OB Chapter 28

OB Chapter 28

Exam 4

Follow-Up Care

A contraceptive method should be used for at least three menstrual cycles to allow time for the woman's body to heal.

Fetal Risks from Maternal Hemorrhage:

Blood loss/anema Hypoxemia Hypoxia Anoxia Preterm birth

Placenta Previa - Treatment

Delivery if needed, if not then bed rest, with BRP, no vaginal or rectal examinations, u/s every 2 to 3 weeks and NST once a week.

Miscarriage (Spontaneous Abortion) - Late miscarriage

(second-trimester loss) between 12 and 20 weeks. Usually results from maternal causes such as: Advancing maternal age and parity Premature dilation of the cervix and other anomalies of the reproductive tract Inadequate nutrition Recreational drug use Obesity Stressful life events

Placenta Previa

*Complete placenta previa* - totally covers the internal cervical os. *Marginal placenta previa* - the edge of the placenta is seen on transvaginal ultrasound to be 2.5 cm or closer to the internal cervical os. *Low lying placenta* - when the exact relationship of the placenta to the internal cervical os has not been determined or in the case of apparent placenta previa in the second trimester.

Miscarriage (Spontaneous Abortion)

A pregnancy that ends as a result of natural causes before 20 weeks of gestation. 20 week marker is considered to be the point of viability Fetal weight less than 500 g also may be used to define an abortion.

Ectopic Pregnancy - Clinical manifestations

Abdominal pain occurs in almost every case. It begins as a dull, lower quadrant pain on one side, progress to a colicky pain when the tube stretches, to sharp, stabbing pain. It then progresses to a diffuse, constant, severe pain that is generalized throughout the lower abdomen.

Hydatidiform Mole - Management

Although most moles abort spontaneously, suction curettage offers a safe, rapid, and effective method of evacuating a hydatidiform mole if necessary. Induction of labor with oxytocic agents or prostaglandin is not recommended because of the increased risk of embolization of trophoblastic tissue. Post-evacuation administration of Rho(D) immune globulin to women who are Rh negative is necessary to prevent isoimmunization.

Hydatidiform Mole - Clinical Manifestations

Anemia from blood loss, excessive nausea and vomiting (hyperemesis gravidarum), and abdominal cramps caused by uterine distention are relatively common findings. Women may also pass vesicles, which are frequently avascular edematous villi, from the uterus.

Ectopic Pregnancy - Management

Another laboratory test: A progesterone level greater than 25 ng/ml almost always rules out the presence of an ectopic pregnancy. A progesterone level less than 5 ng/ml suggests either an ectopic pregnancy or an abnormal intrauterine pregnancy.

Miscarriage (Spontaneous Abortion) - Incidence and Etiology

Approx. 10% to 15% of all clinically recognized pregnancies in the US end in miscarriage. *Early miscarriage* is one that occurs before *12 weeks*. 50% of all clinically recognized pregnancy losses result from chromosomal abnormalities. More than 80% of miscarriages occur before 12 weeks.

Premature Separation of Placenta - Diagnosis

Approximately 60% of live fetuses exhibit abnormal (nonreassuring) FHR patterns, and elevated uterine resting tone may also be noted on the monitor tracing. Coagulopathy, as evidenced by abnormal clotting studies (fibrinogen, platelet count, partial thromboplastin time [PTT], fibrin split products), may be present if a large or complete abruption has occurred.

Incompetent Cervix (Recurrent Premature Dilation of the Cervix) - Management

Bed rest, pessaries, antibodies, antinflammatory drugs and progesterone supplementation . A cerrvical cerclage may be performed: a McDonald cerclage, a band of homologous fascia or nonabsorbable ribbon (Mersilene), may be placed around the cervix beneath the mucosa to constrict the internal os of the cervix. A cerclage procedure can be classified according to time, or whether it is elective (prophylactic), urgent, or emergent.

Antepartum Hemorrhagic Disorders

Bleeding in pregnancy jeopardizes both maternal and fetal well-being Maternal blood loss decreases oxygen-carrying capacity, increases risk for: Hypovolemia Anemia Infection Preterm labor Adversely affects oxygen delivery to fetus

Placenta Previa- Maternal and Fetal outcomes

Complication associate with placenta previa is hemorrhage. (also an abnormal placental attachment - placenta accreta, increta or perceta) all this can lead to hysterectomy

Disseminated Vascular Coagulation (DIC)

DIC is an overactivation of the clotting cascade and the fibrinolytic system, resulting in depletion of platelets and clotting factors, which results in the formation of multiple fibrin clots throughout the body's vasculature, even in the microcirculation. Blood cells are destroyed as they pass through these fibrin choked vessels. Thus DIC results in a clinical picture of clotting, bleeding, and ischemia.

