antepartum haemorrhage

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WOMEN’S HEALTH OBSTETRIC ANTEPARTUM HAEMORRHAGE

Transcript of antepartum haemorrhage

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WOMEN’S HEALTHOBSTETRICANTEPARTUM HAEMORRHAGE

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DEFINITION ANTEPARTUM

~Occuring before the onset of labour.

HAEMORRHAGE

~Bleeding from the genital tract after the 24th week of pregnancy until the birth of the baby.

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Antepartum haemorrhage is the bleeding from the vagina during;

1)The second half of pregnancy. 2)Earlier commences labour. 3)Bleeding from the vagina

afterwards 24th weeks gestation up until labour.

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ETIOLOGY Placenta previa Placental abruption Local causes; cervical

polyps,cervicitis,cancer of the cervix,post-coital genital laceration

vasa praevia Unknown

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TYPES OF ANTEPARTUM HAEMORRHAGE

EARLY PREGNANCY BLEEDING

~Miscarriage(spontaneous abortion)

~Incompetent cervix (Recurrent premature dilation of the cervix)

~ Ectopic pregnancy ~Hydatidiform mole(Molar

pregnancy)

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LATE PREGNANCY BLEEDING

~Placenta previa ~Premature separation of

placenta ~Cord insertion and

placental variations

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MISCARRIAGE

Miscarriage or spontaneous abortion is the spontaneous end of a pregnancy

At a stage where the embryo or fetus is incapable of surviving,generally defined in humans at prior to 20 weeks of gestation.

Miscarriage is the most common complication of early pregnancy.

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ETIOLOGY

Genetic Uterine or hormonal abnormalities Reproductive tract infections Tissue rejection Problem with the body immune

system Physical problem with the mother’s

reproductive system Age-higher than 35years old

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CLINICAL MANIFESTATIONS

Low back pain or abdominal pain that is dull, sharp, or cramping

Tissue or clot-like material that passes from the vagina

Vaginal bleeding, with or without abdominal cramps

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TREATMENT

Abdominal or vaginal ultrasound. Blood test;CBC,WBC Medication;Misoprostol(to remove

the remaining contents from the womb)

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INCOMPETENT CERVIX

Where the pregnant women begin to dilate and thin before her pregnancy has reached term.

It may cause miscarriage or preterm birth when 2nd and 3rd trimester.

In a normal pregnancy,dilation and effacement occurs in response to uterine contractions.

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ETIOLOGY

Painless History of previous cervical lacerations

during childbirth Miscarriage starting at 2nd trimester.

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TREATMENT

It can be treat using cervical cerclage,cervical technique that reinforces the cervical muscle by placing suture above the opening of cervix to narrow the cervical canal.

Cerclage usually performed between 14 to 16weeks of the pregnancy the suture removed between 36 and 38weeks to avoid problem between labour.

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ECTOPIC PREGNANCY

An Ectopic pregnancy is the implantation of the fertilized ovum outside the uterine cavity.

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ETIOLOGY

History of prior ectopic pregnancy Pelvis inflammation disease History of tubal surgery and

conception after tubal ligation. Use of fertility drugs or assisted

reproductive technology Use of an intrauterine device

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PATHOPHYSIOLOGY

An blockage of the tube or reduction of tubal peristalsis that impedes of delays the zygote passing to the uterine cavity can result in tubul implantation.

Less acute symptoms usually begin within 6 to 8weeks after the last normal menstrual period and weeks before rupture would occur.

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CLINICAL MANIFESTATION

Abdominal or pelvic pain Irregular vaginal bleeding Adrenal fullness Tenderness may suggest an

interruptured tubal pregnancy Pain while having bowel movement Red or brown abnormal vaginal

bleeding 50% or 80% of women.

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TREATMENT

Medical therapy Embryo transfer Blood test Pelvic examination

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HYDATIDIFORM MOLE

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DEFINITION

Gestational trophoblastic disease is abnormal proliferation and degeneration ofthe trophoblasitic villi. As the cells degenerate,they become filled with fluid and appear as clearfluid, grape-sized vesicles. With this condition,the embryo fails to develop beyond a primitivestart.

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CAUSES

A hydatidiform mole, or molar pregnancy,

results from over-production of the tissue that is

supposed to develop into the placenta. The

placenta normally feeds a fetus during

pregnancy. In this condition, the tissues develop

into an abnormal growth, called a mass.

