Module 2

as proof of carditis. On rare occasions,

second- or third-degree heart block is
present. In patients with chronic rheumatic
Heart Disease heart disease, electrocardiography may
- Fourth leading cause of maternal show left atrial enlargement secondary to
mortality mitral stenosis.
• Auscultation:
CLASSIFICATION OF HEART DISEASE Apical pansystolic murmur is a high-pitched,
• Class I- Uncompromised: Physical Activity blowing-quality murmur of mitral
is not limited by angina or symptoms of regurgitation that radiates to the left axilla.
insufficiency. The murmur is unaffected by respiration or
position. Intensity varies but is grade 2/6 or
• Class II- Slightly Compromised: greater. The mitral insufficiency is related to
Comfortable at rest but normal activity dysfunction of the valve, chordae, and
causes fatigue, palpitations, dyspnea or papillary muscles.
angina.
Apical diastolic murmur (also known as
• Class III- Markedly Compromised: a Carey-Coombs murmur)
Comfortable at rest but less than ordinary - heard with active carditis and
activity causes excessive fatigue, accompanies severe mitral insufficiency.
palpitation, dyspnea or angina. The mechanism for this murmur is
postulated to be due to mitral valvulitis,
• Class IV- Severely Compromised: Unable relative mitral stenosis, as the large
to perform any activity without discomfort; volume of regurgitant flow traverses the
may experience angina or signs of cardiac mitral valve during ventricular filling, or
insufficiency while at rest. combination thereof. It is heard best with the
bell of the stethoscope, while the patient is
*Note: Clients with Class I and Class II Heart in the left lateral position and the breath
Disease have a potential for a good pregnancy held in expiration.
outcome. Those with Class III or Class IV are at
risk for serious complications and may be Basal diastolic murmur
advised to avoid - an early diastolic murmur of aortic
pregnancy. regurgitation and is high-pitched, blowing,
decrescendo, and heard best along the right
MEDICAL CARE upper and mid-left sternal border after deep
Physical Assessment and Diagnostics expiration while the patient is leaning
• Echocardiogram: Valvular stenotic forward.
lesions, especially of the mitral valve, can Medications
be observed in rheumatic heart disease. • Vitamins and Iron
• Chest X-ray: May reveal cardiomegaly • Flu vaccine
and CHF in patients with carditis. • Heparin (coumadin is teratogenic)
• Electrocardiogram: A prolongation of the • Thiazide Diuretics
PR interval, which is a nonspecific finding, • Furosemide
but counts as a minor manifestation in the • Cardiac Glycosides
• Prophylactic antibiotics
Jones diagnostic criteria. It does not count
 Nursing Interventions bacterial endocarditis caused by introduction of
Prepartum microorganisms through the placental site.
• Promote Rest. Two rest periods a day, full
night’s sleep in the left lateral recumbent
position.
• Promote Healthy Nutrition. Must gain enough Diabetes Mellitus
weight to ensure a healthy pregnancy, but she - pancreas cannot produce adequate insulin
must not gain so much weight to regulate body glucose levels. The primary
• Educate Regarding Medication. Women problem of any woman with this disorder is
taking cardiac medication before pregnancy may controlling the balance between insulin and
need to increase their maintenance dose due to blood glucose levels to prevent
their expanded blood volume during pregnancy.
hyperglycemia or hypoglycemia.
• Educate Regarding Avoidance of Infection.
• Be Prepared for Emergency Actions.
Women with heart disease may need RISK FACTORS
supplemental oxygen if they overexert as could M- MATERNAL AGE (>25 yrs old)
happen during a prenatal visit. O- OBESITY OR OVERWEIGHT
M- MACROSOMIA
Intrapartum M- MULTIPLE PREGNANCY
• Monitor fetal heart rate and uterine A- A HISTORY (family hx of diabetes,
contractions during labor in all women with congenital anomalies in previous
heart disease. pregnancy, polycystic ovary syndrome,
• Assess a woman’s blood pressure, pulse,
unexplained fetal or perinatal loss)
and respirations frequently. A rapidly
increasing pulse rate 100 bpm indicates heart is
pumping ineffectively and has increased its rate DIAGNOSTICS
in an effort to compensate. Laboratory and Diagnostics
• Advise a woman to assume a side-lying ● Blood glucose test
position. If she has some pulmonary edema, it Fasting: >126 mg/dl
may be necessary for her to have her chest and Non-fasting:>200 mg/dl
head elevated (semi-Fowler’s position) to ease ● Urine analysis: for presence of
the work of breathing. glucose and ketones.
