Antepartal Hemorrhagic disorders

Antepartal Hemorrhagic disorders

Prepared by assistant professor N.Petrenko, MD, PhD

 

HEMORRHAGIC COMPLICATIONS

Bleeding in pregnancy may jeopardize both maternal and fetal well-being. Maternal blood loss decreases oxygencarrying capacity, which predisposes the woman to increased risk for hypovolemia, anemia, infection, preterm labor, and preterm birth and adversely affects oxygen delivery to the fetus. Fetal risks from maternal hemorrhage include blood loss or anemia, hypoxemia, hypoxia, anoxia, and preterm birth. Antepartal hemorrhage is a leading cause of maternal death, with ectopic pregnancy rupture and abruptio placentae being responsible for most maternal deaths (Koonin et al., 1997).

 

EARLY PREGNANCY BLEEDING

Bleeding during early pregnancy is alarming to the woman and of concern to the health care provider and nurse. The common bleeding disorders of early pregnancy include miscarriage, incompetent cervix, ectopic pregnancy, and hydatidiform mole (molar pregnancy).

 

Miscarriage

Miscarriage is a pregnancy that ends before 20 weeks of gestation. The 20-week marker is considered the point of viability, or when the fetus is able to survive in an extrauterine environment. A fetal weight less than 500 g may also be used to define miscarriage (Cunningham et al., 2001). A miscarriage results from natural causes. Induced abortion (intentional interruption of pregnancy) is discussed in Chapter 6.

Incidence and etiology. Approximately 10% to 15% of all clinically recognized pregnancies end in miscarriage (Simpson, 2002). An early miscarriage is one that occurs before 12 weeks of gestation. At least 50% of all clinically recognized pregnancy losses result from chromosomal abnormalities (Simpson, 2002). The majority (over 90%) of miscarriages occur early, before 8 weeks of gestation (Simpson, 2002). Possible causes of early miscarriage include endocrine imbalance (as in women who have luteal phase defects or insulin-dependent diabetes mellitus with high blood glucose levels in the first trimester), immunologic factors (such as antiphospholipid antibodies), infections (such as bacteriuria and Chlamydia trachomatis), systemic disorders (such as lupus erythematosus), and genetic factors (ACOG, 1995; Gilbert & Harmon, 1998).

A late miscarriage is one that occurs between 12 and 20 weeks of gestation. Late miscarriages usually result from maternal causes, such as advancing maternal age and parity, chronic infections, premature dilation of the cervix and other anomalies of the reproductive tract, chronic debilitating diseases, nutrition, and recreational drug use (Cunningham et al., 2001). Little can be done to avoid genetically caused pregnancy loss, but correction of maternal disorders, immunization against infectious diseases, adequate early prenatal care, and treatment of pregnancy complications can do much to prevent miscarriage.

Types. The types of miscarriage include threatened, inevitable, incomplete, complete, and missed. Miscarriages (both early and late) can recur; all but the threatened miscarriage can lead to infection (Fig. 6).

 

 

Clinical manifestations. Signs and symptoms of miscarriage depend on the duration of pregnancy. Once pregnancy has been diagnosed, the presence of uterine bleeding, uterine contractions, and uterine pain are ominous signs that must be considered a threatened miscarriage until proven otherwise.

If miscarriage occurs before the sixth week of pregnancy, the woman may report a heavy menstrual flow. Miscarriage that occurs between the sixth and twelfth weeks of pregnancy causes moderate discomfort and blood loss. After the twelfth week, miscarriage is typified by more severe pain, similar to that of labor, because the fetus must be expelled. Diagnosis of the type of miscarriage is based on the signs and symptoms present (Table 6).

 

TABLE 6 Assessing Miscarriage and the Usual Management

TYPE OF MISCARRIAGE

AMOUNT OF BLEEDING

UTERINE CRAMPING

PASSAGE OF TISSUE

CERVICAL DILATION

MANAGEMENT

Threatened

Slight, spotting

Mild

No

No

Bed rest, sedation, and avoidance of stress and orgasm usually recommended. Further treatment depends on woman's response to treatment.

Inevitable

 

Incomplete

Moderate

 

Heavy, profuse

Mild to severe

Severe

No

 

Yes

Yes

 

Yes, with tissue in cervix

Prompt termination of pregnancy is accomplished, usually by  dilation and curettage.

Complete

Slight

Mild

Yes

No

No further intervention may be needed if uterine contractions are adequate to prevent hemorrhage and there is no infection.

Missed

None, spotting

None

No

No

If spontaneous evacuation of the

uterus does not occur within 1 month, pregnancy is terminated by method appropriate to duration of pregnancy. Blood clotting factors are monitored until uterus is empty. DIC and incoagulability of blood with uncontrolled hemorrhage may develop in cases of fetal death after the twelfth week, if products of conception are retained for longer than 5 weeks.

Septic

Varies, usually malodorous

Varies

Varies

Yes, usually

Immediate termination of pregnancy by method appropriate to duration of pregnancy. Cervical culture and sensitivity studies are done, and broad-spectrum antibiotic therapy (e.g., ampicillin) is started. Treatment for septic shock is initiated if  necessary.

Recurren

Varies

Varies

Yes

Yes, usually

Varies, depends on type. Prophylactic cerclage may be done if premature cervical dilation is the cause.

 

Symptoms of a threatened miscarriage (see Fig. 6, A) include spotting of blood but with the cervical os closed. Mild uterine cramping may be present. Inevitable (see Fig. 6, B) and incomplete (see Fig. 6, C) miscarriages involve a moderate to heavy amount of bleeding with an open cervical os. Tissue may be present with the bleeding. Mild to severe uterine cramping may be present. An inevitable miscarriage is often accompanied by rupture of membranes (ROM) and cervical dilation; passage of the products of conception is a certainty.

An incomplete miscarriage involves the expulsion of the fetus with retention of the placenta (Cunningham et al., 2001).

In a complete miscarriage (see Fig. 6, D), all fetal tissue is passed, the cervix is closed, and there may be slight bleeding. Mild uterine cramping may be present. The term missed miscarriage (see Fig. 6, E) refers to a pregnancy in which the fetus has died but the products of conception are retained in utero for several weeks. It may be diagnosed by ultrasonic examination after the uterus stops increasing in size or even decreases in size. There may be no bleeding or cramping, and the cervical os remains closed.

Recurrent early (habitual) miscarriage is the loss of three or more previable pregnancies. Women having three or more miscarriages are at increased risk for preterm birth, placenta previa, and fetal anomalies in subsequent pregnancies (Cunningham et al., 2001).

Miscarriages can become septic, although this is not a common occurrence. Symptoms of a septic miscarriage include fever and abdominal tenderness. Vaginal bleeding, which may be slight to heavy, is usually malodorous.

 


CARE MANAGEMENT

Whenever a woman with vaginal bleeding early in pregnancy seeks treatment, a thorough assessment should be performed (Box 6). Information to be obtained includes chief complaint, type and location of pain, quantity and nature of bleeding, and date of last menstrual period (LMP) to determine approximate gestational age. The initial database should also include vital signs, previous pregnancies, previous pregnancy losses, allergies, and emotional status. Frequently the woman is anxious and fearful of what may happen to her and to her pregnancy.

