NMx of Pregnancy at Risk: Pregnancy-Related Complications, Selected Health Conditions and Vulnerable Populations

Question 1

How does should a nurse manage spontaneous abortion?

Constant Monitoring, Support Interventions

Answer 1

Continue Monitoring
* Passage of products of conception
* Vaginal bleeding*
* Pad count
* Pain level
* Preparation for procedures
* Medications

Support
* Physical and emotional
* Stress that woman is not the cause of the loss
* Verbalization of feelings
* Grief support
* Referral to community support group

*gushing, blood clots; more remnants

Question 2

Threatened Spontaneous Abortion

Answer 2

Assessment findings
* Slight vaginal bleeding present in early pregnancy
* No cervical dilation
* Mild abdominal cramping
* Closed cervical os
* No passage of fetal tissue

Diagnosis
- Vagina, ultrasound to confirm if sac is empty 
- Declining maternal serum, hCG and progesterone levels to provide additional information about viability of pregnancy

Therapeutic management
- Conservative, supportive treatment
- Possible reduction in activity in conjunction with nutritious diet and etiquette hydration 

Question 3

Complete Spontaneous Abortion
(Passage of all products of conception)

Answer 3

Assessment findings:
- History of vagina bleeding in abdominal pain
- Passage of tissue with subsequent decrease in pain and significant decrease in vagina bleeding

Diagnosis
-Ultrasound demonstrating an empty uterus

Therapeutic management
- No medical or surgical intervention necessary
-Follow up appointment to discuss family planning 

Question 4

Inevitable Spontaneous Abortion

Answer 4

Assessment findings
* Vaginal bleeding
* Rupture of membranes
* Cervical dilation
* Strong abdominal cramping
* Possible passage of products of conception

Diagnosis
- Ultrasound and the hCG Levels to indicate pregnancy loss

Therapeutic management
- Vacuum Curettage of products of conception are not passed to reduce risk of excessive bleeding and infection 
- Prostaglandin analogues, such as misoprostol to empty out uterus of retain tissue (Only used in fragments are not completely passed)

Question 5

Missed Spontaneous Abortion

Answer 5

Assessment findings

* Absent uterine contractions
* Irregular spotting
* Possible progression to inevitable abortion

Diagnosis
- Ultrasounds identify projects of conception in Uterus

Therapeutic management
- Evaluation of uterus, but using suction Curettage during first trimester, dilation and evacuation during second trimester 

Question 6

Incomplete Spontaeous Abortion

Answer 6

Assessment findings
* Heavy vaginal bleeding
* Intense abdominal cramping
* Cervical dilation

Diagnosis
* Ultrasound demonstrating their products of conception still in Uterus

Therapeutic management
- Client stabilization
- Evaluation of uterus via D&C or prostaglandin analogue 


Question 7

What to assess for an spontaneous abortion?

Answer 7

• Vaginal bleeding*
• Cramping or contractions
• Vital signs
• Continuous monitoring
• Pain level
• Patient understanding
• Provide support

*Is it a bright or dark red
Saturation of pad
How often must she change pad
saturated pad within 1 hour is SIGNIFICANT

Question 8

What are the medications used for spontaneous abortion?

Answer 8

• Misoprostol (cytotec)
• Mifepristone (RU-486)
• Dinoprostone (cervidil)

Question 9

What is the hallmark sign of ectopic pregnancy?

Ectopic Preganancy: Eggs implants outside of the uteris.

Answer 9

Abdominal pain with spotting within 6 to 8 weeks after missed menses.

Question 10

What are the laboratory and diagnostic findings of ectopic preganancy?

Answer 10

Transvaginal Ultrasound
Serum Beta hCG

Absence of hCG indicated no pregnancy.
Include additional testing to prevent rupture.

Question 11

What is the therapeutic management of ectopic pregnancy?

