COMPLICATION OF PREGNANCY

BY: HEIDI CUTLER CABANATAN

BLEEDING DURING PREGNANCY
 Spontaneous Miscarriage
 Abortion
 Threatened miscarriage
 Imminent (inevitable) miscarriage
 Complete miscarriage
 Incomplete miscarriage
 Missed miscarriage
 Recurrent pregnancy loss
 ABORTION
 any interruption of a pregnancy before a fetus is viable
 spontaneous miscarriege
 15% to 30% of all pregnancies
 arises from natural causes
 EARLY MISCARRIAGE if it occurs before week 16 of pregnancy
 LATE MISCARRIAGE if it occurs between weeks 16 and 20

VIABLE FETUS
 fetus of more than 20 to 24 weeks of gestation or one that weights at least 500 g.
 a fetus is born before this point is considered a miscarriage or is termed a premature or
immature birth.
weeks of pregnancy placental bleeding
attachment
 first 6 weeks  placenta is  rarely severe
tentatively attached
to the decidua of
the uterus

 during 6-12 weeks  moderately

attached

 after week 12  attachment is  profuse

penetrating and fetus - expelled as in
deep natural childbirth
before the placenta
separates
 COMMON CAUSES OF MISCARRIAGE
 first trimester - abnormal fetal development due to :
teratogenic factor or chromosomal
aberrations

TERATOGENIC - is any factor, chemical, or physical, that adversely affects the

fertilized ovum, embr, or fetus.
 COMMON CAUSES OF MISCARRIAGE
 Immunologic factor
 Implantation abnormalities
 Corpus luteum fails to produce enough progesterone to
maintain the decidua basalis
 UTI
 Systemic infections
 Rubella cytomegalovirus
 syphilis toxoplasmosis
 poliomyelitis
IMMEDIATE ASSESSMENT OF VAGINAL BLEEDING
 CONFIRMATION OF PREGNANCY
 PREGNANCY LENGTH
 DURATION
 INTENSITY
 DESCRIPTION
 FREQUENCY
 ASSOCIATED SYMPTOMS
 ACTION
 BLOOD TYPE
THERAPEUTIC MANAGEMENT
 Depending on the symptoms and the description of the
bleeding.
DIAGNOSIS
THREATENED MISCARRIAGE
 symptoms begin as vaginal bleeding - scant and bright red
 may notice slight cramping, but no cervical dilatation is present on vaginal
examination
 woman may be asked to come - for fetal hearts asounds assessment and
ultrasound to assess viability of the fetus
 labs: test for hCG hormone - at the start of bleeding then after 48 hours if the
placenta is still intact
 avoidance of strenuous activity for 24 to 48 hours
THREATENED MISCARRIAGE
Management:
– complete bed rest for 24-48 hours. If bleeding will stop , it usually
stops within this time
– Coitus is restricted for 2 weeks after bleeding has stopped in order to
prevent further bleeding or infection
– Advise patient to save all pads, clots and expelled tissues
IMMENENT (INEVITABLE MISCARRIAGE
 uterine contractions and cervical dilation occur - loss of the products of
conception cannot be halted
 with cramping or uterine contractions
 if no fetal heart sounds are detected and ultrasound reveals - an empty
gestational sac or non viable fetus - medication to help the pregnancy pass or
perform
 D and C (Dilatation and Curettage
 D and E (Dilatagtion and Evacution)
COMPLETE MISCARRIAGE
 entire products of conception (fetus, membranes, and placenta) are expelled
spontaneously without any assitance.
 bleeding - usually slows within 2 hours and the ceases within a few days after
passage
 no therapy is needed other than advising the woman to report heavy bleeding
INCOMPLETE MISCARRIAGE
 part of the conceptus (usually the fetus) is expelled, but the membranes or
placenta are retained
 danger of maternal hemorrhage - for as long as part of conceptus is retained in
the uterus because the uterus cannot contract effectively under this condition.
 D and C or suction curettage to evacuate the remainder of the pregnancy.
 be certain the woman knows the pregnancy is already lost - the procedure is to
protect her from hemorrhage and infection, not to end pregnancy
MISSED MISCARRIAGE
 also referred as early pregnancy failure
 fetus dies in utero but is not expelled
 when no increase in fundic height and no fetal heart sounds
 may have had symptoms of a threatened miscarriage or she may have no prior
clinical symptoms.
 D and C or D and E
 if pregnancy is over 14 weeks in length - labor can be induced by a
PROSTAGLANDIN SUPPOSITORY OR MISOPROSTOL (CYTOTEC)
- inserted into the posterior fornix of the vagina to cause dilatation followed by
OXYTOCIN stimulation or adminstration of MIFEPRISTONE
 if nonviable fetus remains too long in utero - DIC may develop
RECURRENT PREGNANCY LOSS
 habitual abortion - miscarriags that occurred at the same gestational age for
three times
POSSIBLE CAUSES:
 defective spermatozoa or ova
 endocrine factors: low levels of protein-bound iodine, butanol-extractable iodine
and globulin-bound iodine; poor thyroid funtion; or luteal phase defect
 deviation of the uterus - septate or bicornuate uterus
 resistance to uterine artery blood flow
 Chorioamnionitis or uterine infection
 autoimmune disorders - lupus anticoagulant and antiphospholipid antibodies
BLEEDING DURING PREGNANCY

