NCM 109 [R]

• Hyperemesis gravidarum


  A serious condition in which nausea and vomiting of pregnancy has become prolonged past week 12 AOG or is so severe that dehydration, ketonuria, and significant weight loss occur within the first 12 weeks of pregnancy
• Suggested causative factors of hyperemesis gravidarum


  • High levels of HCG in early pregnancy
  • Metabolic or nutritional deficiencies
  • Thyroid dysfunction
  • Ambivalence toward the pregnancy and family-related stress
  • Most common in primigravid clients
• Nursing process for hyperemesis gravidarum

  1. Assessment

  2. Diagnostic tests & lab

  3. Diagnosis

  4. Implement common N/V nursing interventions

  5. Treatments & goals for hospitalized client
• Abortion


  A medical term for any interruption of a pregnancy before a fetus is viable
• Viable fetus


  A fetus of more than 20-24 weeks of gestation or one that weighs at least 500 g
• Miscarriage


  An interruption of a pregnancy that occurs spontaneously
• Causes of spontaneous miscarriage

  • Abnormal fetal development
  • Immunologic factor
  • Implantation abnormalities
  • Insufficient levels of progesterone
  • Systemic infection
  • Ingestion of a teratogenic drug
  • Ingestion of alcohol
• Threatened miscarriage


  A miscarriage where there is vaginal spotting with slight cramping but no cervical dilation
• Actions/implementation for threatened miscarriage

  1. Assess fetal viability

  2. Test blood for HCG level

  3. Avoidance of strenuous activity for 24-48 hours

  4. Offer emotional support

  5. Restrict coitus for 2 weeks after bleeding episode
• Imminent (inevitable) miscarriage


  A threatened miscarriage becomes imminent if uterine contractions and cervical dilation occur
• Actions/implementation for imminent miscarriage


  1. Advise women to come to the hospital

  2. Assess/Monitor spontaneous vaginal bleeding and cramping

  3. Save expelled tissues/clots

  4. Count perineal pads to evaluate blood loss

  5. Monitor vital signs

  6. Provide IV fluids

  7. Prepare clients for dilatation and evacuation as prescribed
• Complete miscarriage


  The uterine products of conception are expelled spontaneously without any assistance
• Incomplete miscarriage


  A part of the conceptus is expelled (usually the fetus), but the membrane or placenta is retained in the uterus

  
• Missed miscarriage


  The fetus dies in the uterus but is not expelled
• Actions/implementation for missed miscarriage

  1. Ultrasound has to be performed

  2. Prepare client for D & E

  3. Prepare clients for labor if pregnancy is over 14 weeks

  4. Provide IV fluids

  5. Offer emotional support/counseling
• Complications of miscarriage


  • Hemorrhage
  • Infection
  • Septic abortion
• Implementation for hemorrhage complication

  1. Monitor vital signs to detect possible hypovolemic shock

  2. Position woman flat and massage the uterine fundus

  3. Prepare patients for D & C

  4. Administer BT as prescribed

  5. Prepare replacement of fibrinogen or another clotting factor as required/prescribed

  6. Teach patients the importance of taking methylergonovine maleate, including the dosage

  7. Offer/Provide emotional support

  
• Septic abortion


  An abortion that is complicated with infection, occurring more frequently in women who have tried to self-abort or were aborted illegally using a non sterile instrument
• Septic abortion may lead to infertility due to uterine scarring or fibrotic scarring of the fallopian tube
• Management of septic abortion

  CBC, serum electrolytes, serum creatinine, blood type & cross match, cervical, vaginal, & endometrial cultures
• Septic abortion


  An abortion that is complicated with infection
• Infection occurs more frequently in women who have tried to self-abort or were aborted illegally using a non sterile instrument
• Signs and symptoms of septic abortion

  • Fever, crampy abdominal pain, & tender uterus
• Complications of septic abortion


  • Toxic Shock Syndrome
  • Septicemia
  • Kidney Failure
  • Death
• Management of septic abortion

  1. CBC, serum electrolytes, serum creatinine, blood type & cross match, cervical, vaginal, & urine cultures

  2. I & O q hourly

  3. IVF administration

  4. CVP or Pulmonary artery catheterization

  5. D & C

  6. Oxygen and other ventilatory support
• Pharmacology for septic abortion

  • Antibiotic (Penicillin, Gentamicin, clindamycin)
  • Tetanus toxoid
  • Dopamine & Digitalis
• Isoimmunization


  The woman is Rh negative against Rh positive fetal blood which may enter maternal the circulation, leading to the production of maternal antibodies against Rh positive blood
• Management of isoimmunization


  After a miscarriage, all women with Rh negative blood should receive Rh (D antigen) immune globulin (RhIG) to prevent building-up antibodies in the event the conceptus was Rh positive
• Ectopic pregnancy


  Implantation occurs outside the uterine cavity
• Common sites of ectopic pregnancy

  • Fallopian tube (95%)
  • Cervical
  • Abdominal
  • Ovarian
• 2% of pregnancies are ectopic
• Ectopic pregnancy is the second most frequent cause of bleeding early in pregnancy
• Predisposing factors for ectopic pregnancy


  • Adhesion of the fallopian tube caused by chronic salpingitis or Pelvic Inflammatory Disease
  • Congenital malformations such as webbing in the fallopian tube
  • Scars from tubal surgery
  • Uterine tumor pressing on the proximal end of the tube
  • IUD

  
• Assessment findings for ectopic pregnancy

  • Amenorrhea or abnormal menstrual period/spotting
  • Nausea & vomiting
  • Positive pregnancy test
  • Tubal rupture signs: sudden, acute low abdominal pain radiating to the shoulder - Kehr's sign (referred shoulder pain) or neck pain
  • Bluish navel (Cullen's sign) due to blood accumulated in the peritoneal cavity
  • Rectal pressure because of blood in the cul-de-sac
  • Sharp localized pain when cervix is touched
  • Signs of shock/circulatory collapse
• Laboratory findings for ectopic pregnancy

  • Low hemoglobin count, low hematocrit level due to bleeding process or loss of blood
  • Low HCG indicating that pregnancy has ended
  • Elevated WBC due to trauma
• Diagnosis of ectopic pregnancy

  • Pelvic Ultrasonography - no embryonic sac in the uterine cavity
  • Culdocentesis - aspiration of non-clotting blood from the cul-de-sac of Douglas (positive tubal rupture)
  • Laparoscopy - not common; requires direct visualization

  
• Treatment of ectopic pregnancy

  • Methotrexate - indicated for unruptured ectopic (mass) smaller than 4 cm, to induce labor and preserve fallopian tube
  • Surgical removal of ruptured tube: SALPINGECTOMY
  • Management of Profound shock if ruptured: blood replacement and IVF
  • Antibiotics
• Complications of ectopic pregnancy

  • Hemorrhage
  • Infection
  • Rh sensitization
• Nursing diagnosis for ectopic pregnancy


  Powerlessness related to early loss of pregnancy secondary to ectopic pregnancy
• Nursing implementation for ectopic pregnancy

  1. Obtain assessment data rapidly especially for anticipatory shock

  2. Implement measures for shock as soon as possible

  3. Position patient on Modified Trendelenburg (shock)

  4. Start IVF, D5LR for plasma administration, blood transfusion, or drug administration as ordered

  5. Monitor V/S, bleeding, I & O

  6. Provide physical & psychological support - anticipate grief, guilt responses, fear related to potential disturbance in childbearing capacity in the future