1. Bleeding Disorders

2. 2
1st Trimester Bleeding
Spontaneous miscarriage
Threatened
Imminent
Complete
Missed
Recurrent pregnancy loss

3. 3
Abortion
• ABORTION Early (before 20 wks)
- Any pregnancy that terminates before the age
of viability
• Spontaneous abortion characterized by
painless (may be cramping) dark-bright red
vaginal bleeding

4. Spontaneous Abortion
• Miscarriage
Causes: Abnormal fetal formation, chromosomal
aberration, Infections (CMV & Toxoplasmosis)
S/Sx: Vaginal spotting
Managements:
- Depending on the manifestations

5. Threatened Abortion
Cause: Unknown
S/Sx: Scant bright red vaginal bleeding
with slight abdominal cramping and
no cervical dilation
Managements:
• No treatment to hold pregnancy
• Complete Bed rest (Limit activity)
• Coitus restricted for 2 wks

6. Inevitable Abortion
• Imminent
S/Sx: Moderate bright red bleeding; uterine contraction
and effacement
Managements:
• Establish IV line;Draw blood
• Administer pitocin
• WOF: signs of hypovolemic shock
• D&C

7. Complete Abortion
• All the products of conception are expelled (placenta
and fetus)
• Bleeding shows within 2 hrs and ceases within few
days after the passage of conceptus

8. Incomplete Abortion
• Part of the conception is expelled usually the fetus
• S/Sx: massive bleeding and clot bloods

9. Missed Abortion
• Intrauterine fetal death
• Fetus die in utero but not expelled
S/Sx: Asymptomatic or same with threatened abortion
Dx:
• Fetus died but not expelled
• Discovered in prenatal check-up
• Fundal height in Increasing
• No FHT

10. Missed Abortion
Cx: Disseminated Intravascular Coagulation
Management:
1. Replacement of IV fluids
2. Administer pitocin.
3. D&C

11. Habitual Abortion
• Recurrent
Cause: Defective spermatozoa, autoimmune, infection
Cx: Hemorrhage and Infection

12. 12
CLINICAL CLASSIFICATIONS OF SPONTANEOUS ABORTION
Type Assessment Nursing Considerations
Threatened Vaginal bleeding and
cramping
Soft uterus, cervix closed
Ultrasound for intrauterine sac, quantitative HCG
Decrease activity for 24-48 h, avoid stress, no sexual
intercourse for 2 wk after bleeding stops
Monitor amount and character of bleeding; report
clots, tissue, foul odor
Inevitable, if
cervical dilation
cannot be
prevented
(Imminent)
Persistent symptoms,
hemorrhage, moderate to
severe cramping
Cervical dilatation and
effacement
Monitor for hemorrhage (save and count pads) and
infection; if persistent or increased symptoms, D
and C
Emotional support for grief and loss
Incomplete Persistent symptoms,
expulsion of part of
products of conception
Administer IV/blood, oxytocin
D and C or suction evacuation
Complete As above, except no retained
tissue
Possible oxytocin PO; no other treatment if no
evidence of hemorrhage or infection
Missed – fetus dies
in utero but is not
expelled
May be none/some abating of
above symptoms
Cervix is closed
If retained >6 wk, increased
risk of infection, DIC, and
emotional distress
D and C evacuation within 4-6 wk
After 12 wk, dilate cervix with several applications of
prostaglandin gel or suppositories of laminaria
(dried sterilized seaweed that expands with cervical
secretions)
Habitual – 3 or
more
May be incompetent cervix,
infertility
Cerclage (encircling cervix with suture)

13. 13
1st Trimester Bleeding
Ectopic pregnancy
Implantation occurs outside of the uterine
cavity

14. 14
SITES AT WHICH ECTOPIC PREGNANCY CAN OCCUR

15. 15
Ectopic pregnancy
– implantation outside uterus (commonly in fallopian tube)
- potentially life threatening to mother
- Characterized by:
 unilateral lower quadrant pain after 4-6 weeks of normal
signs and symptoms of pregnancy (amenorrhea, (+)
pregnancy test
 bleeding may be gradual oozing to frank bleeding
 may be palpable unilateral mass in adnexa
 low HCG levels
 rigid and tender abdomen
 signs and symptoms of hemorrhage

16. 16
Ectopic Pregnancy
– Necessary to be alert for signs and symptoms –
investigate risk factors especially PID, multiple sexual
partners, recurrent episodes of gonorrhea, infertility
Management
– prepare for surgery
– Shock monitoring and management
– postoperatively, monitor for infection and paralytic ileus
– Provide support for emotional distress
– RhoGam for Rh- negative woman
– monitor Hgb and Hct
– ultrasound for adnexal mass/ gestational sac in tube
– culdocentesis (indicated by nonclotting blood)
– laparoscopy and/or laparotomy
– adequate blood replacement (type and X match, IV with
large-bore needle)

17. 17
2nd Trimester Bleeding
Premature cervical dilatation
Cannot hold the fetus until term
Cervical cerclage

