ECTOPIC

PREGNANC
YNursing Care of Family
Experiencing a Sudden
Pregnancy
Complication
ECTOPIC
P REG NANC Y
• An ectopic pregnancy is one in which implantation occurs
outside the uterine cavity.

• Occurs as usual in the distal third of the fallopian tube.

Approximately 2% of pregnancies are ectopic; it is the
second most frequent cause of bleeding early in
pregnancy.
• Women who have one ectopic pregnancy have a 10% to
20% chance that a subsequent pregnancy will also be
ectopic. This is because salpingitis that leaves scarring is
usually bilateral.
Risk Factors
• Women who smokes

• Alcohol use

• Early use of contraceptive pills

• Intrauterine Device (IUD) use

• History of infertility

• In vitro fertilization in current pregnancy

• Prior abdominal or pelvic surgery, particularly tubal

surgery, including tubal ligation
SIGNS AND
SYMP TO MS
• No menstrual flow occurs. A woman may experience the nausea and vomiting of early
pregnancy, and a pregnancy test for hCG will be positive

• A woman usually experiences a sharp, stabbing pain in one of her lower abdominal quadrants
at the time of rupture, followed by scant vaginal spotting

• pelvic pain (which can be dull, sharp, or crampy)

• Rupture may be heralded by sudden, severe pain, followed by syncope or by symptoms and
signs of hemorrhagic shock or peritonitis.
DIAG NO STIC
PROCEDURE
Early Pregnancy Ultrasound - The timing of your first ultrasound varies depending on your
provider. Some people have an early ultrasound (also called a first-trimester ultrasound or dating
ultrasound).
This can happen as early as seven to eight weeks of pregnancy

Magnetic Resonance Imaging - is a non-invasive imaging technology that produces three

dimensional detailed anatomical images. It is often used for disease detection, diagnosis,
and treatment monitoring.

Laparoscopy - examination of the abdominal cavity and organs by insertion of a surgical

instrument through the anterior abdominal wall
DIAG NO STIC
PROCEDURE
Culdoscopy - used to visualize female pelvic organs—is inserted through the incision into
the peritoneal cavity

Ultrasonography - A procedure that uses high-energy sound waves to look at tissues and
organs inside the body.
Hysterosalpingogram - an X-ray procedure that is used to view the inside of the uterus and
fallopian tubes. It often is used to see if the fallopian tubes are partly or fully blocked. It also can
show if the inside of the uterus is a normal size and shape
THERAP EUTIC
MANAGEMENT
Some ectopic pregnancies spontaneously end before they rupture and are reabsorbed over the
next few days, requiring no treatment. It is difficult to predict when this will happen, so when an
ectopic pregnancy is revealed by an early ultra sound, some action is taken

Oral adm inistration of m ethotrexate followed by leucovorin - Methotrexate, a folic

acid antagonist chemotherapeutic agent, attacks and destroys fast-growing cells

Mifepristone - an abortifacient, is also effective at causing sloughing of the tubal

implantation site.

The advantage of these therapies is that the tube is left intact, with no surgical scarring that
could cause a second ectopic implantation
THERAPEUTIC
MANAGEMENT
If an ectopic pregnancy ruptures, it is an emergency situation (Stevens & Gilbert-Cohen, 2007). Keep
in mind the amount of blood evident is a poor estimate of the actual blood loss.

A blood sample needs to be drawn immediately for hemoglobin level, typing and cross-
matching, and possibly hCG level for immediate pregnancy testing, if pregnancy has not yet
been confirmed.

Intravenous fluid using a large-gauge catheter to restore intravascular volume is begun.

Blood then can be administered through this same line when matched.

The therapy for a ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and
to remove or repair the damaged fallopian tube. A rough suture line on a fallopian tube may
lead to another tubal pregnancy, so either the tube will be removed or suturing on the tube is
done with microsurgical technique
THERAPEUTIC
MANAGEMENT

If a tube is removed, a woman is theoretically only 50% fertile, because every other month, when
she ovulates from the ovary next to the removed tube, sperm cannot reach the ovum on that
side.
However, this is not a reliable contraceptive measure. Research in rabbits has shown that
translocation of ova can occur—that is, an ovum released from the right ovary can pass through
the pelvic cavity to the opposite (left) fallopian tube and become fertilized, and vice versa.

