PREGNANCY RELATED DISORDERS

1. Abruptio Placenta 2. Placenta Previa 3. Disseminated Intravascular Coagulation 4. Hyatidiform Mole 5. Abortion 6. Atopic Pregnancy

PLACENTA PREVIA

Abnormal implantation of the placenta in the lower uterine segment, partially or completely covering the internal cervical os. Partially, total, marginal, low lying Occurs in 3 to 6 in 1000 pregnancies Etiology: Unknown Seen with history of previous placenta previa, abortion, C/S, and uterine scarring Age greater than 35 years old. Large placenta such as multifetal gestation

PLACENTA PREVIA

Clinical Manifestation: painless vaginal bleeding. Bleeding appears without warning Diagnostic Evaluation: Transabdominal Ultrasound

PLACENTA PREVIA MANAGEMENT

Bed rest and hospitalization until fetus is mature and delivery can be accomplished. IV access and at least 2 units of blood should be available at all times. Continuous maternal and fetal monitoring. Amniocentesis may be done to determine fetal lung maturity.

NURSING ASSESSMENT

Determine the amount and type of bleeding. Inquire as to the presence or absence of pain in association with bleeding. Record maternal and fetal vital signs Palpate for the presence of uterine contractions Evaluate laboratory data on hemoglobin and hematocrit status. Assess the fetal status with fetal monitoring.

PLACENTA PREVIA

Nursing Diagnoses: Altered Tissue Perfusion related to excessive bleeding causing fetal compromise Fluid Volume Deficit related to excessive bleeding Risk for Infection related to excessive blood loss and open vessels near the cervix

PLACENTA PREVIA

Nursing Interventions 1. Promoting tissue perfusion 2. Maintaining Fluid Volume 3. Preventing Infection 4. Decreasing anxiety

ABRUPTIO PLACENTAE

Is a premature separation of the normally implanted placenta. It may be classified as partial, complete, or marginal

ABRUPTIO PLACENTA

Etiology: Unknown Risk Factors: history of hypertension or previous abruptio placenta, short umbilical cord, presence of uterine anomaly or tumor; preterm, premature rupture of membranes.

ABRUPTIO PLACENTA

Clinical Manifestations: sudden onset, intense, localized, uterine pain/tenderness with external or without vaginal bleeding Uterine contractions may be low amplitude and high frequency. FHR may change depending on the degree of hemorrhage, increased FHR

ABRUPTIO PLACENTA

GRADES Grade 0 (mild) small, retroplacental clot or small rupture of marginal sinus; <100mL blood. Grade 1 (moderate)- small, retroplacental clot; detachment ,50%; >100mL but <500mL Grade 2 (moderate to severe)- significant retroplacental clot; detachment approaches 50%; blood loss approached 500mL Grade 3 (moderate to severe)- significant retroplacental clot; detachment >50%; >500mL blood loss

ABRUPTIO PLACENTA

Diagnostic Evaluation: Ultrasound, laboratory screen tests

ABRUPTIO PLACENTAE

Management 1. Mild- conservative management with bed rest, tocolytics, and evaluation of fetus with fetal assessment methods until fetal lung maturity can be established and delivery accomplished. 2. Moderate- augment labor if stable and decreased blood loss. Vaginal delivery is accomplished if cervix dilates

ABRUPTIO PLACENTA

3. Moderate to Severe- restore and maintain maternal physiologic status. 4. Management of hemorrhagic shock with fluid resuscitation.

ABRUPTIO PLACENTA

Complications: 1. Maternal Shock 2. DIC 3. AFE 4. Prematurity 5. Maternal/ fetal death 6. ARDS 7. Rapid labor and delivery

ABRUPTIO PLACENTA

Assessment: Determine the amount and type of bleeding and the presence or absence of pain Monitor maternal and fetal vital signs, especially maternal blood pressure, pulse and FHR. Palpate the abdomen. Prepare for possible delivery.

