3Bleeding in Early Pregnancy Spontaneous AbortionThe major cause of bleeding in the first and second trimestersOccur naturallyExpulsion of the fetus prior to 20 weeks/500 gmsMay end as many of 60% of all pregnanciesEnds 20% of known pregnanciesSeven types noted
4Bleeding in Early Pregnancy SpontaneousThreatenedBleeding, cramping or backache, but cervix is closedEvaluate for ectopic pregnancy or hyatidiform moleOlds, Ladewig, London, Davidson. Pg. 469 Figure Can the illustration be separated into the relevant components, and so Figure 20-1 A goes here, after this?
5Bleeding in Early Pregnancy SpontaneousThreatenedImminent/InevitableBleeding/cramping increaseInternal cervical os dilatesMembranes may ruptureOlds, Ladewig, London, Davidson. Pg. 469 Figure 20-1, B after this?
6Bleeding in Early Pregnancy SpontaneousThreatenedImminent/InevitableIncompletePart of the products of conception are retainedUsually placenta and/or membranesInternal cervical os is dilatedDilation and curettage performed to remove the tissuesOlds, Ladewig, London, Davidson. Pg. 469 Figure 20-1, C after this slide?
7Bleeding in Early Pregnancy SpontaneousThreatenedImminent/InevitableIncompleteCompleteAll products of conception expelledUterus contracts, bleeding slowsCervix may be closed
8Bleeding in Early Pregnancy SpontaneousThreatenedImminent/InevitableIncompleteCompleteMissedFetus dies in utero, but is not expelledBreast changes regress, may be brownish vaginal discharge.Cervix is closedDrop in HCG levels and ultrasound confirms lossAfter 4 weeks, breakdown of fetal tissue releases thromboplastin, and DIC can result
9Bleeding in Early Pregnancy SpontaneousThreatenedImminent/InevitableIncompleteCompleteMissedRecurrent pregnancy lossConsecutively in three or more pregnancies
10Bleeding in Early Pregnancy SpontaneousThreatenedImminent/InevitableIncompleteCompleteMissedRecurrent pregnancy lossSeptic abortionInfection, usually with PPROM, pregnancy with IUD in place, or attempts to terminate a pregnancy by untrained persons
11Bleeding in Early Pregnancy Induced abortionOccur as a result of mechanical or chemical interruption88% are done prior to 12 weeks of pregnancyMedical (mifepristone+ misoprostol)Aspiration or suction curettage also usedAfter 14 weeks, may need dilation and evacuationMay be incomplete, or cause infectionPost procedure, bleeding shouldn’t soak a pad in one hour
12Nursing Care for Women At Risk Due to Bleeding in Pregnancy Monitor BP and pulse frequentlyAssess for s/s shockCount/weigh pads to estimate blood lossBeyond 12 weeks, FHT by DopplerPrepare for IV therapyObtain/prepare equipment for speculum examOrder labs as requested; usually CBC, coagulation studies, HCG, type and screen or cross
13Nursing Care for Women At Risk Due to Bleeding in Pregnancy Have oxygen therapy availableUltrasound machine availableAssess coping of the woman and her familyCommonly ordered but not proven effective:Bed rest with BRPPelvic rest is advised
14HCG: Human Chorionic Gonadatropin Detectable in blood after implantation (about 1 week after fertilization)Levels rise rapidly, peak around 9-10 weeks pregnancyDoubling every hours seen as sign of viabilityStimulates progesterone and estrogen production by corpus luteum until placenta takes over
15Nursing Care for Women After Pregnancy Loss Counsel patient to expect 8-10 days of bleeding after pregnancy lossSexual relations may resume once bleeding ends and patient feels readyPregnancy can occur, so contraception is advisedPatients are advised to wait 2-3 cycles to become pregnant againRh-negative woman must get RhoGAM IM
16Reflective ThinkingMonica is 12 weeks pregnant. She has saturated 2 pads and is experiencing cramping.What type of abortion may Monica have?What are the other types of abortion?What are the priorities in her nursing care?Monica asks why this happened? What would your response be?Monica is scheduled for a dilatation and curettage. What is probably happening? How would you explain this to Monica?
