CARE OF MOTHER AND CHILD SEM 02 | 01

LECTURE / AT RISK OR WITH ACUTE/CHRONIC PROBLEMS AUF-CON

MODULE 02 – FIRST TRIMESTER CONDITIONS [ABORTION AND ECTOPIC

NCM 0109
PREGNANCY]
3. The ultrasound report of a woman diagnosed with
OUTLINE ectopic pregnancy shows presence of a ruptured
I First Trimester Conditions fallopian tube and extensive bleeding. Which
A Ectopic Pregnancy medical management will she likely undergo?
B Spontaneous Abortion
i Threatened Miscarriage a. Oral administration of methotrexate
ii Imminent (Inevitable) Miscarriage b. Surgical repair of the ruptured tube
iii Complete Miscarriage c. Intravenous infusion of fluids
iv Incomplete Miscarriage
v Missed Miscarriage
d. Oral mifepristone
vi Recurrent Pregnancy Loss
4. Which client is most likely at risk to experience
ectopic pregnancy?
INTRODUCTION a. A 25-year-old woman who smokes
b. A 28-year-old woman with healthy lifestyle
● HEMORRHAGE AND ECTOPIC PREGNANCY
c. A 30-year-old woman with history of
○ Leading complications related directly to
previous ectopic pregnancy
pregnancy
d. A 32-year-old woman with controlled
○ Have the potential to threaten the life of the
diabetes
mother and the fetus
● RESPONSIBILITY OF NURSES
5. A fetus is said to be viable when:
○ Help to ensure that women are well informed
a. He reaches 24 weeks AOG
about the normal course of pregnancy so they
b. His weight is less than 500 grams
can recognize and alert the health team when
c. The AOG is more than 4 weeks
complications are occurring
d. He cannot survive outside the utero
○ Actively participate in risk assessment,
management and treatment, and provision of
6. A type of miscarriage where there is no cervical
support to the pregnant woman and her family
dilation:
● All families benefit from the support and
a. Spontaneous miscarriage
skill of a professional nurse who helps them
b. Inevitable miscarriage
work through the stages of pregnancy and
c. Complete miscarriage
provides special care to ensure the
d. Threatened miscarriage
continuation of pregnancy.

7. A type of miscarriage where only parts of the

PRETEST
conception are expelled:
1. Which statement is TRUE regarding ectopic a. Complete miscarriage
pregnancy? b. Inevitable miscarriage
a. Bleeding is uncommon c. Incomplete miscarriage
b. The most common site occurs in the isthmus d. Threatened miscarriage
of the fallopian tubes
c. Previous use of Norplant is a risk factor 8. A type of miscarriage where uterine contractions
d. The woman may experience shock occur, cervix is dilated, and miscarriage is
uncontrollable:
2. Which of the following is a sign and symptom in a. Complete miscarriage
ectopic pregnancy? b. Inevitable miscarriage
a. Absence of menstrual flow c. Incomplete miscarriage
b. Increased level of hCG d. Threatened miscarriage
c. Cullen’s sign
d. Nausea and vomiting 9. A medical procedure done in miscarriage for the
purpose of cleaning the uterus and prevent further
complications:

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 MODULE 02 — FIRST TRIMESTER CONDITIONS (ABORTION AND ECTOPIC PREGNANCY)

a. Ultrasonography ○ Interstitial/fimbrial (can cause intraperitoneal

b. Dilatation and evacuation bleeding; 8%)
c. Foley catheterization ● Interstitial: a connection on the uterus and
d. Laparoscopy has large blood vessels
○ Ovary, abdominal cavity, cervix, or anywhere
10. Which nursing diagnosis is appropriate for a outside the uterine cavity (remaining 5%)
patient who experienced miscarriage?
a. Readiness for enhanced parenting
b. Risk for impaired parental bonding
c. Deficient knowledge
d. Powerlessness

DEFINITION OF TERMS

● ABORTION
○ Any interruption of a pregnancy before the age
of viability
● ECTOPIC PREGNANCY ​
○ An implantation that occurs outside the uterine
cavity Fertilization where there is a union of egg and
sperm occurring in the distal third of the
● MISCARRIAGE 1 fallopian tube is considered as the normal
○ Interruption in pregnancy that occurs
pregnancy
spontaneously
2 Zygote divides and grows normally
MODULE PROPER Zygote cannot reach proper site of
implantation (uterus) d/t obstruction (cannot
A. ECTOPIC PREGNANCY travel length of the tube)
● Uterine tumor
● Scars from tubal surgery
● ECTOPIC: an abnormal place, location or position 3 ● Congenital malformations
○ Not only limited to pregnancy
● Adhesion of fallopian tube from previous
● Implantation occurs outside the uterine cavity infection
(emergency) ● Chronic salpingitis/Pelvic Inflammatory
● 2% of pregnancies are ectopic Disease
● Second most leading cause of bleeding early in Zygote lodges at a stricture site along the tube
pregnancy (16 weeks of pregnancy [first 4 and implants there
trimester])
● Accounts for 6% of all maternal deaths in the US
5 Ectopic pregnancy = termination

