This document discusses several gestational conditions including hyperemesis gravidarum, ectopic pregnancy, gestational trophoblastic disease, and spontaneous abortion or miscarriage. It provides details on the symptoms, causes, assessment, and nursing management of hyperemesis gravidarum. It also defines threatened miscarriage, imminent miscarriage, and different types of miscarriage and outlines assessments and interventions for spontaneous miscarriage.
This document discusses several gestational conditions including hyperemesis gravidarum, ectopic pregnancy, gestational trophoblastic disease, and spontaneous abortion or miscarriage. It provides details on the symptoms, causes, assessment, and nursing management of hyperemesis gravidarum. It also defines threatened miscarriage, imminent miscarriage, and different types of miscarriage and outlines assessments and interventions for spontaneous miscarriage.
This document discusses several gestational conditions including hyperemesis gravidarum, ectopic pregnancy, gestational trophoblastic disease, and spontaneous abortion or miscarriage. It provides details on the symptoms, causes, assessment, and nursing management of hyperemesis gravidarum. It also defines threatened miscarriage, imminent miscarriage, and different types of miscarriage and outlines assessments and interventions for spontaneous miscarriage.
This document discusses several gestational conditions including hyperemesis gravidarum, ectopic pregnancy, gestational trophoblastic disease, and spontaneous abortion or miscarriage. It provides details on the symptoms, causes, assessment, and nursing management of hyperemesis gravidarum. It also defines threatened miscarriage, imminent miscarriage, and different types of miscarriage and outlines assessments and interventions for spontaneous miscarriage.
Semifinals: Gestational Conditions | April 13, 2023
Quezon, Britney Kim E. | BSN 2-L GESTATIONAL CONDITIONS Therapeutic Nursing Management Late Miscarriage 1. Hyperemesis Gravidarum Goal: Hospitalization is required for severe symptoms of Hyperemesis - spontaneous miscarriage happens after 16 wks 2. Ectopic Pregnancy Gravidarum which intravenous hydration and correction of metabolic (16-24 wks AOG) 3. Gestational Trophoblastic Disease (Hmole) imbalances are needed. Cause of Spontaneous Miscarriage 4. Incompetent Cervix a. Implement Common N/V Nursing Interventions Abnormal fetal development 5. Spontaneous Abortion - Recommend smaller, frequent meals; include salty food Immunologic factor 6. Placenta Previa - Suggest crackers before arising Implantation abnormalities 7. Abruptio Placenta - Avoid spicy and fried foods 8. Premature Rupture of Membrane - Advise to remain upright for 30 min after eating Insufficient levels of progesterone 9. Pregnancy Induced Hypertension - Discuss use of antacids with primary care provider Systemic infection HYPEREMESIS GRAVIDARUM b. Treatment and Goals for Hospitalized Client Ingestion of a teratogenic drug Otherwise known as Pernicious vomiting - Conrtol vomiting ( anti-emetics i.e. Reglan) Ingestion of alcohol A serious condition in which nausea and vomiting of - NPO Assessment of Spontaneous Miscarriage pregnancy has become prolonged past week 12 AOG or is - Progress to small feedings every 2-3 hours, then a. Vaginal Spotting with Slight Cramping – the presenting symptom so severe that dehydration, ketonuria, and significant weight advanced to a soft diet, then to a normal diet. Assessment factor of vaginal bleeding during pregnancy: loss occur within the first 12 weeks of pregnancy - Quiet environment confirmation of pregnancy - Intake & Output pregnancy length in weeks Cause: unknown - Adequate nutrition-nasogastric tube feeding may be Suggested Causative Factors necessary duration of bleeding High levels of HCG in early pregnancy Therapeutic Management intensity (amount of bleeding occurred) Metabolic or nutritional deficiencies a) Pharmacology frequency Thyroid dysfunction - sedatives associated symptoms Ambivalence toward the pregnancy and family-related stress - antiemetics action Most common in primigravid clients - correction of fluid and electrolyte imbalances blood type Assessment - IV lactated ringers Types of Miscarriage Nausea most pronounced on arising; however can occur at b) Complications I. Threatened MIscarriage other times during the day - dehydration s/s: vaginal spotting w/ slight cramping (scanty at first, bright red) - electrolyte imbalance Persistent vomiting - severe weight loss no cervical dilation Weight loss Actions/Implementation: - metabolic alkalosis Signs of dehydration (decreased urinary output, rapid pulse assess fetal viability (FHR, ultrasound) BLEEDING DURING PREGNANCY rate, low-grade fever, dry skin, sunken eyes, dry lips) 1. Spontaneous