10/5/2021

College: Applied Medical Silences

Department: Nursing

Bleeding in Early Pregnancy

Dr. Murtada Mustafa Gabir
RN, PhD

Learning objectives
•By the end of this lecture the student should be able
to:
1.Describe the hemorrhagic conditions of early
pregnancy, including spontaneous abortion,
ectopic pregnancy, and gestational trophoblastic
disease.
2.Explain nursing considerations for each
complication of pregnancy.
3.Application of the nursing process

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Introduction

•The three most common causes of hemorrhage

during the first half of pregnancy are:

1. Abortion

2. Ectopic pregnancy

3. Gestational trophoblastic disease.

Abortion

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Definition
•Abortion is the loss of pregnancy
before the fetus is viable, or capable of
living outside the uterus.
•A fetus of less than 20 weeks of
gestation or one weighing less than 500
g is not viable.

Types of abortion
•Abortion may be either spontaneous
or induced.
A. Spontaneous abortion
•is a termination of pregnancy without
action taken by the woman or another
person.

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•Spontaneous abortion is divided into

six subgroups:
1. Threatened
2. Inevitable
3. Incomplete
4. Complete
5. Missed
6. Recurrent.

Threatened abortion
Clinical Manifestations
•The vaginal bleeding.
•Uterine cramping.
•Persistent backache.
•Pelvic pressure

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Therapeutic Management
•MONITOR VAGINAL BLEEDING,
UTERINE CRAMP OR ABDOMINAL
PAIN
•Abdominal ultrasound
examination:
oTo determine if the embryo or fetus is
present and alive and the approximate
gestational age.

•Vaginal ultrasound
examination:
oTo determine whether a fetus is present and,
if so, whether it is alive.
•Maternal serum beta HCG and
progesterone levels
oMaternal serum beta HCG and progesterone
levels provide added information about the
viability of the pregnancy.

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Advised to The woman :

oLimit sexual activity until bleeding has
ceased.
oCount the number of perineal pads used.
oNote the quantity and color of blood on the
pads.
oLook for evidence of tissue passage.
oDrainage with a foul odor suggests infection.
oThe women must be advised to notify their
physician if brownish or red vaginal bleeding
is noted.

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Inevitable Abortion
•Abortion is usually inevitable when
membranes rupture and the cervix dilates.
Clinical Manifestations:
•Rupture of membranes generally is
experienced as a loss of fluid from the vagina
and subsequent uterine contractions and
active bleeding.
•Incomplete evacuation of the products of
conception can result in excessive bleeding or
infection can occur.

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•Therapeutic Management
•Natural expulsion of uterine contents is
common in inevitable abortion.
•Vacuum curettage (removal of uterine
contents with a vacuum curette) is used
to clear the uterus if the natural
process is ineffective or incomplete.

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•If the pregnancy is more advanced or if

bleeding is excessive
• Dilation and curettage (D&C)
(stretching the cervical os to permit
suctioning or scraping the uterine walls)
may be needed.

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Incomplete Abortion
•Incomplete abortion occurs when some
but not all of the products of conception
are expelled from the uterus.
•Clinical Manifestations
•The major manifestations are active
uterine bleeding and severe abdominal
cramping.

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•The cervix is open, and fetal and

placental tissues are passed.
•Retained tissue prevents the uterus
from contracting firmly

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•Therapeutic Management
•Initial treatment should focus on
stabilizing the woman’s cardiovascular
state.
✓A blood specimen is drawn for blood
type and cross match.
✓IV line is inserted for fluid
replacement and drug administration.

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✓D&C; after stabilizing the woman's

state, to remove the remaining tissue.
✓A later pregnancy and a larger amount
of fetal tissue may require a greater
cervical dilation and evacuation (D&E)
with removal of fetal tissue, followed by
vacuum or surgical curettage.

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Complete Abortion
•Complete abortion occurs when all products of
conception are expelled from the uterus.
Clinical Manifestations
•All products of conception, uterine
contractions and bleeding subside, and the
cervix closes.
•The uterus feels smaller than the length of
gestation.
•The symptoms of pregnancy are no longer
present, and the pregnancy test becomes
negative as hormone levels fall.

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•Therapeutic Management:
•Once complete abortion is confirmed No
additional intervention is required unless
excessive bleeding or infection develops.
•The woman is advised to rest and to watch for
further bleeding, pain, or fever.
•She should not have sexual intercourse until
after a follow-up visit.
•Contraception is discussed at the follow-up
visit.

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Missed Abortion

•Missed abortion occurs when the fetus

dies during the first half of pregnancy
but is retained in the uterus.

