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Antepartum (UPenn) > Abnormal placentation/bleeding in pregnancy > Flashcards

Abnormal placentation/bleeding in pregnancy Flashcards

1
Q

Placenta accreda

(general definition)

A
  • “Abnormal placental attachment due to absence of decidua basalis and incomplete development of fibrinoid (Nitabuch) layer”
  • Fibrinoid tissue deposits (nitabuch) incomplete → abnormal/increased invasion of trophoblasts into decidua basalis → bound to uterus (doesn’t separate after birth)
  • One of the most serious complications of pregnancy → risk of maternal mortality
  • U/S picks up 80-90% of time with experienced sonographers
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2
Q

Name/describe 3 variations of placenta accreda

A
  • Accreda vera - adherence to myometrium
  • Increda - growth INTO the myometrium
  • Percreta - growth through uterine wall and adheres to other structures and maybe bladder/bowel (depending on where it attaches)
  • Bonus:
    • Partial accreda – placenta can being to separate (aka abrupt) → see bleeding
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3
Q

Placenta accreda

Incidence + risk factors

A
  • Incidence 1 in 533 birth,
  • Risk factors:
    • Placenta previa
    • Prior c/s or myomectomy (scar on uterus)
    • Also: increased parity, maternal age, submucosal fibroids, female fetus
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4
Q

Management/Complications of placenta accreda

A
  • Cesarean at 34-0 to 35-6
  • Risk of massive post partum hemorrhage in 2/3 patients, requiring cesarean and hysterectomy
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5
Q

Vasa previa

A
  • Fetal vessels run through the membranes over the cervix unprotected by the umbilical cord or placental tissue
  • Associated with velementous insertion but more rare.
    • 0.04-0.02% pregnancies
  • Associated low lying pregnancies, multiple gestation, resolved previa
  • Must plan cesarean before membranes rupture​
    • sometime between 34-6 to 36-0
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6
Q

Placenta previa

Definition, types

A
  • Placenta implanted very close to or over internal Os of uterus
  • Types: Complete, partial, marginal, low lying (not really a previa)
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7
Q

Risk factors for placenta previa

A
  • Advanced maternal age > 35
  • Multiparity
  • Prior cesarean section - 0.3-0.7%, higher with 1st section and goes up with each subsequent one
  • Infertility treatments
  • Smoking
  • Unexplained elevated alpha-fetoprotein (AFP)
  • Multiple gestation
  • Short interpregnancy interval
  • Prior uterine curettage
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8
Q

Main symptom of placenta previa

A
  • Painless vaginal bleeding
  • Usually self limiting and presents in late 2nd or early 3rd
    • 1st episode often stops after a few hours
    • Subsequent bleeds tend to become worse (deattachment from LUS)
  • Some may experience pain/cramping due to uterine irritibility
  • Don’t do a digital exam on someone that has painless vag bleeding who hasn’t had an ultrasound showing no previa (ie if you don’t know if they have a previa). Speculum exam is ok
  • Hard to tell if/when they might bleed again or be delivered
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9
Q

Placenta previa monitoring/management

A
  • Serial US to assess placental location and fetal growth
  • Avoidance of cervical examinations and intercourse
  • Activity restrictions
  • Counseling regarding labor symptoms and vaginal bleeding
  • Dietary and nutrient supplementation to avoid maternal anemia
  • Early medical attention if any vaginal bleeding occurs.
  • Asymptomatic (no bleeding) → expectant mgmt as long as compliant and live close to hospital
  • Bleeding previa → hospitalization/monitoring/stabilization
    • < 34 wks → steroids
  • Cesarean
  • H/H, Ferritin if chronic
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10
Q

Placental abruption

A
  • Antepartal decidual hemorrhage leading to premature separation of the placenta.
  • Often caused by rupture of maternal vessels in the decidua basalis, where it comes into contact with the anchoring villi of the placenta.
  • Bleeding is almost always maternal in origin.
  • 1% of all pregnancies
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11
Q

Placental abruption risk factors

A
  • Usually defect in maternal vessels
  • HTN (chronic, gestational, PEC), interpregnancy interval < 1 year doubles risk
  • PPROM
  • Smoking - dose dependent relationship with # cigs smoked
  • Trauma
  • Cocaine
  • Older maternal age
  • Polyhydramnios
  • Multiple gestation
  • Fibroids
  • Thrombophelias
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12
Q

Peak occurance of placental abruption

A
  • 24-26 weeks
  • Recurrence 5-17% higher with more episodes
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13
Q

