Table of Contents

Introduction to Early Pregnancy Hemorrhage

Early pregnancy hemorrhage is a critical condition that occurs within the first 20 weeks of gestation and may indicate serious complications. It represents a significant cause of maternal morbidity and mortality worldwide. Nurses play a pivotal role in recognizing signs of abnormal bleeding, assessing the patient’s condition, and implementing timely interventions.

Vaginal bleeding in early pregnancy affects approximately 20-30% of all pregnancies. While many cases resolve without complications, significant hemorrhage requires immediate medical attention and may indicate one of three major conditions:

• Abortion (Miscarriage): Spontaneous or induced termination of pregnancy before 20 weeks gestation
• Ectopic Pregnancy: Implantation of fertilized ovum outside the uterine cavity, most commonly in the fallopian tube
• Vesicular (Hydatidiform) Mole: Abnormal proliferation of trophoblastic tissue with potential for malignant transformation

Abortion (Miscarriage)

Abortion refers to the termination of pregnancy before 20 weeks gestation or when the fetus weighs less than 500 grams. Spontaneous abortion (miscarriage) occurs in approximately 10-15% of clinically recognized pregnancies, with the majority occurring in the first trimester due to chromosomal abnormalities.

Types of Abortion

Type	Characteristics	Clinical Presentation	Bleeding Risk
Threatened Abortion	Vaginal bleeding with a closed cervical os	Mild cramping, minimal hemorrhage	Low to moderate
Inevitable Abortion	Vaginal bleeding with dilated cervical os	Moderate to severe cramping, moderate hemorrhage	Moderate
Incomplete Abortion	Partial expulsion of products of conception	Severe cramping, heavy hemorrhage	High
Complete Abortion	Total expulsion of products of conception	Diminishing cramping, decreasing hemorrhage	Initially high, then decreasing
Missed Abortion	Fetal demise without expulsion	Absence of fetal heart tones, brown vaginal discharge	Low, but risk of DIC with prolonged retention
Septic Abortion	Infection of the products of conception	Fever, purulent discharge, uterine tenderness	Moderate to high, with septic shock risk
Recurrent Abortion	Three or more consecutive spontaneous abortions	Repeated pattern of early pregnancy loss	Variable

Diagnosis

Diagnosis of abortion is based on clinical presentation, physical examination, laboratory tests, and ultrasound findings:

• History: Pregnancy symptoms, onset of vaginal bleeding, amount of hemorrhage, associated pain
• Physical Examination: Vital signs, abdominal examination, speculum examination to assess cervical dilatation and products of conception
• Laboratory Tests:
  • Complete blood count to assess hemorrhage severity
  • Quantitative β-hCG levels (may be decreasing or lower than expected)
  • Blood type and Rh status
  • Coagulation profile if significant bleeding
• Ultrasound: Transvaginal ultrasound to evaluate gestational sac, fetal pole, cardiac activity, and retained products

Management

Management depends on the type of abortion and clinical presentation:

Nursing Care

Ectopic Pregnancy

An ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity. Approximately 95% of ectopic pregnancies occur in the fallopian tubes. This condition accounts for 2% of all pregnancies but is responsible for up to 9% of pregnancy-related deaths due to the risk of severe internal hemorrhage if rupture occurs.

Etiology and Risk Factors

Any condition that impairs or prevents the migration of the fertilized ovum to the uterine cavity can predispose to ectopic pregnancy. The most common cause is tubal damage from previous pelvic inflammatory disease (PID).

Diagnosis

Management

Management of ectopic pregnancy depends on the patient’s clinical status, desire for future fertility, location and size of the ectopic mass, and β-hCG level:

Nursing Care

Vesicular Mole (Hydatidiform Mole)

A vesicular (hydatidiform) mole is an abnormal form of pregnancy characterized by trophoblastic proliferation and hydropic degeneration of placental villi. It is part of a spectrum of gestational trophoblastic diseases (GTD) and can lead to persistent trophoblastic disease or choriocarcinoma if not properly managed.

Etiology and Types

The incidence of vesicular mole varies geographically, with higher rates in Southeast Asia (1 in 120 pregnancies) compared to North America and Europe (1 in 1,500 pregnancies). Risk factors include:

• Maternal age <20 or >35 years (especially >40)
• Previous molar pregnancy (7-10 times increased risk)
• Dietary deficiencies (low protein, folic acid, carotene)
• Asian ethnicity
• Blood group A female with blood group O male (controversial)

Diagnosis

Management

The primary treatment for vesicular mole is evacuation of the uterine contents, followed by close monitoring to detect persistent disease:

1. Pre-evacuation Assessment:
   • Evaluate for anemia, electrolyte imbalance, coagulopathy
   • Assess thyroid function
   • Screen for metastatic disease
   • Cross-match blood for potential hemorrhage
2. Uterine Evacuation:
   • Suction curettage (method of choice)
   • Oxytocin administration after evacuation begins
   • Careful monitoring for hemorrhage
   • Histopathological examination of all evacuated tissue
3. Post-evacuation Follow-up:
   • Weekly β-hCG until negative for 3 consecutive weeks
   • Monthly β-hCG for 6-12 months
   • Reliable contraception for at least 1 year
   • Chest X-ray every 2 months for 6 months
4. Treatment of Persistent Disease:
   • Chemotherapy (methotrexate or actinomycin D for low-risk)
   • Combination chemotherapy (EMA-CO) for high-risk disease
   • Hysterectomy may be considered for women who have completed childbearing

Nursing Care

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