1. Hemorrhagic disorders in pregnancy can occur early or late term and include conditions like spontaneous or induced abortion, ectopic pregnancy, molar pregnancy, and placental abnormalities. 2. Spontaneous abortion, also called miscarriage, is the unintentional termination of pregnancy before 20 weeks gestation. Risk factors include chromosomal abnormalities, infections, or lifestyle factors. Ectopic pregnancy occurs when the fertilized egg implants outside the uterus, usually in the fallopian tubes. 3. Molar pregnancy results from abnormal placenta formation causing a cluster of cysts instead of a normal placenta and baby. It carries risks for hemorrhage and later development of gestational troph

1. Hemorrhagic Disorder

2. Hemorrhagic Disorder
• Early term:
– Abortion
– Ectopic Pregnancy
– Hydatid Form Mole
Late term
Placenat previa
Abruption Placenta

3. Abortion Tree
abortion
Spontaneous A
Threatened
A
Induced A.
therapeutic
inevitable
missed
incomplete
may go to term
criminal
septic
complete
habitual

4. SPONTANEOUS ABORTION
• Spontaneous abortion is the unintended
termination of pregnancy at any time
before the fetus has attained viability (20
weeks' gestation or fetal weight of 500 g
[1.1 lb]). See Table 37-1. For a discussion
of therapeutic or voluntary abortion

5. Spontaneous Abortion
1. Also called miscarriage
2. Unpreventable loss of pregnancy
3. Loss of pregnancy before 20 weeks
4. Maybe 20-25% of all pregnancies

6. Spontaneous Abortion
• Most occur
before 8 weeks
(about 90%)
• 50% caused by
chromosomal
abnormalities
• Late miscarriage • Miscarriage may
occurs between
be caused by
12 and 20 weeks
several factors

8. Spontaneous Abortion
• Types of miscarriage
1.
2.
3.
4.
5.
Incomplete
Complete
Missed
Recurrent
Septic

9. Classification Clinical Manifestations
Management
1. Threatened
Clinical manifestation
• Vaginal bleeding or spotting
• Mild pain, Tenderness over uterus, low backache
• Cervix closed
Management
• Bed rest(ABR)
• Pad count
2. Inevitable
Clinical manifestation
• Bleeding more profuse
• Cervix dilated
• Painful uterine contractions
• Embryo delivered complete or incomplete , followed by dilatation and
curettage (D&C)

10. 3. Incomplete
Clinical manifestation
• Fetus usually expelled
• Placenta and membranes retained
Management
• Embryo delivered, followed by dilatation and curettage (D&C)
4. Missed
Clinical manifestation
• Fetus dies in utero and is retained
• Maceration
• No symptoms of abortion, but symptoms of pregnancy regress (uterine size,
breast changes)
Management
• Ultrasound,
• Fetal monitoring
• If fetus is not passed after diagnosis, oxytocin induction may be used.
• Retained dead fetus may lead to development of disseminated intravascuia
coagulation or infection
• Fibrinogen concentrations should be measured weekly

11. 3. Habitual
• Spontaneous abortion occurs in
successive pregnancies (3 or more)

12. Pathophysiology/Etiology
1. Cause frequently unknown, but 50% are due to
chromosomal anomalies
2. Exposure or contact with teratogenic agents
3. Poor maternal nutritional status
4. Maternal illness with or specific bacterial
microorganisms
5. History of diabetes, thyroid disease,
6. Smoking or drug abuse or both
7. Immunologic factor
8. Luteal phase defect
9. Postmature sperm or ova
10. Structural defect in the maternal reproductive
sysytem (including an incompetent cervix)

13. Induced Abortion.
Therapeutic/ Voluntary Abortion
• Therapeutic abortion is the termination of
pregnancy before fetal viability for the
purpose of safeguarding the woman's
health.
• Voluntary abortion is the termination of a
pregnancy before fetal viability as a choice
of the woman(nontherapeutic).

14. Complications
1. Hemorrhage
2. Uterine infection
3. Septicemia
4. Uterine perforation
5. Disseminated intravascular coagulation
(DIC) in a missed abortion

15. Nursing Assessment
1. Evaluate the amount and color of blood
2. Determine gestational age, LMP and EDC
3. Monitor maternal vital signs for indications
of complications such as
hemorrhage, infection.
4. Evaluate any blood or clot tissue for the
presence of fetal membranes, placenta, or
fetus.

16. Nursing Diagnoses
A. Risk for Fluid Volume Deficit related to
maternal bleeding
B. Anticipatory Grieving related to loss of
pregnancy, cause of the abortion, future
childbearing
C. Risk for Infection related to dilated cervix
and open uterine vessels
D. Pain related to uterine cramping and
possible procedures

17. Nursing Interventions
A. Maintaining Fluid Volume
1. Report shock sign(tachycardia, hypotension,
diaphoresis, or pallor) indicating hemorrhage.
2. Screen blood type, blood administration( if
needed).
3. Establish and maintain an IV with large-bore
catheter for possible transfusion
4. Inspect all tissue passed for completeness.