Abortion / Miscarriage test blood for HCG level (a double result means placenta is Electrolyte imbalances (↓ Na, K, chloride; hypokalemic 2. Ectopic Pregnancy still intact) alkalosis) 3. Gestational Trophoblastic Disease avoidance of strenuous activity for 24-48 hours Ketonuria 4. Premature Cervical Dilation complete bed rest may not be necessary Increased hematocrit levels 5. Placenta Previa offer emotional support Diagnostic Tests and Lab 6. Abruptio Placenta woman can resume her activities once bleeding stops after SPONTANEOUS ABORTION / MISCARRIAGE: (1st Trimester Hematocrit, hemoglobin 48 hours Bleeding) Electrolytes coitus is restricted for 2 wks after the bleeding episode Abortion II. Imminent (Inevitable) Miscarriage Urine protein and acetone - a medical term for any interruption of a pregnancy before a Nursing Diagnosis A threatened miscarriage becomes imminent if uterine contractions fetus is viable and cervical dilation occur Imbalance nutrition, less than body requirements, related to - viable fetus: a fetus more than 20-24 wks of gestation or one s/s: vaginal spotting with cramping prolonged vomiting that weighs at least 500g positive uterine contraction Risk for deficient fluid volume related to vomiting secondary Miscarriage cervical dilation to hyperemesis gravidarum - an interruption of pregnancy that occurs spontaneously loss of some tissues (products of conception) Early Miscarriage Action/Implementation: - interruption of pregnancy occurs spontaneously before 16 wks Advise woman to come to the hospital if uterine contractions and cramping happen. NCM 109: MCN Semifinals: Gestational Conditions | April 13, 2023 Quezon, Britney Kim E. | BSN 2-L Assess/Monitor spontaneous vaginal bleeding and cramping Position woman flat and massage the uterine fundus. CVP or Pulmonary artery catheterization Save expelled tissues/clots. Prepare patient for D&C. D&C Count perineal pads to evaluate blood loss Administer BT as prescribed. Oxygen and other ventilatory support Monitor vital signs Prepare replacement of fibrogen or another clotting factor as Pharmacology: Provide IV fluids required/prescribed. a. Antibiotic (Penicillin, Gentamicin, clindamycin) Prepare client for dilatation and evacuation as prescribed. Teach patient the importance of taking methylergonovine b. Tetanus toxoid III. Complete Miscarriage maleate, including the dosage. c. Dopamine & Digitalis The uterine products of conception are expelled spontaneously Offer/provide emotional support. iv. Isoimmunization without any assistance ii. Infection - the woman is Rh negative against Rh positive fetal blood s/s: - its possibility is minimal if pregnancy loss occurs over a short which may enter the maternal circulation - vaginal spotting and cramping (bleeding slows within 2 hrs, time, bleeding is self-limiting, and instrumentation is less - the production of maternal antibodies against Rh positive and stops within a few days after the passage of the uterine - increase possibility may happen for women who have lost a blood products large amount of blood management: - cervical dilation - infectious organism: Escherichia coli after a miscarriage, all women with Rh negative blood should - uterine contractions s/s: receive Rh (D antigen) immune globulin (RhIg) to prevent - passage of complete uterine contents (fetus, membranes, fever (38ºC) building-up antibodies in the event the conceptus was Rh positive and placenta) abdominal pain or tenderness IV. Incomplete Miscarriage nursing problem: foul vaginal discharge A part of the conceptus is expelled (usually the fetus), but the implementation: powerlessness or anxiety r/t loss of pregnancy membrane or placenta is retained in the uterus Teach women the danger signs of infection. sadness/grief Complication: maternal hemorrhage Instruct woman to wipe her perineal area from front to back The physician usually will prescribe dilatation and curettage after voiding and after defecation. ECTOPIC PREGNANCY: 1st Trimester Bleeding to evacuate the placental remains, clots, and other tissues. Main problem: implantation occurs outside the uterine cavity Caution her not to use tampons to control vaginal discharge. Do not give false hopes, the woman has to know that her Common Site: pregnancy is lost Encourage more intake of fluids. a. Fallopian Tube (95%) – tubal rupture occurs before 12 wks V. Missed Miscarriage Provide IV if required/as prescribed Ampulla (80%) otherwise called as early pregnancy failure iii. Septic Abortion Isthmus (12%) - an abortion that is complicated with infection Interstitial or fimbrial (8%) the fetus dies in the uterus but is not expelled - infection occurs more frequently in women who have tried to s/s: b. Cervical self-abort or were aborted illegally using a non-sterile c. Abdominal - absence