Antepartum Bleeding - Miscarriage, Ectopic, Placenta praevia, Placental abruption, Vasa previa, PPROM, Chorioamnionitis, Abortion Flashcards
Possible causes of bleeding in each trimester
1st - 1-12
-miscarriage
-hydatidiform mole
-ectopic
2nd - 13-27
-miscarriage
-hydatidiform mole
-placental abruption
3rd - 28-40
-bloody show
-placental abruption
-placental previa
-vasa previa
Miscarriage
-definition
-types
Expulsion of conception products before 24wks
-1 in 5
Threatened - cervical os closed, spotting
Missed - cervical os closed, light bleed/discharge
-gestational sac containing dead fetus before 20wks with no symptoms of expulsion
Inevitable - cervical os open, heavy bleed/clots/pain
Incomplete - cervical os open, pain and bleeds
Ectopic pregnancy
-most common locations and 3 fates
-risk factors
-presentation
-investigations
Majority tubal - ampulla, dangerous if isthmus
=> tubal abortion, absorption, rupture
Damage to tubes - PID, pelvic surgery
Past ectopic
Endo
POP
IVF
Stable => EPAGU
Unstable => ED
Positive pregnancy test, serum hCG
TVUS - see that pregnancy is not in uterus
Hydatidiform mole
-presentation
Vaginal bleeding
Uterus size greater than expected for dates
Abnormally high hCG
Snowstorm US
Placental abruption
-pathophysiology
-risk factors
-presentation
-investigations
Separation of placenta from uterine wall => maternal hemorrhage into intervening space
Increased maternal age
Multiparous
Cocaine use
Maternal trauma
PVB 24wks => can lead to shock
PAIN over uterus
Tender, tense uterus
Cannot palate fetus
Woody uterus => clinical diagnosis
FBC, coagulation, 4U cross match
U&E, LFT
CTG
Stabilise mother
Fetal distress at any point => CSection
No distress U36wks => observe, steroids
No distress 36wks+ => vaginal delivery
Fetus dead => induce vaginal delivery
Placental previa
-pathophysiology
-risk factors
-presentation
Placenta lying in lower uterine segment - most spontaneously resolve by 32wks
Multiparous
Multigravid
Past CS scar
No pain, tenderness
Small bleeds
Fetal heart normal, abnormal lie and presentation
Abdo US - 20wk anomaly scan
-f/u 32wks to identify unresolved cases
-36wks plan delivery
TVUS - more accurate
If bleeding => admit, A-E
-if unable to stabilise, labour or term => emergency CSection
Antepartum hemorrhage
-definition
-main 2 causes
24wks onwards
Abruption or previa
Spontaneous abortion
-management
1st line
Expectant - wait for 1-2wks for completion
If expectant unsuccessful or unsuitable because
Increased risk of bleeds
-late 1st trimester
-coagulopathies, can’t have transfusion
Past adverse/traumatic EXP in pregnancy
Infection
Medical
Missed miscarriage
-PO mifepristone to induce contraction
-48hrs later, misoprostol to expel products of conception
Incomplete
-1 dose misoprostol
Try before surgical
Surgical - vacuum (LA) or in theatre (GA)
Ectopic pregnancy
-presentation
6-8wks amenorrhea
Lower constant, unilateral abdo pain
Vaginal bleed
-less than normal period, dark brown
Hemodynamic instability if ruptured
Abdo tenderness
Adnexal mass - don’t examine due to rupture risk
Cervical motion tenderness
Ectopic pregnancy
-management options
Expectant - close monitoring over 48hrs
-U35mm, unruptured, asymptomatic, no heartbeat, bHCG U1000
-if BhCG increases or symptomatic => intervention
Medical - methotrexate
-U35mm, unruptured, no significant pain, no heartbeat, bHCG U1500
-only possible if patient willing to attend f/u and asymptomatic
Surgery - salpingectomy or salpingotomy
-ruptured, pain, visible fetal heartbeat, BhCG 5000
Salpingectomy - remove tube
-1st line if no other infertility risk factors
Salpingostomy - removal of ectopic
-infertility risk factors
Vasa previa
-pathophysiology
-risk factors
-presentation
-diagnosis
Blood vessels are not protected within the umbilical cord or placenta => get torn during labour/ROM
Placental previa
Multiparous
IVF
Asymptomatic
Vaginal bleeding
PPROM with blood
TVUS
Planned CSection 34-36wks with CS injection before
If vasa previa detected during labour => Emergency CSection
Preterm prelabour rupture of the membranes
-definition
-presentation
-diagnosis
-management
-complications
Before 37wks
Sudden gush/leaking of fluid
Sterile speculum - pooling of amniotic fluid in posterior vaginal wall
-if not visible, test fluid for placental alpha microglobulin 1 protein or IGF binding protein
Abdominal US - oligohydramnios
Admit, regular observations for chorioamnionitis
PO erythomycin 10 days
Antenatal CS - reduce resp distress syndrome
Consider delivering at 34wks - balance risk of chorioamnionitis and resp distress syndrome
Fetal - prematurity, infection, pulmonary hypoplasia
Maternal - chorioamnionitis
Chorioamnionitis
-pathophysiology
-risk factors
-presentation
Ascending bacterial infection of amniotic fluid, membranes, placenta
-Ecoli, GBS
PPROM
UTI, STI
Fever
Tachycardia in mother/fetus
Tender, painful uterus
Offensive vaginal discharge
High vaginal swab, amniotic fluid sample - look for bacteria
US
IV ABx
Early delivery
Pelvic, abdominal infection
Endometritis
Management of antenatal bleeding
-U6wks
-6wks+
U6wks - bleeding, no pain or risk factors for ectopic
-manage expectantly
-return if bleeding continues, pain worsens
-repeat urine pregnancy test after 7-10 days and to return if positive
-negative = miscarriage
6wks + - bleeding => refer to EPAGU for TVUS
-find pregnancy, fetal pole, heartbeat
Termination of pregnancy
-medical law
-medical options
-Rhesus D negative patients
2 registered medical practitioners must sign legal document
-can be 1 in an emergency
Must be a registered medical practitioner in an NHS hospital or licensed premise
Up to 24wks
Abortion 10wk+ => anti D prophylaxis in R-ve mothers
Medical
-Mifepristone (antiprogestogen)
-48hrs later, misoprostol (uterine contractions)
Confirm end with bHCG reading in 2wks time
Surgical (cervical priming with misoprostol +- mifepristone beforehand)
-vacuum aspriation
-dilatation and evacuation
Use intrauterine contraceptive immedietely after evacuation
