CH 28 Antepartal Hemorrhagic Disorders

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Antepartal Hemorrhagic Disorders

Antepartal Hemorrhagic Disorders

Antepartum Hemorrhagic Disorders

Bleeding in pregnancy jeopardizes both maternal and fetal well-being
Maternal blood loss decreases oxygen-carrying capacity, increases risk for:
Hypovolemia
Anemia
Infection
Preterm labor
Adverse oxygen delivery
FETAL RISKS:
Blood loss; anemia, hypoxemia, hypoxia, anoxia, and preterm labor.

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Maternal blood loss decreases oxygen-carrying capacity, which predisposes the woman to increased risk for hypovolemia, anemia, infection, and preterm labor and adversely affects oxygen delivery to the fetus.

Early Pregnancy Bleeding

Miscarriage (spontaneous abortion)
Incidence and etiology
Types
Clinical manifestations
Care management D&C (dilation & curettage)
Follow up care at home

Miscarriage (Spontaneous Abortion)

A pregnancy that ends as a result of natural causes before 20 weeks of gestation is defined as a spontaneous abortion. This 20 week marker is considered to be the point of viability, when a fetus may survive in an extrauterine environment. A fetal weight less than 500 g also may be used to define

Incidence and Etiology

Approximately 10% to 15% of all clinically recognized pregnancies in the United States end in miscarriage ( Simpson & Jauniaux, 2007).

An early miscarriage

is one that occurs before 12 weeks of gestation. At least 50% of all clinically recognized pregnancy losses result from chromosomal abnormalities. The majority (more than 80%) of miscarriages occur early, before 12 weeks of gestation (Cunningham, 2010).

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Possible causes include endocrine imbalance (as in women who have luteal phase defects or insulin-dependent diabetes mellitus with high blood glucose levels in the first trimester), immunologic factors (e.g., antiphospholipid antibodies), systemic disorders (e.g., lupus erythematosus), and genetic factors. Varicella infection in the first trimester increase risk of spontaneous abortions.

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A late miscarriage occurs between 12 and 20 weeks of gestation. It usually results from maternal causes, such as advancing maternal age and parity, premature dilation of the cervix and other anomalies of the reproductive tract, inadequate nutrition, and recreational drug use, obesity, and stressful life events.

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Types
The types of miscarriage include threatened, inevitable, incomplete, complete, and missed. All types of miscarriage can recur in subsequent pregnancies; all types except the threatened miscarriage can lead to infection (Fig. 28-1).

Pitocin

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Hemabate

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Methergine

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Ergot

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Clinical Manifestations
Signs and symptoms of miscarriage depend on the duration of pregnancy. The presence of uterine bleeding, uterine contractions, or abdominal pain is an ominous sign during early pregnancy and must be considered a threatened miscarriage until proven otherwise.

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If miscarriage occurs before the sixth week of pregnancy, the woman may report a heavy menstrual flow. Miscarriage that occurs between weeks 6 and 12 of pregnancy causes moderate discomfort and blood loss. After week 12, miscarriage is typified by more severe pain, similar to that of labor, because the fetus must be expelled. Diagnosis of the type of miscarriage is based on the signs and symptoms present (Table 28-1).

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Symptoms of a threatened miscarriage (see Fig. 28-1, A) include spotting of blood but with the cervical os closed. Mild uterine cramping may be present.

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Inevitable (see Fig. 28-1, B) and incomplete (see Fig. 28-1, C) miscarriages involve a moderate to heavy amount of bleeding with an open cervical os. Tissue may be present with the bleeding. Mild to severe uterine cramping may be present. An inevitable miscarriage is often accompanied by rupture of membranes (ROM) and cervical dilation; passage of the products of conception will occur. An incomplete miscarriage involves the expulsion of the fetus with retention of the placenta.

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In a complete miscarriage (see Fig. 28-1, D), all fetal tissue is passed, the cervix is closed, and there may be slight bleeding. Mild uterine cramping may be present.

