Bleeding in pregnancy

Question 1

How does the pain compare to bleeding in an ectopic or miscarriage?

Answer 1

Miscarriage - bleeding > cramping

Ectopic - cramping > bleeding

Question 2

How is a miscarriage confirmed?

Answer 2

US scan

Question 3

How does a threatened miscarriage present?

Answer 3

painless vaginal bleeding occurring before 24 weeks (typically 6-9 weeks)
Bleeding is often less than menstruation

Question 4

Is the cervical os open or closed in a threatened miscarriage?

Answer 4

Closed

Question 5

What is a delayed (missed) miscarriage?

Answer 5

Gestational sac which contains a dead foetus without the symptoms of expulsion

Question 6

How do delayed (missed) miscarriages present?

Answer 6

May have light vaginal bleeding/discharge
Symptoms of pregnancy may disappear
No pain

Question 7

Is the cervical os opened or closed in a delayed (missed) miscarriage?

Answer 7

Closed

Question 8

How does an inevitable miscarriage present?

Answer 8

Heavy bleeding, clots & pain

Question 9

Is the cervical os open or closed in an inevitable miscarriage?

Answer 9

Open

Question 10

What is an incomplete miscarriage?

Answer 10

When not all the parts of pregnancy have been expelled

Question 11

How does an incomplete miscarriage present?

Answer 11

Pain & vaginal bleeding

Question 12

Is the cervical os open or closed in an incomplete miscarriage?

Answer 12

Open

Question 13

How does an ectopic pregnancy present?

Answer 13

Pain 
Bleeding (dark)
Dizziness/collapse 
Shoulder tip pain 
Peritonism 
Breathlessness

Question 14

What blood test can help to assess if a pregnancy is ectopic?

Answer 14

bHCG
In normal pregnancy will double every 48-72 hours
In ectopic pregnancy wil rise by less than 66%
In miscariage will decline

Question 15

When does implantation bleeding tend to occur?

Answer 15

About 10 ds post ovulations

Question 16

How does a molar pregnancy present on US?

Answer 16

“Snow storm” appearance +/- foetus

Question 17

How does a chorionic haematoma present?

Answer 17

Bleeding
Cramping
Threatened miscarriage

Question 18

How is chorionic haematoma treated?

Answer 18

Usually self-limited & resolves

Question 19

What is cervical ectropion and why does it present in pregnancy?

Answer 19

Larger area of columnar epithelium present at the endocervix due to increased oestrogen levels

Question 20

How does cervical ectropion present?

Answer 20

Vaginal discharge

Post coital bleeding

Question 21

How does a hydatidiform mole present?

Answer 21

Bleeding in first or early second trimester
Exaggerated symptoms of pregnancy
Larg for adtes uterus
serum bHCG very high

Question 22

How is antepartum haemorrhage defined?

Answer 22

Bleeding from the genital tract after 24 weeks gestation

Question 23

What is placental abruption?

Answer 23

Separation of a normally implanted placenta - partially or totally before the birth of the baby

Question 24

What are the risk factors for placental abruption?

Answer 24

Pre-eclampsia/hypertension 
Trauma 
Polyhydramnios 
Multiple pregnancy 
Thrombophillia 
Renal disease 
Diabetes
Smoking

Question 25

How does placental abruption present?

Answer 25

Sudden pain 
Small/large blood loss 
Uterus tender/Wooden hard 
Uterus feels large 
Difficulty feeling foetal parts

Question 26

How is placental abruption diagnosed?

Answer 26

Clinically (CTG)

Question 27

What is placenta praevia?

Answer 27

Placenta is partially or totally implanted in the lower uterine segment

Question 28

Clinical features of placenta praevia

Answer 28

Painless recurrent 3rd trimester bleeding 
Malpresentations
Uterus SNT 
High head
CTG usually normal

Question 29

How is placenta praevia diagnosed?

Answer 29

Ultrasound

Question 30

How is placent praevia managed?

Answer 30

If major (<2cm from os) = C section
If minor (>2cm from os) = consider vaginal delivery
+ Anti-D
+ Steroids (if <34 weeks)

Question 31

Why are steroids given in placenta praevia if <34 weeks?

Answer 31

To accelerate lung maturation

Question 32

What is placenta accreta?

Answer 32

When the placenta invades the myometrium

Question 33

What is placenta percreta?

Answer 33

When the placenta has invaded the myometrium and reached the serosa

Question 34

What are the major risk factos for placenta accreta 7 percreta?

Answer 34

Placenta praevia + prior c section

Question 35

How is placenta accreta treated?

Answer 35

C section at 37 weeks

Question 36

How does uterine rupture present?

Answer 36

Small/large volume of blood 
Obstructed labour 
Intra-partum loss of contractions 
Peritonism 
Haematuria 
Fetal distress

Question 37

What is vasa praevia?

Answer 37

Rare

When foetal blood vessels run close to the opening ofthe cervical os

Question 38

What foetal signis seenclasically with vasa praevia?

Answer 38

Foetal bradycardia

Question 39

How do local causes of APH present?

Answer 39

Small volume 
Painless 
Provoking factor 
Normal placenta 
Uterus SNT 
No foetal distress

Question 40

Which steroid is preferred when given to reduce neonate RDS? And when is it given?

Answer 40

Betamethasone > dexamethasone

Given 24-48hrs before delivery

Question 41

How is PPH defined?

Answer 41

> 500ml blood loss
Primary = within 24 hours
Secondary = 24 hours to 6 months

Question 42

How is the amount of blood in PPH classified?

Answer 42

Minor = <500ml
Moderate = 500-1500ml 
Severe = >1500ml

Question 43

What are the 4 T’s that cause PPH?

Answer 43

Tone (uterus fails to contract)
Trauma
Tissue (retained placenta, inverted uterus)
Thrombin

Question 44

What is the initial management of PPH?

Answer 44

Uterine massage
5 units IV syntocin
40 units syntocin in 500ml

Question 45

If PPH is persistent what is thenext steps in management?

Answer 45

Urinary catheter

500mcg Ergometrine IV

Question 46

When should Ergometrive IV be avoided?

Answer 46

Cardiac disease

Hypertension

Question 47

Where is the most common site of ectopic pregnancy?

Answer 47

Ampulla of fallopian tube