• Provide oxygenation. Evaluate a woman ● Ultrasound: for anomalies and fetal
carefully to determine whether the fatigue is growth patterns.
heart or labor related. Women with extreme ● Fetal movement counting: The
heart disease need oxygen administered during healthy fetus makes approximately 10
labor to compensate movements per hour.

Postpartum
Medications
• Educate on the importance of program of
Insulin – oral hypoglycemic agents are
decreased activity and possibly
contraindicated (teratogenic)
anticoagulant and digoxin therapy until her
circulation stabilizes. Dietary Control: 30 to 35 kcal/kg of ideal body
weight/day with no concentrated sweets.
• Antiembolic stockings and ambulation may
be needed to increase venous return from the Possible induction at 38 to 39 weeks and/or
legs. cesarean delivery.
• Prophylactic antibiotics had not been
started prior to birth, they will be started
immediately after birth to discourage subacute
Hormones produced by placenta that lowers - .140 mg/dl(abnormal)
insulin sensitivity (2nd-3rd trim): proceed to 3 hour OGTT
● Human Placental Lactogen ● 3hr OGTT
● Estrogen - If 1hr OGTT is abnormal
● Cortisol - Blood Drawn: Fasting, 1hr,
● Progesterone 2hr, 3hr
*Note: if 2 or more result is
Complications of GDM abnormal = GDM Diagnosis
1. Hyperglycemia U- Use of Diet and exercise to manage
2. UTI & Yeast infection blood glucose
- Glucose leaked in urine - some patient may need insulin/ oral
increases more bacteria. meds like Glyburide
3. Pre eclampsia G- Glucose monitoring (daily basis)
- Increased glucose level ● FASTING: 70-95 mg/dl
hardens the blood vessels ● 1hr AFTERMEAL: <140 mg/dl
results in increased blood A- Assess Urine for glucose at pre-natal
pressure. visits.
4. Macrosomia (Risk for C-section) - Ask if there’s presence of burning
- increased glucose increases sensation while voiding (UTI)
baby size R- Risk for MOMMA
5. Hypoglycemia (baby) B- Blood Glucose Swing during and after
- During pregnancy, the baby labor.
develops more insulin due to ● Monitor level during and after labor
increased glucose supply. At ● Try to maintain euglycemia
birth, baby will have ● Monitor for hypoglycemia in both
hypoglycemia due to mother and fetus after birth
decreased glucose supply A- Adverse Effect of GDM
(cord cutting) and more ● Pre eclampsia
insulin. ● UTI, Vagina yeast infection
6. Risk for Respiratory Distress ● Risk for C-section (Macrosomia)
- Increased glucose affects ● Preterm labor
lung maturity ● Hypoglycemia and respiratory
distress in fetus
3 Ps of Hyperglycemia B- Blood Glucose Monitoring Postpartum
1. Polyphagia (excessive hunger) ● 6-12 weeks after delivery
2. Polydipsia (excessive thirst) ● 2 hr OGTT
3. Polyuria (excessive voiding) E- Educate about the importance of regular
4. Sugar in urine diabetic testing due to the risk of developing
TYPE 2 DM… if GDM disappears.
Nurses Role and Treatment ● 1-3 years
“SUGAR BABE”
S- Screening for GDM
● 1hr. OGTT
- 24-38 weeks gestation
SUBSTANCE ABUSE 3. Marijuana and Hashish
- Obtained from the hemp plant,
- Substance abuse is defined as the
cannabis
inability to meet major role
- When smoked, they produce
obligations, an increase in legal
tachycardia and a sense of
problems or risk-taking behavior, or
well-being
exposure to hazardous situations
- Associated with loss of short-term
because of an addicting substance.
memory and an increased incidence
of respiratory infection in adults.
MEDICAL CARE
- A frequent user may not be able to
1. Laboratory and Diagnostics
breastfeed due to reduced milk
Urine Toxicology Screening: May
production and the risk to the
be done at intervals during
newborn from excretion of the drug
pregnancy
in the milk.
2. Referral to Alcoholic Anonymous,
addiction counseling or psychiatric
4. Phencyclidine Phencyclidine (PCP)
consult if indicated
- An animal tranquilizer that is a
frequently used street drug in
3. Heroin may not be discontinued
polydrug abuse.
abruptly as it will lead to decreased
- Causes increased cardiac output
placental blood flow; methadone
and a sense of euphoria.
maintenance therapy may be used
- It has the potential for causing
for women addicted to narcotics
long-term hallucinations (flashback
though it does cross the placenta.
episodes).
