Hemorrhagic Disorders of Pregnancy Practice Flashcards

Learning Objectives for Hemorrhagic Disorders during Pregnancy

Examine the anatomy, physiology, and pathophysiology of hemorrhagic disorders during pregnancy.
Explore epidemiology, etiology, and risk factors that contribute to hemorrhagic disorders.
Differentiate the clinical presentation and treatment of hemorrhagic disorders.
Describe the impact of hemorrhagic disorders on clients’ overall health.
Explore the role of the nurse when caring for clients experiencing hemorrhagic disorders.
Apply the nursing process using clinical judgment functions while providing care to clients experiencing hemorrhagic disorders.

Anatomy and Physiology: Reproductive System and Pregnancy

Uterus and Female Reproduction: * The uterus consists of a uterine wall surrounding the cavity of the uterine body. * At the bottom of the uterine cavity is the internal orifice of the cervix. * The cervical structure includes the cavity of the cervix and the external orifice of the cervix, which leads to the vagina. * Key changes occur in the uterus, cervix, and vagina during pregnancy and labor to accommodate the growing fetus and facilitate delivery.
The Menstrual Cycle and Implantation: * Days 1 through 5: Involved in the breakdown and shedding of the endometrium. * Days 6 through 10: Phase of endometrium repair and growth. * Days 11 through 18: Continued growth of the endometrium. * Days 19 through 28: The endometrium continues to thicken to prepare for potential pregnancy. * Day 23: Around this approximate day, the implantation of a blastocyst may occur into the thickened endometrial lining.
Clotting Factors and Mediation: * Pregnancy involves significant changes in clotting factors and clotting mediation to manage the risk of hemorrhage. * Clotting Factors: Essential components include Factor VII, Factor VIII, Factor X, and Fibrinogen. * Clotting Mediators: Include Protein X, Plasmin, and Platelets.

Spontaneous Abortion (Miscarriage)

Pathophysiology and Definitions: * Commonly known as a miscarriage, it refers to the loss of a pregnancy before the fetus is viable. * Threatened abortion: Vaginal bleeding occurs, but the cervix remains closed. * Inevitable abortion: Vaginal bleeding is accompanied by cervical dilation. * Incomplete abortion: Some products of conception are expelled, but some remain within the uterus. * Complete abortion: All products of conception are expelled from the uterus. * Septic abortion: A spontaneous abortion that is complicated by an intrauterine infection. * Missed abortion: The fetus has died in utero, but the products of conception are not expelled.
Management and Treatment: * Medical Management: It may be necessary to dilate the cervix to remove the products of conception. * Expectant Management: Monitoring to see if the body expels the tissue naturally. * Procedural Management: Surgical intervention to evacuate the uterus. * Alloimmunization: Assessment and treatment for Rh incompatibility (e.g., RhoGAM) are crucial following an abortion.
Role of the Nurse: * Monitor the client's physical status (bleeding, pain, vitals). * Administer prescribed medications and treatments. * Provide essential emotional support to the client and family. * Implement teaching as a nursing intervention regarding physical recovery and warning signs.
Impact on Health: * Psychosocial impact includes complex feelings of grief and loss. * Nursing care must consider the maternal client's specific needs, health promotion, and disease prevention.

Molar Pregnancy (Gestational Trophoblastic Disease)

Pathophysiology: * A molar pregnancy is characterized by the absence of a viable fetus and hydropic vesicle changes of the trophoblast. * The vesicles have a typical "grape-like" appearance.
Types of Moles: * Complete Mole: Results when an ovum that does not contain maternal genetic material is fertilized by a single sperm. This results in an embryo with $46XX$ chromosomes. * Partial Mole: Results when an ovum containing maternal genetic material is fertilized by two sperm. This results in an embryo with $69XXY$ chromosomes. * Invasive Mole: A mole that invades the uterine wall.
Clinical Presentation and Diagnostics: * Laboratory Testing: Serial measurement of human chorionic gonadotropin (hCG) levels. * Diagnostic Studies: Ultrasound to identify the grape-like vesicles and absence of a fetus.
Client-Centered Care and Treatment: * Uterine Evacuation: The primary treatment to remove the abnormal tissue. * Hysterectomy: May be considered if the client does not desire future pregnancies or due to complications. * Chemotherapy: Indicated if gestational trophoblastic neoplasia develops. * Nursing Role: Includes teaching, monitoring for complications, and addressing grief and loss.

