Bleeding in Pregnancy

NURS546

What is the HCG discriminatory zone for a gestational sac to be visible by transvaginal ultrasound?

1500-3000

What is defined as a pregnancy of unknown location?

Positive pregnancy test but pregnancy cannot be visualized with ultrasound.

When are we concerned about first trimester bleeding?

heavy painful bleeding

What is implantation bleeding defined as?

Bleeding that occurs 5-10 days following implantation. Usually light, intermittent, and painless.

How would we diagnose implantation bleeding?

Patient information (timing, other symptoms, amount of bleeding), ultrasound (diagnosis of exclusion), labs (HCG)

What is defined as a vanishing twin?

Spontaneous reduction of a multi-fetus pregnancy to a singleton pregnancy. Typically happens in the first trimester. Symptoms: bleeding or no symptoms. Diagnosis: First US: 6-7 weeks with twin gestation. Second US: a single fetus.

What happens in a subchorionic hemorrhage/hematoma?

Bleeding between the chorion and the myometrium or between the chorion and the placenta. Large, painless amount of bright red bleeding. This carries a higher miscarriage risk (9-30%) and may be associated with preterm birth, PROM or growth restriction (>25%)

How can a patient get cervicitis and what does it look like and how do we manage it?

Infections (GC, Chlamydia, trichomonas, other bacteria, yeast), trauma/irritants, or pregnancy. Assessment: Hx of bleeding, wet mount & cultures. Management: treat the causative organism → test of cure for all infections but yeast.

What causes miscarriages and when do they commonly happen?

Chromosomal abnormalities, uncontrolled disease, substance use, toxins and age. Most happen in the first 10 weeks.

What is an anembryonic pregnancy?

Development of gestational sac without the development of an embryo. Also called a biochemical pregnancy

What is a threatened abortion and how do we manage this?

Painless, vaginal bleeding during first half of pregnancy (subchorionic hemmorhage/hematoma). Management: physical exam, serial bHCG’s and/or ultrasound. Good news: most pregnancies with both fetal cardiac activity and bleeding will have a good outcome. Bad news: poor prognosis comes with cramping or back ache.

What is an inevitable abortion and how do we manage this?

When SAB is certain and cannot be stopped. Ex. cervical dilation and/or rupture of membranes + vaginal bleeding and cramps/back ache, embryo >5mm w/ no cardiac activity. Management: if bleeding and pain are not excessive, VS and H&H. Await SAB or offer medical/surgical intervention.

What is a missed abortion and how do we manage this?

A fetus w/o cardiac activity but remains in the uterus. Vaginal bleeding may or may not occur, fundal height less tha expected, resolution of pregnancy symptoms, no FHTs. Management: US, consult MD, wait SAB or offer medical/surgical intervention, pain management

What is an incomplete abortion and how do we manage this?

When products of conception remain in uterus. Profuse bleeding and infection can occur. Management: Physician to manage infection and consider medical/surgical intervention.

When should beta HCGs double and if it doesnt double by then what does this mean?

beta HCGs should doube every 48-72 hours (not always doubled by 48h, should be doubled by 72). If HCG doesnt double, it could indicate ectopic pregnancy or miscarriage

What does expectant management look like in abortion?

After discovery of pregnancy loss, they can f/u with US and bHCGs for up to eight weeks. HCG should drop 90% after 7 days. They should watch for fever (infection) and heavy bleeding (soak >1 pad/hour). NSAIDs for pain relief.

What does medical management look this for abortion?

Mifeprostone (oral) 200mg → (24 hours later) 1 dose of Misoprostol (vaginal) 800mcg → (12-24 hours later) 1 dose of Misoprostol (vaginal) 800mcg

What should be considered with medical management for signs and symptoms to report?

Misoprostol can cause fevers.

What. dose surgical management look like in abortion?

Suction (manual vacuum aspiration) or cutterage.

What does after care look like for surgical management?

No sex for 1-2 weeks, follow up 7-14 days bHCG (repeat until 5mlU/ml, family planning.

What happens in ectopic pregnancies and what are some risk factors?

Blastocyst implants out side of the endometrium of the uterus (most commonly fallopian tubes). Risk factors: pelvic infections, IUDs, previous ectopic pregnancy)

What is the treatment for ectopic pregnancies?

Methotrexate and surgery.

What are some signs of a ruptured ectopic?

Pelvic pain, shoulder pain, render abdomen, cervical motion tenderness, adnexal mass, hypotension.

What is a hydatidiform mole?

Gestational trophoblastic disease. The abnormal union of sperm and egg and placentation. No or limited fetal tissue. abnormal trophoblastic tissue proliferates Placental villi become edematous grape-like structures (seen on ultrasound)

How do we manage hydatidiform moles?

Dilation and evacuation. Education: No pregnancy for 6-12 months.

What are some sources of bleeding in late pregnancy?

Bloody show, Placental abnormalities (abruption, previa), ruptured uterus, ruptured vasa previa (velamentous cord), ruptured vaginal varicosities, and preterm labor.

If a low lying placenta was found on the fetal anatomy ultrasound, when do we follow up?

Another ultrasound follow up is scheduled for 28-30 weeks

What is placental abruption and what do the signs and symptoms look like?

Premature separation of normally implanted placenta >20wks. S/S: colicky uterus or back pain, board like abdomen in severe case.

What happens with uterine rupture?

This is a medical emergency, the uterus opens up leaving baby in the abdominal cavity. Patients would have abdominal pain, feeling that something gave way, vaginal bleeding, hypovolemic shock.