DO NOT FORGET TO PRAY before you start to study.

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DO NOT FORGET TO PRAYbefore you start to study.

• Have fun learning!

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(No Transcript)
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I BLEEDING DURING PREGNANCY
FIRST TRIMESTER BLEEDING
ECTOPIC PREGNANCY
ABORTION
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ABORTION
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DEFINITION OF ABORTION

• Any interruption in pregnancy BEFORE the
• AGE OF VIABILITY

The ability of the fetus to survive outside the
mothers womb.
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What month is the Age of Viability?

• or

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HIGHER AGE
LOWER AGE
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WHY BETWEEN 6-7 MONTHS?

• These months mark the start of the production of
• FAST FACTS
• ecreases alveolar surface tension
• xcreted by the alveolar cells
• stablish basis for lung maturity
• revents lung collapse

LUNG SURFACTANT
D
E
E
P
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CAN YOU STILL REMEMBER THE 2 COMPONENTS OF LUNG
SURFACTANT?

• TIP
• REMEMBER THE FIRST LETTERS OF THE WORDS LUNG
  SURFACTANT.
• ECITHIN ( surges at 35 weeks
  gestation )
• PHINGOMYELIN ( chief component EARLY
• formation )

L
S
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THEREFORE, WHAT IS THE RATIO OF L/S INDICATIVE OF
FETAL LUNG MATURITY?

• L / S
• 2 1

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• Q Which of the following diagnostic procedures
  will determine the Lecithin/Sphingomyelin ratio?
• Amniocentesis
• CBC
• Incentive Spirometry
• Arterial Blood Gas ( ABG )

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CLASSIFICATIONS OF ABORTION

• 1 ) SPONTANEOUS
• Threatened
• Imminent
• Complete
• Incomplete
• 2 ) INDUCED
• 3 ) MISSED

S . I. M.
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SPONTANEOUS ABORTION

• Common Term
• Causes
• Abnormal Fetal Formation
• Implantation Abnormalities
• Defective Corpus Luteum
• Infection and Teratogenic Drugs

MISCARRIAGE
NATURAL ABORTION
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Questions to Answer

1. Why is Spontaneous Abortion also called Natural
   Abortion?
2. What causes implantation abnormalities?
3. What are some examples of teratogenic drugs? What
   are its effects?

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TYPES OF SPONTANEOOUS ABORTION

• A ) THREATENED
• Manifested by a BRIGHT RED vaginal bleeding which
  is moderate in amount.
• There might be slight cramping BUT NO SIGNS OF
  CERVICAL DILATATION

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• WHAT WILL BE YOUR MGT?
• CBR s TP for How many Hours? Why?
• Restriction of coitus for how long? Why?
• What are the important things that must be
  monitored?
• Why is there a need to assess blood for 2 times?
  What is the interval of the blood tests?

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IMMINENT / INEVITABLE

• Manifestations ( C.U.B. )
• CERVICAL DILATATION
• UTERINE CONTRACTIONS
• BRIGHT RED VAGINAL BLEEDING ( also present in
  Threatened abortion.)

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• Management ( Depends on the Type )
• A ) COMPLETE
• B ) INCOMPLETE
• Which of the 2 will DC be most likely performed?
  Why?

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MANIFESTATION THREATENED IMMINENT
BRIGHT RED VAGINAL BLEEDING
CONTRACTIONS
DILATATION
Y
Y
N
Y
N
Y
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2 ) INDUCED ABORTION

• Intentional induction of abortion
• Types
• Therapeutic
• Eugenic

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3 ) MISSED ABORTION

• Correct names are
• Early Pregnancy Abortion ( EPA ) or
• Early Pregnancy Failure ( EPF )
• Q Why is the main reason why the term MISSED
  abortion is no longer appropriate?

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COMPLICATIONS OF ABORTION

• MOST COMMON
• A ) HEMORRHAGE
• B ) INFECTION

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HEMORRHAGE

• SPONTANEOUS ABORTION NOT COMMON
• EARLY PREGNANCY ABORTION COMMON R/T D.I.C.

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• WHAT PREDISPOSES A WOMAN TO INFECTION?

