GESTATIONAL

CONDITIONS
AFFECTING
PREGNANCY:
BLEEDING
(H-mole, placenta previa,
abruption placenta,
disseminatedintravascular
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coagulation)
 Hello! I’m JOHANNA M.
BELIGANIO
BSN 2- FITZPATRICK
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 BLEEDING
● Vaginal bleeding during pregnancy is always a
deviation from the normal, may occur at any
point during pregnancy, and is always
frightening. It must always be carefully
investigated because if it occurs in sufficient
amount or for sufficient cause, it can impair both
the outcome of the pregnancy and a woman’s
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life or health.
 BLEEDING:

01 02
Placenta
H-Mole Previa
03 04
Disseminated
Abruption
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Placenta Intravascular
Coagulation
 We will talk about this first.
Hydatidiform Mole (H-Mole) - Gestational trophoblastic
disease is abnormal proliferation and then degeneration
of the trophoblastic villi (Garg & Giuntoli, 2007). As the
cells degenerate, they become filled with fluid and
appear as clear fluid-filled, grape-sized vesicles. The
embryo fails to develop beyond a primitive start.
Abnormal trophoblast cells must be identified because
they are associated with choriocarcinoma, a rapidly
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metastasizing malignancy.
 RISK FACTORS:

● Low protein intake.

● Women older than 35 years old.
● Asian women.
● Women with a blood group of A who
marry men with blood group O.
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 CAUSES:
● The most common types of gestational
trophoblastic disease occur when a sperm
cell fertilizes an empty egg cell or when
two sperm cells fertilize a normal egg cell.
Your risk is higher based on your:
● Age
● History of molar pregnancy
● Prior miscarriage(s) or problems getting
pregnant.
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 ● Diet
● Blood type: Women with blood types A or AB are at
slightly higher risk than those with types B or O.
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 SIGNS AND SYMPTOMS:

● Uterus expands faster than normal.

● A very high serum or urine test for hCg.
● Vaginal bleeding.
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 COMPLICATIONS:

● Uterine infection
● Sepsis
● Hemorrhagic shock
● Preeclampsia
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 LABORATORY
TESTS/DIAGNOSIS:
● CA-125 blood test
● Serum tumor marker test
● Chest X-ray
● Abdominal/pelvic CT (computed
tomography) scans
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 MEDICAL MANAGEMENT:
● Methotrexate. Physicians may
order a prophylactic course of
methotrexate, which attacks
rapidly growing cells like the
abnormally growing
trophoblastic cells.
● Dactinomycin. This is ordered by
the physician once metastasis
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occurs.
 NURSING MANAGEMENT:

Nursing Assessment
● Assess the abdominal girth of the pregnant woman to
check if it is within the usual landmark of pregnancy.
● Assess for signs and symptoms of pregnancy induced
hypertension, because for a woman with H-mole, they
occur earlier than the 20th week of pregnancy.
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 ● Instruct the woman to save all perineal pads
containing any clots or tissue that has passed out
of her during bleeding.
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 Nursing Diagnosis
● Grieving related to loss of pregnancy as evidenced
by anger and social detachment.
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 Nursing Interventions
● Measure abdominal girth and fundal height to
establish baseline data regarding the growth of the
uterus.
● Assist patient in obtaining a urine specimen for urine
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test of hCg.
● Save all pads used by the woman during bleeding to
 ● Save all pads used by the woman during bleeding to
check for clots and tissues she may have discharged.
● Provide your patient with an open environment and a
trusting relationship so she would be encouraged to
express her feelings.
● Honestly answer the patient’s questions to foster a
trusting relationship between nurse and client.
● Provide an assurance that it is not her own fault that
this happened to her to lessen her sense of guilt and
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self-blame.
 Evaluation

● Patient must be able to express her feelings

effectively.
● Patient must acknowledge the situation and seek
for appropriate help.
● Patient must learn to look forward for the future step
by step.
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 PROGNOSIS:

● Low-risk GTD often responds well to treatment and

tends to have a good prognosis even if a tumour
has spread. High-risk GTD may be less responsive
to treatment and may require more aggressive
chemotherapy. In general, all women with non-
metastatic, low-risk GTD have an excellent survival
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rate, and all women are cured.

 PLACENTA
PREVIA
Placenta Previa is a condition of
pregnancy in which the placenta is
implanted abnormally in the uterus. It
is the most common cause of
painless bleeding in the third
trimester of pregnancy (Scearce &
Uzelac, 2007).
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 ● It occurs in four degrees: implantation in the lower
rather than in the upper portion of the uterus (low-
lying placenta); marginal implantation (the placenta
edge approaches that of the cervical os);
implantation that occludes a portion of the cervical os
(partial placenta previa); and implantation that totally
obstructs the cervical os (total placenta previa).
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 RISK FACTORS:

● Advanced maternal age.

