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An arterial blood gas (ABG) test is a procedure that involves taking a blood sample from an artery in the wrist, arm, or groin to measure oxygen levels. The test is often performed by a respiratory therapist and is usually safe, but it can be more painful than a traditional blood draw.
Here are some steps that may be involved in an ABG test:
An arterial blood gas (ABG) test is a procedure that involves taking a blood sample from an artery in the wrist, arm, or groin to measure oxygen levels. The test is often performed by a respiratory therapist and is usually safe, but it can be more painful than a traditional blood draw.
Here are some steps that may be involved in an ABG test:
An arterial blood gas (ABG) test is a procedure that involves taking a blood sample from an artery in the wrist, arm, or groin to measure oxygen levels. The test is often performed by a respiratory therapist and is usually safe, but it can be more painful than a traditional blood draw.
Here are some steps that may be involved in an ABG test:
An arterial blood gas (ABG) test is a procedure that involves taking a blood sample from an artery in the wrist, arm, or groin to measure oxygen levels. The test is often performed by a respiratory therapist and is usually safe, but it can be more painful than a traditional blood draw.
Here are some steps that may be involved in an ABG test:
An arterial blood gas (ABG) test is a procedure that involves taking a blood sample from an artery in the wrist, arm, or groin to measure oxygen levels. The test is often performed by a respiratory therapist and is usually safe, but it can be more painful than a traditional blood draw.
Here are some steps that may be involved in an ABG test:
An arterial blood gas (ABG) test is a procedure that involves taking a blood sample from an artery in the wrist, arm, or groin to measure oxygen levels. The test is often performed by a respiratory therapist and is usually safe, but it can be more painful than a traditional blood draw.
Here are some steps that may be involved in an ABG test:
An arterial blood gas (ABG) test is a procedure that involves taking a blood sample from an artery in the wrist, arm, or groin to measure oxygen levels. The test is often performed by a respiratory therapist and is usually safe, but it can be more painful than a traditional blood draw.
Here are some steps that may be involved in an ABG test:
An arterial blood gas (ABG) test is a procedure that involves taking a blood sample from an artery in the wrist, arm, or groin to measure oxygen levels. The test is often performed by a respiratory therapist and is usually safe, but it can be more painful than a traditional blood draw.
Here are some steps that may be involved in an ABG test:
An arterial blood gas (ABG) test is a procedure that involves taking a blood sample from an artery in the wrist, arm, or groin to measure oxygen levels. The test is often performed by a respiratory therapist and is usually safe, bu

1. High Risk Pregnancies

2. Objectives Discuss PIH, pre-eclampsia & eclampsia Review the management of PIH, pre-eclampsia & eclampsia Discuss GDM & its management Discuss abortion ,its type and management Discuss the role of community health care providers

3. Introduction Chronic hypertension: hypertension present at the booking visit or before 20 weeks. Gestational hypertension/PIH: hypertension presenting after 20 weeks of gestation without significant proteinuria. Pre-eclampsia : hypertension presenting after 20 weeks of gestation with significant proteinuria. Eclampsia: is a convulsive condition associated with pre-eclampsia. (NICE, 2011)

4. Classification of Hypertension Mild hypertension: diastolic blood pressure 90–99 mmHg, systolic blood pressure140–149 mmHg. Moderate hypertension: diastolic blood pressure 100–109 mmHg, systolic blood pressure150–159 mmHg. Severe hypertension: diastolic blood pressure 110 mmHg or greater, systolic blood pressure 160 mmHg or greater. (NICE, 2011)

5. Classification of Protein urea Mild Pre-eclampsia: Protein up to 2+ An excretion of 0.3 g (300mg) protein/24 hours Severe Pre-eclampsia: protein 3+ or more

6. Risk Factors First pregnancy Age ≥ 40 years Previous pre-eclampsia Body mass index ≥ 35 Family history of pre-eclampsia Booking diastolic blood pressure ≥ 80 mm Hg Proteinuria at booking (≥ 300 mg/24 h) Multiple pregnancy Underlying medical conditions: – Pre-existing hypertension, renal disease, diabetes, presence of anti-phospholipid antibodies

7. Clinical features History Usually asymptomatic Headache Drowsiness Visual disturbance Nausea & vomiting Epigastric pain Decrease urinary output Decreased fetal movement Examination Oedema (hands and face) Proteinuria on dipstick Epigastric tenderness (liver involvement)

8. Management of PIH Aim of care is to have safe delivery at term Rest, lying left side to ensure ample fetal blood supply Ensure regular pre-natal visits Progress of gestation: Any abdominal discomfort PV bleeding (placenta abruptio--- separation of placenta before term; painless bleeding occur) BP monitoring Fetal assessment Fluid intake Urine test for creatinine and protein

