Conditions Associated

with First Trimester

Bleeding

Chiradee May P. Marquez, RN, MAN

Two most common causes of bleeding during
the first trimester are:

1 ABORTION

2 ECTOPIC PREGNANCY
ABORTION
a procedure to end a pregnancy.

the expulsion of a fetus from the uterus before

it has reached the stage of viability
(Britannica).

the pregnancy is ended either by taking

medicines or having a surgical procedure.
SPONTANEOUS ABORTION
abortion (defined as any interruption of pregnancy
before the age of viability)

when the interruption occurs spontaneously, it is clear to

refer to it as a MISCARRIAGE

when pregnancy is medically or surgically interrupted,

this is typically termed as ABORTION

stage of viability (a stage when the fetus is capable of

surviving outside the uterus, more than 20- 24 weeks)
SPONTANEOUS ABORTION
occurs in 15% to 30% of all pregnancies and occurs from
natural causes

a spontaneous miscarriage is an early miscarriage if it

occurs week 16 of pregnancy and a late miscarriage if it
occurs between weeks 16 and 24

its presenting symptoms is almost always vaginal

spotting
CAUSES:
abnormal fetal formation, due to either to a teratogenic
factor or to chromosomal aberration

implantation abnormalities. Approximately 50% of zygotes

are never implanted

corpus luteum fails to produce enough progesterone to

maintain the decidua basalis

infection (rubella, syphilis, poliomyelitis, cytomegalovirus

and toxoplasmosis infections readily cross the placenta and
possibly causing fetal death)

ingestion of teratogenic drug

THREATENED ABORTION
is manifested by vaginal bleeding, initially beginning as
scant bleeding and usually bright red. There may be
slight cramping, but no cervical dilatation is present on
vaginal examination.

limiting activity to no strenuous activity for 24-48 hours

is the key intervention to stop vaginal bleeding. complete
bed rest is usually not indicated

coitus is usually restricted for 2 weeks after the bleeding

episode to prevent infection and to avoid inducing
further bleeding
IMMINENT (INEVITABLE) ABORTION
it happens with uterine contraction, cramping and
cervical dilatation
the loss of the products of conception cannot be halted
because of cervical dilatation
instruct the mother to save tissue fragments that has
passed and bring to the clinic to be examined
the physician may perform D & C (dilatation and
curettage) to ensure that all products of conception are
removed, preventing further complication such as
infection
after D & C the woman is advised to record the number
of pads used to assess for heavy bleeding
IMMINENT (INEVITABLE) ABORTION
it happens with uterine contraction, cramping and
cervical dilatation

the loss of the products of conception cannot be halted

because of cervical dilatation

instruct the mother to save tissue fragments that has

passed and bring to the clinic to be examined

the physician may perform D & C (dilatation and

curettage) to ensure that all products of conception are
removed, preventing further complication such as
infection
COMPLETE ABORTION
the entire products of conception (fetus,
membranes and placenta) are expelled
spontaneously without any assistance

the bleeding usually slows within 2 hours and then

ceases within a few days after passage of the
products of conception
INCOMPLETE ABORTION
part of the conceptus (usually the fetus) is
expelled, but the membranes or placenta is
retained in the uterus

the physician will usually perform a D & C

(dilation and curettage) or a suction curettage
to evacuate the remainder of the pregnancy
from the uterus
MISSED ABORTION
commonly referred to as early pregnancy failure,
the fetus dies in the utero but is not expelled

a sonogram can establish that the fetus is dead.

Often the embryo actually died 4-6 weeks before
the onset of miscarriage symptoms. After the
sonogram, a D & C most commonly will be done

if the pregnancy is over 14 weeks, labor may be

induced by a prostaglandin suppository or
Misoprostol (Cytotec) to dilate the cervix, followed
by oxytocin administration
MISSED ABORTION
DIC (disseminated intravascular coagulation),
coagulation defect, may develop if the dead fetus
remains tool long in utero

FDIU – Fetal Death In-utero

RECURRENT PREGNANCY LOSS

commonly referred to as habitual abortion

3 or more consecutive pregnancies result in

miscarriage usually related to incompetent cervix.
MANAGEMENT:
MCDONALD PROCEDURE
Temporary Circlage
Side effect – infection
May have NSD

SHIRODKAR
CS Delivery
Emergency
Cerclage
COMPLICATIONS OF
ABORTION
HEMORRHAGE
a woman who develops DIC has a major
possibility for hemorrhage

1. If excessive vaginal bleeding is occurring,

immediately position the woman flat and massage
the uterine fundus to aid contraction

2. Monitor vital signs for changes to detect possible

hypovolemic shock
HEMORRHAGE
3. A blood transfusion may be necessary to replace
blood loss

4. Instruct the woman on how much bleeding is

abnormal, what color changes she should expect in
bleeding, and any unusual odor or passage of large
clots is also abnormal
INFECTION
the possibility of infection is minimal when
pregnancy loss occurs a short period, bleeding is
self limiting and instrumentation is limited

1. educate the woman about the danger signs of

infection, such as fever, abdominal pain or
tenderness and a foul smelling discharge

2. organism responsible for infection after

miscarriage is usually Escherichia Coli (E Coli)
INFECTION
3. caution the woman to wipe the perineal area from
front to back after voiding and particularly after
defecation to prevent the spread of bacteria from
rectal area