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The term missed miscarriage (see Fig. 28-1, E) refers to a pregnancy in which the fetus has died, but the products of conception are retained in utero for up to several weeks. It may be diagnosed by ultrasonic examination after the uterus stops increasing in size or even decreases in size. No bleeding or cramping may be present, and the cervical os remains closed.

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Habitual miscarriage or recurrent spontaneous abortion (RSA) is three or more consecutive pregnancy losses before 20 weeks of gestation. The causes are some of those discussed earlier, it may be related to chromosomal abnormalities.

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CARE MANAGEMENT
Whenever a woman has vaginal bleeding early in pregnancy, a thorough assessment should be performed (Box 28-1). Laboratory findings are characteristic of miscarriage. Evaluation of human chorionic gonadotropin (hCG), a placental hormone, is used in the diagnosis of pregnancy and pregnancy loss along with progesterone.

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Medical management (see Table28-1 depends on the classification of the miscarriage and on signs and symptoms. Traditionally, threatened miscarriages have been managed with bed rest and supportive care. Follow-up treatment depends on whether the threatened miscarriage progresses to actual miscarriage, or symptoms subside and the pregnancy remains intact.

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Prostaglandin medication ( misoprostol ( cytotec) may be given orally or vaginally and is usually effective in completing the miscarriage within 7 days. Dilation and curettage (D&C) is a surgical procedure in which the cervix is dilated and a curette is inserted to scrape the uterine walls and remove uterine contents. A D&C is commonly performed to treat inevitable and incomplete miscarriage. The nurse reinforces explanations, answers any questions or concerns, and prepares the woman for surgery.

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Intravenous (IV) oxytocin is given afterwards to prevent hemorrhage. ( methergine ( ERGOT product may be given or HEMABATE if oxytocin does not work.

Nursing Care
Immediate nursing care focuses on physiologic stabilization. Teaching BOX.

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NURSE ALERT
Procedures for disposition of the fetal remains vary from hospital to hospital and state to state. The nurse should know what the usual procedures are in his or her setting.
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Miscarriages A. Threatened B. Inevitable. C. Incomplete. D. Complete E. Missed

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Incompetent Cervix (Recurrent Premature Dilation of the Cervix)
which has traditionally been defined as passive and painless dilation of the cervix during the second trimester. This definition assumes an "all-or-nothing" role for the cervix; it is either "competent" or "incompetent." Some books may refer to it as cervical insufficiency.

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Etiology
Etiologic factors include a history of previous cervical lacerations during childbirth, excessive cervical dilation for curettage or biopsy, or the woman's mother's ingestion of diethylstilbestrol (DES)during pregnancy with the woman. Multiple gestation may provide an additional stress on the cervix but alone does not produce cervical incompetency or justify prophylactic cervical cerclage A short cervix (less than 25 mm in length) is indicative of reduced cervical competence.

Diagnosis

Reduce cervical competence is the diagnosis and is seen on ultrasound, it can be accompanied by cervical funneling ((breaking) or effacement if the internal os.

Management

Bed rest, pessaries, antibodies, antinflammatory drugs and progesterone supplementation . A cervical cerclage may be performed. During gestation, a McDonald cerclage, a band of homologous fascia or nonabsorbable ribbon (Mersilene), may be placed around the cervix beneath the mucosa to constrict the internal os of the cervix (Fig. 28-2). A cerclage procedure can be classified according to time, or whether it is elective (prophylactic), urgent, or emergent (Cunningham, 2011).
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Prophylactic cerclage is placed at 11 to 15 weeks of gestation, after which the woman is told to refrain from intercourse. She is monitored during the course of her pregnancy with ultrasound scans to assess for cervical shortening and funneling. The cerclage is electively removed (usually an office or a clinic procedure) when the woman reaches 37 weeks of gestation, or it may be left in place and a cesarean birth performed.

