Books Chapter 19 Flashcards
How many pregnant women experience a high-risk pregnancy?
1 in 4
What’s the biggest cause of maternal death?
hemorrhage
What are the conditions associated with early bleeding? with late bleeding
(have this slide b/c it lists all of the pathos we’ll be reviewing organized by when bleeding happens)
Early
- spontaneous abortion
- ectopic pregnancy
- gestational trophoblastic disease
- cervical insufficiency
Late
- placenta previa
- abruptio placentae
- placenta accreta
What is the medical definition of abortion ?
loss of an early pregnancy before 20 weeks gestation
What are the two types of abortion?
1) spontaneous abortion (miscarriage): result from natural causes, usually not elective or therapeutically induced by procedure
2) induced abortion
When do 80% of spontaneous abortions occur?
within the 1st trimester
What’s the difference between miscarriage and stillbirth? which one’s more common?
- Stillbirth is a spontaneous abortion after 20th week and miscarriage is before 20th week
- miscarriage is more common
What is the most common cause of spontaneous abortion?
usually chromosomal/genetic abnormality in 1st trimester
If a spontaneous abortion occurs during the 2nd trimester, what’s most likely the cause?
abnormality related to the mother
After a spontaneous abortion occurs, why is it important to keep monitoring hCG levels?
to make sure all tissues have been expelled
- a similar example is if you have an ectopic pregnancy and use methotrexate as a medical regime to expel the zygote, you will monitor hCG levels to predict success
When assessing bleeding, what signs would indicate significant bleeding (think color, amount, what you don’t want to find)?
significant bleeding = bright red, saturate one or more peripad per hour
- bad: clots, tissue in blood
If woman experiences a spontaneous abortion and is Rh negative, what drug should you expect to administer? When should this be administered?
- expect to administer RhoGAM (so if fetus/zygote had developed a Rh+ blood type, the mother won’t form antibodies against it which could complicate later pregnancies)
- this must be administered within 72 hours after the abortion is complete
What are the categories of abortion and the signs/symptoms of each?
1) Threatened abortion
- vaginal bleeding early in pregnancy
- no cervical dilation and closed cervical os
- mild ab cramping
- no fetal tissue passage
2) Inevitable abortion
- vaginal bleeding more than threatened
- membrane rupture
- cervical dilation
- strong ab cramping
- possible tissue passage
3) Incomplete abortion (passage of some products)
- intense ab cramping
- heavy vaginal bleeding
- cervical dilation
4) Complete abortion (passage of all products)
- hx of vag bleeding and ab pain
- after product passage: decreased pain/bleeding
5) Missed abortion (nonviable embryo maintained in uterus for at least 6 weeks)
- no uterine contractions
- irregular spotting
6) Habitual abortion
- hx of 3 or > consecutive spontaneous abortions
What are four drugs used with spontaneous abortions and a short description of what they do?
1) misoprostol (Cytotec): stimulates contraction to terminate pregnancy and can evacuate uterus of remaining tissue
2) mifepristone (RU-486): progesterone antagonist, stimulates uterine contraction, causes endometrium to slough, sometimes followed by misoprostol within 48 hours
3) PGE2, dinoprostone (Cervidil, Prepidil Gel, Prostin E2): stimulates uterine contraction to expel uterine contents, also used to thin/dilate cervix in term pregnancies
4) Rh(D) immunoglobulin (RhoGAM): suppresses immune response of nonsensitized Rh-negative clients to prevent antibody formation
What is the site of administration for RhoGAM?
IM in deltoid
What is an ectopic pregnancy?
preg where the zygote implants outside of uterus
what’s the most common place of implantation for an ectopic pregnancy?
the fallopian tubes
What’s the most common cause of ectopic pregnancy?
tubal scarring due to pelvic inflammatory disease (think STI infections)
When is medical treatment an option for an ectopic pregnancy?
if the fallopian tubes are still intact (assuming implantation is in fallopian tube), mass is unruptured, and the client is hemodynamically stable
what is considreed the treatment of choice over surgical interventions for ectopic pregnancies? how do we determine the dose?
methotrexate, IM determined by client’s body SA
What are the hallmark sign of ectopic pregnancy?
a triad
- ab pain
- spotting
- symptoms within 6-8 weeks after missed period
What is GTD?
gestational trophoblastic disease
- a spectrum of abnormal growth disorders that originate in the placenta, so gestational tissue present but not viable
(note: more common in Asian countries)
what are the two most common types of GTD?
1) hydatidiform mole (there’s partial and complete)
2) choriocarcinoma
What is a hydatidiform mole?
- benign, abnormal growth of the chorion
- chorionic villi degenerate and becomes transparent sacs containing clear fluid
What’s the difference between complete and partial hydatidiform mole?
