Spontaneous Abortion

Spontaneous Abortion

• Interruption of pregnancy before the fetus is viable, usually 20 to 24 weeks' gestation or weighing 500 g.
• Also called a miscarriage, occurring from natural causes.
• One of the most common causes of bleeding during the first trimester of pregnancy.
• Caused by abnormal fetal formation, either from a teratogenic factor, chromosomal aberration, or implantation abnormalities.

Types of Spontaneous Abortion

Threatened Abortion

• Moderate bright red vaginal bleeding
• No cramping
• No cervical dilatation

Imminent Abortion

• Moderate bright red vaginal bleeding
• Uterine contractions
• Cervical dilatation
• Spontaneous expulsion of entire products of conception

Complete Abortion

• Moderate bright red vaginal bleeding
• Uterine contractions
• Cervical dilatation
• Spontaneous expulsion of part of the products of conception

Incomplete Abortion

• Moderate bright red vaginal bleeding
• Uterine contractions
• Cervical dilatation
• Possible passage of tissue fragments

Missed Abortion

• No increase in fundal height measurements
• Inaudible fetal heart sounds
• Painless vaginal bleeding or no symptoms at all

Recurrent Abortion

• History of three spontaneous abortions occurring at the same gestational age in three pregnancies

Nursing Implications for Spontaneous Abortion

• Obtain thorough history and physical examination to establish a baseline and include estimating the date of birth.
• Assess the client's complaints of vaginal bleeding, including onset, duration, frequency, intensity, amount, color, and any associated symptoms.
• Ascertain if anything happened that may have started the bleeding and what, if anything, the client has done to control the bleeding.
• Obtain ultrasonography to confirm pregnancy.
• Weigh perineal pads to determine accurately the amount of vaginal blood loss.
• Monitor vital signs frequently for signs of hemorrhage.
• Recommend iron supplements and increases in dietary iron as indicated.
• Prepare for RhoGAM administration to an Rh-negative mother, as prescribed.
• Monitor fluid balance, including intravenous fluids and laboratory studies, especially in the presence of heavy vaginal bleeding to prevent shock.
• Offer support to the client and partner and reassure the client that abortions happen spontaneously.
• Provide support to help the client accept the reality of the fetus' death and anticipate counseling for anxiety about future pregnancies.

Complications of Abortion

• Hemorrhage
• Infection

Ectopic Pregnancy

• A complication of pregnancy in which implantation occurs outside the uterine cavity.
• The second most frequent cause of vaginal bleeding early in pregnancy.
• Associated with the use of intrauterine devices, pelvic inflammatory disease, progestin-only oral contraceptives, postconceptual estrogen, or ovarian induction drugs
• At about 6 to 12 weeks of pregnancy, the growing zygote ruptures the slender tube with resultant invasion and destruction of the blood vessel in the tube
• A ruptured ectopic pregnancy is a serious condition

Types of Ectopic Pregnancy

• Ovarian
• Cervical
• Abdominal
• Tubal (most common)

Assessment Findings of Ampullar Type Ectopic Pregnancy

• Sharp, stabbing pain in one of the lower abdominal quadrants
• Rigid abdomen
• Positive Cullen's sign
• Excruciating pain when the cervix is moved on IE (Internal Examination)
• Referred shoulder pain
• Signs of shock
• A tender mass is usually palpable in Douglas' cul-de-sac

Nursing Implications for Ectopic Pregnancy

• Immediately assess the client's hemodynamic status to determine the extent of blood loss.
• Obtain hemoglobin level, type, and crossmatch.
• Obtain serum HCG level to confirm pregnancy.
• Administer fluid volume replacement intravenously.
• Prepare for abdominal laparotomy to ligate bleeding vessels and remove or repair damaged tube.
• Administer Rh(D) immune globulin (RHIG) for isoimmunization protection for the client with Rh-negative blood.
• If the tube has not ruptured, anticipate using oral methotrexate followed by leucovorin until a negative HCG titer is achieved.
• Offer emotional support to the client and partner; allow them to grieve over the loss of pregnancy and possible loss of the fallopian tube.

Gestational Trophoblastic Disease (GTD)/Hydatidiform Mole

• Proliferation and degeneration of the trophoblast villi.
• Cells degenerate and become filled with fluid, appearing as fluid-filled, grape-sized vesicles.
• The embryo fails to develop beyond a primitive start.
• Structures are associated with choriocarcinoma, a rapidly metastasizing malignancy.