17Incompetent Cervix Causes loss at second trimester Definiton: Painless dilatation of the cervix without contractions due to a structural or functional defect of the cervixClients present with pelvic pressureSpeculum exam shows effacement, dilatation and often a bulging bag of waters
18Incompetent Cervix Contributing Factors: Congenital Uterine anomalies DES exposure
19Incompetent Cervix Contributing Factors: Acquired Inflammation InfectionSubclinical uterine activityCervical scarring from trauma, cone biopsy or late second trimester elective abortionsIncreased uterine volume (multiple gestations)
20Incompetent Cervix Contributing Factors: Hormonal Increased relaxin levels related to ovulation induction may contribute to connective tissue changes in the cervix
21Factors that increase risk for incompetent cervix Repetitive second trimester lossPrevious preterm birthProgressively earlier births with each subsequent pgShort laborsHistory of causes of cervical scarringUterine anomalyDES exposure
22Incompetent Cervix Management Teach warning signs: back pain, pelvic pressure and changes in vaginal dischargeClose surveillance by provider of cervical lengthBedrest/pelvic rest if length of 25-30mm found
23Incompetent Cervix Management (con’t) Provision of cerclage Placed late in first or early in second trimester (11-15 weeks)Heavy suture at level of internal osUncomplicated can be outpatient to 48 hour stayRescue cerclage can be placed once cervix effaces and dilates, but higher risk for ROM, infectionGiven abx, tocolytics, anti-inflammatory drugs with rescue cerclageRequires 5-7 days in hospitalOlds, Ladewig, London, Davidson. Pg 199 Figure Will use to show internal os
24Incompetent Cervix Management (con’t) Cerclage is cut at 37 weeks gestation for vaginal birth, or left in and Cesarean birth completedLaboring against a cerclage can damage the cervixVaginal cultures for GBS, STI, BV, Candida should be done at time of placement
25Incompetent Cervix Contraindications of Cerclage: Intra-amniotic infectionFetal death or anomalyVaginal bleedingPROM
26Incompetent Cervix Complications of cerclage Anesthetic risks Maternal soft tissue injuryPROMInfectionCervical lacerations and fistulaeDisplacement of cervical suture
27ReflectionSandy has had 3 miscarriages in the 18th week of her pregnancies. She is pregnant at 14 weeks gestation. She is scheduled for a cerclage.What is Sandy’s probable diagnosis?How would you explain the procedure to the patient and her family?What are the physical priorities for her care?What are the psychological considerations for Sandy?
28Ectopic PregnancyImplantation of a fertilized ovum in a site other than the uterus95% are in the fallopian tubeIncidence is rising, but mortality has declined by 90%Caused by obstructed or slowed passage of fertilized ovum through the Fallopian tubeOlds, Ladewig, London, Davidson. Pg. 472 Figure Sites of ectopic pregnancy after this slide
29Ectopic Pregnancy Risk factors: Tubal damage with PID Previous pelvic/tubal surgeryEndometriosisPrevious ectopic pregnancyPresence of an IUDSmokingOvulation-inducing drugsAdvanced maternal ageTubal ligation or reversal of same
30Ectopic Pregnancy Symptoms Early pregnancy signs (amenorrhea, breast tenderness and nausea) may be presentClinical exam (Chadwicks, Hegar’s and uterine enlargement) may be normal initiallyAs placenta grows improperly, hormone levels begin to fluctuate, with vaginal bleeding often seen-usually scant, like spotting
31Ectopic Pregnancy Symptoms (con’t) Lower abdominal pain (one-sided or diffuse) beginsOn exam, an adnexal mass is usually felt 50% of the time by the provider; the adnexa usually is tenderThere is also bleeding into the abdomenMay be severe and sudden with hypovolemiaThis can cause fainting or dizziness
32Ectopic Pregnancy Symptoms (con’t) Shock from hypovolemia is first s/s in 20% of ectopic pregnancies50% of women have referred right shoulder pain from irritation of the subdiaphragmatic phrenic nerveBleeding more commonly slow with worsening abdominal rigidity and tendernessHCG titers usually rise more slowlyHemoglobin and hematocrit will be normal or low, and WBC’s normal or elevated
33Ectopic Pregnancy Diagnosis Thorough menstrual history w/LMP Pelvic exam by providerCBC, HCGUltrasonography, route dependent on HCGLaparoscopyCuldocentesisD & C (rule out non-viable IUP)
34Ectopic Pregnancy Treatment: non-ruptured ectopic Smaller than 3.5cm Methotrexate IM for 1-2 dosesContraindicated with:Fetal cardiac motionThrombocytopeniaLeukopeniaKidney diseaseLiver diseaseAdministered with careful outpatient monitoring of the woman and serial quantitative HCGs, CBCs, and liver function tests
35Ectopic Pregnancy Treatment: ruptured or >3.5 cm ectopic Treat shock w/ IV fluids, oxygen, possibly blood, vasoconstrictorsLaparoscopy to remove ruptured tube, or abdominal approach for salpingotomy if unstableIf large, but intact, may do laparoscopic linear salpingostomy to remove products of conception, and repair surrounding tissue damageRh-negative women get RhoGAM to prevent sensitization
36Ectopic Pregnancy Prognosis Subsequent ectopic pregnancy may occur in 10-20% of all women85% of all women with one ectopic pregnancy will be able to have a subsequent normal pregnancy
37Ectopic PregnancyPrevention for tubal ectopics by avoiding tubal scarringAvoiding risk factors for PID -- multiple partners, intercourse without a condom, and sexually transmitted infections (STIs)Early diagnosis and adequate treatment of STIsEarly diagnosis and adequate treatment of salpingitis and pelvic inflammatory disease (PID)
38Reflection Nancy is in the ED with severe LLQ pain. LMP 2 months ago. What condition do you suspect?What laboratory tests do you expect the provider to order?What are you expecting to see with the HCG level?What complications are you alert for?What are the two ways to ultrasound a patient to examine the uterus for products of conception?
