Chapter 28 Flashcards
bleeding during pregnancy
ABORTION ECTOPIC PREGANACY (tubal pg) GESTATIONAL TROPHOBLASTIC DISEASE- (Hydatidiform mole or “molar pg”) PLACENTA PREVIA ABRUPTIO PLACENTA
spontaneous abortions
- 10-15% of all pregnancies end in a spontaneous abortion
- An abortion is the termination of a pregnancy before viability (20 weeks or 500 gm/16ozs)
- 80% occur before 12 weeks
- 50% are caused by severe congenital anomalies
early AB
prior to 12 wks
late AB
12-20 wks
other causes for AB’s
Immunologic factors (antibodies turn against fetus) Varicella infection / small pox Malnutrition Endocrine imbalances Chronic maternal diseases Trauma (rare) Incompetent cervix - opens up too early
abortion types
Recurrent Threatened Inevitable Missed Incomplete Complete
management with slight bleeding and no pain
Bed rest Eat light Avoid straining with bowel movement Possible mild sedative Save all pads, tissue and clots If no bleeding or infection continued pregnancy management
management with heavy bleeding
prognosis is poor for saving the pregnancy
Give Pit or Cytotec if needed and do D&C if indicated
recurrent -
loss of 3 or more
threatened -
jeopardized pregnancy
inevitable -
s/s gone so far that can’t stop
missed -
when fetus dies in utero and is not expelled, can cause infection to mother so give antibiotics
incomplete -
not all parts are expelled
complete -
all parts are expelled
incompetent cervical os -
(when cervix opens early)
- Cause of habitual 2nd trimester abortions- PASSIVE AND PAINLESS DILATION OF THE CERVIX
- Based on history of pregnancy loss at progressively earlier gestational ages, advanced dilation at early stage of pregnancy and prior cervical surgery
- ULTRASOUNDS DONE: SHORT CERVIX (<25MM) INDICTIVE OF INCOMPETENCE
cerclage -
- usually done at 14-18weeks with 80-90% success rate (Shirodkar Technique) Done at this time to avoid having to remove the suture for a first trimester AB
- It prevents dilation of the cervix by suturing the cervical os closed
- if any bleeding or uncomfortable at all notify immediately, bc could rupture if the cerclage isn’t cut
incompetent cervix after procedure
- Watch for ROM & contractions- possible uterine rupture
- If contractions occur, try to stop with tocolytic drugs or remove suture
ectopic pregnancy
(not in uterus)
- A common cause of bleeding in the first trimester, 2% of all pregnancies, highest in non-white women >35 yrs. old
- DEF: any gestation located outside the the uterine cavity- 95% in fallopian tubes
- 5% of abdominal pgs. reachviability
ectopic caused by
conditions that narrow the tube-STD’s, tubal damage w/surgery, IUD’s
-Transvaginal ultrasounds and more sensitive measurement of HCG have helped to detected before rupture occurs
ectopic before rupture
abd. pain, no menses, spotting (dk. red or brown) possible 6-8 wks after LMP
ectopic s/s with rupture
within 2-3 weeks of LMP: knifelike pain in one side, Abdominal tenderness, posterior fornix bulges w/ bimanual exam, may show signs of shock: >pulse & < B/P, or ecchymotic blueness around umbilicus (Cullen sign)
ectopic treatment
Medical:Methotrexate if rupture has not occurred
-give chem drugs to kill the rapidly multiplying cells
Surgical: a)Remove the tube with rupture or b)remove the products of conception and leave the tube to heal itself when there has not been a rupture
ectopic goals
repair, control bleeding and prevent shock
-If one ectopic likely to have another
hydatidiform mole
- Also called “ molar pregnancy”
- 1:1000 pgs, Increased w/ age and previous occurrence
- Benign proliferative growth of placenta trophoblast in which the chorionic villi develop abnormally and degenerate into grape like clusters of transparent vesicles that contain clear, viscid fluid
complete molar preg
occurs when only the sperm chromosomes multiply and there is no fetus present
partial molar preg
fetal tissue/membranes are present
molar preg symptoms
Nausea more severe, starts earlier and lasts longer ,Blood stained vaginal discharge (95%), Rapid uterine enlargement, Strongly positive pregnancy test, S/S of pregnancy induced
hypertension BEFORE 20 weeks
molar preg treatment
- Empty the uterus, spontaneous AB sometimes occurs or suction curettage is done—induction of labor contraindicated due the possible emboli formation of the of the trophoblastic tissue
- Make sure ALL tissue is removed- HCG levels for 1 year
- Treat with Methotrexate to prevent choriocarcinoma
placenta previa
- One of the two main causes of bleeding after the 20th week (abruptio is the other)
- 1:200 pregnancies
- DEF: abnormal implantation of the placenta involving the internal os and lower uterine segment
- Classified in relationship to where it is to cervical os- Marginal,Partial and Total
previa cause
unknown but predisposing factors include: previous c-section, Multipara, Smoking/Cocaine use, Rapid succession of pgs., older women (35-40), history of a S&C; previous previa
-In the past usually painless vaginal bleeding before assessment and diagnosis. Now with routine ultrasounds many times picked up early.
