NUR1213

therefore, needs to be evaluated for the possibility

Nursing Care of the High- that she is experiencing a significant blood loss or
Risk Pregnant Client is developing hypovolemic shock.

(Bleeding Disorders)
OUTLINE
I. Hemorrhagic Disorder
II. Abortion
III. Ectopic Pregnancy
IV. Hydatidiform Mole
V. Premature Cervical Dilatation
VI. Placenta Previa
VII. Abruptio Placenta
VIII. Disseminated Intravascular
Coagulation

I. Hemorrhagic Disorder

Alarming to the client and considered medical

emergencies. Cause by genetic factors, hormone
imbalance, psychological infection, and systemic
disorder. II. Abortion

Assessment in Hemorrhagic Disorders in Abortion – expulsion of the products of conception

Pregnancy before the age of viability.

• Increased pulse rate: Heart is attempting to <20 – 24 weeks

circulate decreased blood volume. <500 grams
• Decreased blood pressure: Less peripheral <20 cm
resistance because of decreased blood
volume. Layman’s Term = Miscarriage
• Increased respiratory rate: Increases gas
exchange to better oxygenate decreased red Types of Abortion
blood cell volume
• Cold, clammy skin: Vasoconstriction A. Induced
occurs to maintain blood volume in central
body core. • Therapeutic
• Decreased urine output: Inadequate blood is • Non-Therapeutic
reaching cerebrum because of decreased
blood volume. B. Spontaneous – natural causes
• Dizziness or decreased level of
consciousness: Inadequate blood is • Threatened
reaching cerebrum because of decreased • Incomplete
blood volume. • Complete
• Decreased central venous pressure: • Missed
Decreased blood is returning to heart • Inevitable
because of reduced blood volume. • Habitual

Hypovolemia - The process of shock because of Predisposing factors for Abortion:

blood loss
- Abnormal fetal formation due to alcohol
Vaginal bleeding during pregnancy is always ingestion or chromosomal abnormalities
abnormal, A woman with any degree of bleeding, - Implantation Abnormalities
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- Systemic infections: rubella, syphilis,
poliomyelitis, cytomegalovirus,
toxoplasmosis
- Infections – UTI
- Chronic wasting disease (cardiac failure,
chronic nephritis, diabetes)
- Retroverted uterus
- Developmental defects – bicornuate uterus,
myomas
- Cervical incompetence – due to weakness
or trauma
- Teratogenic drugs (Isotretinoin: present in
skincare products)
- Endocrine imbalance
- Psychological factors
- Trauma – accidents
- Severe nutritional deprivation
Spontaneous Abortion – termination of pregnancy
spontaneously at any time before the fetus has
attained viability.
Assessment!
1. Persistent uterine bleeding and cramp like
pain
2. Passage of fetal tissues
3. Laboratory finding – negatively or weakly
positive urine pregnancy test
4. Obtain history, including last menstrual
period
Types of Spontaneous Abortion
1. Complete Abortion – the fetus and the
placenta are expelled complete
2. Incomplete Abortion – Expulsion is
incomplete, Membranes or placenta
retained, Treatment is by evacuation –
Curettage.
3. Threatened Abortion – early – under 16
weeks to late – 16-24 weeks.
Assessment!
a. Scanty bleeding
b. Slight pain or cramping
c. Closed cervical OS – tocolytic agent is not
effective.
Management!
a. Limit activities
b. Mild sedative to aid relaxation
c. Coitus is restricted for 2 weeks
4. Inevitable Abortion
– cervix opens begin to dilate
Heavier bleeding and stronger contractions
Loss of fetus usually not avoidable
Bleeding is retroplacental and ovum is
already dead
Treatment is by evacuation of uterus; BOW
5. Imminent Abortion
- Open cervical os
- Heavier bleeding and stronger contractions
- Loss of uterus not avoidable
- Unruptured BOW
6. Habitual Abortion – (Recurrent abortion)
occurrence of at least 3 consecutive
spontaneous abortion.
these are commonly due to genetic or chromosomal
problems of the embryo, with 50-80% of
spontaneous losses having abnormal chromosomal
number.
Prevention!
a. Quit smoking – higher risk of miscarriage
b. Limit caffeine
c. Screen for STDs
d. Take Folic acid
e. Get tested for Diabetes
7. Missed Abortion – fetus dies in uterus and
is retained inside. Occurs 4-6 weeks after
fetal death.
General softening-Mummification-Stony Material
Blood mole – a retained blood covered which forms
a firm, nodular fleshy mass.
Carneous mole – a fleshy mass consisting pieces of
placenta and products of conception.
Management!
a. Dilatation and Curettage
b. If over 14 weeks administer Prostaglandin
Suppository Cytotec or Oxytocin
c. Disseminated Intravascular coagulation
8. Septic Abortion
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- associated with incomplete abortion and Minor risk factors include: Prior abdominal or
fever pelvic surgery, exposure utero diethylstilbestrol
- foul smelling vaginal discharge (DES)(Estrogen), In vitro fertilization and embryo
- can lead to Toxic Shock Syndrome transfer
- Symptoms usually are fever and crampy
abdominal and tender uterus upon Sites of Ectopic pregnancy
palpation.
- Obtain CBC, serum electrolytes, creatinine, 1. Fallopian tubes
blood type and crossmatch, and cervical, 2. Cervix
vaginal and urine culture. 3. Uterine cornu
4. Ovaries
Management! 5. Abdomen
6. Broad ligament
a. Broad spectrum antibiotics
b. Dilatation and Curettage Assessment!
c. Tetanus Toxoid
d. Rh (D Antigen) immunoglobulin (RhIg) • History of missed periods
given to Rh Negative mothers to prevent • Abdominal pain, may be localized to one
Isoimmunization side (unilateral)
• Rigid tender abdomen; sometimes
Nursing Interventions abnormal pelvic mass
• Bleeding
• Save all tissue passed • Low hemoglobin and hematocrit, rising
• Keep client at rest and teach reason for bed white cell count
rest • HCG titers usually lower than in
• Prepare client for surgical intervention intrauterine pregnancy
(D&C) • Knife-like pain in lower quadrant
• Provide discharge teaching about limited • Dark red vaginal spotting
activities and coitus after bleeding ceases • Cullen’s sign – bluish tinge at the peri-
• Observe reaction of others and provide umbilical area
emotional support, and give opportunity to • Mass at the cul de sac of douglas and blood
express feelings of grief and loss. during needle aspiration (Culdocentesis)
• Administer Rhogam if mother is Rh
negative Management!

