Preterm Labor and Bleeding Flashcards
What is the leading cause of mortality and morbidity in labor and birth for the newborn?
Preterm labor
Why are the rates of preterm labor and preterm birth increasing?
§ Assisted Reproductive Technology (ART)
§ Increasing role of infection in PTL / PTB
Most common indicator of preterm labor
Previous PTB
What are the causes of preterm labor?
§ Race
§ Age extremes (<17 or >35)
§ Smoking/Alcohol/Drugs
§ Infection/Inflammation/Toxicology
§ Stress (strenuous work, physical and emotional abuse)
§ Hypertensive disorder of pregnancy
§ Prenatal care, nutrition and oral health
§ Cervical abnormalities or surgery
§ Placental problems (previa, abruptio)
§ Uterine distention (multiples, polyhydramnios)
§ Previous PTB
What are the symptoms of preterm labor common to and why?
Normal labour but more subtle as fetus is smaller
5 Symptoms of Preterm Labor
- contractions: low abdominal pain, cramps backache, not recognized as contractions
- bleeding, spotting show, ROM
- increased amount or changes in vaginal discharge
- contractions every 10 min or more often
Fetal Fibronectin
Glycoprotein released into cervical/vaginal fluid in response to inflammation or separation of amniotic membranes
When is fetal fibronectin normal in secretions?
until 22 weeks gestation and again near the time of labour – after/inbetween that there should be none present unless client is actually in labour
Implication of negative ffn
pregnancy is likely to continue for at least another two weeks (95-98%); helpful in knowing if you can send patient home
Implication of positive ffn
present 24 through 34 weeks gestation indicates ↑ risk of preterm delivery
Is FFN a stronger positive or negative predictive value?
Negative
3 Points of Management of Preterm Labor
- Assess if labor should be stopped (rx, how far along, etc)
- Assess + monitor VS, contractions, fetus
- Avoid stimulation
What stimulation should be avoided in management of PTL?
- vaginal exams
- sexual intercourse
- nipple stimulation
- full bladder
What interventions are no longer recommended in the management of PTL?
- bedrest
- IV hydration
- Magnesium Sulfate
- Sedation
3 Drugs for medical management of PTL
- indomethacin
- nifedipine/CCB
- vaginal progesterone
MOA Indomethacin
Tocolytic: anti-prostaglandin inhibits uterine activity
What in indomethacin effective for and how long
tocolytic - effective in delaying delivery x 48 hours
Why is indomethacin not recommended for and why?
not recommended for long term - premature closure fetal ductus arteriosus
What is vaginal progesterone ONLY effective for?
May prevent and reduce incidence of PTB ONLY if prev. hx of PTB or short cervical length
Define cervical insufficiency
Premature painless dilatation of cervix without contractions
When is cervical insufficiency seen and why?
20-28 weeks because weight of fetus/placenta is such that cervix can’t stay close
What is the main cause of 2nd trimester abortion?
Cervical Insufficiency
3 Things that Increase Risk for Cervical Insufficiency
- anomalies of cervix
- infections
- multiple gestation, polyhydraminos (increased pressure
What cervical anomalies increase risk for cervical insufficiency?
- DES
- Previous 2nd trimester abortions
- Invasive cervical biopsy
Diagnosis of cervical insufficiency
- heaviness in pelvic area
- PPROM
- US for confirmation
Treatment of cervical insufficiency
- bedrest, pelvic rest, avoid heavy liftin
- cervical cerclage
Define cervical cerclage
treatment of cervical insufficiency
suturing the cervix shut
Risks of cervical cerclage
- infection blood loss
- PPROM
- Preterm labour
- damage to the cervix
When is cervical cerclage not appropriate?
if vaginal bleeding, infection, uterine contractions, membranes have ruptured
Who receives corticosteroids in pregnancy and when?
All pregnant clients between 24 and 34 weeks’ gestation, who are at risk of preterm delivery within 7 days should be considered candidates for antenatal treatment with a single course of corticosteroids.
A single course of corticosteroids antenatally reduces risk for what 3 things/what is overall effect?