As with miscarriage, women with Rh-negative blood should receive Rh (D) immune globulin (RhIG)
after an ectopic pregnancy for isoimmunization protection in future childbearing.
A woman who has had an ectopic pregnancy not
only has grief stages to work through (she has lost a
child) but also may have problems of diminished
self image and a sense of powerlessness to resolve if
surgery included removal of a fallopian tube. She
may believe that she is now “half a woman” if she
equated reproductive structures and childbearing with
being feminine. Encourage her to verbalize her
concerns about this and future childbearing. The
process of working through grief and role images
takes weeks to months. It should begin in the
hospital, however, where a woman has professional
people to help her through the first days and to deter
mine
whether she will need further counseling
Previous Ectopic Pregnancy Pelvic Inflammatory Disease Smoking Alcohol Use In Vitro Fertilization

Underlying tubal disorder

Tubal scarring leading to Tubal disorders leading to
leading to previous ectopic Impairement in tubal motility
adhesions unknown procedural causes
Pregnancy

ECTOPIC PREGNANCY Pregnancy cannot survise Embryo & trophoblast death

without the uterine leads to loss of hormone
endometrium support for the decidua

Prenetration of ovum into the Maternal blood extrudes

muscular wall through fimbrae of fallopian
tubes and into peritoneal cavity
Vaginal Bleeding

Lower abdominal pain

Tubal Distention ( including peritonitis in cases of
hemoperitonium)

Intra-Abdominal Hemorrhage Hemoperitoneum

Syncope, Hypotension, Low

Level of Consciousness
NURSIN
DIAGNOS IS
G

Powerlessness related to early loss of pregnancy secondary to ectopic

pregnancy

Acute pain related to distention or rupture of fallopian tube

Abdominal

Pregnancy
Nursing Care of Family
Experiencing a Sudden
Pregnancy
Complication
ABDOMINAL

Pa rare
REG formNANC Y
of ectopic pregnancy in which the pregnancy
implants within the peritoneal cavity, exclusive of the
fallopian tubes, ovaries, broad ligament, and cervix

This can also occur if a uterus ruptures because an old

uterine scar ruptures during pregnancy (Teng, Kumar, &
Ramli, 2007).

The fetal outline can be easily palpable through the

abdomen because it is located below the abdominal wall
and not in the uterus. A woman may not feel anything, or
she may experience painful fetal movements and
abdominal cramping with fetal movements.
 SIGNS AND SYMPTOMS
Symptoms of an abdominal pregnancy are very
nonspecific and often include:

abdominal pain on fetal movement

pain
displacement of the
nausea cervix
vomiting • lower quadrant pain

palpable fetal
parts
Dabiri, T. O., Marroquin, G. A., Bendek, B., Agamasu, E., &
fetal mal
Mikhail, M. S. (2014). Advanced Extrauterine Pregnancy at 33
presentation Weeks with a Healthy Newborn. BioMed Research
International, 2014, 1–3.
palpable fetal parts https://doi.org/10.1155/2014/102479
DIAGNOSTIC PROCEDURES
Ultrasound : fetus and a gestational sac observed outside
the uterine cavity, or the visualisation of an abdominal or
pelvic mass identifiable as an uterus and separated from the
fetus, absence of the uterine wall between the bladder and
the fetus, adherence of the fetus to an abdominal organ and
abnormal location of placenta outside the uterine cavity

Magnetic Resonance Imaging (MRI) is a non-invasive

imaging technology that produces three dimensional
detailed anatomical images. It is often used for disease
detection, diagnosis, and treatment monitoring.
DANGERS OF ABDOMINAL
PREGNANCY
The placenta will infiltrate and erode a major blood
vessel in the abdomen leading to hemorrhage

If implanted on the intestine, it may erode so deeply that

it causes bowel perforation and peritonitis

The fetus is also at high risk because without a good

uterine blood supply, nutrients may not reach the fetus in
ad equate amounts

The survival rate in an abdominal pregnancy is

only approximately 60% because of poor nutrient
supply
DANGERS OF ABDOMINAL
PREGNANCY

