Antepartal hemorrhagic Disorders

Lectures

Dr. N. Petrenko, MD, PhD

AND-2

Nursing Care of Child bearing Family

Maternal adaptation to pregnancy

• Increases in plasma volume and red blood cell mass– Meet metabolic demands of mother and

fetus– Protect against potentially deleterious

impairment in venous return– Safeguard the mother against effects of

blood loss at birth

Antepartal 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

Antepartal Hemorrhagic Disorders

• Fetal risks from maternal hemorrhage– Blood loss, anemia– Hypoxemia – Hypoxia– Anoxia– Preterm birth

Early pregnancy Early pregnancy bleedingbleeding

Spontaneous abortionSpontaneous abortionIncompetent cervixIncompetent cervixEctopic pregnancyEctopic pregnancyHydatiform moleHydatiform mole

AbortionAbortion

AbortionAbortion//miscarriagemiscarriage

• End of pregnancy before 20 weeks

• Fetal weight less than 500 mg

• Result of natural cause

miscarriagemiscarriage• 10-15% of recognize pregnancy end in

miscarriage• Early (till 12 weeks)• before 8 weeks• 50% - result from chromosomal abnormalities• endocrine imbalance (luteal phase defects,

insulin-dependent diabetes mellitus with high blood glucose levels in the first trimester),

• immunologic factors (antiphospholipid antibodies), • Infections (bacteriuria and Chlamydia

trachomatis), • Systemic disorders (lupus erythematosus), • genetic factors

miscarriagemiscarriage• Late 12 - 20 weeks • Result from maternal causes:• advancing maternal age and parity, • chronic infections, • premature dilation of the cervix and other

anomalies of the reproductive tract,• chronic debilitating diseases, • nutrition, and recreational drug use

miscarriagemiscarriage• Little can be done to avoid genetically

caused pregnancy loss, but correction of maternal disorders, immunization against infectious diseases, adequate early prenatal care, and treatment of pregnancy complications can do much to prevent miscarriage.

miscarriagemiscarriageTypes of miscarriage

• threatened,

• inevitable,

• incomplete,

• complete,

• missed.

miscarriagemiscarriage

missed.

• threatened

• inevitable

incomplete

complete

miscarriagemiscarriageClinical manifestation

• uterine bleeding,• uterine contractions, • uterine pain are ominous• before the sixth week - a heavy menstrual

flow.• between the sixth and twelfth weeks -

moderate discomfort and blood loss. • After the twelfth week – more severe pain,

similar to that of labor, because the fetus must be expelled.

miscarriagemiscarriage• threatened miscarriage - spotting of blood but with

the cervical os closed, Mild uterine cramping• Inevitable and incomplete - a moderate to heavy

amount of bleeding with an open cervical os, Tissue may be present with the bleeding, Mild to severe uterine cramping

• An inevitable miscarriage is often accompanied by rupture of membranes (ROM) and cervical dilation; passage of the products of conception is a certainty.

• An incomplete miscarriage involves the expulsion of the fetus with retention of the placenta

miscarriagemiscarriage• complete miscarriage all fetal tissue is passed, the cervix

is closed, slight bleeding, mild uterine cramping • missed miscarriage - fetus has died but the products of

conception are retained in utero for 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, and the cervical os remains

closed.• Recurrent early (habitual) miscarriage is the loss of three

or more previable pregnancies. Women having three or more miscarriages are at increased risk for preterm birth, placenta previa, and fetal anomalies in subsequent pregnancies

miscarriagemiscarriage• Assessment

• Complain (pain, bleeding)• LMP• Vital sign (t, Ps, BP)• Previous pregnancy• hCG• US• CBC (Hb, Ht, WBC, ESR)• Blood type & Rh

miscarriagemiscarriage• Management

• Threatened – bed rest supportive therapy

• inevitable, incomplete, complete, missed – D&C

miscarriagemiscarriage• Postoperative care

• Oxiticin 10-20 U in 1000 ml of fluid

• Antibiotics

• Analgetics

• Transfusion

miscarriagemiscarriage• Discharge

• Rest• Iron supplementation• Sexual behavior• Emergency sign• Contraception

• http://www.youtube.com/watch?v=9LJESmC5-wA

Incompetent cervixIncompetent cervix

Incompetent cervixIncompetent cervix• passive and painless dilation of the cervix during the

second trimester. • Etiology.• a history of previous cervical lacerations during childbirth,• excessive cervical dilation for curettage or biopsy, • ingestion of diethylstilbestrol by the woman's mother while

being pregnant with the woman. • a congenitally short cervix or cervical or uterine anomalies.

