OB chapter 28--> Hemorrhagic disorders

fetal risk from maternal hemorrage

1. blood loss--> anemia

2. hypoxia, hypoxemia

3. anoxia

4. preterm birth

defintion of miscarriage and overview

- also known as a spontanous abortion

- pregancy will end due to natrual causes before fetal viabilty

- 10-15% of pregnancies end in misscarriage

- 80% of misscarriages occur before 12 weeks

threatened abortion

1. cervix is not dilated --> closed

2. placenta is still attached to uterine wall, will see some bleeding

inevitable abortion

1. cervix is dilated

2. placenta is no longer attached to uterine wall, see alot more bleeding

incomplete abortion vs complete abortion

- incomplete abortion

1. fetus or embryo has passed through the uterus, placenta has not

2. increases risk of hemerhage

- complete abortion

1. fetus and placenta are expelled from the uterus

2. see less bleeding

missed aborton

1. fetus is dead and cervix is not dilated

2. body does not expell fetus, will see little to no bleeding

recurrent abortion

2 or more consecutive abortions

assesment of a person when they come in concered of a miscarriage

1. always gather pregancy history, vital signs, type and location of pain and lab values

2. want to ask how much a patient is bleeding and when it began

intial care for miscarriages (3 types of care)

- our inital care of a patient with a miscarriage is based on the type of miscarriage and her signs and symptoms

1. expectant care --> waiting to see if the women can expell the tissue on her own

2. medical care --> use misoprol (cytotdec) which is a prostagladin to stimualte uterine contractions so women can expell tissue

3. surgical care --> dilation and curettage which will allow for surgical removal of tissue

follow up care for a women after a miscarriage

1. discharge teaching highlights the importance of rest

2. adress questions regarding trying for another pregnancy

3. provide support, phone calls and resources

cervical insufficiency etiology

- passive and painless dilation of the cervix in the 2nd trimester--> typically due to a weak cervix, cannot stay closed

- can be aquired or congenital

diagnosis of cervical insufficeny

- disgnosed by doing a measurement of the cervix, will see a short cervix 25 cm or less

- done with a speculum exam or a transvaginal ultrasound

treatment of cervical insufficeny

1. bed rest is not a useful form of treatment

2. we can use progestrone to cause contraction of the cervix to maintain pregancy

3. always want to report any signs of rupture, preterm labor or infection

ectopic pregancy defintion and symptoms

- occurs when a fertlized egg implants in a area outside of the uterus --> also known as a tubal pregancy

- 3 common symptoms : abdominal pain, delayed period, abnormal spotting or bleeding

diagnosis of an ectopic pregnancy

- diagnosis is difficult because symptoms are simillar to many other condtions

1. can do a transvaginal ultrasound to determine where implantation occured

2. can also look at HCG levels, if we see high HCG level and no intrauterin implantation on the ultrasound--> ectopic pregancy

treatment/ interventions of ectopic pregancies

1. medical intervention

- can use methotrexate which is a antimetabolite ad folic acid antagonist, so it will destory the rapidly dividing cell

- will dissolve the pregancy when the tube is still in tact, if the tube is destroyed we cannot fix it, now we only have one tube

2. surgical intervention

- type of surgery for an ectopic pregancy depends on where the implantation occured, the amout of tissue involvment and on the mothers preference for furture prganies

- can do a salpingectomy--> surgical removial of the entire tube

overview of a molar pregancy (hydratiform mole)

- a type of trophoblastic disease, will hear no heart beat

- basically an adnormal accumulation of cells un the uterus that have the abilty to emit HCG and will cause stomach to grow

- typically will dissolve or be absorbed on its own

- increased risk of cervical cancer when a person has a molar pregancy due to abnormal growth of cells

-placental trophblast will accumlate and cause chronic villis to become edematous and cystic, will look like a chain of grapes

type and etiology of molar pregancy

1. complete: will have no fetal parts present

2. partial: will have some fetal/embryotic parts, will see amniotic sac

- will occur in 1/ 1000 pregancies in the US

symptoms of a molar pregancy

1. extremly large uterus

2. abnormal bleeding

3. extreme N/V

4. abnormally high HCG

5. anemia

6. early preclamsiya in 70% of the cases

diagnosis and treatment of molar pregnancy

- diagnosis of a molar pregancy will be done with a transvaginal ultrasound or serum hcg levels

