OB 7 Handout Bleeding Conditions of Pregnancy

8/10/2019 OB 7 Handout Bleeding Conditions of Pregnancy

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4Bleeding Conditions of Pregnancy

First Trimester Bleeding (a) ABORTION(b) ECTOPIC PREGNANCY

I. Bleeding Occurs anytimenever normal, no matter how slight Frigthening experience

Need to be assessed Threatens both mother & fetus Client needs reassuranceit is not because of what she did to free her from guilt

SIGNS & SYMPTOMS OF HEMORRHAGIC SHOCK

ASSESSEMENT SIGNIFICANCE

Increase pulse rate Heart attempting to circulate decreased bloodvolume

Decreased blood pressure Less peripheral resistance because of decreaseblood volume

Increased respiratory rate Increased gas exchange to better oxygenate

decreased RBC volume

Cold, clammy skin Vasoconstriction occurs to maintain blood volumein central body core

Decreased urine output Inadequate blood is entering kidney due todecreased blood vol.

Dizziness or decreased level of consciousness Inadequate blood is reaching cerebrum due todecreased blood volume.

Decreased central venous pressure Decreased blood is returning to heart due toreduced blood volume.

The process of shock due to blood loss (Hypovolemia)- Blood Loss

- Decreased intra-vascular volume

-

Decreased venous return/ cardiac output,& lowered BP- Body compensating by increasing HR to circulate the dec.vol. faster; vasoconstriction ofpreipheral vessels (to save blood for vital organs). Increased RR & feeling of apprehension atbody changes also occur.

- Cold clammy skin, dec.uterine perf. In the face of continued bld.loss, although the body shiftsfluid from interstitial to intra-vascular spaces, bld.pressure continue to fall.

- Reduced renal, uterine, & brain perfusion- Lethargy, coma, decreased renal output- Renal failure- Maternal and Fetal Death

Emergency Interventions for Bleeding in Pregnancy

INTERVENTION RATIONALEAlert health care team of emergency situation. Provides maximum coordination of care.

Place woman flat in bed on her side. Maintains optimal placental and renal function.

Begin IVF such as LR with a 16 or 18 gauge needle. Replaces intravascular fluid vol.; Prepare IV line for

blood replacement.

Administer O2 as necessary @ 6-10L/min by face

mask.

Provides adequate fetal oxygenation despite

lowered maternal circulating blood.

Monitor uterine contractions & FHR by external

monitor.

Assess whether labor is present and fetal status;

external system avoids cervical trauma.

Omit vaginal examination. Prevents tearing of placenta if placenta previa is

cause of bleeding.

Withhold oral fluid. Anticipate need for emergency surgery.Order type & cross match of 2 units whole blood. Allows for restoring circulating maternal blood

volume if needed.

Assess VS (pulse, respi and BP ever 15 mins. Provides baseline data on maternal response to

blood loss.

Assist with placement of CVP or pulmonary artery

cath and blood determinations.

Provides more accurate data on maternal

hemodynamic state.

Measure maternal blood loss by weighing perineal Provides objective evidence of amount of


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pads; save any tissue passed. bleeding. Saturating a sanitary pad in less than 1 hr

is heavy blood loss; tissue may be abnormal

trophoblast tissue.

Set aside 5 ml of blood drawn intravenously in a

clean test tube; Observe in 5 min for clot

formation.

Test for possible blood coagulation problem.

Maintain a positive attitude about fetal outcome. Supplies information on placental and fetal well-

being.

Support womans self-esteem; provide emotional

support to woman and her support person.

Assist problem solving, which is lessened by poor

self-esteem.

ABORTION- loss of fetus before age of viability prepare for complete abortion (D&C)

> IV line - fluid replacement, oxytocin administrationd. Complete- occurs when all products of conception are expelled from the uterus.

