Nursing Management of Spontaneous Abortion and Ectopic Pregnancy

Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications (Ch. 19)

• This chapter covers nursing management of high-risk pregnancies, including complications.
• Objectives include differentiating various pregnancy complications.
• Objectives include comparing and contrasting complications like placenta previa and abruptio placentae.
• Objectives include explaining the effects of hyperemesis gravidarum on maternal and fetal well-being.
• Objectives include explaining the effects of ABO and Rh incompatibility on fetal well-being.
• Objectives include understanding amniotic fluid imbalances such as polyhydramnios and oligohydramnios.

High-Risk Pregnancy

• A "high-risk pregnancy" is a condition related to pregnancy or a pre-existing condition endangering the mother, fetus, or both.
• Higher morbidity and mortality are associated with high-risk pregnancies.
• Risk assessment is crucial throughout pregnancy, beginning with the first antepartal visit.
• Diverse factors contribute to high-risk pregnancies, including genetics, environment, lifestyle, diet, and medical conditions.

Bleeding During Pregnancy

• Bleeding during pregnancy can jeopardize maternal and fetal well-being.
• Maternal risks include hypovolemia, anemia, infection, and premature labor (PTL).
• Fetal risks include blood loss, anemia, hypoxemia, hypoxia, anoxia, and preterm birth.

Early Pregnancy Bleeding (Before 20 Weeks)

• Spontaneous abortion (miscarriage) is a common cause of early pregnancy bleeding.
• Ectopic pregnancy is implantation outside the uterus.
• Gestational trophoblastic disease (hydatiform mole) is a benign growth affecting the placenta.
• Cervical insufficiency is a risk factor for early pregnancy bleeding.

Nursing Assessment for Early Pregnancy Bleeding

• Assess vaginal bleeding (pad count, POC).
• Assess cramping or contractions.
• Assess vital signs and pain level.
• Classification guidelines will determine management.
• Management differs based on the type of bleeding.

Nursing Assessment and Management of Early Pregnancy Bleeding: Spontaneous Abortion (Miscarriage)

• Classification includes threatened, inevitable, incomplete, complete, missed, and recurrent.
• Assessment involves vaginal bleeding, cramping, vital signs, and pain level.
• Management depends on the classification and symptoms.
• Potential medications include misoprostol, and possible procedures such as D&C.

Psychosocial Support for Early Pregnancy Bleeding

• Provide emotional and physical support.
• Acknowledge stress.
• Encourage verbalization of emotions.
• Provide grief support.
• Referral to community support groups.

Early Pregnancy Bleeding: Ectopic Pregnancy

• Ovum implants outside the uterus.
• Accounts for 2% of pregnancies in the U.S and 9% of all pregnancy-related deaths (primarily due to blood loss).
• Typically occurs in the fallopian tubes.
• Locations include the abdominal cavity, ovaries, and cervix.

Ectopic Pregnancy: Risk Factors

• Previous ectopic pregnancies.
• History of sexually transmitted infections (STIs).
• Scarring from pelvic inflammatory disease (PID).
• Endometriosis.
• Previous tubal or pelvic surgery.
• Treatment for infertility.
• Uterine fibroids.
• Previous intrauterine device (IUD) use.

Ectopic Pregnancy: Manifestations

• Before Rupture:
• Abdominal pain (dull, lower quadrant pain on one side).
• Delayed menses.
• Abnormal vaginal bleeding (spotting).
• After Rupture:
• Referred shoulder pain.
• Generalized, one-sided or deep lower quadrant acute abdominal pain.
• Faintness and dizziness.
• Cullen sign (ecchymotic blueness around umbilicus).

Ectopic Pregnancy: Management

• Laboratory and diagnostic testing: Transvaginal ultrasound, serial serum beta hCG levels.
• Medications (for certain cases): Methotrexate IM, prostaglandins, misoprostol.
• Surgery: Salpingectomy (removal of tube), or Salpingostomy (incision for removal of products of conception).

Early Pregnancy Bleeding: Gestational Trophoblastic Disease (GTD)

• A group of pregnancy-related trophoblastic proliferative disorders without a viable fetus that result from abnormal fertilization.

• Rare (1 in 1000 pregnancies).

• Two types: Hydatidiform mole and choriocarcinoma.

