Keppler vaginal bleeding in pregnancy Flashcards
What are some pregnancy related reasons for first trimester bleeding?
- Ectopic
- Spontaneous abortion
- Subchorionic bleeding
What are other non-pregnancy related reasons for first trimester bleeding?
- Bladder (UTI)
- Hemorrhoids
- Vaginitis
- Cervical
What are some things that increase your risk for ectopic pregnancy?
- IUD
- Tubal surgery
- Excessive age
- PID
True or false: Beta HCG levels should double every 48 hours?
True
What are some indications that its an ectopic pregnancy?
- Beta HCG not rising
- You see a mass near the ovaries that looks vascular cystic?
- A heart beat near an ovary is never good
If the pt is stable and has an ectopic pregnancy would you treat it medically or surgically?
Medically with Methotrexate
What do you need to check weekly if treating an ectopic pregnancy medically with methotrexate?
need to check the BHCG weekly until it reaches zero
If the pt has fluid in the pelvis and has an ectopic are the stable or unstable?
They are unstable and this will have to be treated surgically
What is considered a spontaneous abortion?
IUP 0.5cm w/o Fetal cardiac activity (FCA)
What percent of recognized pregnancies are spontaneous abortions
20%
What is the diagnostic criteria for spontaneous abortion?
- Empty gestational sac 2.5+cm, or unchanged
- HCG above discriminatory zone without viable fetal pole
- Previous viable fetus with no cardiac activity
- Fetal pole > 7 weeks by Crown rump length (CRL) without cardiac activity
What are the three management options for spontaneous abortion?
- Expectant- just wait and see
- Medical- Misoprostol
- Surgical
Spontaneous abortions can put the mother at risk of what?
- infection (septic abortion)
- Rare risk of DIC
- Bleeding/transfusion
What are some non-obstetric causes for second/third trimester bleeding?
- Infection
- Hemorrhoids
- Trauma
- Cervical
What are some obstetric causes for second and third trimester bleeding?
- Labor
- Abruption
- Placenta/ vasa previa
What is the general management of second and third trimester bleeding?
- Iv access
- Fluids
- Rapid transfusion protocol
What is the main difference between placenta abruption vs previa?
abruption is PAINFUL
What are some things that can cause a placenta abruption?
- HTN
- expose to nicotine, tobacco, amphetamines, caffeine
- trauma
- rupture of membrane
- and of course prior history
How do you diagnose placenta abruption?
- Gross bleeding
- check for uterine activity
- is there pain
- ultrasound? labs?
True or false: with a placental abruption your only method of delivery is a c-section?
False- with placental abruption you can try to deliver the child vaginally
What are some things that could cause placenta previa?
- Advancing maternal age
- prior uterine surgery
- again happened before
If some one gets placenta previa at 20 weeks should it go away by week 28?
yes
True or false: you can stimulate the cervix of someone with placenta previa?
False- no cervical stimulation absolutely no sex
True or false: the more C-sections you have the more likely you are to have placenta previa?
True
What is vasa previa?
vasa previa is when membranes that contain fetal blood vessels connecting the umbilical cord and placenta overlie or are with 2cm of the internal cervical os
Should you have a low or high index of suspicion for the vasa previa?
high index
What causes postpartum hemorrhage?
- Atony
- Atony
- Atony
What is atony?
this is when the uterus has no tone and cant contract to slow down the bleeding
What are some other reasons for postpartum hemorrhage?
- Laceration
- Retained placenta
- Placenta accreta spectrum
- Uterine rupture
- DIC/Coagulopathies
With postpartum hemorrhage would you exam the pt under anesthesia or awake?
under anesthesia
What are some management option in the OR for postpartum hemorrhage?
- Uterine curettage
- Uterine tamponade
- IR embolization
- uterine artery ligation
- B-lynch suture
- Hysterectomy
Because atony is the most common reason for postpartum hemorrhage, how would you treat this?
you would give uterotonics (pitocin, misoprostol things of this nature)
which puts you at a higher risk of coagulopathies, pregnancy or BCPs?
pregnancy puts you at an 8x higher risk for VTE
What is virchows tried?
- venous stasis
- hypercoaguable state
- intervascular vessel wall damage
What are some things that can cause a hypercoagulable state?
- BCP
- Pregnancy
- Prothrombin gene mutation
- Antithrombin III
- Factor V leiden
- Protein C or 5 deficiencies
How would you evaluate someone for DVT/PE
- Check genetic predisposition/history
- Lower extremity doppler ultrasound
- VQ/perfusion (rarely used)
- CT PE (used frequently)
Treatment for DVT/PE in preggos?
usually treated with LMWH those that are at a high risk will most likely be prophylaxed with LMWH throughout the pregnancy
What are some causes of DIC in pregnancy?
- Acute blood loss
- HELLP/preeclampsia
- Amniotic fluid embolism
How do you manage DIC?
- Massive transfusion protocol
- Replace clotting factors
- Control sources of bleeding
