10.2a Early Pregnancy Bleeding

Question 1

Bleeding Disorders in Early Pregnancy

Answer 1

• Miscarriage (spontaneous abortion)
• Cervical Insufficiency
• Ectopic Pregnancy
• Hydatidiform mole (Molar Pregnancy)

Question 2

Miscarriage (Spontaneous Abortion)

Answer 2

• Pregnancy that ends as a result of natural causes before fetal viability
• Occurs before 20 weeks of gestation
• Fetal weight less than 500g is defined as abortion

Question 3

Etiology of Miscarriage

Answer 3

• 80% occur before 12 weeks gestation
• Half are chromosomally normal and half are chromosomally abnormal

CAUSES

• Medical Disorders (DM, Obesity, Thyroid Disease, Systemic Lupus Erythematosus)
• Alcohol
• Excessive Caffeine Intake (>500 mg/day)
• Environmental Toxins
• Increasing PATERNAL age
• INFECTION IS NOT A COMMON CAUSE OF MISCARRIAGE

Question 4

Types of Miscarriage

Answer 4

• Threatened (Cervix is closed but shows signs of miscarriage like light vaginal bleeding or lower abdominal pain)
• Inevitable (Cervix is open and developing fetus will come out in bleeding. A lot more vaginal bleeding and strong lower stomach cramps)
• Incomplete (Some pregnancy tissue remains in uterus and vaginal bleeding and lower abdominal cramping will continue in efforts to empty itself)
• Complete (All pregnancy tissue has left the uterus. Vaginal bleeding may continue for a few days)
• Missed (Fetus has died but stayed in the uterus. May have brownish discharge and feelings of pregnancy may be gone)

ALL TYPES EXCEPT THREATENED CAN LEAD TO INFECTION

Question 5

Signs and Symptoms of Miscarriage

Answer 5

• Uterine Bleeding
• Uterine Contractions
• Abdominal Pain
• Before 6 weeks of pregnancy, may seem like a heavy menstrual flow.
• Between 6-12 weeks there is moderate discomfort and blood loss
• After week 12 there is severe pain due to fetus needing to be expelled

Question 6

Recurrent Miscarriage

Answer 6

• 3+ spontaneous pregnancy losses before 20 weeks or under 500g fetal weight.
• Most common cause is parental chromosomal abnormalities, antiphospholipid antibody syndrome, and certain uterine abnormalities

Question 7

Evaluation of Recurrent Miscarriages

Answer 7

• Karyotyping (chromosomal assessment) of partners and placenta assessment
• Uterine cavity evaluation
• Screening for abnormal prolactin/thyroid disease
• Psychological response of parents

Question 8

Sepsis

Answer 8

• Some miscarriages can become septic (uncommon)

S/S

• Fever
• Abdominal tenderness
• Vaginal bleeding (malodorous - smells bad)

Question 9

Threatened Miscarriage

Answer 9

• Slight spotting of bleeding
• Mild uterine cramps
• No passage of tissue or cervical dilation

MANAGEMENT

• Bed rest (although not proven to be effective in preventing miscarriage)
• Ultrasounds and assessment of hCG and progesterone to determine if fetus is still alive

Question 10

Inevitable Miscarriage

Answer 10

• Moderate Bleeding
• Mild-Severe Uterine Cramps
• No passage of tissue but cervix is dilated

MANAGEMENT

• Expectant management (keeping close eye) if there is no pain, bleeding, or infection.
• If pain/bleeding/infection is present then termination of pregnancy is done by surgical dilation and suction.

Question 11

Incomplete Miscarriage

Answer 11

• Heavy/Profuse Bleeding
• Severe Uterine Cramps
• Passage of Tissue and Cervical Dilation

MANAGEMENT

• Suction curettage is preformed
• Can also be managed with misoprostol (Cytotec) instead of suction
• PRIORITY MANAGEMENT IS FLUID VOLUME DEFICIT DUE TO BLOOD LOSS FROM INCOMPLETE ABORTION

Question 12

Complete Miscarriage

Answer 12

• Slight Bleeding
• Mild Uterine Contractions
• There was passage of tissue but cervix is no longer dilated after the tissue has passed

MANAGEMENT

• No interventions if no hemorrhage/infection and adequate uterine contractions
• Ultrasound can also be done to make sure it was a complete miscarriage

Question 13

Missed Miscarriage

Answer 13

• No Bleeding
• No Uterine Cramping
• No passage of tissue or cervical dilation

MANAGEMENT
- Pregnancy can be terminated either with misoprostol (oral/vaginal) or surgical dilation and suction

Question 14

NURSING MANAGEMENT OF MISCARRIAGE

Answer 14

• Ask about s/s such as pain, cramping, and determine gestational age
• Prepare woman for termination of pregnancy by assessing dilation/curettage before and after procedure as well as explaining the procedure. Emotional support
• During discharge teach for signs of infection/bleeding and the importance of hygiene, nutrition and rest.
• Acknowledge the woman’s loss and allow her time to express her feelings.

