Bleeding in pregnancy

88 Bleeding in pregnancy




Overview/pathophysiology


Hemorrhage during pregnancy continues to be a leading cause of morbidity and mortality. Although at times it may be minor, bleeding can be life threatening when profuse hemorrhage leads to maternal hypovolemia, anemia, and infection. Major causes of hemorrhage during pregnancy include ectopic pregnancy (implantation outside of the uterus), threatened spontaneous abortion (confirmed pregnancy with vaginal bleeding), inevitable spontaneous abortion (ruptured membranes with progressive cervical dilation before 20 wk gestation), complete spontaneous abortion (bleeding and cramping until passage of the whole conceptus (before 20 wk gestation), incomplete abortion (bleeding and cramping with retention of some of the conceptus), missed abortion (fetus has died but is retained with the placenta in the uterus), septic abortion (from infection), gestational trophoblastic disease (includes hydatidiform mole [molar pregnancy]), cervical insufficiency (painless dilation of the cervix in the absence of contractions), placenta previa (abnormally implanted placenta that partially or completely covers the cervix), placental abruption (premature separation from the uterine wall of a normally implanted placenta), and uterine rupture (may be seen after a previous classical cesarean). Bleeding can manifest as non–life-threatening conditions such as cervicitis (spotting after intercourse or exercise from the highly vascular cervix), cervical polyps, or cervical dysplasia.



Health care setting


Primary care or acute care when bleeding persists or surgical intervention is necessary



Assessment


In early pregnancy, assessments begin with confirmation of pregnancy, determination of gestational age, and correlation of gestational age with fundal height. The amount and characteristics of bleeding as well as its location, the severity of pain, and other accompanying signs determine priorities in physical assessment. In late pregnancy, medical and nursing assessments are often simultaneous. Bleeding can range from light pink spotting to dark brown (old blood). It may be like a heavy menses (up to 1000 mL of blood flows through the placenta at term). Bleeding can progress rapidly to massive hemorrhage with significant morbidity or mortality for mother and fetus. When bleeding is associated with a complication of pregnancy, the priorities focus on:


Amount of and characteristics of the blood: Vaginal bleeding can occur at any time in pregnancy. Is the blood viscous, thin, and watery; does it have clots; is it light pink or bright red or deep red or brown? Is there other tissue, odor, or continuous or recurrent bleeding; and what is the number and saturation of pads?

Pain: Was the onset sudden or gradual? Is it localized or generalized, intermittent or continuous, sharp, dull, aching, radiating, or changing in nature? What is its relationship to the uterus or to activities? Pain may be the only sign of an ectopic pregnancy if bleeding is concealed within the abdomen. Abdomen may be tender and exceptionally hard (board-like) with central abruption.

Cardiovascular and respiratory status: Assess for hypertension or hypotension, tachycardia, tachypnea, postural hypotension, dizziness, lightheadedness, or syncope.

Uterine contractions: Assess for frequency, duration and intensity, resting tone, rupture of membranes, and uterine irritability.

Condition of fetus: Assess for decreased or absent fetal activity relative to gestational age. After 20 wk gestation, monitor baseline variability and rate, fetal heart rate (FHR) accelerations, FHR decelerations, and FHR changes associated with uterine contractions.

Accompanying signs: Assess for additional signs of shock with massive blood loss, including cool, pale skin and mucous membranes; oliguria; and altered consciousness. Vaginal discharge before a bleeding episode may range from thin to thick or clumpy and white, yellow, or green. Fever and malodorous vaginal discharge are indications of infection. Assess the woman’s anxiety state, as well as her family’s emotional response to the bleeding episode.

Obstetric history: Assess for gravida (total number of pregnancies), para (number of live births at more than 20 weeks gestation), previous abortions or preterm births, history of previous bleeding in this pregnancy, or prior pregnancy complications.


Diagnostic tests




Obstetric ultrasound:


Transabdominal, transvaginal, or translabial ultrasound locates the gestational sac as intrauterine or ectopic. Real-time ultrasound confirms cardiac activity and a viable fetus. Ultrasound identifies multiple gestation, position of placenta, number of vessels, presence of subchorionic hemorrhage (bleeding beneath the outer membrane), and abruption. Ultrasound allows differential diagnosis between the two types of gestational trophoblastic disease (GTD).



Speculum examination:


A careful speculum vaginal examination safely visualizes the cervix after vaginal bleeding, when a vaginal exam is always contraindicated. The examiner can observe dilation and effacement, presence of tissue in the cervix or vaginal vault, polyps, cervical friability, lacerations, or other lesions. Cultures may be obtained. Rupture of membranes can be evaluated using nitrazine paper or a specimen for microscopic evaluation of ferning (the fern leaf pattern seen by a microscope when amniotic fluid dries).