Surgical Management

Depends on the location and cause of the ectopic pregnancy, the extent of tissue involvement, and the woman's desires regarding future fertility. One option is removal of the entire tube (salpingectomy). If the tube has not ruptured and the woman desires future fertility, salpingostomy may be performed instead.

Hydatidiform Mole - Clinical Manifestations

Early in pregnancy the uterus in approximately one half of affected women is significantly larger than expected from menstrual dates. The percentage of women with an excessively enlarged uterus increases as length of time since the last menstrual period increases. Approximately 25% of affected women have a uterus smaller than would be expected from menstrual dates.

Premature Separation of Placenta - Clinical Manifestations

Extensive myometrial bleeding damages the uterine muscle. If blood accumulates between the separated placenta and the uterine wall, it may produce a couvelaire uterus. The uterus appears purple or blue, rather than its usual "bubble gum pink" color, and contractility is lost. Shock may occur and is out of proportion.

Ectopic Pregnancy - Treatment

Give methotrexate to dissolve the tubal pregnancy. Methotrexate is an antimetabolite and folic acid antagonist that destroys rapidly dividing cells. The woman must be hemodynamically stable to be eligible for medical management. The best results following methotrexate therapy are usually obtained if the mass is unruptured and measures less than 3.5 cm in diameter by ultrasound, if no fetal cardiac activity is noted on ultrasound, and if the serum β-hCG level is less than 5000 milli-International Units/L.

Incompetent Cervix (Recurrent Premature Dilation of the Cervix) - Etiology

History of previous cervical lacerations during childbirth, excessive cervical dilation for curettage or biopsy, or the woman's mother's ingestion of diethylstilbestrol (DES) during pregnancy with the woman. Short cervix (less than 25 mm in length) is indicative of reduced cervical competence.

Premature Separation of Placenta - Diagnosis

Hypofibrinogenemia and evidence of DIC support the diagnosis, but many women with placental abruption do not develop coagulopathy. The diagnosis of abruption is confirmed after birth by visual inspection of the placenta. Adherent clot on the maternal surface of the placenta and depression of the underlying placental surface are usually present.

Premature Separation of Placenta - Clinical Manifestations

If cesarean birth is performed, blood clots may be noted on entry into the uterus. A blood clot often will be attached to the posterior surface of the placenta (referred to as a retroplacental clot).

Ectopic Pregnancy - Management

If internal bleeding is present, assessment may reveal vertigo, shoulder pain, hypotension, and tachycardia. A vaginal examination should be performed only once, and then with great caution. Approximately 20% of women with a tubal pregnancy have a palpable mass on examination. Rupturing the mass is possible during a bimanual examination, thus a gentle touch is critical.

Ectopic Pregnancy - Clinical manifestations

If not diagnosed until after rupture has occurred, referred shoulder pain may be present in addition to generalized, one-sided, or deep lower quadrant acute abdominal pain. Referred shoulder pain results from diaphragmatic irritation caused by blood in the peritoneal cavity.

Ectopic Pregnancy - Management

If β-hCG levels are greater than 1500 milli-International Units/ml but no intrauterine pregnancy is seen on transvaginal ultrasound, an ectopic pregnancy is very likely. β-hCG levels will probably be redrawn every 48 hours to determine if the pregnancy is viable. A transvaginal ultrasound may also be repeated to determine if the pregnancy is inside the uterus. Sometimes the location of an ectopic pregnancy will be visible on transvaginal ultrasound.

Premature Separation of Placenta - Active Management

Immediate birth is the management of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy. At least one large-bore (16- to 18-gauge) IV line should be started. Maternal vital signs are monitored frequently to observe for signs of declining hemodynamic status, such as increasing pulse rate and decreasing BP.

Placenta Previa - Incidence and Etiology

In addition to a history of previous cesarean birth, other risk factors for placenta previa include advanced maternal age (more than 35 to 40 years of age), multiparity, history of prior suction curettage, and smoking. Cigarette smoking leads to a decrease in uteroplacental oxygenation and thus a need for increased placental surface area.

