BLEEDING IN PREGNANCY

From Group 2 :

Reznita Adityani D. Akhmad

Indahwati

Nur Anisya Devi

Evi Apnitasari

Wiwin Alfina Damayanti

Suci Rahmania

Nuraini

Health Polytechnic Of Makassar

MIDWIFERY DIV

2020/2021
 Pembahasan

A. Abortion
a. Definition of Abortion

Abortion is a threat or release of the product of conception before the fetus can
live outside the womb. As a limitation is a pregnancy of less than 20 weeks or
the fetal weight is less than 500 grams, (Prawirohardjo, 2009).

Abortion is a threat or release of the product of conception at a gestational age

of less than 20 weeks or a fetal weight less than 500 grams, (Mansjoer, et al,
2000).

Abortion is the termination of an unwanted pregnancy through drugs or

surgery (Morgan, 2009).

The end of a pregnancy before the child can live in the outside world is called
an abortion. New children may live in the outside world when their weight
reaches 1000 grams or 28 weeks of gestation. There are also those who take as
a limit for abortions of children weighing less than 500 grams. If a child born
weighing between 500 - 999 grams is also called immature.

Abortion is the end of a pregnancy (due to certain consequences) at or before

the pregnancy is 22 weeks old or the fruit of the pregnancy has not been able
to live outside the womb, (Prawirohardjo, 2010).
b. Etiology of Abortion

Causes Spontaneous abortion cannot always be stopped, the most common are:

1. Chromosomal abnormalities

Chromosomal abnormalities that occur during the fertilization process most often
occur because the incoming sperm has the wrong number of chromosomes, so that
the fertilized egg or embryo cannot develop normally, and chromosomal
abnormalities can also be caused by genetic factors, where genetic factors are
often causes spontaneous abortion on fetal chromosomes are more than 60%, and
this spontaneous abortion occurs during gestations where the pregnancy is less
than 22 weeks.

2. Abnormalities in the placenta

Inflammation that is in the uterine wall and causes oxygenation of the placenta to
be disturbed, resulting in impaired growth and fetal death, and this situation can
occur since the mother has a young pregnancy and will result in an abortion as
much as 40%, for example because the mother has hypertension for years.

3. Diabetes

Diabetes in normal pregnancy is accompanied by an increase in the hormone

insulin and usually diabetes occurs for the first time during pregnancy in the
second or third trimester, while gestational diabetes in Indonesia is 1.5-2.3% with
a population age less than> 20 years. The diabetes in pregnancy includes type-1
diabetes which is due to genetic factors and immunological factors when the
mother is pregnant.

4. Hormonal Factors

Hormonal factors can be associated with an increased risk of spontaneous

abortion, and hormonal factors that can cause recurrent abortion by about 50-60%,
due to hormonal factors and also pregnant women who have abnormalities in the
hormonal system (can be too high maternal prolactin hormone or maternal
progesterone. too low which can result in a miscarriage.

5. Infection

The mother is infected with a large number of organisms which then causes
spontaneous abortion. Examples of infections that have been associated with
spontaneous abortion in as much as 20-30% include infection by Listeria
monocytogenes, where the infection can cause miscarriage in pregnant women
and will develop mild flu-like symptoms.

6. Abnormal

Structural Anatomy Abnormal uterine anatomy can also result in spontaneous

abortion. In some women there is a tissue bridge (uterine septum), which acts like
a portion of the wall of the uterine cavity dividing into several parts. The septum
usually has very little blood supply, and is not suitable for placental growth.
Therefore, an embryo implanted in the septum will increase the risk of
spontaneous abortion by 40-50%.

7. Other causes

Invasive surgical procedures in the uterus, such as amniocentesis and chorionic

villus smpling, can also increase the risk of spontaneous abortion.

8. Lifestyle
a) Smoking more than 10 cigarettes per day is associated with an increased risk
of spontaneous abortion, and some studies show that the risk of spontaneous
abortion increases with father smokers. Other factors, such as alcohol use, can
directly poison the fetus.
b) Obesity can also have hormonal disturbances that will result in disturbances in
pregnancy.
c. Type of Abortion

Based on the type, abortion is divided into several types, namely:

1. Imminent Abortion (Threatened)

Imminent abortion is suspected if there is bleeding from the vagina, or vaginal

bleeding in the first trimester of pregnancy. Can or without ccompanied by mild
mules, the same as at the time of menstruation or pain lower waist. Bleeding in
imminent abortion is often only a little, however, it lasts several days or weeks.
Examination vagina in this abnormality shows the absence of cervical opening.
Meanwhile, real time ultrasound examination of the pelvis indicates normal
amniotic sac size, fetal heart beat, and the amniotic sac is empty, the cervix is
closed, and the fetus is still intact.

