HIGH RISK PREGNANCY

Bleeding During Pregnancy (First Trimester)

ABORTION
is the loss of pregnancy before the fetus is viable or capable of living outside the uterus.

Spontaneous abortion
is the termination of pregnancy without action taken by the woman or another person. It usually occurs at the first 12 weeks of pregnancy, with the rate declining rapidly thereafter.

Causes of Spontaneous Abortion

        Severe congenital abnormalities that are often incompatible with life Chromosomal abnormalities Maternal infections IntraIntra-abdominal infections Maternal endocrine disorders Abnormalities of the reproductive organ Immunologic factors Anatomic defects of the uterus and the cervix

Threatened abortion
 the first sign is vaginal bleeding, which is rather common during pregnancy. One thirds of pregnant women experience spotting in early pregnancy and 50% of these end up in spontaneous abortion

Clinical Manifestations:
   
bleeding rhythmic uterine cramping persistent backache feelings of pelvic pressure

Management
   
Notify the physician. Obtain detailed health history. The woman is instructed to limit sexual activity until the bleeding ceases. The woman is instructed to count the number of perineal pads used and to not the quantity and color of blood on the pad. Check for evidence of tissue passage. Provide accurate information and avoid false reassurance

 

Inevitable abortion
 it occurs when the membranes rupture and the cervix dilates. it cannot be stopped

Management

Vacuum curettage is done to clean out the uterus if the natural process is ineffective or incomplete. Dilatation and curettage may be needed if pregnancy is more advanced or if bleeding is excessive.

Incomplete abortion
 It occurs when some but not all of the products of conception are expelled from the uterus.

Clinical Manifestations
  
active uterine bleeding severe abdominal cramping cervix is open, fetal and placental tissue is passed

Management
      Treatment should focus on stabilizing the woman cardiovascularly. Blood should be ready for blood typing and cross matching. Intravenous line should be inserted for fluid management. Dilatation and curettage is done when the woman is stable. After D and C, IV administration of oxytocin or IM administration of methergin. If pregnancy is beyond 14 weeks, D and C cannot be performed because of the danger of excessive bleeding, so oxytocin or prostaglandin is administered

Complete abortion
 it occurs when all products of conception are expelled from the uterus. Uterine contraction and bleeding subsides, the cervix closes.

Management
  
If complete abortion is determined, no additional intervention is required. Advise woman to rest and watch out for further bleeding. Advise no intercourse until after the followfollowup visit with the physician

Missed abortion
 it occurs when the fetus dies during the first half of pregnancy but is retained in the uterus.

Diagnosis
 
Ultrasound Pregnancy test for HCG

Management

Evacuation of contents of the uterus
First trimester- D and C trimester Second trimester- D and E or the use of trimestervaginal prostaglandin or Misoprostol

Complications of missed abortion


Infection
Elevated temperature Vaginal discharge with foul odor Abdominal pain

Disseminated Intravascular Coagulation

Recurrent spontaneous abortion

 it is 3 or more spontaneous abortions

Causes
   
genetic or chromosomal abnormalities anomalies of the reproductive tract systemic diseases reproductive infections and some STDs

Management
       

Thorough examination of the reproductive system. If the cervix or uterus are normal, the couple is referred for genetic counseling. If the woman is diabetic, assist the woman to develop regimen to maintain normal blood glucose. Supplemental hormones may be given if her progesterone or other hormonal levels are lower than normal. Antimicrobials are prescribed for the woman with infection. Hormone related drugs may be prescribed if imbalance preventing normal fetal implantation and support is found. If the woman has cervical incompetence, the cervix may be sutured to keep it from opening in a cerclage procedure. Rh immune globulin (RhoGAM) is given to the unsensitized Rh negative woman

Nursing Considerations
 
Psychological needs of the woman (grief) Recognizing the meaning of the loss to each woman and her significant other is important. Provide information and simple brief explanation of what has occurred and what will be done

Assessment
     
Confirmation of pregnancy and length of gestation. Physical assessment to determine amount of bleeding and description. Location and severity of pain. Vital signs Urine output Assess for signs of infection.

Diagnostics
  
hemoglobin and hematocrit coagulation factors identify women with Rh negative

ECTOPIC PREGNANCY
 When implantation occurs outside the uterine cavity  It could be at the surfaces of the ovary or in the cervix  Most common is at the fallopian tube

Obstructions of the fallopian tube:

 Adhesion of the fallopian tube from previous infection  Congenital malformations  Scars from tubal surgery  Uterine tumor pressing on the proximal end of the tube

Assessment
 Sharp, stabbing pain in one of the lower abdominal quadrant at the time of rupture  Scant vaginal spotting

Management
 Ruptured
Womans condition should be evaluated quickly Blood extraction Hcg level should be checked IV using large bore needle Laparoscopy

 If ectopic pregnancy was diagnosed by sonography before rupture:

Methotrexate Leucovorin

 Sonography  Mifepristone
*the tube is left intact with no surgical scarring

ABDOMINAL PREGNANCY
 It occurs when after ectopic pregnancy rupture, the product of conception is expelled into the pelvic cavity.

