Ch 28
Nursing care for miscarriage
Focuses on physiologic stabilization
Complications with placenta previa
Hemorrhage which can lead to hysterectomy
Meds for hemorrhaging moms
Pitocin, ergot, hemabate, methergine
Placental abruption perinatal morbidity
20-30% mortality rate; more than 50% death
Habitual miscarriage or recurrent spontaneous abortion (RSA)
3 or more consecutive pregnancy losses before 20 weeks gestation; causes may be related to chromosomal abnormality
Tx of placenta previa
Delivery if needed, if not then bed rest with bathroom privileges, ultrasound every 2-3wks, NST once weekly
Maternal complications/outcomes with abruption placentae
1% mortality rate; Hemorrhage, hypovolemic shock, hypofibrinogenemia, and thrombocytopenia are associated with severe abruption.
Nursing interventions for DIC
Assess s/s of bleeding; assess signs of complications from blood/blood products administered; administer fluid or blood as ordered; cardiac/hemodynamic monitoring; protect from injury; monitor urinary output (renal failure is a consequence of DIC); VS frequently; if before birth: continuous fetal monitoring, side-lying tilt to maximize blood flow to uterus, oxygen via nonrebreather @ 8-10L/min
Medical management of threatened miscarriage
Depends on classification of miscarriage & s/s; threatened miscarriages managed with bed rest & supportive care; follow-up tx depends on whether the threatened miscarriage progresses to actual miscarriage or symptoms subside & pregnancy remains intact
Ectopic pregnancy
Fertilized ovum is implanted outside the uterine cavity; women are less likely to have successful subsequent pregnancies after ectopic pregnancy; leading cause of infertility; may occur in tube, abdomen, ovary, or cervix; 95% in tube
Complete miscarriage
All fetal tissue is passed, cervix is closed, may be slight bleeding, mild uterine cramping may be present
Incidence & Etiology of spontaneous abortion
Approx. 10-15% of all clinically recognized pregnancies in US end in miscarriage; early miscarriage is before 12wks-50% due to chromosomal abnormality; majority of miscarriages occur early, possible causes: endocrine imbalance, immunologic factors, systemic disorders & genetic factors; varicella infection in 1st trimester increases risk
Partial hydatidiform mole
Arrangement that occurs as result of 2 sperm fertilizing an apparently normal ovum
Incompetent cervix management: Cerclage
Bed rest, pessaries, antibodies, antinflammatory drugs and progesterone supplementation . A cervical cerclage may be performed. During gestation, a McDonald cerclage, a band of homologous fascia or nonabsorbable ribbon (Mersilene), may be placed around the cervix beneath the mucosa to constrict the internal os of the cervix (Fig. 28-2). A cerclage procedure can be classified according to time, or whether it is elective (prophylactic), urgent, or emergent. Cervical length must be 20-25mm to be able to have a cerclage; will not put one in past 24wks; cut cerclage @ 37 wks to allow labor
Hydatidiform Mole/Molar Pregnancy
Benign proliferative growth of placental trophoblast in which the chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in a grape-like cluster; type of gestational trophoblast disease with no viable fetus; may be further categorized as complete or partial
Antepartal hemorrhagic disorders causes
Bleeding in pregnancy jeopardizes maternal & fetal well being; maternal blood loss decreases oxygen capacity & increases risk for: hypovolemia, anemia, infection, pre-term labor, adverse oxygen delivery; fetal risks: blood loss, anemia, hypoxemia, hypoxia, anoxia, preterm labor
Clinical manifestations of placenta previa
Characterized by painless, bright red vaginal bleeding in 2nd and 3rd trimester; most cases are diagnosed by ultrasound before significant vaginal bleeding occurs. This bleeding is associated with the disruption of placental blood vessels that occurs with stretching and thinning of the lower uterine segment. Dx with ultrasound, no vaginal exams
Dx of abruptio placentae
Clinical dx; 50% can't be identified via ultrasound; dx confirmed after birth by inspection of placenta;
DIC Management
Correction of underlying cause; volume replacement; blood component therapy; optimization of oxygenation & perfusion status; continued reassessment of labs; Vitamin K & recombinant activated factor VII may be used
Lab results for DIC
Decreased: platelets, fibrinogen, factor V, factor VII; prolonged: PT, PTT; increased: fibrin degradation products, d-dimer tests; red blood smear shows fragmented cells
S/S of miscarriage