2. Inevitable Abortion

Incipient abortion is a threatening abortion, marked with rupture of the fetal

membrane and the presence of a flattened cervix and ostium uteri has opened.
Characterized by lower abdominal pain or colicky pain uterus. On vaginal
examination reveals cervical dilation with a prominent conception pouch.
Ultrasound examination results empty (5-6.5 weeks), empty uterus (3-5 weeks) or
bleeding many subchhorionic at the bottom.

3. Incomplete Abortion (Incomplete)

Incomplete abortion is the removal of a portion of the product of conception

pregnancy before 20 weeks with lingering residue uterus. On vaginal examination,
the cervical canal is open and tissue can palpable in the uterine cavity or
sometimes already protruding from the ostium uteri externum. On
ultrasonography (USG), the endometrium is found thin and irregular.
4. Complete Abortion (Complete)

Complete abortion of all products of conception was excluded. In sufferers there

is slight bleeding, the uterine ostium has closed, and the uterus has closed much
shrinks. Apart from this, there are no more pregnancy symptoms and pregnancy
testing to be negative. On ultrasound examination (USG) found the uterus empty.

5. Missed Abortion

Missed abortion is an embryo or fetus that has died in the womb efore 20 weeks
of gestation, however, the complete conception is still stays in the womb for 8
weeks or more. Usually preceded signs of imminent abortion which then
disappear spontaneously or after treatment

6. Habitual Abortion

Habitual abortion is a spontaneous abortion that occurs three times in a row or

more. In general, sufferers are not difficult to get pregnant, however her
pregnancy ended before 28 weeks.

d. Early Treatment of Abortion

1. Early Treatment of Mothers with Imminent Abortion:

a) Patients are asked to do bed rest until the bleeding stops.
b) Patients are reminded not to have intercourse for at least 2 weeks.
c) There is no special treatment that can only be given sadativa, for example
with codeine or morphine (according to the doctor's instructions and
instructions)
 d) Discharge of the fetus can still be prevented by giving hormonal drugs
such as progesterone 10 mg every day for therapy and reducing the
vulnerability of the uterine muscles
e) Giving analgesics so that the uterus does not continue to contract until the
uterine mechanical stimulation is reduced.

2. Early Treatment of Mothers With Incipient Abortion :

a) Patients should be admitted to hospital
Because there is no chance of survival for the fetus
b) In incidental abortion, the task of nurses and midwives as assistants is to
prepare equipment, monitor the patient's condition, help administer
intravenous drugs according to doctor's instructions, and administer an RL
infusion with 20 units of oxytocin. with 40 drops per minute to assist in
expulsion of the fetus (under the supervision of a doctor).

3. Early Treatment of Mothers with Complete Abortion :

a) On vaginal examination, cervical canal and tissue can be felt in the uterine
cavity or sometimes already protruding from the external uterine ostium.
b) Bleeding in incomplete abortion can be a lot, causing shock and bleeding
will not stop before the rest of the conception is released.
c) In handling, if an incomplete abortion is accompanied by shock due to
bleeding, then the infusion of physiological NaCl or RL fluid should be
given as soon as possible, followed by transfusion.
d) After the shock is resolved, then scraping is performed 5. Post-procedure
injection of 0.2 mg intramuscularly ergometrine or 400 meg of
misoprostol orally to maintain uterine muscle contractions.

4. Early Treatment of Mothers with Complete Abortion

If midwives and nurses find a client with a complete abortion, several things
can be done, among others
a) The conception result does not need to be evaluated again because it is out.
 b) Only observe for profuse bleeding, making sure to monitor the general
state of the mother after the abortion.
c) If there is moderate anemia, give sulfas ferrosus tablets 600 mg / day for 2
weeks.
d) If anemia is severe give blood transfusions, and only with uteratonics, and
provide post-abortion counseling and follow-up monitoring.
5. Early Mothers With Missed Abortion
If the midwife or nurse performs a missed abortion case
a) Immediately refer to the hospital for consideration: the placenta can be
firmly attached to the uterine wall, so that the evacuation procedure
(curettage) will be more difficult than the risk of perforation, in general the
cervical canal is closed so it needs dilatation with the tuberculosis (a tool
that will dilate it). cervix) for 12 hours, a high incidence of
hypofibrinogenic complications that continue with blood clotting
disorders.
b) Treatment of suction curettage and prostaglandins by obstetricians is
preferred depending on the size of the uterus and the day of menstruation.

