Reproduction III 2500

What is a High Risk Pregnancy?

- When there is jeopardy for mother and/or fetus.

- Normally happens with mothers who are diabetic, hypertensive, teenagers, or over 35.

- Must conduct ongoing risk assessment and get a good baseline from the first prenatal visit.

What is Physiological Anemia?

An increase in maternal blood volume reduces red blood cell concentration.

How does the Heart size, Blood Volume, and RBC Volume change with pregnancy?

- Heart Size: Becomes enlarge.

- Blood volume: There is a 40-50% increase for nutrients and O2 transport and for blood reserves.

- RBC Volume: There is a 20-30% increase.

How does pregnancy change the WBC count and the Cardiac Output?

- WBCs: Usually around 5,000 to 10,000 during pregnancy, but can go up to 25,000 at time of labor.

- Cardiac output: Is increased 30-50%. HR goes up 15-20 BPM.

What happens to Peripheral Vascular Resistance in Pregnancy?

It is decreased.

How does Blood Flow and Blood Pressure change in Pregnancy?

- Blood Flow: There is 500ml per minute through placenta. There is 30% more to perfuse kidneys.

- Blood Pressure: Stays stable. There may not be any BP changes until there is severe bleeding and blood loss.

What are the Early Pregnancy Perfusion Disorders?

- Abortions

- Ectopic Pregnancy

- Gestational Trophoblastic Disease

What are the Late Pregnancy Perfusion Disorders?

- Placenta Previa

- Placenta Accreta

- Abruptio Placenta

- Amniotic Emboli

Is Bleeding Normal in Pregnancy?

Any bleeding is considered a medical emergency related to the amount of blood loss.

Causes of Spontaneous Abortions (Miscarriage)

- 1st Trimester is commonly due to fetal genetic abnormalities (50-60%).

- 2nd Trimester is more likely related to maternal conditions like infections and immune disorders.

Nursing Assessment with Spontaneous Abortions

- Check: Vaginal Bleeding (especially if it is bright red)

- Cramping (especially if it is getting worse)

- VS and Pain level

- Client's understanding

What is the Criteria for Spontaneous Abortion?

Loss of the fetus prior to viability.

- Less than 20 weeks gestation or less than 500 grams.

Most occur within first 12 weeks.

Above this criteria is called Intra-Uterine Fetal Death (IUFD)

Threatened, Inevitable, and Incomplete Spontaneous Abortions

- Threatened: There will be vaginal bleeding (spotting), but the cervix remains closed. Bleeding may stop or increase. Need vaginal rest.

- Inevitable: There is ROM and the cervix is dilated. The fetus is nonviable and nurse should look for pt passing fetal tissue.

- Incomplete: Pt will have bleeding. When not all products of conception are expelled.

What does the Cervix opening early mean?

That there will most likely be a miscarriage.

Complete, Missed, and Recurrent Spontaneous Abortions

- Complete: May have bleeding and cervix will be open. When all contents of conception are expelled.

- Missed: When the fetus dies and remains in uterus.

- Recurrent: When pt has 3 or more consecutive abortions.

What are the Signs of a Threatened Abortion?

- Vaginal Bleeding (brief or last for weeks)

- Pelvic Pressure/Uterine cramping

- Cervix remains closed and membranes are intact

- B-hCG levels rise, fetus grows.

How Should you Manage a Threatened Abortion?

- Have pt do pad count.

- Emotional support for anxiety, fear, guilt, and counseling referral.

- Ultrasound (to see if fetus is still present)

- Uterine tenderness and fever may mean chorioamnionitis.

- Get Hematocrit and Hemoglobin (H+H).

What are the Signs of an Inevitable Abortion?

- ROM

- Cervical Dilation

- Active, heavy bleeding.

How to manage an Inevitable Abortion

- No further treatment is needed if delivery of fetus occurs.

- If tissue remains in uterus, will need D and C.

What is D and C?

