Early Pregnancy Bleeding

By
Captain Ala’a Ababneh RN, MSC
 Abortion
 Abortion: ending of the pregnancy before 20 weeks
of gestation. Expulsion of the uterine contents either
spontaneously or induced before the point of viability
24 or 20 weeks and weight less than 500g.
 Incidence: 10-15% of all pregnancies. The majority
of spontaneous abortion occur between the 8th and
12th weeks when the level of progesterone secreted
by the corpus luteum falls and the placental hormone
has not reached a sufficiently high level to sustain
the conception.
 Causes
 Maternal causes:
 Rh incompatibility and ABO
incompatibility.
 Endocrine deficiencies.
 Abnormalities of maternal reproductive
organ ( bicornate uterus).
 Chronic illness and acute infections.
 Physiological and psychological.
 Fetal causes:
 Chromosomal abnormalities.
 Poor implantation.
 Types of abortion
 Threatened Miscarriage
 Inevitable Miscarriage
 Incomplete Miscarriage
 Complete Miscarriage
 Missed Miscarriage
 Septic Miscarriage
 Habitual Miscarriage
 Therapeutic Abortion
 Criminal Abortion
 Threatened Miscarriage
 Threatened miscarriage affects one in five
pregnancies.
 Signs & Symptoms

Cervical os close , membrane intact ,mild

cramping ,spotting of blood.
 Management

Complete bed rest ,sedative , avoid sexual intercourse,

good observation for amount of bleeding ,V/S , check
fetal H.R . Give Anti D if indicated.
 Although there is no definite evidence that bed rest can
affect the course of pregnancy abstinence from active
environment for a couple of days may help women feel
safer
Inevitable Miscarriage
Signs & Symptoms 

mild to severe cramping, moderate

amount of bleeding ,cervical os
.dilated ,ROM
Bed rest, sedation transfusion may be
indicated, observe amount of bleeding,
.color, give anti D if indicated
Incomplete Miscarriage
 S&S
Parts of the products of conception are
expelled ( fetus expelled from uterus
placenta and membranes are still inside ),
severe bleeding ,cervical os partly closed,
. severe pain
 Management

May or may not additional dilation needed

.before curettage (D&E)
.Anti D if indicated, V/S, sedation
 Complete Miscarriage
 S&S
All contents expelled without assistance,
minimal bleeding ,cervix is closed and
.uterus is empty ,pain is stopped
 Management

.No further interventions needed

.Anti D if indicated
 Missed Miscarriage
 S&S
Fetus dies and retained in uterus, signs of pregnancy
disappear, pregnancy test negative, fundal height not
increase in size, FHR absent, cervix os is closed, sonar
confirm fetal death ,may spotting blood present
 Management

If spontaneous evacuation of uterus not occur within one

month, pregnancy is terminated .blood clotting factors
are monitored ,DIC may develop in cases of fetal death
after 12th weeks ,if products of conception are retained
.for longer than 5 weeks .D&C or misoprostol is the rx
.Mother may develop hypofibrinogenaemia
Septic Miscarriage
 S&S
Fever ,abdominal tenderness, vaginal bleeding and
chills, Nausea, Vomiting.
 Management

