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(Exam 3) Hyperemesis, ectopic pregnancy, hydadtiform mole, abortion

Terms in this set (47)

Hyperemesis gravidum?
-happens in 1st and 2nd trimester while being resolved in the 3rd
- can lead to electrolyte imbalance

-it is vomiting during pregnancy that becomes excessive enough to cause weight loss of at least 5% of pre pregnancy weight
-accompanied by dehydration, electrolyte imbalance, ketosis, and acetonuira
What are risk factors for Hyperemesis gravidum?
-nullparous (1st time pregnant)
-increased body weight or LBW
-history of migraines
-pregnant with twins
-pregnant with Hydatidform mole
-psychological component
-low socioeconomic class
-asthma
-female fetus
-family history
What are complications of Hyperemesis gravidum?
-esophageal rupture
-wornex encephaly- deficient in vitamin k and thiamin
-fetus small for gestational age, LBW, or premature
What is the etiology of Hyperemesis gravidum?
-unknown
-may be related to high levels of estrogen or hCG
-can be related to hyperthyroidism during pregnancy
-women with severe N/V has an increased chance of carrying a girl
-can be from esophageal reflux , reduced gastric motility, decrease secretion of free hydrochloric acid
-nervous about pregnancy
-increased stress
-unresolved feelings about pregnancy
-fear of body changes
What are clinical manifestations of Hyperemesis gravidum?
-significant weight loss (5%)

-dehydration s/s
-decreased urine output
-tenting
-infant's fontanel sunk in
-dry MM
-low BP
-increased HR
-low potassium
-unable to keep fluids down

-lab tests will reveal electrolyte imbalances
Collaborative care for Hyperemesis gravidum?
assess
-frequency, severity, and duration of episodes of vomiting
-diarrhea, indigestion, and abdominal pain or distention
-What have they been doing for their vomiting?
-pre pregnancy weight and evidence of documented weight gain or loss during pregnancy

-weight, VS and PE

-pay attention to s/s of fluid and electrolyte imbalances and nutritional status

----Initial laboratory test are obtained via dipstick urine for presence of ketonuria (dehydration)
Lab tests for Hyperemesis gravidum?
-urinalysis
-CBC
-electrolytes
-liver enzymes
-bilirubin levels

all of these tests help rule out the presence of underlying diseases such as
-pyelonephritis (kidney infection)- pain, fever, N/V
-pancreatitis
-cholecystitis
-hepatitis

-TSH and T4

-ask women about fears and anxiety related to her own health and effects on pregnancy outcome
What is initial care for Hyperemesis gravidum?
-IV therapy to correct fluid and electrolyte imbalance

---NPO until dehydration resolved and for AT LEAST 48 HOURS after vomiting

antiemetics:
-pyrixodine Vitamin B6 and doxylamine Unisom are both OTC and most recommended; can be taken together

-promethazine (phenergan) and metoclopromide (Reglan) are safe for pregnancy
Other medications that an be used for Hyperemesis gravidum?
-meclizine (Antivert)
-dimenhydrinate (Dramamine)
-dephenhydramine (Benadryl)
-ondansetron (Zofran)- safety not established

Corticosteroids (methylprednisolone) may be used to treat refractory hyperemesis
-only use when necessary
-can develop fetal cleft
-avoid in 1st trimester
Interventions for Hyperemesis gravidum?
-initiate and monitor IV
-administer drug and nutritional supplements
-monitor woman's response
-stress reduction

observe for signs and complications:
-metabolic acidosis- from vomiting
-jaundice
-hemorrhage

Monitoring:
-assess nausea
-retching without vomiting- dry heaving
-vomiting

Score:
Pregnancy-unique quantification of emesis/nausea (PUQE)
-total score from 3 questions
-Mild NVP: less than or equal to 6
-Moderate: 7-12
-Severe: more than or equal to 13

-I&O, amount of emesis
-oral hygiene
-assistance with position
-rest, quiet, free from odors

when the woman starts responding to therapy:
-give a limited amount of fluids and bland foods (crackers, toast, baked chicken)
-If 48 hours free vomiting

use IV and NPO for 48 hrs of vomiting

-diet is progress as tolerated
-rest
Follow up care for Hyperemesis gravidum?
-encourage to eat small, frequent meals consisting of low fat, high protein foods

