- is the unintended termination of pregnancy at any time before the fetus has attained viability (20 weeks' gestation or fetal weight of more than 500 g). SPONTANEOUS ABORTION
Types of Spontaneous Abortions CLASSIFICATI ON
Threatened
CLINICAL MANIFESTATIONS •
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Inevitable
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Habitual
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Vaginal bleeding or spotting Mild cramps Tenderness over uterus, simulates mild labor or persistent lower backache with feeling of pelvic pressure Cervix closed or slightly dilated Symptoms subside or develop into inevitable abortion Bleeding more profuse Cervix dilated Membranes rupture Painful uterine contractions Spontaneous abortion occurs in successive pregnancies (three or more)
MANAGEMENT • •
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Incomplete
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Missed
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Fetus usually expelled
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Placenta and membranes retained Fetus dies in utero and is retained Maceration
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No symptoms of abortion, but symptoms of pregnancy regress (uterine size, breast changes) •
Vaginal examination Bed rest (some clinicians will not limit activity in belief that the embryo will be aborted anyway) Pad count
Embryo delivered, followed by dilatation and evacuation (D&E)
D&E Treatment of possible causes: hormonal imbalance, tumors, thyroid dysfunction, abnormal uterus, incompetent cervix; with treatment, 70% to 80% carry a pregnancy successfully Hysterogram to rule out uterine abnormalities, infections Surgical suturing of the cervix if incompetent cervix is a causative factor D&E
Real-time ultrasound, and if second trimester, fetal monitoring to determine if fetus is dead If fetus is not passed after diagnosis, oxytocin induction may be used. Retained dead fetus may lead to development of disseminated intravascular coagulation or infection Fibrinogen concentrations should
be measured weekly Pathophysiology and Etiology • • • • •
Abnormal fetal formation due to teratogenic factor or chromosomal anomalies Rejection of the embryo Implantation abnormalities Not enough amount of progesterone to maintain the deciduas basalis Infection
Diagnostic Evaluation • •
Ultrasound Visualization of the cervix
Complications • • • •
Hemorrhage Uterine infection Septicemia Disseminated Intravascular Coagulation in a missed abortion
Nursing Assessment • •
Evaluate the amount and color of blood that is present Evaluate any blood or clot tissue for the presence of fetal membranes, placenta or fetus
Nursing Interventions
Maintaining Fluid Volume o Report tachycardia, hypotension, diaphoresis, or pallor, indicating hemorrhage and shock. o Draw blood for CBC as well as type and screen for possible blood administration. o Establish and maintain an I.V. with large-bore catheter for possible transfusion and large quantities of fluid replacement. Providing Support through the Grieving Process Preventing Infection •
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- gestation located outside the uterine cavity (ie, implantation occurs at a site other than the endometrium). o Most tubal pregnancies occur in the distal (ampullary) two-thirds of the tube. o Some are located in the proximal portion of the extrauterine part of the tube (isthmic). o Rarely, intrauterine and extrauterine gestations can exist as the same time (heterotopic pregnancy). ECTOPIC PREGNANCY
Risk Factors: •
Structural factors that prevent or delay the passage of the fertilized ovum include adhesions of the tube, salpingitis, congenital and developmental anomalies of the fallopian or uterine tube, previous ectopic pregnancy, use of an intrauterine device for more than 2 years, and multiple induced elective abortions
Clinical Manifestations: Manifestations:
If tube is unruptured, slow, chronic bleeding usually occurs and the abdomen becomes rigid and very tender If a tube ruptures, sudden excruciating pain is felt in the lower abdomen, usually over the mass; referred shoulder pain is possible as the abdomen fills with blood; vaginal bleeding and shock may also occur
Treatment:
A. Surgical: Surgical: laparos laparoscopy, copy, laparotomy, laparotomy, salpingecto salpingectomy my B. Medical: Medical: methotrexa methotrexate te used to dissolve dissolve residual residual tissue tissue or as a one time treatment treatment for unruptured pregnancy
Nursing Interventions • • •
Maintaining Fluid Volume Promoting Comfort Providing Support through the Grieving Process
- is an abnormal pregnancy resulting from a developmental anomaly of the placenta. It is characterized by the conversion of the chorionic villi into a mass of clear vesicles. There may be no fetus, or a degenerating fetus may be present. HYDATIDIFORM MOLE
Clinical Manifestations • • • • • • •
First trimester vaginal bleeding Absence of fetal heart tones and fetal structures Rapid enlargement of the uterus; size greater than dates β-hCG titers greater than expected for gestational age Expulsion of the vesicles Hyperemesis (severe nausea and vomiting) Signs of preeclampsia before 24 weeks' gestation
Diagnostic Evaluation • •
β-hCG levels elevated Ultrasound shows a characteristic picture of the mole in most cases
Management
Suction curettage is the method of choice for immediate evacuation of the mole with possibility of laparotomy. Follow-up for detection of malignant changes because a complication is the development of choriocarcinoma of the endometrium. Administer RhIG (RhoGAM) per your facility's policy if woman is Rh negative. Complications : Significant blood loss •
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Nursing Interventions • •
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Maintaining Fluid Volume Decreasing Anxiety o Prepare for surgery Patient Education and Health Maintenance o Follow up supervision for 1 yr o Pregnancy should be avoided for at least 1 yr