● Multiple gestations.
● Increased parity.
● Past caesarean births.
● Past uterine curettage.
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 CAUSES:

● The exact cause of placenta previa

is unknown.
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 SIGNS AND
SYMPTOMS:

● Bright red bleeding.

● Painless. Bleeding in placenta
previa is not painless and may also
stop as abruptly as it had begun.
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 COMPLICATIONS
● Bleeding. Severe, possibly life-
threatening vaginal bleeding
(hemorrhage) can occur during labor,
delivery or in the first few hours after
delivery.
● Preterm birth. Severe bleeding may
prompt an emergency C-section before
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your baby is full term.

 LABORATORY
TESTS/DIAGNOSIS
:● Placenta previa is diagnosed
through ultrasound, either during a
routine prenatal appointment or
after an episode of vaginal
bleeding. Most cases of placenta
previa are diagnosed during a
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second trimester ultrasound exam.

 MEDICAL
MANAGEMENT:

● Intravenous therapy.
● Avoid vaginal examinations.
● Attach external monitoring
equipment.
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 NURSING
MANAGEMENT:
Nursing Assessment
● Assess baseline vital signs especially the blood
pressure. The physician would order monitoring of
the blood pressure every 5-15 minutes.
● Assess fetal heart sounds to monitor the wellbeing of
the fetus.
● Monitor uterine contractions to establish the progress
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of labor of the mother.

 ● Weigh perineal pads used during
bleeding to calculate the amount of
blood lost.
● Assist the woman in a side lying
position when bleeding occurs.
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 Nursing Diagnosis

● Fear related to outcome of

pregnancy due to bleeding.
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 Nursing Interventions
● Assess fetal heart sounds so the mother would be
aware of the health of her baby.
● Allow the mother to vent out her feelings to lessen her
emotional stress.
● Assess any bleeding or spotting that might occur to give
adequate measures.
● Answer the mother’s questions honestly to establish a
trusting environment.
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● Include the mother in the planning of the care plan for

both the mother and the baby.
 Evaluation

● Woman is able to discuss her

concerns with the health care
providers.
● States that hearing the fetal
heartbeat assures her of the baby’s
safety.
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 PROGNOSIS

● About 90% of placenta previa cases resolve

through delivery. Jing et al. found that women
with anterior placentas have poorer
prognostic factors and are more likely to have
massive blood loss and higher hysterectomy
rates compared to any other location.
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 ABRUPTION PLACENTA
premature separation of the placenta (also
called abruptio placentae; the placenta
appears to have been implanted correctly.
Suddenly, however, it begins to separate
and bleeding results. Premature
separation of the placenta occurs in about
10% of pregnancies and is the most
frequent cause of perinatal death
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(Arquette & Holcroft, 2007).

 RISK FACTORS:

● High parity.
● Short umbilical cord.
● Advanced maternal age.
● Direct trauma.
● Chorioamnionitis.
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 SIGNS AND SYMPTOMS/MANIFESTATIONS:
● Vaginal bleeding, although there might not be any
● Abdominal pain
● Back pain
● Uterine tenderness or rigidity
● Uterine contractions, often coming one right after
another
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 COMPLICATIONS:

For the mother, placental abruption can lead to:

● Shock due to blood loss
● Blood clotting problems
● The need for a blood transfusion
● Failure of the kidneys or other organs resulting
from blood loss
● Rarely, the need for hysterectomy, if uterine
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bleeding can't be controlled

 For the baby, placental
abruption can lead to:

● Restricted growth from not

getting enough nutrients
● Not getting enough oxygen
● Premature birth
● Stillbirth
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 LABORATORY TESTS/DIAGNOSIS:

● Hemoglobin level and fibrinogen level.

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 MEDICAL MANAGEMENT:

● Intravenous therapy. Once the woman starts to

bleed, the physician would order a large gauge
catheter to replace the fluid losses.
● Oxygen inhalation. Delivered via face mask, this
would prevent fetal anoxia.
● Fibrinogen determination. This test would be
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taken several times before birth to detect DIC.

