10.2b Late Pregnancy Bleeding Flashcards
1
Q
Placental Previa
A
- Placenta completely or partially covers the cervix or close enough to cause bleeding during dilation or effacement
- Ultrasound is used to diagnose
Complete - Total coverage of cervical os
Marginal - Edge is 2.5 cm or closer to internal cervical os
Low-Lying - Relationship between placenta and cervix is not determined or if it happens in the second trimester.
2
Q
Placental Previa Risk Factors
A
- More c-section births
- 35-40+ years of age
- Multiparity with history of prior suction curettage
- Smoking
- Living in high altitudes
- Asians have the highest risk
- Women carrying male fetuses
- Multiple gestations
- History of Placental Previa
3
Q
Clinical Manifestations of Placental Previa
A
- Painless bright red bleeding in 2nd - 3rd trimester
- Usually diagnosed via ultrasound before significant bleeding occurs
- Bleeding occurs from stretching/thinning of lower uterine segment disrupting placental blood flow
- V/S ARE NORMAL EVEN WITH HEAVY BLOOD LOSS (PREGNANT WOMEN CAN LOSE UP TO 40% BLOOD VOLUME BEFORE SHOWING SIGNS OF SHOCK
- DECREASED URINE OUTPUT IS A BETTER INDICATOR OF BLOOD LOSS
- FHR IS NORMAL UNLESS PLACENTA DETACHES
ABDOMINAL EXAMINATION
- Soft, Relaxed, Non-Tender Uterus with Normal Tone
- Presenting part of fetus remains high due to placenta occupying lower uterine segment
- Fundal height is greater than gestational age
- Breech or transverse lie is common
4
Q
Outcomes of Placental Previa
A
- Major complication is hemorrhage
- Morbidly adherent placenta (abnormally firm placenta attachment) is another serious complication
- Removal of uterus may be necessary for uncontrollable bleeding (hysterectomy)
- Birth must be via c-section
- Can result in IUGR
- Increased incidence of fetal anomalies
5
Q
Diagnosis of Placental Previa
A
- Women with painless vaginal bleeding after 20 weeks of gestation should be assumed to have placental previa.
- Transabdominal ultrasound is done to reveal placental previa
6
Q
Care Management Placental Previa
A
- Either Expectant or Active Management depending on the severity
Complications of Placental Previa
- Inadequate tissue perfusion due to blood loss
- Dehydration due to blood loss
- Decreased placental perfusion due to hypovolemia
- Anxiety/Grieving
7
Q
Expectant Management of Placental Previa
A
- Observation and bed rest if fetus is less than 37 weeks and there is no complications
- Hospitalized with continuous FHR and UC monitoring
- IV Access should be available
LABS
- Hemoglobin, Hematocrit, Platelets, “Type and Screen” blood sample, coagulation studies
LESS THAN 34 WEEKS GESTATION
- Antenatal Corticosteroids
- Tocolytic Medications if bleeding associated with uterine contractions
- With no bleeding women is on bed rest with limited activity (walk around 15-30 min 4 times a day)
- Women should avoid intercourse
- No vaginal/rectal examinations
8
Q
Home Care Placental Previa
A
- Women need to be stable and no bleeding for 48 hours prior to discharge
- They must comply with bed rest
- Live in a short distance from hospital
- Have constant access to transportation
- Verbalize understanding of the risk for Placental Previa
9
Q
Active Management Placental Previa
A
- If the fetus is above 36 weeks then birth is appropriate action
- If bleeding is excessive than immediate birth is given regardless of gestational age
- Blood loss may not stop with birth due to diminished muscle content in the lower uterine segment
ASSESSMENT
- Decreasing BP
- Increasing Pulse
- LOC
- Oliguria
10
Q
Placental Abruption
A
- Detachment of placenta from uterus after 20 weeks of gestation before birth
11
Q
Risk Factor for Placental Abruption
A
- Maternal Hypertension is the biggest one
OTHERS INCLUDE..
