10.2b Late Pregnancy Bleeding

Question 1

Placental Previa

Answer 1

• 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.

Question 2

Placental Previa Risk Factors

Answer 2

• 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

Question 3

Clinical Manifestations of Placental Previa

Answer 3

• 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

Question 4

Outcomes of Placental Previa

Answer 4

• 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

Question 5

Diagnosis of Placental Previa

Answer 5

• 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

Question 6

Care Management Placental Previa

Answer 6

• 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

Question 7

Expectant Management of Placental Previa

Answer 7

• 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

Question 8

Home Care Placental Previa

Answer 8

• 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

Question 9

Active Management Placental Previa

Answer 9

• 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

Question 10

Placental Abruption

Answer 10

• Detachment of placenta from uterus after 20 weeks of gestation before birth

Question 11

Risk Factor for Placental Abruption

Answer 11

• Maternal Hypertension is the biggest one

OTHERS INCLUDE..

• Cocaine
• Blunt Trauma (motor vehicle accidents)
• Smoking
• History of Placental Abruption
• PROM
• Thrombophilic Disorders
• Twin Gestation

Question 12

Symptoms of Placental Abruption

Answer 12

• Bleeding
• Abdominal Pain
• Uterine Tenderness
• Contractions
• Hypovolemia (shock, oliguria/anuria)
• Coagulopathy
• Mild-Severe Uterine Hypertonicity
• Pain with board like abdomen

Question 13

Couvelaire Uterus

Answer 13

• Uterus becomes blue/purple
• Contractility is lost
• Due to blood accumulating between separated placenta and uterine wall

Question 14

Lab Tests Placental Previa

Answer 14

• 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

Question 15

Outcomes of Placental Abruption

Answer 15

MOM

• Hemorrhage
• Hypovolemic Shock
• Hypofibrinogenemia
• Thrombocytopenia
• Renal Failure and Pituitary Necrosis (due to ischemia)
• Isoimmunization

FETUS

• IUGR
• Oligohydramnios
• Preterm Birth
• Hypxemia
• Stillbirth

Question 16

Diagnosis of Placental Abruption

Answer 16

Ultrasound to identify the source of abruption

• Subchorionic (between placenta and membrane)
• Retroplacental (between placenta and uterine wall)
• Preplacental (between placenta and amniotic fluid)

Question 17

Symptoms of Placental Abruption

Answer 17

• 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

Question 18

Expectant Management of Placental Abruption

Answer 18

• 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)

Question 19

Active Management of Placental Abruption

Answer 19

• 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

Question 20

Cord Insertion and Placental Variations

Answer 20

Listed Below

Question 21

Vasa Previa

Answer 21

• 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

Question 22

Risk Factors for Vasa Previa

Answer 22

• 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

Question 23

Velamentous Insertion of Cord

Answer 23

• Cord vessels branch onto placenta

Question 24

Succenturiate Placenta

Answer 24

• 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

Question 25

Clotting Disorders in Pregnancy

Answer 25

- Hemostatic System (platelets plug an injury and form a fibrin clot)

Question 26

Disseminated Intravascular Coagulation

Answer 26

- 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.

Question 27

Tissue Factor

Answer 27

- 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

Question 28

Causes of Disseminated Intravascular Coagulation

Answer 28

- Placental Abruption - Preeclampsia/Eclampsia/HELLP Syndrome - Amniotic Fluid Embolism - Postpartum Hemorrhage - Sepsis - Fatty liver - Retained IUFD (Delayed birth of a dead fetus)

Question 29

Care Management of DIC

Answer 29

- 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

Question 30

Nursing Interventions of DIC

Answer 30

- 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

Question 31

DIC Manifestations

Answer 31

- 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

Question 32

Placental Abruption Grade 1 (Mild Separation 10-20%)

Answer 32

- Minimal Bleeding (<500 mL) - Dark Red Blood - No Shock/Coagulopathy/Pain - Normal Uterine Tonicity

Question 33

Placental Abruption Grade 2 (Moderate Separation 20-50%)

Answer 33

- Absent to moderate bleeding (1000-1500 mL) - Mild Shock - Dark red Urine - Occasional DIC - Increased uterine tonicity and fails to relax between contractions - Pain

Question 34

Placental Abruption Grade 3 (Severe Separation Greater than 50%)

Answer 34

- Absent to Moderate Bleeding (>1500 mL) - Common Shock - Dark Red Urine - Frequent DIC - Persistent Uterine Contractions with Board Like Uterus - Agonizing Pain

Question 35

Placental Previa

Answer 35

- Minimal to Severe (Life-threatening) bleeding (Varies in Blood Loss) - Bright Red Blood - Shock is uncommon - No Coagulopathy - Normal Uterine Tonicity - No pain