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Bleeding in Pregnancy a Variety of Conditions Or Problems May Cause Bleeding During Pregnancy (Table 4)

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Bleeding in Pregnancy a Variety of Conditions Or Problems May Cause Bleeding During Pregnancy (Table 4) NWT Clinical Practice Guidelines for Primary Community Care Nursing - Obstetrics Bleeding In Pregnancy A variety of conditions or problems may cause bleeding during pregnancy (Table 4). Many of these are obstetric emergencies and are discussed in detail below. Table 4: Differential diagnosis of bleeding in pregnancy Gestational age < 20 weeks Gestational age ≥20 weeks Implantation bleeding Placenta previa Delayed normal menses Abruptio placentae Cervical lesions (erosion, polyp, dysplasia) Premature labour Ectopic pregnancy Hydatidiform mole Spontaneous abortion Intrauterine death (threatened, inevitable, incomplete) Cervical lesions Missed abortion “Show” Spontaneous Abortion Definition the uterus (where blood clots may be mistaken Loss or impending loss of pregnancy before 20 for tissue) or cervical canal, a situation that weeks gestation. causes ongoing cramping and excessive bleeding • Speculum examination reveals dilated internal Threatened Abortion os and tissue within the endocervical canal or • Early symptoms of pregnancy may be present vagina. • Mild cramps with bleeding • Bleeding may be heavy. • Cervix long and closed • Uterus appropriate for gestational age Missed Abortion • Progresses to inevitable abortion in • Products of conception retained 3 or more weeks approximately 50% of cases after fetal death • Signs and symptoms of pregnancy abate; Inevitable Abortion pregnancy test becomes negative • Persistent cramps and moderate free bleeding • Brownish vaginal discharge (rarely frank • Cervical os is open bleeding) occurs • Should not be confused with incompetent cervix, • Cramping rare which is not associated with cramping and is • Uterus soft, irregular and smaller than potentially treatable; incompetent cervix is gestational age associated with painless cervical dilatation • Ultrasonography rules out live fetus Complete Abortion Septic Abortion • Entire conceptus expelled, followed by decrease • Any of the above scenarios and temperature > or cessation of cramps and bleeding 38°C without other source of fever • On examination, uterus is firm and smaller than • Associated with intrauterine device or would be expected for gestational length of instrumentation during therapeutic abortion pregnancy procedure • Abdominal and uterine tenderness are present, as Incomplete Abortion well as purulent discharge and possibly shock • Symptoms the same as for inevitable abortion but some products of conception are retained in August 2007 Bleeding In Pregnancy 1 NWT Clinical Practice Guidelines for Primary Community Care Nursing - Obstetrics Causes • Incomplete abortion: cervical os open, bleeding Spontaneous abortion occurs in 15% to 25% of from os can be seen, mild suprapubic tenderness clinically recognized pregnancies and perhaps present, uterus may be small for dates closer to 50% of all conceptions. • Fetal abnormalities incompatible with life Differential Diagnosis (chromosomal and other) • Ectopic pregnancy • Defective implantation • Hydatidiform mole • Maternal infection • Other common causes of vaginal bleeding (e.g. • Uterine and cervical anomalies cervical erosion, polyp, cervicitis, local trauma) History For other entities, see Table 4, above, this chapter. • Symptoms and signs suggestive of pregnancy (missed period or periods, nausea, vomiting, Complications breast tenderness) • Severe hemorrhage • Cramping pain • Hypovolemic shock • Vaginal bleeding often with passage of tissue • Retention of products with or without endometritis All clients with bleeding sufficient to soak one pad • Cervical shock (vasovagal hypotension due to per hour or symptoms of orthostatic drop in blood dilatation of cervix by tissue) pressure (dizziness upon standing, faintness) need • An infection to be examined. Physical Findings Diagnostic Tests • Pregnancy test positive in 75% of cases, so Examination should include stability of vital signs, orthostatic vital signs, pelvic examination to look negative result does not rule out spontaneous for open or closed cervical os, presence of tissue abortion. and other causes of vaginal bleeding (such as • Measure hemoglobin level cervical erosion, polyp, infection, vaginal lesion or • Urinalysis ectopic fetus). The uterus should be measured. Fetal heart tones should be checked carefully with Management Doppler scanning. Goals of Treatment • Heart rate may be elevated • Prevent complications • Blood pressure may be low • Control blood loss • Postural blood pressure drop may be present • Maintain blood volume • Oxygen saturation may be abnormal if in shock • Client appears anxious In an outpatient setting it is often difficult to determine if a spontaneous abortion is complete or Pelvic Examination incomplete. It is probably prudent to manage all • Keep to a minimum spontaneous abortions as incomplete abortions if • Only use gentle speculum exam on advice of there is significant, active vaginal bleeding physician associated with abdominal pain. • Threatened abortion: cervical os closed, bleeding from os may be seen Threatened, Incomplete or Inevitable • Inevitable abortion: cervical os open, some Abortion without Hemodynamic products of conception bulging through os, Compromise bleeding from os can be seen If there is no hemodynamic compromise, threatened, incomplete or inevitable abortion should be managed as outlined in Table 5. August 2007 Bleeding In Pregnancy 2 NWT Clinical Practice Guidelines for Primary Community Care Nursing - Obstetrics Inevitable or Incomplete Abortion in If you cannot start IV therapy and bleeding is Hemodynamically Unstable Client significant: oxytocin (D class drug), 5-10 mg IM and consult Appropriate Consultation physician. Consult a physician as soon as client is stabilized. Verify Rh status and give Rh immune globulin Nonpharmacologic Interventions (RhIG) within 48 hours, if indicated (available • Nothing by mouth from the Laboratory Department of Regional Hospitals). • Bed rest • Trendelenburg position (prn) to aid venous Monitoring and Follow-Up return • Monitor vaginal bleeding, cramps, passage of • Insert urinary catheter if client is in shock tissue or clots, vital signs, intake and output • Monitor intake and output hourly • Save all products of conception passed and send • Aim for urine output of 50 mL/h to hospital with client Adjuvant Therapy Referral Initial aggressive fluid resuscitation is needed if Medevac as soon as possible. client is in hypovolemic shock: • Start IV therapy with normal saline References • Start two large-bore IV lines if client is websites and references: (last accessed 18 hypotensive September 2006) • Give 20 mL/kg normal saline as a bolus over 15 http://www.emedicine.com/med/topic3241.htm minutes Early Pregnancy Loss; Petrozza, J.C. et al • Reassess for signs of shock http://www.emedicine.com/EMERG/topic3.htm • Repeat 20 mL/kg boluses until systolic blood Abortion, Complete; Valley, V.T., et al pressure stabilizes at >90 mm Hg, then adjust http://www.emedicine.com/EMERG/topic5.htm rate according to severity of vaginal bleeding Abortion, Incomplete; Valley, V.T., et al and vital signs http://www.emedicine.com/emerg/topic6.htm • Oxygen to keep saturation > 97% Abortion, Inevitable; Valley, V.T., et al Refer to protocol for managing hypovolemic http://www.emedicine.com/emerg/topic7.htm shock, under "Shock," in chapter 14, "General Abortion, Missed; Valley, V.T., et al Emergencies and Major Trauma." http://www.emedicine.com/EMERG/topic11.ht m Abortion, Threatened; Gaufberg, S.V. Pharmacologic Interventions http://www.emedicine.com/EMERG/topic10.ht oxytocin drip (D class drug), 20 units in 1 L m Abortion, Septic; Gaufberg, S.V. normal saline or Ringer's lactate, 50-100 mL/h August 2007 Bleeding In Pregnancy 3 NWT Clinical Practice Guidelines for Primary Community Care Nursing - Obstetrics Table 5: Management of threatened, incomplete or inevitable abortion without hemodynamic compromise Threatened abortion Incomplete or inevitable abortion • Rest has traditionally been advised however, • Rest is not indicated as it is not expected to save there is not enough evidence to suggest that this pregnancy increased rest has any effect on the outcome. • acetaminophen (A class drug) 500mg 1-2 tabs www.cochrane.org/reviews/en/ab003576.html PO q4h prn for discomfort accessed 18 Sept 2006 • Nothing in the vagina (no tampons, douches, • acetaminophen (A class drug) 500mg 1-2 tabs intercourse) PO q4h prn for discomfort • Tissue visible in os should be gently removed • Nothing in the vagina (no tampons, douches, with ring forceps to allow contraction of uterus; intercourse) minimize manipulation to minimize risk of infection • Consider ultrasonography to visualize gestational • Consider pharmacologic interventions as above sac and cardiac activity or to rule out ectopic • Clients with incomplete abortion (tissue passed pregnancy and multiple pregnancy. (Cardiac with continued bleeding) often require suction activity predictive of continued pregnancy in >90% curettage or dilatation and curettage of cases) • Provide emotional support • Consider monitoring quantitative ß-HCG (human chorionic gonadotropin) for prognosis (increase of <66% in 48 hours predictive of abortion or ectopic pregnancy) • Provide emotional support August 2007 Bleeding In Pregnancy 4.
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