NCM 109: Maternal: Jan 30, 2023

BLEEDING DURING PREGNANCY

• Vaginal bleeding during pregnancy is always a
deviation from the normal, is always potentially
serious, may occur at any point during
pregnancy, and is always frightening.
• Maternal blood loss decreases the oxygen-
carrying capacity of the blood, resulting in
fetal hypoxia, and places the fetus at risk.
• Bleeding during pregnancy happens due to
certain physiological problems in the early or
late stages of pregnancy, each with its own signs
and symptoms, which aids in determining a
differential diagnosis and in formulating a care
plan.

HYPOVOLEMIC SHOCK
- an emergency condition in which severe blood
or other fluid loss makes the heart unable to
pump enough blood to the body. This type of
shock can cause many organs to stop working.
- Because the uterus is a nonessential body
organ, danger to the fetal blood supply occurs
when a woman's body begins to decrease blood
flow to peripheral organs
(not enough volume)

PATHOPHYSIOLOGY OF HYPOVOLEMIC SHOCK

ASSESSING A PREGNANT WOMEN WITH
HYPOVOLEMIC SHOCK

• Decreased in blood circulation (less in blood return)

• Increase cardiac output
• Mean arterial pressure
• Poor oxygenation (lungs needs to pump more=increase in RR)
• Decrease conscious level
• Cold cranking extremities= extremities (low-blooded)
• Pallor
• Oliguria (decreased in urine output) By NAYA & GETTE <3
 01 ABORTION Management:
• Further observation
- Termination of pregnancy before the age of
• No intervention is generally indicated
viability (« 20 weeks)
• Avoid strenuous activity
• Complete bed rest may be recommended
“Abortion and miscarriage are just the same.”
• Abstinence from intercourse
COMMON CAUSES
-abnormal fetal development
Note: Patient should report increased bleeding,
-implantation abnormalities
passage of tissue, or fever.
-fails to produce enough progesterone
-ingestion of alcohol systemic infection
Inevitable Abortion
IMMEDIATE ASSESSMENT OF VAGINAL
• Also known as imminent abortion
BLEEDING DURING PREGNANCY
• Vaginal bleeding & uterine cramping leading to
• Confirmation of pregnancy
cervical dilatation but no products of conception
• Pregnancy length
has yet passed
• Duration
• Intensity
Management
• Description • Emergency suction dilatation and curettage to
• Frequency prevent further blood loss an anemia
• Associated symptoms
• Action Dilatation & Curettage
• Blood type • A dilation and curettage procedure, also called
a D&C, is a surgical procedure in which the cervix
TYPES OF ABORTION (lower, narrow part of the uterus) is dilated
SPONTANEOUS ABORTION (expanded) so that the uterine lining
•Nature's way of expelling a defective fetus. (endometrium) can be scraped with a curette
•Caused by chromosomal aberration, blighted (spoon-shaped instrument) to remove
ovum, and germ plasma defect abnormal tissues.
• Maternal age of »35 years old - Removal of tissue with a curette (a spoon-
shaped instrument with a sharp edge).
INDUCED ABORTION
•Abortion that is brought about Complete Abortion
Intentionally • All products of conception are expelled
•AKA artificial or therapeutic abortion •The uterus is well contracted, and the cervical
os may be closed or opened.
Types of Spontaneous Abortion • No need for dilatation and curettage
Threatened Abortion supportive care emotional support
• Sonogram finding of a viable pregnancy with
vaginal bleeding but no cervical dilatation. Incomplete Abortion
• Pregnancy is jeopardized by bleeding and • Vaginal bleeding and uterine cramping leading
cramping but the cervix is closed to cervical dilatation, with some, but not all,
Signs: products of conception having been posed
Painless Vaginal Bleeding • Placenta and membranes retained
Bright red blood

