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, b. Mild sedative to aid relaxation
poliomyelitis, cytomegalovirus, c. Coitus is restricted for 2 weeks
toxoplasmosis
- Infections – UTI 4. Inevitable Abortion
- Chronic wasting disease (cardiac failure, – cervix opens begin to dilate
chronic nephritis, diabetes) Heavier bleeding and stronger contractions
- Retroverted uterus Loss of fetus usually not avoidable
- Developmental defects – bicornuate uterus, Bleeding is retroplacental and ovum is
myomas already dead
- Cervical incompetence – due to weakness Treatment is by evacuation of uterus; BOW
or trauma
- Teratogenic drugs (Isotretinoin: present in 5. Imminent Abortion
skincare products) - Open cervical os
- Endocrine imbalance - Heavier bleeding and stronger contractions
- Psychological factors - Loss of uterus not avoidable
- Trauma – accidents - Unruptured BOW
- Severe nutritional deprivation
6. Habitual Abortion – (Recurrent abortion)
occurrence of at least 3 consecutive
Spontaneous Abortion – termination of pregnancy spontaneous abortion.
spontaneously at any time before the fetus has
attained viability. these are commonly due to genetic or chromosomal
problems of the embryo, with 50-80% of
Assessment! spontaneous losses having abnormal chromosomal
number.
1. Persistent uterine bleeding and cramp like
pain Prevention!
2. Passage of fetal tissues
3. Laboratory finding – negatively or weakly a. Quit smoking – higher risk of miscarriage
positive urine pregnancy test b. Limit caffeine
4. Obtain history, including last menstrual c. Screen for STDs
period d. Take Folic acid
e. Get tested for Diabetes
Types of Spontaneous Abortion
7. Missed Abortion – fetus dies in uterus and
1. Complete Abortion – the fetus and the is retained inside. Occurs 4-6 weeks after
placenta are expelled complete fetal death.
2. Incomplete Abortion – Expulsion is
incomplete, Membranes or placenta General softening-Mummification-Stony Material
retained, Treatment is by evacuation –
Curettage. Blood mole – a retained blood covered which forms
3. Threatened Abortion – early – under 16 a firm, nodular fleshy mass.
weeks to late – 16-24 weeks.
Carneous mole – a fleshy mass consisting pieces of
Assessment! placenta and products of conception.

a. Scanty bleeding Management!

b. Slight pain or cramping
c. Closed cervical OS – tocolytic agent is not a. Dilatation and Curettage
effective. b. If over 14 weeks administer Prostaglandin
Suppository Cytotec or Oxytocin
Management! c. Disseminated Intravascular coagulation

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