Chapter 19

Conditions of early pregnancy bleeding

"first half of pregnancy" *spontaneous abortion, *uterine fibroids, *ectopic pregnancy, *gestational trophoblastic disease, *cervical insufficiency

Classic triad of preeclampsia

(hypertension, proteinuria, and edema or weight gain) and more on decreased organ perfusion, endothelial dysfunction (capillary leaking and proteinuria), and elevated blood pressure as key indicators

Missed abortion

(nonviable embryo retained in utero for at least 6 weeks) Assessment:Absent uterine contractions *Irregular spotting *Possible progression to inevitable abortion Diagnosis: Ultrasound to identify products of conception in uterus Management: Evacuation of uterus (if inevitable abortion does not occur): suction curettage during first trimester, dilation and evacuation during second trimester *Induction of labor with intravaginal PGE2 suppository to empty uterus without surgical intervention

Complete abortion

(passage of all products of conception) Assessment: History of vaginal bleeding and abdominal pain *Passage of tissue with subsequent decrease in pain and significant decrease in vaginal bleeding Diagnosis: Ultrasound demonstrating an empty uterus Management: No medical or surgical intervention necessary *Follow-up appointment to discuss family planning

Incomplete abortion

(passage of some of the products of conception) Assessment: Intense abdominal cramping *Heavy vaginal bleeding Cervical dilation Diagnosis: Ultrasound confirmation that products of conception still in uterus Management: Client stabilization *Evacuation of uterus via D&C or prostaglandin analog

major conditions that can complicate a pregnancy

*bleeding during pregnancy (spontaneous abortion) *ectopic pregnancy, *gestational trophoblastic disease, *cervical insufficiency, *placenta previa, *abruptio placentae, and placenta accreta, *hyperemesis gravidarum, *gestational hypertension, *HELLP syndrome, *gestational diabetes, *blood incompatibility, *amniotic fluid imbalances (polyhydramnios and oligohydramnios), *multiple gestation, *premature rupture of membranes

Conditions of late pregnancy bleeding

*placenta previa, *abruptio placentae, and *placenta accreta, which usually occur after the 20th week of gestation

1+ pitting edema

= 2-mm depression into skin; disappears rapidly

2+ pitting edema

= 4-mm skin depression; disappears in 10 to 15 seconds

3+ pitting edema

= 6-mm depression into skin; lasts more than 1 minute

4+ pitting edema

= 8-mm depression into skin; lasts 2 to 3 minutes

Abruptio Placentae

Abruptio placentae is the premature separation of a normally implanted placenta after the 20th week of gestation prior to birth, which leads to hemorrhage *It typically peaks between 24 and 26 weeks' gestation **DETACHMENT issue

Severe (grade 3)

Absent to moderate bleeding (more than 1,500 mL), *severe separation (more than 50%), *profound shock, *dark vaginal bleeding, *agonizing abdominal pain, *decreased maternal blood pressure, *significant maternal tachycardia and development of DIC

Mifepristone (RU-486)

Acts as progesterone antagonist, allowing prostaglandins to stimulate uterine contractions; causes the endometrium to slough; *may be followed by administration of misoprostol within 48 hours.

Risk factors for placenta previa

Advancing maternal age (more than 35 years) *Previous cesarean birth *Multiparity *Uterine insult or injury *Cocaine use *Prior placenta previa *Infertility treatment *Multiple gestations *Previous induced surgical abortion *Smoking *Previous myomectomy to remove fibroids *Short interval between pregnancies *Hypertension or diabetes

Biophysical profile:

Aids in evaluating clients with chronic abruption; a low score (less than 6 points) suggests possible fetal compromise

Monitoring Maternal-Fetal Status

Assess the degree of vaginal bleeding; inspect the perineal area for blood that may be pooled underneath the woman *Monitor the woman's cardiopulmonary status, reporting any difficulties in respirations, changes in skin color, or complaints of difficulty in breathing. *Have oxygen equipment readily available should fetal or maternal distress develop *Monitor tocolytic (anticontraction) medication if prevention of preterm labor is needed

Habitual abortion

Assessment: History of three or more consecutive spontaneous abortions *Not carrying the pregnancy to viability or term Diagnosis: Validation via client's history Management: Identification and treatment of underlying cause (possible causes such as genetic or chromosomal abnormalities, reproductive tract abnormalities, chronic diseases or immunologic problems) *Cervical cerclage in second trimester if incompetent cervix is the cause

