Molar

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Molar pregnancy

• Molar pregnancy- complete or partial
• chorion develop despite grossly abnormal number
  of chromosomes
• Abnormal placental development

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• Molar pregnancy is an abnormal form of pregnancy
  in which a non-viable fertilized egg implants in
  the uterus and converts a normal pregnancy into
  an abnormal one
• A molar pregnancy can develop when an egg that is
  missing its nucleus is fertilized and that may or
  may not contain fetal tissue. It is characterized
  by the presence of a hydatidiform mole
• Mole as used here simply indicates clump of
  growing tissue, or a 'growth'.

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Risk factors

• Age gt 40 yrs
• Previous miscarriages or ectopic pregnancy
• Mexico, Phillippines, Southeast Asia
• Incidence
• 80 non-aggressive
• 15 aggressive
• 2 cancerous

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Signs and symptoms

• Abnormally high Hcg levels
• Brownish vaginal discharge
• Abdominal pain, distention
• Hydropic vesicles may be passed
• Uterine enlargement may be greater than expected
  with pregnancy
• Hyperemesis/anemia
• Diagnosed with transvaginal ultrasound, Hcg
  (quantitative) testing

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Treatment of Molar pregnancy

• D and C or D and E microscopic examination
• Risk for choriocarcinoma
• Serum Hcg q 2 weeks X 3 months, then q 1 months
  for up to 1 year
• Advised not to conceive for 1 year, contraception
  provided
• With no increased Hcg for 1 year, low risk of
  recurrence or choriocarcinoma
• Methotrexate agent used for carcinoma

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Abortion- Termination of pregnancy prior to age
of viability

• Spontaneous 20 of all pregnancies prior to
  week 20. May be unknown to patient.
• Etiology ? Fetal/placental growth abnormalities
• Chromosomal defects
• Faulty implantation
• Drugs/ Infection
• Endocrine/ reproductive tract problems

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• THREATENED AB
• Unexplained vaginal bleeding, cramping. May or
  may not have fetal demise.
• Membranes remain intact and cervical os remains
  closed
• Rx limit activities
• bedrest
• no sexual relations
• IMMINENT or INEVITABLE AB
• Bleeding increases, Os dilates
• COMPLETE AB
• All products of conception are expelled

8

• INCOMPLETE AB
• Products of conception are retained
• Pt will need D C
• MISSED AB
• Fetal demise in utero
• May or may not abort spontaneously
• May need induction of labor or D C
• SEPTIC AB
• Pt presents with uterine infection, elevated
  temp, malodorus bleeding, abdominal tenderness.
• Often due to missed abortion, serious condition
• Recurrent Pregnancy Loss may signal chromosomal
  or hormonal abnormality

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Nursing Interventions

• Emotional Support for Family
• Help mother and family through grieving process.
  This can take 6-24 months
• shock, disbelief, grief, sadness, anger, guilt
• mourning
• resolution, acceptance
• Be available, listen, encourage family to
  verbalize. Provide family opportunity to hold
  aborted fetus, foot prints, photo (if applicable)
• Refer to Support Group- Resolve through Sharing,
  Spiritual Counsel
• Maternal care same as post partum, Rhogam

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Incompetent or Dysfunctional Cervix

• When 2 or more spontaneous abs occur in the 2nd
  trimester
• Usually a result of weak, torn, or absent
  sphincter muscle at cervical os
• Causes include Cervical trauma, infection,
  multiple gestation, cone bx, late term abortion
• Premature dilation is painless. S/S contraction,
  bleeding, leaking amniotic fluid
• Treatment Bedrest, possible cerclage

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Cerclage

• Cerclage- surgical suture around internal os
  around week 13-15
• Suture must be opened for delivery, usually
  around 37 weeks
• Mom must notify if SROM occurs
• Risks to fetus not 100 effective

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Premature Rupture of Membranes

• Many predisposing risk factors
• Maternal Sequelae Abruption, Intra-amniotic
  infection, post-partum infection of endometrium
• Fetal sequelae Respiratory distress, sepsis,
  prolapsed cord
• Diagnoses nitrazine paper, microscopic test of
  amniotic fluid
• No digital examination!!!

