Ectopic (tubal) pregnancy

Definition:
An ectopic pregnancy, or eccysis, is a complication of pregnancy in which the pregnancy implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the mother, internal bleeding being a common complication. Most ectopic pregnancies occur in the Fallopian tube (so-called tubal pregnancies), but implantation can also occur in the cervix, ovaries, and abdomen. An ectopic pregnancy is a potential medical emergency, and, if not treated properly, can lead to death.

Signs and symptoms:

Early signs include: Pain in the lower abdomen, and inflammation (Pain may be confused with a strong stomach pain, it may also feel like a strong cramp) Pain while urinating Pain and discomfort, usually mild. A corpus luteum on the ovary in a normal pregnancy may give very similar symptoms. Vaginal bleeding, usually mild. An ectopic pregnancy is usually a failing pregnancy and falling levels of progesterone from the corpus luteum on the ovary cause withdrawal bleeding. This can be indistinguishable from an early miscarriage or the 'implantation bleed' of a normal early pregnancy. Pain while having a bowel movement. Late signs include: External bleeding is due to the falling progesterone levels. Internal bleeding (hematoperitoneum) is due to hemorrhage from the affected tube. More severe internal bleeding may cause: Lower back, abdominal, or pelvic pain. Shoulder pain. This is caused by free blood tracking up the abdominal cavity and irritating the diaphragm, and is an ominous sign. There may be cramping or even tenderness on one side of the pelvis. The pain is of recent onset, meaning it must be differentiated from cyclical pelvic pain, and is often getting worse.

Nursing management:

Bed rest Increase oral fluid intake (hydration) Emotional support

Medical management:
Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical treatment since at least 1993. If administered early in the pregnancy, methotrexate terminates the growth of the developing embryo; this may cause an abortion, or the tissue may then be either resorbed by the woman's body or pass with a menstrual period.

Surgical management:
If hemorrhage has already occurred, surgical intervention may be necessary. However, whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of blood clot on ultrasound. Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy).

Hydatidiform mole (gestational trophoblastic disease)

Definition:
Molar pregnancy is an abnormal form of pregnancy, wherein a non-viable, fertilized egg implants in the uterus, and thereby converts normal pregnancy processes into pathological ones. It is characterized by the presence of a hydatidiform mole (or hydatid mole, mola hydatidosa).

Signs and symptoms:

Molar pregnancies usually present with painless vaginal bleeding in the fourth to fifth month of pregnancy. The uterus may be larger than expected, or the ovaries may be enlarged. There may also be more vomiting than would be expected (hyperemesis). Sometimes there is an increase in blood pressure along with protein in the urine. Blood tests will show very high levels of human chorionic gonadotropin (hCG).

Nursing management:
Bed rest

Increase intake in oral fluids (hydration) Emotional support Encourage to undergo medical management after the pregnancy Reintroduce PO intake Monitor I/O

Medical management:
Patients are followed up until their serum human chorionic gonadotrophin (hCG) level has fallen to an undetectable level. Invasive or metastatic moles (cancer) may require chemotherapy and often respond well to methotrexate. Patients are advised not to conceive for one year after a molar pregnancy. Carboprost medication may be used to contract the uterus.

Surgical management:
Hydatidiform moles should be treated by evacuating the uterus by uterine suction or by surgical curettage as soon as possible after diagnosis, in order to avoid the risks of choriocarcinoma.

Premature cervical dilatation

Definition:
Cervical incompetence is a medical condition in which a pregnant woman's cervix begins to dilate (widen) and efface (thin) before her pregnancy has reached term. Cervical incompetence may cause miscarriage or preterm birth during the second and third trimesters.

Signs and symptoms:

In a woman with cervical incompetence, dilation and effacement of the cervix may occur without pain or uterine contractions. In a normal pregnancy, dilation and effacement occurs in response to uterine contractions. Cervical incompetence occurs because of weakness of the cervix, which is made to open by the growing pressure in the uterus as pregnancy progresses. If the responses are not halted, rupture of the membranes and birth of a premature baby can result.

