Ricci chapter 19

spontaneous abortion

Abortion is considered not only a major reproductive health matter, but also a health risk factor for women's well-being. Spontaneous abortion is the most common complication of early pregnancy (Tulandi & Al-Fozan, 2014). An abortion is the loss of an early pregnancy, usually before week 20 of gestation. Abortion can be spontaneous or induced. A spontaneous abortion refers to the loss of a fetus resulting from natural causes, that is, not elective or therapeutically induced by a procedure. A stillbirth is the loss of a fetus after the 20th week of development, whereas a miscarriage refers to a loss before the 20th week. Nonmedical people often use the term miscarriage to denote an abortion that has occurred spontaneously. A miscarriage can occur during early pregnancy, and many women who miscarry may not even be aware that they are pregnant. About 80% of spontaneous abortions occur within the first trimester. The terms stillbirth and miscarriage can sometimes be confusing. Both refer to the loss of an early pregnancy; however, stillbirth occurs later in pregnancy. Some stillbirths can occur right up to the time of labor and delivery. Stillbirths are much less common than miscarriages, occurring in only 1 out of every 160 pregnancies (March of Dimes, 2015a). The overall rate for spontaneous abortion in the United States is reported to be 15% to 20% of recognized pregnancies in the United States. 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 60% to 70% (King et al., 2015). The frequency of spontaneous abortion increases further with maternal age. Pathophysiology The causes of spontaneous abortion are varied and often unknown. The most common cause for first-trimester abortions is fetal genetic abnormalities, usually unrelated to the mother. Chromosomal abnormalities are more likely causes in the first trimester and maternal disease is more likely in the second trimester. Those 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 thrombophilias, lupus, polycystic ovary syndrome, severe hypertension, and acute infection such as rubella virus, cytomegalovirus, herpes simplex virus, bacterial vaginosis, and toxoplasmosis (Jones & Lopez, 2014). Women experiencing a first-trimester abortion at home without a dilation and curettage (D&C) to resolve it require frequent monitoring of hCG levels to validate that all the conceptus tissues have been expelled. Women going through a second-trimester abortion are admitted to the hospital to have an augmented labor and delivery. Nursing care would focus on care of the laboring women with tremendous attention paid to providing emotional support to the woman and her family. Nursing Assessment When a pregnant woman calls and reports vaginal bleeding, she must be seen as soon as possible by a health care professional to ascertain the etiology. Varying degrees of vaginal bleeding, low back pain, abdominal cramping, and passage of products of conception tissue may be reported. Ask the woman about the color of the vaginal bleeding (bright red is significant) and the amount—for example, question her about the frequency with which she is changing her peripads (saturation of one peripad hourly is significant) and the passage of any clots or tissue. Instruct her to save any tissue or clots passed and bring them with her to the health care facility. Also, obtain a description of any other signs and symptoms the woman may be experiencing, along with a description of their severity and duration. It is important to remain calm and listen to the woman's description. When the woman arrives at the health care facility, assess her vital signs and observe the amount, color, and characteristics of the bleeding. Ask her to rate her current pain level, using an appropriate pain assessment tool. Also, evaluate the amount and intensity of the woman's abdominal cramping or contractions, and assess the woman's level of understanding about what is happening to her. A thorough assessment helps in determining the type of spontaneous abortion, such as threatened abortion, inevitable abortion, incomplete abortion, complete abortion, missed abortion, and habitual abortion, that the woman may be experiencing (Table 19.1). Nursing Management Nursing management of the woman with a spontaneous abortion focuses on providing continued monitoring and psychological support, for the family is experiencing acute loss and grief. An important component of this support is reassuring the woman that spontaneous abortions usually result from an abnormality and that her actions did not cause the abortion. PROVIDING CONTINUED MONITORING Continued monitoring and ongoing assessments are essential for the woman experiencing a spontaneous abortion. Monitor the amount of vaginal bleeding through pad counts and observe for passage of products of conception tissue. Assess the woman's pain and provide appropriate pain management to address the cramping discomfort. Assist in preparing the woman for procedures and treatments such as surgery to evacuate the uterus or medications such as misoprostol or PGE2. If the woman is Rh negative and not sensitized, expect to administer RhoGAM within 72 hours after the abortion is complete. Drug Guide 19.1 gives more information about these medications. PROVIDING SUPPORT A woman's emotional reaction may vary depending on her desire for this pregnancy and her available support network. Provide both physical and emotional support. In addition, prepare the woman and her family for the assessment process and answer their questions. Explaining some of the causes of spontaneous abortions can help the woman to understand what is happening and may allay her fears and guilt that she did something to cause the pregnancy loss. Most women experience an acute sense of loss and go through a grieving process with a spontaneous abortion. Providing sensitive listening, counseling, and anticipatory guidance to the woman and her family will allow them to verbalize their feelings and ask questions about future pregnancies. The grieving period may last as long as two years after a pregnancy loss, with each person grieving in his or her own way. Encourage friends and family to be supportive but give the couple space and time to work through their loss. Referral to a community support group for parents who have experienced a miscarriage can be very helpful during this grief process. (Ricci 649-650) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

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 is a significant cause of third-trimester bleeding, with a high mortality rate. It occurs in about 1% of all pregnancies throughout the world, or approximately 1 in 100 pregnancies. There is a 10 to 20 times greater risk of reoccurrence in a subsequent pregnancy. It typically peaks between 24 and 26 weeks' gestation. Maternal risks include obstetric hemorrhage, need for blood transfusions, emergency hysterectomy, disseminated intravascular coagulopathy (DIC), and renal failure. Maternal death is rare, but seven times higher than the overall maternal mortality rate. Perinatal consequences include low birth weight, preterm delivery, asphyxia, stillbirth, and perinatal death. In developed countries, approximately 10% of all preterm births and 10% to 20% of all perinatal deaths are caused by placental abruption (Mukherjee et al., 2014). The overall fetal mortality rate for placental abruption is up to 50%, depending on the extent of the abruption. Maternal mortality is approximately 6% in abruptio placentae and is related to cesarean birth and/or hemorrhage/coagulopathy (Jaju, Kulkarni, & Mundada, 2014). Pathophysiology 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 (Moses, 2015a). Fetal blood supply is compromised and fetal distress develops in proportion to the degree of placental separation. This is caused by the insult of the abruption itself and by issues related to prematurity when early birth is required to alleviate maternal or fetal distress. Abruptio placentae is classified according to the extent of separation and the amount of blood loss from the maternal circulation. Classifications include: 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 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(Atkinson et al., 2015). Abruptio placentae also may be classified as partial or complete, depending on the degree of separation. Alternately, it can be classified as concealed or apparent, by the type of bleeding (Fig. 19.5). Remember Helen, the pregnant woman with severe abdominal pain? Electronic fetal monitoring revealed uterine hypertonicity with absent fetal heart sounds. Palpation of her abdomen revealed rigidity and extreme tenderness in all four quadrants. Her vital signs were as follows: temperature, afebrile; pulse, 94; respirations, 22; blood pressure, 130/90 mm Hg. What might you suspect as the cause of Helen's abdominal pain? What course of action would you anticipate for Helen? FIGURE 19.5 Classifications of abruptio placentae. A. Partial abruption with concealed hemorrhage. B. Partial abruption with apparent hemorrhage. C. Complete abruption with concealed hemorrhage. Therapeutic Management Treatment of abruptio placentae is 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 (Box 19.2). 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. 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. Because of the possibility of fetal blood loss through the placenta, 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. (Ricci 664-665) Ricci, Susan. Lippincott CoursePoint for Ricci: Essenti If the woman develops DIC, treatment focuses on determining the underlying cause of DIC and correcting it. 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. The use of blood products must be dictated by the clinical picture and not simply to normalize laboratory test results (Holt, 2015). Prompt identification and early intervention are essential for a woman with acute DIC associated with abruptio placentae to treat DIC and possibly save her life. Nursing Assessment Abruptio placentae is a medical emergency. The nurse plays a critical role in assessing the pregnant woman presenting with abdominal pain and/or experiencing vaginal bleeding, especially in a concealed hemorrhage, in which the extent of bleeding is not recognized. Rapid assessment is essential to ensure prompt, effective interventions to prevent maternal and fetal morbidity and mortality. Comparison Chart 19.1 compares placenta previa with abruptio placentae. HEALTH HISTORY AND PHYSICAL EXAMINATION Abruptio placentae produces a wide range of clinical effects, depending on the extent of placental separation and the amount of maternal blood loss. Begin the health history by assessing the woman for risk factors that may predispose her to abruptio placentae, such as 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 (Deering, 2015). In addition, be alert for other notable risk factors, such as male fetal gender, chorioamnionitis, prolonged premature ruptured membranes (more than 24 hours), oligohydramnios, preeclampsia, and low socioeconomic status (Nagtalon-Ramos, 2014). (Ricci 665-666) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file. Assess the woman for bleeding. As the placenta separates from the uterus, hemorrhage ensues. It can be apparent, appearing as vaginal bleeding, or it can be concealed. Vaginal bleeding is present in 80% of women diagnosed with abruptio placentae and may be significant enough to jeopardize both maternal and fetal health within a short time frame. The remaining 20% of abruptions are associated with a concealed hemorrhage and the absence of vaginal bleeding. Monitor the woman's level of consciousness, noting any signs or symptoms that may suggest shock. 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 (Schultz & McConachie, 2015). Assess the woman for complaints of pain, including the type, onset, and location. Ask if she has had any contractions. Palpate the abdomen, noting any contractions, uterine tenderness, tenseness, or rigidity. Ask if she has noticed any changes in fetal movement and activity. Decreased fetal movement may be the presenting complaint, resulting from fetal jeopardy or fetal death (Cunningham et al., 2014). Assess fetal heart rate and continue to monitor it electronically. 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. LABORATORY AND DIAGNOSTIC TESTING Laboratory and diagnostic tests may be helpful in diagnosing the condition and guiding management. These studies may include: CBC: Determines the current hemodynamic status; however, it is not reliable for estimating acute blood loss. 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. Prothrombin time (PT)/activated partial thromboplastin time (aPTT): Determines the client's coagulation status, especially if surgery is planned. Type and cross-match: Determines blood type if a transfusion is needed Nonstress test: Demonstrates findings of fetal jeopardy manifested by late decelerations or bradycardia. Biophysical profile: Aids in evaluating clients with chronic abruption; a low score (less than 6 points) suggests possible fetal compromise (Creasy et al., 2014). Ultrasound is not useful for making a definitive diagnosis because the clot is sonographically visible in less than 50% of the cases. A CT scan is a more reliable method for evaluation of placental abruption (Hosein, Abdel-Kariem, & Shriki, 2014). Nursing Management Nursing management of the woman with abruptio placentae warrants immediate care to provide the best outcome for both mother and fetus. p. 666 p. 667 ENSURING ADEQUATE TISSUE PERFUSION When the woman arrives at the facility, 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. Also 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 if DIC occurs. Institute continuous electronic fetal monitoring. Assess uterine contractions and report any increased uterine tenseness or rigidity. Also observe the tracing for tetanic uterine contractions or changes in fetal heart rate patterns suggesting that the fetus has been compromised. PROVIDING SUPPORT AND EDUCATION A woman diagnosed with abruptio placentae may be filled with a sense of heightened anxiety and apprehension for her own health as well as for the health of her fetus. Communicate empathy and understanding of the client's experience, and provide emotional support throughout this frightening time. Remain with the woman and her partner, acknowledge their emotions and fears, and address their spiritual and cultural needs. Answer their questions about the status of their fetus openly and honestly, being sure to explain indicators of fetal well-being. Provide information about the various diagnostic tests, treatments, and procedures that may be done, including the possible need for a cesarean birth. Depending on the client's status, extent of bleeding, and length of gestation, the fetus may not survive. If the fetus does survive, he or she most likely will require neonatal intensive care. Assist the client and family to deal with the loss or with the birth of a newborn in the neonatal intensive care unit. Although abruptio placentae is not a preventable condition, client education is important to help reduce the risk for a recurrence of this condition. Encourage the woman to avoid drinking, smoking, or using drugs during pregnancy. Urge her to seek early and continuous prenatal care and to receive prompt health care if any signs and symptoms occur in future pregnancies. (Ricci 666-667) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Amniotic fluid imbalances

