week 7 n360 ch28 antepartal hemorrhagic

Chapter 28Chapter 28Antepartal Hemorrhagic Disorders

Mosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

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Antepartal Hemorrhagic Antepartal Hemorrhagic Disorders Disorders Bleeding in pregnancy

jeopardizes both maternal and fetal well-being

Maternal blood loss decreases oxygen-carrying capacity, increases risk for:


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Antepartal Hemorrhagic Antepartal Hemorrhagic Disorders Disorders Fetal risks from maternal

hemorrhage◦Blood loss, anemia◦Hypoxemia ◦Hypoxia◦Anoxia◦Preterm birth


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Antepartal Hemorrhagic Antepartal Hemorrhagic Disorders Disorders

Remember:In pregnancy, increases in plasma

volume and red blood cell mass serve to

So:Hemorrhagic disorders in pregnancy

are medical emergenciesMosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

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Timing of Hemorrhagic Timing of Hemorrhagic DisordersDisorders

Early Pregnancy Bleeding◦Miscarriage◦Premature dilation of cervix◦Ectopic pregnancy◦Hydatidiform mole

Late Pregnancy Bleeding◦Placenta previa◦Abruptio placentae◦Cord insertion and placental variations◦Clotting disorders in pregnancy

Early Pregnancy Bleeding Early Pregnancy Bleeding Miscarriage (spontaneous abortion, SAB)

before 20 weeks, fetal weight less than 500g◦Incidence and etiology◦Types

Threatened, inevitable, incomplete, complete and missed

◦Clinical manifestations◦Care management

HCG levels, U/S Dilation and curettage ( D&C) Misoprostol (Cytotec), prostaglandins Psychosocial care


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Early Pregnancy BleedingEarly Pregnancy BleedingIncompetent cervix (recurrent

premature dilation of cervix)◦Etiology

Short cervix, previous cervical trauma or procedure, multiple gestation

◦Collaborative care Conservative management- bedrest, hydration

and tocolysis, antibiotics, antiinflammatory drugs

Cervical cerclage placement -11-15 weeks U/S

Early Pregnancy Bleeding Early Pregnancy Bleeding Ectopic pregnancy ( gestational

sac is implanted outside the uterine cavity)◦Incidence and etiology◦Clinical manifestations◦Collaborative care

Hospital care Home care


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Early Pregnancy Bleeding Early Pregnancy Bleeding Hydatidiform mole (molar

pregnancy)◦Gestational trophoblastic disease◦Two types

Complete Partial

◦Incidence and etiology◦Clinical manifestations◦Collaborative care


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Late Pregnancy Bleeding Late Pregnancy Bleeding Placenta previa

◦Placenta abnormally implants in lower uterine segment near or over internal cervical os

◦Degree to which the internal cervical os is covered by placenta used to classify types Complete (Total) placenta previa Partial placental previa Marginal placenta previa


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Late Pregnancy Bleeding Late Pregnancy Bleeding Placenta previa―continued

◦1 in 200 pregnancies at term◦Clinical manifestations

Painless bright red vaginal bleeding occurs in 70% of women in 2nd or 3rd trimester

◦Maternal and fetal outcomes Maternal complications: hemorrhage Fetal mortality risk is related to preterm

birthMosby items and derived items © 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc.

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Late Pregnancy BleedingLate Pregnancy BleedingPlacenta previa—continued

◦Hospital care Active management Expectant management

◦Home care Limitation of activities Fetal monitoring


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Late Pregnancy Bleeding Late Pregnancy Bleeding Premature separation of placenta

(abruptio placentae)◦1 in 75 to 1 in 226 of pregnancies◦Detachment of part or all of placenta

from implantation site◦Accounts for significant maternal and

fetal morbidity and mortality◦Classification systems

Grades 1, Grade 2, Grade 3


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Late Pregnancy Bleeding Late Pregnancy Bleeding Premature separation of placenta

(abruptio placentae)―continued◦Clinical manifestations

Separation may be partial, complete, or only involve margin of placenta

◦Maternal/perinatal outcomes Maternal- 1% mortality rate-leading cause

of maternal death Perinatal- 20%-30% mortality rate

◦Hospital care


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Late Pregnancy Bleeding Late Pregnancy Bleeding Cord insertion and placental variations

◦Velamentous insertion of the cord: rare placental anomaly associated with placenta previa and multiple gestation Cord vessels branch at membranes and then

onto placenta ◦Battledore insertion of cord: marginal

insertion Risk for fetal hemorrhage

◦Succenturiate placenta: rare. Divided into two or more separate lobes


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Late Pregnancy Bleeding Late Pregnancy Bleeding Clotting Disorders in Clotting Disorders in PregnancyPregnancy Normal clotting

◦Hemostatic system stops flow of blood from injured vessels,

first by a platelet plug, then formation of a fibrin clot.

◦Fibrinolytic system Process through which fibrin is split into

fibrinolytic degradation products and circulation is restored


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Late Pregnancy Bleeding Late Pregnancy Bleeding Clotting Disorders in Clotting Disorders in PregnancyPregnancyClotting problems

◦Concern is in immediate postpartum period

◦Recognition in antepartal period may decrease hemorrhagic problems

◦Disseminated Intravascular Coagulation (DIC) Pathologic form of diffuse clotting that

consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both


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ATI QuestionA nurse is caring for a patient who

has been diagnosed with placenta previa. The nurse should expect which of the following findings?a. painful vaginal bleedingb. late fetal decelerationsc. painless vaginal bleedingd. early fetal decelerations

Key Points Key Points Blood loss during pregnancy should

always be regarded as warning sign until cause is determined

Some miscarriages occur for unknown reasons, but fetal or placental maldevelopment and maternal factors account for many others

Type of miscarriage directs care management


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Key Points Key Points Ectopic pregnancy is a significant

cause of maternal morbidity and mortality, even in developed countries

Two distinctive types of hydatidiform mole: complete and partial


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Key Points Key Points Premature separation of placenta

and placenta previa are differentiated by: ◦Type of bleeding◦Uterine tonicity◦Presence or absence of pain


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Key Points Key Points Clotting disorders are associated

with many obstetric complications

Management of late pregnancy bleeding requires immediate evaluation; care based on: ◦Gestational age◦Amount of bleeding◦Fetal condition


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week 7 n360 ch28 antepartal hemorrhagic

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