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• High risk pregnancy (bleeding disorders) are the focus for a second year nursing class studying mother and child care.

Bleeding Disorders

• Divided into first, second, and third trimesters with specific conditions for each.

First Trimester

• Abortion or miscarriage occurs
• Ectopic pregnancy is possible

Second Trimester

• Hydatidiform mole may occur.
• Incompetent cervix may be present

Third Trimester

• Placenta previa can occur.
• Abruptio placenta may be present
• Preterm labor occurs

Emergency Interventions

• Alert the healthcare team.
• Place the mother flat in bed on her side.
• IV fluids are administered as ordered such as Lactated Ringers.
• Administer oxygen (6-10 LPM) via face mask.
• Uterine contractions and FHR must be monitored
• Vaginal examinations are avoided.
• Oral fluids are withheld.
• Blood typing and crossmatching is done.
• Input and output are measured.
• Vital signs must be assessed every 15 minutes, including pulse oximeter and automatic BP cuff
• Assist with central venous pressure or pulmonary artery catheter placement.
• Measure maternal blood loss by weighing perineal pads, saving any passed tissue.
• A blood sample is observed for clot formation
• Assist with ultrasound and provide emotional support.

Spontaneous Miscarriage/Abortion

• Abortion is the medical term for interruption of a pregnancy before the fetus is viable
• Elective abortion is a planned medical termination of a pregnancy.
• Miscarriage is the spontaneous interruption of a pregnancy.

Causes

• Abnormal fetal development caused by teratogenic factors or chromosomal aberration can cause issues
• Immunologic factors cause possible rejection of the embryo through immune responses
• Implantation abnormalities and inadequate progesterone leads to miscarriage
• Systemic infections like Rubella and syphilis can cause miscarriages
• Ingestion of teratogenic drugs may put the pregnancy at risk

Types

• Threatened, Inevitable/Imminent, Complete, Incomplete, Missed, Recurrent/Habitual, and Septic are the types of spontaneous abortion

Ectopic Pregnancy

• Implantation occurs outside the uterine cavity.

Types

• Tubal (fallopian tube), cervical, abdominal, ovarian are the different types

Predisposing Factors

• Fallopian tube narrowing or constriction
• Pelvic inflammatory disease (PID) history is a factor
• Puerperal and postpartal sepsis can be a cause
• Surgery on the fallopian tubes
• Congenital anomalies in this area
• Adhesions, spasms, tumors can be causes
• IUD usage

Assessment Findings

• Amenorrhea or abnormal menstrual cycle
• Early signs of pregnancy are likely
• Tubal rupture signs: acute low abdominal pain radiating to the shoulder (Kehr's sign) or neck pain.
• Nausea
• Bluish navel (Cullen's sign).
• Rectal pressure and positive pregnancy test (50%)
• Sharp localized pain when the cervix is touched.
• Signs of shock/circulatory collapse.

Diagnostics

• Ultrasonography
• Culdocentesis
• Laparoscopy
• Serial testing of HCG beta-subunit

Treatment

• Methotrexate, Leucovorin can be used for Unruptured

Nursing Management for Ectopic Pregnancy

• Ongoing assessment for shock
• Implement shock treatment promptly.
• Position in modified Trendelenburg
• Infuse D5LR, plasma administration, blood transfusion, or drugs as ordered.
• Monitor vital signs and bleeding
• Psychological support

Hydatidiform Mole

• Abnormal proliferation and degeneration of the trophoblastic villi.
• Cells degenerate, fill with fluid, and appear as clear fluid-filled, grape-sized vesicles.
• Gestational Trophoblastic Disease
• Cause unknown

Risk Factors

• Low protein intake
• Women older than 35 years old
• Asian women
• Women with a blood group of A who marry men with blood group O

Assessment Findings

• Brown or red, intermittent or profuse vaginal bleeding by 12 weeks.
• Spontaneous expulsion of molar cyst typically occurs between the 16th to 18th weeks of pregnancy.
• Rapid uterine enlargement inconsistent with the age of gestation.
• Symptoms of PIH before 20 weeks
• Excessive nausea and vomiting because of excessive HCG (1-2 million IU/L/24 hours).
• Positive pregnancy test
• No fetal signs, nor movement
• Abdominal pain

Diagnosis

• Passage of vesicles
• Triad signs: big uterus, vaginal bleeding, HCG greater than 1 million.
• Ultrasound can be used