Question 15

Assessment of Miscarriage

Answer 15

• Pregnancy History
• Vital Signs
• Type/Location of Pain
• Quantity/Nature of Bleeding
• Emotional Status

LABS

• hCG (Pregnancy)
• Hemoglobin (Anemia)
• WBC (Infection)

Question 16

Issues with Miscarriage

Answer 16

• Anxiety
• Disrupted Fluid Balance from Bleeding due to Miscarriage
• Acute Pain from Uterine Contractions
• Decreased Self Esteem
• Potential Infection from Surgery and Dilated Cervix

Question 17

Initial Care of Miscarriage

Answer 17

• For threatened miscarriages, if there is no bleeding or infection, acetaminophen is given as analgesia to reduce uterine cramping pain.
• If miscarriage becomes inevitable and it is incomplete miscarriage with heavy bleeding, excessive cramping, or infection, suction must be used to remove placental tissue. If the women is clinically stable, misoprostol can be used as well.

Missed Miscarriage

• Medical management (less invasive, more bleeding, longer completion, and lower success rate)
• Surgical management (more invasive, less bleeding, quicker completion, higher success rate)

Question 18

Dilation and Curettage (D&C)

Answer 18

Surgical “Abortion”
- Cervix is dilated and uterine contents are removed by suction curettage with a catheter and vacuum.

POST OP CARE

• Pain Management
• Anesthesia Recovery
• Discharge
• After fetus is evacuated, oxytocin is given to prevent hemorrhage.
• Ergonovine (Methergine) and Tromethamine (Hemabate) are used for excessive bleeding
• Prophylactic antibiotics and analgesics are also given
• Transfusion therapy is used if patient goes into shock or for anemia
• Rhogam is given for Rh negative non isoimmunized patients

Question 19

D&C Follow-Up Care

Answer 19

• Discharged in a few hours once patient’s stable (v/s, bleeding, anesthesia)
• Iron supplements if there was significant blood loss

Question 20

Cervical Insufficiency

Answer 20

• Passive and painless dilation of cervix leading to preterm birth in the 2nd trimester
• Diagnosed via measurement of cervix length
• Abnormally short cervix in 2nd trimester is a major risk of pre-term labor
• Assessment of function of cervix to diagnose cervical insufficiency can only be done in pregnancy

Question 21

Cervical Insufficiency Etiology

Answer 21

• Can be Acquired/Congenital

CONGENITAL

• Collagen Disorders
• Uterine Anomalies
• Ingestion of diethylstilbestrol (DES) by mother of pregnancy women while pregnant

Acquired

• Cervical trauma related to lacerations during birth or mechanical dilation of cervix during GYN exams
• Prior cervical surgery (biopsy where specimen is taken out of cervix)

Question 22

Cervical Insufficiency Diagnosis

Answer 22

• Done via speculum and digital pelvis exam or ultrasound
• Short Cervix <25mm
• Signs of Cervical Funneling (Beaking), Effacement of Internal Cervical OS with External Cervical OS remaining closed.

Question 23

Cervical Cerclage/McDonald Technique

Answer 23

• Treatment for patients with cervical insufficiency

USED IN WOMEN WITH

• Poor OB history
• Short (<25mm) cervical length
• Open cervix
• Cerclage can be placed prophylactically or as a rescue procedure
• MCDONALD TECHNIQUE where suture is placed around the cervix beneath the mucosa to constrict the internal os of cervix (Preferred Method)

Question 24

Cerclage (Cont)

Answer 24

• History indicated cerclage placed at 12-14 weeks
• Ultrasound indicated cerclage (short cervix) placed at 14-23 weeks gestation
• Rescue cerclage placed between 16-23 weeks gestation who are greater than 1cm dilated or have prolapsed membranes

Question 25

Cerclage Management

Answer 25

- Removed if there is PROM or advanced pre-term where pressure is put on the stitches - With no complications it is removed at 36 weeks

Question 26

Follow-up Care Cerclage

Answer 26

- Progesterone therapy (IM,IV) SIGNS THAT WARRANT HOSPITAL RETURN - Strong contractions less than 5 min apart - PROM - Severe perineal pressure - Urge to push

Question 27

Ectopic Pregnancy

Answer 27

- Fertilized ovum is implanted outside the uterine cavity (usually in the uterine tubes) - Can also occur in ovaries, cervix, abdominal cavity, or c-section scar - Leading cause of infertility

Question 28

Ectopic Pregnancy Risk Factors

Answer 28

- Tubal infections, fertility restoration, sterilization surgery, STI - Smoking - IUD's

Question 29

Ectopic Pregnancy Manifestations

Answer 29

BEFORE RUPTURE - Abdominal Pain - Delayed Menses - Abnormal Vaginal Bleeding (spotting) AFTER RUPTURE - Shoulder Pain (from diaphragmatic irritation from blood in peritoneal cavity) - Deep Lower Quadrant Abdominal Pain - May need medication for pain and may show signs of shock (faint and dizzy) related to abdominal bleeding.