ABRUPTIO PLACENTAE

Nursing Diagnosis: 1. Altered Placental Tissue Perfusion related to excessive bleeding, hypotension, and decreased cardiac output. 2. Fluid Volume Deficit related to excessive bleeding. 3. Fear related to excessive bleeding, procedures, and unknown outcome.

ABRUPTIO PLACENTA

Nursing Interventions: 1. Maintaining tissue perfusion 2. Maintaining fluid volume 3. Decreasing fear

HYDATIDIFORM MOLE

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

Etiology: 1. It is believed to be derived from genetic abnormalities as the paternal haploid, Xcarrying set of chromosomes that reaches 46 XX by its own duplication. Not all moles have the 46 XX chromosomal make up. 2. Large amounts of hCG are present secondary to the proliferation of chorionic tissue.

HYDATIDIFORM MOLE

Factors: 1. Chromosomal abnormalities 2. Malnutrition 3. Hormonal imbalance 4. Age 20 or over 40 years old

HYDATIDIFORM MOLE

Clinical Manifestations 1. First trimester vaginal bleeding 2. Absence of fetal heart tones and fetal structures 3. Rapid enlargement of the uterus; size greater than dates 4. Expulsion of vesicles 5. Hyperemesis

HYDATIDIFORM MOLE

Diagnostics: 1. hCG levels 2. Ultrasound

HYDATIDIFORM MOLE

Management: 1. Suction curettage is the method of choice for immediate evacuation of the mole with possibility of laparotomy. 2. Follow up for detection of malignant changes because of a complication is the development of choriocarcinoma of the endometrium. 3. Administer RhoGAM per institutional policy.

HYDATIDIFORM MOLE

Assessment: 1. Monitor vital signs; note presence of hypertension 2. Assess the amount and amount of vaginal bleeding; note the presence of any other vaginal discharge 3. Assess the urine for the presence of protein. 4. Determine date of last menstrual period and date of positive pregnancy test.

HYDATIDIFORM MOLE

Nursing Diagnosis: 1. Potential for Fluid Volume Deficit related to maternal hemorrhage. 2. Anxiety related to loss of pregnancy and medical interventions.

HYDATIDIFORM MOLE

Nursing Interventions 1. Maintaining fluid volume 2. Decreasing anxiety

Considerations: 1. Measure hCG levels every 1 to 2 weeks until normal- then begin monthly testing for 6 months, then every 2 months for a total of 1 year.

ECTOPIC PREGNANCY

Is any gestation located outside the uterine cavity.

ECTOPIC PREGNANCY

Pathophysiology: 1. The fertilized ovum implants outside the uterus. a. The most common site of implantation is the fallopian or uterine tube. b. Other sites include the abdomen and the ovaries. 2. Functional factors such as decreased tubal motility

ECTOPIC PREGNANCY

Clinical Manifestations: 1. Intermittent abdominal or pelvic pain 2. Irregular vaginal bleeding- usually scanty and dark. 3. Uterine size is usually similar to what it would be in a normally implanted pregnancy. 4. Abdominal tenderness on palpation. 5. Shoulder pain 6. Increased pulse and anxiety. 7. Nausea, vomiting, faintness or vertigo and syncope

ECTOPIC PREGNANCY

Diagnostic Examination: 1. hCG 2. Ultrasound 3. Culdocentesis 4. Laparoscopy 5. Laparotomy

ECTOPIC PREGNANCY

1. Conservative therapy is chosen should the patient desire future childbearing. Treatment with methotrexate is fats becoming the standard of care for ectopic therapy. 2. Surgery 3. Treat shock or hemorrhage.

