Maternal Hemorrhagic Disorders

• Maternal hemorrhagic disorders involve bleeding conditions during pregnancy or after childbirth.
• These disorders can arise from bleeding issues, placental abnormalities, or uterine atony.

Types of Maternal Hemorrhagic Disorders

• Antepartum hemorrhage
• Postpartum hemorrhage
• Bleeding disorder

Antepartum Hemorrhage

• It occurs during the first, second, or third trimester.

First Trimester Bleeding

• Abortion
• Ectopic pregnancy
• Fetal demise

First Trimester Abortion

• The preferred term is spontaneous miscarriage.
• It is the medical term for the interruption of pregnancy before a fetus is viable.
• Early miscarriages happen before week 16 of pregnancy.
• Late miscarriages happen between 16-20 weeks.

Causes of First Trimester Abortion

• Abnormal fetal development from teratogenic factors or chromosomal aberration can cause abortion.
• Immunologic factors
• Implantation abnormalities from inadequate endometrial formation can cause abortion
• Ingestion of alcohol can cause abortion
• Urinary tract infections and systemic infections can cause abortion, including rubella, syphilis, poliomyelitis, cytomegalovirus, and toxoplasmosis.

Types of abortion:

• Spontaneous abortion
• Induced abortion

Spontaneous Abortion

• Types included threatened, inevitable, complete, incomplete, missed, and habitual abortions.

Threatened Abortion

• Causes are unknown and may be due to chromosomal or uterine abnormalities.
• Mild uterine contractions and scant, bright red vaginal bleeding will occur along with a closed cervix.
• Diagnostic testing will confirm viable pregnancy with ultrasound and HCG testing.
• Management includes complete bed rest, no coitus for 2 weeks, progesterone medications, avoiding strenuous activity, avoiding tampons, and instructions regarding the passage of products of conception.

Inevitable Abortion

• The cause is unknown but possibly from poor placental attachment.
• Moderate to severe uterine contractions, moderate to heavy vaginal bleeding, and an open cervix will occur.
• HCG blood tests, pelvic exams, and ultrasound imaging will be used.
• Management includes a D&C, administration of Rhogam, saving passed tissue fragments, and emotional support.

Complete Abortion

• The cause is unknown but possibly chromosomal or uterine abnormality
• Okay uterus, open cervix, expulsion of all products of conception, vaginal spotting and cramping will occur.
• Management is through a blood test, ultrasound, pelvic examination, emotional support and supportive care.

Incomplete Abortion

• The cause is unknown but possibly chromosomal or uterine abnormality.
• Assessment will be not all products of conception are expelled, not okay uterus and cervix, vaginal spotting and cramping.
• Diagnostic testing includes a blood test, ultrasound, and pelvic examination.
• Management includes D&C, suction curettage, and administration of Rhogam.

Missed Abortion

• The cause is unknown.
• All products of conception remain.
• Assessment will find not okay uterus, cervix, and fetus.
• Diagnostic testing includes ultrasound and a blood test.
• Management includes a D&C, antibiotic therapy, Rhogam, and monitoring for disseminated intravascular coagulation (DIC).
• If pregnancy exceeds 14 weeks, labor is induced via prostaglandin suppository like Cytotec, with emotional support and supportive care.

Habitual Abortion/Recurrent Pregnancy Loss

• Causes include defective spermatozoa or ova, endocrine factors, deviation of the uterus, resistance to uterine artery blood flow, uterine infections, chorioamnionitis, and autoimmune disorders
• Three or more consecutive pregnancies result in abortion, usually related to incompetent cervix.
• Assessment includes an incompetent cervix.
• Diagnosis is based on ultrasound, psychogenic factors, and co-morbidity.
• Treatment includes McDonald Operation and Shirodkar procedure.

Induced Abortion

• There are two types including therapeutic and illegal abortions.

Therapeutic Induced Abortion

• Medical intervention ensures the mother's life, especially with bioethical issues.
• It considers the option of lesser evil due to its two-fold effect.

