Hemorrhagic Disorders in Pregnancy

Bleeding in early pregnancy

Definition:

it means bleeding before 20 weeks of gestation)

Causes

1- Abortion.

2- Vesicular mole.

3- Ectopic pregnancy.

4- Local lesions — cervical polyps — cervical cancer.

1- Abortion

Definition: It is the termination of pregnancy before 24 weeks, or products of

conception weighing below 500 grams. It occurs in 10-15% of pregnancy , 80% of

them occur in the first trimester.

Causes:

 Fetal: - Chromosomal anomalies. - Diseases of the fertilized ovum. - Hypoxia.

 Maternal: - Infections e.g. influenza, malaria, syphilis ,HIV. - Disease such as chronic nephritis,TB. -
Drug intake during pregnancy. - Rh and ABO incompatibility. - Incompetent cervix. - Uterine
malformation. - Acquired uteine defect as uterine fibroid or adhesions - Trauma - criminal interference, -
Endocrinal disorder as hypothyrodism , daibetes mellitus

Types of abortion: - Spontaneous abortion - Threatened abortion - Missed abortion - Inevitable

abortion - Complete abortion - Incomplete abortion - Habitual abortion - Therapeutic abortion -
Criminal abortion - Septic abortion

2- Threatened abortion:

It is an attempt of uterus to get rid of its contents

Signs & symptoms: - Vaginal bleeding, mild & bright red in color - Abdominal pain and backache may or
may not be present. - Cervical os is closed. - Membranes are intact.

Nursing management: - Complete bed rest - Avoid, heavy work enema &constipation - no sexual
intercourse - Administration of prescribed drugs

2- Inevitable abortion

• Bleeding is excessive (more than 10 days).

• Blood is red in color with clots.

• Severe colicky lower abdominal pain.

• Cervical os is dilated and rupture of membranes has occurred.

• There is severe blood loss and the woman becomes shocked.

Nursing management: - Hospitalization - Antisock measure: - Fluid infusion - Bl. transfusion if indicate -
O2/mask 6-8L/m - Warmth - Sedative ; 10mg morphia - If no heart beats are detected a dilute solution
of oxcytocin may be given as

the doctor orders to help in the expulsion of the contents of the uterus. - Dilatation and curettage
should be done.

3-Missed abortion:

Fetus is dead and retained inside the uterus

Signs & symtomes: - Some signs of pregnancy disappear. - Pregnancy test will be negative. - Fundal
height does not increase in size. - The breasts may secrete milk due to hormonal changes - FHR are
absent. - No fetal movement. - A sonar test confirms fetal death. - Some brownish vaginal discharge

Management - Wait about 2-4 weeks aiming spontaneous expulsion & follow up by

coagulation profile - Evacuation

4- Septic abortion:

Definition; any type of abortion complicated by infections e.g., missed or criminal

abortion

Signs & symptoms:

 Tender and painful uterus.

 Offensive vaginal bleeding.

 High temperature.Rapid pulse. .Unstable blood pressure.

 Shock.

Nursing management: - Isolation. - Complete bed rest → in fowler's position - Monitoring for vital signs
& fluid chart. - Fluid infusion (5% glucose + saline) to maintain urine flow >30 ml/hr - Clinical
bacteriological to identify the infectious organisms. - Administration of antibiotics, Antipyretic
&Analgesic as doctor orders. - The soiled pads should be properly collected and burned

5- Incomplete abortion

Signs & symptoms: - Severe bleeding. - Cervical is partly closed. - No uterine involution. - Pain may or
may not be present. - Uterus is soft and smaller than the expected period of pregnancy.

6-Complete abortion:
Signs & symptoms: - There is minimal bleeding. - Pain stops. - Uterus is hard and much smaller - The
cervix is closed - Rh incompatibility.

Treatment: of the cause such as cervical incompetence or treatment of causative

diseases as syphilis, DM, etc.

Nursing Management of Abortion

Prevention measures should be taken to avoid risk of a spontaneous abortion:

• A nutritional diet.

• Avoiding smoking or drinking.

• Receiving available immunizations against infectious diseases.

• Treatment of vaginal or pelvic infections.