- perinatal mortality
- respiratory distress syndrome,
- and intraventricular hemorrhage
- Matures fetus quicker
Corticosteroid Dosage Antenatally
Betamethasone 12 mg IM q 24 hr x 2 doses or Dexamethasone 6 mg IM q 12 hr x 4 doses
What drug is used for fetal neuroprotection antenatally?
MgSO4
How far along would a client be for MgSO4 be prescribed antenatally?
Imminent preterm birth at < 31 w 6
Along with imminent preterm birth, what 2 other factors could lead to a client to receive MgSO4 antenatally?
- Active labor with ≥ 4cm dilation with or without PROM
- Planned preterm birth for fetal or pregnant client indications
Dosage/administration of MgSO4 for fetal neuroprotection
4g IV loading dose over 30 mins then 1g/hour maintenance until delivery
Why is MgSO4 only given to infant up to 31 w 6
Effect is negligible about 32 weeks
Magnesium Sulfate is used for ________ birth
imminent
Bleeding in pregnancy is divided into
- First/second trimester (before 20-24 weeks)
- Antepartum (after 20-24 weeks)
3 Causes of bleeding in first and second trimester
- spontaneous abortion
- ectopic/tubal pregnancy
- gestational trophoblastic disease
Abortion is defined as
- Expulsion of fetus before 20 wks gestation
- OR
- Expulsion of fetus less than 500g
Treatment of spontaneous abortion with minimal bleeding
Bed rest and abstinence from sex
Treatment of spontaneous abortion with persistent/heavy bleeding, pain and fever
- misoprostol/cervidil to evacuate uterus
- winrho to prevent sensitization for future pregnancies
- IV therapy/blood transfusion
- Surgical dilation and curettage/suction evacuation
What is an ectopic/tubal pregnancy?
Implantation of fertilized ovum outside uterus
Initial symptoms of ectopic/tubal pregnancy
Similar to symptoms of pregnancy - positive hCG
Where is an ectopic/tubal pregnancy most common?
Can be anywhere; commonly in fallopian tube.
Symptoms/problem arises from ectopic/tubal pregnancy arise when
Tube/structure pregnancy was in ruptures
Result of rupture tubal/ectopic pregnancy
- sharp unilateral pain
- decreased BP
- syncope
Presentation of ruptured ectopic pregnancy
- referred shoulder pain/low abd pain r/t shifting of organs
- vaginal bleeding
- hypovolemic shock
What is gestational trophoblastic disease?
RARE (< 1/1000) pathologic tumor of childbearing age client, abnormal overdevelopment of the placenta overtaking pregnancy
In GTD, ________ cells that __________ the pregnancy
trophoblastic
obliterate
GTD can also be called __________ and develop into _________
hydatidiform mole (benign)
choriocarcinoma (rare)
What are the classic signs/classic presentation of GTD?
Pregnancy on steroids/exacerbated
- uterine enlargements greater than gestational age
- vaginal bleeding with clots
- hyperemesis gravidarum
- pre-eclampsia development prior to 24 weeks
What is antepartum hemorrhage?
Vaginal bleeding from 20 weeks to delivery
Antepartum hemorrhage is by and large caused by
Placental alterations
2 main causes of antepartum hemorrhage
- placenta previa
- abruptio placentae
Uteroplacental blood flow is __________ ; if issues with _________ that blood can drain into __________
700-1000ml/min
placenta
uterus and be lost
_______________ may be the first indication of compensation by pregnant client secondary to hemorrhage.. ______ issue before ________
A change in fetal status
fetal, maternal
Define placenta previa
Absolutely normal placenta implanting in the wrong place
4 Categories of Placenta Previa
o Total/Complete: completely (highest risk)
o Partial: partial coverage
o Marginal: touching opening
o Low-lying placenta: not covering (lowest risk)
Result of placenta previa
All will result in c-section except low lying
Detection of placenta previa
Can be detected at routine ultrasound
or at Ultrasound at time of presentation with bleeding to r/o previa as cause
What percent of placentas migrate during pregnancy
80%
Goal of gestation for placenta previa and why
Goal is to get to 36-37 weeks gestation
Not 40 to avoid contractions, labor, dilation because separation could occur and risk of bleeding increases
5 Risk Factors of Placenta Previa
- previous placenta previa (why did it go to that location in first place)
- uterine abnormalites/endometrial scarring
- impeded endometrial vascularization
- large placental mass
- unknown
Define abruptio placentae
Premature separation of normally implanted placenta from uterine wall
What cause of antepartum hemorrhage is more common
abruptio placentae
What occurs regarding blood flow in abruptio placentae?
