Causes:

>Fallopian tube damage often from infection-can block the

fertilized egg’s path to the uterus causing it to implant and
grow in the tube

>Surgery

>Endometriosis

>Smoking
Signs and Symptoms: >Previous ectopic pregnancy

>Fever (sudden onset, often spiking) >Pelvic infection – chlamydia or gonorrhea

>Chills >Fertility drugs that increase egg production

>Toxic looking (looks acutely ill) >Pelvic or abdominal surgery

>Changes in mental state RISKS:

>Irritable >Can damage the fallopian tube

>Lethargic

>Anxious

>Agitated

>Unresponsive

>comatose

>Shock

>cold, clammy skin

>Pale

>Cyanotic

>Skin signs associated with clotting abnormalities

>Petechiae

>Ecchymosis (often large, flat, purplish lesions that

do not blanch when pressed)

>Gangrene (early changes in the extremities

suggesting decreased or absent blood flow)

>Decreased or no urine output

SIGNS & SYMPTOMS
TEST THAT CAN CONFIRM INFECTION:
Normal signs of pregnancy
>Blood culture
Pain- first red flag sign
>Urine culture
Other Signs and Symptoms:
>CSF culture
Vaginal spotting or bleeding
>CBC
Dizziness or fainting (caused by blood loss)
>Platelet count
Low blood pressure (caused by blood loss)
>Clotting studies – Pt, PTT, fibrinogen levels
Lower back pain
Complications:
 Unruptured
>Irreversible shock
>missed period
>Waterhouse-Friderichsen syndrome
abdominal pain within 3-5 weeks
>Adult respiratory distress syndrome (ARDS)
scant, dark brown vaginal bleeding
2. ECTOPIC PREGNANCY
vague discomfort
- An ectopic pregnancy occurs when a fertilized egg
implants and grows outside the main cavity of the  Tubal Ruptured
uterus. -An ectopic pregnancy most often occurs in a
>sudden sharp severe pain
fallopian tube, which carries eggs from the ovaries to
the uterus. >shoulder pain (indicative of intraperitoneal bleeding that
extends to diaphragm and Phrenic nerve)
-occurs when gestation is located outside the uterine
> + Cullen’s sign – bluish tinged umbilicus
cavity/tubal pregnancies
Diagnostic Test: Vaginal suppositories or IM injection of F2 analogs.

>Urine pregnancy test Laminaria or Magnesium Sulfate tents - may be used

before prostaglandin induction – to soften the cervix and
> If (+) pregnancy test – quantitative HCG test 🡪 to know assist with dilation.
the fetal age 3. Late second trimester abortion can be done using
>Pelvic exam intra amniotic saline injection, hysterotomy or
hysterectomy
>Ultrasound
THERAPEUTIC OR VOLUNTARY ABORTION
>Culdocentesis
NURSING CONSIDERATIONS:
Treatment:
-Review the woman knowledge of her choice and the
>Vary depending on its size and location
options available in regard to childbearing to allow for
>Injection of methotrexate
informed decision making.
>Surgery
-Ensure that patient understands the possible benefits
>Laparoscopy and risk of a therapeutic or voluntary abortion
Future Pregnancies: -Encourage patient to have support person accompany
her and drive her at home after the procedure
-30% who have had ectopic pregnancy will have
-Teach that cramping and bleeding, similar to a regular
difficulty becoming pregnant again.
menstrual period, can be expected. Length of bleeding
-If the fallopian tube has been spared, the chances of a varies but usually subside in 3 to 4 days
future successful pregnancy are 60%. Even if one
-Discuss the need for contraception and advise when to
fallopian tube has been removed, the chances of having
begin again
a successful pregnancy with the other tube can be
greater than 40%. -Inform that normal menstrual cycle should resume in 4
to 6 weeks.
High Risk Women:
-Discuss the needs of pelvic rest, as ordered , usually 2
 Age – 35 and 44 y/o
 With PID – Pelvic Inflammatory Disease to 3 weeks to prevent infection, consisting of avoidance
 Previous Ectopic Pregnancy
of sexual intercourse, douching, inserting tampons.
 Surgery on fallopian tube
 Infertility problems or medication to stimulate -Teach sign of infection like fever , pelvic pain, increased
ovulation
bleeding and advise to report them to health care
Nursing Care:
provider immediately.
 Vital Signs
-Arrange for follow-up appointment and counselling if
 Administer IVF
 Monitor vaginal bleeding necessary.
 Monitor I&O
 Prepare for Culdocentesis

CULDOCENTESIS - is a procedure in which peritoneal

fluid is obtained from the cul de sac of a female patient.
It involves the introduction of a spinal needle through the
vaginal wall into the peritoneal space of the pouch of
douglas.

