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Reproductive System > Bleeding in Pregnancy > Flashcards

Bleeding in Pregnancy Flashcards

1
Q

What is the differential diagnosis for bleeding in early pregnancy?

A 
Miscarriage
Ectopic pregnancy
Molar pregnancy
Cervial lesions
Unknown
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2
Q

Define miscarriage

A

Expulsion of the conceptus before week 24

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3
Q

List the different classifications of miscarriage

A 
Threatened
Inevitable
Complete
Incomplete
Missed
Septic
(Recurrent)
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4
Q

What is meant by “threatened miscarriage”?

A

There is some vaginal bleeding but the cervix remains closed, and the pregnancy is still viable.

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5
Q

What is meant by “inevitable miscarriage?”. How does the presentation differ to that of a threatened miscarriage?

A

The pregnancy is still viable at this stage, however, the cervix has begun to dilate; this process is irreversible and means that there will be a miscarriage.
Presents with heavier bleeding and abdominal pain.

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6
Q

Describe a “complete miscarriage”

A

All of the uterine content has been expelled; the cervix is now closed and bleeding has stopped

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7
Q

Describe an “incomplete miscarriage”

A

Some of the uterine content has been expelled but some tissue remains; e.g. chorionic and/or placental tissue. The cervix is still open.

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8
Q

What risks are associated with an incomplete miscarriage?

A

Sepsis

Bleeding (could lead to hypovolaemia and shock)

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9
Q

What are the management options for a patient with an incomplete miscarriage?

A

Uterus must be evacuated;
Medical evacuation: prostaglandins
Surgical evacuation: Manual Vacuum Aspiration (MVA) or Evacuation of Retained Products of Conception (ERPC)

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10
Q

What is meant by a “missed miscarriage”? What would be seen on ultrasound?

A

The pregnancy is non-viable, but the cervix is still closed and the uterine content has not been expelled.
On USS: an empty gestational sac or foetal pole with no heartbeat.

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11
Q

Describe the management of a patient with a septic miscarriage.

A

Broad-spectrum antibiotics
Emergency evacuation of the uterus
Monitor for signs of sepsis and septic shock

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12
Q

List the main causes of spontaneous miscarriage

A

Abnormal conceptus (chromosomal, genetic or structural abnormality)
Uterine abnormality (congenital or due to fibroids)
Cervical incompetence
Maternal (e.g. increasing age, diabetes)
Unknown

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13
Q

What is meant by cervical incompetence?

A

Cervix begins to dilate before the pregnancy has reached term.

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14
Q

Give four risk factors for ectopic pregnancy

A

Pelvic inflammatory disease (e.g. due to Chlamydia)
Previous tubal surgery
Previous ectopic pregnancy
Assisted conception

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15
Q

What is an ectopic pregnancy?

A

The conceptus implants anywhere outside of the uterine cavity

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16
Q

Describe the difference in typical presentations of miscarriage vs ectopic pregnancy

A

Miscarriage tends to have heavier bleeding whereas in ectopic pregnancy the main symptom tends to be abdominal pain

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17
Q

Describe how B-hCG level can be used to assess whether a patient is likely to have an ectopic pregnancy

A

Take paired B-hCG samples 48 hours apart:

  • normal pregnancy: level will double
  • miscarriage: level will fall
  • ectopic pregnancy: level will rise slightly
18
Q

Describe how a patient with an ectopic pregnancy may present

A 
Period of amenorrhoea (may or may not have a positive pregnancy test)
May also have:
 - lower abdominal pain
 - vaginal bleeding
 - GI/urinary symptoms
19
Q

Describe the management options for an ectopic pregnancy

A

Medical: methotrexate
Surgical: salpingectomy/salpingotomy
Conservative management

20
Q

What is a molar pregnancy? How does it form?

A

Large chorionic villi with overgrowth of trophoblast cells.