• Clinical diagnosis based on:• history of short labors and recurring loss of pregnancy at

progressively earlier gestational ages are characteristics of reduced cervical competence.

• Ultrasound: cervix (less than 20 mm in length) is indicative of reduced cervical competence.

• Often, but not always, the short cervix is accompanied by cervical fanneling, or effacement of the internal cervical os

Incompetent cervixIncompetent cervix

Incompetent cervixIncompetent cervix• Conservative management• bed rest, hydration, and tocolysis (inhibition of uterine contractions). • A cervical cerclage may be placed around the cervix beneath the

mucosa to constrict the internal os of the cervix • Prophylactic cerclage is placed at 10 to 14 weeks of gestation, after

which the woman is told to refrain from intercourse, prolonged (more than 90 minutes) standing, and heavy lifting. She is followed 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. If removed, cerclage placement must be repeated with each successive pregnancy.

• Risks r/t of the procedure:• premature rupture of membranes,• preterm labor,• chorioamnionitis. • Because of these risks, and because bed rest and tocolytic therapy

can be used to prolong the pregnancy cerclage is rarely performed after 25 weeks of gestation

Ectopic pregnancyEctopic pregnancy

Ectopic pregnancyEctopic pregnancy

• abdominal cavity (3% to 4%),

• ovary (1%),

• and cervix (1%).

• Implantation of the fertilized ovum outside the uterine cavity

• uterine (fallopian) tube 95%, with most located on the ampullar

Ectopic pregnancyEctopic pregnancy

Ectopic pregnancyEctopic pregnancy• Clinical manifestation & assessment

• missed period,• Adnexal fullness, and tenderness • The tenderness can progress from a dull pain to a colicky pain when the

tube stretches. Pain may be unilateral, bilateral, or diffuse over the abdomen.

• Abnormal vaginal bleeding that is dark red or brown occurs in 50% to 80% of women.

• If the ectopic pregnancy ruptures, pain increases. This pain may be generalized, unilateral, or acute deep lower quadrant pam caused by blood irritating the peritoneum. Referred shoulder pain can occur as a result of diaphragmatic irritation caused by blood in the peritoneal cavity.

• The woman may exhibit signs of shock 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 develop in a neglected ruptured intraabdominal ectopic pregnancy.

• hCG, US, CBC• Ps, BP

Ectopic pregnancyEctopic pregnancy• Differential diagnosis

• miscarriage, ruptured corpus luteum cyst, appendicitis, salpingitis, ovarian cysts, torsion of the ovary, and urinary tract infection

Ectopic pregnancyEctopic pregnancy• Management

• Surgery (tubeectomy, remove ectopic pregnancy)

• Methotrexate

• Antibiotics

• Transfusion

• Contraception

• Restoring of fertility

Ectopic pregnancyEctopic pregnancy• Nursing Interventions with Ectopic

Pregnancy• Prepare patient for surgery.• Institute measures to control bleeding/treat

shock if hemorrhage severe and continue to monitor postoperatively

• May be given methotrexate instead of surgery

• Allow patient to express feelings about loss of pregnancy and concerns about future pregnancies.

Hydatidiform moleHydatidiform mole

Hydatidiform moleHydatidiform mole• is a gestational trophoblastic disease. There are two distinct

types of hydatidiform moles: complete (or classic) mole and partial mole.

• The etiology is• unknown,

• may be • an ovular defect or a nutritional deficiency. • Using clomiphene (Clomid) • early teens or older than 40 years of age. • Chromosomal abnomalities

• Types. The complete mole results from fertilization of an egg whose nucleus has been lost or inactivated nucleus (46 XX).