Blood flow that should be going into placenta/fetus goes into uterus
Total/Complete Abruptio Placentae Result
- Hemorrhage (1000mls/min) in pregnant client
- fetal death
In partial abruptio placenta, fetus can tolerate:
up to 30 - 50% abruption
True or false: patient will always present with vaginal bleeding in abruptio placenta
False; will not always be present in partial
Risk factors for Abruptio Placentae
- Previous abruption
- Hypertension in pregnancy
- Blunt abdominal trauma – MVA, IPV, falls
- Overdistended uterus (multiples, polyhydramnios)
- PPROM < 34 wks gestation
- Previous C/section - scarring
- Cocaine or crack use, alcohol use
- Smoking, especially > 1 pack / day
- Extremely short umbilical cord: As fetus grows, can pull placenta off wall
- Uterine abnormalities – fibroids at implantation site
- Advanced age in pregnancy (>35) or high parity
Implications of abruptio placenta for pregnant client
§ Antepartum/intrapartum hemorrhage
§ Postpartum hemorrhage
§ DIC – imbalance in clotting factors
§ Hemorrhagic shock
Implications of abruptio placenta for fetal/neonatal client
§ Sequelae of prematurity
§ Hypoxia
§ Anemia
§ Brain damage
§ Fetal demise
Onset of placenta previa vs abruptio placentae
P: insidious
A: sudden
Type of bleeding of placenta previa vs abruptio placentae
P: always visible, slight, then more profuse
A: can be concealed or visible
Blood description of placenta previa vs abruptio placentae
P: bright red
A: dark
Discomfort pain of placenta previa vs abruptio placentae
P: none
A: constant; uterine tenderness on palpation
Uterine Tone of placenta previa vs abruptio placentae
P: soft and relaxed
A: firm to rigid
Fetal heart of of placenta previa vs abruptio placentae
P: usually normal
A: fetal distress/absent
Fetal presentation of placenta previa vs abruptio placentae
P: may be breech/transverse/engagement is absent
A: no relationship
3 Issues of Abnormal Placentation/Overimplantation
- Placenta Accreta
- Placenta Increta
- Placenta Percreta
Placenta Accreta
placenta attaches itself too deeply into the surface of the myometrium
Placenta Increta
penetrates into the myometrium
Placenta Percreta
WORST form- placenta through myometrium and into tissue or organs and onto outside of uterus
Immediate Care for AP Bleeding
§ As able, a complete history and physical
§ Assess pregnant client cardiovascular status frequently. Include O2 saturation, output, LOC – similar to hemorrhaging patient of any kind
§ Fluid resuscitation if active bleeding or unstable
§ Monitor fetus and uterine activity electronically
Nursing care for AP bleeding
§ Prepare equipment for examination
* Vaginal exams not done on anyone with bleeding – do not want to stimulate, rupture previa, etx
§ Oxygen per mask/prongs
§ Assess coping mechanisms of woman and family, support
§ Review and evaluate diagnostic tests
* Hgb, PT/PTT, Type and Cross match, Watch for DIC
§ Prepare for cesarean, as needed
§ Neonatal resuscitation team, as needed
§ Pain relief, as needed
§ Similar care for both placenta previa and abruptio
* Bed rest, may need hospitalization
* Avoid sexual activity
§ No vaginal exams!
* Why?
§ Objectively and subjectively assess ongoing
* blood loss, pain, uterine contractility, coping
Velamentous Insertion of Cord
an abnormal cord insertion (CI) in which the umbilical vessels diverge as they traverse between the amnion and chorion before reaching the placenta. It is characterized by membranous umbilical vessels at the placental insertion site; the remainder of the cord is usually normal. Because of the lack of protection from Wharton’s jelly, these vessels are prone to compression and rupture
Risk in Velamentous Insertion of Cord
- Risk of torn vessel leads to fetal hemorrhage
- leads to non-reassuring fetal status and high mortality
What is vasa previa
cord and membranes over opening/os