of fetal heart sound instrument d. Ovarian - no increase in size AEB; no increase in fundal height - may lead to infertility d/t uterine scarring or fibriotic scarring *2% of pregnancies are ectopic - painless vaginal bleeding of the fallopian tube *the 2nd most frequent cause of bleeding early in pregnancy Action/Implementation: s/s: Ultrasound has to be performed fever Predisposing Factors Prepare client for D & E Adhesion of the fallopian tube caused by chronic salpingitis crampy abdominal pain or Pelvic Inflammatory Disease Prepare client for labor if pregnancy is over 14 weeks. tender uterus Misoprostl (Cytotec) and oxytocin for elective termination of Congenital malformations such as webbing in the fallopian complications: tube pregnancy. toxic shock syndrome Scars from tubal surgery Provide IV fluids septicemia Utrerine tumor pressing on the proximal end of the tube Offer emotional support/counselling Complications of Miscarriage kidney failure IUD i. Hemorrhage death Assessment Findings - not serious and fatal with complete spontaneous miscarriage management: *no unusual symptom at the time of implantation - major hemorrhage is possible for incomplete miscarriage CBC, serum electrolytes, serum creatinine, blood type & amenorrhea or abnormal menstrual period/spotting – most with accompanying coagulation defect (DIC) cross match, cervical, vaginal, & urine cultures. common sign (slight, dark vaginal bleeding) Implementation: I & O q hourly. nausea and vomiting Monitor VS to detect possible hypovolemic shock IVF administration. NCM 109: MCN Semifinals: Gestational Conditions | April 13, 2023 Quezon, Britney Kim E. | BSN 2-L positive pregnancy test Start IVF, D5LR for plasma administration, blood tubal rupture signs: sudden, acute low abdominal pain transfusion, or drug administration as ordered. radiating to the shoulder – KEHR’S SIGN (referred shoulder Monitor V/S, bleeding, I & O pain) or neck pain Provide physical & psychological support. bluish navel (CULLEN’S SIGN) d/t blood in the cul-de-sac - anticipate grief sharp localized pain when cervix is touched - anticipate possible guilt responses signs of shock/circulatory collapse - anticipate fear related to potential disturbance in Laboratory Findings childbearing capacity in the future low hemoglobin count, low hematocrit level d/t bleeding process or loss of blood low HCG indicating that pregnancy has ended elevated WBC d/t trauma Diagnosis 1. Pelvic Ultrasonography - no embryonic sac in the uterine cavity 2. Culdocentesis - aspiration of non-clotting blood from the cul-de-sac of Douglas (positive tubal rupture) 3. Laparoscopy - not common; requires direct visualization - therapy for a ruptured ectopic pregnancy which is to ligate the bleeding vessels, and to remove or repair the damaged fallopian tube Treatment 1. Methotrexate - indicated for unruptured ectopic (mass) smaller than 4cm - to induce labor and preserve fallopian tube 2. Salphingectomy - surgical removal of ruptured tube 3. Management of profound shock if ruptured: blood replacement and IVF 4. Antibiotics Complications 1. Hemorrhage 2. Infection 3. Rh Sensitization – RhoGAM prevents isoimmunizations; given to Rh negative mother with Rh positive ectopic pregnancy Common Nursing Dx: powerlessness r/t early loss of pregnancy secondary to ectopic pregnancy Nursing Implementation Obtain assessment data rapidly especially for anticipatory shock Implement measures for shock as soon as possible. Position patient on Modified Trendelenburg (shock) NCM 109: MCN Semifinals: Gestational Conditions | April 13, 2023 Quezon, Britney Kim E. | BSN 2-L GESTATIONAL TROPHOBLASTIC DISEASE (HYDATIDIFORM c. ultrasound PREMATURE CERVICAL DILATATION (INCOMPETENT CERVIX) MOLE / HMOLE) d. flat plate of the abdomen done after 15 weeks – no fetal skeleton Previously termed as incompetent cervix Abnormal proliferation and then degeneration of the Prognosis: A cervix that dilates prematurely and therefore cannot hold a trophoblastic villi 80% remission after D&C; may progress to cancer of the fetus until term A developmental anomaly of the placenta that changes chorion – CHORIOCARCINOMA It occurs in about 1 % of women chorionic villi into a mass of clear visicles. Treatment: This commonly occurs at approximately week 20 of pregnancy Presents as an edematous grapelike cluster that may be a. Evacuation by D & C or hysterectomy if no spontaneous the cervical dilation is painless nonmalignant or may develop in choriocarcinoma. evacuation Incidence: b. Hysterectomy if above 45 years old and no future pregnancy Manifestations 1:1500 pregnancies is desired, or with increased chorionic gonadotropin after D Show, a pink-stained vaginal discharge (first symptom) common in the Orient and in people of low socioeconomic &C status c. HCG