 

BOX 6 Assessment of Bleeding in Pregnancy

INITIAL DATABASE

Chief complaint

Vital signs

Gravidity, parity

LMP/estimated date of birth

Pregnancy history (previous and current)

Allergies

Nausea and vomiting

Pain (onset, quality, precipitating event location)

Bleeding or coagulation problems

Level of consciousness

Emotional status

EARLY PREGNANCY

Confirmation of pregnancy

Bleeding (bright or dark, intermittent or continuous)

Pain (type, intensity, persistence)

Vaginal discharge

LATE PREGNANCY

Estimated date of birth

Bleeding (quantity, associated pain)

Vaginal discharge

Amniotic membrane status

Uterine activity

Abdominal pain

Fetal status/viability

 

Various laboratory findings are characteristic of miscarriage. Evaluation of hCG, a placental hormone, is used in the diagnosis of pregnancy and pregnancy loss. The beta subunit of hCG (/3-hCG) can be detected in maternal plasma and urine 8 to 9 days after ovulation if the woman  is pregnant. In early pregnancy, the concentration of /3-hCG before 20 weeks of gestation should double every 1.4 to 2 days until approximately 60 or 70 days of gestation (Cunningham et al., 2001). Before 8 weeks of gestation, if miscarriage is suspected, two serum quantitative /3-hCG levels are drawn 48 hours apart. If a normal pregnancy is present, the /3-hCG level doubles in this time frame. Ultrasonography can then be used to determine the presence of a viable gestational sac. With considerable or persistent blood loss, anemia is likely (hemoglobin level less than 11 g/dl). If infection is present, the white blood cell (WBC) count is greater than 12,000 cells/mm3.

The following nursing diagnoses are appropriate for the woman experiencing miscarriage:

Anxiety/fear related to

-unknown outcome and unfamiliarity with medical procedures

Deficient fluid volume related to

-excessive bleeding secondary to miscarriage

Anticipatory grieving related to

-unexpected pregnancy outcome

Situational low self-esteem related to

-inability to successfully carry a pregnancy to term gestation

Risk for infection related to

-surgical treatment

-dilated cervix

Immediate nursing care focuses on physiologic stabilization. Typical orders to be followed would be initiation of an IV line, request for blood testing of hemoglobin and hematocrit, blood type and Rh, and indirect Coombs' screen. An ultrasound is performed for diagnostic confirmation.

 

Medical management. Medical management (see Table 6) depends on the classification and on signs and symptoms. Traditionally, threatened miscarriages have been managed with bed rest and supportive care. Followup treatment depends on whether the threatened miscarriage progresses to actual miscarriage or symptoms subside and the pregnancy remains intact. Dilation and curettage (D&C) is a surgical procedure in which the cervix is dilated and a curette is inserted to scrape the uterine walls and remove uterine contents. A D&C is commonly performed to treat inevitable and incomplete miscarriage. The nurse reinforces explanations, answers any questions or concerns, and prepares the woman for surgery.

Dilation and evacuation, performed after 16 weeks of gestation, consists of wide cervical dilation followed by instrumental removal of the uterine contents.

Before either surgical procedure is performed, a full history should be obtained and general and pelvic examinations should be performed. General preoperative and postoperative care are appropriate for the woman requiring surgical intervention for miscarriage. Analgesics or anesthesia appropriate to the procedure are used.

For late incomplete or inevitable miscarriages (16 to 20 weeks) and missed miscarriages, prostaglandins may be administered into the amniotic sac or by vaginal suppository to induce or augment labor and cause the products of conception to be expelled. IV oxytocin may also be used.

Nursing care is similar to the care for any woman whose labor is being induced (see Chapter 24). Special care may be needed for management of side effects of prostaglandin, such as nausea and vomiting and diarrhea. If the products of conception are not passed in entirety, the woman may be prepared for manual or surgical evacuation of the uterus.

After evacuation of the uterus, 10 to 20 U of oxytocin in 1000 ml of IV fluids may be given to prevent hemorrhage. For excessive bleeding after the miscarriage, ergot products such as ergonovine or a prostaglandin derivative such as carboprost tromethamine may be given to contract the uterus. Three or four doses of ergonovine, 0.2 mg orally or intramuscularly every 4 hours, may be given if the woman is normotensive. A 25-mg dose of carboprost may be given intramuscularly every 15 to 90 minutes for as many as eight doses (Cunningham et al., 2001). Antibiotics are given as necessary. Analgesics, such as antiprostaglandin agents, may decrease discomfort from cramping. Transfusion therapy may be required for shock or anemia. The woman who is Rh negative and is not isoimmunized is given an intramuscular injection of Rho(D) immune globulin within 72 hours of the miscarriage.

Psychosocial aspects of care focus on what the pregnancy loss means to the woman and her family. Hutti, de-Pacheco, and Smith (1998) found that women's responses to miscarriage ranged from no grief to intense, long-lasting grief. Explanations are provided regarding the nature of the miscarriage, expected procedures, and possible future implications for childbearing.

As with the other fetal or neonatal losses, the woman should be offered the option of seeing the products of conception. She may also want to know what the hospital does with the products of conception or whether she needs to make a decision about final disposition of fetal remains.

Home care. The woman will likely be discharged home within a few hours of undergoing D&C or as soon as her vital signs are stable, vaginal bleeding is minimal, and she has recovered from anesthesia. Discharge teaching should emphasize the need for rest. If significant blood loss has occurred, iron supplementation may be ordered. Teaching includes information about normal physical findings, such as cramping, type and amount of bleeding, resumption of sexual activity, and family planning. Follow-up care should assess the woman's physical and emotional recovery. Referrals to local support groups should be provided as needed (see Teaching Guidelines box).

Follow-up phone calls after a loss are important. The woman may appreciate a phone call on what would have been her due date. These calls provide opportunities for the woman to ask questions, seek advice, and receive information to help process her grief.

 

TEACHING GUIDELINES

Discharge Teaching for t h e Woman

After Early Miscarriage

• Advise woman to report any heavy, profuse, or bright red bleeding to health care provider.

• Reassure woman that a scant, dark discharge may persist for 1 to 2 weeks.

• To reduce the risk of infection, remind the woman not to put anything into the vagina until bleeding has stopped (e.g., no tampons, no vaginal intercourse). She should take antibiotics as prescribed.

• Acknowledge that the woman has experienced a loss and that time is required for recovery. She may have mood swings and depression.

• Refer the woman to support groups, clergy, or professional counseling as needed.

• Advise woman that attempts at pregnancy should be postponed for at least 2 months to allow body to recover

 

Recurrent premature dilation of the cervix (incompetent cervix)

Another cause of late miscarriage is incompetent cervix, which has traditionally been defined as passive and painless dilation of the cervix during the second trimester. This definition assumes an "all or nothing" role for the cervix; it is either "competent" or "incompetent." Newer thinking contends that cervical competence is variable and exists as a continuum that is determined in part by cervical length. Other related factors include composition of the cervical tissue and the individual circumstances associated with the pregnancy in terms of maternal stress and lifestyle. Lams (2002) refers to this condition as abnormal or reduced cervical competence. Freda (1999) suggests the term recurrent premature dilation of the cervix.

Etiology. Etiologic factors include a history of previous cervical lacerations during childbirth, excessive cervical dilation for curettage or biopsy, or ingestion of diethylstilbestrol by the woman's mother while being pregnant with the woman. Other instances may result from a congenitally short cervix or cervical or uterine anomalies. Reduced cervical competence is a clinical diagnosis, based on history. Short labors and recurring loss of pregnancy at progressively earlier gestational ages are characteristics of reduced cervical competence. Ultrasound is used to diagnose this condition objectively. A short cervix (less than 20 mm in length) is indicative of reduced cervical competence. Often, but not always, the short cervix is accompanied by cervical fanneling, or effacement of the internal cervical os (lams, 2002).


CARE MANAGEMENT

The nurse assesses the woman's feelings about her pregnancy and her understanding of reduced cervical competence. It is also important to evaluate the woman's support systems. Because the diagnosis of reduced cervical competence is usually not made until the woman has lost one or two pregnancies, she may feel guilty or responsible for this impending loss. It is therefore important to assess for previous reactions to stresses and appropriateness of coping responses. The woman needs the support of her health care providers, as well as that of her family.

Medical management. Conservative management consists of bed rest, hydration, and tocolysis (inhibition of uterine contractions). A cervical cerclage may be performed. During gestation, a McDonald cerclage, band of homologous fascia, or nonabsorbable ribbon (Mersilene) may be placed around the cervix beneath the mucosa to constrict the internal os of the cervix (Fig. 7). Prophylactic cerclage is placed at 10 to 14 weeks of gestation, after which the woman is told to refrain from intercourse, prolonged (more than 90 minutes) standing, and heavy lifting. She is followed during the course of her pregnancy with ultrasound scans to assess for cervical shortening and funneling. The cerclage is electively removed (usually an office or a clinic procedure) when the woman reaches 37 weeks of gestation, or it may be left in place and a cesarean birth performed. If removed, cerclage placement must be repeated with each successive pregnancy.  Approximately 80% to 90% of pregnancies treated with cerclage result in live, viable births (lams, 2002).

