Spontaneous Abortion – Early Pregnancy Bleeding (Nursing)

00:01 Today we're going to talk about a group of complications in pregnancy that all relate to bleeding.

00:07 We're going to break these down into early and late symptoms and see how we do.

00:13 Early causes of bleeding could be the following: a spontaneous abortion, an ectopic pregnancy, or gestational trophoblastic disease.

00:24 Late causes of bleeding might be placenta previa, an abruptio placenta, preterm labor, a vasa previa or a postpartum hemorrhage.

00:37 So let's break down those early causes of bleeding.

00:40 One more time, they are spontaneous abortion, ectopic pregnancy and gestational trophoblastic disease.

00:49 A spontaneous abortion is any loss of pregnancy where the pregnancy ends prior to 20 weeks gestation.

00:57 In the cases where we don't know exactly the gestation of the fetus, then we would weigh the products of conception.

01:03 And so any products of conception that weigh less than 550 grams would also fit under the category of a spontaneous abortion.

01:12 This occurs in about 10 to 15% of known pregnancies.

01:17 So what that means is that some clients are going to experience a spontaneous abortion and they never know.

01:24 There are several types of spontaneous abortion: threatened, inevitable, incomplete, complete and missed.

01:34 We're going to break down each one.

01:37 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.

01:49 So let's start with the threatened abortion.

01:51 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.

02:01 So when we look at the cervix, the cervix will be closed, will not be open, it will not be dilated.

02:06 On ultrasound, we will visualize an intrauterine pregnancy.

02:10 And for the description, we have bleeding but we also see a heartbeat with the fetus and so it is alive.

02:17 That is a threatened abortion.

02:20 Now let's look at an inevitable abortion.

02:22 Unfortunately, this usually means that the fetus is going to be lost at some point.

02:27 maybe right away, maybe in a few days or weeks but it's going to happen.

02:31 So with the cervical OS, we'll find in this case that it's actually open and not closed.

02:36 On ultrasound, we'll still be able to see an intrauterine pregnancy but we will usually find that the heartbeat has stopped or slowed.

02:45 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.

02:58 Next, let's look at a complete abortion.

03:00 In this case, the cervical OS will be closed.

03:04 When we look on the ultrasound, there will not be a baby inside the uterine cavity.

03:09 Typically this means that the baby has already passed.

03:12 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.

03:18 This is complete.

03:20 A missed abortion in this case, the cervix is also closed.

03:24 We actually will see parts of the fetus but there will be no cardiac motion.

03:29 And what this means is that the fetus has died.

03:32 So we will be able to see all the parts, but we know that this baby will not live.

03:43 So risk factors for spontaneous abortion include chromosomal abnormalities and this is the number one risk factor.

03:50 So when we think about why pregnancies are lost, the number one reason is because of chromosomal abnormalities.

03:57 There can also be medical conditions that contribute to the formation of chromosomal abnormalities or other issues.

04:03 So think about diabetes or other types of genetic factors.

04:08 Advanced maternal age.

04:10 So I'd like to use a popcorn analogy here, so go with me for a second.

04:14 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.

04:27 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.

04:37 So think about our ovaries the very same way.

04:39 When we we begin our childbearing process, we have all perfect eggs that have wonderful genetic material.

04:46 The older we get, however, the further into the popcorn bucket we get and the more kernels we see and the more abnormalities.

04:54 So as we get to be 35, we are sort of at bottom of the popcorn bucket.

04:58 We have more abnormal eggs than normal.

05:01 So the older we get, the more likely we are to have chromosomal abnormalities.

05:07 Popcorn.

05:08 Also, cervical incompetence.

05:10 What this means is that the cervix is not able to maintain the weight of the fetus.

05:15 So instead of staying tight and closed, it just opens up as the fetus gets larger.

05:21 Any kind of trauma.

05:23 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.

05:35 An infectious process.

05:36 It may not necessarily begin in the uterus, but any kind of infection that eventually gets to the uterus may lead to a loss.

05:44 Fetal anomalies, also any substance misuse, so any kind of substance.

05:49 So think about tobacco, alcohol, recreational drugs and also environmental exposures can also lead to a spontaneous abortion.

05:58 And finally, specifically this disorder, antiphospholipid syndrome, can cause abortions.

06:05 It has more to do with clotting but we'll talk more about that later.

06:09 When we think about assessing someone who is experiencing an abortion, we want to talk about pain.

06:14 Because anytime the cervix opens or dilates, typically there is going to be some discomfort associated with that.

06:20 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.

06:27 We want to assess if there's been any leaking of fluid.

06:30 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.

06:39 Cervical dilation, so doing a bimanual cervical exam and figuring out whether the cervix is open or closed will help us diagnose the abortion.

06:49 Also looking for signs of infection, like a fever.

06:53 We want to also look at the hemoglobin and hematocrit.

06:56 Sometimes the bleeding is so significant that someone can actually experience a decrease in their hemoglobin or hematocrit.

07:03 So drawing labs will help us to determine that.

07:06 Also, an increased white blood count.

07:08 Specifically in the septic abortion, we will actually see an increase in the white blood cell count indicating that an infectious process has begun.

07:17 We may also notice a decrease in HCG.

07:20 Remember, HCG stands for human chorionic gonadotropin and that's the pregnancy hormone, the one we check for in a pregnancy test.

07:29 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.

07:37 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.

07:48 Let's talk about management of spontaneous abortion.

07:51 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.

08:00 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.

08:14 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.

08:22 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.

08:37 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.

08:48 This is a medication, Misoprostol that can be given to cause uterine contractions.

08:53 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.

09:00 But given at higher doses, it causes massive uterine contractions.

09:04 So this can be a way to evacuate the uterus and all the products of conception that may still be there.

09:11 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.

09:25 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.

09:34 So even though we talk about spontaneous abortion, that brings up a lot of feelings.

09:40 So we want to make sure that we talk about that in a way that is okay with the patient.

09:44 So offering your condolences, being sorry for their loss and expressing it in that way is really important.

09:52 Also, offering education.

09:53 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.

10:09 This will help in the process of healing after such an event.