4. caution the woman not to use tampons to control

vaginal discharge because stasis of any blood
increases the risk of infection
ISOIMMUNIZATION
happens when the mother’ s blood is Rh negative,
while the fetus is Rh positive.

after spontaneous abortion or D & C. some Rh

positive fetal blood may enter the maternal
circulation and mother will develops antibodies
against Rh positive fetus blood.

during the succeeding pregnancies when the

fetus is Rh positive again, those antibodies would
attempt to destroy the fetus RBC
ISOIMMUNIZATION
all women with Rh negative blood should receive
Rhogam (Rh Immune Globulin) to prevent the
build up of Rh antibodies
POWERLESSNESS

sadness and grief over the loss or a feeling that

she has lost control of her life is to be expected

emotional support
PROCEDURES USED
IN PREGNANCY
TERMINATION
VACUUM CURETTAGE
cervical dilation followed by controlled suction
through a plastic cannula to remove all products
of conception

used for first trimester abortions, also used to

remove remaining products of conception after
spontaneous abortion

local anesthesia of the cervix is needed

DILATION AND CURETTAGE
dilation of cervix followed by gentle scraping of
the uterine walls to remove products of
conception

used for first-trimester abortions and to remove

all products of conception after spontaneous
abortions

greater risk of cervical or uterine trauma and

excessive blood loss

local anesthesia or general anesthesia is needed

Nursing Care of Clients with Abortion
1. Document the amount and character of bleeding
and saves tissues or clots for evaluation.

2. Check the bleeding and vitals signs to identify

hypovolemic shock resulting from blood loss.

3. After vacuum aspiration or curettage, the amount

of vaginal bleeding is observed.

4. Provide home health teaching after curettage

such as:
Nursing Care of Clients with Abortion
a. report increase bleeding

b. take temperature every 8 hours for 3 days

c. take an oral iron supplement if prescribed

d. resume sexual activity as recommended by the

health care provider

e. return to the health care provider at the

recommended time for a check up
Nursing Care of Clients with Abortion
5. Check laboratory test such as hemoglobin level
and hematocrit

6. Promote expression of grief by providing privacy,

allowing support persons to help in pregnancy loss
ECTOPIC PREGNANCY
is one in which implantation occurs outside the uterine
cavity.

the most common site (in approximately 95% of such

pregnancies) is in a fallopian tube. Of these fallopian
tube sites, approximately 80% occur in the ampullar
portion, 12% occur in the isthmus and 8% in interstitial.

approximately 2% of pregnancies are ectopic; ectopic

pregnancy is the second most frequent cause of bleeding
in early pregnancy.
RISK FACTORS
increase incidence in women who have PID (pelvic
inflammatory disease) which leads to tubal scarring

occurs more frequently in women who smoke

occurs more frequently in women who douche, possibly

due to risk of introducing an infection

used of IUD (intrauterine device) for contraception

SIGNS AND SYMPTOMS
Before Rupture:
no menstrual flow occurs

nausea and vomiting

positive pregnancy test for hCG

Abdominal pain within 3- 5wks of missed period (maybe

generalized or one sided)

Scant, dark brown vaginal bleeding

SIGNS AND SYMPTOMS
During Rupture:
sharp, stabbing pain in one of the lower abdominal
quadrants at the time of rupture, followed by scant
vaginal bleeding

lightheadedness, rapid pulse and signs of shock (rapid

thread pulse, rapid respirations and falling blood
pressure)

rigid abdomen from peritoneal irritation(board-like

abdomen)
SIGNS AND SYMPTOMS
During Rupture:
Cullen’s sign (bluish tinged umbilicus) – because blood seeping
into the peritoneal cavity

dull, excruciating pain on the abdomen that may radiate on the

shoulder caused by irritation of the phrenic nerve
DIAGNOSTICS
1. Transvaginal UTZ will demonstrate ruptured tube

2. Insertion of a needle through the post vaginal fornix into

the cul-de-sac under the sterile conditions to see whether
blood that has collected there from internal bleeding can be
aspirated

3. Laparoscopy Culdoscopy can be used to visualize the

fallopian tube
Culdocentesis
Transvaginal UTZ
Laparoscopy
MANAGEMENT
1. Once an ectopic pregnancy ruptures, it is an emergency
situation and the woman’s conditions must be evaluated
quickly (monitor for the symptoms of shock)

2. Therapy for a ruptured ectopic pregnancy is laparoscopy

to ligate the bleeding vessels and to remove or repair the
damaged fallopian tube

3. Women with Rh negative blood should receive Rh immune

globulin (Rhogam) after an ectopic pregnancy for
isoimmunization protection in future childbearing
MANAGEMENT
4. Treated medically by the oral administration of
Methotrexate, a folic acid antagonist chemotherapeutic
agent, attacks and destroys fast growing cells. Because
trophoblast and zygote growth is rapid, the drug is drawn to
the site of ectopic pregnancy

5. Hysterosalpingogram performed after chemotherapy to

assess the patency of the tube

6. Provide emotional support

Conditions Associated
with Second Trimester
Bleeding
Two most common causes of bleeding during
the second trimester are:

1 H-MOLE

2
Premature Cervical
Dilatation
GESTATIONAL TROPHOBLASTIC DISEASE
Hydatidiform Mole or H-Mole

is proliferation and degeneration of the trophoblastic

villi, which becomes filled with fluid and appear as
grape-sized vesicles

incidence is approximately 1 in every 2,000 pregnancies

CAUSE
Unknown

RISK FACTORS
occurs most often in women who have a low protein
intake

in young women under age 18 years

in older women older than 35 years

TYPES OF H-MOLE
Complete Mole
embryo dies early at only 1 to 2 mm in size with no fetal
blood present in the villi

on chromosomal analysis, although the karyotype is a

normal 46XX or 46XY, this chromosome component was
contributed only by the father or an “empty ovum” was
fertilized and the chromosome material was duplicated

this type usually lead to choriocarcinoma

TYPES OF H-MOLE
Partial Mole - some of the villi form normally

although no embryo is present, fetal blood may be

present in the villi

has 69 chromosomes (a triploid formation in which

there are three chromosomes instead of two for every
pair, one set supplied by an ovum that was fertilized by
two sperm or an ovum fertilized by one sperm in which
meiosis or reduction division did not occur)
SIGNS AND SYMPTOMS
1. uterus tends to expand than normally

2. no Fetal heart sounds are heard because there is no viable fetus

3. hCG serum levels are abnormally high

4. severe nausea and vomiting

5. symptoms of hypertension of pregnancy is present before week 20 of

pregnancy

6. a sonogram/UTZ will show dense growth (typically a “snowstorm”

pattern) but no fetal growth in the uterus

7. vaginal spotting of dark brown blood

8. discharge of the clear fluid filled vesicles

MANAGEMENT
1. suction curettage to evacuate the mole

2. after extraction, women should have a baseline serum test for the
beta subunit of hCG

3. educate on avoiding pregnancy for at least one year

4. hCG is analyzed every 2-4 weeks for 6-12 months (gradually

declining hCG suggest no complications)

5. prophylactic course of Methotrexate is the drug of choice for

choriocarcinoma. This must be weigh carefully because it interferes
with WBC formation which can lead to leucopenia

6. observe for bleeding and hypovolemic shock

PARTIAL CERVICAL
DILATATION
PREMATURE CERVICAL DILATATION

previously termed as “Incompetent cervix”

refers to a cervix that dilates prematurely and therefore

cannot hold a fetus until term

commonly occurs at approximately week 20 of

pregnancy
CAUSE
Unknown

RISK FACTORS
associated with increased maternal age, congenital
structural defects and trauma to the cervix such as
might occurred with biopsy or repeated D & C
SIGNS AND SYMPTOMS
1. often the first symptom is show (a pink-stained vaginal
discharge) or increased pelvic pressure followed by rupture
of membranes and discharge of amniotic fluid

2. painless cervical dilatation

3. uterine contractions followed by birth of fetus

MANAGEMENT
1. bed rest in Trendelenburg position

2. monitor FHT

3. observe for the rupture of BOW

4. avoid coitus and limit activities

5. avoid vaginal douche

6. Surgical Operation termed as “Cervical Cerlage” is

performed
to be continued...
Conditions Associated
with Third Trimester
Bleeding
 Thirteen most common causes of bleeding
during the third trimester are:

1 Placenta Previa 4 Premature ROM

2 Abruptio Placenta 5 PIH

3 Preterm Labor 6 Multiple Pregnancies

7 Hydramnios 11 Gestational DM

8 Esophageal Atresia 12 Macrosomia

9 13 Heart Disease
Anencephaly

10 Post Term Pregnancy

PLACENTA
PREVIA
PLACENTA PREVIA
- is low implantation of the placenta.

-is a problem during pregnancy when the placenta completely or

partially covers the opening of the uterus (cervix).
4 Degrees of Placenta Previa
1. Low-lying placenta – implantation in the lower rather than in the
upper portion of the uterus

2. Partial placenta previa – implantation that occludes a portion of

the cervical OS

3. Marginal – placenta edge approaches the cervical OS. Lower

border is within 3 cm from internal cervical OS but does not cover
the OS

4. Total placenta previa – implantation that totally obstructs the

cervical OS

- incidence is approximately 5 per 1000 pregnancies

RISK FACTORS
increased parity
advanced maternal age
past cesarean births
past uterine curettage
multiple gestation

COMPLICATIONS
postpartum hemorrhage
hypovolemic shock
preterm labor
fetal distress
SIGNS AND SYMPTOMS
1. sudden onset of painless bright red vaginal bleeding
(latter half of pregnancy)

2. bleeding may be profuse or scanty

Note:
onsite of bleeding: uterine deciduas (maternal
blood) places the mother at risk for hemorrhage
bleeding may not occur until the onset of cervical
dilatation causing the placenta to loosen from the
uterus
MANAGEMENT
1. bleeding is an emergency. (fetal oxygen may be
compromised and preterm birth may occur)

2. assess the amount of blood loss (duration, time of

bleeding began, accompanying pain, and color of the
blood)

3. bed rest with oxygenation prescribed

4. side-lying or trendelenburg position (for 72 hours)

FETAL ASSESSMENT
1. monitor fetal status, heart tone and movement

2. determine fetal lung maturity; amniocentesis

3. Bethamethasone may be prescribed (encourage

maturity of fetal lungs; if fetus is less than 34 weeks
gestation)
ABRUPTIO
PLACENTA
ABRUPTIO PLACENTA
-premature separation of a normally implanted placenta.