 

Fig. 7 A, Cerclage correction of premature dilation of the cervical os. B, Cross-sectional view of closed internal os.

 

A woman whose reduced cervical competence is diagnosed during the current pregnancy may undergo emergency cerclage placement. Risks of the procedure include premature rupture of membranes, preterm labor, and chorioamnionitis. Because of these risks, and because bed rest and tocolytic therapy can be used to prolong the pregnancy, cerclage is rarely performed after 25 weeks of gestation (lams, 2002).

Nursing management. If a cerclage is performed, the nurse monitors the woman postoperatively for contractions, ROM, and signs of infection. Discharge teaching focuses on continued monitoring of these aspects at home. Home uterine monitoring may be indicated with followup from a home health agency.

Home care. The woman must understand the importance of activity restriction at home and the need for close observation and supervision. Instruction includes the rationale for bed rest or activity restriction and warning signs of preterm labor, ROM, and infection to report (Lowdermilk & Grohar, 1998). The woman must be instructed on the importance of taking oral tocolytic medication if prescribed, the expected response, and possible side effects. Tocolytics may be given prophylactically to prevent uterine contractions and further dilation of the cervix. If home uterine monitoring is implemented, the woman is taught how to apply a uterine contraction monitor and transmit the monitor tracing by telephone to the monitoring center. Nurses at the monitoring center assess the tracing for contractions, answer questions, provide emotional support and education, and report information to the woman's physician or nurse-midwife. The woman should know the signs that would warrant immediate transfer to the hospital, including strong contractions less than 5 minutes apart, rupture of membranes, severe perineal pressure, and an urge to push (Health Care Resources, 1997). If management is unsuccessful and the fetus is born before viability, appropriate grief support should be provided. If the fetus is born prematurely, appropriate anticipatory guidance and support will be necessary.

 

Ectopic pregnancy

Incidence and etiology. Ectopic pregnancy is one in which the fertilized ovum is implanted outside the uterine cavity (Fig. 8). Approximately 95% of ectopic pregnancies occur in the uterine (fallopian) tube, with most located on the ampullar or largest portion of the tube. Other sites include the abdominal cavity (3% to 4%), ovary (1%), and cervix (1%).

 

Fig. 8 Sites of implantation of ectopic pregnancies. Order of frequency of occurrence is ampulla, isthmus, interstitium, fimbria, tuboovarian ligament, ovary, abdominal cavity, and cervix (external os).

 

Ectopic pregnancy is responsible for 10% of all maternal deaths, and it is the leading pregnancy-related cause of firsttrimester maternal death (Powell & Spellman, 1996). Moreover, ectopic pregnancy is a leading cause of infertility. Approximately 60% of women who have been treated for ectopic pregnancy are able to conceive afterward, and approximately 40% of those pregnancies are ectopic (Powell & Spellman, 1996).

The reported incidence of ectopic pregnancy is rising as a result of improved diagnostic techniques, such as more sensitive /3-hCG assays, and the availability of transvaginal ultrasound. An increased incidence of sexually transmitted infections, better treatment of pelvic inflammatory disease (PID) (which formerly would have caused sterility), increased numbers of tubal sterilizations, and surgical reversal of tubal sterilizations also have resulted in more ectopic pregnancies (Simpson, 2002).

Ectopic pregnancy is classified according to site of implantation (e.g., tubal or ovarian). The uterus is the only organ capable of containing and sustaining a term pregnancy. However, abdominal pregnancy with birth by laparotomy may result in a living infant (Fig. 9) in 5% to 25% of such pregnancies; however, the risk of deformity is as high as 40% (Gilbert & Harmon, 1998).

Fig. 9 Ectopic pregnancy, abdominal.

 

Clinical manifestations. A missed period, adnexal fullness, and tenderness may suggest an unruptured tubal pregnancy. The tenderness can progress from a dull pain to a colicky pain when the tube stretches. Pain may be unilateral, bilateral, or diffuse over the abdomen. Abnormal vaginal bleeding that is dark red or brown occurs in 50% to 80% of women. If the ectopic pregnancy ruptures, pain increases. This pain may be generalized, unilateral, or acute deep lower quadrant pam caused by blood irritating the peritoneum. Referred shoulder pain can occur as a result of diaphragmatic irritation caused by blood in the peritoneal cavity. The woman may exhibit signs of shock related to the amount of bleeding in the abdominal cavity and not necessarily related to obvious vaginal bleeding. An ecchymotic blueness around the umbilicus (Cullen sign), indicating hematoperitoneum, may develop in a neglected ruptured intraabdominal ectopic pregnancy.

 


CARE MANAGEMENT

The differential diagnosis of ectopic pregnancy involves consideration of numerous disorders that share many signs and symptoms. The physician, nurse-midwife, or nurse practitioner must consider miscarriage, ruptured corpus luteum cyst, appendicitis, salpingitis, ovarian cysts, torsion of the ovary, and urinary tract infection (Table 7). The key to early detection of ectopic pregnancy is having a high index of suspicion for this condition. Any woman with abdominal pain, vaginal spotting or bleeding, and a positive pregnancy test should undergo screening for ectopic pregnancy, especially if she has any of the risk factors previously mentioned. Laboratory screening includes determination of serum progesterone and /3-hCG levels. If either of these values is lower than would be expected for a normal pregnancy, the woman is asked to return within 48 hours for serial measurements. At this time, the woman will also undergo transvaginal ultrasound to confirm intrauterine or tubal pregnancy (Gracia & Barnhart, 2001).

 

Table 7 Differential Diagnosis of Ectopic Pregnancy

 

ECTOPIC PREGNANCY

APPENDICITIS

SALPINGITIS

RUPTURED OVARIAN CYST

MISCARRIAGE

Pain

Unilateral cramps and Tenderness before rupture May be colicky after rupture Sudden sharp abdominal pelvic pain Abdominal tenderness

Epigastric, periumbilical, then right lower quadrant pain, tenderness localizing at McBurney's point, rebound tenderness

Usually in both lower quadrants with or without rebound Mild to severe pelvic pressure

Unilateral, becoming general with progressive bleeding, dull cramping

Mild uterine cramps to severe uterine pain

Nausea and vomiting

Occasionally before, frequently after rupture

Usual, precedes shift of pain to right lower quadrant

Infrequent

Rare

Almost never

Menstruation

Some aberration, missed period,

Unrelated to menses

Hypermenorrhea, metrorrhagia. or both

Period delayed, then bleeding, often with pain

Amenorrhea then spotting, then brisk bleeding

Temperature pulse, and blood pressure

37.2°-37.8° C, pulse variable normal before and rapid after rupture, 4 BP after rupture

37.2°-37.8° C, pulse rapid

37.2°-40° C: pulse elevated in proportion to fever

Not over 37.2° C, pulse normal unless blood loss marked, then rapid

To 37.2° C Signs of shock related to obvious bleeding

Pelvic examination

Unilateral tenderness. especially on movement of cervix, crepitant mass on one side or in culde-sac; dark red or brown vaginal discharge

No masses, rectal tenderness high on right side No vaginal discharge

Bilateral tenderness on movement of cervix Purulent discharge

Tenderness over affected ovary, no masses

Cervix open or closed, uterus slightlyenlarged.