18. B. Providing Support Through the
Grieving Process
Grieving process;
Denial, Anger, Bargaining, Depression,
Acceptance
1. Accesss the reaction of patient and support person and
provide information regarding current status, as needed.
2. Encourage the patient to discuss feelings about the loss of
the baby; include effects on relationship with the father.
3. Do not minimize the loss by focusing on future
childbearing; rather acknowledge the loss and allow
grieving.
4. Provide time alone for the couple to discuss their feelings.
5. Discuss the prognosis of future pregnancies with the
couple.
6. If the fetus is aborted intact, provide an opportunity for
viewing, if parents desire.

19. C. Preventing Infection
1. Evaluate temperature every 4 hours if
normal, and every 2 hours if elevated.
2. Check vaginal drainage for increased
amount and odor, which may indicate
infection.
3. Instruct on and encourage perineal care
following each urination and defecation to
prevent contamination.

20. D. Promoting Comfort
1. Reduced anxiety.
2. Instruct and encourage the use of
relaxation techniques to augment
analgesics.
3. Administer pain medications as needed
and as prescribed.

21. Patient Education/Health Maintenance
• 1. Provide the names of local support groups for
couples who have experienced an early
pregnancy loss
• 2. Discuss with the couple the methods of
contraception to be used.
• 3. Explain the need to wait at least 3 to 6 months
before attempting another pregnancy.
• 4. Teach the woman to observe for signs of
infection (fever, pelvic pain, change in character
and amount of vaginal discharge), and advise to
report them to provider immediately.

22. Evaluation
A. Vital signs remain normal; minimal blood
loss
B. Expresses feelings regarding the loss of
the pregnancy
C. No signs of infection, temperature normal,
performs perineal care
D. Verbalizes relief of pain

23. ECTOPIC PREGNANCY
• Ectopic pregnancy is any gestation located
outside the uterine cavity.

24. Pathophysiology/Etiology
1. The fertilized ovum implants outside of the uterus.
a. ampler portion of fallopian tube.
b. abdomen and the ovaries.
2. Structural factors; adhesions of the tube, salpingitis,
congenital and developmental anomalies
induced(septic) abortions.
3. Functional factors include menstrual reflux and decreased
tubal motility.
4. Contributing factors may include:
a. History of pelvic inflammatory disease (PID)
b. Endometriosis
c. Previous tubal surgery

25. Clinical Manifestations
1. Abdominal or pelvic pain
2. Amenorrhea—in 75% of the cases
3. Vaginal bleeding—usually scanty and dark
4. Uterine size is usually similar to what it would be in a
normally implanted pregnancy.
5. Abdominal tenderness on palpation
6. Nausea, vomiting, or faintness may be present.
7. Pelvic examination reveals a pelvic mass, posterior or
lateral to the uterus, and cervical pain on movement of
the cervix.
8. Pain may become severe if a tubal rupture occurs and
clinical presentation will be that of shock.

26. Diagnostic Evaluation
1. Serum β-human chorionic gonadotropin (βhCG)— when done serially, will not show
characteristic rise as in intrauterine pregnancy
2. Ultrasound—may identify tubal mass, absence of
gestational sac within the uterus
3. Culdocentesis—bloody aspirate from the cul-desac of Douglas indicates intraperitoneal bleeding
from tubal rupture
4. Laparoscopy—visualization of tubal pregnancy
5. Laparotomy—indication for surgery if there is any
question about the diagnosis

27. Management
1. Surgeries range from removal of ectopic
pregnancy with tubal resection,
salpingostomy, salpingectomy, and
possibly sal- pingo-oophorectomy.
2. Treat shock and hemorrhage if
necessary(rupture)

28. Nursing Assessment
• Evaluate the following to determine pregnancy and
to monitor for changes in patient's status, such as
rupture or hemorrhage:
1. Maternal vital signs
2. Presence and amount of vaginal bleeding
3. Amount and type of pain
4. Presence of abdominal tenderness on
palpation(bluish low lateral abdomen)
5. Date of last menstrual period
6. Presence of positive pregnancy test

29. Nursing Diagnoses
A. Risk for Fluid Volume Deficit related to
blood loss from ruptured tube
B. Pain related to ectopic pregnancy or
rupture and bleeding into the peritoneal
cavity
C. Anticipatory Grieving related to loss of
pregnancy and potential loss of
childbearing capacity

30. Nursing Interventions
A. Maintaining Fluid Volume
1. Establish an intravenous (IV) line with a
large-bore catheter and infuse fluids and
blood products as prescribed.
2. Obtain blood samples for complete blood
count (CBC) and type and screen for whole
blood, as directed.
3. Monitor vital signs and urine output
frequently, depending on condition.

31. B. Promoting Comfort
1. Administer analgesics as needed and
prescribed.
2. Encourage the use of relaxation
techniques.

