Bleeding in Pregnancy

Describe the most common causes of bleeding in late pregnancy

Describe the most common causes of bleeding in early pregnancy

 Miscarriage (spontaneous abortion)

 Ectopic pregnancy

 Gestational trophoblastic disease (hydatidiform mole/molar pregnancy).

Is bleeding normal in early pregnancy?

Bleeding during early pregnancy is alarming to the pregnant individual and of concern to health care providers

Understand the definitions pertaining to early pregnancy bleeding

Recognize signs and symptoms of various causes of bleeding in pregnancy and subsequent nursing interventions

Which test is ordered at 36w of pregnancy?

A. GCT
B. GBS
C. GTT
D. CST

B

Ebony is a 36-year-old female presenting for her first prenatal visit at 8 weeks gestation. She had 2 vaginal deliveries at 39 weeks gestation and 1 stillbirth at 24 weeks gestation. How will you document her GTPAL?

G4P2102

Abortion definition

Abortion is the loss of pregnancy before the fetus is viable, that is, before it is capable of living outside the uterus.

 The medical consensus today is that a fetus of less than 20 weeks of gestation or one weighing less than 500 g is not viable

Spontaneous abortion “miscarriage”

Termination of a pregnancy without action taken by the pregnant person or any other person, natural causes.

Induced abortion

The purposeful interruption of a pregnancy

 If it is performed at the patient’s request the term elective abortion is used

 If performed for reasons of maternal or fetal health the term therapeutic abortion is used

Causes of spontaneous abortion of miscarriage

 Chromosomal abnormalities (50-60%)

 Maternal infection/endocrine disorder

 Anatomic defects

 Environmental

Likelihood of an early pregnancy loss

incidence increases with age

80% occur in first tri

Pathophysiology: spontaneous abortion

1. Embryonic mortality/failure to develop

2. Decrease in estrogen & progesterone

3. Uterine decidua is sloughed off (vaginal bleeding)

4. Uterine irritability and contractions with expulsion of embryo/fetus and placenta (products of conception/POC)

risk factors of spontaneous abortion

 Maternal and paternal age >40

 History of miscarriage

 Obesity

 Chronic disease (i.e., Hypothyroidism, Diabetes Mellitus (Type 1), HTN, Autoimmune)

 Infection

 Immunological response

 Environmental toxins

 ATOD use

 Abnormalities of the cervix (e.g., incompetent) or uterus (e.g., bicornate)

Management goals of a spontaneous abortion

empty uterus of POC

expectant management goal of a spontaneous abortion

await spontaneous/complete expulsion

medical management goal of a spontaneous abortion

medication to induce expulsion

surgical management goal of a spontaneous abortion

 Dilation & Curettage (D&C) (1st trimester)
- Suction aspiration
 Dilation & Evacuation (D&E) (2nd trimester)

nursing role during a spontaneous abortion

Assessment of symptoms
- Bleeding pattern, amount, duration, pain etc.
Prevention and identification of complications:
- i.e. Infection, heavy bleeding
Therapeutic listening
Emotional Support

ectopic pregnancy

Implantation of fertilized ovum outside uterine cavity

signs of ectopic pregnancy

 Lower abdominal pain/one-sided

 Vaginal bleeding/spotting ~5-6 weeks GA

 + pregnancy test, pregnancy symptoms

risk factors of a ectopic pregnancy

 h/o PID/ STI’s such as chlamydia/gonorrhea
 Smoker
 Pelvic surgery
 H/o ectopic
 IUD in place

patho of a ectopic pregnancy

1. Ectopic implantation trophoblastic cells grow into the adjacent tissue and arterial vessels

2. Faulty implantation causes fluctuationin hormones first stimulating endometrium, hormones then withdrawal and vaginal bleeding occurs

3. Growing embryo ruptures the tube

4. Internal hemorrhage

Managment goals of a ectopic pregnancy

preserve the tube

medical management of an ectopic pregnancy

Methotrexate stops the growth of the pregnancy and it will be absorbed

surgical management of an ectopic pregnancy

Required if hemorrhaging from ruptured tube

Nursing Care: early pregnancy bleeding

Assess:
 Gestation
 Bleeding (timing, duration, amount, associated cramping etc.)
 Vitals signs
 Pain assessment
- Signs/symptoms of complications
 Hemorrhage, infection, shock
 Anxiety, Fear, Coping

Nursing Care: early pregnancy bleeding interventions

Notify provider
Supportive care for anxiety and fear
Supportive care for coping related to possible loss or loss
Determine understanding of treatment options
Educate regarding after care

labs to get during early pregnancy bleeding

CBC: white blood count, hemoglobin
Blood type/Rh and Antibody screen
hCG levels
Others may be indicated.

Bleeding conditions of late pregnancy

Placenta previa

Placental abruption

when does placenta previa occur?

