CARE OF MOTHER AND CHILD SEM 02 | 01

LECTURE / AT RISK OR WITH ACUTE/CHRONIC PROBLEMS AUF-CON

MODULE 03 – SECOND TRIMESTER CONDITIONS [HYPEREMESIS GRAVIDARUM,

NCM 0109
HYDATIDIFORM MOLE, AND CERVICAL INSUFFICIENCY]

OUTLINE
I Second Trimester Conditions
A Gestational Trophoblastic Disease (H-Mole)
B Hyperemesis Gravidarum
C Premature Cervical Dilatation (Incompetent Cervix)

INTRODUCTION

PRETEST (True or False)

1. Hyperemesis Gravidarum is nausea and vomiting

TWO TYPES OF MOLAR GROWTH
of pregnancy that is prolonged past week 12 of
pregnancy.
● Identified through chromosomal analysis
2. One of the manifestations of hyperemesis
gravidarum is hypokalemic acidosis. CHARAC-
COMPLETE PARTIAL
TERISTIC
3. In complete H-mole, a macerated embryo may be May grow up to 9
present and fetal blood may be present in the villi. Dies early at 1–2 weeks but
EMBRYO
mm size becomes
4. After the diagnosis of H-mole, pregnancy should be macerated
prevented for 12 months. Some form
All swell and normally while
5. Premature cervical dilatation refers to a cervix that become cystic, some appear
TROPHOBLAS
dilates prematurely and cannot hold the fetus until no viable and swollen and
-TIC VILLI
term. This commonly occurs at approximately 38 functional = no misshapen, some
weeks of pregnancy. baby are viable and
functional
6. After cervical cerclage, the woman remains on bed
FETAL BLOOD (-) on villi (+) on villi
rest.
69 XX/XY
MODULE PROPER KARYOTYPE 46 XX/XY (triploid
formation)
A. GESTATIONAL TROPHOBLASTIC DISEASE CHORIOCAR
More likely Rare
(Hydatidiform Mole/H-Mole) CINOMA
Lower than
● Abnormal proliferation and degeneration of the complete but still
HCG TITER Elevated
trophoblastic villi above
average/normal
○ Must be identified because of its association
with gestational trophoblastic neoplasia KARYOTYPES IN H-MOLE
○ Proliferation: rapidly multiplying or growing
structure ● COMPLETE MOLE
● There is still a union of the egg and sperm cell, ○ Diploid formation: 46XX or 46XY
however, as cells degenerate, they become filled ○ Chromosome component is either contributed
with fluid and appear as clear fluid-filled only by the sperm (dinu-duplicate since 23
(hydropic), grape-sized vesicles = embryo fails to lang originally ‘yung chromosomes sa sex
develop beyond a primitive start cells)
● Occurs in 1/1,500 pregnancies ● Fertilization of the sperm by an empty ovum
● All components are of paternal origin