32. C. Providing Support During Grief
1. Be available to patient and provide emotional
support.
2. Listen to concerns of patient and significant
others.
3. Be aware that family may be experiencing
denial or other stage of grieving.
4. Suggest referrals such as social worker,
psychiatry, and clergy, as appropriate.

33. Patient Education/Health
Maintenance
1. Teach signs of postoperative infection;
fever, abdominal pain, and increased or
malodorous vaginal discharge.
2. Reinforce that chances of another ectopic
pregnancy are increased
3. Discuss contraception.
4. Teach signs of recurrent ectopic
pregnancy—abnormal vaginal bleeding,
abdominal pain, menstrual irregularity.

34. Evaluation
A. Vital signs stable
B. Verbalizes pain relief
C. Patient and support person express
sorrow over their loss

35. HYDATIDIFORM MOLE
• Hydatidiform mole is an abnormal
pregnancy resulting from a developmental
anomaly of the placenta.
• It is characterized by the conversion of
the chorionic villi into a mass of clear
vesicles.
• There may be no fetus or a degenerating
fetus may be present.

36. • Abnormal
fertilization results
in abnormal growth
of cells in uterus.
The ―mole‖ grows
in the uterus
instead of a baby.
The ―mole‖ looks
like a cluster of
grapes.

37. • Occurrence
1. May occur in 1 out of every 1200
pregnancies (U.S data)
2. May be higher in Asian countries

38. • Possible Causes
1.
2.
3.
4.
Nutritional deficiencies
Age: early teens, over 40
Ovulation stimulation with Clomid
History of miscarriage

39. Pathophysiology/Etiology
1. Large amounts of hCG are present
secondary to the proliferation of chorionic
tissue. Assay values of β-hCG are
elevated in the condition.
2. Contributing factors may include
chromosomal
abnormalities, malnutrition, hormonal
imbalance, age under 20 or over 40, and
low economic status.

40. Hydatidiform mole
• Signs and Symptoms
1.
2.
3.
4.
5.
6.
Pregnancy symptoms
Larger than normal uterus
95% of women will eventually bleed
Excessive nausea and vomiting
Anemia
Abdominal cramps

41. Clinical Manifestations
1. First trimester bleeding
2. Absence of fetal heart tones and fetal
structures (by ultrasound)
3. Rapid enlargement of the uterus; size
greater than dates
4. β-hCG titers greater than expected for
gestational age
5. Expulsion of the vesicles
6. Hyperemesis
7. Signs of pregnancy-induced hypertension
(PIH) prior to 20 weeks' gestation

42. Diagnostic Evaluation
1. β-hCG levels—elevated
2. Ultrasound—shows a characteristic
picture of the mole in most cases

43. Management
1. D&C(dilatation and curettage) or
D&E(dilatation and evacuation)
2. Follow-up for detection of malignant
changes because a complication is the
development of choriocarcinoma of the
endometrium.

44. Complications
1. Complete mole can cause cancer. About
20% will develop into a rare cancer called
choriocarcinoma.
2. 15% of women will develop early high
blood pressure disease (at 9 – 12 weeks).

45. Nursing Assessment
1. Monitor maternal vital signs; note presence
of hypertension.
2. Assess the amount and type of vaginal
bleeding; note the presence of any other
vaginal discharge.
3. Assess the urine for the presence of protein
and β-hCG.
4. Palpate uterine height; if above the
umbilicus, measure the fundal height.
5. Determine date of last menstrual period and
date of positive pregnancy test.

46. Nursing Diagnoses
A. Potential for Fluid Volume Deficit related
to maternal hemorrhage
B. Anxiety related to loss of pregnancy and
medical interventions

47. Nursing Interventions
A. Maintaining Fluid Volume
1. Obtain blood samples for type for whole
blood transfusion
2. Establish and maintain IV line.
3. Assess maternal vital signs and evaluate
bleeding.
4. Monitor laboratory results to evaluate
patient's status.

48. B. Decreasing Anxiety
1. Prepare the patient for surgery; explain
preoperative and postoperative care
along with intraoperative procedures.
2. Educate patient and family on the disease
process.
3. Allow the family to grieve over the loss of
the pregnancy.

49. Patient Education/Health
Maintenance
1. Advise the woman on the need for continuous followup care(for monitor choriocarcinoma).
2. Provide reinforcement of follow-up procedures:
a. Measure hCG levels every 1 to 2 weeks until
normal—then begin monthly testing for 6 months, then
every 2 months for a total of 1 year.
b. Consider chemotherapy or hysterectomy if β-hCG
levels rise or begin to plateau or there is evidence of
metastasis.
3. Encourage ongoing discussion of care with health care
provider.
4. Avoid pregnancy for a minimum of I year.

50. Evaluation
A. Vital signs stable; laboratory work within
normal limits
B. Verbalizes concerns about self and
related procedures; describes follow-up
care and its importance