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• Hyperemesis gravidarum is characterized by severe and excessive nausea and vomiting during pregnancy, leading to electrolyte, metabolic, and nutritional imbalances
• Hyperemesis gravidarum is linked to trophoblastic activity, gonadotropin production, and psychological factors
• Possible causes of hyperemesis gravidarum include:

  • Pancreatitis
  • Biliary tract disease
  • Decreased secretion of free hydrochloric acid in the stomach
  • Decreased gastric motility
  • Drug toxicity
  • Inflammatory obstructive bowel disease
  • Vitamin deficiency (especially B vitamins)
  • Psychological factors in some cases
  • Transient hyperthyroidism
• Assessment findings of hyperemesis gravidarum include severe nausea and vomiting, weight loss, hiccups, oliguria, vertigo, headache, electrolyte imbalance, dehydration, and metabolic alkalosis
• Diagnostic test findings for hyperemesis gravidarum:

  • Decreased protein, sodium, and potassium levels
  • Increased blood urea nitrogen levels
  • Elevated hemoglobin levels
  • Elevated white blood cell count
• Nursing diagnoses for hyperemesis gravidarum:

  • Imbalanced nutrition, less than body requirement related to frequency of excessive nausea & vomiting
  • Fluid volume deficit related to excess fluid loss
  • Anxiety related to ineffective gravidarum coping, physiological changes of pregnancy
  • Activity intolerance related to weakness
• Medical management of hyperemesis gravidarum includes:

  • Withholding oral fluids and food until there's no vomiting for 24 hours
  • Administering antiemetic medications
  • Monitoring fluid intake and output, vital signs, skin turgor, daily weight, serum electrolyte levels, and urine for ketones
  • Providing frequent mouth care
  • Recommending a diet high in dry, complex carbohydrates and suggesting eating two or three dry crackers before getting out of bed in the morning
  • Suggesting decreased liquid intake during meals
• Ectopic Pregnancy: implantation of the fertilized ovum outside the uterine cavity
• Types of Ectopic Pregnancy:

  • Interstitial pregnancy
  • Isthmic pregnancy
  • Ampullary pregnancy
  • Abdominal pregnancy
  • Cervical pregnancy
  • Ovarian pregnancy
  • Fimbrial pregnancy
• Abdominal Pregnancy:

  • Product of conception is expelled into the pelvic cavity
  • Fetal outline is easily palpable
  • Sonogram or MRI is used to reveal the fetus outside the uterus
  • At term, the infant may be born by laparotomy
• Assessment Findings/Signs and Symptoms:

  • Mild abdominal pain
  • Amenorrhea / absence of menses
  • Extreme pain & lower abdominal pain
  • Uterus is boggy & tender
  • Rupture of tube
  • Nausea & vomiting
  • Syncope
  • Shock
• Causes of ectopic pregnancy:

  • Endosalphingitis
  • Diverticula
  • Tumors pressing on the tube
  • Previous surgery like tubal ligation or resection, or adhesions from previous abdominal or pelvic surgery
  • Transmigration of the ovum, resulting in delayed implantation
• Diagnostic Test Findings:

  • Serum - pregnancy (hCG, "Human chorionic gonadotropin")
  • Ultrasound
  • Culdocentesis: detects blood in the peritoneum
  • Laparoscopy
• Nursing Diagnosis:

  • Risk for deficient fluid volume related to bleeding from a ruptured ectopic pregnancy
  • Powerlessness related to early loss of pregnancy secondary to ectopic pregnancy
• Goal of care:

  • Ensure maternal blood loss is replaced and bleeding stops
  • Patient maintains adequate fluid volume as evidenced by normal urine output at 30-60ml/hr

  Complications:

  • Rupture of the Tube
  • Infertility
• Nursing Management of Ectopic Pregnancy

  • Salpingectomy
  • Salpingostomy
  • Oophorectomy
  • Administer Methotrexate
  • Blood transfusion
  • Antibiotic
  • High CHON diet
  • Emotional support
• Nursing Interventions:

  • Date of patient’s last menses and obtain serum hCG levels
  • Assess vital signs and monitor vaginal bleeding for extent of fluid loss
  • Check amount, color, and odor of vaginal bleeding; monitor pad count
  • Withhold fluid/food
  • Assess signs and symptoms of hypovolemic shock secondary to blood loss from tubal rupture
  • Administer blood transfusion and analgesic
  • Determine if the patient is Rh – negative
  • Urge prompt treatment of pelvic infections to prevent recurrent ectopic pregnancy
  • Inform patients with fallopian tube surgery or confirmed pelvic inflammatory disease of increased risk for another ectopic pregnancy
• Gestational Trophoblastic Disease, specifically Hydatidiform Mole, involves the rapid deterioration of trophoblastic villi cells, leading to grapelike clusters of vesicles due to fluid-filled cells

  
  

