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NURS 4500: Midterm Material > Class 3: Antepartum Bleeding > Flashcards

Class 3: Antepartum Bleeding Flashcards

1
Q

bleeding in pregnancy is considered?

A
  • a medical emergency
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2
Q

50% of bleeding in the 3rd trimester is (2)

A
  • placenta previa
  • or placental abruption
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3
Q

maternal blood loss leads to…

A
  • decreased O2 carrying capacity
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4
Q

decreased O2 carrying capacity can lead to what maternal risks (6)

A
  • hypovolemia
  • anemia
  • infection
  • preterm labour
  • preterm birth
  • exsanguination
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5
Q

decreased O2 carrying can lead to which fetal risks? (7)

A
  • blood loss
  • anemia
  • hypoxemia
  • hypoxia
  • anoxia (extreme form of hypoxia)
  • preterm birth
  • still birth
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6
Q

why is exsanguination a risk with pregnancy bleeding?

A
  • approx 750-1000 ml/min (15% of cardiac output) of blood flow to the uterine vasculature and placenta = diruption of vascular integrity has a potential for maternal exsanguination within 8-10 min
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7
Q

pregnant persons who are rh negative may receive ______ in which scenarios where antepartum bleeding is involved (3)

A
  • may receive anti-D (Rh immune globulin WinRho)

scenarios:
- when worried about maternal & fetal blood mixing
- miscarriage/threatened abortion/induced abortion/ectopic pregnancy
- if fetal to maternal hemorrhage occurs/suspected fetal blood is Rh positive (placental abruption, placental previa)

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8
Q

what is included in early pregnancy bleeding (3)?

A
  • miscarriage/spontaneous abortion
  • premature dilation of the cervix
  • ectopic pregnancy
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9
Q

define: miscarriage/spontaneous abortion

A
  • a pregnancy that ends without medical or surgical intervention prior to 20 weeks of gestation or 500g fetal weight is defined as a miscarriage or spontaneous abortion
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10
Q

what is a threatened pregnancy loss

A
  • vaginal bleeding that occurs during the first 20 weeks of pregnancy
  • does not necessarily mean your pregnancy will end in a miscarriage
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11
Q

what are clinical manifestations of a threatened pregnancy loss (4)

A
  • mild spotting
  • mild cramping
  • closed cervical os
  • may progress to actual miscarriage
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12
Q

what is an inevitable miscarriage (2)

A
  • refers to unexplained vaginal bleeding and abdominal pain during early pregnancy
  • unlike threatened miscarriage, an inevitable miscarriage is also accompanied by dilation of the cervical canal. The open cervix is a sign that the body is in the process of miscarrying the pregnancy.
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13
Q

what are clinical manifestations of inevitable miscarriage? (4)

A
  • moderate bleeding
  • mild to severe cramping
  • dilated cervix (will happen/inevitable)
  • no passage of tissue
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14
Q

what is an incomplete miscarriage

A
  • some—but not all—of the pregnancy tissue is passed.
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15
Q

what are clinical manifestations of an incomplete miscarriage (4)

A
  • heavy bleeding
  • severe cramping
  • open cervical os
  • tissue passage, likely in cervix
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16
Q

what is a complete spontaneous abortion

A
  • refers to a miscarriage in which all of the pregnancy tissue is expelled from the uterus
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17
Q

what are signs of a complete spontaneous abortion (4)

A
  • all fetal tissue is passed
  • cervix is closed
  • possible slight bleeding
  • mild cramping
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18
Q

what is a missed abortion

A
  • occurs when a fetus implants, but fails to develop.
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19
Q

what are signs of a missed abortion (3)

A
  • products of conception are retained in utero for up to several weeks
  • potentially no bleeding or cramping
  • cervical os remains closed
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20
Q

management of a miscarriage depends on…

A
  • type and symptoms
    ex. infection? bleeding? retained products?
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21
Q

what is involved in assessment of miscarriages ? (6)

A
  • US (rule out ectopic pregnancy)**
  • VS & FHR (is there a FHR??)
  • vaginal discharge and bleeding
  • uterine activity (cramps)
  • pain assessment
  • lab tests
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22
Q

what lab tests are involved in assessment of miscarriages (2)

A
  • check serum hCG x2 over 48 hrs
  • other tests depend on symptoms and history (ex. CBC)
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23
Q

what nursing care is involved in management of miscarriages (6)

A
  • support
  • education
  • prep for medical and surgical procedures
  • admin of analgesia and other meds as ordered
  • blood admin as ordered
  • discharge teaching
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24
Q

medical and/or surgical management of a misscarriage depends on…

A
  • the overall clinical picture and the type of spontaneous abortion
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25
Q

inevitable abortion with fever or bleeding will require…

A
  • prompt emptying of the uterus, usually by dilatation and curettage
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26
Q

what is premature dilation of the cervix

A
  • passive and painless dilation of the cervical os without labor or contraction of the uterus
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27
Q

premature dilation of the cervix can result in.. (2)

