EARLY BLEEDING DISORDERS

ABORTION

• any interruption / termination of a pregnancy before the age of viability (20th week of gestation).
• Usually spontaneous abortions (75-80% happen on the 2nd & 3rd month).

RISK FACTORS PETE-PEM

1. Presence of Acute Infections (German measles).

2. Endocrine disturbance

• (Progesterone Therapy / Hypothyroidism → meds can cause abortion).
• PTU – Prophylthiouracil.

3. Trauma (a fall from the stairs)

4. Exposure to Teratogens

5. Psychological Factors

6. Evidence of Malnutrition

7. Maternal Factors ( C F S )

• Chronic Infections
• Fibroid Tumors
• Structural Uterine Anomalies

↓ hemoglobin (bleeding) if less than 10.5g/dl = + abortion

TYPES OF ABORTION

SI

Spontaneous Abortion TIMH

1. Threatened Abortion - slight to moderate, bright red vaginal bleeding, mild back & lower abdominal cramping. No cervical dilation & no passage of products of conception

Management

• Complete bed rests (24-48 hrs.) no bathroom privilege
• Pt. may be sedated to avoid movements
• Coitus is prohibited 2 wks. after bleeding has stopped
• Endocrine or Progesterone therapy – can cause congenital abnormalities.
• Advise Pt. to save all pads, clots & expelled tissues for evaluation of Dr. to see if condition is beyond threatened or not threatened anymore.

2. Imminent or Inevitable Abortion - moderate amt. of bright red vaginal bleeding, cramping, dilation of cervix, membranes may rupture.

• Complete – all prod. of conception are expelled & bleeding is minimal & self-limiting. No intervention necessary except emotional & psychological support.
• Incomplete – part of the fetus is expelled, but membranes & placenta remain

Management FAAD

• Fluid replacement – I V line, type & cross-match pt. blood for blood transfusion (nurse will request, med. tech does blood typing)
• Administer oxytocin → uterus contraction → further expel fetus
• Admin. of Rhogam if mother is Rh(-), given w/in 72 hrs after abortion / giving birth to prevent incompatibility on next pregnancy
• Dilatation & Curettage / Suction Evacuation – to remove the other products of conception.

3. Missed Abortion – fetus dies in utero, & products of conception are retained from 4-8 wks. Symptoms of preg. also subside 4-8 wks. after fetal death. Then in 2 weeks time, signs of abortion would occur.

Management

• If fetus does not come out, labor is induced to prevent bleeding problems on the mother called Hypofibrinogenemia
• After 6 weeks, if baby still in womb, autolysis occurs, Disseminated Intravascular Coagulation problem would occur this time. A systemic coagulation that would eventually cycle into a bleeding disorder and back.
• D&C / Suction evacuation is performed to prevent all of these (No anesthesia is given. Sedation only) Saddle block may be given (Xylocaine)
• If preg is past 12 wks., induced labor is done by IV Pitocin (Oxytocin) or prostaglandin

4. Habitual Abortion – 3 or more consecutive spontaneous abortion.

Management

• Determine the cause and specific treatment to correct the problem.

Induced Abortion

1. Therapeutic Abortion – performed by Dr. in a controlled hospital, or clinical setting for medical or legal reasons. Also known as Medical / Planned / Legal Abortion.

• From Fertilization – 1st month = least amount of risk when performed on mom, but can be done anytime from 0- 9 months duration of pregnancy
• If fetus is less than 12 wks: D&C, Dilatation & vacuum extraction – pt. given oxytocin after procedure. After 4 hrs. if no complications, pt. may go home. Given a saddle block anesthesia or epidural (D&C)
• If fetus 12-16 wks: Saline Induction – 20% hypertonic saline sol. , --anesthetize abdominal wall. Solution is injected into amniotic cavity. If ingested, fetus will die w/in 1 hr. After (12-26 hrs.) of fetal death, labor is induced by adding diluted oxytocin solution. Wait for expulsion. Watch for signs of Hypernatremia (thirst, dry mouth) NaCl can enter bloodstream of uterus. Inform Dr. immediately.
• If fetus is greater than 16 wks: Hysterotomy – remove fetus like C-section, retain uterus

Complications of Abortion
Hemorrhage
Infection

Management for all kinds of Abortion COPE AV

Counting of Perineal pads – assess its contents

Observe for shock & other complications

Prevent ISO-immunization by RhoGam

Encourage verbalization of feelings & concerns

Assess for infection & anemia

Vital Signs monitoring à Low BP = fast drip but without OXYTOCIN

Hydatidiform Mole / Molar Pregnancy (H-Mole)

• a developmental anomaly of the placenta, resulting in the proliferation & degeneration of chorionic villi w/c develops into a grape like clusters of vesicles.
• Incidence of H-mole – most common lesion anteceding choriocarcinoma.