  • The embryo fails to develop past the early stages due to these cell abnormalities
• Possible causes of Gestational Trophoblastic Disease include chromosomal abnormalities, hormonal imbalances, or deficiencies in protein and folic acid
• Assessment findings for Gestational Trophoblastic Disease include vaginal bleeding, hyperemesis, lower abdominal cramps, an exceptionally large uterus for the gestational date, grapelike vesicles in the vagina, ovarian enlargement from cysts, and absence of fetal heart rate tones
• Diagnostic tests for Gestational Trophoblastic Disease include Radioimmunoassay, Histologic examination, Ultrasonography after the 3rd month, Amniography, Doppler ultrasonography, and blood tests like WBC and urine hCG levels
• Medical management of Gestational Trophoblastic Disease involves dilatation and suction curettage, postoperative treatment based on blood loss and complications, monitoring hCG levels, prophylactic chemotherapy, and chemotherapy and radiation for metastatic choriocarcinoma
• Nursing management includes assessing vital signs, monitoring for complications like hemorrhage and uterine infection, saving expelled tissue for analysis, explaining contraceptive use, and dietary recommendations
• Two types of Gestational Trophoblastic Disease are Complete Moles, characterized by swelling and cystic formation of all trophoblastic cells, and Partial Moles, with edema of some trophoblastic villi and some normal villi
• Complete Moles are genetically diploid, paternal-derived, associated with choriocarcinoma, and have no fetal blood present
• Partial Moles may have fetal blood present, an embryo up to 9 weeks gestation, are genetically triploid, derived from both parents, and have 69 chromosomes with 3 chromosomes for every pair
• Invasive types of Gestational Trophoblastic Neoplasia include Invasive mole (limited to the uterus), Choriocarcinoma (can metastasize to the lungs), and Placental site tumor (rare, arising from trophoblastic cells)
• Incompetent cervix, also known as premature cervical dilation, typically occurs around week 20 of pregnancy
• Pathophysiology of incompetent cervix:

  • Associated with congenital structural defects or previous cervical trauma
  • Also linked to increasing maternal age
  • Connective tissue structure of the cervix is not strong enough to maintain closure of the cervical OS during pregnancy
• Assessment findings of incompetent cervix include:

  • History of repeated 2nd trimester spontaneous abortions
  • Cervical dilation
  • Pink-stained vaginal discharge
  • Increased pressure with possible ruptured membranes
• Nursing diagnosis of incompetent cervix: Anxiety related to impending loss of pregnancy as evidenced by premature dilation of the cervix

  
  

  Diagnostic test findings of incompetent cervix:

  • Ultrasound
  • Nitrazine test (on amniotic fluid)
• Medical management of incompetent cervix includes:

  • McDonald’s procedure: using a nylon suture horizontally and vertically
  • CERCLAGE: Placement of a purse-string suture in the cervix
  • Shirodkar procedure: using sterile tape in a purse-string suture
• Nursing Interventions of incompetent cervix:

  • Bed rest after surgery
  • Prepare the woman for cervical cerclage under regional anesthesia as indicated
  • Sutures will be removed around the 37th-39th week of pregnancy

  Possible complications of incompetent cervix: spontaneous abortion and preterm birth
• Spontaneous Abortion: pregnancy loss at less than 20 weeks gestation in the absence of medical or surgical measures
• Types of Spontaneous Abortion:

  • Complete Abortion: Entire products of conception are expelled spontaneously without any assistance
  • Habitual Abortion/Recurrent: Spontaneous loss of 3 or more consecutive pregnancies at the same gestation age
  • Incomplete abortion: Uterus retains part or all of the membranes/placenta
  • Inevitable/Imminent Abortion: Membranes rupture and the cervix dilates
  • Missed abortion: fetus dies in utero but is not expelled
  • Threatened abortion: Bloody vaginal discharge occurs during the 1st half of pregnancy
  • Septic abortion: Infection accompanies abortion
• Causes of Spontaneous Abortion (Fetal Factors):

  • Defective embryologic development from abnormal chromosome
  • Faulty implantation of fertilized ovum
  • Failure of the endometrium to accept the fertilized ovum
• Causes of Spontaneous Abortion (Maternal Factors):

  • Maternal infections
  • Severe malnutrition
  • Abnormalities of the reproductive organs

  Causes of Spontaneous Abortion (Placental Factors):

  • Premature separation of the normally implanted placenta
  • Abnormal placental implantation
  • Abnormal platelet function
• Diagnostic test findings:

  • Evidence of expulsion of uterine contents, pelvic examination, laboratory studies and Ultrasonography

  Assessment Findings:

  • Pink discharge for several days
  • Scant brown discharge for several weeks before the onset of cramps and increased vaginal bleeding
• Complications of spontaneous abortion:

  • Hemorrhage: Position the woman flat, massage the uterine fundus, Dilatation and curettage, Direct replacement of fibrinogen, Methergine (methylergonovine maleate)
  • Infection: E. Coli (spread from the rectum forward into the vagina), Endometritis
  • Sepsis: complicated by infection
  • Isoimmunization: Production by the mother’s immunologic system of antibodies against Rh-positive blood
  • Powerlessness
• Procedures Used in Pregnancy Termination:

  • Vacuum Curettage: Used for 1st tri abortions to remove remaining products of conception
  • Dilatation & Curettage: Dilatation of the cervix followed by gentle scraping of the uterine walls to remove products of conception, local or general anesthesia is needed