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Bleeding during late pregnancy, Nursing Care, :, . - Coggle Diagram
Bleeding during late pregnancy
1.Placenta Previa
Pathophysiology:
Placental implantation in the lower uterine segment → vascularization of the cervix → bleeding when the cervix dilates or the lower uterine segment stretches.
Clinical Presentation:
Signs
General Signs:
Pallor, tachycardia, tachypnea, hypotension, cold sweat.
Abdomin Signs
Uterus: Lax, non-tender, appropriate size for gestational age.
Malpresentation (breech, transverse lie).
Presenting part not engaged.
Symptoms
Vaginal Bleeding
Painless, bright red, recurrent.
May be triggered by exercise, vaginal exams, or coitus.
Symptoms of Blood Loss:
Fatigue, palpitations, weakness, anemia, fainting, shock.
Risk Factors:
Lifestyle Factors
Maternal smoking.
Cocaine use.
Reproductive History:
Previous induced abortions.
High gravidity and parity.
Demographics:
Advanced maternal age (>35 years).
Male fetus.
Uterine Scarring:
Previous cesarean sections (risk increases with number).
Uterine surgeries (e.g., myomectomy).
Management
Severe Hemorrhage
Immediate delivery (cesarean section).
Volume resuscitation (IV fluids, blood transfusion).
Laboring Patient:
Cesarean section unless marginal previa (vaginal delivery possible with precautions).
Stable Patient (Preterm):
Hospitalization or home care if bleeding stops.
Avoid vaginal exams and uterine stimulation.
Administer corticosteroids for fetal lung maturity if <34 weeks.
Types(grades)
Incomplete Central Placenta Previa:
Placenta partially covers the internal os when the cervix is closed or partially dilated.
Complete central placenta previa
Placenta completely covers the internal os, even when fully dilated.
Marginal Placenta Previa
Placenta reaches the edge of the internal os but does not cover it.
Nursing Care:
Monitoring:
Bleeding, pain, uterine contractions, fetal heart rate (FHR).
Interventions
Bed rest with bathroom privileges.
No vaginal exams.
Large-bore IV access for fluid/blood transfusion.
Two units of cross-matched blood on standby.
supportive care
Emotional support and patient education.
Social services for financial/travel assistance.
Skin care and hygiene for bedridden patients.
Discharge Instructions:
Return for contractions, bleeding, or reduced fetal movement.
Definition:
Abnormal implantation of the placenta in the lower uterine segment, covering or reaching the internal os.
Diagnosis:
Transabdominal Ultrasound (TAUS):
Initial screening tool.
Transvaginal Ultrasound (TVUS): Gold standard for diagnosis and determines placenta location and relation to the internal os.
Gold standard for diagnosis.
Determines placental location and relationship to the internal os
MRI:
Used if ultrasound findings are inconclusive.
2.Abruptio Placentae (Placental Abruption)
Definition:
Premature separation of a normally implanted placenta from the uterine wall.
Causes:
Hypertension:
Most common cause (e.g., preeclampsia, chronic hypertension)
Trauma:
Direct abdominal trauma (e.g., car accidents, falls).
Uterine Factors:
Rapid uterine decompression (e.g., hydramnios, multiple gestations).
Uterine malformations or fibroids.
Cocaine use and smoking.
Thrombophilia Disorders:
Increased risk of vascular disruption.
History:
Previous abruptions (25% recurrence risk).
Pathophysiology:
Hemorrhage into the decidua basalis → placental separation → compromised uteroplacental circulation → fetal hypoxia
Types
Revealed Hemorrhage:
Blood expelled through the cervix
Concealed Hemorrhage:
Blood retained inside the uterus.
Combined (Mixed) Hemorrhage:
Some blood retained, some expelled.
Clinical Presentation:
Revealed Abruption:
Vaginal bleeding (dark red, clotted).
Signs of blood loss (pallor, tachycardia, hypotension).
Mild abdominal discomfort.
Uterus: Normal size, lax between contractions.
Fetal parts easily felt; FHR present if <50% separation
Concealed Abruption:
Sudden, severe abdominal pain.
Shock (pallor, irritability, hypotension).
Abdomen: Tender, rigid, enlarged uterus.
No vaginal bleeding.
No fetal movement or FHR.
Combined Abruption:
Mixed symptoms of revealed and concealed types.
Diagnosis:
Clinical Evaluation:
History, symptoms, and physical examination
Ultrasound:
May show retroplacental hematoma (but can be normal in early stag
Laboratory Tests:
CBC, coagulation profile (DIC screening), Kleihauer-Betke test (fetal-maternal hemorrhage)
Complications:
Maternal:
Disseminated intravascular coagulation (DIC).
Acute renal failure.
Anemia, sepsis, shock.
Fetal/Neonatal:
Preterm birth, anemia, respiratory distress syndrome (RDS).
Perinatal mortality (20-35%).
Fetal hypoxia.
Management:
Stable Patient (Preterm):
Expectant management with close monitoring.
Tocolytic agents to stop contractions if needed.
Administer corticosteroids for fetal lung maturity if <34 weeks.
Acute Hemorrhage:
Immediate delivery (cesarean section).
Volume resuscitation (IV fluids, blood transfusion).
Oxygen therapy.
Intrauterine Fetal Death:
Induce delivery after maternal stabilization.
Nursing Care
Interventions:
Continuous fetal monitoring for viable fetus.
Large-bore IV access for fluid/blood replacement.
Foley catheter for hourly intake/output measurement.
Supportive Care:
Pain relief and emotional support.
Educate patient and family about condition and plan of care.
Grief support for fetal/neonatal death.
Assessment:
Vaginal bleeding (pad count if ongoing).
Uterine tenderness, rigidity, fundal height.
Vital signs for hypovolemic shock.
:
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