- PCP tends to leave the maternal
Commonly Abuse Substance
circulation and concentrate in fetal
1. Cocaine
cells, so it may be particularly
- Erythroxylum coca
injurious to a fetus.
- Affects the Central nervous system
and results in sudden
5. Inhalants
vasoconstriction which causes
- refers to the “sniffing” or “huffing” of
increased respiratory rate, cardiac
aerosol drugs. Frequently abused
rate, and blood pressure.
substances include airplane glue,
2. Amphetamines
cooking sprays, and computer
- Methamphetamine
keyboard cleaner which contains
- Produce high concentration of drug
freon as a propellant and can lead to
to maternal circulation
severe respiratory and cardiac
- Newborns whose mothers used the
irregularities.
drug show jitteriness and poor
feeding at birth and may be growth
restricted
6. Alcohol. usually detect HIV infection 18 to 45
- detrimental to fetal growth as illegal days after an exposure.
drugs. • Antibody tests
- Fetal alcohol syndrome, a syndrome - look for antibodies to HIV in your
with significant facial features, blood or oral fluid. Antibody tests
possible cognitive challenges and can take 23 to 90 days to detect HIV
memory deficits, occurs, so women infection after an exposure.
are advised to drink no alcohol - tests that use blood from a vein can
during pregnancy detect HIV sooner after infection
than tests done with blood from a
Infection finger prick or with oral fluid. The
enzyme-linked immunosorbent
- Infection may affect the fetus by
assay (ELISA) tests a patient's blood
crossing the placenta or ascending
sample for antibodies. The Western
the vagina.
blot is used to confirm a positive
ELISA.
AIDS
• CD4 cell count
- End stage of acquired
- in the laboratory determines how
immunodeficiency caused by
many cells are still present and
infection with the RNA human
functioning. Because B-lymphocyte
immunodeficiency retrovirus HIV
or humoral immune function, which
initiates the production of antibodies,
Two divisions
is affected, antibody formation will
HIV-1
be decreased
HIV-2
(hypogammaglobulinemia). When
monocytes and macrophages
MEDICAL CARE
become affected as well, the person
Laboratory and Diagnostics
with HIV infection cannot resist
• Nucleic Acid Tests
normal infection. When this CD4
- detect HIV infection 10 to 33 days
count falls below 500 cells/mm3 or
after an exposure
the viral load rises above 5000
- look for the actual virus in the blood;
copies/mL, it is difficult for infected
expensive and is not routinely used
individuals to resist opportunistic
for HIV screening unless the person
infections such as fungal infections.
recently had a high-risk exposure or
Normal counts vary according to age
a possible exposure with early
because the lymphocyte count
symptoms of HIV infection.
normally varies by age.
• Antigen/antibody tests
- look for both HIV antibodies and
The CDC classification of HIV infection in
antigens. If you have HIV, an antigen
children has three categories:
called p24 is produced even before
• Category A, Mildly Symptomatic: two or
antibodies develop. PCR
more symptoms such as enlarged lymph
(polymerase chain reaction), an
nodes, liver, or spleen, or recurrent or
antigen/antibody test performed by a
laboratory on blood from a vein can
persistent upper respiratory infections, RH Sensitization
sinusitis, or otitis media.
RH Incompatibility
• Category B, Moderately Symptomatic:
- Occurs when an Rh-negative mother
more serious illnesses such as
(one negative for a D antigen or one
oropharyngeal candidiasis, bacterial
with a dd genotype) carries a fetus
meningitis, pneumonia, or sepsis,
with an Rh positive blood type (DD
cardiomyopathy, cytomegalovirus infection,
or Dd genotype).
hepatitis, herpes simplex virus (HSV),
bronchitis, pneumonitis, or esophagitis,
Hemolytic disease of the newborn or
herpes zoster (shingles), lymphoid
Erythroblastosis fetalis
interstitial pneumonia (LIP), pulmonary
- A condition where the fetus can
lymphoid hyperplasia complex, or
become so deficient in red blood
toxoplasmosis.
cells that sufficient oxygen transport
to body cells cannot be maintained.
