GESTATIONALTROPHOBLASTIC DISEASE (HYDATIDIFORM MOLE)

 A spectrum of diseases resulting from abnormal proliferation of the placenta - hydatidiform moles,
gestational trophoblastic neoplasia, choriocarcinoma (rapidly metastasizing malignancy)

 1 in every 1,500 pregnancies.

 OCCUR
 Women who have a low-protein intake ------------ Women older than 35 years of age
 Women of Asian heritage --------- Blood group A women who marry blood group O men

 Two types of molar growth

 Complete mole - all trophoblastic villi swell and become cystic. -- dies, 1 to 2 mm size
- 46XX or 46 XY
 Partial mole - some of the villi form normally ---- swollen and misshapen. – grow, 9 w
- 69XX or 69XY ----- lead to choriocarcinoma.

 hCG - produced by the trophoblast cells that are overgrowing

 Symptoms of gestational hypertension - Increased blood pressure, edema, / proteinuria

Therapeutic Management

 Suction curettage - to evacuate the abnormal trophoblast cells.

 Baseline pelvic examination and a serum test ------- / Contraceptive such as oral estrogen/progesterone

Risk Factors

1. Found more commonly in Southeast Asia and the Far East.

2. A molar pregnancy creates a 20 to 40 times higher risk of having it again.
3. Increased incidence with advanced maternal age.

Diagnostics

 Ultrasonography reveals no fetal skeleton. ------ / Elevated HCG level. (human chorionic gonadotropin)

Clinical Manifestations

1. Exaggerated symptoms of pregnancy: uterus too enlarged for pregnancy, excessive nausea and
vomiting, early symptoms of PIH. (pregnancy induced hypertension)
2. Discharge of brownish-red fluid (like prune juice) from vagina around the twelfth week; fluid may
contain vesicles.
3. Anemia caused by loss of blood. --------------------- 4. Absence of fetal heart sounds.

Complications

 Infection -------------- DIC -------------------- Possible choriocarcinoma

 Trophoblastic embolization occurring after evacuation of molar pregnancy

Treatment SURGICAL: D&C to empty uterus MEDICAL: follow up supervision for 1 year

1. Weekly serum HCG level until it is negative; then every other week for 3 to 4 months; then monthly
for a year, pelvic exams may be required every 2 weeks during the early period after the D&C.
2. Rising titers of HCG indicate disease: choriocarcinoma.
3. Pregnancy should be avoided for at least 1 year.
4. Oral contraceptive use to prevent pregnancy is controversial, because it may delay the fall in the HCG
level.
PREMATURE CERVICAL DILATATION (CERVICAL INSUFFICIENCY)

 Incompetent cervix

 Refers to a cervix that dilates prematurely and therefore cannot retain a fetus until term.
Occurs in about 1% of women characterized by a painless dilation and occurs at about 20th
week of pregnancy.

 First symptom - a pink-stained vaginal discharge or increased pelvic pressure

 Cervical cerclage - can be performed to prevent loss of child in a second pregnancy.

 Healthy (weeks 12 to 14)

 McDonald or a Shirodkar procedure - purse-string sutures are placed in the cervix by the
vaginal route under regional anesthesia.

 McDonald procedure - nylon sutures are placed horizontally and vertically across the cervix
and pulled tight to reduce the cervical canal to a few millimeters in diameter.

 Shirodkar technique - sterile tape is threaded in a pursestring manner under the

submucous layer of the cervix and sutured in place to achieve a closed cervix.

 Trendelenburg position – bed rest

 Weeks 37 to 38 of pregnancy - sutures are removed

Etiology

 Increased maternal age.

 History of traumatic birth.
 Repeated dilatation and curettage.
 Client's mother treated with diethylstilbestrol (DES) when pregnant with the client.
 Congenitally short cervix.
 Uterine anomalies
 Unknown etiology

Pathophysiology

 Connective tissue structure of the cervix is not strong enough to maintain closur of the cervical
os during pregnancy.

Clinical Manifestations

 Appreciable cervical dilation with prolapse of the membranes through the cervix without
contraction.

Nursing Management

 Provide client and family teaching.

 Maintain an environment to preserve the integrity of the pregnancy.
 Prepare for the birth if membranes are ruptured.
 Address emotional and psychosocial needs.
ANTEPARTUM COMPLICATIONS
 This may occur at any time during pregnancy and can result from pre-existing maternal
medical problems or from the pregnancy itself.

