Ch 28

Nursing care for miscarriage

Focuses on physiologic stabilization

Complications with placenta previa

Hemorrhage which can lead to hysterectomy

Meds for hemorrhaging moms

Pitocin, ergot, hemabate, methergine

Placental abruption perinatal morbidity

20-30% mortality rate; more than 50% death

Habitual miscarriage or recurrent spontaneous abortion (RSA)

3 or more consecutive pregnancy losses before 20 weeks gestation; causes may be related to chromosomal abnormality

Tx of placenta previa

Delivery if needed, if not then bed rest with bathroom privileges, ultrasound every 2-3wks, NST once weekly

Maternal complications/outcomes with abruption placentae

1% mortality rate; Hemorrhage, hypovolemic shock, hypofibrinogenemia, and thrombocytopenia are associated with severe abruption.

Nursing interventions for DIC

Assess s/s of bleeding; assess signs of complications from blood/blood products administered; administer fluid or blood as ordered; cardiac/hemodynamic monitoring; protect from injury; monitor urinary output (renal failure is a consequence of DIC); VS frequently; if before birth: continuous fetal monitoring, side-lying tilt to maximize blood flow to uterus, oxygen via nonrebreather @ 8-10L/min

Medical management of threatened miscarriage

Depends on classification of miscarriage & s/s; threatened miscarriages managed with bed rest & supportive care; follow-up tx depends on whether the threatened miscarriage progresses to actual miscarriage or symptoms subside & pregnancy remains intact

Ectopic pregnancy

Fertilized ovum is implanted outside the uterine cavity; women are less likely to have successful subsequent pregnancies after ectopic pregnancy; leading cause of infertility; may occur in tube, abdomen, ovary, or cervix; 95% in tube

Complete miscarriage

All fetal tissue is passed, cervix is closed, may be slight bleeding, mild uterine cramping may be present

Incidence & Etiology of spontaneous abortion

Approx. 10-15% of all clinically recognized pregnancies in US end in miscarriage; early miscarriage is before 12wks-50% due to chromosomal abnormality; majority of miscarriages occur early, possible causes: endocrine imbalance, immunologic factors, systemic disorders & genetic factors; varicella infection in 1st trimester increases risk

Partial hydatidiform mole

Arrangement that occurs as result of 2 sperm fertilizing an apparently normal ovum

Incompetent cervix management: Cerclage

Bed rest, pessaries, antibodies, antinflammatory drugs and progesterone supplementation . A cervical cerclage may be performed. During gestation, a McDonald cerclage, a band of homologous fascia or nonabsorbable ribbon (Mersilene), may be placed around the cervix beneath the mucosa to constrict the internal os of the cervix (Fig. 28-2). A cerclage procedure can be classified according to time, or whether it is elective (prophylactic), urgent, or emergent. Cervical length must be 20-25mm to be able to have a cerclage; will not put one in past 24wks; cut cerclage @ 37 wks to allow labor

Hydatidiform Mole/Molar Pregnancy

Benign proliferative growth of placental trophoblast in which the chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in a grape-like cluster; type of gestational trophoblast disease with no viable fetus; may be further categorized as complete or partial

Antepartal hemorrhagic disorders causes

Bleeding in pregnancy jeopardizes maternal & fetal well being; maternal blood loss decreases oxygen capacity & increases risk for: hypovolemia, anemia, infection, pre-term labor, adverse oxygen delivery; fetal risks: blood loss, anemia, hypoxemia, hypoxia, anoxia, preterm labor

Clinical manifestations of placenta previa

Characterized by painless, bright red vaginal bleeding in 2nd and 3rd trimester; most cases are diagnosed by ultrasound before significant vaginal bleeding occurs. This bleeding is associated with the disruption of placental blood vessels that occurs with stretching and thinning of the lower uterine segment. Dx with ultrasound, no vaginal exams

Dx of abruptio placentae

Clinical dx; 50% can't be identified via ultrasound; dx confirmed after birth by inspection of placenta;

DIC Management

Correction of underlying cause; volume replacement; blood component therapy; optimization of oxygenation & perfusion status; continued reassessment of labs; Vitamin K & recombinant activated factor VII may be used

Lab results for DIC

Decreased: platelets, fibrinogen, factor V, factor VII; prolonged: PT, PTT; increased: fibrin degradation products, d-dimer tests; red blood smear shows fragmented cells