• Category C, Severely Symptomatic
(AIDS), serious bacterial infections such as
MEDICAL CARE
septicemia, pneumonia, meningitis, bone or
Laboratory and Diagnostics
joint infection, or abscess of an internal
• Anti-D antibody titer- done at a first
organ or body cavity; candidiasis
pregnancy visit. If the results are normal or
(esophageal or pulmonary),
the titer is minimal (normal is 0; a ratio
encephalopathy, herpes simplex lasting
below 1:8 is minimal), the test will be
over 1 month, histoplasmosis, lymphoma,
repeated at week 28 of pregnancy. If this is
tuberculosis, Mycobacterium or
also normal, no therapy is needed. If a
Pneumocystis carinii pneumonia.
woman’s anti-D antibody titer is elevated at
a first assessment (1:16 or greater),
Medication: Zidovudine
showing Rh sensitization, the well being of
the fetus in this potentially toxic environment
Nursing Interventions
will be monitored every 2 weeks (or more
● Avoid Invasive procedures
often) by Doppler velocity.
(amniocentesis, culdocentesis…)
• Indirect Coombs test can be used to
● Avoid Episiotomy
determine whether there are antibodies to
● Avoid Breastfeeding
the Rh factor in the mother's blood(serum).
● Normal (negative) result means that
the mother has not developed
antibodies against the fetus's blood.
A negative Coombs test indicates
that the fetus is not presently in
danger from problems relating to Rh
incompatibility.
● An abnormal (positive) result means
that the mother has developed
antibodies to the fetal red blood
cells and is sensitized.
 ● Amniocentesis Iron Deficiency Anemia
- as early as 26 weeks of - Iron stores are apt to be low in
gestation—amount of women who were pregnant less than
bilirubin by products 2 years before the current
indicates severity of pregnancy or those from low
hemolytic activity. socioeconomic levels who have not
had iron-rich diets. When the
Medications hemoglobin level is below 12 mg/dL
● Rh (D) immune globulin (RhIG), a (hematocrit 33%), iron deficiency is
commercial preparation of passive suspected.
Rh (D) antibodies against the Rh - Iron-deficiency anemia is
factor, is administered to women characteristically a microcytic (small
who are Rh-negative at 28 weeks of red blood cell), hypochromic (less
pregnancy. RhIG is given again by hemoglobin than the average red
injection to the mother in the first 72 cell) anemia because when an
hours after birth of an Rh-positive inadequate supply of iron is
child to further prevent the woman ingested, iron is unavailable for
from forming natural antibodies. incorporation into red blood cells.
Both hematocrit and hemoglobin will
Intrauterine Transfusion to restore fetal be reduced (<33% and <12 mg/dL,
red blood cells. This is done by injecting red respectively).
blood cells, by amniocentesis technique,
directly into a vessel in the fetal cord or Folic Acid Deficiency Anemia
depositing them in the fetal abdomen where - Folic acid, or folacin, one of the B
they migrate into the fetal circulation. vitamins, is necessary for the normal
formation of red blood cells in the
mother as well as being associated
Anemia with preventing neural tube defects
in the fetus. It occurs most often in
Pseudoanemia- common in pregnant multiple pregnancies because of the
women; due to increased blood volume increased fetal demand; in women
slightly ahead to RBC count. with a secondary hemolytic illness in
which there is rapid destruction and
Anemia production of new red blood cells; in
● 1st or 3rd Trimester: Hemoglobin women who are taking hydantoin, an
concentration <11g/dl (hematocrit anticonvulsant agent that interferes
<30%) with folate absorption; in women
● 2nd Trimester: hemoglobin who have been taking oral
concentration is <10.5g/dl contraceptives; and in women who
(hematocrit<32%) have had a gastric bypass for
morbid obesity
Sickle Cell Anemia • Tests for the level of iron in your blood
- Sickle cell anemia is a recessively and body. These tests include serum iron
inherited hemolytic anemia caused and serum ferritin tests. Transferrin level
by an abnormal amino acid in the and total iron-binding capacity tests also
beta chain of hemoglobin. If the measure iron levels.
abnormal amino acid replaces the
amino acid valine, sickle hemoglobin Medications
(HbS) results; if it is substituted for Iron Deficiency Anemia
the amino acid lysine, nonsickling • Iron supplement of 60 mg elemental iron
hemoglobin (HbC) results. An as prophylactic therapy during pregnancy.
individual who is heterozygous (has • Vitamin C supplement, which supplies
only one gene in which the abnormal ascorbic acid, in combination with Iron
substitution has occurred) has the supplement for better absorption.
sickle cell trait (HbAS). If the person
is homozygous (has two genes in Folic Acid Deficiency Anemia
which the substitution has occurred), • Folic Acid 400 ug daily in addition to
sickle cell disease (HbSS) results. eating folacin-rich foods (green leafy
With the disease, the majority of red vegetables, oranges, dried beans). During
blood cells are irregular or sickle pregnancy, the folic acid requirement
shaped so they cannot carry as increases to 600 ug/day.
much hemoglobin as can normally
shaped red blood cells. Sickle Cell Anemia
• Periodic exchange transfusions
MEDICAL CARE throughout pregnancy to replace sickled
Laboratory and Diagnostics cells with non-sickled cells.