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Treatment options

• Assess fetal well-being, gestational age
• Give antibiotics
• lt 37 weeks gestation, minimal options
• gt 34 weeks, assess lung maturation of fetus,
  possibly single dose betamethasone may be
  administered
• Monitor for signs and prevent premature labor
• Provide psychological support for mother and
  family

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Pre-term Labor

• Onset of Labor from 20-37 weeks
• Rarely due to a single cause
• Common problem 11.6 of all births are premature
• Multiple causes
• Maternal renal, CV, DM, PIH, Placental problems,
  Trauma, PROM
• Effect to fetus
• Maturational deficiencies- no body fat
• Respiratory Distress
• Poor glucose, heat regulation

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• Strongest predictors hx of previous bacterial
  vaginosis, abnormal cervical length or
  funneling, fetal fibronectin screening
• Dx based on cervical dilation gt 1cm, effacement
  or gt 80
• Greater than 4 contractions in 20 minutes or
  greater than 8 in one hour

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• TOCOLYTIC DRUGS
• Maternal Steroid Injection (24-36 weeks)
• In hospital Continuous FHR, monitoring of
  contractions, hydration, treatment of any
  causative infections

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Patient education

• Braxton Hicks versus Labor greater than 4 cx
  per hour
• New low back pain
• Spotting or bleeding
• Increase in vaginal discharge
• Pelvic pressure
• Bedrest side-lying position, adequate hydration,
  frequent voiding, avoid nipple stimulation and
  sexual activity, other self care measures.

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ABO and Rh Incompatibility

• Preventing maternal sensitization and risks to
  the fetus

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Rh Incompatibility

• Blood entering maternal circulation from Rh
  positive fetus causes immune reaction. Mother
  produces antibodies to babys blood.
• Result? Agglutination and hemolysis of the babys
  rbcs

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Rh Immune globulin

• RhoGAM helps prevent maternal sensitization in
  the Rh negative mom
• Initial Rh and ABO testing antepartally followed
  by Rh antibody screening at 28 weeks
• RhoGAM given after abortion, ectopic pregnancy,
  amniocentesis and within 72 hrs after birth

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ABO Incompatibiltiy

• O positive mother has A, B or AB fetus with
  antigens causing maternal antibody reaction
• Rarely causes significant hemolysis, unlike Rh
  incompatibility, therefore requires no antepartal
  treatment usually

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TORCH Infections Perinatal infections affecting
the fetus

• Toxoplasmosis
• O ther
• Rubella
• Cytomegalovirus
• Herpes simplex virus
• Cause fetal loss, IUGR, anomalies, premature
  birth, chronic post-natal infection

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TORCH INFECTIONS

• Toxoplasmosis (also an opportunistic infection in
  HIV)
• Produces flu like symptoms, lymphadenopathy
• Fetal demise, AB, retardation, blindness and
  other anomalies
• Treated with Sulfa/ clindamycin
• Avoid Eating Raw/ improperly cooked meat
• Stay away from Kitty litter
• Wear gloves when gardening- animal feces

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• Other- Hepatitis A,B, C, D, E, Syphilis,
  Chlamydia, Trichomonas, Gonorrhea, Condyloma,BV,
  Urinary tract infections,
• Hep A- Due to poor sanitation, hand washing,
  foodborne
• Maternal flu like symptoms
• Fetal anomalies
• Vaccination post partum
• Hep B- blood borne/ sexually transmitted
• Maternal flu like symptoms, jaundice
• Fetal like Hep A
• Rx Prevention with Hep B Vaccine which also
  prevents Hep D