Inevitable abortion

Assessment: Vaginal bleeding (greater than that associated with threatened abortion) *Rupture of membranes *Cervical dilation *Strong abdominal cramping *Possible passage of products of conception Diagnosis: Ultrasound and hCG levels to indicate pregnancy loss Management: Vacuum curettage if products of conception are not passed, to reduce risk of excessive bleeding and infection *Prostaglandin analogs such as misoprostol to empty uterus of retained tissue (only used if fragments are not completely passed)

Threatened abortion

Assessment: Vaginal bleeding (often slight) early in a pregnancy *No cervical dilation or change in cervical consistency *Mild abdominal cramping *Closed cervical os *No passage of fetal tissue Diagnosis: Vaginal ultrasound to confirm if sac is empty *Declining maternal serum hCG and progesterone levels to provide additional information about viability of pregnancy Management: Conservative supportive treatment *Possible reduction in activity in conjunction with nutritious diet and adequate hydration

Take Note

Avoid doing vaginal examinations in the woman with placenta previa because they may disrupt the placenta and cause hemorrhage

Gestational hypertension

Blood pressure elevation (140/90 mm Hg) identified after 20 weeks' gestation without proteinuria. Blood pressure returns to normal by 12 weeks' postpartum.

Management of Cervical Insufficiency

Cervical insufficiency may be treated in a variety of ways: bed rest; pelvic rest; avoidance of heavy lifting; progesterone supplementation in women at risk for preterm birth; placement of a cervical pessary (a round, silicone device at the mouth of the cervix) or surgically, via a cervical cerclage procedure in the second trimester

Cervical Insufficiency

Cervical insufficiency, also called premature dilation of the cervix, describes a weak, structurally defective cervix that spontaneously dilates in the absence of uterine contractions in the second trimester, or early third trimester, resulting in the loss of the pregnancy

Take Note

Classic manifestations of abruptio placentae include painful, *dark-red vaginal bleeding (port-wine color) because the bleeding comes from the clot that was formed behind the placenta; *"knife-like" abdominal pain; uterine tenderness; *contractions; and decreased fetal movement. **Rapid assessment is essential to ensure prompt, effective interventions to prevent maternal and fetal morbidity and mortality

Management for Hyperemesis Gravidum

Conservative management in the home is the first line of treatment for the woman with hyperemesis gravidarum *The first choice for fluid replacement is generally normal saline, which aids in preventing hyponatremia, with vitamins (pyridoxine [B6]) and electrolytes added. *Oral food and fluids are withheld for the first 24 to 36 hours to allow the gastrointestinal tract to rest. *Antiemetics may be administered rectally or intravenously to control the nausea and vomiting * If the client does not improve after several days of bed rest, "gut rest," intravenous fluids, and antiemetics, total parenteral nutrition or feeding through a percutaneous endoscopic gastrostomy tube is instituted to prevent malnutrition *Promethazine (Phenergan) and prochlorperazine (Compazine) are among the older preparations usually tried first. *If they fail to relieve symptoms, newer drugs such as ondansetron (Zofran) may be tried

Patho of Hyperemesis Gravidarium

Decreased fluid intake and prolonged vomiting cause dehydration; dehydration increases the serum concentration of hCG, which in turn exacerbates the nausea and vomiting—a vicious cycle

Nonstress test:

Demonstrates findings of fetal jeopardy manifested by late decelerations or bradycardia.

Type and cross-match:

Determines blood type if a transfusion is needed

Prothrombin time (PT)/activated partial thromboplastin time (aPTT):

Determines the client's coagulation status, especially if surgery is planned.

CBC:

Determines the current hemodynamic status; however, it is not reliable for estimating acute blood loss.

Biophysical Risk Factors During Pregnancy

Genetic conditions *Chromosomal abnormalities *Multiple pregnancy *Defective genes *Inherited disorders *ABO incompatibility *Large fetal size *Medical and obstetric conditions *Preterm labor and birth *Cardiovascular disease *Chronic hypertension *Cervical insufficiency *Placental abnormalities *Infection *Diabetes *Maternal collagen diseases *Thyroid disease *Asthma *Post-term pregnancy *Hemoglobinopathies *Nutritional status *Inadequate dietary intake *Food fads *Excessive food intake *Under- or overweight status *Hematocrit value less than 33% *Eating disorder

Endocrine theory

High levels of hCG and estrogen during pregnancy.

Pathophysiology of GTD

Hydatidiform mole is a benign neoplasm of the chorion in which the chorionic villi degenerate and become transparent vesicles containing clear, viscid fluid *The complete mole contains no fetal tissue and develops from an "empty egg," which is fertilized by a normal sperm (the paternal chromosomes replicate, resulting in 46 all-paternal chromosomes *The embryo is not viable and dies *with a classic complete mole present with vaginal bleeding, anemia, excessively enlarged uterus, preeclampsia, and hyperemesis.

