m






 






› 

÷ ANTEPARTUM
~Occuring before the onset of labour.
÷ HAEMORRHAGE

~Bleeding from the genital tract after the

24th week of pregnancy until the birth of
the baby.
÷ Antepartum haemorrhage is the bleeding
from the vagina during;
1)The second half of pregnancy.
2)Earlier commences labour.
3)Bleeding from the vagina afterwards 24th
weeks gestation up until labour.


÷ Placenta previa
÷ Placental abruption

÷ Local causes; cervical polyps,cervicitis,cancer

of the cervix,post-coital genital laceration
÷ vasa praevia

÷ Unknown

 





÷ EARLY PREGNANCY BLEEDING
~Miscarriage(spontaneous abortion)
~Incompetent cervix (Recurrent
premature dilation of the cervix)
~ Ectopic pregnancy
~Hydatidiform mole(Molar pregnancy)
÷ LATE PREGNANCY BLEEDING
~Placenta previa
~Premature separation of placenta
~Cord insertion and placental
variations
6
 

÷ Miscarriage or ’

’



’
’

’
 
÷ At a stage where the embryo or fetus is
incapable of surviving,generally defined in
humans at prior to 20 weeks of gestation.
÷ Miscarriage is the most common complication
of early 
  

÷ Genetic
÷ Uterine or hormonal abnormalities
÷ Reproductive tract infections
÷ Tissue rejection
÷ Problem with the body immune system
÷ Physical problem with the mother·s
reproductive system
÷ Age-higher than 35years old
   6 
 

÷ Low back pain or abdominal pain that is dull,

sharp, or cramping
÷ Tissue or clot-like material that passes from the
vagina
÷ Vaginal bleeding, with or without abdominal
cramps
6

÷ Abdominal or vaginal ultrasound.

÷ Blood test;CBC,WBC

÷ Medication;Misoprostol(to remove the

remaining contents from the womb)
6 

÷ Where the pregnant women begin to dilate and

thin before her pregnancy has reached term.
÷ It may cause miscarriage or preterm birth when
2nd and 3rd trimester.
÷ In a normal pregnancy,dilation and effacement
occurs in response to uterine contractions.
  

÷ Painless
÷ History of previous cervical lacerations during
childbirth
÷ Miscarriage starting at 2nd trimester.
6

÷ It can be treat using cervical cerclage,cervical

technique that reinforces the cervical muscle
by placing suture above the opening of cervix to
narrow the cervical canal.
÷ Cerclage usually performed between 14 to
16weeks of the pregnancy the suture removed
between 36 and 38weeks to avoid problem
between labour.
 

÷ An M

 is the implantation of
the fertilized ovum outside the uterine cavity.
  

÷ History of prior ectopic pregnancy

÷ Pelvis inflammation disease

÷ History of tubal surgery and conception after

tubal ligation.
÷ Use of fertility drugs or assisted reproductive
technology
÷ Use of an intrauterine device


 

An blockage of the tube or reduction of

tubal peristalsis that impedes of delays the
zygote passing to the uterine cavity can result
in tubul implantation.
Less acute symptoms usually begin within
6 to 8weeks after the last normal menstrual
period and weeks before rupture would occur.
   6 
 

÷ Abdominal or pelvic pain

÷ Irregular vaginal bleeding

÷ Adrenal fullness

÷ Tenderness may suggest an interruptured tubal

pregnancy
÷ Pain while having bowel movement

÷ Red or brown abnormal vaginal bleeding 50%

or 80% of women.
6

÷ Medical therapy
÷ Embryo transfer

÷ Blood test

÷ Pelvic examination
Ú







Gestational trophoblastic disease

is abnormal proliferation and degeneration of
the trophoblasitic villi. As the cells degenerate,
they become filled with fluid and appear as clear
fluid, grape-sized vesicles. With this condition,
the embryo fails to develop beyond a primitive
start.
Ê 

A hydatidiform mole, or molar pregnancy,

results from over-production of the tissue that is
supposed to develop into the placenta. The
placenta normally feeds a fetus during
pregnancy. In this condition, the tissues develop
into an abnormal growth, called a mass.
There are two types:
Partial molar pregnancy
Complete molar pregnancy
÷ A partial molar pregnancy means there is an
abnormal placenta and some fetal
development.
In a complete molar pregnancy, there is an
abnormal placenta but no fetus.

