FN - Chapter 19

Gestational HTN

This is HTN that includes a BP increase (140/90) identified after 20 weeks' gestation WITHOUT proteinuria. In this condition, BP returns to normal by 12 weeks' postpartum.

Hydatidiform mole

This is a benign neoplasm of the chorion in which the chorionic villi degenerate and become transparent vesicles containing clear, viscid fluid.

Delivery of the placenta

What is the "cure" for preeclampsia/eclampsia?

As soon as possible by a health care professional to ascertain the etiology.

When a pregnant woman calls and reports vaginal bleeding, when must she be seen?

Placenta accreta

A condition in which the placenta attaches itself too deeply into the wall of the uterus but does not penetrate the uterine muscle.

Placenta Percreta

A condition when the placenta has extended through the myometrium and uterine serosa and adjacent tissue

Placenta Increta

A condition when the placenta invades the myometrium

High-Risk Pregnancy

A term for a pregnancy in which a condition exists that jeopardizes the health of the mother, her fetus, or both. The condition may result from the pregnancy, or it may be a condition that was present before the woman became pregnant.

Hyperemesis gravidarum

A term for a severe form of uncontrollable nausea and vomiting that begins in the first trimester and causes dehydration, ketosis, weight loss of more than 5% of pre-pregnancy body weight, electrolyte imbalance, and the need for hospitalization. This condition is also associated with significant costs and psychosocial impacts.

Stillbirth

A term for the loss of a fetus after the 20th week of development

Abortion

A term for the loss of an early pregnancy, usually before week 20 of gestation.

salpingectomy

A term for the removal of a fallopian tube during ectopic pregnancy.

Miscarriage

A term that refers to a loss of the fetus before the 20th week.

Ondansetron (Zofran)

This drug blocks serotonin release, which stimulates the vagal afferent nerves, thus preventing the stimulating of the vomiting reflex.

Promethazine (Phenergan)

This drug diminishes vestibular stimulation and acts on the chemoreceptor trigger zone (CTZ) to provide symptomatic relief of nausea and vomiting, and motion sickness

Misoprostol (Cytotec)

This drug is used to stimulate uterine contractions to either terminate a pregnancy or evacuate the uterus after an abortion to ensure passage of all the products of conception

First Trimester

About 80% of spontaneous abortions occur within the what trimester?

Progesterone supplementation in the 1st Trimester

According to a recent study, what may reduce the incidence of gestational HTN and fetal distress in primigravida women?

1.) Assess VS 2.) Observe amount, color, and characteristics of the bleeding. 3.) Pain Rating 4.) Evaluate amount and intensity of abdominal cramping or contractions 5.) Assess woman's level of understanding about what is happening to her.

After a woman has arrived at the health care facility following a phone call to note vaginal bleeding, what should be done?

one in four

Approximately how many pregnant women are considered to be at high risk or diagnosed with complications?

As partial of complete, depending on the degree of separation. Or, as concealed or apparent dependent on the type of bleeding.

Aside from mild, moderate, and severe, how can Abruptio Placentae also be classified?

This is a temporary diagnosis for HTN pregnant women who DO NOT meet the criteria for preeclampsia and chronic hypertension. Defined as systolic BP >140 mm Hg and/or diastolic >90 mm Hg WITHOUT proteinuria on at least two occasions at least 4 to 6 hours apart after the 20th week of gestation in women known to be normotensive prior to this time and prior to pregnancy. It resolves by 12 weeks' postpartum.

Describe Gestational HTN

PP = Usually in normal range AP = Fetal distress or absent

Describe the FHR associated with Placenta Previa and Abruptio Placentae.

PP = None (painless) AP = Constant; uterine tenderness on palpation

Describe the discomfort/pain associated with Placenta Previa and Abruptio Placentae.

PP = May be breech or transverse lie; engagement is absent AP = No relationship

Describe the fetal presentation associated with Placenta Previa and Abruptio Placentae.

A single-dose IM injection of methotrexate with outpatient follow-up.

Describe the medical approach to treating ectopic pregnancy.

Partial moles rarely transform into choriocarcinoma.

Do partial moles have a high incidence of cancer development?

1 in every 50 pregnancies in the United States or roughly 2% of all pregnancies. This rate has increased dramatically during the past 30 years.

How often do ectopic pregnancies occur? What is the trend for ectopic pregnancies?

Immediate evacuation of the uterine contents via D&C and long-term follow-up of the client to detect any remaining trophoblastic tissue , typically including hCG level monitoring for 1 year.

How are molar pregnancies treated?

It can either be performed transvaginally or transabdominally. Cervical cerclage involves using a heavy purse-string suture to secure and reinforce the internal os of the cervix

How can cerclage be performed? What does it involve?

Positive history of repeated second trimester abortions

How is Cervical Insufficiency typically diagnosed?

The diagnosis is made by very high hCG levels and the characteristic appearance of the vesicular molar pattern in the uterus via transvaginal ultrasound.

How is GTD diagnosed?

According to the extent of separation and the amount of blood loss from the maternal circulation.

How is abruptio placentae classified?

complete or partial

How may Hydatidiform mole be classified?

• US demonstrating empty uterus

How might a complete abortion be diagnosed?

1.) Monitored closely for s/s of severe preeclampsia or impending eclampsia 2.) Daily weights and BP to detect excessive weight gain resulting from edema. 3.) Fetal surveillance via daily fetal movement counts, nonstress testing, and serial ultrasounds to evaluate fetal growth and amniotic fluid volume to confirm fetal well-being.