Result: to determine if clotting or non-clotting

If clotting – negative for ectopic pregnancy

If non – clotting – positive for ectopic pregnancy

INDUCED ABORTION

1. THERAPEUTIC

2. ILLEGAL

-Is the termination of pregnancy before fetal viability for

the purpose of safeguarding the womans health.

-Elective abortion is the termination of pregnancy before

fetal viability as a choice of the woman

PROCEDURE:

-First trimester abortion can be managed by dilatation

and curettage or Dilatation and Suction.

-Second trimester abortion can be managed using:

Prostaglandin E2,
B. BLEEDING DISORDER DURING THE SECOND  Pre-eclampsia at about 12 weeks
TRIMESTER OF BLEEDING
Late Signs
1. Hydatidiform Mole (H-Mole)
 HPN before 20th week
- an abnormal proliferation and degeneration of the  Vesicles look like a ‘snowstorm” on sonogram
trophoblastic villi  Anemia
 Abdominal cramping
-Molar pregnancy
Serious late Complications
-Gestational Trophoblastic Disease
 Hyperthyroidism
-Bunch of Grapes  Pulmonary embolus
Hydatid – means drop of water; mole – means spot Diagnosis:
Types: suspect until 3rd month or later if fetal heartbeat is
a. Partial Molar – pregnancy that includes an present with bleeding and severe nausea and vomiting
abnormal embryo (a fertilized egg that has > Physician will examine the woman’s abdomen feeling
begun to grow) but does not survive. for any strange humps or abnormalities in the uterus
b. Complete Molar –pregnancy in which there is
small cluster of clear blisters or pouches that > Tubal pregnancy will be ruled out
don’t contain an embryo
> Abnormally increased HCG level with vaginal bleeding;

> (-) FHB

> unusually large uterus will indicate a molar pregnancy

> Ultrasound – confirm no living fetus

TREATMENT

-often, the tissue is naturally expelled by the fourth

month of pregnancy.

-In some instances, the physician will give the woman a

Drug of Choice: Methotrexate drug called oxytocin to trigger the release of the mole

Etiology: Unknown that is not spontaneously aborted

Other Causes: -If this does not happen, a vacuum aspiration can be

 Problems with the chromosome performed to remove the mole

 Problem with the nutrition – low protein intake
D&C
 Problem with the ovaries and uterus
 Mole sometimes can develop from a placental -woman is given anesthetic
tissue that
 is left behind in the uterus after a miscarriage or -Cervix is dilated and the contents of the uterus is gently
 childbirth suctioned out.
Signs and Symptoms o -After the mole has been mostly removed, gentle
 (+) pregnancy test scraping of the uterus lining is usually
 Symptoms for the first 3-4 months performed.
 Uterus grow abnormally fast o -If the woman is older and does not want any
 End of 3rd month-woman will experience vaginal more children, the uterus can be surgically
bleeding ranging from scant spotting to removed (hysterectomy) instead of a vacuum
excessive bleeding aspiration because of the higher risk of
cancerous moles in this age group
May predispose the: o -Monitoring the patient for at least 2 months after
the end of a molar pregnancy for HCG level
 Presence of hyperthyroidism (overproduction of
o Hcg level will be checked every 2 weeks – if
thyroid
don’t return to normal by that time, the mole may
 hormone) leads to:
have become cancerous
 Weight loss o If HCG level is normal, the woman’s HCG will be
 Increase appetite tested each month for 6 months and every 2
 Intolerance to heat months for a year
 Grapelike cluster of cells itself will be shed with o If mole become cancerous, treatment includes
the blood during this time removal of the cancerous tissue and
 Nausea and vomiting due to increase HCG and chemotherapy
progesterone o If cancer spread to other parts of the body,
 (-) fetal movement radiation will be added. Woman should not be
 (-)fetal heart rate pregnant within a year after HCG levels have
returned to normal
Early Signs:
o -If woman got pregnant within that time, it is
 Vesicles passed thru the vagina Hyperemesis difficult to tell whether the resulting high levels of
gravidarum HCG were caused by the pregnancy or as a
 Fundal height – rapidly increases cancer from the mole
 Vaginal bleeding (scant or profuse)

