Today we're going to talk about a
group of complications in pregnancy
that all relate to bleeding.
We're going to break these down into
early and late symptoms and see how we do.
Early causes of bleeding could be the following:
a spontaneous abortion, an ectopic pregnancy,
or gestational trophoblastic disease.
Late causes of bleeding might be
placenta previa, an abruptio placenta,
preterm labor, a vasa previa
or a postpartum hemorrhage.
So let's break down those early causes of bleeding.
One more time, they are spontaneous abortion, ectopic
pregnancy and gestational trophoblastic disease.
A spontaneous abortion is any loss
of pregnancy where the pregnancy ends
prior to 20 weeks gestation.
In the cases where we don't know
exactly the gestation of the fetus,
then we would weigh the products of conception.
And so any products of conception
that weigh less than 550 grams
would also fit under the category
of a spontaneous abortion.
This occurs in about 10 to 15% of known pregnancies.
So what that means is that some clients are
going to experience a spontaneous abortion
and they never know.
There are several types of spontaneous abortion:
incomplete, complete and missed.
We're going to break down each one.
Now let's break down each of the
types of abortion and look at
what's going on with this cervix,
is it open or closed?
What we can see on the ultrasound
and then an overall description.
So let's start with the threatened abortion.
Now in many cases, a threatened abortion will go
on to become a normal, viable, termed delivery
but threatened just means that we're suspicious.
So when we look at the cervix,
the cervix will be closed,
will not be open, it will not be dilated.
On ultrasound, we will visualize
an intrauterine pregnancy.
And for the description, we have bleeding
but we also see a heartbeat with the fetus
and so it is alive.
That is a threatened abortion.
Now let's look at an inevitable abortion.
Unfortunately, this usually means that the
fetus is going to be lost at some point.
maybe right away, maybe in a few
days or weeks but it's going to happen.
So with the cervical OS, we'll find in this
case that it's actually open and not closed.
On ultrasound, we'll still be able
to see an intrauterine pregnancy
but we will usually find that the
heartbeat has stopped or slowed.
When we look at an incomplete abortion
again, the cervix will be open
and the intrauterine pregnancy
will be there but perhaps,
part of the products of conception
will have already started to come out.
Next, let's look at a complete abortion.
In this case, the cervical OS will be closed.
When we look on the ultrasound, there will
not be a baby inside the uterine cavity.
Typically this means that
the baby has already passed.
So it doesn't mean there wasn't
a baby there, It just means
by the time we get to the
ultrasound, there's nothing there.
This is complete.
A missed abortion in this case,
the cervix is also closed.
We actually will see parts of the
fetus but there will be no cardiac motion.
And what this means is that the fetus has died.
So we will be able to see all the parts,
but we know that this baby will not live.
So risk factors for spontaneous abortion
include chromosomal abnormalities
and this is the number one risk factor.
So when we think about why pregnancies
are lost, the number one reason
is because of chromosomal abnormalities.
There can also be medical conditions
that contribute to the formation of
chromosomal abnormalities or other issues.
So think about diabetes or
other types of genetic factors.
Advanced maternal age.
So I'd like to use a popcorn analogy
here, so go with me for a second.
So when you think about going to a
movie or being at home and watching TV
and you have a nice big bowl of popcorn
and when you start off at the top,
all the popcorn is nice and
fluffy and perfectly popped.
And then when you get to the middle there
are some popcorn that are well popped
and some that are not quite as well popped
but by the time you get to the bottom,
a lot of it is kernels.
So think about our ovaries the very same way.
When we we begin our childbearing
process, we have all perfect eggs
that have wonderful genetic material.
The older we get, however, the
further into the popcorn bucket we get
and the more kernels we see
and the more abnormalities.
So as we get to be 35, we are sort
of at bottom of the popcorn bucket.
We have more abnormal eggs than normal.
So the older we get, the more likely we
are to have chromosomal abnormalities.
Also, cervical incompetence.
What this means is that the cervix is not
able to maintain the weight of the fetus.