Depend on the duration of pregnancy; presence of uterine bleeding, uterine contractions or abdominal pain is an ominous sign during early pregnancy & must be considered a threatened miscarriage until proven otherwise; before 6wks woman may report a heavy menstrual flow; between 6-12wks causes moderate discomfort & blood loss; after 12wks more severe pain (similar to labor) because fetus must be expelled
Surgical management of ectopic pregnancy
Depends on location/cause, extent of tissue involvement & woman's desires regarding future fertility; one option is removal of entire tube (salpingectomy), if tube hasn't ruptured & woman desires fertility, salpingostomy may be performed-makes incision over pregnancy site & products of conception are carefully removed, incision is left to close by secondary intention instead because it results in less scarring; birth control for at least 3mos
Management of placental abruption
Depends on severity of blood loss & fetal maturity/status; fetus less than 34wks & both woman & fetus are stable, expectant management can be implemented-woman is closely monitored because abruption could extend any time, regularly assess fetus for sign of appropriate growth
Premature separation of placenta (abruption placentae)
Detachment of part or all of the placenta from implantation site; separation occurs in the area of the decidua basalis after 20wks of pregnancy & before birth; accounts for significant maternal and fetal morbidity and mortality
Complete placenta previa
During transvaginal ultrasound, the placenta totally covers the cervical os
Clinical manifestations of hydatidiform mole
Early stage: can't be distinguished from normal pregnancy; later: vaginal bleeding, dark brown/prune juice vaginal discharge or bright red which may be scant or profuse, may continue for a few days or intermittently for weeks, uterus may be larger than expected; common findings include anemia, excess N/V, abdominal cramps; may pass vesicles which are frequently avascular edematous villi from uterus; preeclampsia occurs with larger moles & occurs earlier than usual in pregnancy, hyperthyroidism is another complication
Tubal pregnancy
Ectopic pregnancy that occurs in the uterine tube; most commonly in ampulla
Marginal placenta previa
Edge of placenta is seen on transvaginal ultrasound to be 2.5cm or closer to internal cervical os
Placenta previa risk factors
History of cesarean birth, advanced maternal age, multiparity (due to larger placental area), history of prior curettage, smoking
Active management for placental abruption
Immediate birth if fetus is at term or bleeding is moderate-severe; one large bore IV line should be started; monitor maternal VS to observe for signs of declining hemodynamic status (increase P and decreased BP); serial labs: hgb, hct, clotting; indwelling catheter for urine output monitoring, blood & fluid volume replacement may be needed; continuous external fetal monitoring; vaginal birth is usually feasible & desirable especially if fetal death
Symptoms of a threatened miscarriage
Include spotting of blood but with cervical os closed; mild uterine cramping may be present
Risk factors for placental abruption
Maternal HTN, cocaine use, blunt abdominal trauma
Tocolytics
May be given prophylactically to prevent uterine contractions & further dilation of cervix
Clinical manifestations of placental abruption
May be partial or complete-sx vary with degree of separation; with c-section blood clots may be noticed on entry into uterus; classic sx include vaginal bleeding, abdominal pain, uterine tenderness, contractions, board-like abdomen; there are different grades
Ectopic pregnancy treatment
Medical management involves giving methotrexate to dissolve the tubal pregnancy, this destroys rapidly dividing cells & shouldn't be given to those taking additional folic acid or drinking alcohol because these increase risk of rupture; requires post-treatment lifestyle restrictions & monitoring;
Symptoms of inevitable & incomplete miscarriages
Moderate-heavy amount of bleeding with open cervical os; tissue may be present with bleeding; mild-severe uterine cramping; inevitable miscarriage often accompanied by ROM & cervical dilation; passage of products of conception will occur; incomplete miscarriage involves expulsion of fetus with retention of placenta—cant prevent
Bleeding with placenta previa
Mom can lose up to 40% of blood volume without showing signs of shock; decreased urinary output may be a better indicator of acute blood loss than VS
Possible reasons for rise in ectopic pregnancy
