ch. 28 hemorrhage disorders

Question 1

miscarriage (spontaneous abortion)

Answer 1

a pregnancy that ends as a result of natural causes before fetal viability

Question 1

antepartal hemorrhagic disorders (what, ___ maternal blood loss decreases ___ and increases risk for (5), fetals risks from maternal hemorrhage (5), ________ medical emergencies, ____________ essential to save lives of both women/fetus)

Answer 1

bleeding in pregnancy jeopardizes maternal and fetal well being
1) maternal blood loss decreases oxygen carrying capacity and increases risk for:
- hypovolemia
- anemia
- infection
- preterm labor
- impaired oxygen delivery to the fetus
2) fetal risks from maternal hemorrhage:
- blood loss, anemia
- hypoxemia
- hypoxia
- anoxia
- preterm birth (still birth)
3) hemorrhagic disorders in pregnancy are medical emergencies (vary by trimester)
4) prompt assessment and intervention by the interprofessional health care team are essential to save the lives of both the woman and her fetus

Question 2

miscarriage incidence and etiology (2)

Answer 2

• approxiamtely 10% of all clinically recognized pregnancies and about 25% of all pregnancies end in miscarriage (1/3 first time women)
• the majority (greater than 80% miscarriages) are early pregnancy losses, occurring before 12 weeks of gestation

Question 3

types of miscarriage (6)

Answer 3

• threatened (spotting)
• inevitable (cervix completely open)
• incomplete (embryo/fetus expell but placenta still in)
• complete: all expelled
• missed: gone, not expelled
• recurrent: trouble carrying

clinica manifestations; recurrent (habitual miscarriages)

Question 4

threatened abortion (4)

Answer 4

• cervix not dilated
• placenta still attached to uterine wall
• unexplained bleeding/cramping for days
• r/o ectopic pregnancy or hydatidiform mole

Question 5

imminent abortion (3)

Answer 5

• placental separation
• cervix dilated
• increased bleeding

Question 6

incomplete abortion (2)

Answer 6

• passage of fetus
• placenta remains

Question 7

complete abortion (1)

Answer 7

passage of fetus and placenta

Question 8

missed abortion (2)

Answer 8

dies in utero, NOT expelled

expired, NOT expelled

Question 9

early pregnancy bleeding: inter-professional care mgmt (assessment (7), initial care (depends on, expectant mgmt, medical mgmt, surgical mgmt, psychosocial), f/u (2))

Answer 9

1) assessment
- pregnancy history
- V/S
- type and location of pain
- quantity and nature of bleeding
- emotional status
- lab tests
- LMP

2) initial care:
- depends on the classification of the miscarriage and s/sx
- expectant mgmt (let nature takes its course)
- medical mgmt: misoprostol (cytotec) - evaluate uterine contents
- surgical mgmt: dilation and curettage (D&C) - uterine lining (dusting and cleaning)
- psychosocial aspects of care - how is she dealing emotionally

3) follow up care
- discharge teaching emphasizes the need for rest
address questions about attempting another pregnancy
- follow up phone calls: support groups

Question 10

early pregnancy bleeding: cervical insufficiency (etiology (2), diagnosis (3), interprofessional care mgmt (3), f/u (3))

Answer 10

1) etiology:
- passive and painless dilation of the cervix during the second trimester (18-20 weeks, effacement for no good cause)
- may be either acquired or congenital

2) diagnosis:
- measurement of cervical length has been used as a way to diagnose cervical insufficiency -> identify women who have cervical changes b/c impaired cervical strength before conception or in early pregnancy rather than when they are beginning the process of preterm labor
- speculum/digital pelvic exams; transvaginal U/S -> abnormally short cervix, less than 25 mm
- cervical funneling

3) interprofesional care mgmt:
- cerclage: treatment of choice for women with cervical insufficiency due to cervical weakness
- mcdonald technique: a suture is placed around the cervix beneath the mucosa to constrict the internal os of the cervix
- abdominal cerclage: suture (mersilene tape) is placed at the junction of the lower uterine segment and the cervix

