Complications of Pregnancy: Hemorrhagic Disorders

Molar Pregnancy

complete, partial, or invasive.

partial molar pregnancy

there is an embryo in which two sperm fertilize one egg

Gestational trophoblastic disease

Lesions or tumors, including placental site nodules, exaggerated placental sites, and molar pregnancies, that demonstrate unexpected growth of trophoblast of the placenta

Complete

(Sperm fertilize one egg) but there are no genetic material in the egg – no embryo (fetal tissue) formed

Invasive

a tumor that grows where the placenta attaches to the uterus. An invasive mole has a molar pregnancy with enlarged villi that attaches through the myometrium and possibly into vascular spaces or extrauterine areas

Risk Factors for Molar Pregnancy

Maternal Age (less than 15 greater than 35)

Previous history of molar pregnancy

History of infertility/spontaneous abortions

Impact of Molar Pregnancy on Health

Psychosocial- coping of a pregnancy loss

Consideration of Maternal Client’s Needs

Health Promotion and Disease Prevention

Grief and Loss

Psychosocial relating to molar pregnancy

Learning to cope with a loss of pregnancy. They will also need surgery and follow-up with monitoring by their provider, which can cause anxiety, depression, and distress

Consideration of Maternal Client’s Physical Needs related to molar pregnancy

Having a molar pregnancy places the client at a higher risk of having another one, so future pregnancies must be monitored closely

Risk for gestational trophoblastic neoplasia

Health Promotion and Disease Prevention related to molar pregnancy

No modifiable risk factors

Grief and Loss related to molar pregnancy

May experience grief and loss

A support group may be of benefit

Emotional support from interdisciplinary team can improve client’s quality of life

Molar Pregnancy Role of the Nurse

Be aware that the client or family may experience grief and loss.

The client may require help from a support group. Resources, such as local support groups and psychologists, should be provided to the client.

Molar Pregnancy Care of the Client

Assess for manifestations of hypovolemia related to blood loss

Labs

Intake and output

Vital signs

Assess hCG levels

Be prepared to treat hypovolemia

Replace fluids – IV and possible blood transfusion.

Molar Pregnancy Teaching as an Intervention

Education includes potential complications following surgical procedure.

Need for reliable contraceptive during treatment phase ad follow up hCG monitoring

Mole Pregnancy Treatments and Therapies

Uterine evacuation: mechanical dilation of the cervix, then suction aspiration and sharp curettage to ensure that there is complete evacuation of the molar tissue.

Hysterectomy: If done having children, have complete mole or risk factors for gestational trophoblastic neoplasia

Chemotherapy: Prophylactic chemotherapy is used to prevent the progression of a complete mole to gestational trophoblastic neoplasia

Cervical Insufficiency

Painless cervical dilation that leads to a second-trimester pregnancy loss

Cervicale Insufficiency Medication Management

For clients who have a history of cervical insufficiency, progesterone may be prescribed beginning at 16 weeks gestation as an injection or as a vaginal suppository

Cervical Insufficiency: Surgical Management

A transvaginal or transabdominal cervical cerclage placement may be performed.

Cerclage where a stitch is placed around the cervix to prevent dilation can be performed on clients who have a diagnosis based on history or on physical exam.

A cerclage is usually placed around 13 to 14 weeks gestation but can be placed up until 24 weeks gestation and removed at week 36 or 37 in preparation for delivery.

Ectopic Pregnancy

The embryo implants somewhere else than the endometrium

Ectopic Pregnancy:Epidemiology

Varies across populations may be as high as 2%-5% in clients who use assisted reproduction and higher among persons using intrauterine devices (IUD)

Ectopic Pregnancy: Etiology

Pregnancy can occur in numerous areas outside of the uterus. Conditions that affect the fallopian tubes cause it to be the most common site for an ectopic pregnancy

Risk Factors for Ectopic Pregnancy

include maternal age greater than 35 years,  history of endometriosis, infertility, pelvic inflammatory disease, cigarette smoking, pregnancy while using contraceptive or IUD, exposure to diethylstilbestrol (DES)

Clinical Presentation of Ectopic Pregnancy

Vaginal Bleeding & abdominal pain

vomiting; diarrhea; lower urinary tract manifestations, such as urinary frequency and painful urination; and rectal pressure

Laboratory Testing and Diagnostic Studies for Ectopic

Serial hCG levels & ultrasound used to confirm ectopic pregnancy

The most definitive diagnosis of ectopic pregnancy is a fetal heartbeat outside the uterine cavity, located on ultrasound

CBC to monitor hemoglobin, hematocrit and platelets related to potential bleeding

Liver function and renal function if client is receiving methotrexate

Ectopic: Expectant Management

Monitoring client to determine if ectopic pregnancy resolves on it’s own – only for asymptomatic clients that is not in fallopian tube and hCG serum level is low and declining

Ectopic: Medical Management

Medical management is appropriate for hemodynamically stable clients who have a confirmed ectopic pregnancy without rupture and do not have contraindications to methotrexate administration

Ectopic: Surgical Management

Salpingectomy or salpingostomy

Surgery is required for clients who are unstable and clients who have suspected tubal rupture, a heterotopic pregnancy with a coexisting viable intrauterine pregnancy, or a contraindication to methotrexate use or failed methotrexate treatment

marginal placenta previa

placenta lies near the cervix but does not cover the opening

partial placenta previa

placenta covers a portion of the cervix

complete placenta previa

placenta completely covers the cervical opening

Major Risk factors for Placenta Previa

previous placenta previa, previous cesarean births, and multiple gestation

Clinical Presentation of Placenta Previa

Painless vaginal bleeding in the second half of pregnancy

May have no manifestations

Vaginal bleeding during a vaginal exam, sexual intercourse and placenta may be visible during speculum exam

Placenta Previa: Activity After 20 weeks gestation

Avoid moderate to strenuous exercise, heavy lifting (greater than 20 pounds), or standing for prolonged periods of time (greater than 4 hr)

Risks for Placenta Previa

Risk for hemorrhaging

Possible extended hospitalization for observation is bleeding occurs

When to contact provider and go to hospital if bleeding occurs

Mag Sulfate

is given to relax the uterine muscle for preterm labor or to control maternal preeclampsia prior to deliveries before 32 weeks

Antenatal corticosteroids

such as betamethasone may be used to promote fetal lung maturity for deliveries prior to 34 to 36 weeks gestation

Risk factors for Placental Abruption

Include history of an abruption, cocaine use, cigarette smoking, maternal age greater than 35 years, hypertension, multiple gestation pregnancy, polyhydramnios, preeclampsia, submucosal myomas, a short umbilical cord and abdominal trauma

Clinical Presentation: Acute abruption

a sudden onset of vaginal bleeding, mild to moderate abdominal pain, and uterine contractions. Tachycardia, uterus rigidity and tender to palpation

Clinical Presentation: Chronic abruption

light, chronic, intermittent bleeding