SECOND TRIMESTER BLEEDING

GESTATIONAL TROPHOBLASTIC
DISEASE (HYDATIDIFORM MOLE OR
H MOLE)

• Refers to a rare condition in which the

chorionic tissue increases abnormally
and forms sacs vesicles
• A vascular vesicle hangs in a grapelike
clusters that produce large amounts of
HCG- associated wit Choriocarcinoma
(Pilitteri, 2018)
PREDISPOSING FACTORS
• Cause is unknown
• 17 years old below and 35 years above
• Low socioeconomic status
• Low protein intake
• Previous mole
• Higher incidence in Asian women
 SIGNS AND SYMPTOMS
• Rapid increase in uterine size greater than gestational age of the
fetus
• Marked increase HCG
• Excessive nausea and vomiting
• Brownish vaginal discharge around 4th month containing grapelike
vesicles
• No FHT is detected after 10-12 weeks, no fetal movement after 18-20
weeks
• No fetal parts
• Bleeding may vary from spotting to profuse hemorrhage and
is usually brownish but may be bright red
• Hypertension and other symptoms of pre-eclampsia
• Symptoms of PIH before 24th week gestation
• Ultrasound reveal a snowflake pattern dense growth of grape-
like vesicles
TREATMENT AND MANAGEMENT
• 1. Dilatation and curettage to remove the mole
• 2. If the woman is more than 40 years old, a hysterectomy is done
since she has higher chance of developing Choriocarcinoma
• 3. Monitor HCG for one year (HCG should be negative two to six
after removing H mole)
• 4. Chest Xray every 3 mos. for six mos.- the lungs are the most
common site of metastasis of Choriocarcinoma
5. Chemotherapy (methotrexate) if;
• HCG tare increased for three consecutive weeks or double at
anytime
• HCG remain elevated three to four months after delivery
6. The woman is advised not to get pregnant for one year
7. The contraceptive method should not be the pills.
Pills contain estrogen, which promotes regrowth of the
chorionic villi
8. Hysterectomy is the treatment method for women above 40
years old because of the higher incidence of malignancies and
clients who have completed childbearing and require
sterilization.
COMPLICATIONS OF H MOLE
• 1. Gestational Trophoblastic Tumors
• Persistent trophoblastic proliferation after H mole
• 2. Choriocarcinoma
• The most severe malignant complication involves
transforming chorion into cancer cells that invade and erode
blood vessels and uterine muscles
Nursing Management:
• 1. Maintain fluid and electrolyte balance
• 2. Emphasize that pregnancy should be avoided for one year
( greater chance of it to recure and may even lead to
Choriocarcinoma)
• 3. Administer blood replacement as ordered.
• 4. Provide emotional support.
 INCOMPETENT CERVIX OR PREMATURE
CERVICAL DILATATION
• refers to a cervix that dilates prematurely and
cannot hold a fetus until term (Kogan,
BenShushan, & Pernoll, 2007). It occurs in
about 1% of women.
• The dilatation is usually painless.
• Often the first symptom is a show (a pink-
stained vaginal discharge) or increased pelvic
pressure, followed by rupture of the
membranes and discharge of the amniotic
fluid.
•.
• It is associated with increased maternal age, congenital
structural defects, and trauma to the cervix, such as might have
occurred with biopsy or repeated D&Cs.
• Although an early ultrasound may diagnose it before symptoms
occur, it is usually diagnosed only after the pregnancy is lost.
• After the loss of one child because of premature cervical dilatation, a
surgical operation termed cervical cerclage can be performed to
prevent this from happening in a second pregnancy (Fox&
Chervenak, 2008). Painless cervical effacement and dilatation in
early mid-trimester resulting in the expulsion of products of
conception.
• ●Most common cause of habitual abortion
Causes
• 1. Increased maternal age
• 2. Congenital mal-development of the cervix – short
cervix
• 3. Trauma to the cervix
• 4. History of repeated Dilatation and Curettage;
cervical lacerations with previous pregnancies
SIGNS AND SYMPTOMS
• ●Slight vaginal bleeding
• ●Presence of uterine contractions in mid-trimester
• ●Rupture of the bag of water
• ●Expulsion of the conceptus
• ●Presence of painless cervical dilatation
• ●Relaxed cervical os on pelvic examination
 MANAGEMENT
1. Cervical Cerclage
●Medical management wherein the physician sutures
a certain part of the cervix between 14- and 16-weeks’
gestation to prevent cervical dilatation.
.
a. MCDONALD’S – (temporary) nylon sutures are placed
horizontally & vertically across the cervix and pulled
tight to reduce the cervical canal to a millimeter in
diameter.
b. SHIRODKAR – (permanent) sterile tape is threaded in
a purse-string manner under the cervix's submucous
layer and sutured in place to achieve a closed cervix
After suturing the cervix:
• 1. Place woman on bed rest for 24 hours
• 2. Observe for bleeding, uterine contractions, and rupture of
BOW
• 3. If BOW ruptures – the sutures are removed
• 4. If uterine contractions occur, the woman is given ritodrine
to stop the contractions
Post-operative care
• :●Restrict activities for the next two weeks, including
coitus.
Pre-requisites of Cervical Cerclage
• ●Cervix not dilated
• ●Intact membranes
• ●No vaginal bleeding & uterine cramping
THIRD TRIMESTER BLEEDING