Hypertensive Disorders of Pregnancy

Hypertension remains the most commonly encountered medical condition in pregnant women *comprise a spectrum of severity ranging from a mild elevation of blood pressure to severe preeclampsia and hemolysis *Hypertensive disorders of pregnancy include chronic hypertension, gestational hypertension, preeclampsia, eclampsia, and chronic hypertension with superimposed preeclampsia

Chronic hypertension

Hypertension that exists prior to pregnancy or that develops before 20 weeks' gestation.

Take Note

If hyperemesis progresses untreated, it may cause neurologic disturbances, *renal damage, *dehydration, *ketosis, *alkalosis from loss of hydrochloric acid, *hypokalemia, *retinal hemorrhage, or *death

Management of Placenta Previa

If the mother and fetus are both stable, therapeutic management may involve expectant ("wait-and-see" or watchful waiting) care

Environmental Risk Factors During Pregnancy

Infections *Radiation *Pesticides *Illicit drugs *Industrial pollutants *Second-hand cigarette smoke *Personal stress

Mild (grade 1)

Minimal bleeding (less than 500 mL), *marginal separation (10% to 20%), *tender uterus, *no coagulopathy, *no signs of shock, *no fetal distress

Moderate (grade 2)

Moderate bleeding (1,000 to 1,500 mL), *moderate separation (20% to 50%), *continuous abdominal pain, *mild shock, *normal maternal blood pressure, *maternal tachycardia

Chronic hypertension with superimposed preeclampsia

Occurs in approximately 20% of pregnant women with increased maternal and fetal morbidity rates

Eclampsia

Onset of seizure activity in a woman with preeclampsia

Placenta Previa

Onset: Insidious Type of Bleeding: Always visible, slight then more profuse Blood: Bright red Pain: NONE Uterine Tone: soft and relaxed Fetal Heart Rate: usually normal Fetal Presentation: may be breach or in transverse lie; engagement is absent

Abruptio Placentae

Onset: Sudden Type of Bleeding: can be concealed or visible Blood: Dark Pain: Constant; uterine tenderness on palpation Uterine Tone: Firm to rigid Fetal Heart Rate: Fetal distress or absent Fetal Presentation: No relationship

Placenta Acerta

Placenta accreta is a potentially life-threatening obstetrical hemorrhagic condition *Placenta accreta is typically diagnosed after birth when the placenta fails to normally separate from the uterine wall

Sociodemographic Risk Factors During Pregnancy

Poverty status *Lack of prenatal care *Age younger than 15 years or older than 35 years *Parity—All first pregnancies and more than five pregnancies *Marital status—Increased risk for unmarried women *Accessibility to health care *Ethnicity—Increased risk in non-White women

Possible Contributing Factors for Ectopic Pregnancy

Previous ectopic pregnancy *History of sexually transmitted infections (STIs) *Fallopian tube scarring from PID *In utero exposure to DES *Endometriosis *Previous tubal or pelvic surgery *Infertility and infertility treatments, including use of fertility drugs *Uterine abnormalities such as fibroids *Presence of intrauterine contraception *Use of progestin-only mini pill (slows ovum transport) *Postpartum or postabortion infection *Altered estrogen and progesterone levels (interferes with tubal motility) *Increasing age (older than 35 years) *Cigarette smoking **If rupture or hemorrhage occurs before treatment begins, symptoms may worsen and include severe, sharp, and sudden pain in the lower abdomen as the tube tears open and the embryo is expelled into the pelvic cavity; feelings of faintness; referred pain to the shoulder area, indicating bleeding into the abdomen, caused by phrenic nerve irritation; hypotension; marked abdominal tenderness with distention; and hypovolemic shock

Risk Factors for Preeclampsia

Primigravida status *Chromosomal abnormalities *Structural congenital anomalies *Multiple gestation *History of preeclampsia in a previous pregnancy *Excessive placental tissue, as is seen in women with GTD *Chronic stress *Use of ovulation drugs *Family history of preeclampsia (mother or sister) *Lower socioeconomic status *History of diabetes, hypertension, or renal disease *Poor nutrition *African-American ethnicity *Age extremes (younger than 20 or older than 35) *Obesity

Take Note

Proteinuria is defined as 300 mg or more of urinary protein per 24 hours or more than 1+ protein by chemical reagent strip or dipstick of at least two random urine samples collected at least 4 to 6 hours apart with no evidence of urinary tract infection

Prevention Education

Reduce risk factors such as sexual intercourse with multiple partners or intercourse without a condom. *Avoid contracting STIs that lead to PID. *Obtain early diagnosis and adequate treatment of STIs. *If an intrauterine contraceptive system is chosen, descriptions of the signs of PID should be included to reduce the risk of repeat ascending infections, which can be responsible for tubal scarring. *Avoid smoking during childbearing years since a correlation and increase in risk exists. *Use condoms to decrease the risk of infections that cause tubal scarring. *Seek prenatal care early to confirm the location of pregnancy.