Significant complications of pregnancy includes:

 Spontaneous abortion ---------------- / Gestational trophoblastic disease (hydatidiform mole)

 Ectopic pregnancy -----------------/ Incompetent cervix --------------- / Hyperemesis gravidarum
 Anemia ---------------------- / Placenta previa -----------------------/ Abruptio placenta
 Preeclampsia and eclampsia ----------------------- / Gestational diabetes
 Hemolytic disease of the fetus and newborn ------------------- / Infections

Maternal conditions that significantly affect the fetus or the progress of pregnancy:

 Diabetes Mellitus ------------------ / Cardiac disease --------------------------/ Hypertensive disease

 Hematologic disorders ----------------- / Infections ---------------- / Sexually transmitted diseases
 Smoking ---------------------- / Substance abuse

Cardinal signs and symptoms

 Dizziness --------------- / Nausea and vomiting ----------------- / Headache

 Fatigue --------------------- / Abdominal pain and cramping
 Uterine labor contractions before the estimated date of delivery

Physical Examination

 Measure weight for excessive loss and gain ------------- / Measure for increased blood pressure
 Measure for rapid pulse ------------------- / Measure for increased temperature.
 Assess for vaginal bleeding --------- / Inspect for premature rupture of the membranes (PROM)
 Assess the skin for rash, pale, dry kin, or edema
 Inspect the oral cavity for overall dental health and signs of poor nutrition
 Palpate the uterus to determine whether it is abnormally soft or hard and whether it is
abnormally soft or smaller than expected for gestational age.
 Palpate the cervix to detect preterm cervical dilation.
 Auscultate the fetal heart rate (FHR) to detect abnormally fast or slow rates

Laboratory studies and diagnostic tests

 Complete blood count (CBC) ------------------ / Pregnancy test --------------------- / Ultrasound

 Serum alpha-fetoprotein measurement ------------ / Blood glucose and glycosylated hemoglobin
 Indirect cooms test -----------/ Amniocentesis ----------- / Serologic tests --------- / Cultures

Nursing Management

 Ensure that appropriate physical needs are addressed and monitor for additional
complications. ----------------------- / Address emotional ad psychosocial needs.
 Provide client and family teaching ------------------ / Promote compliance
SPONTANEOUS ABORTION

 The expulsion of the fetus and other products of conception from the uterus before the fetus
are capable of living outside of the uterus.

 Abortion - any interruption of a pregnancy before a fetus is viable

 Viable fetus - 20 to 24 weeks of gestation or weighs at least 500 g.

 Miscarriage or premature or immature birth ---------- 15% to 30%

 Early miscarriage - before week 16 --------- late miscarriage - between weeks 16 and 20

 Weeks 6 and 12 - lead to the most severe, even life-threatening bleeding.

 Abnormal fetal development - frequent cause of first trimester due to teratogenic factor or
to a chromosomal aberration.

 Implantation abnormalities (another cause) – zygotes, never implant securely because of

inadequate endometrial formation

 Corpus luteum (cause) - fails to produce enough progesterone to maintain the decidua
basalis. --- Progesterone therapy

 Assessment - almost always vaginal spotting

4 Tyoes of Spontaneous Abortion

1. Threatened Abortion - is characterized by cramping and vaginal bleeding in early pregnancy

with no cervical dilation. It may subside or an incomplete abortion may follow.

- Symptoms - vaginal bleeding, initially only scant and usually bright red.
- Intervention - strenuous activity for 24 to 48 hours
- Complete bed – not necessary, appear to stop the vaginal bleeding but only because
blood pools vaginally.

2. Imminent or Inevitable Abortion - is characterized by bleeding, cramping, and cervical

dilation. Termination cannot be prevented.

- Dilatation and Curettage (D&C) or a Dilation and Evacuation (D&E)

3. Complete abortion - is characterized by complete expulsion of all products of conception.

- Products of conception (fetus, membranes, and placenta)

4. Incomplete abortion -is characterized by expulsion of only part of the products of

conception. Bleeding occurs with cervical dilation.