- ( - ) pregnacy test & symptoms no longers present- Mgt: bedrest & watch for bleeding, pain & fever.e. Missed- Fetus dies in utero before 20 weeks AOG & retained 2 months or longer- Cervix: closed

- Discharges: Foul smelling discharge, red or brownish or may not occur.- Uterus stops growing, decreases in size- Fetus will undergo changes:

a. Fluffling- gray scale

- thickening & coverin of fetal skull and thoraxb. Macerationsofteningc. Mummificationleather like changes


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d. Lithopedion formationstoneymaterial

f. Habitual- repeated abortion (spontaneous of any type)- 3 or more pregnancies at same age or pre-viable stage

Causes of recurrent/habitual

1. defective spermatozoa

2. Hormonal influenceEndocrine factors3. nutritional status4. Deviation of uterusmid-septum,

Bicornuate-horns or poles small space for implantation5. Psychological factor- stress

6. Blood incompatibility- ABO, Rh factor7. Infection

Medical termination of pregnancy or, also called Induced Abortion-voluntary/deliberately terminating pregnancy

a. Therapeuticmedically indicated

b. Criminalintentionallyc. Septicinfected abortion, secondary to infection

Purposes:

1. When there is threat to mother's life (heart disease)2. to prevent birth of infant w/ severe defects (malfomations, chromosomal)

3. psychological implication (incest or rape)

Therapeutic Abortion: According to US Supreme court ruling (Jan 22, 1973) pregnancy may be

terminated as follows:1. 1st trimester abortiondecision is left to the woman and her physician.2. 2nd trimesterstate may not prohibit but may regulate practice for woman's health.3. Final trimester state may choose to protect the potential life of the fetus by prohibiting abortionexcept when there is threat to the life or health of the mother.

4. Religous belief of the mother is always respected.

Procedures Used to Induce Abortion

I. Menstrual Extraction* Simplest type done on the 4th - 6th weeks AOG* Uterine lining is suctionclient bleeds normal menses* Oxytocin given orally* follow-up check up & Pregnancy test* Complications:

> Hemmorrhage: - 2 pads/hr, clots> Infection: - fever, abdominal pain and tenderness, endometritis

II. Dilatation and vacumm Extraction- Paracervical block

- Cervix is dilated with dilators

- LAMINARIA dried sterilized seaweeds cervix swells,after 24 hrs becomes dilatable, vacuum extraction isinserted and evacuate uterine contents in 15mins.

- Antibiotics, oxytocin, MGH after 4 hrs.

- bleeding same as mensesComplications:

> Hemmorrhage: - 2 pads/hr, clots> Infection: - fever, abdominal pain and tenderness,

endometritis

III. Saline Inductiona. Salt poisoning Abortion done on 14th -16th weeks AOGthen D&E is used.

-salt water kills the fetus.-uterus starts contracting usually within the next 2 days,resulting in the delivery of the dead fetus.b. Saline & prostaglandin induction done on 17th -24thweeks AOG.

Mechanisms:*Saline interferes w/ progesterone function-ing causingendometrial sloughing.*needle is inserted into the uterus through the abdominalwall.


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5. Mass in Cul-de-sac of Douglas (pouch) may be palpated or bloody fluid may be aspirated by culdocentesis

6. Excorciating pain at cervix when IE is done7. Knifelike pain either lower quadrant8. WBC- 15,000/UL>, RBCdecrease, ESR- slightly elevated9. S/S of shock

Signs & symptoms (early ectopic pregnancy)

1. Amenorrhea or abnormal mensesspotting2. Cul-de-sac massS/S acute ruptured

1. shock2. referred shoulder pain

3. evidence of acute blood lossS/S Chronic rupture - occurs 50% in tubal ectopic pregnancy

1. slowinternal bleeding2. atypical or inconclusive symptoms as

a. Slight, dark, vaginal bleeding

b. Renal or pelvic pressure or fullnessc. Lower abdominal tendernessd. Slight fever

e. Leukocytosisf. Cullen's sign

g. Decrease hgb. & hct.Diagnostic test:1. Ultrasoundreveal site of ectopic pregnancy