Nursing management:
Bed rest (modified trendelenburg) Increase intake in oral fluid (hydration)

Medical management:
Isoxsuprine is oftenly used on the case of premature cervical dilatation to halt preterm labor. Dexamethasone is given to promote long maturity.

Surgical management:
Cervical incompetence is not generally treated except when it appears to threaten a pregnancy. Cervical incompetence can be treated using cervical cerclage, a surgical technique that reinforces the cervical muscle by placing sutures above the opening of the cervix to narrow the cervical canal.

Spontaneous abortion
Definition:
Miscarriage or spontaneous abortion is the spontaneous end of a pregnancy at a stage where the embryo or fetus is incapable of surviving, generally defined in humans at prior to 24 weeks of gestation. Miscarriage is the most common complication of early pregnancy.

Signs and symptoms:

The most common symptom of a miscarriage is bleeding; bleeding during pregnancy may be referred to as a threatened abortion. Of women who seek clinical treatment for bleeding during pregnancy, about half will go on to have a miscarriage. Symptoms other than bleeding are not statistically related to miscarriage.

Nursing management:
Bed rest Increase in oral fluid intake (hydration) Emotional support

Medical management:
Blood loss during early pregnancy is the most common symptom of both miscarriage and of ectopic pregnancy. Pain does not strongly correlate with miscarriage, but is a common symptom of ectopic pregnancy. In the case of concerning blood loss, pain, or both,

transvaginal ultrasound is performed. If a viable intrauterine pregnancy is not found with ultrasound, serial HCG tests should be performed to rule out ectopic pregnancy, which is a life-threatening situation. Medical management usually consists of using misoprostol (a prostaglandin, brand name Cytotec) to encourage completion of the miscarriage.

Surgical management:
Surgical treatment (most commonly vacuum aspiration, sometimes referred to as a D&C or D&E) is the fastest way to complete the miscarriage. It also shortens the duration and heaviness of bleeding, and avoids the physical pain associated with the miscarriage. In cases of repeated miscarriage, D&C is also the most convenient way to obtain tissue samples for karyotype analysis (cytogenetic or molecular), although it is also possible to do with expectant and medical management.

Placenta previa
Definition:
Placenta praevia (placenta previa AE) is an obstetric complication in which the placenta is attached to the uterine wall close to or covering the cervix. It can sometimes occur in the later part of the first trimester, but usually during the second or third. It is a leading cause of antepartum haemorrhage (vaginal bleeding).

Signs and symptoms:

Women with placenta previa often present with painless, bright red vaginal bleeding. This bleeding often starts mildly and may increase as the area of placental separation increases. Praevia should be suspected if there is bleeding after 24 weeks of gestation. Abdominal examination usually finds the uterus non-tender and relaxed.

Nursing management:
Bed rest Increase in oral fluid intake (hydration) Emotional support Observe contractions, rapture of membranes, maternal and fetal V/S Position client to minimize pressure (modified trendelenburg)

Watch out for signs of bleeding

Medical management:
Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement (to maintain blood pressure) and blood plasma replacement (to maintain fibrinogen levels) may be necessary. An Apt or Kleikauer-Betke test (test strip procedures) can be used to detect whether the blood is of fetal or maternal origin.

Surgical management:
It is controversial if vaginal delivery or a Caesarean section is the safest method of delivery. In cases of fetal distress a Caesarean section is indicated. Caesarian section is contraindicated in cases of disseminated intravascular coagulation.

Premature separation of the placenta (abruptio placentae)

Definition:
Placental abruption (also known as abruptio placentae) is a complication of pregnancy, wherein the placental lining has separated from the uterus of the mother. It is the most common pathological cause of late pregnancy bleeding. In humans, it refers to the abnormal separation after 20 weeks of gestation and prior to birth.

Signs and symptoms:

Contractions that don't stop (and may follow one another so rapidly as to seem continuous) Pain in the uterus Tenderness in the abdomen Vaginal bleeding (sometimes) Uterus may be disproportionately enlarged Pallor

Nursing management:
Bed rest Monitor maternal vital signs and fetal heart tone Increase in oral fluid intake (hydration) Monitor urine output Watch out for signs of bleeding

Medical management:
Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother are in distress. Blood volume replacement and to maintain blood pressure and blood plasma replacement to maintain fibrinogen levels may be needed. Vaginal birth is usually preferred over caesarean section unless there is fetal distress.