Amniotic fluid develops from several maternal and fetal structures, including the amnion, chorion, maternal blood, fetal lungs, gastrointestinal tract, kidneys, and skin. Any alteration in one or more of the various sources will alter the amount of amniotic fluid. Polyhydramnios and oligohydramnios are two imbalances associated with amniotic fluid. Polyhydramnios 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. It occurs in approximately 2% of all pregnancies and is 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 (Carter & Boyd, 2015). Approximately 18% of all women with diabetes will develop polyhydramnios during their pregnancy. There is an increase in cesarean births for fetal labor intolerance, low 5-min Apgar scores, increased neonatal birth weight, congenital anomalies, and newborn intensive care unit admissions for women with too much amniotic fluid at term (Moore, 2015). Overall, it is associated with poorer fetal outcomes because of the increased incidence of preterm births, fetal malpresentation, and cord prolapse. There are several causes of polyhydramnios. Generally, too much fluid is being produced, there is a problem with the fluid being taken up, or both. It can be associated with maternal disease and fetal anomalies, but it can also be idiopathic (of unknown cause) in nature. Therapeutic Management Treatment may include close monitoring and frequent follow-up visits with the health care provider if the polyhydramnios is mild to moderate. In severe cases in which the woman is in pain and experiencing shortness of breath, an amniocentesis or artificial rupture of the membranes is done to reduce the fluid and the pressure. Removal of fluid by amniocentesis is only transiently effective. A noninvasive treatment may involve the use of a prostaglandin synthesis inhibitor (indomethacin) to decrease amniotic fluid volume by decreasing fetal urinary output, but this may cause premature closure of the fetal ductus arteriosus (King et al., 2015). Nursing Assessment Begin the assessment with a thorough history, being alert to risk factors such as maternal diabetes or multiple gestations. Review the maternal history for information about possible fetal anomalies including fetal esophageal or intestinal atresia, neural tube defects, chromosomal deviations, fetal hydrops, CNS or cardiovascular anomalies, and hydrocephaly. Determine the gestational age of the fetus and measure the woman's fundal height. With polyhydramnios, there is a discrepancy between fundal height and gestational age, or a rapid growth of the uterus is noted. Assess the woman for complaints of discomfort in her abdomen, such as being severely stretched and tight. Also note any reports of uterine contractions, which may result from overstretching of the uterus. Assess for shortness of breath resulting from pressure on her diaphragm and inspect her lower extremities for edema, which results from increased pressure on the vena cava. Palpate the abdomen and obtain fetal heart rate. Often the fetal parts and heart rate are difficult to obtain because of the excess fluid present. Prepare the woman for possible diagnostic testing to evaluate for the presence of possible fetal anomalies. An ultrasound usually is done to measure the pockets of amniotic fluid to estimate the total volume. In some cases, ultrasound also is helpful in finding the etiology of polyhydramnios, such as multiple pregnancy or a fetal structural anomaly. Nursing Management Nursing management of the woman with polyhydramnios focuses on ongoing assessment and monitoring for symptoms of abdominal pain, dyspnea, uterine contractions, and edema of the lower extremities. Explain to the woman and her family that this condition can cause her uterus to become overdistended and may lead to preterm labor and preterm rupture of membranes. Outline the signs and symptoms of both conditions and instruct the woman to contact her health care provider if they occur. If a therapeutic amniocentesis is performed, assist the health care provider and monitor maternal and fetal status throughout for any changes. Oligohydramnios Oligohydramnios is a decreased amount of amniotic fluid (less than 500 mL) between 32 and 36 weeks' gestation. It occurs in approximately 4% of all pregnancies. Oligohydramnios may result from any condition that prevents the fetus from making urine or blocks it from going into the amniotic sac. Oligohydramnios occurs in about four out of every 100 pregnancies. It is most common in the last trimester of pregnancy, but it can develop at any time in the pregnancy. About one out of eight women whose pregnancies last 2 weeks past the due date develops oligohydramnios. This happens as amniotic fluid levels naturally decline. This condition puts the fetus at an increased risk of perinatal morbidity and mortality (March of Dimes, 2015e). 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. Therapeutic Management The woman with oligohydramnios can be managed on an outpatient basis with serial ultrasounds and fetal surveillance through nonstress testing and biophysical profiles. As long as fetal well-being is demonstrated with frequent testing, no intervention is necessary. If fetal well-being is compromised, however, birth is planned along with amnioinfusion (the transvaginal infusion of crystalloid fluid to compensate for the lost amniotic fluid). The fluid is introduced into the uterus through an intrauterine pressure catheter. The infusion is administered in a controlled fashion to prevent overdistention of the uterus. Amnioinfusion is thought to improve abnormal fetal heart rate patterns, decrease cesarean births, and possibly minimize the risk of neonatal meconium aspiration syndrome, but more studies need to be done to validate this (Carter & Boyd, 2015). p. 683 p. 684 Nursing Assessment Review the maternal history for factors associated with oligohydramnios, including: Uteroplacental insufficiency Premature rupture of membranes prior to labor onset Hypertension of pregnancy Maternal diabetes Intrauterine growth restriction Post-term pregnancy Fetal renal agenesis Polycystic kidneys Urinary tract obstructions Assess the client for complaints of fluid leaking from the vagina. Leaking of amniotic fluid from the vagina occurs with rupture of the amniotic sac. Leaking in conjunction with a uterus that is small for expected dates of gestation also suggests oligohydramnios. Unfortunately, the woman may not present with any symptoms. Typically, the reduced volume of amniotic fluid is identified on ultrasound. Nursing Management Nursing management of the woman with oligohydramnios involves continuous monitoring of fetal well-being during nonstress testing or during labor and birth by identifying category II and III patterns on the fetal monitor. Variable decelerations indicating cord compression are common. Changing the woman's position might be therapeutic in altering this fetal heart rate pattern. After the birth, evaluate the newborn for signs of postmaturity, congenital anomalies, and respiratory difficulty. Assist with amnioinfusion as indicated and continue to assess the woman's vital signs and contraction status and the fetal heart rate throughout the procedure. Provide comfort measures such as changing the bed linens and the woman's bed clothes frequently because of the constant leakage of fluid from the vagina. Also provide frequent perineal care during the infusion. (Ricci 682-684) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

ectopic pregnancy

An ectopic pregnancy is any pregnancy in which the fertilized ovum implants outside the uterine cavity. The term ectopic is derived from the Greek word ektopos, meaning "out of place," and 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. This abnormally implanted embryo grows and draws its blood supply from the site of abnormal implantation. As the embryo enlarges, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal development. Ectopic pregnancy can lead to massive hemorrhage, infertility, or death. (Ricci 651-652) Ectopic pregnancies occur in 1 in every 50 pregnancies in the United States or roughly 2% of all pregnancies are diagnosed as ectopic; this rate has increased dramatically during the past 30 years (March of Dimes, 2015b). It is a major health concern for women of reproductive age and is the primary cause of death during the first trimester of pregnancy in the United States (Szypulski, 2015). The discovery of ectopic pregnancies prior to rupture has increased dramatically in the past few decades as a result of improved diagnostic techniques such as the development of sensitive and specific radioimmunoassays for hCG, high-resolution ultrasonography, and the widespread availability of laparoscopy (Desai et al., 2014). With an ectopic pregnancy, rupture and hemorrhage may occur due to the growth of the embryo. A ruptured ectopic pregnancy is a medical emergency; therefore prediction of any tubal rupture before its occurrence is extremely important. It is a potentially life-threatening condition and involves pregnancy loss. Even in the United States, women can and do still die from ectopic pregnancy, although early diagnosis has helped prevent that. Pathophysiology Normally, the fertilized ovum implants in the uterus. In ectopic pregnancy, the journey along the fallopian tube is arrested or altered in some way. With an ectopic pregnancy, the ovum implants outside the uterus. The most common site for implantation is the fallopian tubes, but some ova may implant in the ovary, the intestine, the cervix, or the abdominal cavity (Fig. 19.1) (Sepilian & Wood, 2015). None of these anatomic sites can accommodate placental attachment or a growing embryo. FIGURE 19.1 Possible sites for implantation with an ectopic pregnancy. Risk Factors Ectopic pregnancies usually result from conditions that obstruct or slow the passage of the fertilized ovum through the fallopian tube to the uterus. This 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. In the general population, most cases are the result of tubal scarring secondary to pelvic inflammatory disease (PID). Organisms such as Neisseria gonorrhea and Chlamydia trachomatis preferentially attack the fallopian tubes, producing silent infections. A recent study reported a twofold increased risk for ectopic pregnancy in women with a history of a chlamydia infection, secondary to tubal damage (Randall & LaMontagne, 2015). Other associated risk factors for ectopic pregnancy include 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) (Ardehali & Casikar, 2015). Therapeutic Management The diagnosis of ectopic pregnancy can be challenging because 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. Diagnostic procedures used for a suspected ectopic pregnancy 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 (Bourne, 2015). Historically, the treatment of ectopic pregnancy was limited to surgery. The therapeutic management of ectopic pregnancy depends on whether the tube is intact or has ruptured, creating a medical emergency. In the event of a surgical intervention, preservation of the affected fallopian tube is attempted (King et al., 2015). MEDICAL INTERVENTION With early diagnosis, most women with ectopic pregnancy could be treated with methotrexate. The overall success rate of medical treatment in properly selected women is nearly 90%. To be eligible for medical therapy, the client must be hemodynamically stable, with no signs of active bleeding in the peritoneal cavity, low beta-hCG levels (<5,000 mIU/mL) and the mass (which must measure less than 4 cm as determined by ultrasound) must be unruptured. Contraindications to medical treatment include an unstable client, severe persistent abdominal pain, renal or liver disease, immunodeficiency, active pulmonary disease, peptic ulcer, suspected intrauterine pregnancy, and poor client compliance (Tulandi, 2015). The potential advantages include avoidance of surgery, the preservation of tubal patency and function, and a lower cost. The medical approach today for an unruptured tubal pregnancy most often consists of a single-dose IM injection of methotrexate (Rheumatrex; Trexall) with outpatient follow-up. Medical management with methotrexate, though not approved by the Food and Drug Administration for this purpose, has been endorsed by the American College of Obstetricians and Gynecologists. Prostaglandins, misoprostol, and actinomycin have also been used in the medical (nonsurgical) management of ectopic pregnancy, with a reported success rate of approximately 90%. Methotrexate is a folic acid antagonist that inhibits cell division in the developing embryo. It typically has been used as a chemotherapeutic agent in the treatment of leukemia, lymphomas, and carcinomas. It has been shown to produce results similar to that for surgical therapy in terms of high success rate, low complication rate, and good reproductive potential (Dalia et al., 2014). Adverse effects associated with methotrexate include nausea, vomiting, stomatitis, diarrhea, gastric upset, increased abdominal pain, and dizziness. Methotrexate for an ectopic pregnancy is ordered based on the client's body surface area. The administration of methotrexate should be limited to people who have had education and training in the handling and administration of hazardous drugs. In some facilities internal policies require that only nurses who have completed a chemotherapy certification and/or hazardous drug competency program can administer this product (Cohen et al., 2015). Prior to receiving the single-dose intramuscular injection to treat unruptured pregnancies, the woman needs to be counseled on the risks, benefits, adverse effects, and the possibility of failure of medical therapy, which would result in tubal rupture, necessitating surgery (Tulandi, 2015). The woman is then instructed to return weekly for follow-up laboratory studies for the next several weeks until beta-hCG titers decrease. Beta-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 (Agarwal & Odejinmi, 2014). SURGICAL INTERVENTION Surgical management for the unruptured fallopian tube might involve a linear salpingostomy to preserve the tube—an important consideration for the woman wanting to preserve her future fertility. It may also be considered when medical treatment is considered unsuitable. With a ruptured ectopic pregnancy, surgery is necessary as a result of possible uncontrolled hemorrhage. A laparotomy with a removal of the tube (salpingectomy) may be necessary. With earlier diagnosis and medical management, the focus has changed from preventing maternal death to facilitating rapid recovery and preserving fertility. Regardless of the treatment approach (medical or surgical), the woman's beta-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. Nursing Assessment Nursing assessment focuses on determining the existence of an ectopic pregnancy and whether or not it has ruptured. A woman with a suspected ectopic pregnancy may have to undergo several diagnostic tests, some of which are invasive. Consider how she might feel during all of these tests, anticipate her questions, and offer her thorough explanations and reassurances. HEALTH HISTORY AND PHYSICAL EXAMINATION Assess the client thoroughly for signs and symptoms that may suggest an ectopic pregnancy. The onset of signs and symptoms varies, but they usually begin at about the seventh or eighth week of gestation. A missed menstrual period, adnexal fullness, and tenderness may indicate an unruptured tubal pregnancy. As the tube stretches, the pain increases. Pain may be unilateral, bilateral, or diffuse over the abdomen. Take Note! The hallmark of ectopic pregnancy is abdominal pain with spotting within 6 to 8 weeks after a missed menstrual period. Although this is the classic triad, all three of these signs and symptoms occur in only about 50% of cases. Many women have symptoms typical of early pregnancy, such as breast tenderness, nausea, fatigue, shoulder pain, and low back pain. In addition, review the client's history for possible contributing factors. These may include: 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 (Ardehali & Casikar, 2015). 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 (Cunningham et al., 2014). LABORATORY AND DIAGNOSTIC TESTING The use of 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. The visualization of an adnexal mass and the absence of an intrauterine gestational sac are diagnostic of ectopic pregnancy (Kao et al., 2014). 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 (Ko & Cheung, 2014).). Therefore, low beta-hCG levels are suggestive of an ectopic pregnancy or impending abortion. Additional tests may be done to rule out other conditions such as spontaneous abortion, ruptured ovarian cyst, appendicitis, and salpingitis. p. 654 p. 655 Nursing Management Nursing management for the woman with an ectopic pregnancy focuses on preparing the woman for treatment, providing support, and providing education about preventive measures. PREPARING THE WOMAN FOR TREATMENT Administer analgesics as ordered to promote comfort and relieve discomfort from abdominal pain. Although the intensity of the pain can vary, women often report a great deal of pain. If the woman is treated medically, explain the medication that will be used and what she can expect. Also review signs and symptoms of possible adverse effects. If treatment will occur on an outpatient basis, outline the signs and symptoms of ectopic rupture (severe, sharp, stabbing, unilateral abdominal pain; vertigo/fainting; hypotension; and increased pulse) and advise the woman to seek medical help immediately if they occur. If surgery is needed, close assessment and monitoring of the client's vital signs, bleeding (peritoneal or vaginal), and pain status are critical to identify hypovolemic shock, which may occur with tubal rupture. Prepare the client physiologically and psychologically for surgery or any procedure. Provide a clear explanation of the expected outcome. Astute vigilance and early referral will help reduce short- and long-term morbidity. PROVIDING EMOTIONAL SUPPORT The woman with an ectopic pregnancy requires support throughout diagnosis, treatment, and aftercare. A woman's psychological reaction to an ectopic pregnancy is unpredictable. However, it is important to recognize she has experienced a pregnancy loss in addition to undergoing treatment for a potentially life-threatening condition. The woman may find it difficult to comprehend what has happened to her because events occur so quickly. In the woman's mind, she had just started a pregnancy and now it has ended abruptly. Bleeding during any pregnancy is traumatic because of the uncertainty of the outcome. Help her to make this experience more "real" by encouraging her and her family to express their feelings and concerns openly, and by validating that this is a loss of pregnancy and that it is okay to grieve over the loss. Although the woman may have physically recovered following an ectopic pregnancy, she may still experience significant emotional distress for a long time. Provide emotional support, spiritual care, and information about community support groups (such as Resolve through Sharing) as the client grieves for the loss of her unborn child and comes to terms with the medical complications of the situation. Acknowledge the client's pregnancy and allow her to discuss her feelings about what the pregnancy means. Also, stress the need for follow-up blood testing for several weeks to monitor hCG titers until they return to zero, indicating resolution of the ectopic pregnancy. Ask about her feelings and concerns about her future fertility, and provide teaching about the need to use contraceptives for at least three menstrual cycles to allow her reproductive tract to heal and the tissue to be repaired. Include the woman's partner in this discussion to make sure both parties understand what has happened, what intervention is needed, and what the future holds regarding childbearing. EDUCATING THE CLIENT Preventing ectopic pregnancies through screening and client education is essential. Many can be prevented by avoiding conditions that might cause scarring of the fallopian tubes. In addition, a contributing factor to the development of ectopic pregnancy is a previous ectopic pregnancy. Therefore, educating the woman is crucial. Prevention education may include the following: 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. (Ricci 652-655) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

