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Hyperemesis Gravidarum: Bleeding Complications of Pregnancy
Hyperemesis Gravidarum: Bleeding Complications of Pregnancy
Bleeding Complications of Pregnancy o Too much KCl will stop the heart
o Administer vitamin B6- nerves
Hyperemesis Gravidarum Administer total parenteral nutrition as needed
Etiology o Maintains adequate nutrition
Increased level of HCG o Should be consumed within 24 hours, regulate
o Weight decreases the TPN
Transient hyperthyroidism
Hypofunction of the anterior pituitary gland and adrenal Gestational Trophoblastic Disease (Hydatidiform)
cortex Occurs at 16th week of gestation (2nd trimester)
o Undiagnosed problem of the neurologic system o No heartbeat of baby, but only proliferated cells
Abnormalities of the corpus luteum At 12 weeks fundic height is at pubic area, by 20 weeks of
Helicobacter pylori infection gestation- umbilicus level. But for this woman, it is already
o GI bacteria at 30weeks gestation level
o Higher episodes of vomiting Abnormal proliferation then degeneration of trophoblastic
Manifestations villi
Persistent N/V beyond 16 weeks o Develops into placenta
Weight loss of 5% minimum Cells become fluid filled= fluid filled, grapelike cluster
Dehydration Proliferation= Large FH
Electrolyte and acid-base imbalance Persistence GTD may undergo malignant change
Unusual stress (choriocarcinoma) and metastasize
o Accepting the pregnancy 2 Types of GTD
Nursing Responsibilities 1. Complete
Exclude gestational trophoblastic disease No fetus; “empty egg” fertilized by sperm
o No heartbeat upon ultrasound but positive on Associated with choriocarcinoma- cancer
pregnancy test and abdomen enlarges Chromosomal analysis
IV fluids (Lactated Ringer’s Sol’n- D5LR) o Sperm 23 + Ovum 0 + duplication= 46
o Provides nutrition to client Hydatiform mole
o Correct acid-base imbalance If not treated:
Monitor intake and output o Vaginal bleeding (16 wks)- anemia; 2nd trimester
o Measure vomit using kidney basin calibration bleeding
NPO x 1st 24 hours then small frequent feeding if no o Increased uterus size, cramps
vomiting o No FHT’s
o Every 2-3 hours, dry toast/ crackers o Increased N/V because each mole is producing
o Bland taste to minimize triggering factors for HCG level
vomiting o Early PIH rather than 20-24 weeks because of
Minimize food odors abnormal proliferation and uterus expansion
Provide oral hygiene Management: Vacuum aspiration and curettage
o Allow client to gargle every time she vomits 2. Partial
Monitor weight Only part of the placenta has vesicles
o If drastic weight loss, total parental nutrition will Has chorionic villi but the rest are cells
be ordered by physician Chromosomal analysis
Goal of treatment o Ovum 23 + 2 sperm (dispermy)= triploid
Correct electrolyte imbalances and acid-base imbalances karyotype (69 chromosomes) OR
with oral or IV fluids o Ovum 23 + sperm 46= triploid karyotype (69
Minimize vomiting by antiemetic drugs chromosomes)
Drug therapy Etiology
Metoclopramide (Reglan)- Cat.B; Pre-op 36 above
o If not PO, then give direct parenteral Asian
Promethazine, Diphenhydramine Previous molar pregnancy
Famotidine, Ranitidine (Pre-op) Treatment of Hydatiform mole
Ondansetron Suction curettage
Nursing Care Baseline level of hCG is tested every 2 wks
Avoid foods that trigger N/V Once normal, every 4 weeks for 6-12 months, to rule out
o Spicy, oily, aromatic, texture malignancy
Small frequent feeding hCG plateu or increase = malignancy
Women advised to delay conception until follow-up care
Increase K and Na rich food complete
o Replacement of electrolytes If conceived hCG will increase and cannot be
Provide support to the mother distinguishable whether pregnancy or malignancy induced
o Encourage verbalizations of feeling and thoughts 6 months hCG (-)- malignancy risk
Management 12 months hCG free- pregnancy is now allowed
Provide IV fluids Malignancy
Restore electrolyte balance o Methotrexate
o Add potassium chloride to IV fluids o Dactinomycin
Kristen Azusano
Nursing Care 2. Inevitable abortion- membranes rupture and cervix
Observe for bleeding and shock dilates/opened, pregnancy cannot be saved
Emotional support Uterus contracts, internal cervical os dilates, ruptured
Education on reasons to delay pregnancy membrane
Contraception education Save tissue fragments she has passed for analysis
o Condom o Fetus is brought to the hospital for
o Pills Pad counting after dilatation and curettage
Administer oxytocin Management
o Contraction of uterus to prevent bleeding Prevention of bleeding and infection
Assess for anemia Curettage- ensures all products of conception are
o High risk for profuse bleeding removed after miscarriage
o Inspection: Pallor o Dilatation and evacuation
o Lab: CBC, Hemoglobin, HCT count o Dilatation and curettage
o *Inform the woman that the pregnancy is los prior
Miscarriage to procedure
Expulsion of the fetus prior to viability (20 weeks AOG or 3. Missed miscarriage
<500 gms) Early pregnancy failure