Grading of Deep Tendon Reflexes

Reflex absent, none elicited=0 *Hypoactive response, sluggish=1 *Reflex in lower half of normal range=2 *Reflex in upper half of normal range=3 *Hyperactive, brisk, clonus present=4

Clinical Manifestations of GTD

Report of early signs of pregnancy, such as amenorrhea, breast tenderness, fatigue *Brownish vaginal bleeding/spotting *Anemia *Inability to detect a fetal heart rate after 10 to 12 weeks' gestation *Fetal parts not evident with palpation *Bilateral ovarian enlargement caused by cysts and elevated levels of Hcg *Persistent, often severe, nausea and vomiting (due to high hCG levels) *Fluid retention and swelling *Uterine size larger than expected for pregnancy dates *Extremely high hCG levels present; no single value considered diagnostic *Early development of preeclampsia (usually not present until after 24 weeks) *Absence of fetal heart rate or fetal activity *Expulsion of grapelike vesicles (possible in some women)

Management of mild preeclampsia

Rest in a quiet environment to prevent cerebral disturbances *Drink 8 to 10 glasses of water daily *Consume a balanced, high-protein diet including high-fiber foods *Obtain intermittent bed rest to improve circulation to the heart and uterus *Limit your physical activity to promote urination and subsequent decrease in blood pressure *Enlist the aid of your family so that you can obtain appropriate rest time *Perform self-monitoring as instructed, including: -Taking your own blood pressure twice daily -Checking and recording weight daily ◦Performing urine dipstick twice daily -Recording the number of fetal kicks daily *Contact the home health nurse if any of the following occurs: -Increase in blood pressure ◦Protein present in urine◦Gain of more than 1 lb in 1 week -Burning or frequency when urinating◦Decrease in fetal activity or movement◦Headache (forehead or posterior neck region) -Dizziness or visual disturbances -Increase in swelling in hands, feet, legs, and face -Stomach pain, excessive heartburn, or epigastric pain -Decreased or infrequent urination -Contractions or low back pain -Easy or excessive bruising -Sudden onset of abdominal pain -Nausea and vomiting

Rh Incompatibility

Rh incompatibility is a condition that develops when a woman with Rh-negative blood type is exposed to Rh-positive blood cells and subsequently develops circulating titers of Rh antibodies *most commonly arises with exposure of an Rh-negative mother to Rh-positive fetal blood during pregnancy or birth *Isoimmunization can also occur during an amniocentesis, ectopic pregnancy, placenta previa, placenta abruption, in utero fetal death, spontaneous abortion, or abdominal/pelvic trauma *Once sensitized, it takes approximately a month for Rh antibodies in the maternal circulation to cross over into the fetal circulation

Management for Severe Preeclampsia

Severe preeclampsia may develop suddenly and bring with it high blood pressure of more than 160/110 mm Hg, *proteinuria of more than 5 g in 24 hours, *oliguria of less than 400 mL in 24 hours, *cerebral and visual symptoms, and *rapid weight gain ** The woman in labor with severe preeclampsia typically receives oxytocin to stimulate uterine contractions and magnesium sulfate to prevent seizure activity. *Oxytocin and magnesium sulfate can be given simultaneously via infusion pumps to ensure both are administered at the prescribed rate. *Magnesium sulfate is given intravenously via an infusion pump. *A loading dose of 4 to 6 g is given over 5 minutes. Then, a maintenance dose of 2 g/hr is given. ** PGE2 gel may be used to ripen the cervix

Psychosocial Risk Factors During Pregnancy

Smoking *Caffeine *Alcohol and substance abuse *Maternal obesity *Inadequate support system *Situational crisis *History of violence *Emotional distress *Unsafe cultural practices

Misoprostol (Cytotec)

Stimulates uterine contractions to terminate a pregnancy; *to evacuate the uterus after abortion to ensure passage of all the products of conception.

PGE2, dinoprostone (Cervidil, Prepidil Gel, Prostin E2)

Stimulates uterine contractions, causing expulsion of uterine contents; *to expel uterine contents in fetal death or missed abortion during second trimester, or to efface and dilate the cervix in pregnancy at term.