Dilation and Curettage. A procedure to remove tissue from inside your uterus.

What are the Signs of Incomplete Abortion?

- Active uterine/vaginal bleeding

- Severe abdominal cramping

- Cervix is open/dilated

- Products of conception have been expelled but remain in vagina.

- Retained tissue prevents uterus from contracting firmly, thus allowing profuse uterine bleeding.

How to Manage Incomplete Abortion?

- CV stabilization (bleeding)

- Type and crossmatch for blood

- IV lines: Oxytocin and fluids

- IM methylergonovine

- Curettage

What happens if an incomplete abortion is beyond 14 weeks?

Curettage may not be performed because of danger of excessive bleeding. Oxytocin or prostaglandins are given to stimulate uterine contractions until all products of conception are expelled.

What is the sign of a complete abortion?

When all products of conception are expelled from the uterus.

How to manage a a complete abortion

- Do not need to manage unless there is excessive bleeding or infection occurs.

- Watch for bleeding, pain, or fever.

- Abstain from intercouse until follow up with physician.

What is Habitual/Recurrent Abortion and its causes?

3 or more consecutive spontaneous abortions.

Causes: Genetic/Chromosomal abnormalities

- Reproductive anomalies: Bicornuate uterus and incompetent uterus.

- Lupus (immune disorder), diabetes, STDs, PID, and inadequate hormones in luteal phase of cycle.

What is a Bicornuate Uterus?

A heart shaped uterus or one that appears to have 2 chambers.

What is Cervical Incompetence?

- When the fetus begins to grow and the weight causes the cervix to open and pregnancy is lost.

- Has painless dilation of cervix in 2nd trimester.

- Treatment is to put in a cervical stitch to keep the cervix closed (McDonald's or Shirodkar stitch). Stitch may need to be removed at later time.

How to Manage Habitual/Recurrent Abortions

The management depends on the cause.

- Examine reproductive organs

- Genetic testing

- Lab test for STDs

What are the symptoms of a missed abortion?

- The uterus stops growing (seen with ultrasound)

- Nausea, breast tenderness disappear with fetal death.

How to Manage a Missed Abortion

- Fetal death is confirmed by ultrasound

- 1st Trimester: D and C

- 2nd Trimester: Induction

- Look at labs for DIC and antibiotics for infection.

What are the 2 complications of missed abortions?

- Infection: Causes fever, foul vaginal discharge, abdominal pain, and tenderness.

- DIC: Defect in coagulation when fetus is retaine. Increase in risk, longer fetus is carried.

What is an Ectopic Pregnancy?

- When the ovum implants outside the uterus.

- Causes by anything that obstructs/slows passage of ovum through tube to uterus.

- Most occur in ampulla, middle of fallopian tube related to scarring from pelvic infections, inflammation, or surgery.

- Can also implant in cervix, ovaries, intestines, or abdomen.

Risk Factors for Ectopic Pregnancy

- Non white women over 35.

- Scarring of fallopian tubes caused by STDs, pelvic infection, inflammation, surgery.

- Pelvic Inflammatory Disease (PID)

- Anatomic Defect

- Use of IUD

What are the symptoms if a fallopian tube ruptures with an ectopic pregnancy?

- Sudden, severe pain in lower right abdominal quadrant.

- Intraabdominal hemorrhage.

- Irritation of Diaphragm which leads to shoulder or neck pain that is worse on inspiration.

- Symptoms of Hypovolemic Shock: Increased HR, tachypnea, weakness, confusion, low BP, clammy, cool skin.

Triad of Symptoms for Ectopic Pregnancy

- Missed Menstrual Period

- Abdominal and Pelvic pain

- Vaginal spotting or light bleeding

How to diagnose an Ectopic Pregnancy?

- Ultrasound

- B-hCG: Lower than normal levels may indicate abnormal pregnancy like an ectopic or nonviable.

What is B-hCG?

Human Chorionic Gonadotropin.

Is a hormone that the placenta makes when a woman is pregnant.

