Bleeding During Pregnancy

Pregnancy Bleeding Early Causes

Spontaneous Abortion, Ectopic Pregnancy, Gestational Trophoblastic Disease & Cervical Insufficiency

Spontaneous Abortion or miscarriage

Loss of pregnancy where the pregnancy ends prior to 20 weeks gestation, 10-15% of known pregnancies; women may experience an abortion and may not know it

Spontaneous Abortion If gestation unknown

weigh products of conception (POC)

Any POC that weighs less than 550 g is categorized as

a spontaneous abortion

Threatened abortion- suspicious

Vaginal bleeding, cramping, back painCervical os closed, Intrauterine pregnancy viable , has heart rate

Inevitable abortion – often leads to loss

Vaginal bleeding – more bleeding than threaten, also leak of amniotic fluid, Cervical os is open, Fetal heartbeat has stopped or slowed

Incomplete abortion

Cervical os is open, Intrauterine pregnancy will be there, but some products of conception will already have come out – may need to be removed, No heartbeat at all

complete abortion

Cervical os is closed, There is no intrauterine pregnancy out. Passage of all products of conception, No bleeding no pain no heartbeat

Missed abortion

Cervical os is closed, Fetus present but no cardiac function, No more growth in the embryo but body doesn’t realized the pregnancy is over

Spontaneous Abortion Risk Factors

Chromosomal abnormalities (common with first pregnancy ) Maternal medical conditions – uncontrolled HTN, DM, infections, Advanced maternal age – over 35 is advance, or less than 20 are at higher risk Cervical incompetence, Trauma or injury – infection, fetal anomalies Substance use, Environmental exposures

Infection – in the uterus,

increase WBC, high temp. cramping bleeding, tenderness when touching belly

Spontaneous Abortion Nursing Assessment

Bleeding (first sign), abdominal pain or cramping, rupture of membranes, backache, dilated cervix, fever

Spontaneous Abortion Laboratory Tests

Hgb and Hct- with significant blood loss, Clotting studies- Is the patient developing DIC, WBC- with concerns of suspected infection, Human chorionic gonadotropin (hCG)- confirming the pregnancy (if losing pregnancy hcG goes down)

Spontaneous Abortion Diagnostics - Tells us what kind of abortion

Ultrasound- is there a viable fetus, Cervical exam- cervix open or close

Spontaneous Abortion D&C or S&C

remove products of conception for inevitable or incomplete abortion

D+C

dilate the cervix and scrape out

S+C

dilatate and suction out

Spontaneous Abortion treatment Misoprostol

to induce contractions for expulsion of conception products.

Spontaneous Abortion treatment Rho(D) immune globulin

this will suppress the immune response in women that are Rh negative

Spontaneous Abortion treatment

Connect with clients, using supportive language, offering condolences, being sorry for their loss Education, what happens next, when can I try again, what happened

Ectopic Pregnancy Pathophysiology

Abnormal implantation of fertilized ovum outside of uterine cavity, Occurs about 0.5%-2% of all pregnancies Most common in fallopian tubes; can lead to tubal rupture causing hemorrhage, Reduces woman’s chance of subsequent pregnancies.

Ectopic Pregnancy Risk Factors

STI sequalae – multiple sti / untreated sti/IVF surgeries = scarring of fallopian tubes (most happen in fallopian tube, Tubal surgery, Infertility (procedures that are done to relieve infertility)

Ectopic Pregnancy Nursing Assessment

Focuses on determining the existence of an ectopic pregnancy and whether it has ruptured.

Ectopic Pregnancy signs

Unilateral stabbing pain and tenderness in lower abdominal quadrant, The menstrual period may be different (light or missed). Dark red or brown vaginal spotting, Referred shoulder pain – Cullen sign – discoloration around bellybutton

Ectopic Pregnancy Laboratory Tests

Progesterone and beta-hCG levels will be low < 5,000 mIU/ml. – Visualize an empty uterus via transvaginal ultrasound.