- Part of the conceptus (usually the fetus) is expelled, but the membranes or placenta are
retained in the uterus. -------- hemorrhage and infection

5. Missed abortion - is characterized by early fetal intrauterine death without expulsion of the
products of conception. The cervix is closed, and the client may report dark brown vaginal
discharge. Pregnancy test findings are negative. ---------- misleading
 - Also known as early pregnancy failure ------- fetus dies in utero but is not expelled.
- discovered at a prenatal examination when the fundal height is measured and no
increase in size
- labor - can be induced by a prostaglandin suppository or misoprostol (Cytotec)
- Oxytocin stimulation or administration of mifepristone techniques - used for elective
termination of pregnancy, which cause contractions and birth.
- Disseminated Intravascular Coagulation (DIC) - a coagulation defect, may
develop if the nonviable (and possibly toxic) fetus remains too long in utero.

Recurrent Pregnancy Loss (1%)

 Habitual aborters - women who had three spontaneous miscarriages that occurred at the
same gestational age.
 Possible causes include
- Defective spermatozoa or ova
- Endocrine factors such as lowered levels of protein-bound iodine (PBI), butanol
extractable iodine (BEI), and globulin-bound iodine (GBI); poor thyroid function; or a
luteal phase defect
- Deviations of the uterus, such as septate or bicornuate uterus
- Resistance to uterine artery blood flow --------------- Chorioamnionitis or uterine infection
- Autoimmune disorders such as those involving lupus anticoagulant and antiphospholipid
antibodies

Complications of Miscarriage (after)

1. Hemorrhage
 Disseminated Intravascular Coagulation (DIC) - major hemorrhage
 Excessive vaginal bleeding - position a woman flat and massage the uterine fundus
to try to aid contraction.
 Pneumatic antishock garments – apply to help maintain blood pressure

2. Infection
 Often a reason for excessive blood loss.
 Danger signs
- Fever higher than 100.4°F (38.0°C)
- Abdominal pain or tenderness ------------- Foul-smelling vaginal discharge.
 Escherichia coli - organisms responsible for infection - spread from the rectum
forward into the vagina --------- group A streptococcus
 Tampons - stasis of any body fluid increases the risk of infection

Septic Abortion

 an abortion complicated by infection

Isoimmunization
  The production of antibodies against Rh-positive blood.

Etiology

 may result from unidentified natural causes or from fetal, placental, or maternal factors

Fetal factors

 Defective embryonic development

 Faulty ovum implantation
 Rejection of the ovum by the endometrium
 Chromosomal abnormalities

Placental factors

 Premature separation of the normally implanted placenta

 Abnormal placental implantation
 Abnormal placental function

Maternal factors

 Infection
 Severe malnutrition
 Reproductive system abnormalities
 Endocrine problems
 Trauma
 Drug ingestion

Clinical Manifestations

 Vaginal bleeding in the first 20 weeks of pregnancy

 Complaints of cramping in the lower abdomen
 Fever, malaise, or other symptoms of infection

Diagnostic Procedure

 Serum beta hCG levels are quantitatively low

 Ultrasound reveals the absence of a viable fetus

Nursing management

 Provide appropriate management and prevent complications

 Provide client and family teaching
 Address emotional and psychosocial needs
ECTOPIC PREGNANCY
 Any pregnancy that develops outside the uterus. 99% of ectopic pregnancies are tubal (fallopian
tube); they are more common on the right side. Approximately one of every 300 pregnancies is
ectopic.

 80% - ampullar portion ------------ 12% - isthmus ---------- 8% - interstitial or fimbrial

 Sites of ectopic pregnancy - Fallopian tube, cervix, ovary and intestine

 2% of pregnancies are ectopic – 2nd cause of bleeding early in pregnancy

 Increasing

- Pelvic inflammatory disease (chronic salpingitis) – lead to tubal scarring

- in vitro fertilization (because of tubal scarring) ------------- women who smoke

 Webbing (fibrous bands) – a congenital anomalies that block a fallopian tube may also occur in both
tubes.

 MRI - Magnetic resonance imaging

 Ampullar area (the distal third) – happen to be the highest incidence of tubal pregnancies

 Cullen sign - bluish-tinged hue ---- ambilicus – before seeking help

 Sonogram – advantage, the tube is left intact, with no surgical scarring that could cause a second
ectopic implantation.

 Laparoscopy - therapy for ruptured ectopic pregnancy --- ligate the bleeding vessels and to remove
or repair the damaged fallopian tube.