Surgical management:
Caesarean section is contraindicated in cases of disseminated intravascular coagulation or if there is fetal distress.

Preterm labor
Definition:
Babies born prior to 37 weeks of pregnancy may experience various problems due to incomplete growth and development.

Signs and symptoms:

Uterine contractions Menstrual-like cramps Lower, dull backache Pelvic pressure Intestinal cramps Increase or change in vaginal discharge A general feeling that something is not right

Nursing management:
Bed rest to decrease pressure Increase oral fluid intake to prevent dehydration Vaginal or cervical secretions should be cultured by clean catch Encourage to limit strenuous activities Monitor maternal V/S and FHT

Medical management:

Isoxsuprine is oftenly used on the case of premature cervical dilatation to halt preterm labor. Dexamethasone is given to promote long maturity.

Surgical management:
Caesarian section is performed if there is presence of feto-maternal indication.

Pregnancy-induced hypertension
Definiton:
Gestational hypertension or pregnancy-induced hypertension is defined as the development of new arterial hypertension in a pregnant woman after 20 weeks gestation. Hypertension can arise before week 20 if the woman has multiple fetuses or a hydatidiform mole.

Signs and symptoms:

Edema Proteinuria Elevated blood pressure

Nursing management:
Bed rest (lateral recumbent) Emotional support

Medical management:
Drug treatment options are limited, as many antihypertensives may negatively affect the fetus; methyldopa, hydralazine and labetalol are most commonly used for severe pregnancy hypertension.

Surgical management:
Caesarian Section is preformed to terminate the pregnancy and stop the cause of blood pressure elevation.

Hemolytic anemia Elevated Liver enzyme Low Platelet syndrome (HELLP Syndrome)

Definition:
HELLP syndrome is a life-threatening obstetric complication usually considered to be a variant of pre-eclampsia. Both conditions usually occur during the later stages of pregnancy, or sometimes after childbirth.

Signs and symptoms:

Often, a patient who develops HELLP syndrome has already been followed up for pregnancy-induced hypertension (gestational hypertension), or is suspected to develop pre-eclampsia (high blood pressure and proteinuria). There is gradual but marked onset of headaches (30%), blurred vision, malaise (90%), nausea/vomiting (30%), "band pain" around the upper abdomen (65%) and paresthesia (tingling in the extremities). Edema may occur but its absence does not exclude HELLP syndrome. Arterial hypertension is a diagnostic requirement, but may be mild. Rupture of the liver capsule and a resultant hematoma may occur. If the patient has a seizure or coma, the condition has progressed into full-blown eclampsia.

Nursing management:
Safety Watch out for signs of bleeding Monitor maternal V/S and FHT Bed rest Increase oral fluid intake (hydration) Monitor urine output Assess level of consciousness

Medical management:
The only effective treatment is prompt delivery of the baby. Several medications have been investigated for the treatment of HELLP syndrome, but evidence is conflicting as to whether magnesium sulfate decreases the risk of seizures and progress to eclampsia. The DIC is treated with fresh frozen plasma to replenish the coagulation proteins, and the anemia may require blood transfusion. In mild cases, corticosteroids and antihypertensives (labetalol, hydralazine, nifedipine) may be sufficient. Intravenous fluids are generally required. Hepatic hemorrhage can be treated with embolization as well if life-threatening bleeding ensues.

Surgical management:

Csection is perform to stop worsening of the mothers condition.

RH Isoimmunization
Definition:
Rh disease (also known as Rh (D) disease, Rhesus incompatibility, Rhesus disease, RhD Hemolytic Disease of the Newborn, Rhesus D Hemolytic Disease of the Newborn or RhD HDN) is one of the causes of hemolytic disease of the newborn (also known as HDN).