 NURSING MANAGEMENT:
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 for the time the bleeding began, the
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amount and kind of bleeding, and interventions

 ● Assess for the time the bleeding began,
the amount and kind of bleeding, and
interventions done when bleeding
occurred if it started before admission.
● Assess for the quality of pain.
Nursing Diagnosis
● Deficient fluid volume related to
bleeding during premature
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placental separation.
 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
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examinations to prevent further injury to the

placenta.
 Evaluation

● Maternal vital signs are all within the normal

range, especially the blood pressure.
● Urine output should be more than 30mL/hr.
● No bleeding or minimal amount of bleeding
observed.
● Uterus is not tense and rigid.
● Fetal heart sounds are within the normal
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range.
 PROGNOSIS:
● In near-complete or complete abruption, fetal
death is inevitable unless an immediate cesarian
delivery is performed. If an abruption occurs, the
risk of perinatal mortality is reported as 119 per
1,000 people in the United States, but this can
depend on the extent of the abruption and the
gestational age of the fetus.
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 DISSEMINATED
INTAVASCULAR
COAGULATION
DIC is an acquired disorder of blood clotting in which
the fibrinogen level falls to below effective limits.
Early symptoms include easy bruising or bleeding
from an intravenous site.
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 ● Conditions such as premature
separation of the placenta, pregnancy-
induced hypertension, amniotic fluid
embolism, placental retention, septic
abortion, and retention of a dead fetus
are all associated with its development
(Goldberg & Smith, 2007).
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 ISK FACTORS:
● Infection
The infection may be caused by
parasites, bacteria, fungi, or
viruses.
● Injury
Examples include cirrhosis, 
pancreatitisexternal link, severe
trauma or injury, burns, or major
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surgery.
 ● Lifestyle habits
● Other medical conditions
● Blood vessel abnormalities -
including aortic aneurysms and
large hemangiomas, which are
growths of tangled blood vessels
● Cancer
● Heat stroke
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 ● Pregnancy
complications
● Severe immune
reactions
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 CAUSES:

● Inflamation
● Severe tissue damage
● Clotting factors
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 SIGNS AND
SYMPTOMS:
● Bruising, which may appear easily, and often in
various areas as small dots or larger patches
● Bleeding at the site of wounds from surgical cuts or
from placement of a needle
● Bleeding from the nose, gums, or mouth, including
when you brush your teeth
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 ● Blood in the stools from bleeding in
the intestines or stomach. Stools
may appear dark red or like tar.
● Blood in the urine
● Chest pain, trouble breathing, and
shortness of breath
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 ● Confusion, speech changes
or trouble speaking,
dizziness, or seizures
● Headaches
● Low blood pressure
● Pain, redness, warmth, and
swelling in the lower leg
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● Unusually heavy periods

 COMPLICATIONS:

● Acute respiratory distress syndrome

(ARDS)
● Bleeding from the gastrointestinal
tract (GI tract) or elsewhere in the
body if you have acute DIC.
● Heart attack
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 ● Multiple organ failure, if blood clots
prevent oxygen from reaching your
organs.
● Shock
● Stroke
● Venous thromboembolism (VTE
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 LABORATORY
● Diagnosis of DIC involves a TESTS/DIAGNOSIS
combination of laboratory tests and
clinical evaluation. Laboratory findings
suggestive of DIC include a low
platelet count, elevated D-dimer
concentration, decreased fibrinogen
concentration, and prolongation of
clotting times such as prothrombin
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time (PT).
 MEDICAL
MANAGEMENT

● Plasma transfusions to
reduce bleeding.
● Transfusions of red blood
cells and/or platelets.
● Anti-coagulant medication
(blood thinners) to prevent
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blood clotting.
 NURSING
MANAGEMENT:
Impaired Gas Exchange
● Nursing Diagnosis
Impaired Gas Exchange
- May be related to
Altered oxygen-carrying capacity of blood
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 Possibly evidenced by
Abnormal breathing (rate, depth, and rhythm)
Dyspnea
Hypercapnia
Hypoxemia
Hypoxia
Irritability
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Restlessness
 Ineffective Tissue Perfusion
● Nursing Diagnosis

Ineffective Tissue Perfusion

- May be related to

Blood circulation disruption

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Microthrombi
 - Possibly evidenced by
Abnormal blood profile
Capillary refill >3 seconds
Changes in the level of consciousness
Chest pain
Cyanosis
Hematuria
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Oliguria
Shortness of breath
 Deficient Knowledge
● Nursing Diagnosis

Deficient Knowledge
- May be related to

Complexity of treatment
Emotional state affecting learning
New condition and/or treatment
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Unfamiliar environment
 - Possibly evidenced by
Questioning health care team
Verbalizing inaccurate information
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 Risk for Bleeding
● Nursing Diagnosis

Risk for Bleeding

- May be related to

Abnormal blood profile (depleted

coagulation factors)
Drug therapy (adverse effects of
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heparin)
 PROGNOSIS:

● The prognosis depends

mostly upon the
underlying condition,
but also on the severity
of DIC and comorbidity.
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Thank you!
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