If home management fails to reduce blood pressure associated with mild preeclampsia, hospitalization is warranted. What treatment strategies are enacted at the hospital?

1.) neurologic disturbances 2.) renal damage 3.) dehydration 4.) ketosis 5.) alkalosis from loss of hydrochloric acid 6.) hypokalemia 7.) retinal hemorrhage 8.) death

If hyperemesis gravidarum is left untreated, what can result?

8 to 12

In 80% of women with a benign hydatidiform mole, serum hCG titers steadily drop to a normal level with ___-____ weeks. In the other 20% with a malignant mole, the levels begin to rise

1.) Woman counseled on the risks, benefits, adverse effects, and the possibility of failure of medical therapy, which would result in tubal rupture, necessitating surgery 2.) Woman instructed to return weekly for follow-up laboratory studies for the next several weeks until beta-hCG titers decrease.

Prior to receiving a single-dose of methotrexate to treat the unrupture ectopic pregnancy, what must be done?

Vasospasm Hypoperfusion

Pre-eclampsia is a two-stage event. Note the two stages.

1.) Ability to invade the wall of the uterus 2.) Tendency to recur in subsequent pregnancies 3.) Possible development into choriocarcinoma 4.) An influence of nutritional factors, such as protein deficiency 5.) Tendency to affect older women more often than younger women

Studies have revealed some remarkable features about molar pregnancies, note 5 of these features.

<1%

The incidence of cervical insufficiency is less than ____% in the obstetrical population

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

This drug suppresses the immune response of nonsensitized Rh-negative clients who are exposed to Rh-positive blood; prevents isoimmunization in Rh-negative women exposed to Rh-positive blood after abortions, miscarriages, and pregnancies.

TRUE

TRUE or FALSE: Some stillbirths can occur right up to the time of labor and delivery.

TRUE

TRUE or FALSE: Women considered as high risk pregnancies have a higher morbidity and mortality compared with mothers in the general population.

Chronic HTN

This is HTN that exists prior to pregnancy or that develops before 20 weeks' gestation.

thrombin; plasmin

The clinical and pathologic manifestations of DIC can be described as a loss of balance between the clot-forming activity of ________________ and the clot-lysing activity of _______________.

15% to 20%; 60% to 70%

The overall rate for spontaneous abortion in the United States is reported to be ____-____% of recognized pregnancies. However, with the development of highly sensitive assays for human chorionic gonadotropin (hCG) levels that detect pregnancies prior to the expected next menses, the incidence of pregnancy loss increases significantly—to about _____-_____% (King et al., 2015).

Spontaneous Abortion

The term for the loss of a fetus resulting from natural causes, that is, not elective or therapeutically induced by a procedure.

Placenta previa

This is a bleeding condition that occurs during the last two trimesters of pregnancy. The condition involves the implantation of the placenta over the cervical os. It is associated with potentially serious consequences from hemorrhage, placental abruption, or emergency c-section.

Preeclampsia

This is the MOST COMMON HTN 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.

Eclampsia

This type of HTN pregnancy problem includes the onset of seizure activity following preeclampsia.

hydatidiform mole (partial or complete) choriocarcinoma.

What are the two most common types of GTD?

seventh or eighth week of gestation

When do signs and symptoms of ectopic pregnancy typically onset?

The optimal timing for cerclage removal is unclear, but ACOG supports cerclage placement up to 28 weeks' gestation.

When is the optimal time to place and remove a cerclage?

Miscarriages

Which is more common, stillbirths or miscarriage?

1.) Sudden gush of fluid from vagina 2.) Vaginal bleeding 3.) Abdominal pain 4.) Persistent vomiting 5.) Epigastric pain 6.) Edema of face and hands 7.) Severe, persistent headache 8.) Blurred vision or dizziness 9.) Chills with fever over 38.0 C (100.4F) 10.) Painful urination or reduced urine output

Note 10 Danger Signs in Pregnancy

1.) Genetic conditions 2.) Chromosomal abnormalities 3.) Multiple pregnancy 4.) Defective genes 5.) Inherited disorders 6.) ABO incompatibility 7.) Large fetal size 8.) Medical and obstetric conditions 9.) Preterm labor and birth 10.) Cardiovascular disease 11.) Chronic hypertension 12.) Cervical insufficiency 13.) Placental abnormalities 14.) Infection 15.) Diabetes 16.) Maternal collagen diseases 17.) Thyroid disease 18.) Asthma 19.) Postterm pregnancy 20.) Hemoglobinopathies 21.) Nutritional status 22.) Inadequate dietary intake 23.) Food fads 24.) Excessive food intake 25.) Under- or overweight status 26.) Hematocrit value less than 33% 27.) Eating disorder

Note 27 biophysical factors that place a woman at risk during pregnancy.

1.) Placenta Previa 2.) Abruptio Placentae 3.) Placenta Accreta

Note 3 conditions associated with Late Bleeding (I.e., after 20 weeks)

1.) Placenta Previa 2.) Abruptio Placentae 3.) Placenta Accreta

Note 3 conditions associated with late bleeding (typically after the 20 week gestation) in pregnancy.

1.) Spontaneous abortion 2.) Uterine fibroids 3.) Ectopic pregnancy 4.) GTD 5.) Cervical insufficiency.