39Gestational Trophoblastic Disease Pathologic proliferation of trophoblastic cells1/1000 pregnanciesIncludes four different conditions:Partial hydatidiform moleComplete hydatidiform moleChorioadenoma destruens/ invasive moleChoriocarcinomaMore than 80% of GTD is non-cancerousOlds, Ladewig, London, Davidson. Pg Figure Hydatidiform mole
40Gestational Trophoblastic Disease Hydatidiform moleTrophoblastic proliferation results in the formation of hydropic “grape-like” clustersThree types: complete, partial, and invasiveComplete hydatidiform moleDevelops from an annuclear ovum, and division is from paternal genetic material onlyNo embryonic or fetal tissue or membranes are foundAll tissue is avascularOlds, Ladewig, London, Davidson. Pg 225 Figure review of meiosis
41Gestational Trophoblastic Disease Partial hydatidiform moleUsually a normal ovum fertilized with either:Two spermA sperm that did not undergo the first meiosis20% begin with an ovum that does not undergo meiosisAll end with 69 chromosomes (triploid)Villi partially vascularized; may also be normal placenta and fetal tissueNot commonly associated with choriocarcinoma
42Gestational Trophoblastic Disease Chorioadenoma destruens/ invasive moleIn 10-15% of cases, hydatidiform moles may develop into invasive molesThese intrude into the uterine myometriumHemorrhage/complications can developTreated as a complete mole
43Gestational Trophoblastic Disease ChoriocarcinomaMalignant, rapidly growing, and metastatic form of cancerOccur following evacuation of a mole in 20% of womenChemotherapy involves methotrexate alone or in combination with other drugs.
44Gestational Trophoblastic Disease Signs and symptomsVaginal bleeding, brownish to bright red, small amounts to hemorrhagePassage of hydropic vesicles (w/partial are smaller and may not be noticed)Uterus large for dates 50% of the timeUterus small for dates 33% of the timeAbsence of fetal heart sounds w/ s/s pgMarkedly elevated serum HCG
45Gestational Trophoblastic Disease Signs and symptoms (con’t)Low maternal serum AFPHyperemesis gravidarum 14-33% of patientsPre-eclampsia prior to 20 weeks10% present with laboratory hyperthyroidism, but only 1% have clinical diseaseProduces thyrotoxicosis
46Gestational Trophoblastic Disease TreatmentSuction evacuation of the moleAvoids hemorrhage risk with sharp curettageFollowed by curettage of the uterus to remove all traces of placental tissueWith excessive bleeding, hysterectomy may be necessary
47Gestational Trophoblastic Disease Treatment (con’t)Serial HCG q 1-2 weeks until HCG undetectable twice consecutivelyMonthly pelvic exams during this timeUndetectable HCG indicates spontaneous remission (80-85% of patients)Followed with serial HCG q 1-2 months for 1 yearPelvic exams q 3 months during this timeEffective contraception until all follow-up is negative
48Gestational Trophoblastic Disease Treatment (con’t)Continued high or rising HCG suggests malignancyDiagnostic work up to determine extent of disease, exclude pregnancyBegin chemotherapy immediately100% remission w/ tx if disease is uterine/low riskW/ metastatic disease (2-3%of patients) multi-agent therapy has 84% or higher remission rates
49Gestational Trophoblastic Disease ComplicationsAnemiaHyperthyroidismInfectionDIC: disseminated intravascular coagulationTrophoblastic embolization of the lungUsually seen after uterus is emptied of molar pgCardio-respiratory emergencyTheca-lutein ovarian cysts
50ReflectionPam is admitted with severe N/V. She c/o brownish discharge for the last two weeks.Her uterus is at the level of her umbilicus, but no fetal heart tones are heard.What do you suspect?What complications are possible?
