Bleeding in pregnancy Flashcards by Christina Wilson

What is the definition of spontaneous miscarriage?

Expulsion or removal of the products of conception prior to 24 weeks of gestation

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What is the most common cause of bleeding in early pregnancy?

Spontaneous miscarriage

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What is threatened miscarriage?

When bleeding and occasionally abdominal pain occurs but the pregnancy continues

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What is incomplete miscarriage?

A miscarriage has occurred but some of the tissue remains in the uterus and the cervix is open POC (products of conception) may be present in cervix

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How does incomplete miscarriage present?

Lower abdominal bleeding

Heavy vaginal bleeding with clots/tissues

Shock

Tenderness

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What is the difference between incomplete miscarriage and inevitable miscarriage?

Fetal heartbeat is present in inevitable miscarriage, not incomplete miscarriage

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How can you tell if a miscarriage is complete?

Bleeding has ceased

Cervix closed

Fetal heartbeat negative

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What is septic miscarriage?

Infection following a miscarriage

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What is the most common cause of miscarriage in early pregnancy?

Chromosomal abnormalities

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What is the name given to this uterine abnormality?

Bicornuate nucleus or “heart-shaped uterus”

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What is a bicornuate uterus and how does it occur?

A uterus composed of two “horns” separated by a septum

Occurs during embryogenesis, when the fusing of the paramesonephric ducts is altered, preventing fusion of the upper part of the uterus

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What other embryological development abnormality is commonly associated with uterine development abnormalities?

Renal

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What is the treatment for threatened miscarriage?

Reassurance and rest

Avoid intercourse

Remove IUCD if present

Aspirin, heparin or prednisolone for APLS after 1st trimester

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What is the treatment for inevitable miscarriage?

Allow uterus to evacuate itself or use oxytocin

Pain relief

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What is the treatment for incomplete miscarriage?

Blood transfusions for shock

Oxytocin

Removal of POC if still present

Evacuation of uterus

Bimanual compression

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When are miscarriages defined as recurrent?

3 or more consecutive occasions

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What is the probability of having a live baby when recurrent miscarriages have occured?

40-50%

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What investigations should be carried out for recurrent miscarriages?

Karyotyping of both parents

Glucose tolerance test, T4, TSH

Hysteroscopy, hysterosalpingogram, laparoscopy, intravenous pyelogram

What is ectopic pregnancy?

Implantation of the conceptus outside the uterine cavity

What is the recurrence rate for ectopic pregnancy?

10-15%

What are some of the predisposing factors to ectopic pregnancy?

Chlamydial or gonoccocal salpingitis

Previous tubal surgery

Endometriosis

IUCD

Previous tubal ligation

What are the symptoms of ectopic pregnancy?

Amenorrhoea

Lower abdominal pain

Vaginal bleeding

Shock and syncope

Abdominal guarding and rigidness

What are the possible outcomes of ectopic pregnancy?

Tubal abortion

Tubal rupture

What is antepartum haemorrhage?

Bleeding from the genital tract after 24 weeks gestation

What is placental abruption?

Separation of a normally implanted placenta, partially or totally before birth of the fetus

Where should be placenta be implanted normally?

In the upper segment of the uterus

What are the causes of placental abruption?

Preeclampsia Hypertension Trauma (car accidents, domestic violence) Smoking Cocaine Amphetamine Medical causes (thrombophilias, renal disease, diabetes) Polyhydramnios – sudden rupture of membrane by negative pressure Multiple pregnancy Preterm-PROM Abnormal placenta

What is polyhydramnios?

Too much amniotic fluid surrounding the fetus

What is the rate of recurrence with placental abruption?

10% if 1 previous abruption 25% if two previous abruptions

What is utero-placental apoplexy?

The uterus will become blotchy and bruised following abruption as blood from abruption goes into myometrium

What are the clinical features of placental abruption?

- blood loss - pain, - ‘wooden-hard’ consistency of uterus - uterus feels larger - difficulty feeling fetal parts

Why is ultrasound done in placental abruption even though diagnosis is clinical?

To excluse placenta previa

What is placenta previa?

A condition in which the uterus implants in the lower segment of the uterus, below the presenting part

How is placenta previa classified?

What are the risk factors for placenta previa?

Previous caesarean section Multiparity Multiple pregnancy

Does placenta previa cause painful bleeding?

What are the features of placenta previa?

- blood loss - painless - may have recurrent bleeding - soft uterus - fetus easy to palpate - high presenting part - head not engaged - malpresentation i.e. breech or transverse lie - CTG - usually no fetal distress

Why should vaginal exam never be performed in vaginal bleeding?

If placenta previa, VE can cause massive, fatal haemorrhage

What happens in vasa previa?

Fetal blood vessels implant into the placenta in a way that covers the internal os of the uterus

What is the risk in vasa previa?

Fetal vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue

What is the management for placenta previa?

- admit to ward - IV access - blood tests: FBC, coagulation screen - cross match - rescan after interval - anti-D - steroids - caesarean section at 38 weeks - deliver sooner if significant haemorrhage

Why are steroids given before delivery?

Reduces chance of neonatal respiratory distress by 50% if given 24-48h before delivery

What is the treatment for placental abruption?

- admit - IV access - blood tests: FBC, coagulation screen - cross match - resuscitate / Manage DIC - deliver viable baby - C/S versus Vaginal - call pediatrician - stillbirth: vaginal delivery - anti-D - steroids if expectant management