NCM1022L: CMCA LECTURE

LESSON 1: Complications of Pregnancy

PRELIMS | 2024 | 2ND SEMESTER
NURS 2-1
LEADING CAUSES OF MATERNAL DEATH TYPES OF ABORTION
THROMBOEMBOLISM SPONTANEOUS ABORTION

o Obstruction of a blood vessel by a blood clot that has ➢ Defined as involuntary loss of the product of conception
become dislodged from another site in the circulation. prior to 20 weeks gestation.
o Can also cause stroke ➢ Incidence:
o 15% in all confirmed pregnancy
HEMORRHAGE o 80% occurs in 1st trimester
➢ Abnormal fetal formation
o Uterine atony
➢ Chromosomal defects
o Unsutured laceration
➢ Genetic and structural abnormalities
o Retain placental fragments
o Incompetent Cervix – when your cervix shortens
INFECTION or opens too early in pregnancy.
o Immature Uterus
HYPERTENSION DURING PREGNANCY o Bicornuate Uterus

o Pre-eclampsia

ANESTHESIA COMPLICATIONS

ECTOPIC PREGNANCY

HEART DISEASE

ANTEPARTUM/PRENATAL HEMORRHAGE
➢ APH is blood loss per vagina after 20 weeks’ gestation.
➢ Complicates close to 4% of all pregnancies and is a
MEDICAL EMERGENCY!
➢ Is one of the leading causes of antepartum
hospitalization, maternal morbidity, and operative
intervention.

MISCARRIAGE ABORTION ➢ Implantation abnormalities

Pregnancy loss from natural The most common bleeding
causes before 20 weeks. As disorder of early pregnancy.
many as 20 percent of
pregnancies end in The termination of pregnancy
miscarriage. Often, before viability, that is, before
miscarriage occurs before a 20 weeks gestation from LMP
woman even knows she is or before the fetus weighs 500
pregnant. grams.

SIGNS: ABORTUS – a fetus that is

o Vaginal spotting or absorbed weighing less than
bleeding 500 grams.
o Cramping or
abdominal pain BLIGHTED OVUM – a small
o Fluid or tissue macerated fetus sometimes
passing from the there is no fetus, surrounded
vagina by a fluid inside an open sac.

Spotting early in pregnancy

doesn’t mean miscarriage is
certain. Still, contact your ➢ Infection
doctor right away if you have o Rubella (German Measles) – contagious
any bleeding. disease caused by a virus.
In most cases, miscarriage
cannot be prevented.
Sometimes, a woman must
undergo treatment to
remove pregnancy tissue in
the uterus. Counseling can
help with emotional support.

01 / 24 / 24 PRELIMS| 1
➢ Ingestion of TERATOGENIC DRUGS
o Can cause fetal malformation
o THALIDOMIDE – can cause phocomelia

➢ Maternal diseases
➢ Failure of the uterus to produce enough progesterone
and estrogen.
o Progesterone is an endogenous steroid
hormone that is commonly produced by the
adrenal cortex as well as the gonads, which
consist of the ovaries and the testes.
Progesterone is also secreted by the ovarian
corpus luteum during the first ten weeks of
pregnancy, followed by the placenta in the
later phase of pregnancy.
o Estrogen is a steroid hormone associated with
the female reproductive organs and is
responsible for developing female sexual
characteristics.

01 / 24 / 24 PRELIMS| 2
 TYPES OF SPONTANEOUS ABORTION
TYPES DEFINITION SIGNS AND SYMPTOMS NURSING MANAGEMENT
THREATENED Refers to the possible loss of the • Scanty blood loss bright red in color, ✓ Instruct client to have bed rest
products of conception. with or without low backache. until three days after bleeding
• Slight cramping, but there is no has stopped.
Occurs as early as 16 weeks but cervical dilatation. ✓ Advice the couple not to
not late than 24 weeks. • Cervix is closed. engage in coitus up to 2 weeks
• The uterus is soft with no tenderness after bleeding stopped to
upon palpation. prevent infection.
✓ Instruct client to save all pads
for examination and for
presence of clots.
✓ Advise client to limit physical
activity.

However, parents usually worry that

they might have lost the baby or
may lose the baby anytime soon
after a bleeding episode.

