Care of Mother and Child At-Risk or with

Problems (Acute and Chronic)- Lecture

STUDENT ACTIVITY SHEET BS NURSING / SECOND YEAR
Session # 8

LESSON TITLE: CARE OF THE HIGH-RISK PREGNANT Materials:

CLIENT (PRE-GESTATIONAL CONDITIONS- ANEMIAS OF
Book, pen, SAS and notebook
PREGNANCY) AND (GESTATIONAL CONDITIONS-
HYPEREMESIS GRAVIDARUM AND ECTOPIC
References:
PREGNANCY)
Pilliteri, Adele and Silbert-Flagg, JoAnne (2018)
LEARNING OUTCOMES: th
Maternal and Child Health Nursing, 8 Edition.
At the end of the lesson, the student nurse can: USA: Lippincott Williams and Wilkins

1. Define Anemia, Hyperemesis Gravidarum and Ectopic Perry, Shannon, Hockenberry, Marilyn J.,
Pregnancy) its relation to pregnancy, including pre-existing Lowdermilk Deitra Leonard and Wilson, David
th
factors that contribute to its development. (2015) Maternal and Child Nursing Care,6
Edition. USA: Elsevier
2. Integrate knowledge of Anemia, Hyperemesis Gravidarum
and Ectopic Pregnancy in relation to pregnancy and nursing Hockenberry, Marilyn and Wilson, David (2013)
process to achieve quality maternal and child health nursing Wong’s Essential of Pediatric Nursing,9th
care. Edition. USA: Elsevier

LESSON PREVIEW/REVIEW (5 minutes)

MAIN LESSON (50 minutes)

GESTATIONAL TROPHOBLASTIC DISEASE/HYDATIDIFORM MOLE/MOLAR PREGNANCY (please refer to Chapter
21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication-Bleeding During Pregnancy page 526)

Gestational trophoblastic disease is abnormal proliferation and then degeneration of the trophoblastic villi (Jean-Jacques,
2016). As the cells degenerate, they become filled with fluid and appear as clear fluid-filled, grape-sized vesicles.

The embryo fails to develop beyond a primitive start. Abnormal trophoblast cells must be identified because they are
associated with choriocarcinoma, a rapidly metastasizing malignancy.

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The incidence of gestational trophoblastic disease is approximately 1 in every 1,500 pregnancies.
The condition tends to occur most often in women who have a low-protein intake, in women older than 35 years of age, in
women of Asian heritage, and in blood group A women who marry blood group O men.

2 Types of H Mole

1. Complete Mole-All trophoblastic villi swell & become cystic; embryo dies early
-Chromosomes are normal, 44xy or 44xx but are contributed by only by the father or an empty ovum was fertilized &
the chromosome material from the sperm was duplicated
-May lead to choriocarcinoma

2. Partial Mole-Some of the villi form normally

-Syncytiotrophoblast layer is swollen & misshapen
-It has 69 chromosomes (3 chromosomes instead of 2 for every pair) resulting from 2 sperms fertilizing an ovum
-Rarely leads to choriocarcinoma

Assessment

1. Uterus expands faster than normal 7. Signs of Pregnancy induced HPN (HPN, proteinuria,
2. No fetal heart sounds edema) present before week 20 of pregnancy
3. hCG test is strongly positive( 1 to 2 million IU) dt 8. UTZ shows dense growth (snowflake pattern) but no
overgrowing trophoblast cells & remains positive after fetal growth
the 100th day of gestation 9. Vaginal bleeding in the 1st trimester, may be brown
4. Marked N/V due to high hCG levels( 1-2 Million like prune juice & may contain grapelike vesicles
IU/24hrs) 10. Very low msAFP levels
5. Positive pregnancy test 11. Expulsion of molar cyst by 16th-18th week
6. Abdominal pain
Diagnosis Therapeutic Management
1. Passage of vesicles- 1st sign
2. TRIAD SIGNS; 1. Monitor for signs of hemorrhage, PIH, or other
-Big uterus complications such as HELLP Syndrome
-Vaginal bleeding: brownish, intermittent 2. Suction & curettage to evacuate the mole
-HCG >1 Million IU/24 hrs (NV: 400,000 3. After extraction, chest xray, pelvic examination,
IU/24hrs) serum test for ß subunit of hCG

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 3. Ultrasound: no fetal sac, no fetal parts 4. hCG is analyzed every 2 weeks until levels are
4. XRAY: no fetal skeleton normal. Afterwards, q 4 weeks for 6 to 12 months
(increase suggests malignancy)
5. Should not get pregnant within 1 year of diagnosis
because signs of pregnancy can mask signs of
choriocarcinoma
6. Chest X-ray to detect early lung metastasis
7. if malignant, methotrexate is the DOC
8. Provide RhOGAM if Rh (-)
9. Address emotional & psychosocial needs.

CERVICAL INSUFFICIENCY (PREMATURE CERVICAL DILATATION/INCOMPETENT CERVIX)

(Please read Chapter 21: Nursing Care of a Family Experiencing A Sudden Pregnancy Complication, page. 537.)
Description & Etiology
-cervix that dilates prematurely and cannot hold a fetus until term
-cause of habitual abortion
-It usually at week 20 when the fetus is still too immature to survive.