Rh(D) immunoglobulin (Gamulin, HydroRho-D, RhoGAM, MICRhoGAM)

Suppresses immune response of nonsensitized Rh-negative clients who are exposed to Rh-positive blood; *to prevent isoimmunization in Rh-negative women exposed to Rh-positive blood after abortions, miscarriages, and pregnancies

Education for Placenta Previa

Teach the woman how to perform and record daily fetal movement. This action serves two purposes: (1) It provides valuable information about the fetus and (2) it is an activity in which the client can participate, thereby fostering some feeling of control over the situation *Encourage her to eat a balanced diet with adequate fluid intake to ensure adequate nutrition and hydration and prevent complications associated with urinary and bowel elimination secondary to bed rest

Pathophysiology of Cervical Insufficiency

The cervix may have less elastin, less collagen, and greater amounts of smooth muscle than the normal cervix, and thus results in loss of sphincter tone *The cervical dilation is typically rapid, relatively painless, and accompanied by minimal bleeding *Other conditions such as previous precipitous birth, a prolonged second stage of labor, increased amounts of relaxin and progesterone, or increased uterine volume (multiple gestation, hydramnios) are associated with cervical insufficiency *Cervical length also has been associated with cervical insufficiency and, subsequently, preterm birth

Transvaginal Ultrasound

Transvaginal ultrasound typically is done between 16 and 24 weeks' gestation to determine cervical length, evaluate for shortening, and attempt to predict an early preterm birth *A cervical length of less than 25 mm is abnormal between 16 and 24 weeks and may increase the risk of preterm labor

Fibrinogen levels:

Typically are increased in pregnancy (hyperfibrinogenemia); thus, a moderate dip in fibrinogen levels might suggest DIC and, if profuse bleeding occurs, the clotting cascade might be compromised.

Nursing Assessment of Vaginal Bleeding

Varying degrees of vaginal bleeding, low back pain, abdominal cramping, and passage of products of conception tissue may be reported. *color of the vaginal bleeding (bright red is significant) and the amount— *the frequency with which she is changing her peri pads (saturation of one peri pad hourly is significant) *the passage of any clots or tissue **save any tissue or clots passed and bring them with her to the health care facility **assess her vital signs and observe the amount, color, and characteristics of the bleeding

Take Note

Vital signs can be within normal range, even with significant blood loss, because a pregnant woman can lose up to 40% of her total blood volume without showing signs of shock

Metabolic theory

Vitamin B6 deficiency.

Lab & Diagnostic Testing

a CBC, serum electrolytes, BUN, creatinine, and hepatic enzyme levels. Urine specimens are checked for protein; if levels are 1 to 2+ or greater, a 24-hour urine collection is completed.

Clinical Triad of Ectopic Pregnancy

abdominal pain, *amenorrhea, and *vaginal bleeding *Diagnostic procedures include a urine pregnancy test to confirm the pregnancy, beta-hCG concentrations to exclude a false-negative urine test, and a transvaginal ultrasound to visualize the misplaced pregnancy

Risk factors for Abruptio Placentae

advanced maternal age (over 35 years old), *poor nutrition, *multiple gestation, *excessive intrauterine pressure caused by polyhydramnios, *chronic hypertension, *cigarette smoking, *severe trauma (e.g., auto accident, intimate partner violence), *history of abruption in a previous pregnancy, *placental abnormalities, *cocaine or methamphetamine abuse, *thrombophilia, *alcohol ingestion, and *multiparity

Polyhydramnios,

also called hydramnios, is a condition in which there is too much amniotic fluid (more than 2,000 mL) surrounding the fetus between 32 and 36 weeks *associated with fetal anomalies of development such as upper gastrointestinal obstruction or atresias, neural tube defects, and anterior abdominal-wall defects, together with impaired swallowing in fetuses with chromosomal anomalies, such as trisomy 13 and 18

Blood type incompatibility,

also known as ABO incompatibility, arises when a mother with blood type O becomes pregnant with a fetus with a different blood type (type A, B, or AB). *The mother's serum contains naturally occurring anti-A and anti-B, which can cross the placenta and hemolyze fetal red blood cell

Management of HELLP Syndrome

based on the severity of the disease, the gestational age of the fetus, and the condition of the mother and fetus. *The mainstay of treatment is lowering of high blood pressure with rapid-acting antihypertensive agents, prevention of convulsions or further seizures with magnesium sulfate, and use of steroids for fetal lung maturity if necessary, followed by the birth of the infant and placenta

Categories of risk

biophysical psychosocial sociodemographic environmental

Preeclampsia

can be described as a multisystem, vasopressive disorder that targets the cardiovascular, hepatic, renal, and central nervous systems (CNSs) *the first stage, the key feature is widespread vasospasm *second stage of preeclampsia is the woman's response to abnormal placentation, when symptoms appear, i.e., hypertension, proteinuria, and edema due to hypoperfusion.

