Complications during pregnancy/interventions

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dsherman
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119020
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Complications during pregnancy/interventions
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2011-11-28 13:25:02
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Complications during pregnancy interventions
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Complications during pregnancy/intervantions
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  1. First trimester
    Sponraneous abortion: vaginal bleeding, uteine cramping, and partial or complete expulsion of products of conception

    Ectopic pregnancy: Abrupt unilateral lower-quadrant abdominal pain with or without vaginal bleeding
  2. Second trimester
    Gestational trophoblastic disease: uterine size increasing abnormally fast, abnormally high levels of hCG, nausea and increased emesis, no fetus present on ultrasound, and scant or profuse dark brown or red vaginal bleeding
  3. Third trimester
    • Placenta previa: painless vaginal bleeding
    • Abruptio placenta: Vaginal bleeding, sharp abdominal pain, and tender rigid uterus
    • Vasa previa: fetal vessel cross over the cervix abrupt bright red vaginal bleeding following reupture of membranes
  4. Spontaneous abortion
    when a pregnancy is terminated before 20 weeks of gestation (the point of fetal viability) fetal weight less then 500g

    types of abortion are clinically classified according to symptoms and wheather the products of conception are partially or completely retained or expulsed

    • types of abotion are:
    • threatened-with or without slight cramps, spotting to moderate bleeding, no tissue passed, cervical opening closed
    • inevitable- moderate cramps, mild to severe bleeding, no tissue passed, cervical opening silated with membranes or tissues bulging at cervix
    • incomplete-severe cramps, continuous and severe bleeding, partial fetaltissue or placenta passed, cervical opening dilated with tissue in cervical canal or passage of tissue
    • complete-mild cramps, minimal bleeding, complete expulsion of uterine contents, cervical opening closed with no tissue in cervical canal
    • missed-no cramps, brownish discharge, no prolonged retention of tissue, cervical opening closed
    • Septic-malodorous cramping, malodorous discharge, tissue passed varies, cervical opening usually dilated
    • Recurrent-cramping varies, bleeding varies, tissue is passed and cervical opening is usually dilated
  5. Other causes of bleeding during pregnancy
    incompentent cervix: painless bleeding with cervical dilation leading to fetal expulsion

    preterm labor: pink-stained vaginal discharge, uterine contractions becoming regu.ar, cervical dilation and effacement
  6. Risk factors for spontaneous abortion
    • chromosomal abnormalities (account for 50%)
    • maternal illness, such as insulin-dependent diabetes mellitus
    • advancing maternal age
    • premature cervical dilation
    • chronic maternal infections
    • maternal malnutrition
    • trauma or injury
    • anomalies in the fetus or placenta
    • substance abuse
  7. Subjective and Objective Data assessment for spontaneous abortion
    • Backache
    • rupture of membranes
    • dilation of the cervix
    • fever
    • abdominla tenderness
    • signs and symptoms of hemorrhage such as hypotension and tachycardia
  8. Laboratory test/diagnostic procedures that would indicate a spontaneous abortion
    • Hgb and Hct, if considerable blood loss
    • Clotting factors monitored for disseminated intravascular coagulapathy (DIC), a complication with retained products of conception
    • WBC for suspected infection
    • Serum hyuman chorionic gonadotropin (hCG) levels to confirm pregnancy
    • Dignostic proceedures:
    • ultrasound is used to determine the presence of a viable or dead fetus or partial or complete products of conception within the uterine cavity
    • an examination of the cervix to observe if it is open or closed
    • dilation and curettage (D&C) is done to dilate and scrape the uterine walls to remove uterine contents for inevitable and incomplete abortions
    • dilation and evacuation (D&E) is done to dilate and evacuate uterine contents after 16 weeks of gestation
    • prostaglandin is administered into the amniotic sac or by a vaginal suppository to augment or induce labor to expulse the products of conception for a late term, incomplete, inevitable, or missed abortion
  9. Collaborative care for spontaneous abortion
    • Nursing care
    • observe bleeding amount and color (count pads)
    • perform a pregnancy test
    • use the lay term miscarrage with patients, because abortion will likely sound insensitive
    • place patient on bed rest with the administration of sedation for threatened, inevitable, and incomplete abortions
    • avoid a vaginal exam
    • assist with an ultrasound
    • administer analgesics and blood products as prescribed
    • determine how much tissue has passed and saving all passed tissue for examination
    • assist with termination of pregnancy (D&C, D&E) as indicated based on duration of pregnancy
    • provide patient education and emotional support
    • Medication:
    • Rho immune globulin (RhoGAM), Rh-neg patients
    • administer prostaglandins or IV oxytocin (Pitocin) as prescribed to expulse products of conception in late, incomplete, inevitable, or missed abortions
    • administer broad-spectrum antibiotics as prescribed for treatment of septic abortion
  10. Discharge instructions for patients who have experienced a spontaneous abortion
    • instruct the patient to notify the physician of heavy, bright red vaginal bleeding
    • take prescribed antiboitics
    • tell the patient that a small amount of discharge is normal for 1-2 weeks
    • refrain from sexual intecourse or placing anything into the vagina for 2 weeks
    • provide contacts for breavement support groups
    • instruct the patient to avoid pregnancy for 2 months
  11. Ectopic pregnancy
    • is the abnormal implantation of a fertilized ovum outside of the uterine cavity uaually in the fallopian tube, which can result in a tubal rupture causing a fatal hemorrhage
    • Ectopic pregnancy is the second most frequent cvause of bleeding in early pregnancy
    • Risk factors for ectopic pregnancy:
    • any factor that compromises tubal patency (pelvic inflammatory disease, contraceptive intrauterine device [IUD])
  12. Assessments for Ectopic pregnancy
    • subjective data:
    • one or two missed menses
    • unilateral stabbing pain and tenderness in the lower abdominal quadrant
    • scant, dark red, or brown vaginal spotting if tube ruptures (bleeding may be into intraperitoneal area)
    • referred shoulder pain from blood irritation of the diaphragm or phrenic nerve (common symptom)
    • frequent nausea and vomiting after tube rupture