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Clinical Manifestations
•The early symptoms of pregnancy
disappear.
•The uterus stops growing and decreases in
size, reflecting the absorption of amniotic
fluid
•Maceration: discoloration, softening, and
tissue degeneration of the fetus.
•Vaginal bleeding of a red or brownish color
may or may not occur.

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•Therapeutic Management
•An ultrasound examination confirms
fetal death by identifying a gestational
sac or fetus that is too small for the
presumed gestational age.
•No fetal heart activity can be found.
•Pregnancy tests for hCG should show a
decline in placental hormone production.

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•In most cases, the contents of the uterus

would be expelled spontaneously, but
this is emotionally difficult once the
woman knows that her fetus is not alive.
•Therefore, her uterus usually is emptied
by the most appropriate method for the
size when the diagnosis of missed
abortion is made.

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•For a first-trimester missed abortion,

a D&C usually can be done.
•During the second trimester, when the
fetus is larger, a D&E may be done, or
vaginal prostaglandin E2 (PGE2) to
induce uterine contractions that expel
the fetus.
•A D&C may be needed to remove the
placenta.

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Complications of missed abortion:

1. infection
2. disseminated intravascular coagulation
(DIC). Signs such as elevation in
temperature, vaginal discharge with a
foul odor, and abdominal pain indicate
uterine infection, and evacuation of the
uterus is delayed until cultures are
obtained and antimicrobial therapy is
initiated.

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•It is defined as three or more spontaneous

abortions.
Clinical Manifestations
•Two or more pregnancy losses.
•Etiology
•Genetic or chromosomal abnormalities and
anomalies of the reproductive tract, such as
incompetent cervix.
•Inadequate luteal phase with insufficient
secretion of progesterone may cause.
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•Therapeutic Management
•Examination of the reproductive system
to determine whether anatomic defects
are the cause.
•If the cervix and uterus are normal, the
woman and her partner are usually
referred for genetic screening.

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•Additional therapeutic management of

recurrent pregnancy loss depends on the cause.
1. For instance, treatment may involve
assisting the woman to develop a regimen to
maintain normal blood glucose level if
diabetes mellitus is a factor.
2. In case of cervical incompetence; an
anatomic defect that results in painless
cervical dilation in the 2nd trimester, a
cerclage procedure; suturing of the cervix to
prevent early dilation, may be performed.

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•Nursing Considerations
•Nurses must consider the psychological
needs of the woman experiencing
spontaneous abortion.
•Nurses must convey their acceptance of
the feelings expressed or demonstrated
by the couple.

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•The couple should remain together as

much as possible.
•Providing information and simple brief
explanations of what has occurred and
what will be done facilitates the family’s
ability to grieve.
•Family support, knowledge of the grief
process, spiritual counselors, and support
from other bereaved couples may provide
needed assistance during this time.

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Ectopic Pregnancy

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•Definition
oIt is an implantation of a
fertilized ovum in an area
outside the uterine cavity.

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•Tubal damage reduces the woman’s

chances of subsequent pregnancies.
•Ectopic pregnancy remains a significant
cause of maternal death from
hemorrhage.

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•Risk factors for ectopic

pregnancy
▪History of previous ectopic
pregnancies.
▪Peak age-specific incidence 25-34
years.
▪History of sexually transmitted
diseases
▪Multiple sexual partners.

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▪Tubal sterilization and tubal

reconstruction.
▪Infertility.
▪Assisted reproductive techniques
such as gamete intrafallopian
transfer.
▪Intrauterine device (IUD).
▪Multiple induced abortions.

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•Clinical Manifestations
The classic signs of ectopic pregnancy
include the following:
✓Missed menstrual period.
✓Positive pregnancy test.
✓Abdominal pain.
✓Vaginal “spotting”.

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Diagnosis
•The combined use of transvaginal
ultrasound examination and determination
of beta-hCG usually results in early
detection of ectopic pregnancy. An
abnormal pregnancy is suspected if beta-
hCG is present but at lower levels than
expected.
•If a gestational sac cannot be visualized
when beta-hCG is present, a diagnosis of
ectopic pregnancy may be made with great
accuracy.

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•The use of sensitive pregnancy tests,

maternal serum progesterone levels,
and high-resolution transvaginal
ultrasound has largely eliminated
invasive tests for ectopic pregnancy.
•Laparoscopy (examination of the
peritoneal cavity by means of a
laparoscope) occasionally may be
necessary to diagnose rupture of an
ectopic pregnancy.

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•Therapeutic Management
A. If the tube is unruptured.
•The goal of medical management is to
preserve the tube and improve the
chance of future fertility.
• The chemotherapeutic agent
methotrexate (a folic acid antagonist)
is used to inhibit cell division in the
developing embryo.

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B. If the tube is rupture:

•The goal of therapeutic
management is to control the
bleeding and prevent
hypovolemic shock.
•Salpingectomy (removal of the
tube) with ligation of bleeding
vessels may be required.