In infants who do survive, there is an increased threat

of fetal deformity or growth restriction from an
inadequate nutrient supply.
MEDICAL PROCEDURES
At term, the infant must be born through laparotomy.
The placenta is often diffificult to remove after birth if it
has implanted onto an abdominal organ such as the
intestine. It may be left in place, therefore, and allowed to
absorb spontaneously in 2 or 3 months

A follow-up ultrasound can be used to detect whether this

has occurred, or a woman can be treated with
methotrexate to help the placenta absorb. This therapy
may not be effective because the remaining trophoblasts
are no longer fast- growing.
 Gestational
Trophoblastic
Disease
Nursing Care of Family Experiencing a
Sudden Pregnancy Complication
GESTATIONAL
TROPHOBLASTIC DISEASE
is abnormal proliferation and then degeneration of
the trophoblastic villi (Garg & Giuntoli, 2007).

In occurs in the woman's uterus, 1 in every 1500

pregnancies

As the cells degenerate, they become filled with fluid

and appear as clear fluid-filled, grape-sized vesicles.

Abnormal trophoblast cells must be identified because they

are associated with choriocarcinoma, a rapidly
metastasizing malignancy
RI S K F A C T O R S
According to Aghajanian, 2007, the condition tend to
occur most often in:

women who have a low protein

intake women older than age 35

years women of Asian heritage

in blood group A women who marry

blood group O men
There are two types of molar
growth, COMPLETE MOLE and
PARTIAL MOLE

Two types of molar growth can be identified

by
chromosome analysis
COMPLETE
MOLE
all trophoblastic villi swell and become
cystic
If an embryo forms, it dies early at only 1
to 2 mm in size, with no fetal blood
present in the villi
On chromosomal analysis, although the
karyotype is a normal 46XX or 46XY, this
chromosome component was contributed
only by the father or an “empty ovum” was
fertilized and the chromosome material
was duplicated
PARTIAL
MOLE
some of the villi form normally
syncytiotrophoblastic layer of villi is
swollen and misshapen
A macerated embryo of approximately
9 weeks’ gestation may be present and
fetal blood may be present in the villi
has 69 chromosomes (a triploid formation in
which there are three chromosomes instead of
two for every pair, one set supplied by an
ovum that apparently was fertilized by two
sperm or an ovum fertilized by one sperm in
which meiosis or reduction division did not
occur)
In contrast to complete moles, partial
moles rarely lead to choriocarcinoma.
Although still above average, hCG titers are
lower in partial than in complete moles;
titers also return to normal faster after
mole evacuation.
ASSESSMENT
Because proliferation of the trophoblast cells occurs so
rapidly with this condition, the uterus tends to expand
faster than normally. This causes the uterus to reach its
landmarks (just over the symphysis brim at 12 weeks, at
the umbilicus at 20 to 24 weeks) before the usual time

Because hCG is produced by the trophoblast cells that are

overgrowing, a serum or urine test of hCG for pregnancy will
be strongly positive (1 to 2 million IU compared with a
normal pregnancy level of 400,000 IU).
SIGNS AND SYMPTOMS
Because proliferation of the trophoblast cells occurs so
rapidly with this condition, the uterus tends to expand
faster than normally. This causes the uterus to reach its
landmarks (just over the symphysis brim at 12 weeks, at
the umbilicus at 20 to 24 weeks) before the usual time

Symptoms of pregnancy-induced hypertension such as

hypertension, edema, and proteinuria appears early
(the normal is not present 20 weeks gestation)
SIGNS AND SYMPTOMS
At approximately week 16 of pregnancy, if the structure was not identifified earlier by
ultrasound, it will identify itself with vaginal bleeding. This may begin as spotting of dark brown
blood or as a profuse fresh flow. As the bleeding progresses, it is accompanied by discharge
of the clear fluid- filled vesicles. This is why it is important for any woman who begins to
miscarry at home to bring any clots or tissue passed to the hospital with her. The presence of
clear fluid-filled cysts changes the diagnosis from miscarriage to gestational trophoblastic
disease. Extreme nausea and vomiting is also associated with GTD
DIAGNOSTIC PROCEDURES
Pelvic examination. The doctor may feel the uterus,
vagina, ovaries, bladder, and rectum to check for
lumps or any unusual changes. This is similar to the
physical exam done during an annual gynecologic
checkup.

