MODULE 5.1: PAT:GP: Bleeding during 1st Trimester: Abortion or Miscarriages Flashcards
Vaginal Bleeding During Pregnancy
Vaginal Bleeding
Vaginal Bleeding
a. Discharge of blood from the vagina
b. It can happen any time from conception (when the egg is
fertilized) to the end of pregnancy
Spotting
a. Few drops < 500 cc;
no pain
b. Possible causes:
- Zygote is implanted to
the uterus
- Infection
- Hormonal changes
Bleeding
a. heavier flow
b. Serious causes:
- Miscarriage/abortion
- H. Mole/Molar
pregnancy
- Ectopic pregnancy
- Tubal pregnancy
Bleeding during the 1st Trimester
abortion or miscarriages
Early miscarriage
less than 16 weeks
Late miscarriage
16-20 weeks
Abortion
a. Interruption of pregnancy before a fetus is viable
o Age of viability: 20-24 weeks AOG
o (+) Cervical dilatation
b. WHO: Expulsion or extraction of an embryo or fetus weighing
500g or less from its mother
Common causes of Abortion
a. Abnormal fetal development – May due to teratogen
b. Implantation abnormalities
▪ Normal implantation: endometrium
c. Lack of progesterone produced
▪ Dydrogesterone (Duphaston) – given to patients
with spotting during early pregnancy; helps to
progress the pregnancy
d. Infections – can cross the placenta
▪ UTI, Chorioamnionitis
▪ Rubella
▪ Syphilis
▪ Cytomegalies
▪ Toxoplasmosis
o Ingestion of teratogens/substance abuse
o Stress
▪ Can trigger release of prostaglandin -> contractions
Threatened Abortion: Assessment
a. Scanty vaginal bleeding
b. Bright red vaginal bleeding
c. Slight abdominal cramping
d. NO cervical dilations on IE
e. (+) HCG
f. Note: There is bleeding but CERVICAL OS is INTACT
Case of Threatened Miscarriage
An 18-year-old G1P0 woman, who is pregnant at 7 weeks’ gestation by last menstrual period, complains of a 2-day history of vaginal spotting and lower abdominal pain. She denies a history of sexually transmitted diseases. On examination, her BP is 130/60 and HR 70 bpm, and temperature is 99F. Her neck is supple and the heart examination is normal. The lungs are
clear bilaterally. The abdomen is non-tender and no masses are palpated. On pelvic examination, the uterus is 4-week size and non-tender. There are no adnexal masses on pelvic
examination. The quantitative beta-hCG level is 700mIU/mL and
a transvaginal ultrasound reveals an empty uterus and no adnexal masses
Imminent/ inevitable Abortion
a. Miscarriage when uterine contractions and cervical
dilatations occur
o Cervix is open – inevitable loss of products of
conception
Imminent/ inevitable Abortion: Assessment
a. Moderate to profuse bleeding
b. Moderate to severe uterine cramping/contraction
c. Cervix dilated
d. Membranes have ruptured
Complete Miscarriage
Entire products of conception (fetus, membrane, placenta)
are expelled spontaneously without any assistance
Dilation and Evacuation
a. To clean the uterus and prevent further infection
b. After the procedure, assess patient for vaginal bleeding and
count number of pads used
Complete Miscarriage: Assessment
a. Lower abdominal cramping
b. Vaginal bleeding
o Bleeding subsides after passage of products of
conception
o Advise to report any heavy bleeding
c. Passage of products of conception
Case of Complete Miscarriage
A 35-year-old woman at 8 weeks’ gestation complains of crampy
lower abdominal pain and vaginal bleeding. She states that the pain was intense last night, and that something that looked like liver passed per vagina. After that, the pain subsided
tremendously as did the vaginal bleeding. On examination, her BP is 130/80, HR 90/min, and temperature is 98F. Her abdominal examination is unremarkable. The pelvic
examination reveals normal external female genitalia. The cervix is closed and nontender, and no adnexal masses are appreciated.
Incomplete Miscarriage
Products of conception is expelled, but membrane or placenta is retained in the uterus
Incomplete Miscarriage: Assessment
a. abdominal cramping
b. vaginal bleeding
Missed Abortion
a. Also known as “Early Pregnancy Failure”
b. Fetus dies in utero but is not expelled
Missed Abortion: Assessment
a. Fundic height remains the same
b. No fetal heart tones heard
c. Painless vaginal bleeding
d. UTZ confirmation – fetus has no heart rate
Recurrent Pregnancy Loss is also called as
Habitual Aborters
Recurrent Pregnancy Loss
Woman who had a history of 3 spontaneous miscarriage at
the same gestational age
Recurrent Pregnancy Loss: Possible causes
a. Defective spermatozooa or ova
b. Endocrine factors
o Decreased protein-bound iodine
o Poor thyroid function
o Luteal phase will be defective
c. Deviation of uterus (septate, bicornuate)
o Septate – congenital anomaly; membrane in between
o Bicornuate – congenital anomaly; heart-shaped uterus
d. Chorioamnionitis or uterine infection
e. Autoimmune disorders (Lupus – body rejects growing embryo)
Complications of Abortions
a. hemorrhage
b. infection
c. isoimmunization: RH incompatibility
d. powerlessness and anxiety
e. septic abortion
Hemorrhage
a. Assess the cause of miscarriage
b. Check extent of bleeding, color and odor of blood
c. Monitor vital signs – check signs of hypovolemic shock
o Tachycardia
o Hypotension
o Cold, clammy skin
o Pallor
d. Place patient in supine position
e. Provide fundal massage → stimulate contraction → stops
bleeding
f. Demonstrate supportive attitude
g. Prepare for D&C if possible
h. Administer blood components (as prescribed)
o Blood transfusion
i. Administer oral medication (Methergine) as prescribed
Infection
a. Check for fever (38C), abdominal pain or tenderness, and foul
vaginal discharge
b. Instruct the patient to practice proper perineal cleaning
c. Avoid use of tampons
d. Demonstrate aseptic technique in handling the patient
Isoimmunization: RH Incompatibility
administer RhIG (RhoGAM) as prescribed
Powerlessness and Anxiety
a. Deal with the patient with an understanding and supportive
attitude
b. Encourage verbalization of feelings
c. Refer to counseling (if necessary)
Septic Abortion
a. abortion that is complicated by infection
Septic Abortion: Assessment
a. Foul smelling vaginal discharge
b. Uterine cramping
c. Chills and Fever
Case of Septic Abortion
A 23-year-old woman underwent a dilation and curettage (D&C) for an incomplete abortion 3 days previously. She complains of continued vaginal bleeding and lower abdominal cramping. Over the last 24-hr, she notes significant fever and chills. On examination, her temperature is 102.5F, BP 90/40, and HR 120bpm. The cardiac examination reveals tachycardia and the
lungs are clear. There is moderately severe lower abdominal tenderness. The pelvic examination shows the cervix to be open to 1.5cm, and there is uterine tenderness. The leukocyte count is 20,000/mm3 and the hemoglobin level is 12g/dL. The urinalysis shows 2 wbc/hpf.
