Bleeding In Pregnancy + Ectopic Flashcards
covers c section, abortions, miscarriage and ectopics
What are the main causes of vaginal bleeding in late pregnancy?
Placenta Previa,
Placental Abruption,
Ruptured Vasa Previa,
Uterine rupture
These four causes are considered life-threatening.
What is the classification of Placenta Previa?
Low Lying: 2-3cm from os
Marginal: encroaching, not covering
Complete: Covering entire os
Low lying is very common in early pregnancy and may resolve; marginal encroaches on cervix; complete covers the cervix.
What are the risk factors for Placenta Previa?
Previous C/S,
Previous placenta previa,
Multiparity,
Advanced maternal age,
Smoking,
Fibroids in lower uterine segment
Previous surgical scars on the uterus are significant risk factors.
What are the consequences of Placenta Previa?
'’POMP’’
Maternal hemorrhage
Operative delivery
Premature baby
Placenta accreta/increta/percreta
These complications arise due to the placenta’s abnormal position.
What is a ‘Sentinel bleed’ in the context of Placenta Previa?
First bleed that stops, warning of a larger bleed to come
This can indicate a serious condition developing.
What should NEVER be done when assessing a woman with bleeding and suspected Placenta Previa?
Assess cervical dilation with vaginal exam
This should only be done once the placenta’s position is confirmed.
How would you assess someone with a bleed in pregnancy?
Hx + clinical exam + vitals: SFH, determine fetal lie and presentation, auscultation
Speculum exam - assess appearance of cervix
Investigation:
FBC, blood type and crossmatch, Rh status, coagulation tests
TVUS
How to manage a bleed due to Placenta Previa in late pregnancy?
ACBD - STAP
ABCD + vitals + clinical exam + Speculum Exam
CTG if after 28 weeks
Consider steroids + tocolysis: (Dexamethasone 12mg x 2 doses 12 hours apart IM or beclamethasone 12mg x 2 doses 24 hours apart IM. )
Analgesia: Pethidine or paracetamol
Plan for delivery: C/S @ 37 weeks
What is the hallmark symptom of Placental Abruption?
Pain
Pain can vary from mild cramping to severe abdominal pain.
What are the risk factors for Placental Abruption?
A - Abruption previously
BP - HTN or pre eclampsia
R - Ruptured membranes
U - Uterine injury like trauma
P - Polyhydramnios
T - Twins for multiple gestation
I - infection like chorioamnionitis
N - Narcotic use (cocaine or smoking)
These factors can significantly increase the risk of abruption.
What are the complications associated with Placental Abruption?
Prematurity,
Growth restriction,
Stillbirth,
Bloody amniotic fluid
DIC
Retroplacental clot
Complications can also include retroplacental clot.
What are the causes of Uterine Rupture?
Previous C/S incision, uterine curettage, inappropriate oxytocin use, trauma
These are the most common causes leading to uterine rupture.
Risk factors for uterine rupture (FAG-POP)
Fetal Anomaly / Congenital uterine anomaly
Adenomyosis
GTN
Prev uterine surgery
Overdistension of uterus
Placenta Increta / Percreta
Complications of uterine rupture?
Maternal:
Hemorrhage leading to anemia
Bladder rupture
Hysterectomy
Death
Fetal: RDS
death
Clinical features of someone with uterine rupture
Pain
Bleeding
Cessation of contractions
Maternal tachy and hypotension
Investigate with TVUS or MRI
Fetal HR
How to manage placental abruption?
Stabilise using ABCD for Mum and fetus + IV cannulla
Take bloods: FBC/Coag Screen/Cross-match for 4 units of blood
Give fluids, replace blood
Expedite delivery - amniotomy
Prep for neonatal resuscitation (umbilical IV catheter for fluid of transfusion)
If DIC, give platelets, FFP, factor 8
What are the major risks associated with C-sections?
Bleeding, infection, hysterectomy, bladder injury, bowel involvement, future risk of APH/Stillbirth
Other risks include hypoglycemia and TTN (transient tachypnea of the newborn).
What is the definition of Spontaneous Abortion?
Involuntary loss of pregnancy during the first 20 weeks
This is commonly referred to as miscarriage.
Define vasa previa
Fetal blood vessels cover the cervical os - rarest cause of hemorrhage. Caused by low lying placenta
Causes/Differentials of bleeding in first trimester?
'’STEM-C’’
Spontaneous abortion
Trophoblastic Disease
Ectopic pregnancy
Miscarriage / Molar
Cervical polyps, cervicitis, cancer
How would you assess someone with a bleed in early pregnancy
ABCDE approach
History
Clinical Exam - Abdo, bimanual, speculum
Investigations - FBC, group and cross match, urinary bHCG, TVUS
What labs would you do for first trimester bleed?
Quantitative bHCG, 2 measurements 2-3 days apart and it should double
Falling or plateauing levels = Bad
Progesterone: >25 = intrauterine pregnancy
<5 = poor outcome possible
When is an US indicated in first trimester?
Miscarriage
Molar or ectopic pregnancy
Vaginal bleeding
Uterine abnormality
Maternal pelvic mass
CVS procedures
Dating
Define Blighted Ovum
No embryo but sac and placenta present
Risk factors for misscarriage
Uterine anomalies: fibroids, incompetent cervix
Lifestyle: Smoking, alcohol, cocaine, infection (i.e. parvovirus or flu)
Define miscarriage
Spontaneous loss of pregnancy prior to viability <24 weeks.