ECTOPIC PREGNANCY

Assessment: 1. Vital signs 2. Presence and amount of bleeding 3. Amount and type of pain 4. Presence of abdominal tenderness on palpation 5. Date of last menstrual period 6. Presence of positive pregnancy test 7. RH Type

ECTOPIC PREGNANCY

Diagnosis: Risk for Fluid Volume Deficit Pain related to ectopic pregnancy Anticipatory Grieveing

ECTOPIC PREGNANCY

Nursing Management 1. Maintaining Fluid Volume 2. Promoting comfort 3. Providing support during grief 4. Patient Education

ABORTION

Spontaneous Abortion- is the unintended termination of pregnancy at any time before the fetus has attained viability.
Types: a. Threatened Abortion b. Inevitable Abortion c. Habitual d. Incomplete e. Missed

ECTOPIC PREGNANCY

Pathophysiology and Etiology: Cause frequently unknown but 50% are chromosomal activities Exposure to teratogenic agents Poor maternal nutritional status Postmature sperm or ova Imperfect sperm or ova

ABORTION

Clinical Manifestations 1. Uterine cramping, low back pain 2. Vaginal bleeding usually begins as dark spotting, then progresses to frank bleeding as the embryo separates from the uterus 3. hCG levels may be elevated for as long as 2 weeks after loss of embryo.

ABORTION

Diagnostic Evaluation: 1. Ultrasound evaluation of the gestational sac or embryo. 2. Visualization of the cervix; presence of dilation or tissue evaluated.

ABORTION

Complications: Hemorrhage Uterine Infection Septicemia DIC (in missed abortion)

ABORTION

Nursing Assessment: Evaluate the amount and color of blood that is present; determine the time the bleeding began and any precipitating factors. Determine whether a positive pregnancy test has previously been obtained, also the date of the last menstrual period. Monitor maternal vital signs for indications of complications such as hemorrhage, infection.

ABORTION

Nursing Diagnosis Risk for fluid volume deficit related to maternal bleeding Anticipatory Grieving related to loss of pregnancy, cause of abortion, future child bearing Risk for infection related to dilated cervix and open uterine vessels. Pain related to uterine cramping and possible procedures.

ABORTION

Nursing Interventions 1. Maintaining fluid volume 2. Providing support through the grieving process. 3. Preventing infection. 4. Promoting comfort.

ABORTION

Threatened Abortion Clinical manifestations: Vaginal bleeding, mild cramps, tenderness over uterus, simulates mild labor or persistent low backache with feeling of pelvic pressure, cervix closed or slightly dilated. Management: Vaginal examination, bed rest, and pad count

ABORTION

Inevitable Abortion: Clinical manifestations: Bleeding more profuse Cervix dilated Membranes rupture Painful uterine contractions Management: Embryo delivered followed by D&C

ABORTION

Habitual Abortion: Spontaneous Abortion occurs in successive pregnancies (three or more) Management: D&C, treatment of possible causes.

ABORTION

Incomplete Abortion: Fetus is usually expelled. Placenta and membranes retained. Management: D&C

ABORTION

Missed Abortion Fetus dies in utero and is retained. Maceration. No symptoms of abortion but symptoms of pregnancy regress Management: Ultrasound and fetal monitoring. Delivery of fetus

DISSEMINATED INTRAVASCULAR COAGULATION

Is a response of body's hemostatic mechanisms to a variety of diseases and injuries. DIC is a complicated and potentially fatal process characterized first by clotting and secondarily by hemorrhage. It always occurs in response to another disease or condition.

DIC

Management: Administration of blood products Record the amount of drainage from chest and NGT Observe for bleeding sites Maintain fluid balance

SYPHILIS

bad blood, lues, pox, syph Systemic, highly infectious STI Cofactor for the development of HIV infection

Etiology and Risk Factors Exposure to a delicate motile (self-moving) spirochete TREPONEMA PALLIDUM Greatest risk: adolescents, young adults, MSM Pathophysiology T.PALLIDUMintactmucousmembrane/abraded skinthrudirectsexualcontactorganisms multiply locally, disseminate systematically thru blood and lymph or transplacentally

Rare: nonsexual personal contact, accidental inoculation, blood transfusion from a syphilitic donor Complications: irreversible blindness mental illness paralysis heart disease death Clinical Manifestations: - depends on the stage

