Bleeding Disorders of Early Pregnancy

1. Bleeding Disorders of Early Pregnancy

2. Bleeding Disorders of Early Pregnancy • Abortion • Spontaneous (non-intentional) Abortion • A pregnancy that ends before 20 weeks • Threatened Abortion • Light spotting; cervix is closed & no tissue is passed • Inevitable Abortion • Increased bleeding & cervix dilates • Incomplete Abortion • Bleeding dilation of cervix & passage of tissue

3. Bleeding Disorders of Early Pregnancy (continued) • Abortion • Complete • Passage of all products of conception, cervix closes and bleeding stops • Missed • Fetus dies in utero but is not expelled, uterine growth stops and spetis is possible • Recurrent • 2 or more consecutive spontaneous abortions

4. Induced Abortions • Therapeutic Abortion • Intentional termination of pregnancy before age of viability to preserve the health of the mother • Elective Abortion • Intentional termination of pregnancy for reasons unrelated to mothers health

5. Abortion

6. threatened inevitable missed incomplete

7. Nursing Care of Early Pregnancy Bleeding Disorders • Document amount and character of bleeding • Save anything that looks like clots or tissue for evaluation by a pathologist • Perineal pad count with estimated amount of blood per pad, such as 50% (could weight pads before/after) • Monitor vital signs • If actively bleeding, woman should be kept NPO in case surgical intervention is needed

8. Post-Abortion Teaching • Report increased bleeding • Take temperature every 8 hours for 3 days • Take an oral iron supplement if prescribed • Resume sexual activity as recommended by the health care provider • Return to health care provider at the recommended time for a checkup and contraception information • Pregnancy can occur before the first menstrual period returns after the abortion procedure

9. Emotional Care • Spiritual support from someone of the family’s choice and community support groups may help the family work through the grief of any pregnancy loss • Review effective and ineffective communication techniques found in Table 5-4 on page 84

10. Effective Communication

11. Ectopic Pregnancy • 95% occur in fallopian tube • Scarring or tubal deformity may result from: • Hormonal abnormalities • Inflammation • Infection • Adhesions • Congenital defects • Endometriosis

12. Ⅰ.Definition • The blastcyst normally implants in the endometrial lining of the uterine cavity. Implantation anywhere else is an ectopic pregnancy. • It is one in which the fertilized ovum is implanted and developed outside of the uterine cavity.

13. Tubal 95% Ovarian 0.5-1% Cervical Abdominal Broad ligament II.Incidence more than 1 in every 100 pregnancy III .Types of ectopic pregnancy

15. Ⅳ.Tubal pregnancy • It is one of abdominal emergency. • Interabdominal hemorrhage sever hemorrhge shock died • 1.site ※(1)Ampullar 60% (2)isthmic 25% (3)fimbrial 17% (4)Interstitial 2%~4%

16. Symptoms • (1)amenorrhea • (2)low abdominal pain • (3)vaginal bleeding • (4)shock and collapse

17. Signs • (1)general condition • (2)abdominal examination • (3)pelvic examination 　　①the posterior fornix: tendness ②pain on motion of cervix ③uterus: 6~8w size, soft, float ④a soft and elastic mass

18. Complications of Pregnancy • Ectopic Pregnancy (EP) • Clinical Presentation Amenorrhea Bleeding/Spotting Abdominal Pain

19. A. tubal pregnancy • (1)tubal abortion • common in ampular tubal pregnancy • (2)tubal rupture: profuse hemorrhage common in isthmic TP: 6w interstitial TP: 16w (3)abdominal pregnancy

22. Clinical Manifestations • Abdominal or pelvic pain (most common). • Irregular vaginal bleeding — usually scanty and dark (most common). • Amenorrhea”in 75% of the cases. • Uterine size is usually similar to what it would be in a normally implanted pregnancy. • Abdominal tenderness on palpation. • Shoulder pain. • Increased pulse and anxiety. • Nausea, vomiting, faintness, or vertigo and syncope with abdominal pain may develop. • Pelvic examination reveals a pelvic mass, posterior or lateral to the uterus, adnexal tenderness, and cervical pain on movement of the cervix.

