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129 Cards in this Set
- Front
- Back
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Causes for bleeding in early pregnancy
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spontaneous abortion or miscarriage
incompetent cervix ectopic pregnancy hydatidiform mole |
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causes for bleeding in late pregnancy
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abruptio placenta
placenta previa |
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blood loss management
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ultrasound including vaginal to look for cause of bleeding
bed rest often prescribed but no evidence to support it termination may be medically necessary if bleeding cannot be controlled |
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Miscarriage classifications
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threatened
inevitable incomplete complete |
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signs and symptoms of inevitable or imminent miscarriage
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bleeding, cramping increase cervix dilation- cannot save pregnancy, ROM
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lab values of inevitable or imminent miscarriage
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H & H
T & C |
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interventions of inevitable or imminent miscarriage
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possible D & C if bleeding is excessive
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D & C
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Dilation and Cutting
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characteristics of spontaneous miscarriage or abortion
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15-30 percent of all pregnancies
natural causes bleeding before week 6 is rarely severe bleeding after week 12 can be profuse |
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# of weeks considered to be an early miscarriage
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before week 16 of preg.
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late miscarriage
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between 16-24 weeks
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Incomplete miscarriage
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part of POC are retained, usually placenta
heavy bleeding continues |
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reaction to an incomplete miscarriage
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stabilize
iv fluids T&C, D&C-or induce labor if greater than 14-16 weeks pitocin or methergine |
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Complete miscarriage
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All POC are expelled
No interventions other than rest: watch for bleeding, fever, pain Give Rhogam given if woman is Rh- |
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Nursing management of miscarriage
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monitor for hemorrhage and infection
relieve pain and anxiety prepare for D and C Provide emotional supoort Provide education |
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Missed miscarriage
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fetus dies in utero but is not expelled
cervix is closed and signs of pregnancy subside |
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complications of missed miscarriage
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infection and DIC
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DIC
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Disseminated Intervascular Coagulation
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Ectopic Pregnancy
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fertilized ovum implants outside the uterine cavity
usually tubal and 98% ampulla Incidence is increasing |
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Recurrent or habitual miscarriage
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three or more consecutive spontaneous abortions
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ways to determine cause of recurrent miscarriage
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defective spermatosoa or ova
endocrine factors deviations of uterus infection autoimmune |
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Ectopic pregnancy-Causes
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caused by any condition that narrows the lumen of tub or delays transport such as:
infection peritubal adhesions endometriosis developmental abnormalities |
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pathophysiology of ectopic pregnancy
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Conception
implantation corpus luteum functions normally at weeks 6-12, zygote grows large enough to rupture tube 2% of all pregnancy 10-20% chance of having another pregnancy |
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Diagnosis of Ectopic Pregnancy
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Ultrasound
hCG levels are lower than usual pregnancy increases Culdocentesis Laparoscopy PE: pelvic mass or adnexal tenderness |
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Manifestations of ectopic pregnancy
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Amenorrhea
Spotting or light bleeding abdominal or pelvic pain |
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Management if unruptured ectopic pregnancy
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methotrexate followed by leucovorin
linear salpingostomy |
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Manifestations of ruptured pregnancy
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Rupture-->internal hemorrhage
Sudden, sharp, knife-like pain in LQ spotting or light bleeding faintness, syncope, shock, referred shoulder pain |
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management of ruptured ectopic pregnancy
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surgical emergency
salphingectomy Cullins sign-umbullicus has bluish tint |
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Nursing care of ectopic pregnancy
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monitor ammount and characteristics of vaginal bleeding
Monitor for S&S of impending shock: VS Assess and control pain emotional support:loss of pregnancy and possiblity of infertility fluids |
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2nd trimester bleeding
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gestational trophoblastic disease
premature cervical dilation |
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nursing care of ectopic pregnancy
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Post-op care
methotextrate- teach: side effects, no folic acid or alcohol, no sex until hCG level=0, keep all follow-up appointments |
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benign neoplasm of the trophoblast in which the chorionic villi of the placenta proliferate and fill with clear, viscous fluid, forming grape-like clusters that fill the uterus
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Gestational trophoblastic disease- hydatidiform Mole
