SECOND TRIMESTER

BLEEDING

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 GESTATIONAL TROPHOBLASTIC DISEASE
Also known as Hydatidiform mole

Trophoblastic villi in the placenta begin to

degenerate and become swollen and filled
with fluid.

The embryo does not develop beyond the

cell duplication, becoming a mole-like mass
with an appearance similar to grape
clusters.

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 GESTATIONAL TROPHOBLASTIC DISEASE

The genetic material in the mass can be

derived from paternal DNA or maternally
and paternally

While some fetal material might be present

in the mass, and human chorionic
gonadotropin (hCG) levels are high, there is
no growth, organ development, or activity.
Life is not present.

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 GESTATIONAL TROPHOBLASTIC DISEASE

Embryo dies early at only 1 to 2 mm in

size, with no fetal blood present in the villi

Chromosomal analysis, was contributed

only by the father or an “empty ovum”
was fertilized and the chromosome
material was duplicated

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 GESTATIONAL TROPHOBLASTIC DISEASE
TYPES
 COMPLETE mole, the chromosomes are
either 46XX or 46 XY but are contributed
by only one parent and the chromosome
material duplicated. This type usually
leads to choriocarcinoma.

 PARTIAL mole has 69 chromosomes.

There are three chromosomes for every
pair instead of two. This type of mole
rarely leads to choriocarcinoma.
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 GESTATIONAL TROPHOBLASTIC DISEASE
PATHOPHYSIOLOGY
• Fertilization occurs as the sperm
enters the ovum. In instances of a
partial mole, two sperms might
fertilize a single ovum

• Reduction division or meiosis was

not able to occur in a partial mole.
In a complete mole, the
chromosome undergoes
duplication
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 GESTATIONAL TROPHOBLASTIC DISEASE

• The embryo fails to develop

completely. There are 69
chromosomes that develop for the
partial mole, and 46 chromosomes
for the complete mole

• The trophoblastic villi start to

proliferate rapidly and become fluid
– filled grape – like vesicles

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GESTATIONAL TROPHOBLASTIC DISEASE
RISK FACTORS
This incidence happens in 1 of every 1,500
pregnancies. There are risk factors that
could precipitate the formation of
hydatidiform mole, and they are as follows:

LOW PROTEIN INTAKE. Women with low

protein intake have a possibility of
developing an H. mole because protein is
needed for the development of the
trophoblastic villi.
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GESTATIONAL TROPHOBLASTIC DISEASE

WOMEN OLDER THAN 35 YEARS OLD.

Being pregnant beyond 35 years old
presents a lot of risky conditions like H.
mole.

ASIAN WOMEN. Asians have a higher

chance of acquiring the disease because of
their genetic formation.

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GESTATIONAL TROPHOBLASTIC DISEASE

WOMEN WITH A BLOOD GROUP OF A

WHO MARRY MEN WITH BLOOD
GROUP O. These blood groups, when
combined together results in unfavorable
conditions like H. mole

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GESTATIONAL TROPHOBLASTIC DISEASE
SIGNS AND SYMPTOMS
 Uterus expands faster than normal.
Because the trophoblast cells proliferate
abnormally, it does so in such a rapid pace
that the uterus reaches its growth
landmarks before the usual time.

 A very high serum or urine test for HCG.

Trophoblast cells produce HCG, and they
are produced in large amounts because
the trophoblast cells are growing rapidly
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GESTATIONAL TROPHOBLASTIC DISEASE

 Vaginal bleeding. When the H.

mole is still not identified at the 16th
week of pregnancy, it will identify
itself through vaginal bleeding
accompanied by clear fluid filled
vesicles.

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 GESTATIONAL TROPHOBLASTIC DISEASE
THERAPEUTIC MANAGEMENT

METHOTREXATE
Physicians may order a prophylactic course
of methotrexate, which attacks rapidly
growing cells like the abnormally growing
trophoblastic cells.

DACTINOMYCIN
This is ordered by the physician once
metastasis occurs.
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 GESTATIONAL TROPHOBLASTIC DISEASE
o Educate in avoiding pregnancy for at
least 1 year

o Educate on the need to monitor HCG

for 1 year (biweekly until low, monthly
for 6 months, q2 months for the next 6
months)

o If there is still a rise in HCG, further

treatment (hysterectomy or
chemotherapy)
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 GESTATIONAL TROPHOBLASTIC DISEASE
SURGICAL MANAGEMENT
Upon identification of the H. mole, the
physician would schedule a surgical
intervention to remove it from the uterus
of the woman.