- treatment: will typically resolve on its own, if not can do a suction curttiage

two major causes of early pregancy bleeding

1. spontous abortion

2. ectopic pregnancy

- remember bleeding during pregancy always requires medical attention

placenta previa defintion and types

- placenta implants in lower segment of the uterus over or near cervical os

- degree to which cervical os is covered is based on the type --> complete, marginal and low lying

incidence and risk factors for placental previda

- will occur in 1 out of eveyr 200 pregancies

- risk factors include

1. previous c section

2. older then 35

3. multiparity

4. smoking

5. previous suctioning curritage

types of placental previda and intervention needed

1. low lying --> simply placenta is implanted lower in the uterus, cervical os is not touched or covered

- may require c section, needs close monitering

2. marginal placenta previa--> placenta will implant where it is touching the edge of the cervical os

3. complete placenta previa--> placenta implants completly over cervical os

- both reqiire immediate C sections, must work with interdispliany team and blood bank due to large risk of hemorrhage--> want to have 2 iv's ready type and cross match of blood and transfushion protocol prepared

clinical manifestation and diagnosis of placental previa

- will see painless bright red vaginal bleeding in the 2nd or 3rd trimester

- diagnose with a transabdominal ultrasound, do not use transvaginal ultrasound or stick fingers in women as we dont know where placenta is

major risks for placenta previa

1. hemerphage --> increased with marginal and complete types

2. morbitiy adherent placenta --> placenta is attached very firmily to uterine wall--> increases risk of hemerhage

3. can see preterm labor and severe intrauterine growth restriction

expected delivery for placenta previa and active managment

- always going to be a c section, typically planned for marginal and complete

- can moniter for low placental

- always immedatly deliver placenta previa babies if greater then 36 weeks or has excessive bleeding

home care for placenta previa

- home care can be done if patient is stable, no bleeding for 48 hours

- patient should be on bedrest with bathroom prevlidges

- pelvic rest --> no tampons or sex

defintion of placental abruption and risk factors

- defined as premature sepration of some or all of the placenta after 20 weeks gestation

risk factors:

1. primary risk factor is maternal HTN

2. smoking and cocaine use

3. blunt force to abdomen

4. previous placental abruption

two types of placental abruption

1. partial placental abruption--> small portion is seprated, will form a clot and see little to no bleeding

2. complete abruption --> placenta entirely seprates, fetus cannot get oxygen, HR will be very low

-immediate C section

clinical manifestation of placental abruption

1. dark red bleeding that is excessive with absloutly unbearable pain

2. will see very solid and firm abdomen

maternal and fetal outcomes with placental aburption

- can see hemerhage and hypovolemic shock

- fetal hypoxia, oligo, stillbirth

- toco will show a ton of contractions

diagnosis of placental abruption

- typically an ultrasound to show the dgeree to which the placenta seprated

treatment of placental abruption (expectant and active management)

1. if fetus is within 20-34 weeks we are going to use expectant mangement and close fetal monitering

2. active managmenr will occur at term, if we see excessive bleeding or decline in mother or fetal state

disseminated intravascular cougulation is caused by

1. amniotic fluid emboli --> get into mothers vasculature and cause issues with clotting leading to dic

2. preclamsiya that progresses into hellp--> causes issues with cougulation

- remeber dic is never a primary diagnosis but a result of another event that causes cougulation

3. in obestrics dic is most commonly caused by a placental abruption from release of tissue factors

signs and symptoms of DIC

- signs of thrombosis like cynosis and confusion

- bleeding from 3 sites like epitaxisis, bleeding from venipuncture, hypotension, tachycardia , bruises

treatment of DIC

- want to treat underying cause like removal of placental abruption, dead fetus or treating underlying infection

- want to do proper transfushion of blood products, and to adminster alot of LC or NS to make patient hemodyanmically stable