Bleeding Disorders

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1st Trimester BleedingSpontaneous miscarriage

ThreatenedImminent Complete MissedRecurrent pregnancy loss

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Abortion

• ABORTION Early (before 20 wks)- Any pregnancy that terminates before the age

of viability • Spontaneous abortion characterized by

painless (may be cramping) dark-bright red vaginal bleeding

Spontaneous Abortion

• MiscarriageCauses: Abnormal fetal formation, chromosomal

aberration, Infections (CMV & Toxoplasmosis)S/Sx: Vaginal spottingManagements:- Depending on the manifestations

Threatened Abortion

Cause: UnknownS/Sx: Scant bright red vaginal bleeding

with slight abdominal cramping and no cervical dilation

Managements:• No treatment to hold pregnancy• Complete Bed rest (Limit activity)• Coitus restricted for 2 wks

Inevitable Abortion

• ImminentS/Sx: Moderate bright red bleeding; uterine contraction

and effacementManagements:• Establish IV line;Draw blood• Administer pitocin• WOF: signs of hypovolemic shock• D&C

Complete Abortion

• All the products of conception are expelled (placenta and fetus)

• Bleeding shows within 2 hrs and ceases within few days after the passage of conceptus

Incomplete Abortion

• Part of the conception is expelled usually the fetus• S/Sx: massive bleeding and clot bloods

Missed Abortion

• Intrauterine fetal death• Fetus die in utero but not expelledS/Sx: Asymptomatic or same with threatened abortionDx: • Fetus died but not expelled• Discovered in prenatal check-up• Fundal height in Increasing• No FHT

Missed Abortion

Cx: Disseminated Intravascular CoagulationManagement: 1. Replacement of IV fluids2. Administer pitocin.3. D&C

Habitual Abortion

• RecurrentCause: Defective spermatozoa, autoimmune, infectionCx: Hemorrhage and Infection

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CLINICAL CLASSIFICATIONS OF SPONTANEOUS ABORTION Type Assessment Nursing Considerations Threatened Vaginal bleeding and

cramping Soft uterus, cervix closed

Ultrasound for intrauterine sac, quantitative HCG Decrease activity for 24-48 h, avoid stress, no sexual

intercourse for 2 wk after bleeding stops Monitor amount and character of bleeding; report

clots, tissue, foul odor Inevitable, if

cervical dilation cannot be prevented (Imminent)

Persistent symptoms, hemorrhage, moderate to severe cramping

Cervical dilatation and effacement

Monitor for hemorrhage (save and count pads) and infection; if persistent or increased symptoms, D and C

Emotional support for grief and loss

Incomplete Persistent symptoms, expulsion of part of products of conception

Administer IV/blood, oxytocin D and C or suction evacuation

Complete As above, except no retained tissue

Possible oxytocin PO; no other treatment if no evidence of hemorrhage or infection

Missed – fetus dies in utero but is not expelled

May be none/some abating of above symptoms

Cervix is closed If retained >6 wk, increased

risk of infection, DIC, and emotional distress

D and C evacuation within 4-6 wk After 12 wk, dilate cervix with several applications of

prostaglandin gel or suppositories of laminaria (dried sterilized seaweed that expands with cervical secretions)

Habitual – 3 or more

May be incompetent cervix, infertility

Cerclage (encircling cervix with suture)

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1st Trimester BleedingEctopic pregnancy

Implantation occurs outside of the uterine cavity

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SITES AT WHICH ECTOPIC PREGNANCY CAN OCCUR

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Ectopic pregnancy

– implantation outside uterus (commonly in fallopian tube)- potentially life threatening to mother

- Characterized by: unilateral lower quadrant pain after 4-6 weeks of normal

signs and symptoms of pregnancy (amenorrhea, (+) pregnancy test

bleeding may be gradual oozing to frank bleeding may be palpable unilateral mass in adnexa low HCG levels rigid and tender abdomen signs and symptoms of hemorrhage

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Ectopic Pregnancy– Necessary to be alert for signs and symptoms –

investigate risk factors especially PID, multiple sexual partners, recurrent episodes of gonorrhea, infertility

Management – prepare for surgery– Shock monitoring and management– postoperatively, monitor for infection and paralytic ileus– Provide support for emotional distress– RhoGam for Rh- negative woman– monitor Hgb and Hct– ultrasound for adnexal mass/ gestational sac in tube – culdocentesis (indicated by nonclotting blood)– laparoscopy and/or laparotomy– adequate blood replacement (type and X match, IV with

large-bore needle)

