Hemorrhage Marianne F. Moore

Hemorrhage Early Pregnancy Late Pregnancy/Intrapartum Postpartum

Bleeding in Early Pregnancy Spontaneous Abortion The major cause of bleeding in the first and second trimesters Occur naturally Expulsion of the fetus prior to 20 weeks/500 gms May end as many of 60% of all pregnancies Ends 20% of known pregnancies Seven types noted

Bleeding in Early Pregnancy Spontaneous Threatened Bleeding, cramping or backache, but cervix is closed Evaluate for ectopic pregnancy or hyatidiform mole Olds, Ladewig, London, Davidson. Pg. 469 Figure 20-1. Can the illustration be separated into the relevant components, and so Figure 20-1 A goes here, after this?

Bleeding in Early Pregnancy Spontaneous Threatened Imminent/Inevitable Bleeding/cramping increase Internal cervical os dilates Membranes may rupture Olds, Ladewig, London, Davidson. Pg. 469 Figure 20-1, B after this?

Bleeding in Early Pregnancy Spontaneous Threatened Imminent/Inevitable Incomplete Part of the products of conception are retained Usually placenta and/or membranes Internal cervical os is dilated Dilation and curettage performed to remove the tissues Olds, Ladewig, London, Davidson. Pg. 469 Figure 20-1, C after this slide?

Bleeding in Early Pregnancy Spontaneous Threatened Imminent/Inevitable Incomplete Complete All products of conception expelled Uterus contracts, bleeding slows Cervix may be closed

Bleeding in Early Pregnancy Spontaneous Threatened Imminent/Inevitable Incomplete Complete Missed Fetus dies in utero, but is not expelled Breast changes regress, may be brownish vaginal discharge. Cervix is closed Drop in HCG levels and ultrasound confirms loss After 4 weeks, breakdown of fetal tissue releases thromboplastin, and DIC can result

Bleeding in Early Pregnancy Spontaneous Threatened Imminent/Inevitable Incomplete Complete Missed Recurrent pregnancy loss Consecutively in three or more pregnancies

Bleeding in Early Pregnancy Spontaneous Threatened Imminent/Inevitable Incomplete Complete Missed Recurrent pregnancy loss Septic abortion Infection, usually with PPROM, pregnancy with IUD in place, or attempts to terminate a pregnancy by untrained persons

Bleeding in Early Pregnancy Induced abortion Occur as a result of mechanical or chemical interruption 88% are done prior to 12 weeks of pregnancy Medical (mifepristone+ misoprostol) Aspiration or suction curettage also used After 14 weeks, may need dilation and evacuation May be incomplete, or cause infection Post procedure, bleeding shouldn’t soak a pad in one hour

Nursing Care for Women At Risk Due to Bleeding in Pregnancy Monitor BP and pulse frequently Assess for s/s shock Count/weigh pads to estimate blood loss Beyond 12 weeks, FHT by Doppler Prepare for IV therapy Obtain/prepare equipment for speculum exam Order labs as requested; usually CBC, coagulation studies, HCG, type and screen or cross

Nursing Care for Women At Risk Due to Bleeding in Pregnancy Have oxygen therapy available Ultrasound machine available Assess coping of the woman and her family Commonly ordered but not proven effective: Bed rest with BRP Pelvic rest is advised

HCG: Human Chorionic Gonadatropin Detectable in blood after implantation (about 1 week after fertilization) Levels rise rapidly, peak around 9-10 weeks pregnancy Doubling every 48-72 hours seen as sign of viability Stimulates progesterone and estrogen production by corpus luteum until placenta takes over

Nursing Care for Women After Pregnancy Loss Counsel patient to expect 8-10 days of bleeding after pregnancy loss Sexual relations may resume once bleeding ends and patient feels ready Pregnancy can occur, so contraception is advised Patients are advised to wait 2-3 cycles to become pregnant again Rh-negative woman must get RhoGAM IM

Reflective Thinking Monica 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?

