Spontaneous Abortion Chapter 7 PDF

**SPONTANEOUS ABORTION** - Spontaneous Abortion - Natural causes before 20 weeks - Possible Causes of Bleeding - First Trimester - Spontaneous abortion - Ectopic pregnancy - Second Trimester - Gestational Trophoblastic disease - Thir...

**SPONTANEOUS ABORTION** - Spontaneous Abortion - Natural causes before 20 weeks - Possible Causes of Bleeding - First Trimester - Spontaneous abortion - Ectopic pregnancy - Second Trimester - Gestational Trophoblastic disease - Third Trimester - Placenta Previa - Abruptio Placentae - Vasa Previa - Expected findings - ABD cramping or pain - Rupture of membranes - Dilation of the cervix - Fever - Manifestations of hemorrhage - Lab test - Hgb and Hct - Clotting factors - WBC - hCG (Serum human chorionic gonadotropin **SPONTANEOUS ABORTION Types** - Threatened - Possible mild cramping - Slight spotting - Inevitable - Mild to moderate cramping - Moderate bleeding - Cervical opening usually dilated. (3cm is the magic number) - Incomplete - Severe cramping - Heavy, professed bleeding - Tissue has passed - Dilated with tissue in cervical canal or passage of tissue. - Complete - Mild cramping - Minimal bleeding - Tissue passed - No dilation. (Cervix closed after tissue passed) - Missed - No cramping - Little to no spotting - No tissue passed. Prolonged retention of tissue. - Cervical opening is closed - Septic - Varies in cramping - Varies in bleeding; malodorous discharge - Varies in tissue passed - Cervical opening is usually dilated - Recurrent - Varies in cramping - Varies in bleeding - Tissue passed - Cervical opening is usually dilated **Spontaneous Abortion procedures** - Ultrasound - Determine the presence of a viable or dead fetus - Examination of Cervix - To observe whether it is open or closed - Dilation and Currettage (D&C) - To dilate and scrape the uterine walls to remove uterine contents. - Dilation and Evacuation (D&E) - To dilate and evacuate uterine contents - Prostaglandins and Oxytocin - To augment to induce uterine contractions and expulse the products. **Spontaneous Abortion Care** - Nursing Care - Emotional support - Helping them with follow up. - Medications - Analgesic and sedative - Prostaglandin, as a vaginal suppository - Oxytocin - Broad-Spectrum antibiotics, in septic abortion - Rho(D) immune globulin, suppresses immune response of client who are Rh-neg. - Client education - No tub baths - Notify provider of heavy bleeding - Take antibiotics - Small amount of discharge is normal for 1 -- 2 weeks. - No sex or placing anything in the vagina for 2 weeks. - Discuss grief and loss with provider before attempting another pregnancy. **ECTOPIC PREGNANCY** - Abnormal implantation of the fertilized ovum outside the uterine cavity. - **Risk Factors** - Tubal patency (STI) - Tubal surgry - Contraceptive intrauterine device (IUD) - **Findings** - Unilateral stabbing pain and tenderness in lower ABD - Menses' that is delayed 1 -- 2 weeks, lighter than normal - Scant, dark red, or brown vaginal spotting 6 to 8 weeks after LMC. Red, vaginal bleeding if rupture has accrued. - Referred shoulder pain due to blood in the peritoneal cavity irritating the diaphragm or phrenic nerve after tubal rupture. - Hemorrhage and shock, pallor, hypotension, tachycardia, dizziness. - **LAB TEST** - Hcg - **Diagnostic and Threptic Procedures** - Transvaginal UA shows an empty uterus - Use caution if vaginal and bimanual examination are used. - Medical management if rupture has not occurred and tube preservation desired. - Methotrexate inhibits cell division and embryo enlargement, dissolving the pregnancy. - Salpingostomy is done to salvage the fallopian tube if not ruptured. - Laparoscopic salpingectomy (removal of the tube) is performed when the tube has ruptured. - **Nursing Care** - Replace fluid and maintain electrolyte balance - Psychological support - Meds as prescribed - Prepare client for surgery - Emotional care and support - Referral to pregnancy loss support group - hCG and progesterone levels, liver and renal function, CBC and type and Rh. - **Client Education** **GESTATIONAL TROPHOBLASTIC