1 in 200-300 pregnancies

placenta previa

placenta completely or particially covers the cervix

• low-lying vs. complete

complications of placenta previa

 Bleeding in pregnancy, labor, or delivery
 Preterm birth
 Placenta accreta

risk factors of placenta previa

 Previous c/section or uterine surgery

 35 years or older

 Smoking or cocaine use

signs /symptoms of placenta previa

 Sudden onset of painless, bright red bleeding

 Bleeding usually slight to moderate

management of placenta previa

 Pelvic rest and education on warning signs
 What is pelvic rest? limiting activities that put pressure on the pelvis
 Planned C-section for complete previa

nursing care during a placenta previa

 Support patient, listen to fears/anxieties
 No vaginal or cervical exams!

placental abruption

When placenta detaches from uterine wall before birth

Severity depends on amt of bleeding and size of hematoma

risk factors of placental abruption

 Hypertension

 Smoking

 Multigravida

 abdominal trauma

 IPV: intra personal violence- trauma to the pelvis

 cocaine use

• also: lupus, factor V.

patho of placenta abruption

1. Bleeding and formation of a hematoma on the maternal side of the placenta

2. Clot expands, further placental separation occurs

3. Hematoma expands and obliterates intervillous spaces where fetal gas
   and nutrient exchange occur

4. Fetal vessels disrupted as placental separation occurs, resulting in fetal as well as maternal bleeding

signs of placental abruption

Vaginal bleeding
abdominal/low back pain
Uterine irritability/frequent low- intensity contractions
High uterine resting tone
Uterine tenderness

diagnosis of a placental abruption

◦ Fetal monitoring
◦ Ultrasound to rule out other causes of bleeding

treament of a placental abruption

◦ If mild and fetus is <34w, may consider conservative management with
hospitalization, bedrest, tocolytic, administer Rhogam if Rh-neg, Kleihauser-
Betke to determine if fetal bleeding is worsening
◦ If severe: Emergency c/s

What to do immediately with abruption

You may be the first to identify abruption symptoms!
Prepare for immediate delivery if severe bleeding and/or non-reassuring fetal status

• Alert provider team (MD, CNM, Anesthesia)

• Maternal monitoring

• Fetal monitoring

• IV insertion
  Emotional support of pregnant person and family

37 yr old Caucasian female, G3P2002, who presents to triage today at 37 weeks gestation with vaginal bleeding and contractions. Her pregnancy is complicated by Advanced Maternal Age, gestational HTN, and cocaine use. She has had increasing abdominal pain over the last several hours.
What would a nursing diagnosis be for this patient?

• risk of placenta abruption

• risk of bleeding

• risk for fetal distress

37 yr old Caucasian female, G3P2002, who presents to triage today at 37 weeks gestation with vaginal bleeding and contractions. Her pregnancy is complicated by Advanced Maternal Age, gestational HTN, and cocaine use. She has had increasing abdominal pain over the last several hours.

As the triage nurse, what assessments would you perform?

Ultrasound, vitals, fetal monitoring, CBC, pain

37 yr old Caucasian female, G3P2002, who presents to triage today at 37 weeks gestation with vaginal bleeding and contractions. Her pregnancy is complicated by Advanced Maternal Age, gestational HTN, and cocaine use. She has had increasing abdominal pain over the last several hours.

What are this patient’s risk factors for placental abruption?

cocaine use, advance maternal age and hypertension

37 yr old Caucasian female, G3P2002, who presents to triage today at 37 weeks gestation with vaginal bleeding and contractions. Her pregnancy is complicated by Advanced Maternal Age, gestational HTN, and cocaine use. She has had increasing abdominal pain over the last several hours.

If considered severe, what would you do to anticipate the provider’s needs for this patient and increase the quality and safety of care?

emergency c section

• alert staff, labs, continued monitoring on fetus and maternal, IV insertion

When does ABO incompatibility occur?

when maternal blood type is O and newborn is A, B, AB

Postpartum concern for ABO incompatibility

Hemolytic Disease of the Newborn (HDN), early jaundice in first 24 hrs

Nursing interventions during ABO incompatibility

• Save cord blood at delivery.

• Check newborn’s blood type and DAT (Direct Coombs Test).

• Monitor for jaundice, support feeding/hydration, apply phototherapy if needed

What can Rh incompatibility lead to?

HDN, fetal hydrops, or intrauterine fetal death

Rh incompatibility

•Rh⁻ mom + Rh⁺ fetus = risk of sensitization.

•Once sensitized, maternal anti-D antibodies can cross the placenta, destroying fetal RBCs.

When is Rhogam given?

Given at 28 weeks, and within 72 hours postpartum if mom is Rh-, unsensitized, and baby is Rh+

• indicated after abortion, trauma, version

rhogam

IM injection of anti-D IgG

When is a Antibody screen (Indirect Coombs test / Indirect Antiglobulin Test - IAT) preformed

prenatal visit to check if the mother has antibodies in her blood that might attack the baby’s red blood cells. It detects antibodies that are circulating freely in the mother's blood but not yet attached to cells

A patient is blood type O and gives birth to a baby who is type A. The newborn's DAT is positive. What should the nurse monitor closely in the first 24 hours?
A. Apgar scores
B. Jaundice and bilirubin levels
C. Feeding intolerance
D. Heart rate variability

B. Jaundice and bilirubin levels

A postpartum person is Rh negative with a negative antibody screen. Their baby is Rh positive with a negative DAT. What is the next best nursing action?
A. Give a second dose of Rhogam at 6 weeks
B. Order phototherapy
C. Administer Rhogam within 72 hours
D. Repeat the antibody screen

C. Administer Rhogam within 72 hours