Antepartal hemorrhagic Disorders

1. AND-2 Nursing Care of Child bearing Family Antepartal hemorrhagic Disorders Lectures Dr. N. Petrenko, MD, PhD

2. 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

3. 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

4. Antepartal Hemorrhagic Disorders • Fetal risks from maternal hemorrhage • Blood loss, anemia • Hypoxemia • Hypoxia • Anoxia • Preterm birth

5. Early pregnancy bleeding Spontaneous abortionIncompetent cervixEctopic pregnancyHydatiform mole

6. Abortion

7. Abortion/miscarriage • End of pregnancy before 20 weeks • Fetal weight less than 500 mg • Result of natural cause

8. 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

9. 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

10. 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.

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

12. miscarriage • threatened missed. incomplete • inevitable complete

13. 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.

14. 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

15. 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

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

18. miscarriage • Management • Threatened – bed rest supportive therapy • inevitable,incomplete, complete,missed – D&C

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

20. miscarriage • Discharge • Rest • Iron supplementation • Sexual behavior • Emergency sign • Contraception • http://www.youtube.com/watch?v=9LJESmC5-wA

21. Incompetent cervix

22. 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

23. Incompetent cervix

24. 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

25. Ectopic pregnancy

26. Ectopic pregnancy • Implantation of the fertilized ovum outside the uterinecavity • uterine (fallopian) tube 95%, with most locatedon the ampullar • abdominal cavity (3% to 4%), • ovary (1%), • and cervix (1%).

27. Ectopic pregnancy

28. 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

29. Ectopic pregnancy • Differential diagnosis • miscarriage, ruptured corpus luteumcyst, appendicitis, salpingitis, ovarian cysts, torsionof the ovary, and urinary tract infection

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

31. 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.

32. Hydatidiform mole

33. 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). • Partialresult 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

34. 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.

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

36. Late pregnancy bleeding Placenta previaAbruptio placenta

37. Placenta previa

38. 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.

39. Placenta Praevia

40. 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

41. 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.

42. 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

43. 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

44. Placenta Praevia • Management based on: • Gestational age • Amount of bleeding • Fetal condition • CS

45. 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 >30% covered or if bleeding is excessive; otherwise, attempt at vaginal delivery is indicated (double set-up)

46. 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

47. Placenta abruptio

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

49. 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%

50. Placenta abruptio • Clinical symptoms • Vaginal bleeding • Abdominal pain • Uterine tenderness • Uterine contraction • Couvelaire uterus