-avoid greasy and highly seasoned foods

-increase dietary intake of potassium and magnesium (orange juice)

-herbal teas may decrease nausea
-ginger, chamomile, raspberry leaf

-NG tube may be used

-take in fluids between meals
-eat cracker before getting out of bed

-allow someone else to cook

dietary instructions:
-dry, bland foods
-high protein foods
-small frequent meals
-cold food
-snack before bedtime
-drink tea or water with lemon
-avoid high fat or spicy foods
Follow up and teaching for Hyperemesis gravidum?
-contact OB if N/V occur
-abdominal pain is present
-if dehydration occurs or if weight loss more than 5 pounds occurs in one week
What is Ectopic pregnancy?
-the fertilized ovum is implanted outside the uterine cavity
-not a viable fetus
-can happen in the ovaries, abdominal cavity (this one can be viable), cervix, Fallopian tubes (not viable)

-classified according to the site of implantation
i.e tubal pregnancy

-the uterus is the only organ capable of containing and sustaining a pregnancy
-but an abdominal pregnancy via birth by laparotomy can be achieved but the infant can be deformed

-the leading pregnancy related cause of first trimester maternal death

-leading cause in infertility
-can reoccur

---more ectopic pregnancies have been reported due to the increased incidence of STI's, PID, reversal or tubal sterilizations
Clinical manifestations of ectopic pregnancy?
-missed menstrual period

-adnexal fullness

-tenderness that may suggest an enraptured tubal pregnancy
-progresses from dull to colicky as the tube stretches
-may be unilateral, bilateral or defuse over abdomen (will need ultrasound)

-dark red or brown abnormal vaginal bleeding occurs and can be mistaken for implantation bleeding
Pain in ectopic pregnancy:
-if it rupture, pain increases

-may be generalized, unilateral or acute deep lower quadrant pain caused by blood irritating the peri area

---referred shoulder pain can occur from diaphragmatic irritation caused by blood in the peri cavity

-signs of shock r/t the amount of bleeding in the abdominal cavity and not really vaginal bleeding

---Cullen sign:
-an ecchymotic blueness around umbilicus
-this occurs with an undiagnosed rupture of ectopic pregnancy
Collaborative care for ectopic pregnancy:
-looks at the disorders that may share s/s

-may present bleeding or pain in 1st trimester

-miscarriage, ruptured ovarian cyst, appendicitis, salpingitis, torsion of the ovary, and UTI may have the same symptoms


quick treatment is the best treatment
-lab screen
-serum progesterone
-B-hCG
-if levels are lower than expected, encourage a recheck in 48 hours

-transvaginal ultrasound that confirms
Assessment of ectopic pregnancy:
-presence of active bleeding

-assess for vertigo, shoulder pain, hypotension, tachycardia, internal bleeding

-vaginal exam with greta caution

-palpable mass found upon vaginal exam
-be gently because the mass can rupture
Treatment:
-remove via salpingostomy before rupture

-methotrexate before surgery resolves residual tissue
-this is an antimetabolite and folic acid antagonist that destroys rapidly dividing cells
-single dose IM injection
-useless after rupture
-DO NOT take anything stronger than acetominophen- can mask symptoms of tubal rupture

-abdominal pregnancies removed via laparotomy
-BUT if it is 2nd or 3rd trimester and attached to vital organs, the cord is cut and the abdomen is closed leaving the placenta there

