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Bleeding during pregnancy Flashcards

1
Q

What bleeding during pregnancy is benign?

A

Implantation bleeding
Spotting after intercourse or a pap smear
Bloody “show” during labor
Treatable infection (such as Chlamydia or vaginitis)

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2
Q

What is more serious or concerning bleeding in pregnancy? (8)

A

Spontaneous abortion (aka miscarriage)
Ectopic pregnancy
Incompetent cervix
Gestational trophoblastic disease (Molar pregnancy)
Placenta previa
Placenta abruptio (Abruption)
Preterm labor*
Uterine rupture*

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3
Q

Which trimester is bleeding more common? There is a higher chance of loss if _____ and a lower change of loss if ____

A

1st trimester and about half will result in pregnancy loss

Higher chance of loss if:
Bleeding is accompanied by pain (cramping or back pain)

Lower chance of loss (less than 10%):
Once normal FHT are documented by doppler or ultrasound

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4
Q

What is a spontaneous abortion (SAB)?

A

Expulsion of fetus prior to 20 weeks gestation or weight less than 500 grams

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5
Q

What are the causes of SAB? (8)

A

Chromosomal abnormalities (common – usually incompatible with life body will try to remove it)
uterine or cervical problems
Inherited thrombophilia
Endocrine disorders
Teratogenic drugs
Uncontrolled chronic diseases (HTN, DM, hypothyroidism)
Infections
Trauma

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6
Q

What is the patho of a SAB?

A

Embryonic death → loss of hCG → decreased progesterone & estrogen → uterine decidua sloughed off → uterus irritated and contracts → expels embryo or fetus

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7
Q

What is a threatened abortion?

A

Bleeding for unexplained reasons prior to 20 weeks, cervix is closed

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8
Q

What is an imminent abortion?

A

Going to happen just a matter of time
Bleeding, cramping, os open, membranes may rupture

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9
Q

What is an incomplete abortion?

A

Explosion of some products of conception but some are retained

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10
Q

What is a complete abortion?

A

All products of conception are expelled

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11
Q

What is a missed abortion?

A

Fetus dies but not expelled, diagnosis made by ultrasound

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12
Q

What is recurrent pregnancy loss?

A

loss of 3 or more pregnancies

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13
Q

What is the cause of septic abortion-presence in infection?

A

Usually from prolonged rupture of membranes
May be associated with IUD, illegal abortion

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14
Q

How do you diagnose a SAB?

A

Physical exam – looking at cervix (open or anything coming out)
Ultrasound – Gestational sac with embryo, size of embryo, FHT
HCG (quantitative) expected to rise at least 50% every 48-72 hours until 10 weeks when it levels out.
CBC (to check for anemia following significant blood loss)

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15
Q

If patent has a SAB what lab should be drawn? What med may need to be given?

A

Blood type and Rh
RhoGAM for Rh neg women

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16
Q

What is the treatment for a 1st trimester loss?

A

No interventions to prevent

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17
Q

What are the 3 treatment options for an inevitable loss?

A

Expectant: Watch and wait to see if tissues pass on own (safe to wait 3-4 weeks if in 1st trimester)

Medical: Mifepristone, Misoprostol (helps cervix dilate and soften and cause contractions of uterus)

Surgical: dilatation and curettage (D&C); dilatation and evacuation (D&E)

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18
Q

If patient is having heavy bleeding, cramping or s/s of infection which intervention is recommended with a inevitable SAB?

A

Surgical

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19
Q

What SE does medical management have compared to surgical management?

A

Can have more bleeding, longer time to pass all products of conception, and lower success rate than surgical treatment

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20
Q

What is D&C or D&E?

A

Mechanically dilating cervix and using an instrument or suction to remove anything from uterus

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21
Q

What is an ectopic pregnancy?

A

Implantation of fertilized egg in a site other than the endometrial lining of the uterus (most common in the fallopian tube)

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22
Q

What is the patho of an ectopic pregnancy?

A

Eggs is fertilized
Prevented or slowed progress down the tube; fails to implant in uterus
Trophoblasts grow into and through wall of tube causing internal hemorrhage – not viable fetus

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23
Q

What are the risk factors for ectopic pregnancy? (7)

A

previous ectopic
PID (pelvic inflammatory disease –> scaring)
Pelvic surgery
Endometriosis (endometrial tissue is outside of uterus)
Smoking (slows movement of cilia which helps transport of egg)
AMA (less effective cilia)
IUD (slows movement so don’t meet when either are still fertile)

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24
Q

What is the most common place for an ectopic pregnancy? Why?

