MODULE 1 LESSON 1 tenderness or pain should always be evaluated for an ectopic

pregnancy. Pain increases after rapture of the ectopic pregnancy

and the woman may experience referred shoulder pain from
Pregnancy is a normal physiological function of all living species. Couples
diaphragmatic irritation caused by blood in the peritoneal cavity.
(or, in more recent times, single individuals) who have chosen to become
parents look forward to having a healthy, happy, and bright newborn enter
their lives. They anticipate the arrival of a baby who they will be able to
Risk Factors:
love and nurture over the years to grow into a happy, healthy and
productive adult. However, pregnancies do not always progress smoothly History Of Sexually Transmitted Infections Or Pelvic Inflammatory
and the pregnant woman and her family or significant other may Disease
experience a complication at some point during the childbearing year. Prior Ectopic Pregnancy
Previous Tubal, Pelvic, Or Abdominal Surgery
Complications that arise during this time are often challenging and Endometriosis
demand the perinatal nurse’s skills, knowledge, and expertise combined Current Use Of Exogenous Hormones (I.e., Estrogen,
with the nursing process to first identify the pregnant patient at risk and Progesterone)
then formulate, implement, and evaluate an appropriate, holistic plan of In Vitro Fertilization Or Other Method Of Assessing A Production
care. Identification and activation of appropriate community resources is In Utero Diethylstilbestrol (Des) Exposure With Abnormalities Of
also an essential component of the care plan. Throughout the entire The
process, the nurse must remain cognizant of the unique individuality of Reproductive Organs
the patient and Use Of An Intrauterine Device Assessment and Diagnosis
her family and deliver care that is respectful of their diversity and culture
ASSESS FOR:
Unilateral, bilateral or diffuse abdominal pain
An ectopic pregnancy Missed period
is one of the implants Palpable mass is present on bimanual examination in approx. 50%
outside of the uterine of women
cavity. Implantation Active bleeding is associated with rupture hypotension,
may occur in the tachycardia, vertigo and shoulder pain
fallopian tube (99%),
the ovary, the cervix, DIAGNOSIS:
on the outside of the Increased WBC
fallopian tube, the TVS (transvaginal ultrasound)
abdominal wall, or on
the bowel. MANAGEMENT
Salpingectomy (removal of the ruptured fallopian tube) by
Patients who present laparotomy (surgical procedure in which the abdomen is opened
with vaginal bleeding, to visualize the abdominal organs) has long offered an almost
a missed period, and 100% cure for the treatment of an ectopic pregnancy. However,
abdominal current clinical emphasis is aimed not only on prevention of

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 maternal death but also on the prompt restoration of health CAUSE:
through a rapid recovery with preservation of fertility. To achieve The cause of molar pregnancy is unknown.,
this goal, laparoscopic (visualization of the reproductive organs but it is thought that complete moles result
using a laparoscope inserted into the pelvic cavity through a small from the fertilization of an empty ovum (one
incision in the abdomen) SALPINGOSTOMY (incision into the whose nucleus is missing or nonfunctional) by
fallopian tube to remove the pregnancy) and partial salpingectomy a normal sperm. Since the ovum contains no
are replacing laparotomy as the treatment mode of choice. maternal genetic material, all chromosomes in
a molar pregnancy are paternally derived.
At present, laparotomy is performed only when a laparoscopic 2 TYPES
approach is too difficult, the surgeon is not trained in operative Complete Mole - characterized by trophoblastic proliferation and
laparoscopy, or the patient is hemodynamically unstable. the absence of fetal parts
Incomplete - often appear with a coexistent fetus that has a triploid
NON-SURGICAL genotype (6g chromosomes) and multiple anomalies. Most fetuses
METHOTREXATE, a chemotherapeutic drug and folic acid associated with incomplete moles survive only several weeks in
inhibitor that stops cell production and destroys remaining utero before being spontaneously aborted.
trophoblastic tissue, is used in the management of uncomplicated,
non-life-threatening ectopic pregnancies. Patients are considered SIGNS AND SYMPTOMS
to be eligible for methotrexate therapy if the ectopic mass is - Vaginal bleeding which may be scant or profuse and ranges in
unruptured and measures 1.6 inch (4cm) or less on ultrasound color from dark brown to bright red; Anemia
examination. Patients with larger ectopic masses, embryonic - Discrepancy between uterine size and dates
cardiac activity, or clinical evidence of acute intra-abdominal
- Severe nausea and vomiting
bleeding (acute tender abdomen, hypotension, or falling
- Abdominal pain
hematocrit) are not eligible for this mode of treatment (Murray et
al., 2005) - Pre-eclampsia
- Absence of FHT
GTD - Gestational Trophoblastic Disease - Elevated hCG and low maternal serum alpha-fetoprotein (MSAFP)

Is a clinical diagnosis that includes the histologic diagnosis that RISK FACTORS
includes the histologic diagnosis of hydatidiform mole (“molar - Women of higher age
pregnancy”), locally invasive mole, metastatic mole and - History of previous molar pregnancy
choriocarcinoma. - Maternal diet is low in betacarotene, animal fats, and folic acid and
It is a disease characterized by an abnormal placental also in women with blood type A whose partners are blood type O
development that results in the production of fluid-filled grapelike - Prior miscarriages
clusters (instead of normal placental tissue) and a vast - Women who had undergone ovulation stimulation with clomiphene
proliferation of trophoblastic tissue. It is associated with loss of the (Clomid)
pregnancy and rarely, the development of cancer. GTD occurs in 1
in 1200 pregnancies (Berman, DIAGNOSIS
DiSaia, & Tewari, 2004)

