Bleeding During Pregnancy: Causes and Risks

Bleeding During Pregnancy

• Vaginal bleeding at any point during pregnancy is abnormal and potentially serious for both maternal and fetal health
• Bleeding causes vary by trimester

First and Second Trimester Bleeding

• Miscarriages can be threatened, imminent, missed, incomplete, or complete
• Miscarriages are caused by chromosomal abnormalities or uterine issues
• Miscarriage symptoms include vaginal spotting, cramping, and cervical changes
• Ectopic pregnancy involves implantation outside the uterus, commonly in the fallopian tube
• Ectopic pregnancy results in unilateral abdominal pain and potential hypovolemic shock
• Gestational Trophoblastic Disease (Hydatidiform Mole) involves abnormal placental growth, excessive hCG levels, enlarged uterus, and potential malignancy
• Premature Cervical Dilation leads to painless bleeding and pregnancy loss around 20 weeks due to cervical insufficiency

Third Trimester Bleeding

• Placenta Previa occurs when there is low implantation of the placenta, causing painless bleeding as the cervix dilates. Avoid vaginal exams
• Abruptio Placentae is premature placental separation from conditions like hypertension or substance use
• Symptoms of Abruptio Placentae include severe pain, vaginal bleeding, fetal distress, and potential disseminated intravascular coagulation (DIC)
• Preterm Labor involves contractions leading to early labor and may be preventable if detected early
• Corticosteroids for fetal lung maturity may be given

Hypovolemic Shock Due to Blood Loss

• Blood loss during pregnancy can result in hypovolemic shock which impairs organ function and fetal oxygenation
• Signs of hypovolemic shock include decreased urine output, dizziness, increased heart and respiratory rates, cold and clammy skin, decreased blood pressure, and loss of consciousness

Emergency Nursing Interventions for Bleeding

• Immediately alert the healthcare team, place the patient in a side-lying position, and begin IV fluid resuscitation with Ringer's lactate
• Monitor vital signs, fetal heart rate, and uterine contractions
• Avoid vaginal exams in suspected placenta previa
• Order blood typing and cross-matching for potential transfusion
• Weigh perineal pads to estimate blood loss
• Provide supportive care by administering oxygen at 6-10 L/min, emotional support, and a positive outlook on fetal outcomes

Spontaneous Miscarriage

• Pregnancy loss before fetal viability (20–24 weeks) is a spontaneous miscarriage
• Affects 15-30% of pregnancies and is classified as early (before 16 weeks) or late (between 16-20 weeks)

Common Causes of Miscarriage

• Chromosomal abnormalities, teratogenic factors, implantation issues, hormonal imbalances (low progesterone), maternal infections (rubella, syphilis, CMV, toxoplasmosis), and alcohol consumption

Assessment for Miscarriage

• Vaginal spotting is the primary symptom
• Assess pregnancy confirmation and duration, bleeding duration, intensity, frequency, associated symptoms, and blood type Rh-negative patients need Rh immunoglobulin injection

Types of Miscarriage and Management

• Threatened Miscarriage causes vaginal bleeding without cervical dilation. Manage by monitoring fetal heart sounds and hCG levels, and reducing activity
• Imminent/Inevitable Miscarriage causes cervical dilation with cramping and tissue passage. Medication or D&C/D&E prevents complications
• Complete Miscarriage causes full expulsion of fetal tissue which needs no further intervention but is advised to monitor for excessive bleeding
• Incomplete Miscarriage causes retained products of conception. D&C/D&E prevents hemorrhage and infection
• Missed Miscarriage occurs when the fetus dies but is not expelled. Medication (misoprostol), or surgical removal is performed
• Recurrent Pregnancy Loss is defined as three consecutive miscarriages. Chromosomal issues, uterine abnormalities, autoimmune disorders, or hormonal imbalances are the causes

Miscarriage Complications

• Hemorrhage can occur in incomplete miscarriage
• Risk of uterine infection or chorioamnionitis
• Rh-negative mothers require Rh immunoglobulin for Rh Isoimmunization
• Psychological support and counseling are vital for grieving parents

Ectopic Pregnancy

• Ectopic pregnancy is when a fertilized egg implants outside uterus cavity, commonly in the fallopian tube (95%)
• 80% occur in the ampulla, 12% in the isthmus, and 8% in the interstitial or fimbrial regions

Causes and Risk Factors of Ectopic Pregnancy

• Obstructions in the fallopian tube prevent the zygote from reaching the uterus
• Pelvic inflammatory disease (PID), tubal scarring from surgery or infections, congenital malformations, uterine tumors, smoking, alcohol use, early contraceptive use, IUD use, and history of infertility also increase the risk