RhoGAM – a prescription medicine (via IM) that is
used to prevent RH immunization, a condition in
which an individual with Rh negative blood
develops antibodies after exposure to Rh positive
blood.
III. Ectopic Pregnancy
Any gestation outside the uterine cavity. Most
frequent in the fallopian tubes, where the tissue is
incapable of growth needed to accommodate
pregnancy, do rupture of the site usually occurs
before 12 weeks.
Major risk factors include: Prior tubal surgery, Use
of intrauterine device, Tissue insult resulting from
pelvic inflammatory disease
a. Salpingostomy – contents of the fallopian
tubes are removed by making an opening;
fallopian tubes is replaced and pregnancy is
terminated.
b. Salpingectomy – removal of Fallopian tube
c. Methotrexate:
1 mg/kg per day (ODD# DAYS)
Asymptomatic, motivated
Low serum B-HcG level (<1000 mlU/ml)
<3.5 cm ectopic pregnancy
Absent fetal cardiac activity
Adverse effect: liver involvement, stomatitis,
gastroenteritis.
Heterotopic Pregnancy
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A tubal pregnancy with co-existing intrauterine
pregnancy. One of which is a viable intrauterine
pregnancy and other of which is non-viable ectopic
pregnancy.
Treatment includes Laparoscopic surgery and
Laparotomy.
IV. Hydatidiform Mole
Hydatidiform Mole also known as Gestational
Trophoblastic Disease a form of trophoblastic
neoplasia which may lead to a frankly malignant
proliferation of trophoblast cells known as
choriocarcinoma.
The mole looks like a bunch of whitish grapes,
often interspersed with blood clot.
The baby do not develop and only placenta forms
with abnormal large cysts (sacs of fluid).
Complete mole
• There is total hydatidiform change with no
evidence of fetal circulation.
• Proliferation of the trophoblasts cells is
marked
• All trophoblastic villi swell and become
cystic
Karyotype is 46xx from paternal contribution
Partial mole
• Associated with a fetus
• Hydatidiform change is variable
• Karyotype is abnormal and chromosome is
triploid 69 xxx or xxy
Assessment!
• Bleeding
• Hyperemesis
• Pallor and Dyspnea
• Anxiety and tremor
Signs
• Uterine enlargement
• Absent fetal heart and parts
• Signs of preeclampsia (elevated BP and
Proteinuria)
• Unexplained degree of anemia
• Passage of vesicles per vagina
• Signs of hyperthyroidism
Nursing Interventions
• Suction curettage. After D&C, a weekly
HCG test until normal levels are obtained.
• Teach contraceptive use so that pregnancy
is delayed for at least one year
• Teach client for follow-up lab work and the
rising of HCG levels
• Women who were diagnosed with a partial
mole will then be reviewed monthly for at
least six months.
• Women are not recommended to become
pregnant until 6 months for partial mole and
12 months for complete mole.
• It is recommended to use hormonal method.
V. Premature Cervical Dilatation
It is a painless condition in which the cervix dilates
without uterine contractions and allows passage of
the fetus usually the result of prior cervical trauma.
Occurs most often in the fourth or fifth month of
pregnancy.
Assessment!
• History of repeated, relatively painless
abortions
• Early and effacement and dilation of cervix
• Bulging of membranes through cervical os
Medical Management!
• Cervical Cerclage on the 12th – 14th week of
gestation thru vaginal route by regional
anesthesia
a. Shirodkar Procedure – permanent type:
suture is threaded in the submucous
layer of the cervix.
b. McDonald Procedure – temporary type:
nylon suture are placed horizontally and
vertically across the cervix and pulled
tight to reduce the cervical canal.
Sutures are removed at 37th - 38th week
of gestation.
After cerclage it is advised for bedrest and placed
on slight modified Trendelenburg position.
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• Observe for contractions, rupture of
membranes, and monitor fetal heart tones
• Position client to minimize pressure on
cervix.
VI. Placenta Previa
Low implantation of the placenta so that it overlays
some or all of the internal cervical os.
• Delivery by cesarean if evidence of fetal
maturity, excessive bleeding, active labor,
other complications
VII. Abruptio Placenta
Premature separation of the placenta from the
uterine wall after the twentieth week of gestation
and before the fetus is delivered.