o Age of viability=20 weeks (potential of fetus to Fetus die in utero but is not expelled
survive outside uterus) May or may not have bleeding
o 500gms> can be considered as early preterm No increase fundic height, no FHT
Also called abortion ULTRASOUND confirms no FHT
Spontaneous or Induced o 10-12 weeks via doppler then ultrasound for
Early miscarriage= before 16 wks confirmation
o Dilatation and curettage Intrauterine fetal death stages
Late miscarriage= 16-20 wks o Fetal maceration- 1-2 wks missed IUFD
o Given a medication to contract uterus and expel o Fetal mummification- 2-4 wks missed IUFD
the fetus o Lithopedion/ Womb stone- 4 wks and above
o Delivery of immature placenta IUFD
o Dilatation and curettage if incomplete Management
Etiology Pregnancy before 14 weeks
Chromosomal abnormalities o Dilatation and evacuation
Teratogenic drugs o Dilatation and curettage
Faulty implantation Pregnancy over 14 weeks
Immunologic factor o Induction of labor
o Blood incompatibility o Misoprostol (Cytotec) is introduced into the
Weakened cervix posterior fornix of vagina to cause dilatation
o Cervix should be closed until 37th week o Oxytocin causes uterine contraction
Not enough production of progesterone No management = spontaneous miscarriage within 2 weeks
o Progesterone thickens endometrium, maintain Danger in no management
placental function and it is the pregnancy o Disseminated Intravascular Coagulation (DIC)
hormone may develop if the new toxic dead fetus remains
o Developing embryo will not be able to attach too long in the utero
onto the endometrium/ uterus o Underlying disorder- systemic activation of
Maternal conditions coagulation to A or B
o Chronic disease (nutritional deficiency, o A-Widespread fibrin deposition- microvascular
teratogenic medications) thrombotic obstruction- organ failure
o Endocrine imbalances (progesterone hormone) o B-Consumption of platelets and clotting factors-
o Infections (perineal area- urinary tract, thrombocytopenia coagulation factor deficiency-
Subcategories bleeding in eyes, gums, ears etc. (most common)
1. Threatened abortion- vaginal bleeding occurs, but pregnancy 4. Recurrent pregnancy loses
can still be saved Habitual, consecutively in three or more pregnancy usually
Cervix closed due to
+ bright red bleeding o Incompetent cervix
Blood hCG within 48-hour period = placenta and o Bicornate uterus
amniotic sac is still intact o Defective sperm or ovum
Management o Endocrine problems
Assess vaginal d/c, NPO if severe bleeding o Resistance to uterine artery blood flow
Assess accompanying symptoms o Autoimmune
o Nausea, palpitations, tachycardia for hypovolemia Management
Transvaginal ultrasound to verify fetal status Assess maternal reproductive system
o Placenta is still intact and BOW, fetus heartbeat o Incompetent cervix= cerclage
Limit activities (limit sexual activities x2wks) Genetic screening
Pad counting Screening for maternal factors
o Monitor increased vaginal bleeding 5. Complete miscarriage
All products of conception expelled
Kristen Azusano
Bleeding slows within 2 hours Management
No procedure required o Rhogam administration to mother
Verified through ultrasound o After birth of first child, within 72 hours-
6. Incomplete abortion- Some products of conception have been Rhogam is administered to prevent developing
expelled, but some remain antigen
Part of coneptus remains inuterus
Risk for infection Ectopic Pregnancy
DNC is done Occurs when fertilized egg is implanted outside uterine
Management cavity
Stabilize CV state (Vital signs monitoring) o 95% in fallopian tube- 80% ampulla, 12%
Removal of retained tissues isthmus, 8% interstitial or fibrial
D&C (<14 wks) Risk factors
D&E (>14 wks) ff. by curettage Previous tubal damage or tubal surgery
Uterotonics may be administered Congenital abnormalities
Post miscarriage education Endometriosis
Bleeding should be subsiding Presence of an IUD
Cramping X 1-2 wks Uterine exposure to diethylstilbestrol (DES)
Vaginal rest x 1 wk May result from
Monitor temp BID Hormonal abnormalities
Follow up in 2 wks Congenial defects
Complications of miscarriage Vasconstrictive effects of smoking
Hemorrhage Obstruction
o Fully soaking more than 1 pad per hour o Inflammation from infection
o Passing large blood clots o Scarring from fallopian surgeries
o Might case or an effect of DIC Assessment
Management Probable and presumptive signs of pregnancy
o Monitor VS closely (signs of hypovolemia) o hCG hormone is elevated
o Uterine massage over symphysis pubis (<20 wks) Localized sharp stabbing abdominal pain (R or L lower
o D&C quadrant)
o Methylergonovine maleate (methergine) Spotting
administration (contract uterus and elevate BP) No gestational sac on transvaginal ultrasound
Infection may rupture fallopian tube at 6-12th AOG
o Common if instruments used are not sterile Fallopian rupture
o Retained products of conception can cause both Interstitial implantation- severe intraperitoneal bleeding
infection and bleeding o May experience shoulder pain
