maternal complications

7/30/2019 Maternal Complications

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Complications of Labor


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Complications ofPregnancy

ANTEPARTUM

COMPLICATIONS
http://www.shutterstock.com/pic-1952869-pregnant-woman-holding-her-belly-and-flower.html


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Placenta previa is an obstetric complication that can occur in the second

or third trimester of pregnancy .

It can some times occur in the latterpart of the first trimester. It is a leadingcause of antepartum hemorrhage (vaginal bleeding)

characterized by the implantation of theplacenta over or near the top of the

cervix .
http://en.wikipedia.org/wiki/Obstetricshttp://en.wikipedia.org/wiki/Trimesterhttp://en.wikipedia.org/wiki/Pregnancyhttp://en.wikipedia.org/wiki/Antepartum_haemorrhagehttp://en.wikipedia.org/wiki/Vaginahttp://en.wikipedia.org/wiki/Placentahttp://en.wikipedia.org/wiki/Cervixhttp://en.wikipedia.org/wiki/Cervixhttp://en.wikipedia.org/wiki/Placentahttp://en.wikipedia.org/wiki/Vaginahttp://en.wikipedia.org/wiki/Antepartum_haemorrhagehttp://en.wikipedia.org/wiki/Pregnancyhttp://en.wikipedia.org/wiki/Trimesterhttp://en.wikipedia.org/wiki/Obstetrics


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Placenta previa is classifiedaccording to the placement ofthe placenta :

Type I or low lying: The placenta encroaches the lowersegment of the uterus but does not infringe on thecervical os.Type II or marginal: The placenta touches, but does notcover, the top of the cervix.Type III or partial: The placenta partially covers the top

of the cervix.Type IV or complete: The placenta completely covers thetop of the cervix. This type of praevia often will notbleed until labour starts.
http://en.wikipedia.org/wiki/Oshttp://en.wikipedia.org/wiki/Os


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Causes: unknown

Risk Factors

MultiparityAdvancing maternal ageMultiple gestationPrevious cesarian birthUterine incisions


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Signs and Symptoms.bright red, painless vaginal

bleeding

.soft, nontender abdomen; relaxesbetween contractions, if presentFHR stable and within normallimits


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Medical Intervention

Immediate delivery of the fetus Blood volume replacement (to maintain blood

pressure) and blood plasma replacement (to maintainfibrinogen levels) may be necessary.

In cases of fetal distress, a Ceasarean section isindicated.

Vaginal delivery.There are two ways of doing this with a placenta

previa:

1. The baby's head can be brought down to theplacental site (if necessary with Willet's forceps or avulsellum) and a weight attached to his scalp

2. A leg can be brought down and the baby's buttocksused to compress the placental site.


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Abruptio placenta

is the separation of the placental lining from the uterus of a female .

it refers to the abnormal separationafter 20 weeks of gestation and prior tobirth.
http://en.wikipedia.org/wiki/Placentahttp://en.wikipedia.org/wiki/Uterushttp://en.wikipedia.org/wiki/Femalehttp://en.wikipedia.org/wiki/Femalehttp://en.wikipedia.org/wiki/Uterushttp://en.wikipedia.org/wiki/Placenta


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Abruptions are classified according to severityin the following manner:

Grade 0: Asymptomatic and only diagnosed throughpost partum examination of the placenta.

Grade 1: The mother may have vaginal bleeding with milduterine tenderness or tetany, but there is nodistress of mother or fetus.

Grade 2: The mother is symptomatic but not in shock. There issome evidence of fetal distress can be foundwith fetal heart rate monitoring.

Grade 3: Severe bleeding (which may be occult) leads tomaternal shock and fetal death. There may bematernal disseminated intravascularcoagulation. Blood may force its way throughthe uterine wall into the serosa, a condition

known as Couvelaire uterus .
http://en.wikipedia.org/wiki/Disseminated_intravascular_coagulationhttp://en.wikipedia.org/wiki/Disseminated_intravascular_coagulationhttp://en.wikipedia.org/wiki/Couvelaire_uterushttp://en.wikipedia.org/wiki/Couvelaire_uterushttp://en.wikipedia.org/wiki/Disseminated_intravascular_coagulationhttp://en.wikipedia.org/wiki/Disseminated_intravascular_coagulationhttp://en.wikipedia.org/wiki/Disseminated_intravascular_coagulationhttp://en.wikipedia.org/wiki/Disseminated_intravascular_coagulationhttp://en.wikipedia.org/wiki/Disseminated_intravascular_coagulation


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Causes: unknownRisk factors Maternal hypertension is a factor in 44% of allabruptions. Materna l trauma, such as mo tor vehicle accidents ,

assaults , falls, or nosocomial Drug use is a factor, particularly tobacco , alcohol ,

and cocaine . 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 greaterrisk.