A

ampullar tubal because that’s where sperm meets egg

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25
What are the s/s of ectopic pregnancy? (8)
Initially, normal pregnancy signs such as missed menses, positive pregnancy test, breast tenderness, nausea Bleeding/spotting Lower quadrant abdominal or rectal pain Fainting, dizziness Right shoulder pain Sub-diaphragmatic irritation from blood in abdomen Hypovolemic shock Slow to rise HCG, US with no IUP or mass in tube, low hemoglobin & hematocrit
26
What is the triad of symptoms for ectopic pregnancy?
Missed menses or positive pregnancy test Vaginal bleeding, spotting, brownish discharge Lower quadrant pain
27
What is the 2 treatment options for ectopic pregnancy?
Medical management with Methotrexate– IM folic acid antagonist Surgical Management done with abd incision and can be emergent situation if fallopian tube rupture
28
How does methotrexate treat an ectopic pregnancy?
prevent/inhibits growth of trophoblastic cells to stop embryo growth and reabsorbed by maternal body
29
If ectopic pregnancy is not treated right away what can it lead to?
Can lead to hemorrhage, future infertility and death Longer it occurs, increases chance of fallopian tube to rupture
30
What follow-up care should be completed with an ectopic pregnancy?
Follow up will include H&H/blood replacement and Rhogam as indicated
31
What is gestational trophoblastic disease (GTD)? Two different types?
Pathologic proliferation of trophoblastic cells and usually no embryo forms Hydatidiform mole (molar pregnancy) Choriocarcinoma
32
What are the s/s of a molar pregnancy? (8)
Vaginal Bleeding (prune colored or bright red) Uterine Enlargement (S>D) – size greater than date No fetal heart tones “Snowstorm” on US Large elevation in serum HCG Hyperemesis gravidarum (very severe n/v) Early (2nd trimester) Very early Preeclampsia Grape-like cysts coming out of the vagina
33
What are the complications of a molar pregnancy? (8)
Metastasis of cancer cells Anemia Ovarian cyst Hyperthyroidism Infection Embolization to lungs Hemorrhage Death
34
What is the treatment for a molar pregnancy?
Suction evacuation of mole ASAP Possible chemotherapy (esp. if metastasis present) with methotrexate or other chemo drugs
35
What follow up should occur for a molar pregnancy?
Chest x-ray to evaluate for metastasis Frequent hCG monitoring monthly for at least to a year and if continues to rise > probable GTD or cancer so treat with chemo
36
How long should a patient wait to get pregnant after a molar pregnancy?
No pregnancy x 6 months -1 year, as rising hCG could be potential for malignancy pregnancy and Effective contraception for year
37
What is cervical insufficiency? What is It caused by?
Painless dilation of the cervix without contractions before 16-18 weeks gestation Caused by a structural or functional defect of the cervix
38
What are the risk factors for cervical insufficiency?
Congenital (bicornuate uterus – septum down middle of uterus and may extend completely down uterus) Acquired (infection, inflammation, twins, extensive treatment of an abnormal pap smears? Hormonal (endocrine) Structural laxity of cervical collagen
39
What is the treatment of an abnormal Pap smear? Why does it increase risk for cervical insufficiency?
Cone biopsy Cone wedge section of cervix is removed so cervix doesn’t have enough structural integrity
40
What obstetric history would give you clues that there is higher cervical insufficiency?
Repetitive 2nd trimester losses especially if no pain involved Progressively early births
41
What is the treatment for cervical insufficiency?
Close surveillance with serial US cervical length checks watching for any shortener Cerclage – pursestring suture around cervix to help hold It closed to provide structure to pregnancy
42
What are the 2 reason a cerclage is placed?
Prophylactically - Done around 14-16 weeks in pregnancy Or rescue measure if cervix starts to open up or part of baby is starting to protrude. Risky as a rescue measure because could cause rupture of membranes and infection.
43
What are the 2 reasons a cerclage is removed?
If they are contracting at all then the suture will not hold the pregnancy any longer, and tissue will start to tear and bleed. The cerclage must be removed at this point At 36 weeks and mom can labor and delivery at any point after this
44
What is a placental abruption?
Premature separation of a normally implanted placenta from uterine wall
45
What is a partial abruption? What is a complete/total abruption?
Partial: Part of the placenta detaches from uterine wall Complete or total concerning: Occurs when the entire placenta detaches from uterine wall Massive bleeding and increase risk of fetal and maternal death
46
What is a marginal placental abruption? Is there visible bleeding? Why?
Separation occurs at the edge of the placental Blood passes between membranes and uterine wall Moderate to severe vaginal bleeding that is visible b/c edge is not intact against uterine wall allowing blood to pass
47
What is central placental abruption? Is there visible bleeding? Why?