blood incompatibility

Blood incompatibility most commonly involves one of two issues: blood type or the Rh factor. 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 cells. It is usually less severe than Rh incompatibility. One reason is that fetal red blood cells express less of the ABO blood group antigens compared with adult levels. In addition, in contrast to the Rh antigens, the ABO blood group antigens are expressed by a variety of fetal (and adult) tissues, reducing the chances of anti-A and anti-B binding their target antigens on the fetal red blood cells. ABO incompatibility rarely causes significant hemolysis, and prenatal treatment is not warranted. Rh isoimmunization occurs when a pregnant woman's immune system creates antibodies against fetal Rh blood factors. Although the mother will exhibit no symptoms of Rh incompatibility, Rh antibodies adversely affect fetal health. Rh antibodies can cause fetal heart problems, breathing difficulties, jaundice, and a form of anemia known as hemolytic disease of the newborn. Rh sensitization occurs in approximately 1 in 1,000 births to Rh-negative women (March of Dimes, 2015d). Today RH isoimmunization in pregnant women and hemolytic disease of the newborn are rarely seen, primarily because 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. Pathophysiology ABO Incompatibility Hemolysis associated with ABO incompatibility is limited to type O mothers with fetuses who have type A or B blood. In mothers with type A and B blood, naturally occurring antibodies are of the IgM class, which do not cross the placenta, whereas in type O mothers, the antibodies are predominantly IgG in nature. Because A and B antigens are widely expressed in a variety of tissues besides red blood cells, only a small portion of the antibodies crossing the placenta is available to bind to fetal red cells. In addition, fetal red cells appear to have less surface expression of A or B antigen, resulting in few reactive sites—hence the low incidence of significant hemolysis in affected neonates. With ABO incompatibility, usually the mother is blood type O, with anti-A and anti-B antibodies in her serum; the infant is blood type A, B, or AB. The incompatibility arises as a result of the interaction of antibodies present in maternal serum and the antigen sites on the fetal red cells. 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. Individuals with Rh-positive blood type have the D antigen present on their red cells, whereas individuals with an Rh-negative blood type do not. The presence or absence of the Rh antigen on the RBC membrane is genetically controlled. In the United States, about 15% of the White population, 5% to 8% of the African American and Hispanic populations, and 1% to 2% of the Asian and Native American populations are Rh negative. The vast majority (85%) of individuals is considered Rh positive (March of Dimes, 2015d). Rh incompatibility most commonly arises with exposure of an Rh-negative mother to Rh-positive fetal blood during pregnancy or birth, during which time erythrocytes from the fetal circulation leak into the maternal circulation. Isoimmunization can also occur during an amniocentesis, ectopic pregnancy, placenta previa, placenta abruption, in utero fetal death, spontaneous abortion, or abdominal/pelvic trauma. After a significant exposure, alloimmunization or sensitization occurs. As a result, maternal antibodies are produced against the foreign Rh antigen. Theoretically, fetal blood and maternal blood do not mix during pregnancy. In reality, however, small placental accidents (transplacental bleeds secondary to minor separation), abortions, ectopic pregnancy, abdominal trauma, trophoblastic disease, amniocentesis, placenta previa, and abruptio placentae allow fetal blood to enter the maternal circulation and initiate the production of antibodies to destroy Rh-positive blood. The amount of fetal blood necessary to produce Rh incompatibility varies. In one study, less than 1 mL of Rh-positive blood was shown to result in sensitization of women who are Rh negative (Salem & Singer, 2015). Once sensitized, it takes approximately a month for Rh antibodies in the maternal circulation to cross over into the fetal circulation. In 90% of cases, sensitization occurs during delivery (Cunningham et al., 2014). Thus, most firstborn infants with Rh-positive blood type are not affected because the short period from first exposure of Rh-positive fetal erythrocytes to the birth of the infant is insufficient to produce a significant maternal IgG antibody response. The risk and severity of alloimmune response increase with each subsequent pregnancy involving a fetus with Rh-positive blood. A second pregnancy with an Rh-positive fetus often produces a mildly anemic infant, whereas succeeding pregnancies produce infants with more serious hemolytic anemia. Nursing Assessment At the first prenatal visit, determine the woman's blood type and Rh status. Also obtain a thorough health history, noting any reports of previous events involving hemorrhage to delineate the risk for prior sensitization. When the client's history reveals an Rh-negative mother who may be pregnant with an Rh-positive fetus, prepare the client for an antibody screen (indirect Coombs test) to determine whether she has developed isoimmunity to the Rh antigen. This test detects unexpected circulating antibodies in a woman's serum that could be harmful to the fetus (Davidson, 2014). Nursing Management If the indirect Coombs test is negative (meaning no antibodies are present), then the woman is a candidate for RhoGAM. If the test is positive, RhoGAM is of no value because isoimmunization has occurred. In this case, the fetus is carefully monitored for hemolytic disease. The incidence of isoimmunization has declined dramatically as a result of prenatal and postnatal RhoGAM administration after any event in which blood transfer may occur. The standard dose is 300 mcg, which is effective for 15 mL of fetal blood cells. Rh immunoglobulin helps to destroy any fetal cells in the maternal circulation before sensitization occurs, thus inhibiting maternal antibody production. This provides temporary passive immunity, thereby preventing maternal sensitization. The current recommendation is 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. Other indications for RhoGAM include: Ectopic pregnancy Chorionic villus sampling Amniocentesis Prenatal hemorrhage Molar pregnancy Maternal trauma Percutaneous umbilical sampling Therapeutic or spontaneous abortion Fetal death Fetal surgery (King et al., 2015). Despite the availability of RhoGAM and laboratory tests to identify women and newborns at risk, isoimmunization remains a serious clinical reality that continues to contribute to perinatal and neonatal mortality. Nurses, as client advocates, are in a unique position to make sure test results are brought to the health care provider's attention so appropriate interventions can be initiated. In addition, nurses must stay abreast of current literature and research regarding isoimmunization and its management. Stress to all women that early prenatal care can help identify and prevent this condition. Because Rh incompatibility is preventable with the use of RhoGAM, prevention remains the best treatment. Nurses can make a tremendous impact to ensure positive outcomes for the greatest possible number of pregnancies through education. (Ricci 681-682) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

gestational trophoblastic disease

Gestational trophoblastic disease (GTD) comprises a spectrum of neoplastic disorders that originate in the placenta. There is abnormal hyperproliferation of trophoblastic cells that normally would develop into the placenta during pregnancy. GTDs encompass hydatidiform mole (complete and partial), invasive mole, gestational choriocarcinoma, placental-site trophoblastic tumor, and epithelioid trophoblastic tumor (Nguyen & Slim, 2014). Gestational tissue is present, but the pregnancy is not viable. The incidence is hard to determine due to uncommon diagnosis and inaccuracy of documentation of pregnancy loss, but it is thought to occur in about 1 in 1,000 pregnancies in the United States; in Asian countries, the rate is 1 of every 120 pregnancies American Cancer Society (ACS, 2015). The two most common types of GTD are hydatidiform mole (partial or complete) and choriocarcinoma. Pathophysiology The pathogenesis is unique because the maternal tumor arises from gestational rather than maternal tissue. Hydatidiform mole is a benign neoplasm of the chorion in which the chorionic villi degenerate and become transparent vesicles containing clear, viscid fluid. Hydatidiform mole is classified as complete or partial, distinguished by differences in clinical presentation, pathology, genetics, and epidemiology (Strohl & Lurain, 2014). 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) (Fig. 19.2). The embryo is not viable and dies. No circulation is established, and no embryonic tissue is found. The complete mole is associated with the development of choriocarcinoma. Surgery can totally remove most complete moles, but as many as one in five women will have some persistent molar tissue and require further treatment (ACS, 2015). Most women with a classic complete mole present with vaginal bleeding, anemia, excessively enlarged uterus, preeclampsia, and hyperemesis. FIGURE 19.2 Complete hydatidiform mole as seen in a cutaway of a uterus. The chorionic villi degenerate and become filled with a viscid fluid, forming transparent vesicles. (From Reichert (2011). Diagnostic Gynecologic and Obstetric Pathology. Courtesy of Dr. Enrique Higa. Philadelphia, PA: LWW.) The partial mole has a triploid karyotype (69 chromosomes), because two sperm have provided a double contribution by fertilizing the ovum. Women with a partial mole usually present with the clinical features of a missed or incomplete abortion, including vaginal bleeding and a small- or normal-size for date uterus (Dickson & Mullany, 2015). The exact cause of molar pregnancy is unknown, but researchers are looking into a genetic basis. Other theories include an ovular defect, stress, or a nutritional deficiency (carotene). Although the etiology remains uncertain, at some point in the pregnancy trophoblastic cells that normally would form the placenta proliferate and the chorionic villi become edematous. The latter changes become the grape-like clusters that characterize the molar pregnancy (King et al., 2015). Studies have revealed some remarkable features about molar pregnancies, including: Ability to invade into the wall of the uterus Tendency to recur in subsequent pregnancies Possible development into choriocarcinoma, a virulent cancer with metastasis to other organs Influence of nutritional factors, such as protein deficiency Tendency to affect older women more often than younger women Having a molar pregnancy (partial or complete) results in the loss of the pregnancy and the possibility of developing choriocarcinoma, a chorionic malignancy from the trophoblastic tissue. Typically asymptomatic, the first symptoms of choriocarcinoma in 80% of cases are shortness of breath, indicative of metastasis to the lungs. Choriocarcinoma affects women of all ages and can occur during pregnancy, after childbirth, or even years remote from the antecedent pregnancy. The most frequent sites of metastases are the lungs, lower genital tract, brain, and liver. Choriocarcinoma is highly responsive to chemotherapy, with an overall remission rate greater than 90% (Hensley & Shviraga, 2014). Partial moles rarely transform into choriocarcinoma. Therapeutic Management Treatment consists of 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. If any tissue remains, hCG levels will not regress. In 80% of women with a benign hydatidiform mole, serum hCG titers steadily drop to normal within 8 to 12 weeks after evacuation of the molar pregnancy. In the other 20% of women with a malignant hydatidiform mole, serum hCG levels begin to rise (Berkowitz, Goldstein, & Horowitz, 2014). As a result of the increased risk for cancer, the client is advised to receive extensive follow-up therapy for the next 12 months. The follow-up protocol may include: Baseline hCG level, chest radiograph, and pelvic ultrasound Quantitative hCG levels every week until undetectable for 3 consecutive weeks; then serial hCG levels monthly for 1 year Chest radiograph 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 (Cunningham et al., 2014) Nursing Assessment The nurse plays a crucial role in identifying and bringing this condition to the attention of the health care provider based on sound knowledge of the typical clinical manifestations and through astute antepartal assessments. Clinical manifestations of GTD are very similar to those of spontaneous abortion at about 12 weeks of pregnancy. Assess the woman for potential clinical manifestations at each antepartal visit. Be alert for the following: 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) The diagnosis is made by very high hCG levels and the characteristic appearance of the vesicular molar pattern in the uterus via transvaginal ultrasound. Nursing Management Nursing management of the woman with GTD focuses on preparing her for a D&C, providing emotional support to deal with the loss and potential risks, and educating her about the risk that cancer may develop after a molar pregnancy and the strict adherence needed with the follow-up program. The woman must understand the need for the continued follow-up care regimen to improve her chances of future pregnancies and to ensure her continued quality of life. PREPARING THE CLIENT Upon diagnosis, the client will need an immediate evacuation of the uterus. Perform preoperative care, preparing the client physically and psychologically for the procedure. PROVIDING EMOTIONAL SUPPORT To aid the client and her family in coping with the loss of the pregnancy and the possibility of a cancer diagnosis, use the following interventions: Listen to their concerns and fears. Allow them time to grieve for the pregnancy loss. Acknowledge their loss and sad feelings (say you are sorry for their loss). Encourage them to express their grief; allow them to cry. Provide them with as much factual information as possible to help them make sense of what is happening. Enlist support from additional family and friends as appropriate and with the client's permission. EDUCATING THE CLIENT After GTD is diagnosed, teach the client about the condition and appropriate interventions that may be necessary to save her life. Explain each phase of treatment accurately and provide support for the woman and her family as they go through the grieving process. (Ricci 655- As with any facet of health care, be aware of the latest research and new therapies. Inform the client about her follow-up care, which will probably involve close clinical surveillance for approximately 1 year, and reinforce its importance in monitoring the client's condition. Tell the client that serial serum beta-hCG levels are used to detect residual trophoblastic tissue. Continued high or increasing hCG titers are abnormal and need further evaluation. Inform the client about the possible use of chemotherapy, such as methotrexate, which may be started prophylactically. Strongly urge the client to use a reliable contraceptive to prevent pregnancy for 1 year, because a pregnancy would interfere with tracking the serial beta-hCG levels used to identify a potential malignancy. Stress the need for the client to cooperate and adhere to the plan of therapy throughout this yearlong follow-up period. (Ricci 658) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Preeclampsia and eclampsia

