26 28 bleeding during 1st trimester cô liên

General principles of nursing interventionCount and weigh pads to assess amount of bleeding over a given time period; save any tissue or clots expelled.. General principles of nursing

Bleeding during the first trimester of pregnancy

DAM THI QUYNH LIEN, MD.

General principles of nursing intervention

Monitor blood pressure and pulse frequently The frequency is determined by the extent of the bleeding and the stability of the woman’s condition.

Observe the woman for indications of shock, such as pallor, clammy skin, perspiration, dyspnea, or restlessness.

General principles of nursing intervention

Count and weigh pads to assess amount of bleeding over a given time period; save any tissue

or clots expelled.

Assess fetal heart tones with a Doppler.

General principles of nursing intervention

Prepare for intravenous (IV) therapy There may

be standing orders to start IV therapy on bleeding patients.

Prepare equipment for examination.

Have oxygen therapy available.

General principles of nursing intervention

Collect and organize all data, including antepartum history, onset of bleeding episode, any associated pain, laboratory studies (Hb, Ht,

Rh status, and hormonal assays).

Application: Potential Pregnancy Complications

Obtain an order to type and cross-match for blood if there is evidence of significant blood loss

General principles of nursing intervention

Assess coping mechanisms and support system

of the woman in crisis Give emotional support to enhance her coping abilities by continuous, sustained presence, by clear explanation of procedures, and by communicating her status to her family

General principles of nursing intervention

Most important, prepare the woman for possible fetal loss Assess her expressions of anger, denial, guilt, depression, or self-blame.

Assess the family’s response to the situation.

Spontaneous Abortion

 It is the termination of pregnancy before

22 weeks, or products of conception weighing below 500 grams

 The termination is either spontaneous or induced, before the fetus develops sufficiently to survive

Spontaneous Abortion

Incidence

 Spontaneous abortion occurs in 10-15% of pregnancy , 80% of them occur in the first trimester.

Spontaneous Abortion

Causes

50%-80% of abortions in the first 12 weeks of

pregnanacy result from Chromosomal anomalies.

Fetal

Chromosomal anomalies.

Diseases of the fertilized ovum.

Hypoxia.

Spontaneous Abortion

Maternal

Infections e.g influenza, malaria, syphilis ,HIV.

Disease such as chronic nephritis,TB.

Drug intake during pregnancy.

Rh and ABO incompatibility.

Incompetent cervix.

Trauma - criminal interference,

Endocrinal disorder as hypothyrodism , daibetes mellitus

The cervix is not dilated, and the placenta is still attached

to the uterine wall, but some bleeding occurs

Threatened

The placenta has separated from the uterine wall, the cervix has dilated, and the amount of bleeding has increased

Imminent

The embryo or fetus has passed out of the uterus, but

the placenta remains

Incomplet

e

Spontaneous Abortion

Treatment

Risk

Spontaneous Abortion

Nursing assessment and interventions

Amount and appearance of vaginal bleeding

Pathology of abortion

First 8 weeks gestation

Separation of decidua basalies and expulsion of the ovum

If retained within the uterus, the ovum becomes surrounded

by decidua and blood clot

Signs and Symptoms of Abortion

Threatened abortion:

Cervical os is closed.

Membranes are intact.

Pain and backache may or may not be present.

Treatment

Complete bed rest

Avoid enema &constipation

no sexual intercourse

Administration of prescribed drugs

Incomplete abortion

Severe bleeding.

Cervical os partly closed.

No uterine involution.

Pain may or may not be present.

Uterus is soft and smaller than the expected period of pregnancy.

Complete abortion:

There is minimal bleeding.

Pain stops.

Uterus is hard and much smaller

The cervix is closed

Septic abortion

Signs

Tender and painful uterus.

Offensive vaginal bleeding.

High temperature.Rapid pulse .Unstable blood pressure.

Shock.

Administration of antibiotics as doctor orders.

Intake and output chart should be kept.

The soiled pads should be properly collected and burned

Inevitable abortion

occurred.

shocked.

Inevitable abortion

Treatment

Hospitalization

If no heart beats are detected a dilute solution

of oxcytocin may be given as the doctor orders

to help in the expulsion of the contents of the uterus.

Dilatation and curettage should be done.

Missed abortion

Nursing Management

Prevention measures should be taken to avoid risk of a spontaneous abortion

A nutritional diet.

Avoiding smoking or drinking.

Receiving available immunizations against infectious diseases.

Treatment of vaginal or pelvic infections.

Ectopic Pregnancy

Any pregnancy outside the uterine cavity

Risk hemorrhage and death– hemorrhage and death

Leading cause of 1 st trimester maternal death

Second leading cause of all maternal deaths

More common in AA population

Prevalence has increased but death rate decreased

Ectopic Pregnancy

3.8 deaths per 10,000 cases

Incidence is 20/1000 pregnancies age 15 to 44

The rate of ectopics increase with increasing age and non white race

85% of ectopics occur in multiparas

Various implantation sites in ectopic pregnancy The most common site is within the fallopian tube, hence the

name “tubal pregnancy.”