Incompetent Cervix Causes loss at second trimester Definiton: Painless dilatation of the cervix without contractions due to a structural or functional defect of the cervix Clients present with pelvic pressure Speculum exam shows effacement, dilatation and often a bulging bag of waters

Incompetent Cervix Contributing Factors: Congenital Uterine anomalies DES exposure

Incompetent Cervix Contributing Factors: Acquired Inflammation Infection Subclinical uterine activity Cervical scarring from trauma, cone biopsy or late second trimester elective abortions Increased uterine volume (multiple gestations)

Incompetent Cervix Contributing Factors: Hormonal Increased relaxin levels related to ovulation induction may contribute to connective tissue changes in the cervix

Factors that increase risk for incompetent cervix Repetitive second trimester loss Previous preterm birth Progressively earlier births with each subsequent pg Short labors History of causes of cervical scarring Uterine anomaly DES exposure

Incompetent Cervix Management Teach warning signs: back pain, pelvic pressure and changes in vaginal discharge Close surveillance by provider of cervical length Bedrest/pelvic rest if length of 25-30mm found

Incompetent 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 os Uncomplicated can be outpatient to 48 hour stay Rescue cerclage can be placed once cervix effaces and dilates, but higher risk for ROM, infection Given abx, tocolytics, anti-inflammatory drugs with rescue cerclage Requires 5-7 days in hospital Olds, Ladewig, London, Davidson. Pg 199 Figure 10-5. Will use to show internal os

Incompetent Cervix Management (con’t) Cerclage is cut at 37 weeks gestation for vaginal birth, or left in and Cesarean birth completed Laboring against a cerclage can damage the cervix Vaginal cultures for GBS, STI, BV, Candida should be done at time of placement

Incompetent Cervix Contraindications of Cerclage: Intra-amniotic infection Fetal death or anomaly Vaginal bleeding PROM

Incompetent Cervix Complications of cerclage Anesthetic risks Maternal soft tissue injury PROM Infection Cervical lacerations and fistulae Displacement of cervical suture

Reflection Sandy 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?

Ectopic Pregnancy Implantation of a fertilized ovum in a site other than the uterus 95% are in the fallopian tube Incidence is rising, but mortality has declined by 90% Caused by obstructed or slowed passage of fertilized ovum through the Fallopian tube Olds, Ladewig, London, Davidson. Pg. 472 Figure 20-2. Sites of ectopic pregnancy after this slide

Ectopic Pregnancy Risk factors: Tubal damage with PID Previous pelvic/tubal surgery Endometriosis Previous ectopic pregnancy Presence of an IUD Smoking Ovulation-inducing drugs Advanced maternal age Tubal ligation or reversal of same

Ectopic Pregnancy Symptoms Early pregnancy signs (amenorrhea, breast tenderness and nausea) may be present Clinical exam (Chadwicks, Hegar’s and uterine enlargement) may be normal initially As placenta grows improperly, hormone levels begin to fluctuate, with vaginal bleeding often seen-usually scant, like spotting

Ectopic Pregnancy Symptoms (con’t) Lower abdominal pain (one-sided or diffuse) begins On exam, an adnexal mass is usually felt 50% of the time by the provider; the adnexa usually is tender There is also bleeding into the abdomen May be severe and sudden with hypovolemia This can cause fainting or dizziness

Ectopic Pregnancy Symptoms (con’t) Shock from hypovolemia is first s/s in 20% of ectopic pregnancies 50% of women have referred right shoulder pain from irritation of the subdiaphragmatic phrenic nerve Bleeding more commonly slow with worsening abdominal rigidity and tenderness HCG titers usually rise more slowly Hemoglobin and hematocrit will be normal or low, and WBC’s normal or elevated

Ectopic Pregnancy Diagnosis Thorough menstrual history w/LMP Pelvic exam by provider CBC, HCG Ultrasonography, route dependent on HCG Laparoscopy Culdocentesis D & C (rule out non-viable IUP)

Ectopic Pregnancy Treatment: non-ruptured ectopic Smaller than 3.5cm Methotrexate IM for 1-2 doses Contraindicated with: Fetal cardiac motion Thrombocytopenia Leukopenia Kidney disease Liver disease Administered with careful outpatient monitoring of the woman and serial quantitative HCGs, CBCs, and liver function tests

Ectopic Pregnancy Treatment: ruptured or >3.5 cm ectopic Treat shock w/ IV fluids, oxygen, possibly blood, vasoconstrictors Laparoscopy to remove ruptured tube, or abdominal approach for salpingotomy if unstable If large, but intact, may do laparoscopic linear salpingostomy to remove products of conception, and repair surrounding tissue damage Rh-negative women get RhoGAM to prevent sensitization