Hydatidiform Mole: Risk Factors and S&S

• Exact cause is unknown; possible ovular defect or nutritional deficiency. Risk factors include prior molar pregnancy, early teens, or age 40 and over.
• Manifestations include dark brown vaginal bleeding, excessive nausea/vomiting, abdominal cramps, and possible preeclampsia before 24 weeks.

Hydatidiform Mole: Management

• Medical Management: D&C to evacuate uterine contents. Long-term follow-up monitoring of serial hCG levels is essential.
• Nursing considerations: Emotional support, education, serial hCG monitoring, and prophylactic chemotherapy.

Early Pregnancy Bleeding: Cervical Insufficiency

• Passive and painless dilation of the cervix during the second trimester (incompetent cervix).
• Etiology is unknown, but potentially due to cervical damage from childbirth lacerations, excessive cervical dilation, and exposure to DES.
• Manifestations include pink-tinged vaginal discharge, pelvic pressure, short labors, recurring pregnancy loss at earlier gestational ages, and cervical shortening or dilation as shown by transvaginal ultrasound.

Cervical Insufficiency: Management

• Medical Management: Bedrest, pessaries, antibiotics, anti-inflammatory drugs, and progesterone.
• Surgical Management: Cerclage, a suture around the cervix to constrict the opening. This procedure is typically performed to prevent preterm birth.

Cervical Insufficiency: Cerclage

• Potential risks of cerclage placement include preterm labor (PTL), premature rupture of membranes (PROM), or chorioamnionitis.
• Ongoing care involves bed rest, avoiding sexual activity, close observation, patient education, and monitoring for signs of preterm labor, infection, or imminent delivery (diffuse abdominal pain, back pain, PROM, and signs of imminent delivery).

Late Pregnancy Bleeding: Placenta Previa

• Placenta implants in the lower uterine segment completely or partially covering the cervix. This location can cause bleeding during dilation or effacement.
• Classifications include low-lying, marginal, partial, and complete previa.
• Risk factors include previous C-sections, previous placenta previa, D&C for miscarriage, multiple gestation, multiparity, maternal age less than 35, and history of uterine fibroids or smoking.
• Manifestations include painless bright-red vaginal bleeding, typically in the second and third trimesters, soft relaxed non-tender abdomen.
• Management is dependent upon the amount of bleeding, fetal position and development, and maternal parity.
• Nursing management focuses on monitoring maternal-fetal status, preventing vaginal exams, and preparing for potential cesarean birth. Patient education emphasizes signs and symptoms that need reporting.

Late Pregnancy Bleeding: Abruptio Placentae (Placental Abruption)

• Detachment of a normally implanted placenta from the uterus.
• Occurs after 20 weeks of gestation and before birth.
• Classifications of abruption include partial and complete, with concealed or apparent hemorrhage.

Placental Abruption: Risk Factors

• Maternal hypertension (HTN).
• Cocaine use.
• Abdominal trauma.
• Smoking.
• Preterm premature rupture of membranes (PROM).
• Multiple births.
• History of previous placental abruption.

Placental Abruption: Manifestations

• Vaginal bleeding, either painless or painful, typically in the late second or third trimester.
• Maternal or fetal complications include uterine contractions, hypertonus, abnormal blood loss, or severe cases of DIC and IUGR.
• Management is based on assessment of maternal and fetal compromise, blood loss, fetal status, and indications for possible immediate delivery.

Placental Abruption: Management

• Medical Management: Includes assessment, controlling the situation (stabilizing patient), controlling blood loss, preventing disseminated intravascular coagulation (DIC).
• Nursing Management: Assessment of maternal and fetal status, blood loss monitoring, preparing patient for possible immediate delivery, and avoiding vaginal exams.

Other Gestational Conditions

• Hyperemesis Gravidarum: Excessive vomiting during pregnancy causing dehydration, electrolyte imbalances, nutritional deficiencies, ketonuria, and weight loss.

• Include vomiting, risk factors, assessment (diet history, onset/duration, associated symptoms, associated weight/weight loss, and physical assessment of hydration and electrolyte balance and function.

• ABO incompatibility: Incompatibility arises when the mother's blood type (O) does not match the fetus blood type (A or B), leading to clumping and RBC destruction and potential jaundice.

• Nursing assessment focuses on early detection and intervention and includes monitoring vital signs, assessing hydration, and monitoring for jaundice.

• Management focuses on controlling symptoms and preventing complications, including IV fluids and appropriate medications.