Note 5 conditions associated with early bleeding in pregnancy.

1.) Infections 2.) Radiation 3.) Pesticides 4.) Illicit drugs 5.) Industrial pollutants 6.) Second-hand cigarette smoke 7.) Personal stress

Note 7 Environmental Factors that place a woman at risk during pregnancy.

1.) Poverty status 2.) Lack of prenatal care 3.) Age younger than 15 years or older than 35 years 4.) Parity—all first pregnancies and more than five pregnancies 5.) Marital status—increased risk for unmarried women 6.) Accessibility to health care 7.) Ethnicity—increased risk in non-White women

Note 7 Sociodemographic Factors that place a woman at risk during pregnancy.

1.) Previous pregnancy complicated by hyperemesis 2.) Molar pregnancies 3.) Hx helicobacter pylori infection 4.) Multiple gestation 5.) Pre-pregnancy Hx genitourinary disorders 6.) Clinical hyperthyroid disorders 7.) Pre-pregnancy psychiatric diagnosis

Note 7 risk factors related to hyperemesis gravidarum

1.) Smoking 2.) Caffeine 3.) Alcohol and substance abuse 4.) Maternal obesity 5.) Inadequate support system 6.) Situational crisis 7.) History of violence 8.) Emotional distress 9.) Unsafe cultural practices

Note 9 Psychosocial Factors that place a woman at risk during pregnancy.

1.) Monitor hCG levels 2.) Document amount and character of bleeding 3.) Save clots and tissue 4.) VS and Pad Count (1gm = 1ml) 5.) Dilation and Currettage (Post-op cares) 6.) NPO (if D&C anticipated) 7.) RhoGAM (If Rh-) 8.) Grief support

Note KEY nursing management concepts concerning abortion.

Painful, dark-red vaginal bleeding (port-wine color) "knife-like" abdominal pain uterine tenderness contractions decreased fetal movement.

Note classic manifestation fo abruptio placentae.

1.) Suture displacement 2.) ROM 3.) Chorioamnionitis

Note complications associated with cerclage placement.

1.) Abruptio placentae 2.)Amniotic fluid embolism 3.) Endotoxin sepsis 4.) Retained dead fetus 5.) Posthemorrhagic shock 6.) Hydatidiform mole 7.) Gynecologic malignancies.

Note conditions that DIC can occur secondary to.

• Administer intramuscularly in deltoid area. • Give only MICRhoGAM for abortions and miscarriages <12 wks unless fetus or father is Rh negative (unless client is Rh positive, Rh antibodies are present). • Educate woman that she will need this after subsequent deliveries if newborns are Rh positive; also check lab study results prior to administering the drug.

Note considerations when administering RhoGAM

1.) Starting two large-bore IV lines with NS or LR solution to combat hypovolemia 2.) Obtaining blood specimens for evaluating hemodynamic status values and for typing and cross-matching 3.) Frequently monitoring fetal and maternal well-being. 4.) After the severity of abruption is determined and appropriate blood and fluid replacement is given, cesarean birth is done immediately if fetal distress is evident. If the fetus is not in distress close monitoring continues, with delivery planned at the earliest signs of fetal distress.

Note emergency measures taken with Abruptio Placentae.

1.) Anemia/hypovolemic shock 2.) Fetal hypoxia 3.) Abnormal presentation (breech, transverse) because the placenta is taking up extra room

Note fetal s/s of placenta previa

1.) Vaginal bleeding 2.) Anemia 3.) Excessively enlarged uterus 4.) Preeclampsia 5.) Hyperemesis

Note how most women present when having a complete hydatidiform mole.

1.) Transvaginal ultrasound is done. 2.) MRI may be ordered when preparing for delivery because it allows identification of placenta accreta

Note laboratory and diagnostic testing completed in relation to placenta previa.

Decreased fibrinogen and platelets Prolonged PT and aPTT Positive D-dimer tests and fibrin (split) degradation products

Note laboratory studies that assist in the diagnosis of DIC.

1.) Strict bed rest in a left lateral position to prevent pressure on the vena cava. 2.) Expect to administer oxygen therapy via nasal cannula to ensure adequate tissue perfusion. 3.) Monitor oxygen saturation levels 4.) Obtain maternal vital signs frequently, as often as every 15 minutes as indicated 5.) Observe for changes in vital signs suggesting hypovolemic shock and report them immediately. 6.) Expect to insert an indwelling urinary (Foley) catheter to assess hourly urine output and initiate an IV infusion for fluid replacement using a large-bore catheter. 7.) Assess fundal height for changes. 8.) Monitor the amount and characteristics of any vaginal bleeding as frequently as every 15 to 30 minutes. 9.) Be alert for signs and symptoms of DIC, such as bleeding gums, tachycardia, oozing from the IV insertion site, and petechiae, and administer blood products as ordered if DIC occurs. 10.) Institute continuous electronic fetal monitoring. 11.) Assess uterine contractions and report any increased uterine tenseness or rigidity.

Note measures to take to ensure adequate tissue perfusion when the woman with likely abruptio placentae arrives at the hospital.

Less elastin Less collagen Greater amounts of smooth cervical muscle Trauma to cervix Multiple gestation Hydraminos

Note potential causes of Cervical Insufficiency.

