Pregnancy Bleeding: Types, Causes, and Hemorrhage

Pregnancy Bleeding Types

• Antepartum hemorrhage happens at any time during pregnancy.
• Intrapartum hemorrhage occurs during labor, often due to placental abruption, uterine rupture/inversion, abnormal placental adhesions, or CS complications.
• Postpartum hemorrhage is defined as blood loss exceeding 500ml vaginally or 1000ml during a CS birth.

Primary Causes of Bleeding

• First-trimester causes include abortion and ectopic (tubal) pregnancy.
• Second-trimester causes include hydatidiform mole (gestational trophoblastic disease) and premature cervical dilatation/incompetent cervix.

Hemorrhage

• Rapid blood loss of more than 1% of body weight can lead to inadequate tissue perfusion, glucose/oxygen deprivation, and waste buildup.
• Hypovolemic shock occurs with 1.5 to 2 liters of blood loss.

Pathophysiology of Hypovolemic Shock

• Hypovolemia leads to decreased venous return, decreased cardiac output, hypotension, perfusion failure, tissue hypoxia, organ dysfunction, and ultimately multiorgan failure.

Signs of Hypovolemic Shock

• High heart rate occurs as the heart attempts to circulate low blood volume.
• Low blood pressure results from decreased peripheral resistance.
• High respiratory rate supports gas exchange to oxygenate low red blood cell volume.
• Cold, clammy skin arises as vasoconstriction maintains blood volume in the body core.
• Low urine output indicates inadequate blood flow to the kidneys.
• Dizziness/low consciousness levels happen because inadequate blood reaches the cerebrum.
• Low central venous pressure means reduced blood return to the heart.

Hypovolemic Shock Therapy

• Restoring blood volume and halting hemorrhage is the aim.

Abortion

• Abortion is the medical term for pregnancy interruption before fetal viability.
• Fetal viability is generally defined as >20-24 weeks AOG or fetal weight of at least 500g.
• Occurrence rate is 15-30% of all pregnancies, often from natural causes.

Types of Abortion

• Early abortion occurs before 12 weeks of pregnancy.
• Late abortion occurs between 12 and 20 weeks.
• Elective or therapeutic abortions medically terminate a pregnancy when recommended by a healthcare provider for the mother's physical or mental health.
• Spontaneous abortion refers to the natural loss of a fetus.

Causes of Spontaneous Abortion

• Fetal causes include abnormal formation from teratogenic factors or chromosomal aberrations, accounting for 50-90% of cases.
• Advanced maternal age, especially over 35, is a maternal cause.
• Abortion rates: below 35 years (15%), 35-39 years (20-25%), 40-42 years (35%), above 42 years (50%).
• Congenital uterine defects/uterine septum, fibroids, cervical incompetence, and insufficient progesterone production are structural abnormalities of the reproductive tract.
• Maternal infections such as Rubella virus, Syphilis, cytomegalovirus, toxoplasmosis, and UTIs can cause spontaneous abortions.
• Ingestion of teratogenic drugs like isotretinoin (Accutane) causes spontaneous abortions.
• Polycystic ovary syndrome, poorly controlled diabetes mellitus, renal disease, SLE, untreated thyroid disease, and severe hypertension are chronic and systemic maternal diseases.
• Exogenous factors include tobacco, alcohol, cocaine, high caffeine doses, and radiation.

Assessment Factors for Abortion

• Assessment factors include vaginal spotting, which is often the presenting symptom, confirmation and length of pregnancy, the duration and intensity of bleeding, and a description of blood type.

Therapeutic Management for Abortion

• Physician or nurse-midwife determines management based on symptoms and bleeding description.

Types of Spontaneous Abortion

• Threatened abortion presents with vaginal spotting that is initially scant and bright red, possibly with slight cramping and no cervical dilation.

Threatened Abortion Diagnosis

• Fetal Heart Tones (FHT)/Ultrasound (UTZ) assess fetal viability.
• Serial hCG hormone blood tests assess pregnancy viability.