Gestational trophoblastic disease (GTD)

comprises a spectrum of neoplastic disorders that originate in the placenta *GTDs encompass hydatidiform mole (complete and partial), invasive mole, gestational choriocarcinoma, placental-site trophoblastic tumor, and epithelioid trophoblastic tumor

Management of Abruptio Placentae

designed to assess, control, and restore the amount of blood lost; provide a positive outcome for both mother and newborn; and prevent coagulation disorders, such as DIC *Emergency measures include starting two large-bore intravenous lines with normal saline or lactated Ringer's solution to combat hypovolemia, obtaining blood specimens for evaluating hemodynamic status values and for typing and cross-matching, and frequently monitoring fetal and maternal well-being *cesarean birth is done immediately if fetal distress is evident *Replacement therapy of the coagulation factors is achieved by transfusion of fresh-frozen plasma along with cryoprecipitate to maintain the circulating volume and provide oxygen to the cells of the body. *Anticoagulant therapy (low-molecular-weight heparin), packed red cells, platelet concentrates, antithrombin concentrates, and nonclotting protein-containing volume expanders, such as plasma protein fraction or albumin

Indications for RhoGAM

for every Rh-negative nonimmunized woman to receive RhoGAM at some point between 28 and 32 weeks' gestation and again within 72 hours after giving birth *Ectopic pregnancy *Chorionic villus sampling *Amniocentesis *Prenatal hemorrhage *Molar pregnancy *Maternal trauma *Percutaneous umbilical sampling *Therapeutic or spontaneous abortion *Fetal death *Fetal surgery

Management of GTD

immediate evacuation of the uterine contents as soon as the diagnosis is made and long-term follow-up of the client to detect any remaining trophoblastic tissue that might become malignant. *D&C is used to empty the uterus. *The tissue obtained is sent to the laboratory for analysis to evaluate for choriocarcinoma. *Serial levels of hCG are used to detect residual trophoblastic tissue for 1 year

Management of obstetric hemorrhage

involves early recognition, assessment, and resuscitation. *Various methods are available to try to stop the bleeding, ranging from: -pharmacologic methods to aid uterine contraction (e.g., oxytocin, ergometrine, and prostaglandins) to -surgical methods to stem the bleeding (e.g., balloon tamponade, compression sutures, or arterial ligation).

Placenta previa

is a bleeding condition that occurs during the last two trimesters of pregnancy *(literally, "afterbirth first"), the placenta implants over the cervical os *is associated with potentially serious consequences from hemorrhage, abruption (separation) of the placenta, or emergency cesarean birth *ATTACHMENT issue

Oligohydramnios

is a decreased amount of amniotic fluid (less than 500 mL) between 32 and 36 weeks' gestation *Oligohydramnios may result from any condition that prevents the fetus from making urine or blocks it from going into the amniotic sac *Reduction in amniotic fluid reduces the ability of the fetus to move freely without risk of cord compression, which increases the risk for fetal death and intrapartal hypoxia

Hyperemesis gravidarum

is a severe form of nausea and vomiting of pregnancy *The term morning sickness is often used to describe this condition when symptoms are relatively mild *results in dehydration, weight loss, electrolyte imbalance, and the need for hospitalization *The peak incidence is at 8 to 12 weeks of pregnancy, and symptoms usually resolve by week 20

HELLP syndrome

is an acronym for hemolysis, elevated liver enzymes, and low platelet count *increased risk for complications such as cerebral hemorrhage, retinal detachment, hematoma/liver rupture, acute renal failure, disseminated intravascular coagulation (DIC), placental abruption, and maternal death *has been reported as early as 17 weeks' gestation, most of the time it is diagnosed between 22 and 36 weeks' gestation

ectopic pregnancy

is any pregnancy in which the fertilized ovum implants outside the uterine cavity *refers to the implantation of a fertilized egg in a location outside of the uterine cavity, including the fallopian tubes, cervix, ovary, and the abdominal cavity *can lead to massive hemorrhage, infertility, or death *the primary cause of death during the first trimester of pregnancy

Gestational hypertension

is characterized by hypertension (>140/90) without proteinuria after 20 weeks' gestation resolving by 12 weeks' postpartum *Gestational hypertension is a temporary diagnosis for hypertensive pregnant women who do not meet the criteria for preeclampsia or chronic hypertension *defined as systolic blood pressure > 140 mm Hg and/or diastolic > 90 mm Hg on at least two occasions at least 4 to 6 hours apart after the 20th week of gestation *progesterone supplementation during the first trimester significantly reduced the incidence of gestational hypertension and fetal distress in primigravida women

