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

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