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 MODULE 03 — HYPEREMESIS GRAVIDARUM, HYDATIDIFORM MOLE, AND CERVICAL INSUFFICIENCY
● PARTIAL MOLE
○ Triploid formation: has 69XX or 69XY
● Three chromosomes instead of two for
every pair
○ Takes place because of:
● Fertilization of an ovum by two sperm
● Fertilization by a sperm/egg that did not
undergo meiosis or reduction division
I. ASSESSMENT
BASELINE DATA AND HEALTH HISTORY
● CONFIRMATION OF PREGNANCY
○ (+) serum pregnancy test
○ Length of gestation as initial data
● PHYSICAL ASSESSMENT
○ Bleeding: assess amount, length of episode, if
accompanied by pain, and management
● Examine linens and pads (gaano katagal
bago mapuno? Every kailan
nagpapalit?)
● Weigh linens and pads and estimate blood
loss through cups and tablespoons
○ One saturated pad in an hour means
excessive bleeding
● What was done to control the bleeding?
○ Pain: assess description, location, and severity
● Uterine cramping (spontaneous abortion)
● Deep severe pelvic pain (ruptured ectopic
pregnancy)
● Concealed bleeding and pain only
symptom (unruptured ectopic pregnancy)
○ Vital Signs: ↑ PR, RR, and temperature (38℃)
and ↓ UO
○ Laboratory Values: assess Hg and Hct levels
(especially if decreasing as it might indicate
excessive vaginal bleeding), and coagulation
factors; determine blood type and Rh factor
○ Signs of Infection: Fever, elevated PR, malaise,
prolonged malodorous vaginal discharge
RISK FACTORS
● Low protein and animal fat intake
● Women older than 35 years old and younger than
15 years
● Women of Asian heritage
● Blood group A women who marry blood group O
men (no studies are established; based on
profiling)
● Previous molar pregnancy (can be tagged as
habitual aborters unless full diagnosed = because it
will repeat)
○ For women who have bleeding with fragments
= must be sent to health facility for further
analysis
SIGNS AND SYMPTOMS
● Uterus tends to expand faster than normal
○ Needs further assessment as this may also be
indicative of multiple pregnancy and
miscalculated due date
○ Caused by rapid proliferation of abnormal
trophoblast cells
● Uterus reaches its landmarks before the
usual time
● E.g. at 12th week, fundus could be palpated
at the symphysis pubis, but with H-mole, it
would reach the umbilicus already
○ Assess if it is really related to the H-mole
condition
● Increased hCG levels
○ Overgrowing trophoblast cells produce this
ka
hormone
○ Since the cells are abnormally-growing, the
hCG increases to 1–2 million IU (vs 400,000 IU in
normal pregnancy)
○ Associated with strongly-positive serum
pregnancy tests
● (+) after 100 days, which will then decline
afterwards
● Marked nausea and vomiting d/t high levels of
hCG (not the same with the usual pregnancy)
● Symptoms of pregnancy induced hypertension
○ Normally not present before 20 weeks AOG, but
symptoms can be seen before 20 weeks in
H-mole
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○ Increased BP, edema, and proteinuria
● No viable fetus/fetal
growth
○ Ultrasound shows
dense growth with
snowflake pattern
○ Since there is no fetal
growth, no FHT will be
heard
● Vaginal bleeding
○ Profuse fresh flow occurs at around week 16 if
molar growth is not identified through
ultrasound
○ Characterized by:
● Dark brown blood spotting, resembling
prune juice
● Profuse fresh flow
● May be accompanied by discharge of
fluid-filled vesicles
○ NR: Remind clients to bring any
clots/tissue passed from her to the
hospital (to determine presence of
trophoblastic cells as these can
precipitate to the development of
choriocarcinoma)
II. MEDICAL AND SURGICAL MANAGEMENT
H-MOLE
● SUCTION CURETTAGE
○ Done to evacuate abnormal trophoblast cells
○ Process:
● A speculum is placed in the vagina, a
tenaculum is clamped to the lip of the
cervix
● Suction cannula is inserted into the vagina
to suction fluid filled vesicles
● Uterine cavity is scaped with a curette to
determine whether any significant amount
of tissue remains
● BASELINE PELVIC EXAMINATION AND SERUM TEST
FOR BETA SUBUNIT OF hCG
○ ↑ hCG after D&C
● ½ of women still has (+) elevated hCG for 3
weeks
● ¼ of women (+) 40 days
○ Assessment of serum hCG levels every 2 weeks
until normal, then every 4–6 weeks for the next
6–12 months
● Gradually declining hCG suggests no
complication
○ (-) hCG after 6 months = free from risk
of malignancy
● If the level plateaus for three times or
increases, it suggest that malignant
transformation (choriocarcinoma) has
occurred
○ Continuously assess and monitor if it is
gradually decreasing or plateaus
● ORAL ESTROGEN/PROGESTERONE CONTRACEPTIVES
○ To prevent pregnancy while waiting for hCG
levels to decline
MALIGNANCY
● METHOTREXATE
○ Prophylactic course
○ Drug of choice for choriocarcinoma
○ To check for metastasis, conduct PE + chest
X-ray or CT scan of brain, chest, abdomen, and
pelvis
● Dactinomycin is added to treatment
regimen if metastasis occurs
○ An anti-tumor chemotherapeutic agent
○ Interferes with WBC formation (risk for
leukopenia)
III. NURSING MANAGEMENT
NURSING DIAGNOSES
● Bleeding
● Risk for infection
● Deficient knowledge about diagnostic procedures
and therapeutic procedures, signs and symptoms
of additional complications, dietary measures to
prevent infection
NURSING MANAGEMENT
● Instruct the woman who begin to miscarry at home,
to bring any clots or tissue passed to the hospital
with her
● Instruct the woman to use a reliable contraceptive
method for 12 months to prevent pregnancy
○ Pregnancy increases hCG levels, therefore
causing misinterpretations and confusions
during the treatment of H-Mole if it is a new
pregnancy or a developing malignancy
● Advice to delay childbearing for 1 year to
avoid confusion
○ After 6 months of checking hCG, if it decreases
and no presence in the serum = free from
malignancy, but still cannot get pregnant for a
year
● Instruct to have an early screening with ultrasound
during the next pregnancy to rule out H-mole
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● Provision of emotional support severe that dehydration, ketonuria, and significant