Normal physiologic adaptations to pregnancy are altered in the woman who develops preeclampsia. Preeclampsia can be described as a multisystem, vasopressive disorder that targets the cardiovascular, hepatic, renal, and central nervous systems (CNSs). Preeclampsia can be classified as mild or severe with a potential progression to eclampsia. Each is associated with specific criteria. Comparison Chart 19.2 highlights these classifications. Pathophysiology Preeclampsia remains an enigma. The condition can be devastating to both the mother and fetus, yet the etiology still remains a mystery to medical science despite decades of research. Many theories exist, but none has truly explained the widespread pathologic changes that result in pulmonary edema, oliguria, seizures, thrombocytopenia, and abnormal liver enzymes (Cunningham et al., 2014). Despite the results of several research studies, the use of aspirin or supplementation with calcium, magnesium, zinc, or antioxidant therapy (vitamin C and E), salt restriction, diuretic therapy, or fish oils has not proved to prevent this destructive condition. Preeclampsia is a two-stage event;. the underlying mechanisms involved are vasospasm and hypoperfusion. In the first stage, the key feature is widespread vasospasm. In addition, endothelial injury occurs, leading to platelet adherence, fibrin deposition, and the presence of schistocytes (fragment of an erythrocyte). The second stage of preeclampsia is the woman's response to abnormal placentation, when symptoms appear, i.e., hypertension, proteinuria, and edema due to hypoperfusion. The first stage of generalized vasospasm results in elevation of blood pressure and reduced blood flow to the brain, liver, kidneys, placenta, and lungs. Decreased liver perfusion leads to impaired liver function and subcapsular hemorrhage. This is demonstrated by epigastric pain and elevated liver enzymes in the maternal serum. Decreased brain perfusion leads to small cerebral hemorrhages and symptoms of arterial vasospasm such as headaches, visual disturbances, blurred vision, and hyperactive deep tendon reflexes (DTRs). A thromboxane/prostacyclin imbalance leads to increased thromboxane (potent vasoconstrictor and stimulator of platelet aggregation) and decreased prostacyclin (potent vasodilator and inhibitor of platelet aggregation), which contribute to the hypertensive state. Decreased kidney perfusion reduces the glomerular filtration rate, resulting in decreased urine output and increased serum levels of sodium, BUN, uric acid, and creatinine, further increasing extracellular fluid and edema. Increased capillary permeability in the kidneys allows albumin to escape, which reduces plasma colloid osmotic pressure and moves more fluid into extracellular spaces; this leads to pulmonary edema and generalized edema. 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 (ACOG, 2014c). (Ricci 672-673) Therapeutic Management Management of the woman with preeclampsia varies depending on the severity of her condition and its effects on the fetus. Typically the woman is managed conservatively if she is experiencing mild symptoms. However, if the condition progresses, management becomes more aggressive. The "cure" for preeclampsia/eclampsia is always delivery of the placenta. The resolution following expulsion of the placenta supports theories related to the placental influence on the disease (Dekker, 2014). According to recent studies, 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. While women with chronic hypertension or a personal history of preeclampsia should receive aspirin during pregnancy, further research should be ongoing to predict preeclampsia in low risk women (Bujold, 2015). MANAGEMENT FOR MILD PREECLAMPSIA Conservative strategies for mild preeclampsia are used if the woman exhibits no signs of renal or hepatic dysfunction or coagulopathy. A woman with mild elevations in blood pressure may be placed on bed rest at home. She is encouraged to rest as much as possible in the lateral recumbent position to improve uteroplacental blood flow, reduce her blood pressure, and promote diuresis. In addition, antepartal visits and diagnostic testing—such as CBC, clotting studies, liver enzymes, and platelet levels—increase in frequency. The woman will be asked to monitor her blood pressure daily (every 4 to 6 hours while awake) and report any increased readings; she will also measure the amount of protein found in urine using a dipstick and will weigh herself for any weight gain. She also should 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. A balanced, nutritional diet with no sodium restriction is advised. In addition, she is encouraged to drink six to eight 8-oz glasses of water daily. If home management fails to reduce the blood pressure, admission to the hospital is warranted and the treatment strategy is individualized based on the severity of the condition and the gestational age at the time of diagnosis. p. 673 p. 674 During the hospitalization, the woman with mild preeclampsia is monitored closely for signs and symptoms of severe preeclampsia or impending eclampsia (e.g., persistent headache, hyperreflexia). Blood pressure measurements are frequently recorded along with daily weights to detect excessive weight gain resulting from edema. Fetal surveillance is instituted in the form of daily fetal movement counts, nonstress testing, and serial ultrasounds to evaluate fetal growth and amniotic fluid volume to confirm fetal well-being. Expectant management (watchful waiting) usually continues until the pregnancy reaches term, fetal lung maturity is documented, or complications develop that warrant immediate birth. Women with mild preeclampsia are at greatest risk for postpartum hypertension (King et al., 2015). 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. Intravenous 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. 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. This clinical picture signals severe preeclampsia, and immediate hospitalization is needed. Treatment is highly individualized and based on disease severity and fetal age. Birth of the infant is the only cure, because preeclampsia depends on the presence of trophoblastic tissue. Therefore, the exact age of the fetus is assessed to determine viability. Severe preeclampsia is treated aggressively because hypertension poses a serious threat to mother and fetus. The goal of care is to stabilize the mother-fetus dyad and prepare for birth. Therapy focuses on controlling hypertension, preventing seizures, preventing long-term morbidity, and preventing maternal, fetal, or newborn death (Foo et al., 2015). Intense maternal and fetal surveillance starts when the mother enters the hospital and continues throughout her stay. 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. The client is evaluated closely for magnesium toxicity. If at all possible, a vaginal delivery is preferable to a cesarean birth for better maternal outcomes and less risk associated with a surgical birth. PGE2 gel may be used to ripen the cervix. A cesarean birth may be performed if the client is seriously ill. A pediatrician/neonatologist or neonatal nurse practitioner should be available in the birthing room to care for the newborn. A newborn whose mother received high doses of magnesium sulfate needs to be monitored for respiratory depression, hypocalcemia, and hypotonia. Decreased fetal heart rate variability may occur but, in general, magnesium sulfate does not pose a risk to the fetus. The newborn may exhibit respiratory depression, loss of reflexes, muscle weakness, and neurologic depression (Martin, Fanaroff, & Walsh, 2014). MANAGEMENT OF ECLAMPSIA In the woman who develops an eclamptic seizure, the convulsive activity begins with facial twitching, followed by generalized muscle rigidity. The woman's face initially may become distorted, with protrusion of the eyes, and foaming at the mouth may occur. Respirations cease for the duration of the seizure, resulting from muscle spasms, thus compromising fetal oxygenation. Seizure complications can include tongue biting, head trauma, broken bones, and aspiration. Coma usually follows the seizure activity, with respiration resuming. Eclamptic seizures are life-threatening emergencies and require immediate treatment to decrease maternal morbidity and mortality. As with any seizure, the initial management is to clear the airway and administer adequate oxygen. Positioning the woman on her left side and protecting her from injury during the seizure are the key. Suction equipment must be readily available to remove secretions from her mouth after the seizure is over. Intravenous fluids are administered after the seizure at a rate to replace urine output and additional insensible losses. Fetal heart rate is monitored closely. Magnesium sulfate is administered intravenously to prevent further seizures. Serum magnesium levels, respiratory rate, reflexes, and urine output in women receiving magnesium sulfate are closely monitored to avoid magnesium toxicity and prevent cardiac arrest. Calcium gluconate (1 g intravenously) is typically ordered to counteract magnesium toxicity. Hypertension is controlled with antihypertensive medications. After the woman's seizures are controlled, her stability is assessed. If she is found stable, birth via induction or cesarean birth is performed (Amorim et al., 2015). If the woman's condition remains stable, she will be transferred to the postpartum unit for care. If she becomes unstable after giving birth, she may be transferred to the critical care unit for closer observation. p. 674 p. 675 Nursing Assessment Preventing complications related to preeclampsia requires the use of assessment, advocacy, and counseling skills. Assessment begins with the accurate measurement of the client's blood pressure at each encounter. In addition, nurses need to assess for subjective complaints that may indicate progression of the disease—visual changes, severe headaches, unusual bleeding or bruising, or epigastric pain (Nagtalon-Ramos, 2014). The significant signs of preeclampsia—proteinuria and hypertension—occur without the woman's awareness. Unfortunately, by the time symptoms are noticed, gestational hypertension can be severe. Take Note! The absolute blood pressure (value that validates elevation) of 140/90 mm Hg should be obtained on two occasions 4 to 6 hours apart to be diagnostic of preeclampsia. 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 (ACOG, 2014c). HEALTH HISTORY AND PHYSICAL EXAMINATION Take a thorough history during the first antepartal visit to identify whether the woman is at risk for preeclampsia. Risk factors include: 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 Lower socioeconomic status African-American ethnicity Age extremes (younger than 20 or older than 35) Obesity (Ross, 2015). In addition, complete a nutritional assessment that includes the woman's usual intake of protein, calcium, daily calories, and fluids. Women at risk for preeclampsia require more frequent prenatal visits throughout their pregnancy, and they require teaching about problems so that they can report them promptly. Blood pressure must be measured carefully and consistently. Obtain all measurements with the woman in the same position (blood pressure is highest in the sitting position and lowest in the side-lying position) and by using the same technique (automated vs. manual). This standardization in position and technique will yield the most accurate readings (Norwitz, 2015). Obtain the client's weight (noting gain since last visit), and assess for amount and location of edema. Asking questions such as "Do your rings still fit on your fingers?" or "Is your face puffy when you get up in the morning?" will help to determine whether fluid retention is present or if the woman's status has changed since her last visit. Take Note! Although edema is not a cardinal sign of preeclampsia, weight should be monitored frequently to identify sudden gains in a short time span. Current research relies less on the classic triad of symptoms (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 (Carson & Gibson, 2015). If edema is present, assess the distribution, degree, and pitting. Document your findings and identify whether the edema is dependent or pitting. Dependent edema is present on the lower half of the body if the client is ambulatory, where hydrostatic pressure is greatest. It is usually observed in the feet and ankles or in the sacral area if the client is on bed rest. Pitting edema is edema that leaves a small depression or pit after finger pressure is applied to a swollen area (Carson & Gibson, 2014). Record the depth of pitting demonstrated when pressure is applied. Although subjective, the following is used to record relative degrees: 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 At every antepartal visit, assess the fetal heart rate with a Doppler device. Also check a clean-catch urine specimen for protein using a dipstick. LABORATORY AND DIAGNOSTIC TESTING Various laboratory tests may be performed to evaluate the woman's status. Typically these include 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. Nursing Management Nursing management of the woman with preeclampsia focuses on close monitoring of blood pressure and ongoing assessment for evidence of disease progression. Throughout the client's pregnancy, fetal surveillance is essential. p. 675 p. 676 INTERVENING FOR PREECLAMPSIA The woman with mild preeclampsia requires frequent monitoring to detect changes because preeclampsia can progress rapidly. Instruct all women in the signs and symptoms of preeclampsia and urge them to contact their health care professional for immediate evaluation should any occur. Typically, women with mild preeclampsia can be managed at home if they have a good understanding of the disease process, blood pressure and vital signs are stable, there are no abnormal laboratory test results, and if good fetal movement is demonstrated (Teaching Guidelines 19.2). The home care nurse makes frequent visits and follow-up phone calls to assess the woman's condition, to assist with scheduling periodic evaluations of the fetus (such as nonstress tests), and to evaluate any changes that might suggest a worsening of the woman's condition. (Ricci 673-676) Early detection and management of mild preeclampsia is associated with the greatest success in reducing progression of this condition. As long as the client carries out the guidelines of care as outlined by the health care provider and remains stable, home care can continue to maintain the pregnancy until the fetus is mature. If disease progression occurs, hospitalization is required. INTERVENING FOR SEVERE PREECLAMPSIA The woman with severe preeclampsia requires hospitalization. Maintain the client on complete bed rest in the left lateral lying position. Ensure that the room is dark and quiet to reduce stimulation. Give sedatives as ordered to encourage quiet bed rest. The client is at risk for seizures if the condition progresses. Therefore, institute and maintain seizure precautions, such as padding the side rails and having oxygen, suction equipment, and call light readily available to protect the client from injury. Take Note! Preeclampsia increases the risk of placental abruption, preterm birth, intrauterine growth restriction, and fetal distress during childbirth. Always be prepared if you see symptoms of preeclampsia! Closely monitor the client's blood pressure. Administer antihypertensives as ordered to reduce blood pressure (Drug Guide 19.3). Assess the client's vision and level of consciousness. Report any changes and any complaints of headache or visual disturbances. Offer a high-protein diet with 8 to 10 glasses of water daily. Monitor the client's intake and output every hour and administer fluid and electrolyte replacements as ordered. 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. The treatment of acute pulmonary edema is symptomatic and includes the administration of vasodilating agents and of diuretics. The development of acute pulmonary edema in women with hypertension during pregnancy is associated with high levels of intravenous fluid administration (Pauli & Repke, 2015). To achieve a safe outcome for the fetus, prepare the woman for possible testing to evaluate fetal status as preeclampsia progresses. Testing may include the nonstress test, serial ultrasounds to track fetal growth, amniocentesis to determine fetal lung maturity, Doppler velocimetry to screen for fetal compromise, and biophysical profile to evaluate ongoing fetal well-being (Mattson & Smith, 2016). Other laboratory tests may be performed to monitor the disease process and to determine if it is progressing into HELLP syndrome. These include liver enzymes such as lactic dehydrogenase (LDH), ALT, and AST; chemistry panel, such as creatinine, BUN, uric acid, and glucose; CBC, including platelet count; coagulation studies, such as PT, PTT, fibrinogen, and bleeding time; and a 24-hour urine collection for protein and creatinine clearance. (Ricci 676-678) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file. Administer parenteral magnesium sulfate as ordered to prevent seizures. Assess DTRs to evaluate the effectiveness of therapy. Clients with preeclampsia commonly present with hyperreflexia. Severe preeclampsia causes changes in the cortex, which disrupts the equilibrium of impulses between the cerebral cortex and the spinal cord. Brisk reflexes (hyperreflexia) are the result of an irritable cortex and indicate CNS involvement (Marik, 2015). Diminished or absent reflexes occur when the client develops magnesium toxicity. Because magnesium is a potent neuromuscular blockade, the afferent and efferent nerve pathways do not relay messages properly and hyporeflexia develops. Common sites used to assess DTRs are biceps reflex, triceps reflex, patellar reflex, Achilles reflex, and plantar reflex. Nursing Procedure 19.1 highlights the steps for assessing the patellar reflex. The National Institute of Neurological Disorders and Stroke, a division of the National Institutes of Health, published a scale in the early 1990s that, although subjective, is used widely today. It grades reflexes from 0 to 4+. Grades 2+ and 3+ are considered normal, whereas grades 0 and 4 may indicate pathology (Table 19.2). Because these are subjective assessments, to improve communication of reflex results, condensed descriptor categories such as absent, average, brisk, or clonus should be used rather than numeric codes (Magowan, Owen, & Thomson, 2014). Clonus is the presence of rhythmic involuntary contractions, most often at the foot or ankle. Sustained clonus confirms CNS involvement. Nursing Procedure 19.2 highlights the steps when testing for ankle clonus. With magnesium sulfate administration, the client is at risk for magnesium toxicity. Closely assess the client for signs of toxicity, which include a respiratory rate of less than 12 breaths per minute, absence of DTRs, and a decrease in urinary output (<30 mL/hr). Also monitor serum magnesium levels. Although exact levels may vary among agencies, serum magnesium levels ranging from 4 to 7 mEq/L are considered therapeutic, whereas levels more than 8 mEq/dL are generally considered toxic. As levels increase, the woman is at risk for severe problems: 10 mEq/L: Possible loss of DTRs 15 mEq/L: Possible respiratory depression 25 mEq/L: Possible cardiac arrest (Skidmore-Roth, 2015). If signs and symptoms of magnesium toxicity develop, expect to administer calcium gluconate as the antidote. Throughout the client's stay, closely monitor her for signs and symptoms of labor. Perform continuous electronic fetal monitoring to assess fetal well-being. Note trends in baseline rate and presence or absence of accelerations or decelerations. Also observe for signs of fetal distress and report them immediately. Administer glucocorticoid treatment as ordered to enhance fetal lung maturity and prepare for labor induction if the mother's condition warrants. (Ricci 678) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file. INTERVENING FOR ECLAMPSIA The onset of seizure activity identifies eclampsia. Typically, eclamptic seizures are generalized and start with facial twitching. The body then becomes rigid, in a state of tonic muscular contraction. The clonic phase of the seizure involves alternating contraction and relaxation of all body muscles. Respirations stop during seizure activity and resume shortly after it ends. Client safety is the primary concern during eclamptic seizures. If possible, turn the client to her side and remain with her. Make sure that the side rails are up and padded. Dim the lights and keep the room quiet. Document the time and sequence of events as soon as possible. After the seizure activity has ceased, suction the nasopharynx as necessary and administer oxygen. Continue the magnesium sulfate infusion to prevent further seizures. Ensure continuous electronic fetal monitoring, evaluating fetal status for changes. Also assess the client for uterine contractions. After the client is stabilized, prepare her for the birthing process as soon as possible to reduce the risk of perinatal mortality. PROVIDING FOLLOW-UP CARE After delivery of the newborn, continue to monitor the client for signs and symptoms of preeclampsia/eclampsia for at least 48 hours. Expect to continue to administer magnesium sulfate infusion for 24 hours to prevent seizure activity, and monitor serum magnesium levels for toxicity. (Ricci 679-680) Assess vital signs at least every 4 hours, along with routine postpartum assessments: fundus, lochia, breasts, bladder, bowels, and the woman's emotional state. Monitor urine output closely. Diuresis is a positive sign that, along with a decrease in proteinuria, signals resolution of the disease. (Ricci 680) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

