Lecture 8 Perinatal loss

Question 1

An Rh-negative woman receiving an abortion is a candidate for _

Answer 1

Prophylaxis against Rh isoimmunization. She should receive RhoGAM (Rhₒ(D) immune globulin) within 72 hours after the abortion if she is D negative and if Coombs’ test results are negative (if the woman is unsensitized or isoimmunization has not developed).

Question 2

Methotrexate

Answer 2

1. A cytotoxic drug that causes early abortion by blocking folic acid in fetal cells so that they cannot divide.
2. Medical abortion - given IM or PO (usually mixed with orange juice). Followed with misoprostol after 3-7 days.
3. Ectopic pregnancy - given IM - first-line non-surgical intervention for unruptured ectopic pregnancies. Requires weekly testing of hCG levels to verify that the pregnancy has resolved (2-3 weeks).
4. Side effects - GI distress, N/V, stomatitis, dizziness.
5. Woman should not take any analgesic stronger than Tylenol because it can mask the symptoms of tubal rupture.

Question 3

Misoprostol (Cytotec)

Answer 3

1. A prostaglandin analog that acts directly on the cervix to soften and dilate and on the uterine muscle to stimulate contractions.
2. Placed vaginally after administration of methotrexate; taken orally after administration of mifepristone.

Question 4

Mifepristone (RU 486)

Answer 4

1. Binds to progesterone receptors and blocks the action of progesterone, which is necessary for maintaining pregnancy.
2. 600 mg given orally up to 7 weeks after the last menstrual period. Followed with 400 mcg of misoprostol after 48 hours.

Question 5

When preterm birth appears inevitable _ may be administered to reduce or prevent neonatal neurologic morbidity (e.g., cerebral palsy).

Answer 5

Magnesium sulfate.
[Current recommendations are that magnesium sulfate for neuroprotection is given to women who are at least 24 but less than 32 weeks of gestation at the time birth is expected to occur.]

Question 6

Labor that progressed to a cervical dilation of _ or more is likely to lead to inevitable preterm birth.

Answer 6

4 cm.

Question 7

What drug is given to reverse the effects of respiratory depression caused by magnesium sulfate?

Answer 7

Calcium gluconate.

Question 8

Threatened miscarriage

Answer 8

Symptoms: Spotting of blood but with the cervical os closed. Mild uterine cramping may be present.
Only type of miscarriage that cannot lead to infection.

Question 9

Inevitable miscarriage

Answer 9

Symptoms: Moderate to heavy bleeding, with or without tissue, with an open cervical os. Mild to severe uterine cramping. Accompanied by ROM and cervical dilation, but the fetus has yet to be expelled.

Question 10

Incomplete miscarriage

Answer 10

Symptoms: Moderate to heavy bleeding, with or without tissue, with an open cervical os. Mild to severe uterine cramping. The fetus is expelled but the placenta is retained.

Question 11

Complete miscarriage

Answer 11

The cervix has already closed after all fetal tissue was expelled. Slight bleeding may occur and mild uterine cramping may be present.

Question 12

Missed miscarriage

Answer 12

A pregnancy in which the fetus has died but the products of conception are retained in utero for up to several weeks. The cervical os remains closed; uterine cramping and bleeding may be absent.
Failure to evacuate the products of conception can lead to DIC.

Question 13

A missed miscarriage can be managed with medications such as _ which are usually effective in completing the miscarriage within 7 days.

Answer 13

Prostaglandins, e.g., misoprostol (Cytotec).

Question 14

Cerclage

Answer 14

The placement of a surgical suture around the cervix beneath the mucosa to constrict the internal os. The suture is removed at 36 weeks.
Indications: 3 or more early preterm births or second-trimester losses, a short (less than 25 mm) cervical length, and an open cervix found on digital or speculum examination.

Question 15

“Expectant management” refers to _

Answer 15

Observation and bed rest (“watchful waiting”).

Question 16

The chance of developing _ after the development of a hydatidiform mole is increased.

Answer 16

Choriocarcinoma. [Diagnosis is made by hCG levels; for this reason the woman must use contraception (excluding an IUD) for one year after a molar pregnancy.]

Question 17

If a preterm delivery is likely, the mother is given _ to aid in fetal lung maturity.

Answer 17

Corticosteroids.

Question 18

Cullen sign

Answer 18

Blue ecchymosis observed in the umbilical area; indicates hematoperitoneum associated with an undiagnosed ruptured intraabdominal ectopic pregnancy.

Question 19

The nurse who elects to practice in the area of women’s health must have a thorough understanding of miscarriage. Which statement regarding this condition is most accurate?

Answer 19

If a miscarriage occurs before the 12th week of pregnancy, then it may be observed only as moderate discomfort and blood loss. [Before the sixth week, the only evidence might be a heavy menstrual flow. After the 12th week, more severe pain, similar to that of labor, is likely.]

Question 20

With regard to hemorrhagic complications that may occur during pregnancy, what information is most accurate?

Answer 20

An incompetent cervix is usually not diagnosed until the woman has lost one or two pregnancies. [Short labors and recurring losses of pregnancy at progressively earlier gestational ages are characteristics of reduced cervical competence.]

Question 21

A woman arrives at the emergency department with complaints of bleeding and cramping. The initial nursing history is significant for a last menstrual period 6 weeks ago. On sterile speculum examination, the primary care provider finds that the cervix is closed. The anticipated plan of care for this woman would be based on a probable diagnosis of which type of spontaneous abortion?

Answer 21

Threatened. [A woman with a threatened abortion has spotting, mild cramps, and no cervical dilation. A woman with an incomplete abortion would have heavy bleeding, mild-to-severe cramping, and cervical dilation. An inevitable abortion demonstrates the same symptoms as an incomplete abortion: heavy bleeding, mild-to-severe cramping, and cervical dilation. A woman with a septic abortion has malodorous bleeding and typically a dilated cervix.]

Question 22

Which order should the nurse expect for a client admitted with a threatened abortion?

Answer 22

Bed rest. [Decreasing the woman’s activity level may alleviate the bleeding and allow the pregnancy to continue.]

Question 23

Which finding on a prenatal visit at 10 weeks of gestation might suggest a hydatidiform mole?

Answer 23

Fundal height measurement of 18 cm. [The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy. Nausea increases in a molar pregnancy because of the increased production of hCG. A woman with a molar pregnancy may have early-onset pregnancy-induced hypertension. In the client’s history, bleeding is normally described as brownish.]

Question 24

A nurse caring for a family during a loss might notice that a family member is experiencing survivor guilt. Which family member is most likely to exhibit this guilt?

Answer 24

Grandparents. [Survivor guilt is sometimes felt by grandparents because they feel that the death is out of order; they are still alive, while their grandchild has died. They may express anger that they are alive and their grandchild is not.]

Question 25

When assisting the mother, father, and other family members to actualize the loss of an infant, which action is most helpful?

Answer 25

Ensuring the baby is clothed or wrapped if the parents choose to visit with the baby. [Presenting the baby as nicely as possible stimulates the parents’ senses and provides pleasant memories of their baby. Baby lotion or powder can be applied, and the baby should be wrapped in a soft blanket, clothed, and have a cap placed on his or her head.]

Question 26

For cornea donation, the infant must have been born _

Answer 26

Alive at 36 weeks of gestation or later.