1.) Advanced maternal age (over 35 years old), 2.) Poor nutrition 3.) Multiple gestation 4.) Excessive intrauterine pressure caused by polyhydramnios 5.) Chronic hypertension 6.) Cigarette smoking 7.) Severe trauma (e.g., auto accident, intimate partner violence) 8.) Hx of abruption in a previous pregnancy 9.) Placental abnormalities 10.) Cocaine or methamphetamine abuse, 11.) Thrombophilia 12.) Alcohol ingestion 13.) Multiparity 14.) Male fetal gender 15.) Chorioamnionitis 16.) Prolonged premature ruptured membranes (more than 24 hours), 17.) Oligohydramnios, 18.) Preeclampsia 19.) Low socioeconomic status

Note predisposing/risk factors associated with Abruptio Placentae.

1.) Previous cervical trauma 2.) Preterm labor 3.) Fetal loss in the second trimester, or previous surgeries or procedures involving the cervix. 4.) Loss of pregnancy around 20 weeks.

Note risk factors associated with Cervical Insufficiency.

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 grape-like vesicles (possible in some wom

Note signs and symptoms of GTD

1.) Severe headache 2.) Generalized edema 3.) RUQ or Epigastric Pain 4.) Visual Disturbances 5.) Cerebral hemorrhage 6.) Renal Failure 7.) HELLP

Note signs/symptoms of eclampsia

1.) Mild facial or hand edema 2.) Weight gain

Note signs/symptoms of mild pre-eclampsia

1.) Headache 2.) Oliguria 3.) Blurred vision, scotomata 4.) Pulmonary Edema 5.) Thrombocytopenia (<100,000 platelets) 6.) Cerebral disturbances 7.) Epigastric or RUQ pain 8.) HELLP

Note signs/symptoms of severe pre-eclampsia

1.) Blood tests are ordered to assess the severity of: --dehydration --electrolyte imbalance --ketosis --malnutrition 2.) Parenteral fluids and drugs ordered to rehydrate and reduce symptoms, with the first choice for fluid replacement being NS with vitamins (B6) and electrolytes, which aids in preventing hyponatremia. 3.) NPO are withheld for first 24-36 hours to allow GI tract to rest 4.) Antiemetics administered rectally or IV. Once stable, PO meds may be used. 5.) Medications Used: --Promethazine (Phenergan) --prochlorperazine (Compazine) --ondansetron (Zofran) may be tried if aforementioned options fail to provide relief. Most drugs are given IV or IM 6.) CAMs include: --acupressure --massage --therapeutic touch --ginger --wearing of Sea-Bands to prevent nausea and vomiting

Note steps in managing Hyperemesis Gravidarum upon admission to the hospital.

CBC Fibrinogen levels Prothrombin time (PT)/activated partial thromboplastin time (aPTT) Type and cross-match Nonstress test Biophysical profile CT Scan NOTE: Ultrasound is not useful for making a definitive diagnosis because the clot is sonographically visible in less than 50% of the cases.

Note studies/diagnostic measures that may be helpful in diagnosing Abruptio Placentae.

Bleeding with abdominal or low back pain Uterus is tender and unusually firm Cramping with uterine irritability

Note symptoms of placentae abruptio.

Avoid noxious stimuli that may trigger N&V Avoid tight clothes to reduce ab pressure Eat small, frequent meals (6) Drink fluids between, NOT with meals No lying down for at least 2 hours after eating Use high-protein supplement drinks Avoid high fat foods Increase intake of carbonated beverages Increase exposure to fresh air Eat when hungry, regardless of mealtimes Drink herbal teas with peppermint/ginger. Avoid fatigue and learn to manage stress Schedule daily rest periods Eat foods that settle the stomach (crackers, toast, or soda)

Note teaching guidelines to prevent N&V.

Mild: >140/90 after 20 weeks' gestation Severe: >160/110 Eclampsia: >160/110

Note the BP similarities and differences between mild/severe pre-eclampsia and eclampsia.

1.) Contains no fetal tissue 2.) Develops from an "empty egg," which is fertilized by a normal sperm 3.) The embryo is not viable and dies. 4.) No circulation is established, and no embryonic tissue is found. 5.) The complete mole is associated with the development of choriocarcinoma.

Note the characteristics of the complete hydatidiform mole.

PP - Bright Red AP = Dark Red

Note the coloration of blood for Placenta Previa and Abruptio Placentae

Abdominal pain with spotting within 6 to 8 weeks after a missed menstrual period.

Note the hallmarks of ectopic pregnancy.

In hyperemesis gravidarum, the hCG levels are often higher and extend beyond the first trimester

Note the influence that hCG has on the pathophysiology of Hyperemesis Gravidarum.

Lungs Lower Genital Tract Brain Liver

Note the most frequent sites of metastases with molar pregnancies.are the lungs, lower genital tract, brain, and liver.

PP = insidious AP = sudden

Note the onset in one word for Placenta Previa and Abruptio Placentae.

1.) Implantation of embryo in lower uterus perhaps due to uterine endometrial scarring or damage in the upper segment 2.) Uteroplacental underperfusion may increase surface area required for placental attachment and may cause the placenta to encroach on the lower uterine segment. 3.) With placental attachment and growth, the cervical os may become covered by the developing placenta. 4.) Placental vascularization is defective, allowing the placenta to attach directly to the myometrium (accreta), deeply attach to the myometrium (increta), or infiltrate the myometrium (percreta).

Note the pathophysiology of Placenta Previa.

