COMPLICATIONS OF

PREGNANCY
FIRST TRIMESTER

A. ABORTION/SPONTANEOUS
MISCARRIAGE –
spontaneous interruption of
pregnancy before a fetus is
viable (20 – 24 weeks or at
least 500 grams) associated
with vaginal bleeding
FIRST TRIMESTER
TYPES OF ABORTION
1) THREATENED ABORTION
Bright red, scant bleeding, slight
cramping, no cervical dilatation
Avoid strenuous activities for 24
to 48 hours
Coitus restricted for 2 weeks
FIRST TRIMESTER
2) IMMINENT or
INEVITABLE ABORTION
With uterine contraction
and cervical dilatation
but the products of
conception have not been
expelled
FIRST TRIMESTER

3) COMPLETE ABORTION
The entire products of
conception are expelled
spontaneously without
assistance
FIRST TRIMESTER
4) INCOMPLETE ABORTION
Part of the conceptus
(usually the fetus) is
expelled, but the
membrane or the placenta
is retained in the uterus
Pregnancy is already lost
FIRST TRIMESTER
5) MISSED ABORTION
Early pregnancy failure;
fetus did not form
Fetus died in utero but is
not expelled
DIC may develop if fetus
remains too long in the
uterus
 FIRST TRIMESTER
B. ECTOPIC PREGNANCY
 Implantation outside the uterus; most commonly in
the ampulla
 Amenorrhea with positive pregnancy test
 Rigid, tender abdomen on palpation
 Ruptured: scant vaginal spotting, sharp stabbing pain
in lower abdominal quadrant
 Shock: lightheadedness, rapid pulse & RR, falling BP
 Cullen’s sign; vaginal, abdomen, shoulder pain
 FIRST TRIMESTER
 Treatment
a) If not ruptured,
methotrexate and
leucovorin
b) Ruptured, IVF therapy,
blood transfusion,
laparoscopy to ligate
bleeding vessels
 SECOND TRIMESTER
A. HYPEREMESIS GRAVIDARUM
Exaggerated nausea and vomiting during
pregnancy beyond the first trimester,
resulting to fluid and electrolyte
imbalances, dehydration, jaundice
Obtain 24 to 48 hour dietary recall
Provide bland food (hot if hot, cold if cold;
avoid greasy and spicy food)
 SECOND TRIMESTER
B. HYDATIDIFORM MOLE
o Developmental (degenerative)
anomaly of the placenta
converting chorionic villi into a
mass of clear vesicle
o Appears like clear fluid – filled
grapelike vesicles
o Complete (no embryo) or partial
(a portion of embryo)
 SECOND TRIMESTER
o Elevated HCG levels; no fetal heart
tone
o Uterus is large for gestational age
o Persistent bleeding (dark
red/brown vaginal fluid with
passage of grape like cluster)
o Diagnostic test: ultrasound
o Mole is removed by vacuum
aspiration or curettage
 SECOND TRIMESTER
o Educate in avoiding pregnancy for
at least 1 year
o Educate on the need to monitor
HCG for 1 year (biweekly until low,
monthly for 6 months, q2 months
for the next 6 months)
o If there is still a rise in HCG, further
treatment (hysterectomy or
chemotherapy)
 SECOND TRIMESTER
C. PREMATURE CERVICAL
DILATATION – cervix dilates
prematurely due to cervical
weakness
Show, increased pelvic pressure,
rupture of membranes, discharge
of amniotic fluid
Cervical cerclage prevents
premature cervical dilatation
again
 THIRD TRIMESTER
A. PLACENTA PREVIA
Development of the placenta
in the lower uterine segment,
partially or completely covering
the internal cervical os
Spotting (during 1st and 2nd
trimester)
Bleeding that is sudden,
profuse, bright red and
PAINLESS
THIRD TRIMESTER
Bleeding may not occur until
onset of cervical dilatation
causing the placenta to loosen
from the uterus.
Total placenta previa has
earlier more profuse bleeding
Ultrasound showing the
location and degree of
obstruction
THIRD TRIMESTER
Avoid coitus, get adequate bed rest
with oxygen (as prescribed), notify if
with signs of bleeding
Position: side lying or Trendelenburg
(72 hrs)
NO IE or rectal exam, as it may initiate
massive hemorrhage
Monitor fetal status, determine fetal
lung maturity, keep IV line, blood
transfusion
THIRD TRIMESTER
B. ABRUPTIO PLACENTAE
• Premature separation of a
(normally implanted) placenta,
common among women with
HPN, short umbilical cord, and
alcohol use; also by direct
trauma
• Occurs after 20 to 24 weeks
gestation
THIRD TRIMESTER
B. ABRUPTIO PLACENTAE
• Premature separation of a
(normally implanted) placenta,
