Class 3: Antepartum Bleeding Flashcards
bleeding in pregnancy is considered?
- a medical emergency
50% of bleeding in the 3rd trimester is (2)
- placenta previa
- or placental abruption
maternal blood loss leads to…
- decreased O2 carrying capacity
decreased O2 carrying capacity can lead to what maternal risks (6)
- hypovolemia
- anemia
- infection
- preterm labour
- preterm birth
- exsanguination
decreased O2 carrying can lead to which fetal risks? (7)
- blood loss
- anemia
- hypoxemia
- hypoxia
- anoxia (extreme form of hypoxia)
- preterm birth
- still birth
why is exsanguination a risk with pregnancy bleeding?
- approx 750-1000 ml/min (15% of cardiac output) of blood flow to the uterine vasculature and placenta = diruption of vascular integrity has a potential for maternal exsanguination within 8-10 min
pregnant persons who are rh negative may receive ______ in which scenarios where antepartum bleeding is involved (3)
- may receive anti-D (Rh immune globulin WinRho)
scenarios:
- when worried about maternal & fetal blood mixing
- miscarriage/threatened abortion/induced abortion/ectopic pregnancy
- if fetal to maternal hemorrhage occurs/suspected fetal blood is Rh positive (placental abruption, placental previa)
what is included in early pregnancy bleeding (3)?
- miscarriage/spontaneous abortion
- premature dilation of the cervix
- ectopic pregnancy
define: miscarriage/spontaneous abortion
- a pregnancy that ends without medical or surgical intervention prior to 20 weeks of gestation or 500g fetal weight is defined as a miscarriage or spontaneous abortion
what is a threatened pregnancy loss
- vaginal bleeding that occurs during the first 20 weeks of pregnancy
- does not necessarily mean your pregnancy will end in a miscarriage
what are clinical manifestations of a threatened pregnancy loss (4)
- mild spotting
- mild cramping
- closed cervical os
- may progress to actual miscarriage
what is an inevitable miscarriage (2)
- refers to unexplained vaginal bleeding and abdominal pain during early pregnancy
- unlike threatened miscarriage, an inevitable miscarriage is also accompanied by dilation of the cervical canal. The open cervix is a sign that the body is in the process of miscarrying the pregnancy.
what are clinical manifestations of inevitable miscarriage? (4)
- moderate bleeding
- mild to severe cramping
- dilated cervix (will happen/inevitable)
- no passage of tissue
what is an incomplete miscarriage
- some—but not all—of the pregnancy tissue is passed.
what are clinical manifestations of an incomplete miscarriage (4)
- heavy bleeding
- severe cramping
- open cervical os
- tissue passage, likely in cervix
what is a complete spontaneous abortion
- refers to a miscarriage in which all of the pregnancy tissue is expelled from the uterus
what are signs of a complete spontaneous abortion (4)
- all fetal tissue is passed
- cervix is closed
- possible slight bleeding
- mild cramping
what is a missed abortion
- occurs when a fetus implants, but fails to develop.
what are signs of a missed abortion (3)
- products of conception are retained in utero for up to several weeks
- potentially no bleeding or cramping
- cervical os remains closed
management of a miscarriage depends on…
- type and symptoms
ex. infection? bleeding? retained products?
what is involved in assessment of miscarriages ? (6)
- US (rule out ectopic pregnancy)**
- VS & FHR (is there a FHR??)
