Midwife Licensure Exam High-Risk Pregnancy & Complications (Recognize & Refer) — High-Risk Pregnancy & Bleeding DisordersRevision Notes

Exam Tips

• NLE questions will describe a clinical scenario — first identify the trimester, then use the painless vs. painful bleeding distinction for third-trimester cases.
• Any question asking the PRIORITY nursing action for third-trimester bleeding: do NOT do a vaginal exam — this answer will almost always be among the choices.
• Maslow prioritization: always address circulation/fluid volume before psychosocial needs in active bleeding.

Key Points

• Always classify vaginal bleeding by TRIMESTER first — the differential diagnosis changes completely between the first and third trimesters.
• First-trimester bleeding causes: threatened abortion, inevitable/incomplete/complete/missed abortion, ectopic pregnancy, hydatidiform mole.
• Third-trimester bleeding causes: placenta previa (painless) and abruptio placentae (painful) — the single most important NLE distinction in this chapter.
• GOLDEN RULE for third-trimester bleeding: NEVER perform a vaginal or rectal examination until placenta previa is ruled out by ultrasound — probing a low-lying placenta can cause catastrophic, fatal hemorrhage.
• For ALL bleeding disorders, assess amount of blood loss (count and weigh pads; 1 gram = 1 mL), monitor for hypovolemic shock, establish IV access, and provide emotional support.
• Under RA 9173 (Philippine Nursing Act of 2002), the nurse independently identifies nursing diagnoses, initiates emergency measures, and collaborates with the physician — knowing when to act and when to refer is a legal nursing competency.
• Priority nursing diagnoses across all bleeding disorders follow Maslow's hierarchy: Deficient Fluid Volume / Risk for Shock (physiologic, first priority) before Anxiety or Grieving (psychosocial).

Definitions

Section Title

Overview: Classifying Pregnancy Bleeding by Trimester

Common Mistakes

• Performing a vaginal exam on a patient with third-trimester bleeding before ruling out placenta previa — this is a critical safety error.
• Waiting for hypotension before suspecting shock — tachycardia and restlessness are the FIRST signs.
• Forgetting to save all passed tissue and clots for pathologic evaluation.
• Not counting and weighing perineal pads when estimating blood loss.

Exam Tips

• NLE questions often give a scenario with the cervical os status as the key differentiating detail — always note whether the cervix is open or closed.
• For 'what is the PRIORITY nursing intervention after D&C?' — monitor for hemorrhage and uterine atony first.
• Recurrent abortion = 3 or more consecutive losses — memorize the exact number.
• Missed abortion: retained dead fetus + no initial bleeding + risk of DIC — this triad appears frequently in scenario-based questions.

Key Points

• Abortion = termination of pregnancy before viability (before 20–24 weeks or fetal weight under 500 g).
• Most common cause of spontaneous abortion: chromosomal abnormalities (approximately 50–60% of first-trimester losses).
• Other contributing factors: maternal infection, endocrine imbalance, incompetent cervix, immunologic factors.
• KEY clinical distinction: Cervical os status (open vs. closed) determines the type of abortion and guides management.
• Threatened abortion: slight bleeding + mild cramping + CLOSED cervix — pregnancy may continue; advise pelvic rest.
• Inevitable abortion: moderate bleeding + cramping + OPEN (dilated) cervix ± ruptured membranes — loss cannot be stopped.
• Incomplete abortion: some products of conception expelled, some retained; heavy bleeding, open cervix → requires D&C.
• Complete abortion: ALL products expelled; bleeding and cramping subside; cervix CLOSED — no procedure needed.
• Missed abortion: fetus dies but is RETAINED; initially no bleeding; uterus stops growing; risk of DIC if retained beyond 4–6 weeks.
• Recurrent (habitual) abortion: THREE or more consecutive spontaneous abortions — requires investigation.
• Nursing management for incomplete/inevitable: prepare for D&C or suction evacuation; maintain IV access; monitor vital signs.
• Emotional support is MANDATORY — never minimize pregnancy loss regardless of gestational age.
• Administer Rho(D) immune globulin to ALL Rh-negative unsensitized women after any abortion.