Risk Factors

 Any condition that causes scarring or obstruction of the fallopian tubes (PID, gonorrheal infections,
postabortion salpingitis)

Diagnostics

1. Ultrasonography

2. Culdocentesis: assesses intraperitoneal bleeding by needle puncture of the cul-de-sac of Douglas.

3. Laparoscope: an instrument that provides visualization of the pelvic organs via a small external
incision on the abdomen; if affected tube is found, a laparotomy can be performed for treatment.

Clinical Manifestations

1. If tube is unruptured, slow, chronic bleeding usually occurs, and the abdomen gradually becomes rigid
and very tender.

2. If a tube ruptures, sudden excruciating pain is felt in the lower abdomen, usually over the mass;
referred shoulder pain is possible as the abdomen fills with blood; vaginal bleeding and shock may also
occur.

Treatment

 SURGICAL: Laparoscopy, Laparotomy,salpingectomy

 MEDICAL: Methotrexate
HYPEREMESIS GRAVIDARUM

 A severe and excessive nausea and vomiting during pregnancy which leads to electrolyte,
metabolic and nutritional imbalances in the absence of other medical problems.

Causative factors

 High levels of hCG in early pregnancy

 Metabolic or nutritional deficiencies
 More common in unmarried white women and first pregnancies
 Ambivalence toward the pregnancy or family-related stress
 Thyroid dysfunction

Clinical Manifestations

 Unremitting nausea and vomiting

 Vomitus initially containing undigested food, bile, and mucus; later containing blood and
material that resembles coffee grounds
 Weight loss
 Pale, dry skin
 Rapid pulse
 Fetid, fruity breath odor from acidosis
 Central nervous system affects such as confusion, delirium, headache and lethargy, stupor or
coma.

Nursing Management

1. Promote resolution of the complications.

 Make sure that the client is NPO until cessation of vomiting.

 Administer intravenous fluids as prescribed.
 Measure and record fluid intake and output
 Encourage small frequent meals and snacks once vomiting has subsided,
 Antiemetics as prescribed.

2. Address emotional and psychosocial needs

 Maintain a nonjudgmental atmosphere in which the client express concerns and resolve
some of their fears.
Anemia

 True anemia - Hemoglobin value of less than 11mg/dL or hematocrit value less than 33% during the
second and third trimesters. ------------ 13.5 – average

 Mild anemia (hemoglobin value of 11 mg/dL) poses no threat but is an indication of a less than optimal
nutritional state.

 Iron deficiency anemia is the most common anemia of pregnancy. 15 % to 25 %

 Iron - made available to the body by absorption from the duodenum into the bloodstream after it has
been ingested.

 Women should take iron supplements with orange juice or a vitamin C supplement

 If iron-deficiency anemia is severe and a woman has difficulty with oral iron therapy, intravenous iron
can be prescribed.

 Folic Acid–Deficiency Anemia (another)

- B vitamins, necessary for the normal formation of red blood cells in the woman as well as being
associated with preventing neural tube and abdominal wall defects in the fetus.
- This occurs most often in multiple pregnancies because of the increased fetal demand

 Megaloblastic anemia - enlarged red blood cells – the anemia that develops

 SICKLE-CELL ANEMIA (another)

- A recessively inherited hemolytic anemia caused by an abnormal amino acid in the beta chain of
hemoglobin.

- hemoglobin level of 6 to 8 mg/100 ml.

- amino acid to amino acid valine ----------- RESULT: sickling hemoglobin (HbS)
- amino acid to amino acid lysine ----------- RESULT: nonsickling hemoglobin (HbC)
- Heterozygous - has only one gene in which the abnormal substitution has occurred
- Women should not take a routine iron supplement as sickled cells cannot incorporate iron
- Pica - the craving and eating of substances such as ice or starch

Type of anemia

1. Microcytic - small red blood cell ------ 2. Hypochromic - less hemoglobin than the average red cell

Causes:

 Nutritional deficiency ----------- / Acute and chronic blood loss --------------/ Hemolysis

Clinical Manifestations

 brittle fingernails cheilosis ------------------ / smooth, red, shiny tongue

 Women with sickle cell anemia experience painful crisis episodes

Nursing Management

 Provide client and family teaching (Iron supplements and dietary sources of iron as indicated)
 Prepare for blood-typing and crossmatching, and for dministering packed RBCs during labor if the client
has severe anemia. ------------- / Provide support and management for clients with hemoglobinopathies.
Placenta Previa

 The placenta implants in the lower uterine segment, near the cervical os. The most common cause of
painless bleeding in the 3rd trimester of pregnancy. Incidence is 5 per 1000 pregnancies.

