MCHN CHAPTER 21

Ma. Concepcion A. Maico-Bacus, EdD, MAN, RN, COHN

MCA Maico-Bacus, EdD, MAN, RN, COHN

SUDDEN PREGNANCY
COMPLICATIONS
MCA Maico-Bacus, EdD, MAN, RN, COHN
 BLEEDING DURING PREGNANCY
KEY POINTS • Signs of shock:
• Always a deviation from • 10% blood volume or
normal, potentially serious, approximately 2 units have
been lost
may occur at any point in • Fetal distress occurs (at 25%
pregnancy blood loss)
• Potential emergency
• May mean placenta has
loosened and cut off
nourishment to the fetus
• Visualized blood may only be a
fraction

MCA Maico-Bacus, EdD, MAN, RN, COHN

MCA Maico-Bacus, EdD, MAN, RN, COHN
 BLEEDING DURING PREGNANCY
THERAPEUTIC MANAGEMENT
FOR HYPOVOLEMIC SHOCK
• Monitor urine output
• Obtain hgb and hct levels
• Blood typing and cross-
matching
• IV replacement: D5LR/LR
• Large-gauge Angiocath (16 or
18) for rapid fluid expansion
and to prepare for BT
MCA Maico-Bacus, EdD, MAN, RN, COHN
• If respirations are rapid: O2
by mask and monitor O2
saturation levels by pulse
oximetry
• Frequent vs and fetal
monitoring (external
monitoring device)
• Rest: left lateral side-lying
position or FOB with pillow or
wedge under right hip
 BLEEDING DURING PREGNANCY
Inserted p bleeding is halted:
• Central venous pressure
catheter (measures the
right atrial pressure or the
pressure of blood within the
vena cava): 1-6 mmHg
• Pulmonary capillary wedge
catheter (measures the
pressure in the left atrium
or the filling process of the
left ventricle): 6-12 mmHg

MCA Maico-Bacus, EdD, MAN, RN, COHN

 EMERGENCY INTERVENTIONS FOR BLEEDING IN
PREGNANCY
• Alert healthcare team of • Withhold oral fluid
emergency situation • Order type and cross-match
• Place woman FOB on her side of 2 units FWB (fresh whole
• Begin IV D5LR/LR with 16-18 blood)
gauge Angiocath • Measure I&O
• Administer O2 as necessary at • Assess vs q 15mins; apply pulse
6-10L/min by face mask oximeter and automatic BP
• Monitor uterine contractions cuff as necessary
and FHR by external • Assist with placement of CVP
monitoring or PA catheter and blood
• Omit vaginal exam determinations

MCA Maico-Bacus, EdD, MAN, RN, COHN

 EMERGENCY INTERVENTIONS FOR BLEEDING IN
PREGNANCY
• Measure maternal blood loss
by weighing perineal pads; save
any tissue passed
• Assist with ultrasound
examination
• Maintain positive attitude
about fetal outcome
• Support woman’s self-esteem;
provide emotional support to
woman and her support
person/s

MCA Maico-Bacus, EdD, MAN, RN, COHN

 SPONTANEOUS MISCARRIAGE
KEY POINTS • Early miscarriage –
• Abortion – any interruption occurring before week 16
of a pregnancy before a • Late miscarriage – between
fetus is viable (a viable weeks 16 and 20
fetus is >20-24 weeks of • Bleeding before 6 weeks is
gestation or weighs at least rarely severe; after 12
500g à a fetus born before weeks is profuse
this point is considered a
miscarriage or is termed
premature or immature
birth)

MCA Maico-Bacus, EdD, MAN, RN, COHN

 SPONTANEOUS MISCARRIAGE
COMMON CAUSES • Ingestion of alcohol at the
• 1ST Trimester – abnormal time of conception can
fetal development dt contribute to pregnancy loss
teratogenic factor or a • UTI
chromosomal aberration; • Systemic infections –
immunologic factors; rubella, syphilis,
rejection of the embryo poliomyelitis,
through an immune response cytomegalovirus,
(APS or antiphospholipid toxoplasmosis
syndrome); implantation
abnormalities

MCA Maico-Bacus, EdD, MAN, RN, COHN

 SPONTANEOUS MISCARRIAGE
CLINICAL THERAPEUTIC
MANIFESTATIONS MANAGEMENT
• Spotting (contact • Determined by the primary
healthcare provider at first healthcare provider
indication)
• Read: immediate assessment
of vaginal bleeding