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2nd Trimester Bleeding

Premature cervical dilatationCannot hold the fetus until termCervical cerclage

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Incompetent Cervix

• Painless dilatation of the cervix usually in the 2nd trimester

• May lead to infection, premature rupture of membranes, preterm labor

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SHIRODKAR SUTURE FOR CERVICAL CERCLAGE

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2nd Trimester BleedingGestational trophoblastic disease

(hydatidiform mole)Abnormal proliferation and degeneration of

the trophoblastic villidegenerative anomaly of the placenta

converting the chorionic villi into a mass of clear vesicles

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Hydatidiform moleCharacterized by • elevated HCG levels• uterine size greater than expected for gestational age• no FHR• minimal dark red/brown vaginal bleeding with passage of

grapelike clusters• no fetus by ultrasound• possible increased nausea and vomiting and associated

pregnancy-induced hypertension• treated with curettage to completely remove all molar tissue,

which can become malignant• pregnancy is discouraged for 1 year, and HCG levels are monitored

during that time (if it continues to be elevated, may require hysterectomy and chemotherapy)

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Gestational trophoblastic disease (hydatidform mole)

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3nd Trimester Bleeding Placenta previa

Low implantation of placenta Abruptio Placenta

Premature separation of placentaOccurs suddenly

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Placenta previa• development of the placenta in the lower uterine

segment, partially or completely covering the internal cervical os

• Characterized by painless vaginal bleeding, which is usually slight at first (spotting – 1st and 2nd trimesters) and increases in subsequent unpredictable episodes; usually soft and non tender abdomen

4 Degrees of Placenta previa1. Low-lying - in lower segment2. Marginal - at border of internal cervical os3. Partial – occludes a portion of the cervical os4. Total - complete obstruction of the os

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DEGREES OF PLACENTA PREVIA

LOW IMPLANTATION PARTIAL PLACENTA PREVIA TOTAL PLACENTA PREVIA

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Placenta PreviaManagements• Hospitalization • bed rest • side-lying or Trendelenburg position for at least 72 hours• ultrasound shows the location and degree of obstruction• no vaginal/ rectal exam unless delivery would not be a problem

(if it becomes necessary, it must be done in OR under sterile conditions)

• amniocentesis for lung maturity• monitor for changes in bleeding and fetal status• daily Hgb and Hct; keep IV line and make blood available (blood typed

and cross matched- 2 units)• Delivery by cesarean if evidence of fetal maturity, excessive bleeding,

active labor, other complications• Home - if bleeding ceases and pregnancy to be maintained – limit

activity; no douching, enemas, coitus; monitor FM; NST at least every 1-2 wk

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Abruptio placenta

• premature separation of normally implanted placenta; may be marginal (near edge) with dark red vaginal bleeding or central (at center) with concealed bleeding; life threatening to fetus and mother

• Common among women with hypertension, short umbilical cord and alcohol use; also by direct trauma

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Abruptio PlacentaCharacterized by:- painful (sharp, stabbing) vaginal bleeding/ epigastric pain- uterine rigidity and tenderness: abdomen is tender,

painful and tense (board-like)- rapid signs and symptoms of maternal shock and/or fetal

distress (altered FHR)- May lead to Couvelaire uterus (blood infiltrating the

uterine musculature) forming a hard, board-like uterus without apparent bleeding

- External bleeding may seem out of proportion to symptoms (shock) displayed by the woman

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PREMATURE SEPARATION OF THE PLACENTA

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Abruptio Placenta

• Manage signs and symptoms- Keep woman in lateral position (not supine)- Oxygenation (to limit fetal anoxia)- FHR monitoring; VS monitoring- Baseline fibrinogen (if bleeding is extensive,

fibrinogen reserve may be used up in the body’s attempt to accomplish effective clot formation)

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Abruptio Placenta- NO IE or rectal examination, No enema- Keep IV open for possible blood transfusion• prepare for immediate delivery usually, cesarean

section

• Postoperatively monitor for complications– Infection– Renal failure– Disseminated intravascular coagulation (DIC)

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Disseminated Intravascular Coagulation (DIC) Disorder of blood clotting

Fibrinogen levels fall below effective limits Symptoms

Bruising or bleeding massive hemorrhage initiates coagulation process

causing massive numbers of clots in peripheral vessels (may result in tissue damage from multiple thrombi), which in turn stimulate fibrolytic activity, resulting in decreased platelet and fibrinogen levels and

signs and symptoms of local generalized bleeding (increased vaginal blood flow, oozing IV site, ecchymosis, hematuria, etc)

monitor PT, PTT, and Hct, protect from injury; no IM injections; early anticoagulant therapy is controversial