Ectopic Pregnancy Prognosis Subsequent ectopic pregnancy may occur in 10-20% of all women 85% of all women with one ectopic pregnancy will be able to have a subsequent normal pregnancy

Ectopic Pregnancy Prevention for tubal ectopics by avoiding tubal scarring Avoiding risk factors for PID -- multiple partners, intercourse without a condom, and sexually transmitted infections (STIs) Early diagnosis and adequate treatment of STIs Early diagnosis and adequate treatment of salpingitis and pelvic inflammatory disease (PID)

Reflection 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?

Gestational Trophoblastic Disease Pathologic proliferation of trophoblastic cells 1/1000 pregnancies Includes four different conditions: Partial hydatidiform mole Complete hydatidiform mole Chorioadenoma destruens/ invasive mole Choriocarcinoma More than 80% of GTD is non-cancerous Olds, Ladewig, London, Davidson. Pg. 475 Figure 20-3. Hydatidiform mole

Gestational Trophoblastic Disease Hydatidiform mole Trophoblastic proliferation results in the formation of hydropic “grape-like” clusters Three types: complete, partial, and invasive Complete hydatidiform mole Develops from an annuclear ovum, and division is from paternal genetic material only No embryonic or fetal tissue or membranes are found All tissue is avascular Olds, Ladewig, London, Davidson. Pg 225 Figure 11-3. review of meiosis

Gestational Trophoblastic Disease Partial hydatidiform mole Usually a normal ovum fertilized with either: Two sperm A sperm that did not undergo the first meiosis 20% begin with an ovum that does not undergo meiosis All end with 69 chromosomes (triploid) Villi partially vascularized; may also be normal placenta and fetal tissue Not commonly associated with choriocarcinoma

Gestational Trophoblastic Disease Chorioadenoma destruens/ invasive mole In 10-15% of cases, hydatidiform moles may develop into invasive moles These intrude into the uterine myometrium Hemorrhage/complications can develop Treated as a complete mole

Gestational Trophoblastic Disease Choriocarcinoma Malignant, rapidly growing, and metastatic form of cancer Occur following evacuation of a mole in 20% of women Chemotherapy involves methotrexate alone or in combination with other drugs.

Gestational Trophoblastic Disease Signs and symptoms Vaginal bleeding, brownish to bright red, small amounts to hemorrhage Passage of hydropic vesicles (w/partial are smaller and may not be noticed) Uterus large for dates 50% of the time Uterus small for dates 33% of the time Absence of fetal heart sounds w/ s/s pg Markedly elevated serum HCG

Gestational Trophoblastic Disease Signs and symptoms (con’t) Low maternal serum AFP Hyperemesis gravidarum 14-33% of patients Pre-eclampsia prior to 20 weeks 10% present with laboratory hyperthyroidism, but only 1% have clinical disease Produces thyrotoxicosis

Gestational Trophoblastic Disease Treatment Suction evacuation of the mole Avoids hemorrhage risk with sharp curettage Followed by curettage of the uterus to remove all traces of placental tissue With excessive bleeding, hysterectomy may be necessary

Gestational Trophoblastic Disease Treatment (con’t) Serial HCG q 1-2 weeks until HCG undetectable twice consecutively Monthly pelvic exams during this time Undetectable HCG indicates spontaneous remission (80-85% of patients) Followed with serial HCG q 1-2 months for 1 year Pelvic exams q 3 months during this time Effective contraception until all follow-up is negative

Gestational Trophoblastic Disease Treatment (con’t) Continued high or rising HCG suggests malignancy Diagnostic work up to determine extent of disease, exclude pregnancy Begin chemotherapy immediately 100% remission w/ tx if disease is uterine/low risk W/ metastatic disease (2-3%of patients) multi-agent therapy has 84% or higher remission rates

Gestational Trophoblastic Disease Complications Anemia Hyperthyroidism Infection DIC: disseminated intravascular coagulation Trophoblastic embolization of the lung Usually seen after uterus is emptied of molar pg Cardio-respiratory emergency Theca-lutein ovarian cysts

Reflection Pam 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?