Human chorionic gonadotropin (hCG) test. Tumor

markers are substances found at higher-than-normal
levels in the blood, urine, or body tissues of people with
a tumor. Pregnancy normally causes high levels of hCG in
the blood and urine. High levels of hCG in a woman who
is not pregnant could mean that GTD is present. hCG
tests are also helpful tests to monitor a patient's recovery
during and after treatment for GTD.
Gestational Trophoblastic Disease Treatment (PDQ®)–Patient Version. (2022d, February
25). National Cancer Institute.
DIAGNOSTIC PROCEDURES
Computed tomography (CT or CAT) scan. A CT scan takes pictures of the inside of the body
using x-rays taken from different angles. A computer combines these pictures into a detailed, 3-
dimensional image that shows any abnormalities or tumors. A CT scan can be used to measure
the tumor’s size. Sometimes, a special dye called a contrast medium is given before the scan to
provide better detail on the image. This dye is injected into a patient’s vein or given as a drink or
pill to swallow.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce
detailed images of the body. MRI can be used to measure the tumor’s size. A special dye
called a contrast medium is given before the scan to create a clearer picture. This dye can be
injected into a patient’s vein or given as a pill or liquid to swallow. In GTD, MRIs are most
often used to take pictures of a patient’s brain.

Gestational Trophoblastic Disease - Diagnosis. (2021, March 24). Cancer.Net. https://

www.cancer.net/cancer- types/gestational-trophoblastic-disease/diagnosis
THERAPEUTIC MANAGEMENT
Therapy for gestational trophoblastic disease is
suction curettage to evacuate the mole

Following mole extraction, women should have a baseline

pelvic examination, a chest radiograph, and a serum
test for the beta subunit of hCG

After surgery, hCG levels remain high. Half of women still

have a positive reading at 3 weeks; one-fourth still have a
positive test result at 40 days. The hCG is then analyzed
every 2 weeks until levels are again normal. After that,
serum hCG levels are assessed every 4 weeks for the next 6
to 12 months. Gradually declining hCG titers suggest no
complication is developing
THERAPEUTIC MANAGEMENT
A woman should use a reliable contraceptive method such as an oral contraceptive agent for 12
months so that a positive pregnancy test (the presence of hCG) resulting from a new pregnancy will
not be confused with increasing levels and a developing malignancy. . After 6 months, if hCG levels
are still negative, a woman is theoretically free of the risk of a malignancy developing. By 12 months,
she could plan a second pregnancy

Some physicians give women who have had gestational trophoblastic disease a prophylactic course
of methotrexate, the drug of choice for choriocarcinoma. However, because the drug interferes
with white blood cell formation (leukopenia), prophylactic use must be weighed carefully.
Dactinomycin is added to the regimen if metastasis occurs
 THERAPEUTIC MANAGEMENT

Women need the opportunity to express their anger and sense of unfairness at this type of event.
They may feel inadequate because something went wrong with the pregnancy. They may wonder
whether it will happen again or whether they will ever be able to have children. Unfortunately, women
who have one incidence of gestational trophoblastic disease have an increased risk of a second molar
pregnancy (Aghajanian, 2007). They need early screening with ultrasound during a second pregnancy
to be certain this is not happening again
 Sperm fertilizes an empty egg/ Woman older than 35 years A woman who marry blood
Low protein A woman of Asian Heritage
two sperms fertilizes a single egg group O men

FERTILIZATION

Gestational Trophoblastic Disease

Abnormal proliferation of Hyatidiform Mole (Partial Abnormally High hCG

Choriocarcinoma
Trophoblastic cells and Complete Mole) production

Malignant tumor that

Forms grape-like cluster in spreads to the other parts of Extreme nausea and
Fromation of Tumor
the uterus the body, lungs, liver, brains vomiting

