NUR 3250 Maternal Newbron Exam 2 Review
Module 8 (15 questions)
1. Describe the hemorrhagic conditions of early pregnancy including spontaneous abortion, ectopic
pregnancy and gestational trophoblastic disease
A. Spontaneous abortion
o The leading cause of pregnancy loss prior to 20 weeks
o Most commonly due to chromosomal abnormalities incompatible with life
o Rate increases with age
o Treatment:
▪ Preventing complications such as hypovolemic shock and infection
▪ Providing emotional support for grieving
o Types of Spontaneous abortions
▪ Threatened – Vaginal bleeding occurs
o Clinical findings:
• Report of cramping
• On exam, cervix closed but bleeding evident
o Care considerations:
• Careful monitoring by laboratory testing of beta human
chorionic gonadotropin and ultrasound
• Supportive measures
▪ Inevitable – Membrane rupture and cervix dilate
o Clinical findings:
• Report of cramping
• On exam, cervix closed but bleeding evident
o Care considerations:
• Careful monitoring by laboratory testing of beta human
chorionic gonadotropin and ultrasound
• Supportive measures
▪ Incomplete – Some products of conception have been expelled, but some
remain
o Clinical findings:
• Some POC are expelled
• Active uterine bleeding
• Severe cramping
o Care considerations:
• Retained tissue prevents uterus from contracting & profuse
bleeding may occur
• Dilation and evacuation (D&E) followed by vacuum and
curettage
• Administer Pitocin or Methergine
▪ Complete
o Clinical findings:
• Patient report of passing clots and tissue accompanied by
heavy cramping and bleedings
• All POC have been expelled
• On exam, cervix is closed and possible residual blood is
present in the vagina
o Care considerations:
• Supportive measures
1
,NUR 3250 Maternal Newbron Exam 2 Review
• Medical intervention rarely required if all tissue passes, and no
infection or signs of hemorrhage are expected
▪ Missed - Fetus dies but is retained in the uterus
o Ultrasound to confirm absence of heartbeat
o D&C or D&E
o If second trimester, misoprostol (Cytotec) may be needed to induce
contractions
o Complications include:
• Infection
• Disseminated intravascular coagulation (DIC)
o In event of infection, uterine evacuation is delayed until antibiotic
therapy is initiated
▪ Recurrent (Habitual) Spontaneous Abortion - Three or more consecutive
spontaneous abortions
o Causes may include:
• Genetic
• Chromosomal anomalies
• Anomalies of the woman’s reproductive tract
• Bicornate uterus
• Incompetent cervix
• Insufficient secretion of progesterone
• Lupus
• Diabetes
• Sexually transmitted diseases
• TORCH infections
B. Ectopic Pregnancy – Implantation of the fertilized ovum in an area outside of the uterine
cavity
o 95% occur in the fallopian tubes.