Blood is trapped between placenta and uterine wall in center of placenta Concealed bleeding (little or no visible vaginal bleeding) b/c edges of placenta are holding blood in
48
What are the s/s of abruption?
Sudden onset Bleeding - Dark that is external or concealed Shock and anemia may or may not be reflective of blood lost Severe pain Tender and firm uterus to palpation Abruption pattern (tachysystole) contractions
49
What are the risk factors for abruption? 10
Smoking – vasoconstrciton Hypertensive disorders pPROM Trauma such as DV, MVA, falls Uterine over- distention (multifetal, hydramnios) AMA (>40) Cocaine/meth use High parity History of abruption Unknown
50
How does trauma cause abruption?
blunt force to abd or jarring force w/o physical impact to abd
51
How does cocaine/meth use cause abruption?
vascular disruption of placental bed, cause uterine tachysystole and HTN
52
What are the maternal complications of abruption?
Hemorrhage may result in anemia, hysterectomy, shock and death DIC (disseminated intravascular coagulation) – uses up all clotting factors trying to control hemorrhage
53
What are the fetal-neonatal complications of abruption?
Depends on degree of abruption and gestational age Preterm birth and associated complcaitions Anemia/hypovolemia Hypoxia (brain damage, neurological defects, death)
54
What is the perinatal morality r/t abruption?
Moderate abruption- 25% >50% of placenta is involved - 100%
55
What is the management of a placental abruption?
After diagnosis, plan depends on status of mother & fetus, as well as gestational age a vaginal or c-section Evaluate for symptoms of disseminated intravascular coagulation (DIC ) Correct hypovolemia and blood loss Lab tests
56
What lab tests should be done for a patient diagnosed placental abruption?
Clotting studies PT, PTT Hemoglobin/hematocrit
57
What is placenta previa?
Placenta improperly implanted in lower uterine segment When the egg implants, it implants down low in the uterus and as placental villi develop, it covered those areas. This can lead to bleeding because vili are torn from the uterine wall exposing uterine sinuses at placental site when uterus contracts
58
What are the symptoms of placenta previa?
Bright red bleeding after 20 weeks Generally painless No contractions
59
What are the risk factors of placenta previa? (9)
Multiparity, multiples AMA Placenta Accreta Prior c-section (uterine scar) Smoking Large placenta Cocaine use Non-white race Recent SAB or TAB
60
What is magical placenta previa?
when the placenta is located adjacent to, but not covering, the cervical opening.
61
What is a partial placenta previa?
when the placenta partially covers the cervical opening
62
What is complete placenta previa?
placenta completely covers the opening from the womb to the cervix.
63
What is the treatment of placenta previa depend on?
Gestational age Severity of bleeding Maternal/fetal health
64
What is the management of placenta previa?
"Pelvic rest” (no SVEs, no sex, nothing in the vagina) –WHY? Corticosteroids to mom- under 34-week, mature fetal lungs Evaluation of maternal/fetal status Monitor blood loss
65
How does mom deliver baby with placenta previa? When can you have a vaginal delivery with placenta previa?
Delivery by cesarean if partially or completely covering cervix. You can t have the cervix open up and deliver the placenta before baby is born b/c then no oxygen to baby Needs to be at least 2cm from the cervical os to be able to labor normally
66
Why does a patient with placenta previa need to be on strict pelvic rest? What does pelvic rest means?
No vaginal exam because it can cause you to poke through the placenta and worsen the situation or you can increase the separation of the chorionic villi from the uterus NO sex, no fingers, no tampon NOTHING in the vagina. SVE can cause bleeding because you accidentally tear cotyledon tissue
67
For placenta previa, you can continue expectant management until?
38 weeks
68
If a patent comes in with bright red bleeding what should you look in her records for? What Should you ask the patient? What should be avoided? What tests should be done?
Look in records for evidence of placental location (US)? If no records, ask her if her placenta is “in the right place” No SVE unless location of placenta known Ultrasound prior to SVE if no records and no sono Help determine cause (use your nursing instincts)
69
What can help you determine that cause?
Abruption vs. previa – previa is painless and not frequent hard contractions OR Is she in labor and having bloody show
70
What is the pain for abruption? What is uterine tone for abruption? What does the bleeding look like?
Painful Elevated resting tone Uterine irritability - tachysystole Taut/board like Dark red
71
What is the pain for previa? What is uterine tone for previa? What does the bleeding look like?
Painless Normal uterine tone Contractions only with labor Uterus soft Bright red
72
When is placenta previa typically diagnosed?
Usually diagnosed during routine US at 18-22 weeks if patient has not experienced bleeding prior to that

OB (16 decks)

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