C. BLEEDING DISORDERS DURING THE THIRD
TRIMESTER OF PREGNANCY
1. Placenta Previa – occurs when the placenta is
improperly implanted in the lower uterine segment,
sometimes covering the cervical os.
Signs and Symptoms
Frank, bright red, painless vaginal bleeding
> Engagement (usually has not occurred)
> Fetal distress
> Presentation (usually abnormal) – baby is breech or in
transverse position
>Uterus measures larger than it should according to
gestational age
Types:
a. Partial Placenta Previa – a portion of the cervix is
covered by the placenta
b. Complete Placental Previa/Total – cervical opening
is completely covered
c. Marginal Placenta Previa – extends just to the edge
of the cervix
DIAGNOSTIC EVALUATION:
 Trans-abdominal ultrasound- is the method of
choice to show location of the placenta.
 Sterile speculum examination- can also
confirm placenta previa
MANAGEMENT
 Bed rest and hospitalization until fetus is mature
and delivery can be accomplished as usual.
 Needs immediate transport to the hospital for
recurrent of bleeding if patient is at home.
 IV access and at least 2 units of blood should be
available.
 Amniocentesis may be done to determine fetal
lung maturity for possible delivery.
 Continuous maternal and fetal monitoring
 Immediate Cesarean section is often indicated if
degree of previa is above 30% excessive
bleeding
 Vaginal delivery may attempted in marginal
previa if without active bleeding
 Pediatric team is need at delivery time due to
prematurity and neonatal complication,
COMPLICATION
o Fetal mortality resulting from hypoxia in utero
and prematurity
o Immediate hemorrhage, with possible shock and
maternal death
o Postpartum hemorrhage resulting from
decreased contractility of uterine muscle.
NURSING ASSESSMENT
o Determine the amount and type of bleeding
o Inquire the presence or absence of pain in
association with bleeding.
o Record maternal and fetal vital signs
o Palpate for the presence of uterine contraction.
o Evaluate laboratory data on hemoglobin and
hematocrit status.
o Assess fetal status with fetal monitoring.
NURSING INTERVENTION
1. PROMOTING TISSUE PERFUSION
 Frequently monitor mother and fetus
 Administer IV fluids as prescribed
 Position on side to promote placental perfusion.
 Administer Oxygen by face mask as indicated
 Prepare for an emergency delivery as needed
2. MAINTAINING FLUID VOLUME
 Establish and maintain a large-bore IV line as
prescribed
 Position in sitting position to allow the weight of
fetus to compress the placenta and decrease
bleeding.
 Maintain strict bed rest during any bleeding
episode
 If bleeding is profuse and delivery cannot be
delayed, prepare the woman physically and
emotionally for the cesarean section.
 Administer blood or blood products protocol per
institution policy.
3. PREVENTING INFECTION
 Use aseptic technique when providing care
 Evaluate temperature every 4 hours unless
elevated
 Evaluate white blood cell and different count.
 Teach perenial care and handwashing technique
 Assess odor of all vaginal bleeding or lochia
4. DECREASING ANXIETY
 Explain all treatment and procedure and answer
all related question.
 Encourage verbalization of feelings by patient
and family
 Provide information of cesarean delivery and
prepare patient emotionally.
 Discuss the long-term hospitalization or
prolonged bd rest.
5. COMMUNITY AND HOME CARE CONSIDERATION
 Can care placenta previa with no active
bleeding, no sign of preterm labor, home close
to medical facility and emergency support readily
available.
 Teach woman the sign and symptoms of
hemorrhage
 Monitor vaginal discharges and bleeding after
each urination and bowel movement.
 Instruct woman on doing home uterine activity
monitoring daily by way of palpation.
 Instruct woman on fetal movement count to be
performed daily.
 Perform daily or twice a week a nonstress test.
 Instruct woman to have support person readily
available.
 Instruct woman that there is to be nothing in the
vagina. Discuss alternative methods of sexual
gratification.
6. PATIENT EDUCATION AND HEALTH
MAINTENANCE
  Educate woman and her family about the Other Signs and Symptoms:
etiology and treatment of placenta previa.
 Uterine hypertonous - contractions with a
duration lasting more than 2 minutes
 Back pain
 Educate woman to inform medical personnel  Preterm labor
about her diagnosis and not to have vaginal  Hypovolemic shock
examination.  Non reassuring fetal heart tracking and fetal
 Educate woman who discharged from hospital to demise
avoid intercourse or anything in the vagina, to
limit physical activity, to have an accessible Severe Cases:
person in the event of emergency.
 Maternal hypotension
Predisposing Factors:  Uterine hypertonicity
 Fetal distress
> Old Age  Death
> Smoking  Clotting abnormalities
 Cause: unknown
> Intake of alcoholic beverages
Predisposing Factors:
> history of placenta previa in the past pregnancy
 Mechanical factors such as: abdominal trauma –
Surgical Management: car
 accident of fall
C/S with blood transfusion based on blood loss
 Sudden loss in uterine volume as occurs with
2. Abruptio Placenta rapid loss of amniotic fluid or the delivery of a
first twin
> Premature separation of the placenta from the  Abnormally short umbilical cord
implantation site. It usually occurs after the 20th week of  Hypertension
pregnancy  Pre-eclampsia
 Multiparity
> Bleeding into the deciduas basalis (the layer between  Rupture of membranes more than 24H
the placenta and myometrium) compresses and
compromises the function of adjacent placenta Signs and Tests:

Other Names:  During a physical examination, uterine

tenderness and or increased uterine tone may
> Premature Separation of Placenta be noticed
> Accidental Hemorrhage  CBC – decreased hematocrit and hemoglobin
and platelets
> Ablatio Placenta  Prothrombin time test
 Partial thromboplastin time test
> Placental Abruption
 Fibrinogen level test
Signs and Symptoms:  Ultrasound

> Painful vaginal bleeding Treatment and Management:

> Severe abdominal pain  IVF

> Concealed bleeding (retroplacental)
> Rigid abdomen
> Couvelaire uterus (caused by bleeding into the
myometrium)
> Dropping Coagulation factor (a potential for DIC)
 Blood Transfusion
 Check for presence of shock and fetal distress
 Emergency C/S – for fetal distress or maternal
bleeding
 Immature fetus with small placental separation –
hospitalization – for observation – release after
several days if no evidence of progressing
abruption occurs
 If mature fetus – vaginal delivery if maternal and
fetal distress is minimal
 C/S – to protect the mother and child

General Nursing Care

 Infuse IVF, prepare to administer blood

 Type and cross match blood components
(PRBC)
 Monitor FHR
 Insert foley catheter
 Measure blood loss – count pads
 Report signs and symptoms of DIC
 Monitor V/S
Signs and Symptoms:  Strict I & O
-Couvelaire uterus (also known as uteroplacental DIAGNOSTIC EVALUATION
apoplexy) is a life-threatening condition in which 1. Evaluate woman base history, physical
loosening of the placenta (abruptio placentae) examination laboratory studies and sign and
symptoms, vaginal bleeding, abdominal pain,
causes bleeding that penetrates into the uterine uterine contraction, uterine tenderness, fetal
distress.
myometrium forcing its way into the peritoneal cavity.
2. Ultrasound is done.
 3. Laboratory screening on mother’s blood to check
for fetal hemoglobin.
MANAGEMENT
 Vaginal delivery is accomplished if cervix dilates
 Cesarean section if fetal and maternal status will
deteriorate and blood loss is excessive.
 IV and Blood transfusion replacement.
 Availability of pediatric team for any prematurity
and neonatal complication.
COMPLICATIONS
 Maternal shock
 Amniotic fluid embolism (AFE)
 Postpartum hemorrhage
 Prematurity
 Maternal/ fetal death
 Adult respiratory syndrome (ARDS)
 Renal tubular necroses
 Rapid labor and delivery
NURSING ASSESSMENT
-Determine the amount and type of bleeding and
presence and absence of pain
-Monitor maternal and fetal vital signs especially
maternal blood pressure, pulse , FHR.
-Palpate abdomen –note the presence of contraction
and relaxation and assess the abdomen for firmness.
-Measure and record fundic height – to evaluate the
presence of concealed bleeding
Prepare possible delivery.
NURSING INTERVENTIONS
1. MAINTAINING TISSUE PERFUSION
a) Evaluate amount of bleeding by weighing all
pads.
b) Monitor CBC results and vital signs.
c) Position patient on lateral position with head
elevated to enhance placental perfusion.
d) Administer Oxygen through face mask at 8 to
12L
e) Evaluate fetal status with continuous external
fetal
f) monitoring
g) Encourage relaxation technique.
h) Prepare for possible cesarean section delivery.
2. MAINTAINING FLUID VOLUME
a) Establish and maintain large-bore IV line for
fluids and blood products as prescribed
b) Evaluate coagulation studies
c) Monitor maternal vital signs and contraction
d) Monitor vaginal bleeding and evaluate fundal
height to detect an increase in bleeding.
3. DECREASING FEAR
a) Inform woman and her family about the status of
both herself and the fetus
b) Explain all procedures in advance when possible
to perform
c) Answer question in a calm manner, using simple
terms
d) Encourage the presence of a support person.
4. PATIENT EDUCATION AND HEALTH
MAINTENANCE
a) Provide woman an information about the causes
and treatment of abruptio placentae.
b) Encourage involvement from neonatal team
c) Teach the sign and symptoms and increased
uterine activity
d) Instruct woman to report immediately if
excessive bleeding and pain occur at home.
e) Instruct woman to emergency plan for transport
to medical facility.
DISSEMINATED INTRAVASCULAR
COAGULATION (DIC)