S/S of miscarriage

Depend on the duration of pregnancy; presence of uterine bleeding, uterine contractions or abdominal pain is an ominous sign during early pregnancy & must be considered a threatened miscarriage until proven otherwise; before 6wks woman may report a heavy menstrual flow; between 6-12wks causes moderate discomfort & blood loss; after 12wks more severe pain (similar to labor) because fetus must be expelled

Surgical management of ectopic pregnancy

Depends on location/cause, extent of tissue involvement & woman's desires regarding future fertility; one option is removal of entire tube (salpingectomy), if tube hasn't ruptured & woman desires fertility, salpingostomy may be performed-makes incision over pregnancy site & products of conception are carefully removed, incision is left to close by secondary intention instead because it results in less scarring; birth control for at least 3mos

Management of placental abruption

Depends on severity of blood loss & fetal maturity/status; fetus less than 34wks & both woman & fetus are stable, expectant management can be implemented-woman is closely monitored because abruption could extend any time, regularly assess fetus for sign of appropriate growth

Premature separation of placenta (abruption placentae)

Detachment of part or all of the placenta from implantation site; separation occurs in the area of the decidua basalis after 20wks of pregnancy & before birth; accounts for significant maternal and fetal morbidity and mortality

Complete placenta previa

During transvaginal ultrasound, the placenta totally covers the cervical os

Clinical manifestations of hydatidiform mole

Early stage: can't be distinguished from normal pregnancy; later: vaginal bleeding, dark brown/prune juice vaginal discharge or bright red which may be scant or profuse, may continue for a few days or intermittently for weeks, uterus may be larger than expected; common findings include anemia, excess N/V, abdominal cramps; may pass vesicles which are frequently avascular edematous villi from uterus; preeclampsia occurs with larger moles & occurs earlier than usual in pregnancy, hyperthyroidism is another complication

Tubal pregnancy

Ectopic pregnancy that occurs in the uterine tube; most commonly in ampulla

Marginal placenta previa

Edge of placenta is seen on transvaginal ultrasound to be 2.5cm or closer to internal cervical os

Placenta previa risk factors

History of cesarean birth, advanced maternal age, multiparity (due to larger placental area), history of prior curettage, smoking

Active management for placental abruption

Immediate birth if fetus is at term or bleeding is moderate-severe; one large bore IV line should be started; monitor maternal VS to observe for signs of declining hemodynamic status (increase P and decreased BP); serial labs: hgb, hct, clotting; indwelling catheter for urine output monitoring, blood & fluid volume replacement may be needed; continuous external fetal monitoring; vaginal birth is usually feasible & desirable especially if fetal death

Symptoms of a threatened miscarriage

Include spotting of blood but with cervical os closed; mild uterine cramping may be present

Risk factors for placental abruption

Maternal HTN, cocaine use, blunt abdominal trauma

Tocolytics

May be given prophylactically to prevent uterine contractions & further dilation of cervix

Clinical manifestations of placental abruption

May be partial or complete-sx vary with degree of separation; with c-section blood clots may be noticed on entry into uterus; classic sx include vaginal bleeding, abdominal pain, uterine tenderness, contractions, board-like abdomen; there are different grades

Ectopic pregnancy treatment

Medical management involves giving methotrexate to dissolve the tubal pregnancy, this destroys rapidly dividing cells & shouldn't be given to those taking additional folic acid or drinking alcohol because these increase risk of rupture; requires post-treatment lifestyle restrictions & monitoring;

Symptoms of inevitable & incomplete miscarriages

Moderate-heavy amount of bleeding with open cervical os; tissue may be present with bleeding; mild-severe uterine cramping; inevitable miscarriage often accompanied by ROM & cervical dilation; passage of products of conception will occur; incomplete miscarriage involves expulsion of fetus with retention of placenta—cant prevent

Bleeding with placenta previa

Mom can lose up to 40% of blood volume without showing signs of shock; decreased urinary output may be a better indicator of acute blood loss than VS

Possible reasons for rise in ectopic pregnancy

More sensitive diagnostic tests including transvaginal ultrasound & hCG measurement; increased incidence of STDs, tubal infection/damage, contraceptive methods that predispose failures to be ectopic (IUD), tubal sterilization methods, assisted reproductive techniques & tubal surgeries

