leeding Disorders in the Second and Third Trimester of Pregnancy

Primary causes of bleeding during the 2nd trimester

• Gestational Trophoblastic Disease (Hydatidiform mole)

• Cervical insufficiency (Premature cervical dilatation)

Primary causes of bleeding during the 3rd trimester

• Placenta previa

• Abruptio placenta

• Preterm labor

• Preterm rupture of membranes (PROM)

Learning objectives for bleeding disorders

• Assess pregnant woman with complications

• Implement nursing care for sudden pregnancy complications

What are trophoblast cells?

• Outer layer of blastocyst

• Provide nutrients to embryo

• Form large part of placenta

• Help implantation

What is Gestational Trophoblastic Disease (H-mole)?

• Abnormal proliferation of trophoblastic villi

• Villi become grape-like, fluid-filled vesicles

• Embryo fails to develop

Incidence of H-mole

1 in 1,500 pregnancies

Complication associated with H-mole

Choriocarcinoma

Risk factors for H-mole

• Low protein intake

• Age >35

• Asian

• Blood group A woman × Blood group O man

• Previous H-mole

Diagnostic tests for H-mole

• Ultrasound (snowflake pattern)

• Chromosomal analysis

• Maternal serum screening

• Chorionic villi sampling

Types of Gestational Trophoblastic Disease

• Complete mole

• Partial mole

Complete mole – key points

• All villi are swollen and cystic

• No viable fetus

• Embryo dies early (1–2 mm)

• Chromosomes from father only

• Empty ovum fertilized

Partial mole – key points

• Some villi develop normally

• Embryo may grow until ~9 weeks

• Rarely leads to choriocarcinoma

• 69 chromosomes (XX or XY)

• Fertilization by 2 sperms or failed meiosis

Assessment findings in H-mole

• Enlarged uterus for age

• Very high hCG (1–2 million IU)

• Severe nausea/vomiting

• Dark brown vaginal spotting with vesicles

• No fetal heart sounds

Management of H-mole

• Suction curettage

• Serial hCG monitoring

• Methotrexate (prophylactic)

• Oral estrogen/progesterone contraceptives

• Dactinomycin if metastasis

What is cervical insufficiency?

• Painless premature dilation of cervix

• Occurs around 20 weeks

• Cervix cannot retain fetus

Risk factors for cervical insufficiency

• Advanced maternal age

• Congenital cervical defects

• Cervical trauma

Signs and symptoms of cervical insufficiency

• Painless cervical dilation

• Bloody show

• Pelvic pressure

• PROM

Treatment for cervical insufficiency

• Cervical cerclage

• McDonald procedure

• Shirodkar procedure

• Bed rest, no coitus

Contraindications for cerclage

• Active labor

• PROM

• Abruptio placenta

• Active vaginal bleeding

• Chorioamnionitis

What is placenta previa?

• Placenta implanted in lower uterus

• Partially or totally covers cervical os

Causes of placenta previa

• Multiparity

• Advanced maternal age

• Previous CS

• Uterine curettage

• Multiple gestation

• Male fetus

Signs of placenta previa

• Sudden painless bleeding

• Bright red blood

• Occurs around 30 weeks

Degrees of placenta previa

• Low-lying

• Partial

• Total

• Marginal

Nursing management of placenta previa

• Bed rest (side-lying)

• Monitor bleeding & VS

• NO vaginal exam

• IVF via large-bore catheter

• Betamethasone

• Cesarean delivery

What is abruptio placenta?

• Premature separation of normally implanted placenta

• Most common cause of perinatal death

Risk factors for abruptio placenta

• Hypertension

• Trauma

• Smoking / cocaine use

• Infection

• Short umbilical cord

• High parity

Signs of abruptio placenta

• Severe abdominal pain

• Dark vaginal bleeding

• Rigid, tender uterus

• Hypovolemic shock

• Couvelaire uterus

Management of abruptio placenta

• Left lateral position

• Oxygen therapy

• IVF replacement

• Monitor FHR & VS

• NO vaginal exam

What is PROM?

Rupture of membranes before 37 weeks

Signs and diagnosis of PROM

• Sudden gush of fluid

• Nitrazine test (+)

• Ferning (+)

• High AFP

• Ultrasound ↓ AFI

Management of PROM

• Strict bed rest

• Corticosteroids

• Antibiotics

• Avoid vaginal exam

Criteria for preterm labor

• ≥4 contractions in 20 mins

• Cervical effacement ≥80%

• Cervical dilation >1 cm

Tocolytic drugs & antidotes

• Terbutaline → antidote: Propranolol

• Magnesium sulfate → antidote: Calcium gluconate

What is hyperemesis gravidarum?

• Severe vomiting beyond 12 weeks

• Causes dehydration & weight loss

Management of hyperemesis gravidarum

• NPO 24 hrs

• IVF with Vit B

• Antiemetics

• Gradual diet

• TPN if needed

Terbutaline antidote

Propranolol

Magnesium sulfate antidote

• Calcium gluconate

Why does Gestational Trophoblastic Disease happen?

• Abnormal fertilization occurs

• Trophoblast cells grow uncontrollably

• Placenta develops abnormally

• Embryo cannot develop normally

Why does bleeding happen in H-mole?

• Trophoblastic villi degenerate and swell

• They form fragile, grape-like vesicles

• These vesicles detach from uterine wall

• Causes vaginal bleeding and spotting

Why is hCG very high in H-mole?

Excess trophoblast cells produce large amounts of hCG

Why does cervical insufficiency happen?

• Cervix is structurally weak

• Cannot remain closed during pregnancy

• Dilates too early without contractions

Why does bleeding occur in cervical insufficiency?

• Cervix opens prematurely

• Small blood vessels tear

• Causes bloody show or spotting

Why does placenta previa happen?

• Placenta implants in the lower uterus

• Often due to uterine scarring or previous CS

• Lower uterine segment stretches late in pregnancy

Why does bleeding occur in placenta previa?

• Lower uterine segment stretches

• Placenta partially detaches

• Blood vessels tear

• Results in painless, bright red bleeding

Why is bleeding painless in placenta previa?

• No uterine muscle contraction

• Bleeding is from placental separation only

Why does abruptio placenta happen?

• Blood vessels in placenta rupture

• Placenta separates prematurely from uterus

• Often linked to hypertension, trauma, smoking

Why does bleeding occur in abruptio placenta?

• Placenta detaches suddenly

• Causes internal or external hemorrhage

• Blood collects behind placenta

Why is pain present in abruptio placenta?

• Blood irritates uterine muscles

• Uterus becomes tense and rigid

• Leads to severe abdominal pain

Why does fetal distress occur?

• Placenta separates → oxygen supply decreases

• Fetus becomes hypoxic

Why does PROM happen?

• Weakening of fetal membranes

• Often caused by infection (chorioamnionitis)

• Membranes rupture before term

Why does bleeding or fluid loss occur in PROM?

• Amniotic sac breaks

• Fluid leaks through cervix and vagina

• May irritate cervix causing spotting

Why does preterm labor happen?

• Uterus becomes irritable early

• Triggered by infection, dehydration, stress

• Leads to early contractions

Why does bleeding occur in preterm labor?

• Cervical dilation begins early

• Small blood vessels break

• Causes spotting or bleeding

Why does hyperemesis gravidarum happen?

• Very high hCG levels

• Hormonal imbalance

• Possible thyroid involvement or H. pylori

Why does dehydration occur?

• Persistent vomiting

• Poor oral intake

• Loss of fluids and electrolytes