• Complete Blood Count- checks your • If a crisis occurs, controlling pain,
hemoglobin and hematocrit levels. administering oxygen as needed, and
Hemoglobin is the iron-rich protein in red increasing the fluid volume of the circulatory
blood cells that carries oxygen to the body. system to lower viscosity are important
Hematocrit is a measure of how much interventions. The fluid administered is often
space red blood cells take up in your blood. hypotonic (0.45 saline) to keep plasma
A low level of hemoglobin or hematocrit is a tension low because of the difficulty a
sign of anemia. woman has concentrating urine to remove
large amounts of fluid.
• Hemoglobin electrophoresis- looks at
the different types of hemoglobin in your NURSING CARE
Nursing Diagnosis
blood. The test can help diagnose the type
• Risk for ineffective tissue perfusion related to
of anemia you have. maternal anemia during pregnancy.
Nursing Interventions
• Reticulocyte count- measures the • Monitor client’s hemoglobin which is above 11
number of young red blood cells in your mg/dL.
• Monitor fetal heart rate which is 120 to 160 beats per
blood. The test shows whether your bone
minute
marrow is making red blood cells at the • Educate client to take prenatal supplement daily as
correct rate. prescribed.
Hyperemesis Gravidarum >Fluid replacement with intravenous
therapy: D5LR or D5NS with multivitamins
- Hyperemesis gravidarum
and electrolytes. Intravenous fluid (3000 mL
(sometimes called pernicious or
of Ringer’s lactate with added vitamin B, for
persistent vomiting) is nausea and
example) may be administered to increase
vomiting of pregnancy that is
hydration.
prolonged past week 12 of
pregnancy or is so severe that
>Antiemetic Drug Therapy:
dehydration, ketonuria, and
phenothiazines, antihistamines, 5-HT3
significant weight loss occur within
antagonists.
the first 12 weeks of pregnancy.
- It occurs at an incidence of 1 in 200
>Possible nasogastric feeding once
to 300 women. The cause is
nausea has decreased or Total Parenteral
unknown, but women with the
Nutrition may be necessary.
disorder may have increased
thyroid function because of the
>Possible psychiatric consult
thyroidstimulating properties of
human chorionic gonadotropin.
>Progressive diet after stabilization
- It is associated with Helicobacter
pylori, the same bacteria that cause
Nursing Interventions
peptic ulcers • Encourage a woman to serve herself small portions
- It is diagnosed by its severity so the amount on her plate does not appear
(weight loss >5% of prepregnancy overwhelming.
weight) and by ruling out other • If hospitalized, put kidney basin off sight to refrain
the idea of vomiting.
possible causes such as
• Limit patient’s exposure to food odor.
hydatidiform mole, gastroenteritis or • While she is receiving total parenteral nutrition at
pancreatitis. home, instruct her to check her urine for glucose and
ketones twice daily.
MEDICAL CARE
>Laboratory and Diagnostic
• Complete Blood Count- may show an
elevated hematocrit concentration at her
monthly prenatal visit because her inability
to retain fluid has resulted in
hemoconcentration.
• Serum Electrolytes Level- concentrations
of sodium, potassium, and chloride may be
reduced because of her low intake, and
hypokalemic alkalosis may result if vomiting
is severe.
• Urinalysis- may test positive for ketones,
evidence that a woman’s body is breaking
down stored fat and protein for cell growth.
Ectopic Pregnancy >Medications
• Methotrexate, a folic acid antagonist
- An ectopic pregnancy is one in
chemotherapeutic agent, attacks and
which implantation occurs outside
destroys fast-growing cells. Because
the uterine cavity. The implantation
trophoblast and zygote growth is so rapid,
may occur on the surface of the
the drug is drawn to the site of the
ovary or in the cervix. With ectopic
ectopic pregnancy. . Women are treated
pregnancy, fertilization occurs as
until a negative hCG titer is achieved.
usual in the distal third of the
• Mifepristone, an abortifacient, is also
fallopian tube. Immediately after the
effective at causing sloughing of the tubal
union of ovum and spermatozoon,
implantation site. The advantage of these
the zygote begins to divide and
therapies is that the tube is left intact, with
grow. Unfortunately, because an
no surgical scarring that could cause a
obstruction is present, such as an
second ectopic implantation.