Definitions

Section Title

Abortion (Spontaneous Miscarriage) — First Trimester

Common Mistakes

• Confusing incomplete (some tissue retained, cervix open, heavy bleeding) with complete (all tissue passed, cervix closed, bleeding stops) — the management is opposite.
• Forgetting that missed abortion carries DIC risk even though there is initially NO bleeding.
• Omitting Rho(D) immune globulin for Rh-negative patients after first-trimester losses — it is required after ANY abortion, not just delivery.
• Dismissing the emotional impact of early miscarriage — grief is real at any gestational age.

Exam Tips

• Kehr sign (referred shoulder pain) + sudden severe abdominal pain + pregnancy = ruptured ectopic until proven otherwise — this scenario is a classic NLE question.
• Methotrexate contraindications to remember: liver disease, renal disease, immunodeficiency, and breastfeeding.
• Priority intervention for ruptured ectopic: CIRCULATION first — large-bore IV access, fluids, oxygen, prepare for surgery.
• Empty uterus on ultrasound + positive pregnancy test + adnexal mass = ectopic pregnancy — commit this triad to memory.

Key Points

• Ectopic pregnancy = implantation of a fertilized ovum OUTSIDE the uterine cavity; over 95% occur in the fallopian tube (ampulla is the most common site).
• Risk factors: pelvic inflammatory disease (PID) — the #1 risk factor; prior tubal surgery; previous ectopic pregnancy; intrauterine device use.
• Classic presentation BEFORE rupture: unilateral lower-quadrant pain + delayed or abnormal menses + scant dark vaginal spotting.
• TUBAL RUPTURE is a surgical emergency — sudden sharp stabbing abdominal pain, referred SHOULDER PAIN (Kehr sign — diaphragmatic irritation by intraperitoneal blood), and rapid hypovolemic shock.
• Cullen sign = bluish periumbilical discoloration from intraperitoneal bleeding — a late sign.
• Diagnostics: serial beta-hCG that fails to double in 48 hours (abnormally slow rise); transvaginal ultrasound showing empty uterus + adnexal mass; culdocentesis (aspiration of non-clotting blood from the cul-de-sac).
• Management — UNRUPTURED: Methotrexate IM (folic acid antagonist) — dissolves trophoblastic tissue; monitor declining beta-hCG.
• Management — RUPTURED: Emergency salpingostomy (tube-conserving) or salpingectomy (tube removal). Priority: treat shock — two large-bore IV lines, IV fluids, oxygen, blood products, continuous vital sign monitoring.
• Patient teaching for methotrexate: avoid folic acid supplements, alcohol, and sun exposure; report severe abdominal pain (may indicate treatment failure or rupture).
• Give Rho(D) immune globulin to all Rh-negative unsensitized women after ectopic pregnancy (standard 300 mcg dose).

Definitions

Section Title

Ectopic Pregnancy — First Trimester Surgical Emergency

Common Mistakes

• Missing that shoulder pain in a pregnant patient is a red flag for intraperitoneal bleeding (Kehr sign), not a musculoskeletal complaint.
• Forgetting that a normal-appearing beta-hCG level may still be ectopic if it fails to double — it is the RATE of rise that matters.
• Advising a patient on methotrexate to take folic acid (common prenatal supplement) — this directly antagonizes the drug's mechanism.
• Underestimating the urgency of a ruptured ectopic — delay in recognition and treatment is a leading cause of maternal mortality.

Exam Tips

• NLE scenario clue: 'uterus larger than gestational age' + 'excessively high beta-hCG' + 'snowstorm on ultrasound' + 'no fetal heart tones' = hydatidiform mole.
• Preeclampsia BEFORE 20 weeks = molar pregnancy until proven otherwise — this is a classic trick question.
• Teaching priority after evacuation: 'Avoid pregnancy for 1 year and come back for serial blood tests' — this answer will appear in patient teaching questions.
• Rising beta-hCG during the monitoring period = malignancy → report immediately to physician.

