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

Pregnancy conception 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 Types of Abortion
red blood cell volume
 Cold, clammy skin: Vasoconstriction A. Induced
occurs to maintain blood volume in central
body core.  Therapeutic
 Decreased urine output: Inadequate blood  Non-Therapeutic
is 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 Bleeding is retroplacental and ovum is
uterus, myomas already dead
- Cervical incompetence – due to weakness Treatment is by evacuation of uterus;
or trauma BOW
- Teratogenic drugs (Isotretinoin: present in
skincare products) 5. Imminent Abortion
- Endocrine imbalance - Open cervical os
- Psychological factors - Heavier bleeding and stronger contractions
- Trauma – accidents - Loss of uterus not avoidable
- Severe nutritional deprivation - Unruptured BOW

6. Habitual Abortion – (Recurrent abortion)

Spontaneous Abortion – termination of occurrence of at least 3 consecutive
pregnancy spontaneously at any time before the spontaneous abortion.
fetus has attained viability.
these are commonly due to genetic or
Assessment! chromosomal problems of the embryo, with 50-
80% of spontaneous losses having abnormal
1. Persistent uterine bleeding and cramp like chromosomal number.
pain
2. Passage of fetal tissues Prevention!
3. Laboratory finding – negatively or weakly
positive urine pregnancy test a. Quit smoking – higher risk of miscarriage
4. Obtain history, including last menstrual b. Limit caffeine
period c. Screen for STDs
d. Take Folic acid
Types of Spontaneous Abortion e. Get tested for Diabetes

1. Complete Abortion – the fetus and the 7. Missed Abortion – fetus dies in uterus
placenta are expelled complete and is retained inside. Occurs 4-6 weeks
2. Incomplete Abortion – Expulsion is after fetal death.
incomplete, Membranes or placenta
retained, Treatment is by evacuation – General softening-Mummification-Stony Material
Curettage.
3. Threatened Abortion – early – under 16 Blood mole – a retained blood covered which
weeks to late – 16-24 weeks. forms a firm, nodular fleshy mass.

Assessment! Carneous mole – a fleshy mass consisting pieces

of placenta and products of conception.
a. Scanty bleeding
b. Slight pain or cramping Management!
c. Closed cervical OS – tocolytic agent is not
effective. a. Dilatation and Curettage
b. If over 14 weeks administer Prostaglandin
Management! Suppository Cytotec or Oxytocin
c. Disseminated Intravascular coagulation
a. Limit activities
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8. Septic Abortion Major risk factors include: Prior tubal surgery,
Use of intrauterine device, Tissue insult resulting
- associated with incomplete abortion and from pelvic inflammatory disease
fever
- foul smelling vaginal discharge Minor risk factors include: Prior abdominal or
- can lead to Toxic Shock Syndrome pelvic surgery, exposure utero diethylstilbestrol
- Symptoms usually are fever and crampy (DES)(Estrogen), In vitro fertilization and embryo
abdominal and tender uterus upon transfer
palpation.
- Obtain CBC, serum electrolytes, Sites of Ectopic pregnancy
creatinine,
blood type and crossmatch, and cervical, 1. Fallopian tubes
vaginal and urine culture. 2. Cervix
3. Uterine cornu
Management! 4. Ovaries
5. Abdomen
a. Broad spectrum antibiotics 6. Broad ligament
b. Dilatation and Curettage
c. Tetanus Toxoid Assessment!
d. Rh (D Antigen) immunoglobulin (RhIg)
given to Rh Negative mothers to prevent  History of missed periods
Isoimmunization  Abdominal pain, may be localized to one
side (unilateral)
Nursing Interventions  Rigid tender abdomen; sometimes
abnormal pelvic mass
 Save all tissue passed  Bleeding
 Keep client at rest and teach reason for bed  Low hemoglobin and hematocrit, rising
rest white cell count
 Prepare client for surgical intervention  HCG titers usually lower than in
(D&C) intrauterine pregnancy
 Provide discharge teaching about limited  Knife-like pain in lower quadrant
activities and coitus after bleeding ceases  Dark red vaginal spotting
 Observe reaction of others and provide  Cullen’s sign – bluish tinge at the peri-
emotional support, and give opportunity to umbilical area
express feelings of grief and loss.  Mass at the cul de sac of douglas and
 Administer Rhogam if mother is Rh blood during needle aspiration
negative (Culdocentesis)

RhoGAM – a prescription medicine (via IM) that Management!