 This is often detected during pregnancy through a routine sonogram done to date the pregnancy.
 Degrees of placenta previa – in percentages - 100%, 75%, 30%, and so forth.

 The bleeding is like that of ectopic pregnancy, creates an emergency situation as the open vessels of
the uterine decidua (maternal blood) place the mother at risk for hemorrhage.

 cup is 240 ml ---------- tablespoon is 15 ml)

 Subtraction is a good method to determine vaginal blood loss.

 Apt or Kleihauer– Betke test (test strip procedures) - can be used to detect whether the blood is
of fetal or maternal origin.

 Vaginal birth - always safest for an infant. Essential, therefore, to determine the placenta’s location
as accurately as possible in the hope that its position will make vaginal birth feasible.

 Previa - under 30% by abdominal or intravaginal ultrasound, it may be possible for the fetus to be
born past it.

 Cesarean birth - safest birth method, If over 30%, and the fetus is mature

 Betamethasone - a steroid that hastens fetal lung maturity ------- if less than 34 weeks

 Any woman who has had a placenta previa is more prone than normal to postpartum hemorrhage
because the placental site is in the lower uterine segment, which does not contract as efficiently as the
upper segment.

3 different classifications

1. Total placenta previa - Occurs when the placenta completely covers the internal os.

2. Partial placenta previa - occurs when the placenta partially covers the internal os.

3. Low-lying or low-implantation placenta previa - occurs when the placental border reaches the
border of the internal os.

Marginal implantation - the placenta edge approaches that of the cervical os

Predisposing factors:

 Multiparity  Multiple gestation  Uterine incisions

 Advanced maternal age  Previous cesarean birth  Previous placenta previa

Clinical Manifestations

 Bright red, painless vaginal bleeding ------------- / FHR stable and within normal limits.
 Soft, nontender abdomen; relaxes between contractions, if present.

Diagnostic Procedure ------------- Transabdominal ultrasonography

Nursing Management

 Ensure the physiologic well-being of the client and fetus.

 Provide client and family teaching. -------------- / Address emotional and psychosocial needs.
Abruptio Placenta (PREMATURE SEPARATION OF THE PLACENTA)

 Is a premature separation of normally implanted placenta after the 20th week of pregnancy,
typically with severe hemorrhage. Occurs in 10 out of 1,000 pregnancies because it can lead
to extensive bleeding, is the most frequent cause of perinatal death.

 The primary cause of premature separation is unknown, but certain predisposing factors are
high parity, advanced maternal age, a short umbilical cord, chronic hypertensive disease,
hypertension of pregnancy, direct trauma , vasoconstriction from cocaine or cigarette use, and
thrombophilic conditions that lead to thrombosis formation.

 It also may be caused by chorioamnionitis or infection of the fetal membranes and fluid

 Another possible cause is a rapid decrease in uterine volume, such as occurs with sudden
release of amniotic fluid as can happen with polyhydramnios.

 Couvelaire uterus or uteroplacental apoplexy - forming a hard, boardlike uterus

 A woman needs a large-gauge intravenous catheter inserted for fluid replacement and oxygen
by mask to limit fetal anoxia.

 Monitor fetal heart sounds ---------------- record maternal vital signs every 5 to 15 minutes

 Keep woman in a lateral position to prevent pressure on the vena cava.

Risk factors:

 Uterine anomalies ----------------- / Multiparity ----------------- / Preeclampsia

 Previous cesarean delivery --------------- / Renal or vascular disease
 Trauma to the abdomen ------------------ / Previous third trimester bleeding
 Abnormally large placenta ------------------ / Short umbilical cord
 Cocaine or cigarette use ----------------- / Thrombophilic conditions
 Chorioamnionitis ---------------------- / Rapid decrease in uterine volume

Clinical Manifestations

 Intense, localized uterine pain, with or without vaginal bleeding

 Concealed or external dark red bleeding.
 Uterus firm to boardlike, with severe continuous pain.
 Uterine contractions. Uterine outline possibly enlarged or changing shape.
 FHR present or absent. Fetal presenting part may be engaged.

Nursing management

 Continuously evaluate maternal and fetal physiologic status.

 Assess the need for immediate delivery.
 Provide appropriate management.
 Provide client and family teaching.
 Address emotional and psychosocial needs.