÷ Both forms are due to problems during

fertilization. Potential causes may include
defects in the egg, problems within the
uterus, or a diet low in protein, animal fat,
and vitamin A. Women under age 16 or older
than 40 have a higher risk for this condition.
ÚÚ 
 
Ú

 

 Low intake of proteins and vitamin A, Asian heritage, Women older than 35 years

Partial mole
or
Complete mole

Chronic villi degenerates and become filled with fluid

No vasculature in chorionic villi

Early death & absorption of embryo Absence of FHT

Trophoblastic proliferation Uterus expands abdominal pain

faster than normal

High secretion of hCG High progesterone low estrogen High chorionic

thyrotropin

Marked nausea & vomiting Decreased contraction Amenorrhea Hyperthyroidism

Multiple theca lutein cysts in the ovaries Separation of vesicles from uterine wall Enlarged thyroid gland; tachycardia

Ovarian pain Vaginal bleeding & discharge of vesicles

Pallor Preeclampsia
Ê
Ê


÷ Abnormal growth of the womb (uterus)

r Excessive growth in about half of cases
r Smaller-than-expected growth in about a third of
cases
÷ Nausea and vomiting that may be severe
enough to require a hospital stay
÷ Vaginal bleeding in pregnancy during the first
3 months of pregnancy
÷ Symptoms of hyperthyroidism
r Heat intolerance
r Loose stools
r Rapid heart rate
r Restlessness, nervousness
r Skin warmer and more moist than usual
r Trembling hands
r Unexplained weight loss
÷ Symptoms similar to preeclampsia that occur in the
1st trimester or early second trimester -- this is
almost always a sign of a hydatidiform mole, because
preeclampsia is extremely rare this early in a normal
pregnancy
r High blood pressure
r Swelling in feet, ankles, legs


÷ Curettage to remove cysts

÷ Suction to remove cysts

÷ Close surveillance after therapy with monitoring

of HCG levels
÷ Methotrexate if HCG levels are rising
 

 
› 


· Placenta situated abnormally in the

lower uterine segment ,leading to
unavoidable , painless, recurring
haemorrhage toward the end of
pregnancy as the lower uterine segment
stretches in preparation for labour.


 

Î women with placenta previa often with

painless and bright red vagina bleeding.
Î This bleeding often starts mildly and may
increase as the area of placental separation
increases.
Î Praevia should be suspected if there is
bleeding after 24 weeks of gestation.
  

Î Women who are younger than 20 are at higher

risk and women older than 30 are at increasing
risk as they get older.
Î Women with a large placentae from twins or
erythroblastosis are at higher risk.
Î Women who smoke or use cocaine may be at
higher risk.



66

Î Bleeding occurs spontaneously.

Î causeless.

Î painless.

Î it may anemia.
rPREMATURE
SEPARATION OF
PLACENTA
÷ Detachment of part or all of the placenta from
it implantation site.
÷ It occurs in the area of dedicua basalis after
2oweeks of pregnancy and before the birth of
the baby.
   

÷ Hypertension
÷ Cocaine

÷ Blunt external abdominal trauma

÷ Age older than 35years old

÷ Short umbilical cord

÷ Folic acid deficiency



 

÷ Trauma,hypertension or coagulopathy contributes

to the ovulsion of the anchoring placental villi from
the expanding lower uterine segment.
÷ Then it leads bleeding in decidua basalis,this can
push the placenta away and from the uterus and
cause further bleeding.
÷ Sometimes the blood pull the behind the placenta.
÷ It will present with vaginal bleeding.abdominal
back or pain,abnormal or premature
contractions,it cause fetal distress or death.
   6 
 

÷ Contraction that dint stop

÷ Pain in the uterus

÷ Tenderness in the abdomen

÷ Vaginal bleedings(sometimes)(dark colour)

÷ Uterus maybe disproportionally enlarged

÷ Pallor
6

÷ Treatment depends on the amount of blood loss

and the status of the fetus. If the fetus is less than
36 weeks and neither mother or fetus are in any
distress, then they may simply be monitored in
hospital until a change in condition or fetal
maturity whichever comes first.
÷ Caesarean section is contraindicated in cases of
disseminated intravascular coagulation. Patient
should be monitored for 7 days for PPH.
CORD INSERTION AND
PLACENTAL VARIATIONS
   

A situation where the umbilical cord inserts

into the fetal membranes (amnion and
chorion), rather than the body of the
placenta.
  



