Maternity - Pregnancy, part 7: Complications: Miscarriage, Hydatidiform Mole, Ectopic Pregnancy
by Meris Shuwarger BSN, RN, CEN, TCRN September 09, 2021 Updated: June 16, 2022 13 min read
*Content warning: This nursing education video and article discuss pregnancy loss, including miscarriage, hydatidiform mole, and ectopic pregnancies.
This article explores some of the complications of pregnancy, including miscarriage (or spontaneous abortion), hydatidiform mole (molar pregnancy), and ectopic pregnancies.
This series follows along with our Maternity Nursing Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
A spontaneous abortion, also known as a miscarriage, is the loss of a pregnancy prior to 20 weeks gestation due to natural causes.
The word “abortion” often brings to mind an induced or therapeutic abortion, such as a surgical or medical abortion that a patient chooses to have. But the word “abortion” actually means a termination of pregnancy for any reason. A spontaneous abortion, then, is a medical term that refers to any pregnancy that was lost for some reason through no action of the patient. It happened spontaneously.
Remember that patients are most likely not medically literate. They don’t know that abortion means any sort of loss of a pregnancy for any reason. So while it’s very important to use the correct terminology in charting, when talking to your patients, use simple, layman’s terms, such as “miscarriage,” so as not to cause unwarranted confusion or concern.
Types of miscarriages
There are several different types of spontaneous abortion (miscarriage), including threatened, inevitable, incomplete, complete, or missed abortion. Each has its own diagnostic code for billing and insurance purposes.
The signs and symptoms of a threatened miscarriage include light bleeding, no cervical changes, mild cramping, and no passage of fetal tissue.
The signs and symptoms of an inevitable miscarriage include moderate bleeding, cervical dilation, rupture of membranes, strong cramping, and no passage of fetal tissue.
The signs and symptoms of an incomplete miscarriage include heavy bleeding, cervical dilation, severe cramping, and the passage of some fetal tissue.
The signs and symptoms of a complete miscarriage include a decrease in pain and bleeding after the passage of all fetal tissue.
The signs and symptoms of a missed miscarriage include spotting, no cervical dilation, and no cramping. In a missed miscarraige, the non-viable embryo is retained in the uterus.
Treatment for miscarriage
The treatment for a miscarriage varies based on the type of miscarriage and how advanced the pregnancy.
Dilation and curettage (D&C)
Dilation and curettage, also known as "D&C," is a procedure in which the cervix is dilated to allow surgical instruments to be passed through it and into the uterus. Curettage refers to a kind of a scraping motion — this treatment requires the uterus to be physically cleaned of the pregnancy.
During a D&C, the patient will likely be given some very light medication, usually a benzodiazepine, such as Valium, or Versed (midazolam), which helps sedate the patient without rendering them unconscious.
In a D&C, the cervix is numbed with Lidocaine to help prevent discomfort, but the patient will likely experience cramping, heavier bleeding, and the passage of clots.
With a D&C, the provider may be able to send samples of the products of conception to the lab to see what caused the miscarriage, for example, a genetic abnormality in the fetus.
One way to deal with a miscarriage with medicines is to use prostaglandins (e.g., misoprostol). Misoprostol allows the cervix to soften and dilate on its own to allow for easier passage of the pregnancy contents.
Rhogam, short for “Rh immune globulin,” is a medication that can be given to Rh-negative pregnant patients to help prevent them from developing antibodies against the Rh protein present in the blood of Rh-positive babies. When a miscarriage has occured in an Rh-negative patient, rhogam is administered within 72 hours of the miscarriage to help mitigate any pelvic or abdominal trauma or vaginal bleeding.
Hydatidiform mole (molar pregnancy)
Hydatidiform mole or molar pregnancy is a very rare but serious complication, characterized by the abnormal growth of trophoblastic villi in the placenta, which prevents normal embryo maturity.
A healthy trophoblast is a thin layer of cells that helps a developing embryo attach to the wall of the uterus, protects the embryo, and forms a part of the placenta. The villi in the uterus are tiny hairs that sprout from the chorion (part of the placenta) to provide maximal contact area with maternal blood.
There are two types of molar pregnancy: partial, where there is embryonic tissue present; and complete, where embryonic tissue is absent.