B. Tuba Pregnancy
a. Definiton of Tuba Pregnancy
Tuba pregnancy is an abnormal pregnancy that occurs outside the uterine
cavity, the fetus cannot survive and does not develop at all often. Ectopic
pregnancy is also called ectopic pregnancy, ectopic pregnancy, eccecyesis.
Ectopic pregnancy is the cause of maternal death in the first trimester of
gestation. The frequency of ectopic pregnancy ranges from 1: 14.6% of
pregnancies.
b. Etiology of Tuba Pregnancy
The cause of an tuba pregnancy is not certain. However, the most
common cause of ectopic pregnancy is tubal factor (95%). Below are the
causes of an tuba pregnancy:

1. Tubal factors, including: narrowing of the tubal lumen, tubal cilia

disorders, imperfect tubal surgery and sterilization, tubal
endometriosis, tumors;
2. Ovum factors, including: rapid cell devision, external and internal
migration of the ovum, adhesions to the granulosa membrane;
3. Pelvic inflammatory disease;
4. Contraceptive failure;
5. Hormonal effects, including: the use of mini-pill contraceptives, and
6. History of previous pregnancy termination.

c. Symptoms and Signs of Tuba Pregnancy

Pregnant women who experience an tuba pregnancy will
experience symptoms at 6-10 weeks of gestation. The symptoms and signs
you feel include: amenorrhoea / no menstruation; Lower abdominal pain;
irregular vaginal bleeding (usually in the form of spotting); pain on one
side of the pelvis; looks pale; low blood pressure, increased pulse,
pregnant women experience fainting and sometimes accompanied by
shoulder pain due to irritation of the diaphragm from the hemoperitoneum.

d. Traeatment Of Tuba Pregnancy

The general principles of management of ectopic pregnancy are as follows:

1. Immediately refer to a more complete facility / hospital.

 2. Optimizing the general condition of the mother by administering fluids
and blood transfusions, administering oxygen or giving antibiotics if an
infection is suspected.
3. In a state of shock immediately given fluid infusions such as 5% dextrose,
5% glucose, physiological salts and oxygen while waiting for blood. (the
patient's condition must be improved, control blood pressure, pulse and
respiration).
4. The ideal management is to stop the source of bleeding immediately with
surgical management / laparotomy once the diagnosis is confirmed. (Anik,
2016).

C. Molar Pregnancy
a. Definition of Molar Pregnancy
Molar Pregnancy is a benign tumor of the trophoblast and is an abnormal
pregnancy, with the characteristics of rare, vascularized and edematous
villus stoma, the fetus usually dies but the enlarged and edematous villus
is alive and growing continuously, so the picture given is as a cluster.
grapes
b. Etiology of Molar Pregnancy

The cause of molar pregnancy is not known with certainty, but there are
factors that cause it:

1. Ovum factor

Fertilization of an egg where the nucleus has been lost or is no longer

active by a sperm cell.

2. Immunoselective of trophoblast

The development of hydatidiform mole is thought to be caused by an error

in the mother's immune response to invasion by trophoblasts. As a result
the villi experience a nutrient-rich distension. Primitive blood vessels in
 the villus are not well formed so that the embryo "starves", dies, and is
absorbed, while the trophoblasts continue to grow and under certain
circumstances invade the mother's tissues.

3. Age

Factors of age below 20 years and over 35 years can occur molar
pregnancy. The prevalence of hydatidiform pregnancy occurring at the
beginning or at the end of childbearing age is relatively high. However, it
cannot be denied that at any age during childbearing age, molar pregnancy
can occur.

4. Low socio-economic conditions

During pregnancy, the need for nutrients increases. This is necessary to

meet the growth and development needs of the fetus, with low
socioeconomic conditions, so as to fulfill the nutrients the body needs, it is
deficient, resulting in disturbances in fetal growth and development.