previa complications
spontaneous AB, PROM w/ perterm labor, malpresentations, postpartum hemorrhage, DVT, Infection
with previa no vaginal exam if**
woman reports vaginal bleeding
previa abdominal exam -
soft non-tender uterus, high presenting part with increased fundal height, malpresentations
with previa diagnosis ( and no active bleeding for 48 hours) Home Care
bed rest, assess vaginal discharge, count kicks, contraction assessment, no intercourse
previa expectant care (inpatient)
- Observation and Evaluation with fetus <36 weeks, normal FHR and bleeding has stopped and not in active labor
- Evaluate bleeding, Fetal status assessment, Labor contractions, Intermittent fetal monitoring (NST) At 36wks+ check for fetal lung maturity (L/S ratio)
- Greatest risk of fetal death is preterm delivery
previa active management (inpatient)
- beyond 36 weeks, bleeding excessive or persistent
- If labor starts, decide if vaginal delivery can be done-placenta lies more than 2cms from cervical os. Otherwise do c-section and proceed with delivery
abruptio placenta
The partial or complete premature separation of a normally implanted placenta
1 in every 75-226 pregnancies.
Severity of complications depends on the amount of bleeding and the size of the hematoma formation.
-Separation may be partial or complete
abruptio placenta causes
Hypertension, smoking, multipara, short umbilical cord, abd. Trauma (MVA’s or abuse), hx. of previous abruptio, cocaine use
overt hemorrhage - (abruptio)
vaginal bleeding , abd. pain, uterine contractions, uterine tenderness, high uterine resting tone
- 70-80% of all cases
concealed hemorrhage - (abruptio)
increase in fundal height, hard board like abdomen(COUVELAIRE UTERUS), high uterine resting tone, continuous abd. pain, early s/s of shock, late decelerations, decreased FHR variability,
Signs and Symptoms of Impending Hypovolemic Shock Caused by Blood Loss
- Increased pulse rate, falling blood pressure, increased respiratory rate
- Weak, diminished, or “thready” peripheral pulses
- Cool, moist skin, pallor, or cyanosis (late sign)
- Decreased urinary output (<30 ml/hr)
- Decreased hemoglobin, hematocrit levels
- Change in mental status
couvelaire uterus
Blood clot behind uterus has no place to go and the blood invades the myometrium tissue
Uterus becomes hard and boardlike
Can impede uterine contractions
couvelaire uterus can lead to
Disseminated Intravascular Coagulation (DIC) caused by large amts of thromboplastin being released in response to bleeding and clot formation. This causes depletions of clotting factors(fibrinogen, platelets) and uncontrolled bleeding can occur
abruptio management
- Management depends on degree of detachment , amount of blood loss, degree of coagulopathy present and how close to delivery.
- if mother and baby stable can watch and wait—if condition starts to worsen decide on vaginal verses c-section delivery
- Promote tissue oxygenation: Turn on side, limit maternal movements to decrease O2 tissue demand, give emotional support
