Bleeding in Pregnancy Flashcards
what are the 3 trimesters of pregnancy cut of
1st Trimester –completes @ 12 weeks
2nd trimester – completes @ 28 weeks
3rd trimester – completes @ 40 weeks
what is bleeding in early pregnancy defined as
bleeding in 1st trimester
what is the marker looked for in a pregnancy test
hCG
what can cause bleeding in early pregnancy
Implantation bleeding
Chorionic haematoma
Cervical causes:
- Infection, Malignancy, Polyp
Vaginal causes:
- Infection, Malignancy (rare)
Unrelated : Haematuria, PR bleeding etc.
bleeding in early pregnancy is very rare - true or false
false
- common problem, seen in about 20%
what are Sx of a miscarriage
Postive UPT
Varied gestation
Bleeding (MORE than cramping)
Period-like cramps
Ix of miscarriage
USS
- confirms if pregnancy in situ, process of explosion or empty uterus
Speculum exam
- if os closed (threatened), products are sited at open os (inevitable) or in vagina (complete)
what are the types of miscarriages
threatened miscarriage inevitable miscarriage incomplete miscarriage complete miscarriage early fetal demise
what is early fetal demise
pregnancy in-situ, no heartbeat
mean sac diameter > 25mm
what is the general meaning of all the types of miscarriage
threatened - risk to pregnancy but the pregnancy continues
inevitable - pregnancy can’t be saved
incomplete - part of pregnancy lost already
complete - all of pregnancy lost, uterus is empty
what is ectopic pregnancy
implantation out with uterus
- common site fallopian tube
- other site; ovary, peritoneum, liver, cervix
presentation of an ectopic pregnancy
Pain > bleeding
[pain may seem out of proportion with bleeding]
dizziness/collapse/shoulder tip pain
SOB
what are the findings of ectopic pregnancy
Pallor, hemodynamic instability, signs of peritonism, guarding & tenderness.
how is management of ectopic pregnancies decided
per presentation
Mx of ectopic pregnancies
acutely unwell - surgery
stable, low levels of hCG - medical
what is a molar pregnancy
non-viable fertilized egg implants in the uterus and will fail to come to term
what is the appearance of a molar pregnancy
Overgrowth of placental tissue with chorionic villi swollen with fluid giving picture of “grape like clusters”.
what are the types of molar pregnancy
complete
partial
what is the risk of a complete mole
2.5% risk of developing into Choriocarcinoma
what is the features of a complete mole
Egg without DNA
1 or 2 sperms fertilise, result in diploidy ( paternal contribution only)
no fetus
overgrowth of placental tissue
what is the features of a partial mole
Haploid egg
1 sperm ( reduplicating DNA material) or 2 sperms fertilising egg, result in triploidy
may have fetus
overgrowth of placental tissue
molar pregnancy presentation
hyperemesis
Varied bleeding and passage of “grapelike tissue”
Fundus > dates.
Occasional shortness of breath
what can be seen on USS in a molar pregnancy
“snow storm appearance” +/- fetus
what is implantation bleeding
Fertilised egg when implants into the uterine wall.
Timing is about 10 days post-ovulation
Bleeding is light/brownish and limited > occasionally mistaken as period
Mx of implantation bleeding
watchful waiting
what is Chorionic Haematoma
Pooling of blood between endometrium and the embryo due to separation
Sx of Chorionic Haematoma
Bleeding, cramping, threatened miscarriage
Mx of Chorionic Haematoma
self limiting
resolve eventually
what can happen in Chorionic Haematoma if it is a large haematoma
infection, irritability ( causing cramping) and miscarriage
what infections in the vagina can cause bleeding in early pregnancy
Trichomoniasis ( strawberry vagina)
Bacterial vaginosis
Chlamydia
what is the definition of bleeding in early pregnancy and bleeding in late pregnancy
early < 24 weeks
late > 24 weeks
what are causes of antepartum haemorrhage [i.e. bleeding in late pregnancy]
Placenta previa
Placental Abruption
Local causes – polyps,
Cancer, Infection
Vasa previa – rare
Uterine rupture
what is placental abruption
part of the placenta becomes detached from the uterus
risk factors for abruption
pre-eclampsia/HTN trauma smoking/cocaine/amphetamine renal disease/DM poly-hydramnios multiple pregnancy
what does a placental abruption cause
post partum haemorrhage
DIC
Couvelaire uterus
fetal/maternal death
Sx of placental abruption
painful
uterine tenderness/wooden hard
uterus feels larger
difficult to feel fetal parts
how is a diagnosis of placental abruption made
purely clinical
[not ultrasound]
what is placenta previa
placenta partially or totally implanted in the lower uterine segment
how is placenta previa classified
major (anything over cervix) or minor (anywhere else not covering cervix) on ultrasound
Sx of placenta previa
painless, recurrent 3rd trimester bleeding
uterus soft non tender
Malpresentations – Breech/Transverse/Oblique
High head
CTG usually normal
Ix of placenta previa
ultrasound
[check anomaly scan]
Mx of placenta previa
Major degrees of placenta praevia (< 2cm from os
/covering os) > C-Section
Minor degrees of placenta praevia (>2cm from os) consider vaginal delivery
what is placenta accreta
Placenta invades myometrium
what is placenta accreta associated with
severe bleeding
PPH
risk factors for placenta accreta
placenta praevia & prior caesarean delivery.
what are most uterine ruptures caused by
c-sections
what is vasa praevia
blood vessels within the placenta or the umbilical cord that are trapped between the foetus and the opening to the birth canal
why is vasa praevia worrying
can cause fetal death due to blood loss
what are Sx that would make you think that the cause of APH is local
Small volume Painless Provoking factor Uterus soft, non tender No fetal distress
Tx of placenta praevia
Admit and gain IV access
Blood tests/cross match
12mg Betamethasone IM
Delivery
why are steroids given
promote fetal lung surfactant production
decrease risk of neonatal RDS
what steroid is preffered
Betamethasone
what drugs can be given to delay delivery of the baby by a short period
tocolysis
Tx of vasa praevia
C-Section
Tx of placenta accreta
hysterectomy
what is definition of post partum haemorrhage
the loss of more than 500 ml of blood within the first 24 hours following childbirth
what are complications of PPH
Maternal fatigue feeding difficulties prolonged hospital stay delayed lactation pituitary infarction transfusion haemorrhagic shock DIC death
what is the definition of secondary post partum haemorrhage
blood loss of >500ml more than 24hours after childbirth and before 6 weeks
how is PPH classified
Minor PPH <500ml
Moderate PPH 500 - 1500ml
Major PPH = >1500ml
what is the 4 T’s that cause PPH
Tone
Trauma
Tissue
Thrombin
what are risk factors for PPH
anaemia previous c-section placenta praevia, accreta previous PPH or retained placenta Multiple pregnancy
prolonged labour
retained placenta
Initial Mx of PPH
Uterine massage
5 units iv Syntocinon stat
40 units Syntocinon in 500ml Hartmanns - 125 ml/h
Mx of persistent PPH
Urinary Catheter
500 micrograms Ergometrine IV
Non-surgery - packs&balloons, factor VIIa, arterial embolisation
Surgery - uterine artery ligation, hysterectomy