COMPLICATIONS OF MISCARRIAGE
 Hemorrhage
 Infection
 Septic abortion
 Isoimmunization
 Powerlessness of anxiety
Hemorrhage and infection - most common
HEMORRHAGE
 Complete spontaneous - serious or fatal hemorrhage is rare
 incomplete miscarriage or with DIC (disseminated intravascular coagulation) -
major hemorrhage is possible
 monitor vital signs for any changes to detect possible HYPOVOLEMIC SHOCK
 if with excessive vaginal bleeding - position a woman flat and massage the
uterine fundus to try to aid contraction
 apply pneumatic antishock garments can help maintain blood pressure
 if bleeding doesn’t halt - D and C or suction curettage
 transfusion may be necessary to replace blood loss
 replacement of fibrinogen may be used to increase coagulation ability.
 HYPOVOLEMIC SHOCK
blood loss
↓
decreased intravascular volume
↓
decrease venous return, decreased cardiac output, and lowered blood pressure
↓
body compensating by increasing heart rate to circulate the decreasing volume
faster:
vasoconstriction of peripheral vessels (to save blood for vital organs)
increased respiratory rate and a feeling of apprehension at body changes
↓
 ↓
cold, clammy skin; decreased uterine perfusion
if continued blood loss - blood pressure will continue to fall
↓
reduced renal, uterine, and brain perfusion
lethargy, coma, decreased renal output
↓
renal failure
↓
MATERNAL AND FETAL DEATH
HEMORRHAGE
 if self-limiting complete miscarriage - instruction on how much bleeding is
abnormal (more than 1 sanitary pad per hour) and what color changes she
should expect in bleeding. (from dark color to color of serous fluid)
 report for any unusual odor or passing of large clots
 medication: methylergometrine maleate (Methergine) - to aid uterine
contraction

METHERGINE
INFECTION
 tend to develop more often to women who have loss a large amount of blood.
 infection usually involves the inner lining of the uterus (endometritis)
 it may lead to parametritis, peritonitis, thrombophlebitis, or septicemia
DANGER SIGNS OF INFECTION:
 fever higher than 38.0°C
 abdominal pain or tenderness
 foul-smelling vaginal discharge
 organism responsible for infection - Escherichia coli and Group A Streptococcus
 advise women not to use tampons
SEPTIC ABORTION
 is an abortion complicated by infection.
 it occurs in women who have tried to self-abort or whose pregnancy was aborted
illegally using non-sterile instrument
 symptoms of fever and crampy abdominal pain
 uterus is tender to palpitation
 if left untreated - lead to toxic shock syndrome, septicemia, kidney failure, and
death

Uterus is warm, moist, dark cavity - once infectious organisms are introduce, they
grow rapidly in this environment.
SEPTIC ABORTION
 need immediate, intensive assessment and therapy admitted at ICU
 an indwelling catheter may be inserted to monitor urine output hourly
 IV fluids - to restore fluid volume and to provide a route for medications
 Labs:
 CBC
 serum electrolytes
 serum creatinine
 blood type
 cross matching
 cervical, vaginal and urine culture
 complication - INFERTILITY - because of uterine scarring or fibrotic scarring of
the fallopian tubes
SEPTIC ABORTION
 D and C or D and E will be performed- to remove all infected or necrotic tissue
from the uterus
Medications:
 Penicillin (gram-positive coverage);
 gentamicin (gram-negative aerobic coverage)
 clindamycin (gram-negsative anaerobic coverage)
 Tetanus Toxoid or tetanus immune globulin (IM) - prophylaxis
 Dopamine and digitalis - may be necessary to maintain sufficient cardiac
output
 Oxygen and ventilatory support ( may be necessary) - to maintain respiratory
function
ISOIMMUNIZATION (Rh incompatibility)
 Rh incompatibility is a condition that develops when a pregnant woman has Rh-negative blood
and the baby in her womb has Rh-positive blood
mother (Rh -)
↓
fetal RBC cross into the mother's blood through the placenta
( fetus is Rh positive)
↓
mothers immune system treats fetal RBCs as foreign
makes antibodies against the fetal blood cells
antibodies may cross back through the placenta into the developing
baby
↓
 destroy the baby's circulating red blood cells (hemolysis)

increase bilirubin (infant is yellowish in color- jaundice)