It is important to be honest to the

patient that it is possible to loss the
baby, but treatment is available to
try to save the pregnancy if
bleeding continues.

IMMINENT / Refers to the loss of the products • Uterine contraction and cervical ✓ Because the fetus cannot be
INEVITABLE of conception that cannot be dilation. saved anymore, the
prevented. • Heavy bleeding, with clots and management is directed
product of conception. toward avoiding the
• The membranes can rupture at this complications of infection or
time and amniotic fluid may be excessive blood loss.
seen.
✓ Hospitalization
✓ D & C (Dilation and Curettage)
✓ Oxytocin after D&C
✓ Sympathetic understanding
and emotional support

COMPLETE The product of conception are • Typically, the patient gives a history ✓ On examination, on the clinic
expelled spontaneously before of vaginal bleeding, abdominal or hospital, the following is
the 8 weeks without any pain, and passage of tissue. noted:
assistance. • After the passage of tissue, the - Light bleeding or some
patient observed that the pain and blood in the vaginal vault
vaginal bleeding significantly - No tenderness in the
diminished.
cervix, uterus or abdomen
- None to mild uterine
cramping
- Closed cervix
- Empty uterus on
ultrasound

✓ A complete abortion usually

needs no further medical or
surgical treatment. No
medication is likely to be
needed. Usually, the uterus
contract well after expelling
the entire contents so that
there is no need for
Methergine or Oxytocin. The
risk for infection is also minimal.
- Oxytocin (during labor) =
to stimulate uterine
contractions.
- Methergine (after
pregnancy) = treats
excessive bleeding.
✓ The patient must still be
observed closely for continued
bleeding or signs of infection.
 ✓ Regular diet. Advice to eat
high iron foods as the woman
may have lost a lot of blood.
✓ Instruct patient to rest for a few
days to 2 weeks after a
complete abortion.

INCOMPLETE Parts of the conceptus (usually • Cervix is open ✓ D&C is recommended

the fetus) is expelled but the • Cramping
membranes or placenta is • Bleeding
retained in the uterus.

MISSED Commonly referred to as EARLY • Absence of FHT ✓ A serum (blood) or urine test for
PREGNANCY FAILURE in which • Signs of pregnancy disappear. the subunit of human chorionic
the fetus dies in the uterus but is Missed abortion should be gonadotropin (HCG) becomes
not expelled. suspected when the: negative earlier than expected
- Uterus fails to enlarge. or does not double within 48 –
The embryo actually died 4 to 6 - Fetal heart sounds are not 72 hours.
weeks before the onset of heard at the appropriate or ✓ Ultrasound showing no cardiac
miscarriage symptoms or failure disappears after it has been activity provides the earliest
of growth was noted. initially heard. diagnosis.
✓ Depending on the age of
gestation or size of conceptus,
the product of conception has
been removed from the uterus
to prevent DIC (Disseminated
Intravascular Coagulation)
✓ Late missed abortion may be
completed with a dilute IV
infusion of oxytocin, which
causes contraction of the
uterus and delivery of the
products of conception.
✓ After the uterus has contracted
following delivery of the fetus,
curettage may be needed to
remove fragments of the
placenta.

SEPTIC Abortion that is complicated • Foul smelling vaginal discharge ✓ Treat abortion
with infection. • Fever and chills ✓ High dose IV antibiotic therapy,
• Uterine cramping a combination of penicillin,
• Uterus feels tender upon palpation gentamicin and clindamycin is
commonly used.
IF LEFT UNTREATED, such an infection ✓ D&C if accompanied by
can lead to toxic shock syndrome, incomplete abortion.
septicemia, kidney failure, and death. ✓ Infertility can occur after
recovery due to scarring of
uterus and fallopian tubes,
scarring can interfere with
fertilization and proper
implantation.

INDUCED Termination of pregnancy – –

before the 24th weeks
gestation.

Sometimes it is done because

of medical reason.