1) Complete
- no fetal tissue, fertilized by normal sperm (46 chromosomal number)
- pt presents with vag bleeding, anemia, enlarged uterus, preeclampsia, hyperemesis
2) Partial
- triploid (69) chromosomal number b/c 2 sperms fertilized
- pt presents with missed/incomplete abortion, vag bleeding, small or nomal size uterus
what is a complete mole associated with
the development of choriocarcinoma, partial rarely develop into choriocarcinoma
what are are the main nursing management concerns for a woman with GTD?
- prepare for D&C to evacuate uterus (will need immediately after diagnosis)
- educate on risk of cancer (may use methotrexate as a prophylaxis)
- stress importance of frequent follow up, especialy in next 12 months (promote use of reliable contraceptive to prevent pregnancy during this time)
What is cervical insufficiency?
weak, structurally defective cervix that dilate prematurely resulting in fetal loss
hypothetically, what are women with a short cervix at risk for?
pre-term birth
If the cervix dialates too early, what’s a surgical intervention?
cervical cerclage, using sutures to support os of cervix
when should you proceed with caution in performing a cerclage? up until how many weeks is a cerclage ok to perform?
- 20 weeks or after, can perform up to 28 weeks
what’s the biggest indicator of cervical insufficiency?
previous loss during second or third trimester
others include pink-tinged vaginal discharge, backache, contractility
when is it the easiest to detect a short cervix with an ultrasound?
between 16 and 24 weeks, so ultrasound definitely needs to be done between these times
What length of cervix requires intervention in the pregnant woman?
25mm or less
What is placenta previa
placenta implants into cervical os, bleeding condition
what’s a common risk factor that can increase the incidence of placenta previa?
cesarean section
What initiates placenta previa?
- embryo can’t implant in upper uterus (perhaps due to scarring) so implants in lower uterus and placenta needs SA to grow and extends into lower fetus
What’s the difference between placenta previa - accreta, increta, and percreta
accreta: placenta attaches directly to myometrium
increta: deeply in myometrium
percreta: infiltrates myometrium
how is placenta previa generally classified?
- total: internal cerbical os completely covered
- partial
- marginal: placenta at margin or edge of os
- low-lying: implanted in lower uterine segment and near internal os but does not reach it
in what ethnic group is placenta previa of high incidence?
asian cultural groups, not sure what they mean
what’s the classical presentation of placenta previa and when does it occur?
painless, brigh-red vaginal bleeding usually between 27-32 weeks gestation
why does bleeding often occur in placenta previa?
lower uterus not equipped to contract enought o restrict blood flow
what do you need to avoid doing in a woman with placenta previa?
vaginal exams
whenever a bleeding is suspected what preemptive step should the nurse prepare for?
blood typing and cross-matching
What is abruptio placentae
- sepration of normally located placenta after 20th week but prior to birth
what do they think causes abruptio placentae?
- thinks it starts with degenerative changes in maternal arterioles leading to thrombosis and rupture of vessel and pressure causes placenta to separate
what are the hallmark signs of abruptio placentae?
abdominal pain and rigid, tender uterus
how is abruptio placentae classified?
according to amount of separation and maternal blood loss
- mild/grade 1: minimal bleeding, marginal separation (less than 500mL, 10-20% separation), no coagulopathy, no signs of shock, no fetal distress
- moderate/grade2: moderate bleeding/separation (1000-1500mL, 20-50%), ab pain
- severe/grade 3:(more than 1500mL, more than 50%, profound shock, dark vaginal bleeding, coagulopathy
- also classified as partial or complete AND concealed or apparent by type of bleeding
What is DIC?
disseminated intravascular coagulation: bleeding disorder with less blood clotting factors available due to IV clotting (can occur secondary like in abruptio placentae)
- treat with transfusion of fresh-frozen plasma with cryoprecipitate
describe the difference between placenta previa and abruptio placentae
previa
- insidious onset, bleeding always visible and sligh, bright red, painless, soft and relaxed uterus, normal fetal HR, possible breech
abruptio
- sudden onset, concealed or visible bleeding, dark red, pain, firm rigid uterus, fetal distress or absent HR
What’s the Kleihauer-Berke test
- detects fetal RBCS in maternal circulation, determines degree of fetal-maternal hemorrhage and helps circulate appropriate dosage of RhoGAM
what’s a complication of placenta accreta?
hemorrhaging from manual removal attempt of placenta
what is hyperemesis and what’s the problem with it?
- severe morning sickness causing dehydration electrolyte imbalance and need for hospitalization
what are the different classification of HTN disorders in pregnant women?
1) chronic HTN: exists prior to 20 weeks (140/90 or >)
2) gestational HTN: after
3) preeclampsia: most common and also with proteinuria, after 20 weeks, returns normal 12 weeks postpartum
4) eclampsia: onset of seizure activity in woman with preeclampsia
how to diagnose gestational HTN
> 140/90 on at least 2 occasiona at least 6 hours apart after 20th week
what’s the thrombozane/prostacyclin imbalance with preeclampsia?
increased thromboxane and decreased prostacyclin
what med used to prevent eclampsia?
magnesium sulfate (calcium gluconate kept at bedsi
