2. 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 2
3. 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
5. 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.
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 5
7. 1- Bleeding
in early pregnancy
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8. 1-Bleeding In Early Pregnancy
(Before 20 weeks Gestation)
Causes:-
Abortion.
Vesicular mole.
Ectopic pregnancy.
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9. Related to pregnant state
Abortion
Ectopic pregnancy
Molar pregnancy
Bleeding in early pregnancy
abortion ectopic Vesicular
mole
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11. 1- Abortion :-
Definition
It is the termination
of pregnancy before
24 weeks, or products
of conception
weighing below
500 grams.
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12. 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
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15. 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.
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16. 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.
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17. 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.
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18. pes Types of abortion
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19. Signs and Symptoms of
Abortion
1-Threatened abortion:
Cervical os is closed.
Membranes are intact.
Pain and backache may or may
not be present.
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20. 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
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21. 3- Septic abortion:
Tender and painful uterus.
Offensive vaginal bleeding.
High temperature.
Rapid pulse.
Chills.
Unstable blood pressure.
Shock.
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22. 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.
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23. 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.
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Dr. Soad Abd El salam Ramdan 23
24. 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.
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25. 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.
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26. 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.
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27. 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.
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 27
28. 6- Recurrent (Habitual)
Abortion
Definition:
Three (two by some authors) or
more consecutive abortions.
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29. 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.
Dr. Soad Abd El salam RamdanThursday, April 5, 2018 29
30. Recurrent (Habitual)
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.
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33. Recurrent (Habitual)
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.
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34. Recurrent (Habitual)
Abortion>Aetiology:
5. Immunological:
o Antiphospholipid antibodies:These
antibodies cause placental vessels
thrombosis resulting in infarction and
placental insufficiency.
o Systemic lupus erythematosus.
Dr. Soad Abd El salam RamdanThursday, April 5, 2018 34
35. Recurrent (Habitual)
Abortion>Aetiology:
6. Miscellaneous:
o Chronic malnutrition.
o Chronic anaemia.
o Chronic cardiac and renal diseases.
o Cigarette smoking and alcohol
abuse.
Dr. Soad Abd El salam RamdanThursday, April 5, 2018 35
36. Recurrent (Habitual)
Abortion>:Treatment
Medical treatment:
Treatment of the cause as:
o anaemia and malnutrition,
o diabetes,
o renal diseases,
Dr. Soad Abd El salam RamdanThursday, April 5, 2018 36
37. Recurrent (Habitual)
Abortion>:Treatment
o infections as chlamydia and
mycoplasma (tetracycline or doxycycline)
and toxoplasma (spiramycin) which may
need another coarse(s) of treatment
during pregnancy.
Dr. Soad Abd El salam RamdanThursday, April 5, 2018 37
38. Recurrent (Habitual)
Abortion>:Treatment
Luteal phase defect treated by
progesterone or progestogens in the
secretory phase and up to 16th week of
pregnancy.
Dr. Soad Abd El salam RamdanThursday, April 5, 2018 38
39. Recurrent (Habitual)
Abortion>:Treatment
* Surgical treatment:
Cervical cerclage:
Ultrasonography is done before operation to:
# confirm foetal viability,
# exclude congenital
anomalies,
# measure the internal os.
Dr. Soad Abd El salam RamdanThursday, April 5, 2018 39
40. Recurrent (Habitual)
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.
Dr. Soad Abd El salam RamdanThursday, April 5, 2018 40
41. Recurrent (Habitual)
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.
Dr. Soad Abd El salam RamdanThursday, April 5, 2018 41
42. Recurrent (Habitual)
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.
Dr. Soad Abd El salam RamdanThursday, April 5, 2018 42
43. Recurrent (Habitual)
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.
Dr. Soad Abd El salam RamdanThursday, April 5, 2018 43
45. Hydatidiform Mole (Vesicular
Mole)
Hydatidiform mole is a gross
malformation of the trophoblast
in which the chorionic villi
proliferate and become avascular.
The villi are filled with fluid forming
vesicles, which look like a bunch of
grapes.
It is an abnormal development of
the chorionic villi of conceptus.