Antibiotics , clinical bacteriological and hematological

investigation to identify the infectious
organism ,electrolyte control ,the pads correctly
collected and discarded ,accurate observation of
temp & Bp
Habitual miscarriage
When women have three or more consecutive
. spontaneous abortion
: May due to
Cervical incompetent ,poor nutritional status,
hormonal disturbance, defective ova or
spermatozoa, RH incompatibility
. Pain and bleeding are absent or minimal
Recurrent premature dilation
of the cervix
)Incompetent cervix(
Passive and painless dilation of
cervix os without labor or
contraction of uterus. it occurs in
second or early in third trimester.
As a result miscarriage or preterm
. birth may occur
Etiology
Etiologic factors include : hx of previous cervical
trauma such as laceration during
childbirth ,excessive cervical dilation for
curettage or biopsy ,congenitally short
cervix ,cervical or uterine anomalies. exposed
to the drug diethylstilbestrol (DES) by the
woman’s mother while pregnant with the
.woman
Diagnosis
 Diagnostic criteria for U/S are:
1-short cervix (less than 20 mm in length ).
2- effacement 30%-40% of the internal Os of the cervix.
 Management
1. Bed rest , hydration ,progesterone ,anti-inflammatory
drugs and antibiotics. McDonald procedure done .it is
performed in 11-15 week ,not done after 25 week
because of complications such as PROM ,preterm
labor ,and chorioamnionitis
2. Post op and follow up care include :observe for S&S of
infection ,uterine contraction ,ROM ,educate women
about importance of limited activity and signs of
complications .
Ectopic pregnancy
 Ectopic pregnancy refers to an abnormal
implantation of the fertilized ovum outside
the uterine cavity.
 Approximately 95% of ectopic pregnancy
occur in the uterine ( fallopian) tube, with
most located on the ambullar portion. Other
sites include the abdominal cavity (3-4%),
ovary (1%), and cervix (1%).
 Risk Factors
1. previous ectopic pregnancy, tubal damage from
infection or surgery, history of infertility, treatment
for in vitro fertilization, increased age, and
smoking.
2. history of pelvic inflammatory disease is particularly
important after acute salpingitis the incidence of
ectopic pregnancy increased sevenfold.
 The incidence of ectopic pregnancy is
increasing but mortality is decreasing due to
better diagnostic methods and technology.
 Incidence about 2% (medscape, 2010)
 Ectopic pregnancy is responsible for 10% of
all maternal mortality, and it is the leading
pregnancy related cause of first trimester
maternal mortality.
 Moreover ectopic pregnancy is a leading
cause of infertility.
 Ectopic pregnancy is classified according to
site of implantation.
 The uterus is the only organ capable of
containing and sustaining a term pregnancy.
 However, abdominal pregnancy with birth by
laparotomy may result in a living infant in
5%-25% of such pregnancies.
Clinical manifestation
 A missed period.
 Adnexal fullness.
 Tenderness may suggest an unruptured tubal
pregnancy.
 Tenderness may progress from a dull pain to
a colicky pain when the tube stretches.
 Pain may be unilateral, bilateral, or diffuse
over the abdomen.
 Dark red or brown abnormal vaginal bleeding
occurs in 50%-80% of women.
 If ectopic pregnancy ruptures, pain increases.
Pain may be generalized, unilateral, or acute
deep lower quadrant pain caused by blood
irritating the peritoneum.
 Referred shoulder pain can occur as a result
of diaphragmatic irritation caused by blood in
the peritoneal cavity.
 An ecchymotic blueness around the
umbilicus (Cullen’s sign), indicating
hematoperitoneum. May develop in an
undiagnosed ruptured intraabdominal
ectopic pregnancy.
 The woman may exhibit signs of shock
related to the amount of bleeding.
Assessment and management
 The differential diagnosis of ectopic
pregnancy involves consideration of
numerous disorders that share many
signs and symptoms.
 Miscarriage, appendicitis, salpingitis,
ovarian cysts, UTI.
 Laboratory screening includes
determination of serum progesterone
and beta hCG levels.
 The woman is also undergo
transvaginal ultrasound to confirm
intrauterine or tubal pregnancy.
 Management of tubal pregnancy depends on
whether the tube is intact or ruptured.
 If the tube is intact and hCG levels are
declining, its indicate spontaneous regression
of the tubal pregnancy.
 Methotrexate is a folic acid analogue that
destroys the rapidly dividing cells, may be
used in a single dose intramuscular injection
to treat unruptured pregnancies.
 The primary reason for medical
management is preserving the fallopian
tube to increase the chance of future
pregnancy.
 Methotrexate therapy avoids surgery
and is a safe, effective.
The Medical Management of Ectopic Pregnancy:
A Meta-analysis Comparing "Single Dose" and
"Multidose" Regimens

