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Flashcards in Chapter 25: Complications of Pregnancy Deck (75)
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what are the 3 most common causes of hemorrhage during the first half of pregnancy?

  • abortion
  • ectopic pregnancy
  • gestational trophoblastic dz



  • loss of pregnancy of less than 20 weeks or a fetus less than 500 g
  • can be spontaneous or induced


spontaneous abortion

  • termination of pregnancy w/o action taken by the woman or another person
  • incidence inc with paternal age and with inc maternal age
  • most occur during first 12 weeks of pregnancy
  • most common cause: severe congential abnormalities that are incompatible with life
    • also caused by syphilis, listeriosis, toxoplasmosis, brucellosis, rubela, intraabdominal infections
  • 6 types:
    • threatened 
    • inevitable
    • incomplete
    • complete
    • missed
    • recurrent


threatened abortion

  • first sign is vaginal bleeding
    • other S/S are uterine cramping, persistent backache, feelings of pelvic pressure
  • mgmt:
    • bleeding during 1st half of pregnancy is considered a threatened abortion
    • report bleeding and given detailed hx about bleeding and other symptoms
    • U/S exam is done and test hCG levels
    • should limit sexual activity until bleeding as ceased 
    • count perineal pads and note quantity/color


what problems may result from a pregnancy that does not end in spontaneous abortion after early bleeding?

  • prematurity
  • SGA infant
  • abnormal presentation
  • perinatal asphyxia


inevitable abortion

  • ROM and cervix dilates
    • incomplete evacuation-->infection/sepsis
  • mgmt:
    • natural expulsion is common 
      • vacuum curettage: removal of uterine contents with vacuum-->clear uterus if natural process is not effective
      • D&C: used if pregnancy is more advanced or bleeding is excessive
        • involves stretching the cervical os to scrape/suction uterus


incomplete abortion

  • some but not all of products of conception are expelled
    • S/S: active uterine bleeding, severe abdominal cramping, cervix opened
  • mgmt:
    • retained tissue prevents uterus from contracting firly, so profuse bleeding occurs
      • MUST first stabilize CV state
    • draw blood specimen for type and cross
    • insert IV for fluid replacement and drug administration
    • D&C done to remove tissue
      • D&E done if the pregnancy is more advanced w/ a larger amount of tissue
      • may need to administer oxytocin or methylergonovine to help stop bleeding
      • D&C cannot be done after 14 wks gestation b/c of danger of excessive bleeding


complete abortion

  • occurs when all products of conception are passed from uterus
    • after passage, uterine contractions and bleeding subsides and cervical os closes
    • uterus feels small
    • negative pregnancy test
  • only have to intervene if excessive bleeding or infection occur
  • woman should rest and watch for bleeding, pain, fever
    • do not have sex until follow up with HCP


missed abortion

  • occurs when fetus dies during first half of pregnancy but is retained in the uterus
    • when fetus dies, early signs of pregnancy disappear (nausea, breast tenderness, urinary frequency)
    • uterus stops growing and dec in size which reflects absorption of amniotic fluid and maceration of fetus (discoloration, softening, and tissue degeneration)
  • mgmt:
    • U/S confirms fetal death 
      • no fetal heart activity can be found
      • hCG will be decreasing
    • D&C or D&E are done
      • PGs or misoprostol may be needed to induce contractions to expel the fetus
    • 2 complications:
      • infection
      • DIC


recurrent spontaneous abortion

  • 3 or more spontaneous abortions
  • primary causes: genetic or chromosomal abnormalities and anomalies of the reproductive tract (such as bicornuate uterus) or incompetent cervix
  • mgmt:
    • examine woman's body for anomalies
    • genetic screening for woman and partner
    • cerclage: procedure to prevent early dilation of cervix may be done if abortions caused by cervical incompetence
    • RhoGAM can be given to woman with Rh negative blood


nursing considerations for abortion

  • psychological care: help them to grieve, answer questions
  • listen to the woman and observe how she behaves
  • convey acceptance of the feelings expressed
  • teach that grief may last from 6 mos to one year



