4Bleeding Conditions of Pregnancy

First Trimester Bleeding (a) ABORTION

(b) ECTOPIC PREGNANCY
I. Bleeding
Occurs anytime never normal, no matter how slight
Frigthening experience
Need to be assessed
Threatens both mother & fetus
Client needs reassurance it is not because of what she did to free her from guilt
SIGNS & SYMPTOMS OF HEMORRHAGIC SHOCK
ASSESSEMENT
Increase pulse rate
Decreased blood pressure
Increased respiratory rate
Cold, clammy skin
Decreased urine output
Dizziness or decreased level of consciousness
Decreased central venous pressure

SIGNIFICANCE
Heart attempting to circulate decreased blood
volume
Less peripheral resistance because of decrease
blood volume
Increased gas exchange to better oxygenate
decreased RBC volume
Vasoconstriction occurs to maintain blood volume
in central body core
Inadequate blood is entering kidney due to
decreased blood vol.
Inadequate blood is reaching cerebrum due to
decreased blood volume.
Decreased blood is returning to heart due to
reduced blood volume.

The process of shock due to blood loss (Hypovolemia)

- Blood Loss
- Decreased intra-vascular volume
- Decreased venous return/ cardiac output,& lowered BP
- Body compensating by increasing HR to circulate the dec.vol. faster; vasoconstriction of
preipheral vessels (to save blood for vital organs). Increased RR & feeling of apprehension at
body changes also occur.
- Cold clammy skin, dec.uterine perf. In the face of continued bld.loss, although the body shifts
fluid from interstitial to intra-vascular spaces, bld.pressure continue to fall.
- Reduced renal, uterine, & brain perfusion
- Lethargy, coma, decreased renal output
- Renal failure
- Maternal and Fetal Death
Emergency Interventions for Bleeding in Pregnancy
INTERVENTION

Alert health care team of emergency situation.

Place woman flat in bed on her side.
Begin IVF such as LR with a 16 or 18 gauge needle.

RATIONALE

Provides maximum coordination of care.

Maintains optimal placental and renal function.
Replaces intravascular fluid vol.; Prepare IV line for
blood replacement.
Administer O2 as necessary @ 6-10L/min by face Provides adequate fetal oxygenation despite
mask.
lowered maternal circulating blood.
Monitor uterine contractions & FHR by external
Assess whether labor is present and fetal status;
monitor.
external system avoids cervical trauma.
Omit vaginal examination.
Prevents tearing of placenta if placenta previa is
cause of bleeding.
Withhold oral fluid.
Anticipate need for emergency surgery.
Order type & cross match of 2 units whole blood.
Allows for restoring circulating maternal blood
volume if needed.
Assess VS (pulse, respi and BP ever 15 mins.
Provides baseline data on maternal response to
blood loss.
Assist with placement of CVP or pulmonary artery Provides more accurate data
on maternal
cath and blood determinations.
hemodynamic state.
Measure maternal blood loss by weighing perineal Provides objective evidence of amount of

pads; save any tissue passed.

