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OB TEST THREEChapter 18: Gestational Onset Bleeding during pregnancy (care)Nursing interventionsoObtain accurate patient historyoAssess vital signs, s+s of shock, amount of bleeding, FHR, support system, coping mechanisms oIntervene with IV fluids/blood, type and cross for blood, give oxygenBleeding disorders (many causes)oCauses:Exercise/sex – most common cause of bleedingMiscarriage S+S: pelvic cramping, back ache, spotting, vaginal bleeding (25% of the time)o*Cramping on sides/groin = round ligament painCauses: oEarly (1sttrimester) 4-8w: chromosomal10w: hormonal12w: infections or environmental oLate (2ndtrimester up to 20 weeks/500g)Maternal factors Reproductive structureCervical insufficiency (14-18w cervix cannot handle increased weight and premature dilation causes bleeding)Maternal disease (HTN, DM)Medical/Nursing CareoEmotional support, grieving guidanceoTeach about physical pain managementoAssess vaginal bleeding, and where it is coming fromoSuction D+C – if its incomplete (outpatient)oRhoGam – if Rh(-) TeachoReport any foul smelling discharge, bleeding, tenderness, fever, chillsoShould have support person for 12-24 hours at leastoSupport groups/grief counseling Ectopic pregnancy – attaches somewhere besides uterusOften attaches in ampulla of fallopian tubeRisk FactorsoPID (pelvic inflamm disease)oIUD (intrauterine device) alters the lining of the uterus1
oEndometriosis oTubal damage (previous surgery, congenital problem)oPrevious ectopic pregnancy oHormones or fertility drugs with increased progesterone or estrogenHigh levels of progesterone alters motility of egg in tubeoSmoking paralyzes ciliaoAdvanced maternal ageS+S:oNormal symptoms of pregnancy like amenorrhea, breast tenderness, n/v, chadwicks (blue discoloration), hegars (softening of isthmus), hCG is in blood and urineoFainting and dizziness oOne sided lower abdominal painoDiffuse lower abdominal pain between 4-7 weeksoReferred right shoulder pain from blood on nerveoPhysical examsTenderness of fallopian tube and ovaries (adnexal tenderness and adnexal mass)Bleeding is slow and chronic –abdomen becomes rigid and tenderPelvic exam is painfulMass of blood can be palpatedH+H decrease, WBCs increaseClinical therapyoRule out appendicitis, UTI, PID, ruptured cyst, inflamm of fallopian tubeoMenstrual history –LMP, crampsohCG – gradual decreaseoPelvic exam, transvaginal ultrasound (FHR)Medical txoMethotrexate (Folic acid antagonist): End life of baby, given when tube is in tact to save mom’s tube. Used if the woman wants to have future pregnancy Surgical txoLaparoscopic linear salpingectomy – evacuates pregnancy and saves the tube (if ruptured then tube will be removed –ectomy)Pt. educationoReport s+s of infectionoKnow future risk of ectopic pregnancy is increasedGestational trophoblastic disease (GTD), Hydatidiform mole, molarAbnormal placental development proliferation of trophoblastic cells 2