Multipara : Women who have given birth many timesare at greater risk.
http://en.wikipedia.org/wiki/Hypertensionhttp://en.wikipedia.org/wiki/Assaulthttp://en.wikipedia.org/wiki/Nosocomialhttp://en.wikipedia.org/wiki/Nosocomialhttp://en.wikipedia.org/wiki/Motor_vehicle_accidenthttp://en.wikipedia.org/wiki/Assaulthttp://en.wikipedia.org/wiki/Nosocomialhttp://en.wikipedia.org/wiki/Cocainehttp://en.wikipedia.org/wiki/Tobaccohttp://en.wikipedia.org/wiki/Alcoholhttp://en.wikipedia.org/wiki/Cocainehttp://en.wikipedia.org/wiki/Umbilical_cordhttp://en.wikipedia.org/w/index.php?title=Retroplacental_fibromyoma&action=edithttp://en.wikipedia.org/wiki/Multiparahttp://en.wikipedia.org/wiki/Multiparahttp://en.wikipedia.org/w/index.php?title=Retroplacental_fibromyoma&action=edithttp://en.wikipedia.org/wiki/Umbilical_cordhttp://en.wikipedia.org/wiki/Cocainehttp://en.wikipedia.org/wiki/Alcoholhttp://en.wikipedia.org/wiki/Tobaccohttp://en.wikipedia.org/wiki/Nosocomialhttp://en.wikipedia.org/wiki/Assaulthttp://en.wikipedia.org/wiki/Motor_vehicle_accidenthttp://en.wikipedia.org/wiki/Hypertension


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Signs and Symptoms

>contractions that don't stop>pain in the uterus

>tenderness in the abdomen>vaginal bleeding (sometimes)>fetal distress

>back pain


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..Monitor the fundus.

..Give Rhogam if mother is Rh negative .

..Immediate delivery of the fetus may beindicated if the fetus is mature or if the

fetus or mother is in distress...Blood volume replacement...Blood plasma replacement..Vaginal birth is usually preferred over

caesarean section unless there is fetaldistress.
http://en.wikipedia.org/wiki/Rhogamhttp://en.wikipedia.org/wiki/Blood_typehttp://en.wikipedia.org/wiki/Blood_plasmahttp://en.wikipedia.org/wiki/Caesarean_sectionhttp://en.wikipedia.org/wiki/Caesarean_sectionhttp://en.wikipedia.org/wiki/Blood_plasmahttp://en.wikipedia.org/wiki/Blood_plasmahttp://en.wikipedia.org/wiki/Blood_typehttp://en.wikipedia.org/wiki/Rhogam


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Nursing Intervention1.Primarily, continue evaluate maternal and fetal physiologic status

particularly.Vital signs Bleeding Electronic fetal and maternal monitoring tracings Signs of shock rapid pulse, pallor, cold and moist skin decrease

in blood presureDecreasing uterine output

2. Never perform vaginal or rectal examinations or take any actions

that would stimulate uterine activity.3. Assess the need for immediate delivery.4. If the client is in active labor and bleeding cannot be stopped

with bed rest, emergency cesarean delivery may beindicated.5. Provide bed rest in lateral position.

6. Insert a large gauge intravenous catheter into a large vein forfluid replacement.7. Obtain a blood sample for fibrinogen levels.8. Monitor the FHR. 9. Measure maternal vital signs every 5 to 15

minutes.10. Administer oxygen to the mother via mask and prepare for

cesarean section.11. Address emotional and psychosocial needs.


