MODULE 5.2: PAT: GP: Bleeding during 1st Trimester: Ectopic Pregnancy & Hydatidiform Mole & Incompetent Cervix Flashcards
Ectopic Pregnancy
a. Implantation occurs outside the uterine cavity
b. Usually occurs in the fallopian tube, cervix and ovaries
o 80% occurs in the ampullar
o 12% occurs in the isthmus
o 2% occurs in the interstitial
c. Second leading cause of bleeding in early pregnancy
Etiology of Ectopic Pregnancy
a. History of ectopic pregnancy
b. Smoking
c. Tubal surgery
d. Previous pelvic and/or abdominal surgery
e. Previous genital infections
o Gonorrhea
o Chlamydia
o Pelvic inflammatory disease
f. Sexual intercourse early before 18 years old
Note: These risk factors would create scars in the fallopian
tube → zygote cannot travel towards the uterus, thus, will
lodge to the site = implantation = ectopic pregnancy
Patophysiology of Ectopic Pregnancy
- risk factors
- dysfunction of the cilia
- disruption of scarring of F. tubes
- blocks or slow movement of fertilized ovum in the f.tube to the uterus
- fertilized egg searches for an area where it implants
- signs and symptoms appear
Ectopic Pregnancy: Assessment
a. Amenorrhea or abnormal menstruation followed by slight
bleeding
b. Vaginal spotting or bleeding (scanty to profuse)
c. UTZ – ruptured tube and blood at the peritoneum
d. Sharp stabbing pain
o Ruptured ectopic pregnancy
e. Decreasing hCG level/serum progesterone
o Suggest that pregnancy has ended
f. Hard or rigid abdomen
o Board-like abdomen because of peritoneal irritation
g. Cullen’s sign
o Bluish discoloration in the umbilicus
h. Continuous and extensive or dull abdominal and vaginal pain
i. Shoulder pain – phrenic nerve
j. Palpable tender cul-de-sac mass
k. Late signs of ruptured membrane:
o Lightheadedness
o Tachycardia
o Tachypnea
o Hypotension
o Pallor
o Cold, clammy skin
o Cyanotic nail beds
cul-de-sac mass
space between uterus and rectum in females
Ectopic Pregnancy: Diagnostic Tests
a. Culdocentesis – checks for abnormal fluid in the abdominal
- good result: no blood or purulent bleeding
- bad result: presence of blood or purulent bleeding
cavity behind the uterus
b.Ultrasound
Surgical Intervention: Salpingostomy
If not ruptured: Removal of a conceptus less than 2cm located at the distal portion of the fallopian tube by performing a linear incision over the ectopic pregnancy.
The conceptus will extrude from the incision andremoved manually
Surgical Intervention: Salpingotomy
Longitudinal incision is made over the ectopic pregnancy and the conceptus is removed using forceps or gentle
suction
Surgical Intervention: Fibril Evacuation
Removal of the conceptus by milking and suctioning of the fallopian tube
Surgical Intervention: Salpingectomy
If ruptured: Removal/cutting of the ruptured tube because if the presence of scar in tube is repaired and
left, can lead to another tubal pregnancy
Surgical Intervention: Others
a. Salpingo-oopherectomy
- Surgical procedure that involves the removal of one or both ovaries and their corresponding fallopian tubes
b. Administration of RhIG
Hydatidiform Mole (Molar Pregnancy)
a. Gestational Trophoblastic Disease
b. Abnormal proliferation and degeneration of trophoblastic villi
o Degenerate -> become fluid-filled (grape-size vesicles)
c. Is a mass of abnormal rapidly growing trophoblastic tissue in
which avascular vesicles hang in grapelike clusters that
produce large amounts of HCG
d. Highly associated with metastatic cancer (choriocarcinoma)
Predisposing Factors
a. Age of pregnancy is 17 years old below and above 35 years
old
b. Low socioeconomic status
c. Low protein intake
d. History of H. Mole (Complete – 20%; Partial – 15%)
e. Higher incidence in Asian women
2 Types of H.Mole
a. complete mole
b. partial mole
Complete Mole
a. (All) Trophoblastic villi swell and becomes cystic
b. Embryo is dead (1-2mm)
c. No fetal blood present in the villi
d. 46XX or 46XY
▪ Duplication of chromosome carried by the sperm
cell; empty ovum
e. Higher risk to develop choriocarcinoma
Partial Mole
a. Some villi are formed normally
b. Villi are swollen and mishappen
c. Rare: Embryo can grow up to 9 weeks but macerates
d. Fetal blood present in the villi
e. 69 chromosomes
f. 69XX or 69XY
▪ Triploid formation: ovum is fertilized by two sperm
* (Ovum) 23 + (Sperm) 23 + (Sperm) 23 = 69
▪ Sperm did not undergo meiosis = duplication of
chromosomes
g. Rapid decrease of hCG level compare to complete mole
*
Note: Trophoblastic villi produces hCG
Assessment of H.Mole
a. Amenorrhea
b. Positive pregnancy test
c. H. Mole: 1-2 million IU hCG
o Normal pregnancy: 400,000 IU hCG
▪ 100-130 days – hCG levels decline
o Classic sign: No fetal heart sound is heard
d. Uterine size increases faster than usual
o Multiple pregnancy
▪ Increase hCG
▪ Increase uterine size
e. Nausea and vomiting (Hyperemesis Gravidarum)
f. Gestational Hypertension
o Normal: occurs at 20 weeks
o H. Mole: occurs at an early week
o Hypertension, Proteinuria, Edema
g. UTZ will reveal dense growth (snowflake pattern) but no fetal
growth in uterus
h. Vaginal bleeding (4
th to 16th week)
o Spotting (dark brown blood)
o Profuse fresh flow
i. Discharge of clear fluid-filled vesicles (Hydropic vesicles)
Nursing Management
a. Maintain fluids and electrolyte balance
b. Emphasize that pregnancy should be avoided for 1 year
c. Administer blood replacement as ordered
o Properly typed and properly cross-matched
d. Provide emotional support
Premature Cervical Dilatation also called
Incompetent Cervix
Complications of H. Mole
a. Gestational Trophoblastic Tumors
o Persistent trophoblastic proliferation after H. mole.
o Choriocarcinoma – most severe malignant
complication that involve the transformation of chorion into cancer cells that invade and erode blood vessels, and uterine muscles
Incompetent Cervix
a. “Habitual Aborters”
b. The cervix dilates prematurely and cannot hold the fetus
until term
c. Painless cervical effacement and dilatation in early midtrimester resulting in expulsion of products of conception
Risk Factors
a. Increased maternal age
b. Congenital structural defects
c. Trauma to cervix
d. Repeated D&C – may be due to cervical tear
Incompetent Cervix: Assessment
a. (Bloody) Show-pink-stained vaginal discharge – mucus plug
b. Increased pelvic pressure
c. Premature rupture of membrane
d. Contractions in mid-trimester
e. Presence of painless cervical dilatation
f. Note: Possible loss of pregnancy if not managed treated
Incompetent Cervix: Nursing Management
a. Place woman on bed rest for 24 hours
b. Observe for bleeding, uterine contractions, and rupture of
BOW
c. If BOW ruptures, the sutures are removed
d. If uterine contractions occur, the woman is given Ritodrine to
stop the contractions
o Ritodrine – tocolytic drug
e. Post-op care: Restrict activities for the next 2 weeks including
coitus
f. Place in a slight or modified Trendelenburg position
