Pregnancy Complication: Perfusion Concept
Scope of Concepts
- No clotting = No perfusion
Consequences of Excessive Bleeding Due to Hemorrhage
- Discuss localized versus systemic bleeding and how the two types of bleeding differ.
What are the OB patient’s risk factors for hemorrhage?
- Older adults
- African Americans with sickle cell
- Missing genetic clotting factors
- Immobile patients
- Patients that smoke
How Do You Know Your Patient Is Having Hemorrhage?
- LOCALIZED:
oBleeding or ecchymosis at injury site
oBleeding into a joint causing redness, warmth, edema and severe pain in the
affected area
oBleeding at surgical site
oIntracranial bleeding
- SYSTEMIC:
oEcchymosis, petechiae, purpura
oFrequent nosebleeds
oBlood in stool, urine, emesis
oBleeding gums
oBleeding within joints
oExcessive menstrual bleeding
oBleeding within joints
oExcessive menstrual bleeding
oEXCESSIVE UTERINE BLEEDING
Why do I care about impaired perfusion or no perfusion?
- Hemorrhage
- Hemolytic anemia
Nursing Interventions For Hemorrhage
- I&O’s
- Administer fluids using large bore needle for rapid administration.
- Administer blood products.
- Compress the site of bleeding to stop bleeding.
- Ice or some way of vasoconstricting the vessel bleeding
- Medications to replace missing clotting factors.
- Gel foam or fibrin foam to help clot.
- Critical care management if shock occurs
Impaired Perfusion in The OB Patient with a Complication
- 1st trimester:
oEctopic vs miscarriage (abortion)
- 2nd trimester:
oMolar pregnancy
- 3rd trimester:
oPlacenta previa
oPlacenta abruption
How Will You Recognize an Issue?
- 1st trimester
oEctopic
Unilateral lower abdominal pain
Spotting to none visualized.
Vs changes when enough blood is lost:
^HR
Low bp (late sign)
Anxiety, confusion, altered loc with hemorrhage.
Anxiety, confusion, altered loc with hemorrhage.
oSpontaneous abortion (miscarriage)
Cramping pain in lower abdomen
Spotting to hemorrhage
Vs changes when enough blood is lost:
^HR
Low bp (late sign)
Anxiety, confusion, altered loc with hemorrhage.
Who is at risk?
- Ectopic
oNonwhite and women over 35 years old
oFertility treatment
oPatients with STD’s leading to PID.
- Spontaneous Abortion
oYounger than 20 and older than 40 years old
oOlder paternal age
oGenetic problem
Diagnosis:
- Ectopic
oUltrasound
oLab work to make sure they are pregnant and for base line if hemorrhaging
patient.
- Spontaneous abortion
oUltrasound
Medical Management
- Ectopic
oRuptured tube: surgery to remove tubal pregnancy and repair or remove tube
oRuptured tube: surgery to remove tubal pregnancy and repair or remove tube
(salpingectomy)
oIntact tube: medical management (methotrexate)
oMake sure to teach – no alcohol or foods with folic acid while on methotrexate.
- Spontaneous abortion.
oIf incomplete, missed, or septic: D&C
oIf complete/inevitable: watch for hemorrhage and infection after spontaneous
delivery of previable fetus
Nursing Interventions
- Ectopic:
oIdentify shock.
oIv fluid replacement
oBlood transfusion as needed.
oPrep for surgery
oMonitor I&O’s.
oControl pain
oEducate patient on treatment plan and discharge info.
oPsychological support
- Spontaneous abortion:
oIdentify shock.
oIv fluid replacement
oBlood transfusion as needed.
oPad count
oMonitor I&O’s.
oEducate on signs of hemorrhage and infection for discharge.
oPsychological support
Evaluation
- Ectopic:
oIf your patient is medically managed:
oFollow up for HCG level and repeat Methotrexate IM shot.
oIf you had a surgical patient:
oPt is free of hemorrhage.
oPt is free of signs of infection.
oPt is going through normal stages of grief.
