bleeding

• High-Risk Pregnancy


  Pregnancy associated with any other condition, either medical or obstetrical that has an adverse effect on the mother and/or the fetus
• A pregnancy risk grading is necessary to ensure safety of the mother and the fetus. Any identified risk is promptly addressed and treated to avoid further complications.
• Hemorrhage is the first of ten leading causes of maternal mortality in Egypt.
• Bleeding in pregnancy is never normal, it should always be investigated.
• Many women do not understand that bleeding in pregnancy is abnormal.
• Classification of the risks

  • Low Risk
  • Intermediate Risk
  • High Risk
• Low Risk


  • Parity 1-3
  • Primigravida
  • Parity 4 and more
• Intermediate Risk


  • Normal weight and height (> 152 cm. 40-80 kg)
  • Height less than 152 cm
  • Obesity, weight 80 kg. and more
  • Low body weight, less than 40 kg
• High Risk


  • Fundal height measurements correct for dates
  • Previous abortion in 50% or more of previous pregnancies
  • History of primary or secondary infertility for 3 years
  • No previous low-birth-weight infant (< 2.5 kg)
  • Previous stillbirth or neonatal death
  • No previous still birth or neonatal death
  • Previous difficult delivery or prolonged labor
  • Uterine anomaly or fibroids
  • No previous high birth weight infant (>4.0 kg)
  • Previous uterine surgery including cesarean section
  • Abnormal hemoglobin (sickling etc)
  • Essential hypertension: 140/90 or greater
  • Renal disease with or without hypertension
  • Sexually transmitted diseases
  • Diabetes mellitus
  • Heart disease unless mild and well tolerated
  • Renal disease with hypertension or impaired renal function
  • Antepartum hemorrhage
  • Hydramnios
  • Pre-eclamptic toxemia
  • Moderate intrauterine growth retardation
  • Premature labor or rupture of membranes at 34-37 weeks
  • Multiple pregnancy
  • Breech after 36 weeks
  • Other malpresentation after 36 weeks
  • Anemia (less than 10 g/dl) not responding to treatment, 32 weeks upward
  • Post-maturity (42 weeks and more)
  • Rhesus antibodies
  • Cervical incompetence
  • Premature rupture of membranes between 28-33 weeks
  • Oligohydramnios
  • Fetal abnormality-incompatible with life
  • Severe intrauterine growth retardation
  • Uncontrolled premature labor before 34 weeks
• Causes of bleeding in early pregnancy (before 20 weeks gestation)


  • Abortion
  • Ectopic pregnancy
  • Hydatidifrom mole or vesicular mole
  • Local lesion, cervical polyps, cervical cancer
• Abortion


  Termination of pregnancy before 28th week of pregnancy or products of conception weighing below 500 grams
• Causes of abortion


  • Fetal (genetic diseases, congenital anomalies, malformation of trophoblast, chromosomal anomalies, hypoxia)
  • Paternal (weak sperm, diseases like DM, TB, anemia)
  • Maternal (fever, chronic diseases, hormonal insufficiency, Rh incompatibility, cervical incompetence, uterine malformation, trauma)

  
• Clinical types of abortion

  • Spontaneous abortion
  • Threatened abortion
  • Inevitable abortion
  • Incomplete abortion
  • Complete abortion
  • Missed abortion
  • Septic abortion
  • Therapeutic abortion
  • Criminal for no medical cause

  
• Threatened abortion


  Slight bleeding, no marked pain, breasts may be active, no pelvic tenderness, uterus enlarged, cervix closed, fetus viable
• Inevitable abortion


  Persistent bleeding and cramps with dilatation of the cervix, severe bleeding, severe pain, cervix opened, no viable fetus

  
• Complete abortion


  All products of conception expelled, uterine contents expelled, no retained parts, minimal bleeding and pain
• Incomplete abortion


  Some parts of the products of conception expelled, others remain, severe bleeding continues, pain persists and worsens

  
• Habitual abortion


  Three or more successive spontaneous abortions, may be primary (no viable child) or secondary, associated with maternal conditions like antiphospholipid syndrome, polycystic ovaries, cervical incompetence, uterine malformation

  
• Incomplete Abortion


  Abortion complicated by infection of the uterine cavity
• Septic Abortion


  Infected abortion with dissemination of bacteria via the maternal circulation
• Therapeutic Abortion


  Artificial legal termination of pregnancy by a physician due to medical indication
• Criminal Abortion


  Illegal termination of pregnancy without medical or obstetrical indications
• The retention of a dead embryo (or a dead fetus following intrauterine death) for more than 4 weeks can lead to defibrination and coagulation failure
• Management of Missed Abortion