Irregularly softened, tender with infection, vaginal bleeding

Laboratory findings

WBC to 15,000/mm3 Pregnancy test positive Ultrasound to rule out pregnancyafter 6 weeks  

WBC 10,000-18,000/mm3 (rarely normal) Pregnancy test negative

WBC 15,000-30,000/mm3 Pregnancy test negative

WBC normal to 10,000/mm3 Pregnancy test negative unless also pregnant Ultrasound will show ovarian cyst

WBC normal Pregnancy test positive

 

The woman should also be assessed for the presence of active bleeding, associated with tubal rupture. If internal bleeding is present, assessment may reveal vertigo, shoulder pain, hypotension, and tachycardia. A vaginal examination should be performed only once, and then with great caution. Approximately half of patients with a tubal pregnancy have a palpable mass on examination. It is possible to rupture the mass during a bimanual examination, so gentleness is critical (Simpson, 2002).

Removal of the ectopic pregnancy by salpingostomy is possible before rupture. Residual tissue is dissolved with a dose of methotrexate postoperatively. Methotrexate is a folk acid analog that destroys the rapidly dividing cells (DeLoia, Stewart-Akers, & Creinin, 1998). It may also be used in a single-dose IM injection to treat unruptured pregnancies (Lipscomb et al., 1998). It has been shown to produce results similar to those of surgical therapy, in terms of high success rate, low complication rate, and good reproductive potential (Buster & Heard, 2000).

Advanced ectopic abdominal pregnancy requires laparotomy as soon as the woman has been stabilized for operation. If the placenta of a second- or third-trimester abdominal pregnancy is attached to a vital organ, such as the liver, separation is usually not attempted because of the risk of hemorrhage. The cord is cut flush with the placenta and the abdomen is closed, with the placenta left in place. Degeneration and absorption of the placenta usually occur without complication, although infection and intestinal obstruction may occur. Methotrexate may be given to dissolve the residual tissue (Cunningham et al., 2001).

If surgery is planned, general preoperative and postoperative care is appropriate for the woman with an ectopic pregnancy. Before surgery, vital signs (pulse, respirations, and blood pressure) are assessed every 15 minutes or as needed, according to severity of the bleeding and the woman's condition. Preoperative laboratory tests include determination of blood type and Rh factor, complete blood cell count, and serum quantitative /3-hCG assay. Blood replacement may be necessary. Postoperatively, the nurse needs to verify the woman's Rh and antibody status and administer Rho(D) immune globulin if appropriate. The woman should be encouraged to verbalize her feelings related to the loss. Referral to community resources may be appropriate.

Hemodynamically stable women with ectopic pregnancies are eligible for methotrexate therapy if the mass is unruptured and measures less than 4 cm in diameter by ultrasound (Simpson, 2002). Management is almost always accomplished on an outpatient basis. The woman is informed how the medication works, what adverse effects are possible, whom to call if she has concerns or problems develop, and the importance of follow-up care. After receiving the methotrexate injection, the woman will need to return at least weekly for follow-up laboratory studies and possibly another dose for an average of 2 to 8 weeks until /3-hCG level drops. During that time, she is instructed to put nothing in her vagina (no tampons, douches, or intercourse) and to avoid sun exposure because the drug will make her more photosensitive (Powell & Spellman, 1996).

 

NURSE ALERT The woman on methotrexate therapy who drinks alcohol and takes vitamins containing folic acid (such as prenatal vitamins) increases her risk of experiencing side effects of the drug or exacerbating the ectopic rupture.

 

Future fertility should be discussed. Any woman who has been diagnosed with an ectopic pregnancy should be told to contact her health care provider as soon as she suspects that she might be pregnant, because of the increased risk for recurrent ectopic pregnancy. These women may need referral to grief or infertility support groups. In addition to the loss of the current pregnancy, they are faced with the possibility of future pregnancy losses or infertility.

 

Hydatidiform mole

Hydatidiform mole (molar pregnancy) is a gestational trophoblastic disease. There are two distinct types of hydatidiform moles: complete (or classic) mole and partial mole.

Incidence and etiology. Hydatidiform mole occurs in 1 in 1200 pregnancies in the United States and Europe, but a higher incidence has been reported in Asian countries (Berman, DiSaia, & Brewster, 1999). The etiology is unknown, although there may be an ovular defect or a nutritional deficiency. Women at higher risk for hydatidiform mole formation are those who have undergone ovulation stimulation with clomiphene (Clomid) and those who are in their early teens or older than 40 years of age. The risk of a second mole is 1% to 2%.

Types. The complete mole results from fertilization of an egg whose nucleus has been lost or inactivated (Fig. 10, A). The mole resembles a bunch of white grapes (Fig. 10, B). The fluid-filled vesicles grow rapidly, causing the uterus to be larger than expected for the duration of the pregnancy. Usually the complete mole contains no fetus, placenta, amniotic membranes, or fluid. Maternal blood has no placenta to receive it; hemorrhage into the uterine cavity and vaginal bleeding therefore occur. In approximately 20% of cases of complete mole, progression toward choriocarcinoma occurs.

 

Fig. 10 A, Chromosomal origin of complete mole. Single sperm (color) fertilizes an "empty" ovum. Reduplication of sperm's 23,X set gives completely homozygous diploid 46,XX. Similar process follows fertilization of empty ovum by two sperm with two independently drawn sets of 23,X or 23,Y; both karyotypes of 46,XX and 46,XY can therefore result. B, Uterine rupture with hydatidiform mole. 1, Evacuation of mole through cervix. 2, Rupture of uterus and spillage of mole into peritoneal cavity (rare).

 

A partial mole often has embryonic or fetal parts and an amniotic sac present. Congenital anomalies are usually present. The potential for malignant transformation is much less (less than 6%) than that associated with the complete hydatidiform mole (Copeland & Landon, 2002).

Clinical manifestations. The signs and symptoms of a complete hydatidiform mole in the early stages cannot be distinguished from those of normal pregnancy. Later, vaginal bleeding occurs in almost 95% of cases. The vaginal discharge may be dark brown (resembling prune juice) or bright red and either scant or profuse. It may continue for only a few days or intermittently for weeks. Early in pregnancy the uterus in approximately half of affected women is significantly larger than expected from menstrual dates. The percentage of women with an excessively enlarged uterus increases as length of time since LMP increases. Approximately 25% of affected women have a uterus smaller than would be expected from menstrual dates.

Anemia from blood loss, excessive nausea and vomiting (hyperemesis gravidarum), and abdominal cramps caused by uterine distention are relatively common findings. Preeclampsia occurs in approximately 15% of cases, usually between 9 and 12 weeks of gestation, but any symptoms of PIH before 20 weeks of gestation may suggest hydatidiform mole. Hyperthyroidism and pulmonary embolization of trophoblastic elements occur infrequently but are serious complications of hydatidiform mole. Partial moles cause few of these symptoms and may be mistaken for an incomplete or missed miscarriage.


CARE MANAGEMENT

Nursing assessments during prenatal visits should include observation for signs of molar pregnancy during the first 24 weeks. If hydatidiform mole is suspected, ultrasonography and serial /3-hCG immunoassays are used to confirm the diagnosis. The sonographic pattern of a molar pregnancy is characterized by a diffuse "snowstorm" pattern. A /3-hCG titer will remain high or rise above normal peak after the time at which it normally drops (70 to 100 days) (Cunningham et al., 2001).

Although most moles abort spontaneously, suction curettage offers a safe, rapid, and effective method of evacuation of hydatidiform mole if necessary (Gilbert & Harman, 1998). Induction of labor with oxytocic agents or prostaglandins is not recommended because of the increased risk of embolization of trophoblastic tissue (Copeland & Landon, 2002). Administration of Rho(D) immune globulin to women who are Rh negative is necessary to prevent isoimmunization.

The nurse provides the woman and her family with information about the disease process, the necessity for a long course of follow-up, and the possible consequences of the disease. Follow-up management includes frequent physical and pelvic examinations and biweekly measurements of /3-hCG level until the level drops to normal and remains normal for 3 weeks. Monthly measurements are taken for 6 months and then every 2 months for a total of 1 year. A rising titer and an enlarging uterus may indicate choriocarcinoma. The nurse helps the woman understand and cope with pregnancy loss and recognize that the pregnancy was abnormal. Explanations about the importance of the need to postpone a subsequent pregnancy and contraceptive counseling are provided to emphasize the importance of consistent and reliable use of the method chosen. To avoid confusion with signs of pregnancy, pregnancy should be avoided for 1 year. Any contraceptive method except an intrauterine device is acceptable. Oral contraceptives are highly effective. The woman and her family are encouraged to express their feelings, and information is provided about support groups or counseling resources
if needed.


