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Learning Objectives
• At the end of the session, students should be able to:
1. Define the different gestational conditions and their
GESTATIONAL CONDITIONS (I) pathophysiology.
2. Identify the signs and symptoms of each gestational
conditions and understand their potential complications
for both the mother and the fetus.
Prepared by: 3. Explain the management strategies for each gestational
Mercy Liza R. Cruz RM MAN
School of Nursing
conditions.

Definition

1. Hyperemesis
Hyperemesis gravidarum (sometimes called pernicious or
Gravidarum persistent vomiting) is nausea and vomiting of pregnancy that
is prolonged past week 12 of pregnancy or is so severe that
dehydration, ketonuria, and significant weight loss occur
within the first 12 weeks of pregnancy.

Clinical Presentation
Pathophysiology
• Severe weight loss due to severe nausea and vomiting
• Etiology: unknown • Ketonuria, due to breaking down of stored fats and
• Rising level of estrogen, progesterone, protein
HCG, thyroxine and thyroid stimulating • Elevated hematocrit, due to hemoconcentration
hormone (TSH) • Reduce electrolyte blood levels
• Helicobacter pylori • Signs of dehydration
• Jaundice maybe present in severe cases.

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Maternal Complications
•Significant weight loss
•Ketonemia
•Electrolyte imbalance and dehydration
•Hepatic, CNS and renal damage
• Wernicke’s encephalopathy
- A neuropsychiatric syndrome that is caused by
severe thiamine deficiency because of the persistent
vomiting.
Management
• Hospitalization for about 24 hours.
• All oral food and fluids are usually withheld.
• Intravenous fluid (3000 mL of Ringer’s lactate with added
vitamin B, for example) may be administered.
• An antiemetic, such as metoclopramide (Reglan), may be
prescribed to control vomiting.
• Carefully measure intake and output, including the amount
of vomitus.
2. ECTOPIC PREGNANCY
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Fetal Complications
• Fetal loss
• Intrauterine growth restriction (IUGR)
Management
• If there is no vomiting after the first 24 hours of oral
restriction, small amounts of clear fluid may be begun
and the woman may be discharged home.
• If she can continue to take clear fluid, small quantities of
dry toast, crackers, or cereal may be added every 2 or 3
hours, then she can be gradually advanced to a soft diet,
then to a normal diet.
• If vomiting returns at any point, enteral or total
parenteral nutrition may be prescribed.
ECTOPIC PREGNANCY
• is one in which implantation occurs outside the uterine
cavity.
• It is the second most leading cause of bleeding early in
pregnancy.
• The most common site is on the ampulla of the fallopian
tube.
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ECTOPIC PREGNANCY

• It starts as a normal pregnancy, with fertilization occurring

in the distal third of the fallopian tube. Because of an
obstruction, however, the zygote cannot travel the length of
the tube for proper implantation in the uterus.
• Will result to termination of pregnancy
• 2% of pregnancies are ectopic

Sites for Ectopic Pregnancy Risk Factors

• The implantation may occur
on the surface of the ovary 1. Pelvic Inflammatory Disease
or in the cervix. The most 2. In vitro fertilization
common site (in 3. Smoking
approximately 95% of such
4. Previous history of ectopic pregnancy
pregnancies) is in a
5. Current use of intrauterine device (IUD)
fallopian tube .
6. Congenital anomalies that block a fallopian tube
• 80% - ampullar portion
• 12% - isthmus (very painful)
• 8% - interstitial or fimbrial.

Signs and Symptoms Signs and Symptoms

1. Bleeding
• There is no unusual symptoms at the time of implantation - Growth of the zygote possibly ruptures the fallopian tubes.
(symptoms similar to a normal pregnancy) - Ruptured ectopic pregnancy is SERIOUS regardless of the
No menstrual flow site of implantation.
Nausea and vomiting of early pregnancy 2. Sharp, stabbing pain in one of the lower abdominal
Breast tenderness quadrants
Pregnancy test for hCG will be positive (53%) 3. Severe intra-peritoneal bleeding
4. Scant vaginal spotting
Diagnosis thru UTZ (can be shown that the baby is not
5. Vaginal Bleeding
present in the uterus)
• Weeks 6-12 of pregnancy (possible rupture of fallopian tube)

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Signs and Symptoms Diagnostic Procedures

6. Lightheadedness/ 1. Transvaginal sonogram
syncope; rapid RR; falling - Reveals the rupture tube and blood collecting in the peritoneum
BP; and rapid thread pulse
2. Laparoscopy or culdoscopy
7. Cullen’s sign
- Used to visualize the fallopian tube if the symptoms do not reveal
- umbilicus develop a bluish- clear picture
tinged hue
8. Right shoulder pain 3. Ultrasonography
because of peritoneal - Reveals a clear-cut diagnostic picture
irritation

Laboratory Procedures Medical/ Surgical Management

1. Unruptured tube
• CBC • IM/oral methotrexate, a chemotherapeutic agent to induce
• Blood typing and cross therapeutic abortion
matching - Received until hCG titer is negative. UTZ is done after to check
sac collapse and patency of tubes.
- For blood transfusion
purposes because of - Leucovorin is given 24 hrs after initiation of methotrexate to
protect cells from effects of methotrexate and decrease its side
bleeding effects.
• Pregnancy test (HCG and
progesterone level) • Mifepristone, an abortifacient; causes sloughing of the tubal
implantation site