I. ASSESSMENT

A. SIGNS AND SYMPTOMS

1. AT THE TIME OF IMPLANTATION

● No unusual symptoms (symptoms similar to a

● FALLOPIAN TUBE: most common site as it is the site
of fertilization (95%)
○ Ampullar (most common; 80%)
● Ampulla: largest portion in the distal third
of the fallopian tube
○ Isthmus (narrowest site; very painful; 12%)
normal pregnancy)
○ Implantation proceeds but not in the uterus
● No menstrual flow
○ Corpus luteum continues to function as if the
implantation occurred in the uterus
● Nausea and vomiting in early pregnancy
● Breast tenderness
● Pregnancy test for hCG will be positive (53%)
● DIAGNOSIS: early pregnancy UTZ or MRI
○ Shows that there is no baby inside the womb

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 MODULE 02 — FIRST TRIMESTER CONDITIONS (ABORTION AND ECTOPIC PREGNANCY)
○ An early pregnancy UTZ would be enough to
check for this condition
2. WEEKS 6-12 OF PREGNANCY (POSSIBLE RUPTURE OF
FALLOPIAN TUBE)
● 2-8 weeks after missed menstrual period
● Bleeding due to rupture of fallopian tubes
Zygote grows large enough (becomes too big to
1 be accommodated by the fallopian tube)
2 Fallopian tube ruptures (overstretched)
3 Tearing and destruction of blood vessel walls
Intraperitoneal bleeding takes place; patient
4 may die of shock
○ Extent depends on the number and size of
ruptured vessels
● Interstitial portion (junction where tube
joins the uterus): severe intraperitoneal
bleeding
○ ✓ pelvic cavity
○ X vaginal bleeding
● Ampulla (distal third): less likely to be
profuse
○ Continued bleeding (even if scant amount)
result in large amount of blood loss
● Ruptured ectopic pregnancy is SERIOUS
regardless of the site of implantation
● Sharp, stabbing pain in one of the lower abdominal
quadrants (hypogastric pain)
○ Most common symptom
● Scant vaginal spotting
○ Placenta dislodges
● No longer do its action of maintaining
appropriate amounts of progesterone,
leading to sloughing of endometrium
○ Progesterone prepares the
endometrium for the potential of
pregnancy after ovulation
○ No secretion of progesterone, causing
sloughing of endometrium (termination of
pregnancy)
○ BAKIT KAUNTI LANG?: because of the distance
between the fallopian tube and vagina
○ NOTE: The amount of bleeding does not
determine the actual amount of bleeding
● Blood is expelled into pelvic cavity rather
than uterus; blood does not reach the
vagina to become evident
● Shock from blood loss
○ Beginning Shock: hypovolemic shock
● Lightheadedness and syncope (fainting)
because of bleeding internally = ↓ blood
volume; ↓ oxygen saturation
○ Severe Shock
● Rapid respirations: the body would
compensate to increase the oxygen by
increasing respiration because of rapid loss
of blood, and there is decreased RBCs and
hemoglobin, lowering the oxygen in the
body
● Falling BP: due to falling blood volume
(directly proportional)
● Rapid and thready pulse: the heart
compensates by increasing its cardiac
contraction to increase the falling blood
volume and BP
● Leukocytosis (not from infection but from trauma
or an inflammatory process)
○ Rise in number of white blood cells
3. LATE CONSULTATION
● Abdominal rigidity from peritoneal irritation
● Dull vaginal and abdominal pain (adnexal
tenderness over ovary and fallopian tube)
● Pain in the shoulders from irritation of the phrenic
nerve d/t blood collecting in the peritoneal cavity
(right shoulder; causes irritation to phrenic nerve)
● Cullen’s sign (bluish tinge
umbilicus)
○ Blood at the peritoneal
cavity
○ Umbilicus develop a
bluish tinge and rigid
abdomen (peritoneal
irritation)
● Movement of cervix on pelvic examination that
causes excruciating pain
● Palpable, tender mass in Douglas cul-de-sac on
vaginal examination
B. RISK FACTORS
● FACTORS THAT CAUSE OBSTRUCTION
○ Adhesions from previous infection such as
salpingitis (infection of the fallopian tube) or
pelvic inflammatory disease
○ History of congenital malformations (webbing/
fibrous bands)
○ Scars from tubal surgery
○ Uterine tumor
● Smoking d/t vasoconstriction
● Previous use of IUD (leads to ovarian implantation;
structures block the pathway)
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 MODULE 02 — FIRST TRIMESTER CONDITIONS (ABORTION AND ECTOPIC PREGNANCY)
● In vitro fertilization (can cause tubal/fallopian tube
pathology [obstruction])
● Previous history of ectopic pregnancy d/t tubal
bilateral scarring
● Uterus exposed to diethylstilbestrol (DES)
○ Synthetic form of estrogen (oral contraceptive)
○ Affects tubal motility
○ Causes increased proliferation of uterine cells =
increased blockage
● Oral contraceptives
● History of infertility
II. DIAGNOSIS
A. DIAGNOSTIC PROCEDURES
● TRANSVAGINAL SONOGRAM
○ Reveals the rupture tube and blood collecting in
the peritoneum
● INSERTION OF A NEEDLE THROUGH POSTERIOR
VAGINAL FORNIX (CULDOCENTESIS)
○ Only performed when the results of
transvaginal sonogram is not definite of the
condition/rupture fallopian tube
○ Inserted into the cul de-sac under sterile
conditions
● Physician inserts a flexible needle through
the vagina to the posterior cervix and to the
cul-de-sac/back
○ PURPOSE: To determine if bleeding is present
○ RESULT: If there is an aspiration of blood,
bleeding is present from rupture ectopic
pregnancy
● LAPAROSCOPY OR CULDOSCOPY
○ Used to visualize the fallopian tube if the
symptoms do not reveal a clear picture