5. High parity

In high parity women, there is a tendency to be at risk of developing

hydatidiform mole pregnancies due to birth trauma or genetic transmission
disorders that can be identified with the use of stimulants such as
clomiphene or menotropic (pergonal). However, it is also undeniable that
in primiparous, non-malformed pregnancies can occur.

6. Protein deficiency

Protein is a substance to build tissue parts of the body in connection with

the growth of the fetus, the growth of the mother's uterus and breasts, the
need for protein during pregnancy is greatly increased when a lack of
protein in food results in imperfect fetal growth.

7. Unclear viral infection and chromosomal factors

 Microbial infections can affect anyone, including pregnant women. The
entry or presence of microbes in the human body does not always cause
disease (desease). This really depends on the number of microbes (germs
or viruses) including their virulence and immunity.

8. Previous molar pregnancy history

Recurrence of hydatidiform mole is found in about 1-2% of cases. In an

incident of 12 studies covering a total of nearly 5000 births, the mole
frequency was 1.3%. In a review of recurrent hydatidiform mole but
different pairs it can be concluded that there may be a "primary oocyte
problem".

c. Treatment of Molar Pregnancy

Improvement of General Conditions :

1. Improvement of the general condition of Molar Pregnancy patients,

namely:
2. Correction of dehydration.
3. Blood transfusions if there is anemia (Hb 8 g% or less), also to correct
shock.
4. If there are symptoms of preeclampsia and hyperemesis gravidarum, treat
them according to the treatment protocol.
5. If there are symptoms of thyrotoxicosis, consult the Internal Medicine
section.
6. Removal of the mala tissue by means of curettage and hysterectomy.

D. Placental Abruption
a. Definition of Placental Abruption
Placental abruption (abrubtio placenta) is the detachment of part or all of the
placenta which in normal circumstances implies over 22 weeks and before
the birth of the child. Placental abruption is the release of the placenta which
 is normally located in the uterine fundus / uterine body before the fetus is
born (PB POGI, 1991). Placental abruption is the detachment of the placenta
from its normal implantation site in the uterus before the fetus is born. Which
occurs at 22 weeks gestation or the fetus weight is above 500 grams (Rustam
2002). So the complete definition is: placental abruption is part or all of the
normal placenta implantation between week 22 and the birth of the child
(according to Obstetric Pathology 2002).

b. Etiology of Placental Abruption

The main cause of placental abruption is not clear. However, some of the
things below are suspected to be factors that influenced its occurrence, including
the following:

1. Essential hypertension or preeclampsia.

2. Short umbilical cord due to excessive or free fetal movement.
3. Abdominal trauma such as falling face down, kicking a child who is being
carried.
4. Pressure of the enlarged uterus on the inferior vena cava.
5. Very small uterus.
6. Maternal age (<20 years or> 35 years
7. Your membranes break prematurely.
8. Myoma uteri.
9. Folic acid deficiency.
10. Smoking, alcohol, and cocaine.
11. Retroplacental bleeding.
12. The strength of the mother's uterus is reduced at multiparity.
13. Maternal blood circulation is disturbed so that blood supply to the fetus is
not available.
14. Sudden shrinkage at hydromnion and gamely.
c. Treatment of Placental Abruption

Treatment of placental abruption according to Manuaba (1998: 260-261):

