NUMA.

1212
Daw May Thin Han
Tutor
MTS
Taunggyi
10.12.220 (9:30 Am to 11:30 Am)
 Unit . 1
Nursing Management of Pregnant Woman
with abnormal conditions
 Unit . 1
1.1. SEXUAL TRANSMISSIBLE AND REPRODUCTIVE

TRACT INFECTION

1.2. HYPERTENSIVE DISORDERS OF PREGNANCY

1.3. PREGNANCY WITH HEALTH PROBLEMS

1.4. MULTIPLE PREGNANCY

1.5. BLEEDING DURING PREGNANCY

1.6. INTRAUTERINE GROWTH RETARDATION,

INTRAUTERINE FETAL DEATH

1.7. POST-TERM PREGNANCY

 1.2. HYPERTENSIVE DISORDERS OF PREGNANCY

ECLAMPSIA
- When the patient in convulsions and coma -called eclampsia
- epilepsy may have convulsions in pregnancy, but not
accompanied by oedema, hypertension and proteinuria which
characterize eclampsia
- pre-eclamptic patient has fits that toxaemia has seriously
affected central nervous system
- may occur before during and after delivery
Stages of Eclamptic Fit (Convulsion)
- Premonitory stage
- Tonic stage or stage of rigidity
- Clonic or convulsive stage
- Stage of coma or unconsciousness
 1.2. HYPERTENSIVE DISORDERS OF PREGNANCY

ECLAMPSIA
Stages of Eclamptic Fit (Convulsion)
Premonitory stage- restless and rolls eyes, extends neck to one
side. Twitching of facial muscles (few seconds)
Tonic stage or stage of rigidity- whole body rigid, teeth clenched,
the eyes open & staring, diaphragm withdrawn, respiration ceases
cyanosed for a few seconds
Clonic or convulsive stage- whole body twitches with convulsion,
grinds teeth together & may bite tongue, Urine and faces may be
passed involuntarily
Stage of coma or unconsciousness -muscles relax and state of
coma with deep stertorous breathing. Consciousness regained after
an interval lasting a few moments or many hours, or may still be
unconscious when the next fit
 1.2. HYPERTENSIVE DISORDERS OF PREGNANCY

ECLAMPSIA
Management during a Convulsion
• anti-convulsive drugs
• Gather equipment (airway, suction, mask and bag, oxygen)
• give oxygen at 4-6 L /min
• Protect from injury
• Place on her left side to reduce risk of aspiration
• After convulsion, aspirate mouth and as necessary
 1.2. HYPERTENSIVE DISORDERS OF PREGNANCY

General Management
• diastolic BP >110 mmHg, give antihypertensive& Reduce to
<100 mm Hg but not <90 mm Hg.
• IV infusion
• strict I/Ochart (monitor fluids administered & output to ensure
no fluid overload
• Catheterize to monitor urine output and proteinuria
• If urine output is less than 30 ml per hour:
Withhold magnesium sulfate and infuse IV fluids (N/S or R/L)

Monitor for pulmonary oedema (Auscultate the lung bases

hourly)
• Never leave the woman alone
• Observe vital signs, reflexes & FHS hourly
 1.2. HYPERTENSIVE DISORDERS OF PREGNANCY

Anticonvulsive Drugs
• adequate administration of anticonvulsive drugs
• Magnesium sulfate is the drug of choice for preventing and
treating convulsions in severe pre-eclampsia and eclampsia
• If not available, diazepam may be used (greater risk for neonatal
respiratory depression -passes the placenta freely)
• A single dose seldom causes neonatal respiratory
depression. Long-term administration increases the risk &
suffering from utero-placental ischaemia & preterm birth)
Box S-3 Magnesium sulfate schedules for severe pre-eclampsia and eclampsia

Loading dose

 Magnesium sulfate 20% solution, 4g IV over 5 minutes.

 Follow promptly with 10g of 50% magnesium sulfate solution, 5g in each
buttock
as deep IM injection with 1 ml of 2 % lignocaine in the same syringe.
Ensure that aseptic technique is practiced when giving magnesium sulfate
deep IM
injection. Warm the women that a feeling of warmth will be felt when
magnesium
sulfate is given.
 If convulsions recur after 15 minutes, give 2 g magnesium sulfate (50%
solution ) IV over 5 minutes.
Maintenance dose
 5g magnesium sulfate (50 % solution) 1 ml lignocaine 2 % IM every 4
hours into alternate buttocks.
 Continue treatment with magnesium sulfate for 24 hours after delivery or
the last convulsion, whichover occurs last.
Before repeat administration, ensure that:
 Respiratory rate is at least 16 per minute.
 Patellar reflexes are present.
 Urinary output is at least 30 ml per hour over preceding 4 hours.
Withhold or Delay drug if:
 Respiratory rate falls below 16 per minute.
 Patellar reflexes are absent.
 Urinary output is falls below 30 ml per hour over preceding 4 hours.
Keep antidote ready
 In case of respiratory arrest.
 Assist ventilation mask and bag, anesthesia apparatus, intubation).
Give calcium gluconate 1 g (10 ml of 10 % solution ) slowly until
respiration begins to antagonize the effects of magnesium sulfate.
Note : Use diazepam only if magnesium sulfate is not available.