Illegal Induced Abortion

• It refers to the unwanted termination of a pregnancy and puts the mother's and the fetal life at stake.
• Not permitted by law in the Philippines.

Fetal demise

• The termination of the pregnancy after the age of viability
• The two types of fetal demise include antenatal and intrapartum demise.
• Antenatal demise occurs before labor.
• Intrapartum demise occurs after the onset of labor.

Risk Factors for Fetal Demise

• Idiopathic factors
• Antiphospholipid Antibody Syndrome (APAS)
• Maternal diabetes
• Maternal trauma
• Severe maternal isoimmunization
• Fetal aneuploidy
• Fetal infection

Fetal Demise Characteristics

• Macerated baby refers to a soft body of the dead baby within 1-2 weeks.
• Mummification refers to a leather-like body that forms when the fetus is in the womb for more than 2 weeks.
• Lithopedion refers to a stone hard body.

Ectopic Pregnancy

• The implantation occurs outside the uterine cavity, such as an extrauterine implantation.
• Ninety percent of ectopic pregnancies are tubal pregnancies.
• Eighty percent of ectopic pregnancies occur in the ampullar portion, with 12% occurring in the isthmus.
• Eight percent are interstitial or fimbrial.

Sites for Ectopic Pregnancy

• Most common is tubal implantation.
• Ovarian implantation
• Rare is cervical implantation.
• Most dangerous is abdominal implantation.

Risk Factors for Ectopic Pregnancy

• Previous pelvic or abdominal surgery
• Cigarette Smoking
• Vaginal douching
• Age of first intercourse <18 years
• Previous genital infection
• Infertility
• Multiple sexual partners
• Previous ectopic pregnancy
• Previous tubal surgery or sterilization
• Diethylstilbestrol exposure in utero
• Documented tubal scarring
• Use of IUD

Types of Ectopic Pregnancy

• Unruptured Ectopic Pregnancy
  • Missed period
  • Abdominal pain within 3-5 weeks of amenorrhea
  • Scanty, dark brown vaginal bleeding
  • Vague discomfort
• Ruptured Ectopic Pregnancy
  • Sudden, sharp, knifelike, unilateral severe pain
  • Kehr's sign
  • (+) Cullen's sign
  • Syncope

Management of Ectopic Pregnancy

• Termination of pregnancy
• Exploratory Laparotomy
• Fluid Replacement
• Administration of Methotrexate
• Testing for HCG Titer
• RhoGam
• Salphingostomy/Salphigectomy
• Combat Shock

Second Trimester Bleeding

• Hydatidiform Mole (H-Mole) or Gestational Trophoblastic Disease is present.

Hydatidiform Mole (H-Mole) or Gestational Trophoblastic Disease

• This has an abnormal proliferation and degeneration of the trophoblastic villi.
• Referred to as a "bunch of grapes" and is a gestation anomaly of the placenta with an approximate incidence of 1 in every 1500 pregnancies.

Risk Factors of Hmole

• Pregnancies below 17 and above 35 years old
• Low CHON Diet
• Previous H.Mole

Types of Hmole

• Complete Mole occurs when a sperm fertilizes an empty egg, resulting in a placenta with no fetal development with only paternal DNA.
• Partial Mole happens when two sperm fertilize a normal egg, leading to some fetal development and a mix of maternal and paternal DNA.

Assessment for Hmole

• Early signs include vesicles passed through the vagina.
• Hyperemesis gravidarum, increased Fundic HGT, absent *FHT, vaginal bleeding, metastasis, increased HCG Levels, and Preeclampsia @ 12 weeks can occur.
• Late signs include hypertension before 20th week, snowstorm on sonogram, anemia, and abdominal cramping
• Serious late complications include hyperthyroidism, and pulmonary embolisms.

Diagnostics of Hmole

• Pelvic examination
• Serum HCG level monitoring assessed every 4 weeks for 6-12 months.
• After 6 months if HCG levels are already negative, the patient is theoretically free from the risk of malignancy.