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There are two types: · Partial molar pregnancy · Complete molar pregnancy

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A partial molar pregnancy means there is an

abnormal placenta and some fetal development.

In a complete molar pregnancy, there is an

abnormal placenta but no fetus.

Both forms are due to problems during fertilization. Potential causes may include defects in the egg, problems within the uterus, or a diet low in protein, animal fat, and vitamin A. Women under age 16 or older than 40 have a higher risk for this condition.

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PATHOPHYSIOLOGY OF HYDATIDIFORM MOLE

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Low intake of proteins and vitamin A, Asian heritage, Women older than 35 years

Partial moleor

Complete mole

Chronic villi degenerates and become filled with fluid

No vasculature in chorionic villi

Early death & absorption of embryo Absence of FHT

Trophoblastic proliferation Uterus expands abdominal pain faster than normal

High secretion of hCG High progesterone low estrogen High chorionic thyrotropin

Marked nausea & vomiting Decreased contraction Amenorrhea Hyperthyroidism

Multiple theca lutein cysts in the ovaries Separation of vesicles from uterine wall Enlarged thyroid gland; tachycardia

Ovarian pain Vaginal bleeding & discharge of vesicles

Pallor Preeclampsia

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CLINICAL MANIFESTATION

Abnormal growth of the womb (uterus) Excessive growth in about half of cases Smaller-than-expected growth in about

a third of cases Nausea and vomiting that may be

severe enough to require a hospital stay

Vaginal bleeding in pregnancy during the first 3 months of pregnancy

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Symptoms of hyperthyroidism Heat intolerance Loose stools Rapid heart rate Restlessness, nervousness Skin warmer and more moist than usual Trembling hands Unexplained weight loss

Symptoms similar to preeclampsia that occur in the 1st trimester or early second trimester -- this is almost always a sign of a hydatidiform mole, because preeclampsia is extremely rare this early in a normal pregnancy High blood pressure Swelling in feet, ankles, legs

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TREATMENT

Curettage to remove cysts Suction to remove cysts Close surveillance after therapy

with monitoring of HCG levels Methotrexate if HCG levels are

rising

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PLACENTA PRAEVIA

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DEFINITION

Placenta situated abnormally in the lower uterine segment ,leading to unavoidable , painless, recurring haemorrhage toward the end of pregnancy as the lower uterine segment stretches in preparation for labour.

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PATHOPYSIOLOGY

women with placenta previa often with painless and bright red vagina bleeding.

This bleeding often starts mildly and may increase as the area of placental separation increases.

Praevia should be suspected if there is bleeding after 24 weeks of gestation.

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ETIOLOGY

Women who are younger than 20 are at higher risk and women older than 30 are at increasing risk as they get older.

Women with a large placentae from twins or erythroblastosis are at higher risk.

Women who smoke or use cocaine may be at higher risk.

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SIGN AND SYMPTOM

Bleeding occurs spontaneously.

causeless.

painless.

it may anemia.

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PREMATURE SEPARATION OF PLACENTA

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Detachment of part or all of the placenta from it implantation site.

It occurs in the area of dedicua basalis after 2oweeks of pregnancy and before the birth of the baby.

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ETIOLOGY

Hypertension Cocaine Blunt external abdominal trauma Age older than 35years old Short umbilical cord Folic acid deficiency

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PATHOPHYSIOLOGY

Trauma,hypertension or coagulopathy contributes to the ovulsion of the anchoring placental villi from the expanding lower uterine segment.

Then it leads bleeding in decidua basalis,this can push the placenta away and from the uterus and cause further bleeding.

Sometimes the blood pull the behind the placenta. It will present with vaginal bleeding.abdominal back

or pain,abnormal or premature contractions,it cause fetal distress or death.

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CLINICAL MANIFESTATIONS

Contraction that dint stop Pain in the uterus Tenderness in the abdomen Vaginal bleedings(sometimes)

(dark colour) Uterus maybe disproportionally

enlarged Pallor

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TREATMENT

Treatment depends on the amount of blood loss and the status of the fetus. If the fetus is less than 36 weeks and neither mother or fetus are in any distress, then they may simply be monitored in hospital until a change in condition or fetal maturity whichever comes first.