Home Care.
The woman must understand the importance of activity restriction at home and the need for close observation and supervision. She must be instructed on the importance of taking oral tocolytic medication if prescribed, the expected response, and possible side effects. Tocolytics may be given prophylactically to prevent uterine contractions and further dilation of the cervix. If home uterine monitoring is implemented, the woman is taught how to apply a uterine contraction monitor and transmit the monitor tracing by telephone to the monitoring center. Nurses at the monitoring center assess the tracing for contractions, answer questions, provide emotional support and education, and report information to the woman's physician or nurse-midwife.

The woman must be aware that strong contractions less than 5 minutes apart, ROM, severe perineal pressure, and an urge to push will warrant immediate transfer to the hospital setting. If management is unsuccessful and the fetus is born before viability, appropriate grief support should be provided. If the fetus is born prematurely, appropriate anticipatory guidance and support will be necessary.

CERCLAGE

Cerclage correction of premature dilatation of the cervix.

An ectopic pregnancy

is one in which the fertilized ovum is implanted outside the uterine cavity (Fig. 28-3). Two percent of all first-trimester pregnancies in the United States are ectopic, and these account for 9% of all pregnancy-related maternal deaths. Women are less likely to have a successful subsequent pregnancy after an ectopic pregnancy

Ectopic pregnancy

is also a leading cause of infertility.
Ectopic pregnancies are often called tubal pregnancies because approximately 95% are located in the uterine tube (Cunningham et al., 2010).

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Although they are much less common, ectopic pregnancies can also occur in the abdominal cavity, on an ovary, or on the cervix. Of all tubal ectopic pregnancies, more than half (approximately 55%) are located in the ampulla, or largest portion of the tube (Gilbert, 2011).

The reported incidence of ectopic pregnancy

rose through 1990 in the United States. Since then, because more cases are managed medically, reliable data on the actual number of ectopic pregnancies have not been available (Cunningham et al., 2010). Some of the increased incidence is likely because of improved diagnostic techniques, such as more sensitive β-hCG measurement and transvaginal ultrasound, resulting in the identification of more cases. Other causes for the rise include an increased incidence of sexually transmitted infections, tubal infection and damage, popularity of contraceptive methods that predispose failures to be ectopic (e.g., the intrauterine device [IUD]), use of tubal sterilization methods that increase the chance of ectopic pregnancy, increased use of assisted reproductive techniques, and increased use of tubal surgery (Cunningham et al.; Gilbert, 2011).

Clinical Manifestations

Most cases of ectopic (tubal) pregnancy are diagnosed before rupture based on the three most classic symptoms: (1) abdominal pain, (2) delayed menses, and (3) abnormal vaginal bleeding (spotting) that occurs approximately 6 to 8 weeks after the last normal menstrual period (Gilbert, 2011). Abdominal pain occurs in almost every case. It usually begins as a dull, lower quadrant pain on one side. The discomfort can progress from a dull pain to a colicky pain when the tube stretches, to sharp, stabbing pain (Cunningham et al., 2010; Gilbert). It progresses to a diffuse, constant, severe pain that is generalized throughout the lower abdomen (Gilbert). Up to 90% of women with an ectopic pregnancy report a period that is delayed 1 to 2 weeks or is lighter than usual, or an irregular period. Mild to moderate dark red or brown intermittent vaginal bleeding occurs in up to 80% of women (Gilbert).
If the ectopic pregnancy is not diagnosed until after rupture has occurred, referred shoulder pain may be present in addition to generalized, one-sided, or deep lower quadrant acute abdominal pain. Referred shoulder pain results from diaphragmatic irritation caused by blood in the peritoneal cavity. The woman may exhibit signs of shock, such as faintness and dizziness, related to the amount of bleeding in the abdominal cavity and not necessarily related to obvious vaginal bleeding. An ecchymotic blueness around the umbilicus (Cullen sign), indicating hematoperitoneum, may also develop in an undiagnosed, ruptured intraabdominal ectopic pregnancy.

