T4 Advanced Organizer Part 4 Flashcards
What are the different types of abortion?
- Threatened
- Inevitable
- Incomplete
- Septic
- Missed
- Habitual (Recurrent)
What makes up Threatened Abortion?
Bleeding: Vaginal spotting early in gestation
Cramping: Mild
Passage of tissue: No
Cervical dilation: No (cervix is closed)
Management for Threatened Abortion?
Possible mild activity restriction with bedrest 24-48 hours
no stimulation of sexual intercourse or orgasm for 2 weeks
What makes up Inevitable Abortion?
Bleeding: Moderate/heavy
Cramping: Mild-severe
Passage of tissue: Maybe (if all products of conception not passed spontaneously, they can be manually removed)
Cervical dilation: Yes
How may additional products of conception be removed?
- vacuum curettage (prostaglandin analog) to evacuate uterus
- D&C
Management of Inevitable abortion
Bed rest if no pain, bleeding or infection
if ROM, pain, bleeding, or infection then preg termination is accomplished by D and C
What makes up Incomplete abortion?
Bleeding: Heavy/profuse
Cramping: Severe
Passage of tissue: Yes
Cervical dilation: Yes, with tissue in cervix
Management of Inevitable Abortion?
May require additional cervical dilation before curettage
What makes up Complete abortion?
Bleeding: Slight
Cramping: Mild
Passage of tissue: Yes
Cervical dilation: No (cervix has already closed after tissue is passed)
Which abortion?
All fetal tissue and products of conception passed in bleeding; ultrasound shows empty uterus
Complete
Which abortion?
Involves expulsion of the fetus with retention of the placenta
Incomplete
What makes up septic abortion?
Bleeding: Varies (scant to heavy, malodorous)
Cramping: Varies
Passage of tissue: Varies
Cervical dilation: Yes, usually
Other: Fever, abdominal pain and tenderness
Management of Septic Abortion?
Termination of pregnancy
Culture and sensitivity studies to initiate appropriate antibiotics
Management of complete abortion?
No other interventions needed if UC are adequate to prevent hemorrhage and no infection is present
May need suction curettage to ensure there is no retained fetal or maternal tissue
Which abortion?
Has an ODOR
Septic
What makes up a missed abortion?
Bleeding: None, spotting
Cramping: None
Passage of tissue: No
Cervical dilation: No
Management of missed abortion?
If spontaneous evacuation of the uterus does not occur within one month uterus is evacuated by method appropriate to duration of pregnancy
Blood clotting factors monitored
DIC with uncontrolled hemorrhage may develop in cases of fetal death after week 12
Which abortion?
Retained nonviable embryo or fetus for 6 weeks or more– fetus has died and placenta atrophied but products of conception are retained; cervix is closed
Missed
What makes up habitual or recurrent abortion?
Bleeding: Varies
Cramping: Varies
Passage of tissue: Yes
Cervical dilation: Yes, usually
Which abortion?
3 or more consecutive losses before 20 weeks gestation
Habitual/recurrent
Management of recurrent abortion?
ID and treat underlying cause if possible
Prophylactic cerclage if r/t cervical insuffici
Education for after an abortion?
- Clean the perineum after each voiding or BM and change perineal pads often
- Shower (avoid tub baths) for 2 weeks
- Avoid tampon use, douching, and vag intercourse for 2 weeks
- Notify doc if an elevated temp (>100.4) or a foul smelling vag discharge develops; also notify doc if bright red bleeding occurs or if there is bleeding with tissue fragments
- Eat foods high in iron and protein to promote tissue repair and RBC replacement
- Seek assistance from support groups, clergy, or professional counseling as needed
- Allow yourself (and your partner) to grieve the loss before becoming a parent again
Early pregnancy loss
Don’t forget to look at handout!!
What is a missed abortion?
Retained nonviable embryo or fetus for 6 weeks or more–the fetus has died and the placenta is atrophied but products of conception are retained–the cervix is closed
How is a missed abortion treated?
If spontaneous evacuation of the uterus does not occur within one month, uterus is evacuated by method appropriate to duration of the pregnancy. Blood clotting factors are monitored
What may develop from a missed abortion?