SUCTION CURETTAGE. This is the ideal

management for H. mole to evacuate the
mole inside the woman’s uterus and avoid
further complications if it stays longer inside
the reproductive system.
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 GESTATIONAL TROPHOBLASTIC DISEASE
NURSING MANAGEMENT
ASSESSMENT
 Assess the abdominal girth of the
woman to check if it is within the usual
landmark of pregnancy

 Assess for signs and symptoms of

pregnancy induced HPN, because for
a woman with H. mole, they occur
earlier than the 20th week of
pregnancy.
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 GESTATIONAL TROPHOBLASTIC DISEASE

 Instruct the woman to save all

perineal pads containing any clots
or tissue that has passed out of her
during bleeding

NURSING DIAGNOSIS
GRIEVING related to loss of
pregnancy as evidenced by anger

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 GESTATIONAL TROPHOBLASTIC DISEASE
NURSING INTERVENTIONS
 Measure abdominal girth and fundal
height to establish baseline data
regarding the growth of the uterus.

 Assist patient in obtaining a urine

specimen for urine test of HGG

 Save all pads used by the woman

during bleeding to check for clots and
tissues she may have discharged
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GESTATIONAL TROPHOBLASTIC DISEASE
 Provide your patient with an open
environment and a trusting relationship
so she would be encouraged to express
her feelings

 Honestly answer the patient’s questions

to foster a trusting relationship

 Provide an assurance that this is not her

own fault that this happened to her to
lessen her sense of guilt and self – blame
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GESTATIONAL TROPHOBLASTIC DISEASE

EVALUATION

 Patient must be able to express her

feelings effectively
 Patient must acknowledge the situation
and seek appropriate help
 Patient must learn to look forward for
the future step by step

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PREMATURE CERVICAL DILATATION
INCOMPETENT CERVIX
A condition that refers to the inability of
the cervix to hold the fetus any longer until
term because it has dilated prematurely.
This happens in the absence of uterine
contractions or labor (painless cervical
dilatation), owing to a functional or
structural defect.
It is cervical ripening that occurs far from
the term.
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PREMATURE CERVICAL DILATATION
ETIOLOGY
Cervical incompetence usually occurs
during the middle of the second or early
trimester, depending upon the severity of
incompetence.
Cervical incompetence may be congenital
or acquired.
The most common congenital cause is a
defect in the embryological development
due to the deficiency in collagen, the cervix
is unable to perform adequately. 22
 PREMATURE CERVICAL DILATATION
The most common acquired cause is
cervical trauma such as cervical lacerations
during childbirth, cervical conization, loop
electrosurgical excision procedure) or forced
cervical dilatation during the uterine
evacuation in the first or second trimester of
pregnancy.

However, in most patients, cervical changes

are a result of infection/inflammation,
causing insufficiency.
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 PREMATURE CERVICAL DILATATION
CONGENITAL STRUCTURAL
DEFECTS. There are defects that
might contribute to the cervix’
incapability of holding in the fetus.

TRAUMA TO THE CERVIX. Any

trauma experienced by the cervix
could weaken the muscles
surrounding it, thus leading to its
premature dilation.
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 PREMATURE CERVICAL DILATATION
PATHOPHYSIOLOGY
1) When the fetus reaches its 20th
week, it starts to become heavy
and gain fats
2) The mother’s cervix is weak, and it
could not hold the fetus’ weight
anymore as it slowly starts to
dilate
3) This would cause the appearance
of a show, pink – tinged vaginal
discharge 25
 PREMATURE CERVICAL DILATATION

4) Then, the membranes would

rupture and amniotic fluid would
be discharged.

5) Uterine contractions would start

followed by a short labor, then the
birth of the fetus

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 PREMATURE CERVICAL DILATATION
SIGNS AND SYMPTOMS
SHOW. This is a pink – tinged vaginal
fluid that is discharged from the vaginal
opening as a sign that the cervix has
dilated.
INCREASED PELVIC PRESSURE. The fetus
is already descending, causing a pressure
felt by the mother on her pelvis.
CERVICAL DILATION. Upon inspection of
the physician, the cervix would show
dilation. 27
 PREMATURE CERVICAL DILATATION
DIAGNOSTIC TESTS
There are a few diagnostic tests could
detect an incompetent cervix before it
usually happens. It is usually diagnosed
after the pregnancy has already been lost.

ULTRASOUND
This is the only test that the physician
could order if an incompetent cervix is
already suspected.
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PREMATURE CERVICAL DILATATION
MEDICAL MANAGEMENT

Medical management by the physician

would not include any medications that
could hinder the dilation of the cervix.