Management of Hmole

• Suction curettage will be performed.
• The patient must avoid getting pregnant for 1 year to allow HCG to decrease.
• Prophylaxis involves using Methotrexate
• If metastasis occur, then dactinomycin will be used
• Hysterectomy

Premature Cervical Dilatation

• Cervix dilates prematurely, and therefore cannot hold a fetus until term.
• Condition occurs in approximately 1% of women.
• Condition commonly occurs at approximately week 20 of pregnancy.

Risk Factors for Premature Cervical Dilation

• Increased maternal age is a risk factor.
• Congenital structural defects
• Trauma to the cervix

Assessment for Premature Cervical Dilation

• Dilation is usually painless
• Show
• Increased pelvic pressure.
• Premature Rupture of membranes(PROM)
• Uterine contractions

Diagnostic Procedures for Premature Cervical Dilation

• Early sonogram

Therapeutic Management for Premature Cervical Dilation

• Cervical cerclage
  • McDonald Procedure
  • Shirodocar Procedure

Third Trimester Bleeding

• Placental anomalies

Placenta Previa

• Placenta is implanted abnormally in the lower part of the uterus.
• It the is most common cause of painless bleeding in the third trimester.

Degrees of Placenta Previa

• Low lying placenta
• Marginal placenta
• Partial previa
• Complete previa

Predisposing Factors for Placenta Previa

• Presence of scars and tumors in the uterine lining
• Multigravida
• Presence of fibroids
• Previous Cesarean section
• Increasing maternal age
• Cigarette smoking
• Previous previa
• Prior curettage

Assessment for Placenta Previa

• Painless bright red bleeding beginning in the 7th month
• Engagement usually has not occurred
• Fetal distress
• Presentation of placenta

Diagnostic Assessment for Placenta Previa

• Ultrasound
• Less than 30% blockage possible for NSD
• More than 30% blockage candidate for CS
• APT or Kleihauer Betke test
• Blood test

Management of Placenta Previa

• Secure consent
• Place patient in a side lying position
• No coitus, No Internal Exam ie, No Enema
• Cesarean Birth Ready and Strict Bed Rest/ Bathroom Privileges
• Prepare to induce labor if the cervix is ripe or dilated
• IV Fluids
• Place patient on Nothing By Mouth for possible Cesarean Section
• Prepare for double set-up
• Estimate the present blood loss

Abruptio Placenta

• Premature separation of a normally implanted placenta occurs in about 10 out of 1000 pregnancies and can lead to extensive bleeding which is the most frequent cause of perinatal death.

Degrees of Placental Separation

• Partial Separation (Concealed Hemorrhage)
• Partial Separation (Apparent Hemorrhage)
• Complete Separation (Concealed Hemorrhage)

Predisposing Factors for Abruptio Placenta

• Preeclampsia and hypertensive disorders
• Illicit drug use
• Trauma
• History of placenta abruptio
• Multigravida
• Increase maternal age
• Cigarette smoking
• Short umbilical cord
• Chorioamnionitis

Assessment for Abruptio Placenta

• Sharp, stabbing pain high in the uterine fundus as the initial separation occurs.
• Dark red painful vaginal bleeding, concealed bleeding, rigidity of the abdomen, moderate to severe abdominal pain, drop in coagulation factors, hyperactivity then cessation of fetal movement.

Complications With Abruptio Placenta

• Disseminated Intravascular Coagulation (DIR)
• Couvelaire uterus/uteroplacental apoplexy

Medical Management of Abruptio Placenta

• Emergency Cesarean Section
• Vaginal Delivery
• Conservative in-hospital observation

Management of Abruptio Placenta

• Secure consent
• Place patient in a side lying position
• No coitus, No Internal Exam ie, No Enema
• IV Fluids
• Blood typing and cross matching for possible blood transfusion
• Monitor fetal heart tones and maternal vital signs for shock
• Measure blood loss
• Strict Intake and Output
• Report signs and symptoms of Disseminated Intravascular Coagulation
• Restrict from doing any abdominal, pelvic, and vaginal examination

Postpartum Hemorrhage

• Uterine Atony

Uterine Atony

• The uterus does not contract enough after childbirth, leading to heavy bleeding.
• Atony is the most common cause of postpartum hemorrhage.

