1. Bleeding Disorders of Early Pregnancy

2. Bleeding Disorders of Early Pregnancy
Abortion
Spontaneous (non-intentional) Abortion
A pregnancy that ends before 20 weeks
Threatened Abortion
Light spotting; cervix is closed & no tissue is passed
Inevitable Abortion
Increased bleeding & cervix dilates
Incomplete Abortion
Bleeding dilation of cervix & passage of tissue
Incomplete abortion is the bleeding dilation of cervix and passage of tissue!

3. Bleeding Disorders of Early Pregnancy (continued)
Abortion
Complete
Passage of all products of conception, cervix closes and bleeding stops
Missed
Fetus dies in utero but is not expelled, uterine growth stops and spetis is possible
Recurrent
2 or more consecutive spontaneous abortions

4. Induced Abortions Therapeutic Abortion Elective Abortion
Intentional termination of pregnancy before age of viability to preserve the health of the mother
Elective Abortion
Intentional termination of pregnancy for reasons unrelated to mothers health

5. Abortion

6. threatened
inevitable
missed
incomplete

7. Nursing Care of Early Pregnancy Bleeding Disorders
Document amount and character of bleeding
Save anything that looks like clots or tissue for evaluation by a pathologist
Perineal pad count with estimated amount of blood per pad, such as 50% (could weight pads before/after)
Monitor vital signs
If actively bleeding, woman should be kept NPO in case surgical intervention is needed

8. Post-Abortion Teaching
Report increased bleeding
Take temperature every 8 hours for 3 days
Take an oral iron supplement if prescribed
Resume sexual activity as recommended by the health care provider
Return to health care provider at the recommended time for a checkup and contraception information
Pregnancy can occur before the first menstrual period returns after the abortion procedure

9. Emotional Care
Spiritual support from someone of the family’s choice and community support groups may help the family work through the grief of any pregnancy loss
Review effective and ineffective communication techniques found in Table 5-4 on page 84

10. Effective Communication

11. Ectopic Pregnancy Hormonal abnormalities Inflammation Infection
95% occur in fallopian tube
Scarring or tubal deformity may result from:
Hormonal abnormalities
Inflammation
Infection
Adhesions
Congenital defects
Endometriosis
95% occur in the fallopian tube
The zygote or embryo may die and be absorbed by the body, or the tub could rupture with bleeding into the abdominal cavity . This is a surgical emergency.

12. Ⅰ.Definition
The blastcyst normally implants in the endometrial lining of the uterine cavity. Implantation anywhere else is an ectopic pregnancy.
It is one in which the fertilized ovum is implanted and developed outside of the uterine cavity.

13. II.Incidence more than 1 in every 100 pregnancy
III . Types of ectopic pregnancy
Tubal %
Ovarian %
Cervical
Abdominal
Broad ligament

15. Ⅳ.Tubal pregnancy It is one of abdominal emergency.
Interabdominal hemorrhage sever hemorrhge shock died
1.site
※(1)Ampullar 60%
(2)isthmic %
(3)fimbrial 17%
(4)Interstitial 2%~4%

16. Symptoms (1)amenorrhea (2)low abdominal pain (3)vaginal bleeding
(4)shock and collapse

17. Signs (1)general condition (2)abdominal examination
(3)pelvic examination
　　①the posterior fornix: tendness
②pain on motion of cervix
③uterus: 6~8w size, soft, float
④a soft and elastic mass

18. Complications of Pregnancy
Ectopic Pregnancy (EP)
Clinical Presentation
Amenorrhea
Bleeding/Spotting Abdominal Pain

19. A. tubal pregnancy (1)tubal abortion common in ampular tubal pregnancy
(2)tubal rupture: profuse hemorrhage
common in isthmic TP: 6w
interstitial TP: 16w
(3)abdominal pregnancy

22. Clinical Manifestations
Abdominal or pelvic pain (most common).
Irregular vaginal bleeding — usually scanty and dark (most common).
Amenorrhea”in 75% of the cases.
Uterine size is usually similar to what it would be in a normally implanted pregnancy.
Abdominal tenderness on palpation.
Shoulder pain.
Increased pulse and anxiety.
Nausea, vomiting, faintness, or vertigo and syncope with abdominal pain may develop.
Pelvic examination reveals a pelvic mass, posterior or lateral to the uterus, adnexal tenderness, and cervical pain on movement of the cervix.