○ If planning for another pregnancy
● ULTRASONOGRAPHY
○ Reveals a clear-cut diagnostic picture
○ Based on literature, an ultrasound is adequate
enough to provide a clear picture of ectopic
pregnancy
B. LABORATORY PROCEDURES
● Hgb and Hct levels
○ Lowered d/t bleeding
● Blood typing and cross matching
○ For blood transfusion purposes d/t internal
bleeding
○ To check fetal blood for Rh incompatibility
● Administer RhoGAM
● ↓hCG level/progesterone
○ Pregnancy has ended, because hCG level
should be elevated in a normal pregnancy
● Do not rely on vaginal bleeding
○ Nonspecific: could signify another gestational
problem
○ Bleeding in ectopic pregnancy is only scanty
III. MEDICAL AND SURGICAL MANAGEMENT
A. UNRUPTURED TUBE
● Expel the terminated fetus, not to induce
termination
A. ORAL METHOTREXATE FOLLOWED BY LEUCOVORIN
● A chemotherapeutic agent
● WHY SHOULD IT BE FOLLOWED BY LEUCOVORIN?
○ Methotrexate competes with folic acid, leading
to deficiency
○ Leucovorin calcium is the antidote to prevent
toxicity and is a reduced form of folic acid that
can be administered 24 hours after initiation of
methotrexate
● Given until (-) HCG titer; medication is discontinued
and UTZ is performed after HCG becomes negative
○ To check if the tube is left intact or patent
● Attacks and destroys fast-growing cells of the
pregnancy (e.g., zygote)
● Administration: given via IM only if the tube is
unruptured / ↓ 3.5 cm
● Side Effects
○ Avoid sun exposure d/t photosensitivity
○ Abdominal pain after injection
● IMPORTANT CONSIDERATION: tube left intact and
patent
○ No surgery → less chance of surgical scarring
→ less chance of causing 2nd ectopic
pregnancy
● FOLLOW-UP
○ Blood draws: taken until negative hCG titer is
achieved
○ Hysterosalpingogram/UTZ: performed to
assess that the pregnancy is no longer present
and to confirm tube patency
B. MIFEPRISTONE
● An abortifacient; usually given vaginally
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 MODULE 02 — FIRST TRIMESTER CONDITIONS (ABORTION AND ECTOPIC PREGNANCY)
● Causes sloughing of the tubal implantation site
○ Matatanggal ang implantation site
● Ultrasound after chemotherapy to assess tubal
patency
● Both drugs leave no surgical scarring; second
ectopic pregnancy is prevented
B. RUPTURED TUBE
● Medical emergency due to bleeding internally
● Make sure to perform blood sampling for
hemoglobin levels and cross-matching
● INTRAVENOUS FLUIDS
○ Normal saline solution would not cause
interactions with blood components and has
the same osmolality as the body’s serum
○ Infusion is done using a large-gauge catheter
(18–20 G) to prepare for blood transfusion
● Main line is PNSS, while side drip is blood
transfusion
● In case of reactions, stop BT and increase
NSS
● LAPAROSCOPY
○ Could be
laparoscopic
linear
salpingostomy or
laparoscopic
salpingectomy
○ Ligation of
bleeding vessels
and removal or
repair of damaged fallopian tube (tatahiin)
○ Microsurgical technique (does not require a
large incision; less chance of creating rough
sutures/lines on fallopian tube = less chance
for another TP [a rough suture line of FT will
likely cause another tubal pregnancy])
○ If the ruptured ectopic pregnancy might be too
severe, a laparoscopy would not be enough
and appropriate so the traditional opening of
the abdominal area would be performed
instead
● But in certain circumstances, a laparoscopy
would be adequate
C. IN CASE OF MISCARRIAGE
● Women with Rh-negative blood should receive Rh D
immune globulin (RhIG) after an ectopic pregnancy
○ To prevent HDN especially in 2nd pregnancy
IV. NURSING MANAGEMENT
A. DIAGNOSES
● Powerlessness related to early loss of pregnancy
secondary to ectopic pregnancy
○ An ectopic pregnancy cannot be continued
● Acute pain related to abdominal bleeding
secondary to tubal rupture
● Deficient fluid volume related to hypovolemia
secondary to maternal blood loss
○ We cannot use vaginal spotting and bleeding
to determine the extent of blood loss
● Mostly sa pelvic cavity pumapasok ang
blood kaysa sa uterus kaya hindi
ma-reach ang vagina
● Grieving related to loss of pregnancy
B. INTERVENTIONS
● Encourage the patient to verbalize her concerns
about her ectopic pregnancy and future
childbearing
○ Child loss
○ Decreased self-image because of another EP
○ Sense of powerlessness
● Assess patient’s need for counseling
○ Refer to appropriate HCP if patient cannot cope
up with the situation
○ Always include the partner during counseling
SELF-CHECK
1. Which of the following is a sign and symptom in
ectopic pregnancy?
a. Absence of menstrual flow
b. Increased level of hCG
c. Cullen’s sign
d. Nausea and vomiting
2. The ultrasound report of a woman diagnosed with
ectopic pregnancy shows presence of a ruptured
fallopian tube and extensive bleeding. Which
medical management will she likely undergo?
a. Oral administration of methotrexate
b. Surgical repair of the ruptured tube
c. Intravenous infusion of fluids
d. Oral mifepristone
3. Which client is most likely at risk to experience
ectopic pregnancy?
a. A 25-year-old woman who smokes
b. A 28-year-old woman with healthy lifestyle
c. A 30-year-old woman with history of
previous ectopic pregnancy
d. A 32-year-old woman with controlled
diabetes
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 MODULE 02 — FIRST TRIMESTER CONDITIONS (ABORTION AND ECTOPIC PREGNANCY)