Types of Molar Growth

• Complete Mole: all trophoblastic villi swell and become cystic.
• Partial Mole: some of the villi form normally, however, some are swollen and mishapen.

Predisposing Factors for Molar Pregnancy

• Women from low socioeconomic groups
• Women who have a low protein intake
• Young women < 18 years and older than age 35
• Women of Asian Heritage

Signs and Symptoms of Molar Pregnancy

• Uterus expands faster than normal
• No fetal heart sounds
• Strongly positive serum or urine HCG tests
• Excessive nausea and vomiting
• Hypertension, edema, and proteinuria present before the 20th week of pregnancy
• Dense growth (snowflake-like pattern) on ultrasonography
• Vaginal bleeding in the 4th month – dark brown blood

Nursing Implications for Molar Pregnancy

• Inspect vaginal bleeding for passage of clear fluid-filled vesicles.
• Prepare the client for diagnostic evaluation, including serum or urine HCG levels and ultrasonography.
• Prepare the client for suction and curettage to evaluate the mole.
• Monitor serum HCG levels at regular intervals following suction and curettage.
• Instruct the client about the need for follow-up visits, serum HCG levels every 2 to 4 weeks until levels are normal, and chest x-ray every month for a full year.
• Instruct the client to use a reliable contraceptive method during the year, so that a positive pregnancy test from a new pregnancy will not be confused with a developing malignancy.
• Some physicians prescribe a prophylactic course of methotrexate, the drug of choice for choriocarcinoma.
• Advise the client to postpone a second pregnancy until after the first year, when if HCG levels are still negative, the risk of malignancy is theoretically done.

Incompetent Cervix

• Premature cervical dilatation, which means the cervix cannot hold a fetus until term.
• Associated with increased maternal age and congenital development or endocrine factors.
• Trauma to the cervix, such as might have occurred with dilatation and curettage or traumatic delivery, is often the cause.

Predisposing Factors for Incompetent Cervix

• Increased maternal age
• Trauma to the cervix
• Congenitally short cervix
• Hormonal influences

Signs and Symptoms of Incompetent Cervix

• Painless cervical dilatation
• Show
• Uterine contractions
• Rupture of membranes

Management of Incompetent Cervix

• Cervical cerclage involves placing purse-string sutures in the cervix at approximately weeks 12 to 14 under regional anesthesia.
• Sutures strengthen the cervix and prevent it from dilating.
• McDonald technique is temporary; Shirodkar technique is permanent.

Nursing Implications for Incompetent Cervix

• Obtain a thorough history and physical examination to establish a baseline and identify a history of incompetent cervix.
• Anticipate ultrasonography at approximately 12 to 14 weeks of pregnancy to confirm the health of the fetus.
• Prepare the client for McDonald or Shirodkar procedure by vaginal route under regional anesthesia.
• Anticipate the removal of these sutures at about weeks 38 to 39 of pregnancy to allow a vaginal delivery. If sutures are left in place, prepare the client for cesarean birth.

Placenta Previa

• Low implantation of the placenta.
• Occurs in four degrees: low-lying placenta, marginal, partial, and total.
• An increase in congenital anomalies in the fetus may occur if the low implantation does not allow for optimal fetal nutrition or oxygenation.

Predisposing Factors for Placenta Previa

• Increased parity
• Number of past cesarean births
• Number of past uterine curettage
• Smoking
• Male fetus
• Multiple gestation

Assessment Findings of Placenta Previa

• Low-lying placenta on ultrasonography
• Abrupt, painless bright red vaginal bleeding

Nursing Implications for Placenta Previa

• Caution the client to avoid coitus, to get adequate rest preferably in a side-lying position, and to notify the physician of any sign of vaginal bleeding.
• Observe the perineum for bleeding.
• Observe vital signs as well as monitor fetal heart rate and uterine contractions.
• Obtain laboratory specimens for hemoglobin, hematocrit, prothrombin, partial thromboplastin, fibrinogen, platelet count, and type and cross-match blood.
• Obtain urine specimen for routine urinalysis.
• Prepare the client for ultrasonography.
• Administer intravenous fluid replacement as prescribed.
• Prepare to administer betamethasone to encourage lung maturity as prescribed.

Complications of Placenta Previa

• Hemorrhage
• Infection
• Prematurity

Abruptio Placenta

• Premature separation of the placenta.