Intravenous administration

Loading dose
 Diazepam 10 mg IV slowly over 2 minutes.
 If convulsions recur, repeat loading dose.
Maintenance dose
 Diazepam 40 mg in 500 ml. IV fluids (normal saline or Ringer’s lactate)
Trained to keep the women sedated but rousable.

 Maternal respiratory depression may occur when dose exceeds 30 mg in 1 hour.

Assist ventilation (mask and bag, anesthesia apparatus, intubation), if necessary.

Do not give more than 100 mg in 24 hours.

Rectal administration
 Give diazepam rectally when IV access is not possible. The loading dose is 20
mg in a 10 ml syringe. Remove the needle, lubricate the barrel and insert the
syringe into the rectum to half its length. Discharge the content and leave the
syringe is place, holding the buttocks together for 10 minutes to prevent
expulsion of the drug. Alternatively, the drug may be instilled in the rectum
through a catheter.
 If convulsions are not controlled within 10 minutes, administer an additional 10
mg per hour or more, depending on the size of the woman and her clinical
response.
 1.2. HYPERTENSIVE DISORDERS OF PREGNANCY

ANTIHYPERTENSIVE DRUGS
• to keep the diastolic pressure between 90 mmHg & 100 mmHg
• to prevent cerebral haemorrhage
• Hydralazine is the drug of choice.
• 5mg IV slowly every 5 min until Bp lowered. Repeat hourly as
12.5 mg IM every 2 hr
• If not available, give labetolol 20 mg IV: (If inadequate, give 20
mmHg IV)
• - Increase dose to 40 mg then 80 mg
• if satisfactory response not obtained after 10 minutes of each
dose;
• - OR Nifedipine 5 mg under the tongue
• - If response is inadequate,, give an additional 5 mg
• Note: possibility interaction with magnesium sulfate (hypotension)
 1.2. HYPERTENSIVE DISORDERS OF PREGNANCY

DELIVERY
• as soon as the condition has stabilized
• Delaying will risk both the woman & fetus (regardless of
gestational age)
• In severe PE, within 24 hours of onset of symptoms
• In eclampsia, within 12 hours of onset of convulsions
Assess the cervix.
• If cervix is favourable (soft, thin, partly dilated), rupture the
membranes & induce by oxytocin/prostaglandins
• If cervix is unfavourable (firm, thick, closed) & fetus is alive,
deliver by caesarean section
If caesarean section is performed, ensure that:
• Coagulopathy
• Safe general anesthesia (Spinal anesthesia - risk of hypotension)
 1.2. HYPERTENSIVE DISORDERS OF PREGNANCY

DELIVERY
• If VD not anticipated within 12 hrs (eclampsia) or 24 hrs (severe
pre- eclampsia- caesarean section
• If FHR abnormalities (<100 or >180 bpm), - caesarean section
• If safe anesthesia not available /fetus is dead / too premature -
vaginal delivery;
• - If the cervix is unfavourable (firm, thick, closed), ripen
by using misoprostol, prostaglandins / Foley catheter
• Do not use local anaesthesia or ketamine in women with pre-
eclampsia or eclampsia
 1.2. HYPERTENSIVE DISORDERS OF PREGNANCY

ECLAMPSIA
POSTPARTUM CARE
• Anticonvulsive for 24 hours after delivery/last convulsion
• antihypertensive till diastolic pressure -110 mmHg or more.
• monitor urine output

REFERRAL FOR TERTIARY LEVEL CARE

• Oliguria for 48 hours after delivery
• Coagulation failure [e.g. (HELIP) syndrome];
• Persistant coma >24 hours after convulsion
 1.2. HYPERTENSIVE DISORDERS OF PREGNANCY
COMPLICATIONS OF PREGNANCY-INDUCED HYPERTENSION
• prevent by early diagnosis & proper management
• management can also lead to complications
• If fetal growth restriction is severe, expedite delivery
• If increasing drowsiness or coma, - cerebral haemorrhage:
• Reduce blood pressure slowly & Provide supportive therapy
• heart, kidney or liver failure -provide supportive therapy &
observe
• failure of clot after 7 min/soft clot breaks down -coagulopathy
• IV lines and catheters, infection prevention & monitor signs of
infection
• IV fluids, -circulatory overload ( I&O)
 1.2. HYPERTENSIVE DISORDERS OF PREGNANCY

CHRONIC HYPERTENSION
• Encourage rest
• Blood pressure should not be lowered below pre-pregnancy
level
• anti-hypertensive medication before pregnancy and
• well-controlled, continue the same
• diastolic pressure 110 mmHg or more or systolic blood
pressure is 160mmHg or more- antihypertensive drugs
• proteinuria or other S&S present,- superimposed PE -manage
as mild pre-eclampsia
• Monitor fetal growth & condition
• no complications - deliver at term
 1.2. HYPERTENSIVE DISORDERS OF PREGNANCY

CHRONIC HYPERTENSION
• pre-eclampsia - manage as mild/severe pre-eclampsia
• FHR abnormalities - fetal distress
• If fetal growth restriction is severe and pregnancy dating is
accurate, assess the cervix and consider delivery:
Assess the cervix.
• If cervix is favourable (soft, thin, partly dilated), rupture the
membranes & induce by oxytocin/prostaglandins
• If cervix is unfavourable (firm, thick, closed) ripen the cervix
with prostaglandins or Foley catheter
• Observe for complications (abruptio placentae & superimposed
pre- eclampsia
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Management
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