-occurs after 20-24 weeks of pregnancy.

CAUSE
unknown

RISK FACTORS
high parity
advanced maternal age
short umbilical cord
chronic hypertensive disease
PIH
direct trauma (from VA)
cocaine or cigarette use (Vasoconstriction)
COMPLICATIONS
fetal distress (altered HR)
Couvelaire uterus or Uteroplacental apoplexy
disseminated intravascular coagulation (DIC)

SIGNS AND SYMPTOMS

vaginal bleeding (may not reflect the true amount of blood
loss)
abdominal and low back pain (dull or aching)
sharp stabbing pain high in the fundus
uterine irritability (frequent low intensity contractions)
high uterine resting tone
uterine tenderness
Degree of Placental Separation
No symptoms of separation. Slight separation occurs after
0 birth. When placenta is examined, a segment shows recent
adherent clots.

Minimal separation, enough to cause bleeding and changes

1 in vital signs. However, there is no occurrence of fetal
distress and hemorrhagic shock.

Moderate separation. There is evidence of fetal distress,

2 and the uterus is tense and painful on palpation.

Extreme separation, and maternal shock or fetal death will

3 result.
MANAGEMENT
keep the client in lateral position, not supine

oxygen therapy (limit fetal anoxia)

monitor FHT and record maternal vital signs every 5 to 15

minutes

baseline fibrinogen(if bleeding is extensive. Fibrinogen reserve

may be used up in the body’s attempt to accomplish effective
clot formation)

NO IE or rectal exam. No Enema.

keep IV line open (possible BT)

PRETERM
LABOR
PRETERM LABOR
Premature Labor

labor that occurs after 20 weeks and before the end

approximately 9-10% of all pregnancies

labor contractions that happens every 10-20 minutes

usually leads to progressive cervical dilatation of >2 cm and

effacement of >80%
CAUSE
unknown

RISK FACTORS
Dehydration (stimulates APG to release ADH/Oxytocin that
strengthen uterine contractions)
UTI
Chorioamnionitis (infection of the fetal membranes and fluid)
Younger than 17 and over 35 years old
Inadequate prenatal care
Emotional and physical stress
Previous pre-term labor
Low socio-economic class
MANAGEMENT
FOCUS: Prevention of the delivery of premature fetus

The woman should first admitted to the hospital

Place in left lateral position
BEDREST to relieve the pressure of the fetus on the cervix
Intravenous fluid therapy to promote hydration
Medical Management

a. Bethamethasone/Glucocorticoids – steroid, given in an attempt

to hasten fetal lung maturity
given in 2 doses, 12 mg IM 24 hours apart
MANAGEMENT
b. Tocolytic agents (halt labor)
Calcium channel blockers – Beta adrenergic drugs
Indomethacin (prostaglandin antagonist)
- it can decrease fetal urine output, causing a decrease in
amniotic fluid, not DOC because it can stimulate the early closure
of ductus arteriosus
Magnesium Sulfate – often the first drug used to halt
contractions
CNS depressant
halts uterine contraction
Ritodrine Hydrochloride (Yutopar) and Terbutaline (Brethine)
- acts on entire beta 2 receptors sites (uterine and bronchial
smooth muscles) causing mild hypotension and tachycardia
effects, hypokalemia, hyperglycemia, pulmonary edema
SIDE EFFECTS
Headache (most common) – due to dilatation of cerebral
blood vessels
Nausea and vomiting

NSG. Responsibilities before

Tocolytic Administration
assess baseline blood data: hct, glucose, potassium, NaCl, ECG
(tachycardia)
Uterine and fetal monitoring (external fetal monitors)
mix the drug with lactated Ringers solution to prevent
hyperglycemia
NSG. Responsibilities before
Tocolytic Administration
assess BP and pulse every 15 minutes and every 30 minutes
until contractions stop
reports PR>120 bpm, BP < 90/60 chest pain, dyspnea, rales
PREMATURE
RUPTURE
OF
MEMBRANE
PREMATURE RUPTURE OF
MEMBRANE (PROM)
rupture and loss of amniotic fluid that occurs before labor
begins

occurs in 2-18 % of pregnancies

CAUSE
unknown, but associated with infection of fetal membranes
(Chorioamnionitis)

nutritional deficiency involving ascorbic acid

COMPLICATIONS
Fetal infections – after the rupture of BOW, the seal to the fetus
is lost

Cord Compression – pressure on the umbilical cord because of

the loss of the amniotic fluid, which can cut off the nutrient
supply to the fetus (fetal distress)

Cord prolapse – the extension of the umbilical cord into the

vagina which can also interfere with fetal blood circulation
SIGNS AND SYMPTOMS
Sudden gush of clear fluid from the vagina

Fluid should be tested for:

Nitrazine Paper test – amniotic fluid causes alkaline (>6.5 ph)
reaction to the paper (turns to blue) and urine causes acidic
reaction (remains yellow)

Ferning test – get the sample of fluid then place on the slide
and view it under the microscope