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• Urinary Tract Infections,
• Need early detection Tx
• Urine CS
• NO TETRACYCLINE
• If untreated can ascend to pyelonephritis
• High fevers, pain, NV, ? GFR
• Hospitalization with IV Antibiotics
• Premature delivery, IUGR
• SYPHILIS- CROSSES THE PLACENTA
• VDRL
• Can cause fetal disease/ demise/ miscarriage
• TX Penicillin or Erythromycin

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• Gonorrhea/ Chlamydia
• Usually exist together/ treat pt. For both
• Can affect newborn at birth/ vision
• Usual TX
• Erythromycin for Chlamydia Newborn eyes treated
  with Erythromycin opthalmic ointment
• B.Hemolytic Strep-
• 30 of women harbor Gr. B. Strep
  vaginally/rectally/ can enter amniotic fluid
• Can cause respiratory distress, sepsis,
  meningitis in newborn
• RX with Ampicillin, Amoxicillin, Erythromycin

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• R Rubella or German Measles
• A Virus if contracted in 1st trimester can cause
  multiple congenital anomalies. Heart, vision,
  hearing, retardation
• Diagnosed by blood
• Ideal to immunize all women before child bearing
  , Offer post partum
• C Cytomegaly virus-CMV
• A virus spread by close contact. Common in HIV.
  Can cross the placenta
• Can cause fetal cognitive and hearing impairment
• Prevention with Standard precautions

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• H Herpes (HSV 1 2)
• Painful blisters(vessicles) on genitalia
• Neonatal mortality high if fetus exposed to
  active disease after ROM or in Vaginal delivery
• Brain damage, fever, jaundice, seizures poor
  feeding, skin lesions can occur in the neonate
• Moms treated with antivirals if active
  lesions, must have C/S
• Healthcare workers with HSV1 should wear face
  mask around newborns to prevent transmission and
  avoid direct contact
• Good handwashing

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Herpetic Lesions
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Advanced Maternal AgePregnancy gt35 years

• For a woman in good health gt35 who gets prenatal
  care early risks are similar to younger women
• As biologic clock runs out conception may
  become more difficult
• Increased risk of genetic disorders can be
  detected early with Amniocentesis
• Fatigue may be greater prenatal and postpartum

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Multiple Pregnancy
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Multiple Pregnancy

• Twins- 1 in 90 births
• Triplets1 in 7600 births
• Familial tendency/ fertility drugs
• Monozygotic twins- Identical
• from one fertilized egg- always same sex
• one placenta, two amnions
• Dizygotic- Fraternal
• from 2 fertilized eggs- gender can vary
• 2 placentas

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• All multiple pregnancies carry increased risk to
  mom and fetus
• High risk for
• spontaneous abortions, placenta previa, placenta
  abruptia, PIH
• Congenital defects
• Pre term Labor
• Need for C-S
• Additional parental responsibilities
• family needs additional support encouragement/
  help

The Dionne Quintuplets born 1934
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Post-term pregnancy

• Pregnancy that goes beyond 42 weeks
• Most common cause
• Miscalculation of dates
• After 42 weeks
• decreased placental function/ amniotic fluid
• decrease rate of fetal growth
• fetal distress
• Fetal changes
• Increase scalp hair, long thin body, less subcu
  fat, long nails, decrease vernix, dry skin
• Rx Fetal surveillance, Induction or C-S

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ABUSE DURING PREGNANCY

• 4-14 of Adult pregnant women are physically by
  an intimate partner
• 20 of adolescents say they are abused during
  pregnancy
• Pts must be assess for this at every prenatal
  visit.
• A safe trusting relationship must be built
• Look for bruises, abrasions, cuts, burns.
  Injuries to the abdomen, breasts, neck, head
• Ask the questions when pt. Is alone and in a
  soundproof, intrusion proof area

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• If a woman discloses abuse
• Be non-judgmental
• Give the patient time
• Offer Support and reassure her that she is not
  responsible for the abusive behavior/ and does
  not deserve it
• Discuss safety plan and refer to legal, social
  service, and healthcare providers.
• Document your findings carefully. Use pts own
  words. Record your interventions, referrals