Incidence and Diagnosis of Ectopic Pregnancy

• Incidence is around 2% of pregnancies
• Diagnose with early ultrasound, MRI, transvaginal ultrasound, and hCG level monitoring

Symptoms of Ectopic Pregnancy

• Early pregnancy symptoms ( missed period, nausea), sharp abdominal pain (especially at rupture), vaginal spotting and hypotension, dizziness, rapid pulse (signs of internal bleeding and shock)

Management & Treatment of Ectopic Pregnancy

• If detected early, methotrexate is given to dissolve the pregnancy
• hCG levels are monitored until they return to normal
• Surgical management includes laparoscopy to remove or repair the damaged fallopian tube
• If the tube is removed, fertility decreases by about 5%, but ovulation from either ovary can still result in pregnancy
• Cases of ruptured ectopic pregnancy needs immediate IV fluids and blood transfusion and urgent surgery to stop internal bleeding
• Rh-negative patients should receive RhIG/RhoGAM to prevent future complications

Gestational Trophoblastic Disease (Hydatidiform Mole)

• Gestational trophoblastic disease (GTD) involves abnormal proliferation and degeneration of trophoblastic cells, forming fluid-filled vesicles resembling grape clusters
• The embryo fails to develop, and GTD may lead to choriocarcinoma, a highly metastatic malignancy

Incidence & Risk Factors of GTD

• Affects 1 in 1,000 pregnancies but is more common in Asian women, those with low animal fat intake, and those <15 or >35 years old

Types of Molar Pregnancy

• Complete Mole has 46XX or 46XY chromosomes from sperm only
• All villi become cystic with no fetal tissue
• Increases the risk of choriocarcinoma and extremely high hCG levels
• Partial Mole has 69XXY or 69XXX chromosomes and is triploid
• Some villi are normal and fetal tissue may be present but nonviable
• Lower hCG levels than a complete mole and rarely leads to malignanc

Diagnosis of GTD

• Early ultrasound shows a snowflake pattern with no fetal growth
• Persistently high hCG levels (1-2 million IU), enlarged uterus growing faster than normal with vaginal bleeding (dark brown or profuse fresh flow), often at 16 weeks

Management & Treatment of GTD

• Suction Curettage removes trophoblastic tissue, followed by serial hCG monitoring - weekly until negative, then monthly for up to 3 months
• Contraception is advised to prevent pregnancy, and chemotherapy (Methotrexate) is only needed if malignancy develops
• Emotional Support is crucial, as patients may experience grief and anxiety over fertility concerns
• Increased Risk in Future Pregnancies and early ultrasounds for detection

Cervical Insufficiency (Premature Cervical Dilatation)

• It is a painless cervical dilation leading to mid-pregnancy loss at around 20 weeks and is associated with maternal age, cervical trauma, or congenital defects

Diagnosis & Symptoms of Cervical Insufficiency

• Pink-stained vaginal discharge or pelvic pressure and sudden rupture of membranes leading to preterm birth
• Diagnosed after pregnancy loss, but can have early detection via ultrasound

Treatment: Cervical Cerclage

• McDonald or Shirodkar Procedure places purse-string sutures around the cervix at 12–14 weeks to prevent dilation
• Care post-surgery: Bed rest for a few days, then normal activity
• Suture removal at 36–37 weeks for vaginal birth, or C-section if placed abdominally
• Emergency cerclage is possible if detected later in pregnancy, but has lower success rates
• 80–90% success rate after cerclage and monitoring in future pregnancies

Placenta Previa

• It is abnormal placenta implantation in lower part of uterus
• Often causes painless 3rd trimester bleeding

Types of Placenta Previa

• Low-lying placenta: Placenta positioned in lower part of uterus, no cervical opening
• Marginal placenta previa: Placenta edge is near cervical opening
• Partial placenta previa: Placenta partially covers cervical opening
• Total placenta previa: Placenta completely obstructs cervical opening
• More common in women with high parity, advanced age, prior cesarean sections, previous uterine surgeries, or multiple pregnancies

Symptoms of Placenta Previa

• Detected during routine ultrasound
• Bleeding often begins around 30 weeks, placenta cannot stretch, the cervix dilates
• Bleeding is usually painless, bright red, and may stop

Management of Placenta Previa

• Immediate care includes bed rest and side-lying position, fetal risk reduction, and to stop further bleeding
• Assess blood amount/color, vital signs, and fetal heart rate
• Provide IV fluids, blood transfusions - controls bleeding and prevents hypovolemic shock
• Vaginal delivery is avoided and cesarean birth is recommended especially if the placenta covers the cervix
• Expectant management and monitoring is used if bleeding stops and the pregnancy is less than 36 weeks
• Betamethasone, a corticosteroid, may be administered to accelerate fetal lung maturity if the fetus is less than 34 weeks