● Inadequate implantation → placental

B. SPONTANEOUS ABORTION
● Occurs in 15-30% of all pregnancies
● Occurs from natural causes/unplanned
● ABORTION
○ Medical term for any interruption of a
pregnancy before a fetus is viable
○ BLEEDING
● 1st 6 weeks
○ Rarely severe bleeding
○ Placenta attached to decidua (uterine
endometrium: superficial attachment)
● 12 weeks
○ Profuse bleeding
○ Deep implantation of the placenta
○ With such deep placental implantation,
the fetus tends to be expelled as in
natural childbirth before the placenta
separates
● VIABLE FETUS
○ Usually defined as a fetus that is:
✅ More than 20–24 weeks AOG
✅ Weighs >500 grams
✅ Can survive out of the uterus if born at that
time
● WHAT HAPPENS WHEN THE INTERRUPTION OCCURS
SPONTANEOUSLY?
○ Becomes clearer to refer to it as miscarriage
● Early miscarriage: before 16 weeks
● Late miscarriage: weeks 16–24
circulation cannot function adequately →
poor fetal nutrition → fetus dies (SA)
● Inadequate production of progesterone by corpus
luteum
○ Corpus luteum supplies progesterone in early
pregnancy; placenta will replace it in the latter
part
● Progesterone maintains pregnancy by
maintaining the site of implantation and
thickness of the endometrium
○ ↓ Progesterone → cannot maintain decidual
basalis (decidua basalis is the site of
implantation in the uterus)
○ Placenta fails to produce hormones leading to
endometrial sloughing
● Consequently leads to release of
prostaglandins causing uterine contraction
and cervical dilation
● Systemic infection and UTI
○ Rubella, syphilis (plasma reagin test),
poliomyelitis, CMV, and toxoplasmosis cross the
placenta (causative factors)
○ UTI: most common cause of premature
contractions and preterm birth
● Ingestion of a teratogenic drug
○ Isotretinoin/Accutane: drug for acne that is
teratogenic
○ Alcoholic beverage
● Miscarriage and fetal abnormality leading
to SA

B. RISK FACTORS
I. ASSESSMENT

A. CAUSES ● Maternal age

○ Underage: 20 (12%)
● Abnormal fetal formation ● Due to underdeveloped reproductive
○ Due to teratogenic factor or chromosomal system
aberration ○ Overage: 40 (26%)
○ 50-80% of fetus aborted have structural ● Age-related concern with the reproductive
abnormalities system
● Presence of immunologic factors or rejection of the ● Hot tub or Jacuzzi
embryo through the maternal immune response ○ Prolonged soaking in hot tubs and jacuzzi →
○ APAS (Antiphospholipid Antibody Syndrome) hyperthermia from increased core body
● Implantation abnormalities temperature → precipitates spontaneous
○ Due to inadequate endometrial formation or abortion
from inappropriate site of implantation
● Sloughing off of endometrial lining d/t poor C. SIGNS AND SYMPTOMS
progesterone production
○ 50% of zygotes are probably never implanted ● Vaginal spotting (nonspecific sign)
○ Placental circulation is inadequate leading to ○ Early sign of SA
poor fetal nutrition ○ Confirm the pregnancy
○ PURPOSES
● Determine pregnancy length in weeks

