1st Trimester Bleeding

1st Trimester Bleeding 1. ABORTION - any interruption of pregnancy before the fetus is viable *Causes: a. Abnormal fetal formation b. Implantation abnormalities c. Lack of progesterone production by Corpus Luteum d. Infection e. Trauma f. Ingestion of teratogenic drugs *Types: A. Spontaneous Abortion - loss of pregnancy that occurs naturally for unknown reasons. *s/s: a. Vaginal Bleeding * Pathophysiology: a. Loss of HCG, decrease progesterone and estrogen level Normal HCG: 400,000 IU Abnormal: 1-2M IU b. Uterine decidua sloughs off c. Vaginal Bleeding d. Uterus becomes irritable e. Contracts and expels the fetus B. Induced Abortion - abortion done intentionally * Types: a. Therapeutic/Medical Abortion b. Criminal Abortion C. Threatened Abortion - unexplained vaginal bleeding w/o cervical dilation *Doctor’s Advise: a. Bed Rest b. Limiting Activity/No strenuous activity *s/s: a. Vaginal Bleeding b. Rhythmic uterine cramping c. Persistent backache d. Feelings of pelvic pressure D. Imminent/Inevitable - situation where irreversible uterine evacuation has begun - D&C is done if no FHB E. Complete - entire contents of the conception is expelled spontaneously w/o any assistance - bleeding is minimal & observed for 24-48 hrs F. Incomplete - part of the conceptus is expelled but the membranes or placenta are retained in the uterus *s/s: a. uterine bleeding b. severe abdominal cramping G. Missed Abortion - fetus dies in utero & is retained for 2 or more months * Early s/s: a. Uterus stops growing b. Painless vaginal bleeding *Marked generative changes in fetus a. Maceration b. Mummification c. Lithopedian formation H. Habitual/Recurrent - abortion that occurs ff. 2 previous consecutive pregnancy losses. *Common Cause: INCOMPETENT CERVIX *other cause: a. Autoimmune b. Infection of the developing fetus c. Deviation of the uterus d. Defective sperm/ovum I. Septic Abortion - abortion that is complicated by infection *Causes: a. prolonged unrecognized ROM b. Pregnancy with IUD in utero c. criminal attempts to terminate pregnancy *s/s: a. fever b. Crampy abdominal pain c. Uterus feels tender on palpation *If untreated: a. Toxic shock syndrome

b. Septicemia c. Kidney failure d. Death *Management: a. IVF – avoid hypovolemic shock/for fluid replacement b. High doses of antibiotics c. Removal of infected and necrotic tissue – D&C d. TT immunization – 7.5 ml vaccine *General care for Abortion: 1. monitor BP/PR 2. observe for behaviors indicative of shock 3. count pads and weigh them 4. assess FHB 5. prepare IV therapy 6. have 02 available 7. CBR w/o BP 8. inform client to abstain from coitus 2. ECTOPIC PREGNANCY - refers to pregnancy outside the uterine cavity - causes: unknown *Sites of implantation: a. Fallopian tube b. surface of the ovary c. cervix d. Intestine (abdominal ectopic pregnancy) *Early signs: a. usual symptom of pregnancy b. dull pain on the affected side *Tubal Rupture: (6-14 wks) a. sudden, sharp, severe low quadrant pain that radiates to the shoulders - PHRENIC NERVE in the abdominal area up to the shoulders become irritated b. Vaginal bleeding or Spotting c. Signs of shock - increase RR, PR, paleness d. Cullen’s Sign - bluish discoloration under the navel - signify bleeding underneath d. excruciating pain in the cervix upon examination e. tender mass is usually palpable in the CUL-DE-SAC of DOUGLAS - recto-uterine pouch; palpated through vagina f. Decreased hemoglobin, hematocrit, Increased WBC *Diagnostic Evaluation: a. Transvaginal ultrasound b. Pregnancy test c. High resolution ultrasound d. Culdocentesis e. Laparoscopy - viewing of peritoneal cavity using laparoscope Exploratory laparoscopy - literally looking at peritoneal cavity; xiphoid to sympysis pubis * Therapeutic Management: A. Medical Management o METHOTREXATE - folic acid antagonist that interferes cellular regeneration or building up of new cells - given until woman is (-) for HcG B. Surgical Management o LINEAR SALPHINGOSTOMY - open the fallopian tube, remove fetus, and close again Salphingectomy - removal of F. tube Histerectomy - removal of uterus TAHBSO - Total Abdominal Histerectomy with Bilateral Salphingo Oophorectomy; indicated for older adults * Nursing Care: a. Modified Trendelenburg Position b. Observe for increasing pain especially on the shoulders c. Assess for vaginal bleeding d. Observe for signs of hypovolemic shock e. Monitor v/s f. Advice to avoid sexual intercourse until medical treatment is successful 2nd Trimester Bleeding 1. Gestational Trophoblastic Disease - proliferation & degeneration of trophoblastic villi filled with fluid; grapelike clusters *Also known: H-mole, Molar Pregnancy * Reason: Ovum is too immature, penetrated by multiple sperm * Risk factors: a. Low CHON intake

