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OB > 10.2b Late Pregnancy Bleeding > Flashcards

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.

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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
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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
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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
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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
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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
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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
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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
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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
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10
Q

Placental Abruption

A
  • Detachment of placenta from uterus after 20 weeks of gestation before birth
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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
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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
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13
Q

Couvelaire Uterus

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

Clotting Disorders in Pregnancy

A
  • Hemostatic System (platelets plug an injury and form a fibrin clot)
26
Q

Disseminated Intravascular Coagulation

A
  • 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
Q

Tissue Factor

A
  • 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
Q

Causes of Disseminated Intravascular Coagulation

A
  • Placental Abruption
  • Preeclampsia/Eclampsia/HELLP Syndrome
  • Amniotic Fluid Embolism
  • Postpartum Hemorrhage
  • Sepsis
  • Fatty liver
  • Retained IUFD (Delayed birth of a dead fetus)
29
Q

Care Management of DIC

A
  • 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
Q

Nursing Interventions of DIC

A
  • 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
Q

DIC Manifestations

A
  • 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
Q

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

A
  • Minimal Bleeding (<500 mL)
  • Dark Red Blood
  • No Shock/Coagulopathy/Pain
  • Normal Uterine Tonicity
33
Q

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

A
  • 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
Q

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

A
  • Absent to Moderate Bleeding (>1500 mL)
  • Common Shock
  • Dark Red Urine
  • Frequent DIC
  • Persistent Uterine Contractions with Board Like Uterus
  • Agonizing Pain
35
Q

Placental Previa

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

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