LATE PREGNANCY BLEEDING

Late pregnancy bleeding disorders include placenta previa, premature separation of placenta (abruptio placentae), and cord insertion and placental variations. Expedient assessment for and diagnosis of the cause of bleeding is essential to reduce risk of maternal and perinatal morbidity and mortality (Fig. 11).

 

 

Fig. 11 Bleeding during late pregnancy. CBC, Complete blood count; IV, intravenous.

 

Placenta previa

Fig. 12 Types of placenta previa after onset of labor. A, Complete, or total. B, Incomplete, or partial. C, Marginal, or low lying

 

In placenta previa, the placenta is implanted in the lower uterine segment near or over the internal cervical os. The degree to which the internal cervical os is covered by the placenta has traditionally been used to classify three types of placenta previa (Fig. 12). Placenta previa often is described as total or complete if the internal os is entirely covered by the placenta when the cervix is fully dilated. Partial placenta previa implies incomplete coverage of the internal os. Marginal placenta previa indicates that only an edge of the placenta extends to the internal os but may extend onto the os during dilation of the cervix during labor. The term low-lying placenta is used when the placenta is implanted in the lower uterine segment but does not reach the os.

Incidence and etiology. The incidence of placenta previa is approximately 0.5% of births (Clark, 1999). The most important risk factors are previous placenta previa, previous cesarean birth, and induced abortion, possibly related to endometrial scarring (Ananth et al., 1997). The risk also increases with multiple gestation (because of the larger placental area), closely spaced pregnancies, advanced maternal age (older than 35 years), African or Asian ethnicity, smoking, and cocaine use (Clark, 1999).

Clinical manifestations. Approximately 70% of women with placenta previa have painless vaginal bleeding; 20% have vaginal bleeding associated with uterine activity. Previa should be suspected whenever vaginal bleeding occurs after 24 weeks of gestation. This bleeding is associated with the stretching and thinning of the lower uterine segment that occurs during the third trimester. Placental attachment is gradually disrupted, and bleeding occurs when the uterus is not able to adequately contract and stop blood flow from open vessels (Benedetti, 2002). The initial bleeding is usually a small amount and stops as clots form; however, it can recur at any time (Table 8). It is bright red in color.

 

 

ABRUPTIO PLACENTAE

 

 

PLACENTA PREVIA

 

GRADE 1

MILD SEPARATION (10% TO 20%)

GRADE 2

MODERATE SEPARATION (20% TO 50%)

GRADE 3

SEVERE SEPARATION (>50%)

Bleeding, external, vaginal

Minimal

Absent or moderate

Absent to moderate

Minimal to severe and life-threatening

Total amount of blood loss

<500 ml

1000-1500 ml

>1500 ml

Varies

Color of blood

Dark red

Dark red

Dark red

Bright red

Shock

Rare; none

Mild shock

Common, often sudden, profound

Uncommon

Coagulopathy

Rare; none

Occasional DIC

Frequent DIC

None

Uterine tonicity

Normal

Increased, may be localized to one region or diffuse over uterus, uterus fails to relax between contractions

Tetanic, persistent uterine contraction, boardlike uterus

Normal

Tenderness (pain)

Usually absent

Present

Agonizing, unremitting uterine pain

Absent

Ultrasonographic findings

 

 

 

 

Location of placenta

Normal, upper uterine segment

Normal, upper uterine segment

Normal, upper uterine segment

Abnormal, lower uterine segment

Station of presenting part

Variable to engaged

Variable to engaged

Variable to engaged

High, not engaged

Fetal position

Usual distribution*

Usual distribution*

Usual distribution*

Commonly transverse, breech, or oblique

Pregnancy-induced or chronic hypertension

Usual distribution*

Commonly present

Commonly present

Usual distribution*

Fetal effects

Normal fetal heart rate patten

Nonreassuring fetal heart rate pattern

Nonreassuring fetal heart rate pattern, death can occur

Normal fetal heart rate pattern

 

Vital signs may be normal, even with heavy blood loss, because a pregnant woman can lose up to 40% of blood volume without showing signs of shock. Clinical presentation and decreasing urinary output may be better indicators of acute blood loss than vital signs alone (Gilbert & Harmon, 1998). The fetal heart rate is reassuring unless there is a major detachment of the placenta. Abdominal examination usually reveals a soft, relaxed, nontender uterus with normal tone. If the fetus is lying longitudinally, the fundal height is usually greater than expected for gestational age because the low placenta hinders descent of the presenting fetal part. Leopold's maneuvers may reveal a fetus in an oblique or breech position or lying transverse because of the abnormal site of placental implantation.

Maternal and fetal outcome. The maternal morbidity rate is approximately 5% and the mortality rate is less than 1% with placenta previa (Clark, 1999). Complications associated with placenta previa include premature ROM, preterm birth, surgery-related trauma to structures adjacent to the uterus, anesthesia complications, blood transfusion reactions, overinfusion of fluids, abnormal placental attachments to the uterine wall (e.g., placenta accreta), postpartum hemorrhage, thrombophlebitis, anemia, and infection  (Crane et al., 2000).

The greatest risk of fetal death is caused by preterm birth. Other fetal risks include hypoxia in utero and congenital anomalies. Infants who are small for gestational age or have IUGR have been associated with placenta previa; this association may be related to poor placental exchange  or hypovolemia resulting from maternal blood loss and maternal anemia (Clark, 1999).


CARE MANAGEMENT

Assessment and Nursing Diagnoses

A woman with third-trimester vaginal bleeding requires immediate evaluation. Necessary history data include gravidity, parity, and a description of the bleeding (how long, precipitating event, estimation of amount). Other assessment data to be collected are the woman's general status, estimated gestational age, current amount of bleeding, vital signs, and fetal status (see Box 6). Laboratory studies include a complete blood count, determination of blood type and Rh status, a coagulation profile, and a possible type and crossmatch.

Placenta previa can be diagnosed using transabdominal ultrasound, which is accurate 93% to 97% of the time. Transvaginal ultrasound examination may also be used. If the ultrasound reveals a normally implanted placenta, a speculum examination may be performed to rule out local causes of bleeding (e.g., cervicitis, polyps, or carcinoma of the cervix), and a coagulation profile is obtained to rule out other causes of bleeding. If expectant management is to be implemented, a vaginal speculum examination is postponed until fetal viability has been reached (preferably after 34 weeks of gestation). If a pelvic examination is needed before that time, anticipate the possibility that an immediate cesarean birth may be required. The woman is taken to a delivery room or an operating room set up for cesarean birth because profound hemorrhage can occur during the examination. This type of vaginal examination, known as the double-setup procedure, is not done often.

Potential nursing diagnoses for the woman experiencing placenta previa include the following:

Deficient fluid volume related to

-excessive blood loss secondary to placenta previa

Risk for excess fluid volume related to

-fluid resuscitation

Ineffective peripheral tissue perfusion related to

-hypovolemia and shunting of blood to central circulation

Risk for injury (fetal) related to

-decreased placental perfusion secondary to placenta previa

Anxiety/fear related to

-maternal condition and pregnancy outcome

Interrupted family processes related to

-woman's condition and hospitalization

Anticipatory grieving related to

-actual/perceived threat to self, pregnancy, or infant

Risk for infection related to

-anemia, hemorrhage, placenta previa, and transfusions

Risk for injury (mother) related to

-invasive monitoring procedures and treatment

 

Expected Outcomes of Care

Expected outcomes for the woman experiencing placenta previa may include that the woman will do the following:

• Verbalize understanding of her condition and its management

• Identify and use available support systems

• Demonstrate compliance with prescribed activity limitations

• Develop no complications related to bleeding

• Give birth to a healthy infant at or near term

 

Plan of Care and Interventions

Active management

Once placenta previa has been diagnosed, a management plan is developed based on gestational age, amount of bleeding, and fetal condition. If the woman is at term (greater than or equal to 37 weeks of gestation) and in labor or bleeding persistently, immediate delivery by cesarean is almost always indicated. In women with partial or marginal previa who have minimal bleeding, vaginal birth may be attempted. Vaginal birth may also be indicated for previable gestations or births involving intrauterine fetal demise (Benedetti, 2002).