o The incidence of ectopic pregnancy is increasing as a result of pelvic inflammation (PID)
o Therapeutic management:
▪ Medical management (Methotrexate)
▪ Prevent severe hemorrhage
▪ Salpingectomy
o Manifestations:
▪ Early signs
o Missed menstrual period
o Abdominal and pelvic pain
o Vaginal spotting
▪ Signs of Tubal rupture
o Sudden, severe pain in one of the lower quadrants of abdomen
o Shoulder or neck pain
o Signs of hypovolemic shock
o Diagnostic evaluation:
▪ Transvaginal ultrasound (no gestational sac)
▪ Determination of the beta-hCG level (lower than expected)
▪ Laparoscopy
o Examination of the peritoneal cavity (diagnose tubal rupture)
o Nursing Considerations:
▪ Preventing or identifying hypovolemic shock
2
,NUR 3250 Maternal Newbron Exam 2 Review
▪ Controlling pain
▪ Providing psychological support
▪ Side effects of methotrexate
▪ Importance of notifying provider if worsening signs appear
▪ Woman must refrain from alcohol and vitamins with folic acid
▪ Importance of keeping up follow-up appointments
C. Gestational Trophoblastic Disease (Hydatidiform Mole)
• Trophoblasts develop abnormally
• Abnormal growth causes placenta (but not fetus) to develop
• Characterized by proliferation and edema of the chorionic villi (fluid-filled grapelike vesicles)
that grows large enough to fill the uterus similar to an advanced pregnancy
Types of moles:
• Complete
o No fetus presents
o Ovum is fertilized by sperm that duplicates its own chromosomes while the
chromosomes of the ovum are inactivated
• Partial
o Fetal tissue or membranes present
o Maternal contribution is usually present, but the paternal contribution is double
• Choriocarcinoma (gestational trophoblastic neoplasm)
o Malignant change and proliferation of residual trophoblastic tissue
o Life-threatening complication
o Vesicles of the mole enter woman’s circulation causing embolism
o May spread to distant sites (vagina, lung, liver, kidneys, brain)
D. Molar Pregnancies: Manifestation and Diagnostic Evaluation
• Diagnosed by ultrasound
• Levels of beta – hCG are high due to rapidly proliferating abnormal villi
• Symptoms may vary with gestation:
o Vaginal bleeding, which varies from dark brown spotting to profuse bleeding
o Uterus larger than expected for the duration of the pregnancy
o Excessive nausea and vomiting (high beta-hCG levels)
o Early development of preeclampsia (prior to 24 weeks)
E. Hydatidiform Mole Management
• Vacuum aspiration to extract mole
• Curettage to remove all remaining molar tissue (send to pathology)
• IV oxytocin to contract uterus after all tissue is removed
• Follow-up to detect malignant changes
• Evaluation of serum beta-hCG levels every 1-2 weeks until 3 normal pre -pregnancy levels
are obtained
• Levels repeated every 1-2 months for up to a year
• Pregnancy must be avoid for one year during follow-up (oral contraceptives)
• Suspect choriocarcinoma if beta-hCG levels do not fall or if they rise after an initial fall
3
, NUR 3250 Maternal Newbron Exam 2 Review
• Chemotherapy is the primary treatment for choriocarcinoma (high cure) –
Methotrexate
2. Explain disorders of the placenta, such as placenta previa, vasa previa and abruption placentae,
which may result in hemorrhage during late pregnancy.
A. Placenta Previa
o Implantation of the placenta in the lower uterus
• Requires delivery by cesarean section
• Manifestations:
o Sudden onset of painless uterine bleeding
o Placenta villi are torn from the uterine wall with contractions or vaginal
examination
B. Placental Abruption - (Abruptio Placentae)
o Separation of a normally implanted placenta before the fetus is born
• Manifestations:
o Abdominal or low back pain
o Vaginal bleeding (may have concealed bleeding)
o Hypertonic contractions
o Uterine tenderness at the site of the abruption
o Abdomen may feel firm (board like)
• Risk Factors:
o Abdominal trauma
▪ MVA
▪ Domestic abuse
o Smoking
o Maternal use of cocaine
o Hypertension
o History of a previous abruption
o Autoimmune factors
o Certain coagulopathies
• Signs and Symptoms of Hypovolemic Shock
o Increased pulse rate, falling blood pressure, increased respiratory rate
o Weak, diminished, or “thready” peripheral pulses
o Cool, moist skin; pallor, or cyanosis (Late Sign)
o Decreased urinary output <30 ml/hr
o Decreased hemoglobin, hematocrit levels
o Change in mental status (restlessness, agitation, difficulty concentrating)
3. Compare Rh and ABO incompatibility in terms of etiology, fetal and neonatal complications and
management.
o Rh incompatibility
▪ Rh– woman conceives an Rh+ child.
▪ Maternal antibodies may then develop after exposure to fetal Rh+ blood.
