HYPEREMESIS GRAVIDARUM

Definition:

 Hyperemesis gravidarum is extreme, persistent nausea and vomiting during pregnancy. It can
lead to dehydration, weight loss, and electrolyte imbalances. Morning sickness is mild nausea
and vomiting that occurs in early pregnancy.

https://medlineplus.gov/ency/article/001499.htm

 Nausea and vomiting is a common occurrence in pregnancy, with at least 70 percent of women
experiencing some form of it, according to the March of Dimes. It’s typically referred to as
morning sickness, though it can happen at any time of day.right up arrow
 But sometimes the symptoms are so extreme — severe, persistent nausea, vomiting, and weight
loss during pregnancy — that it may be diagnosed as a less common disorder known as
hyperemesis gravidarum.
 Hyperemesis gravidarum can lead to dehydration and nutrient loss, affecting both the health of
a pregnant woman and the fetus she's carrying. The nausea can be debilitating, interfering with
daily activities and quality of life.right up arrow It usually subsides at between 14 and 20 weeks
of gestation.right up arrow
 Women with hyperemesis gravidarum have an increased risk of preterm labor and
preeclampsia, among other complications, but the risk is low.right up arrow

https://www.everydayhealth.com/hyperemesis-gravidarum/guide/

Causes and Risk Factors of Hyperemesis Gravidarum

 While there is no proven cause of hyperemesis gravidarum, a number of possibilities have been
proposed and studied over the years. The most recent research points to genetics and the role
that the placenta and appetite genes GDF15 and IGFBP7 may play.right up arrow A study
implicating these genes, published in March 2018 in Nature Communications, noted that more
research into a causal relationship is necessary.right up arrow
 It has also been proposed that rising levels of the hormone human chorionic gonadotropin
(HCG) in pregnancy contribute to hyperemesis gravidarum.right up arrow And higher levels of
estrogen and progesterone have been suspected to play a role in nausea symptoms and
digestive issues.right up arrow
Other associations include:
 Increase in blood levels of thyroxine (a growth-regulating hormone produced by the thyroid),
which has been documented in up to 73 percent of hyperemesis gravidarum cases, according to
the HER Foundationright up arrow
 Abnormal tissue growth in the uterus, called a molar pregnancyright up arrow
  The following factors may increase your chances of getting hyperemesis gravidarum:
 Having the condition during a previous pregnancy
 Other women in your family developed the conditionright up arrow
 Multiple pregnancyright up arrow
 First-time pregnancy
 Obesity
 Younger maternal age; risk may decrease after age 35right up arrow

https://www.everydayhealth.com/hyperemesis-gravidarum/guide/

Signs and Symptoms of Hyperemesis Gravidarum

The primary symptom of hyperemesis gravidarum is severe nausea and vomiting, meaning more than
four episodes a day.right up arrow This vomiting can lead to:

 Feeling dizzy, lightheaded, and faint

 Losing more than 5 percent of body weight
 Becoming dehydrated, with signs of dehydration such as dark urine and dry skin
 Electrolyte and nutritional imbalances
 Increased salivationright up arrow
 Rapid heart rateright up arrow
 Low blood pressure
 Headaches
 Yellowing of the skin and eyes (jaundice)
 Depression and anxietyright up arrow

https://www.everydayhealth.com/hyperemesis-gravidarum/guide/

Diagnostic Exam

 A complete blood count

 A serum electrolyte test (blood test)
 Ketones urine test (when the body isn't getting enough nutrients, it begins to break down fat,
which leads to an increase in waste products known as ketones)right up arrow
 An ultrasound can confirm if you are carrying twins or multiples and can diagnose a molar
pregnancy.right up arrow
https://www.everydayhealth.com/hyperemesis-gravidarum/guide/

Goal and priorities

INCOMPETENT CERVIX

Definition:

 An incompetent cervix, also called a cervical insufficiency, occurs when weak cervical tissue
causes or contributes to premature birth or the loss of an otherwise healthy pregnancy.
 Before pregnancy, your cervix — the lower part of the uterus that opens to the vagina — is
normally closed and firm. As pregnancy progresses and you prepare to give birth, the cervix
gradually softens, decreases in length (effaces) and opens (dilates). If you have an incompetent
cervix, your cervix might begin to open too soon — causing you to give birth too early.
 An incompetent cervix can be difficult to diagnose and treat. If your cervix begins to open early,
or you have a history of cervical insufficiency, your doctor might recommend preventive
medication during pregnancy, frequent ultrasounds or a procedure that closes the cervix with
strong sutures (cervical cerclage).
https://www.mayoclinic.org/diseases-conditions/incompetent-cervix/symptoms-causes/syc-
20373836#:~:text=An%20incompetent%20cervix%2C%20also%20called,is%20normally
%20closed%20and%20firm.

