Hemorrhage Disorders Flashcards
What is a miscarriage?
Considered a spontaneous abortion from natural causes
What is a major symptom of miscarriage?
Early bleeding in first trimester BUT this doesn’t mean an automatic miscarriage yet. Need to go to doctor to check
Legal documentation for miscarriage/spontaneous abortion?
Less than 20 weeks.
If you’re not sure how old the fetus is, then if it is less than 500 grams
Induced miscarriage
Intentional termination of pregnancy
When do majority of miscarriages happen?
Before 12 weeks gestation. Some moms may not even realize they were pregnant to begin with.
Etiology of Miscarriages
Chromosomal abnormalities Teratogenic drugs Faulty implantation Weak cervix Placental abnormalities Chronic maternal disease like diabetes Smoking Alcohol abuse Advanced maternal age
Explain why chromosomal abnormalities may cause miscarriage
A fetus’s chromosomes may not be compatible for life
Explain why teratogenic drugs can cause miscarriage
Teratogenic means the drug is able to cross the placenta. And if it can cross, it affects the fetus wellbeing and can cause miscarriage.
Explain why faulty implantation can cause miscarraige
A faulty implantation means the egg and sperm implanted in the uterus where they couldn’t survive well enough to develop.
Explain how a weakened cervix can cause miscarriage
Weakened or incompetent cervix means the cervix opens too early on in PG despite the baby not being ready for life. If the cervix opens, the uterus contents could be expelled too early and cause miscarriage.
Explain how placental abnormalities could cause a miscarriage
Anything regulated to the placenta being abnormal can harm the fetus’s development. The placenta is the life-line to mom.
Explain or list chronic maternal diseases that can cause miscarriage
Diabetes or Hypertension are some to name a few
Explain how smoking or alcohol abuse can cause miscarriage
Each of these impacts mom and fetus in a negative way.
Smoking leads to decreased oxygenation.
Alcohol abuse can affect the baby’s viability in the womb
Explain how advanced age can cause miscarriage
If over the age of 40, they are twice as likely to have a miscarriage than a 20 yr old
Threatened abortion
Cervix is closed but there is bleeding, cramping, and backache
Imminent or inevitable abortion
Cervix is dilating/opening and it is just a matter time of miscarriage.
Increased bleeding and cramping
Incomplete abortion
Fetus is expelled but the placenta is left behind
Heavier bleeding
Mom may need to go back for surgery to remove the placenta
Complete abortion
Both the fetus and placenta have expelled as it is supposed to leaving the uterus empty and able to close. Bleeding is dim.
Missed abortion
What are common signs of missed abortion?
What risks happen if mom retains it or it is left in her?
When the fetus dies but it remains in the womb.
Mom may notice her PG symptoms going away. Breasts loose engorgement, no n/v.
1) DIC bleeding due to composing tissue releasing toxins that ruin clotting ability
2) Sepsis due to necrosing tissue harvesting bacteria
Recurrent pregnancy loss
Why might this happen?
Losing 2 consecutive miscarriages
Hormones or Structural abnormality (fibroids, faulty cervix) going on here
Septic abortion
What is this associated with?
What is indicated here for diagnosis?
Miscarriage from infection
Can be associated with IUD or SROM not being septic
A aseptic back-alley abortion
Culture and sensitivity
Threatened abortion Assessment:
What will they do first?
What can aid in evaluation?
Additional labs they may do to rule things out?
Diagnostic testing done to see if baby is till alive?
Threatened abortion: possible abortion on the way. Spotting and pain
First, look at her cervix.
HCG qualitative and quantitative
CBC to evaluate sepsis and anemia possibility
Ultrasound bc it can check baby heart
Threatened abortion post assessment if baby is still viable:
Instruct her to do what?
What meds?
What are we hoping for?
If baby is still alive:
Tell her bed rest short term but it is to help her emotions bc there’s probably not a way to prevent it .