A
  • preterm birth
  • miscarriage
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28
Q

whats included in mngmt of premature dilation of the cervix (2)

A
  • restrict activity
  • cerclage (thread to singe cervix shut & remove at 35-38 weeks gestation)
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29
Q

what is an ectopic pregnancy

A
  • involves the implantation of the fertilized ovum outside of the uterine cavity
  • condition where fertilized egg attaches outside the uterus
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30
Q

where else can the fertilized ovum implant in an ectopic pregnancy (3)

A
  • fallopian tubes (usually)
  • abdomen
  • cervix
31
Q

what are the 3 classic symptoms of an ectopic pregnancy

A
  • abdominal pain
  • delayed menses
  • abnormal vaginal bleeding
32
Q

what can ectopic pregnancy lead to

A
  • rupture of the fallopian tube = hemorrhage
33
Q

if rupture has occured with an ectopic pregnancy, what symptoms might be experiences? (2)

A
  • referred shoulder pain
  • one-sided or deep lower quadrant acute abdominal pain
34
Q

what are causes of late pregnancy bleeding? (3)

A
  • placenta previa
  • placental abruption
  • variations in cord insertion
35
Q

what is placenta previa

A
  • the placenta completely or partially covers the opening of the uterus
  • the placenta is implanted in lower uterine segment near or over the internal cervical os
36
Q

classification of placenta previa is based on…

A

degree that internal cervical os is covered by the placenta

37
Q

what are 3 types of placenta previa

A
  1. complete placenta previa
  2. marginal placenta previa
  3. low-lying placents
38
Q

what is complete placenta previa

A
  • placenta completely covers the internal cervical os
39
Q

what is marginal placenta previa

A
  • edge of the placenta is 2.5 cm or closer to the internal cervical os
40
Q

what is low-lying placenta (3)

A
  • placenta has formed low in the uterus
  • no overlap is seen
  • exact relationship undetermined
41
Q

what are risk factors for placenta previa (8)

A
  • previous placenta previa
  • previous c-section
  • suction curettage for miscarriage or induced abortion
  • multiparity
  • maternal age over 35 years old
  • ethnincity
  • smoking
  • living at higher altitude
42
Q

what is the main clinical manifestation of placenta previa

A
  • painless bright red vaginal bleeding in the 2nd and 3rd trimesters
  • bleeding can recur at any time
43
Q

on examination, what signs are seen with placenta previa (4)

A
  • uterus is soft, relaxed, and non-tender w normal tone
  • fetal presenting part is high (placenta takes up signif space in lower segment)
  • fetal malpresentation may occur
  • fundal height may be greater than expected as placenta occupies the lower segment of fundus
44
Q

when placenta previa typically diagnosed

A
  • during routine prenatal US
45
Q

what is a major concern w placenta previa

A
  • hemorrhage –> hypovolemic shock
46
Q

why is hypovolemic shock a concern w placenta previas

A
  • due to compensatory mechanisms of pregnancy, up to 40% of blood volume can be lost without showing signs of shock = VS may remain normal
47
Q

what is an additional potential complication of placenta previa

A
  • abnormal placental attachment –> may require hysterectomy
48
Q

what are fetal risks of placenta previa (5)

A
  • preterm births
  • still birth
  • malpresentation –> oblique lie, breech, transverse
  • fetal anemia
  • IUGR
49
Q

what is included in management of placenta previa (7)

A

-NO pelvis/vaginal exam (don’t want any damage to placenta)
- education on when to come to hospital
- limit activity
- US for ongoing monitoring of placenta (every 2 weeks)
- c-section will be scheduled
- blood work
- emotional support

50
Q

in a marginal placenta previa with minimal bleeding, what may be attempted?

A
  • vaginal birth
51
Q

if a bleeding episode occurs with placenta previa, mngmt depends on? what does it require?

A
  • depends on gestational age
  • amount of blood loss/active bleeding
  • requires admission to labour and birth unit w c-section capabilities and NICU
52
Q

if a pregnant person has placenta previa, is <36 weeks of gestation AND NOT in labour AND bleeding is mild or stopped, what kind of mngmt is done and where?

A
  • expectant mngmt = reduced activity/close observation
  • may be admitted to hospital, home w antenatal homecare program, depending on stability –> allows fetus time to mature
53
Q

what is included in mngmt of placenta previa if the pt is <36 weeks of gestation, not in labour, and bleeding is mild or stopped (9)

A
  • frequent repeat US
  • fetal surveilance (NST, BPP) 1-2x/week
  • regular lab values (hgb, hct, coagulation values)
  • antepartum steroids to promote lung maturity if between 24+0 and 34+6 weeks gestation, when delivery is expected within 7 days
  • assessment of bleeding (1g = 1ml)
  • large bore IV 18G
  • NO vaginal exams/pelvix rest (nothing in the vagina)
  • Rh immune globulin (if Rh negative and delivery not indicated)
  • c-section scheduled once reaches 37 weeks gestation and fetal lung maturity is achieved
54
Q

if a pt has placenta previa, is >36 weeks of gestation OR bleeding is excessive/persistent OR active labor occurs OR other obstetrical complications (ex. infection), what kind of mngmt is done?

