Bleeding Disorders During Pregnancy

Bleeding Disorders of Pregnancy

• Rapid blood loss of more than 1% of body weight is considered hemorrhage.
• Hemorrhage can lead to inadequate tissue perfusion, deprivation of glucose and oxygen, and build-up of waste products.

Perinatal Hemorrhage Types

• Antepartum hemorrhage occurs anytime during pregnancy.
• Early antepartum hemorrhage occurs before 20 weeks of gestation.
• Late antepartum hemorrhage occurs after 20 weeks of gestation.
• Intrapartum hemorrhage occurs during labor.
• Postpartum hemorrhage involves blood loss greater than 500ml with vaginal delivery or 1000ml with cesarean birth.
• Early postpartum hemorrhage occurs within the first 24 hours of delivery.
• Late postpartum hemorrhage occurs after 24 hours of delivery.

Hypovolemic Shock

• Hypovolemic shock is associated with blood loss amounting to 1.5 to 2 liters.

Abortion

• Abortion is the most common bleeding disorder of early pregnancy.
• It is defined as the termination of pregnancy before viability.
• It occurs before 20 weeks gestation or before the fetus weighs 500 grams.

Types of Abortion

• Early abortion is termination of pregnancy before 12 weeks.
• Late abortion is termination of pregnancy after 12 weeks.
• Abortus refers to a fetus that is aborted weighing less than 500 grams.

Fetal Weight

• Normal fetal weight is between 2.5 and 3.5 kg.
• LBW (Low Birth Weight) is defined as weight < 2.5 kg.
• VLBW (Very Low Birth Weight) is defined as weight < 2000 g.
• ELBW (Extremely Low Birth Weight) is defined as weight < 1500 or 1000 g.

Definition of Terms Related to Abortion

• Occult pregnancy refers to zygotes that are aborted before pregnancy is diagnosed or recognized.
• Blighted ovum is a small macerated fetus surrounded by fluid inside an open sac, sometimes without a fetus.
• Carnerous mole is a zygote surrounded by a capsule of clotted blood.
• Fetus compressus is a fetus compressed upon itself and desiccated with dried amniotic fluid.
• Fetus papyraceous is a fetus that is so dry that it resembles parchment.
• Lithopedion refers to a calcified embryo.
• Immature infants are infants having a birth weight between 500 and 1000 grams.
• Full-term infants are infants born between 38 to 42 weeks.
• Spontaneous or induced loss of an early pregnancy before fetal viability (20 weeks) is referred to as "miscarriage".

Elective or Therapeutic Abortion

• Elective/Therapeutic abortion involves deliberate termination of pregnancy, initiated by personal choice.
• It is recommended by healthcare providers to protect the mother's physical or mental health.

Spontaneous Abortion

• Spontaneous abortion is the loss of a fetus due to natural causes (MedlinePlus 2002).

Causes of Spontaneous Abortion

• Fetal causes include developmental anomalies and chromosomal abnormalities.
• Maternal causes include advanced maternal age (35 y/o and up), structural abnormalities of the reproductive tract, inadequate progesterone production, maternal infections, chronic and systemic diseases, and exogenous factors.

TORCH Infection

• TORCH includes:
• T-oxoplasmosis (Toxoplasma Gondii)
• O - other (HepA B, HIV, TB)
• R - ubella (German Measles)
• C - ytomegalovirus
• H - erpes Simplex

Rubella Syndrome

• Rubella Syndrome presents with:
• Microcephaly
• Anencephaly
• Blindness
• Deafness
• Cleft Lip/palate
• Heart disease

Immunoglobulins

• IgG can cross the placenta; panGalawa (second).
• IgA is found in milk; gAtas (milk)
• IgM is present first; Mauna (first)
• IgE is associated with allergies; Ellergy (parasitic infant)
• IgD are proteins

Threatened Abortion

• Threatened Abortion refers to the possible loss of the products of conception.
• All vaginal bleeding in early pregnancy without cervical changes is considered a threatened abortion.

Threatened Abortion Management

• Assess using the 3 A's:
• Assess <12/>12
• Ask LMP
• Ask for presence of blood clots (Retained Products of conception)
• Abdominal pain Conservative management includes bed rest and hydration.

Inevitable Abortion

• Inevitable Abortion refers to the situation where there is vaginal bleeding or rupture of the membranes before 20 weeks of gestation, accompanied by advanced dilation of the cervix.
• The process of abortion has begun and cannot be stopped, resulting in the unavoidable loss of the pregnancy.

Inevitable Abortion Signs

• Profuse vaginal bleeding and open cervix

Inevitable Abortion Management

• Directed towards avoiding complications of infection or excessive blood loss through hospitalization and sympathetic understanding and emotional support.

