BLEEDING DISORDERS

Complications of Pregnancy

I. Complications of Pregnancy

• A. Non-bleeding Disorder

• B. Bleeding Disorder

II. Identifying a High-Risk Pregnancy

• Definition of High-risk pregnancy:

  • High-risk pregnancy: one in which a concurrent disorder, pregnancy-related complication, or external factor jeopardizes the health of the woman, the fetus, or both.

III. Factors That Categorize a Pregnancy as High Risk

A. Psychological Factors

• History of:

  • Drug dependence (including alcohol)

  • Intimate partner abuse

  • Mental illness

  • Poor coping mechanisms

  • Cognitive challenges

  • Survivor of childhood sexual abuse

• Loss of support person

• Decrease in self-esteem

• Drug abuse (including alcohol and cigarette smoking)

• Poor acceptance of pregnancy

B. Social Factors

• Occupation involving handling toxic substances (including radiation and anesthesia gases)

• Environmental contaminants at home

• Isolation

• Lower economic level

• Poor access to transportation for care

• Lack of support people

C. Physical Factors

• Prepregnancy and current medical history:

  • Previous complications:

  • Hx of previous poor pregnancy outcomes (miscarriage, stillbirth, intrauterine fetal death)

  • Hx of child with congenital anomalies

  • Pelvic inadequacy or misshape

  • Uterine incompetency, position, or structure

  • Secondary major illnesses:

  • Heart disease

  • Diabetes mellitus

  • Kidney disease

  • Hypertension

  • Chronic infections (e.g., tuberculosis)

  • Hematologic or blood disorders

  • Malignancies

  • Obesity (BMI > 30) or underweight (BMI < 18.5)

  • History of inherited disorders

  • Visual or hearing challenges

  • Small stature

  • Potential blood incompatibility

  • Age factors: younger than 18 years or older than 35 years

  • Substance abuse: Cigarette smoking

IV. Psychological, Social, and Physical Factors Affecting Pregnancy

A. Psychological Factors

• Issues during Pregnancy:

  • Illness of a family member

  • Disruptive family incident

  • Decreased economic support

  • Conception less than one year after last pregnancy

  • Trauma exposure

• Physiological Challenges:

  • Fluid or electrolyte imbalance

  • Intake of teratogens such as drugs

  • Multiple gestation

  • Bleeding disruptions

  • Gestational diabetes

  • Nutritional deficiencies (iron, folic acid, protein, poor weight gain)

  • Pregnancy-induced hypertension

  • Infection

  • Amniotic fluid abnormalities (post-maturity)

B. Social Factors

• Labor and Birth Anxieties:

  • Fear associated with labor and birth experience

  • Lack of preparation for labor

  • Birth of an infant who is disappointing in some aspect (sex, appearance, congenital anomalies)

  • Illness in newborn

  • Inadequate home for infant care

  • Unplanned cesarean birth

  • Lack of access to continued healthcare

  • Lack of access to emergency personnel or equipment

C. Physical Complications During Labor and Birth

• Possible complications:

  • Hemorrhage

  • Infection

  • Fluid and electrolyte imbalances

  • Dystocia

  • Precipitous labor

  • Lacerations of cervix or vagina

  • Cephalopelvic disproportion

  • Internal fetal monitoring issues

  • Retained placenta

V. Non-bleeding Pregnancy-related Complications

A. Hyperemesis Gravidarum

• Definition:

  • Hyperemesis Gravidarum: Excessive nausea and vomiting resulting in dehydration and electrolyte imbalance that interferes with food intake.

B. Assessment of Hyperemesis Gravidarum

• Risk factors: Unknown

• Diagnostics: By symptoms

• Clinical Manifestations:

  • Persistent nausea and vomiting, often with complete inability to retain food and liquids

  • Significant weight loss

  • Dehydration

  • Electrolyte and acid-base imbalances

C. Treatment of Hyperemesis Gravidarum

• Medical treatment includes:

  • Replacement of parenteral fluids, electrolytes, and vitamins

  • Dietary protocols:

  • NPO (nothing by mouth) for the first 48 hours

  • After condition improves, six small feedings alternating with liquid nourishment every one to two hours

  • If vomiting reoccurs, resume NPO and administer IV fluids

  • May require placement of central line for extended use of TPN (Total Parenteral Nutrition) or lipids

D. Nursing Care Goals

• Assist with medical and dietary management of hyperemesis gravidarum.

VI. Bleeding During Pregnancy

A. Vaginal Bleeding

• Characteristics and Clinical Importance:

  • Vaginal bleeding during pregnancy is always a deviation from the normal.

  • It can occur at any point during pregnancy and is always frightening; must be investigated as it can impair both pregnancy outcomes and the woman's health.