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 MODULE 02 — FIRST TRIMESTER CONDITIONS (ABORTION AND ECTOPIC PREGNANCY)

● Determine duration, intensity, description, ● If accompanied by tissue fragments, ask

and frequency of bleeding the client to bring them upon going to the
○ INTERVENTIONS health facility. This is to confirm if the
● Note if there are associated symptoms fragments are products of conception
such as pain pertaining to the fetus, placenta, or the
● Identify any actions done by the pregnant membranes OR a fragment of H-mole
client (i.e., events preceding the bleeding,
initial interventions to control bleeding) LARGE FRAGMENTS Complete abortion; no
● Know the blood type (BABY AND PLACENTA) additional management
● Report immediately to HCP even if the Incomplete abortion;
amount of spotting is small retained fragments cause
BABY OR PLACENTAL
● Ask the mother what did she do in order to bleeding
FRAGMENT
stop the bleeding
Simulation of labor/raspa
● Ensure that it is not self-abortion or polyps
○ Polyps (tissue growths): checked via UTZ ○ Color: Bright red (fresh blood; near the vagina),
(if due to polyps, only vaginal spotting is dark (old blood; patient with abruptio placenta)
present, no abdominal pain and
○ Odor: Is it odorous?
backache) FREQUENCY: Is it steady or did it occur in a single
●
● Abdominal cramps episode?
○ PURPOSES ● ASSOCIATED SYMPTOMS: Cramping? Sharp pain?
● Prevent further bleeding Dull pain? Cervical surgery?
● Expel the product of conception upon ● ACTION: What were you doing prior to the
termination of pregnancy bleeding? What did you do to control the bleeding?
● Clean the uterus ○ Tampons could easily cause infection. Thus, if
● Backache d/t uterine cramping (+) vaginal bleeding, advise against use of
such; use pads instead
C.1. IMMEDIATE ASSESSMENT OF VAGINAL BLEEDING
DURING PREGNANCY ○ Saturation of one pad/hour = excessive
bleeding
● CONFIRMATION OF PREGNANCY ● BLOOD TYPE: Do you know your blood type?
○ Through pregnancy test or IE to check for ○ If the mother is Rh-, administer RhoGAM
softening of the cervix
○ Ascertain pregnancy through positive I.A. COMPLICATIONS OF MISCARRIAGE
pregnancy test or through confirmation of MD,
A. HEMORRHAGE
RN, or RM
● PREGNANCY LENGTH
● COMPLETE SPONTANEOUS MISCARRIAGE
○ Length of pregnancy in weeks
○ Fetal hemorrhage is rare
● If >12 weeks, check FHT with Doppler to
○ Observe bleeding (rule of thumb)
confirm
● Color changes in bleeding
○ LMP of the patient (Naegele’s rule)
● Abnormal: unusual odor/(+) large clots
● DURATION
○ Methylergonovine maleate (methergine)
○ How long did the bleeding episode last?
● Administer via IM to promote uterine
○ Is it continuing (once or continuous)?
contractions, reducing chances of
● INTENSITY
hemorrhage
○ How much bleeding?
● RESPONSIBILITY: Monitor BP
● Measure through tablespoon/cup
● INCOMPLETE ABORTION
○ Steady stream: how many tbsp?
○ Disseminated intravascular coagulation
(possible hemorrhage)
TSP TBSP CUP GLASS
○ Monitor VS (hypovolemic shock)
5 mL 15 mL 180/240 mL 360 mL
● WOF PPCDR: pallor, perspiration, clammy
skin, dyspnea, and restlessness
● DESCRIPTION
○ (+) excessive vaginal bleeding
○ Components: Is the blood mixed with AF or
● Flat position and massage uterine fundus
mucus? Are there tissue fragments?
(stimulate contractions)

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 MODULE 02 — FIRST TRIMESTER CONDITIONS (ABORTION AND ECTOPIC PREGNANCY)

○ Impossible in early pregnancy d/t size ○ Endometritis

of uterus; not palpable above ○ Peritonitis: rigid abdomen
symphysis pubis ○ Thrombophlebitis: sharp, shooting pain on legs;
● Nipple stimulation (+) Homan’s sign
● Educate pt on monitoring of bleeding ○ Septicemia: generalized infection that leads to
(amount, color, odor, presence of clots) blood poisoning
● Effective only beyond 20 weeks
○ Dilation and curettage or suction curettage C. SEPTIC ABORTION
● Empty material from uterus that is
preventing it from contracting and achieving ● An abortion that is complicated by infection
hemostasis ● Commonly occurs when abortion is induced
○ Blood transfusion to replace blood loss illegally using a non-sterile instrument
● PNSS is the only IVF used to initiate BT (self-abortion)
○ Direct replacement of fibrinogen to increase ● Prolonged and unrecognized rupture of
coagulation ability membranes
● PATIENT EDUCATION ● Pregnancy with IUD
○ Bleeding: note for excessive saturation, color
changes, odor, and clots The uterus is a warm, moist cavity. This makes
○ Drugs: review importance of drugs (e.g., 1 it an ideal environment for microorganisms to
thrive.
methylergonovine maleate) and reason behind
prescription 2 Introduction of infectious organisms
3 Rapid growth of organisms
B. INFECTION Infection + presence of products of conception