-Is an acquired disorder of blood clotting in which the
fibrogen level falls to below effective limits.
EARLY SYMPTOMS
-bruising or bleeding from the intravenous site.
CAUSES:
a) Premature separation of the placenta
b) Pregnancy – induced Hypertension
c) Amniotic fluid embolism
d) Placental retention
e) Septic abortion
f) Retention of a dead fetus
MEDICAL MANAGEMENT:
 Give anticoagulant- to prevent to much
clotting
 Rapid Fetal fibronectin test –
PRETERM LABOR
Preterm Labor- Labor that occurs before the end of week
37 of gestation
Danger: Infant is immature
Assessment:
-Any pregnant woman having persistent uterine
contractions, mild and widely spaced should be
considered to be in labor, if contractions have caused
cervical effacement or dilatation over 1 cm
Measures on How to Prevent Preterm Labor:
1. Remain on bed rest except to use on bathroom.
2.Drink 8 to 10 glasses of fluids daily
3. Keep mentally active by reading or working on a
project to prevent boredom
4. Avoid activities that could stimulate labor
5. Consult your primary care giver whether sexual
relations should be restricted
6. Immediately report signs of ruptured membranes and
sudden gush of fluid from the vagina) or vaginal bleeding
7. Report signs of urinary tract infections or vaginal
infection (burning or frequency of urination, vaginal
itching or pain)
8. Keep appointments for prenatal care.
9. Empty bladder to prevent pressure on the uterus
10. Lie down on your left or right side to encourage blood
return to the fetus
Diagnosis:
 Analyzing changes in the length of the cervix by
ultrasound
 Analysis of vaginal mucus for the presence of
fetal
  fibronectin, a protein produced by trophoblast ECG, CBC, ELECTROLYTE, GLUCOSE, BUN,
cells
CREATININE, PROTHOMBIN TIME.
* If this is present in vaginal mucus, preterm labor
occurs, labor will not occur if the protein is absent for at
least 14 days b. Magnesium Sulfate - interfere with smooth muscle
Risk factor are divided into three categories like: contractility.
1. Medical/ obstetrical predating the pregnancy c. Indomethacin (Indocin) - is a prostaglandin inhibitor
that inhibits contraction.
 Miscarriage
 Cervical incompetence d. Nifedipine - is a channel blocker that relaxes smooth
 Uterine /cervical abnormalities muscle by inhibiting the transport of calcium.
 Hypertension
 Diethylstilbestrol exposure e. Oxytocin antagonists - is the receptor and inhibits
uterine contractions.
2. Current pregnancy related:
NURSING ASSESSMENT:
o Anemia
 Assess fetal status by way of electronic fetal
o Multiple gestation
 monitoring.
o Placenta previa
 Assess uterine activity pattern.
o Abruptio placenta  Assess respiratory status
o Fetal anomaly  Assess muscular tremors
o Hydramnios  Palpitations
o Abdominal surgery  Dizziness/ light headache
o Maternal infection  Urinary output
o Maternal bleeding  Assess the s/s of PTL
o Previous PTL  Assess the s/s of infection
o Uterine distention
NURSING INTERVENTION:
o Cervical incompetence
 Provide accurate information on the status of the
3. Demographic and behavioral fetus and labor
o Maternal age below 20 or above 35 years old  Determine quiet craft activities that can be done
o Low socioeconomic status in bed.
 Monitor fetal status and progress of labor.
o Single parent
 Maintain accurate intake and output
o Smoker
 Encourage private time for woman and partner.
o Chemical drug use or dependent
o Pre-pregnancy weight below 100lbs
o Poor weight gain
o Inadequate prenatal care
o Psychological stress

CLINICAL MANIFESTATION

1. Uterine cramps

2. Uterine contraction every 10 to 15 minutes

3. Low abdominal pressure

4. Low back pain

5. Vaginal bleeding

6. Increased vaginal discharge of clear or tan fluid

7. Feeling that something on her vagina

8. Abdominal cramping with nausea and vomiting

9. Persistent thigh pain

1. CONSERVATIVE TREATMENT

-Bed rest in a lateral position

-Hydration with IV fluids and continuous monitoring of

fetus status

2. TOCOLYTIC THERAPY

a. Betamimetic agents such as - Ritodrine and

terbutaline

1. Frequent monitoring to observe for the side effects of

increased blood pressure, hypervolemia.

2. Have laboratory test request of the following test: