Ricci Chapter 19; ATI Chapters 7 and portions of 9
Differentiate between “MISCARRIAGE” and “ABORTION”. Understand the types of early pregnancy bleeding, how a woman
would present with each, and the management for each:
Spontaneous abortion body does it on its own --- “miscarriage”
Threatened abortion spotting and cramping with NO cervical changes.
Inevitable abortion spotting, cramping, dilation and effacement of cervix
Incomplete abortion portions of embryo or fetus or placenta retained in the uterus.
Complete abortion bleeding cervical dilation, loss of all tissue and conception products.
Missed abortion fetal or embryonic demise, but no outward signs and all components remain in the uterus. No vaginal
bleeding.
Habitual abortion spontaneous abortion (miscarriage) for 3 or more pregnancies on a row.
Induced medically initiated
Methotrexate, prostaglandins (Cytotec) and methylergonovine (methergine)
Assessment
Vaginal spotting US to visualize
Abdominal pain or cramping Bleeding may signify another issue, doesn’t always
Cervical os – open or closed indicate miscarriage.
Fluid or tissue passing from the vagina
Therapeutic Management
If any parts of the embryo/fetus are still present, Count perineal pads
prepare the client for D&C (dilation and curettage) to Save expelled contents
remove contents of the uterus. Replace IVF per orders
Must be performed because of risk of Check blood type of mom.
infection Give RhoGAM if Rh-negative. ALWAYS
Evaluate blood loss give IF Rh-negative.
Definition, pathophysiology, presentation, assessment, management of:
ECTOPIC PREGNANCY
When a fertilized egg (ovum) implants outside of the uterine cavity
“ectopic” = out of place
It could be in multiple different locations (cervix, abdominal cavity), however most are in fallopian tubes (ampullar).
Patient may have missed period/presumptive signs of pregnancy, but do not know that it is ectopic without ultrasound or until it
ruptures
This can be an emergency, especially if the fallopian tube has ruptured. 3 rd most common cause of mortality in pregnancy.
Assessment
Classic signs are pregnancy symptoms (missed period, positive pregnancy test) followed by vaginal spotting and severe
abdominal pain
Signs of ruptured fallopian tube include severe pain on one side, signs of shock, and pain referring to the right shoulder
Referred pain is due to blood in the abdomen
Therapeutic Management
Goals are to prevent rupture, bleeding, and shock --- assess VS
Surgical removal - laparoscopic
Medical
Methotrexate-inhibits cellular division of the embryo (aborts)
Fallopian tube may be compromised and need to be removed
Rh immune globulin if mom is Rh negative
Patient Education
Report severe pain, especially right shoulder pain.
Report vaginal bleeding.
Ectopic pregnancies cannot survive, the pregnancy will have to be terminated.
Comfort patient regarding fertility and future pregnancies – remember we have 2 ovaries and tubes!
GESTATIONAL TROPHOBLASTIC DISEASE (MOLAR PREGNANCY)
Abnormal fertilization
Rev. Fall 2019
, Antepartum Complications
The developing cells outside of the fertilized egg (ovum) develop abnormally, creating a nonviable pregnancy and noncancerous
tumor
The cells that divide to make the placenta abnormally divide and cause the molar pregnancy.
Mole = clump of growing tissue
Abnormal fertilization
Doesn’t contain original maternal nucleus
Two sperm, one ovum
Not correct genetic material
Grape-like appearance – caused by the distention of the
chorionic villi
Grape like clusters in the uterus
Almost always results in a miscarriage
Can develop into choriocarcinoma
Assessment
No fetal heart rate Dark brown/bright red bleeding
High blood pressure hCG levels higher than expected
Vaginal bleeding in first trimester Fundal height greater than expected
Grape like clusters Rapid division→ fast uterine growth
Therapeutic Management
Pregnancy is nonviable and it can turn into a Trophoblastic disease --- methotrexate
malignancy, therefore it must be removed treatment
D&C -- vacuum aspiration Watch hCG levels
Hysterectomy Monitor until pre-pregnancy levels
Oxytocin is given to contract uterus after mole is reached
removed Monitoring might continue for 6 months
Monitor for hemorrhage and infection to a year
Sending to lab for pathology is ESSENTIAL to see if No pregnancy during this time --- use
there are any signs of malignancy contraception
Patient Education
Resources for coping after loss of pregnancy
Help them understand why the pregnancy is nonviable
Educate on methotrexate use
Educate on the need for contraception
CERVICAL INSUFFICIENCY (PREMATURE DILATION OF CERVIX) --- called incompetent cervix before
Cervix begins to thin and shorten too early in pregnancy --- prior to 28 weeks.
Dilation and effacement occur without contractions.
Assessment
Vaginal bleeding or discharge (progressing from clear/white to pink/tan
Pelvic pressure
Cramping
backache
Therapeutic Management
Prevent contractions
Bed rest, fluids, meds (tocolytics)
Prepare for placement of a cervical cerclage (suture) if it appears that the pregnancy has been threatened
May be monitored overnight for premature labor
This reinforces the cervix, preventing further premature dilation
Contraindications for cerclage
o Ruptured membranes
o Labor
o Intrauterine or vaginal infection
o Pregnancy beyond 28 weeks
o Fetus is too low in cervix
Rev. Fall 2019
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