Uterus expands faster than Forms grape-like cluster in

Abdominal Pain
normal the uterus
 Premature
Cervical
Dilatation
Nursing Care of Family Experiencing a
Sudden Pregnancy Complication
PREMATURE
CERVICAL
DILATATION
previously termed an incompetent cervix, refers to a
cervix that dilates prematurely and therefore cannot hold
a
In fetus
occursuntil
in 1%term
of women

The dilatation is usually painless

According to Friedman and colleagues, the rate of cervical

dilation should be at least 1 cm/h in a nulliparous
woman and 1.2 cm/h in a multiparous woman during
the active phase of labor.
SIGNS AND SYMPTOMS
Often the first symptom is show (a pink-stained
vaginal discharge) or increased pelvic pressure

Followed by rupture of the membranes and discharge

of the amniotic fluid

Uterine contractions begin, and after a short labor

the fetus is born

Unfortunately, this commonly occurs at approximately week

20 of pregnancy, when the fetus is still too immature to
survive
ASSESSMENT
It is often diffificult to explain in a particular instance what
causes premature dilatation. It is associated with increased
maternal age, congenital structural defects, and trauma to
the cervix, such as might have occurred with a cone biopsy
or repeated D&C

Although it may be diagnosed by an early ultrasound

before symptoms occur, it is usually diagnosed only after
the pregnancy is lost
THERAPEUTIC MANAGEMENT

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)

McDonald or a Shirodkar procedure - As soon as an

ultrasound confirms that the fetus of a second pregnancy is
healthy, at approximately weeks 12 to 14, purse-string
sutures are placed in the cervix by the vaginal route under
regional anesthesia
THERAPEUTIC MANAGEMENT
McDonald procedure - nylon sutures are
placed horizontally and vertically across the
cervix and pulled tight to reduce the
cervical canal to a few millimeters in
diameter

Shirodkar technique - sterile tape is threaded

in a purse string manner under the submucous
layer of the cervix and sutured in place to
achieve a closed cervix. Although routinely
accomplished by a vaginal route, sutures may
be placed by a transabdominal route
THERAPEUTIC MANAGEMENT
With these procedures, the sutures are then removed at weeks 37 to 38 of pregnancy so
the fetus can be born vaginally. When a transabdominal approach is used, the sutures
may be left in place and a cesarean birth performed.

Be certain to ask women who are reporting painless bleeding (the symptoms of
spontaneous miscarriage also) whether they have had past cervical operations, to
remind them they may have sutures in place. The success rate with both types of
cerclage techniques is 80 % to 9 0%
 After cerclage surgery, women remain
on bed rest (perhaps in a slight or
modified Trendelenburg position) for
a few days to decrease pressure on
the new sutures. Usual activity and
sexual relations can be resumed in
most instances after this rest period.

The patient is supine on the table

with their head declined below their
feet at an angle of roughly 16
 Hormonal Changes Trauma Genetic Factors Infection Cervical Incompetence

Changes in the hormonal Trauma to the cervix can Can lead to inflammation, Condition in which the cervix
balance can affect the cause damage to the cervical Ehlers-Danlos Syndrome weakening of the cervcal in unable to support the
cervical tissue tissue tissue weight of the growing fetus

PREMATURE CERVICAL DILATATION

Vaginal Bleeding Uterine Contactions Ruptureof membranes

Placenta
Previa
Nursing Care of Family Experiencing a
Sudden Pregnancy Complication
 PLACENTA PREVIA
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)

It occurs in degrees:
implantation in the lower rather than in
the upper portion of the uterus (low-lying
placenta) marginal
implantation (the placenta edge approaches that of the cervical
os) implantation that occludes a portion of the cervical os
(partial placenta previa)
implantation that totally obstructs the cervical os (total placenta
previa)
PLACENTA PREVIA
The incidence is approximately 5 per 1000 pregnancies

Increased parity, advanced maternal age, past cesarean

births, past uterine curettage, multiple gestation, and
perhaps a male fetus are all associated with placenta previa

An increase in congenital fetal anomalies may occur if the

low implantation does not allow optimal fetal nutrition or
oxygenation (Arquette & Holcroft, 2007).
Types Of Placenta Previa
A. Low Implantation- means the placenta has
implanted at the bottom of the uterus, over the
cervix or close by, which means the baby can't
be born vaginally.