Hydatidiform Mole - Clinical Manifestations

In the early stages the clinical manifestations of a complete hydatidiform mole cannot be distinguished from those of normal pregnancy. Later, vaginal bleeding occurs in almost 95% of cases. The vaginal discharge may be dark brown (resembling prune juice) or bright red and either scant or profuse. It may continue for only a few days or intermittently for weeks.

Disseminated Vascular Coagulation (DIC)

In the obstetric population, DIC is most often triggered by the release of large amounts of tissue thromboplastin, which occurs in placental abruption (the most common cause of severe consumptive coagulopathy in obstetrics) and in the retained dead fetus syndrome and the anaphylactoid syndrome of pregnancy (amniotic fluid embolus). Severe preeclampsia, HELLP syndrome, and gram-negative sepsis are examples of conditions that can trigger DIC because of widespread damage to vascular integrity.

Follow-Up Care

Includes frequent physical and pelvic examinations along with weekly measurements of the β-hCG level until the level decreases to normal and remains normal for 3 consecutive weeks. Monthly measurements are then taken for 6 months. The follow-up assessment period usually continues for a year. During that time, a rising β-hCG level and an enlarging uterus may indicate GTD.

Ectopic Pregnancy

Is a leading cause of infertility. Called tubal pregnancies because approximately 95% are located in the uterine tube. Can also occur in the abdominal cavity, on an ovary, or on the cervix. More than half (approximately 55%) are located in the ampulla, or largest portion of the tube.

Premature Separation of Placenta - Diagnosis

Is primarily a clinical diagnosis. Ultrasound can be used to rule out placenta previa, it cannot detect all cases of abruption. A retroplacental mass may be detected with ultrasonographic examination, but negative findings do not rule out a life-threatening abruption. At least 50% of abruptions cannot be identified on ultrasound.

Placenta Previa - Diagnosis

with painless bleeding after 20 weeks - ultrasound with clearly diagnosis.

Disseminated Vascular Coagulation (DIC) - Clinical Manifestations & tests

LABORATORY COAGULATION SCREENING TEST RESULTS • Platelets—decreased • Fibrinogen—decreased • Factor V (proaccelerin)—decreased • Factor VIII (antihemolytic factor)—decreased • Prothrombin time—prolonged • Partial prothrombin time—prolonged • Fibrin degradation products—increased • D-dimer test (specific fibrin degradation fragment)—increased • Red blood smear—fragmented red blood cells

Premature Separation of Placenta - Active Management

Labor induction or augmentation may be initiated so long as the mother and fetus are closely monitored for any evidence of compromise. Cesarean birth should be reserved for cases of fetal distress or other obstetric complications. Cesarean birth should not be attempted when the women has severe and uncorrected coagulopathy because it can result in uncontrollable bleeding.

Premature Separation of Placenta - Expectant Management

Management depends on the severity of blood loss and fetal maturity and status. If the fetus is less than 34 weeks of gestation and both the woman and fetus are stable, expectant management can be implemented. The woman is monitored closely because the abruption may extend at any time. The fetus will be regularly assessed for evidence of appropriate growth, because there is risk for IUGR. In addition, assessments of fetal well-being (e.g., NST and BPP) are performed regularly. Corticosteroids will be given to accelerate fetal lung maturity.

Premature Separation of Placenta - Clinical Manifestations

May be partial or complete Bleeding from the placental site may dissect (separate) the membranes from the decidua basalis and flow out through the vagina (70% to 80%), it may remain concealed (retroplacental hemorrhage) (10% to 20%), or both. Symptoms vary with degree of separation.

Ectopic Pregnancy - Clinical manifestations

May exhibit signs of shock, such as faintness and dizziness, related to the amount of bleeding in the abdominal cavity and not necessarily related to obvious vaginal bleeding. An ecchymotic blueness around the umbilicus (Cullen sign), indicating hematoperitoneum, may also develop in an undiagnosed, ruptured intraabdominal ectopic pregnancy.

Disseminated Vascular Coagulation (DIC) - Management

Medical management in all cases of DIC involves correction of the underlying cause (e.g., removal of the dead fetus, treatment of existing infection or of preeclampsia or eclampsia, or removal of an abrupted placenta). Volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters are the usual forms of treatment. Vitamin K administration and recombinant activated factor VIIa may be considered as additional therapies.