premature rupture of membranes

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 (Jazayeri, 2015). If prolonged (greater than 24 hours), the woman's risk for infection (chorioamnionitis, endometritis, sepsis, and neonatal infections) increases and continues to increase the longer the time since the bag of waters ruptured. The time interval from rupture of membranes to the onset of regular contractions is termed the latent period. Women with PROM present with leakage of fluid, vaginal discharge, vaginal bleeding, and pelvic pressure, but they are not having contractions. PROM is diagnosed by speculum vaginal examination of the cervix and vaginal cavity. Pooling of fluid in the vagina or leakage of fluid from the cervix, ferning of the dried fluid under microscopic examination, and alkalinity of the fluid as determined by nitrazine paper (ph indicator) confirm the diagnosis. The terminology of PROM can be confusing. PROM is rupture of the membranes prior to the onset of labor and is used appropriately when referring to a woman who is beyond 37 weeks' gestation, has presented with spontaneous rupture of the membranes, and is not in labor. A related term is 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. Eighty-five percent of neonatal morbidity and mortality is a result of prematurity. PPROM is associated with 30% to 40% of preterm deliveries and is the leading identifiable cause of preterm delivery. PPROM complicates 3% of all pregnancies and occurs in approximately 150,000 pregnancies yearly in the United States (Jazayeri, 2015). The exact cause of PROM is not known, but may be associated with vaginal bleeding, placental abruption, microbial invasion of the amniotic cavity, and defective placentation. In many cases, PROM occurs spontaneously. Increasing evidence associates abnormalities in vaginal flora during pregnancy with preterm labor and birth with potential neonatal sequelae due to prematurity and poor perinatal outcome (Gilbert, 2014). A recent study found that women with previous PPROM are at increased risk for recurrence, and a short interval between pregnancies is associated with increased risk (Gibbins et al., 2014). Therapeutic Management Treatment of PROM typically depends on the gestational age. Under no circumstances is an unsterile digital cervical examination done until the woman enters active labor, to minimize infection exposure. If the fetal lungs are mature, induction of labor is initiated. PROM is not a lone indicator for surgical birth. If the fetal lungs are immature, expectant management is carried out with adequate hydration, reduced physical activity, pelvic rest, and close observation for possible infection, such as with frequent monitoring of vital signs and laboratory test results (e.g., the white blood cell count). Corticosteroids may be given to enhance fetal lung maturity if lungs are immature, although this remains controversial. Recent studies have shown clear benefits of antibiotics to decrease neonatal morbidity associated with PPROM (Mattson & Smith, 2016). Nursing Assessment Nursing assessment focuses on obtaining a complete health history and performing a physical examination to determine maternal and fetal status. An accurate assessment of the gestational age and knowledge of the maternal, fetal, and neonatal risks are essential to appropriate evaluation, counseling, and management of women with PROM and PPROM. Nurses need to be aware that the risk of infection increases with the duration of PPROM. Health History and Physical Examination Review the maternal history for risk factors such as infection, increased uterine size (polyhydramnios, macrosomia, multiple gestation), uterine and fetal anomalies, lower socioeconomic status, STIs, cervical insufficiency, vaginal bleeding, and cigarette smoking during pregnancy. Ask about any history or current symptoms of urinary tract infection (frequency, urgency, dysuria, or flank pain) or pelvic or vaginal infection (pain or vaginal discharge). Assess for signs and symptoms of labor, such as cramping, pelvic pressure, or back pain. Also assess her vital signs, noting any signs indicative of infection such as fever and elevated white blood cell count (more than 18,000 cells/mm3) (Nagtalon-Ramos, 2014). Institute continuous electronic fetal heart rate monitoring to evaluate fetal well-being. Conduct a vaginal examination to ascertain the cervical status in PROM. If PPROM exists, a sterile speculum examination (where the examiner inspects the cervix but does not palpate it) is done rather than a digital cervical examination because it may diminish latency (period of time from rupture of membranes to birth) and increase newborn morbidity (Cunningham et al., 2014). Observe the characteristics of the amniotic fluid. Note any evidence of meconium, or a foul odor. When meconium is present in the amniotic fluid, it typically indicates fetal distress related to hypoxia. Meconium stains the fluid yellow to greenish brown, depending on the amount present. A foul odor of amniotic fluid indicates infection. Also observe the amount of fluid. A decreased amount of amniotic fluid reduces the cushioning effect, thereby making cord compression a possibility. Some research shows that restoring the volume of lost amniotic fluid will help to reduce the risk of infection and reduce cord compression. See Evidence-Based Practice 19.1. Key assessments are summarized in Box 19.3. (Ricci 685-686) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file. Laboratory and Diagnostic Testing To diagnose PROM or PPROM, several procedures may be used: the nitrazine test, fern test, or ultrasound. After the insertion of a sterile speculum, a sample of the fluid in the vaginal area is obtained. With a nitrazine test, the pH of the fluid is tested; amniotic fluid is more basic (7.0) than normal vaginal secretions (4.5). Nitrazine paper turns blue in the presence of amniotic fluid. However, false-positive results can occur if blood, urine, semen, or antiseptic chemicals are also present; all will increase the pH. For the fern test, a sample of vaginal fluid is place on a slide to be viewed directly under a microscope. Amniotic fluid will develop a fern-like pattern when it dries because of sodium chloride crystallization. If both of these tests are inconclusive, a transvaginal ultrasound can also be used to determine whether membranes have ruptured by demonstrating a decreased amount of amniotic fluid (oligohydramnios) in the uterus (Jazayeri, 2015). Other laboratory and diagnostic tests that may be used include: Urinalysis and urine culture for UTI or asymptomatic bacteriuria Cervical test or culture for chlamydia or gonorrhea Vaginal culture for bacterial vaginosis and trichomoniasis Vaginal introital/rectal culture for group B streptococcus Nursing Management Nursing management for the woman with PROM or PPROM focuses on preventing infection and identifying uterine contractions. The risk for infection is great because of the break in the amniotic fluid membrane and its proximity to vaginal bacteria. Therefore, monitor maternal vital signs closely. Be alert for a temperature elevation or an increase in pulse, which could indicate infection. Also monitor the fetal heart rate continuously, reporting any fetal tachycardia (which could indicate a maternal infection) or variable decelerations (suggesting cord compression). If variable decelerations are present, anticipate amnioinfusion based on agency policy. Evaluate the results of laboratory tests such as a CBC. An elevation in white blood cells would suggest infection. Administer antibiotics if ordered. Encourage the woman and her partner to verbalize their feelings and concerns. Educate them about the purpose of the protective membranes and the implications of early rupture. Keep them informed about planned interventions, including potential complications and required therapy. As appropriate, prepare the woman for induction or augmentation of labor as appropriate if she is near term. If labor does not start within 48 hours, the woman with PPROM may be discharged home on expectant management, which may include: Antibiotics if cervicovaginal cultures are positive Activity restrictions Education about signs and symptoms of infection and when to call with problems or concerns (Teaching Guidelines 19.3) Frequent fetal testing for well-being Ultrasound every 3 to 4 weeks to assess amniotic fluid levels Possible corticosteroid treatment depending on gestational age Daily kick counts to assess fetal well-being (Ricci 687) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Bleeding during pregnancy