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ECLAMPSIAAND

PRE-ECLAMPSIA


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Pre-eclampsia

is said to be present when hypertension arises in pregnancy ( pregnancy-inducedhypertension ) in association withsignificant protein in the urine.
http://en.wikipedia.org/wiki/Hypertensionhttp://en.wikipedia.org/wiki/Pregnancy-induced_hypertensionhttp://en.wikipedia.org/wiki/Pregnancy-induced_hypertensionhttp://en.wikipedia.org/wiki/Pregnancy-induced_hypertensionhttp://en.wikipedia.org/wiki/Pregnancy-induced_hypertensionhttp://en.wikipedia.org/wiki/Pregnancy-induced_hypertensionhttp://en.wikipedia.org/wiki/Pregnancy-induced_hypertensionhttp://en.wikipedia.org/wiki/Hypertension


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Signs and Symptoms

Hypertension more than140/90Proteinuria 300mg in a 24

hour urine sampleEdema on hands and face.

zarlynm


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Eclampsia

is a serious complication of pregnancy and is characterized by convulsions.Usually eclampsia occurs after theonset of pre-eclampsia thoughsometimes no pre-eclamptic symptoms

are recognizable.Cause: unknown
http://en.wikipedia.org/wiki/Pregnancyhttp://en.wikipedia.org/wiki/Seizurehttp://en.wikipedia.org/wiki/Pre-eclampsiahttp://en.wikipedia.org/wiki/Pre-eclampsiahttp://en.wikipedia.org/wiki/Pre-eclampsiahttp://en.wikipedia.org/wiki/Pre-eclampsiahttp://en.wikipedia.org/wiki/Seizurehttp://en.wikipedia.org/wiki/Pregnancy


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Signs and symptomsThe majority of cases are heralded by pregnancy-

induced hypertension and proteinuria but the only true

sign of eclampsia is an eclamptic convulsion, of whichthere are four stages.

Premonitory stage This stage is usually missed unless constantly

monitored, the woman rolls her eyes while her facialand hand muscles twitch slightly.

Tonic stage

After the premonitory stage the twitching turnsinto clenching. Sometimes the woman may bite hertongue as she clenches her teeth, while the arms andlegs go rigid. The respiratory muscles also spasm,causing the woman to stop breathing. This stagecontinues for around 30 seconds.
http://en.wikipedia.org/wiki/Pregnancy-induced_hypertensionhttp://en.wikipedia.org/wiki/Pregnancy-induced_hypertensionhttp://en.wikipedia.org/wiki/Proteinuriahttp://en.wikipedia.org/wiki/Respiration_%28physiology%29http://en.wikipedia.org/wiki/Respiration_%28physiology%29http://en.wikipedia.org/wiki/Proteinuriahttp://en.wikipedia.org/wiki/Pregnancy-induced_hypertensionhttp://en.wikipedia.org/wiki/Pregnancy-induced_hypertensionhttp://en.wikipedia.org/wiki/Pregnancy-induced_hypertension


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Clonic stage The spasm stops but the muscles start to

jerk violently. Frothy, slightly bloodied salivaappears on the lips and can sometimes beinhaled. After around two minutes theconvulsions stop, leading into a coma , but some

cases lead to heart failure .

Comatose stage The woman falls deeply unconscious,

breathing noisily. This can last only a fewminutes or may persist for hours.
http://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Congestive_heart_failurehttp://en.wikipedia.org/wiki/Congestive_heart_failurehttp://en.wikipedia.org/wiki/Coma


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Prenatal health supervision. Admission to maternal -fetalintensive care unit.

Restriction of activities Administration of sedative drugs


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Nursing Intervention

Balanced diet high in proteinMonitor vital signs and FHRMinimize external stimuli, promote rest and

relaxation.Measure and record urine output, protein level, and

specific gravity.Assess for edema especially on the face, arms,hands, legs, ankles and feet.

Assess if there is presence of pulmonary edema.Weight the patient daily and assess deep tendon

reflexes every four hours.Assess for the placental separation, headeache and

visual disturbancess, epigastric pain andaltered level of consciousness.


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INTRAPARTUMCOMPLICATIONS

PREMATURE

RUPTUREOFMEMBRANES
http://www.shutterstock.com/pic-66875-baby-smiling-inside-the-belly-of-her-mother.html


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Signs and Symptoms

Marked by amniotic fluidgushing from the vaginaMaternal fever

Fetal tachycardiaMalodorous discharge mayindicate infection


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Predisposing factors include: multiparity incompitent cervix maternal age greater than 35 years

old low weight gain during pregnancy and cervical damagefrom cervical

instrumentation Diagnosis can usually be confirmed

with nitrazine paper, which turns darkblue in the presence of amniotic fluid.