adhesion of the fallopian tube from a
• Rh (D) immune globulin (RhIG)- mother
previous infection (chronic salpingitis
with Rh-negative blood should receive after
or pelvic inflammatory disease),
an ectopic pregnancy for isoimmunization
congenital malformations, scars from
protection in future childbearing.
tubal surgery, or a uterine tumor
pressing on the proximal end of the
NURSING CARE
tube, the zygote cannot travel the Nursing Diagnoses
length of the tube. It lodges at a • Powerlessness related to early loss of pregnancy
strictured site along the tube and secondary to ectopic pregnancy.
implants there instead of in the • Risk for Deficient Fluid Volume related to bleeding
from a ruptured ectopic pregnancy.
uterus.
Nursing Interventions
• Assess the vital signs to establish baseline data and
MEDICAL CARE determine if the patient is under shock.
>Laboratory and Diagnostic • Maintain accurate intake and output to establish the
patient’s renal function.
• Abdominal Ultrasound- at 6 to 12 weeks
• Encourage her to verbalize her concerns about this
to determine placement. and future childbearing.
• Magnetic Resonance Imaging- to use if
not determined by ultrasound.
• Transvaginal ultrasound- will
demonstrate the ruptured tube and blood
collecting in the peritoneum.
• Complete Blood Count- Leukocytosis
may be present, not from infection but from
the trauma. Temperature is usually normal.
• Laparoscopy or culdoscopy- to visualize
the fallopian tube if the symptoms alone do
not reveal a clear picture of what has
happened.
Gestational Trophoblastic Disease • Oral contraceptive agent- given for 12
months so that a positive pregnancy test (the
presence of hCG) resulting from a new
Gestational Trophoblastic Disease
pregnancy will not be confused with increasing
(Hydatidiform Mole) is abnormal proliferation
levels and a developing malignancy. After 6
and then degeneration of the trophoblastic villi.
months, if hCG levels are still negative, a
As the cells degenerate, they become filled with
woman is theoretically free of the risk of a
fluid and appear as clear fluid-filled, grape-sized
malignancy developing.
vesicles. The embryo fails to develop beyond a
• Methotrexate- as a prophylactic course, the
primitive start. Abnormal trophoblast cells must
drug of choice for choriocarcinoma. However,
be identified because they are associated with
because the drug interferes with white blood cell
choriocarcinoma, a rapidly metastasizing
formation (leukopenia), prophylactic use must be
malignancy. Complete mole, all trophoblastic villi
weighed carefully. If malignancy should occur, it
swell and become cystic. If an embryo forms, it
can be treated effectively in most instances with
dies early at only 1 to 2 mm in size, with no fetal
methotrexate at that time.
blood present in the villi. Partial mole, some of
• Dactinomycin- is added to the regimen if
the villi form normally. The syncytiotrophoblastic
metastasis occurs.
layer of villi, however, is swollen and misshapen.

NURSING CARE
Complete mole, all trophoblastic villi swell and
Nursing Diagnoses
become cystic. If an embryo forms, it dies early
• Acute pain related to the disease process:
at only 1 to 2 mm in size, with no fetal blood
Hydatidiform Mole
present in the villi.
• Deficient fluid volume related to heavy vaginal
bleeding
Partial mole, some of the villi form normally.
• Grieving related to loss of pregnancy as
The syncytiotrophoblastic layer of villi, however,
evidenced by anger and social detachment.
is swollen and misshapen.
Nursing Interventions
• Provide comfort measures to reduce pain.
MEDICAL CARE
• Measure abdominal girth and fundal height to
>Laboratory and Diagnostics
establish baseline data regarding the growth of
• Pregnancy test- this may not be able to detect
the uterus.
specifically the H mole, but this will confirm if the
• Assist patient in obtaining a urine specimen for
woman is pregnant or not.
urine test of hCg.
• Serum or urine test of hCG- will be strongly
• Save all pads used by the woman during
positive (1 to 2 million IU compared with a
bleeding to check for clots and tissues she may
normal pregnancy level of 400,000 IU).
have discharged.
• Ultrasound- will show dense growth (typically
• Provide your patient with an open environment
a snowflake pattern) but no fetal growth in the
and a trusting relationship so she would be
uterus.
encouraged to express her feelings.
• Honestly answer the patient’s questions to
>Therapy for gestational trophoblastic disease is
foster a trusting relationship between nurse and
suction curettage to evacuate the mole.
client.