Placenta Previa 80% of all placentas implant on the upper rear uterine wall In previa, the placenta implants in the lower part of the uterus 1/200 pregnancies Classification: Total placenta previa Partial placenta previa Marginal placenta previa Low-lying placenta Olds, Ladewig, London, Davidson. Pg. 724 Figure 26-17.

Placenta Previa Factors associated with previa Multiparity Increasing maternal age Placenta accreta Defective development of blood vessels in the decidua Prior cesarean birth Smoking Recent spontaneous/induced abortion Large placenta

Placenta Previa As the lower uterine segment contracts and dilates late in pregnancy, the placenta is torn away from the uterus Bleeding may be scanty or profuse Exact cause is unknown Any woman who presents with late pregnancy bleeding may have an undiagnosed placenta previa

Placenta Previa If no US and no prior bleeding, DO NOT do SVE Confirm placental location first by US Provider follow with speculum exam for other sources of bleeding if placenta is confirmed as non-previa SVE w/ previa can cause hemorrhage

Placenta Previa Care of the woman with painless late pregnancy bleeding and diagnosed previa Depends on gestational age Depends on amount of bleeding With continued or heavy bleeding, regardless of gestation, cesarean delivery If bleeding stops, then depends on gestational age

Placenta Previa < 37 weeks If no contractions, reactive NST, no abdominal pain Bedrest VS every 4 hours IV fluids Type and cross-match\ Observe Betamethasone IM to facilitate lung maturity up to 34 weeks gestation Goal is to achieve 37 weeks gestation

Placenta Previa >37 weeks If bleeding stops or is minimal and there is no fetal distress Marginal previa or low-lying placenta Fetus is vertex, cephalic and engaged in pelvis Ripe cervix Induction of labor started With complete previa, cesarean section

Placenta Previa With partial or low-lying placenta, bleeding can start after labor begins Continuation of labor depends on amount of bleeding and fetal condition

Abruptio Placenta Premature separation of a normally implanted placenta from the uterine wall after 20 weeks and before delivery 1/120 births Causes 15% of perinatal mortality Risk of recurrence after first time, 5-17% After two abruptions, risk of recurrence is 25% More frequent if cocaine abuse is present

Abruptio 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, cocaine Advanced maternal age Fibroids Multiparity More common in Caucasian and African-American women

Abruptio Placenta Classifications: Maternal morbidity Marginal Central Complete Couvelaire uterus Maternal morbidity Hemorrhage and hemorrhagic shock DIC Renal failure Hysterectomy may be necessary Olds, Ladewig, London, Davidson. Pg. 720 Figure 26-16.

Abruptio Placenta Fetal mortality of 25% with abruption With a 50% abruption, mortality is 100% Other fetal complications from Preterm labor Anemia Hypoxia Some deficits are not seen until baby is older

Differentiating Abruption and Previa Placenta Previa Quiet onset External bleeding Bright red blood Only labor pain No uterine tenderness Uterus soft, relaxed FHT usually present Abruption Sudden onset External or hidden Dark venous blood Severe steady pain Tenderness present Firm to stony hard FHT present or absent

Abruptio Placenta Diagnosis Because bleeding can be hidden, it does not indicate the severity/extent of abruption Labs: CBC (may be normal or decreased H/H, platelets) Clotting studies (PT, PTT) Fibrinogen, d-Dimer Ultrasound to exclude previa; not always dx for abruption

Abruptio Placenta Management Fetus at or near term Evaluation of fetal and maternal status No distress, consider vaginal birth; may induce w/ oxytocin using internal monitors If labor doesn’t begin promptly, Cesarean delivery is completed W/ distress, immediate Cesarean birth

Abruptio Placenta Immature fetus w/ no distress and mild abruption, attempt to prolong pregnancy until term Delivery will need to occur if condition deteriorates

Abruptio Placenta Nursing Implications Rapid and frequent assessment of maternal vital signs Continuous EFM Large bore IV access; consider 2 lines if any signs of severe hemorrhage Foley catheter No vaginal exams (may be undiagnosed previa) Deterioration of VS means >25% of maternal blood volume has been lost

What is DIC? Disseminated Intravascular Coagulation Occurs when the coagulation mechanisms are inappropriately triggered In abruption, the placental injury is the trigger Other causes: fetal demise, eclampsia, amniotic fluid embolism, sepsis It causes widespread intravascular activation of the clotting cascade