2-Hydatidiform Mole (Vesicular Mole)

Definition: is a gross malformation of the trophoblast in which the chorionic villi

proliferate and become avascular.

Causes:

• The exact cause is unknown.

Risk factors are:

• Maternal age above 40 years or below 19 years.

• Malnutrition

Types

• partial mole

• complete mole

Signs and Symptoms

• Excessive frequent vomiting.

• Over distension of the uterus and larger than expected for weeks of

gestation.

• Some vaginal bleeding may occur plus vesicles.

• No fetal movements ,No fetal parts

• Positive pregnancy test result in highly diluted urine 1:500.

Complications:

• Hemorrhage.

• shock

• perforation

• Uterine sepsis.

• Choriocarcinoma

Nursing management:

• Admit the woman into hospital.

• Evacuation of the uterus under

general anesthesia.

• Health education on the following:

• Need for monitoring HCG levels for two years (monthly for the first 3

months, then every three months for one year).

• Birth spacing methods to prevent pregnancy for two years.

• If HCG levels remain more than five international units per liter eight weeks

postpartum, prophylactic chemotherapy is indicated.

3-Ectopic Pregnancy

Definition :

pregnancy occurring outside the normal uterine cavity .it

usually occurs 99% of cases in the uterine tube.

Tubal Pregnancy

Causes:

• Impaired tubal cilliary action.

• Impaired tubal contractility.

• Decreased sperm mobility.

• The use of intrauterine contraceptive device.

Risk Factors:

• Pelvic inflammatory disease.

• History of previous pelvic operations such as D and C, ovarian surgery.

Signs and Symptoms

• Short periods of amenorrhea.

• Blood stained vaginal discharge.

• Signs of shock.

• Dyspareunia.

Management:

Surgical

• Sudden/recurrent severe, colicky abdominal pain in one iliac fossa or entire

lower abdomen.

• Especially in undisturbed ectopic.

• Evacuated immediately.

• Salpingectomy is performed.

• Provide emotional support.

• Follow-up is needed.

Medical

 When undisturbed.

 B-HCG less than 10000

 Mthotrexate is used and follow up of B-HCG titre is a must.

Bleeding late in pregnancy

Definition:

It is defined as bleeding from the genital tract between 28th week of pregnancy and

onset of labor.

Classification:

• Placenta previa

• Abruptio placenta

• Vasa previa

1-Placenta Previa
Abnormal situated placenta in lower uterine segment.

Signs & Symptoms:

 Vaginal bleeding bright red, painless, recurrent

 Soft, pain free uterus

 Easy to feel fetus & hear FHR

Degrees

1.Complete "Centralis";placenta completely covers the internal os even when it is

fully dilated.

2. Incomplete "Partials";placenta covers the internal os when it is closed, but covers

it partially when it is fully dilated.

3. Lateralis:placenta on LUS but does not reach internal os.

4. Marginalis:placenta reaches internal os but does not cover it

Nursing management:

• Bed rest and restriction of physical activity for at least 24 hours after

admission.

• Avoid constipation, enemas, and vaginal and rectal examinations

• Follow strict aseptic technique to avoid infection.

• Continuous observation of bleeding and signs of shock.

• listening FHR every 4 hours.

• accurate recording of intake and output.

• I.V fluids & o2 mask

2-Abruptio Placenta:

Premature separation of normally situated placenta.

Signs & Symptoms

 Abdominal pain

 Dark red vaginal bleeding

 Tender uterus

 Fetal parts hard to feel

 No fetal heart is heard

Types

• Revealed: almost all the blood expelled through the cervix.

• Concealed: almost all the blood is retained inside the uterus.

• Combined: some blood is retained inside the uterus and some is expelled

through the cervix.

Nursing management:

 Continuous observation of patient‘s general condition, blood pressure, vital

signs, bleeding and signs of shock.

• Continuous observation of fetal condition.

• Initiation and continuous observation of IV transfusion.

• Give medications accurately, especially for hypotension and shock if

present.

• Regular urine analysis for proteinuria.

• Assessment and recording of intake and output.

• Assist in vaginal delivery,

• Provide pre-operative care & post-operative care.