Hemorrhage

1. Hemorrhage Marianne F. Moore

2. Hemorrhage • Early Pregnancy • Late Pregnancy/Intrapartum • Postpartum

3. 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

4. Bleeding in Early Pregnancy • Spontaneous • Threatened • Bleeding, cramping or backache, but cervix is closed • Evaluate for ectopic pregnancy or hyatidiform mole

5. Bleeding in Early Pregnancy • Spontaneous • Threatened • Imminent/Inevitable • Bleeding/cramping increase • Internal cervical os dilates • Membranes may rupture

6. 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

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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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?

17. 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

18. Incompetent Cervix Contributing Factors: • Congenital • Uterine anomalies • DES exposure

19. 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)

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

21. Incompetent 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

22. 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

23. 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

24. 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

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

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

27. 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?

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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)

34. 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

35. 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

36. 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

37. 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)

38. 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?

39. 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

40. 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

41. 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

42. 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

43. 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.

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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?