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Prophylactic administration of broad-spectrum antibiotics must be givenquickly.

Intravenous administration of penicilin or

ampicilin.Application of a fibrin -based sealant toruptured membranes

Sterile speculum examination

Cervical culturesUltrasonographic documentationImmediate delivery


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Nursing Interventions

.Strict bed rest.Teach pt. how to readthermometer

.Avoid digital examination

.FHR monitoring

.Maternal vital signs


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Preterm labor

(also known as preterm birth ) isdefined medically as childbirth

occurring earlier than 37completed weeks of gestation .

Cause: unknown
http://en.wikipedia.org/wiki/Childbirthhttp://en.wikipedia.org/wiki/Gestationhttp://en.wikipedia.org/wiki/Gestationhttp://en.wikipedia.org/wiki/Childbirth


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RISK FACTORS1.A woman's previous history of preterm birth, or

pregnancies that ended in miscarriage .2.Multiple pregnancies ( twins, triplets, etc.) are at a higherrisk for premature birth.Uterine or cervical abnormalities.

3.Certain chronic disease such as high blood pressure ,kidney disease and diabetes .

4.Infections of the cervix, uterus or urinary tract . CertainSTDs, Beta Strep .

5.Substance abuse of tobacco , alcohol and other drugs .

Women who have tried to conceive for more than a yearbefore getting pregnant are at a higher risk for prematurebirth. Women under 18 or over 35 are at a higher risk forpremature birth.
http://en.wikipedia.org/wiki/Miscarriagehttp://en.wikipedia.org/wiki/Twinshttp://en.wikipedia.org/wiki/Uterushttp://en.wikipedia.org/wiki/Cervixhttp://en.wikipedia.org/wiki/High_blood_pressurehttp://en.wikipedia.org/wiki/Kidney_diseasehttp://en.wikipedia.org/wiki/Diabeteshttp://en.wikipedia.org/wiki/Urinary_tracthttp://en.wikipedia.org/wiki/STDhttp://en.wikipedia.org/wiki/Beta_strephttp://en.wikipedia.org/wiki/Tobaccohttp://en.wikipedia.org/wiki/Alcoholhttp://en.wikipedia.org/wiki/Drug_abusehttp://en.wikipedia.org/wiki/Drug_abusehttp://en.wikipedia.org/wiki/Alcoholhttp://en.wikipedia.org/wiki/Tobaccohttp://en.wikipedia.org/wiki/Beta_strephttp://en.wikipedia.org/wiki/STDhttp://en.wikipedia.org/wiki/Urinary_tracthttp://en.wikipedia.org/wiki/Diabeteshttp://en.wikipedia.org/wiki/Kidney_diseasehttp://en.wikipedia.org/wiki/High_blood_pressurehttp://en.wikipedia.org/wiki/Cervixhttp://en.wikipedia.org/wiki/Uterushttp://en.wikipedia.org/wiki/Twinshttp://en.wikipedia.org/wiki/Miscarriage


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6.Inadequate nutrition during pregnancy.7.Antepartum hemorrhage8.Pre-eclampsia 9.Stress10.Periodontal disease increases the risk

of preterm birth more than 4 times. Asa matter of fact this is one of the mostserious risk factors, that is completelypreventable.
http://en.wikipedia.org/wiki/Nutritionhttp://en.wikipedia.org/wiki/Pre-eclampsiahttp://en.wikipedia.org/wiki/Periodontal_diseasehttp://en.wikipedia.org/wiki/Periodontal_diseasehttp://en.wikipedia.org/wiki/Pre-eclampsiahttp://en.wikipedia.org/wiki/Pre-eclampsiahttp://en.wikipedia.org/wiki/Pre-eclampsiahttp://en.wikipedia.org/wiki/Nutrition


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Signs and Symptoms1. Four or more uterine contractions in one

hour, before 37 weeks' gestation.2. A watery discharge from the vagina

which may indicate premature rupture

of the membranes surrounding thebaby.3. Pressure in the pelvis or the sensation

that the baby has "dropped".