Premature Separation of the Placenta (Abruptio Placentae)

• Placenta separates prematurely from the uterus late in pregnancy, leading to bleeding
• Occurs in 10 out of 1,000 pregnancies
• Is leading cause of perinatal death

Causes and Risk Factors of Abruptio Placentae

• Often unknown, some factors are high parity, advanced maternal age, trauma, hypertension, drug use, thrombophilia, and infections

Symptoms of Abruptio Placentae

• Sudden sharp pain in uterine fundus, often with additional pain during contractions
• Bleeding can be external or internal
• The uterus becomes tense and rigid signs of hypovolemic shock may develop quickly, including a hard "boardlike" uterus
• Coagulation issues may also arise, can lead to DIC (Disseminated Intravascular Coagulation)

Management of Abruptio Placentae

• It is emergency requiring immediate action and treatment includes IV fluid administration, oxygen therapy, and monitoring of fetal heart sounds and maternal vital signs
• If separation is severe, cesarean birth is necessary, especially if fetal distress is evident
• Fibrinogen elevation may be needed before surgery. Hysterectomy is rarely needed to prevent severe blood loss

Prognosis of Abruptio Placentae

• Outcome depends on the degree of placental separation and fetal hypoxia
• Left untreated, it can lead to fetal death, severe hemorrhage, shock, and even maternal renal failure and patients who experience placental separation are at higher risk of infection postpartum

Disseminated Intravascular Coagulation (DIC)

• It is acquired blood clotting disorder where fibrinogen levels drop, can lead to excessive clotting and bleeding
• Associated with conditions like premature placental separation, pregnancy hypertension, amniotic fluid embolism, placental retention, septic abortion, and fetal retention

Pathophysiology of DIC

• Blood clotting occurs to seal a wound with coagulation processes strengthening the clot
• Excess fibrin is then digested by fibrinolysin to prevent over-clotting
• In DIC, there is excessive clot formation at injury sites, consuming platelets and coagulation factors
• Results in insufficient clotting capacity through the body and bleeding elsewhere

Diagnosis of DIC

• Low platelets, prothrombin, and fibrinogen, high thrombin time, and fibrin split products
• D-dimer test is typically elevated in 90% of DIC patients

Management of DIC

• Address underlying cause (placental separation), deliver the fetus and placenta in pregnancy-related DIC
• Use heparin to halt clotting cascade and may cautiously use this to prevent excessive coagulation as this could cause postpartum hemorrhage
• May need transfusions (blood, platelets, fibrinogen, cryoprecipitate) and administered after heparin
• Educate patient that heparin will stop excessive clotting and restore normal coagulation

Evaluation of DIC

• Monitor blood coagulation studies, check for organ damage (especially renal/brain cells), and ensure the fetus has adequate placental circulation

Preterm Labor

• Occurs before the 37th week of gestation and is responsible for 2/3rds of neonatal deaths
• Caused by preterm births, short cervical length, smoking, infections, and socioeconomic status
• Symptoms are low back pain, vaginal spotting, pelvic pressure, abdominal tightening, menstrual cramps, and inreased discharge

Prevention and Risk Factors of Preterm Labor

• Maintain good health during pregnancy
• Bed rest helps to prevent recurrence by staying hydrated, resisting and avoiding nipple stimulation and should report ruptured membranes, bleeding or infection
• Previous preterm births, short pregnancy intervals, smoking, infections, and age increase risks

Diagnosis and Management of Preterm Labor

• Symptoms are subtle and encouraged to seek medical help and have possible hospitalization, bed rest monitoring and IV hydration
• Terbutaline can halt labor
• Magnesium sulfate is used for fetal neuroprotection before 32 weeks
• Corticosteriods help acclerate lung development and reduce respiratory distress

Preterm Rupture of Membranes (PROM)

• Fetal membranes rupture before 37 weeks of pregnancy
• Linked to infections like Chorioamnionitis and lead to fetal complications
• Labor is likely to occur if it doesnt start after rupture

Assessment of PROM

• Reports of sudden gush of clear fluid
• Check the fluid pool, color by nitrous paper or fluid microscope
• Check infection and blood test with white blood cell count

Management of PROM

• Mambranes will reseal but if thats not the case start labor at 34 weeks
• Give corticostreriods at 36 weeks
• Given IV antibiotics to prevent infections
• Give tocolytic agents and amnioinfusion to reduce complications

Gestational Hypertension

• Defined as vasospasm in small and large arteries causing increased blood pressure
• Key features are increased blood pressure without proteinuria and usually it resolves during pregnancy