Bleeding Disorders and Types of Abortions

Bleeding disorders in the 1st trimester

• abortion (spontaneous miscarriage)

• ectopic pregnancy

Bleeding disorders in the 2nd trimester

• hydatidiform mole (gestational trophoblastic disease)

• incompetent cervix (premature cervical dilatation)

Bleeding disorders in the 3rd trimester

• placenta previa

• abruption placenta

• preterm labor

This is a medical term for any interruption of a pregnancy before a fetus is viable.

abortion or spontaneous miscarriage

This is a fetus more than 20 to 24 weeks of gestation or one that weights at least 500g

viable fetus

A fetus born before 20 - 24 weeks is considered what?

miscarriage or premature or immature birth

When does early miscarriage occur?

before 16th week of pregnancy

When does late miscarriage occur?

between 16 - 20th weeks

This type of abortion is deliberate

• elective abortion

• therapeutic abortion

This deliberate type of abortion is by personal choice

elective abortion

This deliberate type of abortion is recommended by doctor to protect mental and physical health

therapeutic abortion

What are the 4 stages of spontaneous abortion (due to natural causes)

1. threatened abortion

2. inevitable abortion

3. incomplete abortion

4. complete abortion

Common fetal causes of abortion

• abnormal fetal development

• chromosomal abnormalities

Maternal factors of abortion

• age

• structural abnormalities of the reproductive tract

• inadequate progesterone production

• maternal infections

• chronic and systemic maternal disease

• exogenous factors

• immunologic factors or rejection of embryo through an immune response

• antiphospholipid antibody syndrome

• This is an autoimmune disease in which abnormal proteins (antiphospholipid autoantibodies) initiate coagulation leading to clotting in arteries and veins.

• If clotting occurs in placental vessels, it can block placental growth, & thrombi that form can loosen the placenta & interfere w/ oxygen & nutrient.

antiphospholipid antibody syndrome (APS)

Prophylaxis to prevent miscarriages

• oral low-dose aspirin

• heparin (subcutaneous) - beginning pregnancy to several weeks postpartum

• IV immunoglobulin infusion or corticosteroid - can be added if heparin and aspirin alone is not adequate

What is always the presenting symptoms of spontaneous miscarriage?

vaginal spotting

This refers to possible loss of the products of conception

threatened abortion

S/S of threatened abortion

• light vaginal bleeding (scanty, bright red)

• none to mild uterine cramping

• no cervical dilatation

Management of threatened abortion

1. assess for LMP; ask for presence of clots; pain

2. conservative management: bed rest and avoiding coitus

3. provide reassurance, showing normal pregnancy ultrasound

4. assess FHR

5. HCG monitoring

Key intervention of threatened miscarriage

avoiding of strenuous activity for 24 - 28 hours

How often should blood be drawn for HCG monitoring for threatened abortion?

start of bleeding and again in 48 hours

Conservative management of threatened abortion

• bedrest until 3 days after bleeding has stopped (usually w/in 24 hours of bleeding will stop

• no coitus up to 2 weeks after bleeding has stopped

This conservative management for threatened abortion may cause congenital anomaly and is no longer advocated

hormonal therapy

This refers to the loss of the product of conception that cannot be prevented

inevitable or imminent abortion

When does a threatened abortion become an imminent or inevitable abortion?

if uterine contractions and cervical dilatation occur as, with cervical dilatation, the loss of the products of conception cannot be halted

S/S of inevitable or imminent abortion

• moderate to profuse bleeding

• moderate to severe cramping

• open cervix or dilatation of cervix

• rupture of membranes

• no tissue has passed yet

Management of inevitable or imminent abortion

• hospitalization

• vacuum extraction, dilatation & curettage or dilatation & evacuation

• oxytocin after D&C

• after D&E, woman should monitor vaginal bleeding

• sympathetic understanding and emotional support

• This refers to the spontaneous expulsion of the products of conception

• The entire products of conception (fetus, membranes, and placenta) are expelled spontaneously without any assistance

complete abortion

For a patient with complete abortion, what should be seen her history?

History of the following:

• vaginal bleeding

• abdominal pain

• passage of tissue

On examination, what are noted for a patient who went a complete abortion?