- Increases during early gestation to cause corpus luteum to seret progesterone.

- Decreases between 50-70 days gestation as placenta takes over progesterone production.

How to Manage an Ectopic Pregnancy

Unruptured: Methotrexate to inhibit cell division. Best treatment to prevent more scarring.

Surgery to open tube and remove embryo. Can cause more scarring.

Ruptured: Control bleeding

Prevent hypovolemic shock

Surgery to remove affected tube.

What are the Nursing Considerations for Ectopic Pregnancy?

- Prevent, identify, and treat hypovolemic shock.

- Pain control (pts will jittery/hyper afterwards)

- Psychological support - Ask pt what they need/want from nurse.

- Explaining Methotrexate.

Nursing Considerations for Methotrexate

- Explain side effects (N/V) and that it is a cancer drug.

- Educate with signs/symptoms of tubal rupture.

- No alcohol or folic acid vitamins.

- Refrain from intercourse until B-hCG is undetectable.

- Keep follow-up appointment.

What are Gestational Trophoblastic Diseases?

Hydatidiform mole (occurs initially)

Choriocarcinoma (malignant tissue changes that follow in 15-20% of cases).

- When the trophoblasts (peripheral cells that attach the fertilized ovum to the uterine wall develop abnormally. Leads to placenta development but no development of fetus.

Types of Hydatidiform Moles

- Complete Mole: When there is no fetus present. Believed to occur when ovum is fertilized by a sperm that duplicates its own chromosomes whole those of ovum are inactivated.

- Partial mole: When there is some fetal tissue or membranes. Believed to occur when there is some maternal contribution, nut double paternal contribution.

Symptoms of Hydatidiform Mole

- Vaginal Bleeding

- Uterus larger than expected for gestational age (fundus will be high).

- Excessive N/V

- Early development of pre-eclampsia

How to diagnose Hydatidiform Mole

Ultrasound and B-hCG (will be high).

What is the Management of Hydatidiform Mole?

- Complete evacuation of uterine contents.

- Follow up: B-hCG levels every 1-2 weeks until WNL. Then B-hCG and CXR ever month for a year.

- IF B-hCG levels plateau or rise is indicative of choriocarcinoma.

- Cannot get pregnant again for 1 year.

What is Placenta Previa and what are the types?

An abnormal implantation location of placenta.

- Marginal (low-lying): Implanted more than 3 cm from cervical os. In the part of the uterus that doesn't contract.

- Partial: Implanted within 3 cm of cervical os. When cervix opens placenta is pulled on.

- Total: Placenta completely covers cervical os. Will likely need a C-section.

Where should the placenta normally be in pregnancy?

Normally should be in fundus where uterine can contract.

What are the 2 major causes of hemorrhage after 20 weeks gestation?

Placenta Previa and Abruptio

What are the Risk Factors for Placenta Previa?

- Older women

- Miltiparas

- Male fetus

- Smoking/cocaine use

- Prior Placenta previa

Manifestations of Placenta Previa

- Sudden onset of painless bleeding

- Bleeding may be scant or profuse, start and stop at random, or not occur until labor starts.

- Is maternal blood because villi are torn from uterus wall.

- Is painless because it doesn't put pressure on adjacent tissue.

Diagnostics for Placenta Previa

- External fetal monitoring

- Ultrasound: To buy some time while fetal weight and maturity of lungs increases.

Management of Placenta Previa

- if bleeding has slowed/stopped and CV system is stable, watch and monitor to get as close to term as possible. Have pt do pad count.

- Have pt be educated and do daily fetal assessments.

- Schedule C-section if 36 weeks or greater and fetal lungs are mature.

- Emergency C-section if excessive vaginal bleeding, or CV system alteration.

- May be long term inpatient, so manage anxiety.

Nursing Considerations for Placenta Previa

- If pt comes in with vaginal bleeding, do not do vaginal exam, or oxytocin until ultrasound. Need to see cause of bleeding.