- vaginal discharge and bleeding
- uterine activity (cramps)
- pain assessment
- lab tests
what lab tests are involved in assessment of miscarriages (2)
- check serum hCG x2 over 48 hrs
- other tests depend on symptoms and history (ex. CBC)
what nursing care is involved in management of miscarriages (6)
- support
- education
- prep for medical and surgical procedures
- admin of analgesia and other meds as ordered
- blood admin as ordered
- discharge teaching
medical and/or surgical management of a misscarriage depends on…
- the overall clinical picture and the type of spontaneous abortion
inevitable abortion with fever or bleeding will require…
- prompt emptying of the uterus, usually by dilatation and curettage
what is premature dilation of the cervix
- passive and painless dilation of the cervical os without labor or contraction of the uterus
premature dilation of the cervix can result in.. (2)
- preterm birth
- miscarriage
whats included in mngmt of premature dilation of the cervix (2)
- restrict activity
- cerclage (thread to singe cervix shut & remove at 35-38 weeks gestation)
what is an ectopic pregnancy
- involves the implantation of the fertilized ovum outside of the uterine cavity
- condition where fertilized egg attaches outside the uterus
where else can the fertilized ovum implant in an ectopic pregnancy (3)
- fallopian tubes (usually)
- abdomen
- cervix
what are the 3 classic symptoms of an ectopic pregnancy
- abdominal pain
- delayed menses
- abnormal vaginal bleeding
what can ectopic pregnancy lead to
- rupture of the fallopian tube = hemorrhage
if rupture has occured with an ectopic pregnancy, what symptoms might be experiences? (2)
- referred shoulder pain
- one-sided or deep lower quadrant acute abdominal pain
what are causes of late pregnancy bleeding? (3)
- placenta previa
- placental abruption
- variations in cord insertion
what is placenta previa
- the placenta completely or partially covers the opening of the uterus
- the placenta is implanted in lower uterine segment near or over the internal cervical os
classification of placenta previa is based on…
degree that internal cervical os is covered by the placenta
what are 3 types of placenta previa
- complete placenta previa
- marginal placenta previa
- low-lying placents
what is complete placenta previa
- placenta completely covers the internal cervical os
what is marginal placenta previa
- edge of the placenta is 2.5 cm or closer to the internal cervical os
what is low-lying placenta (3)
- placenta has formed low in the uterus
- no overlap is seen
- exact relationship undetermined
what are risk factors for placenta previa (8)
- previous placenta previa
- previous c-section
- suction curettage for miscarriage or induced abortion
- multiparity
- maternal age over 35 years old
- ethnincity
- smoking
- living at higher altitude
what is the main clinical manifestation of placenta previa
- painless bright red vaginal bleeding in the 2nd and 3rd trimesters
- bleeding can recur at any time
on examination, what signs are seen with placenta previa (4)
- uterus is soft, relaxed, and non-tender w normal tone
- fetal presenting part is high (placenta takes up signif space in lower segment)
- fetal malpresentation may occur
- fundal height may be greater than expected as placenta occupies the lower segment of fundus
when placenta previa typically diagnosed
- during routine prenatal US
what is a major concern w placenta previa
- hemorrhage –> hypovolemic shock
why is hypovolemic shock a concern w placenta previas
- due to compensatory mechanisms of pregnancy, up to 40% of blood volume can be lost without showing signs of shock = VS may remain normal
what is an additional potential complication of placenta previa
- abnormal placental attachment –> may require hysterectomy
what are fetal risks of placenta previa (5)
- preterm births
- still birth
- malpresentation –> oblique lie, breech, transverse
- fetal anemia
- IUGR
what is included in management of placenta previa (7)
-NO pelvis/vaginal exam (don’t want any damage to placenta)
- education on when to come to hospital
- limit activity
- US for ongoing monitoring of placenta (every 2 weeks)
- c-section will be scheduled
- blood work
- emotional support
in a marginal placenta previa with minimal bleeding, what may be attempted?
- vaginal birth
if a bleeding episode occurs with placenta previa, mngmt depends on? what does it require?
- depends on gestational age
- amount of blood loss/active bleeding
- requires admission to labour and birth unit w c-section capabilities and NICU
if a pregnant person has placenta previa, is <36 weeks of gestation AND NOT in labour AND bleeding is mild or stopped, what kind of mngmt is done and where?
- expectant mngmt = reduced activity/close observation
- may be admitted to hospital, home w antenatal homecare program, depending on stability –> allows fetus time to mature
what is included in mngmt of placenta previa if the pt is <36 weeks of gestation, not in labour, and bleeding is mild or stopped (9)
- frequent repeat US
- fetal surveilance (NST, BPP) 1-2x/week
- regular lab values (hgb, hct, coagulation values)
- antepartum steroids to promote lung maturity if between 24+0 and 34+6 weeks gestation, when delivery is expected within 7 days
- assessment of bleeding (1g = 1ml)
- large bore IV 18G
- NO vaginal exams/pelvix rest (nothing in the vagina)
- Rh immune globulin (if Rh negative and delivery not indicated)
- c-section scheduled once reaches 37 weeks gestation and fetal lung maturity is achieved
if a pt has placenta previa, is >36 weeks of gestation OR bleeding is excessive/persistent OR active labor occurs OR other obstetrical complications (ex. infection), what kind of mngmt is done?