Placenta Previa - Clinical Manifestations

Mom can lose up to 40% of her blood volume without showing signs of shock. Decrease in urinary output may be better indicators of the acute blood loss than the vital signs. Abdominal exam will reveal soft, relaxed non tender uterus with normal tone, usually fetal presentation is breech or oblique is common.

Ectopic Pregnancy - Clinical manifestations

Most cases are diagnosed before rupture based on the three most classic symptoms: (1) abdominal pain (2) delayed menses (3) abnormal vaginal bleeding (spotting) that occurs approx 6 to 8 weeks after the last normal menstrual period.

Clotting Disorders - Normal Clotting

Normally a delicate balance (homeostasis) exists between the opposing hemostatic and fibrinolytic systems. The hemostatic system is involved in the life-saving process. This system stops the flow of blood from injured vessels, in part through the formation of insoluble fibrin, which acts as a hemostatic platelet plug. The phases of the coagulation process involve an interaction of the coagulation factors in which each factor sequentially activates the factor next in line, the "cascade effect" sequence. The fibrinolytic system is the process through which the fibrin is split into fibrinolytic degradation products and circulation is restored.

NI

Nursing interventions include assessment for signs of bleeding and signs of complications from the administration of blood and blood products, administering fluid or blood replacement as ordered, cardiac and hemodynamic monitoring, and protecting the woman from injury. Because renal failure is one consequence of DIC, urinary output is closely monitored by using an indwelling catheter. Urinary output must be maintained at more than 30 ml/hr. If DIC develops before birth, continuous electronic fetal monitoring is necessary. The woman should be maintained in a side-lying tilt to maximize blood flow to the uterus. Oxygen may be administered through a nonrebreather face mask at 8 to 10 L/min or per hospital protocol or physician order. DIC usually is "cured" with the birth and as coagulation abnormalities resolve.

Disseminated Vascular Coagulation (DIC) - Clinical Manifestations & tests

POSSIBLE PHYSICAL EXAMINATION FINDINGS • Spontaneous bleeding from gums, nose • Oozing, excessive bleeding from venipuncture site, intravenous access site, or site of insertion of urinary catheter • Petechiae, for example, on the arm where blood pressure cuff was placed • Other signs of bruising • Hematuria • Gastrointestinal bleeding • Tachycardia • Diaphoresis

Premature Separation of Placenta - Diagnosis

Placental abruption should be highly suspected in the woman who experiences a sudden onset of intense, usually localized, uterine pain, with or without vaginal bleeding. Initial assessment is much the same as for placenta previa. Physical examination usually reveals abdominal pain, uterine tenderness, and contractions. The fundal height may be measured over time because an increasing fundal height indicates concealed bleeding.

Miscarriage (Spontaneous Abortion) - Incidence and Etiology

Possible causes: Endocrine imbalance (as in women who have luteal phase defects or insulin-dependent diabetes mellitus with high blood glucose levels in the first trimester) Immunologic factors (e.g., antiphospholipid antibodies) Systemic disorders (e.g., lupus erythematosus) Genetic factors Varicella infection in the first trimester increase risk of spontaneous abortions.

Hydatidiform Mole - Clinical Manifestations

Preeclampsia occurs in approximately 70% of women and occurs earlier than usual in the pregnancy. If preeclampsia is diagnosed before 24 weeks of gestation, hydatidiform mole should be suspected and ruled out. Hyperthyroidism is another serious complication of hydatidiform mole. Usually treatment of the hydatidiform mole restores thyroid function to normal. Partial moles cause few of these symptoms and may be mistaken for an incomplete or missed miscarriage.

Miscarriage - Medical Management

Prostaglandin medication -misoprostol (cytotec) may be given orally or vaginally and is usually effective in completing the miscarriage within 7 days.

Incompetent Cervix (Recurrent Premature Dilation of the Cervix) - Diagnosis

Reduce cervical competence is the diagnosis and is seen on ultrasound, it can be accompanied by cervical funneling (breaking) or effacement of the internal os.

Ectopic Pregnancy - Management

The most important screening tools for ectopic pregnancy are quantitative β-hCG levels and transvaginal ultrasound examination. When β-hCG levels are greater than 1500 to 2000 milli-International Units/ml, a normal intrauterine pregnancy should be visible on transvaginal ultrasound.