ELECTIVE / A therapeutic abortion may be • Serious kidney or liver disease –

THERAPEUTIC indicated if a woman has a • Certain types of infection
pregnancy-related health • Malignancy (cancer)
condition that endangers her • Multifetal pregnancy
life. Some examples of such
conditions include:
- Severe hypertension
- Cardiac disease
- Severe depression or
other psychiatric
conditions

RECURRENT Refers to the loss of three or – –

more consecutive pregnancies
 with the following factors to
consider:
- Genetic disorder
- Immunologic Factor
- Hyper secretion of the
LH
- Infection
- Structural Abnormalities
- Cervical
Incompetence

IDENTIFIED AREAS THAT ALLOWS ABORTION

➢ Continuation of pregnancy would involve the risk greater than if pregnancy were terminated, of injury to the
physical or mental health of the pregnant woman.

➢ Termination is necessary to prevent grave permanent injury to the physical or mental health of the mother.

➢ The continuance of pregnancy would involve risk to the life of the pregnant woman, greater than if the
pregnancy were terminated.

➢ There is substantial risk that if the child were born it would suffer such physical or mental abnormalities as to be
seriously handicapped.
 NCM1022L: CMCA LECTURE
LESSON 2: Implantation Bleeding
PRELIMS | 2024 | 2ND SEMESTER
NURS 2-1
IMPLANTATION BLEEDING • Their sizes vary and can be anywhere from a few
➢ Implantation bleeding can occur about 6-10 days after millimeters (size of a seed) to 1-2 centimeters (size of a
conception when the fertilized egg attaches to the large grape).
interior lining of the uterus. • Polyps are most commonly diagnosed in pregnant
➢ Generally, around 1/3 of pregnant women will women, or in women over 40 years of age.
experience implantation bleeding.
➢ There is a scanty vaginal discharge occurring as the
trophoblast erodes and the blastocyst implants.

SIGNS OF IMPLANTATION BLEEDING

1. Headache
2. Light pink to rust-colored spotting, light bleeding, pink
discharge
3. Light cramping
4. Nausea
5. Changes in mood
6. Lower backache

NURSING MANAGEMENT:

A. Prompt obstetric consultation

B. Emotional support
C. Health Education

CERVICAL POLYPS

CARCINOMA OF THE CERVIX

• Cancer of the cervix which is considered the most

common form of CA in women.
• The principal screening test is the Papanicolau Smear or
Pap’s Smear

ECTOPIC PREGNANCY

• Small vascular, pedunculated growths attached to the

cervix which may bleed during pregnancy.
• They can be visualized on speculum examination and no
treatment is required during pregnancy, unless bleeding
occurs, or a cervical smear suggest malignancy.
• Cervical polyps are small benign tumors on the cervix.

01 / 25 / 24 PRELIMS| 1
 • Implantation of the zygote that occurs on a site other
than the uterine cavity.
• EP is the 2nd most frequent cause of bleeding in early
pregnancy.

➢ UTERINE TUBE (TUBAL) 95% of EP are tubal.

➢ AMPULLA most common site 80%
➢ INTERSTITIAL least common site 8%
➢ ISTHMUS 12%

SIGNS AND SYMPTOMS:

CAUSES OF ECTOPIC PREGNANCY:
o Sudden sharp unilateral abdominal pain
A. Adhesion of the fallopian tube from a previous infection o Minimal vaginal bleeding
B. Congenital malformation o Signs of shock
C. Scars from tubal surgery and PID
D. Smoking CULLEN’S SIGN
E. Uterine tumor
F. Long length of the FP

RISK FACTORS:

A. Hx of tubal surgery
B. Hx of STD’s (such as chlamydia)
C. Hx of ART
D. Hx of ectopic (esp if conservatively managed without
surgery)
E. Smoking
F. IUD (Intrauterine Device) in place at time of conception.

MECHANICAL FACTORS:

A. CONGENITAL long narrow tube, diverticulae and

accessory ostia.
B. TRAUMATIC operation on the tubes as salpingoplasty and
tubal reversal following ligation.
C. INFLAMMATORY chronic salpingitis (inflammation of the
fallopian tubes, caused by bacterial infection).
D. NEOPLASTIC narrowing of the tube by a fibroid or a broad
ligament tumor.
E. FUNCTIONAL as tubal spasm or antiperistaltic
F. ENDOMETRIOSIS in the tube, encourages embedding of
the fertilized ovum. • A medical term used to represent periumbilical
ecchymosis.
TYPES OF ECTOPIC PREGNANCY • Thomas Stephen Cullen, who first linked periumbilical
bruising to abdominal hemorrhage.
• Specifically, he noted this association with ruptured
ectopic pregnancy and hemorrhagic pancreatitis.

01 / 25 / 24 PRELIMS| 2
 OUTCOMES HYPEREMESIS GRAVIDARUM
• It is sometimes called the PERNICIOUS VOMITING.
• It is nausea and vomiting of pregnancy that is prolonged
past 12 weeks of gestation.
• That may lead to DHN, ketonuria, and significant weight
loss.
• Usually occurs during the first trimester.
• This mother requires hospitalization.

PREDISPOSING FACTORS:

A. Increased thyroid function due thyroid stimulating

properties of Hcg.
B. Hormonal flood of Hcg and estrogen that triggers the
vomiting center.
C. Being pregnant with multiples, A family history of HG,
having HG during a previous pregnancy, being
overweight, being a first-time mother, and Trophoblastic
disease (abnormal cell growth in the uterus).

SIGNS AND SYMPTOMS:

o Excessive vomiting anytime of the day.

o Elevated Hct level due to inability to retain fluid that
results in Hemoconcentration.
o Oliguria (low urine output)
o Weight loss and sunken eyes
o Concentration of NA, K, and Cl may be reduced due to
low intake urine exam is positive for ketones.
o Dry tongue
o Increase PR and decrease BP
o Fever
o Restlessness, confusion with memory loss (rare)

THERAPEUTIC MANAGEMENT:

A. Hospitalization for approximately 24 hours to monitor I&O

and blood chemistries.
B. Immediate fluid replacement (3,000 ml of lactated
ringers)
C. All oral foods and fluids are withheld.
D. Administration of anti-emetic medication to control
vomiting.

MANAGEMENT:

A. Removal of the trophoblast while preserving the

unaffected tube.
B. Support the mother during the grieving process.
C. EP is a life-threatening condition, if the woman waits
before seeking help, gradually her abdomen becomes
rigid from peritoneal irritation. If blood is slowly seeping
into the peritoneal cavity, the umbilicus will develop a
bluish tinged referred to as the CULLEN’S SIGN.

01 / 25 / 24 PRELIMS| 3
 NCM1022L: CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)
LESSON 3: Gestational Trophoblastic Disease
PRELIMS | 2024 | 2ND SEMESTER
NURS 2-1
GESTATIONAL TROPHOBLASTIC DISEASE
• Abnormal proliferation of the Trophoblastic Villi

➢ Hydatidiform Mole
– a term applied to a gross
malformation of the
trophoblast in which the
chorionic villi proliferates
and becomes avascular.

➢ It is a proliferation
and degeneration of the
trophoblastic villi.

➢ The embryo fails to

develop completely.

➢ There are 69 chromosomes that develop for the partial

mole, and 46 chromosomes for the complete mole.

➢ The trophoblastic villi start to proliferate rapidly and

become fluid-filled grape-like vesicles.

CAUSES OF H. MOLE
• Abnormal Fertilization
• Advanced Maternal Age
• Malnutrition
• Large Amount of HCG (Human Chorionic
Gonadotrophin) – a hormone produced by the placenta
during pregnancy.
• Chromosomal Abnormalities
• Hormonal Imbalances
• Low socio-economic status
• Below 18 and or above 40 years old MANAGEMENT
✓ Suction Curettage to evacuate the mole.
SIGNS AND SYMPTOMS OF H. MOLE ✓ Monitoring of Hcg level for 6 months (every 2-4 weeks)
o Uterus tends to expand faster than normal ✓ The woman should be instructed to use a reliable
o Strongly positive PT after day 100 contraceptive method such as an oral contraceptive
o Increase nausea and vomiting agent for 6 months.
o Sonogram shows dense growth but no fetal growth ✓ DRUG OF CHOICE: Methotrexate
o No FHT
o At 16th weeks there is vaginal spotting COMPLICATION
CHORIOCARCINOMA – malignant neoplasm which can be
TYPES OF H. MOLE develop as a consequence of molar pregnancy.
COMPLETE H. MOLE

➢ All trophoblastic villi swells and becomes cystic.

➢ Contains no evidence of embryo, cord, or membranes.
But if there is an embryo forms, it dies early at only 1-2 mm
in size.
➢ The chorionic villi alter to form clear, hydropic vesicles,
which hand in clusters forming small pedicles that may
resemble a bunch of grapes.