DIC with uncontrolled hemorrhage may develop in cases of fetal death after week 12
What occurs with a D&C?
A surgical procedure in which the cervix is dilated if necessary and a curette is inserted to scrape the uterine walls and remove uterine contents
What pain relief is given during D&C?
Administer analgesics or sedatives IV or orally (conscious sedation)
Paracervical block using local anesthetic may be administered
What needs to be done prior to a D&C?
- Full history obtained
2. General and pelvic exams conducted
What is done after evacuation of particles from the uterus?
oxytocin is given to prevent hemorrhage
What is given for excessive bleeding after a miscarriage?
Methergine or prostaglandin derivative
contract the uterus
What is hyperemesis?
Severe vomiting of pregnancy that causes weight loss of > 5% of prepregnancy weight
What is the problem with hyperemesis?
Dehydration, electrolyte imbalance, nutritional deficiencies (to mom and growing baby).
Ketonuria (which CAN cross the placenta)
What causes hyperemesis?
- Increasing levels of: estrogen, progesterone, hCG
- Hyperthyroidism during pregnancy
- Esophageal reflux
- Reduced GI motility (progesterone works on smooth muscles)–decreased secretion of free HCl
- Psychosocial: ambivalence towards pregnancy, increased stress, conflicting feeling regarding motherhood, body changes, lifestyle alterations
What is heightened during pregnancy that may affect hyperemesis?
Sense of smell HEIGHTENED during pregnancy (nose becomes larger to allow for my oxygen) which can potentiate N/V
What kinds of food with a pt with hyperemesis need?
BLAND DIET with small frequent meals
Keep DRY foods at bedside
Dry to wet
Do not drink mass amounts of liquids with meals
Herbal remedies: ginger and lemon
Why is ketonuria so important in the hyperemesis pt.
- Ketones can cross the placenta to the baby
- It is a sign of acid-base imbalance–metabolic acidosis
When should a cerclage be placed?
11-15 weeks on patients known to have prior short cervix or spontaneous miscarriages
Why is a cerclage placed?
This is used in patients with incompetent cervix (cervical dilation without contractions or pain–cervix isn’t holding the pregnancy)
(11-15 wks)
What education do you give the patient who has cerclage?
- Monitor for s/s of preterm labor or infection
- Antibiotics or anti-inflammatory meds may be administered
- If labor begins, tocolytics may be administered
Main thing: SUTURES MUST BE REMOVED before vaginal birth
S/S of pretrm labor/infection?
- PROM
- Mom fever greater than 100.4
- Contractions
- Decreased fetal movement
Why may a pt have sutures closing cervix?
(cerclage)
of they have a short cervix/hx of abortion due to cervical insufficiency
What is gestational trophoblastic disease?
Abnormal growth of trophoblastic tissues, including the placenta and chorion
MOLEY MOLEY MOLEY
Ovum with no yolk sac or partial yolk sac occurs in:
Gestational trophoblastic disease
What is gestational trophoblastic disease PRECURSOR TO?
Cancer!!
it must all be taken out!!
Assessment findings of gestational trophoblastic disease?
- Vaginal bleeding→ brown “prune juice” containing grape like vesicles
- Disparity between uterine size/gest age
- FHT absent (we’d normally be able to heat at 8-10 weeks)
- Ultrasound shows characteristic molar pattern
- Elevated hCG levels
What do you think about when a patient urinates what looks like brown prune juice?
Gestational trophoblastic disease
H. Mole
Treatment of H. Mole?
Suction evacuation regardless of type
Most abort spontaneously, but suction curettage offers a safe, rapid, and effective method of evacuating a h. Mole if necessary
Tested for evidence of malignancy
Treatment initiated for malignancy
Dicharge teaching for H. Mole?
Follow up care for non-malignant GTD:
- Weekly hCG levels iniitally to ensure that any remaining tissue does not turn malignant
- hCG levels monthly for one year
- Chemo prophylactic or as treatment
- Encourage client to prevent pregnancy for one year
Official name of H. Mole?
Gestational trophoblastic disease
What is a Fertilized ovum implanted outside the uterine cavity?
