Emergency Conditions by Trimester

Common Complications of Pregnancy

First Trimester Complications

1. Complications affecting fluid-gas transport: hemorrhagic disorders
   • General aspects
     1. Assessment:
        • Vital signs, output, general status.
        • Evidence of internal/external bleeding (pad count).
        • Pain.
        • Emotional response.
        • Perineal pads saturated and number.
        • Speculum examination.
     2. Analysis/nursing diagnosis:
        • Knowledge deficit related to diagnosis, prognosis, treatment, sequelae.
        • Anxiety/fear related to loss of pregnancy, surgery.
        • Fluid volume deficit, potential/actual, related to excessive blood loss.
        • Pain.
        • Ineffective coping, individual/family, related to knowledge deficit and fear.
        • Anticipatory/dysfunctional grieving, related to loss of pregnancy.
        • Disturbance in self-esteem, body image, role performance, related to threat to selfimage as woman and childbearer.
     3. Nursing care plan/implementation:
        • Goal: minimize blood loss, stabilize physiological status.
          1. Facilitate prompt medical management.
          2. Administer IV fluids, blood, as ordered.
          3. Administer analgesics, as needed.
        • Goal: prevent infection. Strict aseptic technique.
        • Goal: emotional support.
          1. Encourage verbalization of anxiety, fears, concerns.
          2. Supportive care for grief reaction.
     4. Evaluation/outcome criteria:
        • Blood loss minimized; physiological status stable.
        • Copes effectively with loss of pregnancy.
   • Spontaneous abortion: before viable age of 20-22 weeks
     1. Etiology:
        • Defective products of conception.
        • Insufficient production of progesterone.
        • Acute infections.
        • Reproductive system abnormalities, e.g., incompetent cervical os.
        • Trauma (physical or emotional).
        • Rh incompatibility.
     2. Assessment: types
        • Threatened - mild bleeding, spotting, cramping; cervix closed.
        • Inevitable - moderate bleeding, painful cramping; cervix dilated, positive Nitrazine test (membranes ruptured).
        • Imminent - profuse   bleeding, severe cramping, urge to bear down.
        • Incomplete - fetal parts or fetus expelled; placenta and membranes retained.
        • Complete - all products of conception expelled; minimal vaginal bleeding.
        • Habitual/recurrent - history of spontaneous loss of three or more successive pregnancies.
        • Missed - fetal death with no spontaneous expulsion within 4 weeks.
          1. Anorexia, malaise, headache.
          2. Fundal height - inconsistent with gestational estimate.
          3. Laboratory - prolonged clotting time, due to resultant concurrent hypofibrinogenemia (disseminated intravascular coagulation [DIC], a major threat to mother).
        • Elective abortions (intentionally introduced loss of pregnancy).
     3. Analysis/nursing diagnosis:
        • Altered family processes related to pregnancy, circumstances surrounding abortion.
        • Sexual dysfunction related to compromised self-image, altered interpersonal relationship, guilt feelings.
     4. Nursing care plan/implementation:
        • Threatened-Goal: health teaching. Suggest: avoid coitus and orgasm, especially around normal time for menstrual period.
        • Incomplete, inevitable, imminent.
          1. Goal: safeguard status.
             • Save all pads, clots, tissue for expert diagnosis.
             • Report immediately any change in status, excessive bleeding, signs of infection, shock.
             • Prepare for surgery.
          2. Goal: comfort measures.
             • Administer analgesics, as necessary
             • Bed rest, quiet diversional activities.
          3. Goal: emotional support.
             • Encourage verbalization of fear, concerns.
             • Reduce anxiety, as possible.
             • If pregnancy terminates, facilitate grieving process; assist in working through guilt feelings.
             • Supportive care for grief reaction.
          4. Goal: prevent isoimmunization.
          5. Medical management:
             • Laboratory - blood type and Rh factor, indirect Coombs, platelets, serum fibrinogen, clotting time.
             • Replace blood loss; maintain fluid levels with IV.
             • Dilation and curettage or dilation and evacuation.
             • Habitual - determine etiology.
     5. Evaluation/outcome criteria:
        • Threatened - responds to medical/nurs-ing regimen; abortion avoided, successfully carries pregnancy to term.
        • Spontaneous abortion - after uterus emptied.
          1. Her bleeding is controlled.
          2. Her vital signs are stable.
          3. Copes effectively with loss of pregnancy.
          4. Expresses satisfaction with care.
        • Habitual abortion - cause identified and corrected; carries subsequent pregnancy to successful termination.
   • Hydatidiform mole (complete)
     1. Pathophysiology - chorionic villi degenerate into grapelike cluster of vesicles; may be antecedent to choriocarcinoma.
     2. Etiology - genetic base of complete mole (sperm enters empty egg and its chromosomes replicate; 23 pairs of chromosomes are all paternal); rare complication; more common in women over 45 years of age and Asian women.
     3. Assessment:
        • Uterus - rapid enlargement; fundal height inconsistent with gestational estimate.
        • Brownish discharge - beginning about week 12; may contain vesicles.
        • Signs and symptoms of preeclampsia/ eclampsia (before third trimester), increased incidence of hyperemesis gravidarum.
        • Medical evaluation - procedures:
          1. Sonography, x-ray, amniography - no fetal parts present; "‘snowstorm"
          2. Laboratory test - for elevated human chorionic gonadotropin (HCG) levels.
          3. Follow-up surveillance of HCG levels for at least 1 year; persistent HCG level is consistent with choriocarcinoma; x-ray.
     4. Analysis/nursing diagnosis:
        • Anxiety/fear related to treatment, possible sequelae of hydatidiform mole (choriocarcinoma).
        • Potential for injury related to hemorrhage, perforation of uterine wall, preeclamp-sia/eclampsia.
        • Fluid volume deficit related to hemorrhage.
     5. Nursing care plan/implementation:
        • Medical management
          1. Monitor for pregnancy - induced hypertension (PIH).
          2. Evacuate the uterus - hysterectomy may be necessary.
          3. Strict contraception for at least 1 year to enable accurate assessment of status.
          4. Choriocarcinoma - chemotherapy (methotrexate plus Dactinomycin) or radiation therapy, or both.
        • Nursing management
          1. Goal: safeguard status. Observe for hemorrhage, passage of retained vesicles and abdominal pain, or signs of infection (because woman is at risk for perforation of uterine wall).
          2. Goal: health teaching.
             • Explain, discuss diagnostic tests; prepare for tests.
             • Discuss contraceptive options.
             • Importance of follow-up.
          3. Goal: preoperative and postoperative care.
          4. Goal: emotional support. Facilitate grieving.
     6. Evaluation/outcome criteria:
        • Verbalizes understanding of diagnosis, tests, and treatment.
        • Complies with medical/nursing recommendations.
        • Tolerates surgical procedure well.
          1. Bleeding controlled.
          2. Vital signs stable.
          3. Urinary output adequate.
        • Copes effectively with loss of pregnancy,
        • Returns for follow-up care/surveillance.
        • Selects and effectively implements method of contraception; avoids pregnancy for 1 year or more.
        • Tests for HCG remain negative for 1 year; no evidence of malignancy.
        • Achieves a pregnancy when desired.
        • Successfully carries pregnancy to term; normal, uncomplicated birth of viable infant.
   