• Partial result of 2 sperm fertilize 1 egg, kariotype 69,XXY; 69XXX; 69 XYY

• The mole resembles a bunch of white grapes .• The fluid-filled vesicles grow rapidly, causing the uterus to

be Rupture of uterus

Hydatidiform moleHydatidiform mole• Clinical manifestations• early stages same as normal pregnancy. • Later, vaginal bleeding (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 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 LMP 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.

• Preeclampsia occurs in approximately 15% of cases, usually between 9 and 12 weeks of gestation, but any symptoms of PIH before 20 weeks of gestation may suggest hydatidiform mole.

• Hyperthyroidism and pulmonary embolization of trophoblastic elements occur infrequently but are serious complications of hydatidiform mole. Partial moles cause few of these symptoms and may be mistaken for an incomplete or missed miscarriage.

Hydatidiform moleHydatidiform mole• Management• US (snowstorm pattern)• hCG• Uterine height• D&C• Induced labour• Contraception• hCG level control 1 year

Late pregnancy Late pregnancy bleedingbleeding

Placenta previaPlacenta previaAbruptio placentaAbruptio placenta

Placenta previaPlacenta previa

Placenta previaPlacenta previa• the placenta is implanted in the lower uterine

segment near or over the internal cervical os. • Total or complete placenta previa - if the internal

os is entirely covered by the placenta when the cervix is fully dilated.

• Partial placenta previa implies incomplete coverage of the internal os.

• Marginal placenta previa indicates that only an edge of the placenta extends to the internal os but may extend onto the os during dilation of the cervix during labor.

• The term low-lying placenta is used when the placenta is implanted in the lower uterine segment but does not reach the os.

Placenta PraeviaPlacenta Praevia

Placenta PraeviaPlacenta Praevia• Etiology / risk factors • previous placenta previa,• previous cesarean birth,• induced abortion, possibly related to

endometrial scarring• multiple gestation (because of the larger

placental area), • advanced maternal age (older than 35

years), • African or Asian ethnicity,• smoking, and cocaine us

Placenta PraeviaPlacenta Praevia• painless vaginal bleeding• vaginal bleeding associated with uterine activity.• after 24 weeks of gestation. • This bleeding is associated with the stretching and thinning of

the lower uterine segment that occurs during the third trimester. • It is bright red in color. • Vital signs may be normal, even with heavyblood loss, because

a pregnant woman can lose up to 40% of blood volume without showing signs of shock.

• Clinical presentation and decreasing urinary output may be better indicators of acute blood loss than vital signs alone.

• The fetal heart rate is reassuring unless there is a major detachment of the placenta.

• Abdominal examination usually reveals a soft, relaxed, nontender uterus with normal tone. If the fetus is lying longitudinally, the fundal height is usually greater than expected for gestational age because the low placenta hinders descent of the presenting fetal part. Leopold's maneuvers may reveal a fetus in an oblique or breech position or lying transverse because of the abnormal site of placental implantation.

Placenta PraeviaPlacenta Praevia• Related risk: mother• premature ROM,• preterm birth, • surgery-related trauma to structures adjacent to

the uterus, anesthesia complications, blood transfusion reactions, overinfusion of fluids, abnormal placental attachments to the uterine wall (e.g., placenta accreta), postpartum hemorrhage, thrombophlebitis, anemia, and infection.

• Fetus• death is caused by preterm birth. • hypoxia in utero • Congenital anomalies. • IUGR

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Placenta PreviaPlacenta PreviaNursing Management

Assess the amount and character of bleeding

• Monitor Fetal Heart Tones (FHT) and activity monitoring (kick count)

• Bedrest and no sexual activity

• Report signs of preterm labor

• Conservative management of pregnancy

Placenta PraeviaPlacenta Praevia• Management based on:

• Gestational age

• Amount of bleeding

• Fetal condition

• CS

ManagementManagement• Hospitalize if actively bleeding; if not minimal

activity at home is OK---pelvic rest• Check Hgb & Hct routinely• Transfusion may be necessary to maintain

maternal and fetal stability (goal is to keep maternal Hct between 30-35%)

• If bleeding is severe, delivery is indicated regardless of gestational age or fetal lung maturity

• Birth by cesarean if cervix is >30% covered or if bleeding is excessive; otherwise, attempt at vaginal delivery is indicated (double set-up)

Placenta PreviaPlacenta Previa• Nursing Care of the Patient Maintain IV

access

• O2 PRN

• Continuous fetal monitoring if active bleeding

• Hourly pad count noting color and amount• Digital cervical exams are contraindicated!!