By NAYA & GETTE <3

• Dilatation and curettage is done to prevent growing fetus and is removed by 36
further blood loss and anemia weeks gestations to allow the mother to
deliver via NSD.
Missed Abortion 2. Shirodkar Procedure - the suture is buried
"commonly referred to as early pregnancy beneath the cervical mucosa and
failure” Is often left in place (permanent cerclage)
•Is diagnosed when products of conception are - delivery via C-section only
retained after the fetus has expired
• If product is/are retained, a severe Induced/Surgical Abortion
coagulopathy with bleeding often occurs. Therapeutic Abortion
• After an ultrasound establishes the fetus has • Ensures life of the mother especially it
no heart rate, a D8C may be done to evacuate there are bioethical issues [Le, presence
the pregnancy of cardiorespiratory illnesses that may
put the mother's life in danger). it has
Missed Abortion two-fold effect which opts for the choice
When the fetus dies: of lesser evil.
• Should be suspected when the pregnant Illegal Abortion
uterus fails to grow as expected or when • Unwarranted termination of pregnancy
fetal heart tones disappear which does not put the life of the mother
• Amenorrhea may persist, or nor the fetus' life jeopardy and is not
intermittent vaginal bleeding. spotting permitted by Philippine law.
or brown discharge may be noted
• Ultrasound confirms the diagnosis FETAL DEMISE
• Also called Stillbirth
Habitual Abortion • Termination of pregnancy after the age of
• recurrent pregnancy loss viability
• Three or more consecutive pregnancies result Types:
in abortion which is usually related to an 1. Antenatal demise - occurs before labor
incompetent cervix 2. Intrapartum demise - occurs after the
Possible Causes: onset of labor
• Abnormalities of the fetus, blighted embryo Risk Factors:
• Abnormalities of the reproductive tract o Mostly idiopathic
• Physical and emotional shocks o Antiphospholipid syndrome
• Endocrine problems o Maternal diabetes
• Infectious diseases o Maternal trauma
• Maternal diseases o Severe maternal isoimmunization
• Psychogenic problems o Fetal aneuploidy (is a condition where
the fetus has one or more extra or
Management: Surgery of the Cervix missing chromosomes leading to either
1. McDonald Operation - temporary cerclage of a nonviable pregnancy, offspring that
the incompetent cervical OS. may not survive after birth, or surviving
a. done at 2-3 months gestation newborn with congenital birth defects
b. suturing is done around the cervix in a and functional abnormalities)
simple purse-string fashion to hold o Fetal infection

By NAYA & GETTE <3

 02 ECTOPIC PREGNANCY - Abnormal proliferation and then degeneration
of the trophoblastic vill. As the cells degenerate,
Pregnancy is one in which implantation occurred
they become filled with fluid and appear as clear
outside the uterine cavity,
fluid-filled, grape-sized vesicles.
-most dangerous site: fibrial

Progressive degeneration of chorionic villi with

TYPES OF ECTOPIC PREGNANCY
unknown cause
o Unruptured
o Missed period
Assessment
o Abdominal pain within 3-5 weeks of the
Early Signs:
missed period (maybe generalized or
• Most common symptom: Vesicles passed thru
one sided)
the vaginal (fluid filled)
o Scanty, dark brown vaginal bleeding
• Hyperemesis gravidarum
o Vague discomfort
• Most common sign: rapid increase in fundic
height, absence of fetal heart tones.
Ruptured
• Vaginal bleeding (scant or profuse)
o Sudden, sharp, knifelike, unilateral
• Most common site of distant metastasis is the
severe pain
lungs.
o Shoulder pain (Indicative of
intraperitoneal bleeding that extends to
Early in Pregnancy:
diaphragm and phrenic nerve)
• High levels of HCG (Normal: 400,000 IU)
o (+) Cullen's sign (Bluish)
• Preeclampsia at about 12 weeks
o Syncope

Late Signs:
Nursing Intervention
• Hypertension before 20th week
• Vital signs monitoring
• Vesicles look like a "snowstorm on sonogram
• administer IV fluids as ordered
• Anemia
• Monitor vaginal bleeding
• Abdominal cramping
• Monitor intake and output
• Culdocentesis - to determine
Nursing Interventions:
hemoperitoneum (bleeding in peritonial
• Prepare for D & C
cavity)
• do not give oxytocin drugs
• Non surgical management -
• Teachings: return for pelvic exams as
Methotrexate
scheduled for one year to monitor HCG and
(Check presence of HCG)
assess for enlarged uterus and rising titer could
be indicative of choriocarcinoma
*Culdocentesis: checks for abnormal fluid in the
• Avoid pregnancy for at least 1 year and have
abdominal cavity behind the uterus
regular exams
• 12-18 months of regular monthly urine exam
03 HYDATIDIFORM MOLE or (HMOL) • Sex allowed but advice on the use of condom
- Gestational Trophoblastic Disease is a • No pills, it will alter the result of HCG
gestational anomaly of the placenta consisting of
a bunch of cigar vesicles.

By NAYA & GETTE <3