Treatment for the mother: should receive RhIG - RHOGAM on the second pregnancy
ECTOPIC PREGNANCY
 implantation occurred
outside the uterine cavity
 most common - fallopian
tube (95%)
 of these fallopian tube -
80% - ampullar portion
 12% - isthmus
 8% interstitial or fibrial
ETIOLOGY:
 adhesion of the fallopian tube -
from previous infection
 chronic salpingitis
 Pelvic Inflammatory Disease
(PID)
 congenital malformations
 scars from tubal surgery
 uterine tumor
 Approximately 2% of pregnancies are
ectopic
 2nd most frequent cause of bleeding early in
pregnancy
 increase incidence rate due to :
 increase rate of pelvic inflammatory
disease
 following in vitro fertilization
 women who smoke
ASSESSMENT :
 no unusual symptoms at the time of implantation
 6-12 weeks - zygote grows large enough that it ruptures.
 tearing and destruction of blood vessels and bleeding result
 if implantation - interstitial portion - of the tube - rupture can cause severe
intraperitoneal bleeding
 ampullar area - profuse hemorrhage is less likely
 a ruptured ectopic pregnancy - serious regardless of the site of implantation
SIGNS AND SYMPTOMS: ECTOPIC PREGNANCY
 sharp, stabbing pain in one of the lower abdominal quadrants at the time of
rupture followed by scant vaginal spotting
- the amount of bleeding evident with ruptured ectopic pregnancy usually does
not reveal the actual amount present
 at the point the placenta dislodges, progesterone secretion will stop and the
uterine decidua will begin to slough, causing additonal bleeding
 adomen gradually becomes rigid from peritoneal irritation
 extensive or dull vaginal and abdominal pain
 movement of the cervix on pelvic examination causes excruciating pain
SIGNS AND SYMPTOMS: ECTOPIC PREGNANCY
 pain on shoulders - blood in the peritoneal cavity causing irritation to the
phrenic nerve
 Leukocytosis (not from infection but from trauma)
 TVS - rupture tube and blood collecting in the peritoneum
 adomen gradually becomes rigid from peritoneal irritation
 woman becomes hypotensive from blood loss - light-headedness, rapid pulse,
signs of hypovolemic shock
signs of severe shock :
 rapid, thready pulse
 rapid respirations
 falling blood pressure
 tender mass is palpable in Douglas cul-de-sac - on vaginal examination
CULLEN SIGN
 is superficial edema and bruising in
the subcutaneous fatty tissue around
the umbilicus.
 bluish discoloration of the Umbilicus
DIAGNOSTICS:
 a falling hCG and progesterone levels (suggest that the pregnancy has ended)
- the level of hCG doubled in early normal pregnancy every 3 days but are
reduced in abnormal or ectopic pregnancy
- level less than 5ng/ml are considered abnormal - levels greater than 25 ng/ml
are associated with a normall developing pregnancy
Culdoscopy
 is an endoscopic procedure
performed to examine the
rectouterine pouch and pelvic viscera
by the introduction of a culdoscope
through the posterior vaginal wall.
THERAPEUTIC MANAGEMENT
 some ectopic pregnancies - spontaneously end before they rupture - are
reabsobed over the next few days → NO TREATMENT
 METHOTREXATE -
 This drug stops cells from growing, which ends the pregnancy.
 The pregnancy then is absorbed by the body over 4–6 weeks.
 This does not require the removal of the fallopian tube.
 treatment until a negative hCG titer is achieved
 a hysterosalphingogram or ultrasound is usually performed - to assess pregnancy
 Ruptured ectopic pregnancy - emergency
 LAPAROSCOPY - to ligate the bleeding vessels and to remove or repair the
damage fallopian tube
HYSTEROSALPINGOGRAPHY
 is a type of X-ray that
looks at a woman's uterus
(womb) and fallopian
tubes (structures that
transport eggs from the
ovaries to the uterus). This
type of X-ray uses a
contrast material so that
the uterus and fallopian
tubes show up clearly on
the X-ray images.
ABDOMINAL PREGNANCY
 the products of conception are expelled
into the pelvic cavity
 placenta continues to grow in the
fallopian tube, spreading into the uterus
 it may escape into the pelvic cavity and
implant on an organ (intestine)
 can occur if a uterus ruptures because
of an old uterine scar
 fetal outline is palpable through the
abdomen
ABDOMINAL PREGNANCY
 may experience painful fetal movements and abdominal cramping with fetal
movements
 sudden lower quadrant pain earlier in pregnancy
 USD or MRI - fetus is outside the uterus
Danger of abdominal pregnancy
 placenta could infiltrate and erode a major blood vessel in the abdomen
↓
hemorrhage
 if implanted in the intestine - may erode → bowel perforation, leaking intestinal
contents and peritonitis
 fetus is high risk - nutrients may not reach the fetus→fetal deformity or growth
restriction
(only 60% come to term)
 at term - infant must be born through LAPAROTOMY
 placenta - may be left in place and allowed to absob spontaneously in 2 to 3
months - follow up USD - if not absorbed - Methotrexate
GESTATIONAL TROPHOBLASTIC
DISEASE (HYDATIDIFORM MOLE)
 is abnormal proliferation and then
degeneration of the trophoblastic
villi.
 as the cells degenerate, they
become filled with fluid and appear
as clear fluid-filled, grape -sized
vesicles
 the embryo fails to develop
 associated with choriocarcinoma
CHORIOCARCINOMA
HYDATIDOFORM MOLE
 incidence - approx. 1 in every 1,500 pregnancy
 condition tends to occur most often
 in women who have a low-protein intake
 in women older than 35 years of age
 women of Asian heritage, and
 in blood group A women who marry blood group O men
TWO TYPES:
COMPLETE MOLE
 all trophoblastic villi swell and
become cystic.
 if embryo forms - it dies early at only
1 to 2 mm in size, with no fetal blood
present in the villi.
 usually arise when an ovum without
maternal chromosomes is fertilized
by one sperm which then duplicates
its DNA, resulting in a 46, XX
androgenic karyotype in which all the
chromosomes are paternally derived
PARTIAL MOLE
 some of the villi form normally
 syncytiotrophoblast layer of villi -
swollen and mishapen
 embryo may grow for about 9 weeks
but macerates
 some fetal blood may be present in
the villi
 has 69 chromosomes - triploid
formation.
 rarely lead to choriocarcinoma
 hCG titers are lower in partial than in
complete
ASSESSMENT: HYDATIDIFORM MOLE
 uterus tend to expand faster tahn  USD - snowflake pattern
usual or the uterus reaches its
landmarks ( just over the symphysis
brim at 12 weeks, at the umbilicus
at 20-24 weeks)
 hCG - serum or urine - strongly
positive = 1 to 2 milion IU
normal level (pregnant) = 400,000IU
 symptoms of gestational
hypertension - ↑BP,
edema,proteinuria are ordinarily not
present before week 20 of
pregnancy
ASSESSMENT: HYDATIDIFORM MOLE