Key Points

• Hydatidiform mole = abnormal proliferation of the trophoblast; chorionic villi degenerate into grape-like fluid-filled vesicles instead of forming a normal placenta.
• COMPLETE MOLE: No fetal tissue; all chromosomes are paternal (46,XX karyotype); higher risk of progressing to choriocarcinoma (malignant transformation).
• PARTIAL MOLE: Contains some fetal/embryonic tissue; triploid karyotype; lower malignant potential.
• Classic manifestations: uterus LARGER THAN EXPECTED for gestational age; dark-brown ('prune juice') or bright-red bleeding sometimes with passage of grape-like vesicles; excessively HIGH beta-hCG; hyperemesis gravidarum (driven by high hCG).
• RED FLAG: Preeclampsia (hypertension + proteinuria) appearing BEFORE 20 weeks — normally preeclampsia appears after 20 weeks; early onset is a hallmark of molar pregnancy.
• NO fetal heart tones detectable; ultrasound shows 'snowstorm' or 'cluster of grapes' pattern.
• Management: SUCTION CURETTAGE to evacuate the uterus.
• CRITICAL follow-up: Serial beta-hCG monitoring for 6–12 months to detect choriocarcinoma. hCG must progressively fall to zero.
• AVOID PREGNANCY FOR AT LEAST 1 YEAR after molar evacuation — a new pregnancy would cause a beta-hCG rise that masks malignant transformation.
• Provide RELIABLE CONTRACEPTION (oral contraceptive pills are preferred; IUD is avoided while cervix heals).
• Rising beta-hCG during follow-up = malignant transformation → chemotherapy (methotrexate or actinomycin-D).
• Give Rho(D) immune globulin to Rh-negative unsensitized women.

Definitions

Section Title

Hydatidiform Mole (Gestational Trophoblastic Disease)

Common Mistakes

• Forgetting that preeclampsia before 20 weeks is abnormal and should raise suspicion of hydatidiform mole.
• Not educating patients that oral contraceptives are preferred post-mole — students often think any contraception will do.
• Advising the patient they can try to conceive after 6 months — the standard is AT LEAST 1 YEAR.
• Confusing complete mole (no fetal tissue, higher cancer risk) with partial mole (some fetal tissue, lower cancer risk).

Exam Tips

• NLE key phrase: 'painless bright-red bleeding' in the third trimester = placenta previa until proven otherwise.
• The single most important nursing intervention: DO NOT perform a vaginal exam — this answer appears in almost every NLE question about third-trimester bleeding.
• Betamethasone dose and indication: 12 mg IM q24h × 2 doses, given before 34 weeks for fetal lung maturity — memorize this.
• Placenta previa with malpresentation (breech/transverse) on the same scenario = classic NLE finding to support the diagnosis.

Key Points

• Placenta previa = placenta implants in the LOWER uterine segment, partially or completely covering the internal cervical os.
• Types: Total (complete) previa — os completely covered; Partial — os partially covered; Marginal — placenta edge reaches the os margin; Low-lying — placenta within 2 cm of os but not covering it.
• Risk factors: multiparity, prior cesarean section, prior placenta previa, advanced maternal age, multiple gestation, uterine scars.
• CLASSIC PRESENTATION: PAINLESS, BRIGHT-RED vaginal bleeding, typically sudden onset in the third trimester; uterus is SOFT and NON-TENDER with NORMAL tone.
• Malpresentation (breech, transverse lie) is common because the placenta occupies the lower segment and blocks engagement of the presenting part.
• DIAGNOSIS: Transabdominal ultrasound — confirms placental location. NEVER perform a vaginal exam.
• Nursing management: Bed rest; continuous monitoring of bleeding, vital signs, and FHR; IV access; type and crossmatch blood.
• Expectant management for stable preterm fetus: prolong pregnancy; administer BETAMETHASONE 12 mg IM every 24 hours for 2 doses for fetal lung maturity if delivery may occur before 34 weeks.
• Delivery by CESAREAN SECTION for total previa (vaginal delivery is contraindicated).
• Postpartum hemorrhage risk is HIGH because the lower uterine segment contracts poorly after delivery.
• Priority NANDA nursing diagnosis: Deficient Fluid Volume related to excessive bleeding; Risk for Impaired Fetal Gas Exchange.