- Cocaine
- Blunt Trauma (motor vehicle accidents)
- Smoking
- History of Placental Abruption
- PROM
- Thrombophilic Disorders
- Twin Gestation
12
Q
Symptoms of Placental Abruption
A
- Bleeding
- Abdominal Pain
- Uterine Tenderness
- Contractions
- Hypovolemia (shock, oliguria/anuria)
- Coagulopathy
- Mild-Severe Uterine Hypertonicity
- Pain with board like abdomen
13
Q
Couvelaire Uterus
A
- Uterus becomes blue/purple
- Contractility is lost
- Due to blood accumulating between separated placenta and uterine wall
14
Q
Lab Tests Placental Previa
A
- Positive APT Test (Blood in Amniotic Fluid)
- Decrease in Hemoglobin and Hematocrit
- Decrease in coagulation factors
- Clotting Defects
- Patients will be given a Kleihauer-Betke (KB) Test to see if fetal blood has entered moms blood. This is to check for isoimmunization
15
Q
Outcomes of Placental Abruption
A
MOM
- Hemorrhage
- Hypovolemic Shock
- Hypofibrinogenemia
- Thrombocytopenia
- Renal Failure and Pituitary Necrosis (due to ischemia)
- Isoimmunization
FETUS
- IUGR
- Oligohydramnios
- Preterm Birth
- Hypxemia
- Stillbirth
16
Q
Diagnosis of Placental Abruption
A
Ultrasound to identify the source of abruption
- Subchorionic (between placenta and membrane)
- Retroplacental (between placenta and uterine wall)
- Preplacental (between placenta and amniotic fluid)
17
Q
Symptoms of Placental Abruption
A
- Should be suspected in sudden onset of intense, localized, uterine pain with/without vaginal bleeding
- Abdominal pain
- Uterine Tenderness
- Contractions
- Increasing fundal height can mean concealed bleeding
- Elevated uterine resting tone
- Abnormal clotting
18
Q
Expectant Management of Placental Abruption
A
- Used if fetus is between 20-34 weeks of gestation and women/fetus are stable
- Fetus is assessed for regular growth due to risk of IUGR (NST and BPP)
19
Q
Active Management of Placental Abruption
A
- Immediate birth if bleeding is severe
- Monitor VS for dropping BP and increasing HR
LABS
- Hematocrit/Hemoglobin
- Clotting studies
- Continuous EFM
- Indwelling catheter
- Fluid volume replacement
20
Q
Cord Insertion and Placental Variations
A
Listed Below
21
Q
Vasa Previa
A
- Fetal vessels lying over cervical OS
- Vessels are implanted into fetus instead of placenta and there is no Wharton Jelly putting it at risk for compression and rupture
- Diagnosed via ultrasound or Doppler Imaging
22
Q
Risk Factors for Vasa Previa
A
- History of 2nd trimester placental previa
- Low-lying placenta
- Pregnancies from assistive technologies
- Multiple gestations
- RUPTURE OF MEMBRANE CAN RUPTURE FETAL BLOOD VESSELS WHICH CAUSES FETUS TO BLEED TO DEATH. BE CAREFUL
23
Q
Velamentous Insertion of Cord
A
- Cord vessels branch onto placenta
24
Q
Succenturiate Placenta
A
- Placenta divides into 2 or more lobes instead of a single mass
- During birth, one of the lobes can remain attached to the uterus preventing contractions and increasing risk of hemorrhage
- Battledore (marginal) insertion of cord increases risk of fetal hemorrhage
25
Clotting Disorders in Pregnancy
- Hemostatic System (platelets plug an injury and form a fibrin clot)
26
Disseminated Intravascular Coagulation
- Consumptive Coagulopathy (Defibrination syndrome)
- Acquired syndrome by widespread activation of intravascular coagulation which results in excessive clot formations and hemorrhage
- It is always caused by something else such as release of tissue factor from placental abruption.
27
Tissue Factor
- Glycoprotein found in body organs with blood vessels (brain, lungs, placenta)
- This activates clotting factors when released from damaged tissue
- This is what results in widespread formation of fibrin clots
28
Causes of Disseminated Intravascular Coagulation
- Placental Abruption
- Preeclampsia/Eclampsia/HELLP Syndrome
- Amniotic Fluid Embolism
- Postpartum Hemorrhage
- Sepsis
- Fatty liver
- Retained IUFD (Delayed birth of a dead fetus)
29
Care Management of DIC
- Removal of abrupted placenta or dead fetus. Treating pre-eclampsia
- Volume Expansion
- Rapid replacement of blood and clotting factors
- Oxygenation
- Achieving normal body temperature
- Vitamin K
- Recombinant activated factor VIIa
- Fibrinogen Concentrate
- Hemostatic Agents
30
Nursing Interventions of DIC
- Assessment of bleeding and administration of blood products
- Protecting woman from injury
- Monitor urinary output (at least 30mL/Hr) with indwelling catheter due to renal failure being a major risk
- Continuous EFM and VS
- Side lying tilt position to maximize blood to uterus
- Non re-breather oxygen face mask at 10 L/min
- Cured with birth
31
DIC Manifestations
- Signs of thrombosis (peripheral cyanosis, renal impairment, drowsiness/confusion, coma, cardiorespiratory failure)
- Bleeding from 3 unrelated sites
- Spontaneous epistaxis (nosebleed)
- Oozing blood from venipuncture sites
- Petechiae (on arm where BP is taken)
- Ecchymosis (bruising)
- Large SubQ Hematomas
- Hypotension
- Tachycardia
LABS
- Decreased platelets/fibrinogen
- Increased fibrin degrading products/D-dimer test
- Prolonged PT and APTT
32
Placental Abruption Grade 1 (Mild Separation 10-20%)
- Minimal Bleeding (<500 mL)
- Dark Red Blood
- No Shock/Coagulopathy/Pain
- Normal Uterine Tonicity
33
Placental Abruption Grade 2 (Moderate Separation 20-50%)
- Absent to moderate bleeding (1000-1500 mL)
- Mild Shock
- Dark red Urine
- Occasional DIC
- Increased uterine tonicity and fails to relax between contractions
- Pain
34
Placental Abruption Grade 3 (Severe Separation Greater than 50%)
- Absent to Moderate Bleeding (>1500 mL)
- Common Shock
- Dark Red Urine
- Frequent DIC
- Persistent Uterine Contractions with Board Like Uterus
- Agonizing Pain
35
Placental Previa
- Minimal to Severe (Life-threatening) bleeding (Varies in Blood Loss)
- Bright Red Blood
- Shock is uncommon
- No Coagulopathy
- Normal Uterine Tonicity
- No pain