o Monitor for fever >38 C, foul smelling vaginal Initial scanty vaginal bleeding bec. Blood is in the pelvic
and heavy vaginal discharge and abdominal pain cavity
o Instruct proper pericare to avoid E.coli spread to Rigid abdomen from peritoneal irritation
vagina (front to back) Cullen sign
Septic abortion Palpable mass on Cul de sac
o Usually occurs when on sterile instruments used Additional vaginal bleeding as placenta dislodge and
for abortion decidua sloughs off
o Needs immediate intensive assessment and (+) signs of hypovolemia: Increase RR and HR, pulses
therapy thready, lower BP
o High dose broad spectrum antibiotic is prescribed Treatment
o Hemodynamic monitoring done Medical treatment
o D&C and tetanus toxoid administration done No action if reabsorbed
o Infertility may be a complication o Methotrexate (if tube not ruptured)
Folic acid antagonist and inhibits scell
Isoimmunization
divison
o Occurs when
Given until (-) hCG titer
Mother is Rh -ve and father is Rh +ve
o Hysterosalpingogram to check if pregnancy is
Baby is Rh +ve
still present
Fetomaternal haemorrhage occurs
o 1st baby has no problem, but succeeding
Surgery to remove pregnancy from tube or entire tube if
pregnancy is in danger if not managed
damage is severe
o During birth, separation of placenta from mother,
o Salpingostomy via laparascope- another risk for
fetal blood mixes with mother’s blood and the
ectopic PG
mother develops antibody against the negative
o Salpingectomy- removal of affected fallopian
blood
o Next pregnancy, baby is Rh +ve, but since tube
Nursing care for EP
antigen is now present, it will attack the baby’s
blood as something that is foreign= Vital signs
erythroblastosis fetalis IV fluids
o Blood replacement as necessary
o Pregnancy is terminated <20wk) Antibiotics
Kristen Azusano
Pain management No pelvic or rectal exam
NPO Treatment
Indwelling catheter Depends on length of gestation and amount bleeding
Bed rest Goal: maintain pregnancy as long as safely possible (at
Emotional support least 36 weeks)
Mother encouraged to lie on side of with pelvic tilt to avoid
Bleeding disorder of late pregnancy (Third trimester) supine hypotension
Cervical insufficiency C-section if total or partial
Incompetent cervix Deliver vaginally if low-lying or marginal under 30%
Dilates and cannot retain fetus until term previa
Cervical dilatation is painless With no active bleeding
Risk factors o Expectant management
Increased maternal age o No intercrouse, digial exams
Uterine congenital defects With late pregnancy bleeding
Cervix trauma o Assess status, circulatory stability
Repeated history of D&C o May need corticosteriouds, tocolysis,
Assessment amniocentesis
Pinkish vaginal discharge
Pelvic pressure
Watery vaginal discharge
Uterine contractions
Very short labor then delivery of fetus
Treatment
Cerclage
o Cervical stitching at 12-14 weeks upon
confirmation of viable pregnancy
o Preventive measure most of the time
McDonald
o Vertical and horizontal suturing is done
Shirodkar
o Sterile tape is secured in a purse-string manner
Nursing responsibility
Post cerclage
o Inform woman that she must remain on a bed rest Expectant management
for a few days May be discharged if stable after 72 hours of inpatient
Ideal position Trendelenburg observation
Sexual activites may resume after bed rest period No increase in
Birth post cerclage o Hemorrhage
Vaginal birth- sutures removed o Need for transfusion
Abdominal approach- sutures remain Tocolysis in placenta previa
Relax the uterus
Placenta Previa Greatest morbidity and mortality related to prematurity
Placenta develops in the lower part of the tuers Tocolysis can add an additional 11 days to pregnancy
4 degrees of previa o Allows for administration of corticosteroids
o Low lying placenta o Increase in maternal or fetal complications
o Marginal- lower placental border > 3cm from o Increase birth weights average of 320 grams
internal os, almost touching cervical os Relax uterus prolongs pregnancy and gives more time for
o Partial- within 3cm of cervical opening lung maturity
o Complete or total- completely covers the opening Double set-up exam
Manifestations Evaluation of previa by digital exam in operating room set
Bright red, painless vaginal bleeding not associated with for immediate cesarean delivery
activities Appropriate only in less than 30% previa with vertex
Fetus often in abnormal presentation presentation
Fetus may have anemia Carefully palpate placental edge and fetal head
Risk of hemorrhage increases with nearing labor Perform cesarean delivery for:
approximately 30 wks o Complete previa
Mother may be more at risk postpartum for infection and o Fetal head not engaged
hemorrhage o Non-reassuring tracing
o Vaginal organisms can easily reach placental site o Brisk or persistent bleeding
o Lower portion of uterus has fewer muscles Home care criteria
resulting in lower contractions No active bleeding
Diagnosis: Ultrasound to confirm Bed rest is possible
Full bladder can create false appearance of anterior previa Home is near hosp.
