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What is Hyperemesis?

When vomiting during pregnancy becomes excessive enough to cause weight loss of at least 5% of pre-pregnancy weight AND is accompanied by dehydration, electrolyte imbalance, ketosis, and acetonuria.

*usually begins in the first 10 wks of pregnancy.


Risk factors of Hyperemesis

Increased body weight
history of migraines
pregnant with twins
pregnant with hydatidiform mole
psychological component


What does Hyperemesis look like?

significant weight loss
symptoms of dehydration
decreased BP
increased pulse rate
poor skin turgor
Inability to keep down even clear liquids
lab test that reveal electrolyte imbalance (Potassium, calcium, and sodium)


Potassium Lab values

3.8-5.0 mEq/L


Calcium Lab Values

8.5-10.5 mg/100ml


Sodium Lab Values

135-145 mEq/L


How is Hyperemesis Diagnosed?

Urinalysis, CBC, Electrolytes, Liver enzymes and Bilirubin levels rule out the presence of underlying diseases (pyelonephritis, pancreatitis, cholecytitis, hepatitis)

test TSH and T4 should be assessed because of hyperthyroidism.


How is Hyperemesis Treated?

**Esp. if woman cannot keep down liquids:
IV therapy
NPO until dehydration resolved and for at least 48 hours after vomiting stopped


Different types of Antiemetics:

Pyridoxine --Vitamin B6
Doxylamine-- Unisom
Promethazine-- Phenergan
Metoclopromide-- Reglan


Interventions of Hyperemesis include:

Initiate and monitor IV therapy
Administer drug and nutritional supplements
Monitor woman's response to interventions
Psychotherapy and stress reduction
Observe for signs of complications (metabolic acidosis, jaundice, and hemorrhage)
Monitor: assessment of nausea, retching without vomiting, and vomiting
Accurate measurement of I&O
oral hygiene
assist w positioning
quiet,restful environment free from odors


What is the tool that allows quantification of the presence and severity of nausea and vomiting and promotes accurate monitoring?

Pregnancy-Unique Quantification of Emesis/Nausea (PUQE) index.


How does the PUQE work?

total score is three replies to each of the three questions:
Nausea score: mild NVP less than six; moderate NVP 7-12; Severe NVP is greater than 13.


Interventions of Hyperemesis after woman starts responding to therapy:

limited amounts of fluids and bland foods
(Crackers, toast, or baked chicken)
diet is progressed slowly as tolerated.
promote adequate rest
coordinate treatment to allow for rest periods


What do I teach my patient about Hyperemesis?

eat small, frequent meals consisting of low fat, high protein foods
avoid greasy and highly seasoned foods
increase intake of potassium and magnesium
herbal teas may decrease nausea
take in fluids between meals rather than with meals helps to decrease nausea
have other family members cook if possible


Dietary instructions for hyperemesis:

eat dry bland foods
high protein
small frequent meals
cold food
snack before bedtime
drink tea or water with lemon
avoid high fat or spicy foods


What is Ectopic Pregnancy?

A pregnancy in which the fertilized ovum is implanted outside of the uterine cavity, mainly in the fallopian tubes, but can also occur in the ovaries, abdominal cavity, and cervix.


How is an Ectopic Pregnancy classified?

According to the site of implantation.
Ex: tubal, cervical, abdominal, or ovarian

**The uterus is the only organ capable of containing and sustaining a term pregnancy.


What does Ectopic Pregnancy look like?

missed menstrual period
adnexal fullness
tenderness that may suggest an unruptured tubal pregnancy
dark red/brown abnormal vaginal bleeding


If ectopic pregnancy ruptures....

pain increases.
May be generalized, unilateral, or acute deep lower quadrant pain caused by blood irritating the peritoneum
referred shoulder pain can occur from diaphragmatic irritation caused by blood in the peritoneal cavity.
signs of shock related to the amount of bleeding in the abdominal cavity and not necessarily vag. bleeding
Cullen sign: an ecchymotic blueness around the umbilicus


How is Ectopic Pregnancy diagnosed?

Serum progesterone, B-hCG, Transvaginal ultrasound,


How is Ectopic Pregnancy treated?

Quick treatment is the best treatment.

Recommended to remove the pregnancy by salpingostomy before rupture.
general preop and post op care
vital signs per protocol
blood type
rh factor


residual tissure is resolved with a dose of what?