 no fetal growth in the uterus

 no fetal heart sounds
 at approx. week 16 - vaginal bleeding
 dark-brown blood or as profuse fresh flow
 as the bleeding progresses - it is accompnaied by discharge of
the clear fluid-filled vesicles
THERAPEUTIC MANAGEMENT:
 Suction curettage - to evacuate the abnormal trophoblast cells
 following extraction - baseline pelvic examination and a serum test
for the beta subunit of hCG
 serumhCG level is then assessed every 4 weeks for the next 6 to
12 months to see if declining
 half of women will still have positive reading at 3 weeks; 1/4 still have a
positive result at 40 days.
 if level increases - it suggests a malignant transformation is occurring
THERAPEUTIC MANAGEMENT
 should use oral contraceptive
 after 6 months - if hCG levels is negative - woman is free from the risk of a
malignancy
 by 12 months - can get pregnant
 Methotrexate - prophylaxis
 drug interferes with white blood cell formation (leukopenia), prophylactic use must be
weighed carefully
 Dactinomycin - can be added to the regimen if metastasis occur
Dactinomycins,
 also known as actinomycins, are antibiotic metabolites derived from several
species of Streptomyces.
 Dactinomycin D, a potent derivative in the dactinomycin superfamily, shows
both strong antibacterial and antitumor activity.
 It has been extensively exploited in clinical practices as an anticancer drug since
1954.
 Dactinomycin D suppresses DNA replication and it has been utilized for the
treatment of neuroblastoma and lymphomas.
 Dactinomycin D is comprised of a central phenoxazone ring containing two
cyclic peptides containing D-amino acids.
Dactinomycin D Mode of Action (MOA) in Cancer Treatments
 The cytotoxic and antitumor actions of dactinomycin D is associated with the
disruption of DNA transcription machinery that leads to RNA and protein
biosynthesis.
 Two proposed MOA of dactinomycin D include the prevention of RNA
polymerases progression via DNA intercalation and the stabilization of the
molecular complexes formed by DNA and topoisomerases I and II.
 In the later MOA, the phenoxazone ring of dactinomycin D is inserted between
GpC base pair sequences in the double-stranded DNA.