- Always get IV access for pts.

- Know that they are at risk for prolapsed cord and variable/late decelerations.

- Know that hysterectomy is likely with complete placenta previa.

What is Abruptio Placenta?

- The separation of a normally implanted placenta before the fetus is born.

- Occurs when there is bleeding and formation of hematoma on maternal side of placenta, which causes separation of placenta.

- Can be a concealed abruption where the blood is going behind the placenta.

- Biggest contributor to perinatal death.

- Severity depends on amount of bleeding and size of hematoma. Can self limit or block off intervillous spaces where gas exchange occurs.

Risks for Abruption Placenta

- ROM

- Abdominal trauma especially domestic violence.

- Previous abruption

- Cocaine use (causes vasoconstriction)

- Coagulopathies (tendency to form clots).

Difference in Symptoms for Abruptio and Previa

Abruptions are painful, previas are not.

5 Classic Signs and Symptoms of Abruptio Placenta

1. Vaginal Bleeding

2. Abdominal/low back pain (may be aching or dull)

3. Uterine irritability with frequent low intensity contractions

4. High uterine resting tone

5. Uterine tenderness

Symptoms of Concelaeld Hemorrhage in Abruptio Placenta

- Increased fundal height

- Symptoms of hypovolemia with no apparent bleeding.

- Persistent abdominal pain

- Persistent late decelerations

- Maternal and fetal tachycardia

What is the management for Abruptio Placenta?

Surgical management and monitor fetus.

What is Placenta Accreta?

When there is a missing layer in the wall of the endometrium, placenta grows into wall of uterus during pregnancy.

- Occurs without symptoms, but look for boggy uterus and bleeding.

- Can't be prevented.

Risk Factors for Placenta Accreta

- Previous C-section

- Placental attachment in lower uterine segment.

- Women over 35.

- Previous deliveries or uterine surgeries.

Complications of Placenta Accreta

- Excessive Bleeding (Hypovolemia and DIC).

- Preterm delivery

- Prolonged hospital stay

- Hysterectomy

- Surgical injury to organs

What is important to look for if placenta has to be manually released through surgery?

Retained placental fragments.

What is an Amniotic Emboli?

- When amniotic fluid is drawn into maternal circulation and carried to lungs.

- Fetal skin cells, vernix, and meconium can all be present in amniotic fluid and obstruct pulmonary vessels.

- More likely with strong labor because high intrauterine pressure forces fluid into open uterine or cervical vessels.

Symptoms of Amniotic Embolism

- Abrupt respiratory distress

- Depressed cardiac function - Right ventricle can fail, the left fails which leads to circulatory collapse.

- Is often fatal with a 50% maternal death rate.

- Survivors usually have neuro defects.

Management of Amniotic Embolism

- CPR

- O2 and may need to intubate.

- Call rapid response

- Put in left lateral position

- Correct hypotension because of the hemodynamic shift

- Blood products for coagulation defects (Fibrinogen, PRBCs, FFP)

- Immediate C-section to increase fetal survival rate.

What is Disseminated Intravascular Coagulation (DIC)?

Placental/uterine bleeding leads to thromboplastin (clotting factor) being released into maternal circulation. Activated widespread clotting is happening in small vessels through entire body, and this leads to other clotting factors (fibrinogen and platelets) being used up. The fibrinolytic system is activated to destroy these clots but because there is a drop in clotting factors bleeding continues to occur. Because there is an increase in anticoagulants and a drop in clotting factors, blood does not clot and pt bleeds from all sites (IV site, incisions, gums, nose, uterus, and other body orifices). Pt is bleeding and clotting at same time.

What do Labs look like in DIC?

- Decreased Clotting factors, fibrinogen, and platelets.

- Increased Fibrinolysis and FDP.

- Positive D-Dimer because of clots.

- Prolonged Prothrombin time (PT) and PTT

How to manage DIC

- The priority is to get pt to deliver.

- Get blood replacement.