B. Partial Placenta Previa- the cervix is partly

blocked

C. Total Placenta Previa- the entire cervix is

obstructed
SIGNS AND S Y M P T O M S
Vaginal Bleeding - bleeding that occurs is
usually abrupt, painless, bright red, and
sudden enough to frighten a woman
DIAGNOSTIC P RO C E D U RE S
Ultrasounds - are performed so frequently
during pregnancy, most instances of
placenta previa are diagnosed today
before any symptoms occur

Bleeding with placenta previa begins when the

lower uterine segment starts to differentiate
from the upper segment late in pregnancy
(approximately week 30) and the cervix begins
to dilate
NURSING RESPONSIBILITIES
Immediate Care Measures. To ensure an adequate blood
supply to a woman and fetus, place the woman
immediately on bed rest in a side-lying position. Be sure
to assess:

• Duration of the pregnancy

• Time the bleeding began
•Woman’s estimation of the amount of blood—ask her
to estimate in terms of cups or tablespoons (a cup is
240 mL; a tablespoon is 15 mL)
• Whether there was accompanying pain
•Color of the blood (red blood indicates bleeding is
fresh or is continuing)
NURSING RESPONSIBILITIES
•What she has done for the bleeding (if she inserted a tampon to halt the
bleeding, there may be hidden bleeding)
• Whether there were prior episodes of bleeding during the pregnancy
• Whether she had prior cervical surgery for premature cervical dilatation

Inspect the perineum for bleeding. Estimate the present rate of blood loss.
Weighing perineal pads before and after use and calculating the difference by
subtraction is a good method to determine vaginal blood loss.

Kleihauer-Betke test (test strip procedures) can be used to detect whether the
blood is of fetal or maternal origin

Never attempt a pelvic or rectal examination with painless bleeding late in pregnancy
because any agitation of the cervix when there is a placenta previa may initiate
massive hemorrhage, possibly fatal to both mother and child
NURSING RESPONSIBILITIES
• Obtain baseline vital signs to determine whether symptoms of shock are
present. Continue to assess blood pressure every 5 to 15 minutes or
continuously with an electronic cuff
• Other necessary actions are intravenous fluid therapy using a large-gauge catheter
and monitoring urine output frequently, as often as every hour, as an indicator of
blood volume adequacy
• Hemoglobin, hematocrit, prothrombin time, partial thromboplastin time,
fibrinogen, platelet count, type and cross-match, and antibody screen will be
assessed to establish baselines, detect a possible clotting disorder, and ready
blood for replacement if necessary
NO TE
:
Vaginal birth is always safest for an infant. Therefore, it is essential to determine the placenta’s
location as accurately as possible in the hope that its position will make vaginal birth feasible. If the
previa is under 30% by ultrasound, it may be possible for the fetus to be born past it. If over 30%,
and the fetus is mature, the safest birth method for both mother and baby is often a cesarean
birth

Vaginal examinations (actual investigation of dilatation) to determine whether placenta previa exists
are done in an operating room or a fully equipped birthing room so that if hemorrhage does occur
with the manipulation, an immediate cesarean birth can be carried out to remove the child and the
bleeding placenta and contract the uterus. Have oxygen equipment available in case the fetal heart
sounds indicate fetal distress, such as bradycardia or tachycardia, late deceleration, or variable
decelerations
NURSING RESPONSIBILITIES
Continuing Care Measures. The point at which a diagnosis of placenta previa is made and the age of
the gestation dictate the final management. If labor has begun, bleeding is continuing, or the fetus is
being compromised (measured by the response of the fetal heart rate to contractions), birth must be
accomplished regardless of gestational age. If the bleeding has stopped, the fetal heart sounds are of
good quality, maternal vital signs are good, and the fetus is not yet 36 weeks of age, a woman is
usually managed by expectant watching. As many as half of all women with bleeding from placenta
previa are managed this way