Threatened Abortion Management

• Management includes avoiding strenuous activity for 24-48 hours, complete bed rest, emotional support, counseling, and restricting coitus for 2 weeks after the bleeding episode.

Imminent Abortion

• Imminent (inevitable) abortion involves uterine contractions and cervical dilation.

Imminent Abortion Diagnosis

• FHT/UTS tests and examination of tissue fragments passed from the labor room or brought from home are used for diagnosis.

Imminent Abortion Management

• Management includes D&E (dilation & evacuation)
• Inform the patient about procedure & its rationale

Post-D&E Assessment

• After D&E, assess vaginal bleeding, excessive bleeding is defined by soaking "1 pad / hour."

Complete Abortion

• Complete abortion involves the spontaneous expulsion of all Products of Conception (POC) without assistance.
• Bleeding usually slows within 2 hours and ceases within a few days after POC passage.

Incomplete Abortion

• In incomplete abortion, part of the POC is expelled, but the membrane or placenta is retained, which may result in maternal hemorrhage.

Incomplete Abortion Management

• Management includes dilation and curettage.

Missed Abortion

• Missed abortion involves the retention of all POCs after the fetus dies in the uterus the signs of pregnancy disappear, and there may be painless vaginal bleeding or no symptoms.

Missed Abortion Diagnosis

• Lack of fundal height increase, inability to hear FHT, and UTS confirmation of fetal death confirm the diagnosis.

Missed Abortion Management

• Management includes D&E, induced labor if >14 weeks, and emotional support and counseling.

Induced Labor after 14 Weeks

• Prostaglandin suppositories or misoprostol (Cytotec) dilate the cervix.
• Oxytocin is used for stimulation, or mifepristone is administered.
• If miscarriage does not occur spontaneously within 2 weeks, it’s actively terminated.
• Disseminated Intravascular Coagulation (DIC) can result if a dead fetus remains too long in utero.

Recurrent Abortion

• Recurrent (habitual) abortion is defined as three or more successive spontaneous abortions, occurring in 1% of pregnancies.

Recurrent Abortion Causes

• Possible causes include defective spermatozoa or ova, endocrine factors, deviation of the uterus, chorioamnionitis, or uterine infection.

Complications of Abortion

• Potential complications include hemorrhage, infection, Rh isoimmunization, and psychological distress.

Hemorrhage Management

• Management includes monitoring vital signs, D&C, possible blood transfusions, and oral Methergine.

Patient Education About Infection

• Teach patients to monitor bleeding amount/color/odor.
• Minimal blood loss is self-limiting.

S/Sx of Infection

• Teach the patient about signs and symptoms of infection, including fever (>38°C), abdominal pain, tenderness, and foul vaginal discharge.
• Advice: Wipe front to back and avoid tampons.

Infections that May Occur

• Infection examples include endometritis, parametritis, peritonitis, and thrombophlebitis.

Septic Abortion

• Septic abortion is an abortion complicated by infection.
• Bacteria/toxins disseminate into the maternal circulatory and organ system.
• It often occurs during self-induced or illegal abortions with nonsterile instruments or untrained individuals.
• Infectious organisms grow rapidly, especially if POC remains, and; if untreated, it can lead to toxic shock syndrome, septicemia, kidney failure, and death.

Septic Abortion S/Sx

• Signs and symptoms include fever, crampy abdominal pain, and a tender uterus upon palpation.

Septic Abortion Complications

• Possible complications are infertility, infection, and hemorrhage.

Isoimmunization

• Occurs when fetal blood enters maternal circulation.
• If the fetus is Rh-positive and the mother is Rh-negative, the mother produces antibodies.
• In subsequent pregnancies, if the fetus is Rh-positive, these antibodies can destroy fetal red blood cells.
• Rh-negative women should receive Rh (D antigen) immune globulin (RhIG).