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Surgical Management
Surgical management depends on the location and cause of the ectopic pregnancy, the extent of tissue involvement, and the woman's desires regarding future fertility. One option is removal of the entire tube (salpingectomy). If the tube has not ruptured and the woman desires future fertility, salpingostomy may be performed instead. In this procedure an incision is made over the pregnancy site in the tube and the products of conception are gently and very carefully removed. The incision is not sutured but left to close by secondary intention instead, given that this method results in less scarring.

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If surgery is planned, general preoperative and postoperative care is appropriate for the woman with an ectopic pregnancy. Before surgery, vital signs (pulse, respirations, and blood pressure [BP]) are assessed every 15 minutes or as needed, according to the severity of the bleeding and the woman's condition. Preoperative laboratory tests include determination of blood type and Rh factor, complete blood cell count, and serum quantitative β-hCG level. Ultrasonography is used to confirm an extrauterine pregnancy. Blood replacement may be necessary. The nurse verifies the woman's Rh and antibody status and administers Rho(D) immune globulin postoperatively if appropriate.

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Follow-up Care
The woman and her family should be encouraged to share their feelings and concerns related to the loss. Future fertility should be discussed. A contraceptive method should be used for at least three menstrual cycles to allow time for the woman's body to heal (Gilbert, 2011). Every woman who has been diagnosed with an ectopic pregnancy should be instructed to contact her health care provider as soon as she suspects that she might be pregnant because of the increased risk for recurrent ectopic pregnancy. These women may need referral to grief or infertility support groups. In addition to the loss of the current pregnancy, they are faced with the possibility of future pregnancy losses or infertility.

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FIG. 28-3 Sites of implantation of ectopic pregnancies. Order of frequency of occurrence is ampulla, isthmus, interstitium, fimbria, tuboovarian ligament, ovary, abdominal cavity, and cervix (external os).

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Hydatidiform mole (molar pregnancy) is a benign proliferative growth of the placental trophoblast in which the chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in a grapelike cluster. Hydatidiform mole is a gestational trophoblastic disease. Gestational trophoblastic disease (GTD) is a group of pregnancy-related trophoblastic proliferative disorders without a viable fetus. In addition to hydatidiform mole, GTD includes invasive mole, gestational choriocarcinoma, placental site trophoblastic tumor, and gestational trophoblastic neoplasia (GTN) (American College of Obstetricians and Gynecologists [ACOG], 2004). (See Chapter 11 for a discussion of GTN.)

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A hydatidiform mole may be further categorized as a complete or partial mole. The complete mole results from fertilization of an egg in which the nucleus has been lost or inactivated (Fig. 28-5, A). The partial mole is an arrangement that occurs as a result of two sperm fertilizing an apparently normal ovum.

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Clinical Manifestations
In the early stages the clinical manifestations of a complete hydatidiform mole cannot be distinguished from those of normal pregnancy. Later, vaginal bleeding occurs in almost 95% of cases. The vaginal discharge may be dark brown (resembling prune juice) or bright red and either scant or profuse. It may continue for only a few days or intermittently for weeks. Early in pregnancy the uterus in approximately one half of affected
women is significantly larger than expected from menstrual dates. The percentage of women with an excessively enlarged uterus increases as length of time since the last menstrual period increases. Approximately 25% of affected women have a uterus smaller than would be expected from menstrual dates.
Anemia from blood loss, excessive nausea and vomiting (hyperemesis gravidarum), and abdominal cramps caused by uterine distention are relatively common findings. Women may also pass vesicles, which are frequently avascular edematous villi, from the uterus. Preeclampsia occurs in approximately 70% of women with large, rapidly growing hydatidiform moles and occurs earlier than usual in the pregnancy. If preeclampsia is diagnosed before 24 weeks of gestation, hydatidiform mole should be suspected and ruled out. Hyperthyroidism is another serious complication of hydatidiform mole. Usually treatment of the hydatidiform mole restores thyroid function to normal. Partial moles cause few of these symptoms and may be mistaken for an incomplete or missed miscarriage (Cohn et al., 2009; Nader, 2009; Roberts & Funai, 2009).