+ferning patterns means –BOW

MANAGEMENT
Strict Bed Rest
Observe, document and report maternal temperature above
38C, fetal tachycardia
Monitor for signs of infections (fever, uterine tenderness)
Avoid sexual intercourse/orgasm
Avoid vaginal exams (risk of infection)
Avoid breast stimulation
Record fetal movements daily and report fewer than 10 in a 12
hour period
Administer broad spectrum ATBC to reduce the risk of infection
e.g. Penicillin/Ampicillin
 PREGNANCY
INDUCED
HYPERTENSION
Pregnancy Induced Hypertension (PIH)
originally called “Toxemia of Pregnancy”

condition in which vasospasm occurs during pregnancy

accompanied by hypertension, proteinuria and edema

Onset: occurs after 20th week of pregnancy and may appear up to

48 hours (2 weeks) postpartum
occurs 5-10% pregnancies
CAUSE
unknown

RISK FACTORS
-related to different associative factors:

Primipara- < 20 years old and > 40 years old

Low socio-economic status (poor nutrition – decrease CHON
intake)
Women who have 5 or more pregnancies
Multiple pregnancies
Hydramnios (pre-exisiting)
Underlying HPN/DM
Poor calcium/Magnesium intake
H-mole
Kidney Effects
Vasospasm in the kidney increases blood flow resistance

leads to increase permeability of the glomerular membranes,

allowing the serum CHONS and globulin to escape in the urine
(proteinuria)

Results in decreased glomerular filtration – lowers urine output

Interstitial Effects
Because of more CHON (carbon, hydrogen, oxygen, and
nitrogen) is lost, the osmotic pressure is decreased and the
excessive fluid shifts/diffuses from vascular spaces to the
interstitial spaces

leads to edema (extreme edema can lead to pulmonary

edema and seizure (Eclampsia) and it increases tubular
reabsorption of Na in kidneys)

Feto-Placental Effects
poor placental perfusion may reduce the fetal nutrient and
oxygen supply
SIGNS AND SYMPTOMS
Triad of Symptoms
Hypertension
Proteinuria
Edema
CLASSIFICATION OF PIH
A. Gestational Hypertension
Transient HPN

develops Increase BP (>140/90) but has no proteinuria and

edema

decrease maternal mortality so no drug therapy is necessary

BP returns to normal by 10th day of postpartum

CLASSIFICATION OF PIH
B. Mild Pre-Eclampsia
1st criteria – Increase BP of >140/90 mmHg taken on 2 occasion at least 6
hours apart

2nd criteria – Systolic BP is > 30 mmHg and Diastolic BP is >15 mm Hg

above baseline BP
Proteinuria
+1 or +2 (represents a loss of 1 g/dl of CHON
Edema (weight gain)

-due to CHON loss, sodium retention and decrease GFR

-begins to accumulate on the upper part of the body (hands/face)
-weight gain of >2 lb/wk in the second semester or > 1 lb/wk in the 3rd
trimester (abnormal)
-Normal Weight Gain; 1st Trimester – 1 lb/month, 2nd/3rd trimester – 4
lbs/mo
NURSING MANAGEMENT
- can be managed at home with frequent follow-ups

1. BED REST (bathroom privileges)

facilitate Na excretion
decreases oxygen demand
position on left lateral position to prevent uterine pressure on the vena cava

2. Assess the BP in sitting/left lateral position, CHON level in the urine

(Urinalysis), changes in Level Of Consciousness (Patient), fetal movements
and FHT

3. Regular diet with NO salt restriction

Na restriction may activate the RAAS (renin-angiotensin-aldosterone
system) which can result in increase BP

4. if symptoms progress to Severe Pre-Eclampsia – REFER immediately to

HOSPITAL.
CLASSIFICATION OF PIH
C. Severe Pre-Eclampsia
Presence of any of the following:

a. increase BP >160/110 mm Hg on at least 2 occasions 6 hours apart at

bed rest (the position in which BP is lowest)

b. marked proteinuria – 3+ or 4+ on a random urine sample (Urinalysis)

c. generalized edema noticeable in woman’s face (facial edema) and

hands (wedding ring can’t be removed), pulmonary edema (dyspnea,
crackles on auscultation), cerebral edema (visual disturbances i.e blurred
vision, headache)

d. urine output – oliguria (less than 500 ml/24 hrs) or 30 ml/hr

NURSING MANAGEMENT
-usually hospitalized until the baby is delivered

1. BED REST (patient must be observe more closely)

2. Provide a quiet and calm environment – any noise can trigger a seizure
activity and leads to eclampsia

3. Administer precautions on the patient’s room:

a. patient’s bed must be near nurse’s station with code cart nearby
b. placed in private room (undisturbed)
c. the room should be darkened (because bright light can trigger seizure)
d. raise padded side rails to prevent falls or injury from seizure activity
NURSING MANAGEMENT
4. frequent maternal assessments every 4 hours (seizure precautions)

a. sudden rise of BP
b. blood studies – CBC, platelet count, liver function (SGOT & SGPT),BUN,
Creatinine, urine CHONS (Urinalysis)
c. urine output – normal 600ml/24hours or 30 ml/hour
d. daily weights – same time each day same clothes
e. impeding seizure signs (aura) such as headache, visual disturbances,
epigastric pain