Mild: 300mg/24 hr or greater than 1+ protein on random dipstick urine sample Severe: >500mg/24 hr; >3+ on random dipstick urine sample Eclampsia: Marked Proteinuria

Note the proteinuria similarities and differences between mild/severe pre-eclampsia and eclampsia.

Mild: NO Severe: YES Eclampsia: YES

Note the similarities and differences between mild/severe pre-eclampsia and eclampsia concerning hyperreflexia.

Mild: NO Severe: NO Eclampsia: YES

Note the similarities and differences between mild/severe pre-eclampsia and eclampsia concerning seizures/coma.

Threatened Inevitable Incomplete Complete Missed Habitual

Note the six types of abortions.

PP = Always visible; slight, then more profuse AP = Can be concealed or visible

Note the type of bleeding for Placenta Previa and Abruptio Placentae.

Chronic HTN Gestational HTN Preeclampsia Eclampsia Chronic HTN w/superimposed preeclampsia.

Note the various HTN disorders associated with pregnancy.

1.) Assess degree of bleeding 2.) Inspect perineal area for blood that may be pooled 3.) Estimate and document the amount of bleeding 4.) Perform a peripad count on an ongoing basis 5.) If active bleeding, prepare for blood typing and cross-matching in the event a blood transfusion is needed. 6.) Monitor maternal VS (q5-15 minutes in active hemorrhage) and uterine contractility frequently 7.) Have patient rate pain 8.) Assess FHR via Doppler or electronic monitoring 9.) Monitor woman's cardiopulmonary status, reporting any difficulties in respirations, changes in skin color, or complaints of difficulty breathing. 10.) Have oxygen equipment readily available should fetal or maternal distress develop. 11.) Encourage the client to lie on her side to enhance placental perfusion. 12.) Inspect IV site frequently. 13.) Obtain laboratory tests as ordered, including complete blood count (CBC), coagulation studies, and Rh status if appropriate. 14.) Administer pharmacologic agents as necessary. Give Rh immunoglobulin if the client is Rh negative at 28 weeks' gestation. 15.) Monitor tocolytic (anticontraction) medication if prevention of preterm labor is needed.

Note things to monitor in maternal and fetal status related to placenta previa

Baseline hCG level, chest x-ray, and pelvic ultrasound Quantitative hCG levels every week until undetectable for 3 consecutive weeks; then serial hCG levels monthly for 1 year Chest x-ray every 6 months to detect pulmonary metastasis Regular pelvic examinations to assess uterine and ovarian regression Systemic assessments for symptoms indicative of lung, brain, liver, or vaginal metastasis Strong recommendation to avoid pregnancy for 1 year because the pregnancy can interfere with the monitoring of hCG levels Use of a reliable contraceptive for at least 1 year

Note treatment measures for follow-up after removal of a hydatidiform mole.

Reassuring the woman that spontaneous abortion usually results from an abnormality and that her actions did not cause the abortion.

Nursing management of the woman with a spontaneous abortion focuses on providing continued monitoring and psychological support. What is an important component of this support?

hCG level is monitored until it is undetectable to ensure that any residual trophoblastic tissue that forms the placenta is gone. Also, all Rh-negative unsensitized clients are given Rh immunoglobulin to prevent isoimmunization in future pregnancies.

Regardless of the ectopic pregnancy treatment approach what is monitored?

1.) Urine pregnancy test (confirm pregnancy) 2.) hCG levels (exclude false-negative) 3.) Transvaginal US (visualize misplaced pregnancy)

What diagnostic procedures are used when an ectopic pregnancy is suspected?

Transvaginal Ultrasound - done between 16 and 24 weeks' gestation to determine cervical length, evaluate for shortening, and attempt to predict an early preterm birth. Cervical shortening occurs from the internal os outward and can be viewed on ultrasound as funneling. Home Uterine Activity Monitoring -For a woman at risk for preterm birth, home uterine activity monitoring can be used to screen for pre-labor uterine contractility so that escalating contractility can be identified, allowing earlier intervention to prevent preterm birth.

What diagnostic tests may be performed to help determine if Cervical Insufficiency is an issue?

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.

What does the nurse need to keep in mind concerning VS and placental abruptions.

Repeated second trimester losses

What is Cervical Insufficiency associated with?

The possibility of hemorrhaging during manual attempts to detach the placenta

What is a common risk of placenta accreta during the birthing process?

Determining and correct underlying cause of DIC 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, are also used to combat this serious condition.

What is done is a women develops DIC during abruptio placentae?

Painless, bright-red vaginal bleeding during the second or third trimester that is usually not profuse and ceases spontaneously, only to recur again. The first episode of bleeding occurs (on average) at 27 to 32 weeks' gestation. The bleeding is thought to continue due to the lower uterus not being able to contract adequately and stop the flow of blood from the open vessels.

What is the classic clinical presentation of placenta previa?

Chromosomal abnormalities

What is the likely cause of spontaneous abortion during the first trimester?

Maternal disease including: -cervical insufficiency -congenital or acquired anomaly of the uterine cavity (uterine septum or fibroids) -hypothyroidism -DM -chronic nephritis -use of crack cocaine -inherited and acquired thrombophilias -lupus -polycystic ovary syndrome -severe hypertension -acute infection such as rubella virus, cytomegalovirus, herpes simplex virus, bacterial vaginosis, and toxoplasmosis

What is the likely cause of spontaneous abortion during the second trimester?

