NMx of Pregnancy at Risk: Pregnancy-Related Complications, Selected Health Conditions and Vulnerable Populations Flashcards
Chapter 19+20
How does should a nurse manage spontaneous abortion?
Constant Monitoring, Support Interventions
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
Threatened Spontaneous Abortion
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 
Complete Spontaneous Abortion
(Passage of all products of conception)
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 
Inevitable Spontaneous Abortion
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)
Missed Spontaneous Abortion
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 
Incomplete Spontaeous Abortion
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 

What to assess for an spontaneous abortion?
- 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
What are the medications used for spontaneous abortion?
- Misoprostol (cytotec)
- Mifepristone (RU-486)
- Dinoprostone (cervidil)
What is the hallmark sign of ectopic pregnancy?
Ectopic Preganancy: Eggs implants outside of the uteris.
Abdominal pain with spotting within 6 to 8 weeks after missed menses.
What are the laboratory and diagnostic findings of ectopic preganancy?
Transvaginal Ultrasound
Serum Beta hCG
Absence of hCG indicated no pregnancy.
Include additional testing to prevent rupture.
What is the therapeutic management of ectopic pregnancy?
Meds, Surgery
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-
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
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
Hydatiform Mole
GTD
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
Choriocarcinoma
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 
Cervical Insufficiency
Clinical Manifestation & Diagnostic Tests
*Premature dilatation of cervix
Cause unknown; possibly due to cervical damage
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
Cervical Insufficiency
Cervical Cerclage Management
Indications, Complication
- Sewn cervix with ligature
- 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
Therapetic Management for Cervical Insuffiency
- 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
Placenta Previa
Clinical Manifestation, Therapeutic/ Nursing Management
- Cause unknown; placental implants over cervical os
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
What are the risk factors and clinical manifestations of Placental Abruption?
*Separation of placenta leading to compromised fetal blood supply
MEDICAL EMERGENCY
Etiology unknown
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
What are the therapeutic and nursing managements of Placental Abruption?
*Separation of placenta leading to compromised fetal blood supply
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
What are the risk factors and symptoms of hyperemesis  gravidarum?
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.
What are the therapeutic managements of Hyperemesis Gravidarum?
NonPharm/ Pharm Interventions
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
When does chronic hypertenion develop into preeclampasia?
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.
What is gestational hypertension?
An onset of hypertension without proteinuria after 20 weeks of preganancy.
For a woman who previously had a normal blood pressure prior pregnancy.