Diagnostics

• Ultrasound – reveals no fetal skeleton
• High HCG level in urine or blood

Risk Factors: Can predispose but not really cause

• Taiwanese & Mexicans - ↓ protein diet (noodles)
• Familial Tendency – “buntis pero di bata ang laman” , “buwa”
• ↑ incidence w/ advanced maternal age; assoc. w/ induction of ovulation by Clomiphine Therapy (hormone) ↑ 35 & ↓ 18 yr. old
• In women w/ ↓ socio-economic status

Clinical Manifestations ADEA

• Anemia due to loss of blood
• Discharge of brownish red fluid (like prune juice) from vagina, around the 12th wk. w/c may contain clear fluid filled grape sized vesicles.
• Exaggerated symptoms of pregnancy
  Uterus too large for pregnancy
  Excessive Nausea & vomiting
  Early signs of PIH (before 24 weeks.)
• Absence of Fetal Heart sound

Complications DICT

• DIC – Disseminated Intravascular Coagulation
• Infection
• Choriocarcinoma is possible
• Trophoblastic embolization after evacuation of molar pregnancy can cause
  Cardio-pulmonary arrest

Management

• D & C to empty the uterus
• Medical mgmt after D & C
  Follow-up supervision (1 yr.) – monitor HCG level every wk., on 3-4 mos. every other wk., then every month until 1 year is completed. If there is rising ↑ titer of HCG, indicates pathology of choriocarcinoma.
• Drug of choice: Methotrexate (chemo-therapeutic drug)
• Pregnancy shld. be avoided for at least 1 yr. – can use contraceptives but not pills (alters HCG levels)

Nursing care for Pt. w/ H-mole

• Assess for complications assoc. w/ hemorrhage & possibility of uterine rupture
• Provide emotional support & assist in selection of contraceptive methods.
  

Ectopic Pregnancy

• Any pregnancy that develops outside the uterus.

Types TACO

• Tubal – most common, 90% in Fallopian tube
• Abdominal
• Cervical
• Ovarian

Risk Factors PGP-O

Any condition causing scarring or obstruction of Fallopian tubes

Pelvic Inflammatory Disease

Gonorrheal Infection

Post-Abortion Salphingitis – Inflammation of F. Tubes due to frequent abortions

Obstructions & Infections – presence of untreated reproductive Tract infection may cause adhesion. If adhesion is (+), the fertilized zygote cannot traverse the tube into the uterus where it should be implanted.

Diagnostics CUL

• Culdocentesis – insertion of needle in cul de sac of Douglas, to assess for intra-peritoneal bleeding.
• Ultrasound – visualize where ectopic pregnancy is
• Laparascope – uses instrument to visualize pelvic organ by small incision to abdomen. If affected tube is found : Laparotomy is done

Clinical Manifestations
If Tube is Unruptured – there is slow chronic bleeding w/ the abdomen gradually becoming rigid & very tender. Presence of Cullen Sign (bluish umbilicus)
If Tube is Ruptured – sudden excruciating pain in the lower abdomen. There is possible referred shoulder pain as abdomen fills w/ blood. Can lead to vaginal bleeding & shock.

(+) Vaginal bleeding & Shock (Hypovolemic) LL-PR-PR-C

Lightheadedness, Lowering BP

Pulse Rate > 100, Rapid RR

Pallor, Restlessness

Cold clammy Perspiration

Management CAPP
it is an emergency situation (stat OR)
if no plans of getting preggy again : Salphingectomy + blood transfusion.
if there are plans of having pregnancy in the future, Salphingotomy

• Combat Shock – elevate foot of bed, maintain body heat by hot H2O bottles covered in cloth to prevent burns, & use of blankets.
• Administer RhoGam
• Prepare Pt. for surgery
• Provide emotional support
  

Incompetent Cervix or Cervical Os

• defect of cervix “one that dilates prematurely” usually related to trauma, w/c leads to habitual abortion & premature labor.

Risk Factors CC-EC

• Cervical Trauma related to D&C
• Congenital developmental factors
• Endocrine factors
• Cervical lacerations from previous deliveries

Clinical Manifestations CPM

• Cervical Dilation w/o painful uterine contractions
• Presence of show (mucus plug)
• Membranes rupture - labor sets in → premature delivery

Management

• McDonald / Shirodkar-Barter Procedure
  a purse string suture is placed around the cervix on the 14-18th wk. gestation
  McDonald – temporary suture (vaginal delivery)
  Shirodkar-Barter – permanent suture (for CS pts.) just remove McDonald suture

Nursing Care

• Advise pt. that some vaginal spotting may occur for several days after placement of suture.
• Patient. should abstain from intercourse & douching along w/ ↓ activity level, 2 weeks after procedure