More sensitive diagnostic tests including transvaginal ultrasound & hCG measurement; increased incidence of STDs, tubal infection/damage, contraceptive methods that predispose failures to be ectopic (IUD), tubal sterilization methods, assisted reproductive techniques & tubal surgeries
Management of hydatidiform mole
Most abort spontaneously; suction curettage offers safe, rapid, effective method of evacuation; induction of labor is not recommended; give RhoGAM after if mom is Rh-; provide support & education regarding the disease process & future pregnancies/fertility
Late miscarriage
Occurs between 12-20wks; usually results from maternal causes, such as advancing maternal age and parity, premature dilation of the cervix and other anomalies of the reproductive tract, inadequate nutrition, and recreational drug use, obesity, and stressful life events
Incompetent cervix aka recurrent premature dilation of cervix
Passive & painless dilation of cervix during 2nd trimester; assumes an "all or nothing" role for the cervix, it is either competent or incompetent; dx with 1 or 2 pregnancy losses & short labors
Miscarriage/Spontaneous abortion
Pregnancy that ends as a result of natural causes before 20wks; 20wk marker considered the point of viability when a fetus may survive in extrauterine environment; fetal weight less than 500g may also be used to define abortion
Nursing Alert with Miscarriage
Procedures for disposition of fetal remains very from hospital to hospital & state to state; nurse should know the usual procedures in his/her hospital
Fibrinolytic system
Process through which fibrin is split into fibrinolytic degradation products and circulation is restored
Medical management of miscarriage
Prostaglandin meds (misoprostol/cytotec) may be given orally or vaginally & is usually effective in completing the miscarriage within 7d; dilation & curettage (D&C) is surgical procedure in which cervix is dilated & a curette is inserted to scrape the uterine walls & remove uterine contents; D&C is commonly performed to treat inevitable & incomplete miscarriage; nurse reinforces explanation, answers questions/concerns & preps woman for surgery; IV oxytocin afterward to prevent hemorrhage-may use methergine or hemabate if oxytocin is ineffective
Incompetent cervix Dx
Reduce cervical competence is the diagnosis and is seen on ultrasound, it can be accompanied by cervical funneling ((breaking) or effacement if the internal os.
Clinical manifestations of ectopic pregnancy after rupture
Referred shoulder pain; signs of shock, such as faintness and dizziness, related to the amount of bleeding in the abdominal cavity and not necessarily related to obvious vaginal bleeding. An ecchymotic blueness around the umbilicus (Cullen sign), indicating hematoperitoneum, may also develop in an undiagnosed, ruptured intraabdominal ectopic pregnancy.
Missed miscarriage
Refers to a pregnancy in which the fetus has died but all products of conception are retained in utero for up to several weeks; may be diagnosed by ultrasonic exam after uterus stops increasing in size or decreases in size; no bleeding or cramping may be present & cervical os remains closed; requires D&C
Complete hydatidiform mole
Results from fertilization of an egg in which nucleus has been lost or inactivated
Follow up for surgery for ectopic pregnancy
RhoGAM may be necessary; encourage to share feelings/concerns related to loss; report suspected pregnancy immediately due to increased risk of subsequent ectopic pregnancy
Abdominal exam in placenta previa
Soft, relaxed, non-tender uterus with normal tone; fetal presentation is usually breech or oblique
Clinical manifestations of DIC
Spontaneous bleeding from gums/nose; oozing, excess bleeding from venipuncture site/IV access site/catheter insertion site; petechiae where pressure was placed (around BP cuff); other signs of bruising; hematuria; GI bleed; tachycardia; diaphoresis
Nursing alert for Methotrexate
The woman on methotrexate therapy who drinks alcohol and takes vitamins containing folic acid (such as prenatal vitamins) increases her risk of having side effects of the drug or exacerbating the ectopic rupture
Care management for early pregnancy bleeding
Thorough assessment should be performed; lab findings are characteristic of miscarriage; evaluation of hCG is used in the dx of pregnancy & pregnancy loss along with progesterone
Nursing alert hydatidiform mole
To avoid confusion in regard to rising levels of hCG that are normal in pregnancy but could indicate GTD, pregnancy should be avoided during the follow-up assessment period. Any contraceptive method except an IUD is acceptable. Oral contraceptives are preferred because they are highly effective.
