Bleeding during pregnancy

Dr/ Wafy Anwar Azaz, MD

 Classification

Accidental
Abortion
hge

LATE EARLY Ectopic

pregnancy

Placenta Vesicular
previa mole
01 Bleeding in early pregnancy

(Before 20 weeks Gestation)

➢ Causes: -
1-Abortion.
2- Vesicular mole.
3- Ectopic pregnancy.

01 Abortion:
➢ Definition:
➢ It is the termination of pregnancy before 24 weeks, or products of conception
weighing below 500 grams
 Causes of abortion :
Maternal causes Fetal causes
❑ General conditions:
• Infections acute febrile conditions ❑ Chromosomal abnormalities
e.g., influenza, malaria.
• Disease such as chronic nephritis. ❑ Diseases of the fertilized ovum
• Drug intake during pregnancy.
❑ Hypoxia
• Rh and ABO incompatibility.
❑ Local conditions:
• Implantation of the ovum in the lower uterine
segment.
• Incompetent cervix.
• Uterine malformation.
• Trauma
• Endocrine dysfunction
 Types of abortion :

Abortion

Spontaneous Induced

Therapeutic Criminal
 A Spontaneous abortion:

It means termination of pregnancy through natural causes.

01 Threatened abortion:
It is one of the subdivisions of spontaneous abortion. It may go to
term, or it may become inevitable
02 Missed abortion:
Occurs when the fetus dies and is not expelled but it is retained
in utero for two months or longer
03 Inevitable abortion:
Persistent bleeding and cramps with dilatation of the cervix

04 Incomplete abortion: Some parts of the products of conception is

expelled, while others (placenta and membranes) remain
01 Septic abortion:
Incomplete abortion complicated by infection in the uterine
cavity

02 Habitual abortion:
The patient had 3 or more successive spontaneous abortions
 B Induced abortion:

01 Therapeutic abortion :
Artificial legal termination of pregnancy by the doctor due
to medical indication

02 Criminal abortion:
The illegal termination of pregnancy without medical or
obstetrical indications
 Treatment of abortion :
01 Threatened abortion

Complete bed rest

All vaginal pads and stained linen should be kept to estimate the amount of blood loss
Good personal hygienic care
Sedatives to relive pain
Checking for TPR and BO twice daily or every 4 hours
Avoid enema and purgatives
Avoid constipation and diarrhea
Rich protein diet with supplementary iron and vitamins
No sexual intercourse
Accurate observation of blood loss
 Treatment of abortion :
02 Incomplete abortion

Go to hospital for assessment and proper intervention

If no heartbeats are detected a dilute solution of oxytocin maybe given
as the doctor orders to help in expulsion of the content of the uterus
Dilatation and curettage should be done (D&C)
 Treatment of abortion :
03 Septic abortion

Isolation
Clinical bacteriological and hematological investigation to identify the organism
Antibiotics
Accurate observation of renal function
General hygiene care
The soiled pad should be properly collected and burned
Accurate observation of TPR and BP
Understanding and supporting
01 Bleeding in early pregnancy

(Before 20 weeks Gestation)

➢ Causes: -
1-Abortion.
2- Vesicular mole.
3- Ectopic pregnancy.

02 Vesicular mole:
➢ Definition:
➢ Gross malformation of the trophoblast in which chorionic villi proliferate to
become avascular and filled with fluid forming vesicles
 Causes of Vesicular mole :
The exact cause is unknown

❑ Risk factors :
• Age : >45 years or < 20 years
• Parity : more with high parity
• Socioeconomic : more in poor
• Previous obstetric performance :
common with one or more abortions
Signs and symptoms
 Types of Vesicular mole:

Vesicular mole

Partial Complete

Baby starts to develop , but is Baby never develops , but the

unable to survive , often being placenta implants and grow
absorbed into vesicles that many small cysts like sacs filled
continue to multiply with fluids
Investigations :

Pregnancy test : +ve in high dilution

Ultrasound
X-ray : no fetal skeleton

Complications :
Hemorrhage
Uterine sepsis
Choriocarcinoma
Management :

Admit patient to hospital

Fluid replacemt and packed RBCs
Preparation for evacuation of the uterus under general anesthesia
HCG levels should be checked periodically:
➢ Health education for the following
➢ Need for monitoring HCG levels for 2 years
➢ Birth spacing methos to prevent pregnancy for 2 years
01 Bleeding in early pregnancy

(Before 20 weeks Gestation)

➢ Causes: -
1-Abortion.
2- Vesicular mole.
3- Ectopic pregnancy.

