are available if I am experiencing low amniotic fluid? The treatment for low levels of amniotic fluid is based on gestational age. If you are not full tem yet, your doctor will monitor you and your levels very closely. Tests such as non-stress and contraction stress test may be done to monitor your babys activity. If you are close to full term, then delivery is usually what most doctors recommend in situations of low amniotic fluid levels. Other treatments that may be used include:

Amnio-infusion during labor through an intrauterine catheter. This added fluid helps with padding around the umbilical cord during delivery and is reported to help lower the chances of a cesarean delivery. Injection of fluid prior to delivery through amniocentesis. The condition of oligohydramnios is reported to often return within one week of this procedure, but it can aid in helping doctors visualize fetal anatomy and make a diagnosis. Maternal re-hydration with oral fluids or IV fluids has shown to help increase amniotic fluid levels.

POLYHYDRAMNIOS

Polyhydramnios (polyhydramnion, hydramnios, polyhydramnios) is a medical condition describing an excess of amniotic fluid in the amniotic sac. It is seen in 0.2 to 1.6% of pregnancies, It is typically diagnosed when the amniotic fluid index (AFI) is greater than 20 cm ( 20 cm

CAUSES A single case of polyhydramnios may have one or more causes. About 14% of cases are due to maternal diabetes mellitus, which causes fetalhyperglycemia and resulting polyuria (fetal urine is a major source of amniotic fluid) and also rh-isoimmunisation can cause it. About another 20% of cases are associated with fetal anomalies that impair the ability of the fetus to swallow (the fetus normally swallows the amniotic fluid). These anomalies include:

gastrointestinal abnormalities such as esophageal atresia, duodenal atresia, facial cleft, neck masses, and tracheoesophageal fistula fetal renal disorders that results in increased urine production during pregnancy, such as in antenatal Bartter syndrome.[6] Molecular diagnosis is available for these conditions.[7] chromosomal abnormalities such as Down's syndrome and Edwards syndrome (which is itself often associated with GI abnormalities) neurological abnormalities such as anencephaly, which impair the swallowing reflex

It may also be caused by a congenital defect (a congenital diaphragmatic hernia), Bochdalek's hernia, in which the pleuro-peritoneal membranes (especially the left) will fail to develop & seal the pericardio- peritoneal canals. This results in the stomach protrusion up into the thoracic cavity, and the fetus is unable to swallow sufficient amounts of amniotic fluid. In a multiple gestation pregnancy, the cause of polyhydramnios usually is twin-twin transfusion syndrome. It can also be caused by some systemic medical conditions in the mother, including cardiac or kidney problems. it can also be caused by intrauterine infection (TORCH) Additionally, chorioangioma of the placenta can also cause this condition. However, it should be reported that in 60-65% of cases it is unknown why polyhydramnios happens.

DIAGNOSIS There are several pathologic conditions that can predispose a pregnancy to polyhydramnios. These include a maternal history of diabetes mellitus, Rh incompatibility between the fetus and mother, intrauterine infection, and multiple pregnancies. During the pregnancy, certain clinical signs may suggest polyhydramnios. In the mother, the physician may observe increased abdominal size out of proportion for her weight gain and gestation age, uterine size that outpaces gestational age, shiny skin with stria (seen mostly in severe polyhydramnios), dyspnea, and chest heaviness. When examining the fetus, faint fetal heart sounds are also an important clinical sign of this condition.

Fetuses with polyhydramnios are at risk for a number of other problems including cord prolapse, placental abruption, premature birth and perinatal death. At delivery the baby should be checked for congenital abnormalities. Another cause of polyhydramnios is skeletal dysplasia, or dwarfism, in the baby. There is a possibility of the chest cavity not being large enough to house all of the baby's organs causing the trachea and esophagus to be restricted, not allowing the baby to swallow the appropriate amount of amniotic fluid.