Spontaneous Abortion

What is the most common complication of early pregnancy?

Kleihauer-Betke test

What is the name of the test that detects fetal RBCs in the maternal circulation to determine the degree of fetal-maternal hemorrhage and calculate the appropriate dosage of RhoGAM to give to Rh-negative clients?

90%

What is the overall success rate of methotrexate treatment in women with ectopic pregnancy?

Assess, control, and restore the amount of blood lost Provide a positive outcome for both mother and newborn Prevent coagulation disorders, such as DIC

What is treatment of abruptio placentae designed to do?

Methotrexate

What may possibly be administered to treat a malignant case of GTD?

Increases

What occurs to the frequency of spontaneous abortions related to advanced maternal age?

Gonorrhea and Chlamydia

What organisms preferentially attach the fallopian tubes causing silent infections that subsequently result in a twofold increase in ectopic pregnancy risk?

90% have postpartum hemorrhage, and 50% of these will result in a hysterectomy

What percentage of placenta accreta pregnancies experience postpartum hemorrhage? Of this percentage, what percentage will result in hysterectomy?

++Caution to not drive as a result of drowsiness or dizziness. ++Advise to change position slowly to minimize orthostatic hypotension

What should the nurse advise the client that is taking Prochlorperazine (Compazine) for Hyperemesis Gravidarum?

1.) Patterns that contribute or trigger distress 2.) mucous membranes for dryness 3.) skin turgor for fluid loss and dehydration. 4.) BP or changes, such as hypotension, that may suggest a fluid volume deficit. 5.) Note any complaints of weakness, fatigue, activity intolerance, dizziness, or sleep disturbances.

What should the nurse assess in treating a patient with Hyperemesis Gravidarum?

1.) Pink-tinged vaginal discharge 2.) Increase in low pelvic pressure 3.) Loss of amniotic fluid 4.) Cervical dilation

What signs should a nurse be alert for in relation to cervical insufficiency?

-Missed period -Adnexal fullness -Tenderness -Pain unilatarel, bilateral, or diffuse over the abdomen

What signs/symptoms may indicated an unruptured tubal pregnancy?

Severe, sharp, sudden lower abdominal pain Faintness Should pain Hypotension Hypovolemic Shock

What symptoms indicate potential rupture of ectopic pregnancy?

Low birth weight Preterm delivery Asphyxia Stillbirth Perinatal death.

What the fetal risks associated with Abruptio Placentae

• No medical or surgical intervention necessary • Follow-up appointment to discuss family planning

What therapeutic management is needed for a complete abortion?

• ID and Tx 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 cause

What therapeutic management is needed for a habitual abortion?

• 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

What therapeutic management is needed for a missed abortion?

• Conservative support treatment • Possible reduction in activity in conjunction with nutritious diet and adequate hydration

What therapeutic management is needed for a threatened abortion?

• Client stabilization • Evacuation of uterus via D&C or prostaglandin analog

What therapeutic management is needed for an incomplete abortion?

• 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)

What therapeutic management is needed for an inevitable abortion?

Vaginal examinations; because they may disrupt the placenta and cause hemorrhage

What type of exam is avoided with placenta previa?

linear salpingostomy

What type of surgical procedure, if warranted, is used to preserve the fallopian tube during ectopic pregnancy?

1.) Color of the vaginal bleeding (bright red is significant) 2.) Amount (frequency of peripad change (saturation of one peripad hourly is significant) 3.) Passage of any clots or tissue. (Instruct her to save any tissue or clots passed and bring them with her) 4.) Description of any other signs and symptoms the woman may be experiencing, along with a description of their severity and duration.

When a pregnant woman calls and report vaginal bleeding, what questions should be asked?

apparent; concealed

80% if placental abruptions have ______________ bleeding and 20% have ______________ bleeding.

Disseminated Intravascular Coagulation (DIC)

A bleeding disorder characterized by an abnormal reduction in the elements involved in blood clotting resulting from their widespread intravascular clotting.

Total placenta previa

A type of placenta previa in which the internal cervical os is completely covered by the placenta.

Partial placenta previa

A type of placenta previa in which the internal os is partially covered by the placenta

Marginal placenta previa

A type of placenta previa in which the placenta is at the margin or edge of the internal os

Low-lying placenta previa

A type of placenta previa in which the placenta is implanted in the lower uterine segment and is near the internal os but does not reach it

Ectopic Pregnancy

A type of pregnancy in which implantation of a fertilized egg occurs outside of the uterine cavity.

Abruptio placentae

This condition is the premature separation of a normally implanted placenta after the 20th week of gestation prior to birth, which leads to hemorrhage. It is a significant cause of third-semester bleeding, with a high mortality rate.

Cervical insufficiency

This condition, 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. Since this typically occurs in the fourth or fifth month of gestation before the point of fetal viability, the fetus dies unless the dilation can be arrested.

Prochlorperazine (Compazine)

This drug acts centrally to inhibit dopamine receptors in the CTZ and peripherally to block vagus nerve stimulation in the gastrointestinal tract. It is used to control severe nausea and vomiting.

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

This drug 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

Chronic HTN with superimposed preeclampsia

This type of HTN pregnancy problem occurs in approximately 20% of pregnant women with increased maternal and fetal morbidity rates.

TRUE

True or False: Choriocarcinoma is highly responsive to chemotherapy, with an overall remission rate greater than 90%

TRUE

True or False: DIC is usually associated with high mortality and morbidity rates.