4) follow up care:
- validity of bed rest has not been scientifically proven
- progesterone therapy may be recommended for some women (progesterone, cream, oral, IM)
- watch for and report signs of preterm labor, rupture of membranes, and infection

Question 11

early signs bleeding: ectopic pregnancy (what, etiology, clinical manifestation (3), diagnosis (3), interprofessional care mgmt (2), f/u)

Answer 11

the fertilized ivum is implanted outside the uterine cavity; also called “TUBAL PREGNANCIES”

1) incidence/etiology
- account for 2% all pregnancies in US

2) clinical manifestation
- 3 most classic symptoms:
(a) abdominal pain
(b) delayed menses
(c) abnormal vaginal bleeding (spotting)

3) diagnosis
- difficult differential diagnosis: numerous disorders share similar s/sx
- quantitative beta hcg levels/transvaginal U/S examination
- discriminatory zone: a B-hcg level above which a normal intrauterine pregnancy should be visible on U/S

4) interprofessional care mgmt:
- medical mgmt: methotrexate (cancer drug, used to destroy cells in fallopian tubes, causing pregnancy to break down and past through)
- surgical mgmt: type of surgery depends on the location and cause of ectopic pregnancy, the extent of tissue involvement, and the woman’s desires regarding future fertility

5) follow up care

TIP:
- tubal pregnancy can’t survive, has to be removed -> Medical emergency
- ruptured uterus -> baby may/may not be alive -> Medical emergency

Question 12

early pregnancy bleeding: molar pregnancy (hydatidiform mole) (what (2), etiology (2), types (2))

Answer 12

• type of gestational trophoblastic neoplasia (GTN)
• benign proliferative growth of the placental trophoblast in which the chorionic villi develop in the edematous, cystic, avascular transparent vesicles that hang in a grape like cluster

1) incidence/etiology:
- occurs in 1/1000 pregnancies
- cause is unknown -> may be r/t ovular defect or a nutritional deficiency

2) types:
- complete: no embryonic or fetal parts
- partial: often have embryonic or fetal parts and an amniotic sac

Question 13

gestational trophoblastic disease: sx (9)

Answer 13

• vaginal bleeding
• anemia
• passing hydropic vessels (grapelike vessels)
• uterine enlargement greater than expected for gestational age
• absence of fetal heart sounds
• elevated Hcg
• low MSAFP levels
• hyperemesis gravidarium (severe nausea)
• preeclampsia (high risk, adenocarcinoma high risk)

Question 14

gestational trophoblastic disease: tx (3)/nursing care (4)

Answer 14

treatment:
- D/C (dilation/curretage)
- hysterectomy
- close follow up

nursing care:
- monitor V/S
- monitor vaginal bleeding
- assess abdominal pain
- assess the woman’s emotional state and coping ability

Question 15

late pregnancy bleeding: placenta previa (what (2), etiology/risk factors (6), clinical manifestations (3), maternal/fetal outcomes (4))

Answer 15

placenta implanted in lower uterine segment near or over internal cervical OS
- degree to which the internal cervical os is covered by placenta used to classify 3 types: (1) complete placenta previa, (2) marginal placenta previa, (3) low lying placenta

1) incidence/etiology:
- 1/200 pregnancies
- risk factors: previous c section, advanced maternal age (35-40), muliparity, history of prior suction curettage, maternal cocaine use, smoking

2) clinical manifestations:
- painless bright red vaginal bleeding during 2/3 trimester
- most cases diagnosed by U/S before significant vaginal bleeding occurs
- abdominal examination usually reveals a soft, relaxed, nontender uterus w/ normal tone

3) maternal/fetal outcomes:
- major complication: hemorrhage
- morbidity adherent placenta, an abnormally firm placental attachment
- surgery related trauma (most delivered by c section)
- preterm birth, IUGR

TIP: curettage (multiple terminations)

Question 16

low placental implantation (3)

Answer 16

approach lower segment
2nd trimester diagnosis
possible vaginal birth

Question 17

partial placenta previa

Answer 17

no vaginal birth

Question 18

total placenta previa

Answer 18

c section

Question 19

nursing care of patients with placenta previa (10)