2. Culdocentesisyields free blood that will not clot or is already clotted3. Laparoscopydiscloses extrauterine preg.

Treatment:1. Culdotomyrelease clotted blood and product of extra-uterine pregnancy.2. Laparotomyreveal correct diagnosis

3. SalpingostomyNursing Managment:1. Monitor V/S, watch for signs of shock

2. Nursing care to bleeding clients3. Observe nature of bleeding4. Administration of narcotics or analgesic as ordered5. Prepare clients for diagnosis and treatment6. Provide post-operative care

Second Trimester Bleeding (a) HYDATIDIFORM MOLE(b) INCOMPETENT CERVIX

GESTATIONAL TROPHOBLASTIC DISEASE (Hydatidiform Mole or Molar Pregnancy)

Pathophysiology:1. The embryo & the placenta deteriorate & loose its identity2. A rapidly growing throphoblastic tissue develop3. Resembles clusters of small graped- sized vesicles with tapioca like consistency.

4. Abnormal proliferation & degeneration of the trophoblastic villi.2 Types of Molar Growth:

1. Complete mole- no fetus- all trophoblastic villi

- embryo dies early- no fetal blood found

2. Partial mole- some villi formed

- presence of 9th week fetal mass & fetal blood in the villi.- Rarely lead to choriocarcinoma.

Pre-disposing Factors:1. Malnutritionlow protein intake2. Agewoman under 20 & above 35yrs.old

- low socio economic status3. Chromosomal abnormalities4. Hormonal imbalanceuse of Clomiphene citrate (clomid) and women of asian heritage


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Sign & Symptoms:

a. rapid enlargement of the uterus Like 3 mos.= 5 mos.b. absence of fetal heart tones or movement & fetal structuresc. HCG titers greater than expected for gestational age (+) pregnancy testd. hyperemesis gravidarume. signs of PIH before 20m weeks AOG

f. vaginal bleedingdark-brown blood

g. passing out of grape-like clusters Latu-latuappearanceh. @ 16 weeks AOGthe client bleeds with molar expulsion.

Diagnostic test:

1. Ultrasound (sonogram) - reveals molar pregnancy, show-dense growth [typically snow flake pattern]but no fetal growth.2. Pregnancy test (+) due to elevated hCG titer. HCG= increase 1.2 mil. IU in 24 hrs.[normal =400,000 IU3. Hct.& Hgbdecrease due to bleeding

4. ESR & WBC- increase due to infectionManagement:1. Evacuation by:

a. D&C or Suction curettageb. Hysterotomy

c. Hysterectomy- above 45yrs.old2. Follow-up management for detection of malignant changes of complication.

a. HCG levels

# every 2 weeks until titers are negative for 3 consecutive results# once monthly x 6 mos.# every 2 mos. X 6 mos.# every 6 mos. X 1 year.

- if hCG are negativefree of risk of developing malignancy.

Note: continual rising of HCG (3x) indicates pathologic condition- D&C is to be done if the uterus is intactthen tissue can be examined (biopsy).3. Prophylactic treatment of choriocarcinoma

- Methotrexatedrug of choice, but this drug inteferes with WBC formation (Leukopenia)- Dactinomycindrug used if metastasis occurs.- if untreated, death results

4. CXRto detect metastasis to the other systems of the body as to the lungs- to be done until hCG titers are negative.- then every 2 mons x 1 yr.

5. Oral contraceptionused toa. prevent another molar pregnancy.

b. suppress Endogenous Pituitary Leutenizing Hormones (LH)which will distort hCG titer assay.6. Provide emotional support.

