2155 Complications of Pregnancy - Hemorrhages

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What are 6 Maternal hemorrhagic disorders

1. Miscarriage/spontaneous Abortion
2. Ectopic pregnancy
3. Gestational trophoblastic disease (Molar)
4. Cervical insufficiency
5. Placenta previa
6. Placental abruption

What is an abortion (4)?

1. The loss of pregnancy before the fetus is viable, or capable of living outside the uterus
2. < 20 weeks gestation
3. < 500 grams (<400 grams in MI)

4. Either Spontaneous (miscarriage) or Induced

What is a spontaneous abortion (8)?

1. Termination of pregnancy w/o action taken by the woman or another person
2. Usually 1st trimester
3. Most common cause is chromosomal abnormalities that are incompatible w/ life
4. May never know why
5. Fetal +/or maternal factors
6. Implantation defect - inadequate endometrium, maternal anatomy=septum or uterine fibroids
7. Placental factors
8. Maternal trauma, endocrine, autoimmune-systemic

What are S/S of spontaneous abortion (6)?

1. bleeding "spotting". Need to assess, pt. may be biased
2. NO vaginal bleeding is WNL. They NEED to come in
3. Cramping to abdominal/pelvic pain
4. Loss of pregnancy symptoms b/c ↓ in pregnancy hormones
5. fever & malaise = septic abortion
6. Patient & family emotions are wide ranging

What is toxoplasmosis?

Caused by pprotozoan agent
Transmitted by eating raw meat containing T. gondii (esp. pork, beef, lamb) or contact w/ infected fat feces
Detected through blood test
Maternal S/E- malaise, lymphedema, preterm labor
Newborn S.E- miscarriage, if occurs in early gestation causes IUGR, opthamologic, neurological, hydrocephaly, microcephaly
TX: Pyrimethamine, folic acid, sulfadiazine

What is Threatened abortion & what is the first sign of a threatened abortion?

1. might happen
2. vaginal bleeding

What are the nursing interventions for a threatened abortion (6)?

1. Notify MD
2. Vaginal US to visualize fetus is present
3. Serum hCG and progesterone levels
4. Bedrest (no research supports this)
5. Pad count
6. Psychological supprot

What is an inevitable abortion & what happens (2)?

1. Cannot be stopped
2. Membranes rupture, cervix dilates, contractions, bleeding

What are the nursing interventions for an inevitable abortion (3)?

1. Allow natural evacuation of the uterine contents
2. Vacuum curettage to clean out the uterus if incomplete
3. If pregnancy is more advanced or bleeding it excessive, dilation and curettage (D&C)

What is an incomplete abortion (3)?

1. Some but not ALL POC (products of conception) are expelled from uterus
2. Major symptoms are bleeding and abd. cramping
3. Retained tissue prevents uterus from contracting

What are the nursing interventions for an incomplete abortion (3)?

1. Type and cross match blood, IV started and fluids infused
D&C
2. IV oxytocin or IM methylergonovine
3. May not perform D&C if > 14 weeks gestation, requires oxytocin or prostoglandin administration to stimulate uterine contractions to expel POC

What is a complete abortion?

All products of conception are expelled from the uterus spontaneously

What are the nursing interventions for a complete abortion (3)?

1. Verify all POC expelled
2. No additional interventions are required
3. Monitor for further bleeding, pain, fever

What is a missed abortion (5)?

1. None of POC is passed
2. Fetus dies during 1st half of pregnancy, retained in the uterus
3. S/S nausea, breast tenderness, urinary frequency disappear
4. Uterus stops growing and decreases in size
5. Vaginal bleeding of a red/brownish color may or may not occur

What are the nursing interventions for a missed abortion (5)?

1. US to confirm no FHR
2. Serial hCG tests (decreased)
3. Can either wait for spontaneous abortion or D&C
4. Vaginal prostaglandin E2 or cytotex to induce contractions
5. Major complication- infection (temp, foul smelling vaginal discharge and DIC

What is a septic abortion?

POC infected during process

What is defined as a recurrent spontaneous abortion (3)?

1. 2-3 or more spontaneous abortions
2. Primary cause- genetic/chromosomal abnormalities of the reproductive tract (bicornate uterus, incompetent cervix)
3. Others- inadequate progesterone secretion by the corpus luteum, lupus, DM, immunologic causes

What are the interventions someone who keeps having recurrent spontaneous abortions?