common among women with
HPN, short umbilical cord, and
alcohol use; also by direct
trauma
• Occurs after 20 to 24 weeks
gestation
THIRD TRIMESTER
• Painful (sharp stabbing)
vaginal bleeding
• Abdomen is tender, painful,
and tense (board – like)
• There is fetal distress
• May lead to Couvelaire uterus
(blood infiltrating the uterine
musculature) forming a hard,
board – like uterus without
apparent bleeding
THIRD TRIMESTER
• Keep woman in lateral position
• Oxygenation
• FHT monitoring
• Baseline fibrinogen (DIC)
• NO IE or rectal exam, NO
enema
• Keep IV open for possible blood
transfusion
THIRD TRIMESTER
C. DISSEMINATED INTRAVASCULAR
COAGULATION
Fibrinogen level falls to below
effective limits
Easy bruising or bleeding from IV site
Occurs if with extreme bleeding and
so many platelets and fibrin rush to
the site that not enough are left
Heparin, BT
THIRD TRIMESTER
D. PRETERM LABOR
Labor occurring after 20 weeks and
before the end of 37 weeks gestation
Persistent, dull low backache,
vaginal spotting, pelvic pressure or
abdominal tightening, menstrual
like cramping, increased vaginal
discharge, uterine contraction,
intestinal cramping
THIRD TRIMESTER
Contractions are less than 10
minutes apart leading to progressive
cervical changes
Risk Factors: previous preterm
labor, abdominal surgery, younger
than 17, older than 35, abnormality
of fetus or placenta, multiple
gestation, nutritional deficiency,
emotional and physical stress
THIRD TRIMESTER
FOCUS: prevention of the delivery
of a premature fetus
Conditions to halt labor: intact
membranes, good FHT, no
evidence of bleeding, cervix not
dilated more than 3 or 4 cm,
effaced <50%. If any of these
conditions is not present, delivery,
regardless of fetal age, is
inevitable.
THIRD TRIMESTER
Conservative treatment:
a. Place in left lateral position; bed
rest
b. Hydration which influence on
stopping of labor
c. Relieve anxiety by providing
assuring information
d. Relaxation techniques
THIRD TRIMESTER
Conservative treatment:
a. Place in left lateral position; bed
rest
b. Hydration which influence on
stopping of labor
c. Relieve anxiety by providing
assuring information
d. Relaxation techniques
THIRD TRIMESTER
E. PREMATURE RUPTURE OF
MEMBRANES (PROM)
o Rupture and loss of amniotic fluid
that occurs before labor begins. If
associated with premature labor,
PROM poses the risk of immature
birth
o There is a gush of clear fluid from
the vagina
THIRD TRIMESTER
o Differentiated from urine by nitrazine
paper (turns blue for pH more than
6.5 or the alkaline amniotic fluid)
o No coitus and douching
o Strict bed rest
o Tocolytic therapy until fetal lungs
mature, resulting from corticosteroid
administration
o Watch and monitor for signs of
infection
THIRD TRIMESTER
F. PREGNANCY INDUCED
HYPERTENSION
Originally called toxemia
Pathophysiology is based on
vascular spasm leading to
hypertension, edema, and
proteinuria
THIRD TRIMESTER
MILD PREECLAMPSIA
BP of 140/90 taken on 2 occasions 6h
apart (may increase to 30/15)
1+ to 2+ protein in urine on random
urinalysis
Weight gain of 2 lbs per week (2nd
trimester) and 1 lb per week (3rd
trimester); abnormal weight gain
THIRD TRIMESTER
MILD PREECLAMPSIA
Slight edema in upper extremities and
face
Left side lying
Bed rest
THIRD TRIMESTER
SEVERE PREECLAMPSIA
BP of 160/110 on 2 occasions 6h apart
3+ to 4+ protein in urine on random
Oliguria (<500ml/24hrs)
Cerebral or visual disturbance
Epigastric pain, shortness of breath
Peripheral edema
Pulmonary edema
Hepatic dysfunction
THIRD TRIMESTER
Extensive edema (puffiness of face
and hands)
Bed rest (limit visitors, darken room)
Avoid stress, monitor BP, obtain
daily weights
Moderate to high protein diet,
moderate sodium
Administer hydralazine and
labetalol (causes tachycardia)
THIRD TRIMESTER
Assess BP and pulse after
administration
DOC: Magnesium sulfate – reduces
edema and lessens possibility of
seizures
a. Overdose: decreased UO,
respirations, consciousness, DTR
b. Calcium gluconate (antidote) at
bedside for magnesium toxicity
THIRD TRIMESTER
HELLP
Hemolysis