Prognosis

• 80% remission after D&C
• May progress to cancer, choriocarcinoma

Treatment

• Evacuation by suction dilatation and curettage (D&C) or hysterectomy if no spontaneous evacuation.
• Hysterectomy if above 45 years old and no future pregnancy is desired.
• HCG titer monitoring for one year
• Medical replacement of blood, fluid, and plasma may be needed
• Chemotherapy for malignancy: Methotrexate is the drug of choice
• Chest X-ray

Nursing Management for Hydatidiform Mole

• Advises to bed rest and monitor vitals
• Monitor blood loss, molar/tissue passage, and I&O.
• Maintain fluid and electrolyte balance, plasma, and blood volume
• Prepare for suction D&C or hysterectomy
• Provide psychological support.
• Need for follow-up HCG titer determination for 1 year is emphasized

Premature Cervical Dilatation (Incompetent Cervix)

• Condition characterized by a mechanical defect.

Associated With

• Increased maternal age
• Congenital structural defects
• Trauma to the cervix

Assessment Findings

• Painless contractions
• History of abortions with the delivery of dead or nonviable fetus
• Relaxed cervical os on pelvic examination

Treatment

• Conservative management of bed rest, avoidance of heavy lifting, and not coitus
• Women With Previous Losses can have elective cervical cerclage such as Shirkodar or McDonald procedure

Nursing Management for Premature Cervical Dilatation

• Provide psychological support to client who may have negative feelings.
• Provide post-cerclage procedure care.
• Advise limitation of physical activities within 2 weeks after treatment.
• Matrnal and fetal growth monitoring.
• Instruct to report promptly signs of labor.

Abruptio Placenta

• Premature separation of the implanted placenta before the birth of the fetus

Predisposing Factors

• Arterial hypertension
• Uterine fibroids
• Previous placental abruption
• Uterine infection
• Maternal age
• Smoking

Types

• Type I: Concealed, Covert or Central type will have concealed bleeding
• Type II: Marginal, Overt or External bleeding type presents visible bleeding

Assessment Findings

• Painful, vaginal bleeding
• Rigid, board-like, painful abdomen
• Enlarged uterus due to concealed bleeding
• If in labor: tetanic contractions without alternating contraction and relaxation of the uterus

Complications

• Hemorrhagic shock has a risk for
• Couvelaire uterus due to blood in musculature
• Disseminated Intravascular Coagulation (DIC)
• Cerebrovascular Accident (CVA) from DIC
• Hypofibrinogenemia
• Renal failure
• Infection
• Prematurity and fetal stress

Preterm Labor

• Labor that occurs after the 20th week and before the 37th week of gestation.
• In >30% of cases, exact cause is unknown.
• Occurs approximately 9-11% of all pregnancies.
• Any woman with persistent uterine contraction (4 q 20 minutes).

Associated With

• Dehydration and UTI's
• Periodontal disease and chorioamnionitis
• Strenous job or fatigue

Complications

• Prematurity and fetal death
• Small-for-gestational age (SGA) / Intrauterine Growth Restriction (IUGR)
• Increased perinatal morbidity and mortality

Treatment

• Bed rest on Left Lateral Recumbent (LLR)
• Adequate hydration

PROM: Premature Rupture of Membrane

• Known as Spontaneous rupture of fetal membrane any time after the peiod of viability but before the onset of labor
• Largely unknown, and may be associated with the infection of the membrane (Chorioamnionitis).
• Occurs in 5-10% of pregnancies

Assessment Findings

• Maternal report of passage of fluid per vagina is present
• Determination of alkaline amniotic fluid
• Not acidic urine or vaginal discharge

Diagnosis

• Nitrazine Test with color change of nitrazine paper from yellow to to blue color because of neutral to slightly alkaline amniotic fluid
• Ferning Test will examine the Amniotic fluid, which is high in sodium content
• Sterile Speculum Examination that does direct visualization of fluid from cervical os

Complications

• Maternal infection or chorioamnionitis
• Cord prolapse
• Premature labor

Management

• Initial Assessment to confirm the diagnosis of PROM, gestation of the fetus, identify the woman who need to deliver.
• If > 37 weeks and with presence of the if, the delivery happens
• Congenital anomalies, fetal distress, cord prolapse, Signs of chorioamnionitis
• Induction of labor with no contraindication
• If it is before 34 weeks will aim is to prolong the pregnancy for fetal maturity so bed rest, CBC and Cervical swab c/s, give corticosteroid and tocolytics, and antibiotics while watching signs for chorioamnionitis, maternal and fetal condition will be needed.