Ch 21 lecture Flashcards
Vaginal Bleeding during pregnancy is always a __.
deviation from the normal
Always serious
May occur at any point during pregnancy
Frightening
Must have a diagnosis
Spotting in pregnancy
Spotting is common during the first trimester because of the highly vascular cervix.
Advise client to report any spotting or bleeding for evaluation
Can occur after exercise or intercourse
Common causes of bleeding during pregnancy:
First half of pregnancy
- Ectopic pregnancy
- Gestational trophoblastic disease (GTD)
Second half of pregnancy
- Placenta previa
- Abruptio placentae
threatened abortion
Embryo or fetus is jeopardized
May be followed by partial or complete expulsion of products of conception
Begins with bleeding
Dr often puts on bedrest
imminent abortion
Increased bleeding and cramping
Term “inevitable abortion“ applies
complete abortion
all production of conception expelled
incomplete abortion
Some products of conception are retained, most often the placenta
Will usually go in and do a D&C (dilation and curettage)
missed abortion
Fetus dies in utero but is not expelled
If fetus is retained beyond 6 weeks, disseminated intravascular coagulation (DIC) may develop
Dilatation and curettage or suction evacuation if first trimester. Induction of labor or dilatation and evacuation (D&E) if second trimester.
recurrent pregnancy loss
Formerly called habitual abortion
Abortion in three or more consecutive pregnancies
septic abortion
Prolonged, unrecognized rupture of membranes
Pregnancy with intrauterine device (IUD) in utero
Attempts by unqualified individuals to terminate pregnancy
- Products of Conception (POC)
- Often b/c woman will try to do an abortion on self
ectopic pregnancy
Implantation of fertilized ovum in a site other than uterine endometrial lining
Ampulla of fallopian tube is most common site of implantation
Accounts for 9% of all maternal deaths in the United States
Surgical emergency if tube ruptures
**Large bore IV (possibly 2!!) **
Signs and symptoms of ectopic pregnancy
Mother will test + for pregnancy, but nothing will show on ultrasound!!
Sharp, one-sided pain Syncope (pass out from shock) Referred right shoulder pain Lower abdominal pain Adnexal tenderness (Pelvic/uterine tenderness) Abdominal rigidity and tenderness Decreased hemoglobin and hematocrit Increased leukocytes
What is the treatment for ectopic pregnancy?
Medical-Methotrexate
- only given if not ruptured (ie identified early)
- Given IM; is a folic acid antagonist that interferes with the proliferation of the trophoblastic cells
Surgical
- Laparoscopic linear salpingostomy – LOOK
- Laparoscopic salpingectomy – REMOVE
- With both medical and surgical therapies, Rh immune globulin is administered to Rh-negative nonsensitized women
Gestational Trophoblastic Disease (GTD)
Pathologic proliferation of trophoblastic cells (which is the outer most layer of the embryonic cells)
- So mimics a pregnancy w/proliferation of cells, but is NOT
- Risk factors largely unknown
Types of GTD
- Hydatidiform mole: This leads to the invasive mole and/or choriocarcinoma if not caught early!
- Invasive mole (chorioadenoma destruens)
- Choriocarcinoma
Hydatidiform mole (molar pregnancy)
Proliferation of trophoblastic cells creates placenta characterized by hydropic (fluid-filled) grapelike clusters
Complete or partial moles
Consequences
i. Loss of pregnancy
ii. Remote possibility of developing choriocarcinoma
complete mole (hydatidiform mole)
Ovum containing no maternal genetic material (“empty egg”)
Fertilized by a normal sperm
A complete mole can turn into an Invasive mole (chorioadenoma destruens)
A complete mole can also produce choriocarcinoma – a RAPIDLY growing cancer
choriocarcinoma
a fast-growing form of cancer that occurs in a woman’s uterus (womb). The abnormal cells start in the tissue that would normally become the placenta.
Follow up includes a baseline chest Xray to detect lung metastasis and a physical exam
Pregnancy should be avoided for 1 year
Signs and symptoms of a molar pregnancy
Vaginal Bleeding: Often brownish (like prune juice) but it may be bright red.