Meds, Surgery

Answer 11

Medical: drug therapy (methotrexate*, prostaglandins, misoprostol, and actinomycin)

Surgery if rupture (salpingostomy)

Rh immunoglobulin

*methotrexate slows down the immune system and reduces inflammation

*Salpingostomy - removal of fallopian tube (unilateral or B/L depending on situation and maternal age)

*Rh immunoglobulin is administered if the women is Rh-

Question 12

What is the therapeutic management of Gestational Throblastic Disease?

Gestational Thromoblastic Disease (GTD) is when the egg and sperm produces an empty embryo. Two types: Hydatidiform Mole (Placental development)  and Choriocarcinoma (trophoblast) . Cause is unknown. PREGNANCY IS NOT VIABLE

Answer 12

Dilatation & curretage (D&C)
* Immediate evacuation of uterine contents

Long term follow up and monitoring of hcG levels
* Check hcG levels every week for 3 consecutive weeks until hcG serum levels are undetectable, then monthly for 1 year
Chest radiograph every 6 months

Prophylactic chemotherapy

Choriocarcinoma

NO PREGNANCY FOR 1 YEAR
* Pregnancy within 1 → risk for hemorrhage
Use birth control for the duration of that year

*Intervention: D&C

Question 13

Hydatiform Mole

GTD

Answer 13

Disorder of placental development

COMPLETE MOLE
* Benign neoplasmic tissue coming from gestation, not mother
* Mole contains no fetal tissue and develops from an “empty egg,” which is fertilized by normal sperm
* The embryo is not viable and dies, No circulation is established and no embryonic tissue is found.
* Associated with the development of trio carcinoma
Uterine enlargement, greater than expected for gestational dates, hyperemesis and preeclamptic symptoms

PARTIAL
* Triploid karyotype (69 chromosomes, Since to sperm cells, have double contribution by fertilizing the oven
* Women present clinical features of mist or incomplete abortion, including: Vagina bleeding, and a small or normal size for date uterus 

Clinical Manifestations
* Vaginal bleeding
* Anemia
* Excessively large uterus
* Preeclampsia
* Hyperemesis
* Amenorrhea
* Fluid retention and swelling
* Extremely high hcG levels
* Absence of FHR or fetal activity expulsion of grape-like vesicles

*vaginal bleeding and cramping or contractions

Question 14

Choriocarcinoma

Answer 14

Results from chorionic malignancy from the trophoblastic tissue
Typically asymptomatic.

Indications:
* SOB (Indicates metastasis to lungs)
* Vaginal bleeding
* Small to normal sized uterus

Therapeutic management:

Chemotherapy 

Question 15

Cervical Insufficiency

Clinical Manifestation & Diagnostic Tests

*Premature dilatation of cervix
Cause unknown; possibly due to cervical damage

Answer 15

Clinical Manifestation
* Pink tinged vaginal discharge
* Low pelvic pressure
* Cramping with abdominal bleeding
* Loss of amniotic fluid
* Cervical dilation

Diagnostic Tests
* Transvaginal ultrasound b/w 16-24 weeks
* Determines cervical length
* Evaluate for shortening
* Can predict early preterm labor

Question 16

Cervical Insufficiency

Cervical Cerclage Management

Indications, Complication

• Sewn cervix with ligature

Answer 16

• Placed up to 28 weeks gestation, cannot be done after 28 weeks*
• Indications of cerclage
  
  • History of second trimester pregnancy loss with PAINLESS DILATION
  • Prior cerclage placement for cervical insufficiency
  • Spontaneous preterm birth prior to 34 weeks gestation
  • Painless cervical dilatation on physical exam of 2nd trimester
• Complications
  
  • Suture displacement
  • Rupture of membranes
  • Chorioamnionitis

• by the 28th week, remove cerclage prior term and give betamethazone

Question 17

Therapetic Management for Cervical Insuffiency

Answer 17

• Monitor closely for signs of preterm labor
  
  • Backache
  • Increase in vaginal discharge
  • Rupture of membrane
  • Uterine contractions
• Bed rest
• Pelvic rest
• Avoidance of heavy lifting
• Progesterone supplementation of women at risk for preterm birth
• Placement of cervical pessary