23. 5.Diagnosis Symptom Sign axillary examination

24. (1) pregnancy tests:β-HCG>25u • quantitive serum β-HCG • (2) pelvic ultrasound • (3) the bloody fluid does not clot (4)laproscopy: diagnosis and treatment • (5)endometrial histology: Arias-Stella reaction

25. Complications of Pregnancy • Ectopic Pregnancy (EP) • Management • Pertinent hx • Missed menses • Sexually active • Previous EP, STD, surgery, etc. • Lower quadrant pain/tenderness • Avoid aggressive palpation/repeated exam • Vital signs • Orthostatic as appropriate • High flow O2 • Treat for shock • Position • IV access • Surgical intervention usually required

27. Surgical Treatment • If woman does not consent to or meet criteria for methotrexate, surgical intervention is instituted. The surgical procedure depends on the extent of tubal involvement and if rupture has occurred. • The surgery of choice used to preserve future fertility is a salpingostomy. • Should a woman not desire future fertility, the surgery of choice is salpingectomy. • Other surgeries range from removal of ectopic pregnancy with tubal resection, salpingostomy (removes conceptus leaving tube intact, yet scarred), and possibly salpingo-oophorectomy. • Treat shock and hemorrhage if necessary. • Administer RhIG (immune globulin) per your facility's policy if woman is Rh negative.

28. Ectopic Pregnancies (Continued) Complications • Infertility • Hemorrhage and death

29. Nursing Assessment • Evaluate the following to determine pregnancy and to monitor for changes in patient's status, such as rupture or hemorrhage: • Maternal vital signs • Presence and amount of vaginal bleeding • Amount and type of pain • Presence of abdominal tenderness on palpation/shoulder pain • Date of last menstrual period • Presence of positive pregnancy test • Rh type

30. Nursing Diagnoses • Risk for Deficient Fluid Volume related to blood loss from ruptured tube • Acute Pain related to ectopic pregnancy or rupture and bleeding into the peritoneal cavity • Anticipatory Grieving related to loss of pregnancy and potential loss of childbearing capacity

31. Nursing Interventions • Maintaining Fluid Volume • Establish an I.V. line with a large-bore catheter, and infuse fluids and packed RBCs as prescribed. • Obtain blood samples for complete blood count (CBC) and type and screen for whole blood, as directed. • Monitor vital signs and urine output frequently, depending on condition. • Promoting Comfort • Administer analgesics as needed and prescribed. • Encourage the use of relaxation techniques.

32. Hydatidiform Mole (Molar Pregnancy) • Also known as Gestational Trophoblastic Disease • Occurs when chorionic villi abnormally increase and develop vesicles • May cause hemorrhage, clotting abnormalities, hypertension, and later development of cancer • More likely to occur in women at age extremes of the reproductive life

36. Hydatidiform Mole (Continued) • Manifestations • Bleeding • Rapid uterine growth • Failure to detect fetal heart activity • Signs of hyperemesisgravidarum • Unusually early development of GH • Higher than expected levels of hCG • A distinct “snowstorm” pattern on ultrasound with no evidence of a developing fetus • Treatment • Uterine evacuation • Dilation and evacuation

37. Management • Suction curettage is the method of choice for immediate evacuation of the mole with possibility of laparotomy. • Follow-up for detection of malignant changes because a complication is the development of choriocarcinoma of the endometrium.

38. Nursing Assessment • Monitor maternal vital signs; note presence of hypertension. • Assess the amount and type of vaginal bleeding; note the presence of any other vaginal discharge. • Assess the urine for the presence of protein. • Palpate uterine height; if above the umbilicus, measure the fundal height. • Determine date of last menstrual period and date of positive pregnancy test. • Evaluate CBC results and Rh type.

39. Nursing Interventions • Maintaining Fluid Volume • Obtain blood samples for type and screen, and have 2 to 4 units of whole blood available for possible replacement. • Establish and maintain I.V. line; start with a large needle to accommodate possible transfusion and large quantities of fluid. • Assess maternal vital signs, and evaluate bleeding. • Monitor laboratory results to evaluate patient's status. • Decreasing Anxiety • Prepare the patient for surgery. Explain preoperative and postoperative care along with intraoperative procedures. • Educate patient and family on the disease process. • Allow the family to grieve over the loss of the pregnancy.

40. Patient Education and Health Maintenance • Advise the woman on the need for continuous follow-up care. • Provide reinforcement of follow-up procedures: • Measure-hCG levels every 1 to 2 weeks until normal — then begin monthly testing for 6 months, then every 2 months for a total of 1 year. • Consider chemotherapy or hysterectomy if -hCG levels rise or begin to plateau or there is evidence of metastasis. • Encourage ongoing discussion of care with health care provider