What is hCG doing in early pregnancy

hCG doubles about every 48 hours until about 10 weeks. In ectopic it will only go up about ¼ or it doesn’t go up at all, or it will drop

Ectopic Pregnancy Management

Cervical exam, D&C or D&E

Ectopic Pregnancy if Methotrexate (folic acid antagonist)

prevents division that occurs in ovum, only if unruptured fallopian tube, no cardiac activity, and hemodynamically stable and mass < 4 cm in size

Ectopic Pregnancy Surgical-ruptured fallopian tube (If VS are unstable, or ruptured)

Salpingectomy Salpingostomy

Salpingectomy

removal of tube – if tube ruptured, decreases her change of getting pregnancy

Salpingostomy

save tube and remove obstruction

Ectopic Pregnancy Nursing Management

Obtaining the hCG, Assist with medical procedure, Monitor for complications

Ectopic Pregnancy Offer support and education

decrease pregnancy, resting after procedure, call HCP if heavy bleeding, signs of infection but also support bc this is a loss to mom, may need support groups

Gestational Trophoblastic Disease – or Moral

Production and breakdown of trophoblastic tissue in the placenta, The villi become swollen and grapelike clusters., The fetus does not develop beyond the primordial stage, May develop choriocarcinoma. Occurs in one out of 1000 pregnancies

Gestational Trophoblastic Disease Two types

partial (hydatidiform mole) & complete can lead to (choriocarcinoma)

Partial mole

1 ovum and two sperm, Maternal and paranal genetic material , May contain some fetal parts, but lots of anomalies that make it incompatible with life

Complete mole

No maternal genetic material, No fetus no placenta, no amniotic fluid, May lead to bleeding in the uterine cavity , 20% will progress to a carcinoma

Gestational Trophoblastic Disease Risk Factors

Prior molar pregnancy, Maternal age>35 years old or < 20 years old

Gestational Trophoblastic Disease Nursing Assessment

Excessive vomiting, Rapid uterine growth, Uterine high greater than gestational age, Vaginal bleeding (dark brown like prune juice or bright red and scant or profuse) Anemia, preeclampsia signs before 24-week gestation

Gestational Trophoblastic Disease Excessive vomiting due

to elevated hCG levels

Gestational Trophoblastic Disease Rapid uterine growth due to

increased proliferation of trophoblastic cells

Gestational Trophoblastic Disease Clinical findings of preeclampsia before 24-week gestation

high BP, blurry vision, epigastric pain,

Gestational Trophoblastic Disease Laboratory Tests

Serum hCG is persistently elevated compared to normal decline after week 10-12. , Transvaginal ultrasound

Gestational Trophoblastic Disease nursing management

Measure fundal height. Assess vaginal bleeding, Assess GI and appetite, Monitor for manifestations of preeclampsia, Provide emotional support

Gestational Trophoblastic Disease Evacuate tissue with

D&C or S&C; afterwards monitor for bleeding – h/h dropping, anemia may need transition, monitor BP, pain, and cardiopulmonary problems – depends on size, must be removed

Gestational Trophoblastic Disease Administer medications

Rho(D) to Rh neg patients – Chemotherapeutic medications for choriocarcinoma

Gestational Trophoblastic Disease Patient education

Follow up with pelvic exams, ultrasounds Serial hCG levels-Weekly for 3 weeks and then monthly for 3 months up to a year, Birth control for a year, Consider pregnancy loss support groups

Cervical Insufficiency

a weak, structurally defective that spontaneously dilates in the absence of uterine contractions in the second trimester, or early third trimester, resulting in the loss of the pregnancy. Exact cause unknown; possibly related to tissue changes or alterations in the length of the cervix during pregnancy.

Cervical Insufficiency Risks Factors

History of cervical trauma, cervical tears from previous births, Repeated losses, Surgical procedures, Advanced cervical dilation in early weeks, Congenital- uterine anomalies e.g., exposure to diethylstilbestrol

Cervical Insufficiency Nursing Assessment

Increased pelvic pressure, Vaginal discharge or bleeding, Dilated cervix , Shortening before term

Cervical Insufficiency Diagnostic Tests

Transvaginal ultrasound- shortened cervix

Cervical Insufficiency Therapeutic Management

Bedrest, pelvic rest, no heavy lifting, nothing in the vagina. Cerclage may need to be inserted

Cervical Insufficiency Nursing Management

Monitor for bleeding and contractions, Patient education

Pregnancy Bleeding-Late Causes

Placenta previa, Abruptio placenta, and Vasa previa

Late Pregnancy Bleeding

occurring after 20 weeks gestation

Placenta previa

Placenta abnormal implants near or over the cervical os instead of in the fundus. Occurs in one out of 200 pregnancies

