GESTATIONAL CONDITIONS 1

• Hyperemesis gravidarum


  Severe, persistent nausea and vomiting during pregnancy typically leads to weight loss, fluid & electrolyte imbalance and deficiencies in nutrition
• Hyperemesis gravidarum


  • Occurs between 4-8 weeks gestation and lasts > 16 weeks
  • HCG peaks at 6 weeks and declines at 12 weeks
• Pernicious vomiting


  Another term for hyperemesis gravidarum
• 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
• Cause of hyperemesis gravidarum is unknown
• 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
• Risk factors for hyperemesis gravidarum


  • Multiple gestation
  • Hydatidiform mole
  • History of HG
  • Migraine headaches
• Signs and symptoms of hyperemesis gravidarum


  • Excessive nausea & vomiting
  • Signs of dehydration – poor turgor, dry mucous membranes, HR, BP
  • Weight loss
  • Malaise
• Assessment of hyperemesis gravidarum

  • Nausea most pronounced on arising; however can occur at other times during the day
  • Persistent vomiting
  • Weight loss
  • Signs of dehydration (decreased urinary output, rapid pulse rate, low-grade fever, dry skin, sunken eyes, dry lips)
  • Electrolyte imbalances (↓ Na, K, chloride; hypokalemic alkalosis)
  • Ketonuria
  • Increased hematocrit levels
• Diagnostic tests and lab for hyperemesis gravidarum

  • Hematocrit, hemoglobin – CBC (↑ hematocrit)
  • Electrolytes – CMP (↓ K, ↓ Na)
  • Urine protein and acetone - Urinalysis (+ ketones, ↑ specific gravity)
• Medications for hyperemesis gravidarum


  • Antiemetics – Metaclopramide (reglan), Prochlorperazine (compazine), Ondansetron (zofran)
  • IV Fluids - LR
  • Thiamine (B1), Pyridoxine (B6)
  • TPN/Enteral Feeding
• Therapeutic nursing management for hyperemesis gravidarum

  • Hospitalization is required for severe symptoms, with intravenous hydration and correction of metabolic imbalances needed
  • Implement common N/V nursing interventions (smaller, frequent meals; salty foods; crackers before arising; avoid spicy/fried foods; remain upright after eating; discuss antacids)
  • Control vomiting with antiemetics
  • NPO, progress to small feedings, then soft/normal diet
  • Quiet environment
  • Intake & Output monitoring
  • Adequate nutrition - nasogastric tube feeding may be necessary
• Pharmacology for hyperemesis gravidarum

  • Sedatives
  • Antiemetics
  • Correction of fluid and electrolyte imbalances
  • IV Lactated Ringers
• Complications of hyperemesis gravidarum


  • Dehydration
  • Electrolyte imbalance
  • Severe Weight loss
  • Metabolic alkalosis
  • Maternal - hypokalemia, Wernicke Encephalopathy (low thiamine; confusion, ataxia, nystagmus)
  • Fetal - intrauterine growth restriction, low birth weight, preterm birth
• BLEEDING

  A. First Trimester

  (1) Spontaneous Abortion/Miscarriage

  (2) Ectopic (Tubal) Pregnancy

  B. Second Trimester

  (1) Hydatidiform mole (Gestational Trophoblastic Disease)

  (2) Premature Cervical Dilatation

  C. Third Trimester

  (1) Placenta Previa

  2) Abruptio Placentae

  (3) Premature Rupture of Membrane/Preterm Labor
• 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
• Types of miscarriage


  • Threatened miscarriage
  • Imminent (Inevitable) miscarriage
  • Complete miscarriage
  • Incomplete miscarriage
  • Missed miscarriage
• 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
• Assessment factors for vaginal bleeding during pregnancy

  • Confirmation of pregnancy
  • Pregnancy length in weeks
  • Duration of bleeding
  • Intensity (amount of bleeding occurred)
  • Frequency
  • Associated symptoms
  • Action
  • Blood type
• Implementation for threatened miscarriage

  • Assess fetal viability (FHR, ultrasound)
  • Test blood for HCG level
  • Avoidance of strenuous activity for 24-48 hours
  • Complete bed rest may not be necessary
  • Offer emotional support
  • Woman can resume activities once bleeding stops after 48 hours, coitus restricted for 2 weeks
• Implementation for imminent (inevitable) miscarriage

  • Advise woman to come to hospital if uterine contractions and cramping happen
  • Assess/Monitor spontaneous vaginal bleeding and cramping
  • Save expelled tissues/clots
  • Count perineal pads to evaluate blood loss
  • Monitor vital signs
  • Provide IV fluids
  • Prepare client 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
• Implementation for missed miscarriage

  • Ultrasound has to be performed
  • Prepare client for D & E
  • Prepare client for labor if pregnancy is over 14 weeks, using Misoprostol (Cytotec) and oxytocin
  • Provide IV fluids
  • Offer emotional support/counselling
• Complications of miscarriage


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

  • Monitor vital signs to detect possible hypovolemic shock
  • Position woman flat and massage the uterine fundus
  • Prepare patient for D & C
  • Administer BT as prescribed
  • Prepare replacement of fibrinogen or another clotting factor as required/prescribed
  • Teach patient the importance of taking methylergonovine maleate, including the dosage
  • Offer/Provide emotional support
• Implementation for infection complication

  • Teach women the danger signs of infection
  • Instruct woman to wipe her perineal area from front to back after voiding and after defecation
  • Caution her not to use tampons to control vaginal discharge
  • Encourage more intake of fluids
  • Provide IV if required/as prescribed
• Septic abortion may lead to infertility due to uterine scarring or fibrotic scarring of the fallopian tube
• Infection - Morbidity is minimal if pregnancy loss occurs over a short time, bleeding is self-limiting, and instrumentation is less
• Infection - Increase possibility may happen for women who have lost large amount of blood
• Infection

  S/sx: fever (38ºC), abdominal pain or tenderness, and foul vaginal discharge
• Infectious Organism

  Escherichia coli (E. coli)
• Infection Implementation

  1. Teach women the danger signs of infection

  2. Instruct woman to wipe her perineal area from front to back after voiding and after defecation

  3. Caution her not to use tampons to control vaginal discharge

  4. Encourage more intake of fluids

  5. Provide IV if required/as prescribed
• Septic Abortion


  An abortion that is complicated with infection
• Septic Abortion


  Infection occurs more frequently in women who have tried to self-abort or were aborted illegally using a nonsterile instrument
• Septic Abortion


  S/sx: fever, crampy abdominal pain, & tender uterus
• Septic Abortion Complications

  • Toxic Shock Syndrome
  • Septicemia
  • Kidney Failure
  • Death