● MOST FATAL COMPLICATION 4 If left untreated, toxic shock syndrome,

○ Possibility of infection is minimal when septicemia, kidney failure, and death may
occur
pregnancy loss occurs over a short period
○ Tends to develop in women who have lost
● SYMPTOMS
considerable amounts of blood
○ Fever, crampy abdominal pain, tender uterus
● DANGER SIGNS
● MEDICAL MANAGEMENT
○ Fever: most common and most significant;
○ Laboratory Tests: CBC, serum electrolytes, and
temperature of 38℃; rule out fluid deficit
serum creatinine (determines filtration ability of
○ Abdominal pain or tenderness
kidneys), blood typing and cross matching
○ Foul vaginal discharge
(preparing for transfusion if needed),
○ Eschierichia coli
cervical/vaginal/urine cultures (determines
● Found in the lower gut and rectum
causative agent), Hcg (decreases with fetal
● Responsible for infection after miscarriage
death)
● Spread from rectum to vagina (d/t faulty
○ Procedures
perineal cleaning)
● Foley catheter: monitor hourly output (to
● NURSING RESPONSIBILITIES
assess kidney function)
○ Close observation is important
● IV fluids
○ Educate client about danger signs of infection
○ Restore fluid volume
(fever, abdominal pain, foul vaginal discharge)
○ Keep Vein Open: Best route for
○ Carefully evaluate temperatures higher than
high-dose broad spectrum antibiotics
100.4°F (38°C)
(administered to prevent infection)
○ Educate client to wipe from front to back to
● Dilation and curettage or dilation and
prevent bacterial spread from rectal area after
evacuation: removes all infected and
voiding and defecating
necrotic uterine tissue
○ Discourage use of tampons in controlling
● Oxygen and ventilator support: maintains
vaginal discharge; use ordinary perineal pads
respiratory function
instead
○ Pharmaceutical Interventions
● Causes fluid (vaginal secretion) stasis =
● Subcutaneous administration of tetanus
increased risk for infection
toxoid (active immunity)
● COMMON INFECTIONS

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 MODULE 02 — FIRST TRIMESTER CONDITIONS (ABORTION AND ECTOPIC PREGNANCY)
● Intramuscular administration of tetanus
immune globulin (as prophylaxis against
tetanus; passive immunity)
● Dopamine and digitalis: maintains sufficient
cardiac output
○ (+) inotropic effect: increases force of
heart contractions
● Antibiotic therapy using combination drug of
penicillin (Gram+), gentamicin (Gram-
aerobic), and clindamycin (Gram-
anaerobic)
● NURSING RESPONSIBILITY: Counsel those who
underwent self-abortion; assist them to learn better
problem-solving techniques
D. ISOIMMUNIZATION
● All women with Rh-negative blood should receive
RhIG
Dislodged placenta (active exchange of
1 maternal-fetal circulation)
Mixing of fetal (Rh+) and maternal (Rh-) blood
2 results in isoimmunization
3 Production of antibodies against Rh+ blood
Administration of RhoGAM to protect next
4 pregnancy
● THERAPEUTIC MANAGEMENT
○ Depending on the symptoms and the
description of the bleeding a woman gives, the
physician or nurse-midwife will decide whether
she needs to be seen and, if so, seen in an
ambulatory setting or the hospital
● NURSING MANAGEMENT
○ Possible Nursing Diagnoses
● Powerlessness or anxiety related to early loss
of pregnancy secondary to miscarriage
● Deficient fluid volume r/t excessive bleeding
secondary to spontaneous abortion
● Acute pain r/t abdominal cramping
secondary to threatened abortion
● Grieving r/t expected loss of unborn child
○ Interventions
● Assess a woman’s adjustment to a
spontaneous miscarriage
● Assess the woman’s partner’s feelings as
well
● Provide emotional support in accepting the
reality of the situation
● Provide counseling to accept future
pregnancy because of fears that they may
never be able to carry a baby to full term
II. DIAGNOSIS
B.1. THREATENED MISCARRIAGE
● 50% of women with threatened miscarriage
continue pregnancy, while 50% result in
imminent/inevitable pregnancy
● CLOSED CERVIX & (+) FHT
● Cause is unknown; possibly chromosomal or
uterine abnormalities
SIGNS AND SYMPTOMS
● Painless vaginal bleeding
○ Initially begins as scant bleeding
○ Usually bright red (fresh blood)
○ Worried at sight of bleeding
● NR: Be a sympathetic and a supportive
person
● Explain to the mother that the activities she
mentions such as lifting heavy objects, being
angry at someone, and running, are not the
cause of the bleeding
● Slight cramping and backache
● (-) cervical dilatation on vaginal examination
○ Kaya naisasalba pa ang threatened abortion
and can proceed pa
NURSING MANAGEMENT
● Assessment of fetal heart sounds or sonography to
evaluate viability of the fetus
○ If there is no fetal heartbeat, the pregnancy
becomes terminated
● Blood for hCG may be drawn at the start of
bleeding and 48 hours
○ If placenta is still intact, hCG levels should
double in 48 hours
○ If the value does not double, there is poor
placental function = pregnancy is lost
● Avoiding strenuous activity for 24–48 hours is the
key intervention
○ Complete bed rest is usually not necessary as
this may appear to stop the vaginal bleeding
but only because blood pools vaginally
● Kapag tumayo na, magde-drain ‘yung
blood = blood will reappear
● Spotting usually stops within 24–48 hours after
reducing activity
○ She can gradually resume with her normal
activities after bleeding stops
● Coitus is usually restricted for 2 weeks after the
bleeding episode
NCM 0109|9
 MODULE 02 — FIRST TRIMESTER CONDITIONS (ABORTION AND ECTOPIC PREGNANCY)

