2. Hemorrhagic Disorder Early term: Abortion Ectopic Pregnancy
Hydatid Form MoleLate term Placenat previa Abruption Placenta 3.
Abortion Tree abortion Spontaneous A Threatened AInduced A.
therapeuticinevitablemissedincomplete may go to termcriminal
septiccompletehabitual 4. SPONTANEOUS ABORTION Spontaneous abortion
is the unintended termination of pregnancy at any time before the
fetus has attained viability (20 weeks' gestation or fetal weight
of 500 g [1.1 lb]). See Table 37-1. For a discussion of therapeutic
or voluntary abortion 5. Spontaneous Abortion 1. Also called
miscarriage 2. Unpreventable loss of pregnancy 3. Loss of pregnancy
before 20 weeks 4. Maybe 20-25% of all pregnancies 6. Spontaneous
Abortion Most occur before 8 weeks (about 90%) 50% caused by
chromosomal abnormalities Late miscarriage Miscarriage may occurs
between be caused by 12 and 20 weeks several factors 7. Spontaneous
Abortion Types of miscarriage 1. 2. 3. 4. 5.Incomplete Complete
Missed Recurrent Septic 8. Classification Clinical Manifestations
Management 1. Threatened Clinical manifestation Vaginal bleeding or
spotting Mild pain, Tenderness over uterus, low backache Cervix
closed Management Bed rest(ABR) Pad count 2. Inevitable Clinical
manifestation Bleeding more profuse Cervix dilated Painful uterine
contractions Embryo delivered complete or incomplete , followed by
dilatation and curettage (D&C) 9. 3. Incomplete Clinical
manifestation Fetus usually expelled Placenta and membranes
retained Management Embryo delivered, followed by dilatation and
curettage (D&C) 4. Missed Clinical manifestation Fetus dies in
utero and is retained Maceration No symptoms of abortion, but
symptoms of pregnancy regress (uterine size, breast changes)
Management Ultrasound, Fetal monitoring If fetus is not passed
after diagnosis, oxytocin induction may be used. Retained dead
fetus may lead to development of disseminated intravascuia
coagulation or infection Fibrinogen concentrations should be
measured weekly 10. 3. Habitual Spontaneous abortion occurs in
successive pregnancies (3 or more) 11. Pathophysiology/Etiology 1.
Cause frequently unknown, but 50% are due to chromosomal anomalies
2. Exposure or contact with teratogenic agents 3. Poor maternal
nutritional status 4. Maternal illness with or specific bacterial
microorganisms 5. History of diabetes, thyroid disease, 6. Smoking
or drug abuse or both 7. Immunologic factor 8. Luteal phase defect
9. Postmature sperm or ova 10. Structural defect in the maternal
reproductive sysytem (including an incompetent cervix) 12. Induced
Abortion. Therapeutic/ Voluntary Abortion Therapeutic abortion is
the termination of pregnancy before fetal viability for the purpose
of safeguarding the woman's health. Voluntary abortion is the
termination of a pregnancy before fetal viability as a choice of
the woman(nontherapeutic). 13. Complications 1. Hemorrhage 2.
Uterine infection 3. Septicemia 4. Uterine perforation 5.
Disseminated intravascular coagulation (DIC) in a missed abortion
14. Nursing Assessment 1. Evaluate the amount and color of blood 2.
Determine gestational age, LMP and EDC 3. Monitor maternal vital
signs for indications of complications such as hemorrhage,
infection. 4. Evaluate any blood or clot tissue for the presence of
fetal membranes, placenta, or fetus. 15. Nursing Diagnoses A. Risk
for Fluid Volume Deficit related to maternal bleeding B.
Anticipatory Grieving related to loss of pregnancy, cause of the
abortion, future childbearing C. Risk for Infection related to
dilated cervix and open uterine vessels D. Pain related to uterine
cramping and possible procedures 16. Nursing Interventions A.
Maintaining Fluid Volume 1. Report shock sign(tachycardia,
hypotension, diaphoresis, or pallor) indicating hemorrhage. 2.
Screen blood type, blood administration( if needed). 3. Establish
and maintain an IV with large-bore catheter for possible
transfusion 4. Inspect all tissue passed for completeness. 17. B.