Dx of hydatidiform mole
Transvaginal ultrasound, serum hCG levels
Home care for Incompetent cervix
Woman must understand the importance of activity restriction at home & need for close observation & supervision; important to take oral tocolytic meds & know the expected response/possible side effects; with home uterine monitoring woman is taught to apply contraction monitor & transmit monitor tracing by telephone to health care provider; woman must be aware that strong contractions less than 5min apart, ROM, severe perineal pressure & urge to push will warrant immediate transfer to hospital; if fetus is born premature or isn't viable, provide grief support and/or anticipatory guidance
Etiologic factors of incompetent cervix
history of previous cervical lacerations during childbirth, excessive cervical dilation for curettage or biopsy, or the woman's mother's ingestion of diethylstilbestrol (DES)during pregnancy with the woman. Multiple gestation may provide an additional stress on the cervix but alone does not produce cervical incompetency or justify prophylactic cervical cerclage A short cervix (less than 25 mm in length) is indicative of reduced cervical competence
S/S of ectopic pregnancy
dull, achy pain that progresses to a sharp, stabbing pain usually on side that the ectopic pregnancy has occurred; cycle 1-2wks late or lighter than usual; often complain of mild-moderate dark red or brown intermittent bleeding; dx & surgically take care of it before it ruptures is the goal; if it ruptures they'll arrive to ER complaining of shoulder pain along with abdominal pain due to build-up of blood in peritoneal cavity where rupture occurred—This is an emergency, can go into shock, may notice ecchymosis/blueness around umbilicus (Cullen Sign); screen by monitoring HcG levels (will be high), transvaginal ultrasound, may also draw progesterone level-if less than 5 indicates ectopic
Follow up for hydatidiform mole
frequent physical and pelvic examinations along with weekly measurements of the β-hCG level until the level decreases to normal and remains normal for 3 consecutive weeks. Monthly measurements are then taken for 6 months. The follow-up assessment period usually continues for a year. During that time, a rising β-hCG level and an enlarging uterus may indicate GTD; birth control for up to 6 months after pregnancy & monitor hCG levels for 1 year—goal is a level of 0 for at least 3 consecutive weeks during that year, if hCG continues to increase may indicate cancer
DIC in pregnancy
most often triggered by the release of large amounts of tissue thromboplastin, which occurs in placental abruption (the most common cause of severe consumptive coagulopathy in obstetrics) and in the retained dead fetus syndrome and the anaphylactoid syndrome of pregnancy (amniotic fluid embolus). Severe preeclampsia, HELLP syndrome, and gram-negative sepsis can trigger DIC
Disseminated intravascular coagulation (DIC)
pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both, and clotting; never a primary diagnosis; results from some problem that triggered the clotting cascade, either extrinsically, by the release of large amounts of tissue thromboplastin, or intrinsically, by widespread damage to vascular integrity
Prophylactic cerclage
placed at 11 to 15 weeks of gestation, after which the woman is told to refrain from intercourse. She is monitored during the course of her pregnancy with ultrasound scans to assess for cervical shortening and funneling. The cerclage is electively removed when the woman reaches 37 weeks of gestation, or it may be left in place and a cesarean birth performed
Placenta previa
placenta is implanted in the lower uterine segment such that is completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces. near or over the internal cervical os.
Incompetent Cervix Etiology
starts opening on its own before it is supposed to; on bed rest, ATB, anti-inflammatory, progesterone, if cervix continues to try to open may put in a cervical cerclage
Normal clotting in pregnancy
stops the flow of blood from injured vessels, in part through the formation of insoluble fibrin, which acts as a hemostatic platelet plug. The phases of the coagulation process involve an interaction of the coagulation factors in which each factor sequentially activates the factor next in line, the "cascade effect" sequence
Clinical manifestations of ectopic pregnancy
three most classic symptoms: (1) abdominal pain, (2) delayed menses, and (3) abnormal vaginal bleeding (spotting) that occurs approximately 6 to 8 weeks after the last normal menstrual period; Abdominal pain occurs in almost every case. It usually begins as a dull, lower quadrant pain on one side. The discomfort can progress from a dull pain to a colicky pain when the tube stretches, to sharp, stabbing pain; Up to 90% of women with an ectopic pregnancy report a period that is delayed 1 to 2 weeks or is lighter than usual, or an irregular period. Mild to moderate dark red or brown intermittent vaginal bleeding occurs in up to 80% of women
Physical exam with placental abruption
usually reveals abdominal pain, uterine tenderness, and contractions. The fundal height may be measured over time because an increasing fundal height indicates concealed bleeding. Approximately 60% of live fetuses exhibit abnormal (nonreassuring) FHR patterns, and elevated uterine resting tone may also be noted on the monitor tracing