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Third Trimester Bleeding

Teri Campbell RNFlight NurseUniversity of Chicago Aeromedical Network

You Must Fear Anything ThatCan Bleed That Much and

LIVE!

Objectives• Identify normal physiologic hemodynamic changes in pregnancy

• Discuss the assessment and care of placenta previa

• Review the assessment and care of placenta abruptio

• Identify hemorrhage risks associated with maternal trauma

• Discuss DIC considerations for the pregnant patient

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Cardiovascular

• Blood- volume- coagulation factors- fibrinogen

• Vital Signs

• Heart Sounds

Reproductive

• Uterus: intrabdominal

• Increased vascularity

800cc !

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Third Trimester Bleeding

• Placenta Abruptio

• Placenta Previa

Third Trimester Bleeding

Placenta Previa

• Types- Complete- Partial- Low lying

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Placenta Previa

• Initiation of the bleed• Reoccurrence

Placenta Previa

• Presentation- Usually bright red blood- Usually painless

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Placenta Previa

No Vaginal Exams!

Third Trimester Bleeding

Treatment / Management

• Assess bleeding objectively

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Third Trimester Bleeding

• Monitor fetus for tachycardia

• Assess for signs of shock

• IVF bolus’

• Assess for contractions

Chicken or the Egg?

• Bleeding causes contractions…

• Contractions cause bleeding…

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Third Trimester Bleeding

Abruptio Placenta

• Definition

• Types

• Causes

Third Trimester Bleeding

Abruptio Placenta

• Presentation- Acute pain- Tetanic contractions- Usually dark red, painful bleeding- Shock- * Board-like abdomen

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Third Trimester Bleeding

Abruptio Placenta

• Management- Check for vaginal bleeding

- Save chux pads- IVF bolus’- Left lateral tilt- Delivery

The Mama Trauma

• Blunt

• Penetrating

• Burns

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The Mama Trauma…complications

• Abruptio• liver laceration• spleen rupture• pelvic fractures • fetal skull fractures / other fetal insults

I’m all choked up…• Pulmonary emboli

• Virchow’s Triad…for a green piece of pie?

• ↑ BMI = ↑ risk of DVT

• Prolonged immobilization

• Prevention

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Trauma complications

• Uterine rupture

Post mortum assessment

Maternal / Fetal Assessment

• A,B,C’s• Positioning• R/O hypovolemia vs IVCS

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Maternal / Fetal assessment

• Palpate the uterus• Fundal height assessment

Fundal Height• Gross estimation of fetal age

• Tenderness? Firm? UC’s?

• FM?

• Mark it with a sharpie

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They need the “red stuff”

• Lots and lots of it

• PRBCs, FFP and Cryo

• ↑ risk of DIC

• Petechia (B/P cuff, periorbital)

• Oozing sites

• Red top (test)

Pregnancy Hemostasis

Hypercoaguable state

Protective mechanism developed in the placenta to protect mother from

hemorrhage after delivery

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DIC Made Easy!Long Name?...NEVER GOOD!

Disseminated:

Intravascular:

Coagulation:

“Disorganized”

Occurs within the vascular bed

Clot formation and clot lysing

Intrinsic and Extrinsic Pathways

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Keep It Simple

Intrinsic and Extrinsic Pathway

Intrinsic: Initiated by blood vessel damage

Extrinsic: Initiated by tissue damage

PTT

PT

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Clotting Pathology (A), (B), (C)

(A): Precipitating event (i.e. sepsis, abruption)

releases excessive amount of Thrombin

Initiates both the intrinsic and extrinsic pathways. ↑Thrombin→Fibrinogen→Fibrin

= ↑ CLOTS

innumerable clots clog microcirculation leading to hypoxia and tissue ischemia

Clotting Pathology (B) and (C)

(B): Injured platelets and RBC’s release

Phospholipids. Potent clotting factorsthat causes even more clots!

(C): Decreased clearing ability of the

reticuloendothelial system

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Consumptive Coagulopathy

(A): ↑ Thrombin release leading to increasedclot production. Occluding microcirculation.

(B): Injured blood cells release phospholipids,

potent clotting factors.

(C): ↓ clearing ability of the reticuloendothelialsystem.

When all the clotting factors have been consumed…

A+ B +C= CONSUMPTIVE COAGULOPATHY

DIC Pathophysiology

DIC is a positive feedback system where

CLOTTING is the problems and

HEMORRHAGEis the finding

PROBLEM: Excessive Thrombin affects both COAGULATION

as well asFIBRINOLYSIS

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Second Half of DIC…

HEMORRHAGESimultaneous initiation of the fibrinolytic system.

FIBRINOLYSIS→lyses→CLOT→resulting in→FSP’S AND FDP’S

FSP and FDP’s: Potent anticoagulants

Fibrinolysis + FSP anticoagulants + consumed clot factors

=Hemorrhage and rapid exsanguination

Mommy! Make it go AWAY

• Delivery

• Blood Productsmay run out

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Blood Products

PRBC’S: Indication: need to increase blood volume & clotting factors. Each unit increases HgB by 1g/dl & the Hct by 3%

Platelets:Indication: Need to increase platelet # or function.Usually given for platelet count of ↓ 50K if bleeding & ↓ 20K if not bleeding. Each unit raises platelets by 5,000-8,000 / unit.

Blood Products

Cryoprecipitate:Indications: Decreased fibrinogen. Each unit contains 200mg of fibrinogen.

Fresh Frozen Plasma (FFP):Indications: Need for clotting factors as well as volume expanders.

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Call the OR!

Possible hysterectomy

Pre-hospital / Inter-facility transfer

DLABOOH !

FLABOOH!

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Her Emergency not YOURS

In Conclusion….

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Wrapping It All Up

• Fix underlying problem…..?• Maternal compensatory mechanism• Objective EBL• Low threshold for blood products• Early assessment of DIC

Questions???

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Third Trimester Bleeding

Teri Campbell RNFlight NurseUniversity of Chicago Aeromedical Network

You Must Fear Anything ThatCan Bleed That Much and

LIVE!