NCM234 Lesson 2.2 Maternal Conditions PDF

NCM 234 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC)  HYPEREMESIS GRAVIDARUM -produce high HYPEREMESIS levels of Human GRAVIDARUM Chorionic Gonadotropin (HCG), such as is severe and excessive gestational nausea and vom...

NCM 234 CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND CHRONIC)  HYPEREMESIS GRAVIDARUM -produce high HYPEREMESIS levels of Human GRAVIDARUM Chorionic Gonadotropin (HCG), such as is severe and excessive gestational nausea and vomiting during pregnancy, which leads to trophoblastic electrolyte, metabolic, and disease or multiple nutritional imbalances in pregnancy the absence of the medical problems that persists after the 1st trimester.  - Exact cause is HYPEREMESIS unknown, but it’s GRAVIDARUM linked to trophoblastic PATHOPHYSIOLOGY: activity, gonadotropin production, and psychological factors  HYPEREMESIS Pancreatitis Biliary tract disease GRAVIDARUM Decreased secretion of free hydrochloric acid in the Various possible causes: stomach Decreased gastric motility Drug toxicity Inflammatory obstructive bowel disease Vitamin deficiency (esp. B) Psychological factors in some cases Transient hyperthyroidism  Severe nausea and HYPEREMESIS vomiting Weight loss and GRAVIDARUM eventual emaciation Hiccups ASSESSMENT FINDINGS: Oliguria Vertigo and headache Electrolyte imbalance Dehydration Metabolic alkalosis  Decreased protein, HYPEREMESIS GRAVIDARUM chloride, sodium, and potassium levels Increased blood DIAGNOSTIC TEST FINDINGS: urea nitrogen levels Elevated hemoglobin levels Elevated WBC count  IMBALANCED HYPERMESIS NUTRITION , LESS THAN BODY REQUIREMENT GRAVIDARUM RELATED TO FREQUENCY OF EXCESSIVE NAUSEA & NURSING DIAGNOSIS VOMITING FLUID VOLUME DEFICIT RELATED TO EXCESS FLUID LOSS  HYPERMESIS ANXIETY RT INEFFECTIVE GRAVIDARUM COPING , PHYSIOLOGICAL NURSING DIAGNOSIS CHANGES OF PREGNANCY ACTIVITY INTOLERANCE RT WEAKNESS  Oral fluids and food are HYPEREMESIS usually withheld until GRAVIDARUM there’s no vomiting for 24 hours antiemetic medications MEDICAL MANAGEMENT: may be prescribed Consultation with clinical nurse specialist  PLS WATCH THE HYPEREMESIS VIDEO: GRAVIDARUM https://www.youtub NURSING MANAGEMENT e.com/watch?v=WfyI Nzyw5HM  Administer IV fluids HYPEREMESIS Monitor fluid intake and output, vital signs, skin GRAVIDARUM turgor, daily weight, serum electrolyte levels, and urine for ketones NURSING MANAGEMENT Provide frequent mouth care Consult a dietician to provide a diet high in dry, complex carbohydrates Suggest decreased liquid intake during meals  Suggest that the patient HYPEREMESIS eat two or three dry crackers before getting GRAVIDARUM out of bed in the morning Provide reassurance and NURSING MANAGEMENT a calm, restful atmosphere Help the patient develop effective coping strategies Teach the patient protective measures to conserve energy and promote rest ECTOPIC PREGNACY  ECTOPIC PREGNANCY - Refers to the implantation of the fertilized ovum outside the uterine cavity  Endosalphingitis CAUSES: Diverticula Tumors pressing on the tube Previous surgery, such as tubal ligation or resection, or adhesions from previous abdominal or pelvic surgery Transmigration of the ovum, resulting in delayed implantation  Mild abdominal pain ASSESSMENT FINDINGS: Amenorrhea /absence of menses Extreme pain & lower abdominal pain Uterus is boggy & tender Rupture of tube Nausea & vomiting Syncope Shock  Serum- DIAGNOSTIC TEST pregnancy (hCG) FINDINGS: Ultrasound Culdocentesis – detects blood in the peritoneum Laparoscopy,  NURSING DIAGNOSIS RISK FOR DEFICIENT FLUID VOLUME RELATED TO BLEEDING FROM A RUPTURED ECTOPIC PREGNANCY  POWERLESSNESS NURSING DIAGNOSIS RELATED TO EARLY LOSS OF PREGNANCY SECONDARY TO ECTOPIC PREGNANCY  TO ENSURE THAT MATERNAL BLOOD LOSS IS REPLACED AND GOAL OF CARE BLEEDING WOULD STOP THE PATIENT MUST MAINTAIN ADEQUATE FLUID VOLUME AS EVIDENCED BY NORMAL URINE OUTPUT AT 30- 60ML/HR  Salphingectomy MANAGEMENT Salphingostomy Oophorectomy