• light bleeding or some blood in vaginal vault

• no tenderness in cervix, uterus, or abdomen

• none to mild uterine cramping

• closed cervix

• empty uterus on ultrasound

Management of complete abortion

• observe closely for continued bleeding or signs of infection

• advice to eat high iron foods

• advice rest for few days to 2 weeks

• inform patient that she may experience intermittent menstrual-like flow and cramps during the following week

• determine CBC, HCG levels, and Rh factor

For a patient that had complete abortion, when do we advise them to return?

If the following occur:

• profuse vaginal bleeding

• severe pelvic pain

• temperature greater than 100 degree F

• This is the expulsion of some parts and retention of other parts of conceptus in utero.

• Part of the conceptus (usually the fetus) is expelled, but the membranes or placenta is retained in the uterus

incomplete abortion

S/S of incomplete abortion

• heavy vaginal bleeding

• severe uterine cramping

• open cervix

• passage of tissue

• ultrasound shows that some of the products of conception are still inside the uterus

Management of incomplete abortion

• D&C

• monitor blood loss

• monitor I&O

• sympathetic understanding and moral support

• This is the retention of all products of conception after the death of fetus in the uterus

• Also known as early pregnancy failure

missed abortion

S/S of missed abortion

• absence of FHT

• signs of pregnancy disappear

What is inserted to frequently manage medical abortion up to 28 weeks for missed abortion (if pregnancy is over 14 weeks, labor will be induced by what?) How frequent is it administered?

• 20 mg dinoprostone (prostaglandin E2) suppository

• every 3 or 4 hours, as necessary

These are some medications that are used in missed miscarriage, which are the same medications for elective termination

• misoprostol (Cytotec) or a prostaglandin suppository - introduced into the posterior fornix to cause dilation

• mifepristone or oxytocin (after prostaglandin E2 or misoprostol is inserted to cause contractions and birth)

What is administered to expel conceptus in managing missed abortion?

dilute IV infusion of oxytocin

• This is a miscarriage pattern in which three spontaneous abortions occurred at the same gestational age

• “habitual aborters”

recurrent or habitual abortion

Possible causes of recurrent or habitual abortion

• Defective spermatozoa or ova

• Endocrine factors (hormonal influences)

• nutritional status

• listeriosis - eating contaminated food

• Deviations of the uterus

• Resistance to uterine artery blood flow

• Chorioamnionitis or uterine infection

• Autoimmune disorders such as those involving lupus anticoagulant & antiphospholipid antibodies

How to manage a recurrent or habitual abortion?

identify cause to determine the most effective treatment

This is infection involving the products of conception and the maternal reproductive organ

infected abortion

Danger signs of infection

• fever (higher than 38 degrees)

• abdominal pain or tenderness

• foul vaginal discharge

This is the most common cause of infected abortion. It spreads from rectum to the vagina

e. coli

This is the common infection that occurs with infected abortion

endometritis

Management of infected abortion

• wipe front to back after urination and defecation

• no tampon usage

• antibiotic

• antipyretic

Dissemination of bacteria (&/or their toxins) into the maternal circulatory & organ system, complicated by infection

septic abortion

S/S of septic abortion

• foul smelling vaginal discharge

• uterine cramping and tenderness

• fever, chills, and peritonitis

• WBC = 16,000 to 22,000/uL

Critically ill patients may evidence septic or endotoxic shock with what?

• vasomotor collapse

• hypothermia

• hypotension

• oliguria or anuria

• respiratory distress

Management of septic abortion

• high dose of antibiotic therapy

  • penicillin for gram -

  • clindamycin and tobramycin for gram +

• D&C if accompanied by incomplete abortion or removal of all infected or necrotic tissues

• central venous pressure

• Tetanus toxoid subcu or tetanus immune globulin IM

• dopamine & digitalis

• O2 and perhaps ventilatory support

What is the antibiotic administered for gram - for septic abortion?

• penicillin

• metronidazole

What is the antibiotic administered to manage gram + microorganisms for septic abortion

• clindamycin

• tobramycin

• gentamicin

If patient is experiencing excessive vaginal bleeding, how should we position them?

position woman flat and massage the fundus

To manage hemorrhage in abortion, what should be administered to aid uterine contractions

methylergonovine maleate (methergine)

These are used to maintain sufficient cardiac output in septic abortion

• dopamine

• digitalis