Definitions

Section Title

Placenta Previa — Third-Trimester Painless Bleeding

Common Mistakes

• Performing or preparing for a vaginal exam on a patient with painless third-trimester bleeding before ultrasound rules out previa — this is a fatal error.
• Forgetting to assess for and anticipate postpartum hemorrhage after delivery of a previa patient.
• Not giving betamethasone when indicated for preterm delivery — fetal lung maturity is a critical intervention.
• Confusing the presentations: previa (painless, soft uterus, bright red) vs. abruption (painful, rigid uterus, dark red).

Exam Tips

• Key differentiator for NLE: Abruptio = PAINFUL + DARK RED + RIGID UTERUS; Previa = PAINLESS + BRIGHT RED + SOFT UTERUS.
• Hypertension + painful dark bleeding + rigid uterus = abruptio placentae — hypertension is the leading associated risk factor.
• For any question about abruptio, 'shock greater than visible blood loss' is the classic clue pointing to concealed hemorrhage.
• DIC monitoring — watch for oozing from IV sites, petechiae, gums bleeding, hematuria; these signs signal coagulopathy and must be reported immediately.

Key Points

• Abruptio placentae = PREMATURE SEPARATION of a NORMALLY implanted placenta after 20 weeks gestation.
• Leading risk factor: MATERNAL HYPERTENSION (chronic or pregnancy-induced); other major risk: cocaine use, abdominal trauma, short umbilical cord, prior abruption.
• CLASSIC PRESENTATION: PAINFUL, DARK-RED vaginal bleeding + RIGID, BOARD-LIKE, HYPERTONIC, TENDER uterus (wooden abdomen).
• CONCEALED BLEEDING is common: blood may be trapped behind the placenta and not visible externally — external blood loss can GROSSLY UNDERESTIMATE true blood loss and degree of shock.
• Expanding fundal height (increasing fundal measurement between assessments) indicates concealed hemorrhage.
• Fetal distress and uterine hyperactivity/tetanic contractions are common findings on FHR monitoring.
• Major complication: DISSEMINATED INTRAVASCULAR COAGULATION (DIC) — caused by release of thromboplastin from the disrupted placenta into maternal circulation.
• Emergency management: position in LEFT LATERAL TILT (not supine — prevents aortocaval compression); administer oxygen; two large-bore IV lines; IV fluids and blood products; continuous FHR monitoring; monitor coagulation studies; prepare for emergency cesarean.
• Monitor urine output — target above 30 mL/hr; oliguria signals worsening shock.
• Grades of abruption: Grade 0 (no symptoms, diagnosed retrospectively); Grade 1 (mild); Grade 2 (moderate fetal distress); Grade 3 (severe, fetal death possible, DIC risk).
• Priority NANDA nursing diagnosis: Deficient Fluid Volume related to hemorrhage; Impaired Fetal Gas Exchange; Risk for Disseminated Intravascular Coagulopathy.

Definitions

Section Title

Abruptio Placentae (Placental Abruption) — Third-Trimester Painful Bleeding

Common Mistakes

• Assuming external blood loss accurately reflects total blood loss in abruption — concealed hemorrhage can make the clinical picture far worse than it appears.
• Positioning the patient supine rather than in left lateral tilt — supine causes aortocaval compression, worsening perfusion to both mother and fetus.
• Not monitoring coagulation studies (PT, aPTT, fibrinogen, platelets, D-dimer) — DIC is a life-threatening complication of severe abruption.
• Confusing abruption (normally implanted placenta that separates prematurely) with previa (abnormally implanted placenta).

Exam Tips

• NLE will test dose and timing: 300 mcg IM at 28 weeks AND within 72 hours postpartum — memorize both.
• Microdose 50 mcg = first trimester only (before 13 weeks); standard 300 mcg = everything else.
• Eligibility: maternal indirect Coombs NEGATIVE = give RhoGAM; maternal indirect Coombs POSITIVE = do NOT give (already sensitized).
• Classic NLE question: 'What will the nurse assess BEFORE giving RhoGAM?' Answer: Maternal blood type and Rh factor; indirect Coombs test result.
• RhoGAM is given to the MOTHER to protect the NEXT pregnancy — NLE questions may ask who receives it.