Administer Methotrexate Blood transfusion Antibiotic High CHON diet Emotional support  Ask the NURSING patient the INTERVENTIONS date of her last menses and obtain serum hCG levels as ordered  Assess vital NURSING signs and INTERVENTIONS monitor vaginal bleeding for extent of fluid loss  Check the NURSING amount, color, INTERVENTIONS and odor of vaginal bleeding; monitor pad count Withhold fluid/food  Assess the NURSING patient for signs INTERVENTIONS and symptoms of hypovolemic shock secondary to blood loss from tubal rupture  Administer blood NURSING transfusion INTERVENTIONS Record the location and character of pain, and administer an analgesic as ordered  Encourage her NURSING and her partner to INTERVENTIONS express their feelings of fear, loss and grief Refer her to a mental health professional for additional counseling, if necessary  Determine if the NURSING patient is Rh- INTERVENTIONS negative Provide a quiet, relaxing environment, and offer the patient emotional support  To prevent NURSING recurrent ectopic INTERVENTIONS pregnancy, urge the patient to have pelvic infections treated promptly to prevent diseases of the fallopian tube  Inform patients NURSING who have INTERVENTIONS undergone surgery involving the fallopian tubes or those with confirmed pelvic inflammatory disease that they’re at increase risk for another ectopic pregnancy  POSSIBLE Rupture of COMPLICATIONS the tube Infertility  - Product of ABDOMINAL PREGNANCY conception is expelled into the pelvic cavity. - Fetal outline is easily palpable - A sonogram or MRI is used to reveal the fetus outside the uterus - At term, the infant may be born by laparotomy  PLEASE ECTOPIC PREGNANCY WATCH THE VIDEO https://youtu. be/RoBohoUr x4c  Rapid deterioration of GESTATIONAL TROPHOBLASTIC trophoblastic villi cells. As trophoblast cells DISEASE/ HYDATIDIFORM MOLE begin to deteriorate, they fill with fluid. The cells become WHAT HAPPEN? edematous, appearing as grapelike clusters of vesicles. As a result of these cell abnormalities, the embryo fails to develop past the early stages  GESTATIONAL TROPHOBLASTIC COMPLETE MOLES DISEASE/ HYDATIDIFORM MOLE ▪ Characterized by swelling and cystic formation of all trophoblastic cells TWO TYPES: ▪ No fetal blood is present 1. COMPLETE MOLES ▪ If an embryo does develop, 2. PARTIAL MOLES it’s most likely only 1 to 2mm in size and will probably die early in development ▪ This form is associated with the development of choriocarcinoma  PARTIAL MOLES GESTATIONAL TROPHOBLASTIC ▪ Characterized by edema of DISEASE/ HYDATIDIFORM MOLE some of the trophoblastic villi with some of the normal villi. ▪ Fetal blood may be present in the villi, and an embryo up to the size of 9 weeks gestation may be present. Typically, a partial mole has 69 chromosomes in which there are 3 chromosomes for every one pair  The cause of gestational GESTATIONAL TROPHOBLASTIC trophoblastic disease is DISEASE/ HYDATIDIFORM MOLE unknown. Several unconfirmed theories relate gestational trophoblastic disease to PATHOPHYSIOLOGY: chromosomal abnormalities, hormonal imbalances, or deficiencies in protein and folic acid  vaginal bleeding GESTATIONAL TROPHOBLASTIC hyperemesis, lower DISEASE/ HYDATIDIFORM MOLE abdominal cramps a uterus that’s exceptionally large for the ASSESSMENT FINDINGS: patient’s gestational date is detected reveal grapelike vesicles in the vagina ovarian enlargement caused by cysts. absence of fetal heart rate tones  Radioimmunoassay GESTATIONAL TROPHOBLASTIC Histologic examination Ultrasonography performed DISEASE/ HYDATIDIFORM MOLE after the 3rd month Amniography DIAGNOSTIC TEST FINDINGS: Doppler ultrasonography BLOOD TESTS WBC Urine, +hCG (up to 100th day of pregnancy (1-2mIU ), normal pregnancy (400,000IU)  Mrs Smith, 35 yo, married, GESTATIONAL TROPHOBLASTIC came in to CIT_U hospital with a CC : vaginal bleeding that varies from dark DISEASE/ HYDATIDIFORM MOLE brown spotting for 1 day duration. 