Providing Support Through the Grieving Process Grieving process;
Denial, Anger, Bargaining, Depression, Acceptance 1. Accesss the
reaction of patient and support person and provide information
regarding current status, as needed. 2. Encourage the patient to
discuss feelings about the loss of the baby; include effects on
relationship with the father. 3. Do not minimize the loss by
focusing on future childbearing; rather acknowledge the loss and
allow grieving. 4. Provide time alone for the couple to discuss
their feelings. 5. Discuss the prognosis of future pregnancies with
the couple. 6. If the fetus is aborted intact, provide an
opportunity for viewing, if parents desire. 18. C. Preventing
Infection 1. Evaluate temperature every 4 hours if normal, and
every 2 hours if elevated. 2. Check vaginal drainage for increased
amount and odor, which may indicate infection. 3. Instruct on and
encourage perineal care following each urination and defecation to
prevent contamination. 19. D. Promoting Comfort 1. Reduced anxiety.
2. Instruct and encourage the use of relaxation techniques to
augment analgesics. 3. Administer pain medications as needed and as
prescribed. 20. Patient Education/Health Maintenance 1. Provide the
names of local support groups for couples who have experienced an
early pregnancy loss 2. Discuss with the couple the methods of
contraception to be used. 3. Explain the need to wait at least 3 to
6 months before attempting another pregnancy. 4. Teach the woman to
observe for signs of infection (fever, pelvic pain, change in
character and amount of vaginal discharge), and advise to report
them to provider immediately. 21. Evaluation A. Vital signs remain
normal; minimal blood loss B. Expresses feelings regarding the loss
of the pregnancy C. No signs of infection, temperature normal,
performs perineal care D. Verbalizes relief of pain 22. ECTOPIC
PREGNANCY Ectopic pregnancy is any gestation located outside the
uterine cavity. 23. Pathophysiology/Etiology 1. The fertilized ovum
implants outside of the uterus. a. ampler portion of fallopian
tube. b. abdomen and the ovaries. 2. Structural factors; adhesions
of the tube, salpingitis, congenital and developmental anomalies
induced(septic) abortions. 3. Functional factors include menstrual
reflux and decreased tubal motility. 4. Contributing factors may
include: a. History of pelvic inflammatory disease (PID) b.
Endometriosis c. Previous tubal surgery 24. Clinical Manifestations
1. Abdominal or pelvic pain 2. Amenorrheain 75% of the cases 3.
Vaginal bleedingusually scanty and dark 4. Uterine size is usually
similar to what it would be in a normally implanted pregnancy. 5.
Abdominal tenderness on palpation 6. Nausea, vomiting, or faintness
may be present. 7. Pelvic examination reveals a pelvic mass,
posterior or lateral to the uterus, and cervical pain on movement
of the cervix. 8. Pain may become severe if a tubal rupture occurs
and clinical presentation will be that of shock. 25. Diagnostic
Evaluation 1. Serum -human chorionic gonadotropin (hCG) when done
serially, will not show characteristic rise as in intrauterine
pregnancy 2. Ultrasoundmay identify tubal mass, absence of
gestational sac within the uterus 3. Culdocentesisbloody aspirate
from the cul-desac of Douglas indicates intraperitoneal bleeding
from tubal rupture 4. Laparoscopyvisualization of tubal pregnancy
5. Laparotomyindication for surgery if there is any question about
the diagnosis 26. Management 1. Surgeries range from removal of
ectopic pregnancy with tubal resection, salpingostomy,
salpingectomy, and possibly sal- pingo-oophorectomy. 2. Treat shock
and hemorrhage if necessary(rupture) 27. Nursing Assessment
Evaluate the following to determine pregnancy and to monitor for
changes in patient's status, such as rupture or hemorrhage: 1.
Maternal vital signs 2. Presence and amount of vaginal bleeding 3.
Amount and type of pain 4. Presence of abdominal tenderness on
palpation(bluish low lateral abdomen) 5. Date of last menstrual
period 6. Presence of positive pregnancy test 28. Nursing Diagnoses
A. Risk for Fluid Volume Deficit related to blood loss from
ruptured tube B. Pain related to ectopic pregnancy or rupture and
bleeding into the peritoneal cavity C. Anticipatory Grieving
related to loss of pregnancy and potential loss of childbearing
capacity 29. Nursing Interventions A. Maintaining Fluid Volume 1.
Establish an intravenous (IV) line with a large-bore catheter and
infuse fluids and blood products as prescribed. 2. Obtain blood
samples for complete blood count (CBC) and type and screen for
whole blood, as directed. 3. Monitor vital signs and urine output
frequently, depending on condition. 30. B. Promoting Comfort 1.
Administer analgesics as needed and prescribed. 2. Encourage the
use of relaxation techniques. 31. C. Providing Support During Grief
1. Be available to patient and provide emotional support. 2. Listen
to concerns of patient and significant others. 3. Be aware that
family may be experiencing denial or other stage of grieving. 4.