Qualitative and quantitative pregnancy tests:


Urine or serum pregnancy tests measure the presence of human chorionic gonadotropin (hCG). The presence of hCG in serum or urine can confirm a pregnancy. Positive results are possible after implantation is complete, 8-10 days after conception, which may occur before or after a missed period. Because the serum concentration of hCG doubles every 1-2 days, serial testing can indicate gestational age. Declining numbers relate to spontaneous abortion or ectopic pregnancy.



Complete blood count (CBC):


Reflects the amount of blood lost, especially by falling levels of hemoglobin (Hb) and hematocrit (Hct). One pint of blood loss equals approximately 1½ g drop in Hb and 1%-3% decrease in Hct. Likewise these factors will rise with each pint of blood replaced. A rising WBC count may indicate infection. Falling platelets indicate an increasing risk of disseminated intravascular coagulation (DIC). (See “Disseminated Intravascular Coagulation,” p. 457.)



Blood rh factor and antibody screen:


Maternal blood group (ABO) and Rh factor (positive or negative) is determined when medical prenatal care is initiated. An antibody screen (indirect Coombs test) is done to determine whether the Rh-negative woman is sensitized to the Rh antigen. Rh immune globulin (RhoGAM or HypRho-D) is administered within 72 hr after a spontaneous or induced abortion, ectopic pregnancy, or GTD pregnancy; after an external version attempt; after birth with or without a placenta previa or abruption placenta; at any gestational age; and after maternal abdominal trauma.



Kleihauer-betke test:


Checks for the presence of fetal erythrocytes in maternal blood. Fetal-maternal bleeding occurs 3-5 times more often in pregnancy when the mother experiences abdominal trauma.



Uterine and fhr monitoring:


Before gestational viability, uterine activity monitoring alone may be done to demonstrate contraction presence and its pattern. In the second and third trimesters, FHR monitoring reveals fetal well-being or fetal response to blood loss, labor, or induction procedures.


Continuous FHR monitoring is used to identify nonreassuring signs of a compromised fetus. Fetal oxygenation is compromised with a disrupted placental surface area for gas exchange, maternal hypotension, and uterine irritability. The nonreassuring FHR pattern seen with bleeding may include loss of baseline variability, tachycardia or bradycardia, late decelerations in labor, prolonged decelerations, progressively severe variable decelerations, and a sinusoidal pattern. With acute abruptio placenta, there is rapid FHR deceleration indicating imminent fetal demise.



Twenty-minute nonstress test:


Beginning at 27-32 wk gestation, this test can demonstrate reactive FHR activity, which indicates adequate fetal oxygenation and an intact central nervous system. Measurement standards differ for the fetus between 32 wk gestation and term from the fetus under 32 wk gestation because the latter’s central nervous system is less mature.





Nursing diagnoses:


Risk for bleeding

related to pregnancy-related conditions (spontaneous abortion [threatened, inevitable, incomplete, complete, or missed], ectopic pregnancy, placenta previa, or abruptio placenta)



Risk for shock

related to hypovolemia


Desired Outcome: Within 2-3 hr of appropriate intervention, patient returns to a functional level of blood volume/body fluids as measured by return to urinary output greater than 30 mL/hr with urine specific gravity less than 1.030, normotensive blood pressure (BP) (90-130/60-80 mm Hg), heart rate (HR) 60-100 bpm, respiratory rate (RR) 12-20 unlabored breaths/min, capillary refill 2 sec or less, absence of signs of shock (e.g., alert without anxiety, skin warm and pink, bowel sounds active × 4), and a reactive FHR.















ASSESSMENT/INTERVENTIONS RATIONALES
Assess amount and begin measurement of continuing blood loss, including characteristics and the source/site of blood. As indicated, weigh saturated linen or peripads and keep a pad count. Hemorrhage from spontaneous abortions, placenta previa, or abruptio placentae have different characteristics (see Assessment data, earlier). One gram of weight per scale represents 1 mL blood lost.
Assess accompanying signs and symptoms with blood loss (i.e., pain, fever, malodorous vaginal discharge), and their duration and association with behaviors (intercourse, work). Uterine cramping with hemorrhage may indicate one of the spontaneous abortions. Deep abdominal pain may signal ectopic pregnancy (with or without bleeding). Painless vaginal bleeding in third trimester may indicate placenta previa. Board-like painful abdomen may indicate abruption (with or without dark red bleeding). Malodorous vaginal discharge may indicate chorioamnionitis (bacteria-caused inflammation of placental membranes).
Assess maternal vital signs (VS) for signs of shock (hypotension, decreased pulse pressure, tachycardia, delayed capillary refill, cool clammy or mottled skin, and change in mentation and functional ability).
Begin assessments q5-15min and decrease in frequency as condition improves per agency protocol/health care provider directive.
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Bleeding in pregnancy

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