Clinical Manifestations

S/S depend on the duration of pregnancy. Uterine bleeding, uterine contractions, or abdominal pain is an ominous sign during early pregnancy,must be considered a *threatened miscarriage* until proven otherwise. Before the wk 6 may report a heavy menstrual flow. Between wks 6 and 12 moderate discomfort and blood loss. After wk 12 more severe pain, similar to that of labor, because the fetus must be expelled. Diagnosis of the type of miscarriage is based on the s/s.

Premature Separation of Placenta - Active Management

Serial laboratory studies include hematocrit or hemoglobin determinations and clotting studies. Continuous EFM is mandatory. An indwelling catheter is inserted for continuous assessment of urine output, an excellent indirect measure of maternal organ perfusion. Blood and fluid volume replacement may be necessary, along with administering blood products to correct any coagulation defects. Vaginal birth is usually feasible and is desirable, especially in cases of fetal death.

Ectopic Pregnancy

The chance of fetal survival in an abdominal pregnancy depends on gestational age at birth. The risk for fetal deformity in an abdominal pregnancy is high as a result of pressure deformities

Maternal, Fetal, and Neonatal Outcomes

The perinatal mortality rate approaches 20-30% for abruptio placentae; this condition remains a leading cause of maternal death. Maternal complications are associated with the abruption or its treatment. Hemorrhage, hypovolemic shock, hypofibrinogenemia, and thrombocytopenia are associated with severe abruption.

Nursing Alert

The woman on methotrexate therapy who drinks alcohol and takes vitamins containing folic acid (such as prenatal vitamins) increases her risk of having side effects of the drug or exacerbating the ectopic rupture.

Types of Miscarriages

Threatened Inevitable Incomplete Complete Missed All types of miscarriage can recur in subsequent pregnancies; all types except the threatened miscarriage can lead to infection.

Nursing Alert

To avoid confusion in regard to rising levels of hCG that are normal in pregnancy but could indicate GTD, pregnancy should be avoided during the follow-up assessment period. Any contraceptive method except an IUD is acceptable. Oral contraceptives are preferred because they are highly effective.

Hydatidiform Mole - Diagnosis

Transvaginal ultrasound and serum hCG levels are used for diagnosis. Transvaginal ultrasound is the most accurate tool for diagnosing a hydatidiform mole.

Ectopic Pregnancy - Clinical manifestations

Up to 90% of women with an ectopic pregnancy report a period that is delayed 1 to 2 weeks or is lighter than usual, or an irregular period. Mild to moderate dark red or brown intermittent vaginal bleeding occurs in up to 80% of women.

Miscarriage - Care Management

Vaginal bleeding early in pregnancy, requires a thorough assessment. Evaluation of hCG is used in the diagnosis of pregnancy and pregnancy loss along with progesterone.

Premature Separation of Placenta - Clinical Manifestations

Vaginal bleeding, abdominal pain, and uterine tenderness and contractions. Bleeding may result in maternal hypovolemia (i.e., shock, oliguria, anuria) and coagulopathy. Mild to severe uterine hypertonicity is present. Pain is mild to severe and localized over one region of the uterus or diffuse over the uterus with a boardlike abdomen.

S/S of Complete Miscarriage

all fetal tissue is passed, the cervix is closed, and there may be slight bleeding. Mild uterine cramping may be present.

Premature Separation of Placenta

also termed *abruptio placentae*, is the detachment of part or all of the placenta from its implantation site. Separation occurs in the area of the decidua basalis after 20 weeks of pregnancy and before the birth of the baby.

Missed Miscarriage

a pregnancy in which the fetus has died, but the products of conception are retained in utero for up to several weeks. It may be diagnosed by ultrasonic examination after the uterus stops increasing in size or even decreases in size. No bleeding or cramping may be present, and the cervical os remains closed.

Habitual Miscarriage or Recurrent spontaneous abortion (RSA)

is three or more consecutive pregnancy losses before 20 weeks of gestation. May be related to chromosomal abnormalities.

Early Pregnancy Bleeding

common bleeding disorders of early pregnancy include: Miscarriage (Spontaneous abortion) Premature dilations of the cervix (incompetent cervix) Ectopic pregnancy Hydatifdiform mole (molar pregnancy)

Incompetent Cervix (Recurrent Premature Dilation of the Cervix)

defined as passive and painless dilation of the cervix during the second trimester.

Miscarriage - Medical Management

depends on the classification of the miscarriage and on s/s. Threatened miscarriages have been managed with bed rest and supportive care. Follow-up treatment depends on whether the threatened miscarriage progresses to actual miscarriage, or symptoms subside and the pregnancy remains intact.