• Rh Isoimmunization: Rh negative mother exposed to Rh+ fetal blood during pregnancy, causing the mother to form antibodies that destroy the fetus' red blood cells during subsequent pregnancies, primarily manifested by erythroblastosis fetalis and hydrops fetalis. Anti-Rh antibodies can cross the placenta and harm subsequent fetuses. Assessment should include maternal and fetal status and evaluation for blood type and Rh factor. Management includes monitoring for fetal complications and potential intervention for management with medications like RhoGAM and possible future pregnancy interventions.

• Hydramnios/Polyhydramnios: Excess amniotic fluid (>2000 mL), often related to maternal diabetes, fetal genetic disorders, gastrointestinal obstructions, and multiples.

• Assessment includes risk factors, fundal height, abdominal discomfort, and difficulty palpating fetal parts or obtaining fetal heart rates (FHR).

• Management includes close monitoring, fetal fluid removal procedures, and administering medications that limit fetal fluid output such as indomethacin.

• Oligohydramnios: Reduced amniotic fluid (<500 mL), potentially caused by fetal urinary tract or genetic abnormalities or maternal hypertension, diabetes.

• Associated complications can include cord compression, fetal hypoxia, or preterm birth.

• Assessment includes risk factors, fetal fluid leaking from vagina, and continuous fetal status monitoring.

• Management includes monitoring, consideration of fetal surveillance, possible amnioinfusion.

Multiple Gestation

• Pregnancy with two or more fetuses.
• Increased incidence due to fertility drugs.
• Complications include maternal complications such as preterm labor, polyhydraminos, hyperemesis gravidarum, anemia, and preeclampsia.
• Fetal complications include prematurity, respiratoy distress syndrome, birth asphyxia, conjoined twins, and other congenital abnormalities.
• Management focuses on monitoring, possible c-sections and close monitoring during both antepartum and intrapartum phases.

Hypertensive Disorders in Pregnancy

• Common complication with varying classifications.
• Types include chronic HTN, chronic HTN with superimposed preeclampsia, gestational HTN, preeclampsia and eclampsia, and HELLP syndrome.
• Assessment includes thorough history, detailed physical examination, laboratory tests, vital signs, maternal and fetal evaluation.
• Management is dependent on diagnosis, severity, and stage.

Preeclampsia

• Pregnancy disorder (after 20 weeks) involving hypertension and proteinuria, with no previous presence of hypertension or proteinuria.
• Described as vasospastic disorder affecting cardiovascular, hepatic, renal, and central nervous systems.
• Assessment includes monitoring of maternal status (vitals, signs of possible complications such as HELLP and eclampsia).
• Management varies depending on severity, with inpatient care for severe cases.

Preeclampsia: Risk Factors

• Primigravida (first pregnancy) younger than 19 or older than 40.
• History of severe preeclampsia in previous pregnancies.
• Family history of preeclampsia.
• Paternal history of preeclampsia.
• African descent.
• Multifetal gestation.
• Maternal infection/inflammation during pregnancy.
• Pre-existing medical condition (chronic hypertension, renal disease, pregestational diabetes mellitus, connective tissue disease, thrombophilia, obesity).

Preeclampsia: Mild Versus Severe

• Mild preeclampsia involves milder symptoms such as high blood pressure, proteinuria, or other milder physical manifestation.
• Severe preeclampsia involves more serious symptoms that need more aggressive treatment, which includes high blood pressure, proteinuria, edema, headaches, visual problems, and impending complications such as impaired fetal status, placental abruption, or HELLP and eclampsia.

Preeclampsia: Antepartum, Intrapartum, and Postpartum Nursing Care

• Antepartum considerations: Includes daily assessment (fetal well-being, BP monitoring, urine output, lab tests as needed).
• Intrapartum considerations: Includes continuous fetal monitoring, constant maternal assessment, and medication management.
• Postpartum considerations: Includes monitoring for complications (magnesium toxicity, decreased consciousness); assessing physical health, including hemodynamic status, and closely monitoring for possible complications from preeclampsia.

HELLP Syndrome:

• Laboratory definition of a certain form of severe preeclampsia involving hemolysis, elevated liver enzymes, and low platelets.
• Can progress rapidly; most dangerous form of preeclampsia.

Eclampsia

• Onset of seizure activity or coma in women with preeclampsia and no prior history of seizures.
• Usually preceded by symptoms like headache, blurred vision, severe epigastric pain, changes in mental status, and eventual convulsions.