A
  • active mngmt and c-section birth is indicated
55
Q

what is included in mngmt of placenta previa in a pt who is >36 weeks of gestation OR bleeding is excessive/persistent OR active labor occurs OR other obstetrical complications (ex. infection) (8)

A
  • continuous fetal monitoring until surgery
  • freq assessment of maternal VS
  • large bore IV, 18 G, fluid replacement as ordered (may require 2 IVs)
  • monitor urine output
  • monitor bleeding
  • blood product admin as ordered
  • neonatal time at delivery
56
Q

what risk is associated w placenta previa

A
  • risk for postpartum hemorrhage
57
Q

what is placental abruption

A
  • detachment of part or all of the placenta from ist implantation site
  • after 20 weeks gestation and before the birth of the baby
58
Q

what impact does placental abruption have on perfusion to the fetus

A
  • not attached = decreased perfusion and gas exchange to fetus
59
Q

what are risk factors for placental abruption (7)

A
  • HTN disorders of pregnancy
  • cocaine use
  • blunt external abdominal trauma (ex. MVA, maternal battering)
  • smoking
  • previous history
  • preterm premature rupture of membranes
  • thrombophilia
60
Q

placental abruption should be suspected in pregnant people with..

A
  • sudden onset of intense, usually localized, uterine pain, with or without vaginal bleeding
61
Q

what are clinical manifestations of placental abruption (7)

A
  • dark, nonclotting vaginal bleeding
  • abdominal or low back pain
  • uterine contractions or hypertonic uterus (to try to control bleeding)
  • uterine tenderness
  • “port wine” stained amniotic fluid if ROM has occurred
  • FHR tracing –> abnormal patterns (loss of variability, late decelerations)
  • fetal death
62
Q

placental abruption symptoms depends on

A
  • degree of speration
63
Q

what is included in assessment of placental abruption (3)

A
  • physical exam
  • lab studies
  • FHR pattern (decreased variability, decelerations, abnormal tracing)
64
Q

what lab studies are assessed for placental abruption (3)

A
  • hgb and hct will be decreased
  • abnormal clotting studies
  • US (rule out placenta previa, not always diagnosed by US, negative findings on US do not rule out abruption)
65
Q

what maternal complications can occur w placental abruption (8)

A
  • hemorrhage
  • hypovolemic shock
  • couvelaire uterus
  • infection
  • DIC (more likely w mod or severe separation)
  • hypofibrinogenemia
  • thrombocytopenia
  • organ damage
66
Q

what is a Couvelair Uterus

A
  • collection of blood between placenta and wall of uterus = purplish color
67
Q

what fetal complications can occur w placental abruption (6)

A
  • IUGR
  • preterm birth
  • fetal hypoxia
  • neuro defects
  • cerebral palsy
  • fetal or newborn death
68
Q

what does mngmt of placental abruption depend on

A
  • severity and overall fetal and maternal status `
69
Q

if placental abruption if mild AND less than 36 weeks gestation AND stable with NO fetal distress, placental abruption involves: (14)

A
  • admit to hospital
  • monitor for signs of bleeding
  • monitor FHR & continuous fetal monitoring
  • NST/BPP
  • allow for gains in fetal maturity
  • large bore IV, 18 G (maybe 2)
  • frequent VS –> monitor for trends (ex. increasing HR)
  • repeat BW as ordered (hgb, hct, clotting studies)
  • fluid replacement as ordered
  • blood admin as ordered
  • monitor urine output (should maintain 30ml/h) –> may require foley
  • if condition deteriorates to either person, immediate birth
  • emotional support
  • prep for birth
70
Q

what can promote fetal lung maturity to allow for gains in fetal maturity in mngmt of placental abruption

A
  • antepartum steroids to promote fetal lung maturity if between 24+0 and 34+6 weeks gestation when delivery is expected within 7 days
71
Q

when may vaginal birth be attempted w placental abruption (2)

A
  • if pregnant person is hemodynamically stable
  • AND fetus is alive and in no acute distress OR fetus is dead
72
Q

a c-section should be performed w placental abruption if… (5)

A
  • fetal compromise
  • severe hemorrhage
  • coagulopathy
  • poor labour progress
  • increasing uterine resting tone
73
Q

a c-section shoudl not be performed w placental abruption if…

A
  • coagulopathy is severe and uncorrected

NURS 4500: Midterm Material (19 decks)

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