>Following mole extraction, women should have
• Provide an assurance that it is not her own
a baseline pelvic examination, a chest
fault that this happened to her to lessen her
radiograph, and a serum test for the beta
sense of guilt and self-blame.
subunit of hCG.

Medications
Incompetent Cervix Spontaneous Abortion
Premature cervical dilatation, previously termed Abortion is the medical term for any
an incompetent cervix, refers to a cervix that interruption of a pregnancy before a fetus is
dilates prematurely and therefore cannot hold a viable (able to survive outside the uterus if born
fetus until term. at that time).
A viable fetus is usually defined as a
MEDICAL CARE fetus of more than 20 to 24 weeks of gestation
>Laboratory and Diagnostics or one that weighs at least 500 g. A fetus born
• Ultrasound-This is the only test that the before this point is considered a miscarriage or
physician could order if an incompetent cervix is premature or immature birth.
already suspected. A spontaneous miscarriage is an early
miscarriage if it occurs before week 16 of
>McDonald’s Cervical Cerclage- nylon sutures pregnancy and a late miscarriage if it occurs
are placed horizontally and vertically across the between weeks 16 and 24.
cervix. They are pulled back together until the
cervical canal is only a few millimeters in TYPES
diameter. Threatened abortion. The embryo is already
>Shirodkar Cervical Cerclage- sterile tape is viable. The products of conception are still intact
used for this technique, where it is threaded in a and the cervix is closed, but there is vaginal
purse-string manner under the submucous layer bleeding present.
of the cervix. Then, it is sutured in place so it Inevitable/Imminent abortion. The embryo is
would close the cervix dead with the products of conception either
intact or expelled. The cervix is already dilated
NURSING CARE and there is presence of vaginal bleeding.
Nursing Diagnoses Complete abortion. All products of conception
• Anxiety related to impending loss of pregnancy are expelled and the embryo is dead. The cervix
as evidenced by premature dilation of the cervix. is dilated, and there is mild bleeding. Incomplete
• Deficient fluid volume related to surgical abortion. The embryo is dead but some products
procedure to reinforce the incompetent cervix. of conception are still intact. The cervix is
• Anticipatory Grieving related to probable birth already dilated and there is severe vaginal
of nonviable fetus. bleeding.
Nursing Interventions Missed abortion. The embryo is already dead
• Determine any factors that further contribute to while inside the uterus. The products of
the anxiety of the woman so it could be avoided. conception are still intact and the cervix is
• Monitor vital signs to determine any physical closed. There are brown vaginal discharges
responses of the patient that could affect her present.
condition. Recurrent/Habitual abortion. Abortion
• Convey empathy and establish a therapeutic becomes recurrent once the woman has had 3
relationship to encourage client to express her consecutive miscarriages at the same
feelings. gestational age.
• Provide accurate information about the
situation to help client back into reality. MEDICAL CARE
>Laboratory and Diagnostics
• Pregnancy test- This is to confirm the
pregnancy first if vaginal bleeding occurs. If test
turns out negative, then the woman would be
subjected to other diagnostic tests that could
confirm the nature and cause of the vaginal
bleeding. If it is positive, then abortion would be Nursing Interventions
considered and it would be classified according • If bleeding is profuse, place the woman flat in
to the presenting signs and symptoms. bed on her side and monitor uterine contractions
• Ultrasound- The safest and confirmatory test and fetal heart rate through an external monitor.
for pregnancy, the ultrasound would be able to • Also measure intake and output to establish
confirm if the pregnancy is positive, and also renal function and assess the woman’s vital
confirm if the products of conception are still signs to establish maternal response to blood
intact. loss.
• Measure the maternal blood loss by saving and
>Administration of intravenous fluids. Such weighing the used pads.
as Lactated Ringer’s, IV therapy should be • Save any tissue found in the pads because this
anticipated by the nurse as well as might be a part of the products of conception.
administration of oxygen regulated at
6-10L/minute by a face mask to replace Placenta Previa
intravascular fluid loss and provide adequate
Placenta previa is a condition of
fetal oxygenation.
pregnancy in which the placenta is implanted
abnormally in the uterus. It is the most common
Avoid vaginal examinations. The physician
cause of painless bleeding in the third trimester
would also avoid further vaginal examinations to
of pregnancy.
avoid disturbing the products of conception or
triggering cervical dilatation.
