Infertility, Pregnancy Termination and Loss
Chapter 9: Induced abortion (pp 228-232).
1. What is an induced abortion? What other terms are used to
describe this interruption of pregnancy?
Induced abortion is purposeful interruption of pregnancy before 20
wks. Other terms: elective abortion (at woman’s request),
therapeutic (for reasons of maternal or fetal health)
2. When do most induced abortions occur? First trimester
3. What are two reasons that the nurse could choose to not provide
care for this patient?
Conflicting values/ don’t have to participate. Make sure a nurse is
available who will deal with patient.
4. What kind of counseling needs to be provided for patients
seeking an induced abortion?
Information and opportunity to express feelings about pregnancy,
abortion, and impact of choice on her future. Understanding of
alternatives, types of abortions, expected recovery. Need signed
informed consent.
5. How pregnant should a patient be to safely have a vacuum
aspiration abortion?
8-12 wks since LMP
6. What three medications are used in combination for medical
abortions (and why do they all have to start with M and have so
many syllables!) can have med abortions up to 9 wks pregnant
Methotrexate: cytotoxic that causes early abortion by blocking
folic acid so fetal cells can’t divide. given IM or orally
Misoprostol (Cytotec): prostaglandin analog that softens and
dilates cervix and stimulates uterine contractions. Given vaginally
3-7 days after Methotrexate.
Mifepristone (RU 486): blocks action of progesterone. Given
orally, taken up to 7 wks
7. In general, who are the "best" candidates for medical abortions
(this is an opinion question based on the info you have just read!)
8. When is a D&E performed?
Up to 20 wks, most commonly performed betw 13-16 wks
Chapter 10 Infertility
1. How common is infertility?
10-15% reproductive age couples
2. What percentage of time is infertility due to female factors, male
factors and unexplained factors?
F=40%, M=40%, Both=20%, unexplained=20%
3. You are the charge nurse at an infertility clinic. It is your
responsibility to schedule various infertility tests. Look at Table
10-1 on p. 240. A woman calls to schedule these tests. Her LMP is
November 1st and she always has a 28 day cycle (fat chance!).
When would you schedule these various tests?
 Hysterosalpingogram: Nov. 8-11
 Postcoital test: Nov. 10-12
 Sperm immobilization antigen-antibody rxn, assessment of
cervical mucus: Nov. 14-16
 Ultrasound dx of follicular collapse: Nov. 14-16
 Serum assay of plasma progesterone: Nov. 21-26
 Endometrial biopsy: Nov. 22-28
Chapter 10: Adoption
A married couple is considering adoption after five years of
infertility treatments. They had one SAB 1 ½ years ago. The
woman is 42 and the man is 55. She would like to try one more
shot at IVF (they have had three previous attempts without
success) and he is ready to adopt. How would you assist them with
the five emotional stages that contemplating adoptive parents may
use to assist in their decisions?
Have info on options for adoption available, refer to community
resources
Chapter 31 pp. 804-815
1. What are some causes of spontaneous abortions (SAB:early
miscarriage) happens before 12 wks.
50% chromosomal abnormalities, endocrine imbalance (DM type
1), immune immunologic factors, infection, systemic disorders,
systemic disorders, genetic factors.
2. Look at table 31-1 p. 807. What are the differences among
threatened, inevitable and incomplete, complete, missed and septic
SABs?
type
amt. bleeding uterine cramps pass tissue
dilate
threatened slight, spotting
inevitable moderate
incomplete
yes,
cervix
complete
mild
mild to severe
heavy, profuse
slight
missed
none, spotting
septic
usually
varies, smells
severe
no
no
no
yes
yes
w/tissue in
mild
yes
no
none
no
no
varies
varies
recurrent (three or more consecutive abortions)
varies
varies
yes
usually
3. How are the symptoms different among threatened, inevitable
and incomplete SABs? Why would it be important that we
accurately gather information from the patient about her
symptoms?
knowing how to treat: bed rest not effective, but placebo affect is.