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characteristics of gestational trophoblastic disease-Hydatidiform Mole
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Occurs when the trophoblasts develop abnormally
-trophoblasts are the peripheral cells that attach the fertilized ovum to the uterine wall Resulting in abnormal growth of the placenta fetal part of the pregnancy does not develop |
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Incidence of GTD-HM
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1 in every 1000-2000 pregnancies
Condition seems to occur most often in women with low protein intake <18 and >35, Asian heritage, Family history |
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Manifestations of GTD-HM
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elevated hCG levels- Sx vomiting excessively, brown vag. bleeding
passage of vesicles in vaginal discharge uterine size greater than dates absence of FHT in presence of other signs of pregnancy HDP prior to 20-24 weeks anemia from bloodloss hyperthyroidism |
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pathophysiology of GTD-HM
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the fluid-filled vili form grape-like clusters of tissue that can rapidly grow large enough to fill the uterus to size of an advanced pregnancy
maybe complete with no fetus, ore partial with some fetal tissue |
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Hydatiform mole diagnosis
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ultrasound-snowstorm appearance
hCG levels |
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immediate management of hydatidiform mole
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Chest x-ray, CT, or MRI to detect metastasis
CBC and T&C Vacuum aspiration to extract the mole, curettage to remove all tissue only then,IV oxytocin to contract uterus hysterectomy if excessive bleeding or preserving childbearing function is not a consideration |
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Hydatidiform Mole follow-up
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essential to detect chorocarcinoma
monitored through serum hCG levels -q1-2 weeks until negative -then every 1-2 months for one year |
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choriocarcinoma
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a rapidly growing malignancy which is highly metastatic, especially to the lungs
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nursing considerations for hydatidiform mole
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emphasize follow up care
pregnancy must be avoided for 1 year due to monitoring of hCG levels assist in selecting a workable form of birth control |
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Premature cervical dilation
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painless, premature dilation of cervix
usually in 2nd trimester followed by SROM and birth of immature fetus -associated with recurrent 2nd trimester abortions |
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cause of premature cervical dilation
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cause is often unknown but may include cervical trauma and structural defects of cervix
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treatment of Premature Cervical Dilation
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cervical cerclage at 12-15 weeks
McDonalds or Shirodkar's procedure- purse string suture to reinforce cervix done under cervical block as day surgery- Remove at about 36 weeks |
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post-operative care of cerclage
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abstain from intercourse
avoid prolonged standing/heavy lifting expect some discharge periodic ultrasound possible bedrest, tocolytic drugs home monitoring- cramping, vag discharge, backache |
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tocolytic drugs
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drugs that stop contractions
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Contraindications of cerclage
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uncertain diagnosis
ROM vaginal bleeding and cramps cervix dilated >3 cm |
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client education of Cerclage
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sutures can be removed at 37 weeks
if C/S is planned, sutures will be left in place must contact health care provider immediately if ROM of labor begins -contractions < 5 min. apart Success rate of 80-90% for next pregnancy |
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Maternal Hemorrhagic disorders in third trimester pregnancy
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placenta previa
abruptio placentae |
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Placenta Previa
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placenta implants in the lower uterine segment
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Placenta Previa risk factors
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Previous previa, C/S, or induced abortion
Age greater than 35 multiple gestations multiparity smoking and cocaine use African and asian, male fetuses |
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Placenta Previa manifestations
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BRIGHT RED, painless bleeding, usually small amount of tends to recur
Soft, non-tender uterus with normal tone fetus not engaged |
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Cause of Placenta Previa
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5 per 1000 pregnancies
thought to occur when the placenta is forced to spread to find an adequate exchange surface |
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pathophysiology of placenta previa
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stretching and thinning of LUS during 3rd trimester
Causing placental villi to seperate from uterine wall |
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Diagnosis of placenta previa
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made by ultrasound
NO vaginal exam until complete previa is ruled out |
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Placenta previa management
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depends on age of fetus and amount of bleeding
-if preterm and bleeding is slight. Bedrest, pelvic rest, assess amount of bleeding -immediate delivery of bleeding is excessive Risk of postpartum hemorrhage |
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Placenta Previa prognosis
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maternal morbidity rate 5%
mortality rate 1% fetal risk-preterm birth and/or death due to immaturity |
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things to remember for Placenta previa
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bright red blood
painless vaginal bleeding |
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Premature seperation of placenta
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abruptio placenta
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Abruptio placentae characteristics
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serious even accounting for serious maternal and fetal morbidity and mortality
1% pregnancies 10x greater risk in subsequent pregnancies |