Question 30

Ecchymotic Blueness (Cullen Sign)

Answer 30

- Blueness around umbilicus - Indicates hematoperitoneum (blood in perineum cavity) - Develops as rupture of intra-abdominal ectopic pregnancy

Question 31

Diagnosis of Ectopic Pregnancy

Answer 31

The key is early detection with high suspicion of it happening. - Most important screening tool is Quantitative b-hCG Levels and Ultrasound Exams DISCRMINATORY ZONE - Concept that elevated hCG levels in intrauterine pregnancy can be seen on an ultrasound. If hCG is above 1500 units but pregnancy cannot be seen, ectopic pregnancy is very likely OTHER TESTS - Progesterone above 25 ng/mL rules out ectopic pregnancy - Progesterone lower than 5 ng/mL can be ectopic pregnancy or abnormal intrauterine pregnancy - Women should be assessed for bleeding associated with tubal rupture. - If there is bleeding their may also be vertigo, shoulder pain, hypotension, tachycardia - VAGINAL EXAMS SHOULD ONLY BE PREFORMED ONCE WITH GREAT CAUTION. THEY WILL HAVE PALPABLE MASS THAT CAN EASILY BE RUPTURED SO BE CAUTIOUS

Question 32

Management of Ectopic Pregnancy

Answer 32

- Methotrexate (antimetabolite/folic acid antagonist) to kill the rapidly dividing cells. - Women must have normal liver, normal kidneys, and be hemodynamically stable for this - After treatment, hCG levels should be measured weekly to assure success - Treatment can take 2-8 weeks - Contraception should be used during this time to allow body to heal - Surgery can also be done by removal of the entire tube (salpingectomy) however she will be fertile after.

Question 33

Molar Pregnancy (Hydatidiform Mole)

Answer 33

- Benign growth of placental trophoblast where chorionic villi develop into edematous, cystic, transparent vesicles in grape-like clusters. (cysts on placenta) - Molar pregnancy is a type of Gestational Trophoblastic Neoplasia (GTN) that has the potential to for local infiltration, distant metastasis, and death - Gestational choriocarcinoma and placental site trophoblastic tumors are also GTN's

Question 34

Etiology of Molar Pregnancy

Answer 34

- Unknown but may be due to nutrition deficit or ovular defect - Extreme age and prior history are risk factors - Asian/Hispanic/Native American are most at risk - Result from chromosomally abnormal fertilization

Question 35

Complete Mole

Answer 35

- Fertilization of egg where nucleus is lost (inactivated) - Mole looks like white grapes - Uterus is large for the duration of pregnancy due to rapid growth of hydropic (fluid filled) sacs. - Mole has no fetus, placenta, amniotic membranes or fluid - There is no placenta to receive maternal blood so hemorrhage into uterine cavity and vaginal bleeding can occur

Question 36

Partial Mole

Answer 36

- Ovum is fertilized by 2+ sperm causing triploid or quadraploid genotypes. - Contains embryo/fetal parts and amniotic sac - Risk of persistent GTN is less

Question 37

Clinical Manifestations of Molar Pregnancy

Answer 37

- Earlier stages are unnoticeable but later there will be vaginal bleeding with dark brown (prune juice) or bright red vaginal discharge (scant or profuse) - Uterus will most likely be larger than expected - Anemia from blood loss can cause n/v (hyperemesis gravidarum) and abdominal cramps. - If preeclampsia is diagnosed before 24 weeks, molar pregnancy should be considered - Can also cause hyperthyroidism

Question 38

Diagnosis of Molar Pregnancy

Answer 38

- Ultrasound and hCG (High during times it should lower in normal pregnancy) - Ultrasound is the most accurate way -

Question 39

Care for Molar Pregnancy

Answer 39

- D&C (suction) if the mole does not abort spontaneously - Pregnancy should be avoided until follow up exam - Do not use IUD's as contraception until hCG is undetectable - Oral contraceptives are the preferred method

Question 40

Follow up Molar Pregnancy

Answer 40

- Women are still at risk for invasive mole or choriocarcinoma even after the mole has been evacuated. FOLLOW UP CARE - Physical/Pelvic examinations with weekly hCG assessment until levels are normalized for 3 weeks - Monthly measurements for 6-12 months - Follow ups continue for a year - If hCG continues to rise and uterus continues to get bigger, GTN is suspected.