Typically, a woman remains in the hospital on bed rest for close observation for 48 hours. If the
bleeding stops, she can be sent home with a referral for bed rest and home care. Careful assessment
of fetal heart sounds is made and laboratory tests, such as hemoglobin or hematocrit, are frequently
obtained. Betamethasone, a steroid that hastens fetal lung maturity, may be prescribed for the
mother to encourage the maturity of fetal lungs if the fetus is less than 34 weeks’ gestation
NURSING DIAGNOSIS

Fear related to outcome of pregnancy after episode of placenta previa

bleeding
B IRTH
If the initial bleeding happens before 34 weeks and then subsides, the pregnancy will be allowed
to continue to the point bleeding occurs again. If bleeding was past 34 weeks at the time of the
initial bleeding, a birth decision will generally be made immediately

If the placenta previa is found to be total, birth through the placenta is impossible and the baby
must be born by cesarean birth. If the placenta previa is partial, the amount of the blood loss, the
condition of the fetus, and a woman’s parity will inflfluence the birth decision.

With a cesarean birth for placenta previa, although the skin inision is still a transverse (bikini) one,
the uterine cut must be made high, possibly vertically above the low implantation site of the
placenta. If an ultrasound clearly reveals the placental location, a transverse uterine incision may be
possible
NURSING RESPONSIBILITIES

. During the postpartum period, she needs adequate time with her child to be certain he or she is
all right.
C AUTIO N

Any woman who has had a placenta previa is more prone than normal to postpartum hemorrhage
because the placental site is in the lower uterine segment, which does not contract as effificiently as
the upper segment. Also, because the uterine blood supply is less in the lower segment, the placenta
tends to grow larger than it would normally, leaving a larger denuded surface area when it is
removed. As a second complication, a woman is more likely to develop endometritis because the
placental site is close to the cervix, the portal of entry for pathogens.
 Multiple Gestation Male fetus

Placenta Previa
Advance Maternal Age Past Caesarian Birth

Past Uterine Curettage Past Placenta Previa

Total Placenta Previa Low Lying Placenta Partial Placenta Previa

Vaginal Bleeding
 Premature
Separation
of
the
Nursing Care of Family Experiencing a
Sudden Pregnancy Complication

Placenta
PREMATURE SEPARATION
OF PLACENTA
appears to have been implanted correctly. Suddenly,
however, it begins to separate and bleeding results

occurs 10% of pregnancy and is the most frequent cause

of perinatal death

The separation generally occurs late in pregnancy; it may

occur as late as during the first or second stage of labor.
The primary cause of premature separation is
unknown, but certain predisposing factors have been
identified, including:
high vasoconstriction from cocaine or cigarette
parity use
advanced maternal thrombophilitic conditions that lead to
age thrombosis
a short umbilical cord

advanced maternal age

chronic hypertensive

disease

pregnancy-induced
hypertension
SIGNS AND S Y M P T O M S
Uterus becomes tense and feels rigid to touch

Rapid decrease in uterine volume, such as occurs with sudden release of amniotic fluid.

A woman experiences a sharp, stabbing pain high in the uterine fundus as the initial
separation occurs
If labor begins with the separation, each contraction will be accompanied by pain over and
above the pain of the contraction.

In some women, additional pain is not evident with contractions but tenderness can be felt
on uterine palpation.

Heavy bleeding usually accompanies premature separation of the placenta, like placenta
previa, although it may not be readily apparent.
NO TE
External bleeding will only be evident if the placenta separates first at the edges, so blood
escapes freely into the uterus and then the cervix

in contrast, if the center of the placenta separates first, blood can pool under the placenta,
although bleeding is intense, it will be hidden from view
ASSESSMENT
As bleeding progresses, a woman’s reserve of blood fibrinogen may be used up in her body’s attempt
to accomplish effective clot formation, and disseminated intravascular coagulation (DIC syndrome)
can occur

Initial blood work should include hemoglobin level, typing and cross-matching, and a fibrinogen level
and fifibrin breakdown products to detect DIC. For a quick assessment of blood clotting ability, draw 5
mL and place it in a clean, dry test tube. Stand it aside untouched for 5 minutes. At the end of this
time, if a clot has not formed, suspect an interference with blood coagulation.
THERAPEUTIC MANAGEMENT