titer monitoring for one year – NO PREGNANCY for 1 Increased pelvic pressure Cause: year (use contraception) because signs of pregnancy can Rupture of membranes and discharge of amniotic fluid unknown mask early signs of choriocarcinoma (+) uterine contractions Risk Factors: d. Medical replacement: blood, fluid, plasma Associated Factors increased maternal age (women older than 35 years) e. Chemotherapy for malignancy: METHOTREXATE is the Increased maternal age drug of choice low socioeconomic status: low protein intake Congenital structural defects f. Chest X-ray to detect early lung metastasis blood group A women who marry blood group O men Trauma to the cervix occurring after repeated D & C Complications Two Types of Molar Growth Diagnosis a. Choriocarcinoma: most dreaded complication 1. Complete Mole b. Hemorrhage: most serious during the early treatment phase Usually diagnosed only after the pregnancy is lost all trophoblastic villi swell and become cystic c. Uterine perforation Can be detected early before the symptoms occur by embryo forms, it dies early at 1-2 mm in size; no fetal blood d. Infection SONOGRAM in the villi Nursing Implementation Treatment karyotype is normal 46 XY or 46 XX , chromosome Advise bed rest Cervical Cerclage component was contributed only by the father, or an “empty Monitor VS, blood loss, molar/tissue passage, I & O A surgical procedure is performed by suturing the cervix ovum” was fertilized and was duplicated Maintain fluid & electrolyte balance, plasma, blood volume using purse-string technique by the vaginal route under 2. Partial Mole through replacements as ordered regional anesthesia some villi form normally Prepare for D & C, hysterotomy, or hysterectomy as Usually performed at weeks 12-14 of pregnancy after has 69 chromosomes indicated confirming by sonogram that the fetus of a 2nd pregnancy is Assessment Findings Provide psychological support; anticipate – healthy Brownish or reddish, intermittent or profuse vaginal bleeding by 16 weeks with clear-fluid filled vesicles - Fear related to potential development of cancer Its purpose of the suture is to strengthen the cervix and - Disturbance in self-esteem for carrying an abnormal prevent if from dilating Rapid uterine enlargement inconsistent with the age of gestation. pregnancy the sutures are removed at weeks 37-38 of pregnancy Prepare for discharge 80%-90% success rate Symptoms of PIH before 20 weeks (↑BP, edema, - Emphasize the need for follow-up HCG titer proteinuria) Mcdonald Procedure determination for 1 year Excessive nausea and vomiting d/t elevated HCG (1-2 M - nylon sutures are placed horizontally and vertically - Reinforce instructions on NO PREGNANCY FOR ONE IU/L/24 hours) across the cervix and pulled tight to reduce the cervical YEAR; give instructions related to contraceptions. Positive pregnancy test canal to few millimeters in diameter No fetal signs – heart tones, parts, movements Shirodkar Procedure Abdominal pain - sterile tape is threaded in a cervix and sutured in place Diagnosis to achieve a closed cervix a. Passage of clear-fluid filled vesicles – first sign that aids diagnosis b. Triad Signs: - big uterus - vaginal bleeding: brownish and intermittent - HCG greater than 1 million (normal: 400,000 iu/L/24 hrs NCM 109: MCN Semifinals: Gestational Conditions | April 13, 2023 Quezon, Britney Kim E. | BSN 2-L CONDITIONS ASSOCIATED WITH 3RD TRIMESTER BLEEDING C. Double Set-up (One set for vaginal delivery and another for ABRUPTIO PLACENTA placenta previa classical CS): prepared for IE in suspected placenta previa in the A complication of late pregnancy or labor characterized by abruptio placenta following conditions: premature partial or complete separation of a normally premature rupture of membrane/preterm labor Term gestation implanted placenta. PLACENTA PREVIA Mother in labor and progressing well Also termed Accidental Hemorrhage/Ablatio Placenta - low implantation of the placenta Mother and fetus are stable Incidence: 2nd leading cause of bleeding in the 3rd trimester; Four Degrees - If the woman is not in labor or in shock, and/or fetus occurs in 1:300 pregnancies 1. Low-lying Placenta is distressed, only one set-up is to be prepared, an Predisposing Factors - the implantation is lower rather than in the upper portion of emergency classical cesarean section set up Maternal Hypertension: PIH, renal disease the uterus (low-lying) D. Delivery: If conditions for watchful watching are absent: Sudden uterine decompression as in multiple pregnancy and - Marginal Implantation: the placenta edge approaches the Vaginal delivery if birth canal is bot obstructed polyhydramnios cervical os Cesarean section if placental placement prevents vaginal Advance age 2. Partial Placenta Previa birth. In previa, classical