  • occurs when anticoagulation is occurring, inappropriate coagulation also is occurring in the microcirculation
    • tiny clots form in tiny blood vessels-->block blood flow to organs-->ischemia
  • clotting mechanisms activated inappropriately
    • consumption of platelets, fibrinogen, prothrombin, factor V and VIII occur and then they are consumed, the blood becomes deficient in clotting factors and can't clot
  • labs results establish dx: fibrinogen and platelets dec, PT and PTT may be prolonged
  • tx: correct the cause
    • blood replacement


dz that cause DIC fall into 3 major groups:

  • infusion of tissue thromboplastic into the circulatino, which consumes other clotting factors
    • ie placetal abruption, prolonged retention of a dead fetus
  • conductions characterized by endothelial damage:
    • ie severe preeclampsia
    • ie HELLP: hemolysis, elevated levels of liver enzymes, and low platelet levels)
  • nonspecific effects of some dz:
    • ie maternal sepsis, amniotic fluid embolism


nursing considerations of DIC

  • if have a dz that inc risk of DIC, nurse should observe for bleeding from unexpected sites
    • sites for IV insertion or lab work, nosebleeds, or spontaneous bruising
  • if coagulation studies are abnormal, an epidural block may be contraindicated


ectopic pregnancy

  • implantation of fertilized ovum in an area outside the uterine cavity
  • can lead to maternal death from hemorrhage
  • leads to scarring of fallopian tubes
  • pelvic infection (chlamydia and gonorrhea), failed tubal ligation, and hx of ectopic pregnancy in risk
    • also inc risk: IUDs, low dose progesterone contraceptives, assistive reproductive technology


manifestations of ectopic pregnancy

  • missed menstrual period
  • positive pregnancy test
  • abdominal pain
  • vaginal spotting
  • signs can depend on exactly where the implantation takes place
    • if in distal fallopian tube, can support embryo longer, so may experience normal early signs of pregnancy
    • if in proximal fallopian tube, can rupture tube in 2-3 weeks and cause sudden, severe pain in lower quadrants and abdominal hemorrhage which causes radiating pain under the scapula
      • hypovolemic shock is a concern


mgmt and nursing considerations for ectopic pregnancy

  • mgmt depends on if tube is intact or ruptured
    • goal is to preserve tube and improve chance of future fertility
    • methotrexate can be used to inhibit cell division of developing embryo
    • surgical mgmt if unruptured-->linear salpingostomy to salvage the tube
    • surgical mgmt if ruptured-->control bleeding and prevent hypovolemic shock
      • when CV is stable, salpingectomy (removal of tube) w/ ligation of bleeding vessels may be required
  • nurses should focus on early identification of hypovolemic shock, pain control, and psych support
    • administer analgesics
    • teach about SEs of methotrexate: n/v
    • edu about refraining from drinking alcohol, taking vits with folic acid, and having sexual intercourse


what are the 2 main causes of hemorrhage after 20 weeks of gestation?

  • placenta previa
  • placental abruption


placenta previa

  • implantation of uterus in the lower uterus-->placenta closer to the internal cervical os 
  • 3 types depending on how much the internal cervical os is covered by the placenta: total, partial, marginal
    • marginal: placenta implanted more than 3 cm from internal cervical os
    • partial: lower border of placenta w/in 3 cm of internal cervical os but does not completely cover os
    • totaL: completely covered os
  • more common in: older women, multiparas, women who have had C?S, and women who have had suction currettage
  • inc risk if: African/Asian ethnicity, cigarette smoking and cocaine use, and male fetus


clinical manifestations of placenta previa

  • classic sign is sudden onset of painless uterine bleeding in second half of pregnancy
    • results from tearing of placental villi from uterine wall
  • dx by U/S
    • do not manually exam vagina until location and position of placenta verified


mgmt and nursing considerations of placenta previa

  • mgmt: evaluate women to determine amount of hemorrhage and monitor the fetus
    • also must consider gestational age
    • maintain stable CV status for mother
    • try to delay birth to inc birth weight and also administer corticosteroids to mother to speed maturation of fetal lungs
    • home care criteria:
      • no evidence of active bleeding, bed rest, short distance from hospital, can verbalize risks
    • no intercourse to prevent disruption of fetus