Bleeding at any time during pregnancy is potentially life threatening. Every minute of every day, a woman dies in pregnancy or childbirth. The biggest killer is obstetric hemorrhage, the successful treatment of which is a challenge for both the developed and developing worlds. The presence of an attendant at every birth and access to emergency obstetric care are strategic to reducing maternal morbidity and mortality (World Health Organization [WHO], 2015). 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). Bleeding can occur early or late in the pregnancy and may result from numerous conditions. Bleeding is experienced by approximately 20% of women during the first trimester of pregnancy (Knez, Day, & Jurkovic, 2014). Conditions commonly associated with early bleeding (first half of pregnancy) include spontaneous abortion, uterine fibroids, ectopic pregnancy, gestational trophoblastic disease, and cervical insufficiency. Conditions associated with late bleeding include placenta previa, abruptio placentae, and placenta accreta, which usually occur after the 20th week of gestation. (Ricci 648-649) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Placenta accreta

Placenta accreta is a potentially life-threatening obstetrical hemorrhagic condition that requires a multidisciplinary approach to management. The incidence of placenta accreta has increased and seems to parallel the increasing cesarean birth rate or intrauterine procedures. Placenta accreta is a condition in which the placenta attaches itself too deeply into the wall of the uterus but does not penetrate the uterine muscle. It is further subcategorized as placenta increta, when the placenta invades the myometrium, and placenta percreta, when it has extended through the myometrium and uterine serosa and adjacent tissue. A common risk of placenta accreta during the birthing process is the possibility of hemorrhaging during manual attempts to detach the placenta. According to the March of Dimes (2015c), 1 in 530 births results in this condition. The specific cause of placenta accreta is unknown, but it can be related to placenta previa, advanced maternal age, smoking, and previous cesarean births. According to the literature, a cesarean birth increases the possibility of a future placenta accreta; the more cesarean births that are done, the greater the incidence. According to ACOG (2014b), postpartum hemorrhage is a complication associated with placenta accreta. Ninety percent of accretas have postpartum hemorrhage, and 50% of these will result in a hysterectomy (ACOG, 2014b). Women at highest risk of emergency hysterectomy are those who are multiparous, had a cesarean birth in either a previous or the present pregnancy, or had abnormal placentation. The essential management issues are early detection and immediate and appropriate intervention. If a placenta accreta diagnosis is made, the client should be counseled that a cesarean section and possible hysterectomy may be necessary interventions (Creasy et al., 2014). Placenta accreta is typically diagnosed after birth when the placenta fails to normally separate from the uterine wall. A prenatal screening diagnosis via ultrasound and magnetic resonance imaging (MRI) would decrease maternal and fetal morbidities and mortalities. A profuse hemorrhage may result because the uterus cannot contract to close off the open blood vessels. Management will depend on the severity of the bleeding and frequently necessitates a pro (Ricci 667-668) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Chronic hypertension

Chronic hypertension is defined as blood pressure exceeding 140/90 mm Hg before pregnancy or before 20 weeks' gestation. When hypertension is first identified during a woman's pregnancy and she is less than 20 weeks' gestation, blood pressure elevations usually represent chronic hypertension. Chronic hypertension occurs in about 20% of women of childbearing age, with the prevalence varying according to age, race, and body mass index (BMI). As our nation's obesity rate rises, more women will start pregnancies with elevated blood pressures. About 25% of women with chronic hypertension develop preeclampsia during pregnancy (Clausen & Bergholt, 2014). Women with chronic hypertension in pregnancy should be monitored for the development of worsening hypertension and/or the development of superimposed preeclampsia. Women with mild chronic hypertension often do not require antihypertensive therapy during most of pregnancy. 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 (Magee et al., 2015). Nurses can play a large role in educating their hypertensive clients to help them understand potential complications and how simple changes in their lifestyles might be helpful in influencing the pregnancy outcome positively. (Ricci 672) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

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. 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. The incidence of cervical insufficiency is less than 1% in the obstetrical population (AHRQ, 2015). Pathophysiology The exact mechanism contributing to cervical insufficiency is not known. 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 (Magowan, Owen, & Thomson, 2014). Several theories have been proposed that focus on damage to the cervix as a key component of hormonal factors, such as increased amounts of relaxin. 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 (Norwitz & Conroy, 2015). Cervical insufficiency is likely to be the clinical end point of many pathologic processes, such as congenital cervical hypoplasia, in utero DES exposure that caused cervical hypoplasia, or trauma to the cervix (conization, amputation, obstetric laceration, or forced cervical dilation [may occur during elective pregnancy termination]). 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 (Berghella, 2014). However, the exact etiology of cervical insufficiency is not known. Cervical length also has been associated with cervical insufficiency and, subsequently, preterm birth. Recent studies have examined the association between a short cervical length and the risk of preterm birth. Some have demonstrated a continuum of risk between a shorter cervix on ultrasound and a higher risk of preterm birth, leading to the hypothetical argument that women with a short cervix on ultrasound might benefit from cervical cerclage (the sewing closed of the cervix). The American Congress of Obstetricians and Gynecologists (ACOG) does not recommend cerclage placement for women with a short cervix who do not have a history of preterm birth, as it has not been shown to be beneficial in this population (2014a). Therapeutic Management 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. Cerclage was devised more than 50 years ago based on the hypothesis that for some women, weakness or malfunction of the cervix has a causative role in the pathway to preterm birth. 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 (Fig. 19.3). According to the American College of Obstetricians and Gynecologists (ACOG) (2014a), if a short cervix is identified at or after 20 weeks and no infection (chorioamnionitis) is present, the decision to proceed with cerclage should be made with caution. ACOG recommends the following indications for cervical cerclage: history of second trimester pregnancy loss with painless dilatation; prior cerclage placement for cervical insufficiency; history of spontaneous preterm birth prior to 34 weeks' gestation; and painless cervical dilatation on physical examination in the second trimester (2014a). Complications associated with cerclage placement are suture displacement, rupture of membranes, and chorioamnionitis, and their incidence varies widely in relation to the timing and indications for the cerclage (Abu Hashim, Al-Inany, & Kilani, 2014). The optimal timing for cerclage removal is unclear, but ACOG (2014a) supports cerclage placement up to 28 weeks' gestation. A recent meta-analysis of randomized controlled trials concluded that either vaginal progesterone or cerclage are equally efficacious in the prevention of preterm birth in women with a short cervix in the mid trimester, singleton gestation, and previous preterm birth (Jena et al., 2015). p. 658 p. 659 FIGURE 19.3 A. Cervical cerclage. B. Suturing the cervix for cervical insufficiency. Nursing Assessment RISK FACTORS Nursing assessment focuses on obtaining a thorough history to determine any risk factors that might have a bearing on this pregnancy: 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. Commonly with cervical insufficiency the woman will report a pink-tinged vaginal discharge or an increase in low pelvic pressure, cramping to vaginal bleeding, and loss of amniotic fluid. Cervical dilation also occurs. If this continues, rupture of the membranes, release of amniotic fluid, and uterine contractions occur, subsequently resulting in delivery of the fetus, often before it is viable. Take Note! The diagnosis of cervical insufficiency remains difficult in many circumstances. The cornerstone of diagnosis is a history of a pregnancy loss during the second or early third trimester associated with painless cervical dilation without evidence of uterine activity. DIAGNOSTIC TESTS 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. Cervical shortening occurs from the internal os outward and can be viewed on ultrasound as funneling. The amount of funneling can be determined by dividing funnel length by cervical length. The most common time at which a short cervix or funneling develops is 16 to 24 weeks, so ultrasound screening should be performed during this interval (Herrera & Lewis, 2014). A cervical length of less than 25 mm is abnormal between 16 and 24 weeks and may increase the risk of preterm labor. Among clients with a short cervix, provide education concerning the signs and symptoms of preterm labor, especially as the pregnancy approaches potential viability. Prenatal visits/contacts may be scheduled at more frequent intervals to increase client interaction with the care provider, especially between 20 and 34 weeks' gestation, which may decrease the rate of extremely early preterm births. Expect the woman (particularly a woman with pelvic pressure, backache, or increased mucoid discharge) to undergo serial transvaginal ultrasound evaluations every few days to avoid missing rapid changes in cervical dilation or until the trend in cervical length can be characterized (Cunningham et al., 2014). Home Uterine Activity Monitoring. For a woman at risk for preterm birth, home uterine activity monitoring can be used to screen for prelabor uterine contractility so that escalating contractility can be identified, allowing earlier intervention to prevent preterm birth. The home uterine activity monitor consists of a pressure sensor attached to a belt that is held against the abdomen and a recording/storage device that is carried on a belt or hung from the shoulder. Uterine activity is typically recorded by the woman for 1 hour twice daily, while she is performing routine activities. The stored data are transmitted via telephone to a perinatal nurse, and a receiving device prints out these data. The woman is contacted if there are any problems. Although in theory identifying early contractions to initiate interventions to arrest the labor sounds reasonable, a recent Cochrane Review study found that uterine activity monitoring in asymptomatic high-risk women is inadequate for predicting preterm birth. There was no impact on maternal or perinatal outcomes or prediction of preterm births (Urquhart et al., 2015). This practice continues even though numerous randomized trials have found no relationship between monitoring and actual reduction of preterm labor. In more recent research findings, cervical length is predictive of preterm birth in all populations studied. A cervical length of less than 25 mm warrants intervention to improve the health outcomes of pregnant women and their infants (Boots et al., 2014). p. 659 p. 660 Nursing Management Nursing management focuses on monitoring the woman very closely for signs of preterm labor: backache, increase in vaginal discharge, rupture of membranes, and uterine contractions. Provide emotional support and education to allay the couple's anxiety about the well-being of their fetus. Provide preoperative care and teaching as indicated if the woman will be undergoing cerclage. Teach the client and her family about the signs and symptoms of preterm labor and the need to report any changes immediately. Also reinforce the need for activity restrictions (if appropriate) and continued regular follow-up. Continuing surveillance throughout the pregnancy is important to promote a positive outcome for the family. The nurse can play a pivotal role in identifying preterm labor through risk assessment, physical examination, and client advocacy. (Ricci 658-660) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

HELLP syndrome

HELLP syndrome is an acronym for hemolysis, elevated liver enzymes, and low platelet count. It is a variant of the preeclampsia/eclampsia syndrome that occurs in 10% to 20% of clients whose conditions are labeled as severe. Women with HELLP syndrome are at 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 (Vigil-De Gracia, 2015). It is a life-threatening obstetric complication considered by many to be a severe form of preeclampsia involving hemolysis, thrombocytopenia, and liver dysfunction. Both HELLP and preeclampsia occur during the later stages of pregnancy, and sometimes after childbirth. HELLP syndrome is a clinically progressive condition. Early diagnosis is critical to prevent liver distention, rupture, and hemorrhage and the onset of DIC. If the condition presents prenatally, morbidity and mortality can affect both mother and baby. HELLP syndrome occurs in up to 20% of pregnant women diagnosed with severe preeclampsia. It is unique, as it is a laboratory-value specific diagnosis. Women with HELLP usually have fewer signs of abnormalities consistent with the metabolic syndrome and a lower prevalence of thrombophilia as compared with preeclampsia women without HELLP (Sibai, 2015). Although it has been reported as early as 17 weeks' gestation, most of the time it is diagnosed between 22 and 36 weeks' gestation (Cunningham et al., 2014). It can present prior to the presence of an elevated blood pressure. HELLP syndrome leads to an increased maternal risk for developing liver hematoma or rupture, stroke, cardiac arrest, seizure, pulmonary edema, DIC, subendocardial hemorrhage, adult respiratory distress syndrome, renal damage, sepsis, hypoxic encephalopathy, and maternal, or fetal death (Moses, 2015b). The recognition of HELLP syndrome and an aggressive multidisciplinary approach and prompt transfer of these women to obstetric centers with expertise in this field are required for the improvement of maternal-fetal prognosis. Pathophysiology The hemolysis that occurs is termed microangiopathic hemolytic anemia. This cascade of events is thought to happen when red blood cells become fragmented as they pass through small, damaged blood vessels. Elevated liver enzymes are the result of reduced blood flow to the liver secondary to obstruction from fibrin deposits. At the same time, endothelial damage and fibrin deposition in the liver may lead to liver impairment and can result in hemorrhagic necrosis, indicated by right upper quadrant tenderness, nausea, and vomiting. Hyperbilirubinemia and jaundice result from liver impairment. Low platelets result from vascular damage, the result of vasospasm, and platelets aggregate at sites of damage, resulting in thrombocytopenia in multiple sites (Khan & Meirowitz, 2015). Therapeutic Management The treatment for HELLP syndrome is 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 (Foley, Strong, & Garite, 2014). The client should be admitted or transferred to a tertiary center with a neonatal intensive care unit. Additional treatment includes correction of the coagulopathies that accompany HELLP syndrome. After this syndrome is diagnosed and the woman's condition is stable, birth of the infant is indicated. Magnesium sulfate is used prophylactically to prevent seizures. Antihypertensives such as hydralazine or labetalol are given to control blood pressure. Blood component therapy—such as fresh-frozen plasma, packed red blood cells, or platelets—is transfused to address the microangiopathic hemolytic anemia. Birth may be delayed up to 96 hours so that betamethasone or dexamethasone can be given to stimulate lung maturation in the preterm fetus. Nursing Assessment Nursing assessment of the woman with HELLP is similar to that for the woman with severe preeclampsia. Be alert for complaints of nausea (with or without vomiting), malaise, epigastric or right upper quadrant pain, and demonstrable edema. Perform systematic assessments frequently, as indicated by the woman's condition and response to therapy. A diagnosis of HELLP syndrome is made based on laboratory test results, including: Low hematocrit that is not explained by any blood loss Elevated LDH (liver impairment) Elevated AST (liver impairment) Elevated ALT (liver impairment) Elevated BUN Elevated bilirubin level Elevated uric acid and creatinine levels (renal involvement) Low platelet count (less than 100,000 cells/mm3) Nursing Management Nursing management of the woman diagnosed with HELLP syndrome is the same as that for the woman with severe preeclampsia. If possible, the woman with HELLP syndrome should be transferred to a tertiary care center once she has been ass (Ricci 680-681) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