▪ Administration of RhoGAM
o ABO incompatibility
▪ O blood type woman with naturally occurring anti-A and anti-B antibodies
4
Module 8 (15 questions)
1. Describe the hemorrhagic conditions of early pregnancy including spontaneous abortion, ectopic
pregnancy and gestational trophoblastic disease
A. Spontaneous abortion
o The leading cause of pregnancy loss prior to 20 weeks
o Most commonly due to chromosomal abnormalities incompatible with life
o Rate increases with age
o Treatment:
▪ Preventing complications such as hypovolemic shock and infection
▪ Providing emotional support for grieving
o Types of Spontaneous abortions
▪ Threatened – Vaginal bleeding occurs
o Clinical findings:
• Report of cramping
• On exam, cervix closed but bleeding evident
o Care considerations:
• Careful monitoring by laboratory testing of beta human
chorionic gonadotropin and ultrasound
• Supportive measures
▪ Inevitable – Membrane rupture and cervix dilate
o Clinical findings:
• Report of cramping
• On exam, cervix closed but bleeding evident
o Care considerations:
• Careful monitoring by laboratory testing of beta human
chorionic gonadotropin and ultrasound
• Supportive measures
▪ Incomplete – Some products of conception have been expelled, but some
remain
o Clinical findings:
• Some POC are expelled
• Active uterine bleeding
• Severe cramping
o Care considerations:
• Retained tissue prevents uterus from contracting & profuse
bleeding may occur
• Dilation and evacuation (D&E) followed by vacuum and
curettage
• Administer Pitocin or Methergine
▪ Complete
o Clinical findings:
• Patient report of passing clots and tissue accompanied by
heavy cramping and bleedings
• All POC have been expelled
• On exam, cervix is closed and possible residual blood is
present in the vagina
o Care considerations:
• Supportive measures
1
,NUR 3250 Maternal Newbron Exam 2 Review
• Medical intervention rarely required if all tissue passes, and no
infection or signs of hemorrhage are expected
▪ Missed - Fetus dies but is retained in the uterus
o Ultrasound to confirm absence of heartbeat
o D&C or D&E
o If second trimester, misoprostol (Cytotec) may be needed to induce
contractions
o Complications include:
• Infection
• Disseminated intravascular coagulation (DIC)
o In event of infection, uterine evacuation is delayed until antibiotic
therapy is initiated
▪ Recurrent (Habitual) Spontaneous Abortion - Three or more consecutive
spontaneous abortions
o Causes may include:
• Genetic
• Chromosomal anomalies
• Anomalies of the woman’s reproductive tract
• Bicornate uterus
• Incompetent cervix
• Insufficient secretion of progesterone
• Lupus
• Diabetes
• Sexually transmitted diseases
• TORCH infections
B. Ectopic Pregnancy – Implantation of the fertilized ovum in an area outside of the uterine
cavity
o 95% occur in the fallopian tubes.
