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OB > Bleeding during pregnancy > Flashcards

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
Q

What are the s/s of ectopic pregnancy? (8)

A

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

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26
Q

What is the triad of symptoms for ectopic pregnancy?

A

Missed menses or positive pregnancy test
Vaginal bleeding, spotting, brownish discharge
Lower quadrant pain

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27
Q

What is the 2 treatment options for ectopic pregnancy?

A

Medical management with Methotrexate– IM folic acid antagonist

Surgical Management done with abd incision and can be emergent situation if fallopian tube rupture

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28
Q

How does methotrexate treat an ectopic pregnancy?

A

prevent/inhibits growth of trophoblastic cells to stop embryo growth and reabsorbed by maternal body

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29
Q

If ectopic pregnancy is not treated right away what can it lead to?

A

Can lead to hemorrhage, future infertility and death

Longer it occurs, increases chance of fallopian tube to rupture

30
Q

What follow-up care should be completed with an ectopic pregnancy?

A

Follow up will include H&H/blood replacement and Rhogam as indicated

31
Q

What is gestational trophoblastic disease (GTD)? Two different types?

A

Pathologic proliferation of trophoblastic cells and usually no embryo forms

Hydatidiform mole (molar pregnancy)
Choriocarcinoma

32
Q

What are the s/s of a molar pregnancy? (8)

A

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
Q

What are the complications of a molar pregnancy? (8)

A

Metastasis of cancer cells
Anemia
Ovarian cyst
Hyperthyroidism
Infection
Embolization to lungs
Hemorrhage
Death

34
Q

What is the treatment for a molar pregnancy?

A

Suction evacuation of mole ASAP
Possible chemotherapy (esp. if metastasis present) with methotrexate or other chemo drugs

35
Q

What follow up should occur for a molar pregnancy?

A

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
Q

How long should a patient wait to get pregnant after a molar pregnancy?

A

No pregnancy x 6 months -1 year, as rising hCG could be potential for malignancy pregnancy and

Effective contraception for year

37
Q

What is cervical insufficiency? What is It caused by?

A

Painless dilation of the cervix without contractions before 16-18 weeks gestation

Caused by a structural or functional defect of the cervix

38
Q

What are the risk factors for cervical insufficiency?

A

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
Q

What is the treatment of an abnormal Pap smear? Why does it increase risk for cervical insufficiency?

A

Cone biopsy
Cone wedge section of cervix is removed so cervix doesn’t have enough structural integrity

40
Q

What obstetric history would give you clues that there is higher cervical insufficiency?

A

Repetitive 2nd trimester losses especially if no pain involved
Progressively early births

41
Q

What is the treatment for cervical insufficiency?

A

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
Q

What are the 2 reason a cerclage is placed?

A

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
Q

What are the 2 reasons a cerclage is removed?

A

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
Q

What is a placental abruption?

A

Premature separation of a normally implanted placenta from uterine wall

45
Q

What is a partial abruption? What is a complete/total abruption?

A

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
Q

What is a marginal placental abruption? Is there visible bleeding? Why?

A

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
Q

What is central placental abruption? Is there visible bleeding? Why?

A

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
Q

What are the s/s of abruption?

A

Sudden onset
Bleeding- Dark that is external or concealed
Shock and anemia may or may not be reflective of blood lost
Severe pain
Tenderand firm uterus to palpation
Abruption pattern (tachysystole) contractions

49
Q

What are the risk factors for abruption? 10

A

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
Q

How does trauma cause abruption?

A

blunt force to abd or jarring force w/o physical impact to abd

51
Q

How does cocaine/meth use cause abruption?

A

vascular disruption of placental bed, cause uterine tachysystole and HTN

52
Q

What are the maternal complications of abruption?

A

Hemorrhage may result in anemia, hysterectomy, shock and death
DIC (disseminated intravascular coagulation) – uses up all clotting factors trying to control hemorrhage

53
Q

What are the fetal-neonatal complications of abruption?

A

Depends on degree of abruption and gestational age

Preterm birth and associated complcaitions
Anemia/hypovolemia
Hypoxia (brain damage, neurological defects, death)

54
Q

What is the perinatal morality r/t abruption?

A

Moderate abruption- 25%
>50% of placenta is involved - 100%

55
Q

What is the management of a placental abruption?

A

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
Q

What lab tests should be done for a patient diagnosed placental abruption?

A

Clotting studies PT, PTT
Hemoglobin/hematocrit

57
Q

What is placenta previa?

A

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
Q

What are the symptoms of placenta previa?

A

Bright red bleeding after 20 weeks
Generally painless
No contractions

59
Q

What are the risk factors of placenta previa? (9)

A

Multiparity, multiples
AMA
Placenta Accreta
Prior c-section (uterine scar)
Smoking
Large placenta
Cocaine use
Non-white race
Recent SAB or TAB

60
Q

What is magical placenta previa?

A

when the placenta is located adjacent to, but not covering, the cervical opening.

61
Q

What is a partial placenta previa?

A

when the placenta partially covers the cervical opening

62
Q

What is complete placenta previa?

A

placenta completely covers the opening from the womb to the cervix.

63
Q

What is the treatment of placenta previa depend on?

A

Gestational age
Severity of bleeding
Maternal/fetal health

64
Q

What is the management of placenta previa?

A

“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
Q

How does mom deliver baby with placenta previa? When can you have a vaginal delivery with placenta previa?

A

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
Q

Why does a patient with placenta previa need to be on strict pelvic rest? What does pelvic rest means?

A

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
Q

For placenta previa, you can continue expectant management until?

A

38 weeks

68
Q

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?

A

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
Q

What can help you determine that cause?

A

Abruption vs. previa – previa is painless and not frequent hard contractions
OR
Is she in labor and having bloody show

70
Q

What is the pain for abruption? What is uterine tone for abruption? What does the bleeding look like?

A

Painful

Elevated resting tone
Uterine irritability - tachysystole
Taut/board like

Dark red

71
Q

What is the pain for previa? What is uterine tone for previa? What does the bleeding look like?

A

Painless

Normal uterine tone
Contractions only with labor
Uterus soft

Bright red

72
Q

When is placenta previa typically diagnosed?

A

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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