MCA Maico-Bacus, EdD, MAN, RN, COHN

 SPONTANEOUS MISCARRIAGE
DIAGNOSIS: Threatened
miscarriage
• Begin as vaginal bleeding,
scant, bright red, slight
cramping, no cervical dilatation
• May be asked to come to the
clinic for fetal heart sound
assessment or an ultrasound to
determine fetal viability
• Blood test: HCG hormone at
the start of the bleeding and
again in 48hrs
MCA Maico-Bacus, EdD, MAN, RN, COHN
Management
• Avoidance of strenuous
activity for 24-48 hrs
• Bleeding may stop within 24-
48hrs if the woman reduces
activity
• Normal activity resumption
once bleeding stops
• Coitus may be restricted for 2
weeks
 SPONTANEOUS MISCARRIAGE
DIAGNOSIS: Imminent
(Inevitable) Miscarriage
• Bleeding with uterine
contractions and cervical
dilatation
• The loss of the products of
conception cannot be halted
• Primary healthcare provider
may offer medication to help
the pregnancy pass or perform
dilatation & curettage (D&C)
or dilatation & evacuation
(D&E)
MCA Maico-Bacus, EdD, MAN, RN, COHN
Management
• Inform the woman that
pregnancy has already been
lost and procedures are to
clean the uterus and prevent
further complications (not to
end the pregnancy)
• Save any tissue fragments
passed in the labor room
• After discharge: woman should
assess amount of vaginal
bleeding by recording the
number of pads
 SPONTANEOUS MISCARRIAGE
DIAGNOSIS: Complete Management
Miscarriage • No therapy is needed
• The entire products of • Advise woman to report
conception )fetus, heavy bleeding
membranes, and placenta)
are expelled spontaneously
without any assistance
• Bleeding usually slows within
2 hrs and then ceases within
a few days after passage of
the products of conception

MCA Maico-Bacus, EdD, MAN, RN, COHN

 SPONTANEOUS MISCARRIAGE
DIAGNOSIS: Incomplete Management
Miscarriage • Be certain the woman knows
• Part of the conceptus (usually the pregnancy is already lost
the fetus) is expelled, but the and that procedures are being
membranes or placenta are done to protect her from
retained in the uterus hemorrhage and infection, not
• Danger of maternal to end the pregnancy
hemorrhage
• D&C or suction curettage to
evacuate the remainder of the
pregnancy

MCA Maico-Bacus, EdD, MAN, RN, COHN

 SPONTANEOUS MISCARRIAGE
DIAGNOSIS: Missed
Miscarriage
• Also referred to as early
pregnancy failure
• The fetus dies in utero but is
not expelled
• Usually discovered at prenatal
exam when the fundal height
is measured and no increase in
size can be demonstrated or
previously-heard fetal heart
sounds can no longer be heard
MCA Maico-Bacus, EdD, MAN, RN, COHN
Management
• After ultrasound establishes
the fetus has no HR, D&C or
D&E may be done
• If pregnancy is over 14 weeks,
labor is induced by a
prostaglandin suppository or
misoprostol (Cytotec)
introduced into the posterior
fornix of the vagina to cause
dilatation, followed by
oxytocin stimulation or
administration of mifepristone
 SPONTANEOUS MISCARRIAGE
DIAGNOSIS: Recurrent
Pregnancy Loss
• Causes:
• Defective spermatozoa or ova
• Endocrine factors
• Deviations of the uterus
(septate or bicornuate uterus)
• Resistance to uterine artery
blood flow
• Chorioamnionitis or uterine
infection
• Autoimmune disorders (lupus
anticoagulant and
antiphospholipid anitbodies)

MCA Maico-Bacus, EdD, MAN, RN, COHN

MCA Maico-Bacus, EdD, MAN, RN, COHN
 COMPLICATIONS OF MISCARRIAGE
HEMMORHAGE
• Monitor vs for changes to
detect hypovolemic shock
• If excessive bleeding occurs:
immediately position the
woman flat and massage the
uterine fundus
• Applying pneumatic antishock
garments can help maintain BP
MCA Maico-Bacus, EdD, MAN, RN, COHN
• If bleeding doesn’t halt, D&C
or suction curettage
• Transfusion; direct
replacement of fibrinogen or
another clotting factor
• Health education: bleeding
amount, color, odor, passing of
large clots
• Health education: medication,
methylergonovine maleate
(Methergine)
 COMPLICATIONS OF MISCARRIAGE
INFECTION • Advise not to use tampons
• May develop most often in
women who have lost an
appreciable amount of blood
• Signs: fever higher than 38C,
abdominal pain or tenderness,
foul-smelling vaginal discharge
• E. coli or group A
streptococcus
• Wiping perineal area from
front to back