Medical/ Surgical Management

2. Ruptured tube
• Medical emergency
• Initiate intravenous fluid using gauge 18 needle
• Laparoscopy
Ligation of bleeding vessels and removal or repair of
damaged fallopian tube through laparoscopy
Laparoscopic linear sapingostomy
Laparoscopic salpingectomy

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Cont. Nursing Interventions

• Saphingectomy- indicated in uncontrollable hemorrhage and
severely damaged tube. 1. Encourage the patient to verbalize her concerns about her
ectopic pregnancy and future childbearing
• Hysterectomy is often resorted for ruptured interstitial or - Lost of a child
cervical pregnancy. - Decrease self-image
- Sense of powerlessness

2. Assess patient’s need for counselling

3. Gestational Gestational Trophoblastic Disease

Trophoblastic Disease
• The term gestational trophoblastic disease refers to a
(Hydatidiform Mole) spectrum of placental related tumors.

• Hydatidiform mole is a type of Gestational Trophoblastic

Disease (GTD).

Hydatidiform Mole

• is abnormal proliferation and then degeneration of

trophoblastic villi. As the cells degenerate, they become
filled with fluid and appear as clear fluid-filled, grape-sized
vesicles.
• Incidence: 1/1500 pregnancies

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Hydatidiform Mole Risk Factors

• Women with low protein intake
• Women who got pregnant older than 35 years old
• Women of Asian heritage
• Blood group A women who marry blood group O men (no
studies are established; based on profiling)
• Previous molar pregnancy

2 Types
1. COMPLETE MOLE
• ALL trophoblastic villi swell and become cystic
• If (+) embryo, it dies early at 1-2 mm in size, will not progress
to pregnancy.
• On chromosomal analysis, although the karyotype is normal
46XX or 46XY, this chromosome component was contributed
only by the father or an “empty ovum” there is division of
cells; the only divided was the sperm; the sperm met an
empty ovum = no fertilization
• There is an increased HCG levels, (+) choriocarcinoma
Cont..
2. PARTIAL MOLE
• Some of the villi form normally there is a union of a viable
ovum and sperm however it forms 69 chromosomes (triploid
formation) (one egg is fertilized by one sperm but defective
or two effective sperm fertilized the egg however there is a
problem in the division process)
• (+) macerated embryo (9 weeks AOG) there is a fetus formed
• Fetal blood in villi
• (-) choriocarcinoma not too dangerous
• Decreased HCG

Signs and Symptoms

• Early symptoms would show normal signs of pregnancy but
upon further assessment:
- Uterus tends to expand faster than normally
- No fetal heart sounds
- Increased HCG levels
- Marked nausea and vomiting
- Symptoms of PIH (before the 20th week)
- Vaginal bleeding accompanied by discharge of fluid-filled
vesicles

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Medical Management
4. PREMATURE
CERVICAL DILATATION
• Immediate evacuation of mole with aspiration/suction D&C
• Follow-up of hCG levels for at least 6 months to detect (INCOMPETENT CERVIX)
trophoblastic neoplasia. After hCG levels fall to normal for 6
months, pregnancy can be considered.
• Avoid another pregnancy for 6 to 12 months.

Incompetent Cervix Signs and Symptoms

A mechanical defect in the • Show

cervix that results in painless - Pink-stained vaginal discharge bleeding may be painless due
cervical dilation in the second to open cervix
trimester that can progress to • Increased pelvic pressure
ballooning of the membranes • Rupture of membranes
into the vagina and delivery of a • Discharge of amniotic fluid
premature fetus. (Cunningham et al., 2010).
• Uterine contractions
• Short labor then fetus is born

Possible causes
RISK TO THE WOMAN & FETUS
• Increase maternal age WOMAN FETUS
• Abnormal cervical development from genetics or • Repeated second trimester • Preterm birth and
diethylstilbestrol (DES) exposure or early third trimester birth consequences of
• Congenital structural defects • Recurrent pregnancy prematurity
• Trauma to the cervix- such as D&C (dilatation and losses (e.g., spontaneous
curettage ) abortions)
• Preterm delivery
• Rupture of
membranes/infection

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Medical Management
Cervical cerclage is a type of purse string suture placed
cervically to reinforce a weak cervix

■ Prophylactic cerclage may be placed in women with a

history of unexplained recurrent painless dilation and
second trimester birth, generally between 12 and 16
weeks of gestation.

■ Rescue cerclage is placed after the cervix has dilated

with no perceived contractions, up to about 24 weeks of
gestation (Cunningham et al., 2010).

Postoperative Nursing Actions

• Monitor for uterine activity with palpation.

• Monitor for vaginal bleeding and leaking of
fluid/rupture of membranes.
• Monitor for infection.
 Maternal fever
 Uterine tenderness
• Administer tocolytics to suppress uterine activity as mlrcruz

per order.