  1. Check plasma fibrinogen level

  2. Cross matching of blood if prescribed

  3. Assist in medical and surgical induction e.g. prostaglandin, oxytocin, D&C

  4. Give post-abortal and health education
• Role of the nurse in Septic Abortion

  • Assist in laboratory investigation
  • Assist in patient's hospitalization, isolation, administration of medication, fluid and electrolyte support and careful monitoring
  • Assist in surgical induction (D&C)
  • Accurate observation of renal functions
• Nursing Care for Abortion

  • Monitor amount of bleeding
  • Assess vital signs
  • Observe for signs of shock
  • Auscultate for fetal heart tones (FHTs)
  • Collect passed tissue/clots
  • Monitor patient comfort
  • Check blood type and Rh factor
  • Administer Rh(D) immunoglobulin if indicated
  • Initiate IV fluids as ordered
  • Report lab/ultrasound findings
  • Attend to patient's emotional need
• Comparison of Types & Management of Spontaneous Abortion (Miscarriage)

  • Threatened
  • Inevitable
  • Incomplete
  • Complete
  • Missed
  • Recurrent (Habitual)

  
• Hydatidiform Mole


  Benign tumour of both parts of the chorion; the cytotrophoblast and the syncytiotrophoblast may be found in varying proportions
• Hydatidiform moles vary greatly in their rate of growth, in the amount of chorionic gonadotrophin produced and in the amount of invasion of the uterine wall
• Causes of Hydatidiform Mole

  • Maternal age above 40 years or below 19 years
  • Malnutrition (deficiency of proteins)
• Signs and Symptoms of Hydatidiform Mole

  • Bleeding – scanty (brownish) – discharge occur plus vesicles
  • The uterus is larger than expected period of amenorrhea, and feels very soft and boggy
  • History of nausea and excessive frequent vomiting
  • Increased incidence of pre-eclampsia
  • No fetal parts, movements or fetal heart sounds
  • Pregnancy test +ve in highly diluted urine 1/ 500
  • Ultrasound shows no fetal evidence
• Gestational Trophoblastic Disease


  Abnormal proliferation of trophoblastic cells without viable fetus
• Clinical Findings of Gestational Trophoblastic Disease

  • Vaginal spotting (dark brown)
  • Fundal height greater than expected for dates
  • hCG greater than expected for dates
  • Excessive nausea and vomiting
  • Absence of fetal heart tones
  • Ultrasound findings: Snowflake-like clusters, absence of fetus
• Ectopic Pregnancy


  Pregnancy occurring outside the normal uterine cavity
• Locations of Ectopic Pregnancy

  • Uterine cornu
  • Ovary
  • Cervix
  • Abdominal cavity
  • Broad ligament
• Risk Factors for Ectopic Pregnancy

  • Pelvic inflammatory disease (PID)
  • Previous ectopic pregnancy
  • Previous pelvic surgery (D&C, tuboplasty, ovarian surgery)
  • Intrauterine device (IUD)
  • Tubal Sterilization
  • Progesterone only pill (POP)
  • Depoprovera
  • Emergency contraception
• Causes of Ectopic Pregnancy

  • Occlusion of the fallopian tube, and also decrease sperm mobility
  • Previous tubal surgery like sterilization salpingectomy
  • Intrauterine contraceptive device
  • Impaired tubal contractility
  • Congenital abnormality of the tube such as diverticulum
  • Migration of ovum a cross the pelvic cavity to the fallopian tube on the side opposite to the follicle from which ovulation occurred
• Signs and Symptoms of Ectopic Pregnancy

  • Amenorrhea—short period
  • Abdominal Pain—Typically constant and often unilateral due to spasm of the tubal muscle (sudden/ recurrent sever, colicky)
  • Vaginal Bleeding—when a pregnancy implants in the tube, the uterine endometrium is still converted into decidua. When the embryo dies, the decidua in the uterus separates. The bleeding is usually scanty, less than a normal period and dark brown in colour
  • Faintness or even shock with an acute rupture
• Clinical Features of Ectopic Pregnancy

  • Unruptured Ectopic Pregnancy: Slight activity of the breasts; Slight tenderness over one side of the uterus; On bimanual examination, the uterus is slightly enlarged and the cervix is soft; There may be dark blood oozing from the external os; The pregnant tube is usually not palpable
  • Acute Rupture of a Tubal Ectopic: Collapse; Severe abdominal pain; Pallor, rapid pulse and hypotension; Blood may track up under the diaphragm giving shoulder pain; The abdomen is slightly distended, tender and rigid; On vaginal examination, the uterus is soft and may be enlarged but is very tender; A tender tubal mass may not be palpated because of the extreme tenderness and guarding
• Treatment of Ectopic Pregnancy


  • Removal of the pregnancy and sometimes the affected tube by laparoscopy or laparotomy
  • If the tube is patent and not seriously damaged, it may be possible to conserve it and thus leave the woman with a chance of conception later in life