PARTIAL H. MOLE

➢ There is no evidence of an embryo, fetus, or amniotic sac.

➢ Death occurs at 8th to 9th week.

02 / 04 / 24 PRELIMS| 1
 NCM1022L: CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)
LESSON 3: Incompetent Cervix (2nd trimester)
PRELIMS | 2024 | 2ND SEMESTER
NURS 2-1
INCOMPETENT CERVIX 5. Light vaginal bleeding/spotting
Inability of the cervix to hold the fetus 6. A change in vaginal discharge

➢ Refers to the cervix that dilates prematurely and MANAGEMENT

therefore cannot hold fetus until term. CERVICAL CERCLAGE
➢ Pregnancy is lost at about 20 weeks.
➢ Cervical dilatation is usually painless.
➢ There is show (pink stained vaginal discharge)
➢ Increase pelvic pressure.

➢ Surgical procedure done to prevent premature cervical

dilatation at 12-14 weeks in which suture are placed in
the cervix by the vaginal route under regional
anesthesia. Removed at 37 to 38 weeks of pregnancy.

2 TYPES OF CERVICAL CERCLAGE

1. MCDONALD PROCEDURE
• Nylon sutures are placed horizontally and
vertically across the cervix and pulled tight to
reduce cervical canal to a few millimeters in
diameter.

RISK FACTORS
• Short cervical length
• Repeated or late term abortion
• Injury from previous childbirth
• Repeated abortion
• Uterine Abnormality
• Exposure to drug
• Twin or multiple pregnancy
• Prior miscarriage and D&C or Leep

CAUSES
• Congenital uterine abnormalities
• Acquired

SIGN AND SYMPTOMS

Appears typically between weeks 14 and 20 of pregnancy, and
include the following:

1. Backache
2. Sensation of pelvic pressure
3. Premenstrual like cramping
4. Braxton Hicks like contractions

02 / 04 / 24 PRELIMS| 1
MCDONALD’s RULE SUCCESS RATE OF THE PROCEDURE:

✓ For both type of cerclage is 80% to 90%

✓ NOTE: after cervical cerclage woman should remain on
bed rest, in slight or moderate Trendelenburg position for
a few days, sexual relations may resume after the rest
period.

2. SHIRODKAR PROCEDURE
• Sterile tape is threaded in a purse-string manner
under the sub mucosal layer of the cervix and
sutured in placed to achieve a close cervix.

02 / 04 / 24 PRELIMS| 2
 NCM1022L: CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)
LESSON 3: PROM and PPROM
PRELIMS | 2024 | 2ND SEMESTER
NURS 2-1
PRETERM PRELABOR RUPTURE OF MEMBRANE THERAPEUTIC MANAGEMENT
➢ Occurs before the 37th week of gestation where the ✓ Usually admitted and is placed on bed rest.
rupture of fetal membranes occurs without the onset of ✓ Administration of IVF to keep the woman well
spontaneous uterine activity resulting in cervical hydrated/doctors order.
dilatation. ✓ Instruct the woman to drink enough fluid
➢ It accounts for about 10% of cases and observes ✓ Advised to avoid smoking
expectant or active management. ✓ Maintain adequate nutrition
✓ Administration of tocolytic agent
WHAT CAUSES PREMATURE RUPTURE OF MEMBRANES? ✓ To detect presence of amniotic fluid in the urine
• Previous Preterm Birth NITRAZINE TEST should be perform.
• History of Vaginal Bleeding ✓ BLUE (+) positive amniotic fluid in the urine
• Cigarette smoking during pregnancy ✓ YELLOW (–) negative amniotic fluid in the urine
• Trauma
• Cervical incompetence, cervical laceration, cervical
operation
• Polyhydramnios (increase in the amniotic fluid in
pregnancy)
o Oligohydramnios – disorder of amniotic fluid
resulting in decreased amniotic fluid volume.
• Multiple pregnancy
• Urinary Tract Infection
• Woman who works in a strenuous job that leads to
extreme fatigue.
• Chorioamnionitis – an ascending infection, originating in
the lower genitourinary tract and migrating to the
amniotic cavity. NITRAZINE TEST OR PHENAPHTHAZINE is a pH indicator dye Nitrazine
indicates pH in the range 4.5 to 7.5
SIGNS AND SYMPTOMS
• Persistent, dull low backache FALSE POSITIVES:
• Vaginal spotting feeling of pelvic pressure or abdominal
o If blood gets in the sample
tightening.
o If there is an infection present
• Menstrual like cramping
o Recent vaginal intercourse (SEMEN also has a
• Increase vaginal discharge
HIGHER pH)
• Slight uterine contraction
• Intestinal cramping
• Sudden gush of clear fluids from the vagina with
continued leakage.