Multiple gestation

is defined as a pregnancy with two or more fetuses *This includes twins, triplets, and higher-order multiples such as quadruplets *women who are expecting more than one infant are at high risk for preterm labor, polyhydramnios, hyperemesis gravidarum, anemia, preeclampsia, and antepartum hemorrhage *Fetal/newborn risks or complications include prematurity, respiratory distress syndrome, birth asphyxia/perinatal depression, congenital anomalies (CNS, cardiovascular, and gastrointestinal defects), twin-to-twin transfusion syndrome (transfusion of blood from one twin [i.e., donor] to the other twin

Chronic hypertension

is defined as blood pressure exceeding 140/90 mm Hg before pregnancy or before 20 weeks' gestation *Pharmacologic treatment of mild hypertension does not reduce the likelihood of developing preeclampsia later in gestation and increases the likelihood of intrauterine growth restriction. *If maternal blood pressure exceeds 160/100 mm Hg, however, drug treatment is recommended

Bleeding at any time during pregnancy

is potentially life threatening *The biggest killer is obstetric hemorrhage

Dependent edema

is present on the lower half of the body if the client is ambulatory, where hydrostatic pressure is greatest *usually observed in the feet and ankles or in the sacral area if the client is on bed rest

Stillbirth

is the loss of a fetus after the 20th week of development

abortion

is the loss of an early pregnancy, usually before week 20 of gestation. *can be spontaneous or induced *most common cause for first-trimester abortions is fetal genetic abnormalities, usually unrelated to the mother *occurring during the second trimester are more likely related to maternal conditions, such as: -cervical insufficiency, -congenital, or acquired anomaly of the uterine cavity (uterine septum or fibroids), -hypothyroidism, -diabetes mellitus, -chronic nephritis, -use of crack cocaine, -inherited and acquired thrombophilia's, -lupus, -polycystic ovary syndrome, -severe hypertension, and acute infection such as rubella virus, -cytomegalovirus, -herpes simplex virus, - bacterial vaginosis, and toxoplasmosis

Clonus

is the presence of rhythmic involuntary contractions, most often at the foot or ankle. Sustained clonus confirms CNS involvement

Premature rupture of membranes (PROMs)

is the rupture of the bag of waters before the onset of true labor. There are a number of associated conditions and complications, such as infection, prolapsed cord, abruptio placentae, and preterm labor. *High-risk factors associated with preterm PROM include low socioeconomic status, multiple gestation, low BMI, tobacco use, history of preterm labor, placenta previa, abruptio placentae, urinary tract infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis *Women with PROM present with leakage of fluid, vaginal discharge, vaginal bleeding, and pelvic pressure, but they are not having contractions

Management for Severe Preeclampsia

maintain the client on complete bed rest in the left lateral lying position *Report any changes and any complaints of headache or visual disturbances. Offer a high-protein diet with 8 to 10 glasses of water daily *Assess the woman for signs and symptoms of pulmonary edema, such as crackles and wheezing heard on auscultation, dyspnea, decreased oxygen saturation levels, cough, neck vein distention, anxiety, and restlessness *Administer parenteral magnesium sulfate as ordered to prevent seizures. *Assess DTRs to evaluate the effectiveness *Diminished or absent reflexes occur when the client develops magnesium toxicity

Management of Cervical Insufficiency

monitoring the woman very closely for signs of preterm labor: backache, increase in vaginal discharge, rupture of membranes, and uterine contractions

Preeclampsia

most common hypertensive disorder of pregnancy, which develops with proteinuria after 20 weeks' gestation. It is a multisystem disease process, which is classified as mild or severe, depending on the severity of the organ dysfunction.

Maternal risks for abruptio placentae

obstetric hemorrhage, *need for blood transfusions, *emergency hysterectomy, *disseminated intravascular coagulopathy (DIC), and *renal failure **Perinatal consequences include low birth weight, preterm delivery, asphyxia, stillbirth, and perinatal death

Rh isoimmunization

occurs when a pregnant woman's immune system creates antibodies against fetal Rh blood factors *Rh antibodies can cause fetal heart problems, breathing difficulties, jaundice, and a form of anemia known as hemolytic disease of the newborn **women who are Rh negative are given anti-D immune globulin prophylaxis (RhoGAM) in the third trimester of pregnancy and after childbirth if the newborn is Rh positive

