LECTURE C HEMORRHAGIC COMPLICATIONS DURING PREGNANCY LATE Separation of the Placenta

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					                                      LECTURE 6 –
                       HEMORRHAGIC COMPLICATIONS DURING PREGNANCY

LATE PREGNANCY BLEEDING

ABRUPTIO PLACENTAE
Abruptio placentae (placental abruption) is premature separation of a normally implanted placenta in the uterine
wall. It is either a partial or complete separation, and involves an apparent or concealed hemorrhage.

    •   Unknown cause: may be attributed to decreased blood flow to the placenta. #1 cause is maternal
        hypertension. Other risk factors: cocaine use (causes severe HTN), blunt external trauma to the abdomen
        (MVA, physical abuse), cigarette smoking, hx abruption, PROM, twin gestation
    •   Bleeding may or may not be observed depending on the degree and location of the separation.
        Retroplacental hemorrhage occurs about 10-20% of the time, in which the bleeding is “concealed.”
    •   Symptoms: vaginal bleeding, abdominal pain, uterine tenderness, contractions, rigid “boardlike” abdomen.
        Abdominal pain and uterine tenderness are characteristic of abruption.
    •   Maternal outcomes: maternal mortality rate is about 1% (abruption is a leading cause of maternal death).
        Complications: hemorrhage, hypovolemic shock, hypofibrinogenemia, thrombocytopenia, renal failure,
        pituitary necrosis, and maternal sensitization
    •   Fetal outcomes: perinatal mortality rates range from 10-12%. Death attributed to: fetal hypoxia, preterm
        birth, and SGA status. Fetal complications: neurologic defects and congenital anomalies
    •   Recognition of abruption: woman presents with sudden onset of intense, localized, uterine pain with or
        without vaginal bleeding. Fundal height increases over time (concealed bleeding); nonreassuring FHR;
        uterine hyperstimulation with increased resting tone; abnormal clotting studies (fibrinogen, PLT ct, PTT);
        ultrasound is not a reliable diagnostic tool for abruption.
    •   Treatment depends on the severity of blood loss and fetal maturity/status. Patient kept in the hospital.
        • Mild abruption with <36 week fetus in no distress: monitor for bleeding and labor, FHR , NST, BPP
        • Betamethasone if appropriate
        • Rhogam for Rh negative moms
        • Vaginal or c-section birth depending on maternal/fetal status. C-sections are common b/c of fetal or
             maternal distress.
        • Maternal VS, labs, continuous EFM, Foley catheter
        • Blood transfusions as needed
        • Emotional support; all procedures explained to patient

PLACENTA PREVIA
Placenta previa occurs when the placenta is improperly implanted in the lower uterine segment, either near or over
the internal cervical os.
     • Classifcations:
          • Total: placenta completely covers the internal os
          • Partial: placenta partially covers the internal os
          • Marginal: the edge of the placenta extends to the margin of the internal os
          • Low-lying: placenta is in the lower uterine segment, but does not touch the internal os
     • Significant risk factors: hx previa, previous c-section birth, hx suction curettage. Other risk factors:
          multiple gestation, closely spaced pregnancies, advanced maternal age (AMA), African-American or Asian,
          male fetal sex, smoking, cocaine use, multiparity
     • Placenta previa is characterized by painless bright red vaginal bleeding. The abdomen is not rigid: soft,
          relaxed, non-tender uterus with normal tone. VS usually normal & FHR usually reassuring unless the
          placenta detaches. Know the differences in the clinical manifestation of previa vs. abruption.
     • Maternal outcomes: mortality rate <1%. Complications: PROM, PTL and birth, surgery-related trauma,
          anesthesia complications, blood transfusion reactions, fluid overload, abnormal placental attachments
          (accreta), PP hemorrhage/hypovolemic shock, thrombophlebitis, anemia, infection
     • Fetal outcomes: fetal death due to preterm birth. Fetal complications: malpresentation & congenital
          anomalies. Neonatal complications: SGA, IUGR, anemia


                                                      D.Barrios
                                                  Lecture 6 Handout
    •    Diagnosis: transabdominal US
    •    Treatment: bedrest and observation if fetus is not mature (may be on bedrest at home). Vaginal exam is
         contraindicated because it can perforate the placenta and cause massive hemorrhaging. Maternal VS;
         continuous EFM; expectant management if fetus <36 weeks, no labor, and no/mild bleeding. Expectant
         management includes: bedrest or bedrest with BRP, monitor bleeding, US, NST, BPP, maternal labs, IV
         access, betamethasone, and c-section birth at 37 weeks if fetal lungs mature. Term gestation with labor or
         persistent bleeding immediate c-section

EARLY PREGNANCY BLEEDING

Abortion is the termination of the fetus before it reaches viability, which is defined as 20 weeks or 500 g (about 1
lb.). Abortion can be spontaneous or induced.
     • Spontaneous abortion (SAB) occurs naturally = miscarriage
     • Induced, or therapeutic abortion (TAB), occurs from artificial or mechanical interruption = abortion