Placenta previa Risk factors

Previous previa , Adv. Maternal age >35, Previous uterine scar, Multipara or close spacing pregnancy, Multifetal gestation, Smoker

Placenta previa Nursing Assessment

Painless bright red bleeding (at any time), Soft relaxed uterus, Abnormal fetal position, reassuring fetal heart rate, normal vital signs, decreasing urinary output

Placenta previa Laboratory Tests

WBC, H/H, Platelets, PT/INR, PRR, Fibrinogen, platelets, Kleihuer-Betke

Kleihuer-Betke negative/positive

check if mom and fetus blood have mixed

Placenta previa Medical Management

Ultrasound - Locating placenta, Monitor client and fetus, in vital signs or fetal heart rate Monitor for placenta accreta

placenta accreta

Placenta grows into the muscle layer of the uterus

If completes placental pervia

C-section, no vaginal exams

Placenta previa Nursing Management

Monitor for bleeding, leaking or contractions, Monitor fetal well-being Pelvic rest, Have oxygen ready for fetal distress

Pelvic rest

No vaginal exams, no intercourse, nothing in the vagina

Placenta previa meds

Administer IV fluids, blood products, betamethasone (to mature babies lungs) Rho(D) should administer if Rh neg

Placenta abruption Pathophysiology

Premature separation of the placenta from the uterus. It can be partial or complete. Degeneration of small maternal arterioles resulting in thrombosis and rupture of vessels This bleeding forms a clot and puts pressure behind the placenta causing a separation Fetal blood supply compromised causing fetal distress

Placenta abruption Risk factors

Maternal hypertension, Blunt trauma, Smoker, Cocaine abuse, Previous history of abruption, Multiples (more than one fetus), Infections , Premature rupture of membrane, Oxytocin (uterine hyperstimulation)

Oxytocin

stimulate labor

Placenta abruption Nursing Assessment

dark red bleeding , extended fundal height, tender uterus, abdominal pain, concealed bleeding. hard abdomen, experience DIC, distressed fetus

Placenta abruption Laboratory Tests

Hgb, and Hct decreased. Coagulation factors decreased (fibrinogen), Clotting defects (DIC) Cross and type (blood transfusion,) Kleihauer-Betke

Placenta abruption Diagnostics

Ultrasound Biophysical profile (BPP) Fetal heart rate will look distressed high and then drops low, late descalations (drop after contractions),

Biophysical profile (BPP)

looks at fetal well-being, checks how much fluid is around the baby, feta movements

Placenta abruption Medical Management

Getting the baby out immediately – C section

Placenta abruption Nursing Management

Palpate the uterus for rock hard, painful uterus. Perform serial monitoring of the fundal height. Assess FHR pattern. Monitor maternal vital signs, observing for declining hemodynamic status. Perform continuous fetal monitoring. Assess urinary output and monitor fluid balance. Provide emotional support for the client and family.

Placenta abruption Administer

IV fluids, blood products, and medications as prescribed. Administer oxygen 8 to 10 L/min via face mask. Monitor maternal vital signs, observing for declining hemodynamic status.

Vasa Previa

Fetal umbilical vessels implant in the fetal membranes or amniotic sac rather than the placenta

Vasa Previa Three variations

Velamentous insertion Succenturiate insertion Battledore insertion

Velamentous insertion of the cord

Cord vessels sit above the placenta. (Most commonly seen) most dangerous

Succenturiate insertion of the cord

The placenta has divided into two or more lobes and not one mass.

Battledore insertion of the cord

A marginal insertion, Increased risk of fetal hemorrhage

Vasa Previa Diagnostic

ultrasound for fetal well-being and vessel assessment to determine type of vasa and check for bleeding after rupture of membranes (ROM)

Vasa Previa Nursing Management

Monitor closely during labor for excessive bleeding If bleeding is heavy, manage for shock. IV fluids and medications

Vasa Previa Nursing Management Succenturiate lobe or battledore insertion

may not notice prior to delivery, but it is okay we may see after delivery

Velamentous insertion Nursing Management

if we don’t recognize prior to birth may have a fetal death, but if we know before we can plan for a C/S,