Complete Abortion

• Complete Abortion refers to the spontaneous expulsion of the products of conception after the fetus has died in utero.

Internal Examination Findings in Complete Abortion

• Light bleeding or some blood in the vaginal vault, no tenderness in the cervix, uterus or abdomen; none to mild uterine cramping, closed cervix, empty uterus on UTZ.

Signs of Complete Abortion

• Vaginal bleeding, abdominal pain/cramping, and passage of tissues

Complete Abortion Management

• No further medical or surgical treatment needed
• Continuous observation for bleeding
• Regular diet and rest
• Evaluate the passage of tissues
• Advise the patient to return to the ER if they experience profuse vaginal bleeding, severe pelvic pain, or high fever.

Incomplete Abortion

• Incomplete abortion involves the expulsion of some but not all parts of the conceptus.

Incomplete Abortion Signs

• Heavy bleeding, severe uterine cramping, passage of tissues, open cervix, and UTZ shows some POC are still inside.

Incomplete Abortion Management

• Prompt evacuation of the uterus (D&C)
• Monitor blood loss
• Inspect the perineal pad
• Monitor VS
• Monitor the blood studies + I&O
• Provide sympathetic understanding and emotional support

Missed Abortion

• Missed abortion refers to the retention of ALL products of conception after the death of the fetus in the uterus.

Missed Abortion Management

• Management depends on the age of gestation or size of conceptus.

Missed Abortion Signs

• Absence of FHT, signs of pregnancy disappears, and UTZ shows NO cardiac activity.

Habitual Abortion

• Habitual abortion is defined as abortion occurring in 3 or more successive pregnancies.

Habitual Abortion Management

• Treat the cause with cervical cerclage, fertility drugs, luteal phase progesterone support, treatment of uterine abnormalities, or treatment of medical illnesses.

Septic Abortion

• Septic abortion involves dissemination of bacteria into the maternal circulatory and organ system.
• Often associated with induced abortions performed by untrained persons using non-sterile techniques or criminal abortions.

Causative Agents of Septic Abortion

• E. Coli, Enterobacter aerogenes, Proteus Vulgaris, Hemolytic Streptococci, and Staphylococci

Signs and Symptoms of Septic Abortion

• Foul-smelling vaginal discharge, uterine cramping, fever, chills and peritonitis, leukocytosis, shock

Management of Septic Abortion

• Treating abortion
• High-dose IV antibiotics
• D&C (if incomplete)

Ectopic Pregnancy

• Implantation of the zygote outside the uterine cavity or in an abnormal location within the uterus.
• It is the 2nd leading cause of bleeding in early pregnancy with a significant impact on future fertility.

Causes of Ectopic Pregnancy

• mechanical factors, functional factors, assisted reproduction, failed contraception

Types of Ectopic Pregnancy

• Tubal is most common (>95%)
• Interstitial (2-4%)
• Isthmic (12%)
• Ampullary (70%), the most common site of implantation
• Ovarian (3%)
• Symptoms are similar to tubal
• Management: Cystectomy or Oophorectomy
• Abdominal: rare (occurs in 1/15,000 pregnancies)
• Primary original implantation outside the uterus.
• Secondary implantation in the tube or ovary then subsequent implantation in the abdomen after rupture and expulsion.
• Cervical
• Often due to in-vitro fertilization and embryo transfer.
• Heterotypic pregnancy
• Rare; tubal pregnancy accompanied by an intrauterine pregnancy.

Symptoms of Ectopic Pregnancy

• Amenorrhea, spotting, abdominal pain

Ruptured Ectopic Pregnancy

• Isthmic EP ruptures early (at 6 weeks), ampullary EP ruptures later (around 8-12 weeks).
• Cornual EP may reaches 2nd trimester before rupture
• Abdominal EP may terminate anytime depending on the site of implantation

Symptoms of Ruptured Ectopic Pregnancy

• pain, spotting, signs of shock, dizziness or fainting, hard or board-like abdomen, bluish discoloration of the umbilicus

Unruptured vs Ruptured Ectopic Pregnancy

Unruptured

• Missed period, abdominal pain within 3-5 weeks, scant, dark vaginal bleeding, vague discomfort

Tubal Rupture

• Sudden sharp severe pain, shoulder pain (intraperitoneal bleeding extending to diaphragm and phrenic nerve)
• Cullen's sign bluish tinged umbilicus

Diagnostic Tests for Ectopic Pregnancy

• Transvaginal Ultrasound, Serial BHCG Determinations, Pregnancy Test, Culdocentesis aspiration, and Serum Progesterone Levels

Culdocentesis

• Culdocentesis involves obtaining peritoneal fluid from the retrouterus peritoneal pouch or Douglas pouch.

