Complications of Pregnancy Part 1 Hemorrhagic Conditons

Pregnancy test qualitative hCG test (routine), Quantitative hCG test (Non-routine)

Qualitative (routine), Results are + or -, Detectable within 3 days of implantation

Results are a numeric value, Non-pregnant: <5, Pregnant: Greater than or equal to 5, Value doubles approx. every 48 hrs, Example: 2 weeks: 50-500, Peaks~75 days after fertilization, Monitored with pregnancy complications, such as: Threatened abortion, missed abortion, ectopic pregnancy, molar pregnancy, hyperemisis gravidum, etc.

Abortion, Ectopic Preganancy, Gestational trophoblastic disease (aka molar pregnancy and hydatiform mole)

The loss of pregnancy before viability, Medical definition: <20wks gestation or <500grams State of MI: <400 grams, Spontanous (miscarriage,SAB), Induced: MIP (Medical interruption of preg.), VIP (voluntary interruption of preg.), VTP (voluntary termination of preg.)

Termination of pregnancy without action taken by the woman or another person., 19-31% of pregnancies (not including unrecognized losses), 50-70% of losses are in the first trimester, Most common Cause: Severe congenital anomalies Often incompatibile with life Chromosomal: 50-60% of SAB, Other Causes: Maternal infections Endocrine disorders Anatomic defect Alcohol and smoking Unknow Incidence, Care Priorities: Hemorrhage risk Infection risk Pain treatment Psychosocial support

Vaginal bleaching and possibly cramping, backache or pelvic pressure occurs but fetus is still viable, Interventions:, Notify provider, Vaginal ultrasound: Fetus is present? Viable?, Serum beta-hCG and progesterone levels appropriate for GA?, Limit sexual activity while bleeding is present, Monitor S&S of infection, tissue passage and pad count, Psychological support, Up to 25% of women experience “spotting” in early pregnancy & 50% end in SAB

Cannot be stopped: Membranes rupture, cervix dilates, contractions bleeding., Interventions:, IV access and T&S (hemmorrhage risk), Natural Evacuation of POC (products of conception), Vacuum Curettage: Clears out uterus’s w/suction (incomplete/inevitable AB & early GA), Dilation and Curettage (D&C): Scraping of uterine wall to clear all POC (incomplete/inevitable and below 14wks), IOL: Oxytocin or postaglandin administration for IOL after 14 wks

Fetus delivers but some tissue (POC) is retained (bleeding and cramping occur), Interventions: (Hemorrhage risk and infection risk), Type and screen blood, IV and fluids, D&C to remove POC, IV oxytocin (pitocin), Hemorrhage meds PRN: Miso(soup?)prostal (cytotec), methylergonovine (methergine), carboprost (hemabate)

All POC expelled from uterus spontaneously, Interventions:, Verify all POC are expelled, No additional interventions are required unless excessive bleeding or infection occurs, Monitor for bleeding, pain & fever (similar to postpartum), Psychosocial support

Deceases fetus retained in the uterus during the 1st half of pregnancy, S/S: nausea, breast tenderness, uterine growth stops/uterus decreases in size (amniotic fluid absorbed), urinary frequency stops, red/brown vaginal bleeding may or may not occur. Maceration of the fetus (tissue degrading), Interventions: Ultrasound to confirm no FHR hCG tests to look for decreased placental hormones, Delivery options: Watch and wait for the body to recognize loss and miscarry naturally (risks hemorrhage, infection, prolong emotional turmoil) Intervene: Dilation&evacutaion, D&C, of IOL depending on GA, Monitor for S/S infection temp,foul smelling vaginal discharge, abdominal pain

ACOG def: 2 or more SABs (other sources define as 3 or more), 60% chromosomal abnormalities, 40% other causes such as: Abnormalities of reproductive tract: bicornuate uterus (heart shaped could have a septum), uterine septum, adhesions, incompetent cervix, fibroids. Diseases: Antiphospholipid syndrome, diabetesm PCOSm lupus, STDs, endocrine disorders, Interventions:, RhoGAM given to prevent further sensitization with all SABs for (-) moms, Examination of reproductive system structures, Genetic screening, Managing of disease processes: DM= maintain normal BS Endocrine=correct hormones Incompetent cervix (won’t stay closed)= cerclage.

Fertilized ovum implants outside of the uterus, 97%= Fallopian tube (other sites abdomen or cervix), Risk factors: Previous ectopic Preganancy, endometriosis, pelvic infections, PID, surgery, failed tubal ligation, IUDs, ART, or multiple VTPs, S&S: Missed menstrual period, (+) pregnancy test, *UNILATERAL ABDOMINAL PAIN*, vaginal spotting, Ruptured tube= DEADLY: Sudden/sever pain in abdomen, RADIATING SCAPULA pain, hemorrhage and hypo anemic shock

Prorities:, 1. control bleeding, 2. Prevent shock, 3. Preserve tube, 4. treat pain, 5. Psychosocial support, Dx: Transvaginal ultrasound & low beta hCG (rare: laparoscopy), Interventions: Methotrexate, linear salpingostomy**Pictured above** (Open fallopian tube and remove implanted fetus ), spalingectomy (removal of fallopian tube), RhoGam (Rh neg) f/u hCG

Brand names: Otrexup, Rasuvo, Rheumatrex dose pack, Trexall, Xatemp, Chemotheraputic agent & folic acid antagonist (inhibits cell replication), SE: N/V & increased pain r/t egg expulsion, Dosage: Single and multi-dose protocols based on body surface area, Pt education: Don’t take folic acid or drink alcohol (decreases med effectiveness), Use chemo precaution for medication and urine handling procedures

AKA: Hydatidiform mole or molar pregnancy, Trophoblasts from fertilized ovum proliferate abnormally creating PLACENTAL LIKE TISSUE that fills the uterus (NO FETUS), Fluid filed villi form grape-like clusters of tissue. May even contain fetal tissue parts, MAY BECOME CANCEROUS: Persistent gestational trophoblastic disease may undergo malignant change (choriocarcinoma) and metastasize to distant sites, lungs, vagina, liver, brain.