4. Menstrual cramps or abdominal pain.5. Pain or rhythmic tightening inlower abdomen or back.

6.Vaginal spotting or bleeding .
http://en.wikipedia.org/wiki/Contraction_%28childbirth%29http://en.wikipedia.org/wiki/Pelvishttp://en.wikipedia.org/wiki/Menstruationhttp://en.wikipedia.org/wiki/Menstruationhttp://en.wikipedia.org/wiki/Pelvishttp://en.wikipedia.org/wiki/Contraction_%28childbirth%29


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Medical Intervention There are two tactics that can be used to deal with a

potential premature birth:A.delay the arrival of birth as much as possible,

or B. Prepare the prospectively premature fetus for

arrival.

Both of these tactics may be used simultaneously. The first resort is usually complete bed rest. Proper nutrition and especially hydration are

important. In a hospital setting, a drug-free IV drip may be used

to try to stop premature labor simply by improvingthe mother's hydration .

Administer anti- contraction medication s (to colytics ),such as ritodrine , fenoterol , nifedipine and atosiban .
http://en.wikipedia.org/wiki/Ritodrinehttp://en.wikipedia.org/w/index.php?title=Fenoterol&action=edithttp://en.wikipedia.org/wiki/Nifedipinehttp://en.wikipedia.org/wiki/Tocolytichttp://en.wikipedia.org/wiki/Atosibanhttp://en.wikipedia.org/wiki/Ritodrinehttp://en.wikipedia.org/w/index.php?title=Fenoterol&action=edithttp://en.wikipedia.org/wiki/Nifedipinehttp://en.wikipedia.org/wiki/Atosibanhttp://en.wikipedia.org/wiki/Atosibanhttp://en.wikipedia.org/wiki/Nifedipinehttp://en.wikipedia.org/w/index.php?title=Fenoterol&action=edithttp://en.wikipedia.org/wiki/Ritodrinehttp://en.wikipedia.org/wiki/Tocolytic


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Assess the mother and fetus Tocolytic therapy

.beta adrenergic agonist. MgSO4

.prostaglandin synthetase inhibitors

.Steroids


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Placenta accreta is a severe obstetric complication involving anabnormal at tachment of the placenta to themyometrium (the middle layer of the uterine wall ).

Placenta increta occurs when the placenta extends into the muscle ofthe uterine wall and happens in around 17% of allcases.

Placenta percreta the worst form of the condition and occurring in 5 -7% of cases, is when the placenta penetrates theentire uterine wall. This variant can lead to theplacent a attaching to other organs such as thebladder .
http://en.wikipedia.org/wiki/Obstetricshttp://en.wikipedia.org/wiki/Placentahttp://en.wikipedia.org/wiki/Myometriumhttp://en.wikipedia.org/wiki/Placentahttp://en.wikipedia.org/wiki/Uterushttp://en.wikipedia.org/wiki/Myometriumhttp://en.wikipedia.org/wiki/Uterushttp://en.wikipedia.org/wiki/Urinary_bladderhttp://en.wikipedia.org/wiki/Urinary_bladderhttp://en.wikipedia.org/wiki/Urinary_bladderhttp://en.wikipedia.org/wiki/Uterushttp://en.wikipedia.org/wiki/Myometriumhttp://en.wikipedia.org/wiki/Placentahttp://en.wikipedia.org/wiki/Obstetrics


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CAUSES

PLACENTA PREVIA PREVIOUS CESAREAN

SECTION


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Signs and Symptoms

Placenta fails to separate Profuse hemorrhage may result

depending on the portion of placentainvolved

d l


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Hysterectomy Immediate delivery


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Strict bed rest Monitor maternal vital signs Monitor fetal heart rate


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Uterine rupture

is a potentially catastrophic eventduring childbirth by which the integrity

of the myometrial wall is breached.In an incomplete rupture theperitoneum is still intact.