Key Points

• Purpose: Prevents Rh isoimmunization (sensitization) in an Rh-NEGATIVE, UNSENSITIZED mother exposed to Rh-positive fetal blood.
• Mechanism: Provides PASSIVE ANTIBODY that destroys fetal Rh-positive cells before the mother's immune system can mount an active (primary) immune response — protecting future pregnancies from hemolytic disease of the newborn (HDN).
• Standard dose: 300 mcg IM — given at 28 WEEKS GESTATION (antepartum prophylaxis) AND within 72 HOURS AFTER DELIVERY of an Rh-positive infant.
• Also give 300 mcg IM after ANY potential fetomaternal hemorrhage event: spontaneous or induced abortion, ectopic pregnancy, amniocentesis, chorionic villus sampling (CVS), abruptio placentae, external cephalic version, abdominal trauma.
• MICRODOSE: 50 mcg — used for FIRST-TRIMESTER events only (abortion or ectopic pregnancy before 13 weeks).
• ELIGIBILITY CRITERIA: Mother's INDIRECT COOMBS TEST must be NEGATIVE (not already sensitized); Baby's DIRECT COOMBS TEST must be NEGATIVE (no antibodies already on fetal RBCs).
• Given to the MOTHER only — never to the infant.
• If the mother is ALREADY sensitized (indirect Coombs positive), RhoGAM offers NO BENEFIT and should NOT be given.
• Administer IM (not IV); document lot number and date; observe for 20 minutes post-injection for allergic reaction.
• Teaching point: RhoGAM does NOT harm the mother — it is given to PROTECT the NEXT baby from hemolytic disease.

Definitions

Section Title

Rho(D) Immune Globulin (RhoGAM) — Must-Know Pharmacology

Common Mistakes

• Giving the standard 300 mcg dose for a first-trimester loss — the correct dose for events under 13 weeks is the MICRODOSE 50 mcg.
• Giving RhoGAM to a mother who is already Rh-positive — it is only for Rh-NEGATIVE mothers.
• Giving RhoGAM when the mother's indirect Coombs is already positive — it is ineffective once sensitization has occurred.
• Forgetting to give RhoGAM after ectopic pregnancy, abortion, or amniocentesis — it is required after ANY potential fetomaternal bleed, not just delivery.
• Confusing indirect Coombs (maternal serum, detects free antibodies) with direct Coombs (newborn blood, detects antibodies on RBCs).

Exam Tips

• For priority interventions in hemorrhage, the order follows ABCs and Maslow: Airway → Breathing (Oxygen) → Circulation (IV access, fluids) → then assessment and monitoring.
• DIC lab pattern to memorize: Low platelets + Low fibrinogen + High PT/aPTT + High D-dimer = DIC.
• The best early indicator of shock = TACHYCARDIA; the best indicator of renal perfusion = URINE OUTPUT (keep above 30 mL/hr).
• If an NLE question asks about 'oozing from puncture sites' and 'petechiae' in a patient with abruptio placentae — the answer is DIC.