b. Age below 18 yrs old and above 35 yrs old c. Asian Heritage *Types: A. Complete Mole - characterized by the large amount of edematous villi but no fetus or fetal membrane - HcG is present - associated with CHORIOCARCINOMA - anuclear ovum w/o maternal genetic material B. Partial Mole - NO fetus but with fetal circulation - 69 chromosomes - NO embryo but fetal blood is present in the villi - if with embryo, multiple fetal abnormalities - rarely lead to carcinoma *s/s a. s/s of pregnancy b. uterus grow more rapidly than expected c. UTZ show no developing fetus d. HcG titer is usually high e. Vaginal spotting f. No FHB g. Unusually early dev’t of PIH *Therapeutic Management a. immediate evacuation of the mole - D&C b. follow-up to detect malignant changes c. curettage to remove all the molar tissue d. Hysterectomy (for severe, old, many children) e. need for follow-up 1 yr after molar evacuation 2. INCOMPETENT CERVIX - painless condition in which cervix dilates w/o uterine contraction & allows passage of the fetus *Causes: a. congenital anomalies b. trauma to the cervix c. endocrine imbalance - lack of estrogen to keep integrity of muscle d. infection/inflammation e. increase maternal age *Surgical Management a. CERVICAL CERCLAGE - approximately 12-14 wks purse-string sutures are placed in the cervix *Types: a. Shirodkar Technique - vaginal mucous membrane is elevated & narrow strip is carried around the internal OS & tied b. McDonald Technique - non absorbable suture around the cervix - temporary closure *permanent cerclage should avoid labor to avoid uterine contraction that rupture cervix - suturing of cervix only, could give birth normally, strip before 37wk of pregnancy *Post operative care: a. Bed rest after the procedure b. Ritodrine HCl - muscle relaxant that prevents uterine contraction with incompetent cervix c. Monitor FHB d. Observe for signs of rupture of membrane e. Limit activity f. Avoid douching and coitus for 2wks 3rd Trimester Bleeding 1. PLACENTA PREVIA - low implantation of placenta *Degrees: a. Low-lying - it’s implanted near the cervical OS - implanted on the lower segment of the uterus b. Marginal - placental edge is approaching the cervical OS - not covering the cervical OS c. Partial - half of the cervical OS is covered by the placenta d. Total - covers the entire cervical OS *Conditions associated with PP: a. Multiparity b. Multiple gestation c. Alteration in uterine structure d. Uterine scars from previous surgery e. increased maternal age *s/s: a. sudden onset of painless uterine bleeding b. boggy uterus

c. FHB and activity are weak d. Fetus is usually in an abnormal presentation (transverse) *Nsg. ALERT: Do not perform IE until location & position of placenta have been verified by UTZ *Management: a. Conservative treatment - bed rest b. Active approach - vaginal delivery (provided not complete) - C-section - Medications: relaxant 2. ABRUPTIO PLACENTA *Other names: - premature separation of placenta - accidental hemorrhage - apoplexy (stroke of the placenta) - ablation placenta *primary cause: UNKNOWN *predisposing factors: a. chronic hypertensive disorders - increased pressure of blood kick placenta out of where it is implanted b. cocaine used by mother - vasoconstrictor cause early detachment c. multiple gestation d. short umbilical cord e. direct trauma f. manual manipulation of the uterus during pregnancy g. nutritional deficiency (Folate) - helps in proper implantation of placenta; also progesterone *s/s a. If MARGINAL, painless vaginal bleeding b. If CENTRAL, bleeding is painful, dark red in color *types of hemorrhage a. Concealed – pooling of blood in center b. Apparent – certain portion of placenta is not attached; leaking c. Abdomen is hard w/ board-like uterus d. COUVELAIRE uterus – bluish discoloration of uterus signifies bleeding *Types of Abruptio a. Covert/Severe/Central - central separation b. Overt/Partial/Marginal - separation occurs at the margin c. Placenta Prolapse/Complete - complete/ almost total separation associated w/ massive vaginal bleeding - leads to IUFD because of lack of O2 *Management: a. If mild, fetus is immature & shows no sign of distress o Bedrest o Tocolytic drugs – muscle relaxant b. If fetus shows signs of compromise/ when there is excessive bleeding: o CS

o Vaginal delivery *Nsg Care: a. on admission, assess bleeding b. initial blood works c. O2 mask (for mother and child) d. monitor maternal and fetal status e. regulate IVF/BT as ordered f. CBR g. NO vaginal exam h. prepare patient for surgery 3. PREMATURE LABOR - labor that occurs after the 20th wk and before the 37th wk of gestation *Contributing Factors: a. Low socio-economic status b. Medical status c. OB history d. Lifestyle e. Psychological factors *Etiology: a. uterine activity increases when uterine blood flow is compromised b. occupational fatigue *s/s: a. menstrual like b. low backache c. increase in vaginal discharge d. irregular uterine contraction e. bloody show