○ The patient, despite (-) fetal formation, still weight loss occur within the first 12 weeks of
believed that they were pregnant pregnancy
○ Dealing with stress d/t possible malignancy ● Affects 1/200–300 women
and delayed childbearing plans ● CAUSE: Unknown but is associated with thyroid
○ Provide opportunity to express anger, sense of function and bacteria
unfairness, and feelings of inadequacy ○ Thyroid: women with the disorder may have
● ADDITIONAL INTERVENTIONS FOR ABORTION, increased thyroid function because of the
ECTOPIC PREGNANCY, AND H-MOLE thyroid-stimulating properties of HCG
○ Provide information about tests and ○ Bacteria: some studies reveal it is associated
procedures with Helicobacter pylori, the same bacteria that
● Explain diagnostic procedures such as causes peptic ulcers
transvaginal/transabdominal UTZ to lessen ● NOTE: If hyperemesis is identified early in
the anxiety of the mother pregnancy and managed, it will not lead to
● Explain the purpose, how long, and if it pregnancy loss or low birth weight
causes discomfort
● Obtain consent before procedures I. ASSESSMENT
○ Teach measures to prevent infection
● Personal hygiene (daily showers and
careful handwashing before and after ❓ ASK PATIENTS THE FOLLOWING QUESTIONS:
How late into the day did the nausea last?
changing pads) ❓ How many times did they vomit and how much?
● Advise use of perineal pads and against ❓ What was the total amount of food they were able
use of tampons to eat?
● Safe timing of resuming intercourse
○ Provide dietary information
A. RISK FACTORS
● ↑ iron for Hg and Hct
○ Liver, red meat, spinach, egg yolks,
● H. pylori (ulcers)
carrots, raisins
● Increased estrogen and Hcg (due to
● Vitamin C
thyroid-stimulating properties)
○ Citrus fruits, broccoli, strawberries,
● G1 women
cantaloupe, cabbage, green peppers
● Multiple pregnancies (d/t increased Hcg)
○ For faster healing and strengthening of
● Displacement of GI tract
the mother’s immune system
● Hypofunction of the anterior pituitary gland and
● Adequate fluid intake of 2,500 mL for
adrenal cortex
hydration after bleeding episode
● Abnormalities of the corpus luteum
○ Teach signs of infection to report
● Genetics
● Temperature of 38℃
○ Take temperature every 8 hours for first
B. SIGNS AND SYMPTOMS
3 days at home
● Vaginal discharge with foul odor
● Weight loss
● Pelvic tenderness and persistent general
○ Can be severe because, with so much nausea
malaise
and vomiting, a woman cannot maintain her
○ Reinforce follow-up care
usual nutrition
● Monitor hCG levels with H-mole
○ 5% loss from prepregnancy weight → should
● Acknowledge grief and recognize guilt
gain weight during pregnancy
feelings
● (+) ketones in the urine (ketonuria)
● Use reliable contraceptives for 1 year if with
○ Evidence the woman’s body is breaking down
H-mole
stored fat and protein for cell growth
● The body will find a source for energy →
B. HYPEREMESIS GRAVIDARUM fat/protein breakdown → ketoacidosis →
ketones in the urine
● Pernicious or persistent vomiting
○ Associated with inadequate food intake
● Nausea and vomiting of pregnancy that is
● ↑ Hematocrit and Hg concentration
prolonged past week 16 of pregnancy or is so

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 MODULE 03 — HYPEREMESIS GRAVIDARUM, HYDATIDIFORM MOLE, AND CERVICAL INSUFFICIENCY