bleeding. Saturating a sanitary pad in less than 1 hr

is heavy blood loss; tissue may be abnormal
trophoblast tissue.
Set aside 5 ml of blood drawn intravenously in a Test for possible blood coagulation problem.
clean test tube; Observe in 5 min for clot
formation.
Maintain a positive attitude about fetal outcome.
Supplies information on placental and fetal wellbeing.
Support womans self-esteem; provide emotional Assist problem solving, which is lessened by poor
support to woman and her support person.
self-esteem.
ABORTION
- loss of fetus before age of viability <20 weeks of AOG or one weighing less than 500g is not viable.
1. Spontaneous abortion
a. Threatened
b. Imminent
c. Incomplete
d. Complete
e. Missed
f. Habitual
2. Induced abortion
a. Therapeutic medically indicated
b. Criminal intentionally done
c. Septic infected abortion; secondary to infection
Incidence of abortion increases in :
1. Age
2. Parity gravida 6
3. History of previous pregnancy
4. 10% of pregnancy end up in sbortion nature way of eliminating undesirable mal-formed fetus
Spontaneous Abortion
a. Threatened
- Prior to end of 20th weeks of AOG
- Bleeding: slight or spotting
- Cervix: Closed
- Pain: uterine cramping, slight to moderate
- Mgt: CBR without BRP
- Diet: normal diet- high vitamins and protein
b. Imminent (Inevitable)
Abortion is usually inevitable that is, it cannot be stopped when membranes rupture & the cervix dilates.
- Bleeding: moderate to profuse
- Cervix: open
- Pain: moderate to severe
- Possibility of neurogenic & hypovolemic shock
- NPO, D&E
c. Incomplete
- Occurs when some but not all of the products of conception are not been expelled.
- Cervix: opened
- Bleeding:active uterine bleeding & severe abdominal cramping.
- Mgt: > prepare for complete abortion (D&C)
> IV line - fluid replacement, oxytocin administration
d. Complete
- occurs when all products of conception are expelled from the uterus.
- ( - ) pregnacy test & symptoms no longers present
- Mgt: bedrest & watch for bleeding, pain & fever.
e. Missed
- Fetus dies in utero before 20 weeks AOG & retained 2 months or longer
- Cervix: closed
- Discharges: Foul smelling discharge, red or brownish or may not occur.
- Uterus stops growing, decreases in size
- Fetus will undergo changes:
a. Fluffling
- gray scale
- thickening & coverin of fetal skull and thorax
b. Maceration softening
c. Mummification leather like changes

d. Lithopedion formation stoney material

f. Habitual
- repeated abortion (spontaneous of any type)
- 3 or more pregnancies at same age or pre-viable stage
Causes of recurrent/habitual
1. defective spermatozoa
2. Hormonal influence Endocrine factors
3. nutritional status
4. Deviation of uterus mid-septum,
Bicornuate-horns or poles small space for implantation
5. Psychological factor- stress
6. Blood incompatibility- ABO, Rh factor
7. Infection
Medical termination of pregnancy or, also called Induced Abortion
- voluntary/deliberately terminating pregnancy
a. Therapeutic medically indicated
b. Criminal intentionally
c. Septic infected abortion, secondary to infection
Purposes:
1. When there is threat to mother's life (heart disease)
2. to prevent birth of infant w/ severe defects (malfomations, chromosomal)
3. psychological implication (incest or rape)
Therapeutic Abortion: According to US Supreme court ruling (Jan 22, 1973) pregnancy may be
terminated as follows:
1. 1st trimester abortion decision is left to the woman and her physician.
2. 2nd trimester state may not prohibit but may regulate practice for woman's health.
3. Final trimester state may choose to protect the potential life of the fetus by prohibiting abortion
except when there is threat to the life or health of the mother.
4. Religous belief of the mother is always respected.
Procedures Used to Induce Abortion
I. Menstrual Extraction
* Simplest type done on the 4th - 6th weeks AOG
* Uterine lining is suction client bleeds normal menses
* Oxytocin given orally
* follow-up check up & Pregnancy test
* Complications:
> Hemmorrhage: - 2 pads/hr, clots
> Infection: - fever, abdominal pain and tenderness, endometritis
II. Dilatation and vacumm Extraction
- Paracervical block
- Cervix is dilated with dilators
- LAMINARIA dried sterilized seaweeds cervix swells,
after 24 hrs becomes dilatable, vacuum extraction is
inserted and evacuate uterine contents in 15mins.
- Antibiotics, oxytocin, MGH after 4 hrs.
- bleeding same as menses
Complications:
> Hemmorrhage: - 2 pads/hr, clots
> Infection: - fever, abdominal pain and tenderness,
endometritis
III. Saline Induction

a. Salt poisoning Abortion done on 14th -16th weeks AOG

then D&E is used.
-salt water kills the fetus.
-uterus starts contracting usually within the next 2 days,
resulting in the delivery of the dead fetus.

b. Saline & prostaglandin induction done on 17th -24th

weeks AOG.
Mechanisms:
*Saline interferes w/ progesterone function-ing causing
endometrial sloughing.
*needle is inserted into the uterus through the abdominal
wall.