Ectopic Pregnancy

PID/Infection of the uterus/fallopian tubes

Endometriosis

Previous abdominal surgery

Progesterone only OC’s

Smoking

IUD

Ectopic Pregnancy

Signs and Symptoms

Ectopic Pregnancy

Signs and Symptoms

Ectopic Pregnancy

Signs and Symptoms

 hCG

A failure to rise 66% by 48hrs is abnormal (15%

of normal IUP’s will do)

Ectopic Pregnancy

Ultrasound and hCG

Sac seen at 35 gestational days

Fetal pole seen at 40 gestational days

Fetal heart motion- 47 gestational days

Ectopic Pregnancy

Signs and Symptoms

 Laparoscopy

SALPINGOSTOMY

SALPINGECTOMY

 no fetal cardiac motion

 no evidence of maternal throm- bocytopenia, leukopenia, kidney disease, or liver disease.

 No other contraindications for MTX

 If adequate response HCG q week

Full resolution in 3-6 weeks usually

Hydatiform Mole

Complete

No fetus, grapelike clusters line the uterus

The egg is empty of maternal chromosomes and becomes fertilized by the sperm that rapidly divides

Result is paternal 46 XX with no maternal chromosomes

Associated risk of choriocarcinoma – 10-30%

Hydatiform Mole

Complete Hydatiform Mole

Hydatiform Mole

Partial

A normal egg with maternal 23 chromosomes fertilized by two sperm or a haploid sperm that did not divide into 23 chromosomes

Result is a 69 chromosome egg

Only some grapelike villi are present; often end

up as SAB at 8-9 weeks

Partial Hydatiform Mole

Hydatiform Mole

Incidence

years of age, diets low in carotene and animal fat, clomid stimulation of the ovaries

Cause is unknown

Risks – DIC, cysts, trophoblastic emboli, anemia, choriocarcinoma

Clinical course

It has eight of symptoms and physical signs.

 amenorrhea

because it is a pregnancy.

 vaginal bleeding

after a period of amenorrhea (average

12 weeks) may continue intermittently for several weeks -profuse bleeding -anemia and infection

 abdominal cramps

 abnormally enlarged and soft uterus.

in about half the cases, the uterus growth is rapid, it is larger than the dates suggest.

 ovarian cyst torsion

when we do pelvic examination adnexal masses may be found

it is theca lutein cyst in about one third of the cases

 severe and early –onset PIH (Pregnancy Induced Hypertension syndrome)

 hyperthyroidism

plasma thyroxin concentration elevates

 exaggerated early pregnancy symptoms

nausea, vomit etc

suspicion:

abnormal bleeding after amenorrhea

inappropriately enlarged uterus;

absence of fetal heart sounds or could not feel fetal parts by palpation between 16-20 th

week

hyperemesis gravidarum

bilateral ovarian cysts

serum hCG monitor

an unusually high titer of chorionic gonadotropin, especially after the one-hundredth day of pregnancy, help to confirm the diagnosis

of HM.

It is a reliable and sensitive technique for the diagnosis of complete molar pregnancy Because the chorionic villi exhibit diffuse hydatidiform swelling Complete moles produce a characteristic vesicular sonographic pattern, usually referred to as a “ snowstorm ” pattern.

Ultrasonography may also contribute to the diagnosis of partial molar pregnancy by demonstrating focal cystic spaces in the placental tissues and an increase in the transverse diameter of the gestational sac.

Differential diagnosis

abortion;

multiple pregnancy;

polyhydramnios

 the uterus should be evacuated as soon as possible after the diagnosis is made.(by suction curettage)

suction;

oxytocin administration:we can use blood transfusion or/and fluid infusion.it is used to decrease the size of the uterus;

tissue sent for histology: it should be routine

practice with all cases of incomplete miscarriage; acute pulmonary complications

 total abdominal hysterectomy

in older multiparas hysterectomy may

be indicated.

management of theca-lutein cysts

these tumors should not be excised because they regress after the trophoblastic tissue has been removed.

chemotherapy

HM don’t need usually chemotherapy because

HM is benign disease.

Follow-up examinations

follow up mode in the 2

years after discharge

on each follow-up

check, the following

should be addressed

Nursing assessment and

interventions

Monitor VS and evidence of bleeding

Assess emotional state and coping ability

Provide emotional support through grieving process

Provide explanation of procedures

Reinforce importance of follow-up care

Ask question

1 What is the etiology of GTD?

2 What is the classification of HM?

3 What is the main pathologic changes

of HM?

4 What is the clinical course of HM?

5 How Follow-up examinations is we?

About 80% of the cases of HM have a benign course one-half of patients become pregnant subsequently about 16% of HM become invasion moles and some 2.5% progress into choriocarcinoma

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