 PLACENTA PREVIA
• This is a condition of
pregnancy in which the
placenta is implanted
abnormally in the uterus.
• It is the most common cause
of painless bleeding in the third
trimester of pregnancy
(Scearce & Uzelac, 2007).
• TYPES:
• 1.Low lying
• ●Implantation of the placenta in the lower
rather than in the upper portion of the uterus.
• 2. Marginal
• ●Placental edge approaches that of the
cervical os.
• 3. Partial
• ●Implantation that occludes a portion of the
cervical os.
• 4. Complete (total)
• ●Placenta that obstructs the cervical os
 • 5. Cigarette smoking
•Predisposing
• 6. Scarring from previous
factors: cesarean section
• 1. Multiparity • 7. Decreased vascularity
• 2. Advanced maternal of the upper uterine
age – over 35 years old segment
• 3. Multiple pregnancies • 8. Past uterine dilatation
• 4. Uterine tumor and curettage
Signs and Symptoms
• 1. Painless, bright red vaginal bleeding results from the
placenta's inability to stretch to accommodate the lower
uterine segment's different shape or the cervix.
• 2. Abdomen soft, non-tender
• 3. Ultrasound reveals placenta previa
Nursing Management:
• 1. Monitor vital signs & bleeding to determine whether
symptoms of shock are present. ●Weigh unused perineal
pad, then weigh perineal pad-soaked w/ blood, then subtract.
The difference is the weight of the blood loss
• .2. Provide strict bed rest to minimize the risk to the fetus.
(CBR without BRP's) Preferably in a side-lying position to
ensure adequate blood supply both to the mother and the
fetus.
• 3. Observe for further bleeding episodes. Begin IV
Fluid therapy using a large gauge
catheter(prepare for blood transfusion)
• 4. Assess hemoglobin and hematocrit, Prothrombin time,
fibrinogen, and platelet count, type, and cross-matching
• 5. Avoid rectal or vaginal examinations (no internal
examination) because it will agitate the cervix and
initiate massive hemorrhage
• .6. IF IE is indicated, it should be done in a double set-up
environment. The delivery room is prepared for the vaginal
exam and cesarean birth in case the examination precipitates
profuse bleeding) wherein the patient has already:●signed a
consent form. ●Pre-operative medications have been given,
●Abdominal preparation has been done so that if the
placenta is accidentally detached because of manipulations,
a cesarean section can be done immediately
• 7. monitor uterine contractions to establish the progress of
labor
Complications of Placenta Previa:
• 1. Hemorrhage
• 2. Infection (prone to endometritis because it is in the
lower segment of the cervix as the portal of entry)
• 3. Prematurity
ABRUPTIO PLACENTA
• the premature separation of the
placenta
• Premature separation of the
placenta occurs in about 10% of
pregnancies and is the most
frequent cause of perinatal death
(Arquette & Holcroft, 2007). The
separation generally occurs late in
pregnancy; it may occur as late as
during the first or second stage of
labor.
 TYPES
1. Marginal (OVERT)●Separation begins at
the edges of the placenta, allowing
blood to escape from the uterus.
●Bleeding is external.
2. Central (COVERT)●The placenta
separates at the center resulting in
blood being trapped behind the
placenta.●bleeding then is internal and
not obvious.
CAUSES
• 1. Maternal hypertension (chronic or pregnancy-induced)
• 2. Advanced maternal age
• 3. Grand multiparity is more than five pregnancies.
• 4. Trauma to the uterus
• 5. A sudden release of amniotic fluid causes sudden
decompression of the uterus.
• 6. Short umbilical cord
• 7. Cigarette smoking and cocaine abuse (vasoconstriction)
• 8. PROM (premature rupture of membranes
SIGNS AND SYMPTOMS
• 1. Sharp stabbing pain in the fundal area as the placenta separates.
• 2. Painful dark red vaginal bleeding in covert type.
• 3. Painful bright red vaginal bleeding in overt type.
• 4. Hard, rigid, firm, board-like abdomen caused by an
accumulation of blood behind the placenta(Couvelaire uterus
or uteroplacental apoplexy) with fetal parts hard to palpate.
• 5. Abnormal tenderness due to distention of the uterus with blood.
• 6. Signs of shock and fetal distress as the placenta separates.
CLASSIFICATION ACCORDING TO
PLACENTAL SEPARATION:
• Grade 0. No placental separation symptoms are diagnosed
after delivery when the placenta is examined and found to
have a dark, adherent clot on the surface.
• Grade 1. Some external bleeding, no fetal distress, no shock,
slight placental separation.
• Grade 2. External bleeding, moderate placental separation,
uterine tenderness, fetal distress.
• Grade 3. Internal and external bleeding, maternal shock, fetal
death,
Management:
• 1. When placenta abruptio is suspected or diagnosed, hospitalization is a
must.
• 2. Bed rest or side-lying position for optimum placental perfusion.
• 3. Monitor vital signs, fetal heart tone, blood loss, and mask oxygen if
fetal distress is present. Delivery
• •Vaginal delivery if there are no signs of fetal distress, bleeding is minimal
and vital signs arrestable.
• •Cesarean delivery if bleeding is severe, fetal distress is present, and
fetus cannot be delivered immediately with a vaginal method.
HYDRAMNIOS /
POLYHYDRAMNIOS

• is characterized by an
excessive amount of amniotic
fluid, more than 2000 mL. The
normal amount of amniotic
fluid at term is 500 to 1000mL
Causes:
• 1. Multiple Pregnancy is the carrying of more than one fetus
at a time.
• a. Twins, the most common naturally occurring multifetal
pregnancy, occur in approximately one of 20 births
• .b. Triplets occur in about one of 600 pregnancies.
Naturally occurring quadruplets, quintuplets, and
sextuplets are extremely rare. it occurs most commonly from
the use of fertility drugs or in vitro fertilization
• c. It causes hydramnios because one fetus absorbs
the greater part of the circulation, resulting in cardiomegaly,
resulting in increased urine output.
• 2. Fetal Abnormalities:
• a. Esophageal Atresia
• ●Fetal swallowing of amniotic fluid is one of the mechanisms that
regulate the amount of amniotic fluid. In atresia, the fetus cannot
swallow.
• ●Excessive uterine size
• ●Out of proportion to AOG
• ●With difficulty palpating fetal parts and finding fetal heart tone
is primary clinical findings. Shortness of breath is caused by the
pressure of the overly distended uterus against the
diaphragm.
• ●Back pain, varicosities, constipation, frequency of urination,
and hemorrhoids
DIAGNOSTICS:
• ●Ultrasound
• ●Radiography

Complications
• 1. Premature labor and delivery
• 2. Abruptio placenta
• 3. Post-partum hemorrhage due to overdistention
• 4. Cord prolapsed
Management
• 1. Mild to moderate degrees usually do not require treatment.
• 2. Hospitalization if symptoms include dyspnea, abdominal
pain, difficult ambulation.
• 3. Amniocentesis ●removal of amniotic fluid to relieve
maternal distress.
• 4. Indomethacin Therapy
• ●A drug that decreases fetal urine formation.
• ●SE: Potential premature closure of the ductus arteriosus.
5. Health instructions for relief of symptoms.
● Place in semi-fowlers position to assist in breathing.
●Empty bladder frequently.
●Increase fluid intake and a high fiber diet to prevent
constipation.
●Rest frequently in the left lateral position to prevent fatigue
and back pain.
●Watch closely for hemorrhage after delivery