Women need to think they did everything possible to avoid
threatened abortion or they feel guilty.
4. What do HcG levels do at the start of a pregnancy?
levels double every 1.4-2 days until about 60-70 days
5. So what’s an incompetent cervix (could they have named it
anything more degrading to a woman’s concept of her ability to
carry a child)? A cervix that dilates prematurely, usually after 20
wks, and doesn’t hold the pregnancy. Scar tissue can weaken tissue
or cervix won’t open
6. What are the signs of an ectopic pregnancy? What are the major
risks? What other conditions can this life threatening pregnancy
look like?
can be misdiagnosed as UTI, PID, salpingitis,
appendicitis, all kinds of stuff. 10% of maternal morbitity due to
hemorrhage from ectopic pregnancy.
 missed period, adnexal fullness, tenderness-tubal pregnancy
 pain progresses from dull to colicky pain when tube stretches
 pain may be unilateral, bilateral or diffuse over abdomen.
 Dark red or brown abnormal vaginal bleed in 50-80%
women
 Ectopic rupture: increase in pain, may be generalized or acute
lower abdomen. Referred shoulder pain (diaphragmatic
irritation from blood in peritoneal cavity). May show signs of
shock related to amt of bleeding. Ecchymotic blueness
around umbilicus (cullen’s sign)
7. What is the major physical risk with a hydatidiform mole?
We
already discussed previas and abruptions. Just remember to be
aware these can occur anytime, but are most likely to occur in the
third trimester.
Weird tissue that develops; uterus grows too fast, can present with
HTN.
is rare; complete: sperm and empty ovum; choriocarcinoma can
develop. Partial: normal ovum and 2 sperm
anemia from blood loss, n/v, abdominal cramps. At risk for
persistent trophoblastic disease requiring chemotherapy (in
complete). Choriocarcinoma can go to lungs.
8. What are dermoid cysts? p. 282
germ cell tumors, usually occurring in childhood. contain hair,
teeth, sebaceous secretions, and bones.
Chapter 41
1. How can having a miscarriage affect a mother and a father?
Look at Box 41-1 p. 1092 as an overview. phases of parental grief: acute distress, intense grief, reorganization
period of mourning before can move on
2. What is the technical difference between miscarriage, fetal
death, stillbirth, and newborn death?
when it happens: miscarriage early 1st trimester, fetal death later,
stillbirth you carry to term and baby born dead, newborn death is
after live delivery.
3. Name three phases of grief and list at least 2 characteristics of
each phase.
1) acute distress: shock, numbness, intense crying, depression
2) intense grief: loneliness, emptiness, guilt, anger, anxiety,
diorganization
3) reorganization: search for meaning, reduction of distress, reenter
normal life with more enthusiasm
4. Name 4 important assessments when working with a family
which has experienced a perinatal loss.
1) nature of parental attachment, meaning of pregnancy, related
losses
2) circumstances surrounding the loss
3) immediate response of mother and father to the loss, whether are
complementary or problematic, how responses match past
experiences, personalities, and behavioral and cultural backrounds.
4) social support network and extent activated
5. Name 5 nursing interventions when working with a family
which has experienced a perinatal loss.
1) help mother, father and other family members actualize loss
2) help parents with decision making
3) help acknowledge and express feelings
4) normalize grief process and facilitate positive coping
5) meet physical needs of postpartum bereaved mother
6) What are the pros and cons of autopsy?
7. How would you use the Perinatal Grief Scale on page 1095?
If someone is having difficulty articulating feelings, could use
scale to ask questions, to put words to feelings difficult to express
8. Putting a baby up for adoption doesn’t seem to be in our text
so I am including it here because it is also a loss of a newborn for
the woman and her family who is choosing to relinquish her child.
Look back through this chapter form the perspective of assisting
this patient with her loss. What might her (their) grief response be?
Guilt, feeling inadequate, anxiety about choice