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manifestations of abruptio placenta
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dark red vaginal bleeding
acute abdominal or back pain uterine tenderness and hypertonicity (hard) bleeding into myometrium Shock- often out of proportion to blood loss |
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diagnosis of abruptio placenta
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ultrasound
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risk factors of abruptio placenta
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hypertension
cocaine use trauma smoking poor nutrition previous abruption |
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management of abruptio placenta
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depends on amount of blood loss and fetal maturity
-Expectant-v/s, IV fluid, CBC, T&C -Emergent-upright, IV wideopen, OR Prognosis |
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symptoms of premature seperation of Placenta
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KNOW
dark red vaginal bleeding abdominal pain uterine tenderness |
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Hyperemesis Gravidum
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sever, persistent vomiting resulting in dehydration, starvation, and eventually death if not treated
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hyperemesis gravidarum pathophysiology
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dehydration leads to fluid and electrolyte imbalances as well as acid base imbalance
-metabolic lkalosis from loss of hydrochloric acid from stomach -can progress to acidosis from vomiting alkaline intestinal juices |
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clinical manifestations of hyperemesis gravidarum
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severe, persistant vomiting
hypovolemia sever hypokalemia severe protein and vitamin deficiencies |
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etiology of hyperemesis gravidarum
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unknown
thyroid dysfunction decreased gastric motility psychological factors must rule out other causes such as viral hepatitis, pancreatitis, intestinal obstruction, cholecystitis |
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management of hyperemesis gravidarum
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depends on severity of symptoms
initial treatment is conservative -dietary changes -emotional support -alternative therapies such as ginger or acupressure |
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pharmacologic therapy hyperemesis gravidarum
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pyridoxin (vitamin B6)
doxylamine antiemetics antihistamines-benedryl anticholinergics cortico-steriods |
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Hyperemesis Gravidarum hospitalization management
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IV fluids
Glucose, electrolytes, vitamin replacement enteral tube feedings for those who continue to vomit and lose weight despite the above small meals with liquids in between when available |
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Hyperemesis Gravidarum nursing implications
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strict I&O
daily weight Urine for ketones Oral hygiene |
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HDP and PIH
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Hypertensive Disorders of Pregnancy
Pregnancy Induced Hypertension |
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HDP characteristics
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most common medical disorder of pregnancy 12-20% of all pregnancies
leading cause of maternal deaths |
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classifications of HDP
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Chronic hypertension
Gestational HYpertension Transient hypertension |
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chronic hypertension
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hypertension prior to pregnancy
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gestation hypertension
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>140/90
2 elevated measurements in 7 days maternal organ dysfunction |
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Transient hypertension
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documented high blood pressure
no preeclampsia resolves within 12 weeks postpartum |
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Normal BP before birth
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140/90
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HDP
PIH |
Hypertensive Disorders of Pregnancy
Pregnancy Induced Hypertension |
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Chronic hypertension
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hypertension prior to pregnancy
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gestational hypertension
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>140/90 and MAP 105
2 elevated measurements in 7 days classified by maternal organ dysfunction |
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transient hypertension
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documented high blood pressure
no preeclampsia resolves within 12 weeks postpartum |
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Normal BP prior to birth
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140/90
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multi-organ system dysfunction with HDP
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likely due to hypo-perfusion
vasospasm endothelial damage platelet aggregation |
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hypo-perfusion
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decreased circulation
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Pulmonay dysfunction of HDP symptoms
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pulmonary edema
pulmonary embolus cyanosis impaired ventilation |
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cardiovascular dysfunction of hdp symptoms
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myocardial ischemia
decreased ventricular performance pulmonary edema |
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Renal dysfunction symptoms of hdp
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proteinuria
oliguria renal failure |
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oliguria
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no urine
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Diagnosing renal dysfunction of hdp
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creatnine and BUN levels
24 hour I&O |
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Hepatic dysfunction of hdp
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increase hepatic artery resistance
Increase liver enzymes Fibrin deposits in arteries ischemia hepatocellular necrosis |
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hepatocellular necrosis
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bleeding in the liver
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End organs affected by hdp
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placenta
renal system generalized edema lungs brain eyes liver hemotologic |