-degeneration and absorption occurs on its own but may cause infection or intestinal obstruction
Methotrextate administration:
• Obtain the woman's height and weight. These measurements are used to calculate her body surface area in order to determine the correct dose of methotrexate, so they must be accurate.
• The standard dose of methotrexate used to treat ectopic pregnancy is 50 mg/m2 given intramuscularly, although it may also be ordered as 1 mg/kg.
• The dose of methotrexate should be prepared in the hospital pharmacy under a biologic safety cabinet. Syringe(s) containing the methotrexate should be dispensed from the pharmacy no more than three-fourths full in a sealed plastic bag without a needle attached.
• Don two pairs of gloves before removing the syringe(s) from the sealed plastic bag.
• Remove the syringe cap, and replace with an appropriate needle for intramuscular injection.
• Do not expel air from the syringe or prime the needle because these actions could aerosolize the methotrexate.
• Check the patient's identity and the medication and dosage before injecting the methotrexate. Another nurse should also perform an independent check before the injection is given.
• Dispose of any items worn or used to prepare, dispense, or administer the methotrexate injection in a waste container designated specifically for hazardous drugs.
• Wash your hands thoroughly after removing gloves.
Teaching for women receiving methotrexate therapy:
• Explain that methotrexate dissolves ectopic (tubal) pregnancies by destroying rapidly dividing cells.
• Explain that urine contains levels of drug metabolite that could be considered toxic for approximately 72 hours after receiving methotrexate. The levels are highest during the first 8 hours after treatment. Teach the woman to avoid getting urine on the toilet seat and to double flush the toilet (with the lid down) after urinating. Also explain that her stools may contain residual drug for up to 7 days.
• Inform the woman of possible side effects. Gastric distress, nausea and vomiting, stomatitis, and dizziness are common. Rare side effects include severe neutropenia, reversible hair loss, and pneumonitis.
• Advise the woman to do the following:
• Avoid foods and vitamins containing folic acid.
• Avoid "gas-forming" foods.
• Avoid sun exposure.
• Avoid sexual intercourse until the beta-human chorionic gonadotropin (β-hCG) level is undetectable.
• Keep all scheduled follow-up appointments.
• Contact her health care provider immediately if she has severe abdominal pain, which may be a sign of impending or actual tubal rupture.
Hospital care for ectopic pregnancy:
-general preop and postop care
-VS per policy
-blood type
-Rh factor
-CBC
-serum quantitative B-hCG
-Ultrasound to confirm if ectopic


Treated as outpatient if:
-if the mass is unruptured
-measures less than 3.5 cm in diameter
- there is no fetal cardiac activity
- the serum hCg if less than 5000 IU/ml
- no free fluid in cul-de-sac

-methotrexate helps to avoid surgery, is safe and effective
---If patient consumes alcohol or folic acid while on this, she is at an increased risk of ectopic pregnancy
Hydatidform mole:
-gestational trophoblastic disease (GTD)

Two types:
-complete (classic)
-partial

-may be caused by ovular defect
-nutrition deficiency
-women in early teens or over 40
-any women who have undergone ovulation stimulation
-low chance of reoccurrence
What is complete Hydatidform mole:
-result from fertilization of an egg
-the nucleus is lost or inactivated (not a fetus)
-the sperm duplicates itself because the ovum has no genetic material

-the mole resembles a bunch of white grapes

-the hydropic (fluid filled) vesicles grow quickly, causing the uterus to be larger than expected for the duration of the pregnancy

-usually the complete mole contains no fetus, placenta, amniotic membranes or fluid but can contain hair and teeth

-maternal blood loss has no placenta to receive it, leads to hemorrhage into the uterine cavity and vaginal bleeding occurs

-can progress to a carcinoma

-if there is scant white discharge, mom has anemia

-once they have had a Hydatidform mole, they must be followed up for a year
What is partial Hydatidform mole?
-karyotype of 69, XXY; XXX, 69 or 69, XXY

-occurs because of two sperm fertilizing a normal ovum

-have embryonic or fetal parts and an amniotic sac

-congenital abnormalities present

-low potential for malignant transformation
Clinical manifestations of Hydatidform mole:
-early stages not distinguishable between normal pregnancy

-vaginal bleeding

-dark brown discharge- prune juice look
-can be scant or profuse

-significantly larger uterus than expected for pregnancy dates

-anemia from blood loss

-excessive n/v

-abdominal cramps caused by uterine distention

-can become preeclamptic
-between 9-12 weeks gestation

-any symptoms of gestational hypertension before 24 weeks

-hyperthyroidism

-pulmonary embolism

- partial mole can cause a few of these symptoms and be mistaken for a miscarriage
Collaborative care of Hydatidform mole:
-must pass spontaneously but safe and rapid evacuation of mole can be applied