Hydatidiform mole (molar pregnancy)

is a benign proliferative growth of the placental trophoblast in which the chorionic villi develop into edematous, cystic, avascular transparent vesicles that hang in a grapelike cluster.

Hydatidiform Mole

is a gestational trophoblastic disease. *Gestational trophoblastic disease (GTD)* is a group of pregnancy-related trophoblastic proliferative disorders without a viable fetus. In addition to hydatidiform mole, GTD includes invasive mole, gestational choriocarcinoma, placental site trophoblastic tumor, and gestational trophoblastic neoplasia (GTN).

Premature Separation of Placenta - Incidence and Etiology

is a serious event that accounts for significant maternal and fetal morbidity and mortality. *Maternal hypertension* is probably the most consistently identified risk factor for abruption. *Cocaine* use is also a risk factor because of the hypertensive state it can cause. *Blunt external abdominal trauma* is an increasingly significant cause of placental abruption.

Miscarriage - Medial Management - Dilation and Curettage (D&C)

is a surgical procedure in which the cervix is dilated and a curette is inserted to scrape the uterine walls and remove uterine contents. Commonly performed to treat inevitable and incomplete miscarriage. Intravenous (IV) oxytocin is given afterwards to prevent hemorrhage. (methergine (ERGOT) product may be given or HEMABATE if oxytocin does not work.

Ectopic Pregnancy

is classified according to site of implantation (e.g., tubal, ovarian, or abdominal). Only approx 5% of abdominal pregnancies reach viability. Surgery to remove the embryo or fetus is usually performed as soon as an abdominal pregnancy is identified, because of the high risk for hemorrhage at any time during the pregnancy.

Placenta Previa - Incidence and Etiology

is more likely to occur in women with multiple gestations because of the larger placental area associated with these pregnancies. Women who had placenta previa in a previous pregnancy are more likely than others to develop the problem in a subsequent pregnancy, perhaps as a result of a genetic predisposition. Previous cesarean birth and curettage in the past for miscarriage or induced abortion are risk factors for placenta previa because both result in endometrial damage and uterine scarring.

Ectopic Pregnancy

is one in which the fertilized ovum is implanted outside the uterine cavity. 2% of all first-trimester pregnancies in the US are ectopic, and these account for 9% of all pregnancy-related maternal deaths. Women are less likely to have a successful subsequent pregnancy after an ectopic pregnancy.

Incompetent Cervix - Prophylactic Cerclage

is placed at 11 to 15 weeks of gestation, after which the woman is told to refrain from intercourse. She is monitored with ultrasound scans to assess for cervical shortening and funneling. The cerclage is electively removed (usually an office or a clinic procedure) when the woman reaches 37 wks, or it may be left in place and a cesarean birth performed.

Hydatidiform Mole

may be further categorized as a complete or partial mole. *Complete mole* results from fertilization of an egg in which the nucleus has been lost or inactivated. *Partial mole* is an arrangement that occurs as a result of two sperm fertilizing an apparently normal ovum.

Tocolytics

may be given prophylactically to prevent uterine contractions and further dilation of the cervix.

S/S of Inevitable/incomplete Miscarriage

moderate to heavy amount of bleeding with an open cervical os. Tissue may be present with the bleeding. Mild to severe uterine cramping may be present. *Inevitable miscarriage* is often accompanied by rupture of membranes (ROM) and cervical dilation; passage of the products of conception will occur. *Incomplete miscarriage* involves the expulsion of the fetus with retention of the placenta.

Disseminated Vascular Coagulation (DIC)

or consumptive coagulopathy, is a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both, and clotting. DIC is never a primary diagnosis. Instead it results from some problem that triggered the clotting cascade, either extrinsically, by the release of large amounts of tissue thromboplastin, or intrinsically, by widespread damage to vascular integrity.

S/S of Threatened Miscarriage

spotting but with the cervical os closed. Mild uterine cramping may be present.

Placenta Previa

the placenta is implanted in the lower uterine segment such that is completely or partially covers the cervix or is close enough to the cervix to cause bleeding when the cervix dilates or the lower uterine segment effaces. Near or over the internal cervical os.

Placenta Previa - Clinical Manifestations

typically characterized by painless bright red vaginal bleeding during the second or third trimester. Most cases are diagnosed by ultrasound before significant vaginal bleeding occurs.