FOUR DEGREES
• Implantation in the lower rather than in the
Dilatation and Curettage- This is most
upper portion of the uterus (low-lying placenta)
commonly performed for incomplete abortions to
• Marginal implantation (the placenta edge
remove the remainder of the products of
approaches that of the cervical os)
conception from the uterus. Since the uterus
• Implantation that occludes a portion of the
would not be able to contract effectively, the
cervical os (partial placenta previa)
contents might be trapped inside and could
• Implantation that totally obstructs the cervical
cause serious bleeding and infection.
os (total placenta previa).
Dilatation and evacuation- This is to make
MEDICAL CARE
sure that all products of conception would be
>Laboratory and Diagnostic
removed from the uterus. However, before
• Ultrasound- Early detection of placenta previa
undergoing this intervention, the physician must
is always possible through ultrasonography. It is
be sure that no fetal heart sounds could be
the most common and initial diagnostic test that
heard anymore and the ultrasound must show
could confirm the diagnosis.
an empty uterus.

>Intravenous therapy. This would be

NURSING CARE
prescribed by the physician to replace the blood
Nursing Diagnoses
that was lost during bleeding.
• Anxiety related to pregnancy loss
• Anticipatory grieving related to threatened
>Avoid vaginal examinations. This may initiate
abortion
hemorrhage that is fatal for both the mother and
• Risk for deficient fluid volume related to
the baby.
bleeding during pregnancy
• Risk for infection related to internal site for
organism invasion
>Attach external monitoring equipment. To TYPES
monitor the uterine contractions and record fetal Grade 0. No indication of placental separation
heart sounds, an external equipment is preferred and diagnosis of slight separation is made after
than the internal monitoring equipment. birth.
Grade 1. There is minimal separation which
>Cesarean delivery. Although the best way to causes vaginal bleeding, but no changes in fetal
deliver a baby is through normal delivery, if the vital signs occur.
placenta has obstructed more than 30% of the Grade 2. Moderate separation occurs and fetal
cervical os it would be hard for the fetus to get distress is already evident. The uterus is also
past the placenta through normal delivery. hard and painful upon palpation.
Cesarean birth is then recommended by the Grade 3. Extreme separation; maternal shock
physician. and fetal death is imminent if no interventions
are done.
NURSING CARE
Nursing Diagnoses MEDICAL CARE
• Deficient fluid volume: maternal related to active >Laboratory and Diagnostics
blood loss.
• Hemoglobin level and fibrinogen level.
• Activity Intolerance related to enforced bed rest
These tests are performed to rule out
during pregnancy.
• Fear related to outcome of pregnancy due to disseminated intravascular coagulation.
bleeding. • >Intravenous therapy. Once the woman starts
Risk for impaired gas exchange: fetal related to to bleed, the physician would order a large
disruption of placental implantation gauge catheter to replace the fluid losses.
Nursing Interventions >Oxygen inhalation. Delivered via face mask,
• Assess fetal heart sounds so the mother would be this would prevent fetal anoxia.
aware of the health of her baby. >Fibrinogen determination. This test would be
• Allow the mother to vent out her feelings to lessen
taken several times before birth to detect DIC.
her emotional stress.
>Cesarean delivery. If birth is imminent, it is
• Assess any bleeding or spotting that might occur to
give adequate measures. safest to deliver the baby via caesarean delivery.
• Answer the mother’s questions honestly to establish >Hysterectomy. The worst outcome would be
a trusting environment. for the woman to develop DIC, and to prevent
• Include the mother in the planning of the care plan exsanguinations, hysterectomy must be
for both the mother and the baby. performed.

Abruptio Placenta NURSING CARE

Nursing Diagnoses
Premature Separation of the Placenta • Deficient fluid volume related to bleeding during
(Abruptio Placentae) Unlike placenta previa, in premature placental separation.
premature separation of the placenta (also • Impaired gas exchange: fetal related to insufficient
called abruptio placentae; the placenta appears oxygen supply
to have been implanted correctly. Suddenly, • Ineffective tissue perfusion: placental related to
however, it begins to separate and bleeding excessive blood loss
results. The separation generally occurs late in Nursing Interventions
• Place the woman in a lateral, not supine position to
pregnancy; it may occur as late as during the
avoid pressure in the vena cava.
first or second stage of labor. Because
• Monitor fetal heart sounds.
premature separation of the placenta may occur • Monitor maternal vital signs to establish baseline
during an otherwise normal labor, it is important data.
always to be alert to the amount and kind of • Avoid performing any vaginal or abdominal
vaginal bleeding a woman is having in labor. examinations to prevent further injury to the placenta.