Under supervisor Dr:- Ragaa.Dr:- Tereza.

Student name :- Mostafa Mosleh Shakshak.Thorya Abd Elaty

Bleeding in Late Pregnancy

Outline

• Introduction

• Definition

• Causes and high risk

• Clinical manifestation S,S and investigation.

• Complication maternal & fetus.

• Management medical, surgical and nursing.

Introduction

• The causes of bleeding in the second half of pregnancy are different from those in

early pregnancy. Common conditions causing minor bleeding include inflammation

of, or growths on, the cervix. At times sexual intercourse may irritate the cervix and

cause bleeding.

• Bleeding can also be serious and pose a threat to the health of the women or the

fetus. It may require treatment in a hospital. Heavy vaginal bleeding usually

involves a problem with the placenta, The two most common causes are placental

abruption and placenta previa. Preterm labor can also cause vaginal bleeding.

General causes for bleeding

• Placenta previa

• Placenta abruption

• Vasa previa

• Direct truma

• Cancer cervix

• cervities

Normal placenta

Def.:-

- Fetomaternal organ involved in nutrition, waste

elimination and gas exchange between the

developing fetus and mother

- The placenta is usually attached to the upper

part of the uterus, away from the cervix, the

opening which the baby passes through during

delivery.

Definition of placenta Previa

The term placenta previa refers to a placenta that overlies

to the internal os of the cervix. The placenta normally

implants in the upper uterine segment. In placenta previa,

the placenta either

totally or partially lies within the lower

uterine segment.

Placenta Previa has been categorizedinto 3 type

1- Complete placenta Previa, where the placenta completely

covers the internal os.

Symptoms of placenta Previa include:-

• Sudden, painless vaginal bleeding that ranges from slight to heavy. The blood is often bright red. Bleeding can occur as early as the 20th week of pregnancy.

• Symptoms of preterm labor, such as regular, menstrual-like cramps, or a feeling of pressure in lower abdomen. The bleeding from placenta Previa can cause the uterus to contract.

Following types of placenta

2- Partial placenta Previa, where the

placenta partially covers the internal os. As a

result, this situation occurs only when the

internal os is dilated to some degree.

Following types of placenta

• 3- Marginal placenta Previa, OR Low-lying

placenta which extends (SPREAD) into the

lower uterine segment but does not reach the

internal os.

Complete placenta Previa

Causes and high risk• The cause of placenta previa is unknown, but it is

associated with certain conditions including the following

• Chronic hypertension

• Multiparity

• Multiple gestations

• Older age

• Previous cesarean delivery

Following causes .

• Tobacco use

• Uterine curettage D&C

• Abnormally shaped uterus

• Scarring on the lining of the uterus, due to history of surgery, c-section, previous pregnancy, or abortion

Clinical manifestation

• S&S

Painless, bright red vaginal bleeding during the second half of pregnancy is the

main sign of placenta Previa. The bleeding often starts near the end of the second

trimester or beginning of the third trimester. Labor sometimes starts within several

days of heavy bleeding.

• Investigation

Placenta Previa is diagnosed through abdominal ultrasound and transvaginal

ultrasound

complication• Maternal

- shock and death of the mother if the bleeding is excessive

- hysterectomy

- antepartum bleeding

- infection and formation of blood clots

- septicemia

- blood loss requiring transfusion

• Fetus- slow fetal growth due to insufficient blood supply

- fetal death are intra uterine death from hypoxia due to placental separation and maternal anemia

Following complication

• Placenta accrete

• the placenta is attached not on the wall of the uterus, but deeply in it. It

can sometimes go all the way through the uterine wall and attach itself

to a nearby organ as well. A placenta that is so deeply attached in the

uterine wall is not easily expelled after the baby is born. Manual

intervention is necessary, and in most cases, surgery.

The uterus is made up of four layers:

• The endometrium or the innermost layer – the lining of the uterine wall

• The myometrium comes next; this is the muscle layer of the uterus

• then there is the layer of connective tissue around the uterus called the parametrium

• and lastly, there is the perimetrium which is the outermost layer

Following complication

• Vasa Previa

This is an even rarer complication. It happens when the blood vessels

from the umbilical cord run through the membranes covering

the cervix . Because these membranes aren't protected by the

umbilical cord, they can easily tear and cause bleeding.

Management• Medical & Surgical management

- maternal stabilization and fetal monitoring.

- Control of blood loss ,blood replacement .

- With fetus of less than 36 weeks gestation carefully observation

to determine safety of pregnancy or need for preterm delivery.

- Hospitalization with complete bed rest until 36 weeks gestation

with complete placenta Previa.

- Possible vaginal delivery with minimal bleeding .

- Corticosteroid for lung maturity

- No vaginal exams

Management Nursing assessment

1. Determine the amount and type of bleeding and any history of

bleeding throughout any pregnancy.

2. Record maternal and fetal vital signs .

3. Palpate for the presence of uterine contractions.

4. Evaluate laboratory data on hemoglobin and hematocrit status.

5. Assess fetal status with continuous fetal monitoring.

Management Nursing diagnosis

1- Ineffective tissue perfusion, placental, related to excessive bleeding

causing fetal compromise .