Predisposing Factors for Abruptio Placenta

• Pregnancy-induced hypertension
• Chronic hypertensive disease
• Increasing maternal age and parity
• Direct trauma
• Short umbilical cord
• Sudden release of amniotic fluid
• Hypofibrinogenemia
• Cigarette smoking
• Vasoconstriction from cocaine use

Assessment Findings of Abruptio Placenta

• Sharp, stabbing pain high in the uterine fundus
• Hard, boardlike uterus and rigid abdomen if the center of the placenta separates first
• Signs of shock
• Tenderness on uterine palpation with contractions
• External bleeding if the placenta separates first at the edges, and blood escapes freely from the cervix
• Concealed bleeding; if extensive, the uterus becomes ecchymotic and copper-colored, and loses its ability to contract, leading to hypofibrinogenemia (Couvelaire uterus or Uteroplacental apoplexy)

Degrees of Placental Separation

• Grade 0 – No symptoms apparent; diagnosis made after delivery
• Grade 1 - Minimal separation, enough to cause vaginal bleeding and changes in maternal vital signs; no fetal distress or hemorrhagic shock
• Grade 2 - Moderate separation; evidence of fetal distress; uterus tender and painful on palpation
• Grade 3 - Extreme separation; without immediate intervention, maternal shock and fetal death result

Nursing Implications for Abruptio Placenta

• Assess the time bleeding began and whether it was accompanied by pain.
• Evaluate the amount and type of bleeding.
• Anticipate laboratory analysis, including hemoglobin, type and crossmatch, fibrinogen level, and fibrin breakdown products.
• Administer oxygen by mask to minimize fetal anoxia.
• Monitor fetal heart rate and maternal vital signs.
• Position the client in the lateral position to prevent pressure on the vena cava, further compromising fetal circulation.
• Avoid vaginal or pelvic examinations and enemas to prevent further placental disruption.
• Anticipate immediate delivery.
• Assess the client for disseminated intravascular coagulation (DIC) and treat as necessary.
• Assess for signs and symptoms of infection in the postpartal period.

Premature Labor (Preterm)

• Labor occurs before the end of week 37 of gestation, occurring in approximately 9% of all pregnancies.
• A woman is considered to be in preterm labor if she is having uterine contractions that cause cervical effacement and dilation.
• Preterm labor is associated with dehydration, urinary tract infection, and chorioamnionitis.
• Medical attempts can be made to stop labor if the fetal membranes are intact, fetal heart sounds are good, there is no evidence that bleeding is occurring that will affect maternal or fetal welfare, cervical dilation isn't more than 3 to 4 cm, and cervical effacement isn't more than 50%.
• A drug that can halt labor is referred to as a tocolytic agent.
• Preterm labor should be halted, if possible, until the fetus reaches a level of maturity that will allow it to survive in an outside environment.
• If preterm labor cannot be halted, and if the fetus is immature, a cesarean birth may be planned to reduce pressure on the fetal head.

Assessment Findings of Preterm Labor

• Persistent, dull, low backache
• Vaginal spotting
• Feeling of pelvic pressure or abdominal tightening
• Menstrual-like cramps
• Increase in vaginal discharge
• Uterine contractions
• Intestinal cramping

Tocolytic Agents

• Calcium channel blockers such as nifedipine (Procardia)
• Central nervous system depressants such as magnesium sulfate
• Prostaglandin antagonists such as Indomethacin (Indocin)
• Beta-adrenergics such as ritodrine hydrochloride (Yutopar) and terbutaline (Brethine)

Nursing Implications for Preterm Labor

• Instruct the client about signs to watch for indicating preterm labor.
• Administer intravenous fluid replacement to hydrate the client.
• Explain the necessity of complete bed rest.
• Obtain vaginal and cervical cultures and a clean-catch urine specimen to rule out infection.
• Obtain baseline blood data.
• Record fetal heart rate and uterine contractions and observe and report any tachycardia, late decelerations, or variable decelerations.
• Make sure that the client meets the safe criteria for tocolytic administration.
• Report a maternal pulse of more than 120 bpm, blood pressure below 90/60 mm Hg, chest pain, dyspnea, rales, or cardiac arrhythmias while the client is receiving intravenous tocolytics.
• Instruct the client about using a "Daily Fetal Movement Count" to assess fetal welfare.
• Provide adequate nutrition and instruct the client about maintaining bed rest at home.
• Administer betamethasone to the client as prescribed to attempt to hasten the production of surfactant in the fetal lungs.
• Explain to the client that she may experience some tachycardia and hypotension with the use of ritodrine hydrochloride (Yutopar) and terbutaline (Brethine).