Types of placenta previa Types of Abruptio Placenta

Total – cervical os is completely covered a. Marginal (Overt)

Partial – internal os is partially covered b. Central (Concealed)
Marginal – edge of placenta is at the margin
Low lying – implanted in the lower segment; edge Risk factors!
does not reach internal os
1. Increase maternal age
Risk factors! 2. High parity
3. Increased uterine distention
1. Prior previa (4-8%) 4. Diabetes
2. First subsequent pregnancy following a 5. Cocaine and Smoking
caesarean delivery
3. Multiparity Assessment!
4. Advance maternal age
5. Prior induced abortion • Painful vaginal bleeding
6. Smoking • Uterine rigidity or Couvelaire uterus
• Absence of fetal heart tones
Assessment! • Signs of shock

• Bright red vaginal bleeding after 7th month Management!

of pregnancy
• Uterus is soft, relaxed, and nontender a. Obtain IV access using 2 large-bore
• Vaginal examination can result in severe intravenous lines
bleeding and should only be done if the b. Institute crystalloid fluid resuscitation for
fetus is mature enough to be born. the patient
• Diagnosis by sonography c. Begin transfusion if the patient is
hemodynamically unstable
Nursing Interventions d. Correct coagulopathy
e. Administer Rh immune globulin if the
• Hospitalization patient is Rh-negative
• Bedrest side-lying or Trendelenburg at least f. Anticipate coagulation
72 hrs. g. Medications (Magnesium sulfate,
• Ultrasound for placental position Apresoline, Valium)
• No vaginal and rectal examinations h. Vaginal delivery – preferred method if the
• Amniocentesis for lung maturity fetus has died secondary to placental
abruption
• Daily Hgb and Hct
i. Caesarean delivery – necessary for fetal and
• Monitor blood loss
maternal stabilization; if hemorrhage
• Send home if bleeding ceases and cannot be controlled, a cesarean
pregnancy is maintained
hysterectomy is required.
• No douching, enemas, and coitus
• Monitor fetal movement
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VIII. Disseminated Intravascular
Coagulation

A maternal condition in which the clotting cascade

is activated, resulting in the formation of clots in
the microcirculation.

Assessment!

• Uncontrolled bleeding
• Bruising, purpura, petechia, ecchymosis
• Presence of occult blood in excretions
• Hematuria, hematemesis, or vaginal
bleeding
• Signs of shock
• Decreased fibrinogen level, platelet count,
and hematocrit level;
• Increased prothrombin time and partial
thromboplastin time, clotting time, and
fibrin degradation products

Nursing Interventions

• Monitor vital signs; assess bleeding and

shock
• Prepare oxygen therapy, volume
replacement, blood component therapy, and
possibly heparin therapy
• Monitor fluid and blood complications
• Monitor urine output and maintain at least
30mL/hr.