Bleeding During Pregnancy

Question 1

SPONTANEOUS ABORTION (SAB)

Answer 1

SAB #1 cause of bleeding in the 1st & 2nd trimesters
10% incidence when clinically recognized

Classifications
Threatened abortion
Inevitable abortion
Incomplete abortion
Complete abortion
Missed abortion

Pathophysiology
Chromosomal abnormalities (50%)
> 35 y/o
Teratogenic drugs
Faulty implantation
Weak cervix
Placental abnormalities
Endocrine imbalance
Infection/fever
Use of hot tub/jacuzzi
Malnutrition

Question 2

Threatened Abortion

Answer 2

Clinical manifestations
Spotting/bleeding
Cramping or backache

May result in pregnancy loss or may resolve

Cervix remains closed; no tissue passed

Placental remains attached to the uterine wall

Question 3

Inevitable Abortion

Answer 3

Clinical manifestations
Increased cramping
Mild to moderate vaginal bleeding

Cervix dilates

Placental separation from the uterine wall

Membranes may or may not rupture

Question 4

Incomplete Abortion

Answer 4

Clinical manifestations
Increased cramping
Moderate to severe vaginal bleeding

Cervix dilates

Placenta separates from the uterine wall

Fetal tissue is passed, but some products of conception remain

Question 5

Complete abortion

Answer 5

All products of conception have been delivered

Question 6

Missed abortion

Answer 6

The fetus expires in utero, but has not been expelled
Cervix remains closed, but signs & symptoms of pregnancy diminish

Question 7

Habitual abortion

Answer 7

> 3 consecutive abortions

Question 8

Therapeutic Management of SAB

Answer 8

Expectant management

Medical management
↓ time to expulsion and ↑ the rate of complete expulsion without the need for surgical intervention
Mifepristone 200 mg po followed by misoprostol 800mcg vaginally
RhoGAM if Rh (-)

Surgical management
If retained tissue
Evacuation of the uterus with dilation and curettage (D&C)

Question 9

ECTOPIC PREGNANCY

Answer 9

Implantation of the fertilized ovum outside the endometrial lining of the uterus
Ruptured Ectopic Pregnancy
As trophoblastic cells grow into tissue internal hemorrhage results

Incidence
1.5% - 2% of pregnancies

Risk Factors
Tubal damage
Endometriosis
↑ progesterone
Previous ectopic pregnancy
Use of IUDs
Infertility
Smoking

Question 10

Clinical Manifestations of Ectopic Pregnancy

Answer 10

Missed menses
Abdominal pain
Spotting

With rupture/hemorrhage
One-sided or diffuse abdominal pain
Referred shoulder pain
Fainting, dizziness
Rigid, tender abdomen
Hypovolemic shock

Labs
Lower than expected levels of hCG
↑ WBCs & ↓ H&H

Diagnostic testing
Ultrasound

Question 11

Nursing Management of Ectopic Pregnancy

Answer 11

Prepare for treatment
Monitor for rupture

Medical management
Methotrexate
Folic acid antagonist
Monitor hCG levels
RhoGAM if Rh (-)

Surgical management
Salpingostomy
Salpingectomy

If ruptured….
Maintain intravascular volume
Anticipate emergency surgery
Possible blood product administration
Pain management

Education
Prevention
Early pregnancy confirmation

Question 12

GESTATIONAL TROPHOBLASTIC DISEASE (GTD)

Answer 12

AKA hydatidiform mole or molar pregnancy

Pathologic proliferation of trophoblastic (gestational) cells in which the chorionic villi degenerate & become fluid-filled vesicles
Results in nonviable pregnancy
Benign neoplasm
Associated with choriocarcinoma development

Incidence
1 in 1000 pregnancies

Risk factors
Age extremes
Prior GTD
Asian race

Question 13

Pathophysiology of GTD

Answer 13

complete mole
Anuclear ovum or “empty egg” fertilized by a normal sperm that replicates resulting in 46 all paternal chromosomes