5. Monitor Fetal Well-being

placed in External fetal Monitors to asses for FHR and fetal movements
Non-Stress test/Biophysical Profile to assess for Utero-placental sufficiency
(Ultrasound/ Leopold's Maneuver)

6. Moderate high protein diet to compensate for CHON lost (proteinuria)

MEDICAL MANAGEMENT
1.Hydralazine (Apresoline) – antihypertensive – to reduce HPN by
peripheral dilatation
side effects – Tachycardia
check for PR and BP before and after administration

2. Magnesium Sulfate (Bedside)

drug of choice to prevent eclampsia

Action:
a. Cathartic – reduces edema by causing fluid shifting from extracellular
spaces into the intestine (removed by bowel elimination)
b. CNS depressant (anti-convulsant) – lessens the possibility of seizure
activity
c. Decrease neuromuscular irritability (muscle relaxant effect)
d. Promotes maternal vasodilatation – promotes better feto-placental
circulation or tissue perfusion
Nursing Responsibilities during
MgSO4 Admininstration
1. Given IV via Piggyback infusing over 15-30 minutes, loading dose 4-
6g/hr and maintenance dose 1-2 g/hr

2. assess RR, urine output, Deep Tendon Reflex (Medical Hammer) and
ankle clonus before after administration

3. Monitor for magnesium sulfate toxicity:

a. depressed respiration of <12Breaths/min

b. decrease urine output of <30 ml/hr
c. decrease DTR
d. decrease LOC

4. Antidote: Calcium Gluconate – a solution of 10 ml of 10% calcium

gluconate solution given for MGSO4 toxicity
CLASSIFICATION OF PIH
D. Eclampsia
-the most severe classification of PIH

when cerebral edema occurs; onset of seizure or coma occurs

maternal mortality rate is high 20% due to hemorrhage (circulatory

collapse or renal failure)
SIGNS AND SYMPTOMS
1. Increase HPN precedes SEIZURE
impending signs of seizure are headache, visual disturbances and
epigastric pain) followed by circulatory hypotension and collapse

Stages:

a. TONIC PHASE – all body contracts, arching of back, arms and legs are stiff
b. CLONIC PHASE - all of the muscle of body will contract and relax
c. POST-ICTAL PHASE – semi-comatose/ patient cannot be arouse except for
painful stimuli

2. May lead to coma.

3. Labor may begin because of premature separation of placenta secondary

to vasospasm which might lead to preterm delivery
NURSING MANAGEMENT
Priority care for the mother with seizure is to:

1. Maintenance of Patent Airway

administer oxygen by face mask
turning the mother to the side to allow the secretions to drain in the
mouth (preventing aspiration)
2. Raised padded side rails
3. Avoid placing a tongue depressor (during the seizure activity) because it
can obstruct the airway
4. Minimize environmental stimuli
5. Administer medications as ordered i.e MgSO4 and diazepam IV
6. Continue to assess FHT and uterine contractions
7. Check for maternal bleeding
8. Mother can deliver via NSVD, CS is very hazardous because hypotension
might result secondary to anesthesia
9. IV therapy as ordered
HELLP SYNDROME
a variation of PIH abbreviated as Hemolysis, Elevated liver enzymes and
low platelet count

occurs in 4-12% of patients with PIH

a life threatening complication of PIH (because maternal mortality is high

at 24% and infant mortality is 25%)

CAUSE
unknown

ASSOCIATED RISK FACTORS

Primipara/Multipara mothers
SIGNS AND SYMPTOMS
nausea
epigastric pain
generalized body malaise
right upper quadrant tenderness

LABORATORY DATA
hemolytic RBC
thrombocytopenia (low platelet count of below 100,000/m3)
elevated liver enzyme (because of hemorrhage and necrosis of liver)
serum ALT (Alanine Aminotransferase), and ALT (Aspartate
aminotransferase)
MEDICAL MANAGEMENT
1. Blood transfusion of fresh frozen plasma or platelets

2. Infant is delivered ASAP via NSD or CS (lab. Results will return to normal
after delivery

3. Monitor for bleeding

 MULTIPLE
PREGNANCIES
MUTIPLE PREGNANCIES
a pregnancy in which there is more than one fetus in the uterus at the
same time

Incidence rate is 2% of pregnancies

TYPES
A. Monozygotic Twins

B. Dizygotic Twins
MONOZYGOTIC
Identical twins

begins with single ovum and spermatozoa, during the process of

fusion, the zygote divides into two identical individuals

have 1 placenta, 1 chorion, 2 amnion, 2 umbilical cords

always of the same sex

DIZYGOTIC
Non-identical/fraternal twins

result from the fertilization of two separate eggs with two different
sperm during the same pregnancy

have 2 placenta, 2 chorions, 2 amnions, 2 umbilical cords

twins may be of the same or different sex

2/3 of twins are dizygotic

ASSOCIATIVE FACTORS
more frequent in non-whites than in
whites

increase in parity

advance maternal age

familial inheritance
DIAGNOSTIC PROCEDURE
Sonogram/Ultrasound

SIGNS AND SYMPTOMS

Increase uterine size faster than usual

quickening at the different portion of the abdomen

more than expected fetal activity

multiple sets of FHT

extreme fatigue and backache

MANAGEMENT
mother is more susceptible to complications of pregnancy i.e. PIH,
hydramnios, placenta previa, pre-term labor, anemia compared to a
women carrying only one fetus