TRUE

True or False: No single laboratory test is sensitive or specific enough to diagnose DIC definitively, but it can be diagnosed by using a combination of multiple clinical and laboratory tests that reflect the pathophysiology of the syndrome.

SOB (indicative of metastasis to the lungs)

Typically asymptomatic, the first symptoms of choriocarcinoma in 80% of cases include what symptoms?

1.) Hx 2nd-trimester pregnancy loss with painless dilatation 2.) Prior cerclage placement for cervical insufficiency 3.) Hx spontaneous preterm birth prior to 34 weeks' gestation 4.) Painless cervical dilatation on physical examination in the second trimester

What are ACOG recommendations concerning cervical cerclage?

Obstetric hemorrhage Need for blood transfusions Emergency hysterectomy Disseminated intravascular coagulopathy Renal failure.

What are the maternal risks of Abruptio Placentae

A neonatal intensive care team should be available during the birth process to assess and treat the newborn immediately for shock, blood loss, and hypoxia.

Because of the possibility of fetal blood loss through the placenta during abruptio placentae, what should be available during birth and why?

hCG level changes between days 0 and 4 after methotrexate therapy have clinical significance and predictive value. A decreasing beta-hCG level is highly predictive of treatment success

Beta-hCG monitoring is done following medical treatment of ectopic pregnancy. Note clinical significance of the results of said monitoring.

The separation is determined by if the bleeding occurs early or after 20 weeks of pregnancy.

Bleeding during pregnancy can be divided into two separate categories. What separates these categories?

• Bring gel to room temperature before administering. • Avoid contact with skin. • Use sterile technique to administer. • Keep client supine for 30 min after administering. • Document time of insertion and dosing intervals. • Remove insert with retrieval system after 12 hrs or at the onset of labor. • Explain purpose and expected response to client.

Concerning PGE2 or dinoprostone administration, what needs to be considered?

• Hx of vaginal bleeding and abdominal pain • Passage of tissue with subsequent decrease in pain and significant decrease in vaginal bleeding

Concerning a complete abortion, what findings may be seen?

• Hx of three or more consecutive spontaneous abortions • Not carrying the pregnancy to viability or term

Concerning a habitual abortion, what findings may be seen?

• Absent uterine contractions • Irregular spotting • Possible progression to inevitable abortion

Concerning a missed abortion, what findings may be seen?

• Presence of 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.

Concerning a threatened abortion, what findings may be seen?

• Intense abdominal cramping • Heavy vaginal bleeding • Cervical dilation

Concerning an incomplete abortion, what findings may be seen?

• Vaginal bleeding (greater than that associated with threatened abortion) • Rupture of membranes • Cervical dilation • Strong abdominal cramping • Possible passage of products of conception

Concerning an inevitable abortion, what findings may be seen?

There is no evidence that any antiemetic class is superior to another with respect to effectiveness.

Concerning antiemetic options for Hyperemesis Gravidarum, is there a preference concerning most effective.

--urinary retention --dizziness -hypotension --involuntary movements.

Concerning use of Promethazine (Phenergan) to treat Hyperemesis Gravidarum, for what adverse effects should the nurse look for?

Defined as BP exceeding 140/90 mm Hg before pregnancy or before 20 weeks' gestation. As our nation's obesity rate rises, more women will start pregnancies with elevated blood pressures. However, if maternal blood pressure exceeds 160/100 mm Hg, drug treatment is recommended

Describe Chronic HTN

Focuses on monitoring the woman very closely for signs of preterm labor: -backache -increase in vaginal discharge -ROM -uterine contractions

Describe the nursing management of Cervical Insufficiency.

The etiology of this condition is unknown; however, it has been proposed that abruption 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. The continued bleeding causes increased pressure behind the placenta and results in separation from the uterine wall

Describe the pathophysiology of Abruptio Placentae.

When the pressure of the expanding uterine contents becomes greater than the ability of the cervical sphincter to remain closed, the cervix suddenly relaxes, allowing effacement and dilation to proceed. The cervical dilation is typically rapid, relatively painless, and accompanied by minimal bleeding.

Describe the pathophysiology of Cervical Insufficiency

Minimal bleeding (<500mL) Marginal separation (10-20%) Tender Uterus No Coagulopathy No Signs of Shock No Fetal DistressMild (grade 1)

Describe the qualifications of Mild (grade 1) Abruptio Placentae

Moderate bleeding (1,000 to 1,500 mL), Moderate separation (20% to 50%) Continuous abdominal pain Mild shock Normal maternal blood pressure Maternal tachycardia

Describe the qualifications of Moderate (grade 2) Abruptio Placentae

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 Development of DIC

Describe the qualifications of Severe (grade 3) Abruptio Placentae

Many women are asymptomatic before tubal rupture. The classic clinical triad of ectopic pregnancy includes abdominal pain, amenorrhea, and vaginal bleeding. Unfortunately, only about half of women present with all three symptoms.

Describe the symptomatic nature of ectopic pregnancy?

PP = soft and relaxed AP = firm to rigid

Describe the uterine tone associated with Placenta Previa and Abruptio Placentae.