Management for Abruptio Placentae

place her on strict bed rest and in a left lateral position to prevent pressure on the vena cava. This position provides uninterrupted perfusion to the fetus. Expect to administer oxygen therapy via nasal cannula to ensure adequate tissue perfusion. Monitor oxygen saturation levels via pulse oximetry to evaluate the effectiveness of interventions. Obtain maternal vital signs frequently, as often as every 15 minutes as indicated, depending on the woman's status and amount of blood loss. *Observe for changes in vital signs suggesting hypovolemic shock and report them immediately *expect to insert an indwelling urinary (Foley) catheter to assess hourly urine output and initiate an intravenous infusion for fluid replacement using a large-bore catheter. *Assess fundal height for changes, an increase in size would indicate bleeding. *Monitor the amount and characteristics of any vaginal bleeding as frequently as every 15 to 30 minutes. *Be alert for signs and symptoms of DIC, such as bleeding gums, tachycardia, oozing from the intravenous insertion site, and petechiae, and administer blood products as ordered

Risk Factors of Cervical Insufficiency

previous cervical trauma, preterm labor, fetal loss in the second trimester, or previous surgeries, or procedures involving the cervix. History may reveal a previous loss of pregnancy around 20 weeks. *Also be alert for complaints of vaginal discharge or pelvic pressure

Psychological theory

psychological stress increases the symptoms.

serum magnesium levels

ranging from 4 to 7 mEq/L are considered therapeutic, *levels more than 8 mEq/dL are generally considered toxic. As levels increase, *10 mEq/L: Possible loss of DTRs *15 mEq/L: Possible respiratory depression *25 mEq/L: Possible cardiac arrest

Miscarriage

refers to a loss before the 20th week

spontaneous abortion

refers to the loss of a fetus resulting from natural causes, that is, not elective or therapeutically induced by a procedure *the most common complication of early pregnancy

Pathophysiology for Abruptio Placentae

starts with degenerative changes in the small maternal blood vessels, resulting in blood clotting, degeneration of the decidua (uterine lining), and possible rupture of a vessel. Bleeding from the blood vessel forms a blood clot between the placenta and the uterine wall

Management of preeclampsia

the "cure" for preeclampsia/eclampsia is always delivery of the placenta. *prevention of preeclampsia should be considered with daily low-dose aspirin from 12 weeks' gestation and onward to women identified at high risk for it

Clinical manifestations of Placenta Previa

the classical clinical presentation is painless, bright-red vaginal bleeding occurring during the second or third trimester *The first episode of bleeding occurs (on average) at 27 to 32 weeks' gestation

Management of Eclampsia

the convulsive activity begins with facial twitching, followed by generalized muscle rigidity *Seizure complications can include tongue biting, head trauma, broken bones, and aspiration. *Coma usually follows the seizure activity, with respiration resuming *left side, oxygen, suction equipment, IV fluids

Total placenta previa

the internal cervical os is completely covered by the placenta

Partial placenta previa

the internal os is partially covered by the placenta

Marginal placenta previa

the placenta is at the margin or edge of the internal os

Low-lying placenta previa

the placenta is implanted in the lower uterine segment and is near the internal os but does not reach it

Lab & Diagnostic test of Placenta Previa

to validate the position of the placenta, a transvaginal ultrasound is done

Lab & Diagnostic Test

transvaginal ultrasound to visualize the misplaced pregnancy and low levels of serum beta-hCG assist in diagnosing an ectopic pregnancy. The ultrasound determines whether the pregnancy is intrauterine, assesses the size of the uterus, and provides evidence of fetal viability *In a normal intrauterine pregnancy, beta-hCG levels typically double every 2 to 4 days until peak values are reached 60 to 90 days after conception. Concentrations of hCG decrease after 10 to 11 weeks and reach a plateau at low levels by 100 to 130 days

Risk Factors of Ectopic Pregnancy

usually result from conditions that obstruct or slow the passage of the fertilized ovum through the fallopian tube to the uterus *may be a physical blockage in the tube, or failure of the tubal epithelium to move the zygote (the cell formed after the egg is fertilized) down the tube into the uterus *previous tubal surgery, -infertility, -PID, -previous pregnancy loss (induced or spontaneous, -use of an intrauterine contraceptive system, -previous ectopic pregnancy, -uterine fibroids, -sterilization, -smoking (which alters tubal motility), -history of multiple sexual partners, -use of progestin -only oral contraceptives, -douching, and -exposure to diethylstilbestrol (DES)

preterm premature rupture of membranes (PPROM),

which is defined as rupture of membranes prior to the onset of labor in a woman who is less than 37 weeks' gestation *Perinatal risks associated with PPROM may stem from immaturity, including respiratory distress syndrome, intraventricular hemorrhage, patent ductus arteriosus, and necrotizing enterocolitis *may be associated with vaginal bleeding, placental abruption, microbial invasion of the amniotic cavity, and defective placentation