- active mngmt and c-section birth is indicated
what is included in mngmt of placenta previa in a pt who is >36 weeks of gestation OR bleeding is excessive/persistent OR active labor occurs OR other obstetrical complications (ex. infection) (8)
- continuous fetal monitoring until surgery
- freq assessment of maternal VS
- large bore IV, 18 G, fluid replacement as ordered (may require 2 IVs)
- monitor urine output
- monitor bleeding
- blood product admin as ordered
- neonatal time at delivery
what risk is associated w placenta previa
- risk for postpartum hemorrhage
what is placental abruption
- detachment of part or all of the placenta from ist implantation site
- after 20 weeks gestation and before the birth of the baby
what impact does placental abruption have on perfusion to the fetus
- not attached = decreased perfusion and gas exchange to fetus
what are risk factors for placental abruption (7)
- HTN disorders of pregnancy
- cocaine use
- blunt external abdominal trauma (ex. MVA, maternal battering)
- smoking
- previous history
- preterm premature rupture of membranes
- thrombophilia
placental abruption should be suspected in pregnant people with..
- sudden onset of intense, usually localized, uterine pain, with or without vaginal bleeding
what are clinical manifestations of placental abruption (7)
- dark, nonclotting vaginal bleeding
- abdominal or low back pain
- uterine contractions or hypertonic uterus (to try to control bleeding)
- uterine tenderness
- “port wine” stained amniotic fluid if ROM has occurred
- FHR tracing –> abnormal patterns (loss of variability, late decelerations)
- fetal death
placental abruption symptoms depends on
- degree of speration
what is included in assessment of placental abruption (3)
- physical exam
- lab studies
- FHR pattern (decreased variability, decelerations, abnormal tracing)
what lab studies are assessed for placental abruption (3)
- hgb and hct will be decreased
- abnormal clotting studies
- US (rule out placenta previa, not always diagnosed by US, negative findings on US do not rule out abruption)
what maternal complications can occur w placental abruption (8)
- hemorrhage
- hypovolemic shock
- couvelaire uterus
- infection
- DIC (more likely w mod or severe separation)
- hypofibrinogenemia
- thrombocytopenia
- organ damage
what is a Couvelair Uterus
- collection of blood between placenta and wall of uterus = purplish color
what fetal complications can occur w placental abruption (6)
- IUGR
- preterm birth
- fetal hypoxia
- neuro defects
- cerebral palsy
- fetal or newborn death
what does mngmt of placental abruption depend on
- severity and overall fetal and maternal status `
if placental abruption if mild AND less than 36 weeks gestation AND stable with NO fetal distress, placental abruption involves: (14)
- admit to hospital
- monitor for signs of bleeding
- monitor FHR & continuous fetal monitoring
- NST/BPP
- allow for gains in fetal maturity
- large bore IV, 18 G (maybe 2)
- frequent VS –> monitor for trends (ex. increasing HR)
- repeat BW as ordered (hgb, hct, clotting studies)
- fluid replacement as ordered
- blood admin as ordered
- monitor urine output (should maintain 30ml/h) –> may require foley
- if condition deteriorates to either person, immediate birth
- emotional support
- prep for birth
what can promote fetal lung maturity to allow for gains in fetal maturity in mngmt of placental abruption
- antepartum steroids to promote fetal lung maturity if between 24+0 and 34+6 weeks gestation when delivery is expected within 7 days
when may vaginal birth be attempted w placental abruption (2)
- if pregnant person is hemodynamically stable
- AND fetus is alive and in no acute distress OR fetus is dead
a c-section should be performed w placental abruption if… (5)
- fetal compromise
- severe hemorrhage
- coagulopathy
- poor labour progress
- increasing uterine resting tone
a c-section shoudl not be performed w placental abruption if…
- coagulopathy is severe and uncorrected
