bleeding + pain in pregnancy

Question 1

what drug is used for IOL?

Answer 1

syntocinon

Question 2

anti-D - when to give + how much?

Answer 2

even if prophylactic anti-D given, always give if sensitising event
Kleihauer blood test detects/quantifies foetal cells in maternal circulation + determines how much to give

Question 3

placenta praevia - presentation, detection, types, risks, management

Answer 3

features:
abnormal lie - blocks baby ± painless bleeding
minor - partially covers cervix
major - totally covers
detected 20wk scan → do TVUSS

management:
caesarean
advise against sex if bled + eat high iron
safety net - anaemia symptoms? come in if bleeding - may need admission

Question 4

causes of abdo pain in pregnancy

Answer 4

OBSTETRIC

• labour
• placental abruption
• preeclampsia
• miscarriage
• ectopic
• red degen
• intraperitoneal haemorrhage
• trauma
• HELLP

NON-OBSTETRIC

• appendicitis
• UTI

Question 5

what is HELLP?

Answer 5

haemolysis
elevated liver enzymes
low platelets

Question 6

abdo pain in pregnancy - investigation

Answer 6

USS

foetal fibronectin - + indicates preterm labour

Question 7

RFs for preterm labour

Answer 7

maternal age extremes
low BMI
LLETZ
smoking
previous hx
polyhydramnios/twins/other causes of uterine overdistension

Question 8

preterm labour - management

Answer 8

betamethasone 2h apart - lungs
tocolysis - nifedipine
MgSO4 - foetal neuroprotection

delays labour to allow steroids to work - prevent CP

Question 9

what is placental abruption?

Answer 9

separation of placenta from uterine wall

→ maternal haemorrhage into intervening space

Question 10

RFs for placental abruption

Answer 10

maternal thrombophilia
abdo trauma
preeclampsia
smoking
cocaine
prev hx
>35y
twins

Question 11

placental abruption - symptoms

Answer 11

constant pain
bleeding - (partially/) revealed / concealed (abdo pain ++)
uterus - tender + tense
shock, coagulopathy, preeclampsia
foetal compromise

Question 12

placental abruption - management

Answer 12

minor, <37wk - expectant, + steroids if <36

maternal/foetal compromise - deliver

Question 13

placental abruptions - complications

Answer 13

MATERNAL:
shock + AKI
DIC
ischaemia of myometrium
bleed into myometrium + peritoneum → uterus can't contract properly → PPH on delivery

FOETAL:
IUGR
foetal death

Question 14

uterine rupture - what is it, RFs, symptoms?

Answer 14

rupture through uterus → blood into abdo

symptoms - shock, pain, bleeding, CTG abnormalities, halted contractions, palpation of foetus outside uterus

RFs: hx caesarean, current IOL,

Question 15

what are the common non-obs causes of abdo pain in pregnany?

Answer 15

appendicitis
UTI
acute cholecystitis
pancreatitis
renal stones
ovarian torsion

Question 16

appendicitis in pregnancy: symptoms, risks, investigations + mgmt

Answer 16

trim 1 - RLQ pain
trim 2 - umbilicus pain
trim 3 - RUQ / diffuse pain

rebound + abdo tenderness; mcburney point pain
risks - rupture, foetal loss
inv - WCC, MRI
mgmt - laparoscopy/otomy

Question 17

what are the 3 classes of antepartum bleeding?

Answer 17

lower anogenital tract + cervix
placental
unexplained

Question 18

lower anogenital tract bleeding - causes

Answer 18

post coital - vaginal abrasion or cervical (trauma - ectropion)
anal fissures
candidasis
early cervical dilation - not problem unless <37wk (risk labour)
cancer

Question 19

placental causes of bleeding

Answer 19

abruption
praevia
vasa praevia

Question 20

what is vasa praevia?

Answer 20

cord fails to insert into placental body
foetal blood can rapidly bleed into vagina

rupture of membranes → bleeding + foetal brady

Question 21

antepartum haemorrhage - investigation

Answer 21

don’t VE in case praevia
need resus? preg women decompensate late
ABC + obs
abdo - tender, contracted, woodiness (abrup)
vagina VE can make praevia worse - laceration/erosion/infection, blood on spec, cervix
?FBC, crossmatch, clotting
FBC + G+S - G+S determines rh status too
clotting screen - abruption can → coagulopathy
kleihauer - ?foetomaternal haemorrhage
CTG - ?foetal heart

Question 22

APH - history

Answer 22

first time bleeding?
how heavy?
abdo pain - episodic?
itchy, sore, discharge?
post-coital?
smears?
placenta localised at 20wk?

Question 23

APH - mgmt of minor bleeds

Answer 23

treat cause + observe

Question 24

whats a risk of APH? how can you investigate it in non-acute setting?

Answer 24

FGR - USS to assess placental site + foetal growth

Question 25

APH - mgmt of major bleeds

Answer 25

get help + resus - large bore cannulas into ACF + fluids

deliver baby always - method depends on viability

Question 26

causes of pain in early pregnancy

Answer 26

ectopic
miscarriage

appendicitis
UTI

Question 27

causes of pain in late pregnancy

Answer 27

labour
placental abruption
PET
HELLP
uterine rupture

appendicitis
UTI

Question 28

UTI in pregnancy - complications

Answer 28

preterm delivery

IUGR

Question 29

differentiating placenta praevia from placental abruption

Answer 29

both causes of antepartum haemorrhage

abruption:
constant pain
shock out of keeping with visible loss
uterus tender + tense
normal lie + presentation
foetal heart problems
coagulation problems

placenta praevia:
painless
bleeds small before large
shock in proportion to visible loss
uterus not tender
\+- abnormal lie/presentation
foetal heart usually normal
coagulation problems rare

Question 30

common causes of bleeding in pregnancy by trimester

Answer 30

1 - miscarriage, ectopic
2 - miscarriage, abruption
3 - bloody show, abruption, praevia, vasa praevia

Question 31

placenta praevia - management

Answer 31

if found at 18wk scan, rescan at 34, then 2wkly. safety net - come in if bleed (may need admission). eat high iron. avoid sex if bleed. if high presenting part/abnormal lie at 37 then caesarean

Question 32

placenta praevia with bleeding - management

Answer 32

admit
treat shock
cross match
USS at 37 to determine delivery - mild - vaginal, sev - caesarean