If cesarean birth is undertaken, the nurse continuously assesses maternal and fetal status while preparing the woman for surgery. Maternal vital signs are assessed frequently for decreasing blood pressure, rising pulse rate, changes in level of consciousness, and oliguria. Fetal assessment is maintained by continuous electronic fetal monitoring to assess for signs of hypoxia.

Blood loss may not cease with the birth of the infant. The large vascular channels in the lower uterine segment may continue to bleed because of that segment's diminished muscle content. The natural mechanism to control bleeding so characteristic of the upper part of the uterus—the interlacing muscle bundles, the "living ligature" contracting around open vessels-is absent in the lower part of the uterus. Postpartum hemorrhage may therefore occur even if the fundus is contracted firmly.

Emotional support for the woman and her family is extremely important. The actively bleeding patient is concerned not only for her own well-being but for the wellbeing of her fetus. All procedures should be explained, and a support person should be present. The woman should be encouraged to express her concerns and feelings. If the woman and her support person or family desire spiritual support, the nurse can notify the hospital chaplain service or provide information about other supportive resources.

Expectant management

If the woman is less than 36 weeks of gestation and not in labor, and the bleeding is mild or has stopped, expectant management is generally the treatment of choice to give the fetus time to mature in utero. Expectant management consists of rest and close observation. The woman is usually placed on bed rest, although she may be allowed bathroom privileges and limited activity (up in a wheelchair for an hour or so daily). Bleeding is assessed by checking the amount of bleeding on perineal pads, bed pads, and linens. Weighing pads, although not frequently used, is one way to more accurately assess blood loss: 1 g represents 1 ml of blood.

Ultrasonographic examinations may be done every 2 to 3 weeks. Fetal surveillance may include NSTs or BPPs once or twice weekly. Antepartum steroids (betamethasone) may be ordered to promote fetal lung maturity if the woman is less than 34 weeks of gestation. No vaginal or rectal examinations are performed, and the woman is placed on pelvic rest (nothing in the vagina). Once she reaches 37 weeks of gestation and fetal lung maturity is documented, cesarean birth can be scheduled.

The woman with placenta previa should always be considered a potential emergency because massive blood loss with resulting hypovolemic shock can occur quickly if bleeding resumes. The possibility that she may require an emergency cesarean for birth always exists. Placenta previa in a preterm gestation may be an indication for transfer to a tertiary perinatal center because many community hospitals are not equipped to perform emergency cesarean births 24 hours per day, 7 days per week.

Home care

Criteria for home care management vary with primary perinatal provider and home care agency. To be considered for home care referral, the woman must be in stable condition with no evidence of active bleeding and must have resources to be able to return to the hospital immediately if active bleeding resumes (Lowdermilk & Grohar, 1998). She must have close supervision by family or friends in the home. The woman should be taught how to assess fetal and uterine activity and bleeding and told to avoid intercourse, douching, and enemas. She should limit her activities according to the advice of her physician and be informed to keep all appointments for fetal testing, laboratory assessments, and prenatal care. Visits by a perinatal home care nurse may be arranged.

If hospitalization or home care with activity restriction is prolonged, the woman may have concerns about her work- or family-related responsibilities or may become bored with inactivity. She should be encouraged to participate in her own care and decisions about care as much as possible. Provision of diversionary activities or encouragement to participate in activities she enjoys and can do during bed rest is needed (see suggestions for activities in the Self-Care box on p. 613). Participation in a support group made up of other women on bed rest while hospitalized may be a helpful coping mechanism (Maloni & Kutil, 2000).

Evaluation

The expected outcomes of care are used to evaluate the care for the woman with placenta previa (see Plan of Care).


PLAN OF CARE Placenta Previa

NURSING DIAGNOSIS Decreased cardiac output related to bleeding secondary to placenta previa

Expected Outcomes Patient will exhibit signs of increased blood volume and restoration of cardiac output (i.e., normal pulse and blood pressure, normal heart and breath sounds, normal skin color, tone and turgor, normal capillary refill).

Nursing Interventions/Rationales

Palpate uterus for tenderness and tone; assess bleeding rate, amount, color, degree of bleeding, CBC values, and coagulation profile to determine severity of situation. (Do not perform vaginal examination, because it may stimulate further bleeding.)

Establish baseline data for cardiac output (vital signs; heart and breath sounds; skin color, tone, turgor; capillary refill; level of consciousness; urinary output; pulse oximetry) to use as basis for evaluating effectiveness of treatment.

Initiate intravenous therapy or blood transfusions and medications per physician order to restore blood volume and prevent organ compromise to mother and fetus.

Place woman on bed rest to decrease oxygen demands.

Monitor vital signs, intake and output, hemodynamic status, and laboratory values to evaluate treatment response.

Provide emotional support to woman and her family (i.e., explain procedures and their rationale; explain what is happening and what to expect; keep support person present) to allay fears and provide the family with some sense of control.

After stabilization, teach woman home management, including bed rest, watching for spotting/bleeding, close followup with her health care provider and preparation for immediate return to hospital if needed to prevent or stem further complications.

 

NURSING DIAGNOSIS Risk for injury to the fetus related to decreased uterine/placental perfusion secondary to bleeding

Expected Outcome Patient will exhibit ongoing signs of fetal well-being (i.e., adequate fetal movement, normal FHR, reactive NST, normal BPP).

Nursing Interventions/Rationales

Monitor fetus daily for signs of tachycardia, decreased movement, loss of reactivity on NST to identify and treat changes in fetal status early.

Obtain BPP per physician order to assess for signs of chronic asphyxia.

Maintain maternal side-lying position to prevent compression of aorta and vena cava.

 

NURSING DIAGNOSIS Risk for infection related to anemia and bleeding secondary to placenta previa

Expected Outcome Patient will show no signs of intrauterine infection.

Nursing I nterventions/ Rationales

Monitor vital signs for elevated temperature, pulse, and blood pressure; monitor laboratory results for elevated WBC count, differential shift; check for uterine tenderness and malodorous vaginal discharge to detect early signs of infection resulting from exposure of placenta! tissue.

Provide/teach perineal hygiene to decrease the risk of ascending infection.

 

 


Premature separation of placenta

Premature separation of the placenta, also termed abruptio placentae (Fig. 13) occurs in the area of the decidua basalis after the twentieth week of pregnancy and before the birth of the baby.

 

Fig. 13 Abruptio placentae. Premature separation of normally implanted placenta.

 

Incidence and etiology. Premature separation of the placenta is a serious event that accounts for significant maternal and fetal morbidity and mortality rates. One percent of all pregnancies are complicated by abruptio placentae, but it accounts for approximately 15% of all perinatal deaths. More than 50% of these deaths are the result of preterm birth; many others are the result of intrauterine hypoxia.

Maternal hypertension is probably the most consistently identified risk factor for abruption (Benedetti, 2002). Cocaine use is also a risk factor, probably in part because cocaine use is associated with the development of hypertension (Andres & Day, 2000). Blunt external abdominal trauma, most often the result of motor vehicle accidents or maternal battering, is an increasingly significant cause of placental abruption (Benedetti, 2002). Maternal smoking and poor nutrition may be associated with an increased risk. Abruption is more likely to occur in twin gestations (Ananth et al., 2001). There is a significant risk for recurrence of placental abruption in subsequent pregnancies.

Classification. The most common classification of placental abruption is according to type and severity. This classification system is summarized in Table 8.

Clinical manifestations. The separation may be partial or complete, or only the margin of the placenta may be involved. Bleeding from the placental site may dissect (separate) the membranes from the decidua basalis and flow out through the vagina, it may remain concealed (retroplacental hemorrhage), or it may do both (see Fig. 13). Clinical symptoms vary with degree of separation (see Table 8).