-women who use sterilization may have hysterectomy

-avoid oxytoxic agents and prostaglandins

Nurses should:
-observe for signs of molar pregnancy
-USG (diffuse snowstorm appearance)
-B-hCG (remains high or rises above the normal peak after the time it normally drops (above 100,000 IU/ml)

Important teaching:
-pregnancy should be avoided for 1 year to avoid confusing signs of carcinoma to pregnancy
-any contraceptive device can be used except for IUD's

Follow up:
-close observation for 1 year
-pelvic exams and measure B-hCG (normal for 3 weeks, can progress to every 6 months)
-rising Hcg and enlarging uterus are signs of carcinoma
Abortion:
-a pregnancy that ends without medical or surgical method before 20 weeks gestation or 500 gram birthweight is miscarriage/spontaneous abortion
-abortion can seem harsh- use miscarriage

-early miscarriage- ends before 12 weeks
-late miscarriage- between 12-20 weeks gestation

-half of all miscarriages are because of chromosome abnormalities

late miscarriages are caused via:
-advanced maternal age
-chronic infections
-premature dilation of cervix
-chronic disease
-inadequate nutrition
-recreational drug use


signs and symptoms of miscarriage depends of duration of pregnancy
Possible causes of early miscarriages:
-endocrine imbalance
-immunologic factors
-infections
-systemic disorders
-genetic factors
Types of spontaneous abortions:
threatened
-spotting, cervix not open

inevitable
-more spotting and cramping than threatened

incomplete
-parts and placenta found

complete
-everything expelled

missed
-not expelled
Early pregnancy abortion/miscarriage s/s:
-uterine bleeding
-contractions
-uterine pain

all are ominous signs in early pregnancy and must be considered a threatened miscarriage until proven otherwise

if it occurs before 6 weeks- heavy menstrual flow

6-12 weeks- moderate discomfort and blood loss

after 12 weeks- severe pain like labor, fetus must be expelled
S/s of threatened abortion
-spotting of blood
-closed cervix
-mild uterine cramping
inevitable and incomplete abortion:
-moderate to heavy amount of bleeding
-open cervix
-tissue present
-mild to severe uterine pain and cramping
Inevitable s/s:
-ruptured membranes
-conception products passed
-cervical dilation
Incomplete s/s
-fetus expulsion
-placenta retention
Complete s/s
-all fetal tissue passed
-cervix closed
-slight bleeding
-mild uterine cramping
Missed miscarriage
s/s
-fetus is dead but products of conception are still in utero for several weeks
-confirmed via ultrasound after no increase in fetal size (or even decrease)
-may have no bleeding or pain
-cervix closed

-products in the womb may calcify (Womb stone)

-women can become septic
-fever and abd pain
-malodorous vaginal bleeding
-surgical evacuation required
Habitual miscarriage or recurrent spontaneous abortion:
-3 or more consecutive pregnancy losses before 20 weeks

-reason unknown

-women with this are at risk for preterm labor, placenta previa, fetal anomalies


recurrent interventions:
Prophylactic cerclage may be performed if cervical insufficiency is the cause.
Tests of value include karyotyping of both partners and miscarriage specimens and assessment of the placenta; evaluating the woman's uterine cavity; and testing the woman for antiphospholipid antibody syndrome and thyroid disease.
`Nursing care management of miscarriage:
-measure hCG
-in early pregnancy, it should double every 1.4 to 2 days until 60-70 days of gestation (2 1/2 months)

-if suspected miscarriage, lab conducted
-blood drawn 48 hours apart
-if healthy, should double
-unhealthy- decreases or remains same