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Diagnosis:
Transvaginal ultrasound and serum hCG levels are used for diagnosis. Transvaginal ultrasound is the most accurate tool for diagnosing a hydatidiform mole.

Management
Although most moles abort spontaneously, suction curettage offers a safe, rapid, and effective method of evacuating a hydatidiform mole if necessary (Cunningham et al., 2010; Gilbert, 2011). Induction of labor with oxytocic agents or prostaglandin is not recommended because of the increased risk of embolization of trophoblastic tissue. Post-evacuation administration of Rho(D) immune globulin to women who are Rh negative is necessary to prevent isoimmunization (Gilbert, 2011).

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NURSING ALERT
To avoid confusion in regard to rising levels of hCG that are normal in pregnancy but could indicate GTD, pregnancy should be avoided during the follow-up assessment period. Any contraceptive method except an IUD is acceptable. Oral contraceptives are preferred because they are highly effective.
Follow-up Care
Follow-up care includes frequent physical and pelvic examinations along with weekly measurements of the β-hCG level until the level decreases to normal and remains normal for 3 consecutive weeks. Monthly measurements are then taken for 6 months. The follow-up assessment period usually continues for a year. During that time, a rising β-hCG level and an enlarging uterus may indicate GTD (Gilbert, 2011).

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Rupture of uterus and spillage of mole into peritoneal cavity.

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Placenta Previa
In placenta previa, the placenta is implanted in the lower uterine segment such that is completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces. near or over the internal cervical os.

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In placenta previa the placenta is implanted in the lower uterine segment such that it completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces (Fig. 28-8) (Hull & Resnik, 2009). When transvaginal ultrasound is used, the placenta is classified as a complete placenta previa if it totally covers the internal cervical os. In a marginal placenta previa the edge of the placenta is seen on transvaginal ultrasound to be 2.5 cm or closer to the internal cervical os. When the exact relationship of the placenta to the internal cervical os has not been determined or in the case of apparent placenta previa in the second trimester, the term low-lying placenta is used (Hull & Resnik).

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Incidence and Etilogy
In addition to a history of previous cesarean birth, other risk factors for placenta previa include advanced maternal age (more than 35 to 40 years of age), multiparity, history of prior suction curettage, and smoking (Hull & Resnik, 2009). Cigarette smoking leads to a decrease in uteroplacental oxygenation and thus a need for increased placental surface area. Placenta previa is more likely to occur in women with multiple gestations because of the larger placental area associated with these pregnancies. Women who had placenta previa in a previous pregnancy are more likely than others to develop the problem in a subsequent pregnancy, perhaps as a result of a genetic predisposition. Previous cesarean birth and curettage in the past for miscarriage or induced abortion are risk factors for placenta previa because both result in endometrial damage and uterine scarring (Francois & Foley, 2007; Hull & Resnik).

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Clinical Manifestations:
Placenta previa is typically characterized by painless bright red vaginal bleeding during the second or third trimester. In the past, placenta previa was usually diagnosed after an episode of bleeding. Currently, however, most cases are diagnosed by ultrasound before significant vaginal bleeding occurs. This bleeding is associated with the disruption of placental blood vessels that occurs with stretching and thinning of the lower uterine segment.

Can lose up to 40% of her blood volume without showing signs of shock. Decrease in urinary output may be better indicators of the acute blood loss than the vital signs.

Abdominal exam will reveal soft, relaxed non tender uterus with normal tone, usually fetal presentation is breech or oblique is common.

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Maternal and Fetal outcomes:
Complication associate with placenta previa is hemorrhage. (also an abnormal placental attachment - placenta accreta, increta or perceta) all this can lead to hysterectomy

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Diag - with painless bleeding after 20 weeks - ultrasound with clearly diagnosis.

