Nursing Care for Women with Bleeding in Early Pregnancy

‫الرحيم‬ ‫الرمحن‬ ‫هللا‬ ‫بسم‬
َ‫ل‬ َ‫ك‬َ‫ن‬‫ا‬َ‫ح‬ْ‫ب‬ُ‫س‬ ْ‫ا‬‫و‬ُ‫ل‬‫ا‬َ‫ق‬‫آ‬َ‫ن‬َ‫ل‬ َ‫م‬ْ‫ل‬ِ‫ع‬ّ‫ل‬ِ‫إ‬
ُ‫م‬‫ي‬ِ‫ل‬َ‫ع‬ْ‫ال‬ َ‫ت‬ْ‫ن‬َ‫أ‬ َ‫ك‬ّ‫ن‬ِ‫إ‬ ‫آ‬َ‫ن‬َ‫ت‬ْ‫م‬ّ‫َل‬‫ع‬ ‫ا‬َ‫م‬
ُ‫م‬‫ي‬ِ‫ك‬َ‫ح‬ْ‫ال‬
‫العظيم‬ ‫اهلل‬ ‫صدق‬
‫سورة‬‫البقرة‬‫أية‬32
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 1

High risk pregnancy
Thursday, April 5, 2018
Dr. Soad Abd El salam Ramdan 2

3
• Chairman of obstetrics &woman health
nursing department
• Pre. Vice of dean for students &Education
Affair
Faculty of nursing
Benha University
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan

Learning objectives:-
 Describe causes of bleeding in early pregnancy.
 Apply nursing care plan for woman with
bleeding in late pregnancy.
 Enumerate types of associated medical
problems during pregnancy.
 Describe the nurses responsibilities in relation
to various types of associated medical problems
during pregnancy.

Bleeding during pregnancy
Bleeding
Late
pregnancy
Accidental
hge.
Placenta
previa
Early
pregnancy
Abortion
Ectopic
pregnancy
Vesicular
mole

1- Bleeding
in early pregnancy

1-Bleeding In Early Pregnancy
(Before 20 weeks Gestation)
Causes:-
 Abortion.
 Vesicular mole.
 Ectopic pregnancy.

Related to pregnant state
 Abortion
 Ectopic pregnancy
 Molar pregnancy
Bleeding in early pregnancy
abortion ectopic Vesicular
mole

1- Abortion

1- Abortion :-
Definition
It is the termination
of pregnancy before
24 weeks, or products
of conception
weighing below
500 grams.

Causes
Fetal
 Chromoso
mal
anomalies.
 Diseases of
the
fertilized
ovum.
 Hypoxia.
Maternal
General conditions:
►Infections acute febrile conditions e.g. influenza, malaria.
►Disease such as chronic nephritis.
►Drug intake during pregnancy.
►Rh and ABO incompatibility.
Local conditions:
►Conditions that interfere with embedding, development and
nutrition of the ovum.
►Implantation of the ovum in the lower uterine segment.
►Incompetent cervix.
►Uterine malformation.
►Trauma - criminal interference, accidents, violent exercises,
uterine stimulation.
►Endocrine dysfunction

Types of
Abortion
Spontaneous induced
Therapeutic
Criminal

Spontaneous
Abortion
Threatened
Pregnancy
Progresses
Birth of
Viable Infant
Missed
Carneous
Mole
Inevitable
Incomplete
Septic
Complete

Types of Abortion:-
A- Spontaneous abortion: It means
termination of pregnancy through natural causes.
 ◘ Threatened abortion: It is one of the
subdivisions of spontaneous abortion. It may go to
term, or it may become inevitable.
 ◘ Missed abortion: Occurs when the fetus dies
and is not expelled but it is retained in utero for
two months or longer.

Cont.
◘ Inevitable abortion: Persistent bleeding and
cramps with dilatation of the cervix. Complete
abortion:All the products of conception are expelled.
◘ Incomplete abortion: Some parts of the
products of conception have been expelled, while
others (placenta and membranes) remain within the
uterus.
◘ Septic abortion: Incomplete abortion
complicated by infection of the uterine cavity.
◘ Habitual abortion: The patient has had three or
more successive, spontaneous abortions.

B- Induced abortion
 Therapeutic abortion: It means
artificial legal termination of pregnancy by
a physician due to medical indication.
 ◘ Criminal abortion: The illegal
termination of pregnancy.There are no
medical or obstetrical indications.

pes Types of abortion

Signs and Symptoms of
Abortion
1-Threatened abortion:
Cervical os is closed.
Membranes are intact.
Pain and backache may or may
not be present.

2- Incomplete abortion:
 Parts of the products of conception are
expelled (fetus is expelled from uterus,
placenta and membranes are still inside).
 Severe bleeding.
 Cervical os partly closed.
 No uterine involution.
 Pain may or may not be present.
 Uterus is soft and smaller than the
expected period of pregnancy

3- Septic abortion:
 Tender and painful uterus.
 Offensive vaginal bleeding.
 High temperature.
 Rapid pulse.
 Chills.
 Unstable blood pressure.
 Shock.

4- Inevitable abortion:
 Bleeding is excessive (more than 10 days).
 Blood is red in color with clots.
 Severe colicky lower abdominal pain.
 Cervical os is dilated and rupture of
membranes has occurred.
 Uterus will be firm.
 There is severe blood loss and the woman
becomes shocked.

5- Missed abortion:
 Fetus dies and is retained in the uterus.
 Some signs of pregnancy disappear.
 Pregnancy test will be negative.
 Fundal height does not increase in size.
 The breasts may secrete milk due to
hormonal changes/(Prolactin). FHR are
absent.
 No fetal movement.
 A sonar test confirms fetal death.
 Some brownish vaginal discharge.
 Cervix os is closed.
Thursday, April 5, 2018
Dr. Soad Abd El salam Ramdan 23

Treatment
◘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 such as phenobarbital 60 mg. is
usually ordered, for pain, pethidine 30-60
mg is ordered.
 Checking ofTPR and BP twice daily, or
every 4 hours according to the condition
of the mother.