What is DIC? Once fibrinogen is “used up” with widespread clotting, bleeding can be severe There is simultaneous damage from the micro-clotting Hemorrhagic presentations more common with acute situations, like abruption Presents w/ eccyhomoses, petechiae, epistaxis, hematuria, GI bleeding, venipuncture oozing

Treatment of DIC Identify the cause and treat it (bleeding, sepsis, fetal demise) Administer platelets, FFP, cryoprecipitates as ordered With renal failure or gangrene, may also have heparin ordered Delivery reverses the pathology Normal plasma factors w/i 24 hours of delivery Platelet counts return to normal in 5-7 days

Treatment of DIC With severe hypovolemia, whole blood may also be used, or packed RBCs These patients will require intensive care CVP will be used to monitor fluid balance Hematocrit will be maintained at 30% Renal status closely monitored Remember, ICU for mother and probable NICU for baby separates mom and baby

Reflection Krissy 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?

Reflection Krissy 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 NICU What can the family do to help keep Krissy connected to her baby?

Postpartum Hemorrhage Types Early (first 24 hours after delivery) Late (between 24 hours to 6 weeks after delivery) Definition Usually defined as blood loss of greater than 500 cc Sometimes defined as a drop of more than 10% after childbirth

Postpartum Hemorrhage Early Causes: Uterine atony Genital tract lacerations Episiotomy Retained placental fragments Vulvar/ vaginal/ subperitoneal hematomas Uterine inversion Uterine rupture Placental implantation problems Coagulation disorders

Postpartum Hemorrhage Early postpartum hemorrhage Uterine atony most common cause Related to: Uterine overdistension (hydramnios, multiples, macrosomia) Prolonged labor Oxytocin augmentation/induction Anesthesia, magnesium sulfate, terbutaline use Prolonged third stage (>30 minutes) Preeclampsia Operative birth Asian, Native American, Hispanic heritage Olds, Ladewig, London, Davidson. Pg. 1076 Figure 37-1. After this slide, please.

Postpartum Hemorrhage

Postpartum Hemorrhage Early postpartum hemorrhage Lacerations Suspect if uterus is firm with continuous trickle of bright red blood May be cervical or deep vaginal tears only visible with speculum exam Notify provider if this is suspected

Postpartum Hemorrhage Early postpartum hemorrhage Hematomas Blood collects in an actual or potential space; may be caused by injury to a vessel or inadequate hemostatis w/ laceration May be visible in groin, labia, or introitus May be hidden in connective tissue deep in vagina or perineum Client c/o pain in the area Small hematomas (<5cm) respond to ice and pressure Large may need drainage or surgical evacuation

Postpartum Hemorrhage Early or late postpartum hemorrhage Retained placenta Often related to: placenta accreta (adhered to myometrium) placenta increta (invasion of the myometrium) placenta percreta (penetrates myometrium) Accreta accounts for 80% of retained fragments Removed manually, by D & C or requires hysterectomy

Postpartum Hemorrhage Nursing Implications Frequent fundal assessment (q 15”X5, q30” X 2, q2h X2) and VS assessment Fundal massage to promote uterine contraction Oxytocin, methergine as ordered by provider Avoid bladder distension Notify provider if uterus remains boggy or if clots continue to be expressed

Postpartum Hemorrhage Nursing Implications (con’t) Ice to the perineum for first hour after birth and intermittently for 8-12 hours Teach and perform good perineal care to prevent infection Careful inspection of any repairs/genital lacerations Vigilance for developing/expanding hematomas

Postpartum 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. 1077-1078.

Postpartum Hemorrhage Late postpartum hemorrhage Most often occur 1-2 weeks after birth Related to subinvolution or retained placenta Incidence of 0.7% Causes Subinvolution (failure of the placenta site to heal) Retained placenta Infection

Postpartum Hemorrhage Late postpartum hemorrhage Nursing Implications-Teaching Lochia rubra should end by 2 weeks postpartum Good handwashing and perineal care to decease risk of infection Any fever, foul discharge, odor should be reported to provider Reinforce need to keep postpartum appointments as scheduled; many cases not discovered until 4-6 week appointments