With a complete rupture thecontents of the uterus may spill intothe peritoneal cavity or thebroad ligament .
http://en.wikipedia.org/wiki/Childbirthhttp://en.wikipedia.org/wiki/Myometriumhttp://en.wikipedia.org/wiki/Peritoneumhttp://en.wikipedia.org/wiki/Broad_ligamenthttp://en.wikipedia.org/wiki/Broad_ligamenthttp://en.wikipedia.org/wiki/Peritoneumhttp://en.wikipedia.org/wiki/Myometriumhttp://en.wikipedia.org/wiki/Childbirth


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CAUSES

Scar from previous cesareansection Uterine surgeries such as

myomectomy, hysterotomy andothers. Gunshot wounds or car accidents

with blunt trauma to the abdomen Uterine curettage


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Signs and Symptoms

Abdominal pain Vaginal bleeding Nonreassurinf FHR pattern Palpitation of fetal parts under

the skin Signs of hypovolemic shock


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Medical Intervention Emergency exploratory laparotomy withcesa rean delivery acc ompanied by fluid

and blood transfusion are indicated. Depending on the nature of the rupture

and the condition of the patient theuterus may be either repaired or needsto be removed (cesarean

hysterectomy). If the client has signs of possibleuterine rupture, vaginal delivery isgenerally attempted
http://en.wikipedia.org/wiki/Laparotomyhttp://en.wikipedia.org/wiki/Blood_transfusionhttp://en.wikipedia.org/wiki/Blood_transfusionhttp://en.wikipedia.org/wiki/Blood_transfusionhttp://en.wikipedia.org/wiki/Laparotomy


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Nursing Intervention Monitor maternal labor pattern closely forhypertonicity. Recognize signs of impending rupture,

immediately notify the physician, and call forassistance. Monitor maternal blood pressure, pulse,respirations and FHR.

Insert a urinary catheter for precise

determinations of fluid balance. Obtain blood to assess possible acidosis. Administer oxygen and maintain a patent

airway.


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POSTPARTUM HEMORRHAGEis blood loss of more than 500ml

following the birth of the newborn. CAUSES

uterine atony lacerations retained placental fragments Trauma from delivery Uterine atony


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Signs and Symptoms

Leakage or a gush of blood tingedamniotic fluid from the vagina.

Fever Foul smelling vaginal discharge Uterine tenderness


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Pathophysiology

Delayed uterine atony or placentalfragments prevent the uterus fromcontracting effectively.

The uterus is unable to form an effectiveclot structure and bleeding continues.


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Medical Management

Obstetric ultrasonography Surgical obstetrics

Blood transfusion Pharmacological support Hospitalization for diagnostic studies Induced labor


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Nursing Management

Monitor vital signs Avoid any vaginal douches, sexual

intercourse and putting anything intothe vagina.

Sterile techniques during vaginal exam Avoid baths or hot tubs


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SUBINVOLUTION is delayed return of the enlarged uterusto normal size and function.

CAUSES- retained placentalfragments andmembranes-endometritis oruterine fibroid tumor

Si d S t


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Signs and Symptoms

Prolonged lochial discharge Irregular or excessive bleeding Larger than normal uterus Boggy uterus


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Medical Management

Hospitalization Dilatation and curettage Administer antibiotics


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Nursing Intervention prevent excessive blood loss and resulting

complications massage the uterus monitor BP & pulse rate every 5-15minutes administer IV infusion, oxytocin and blood

transfusion needed

administer medications and oxygen measure and record intake and output prepare for D&C

PUERPERAL


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PUERPERALINFECTION

is an infection developing in the birthstructure after delivery

CAUSESpoor sterile techniquedelivery with significantmanipulationcesarean birthovergrowth of local floraAerobic and anaerobicmicroorganismProlonged labor


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Signs and Symptoms

temperature exceeding 38C or higher -localized vaginal, vulval and perineal

infection -endometritis -parametritis

-peritonitis


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Medical Management

Antibiotic therapy Pelvic examination CBC Urinalysis ultrasound


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Nursing Intervention promote resolution of the infectious

process

inspect perineum twice daily evaluate for abdominal pain, fever,

malaise, tachycardia and foulsmelling lochia

administer antibiotics

AS S


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MASTITIS is the inflammation of the breast tissuethat is usually caused by infection or bystasis of milk in the ducts.

CAUSESinjury to the breastStaphylococcus aureusGroup A beta-hemolyticStreptococcusNewborns mouth infectedwith pathogenMothers hands


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Signs and Symptoms elevated temperature, chills, general

aching, malaise and localized pain increased pulse rate engorgement, hardness and reddening of

the breast nipple soreness and fissures swollen and tender axillary lymph nodes

maternal complications

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