Caesarean section is contraindicated in cases of disseminated intravascular coagulation. Patient should be monitored for 7 days for PPH.

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CORD INSERTION AND PLACENTAL VARIATIONS

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DEFINITION

 A situation where the umbilical cord inserts into the fetal membranes (amnion and chorion), rather than the body of the placenta.

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ETIOLOGY AND PATHOPHYSIOLOGY

The exact etiology of placenta previa is unknown. The condition may be multifactorial and is postulated to be related to multiparity, multiple gestations, advanced maternal age, previous cesarean delivery, previous abortion, and possibly smoking. 

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SIGN AND SYMPTOM

Bleeding is usually bright red and painless

The first bleed occurs (on average) at 27-32 weeks' gestation.

Profuse hemorrhage Hypotension Tachycardia Soft and nontender uterus

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TREATMENT

The safest treatment is a planned caesarian section and abdominal hysterectomy if placenta accreta is diagnosed before birth.

If the woman decides to proceed with a vaginal delivery, blood products for transfusion should be prepared.

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NURSING MANAGEMENT

Nursing diagnosis : impaired fetal gas exchange related to altered blood flow and decreased surface area of gas exchange at site of placenta detachment.

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INTERVENTION

1) Assess vital sign (pulse,respiration,and blood pressure every 15 minute.) to provide baseline data on maternal blood loss.

2) Maintain bed rest or chair rest when indicated to reduce fatigue.

3) Monitor amount and type of bleeding to provide objective evidence of bleeding.

4) Give moral support and maintain positive attitude toward about fetal to support mother and child bonding.

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5) Administer oxygen as indicated to provides adequate fetal oxygenation of lowered maternal circulating volume.

Evaluation : The patient was confident and able to verbalize understanding of causetive factors.

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NURSING DIAGNOSIS

Objective: Changes in fetal heart rate or fetal

activity. Release of meconium.

DIAGNOSIS Impaired fetal gas exchange

related to altered blood flow and decreased surface area of gas exchange at site of placental detachment.

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INTERVENTION AND RATIONALE

Assess vital signs (pulse, respirations, and blood pressure every 15 minutes) to provides baseline data on maternal blood loss.

Maintain bed rest or chair rest when indicated to reduce fatigue, and improve strength.

Monitor amount and type of bleeding to provide objective evidence of bleeding.

Position mother on her left side to promote placental perfusion.

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Restrict vaginal examination to prevents tearing of placenta if placenta previa is the cause of bleeding.

Monitor uterine contractions and fetal heart rate by external monitor to assess whether labor is present and fetal status and external system avoids cervical trauma .

Maintain positive attitude toward about fetal outcome to supports mother and child bonding.

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EVALUATION

After 8 hours of nursing interventions, the patient was able to verbalize understanding of causative factors and appropriate interventions.

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NURSING PROCESS ASSESSMENT:- Hydatidiform mole: to detect a hydatidiform mole early, the nurse should observe for signs of a mole at each prenatal visit during the first 20 weeks of gestation. Such signs as uterine bleeding, uterine size small or large for dates, hyperemesis gravidarum, signs of preeclampsia before 24 weeks of gestation, passage of grapelike vesicles, or inability to detect FHR with Doppler FHR device after 10 to 12 weeks of gestation should be brought to the attention of the obstetrician or healthcare provider immediately.

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Nursing Diagnosis:

- Hemorrhage related to trophoblastic invasion or uterine rupture.

Nursing Intervention: 1.  Monitor for evidence of hemorrhage such as vital

signs, abdominal pain, uterine status, and vaginal bleeding. 2.  Start intravenous (IV) infusion with an 18-gauge

intracatheter. 3.  Prepare for surgery according to preoperative

protocol, and type and cross match 2 to 4 units of blood as ordered. 4.  Postoperative IV infusions with oxytocin added

are usually continued initially to facilitate uterine contractions and

decreaseuterine bleeding.

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INTERVENTION - The signs and symptoms of

hemorrhage will be minimized/managed as measured by distal pulses, stable vital signs, orientation to person, place, and time, urinary output greater than 30 ml/hr, an no signs of bleeding

5.  Do not massage a boggy uterus if ovaries are enlarged since it can cause ovarian rupture. 6.  Notify physician of first signs of bleeding.