DISEASE** - Gestational Trophoblastic Disease - **Complete Mole** - All genetic material is paternally derived - The ovum has no genetic material - Contains no fetus, placenta, amniotic membranes, or fluid. - No placenta to receive maternal blood - **Partial Mole** - Genetic material is derived both maternally and paternally - Normal ovum is fertilized by two perm or one sperm - Contains abnormal embryonic or fetal parts. - **Risk Factors** - Prior molar pregnancy - Clients in early teenage years or older than 40 - **Findings** - Elevated Hcg levels - Nausea and vomiting - Dark brown bleeding resembling prune juice. - May be bright red blood - Anemia from blood lose - **Laboratory Testing** - Hcg levels weekly. Should slowly drop off - Monitored for 1 year - **Monitor** - Bleeding - Hydration status - May do - Save any clots that they pass. - **Client education** **Placenta Previa** - Complete or Total - The cervical os is completely covered by the placental attachment. - Incomplete or Partial - The cervical os is only partially covered by the placental attachment. - Marginal - The placenta is attached in the lower uterine segment but does not reach the cervical os. - Low-Lying - The placenta is attached in the lower uterine segment but does not reach the cervical os. - Risk Factors - Previous placenta previa - Uterine scarring - Maternal age greater than 35 - Multifetal gestation - Multifetal gestation - smoking - Findings - Painless, bright red vaginal bleeding during the 2^nd^ or 3^rd^ trimester. - Uterus soft, relaxed and nontender. - Fundal height greater then usually expected - Fetus un a breach, oblique, or transverse position. - VS within normal limits - Decreasing urinary output - Laboratory Tests - Hgb and Hct - CBC - Rh - Coag profile - Kleihauer-Betke test - Diagnostic Procedures - Transabdominal or Transvaginal ultrasound for placement of the placenta. - Fetal monitoring for fetal well being - Nursing Care - Assess for bleeding - Fundal height - Refrain from vaginal exam. (unless provider is not there) - IV fluids, blood products and medications - oxygen - Client Education - Bed rest - Noting in the vagina **ABRUPTIO PLACENTAE** - **Abruptio Placentae** - Premature separation of the placenta from the uterus - **Risk Factors** - Maternal HTN - Blunt external ABD trauma - Cocaine use - Previous incidents of abruptio placentae - Smoking - Premature rupture membranes - Multifetal pregnancy - **Findings** - Sudden onset of intense localized uterine pain with dark red vaginal bleeding. - Area of uterine tenderness can be localized or diffused over uterus and board like - Fetal distress - Clinical finding of hypovolemic shock - **Laboratory Tests** - Hgb - Coag factors decreased - Clotting defects - Cross type for possible transfusion - Kleihauer-Betke test - **Diagnostic Procedures** - US - Biophysical profile - **Nursing Care** - Palpate the uterus for tenderness and tone - Preform serial monitoring of fundal height - Assess FHR pattern - Immediate birth is the management - Admin IVF, Blood products, and meds - Admin Oxygen 8-10 - Monitor maternal VS, observing for declining hemodynamic status - Preform continuous fetal monitoring. - Assess urinary output. - Provide emotional support **Placental Abruption VS Previa (Slide 14)** **Placental Abruption** **Placental Previa** ---------------------- ---------------------------------------------------------- --------------------------------------------- **Previous Warning** **HTN, TRAUMA** **PREVIOUS PLACENTA PREVIA** **Bleeding** **YES** **BRIGHT RED** **Pain** **SHARP** **NO** **Onset** **3^RD^ TRIMESTER (SUDDEN)** **2^ND^ OR 3^RD^ TRIMESTER** **ABD assessment** **UTERINE TENDERNESS** **UTERUS SOLF, RELAXED, NONTENDER** **Fetal Assessment** **FETAL DISTRESS** **BREECH, OBLIQUE, OR TRANSVERSE POSITION** **Fetal Well-being** **SIGNIFICANT MATERNAL & FETAL MORBIDITY AND MORTALITY** - **Vasa Previa** - **Monitor for this** - Velamentous Insertion of the Cord - Succenturiate Insertion of the Cord - Battledore Insertion of the Cord - Assessment - UA - Nursing Care - Monitor client during labor and delivery for excessive bleeding.