What is Methotrexate?

antimetabolite and folic acid antagonist taht destroys rapidly dividing cells.
Single dose IM injection to treat unruptured pregnancies

**Look up in drug book.
** women recieving methotrexate should not take any analgesic stronger than acetaminophen-- may mask symptoms of tubal rupture.


What is a hydatidiform mole?

A gestational trophoblastic disease (GTD)


What are the two types of hydatidiform mole?



What causes hydatidiform mole?

unknown, but there may be an ovular defect or nutrition deficiency.
women in early teens or over age of 40 OR any woman who has undergone ovulation stimulation


Complete/classic hydatidiform mole:

results from fertilization of an egg, the nucleus of which has been lost or inactivated
The sperm duplicates itself because the ovum has no genetic material.
The mole resembles a bunch of white grapes.
The hydropic(fluid filled) vesicles grow rapidly, causing the uterus to be larger than expected for the duration of pregnancy.
usually contains no fetus, placenta, amniotic membranes, or fluid
maternal blood has no placenta to recieve it, leading to hemorrhage into the uterine cavity vaginal bleeding occurs
can cause choriocarcinoma.


Partial Hydatidiform mole:

chromosome studies often show a karyotype of 69, XXY; 69, XXX; 69, XYY
This occurs because two sperm fertilize an apparent normal ovum.
often have embryonic or fetal parts and an amniotic sac
congenital anomolies are usually present
potential for malignant transformation is less than 6%


What does Hydatidiform mole look like?

prune colored discharge
early stages of complete mole cannot be distinguished from normal pregnancy
vaginal bleeding occurs in 95%
dark brown vaginal discharge (scant or profuse)
significantly larger uterus than expected for pregnancy dates
anemia from blood loss
excessive n/v
abdominal cramps
any symptoms of gestational hypertension before 24 weeks is suggestive of mole
pulmonary embolization of trophoblastic elements
partial mole causes few symptoms and may be mistaken for a miscarriage**


How do you treat Hydatidiform mole?

Most pass spontaneously, but D&C offers safe and rapid evacuation of mole.
hysterectomy is possible
provide woman and fam about the disease
encourage to express feelings


What do I teach my patient about Hydatidiform Mole?

pregnancy should be avoided for one year to void confusing signs of choriocarinoma with pregnancy
any contraceptive is acceptable except intrauterine device.


Follow up of Hydatidform Mole:

close observation for one year
pelvic exams and measurement of B-hCG
rise tite and enlarging uterus are signs of choriocarcinoma.


What is a miscarriage?

Spontaneous abortion-- a pregancy that ends without medical or surgical method before 20 weeks gestation or 500 gram birth weight
*we use the term miscarriage because abortion to some patients seems harsh and insensitive.


What is early miscarriage?

Ends before 12 weeks


Possible causes of early miscarriage:

endocrine imbalance
immunological factors
systemic disorders
genetic factors


What is a late miscarriage?

occurs between 12-20 weeks
usually results from maternal causes*


Causes of late miscarriage:

advanced maternal age
chronic infections
premature dilation of the cervix
chronic debilitating diseases
inadequate nutrition
recreational drug use


What does a miscarriage look like?

Early in preg. --
uterine bleeding
uterine contractions
uterine paine


If miscarriage occurs before six weeks of pregnancy--

heavy menstrual flow


if occurs 6-12 weeks of pregnancy--

moderate discomfort and blood loss


If miscarriage occurs after 12 weeks--

severe pain, similar to labor because fetus must be expelled.


Types of spontaneous abortions:



Threatened S&S:

spotting of blood with a closed cervical os
mild uterine cramping


Inevitable S&S:

moderate to heavy amount of bleeding
open cervical os
tissue may be present with bleeding
mild to severe uterine pain and cramping
passage of products of conception
cervical dilation


incomplete S&S

moderate to heavy amount of bleeding
open cervical os
tissue may be present with bleeding
mild to severe uterine pain and cramping
expulsion of fetus
retention of placenta


Complete S&S

all fetal tissue passed
cervix closed
slight bleeding
mild uterine cramping


Missed miscarriage

Fetus has died but the products of conception are retained in utero for up to several weeks.

Diagnosed by ultra sound after fetus stops increasing or even decreases in size.
may be no bleeding or pain
cervical os closed
if the products remain in the uterus they may calcify (womb stone)


WHat do I teach my patient on miscarriage:

discharge home when vitals are stable
emphasize need for rest
teach normal findings: bleeding, cramping, resumption of sexual activity, family planning, follow up phone calls are important