Clinical features of miscarriage
Lower abdo pain, cramps, back ache
products of conception passed
How would you assess a miscarriage?
Clinical Hx and abdo exam
Speculum: cervical dilation
Bimanual exam: Uterine size and adnexal tenderness, rule out ectopic pregnancy
US: Large yolk sac, no fetal hr
How would you treat miscarriage?
Analgesia
Anti-emetics
Misoprostol vaginally (causes contraction and evacuation)
How would you surgically manage a a miscarriage?
Evacuation of retained products of conception (ERPC) under general anaesthetic.
What characterizes an Ectopic Pregnancy?
Pregnancy occurring outside the uterus, often in the fallopian tube
It is a leading cause of maternal mortality if not diagnosed early.
How might an ectopic pregnancy present?
Pelvic pain + positive pregnancy test have ectopic pregnancy until proven otherwise.
If rupture: Bleed, dizziness, syncope, shoulder pain
What might you find on assessment of a suspected ectopic pregnancy?
Abdo tenders +/- guarding/rigidity
Enlarged uterus
Pain on vaginal exam
Cervical excitation
What is a Complete Hydatidiform Mole?
Placental proliferation in the absence of a fetus, characterized by swollen villi
This condition involves abnormal placental tissue growth.
What is the management for a stable Ectopic Pregnancy?
Methotrexate, if no contraindications
This is a medical management option to preserve fertility.
What should be done if a patient with an ectopic pregnancy is unstable and has hemoperitoneum?
Must do explorative laparotomy
Explorative laparotomy is a surgical procedure to investigate the abdominal cavity.
What are the characteristics of placental villi in a complete hydatidiform mole?
Swollen, grape-like
The appearance of the villi is a key diagnostic feature.
What is a partial mole?
Molar placenta + nonviable fetus; 69XXY
This condition involves both abnormal placental growth and a fetus that cannot survive.
What is a potential complication of a complete hydatidiform mole?
Recurrence leading to metastatic choriocarcinoma
Choriocarcinoma is a malignant tumor that can arise from trophoblastic tissue.
What are some predisposing factors for trophoblastic disease?
- Previous molar disease
- Pregnancy at ends of reproductive life (teens or late 40s)
These factors increase the risk of developing trophoblastic disease.
What are the clinical features of a hydatidiform mole?
- Vaginal bleeding 1st/early 2nd trimester
- bhCG HIGHER than expected
- Uterine size > dates with NO heart tones
- Ovarian enlargement
- Hyperemesis
- Early pregnancy-induced HTN
- Thyrotoxicosis
- U/S: snowstorm appearance
These symptoms can help in the diagnosis of a molar pregnancy.
What is the management for a complete hydatidiform mole?
- Prompt evacuation of uterus via dilatation and curettage
- Serial bhCG monitoring with one year of contraception
Monitoring is crucial due to the risk of choriocarcinoma.
What treatment should be given if trophoblastic disease invades the myometrium or becomes metastatic?
Give METHOTREXATE
Methotrexate is a chemotherapy agent used to treat certain types of trophoblastic disease.
What are the indications for suction dilatation and curettage?
- Heavy bleeding
- Fetal demise and patient does not want to wait for spontaneous loss
- Ruling out ectopic pregnancy
This procedure is done to evacuate the uterus in specific clinical situations.
What are the contraindications for suction dilatation and curettage?
- Active pelvic infection
- Coagulopathy
- Fetal demise not yet proven or patient will wait for spontaneous loss
These conditions can increase the risk of complications during the procedure.
When is suction dilatation and curettage not required?
- Uterus small and firm with no/very little bleeding
- Tissue passed appears complete
- Patient is reliable for f/u
- TV U/S shows empty uterus
In these cases, the procedure may be unnecessary.
What are some complications of suction dilatation and curettage?
- Uterine perforation
- Incomplete evacuation
- Infection/Bleed
- Late: intrauterine synechiae (adhesions – Asherman)
- Depression/psych
These complications can arise from the procedure and may require further management.
What is important in the psychological management of patients after a molar pregnancy?
- Acknowledge grief, guilt
- Support and comfort
- Counsel on how to tell others
- Reassure about future, can still conceive
- Warn of anniversary phenomenon
Psychological support is essential for coping with the loss and future pregnancy concerns.
Risk factors for ectopic pregnancy
Prev ectopic
Prev tubal surgeries / infections
IUDs
Endometriosis
IVF
Complication of ectopic pregnancy?
Intraperitoneal hemorrhage - shock - syncope - death
Investigating someone with ectopic pregnancy
Urinary bHCG
Bloods:
1. FBC
2. Serum bHCG
3. U&Es + LFTs (must be normal to give methotrextate)
4. Group and Save (crossmatch)
Ultrasound
Diagnosis of ectopic pregnancy
Failure of bHCG to double in 48-72 hours
Low progesterone
US: No gestation sac, echogenic mass with fluid
Laparoscopy
Medical management of Ectopic pregnancy
Methotrexate 1mg/kg IM provided no fetal heart beat, bHCG 1500-500, hemodynamically stable.
Must measure bHCG 4th and 7th day post treatment
Contraindications to methotrexate
Hepatic disease
Renal Failure
Pulmonary Fibrosis
Bone marrow suppression
Risks of methotrexate
Tubal rupture
Photosensitivity
Abdo pain
Surgical management of ectopic pregnancy
- Salpingostomy - if both tubes
- Salpingectomy - one tube
- If hemoperitoneum - explorative laparotomy