Surgical procedures are immediately

enforced to prevent compromising the
pregnancy

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PREMATURE CERVICAL DILATATION
SURGICAL MANAGEMENT

MC DONALD’s CERVICAL
CERCLAGE.
Nylon sutures are placed
horizontally and vertically across the
cervix. They are pulled back
together until the cervical canal is
only a few millimeters in diameter.

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PREMATURE CERVICAL DILATATION
SHIRODKAR CERVICAL CERCLAGE.
Sterile tape is used for this technique,
where it is threaded in a purse – string
manner under the submucous layer of
the cervix. Then, it is sutured in place so
it would close the cervix.

These sutures are removed on the 37th

or 38th week of pregnancy for the fetus
to be born vaginally.
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PREMATURE CERVICAL DILATATION
NURSING MANAGEMENT
ASSESSMENT
Ask the woman who is reporting for painless
bleeding if she is feeling an intense pressure
on her pelvis.
Inspect and save pads used by the woman
during bleeding to determine any clots or
tissues that already passed out.
Determine if the woman is experiencing true
contractions to prepare for the birth of the
fetus. 32
PREMATURE CERVICAL DILATATION

NURSING DIAGNOSIS
ANXIETY related to impending loss of
pregnancy as evidenced by premature
dilation of the cervix

INTERVENTIONS
Determine any factors that further
contribute to the anxiety of the woman
so it could be avoided
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PREMATURE CERVICAL DILATATION
Monitor vital signs to determine any
physical responses of the patient that
could affect her condition

Convey empathy and establish a

therapeutic relationship to encourage
client to express her feelings

Provide accurate information about the

situation to help client go back into
reality 34
PREMATURE CERVICAL DILATATION
EVALUATION

Patient would appear relaxed and report

that anxiety has been reduced.
Verbalize awareness of feelings of anxiety.

Enumerate ways to deal with anxiety

Use resources or support system effectively

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FIRST TRIMESTER RISK

HYPEREMESIS GRAVIDARUM
HYPER : excessive
EMESIS : vomit
GRAVIDARUM : pregnancy

Hyperemesis gravidarum is a severe type of

vomiting of pregnancy which has deleterious
effect on the health of the mother and
incapacitates her in day to day activities

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FIRST TRIMESTER RISK

 Nausea and vomiting of pregnancy

that is prolonged past week 12 of
pregnancy

 Severe that dehydration, ketonuria,

and significant weight loss occur
within the first 12 weeks of pregnancy

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FIRST TRIMESTER RISK
There has been marked fall in the
incidence during the last 30 years. Now
the incidence is less than one in 1000
pregnancies.

The reasons are better application of

family planning knowledge which reduces
the number of unplanned pregnancies,
early visit to the antenatal clinic and the
availability of potent antihistaminic and
antiemetic drugs
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 FIRST TRIMESTER RISK
CAUSES
 It is mostly limited to the first trimester
 It is more common in the first pregnancy, with a
tendency to recur again in subsequent
pregnancies
 It has got a family history – mother and sisters
also suffer from the same manifestation
 It is more prevalent in hydatidiform mole and
multiple pregnancies
 It is more common in unplanned pregnancies

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FIRST TRIMESTER RISK
DIETETIC DEFICIENCY: Probably due to
low carbohydrate reserve, as it happens
after a night without food. Deficiency of
vitamin B6, B1 and proteins may be the
effects rather than the cause

ALLERGIC: May be related to some

products secreted from the ovum

IMMUNOLOGICAL BASIS: Immune

response to the “foreign” fetus
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FIRST TRIMESTER RISK
SIGNS & SYMPTOMS
History may reveal risk factors:
• First pregnancy
• Pregnant woman less than 20 years of age
• Obese pregnant woman
• Multiple birth pregnancy
• History of psychiatric disorder
• Hyperthyroidism
• Vitamin B deficiencies
• Elevated stress level
• Gestational trophoblastic disease
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 FIRST TRIMESTER RISK
SYMPTOMS
EARLY STAGE (only the activities are limited without evidence of
dehydration or starvation)

 Vomiting occurs independent of food, spread throughout the day

and everything taken in is rejected. The vomiting consists of bile
stained fluid or only food
 Normal activities are curtailed
 Nutrition of the mother is good
 On examination, she looks well and no abnormality is detected
 Blood investigation and urine analysis is normal
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 FIRST TRIMESTER RISK
LATE STAGE (Evidences of dehydration and
starvation are present)

 Vomiting is increased in amount and in

frequency. Retching and nausea persist in
between vomiting. Vomitus may be coffee
ground or even blood.
 Urinary quantity is diminished
 Constipation, at times diarrhea
 Epigastric pain
 Patient is confined to bed
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 FIRST TRIMESTER RISK