hypermesis gravidarum

Hyperemesis gravidarum is a severe form of nausea and vomiting of pregnancy associated with significant costs and psychosocial impacts. At least 70% to 85% of women experience nausea and vomiting during their pregnancy (Castillo & Phillippi, 2015). The term morning sickness is often used to describe this condition when symptoms are relatively mild. Studies have shown that nausea and vomiting of pregnancy is associated with improved fetal outcomes, such as lower rates of miscarriage (Ayyavoo et al., 2014). Such symptoms usually disappear after the first trimester. This mild form mostly affects the quality of life of the woman and her family, whereas the severe form—hyperemesis gravidarum—results in dehydration, weight loss, electrolyte imbalance, and the need for hospitalization (Taylor, 2014). Unlike morning sickness, hyperemesis gravidarum is a complication of pregnancy characterized by persistent, uncontrollable nausea and vomiting that begins in the first trimester and causes dehydration, ketosis, and weight loss of more than 5% of prepregnancy body weight. Risk factors for hyperemesis include previous pregnancy complicated by hyperemesis, molar pregnancies, history of helicobacter pylori infection, multiple gestation, prepregnancy history of genitourinary disorders, clinical hyperthyroid disorders, and prepregnancy psychiatric diagnosis (King et al., 2015). Hyperemesis (uncontrollable vomiting) is estimated to occur in approximately 2% of pregnant women. The prevalence increases in molar pregnancies and multiple gestations. The peak incidence is at 8 to 12 weeks of pregnancy, and symptoms usually resolve by week 20 (Maltepe et al., 2015). Take Note! Every pregnant woman needs to be instructed to report any episodes of severe nausea and vomiting or episodes that extend beyond the first trimester. Pathophysiology Although the exact cause of nausea and vomiting is unknown, its effects—decreased placental blood flow, decreased maternal blood flow, and acidosis—can threaten the health of the mother and fetus. Dehydration can also lead to preterm labor (Smith et al., 2016). Numerous theories abound, but few studies have produced scientific evidence to identify the etiology of this condition. It is likely that multiple factors contribute to it. Elevated levels of hCG are present in all pregnant women during early pregnancy, usually declining after 12 weeks. This corresponds to the usual duration of morning sickness. In hyperemesis gravidarum, the hCG levels are often higher and extend beyond the first trimester. Symptoms exacerbate the disease. 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. A few other theories that have been proposed to explain its etiology include: Endocrine theory—High levels of hCG and estrogen during pregnancy. Metabolic theory—Vitamin B6 deficiency. Genetic factors that may predispose the woman to this condition. Psychological theory—psychological stress increases the symptoms. Therapeutic Management Hyperemesis gravidarum is a diagnosis of exclusion. Careful consideration of other conditions must be assessed when a client experiences nausea and vomiting for the first time after 9 weeks' gestation. Conservative management in the home is the first line of treatment for the woman with hyperemesis gravidarum. This usually focuses on dietary and lifestyle changes. If conservative management fails to alleviate the client's symptoms and nausea and vomiting continue, hospitalization is necessary to reverse the effects of severe nausea and vomiting. On admission to the hospital, blood tests are ordered to assess the severity of the client's dehydration, electrolyte imbalance, ketosis, and malnutrition. Parenteral fluids and drugs are ordered to rehydrate the woman and reduce the symptoms. 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 initially because the woman is considered NPO (not able to ingest anything by mouth). Once her condition stabilizes and she is allowed oral intake, medications may be administered orally. 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. Administering antiemetics intravenously or intramuscularly is typically the second pillar of treatment for hyperemesis gravidarum. Finding a drug that works for any given client is largely a matter of trial and error. If one drug is ineffective, another class of drugs with a different mechanism of action may help. 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. Most drugs are given intravenously or intramuscularly. There is no evidence that any antiemetic class is superior to another with respect to effectiveness (King et al., 2015) (Drug Guide 19.2). Few women receive complete relief of symptoms from any one therapy. Complementary and alternative medicine therapies appeal to many women as supplements to traditional ones. Some popular therapies include acupressure, massage, therapeutic touch, ginger, and the wearing of Sea-Bands to prevent nausea and vomiting. Recent research has reported a positive effect of using acupressure (provided by Sea-Bands) over the nei guan acupoint on the wrist to control nausea and vomiting associated with pregnancy (Matthews et al., 2014). (Ricci 668-669) Ricci, Susan. Lippincott CoursePoint for Nursing assessment of the woman with hyperemesis gravidarum requires a thorough history and physical examination to identify signs and symptoms associated with this disorder. The client is extremely uncomfortable. She may experience many hours of lost work productivity and sleep, and hyperemesis may damage family relationships. If hyperemesis progresses untreated, it may cause neurologic disturbances, renal damage, dehydration, ketosis, alkalosis from loss of hydrochloric acid, hypokalemia, retinal hemorrhage, or death (Peled et al., 2014). Laboratory and diagnostic tests aid in determining the severity of the disorder. (Ricci 669-670) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file. Health History and Physical Examination Begin the history by asking the client about the onset, duration, and course of her nausea and vomiting. Ask her about any medications or treatments she used and how effective they were in relieving her nausea and vomiting. Obtain a diet history from the client, including a dietary recall for the past week. Note the client's knowledge of nutrition and need for appropriate nutritional intake. Be alert for patterns that may contribute to or trigger her distress. Also ask about any complaints of ptyalism (excessive salivation), anorexia, indigestion, and abdominal pain or distention. Ask if she has noticed any blood or mucus in her stool. Review the client's history for possible risk factors, such as young age, nausea and vomiting with previous pregnancy, history of intolerance of oral contraceptives, nulliparity, trophoblastic disease, multiple gestation, emotional or psychological stress, gastroesophageal reflux disease, primigravida status, obesity, hyperthyroidism, and Helicobacter pylori seropositivity (Ogunyemi, Fong, & Herrero, 2015). Weigh the client and compare this weight with her weight before she began experiencing symptoms and to her prepregnancy weight to estimate the degree of loss. With hyperemesis, weight loss usually exceeds 5% of body mass. Inspect the mucous membranes for dryness and check skin turgor for evidence of fluid loss and dehydration. Assess blood pressure for changes, such as hypotension, that may suggest a fluid volume deficit. Also note any complaints of weakness, fatigue, activity intolerance, dizziness, or sleep disturbances. Assess the client's perception of the situation. Note any evidence of depression, anxiety, irritability, mood changes, and decreased ability to concentrate, which can add to her emotional distress. Much of the psychological distress is self-limiting in this condition and probably in the causal pathway (Tan et al., 2014). Determine the woman's support systems that are available for help. Laboratory and Diagnostic Testing The results of laboratory and diagnostic tests may provide clues to the severity or etiology of the disorder. These may include: Liver enzymes: To rule out hepatitis, pancreatitis, and cholestasis; elevations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are usually present. CBC: Elevated levels of red blood cells and hematocrit, indicating dehydration. Urine ketones: Positive when the body breaks down fat to provide energy in the absence of adequate intake. TSH and T4 to rule out thyroid disease. Blood urea nitrogen: Increased in the presence of salt and water depletion Urine specific gravity—greater than 1.025, possibly indicating concentrated urine linked to inadequate fluid intake or excessive fluid loss; ketonuria. Serum electrolytes: Decreased levels of potassium, sodium, and chloride resulting from excessive vomiting and loss of hydrochloric acid in stomach. Ultrasound: Evaluation for molar pregnancy or multiple gestation (Cunningham et al., 2014). Nursing Management Nursing management for the client with hyperemesis gravidarum focuses on promoting comfort by controlling the client's nausea and vomiting and promoting adequate nutrition. In addition, the nurse plays a major role in supporting and educating the client and her family. Promoting Comfort and Nutrition During the initial period, expect to withhold all oral food and fluids, maintaining NPO status to allow the gastrointestinal tract to rest. In addition, administer prescribed antiemetics to relieve the nausea and vomiting and intravenous fluids to replace fluid losses. Monitor the rate of infusion to prevent overload and assess the intravenous insertion site to prevent infiltration or infection. Also administer electrolyte replacement therapy as ordered to correct any imbalances, and periodically check serum electrolyte levels to evaluate the effectiveness of therapy. Provide physical comfort measures such as hygiene measures and oral care. Pay special attention to the environment, making sure to keep the area free of pungent odors. As the client's nausea and vomiting subside, gradually introduce oral fluids and foods in small amounts. Monitor intake and output and assess the client's tolerance to the increase in intake. Providing Support and Education Women with hyperemesis gravidarum commonly are fatigued physically and emotionally. Many are exhausted, frustrated, and anxious. Offer reassurance that all interventions are directed toward promoting positive pregnancy outcomes for both the woman and her fetus. Providing information about the expected plan of care may help to alleviate the client's anxiety. Listen to her concerns and feelings, answering all questions honestly. Educate the woman and her family about the condition and its treatment options (Teaching Guidelines 19.1). Teach the client about therapeutic lifestyle changes, such as avoiding stressors and fatigue that may trigger nausea and vomiting. Offer ongoing support and encouragement and promote active participation in care decisions, thereby empowering the client and her family. Attempting to provide the client with a sense of control may help her overcome the feeling that she has lost control. If necessary, refer the client to a spiritual advisor or counseling. Also suggest possible local or national support groups that the client may contact for additional information. Arrange for possible home care follow-up for the client and reinforce discharge instructions to promote understanding. Timely counseling, balanced nutrition, pharmacotherapy, and emotional support are associated with favorable outcomes for the woman with this condition. Collaborate with community resources to ensure continuity of care. (Ricci 670-671) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Hypertensive disorders of pregnancy

Hypertension remains the most commonly encountered medical condition in pregnant women, complicating up to 15% of all pregnancies. It results in frequent hospital admissions, maternal morbidity and mortality, and preterm births with concomitant neonatal morbidity and mortality. Hypertensive disorders of pregnancy comprise a spectrum of severity ranging from a mild elevation of blood pressure to severe preeclampsia and hemolysis. Recent data show that hypertensive disorders of pregnancy are associated with long-term cardiovascular risks in women (Miller & Carpenter, 2015). Hypertensive disorders of pregnancy include chronic hypertension, gestational hypertension, preeclampsia, eclampsia, and chronic hypertension with superimposed preeclampsia. Preeclampsia complicates about 3% to 5% of pregnancies. All hypertensive disorders, which affect up to 15% of pregnancies, are on the rise. Hypertensive disorders are associated with higher rates of maternal, fetal, and infant mortality and with severe morbidity, especially in cases of severe preeclampsia, eclampsia, and HELLP syndrome (ACOG, 2014c). ACOG (2010c) and the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy (2002) have identified a classification system for hypertensive disorders. Hypertension may be a preexisting condition (chronic hypertension) or it may present for the first time during pregnancy (gestational hypertension). Both chronic hypertension and preeclampsia can be subclassified as either mild or severe. For chronic hypertension, subclassification is dependent on systolic and diastolic values. For preeclampsia, subclassification is dependent on the severity of end organ involvement (Foley, Strong, & Garite, 2014). Regardless of its onset or subclassification, hypertension jeopardizes the well-being of the mother as well as the fetus. The classification of hypertensive disorders in pregnancy currently consists of five categories: Chronic hypertension: Hypertension that exists prior to pregnancy or that develops before 20 weeks' gestation. 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. 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. Eclampsia: Onset of seizure activity in a woman with preeclampsia Chronic hypertension with superimposed preeclampsia: Occurs in approximately 20% of pregnant women with increased maternal and fetal morbidity rates (King et al., 2015). Population-based data indicate that approximately 1% of pregnancies are complicated by chronic hypertension, 5% to 6% by gestational hypertension (without proteinuria), and 3% to 5% by preeclampsia (Carson & Gibson, 2015). Worldwide, 50,000 to 60,000 women die from preeclampsia each year, corresponding to 12% of all maternal deaths (Clausen & Bergholt, 2014). (Ricci 671) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