    • Objective data:
    • signs of hemorrhage and shock (hypotension, tachycardia, pallor)

    • Laboratory test:
    • hormone levels of progesterone and hCG elevated
    • WBC count elevated to 15,000/mm3
    • Diagnostic procedures:
    • transvaginal ultrasound showing an empty uterus
    • Rapid surgical treatment:
    • linear salpingostomy is done to salvage the fallopian tube if not ruptured
    • laparoscopic salpingostomy (removal of the tube) is performed when the tube has ruptured
  13. Collaborative care for patients with Ectopic pregnancy
    • Nursing care:
    • replace fluids that are lost and maintain electrolyte balance
    • provide client education and psychological support
    • prepare the patient for surgery and postoperative nursing care
    • Medication:
    • Methotrexate (MTX)-used to inhibit cell division and enlargement of the embryo. It also prevents rupture of the fallopian tube to preserve it.
    • Nursing considerations:
    • obtain serum hCG levels, liver and renal function studies, CBC, and type and Rh
    • Patient teaching:
    • instruct the patient prescribed methotrexate to avoid alcohol consumption and vitamins containing folic acid to prevent a toxic response to the medication
    • advise the client to protect herself from sun exposure (photosensitivty)
  14. Gestational trophoblastic disease (Hydatidiform mole, Choriocarcinoma, and Molar pregnancy
    • proliferation and degeneration of trophoblastic villi in the placenta that becomes swollen, fluid-filled and takes on the appearance of grape-like clusters.
    • The embryo fails to develop beyond a primitive state and these structures are associated with choriocarcinoma, which is a rapidly metastasizing malignancy. Two types of molar growths are indetified by chromosomal analysis
    • In complete mole, all genetic material is paternally derivedthe ovum has no genetic material or the material is inactive, the complete mole contains no fetus, placenta, amniotic membranes, or fluid, there is no placenta to recieve maternal blood;therefore, hemorrhage into the uterine cavity occurs and vaginal bleeding results, approximately 20% of complete moles progress twoard a choriocarcinoma
    • Partial mole: genetic material is derived both maternally and paternally, a normal ovum is fertilized by two sperm or one sperm in which meiosis or chromosome reduction and division did not occur, a partial mole often contains abnormal embryonic or fetal parts, and amniotic sac, and fetal blood, but congenital anomalies are present, approximately 6% of partial moles progress towad a choriocarcinoma
  15. Risk factors for Gestational trophoblastic disease (Hydatidiform mole, Choriocarcinoma, and Molar pregnancy)
    • low protein intake
    • under 18 years of age
    • older than 35 years of age
  16. Assessments for Gestational trophoblastic disease (Hydatidiform mole, Choriocarcinoma, and Molar pregnancy)
    • subjective data
    • vaginal bleeding ant approximately 16 weeks of gestation
    • excessive vomiting (hyperemesis gravidarum) due to elevated hCG levels
    • objective data physical assessment:
    • rapid uterine growth larger than expected for the duration of the pregnancy due to the overproliferation of trophoblastic cells
    • bleeding is often dark brown resembling prune juice, or bright red that is either scant or profuse and continues from a few days or intermittently for a few weeks
    • bleeding accompanied by discharge from the clear fluid-filled vesicles
    • symptoms of pregnancy induced hypertension, including hypertension, edema, andproteinuria, that occur prior to 20 weeks of gestation
  17. Laboratory tests that indicate a Gestational trophoblastic disease (Hydatidiform mole, Choriocarcinoma, and Molar pregnancy)
    • Urinalysis for proteinuria
    • serial hCG immuno assays for pregnancy are strongly positive (1 to 2 million IV as compared with normal pregnancy level of 400,000 IU)
    • Diagnostic proceedures:
    • an ultrasound will reveal a dense growth with characteristic vesicles, but no fetus in utero
    • suction curettage is done to aspirate and evacuate the mole
    • following mole evacuation, the patient should undergo a base line pelvic exam and ultrasound scan of the abdomen in addition to frequent follow-up pelvic exams
  18. Collaborative care (Nursing care/medications/health promotion/discharge instructions/client education for Gastational trophoblastic disease (Hydatidiform mole, Choriocarcinoma, and Molar pregnancy)
    • Nursing Care:
    • measure fundal height
    • assess vaginal bleeding and discharge
    • assess gastrointestinal status and appetite
    • assess the patient's extremities and face for edema
    • administer chemotherapy for choriocarcinoma in the event of an abnormal rising hCG titer, and enlarging uterus, and findings of malignant cells
    • Medication:
    • administer Rho(D) immune globulin (RhoGAM) to the patient who is Rh-negitive
    • Discharge instructions:
    • advise the patient to bring any clots or tissue passed to the physician for evaluation
    • Patient teaching:
    • educate and give emotional support regarding the loss of an anticipated pregnancy
    • instruct the patient to use reliable contraception for 12 months because a pregnancy would make it impossible to monitor the decline in hCG levels, which is a significant component of follow-up care
    • instruct the patient about the critical importance of follow-up because of the increased rick of choriocarcinoma

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