Detailed evaluation of reproductive system
Genetic screening
DM- maintain normal BS
Supplemental hormones (progesterone)
Cerclage- cervix sutured to prevent early dilation
RhoGam given to prevent future sensitization

Nursing care for abortions (6)

1. emotional support (50% w/bleed continue w/pregnancy)
2. US & serial quantitative (#) beta HCG -amt should double q 48 hours
3. blood type & screen (Rh), CBC (Hgb b/c bleeding)
4. Possible D&C
5. Referral for losses
6. if Rh- then Rhogam within 72 hours

What is hCG lab?

Human Chorionic Gonadotropin
Presence of this hormone indicates pregnancy
Trophoblasty secretes it in early pregnancy
2 parts:
1. Qualitative: Routine
-detectable within 3 days of implantation
-positive or negative
2. Quantitative: Non Routine
- non pregnant <5, pregnant > 5
-value doubles approximately every 48 hrs
-peaks ~75 days after fertilization

What is a disseminated Intravascular coagulation (DIC)?

Life threatening defect in coagulation, not limited to OB conditions
'macro bleeding, micro clotting'
Insult causes consumption of plasma factors (platelets, fibrinogen, prothrombin, factor V, factor V11)
Remaining circulating blood is deficient in clotting factors and unable to clot
While anticoagulation is occuring, inappropriate coagulation occurs in tiny blood vessels blocking blood flow to the organs and causing ischemia
RESULT: DIC allows excess bleeding to occur from any vunerable area, IV area, IV site, incisions, gums, nose, placental attachment site

What labs change with a DIC?

Fibringoen and platelets decreased
Prothrombin (PT) and activated partial thromboplastin times (aPTT) prolonged
Fibrin degradation products or fibrin split products (FSP) are increased

What are the interventions for a DIC?

primary goal: correct cause
blood replacement, whole blood, packed RBC cryoprecipitate
Monitor for bleeding from unexpected sites, IV site, nosebleed
Epidural may be contraindicated

What is an ectopic pregnancy (10)?

1. Impantation of a fertilized ovum in an area outside of the uterine cavity
2. Mostly in fallopian tube
3. May cause maternal death r/t hemorrhage. Emergency
4. Reduces chance of future pregnancies
5. Siginificant increase r/t scarring of fallopian tube from
pelvic infection and surgery
6. Abdominal pain 100%**
7. Delayed Menses (75-90%)
8. Vaginal bleeding (spotting) 79%**
9. After rupture = and/shoulder pain, syncope, shock
10. If someone seen in ER w/abdominal pain or vaginal bleeding DO pregnancy test

What are some risk factors for an ectopic pregnancy (8)?

1. Hx of STDs
2. Hx of PID
3. Hx of previous ectopic pregnancy
4. Failed tubal ligation
5. Intrauterine device
6. Multiple induced abortions results in salpingitis
7. Maternal age >35
8. GIFT (gamete intrafallopian transfer)

What are the s/s of hypovolemic shock?

Increased HR & RR
Decreased urine output
Decreased BP in late shock

How is an ectopic pregnancy diagnosed?

Transvaginal US
Beta bCG is present but lower then normal
Laparoscopy

What are the interventions for an ectopic pregnancy?

Medical management is to preserve the rube or remove tube and control bleeding
Methotrexate: used to inhibit cell division
S/E- N/V, transient abd. pain

What are the nursing considerations for an ectopic pregnancy?

Treat/prevent shock
Pain control
Psychological support
Pt. education re. Methotrexate: may have increased pain during tx due to expulsion of POC from tube, avoid ETOH (prevents it) and folic acid (promotes cell division)
Rhogam administration

What is gestational Trophoblastic Disease (Hydatiform mole)?

Trophoblasts (peripheral cells that attach the fertilized ovum to the uterine wall) develop abnormally
The placenta but not the fetal part of the pregnancy develops
Proliferation of fluid filled villi form grape-like clusters of tissue, can fill the uterus
Persistent gestational trophoblastic disease may undergo malignant change (choriocarcinoma) and metastasize to distant sites, lungs, vagina, liver, brain

What are the s/s of a hydatiform mole?

Elevated hCG
US: shows vesicles and adsence of fetal sac or FHR
uterus is larger then normal for gestation
Vaginal bleeding-> dark brown-> hemorrhage
Hyperemesis, may be r/t high levels of hCG from proliferating trophoblasts
PIH

How do you diagnosis and treat a hydatiform mole?