Hydatidiform mole can lead to gestational trophoblastic disease, e.g., choriocarcinoma (a type of uterine cancer).
Signs and symptoms of a molar pregnancy
The signs and symptoms of a molar pregnancy include dark vaginal bleeding, often described as having the consistency or color of prune juice, that is, a dark brown-purplish color.
Another sign of hydatidiform mole is a larger uterus or higher fundal height than expected for the gestational age of the fetus.
Other signs and symptoms include high hCG levels, cramping, nausea and vomiting, and the passage of tissue described as “grape-like clusters.”
Diagnosing a molar pregnancy
Hydatidiform mole is diagnosed with an ultrasound and will usually look like TV static or snow.
Treatment of a molar pregnancy
The treatment for a molar pregnancy is surgical uterine evacuation (D&C). This pregnancy is irremediably abnormal, and it needs to be removed from the uterus entirely.
Additionally, following surgery, the patient requires hCG monitoring to ensure that their hCG levels return to zero, that is, back down to normal.
Patient teaching for molar pregnancy
hCG monitoring must continue for six months following the D&C.
The patient must also avoid pregnancy for one whole year. This is because the combination of a pregnancy and high hCG levels makes it difficult to monitor for a choriocarcinoma (which also causes an increase in hCG). "Chorio-" refers to the chorion, part of a developing placenta; carcinoma is cancer. A patient who has experienced a molar pregnancy will be at risk for developing a choriocarcinoma, which is why it is so important to monitor hCG levels (and why it is important not to experience a pregnancy, as this will make it harder to monitor for those hCG levels).
An ectopic pregnancy is a deadly complication of pregnancy, and it is very important to catch it as soon as possible. It occurs when a pregnancy is not growing in the correct place (i.e., inside the uterus). “Ecto-” means outside, and an ectopic pregnancy is a pregnancy that grows outside the uterine cavity, most often in the fallopian tubes. But an ectopic pregnancy can also occur outside of the uterus entirely, for example in the abdomen or the pelvis.
An ectopic pregnancy is a rare complication of pregnancy, in which the pregnancy will not develop normally while putting the patient at significant risk for complications, including hemorrhage and death.
Risk factors for ectopic pregnancy
The risk factors for an ectopic pregnancy include a history of STIs (sexually transmitted infections, such as chlamydia), a history of a previous ectopic pregnancy, the use of an IUD, previous tubal surgery, or previous, multiple pregnancy losses.
Signs and symptoms of ectopic pregnancy
An ectopic pregnancy may be visible on an initial ultrasound, early in the patient's pregnancy.
If not seen at that initial visit, the more common signs and symptoms of an ectopic pregnancy include unilateral (one-sided) stabbing pain in the lower abdomen, usually occurring between five and nine weeks, and vaginal bleeding (i.e., “spotting”). Additionally, signs and symptoms of a hemorrhage (hypotension, tachycardia, pallor) may also indicate an ectopic pregnancy.
Treatment for ectopic pregnancy
Treatment for an ectopic pregnancy may include the medication methotrexate. When given to a patient, methotrexate causes the pregnancy to end by dissolving the pregnancy so the body can absorb it. This will save the fallopian tube.
Surgical options include salpingostomy (a tubal incision to remove an ectopic pregnancy) or salpingectomy (the removal of the fallopian tube). These are emergency procedures to remove the pregnancy so the patient does not hemorrhage, go into shock, and die.
Patient care for all forms of miscarriage
Any time you have a patient who experiences a miscarriage, be prepared to offer thorough therapeutic communication. A miscarriage is very traumatizing, so be sure to ask your patient how best you can support them, what you can do for them.
Some things they may need help with include calling their partner or contacting a family member or friend to come pick them up.
Remember, for the patient, their baby has died, which is deeply personal. This is a time to be extra-mindful of how you communicate with a patient who has just been told that they are experiencing the loss of their pregnancy.
Hi, I'm Meris, and in this video, I'm going to be talking to you about some of the complications of pregnancy. I'm going to be following along using our maternity flashcards. These are available on our website, Leveluprn.com if you want to get a set for yourself. And if you have a set for yourself already, I would invite you to follow along with me.
