Antepartal hemorrhagic Disorders

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Antepartal hemorrhagic Disorders
AND-2 Nursing Care of Child bearing Family

• Lectures
• Dr. N. Petrenko, MD, PhD

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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

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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

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Antepartal Hemorrhagic Disorders

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

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Early pregnancy bleeding
Spontaneous abortionIncompetent cervixEctopic
pregnancyHydatiform mole
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Abortion
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Abortion/miscarriage

• End of pregnancy before 20 weeks
• Fetal weight less than 500 mg
• Result of natural cause

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miscarriage

• 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

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miscarriage

• 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

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miscarriage

• 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.

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miscarriage

• Types of miscarriage
• threatened,
• inevitable,
• incomplete,
• complete,
• missed.

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miscarriage

• threatened

incomplete

• inevitable

• missed.

complete
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miscarriage

• Clinical 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.

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miscarriage

• 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

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miscarriage

• 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

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miscarriage

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

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miscarriage

• Management
• Threatened bed rest supportive therapy
• inevitable, incomplete, complete, missed DC

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miscarriage

• Postoperative care
• Oxiticin 10-20 U in 1000 ml of fluid
• Antibiotics
• Analgetics
• Transfusion

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miscarriage

• Discharge
• Rest
• Iron supplementation
• Sexual behavior
• Emergency sign
• Contraception
• http//www.youtube.com/watch?v9LJESmC5-wA

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Incompetent cervix
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Incompetent 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

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Incompetent cervix
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Incompetent 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

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Ectopic pregnancy
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Ectopic pregnancy

• Implantation of the fertilized ovum outside the
  uterine cavity
• uterine (fallopian) tube 95, with most located
  on the ampullar

• abdominal cavity (3 to 4),
• ovary (1),
• and cervix (1).

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Ectopic pregnancy
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Ectopic 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

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Ectopic pregnancy

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

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Ectopic pregnancy

• Management
• Surgery (tubeectomy, remove ectopic pregnancy)
• Methotrexate
• Antibiotics
• Transfusion
• Contraception
• Restoring of fertility

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Ectopic 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.

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Hydatidiform mole
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Hydatidiform 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

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Hydatidiform 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.

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Hydatidiform mole

• Management
• US (snowstorm pattern)
• hCG
• Uterine height
• DC
• Induced labour
• Contraception
• hCG level control 1 year

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Late pregnancy bleeding
Placenta previaAbruptio placenta
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Placenta previa
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Placenta 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.

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Placenta Praevia
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Placenta 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

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Placenta 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.

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Placenta 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 Previa

• Nursing 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

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Placenta Praevia

• Management based on
• Gestational age
• Amount of bleeding
• Fetal condition
• CS

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Management

• 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 gt30 covered or if
  bleeding is excessive otherwise, attempt at
  vaginal delivery is indicated (double set-up)

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Placenta 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

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Placenta abruptio
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Placenta abruptio

• Risk factors
• Multiparity,
• PIH,
• Polyhydramnios,
• Trauma,
• Smoking,
• Malnutrition,
• Previous abruption,
• Idiopathic

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Placenta 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

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Placenta abruptio

• Clinical symptoms
• Vaginal bleeding
• Abdominal pain
• Uterine tenderness
• Uterine contraction
• Couvelaire uterus

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Placenta 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

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Placental Abruption

• Expectant management- if small bleed, and
  maternal and fetal condition satisfactory.
  Monitor well-being and induce labour gt37weeks.
  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

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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

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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

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Managementcont.

• 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

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Hyperemesis gravidarum
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Diseminated intravasculur coagulation
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Cardiac disease
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Anemia
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Urinary tract ingection
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Chorioamnionitis
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Multiple pregnancy
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Rh-conflict
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Hypertension
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Diabetes mellitus
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Fetal deth in utero