-associated with maternal age, congenital structural defects & trauma to the cervix (cone biopsy, repeated D & C)
-The dilatation is usually painless
-1st symptom is usually SHOW, or increased pelvic pressure, which may be followed by rupture of membranes &
discharge of AF
-Uterine contractions begin & after a short labor, the fetus is born

Diagnosis
May be diagnosed by early UTZ before symptoms occur

Management
 Ultrasound to confirm that the fetus is healthy
 weeks 12 to 14, purse-string sutures are placed in the cervix by the vaginal route under regional anesthesia
(CERVICAL CERCLAGE).
 Sutures strengthen the cervix & prevents it from dilating.
 After surgery, bed rest (in slight or modified Trendelenburg position) for a few days to decrease pressure in the
new sutures
 Sutures are then removed at weeks 37 to 38 so that the fetus can be born vaginally.
McDonald’s cerclage- nylon sutures are placed SHIRODKAR
horizontally & vertically across the PROCEDURE- sterile
cervix & pulled tight to reduce the tape is threaded in a
cervical canal to a few millimeters in purse-string manner
diameter under the submucous
 Usually temporary layer of the cervix &
sutured in place to
achieve a closed cervix.
 May be
permanent

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CHECK FOR UNDERSTANDING (30 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.

Multiple Choice

1.A client makes a routine visit to the prenatal clinic. Although she’s 14 weeks pregnant, the size of her uterus
approximates that in an 18- to 20-week pregnancy. Dr. Diaz diagnoses gestational trophoblastic disease and
orders ultrasonography. The nurse expects ultrasonography to reveal:
A. an empty gestational sac.
B. grapelike clusters.
C. a severely malformed fetus.
D. an extrauterine pregnancy.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

2.Of the following terms, which is used to refer to a type of gestational trophoblastic neoplasm?
A. Hydatidiform mole
B. Dermoid cyst
C. Doderlein’s bacilli
D. Bartholin’s cyst
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

3. Anna is 10 weeks pregnant and was advised to report or seek medical attention if she felt which of the
following signs will require a mother to seek immediate medical attention?
A. When the first fetal movement is felt
B. No fetal movement is felt on the 6th month
C. Mild uterine contraction
D. Slight dyspnea on the last month of gestation
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

4. Cristy is an OB-Gyne Ward Nurse and a pregnant client is admitted to her care with the diagnosis of
Hydatidiform Mole. Which of the following signs and symptoms will most likely make Nurse Cristy suspect that
the patient is having hydatidiform mole?
A. Slight bleeding
B. Passage of clear vesicular mass per vagina
C. Absence of fetal heart beat
D. Enlargement of the uterus
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________________________________________________________________

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5.Upon assessment the nurse found the following: fundus at 2 fingerbreadths above the umbilicus, last
menstrual period (LMP) 5 months ago, fetal heart beat (FHB) not appreciated. Which of the following is the most
possible diagnosis of this condition?
A. Hydatidiform mole
B. Missed abortion
C. Pelvic inflammatory disease
D. Ectopic pregnancy
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

6. The following are correct regarding incompetent cervix: SELECT ALL THAT APPLY
A. occurs in 2nd trimester
B. dilatation is painless and bloodless
C. shortened cervical length
D. minimal symptoms
E. snow-like pattern on ultrasound
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

7. The best time to treat incompetent cervix is between ___ and ____ weeks of pregnancy before the dilatation
occurs.
A. 12, 14
B. 10,12
C. 2,3
D. 18,25
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. Restriction of activities and cervical cerclage are the treatments for __________ .
A. Abruptio Placenta
B. Placenta Previa
C. Incompetent Cervix
D. H-mole
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

9. A client with incompetent cervix with a previous pregnancy had a cerclage procedure done at 18 weeks in the
current pregnancy. The client calls the clinic at 37 weeks gestation because of irregular contractions
occurring every five to seven minutes. Which response by the nurse is the most appropriate?
A. "Go to the hospital to have the cerclage removed so your cervix isn't injured and to allow the birth to progress"
B. "Wait and come in when the contractions are closer and harder"
C. "You sound like you are worried about this baby. It must be frightening for you"
D. "You will need to have a C/S with the cerclage in place"
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

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10. Which of the following procedure applies sterile tape is threaded in a purse-string manner under the
submucous layer of the cervix & sutured in place to achieve a closed cervix?

A. B.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
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2. ANSWER: ________
RATIO:_______________________________________________________________________________________
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3. ANSWER: ________
RATIO:_______________________________________________________________________________________
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4. ANSWER: ________
RATIO:_______________________________________________________________________________________
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5. ANSWER: ________
RATIO:_______________________________________________________________________________________
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6. ANSWER: ________
RATIO:_______________________________________________________________________________________
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7. ANSWER: ________
RATIO:_______________________________________________________________________________________
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8. ANSWER: ________
RATIO:_______________________________________________________________________________________
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9. ANSWER: ________
RATIO:_______________________________________________________________________________________
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10. ANSWER: ________

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 RATIO:_______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________

LESSON WRAP-UP (5 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.
PERIOD 1
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
PERIOD 2
21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
PERIOD 3
41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

AL STRATEGY: CAT: Student Response Cards

1. Your instructor will give a set of student response card for each of you and your classmate which is labeled with
answer choices.
2. Your instructor will pose a question to the class regarding information just covered in your lesson.
3. Hold up their card with the corresponding answer to your instructor’s question.

(For next session, review Chapter 21: Nursing Care of a Family Experiencing a Sudden Pregnancy Complication-
Bleeding During Pregnancy Spontaneous Miscarriage p. 529)

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