Equipment for Culdocentesis

• Bivalve vaginal speculum (Graves or Pederson), Tenaculum or Allis clamp, Ring forceps, Spinal needle, Monsel solution, Butterfly needle, Needle, Antiseptic solution, Lidocaine with epinephrine, Specimen container, Light source

Culdocentesis Procedure

• Start with informed consent and place patient in dorsal lithotomy position
• Perform bimanual pelvic examination, preparing the vagina with povidone-iodine solution
• Insert a bivalve vaginal speculum into the vagina
• Grasp the posterior lip of cervix with a tenaculum or ring forceps
• Attach the spinal needle to a syringe with normal saline and inject into the point of lidocaine infiltration between the uterosacral ligaments in the posterior fornix
• Insert needle parallel to the speculum, confirm placement with free flow of saline
• Apply negative pressure pulling back the syringe plunger
• The interpretation of aspirate: clear is normal, blood is positive, straw or cystic/pus is negative
• Pull the needle out and clean the vagina with antiseptic solution

Culdocentesis Results Interpretation

• Normal: 2-4 mL clear to straw-colored peritoneal fluid
• Positive: >2 mL non-clotting blood
• Negative: Pus, cystic, or straw-colored; purulent fluid
• No diagnostic result: Dry tap (no fluid); <2 mL clotted blood

Methotrexate

• Renally cleared, can be hepato- and myelo-toxic, is a potent teratogen, and is excreted into breastmilk.
• Criteria for methotrexate therapy are unruptured ectopic pregnancy, no FHT, no renal or hepatic disease, normal CBC

Ideal Candidate for Methotrexate

• Hemodynamic stability, no severe/persisting abdominal pain, ability to follow up, normal baseline LFTs and RFTS

Absolute Contraindications for Methotrexate

• Intrauterine pregnancy, immunodeficiency, anemia/leukopenia/thrombocytopenia, sensitivity to MTX, active pulmonary/peptic ulcer disease, hepatic/renal dysfunction, breastfeeding, tubal rupture

Surgeries for Ectopic Pregnancy

• Salpingectomy is a tubal resection for both ruptured and unruptured tubal pregnancy.

Types of Salpingectomy

• Total salpingectomy (removal of entire tube) and partial salpingectomy

Hydatidiform Mole

• Molar pregnancy
• Benign placental disorder with degeneration of the chorion and embryonic death
• Chorionic villi proliferate, becoming grape-like vesicles, producing high levels of HCG.

Types of Molar Pregnancy

• Complete mole has only placental parts, formed when sperm fertilizes an empty egg
• Partial mole has a placenta and fetus formed, but development is incomplete, occurs with fertilization by 2 sperm.

Signs and Symptoms of Molar Pregnancy

• Excessive nausea/vomiting, rapid increase in uterine size, passage of grapelike vesicles, bleeding, absence of fetal heart tones and fetal skeleton, preeclampsia before 24 weeks, fluid-filled vesicles instead of a developing fetus on UTZ

Complications of Hydatidiform Mole

• Choriocarcinoma (most severe) or invasive mole, and trophoblastic tumor

Management of Hydatidiform Mole

• D&C to remove the mole, methotrexate, monitor HCG levels after mole removal, advise not to get pregnant for 1 year

Incompetent Cervix

• Mechanical defect of the cervix
• Painless cervical dilation in the 2nd or early 3rd trimester, followed by prolapse and possible premature rupture of membranes, leading to premature expulsion

Predisposing Factors for Incompetent Cervix

• DES exposure in utero, cervical trauma, hormonal influence, congenital short cervix, forced D&C, and uterine anomalies

Signs and Symptoms of Incompetent Cervix

• painless vaginal bleeding, cervical dilation, rupture of membranes, and subsequent loss of the products of conception

Management for Incompetent Cervix

• Put the patient under spinal or epidural anesthesia
• Cerclage involves suturing the cervix around 14 weeks.

Types of Cervical Cerclage

• Shirodkar suture, a permanent suture left in for subsequent pregnancies that requires C/S for delivery.
• McDonald suture, is a removed around gestation weeks thirty-eight to thirty-nine for vaginal delivery; needs to be removed to prevent cervical lacerations.

After Care of Cerclage

• Bedrest, observation for bleeding and uterine contractions or ROM, tocolytics if contractions occur

Placenta Previa

• Gradual thinning with separation.
• Detachment of the portion of the placenta over the cervix results in bleeding.

Types of Placenta Previa

• Complete/Total: placenta completely covers internal os
• Partial: placenta partially covers internal os
• Marginal: placenta lies at the margin of internal os.
• Low Lying Placenta is near the internal os.

