Bleeding In Late Preg

Question 1

-What is late preg
- causes
- dd

Answer 1

• 24:40
• • obs causes ( commen~> less commen)
• abruption
• placenta previa
• vasa previa

•
Gynecological
- vaginal erosion, lesion : as bleeding after sexual intercourse
- bengin or malignant tumour

•
Systemic or general
- anticoagulant as heparin , clexane
- itp
- htn uncontrolled

Dd
Urinary tract bleeding: in severe uti or renal stone

Rectal bleeding: in bleeding piles

Question 2

Placenta previa
- incidence
- def
- risk factor
- moa
- types

Answer 2

• 2nd most common
• abnormally implanted in lus
  1- previous previa
  2- + cs : proportion to it especially deeply invaded previa
  3- + placental size as in gdm, multifetal
  4- + age , parity
  5- malpresentation
• stretching of lus ( shearing between placenta , lus ) that nay be

• gradully ~>mild reccurent bleeding at 3rd tri
• sudden ~> severe bleeding

• Grade 1 : lateralis ~> > 2cm from os
  Grade 2 : marginalis ~> < 2cm
  Grade 3 : incomplete centralis ~> partially covering cervix
  Grade 4 : complete ~> completely covering

Question 3

Placenta previa
- cp
- comp

Answer 3

• sym : RECUURENT PAINLESS CAUSELESS bleeding
• general sign : anemia or hypovolemic shock
• abd sign :
  fl= amenorrhea
  No tender ut
  Malpresetations breech or transverse
• pv : CONTRA UNTIL PREVIA IS EXCLUDED ( not tvs )
• 1- hge
  2- postpartum hge : due to acqired vascularity on lus by placenta , placental fragments
  3- PAS (4)
  1-
  • acreta : adherent to myometrium with plane of cleavage
  • increta : invasion to myometrium and short of serosa
  • percreta : invasion of myometrium , serosa, othr organs as ub ~> HEMATOURIA

2- diagnosis generally
• us is the gold standard ~> no plane
3- diagnosis on labor
Part of placenta is retained
4- management
Classical cs with hysterectomy increta, percreta
افتح من فوق بالطول اطلع البيبي اقفل واقوم شايلة كل الرحم مينفعش من تحت في invasion

4- fetal comp : + morbidity, mortality due to iugr, massive blood loss

5- increased risk of cs hysterectomy

Question 4

Previa
- inv
- management

Answer 4

-us : to exclude accidental , know type of previa

• TAS/TVS : is the best to determine type of previa due to best measure of distance between os , placenta

Maternal : cbc , liver , kidney, coagulation progile

Fetal : nst , bpt , ua doppler velocimetry studies, amniotic fluid index

Management
*
Termination if
• reached maturity
• labor pain
• maternal or fetal comp

*Otherwise conservative with steroid to acclerate fetal lung maturity

*Termination by cs except lateralis

*Shock manage
*Comp ttt

Question 5

Placenta abruption
- incidence
- def
- risk factors
- moa
- types

Answer 5

• the commenst of both ante and intrapartum
• normally implanted
• • pih
  • trauma
  • ROM with polyhydrominos
  • smoking
  • APS
• In pih : blood ~> inbetween myometrium dissecting it ~> tender hard ut ~> couvelaire( concealed) ~> atong pphge

In trauma ~> normal soft cervix , myometrium) ( revealed )

Types : revealed ( margin) ~>the commenst

         Concealed ( center ~> retroplacental hge) 
         ~>Least common but most serious 

         Mixed ~> 2nd most common

Question 6

Accidental
- cp
- comp

Answer 6

Sym : abd pain with bleeding except in concealed
Genral sign : shock ( hypotension masked by raised bp that soon become hypotension)

Abd : TENDER UT , fl > amenorrhea in concealed
Pv is contra until exclusion

• 1-dic : due to thromboplastin from fetal tissue , massive hematoma ( hypofubringrnmia)
  3- couvlaire : in concealed due to retroplacental hge dissecting ut ~> bruise like lesion ~> failure of ut contra , atony
  3- sheehan syndrome ( acute necrosis of pituitary gland ) due to severe bleeding
  4- HELLP
  5- hge
  6- fetal comp : + morbidity, mortality due to iugr, iufd

Question 7

Accidental
- inv
- management

Answer 7

• us : diagnosis of abruption
• speculum : to exclude gynecological ( vaginal erosion ) if abnormal
  -Maternal : cbc , liver , kidney, coagulation progile

Fetal : nst , bpt , ua doppler velocimetry studies, amniotic fluid index

Management
*Termination if
• reached maturity
• labor pain
• maternal or fetal comp
* Otherwise conservative with steroid to accelerate fetal lung maturity
* termination by vd unless severe bleeding or cs indications
* shock management
* comp ttt

Question 8

When tender ut

Answer 8

• accidental hge
• adenomyosis
• septic abortion

Question 9

What is placental migration

Answer 9

• before 24 w , placenta may migrate on lus but with lus development a relative upward migration occurs with resolution

Question 10

Vasa previa

Answer 10

(5)
- very rare
- fetal origin
- occur when umbilical cord vessels criss over the internal os as in velamentous insertion of cord or bilobed placenta
- during labor ~> progressive dilation of cervix ~> ruptue , bleeding
- emergency cs