 Mental apathy, restlessness,

sleeplessness, convulsion or even coma
 Mental confusion with loss of memory
to recent events
 Features of peripheral neuritis
 Eye complications – double vision,
dimness of vision or even blindness

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 FIRST TRIMESTER RISK
PHYSICAL FINDINGS
 Progressive emaciation with weight loss
 Anxious look
 Sunken eyes, apathetic and becoming dull
 Skin is lusterless and inelastic (may have jaundice)
 Tongue dry, becoming brown, thickly coated or red and raw
 Teeth covered with sordes
 Acetone smell breath
 Rapid pulses (100 – 120/min)
 Low blood pressure

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 FIRST TRIMESTER RISK
DIFFERENCE
MORNING SICKNESS HYPEREMESIS GRAVIDARUM

Nausea sometimes accompanied by vomiting Nausea accompanied by severe vomiting

Nausea that subsides are 12 weeks or soon after Nausea that does not subside

Vomiting that does not cause severe dehydration Vomiting that causes severe dehydration

Vomiting that allows you to keep some food down Vomiting that does not allow you to keep any food
down

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 FIRST TRIMESTER RISK
MEDICAL MANAGEMENT
DIAGNOSTICS

Serum analysis shows decreased protein,

chloride, sodium, and potassium levels and
an increased blood urea nitrogen level.
Other laboratory tests reveal ketonuria,
slight proteinuria, and an elevated white
blood cell count

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 FIRST TRIMESTER RISK

 May require hospitalization to correct

electrolyte imbalance and prevent
starvation
 IV infusions to maintain nutrition until she
can tolerate oral feedings
 Progresses slowly to clear liquid diet, then
full liquid diet, finally to small, frequent
meals of high – protein solid foods
 Midnight snack helps stabilize blood
glucose level.
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 FIRST TRIMESTER RISK

 Parenteral vitamin supplements and

potassium replacement help correct
deficiencies
 Jeopardized health due to persistent
vomiting – antiemetic is administered
 Meclizine and diphenhydramine – low
risk for teratogenicity
 Total parenteral nutrition rarely
needed

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 FIRST TRIMESTER RISK
 If vomiting stops and electrolyte balance
has been restored – pregnancy usually
continues without recurrence of
hyperemesis gravidarum
 Most patients feel better as they begin to
regain normal weight, but some continue
to vomit throughout pregnancy, requiring
extended treatment
 If appropriate, some patients may benefit
from consultations with critical nurse
specialists, psychologists, or psychiatrists
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 FIRST TRIMESTER RISK
NURSING DIAGNOSES
RISK FOR DEFICIENT FLUID VOLUME may be related to gastric
losses and reduced intake, possibly evidenced by dry mucous
membranes, decreased/concentrated urine, decreased pulse volume
and pressure, thirst, and hemoconcentration

 Maintain IV fluids, as ordered, until the patient can tolerate oral

feedings
 Maintain NPO status until vomiting stopped. Ice chips may be given.
 Monitor fluid intake and output, v/s, weight, serum electrolyte levels,
and urine for ketones.
 Medicate with antiemetics, as prescribed.
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 FIRST TRIMESTER RISK
IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS may
be R/T inability to ingest/digest/absorb nutrients (prolonged
vomiting), possibly evidenced by reported inadequate food intake,
lack of interest in food/ aversion to eating, and weight loss

 Suggest decreased liquid intake during meals

 Advise woman that oral intake can be restarted when emesis has
stopped
 Company and diversionary conversation at mealtime may be
beneficial
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 FIRST TRIMESTER RISK

 Obtaining 24 to 48 hour dietary recall

 Provide bland food (hot if hot, cold if cold; avoid greasy and spicy
food)
 Instruct the patient to remain upright for 45 minutes after eating to
decrease reflux
 Suggest that the patient eats 2 – 3 dry crackers on awakening in
the morning, before getting out of bed, to alleviate nausea

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 FIRST TRIMESTER RISK

FATIGUE may be R/T muscle weakness

secondary to emaciation

 Teach the patient protective measures

to conserve energy and promote rest
 Teach relaxation techniques: fresh air
and moderate exercise, if tolerated
 Schedule activities to prevent fatigue

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 FIRST TRIMESTER RISK
RISK FOR INEFFECTIVE COPING MAY BE R/T
STRESS OF PREGNANCY AND ILLNESS
Risk factors may include situational/maturational
crisis (pregnancy, change in health status,
projected role changes, concern about outcome)

 Provide reassurance and a calm, restful

atmosphere
 Encourage the patient to discuss her feelings about
her pregnancy and the disorder
 Help the patient develop effective coping strategies
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