51Placenta Previa80% of all placentas implant on the upper rear uterine wallIn previa, the placenta implants in the lower part of the uterus1/200 pregnanciesClassification:Total placenta previaPartial placenta previaMarginal placenta previaLow-lying placentaOlds, Ladewig, London, Davidson. Pg. 724 Figure
52Placenta Previa Factors associated with previa Multiparity Increasing maternal agePlacenta accretaDefective development of blood vessels in the deciduaPrior cesarean birthSmokingRecent spontaneous/induced abortionLarge placenta
53Placenta PreviaAs the lower uterine segment contracts and dilates late in pregnancy, the placenta is torn away from the uterusBleeding may be scanty or profuseExact cause is unknownAny woman who presents with late pregnancy bleeding may have an undiagnosed placenta previa
54Placenta Previa If no US and no prior bleeding, DO NOT do SVE Confirm placental location first by USProvider follow with speculum exam for other sources of bleeding if placenta is confirmed as non-previaSVE w/ previa can cause hemorrhage
55Placenta PreviaCare of the woman with painless late pregnancy bleeding and diagnosed previaDepends on gestational ageDepends on amount of bleedingWith continued or heavy bleeding, regardless of gestation, cesarean deliveryIf bleeding stops, then depends on gestational age
56Placenta Previa < 37 weeks If no contractions, reactive NST, no abdominal painBedrestVS every 4 hoursIV fluidsType and cross-match\ObserveBetamethasone IM to facilitate lung maturity up to 34 weeks gestationGoal is to achieve 37 weeks gestation
57Placenta Previa >37 weeks If bleeding stops or is minimal and there is no fetal distressMarginal previa or low-lying placentaFetus is vertex, cephalic and engaged in pelvisRipe cervixInduction of labor startedWith complete previa, cesarean section
58Placenta PreviaWith partial or low-lying placenta, bleeding can start after labor beginsContinuation of labor depends on amount of bleeding and fetal condition
59Abruptio PlacentaPremature separation of a normally implanted placenta from the uterine wall after 20 weeks and before delivery1/120 birthsCauses 15% of perinatal mortalityRisk of recurrence after first time, 5-17%After two abruptions, risk of recurrence is 25%More frequent if cocaine abuse is present
60Abruptio Placenta Cause largely unknown Thought to be related to decreased blood flow to the placenta through sinuses in last trimester.Factors associated:Maternal hypertension (44%)Maternal injury/trauma (2-10%)Smoking, ETOH, cocaineAdvanced maternal ageFibroidsMultiparityMore common in Caucasian and African-American women
61Abruptio Placenta Classifications: Maternal morbidity Marginal Central CompleteCouvelaire uterusMaternal morbidityHemorrhage and hemorrhagic shockDICRenal failureHysterectomy may be necessaryOlds, Ladewig, London, Davidson. Pg. 720 Figure
62Abruptio Placenta Fetal mortality of 25% with abruption With a 50% abruption, mortality is 100%Other fetal complications fromPreterm laborAnemiaHypoxiaSome deficits are not seen until baby is older
63Differentiating Abruption and Previa Placenta PreviaQuiet onsetExternal bleedingBright red bloodOnly labor painNo uterine tendernessUterus soft, relaxedFHT usually presentAbruptionSudden onsetExternal or hiddenDark venous bloodSevere steady painTenderness presentFirm to stony hardFHT present or absent
64Abruptio Placenta Diagnosis Because bleeding can be hidden, it does not indicate the severity/extent of abruptionLabs:CBC (may be normal or decreased H/H, platelets)Clotting studies (PT, PTT)Fibrinogen, d-DimerUltrasound to exclude previa; not always dx for abruption
65Abruptio Placenta Management Fetus at or near term Evaluation of fetal and maternal statusNo distress, consider vaginal birth; may induce w/ oxytocin using internal monitorsIf labor doesn’t begin promptly, Cesarean delivery is completedW/ distress, immediate Cesarean birth
66Abruptio Placenta Immature fetus w/ no distress and mild abruption, attempt to prolong pregnancy until termDelivery will need to occur if condition deteriorates
67Abruptio Placenta Nursing Implications Rapid and frequent assessment of maternal vital signsContinuous EFMLarge bore IV access; consider 2 lines if any signs of severe hemorrhageFoley catheterNo vaginal exams (may be undiagnosed previa)Deterioration of VS means >25% of maternal blood volume has been lost