A woman needs a large-gauge intravenous catheter inserted for fluid replacement and oxygen by
mask to limit fetal anoxia

Monitor fetal heart sounds externally and record maternal vital signs every 5 to 15 minutes
to establish baselines and observe progress

Keep a woman in a lateral, not supine, position to prevent pressure on the vena cava and
additional interference with fetal circulation. It is important not to disturb the injured placenta any
further

Do not perform any abdominal, vaginal, or pelvic examination on a woman with a diagnosed
or suspected placental separation.
Unless the separation is minimal (grades 0 and 1),
the pregnancy must be terminated because the
fetus cannot obtain adequate oxygen and nutrients

If vaginal birth does not seem imminent,

cesarean birth is the birth method of choice

If DIC has developed, cesarean surgery may pose a

grave risk because of the possibility of hemorrhage
during the surgery and later from the surgical incision.
Intravenous administration of fibrinogen or
cryoprecipitate (which contains fibrinogen) may be
used to elevate a woman’s fibrinogen level prior to and
concurrently with surgery.
With the worst outcome, a hysterectomy might
be necessary to prevent exsanguination
Any woman who has had bleeding before birth is
more prone to infection after birth than the average
woman. A woman with a history of premature
separation of the pla centa, therefore, needs to be
observed closely for the development of infection in
the postpartum period.
 Disseminated

Intravascular
Coagulation
Nursing Care of Family Experiencing a
Sudden Pregnancy Complication
DISSEMINATED
INTRAVASCULAR
COAGULATION
an acquired disorder of blood clotting in which
the fibrinogen level falls to below effective limits

DIC occurs when there is such extreme bleeding and so

many platelets and fibrin from the general circulation rush
to the site that not enough are left in the rest of the body

The normal range is 200 to 400 mg/dL (2.0 to 4.0

g/L)

Normal blood concentration of fibrinogen in

pregnant women in their third trimester rises close
to 500 mg/dL
DISSEMINATED
INTRAVASCULAR
COAGULATION
Normally, platelets quickly form a seal over a point of
bleeding to prevent further loss of blood. Intrinsic and
extrinsic clotting pathways then activate and strengthen this
plug by fibrin threads to produce a firm, fixed structure.

To prevent too much clotting from occurring, at the same

time the clot is being formed, thrombin activates fibrinolysin,
a proteolytic enzyme, to begin to digest excess fibrin threads
(anticoagulation). This lysis results in the release of
fibrin degradation products.
SIGNS AND SYMPTOMS
Early symptoms include:

Easy bruising

Bleeding from an intravenous site

Conditions such as premature separation of the placenta, pregnancy-induced hypertension,

amniotic fluid embolism, placental retention, septic abortion, and retention of a dead fetus are all
associated with its development
ASSESSMENT

DIC is an emergency because it can result in extreme blood loss. Goals should reflect the presence
of the emergency.

Conditions such as premature separation of the placenta, pregnancy-induced hypertension,

amniotic fluid embolism, placental retention, septic abortion, and retention of a dead fetus are all
associated with its development

To stop the process of DIC, the underlying insult that began the phenomenon must be halted. When
the insult was a complication of pregnancy such as premature separation of the placenta, ending the
pregnancy by birthing the fetus and delivering the placenta is part of the solution.
THERAPEUTIC MANAGEMENT
Next, the marked coagulation must be stopped so that coagulation factors can be freed and normal
clotting function can be restored. This is accomplished by the intravenous administration of
heparin to halt the clotting cascade

Heparin must be given cautiously close to birth or postpartum hemorrhage could occur
from poor clotting after delivery of the placenta

Platelet transfusion - may be necessary to replace blood or platelet loss if bleeding

during pregnancy was the stimulus of the DIC
Antithrombin III factor, fibrinogen, or cryoprecipitate (which contains fibrinogen) -
can all be
used to restore blood clotting If these are not available, fresh frozen plasma or platelets can
also aid in restoring clotting function.