Primary o Genital Chancre oval ulcer with a raised firm border that does not bleed readily, painless unless infected; develops at site of inoculation (genitalia, anus, mouth) 4 wks after infection; heals spontaneously 4-6 wks; leaves a thin atrophic scar o Lymphadenopathy near the chancre; painless nodes, firm and discrete Secondary Develops 6-8wksafterinfectionif1infectionis untreated and disappears after 2-6 wks o Generalized rash ( maculopapular, nonpruritic, on palms of the hands and soles of feet) o Generalized, nontender, discrete lymphadenopathy

Mucous patches (gray, superficial on mucous membranes in the mouth, sore throat) Condylomata lata ( broad-based flat papules; in warm moist body areas like labia, anus, corners of the mouth) General flu-like symptoms (nausea, anorexia, constipation, headache, chronically elevated temp, muscle joint, bone pain) Patchy hair loss from eyebrows and scalp

Latent o Seroreactive (positive blood test) but shows no other evidence of disease o Noninfectious except via transplacental spread or blood transfusion

Early latent syphilis acquired during the previous 12 months Not transmitted by sexual contact unless a 2ndary syphilitic mucocutaneous skin lesion reoccurs during early latent syphilis

Tertiary o Occurs 1-5 years after the primary infection o Complications: chronic bone and joint inflammation, CV problems like aneurysms, opthalmic, auditory, CNS problems o Not infectious but terminal if untreated

DIAGNOSIS Direct test- identifies causative organism Primary and secondary lesions are scraped and causative organism is identified directly with darkfield microscopy (DFA) testing confirms a diagnosis of syphilis in the 1and2stage Indirect test- identifies antibodies of the causative agent (not present in the serum until 4 wks after appearance of chancre) 1. Serologic tests Veneral Disease Research Laboratory (VDRL) test - most commonly used screening for nonspecific antibodies Flourescent Treponemal Antibody Absorption (FTAABS)- measures Ab specific to T. Pallidum;

- Positive 3-4 wks after infection; remains positive throughout life even if tx or cured Note: CDC recommends all clients be counseled on the risks of HIV infection, undergo HIV testing, screening for other common STIs.

MEDICAL MGT. Eradicate infection and manifestations Parenteral penicillin - treatment of choice 1,2,andearlylatentsyphillis benzathine penicillin G (IM in 1 dose) Late latent and tertiary syphilis 3 wk penicillin injections Neurosyphilis- IV acquaeous crystalline penicillin G

Pregnant or noncompliant with therapy desensitization and penicillin treatment Nonpregnant allergic to penicillin doxycycline or tetracycline Reevaluation is done at 6, 12, 24 months of treatment All people who have had sexual contact with a client with 1syphilismustbeidentifiedand evaluated. Sexual contacts are treated as if they have 1 syphilis whether or not they show evidence of infection.

NURSING MGT. Provide information and psychosocial support Teach to abstain from sexual contact for at least one month after treatment Inform that reinfection is possible and importance of proper follow-up and aequate treatment

GENITAL HERPES Chronic, systemic viral infection Most frequent cause of genital ulceration Peak among adolescents and young adults

Etiology and Risk Factors Herpes simplex virus type 2 ( occurs below the waist as STD Pathophysiology HSV in exudate of the lesion (transmitted while a lesion is present and for 10 days after a lesion has healed)directcontactwiththeexudateduring sexual activity or fomites Acquiredfrompeoplewhodontknowtheyare infected or are asymptomatic at time of sexual contact

Clinical Manifestations
Occurs 3-7 days of contact Burning sensation (paresthesia) at site of inoculation Small vesicles with an erythematous border form painful, shallow ulcers then crust and heal with a scar (2-4 wks) Recurrence within 1 year of 1st episode dormant in the nerve ganglions until activated due to stress, infection, trauma, menses, sexual activity: o Burning sensation felt before vesicles erupt at site of previous infection or new sites o Vesicles erupt in 24-48 hrs, lasts for 7-10 days o Complications: meningitis, risk for spontaneous abortion, cancer of cervix