   
   

   Ectopic pregnancy

   
   
   
   
   • Ectopic pregnancy
     1. Pathology - implantation outside of uterine cavity.
     2. Types:
        • Tubal (most common).
        • Cervical.
        • Abdominal.
        • Ovarian.
     3. Etiology:
        • PID - pelvic salpingitis and endometritis.
        • 43% caused by STD-related factors: 25%, chlamydial; 20%, previous STD.
        • Tubal or uterine anomalies, tubal spasm
        • Adhesions from PID or past surgeries.
        • Presence of IUD.
     4. Assessment: dependent on implantation site
        • Early signs - abnormal menstrual period (usually following a missed menstrual period), spotting, some symptoms of pregnancy; possible dull pain on affected side.
        • Impending or posttubal rupture - sudden, acute, lower abdominal pain; nausea and vomiting; signs of shock; referred shoulder pain (Kehrs sign) or neck pain - due to blood in peritoneal cavity; blood in cul-de-sac may —> rectal pressure.
        • Sharp, localized pain when cervix is touched during vaginal exam; shock and circulatory collapse in some, usually following vaginal examination.
        • Positive pregnancy test in many women.
     5. Analysis/nursing diagnosis:
        • Fear related to abdominal pain and pregnancy status.
        • Grief related to pregnancy loss.
     6. Nursing care plan/implementation:
        • Medical management: Surgical removal/ repair. Methotrexate, a folic acid antagonist, which acts by inhibiting cell division (may be used in early ectopic pregnancy).
        • Nursing management:
          1. Goal: preoperative and postoperative care, health teaching.
          2. Goal: supportive care for grief reaction; encourage verbalization of anxiety and concerns of further pregnancies.
     7. Evaluation/outcome criteria:
        • Woman experiences uncomplicated postoperative course.
        • Woman copes effectively with loss of pregnancy.