During the first stage of vasospasm, BP increases causing a reduced blood flow to the brain, liver, kidneys, placenta, and lungs. As a result: --Liver function declines and subcapsular hemorrhage occurs causing epigastric pain and elevated liver enzymes -- Cerebral hemorrhage and symptoms of arterial vasospasm such as headaches, visual disturbances, blurred vision, and hyperactive DTRs. --A thromboxane/prostacyclin imbalance leads to increased thromboxane (a potent vasoconstrictor) and stimulator of platelet aggregation, and decrease prostacyclin (a potent vasodilator and inhibitor of platelet aggregation), which contribute to the HTN state. --GFR is reduced leading to reduced urine output and increased sodium, BUN, uric acid, and creatinine causing edema, both generalized and pulmonary. The second stage of preeclampsia is the woman's response to abnormal placentation, when symptoms appear, that is, hypertension, proteinuria, and edema due to hypoperfusion. Poor placental perfusion resulting from prolonged vasoconstriction helps to contribute to intrauterine growth restriction, premature separation of the placenta (abruptio placentae), persistent fetal hypoxia, and acidosis. In addition, hemoconcentration (resulting from decreased intravascular volume) causes increased blood viscosity and elevated hematocrit.

Describe what occurs during the two stages of pre-eclampsia.

1.) Bed rest at home in the lateral recumbent position 2.) Antepartal visits and diagnostic testing - such as CBC, clotting studies, liver enzymes, and platelet levels - increase in frequency. 3.) Self-monitor BP daily (every 4 to 6 hours while awake) and report any increased readings 4.) Measure the amount of protein found in urine using a dipstick and weigh self for any weight gain. 5.) Take daily fetal movement counts, and if there is any decrease in movement, she needs to be evaluated by her health care provider that day. 6.) Maintain balanced, nutritional diet with no sodium restriction 7.) Drink six to eight 8-oz glasses of water daily.

During pregnancy, what treatments may be enacted for a woman with mild elevations in BP?

At least three menstrual cycles to allow her reproductive tract to heal and the tissue to be repaired

For how long should a woman use contraceptives following ectopic pregnancy and why?

Pain Contractions Abdomen, noting any contractions, uterine tenderness, tenseness, or rigidity Changes in fetal movement and activity. Assess fetal heart rate and continue to monitor it electronically

For what should the nurse assess concerning Abruptio Placentae

--abnormal movements --neuroleptic malignant syndrome (seizures, hyper/hypotension, tachycardia, and dyspnea) --mental status --intake/output

For what should the nurse be alert when using Prochlorperazine (Compazine) to treat Hyperemesis Gravidarum?

Diarrhea Abdominal Pain Nausea Vomiting Dyspepsia Vaginal Bleeding Pain Fever Tachycardia Hypotension Anxiety

For what should the nurse monitor following administration of Misoprostol (Cytotec)?

1.) bed rest 2.) pelvic rest 3.) avoidance of heavy lifting 4.) progesterone supplementation in women at risk for preterm birth 5.) placement of a cervical pessary cervical cerclage procedure in the second trimester

How may cervical insufficiency be treated?

• Validation via client's history

How might a habitual abortion be diagnosed?

• US to identify products of conception in uterus

How might a missed abortion be diagnosed?

• Vaginal Ultrasound to confirm sac is empty • Declining maternal serum hCG and progesterone

How might a threatened abortion be diagnosed?

• US confirmation that products of conception still in uterus

How might an incomplete abortion be diagnosed?

• US and hCG levels to indicate pregnancy loss

How might an inevitable abortion be diagnosed?

Massive Hemorrhage Infertility Death

In ectopic pregnancy, the embryo enlarges and creates potential for organ rupture, as only the uterine cavity is equipped to expand and accommodate the fetal development. What could a rupture result in?

++diarrhea, constipation, abdominal pain, ++headache, dizziness, drowsiness, and fatigue. ++Monitor liver function studies as ordered.

In giving Ondansetron (Zofran) for Hyperemesis Gravidarum, for what should the nurse be on alert for?

When the woman exhibits no signs of renal or hepatic dysfunction or coagulopathy.

In mild preeclampsia, when are conservative strategies utilized?

++Institute safety measures to prevent injury secondary to sedative effects. ++Offer hard candy and frequent rinsing of mouth for dryness.

In treating Hyperemesis Gravidum with Promethazine (Phenergan), what can the nurse do to combat certain adverse/side effects?

Multiparous Cesarean birth in either a previous or the present pregnancy Abnormal placentation

Which women with placenta accreta are at highest risk for emergency hysterectomy?

A profuse hemorrhage may result because the uterus cannot contract to close off the open blood vessels.

Why is hemorrhage a common outcome with placenta accreta?

Methotrexate

With early diagnosis and lack of rupture, what can most women with ectopic pregnancy be treated with?

1.) Missed or incomplete abortion 2.) Vaginal Bleeding 3.) Small or normal size for date uterus

Women with a partial mole usually present with what clinical features?

Postpartum hypertension

Women with mild preeclampsia are at greatest risk for what? Prevention of disease progression is the focus of treatment during labor. Blood pressure is monitored frequently and a quiet environment is important to minimize the risk of stimulation and to promote rest. IV magnesium sulfate is infused to prevent any seizure activity, along with antihypertensives if blood pressure values begin to rise. Calcium gluconate is kept at the bedside in case the magnesium level becomes toxic. Continued close monitoring of neurologic status is warranted to detect any signs or symptoms of hypoxemia, impending seizure activity, or increased intracranial pressure. An indwelling urinary (Foley) catheter usually is inserted to allow for accurate measurement of urine output.