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 45
47. Causes:-
The exact cause is unknown
◘ Risk factors are:-
age ; old than 45 years or younger than
20 years
Parity ;more with high parity
Socioeconomic ;more in poor
Previous obstetric performance
;common with one or more abortion .
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48. Types:
Partial molar pregnancy:
This is where a baby starts to develop, but is
unable to survive, often being absorbed into
the vesicles that continue to multiply.
Complete molar pregnancy:
This is where a baby never develops, but the
placenta implants and grows many small
cysts, like sacs filled with fluid.
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49. Causes
◘ The exact cause is unknown.
◘ Risk factors are:
Maternal age above 40 years
or below 19 years.
Malnutrition (deficiency of
proteins).
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50. Signs and Symptoms
◘ Signs and symptoms of early pregnancy are
present.
◘ Excessive frequent vomiting.
◘ Over distension of the uterus and larger than
expected for weeks of gestation.
◘ vaginal bleeding with passage of vesicles.
◘ No fetal movements are reported by the mother.
◘ No fetal parts can be palpated and no fetal
heartbeats can be detected.
◘ On palpation the uterus may have an elastic
consistency or it may be doughy.
◘ There is an increased incidence of pre-eclampsia.
◘ Positive pregnancy test result in highly diluted
urine 1:500.
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51. Investigations:-
◦ Pregnancy test is +ve in high dilution.
◦ Ultrasound.
◦ X-ray (no fetal skeleton.
◦ If 1/200 is +ve it is highly suggestive.
◦ If 1/500 is +ve it is surely diagnostic
Complications:-
◘ Hemorrhage.
◘ Uterine sepsis.
◘ Choriocarcinoma
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52. Management:-
◘ Admit the woman into hospital.
◘ Fluid replacement and packed RBCs.
◘Prepare the woman for evacuation of the uterus
under general anesthesia.
◘ HCG levels should be checked periodically.
◘ Health education on the following:
Need for monitoring HCG levels for two years
(monthly for the first 3 months, then every three
months for one year).
Birth spacing methods to prevent pregnancy for
two years.
If HCG levels remain more than five international
units per liter eight weeks postpartum,
prophylactic chemotherapy is indicated.
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54. Ectopic Pregnancy:-
Ectopic pregnancy is defined as
pregnancy occurring outside the
normal uterine cavity.
◘ It is an abnormal implantation
of the fertilized ovum that occurs
outside the uterine cavity.
Approximately 2% of
pregnancies are ectopic.
Second most frequent cause of
bleeding.
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55. Sites of ectopic pregnancy
implantation:
1. The surface of the ovary
2. Cervix
3. Fallopian tube (95% ): 80% occur in the
ampullar
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56. Ectopic Pregnancy Incidence
increase with:
Smoking.
Intrauterine devices (IUDs).
In vitro fertilization.
History of ectopic pregnancy (10%-20%).
Pelvic inflammatory disease.
History of previous pelvic operations such as
D and C, tuboplasty, tubal sterilization,
ovarian surgery.
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57. Causes:-
Obstruction, such as an adhesion of the fallopian
tube.
Causes of adhesions:
1. Previous infection.
2. Congenital malformations.
3. Scars from tubal surgery.
4. Uterine tumor.
Impaired tubal ciliary action.
Impaired tubal contractility.
Decreased sperm mobility.
The use of intrauterine contraceptive device.
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 57
58. Signs and Symptoms :-
Short periods of amenorrhea.
History of infertility, tubal surgery, induced
abortion.
Sudden/recurrent severe, colicky abdominal
pain in one iliac fossa or entire lower
abdomen.
Dizziness and fainting attacks.
Blood stained vaginal discharge.
Diffuse tenderness on lower abdomen.
Signs of shock.
Dyspareunia.
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59. Management
Once the diagnosis of ectopic pregnancy has
been made, the pregnancy should be evacuated
immediately.
Salpingectomy is preformed.
Provide emotional support to the patient.
Prepare for emergency surgery.
Monitor the patient for shock. Follow-up is
needed.
Family planning should be discussed.
Thursday, April 5, 2018 Dr. Soad Abd El salam Ramdan 59