Answer 19

• BR w/ BRP unless bleeding
• NO vaginal exams, douching, tampons, sex (remainder pregnancy)
• monitor blood loss, pain, uterine contractions
• evaluate FHR
• monitor mother’s vital signs
• monitor lab values: hgb/hct, Rh factor, UA, PLT
• administer IV fluids
• administer blood if needed
• administer betamethosone if ordered (steroids help mature fetal lungs, increase respiratory status, accelerates)
• administer rhogam if indicated (if Rh -)

Question 20

premature separation of placenta (abruptio placentae or placental abruption)

(what, primary risk factors (6), clinical manifestations (3), maternal/fetal outcomes (1), diagnosis (1), interprofessional care mgmt (2))

Answer 20

detachment of part or ALL of placenta from implantation site AFTER 20 weeks gestation

1) primary risk factor: maternal hypertension
- other: COCAINE/METHAMPHETAMINE use, penetrating/blunt external abdominal trauma, CIGARETTE SMOKE, HX. ABRUPTION PREVIOUS PREGNANCY, PRETERM PRELABOR RUPTURE OF MEMBRANES

2) clinical manifestations:
- vaginal bleeding
- abdominal pain
- uterine tenderness/contractions

3) maternal/fetal outcomes
- prognosis depends on many factors

4) diagnosis
- U/S can diagnose most but NOT ALL cases

5) interprofessional care mgmt:
- expectant mgmt
- active mgmt

Question 21

abruptio placentae (types) (what, 4 types)

Answer 21

premature separation of a normally implanted placenta from uterine wall

1) marginal: separation begins at periphery of placenta (grade 1)

2) central: concealed bleeding

3) partial: separation, but NOT complete

4) complete: massive hemorrage (grade 3) - fetus dies d/t loss lifeline

Question 22

abruptio placentae risks (mom (6), baby (4), nursing care (3))

Answer 22

mom:
- DIC: intrapartum coagulation defects (bleed out)
- severe hemorrhage - hemorrhagic shock
- renal failure d/t shock
- vascular spasm, intravascular clotting (stroke/PE)
- maternal death if NOT resolved
- hysterectomy performed in some cases

baby:
- overal 25% mortality rate
- with 50% or more separation, 100% mortality
- anemia, hypoxia
- neurological defects in 14& infants who survive (cerebral palsy, learning disability)

nursing care:
- c section
- correct shock, administer fluids, cryoprecipitate, FFP
- kleihauer-betke test of fetal-maternal hemorrhage in Rh (-) women (amt rhogam calculated on test results)

Question 23

late pregnancy bleeding: cord insertion and placental variations (4)

Answer 23

1) vasa previa: rare condition in which fetal vessels lie over the cervical os, and the vessels are implanted into the fetal membranes rather than into the placenta (no vessels on placenta)

2) velamentous insertion: cord vessels branched at membranes and then onto placenta

3) succenturiate placenta: placenta has divided into two or more lobes

4) battledore (marginal): insertion of the cord (cord attached at edge of placenta) -> increases risk of fetal hemorrhage (after birth, look at placenta and cord)

Question 24

normal clotting (what, 3)

Answer 24

delicate balance (homeostasis) exists between the opposing hemostatic and fibrinolytic systems
- hemostatic system stops flow of blood from injured vessels
- cascade effect
- fibrinolytic system: process through which fibrin is split into fibrinolytic degradation products and circulation is restored (breaks down fibrinogen)

Question 25

clotting problem: disseminated intravascular coagulation (DIC) (aka, 3, interprofessional care)

Answer 25

AKA consumptive coagulopathy syndrome
- acquired syndrome characterized by intravascular activation of coagulation which is widespread, rather than localized, and results in excessive clot formation and hemorrhage
- DIC is NEVER primary diagnosis -> results from an event that triggered coagulation (eg. preeclampsia, c section, abdominal trauma, placenta abruptio)
- in the obstetric population, DIC is most often triggered by the release of large amounts of tissue factor as a result of placental abruption

interprofessional care mgmt:
- correction of underlying cause

Question 26

in caring for an immediate postpartum women, you note petechiae and oozing from her IV site. you monitor her closely for which clotting disorder?

Answer 26

disseminated intravascular coagulation (DIC)