Manifestations.

Treatment.

The health care provider will rule out other causes for the excessive nausea and vomiting, such as gastroenteritis or liver, gallbladder, or pancreatic disorders, before making this diagnosis. The medical treatment for hyperemesis gravidarum is to correct dehydration and electrolyte or acid-base imbalances with oral or intravenous fluids. Antiemetic drugs may be prescribed after the health care provider informs the woman about any potential risk to the developing fetus. Occasionally, severe cases necessitate total parenteral nutrition. The woman may need hospital admission to correct dehydration and inadequate nutrition if home measures are not successful. The condition is self-limiting in most women, although it is quite distressing to the woman and her family.

Nursing Care.

Nursing care focuses on patient teaching, because most care occurs in the home. The woman should be taught how to reduce factors that trigger nausea and vomiting. She should avoid food odors, which may abound in meal preparation areas and tray carts if she is hospitalized. If she becomes nauseated when her food is served, the tray should be removed promptly and offered again later.

Accurate intake and output records are kept to assess fluid balance. Frequent, small amounts of food and fluid keep the stomach from becoming too full, which can trigger vomiting. Easily digested carbohydrates, such as crackers or baked potatoes, are tolerated best. Foods with strong odors should be eliminated from the diet. Taking liquids between solid meals helps to reduce gastric distention. Sitting upright after meals reduces gastric reflux (backflow) into the esophagus.

The emesis basin is kept out of sight so that it is not a visual reminder of vomiting. It should be emptied at once if the woman vomits and the amount documented on the intake and output record.

Stress may contribute to hyperemesis gravidarum; stress may also result from this complication. The nurse should provide support by listening to the woman’s feelings about pregnancy, child rearing, and living with constant nausea. Although psychological factors may play a role in some cases of hyperemesis gravidarum, the nurse should not assume that every woman with this complication is adjusting poorly to her pregnancy.

Treatment.

Oxytocin (Pitocin) controls blood loss before and after curettage, much as the drugs do after term birth. Rh₀(D) immune globulin (RhoGAM [300 mcg] or the lower-dose MICRhoGAM [50 mcg]) is given to Rh-negative women after any abortion to prevent the development of antibodies that might harm the fetus during a subsequent pregnancy.

Nursing Care

Manifestations.

Treatment.

A sensitive pregnancy test for hCG is done to determine if the woman is pregnant. Trans-vaginal ultrasound examination determines whether the embryo is growing within the uterine cavity. Culdocentesis (puncture of the upper posterior vaginal wall with removal of peritoneal fluid) may occasionally be done to identify blood in the woman’s pelvis, which suggests tubal rupture. A laparoscopic examination may be done to view the damaged tube with an endoscope (lighted instrument for viewing internal organs).

Nursing Care.

Nursing care includes observing for hypovolemic shock as in spontaneous abortion. Vaginal bleeding is assessed, although most lost blood may remain in the abdomen. The nurse should report increasing pain, particularly shoulder pain, to the physician.

In addition to physical preoperative and postoperative care, the nurse provides emotional support because the woman and her family may experience grieving similar to that accompanying spontaneous abortion. Loss of a fallopian tube threatens future fertility and is another source of grief.

Manifestations.

Treatment.

The uterus is evacuated by vacuum aspiration and D&E. The level of hCG is tested and retested until it is undetectable, and the levels are followed for at least 1 year. Persistent or rising levels suggest that vesicles remain or that malignant change has occurred. The woman should delay conceiving until follow-up care is complete because a new pregnancy would confuse tests for hCG. Rh_o(D) immune globulin is prescribed for the Rh-negative woman.

Nursing Care.

Manifestations.

Painless vaginal bleeding, usually bright red, is the main characteristic of placenta previa. The woman’s risk of hemorrhage increases as term approaches and the cervix begins to efface (thin) and dilate (open). These normal prelabor changes disrupt the placental attachment. The fetus is often in an abnormal presentation (e.g., breech or transverse lie) because the placenta occupies the lower uterus, which often prevents the fetus from assuming the normal head-down presentation.

The fetus or neonate may have anemia or hypovolemic shock because some of the blood lost may be fetal blood. Fetal hypoxia may occur if a large disruption of the placental surface reduces the transfer of oxygen and nutrients.

Treatment.

Medical care depends on the length of gestation and the amount of bleeding. The goal is to maintain the pregnancy until the fetal lungs are mature enough that respiratory distress is less likely (at about 34 weeks of gestation). Delivery will be done if bleeding is sufficient to jeopardize the mother or fetus, regardless of gestational age.

The woman should lie on her side or have a pillow under one hip to avoid supine hypotension. If bleeding is extensive or the gestation is near term, a cesarean section is performed for partial or total placenta previa. The woman with a low-lying placenta or marginal placenta previa may be able to deliver vaginally unless the blood loss is excessive.

Nursing Care.

Manifestations.

Bleeding accompanied by abdominal or low back pain is the typical characteristic of abruptio placentae. Unlike the bleeding in placenta previa, most or all of the bleeding may be concealed behind the placenta. Obvious dark-red vaginal bleeding occurs when blood leaks past the edge of the placenta. The woman’s uterus is tender and unusually firm (boardlike) because blood leaks into its muscle fibers. Frequent, cramplike uterine contractions often occur (uterine irritability).

The fetus may or may not have problems, depending on how much placental surface is disrupted. As in placenta previa, some of the blood lost may be fetal, and the fetus or neonate may have anemia or hypovolemic shock.

Disseminated intravascular coagulation (DIC) is a complex disorder that may complicate abruptio placentae. The large blood clot that forms behind the placenta consumes clotting factors, which leaves the rest of the mother’s body deficient in these factors. Clot formation and anticoagulation (destruction of clots) occur simultaneously throughout the body in the woman with DIC. She may bleed from her mouth, nose, incisions, or venipuncture sites because the clotting factors are depleted.

Postpartum hemorrhage may also occur because the injured uterine muscle does not contract effectively to control blood loss. Infection is more likely to occur because the damaged tissue is susceptible to microbial invasion.

Treatment.

The treatment of choice, immediate cesarean delivery, is done because of the risk for maternal shock, clotting disorders, and fetal death. Blood and clotting factor replacement may be needed because of DIC. The mother’s clotting action quickly returns to normal after birth because the source of the abnormality is removed.

Nursing Care.

Preparation for cesarean section and close monitoring of vital signs and fetal heart are essential. Signs of shock and bleeding from the nose, the gums, or other unexpected sites should be promptly reported. Rapid increase in the size of the uterus suggests that blood is accumulating within it. The uterus is usually very tender and hard. Nursing care after delivery is similar to that with placenta previa.

Manifestations of Gestational Hypertension.