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Blood dysfunction of hdp
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thromocytopenia
increased platelet destruction reduced platelet lifespan increased platelet aggregation |
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neurological dysfunction of hdp
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cerebral edema
increased intracranial pressure scotomata stroke coma seizure |
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scotomata
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see spots
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reproductive dyfunction of hdp
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decreased circulation to uterus
IUGR Fetal Demise Abruption fetal intolerance to labor |
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IUGR
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Intra Uterine Growth Retardation
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most important end organ affected by hdp
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the fetus is an end organ
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mild Preeclampsia
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BP>140/90
proteinuria 1-2+ edema- mild facial and upper extremities weight gain> 2 lbs per week |
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severe Preeclampsia
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BP>160/110
proteinuria 3-4+ oliguria CNS irratability/ visual changes hyperflexia and possible clonus epigastric pain |
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clonus
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sever shaking of feet when dorsiflexed
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Risk for Preeclampsia
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Prima and multiparous
Hx of preeclampsia (in partner too) Diabetes/vascular/renal disease <20 and >40 Multiple gestations-5x greater hydatidiform Mole previous preeclampsia family history obesity |
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Etiology of preeclampsia
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increased vasoconstrictor tone
abnormal prostaglandin action endothelial cell action immunologic factors genetic predisposition |
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Eclampsia=
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seizures
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S & S of impending seizure
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sudden rise in BP
increase temp HA blurred visions or spots brisk reflexes |
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occurrence of eclampsia
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71% before delivery
29% after delivery-usually before 48-72 hours after delivery |
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Seizure management
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Maintain oxygenation
minimize aspiration pharmacological agents monitor for increased intercranial pressure fetal surveillance |
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Lab diagnostics of eclampsia
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CBC
alkaline phosphate lactic dehydrogenase aspartate aminotranserase alanine aminotransferase |
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assessment of eclampsia labs
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hemolysis:
coagulation defects rbc destruction decreased platelet count-dangerous decreased H & H |
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Medical management of eclampsia
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magnesium sulfate
antihypertensives: apresoline and labetalol |
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Magnesium sulfate
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prevents seizures
CNS depressant bolus 4-6 grams over 15-20 min keep calcium gluconate on hand if levels become toxic |
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apresoline
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5-10mg q20-30 min
max dose of 30-40mg/24 hours |
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labetalol
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antihypertensive
10mg IV push max dose 330-400mg/24h |
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diagnosis of toxic levels of magnesium sulfate
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assess breathing, I & O, diminished reflexes if too high-->stop IV and call DR
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HELLP syndrome
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unusual manifestation of hdp without signs or symptoms of preeclampsia
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Diagnosing HELLP syndrome
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based off of lab findings
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HELLP stands for...
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Hemolysis
Elevated Liver enzymes Low Platelets |
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Incidents of HELLP syndrome
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4-14%
>25 years white multipara |
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nursing implications for HELLP
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transfer to ICU
supportive care monitor labs closely extreme vigilance |
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complications of HELLP
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abruptio placenta
seizures acute renal failure pulmonary edema cardiac failure cerebral hemorrhage DIC Fetal- IUGR, Hypoxia, death |
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Prevention of HELLP
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Low does aspirin, calcium, magnesium, zinc, fish oil
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management of HELLP
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prevention
early detection only know cure is delivery delivery is recommended as soon as fetus is mature if HDP is mild severe preeclampsia requires prompt delivery regardless of gestational age |
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Nursing assessment for HELLP
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assess for risk factors for developing HDP
assess for subtle symptoms such as HA, visual changes, epigastric pain, edema, clonus, DTR assess fetal health |
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nursing interventions for mild preeclampsia
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usually at home so education
bedrest, frequent bp checks, high protein diet, avoid excessive salty foods, maintain high fiber and water intake |
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signs of magnesium toxicity
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sudden hypertension
urine output of less than 30 ml/hr resps less than 12/min hyporeflexia/absence of DTR's slurred speech |
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Postpartum Care of preeclampsia
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continue to monitor closely for 48 hours
continue magnesium sulfate for 24-48 hours women is at risk of boggy uterus and hemorrhage hemoconcentration makes her less tolerant of excessive blood loss |