– Evaluation of cervical dilatation is obtained visually with a speculum

Placenta abruptioPlacenta abruptio

Placenta abruptioPlacenta abruptio• Risk factors –• Multiparity, • PIH, • Polyhydramnios, • Trauma, • Smoking, • Malnutrition, • Previous abruption, • Idiopathic

Placenta abruptioPlacenta abruptio• Grades 1 (mild), vaginal bleeding

with uterine tendeness, no distress, 10-20 %

• 2 (moderate), uterine tendeness and tetany with or with out external bleeding, fetal distress, 20-50%

• 3 (severe) severe uterine tetany, schock, fetal is dead, coagulopathy, greater than 50%

Placenta abruptioPlacenta abruptio• Clinical symptoms

• Vaginal bleeding

• Abdominal pain

• Uterine tenderness

• Uterine contraction

• Couvelaire uterus

Placenta abruptioPlacenta abruptio• Outcomes• Maternal mortality• Renal failure • pituitary necrosis• Rh negative woman with Rh positive fetus can become

sensitized if fetal-to-maternal hemorrhage • fetal hypoxia, • preterm birth, • Risk for neurologic defects• Perinatal mortality

Placental Abruption

• Expectant management- if small bleed, and maternal and fetal condition satisfactory. Monitor well-being and induce labour >37weeks. Anti-D if indicated.

• Active Management- if severe abruption. Resuscitate and correct shock & DIC. Perform ARM and deliver fetus asap. IV Oxytocics to prevent PPH. Anti-D as above.

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Abruptio Placenta

• Complete of partial premature separation of the placenta from uterus

• Precipitating Factors– Blunt trauma to abdomen– Drug abuse, especially cocaine– Hypertension– Premature rupture of membrane– Smoking

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Abruptio Placenta • Medical emergency because of the risk of

maternal hemorrhage and fetal demise

• May develop Disseminated Intravascular Coagulation (DIC)

• Bleeding may be obvious or concealed

• Concealed bleeding may lead to uterine tenderness and abdominal pain

• Monitoring may reveal elevated uterine resting tone and a rising FHT

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Nursing Management of Abruptio Placenta

• Assess amount and character of bleeding• Assess abdominal/uterine tenderness,

contractions and resting • Monitor for shock • Assess FHT and activity • Measure fundal height since concealed bleeding

may be present• Provide emotional support • Prepare for possible C-Section

Clinical Manifestations

• Vaginal bleeding (external)– May not be present in concealed abruptions

(occult bleeding)

• Abdominal pain (sudden onset/often severe)

• Uterine tenderness• Uterine CTXs/hypertonus/hyperactivity• Hemorrhagic shock• Ischemic necrosis of distant organs• Fetal distress or death

Management• Hospitalize• Large-bore (16-guage) IV access (2 preferable)• Assess Bleeding

– Hgb & Hct monitoring– Coagulation factor monitoring (fibrinogen, platelets,

fibrin split products, PT, PTT)– Transfuse if necessary

• Frequent VS• O2 if necessary• Continuous Fetal Monitoring• Rhogam if necessary

– Rhogam covers 30cc fetal whole blood

Management—cont.• Identify appropriate timing of delivery

– Decision is based on condition of mother and fetus, gestational age of fetus, dilation of cervix

– Possibly use betamethasone to accelerate fetal lung maturity in preparation for delivery

• Type of delivery– Vaginal delivery may be attempted if

abruption is moderate (stable mother and no signs of fetal distress)

– Cesarean section if fetal distress is present

Дякую за увагу!

Hyperemesis Hyperemesis gravidarumgravidarum

Diseminated Diseminated intravasculur intravasculur coagulationcoagulation

CardiacCardiac diseasedisease

AnemiaAnemia

Urinary tract Urinary tract ingectioningection

ChorioamnionitisChorioamnionitis

Multiple pregnancyMultiple pregnancy

Rh-conflictRh-conflict

HypertensionHypertension

Diabetes mellitusDiabetes mellitus

Fetal deth in uteroFetal deth in utero