Diagnosis Viral culture, antigen detection test Pap smear multinucleated giant cells with or without inclusion bodies
Medical Mgt. Reduce Manifestations Acute primary infection : acyclovir (Zovirax), famciclovir (Famvir), valacyclovir (Valtrex) orally 7-10 days Frequent recurrences (more than 6x/yr): daily suppressive therapy as soon as symptomatic or first recognize prodromal sensations Daily acyclovir for 4 months 3 years, reevaluated after 1 year

Nursing Mgt. Prevent Reinfection Wash hands thoroughly after contact with the herpetic lesions Have separate towels and other personal items and avoid touching eyes Avoid sexual contact when vesicles are present Use condoms during latent periods Annual pelvic examinations and Pap smear (women) Provide support Help identify possible triggers Support groups Stress reduction techniques Offer counseling, evaluation and treatment to sexual partners

Reduce Pain
Keep involved area clean and dry Wear loose-fitting nonsynthetic undergarments Use sitz baths, cooling applications and

analgesic medications (aspirin)

GONORRHEA

Clap, white, drips, strain. Dose

Categories: 1. Local mucosal surfaces of the cervix, urethra, rectum, vestibular glands, pharynx, conjunctiva 2. Systemic (disseminated gonococcal infection) - bactermia with polyarthritis, dermatitis, endocarditis, meningitis - more common in women Etiology and Risk Factors Adolsecents and young adults 15-29 yrs; highest rate 20-24 yrs.

Pathophysiology Gram-negative diplococcus Neisseria gonorroeae direct sexual contact (rare: infected infants during vaginal delivery, infection of medical personnel through broken skin Incubation period: 3-8 days

Clinical Manifestations Women maybeasymptomatic,largecarrierpopn endocervical canal (primary site) or urethra, vestibular glands or anus Heavy yellow-green purulent vaginal discharge Cervical erythema Red, swollen, sore vulva Abnormal menstrual bleeding Dysuria, urinary frequency

Complication: salphingitis that can progress to PID infertilityduetoscarringandocclusionto fallopian tubes

Men evident earlier than in women Anterior urethra produces purulent discharge, dysuria, urinary frequency Complications: epididymitis, prostatitis Both conjunctivitis or pharyngitis (orogenital contact) or proctitis (anal contact) Diagnosis History, P.E., identification of the gonococcus on a smear, or culture of the exudate from infected areas

Medical Mgt. Eradicate Infection and Manifestations Screening of sexually active men and women in high-risk froups Clients positive for gonorrhea should also be tested for chlamydial infection Antibiotics even without test results based on clinical manifestations Treatment of choice: penicillin (before) Current recommended regimen for uncomplicated gonorrhea : single IM dose of ceftriaxone (Suprax), ciprofloxacin (Cipro), ofloxacin (Floxin), levofloxacin (Levaquin) Quinolone antibiotics are not given to MSM or in areas with quinolone resistant infections

Canttolerateceftriaxone:singleIMinjectionof spectinomycin (Trobicin) Disseminated gonoccocal infection: ceftriaxone IM or IV every 24 hrs and continued 24-48 hrs after improvementbeginscefiximeorciprofloxacin oral full week Unresolved cases are reevaluated with ff-up culture and tested for antibiotic sensitivity and possible resistant organisms

Nursing Mgt. Eradicate infection and manifestations Discuss importance of identifying and treatment of sexual partners Reinfection indicate for client education and sexual partner referral

Investigate sexual contacts (all sexual partners within the 50 days before diagnosis or the last contact if >60 days must undergo examination, testing, treatment) in a positive nonthreatening way Warn pregnant clients of the danger of infecting their newborns during delivery Explain importance of taking complete course of prescribed medication