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•Nursing Considerations
•Nursing care focuses on prevention or
early identification of hypovolemic
shock, pain control, and psychological
support for the woman who
experiences ectopic pregnancy.
•Monitor for signs and symptoms tubal
rupture or bleeding (e.g., pelvic,
shoulder, or neck pain; dizziness or
faintness; increased vaginal bleeding).

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•Administer ordered analgesics

and evaluate their
effectiveness.
•If methotrexate is used, the
nurse must explain adverse
side effects such as:
oNausea and vomiting
oTransient abdominal pain.

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•The woman must also be instructed

to:
o Stop drinking alcohol because it
decreases the effectiveness of
methotrexate.
o taking vitamins that contain folic
acid.
o having sexual intercourse until
beta-hCG is not detectable.
o If the treatment is successful, this
hormone disappears from plasma
within 2 to 3 weeks.
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•Maintaining follow-up
appointments is essential to
identify whether the hCG titer
becomes negative and remains
negative.
•The nurses should clarify the
physician’s explanation and use
therapeutic communication
techniques that assist the woman
to deal with her anxiety.

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Questions???

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Gestational Trophoblastic Disease

(Hydatidiform Mole)

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•Definition
oIt is proliferation and edema of
the chorionic villi.
oThe fluid-filled villi form
grapelike clusters of tissue that
can rapidly grow large enough to
fill the uterus to the size of an
advanced pregnancy.

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•Types
A. A partial mole that includes
some fetal tissue and
membranes
B. A complete mole that is
composed only of enlarged
villi but contains no fetal
tissue or membranes

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•Etiology and risk factors

•Age is a factor, molar pregnancies highest at
both ends of reproductive life.
•The incidence is higher among Asian women.
•Women who have had one molar pregnancy
have a greater risk to have another in a
subsequent pregnancy.
•Persistent gestational trophoblastic disease
may undergo malignant change
(choriocarcinoma) and may metastasize to
sites such as the lung, vagina, liver, and
brain.

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•Pathophysiology
•Complete mole is thought to occur when
the ovum is fertilized by a sperm that
duplicates its own chromosomes while the
maternal chromosomes in the ovum are
inactivated.
•In a partial mole, the maternal
contribution is usually present, but the
paternal contribution is doubled, and
therefore the karyotype is triploid (69,
XXY or 69, XYY).

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Clinical Manifestations
•Higher levels of beta-hCG than
expected for gestation
•Characteristic “snowstorm”
ultrasound pattern that shows the
vesicles and the absence of a fetal sac
or fetal heart activity in a complete
molar pregnancy
•A uterus that is larger than expected
for gestational age

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•Vaginal bleeding, which varies from

dark-brown spotting to profuse
hemorrhage
•Excessive nausea and vomiting (HEG),
which may be related to high levels of
beta-hCG from the proliferating
trophoblasts
•Early development of preeclampsia,
which is rarely diagnosed before 24
weeks in an otherwise normal
pregnancy.

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•Diagnosis
•Measurement of the beta-hCG levels
detects the abnormally high levels of
the hormone before treatment.
•In addition to the characteristic
pattern showing the vesicles,
ultrasound examination allows a
differential diagnosis to be made
between two types of molar
pregnancies:

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•(1) A partial mole that includes

some fetal tissue and membranes
•(2) A complete mole that is
composed only of enlarged villi
but contains no fetal tissue or
membranes.

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•Therapeutic Management
•Medical management includes
two phases:
o(1) evacuation of the
trophoblastic tissue of the mole
o(2) continuous follow-up of the
woman to detect malignant
changes of any remaining
trophoblastic tissue.

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•The mole usually is removed by

vacuum aspiration followed by
curettage.
•After tissue removal, IV oxytocin is
given to contract the uterus.
• Avoiding uterine stimulation with
oxytocin before evacuation is
important.
•Uterine contractions can cause
trophoblastic tissue to be pulled into
the large venous sinusoids in the
uterus, resulting in embolization of
the tissue and respiratory distress

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•The tissue obtained is sent for laboratory

evaluation.
•Oral contraceptives are the preferred birth
control method.
•Follow-up is critical to detect changes
suggestive of trophoblastic malignancy.
•Beta-hCG is repeated at 6 weeks
postpartum.
•Follow-up protocol involves evaluation of
serum beta-hCG levels monthly for 6
months, then every 2 to 3 months for 6
months until normal for three values.

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•Nursing Considerations
•Emotional care of the woman is also
essential because she become anxious
of:
1. follow-up evaluations.
2. the possibility of malignant change.
3. the need to delay pregnancy for at
least 1 year.

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Questions???

THANK YOU

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