3 days PTA, Mrs. Smith experienced excessive vomiting that NURSING DIAGNOSIS? occurs in the morning. Urine test: hCG revealed positive UTZ: multiple small cystic structures, negative fetal parts, & fetal heart beat  dilatation and suction GESTATIONAL TROPHOBLASTIC curettage Postoperative treatment : DISEASE/ HYDATIDIFORM MOLE ▪ depending on the amount MEDICAL MANAGEMENT of blood lost and complications Monitoring for malignancy: ▪ monitoring hCG levels once weekly until titers are negative for 3 consecutive weeks, then once monthly for 6 months, then every 2 months for 6 months ▪ Contraceptive methods GESTATIONAL TROPHOBLASTIC prevent another pregnancy until at least 1 DISEASE/ HYDATIDIFORM MOLE year after all titers and X- ray findings are negative. Monitoring for malignancy: ▪ Prophylactic chemotherapy chest X-rays to check for lung metastasis once monthly until hCG methotrexate or titers are negative, then once every 2 actinomycin-D (Cosmegen) months for 1 year after evacuation of the uterus Chemotherapy and radiation are used for metastatic choriocarcinoma ▪ Assess the patient’s GESTATIONAL TROPHOBLASTIC vital signs ▪ Preoperatively, observe DISEASE/ HYDATIDIFORM MOLE for signs of complications, such as NURSING MANAGEMENT hemorrhage and uterine infection, and vaginal passage of vesicles. Save any expelled tissue for laboratory analysis ▪ Prepare the patient for surgery ▪ Postoperatively, GESTATIONAL TROPHOBLASTIC monitor vital signs and fluid intake and output, DISEASE/ HYDATIDIFORM MOLE and check for signs of hemorrhage ▪ Encourage the patient NURSING MANAGEMENT and her family to express their feelings about the disorder ▪ Help the patient and her family develop effective coping strategies ▪ Assist with obtaining GESTATIONAL TROPHOBLASTIC baseline information ▪ Instruct the patient to DISEASE/ HYDATIDIFORM MOLE report new symptoms promptly NURSING MANAGEMENT ▪ Explain to the patient that she must use contraceptives ▪ Diet (increased protein, folic acid, vitamin b 12 rich foods) ▪PLS WATCH THE GESTATIONAL TROPHOBLASTIC VIDEO: DISEASE/ HYDATIDIFORM MOLE ▪https://www.yout ube.com/watch?v= gBDDV1UA590  INCOMPETENT CERVIX Also called PREMATURE CERVICAL DILATION Occurs at approximately week 20 of pregnancy  This condition is associated with congenital structural defects or previous cervical trauma INCOMPETENT CERVIX It’s also associated with PATHOPHYSIOLOGY increasing maternal age Connective tissue structure of the cervix is not strong enough to maintain closure of the cervical OS during pregnancy.  History of repeated INCOMPETENT CERVIX 2nd trimester spontaneous abortions ASSESSMENT FINDINGS Cervical dilation Pink-stained vaginal discharge Increased pressure with possible ruptured membranes  Ultrasound INCOMPETENT CERVIX DIAGNOSTIC TEST FINDINGS: Nitrazine test  INCOMPETENT CERVIX Anxiety related to NURSING DIAGNOSIS: impending loss of pregnancy as evidenced by premature dilation of the cervix  McDonald’s procedure, using a nylon suture horizontally and INCOMPETENT CERVIX vertically MEDICAL MANAGEMENT - Placement of a purse-string suture known as CERCLAGE, in the cervix  Shirodkar procedure using sterile tape in a purse-string suture INCOMPETENT CERVIX MEDICAL MANAGEMENT - Placement of a purse- string suture known as CERCLAGE, in the cervix  Bed rest after INCOMPETENT CERVIX surgery MEDICAL MANAGEMENT Emotional support  Assess complaints of vaginal discharge and INCOMPETENT CERVIX investigate history for previous cervical surgeries NURSING INTERVENTIONS Prepare the woman for cervical cerclage under regional anesthesia as indicated; monitor maternal vital signs and FHR patterns closely  - Instruct the woman for signs and symptoms of labor INCOMPETENT CERVIX - Maintain bed rest after surgery as ordered NURSING INTERVENTIONS - Encourage follow- up to evaluate progress of pregnancy - Advise the woman that the sutures will be removed around the 37th-39th week of pregnancy  INCOMPETENT CERVIX Spontaneous POSSIBLE COMPLICATIONS abortion Preterm birth  PLEASE WATCH THE