Bleeding in Pregnancy Flashcards
What is considered “early pregnancy”
<24 weeks
What 4 main infections put pregnant woman at risk of miscarriage
- Cytomegalovirus (CMV)
- Rubella
- Toxoplasmosis
- Liseria
In miscarriage is the bleeding usually greater than the pain or the pain greater than the bleeding?
Bleeding > pain
What is a complication of miscarriage
Cervical shock
What conditions can cause recurrent miscarriages
- Antiphospholipid Syndrome
- Thrombophilia
- Balanced translocation
- Uterine abnormality
Where is the most common place to get an ectopic pregnancy
Ampullary
Where is referred pain during an ectopic pregnancy sometimes felt?
Shoulder-tip pain
What drug is used in the medical management of ectopic pregnancy?
Methotrexate
Histologically, placental tissue shows chorionic villi swollen with fluid giving picture of “grape like clusters”. What does this indicate?
Molar pregnancy
What is the difference between incomplete and complete molar pregnancies
Complete = egg without DNA + 1 or 2 sperm (paternal contribution only)
Incomplete = haploid egg + o 1 sperm (reduplicating DNA material) or 2 sperms fertilising egg, result in triploidy (69XXY)
Which of the 2 types of molar pregnancies may also include a fetus?
Incomplete
What does a complete molar pregnancy look like on ultrasound?
A snowstorm appearance
What cancer does molar pregnancy put you more at risk of?
Choriocarcinoma
What is the definition of an antepartum haemorrhage?
Bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour
What test should be given to RhD negative women who present with antepartum haemorrhage
Kleihauer test - to quantify fetomaternal
haemorrhage in order to gauge the dose of anti-D immunoglobulin required
What drug should be given to babies between 24-34 weeks at risk of preterm birth
Corticosteroids
What is the definition of placental abruption?
Separation of a normally implanted placenta before the birth of the fetus
What are the risk factors for placental abruption?
- Pre-eclampsia/ Hypertension
- Trauma
- Smoking/Cocaine/Amphetamine
- Medical Thrombophilias/Renal diseases/Diabetes
- Poly-hydramnios
- Multiple pregnancy
- Premature rupture of membranes (PROM)
- Abnormal placenta
- Previous Abruption = recurrence 10%
How does the uterus feel in placental abruption?
Woody hard uterus
How do you diagnose placental abruption?
It’s a clinical diagnosis - you don’t have time to look for the clot that caused the vasospasm/rupture
What are the risk factors for placental praevia?
- Previous c-section
- Smoking
- Assisted reproduction
- Previous TOP
- Multiparity
- > 40 years
- Multiple pregnancy
- Deficient endometrium (uterine scar, endometritis etc)
What does the placenta cover in placental praevia?
The internal os
What other cause of antepartum haemorrhage is associated with placental praevia?
Placenta accreta
What examination should you not do in placental praevia?
Vaginal examination
What is the difference between placenta accreta, placenta increta and placenta percreta?
Accreta = placenta adherent to uterine wall
Increta = placenta invading myometrium
Percreta = placenta penetrating to uterus and bladder
What are the risk factors for placenta accreta?
- Placenta praevia
- Multiple c-sections
What are the risk factors for uterine rupture?
- Previous c-section / uterine surgery
- Multiparity
- Use of prostaglandins/ syntocinon
- Obstructed labour
Describe briefly the pathophysiology behind placental abruption
Vasospasm causes arteriole rupture. Blood escapes under placental and into myometrium which causes contraction and interruption of placental circulation. Baby becomes hypoxic
Describe the pain of placental abruption
Severe and continuous (labour pain is intermittent)
If a placenta is posterior and placental abruption occurs, what symptom may be present that would not be present with an anterior placenta
Backache
If a patient presents with severe continous abdominal pain and a woody hard uterus but only minimal bleeding, what would you be concerned about?
That it is placental abruption but the bleeding is concealed
What would the CTG show during placental abruption?
Abnormal fetal heart and irritable uterus
A complication of placental abruption is a couvelaire uterus. Describe this
A haematoma bruised uterus - a life-threatening condition in which placental abruption causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity
How severe is the painless bleeding in placenta praevia?
Any severity from spotting to severe
Bleeding in placenta praevia is usually unprovoked. What is the one thing that is likely to provoke it?
Penetrative vaginal sex
If a woman with placenta praevia is not bleeding, what is the management?
- No sex
- Corticosteroids between 34+0 and 35+6 weeks
- Mg SO4 for neuro-protection at 24-32 weeks
- Delivery via planned c-section at 36-37 weeks
If a woman with placenta praevia is bleeding, what is the management?
- Conservative management if stable / ABCDE
- Anaemia prevention / treatment
- Steroids and magnesium sulphate
- • Delivery – 34+0 to 36+6 weeks
What drug can be used to conservatively manage placenta accreta?
Methotrexate
What is the last resort if bleeding from placenta accreta cannot be controlled?
Caesarean hysterectomy
Where can the pain be felt in uterine rupture?
Severe abdominal pain +/- shoulder-tip pain
What will a CTG show during uterine rupture?
Loss of contractions and fetal distress
What happens to the presenting part in uterine rupture?
It rises
What treatment should be given to RhD negative women who present with antepartum haemorrhage
ABCDE + anti-D + steroids
What drug can be used to conservatively manage ectopic pregnancies?
Methotrexate
What is implantation bleeding?
bleeding from fertilised egg when it implants in the uterine wall at around 10 days post ovulation
What is a chorionic haematoma?
Pooling of blood between endometrium and the embryo due to separation
What is the treatment of chorionic haematoma?
Surveillance - usually self-limiting
What is a complication of chorionic haematoma?
Miscarriage
What is vasa previa?
Unprotected fetal vessels traverse the membranes below the presenting part over the internal cervical os
What are the symptoms of vasa previa?
Waters breaking + sudden dark read bleeding and fetal bradycardia
What is the mortality rate of vasa previa?
60%
What are the 4 Ts of PPH?
- Tone
- Trauma
- Tissue
- Thrombin
What is the timeline of primary vs secondary PPH?
Primary = within 24hrs of delivery Secondary = 6 weeks post delivery
What uteri-tonic agents can be given in uterine atony causing PPH
Syntocinon, misoprostol, ergometrine (not in cardiac disease)