*some amniotic fluid is removed about 100-200ml and replaced with 20% hypertonic saline sol.is
injected into uterus to replace aspirated amniotic fluid.
*Needle is removed - 12-36hrs. ff. injection - Labor contractions begin; supplemented by oxytocin drip.

Complications:

a. Hypernatremia accidental injection of Hypotonic SS to blood vessels in the uterus

*S/S: inc.pulse, flushed face, severe headache
*Mechanism: to equalize osmotic pressure, fluid from tissue transfer to blood vessel which then
leave the
tissue dehydrated.
b. Water intoxication
*Large amount oxytocin used, ADH effect
*S/S: severe headache, confusion, drowiness, edema, decrease urinary output
*Rx: D/C & oxytocin drip
c. Hemorrhage
d. Infection D5W to balance or restore fluid
IV. Protagladin Injection
- Hormone which is abortive
- Administration:
1. IV drip
i. 1hr after adm., labor will start
ii. No oxytocin needed
iii. S/S: nausea, vomiting, and diarrhea
iv. Dx: anticholinergic, and antidiarrheal
v. CI: HPN- vasoconstriction, respiratory disorder bronchial constriction & bronchospasm
2. Vaginal suppository given 3-4 hours as PRN until labors starts.
3. Oral not recommended causes severe N/V, shaky, chills, & increase temperature.
V. Hysterotomy
- done on the 16th - 18th weeks AOG like Cesarean Section.
Complications of Abortion
1. Hemorrhage
2. Infection
3. Isoimmunization- production of antibodies against Rh-positive blood type
ECTOPIC PREGNANCY
Implantation of a fertilized ovum outside uterine cavity.
Ectopic pregnancy has been called a disaster of reproduction for two reasons:
1. it remain a significant cause of maternal death from hemorrhage
2. it reduces the woman's chance of subsequent pregnancies because of damage or destruction of
fallopian
tube.
Types according to sites:
A. Tubal most common
1.fimbriae 8%
2.ampullar 60%-80%
3.isthmic-12%
4.interstitial -8%
B. Ovarian
5. tubo-ovarian
6. Ovarian
C. 7. Cervical
D. 8. Abdominal /Peritoneal- rare
Causes:
1. Adhesions in tubes tubo-ovarian, fallopian tubes
2. Infection chronic salphingitis, PID
3. Congenital malformations infantile uterus
4. Scars of tubal surgery a failed tubal ligation
5. Uterine tumor pressing the tubes
6. Endometriosis
7. Tubal spasm
Signs and symptoms of Ruptured ectopic:
1. spotting bleeding may or may not not be present
2. abdominal rigidity
3. Cullen's signs bluish discolorations around the umbilicus
4. Shoulder pain blood irritating the phrenic nerve in the diaphragm

5.
6.
7.
8.
9.

Mass in Cul-de-sac of Douglas (pouch) may be palpated or bloody fluid may be aspirated by culdocentesis
Excorciating pain at cervix when IE is done
Knifelike pain either lower quadrant
WBC- 15,000/UL>, RBC decrease, ESR- slightly elevated
S/S of shock

Signs & symptoms (early ectopic pregnancy)

1. Amenorrhea or abnormal menses spotting
2. Cul-de-sac mass

S/S acute ruptured

1. shock
2. referred shoulder pain
3. evidence of acute blood loss
S/S Chronic rupture - occurs 50% in tubal ectopic pregnancy
1. slow internal bleeding
2. atypical or inconclusive symptoms as
a. Slight, dark, vaginal bleeding
b. Renal or pelvic pressure or fullness
c. Lower abdominal tenderness
d. Slight fever
e. Leukocytosis
f. Cullen's sign
g. Decrease hgb. & hct.
Diagnostic test:
1. Ultrasound reveal site of ectopic pregnancy
2. Culdocentesis yields free blood that will not clot or is already clotted
3. Laparoscopy discloses extrauterine preg.
Treatment:
1. Culdotomy release clotted blood and product of extra-uterine pregnancy.
2. Laparotomy reveal correct diagnosis
3. Salpingostomy
Nursing Managment:
1. Monitor V/S, watch for signs of shock
2. Nursing care to bleeding clients
3. Observe nature of bleeding
4. Administration of narcotics or analgesic as ordered
5. Prepare clients for diagnosis and treatment
6. Provide post-operative care