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ALERT SIGNS FOR INFECTION R/T MISCARRIAGE

• FEVER OF MORE THAN 38 C
• TENDERNESS ( ABDOMEN )
• FOUL ODOR
• MOST COMMON RESPONSIBLE ORGANISM
• E. Coli
• Teach proper perineal care

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CRITICAL THINKING EXERCISES

• 1 ) A PREGNANT CLIENT RECEIVING HEPARIN SQ ASKS
  WHY SHE CANT TAKE IT ORALLY.
• WHAT WOULD YOU ANSWER?

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• 2 ) THE WOMAN GAVE A FOLLOW UP QUESTION. WILL
  THIS DRUG AFFECT THE CLOTTING ABILITY OF MY BABY?

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ECTOPIC PREGNANCY

• One in which implantation occurs OUTSIDE the
  uterine cavity.
• Common Sites
• Fallopian Tube ( Most Common )
• Ovary
• Cervix
• Intestine

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What causes this problem?

• IDIOPATHIC
• Related Factors
• Fallopian Tube Problems
• Smoking
• Surgery
• Medications

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Fallopian Tube Problems

• Quick Review of the Fallopian Tubes
• Funnel-shaped endings
• 5-6 inches long
• Designed to pick up the egg from the ovary

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A DAMAGED FALLOPIAN TUBE CAN BLOCK THE ENTRY OF
AN EGG TO THE UTERUS
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COMMON CAUSES OF TUBAL DAMAGE

• A ) PELVIC INFLAMMATORY DISEASE (PID)
• Gonorrhea and Chlamydia
• B ) IUD
• C ) ENDOMETRIOSIS

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SMOKING CAN CAUSE ECTOPIC PREGNANCY

• NICOTINE
• STIMULATES CONTRACTION OF F.T.
• CAUSING SPASMS
• RESULTING TO TEMPORARY BLOCKAGE OF THE TUBE

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MEDICATIONS

• SUCH AS THOSE WITH HIGH PROGESTERONE
• PROGESTERONE WEAKENS THE ACTIVITY OF THE
  FALLOPIAN TUBE.

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SIGNS AND SYMPTOMS

• Remember
• The wall of the fallopian tube is not elastic.
  Signs and symptoms may only be evident once the
  tube has ruptured already. Usually during 12
  weeks gestation.
• ( Provided that the woman has not visited her
  doctor )

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If it ruptures EXPECT the ff

• SEVERE, SHARP, KNIFE-LIKE STABBING PAIN
• WILL OCCUR DUE TO INCREASE IN PRESSURE SINCE
  THERE IS NO EXIT OF BLOOD

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CHECK THE ABDOMEN

• WILL BECOME RIGID AND TENDER DUE TO PRESSURE
• EXPECT OF PULLING OF BLOOD IN THE UMBILLICAL AREA
  CALLED
• CULLENS SIGN
• REMEMBER Edward Cullen ( E.C. )
• Ectopic Cullen

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AND DONT FORGET TO ASSESS FOR

• FALLING B.P.
• INCREASED P.R.
• INCREASED R.R.
• LIGHT HEADEDNESS
• WHICH ARE INDICATIVE OF SHOCK

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HOW TO DIAGNOSE ECTOPIC PREGNANCY

• A ) QUANTITATIVE hCG TEST
• Normally hCG develops at to days post
  fertilization
• Level doubles every 2 days for 10 weeks
• LOWER than Normal hCG ECTOPIC PREGNANCY

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• B ) LAPAROSCOPY

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• C ) CULDOCENTESIS
• Used to check for internal bleeding.
• A needle is inserted into the vagina, behind the
  uterus and in front of the rectum.
• Presence of blood may indicate Ectopic Pregnancy.

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MANAGEMENT

• A ) SALPINGOSTOMY / SALPINGECTOMY
• B ) BLOOD TRANSFUSION

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SECOND TRIMESTER BLEEDING
GESTATIONAL TROPHOBLASTIC DISEASE
INCOMPETENT CERVICAL OS
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GESTATIONAL THROPHOBLASTIC DISEASE

• ABNORMAL proliferation and degeneration of the
  trophoblastic villi.
• Common in women with low protein and low folic
  acid diet.

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TYPES OF G.T.D.