RISK OF PPROM
➢ Labor which may intervene anytime resulting to preterm
birth
➢ Chorioamnionitis
➢ Oligohydramnios
➢ Cord prolapse
➢ Malpresentation associated with prematurity
➢ Primary antepartum hemorrhage

02 / 04 / 24 PRELIMS| 1
 NCM1022L: CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)
LESSON 4: Placenta Previa
PRELIMS | 2024 | 2ND SEMESTER
NURS 2-1
PLACENTA PREVIA COMPLETE PLACENTA PREVIA
• When the placenta is implanted partially or completely
over the lower uterine segment (over and adjacent to • The placenta is partially
the internal os) it is called PLACENTA PREVIA. located centrally over the
internal os and hemorrhage is
INCIDENCE: likely to occur.
• Vaginal delivery should not
➢ About one-third cases of antepartum hemorrhage.
be considered.
➢ The incidence of placenta previa ranges from 0.5 – 1%
• CS is recommended to save
➢ In 80% cases, it is found to multiparous women.
the life of both mother and the
➢ Incidence increases beyond the age of 35, with high birth
unborn.
order pregnancies and in multiple pregnancy.

PREDISPOSING FACTORS
1. Increased Parity
2. Advanced Maternal Age
3. Past Caesarian Births ALL DEGREE OF PLACENTA PREVIA GENERAL RULE IS NO
4. Past Uterine Curettage INTERNAL EXAM!!
5. Multiple Gestation
SYMPTOMS
DEGREE OF PLACENTA PREVIA ONLY SYMPTOM = VAGINAL BLEEDING
LOW LYING PLACENTA
Classical features of bleeding suddenonset, painless, apparently
• Placenta implants in the causeless and recurrent.
lower portion instead of the
upper portion of the uterus. • 5% cases occurs for the first time during labor, especially
• Vaginal delivery is possible. in primigravidae.
Blood loss is usually mild. • One-third of cases, there is a history of “warning
• The condition of both the hemorrhage” usually slight.
mother and child are in good • Bleeding is unrelated to activity and often occurs during
condition. sleep and the patient becomes frightened on
awakening to fight herself in a pool of blood.
MARGINAL IMPLANTATION
SIGNS
• The placenta’s edge is GENERAL CONDITION AND ANEMIA ARE PROPORTIONATE TO THE
nearing the cervical os. VISIBLE BLOOD LOSS.
• The placenta is partially
located in the lower segment ABDOMINAL EXAMINATION
near the internal cervical os.
➢ The size of the uterus is proportionate to the period of
• Vaginal delivery is possible.
gestation.
• Blood loss is moderate.
➢ The uterus feels relaxed, soft, and elastic
• Fetal hypoxia is more likely to
➢ Persistence of malpresentation like breech or transverse
occur than maternal shock.
or unstable lie is more frequent.
PARTIAL PLACENTA PREVIA ➢ The head – floating
➢ Fetal heart sound is usually present, unless there is major
• The placenta is located over separation of the placenta with the patient.
the internal cervical os but not
centrally. NURSING MANAGEMENT
• A portion of the cervical os is 1. Ensure the physiologic well-being of the client and fetus.
already covered by the
➢ Take and record vital signs, assess bleeding, and
placenta.
maintain a perineal pad count.
• Bleeding is likely to be severe
➢ Weigh perineal pads before and after use to estimate
especially when the cervix
blood loss.
begins to efface and dilate
➢ Observe for shock, which is characterized by a rapid
late in pregnancy.
pulse, pallor, cold moist skin, and a drop in blood
• Delivery is not appropriate since the placenta precedes
pressure.
the fetus.
➢ Monitor the FHR.
➢ Enforce strict bed rest to minimize risk to the fetus.
➢ Observe for additional bleeding episodes.
➢ Laboratory monitoring = hgb and hct
➢ Administration of Bethamethasone (for <34 weeks
gestation)
➢ Apr or KLEIHAUER – BETKE (test stripe procedure – used to
detect the amount of fetal blood in the maternal
circulation).

