Ch 21 lecture Flashcards by cori verghese

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

Common causes of bleeding during pregnancy:

First half of pregnancy

Ectopic pregnancy
Gestational trophoblastic disease (GTD)

Second half of pregnancy

Placenta previa
Abruptio placentae

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

imminent abortion

Increased bleeding and cramping

Term “inevitable abortion“ applies

How well did you know this?

Not at all

Perfectly

complete abortion

all production of conception expelled

How well did you know this?

Not at all

Perfectly

incomplete abortion

Some products of conception are retained, most often the placenta

Will usually go in and do a D&C (dilation and curettage)

How well did you know this?

Not at all

Perfectly

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.

How well did you know this?

Not at all

Perfectly

recurrent pregnancy loss

Formerly called habitual abortion

Abortion in three or more consecutive pregnancies

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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!!) **

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

1. Placeta covering cervical os 2. Has seen bleeding in pregnancy (prob a lot) 3. Mom on Bedrest 4. 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 1. Nonreassuring fetal status 2. 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: 1. Placenta previa is higher risk for accrete 2. 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 ```