-Ultrasound to determine viable gestational sac
-assess for anemia, WBC for infection
Medical/surgical management of abortion:
threatened:
-bed rest, supportive care
-follow up for resolution of symptoms or actual miscarriage
-first trimester: 6 weeks or younger: synthetic prostaglandins


late, incomplete, inevitable, or missed
-prostagladin to induce labor
-oxytocin after 20 weeks to induce
Surgical intervention of abortion:
dilation and curettage:
-cervix is dilated
-curette inserted to scrape uterine wall and remove contents
-used to treat inevitable and incompletes
nursing care for the miscarriage after 20 weeks:
-monitor for SE of prostaglandin
-N/V, diarrhea

-oxytocin after the evacuation of the fetus

-analgesics

-offer the chance to see fetal remains
Follow up for the miscarriage:
-discharge home when VS stable
-rest

teach pt normal findings:
-cramping
-bleeding
-resumed sexual activity after 6-8 weeks
-family planning

-follow up phone calls
Nursing diagnosis for hyperemesis gravidum:
• Deficient Fluid Volume related to excessive vomiting as evidenced by fluid and electrolyte imbalance
• Imbalanced Nutrition: Less Than Body Requirements related to nausea and persistent vomiting as evidenced by weight decrease as compared with prepregnant weight
• Anxiety related to effects of hyperemesis on fetal well-being as evidenced by woman's statements of concern
Diet for hyperemeis:
• Avoid an empty stomach. Eat frequently, at least every 2 to 3 hours. Separate liquids from solids, and alternate every 2 to 3 hours.
• Eat a high-protein snack at bedtime.
• Eat dry, bland, low-fat, and high-protein foods. Cold foods may be better tolerated than those served at a warm temperature.
• In general, eat what sounds good to you rather than trying to balance your meals.
• Follow the salty and sweet approach; even so-called junk foods are okay.
• Eat protein after sweets.
• Dairy products may stay down more easily than other foods.
• If you vomit even when your stomach is empty, try sucking on a Popsicle.
• Try ginger tea. Peel and finely dice a knuckle-sized piece of ginger and place it in a mug of boiling water. Steep for 5 to 8 minutes and add brown sugar to taste.
• Try warm ginger ale (with sugar, not artificial sweetener) or water with a slice of lemon.
• Drink liquids from a cup with a lid.
Discharge Teaching for the Woman After Early Miscarriage
• Cleanse the perineum after each voiding or bowel movement, and change perineal pads often.
• Shower (avoid tub baths) for 2 weeks.
• Avoid tampon use, douching, and vaginal intercourse for 2 weeks.
• Notify your health care provider if an elevated temperature or a foul-smelling vaginal discharge develops.
• Eat foods high in iron and protein to promote tissue repair and red blood cell replacement.
• Seek assistance from support groups, clergy, or professional counseling as needed.
• Allow yourself (and your partner) to grieve the loss before becoming pregnant again.
Cervical insufficiency
passive and painless dilation of the cervix leading to recurrent preterm births during the second trimester in the absence of other causes

acquired or congenital

collagen disorders, uterine anomalies, and ingestion of diethylstilbestrol (DES) by the woman's mother while pregnant with the woman.

trauma from previous lacerations

A vaginal ultrasound examination will reveal an abnormally short (<25 mm) cervix. Often the short cervix is accompanied by cervical funneling (beaking), effacement of the internal cervical os, although the external cervical os remains closed

management: Cervical cerclage placement has been the treatment of choice for women with cervical insufficiency due to cervical weakness. Indications for cerclage placement are a poor obstetric history (three or more previous early preterm births or second-trimester losses), a short (<25 mm) cervical length identified on transvaginal ultrasound, and an open cervix found on digital or speculum examination
- The McDonald technique is often the procedure of choice because of its proven effectiveness and ease of placement and removal. In this procedure, a suture is placed around the cervix beneath the mucosa to constrict the internal os of the cervix

-bed rest
Nursing alert for Hydatidform mole:
To avoid confusion in regard to rising levels of hCG that are normal in pregnancy but could indicate GTD, pregnancy should be avoided during the follow-up assessment period. Any contraceptive method except an intrauterine device (IUD) is acceptable. Oral contraceptives are preferred because they are highly effective. Injectable medroxyprogesterone acetate (Depo Provera) is a practical option for women who have difficulty complying with the daily dosing required for oral contraceptive use.
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