1. BED REST (during the 2 or 3 months of pregnancy to decrease risk of

preterm labor

2. Closer prenatal supervision

HYDRAMNIOS
HYDRAMNIOS (Polyhydramnios)
Excessive fluid formation of >2000ml or an amniotic fluid index of
above 24 cm (normal 500-1000ml)

COMPLICATIONS
1. Fetal Malpresentation (because of extra-uterine space)

2. Premature rupture of membranes – that leads to infection and

prolapsed cord

3. Preterm labor (because of increasing pressure, prostaglandin release)

RISK FACTORS
1. Maternal diabetes – hyperglycemia in the fetus causes
increase urine production leading to increase urine output

2. Anencephaly - birth defect in which a baby is born without

parts of the brain and skull

3. Esophageal atresia – fetus becomes unable to swallow the

amniotic fluid because of intestinal anomalies or obstruction
ESOPHAGEAL ATRESIA
ANENCEPHALY
MANAGEMENT
maintain bed rest to reduce pressure on cervix and to
prevent premature labor

monitor for rupture or uterine contraction

avoid constipation (it will increase uterine pressure and

rupture of membranes)

amniocentesis (slow and controlled release of fluid to

prevent premature separation of the placenta) guided by
ultrasound
POST TERM
PREGNANCY
POST TERM PREGNANCY
a pregnancy that exceeds 42 weeks of gestation (term pregnancy –
37-42 weeks)

Incidence rate – 3-12% of all pregnancies

RISK FACTORS
Women who have long menstrual cycles (40-45 days)

Women receiving high dose of Salicylates (interferes with synthesis of

prostaglandins that initiates labor)

associates with myometrial quiescence (uterus that do not respond to

normal labor)
COMPLICATION
meconium aspiration

macrosomia – fetus continues to grow

fetal distress – due to placental aging it causes decreased blood

prefusion and inadequate supply of oxygenated blood and nutrients to
fetus

MANAGEMENT
Induction of labor – prostaglandins or misoprostol (cytotec) applied to
cervix to stimulate ripening or stripping of membranes. Followed by
oxytocin infusion to stimulate contraction

CS delivery
GESTATIONAL
DIABETES
MELLITUS
GESTATIONAL DIABETES MELLITUS
a condition in which women exhibit high glucose levels
during pregnancy

an abnormal CHO, fat and CHON metabolism that is first

diagnosed during pregnancy (at the midpoint of pregnancy
when insulin resistance becomes noticeable)

but the symptoms fade again at the completion of

pregnancy (resolves in delivery)

risk of developing type 2 diabetes is high as 56-60% later in

life
CAUSE
unknown

RISK FACTORS
obesity

age over 25 years old (about 50% of the these women

develop diabetes within 22-28 years old)

history of large babies/macrosomia (16 lbs or more)

family history of DM/GDM

DIAGNOSIS
women who are high risk for DM should be screened at first prenatal
visit and again at 24-28 weeks.

A. Glucose Challenge Test

done at first prenatal visit and again at 24-28 weeks

usually consists of 8 hour fasting for FBS

mother is given 50g of glucose load and a blood sample is taken for
serum glucose 1 hour after

diabetic if FBS is more than 95mg/dl or after 1 hour the serum glucose
is >140mg
B. Oral Glucose Tolerance Test
- the gold standard for diagnosing diabetes
- mother is given 100g of CHO/glucose then 3 hours fasting

Test type Pregnancies glucose level (mg/dl)

Fasting 95
1 hour 180
2 hours 155
3 hours 140

rate is abnormal if 2 of the 4 blood samples collected are

abnormal
<70 hypoglycemia, >130 hyperglycemia (normal – 80-
120mg/dl)
MATERNAL EFFECTS OF DM
1. Hypoglycemia during the first trimester – glucose is being
utilized by the fetus for the development of the brain

2. Hyperglycemia during the 2nd /3rd trimester at 6 months –

due to HPL effects (causes insulin resistance)

3. Prone to frequent infections e.g. Moniliasis/Candidiasis

4. Polyhydramnios

5. Dystocia – due to abnormality in fetus/mother

INSULIN REQUIREMENTS
1st trimester – decrease in insulin by 33%

2nd/3rd trimester – increase insulin by 50%

Postpartum – drops suddenly to 25%due to delivery of

placenta
FETAL EFFECTS OF DM
1. Hypoglycemia during the 1st trimester

2. Hyperglycemia during the 2nd/3rd trimester

3. Macrosomia – abnormally large for gestational age(baby is

delivered >4000 g or 4kg)
MACROSOMIA
MACROSOMIA
-refers to growth beyond a specific threshold, regardless of
gestational age
NEWBORN EFFECTS
Hyperinsulinism – because insulin from the mother does not cross the
placenta which lead to increase insulin production from the baby

Hypoglycemia – when the umbilical cord is cut – the supply of glucose

from the mother also stops which results in very hypoglycemia
newborn (normal glucose in NB 45-55mg/dl)

SIGNS AND SYMPTOMS

High pitched shrill cry
tremors
jitteriness

Diagnosis: Heel Stick Test to check glucose level

MANAGEMENT
1. Frequent prenatal visits for close monitoring

2. Insulin (regular/Intermediate acting insulin) – given subcutaneously

(slow absorption)
do not massage the site of injection
rotate the site of injection (to prevent lipodystrohy- inhibits insulin
absorption)
gently roll vial in between the palms (do not shake)

