BLEEDING IN

PREGNANCY
RACHEL P. FUENTES, RN
Ateneo de Davao University
 FIRST TRIMESTER
1. ABORTION – any interruption in
pregnancy before the age of viability
a. Spontaneous
 Occurs from natural causes

 Blighted ovum

 Trauma

 Infection

 Hormonal
a.1. Threatened
 s/s: bright red vaginal bleeding, mod amt
 Mgt:
1. CBR for 24-48°

2. Coitus is restricted for 2 wks

3. Endocrine/hormonal therapy

4. Advise pt to save all pads, clots &

expelled tissues
a.2. Imminent/ Inevitable
 s/s:

 bright red vaginal bleeding, mod amt

 Uterine contractions & cervical dilatation

 Loss of products of conception

Types:
 Complete

 Incomplete – D&C
a.3. Missed
 Fetus dies in utero but is not
expelled
 Has to be expelled w/in 2wks after
dx

b. Induced
b.1. therapeutic
b.2. illegal
At 8 weeks
At 9 weeks
At 10 weeks
At 11 weeks
At 22 weeks
At 22 weeks
At 24 weeks
2. Ectopic Pregnancy – gestation
outside the uterus
Types:
a. Cervical – due to too slow movt of
sperm or too fast movt of ova
b. Abdominal – outside the female
reproductive organs
c. Ovarian
d. Tubal – most common; usually due to
adhesions or scarring from PID
 Tubal
 Ampullar -
 s/s:
 Spotting
 Stabbing excruciating pain in
lower quadrant
 Rigid abdomen
 Cullen’s sign
 Signs of shock
 fever
  Interstitial

 Interstitial portion – has large bld

vessels
 Pregnancy do not progress beyond
12th week causing the tube to
rupture

 Surgical mgt
 Salphingectomy w/ BT for ruptured

 Salphingotomy if not ruptured

 SECOND TRIMESTER
1. Hydatidiform Mole (H-Mole) or Gestational
Trophoblastic Dse
 a dev’tal anomally of placenta resulting
to degeneration & proliferation of
chorionic villi
 Precursor to choriocarsinoma
 S/S:
 Uterine expansion faster than the
normal
 Nausea & vomiting

 No FHT

 (+) pregnancy test

 Signs of toxemia

 Vaginal bleeding
 Mgt:
 Suction curretage

 Actinomycin D or Methotrexate

 Post-evacuation monitoring of HCG

 TAHBSO
2. INCOMPETENT CERVICAL OS
- immature dilation of cervical os due to its inability to
hold the increasing wt of the fetus
Causes: habitual abortion
trauma
hormonal factors
S/S: show
painless uterine contractions
cervical dilatation
PROM
Management
1. CBR until EDC
2. Shirodkar Barter Cerclage – permanent
purse string is placed around the
cervix to prevent from further
dilatation & hold the baby inside the
womb until the time of birth.
- CS is performed near term
3. McDonald’s Cerclage – temporary
method of surgically placing purse
string around the os w/c is removed
2 wks before EDC to facilitate birth.
3RD TRIMESTER
1. PLACENTA PREVIA – wrong implantation of the
placenta
types:
a. Complete placenta previa occurs when the placenta is
implanted in the lower portion covering the whole opening of
the cervix; fetus is delivered via CS
b. Incomplete placenta previa occurs when half of the cervical
opening is covered by the placenta w/ half of the placenta
directed towards the lower segment of the cervix; CS delivery
c. low implantation placenta previa occurs when the placenta
is implanted on the lower portion of the uterus where less
blood vessels are present causing placental insufficiency to
the fetus; may be delivered normally w/ double set up
Predisposing factors
1. Rapid succession of pregnancy
2. Advanced maternal age
3. Increased parity
4. Big tumors in the uterus
1st most constant symptom:
painless bright red vaginal bleeding
Diagnostic evaluation:
1. Ultrasonography
2. Placental scan
Nursing care management
1. CBR w/o BRP
2. Encourage to assume side lying position
R : to avoid compression of the aorta by the growing size
of the fetus
3. Monitor maternal VS &FHT
R: deviations may indicate inadequacy of placenta
perfusion
4. Provide adequate oxygenation
5. Do not attempt to perform IE or rectal exam
R: may dislodge the placenta causing early separation,
exposing large sinuses
Complications
1. Hemorrhage
2. Infection
3. Prematurity
4. FDIU
2. ABRUPTIO PLACENTA – early separation of the
placenta
Predisposing factors
1. Maternal hypertension
2. Trauma
3. Sudden release of the amniotic fluid
4. Short umbilical cord
5. Multiple pregnancy, polyhydramnios
S/S a. severe, sharp, knife-like stabbing pain high in the
fundus
b. hard, board-like uterus, rigid abdomen
c. signs of shock
 d. Couvelaire uterus – ecchymotic & copper-colored;
concealed bleeding, if extensive can cause uterus to lose
its ability to contract
Nursing management
1. CBR w/o BRP
2. Monitor VS and FHT
3. Provide adequate nutrition
4. Administer BT as ordered to replace blood loss
5. Administer analgesics as ordered to relieve pain
Management
hysterectomy
HYPERTENSIVE STATES IN PREGNANCY
PREGNANCY INDUCED HYPERTENSION (PIH)
- group of disorders characterized by presence of
hypertension; onset early in pregnancy, symptoms
during the last trimester.
- originally called Toxemia
Predisposing factors
1. Primiparas
2. Age: <20 yo, >40 yo
3. Low socioeconomic status
4. Women who have 5 or more pregnancies
5. Non-whites
6. Multiple pregnancy
7. Hydramnios
8. W/ underlying dse such as diabetes w/ renal
involvement, ♥ dse, essential hpn
Hallmark
1. Hypertension
2. Proteinuria
3. Edema
Other clinical manifestations
1. ↓ urine output 4. Blurring of vision
2. Convulsion or seizure 5. Fetal distress
3. Epigastric pain 6. Thrombocytopenia
Diagnostic criteria
1. Systolic pressure of 140 mmHg or an ↑ of 30mmHg from
baseline
2. Diastolic pressure of 90 mmHg or an ↑ of 15mmHg from
baseline
3. Abnormal BP taking in 6° apart
Types
HPN types Symptoms

Gestational HPN BP 140/90mmHg or

Systolic pressure ↑ by
30mmHg
Diastolic pressure ↑ by
15mmHg
No proteinuria
Mild Preeclampsia BP 140/90mmHg or
Diastolic pressure ↑ by 30mmHg
Systolic pressure ↑ by 15mmHg
Proteinuria 1-2 + on random sample
Wt gain over 2lbs/wk in 2nd tri
Mild edema in upper extremities or
face
Severe BP 160/110mmHg
Preeclampsia
Proteinuria 3-4 + on a random
sample. 5g on 24° sample
Oliguria (500ml or less in 24°
Cerebral or visual disturbances
Extensive peripheral edema,
puffiness of the face and hands
Thrombocytpenia
Epigastric pain

Eclampsia Convulsion occur

Nursing care management
1. Promote bed rest
2. Promote good nutrition
3. Provide additional support
4. Provide the appropriate environment
5. Measure I&O by inserting indwelling catheter
6. Administer LR IV sol’n w/ MgSO4
7. Weigh daily
8. Prepare @ bedside the ff:
a. Ca gluconate c. O2
b. Padded tongue depressor
Medical management
Drug Indication Nsg responsibilities
Magnesium Anticonvulsant Requisites:
Sulfate
Muscle urine output should not
(MgSO4) be less than 30cc/hr
relaxant
RR >12 b/m
Presence of deep tendon
reflex
Assess the urine output,
deep tendon reflex & RR
q°
Observe for Mg toxicity
Observe for fetal hypotonia
Hydralazine antihypertensive
(Apresoline) peripheral
vasodilator
Administer slowly to avoid
hypotension
Maintain diastolic pressure
of 90mmHg to ensure
placental filling

Diazoxide peripheral Monitor BP 1-2 mins until

(Hyperstat) vasodilator stable, the q 15min as
precipitous drop may
(severe type) occur
Maintain diastolic pressure
of 90mmHg
Diazepam Halt seizure Observe for hypotension in
mother; depression &
(Valium)
hypotonia in infant @ birth

Calcium Antidote for Have it prepared @

gluconate MgSO4 bedside in case of
Mg toxicity

TX delivery
if more than 24 wks AOG, delivery decision will be
made as soon as the woman’s condition stabilizes
(12-24° p convulsion)