INCOMPETENT CERVIX VIDEO: https://www.youtub e.com/watch?v=YIo_ cUKBO8k  ANTEPARTAL COMPLICATIONS ABORTION  SPONTANEOUS ANTEPARTAL ABORTION COMPLICATIONS Refers to pregnancy loss at less than 20 weeks gestation in the absence of medical or surgical measures to terminate pregnancy  COMPLETE TYPES OF SPONTANEOUS ABORTION ABORTION - Entire products of conception are expelled spontaneously without any assistance  HABITUAL TYPES OF SPONTANEOUS ABORTION/RECURRENT ABORTION - Spontaneous loss of 3 or more consecutive pregnancies at the same gestation age  INCOMPLETE TYPES OF SPONTANEOUS ABORTION ABORTION - Uterus retains part or all of the membranes/ placenta  INEVITABLE/ TYPES OF SPONTANEOUS ABORTION IMMINENT ABORTION - Membranes rupture and the cervix dilates  MISSED TYPES OF SPONTANEOUS ABORTION ABORTION - The fetus dies in utero but is not expelled  THREATENED TYPES OF SPONTANEOUS ABORTION ABORTION - Bloody vaginal discharge occurs during the 1st half of pregnancy  SEPTIC TYPES OF SPONTANEOUS ABORTION ABORTION - Infection accompanies abortion  FETAL FACTORS: Defective CAUSES: embryologic development from abnormal chromosome Faulty implantation of fertilized ovum Failure of the endometrium to accept the fertilized ovum  o PLACENTAL FACTORS: CAUSES: Premature separation of the normally implanted placenta Abnormal placental implantation Abnormal platelet function  o MATERNAL CAUSES: FACTORS Maternal infections Severe malnutrition Abnormalities of the reproductive organs  - Pink discharge for ASSESSMENT FINDINGS: several days or a scant brown discharge for several weeks before the onset of cramps and increased vaginal bleeding  - Diagnosis of spontaneous DIAGNOSTIC TEST FINDINGS: abortion is based on evidence of expulsion of uterine contents, pelvic examination, laboratory studies and Ultrasonography  Threatened MANAGEMENT: Abortion: Limitation of the patient’s activities for 24 to 48 hours Bed rest Pad count Restriction of coitus for about 2 weeks  Imminent and MANAGEMENT: Incomplete Abortion: Dilatation and curettage or vacuum and aspiration Rest Monitoring for temperature elevation and bleeding  A. HEMORRHAGE COMPLICATIONS OF With incomplete abortion, major hemorrhage is a ABORTION: possibility Position the woman flat and massage the uterine fundus Dilatation and curettage Monitor vital signs Transfusion to replace blood loss Direct replacement of fibrinogen Methergine (methylergonovine maleate)  B. INFECTION COMPLICATIONS OF Organism ABORTION: responsible for infection after abortion is usually E. Coli (spread from the rectum forward into the vagina) Endometritis  C. SEPSIS COMPLICATIONS OF ABORTION: Abortion complicated by infection  D. ISOIMMUNIZATION COMPLICATIONS OF ABORTION: Production by the mother’s immunologic system of antibodies against Rh-positive blood  E. POWERLESSNESS COMPLICATIONS OF ABORTION: Sadness and grief over the loss or a feeling that she has lost control of her life Emotional support  Vacuum Procedures Used in Curettage Pregnancy Termination: Used for 1st tri abortions to remove remaining products of conception  Dilatation & Curettage Procedures Used in Pregnancy Dilatation of the Termination: cervix followed by gentle scraping of the uterine walls to remove products of conception Local or general anesthesia is needed ❖ANXIETY NURSING DIAGNOSIS: ❖ACUTE PAIN ❖DEFICIENT KNOWLEDGE ❖RISK FOR SPIRITUAL DISTRESS ❖RISK Decisional Conflict  Do not allow bathroom privileges NURSING Note the amount, color, INTERVENTIONS: and odor of vaginal bleeding Place the patient’s bed in trendelenburg’s position as ordered Assess vital signs Monitor urine output closely Provide good perineal care  Check the patient’s NURSING blood type INTERVENTIONS: Provide emotional support and counseling Encourage the patient and her partner to express their feelings Help the patient and her partner to develop effective coping strategies  Explain all procedures NURSING and treatments to the INTERVENTIONS: patient and provide teaching about aftercare and follow-up Arrange for a follow-up visit with the physician in 2-4 weeks Administer analgesics and oxytocin as ordered  PLEASE WATCH THE ABORTION VIDEO: https://www.youtube.com/watch?v=j9peQ FwW7T4  ANTEPARTAL PLACENTA PREVIA COMPLICATIONS THIRD TRIMESTER  Occurs when the placenta implants in the PLACENTA PREVIA lower uterine segment, obstructing the internal cervical os and failing to provide as much nourishment as the fundus. The placenta tends to spread out, seeking the blood supply it needs, and it becomes larger and thinner than normal.  