Placental abruption presentation and differentials

A
  • Vary markedly → can make dx difficult
    • Acute vs chronic
    • Overt vs concealed
    • Severity
  • Hard abdomen
  • Colicky cramping pain that is on/off that makes her irritates, anxious, uncomfortable,
  • Vaginal bleeding
  • Maternal tachycardia or non-reassuring FHR
  • Grades:
    • 1, 2 (more vag bleeding),
    • 3 (severe bleeding and maternal VS changes, risk of DIC)

Differentials: previa, cervical bleeding/infection/cancer, vag trauma

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14
Q

Placental abruption potential complications

A
  • Maternal
    • Significant blood loss →
      • Shock
      • Consumptive coagulopathy
      • Renal failure
      • Death
    • Couvelaire uterus - blood seeping into the uterine musculature
    • High recurrence rate in subsequent pregnancies.
  • Fetal
  • Decreased oxygenation →
    • Cerebral compromise
    • Stillbirth.
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15
Q

Amniotic bands

A
  • Amniotic sacs folds and constricts areas of the fetus → amputation of fingers, limb, palate issues (if comes across face)
  • Can be assiciatied with miscarriage
  • Not likely to reoccur
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16
Q

Placental abruption management

A
  • Ultrasound evalutation - retroplacental clotting indications abruption
    • Normal U/S does not rule out abruption
  • CBC, Type and screen, Coags, FIbrinogen
  • IV access
  • Contonuous FHR monitoring
  • Rhogam if Rh neg (Kleihauer-Betke test to determine dose)
  • Management depends on GA and maternal and fetal statuses
    • Small abruption < 34 wks → expectant mgmt
    • At/near term → delivery (induction/augmantation ok as long as closely monitored)
  • Obstetrical emergency → REFER
17
Q

Bleeding in the 1st half of pregnancy

Etiologies

A
  • Non-pregnancy causes: cervical polyp, sex, sti’s, hemorrhoids, hematuria
  • Subchorionic bleed/hematoma - bleeding due to seperation of chorion to uterine lining. Usually self-resolve and good outcome if occurs early in 1st tri and is small
  • Fibroids - bleeding if intramural fibroid twists on its stalk or placenta implants over one. Increase risk of pregnancy loss
  • Spontaneous pregnancy loss - may manage expectantly, use misoprostol, or aspiration. Rhogam for Rh negative
  • Ectopic
  • Gestational trophoblastic disease (hydatidiform mole) - chorionic villi don’t develop properly → not viable pregnancy → normal pregnancy process turns into benign tumor, can also be malignant
18
Q

Rhogam

A
  • CHECK BLOOD TYPE the minute of a report of 1st or 2nd trimester bleeding → need to prevent isoimmunization if mother is Rh negative
    • If FOB is Rh + (D antigen) fetus can be Rh+ → any blood mixing → maternal isoimmunization → can cause hemolytic anemia in fetus/hydrops in future pregnancy → may never be able to carry Rh+ fetus again
  • Rhogam – antibodies that compete with other antibodies to bind to the D antigen → prevents mom from having a reaction to foreign antigen
  • Rhogram dosing: any dose lasts 12 weeks
    • 50 mcg = microdose given at < 12 weeks for 1st trimester.
      • Lasts for 12 weeks (needs to be redosed after 12 weeks if there is another bleed)
    • 300 mcg dose at 28 weeks
    • KB test (fetal screen) – looks at certain volume of blood – determines percentage of fetal cells – if increased give a bigger dose (ie if placenta abruption)
  • Give post partum Rhogam dose within 72 hours if baby is Rh+
  • Blood product – risk of contaminants and theoretical risk of mad-cow, More common: injection site reactions, fever, allergic reaction to IgA in rhogam
19
Q

Bleeding during second half of pregnancy

Etiologies

A
  • Placenta previa
  • Placental abruption
20
Q

Bleeding during second half of pregnancy

General managment

A
  • Review Rh status
    • Rhogam if Rh negative
    • KB test
  • Review placental location on US reports or perform US
    • Avoid digital exam unless US has r/o previa
    • Transvaginal US best
  • Assess uterine tone
  • Vital signs
  • Potential hospitalization
21
Q

Identify scope of practice for CNM/WHNP when caring for the woman with placental/fetal growth abnormalities in the third trimester

A
  • 2nd + 3rd trimester bleeding almost always abnormal → MD collaboration or referral

Antepartum (UPenn) (26 decks)

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