• A ) HYDATIDIFORM MOLE
• B ) INVASIVE MOLE
• C ) CHORIOCARCINOMA
• D ) PLACENTA SITE TROPHOBLASTIC TUMOR

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HYDATIDIFORM MOLE

• The MOST COMMON form of GTD
• Also known as MOLAR PREGNANCY
• 2 TYPES
• A ) COMPLETE
• B ) PARTIAL

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WOMAN WITH LOW PROTEIN AND FOLIC ACID DIET
COMPLETE
EMPTY EGG
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NO NUCLEUS AND D.N.A.
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FATHERS CHROMOSOME MATERIAL IS DUPLICATED
FAILURE TO DEVELOP FETAL TISSUE DUE TO ABSENCE OF
MOTHERS CHROMOSOME MATERIAL
THROPHOBLASTIC VILLI CONTINOUS TO GROW BUT
DEGENERATES
BECOMES SWOLLEN, CYSTIC, AND FLUID FILLED
CARDINAL FEATURE GRAPE-LIKE FLUID FILLED
STRUCTURES
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• SOME of the villi form normally BUT it is the
  Syncitiotrophoblast that is swollen.
• A partial mole has 69 chromosomes.

PARTIAL
69
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23
69
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INVASIVE MOLE

• Formerly known as CHORIOADENOMA DESTRUENS
• A type of GTD that grows into the MYOMETRIUM (the
  muscle part of the uterus )
• Risks
• Delayed treatment
• Large uterus
• History of GTD and over 40 years old

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CHORIOCARCINOMA

• MALIGNANT form of GTD that usually originated
  from a Complete H. mole
• PLACENTAL SITE TROPHOBLASTIC TUMOR
• Develop on the site where the placenta is
  implanted
• Very rare and responds to Chemotherapeutic drugs

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ASSESSMENT FINDINGS

• 1 ) UTERUS
• Proliferation of trophoblast occurs at a very
  fast rate and the uterus expands faster that
  normally.
• Uterus reaches its landmarks BEFORE its usual
  time.
• Usual Time 12 weeks over the symphisis pubis
• 20-24 weeks at the level of the
  umbillicus

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• Q WHICH SIDE OF THE ABDOMEN CAN YOU HEAR THE
  FETAL HEART TONE?
• VERY HIGH H.C.G. N/V
• Normal Pregnancy 400,000 IU
• GTD 1-2 IU
• Continuous to rise even on the 100th day!

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• S/S of PIH NORMALLY APPEARS AT 20 WEEKS IN
  PREGNANCY BUT IN GTD
• LESS THAN 20 WEEKS OR EARLIER

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MANAGEMENT

• 1 ) EVACUATION OF MOLE THROUGH
• 2 ) PHROPHYLAXIS
• Antineoplstic
• 15-30 mg PO/IM daily for 5 days, repeated after 1
  week. ( Avoid Sunlight. May cause alopecia )

D C
METHOTREXATE
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• MONITORING OF hCG LEVELS

MONITORED EVERY 2 WEEKS UNTIL LEVELS ARE NORMAL
AGAIN
THEN EVERY 4 WEEKS FOR 6-12 MONTHS
DECLINING LEVELS
INCREASING LEVELS
NO MALIGNANCY
SIGN OF MALIGNANCY
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IMPORTANT REMINDERS

• A WOMAN SHOULD USE A CONTRACEPTIVE AGENT FOR 12
  MONTHS AFTER G.T.D.
• Q WHAT IS THE RATIONALE FOR THIS?

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• AFTER 6 MONTHS
• IF HCG LEVELS ARE STILL NEGATIVE
• WOMEN IS FREE OF THE RISKS FOR MALIGNANCY
• CONTINUE TO MONITOR, BY THE END OF 12 MONTHS
• WOMAN CAN GET PREGNANT AGAIN

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INCOMPETENT CERVICAL OS

• Also known as PREMATURE CERVICAL DILATATION OR
  INCOMPETENT CERVIX
• Refers to a cervix that dilates prematurely
  before term making it impossible to hold a fetus.
• Causes Connective tissue structure around the
  cervix is not strong enough to maintain closure.
  MOTHER of patient used DES during her pregnancy.

