Bleeding During Pregnancy Flashcards
SPONTANEOUS ABORTION (SAB)
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
Threatened Abortion
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
Inevitable Abortion
Clinical manifestations
Increased cramping
Mild to moderate vaginal bleeding
Cervix dilates
Placental separation from the uterine wall
Membranes may or may not rupture
Incomplete Abortion
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
Complete abortion
All products of conception have been delivered
Missed abortion
The fetus expires in utero, but has not been expelled
Cervix remains closed, but signs & symptoms of pregnancy diminish
Habitual abortion
> 3 consecutive abortions
Therapeutic Management of SAB
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)
ECTOPIC PREGNANCY
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
Clinical Manifestations of Ectopic Pregnancy
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
Nursing Management of Ectopic Pregnancy
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
GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
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
Pathophysiology of GTD
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
Clinical Manifestations of GTD
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
Nursing Management of GTD
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
ABRUPTIO PLACENTAE aka Placental Abruption
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
Medical Management of an Abruptio Placentae
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 (-)
PLACENTA PREVIA
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
Previa Nursing Management
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
CERVICAL INSUFFICIENCY
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
Cervical Insufficiency Management
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
TRAUMA DURING PREGNANCY
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