Uterine enlargement greater than expected for gestational age
Passage of hydropic vesicles (grapelike clusters)
Serum hCG levels are markedly elevated
Hyperemesis gravidarum – extreme, persistent N/V during pregnancy
Anemia due to blood loss
Very low levels of maternal serum alpha-fetoprotein (MSAFP)
Symptoms of preeclampsia before 24 weeks’ gestation
Absent fetal heart tones
treatment for a molar pregnancy
Suction evacuation of the mole
Uterine curettage
Rhogam - Rh immune globulin administered to Rh-negative women
Hysterectomy may be treatment of choice to reduce risk of choriocarcinoma
For Development of Malignant GTD
a. Early detection requires extensive follow-up therapy
b. Baseline chest x-ray
c. Physical exam including pelvic exam
d. Serial hCG measurements: These should go down to normal after removal
cervical insufficiency
Formerly called incompetent cervix
Painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix
Woman is usually unaware of contractions and presents with advanced effacement and dilatation and, possibly, bulging membranes
cerclage
Surgical procedure in which a stitch is placed in the cervix to prevent spontaneous abortion or premature birth (in cervical insufficiency)
-If had cerclage previously, then one will be placed right away in following pregnancies
Elective cerclage
- May be placed late in first trimester or early in second trimester
- 80% to 90% success rate in preventing fetal loss and premature labor and birth
Emergent cerclage
- Placed when dilatation and effacement have already occurred
- 40% to 60% success rate
placenta previa
Placental implantation in the lower uterine segment
As lower uterine segment contracts and dilates, placental villi are torn from uterine wall
Uterine sinuses exposed at placental site. Amount of bleeding may range from scanty to profuse
Painless bleeding
Placenta Previa: Four Degrees
low-lying (placenta previa)
- Placenta is low
- Possible bleeding
- Mom on bedrest
partial placenta previa
- Placenta even lower!
- Probably bleeding
- Mom on bedrest for as many weeks as possible
complete or total placenta previa
- Placeta covering cervical os
- Has seen bleeding in pregnancy (prob a lot)
- Mom on Bedrest
- Cesarian, no trial of labor
Risk factors for placenta previa
a. Women of Asian descent
b. Prior cesarean birth
c. High gravidity
d. High parity
e. Advanced maternal age
f. Previous miscarriage
g. Previous induced abortion
h. Cigarette smoking
Fetal prognosis in placental previa depends on the __.
extent of placenta previa
Profuse bleeding yields fetal compromise and hypoxia
Fetal heart rate (FHR) monitoring is imperative upon maternal admission, particularly if vaginal birth is anticipated, as the presenting fetal part may obstruct the placental or umbilical cord blood flow
Indications for Cesarean Birth
- Nonreassuring fetal status
- Diagnosis of complete or partial previa
Nursing assessment for placenta previa:
Maternal assessment for painless, bright-red vaginal bleeding
- Most accurate diagnostic sign of placenta previa
- If this sign develops during the last 3 months of pregnancy, placenta previa should always be considered until ruled out by ultrasound examination
- Bleeding usually begins as scant and becomes more profuse
Anticipate unengaged fetal presenting part
-Transverse lie is common
Assessment of fetal status (mom on bedrest)
- FHR: continuous external fetal monitoring
- Electronic monitor tracing
Anticipate need for blood transfusion
Assess maternal vital signs
- Every 15 minutes if no hemorrhage
- Every 5 minutes with active hemorrhage
placenta accrete
a general term used to describe the clinical condition when part of the placenta, or the entire placenta, invades and is inseparable from the uterine wall.
Deep attachment of the placenta to the uterine myometrium, so deep that the placenta will not loosen and deliver pg 620
Can be detected via ultrasound.
Risks:
- Placenta previa is higher risk for accrete
- Placenta scar from cesarian also is higher risk for accreta
Clinically, placenta accreta becomes problematic during delivery when the placenta does not completely separate from the uterus and is followed by __.
massive obstetric hemorrhage.
leading to:
i. disseminated intravascular coagulopathy;
ii. the need for hysterectomy;
iii. surgical injury to the ureters, bladder, bowel, or neurovascular structures;
iv. adult respiratory distress syndrome;
v. acute transfusion reaction;
vi. electrolyte imbalance;
vii. and renal failure.
viii. blood loss
The average blood loss at delivery in women with placenta accreta is __.
3,000–5,000 mL – MASSIVE!!
As many as 90% of patients with placenta accreta require blood transfusion
40% require more than 10 units of packed red blood cells.
Nursing care:
a. Type and cross for blood, have blood ready to go!!
b. 2 IV’s, large bore
Abruptio placentae (Abruption)
Premature separation of a normally implanted placenta from the uterine wall
Cause is largely unknown
Abruption = PAIN, previa = no pain =>difference between previa and abruption is PAIN
Three types: marginal, central, and complete
The difference between previa and abruption is __.
PAIN.
Abruption = PAIN, previa = no pain
marginal abruption
Blood passes between the fetal membranes and the uterine wall and escapes vaginally
Placenta moves away (partially removed) from wall of uterus
central abruption
Blood is trapped between the placenta and uterine wall with concealed bleeding
complete abruption
Total separation of placenta and massive bleeding
Baby getting NO OXYGEN bc it’s seperated
EMERGENCY C/Section to save infant
GET READY – baby will have 0-1 APGAR
Associated risk factors for abruption
1 cocaine abuse!!
Increased maternal age Increased parity Cigarette smoking Trauma Maternal hypertension Previous placental abruption