*Pessary - round silicone device at mouth of cervix

Question 18

Placenta Previa

Clinical Manifestation, Therapeutic/ Nursing Management

• Cause unknown; placental implants over cervical os

Answer 18

Clinical Manifestation
* R/F: previous delivery by caesarean section
* Vaginal bleeding (painless, bright red) in second or third trimester

• spontaneous cessation then recurrence

Therapeutic management:
* dependent on bleeding
* amount of placenta over os
* fetal development and position
* maternal parity
* labor signs and symptoms

Nursing management
* Monitoring of maternal–fetal status
* Vaginal bleeding; pad count
* Avoidance of vaginal exams
* FHR
* Support and education: fetal movement counts, effects of prolonged bed rest (if necessary); signs and symptoms to report
* Preparation for possible cesarean birth

Question 19

What are the risk factors and clinical manifestations of Placental Abruption?

*Separation of placenta leading to compromised fetal blood supply
MEDICAL EMERGENCY
Etiology unknown

Answer 19

Risk factors
* smoking
* cocaine use during pregnancy
* maternal age over 35 years
* hypertension
* placental abruption in a prior pregnancy

Nursing Assessment
* Bleeding (dark red)
* Pain (knife-like), uterine tenderness, contractions
* Fetal movement and activity (decreased)
* Fetal heart rate
* Laboratory and diagnostic testing: CBC, fibrinogen levels, PT/aPTT, type and cross-match, nonstress test, biophysical profile

Question 20

What are the therapeutic and nursing managements of Placental Abruption?

*Separation of placenta leading to compromised fetal blood supply

Answer 20

Therapeutic management:
* assessment, control, and restoration of blood loss
* positive outcome
* prevention of DIC*

Nursing management
* Tissue perfusion: left lateral position, strict bed rest, oxygen therapy, vital signs, fundal height, continuous fetal monitoring
* Support and education: empathy, understanding, explanations, possible loss of fetus, reduction of recurrence

Interventions: blood tranfusions, EFM, two IVs, monitor fetus

*Disseminated Intavascular Coagulation: abnormal blood clots in blood vessels

Question 21

What are the risk factors and symptoms of hyperemesis  gravidarum?

Answer 21

Risk Factors:
* previous pregnancy with HG
* dizygotic birth
* pregnant for the first time

Symptom:
* persistent, uncontrollable N/V*
* Increased hCG

*begins before 9 weeks’ gestation and causes dehydration, nutritional deficiencies, ketosis, electrolyte imbalances, and weight loss of more than 5% of prepregnancy body weight.

Question 22

What are the therapeutic managements of Hyperemesis Gravidarum?

NonPharm/ Pharm Interventions

Answer 22

Therapeutic Management
* Consersative lifestyle and diet
* Hospitalization with I.V. therapy*

Medications:
* Doxylamine (Diclegis)
* Dimenhydrinate (Dramine)
* Promethazine (Phenergan)
* Diphenhydramine (Benadryl)
* Metoclopramide (Reglan)
* Ondansetron (Zofran)

• Primarily Normal Saline; Lactate Ringers for patients going in labor; keep mother NPO for 24-36 hours

Question 23

When does chronic hypertenion develop into preeclampasia?

Answer 23

The pregant patient has a constant BP of more than 140/90 (>S/D) before pregnancy, before 20 weeks of gestation, and more than 12 weeks postpartum.

Question 24

What is gestational hypertension?

Answer 24

An onset of hypertension without proteinuria after 20 weeks of preganancy.

For a woman who previously had a normal blood pressure prior pregnancy.

Question 25

What are the risk factors and signs of preeclampsia?

Preeclampsia: HTN and proteinuria after 20 weeks or early postpartum.