○ May be detected at a monthly prenatal visit ● RULE OUT DISEASES

because the inability to retain fluid (sinusuka ○ Peptic ulcer disease and cholecystitis mimic
lang) has resulted in hemoconcentration the signs and symptoms of hyperemesis
(which is dangerous because it can lead to gravidarum
thromboembolism) ● DIETARY MODIFICATIONS
○ May be indicative of dehydration
NPO status for the first 24 hours
● Lesser plasma = lesser fluid 1 ASSESS FOR: vomiting
● Electrolyte imbalance
○ ↓ sodium, potassium, and chloride (-) vomiting: small amounts of clear fluids;
○ Linked to inadequate nutrition 2 patient is discharged home, usually with a
referral for home care
● Acid-base imbalance
(-) vomiting: small quantities of dry toast,
○ Hypokalemic alkalosis 3 crackers, and cereals every 2–3 hours
● Loss of hydrochloric acid from the stomach
(+) tolerance: soft diet and eventually
● Walang laman ‘yung tiyan pero nagsusuka 4 regular diet
pa rin; acid na ‘yung nilalabas
○ Metabolic acidosis IF VOMITING RETURNS AT ANY POINT (2–4),
the client is prescribed with enteral or total
● From starvation/lack of food intake; release
parenteral nutrition
of ketone bodies
● Ataxia and confusion Total Parenteral Nutrition
○ Caused by deficiency of vitamin B1 (thiamine)
5 ● Not inserted in peripheral veins because
● Polyneuritis of small lumen
○ Numbness, pain, tingling sensation over nerves ● Hypertonic solutions is ideally
over extremities administered in large blood vessels
○ Due to lack of vitamin B and minerals from
inadequate food intake
● INTRAVENOUS INFUSIONS
● Hypovolemia
○ To increase hydration, the client is prescribed
○ From weakness and alteration from
with 3000 mL Ringer’s lactate with Vitamin B1/B6
electrolytes, lack of fluid intake = compensation
○ Do NOT give dextrose solutions as this may
of hypotension and tachycardia
cause hyperglycemia
● ↓ Urine Output
● PHARMACEUTICAL INTERVENTIONS
○ From renal dysfunction due to altered perfusion
○ Antiemetics: Metoclopramide to control
to the kidneys
vomiting
● BRAND NAME: Reglan
C. EFFECTS TO PREGNANCY ● CATEGORY: Pregnancy class B
○ Promethazine (Phenergan) and Ondasetron
● Due to severe dehydration, the mother loses her
(Zofran)
ability to provide the child with essential nutrients
for growth, leading to intrauterine growth
restriction, preterm birth, and even fetal death.
IV. NURSING MANAGEMENT

III. MEDICAL MANAGEMENT
● 24-HR HOSPITALIZATION
○ Monitoring and documentation of intake,
output, and blood chemistries
● Description of output and feces
○ How many mL of IV, urine, vomit
● Normal UO: 1 ml/kg/hour
● Check if ↑ BUN, ↑ creatinine, ↑ liver enzymes
○ An increase is expected d/t renal
dysfunction (decreased perfusion to
affected organs)
○ Monitoring weight and volume to assess degree
of hydration
A. NURSING DIAGNOSES
● Deficient fluid volume r/t severe dehydration
secondary to hyperemesis
● Imbalanced nutrition, less than body requirements,
related to persistent vomiting secondary to
hyperemesis
○ Monitor blood glucose twice daily if receiving
TPN (TPN solutions contain glucose)
○ Monitor for presence of ketones (indicates
inadequacy of nutrients being received, leading
to protein/fat breakdown)
● Fear r/t the effects of hyperemesis on the fetal
well-being
○ Providing emotional support