MISCARRIAGE
   • Causes:
      • Early abortion (before 8 weeks gestation): endocrine imbalance, immunologic factors, infection
           (bacteriuria & Chlamydia), lupus, genetic factors (trisomy)
      • Late abortion (12-20 weeks gestation) usually attributed to maternal causes: AMA and parity, chronic
           infections, incompetent cervix, poor nutrition, recreational drug use, polycystic ovarian syndrome,
           anatomic abnormalities of the uterus, severe maternal illness such as poorly controlled diabetes,
           abdominal trauma
   • Types of miscarriage: threatened, inevitable/imminent, incomplete, complete, missed, septic,
      recurrent/habitual. Amount of bleeding and severity of uterine cramping depends on the type of
      miscarriage (refer to Table 23-6, page 741).
   • Medical management: bedrest and no sex; dilation and curettage (D&C) for inevitable and incomplete
      miscarriage; dilation and evacuation after 16 weeks for incomplete miscarriage; prostaglandins or IV
      pitocin for late incomplete, inevitable, and missed miscarriages
   • Nursing care: IV, labs (H&H, blood type and Rh, indirect Coomb’s test), analgesics, blood transfusion as
      needed, US for diagnostic confirmation, emotional support and pt education

ECTOPIC PREGNANCY
Ectopic pregnancy occurs when a fertilized ovum implants in a site other than the endometrial lining of the uterus.
    • Areas of implantation: ampulla of the fallopian tube (most common site), aka tubal pregnancy; cervix,
         ovary, or abdomen
    • Symptoms: sharp, one-sided lower abdominal pain or diffuse lower abdominal pain @ 5-6 weeks (pain
         caused by blood irritating the peritoneum); abnormal vaginal bleeding – dark red or brownish; syncope;
         referred right shoulder pain; hypovolemic shock
    • Nursing and medical management:
         • US (transvaginal) to confirm intrauterine pregnancy or identify a gestational sac in an
              unruptured tubal pregnancy
         • Monitor bleeding (internal bleeding may manifest as vertigo, shoulder pain, hypotension, tachycardia)
         • Vaginal exam only once (do with caution, in ½ of the cases a mass can be felt)
         • Salpingostomy if pregnancy <2cm in length and located in ampulla, methotrexate
         • Laparotomy for advanced ectopic pregnancy, methotrexate
         • VS, labs (blood type, Rh, antibody screen, CBC, serum hCG), blood transfusion as needed,
              analgesics, emotional support and pt education

GESTATIONAL TROPHOBLASTIC DISEASE
Gestational trophoblastic disease (GTD) is the pathologic proliferation of trophoblastic cells. It includes
hydatidiform mole and gestational trophoblastic neoplasia (GTN). Hydatidiform mole, also called molar pregnancy,
is a condition in which the proliferation of trophoblastic cells leads to abnormal development of the placenta.
Chorionic villi become swollen, fluid-filled grapelike clusters.



                                                        D.Barrios
                                                    Lecture 6 Handout
    •    Types of hydatidiform mole: complete mole and partial mole. Complete moles associated with
         choriocarcinoma or GTN.
    •    Signs & symptoms: clinical picture similar to pregnancy - uterine enlargement (50% of the time, uterus is
         larger than expected from menstrual dates), increased hCG levels, and nausea and vomiting; fetal heart
         tones absent; vaginal bleeding - brownish (prune juice color) or bright red, scant or profuse amount;
         suspect mole if sx of preeclampsia occur before 20 weeks
    •    Management: observe for signs of molar pregnancy; diagnose with US and serum hCG levels (higher with
         mole); may abort spontaneously or require suction evacuation; emotional support and pt education
    •    Follow-up care: weekly hCG levels until negative two consecutive times, then monthly for a year;
         increased hCG levels without pregnancy may indicate cancer, start chemo ASAP; chest x-ray to detect
         metastasis and repeat CXR if chemo was necessary; physical exams with pelvic exams every 4 weeks until
         in remission, then every 3 months for a year; instruct woman to avoid pregnancy b/c elevated hCG
         levels may confuse the diagnosis of choriocarcinoma.

INCOMPETENT CERVIX
Incompetent cervix is a dysfunctional cervix that prematurely dilates painlessly and without labor or contractions. It
may occur in the 2nd trimester or early 3rd trimester of pregnancy.
    • Causes: cervical trauma associated with previous birth/surgery; congenital structural defects associated
        with DES exposure or bicornuate uterus; or uterine anomalies
    • Diagnosis: short cervix (<20mm in length) and funneling internal os,
    • Nurse should assess woman’s feelings and evaluate support systems
    • Medical management: bedrest, hydration, progesterone, anti-inflammatory drugs, antibiotics
    • Cervical cerclage is the standard treatment for incompetent cervix, especially if hx previous losses.
        • Heavy suture reinforces the cervix at the internal os
        • May use Shirodkar or McDonald cerclage
        • Placed at 11-15 weeks; woman must refrain from sex, prolonged standing, heavy lifting; US to monitor
             cervical shortening & funneling
        • Cerclage removed at 37 weeks to have vaginal delivery, or left in place to have c-section delivery
        • Cerclage rarely done after 25 weeks of gestation b/c of risk of PROM, PTL, and chorioamnionitis
        • Nursing care: monitor woman after procedure for contractions, ROM, signs of infection; D/C teaching
             regarding when to notify MD (contractions, ROM, signs of infection); emotional support
        • Home management with cerclage: bedrest or activity restriction; pt knowledge of reportable signs;
             possibly tocolytics, possibly EFM
        • Anticipatory guidance and emotional support when infant born prematurely, grief support if infant
             born before viability




                                                       D.Barrios
                                                   Lecture 6 Handout

				
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