Answer 25

Risk factors:
* family history
* nulliparity
* egg donation
* diabetes
* obesity

Classical signs:
* Dull headache
* Oliguria
* Blurred vision
* Proteinuria
* Epigastric pain
* Right upper quadrant pain
* Hyperactive deep tendon reflexes (DTRs)
* Progressive renal insufficiency

Nursing Assessment:
*BP, urinalysis, nutritional intake, weight, edema, proteinuria

Question 26

How to manage preeclampsia with severe features/ eclampsia?

Answer 26

Hospitalization (Pre-labor/labor)

NONPHARM
* seizure precations
* preconception counseling
* perinatal BP

PHARM
* Daily low dose aspirin (75 to 150mg)
* Betamethasone IM 12 mg 2x in 24 hours for preterm pre-eclamptic/eclamptic clients
* **Magnesium sulfate IV infusion 4 to 6 gm bolus given over 15 to 30 minutes. Maintenance dose of 1 to 2 gm/hr. **
* Hydralazine (Apresoline)- IV bolus 5 to 10 mg every 20 min as needed
* Labetalol (Normodyne)- IV dose 20 to 40 mg every 15 min
* Nifedipine (Procardia)- 10 to 20 mg PO for three doses and then every 4 to 8 hours.
* Furosemide (Lasix)- slow IV bolus of dose 10 to 40 mg over 1 to 2 minutes

*Hydralazine and Labetalol are IV push for HTN. If drops after first adminsitration, don’t give again.

*Furosemide (Lasix) is rarely used, unless patient has a coinciding cardiac issue.

Question 27

How to manage preeclampsia without severe features?

Answer 27

Management for mild symptoms:

Home
* Mild BP - place in bedrest or in side-lying postion
* monitor BP daily every 4-6 hrs/day, report for increased readings
* record daily fetal movement count, report for decrease in movement
* sodium restricted-diet
* encourage to drink six to eight 8-oz glasses of water daily
* go to the hospital if the home management fails to lower BP

Hospitalization
* monitor closely for s/s of severe preeclampsia or impending eclampsia
* give magnesium sulfate during labor

Management continues until the pregnancy reaches at least 37 weeks’ fetal gestation, fetal lung maturity is documented, or complications that immediate birth.

Question 28

How to manage eclamspia?

Eclampsia: onset seizure activity. MEDICAL EMERGENCY.

Answer 28

Management
* Airway, breathing and circulation
* Clear the airway, administer adequate oxygen
* Position woman on left side
* Suction readily available
* IV fluids to replace urine output
* FHR assessment
* Magnesium sulfate and antihypertensive drugs
* Uterine contraction monitoring
* Preparation for birth

Question 29

How to manage Magnesium Sulfate levels?

Magnesium Sulfate helps treat preeclampsia, provides neutral protection of fetus, and slows down labor.

Answer 29

• Normal Magnesium Sulfate levels: 4-7
• Monitor Deep Tendon Reflex (DTR)
• Monitor signs of toxicity (mEq/L)*
  -10, decreased DTR
  -15, respiratory distress
  -25, cardiac arrest

*Antidote: Calciumgluconate (calcium chloride)

Question 30

How to assess for HELLP Syndrome?

Clinical Manifestations and Lab Results

Hemolysis, Elevated Liver enzymes, Low Platelets

Answer 30

Nurse Assessment
* *Monitor for complaints of nausea (with or without vomiting), malaise, epigastric or right upper quadrant pain, headache, and changes in vision.

LAB RESULTS
* Low hematocrit that is not explained by any blood loss
* Elevated LDH, AST, ALT, bilirubin level (liver impairment)
* Elevated BUN, uric acid, and creatinine levels (renal impairment)
* Low platelet count (less than 100,000 cells/mm3)

*Assessment and Management is same as preeclampsia

Question 31

How to manage HELLP Syndrome?

