ATI/ OB | Hemorrhagic Complications

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Early Pregnancy Bleeding Disorders

• Spontaneous Abortion (Miscarriage): Ends up to 26% of pregnancies, mostly due to fetal chromosomal anomalies. Management includes expectant waiting, medical expulsion using misoprostol or mifepristone, or procedural evacuation via suction curettage.
• Ectopic Pregnancy: An embryo implants outside the uterus, most commonly in the fallopian tubes. A ruptured ectopic pregnancy is a life-threatening emergency due to high hemorrhage risk. It presents with vaginal bleeding and sharp abdominal pain. Treatment requires methotrexate (for stable cases) or surgery (salpingectomy).
• Molar Pregnancy: Abnormal trophoblastic/placental growth without a normal viable embryo. It presents with severely elevated hCG levels and "prune juice" appearing bleeding. Patients must undergo serial hCG monitoring and avoid pregnancy post-surgery to ensure the tissue does not develop into gestational trophoblastic neoplasia (cancer).

Mid-to-Late Pregnancy Complications

• Cervical Insufficiency: Painless cervical dilation causing mid-trimester pregnancy loss. Treated with progesterone or a surgical cervical cerclage (placed around 13-14 weeks and removed at 36-37 weeks).
• Placenta Previa: The placenta implants near or completely covers the internal cervical os. It famously presents as painless vaginal bleeding in the second half of pregnancy. Crucial Nursing Rule: Never perform a digital vaginal exam on these clients, as it can puncture the placenta and cause catastrophic hemorrhage. Treatment typically requires planned cesarean birth.
• Placental Abruption: Premature separation of the placenta from the uterine wall. It presents with sudden bleeding, severe abdominal pain, and a rigid, board-like abdomen. This is a massive medical emergency causing fetal hypoxia and maternal shock, frequently requiring an urgent emergency cesarean birth.

Clotting Disorders in Pregnancy

• Pregnancy induces a prothrombotic (hypercoagulable) state, drastically increasing the risk for deep vein thrombosis (DVT) and pulmonary embolism (PE).
• Disorders include inherited thrombophilias (e.g., Factor V Leiden) and acquired conditions like Antiphospholipid Syndrome (APS), which can cause recurrent miscarriages.
• Treatment primarily involves anticoagulation with Low Molecular Weight Heparin (LMWH). While these clients are prone to clots, the required anticoagulants place them at a high risk for postpartum hemorrhage, demanding vigilant postpartum monitoring.

Core Nursing Priorities for All Conditions

• Hemodynamic Stabilization: Monitor vital signs closely for hypovolemic shock (tachycardia, hypotension), measure strict intake and output by weighing pads to quantify blood loss, and establish large-bore IV access for fluid resuscitation and blood transfusions.
• Fetal Monitoring: Continuously assess fetal heart tones for nonreassuring patterns indicating hypoxia.
• Alloimmunization Prevention: Administer Rho(D) immune globulin to all Rh-negative clients experiencing bleeding or pregnancy loss to protect future pregnancies.