Bleeding Disorders During Pregnancy

Bleeding Disorders During Pregnancy

First Trimester Bleeding – Abortion or Ectopic

A. Abortions – termination of pregnancy before age of viability (before 20 weeks)

Causes:
1.) chromosomal alterations

2.) blighted ovum

3.) plasma germ defect

Classifications:

1. Threatened – pregnancy is jeopardized by bleeding and cramping but the cervix is closed
2. Inevitable – moderate bleeding, cramping, tissue protrudes form the cervix (Cervical dilation)

Types:

1.) Complete – all products of conception are expelled. No mgt just emotional support!

2.) Incomplete – Placental and membranes retained. Mgt: D&C

Incompetent cervix – abortion

McDonalds procedure – temporary circlage on cervix

S/E; infection. During delivery, circlage is removed. NSD

Sheridan – permanent surgery cervix. CS

c. Habitual – 3 or more consecutive pregnancies result in abortion usually related to incompetent cervix.nd trimester Present 2

d. Missed – fetus dies; product of conception remain in uterus 4 weeks or longer; signs of pregnancy cease. (-) preg test, scanty dark brown bleeding

Mgt: induced labor with oxytocin or vacuum extraction

5.) Induced Abortion – therapeutic abortion to save life of mom. Double effect choose between lesser evil.

1. Ectopic Pregnancy – occurs when gestation is located outside the uterine cavity. common site: tubal or ampular

Dangerous site - interstitial

Types:

a.) Ruptured

- missed period

- abdominal pain within 3 -5 weeks of missed period (maybe generalized or one sided)

- scant, dark brown, vaginal bleeding

Nursing care:

-Vital signs

-Administer IV fluids

-Monitor for vaginal bleeding
-Monitor I & O


b.)Tubal rupture

- sudden , sharp, severe pain. Unilateral radiating to shoulder.

shoulder pain (indicative of intraperitoneal bleeding that extends to diaphragm and phrenic nerve)

- + Cullen’s Sign – bluish tinged umbilicus – signifies intra peritoneal bleeding

-syncope (fainting)

Management:

- Surgery depending on side

- Ovary: oophrectomy
- Uterus : hysterectomy

Second trimester bleeding

C. Hydatidiform Mole “bunch or grapes” or gestational trophoblastic disease. – with fertilization. Progressive degeneration of chorionic villi. Recurs.

- gestational anomaly of the placenta consisting of a bunch of clear vesicles. This neoplasm is formed form the selling of the chronic villi and lost nucleus of the fertilized egg. The nucleus of the sperm duplicates, producing a diploid number 46 XX, it grows & enlarges the uterus vary rapidly.

Medication: Methotrexate to prevent choriocarcinoma

Assessment:

Early signs - vesicles passed thru the vagina

Hyperemesis gravidarium increase HCG

Fundal height

Vaginal bleeding( scant or profuse)

Early in pregnancy

-High levels of HCG

-Preeclampsia at about 12 weeks

Late signs -hypertension before 20th week

-Vesicles look like a “ snowstorm” on sonogram

-Anemia

-Abdominal cramping

Serious complications

Ø hyperthyroidism

Ø Pulmonary embolus

Nursing care:

Ø Prepare D&C

Ø Do not give oxytoxic drugs

Ø Teachings:

ü Return for pelvic exams as scheduled for one year to monitoring HCG and assess for enlarged uterus and rising titer could indicative of choriocarcinoma

ü Avoid pregnancy for at least one year
Third Trimester Bleeding “Placenta Anomalies”

1. Placenta Previa – it occurs when the placenta is improperly implanted in the lower uterine segment, sometimes covering the cervical os. Abnormal lower implantation of placenta.

- candidate for CS

Symptoms : Bright red and Painless Vaginal bleeding

Diagnosis:

Ultrasound

Avoid: sex, IE, enema – may lead to sudden fetal blood loss

Double set up: delivery room may be converted to OR

Assessment:

- Engagement (usually has not occurred)

- Fetal distress

- Presentation ( usually abnormal)

Complication: sudden fetal blood loss

Nursing Care

-NPO

-Bed rest

-Prepare to induce labor if cervix is ripe

-Administer IV

2. Abruptio Placenta – it is the premature separation of the placenta form the implantation site. It usually occurs after the twentieth week of pregnancy.

Outstanding Sx: dark red, painful bleeding, board like or rigid uterus.

Assessment:

-Concealed bleeding (retroplacental)

-Couvelaire uterus (caused by bleeding into the myometrium)

-inability of uterus to contract

-Severe abdominal pain

-Dropping coagulation factor (a potential for DIC)

Complications:

-Sudden fetal blood loss -Placenta previa & vasa previa

Nursing Care:

-Infuse IV -prepare to administer blood -Type and crossmatch

-Monitor FHR -Insert Foley -Measure blood loss

-Report s/sx of DIC -Monitor v/s for shock -Strict I&O

3. Placenta succenturiata – 1 or 2 more lobes connected to the placenta by a blood vessel may lead to retained placental fragments if vessel is cut.
4. Placenta Circumvalata – fetal side of placenta covered by chorion
5. Placenta Marginata – fold side of chorion reaches just to the edge of placenta
6. Battledore Placenta – cord inserted marginally rather then centrally
7. Placenta Bipartita – placenta divides into 2 lobes
8. Vilamentous Insertion of cord- cord divides into small vessels before it enters the placenta
9. Vasa Previa – velamentous insertion of cord has implanted in cervical OS


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