o The incidence of ectopic pregnancy is increasing as a result of pelvic inflammation (PID)
o Therapeutic management:
▪ Medical management (Methotrexate)
▪ Prevent severe hemorrhage
▪ Salpingectomy
o Manifestations:
▪ Early signs
o Missed menstrual period
o Abdominal and pelvic pain
o Vaginal spotting
▪ Signs of Tubal rupture
o Sudden, severe pain in one of the lower quadrants of abdomen
o Shoulder or neck pain
o Signs of hypovolemic shock
o Diagnostic evaluation:
▪ Transvaginal ultrasound (no gestational sac)
▪ Determination of the beta-hCG level (lower than expected)
▪ Laparoscopy
o Examination of the peritoneal cavity (diagnose tubal rupture)
o Nursing Considerations:
▪ Preventing or identifying hypovolemic shock
2
,NUR 3250 Maternal Newbron Exam 2 Review
▪ Controlling pain
▪ Providing psychological support
▪ Side effects of methotrexate
▪ Importance of notifying provider if worsening signs appear
▪ Woman must refrain from alcohol and vitamins with folic acid
▪ Importance of keeping up follow-up appointments
C. Gestational Trophoblastic Disease (Hydatidiform Mole)
• Trophoblasts develop abnormally
• Abnormal growth causes placenta (but not fetus) to develop
• Characterized by proliferation and edema of the chorionic villi (fluid-filled grapelike vesicles)
that grows large enough to fill the uterus similar to an advanced pregnancy
Types of moles:
• Complete
o No fetus presents
o Ovum is fertilized by sperm that duplicates its own chromosomes while the
chromosomes of the ovum are inactivated
• Partial
o Fetal tissue or membranes present
o Maternal contribution is usually present, but the paternal contribution is double
• Choriocarcinoma (gestational trophoblastic neoplasm)
o Malignant change and proliferation of residual trophoblastic tissue
o Life-threatening complication
o Vesicles of the mole enter woman’s circulation causing embolism
o May spread to distant sites (vagina, lung, liver, kidneys, brain)
D. Molar Pregnancies: Manifestation and Diagnostic Evaluation
• Diagnosed by ultrasound
• Levels of beta – hCG are high due to rapidly proliferating abnormal villi
• Symptoms may vary with gestation:
o Vaginal bleeding, which varies from dark brown spotting to profuse bleeding
o Uterus larger than expected for the duration of the pregnancy
o Excessive nausea and vomiting (high beta-hCG levels)
o Early development of preeclampsia (prior to 24 weeks)
E. Hydatidiform Mole Management
• Vacuum aspiration to extract mole
• Curettage to remove all remaining molar tissue (send to pathology)
• IV oxytocin to contract uterus after all tissue is removed
• Follow-up to detect malignant changes
• Evaluation of serum beta-hCG levels every 1-2 weeks until 3 normal pre -pregnancy levels
are obtained
• Levels repeated every 1-2 months for up to a year
• Pregnancy must be avoid for one year during follow-up (oral contraceptives)
• Suspect choriocarcinoma if beta-hCG levels do not fall or if they rise after an initial fall
3
, NUR 3250 Maternal Newbron Exam 2 Review
• Chemotherapy is the primary treatment for choriocarcinoma (high cure) –
Methotrexate
2. Explain disorders of the placenta, such as placenta previa, vasa previa and abruption placentae,
which may result in hemorrhage during late pregnancy.
A. Placenta Previa
o Implantation of the placenta in the lower uterus
• Requires delivery by cesarean section
• Manifestations:
o Sudden onset of painless uterine bleeding
o Placenta villi are torn from the uterine wall with contractions or vaginal
examination
B. Placental Abruption - (Abruptio Placentae)
o Separation of a normally implanted placenta before the fetus is born
• Manifestations:
o Abdominal or low back pain
o Vaginal bleeding (may have concealed bleeding)
o Hypertonic contractions
o Uterine tenderness at the site of the abruption
o Abdomen may feel firm (board like)
• Risk Factors:
o Abdominal trauma
▪ MVA
▪ Domestic abuse
o Smoking
o Maternal use of cocaine
o Hypertension
o History of a previous abruption
o Autoimmune factors
o Certain coagulopathies
• Signs and Symptoms of Hypovolemic Shock
o Increased pulse rate, falling blood pressure, increased respiratory rate
o Weak, diminished, or “thready” peripheral pulses
o Cool, moist skin; pallor, or cyanosis (Late Sign)
o Decreased urinary output <30 ml/hr
o Decreased hemoglobin, hematocrit levels
o Change in mental status (restlessness, agitation, difficulty concentrating)
3. Compare Rh and ABO incompatibility in terms of etiology, fetal and neonatal complications and
management.
o Rh incompatibility
▪ Rh– woman conceives an Rh+ child.
▪ Maternal antibodies may then develop after exposure to fetal Rh+ blood.
▪ Administration of RhoGAM
o ABO incompatibility
▪ O blood type woman with naturally occurring anti-A and anti-B antibodies
4