Second Trimester Bleeding (a) HYDATIDIFORM MOLE

(b) INCOMPETENT CERVIX
GESTATIONAL TROPHOBLASTIC DISEASE (Hydatidiform Mole or Molar Pregnancy)
Pathophysiology:
1. The embryo & the placenta deteriorate & loose its identity
2. A rapidly growing throphoblastic tissue develop
3. Resembles clusters of small graped- sized vesicles with tapioca like consistency.
4. Abnormal proliferation & degeneration of the trophoblastic villi.
2 Types of Molar Growth:
1. Complete mole
- no fetus
- all trophoblastic villi
- embryo dies early
- no fetal blood found
2. Partial mole
- some villi formed
- presence of 9th week fetal mass & fetal blood in the villi.
- Rarely lead to choriocarcinoma.
Pre-disposing Factors:
1. Malnutrition low protein intake
2. Age woman under 20 & above 35yrs.old
- low socio economic status
3. Chromosomal abnormalities
4. Hormonal imbalance use of Clomiphene citrate (clomid) and women of asian heritage

Sign & Symptoms:

a. rapid enlargement of the uterus Like 3 mos.= 5 mos.
b. absence of fetal heart tones or movement & fetal structures
c. HCG titers greater than expected for gestational age (+) pregnancy test
d. hyperemesis gravidarum
e. signs of PIH before 20m weeks AOG
f. vaginal bleeding dark-brown blood
g. passing out of grape-like clusters Latu-latuappearance
h. @ 16 weeks AOG the client bleeds with molar expulsion.
Diagnostic test:
1. Ultrasound (sonogram) - reveals molar pregnancy, show-dense growth [typically snow flake pattern]
but no fetal growth.
2. Pregnancy test (+) due to elevated hCG titer. HCG= increase 1.2 mil. IU in 24 hrs.[normal =
400,000 IU
3. Hct.& Hgb decrease due to bleeding
4. ESR & WBC- increase due to infection
Management:
1. Evacuation by:
a. D&C or Suction curettage
b. Hysterotomy
c. Hysterectomy- above 45yrs.old
2. Follow-up management for detection of malignant changes of complication.
a. HCG levels
# every 2 weeks until titers are negative for 3 consecutive results
# once monthly x 6 mos.
# every 2 mos. X 6 mos.
# every 6 mos. X 1 year.
- if hCG are negative free of risk of developing malignancy.
Note: continual rising of HCG (3x) indicates pathologic condition- D&C is to be done if the uterus is intact
then tissue can be examined (biopsy).
3. Prophylactic treatment of choriocarcinoma
- Methotrexate drug of choice, but this drug inteferes with WBC formation (Leukopenia)
- Dactinomycin drug used if metastasis occurs.
- if untreated, death results
4. CXR to detect metastasis to the other systems of the body as to the lungs
- to be done until hCG titers are negative.
- then every 2 mons x 1 yr.
5. Oral contraception used to
a. prevent another molar pregnancy.
b. suppress Endogenous Pituitary Leutenizing Hormones (LH)which will distort hCG titer assay.
6. Provide emotional support.
INCOMPETENT CERVIX (Premature Cervical Dilatation)
- A defect in the cervix that makes it unable to remain closed through pregnancy.
- Common cause of late abortions or premature labor.
- Occurs at 20th weeks AOG
Pathophysiology:
-cervix thinned and dilates
-makes it unable to hold product of conception until term
-painless
Causes:
1. Trauma traumatic delivery as forcep extraction
- forceful D&C
2. Congenital anomaly infantile uterus
3. Endocrine factor low progesterone
Criteria before Management: (in the current pregnancy) all must be present
a. Membranes (BOW) must be intact
b. Cervix is not > 3cm.dilated
c. Cervix is not > 50% effaced
Management:
a. Supportive
1. Bedrest
2. Monitor V/S & FHT
3. Psychological support & reassurance
4. Health teaching:

- uterine contraction
- Rupture of Membrane
- Assess presence of fever
- Bleeding and pain
- Abstain coitus
b. Surgery
1. Cervical Cerclage a purse string suture is placed in the cervix.
-done to prevent premature dilatation of the cervix, holds pregnancy inside
the
uterus.
-done after the 12 to 14wks. AOG (age beyond the point that spontaneous
abortion
due to defective embryo usually occurs)
Types of Cerclage Techniques :
a. Shirodkar-Barter procedure or McDonald operation
Shirodkar technique
> sterile tape is threaded in a purse-string manner under the submucous layer of the cervix
> suture in placed to achieve a closed cervix
McDonald technique
> nylon sutures are placed horizontally & vertically across the cervix and pulled tight to reduce
the canal.
> remove if fetus reached almost fullterm - 38th -39th weeks AOG.
b. Transabdominal approach
- a permanent purse-string (cerclage) is placed at the lower end of the uterus or
remaining
cervix.
- the suture is left in place and C/S is performed.
- success of both types: 80% - 90%.
Nursing Intervention:
> After the cerclage:
- observe for spotting of fresh blood expected during the 1st 2nd day [application of suture
induces
bleeding]
- placed on bedrest or slight T-position to decrease pressure on the new sutures.
- sexual activity may resumed after rest period
Third Trimester Bleeding (a) PLACENTA PREVIA
(b) ABRUPTIO PLACENTA
PLACENTA PREVIA
- improperly implanted placenta in the lower uterine segment near or covering the internal cervical os.
- 30% >than average placenta implanted at the fundus site & size related (surface area)
- degree of placenta covers the internal os is estimated by 70-100%, 75% etc.
2nd trimester 45% of placenta are implanted at lower uterine segment
Classification:
1. Complete or Central or Total placenta previa - Internal os is covered entirely by the placenta
2. Incomplete or Partial Placenta Previa occurs when the placenta asymetrically covers only part of the internal
os.
3. Marginal Placenta Previa only an edge of the placenta approaches the internal os.
4. Low-lying (low implantation) is when the placenta is situated in the lower uterine segment but does
not
reach the internal os.
Causes:
1. Unknown
2. Can be attributed to the following conditions:
a. Fibroid tumor in the uterus
b. Uterine scars from previous surgery (c/s, past uterine curettage)
c. Abnormal uterine position or shape
d. Multiparity multiple gestation
e. Age very young & very old
f. Cigarette smoking
Assessment/ Physical exam:(7 months AOG)
1. Uterine bleeding painless
2. Uterine tone normal but relax completely bet.contraction
3. Pain painless non-tenderness uterus- may experience labor contractions
3. Fetal position
- Fundic height is greater placenta hinders descent of,presenting parts
- leopolds manuenver - reveals malposition of fetus transverse or breech