Key Points

• The two complications that CAN KILL across all bleeding disorders: HYPOVOLEMIC SHOCK and DISSEMINATED INTRAVASCULAR COAGULATION (DIC).
• Hypovolemic shock stages — COMPENSATED (early, MUST ACT NOW): tachycardia (first vital sign change), restlessness, anxiety, cool and clammy skin, pallor, normal-to-slightly-reduced BP, urine output slightly decreased.
• Decompensated shock: BP falls significantly, oliguria (urine output below 30 mL/hr), altered mental status, increasing tachycardia.
• Irreversible shock: multiorgan failure — irreversible cellular damage; prevent by acting on EARLY signs.
• PRIORITY interventions for hemorrhage/shock: Position left lateral; oxygen via face mask; two large-bore (16–18 gauge) IV lines; rapid infusion of isotonic crystalloids (0.9% NaCl or Lactated Ringer's); blood transfusion as ordered; continuous vital signs and FHR monitoring; urinary catheter to monitor urine output hourly.
• DIC triggers in obstetrics: MISSED ABORTION (retained dead fetus releases thromboplastin), ABRUPTIO PLACENTAE (disrupted placenta releases thromboplastin), amniotic fluid embolism, severe sepsis, HELLP syndrome.
• DIC clinical signs: oozing from IV sites and venipuncture sites; bleeding from gums; petechiae and ecchymoses; hematuria; abnormal coagulation labs.
• DIC labs: PROLONGED PT and aPTT; LOW fibrinogen; LOW platelets; ELEVATED D-dimer (fibrin degradation product).
• DIC treatment: Remove/deliver the trigger (delivery of placenta, evacuation of dead fetus); replace blood products (packed RBCs for anemia; fresh frozen plasma for clotting factors; cryoprecipitate for fibrinogen; platelets for thrombocytopenia).
• Urine output target: maintain ABOVE 30 mL/hour as a marker of adequate renal perfusion.

Definitions

Section Title

Complications: Hypovolemic Shock and DIC

Common Mistakes

• Waiting for a drop in blood pressure before intervening for shock — hypotension is a LATE and dangerous sign; tachycardia and restlessness signal compensated shock and require IMMEDIATE action.
• Not monitoring urine output hourly in actively bleeding patients — oliguria is an early indicator of inadequate renal perfusion.
• Using hypotonic IV fluids instead of isotonic solutions for volume replacement — 0.9% NaCl or Lactated Ringer's are the correct choices.
• Forgetting DIC risk in missed abortion — students often only associate DIC with abruption.

Exam Tips

• NLE questions on patient teaching often ask for the PRIORITY teaching point — for molar pregnancy, the priority is always: 'Avoid pregnancy for 1 year and follow serial beta-hCG.'
• Therapeutic communication for grief: use open-ended statements, acknowledge the loss directly, use the word 'baby' if the parents do — these principles apply to Philippine culture where family and faith are central.
• RA 9173 connects: patient teaching is within the scope of independent nursing practice — nurses are legally accountable for accurate health education.

Key Points

• Teach ALL pregnant women the WARNING SIGNS to report IMMEDIATELY: any vaginal bleeding; severe or one-sided abdominal pain; shoulder-tip pain; passage of tissue or grape-like material; dizziness, fainting, or palpitations; reduced or absent fetal movement.
• After MOLAR PREGNANCY: stress the critical importance of serial beta-hCG monitoring for 6–12 months; explain why pregnancy MUST BE AVOIDED for at least 1 year; provide reliable contraception (OCP preferred); any rising hCG = report immediately.
• For RH-NEGATIVE women: explain WHY RhoGAM is given at 28 weeks, after any bleeding event, and after birth; it protects future babies from hemolytic disease; it must be repeated with each pregnancy and bleeding event.
• After ABORTION or ECTOPIC PREGNANCY: allow the couple to grieve; avoid minimizing phrases ('at least it was early' or 'you can always try again'); allow parents to name the baby if they wish; refer to support groups and pastoral care as culturally appropriate in the Philippine setting.
• After D&C: report fever, foul-smelling vaginal discharge, heavy bleeding, or persistent pelvic pain — signs of infection or retained tissue.
• BIRTH CONTROL counseling after molar pregnancy: oral contraceptives are preferred; IUDs are avoided initially; barrier methods are acceptable.
• Iron supplementation and diet counseling after significant blood loss.
• Under RA 9173, health education is an independent nursing function — the nurse is accountable for the quality and accuracy of all patient teaching provided.

Section Title

Patient and Family Teaching — Discharge and Follow-up

Common Mistakes

• Using clichés during grief support ('Everything happens for a reason,' 'You can try again') — these are dismissive and therapeutically harmful.
• Not reinforcing the 1-year no-pregnancy rule for molar pregnancy during discharge teaching — patients may not remember this if told only once.
• Failing to provide written instructions for warning signs in addition to verbal teaching — literacy and anxiety may affect retention.