Predisposing Factors or Causes of Placenta Previa

• Multiparity, previous molar pregnancy endometritis, previous C-section, abortion, increased number of D&Cs, multiple pregnancies, advanced maternal age, decreased blood supply, short umbilical cord, abnormal placentas

Signs and Symptoms of Placenta Previa

• Sudden painless vaginal bleeding with bright red blood; fetus may assume transverse lie.

Placenta Previa-Labor and Delivery Management

• Delivery via Cesarean section for total cases.

Nursing Care for Placenta Previa

• Complete bed rest with quiet environment; NPO
• Semi-Fowler's position is OK for marginal/low-lying previa.
• Trendelenburg is okay for total previa.
• Strict NO vaginal exams are to be done, continuous fetal monitoring is required.

Placenta Previa-Postpartum

• Monitor for hemorrhage, monitor for puerperal infection.
• Anemia may occur

Mnemonic for Placenta Previa

• PREVIA Painless bright red bleeding, Replace blood loss, Evident in lower segment, Vitals indicate shock, Inspect FHR, Avoid vaginal exam

Abruptio Placenta

• Premature separation of a normally implanted placenta after 20 weeks' gestation.
• Likely caused by spiral arteriole degenerative changes that decrease blood supply to the decidua.

Separation from the Uterus Causes

• Decidual tissues and blood vessel necrosis, pushing of placenta away from uterus.
• As the placenta separates, fetal oxygen and nutrient supply is cut off.

Abruptio Placenta Causes

• Maternal HTN, Maternal Age greater than 35 y/o,. Grand multiparity, Trauma to the uterus, Rapid decompression of an over- distended uterus, Short Umbilical Cord, Uterine Leiomyoma or Fibroids, Alcohol use

Types of Abruptio Placenta

• Covert/Central: Bleeding begins at the center, is trapped, and concealed
• Overt/Marginal: Seperation beings at the edge and it is not concealed
• Grade 0: No symptoms and discovered ater deliery with the placenta clot.
• Grade 1: Minor signs.
• Grade II: External bleeding and Uterine tetany, distress to fetus due to fetal stress.
• Grade III: Internal and External bleeding (>1000cc), Uterine Tetany.

Signs and Symptoms for Abruptio Placenta

• Dark vaginal bleeding, Painful bleeding and rigid-board like abdomen, signs of shock and fetal distress with severe bleeding.

Management of Abruptio Placenta

• Hospitalization is Required.
• Aimed by prolonging pregnancy with improved fetal maturity with fetal Heart Rate is Normal and Mother who is not in active labor.

EHL

• ABO incompatibility between Mother and fetus with Maternal blood type is O and fetus is Type A, B , or AB.
• RH factor incompatibility with the blood.
• RH factor is distinct protein antigen in RH positive

Management of EHL

If mother is RH -ve give mother the RhoGAM.

• Given at 28 weeks if not present for antibody.

Hemolytic Disease

• HDN is caused by Rh incompability or ABO iNcompatibility.

Rh Sensitization or Isolation

• The exposure of the Rh negative blood to Rh- positive blood that the body will product the antibodies.
• Maternal antibodies that entered after the baby’s birth.

RH Incompatibility Prevention

• prenatal screening, HISTORY, Blood transfusion

Abruptio Placentia signs and symptoms

• Hemorrhage, probable fetal distress.

RH signs and management

• Do not Manual, cord immediately after, and a blood sample must be drawn from the mother for Kleihauer Betke test, and give RhoGAM.
• It’s the test to check presence of the quantity of fetal blood that enters the maternal circulation.

EHL:

• Mother given symptoms of preterm labor counting the fetal movement.

Intreauterine blood transfusion management

• Can do Percutaneous umbilical sampling, and a needle gets sent from the umbilicus for blood sampling.

Multiple Pregnancy

• More than 2 or 7 fetuses gets developed, that its call multiples pregnancy

Causes of Multiple pregnancy

• Heredity, increasing parity and maternal age.

Identical Twins also causes Monozygotic

• Have the same genetics and sex.

Fraternal Twins also cause Dizygotic

• More than 2 OVA, can have different sex.

Multiple Pregnancy Complications

• Preterm labor and abortion.

MultiplePregnancy SIGNS

• History of twins in family and higher hormones.

DIABETES Mellitus

• Indadequate insulin produces to glucose issues and gets herditery.

TYPE 1 DIABETES

• ABSENce of insulin.

TYPE 2 DIABETES

• No more than insulin.

Pre and Gestational DIABETES

• May occurs through pregnancy.

Pregestational diabetes,

• Women who ahve a history of diabeltes.

Pregestational DM

• Monitor woman every month, or every week for 3 weeks.
• 300 additional calories.

Diabete LAB MANAGEMENT.

• Every month vistis and planning pregnancy.

DIABEte SIGNS

• Perspiration and hunger but monitor