18. 18
Incompetent Cervix
• Painless dilatation of the cervix usually in the
2nd trimester
• May lead to infection, premature rupture of
membranes, preterm labor

19. 19
SHIRODKAR SUTURE FOR CERVICAL CERCLAGE

20. 20
2nd Trimester Bleeding
Gestational trophoblastic disease
(hydatidiform mole)
Abnormal proliferation and degeneration of
the trophoblastic villi
degenerative anomaly of the placenta
converting the chorionic villi into a mass of
clear vesicles

21. 21
Hydatidiform mole
Characterized by
• elevated HCG levels
• uterine size greater than expected for gestational age
• no FHR
• minimal dark red/brown vaginal bleeding with passage of
grapelike clusters
• no fetus by ultrasound
• possible increased nausea and vomiting and associated
pregnancy-induced hypertension
• treated with curettage to completely remove all molar
tissue, which can become malignant
• pregnancy is discouraged for 1 year, and HCG levels are monitored
during that time (if it continues to be elevated, may require
hysterectomy and chemotherapy)

22. 22
Gestational trophoblastic disease
(hydatidform mole)

23. 23
3nd Trimester Bleeding
 Placenta previa
Low implantation of placenta
 Abruptio Placenta
Premature separation of placenta
Occurs suddenly

24. 24
Placenta previa
• development of the placenta in the lower uterine
segment, partially or completely covering the internal
cervical os
• Characterized by painless vaginal bleeding, which is
usually slight at first (spotting – 1st and 2nd trimesters)
and increases in subsequent unpredictable episodes;
usually soft and non tender abdomen
4 Degrees of Placenta previa
1. Low-lying - in lower segment
2. Marginal - at border of internal cervical os
3. Partial – occludes a portion of the cervical os
4. Total - complete obstruction of the os

25. 25
DEGREES OF PLACENTA PREVIA
LOW IMPLANTATION PARTIAL PLACENTA PREVIA TOTAL PLACENTA PREVIA

26. 26
Placenta Previa
Managements
• Hospitalization
• bed rest
• side-lying or Trendelenburg position for at least 72 hours
• ultrasound shows the location and degree of obstruction
• no vaginal/ rectal exam unless delivery would not be a problem
(if it becomes necessary, it must be done in OR under sterile conditions)
• amniocentesis for lung maturity
• monitor for changes in bleeding and fetal status
• daily Hgb and Hct; keep IV line and make blood available (blood typed
and cross matched- 2 units)
• Delivery by cesarean if evidence of fetal maturity, excessive
bleeding, active labor, other complications
• Home - if bleeding ceases and pregnancy to be maintained – limit
activity; no douching, enemas, coitus; monitor FM; NST at least every 1-2
wk

27. 27
Abruptio placenta
• premature separation of normally implanted
placenta; may be marginal (near edge) with
dark red vaginal bleeding or central (at
center) with concealed bleeding; life
threatening to fetus and mother
• Common among women with
hypertension, short umbilical cord and
alcohol use; also by direct trauma

28. 28
Abruptio Placenta
Characterized by:
- painful (sharp, stabbing) vaginal bleeding/ epigastric pain
- uterine rigidity and tenderness: abdomen is
tender, painful and tense (board-like)
- rapid signs and symptoms of maternal shock and/or fetal
distress (altered FHR)
- May lead to Couvelaire uterus (blood infiltrating the
uterine musculature) forming a hard, board-like uterus
without apparent bleeding
- External bleeding may seem out of proportion to
symptoms (shock) displayed by the woman

29. 29
PREMATURE SEPARATION OF THE PLACENTA

30. 30
Abruptio Placenta
• Manage signs and symptoms
- Keep woman in lateral position (not supine)
- Oxygenation (to limit fetal anoxia)
- FHR monitoring; VS monitoring
- Baseline fibrinogen (if bleeding is
extensive, fibrinogen reserve may be used up in
the body’s attempt to accomplish effective clot
formation)

31. 31
Abruptio Placenta
- NO IE or rectal examination, No enema
- Keep IV open for possible blood transfusion
• prepare for immediate delivery usually, cesarean
section
• Postoperatively monitor for complications
– Infection
– Renal failure
– Disseminated intravascular coagulation (DIC)

32. 32
Disseminated Intravascular Coagulation (DIC)
 Disorder of blood clotting
Fibrinogen levels fall below effective limits
 Symptoms
Bruising or bleeding
massive hemorrhage initiates coagulation process
causing massive numbers of clots in peripheral vessels
(may result in tissue damage from multiple
thrombi), which in turn stimulate fibrolytic
activity, resulting in decreased platelet and fibrinogen
levels and
signs and symptoms of local generalized bleeding
(increased vaginal blood flow, oozing IV
site, ecchymosis, hematuria, etc)
monitor PT, PTT, and Hct, protect from injury; no IM
injections; early anticoagulant therapy is controversial