Ectopic pregnancy?
What is the most common site of ectopic pregnancy?
Fallopian tube
Predisposing factors of ectopic pregnancy?
(main is STI)
- History of STD or PID
- Previous tubal pregnancy
- Failed tubal ligation
- IUD (scarring)
- Multiple induced abortions
- Maternal age > 35
- Assisted reproductive techniques
Why may STI be a precursor to Ectopic pregnancy?
because that causes scarring→ lots of scar tissue causes the egg to not be able to travel all the way through to the uterus so it implants somewhere else
Main STI to worry about with Ectopic pregnancy?
Gonorrhea
Signs/Symptoms of Ectopic Pregnancy?
Positive pregnancy test
Vaginal spotting or severe bleeding
Sharp abdominal pain, unilateral that GOES UP TO THE SHOULDER
What is this:
Shoulder pain as a result of internal bleeding irritating the diaphragm and phrenic nerve
Ectopic pregnancy
How is ectopic pregnancy confirmed?
transvaginal ultrasound
What is DIC?
A pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding or both and clotting
Is DIC primary or secondary?
Secondary!!
Occurs b/c of something
What can trigger DIC?
- Abruptio placenta
- Retained dead fetus (missed abortion)
- AF embolus
- Severe preeclampsia-
- Gram- sepsis
- HELLP syndrome
What is the main precursor to DIC?
Preeclampsia
What is the management of DIC?
Treat underlying problem
-monitor for S/S of shock
How can the underlying problem of DIC be treated?
- If problem is retained dead fetus→ remove the dead fetus
- If problem is preeclampsia→ treat preeclampsia
- If problem is abrupted placenta→ remove abrupted placenta
What can be a consequence of DIC?
Renal failure
monitor output
What is a D&C?
Dilation and curettage
What urinary output may indicate renal failure?
Symptoms of shock?
- Rapid thready pulse (tachycardia)–first thing you see
- Pallor
- Change in LOC
- Hypotension (last thing)
Management for hypovolemic shock or hemorrhagic shock??
- IV fluids
- T&C for blood products
- Monitor VS & output
- Measure blood loss
How can blood loss be measured?
Weight the pad!
1g=1mL
Who is at more risk of developing placenta previa?
-Multiple gestation
-Closely spaced pregnancies
-Maternal age > 35
High parity
-African or asian ethnicity
-Previous placenta previa
-Previous c/s or suction
What should NOT be done with a client with a hx of placenta previa?
- no vag exams
- no internal monitors on baby
What is placenta previa?
Placenta is planted in the lower uterine segment such that it completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces
Symptoms of placenta previa?
PAINLESS bright red bleeding after 20 weeks
Management of placenta previa?
- observation and bedrest
- NO VAG EXAMS
- C section
Symptoms of Placental abruption
PAINFUL abdominal pain with or without bleeding, uterine tenderness, confirmed after delivery
What is placental abruption?
Premature separation of the placenta; the detachment of part or all of a normally implanted placenta from the uterus before the birth of the infant
P. previa or abruption?
bleeding ALWAYS visible and bright red
P. Previa
P. previa or abruption?
Bleeding may not always be present, if so it is dark red
P. Abruption
P. previa or abruption?
No pain
P. Previa
P. previa or abruption?
constant abdominal pain/tenderness
P. Abruption
P. previa or abruption?
Continuous UC with minimal or no relaxation period
P. Abruption
P. previa or abruption?
NOt in labor
P. Previa
P. previa or abruption?
fetal distress present
late dcels
P. Abruption
What kind of dcels may be present with placental abruption?
LATE decels
P. previa or abruption?
normal FHR unles HEAVY blood loss
P. Previa
P. previa or abruption?
No relationship with the fetal presentation or station
P. Abruption
P. previa or abruption?
fetal MALPRESENTATION is common; engagement absent
P. Previa
What presentation is common with Placenta previa?
breech or transverse lie
engagement absent
P. previa or abruption?
Fundal height is GREATER than expected for gestational age?
P. Previa
P. previa or abruption?
Fundal heigh needs to be measured over time; increase height may be concealed bleeding
P. Abruption