Vagina rest as well. NOTHING GOES IN LOL
Benadryl for rest
Tylenol for discomfort
Stop spotting and cramping over next days
Incomplete Abortion
Procedure?
Meds to aid (or replace) procedure?
What if mom is at risk for hemorrhage tho and they do main procedure?
Infection risks?
Incomplete: when the baby dies but the placenta is left behind
D&C procedure to remove the placenta
Meds like prostaglandins (cytotec) can help to empty uterus if mom is at risk for hemorrhage
Give her oxytocin drugs to help uterus clamp or txa
With procedure mom may be at risk for infection . Give antibiotics
Incomplete abortion
What can they give mom to avoid hemorrhage?
What meds given for infection risk?
Oxytocin drugs for prevention
TXA
Oxytocin Methergine Hemabate
antibiotics
Review:
Type of abortion where you’ll have to have a D&C
or be put on prostaglins
Incomplete abortion
If mom has a D&C for a ____ abortion, and she is RH- what might she need ?
For an incomplete abortion you’ll need the D&C.
And if she is rh- she will need an RHimmune globulin no less than 72 hours later.
Your PG mother reports that she thinks she may have passed a clot in the toilet. What should you as a nurse do?
Your PG mother is actively bleeding. What 3 things should you do for mom? What to do for baby?
Start IV fluids, monitor for shock, administer O2
For baby monitor FHR
What do you need to do after a period of active bleeding if mom is RH-?
Get mom an Rh immune globulin if she is RH- before dismissal
How do women cope with miscarriages?
Older women or women who have been trying to get PG may take it hard
Adolescents or women who didn’t even know or want a pG will be ok.
But regardless, help them cope. Bc they need to resolve the grief before becoming PG again .
Foods that mom should eat after going through a miscarriage?
Education?
Iron rich diet and supplement for possible anemia
We want them to wait till they get pregnant 4-6 months if they can
What does cervical insufficiency mean?
(which trimester?)
What does this feel like to mom?
Painless dilation and effacement of the cervix without contractions in 2nd trimester. And so you don’t even know it is going on.
Again painless but women may feel a heaviness in lower abdomen
Cervical insufficiency causes that are genetic?
Grandma having DES (Dyethial Semestral Exposure) which affects their offspring who is now the mom and patient in question
Collagen disorders
Uterine abnormalities
- ex: membranes with heart uterus, bicords
Cervical insufficiency causes that are acquired?
Inflammation, infection, trauma
trauma: cone or leep procedures , therapeutic abortions
Shape of membranes upon inspection with cervical insufficiency?
Size of cervix in cervical insufficiency?
complaint?
discharge amount?
Hour glass - it bulks through cervix
Internal os has a funneling affect on sonogram
less than 25 mm
“something feels different”
discharge amount is increased
Common health history of cervical insuffiency?
2nd trimester losses Previous preterm births Short labors Des exposure Tab Multipele gestations
How will they assess to see if the cervix is shortening in cervical insuffiency?
Type of activity tolerance prescribed?
Serial sonograms or done multiple times during the 14-28 week mark
Bed rest
With cervical insufficiency, how will they keep the uterus quiet and therefore avoid miscarraige?
Progesterone supplementation or hydroxyprogesterone 16-36 weeks
What surgical procedure can they do for cervical insufficiency?
What is needed pre-procedure though?
Is elective or emergent more successful?
What is post op cerclage procedure like?
How does mom give birth if her cervix is sutured shut?
Cerclage procedure or when they suture the cervix closed
Antibiotics, anti-inflammatory drugs, tocolytic
Elective cerclage are more successful
Post op will be just staying in recovery for a couple hours. but after that she can go home
They’ll just clip the cerclage suture beforehand
What product or tool can be used to help with cervical insufficiency?
Pessaries or ring that is inserted into vagina to distribute weight of uterus away from the cervix
When can pessaries begin being used?
