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Year 4 - O&G > O&G - Third Trimester Bleeding > Flashcards

O&G - Third Trimester Bleeding Flashcards

1
Q

Placental oxygenation changes over the course of pregnancy (largely due to changes to maternal spiral arteries) - describe this relationship.

A

Placental (intervillous) oxygen levels start low in 1st trimester,

rise towards end of 1st trimester and remain high in 2nd trimester

until slowly falling during 3rd trimester

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2
Q

Define Preterm Labour.

A

Labour at < 37-weeks and 0 days

(37+0)

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3
Q

How many weeks gestation should a normal pregnancy last?

A

37 - 42 weeks

(from the 1st day of the LMP)

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4
Q

What are the boundaries in gestation for the following terms:

  • Early term
  • Full term
  • Late term
A
  • Early term = 37+0 through to 38+6
  • Full term = 39+0 through to 40+6
  • Late term = 41+0 through to 41+6
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5
Q

What are the risk factors for preterm labour?

A
  • Hx of preterm birth (strongest risk)
  • ↑ or ↓ maternal age
  • Low maternal BMI
  • Multiple pregnancy - causes over distension of uterus
  • Hx of cervix surgery / uterine surgery
  • Uterine bleeding in 2nd / 3rd trimester
  • Smoking
  • Polyhydramnios - causes over distension of uterus
  • Moderate-severe anaemia in pregnancy
  • Short interval between pregnancies ( < 12-18 months)
  • Some infections e.g. bacterial vaginosis
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6
Q

The normal range for WCC changes during pregnancy (as do many other blood-test ranges) - what is the normal WCC range during pregnancy?

A
  • Non-pregnant adult = ~ 4.0 - 11.0
  • 1st trimester = ~ 6.0 - 14.0
  • 2nd & 3rd trimester = ~ 6.0 - 15.0

↑ WCC is due to neutrophilia

(other causes must be excluded)

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7
Q

What are some obstetric causes of abdominal pain?

A
  • Ectopic pregnancy
  • Miscarriage
  • Preterm / term labour
  • Placental abruption
  • Choriamnionitis
  • Symphysis pubis dysfunction
  • Pre-eclampsia / HELLP syndrome
  • Uterine rupture
  • Acute fatty liver of pregnancy
  • Torsion of the pregnant uterus
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8
Q

What obstetric causes of abdominal pain often occur during early pregnancy?

A

Ectopic pregnancy:

  • 0.5% of all pregnancies
  • Risk factors: hx of salpingotomy, salpingitis, hx of ectopic, IVF (3% are ectopic)
  • Symptoms:
    • 6-8 weeks amenorrhoea
    • Lower abdo pain (often 1st symptom)
    • PV bleeding (may be dark brown)
    • Peritoneal bleeding - shoulder tip pain / pain on defecation or urination

Miscarriage:

  • Threatened:
    • Can involve pain
    • PV bleeding < 24-weeks (often at 6-9 weeks)
    • Closed cervical OS
    • ~ 25% of pregnancies
  • Inevitable:
    • Open cervical OS
    • Heavy PV bleeding + clots
    • Abdo pain
  • Incomplete:
    • Some products of conception retained
    • Abdo pain
    • PV bleeding
    • Open cervical OS
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9
Q

What is symphysis pubic dysfunction?

A

Symphysis pubic dysfunction - describes ligament laxity due to pregnancy hormones

  • Pain over pubic symphysis –> radiates to groins + medial aspect of thighs
  • Waddling gait (may be seen)
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10
Q

What is HELLP syndrome?

A

HELLP syndrome is regarded by some as a serious complication of severe pre-eclampsia and by others as being clinically distinct

HELLP manifests as:

  • Haemolysis
  • Elevated Liver enzymes
  • Low Platelets (thrombocytopenia)
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11
Q

What are the features of HELLP syndrome?

A

Features of HELLP Syndrome:

  • Epigastric or RUQ pain (65%) + tenderness
  • Nausea & vomiting (35%)
  • Urine is ‘tea-coloured’ due to haemolysis
  • Eclampsia can co-exist
  • ↑ BP + features of pre-eclampsia:
    • HTN - typically > 170/110 mmHg
    • Proteinuria - dipstick ++ / +++
    • Headache
    • Visual disturbances e.g. blurring, flashing in front of eyes
    • Papilloedema
    • RUQ / epigastric pain
    • Hyperreflexia
    • Vomiting
    • May have acute oedema of face, hands or feet (non-specific)
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12
Q

How is HELLP syndrome managed?