INCOMPETENT CERVIX (Premature Cervical Dilatation)

- A defect in the cervix that makes it unable to remain closed through pregnancy.- Common cause of late abortions or premature labor.- Occurs at 20thweeks AOGPathophysiology:

-cervix thinned and dilates-makes it unable to hold product of conception until term

-painless

Causes:

1. Traumatraumatic delivery as forcep extraction- forceful D&C

2. Congenital anomalyinfantile uterus3. Endocrine factorlow progesterone

Criteria before Management: (in the current pregnancy) all must be presenta. Membranes (BOW) must be intactb. Cervix is not > 3cm.dilatedc. Cervix is not > 50% effacedManagement:a. Supportive

1. Bedrest2. Monitor V/S & FHT3. Psychological support & reassurance4. Health teaching:


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- uterine contraction

- Rupture of Membrane- Assess presence of fever

- Bleeding and pain- Abstain coitus

b. Surgery

1. Cervical Cerclagea purse string suture is placed in the cervix.

-done to prevent premature dilatation of the cervix, holds pregnancy insidetheuterus.-done after the 12 to 14wks. AOG (age beyond the point that spontaneous

abortion

due to defective embryo usually occurs)Types of Cerclage Techniques :

a. Shirodkar-Barter procedure or McDonald operationShirodkar technique

> sterile tape is threaded in a purse-string manner under the submucous layer of the cervix

> suture in placed to achieve a closed cervixMcDonald technique

> nylon sutures are placed horizontally & vertically across the cervix and pulled tight to reduce

the canal.> remove if fetus reached almost fullterm - 38th-39thweeks AOG.

b. Transabdominal approach- a permanent purse-string (cerclage) is placed at the lower end of the uterus orremaining

cervix.- the suture is left in place and C/S is performed.- success of both types: 80% - 90%.

Nursing Intervention:> After the cerclage:

- observe for spotting of fresh blood expected during the 1st 2nd day [application of sutureinduces

bleeding]

- placed on bedrest or slight T-position to decrease pressure on the new sutures.- sexual activity may resumed after rest period

Third Trimester Bleeding (a) PLACENTA PREVIA(b) ABRUPTIO PLACENTA

PLACENTA PREVIA- improperly implanted placenta in the lower uterine segment near or covering the internal cervical os.

- 30% >than average placenta implanted at the fundussite & size related (surface area)- degree of placenta covers the internal os is estimated by 70-100%, 75% etc.2nd trimester 45% of placenta are implanted at lower uterine segment

Classification:

1. Complete or Central or Total placenta previa - Internal os is covered entirely by the placenta2. Incomplete or Partial Placenta Previa occurs when the placenta asymetrically covers only part of the internalos.3. Marginal Placenta Previa only an edge of the placenta approaches the internal os.

4. Low-lying (low implantation)is when the placenta is situated in the lower uterine segment but doesnot

reach the internal os.Causes:1. Unknown

2. Can be attributed to the following conditions:a. Fibroid tumor in the uterusb. Uterine scars from previous surgery (c/s, past uterine curettage)c. Abnormal uterine position or shape

d. Multiparitymultiple gestatione. Agevery young & very oldf. Cigarette smoking

Assessment/ Physical exam:(7 months AOG)1. Uterine bleedingpainless2. Uterine tonenormal but relax completely bet.contraction3. Painpainless non-tenderness uterus- may experience labor contractions3. Fetal position

- Fundic height is greaterplacenta hinders descent of,presenting parts- leopolds manuenver - reveals malposition of fetustransverse or breech


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Assessment:

- duration of the pregnancy- time the bleeding began- woman's estimation of the amount of blood

> ask to estimate bleeding- whether there was accompanying pain

- color of the blood

- what she has done for bleeding?- whether there were prior episodes of bleeding- whether she had prior surgery for premature dilatation.Diagnostic tests:1. Ultrasoundsafe,accurate, & non-invasive method of visualizing the placenta

2. Amniocentesis- asses fetal lung maturity Lecithin Spingomyelin ratio 1:2- if lung maturity is reached, CS delivery- done

3. No vaginal exam unless patient is place on double preparation procedure4. Laboratory tests:

- hemoglobin- hematocrit- Rh factor

- urinalysis- blood typing

Nursing Management:Goal: to ensure an adequate blood supply to a woman & fetus.1. Inspect perineum for bleeding

2. Test strip procedureto detect blood is fetal or maternal origin3. No IE or rectal exam in painless bleeding.4. Monitor v/s (TPR,B/P), I&O, FHT5. IVF therapy- use largew bore needle (LR, vol. Expander)6. O2 administrationincase of fetal distress