 

÷ The exact etiology of placenta previa is

unknown. The condition may be multifactorial
and is postulated to be related to multiparity,
multiple gestations, advanced maternal age,
previous cesarean delivery, previous abortion,
and possibly smoking.



66

÷ Bleeding is usually bright red and painless

÷ The first bleed occurs (on average) at 27-32
weeks' gestation.
÷ Profuse hemorrhage

÷ Hypotension

÷ Tachycardia

÷ Soft and nontender uterus

6

÷ The safest treatment is a planned caesarian

section and abdominal hysterectomy if
placenta accreta is diagnosed before birth.
÷ If the woman decides to proceed with a vaginal
delivery, blood products for transfusion should
be prepared.

66

Nursing diagnosis : impaired fetal gas

exchange related to altered blood flow and
decreased surface area of gas exchange at site
of placenta detachment.
 

1) Assess vital sign (pulse,respiration,and blood

pressure every 15 minute.) to provide baseline
data on maternal blood loss.
2) Maintain bed rest or chair rest when indicated to
reduce fatigue.
3) Monitor amount and type of bleeding to provide
objective evidence of bleeding.
4) Give moral support and maintain positive attitude
toward about fetal to support mother and child
bonding.
5) Administer oxygen as indicated to provides
adequate fetal oxygenation of lowered
maternal circulating volume.

Evaluation : The patient was confident and able

to verbalize understanding of causetive
factors.
 ›   
Objective:
÷ Changes in fetal heart rate or fetal activity.

÷ Release of meconium.

DIAGNOSIS
÷ Impaired fetal gas exchange related to altered
blood flow and decreased surface area of gas
exchange at site of placental detachment.
 

›

 
÷ Assess vital signs (pulse, respirations, and blood
pressure every 15 minutes) to provides baseline data
on maternal blood loss.
÷ Maintain bed rest or chair rest when indicated to
reduce fatigue, and improve strength.
÷ Monitor amount and type of bleeding to provide
objective evidence of bleeding.
÷ Position mother on her left side to promote placental
perfusion.
÷ Restrict vaginal examination to prevents tearing
of placenta if placenta previa is the cause of
bleeding.
÷ Monitor uterine contractions and fetal heart
rate by external monitor to assess whether
labor is present and fetal status and external
system avoids cervical trauma .
÷ Maintain positive attitude toward about fetal
outcome to supports mother and child bonding.
 

÷ After 8 hours of nursing interventions, the
patient was able to verbalize understanding of
causative factors and appropriate
interventions.
  Ê
÷ ASSESSMENT:-

Hydatidiform mole‰ to detect a hydatidiform mole early,

the nurse should observe for signs of a mole at each
prenatal visit during the first 20 weeks of gestation.

Such signs as uterine bleeding, uterine size small or large

for dates, hyperemesis gravidarum, signs of preeclampsia
before 24 weeks of gestation, passage of grapelike vesicles,
or inability to detect FHR with Doppler FHR device after 10
to 12 weeks of gestation should be brought to the attention
of the obstetrician or healthcare provider immediately.
÷ Nursing Diagnosis:

- Hemorrhage related to trophoblastic invasion or uterine

rupture.

÷ Nursing Intervention:
1. Monitor for evidence of hemorrhage such as vital signs,
abdominal
pain, uterine status, and vaginal bleeding.
2. Start intravenous (IV) infusion with an 18-gauge intracatheter.
3. Prepare for surgery according to preoperative protocol, and
type and
cross match 2 to 4 units of blood as ordered.
4. Postoperative IV infusions with oxytocin added are usually
continued
initially to facilitate uterine contractions and decreaseuterine
bleeding.
 5. Do not massage a boggy uterus if ovaries are
enlarged since it can cause ovarian rupture.
6. Notify physician of first signs of bleeding.

INTERVENTION
- The signs and symptoms of hemorrhage
will be minimized/managed as measured by
distal pulses, stable vital signs, orientation
to person, place, and time, urinary output
greater than 30 ml/hr, an no signs of
bleeding