Presenting part may overshadow posterior previa Immediate transport available
Transvaginal scan can locate placental edge and internal os
Kristen Azusano
Woman understands risks
Abruptio Placentae
Permanent separation of placenta from implantation site
Compromise fetus wellbeing- oxygen and nutrients
Predisposing factors
Hypertension
High parity
Smoking/ drug use
Age
Abdominal trauma
Prior history of abruption placentae
Short umbilical cord
Chorioamionitis
Manifestations
Bleeding with sharp, stabbing pain, painful
Bleeding may be concealed at first DIC- Disseminated Intravascular Coagulation
Dark red vaginal bleeding when blood leaks placenta Complication of bleeding
Uterine tenderness and firm
May have cramp-link contractions Preterm Labor
Fetus may or may not be in distress Labor that occurs before end of 37 weeks
Fetus/ neonate may have anemia or hypovolemic shock Uterine contractiosn are persistent however mild
Complications is the birth of an immature infant
Signs and symptoms True labor
Vaginal bleeding (unless concealed) o Cervic effaces over 80%
Abdominal pain o Cervix dilates more than 1cm
Uterine activity increased Risk factor
Hemorrhage Dehydration -> oxytocin
o Boardlike abdominal (Couvelaire uterus)- UTI
Sustained contraction Periodontal disease
o Late decelerations Chiromantic
o S/sx shock and DIC LGA fetus
Diagnosis: Ultransound- abruption Adolescent pregnancy
Strenuous nature of work
Manifestation
Persistent, dull, low back pain
Vaginal spotting
Pelvic pressure
Abdominal tightening
Increased vaginal discharge
Management
Labor can be halted if
o Intact BOW
o (-) fetal distress
o (-) bleeding
o Cervix is <4cm dilated and not more than 90%
effaced
Bed rest
Cardio tocogram monitoring
Treatment
Hydration thru IV
1st choice- immediate cesarean
Assess for presence of infection
Blood and clotting factor replacement prevent DIC
Medication
Nursing care
o Terbutaline- treatment of asthma by relaxing
Prepare for C-section
smooth muscles
Lateral position
SE: Tachycardia, not used more than 72
Close, continuous monitoring of mother and baby hrs
Observe for S/S shock o Magnesium sulfate- prevention of eclamptic
Prepare for compromised infant seizure by relaxing smooth muscles
Prepare for grieving if infant dies o Betamethasone 12mg/IM q24hrs x 2 doses for
fetual lung surfactant
o Dexamethasone 5 mg/IM q12hrs x 4 doses to aid
in production of fetal lung surfactant if at <34
weeks AOG
Discharge if pretmerm labor is aresred and fetal well being
is evident
Kristen Azusano
Health teachings
o Adequate hydration
o Proper nutrition
o Refrain from smoking
o Kick counting
Anemia
Decline in circulating RBC
Less than 10.5 or 11g/dL
May lead to preterm birth or low birth weight
Iron Deficiency Anemia
Total iron requirement: 1000mg/fetus
Maternal effects: pallor, fatigue, lethargy and headache
Pica- eating things that are not usually edible
Microcytic and hypochromic RBC
Management
Ferrous sulfate OD to TID
Vit. C increases absorption
Hgb < 8.5 mg/dL= Parenteral Fe
Folic Acid Deficiency (Megaloblastic Anemia)
Folic acid functions as coenzyme int eh synthesis of DNA
Essential for cell duplication and fetal growth
RBC formation
Risk factors
Multiple pregnancies
Hemolytic Anemias
Anticonvulsant
Malabsorption problems
Fetal/neonatal effects
Spontaneous abortion Abruptio placenta
Fetal anomalies (NTD)
Management
Daily allowance: doubled during pregnancy (.6mg
supplementation)
If with Hx of child NTD:
o Additional .4mg supplementation 1 mo. prior to
pregnancy
o Best sources: fortified beans, fresh dark green
leafy vegetables
o **Follic acid is destroyed during cooking
Kristen Azusano