- Spontaneous Abortion:
oPt is free of signs of hemorrhage.
oPt is free of signs of infection.
oPt is going through normal stages of grief
2nd trimester IMPAIRED PERFUSION
- Gestational Trophoblastic Disease (GTD or Molar Pregnancy)
oCause: Placenta does not form correctly. The trophoblastic which turns into the
chorionic villi fill with fluid and grow abnormally fast.
oExtra HCG is released
- Assessment: Patient often thinks she is further along than due date or that she is having
twins due to showing early. (large for gestational age) May have excessive nausea and
vomiting due to high levels of HCG. May develop BP problems before 24 weeks in
pregnancy. Dark brown prune colored bleeding
Risk Factors associated with GTD
- Asian, Native American, and Hispanic descent
- Low carotene or animal fat diets
- Below 20 years old and over 40 years old
- Fertility drugs
Diagnosis:
- Ultrasound to detect snowstorm effect noted when a molar pregnancy is present.
- Looks like grape cluster.
Medical Management
- Dilation and curettage (D&C)
- Dilation and evacuation (D&E)
Nursing Interventions
- Identify signs of hemorrhage
- Pad counts after D &C or D&E
- Monitor I&O’s
- Iv fluid replacement
- Administer blood product replacement.
- Educate patient on signs of:
oHemorrhage,
oInfection
oNeed for birth control to prevent pregnancy for one year.
oNeed for follow up appointments to assess potential cancer by tracking HCG
levels and chest x-rays.
3rd Trimester Ineffective Clotting
- Placenta Previa
- Abruptio Placentae
Who is at risk?
- Previa
oScarred Uterus
oAma
oGrand Multiparous
- Abruptio Placentae
oTrauma
oDrug Use (Cocaine)
oAnything That Causes Vasoconstriction (Smoking And Hypertension)
oAnything That Causes Vasoconstriction (Smoking And Hypertension)
How Will You Recognize?
- Placenta Previa
oPain: No
oColor Of Blood: Bright Red
oContractions: No Or Very Few
oAbdomen: Soft
- Abruptio Placenta
oPain: Yes (Severe)
oColor Of Blood: Dark Red
oContractions: Yes, Hypersystole
oAbdomen: Board Like (Hard)
Medical Management: Goal Is Hemostasis
- If Hemorrhaging:
oDeliver Baby Before Mom Bleeds Out
oIf Not Hemorrhaging:
oBed Rest
oBpp And Biophysical Profile Every Other Day
oFetal Monitoring
oWait And See Approach
Nursing Interventions for Both
- Hemorrhaging:
oIv Fluid Replacement If Actively Bleeding with Large Bore Iv To Keep Up Blood
Volume
oBlood Replacement as Needed
oOxygen For Hemorrhage and Fetal Distress
oI &O’s
oPrep For Surgery
- Not Hemorrhaging:
oPad Count to Assess Bleeding
oEducate On How Much Bleeding Is Too Much
oFHR And Contraction Monitoring To Assess Well Being Of Baby And If Having
Contractions
oI&O’s
Evaluation:
- Mom is free from signs of shock and achieves hemostasis.
- Baby is free of distress and transitions normally to extrauterine life.
Disseminating Intravascular Coagulation (DIC)
- DIC is a condition that represents both excessive clotting and bleeding.
- The primary disorder initiates generalized clotting forming numerous thrombi resulting
in multiple organ failure. The abnormal number of thrombi consume and deplete
platelets and coagulation factors, leading to hemorrhaging.
- Thrombotic manifestations are a result of fibrin or platelet deposits in microvasculature
and include cyanosis, paralytic ileus, and kidney damage.
- Bleeding manifestations include oozing blood, upper gastrointestinal bleed, and
hematuria. The causes are numerous, including septicemia, severe trauma, and
neoplasms, and DIC may affect people at any age.
- Diagnosis is based on the presence of degradation products as detected by the D-dimer
test.
What Can Cause This in An Ob Patient?
- Abruptio Placentae
- Septic Abortion
- Pregnancy Induced Hypertension
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