MCA Maico-Bacus, EdD, MAN, RN, COHN

 COMPLICATIONS OF MISCARRIAGE
SEPTIC ABORTION
• An abortion complicated by
an infection
• More frequently occurs in
women who have tried to
self-abort or whose
pregnancy was aborted
illegally using a nonsterile
instrument
• Symptoms of fever and
crampy abdominal pain
MCA Maico-Bacus, EdD, MAN, RN, COHN
• Uterus will feel tender to
palpation
• May lead to toxic shock
syndrome, septicemia,
kidney failure, and death if
infection is left untreated
• CBC, serum electrolytes,
serum creatinine, blood type
and cross-match; cervical,
vaginal, and urine culture
are obtained
 COMPLICATIONS OF MISCARRIAGE
• Foley catheter may be
inserted to monitor urine
output hourly to assess kidney
function
• IVF to restore fluid volume
and provide route for high-
dose, broad-spectrum
antibiotic therapy is begun
• Combination of penicillin,
gentamicin, and clindamycin is
commonly prescribed
MCA Maico-Bacus, EdD, MAN, RN, COHN
• CVP or PA catheter may be
inserted to monitor left atrial
filling pressure and
hemodynamic status
• D&C or D&E
• Tetanus toxoid SQ or tetanus
immune globulin IM:
prophylaxis against tetanus
• Dopamine and digitalis to
maintain cardiac output
• O2 and ventilation support
 COMPLICATIONS OF MISCARRIAGE
• Final result may be
infertility or uterine
scarring or fibrotic scarring
of the fallopian tubes
• Follow up social work
counseling

MCA Maico-Bacus, EdD, MAN, RN, COHN

 COMPLICATIONS OF MISCARRIAGE
ISOIMMUNIZATION POWERLESSNESS OR
• The production of ANXIETY
antibodies against Rh- • Assess a woman’s
positive blood adjustment to a spontaneous
• After miscarriage, all miscarriage
women with Rh- blood should • Assess the partner or the
receive Rh (D antigen) family’s feelings as well
immune globulin (RhIG)

MCA Maico-Bacus, EdD, MAN, RN, COHN

 ECTOPIC PREGNANCY
KEY POINTS
• Implantation outside the
uterine cavity; fallopian
tube is the most common
site
• Obstruction; malformations;
scars
• Increasing rate: increasing
pelvic inflammatory disease,
in vitro fertilization, women
who smoke
MCA Maico-Bacus, EdD, MAN, RN, COHN
 ECTOPIC PREGNANCY
• No unusual symptoms at the • Manifestations: sharp,
time of implantation stabbing pain in one of her
• Diagnosis: early pregnancy lower abdominal quadrants
ultrasound, MRI at the time of rupture,
followed by scant vaginal
• Rupture of fallopian tube (6- spotting; hypotension from
12 weeks of pregnancy) à blood loss, light-headedness,
bleeding rapid PR (signs of
• Implantation at the hypovolemic shock);
interstitial portion of the leukocytosis may be
tube: severe intraperitoneal present, normal temp
bleeding
MCA Maico-Bacus, EdD, MAN, RN, COHN
 ECTOPIC PREGNANCY
• Transvaginal ultrasound:
ruptured tube and blood
collecting in the peritoneum
• Either a falling HCG or
serum progesterone levels
indicate the pregnancy has
ended
• Laparoscopy or culdoscopy
• Ultrasound
MCA Maico-Bacus, EdD, MAN, RN, COHN
• If a woman waits for a time
before seeking help, her
abdomen gradually becomes
rigid and the umbilicus may
develop a bluish-tinged hue
(Cullen sign); may have
continuing extensive or dull
vaginal or abdominal pain;
movement of the cervix on
pelvic exam causes
excruciating pain
 ECTOPIC PREGNANCY
• Pain on the shoulders as well
as blood in the peritoneal
cavity
• Tender mass is palpable in
Douglas cul-de-sac on
vaginal examination
MCA Maico-Bacus, EdD, MAN, RN, COHN
THERAPEUTIC
MANAGEMENT
• Some have no treatment
• If detected early in
pregnancy: IM or oral
administration of
methotrexate; treated until
a negative HCG titer is
achieved
• Hysterosalpingogram or
UTS
 ECTOPIC PREGNANCY
• If the ectopic pregnancy is
discovered only when it
ruptures, it creates an
emergency situation
THERAPEUTIC
MANAGEMENT
• Some have no treatment
• Hgb level; blood typing &
cross-matching, hCG level
MCA Maico-Bacus, EdD, MAN, RN, COHN
• If detected early in
pregnancy: IM or oral
methotrexate; treated until
a negative HCG titer is
achieved
• Hysterosalpingogram or
UTS (to assess tube if
pregnancy is no longer
present and tube patency)
• IVF using large-gauge
catheter
 ECTOPIC PREGNANCY
• Ruptured ectopic pregnancy:
laparoscopy: to ligate the
bleeding vessels and to
remove/repair damaged
fallopian tube
• RhIG/RhoGAM after
ectopic pregnancy for
isoimmunization protection
in future chilbearing