9. Medical Management of PIH Anti hypertensive therapy Steroids, to reduce the risk of neonatal respiratory distress by increasing production of surfactant Aspirin, to inhibit the production of thromboxane (Platelet Aggregating Agent) 9

10. Pre-Eclampsia Toxemia (PET) Profile Liver Function Test (LFTs) Platelets PT/APTT Uric Acid Creatinine Fetal: Ultrasound FHS, Fetal size/growth, amniotic fluid volume, doppler scan ---umbilical cord blood flow CTG

11. Mana g ement **Remember: No cure except delivery Anti-hypertensives: Methyldopa (Aldomat, Adalat) Labetalol **(Avoid beta blocker in asthmatics) Nifedipine In case of eclampsia: Magnesium sulphate --- Anti-convulsant **Calcium gluconate --- antidote Induction of labour: Ensure to administer antenatal steroids (inj. Dexamethasone)

12. Management; Mild Preeclampsia (PET) Bed Rest, only bathroom privilege Rest in left lateral ( ↓pressure to venacava--↑cadiac return--↑ perfusion to vital organs ↑ blood to kidneys --↓ angiotensin – diuresis-- low BP) Keep calm and quite Restrict visitors Diet Protein diet (1.5g / kg ) to replace loss in urine High fiber to avoid constipation Monitor Fetal Activity Kick chart --- note fetal movement every hour (approx. ten kicks in any twelve hour period)

13. Anti-hypertensive (hydralazine) Sedative Diazepam (fetal addiction) Anticonvulsants MgSO4: blocks the neuromuscular transmission by reducing acetylcholine and causing the Smooth Muscle relaxation (Safe for fetus) Management; Severe Preeclampsia

14. Eclam p sia Characterized by: grand mal seizures & coma Tonic clonic form of convulsion Tonic stage: (10-20 seconds) muscle spasms and rigid teeth, clenched, eye staring Clonic stage: (1 minute) violent contraction and intermittent, relaxation, salivation increase and foaming, tongue bite Stage of coma: noisy breathing with unconsciousness 14

15. Signs of MgSO4 Toxicity Respiratory Rate ≤ 12 Decreased deep tendon reflexes, sluggish patellar reflex Urine output < 30ml/hour **Immediately stop MgSO4, administer “calcium gluconate”

16. Maternal Complications Head/brain Eclampsia, Stroke/ cerebrovascular haemorrhage Heart Heart failure Lung Pulmonary oedema, bronchial aspiration, ARDS Liver Hepatocellular injury, liver failure, liver rupture Kidneys Renal failure, oliguria Vascular Uncontrolled hypertension, DIC HELLP syndrome (haemolysis, elevated liver enzymes and low platelets) (RCOG, 2010)

17. Fetal Complications IUGR Oligo-hydramnios Placental infarction Placental abruption --- painless bleeding, often fetal parts non-palpable Utero-placental insufficiency Prematurity

18. GESTATIONAL DIABETES MELLITUS This is defined as carbohydrate intolerance resulting in hyperglycemia Among all pregnancies 65% cases are involved in gestational diabetes Onset during pregnancy, usually in second and third trimester (Fraser & Cooper, 2014)

19. Ca u se Hormones from the placenta (HPL, progesterone, cortisol) block the action of the mother's insulin in her body (insulin resistance) Insulin resistance makes it hard for the mother's body to use insulin GDM starts when body is not able to make & use all the insulin Without enough insulin, glucose cannot leave the blood and be changed to energy hyperglycemia

20. Diagn o sis Monitor for cardinal signs of diabetes, increased thirst (polydipsia), increased urine volume (polyuria), increased hunger (polyphagia), unexplained weight loss OGTT should always be used to diagnose GDM at 28 weeks of gestation, but if the client is at a greater risk then can be done at 20 – 24 weeks

21. Risk factors for GDM Increased maternal age and weight Previous GDM Previous macrosomic infant Family history of diabetes

22. Maternal complications Obstetric complications Polyhydramnios (increased volume of amniotic fluid) Pre-eclampsia Diabetic emergency Hypoglycemia Ketoacidosis Diabetic coma Vascular and organ involvement (cardiac, renal, ophthalmic, and peripheral vascular) Neurologic (peripheral neuropathy) Infection (antepartum and postpartum)

23. Fetal complications Spontaneous abortion Premature labor and delivery (premature preterm rupture of the membrane, PPROM) Unexplained intrauterine fetal demise and stillbirth Macrosomia with traumatic delivery such as cesarean section and shoulder dystocia Delayed organ maturity (lung) Congenital anomalies IUGR

24. Pre-pregnancy Care History Contraceptive advice Risks of pregnancy (maternal and fetal/neonatal) Importance of maintaining blood glucose levels FBS, RBS, HbA1c levels Nutritional and dietary advice

25. Antenatal Care Blood glucose level should be monitored; (glycosylated hemoglobin) HbA1c, OGTT, FBS, RBS levels Obtain follow up history & perform examination Ultrasound: fetal growth Encourage 30 minutes exercise every day Dietary advice

26. Dietary Management Determine weight Eat small frequent meals Take high fiber diet Avoid concentrated sweets Cookies, cakes, pies, soft drinks, chocolate, table sugar, fruit juice, jams or jellies. Avoid convenient foods Instant noodles, canned soups, instant potatoes, frozen meals or packaged stuffing

27. Intrapartum Care Birth of baby should be recommended with neonatal intensive care facilities Monitor & maintain blood sugars: 80-120 mg/dl Administer insulin if sugar more than 120 mg/dl Maintain partograph; assess progress of labor, maternal & fetal condition

28. Postpartum Care After third stage of labor (delivery of placenta) the insulin requirement will rapidly fall; carbohydrate metabolism returns to normal very quickly Reduce the insulin infusion rate at least 50% Monitor blood glucose level Encourage breastfeeding Women with diabetes will prone to infection and delayed wound healing, the administration of antibiotics is useful after operative birth Advice for contraceptive

29. Abortion Abortion is defined as, “the expulsion of fetus before it reaches viability.” The interruption in pregnancy before it is viable. WHO has recommended that the fetus is viable when the gestation period has reached 22 or more weeks, or when the fetus weights 500 grams. 29

30. FE T AL C A U S E S MATERNAL CAUSES Chromosomal abnormalities Structural abnormalities Maternal age Structural abnormalities of the genital tract, reproductive organs Genetic causes (e.g. Cousin marriage Uterine causes Maternal Disease Dietary causes Environmental factors Maternal Immune response Endocrine abnormalities 10.Stress Hormonal deficiency In Vitro Fertilization (21% abort spontaneously) Incompetent cervix, cervical trauma 30

31. Reasons for Pregnancy Termination In adequate finances Lack of readiness for responsibility Change of roles and responsibilities Problems in relationships Unmarried (socio cultural reasons) Too young Possible health problems with fetus Maternal health problems Rape, incest, etc. 31

32. Types of Abortion Spo n taneo u s Abortion Threatened Pregnancy Progre s s e s Birth of a viable Baby Mis s ed Birth Mole Inevitable Incomplete Septic Complete 32

33. Co n t. . . Induced Therapeutic Criminal/Unsafe S e ptic 33

34. Threatened Abortion It means there is only threat of abortion, the process has started but it may be arrested and pregnancy may continue. Symptoms Blood loss may be scanty, with or without low backache and cramping pains. The pain may resemble dysmenorrhea. Cervical os remains closed. Outcomes of Threatened Miscarriage IUGR Pre-term labour Inevitable miscarriage 34

35. Care Limit enemas and vaginal examinations Allow bed rest until bleeding ceases Hospital admission: Ultrasounds for monitoring of fetal growth Bleeding Serum progesterone levels 35

36. Inevitable Abortion The key feature of inevitable abortion is cervical dilatation . It means the process has become irreversible; the expulsion of products of conception has not occurred but bound to happen. Moreover, nothing can be done to stop this process and will proceed to incomplete /complete abortion. There is often severe vaginal bleeding along with labour contractions. 36

37. Signs & Symptoms The size of uterus will be smaller than expected The membranes can rupture, & amniotic fluid will be seen The cervix dilates and heavy bleeding occurs Clots may be seen in the vagina or protruding through the os Severe rhythmical abdominal pain Gestational sac containing embryo or fetus may be expelled Care Clean the vulva using aseptic technique Provide sterile pad Save pads to examine the products of conception Monitor for the signs of shock 37

38. Incomplete Abortion Incomplete abortion means abortion has taken place, but some retained products of conception (RPOCs), are inside the uterine. This is more likely to occur in second trimester of pregnancy. Symptoms Part or all of placenta remains within the uterine cavity contributing to bleeding that may be heavy and profuse, leading to shock. 38

39. Complete Abortion In complete abortion, all the products of conception embryo/ fetus, placenta and membranes are expelled completely and nothing is left behind in the uterine cavity. It is more likely to occur in the first eight weeks of pregnancy. Symptoms Severe pain Heavy profuse bleeding initially, but after expulsion there is light bleeding 39