Answer 31

Hospitalization (Pre-labor/labor)

NONPHARM
* seizure precations
* preconception counseling
* perinatal BP

PHARM
* Daily low dose aspirin (75 to 150mg)
* Betamethasone IM 12 mg 2x in 24 hours for preterm pre-eclamptic/eclamptic clients
* **Magnesium sulfate IV infusion 4 to 6 gm bolus given over 15 to 30 minutes. Maintenance dose of 1 to 2 gm/hr. **
* Hydralazine (Apresoline)- IV bolus 5 to 10 mg every 20 min as needed
* Labetalol (Normodyne)- IV dose 20 to 40 mg every 15 min
* Nifedipine (Procardia)- 10 to 20 mg PO for three doses and then every 4 to 8 hours.
* Furosemide (Lasix)- slow IV bolus of dose 10 to 40 mg over 1 to 2 minutes

Question 32

Blood Incompatability

ABO vs Rh- Incompatibility, Nurse Assessment, and Nurse Management

Answer 32

• ABO incompatibility: type O mothers and fetuses with type A or B blood (less severe than Rh incompatibility)
• Rh incompatibility: exposure of Rh-negative mother to Rh-positive fetal blood; sensitization; antibody production; risk increases with each subsequent pregnancy and fetus with Rh-positive blood

Nursing assessment:
* maternal blood type and Rh status

Nursing management:
* RhoGAM at 28 weeks

Question 33

Polyhydramnios

Nurse Assessment, Therapeutic/Nursing Management

Aka Hydramnios
Amniotic fluid >2,000 mL

Answer 33

Nurse Assessment
* R/F:
* Therapeutic management: close monitoring; removal of fluid, indomethacin (decreases fluid by decreasing fetal urinary output)

Nursing management: ongoing assessment and monitoring; assisting with therapeutic amniocentesis

Question 34

Oligohydramnios

Amniotic fluid <500 mL

Answer 34

Nursing assessment: risk factors, fluid leaking from vagina

Therapeutic management: serial monitoring; amnioinfusion and birth for fetal compromise

Nursing management: continuous fetal surveillance; assistance with amnioinfusion, comfort measures, position changes

Question 35

Multiple Gestation

Assessment, Therapeutic/Nurse Management

Pregnancy with two or three fetuses.

Answer 35

Nursing assessment:
* uterus larger than expected for EDB
* ultrasound confirmation

Therapeutic management: serial ultrasounds, close monitoring during labor, operative delivery (common)

Nursing management: education and support antepartally; labor management with perinatal team on standby; postpartum assessment for possible hemorrhage

Question 36

Premature Rupture of Membranes

Prelabor ROM & PPROM

• Prelabor Rupture of Membranes (PROM): Water breaks before labor
• PPROM: Rupture before 37 weeks of gestation

Answer 36

Diagnostic Tests:

Treatment:
* dependent on gestational age
* no unsterile digital cervical exams until woman is in active labor expectant management if fetal lungs immature

Nursing management
* Infection prevention
* Identification of uterine contractions
* Education and support
* Discharge home (PPROM) if no labor within 48 hours

Question 37

Gestational Diabetes Mellitus (GDM)

Risk Factors and S/S of Hypo/Hyperglycemia

Answer 37

Risk Factors:
* Maternal Obesity (BMI >30)
* Maternal age older than 35 years or older
* Previous birth outcome often associated with GDM-macrosomia, maternal hypertension, fetal death or anomalies
* GDM or polyhydramnios in previous pregnancy
* History of abnormal glucose tolerance
* Family history of diabetes
* Multiple pregnancies
* Member of a high-risk ethnic group

S/S:
Hypoglycemia
* Tired, Irritatibility, Restless, Diaphoresis, Excessive Hunger

Hyperglycemia
* Flushed skin, dry mouth, cheynestokes respiration, fruity breath odor

Question 38

How to manage GDM?

Answer 38

Therapeutic Management
* Preconception counseling
* Blood glucose level control (HbA1c <7%)
* Glycemic control
* Nutritional management
* Hypoglycemic agents
* Close maternal and fetal surveillance
* Management during labor and birth