Late Pregnancy Bleeding

Question 1

Never perform a digital or speculum

examination until ultrasound study rules out________

Answer 1

placenta previa

Question 2

A normally implanted placenta (not in the lower uterine segment) separates from the uterine wall before delivery of the fetus. Separation can be partial or complete

Answer 2

ABRUPTIO PLACENTA

Question 3

What happens if AP is concealed

Answer 3

Less commonly, if bleeding remains concealed or internal, the retroplacental hematoma remains within the uterus, resulting in an increase in fundal height over time.

Question 4

How to Dx AP

Answer 4

This is based on the presence of painful late-trimester vaginal bleeding with a normal fundal or lateral uterine wall placental implantation not over the lower uterine segment

Question 5

It is the most common cause of painful late trimester

bleeding.

Answer 5

AP

Question 6

RF for AP

Answer 6

Abruptio placenta is seen more commonly with previous abruption, hypertension, and maternal blunt trauma.

Other risk factors are smoking, maternal cocaine abuse and premature membrane rupture.

Question 7

Abruptio Placenta

This is performed if maternal or fetal jeopardy is present
as soon as the mother is stabilized.

Answer 7

Emergency cesarean delivery

Question 8

Abruptio Placenta

This is performed if bleeding is heavy but controlled or pregnancy is >36 weeks. Perform amniotomy and induce labor

Answer 8

Vaginal delivery

Question 9

Abruptio Placenta

This is performed if mother and fetus are stable and remote from term, bleeding is minimal or decreasing, and contractions are subsiding.

Answer 9

Conservative in-hospital observation

Question 10

Severe abruption can result in hemorrhagic shock with ____________ from profound hypotension, and DIC from release of tissue_________into the general
circulation from the disrupted placenta

Answer 10

acute tubular necrosis

thromboplastin

Question 11

___________refers to blood extravasating

between the myometrial fibers, appearing like bruises on the serosal surface

Answer 11

Couvelaire uterus

Question 12

___________ is present when the placenta is implanted in the lower uterine segment.

This is common early in the pregnancy, but is most often not associated with bleeding

Answer 12

Placenta previa

Question 13

In Placenta Previa

Usually the lower implanted placenta atrophies and the upper placenta hypertrophies, resulting in______

Answer 13

migration of the placenta

Question 14

Dx of PP

Answer 14

This is based on the presence of painless late-trimester vaginal bleeding with an obstetric ultrasound showing placental implantation over the lower uterine segment

Question 15

What are the types of PP?

• _______ is found when the placenta completely covers the internal cervical os. This is the most dangerous location because of its potential for hemorrhage.
• ________exists when the placenta partially covers the internal os.
• _________ exists when the placental edge is near but not over the internal os.

Answer 15

Total, complete, or central previa

Partial previa

Marginal or low-lying previa

Question 16

Risk Factor for PP

Answer 16

Placenta previa is seen more commonly with previous placenta previa and multiple gestation. Other risk factors are multiparity and advanced maternal age

Question 17

In AP,

This is performed if maternal or fetal jeopardy is present
after stabilization of the mother.

Answer 17

Emergency cesarean delivery

Question 18

In AP,

performed in preterm gestations if mother and fetus are stable and remote from term.

Answer 18

Conservative in-hospital observation

Question 19

In AP,

This may be attempted if the lower placental edge is >2 cm from the internal cervical os

Answer 19

Vaginal delivery

Question 20

In AP,

This is performed if the mother has been stable after
fetal lung maturity has been confirmed by amniocentesis, usually at 36 weeks’ gestation.

Answer 20

Scheduled cesarean delivery

Question 21

Cx of AP,

Answer 21

If placenta previa occurs over a previous uterine scar, the villi may invade into the deeper layers of the decidua basalis and myometrium

Question 22

Occurs when the villi invade the deeper layers of the endometrial deciduus basalis but do not penetrate the myometrium, accounting for approximately 80% of all cases

Answer 22

Placenta accreta

Question 23

________ occurs when the villi invade the myometrium but do not reach the uterine serosal surface or the bladder. It accounts for approximately 15% of all cases.

Answer 23

Placenta increta

Question 24

_________occurs when the villi invade all the way to the uterine serosa or into the bladder.

It is the least common of the 3 conditions, accounting for
approximately 5% of all cases.

Answer 24

Placenta percreta

Question 25

______ is present when fetal vessels traverse the fetal membranes over the internal cervical os

Answer 25

Vasa previa

Question 26

In Vasa Previa

These vessels may be from either a _______ or ______

Answer 26

velamentous insertion of the umbilical cord or may be joining an accessory (succenturiate) placental lobe to the
main disk of the placenta.

Question 27

UTZ findings of VP

Answer 27

This is rarely confirmed before delivery but may be suspected when antenatal sonogram with color-flow Doppler reveals a vessel crossing the membranes over the internal cervical os.

Question 28

Dx of VP (Classic triad)

Answer 28

The classic triad is rupture of membranes and painless vaginal bleeding, followed by fetal bradycardia.

Question 29

RF for VP

Answer 29

Vasa previa is seen more commonly with velamentous insertion of the umbilical cord, accessory placental lobes, and multiple gestation

Question 30

______ is complete separation of the wall of the pregnant uterus with or without expulsion of the fetus that endangers the life of the mother or the fetus, or both.

Answer 30

Uterine rupture

Question 31

Types of uterine rupture

Answer 31

The rupture may be incomplete (not including the peritoneum) or complete (including the
visceral peritoneum

Question 32

MC Sx of uterine rupture

Answer 32

The most common findings are vaginal bleeding, loss of electronic fetal heart rate signal, abdominal pain, and loss of station of fetal head. Rupture may occur
both before labor as well as during labor

Question 33

Definitive Dx of uterine rupture

Answer 33

Confirmation of the diagnosis is made by surgical exploration of the uterus and identifying the tear

Question 34

RF for uterine rupture

Answer 34

The most common risk factors are previous classic uterine incision, myomectomy, and excessive oxytocin stimulation. Other risk factors are grand multiparity and
marked uterine distention.

Question 35

A ____________ is 20 times more likely to rupture than a low segment incision

Answer 35

vertical fundal uterine scar

Question 36

Mx of uterine rupture

_______ is imperative.

______ is indicated in a stable young woman to conserve fertility.

________ is performed in the unstable patient or one who does not desire further childbearing

Answer 36

Immediate delivery of the fetus

Uterine repair

Hysterectomy