cs is indicated as the lower uterine Multiparity segment is occupied by the placenta. Future pregnancies - implantation of the placenta occludes a portion of the Short umbilical cord will be terminated by another CS because the presence of a cervical os classical CS scar is a contraindication to vaginal delivery; it Trauma: fibrin defects 3. Total Placental Previa is the leading the cause of uterine rupture. Types of Abruptio Placenta: - implantation of the placenta totally occludes the cervical os Complications a) Type I: Concealed, covert, or central type; the classic type Associated Factors: Hemorrhage Placenta separates at the center causing blood to Increased parity Prematurity accumulate behind the placenta Advanced maternal age External bleeding not evident Obstruction of birth canal Past cesarean births Nursing Implementation Signs of shock not proportional to the amount of external Past uterine curettage a. Maintain bedrest – left lateral recumbent with a head pillow bleeding Multiple pregnancy b. DO NOT PERFORM an IE or vaginal examination b) Type II: Marginal, overt, or external bleeding type Incidence rate: 5:1000 pregnancies c. Careful assessment : VS, bleeding, onset/progress of labor, FHT Placenta separates at the margins Outcome: Increase in congenital fetal anomalies d. Prepare client for diagnostic ultrasonography Bleeding is external, usually proportional to the amount of Assessment Findings e. Institute shock measures as necessary. Initially, bleeding in internal bleeding Painless vaginal bleeding (fresh, bright red and sudden) in previa is rarely life-threatening but may become profuse with May be complete or incomplete depending on the degree of the third trimester approximately week 30/7th month internal examination detachment Uterine soft/flaccid or intermittent hardening if in labor f. Provide psychological and physical support Assessment Findings g. Prepare for conservative management, double set-up, or a a. Painful vaginal bleeding in the 3rd trimester Intermittent pain if it happens in labor secondary to uterine classical CS b. Rigid, boardlike, and painful abdomen contractions h. Observe for bleeding after delivery: The lower uterine segment, c. Enlarged uterus d/t concealed bleeding; signs of shock not Bleeding may be slight or profuse which may come after an the site of placental detachment, is not a contractile as the upper activity, coitus or internal examination proportional to the degree of external bleeding (classic type) fundal portion d. If in labor: tetanic contractions with the absence of Diagnosis Ultrasonography gives 95% accurate result – detects site of alternating contraction and relaxation of the uterus placental implantation Diagnosis Treatment a. Clinical diagnosis – signs and symptoms A. Watchful waiting: Expectant management, conservative if any b. Ultrasound – detects the retroplacental bleeding - the mother is not in labor c. Clotting studies – reveal DIC, clotting defects - fetus is premature, stable, and not in distress The thromboplastin from retroplacental clot enters - bleeding is not severe maternal circulation and consumes maternal free B. Amniotomy fibrinogen resulting in: - artificial rupture of the bag of waters 1. DIC (Disseminated Intravascular Coagulation): - causes fetal head to descend causing mechanical pressure small fibrin clots in circulation at placental site controlling bleeding 2. Hypofibrinogemia: decrease normal fibrinogen results in the absence of normal blood coagulation NCM 109: MCN Semifinals: Gestational Conditions | April 13, 2023 Quezon, Britney Kim E. | BSN 2-L Complications a. Hemorrhagic shock b. COUVELAIRE UTERUS: The bleeding behind the placenta may cause some of the blood to enter the uterine musculature causing the uterine muscles not to contract well once the placenta is delivered. c. DIC d. CVA secondary to DIC e. Hypofibrinogenemia f. Renal failure g. Infection h. Prematurity, fetal distress/demise (IUFD) Nursing Implementations Maintain bedrest, LLR Careful monitoring: - Maternal VS - FHT - Labor onset/progress - I & O, oliguria/anuria - uterine pain - bleeding (not proportional to degree of shock) Administer intravenous fluid, plasma, or blood as ordered Prepare foe diagnostic exams – explain results Provide psychological support by preparing the patient for all examination, explaining what is happening, and inform/explain results Prepare for emergency birth either per vagina or CS Observe for ASSOCIATED PROBLEMS AFTER DELIVERY - Poorly contracting uterus (Couvelaire uterus) leading to post-partal hemorrhage - Disseminated Intravascular coagulation (DIC) leads to hemorrhage and possibly CVA Hypofibrinogenemia leads to post-partal hemorrhage Prematurity, neonatal distress that will lead to neonatal morbidity and mortality