TREATMENT

Mild asymptomatic polyhydraminos is managed expectantly. For a woman with symptomatic polyhydrminos may need hospital admission. Antacids may be prescribed to relive heartburn andnausea. Dietary salt restriction is recommended. In some cases, amnioreduction, also known as therapeutic Amniocentesis, has been used in response to polyhydramnios

PREGNANCY INDUCED HYPERTENSION

Pregnancy-Induced Hypertension is a group of disorders characterized by the presence of hypertensionbeginning 20 weeks AOG or greater. It is the 2nd cause of maternal mortality in the country (Philippines). Pregnancy-Induced Hypertension is common in those with age below 17 years or more than 35 years, protein malnutrition, pimiparity, diabetes, little or no prenatal care, low socioeconomic status, previous history of hypertension. Basic Manifestations of Pregnancy-Induced Hypertension

proteinuria edema hypertension Types of Pregnancy-Induced Hypertension 1. Toxemia - pre-eclampsia and eclampsia 2. Chronic Essential Hypertension - present during non-pregnant state and combines with pre-eclampsia. I. PRE-ECLAMPSIA 1. Mild Pre-eclampsia

increased BP 20/15 mmHg above baseline (Roll Over Test) weight gain of 1 lb or more per week in last trimester mild generalized edema +1 proteinuria (<300-500> maybe managed at home 2. Severe Pre-eclampsia

BP of 160/110 severe hypertension, 30-40 mmHg while on bedrest massive anasarca and weight gain 3 - +4 proteinuria (5 grams/24 hrs urine collection) less than 500 ml output in 24 hrs (Oliguria) dizziness, headache, blurring or with spots on vision, nausea and vomiting, epigastric pain, and irritabilty) managed in the hospital II. ECLAMPSIA

changes from pre-eclampsia with tonic-clonic seizure attacks to comatose state. Pre-monitoring signs: aura, epigastric pain hypertensive crisis

coma death is from hemorrhage, circulatory collapse, or renal failure obstetrical emergency!!! III. HELLP

characterized by RBC hemolysis, elevated liver enzymes and low platelet count related to severe vasospasm leading to disseminated intravascular coagulation (DIC) platelet and RBC transfusion often are administered, coagulation factors are monitored labor is induced if AOG is more than 32 weeks, cesarean if less than 32 weeks. IV. DIC

clinical manifestations include varying degree of bleeding from oozing to generalized hemorrhage, purpura, and petechiae as a result of overstimulation of coagulation factors coagulation factors are closely monitored and replaced treatment of underlying cause (ie. abruptio placenta, fetal death in utero, PIH) resolves its pathology the only cure is to end the pregnancy Nursing Care for Pregnancy-Induced Hypertension a) closely monitoring of maternal vital signs (esp. BP) and weight, FHR b) bedrest most of the day; side-lying position; 8-12 hours c) high protein (60-70 gram/day), low sodium diet, calcium (1,200 mg), magnesium, 2-6 g of zinc, vit. C and E d) health teachings for symptoms of mild and severe pre-eclampsia e) administration of magnesium sulfate. Corticosteroids and antihypertensives as ordered. HPN drugs are excreted in breast milk f) drug of choice is Magnesium Sulfate (MgSO4) - monitor for magnesium sulfate toxicity

B - blood pressure is decreased U - urine output less than 30 cc/hour R - respiratory rate less than 12 cycles/min (1st to diminish) P - patellar reflex - normal MgSO4 serum level is 1.5 - 3 mEq/L - maintenance dose 4 - 7 mEq/L - at 8-10 mEq/L, respiratory rate starts to diminish - at 10-14 mEq/L, deep tendon reflex is absent g) blood replacements h) monitor for seizure activity and protection from injury i) administer O2 as needed j) prepare mother and her family for early induction of labor. Vaginal delivery is preferred over cesarean k) health teachings on contraception