Assessment:
- duration of the pregnancy
- time the bleeding began
- woman's estimation of the amount of blood
> ask to estimate bleeding
- whether there was accompanying pain
- color of the blood
- what she has done for bleeding?
- whether there were prior episodes of bleeding
- whether she had prior surgery for premature dilatation.
Diagnostic tests:
1. Ultrasound safe,accurate, & non-invasive
method of visualizing the placenta
2. Amniocentesis
- asses fetal lung maturity Lecithin Spingomyelin ratio 1:2
- if lung maturity is reached, CS delivery- done
3. No vaginal exam unless patient is place on double preparation procedure
4. Laboratory tests:
- hemoglobin
- hematocrit
- Rh factor
- urinalysis
- blood typing
Nursing Management:
Goal: to ensure an adequate blood supply to a woman & fetus.
1. Inspect perineum for bleeding
2. Test strip procedure to detect blood is fetal or maternal origin
3. No IE or rectal exam in painless bleeding.
4. Monitor v/s (TPR,B/P), I&O, FHT
5. IVF therapy- use largew bore needle (LR, vol. Expander)
6. O2 administration incase of fetal distress
7. Keep NPO
8. Betamethasone steriod that hasten fetal lung maturity in < 34 weeks gestation.
Management of placenta previa (In General)
> delivery if fetus reached maturity
a. if > 30% previa - Abdominal delivery by C/S
b. if < 30 % previa Vaginal delivery if delivery is not attained within 6hours- C/S is indicated
ABRUPTIO PLACENTA
- is the premature separation of part or all of the placenta from its site of implantation
- can be an abnormal separation of a normally implanted placenta
- occurs at >20 weeks of AOG
Classification:
Hemorrhage is apparent or visible when bleeding separates or dissects the membranes from the
endometrium and blood flows out through the vagina.
Concealed Hemorrhage - the bleeding occurs behind the placenta but the margins remain intact, causing
formation of a hematoma
Incidence and Etiology:
1. Cause is unknown
2. Following factors that increase risk:
a. Maternal use of cocaine leading cause of abruptio placenta
b. Cigarette smoking
c. Maternal HPN ; Multigravida
d. PROM; Advance maternal age
e. History of previous premature separation;abortion, stillbirth, pre-natal hemorrhage; premature
labor
g. Abdominal trauma; short umbilical cord
Degrees of Separation:
Grade 0 - No symptoms of separation were apparent from maternal or fetal side; diagnosis of placental
separation is made during delivery; placenta shows recent adherent clots on maternal surface
Grade 1 - Minimal separation enough to cause vaginal bleeding and changes in the maternal VS; no fetal
distress
or hemorrhagic shock occurs
Grade 2 - Moderate separation with evidence of fetal distress; uterus is tense, painful on palpation
Grade 3 - Extreme separation; without immediate interventions; maternal shock and fetal death will
result
Assessment/Physical exam
-Symptoms vary with degrees of placental separation

Classic symptoms:
- Vaginal bleeding- may be concealed.
- Severe abdominal pain & tenderness
- Uterine contractions (hypertonic)
- Increased abdominal girth
- Other symptoms are signs of shock
- Fetal distress or fetal demise
In severe concealed bleeding, blood may infiltrate the uterine musculature COUVELAIRE uterus
or uteroplacental apoplexy- hard, boardlike uterus- orange or bronze color- uterus becomes tense
and rigid to touch
In extensive bleeding, DIC syndrome occurs; the womans reserve blood fibrinogen may be used
up in her bodys attempt to accomplish effective clot formation.
Signs of Concealed hemorrhage :
- Increase in fundal height
- Hard boardlike abdomen
- Persistent abdominal pain
- Systemic signs of hemorrhage
- persistent late
- deceleration in FHT
- slight or absent
- vaginal bleeding
Laboratory tests:
- Hemoglobin level
- Blood typing & cross-matching
- Fibrinogen level tests for DIC (5 ml of blood to stand for 5 mins; if clot formed- DIC negative; no
clot formation positive to DIC
Nursing Management/Care
1. Admit to hospital
2. Administered oxygen by mask (fetal anoxia)
3. Monitor FHT, VS and record
4. Determine baseline fibrinogen
5. Keep in lateral position -prevent pressure at vena cava; further compromise fetal circulation
6. No IE, pelvic exam, enema
7. Depending on degree of separation if labor starts rupturing BOW may help speed delivery or
administration of oxytocin.
8. If delivery does not occur, cesarean section is the method of choice
9. Cause of maternal death:
- Massive hemorrhage which lead to shock; circulatory collapse or renal failure
- Infection
Purpose of Rupturing BOW
a. Prevents development of couvelaire uterus, prevents pooling of blood in the myometrium of uterus.
b. Prevent DIC (Disseminated Intravascular Coagulation)
c. Speed up delivery
Fetal Complications
1. Prematurity
2. Hypoxia result in irreversible damage & anemia
Maternal Complications
1. Hemorrhage
2. Hypovolemic shock
3. DIC
4. Acute renal failure
5. Infection
6. Post partal hemorrhage
7. Death