Classic symptoms of abruptio placentae include vaginal bleeding, abdominal pain, and uterine tenderness and contractions. Although abdominal pain and uterine tenderness are characteristic for this complication, either finding may be absent in the presence of a silent abruption (Konje & Walley, 1995). Bleeding may result in maternal hypovolemia (shock, oliguria, anuria) and coagulopathy. Mild to severe uterine hypertonicity is present. Pain is mild to severe and localized over one region of the uterus or diffuse over the uterus with a boardlike abdomen.

Extensive myometrial bleeding damages the uterine muscle. If blood accumulates between the separated placenta and the uterine wall, it may produce a Couvelaire uterus. The uterus appears reddish or purplish, it is ecchymotic, and contractility is lost. Shock may occur and is out of proportion to blood loss. Laboratory findings include a positive result of Apt test (blood in amniotic fluid); a drop in hemoglobin and hematocrit levels (which may appear later); and a drop in coagulation factor levels. Clotting defects (such as DIC) develop in 10% to 30% of patients. A Kleihauer-Betke stain may be ordered to determine the presence of fetal-to-maternal bleeding (transplacental hemorrhage).

Maternal and fetal outcomes. Maternal mortality rates approach 1% for abruptio placentae; this condition remains a leading cause of maternal death. The mother's prognosis depends on the extent of placental detachment, overall blood loss, degree of DIC, and time between placental detachment and birth. Renal failure and pituitary necrosis may result from ischemia. In rare cases, women who are Rh negative can become sensitized if fetal-to-maternal hemorrhage occurs and the fetal blood type is Rh positive.

Perinatal mortality rates range from 15% to 30%. Death occurs as a result of fetal hypoxia, preterm birth, and status as small for gestational age. Risk for neurologic defects is increased (Cunningham et al., 2001).


CARE MANAGEMENT

Abruptio placentae should be highly suspected in the woman with a sudden onset of intense, usually localized, uterine pain, with or without vaginal bleeding. Initial assessment is much the same as for placenta previa. Physical examination usually reveals abdominal pain, uterine tenderness, and contractions. Vaginal bleeding is present in approximately 80% of cases (Benedetti, 2002). Approximately 60% of live fetuses exhibit nonreassuring signs on the electronic fetal heart monitor, such as loss of variability and late decelerations; uterine hyperstimulation and increased resting tone may also be noted on the monitor tracing (Benedetti, 2002). Many women demonstrate coagulopathy, as evidenced by abnormal clotting studies (fibrinogen, platelet count, PT, PTT, fibrin split products). Sonographic examination is used to rule out placenta previa; however, it is not always diagnostic for abruption (Cunningham et al., 2001).

Nursing diagnoses and expected outcomes of care are similar to those described for placenta previa.

Treatment depends on the severity of blood loss and fetal maturity and status. Women with abruptio placentae are not usually managed out of the hospital because the placenta can separate further at any time and immediate intervention or delivery may be necessary. If the abruption is mild and the fetus is less than 36 weeks of gestation and not in distress, expectant management may be implemented. The woman is hospitalized and observed closely for signs of bleeding and labor. The fetal status is also monitored with intermittent FHR monitoring and NSTs or BPPs until fetal maturity is determined or until the woman's condition deteriorates and immediate birth is indicated. Use of corticosteroids to accelerate fetal lung maturity is appropriately included in the plan of care for expectant management (ACOG, 1994; Hunter & Weiner, 1996). Women who are Rh negative may be given Rho(D) immune globulin if fetal-to-maternal hemorrhage occurs and the fetal blood is Rh positive. Vaginal birth is expected; cesarean birth may be necessary for cases of fetal distress or other obstetric indications.

Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and mother or fetus is in jeopardy. At least one large-bore (16- gauge) IV line should be started. Maternal vital signs are monitored frequently to observe for signs of declining hemodynamic status, such as increasing pulse rate and decreasing blood pressure. Serial laboratory studies include hematocrit or hemoglobin determinations and clotting studies. Continuous electronic fetal monitoring is mandatory. An indwelling Foley catheter is inserted for continuous assessment of urine output, an excellent indirect measure of maternal organ perfusion (Benedetti, 2002).

Blood and fluid volume replacement will most likely be ordered, with a goal of maintaining the urine output at 30 ml/hr or greater and the hematocrit at 30% or greater. If this goal is not reached despite vigorous attempts at replacement, hemodynamic monitoring may be necessary (Benedetti, 2002). Fresh frozen plasma or cryoprecipitate may be given to maintain the fibrinogen level at a minimum of 100 to 150 mg/dl.

Vaginal birth is possible and is especially desirable in cases of fetal demise; however, cesarean birth is common because of fetal or maternal distress.

Nursing care of patients experiencing moderate-tosevere abruption is demanding because it requires close monitoring of the maternal and fetal condition. All procedures should be explained to the woman and her family. Emotional support is also extremely important because the woman and her family may be experiencing grief over fetal loss in addition to the mother's critical illness.

 

Cord insertion and placental variations

Velamentous insertion of the cord is a rare placental anomaly associated with placenta previa and multiple gestation. The cord vessels begin to branch at the membranes and then course onto the placenta (Fig. 14, A). ROM or traction on the cord may tear one or more of the fetal vessels. As a result the fetus may quickly bleed to death. Battledore (marginal) (Fig. 14, B) insertion of the cord increases the risk of fetal hemorrhage, especially after marginal separation of the placenta.

 

Fig. 14 Cord insertion and placental variations. A, Velamentous insertion of cord. B, Battledore placenta. C, Placenta succenturiate.

 

Rarely, the placenta may be divided into two or more separate lobes, resulting in placenta succenturiate (Fig. 14, C). Each lobe has a distinct circulation; the vessels collect at the periphery, and the main trunks unite eventually to form the vessels of the cord. Blood vessels joining the lobes may be supported only by the fetal membranes and are therefore in danger of tearing during labor, birth, or expulsion of the placenta. During recovery of the placenta, one or more of the separate lobes may remain attached to the decidua basalis, preventing uterine contraction and increasing the risk of postpartum hemorrhage.

 

Clotting disorders in pregnancy

Normal clotting. Normally, there is a delicate balance (homeostasis) between the opposing hemostatic and fibrinolytic systems. The hemostatic system is involved in the lifesaving process. This system stops the flow of blood from injured vessels, in part through the formation of insoluble fibrin, which acts as a hemostatic platelet plug. The phases of the coagulation process involve an interaction of the coagulation factors in which each factor sequentially activates the factor next in line, the "cascade effect" sequence. The fibrinolytic system is the process through which the fibrin is split into fibrinolytic degradation products and circulation is restored.

Clotting problems. A history of abnormal bleeding, inheritance of unusual bleeding tendencies, and a report of significant aberrations of laboratory findings indicate a bleeding or clotting problem. For the obstetric patient, bleeding disorders are suspected if the woman has PIH, HELLP syndrome, retained dead fetus syndrome, amniotic fluid embolism, sepsis, or hemorrhage. Determination of hemostasis is made by testing the usual mechanisms for the control of bleeding, the function of platelets and the necessary clotting factors. Most clotting disorders are more of a concern in the immediate postpartum period. Recognition in the antepartal period may decrease hemorrhagic problems (see Chapter 25).

Disseminated intravascular coagulation. Disseminated intravascular coagulation (DIC) is a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both. It is important to understand that DIC is always a secondary diagnosis. In the obstetric population, HELLP syndrome and gram-negative sepsis are examples of conditions that can trigger DIC because of widespread damage to vascular integrity. Medical management is discussed in Chapter 25.

The nurse caring for the woman at risk for DIC must be aware of risk factors. Careful and thorough assessment is required, with particular attention to signs of bleeding (petechiae, oozing from injection sites, and hematuria). Because renal failure is one consequence of DIC, urinary output is carefully monitored, using an indwelling Foley catheter. Vital signs are assessed frequently.