2- Deficient fluid volume related to excessive bleeding.

3- Risk for infection related to excessive blood loss and open vessels near

cervix .

4- Anxiety excessive bleeding, procedures, and possible maternal – fetal

complications.

Management Nursing intervention

1- If continuation of the pregnancy is thought safe for patient and fetus administer magnesium

sulfate as ordered for premature labor

2- Obtain blood samples for complete blood count and blood type and cross matching

3- complete bed rest

4- If the patient and placenta Previa is experiencing active bleeding, continuously monitor her

blood pressure, pulse rate, respiration, central venous pressure, intake and output, and amount

of vaginal bleeding as well as the fetal heart rate and rhythm

Following Nursing management

5- Administer prescribed IV fluids and blood products.

6- Provide information about labor progress and the condition of the fetus.

7- Prepare the patient and her family for a possible caesarian delivery

8- Assure the patient that frequent monitoring and prompt management greatly reduce the risk of neonatal death.

9- Emotional support

10- Monitor VS for elevated temperature, pulse, and blood pressure, monitor laboratory results for elevated WBC

count,check for vaginal discharge to detect early signs of infection resulting from exposure of placental tissue.

Following Nursing management

11- Provide or teach perineal hygiene to decrease the risk of ascending infection.

12- Observe for abnormal fetal heart rate

13- Position the patient in side lying position

14- Assess fetal movement to evaluate for possible fetal hypoxia.

15- Teach woman to monitor fetal movement to evaluate well being

16- Administer oxygen as ordered to increase oxygenation to mother and fetus.

Placental Abruption

•Abruption occurs in about 1 in150 deliveries.

incidence

•Abruption placenta is separation of the placenta from its implantation site before delivery.

definition

1-centerel abruption:- concealed hemorrhage

2-marginal abruption:- external hemorrhage

3- complete abruption:- Could also be concealed

Types of placental abruption

CON..

cause of placental abruption is unknown. It is, however, associated with certain conditions, including the following:-

• Maternal age .

• multiple pregnancy.

• hypertension in pregnancy.

• Preterm premature rupture of membranes.

• direct trauma.

• cigarette smoking and drugs use .

Causes placental abruption

• vaginal bleeding

• Shock in the mother (hypovolemic shock

• Decreased perfusion to the kidneys during massive blood loss May cause oliguria

• abdominal pain and tenderness or rigid

symptoms of placental abruption:

Following symptoms

• uterine contractions that do not relax

• blood in amniotic fluid

• nausea

• thirst

• decreased fetal movements

Maternal :-

1.preterm birth

2.sever anemia related to hemorrhage 3.postpartum (after delivery) hemorrhage

3. Acute renal failure

4.Hypovolemia shock

5.DIC

6.embolism during the placental separation

7.death.

Complication:-

1. Fetal growth impairment

2. respiratory distress syndrome

3. Sever hypoxic.

4. Intrauterine fetal termination.

5. Fetal death .

Complication:-

Fetal

1-depend on condition of mother and fetus.

2-monitor lab investigation(CBC,ANTICOAGULANT)

3-cross matching and RH.

4-i.v fluid to correct hypovolemic shock.

5-blood transfusion.

Medical management

6- Assessment of fetus

7- Termination of pregnancy: CS or Vaginal delivery

8- anti coagulant drug as physician's describe.

Cont…

1- Determine the amount and type of bleeding and the presence or absence of pain.

2. Monitor maternal and fetal vital signs ,especially maternal Bp ,pulse ,fetal heart rate.

3. Palpate the abdomen .

4. Measure and record fundal height to evaluate the presence of concealed bleeding.

5. Prepare for possible delivery.

Nursing assessment

_Ineffective tissue perfusion: placental related to excessive bleeding,hypotention,and decreased cardiac output, causing fetal compromise.

_ Deficient fluid volume related to excessive bleeding.

_Fear related to excessive bleeding,procedures,and unknown outcome

Nursing Diagnosis:

1. Maintaining tissue perfusion by: Evaluate amount of bleeding by weighing all pads,monitor CBC

and v/s.

2- Position in left lateral position,with the head elevated to enhance placenta perfusion.

3- Maintain oxygen saturation level above 90% by using pulse oximetry monitoring.

4-Evaluate fetal status with continuous external fetal monitoring.

Nursing Intervention

Cont..

5-Encourage relaxation techniques.

6-Prepare for possible cesarean delivery if maternal or compromise is evident.

7. Maintaining fluid volume by :Maintain large –bore I.V line for fluids and blood

products, Evaluate coagulation studies, Monitor maternal v/s and contractions,

Monitor vaginal bleeding.

investigation

1-US:

is essential on diagnosis . Usually TVS.

will determined on going pregnancy, failing pregnancy and rule out ectopic and trophoplastic disease.

2-pregnancy test:

by urinary or serum HCG to distinguish in early complete miscarriage.

3-blood group and RH typing.

Thank you For listening!