 The overall success rate for women treated

with methotrexate for an ectopic pregnancy
was 89%. The single dose was much more
commonly used. The use of single dose was
associated with a significantly greater chance
of failed medical management than the use of
the multidose. The single-dose regimen was
associated with fewer side effects. Women
who experienced side effects were more likely
to have successful treatment regardless of
regimen.(Kurt, 2003)
 Surgical management of an unruptured tubal
pregnancy involve salpingostomy.
 Salpingectomy is performed when the tube is
ruptured to control bleeding and prevent
hypovolemic shock.
 If internal bleeding is present, assessment
may reveal vertigo, shoulder pain,
hypotension, and tachycardia.
 If surgery is planned, general
preoperative and postoperative care.
 Blood transfusion may be necessary.
 Anti D.
 IV fluid, electrolytes.
 Future pregnancy can occur with one
tube remaining.
 Future fertility should be discussed.
 Increased risk for recurrent ectopic
pregnancy.
Gestational Trophoblastic
Disease
 Gestational trophoblastic disease includes
hydatidiform mole, invasive mole, and
choricarcinoma.
 hydatidiform mole (molar prenancy) is a
condition in which the trophoblastic tissue
proliferates and the chorionic villi of the
placenta become swollen and fluid filled,
taking on the appearance of grapelike
clusters.
 The etiology is unknown, although
there may be an ovular defect or
nutritional deficiency.
 Higher risk who have undergone
ovulation stimulation with clomiphene.,
early teens, older than 40 years.
 The risk of a second mole is 1%- 2%.
Risk of recurrent hydatidiform mole and subsequent
pregnancy outcome following complete or partial
hydatidiform molar pregnancy

 Overall recurrence risk for molar

pregnancy was 1.8%.
 is about 1 in
 about 1 in 60 and if this were to occur,
the majority of cases will be of the
same type of mole as the preceding
pregnancy. (Sebire, 2003).
Molar pregnancy and husband’s
occupation: do soil and dust have
?any role

 Comparing all occupations that had

exposure to soil and dust with all those
who did not have this exposure
(physical and non-physical) resulted in
a statistically significant difference in
the occurrence of molar pregnancy.
(Milani,2008)
 Types
 Complete mole: results from fertilization of
an egg with a lost or inactive nucleus. The
nucleus of a sperm duplicates itself.
 The hydropic vesicles grow rapidly, causing
the uterus to be larger than expected for the
duration of the pregnancy.
 Complete mole contains no fetus, placenta,
amniotic membranes, or fluid.
 20 %of cases progression toward
choricarcinoma.
 Partial mole results of two sperm
fertilizing an apparently normal ovum.
 karyotype of 69,XXX; 69,XXY;69,XYY.
 Partial mole often have embryonic or
fetal parts and an amniotic sac.
Congenital anomalies are usually
present.
Clinical manifestations
 Complete mole cannot be distinguished
from those of normal pregnancy.
 Vaginal bleeding occurs later in almost
95% of cases.
 The vaginal discharge may be dark
brown (prune juice) or bright red, either
scant or profuse, continuing for only a
few days or intermittently for weeks.
Clinical manifestations
 Anemia from blood loss.
 Excessive nausea and vomiting.
 Abdominal cramps--- uterine distention.
 Preeclampsia in 15% of causes usually
between 9-12 weeks of gestation.
 Hyperthyroidism, pulmonary embolism .
 Partial mole cause few of these symptoms
and may be mistaken for an incomplete or
missed miscarriage.
Management
 Serial beta hCG levels and ultrasound are the
primary diagnostic tools.
 Treatment begins with evacuation of the
mole.
 Anti D.
 Follow up includes frequent physical and
pelvic examination along with biweekly
measurement of beta hCG level until the level
decrease to normal and remains normal for 3
weeks.
 Monthly measurements are taken for 6
months and then every 2 months for a
total of 1 year.
 A rising titer and enlarged uterus may
indicate choriocarcinoma.
 Chemotherapy may be started.
Bleeding In Late Pregnancy
Placenta Previa
 Placenta previa occurs when the
placenta abnormally implants near or
over the cervical os instead of in the
fundus of the uterus.
 Placenta previa occurred in
approximately 1 in 200 live births
(2007).
Risk factors
 Defective vascularity of the decidua.
 previous infection in the upper uterine
segment.
 Uterine scarring from previous C/S.
 Previous placenta previa.
 Endometritis.
 Multifetal gestation.
 Because the lower uterine segment is
not as well vascularized as the upper
segment, the placenta must cover a
large area for adequate function.
Types of placenta previa
 Complete: the internal os is completely
covered by the placenta.
 Partial: incomplete cover of the internal os.
 Marginal: only an edge of the placenta
extends to the internal os.
 Low lying placenta: placenta is implanted
in the lower uterine segment but does not
reach the os.
Assessment and management
 Placenta previa can be diagnosed before
bleeding occurs in the third trimester because
of performing routine U/S.
 Placenta previa should be suspected with
onset of painless bleeding occur after 24
weeks.
 Abdominal examination reveals a soft,
relaxed, nontender uterus with normal tone.
 Painless bleeding results from the
separation of the placenta that is near ,
or covering , the internal cervical os.
 Bleeding may be intermittent or in
gush. The bleeding can be extensive
and can prove to be fatal.
 The woman diagnosed with placenta
previa must be closely monitored for
the amount and character of blood loss.
 Vital signs, fetal heart rate, and activity
are documented.
 PV exam is contraindicated.
 Management is depend on the
classification of previa and gestational
age of the fetus.
 If the gestational age is less than 36
weeks and bleeding is slight, the
woman is hospitalized for observation.
 Blood count, type, cross match are
performed.
 If bleeding is heavy, an urgent C/S is
performed.
complication
 The main complication is hemorrhage for the
woman and prematurity hypoxia or death of
the fetus.
 Immediate pp hemorrhage often
accompanies this condition because the
surface area of attachment is greater than
usual and the site of placental implantation in
the lower uterine segment dose not contract
well after the placenta is expelled.
Dose the number of the previous C/S affect
?maternal outcome and complication rates
 Dose the number of the previous C/S deliveries affect maternal
outcome and complication rates?
(Alchalabi, 2007)
 PP infection may also occur because of
the closeness of the placental site to
the cervix and vagina.
Abruptio placenta
is the )Premature separation of placenta(
detachment of part or all of the placenta
.from its implantation site
Separation occur in the area of decidua
.basalis after 20 week of gestation
Incidence & Etiology
 1 in 200 of all pregnancies is
complicated by Abruptio placenta
 Hypertension is the most consistently
identified risk factor for Abruptio
placenta.
 cocaine use , Abdominal trauma,
smoking ,previous Abruptio placenta,
PROM ,Twin gestation.
Placental Abruption and Perinatal
Mortality in the United States