TYPES: LOW LYING PLACENTA PREVIA IMPLANTATION – the placenta implants in the lower uterine segment PARTIAL/MARGINAL PLACENTA PREVIA – the placenta partially occludes the cervical os TOTAL /COMPLETE PLACENTA PREVIA – the placenta totally occludes the cervical os  Exact cause is unknown Factors that may affect the site of the placenta’s PLACENTA PREVIA attachment to the uterine wall include: PATHOPHYSIOLOGY Uterine fibroid tumors Uterine scars from surgery Defective vascularization of the deciduas Multiple gestations Multiparity Advanced maternal age  pa i nless, bright red, va ginal bl eeding a fter the 20th week of pregnancy PLACENTA PREVIA About 7% of patients with pl a centa previa are a s ymptomatic ASSESSMENT FINDINGS: Pa l pation may reveal a soft, nontender uterus. Leopold’s maneuver reveals va ri ous malpresentations The fetus remains a ctive, however, with good heart tones a udible on auscultation  Ultrasound Lab studies may reveal PLACENTA PREVIA decreased maternal hemoglobin levels Pelvic examination DIAGNOSTIC TEST FINDINGS should be performed only in a surgical suite or a birthing room that’s equipped for cesarean birth in the event that hemorrhage necessitates immediate delivery  PLACENTA PREVIA Treatment of placenta previa focuses on MEDICAL MANAGEMENT: assessing, controlling, and restoring blood loss; delivering a viable neonate; and preventing coagulation disorders.  Immediate therapy i ncludes: Sta rti ng an IV i nfusion using a l a rge-bore catheter PLACENTA PREVIA Dra wing blood for hemoglobin and hematocrit MEDICAL MANAGEMENT: l evels, typing, and cross- ma tching Ini tiating external electronic feta l monitoring Moni toring maternal blood pres sure, pulse ra te, and res pirations As s essing the a mount of va gi nal bleeding  If the fetus is premature, trea tment consists of careful obs erva tion to allow the fetus more ti me to mature. If clinical PLACENTA PREVIA eva l uation confirms complete placenta previa, the pa tient is MEDICAL MANAGEMENT: us ually hospitalized because of the i ncreased risk of hemorrhage. As s oon as the fetus is s ufficiently ma ture, or in cases of severe hemorrhage, i mmediate cesarean delivery ma y be necessary. Vaginal delivery i s considered onl y when the bleeding is minimal a nd the placenta previa is marginal or when the labor is ra pi d  PLACENTA PREVIA Because of possible fetal blood loss through the MEDICAL MANAGEMENT: placenta, a pediatric team should be on hand during such a delivery to immediately assess and treat neonatal shock, blood loss, and hypoxia  If the patient with placenta previa shows active bleeding, continuously PLACENTA PREVIA monitor her blood pressure, pulse rate, NURSING MANAGEMENT: respirations, central venous pressure, intake and output, and amount of vaginal bleeding as well as the fetus heart rate and rhythm Anticipate the need for electronic fetal monitoring, and assist with application as indicated  Have oxygen readily available in case fetal distress occurs PLACENTA PREVIA If the patient is Rh- negative, administer NURSING MANAGEMENT: Rhogam after every bleeding episode Complete bed rest Prepare the patient and her family for a possible cesarean delivery and the birth of a preterm neonate.  