placental abruption

  • separation of normally implanted placenta before the fetus is born
  • occurs in cases of bleeding and formation of a hematoma on maternal side of the placenta
    • as the clot expands, further separation occurs
  • dangers for woman: hemorrhage, hypovolemic shock, clotting abnormalities (DIC)
  • dangers for fetus: asphyxia, excessive blood loss, prematurity


etiology of placental abruption

  • inc risk: cocaine use (due to vasoconstriction-->abruption), maternal HTN, cigarette smoking, multigravida status, short umbilical cord, abdominal trauma, premature ROM, hx of previous premature separation, maternal age


manifestations of placental abruption

  • bleeding: may be evident vaginally or concealed behind placenta
  • uterine tenderness localized at site of abruption
  • uterine irritability w/ frequent low intensity contractions and poor relaxation b/w contractions
  • abdominal or low back pain that is described as dull/aching
    • may be suffen and severe or intermittent and difficult to distinguish from labor contractions
  • high uterine resting tone identified with intrauterine pressure catheter
    • uterus becomes boardlike and tender
  • also may show: nonreassuring FHR, back pain, signs of hypovolemic shick
  • amniotic fluid may be a port wine color


nursing considerations and mgmt of placental abruption

  • mgmt: 
    • if mild and under 34 weeks, bed rest, tocolytic use, administration of corticosteroids
    • if fetal compromise of excessive bleeding: immediate delivery
      • blood products for replacement and 2 large bore IV placed for fluid replacement
  • may be very frightening b/c of pain and apprent danger
    • if C/S is necessary, woman may feel pwerless and nurse should help explain what is going on
    • excessive bleeding and fetal hypoxia are major concerns and nurse should monitor for these


hyperemesis gravidarum (HEG)

  • most n/v in pregnancy should end by 13-14 weeks
  • HEG is persistent, uncontrollable vomiting that begins in first weeks of pregnancy and may continue throughout pregnancy
    • can have serious consequences (morning sickness is self limiting and has no seirous complications):
      • loss of 5% or more of pre-pregnancy weight, dehydration, acidosis from starvation, elevated levels of blood and urine ketones, alkalosis from loss of HCl in gastric fluids, and hypokalemia
      • short term hepatic dysfunction w/ elevated liver enzymes
      • deficiency of vit K-->coagulation disorders
      • deficiency of thiamine-->encephalopathy


etiology of HEG

  • cause is not known, but more common among unmarried white women, during first pregnancies, and in multifetal pregnancies
  • possible causes include allergy to fetal proteins, elevation of pregnancy hormones, maternal thyroid dysfunction, h. pylori


clinical manifestations of HEG

  • persistent n/v
  • weight loss
  • thirst
  • oliguria
  • dry mucous membranes/skin
  • poor skin turgor
  • constipation
  • lethargy
  • inc urine specific gravity (>1.025)
  • hypovolemia: hypoTN and tachycardia
  • labs: inc BUN and hct, dec Na/K/Cl


therapeutic mgmt of HEG

  • should first exclude other causes of persistent n/v
  • lab studies include H&H which may be elevated b/c of dehydration
    • electrolytes: dec Na, K, and Cl
    • elevated Cr
  • tx: 
    • correct dehydration: IV fluids may be necessary
    • antiemetics: ondansetron, promethazine, H2 receptor antagonistis, PPIs, metoclopramide
    • improve nutrition:
      • vitamin B6 (pyridoxine)
      • diet


nursing considerations for HEG

  • monitor V/S and monitor I&Os
  • daily weights
  • monitor U/S for growth
  • monitor urine for ketones which can indicate fat stores being broken down to meet energy needs
  • monitor for signs of dehydration: dec fluid intake, dec urine output, inc urine SG, dry mucous membranes/skin, skin turgor
  • monitor labs: BMP, H&H
  • to reduce n/v:
    • small portions of food
    • do not eat foods with strong odors
    • carbs are more easily digested
    • take soups and liquids b/w meals 
    • sit up after meals
  • maintain nutrition and fluid balance
    • eat every 2-3 hours
    • salt the food to replace chloride lost in HCl thru vomit
    • consume K and Mg rich foods
    • IV fluids and TPN if needed
  • social support:
    • allow verbalization of impact 
    • explore reluctance to accept pregnancy
    • recognize lack of support available