3. Monitor blood glucose – assess once a week

using finger stick technique, using on fingertips as the site of lancet
puncture, the strip is then inserted into a glucose meter to determine
glucose level (normal <95mg/dl – FBS, <120mg/dl 2 hours post
prandial (after very meal) level
MANAGEMENT
4. Monitor fetal well being
Ultrasound/Sonogram – to determine fetal growth, amniotic fluid
volume, placental location and b-parietal diameter
daily fetal movement count (DFMC) – monitoring for movements of
fetus for 1 hour (normal 10 movement/hour)
amniocentesis – to determine LS ratio by 36 weeks of pregnancy and to
assess fetal lung maturity

5. CS delivery
cervix is not yet ripe or not yet responsive to contractions
babies of diabetic mother are abnormally large making vaginal delivery
difficult

6. Woman with gestational diabetes usually demonstrates normal glucose

levels by 24 hours after birth (and needs no further insulin therapy)
 HEART
DISEASE IN
PREGNANCY
HEART DISEASE
Origin: 90% Rheumatic (incidence expected to decrease as
incidence of rheumatic fever decreases), 10% congenital lesions
or syphilis

Normal hemodynamics of pregnancy that adversely affect the

client with heart disease:
oxygen consumption increased 10% to 20%; related to the
needs of the growing fetus
plasma level and blood volume increase; RBC’s remain the
same (physiologic anemia)
Functional or Therapeutic Classification of Heart Disease
During Pregnancy
CLASS I – no limitation of physical activity; no symptoms of cardiac
insufficiency or angina

CLASS II – slight limitation of physical activity; may experience excessive

fatigue, palpitation, angina or dyspnea

CLASS III – moderate to marked limitation of physical activity; dyspnea,

angina and fatigue occur with slight activity and bed rest is indicated
during most of pregnancy

CLASS IV – marked limitation of physical activity; angina, dyspnea and

discomfort occur at rest; pregnancy should be avoided; indication for
termination of pregnancy
Nursing Care of Pregnant Clients with
Heart Disease
A. Assessment

a. Prenatal period
- vital signs; weight gain; dietary patterns, knowledge about self care;
signs of heart failure, stress factors such as work, household duties

b. Intrapartal period
- vital signs (heart rate will increase); respiratory changes (dyspnea,
coughing, crackles); FHR patterns

c. Postpartal period
- signs of heart failure or hemorrhage related to fluid shifts, intake and
output
Nursing Care of Pregnant Clients with
Heart Disease
B. Analysis and Nursing Diagnosis

activity intolerance related to increased cardiac workload

anxiety related to unknown course of pregnancy, possible loss of fetus and

inability to perform role responsibilities

decreased cardiac output related to stress of pregnancy and pathology

associated with heart disease

fear related to possible death

excess fluid volume related to fluid shifts resulting from a decrease in intra-
abdominal pressure following birth

risk for impaired parenting related to increased responsibility of caring for a

neonate
Nursing Care of Pregnant Clients with
Heart Disease
C. Nursing Interventions

PRENATAL PERIOD

1. teach importance of rest and avoidance of stress

2. instruct regarding use of elastic stockings and periodic evaluation of legs

3. teach appropriate (dietary intake; adequate calories to ensure appropriate,

but not excessive, weight gain; limited, not restricted salt intake

4. administer medications as ordered; heparin, furosemide (lasix), digitalis, beta

blockers (inderal)

5. monitor for signs of heart failure such as respiratory distress and tachycardia;
may be precipitated by severe anemia of pregnancy
Nursing Care of Pregnant Clients with
Heart Disease
C. Nursing Interventions

INTRAPARTAL PERIOD

1. encourage mother to remain in semi Fowler’s position or left lateral position

2. provide continuous cardiac monitoring

3. provide electronic fetal monitoring

4. assist mother to cope with discomfort; minimal analgesia and anesthesia are
used

5. assist with forceps delivery in second stage of labor to avoid work of pushing

6. monitor for signs of heart failure, such as respiratory distress and tachycardia
Nursing Care of Pregnant Clients with
Heart Disease
C. Nursing Interventions

POSTPARTAL PERIOD - most critical time because of increased circulating blood

volume after birth of placenta

1. institute early ambulation schedule; apply elastic stockings

2. monitor for signs of heart failure, such as respiratory distress and tachycardia

3. monitor heart rate; accelerated heart rate of mother in latter half of

pregnancy puts extra workload on her heart

4. provide for adequate rest; the increase in oxygen consumption with

contractions during labor makes length of labor a significant factor
Nursing Care of Pregnant Clients with
Heart Disease
C. Nursing Interventions

5. provide close supervision; sudden tachycardia during birth or sudden

bradycardia and normal increase in cardiac output following birth may cause
cardiac arrest

6. administer prescribed prophylactic antibiotics to mother with history of

rheumatic fever

7. refer to various agencies for family support, if necessary upon discharge

8. newborn risks include intrauterine growth retardation, prematurity and

hypoxia fetal demise may occur
END OF LESSON 3

THANK YOU!