Risk Factors

 Cervical trauma. Some surgical procedures used to treat cervical abnormalities associated with
an abnormal Pap smear can result in cervical insufficiency. Other surgical procedures such as a
D&C could also be associated with cervical insufficiency. Rarely, a cervical tear during a previous
labor and delivery could be associated with an incompetent cervix.
 Race. Black women seem to have a higher risk of developing cervical insufficiency. It isn't clear
why.
 Congenital conditions. Uterine abnormalities and genetic disorders affecting a fibrous type of
protein that makes up your body's connective tissues (collagen) might cause an incompetent
cervix. Exposure to diethylstilbestrol (DES), a synthetic form of the hormone estrogen, before
birth also has been linked to cervical insufficiency.
https://www.mayoclinic.org/diseases-conditions/incompetent-cervix/symptoms-causes/syc-
20373836#:~:text=An%20incompetent%20cervix%2C%20also%20called,is%20normally
%20closed%20and%20firm.
 Increased maternal age. The muscles around the cervix start to slowly lose its elasticity because
of increasing age, and could contribute to the weakening of the cervix.
 Congenital structural defects. There are defects might contribute to the cervix’ incapability of
holding in the fetus.
 Trauma to the cervix. Any trauma experienced by the cervix could weaken the muscles
surrounding it, thus leading to its premature dilation.
Signs And Symptoms

 A sensation of pelvic pressure

 A new backache
 Mild abdominal cramps
 A change in vaginal discharge
 Light vaginal bleeding

https://www.mayoclinic.org/diseases-conditions/incompetent-cervix/symptoms-causes/syc-20373836

 Show. This is a pink-tinged vaginal fluid that is discharged from the vaginal opening as a sign that
the cervix has dilated.
 Increased pelvic pressure. The fetus is already descending, causing a pressure felt by the mother
on her pelvis.
 Cervical dilation. Upon inspection of the physician, the cervix would show dilation.

Diagnostic test

 Transvaginal ultrasound. Your doctor may use transvaginal ultrasound to evaluate the length of
your cervix and to check if membranes are protruding through the cervix. During this type of
ultrasound, a slender transducer is placed in your vagina to send out sound waves that generate
images on a monitor.
 Pelvic exam. Your doctor will examine your cervix to see if the amniotic sac has begun to
protrude through the opening (prolapsed fetal membranes). If the fetal membranes are in your
cervical canal or vagina, this indicates cervical insufficiency. Your doctor will also check for
contractions and, if necessary, monitor them.
 Lab tests. If fetal membranes are visible and an ultrasound shows signs of inflammation but you
don't have symptoms of an infection, your doctor might test a sample of amniotic fluid
(amniocentesis) to diagnose or rule out an infection of the amniotic sac and fluid
(chorioamnionitis).

Nursing Diagnosis

 Anxiety related to impending loss of pregnancy as evidenced by premature dilation of the cervix.
 Acute pain related to dilation of fallopian tube secondary to uterine pregnancy
 Risk for maternal injury related to premature cervical dilation as manifested by threatened
abortion

Nursing Interventions

Nursing Intervention (ADPIE)

 Obtain gynecological history from patient

 Assess for vaginal discharge; note volume, color and consistency
 Screen patient for any history of substance abuse.
 Encourage patient to decrease physical activity, avoid exercise and intercourse and take
frequent breaks
 Administer medications as appropriate
 Assist with amniocentesis
 Prepare patient for cerclage placement
 Provide nutrition and lifestyle education
 Determine any factors that further contribute to the anxiety of the woman so it could be
avoided.
 Monitor vital signs to determine any physical responses of the patient that could affect her
condition.
 Convey empathy and establish a therapeutic relationship to encourage client to express her
feelings.
 Provide accurate information about the situation to help client back into reality.

Rationale

 Information regarding previous pregnancies, difficult births, gynecological treatments, abnormal

Pap smears and other history can help determine risk
 Patients often report a change in vaginal discharge from clear or white to pink or tan, or that
there is an increase of discharge and vaginal bleeding
 Certain medications and substances may cause premature dilation of the cervix.
 Continued pressure on the cervix can cause dilation to progress, thus increasing the risk of
preterm labor.
 Tocolytics and Steroids may be given to help stop preterm labor and help the baby’s lungs
mature faster
 Analgesics (acetaminophen) may be given following cerclage procedure
 Amniocentesis is performed by doctor, but may be required to determine if patient is eligible for
cerclage placement.
 Cervical cerclage is done as an outpatient procedure, usually vaginally to tie the cervix closed.
Stitches removed third-trimester pre-labor maintain healthy weight gain during pregnancy and
avoid smoking or drinking alcohol.

Goals and Priorities

Heath teaching

Lifestyle and home remedies

 Restricting sexual activity or limiting certain physical activities.

 Seek regular prenatal care. Prenatal visits can help your doctor monitor your health and your
baby's health. Mention any signs or symptoms that concern you, even if they seem silly or
unimportant.
 Eat a healthy diet. During pregnancy, you'll need more folic acid, calcium, iron and other
essential nutrients. A daily prenatal vitamin — ideally starting a few months before conception
can help fill any dietary gaps.
 Gain weight wisely. Gaining the right amount of weight can support your baby's health. A weight
gain of 25 to 35 pounds (about 11 to 16 kilograms) is often recommended for women who have
a healthy weight before pregnancy.
 Avoid risky substances. If you smoke, quit. Alcohol and illegal drugs are off-limits, too. In
addition, get your doctor's OK before taking any medications or supplements — even those
available over-the-counter.