 Abruption was recorded in 6.5 per 1,000

births. Perinatal mortality was 119 per 1,000
births with abruption compared with 8.2 per
1,000 among all other births.
 The high mortality with abruption was due, in
part, to its strong association with preterm
delivery; 55% of the excess perinatal deaths
with abruption were due to early delivery.
(Ananth and Wilcox, 2001)
Clinical Manifestations
 Vaginal bleeding
 Abdominal pain
 Uterine tenderness.
Maternal &Fetal outcomes
 It is a leading cause of maternal death
 The mother's prognosis depend on the extent of
placental detachment. ,blood loss ,degree of DIC,
time between placental detachment and birth.
 Maternal complications:
 Hemorrhage, hypovolemic shock ,renal failure, DIC.
 Fetus complications
 Death as a result of hypoxia , SGA , preterm birth .
Management
 It depends on severity of blood loss and fetus
status.
 Women with Abruptio placenta not managed
outside hospital .
 Woman less than 36 week and have mild
Abruptio placenta and fetus not in distress,
close observation for S&S of bleeding and
labor is needed .other wise the choice of
treatment is C/S.
Disseminated intravascular coagulation (DIC)

 DIC is a condition in which coagulation

defect prevents blood from clotting. This
result from overstimulation of the normal
coagulation process.
 Massive rapid fibrin formation results. This
condition causes the widespread appearance
of small thrombi in the small blood vessels.
 Factors that prevent coagulation and factors
that stimulate coagulation are activated at the
same time.
Assessment and management
 Because of the amount of intravascular
clotting, the blood platelets and clotting
factors are depleted.
 The following clinical problems may occur:
1. Tendency toward generalized bleeding.
2. Ischemia of the vital organs caused by
thrombi obstruction in the blood vessels.
3. Sever anemia resulting from excessive
bleeding.
 It should be suspected in woman with placenta
abruptio, retained dead fetus, molar pregnancy,
hemorrhagic shock, and septic abortion.
 This disorder can often be resolved by correcting the
underlying cause which may require termination the
pregnancy to stop the production of thromboplastin,
administering blood products, monitor V/S, intake
and output, administer O2, platelet count and
fibrinogen level, replace depleting clotting factors
 The nurse should be alert to the S&S of DIC bleeding
from gum, epistaxis, and petechiae, provide
emotional support.