Forms when two sperm enter and fertilise an empty ovum. (there are other causes but this is most common)

21
Q

Explain how a molar pregnancy develops

A

Two sperm enter and fertilise one ovum.
- the conceptus has a normal number of chromosomes but two lots of methylated genes from Dad and none from Mum; there is an imbalace.
Mum’s methylated genes promote early baby growth, whereas Dad’s methylated genes promote trophoblast proliferation (placental growth)
Therefore, in molar pregnancy, trophoblasts overproliferate but no fetus forms.

22
Q

What is the major (but rare) risk of molar pregnancy

A

Development of choriocarcinoma

23
Q

How is a molar pregnancy managed?

A

If B-hCG returns to normal, no treatment is needed

If B-hCG stays high, treat with methotrexate (to evacuate the uterus)

24
Q

Describe the differential diagnosis fo bleeding in late pregnancy

A 
Local bleeding (from vulva, vagina or cervix)
Blood dyscrasias
Placenta previa
Placental abruption
Placenta accreta
Uterine rupture
Vasa previa
25
Q

What neonatal morbidities can be caused by prematurity?

A 
Respiratory distress syndrome
Intraventricular haemorrhage
Cerebral palsy
Malnutrition
Temperature control problems
Jaundice
Infections
Visual impairment
Hearing loss
26
Q

What is placenta previa?

A

Where all or part of the placenta implants in the lower uterine segment. Graded 1-4 depending on how much of the internal cervical os is obscured by the placenta.

27
Q

What are the risk factors for placenta previa?

A 
Smoking
Multiparity
Multi pregnancy
Previous C-section
Increasing maternal age
Previous placenta previa
28
Q

Describe the presentation of placenta previa

A

Might be found incidentally on USS

Fresh, painless PV bleeding - due to separation of the placenta as the cervix effaces
Malpresentation and high fetal head

29
Q

What is placental abruption?

A

Where the placenta partially separates from the uterus wall; bleeding comes from behind the placenta.

30
Q

What are the major risks of placental abruption?

A

Life-threatening blood loss; bleeding can be apparent (PV) or concealed (blood collects between the placenta and the uterine wall).
Couvelaire Uterus; bleeding penetrates into the uterine myometrium and peritoneal cavity.

31
Q

How would a major placental abruption present?

A

Constant abdominal pain
Woody-hard, tender uterus
Signs of shock
Signs of fetal distress

32
Q

What are the potential complications of placental abruption?

A

Death
Hypoxic/ischaemic encephalopathy in the fetus
Disseminated IV coagulopathy (DIC) in the mother

33
Q

What are the risk factors for placental abruption?

A 
Multiparity (major risk factor)
Pre-eclampsia
Increasing maternal age
Infection
Polyhydramnios
Smoking, drug misuse (cocaine)
Trauma
Multi pregnancy
34
Q

What is placenta accreta?

A

Where the placenta grows too deeply into the uterine wall

35
Q

What is the most common cause (in the UK) of uterine rupture?

A

Rupture of C-section scar

36
Q

What is Vasa Previa?

A

Where the baby’s uterine vessels cross over/near the uterine opening; these vessels are unsupported and so are at risk of rupture.

37
Q

Which types of miscarriage present with an open cervical os?

A

Inevitable miscarriage

Incomplete miscarriage

38
Q

Which types of miscarriage present with a closed cervical os?

A

Complete miscarriage

Missed miscarriage

39
Q

If an empty uterus is seen on USS after a positive pregnancy test, what are the possible explanations?

A

Very early intrauterine pregnancy
Complete (/missed) miscarriage
Ectopic pregnancy

40
Q

What are US features are definitive indicators of a (viable) intrauterine pregnancy?

A

Intrauterine gestational sac
Fetal pole
Yolk sac
(Fetal heartbeat = viable pregnancy)

41
Q

What investigations should be done if a woman has recurrent miscarriages (3 or more consecutive miscarriages)?

A

Karyotype of both partners
Lupus anticoagulant
Anticardiolipin antibodies
Thrombophilia screen

Reproductive System (22 decks)

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