○ Helps in avoiding infection and further induction

of bleeding
● Caution patients not to use tampons to halt
bleeding as this can lead to infection

B.2. IMMINENT/INEVITABLE MISCARRIAGE

● A threatened miscarriage becomes an imminent

(inevitable) miscarriage if uterine contractions and
cervical dilatation occur
○ With cervical dilation, the loss of the products
(fetus, placenta, other associated membrane)
of conception cannot be halted
● (+) CONTRACTIONS AND DILATATION
● Cause is unknown but is linked to poor placental
attachment
SIGNS AND SYMPTOMS
● Reports cramping/uterine contractions
● (-) fetal heart sounds
NURSING MANAGEMENT
● An examination should be done if the client reports
cramping or uterine contractions
● The client should save any tissue fragments she
has passed and bring them with her so they can be
examined
○ Examined for H-mole
○ For assurance that all products of conception
have been removed
○ To prevent uterine atony as even small tissues
would prevent the uterus to contract as foreign
bodies serve as a medium for microorganisms
leading to infection
● Vacuum extraction (dilation and evacuation)
○ Performed if no fetal heart sounds are
detected and a sonogram reveals an empty
uterus or non-viable fetus
○ Ensure that the pregnant woman has been
informed that pregnancy was lost before
performing the procedure
○ Inform that D&E is done to clean the uterus and
prevent further complications, NOT to end the
pregnancy
● Stop scraping if bleeding becomes
accompanied with bubbles
○ Ensure all products of conception are removed
● If fragments remain, infection is likely to
happen (may lead to sepsis). The uterus
will also contract to remove the retained
fragments, leading to hemorrhage
● Assess for vaginal bleeding after D&E
○ Record the number of pads used
● Saturating of more than one pad per hour is
abnormally heavy bleeding
○ QOBL (quantification of blood loss): 1 g = 1 mL
B.3. COMPLETE MISCARRIAGE
● Entire products of conception (fetus, membrane,
placenta) are expelled spontaneously without any
assistance
● Bleeding usually slows within 2 hours and then
ceases within a few days after the passage of the
products of conception
● There is hemorrhage (fetal hemorrhage is rare)
○ Observe bleeding (rule of thumb):
fully-saturated pad in an hour
○ Color changes in bleeding
○ Abnormal: unusual odor/(+) large clots
● Oral methylergonovinr maleate (Methergine) to
promote uterine contractions but check the blood
pressure first
○ No therapy needed; just report to the HCP if
there is any heavy vaginal bleeding
● CLOSED CERVIX & (-) PRESENCE OF FETUS
B.4. INCOMPLETE MISCARRIAGE
● Part of the conceptus (fetus) is expelled, but the
membrane or the placenta is retained in the uterus
● (+) SLIGHT CERVICAL DILATATION
NURSING MANAGEMENT
● The term “incomplete” can be confusing for
women, be careful not to encourage false hopes
○ They might think that miscarriage is just partial
and pregnancy can continue
○ Avoid in giving false hopes

NCM 0109|10
 MODULE 02 — FIRST TRIMESTER CONDITIONS (ABORTION AND ECTOPIC PREGNANCY)