03 Ectopic pregnancy:
➢ Definition:
➢ Pregnancy outside the normal uterine cavity
➢ 2% of all pregnancies
➢ 2nd most common cause of bleeding
 Sites of ectopic pregnancy

The surface of the ovary

cervix

Fallopian tube : 95%

80% occur in the ampullar part
Risk factors : Causes : causes of adhesions
that cause obstruction of the tubes

Smoking
Previous infection
Intrauterine devices (IUD)
Congenital malformation
Invitro fertilization
Scars from tubal surgery
History of ectopic pregnancy
Impaired ciliary action
Pelvic inflammatory disease
Impaired contractility
History of previous pelvic operations
IUDs
Management :
❖ Once diagnosis of ectopic pregnancy has been made , the pregnancy
should be evacuated immediately

Salpingectomy is performed
Provide emotional support to the patient
Prepare for emergency surgery
Monitor the patient for the shock
Follow up
Family planning
02 Bleeding in late pregnancy

(After 20 weeks Gestation)

➢ Causes: -
Placenta previa
Accidental hemorrhage

01 Placenta previa:
➢ Definition:
➢ Placenta is partially or totally implanted over the lower uterine segment
➢ Occurs in 1/ 200 of pregnancies that reach the 3rd trimester
 Causes of Placenta previa:
No specific cause can be detected but theories

1. Large placenta:
➢ placenta membrana ( large and thin )
➢ Placenta of twins pregnancy
➢ Syphilis
➢ Some cases of DM
2. Low implantation of placenta in LUS:
➢ Due to delayed development of trophoblast
 Risk factors of Placenta previa:

❖ Previous uterine instrumentation : (D&C)

➢ Multiparity
➢ Maternal age over 40 years
➢ Multiple gestation as twines pregnancy
➢ Prior placenta previa
➢ Uterine fibroid
 Complications

Maternal Complications : Fetal Complications :

Abnormal presentation and position Fetal malformation

Premature labor High incidence of fetal hypoxia
Prolonged labor Increase risk of
More chance of surgical intervention Perinatal mortality and morbidity
Placenta may be adherent : placenta accreta Increase risk of prematurity
Postpartum hemorrhage
Maternal shock
Management :
❖ Management of placenta previa depend on:
Amount of bleeding
The condition of mother and fetus
The degree of the placenta
The duration of pregnancy
❖ Therapeutic management
Birth must be accomplished regardless of the gestational age
If labor has begun ………..bleeding is continuing ………fetus in distress
Managed by expectant watching in :
The bleeding has stopped , fetal heart sounds are of good quality ,
maternal vitals are good , fetus is not yet 36 weeks of age
 Nursing care
Assessment :
Nurse asses bleeding on admission to hospital
History data include : gravidity , parity , bleeding and general status
Vital signs assessment
abdominal assessment
Lab investigation for possible cross matching :
CBC , blood group , coagulation profile

Diagnosis :
Focus on alternation of hemodynamic status
 Nursing care
Planning :
Plan must be related to the patient’s clinical and nursing diagnosis
The woman will identify and use available support systems
The woman will not develop complications
The woman will carry here pregnancy to term or near term
The woman will give birth to healthy infant

Evaluation:
The nurse can be assured that care was effective to the degree that goals
for care have been met
02 Bleeding in late pregnancy

(After 20 weeks Gestation)

➢ Causes: -
Placenta previa
Accidental hemorrhage

02 Accidental hemorrhage:
➢ Definition:
➢ Bleeding during last three months of pregnancy the first or second stage of labor
Due to premature separation of normally situated palcenta
 Causes of accidental hemorrhage :

1. Hypertension due to toxemia :

➢ The most common cause
2. Trauma :
➢ 2nd common cause
3. Vitamins deficiency : vitamin C&K
4. Torsion of the pregnant uterus
5. Tractions on the short umbilical cord
6. Sudden reduction of the size of the uterus
 Types of accidental hemorrhage :

1. Reversed
➢ Almost all the blood expelled through the cervix
2. Concealed :
➢ Almost all blood is retained inside the uterus
3. Combined :
➢ Some blood is retained and some is expelled
through the cervix
 Complications

Complications : Prognosis

Hemorrhage A mild case has a good prognosis

Acute renal failure Severe case has serious
Postpartum hemorrhage consequences for the mother and
Pituitary necrosis fetus
Management :

Correction of shock
Termination of pregnancy
1. Dead fetus
➢ Vaginal delivery
➢ C.S if there is contraindication of vaginal delivery
2. Living fetus :
➢ C.S
Treatment of complication :
➢ DIC &PPH
Prevention :

Avoid general pregnancy risk factors :

1. Cocaine
2. Alcohol
3. Smoking
Treating chronic high blood pressure or other conditions like DM
Good antenatal care
 Nursing care
Assessment :
Nurse asses bleeding on admission to hospital
History data include : gravidity , parity , bleeding and general status
Vital signs assessment
abdominal assessment
Lab investigation for possible cross matching :
CBC , blood group , coagulation profile
Identify an increasing fundal height which indicate concealed bleeding
 Nursing care
Diagnosis :
Focus in hemodynamics changes
Pain related to bleeding between the uterine wall and the placenta
secondary to premature separation of placenta
Grieving related to actual or threatened loss of infant
Power lessns related to maternal condition and hospitalization

Planning :
The woman will identify and use available support systems
The woman will not develop complications
The woman will carry here pregnancy to term or near term
The woman will give birth to healthy infant
 Nursing care

Evaluation :
The nurse can be assured that care was effective to the degree that goals
for care have been met
The woman identifies and uses available support systems
Express relief of pain does not develop complications
Give birth to a healthy infant who has ot experienced fetal compromise