No fetal tissue present; no placenta to receive maternal blood

Associated with development of choriocarcinoma

partial mole
Normal ovum is fertilized by two sperm = 69 chromosomes

Only sections of the placenta are hydropic

Fetal parts may be present

Question 14

Clinical Manifestations of GTD

Answer 14

Vaginal bleeding
“prune juice”
Passage of hydropic vesicles

Signs & symptoms of early pregnancy
Hyperemesis
Uterine enlargement

Lab values
Low H&H
Markedly elevated hCG

Early development of preeclampsia

Question 15

Nursing Management of GTD

Answer 15

Preparation for treatment
Immediate evacuation of the uterus via D&C
RhoGAM if Rh (-)

If excess blood loss….
Maintain intravascular volume
Anticipate emergency surgery
Possible blood product administration

Provide emotional support

Education
Clinical surveillance for 1 year for detection of progression to choriocarcinoma
20% following GTD

Serial hCG levels

Prognosis

Use reliable contraceptive for 1 year

Question 16

ABRUPTIO PLACENTAE aka Placental Abruption

Answer 16

Premature separation of the placenta from the uterine wall

Incidence
1% of all pregnancies

Pathophysiology
Small degenerations in maternal arterioles -> thrombosis -> rupture of vessel -> clot formations -> increases pressure behind the placenta causing separation

Risk factors
Hypertension/Preeclampsia
Trauma
Cocaine use
Smoking
Premature rupture of membranes (PROM)
Chorioamnionitis
Multiple gestation
> 35 y/o
Previous placental abruption

Question 17

Medical Management of an Abruptio Placentae

Answer 17

Diagnosed via US/manifestations

Depends on severity/clinical manifestations
If mild
Expectant management
Steroids
Tocolytics
Moderate to severe separation
Emergency C/S

Evaluate degree of blood loss

Evaluate DIC risk
Fibrinogen
RECALL this is elevated in pregnancy
If <300 mg/dL…..think DIC
Platelets
PT & PTT

RhoGAM if Rh (-)

Question 18

PLACENTA PREVIA

Answer 18

Afterbirth first”
Improper implantation of the placenta in the lower uterine segment which may cover the cervical os

Incidence
1 in 200 pregnancies

Risk factors
History of previous previa
Previous cesarean birth or uterine surgery
Recent EAB
Infertility treatments
Multiple gestation
Multiparity
> 35 y/o
Smoking or cocaine use

Question 19

Previa Nursing Management

Answer 19

Monitor pregnant client & fetal status
Pad counts, monitor bleeding
Continuous fetal monitoring
Fetal heart rate (FHR)
Uterine activity

Prevent excess bleeding
No vaginal exams
Bedrest w/ bathroom privileges

Maintain effective tissue perfusion
IV access
CBC, T&S

Provide support & education
Surviving bedrest
S&S to report
Avoid exercise
Avoid intercourse

Medications
IVFs
Betamethasone
Tocolytics
RhoGAM

May need to prepare for urgent delivery

Question 20

CERVICAL INSUFFICIENCY

Answer 20

Premature dilation of the cervix
Painless dilatation of the cervix w/o contractions
4th-5th month of pregnancy

Pathophysiology
Congenital
Pregnant client exposure to DES inutero
Bicornuate uterus
Acquired
Infection
Cervical trauma of any kind
LEEP procedures

Risk Factors
Multiple gestation
Hydramnios
Precipitous deliveries
Hx of cervical manipulation
Repeat second- or third-trimester pregnancy terminations

Question 21

Cervical Insufficiency Management

Answer 21

Transvaginal US for cervical length & presence of “funneling”

Bed rest/pelvic rest

Supplemental IM or vaginal progesterone starting at 16 to 20 weeks of gestation

Cerclage
Stitch is placed in the cervix
Suture cut after 37 weeks gestation for vaginal birth or left in for cesarean section

Question 22

TRAUMA DURING PREGNANCY

Answer 22

Complicates 5%-10% of pregnancies
55% are the result of MVAs
Blunt trauma
Followed by falls & assaults
Penetrating gunshot or knife wounds
Intimate partner violence ↑ in pregnancy

If pregnant client is critically injured  40% fetal death rate