Abortion-Related Nursing Diagnoses

• Anxiety related to possible pregnancy loss.
• Anticipatory grieving related to threatened abortion, and the potential for infant with congenital anomalies.
• Risk for infection from internal organism invasion after vaginal bleeding.
• Risk for deficient fluid volume due to excessive vaginal bleeding during pregnancy.

Ectopic Pregnancy

• Ectopic pregnancy is a pregnancy implanted outside the uterine cavity.
• It occurs in 2% of all pregnancies.

Ectopic Pregnancy Implantation Sites

• Sites of implantation include the surface of the ovary, cervix, abdominal cavity, fallopian tube (95% of cases), ampulla (distal 1/3, 80%), isthmus (proximal, 12%) and the interstitial/fimbrial portion (8%).

Ectopic Pregnancy Risk Factors

• Risk factors include previous infection, congenital malformations, tubal surgery scars, uterine tumors, smoking, and previous ectopic pregnancy.

Pathophysiology of Ectopic Pregnancy

• The zygote cannot travel the tube's length and lodges at a stricture, it implants, grows large over 6-12 weeks, then ruptures the fallopian tube.
• After the zygote ruptures, trophoblast cells break through the narrow base resulting in vessel tearing → Bleeding

Ectopic Pregnancy Signs & Symptoms

• Symptoms include a missed menstrual period of 2 weeks duration (68%), unilateral lower abdominal pain (99%) and irregular vaginal bleeding (75%).

S/Sx Before Rupture

• Amenorrhea with spotting and pelvic/abdominal pain (90%).

S/Sx of Rupturing Ectopic Pregnancy

• Isthmic pregnancy ruptures early at 6 weeks, while ampullary pregnancies rupture later around 8-12 weeks.
• Abdominal pregnancies may initiate anytime.
• S/Sx = sudden, severe, knife-like pain radiating to the neck and shoulder with blood accumulation.
• Lightheadedness, rapid pulse, spotting or dark brown bleeding, Cullen's sign (bluish umbilicus discoloration), and a hard or board-like abdomen.
• Signs of shock include cyanosis, pallor, cold/clammy skin, hypotension, and oliguria.

Ectopic Pregnancy Diagnosis

• Ultrasound (UTS) and MRI determine pregnancy location.
• Falling hCG and serum progesterone indicate ectopic pregnancy.
• Laparoscopy or culdoscopy visualization confirms the diagnosis.

Therapeutic Management for Ectopic Pregnancy

• Unruptured ectopic pregnancies may be treated with oral methotrexate, a chemotherapeutic agent that attacks fast-growing cells.
• Leucovorin reduces methotrexate toxicity.
• Mifepristone is an abortifacient which causes sloughing of the implantation site.
• Ruptured ectopic pregnancies may require salpingostomy (incision and repair) or salpingectomy (removal of the fallopian tube).

Nursing Interventions for Ectopic Pregnancy

• Interventions for maintaining fluid volume include IV fluids, blood samples, blood transfusion (BT), vital sign monitoring, and urine output monitoring.

Nursing Interventions for Ectopic Pregnancy Comfort

• Comfort may be promoted by administering analgesics and encouraging relaxation techniques.

Providing Post-Ectopic Pregnancy Support

• Include emotional support, listening to concerns, and providing grief counseling.

Patient Education on Ectopic Pregnancy

• Teaching women at risk about ectopic pregnancy s/sx
• Instructing patients to report the s/sx
• Discussing contraception

Ectopic Pregnancy Complications

• Potential complications include 50% infertility rates, isoimmunization and hemorrhage.
• Another complication includes the potential for a pregnant woman's blood protein being incompatible with the baby.

Nursing Diagnosis for Ectopic Pregnancies

• Risk for deficient fluid volume related to blood loss from a ruptured tube.
• Acute pain related to ectopic pregnancy or rupture with bleeding into the peritoneal cavity.
• Anticipatory grieving related to pregnancy loss and reduced capacity for childbearing.