See Nursing Process Page 682



Treatment:
Delivery if needed, if not then bed rest, with BRP, no vaginal or rectal examinations, u/s every 2 to 3 weeks and NST once a week.

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Premature separation of the placenta, also termed abruptio placentae, is the detachment of part or all of the placenta from its implantation site (Fig. 28-9). Separation occurs in the area of the decidua basalis after 20 weeks of pregnancy and before the birth of the baby.

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Incidence and Etiology
Premature separation of the placenta is a serious event that accounts for significant maternal and fetal morbidity and mortality. Maternal hypertension is probably the most consistently identified risk factor for abruption (Francois and Foley , 2007).Cocaine use is also a risk factor because of the hypertensive state it can cause. Blunt external abdominal trauma, most often the result of motor vehicle accidents or maternal battering, is an increasingly significant cause of placental abruption (Cunningham, 2010).

Table 28-2 (types)

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Clinical Manifestation:
The separation may be partial or complete, or only the margin of the placenta may be involved. Bleeding from the placental site may dissect (separate) the membranes from the decidua basalis and flow out through the vagina (70% to 80%), it may remain concealed (retroplacental hemorrhage) (10% to 20%), or both (Fig. 28-10) (Francois & Foley, 2007; Gilbert, 2011).

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Maternal, Fetal, and Neonatal Outcomes
The perinatal mortality rate approaches 20-30% for abruptio placentae; this condition remains a leading cause of maternal death.

Maternal complications are associated with the abruption or its treatment. Hemorrhage, hypovolemic shock, hypofibrinogenemia, and thrombocytopenia are associated with severe abruption.

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Diagnosis:Placental abruption is primarily a clinical diagnosis. Although ultrasound can be used to rule out placenta previa, it cannot detect all cases of abruption. A retroplacental mass may be detected with ultrasonographic examination, but negative findings do not rule out a life-threatening abruption. In fact, at least 50% of abruptions cannot be identified on ultrasound (Hull & Resnik, 2009). Hypofibrinogenemia and evidence of DIC support the diagnosis, but many women with placental abruption do not develop coagulopathy. The diagnosis of abruption is confirmed after birth by visual inspection of the placenta. Adherent clot on the maternal surface of the placenta and depression of the underlying placental surface are usually present (see Fig. 28-9) (Francois & Foley, 2007; Gilbert, 2011).

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Disseminated vascular coagulation (DIC), or consumptive coagulopathy, is a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both, and clotting (Cunningham et al., 2010). DIC is never a primary diagnosis. Instead it results from some problem that triggered the clotting cascade, either extrinsically, by the release of large amounts of tissue thromboplastin, or intrinsically, by widespread damage to vascular integrity.

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CLINICAL MANIFESTATIONS AND LABORATORY SCREENING RESULTS FOR WOMEN WITH DISSEMINATED INTRAVASCULAR COAGULATION
POSSIBLE PHYSICAL EXAMINATION FINDINGS
• Spontaneous bleeding from gums, nose
• Oozing, excessive bleeding from venipuncture site, intravenous access site, or site of insertion of urinary catheter
• Petechiae, for example, on the arm where blood pressure cuff was placed
• Other signs of bruising
• Hematuria
• Gastrointestinal bleeding
• Tachycardia
• Diaphoresis

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LABORATORY COAGULATION SCREENING TEST RESULTS
• Platelets—decreased
• Fibrinogen—decreased
• Factor V (proaccelerin)—decreased
• Factor VIII (antihemolytic factor)—decreased
• Prothrombin time—prolonged
• Partial prothrombin time—prolonged
• Fibrin degradation products—increased
• D-dimer test (specific fibrin degradation fragment)—increased
• Red blood smear—fragmented red blood cells
FIBRIN SPLIT PRODUCT INDICATING A MARKER OF dic

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