Management of hydatidiform mole

Most abort spontaneously; suction curettage offers safe, rapid, effective method of evacuation; induction of labor is not recommended; give RhoGAM after if mom is Rh-; provide support & education regarding the disease process & future pregnancies/fertility

Late miscarriage

Occurs between 12-20wks; usually results from maternal causes, such as advancing maternal age and parity, premature dilation of the cervix and other anomalies of the reproductive tract, inadequate nutrition, and recreational drug use, obesity, and stressful life events

Incompetent cervix aka recurrent premature dilation of cervix

Passive & painless dilation of cervix during 2nd trimester; assumes an "all or nothing" role for the cervix, it is either competent or incompetent; dx with 1 or 2 pregnancy losses & short labors

Miscarriage/Spontaneous abortion

Pregnancy that ends as a result of natural causes before 20wks; 20wk marker considered the point of viability when a fetus may survive in extrauterine environment; fetal weight less than 500g may also be used to define abortion

Nursing Alert with Miscarriage

Procedures for disposition of fetal remains very from hospital to hospital & state to state; nurse should know the usual procedures in his/her hospital

Fibrinolytic system

Process through which fibrin is split into fibrinolytic degradation products and circulation is restored

Medical management of miscarriage

Prostaglandin meds (misoprostol/cytotec) may be given orally or vaginally & is usually effective in completing the miscarriage within 7d; dilation & curettage (D&C) is surgical procedure in which cervix is dilated & a curette is inserted to scrape the uterine walls & remove uterine contents; D&C is commonly performed to treat inevitable & incomplete miscarriage; nurse reinforces explanation, answers questions/concerns & preps woman for surgery; IV oxytocin afterward to prevent hemorrhage-may use methergine or hemabate if oxytocin is ineffective

Incompetent cervix Dx

Reduce cervical competence is the diagnosis and is seen on ultrasound, it can be accompanied by cervical funneling ((breaking) or effacement if the internal os.

Clinical manifestations of ectopic pregnancy after rupture

Referred shoulder pain; signs of shock, such as faintness and dizziness, related to the amount of bleeding in the abdominal cavity and not necessarily related to obvious vaginal bleeding. An ecchymotic blueness around the umbilicus (Cullen sign), indicating hematoperitoneum, may also develop in an undiagnosed, ruptured intraabdominal ectopic pregnancy.

Missed miscarriage

Refers to a pregnancy in which the fetus has died but all products of conception are retained in utero for up to several weeks; may be diagnosed by ultrasonic exam after uterus stops increasing in size or decreases in size; no bleeding or cramping may be present & cervical os remains closed; requires D&C

Complete hydatidiform mole

Results from fertilization of an egg in which nucleus has been lost or inactivated

Follow up for surgery for ectopic pregnancy

RhoGAM may be necessary; encourage to share feelings/concerns related to loss; report suspected pregnancy immediately due to increased risk of subsequent ectopic pregnancy

Abdominal exam in placenta previa

Soft, relaxed, non-tender uterus with normal tone; fetal presentation is usually breech or oblique

Clinical manifestations of DIC

Spontaneous bleeding from gums/nose; oozing, excess bleeding from venipuncture site/IV access site/catheter insertion site; petechiae where pressure was placed (around BP cuff); other signs of bruising; hematuria; GI bleed; tachycardia; diaphoresis

Nursing alert for Methotrexate

The woman on methotrexate therapy who drinks alcohol and takes vitamins containing folic acid (such as prenatal vitamins) increases her risk of having side effects of the drug or exacerbating the ectopic rupture

Care management for early pregnancy bleeding

Thorough assessment should be performed; lab findings are characteristic of miscarriage; evaluation of hCG is used in the dx of pregnancy & pregnancy loss along with progesterone

Nursing alert hydatidiform mole

To avoid confusion in regard to rising levels of hCG that are normal in pregnancy but could indicate GTD, pregnancy should be avoided during the follow-up assessment period. Any contraceptive method except an IUD is acceptable. Oral contraceptives are preferred because they are highly effective.