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 MODULE 03 — HYPEREMESIS GRAVIDARUM, HYDATIDIFORM MOLE, AND CERVICAL INSUFFICIENCY
○ Provide opportunity to express how she feels to
be pregnant and to live with HEG
● The nurse can stay with the mother
● Risk for deficient fluid volume related to vomiting
secondary to hyperemesis gravidarum
B. NURSING RESPONSIBILITIES
● MONITOR FOR SIGNS OF DEHYDRATION
○ GOAL: The client should be free from
manifestations of dehydration
○ Decreased fluid intake (<2000 mL/day) and
urine output (<30 mL/hr)
○ Increased urine specific gravity (1.010–1.030)
○ Poor skin turgor
○ Dry skin and mucous membranes
● (-) TALKING ABOUT FOOD
○ Do not talk about food while giving care as it
can precipitate vomiting
○ Do not urge a patient who is already struggling
to eat to “Eat just a little more. You don’t want to
hurt your baby.”
● Urging patients to eat in this way may
cause them to feel guilty on top of feeling
so nauseated
● EMESIS BASIN
○ The emesis basin must be prepared BUT should
not be placed in an area that can be easily
accessed or seen by the client
● They may associate the basin with
vomiting, therefore inducing vomiting upon
seeing the object
○ Inform the patient and the significant other
about its purpose
● CLEANLINESS AND HYGIENE
○ Immediately clean after vomitus but measure
first (part of I/O monitoring)
○ Oral hygiene must be done since the client’s
mouth is dry and irritated
● MONITORING DAILY WEIGHT
○ Monitor significant weight loss
○ Measure at the same time each morning with
the same clothes and weighing scale
● MAINTAINING NUTRITION/FLUID BALANCE
○ Small frequent feedings every 2–3 hours
○ Potassium and magnesium-rich foods to
compensate for nutritional deficiencies
● Mg deficiency worsens nausea and
vomiting
● REDUCING NAUSEA AND VOMITING
○ Ginger acts as a natural remedy
○ Small, frequent feedings
○ Palatability
● Present foods attractively to encourage
eating
● Do not give foods with strong odors like fish,
bacon, and coffee
○ Dietary Considerations
● Provide low-fat foods and easily-digestible
carbohydrates
○ Hypoglycemia precipitates vomiting
● Provide soup and liquids between meals to
prevent abdominal distention
● Sit upright after meals to minimize gastric
irritation
PREMATURE CERVICAL DILATATION
(Incompetent Cervix/Cervical Insufficiency)
● A cervix that painlessly dilates prematurely and
therefore cannot hold the fetus until term
● Commonly occurs at approximately 20 weeks of
pregnancy when the fetus is still immature to
survive in the external environment
● Occurs in 1% of women
● DIAGNOSIS: Diagnosed through ultrasound to
determine presence of cervical dilatation
I. ASSESSMENT
RISK FACTORS
● Increased maternal age
● Congenital structural defects
○ Woman exposed to diethylstilbestrol (purely
estrogen containing pills from contraceptives)
○ Bicornuate uterus
● Acquired factors
○ Inflammation, infection, cervical trauma (from
cone biopsy or repeated D&C), late 2nd
trimester elective abortion, multiple gestation
● Biochemical factors
○ Relaxin: hormone released by the placenta that
causes softening of the cervix in preparation for
labor (in pts with incompetent cervix, relaxin is
released in early part of pregnancy)
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 MODULE 03 — HYPEREMESIS GRAVIDARUM, HYDATIDIFORM MOLE, AND CERVICAL INSUFFICIENCY
● Previous preterm births
● Short labors: labor and delivery less than 3 hours
SIGNS AND SYMPTOMS
● Painless cervical dilatation
● Show (pink-stained vaginal discharge)
● Increased pelvic pressure
● Rupture of the membranes → discharge of
amniotic fluid → uterine contractions → short labor
→ premature delivery of the fetus
II. MEDICAL AND SURGICAL MANAGEMENT
CERVICAL CERCLAGE
● Done after the loss of one child to premature
cervical dilatation
○ Done at approximately 12–14 weeks, prior to
premature cervical dilatation
● Prior to the procedure, confirm if the fetus of
2nd pregnancy is healthy
● PROCEDURE: Manually closing the cervix through
stitching
○ Purse-string sutures are placed in the cervix by
the vaginal/transabdominal route under
regional anesthesia
● PURPOSE: To prevent recurrence in second
pregnancy (strengthens the cervix and prevents
early dilatation)
● Success rate is 80-90%
MCDONALDS PROCEDURE/CERCLAGE
● Most common technique introduced during 1957
● Non-permanent cervical stitching at upper and
lower part of cervix
○ Nylon sutures are placed horizontally and
vertically across the cervix and pulled tight to
reduce the cervical canal to a few millimeters in
diameter
● Strings placed between weeks 12–14; removed by
the 37th week
SHIRODKAR TECHNIQUE (TRANSABDOMINAL ROUTE)
● The Shirodkar technique was first described by Dr. V.
N. Shirodkar in Bombay in 1955
● Less common and technically more difficult
● Permanent sutures pass through walls of cervix
○ Sterile tape is threaded in a purse-string
manner under the submucosal layer of the
cervix and sutured in place to achieve a closed
cervix
○ Sutures are not visible making it difficult to
remove
● Decreased risk for infection
IV. NURSING MANAGEMENT
● POST-SURGICAL MANAGEMENT
○ After the surgery, patients remain on bed rest in
a slight/modified Trendelenburg position
● Decreases pressure on new sutures
○ After the rest period, usual activity and sexual
relations may resume if permitted by the
physician
● SUTURES
○ McDonald technique: removed between weeks
37–38
● Mode of Delivery: NSD
○ Shirodkar technique: left in place
● Mode of Delivery: CS
ANSWER KEY
PRE-TEST:
1. FALSE: 16 weeks of pregnancy
2. FALSE: Hypokalemic ALKALOSIS
3. FALSE: partial H-mole
4. TRUE
5. FALSE: 20 weeks of pregnancy
6. TRUE
Banaag, Cato, Diala, Ingal, Mallari, Malonzo, Paras
BSN 2025
REFERENCES
Asynchronous Lecture: Module 03
Module: NCM 0109 Second Trimester Conditions
Book: Maternal and Child Health Nursing
Practice Questions:
A. Question Bank 1
B. Question Bank 2
C. Question Bank 3
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