1. Mild placental abruption a) The stomach is slightly tense, bleeding is not

too much. b) The condition of the fetus can still be treated conservatively.
c) The bleeding continues and the tension increases, with the fetus still
good for cesarean section. d) Bleeding that stops and the condition is good
in premature pregnancy should be hospitalized
2. Moderate and severe placental abruption. Handling is carried out in a
hospital because it can endanger the patient's life. The treatment is: a)
Installation of infusions and blood transfusions. b) Breaking the amniotic
fluid. c) Labor induction or performed SC. Therefore, treatment of
moderate and severe placental abruption must be carried out in a hospital
with adequate facilities.
3. The attitude of the midwife in dealing with placental abruption. Midwives
are the mainstay of the community to be able to provide midwifery
assistance, so that it can reduce morbidity and mortality rates for both
mother and perinatal. In dealing with bleeding in pregnancy, the midwife's
main attitude is to refer to the hospital. In making a referral, emergency
help is given:
a) Installation of infusion
b) Without doing an internal inspection
c) Delivered by officers who can provide assistance
d) Preparing donors from the community or their families e) Include a
description of what has been done to provide first aid Placental
abruption in hospitals according to Marmi (2011: 80-81): - Blood
transfusion - Water breaking - Oxytocin infusion - In SC, if
necessary
E. Placenta Previa
a. Definition of Placenta Previa
Placenta previa is the condition in which the placenta implants in
abnormal place in the lower segment of the uterus so that it covers partially
or the entire opening of the birth canal (Mochtar, 1998). Ante partum
hemorrhage is bleeding that occurs after 28 weeks of pregnancy (Mochtar,
1998). Sectio caesaria is a method of giving birth with a uterine incision
through the front wall of the stomach or cesarean section is a hysterectomy to
deliver the fetus through an incision in the anterior abdominal wall and uterus
(Hacker, 2001). From the above definition, it can be concluded that sectio
caesaria is an act of giving birth to a baby with utensils through incision in
the abdominal wall and interior uterine wall, because the baby is not can be
born through the birth canal. One of the causes is placenta previa. Placenta
previa is a condition where the placenta is present.
b. Etiology of Placenta Previa

The cause of placenta previa is not clearly known according toMochtar

(1998) there are several factors that cause placenta previa, namely : age,
endometrial hypoplasia, endometrial defects in the formerrepeated, scarring,
curettage, slow-acting corpus luteum, tumor such as uterine myoma,
malnutrition.
According to Mochtar (1998) there are several things that can cause this the
occurrence of antepartum hemorrhage, namely: placental disorders (placenta
previa, placental abruption, antepartum hemorrhage eg, velamentosa insersio,
rupture marginal sinus, circum-valate placenta) not from placental
abnormalities usually cervical and vaginal abnormalities, trauma. The
indications for SC according to Cunningham (1995) are: isproportion of
 pelvic cephalo, placenta previa, transverse location, birth canal tumors,
abdominal sectio caesaria that is not good, abruption of the placenta.

c. Types of Placenta Previa

Types of Placenra Previa (Manuta, Ida Bagus)

1. Placenta previa totalis is placenta previa that covers the birth canal at a 4
cm opening.
2. Placenta Previa Parsialis If the placenta partially covers the uterine osteum
internum.
3. Placenta previa marginalis. Placenta previa which is around the edge of the
osteum uteri internum

d. Treatment of Placenta Previa

Patients with placenta previa come with complaints vaginal bleeding in the
second trimester of pregnancy and trimester of pregnancy third. The
management of placenta previa depends on gestational age patients where
active management will be carried out, namely ending pregnancy, or
expectation i.e. maintaining the pregnancy for possible.

1. Expectative (passive) therapy

The expectative goal is that the fetus is not born prematurely, the patient is
treated without carrying out an internal examination through the canal
servisis. Diagnosis efforts are carried out non-invasively. Monitoring
clinical practice is done strictly and well

2. Active therapy

Pregnant women over 22 weeks with bleeding active vaginal and lots of it,
should be treated immediately active regardless of fetal maturity. How to
complete labor with placenta previa.
1) Caesarean section

The main principle in conducting cesarean section is to save the

mother, so whether the fetus dies or not have hope to live, this action is
still done.

2) melts vaginal discharge

Bleeding will stop if there is pressure on the placenta. This emphasis

can be done in ways as following:

a) Amniotomy and acceleration

Generally performed on the placenta previa lateralis / marginalis with

an opening> 3 cm and a presentation of the head. With break the
amniotic, the placenta will follow the lower segment uterus and
pressed by the fetal head. If the uterus contracts absent or still weak,
accelerated with oxytocin infusion.

b) Braxton Hicks version

The purpose of doing the Baxton Hicks version is to host tamponade of

the placenta with the buttocks (and legs) of the fetus. Version Braxton
Hicks is not performed on living fetuses.

c) Traction with Cunam Willet

The scalp of the fetus is clamped with Cunam Willet, then given load
sufficiently until the bleeding stops. This action less effective at
pressing the placenta and often causes bleeding of the scalp. This
action usually done on fetuses who have died and bleeding is not
active.
Placenta previa with bleeding is an urgent emergency require good handling.
Forms of aid to the placenta is:

 Immediately perform labor surgery to save mother and child to reduce

morbidity and mortality.
 Breaking the amniotic fluid on the operating table further supervision to be
able to do further assistance.
 Take a stand to make referrals to places that have complete facilities