Cervical Insufficiency

Pathophysiology: * Characterized by painless cervical dilation leading to a second-trimester pregnancy loss. * A normal cervix is typically closed with a mucus plug, whereas an insufficient cervix lacks this plug and begins to dilate without contractions.
Treatment and Therapies: * Medical Management: Administration of Progesterone to help maintain the pregnancy. * Surgical Management: Placement of a Cerclage, which is a procedure to stitch the cervix closed to prevent premature dilation.
Impact and Nursing Role: * Consideration of the maternal client's physical needs and psychosocial impact of potential preterm loss. * Education on the risks of preterm birth and preterm labor.

Ectopic Pregnancy

Pathophysiology: * The implantation of a fertilized egg outside of the uterine cavity.
Clinical Presentation: * Abdominal Pain: Often the primary symptom. * Vaginal Bleeding: May or may not be present. * Additional manifestations may mimic other abdominal or gynecological conditions.
Treatments and Therapies: * Expectant Management: Active monitoring in stable, early cases. * Medical Management: Use of Methotrexate to stop the growth of rapidly dividing cells. * Surgical Management: Necessary if the ectopic pregnancy ruptures or medical management is not appropriate. * Teaching: Education on the signs of rupture and recovery.

Placenta Previa

Pathophysiology and Types: * Occurs when the placenta attaches to the lower uterine segment, potentially covering the cervix. * Marginal Placenta Previa: The placenta is attached near the wall of the cervix but does not cover the opening at all. * Partial Placenta Previa: A small portion of the placenta covers the internal cervical os. * Complete Placenta Previa: The placenta entirely covers the internal cervical os.
Anatomical Variations: * Anterior Placenta: Positioned at the front of the uterus. * Posterior Placenta: Positioned toward the top back of the uterus.
Care and Management: * Follow-up ultrasounds to monitor placental position. * Activity restrictions and monitoring for bleeding risks. * Medications: * Magnesium sulfate may be ordered as an anticonvulsant if related to other complications like preeclampsia. * Betamethasone (a glucocorticoid) is administered to promote fetal lung maturity if preterm delivery is anticipated.

Placental Abruption

Pathophysiology: * The premature separation of the placenta from the uterine wall before the birth of the fetus.
Classifications and Stages: * Stage 1: Expected positions of maternal vessels and fetal attachment. * Stage 2: A pool of blood begins to gather at the placental attachment site (hemorrhage). * Stage 3/4: Continued blood pooling leads to the complete detachment of the placenta from the uterine wall.
Clinical Variations: * Abruption with visible hemorrhage: Blood flows from the site of separation through the cervix and out of the vagina. * Concealed Hemorrhage: Blood is trapped behind the placenta with no visible vaginal flow.
Presentation: * Acute Abruption: Sudden onset of pain and bleeding. * Chronic Abruption: Slower, progressive detachment over time.

Clotting Disorders in Pregnancy

Specific Conditions: * Inherited Thrombophilia: Genetic predisposition to clotting. * Gestational Thrombocytopenia: Low platelet count specific to the pregnancy period.
Treatment and Nursing Care: * Treatment goals focus on preventing thromboembolic events and managing bleeding risks during labor. * Nurses must anticipate the administration and timing of anticoagulants or other blood products during pregnancy, labor, and delivery.

Questions & Discussion

Spontaneous Abortion: Who may be impacted by a spontaneous abortion? What resources can a nurse recommend (be specific)?
Gestational Trophoblastic Neoplasia: What is gestational trophoblastic neoplasia? How would the nurse describe this condition to the client? What is the treatment for gestational trophoblastic neoplasia?
Preterm Birth: What is preterm labor and preterm birth? What risks are there for the mother and the infant? Describe the nurse's role in preparing for a preterm delivery.
Methotrexate: Why would methotrexate be ordered for a client experiencing an ectopic pregnancy? Explain how methotrexate works. What education should the client be given regarding methotrexate?
Magnesium Sulfate and Betamethasone: Why may magnesium sulfate (anticonvulsant) and betamethasone (gluco-corticoids) be ordered during pregnancy? How and when are these medications administered?
Clotting Disorders: Describe the goal of treatment for a pregnant client with a clotting disorder such as inherited thrombophilia. What medication should the nurse anticipate will be prescribed? Discuss administration of this medication during each stage of pregnancy, labor, and delivery.