7. Keep NPO8. Betamethasonesteriod that hasten fetal lung maturity in < 34 weeks gestation.Management of placenta previa (In General)

> deliveryif fetus reached maturitya. if > 30% previa - Abdominal delivery by C/Sb. if < 30 % previaVaginal deliveryif delivery is not attained within 6hours- C/S is indicated

ABRUPTIO PLACENTA- is the premature separation of part or all of the placenta from its site of implantation- can be an abnormal separation of a normally implanted placenta

- occurs at >20 weeks of AOGClassification:Hemorrhage is apparent or visible when bleeding separates or dissects the membranes from the

endometrium and blood flows out through the vagina.

Concealed Hemorrhage - the bleeding occurs behind the placenta but the margins remain intact, causingformation of a hematomaIncidence and Etiology:1. Cause is unknown

2. Following factors that increase risk:a. Maternal use of cocaineleading cause of abruptio placenta

b. Cigarette smokingc. Maternal HPN ; Multigravidad. PROM; Advance maternal age

e. History of previous premature separation;abortion, stillbirth, pre-natal hemorrhage; prematurelabor

g. Abdominal trauma; short umbilical cordDegrees of Separation:

Grade 0 - No symptoms of separation were apparent from maternal or fetal side; diagnosis of placentalseparation is made during delivery; placenta shows recent adherent clots on maternal surface

Grade 1 - Minimal separation enough to cause vaginal bleeding and changes in the maternal VS; no fetaldistress

or hemorrhagic shock occursGrade 2 - Moderate separation with evidence of fetal distress; uterus is tense, painful on palpationGrade 3 - Extreme separation; without immediate interventions; maternal shock and fetal death willresult

Assessment/Physical exam-Symptoms vary with degrees of placental separation


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Classic symptoms:

- Vaginal bleeding- may be concealed.- Severe abdominal pain & tenderness- Uterine contractions (hypertonic)- Increased abdominal girth- Other symptoms are signs of shock

- Fetal distress or fetal demise

In severe concealed bleeding, blood may infiltrate the uterine musculatureCOUVELAIRE uterusor uteroplacental apoplexy- hard, boardlike uterus- orange or bronze color- uterus becomes tense

and rigid to touch In extensive bleeding, DIC syndrome occurs; the womans reserve blood fibrinogen may be used

up in her bodys attempt to accomplish effective clot formation.

Signs of Concealed hemorrhage :- Increase in fundal height- Hard boardlike abdomen

- Persistent abdominal pain- Systemic signs of hemorrhage

- persistent late- deceleration in FHT- slight or absent

- vaginal bleeding

Laboratory tests:- Hemoglobin level- Blood typing & cross-matching- Fibrinogen leveltests for DIC (5 ml of blood to stand for 5 mins; if clot formed- DIC negative; no

clot formationpositive to DICNursing Management/Care1. Admit to hospital2. Administered oxygen by mask (fetal anoxia)3. Monitor FHT, VS and record4. Determine baseline fibrinogen5. Keep in lateral position -prevent pressure at vena cava; further compromise fetal circulation6. No IE, pelvic exam, enema7. Depending on degree of separation if labor startsrupturing BOW may help speed delivery oradministration of oxytocin.

8. If delivery does not occur, cesarean section is the method of choice9. Cause of maternal death:

- Massive hemorrhage which lead to shock; circulatory collapse or renal failure

- InfectionPurpose of Rupturing BOW

a. Prevents development of couvelaire uterus, prevents pooling of blood in the myometrium of uterus.b. Prevent DIC (Disseminated Intravascular Coagulation)c. Speed up delivery

Fetal Complications1. Prematurity2. Hypoxiaresult in irreversible damage & anemia

Maternal Complications1. Hemorrhage2. Hypovolemic shock3. DIC4. Acute renal failure5. Infection6. Post partal hemorrhage7. Death

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OB 7 Handout Bleeding Conditions of Pregnancy