If the fetus isn’t mature, expect to administer an initial dose of PLACENTA PREVIA betamethasone (Celestone) IM. Explain NURSING MANAGEMENT: that additional doses may be given again in 24 hours and possibly, 1 to 2 weeks Provide emotional support during labor. Because of the fetus’ prematurity, the patient may not be given analgesics, so labor pain may be intense  If the patient’s bleeding ceases and she’s to return PLACENTA PREVIA home on bed rest, anticipate the need for a NURSING MANAGEMENT: referral for home care. Teach the patient to identify and report signs of placenta previa (bleeding, cramping) immediately  Assess for signs of infection. PLACENTA PREVIA NURSING MANAGEMENT: During postpartum period, monitor the patient for signs of hemorrhage and shock caused by the uterus’ diminished ability to contract  Tactfully discuss the possibility of neonatal death. Assure her that PLACENTA PREVIA frequent monitoring and prompt management NURSING MANAGEMENT: greatly reduce the risk of death Encourage the patient and her family to verbalize their feelings, and help them develop effective coping strategies. Refer them for counseling if necessary  Tactfully discuss the possibility of neonatal death. Assure her that PLACENTA PREVIA frequent monitoring and prompt management NURSING MANAGEMENT: greatly reduce the risk of death Encourage the patient and her family to verbalize their feelings, and help them develop effective coping strategies. Refer them for counseling if necessary  Postpartum PLACENTA PREVIA hemorrhage POSSIBLE COMPLICATIONS: infection  PLEASE WATCH THE VIDEO: PLACENTA PREVIA https://www.yout ube.com/watch?v =DMCowipIXgE&t =10s  ANTEPARTAL COMPLICATIONS ABRUPTIO PLACENTAE  ABRUPTIO PLACENTA Also called placental abruption – occurs when the placenta separates from the uterine wall prematurely, usually after the 20th week of gestation, producing hemorrhage  TYPES: A. REVEALED ABRUPTIO PLACENTA ABRUPTION Blood tracks between the membranes, and escapes through the vagina and cervix. B. CONCEALED ABRUPTION Blood collects behind the placenta, with no evidence of vaginal bleeding.  The cause of abruptio placentae is unknown Predisposing factors include: ABRUPTIO PLACENTA a. Traumatic injury such as a direct blow to the uterus b. Placental site bleeding PATHOPHYSIOLOGY caused by a needle puncture during amniocentesis c. Chronic hypertension or Pregnancy Induced Hypertension d. Multiparity more than 5 e. Short umbilical cord f. Dietary deficiency g. Smoking  Pressure on the vena cavae from an enlarged uterus Consequently, bleeding continuous unchecked, possibly shearing off the ABRUPTIO PLACENTA placenta partially or completely a. Bleeding is external, or PATHOPHYSIOLOGY marginal if a peripheral portion of the placenta separates from the uterine wall b. It’s internal, or concealed if the central portion of the placenta becomes detached and the still intact peripheral portions trap the blood  As blood enters the muscle fibers, complete ABRUPTIO PLACENTA relaxation of the uterus becomes impossible, increasing uterine tone PATHOPHYSIOLOGY and irritability. If bleeding into the muscle fibers is profuse, the uterus turns into blue or purple and the accumulated blood prevents its normal contractions after delivery (Couvelaire uterus, or uteroplacental apoplexy)  MILD Abruptio Placentae: (marginal ABRUPTIO PLACENTA separation) Develops gradually and produces mild to ASSESSMENT FINDINGS: moderate bleeding, vague lower abdominal discomfort, mild to moderate abdominal tenderness, and uterine irritability. Fetal heart tones remain strong and regular  MODERATE Abruptio Placenta ( about 50% placental separation) ABRUPTIO PLACENTA May develop gradually or abruptly and produces continuous abdominal pain, ASSESSMENT FINDINGS: moderate dark red bleeding, a tender uterus that remains firm between contractions, barely audible or irregular and bradycardic fetal heart tones, and possibly signs of shock. Labor usually starts within 2 hours and usually proceeds rapidly  SEVERE Abruptio Placentae (70% placental separations) ABRUPTIO PLACENTA Develops abruptly and ASSESSMENT FINDINGS: causes agonizing, unremitting uterine pain; a