Introduction

Most people view pregnancy as a natural process with a positive outcome—the birth of a healthy newborn. Unfortunately, conditions can occur that may result in negative outcomes for the fetus, mother, or both. A high-risk pregnancy is one 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. Approximately, one in four pregnant women is considered to be at high risk or diagnosed with complications (Nagtalon-Ramos, 2014). Women who are considered to be at high risk have a higher morbidity and mortality compared with mothers in the general population. The risk status of a woman and her fetus can change during the pregnancy, with a number of problems occurring during labor, birth, or afterward, even in women without any known previous antepartal risk. Examples of high-risk conditions include gestational diabetes and ectopic pregnancy. Many obstetric complications and conditions are life-threatening emergencies with high morbidity and mortality rates. It is essential that these be identified early to ensure the best possible outcome for the mother and infant. These conditions are specifically addressed in Healthy People 2020 (U.S. Department of Health and Human Services, 2010). Early identification of the woman at risk is essential to ensure that appropriate interventions are instituted promptly, increasing the opportunity to change the course of events and provide a positive outcome. The term risk may mean different things to different groups. For example, health care providers may focus on the disease processes and treatments to prevent complications. Nurses may focus on nursing care and on the psychosocial impact on the woman and her family. Insurance companies may concentrate on the economic issues related to the high-risk status. The woman's attention may be focused on her own needs and those of her family. Together, working as a collaborative team, the ultimate goal of care is to ensure the best possible outcome for the woman, her fetus, and her family. (Ricci 648) Risk assessment begins at the first antepartal visit and continues with each subsequent visit because factors may be identified in later visits that were not apparent during earlier visits. For example, as the nurse and client develop a trusting relationship, previously unidentified or unsuspected factors (such as drug abuse or intimate partner violence) may be revealed. Through education and support, the nurse can encourage the client to inform her health care provider of these concerns, and necessary interventions or referrals can be made. Various factors must be considered when determining a woman's risk for adverse pregnancy outcomes, and a comprehensive approach to high-risk pregnancy is needed. For example, prenatal stress and distress have been shown to have significant consequences for the mother, child, and family. Pregnancy-specific stress such as depression, anxiety, and perceived stress may increase the risk for adverse birth outcomes and is associated with preterm births (Staneva et al., 2015). Risks are grouped into broad categories based on threats to health and pregnancy outcome. Current categories of risk are biophysical, psychosocial, sociodemographic, and environmental (Box 19.1) (Cunningham et al., 2014). This chapter describes the major conditions directly related to pregnancy that can complicate a pregnancy, possibly affecting maternal and fetal outcomes. These include 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, and premature rupture of membranes. Chapter 20 addresses preexisting conditions that can complicate a woman's pregnancy as well as populations that are considered to be at high risk. (Ricci 648) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

multiple gestation

Multiple gestation is defined as a pregnancy with two or more fetuses.. This includes twins, triplets, and higher-order multiples such as quadruplets. In the past two decades, the number of multiple gestations in the United States has jumped dramatically because of the widespread use of fertility drugs, older age of women having babies, and the development of assisted reproductive technologies to treat infertility. About one third of live births from assisted reproductive technology result in more than one infant, and twins represent 85% of those multiple-birth children (De Sutter, 2015). In the United States, the overall prevalence of twins is approximately 12 per 1,000, and two thirds are dizygotic (derived from two separate ova [March of Dimes, 2015f]). The increasing number of multiple gestations is a concern because 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 [i.e., recipient]), intrauterine growth restriction, and becoming conjoined twins (Martin, Fanaroff, & Walsh, 2014). The two types of twins are monozygotic and dizygotic (Fig. 19.6). Monozygotic twins develop when a single, fertilized ovum splits during the first 2 weeks after conception. Monozygotic twins also are called identical twins. Two sperm fertilizing two ova produce dizygotic twins, which are called fraternal twins. Separate amnions, chorions, and placentas are formed in dizygotic twins. Triplets can be monozygotic, dizygotic, or trizygotic. FIGURE 19.6 Multiple gestation with twins. A. Dizygotic twins, where each fetus has its own placenta, amnion, and chorion. B. Monozygotic twins, where the fetuses share one placenta, two amnions, and one chorion. p. 684 p. 685 Therapeutic Management When a multiple gestation is confirmed, the woman is followed with serial ultrasounds to assess fetal growth patterns and development. Biophysical profiles along with nonstress tests are ordered to determine fetal well-being. Many women are hospitalized in late pregnancy to prevent preterm labor and receive closer surveillance. During the intrapartum period the woman is closely monitored, with a perinatal team available to assist after birth. Operative delivery is frequently needed due to fetal malpresentation. Nursing Assessment Obtain a health history and perform a physical examination. Be alert for complaints of fatigue and severe nausea and vomiting. Assess the woman's abdomen and fundal height. Typically with a multiple gestation the uterus is larger than expected based on the estimated date of birth. Laboratory test results may reveal anemia. Prepare the woman for ultrasound, which typically confirms the diagnosis of a multiple gestation. Nursing Management During the prenatal period, provide education and support for the woman regarding nutrition, increased rest periods, and close observation for pregnancy complications such as anemia, excessive weight gain, proteinuria, edema, vaginal bleeding, and hypertension. Instruct the woman to be alert for and report immediately any signs and symptoms of preterm labor: contractions, uterine cramping, low back ache, increase in vaginal discharge, loss of mucus plug, pelvic pain, and pressure. With the onset of labor, expect to monitor fetal heart rates continuously. Prepare the woman for an ultrasound to assess the presentation of each fetus to determine the best delivery approach. Ensure that extra nursing staff and the perinatal team are available for any birth or newborn complications. After the babies are born, closely assess the woman for hemorrhage by frequently assessing uterine involution. Palpate the uterine fundus and monitor the amount and characteristics of lochia. Throughout the entire pregnancy, birth, and hospital stay, inform and support the woman and her family. Encourage them to ask questions and verbalize any fears and concerns. (Ricci 684-685) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

placenta previa

Placenta previa is a bleeding condition that occurs during the last two trimesters of pregnancy. In placenta previa (literally, "afterbirth first"), the placenta implants over the cervical os. It may cause serious morbidity and mortality to the fetus and mother. The risk of placenta previa in a first pregnancy is 1 in 400, but it rises to 1 in 160 after one cesarean section; 1 in 60 after two; 1 in 30 after three; and 1 in 10 after four cesarean sections and is associated with potentially serious consequences from hemorrhage, abruption (separation) of the placenta, or emergency cesarean birth (Joy & Temming, 2015). With the rising incidence of cesarean section operations combined with increasing maternal age and more infertility treatments, the number of cases of placenta previa is increasing dramatically. The cesarean section rate must be reduced to decrease maternal; morbidity and mortality. Comprehensive risk assessment, combined with advances in ultrasound, can provide earlier detection of this impaired placental implantation (Wiedaseck & Monchek, 2014). FIGURE 19.4 Classification of placenta previa. A. Low-lying. B. Marginal. C. Partial. D. Complete. Pathophysiology The exact cause of placenta previa is unknown. It is initiated by implantation of the embryo in the lower uterus, perhaps due to uterine endometrial scarring or damage in the upper segment, which may incite placental growth in the unscarred lower uterine segment. Uteroplacental underperfusion may also be present, which may increase the surface area required for placental attachment and may cause the placenta to encroach on the lower uterine segment. With placental attachment and growth, the cervical os may become covered by the developing placenta. 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). Placenta previa is generally classified according to the degree of coverage or proximity to the internal os, as follows (Fig. 19.4): 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 p. 660 p. 661 Therapeutic Management Therapeutic management depends on the extent of bleeding, the amount of placenta over the cervical os, whether the fetus is developed enough to survive outside the uterus, the position of the fetus, the mother's parity, and the presence or absence of labor (Cunningham et al., 2014). With the increase in the rate of previous cesarean sections, the frequency of placenta previa has increased. Most women continue to present in emergency departments, therefore the associated morbidity due to hemorrhage remains high. Efforts should be made to avoid primary cesarean section where possible. In addition, prenatal care and timely diagnosis of placenta previa on ultrasound can decrease the associated morbidity. If the mother and fetus are both stable, therapeutic management may involve expectant ("wait-and-see" or watchful waiting) care. This care can be carried out at home or on an antepartal unit in the health care facility. If there is no active bleeding and the client has ready access to reliable transportation, can maintain bed rest at home, and can comprehend instructions, expectant care at home is appropriate. However, if the client requires continuous care and monitoring and cannot meet the home care requirements, the antepartal unit is the best environment. Nursing Assessment Nursing assessment involves a thorough history, including possible risk factors, and physical examination. Evaluate the client closely for these risk factors: 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 (Archibong & Ahmed, 2015). HEALTH HISTORY AND PHYSICAL EXAMINATION Ask the client if she has any problems associated with bleeding, now or in the recent past. The classical clinical presentation is painless, bright-red vaginal bleeding occurring during the second or third trimester. The initial bleeding usually is not profuse and it 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 arise secondary to the thinning of the lower uterine segment in preparation for the onset of labor. When the bleeding occurs at the implantation site in the lower uterus, the uterus cannot contract adequately and stop the flow of blood from the open vessels. Typically with normal placental implantation in the upper uterus, minor disruptive placental attachment is not a problem, because there is a larger volume of myometrial tissue able to contract and constrict bleeding vessels. Assess the client for uterine contractions, which may or may not occur with the bleeding. Palpate the uterus; typically it is soft and nontender on examination. Auscultate the fetal heart rate; it commonly is within normal parameters. Fetal distress is usually absent but may occur when cord problems arise, such as umbilical cord prolapse or cord compression, or when the client has experienced blood loss to the extent that maternal shock or placental abruption has occurred (King et al., 2015). LABORATORY AND DIAGNOSTIC TESTING To validate the position of the placenta, a transvaginal ultrasound is done. In addition, MRI may be ordered when preparing for delivery because it allows identification of placenta accreta (placenta abnormally adherent to the myometrium), increta (placenta accreta with penetration of the myometrium), or percreta (placenta accreta with invasion of the myometrium to the peritoneal covering, causing rupture of the uterus) in addition to placenta previa. These placental abnormalities, although rare, carry a very high morbidity and mortality rate, possibly necessitating a hysterectomy at delivery. Nursing Management Whether the care setting is in the client's home or in the health care facility, the nurse focuses on monitoring the maternal-fetal status, including assessing for signs and symptoms of vaginal bleeding and fetal distress and providing support and education to the client and her family, including providing information about the diagnostic studies and procedures that are performed. For the majority of women, a cesarean birth will be planned. Nursing Care Plan 19.1 discusses the nursing process for the woman with placenta previa. MONITORING MATERNAL-FETAL STATUS Assess the degree of vaginal bleeding; inspect the perineal area for blood that may be pooled underneath the woman. Estimate and document the amount of bleeding. Perform a peripad count on an ongoing basis, making sure to report any changes in amount or frequency to the health care provider. If the woman is experiencing active bleeding, prepare for blood typing and cross-matching in the event a blood transfusion is needed. (Ricci 660-661) Ricci, Susan. Lippincott CoursePoint for Ricci: Monitor maternal vital signs and uterine contractility frequently for changes. Have the client rate her level of pain using an appropriate pain rating scale. Assess fetal heart rates via Doppler or electronic monitoring to detect fetal distress. 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. Encourage the client to lie on her side to enhance placental perfusion. If the woman has an intravenous (IV) line inserted, inspect the IV site frequently. Alternately, anticipate the insertion of an intermittent IV access device such as a saline lock, which can be used if quick access is needed for fluid restoration and infusion of blood products. Obtain laboratory tests as ordered, including complete blood count (CBC), coagulation studies, and Rh status if appropriate. Administer pharmacologic agents as necessary. Give Rh immunoglobulin if the client is Rh negative at 28 weeks' gestation. Monitor tocolytic (anticontraction) medication if prevention of preterm labor is needed. PROVIDING SUPPORT AND EDUCATION Determine the woman's level of understanding about placenta previa and the associated procedures and treatment plan. Doing so is important to prevent confusion and gain her cooperation. Provide information about the condition and make sure that all information related is consistent with information from the primary care provider. Explain all assessments and treatment measures as needed. Act as a client advocate in obtaining information for the family. 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. If the woman will require prolonged hospitalization or home bed rest, assess the physical and emotional impact that this may have on her. Evaluate her coping mechanisms to help determine how well she will be able to adjust and adhere to the treatment plan. Allow the client to verbalize her feelings and fears, and provide emotional support. Also, provide opportunities for distraction—educational videos, arts and crafts, computer games, reading books—and evaluate the client's response. In addition to the emotional impact of prolonged bed rest, thoroughly assess the woman's skin to prevent skin breakdown and to help alleviate her discomfort secondary to limited physical activity. Instruct the woman in appropriate skin care measures. 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. Teach the client and family about any signs and symptoms that should be reported immediately. In addition, prepare the woman for the possibility of a cesarean birth. The woman must notify her health care provider about any bleeding episodes or backaches (may indicate preterm labor contractions) and must adhere to the prescribed bed rest regimen. To ensure adherence to the plan and a positive outcome, the client needs to be aware of and understand the rationales for the ongoing observations. (Ricci 663-664) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.

gestational hypertension

The gestational hypertension category is used in women with nonproteinuric hypertension of pregnancy, in which the pathophysiologic disturbances of the preeclampsia syndrome do not develop before giving birth. Gestational hypertension is a temporary diagnosis for hypertensive pregnant women who do not meet the criteria for preeclampsia (both hypertension and possibly proteinuria) or chronic hypertension (hypertension first detected before the 20th week of pregnancy). Gestational hypertension is characterized by hypertension (>140/90) without proteinuria after 20 weeks' gestation resolving by 12 weeks' postpartum (Magowan, Owen, & Thomson, 2014). Previously, gestational hypertension was known as pregnancy-induced hypertension or toxemia of pregnancy, but these terms are no longer used. Gestational hypertension is 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, in women known to be normotensive prior to this time and prior to pregnancy (King et al., 2015). Gestational hypertension can be differentiated from chronic hypertension, which appears before the 20th week of gestation; or hypertension before the current pregnancy, which continues after the woman gives birth. A recent study found that progesterone supplementation during the first trimester significantly reduced the incidence of gestational hypertension and fetal distress in primigravida women. This supplementation might be a future therapy with addition studies to validate it (Zainul et al., 2014 (Ricci 672) Ricci, Susan. Lippincott CoursePoint for Ricci: Essentials of Maternity, Newborn and Women's Health Nursing, 4th Edition. CoursePoint, 10/1/2016. VitalBook file.