The pregnant woman is maintained in a side-lying tilt to maximize blood flow to the uterus. Oxygen may be administered through a tight-fitting, rebreathing mask at 10 to 12 L/min, or per hospital protocol or physician order. Blood and blood products must be administered safely.

The educational and emotional needs of the woman and her family must be recognized and supported. They need information about her condition and explanations of procedures and will most likely be very anxious about the health of mother and baby.


HYPEREMESIS GRAVIDARUM

Nausea and vomiting complicate approximately 70% of all pregnancies and are usually confined to the first trimester (Gordon, 2002). Although these manifestations are distressing, they are typically benign, with no significant metabolic alterations or risks to the mother or fetus.

When vomiting during pregnancy becomes excessive enough to cause weight loss of at least 5% of prepregnancy weight and is accompanied by dehydration, electrolyte imbalance, ketosis, and acetonuria, the disorder is termed hyperemesis gravidarum. The estimated incidence varies from 0.5 to 10 per 1000 births (Snell et al., 1998). Hyperemesis gravidarum usually begins during the first 10 weeks of pregnancy. Women with hyperemesis tend to be younger than 20 years of age, obese, and nonsmokers. They are also more likely to have multifetal or molar pregnancies (Riely, 1999). The effects of hyperemesis gravi darum on perinatal outcome vary with the severity of the disorder. Women who lose weight are more likely to have low-birth-weight infants.

 

ETIOLOGY

The etiology of hyperemesis gravidarum remains obscure. Several theories have been proposed as to the cause, although none of them adequately explains the disorder. Hyperemesis gravidarum may be related to high levels of estrogen or human chorionic gonadotropin (hCG) and may be associated with transient hyperthyroidism during pregnancy. It may be accompanied by liver dysfunction

with elevation in transaminase and bilirubin levels. Esophageal reflux, reduced gastric motility, and decreased secretion of free hydrochloric acid may contribute to the disorder. Other possible causes include vitamin B deficiencies and increased sensitivity to circulating sex steroid hormones (Hill & Fleming, 1999; Riely, 1999; Snell et al, 1998).

Psychologic factors may also play a part in the development of hyperemesis gravidarum, at least in some women. Ambivalence toward the pregnancy and difficult relationships with mothers or partners have been identified as causative factors. High stress levels are probably also associated with this condition (Hill & Fleming, 1999; Snell et al., 1998). Conflicting feelings regarding prospective motherhood, body changes, and lifestyle alterations may contribute to episodes of vomiting, particularly if these feelings are excessive or unresolved.

 

CLINICAL MANIFESTATIONS

The woman with hyperemesis usually has significant weight loss and dehydration. She may have a decreased blood pressure, increased pulse rate, and poor skin turgor (Snell et al., 1998). She is almost always unable to keep down even clear liquids taken by mouth. Laboratory tests may reveal electrolyte imbalances.

 

CARE MANAGEMENT

Whenever a pregnant woman has nausea and vomiting, the first priority is a thorough assessment to determine the severity of the problem. In most cases, the woman should be told to come immediately to the health care provider's office or to the emergency department, because the severity of the illness is often difficult to determine by phone conversation.

The history includes information about the frequency, severity, and duration of episodes of nausea and vomiting. Other symptoms such as diarrhea, indigestion, and abdominal pain or distention are also identified. The woman is asked to report any precipitating factors relating to the onset of her symptoms. Any pharmacologic or nonpharmacologic treatment measures should be recorded. Prepregnancy weight and documented weight gain or loss during pregnancy are important to note.

The woman's weight and vital signs are measured and a complete physical examination is performed, with attention to signs of fluid and electrolyte imbalance and nutritional status. The most important initial laboratory test to be obtained is a dipstick determination of ketonuria. Other laboratory tests that may be ordered are a urinalysis, a complete blood cell count, electrolytes, liver enzymes, and bilirubin levels. These tests help rule out the presence of underlying diseases such as pyelonephritis, pancreatitis, cholecystitis, and hepatitis (Cruikshank et al., 2002). Because of the recognized association between hyperemesis gravidarum and hyperthyroidism, thyroid levels may also be measured.

Psychosocial assessment includes asking the woman about anxiety, fears, and concerns related to her own health and the effects on pregnancy outcome. Family members should be assessed both for anxiety and in regard to their role in providing support for the woman.

 

Initial Care

Initially, the woman who is unable to keep down clear liquids by mouth will require IV therapy for correction of fluid and electrolyte imbalances. She should be kept on nothing-by-mouth (NPO) status until dehydration has been resolved and for at least 48 hours after vomiting has stopped to prevent rapid recurrence of the problem (Cruikshank et al., 2002). In the past, women requiring IV therapy were admitted to the hospital. Today, however, they may be, and often are, successfully managed at home. Antiemetic medications may be used if nausea and vomiting are uncontrolled; commonly used drugs include pyridoxine, droperidol, promethazine, chlorpromazine, prochlorperazine, and metoclopramide. Corticosteroids have  also been used successfully to treat refractory hyperemesis gravidarum. In addition to medical management, some women can also benefit from psychotherapy or stress reduction techniques (Hill & Fleming, 1999; Snell et al., 1998). Once the vomiting has stopped, feedings are started in small amounts at frequent intervals, and the diet is slowly advanced as tolerated.

Nursing care of the woman with hyperemesis gravidarum involves implementing the medical plan of care, whether this care be given in the hospital or home setting. Interventions may include initiating and monitoring IV therapy, administering drugs and nutritional supplements, and monitoring the woman's response to interventions. The nurse observes the woman for any signs of complications such as metabolic acidosis, jaundice, or hemorrhage and alerts the physician should these occur.

Accurate measurement of intake and output, including the amount of emesis, is an important aspect of care. Oral hygiene while the woman is receiving nothing by mouth, and after episodes of vomiting, helps allay associated discomforts. Assistance with positioning and providing a quiet, restful environment, free from odors, may increase the woman's comfort. When the woman begins responding to therapy, limited amounts of oral fluids and bland foods such as crackers or toast are begun. The diet is progressed slowly as tolerated by the woman until she is able to consume a nutritionally sound diet. Because sleep disturbances may accompany hyperemesis gravidarum, promoting adequate rest is important. The nurse can assist in coordinating treatment measures and periods of visitation to provide opportunity for rest periods.

 

Follow-up Care

Most women are able to take nourishment by mouth after several days of treatment. Education at this time is important to prevent rapid recurrence of nausea and vomiting. Women should be encouraged to eat small, frequent meals and low-fat protein foods, to avoid greasy and highly seasoned foods, and to increase their dietary intake of potassium and magnesium. Herbal teas such as chamomile or raspberry leaf may decrease nausea (Beal, 1998). Taking fluids between meals, rather than with them, sometimes helps decrease nausea. Many pregnant women find exposure to cooking odors nauseating. If other family members can take over cooking chores, even temporarily, the woman's nausea and vomiting may decrease. The woman is counseled to contact her health care provider immediately if the nausea and vomiting recurs, especially if accompanied by abdominal pain, dehydration, or significant weight loss (e.g., more than 2.5 kg [5 pounds] in 1 week) (Lowdermilk & Grohar, 1998).

A few women will continue to experience intractable nausea and vomiting throughout pregnancy. Rarely, it may be necessary to maintain a woman on enteral, parenteral, or total parenteral nutrition to ensure adequate nutrition for the mother and fetus (Hill & Fleming, 1999; Snell et al., 1998). Many home health agencies are able to provide these services, and arrangements for service may be made depending on the woman's insurance coverage. Regardless of the site of care, the nurse must remain calm, compassionate, and sympathetic, recognizing that the manifestations of hyperemesis can be physically and emotionally debilitating. Irritability, tearfulness, and mood changes are often consistent with this disorder. Fetal well-being is a primary concern of the woman. The nurse can provide an environment conducive to discussion of those concerns and assist the woman in identifying and mobilizing sources of support. The family should be included in the plan of care whenever possible. Their participation may help alleviate some of the emotional stress associated with this disorder.