boardlike, tender uterus; moderate vaginal bleeding; rapidly progressive shock; absence of fetal heart tones Top priorities: immediate measures for abruptio ABRUPTIO PLACENTA placentae ▪ Starting an IV infusion of lactated Ringer’s MEDICAL MANAGEMENT: solution to combat hypovolemia ▪ Placing a central venous pressure (CVP) line and urinary catheter to monitor fluid status  ABRUPTIO PLACENTA Pelvic examination and ultrasonography DIAGNOSTIC TEST FINDINGS Decreased hemoglobin levels and platelet counts Periodic assays for fibrin split products Top priorities: immediate measures for abruptio placentae ABRUPTIO PLACENTA ▪ Drawing blood for hemoglobin level, MEDICAL MANAGEMENT: hematocrit, coagulation studies, and typing and cross-matching ▪ External electronic fetal monitoring and monitoring of maternal vital signs and vaginal bleeding  After the severity of abruption has been determined and fluid ABRUPTIO PLACENTA and blood has been replaced, prompt MEDICAL MANAGEMENT: cesarean delivery is necessary if the fetus is in distress. If the fetus isn’t in distress, monitoring continues; delivery (vaginal or cesarean) is usually performed at the first sign of fetal distress  Because of possible fetal blood loss through the placenta, a pediatric team ABRUPTIO PLACENTA should be ready at delivery to assess and treat the MEDICAL MANAGEMENT: neonate for shock, blood loss, and hypoxia. If placental separation is severe and no signs of fetal life are present, vaginal delivery may be performed unless uncontrolled hemorrhage or other complications contraindicate it  Assess the patient’s extent of bleeding and ABRUPTIO PLACENTA monitor fundal height every 30 minutes for changes. NURSING MANAGEMENT: Monitor maternal BP, pulse rate, respirations, CVP, I & O, and amount of vaginal bleeding every 10 to 15 minutes Begin electronic fetal monitoring to assess fetal heart rate continuously  Have equipment for emergency cesarean ABRUPTIO PLACENTA delivery readily available If vaginal delivery is NURSING MANAGEMENT: elected, provide emotional support during labor. Because of the neonate’s prematurity, the mother may not receive analgesics during labor and may experience intense pain Offer emotional support and an honest assessment of the situation  Prepare the patient and ABRUPTIO PLACENTA her family for the possibility of an emergency cesarean NURSING MANAGEMENT: delivery of a premature neonate Tactfully discuss the possibility of neonatal death.  Encourage the patient ABRUPTIO PLACENTA and her family to verbalize their feelings NURSING MANAGEMENT: Help them to develop effective coping strategies, referring them for counseling if necessary  Maternal mortality; postpartum patients are ABRUPTIO PLACENTA at risk for vascular spasm, intravascular clotting or POSSIBLE COMPLICATIONS: hemorrhage, and renal failure from shock Perinatal mortality Neonatal complications stem from hypoxia, prematurity and anemia PLEASE WATCH THE ABRUPTIO PLACENTA VIDEO: https://www.youtube.com/watch?v=79Nns YrAXz4  PROM is rupture of PREMATURE RUPTURE the chorion and OF MEMBRANE amnion 1 hour or more before the onset of labor. The gestational age of the fetus and estimates of viability affect management.  Abbreviations: -  Etiology The precise cause and specific - predisposing factors are unknown.  PROM is associated with malpresentation, possible Pathophysiology weak areas in the amnion and chorion, subclinical infection, and, possibly, incompetent cervix. Basic and effective defense against the fetus contracting an infection is lost and the risk of ascending intrauterine infection, known as chorioamnionitis, is increased.  ASSESSMENT FINDINGS amniotic fluid gushing from the vagina Maternal fever, fetal tachycardia, and malodorous discharge may indicate infection. Rupture of membranes is DIAGNOSTIC TEST FINDINGS confirmed by the following. Ferning is evident. Nitrazine test tape turns a blue-green color.  