Risk factors: Asian ethnicity, young/old maternal ages, hx of molar preganancy (10x risk of recurrence), S&S: elevated hCG, vaginal, large uterus for GA, hyperemisis r/t ⬆️ hCG and PIH, Dx: ⬆️hCG, ultrasound shows vesicles, absence of fetal sac and no FHR., Tx: Pregnancy induced HTN and hyperemisis Removal (vacuum extraction & curettage) ***Follow up*** serial hCG levels for 1 year chest CXR, CT scan, MRI to r/o metastatic disease

#1. Placenta previa (covers cervix partially or complete), #2. Abruptio placental (dark red blood if any), #3. Accreta/increta/percreta, #4. Vasa Previa

Placenta is too close to or covers the cervical OS (baby’s exit is blocked), Risk factors: Previous C/S or other uterine surgery, previous placenta previa, older women, and multiparas, S&S: Sudden onset of **PAINLESS** uterine bleeding, scant or profuse, may not occur until labor starts, Note “bloody show” is the mucous plug this blood would be more like bright red

NO VAGINAL EXAMS: may separate placenta, Repeat US: Placenta’s often migrate & Previa resolve, Deliver route: Depens on position marginal (low lying): may deliver vaginally Total/complete: Always C/S (no oxytocin), No active bleeding: Monitoring at home, no strenuous activity and NO sexual activity, Active bleeding & fetal distress: urgent C/S, Increased risk of PPH: higher risk of placenta accreta among previa patients

Sepertaion of placenta before the fetus is born, 10-15% of perinatal deaths, Maternal risks: Hemorrhage, shock and DIC (disseminated intrvascular coagulation), Fetal risks: Asphyxia & prematurity, Risk factors: Cocaine, trauma, cigarettes, HTN, PROM, multigravida, short cord, & hx of abruption, TX: depends on severity and teal tolerance, TX: Marginal abruption: spotiiong may resolve (bed rest, tocolytics, EFM, steroids, home monitoring when stable), TX: Total abruption: Emergnecy stat C/S (no blood flow to the fetus), treat for hypovolemia and shock

Bleeding: Vaginally or concealed (trapped in a hematoma), Uterine tenderness or abdominal pain, Hard “BOARD-LIKE” abdomen, ⬆️Fundal height ⬆️HR ⬆️Restlessness, ⬇️B/P ⬇️urine output ⬇️FHR (late or prolonged decels), Hypovalemic shock, fetal distress or fetal death, Abruption Pattern: ⬆️ uterine activity and ⬆️uterine tone

Placenta implants TOO DEEP causing retained placenta at delivery, Risk factors: previous C/S or uterine surgeries, placenta previa, AMA (advanced materna age), multiparas, Dx: US (sometimes only Dx during hemorrhage evaluation), Risks: **MASSIVE PPH**, injury to surrounding organs (percreta), infection, infertility due to scar tissue, terilitty due to hysterectomy, Tx: Schedules C/S, additional PPH resources, blood products, hysterectomy. Small accrete pieces sometimes remain undiagnosed causing infection risk and subinvolution of the uterus, To remember severity they’re in alphabetical order AIP from least severe to most severe

Umbilical CORD IMPLANTS IN MEMBRANES & is in front of cervical OS, DX: US, S&S: Sudden painless bleeding, Risk; SROM can cause membranes to rip through the cord & massie FETAL HEMORRHAGE to occur, Goal: prevent SROM, TX: Continuous hospitalization 30+wks, steroids, planned delivery 35wks, immediate delivery with labor, tocolytics, bed rest & no interocurse

Life threatening coagulation disorder causing “Macro Bleeding & Micro clotting” (AKA consumptive coagulopathy), OB risk factors: Missed abortion/retained dead fetus, abruption, severe PIH, HELLP, anaphylactic syndrome (amniotic fluid embolism) & sepsis (but not limited to OB conditions), Lab changes: ⬇️Fibrinogen and platelets ⬆️Prothrombin time (PT) and activated partial thromboplastin time (aPTT) prolonged ⬆️Fibrin degradation products or fibrin split products (FSP), DIC big bleed little clots

Insult causes consumption of plasma factors resulting in a deficit therefore blood is unable to clot, White anticoagulation is occurring, inappropriate coagulation occurs in tiny blood vessels blocking blood flow to the organs and causing ischemia, Resulting S&S: Excess bleeding (vulnerable areas, IV sites, incisions, gums, nose, & placental attachment site), Interventions: Correct underlying cause Blod replacement, whole blood, packed RBC cryoprecipitate, Monitor for bleeding from unexpected sites, Epidurla may be contraindicated