23. Symptom Sign axillary examination
5.Diagnosis
Symptom
Sign
axillary examination

24. (1) pregnancy tests:β-HCG>25u
quantitive serum β-HCG
(2) pelvic ultrasound
(3) the bloody fluid does not clot
(4)laproscopy: diagnosis and treatment
(5)endometrial histology: Arias-Stella reaction

25. Complications of Pregnancy
Ectopic Pregnancy (EP)
Management
Pertinent hx
Missed menses
Sexually active
Previous EP, STD, surgery, etc.
Lower quadrant pain/tenderness
Avoid aggressive palpation/repeated exam
Vital signs
Orthostatic as appropriate
High flow O2
Treat for shock
Position
IV access
Surgical intervention usually required

26. Sights A – G are abnormal implantation sites
Sights A – G are abnormal implantation sites. X indicates the normal implantation sites.

27. Treat shock and hemorrhage if necessary.
Surgical Treatment
If woman does not consent to or meet criteria for methotrexate, surgical intervention is instituted. The surgical procedure depends on the extent of tubal involvement and if rupture has occurred.
The surgery of choice used to preserve future fertility is a salpingostomy.
Should a woman not desire future fertility, the surgery of choice is salpingectomy.
Other surgeries range from removal of ectopic pregnancy with tubal resection, salpingostomy (removes conceptus leaving tube intact, yet scarred), and possibly salpingo-oophorectomy.
Treat shock and hemorrhage if necessary.
Administer RhIG (immune globulin) per your facility's policy if woman is Rh negative.

28. Ectopic Pregnancies (Continued)
Complications
Infertility
Hemorrhage and death
Methotrexate should never be used during an active pregnancy. Prior to use there should be an ultra sound determining implantation site and fetal death . A consent must be signed for the administration of this medication.

29. Nursing Assessment
Evaluate the following to determine pregnancy and to monitor for changes in patient's status, such as rupture or hemorrhage:
Maternal vital signs
Presence and amount of vaginal bleeding
Amount and type of pain
Presence of abdominal tenderness on palpation/shoulder pain
Date of last menstrual period
Presence of positive pregnancy test
Rh type

30. Nursing Diagnoses
Risk for Deficient Fluid Volume related to blood loss from ruptured tube
Acute Pain related to ectopic pregnancy or rupture and bleeding into the peritoneal cavity
Anticipatory Grieving related to loss of pregnancy and potential loss of childbearing capacity

31. Nursing Interventions
Maintaining Fluid Volume
Establish an I.V. line with a large-bore catheter, and infuse fluids and packed RBCs as prescribed.
Obtain blood samples for complete blood count (CBC) and type and screen for whole blood, as directed.
Monitor vital signs and urine output frequently, depending on condition.
Promoting Comfort
Administer analgesics as needed and prescribed.
Encourage the use of relaxation techniques.

32. Hydatidiform Mole (Molar Pregnancy)
Also known as Gestational Trophoblastic Disease
Occurs when chorionic villi abnormally increase and develop vesicles
May cause hemorrhage, clotting abnormalities, hypertension, and later development of cancer
More likely to occur in women at age extremes of the reproductive life

36. Hydatidiform Mole (Continued)
Manifestations
Bleeding
Rapid uterine growth
Failure to detect fetal heart activity
Signs of hyperemesis gravidarum
Unusually early development of GH
Higher than expected levels of hCG
A distinct “snowstorm” pattern on ultrasound with no evidence of a developing fetus
Treatment
Uterine evacuation
Dilation and evacuation

37. Management
Suction curettage is the method of choice for immediate evacuation of the mole with possibility of laparotomy.
Follow-up for detection of malignant changes because a complication is the development of choriocarcinoma of the endometrium.

38. Nursing Assessment
Monitor maternal vital signs; note presence of hypertension.
Assess the amount and type of vaginal bleeding; note the presence of any other vaginal discharge.
Assess the urine for the presence of protein.
Palpate uterine height; if above the umbilicus, measure the fundal height.
Determine date of last menstrual period and date of positive pregnancy test.
Evaluate CBC results and Rh type.

39. Nursing Interventions
Maintaining Fluid Volume
Obtain blood samples for type and screen, and have 2 to 4 units of whole blood available for possible replacement.
Establish and maintain I.V. line; start with a large needle to accommodate possible transfusion and large quantities of fluid.
Assess maternal vital signs, and evaluate bleeding.
Monitor laboratory results to evaluate patient's status.
Decreasing Anxiety
Prepare the patient for surgery. Explain preoperative and postoperative care along with intraoperative procedures.
Educate patient and family on the disease process.
Allow the family to grieve over the loss of the pregnancy.

40. Patient Education and Health Maintenance
Advise the woman on the need for continuous follow-up care.
Provide reinforcement of follow-up procedures:
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.
Consider chemotherapy or hysterectomy if -hCG levels rise or begin to plateau or there is evidence of metastasis.
Encourage ongoing discussion of care with health care provider