A
  1. Delivery - HELLP syndrome = indication for delivery
  2. Dexamethasone IV - maternal benefit (i.e. not for fetal lung maturation in this scenario)
  3. Magnesium sulfate IV - seizure prophylaxis due to risk of eclampsia (check blood levels frequently, especially in renal compromise)
  4. Platelet infusion often not needed - only if bleeding OR surgery + platelets < 40
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13
Q

Name some GI causes of abdominal pain which could occur during pregnancy.

A

Not-exhaustive list:

  • Acute appendicitis
  • Acute pancreatitis
  • Peptic ulcer
  • Gastritis
  • Hepatitis
  • Bowel obstruction
  • Bowel perf
  • Hernia
  • Constipation & irritable bowel
  • Acute cholecystitis
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14
Q

Name some genitourinary problems that can cause abdominal pain during pregnancy.

A
  • Acute pyelonephritis
  • Acute cystitis
  • Ovarian cyst rupture
  • Adnexal torsion
  • Renal stones
  • Ureteral obstruction
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15
Q

What is Red Degeneration?

A

Red Degeneration - is a complication of fibroids in which haemorrhage occurs inside the fibroid tumour –> causes pain

  • Fibroid growth is driven by oestrogen so during pregnancy they increase in size –> this can compromise the blood supply to fibroid centre = red degeneration pain
  • Occurs in ~15% of pregnant women with fibroids
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16
Q

What are the features of Red Degeneration?

A

Red Degeneration Features:

  1. Often occurs between 12-22 weeks pregnancy
  2. Pain - constant, localised to one area of uterus
  3. Low-grade fever
17
Q

What is the management of Red degeneration?

A

Analgesia

Pain should resolve in 4-7 days (can be severe / prolonged)

DO NOT do myomectomy (unless torsion of peduncalated fibroid) - will bleed ++

18
Q

How common in preterm labour?

A

~ 5-12% of pregnancies

19
Q

How can risk of preterm labour be investigated?

A

Fetal fibronectin

  • Fibronectin = ECM glycoprotein prodcued by amniocytes which can be detected in cervical vaginals secretions as a marker for fetal membranes changes for labour
  • 22-36 weeks - Fibronectin normally NOT detected in cervico-vaginal secretions
  • -ve result = PPV of 98% i.e. if negative then highly unlikely pre-term labour in next 7-10 days
  • +ve result = PPV of 40% i.e. +ve result doesn’t guarantee pre-term labour but is a sign alongside risk factors
20
Q

What management might be involved in pre-term labour?

A
  1. Steroids i.e. Dexamethasone or Betamethasone 24 mg in divided doses (12 mg 12-24 hrs apart)
  2. Tocolytics (uterine relaxants) e.g. Nifedipine, Atosiban, Indomethacin
  3. Magnesium sulfate - fetal neuroprotection for seizures
  4. Inform neonatal services in case of delivery
21
Q

What is the normal range for fetal HR on CTG?

A

120-160 BPM

22
Q

Name some causes of antepartum haemorrhage.

A
  • Lower ano-genital tracts:
    • Post-coital bleeding - vaginal abrasions or cervical ectropions
    • Anal fissures
    • Vaginal infections
    • Cervical dilation - if at term, it is self-limiting. If preterm i.e. < 37-weeks then can foreshadow preterm labour
    • Cancer
  • Placenta related:
    • Abruption
    • Placenta Praevia
    • Vasa Praevia
  • Unexplained - for whatever reason ~ 1/3rd of antepartum haemorrhage is unexplained haemorrhage (diagnosis of exclusion)
23
Q

Why do cervical ectropions cause post-coital bleeding?

A

Because the columnar epithelium of the cervical canal which is now present on the vaginal cervix is friable (tissue that tears, sloughs and bleeds easily on contact)

24
Q

What vaginal infections commonly cause bleeding and which do not?

A

Vaginal infections:

Commonly cause bleeding:

  • Candidiasis

Unlikely to cause bleeding:

  • Chlamydia
  • Trichomoniasis (TV)
  • Gonorrhoea
25
Q

What is a MEOWS score?

A

Modified Early Obstetric Warning Score

  • Monitors vital signs to identify if there is deterioration in maternal condition

Year 4 - O&G (12 decks)

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