What do pessaries reduce the need of?
Mid pregnancy
Reduce need of tocolytic meds and need to go to nicu later on when baby is born
Medication that can help with cervical insuffiency?
Progesterone therapy that can be used to relax the uterus
How do they decide the route of progesterone therapy for cervical insufficiency? What routes are available?
Depends on moms compliance
Oral -daily
Vaginally - daily
IM - weekly
Education for cerclage?
Instruct mom that she needs to go to hospital immediately if she has signs of labor approaching bc her suture needs clipped
What is an ectopic pregnancy?
Pregnancy where the implantation site was outside the normal zone of the uterine decidual lining
- we want the back or side wall up high.
- NOT the anterior or low areas
What is the most common type of ectopic pregnancy?
How is this dangerous?
How can this be tricky to diagnose?
Tubal or in ampulla
- it can be a lot of places but this is the usual
The embryo will grow in the ampulla tube but when it is too big, the ampulla tube gets ruptured. So you want to dx before this happens!!
Can be tricky bc you can have referred pain going in tubal pregnancy. The cramps will be collachy but you could have it on the opposite side of your abdomen. .
What is an abdominal ectopic pregnancy?
It is just when there is a pregnancy implantation in the abdominal cavity - and yes a woman has survived this.
What type of BC method puts you at higher risk for ectopic pregnancy?
What type of meds?
IUD
Ovulation inducing drugs rt fertility drugs
High levels of what hormone can increase ectopic pregnancy risk?
Progesterone being high
What type of infection can cause the ectopic pregnancy?
Hx of tubal infections
What type of previous surgeries can cause ectopic pregnancy?
Pelvic or tubal surgery
What kinds of conditions can increase ectopic pregnancy risks?
Endometriosis
Congenital anomalies of fallopian tubes
What age group is at more risk of ectopic pregnancy?
Older or advanced maternal age
What type of unhealthy habit can give you increased risk of ectopic pregnancy?
Smoking :(
T/F
A ruptured appendix can increase risk of ectopic pregnancy
True.
Remember, Ectopic PG can really happen anywhere. And a ruptured appendix is a trauma that leaves behind scarring.
What may mom say her ectopic pregnancy feels like?
Other symptoms?
Dull pain in her lower abdominal quadrant that is colicky pain
positive pregnancy test and delayed menses
What labs can they do for ectopic pregnancy?
HCG qualitative + and low levels in quantitative
Serum progesterone levels
Mom has a positive pregnancy test but she is having pain in her lower abdomen that is colicky in nature. What do you anticipate?
Anticipate an ectopic pregnancy.
They may do hcg which will come back positive but low in number.
Progesterone labs will be less than 5 if ectopic.
Also do an ultrasound but her uterus will be empty.
If you do have an ectopic pregnancy, what will radiologists call it?
Mass w adnexal tenderness
What diagnostic test will they do for ectopic pregnancy?
Ultrasound )but it will be empty)
Mom says she is having shoulder pain and she is dizzy. You saw that radiologist gave the clue she has a mass w adnexal tenderness in her tubes. She says she remembers feeling some pain but didn’t think anything of it.
What do you anticipate?
Mom has ruptured already and she is now in shock. And she could die from this now.
You notice there is blueness around the umbilicus. What is this called and why does this happen?
Happens with ectopic pregnancies and is called the Cullen sign. It is from blood in the abdominal cavity
When diagnosing ectopic pregnancies, what will they want to rule out as well?
Miscarriage UTI Ruptured cyst Salpingitis Appendicitis Ovary torsion
When will they use Methotrexate to treat ectopic pregnancy?
What does methotrexate do?
What does it require tho?
Is the catholic church ok with this?
How do they make sure it the Methotrexate killed the embryo?
