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Bleeding disorders


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Bleeding disorders

  1. 1. Bleeding Disorders
  2. 2. 2 1st Trimester Bleeding Spontaneous miscarriage Threatened Imminent Complete Missed Recurrent pregnancy loss
  3. 3. 3 Abortion • ABORTION Early (before 20 wks) - Any pregnancy that terminates before the age of viability • Spontaneous abortion characterized by painless (may be cramping) dark-bright red vaginal bleeding
  4. 4. Spontaneous Abortion • Miscarriage Causes: Abnormal fetal formation, chromosomal aberration, Infections (CMV & Toxoplasmosis) S/Sx: Vaginal spotting Managements: - Depending on the manifestations
  5. 5. Threatened Abortion Cause: Unknown S/Sx: Scant bright red vaginal bleeding with slight abdominal cramping and no cervical dilation Managements: • No treatment to hold pregnancy • Complete Bed rest (Limit activity) • Coitus restricted for 2 wks
  6. 6. Inevitable Abortion • Imminent S/Sx: Moderate bright red bleeding; uterine contraction and effacement Managements: • Establish IV line;Draw blood • Administer pitocin • WOF: signs of hypovolemic shock • D&C
  7. 7. Complete Abortion • All the products of conception are expelled (placenta and fetus) • Bleeding shows within 2 hrs and ceases within few days after the passage of conceptus
  8. 8. Incomplete Abortion • Part of the conception is expelled usually the fetus • S/Sx: massive bleeding and clot bloods
  9. 9. Missed Abortion • Intrauterine fetal death • Fetus die in utero but not expelled S/Sx: Asymptomatic or same with threatened abortion Dx: • Fetus died but not expelled • Discovered in prenatal check-up • Fundal height in Increasing • No FHT
  10. 10. Missed Abortion Cx: Disseminated Intravascular Coagulation Management: 1. Replacement of IV fluids 2. Administer pitocin. 3. D&C
  11. 11. Habitual Abortion • Recurrent Cause: Defective spermatozoa, autoimmune, infection Cx: Hemorrhage and Infection
  12. 12. 12 CLINICAL CLASSIFICATIONS OF SPONTANEOUS ABORTION Type Assessment Nursing Considerations Threatened Vaginal bleeding and cramping Soft uterus, cervix closed Ultrasound for intrauterine sac, quantitative HCG Decrease activity for 24-48 h, avoid stress, no sexual intercourse for 2 wk after bleeding stops Monitor amount and character of bleeding; report clots, tissue, foul odor Inevitable, if cervical dilation cannot be prevented (Imminent) Persistent symptoms, hemorrhage, moderate to severe cramping Cervical dilatation and effacement Monitor for hemorrhage (save and count pads) and infection; if persistent or increased symptoms, D and C Emotional support for grief and loss Incomplete Persistent symptoms, expulsion of part of products of conception Administer IV/blood, oxytocin D and C or suction evacuation Complete As above, except no retained tissue Possible oxytocin PO; no other treatment if no evidence of hemorrhage or infection Missed – fetus dies in utero but is not expelled May be none/some abating of above symptoms Cervix is closed If retained >6 wk, increased risk of infection, DIC, and emotional distress D and C evacuation within 4-6 wk After 12 wk, dilate cervix with several applications of prostaglandin gel or suppositories of laminaria (dried sterilized seaweed that expands with cervical secretions) Habitual – 3 or more May be incompetent cervix, infertility Cerclage (encircling cervix with suture)
  13. 13. 13 1st Trimester Bleeding Ectopic pregnancy Implantation occurs outside of the uterine cavity
  15. 15. 15 Ectopic pregnancy – implantation outside uterus (commonly in fallopian tube) - potentially life threatening to mother - Characterized by:  unilateral lower quadrant pain after 4-6 weeks of normal signs and symptoms of pregnancy (amenorrhea, (+) pregnancy test  bleeding may be gradual oozing to frank bleeding  may be palpable unilateral mass in adnexa  low HCG levels  rigid and tender abdomen  signs and symptoms of hemorrhage
  16. 16. 16 Ectopic Pregnancy – Necessary to be alert for signs and symptoms – investigate risk factors especially PID, multiple sexual partners, recurrent episodes of gonorrhea, infertility Management – prepare for surgery – Shock monitoring and management – postoperatively, monitor for infection and paralytic ileus – Provide support for emotional distress – RhoGam for Rh- negative woman – monitor Hgb and Hct – ultrasound for adnexal mass/ gestational sac in tube – culdocentesis (indicated by nonclotting blood) – laparoscopy and/or laparotomy – adequate blood replacement (type and X match, IV with large-bore needle)
  17. 17. 17 2nd Trimester Bleeding Premature cervical dilatation Cannot hold the fetus until term Cervical cerclage