Risk Factors for Uterine Atony

• Deep anesthesia or analgesia
• Labor initiated and assisted with an oxytocin agent
• High parity or maternal age of 35 above
• Previous uterine surgery
• Prolonged and difficult labor
• Chorioamnionitis or endometritis
• Secondary maternal illness
• History of Post Partum Hemorrhage
• Prolonged magnesium sulfate or other tocolytic

Therapeutic Management of Uterine Atony

• Administration of Uterotonics
  • Oxytocin
  • Carboprost tromethamine
  • Methargine
  • Misoprostol (Cytotec)
• Fundal massage
• Elevate lower extremities
• CBR S BRP
• Empty bladder - offer bedpan or assist the patient to the bathroom every 4 hours
• Strictly monitor vital signs
• Blood replacement

Laceration

• Small lacerations or tears of the birth canal are common after birth, but a large laceration can be a source of infection or hemorrhage.

Risk Factors for Laceration

• Dystocia or precipitate labor
• Primigravida
• Macrosomia
• With the use of lithotomy position and instruments

Types of Lacerations

• Cervical laceration
• Vaginal laceration
• Perineal laceration
  • 1st degree: damages skin area
  • 2nd degree: includes muscles and bulbocavernosus
  • 3rd degree: includes external anal sphincter
  • 4th degree - anal mucosa

Management of Laceration

• Proper perineal care
• Avoiding strenuous activity
• Applying a cold compress in first 24-48 hours and a warm compress in next 72 hours
• Check for any discharge
• Use a bed commode
• Usage of droplight in the perineal area
• Suturing
• High fiber diet
• A stool softener may be prescribed.
• The patient with 3rd and 4th degree laceration should not have an enema or renal suppository.

Retained Placental Fragments

• Pieces of the placenta remain in the uterus after giving birth because the placenta does not detach entirely.

Risk Factors for Retained Placental Fragments

• Previous cesarean birth
• In Vitro Fertilization
• Succenturiate placenta
• Placenta accreta

Management of Retained Placental Fragments

• D&C
• Observe the color of lochia
• Methotrexate

Uterine Inversion

• Prolapse of the fundus of the uterus through the cervix causes the uterus to turns inside out with either birth of the fetus or delivery of the placenta.

Risk Factors for Uterine Inversion

• Traction of umbilical cord
• Fundal push
• Precipitate labor

Types of Inversion

• Inverted fundus
• Total inversion

Management of Uterine Inversion

• Never attempt to replace an inversion or remove the placenta.
• D/C oxytocin.
• Replace fluids
• Administer oxygen
• The OB will manually replace the fundus.
• After replacement, resume oxytocin
• Antibiotic therapy
• Possible Cesarean Section in the future

Disseminated Intravascular Coagulation

• Rare but serious condition that causes abnormal blood clotting throughout the body's blood vessels.

Risk Factors for Disseminated Intravascular Coagulation

• Abruptio Placenta
• Gestational Hypertension
• Amniotic Fluid Embolism
• Placenta retention
• Septic Abortion

Early Signs of Disseminated Intravascular Coagulation

• Bruising
• IV site bleeding
• Bleeding

Management for Disseminated Intravascular Coagulation

• Administration of Heparin
• Blood Transfusion
• Resolving the underlying insult
• Monitor for bleeding and coagulation levels
• Strictly monitor vital signs

Subinvolution

• Incomplete return of the uterus to its pre-pregnant size and shape caused by small retained placental fragments, a mild endometritis, and other problems.

Management of Subinvolution

• Methergine
• Antibiotics
• Increased fluid intake
• Promote Voiding

Perineal Hematoma

• Collection of blood in the subcutaneous layer of tissue of the perineum
• Hematomas are likely to occur after rapid, spontaneous births and in women in perineal varicosities.

Risk Factors for Perineal Hematoma

• Precipitate labor
• Perineal varicosities
• Episiotomy

Management of Perineal Hematoma

• Cold compress
• Pain reliever
• Check for discharge, color, smell, and circulation