Hemorrhage and DIC

Miscarriage (Medical Term: Abortion)

General Concepts

  • Most miscarriages occur within the first twelve weeks of pregnancy.

  • Late miscarriages can occur beyond this time frame.

  • Unexplained miscarriages are common.

Types of Miscarriages to Study

  • Threatened Miscarriage:

    • Cervix is closed; bleeding can occur.

    • Possible to continue the pregnancy with rest and sedation; about half can carry to term.

  • Inevitable Miscarriage:

    • Cervix is open with bleeding.

    • Cannot save the pregnancy.

    • May have to perform D&C (Dilation and Curettage) if contents aren't expelled naturally.

  • Incomplete Miscarriage:

    • Fetal tissue may have passed, but not all products of conception; placenta is retained.

    • Requires D&C.

  • Missed Miscarriage:

    • No fetal movement detected; nonviable fetus must be addressed.

    • Generally managed within 3 to 5 days.

    • Risks include infection, amniotic fluid embolism, DIC (Disseminated Intravascular Coagulation).

Lab Assessments and Treatments

  • Important Labs & Tests:

    • Hemoglobin and Hematocrit (H & H). Low r/t blood loss.

    • hCG (human chorionic gonadotropin) levels. Levels fall r/t missed abortion.

    • Ultrasound to check for gestational sac, fetal movement.

Postpartum Considerations

Recovery Guidelines

  • Allow area in the uterus (placenta site) to heal.

  • Avoid sex, douching, swimming, tampons, and tub baths for a specific period.

  • Prioritize hygiene and dietary needs for anemia recovery.

  • Expect bleeding for 7 to 10 days.

Incompetent Cervix

  • Cervical dilation occurs without uterine contractions, risking pregnancy.

  • Cerclage may be performed to prevent preterm labor.

  • Women may experience pressure in pelvis & thighs, lower back pain.

Diagnosis and Monitoring

  • Use transvaginal ultrasound to evaluate cervical length (ideally above 30 mm).

  • Monitoring is crucial: Home care must include limited activity and frequent check-ups.

Ectopic Pregnancy (Ruptured v Not Ruptured)

Signs and Symptoms

  • Ruptured: Abnormal vaginal bleeding, pain of the abdomen/shoulder, syncope, dizziness, shock s/s, urinary frequency, and/or Cullen’s sign.

  • Not Ruptured: amenorrhea or abnormal vaginal bleeding, s/s of pregnancy, and lower abdominal tenderness/pain.

Diagnostic Techniques

  • Transvaginal ultrasound not showing gestational sac in the uterus.

  • hCG levels not rising as expected.

  • Lower H&H, and rising leukocytes. >25 progesterone rules of ectopic.

Treatment Options

  • If under 3.5 cm and unruptured, methotrexate can be used to prevent surgery.

  • If ruptured, surgery is required with significant risks to fertility.

Gestational Trophoblastic Disease (GTD)

  • Non-viable fetus/pregnancy characterized by abnormal proliferation of trophoblastic tissue.

  • Symptoms: Elevated hCG levels, enlarged uterus, severe nausea/vomiting, bleeding, passage of vesicles, and pre-E s/s before 20 wks..

Monitoring and Support

  • Ensure monthly monitoring of hCG for at least six months to a year post-diagnosis to rule out choriocarcinoma.

Placenta Previa

Overview

  • Placenta abnormality causing painless, bright red bleeding in mid-pregnancy.

  • Classifications include marginal, partial, and complete previa.

Management

  • Avoid vaginal exams to prevent unnecessary trauma/bleeding. Diagnosed with ultrasound.

  • Continuous fetal monitoring, potential surgical intervention needed if bleeding does not stabilize.

  • Limit activity, serial NST, BPP, and other PTL interventions.

Placental Abruption

Details

  • A normally placed placenta separates from uterine wall prematurely causing painful bleeding.

  • After 20 weeks gestation; classified by how much of the placenta has detached (%).

  • Risks include concealed bleeding and rigid abdomen.

Monitoring

  • Fetal monitoring will reveal late decelerations due to placental detachment.

  • Immediate intervention required if severe.

Postpartum Hemorrhage

Definitions

  • Defined as:

    • More than 500 ml post vaginal delivery or 1000 ml post C-section.

    • A 10% change in hematocrit from labor to postpartum.

Causes

  • The leading cause is uterine atony (not firm/midline).

  • Possible lacerations or retained placental fragments also implicated.

Shock and DIC (Disseminated Intravascular Coagulation)

Pathophysiology

  • Coagulation breakdown, causing widespread bleeding and clot formation across organs.

  • Trauma causes massive clotting (tiny clots everywhere) → tiny clots use up all the clotting factors → no clotting factors when you need them = starts bleeding a ton → micro-clots block blood flow to organs

  • Characterized by bleeding at multiple sites; unrelated to one another (3+).

  • Some R/F include hemorrhage, amniotic fluid embolism, placental abruption, Pre-Eclampsia, and HELLP.

Diagnostics

  • Labs: Schistocytes (+), Prolonged PT & PTT, Decreased Fibrinogen/FV/FVII, Increased d-dimer/FSP/FDP, and Decreased PLTs/H&H.

  • Correct the underlying cause.

  • Monitoring should be continuous; team communication essential for timely management.