Diagnosis by abnormally high hCG levels and US
TX is 2 phases:
1. Removal of mole, vacuum extraction then curettage
2. follow up to detect metastasis
--serial hCG levels for 1 yr
--CXR, CT scan, MRI may be used to r/o metastatic disease
-manage hyperemsis and PIH

What is placenta previa?

Placenta implants in the lower uterus
3 classifications (based upon amt. of internal cervical os is covered by the placenta):
1. Marginal- low lying, 3 cm away from os. Common in early pregnancy, moves up as uterus grows
2. Partial- lower border is within 3 cm of os but does not completely cover the os
3. Total- placenta completely covers internal os

What are the s/s of placenta previa?

Sudden onset of painless uterine bleeding in last half of pregnancy
Bleeding may be scant or profuse, spontaneously occurs only to recur later
Bleeding may occur until labor starts
Must differentiate btwn bloody show

What are the interventions for placenta previa?

Never perform vaginal exam
Conservative management: home care or hospital, bed rest, no sexual activity
No administration of oxycotin
May require C/S
Delaying birth may increase birth weight and maturity of administration of corticosteroids to mo to speed up fetal lung maturation

What is abruptio placenta?

Separation of the normally implanted placenta before the fetus is born
Severity depends on amt. of bleeding and degree of seperation
Dangerous to both mom and fetus
Maternal: hemorrhage, hypovolemic shock, clotting abornomalities
Fetal: asphyxia, excessive blood loss, prematurity
Risk factors: maternal use of cocaine, maternal HTN, maternal cigarette smoking, multigravidas, short umbilical cord, abd. trauma, hx of previous abruption

What are the s/s of abruptio placenta?

Bleeding, maye be evident vaginally or concealed
-bleeding behind placenta but the margins remain intact, causing a hematoma
Uterine ternderness or abd. pain
Hard board like abd
Increase in fundal height
Excess uterine activity
Signs of shock
Late decels, decreasing variability, no accels
High uterine baseline tone on fetal monitor (30)
Fetal distress or fetal death

What are the interventions for abruptio placenta?

Diagnosis: US not reliable
Based upon severity of bleeding
Conservative: bedrest, tocolytic meds, monitor FHR, steroids
Emergent: C/s, blood product administration, prevention or tx of shock

What is hyperemesis Gravidarum?

Persistent, uncontrollable vomitting that begins prior to 20th week gestation, results in disturbed nutritional status, electrolyte imbalance, dehydration, weight loss of 5% or more, acidosis, ketonuria, hypokalemia
Cause is unclear, factors that increase risk are 1st pregnancy, hx of n/v previous pregnancy, intolerance for oral contraceptives, gall bladder disease

What is the tx for hyperemesis gravidarum?

Care is usually provided at home based upon severity
Monitor I&O
Daily weight
Urine for ketones
Vitamin B6
Meds: Phenergan, benadryl, pepcid, zantac, zofran, prilosec
Dietary and liftestyle alterations: small freq, meals, presented attractively, mild odor, avoid high fat foods, choose fruit, bread, cereal, rice, pasta, soups, remain upright after eating, salting food help replace chloride lost when hcl is vomited, increase potassium uptake
IV electrolyte therapy, TPN if 5% of body weight loss
Emotional support, avoid personal bias
Check urine for protein
Check reflexes

What is a Premature rupture of membranes (PROM)?

Spontaneous break or tear in amniotic sac before onset of regular contractions
Preterm PROM: rupture of membranes in preterm gestation
At risk for chorioamnionitis if >24 hrs before onset of labor/delivery, S/S: fetal tachycardia, maternal fever, foul-smelling amniotic fluid, uterine tenderness
Increases risk of sepsis and perinatal mortality

What causes PROM?

Unknown, possible:
Malpresentation, contracted pelvis
Poor nutrition, incompetent cervix
Hydramnios
Multiple gestations
Cervical infections

How do you diagnosis PROM?

Alkaline ph of fluid collected from the posterior fornix turns nitrazine paper blue
Ferning- fluid is placed on slide, dries and fern-like pattern, considered positive

What is the tx for PROM?

Depends upon fetal gestation and infection status
If term, labor induction, if not spontaneous, if fails C/S
If preterm, <34 weeks
-hospitalization while awaiting fetal maturation
-observation for signs of infection
-maternal; leukocytes, fever
-fetal; tachycardia
-if infection, labor induction, antibiotics, C/S

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