Cont. :-
 Avoid enema and purgatives.
 Avoid constipation and diarrhea.
 Rich protein diet with supplementary iron
and vitamin should be provided.
 Advise no sexual intercourse.
 Administration of prescribed drugs.
 Accurate observation of blood loss, color,
odor, amount and content.
 Intake and output chart should be kept.

Treatment of incomplete abortion:
 Go to hospital for assessment and proper
intervention.
 If no heart beats are detected a dilute
solution of oxcytocin may be given as the
doctor orders to help in the expulsion of
the contents of the uterus.
 Dilatation and curettage should be done.

Treatment of Septic abortion:
 Isolation.
 Clinical bacteriological and hematological investigation
to identify the infectious organisms.
 Administration of antibiotics as doctor orders.
Electrolyte control.
 Accurate observation of renal functions.
 Intake and output chart should be kept.
 General hygienic care.
 The soiled pads should be properly collected and
burned.
 Accurate observation of TPR and BP.
 Understanding and supporting.

6- Recurrent (Habitual)
Abortion
 Definition:
Three (two by some authors) or
more consecutive abortions.
Dr. Soad Abd El salam RamdanThursday, April 5, 2018 28

Recurrent (Habitual)
Abortion>Aetiology:
 1. Chromosomal abnormalities: Can be
detected in
o Foetus: e.g. autosomal trisomy, sex
chromosome monosomy (X), and
polyploidy.
o Parents: e.g. balanced translocation.

Abortion>Aetiology:
 2.Uterine abnormalities:
o Congenital anomalies: e.g. hypoplasia, bicornuate, septate
and subseptate uterus.
o Intrauterine synechiae (Asherman’s syndrome).
o Cervical incompetence: whether congenital or acquired.
o Uterine myomas.
o Deficiency of endometrial oestradiol and progesterone
receptors: leads to failure of implantation or early abortion
o Divided uterine artery: uterus with two ascending uterine
arteries may fail to provide adequate blood flow to the
developing placenta and the growing foetus.

Abortion>Aetiology:
 3.Infections:
oToxoplasma.
o Mycoplasma hominis.
o Ureaplasma urealyticum.
o Listeria monocytogenes.
o Brucella.
o Chlamydia.
o Syphilis.
Dr. Soad Abd El salam Ramdan
Thursday, April 5, 2018 31

Abortion>Aetiology:
 4. Hormonal:
o Hypothyrodism,
o Diabetes.
o Luteal phase deficiency.
Dr. Soad Abd El salam Ramdan
Thursday, April 5, 2018 32

Abortion>Aetiology:
 5. Immunological:
o Human leukocyte antigens (HLA): the
difference in HLA between both parents
stimulates the maternal production of the
"blocking factors" which prevent rejection of
the conception. More sharing in HLA
between the parents causes recurrent
abortions. So the incidence of recurrent
abortions is higher if there is positive
consanguinity between the two partners.

Abortion>Aetiology:
 5. Immunological:
o Antiphospholipid antibodies:These
antibodies cause placental vessels
thrombosis resulting in infarction and
placental insufficiency.
o Systemic lupus erythematosus.

Abortion>Aetiology:
 6. Miscellaneous:
o Chronic malnutrition.
o Chronic anaemia.
o Chronic cardiac and renal diseases.
o Cigarette smoking and alcohol
abuse.

Abortion>:Treatment
 Medical treatment:
 Treatment of the cause as:
o anaemia and malnutrition,
o diabetes,
o renal diseases,

Abortion>:Treatment
 o infections as chlamydia and
mycoplasma (tetracycline or doxycycline)
and toxoplasma (spiramycin) which may
need another coarse(s) of treatment
during pregnancy.

Abortion>:Treatment
 Luteal phase defect treated by
progesterone or progestogens in the
secretory phase and up to 16th week of
pregnancy.

Abortion>:Treatment
* Surgical treatment:
Cervical cerclage:
Ultrasonography is done before operation to:
# confirm foetal viability,
# exclude congenital
anomalies,
# measure the internal os.

Abortion>:Treatment
 o Cervical cerclage:
+ It means encircling the cervix at
or as near as possible to the internal os by a
non-absorbable suture.
+ The best time for the operation
is about 12-14 weeks, so that the placenta is
formed and there is no possibility of
abortion due to congenital anomalies of the
early embryo.
+ The suture is removed at 38
weeks or if labour started at any time.

Abortion>:Treatment
Vaginal cerclage:
# Shirodkar operation:
* Two incisions at the reflection of the
vaginal wall on the cervix are done
anteriorly and posteriorly and bladder is
dissected upwards.A nylon or silk suture
or a dacron (mersilene) tape is applied
around the internal os under the cervical
mucosa.

Abortion>:Treatment
 Vaginal cerclage:
 # Mc Donald operation:
* It is the commonest operation.
* The cervix is surrounded from outside by
a nylon or silk purse- string suture.The
suture takes bites of cervical tissue at
3,6,9 and 12 o'clock then tied anteriorly
or posteriorly.
* This operation is easier and gives nearly
the same results as Shirodkar.

Abortion>:Treatment
 + Abdominal cerclage:
# In case of previous high
amputation of the cervix extensive
cervical laceration or repeated failure of
vaginal cerclage.
# The isthmus uteri is
encircled by a non-absorbable suture and
the patient should be delivered by
caesarean section.

THANKYOU
Thank you

Nursing Care for Women with Bleeding in Early Pregnancy

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