Dx of hydatidiform mole

Transvaginal ultrasound, serum hCG levels

Home care for Incompetent cervix

Woman must understand the importance of activity restriction at home & need for close observation & supervision; important to take oral tocolytic meds & know the expected response/possible side effects; with home uterine monitoring woman is taught to apply contraction monitor & transmit monitor tracing by telephone to health care provider; woman must be aware that strong contractions less than 5min apart, ROM, severe perineal pressure & urge to push will warrant immediate transfer to hospital; if fetus is born premature or isn't viable, provide grief support and/or anticipatory guidance

Etiologic factors of incompetent cervix

history of previous cervical lacerations during childbirth, excessive cervical dilation for curettage or biopsy, or the woman's mother's ingestion of diethylstilbestrol (DES)during pregnancy with the woman. Multiple gestation may provide an additional stress on the cervix but alone does not produce cervical incompetency or justify prophylactic cervical cerclage A short cervix (less than 25 mm in length) is indicative of reduced cervical competence

S/S of ectopic pregnancy

dull, achy pain that progresses to a sharp, stabbing pain usually on side that the ectopic pregnancy has occurred; cycle 1-2wks late or lighter than usual; often complain of mild-moderate dark red or brown intermittent bleeding; dx & surgically take care of it before it ruptures is the goal; if it ruptures they'll arrive to ER complaining of shoulder pain along with abdominal pain due to build-up of blood in peritoneal cavity where rupture occurred—This is an emergency, can go into shock, may notice ecchymosis/blueness around umbilicus (Cullen Sign); screen by monitoring HcG levels (will be high), transvaginal ultrasound, may also draw progesterone level-if less than 5 indicates ectopic

Follow up for hydatidiform mole

frequent physical and pelvic examinations along with weekly measurements of the β-hCG level until the level decreases to normal and remains normal for 3 consecutive weeks. Monthly measurements are then taken for 6 months. The follow-up assessment period usually continues for a year. During that time, a rising β-hCG level and an enlarging uterus may indicate GTD; birth control for up to 6 months after pregnancy & monitor hCG levels for 1 year—goal is a level of 0 for at least 3 consecutive weeks during that year, if hCG continues to increase may indicate cancer

DIC in pregnancy

most often triggered by the release of large amounts of tissue thromboplastin, which occurs in placental abruption (the most common cause of severe consumptive coagulopathy in obstetrics) and in the retained dead fetus syndrome and the anaphylactoid syndrome of pregnancy (amniotic fluid embolus). Severe preeclampsia, HELLP syndrome, and gram-negative sepsis can trigger DIC

Disseminated intravascular coagulation (DIC)

pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both, and clotting; never a primary diagnosis; results from some problem that triggered the clotting cascade, either extrinsically, by the release of large amounts of tissue thromboplastin, or intrinsically, by widespread damage to vascular integrity

Prophylactic cerclage

placed at 11 to 15 weeks of gestation, after which the woman is told to refrain from intercourse. She is monitored during the course of her pregnancy with ultrasound scans to assess for cervical shortening and funneling. The cerclage is electively removed when the woman reaches 37 weeks of gestation, or it may be left in place and a cesarean birth performed

Placenta previa

placenta is implanted in the lower uterine segment such that is completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces. near or over the internal cervical os.

Incompetent Cervix Etiology

starts opening on its own before it is supposed to; on bed rest, ATB, anti-inflammatory, progesterone, if cervix continues to try to open may put in a cervical cerclage

Normal clotting in pregnancy

stops the flow of blood from injured vessels, in part through the formation of insoluble fibrin, which acts as a hemostatic platelet plug. The phases of the coagulation process involve an interaction of the coagulation factors in which each factor sequentially activates the factor next in line, the "cascade effect" sequence

Clinical manifestations of ectopic pregnancy

three most classic symptoms: (1) abdominal pain, (2) delayed menses, and (3) abnormal vaginal bleeding (spotting) that occurs approximately 6 to 8 weeks after the last normal menstrual period; Abdominal pain occurs in almost every case. It usually begins as a dull, lower quadrant pain on one side. The discomfort can progress from a dull pain to a colicky pain when the tube stretches, to sharp, stabbing pain; Up to 90% of women with an ectopic pregnancy report a period that is delayed 1 to 2 weeks or is lighter than usual, or an irregular period. Mild to moderate dark red or brown intermittent vaginal bleeding occurs in up to 80% of women

Physical exam with placental abruption

usually reveals abdominal pain, uterine tenderness, and contractions. The fundal height may be measured over time because an increasing fundal height indicates concealed bleeding. Approximately 60% of live fetuses exhibit abnormal (nonreassuring) FHR patterns, and elevated uterine resting tone may also be noted on the monitor tracing