  18. 18. 18 Incompetent Cervix • Painless dilatation of the cervix usually in the 2nd trimester • May lead to infection, premature rupture of membranes, preterm labor
  20. 20. 20 2nd Trimester Bleeding Gestational trophoblastic disease (hydatidiform mole) Abnormal proliferation and degeneration of the trophoblastic villi degenerative anomaly of the placenta converting the chorionic villi into a mass of clear vesicles
  21. 21. 21 Hydatidiform mole Characterized by • elevated HCG levels • uterine size greater than expected for gestational age • no FHR • minimal dark red/brown vaginal bleeding with passage of grapelike clusters • no fetus by ultrasound • possible increased nausea and vomiting and associated pregnancy-induced hypertension • treated with curettage to completely remove all molar tissue, which can become malignant • pregnancy is discouraged for 1 year, and HCG levels are monitored during that time (if it continues to be elevated, may require hysterectomy and chemotherapy)
  22. 22. 22 Gestational trophoblastic disease (hydatidform mole)
  23. 23. 23 3nd Trimester Bleeding  Placenta previa Low implantation of placenta  Abruptio Placenta Premature separation of placenta Occurs suddenly
  24. 24. 24 Placenta previa • development of the placenta in the lower uterine segment, partially or completely covering the internal cervical os • Characterized by painless vaginal bleeding, which is usually slight at first (spotting – 1st and 2nd trimesters) and increases in subsequent unpredictable episodes; usually soft and non tender abdomen 4 Degrees of Placenta previa 1. Low-lying - in lower segment 2. Marginal - at border of internal cervical os 3. Partial – occludes a portion of the cervical os 4. Total - complete obstruction of the os
  26. 26. 26 Placenta Previa Managements • Hospitalization • bed rest • side-lying or Trendelenburg position for at least 72 hours • ultrasound shows the location and degree of obstruction • no vaginal/ rectal exam unless delivery would not be a problem (if it becomes necessary, it must be done in OR under sterile conditions) • amniocentesis for lung maturity • monitor for changes in bleeding and fetal status • daily Hgb and Hct; keep IV line and make blood available (blood typed and cross matched- 2 units) • Delivery by cesarean if evidence of fetal maturity, excessive bleeding, active labor, other complications • Home - if bleeding ceases and pregnancy to be maintained – limit activity; no douching, enemas, coitus; monitor FM; NST at least every 1-2 wk
  27. 27. 27 Abruptio placenta • premature separation of normally implanted placenta; may be marginal (near edge) with dark red vaginal bleeding or central (at center) with concealed bleeding; life threatening to fetus and mother • Common among women with hypertension, short umbilical cord and alcohol use; also by direct trauma
  28. 28. 28 Abruptio Placenta Characterized by: - painful (sharp, stabbing) vaginal bleeding/ epigastric pain - uterine rigidity and tenderness: abdomen is tender, painful and tense (board-like) - rapid signs and symptoms of maternal shock and/or fetal distress (altered FHR) - May lead to Couvelaire uterus (blood infiltrating the uterine musculature) forming a hard, board-like uterus without apparent bleeding - External bleeding may seem out of proportion to symptoms (shock) displayed by the woman
  30. 30. 30 Abruptio Placenta • Manage signs and symptoms - Keep woman in lateral position (not supine) - Oxygenation (to limit fetal anoxia) - FHR monitoring; VS monitoring - Baseline fibrinogen (if bleeding is extensive, fibrinogen reserve may be used up in the body’s attempt to accomplish effective clot formation)
  31. 31. 31 Abruptio Placenta - NO IE or rectal examination, No enema - Keep IV open for possible blood transfusion • prepare for immediate delivery usually, cesarean section • Postoperatively monitor for complications – Infection – Renal failure – Disseminated intravascular coagulation (DIC)
  32. 32. 32 Disseminated Intravascular Coagulation (DIC)  Disorder of blood clotting Fibrinogen levels fall below effective limits  Symptoms Bruising or bleeding massive hemorrhage initiates coagulation process causing massive numbers of clots in peripheral vessels (may result in tissue damage from multiple thrombi), which in turn stimulate fibrolytic activity, resulting in decreased platelet and fibrinogen levels and signs and symptoms of local generalized bleeding (increased vaginal blood flow, oozing IV site, ecchymosis, hematuria, etc) monitor PT, PTT, and Hct, protect from injury; no IM injections; early anticoagulant therapy is controversial