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 Ultrasound: The placental tissue appears in a”snowstorm” pattern CLASSIFICATIONS
due to the profuse swelling of the chorionic villi. INEVITABLE ABORTION: No expulsion of products, but bleeding
and dilation of the cervix such that a pregnancy is unlikely
MANAGEMENT: THREATENED ABORTION: Any intrauterine bleeding before 20
Clinical management involves removal of the uterine contents with weeks of gestation, without dilation of the cervix or expulsion of
meticulous follow-up that includes serial beta-hCG levels. The any
hCG levels should be assessed every 1 to 2 weeks until hCG is POC
undetectable on two consecutive determinations. Thereafter, hCG MISSED ABORTION: Death of the embryo or fetus before 20
should be measured every 1 to 2 months for at least a year weeks of gestation with complete retention of the POC; these often
(Cunningham et al., 2005). proceed to a complete abortion within 1 to 3 weeks but
occasionally they are retained much longer.

CAUSE:
NURSING MANAGEMENT: - It is estimated that 60% to 80% of all SABS in the first trimester
Effective contraception is needed during this time to prevent are associated with chromosomal abnormalities (Griebel,
pregnancy and the resulting confusion about the cause of changes Halvorsen, Goleman, & Day, 2005).
in the hCG levels. In addition, pregnancy could mask an hCG rise - Infections (bacteriuria and Chlamydia trachomatis)
associated with malignant GTD. The perinatal nurse should
- maternal anatomical defects
carefully counsel the patient about different methods of
- immunological and endocrine factors
contraception and stress the importance of avoiding pregnancy for
- Second trimester spontaneous abortions (12 to 20 weeks) have
a year.
been linked to chronic infection, recreational drug use, maternal
uterine or cervical anatomical defects, maternal systemic disease,
SPONTANEOUS ABORTION
exposure to fetotoxic agents, and trauma (Cunningham et al.,
A spontaneous abortion (SAB) or miscarriage is a pregnancy that
2005).
ends before 20 weeks gestation. The type of SAB that occurs is
defined by whether any or all of the products of conception (POC)
DIAGNOSIS:
have been passed and whether or not the cervix is dilated.
A woman who is experiencing a spontaneous abortion usually
presents with bleeding and may also complain of cramping,
CLASSIFICATIONS
abdominal pain, and decreased symptoms of pregnancy; cervical
ABORTUS: Fetus lost before 20 weeks of gestation, less than
changes (dilation) may be present on vaginal examination. An
17.5
ultrasound is performed for placental evaluation and to determine
oz. (500 g), or less than 9.8 inches (25 cm) in size fetal viability (Cunningham et al., 2005).
COMPLETE ABORTION: Complete expulsion of all POC before
20 MANAGEMENT
weeks of gestation - Dilatation and Curettage
INCOMPLETE ABORTION: Partial expulsion of some but not all - For the case of an incompetent cervix - cerclage (temporary
POC before 20 weeks of gestation suturing of the cervix)
- RH negative women - RhoGAM to prevent antibody formation

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HYPEREMESIS GRAVIDARUM MANAGEMENT
✓ Advised to regularly take multivitamins before the next
Nausea and vomiting is a common condition of pregnancy that affects conception
70% to 85% of pregnant women and usually resolves by the 16th week of ✓ Rest
gestation.Hyperemesis gravidarum represents the extreme end of the ✓ avoid foods and sensory stimuli that provoke symptoms✓ eat
nausea/vomiting spectrum in terms of severity. small frequent meals of dry, bland foods and include highprotein
snacks in their diet.
Hyperemesis gravidarum is the most common indication for admission to ✓ Avoid spicy foods.
the hospital during the first part of pregnancy and is second only to ✓ Eating crackers before arising in the morning may be of
preterm labor as the most common reason for hospitalization during benefitand ginger capsules have been shown to be effective.
pregnancy (ACOG, 2004a; Hunter, Sullivan, Young, & Weber, 2007).

RISK FACTORS
generally unknown but; Hyperemesis gravidarum may be related
to the elevated levels of estrogen or hCG. Or, it may be associated
with the transient elevation of thyroid hormone during pregnancy.
✓ increased placental mass associated with multiple gestation
and molar pregnancy;
✓ a history of hyperemesis gravidarum in a previous pregnancy;
✓ a history of motion sickness or migraine headaches;✓ pregnant
with a female child is also considered to be at risk (ACOG,
2004a).
MATERNAL EFFECTS
Serious complications of hyperemesis gravidarum for the woman
and fetus arise in the group of women who cannot maintain their
weight despite antiemetic therapy. In addition to increased hospital
admissions, some women experience psychosocial morbidity of
such significance that they feel compelled to terminate the
pregnancy. Depression, somatization (the conversion of mental
experiences into physical symptoms), and hypochondriasis can
also be a problem for some women (ACOG, 2004a)
FETAL EFFECTS
fetal intrauterine growth restriction (IUGR)

DIAGNOSIS
Criteria for the diagnosis of hyperemesis gravidarum include
persistent vomiting unrelated to other causes, a measure of acute
starvation (usually large ketonuria), and some discrete weight loss,
most often 5% of the pre-pregnancy weight.
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