MCA Maico-Bacus, EdD, MAN, RN, COHN

 ABDOMINAL PREGNANCY
• Fetus grows in the pelvic
cavity
• Fetal outline is usually easily
palpable
• Woman may not be aware of of
movements; she may
experience painful fetal
movements and abdominal
cramping with fetal
movements; sudden lower
quadrant pain
MCA Maico-Bacus, EdD, MAN, RN, COHN
• MRI: fetus outside the uterus
• Danger: the placenta could
infiltrate and erode a major
blood vessel in the abdomen à
hemorrhage
• Intestine: may cause bowel
perforation, leaking of
intestinal contents, peritonitis
• High risk fetus: growth
deformity or growth
restriction
 ABDOMINAL PREGNANCY
• Infant born via laparotomy
• Placenta may be left in place
and allowed to absorb in 2-3
months; ff-up UTS to check
• Methotrexate: helps
placenta absorb

MCA Maico-Bacus, EdD, MAN, RN, COHN

 GESTATIONAL TROPHOBLASTIC DISEASE
KEY POINTS
• H. mole (hydatidiform mole)
• Abnormal proliferation and
then degeneration of
trophoblastic villi
• Associated with
choriocarcinoma
• Tend to occur in women with
low protein intake, >35 yo,
Asian heritage, A women who
marry O men
MCA Maico-Bacus, EdD, MAN, RN, COHN
• 2 types: complete and partial
• Complete: all trophoblastic villi
swell and become cystic; father-
only chromosome; fertilization
of an empty ovum
• Partial: some villi form normally;
syncytiotrophoblastic villi appear
swollen and misshapen; 69
chromosomes (3 chromosomes);
rarely lead to choriocarcinoma
• hCG titers are lower in partial;
return to normal faster after
evacuation
 GESTATIONAL TROPHOBLASTIC DISEASE
ASSESSMENT • UTS: dense growth (snowflake
• Uterus expands further than pattern), but no fetal growth; no
usual; reaches landmark before FH sounds; no viable fetus
the usual time
• Serum or urine test of hCG for
pregnancy will be strongly
positive (1-2M; normal is at
400,000); continues to be
strongly positive after day 100
• Marked N&V
• Symptoms of GHPN: increased
BP, edema, proteinuria (usually
not present before 20th week in
normal pregnancy)

MCA Maico-Bacus, EdD, MAN, RN, COHN

 GESTATIONAL TROPHOBLASTIC DISEASE
THERAPEUTIC MANAGEMENT
• Suction curettage; after:
baseline pelvic exam, serum
test for beta subunit of hCG
• hCG is analyzed q 2wks until
levels are normal
• Serum hCG is then assessed q
4wks for the next 6-12months
to see if it is declining
• If the level increases =
malignant transformation
MCA Maico-Bacus, EdD, MAN, RN, COHN
• While waiting for hCG decline,
woman should use oral
contraceptive (E/P)
• If hCG levels are negative
after 6months, woman is
theoretically free from the
risk of malignancy
• By 12months, she can begin to
plan pregnancy
• Methotrexate; dactinomycin