Assessment
 Fetal outline is easily palpable  The woman may experience painful fetal movements  Abdominal cramping with fetal movements  Sonogram

Maternal effects
 The placenta will infiltrate and erode a major blood vessel in the abdomen  If implanted on the intestine, it may erode so deeply that it may cause bowel perforation and peritonitis

Fetal/Neonatal effects
 No good uterine blood supply, the nutrients may not reach the fetus in adequate amounts  Increased incidence of fetal deformity from inadequate nutrient supply

Managemnent
 Infant must be born by laparotomy  Placenta may be in left in place and allowed to be absorbed spontaneously in 2-3 months 2 Follow-up sonogram is done Follow-

Bleeding During Pregnancy (Second Trimester)

GESTATIONAL THROPHOBLASTIC DISEASE (HYDATIDIFORM MOLE)

 Is proliferation and degeneration of the throphoblastic villi  They become filled with fluid and appear as fluidfluid-filled, grape-sized vesicles grape The embryo fails to develop beyond a primitive start

Associated factors
   
Women who have low CHON intake Young women (under 18 years) Older women (over 35 years) Women of Asian heritage

Assessment
Uterus tends to expand faster than normal No fetal heart sounds Serum or urine test for hcg will be strongly positive Nausea and vomiting Symptoms of hypertension of pregnancy Sonogram will show dense growth but no fetal growth  Vaginal spotting of dark brown blood or profuse fresh flow (16 weeks)  Discharge of fluid-filled vesicles fluid     

Management
 Suction curettage  Baseline pelvic exam, CXR  Hcg level is checked every 1-2 weeks, then every 12-4 weeks for 6 months  Instruct the woman to use a reliable contraceptive method for 6 months  Let the woman express her feelings  Early screening with U/S during second pregnancy

Premature cervical dilatation

 The cervix dilates prematurely and therefore cannot hold the fetus until term

Assessment
     
First symptom is show Increased pelvic pressure Rupture of the membranes Discharge of amniotic fluid Uterine contractions Fetus is expelled

Associated factors
 Increased maternal age  Congenital structural defects  Trauma to the cervix

Management
 Cervical cerclage at 12-14 weeks 12 Bed rest for a few days  Sexual relations may be resumed after rest period  At 37-38 weeks, the sutures may be 37removed

Bleeding During Pregnancy (Third Trimester)

Placenta Previa
 Is the implantation of the placenta on the lower uterus.

Classifications
 Marginal or low-lying when the lower lowborder is more than 3cm from the internal cervical os  Partial when the lower portion of the placenta is within 3 cm from the internal cervical os  Total when the placenta completely covers the internal cervical os

Assessment
 Sudden onset of painless uterine bleeding in the last part of pregnancy  No manual examination should be performed until location and position of the placenta is verified through U/S

Management
 Woman is evaluated  Electronic fetal monitoring  Conservative management
Home care

Criteria for home care

 No evidence of active bleeding  Able to maintain bed rest at home  Home is a reasonable distance away from the hospital  Emergency systems are available for immediate transport

Home care
 To help the woman and the family develop a workable plan for home care SBR with BRP Presence of another adult Procedure to follow if heavy bleeding begins Assess color and amount of vaginal discharge or bleeding Assess fetal activity daily Refrain from sexual intercourse

 Provide specific and accurate information about the condition of the fetus  Help the family understand the doctors plan of care

Inpatient care
 Determine whether the woman experiences bleeding episode or signs of preterm labor  Periodic electronic fetal monitoring  Delivery is scheduled if the fetus is older than 36 weeks AOG and the lungs are mature  Immediate delivery is necessary if:
bleeding is excessive Woman has signs of hypovolemia Signs of fetal compromise

Abruptio placenta
 The separation of a normally implanted placenta before the fetus is born  Hemorrhage may be apparent or concealed  It is a dangerous condition for both the fetus and the woman

Types
 Concealed bleeding occurs behind the placenta but the margins remain intact, causing formation of a hematoma  Apparent bleeding dissects or separates the membranes from the endometrium and blood flows out through the vagina
Does not always correspond to the actual amount of blood loss

Associated factors
        
Maternal use of cocaine Maternal hypertension Maternal cigarette smoking Multigravida status Short umbilical cord Abdominal trauma PROM Maternal age Hx of previous abruptio

Assessment
 Bleeding (may be evident or concealed)  Uterine tenderness  Uterine irritability with frequent low intensity contractions  Abdominal or low back pain that may be described as aching or dull  Hypovolemic shock  Fetal distress  Fetal death

Assessment
 Abdominal pain
May be sudden or severe Intermittent

 Uterus may be firm or board-like board Sonogram

Signs of concealed hemorrhage

    
Increase in fundal height Hard, boardlike abdomen Persistent abdominal pain Signs of early hemorrhage Slight or absent vaginal bleeding

Management
 Focus is on the cardiovascular status of the woman and the condition of the fetus  If condition is mild and the fetus is immature and there are no signs of distress, conservative management may be done bed rest and tocolytic  If fetal compromise exists or the woman shows signs of excessive bleeding, immediate delivery of the fetus is necessary

 Intensive monitoring of both the fetus and the mother  Blood products for replacement should be available  2 large bore IV lines should be started  If C/S is necessary, explain procedure to the woman and family  Continuous monitoring of both the expectant mother and the fetus

ASSESSMENT
       
Amount and nature of bleeding Pain Maternal vital signs Condition of the fetus Uterine contractions Palpation Obstetric history Length of gestation

ASSESSMENT
 Laboratory data
CBC Blood type and Rh Coagulation studies