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SIGNS AND SYMPTOMS

• AINLESS CERVICAL DILATATION
• INK-STAINED VAGINAL DISCHARGE
• ELVIC PRESSURE IS INCREASED

P
P
P
WATCH FOR SIGNS OF R.O.M. and DISCHARGE OF
AMNIOTIC FLUID
SIGNALS START OF CONTRACTION
DELIVERY OF FETUS
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MANAGEMENT

• AFTER THE LOSS OF ONE CHILD, AN OPERATION IS
  PERFORMED TO PREVENT THE EVENT FROM HAPPENING
  AGAIN. THIS IS CALLED
• CERVICAL CIRCLEAGE

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• IF THE COUPLE WANTS TO HAVE A BABY AGAIN, THEY
  MUST CONSULT A PHYSICIAN FOR SPECIFIC
  INSTRUCTIONS
• Next Slide

CONFIRM PREGNANCY THROUGH
SONOGRAM
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• ON THE 12TH-14TH WEEK OF GESTATION
• SUTURES ARE PLACED IN THE CERVIX TO PREVENT
  PREMATURE DILATATION. THIS IS CALLED

Mc DONALD
SHIRODKAR
SUTURES TEMPORARY
SUTURES PERMANENT
VAGINAL TEMPORARY
C/S DELIVERY
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THIRD TRIMESTER BLEEDING
PLACENTAL ANOMALIES ( PLACENTA PREVIA AND
ABRUPTIO PLACENTA )
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PLACENTA PREVIA

• Defined as low implantation of the placenta so
  that it is in the way of the presenting part.
• Types
• LOW IMPLANT
• PARTIAL ( Marginal ) IMPLANT
• TOTAL ( Complete ) IMPLANT

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TYPE VAGINAL DELIVERY
LOW
PARTIAL
TOTAL
OK!
OK! IF ONLY 30 COVERS.
NOT OK! C/S!
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• Causes
• Increasing Parity
• Advanced Maternal Age
• Past C/S
• Multiple Gestation

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SIGNS AND SYMPTOMS

• PAINLESS, BRIGHT RED VAGINAL BLEEDING
• MGT
• CBR
• MONITOR VITAL SIGNS OF BOTH PATIENTS
• PREPARE OXYGEN AND BLOOD

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• I.E. is NOT USUALLY done!
• If ever it should be done, must be double set up!

• DONE IN THE OPERATING ROOM
• PATIENT MUST SIGN CONSENT
• MAKE SURE THAT THE L/S RATIO OF THE BABY IS 21
• IF NOT. WHAT DRUG CAN BE GIVEN TO HASTEN FETAL
  LUNG MATURITY?

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• IMMEDIATE DANGERS OF PLACENTA PREVIA
• The site of bleeding, the decidua, places the
  mother at risk for hemorrhage
• The placenta is loosened
• Compromised oxygenation
• Preterm labor
• An APT or Kleihauer-Betke Test may be used to
  check if the blood is of fetal or maternal
  origin.

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ABRUPTIO PLACENTA

• Defined as the PREMATURE SEPARATION of the
  placenta.
• Predisposing Factor
• Maternal hypertension or toxemia
• Increasing parity and maternal age
• Sudden release of amniotic fluid
• Trauma

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• Signs and Symptoms
• Severe, Sharp, Knife-Like, Stabbing Pain High In
  The Fundus
• Hard, Boardlike uterus, Rigid Abdomen (
  COUVELAIREUTERUS )
• MGT HYSTERECTOMY since the UTERUS CAN NO LONGER
  CONTRACT

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DEGREES OF PLACENTAL SEPARATION DEGREES OF PLACENTAL SEPARATION
GRADE CRITERIA
0 NO SYMPTOMS ( ONLY EVIDENT IF PLACENTA WILL BE EXAMINED )
1 MINIMAL SEPARATION. ENOUGH TO CAUSE VAGINAL BLEEDING. MOTHER MAY BECOME DISTRESS.
2 MODERATE SEPARATION. EVIDENCE OF MATERNAL AND FETAL DISTRESS.
3 EXTREME SEPARATION. MATERNAL SHOCK AND FETAL DEATH WILL OCCUR IF NO TREATMENT.
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• HOPE YOU LEARNED A LOT.
• References
• Review notes from my student years ?
• ( East-West Review Center Book )
• Maternal and Child Care Nursing by A. Pillitteri
• The world wide web
• My previous mentors who are now my colleagues.

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• Please send me a message if there are things that
  you want to be clarified.
• This is my first allthink post.
• THANK YOU AND GOD BLESS YOU ALL!