02 / 16 / 24 PRELIMS| 1
2. Provide client and family teaching

➢ Explain the condition and management options. To

ensure an adequate blood supply to the mother and
fetus, place the woman at bed rest in a side-lying
position. Anticipate the order for a sonogram to localize
the placenta. If the condition of mother or fetus
deteriorates, a caesarean birth will be required.
➢ Prepare the client for ambulation and discharge (may be
within 48 hours of last bleeding episode).
➢ Discuss the need to have transportation to the hospital
available at times.
➢ Instruct the client to return to the hospital if bleeding
recurs and to avoid intercourse until after the birth.
➢ Instruct the client on proper handwashing and toileting
to prevent infection.

02 / 16 / 24 PRELIMS| 2
 NCM1022L: CARE OF MOTHER, CHILD AT RISK OR WITH PROBLEMS (ACUTE & CHRONIC)
LESSON 4: Abruptio Placentae
PRELIMS | 2024 | 2ND SEMESTER
NURS 2-1
ABRUPTIO PLACENTAE DEGREE OF SEPARATION
Or premature separation of the normally implanted placenta, GRADE 0
complicates 0.5% to 1.5% of all pregnancies (1 in 120 births).
Abruption severe enough to result in fetal death occurs in 1 per 500 ➢ No indication of placental separation and diagnosis of
deliveries. slight separation is made after birth.
➢ The diagnosis that the slight separation did occur is made
after birth, when the placenta is examined, and a
segment of the placenta shows a recent adherent clot
on the maternal surface.

GRADE 1

➢ There is minimal separation which

causes vaginal bleeding.
➢ No changes in fetal vital signs occur.

RISK FACTORS
1. Maternal Hypertension, Pre-eclampsia, Chronic
Hypertension
2. Maternal Age
3. Multiparity
4. Cigarette Smoking GRADE 2
5. Maternal Trauma
6. Polyhydramnios ➢ Moderate separation occurs.
7. Poor Nutrition ➢ Fetal distress is already evident.
➢ The uterus is also hard and painful
The most common of these risk factors is maternal upon palpation.
hypertension, either chronic or as a result of pre-eclampsia. The
risk of recurrent abruption is high: 10% after on abruption and 25%
after two.

Approximately 50% of placenta abruptio cases severe

enough to cause fetal death are associated with hypertension.
GRADE 3
SIGNS AND SYMPTOMS OF ABRUPTIO PLACENTA
CLASSICAL SIGN: ➢ Extreme separation
➢ Maternal shock
• UTERUS is HYPERTONIC or TENSE and TENDER on PALPATION
➢ Fetal death is imminent if no
• Abdomen – board – like in rigidity.
interventions are done.
• The woman may experience a sharp, stabbing pain high
in the uterine fundus as the initial separation occurs.
• External heavy bleeding.
• If the center of the placenta separates first, however,
blood will pool under the placenta and be hidden in view
that will lead to COUVELAIRE UTERUS or UTERO PLACENTAL
APOPLEXY
• COUVELAIRE UTERUS (UTERO PLACENTAL APOPLEXY) – A
pathological entity in association with severe form of
concealed abruption placentae. There is massive
intravasation of blood into the uterine musculature upto
the serous coat. The condition can only be diagnosed on
laparotomy.

02 / 16 / 24 PRELIMS| 3
 NURSING ASSESSMENT
• Assess for signs of shock, especially when heavy bleeding
occurs.
• Assess if the bleeding is external or internal.
• Monitor contractions if separation occurs during labor.
• Obtain baseline vital signs.
• Assess the time the bleeding began, the amount and
kind of bleeding, and interventions done when bleeding
occurred if it started before admission.
• Assess the quality of pain.

NURSING INTERVENTIONS
✓ Place the woman in a lateral, not supine position to avoid
pressure in the vena cava.
✓ Monitor fetal heart sounds.
✓ Monitor maternal vital signs to establish baseline data.
✓ Avoid performing any vaginal or abdominal
examinations to prevent further injury to the placenta.

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