PRETERM LABOR

Preterm birth is any birth that occurs before the 37th week of pregnancy. It is the cause of many infant deaths and lingering infant illnesses in the United States. Every pregnant woman needs to know about preterm labor and birth why it happens and what she can do to help prevent it. Preterm birth occurs in about 12 percent of all pregnancies in the United States, often for reasons we just don't understand. A normal pregnancy should last about 40 weeks. That amount of time gives the baby the best chance to be healthy. A pregnancy that ends between 20 weeks and 37 weeks is considered preterm, and all preterm babies are at significant risk for health problems. The earlier the birth, the greater the risk. You might have read in the newspapers about babies who are born really early and do very well. But it's important for you to know that those babies are the exceptions. Babies who are born very preterm are at a very high risk for brain problems, breathing problems, digestive problems, and death in the first few days of life. Unfortunately, they also are at risk for problems later in their lives in the form of delayed development and learning problems in school. The effects of premature birth can be devastating throughout the child's life. The earlier in pregnancy a baby is born, the more health problems it is likely to have. Why Does preterm labor occur? There are no easy answers. Stress might play a part for some women, personal health history or infection for others, or smoking or drug use for others. With funding from the March of Dimes and others, researchers are studying how various factors contribute to the complex problem of premature labor and birth. Who is at risk for preterm labor? Preterm labor and delivery can happen to any pregnant woman. But they happen more often to some women than to others. Researchers continue to study preterm labor and birth. They have identified some risk factors, but still cannot generally predict which women will give birth too early. Having a risk factor does not mean a woman will have preterm labor or preterm birth. It just means that she is at greater risk than other women. Three groups of women are at greatest risk of preterm labor and birth: 1. Women who have had a previous preterm birth 2. Women who are pregnant with twins, triplets or more 3. Women with certain uterine or cervical abnormalities If you have any of these three risk factors, it's especially important for you to know the signs and symptoms of preterm labor and what to do if they occur. Lifestyle and environmental risks Some studies have found that certain lifestyle and environmental factors may put a woman at greater risk of preterm labor. These factors include: Late or no prenatal care Smoking Drinking alcohol Using illegal drugs Exposure to the medication DES Domestic violence, including physical, sexual or emotional abuse Lack of social support

Stress Long working hours with long periods of standing Exposure to certain environmental pollutants

Medical risks Certain medical conditions during pregnancy may increase the likelihood that a woman will have preterm labor. These conditions include: Urinary tract infections, vaginal infections, sexually transmitted infections and possibly other infections Diabetes High blood pressure and preeclampsia Clotting disorders (thrombophilia) Bleeding from the vagina Certain birth defects in the baby Being pregnant with a single fetus that is the result of in vitro fertilization (IVF) Being underweight before pregnancy Obesity Short time period between pregnancies (less than 6-9 months between birth and the beginning of the next pregnancy) Preventing preterm labor and birth You can help prevent preterm birth by learning the symptoms of preterm labor and following some simple instructions. The first thing to do is to get medical care both before and during pregnancy. If you do have preterm labor, get medical help quickly. This will improve the chances that you and your baby will do well. Medications sometimes slow or stop labor if they are given early enough. Drugs called corticosteroids, if given 24 hours before birth, can help the baby's lungs and brain mature. This can prevent some of the worst health problems a preterm baby has. Only if a woman receives medical care quickly can drugs be helpful. Knowing what to look for is essential. Treatment with a form of the hormone progesterone may help prevent premature birth in some women who have already had a premature baby. Symptoms of preterm labor Remember, preterm labor is any labor that occurs between 20 weeks and 37 weeks of pregnancy. Here are the symptoms: Contractions (your abdomen tightens like a fist) every 10 minutes or more often Change in vaginal discharge (leaking fluid or bleeding from your vagina) Pelvic pressurethe feeling that your baby is pushing down Low, dull backache Cramps that feel like your period Abdominal cramps with or without diarrhea