So instead of staying tight and closed,
it just opens up as the fetus gets larger.
Any kind of trauma.
So a car accident or a fall
or any sort of altercation
or anything that may cause trauma to
the uterus and then vicariously the baby
can also cause an abortion.
An infectious process.
It may not necessarily begin in the uterus, but any
kind of infection that eventually gets to the uterus
may lead to a loss.
Fetal anomalies, also any substance
misuse, so any kind of substance.
So think about tobacco, alcohol, recreational
drugs and also environmental exposures
can also lead to a spontaneous abortion.
And finally, specifically this disorder,
antiphospholipid syndrome, can cause abortions.
It has more to do with clotting but
we'll talk more about that later.
When we think about assessing someone
who is experiencing an abortion,
we want to talk about pain.
Because anytime the cervix opens or
dilates, typically there is going to be
some discomfort associated with that.
So we want to ask about when
it started, how does it feel,
how they noticed it getting progressively
worse and where do they feel it.
We want to assess if there's
been any leaking of fluid.
Depending on how far along the pregnancy
is, it may be an appreciable amount of fluid
but if it's early, they may not notice this.
Cervical dilation, so doing a bimanual
cervical exam and figuring out
whether the cervix is open or closed
will help us diagnose the abortion.
Also looking for signs of infection, like a fever.
We want to also look at the
hemoglobin and hematocrit.
Sometimes the bleeding is so significant
that someone can actually experience a
decrease in their hemoglobin or hematocrit.
So drawing labs will help us to determine that.
Also, an increased white blood count.
Specifically in the septic abortion, we will actually
see an increase in the white blood cell count
indicating that an infectious process has begun.
We may also notice a decrease in HCG.
Remember, HCG stands for human chorionic
gonadotropin and that's the pregnancy hormone,
the one we check for in a pregnancy test.
If we find that those hormone levels
are actually going down instead of up,
that's an indication that we
do not have a normal pregnancy.
And finally, if we were to have a situation where
the bleeding continues over a long period of time,
the client may actually present in shock
because they have lost so much blood.
Let's talk about management of spontaneous abortion.
So I want to bring out a concept we're going to
use a lot today which is expectant management
and that just means hands off,
we don't need to do anything.
Sometimes, especially in the case
of, remember a threatened abortion,
where often the pregnancy will go on to
be a perfectly viable full term delivery?
We don't want to do anything
because that is going to resolve.
So if the client is not in shock, the bleeding
is not heavy, there is no signs of infection,
often, we can wait and that's
what expectant management is.
Now if we knew the baby has died and we know
that there's no way that this baby will live
in any capacity, then often we need to
remove the baby from the uterine cavity
and this can be done through a procedure
called a dilation and curettage.
So the cervix will be dilated and
then an instrument called a curette
will be used to scrape the lining of the uterus and
this will remove all the products of conception.
This is a medication, Misoprostol that can
be given to cause uterine contractions.
You might be thinking, I've heard of this one
before, we talked about this one as a way to
ripen the cervix for an induction.
But given at higher doses, it
causes massive uterine contractions.
So this can be a way to evacuate the
uterus and all the products of conception
that may still be there.
Now at the heart of everything, there's a loss of
a pregnancy which is a very difficult situation
for both the person experiencing the loss physically
and the other person who may be there as support,
so we don't want to forget about that.
So as nurses, we want to make sure we
reach out, we connect with the client,
we connect with the family and offer
support in all the ways that we can
and using language that's supportive.
So even though we talk about spontaneous
abortion, that brings up a lot of feelings.
So we want to make sure that we talk about
that in a way that is okay with the patient.
So offering your condolences,
being sorry for their loss
and expressing it in that way is really important.
Also, offering education.
So sometimes the clients want
to know what happens next,
'when can I try again? What does this
mean in the long term? Why did this happen?'
Those are going to be questions that
we need to be prepared to answer
or prepared to refer the client to receive an answer.
This will help in the process
of healing after such an event.