is used to prevent RH immunization, a condition
in which an individual with Rh negative blood a. Salpingostomy – contents of the fallopian
develops antibodies after exposure to Rh positive tubes are removed by making an opening;
blood. fallopian tubes is replaced and pregnancy
is terminated.
III. Ectopic Pregnancy b. Salpingectomy – removal of Fallopian
tube
Any gestation outside the uterine cavity. Most c. Methotrexate:
frequent in the fallopian tubes, where the tissue is
incapable of growth needed to accommodate 1 mg/kg per day (ODD# DAYS)
pregnancy, do rupture of the site usually occurs Asymptomatic, motivated
before 12 weeks. Low serum B-HcG level (<1000 mlU/ml)
<3.5 cm ectopic pregnancy
Absent fetal cardiac activity
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Adverse effect: liver involvement, stomatitis,  Absent fetal heart and parts
gastroenteritis.  Signs of preeclampsia (elevated BP and
Proteinuria)
Heterotopic Pregnancy  Unexplained degree of anemia
 Passage of vesicles per vagina
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 Nursing Interventions
ectopic 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
choriocarcinoma.  Women are not recommended to become
pregnant until 6 months for partial mole
The mole looks like a bunch of whitish grapes, and 12 months for complete mole.
often interspersed with blood clot.  It is recommended to use hormonal
method.
The baby do not develop and only placenta forms
with abnormal large cysts (sacs of fluid). V. Premature Cervical Dilatation

Complete mole It is a painless condition in which the cervix

dilates without uterine contractions and allows
 There is total hydatidiform change with no passage of the fetus usually the result of prior
evidence of fetal circulation. cervical trauma.
 Proliferation of the trophoblasts cells is
marked Occurs most often in the fourth or fifth month of
pregnancy.
 All trophoblastic villi swell and become
cystic
Assessment!
Karyotype is 46xx from paternal contribution

Partial mole  History of repeated, relatively painless

abortions
 Associated with a fetus  Early and effacement and dilation of
cervix
 Hydatidiform change is variable
 Bulging of membranes through cervical os
 Karyotype is abnormal and chromosome is
triploid 69 xxx or xxy
Medical Management!
Assessment!
 Cervical Cerclage on the 12th – 14th week
of gestation thru vaginal route by regional
 Bleeding
anesthesia
 Hyperemesis
 Pallor and Dyspnea a. Shirodkar Procedure – permanent type:
 Anxiety and tremor suture is threaded in the submucous
layer of the cervix.
Signs
 Uterine enlargement
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b. McDonald Procedure – temporary  No vaginal and rectal examinations
type: nylon suture are placed  Amniocentesis for lung maturity
horizontally and vertically across the  Daily Hgb and Hct
cervix and pulled tight to reduce the  Monitor blood loss
cervical canal. Sutures are removed at  Send home if bleeding ceases and
37th - 38th week of gestation. pregnancy is maintained
 No douching, enemas, and coitus
After cerclage it is advised for bedrest and placed
 Monitor fetal movement
on slight modified Trendelenburg position.
 Delivery by cesarean if evidence of fetal
 Observe for contractions, rupture of
maturity, excessive bleeding, active labor,
membranes, and monitor fetal heart tones
other complications
 Position client to minimize pressure on
cervix. VII. Abruptio Placenta
VI. Placenta Previa Premature separation of the placenta from the
uterine wall after the twentieth week of gestation
Low implantation of the placenta so that it and before the fetus is delivered.
overlays some or all of the internal cervical os.
Types of Abruptio Placenta
Types of placenta previa
a. Marginal (Overt)
Total – cervical os is completely covered b. Central (Concealed)
Partial – internal os is partially covered
Marginal – edge of placenta is at the margin Risk factors!
Low lying – implanted in the lower segment; edge
does not reach internal os 1. Increase maternal age
2. High parity
Risk factors! 3. Increased uterine distention
4. Diabetes
1. Prior previa (4-8%) 5. Cocaine and Smoking
2. First subsequent pregnancy following a
caesarean delivery Assessment!
3. Multiparity
4. Advance maternal age
 Painful vaginal bleeding
5. Prior induced abortion
 Uterine rigidity or Couvelaire uterus
6. Smoking
 Absence of fetal heart tones
Assessment!  Signs of shock

 Bright red vaginal bleeding after 7th month Management!

of pregnancy
a. Obtain IV access using 2 large-bore
 Uterus is soft, relaxed, and nontender
intravenous lines
 Vaginal examination can result in severe
b. Institute crystalloid fluid resuscitation for
bleeding and should only be done if the
the patient
fetus is mature enough to be born.
c. Begin transfusion if the patient is
 Diagnosis by sonography hemodynamically unstable
d. Correct coagulopathy
Nursing Interventions e. Administer Rh immune globulin if the
patient is Rh-negative
 Hospitalization f. Anticipate coagulation
 Bedrest side-lying or Trendelenburg at g. Medications (Magnesium sulfate,
least 72 hrs. Apresoline, Valium)
 Ultrasound for placental position
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h. Vaginal delivery – preferred method if the
fetus has died secondary to placental
abruption
i. Caesarean delivery – necessary for fetal
and maternal stabilization; if hemorrhage
cannot be controlled, a cesarean
hysterectomy is required.

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.