● Dilation and curettage (D&C) or suction curettage ○ Prostaglandin suppository (Misoprostol/ Cytotec
is usually performed by a physician [anti-ulcer drug; abortaficient among pregnant
○ To evacuate the remainder of pregnancy from client; not an OTC drug]) to dilate the cervix
the uterus ○ Followed by oxytocin stimulation or
○ Maternal hemorrhage is likely if parts of the administration of mifepristone (inhibits
conception remain progesterone)
● Uterus cannot contract effectively if there is ○ To terminate the pregnancy
something inside even if it is a small clot ● Prenatal examination (no increase in size of fundal
● Curettage and continuous contractions height and no previously heard FHT)
take place to remove remaining products ● If the pregnancy is not actively terminated,
of conception from the uterus miscarriage usually spontaneously occurs within 2
● Monitor the VS weeks
● (+) excessive vaginal bleeding: flat position ● S/sx: Painless brownish vaginal bleeding
and massage uterine fundus ● Disseminated intravascular coagulation may occur
○ Inform patient that D&C or suction curettage is if products are not expelled
performed to clean the uterus and prevent ○ Coagulation defect
further complications (hemorrhage/infection), ○ Pregnancy is not actively terminated (>6
NOT to end the pregnancy weeks)
● HEMORRHAGE ○ Dead toxic fetus remains too long in utero →
○ D&C/Scution curretage: empty material from breakdown of fetal tissue →
uterus that is preventing it from contracting thromboplastin/fibrinogen (coagulation
and achieving homeostasis material) release → bleeding
○ BT: PNSS
○ Direct replacement of fibrinogen (coagulation) B.6. RECURRENT PREGNANCY LOSS

B.5. MISSED MISCARRIAGE ● Habitual abortion/aborters

(Early Pregnancy Failure) ○ Three spontaneous miscarriages at the same
gestational age
● The fetus dies in the utero, but is not expelled
● Occurs in 1% of women
○ Sonogram (embryo died 4-6 weeks before onset
of miscarriage symptoms)
CAUSES
● CLOSED CERVIX, (-) FHT, & (+) PRESENCE OF FETUS
● Usually discovered during prenatal examination Problem in union of sperm and ova (either of them
●
○ Fundal height is measured and no increase in has a problem that pregnancy cannot continue)
size can be demonstrated Defective spermatozoa or ova (pregnancy that
●
○ Previously heard fetal heart sounds cannot be cannot proceed/progress)
heard Endocrine factors (problems with iodine [poor
●
● A client may have painless vaginal bleeding or she thyroid function])
may have had no prior clinical symptoms Deviations of the uterus: uterus is not favorable for
●
fetal growth (irregularly or abnormally-shaped
NURSING MANAGEMENT uterus)
○ Septate uterus
● Like incomplete abortion, the term “missed” could
○ Bicornuate uterus: heart-shaped
also be confusing for women
○ May think that pregnancy can be continued
○ Be careful in providing health teachings
● A sonogram can establish the fetus is dead 4–6
weeks before onset of miscarriage symptoms
○ After the sonogram, D&E (dilatation and
evacuation) is most commonly done
● EXPECTANT MANAGEMENT: the patient can wait up
to 8 weeks for the pregnancy to pass on its own
● MEDICATION MANAGEMENT: if the pregnancy is
over 14 weeks, labor may be induced by:

NCM 0109|11
 MODULE 02 — FIRST TRIMESTER CONDITIONS (ABORTION AND ECTOPIC PREGNANCY)

a. Ultrasonography
b. Dilatation and evacuation
c. Foley catheterization
d. Laparoscopy

ANSWER KEY
SELF-CHECK 01: C, C, C
SELF-CHECK 02: D, C, B, B

Banaag, Cato, Diala, Ingal, Mallari, Malonzo, Paras

BSN 2025
REFERENCES
Synchronous Lecture:
Module: NCM 0109 First Trimester Conditions
Book: Maternal and Child Health Nursing
● Resistance to uterine artery blood flow Practice Questions:
● Chorioamnionitis/uterine infection (infection of the A. Question Bank 1
B. Question Bank 2
amniotic fluid and fetal membrane) (fetal
C. Question Bank 3
membrane infection) D.
E.

● Autoimmune disorders (APAS): the maternal

immune system would target the fetus and would
lead to pregnancy loss
○ Immune system attacks own cells as it cannot
differentiate own cells from foreign cells
○ Suppresses the immune system not to attack
own cells, which is risky

SELF-CHECK
1. A type of miscarriage where there is no cervical
dilation:
a. Spontaneous miscarriage
b. Inevitable miscarriage
c. Complete miscarriage
d. Threatened miscarriage

2. A type of miscarriage where only parts of the

conception are expelled:
a. Complete miscarriage
b. Inevitable miscarriage
c. Incomplete miscarriage
d. Threatened miscarriage

3. A type of miscarriage where uterine contractions

occur, cervix is dilated, and miscarriage is
uncontrollable:
a. Complete miscarriage
b. Inevitable miscarriage
c. Incomplete miscarriage
d. Threatened miscarriage

4. A medical procedure done in miscarriage for the

purpose of cleaning the uterus and prevent further
complications:

NCM 0109|12