68What is DIC? Disseminated Intravascular Coagulation Occurs when the coagulation mechanisms are inappropriately triggeredIn abruption, the placental injury is the triggerOther causes: fetal demise, eclampsia, amniotic fluid embolism, sepsisIt causes widespread intravascular activation of the clotting cascade
69What is DIC?Once fibrinogen is “used up” with widespread clotting, bleeding can be severeThere is simultaneous damage from the micro-clottingHemorrhagic presentations more common with acute situations, like abruptionPresents w/ eccyhomoses, petechiae, epistaxis, hematuria, GI bleeding, venipuncture oozing
70Treatment of DICIdentify the cause and treat it (bleeding, sepsis, fetal demise)Administer platelets, FFP, cryoprecipitates as orderedWith renal failure or gangrene, may also have heparin orderedDelivery reverses the pathologyNormal plasma factors w/i 24 hours of deliveryPlatelet counts return to normal in 5-7 days
71Treatment of DICWith severe hypovolemia, whole blood may also be used, or packed RBCsThese patients will require intensive careCVP will be used to monitor fluid balanceHematocrit will be maintained at 30%Renal status closely monitoredRemember, ICU for mother and probable NICU for baby separates mom and baby
72ReflectionKrissy is 34 weeks pregnant. She is admitted w/ vaginal bleeding and a tender abdomen.What do you suspect?What are the classifications of this disorder?How will you assess her on admission?What are the complications?
73ReflectionKrissy is 34 weeks pregnant. She was admitted w/ vaginal bleeding and a tender abdomen. Her blood pressure and urine output are falling, and she has tiny clots under her skin.How would you explain DIC to her family?Krissy is transferred to ICU after delivery, and her baby goes to NICUWhat can the family do to help keep Krissy connected to her baby?
74Postpartum Hemorrhage TypesEarly (first 24 hours after delivery)Late (between 24 hours to 6 weeks after delivery)DefinitionUsually defined as blood loss of greater than 500 ccSometimes defined as a drop of more than 10% after childbirth
78Postpartum Hemorrhage Early postpartum hemorrhageLacerationsSuspect if uterus is firm with continuous trickle of bright red bloodMay be cervical or deep vaginal tears only visible with speculum examNotify provider if this is suspected
79Postpartum Hemorrhage Early postpartum hemorrhageHematomasBlood collects in an actual or potential space; may be caused by injury to a vessel or inadequate hemostatis w/ lacerationMay be visible in groin, labia, or introitusMay be hidden in connective tissue deep in vagina or perineumClient c/o pain in the areaSmall hematomas (<5cm) respond to ice and pressureLarge may need drainage or surgical evacuation
80Postpartum Hemorrhage Early or late postpartum hemorrhageRetained placentaOften related to:placenta accreta (adhered to myometrium)placenta increta (invasion of the myometrium)placenta percreta (penetrates myometrium)Accreta accounts for 80% of retained fragmentsRemoved manually, by D & C or requires hysterectomy
81Postpartum Hemorrhage Nursing ImplicationsFrequent fundal assessment (q 15”X5, q30” X 2, q2h X2) and VS assessmentFundal massage to promote uterine contractionOxytocin, methergine as ordered by providerAvoid bladder distensionNotify provider if uterus remains boggy or if clots continue to be expressed
82Postpartum Hemorrhage Nursing Implications (con’t)Ice to the perineum for first hour after birth and intermittently for 8-12 hoursTeach and perform good perineal care to prevent infectionCareful inspection of any repairs/genital lacerationsVigilance for developing/expanding hematomas
83Postpartum Hemorrhage “Nurses who care for postpartum clients are wise to appreciate that most deaths from postpartum hemorrhage are not due to gross bleeding but to ineffective management of slow, steady blood loss.”Olds SB, London ML, Ladewig PW, and Davidson MR. Maternal-Newborn Nursing and Women’s Health Care (7th Ed.) Prentice-Hall: Upper Saddle River, NJ. pp
84Postpartum Hemorrhage Late postpartum hemorrhageMost often occur 1-2 weeks after birthRelated to subinvolution or retained placentaIncidence of 0.7%CausesSubinvolution (failure of the placenta site to heal)Retained placentaInfection
85Postpartum Hemorrhage Late postpartum hemorrhageNursing Implications-TeachingLochia rubra should end by 2 weeks postpartumGood handwashing and perineal care to decease risk of infectionAny fever, foul discharge, odor should be reported to providerReinforce need to keep postpartum appointments as scheduled; many cases not discovered until 4-6 week appointments