Make an early and accurate evaluation of NURSING MANAGEMENT membrane status, using sterile speculum examination and 1. Prevent infection and other determination of potential complications. ferning. Thereafter, keep vaginal examinations to a minimum to prevent infection.  NURSING MANAGEMENT encourage the client and partner to 2. Provide client and family prepare themselves education. for labor and birth.  PLEASE WATCH THE LINK: https://www.youtube.com/wa tch?v=e6YLras5ndg  (PIH) PREGNANCY-INDUCED Also called HYPERTENSION HYPERTENSION OF PREGNANCY or GESTATIONAL HYPERTENSIVE DISORDER Is a potentially life- threatening disorder that usually develops after the 20th week of pregnancy. It occurs most commonly in nulliparous women. 1. PREECLAMPSIA PIH ▪ The non-convulsive TWO CATEGORIES OF PIH: form of the disorder, is marked by the onset of hypertension after 20 weeks’ gestation ▪ It develops in about 7% of pregnancies and may be mild or severe 2. ECLAMPSIA ▪ Convulsive form, TWO CATEGORIES OF PIH: occurs between 24 weeks’ gestation and the end of the first postpartum week ▪ Incidence increases among women who are pregnant for the first time, have multiple fetuses, and have a history of vascular disease  PATHOPHYSIOLOGY Exact cause is unknown, systemic peripheral vasospasm occurs that affects every organ systems. Geographic, ethnic, racial, nutritional, immunologic, and familial factors may contribute to preexisting vascular disease which, in turn, may contribute to its occurrence. Age is also a factor. Adolescents and primiparas older than 35 are at higher risk for preeclampsia  PATHOPHYSIOLOGY Other possible causes include potential toxic sources (autolysis of placental infarcts), autointoxication, uremia, maternal sensitization to total proteins, and pyelonephritis Changes associated with PIH: PATHOPHYSIOLOGY Effects on the vascular system: ▪ Vasoconstriction ▪ Impaired organ perfusion ▪ Hypertension Changes associated with PIH: PATHOPHYSIOLOGY Effects on the renal system: Reduced glomerular filtration rate; increased glomerular membrane permeability oliguria Increased serum BUN and creatinine Proteinuria Changes associated with PIH: PATHOPHYSIOLOGY Effects on the interstitial tissues: ▪ Fluid diffusion from vascular space into interstitial space ▪ Edema PATHOPHYSIOLOGY Generalized arteriolar vasoconstriction associated with PIH is thought to produce decreased blood flow through the placenta and maternal organs. PATHOPHYSIOLOGY This can result in intrauterine growth retardation, placental infarcts, and abruptio placentae. PATHOPHYSIOLOGY Hemolysis, elevated liver enzyme levels, and a low platelet count (HELLP syndrome) are associated with severe preeclampsia. Other possible complications include stillbirth of the neonate, seizures, coma, premature labor, renal failure, and hepatic damage in the mother  Blood pressure exceeding 140/90 mmHg; or increase above baseline of 30 mm Hg in systolic pressure or 15 mmHg in diastolic pressure on two readings taken 4- 6 hours ASSESSMENT FINDINGS: apart. Clinical manifestations of mild preeclampsia Generalized edema in the face, hands, and ankles (a classic sign) Weight gain of about 1.5 kg (3.3 lb.) per month in the second trimester or more than 1.3 to 2.3 kg (3 to 5 lb.) per week in the third trimester Proteinuria 1+ to 2+, or 300 mg/dL, in a 24 hour sample  Blood pressure exceeding 160/110 mm Hg noted on two readings taken 6 hours apart with the client on bed rest. ASSESSMENT FINDINGS: Proteinuria exceeding 5 g/24 hours Cl i nical manifestations of severe preeclampsia Oliguria (less than 400 mL/24 hours) Headache Blurred vision, spots before eyes, and retinal edema Pitting edema of the sacrum, face, and upper extremities Dyspnea Epigastric pain Nausea and vomiting Hyperreflexia  Rapid rise in blood pressure ASSESSMENT FINDINGS: Rapid weight gain Generalized edema Increased proteinuria Epigastric pain, marked hyperreflexia, and severe Warning signs of worsening preeclampsia headache, which usually precede convulsions in eclampsia Visual disturbances Oliguria (