Before we start, I do want to just give you a trigger warning here that we are going to be talking about some different types of pregnancy loss, including miscarriage, hydatidiform mole, and ectopic pregnancy. So this is a video that you may not want to watch if you have personal experience with these or if this is a very triggering subject for you. So with all of that said, let's go ahead and get started.
So first and foremost, we're going to be talking about spontaneous abortion which is also known as miscarriage. Now, I need you to understand that an abortion means a termination of pregnancy for any reason. When you hear the word abortion, you may be thinking of an induced or therapeutic abortion such as a surgical or medical abortion that a patient may choose to have. That's not what we're talking about in this case. In this case, we are talking about spontaneous abortion which means that the pregnancy was lost for some reason through no fault of the patient. There was no conscious decision made. It just happened spontaneously. Now, that is what the medical term abortion means. But I want you to remember that your patients are very likely not medically literate. They don't know that abortion means any sort of loss of a pregnancy for any reason. So it's very important to use the correct terminology in your charting or anything like that. However, when you talk to your patients, I would very highly encourage you to use simple English layman's terms, such as miscarriage instead.
So a spontaneous abortion is a miscarriage, and you'll see here that on this card, we have a chart that tells you about the different types. You can have a threatened, inevitable, incomplete, complete, or missed abortion. And all of those are things that you may see as diagnostic codes for billing purposes, for insurance purposes as well. So you can look and see what all of these different ones mean. But the important thing to understand here is that this is the loss of a pregnancy before 20 weeks. Before 20 weeks of gestation, this is called a miscarriage for whatever reason that the pregnancy is lost.
Now, the treatment for miscarriage varies wildly based on what type of miscarriage it was and how far along the pregnancy was, and those sorts of things. So I'm going to tell you a personal story, which is that I have had eight miscarriages. So I have a genetic condition called Familial Mediterranean Fever, and one of the complications of my condition is for unknown reasons it causes a recurrent miscarriage. So I have been pregnant 10 times, and I only have two living children now. Now, most of my miscarriages were very early on, and they required no treatment. The only treatment that I had was continuing to see my doctor, and she would draw my blood levels to make sure that my pregnancy hormone was returning to zero. However, that's not always the case. In two cases, I had to have what's called a D and C, dilation and curettage. And what this means is that the cervix is dilated to allow instruments to be passed through to it, and curettage refers to kind of a scraping motion. So this is where the uterus actually needs to be physically cleaned basically of the pregnancy for one reason or another.
And for both of these instances, I was given some very light medication, like a Valium, or in one case, I did get Versed. The cervix is numbed with Lidocaine, and this helps to prevent discomfort. But your patient will likely experience cramping, heavier bleeding, passage of clots, those sorts of things. Now, the D and C does mean that the provider may be able to send samples of the products of conception to the lab to see what happened. Was there a genetic abnormality with the fetus? All of these kinds of questions can help to be answered in this instance.
There's other ways that a miscarriage may be handled as well such as with medications like Misoprostol, which allow the cervix to soften and dilate on its own to allow for easier passage of the pregnancy contents. So all of this is going to depend on the exact circumstance for your patient. I would very, very, very strongly recommend that any time you have a patient who experiences a miscarriage that you be prepared to offer thorough therapeutic communication. Working as an emergency room nurse, I have had experiences seeing patients have miscarriages where they were not treated with the full therapeutic experience that they should have received. And I, myself, have had that experience, and it is very traumatizing. So be sure to ask your patient how best you can support them, what you can do for them. Do you need me to call your partner? Do you need me to call a family member or friend to come pick you up? Those sorts of things. Do not say anything that starts with the words, "At least." There is no at least. My baby still died. So that's just a personal thing. A soapbox of mine is you really need to watch what you say to patients who have just been told that they are experiencing the loss of their pregnancy.