Elevated Liver
Function Test

Low Platelet Count

THIRD TRIMESTER
ECLAMPSIA
HPN, proteinuria, convulsions,
COMA
Death from cerebral hemorrhage,
circulatory collapse or renal failure
Maintain a patent airway,
administer oxygen, turn woman to
side
Vaginal birth is the preferred
delivery
 THIRD TRIMESTER
FOR PREECLAMPSIA
Assess BP in sitting and left lateral position; protein level in urine;
changes in level of consciousness, weight, FHT, vaginal bleeding
BEDREST (aids in sodium excretion)
Left lateral recumbent position
High protein diet
Seizure precautions (note headaches, visual changes, dizziness,
and epigastric pain)
 THIRD TRIMESTER
FOR ECLAMPSIA
Maintain IV line
Keep oxygen and airway equipment available at bedside, also
padded tongue depressor
Minimize stimuli
Medication as ordered (magnesium sulfate, diazepam,
hydralazine)
Side rails up and padded
Aspiration precaution post ictal phase
THIRD TRIMESTER
MAGNESIUM SULFATE
 DOC for the prevention and treatment
of convulsion by decreasing muscular
irritability and CNS depression
 Therapeutic level is 4 – 7 mg/100ml
 Given slow piggyback IV but may be
irritating to the vein or IM given Z-track
method
 Monitor RR closely as respirations may
depress
THIRD TRIMESTER
 Poor urinary excretion may lead to
toxicity! (accurate I&O); catheterization
 Monitor Deep Tendon Reflex (DTR);
absence means increase in magnesium
level
 Monitoring of maternal and fetal vital
signs
 Calcium gluconate is the ANTIDOTE
DURING PREGNANCY
G. GESTATIONAL DIABETES
Women who do not begin pregnancy
with diabetes become diabetic during
pregnancy (approximately 2% – 3%)
Characterized by: polydipsia,
polyphagia, polyuria (glycosuria,
hyperglycemia)
DURING PREGNANCY
G. GESTATIONAL DIABETES
Women who do not begin pregnancy
with diabetes become diabetic during
pregnancy (approximately 2% – 3%)
Characterized by: polydipsia,
polyphagia, polyuria (glycosuria,
hyperglycemia)
DURING PREGNANCY
GLUCOSE SCREENING TEST
1 hour fasting for FBS
Given 50g glucose load
Blood sample for sugar 1 hour after

If FBS is more than 90 mg/dl and at 1

hour post glucose loading is more than
140 mg/dl, DIABETIC
DURING PREGNANCY
THREE HOUR GLUCOSE TOLERANCE
TEST
3 – hour version of the OGTT
The health care provider will instruct
you to consume a syrupy glucose
solution containing 100g of sugar
Normal findings: FBS – 80 to 100 mg/dl
1 hr: <190 mg/dl; 2 hrs: <165 mg/dl; 3 hours:
<145 mg/dl
DURING PREGNANCY
GLYCOSYLATED HEMOGLOBIN
Hemoglobin A1c – shows what a
person’s average blood glucose was
for the 2 – 3 months before the test
Glycosylated hemoglobin – form of
hemoglobin chemically linked to
sugar
Normal range value: 4.2% to 6.5%
DURING PREGNANCY
MACROSOMIA
Fetal birth weight ≥4000 grams
May affect 12% of newborns of
normal women and 15% to 45%
of newborns of women with GDM
The increased risk of macrosomia
in GDM is mainly due to the
increased insulin resistance of the
mother
DURING PREGNANCY
MACROSOMIA
Fetal birth weight ≥4000 grams
May affect 12% of newborns of
normal women and 15% to 45%
of newborns of women with GDM
The increased risk of macrosomia
in GDM is mainly due to the
increased insulin resistance of the
mother
DURING PREGNANCY
Dizziness if hypoglycemic,
confusion if hyperglycemic
Hydramnios
Possible PIH, moniliasis
Management:
a) Diet: 20% of calories from
protein; 50% from
carbohydrates, 30% from fats;
increased dietary fibers
DURING PREGNANCY
b. Exercise: to lower blood glucose
c. Stress managemet
d. Insulin: usually short acting
(regular)insulin combined with
intermediate acting (clear then
cloudy)
 NO ORAL HYPOGLYCEMIC
AGENTS – it passes through
placental barrier and can be
teratogenic
DURING PREGNANCY