B. Summary of Primary Causes of Bleeding During Pregnancy

1. First Trimester

• Causes:

  • Threatened miscarriage

  • Inevitable miscarriage

  • Missed miscarriage

  • Incomplete miscarriage

  • Complete miscarriage

  • Ectopic pregnancy

• Assessment and Symptoms:

  • Vaginal spotting and cramping

  • Signs of shock or hemorrhage in ectopic pregnancy

2. Second Trimester

• Causes:

  • Hydatidiform mole (gestational trophoblastic disease)

  • Premature cervical dilation

• Assessment and Symptoms:

  • Abnormal proliferation of trophoblast cells

  • Painless bleeding

  • Risks for malignancy after molar pregnancy

3. Third Trimester

• Causes:

  • Placenta previa

  • Abruptio placentae

  • Preterm labor

• Assessment and Symptoms:

  • Painless bleeding in placenta previa

  • Sharp abdominal pain in abruptio placentae

VII. Assessment of Bleeding

• Importance:

  • Women with any bleeding need evaluation for significant blood loss or hypovolemic shock.

A. Blood Loss and Body Compensation

• Effects of blood loss include:

  • Decreased intravascular volume

  • Decreased cardiac output and lowered blood pressure

  • Heart compensates by increasing heart rate and peripheral vasoconstriction

  • Cold, clammy skin, decreased uterine perfusion

• Signs of hypovolemic shock typically occur after the loss of 10% of blood volume (approximately 2 units of blood). Fetal distress occurs with 25% blood volume loss.

B. Signs and Symptoms of Hypovolemic Shock

• Assessment Signs:

• Increased pulse rate

• Decreased blood pressure

• Increased respiratory rate

• Cold, clammy skin

• Decreased urine output

• Dizziness or decreased consciousness

VIII. Emergency Interventions for Bleeding in Pregnancy

• Immediate actions include:

  • Alerting healthcare team

  • Bed rest on side

  • Starting IV with lactated Ringer’s solution

  • Administering oxygen as necessary

  • Monitoring uterine contractions and fetal heart rate by external monitor

  • Omitting vaginal examination

  • Ordering type and cross-match for blood

  • Measuring intake/output and maternal blood loss

  • Assessing vital signs

  • Assisting with ultrasound examination

IX. Clinical Picture of a Patient in Hypovolemic Shock

• Signs include:

  • Altered mental status (restlessness, disorientation)

  • Tachycardia

  • Hypotension due to decreased blood volume

  • Dyspnea from decreased red blood cells

  • Cold, clammy skin

• Necessary interventions:

  • IV fluid replacement

  • Blood transfusions if needed

X. First Trimester Bleeding Disorders

A. Spontaneous Miscarriage

• Definition:

  • Abortion: any interruption of a pregnancy before a fetus is viable (before 20-24 weeks of gestation).

• Incidence:

  • 15% to 30% of all pregnancies.

• Classifications:

  • Early miscarriage: before week 16.

  • Late miscarriage: between weeks 16 and 20.

B. Complications and Causes of Spontaneous Miscarriage

• Causes include:

  • Abnormal fetal development (chromosomal aberrations, teratogenic factors)

• Symptoms and assessment of miscarriage:

  • Vaginal spotting, duration and intensity, associated symptoms, and previous surgical history.

• Types of spontaneous miscarriage include:

  • Threatened, inevitable, complete, incomplete, missed, recurrent pregnancy loss.

C. Management and Monitoring

• Assessment for each type of miscarriage includes:

  1. Threatened Miscarriage

  • Symptoms: vaginal bleeding, cramping

  • Intervention: evaluate fetal heart tones (FHT) and placental function.

  1. Imminent Miscarriage

  • Symptoms: uterine contractions, cervical dilatation

  • Management: report and save tissue fragments for examination.

  1. Complete Miscarriage

  • Definition: entire conceptus expelled.

  1. Incomplete Miscarriage

  • Definition: part expelled, risk of hemorrhage.

  1. Missed Miscarriage

  • Definition: fetus dies in utero, management involves ultrasound and D&E.

  1. Recurrent Pregnancy Loss

  • Definition: three spontaneous losses, management includes endocrinology evaluation and consideration of structural issues.

XI. Ectopic Pregnancy

A. Definition

• Ectopic pregnancy occurs when implantation occurs outside the uterine cavity, commonly in the fallopian tube.

B. Causes and Predisposing Factors

• Previous infections, congenital malformations, tubal surgery scars, smoking, and fertility drugs.

C. Symptoms and Assessment

• Symptoms include:

  • Light vaginal bleeding, abdominal pain, and possible signs of shock if rupture occurs.

  • Physical exam may reveal a tender mass.

D. Management

• Includes methotrexate for unruptured cases and laparoscopic surgery for ruptured ectopic pregnancy.

XII. Gestational Trophoblastic Disease (Hydatidiform Mole)

A. Definition

• An abnormal proliferation and degeneration of trophoblastic villi leading to the failure of embryo development beyond initial stages.

B. Risk Factors and Assessment

• Risk factors include older age, low protein intake, and specific blood types.

• Clinical manifestations include severe nausea, vaginal bleeding, and abnormal uterine growth.

C. Management and Prognosis

• Management includes suction curettage (D&C), and follows an HCG level monitoring to ensure complete resolution post-treatment.

• Typically benign but can evolve into malignancies if not monitored properly.