Suggest referrals such as social worker, psychiatry, and clergy, as
appropriate. 32. Patient Education/Health Maintenance 1. Teach
signs of postoperative infection; fever, abdominal pain, and
increased or malodorous vaginal discharge. 2. Reinforce that
chances of another ectopic pregnancy are increased 3. Discuss
contraception. 4. Teach signs of recurrent ectopic
pregnancyabnormal vaginal bleeding, abdominal pain, menstrual
irregularity. 33. Evaluation A. Vital signs stable B. Verbalizes
pain relief C. Patient and support person express sorrow over their
loss 34. HYDATIDIFORM MOLE Hydatidiform mole is an abnormal
pregnancy resulting from a developmental anomaly of the placenta.
It is characterized by the conversion of the chorionic villi into a
mass of clear vesicles. There may be no fetus or a degenerating
fetus may be present. 35. Abnormal fertilization results in
abnormal growth of cells in uterus. The mole grows in the uterus
instead of a baby. The mole looks like a cluster of grapes. 36.
Occurrence 1. May occur in 1 out of every 1200 pregnancies (U.S
data) 2. May be higher in Asian countries 37. Possible Causes 1. 2.
3. 4.Nutritional deficiencies Age: early teens, over 40 Ovulation
stimulation with Clomid History of miscarriage 38.
Pathophysiology/Etiology 1. Large amounts of hCG are present
secondary to the proliferation of chorionic tissue. Assay values of
-hCG are elevated in the condition. 2. Contributing factors may
include chromosomal abnormalities, malnutrition, hormonal
imbalance, age under 20 or over 40, and low economic status. 39.
Hydatidiform mole Signs and Symptoms 1. 2. 3. 4. 5. 6.Pregnancy
symptoms Larger than normal uterus 95% of women will eventually
bleed Excessive nausea and vomiting Anemia Abdominal cramps 40.
Clinical Manifestations 1. First trimester bleeding 2. Absence of
fetal heart tones and fetal structures (by ultrasound) 3. Rapid
enlargement of the uterus; size greater than dates 4. -hCG titers
greater than expected for gestational age 5. Expulsion of the
vesicles 6. Hyperemesis 7. Signs of pregnancy-induced hypertension
(PIH) prior to 20 weeks' gestation 41. Diagnostic Evaluation 1.
-hCG levelselevated 2. Ultrasoundshows a characteristic picture of
the mole in most cases 42. Management 1. D&C(dilatation and
curettage) or D&E(dilatation and evacuation) 2. Follow-up for
detection of malignant changes because a complication is the
development of choriocarcinoma of the endometrium. 43.
Complications 1. Complete mole can cause cancer. About 20% will
develop into a rare cancer called choriocarcinoma. 2. 15% of women
will develop early high blood pressure disease (at 9 12 weeks). 44.
Nursing Assessment 1. Monitor maternal vital signs; note presence
of hypertension. 2. Assess the amount and type of vaginal bleeding;
note the presence of any other vaginal discharge. 3. Assess the
urine for the presence of protein and -hCG. 4. Palpate uterine
height; if above the umbilicus, measure the fundal height. 5.
Determine date of last menstrual period and date of positive
pregnancy test. 45. Nursing Diagnoses A. Potential for Fluid Volume
Deficit related to maternal hemorrhage B. Anxiety related to loss
of pregnancy and medical interventions 46. Nursing Interventions A.
Maintaining Fluid Volume 1. Obtain blood samples for type for whole
blood transfusion 2. Establish and maintain IV line. 3. Assess
maternal vital signs and evaluate bleeding. 4. Monitor laboratory
results to evaluate patient's status. 47. B. Decreasing Anxiety 1.
Prepare the patient for surgery; explain preoperative and
postoperative care along with intraoperative procedures. 2. Educate
patient and family on the disease process. 3. Allow the family to
grieve over the loss of the pregnancy. 48. Patient Education/Health
Maintenance 1. Advise the woman on the need for continuous followup
care(for monitor choriocarcinoma). 2. Provide reinforcement of
follow-up procedures: a. Measure hCG levels every 1 to 2 weeks
until normalthen begin monthly testing for 6 months, then every 2
months for a total of 1 year. b. Consider chemotherapy or
hysterectomy if -hCG levels rise or begin to plateau or there is
evidence of metastasis. 3. Encourage ongoing discussion of care
with health care provider. 4. Avoid pregnancy for a minimum of I
year. 49. Evaluation A. Vital signs stable; laboratory work within
normal limits B. Verbalizes concerns about self and related
procedures; describes follow-up care and its importance