Only use if the diagnosis of ectopic pregnancy was early
Methotextrate is a folic acid antagonist so it inhibits proliferation of rapidly dividing cells in order to kill the embryo
Requires mom to be stable though
Catholic church is ok with Methotrexate
To make sure the Methotrexate worked, they will monitor hcg levels to make sure it drops to undetectable levels. But this can take 2-8 weeks.
Surgical options for ectopic treatment ?
Risks with surgical options?
Salingostomy where they open the tube and take it out
Salpingectomy where they take the whole tube out and leave it out
Both of these treatment options have hemorrhage risks.
- treat with IV fluids and blood
After Salingostomy or Salpingectomy, how soon do they recommend you are allowed to get pregnant again?
And what do they need to do before getting pregnant again?
Three months and until hen, you’ll be on some reliable form of BC
Contact HCP for early sonogram to rule out ectopic pregnancy just to make sure
What is GTD or gestational trophoblastic disease?
(From what cells?)
Key components of a GTD molar pregnancy?
It is a Molar pregnancy meaning you have conceived but it is really only a placental tumor that was implanted and forms grape clusters of chorionic villi from trophoblast cells (hydatiform mole)
From trophoblast cells that are fluid filled vesicles or clusters
Positive pregnancy test, enlarged uterus , but no baby
Groups at high risk of getting GTD molar pregnancy?
What does GTD molar pregnancy look likeon sonogram?
Nonwhites
Vesicle of snowstorm
What is it called when a GTD molar pregnancy becomes cancerous?
Describe it
Where can it metastasize?
Choriocarcinoma
Malignant and invasive
Metastasize to lung and brain
Diagnostic tests done for Choriocarcinoma (molar PG)?
What will treatment be of?
(cancer from GTD molar PG or grape cluster implantation)
Chest x ray for lung traveling
CT for traveling to brain
Chemotherapy Methotrexate
For an older woman with Choriocarcinoma (molar Pg) what might they just go ahead and do?
Hysterectomy just take her uterus
What type of bleeding will you see in GTD molar pregnancy?
What disorder might you see develop too?
Dark prune juice vaginal bleeding
Anemia can develop
What can be passed in a GTD molar pregnancy?
What size will the uterus be in GTD molar pregnancy?
The grape cluster vesicles
The uterus will be large since the woman’s body really thought it was pregnant . instead of baby there will be proliferation of trophoblast cells
What will cause the cramping in GTD molar pregnancy?
Pain and cramps from uterine distention
If you are using the fetal doppler on a mom with GTD molar pregnancy , what will fhr sound like?
The fetal heart rate won’t be there…
because there’s no actual fetus. Just a clump of cells.
What will Hcg levels be like in GTD molar pregnancy that has no fetus?
Hcg levels will be elevated still due to the trophblast cells being able to secrete the hormone however the moms’ alpha fetal protein will be low
(so she might be vomiting more)
Can you explain why mom with a GTD molar pregnancy has hyperemesis going on?
She is vomiting due to her elevated hcg levels
What category of hypertension could mom with a GTD molar pregnancy develop? And when?
Pre-eclampsia symptoms at less than 24 weeks
What can a GTD molar pregnant mom develop due to the molar tissues?
Hyperthyroidism (tachycardia and hot)
What is a good indicator of a GTD molar pregnancy?
Lack of fhr in the womb on sonogram
Methods to empty the uterus for a GTD molar pregnancy?
D&C
Hysterectomy for older ladies
T/F
Induction of labor with oxytocin is a good option for treatment of GTF molar pregnancy
False. Avoid induction of labor with GTD molar pregnancy bc it can cause a pulmonary emboli!!
With Choriocarcinoma, how long does mom have to wait before becoming pregnant again?
How long will her hcg levels need to be monitored?
1 year and so she will be on BC
1 year hcg testing
GTD molar pregnancy education?
Follow up is very important especially with Choriocarcinoma.
Help her find emotional support
If mom is rh- after a D&C for GTD molar pregnancy, what must you give?
Rh immunoglobulin
Placenta previa
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