40. Recurrent Abortion When a woman has had three or more  consecutive pregnancies ending in spontaneous abortion Mostly, cause is unknown Examine karyotype & autoimmune factors U/S : to assess ovarian morphology (PCOs) & uterine cavity Cervical cerclage, at 14 - 16 weeks in cases with cervical incompetence Administer low dose aspirin during pregnancy; BUT stop it at 36 weeks 40

41. Missed Abortion Features Gradual disappearance of pregnancy signs & symptoms Brownish vaginal discharge Pregnancy test: negative but it may be + ve for 3-4 weeks after the death of the fetus. U/S: absent fetal heart pulsation Complications Infection (Septic abortion) DIC Treatment - Wait 4 weeks for spontaneous expulsion - Evacuate if: Spontaneous expulsion does not occur after 4 weeks Infection DIC Manage according to size of uterus -If uterus size is < 12 weeks: dilatation and evacuation - If uterus size is > 12 weeks: try oxytocin or PGEs. 41

42. Induced Abortion It is an intentional termination of a pregnancy Induced abortion occurs as a result of interference in the natural process which may be medical, surgical or result from the use of herbal preparations or other traditional practices which cause the uterus to completely or partly expel the contents Induced abortion may be legal or illegal according to the law in the country In Pakistan, it is illegal unless required to save a woman’s life 42

43. Methods of Therapeutic Abortion Misoprostol Suction evacuation Manual Vacuum Aspiration (MVA) 43

44. Therapeutic Abortion An abortion is considered legal in conditions where termination is the only way to save the life of a woman or to provide necessary treatment to the woman during pregnancy 44

45. Criminal Abortion Any abortion which is performed by a person who lacks necessary skills; & is not permitted under the country law to carry out such a procedure. There is a very high risk of sepsis and/or haemorrhage as well as other injuries, like fistula. 45

46. Septic Abortion Uterine infection occurring after any abortion or invasive procedures Signs & Symptoms Fever, tachycardia, headache, nausea , general malaise, uterine tenderness, offensive vaginal loss Care Shock management Isolation Microscopy and blood cultures Antibiotics Uterine evacuation 46

47. C o mplicatio n s Septicemia Shock DIC Liver and renal damage (Jaundice, Oligouria) Adhesion formation, salphingitis, infertility

48. Management of Abortions  First Trimester : The first trimester involves less pain and complications. The main procedure involved are as follows: Manual Vacuum Aspiration (MVA) (up to 6 th - 9 th week after conception) Dilation & Curettage (D & C) (up to 9 th and 14 th week) Abortion inducing pills (Misoprostol) Second Trimester : beyond the 14 th week of gestation Dilatation & Evacuation (D & E) Third Trimester : Involve surgical procedure 48

49. Signs & T h reatened Inevitable Incomplete Complete Missed Septic s y m p toms Abortion Abortion Abortion Abortion Abortion Abortion lower abdominal pain Variable Some times Severe /rhythmical somet i mes severe Diminishing /none None Severe / variable Bleeding * Slight to moderate ** Heavy/ clots Heavy profuse Light bleed i ng Light Variable smell may offensive Cervical OS Closed Open Open Closed Closed Open Uterus (if Soft no corresponds Tender/ Softer than Smaller than Bulky/tender Palpable) tenderness to date painful normal expected /painful uterus corres- Smaller than dates ponds to date Add i t ion a l Signs & Tissue present in Nausea & vomiting Maternal pyrexia symptoms cervix, shock 49 Summary

50. References RCOG Green top guidelines The management of severe pre- eclampsia/eclampsia http://www.rcog.org.uk/files/rcog- corp/GTG10a230611.pdf NICE (2010, reviewed 2011 ) High blood pressure in pregnancy, Understanding NICE guidance , National Institute for Health and Clinical Excellence, p7 Fraser, D.M., & Cooper, M.A., (2014). Myles Text Book For Midwives. (16 th ed.). Churchill Living Stone Elsevier. Royal College of Obstetricians and Gynecologists (2007) Pre-eclampsia: what you need to know , p3, http://www.rcog.org.uk/womens- health/clinicalguidance/pre-eclampsia-what-you-need-know, Royal College of Obstetricians and Gynecologists (2006, reviewed 2010) The Management of Severe Pre-eclampsia/Eclampsia , p1, http://www.rcog.org.uk/files/rcog-corp/GTG10a230611.pdf NHS Choices (accessed 2012) Health A-Z, Pre-eclampsia, Overview , http://www.nhs.uk/Conditions/Pre-eclampsia/Pages/Introduction.aspx

51. Thank You