Signs and symptoms:

The disease ranges from mild to severe. When the disease is mild the fetus may have mild anaemia with reticulocytosis. When the disease is moderate or severe the fetus can have a more marked anaemia and erythroblastosis (erythroblastosis fetalis). When the disease is very severe it can cause morbus haemolyticus neonatorum, hydrops fetalis, or stillbirth.

Nursing management:
Bed rest Increase in oral fluid intake (Hydration)

Medical management:
The mother has an intramuscular injection of anti-Rh antibodies (Rho(D) Immune Globulin), sold under the brand name RhoGAM. This is done so that the fetal Rhesus D positive erythrocytes are destroyed before her immune system can discover them. This is passive immunity and the effect of the immunity will wear off after about 4 to 6 weeks (or longer depending on injected dose) as the anti-Rh antibodies gradually decline to zero in the maternal blood.

Surgical management:
Csection to terminate the pregnancy

Disseminated intravascular coagulation (DIC)

Disseminated intravascular coagulation (DIC), also known as consumptive coagulopathy, is a pathological activation of coagulation (blood clotting) mechanisms that happens in response to a variety of diseases. DIC leads to the formation of small blood clots inside the blood vessels throughout the body. As the small clots consume coagulation proteins and platelets, normal coagulation is disrupted and abnormal bleeding occurs from the skin (e.g. from sites where blood samples were taken), the gastrointestinal tract, the respiratory tract and surgical wounds. The small clots also disrupt normal blood flow to organs (such as the kidneys), which may malfunction as a result.

Signs and symptoms:

The affected person is often acutely ill and shocked with widespread haemorrhage (common bleeding sites are mouth, nose and venepuncture sites), extensive bruising, renal failure and gangrene. The onset of DIC can be fulminant, as in endotoxic shock or amnioitic fluid embolism, or it may be insidious and chronic, as in cases of carcinomatosis.

Nursing management:
Safety Watch out for signs of bleeding Monitor maternal V/S and FHT Bed rest Increase oral fluid intake (hydration) Monitor urine output Assess level of consciousness

Medical management:
The only effective treatment is the reversal of the underlying cause. Anticoagulants are given exceedingly rarely when thrombus formation is likely to lead to imminent death (such as in coronary artery thrombosis or cerebrovascular thrombosis).

Surgical management:
Platelets may be transfused if counts are less than 5,000-10,000/mm3 and massive hemorrhage is occurring, and fresh frozen plasma may be administered in an attempt to replenish coagulation factors and anti-thrombotic factors, although these are only temporizing measures and may result in the increased development of thrombosis.

Hydramnios

Definition:
Polyhydramnios (polyhydramnion, hydramnios) is a medical condition describing an excess of amniotic fluid in the amniotic sac. It is seen in 0.2 to 1.6% of pregnancies. It is typically diagnosed when the amniotic fluid index (AFI) is greater than 20 cm ( = 20 cm).

Signs and symptoms:

Rapid growth of uterus Unusual discomfort in the abdomen - due to the extra pressure Wild fluctuations in your weight Increased back pain Extreme swelling in your feet and ankles Uterine contraction

Nursing management:
Limit fluid intake to 1-2 liters Bed rest Watch out for signs of infection Monitor maternal V/S and fetal heart tone Encourage patient to avoid dietary salt intake

Medical management:
In some cases, amnioreduction, also known as therapeutic Amniocentesis, has been used in response to polyhydramnios. In certain cases, your doctor may prescribe a prostaglandin inhibitor like Indomethacin, which has been shown to reduce the baby's urine output.

Surgical management:
Amniocentesis to remove some of the amniotic fluid; this procedure may need to be repeated. An emergency CSection may also be required.

COLEGIO DE DAGUPAN COLLEGE OF NURSING

COMPLICATIONS OF PREGNANCY

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN NCM 102- RELATED LEARNING EXPERIENCES (CUSION FAMILY HOSPITAL DUTY)

Submitted to: Mrs. Shana Ann Q. Cuison, RN, MAN Clinical Instructor Submitted by: Hughver M. Espinoza BSN II - BLK 2