Okay. So let's move on to hydatidiform mole. From here on out, I'm going to call it a molar pregnancy because that's a mouthful, and I don't want to keep saying it. But a molar pregnancy is very rare, but a serious complication. So this is abnormal growth of the trophoblastic villi in the placenta which prevents normal embryo maturity. So when we see this on ultrasound, I always say that it looks like TV static. There's just nonsense in the uterus. It is just black and white craziness. Some other places will describe it differently like it will look like grape-like clusters. And maybe it does. But that's always what it looks like to me is like TV snow or TV static on the ultrasound. Now, your patient may have a dark vaginal bleeding, and this may be described as a prune juice consistency or color. So it's kind of that dark brown purplish color. That should be making you think this might be a molar pregnancy. Your patients, if they-- maybe they were undergoing artificial reproductive therapy or something like that, and they might have been having HCG levels. You likely would have seen that those pregnancy hormone levels were growing at too high of a rate. And that is very classic for molar pregnancies.
So we can diagnose this on ultrasound. Like I said, there's a very classic look to it, and unfortunately, the treatment for this is D and C. This pregnancy is abnormal and cannot ever be normal, and it needs to be removed from the uterus entirely. Not just that, but then your patient needs to have each HCG monitoring to ensure that their levels return to zero, that it goes back down to normal. For six months after the D and C, they're actually going to have that HCG monitoring, and then you're going to teach your patient that they need to avoid pregnancy for one whole year because the pregnancy and HCG levels rising would make it difficult to monitor for something called a Chorriocarcinoma. So Chorrio referring to the chorion, that part of that developing placenta, and carcinoma is cancer. So if your patient has a molar pregnancy, they are at risk for developing a Chorriocarcinoma, which means that we need to monitor those HCG levels and a pregnancy within that year would make it impossible for us to monitor those appropriately. So this is a rare complication, but a very important one to understand.
Okay. Lastly, in this video, we're going to be talking about ectopic pregnancy. Now, ectopic means outside of. This means a pregnancy that is not growing in the correct place, and the only correct place for a pregnancy to grow is in the uterine cavity. So it is not okay for pregnancy to grow in the fallopian tubes, any portion thereof, or outside of the uterus entirely where it's actually growing in the abdomen or the pelvis. This is a rare complication of pregnancy to have it grow completely outside of the reproductive organs, but it does happen, and it can happen. So if I have a pregnancy that's growing in the wrong place. It's not going to be in this organ that allows it to stretch and grow normally. This is going to be something that cannot be brought to life, right? This pregnancy will not develop normally and also puts the patient at significant risk for complications, including hemorrhage and death. So what does the patient look like if they have this? Well, first of all, hopefully, they came in early for their pregnancy, their first pregnancy visit, and we could see it on ultrasound. If not, your patient is going to likely report unilateral, one-sided stabbing pain in early pregnancy somewhere between that five to nine weeks. If you have a patient ever, regardless of their pregnancy status, if you have a woman of reproductive age of childbearing age who presents with unilateral stabbing pain, you need to think ectopic pregnancy until proven otherwise. This is a deadly complication of pregnancy, and it is very important to catch it as soon as possible.
So there are a couple of ways that this can be treated. One is methotrexate. Methotrexate is a medication that can be given to the patient that will actually cause the pregnancy to end and for the body to absorb it.
The other is surgery. The patient can have surgery to remove the pregnancy, especially if they already ruptured that tube, or they are about to rupture that fallopian tube. This is very, very dangerous for this patient. So we have to just-- we can't wait for the methotrexate, basically. We need to get that pregnancy away from the tube so that our patient does not hemorrhage, go into shock, and die.
So these are some very scary complications of pregnancy, but it's very important that you be aware of them so that you understand what can happen to your patient and understand what to look for in those cases.
I hope this review was helpful. If it was, please like this video. I would love to hear any sort of ways that you might remember these difficult concepts. If you want to leave me a comment below, I promise I will read it, and I do hope that you subscribe to the channels that you can be the first to know when our next video comes out.
Here's an ectopic story though. I was an in-vitro fertilization baby, and my parents tried for five years to conceive, and I was finally born. They were very excited, and my mom, when I was two years old, was in the grocery store with me and she said that she all of a sudden felt stabbing pain, and she abandoned her shopping cart, grabbed my hand, and took me to the neighbor's house, and then drove herself to the hospital. And sure enough, she had actually conceived naturally, but, unfortunately, had an ectopic pregnancy. But that's how sudden and severe her pain was, that she literally just abandoned her full shopping cart in the middle of the grocery store. I'm very glad that she was okay, and she was able to have that surgery and survive.
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