SAB & Pre-Eclampsia Flashcards
first trimester bleeding etiology
often unknown
goal –> exclusion
differential diagnosis for FIRST TRIMESTER bleeding
- SAB
- Ectopic pregnancy
- Hydatidiform mole
- Normal/other
- Subchorionic hemorrhage
- Trauma
Normal Etiologies of FIRST TRIMESTER bleeding
- Polyps
- cervivitis
- vaginal infection
- STI
- implantation spotting
- increased vascularization of the cervix in pregnancy= increased friability
- post-coital spotting due to increase friability
implantation spotting
which is most often scant, 7-11 days after conception, lasting only a day or two; minority of pregnant women have this kind of spotting
how would you evaluate when first trimester bleeding present
History: severity, amount, associated s &sx, pain , and cramping
Past history: previous ectopic, prior SABs, medical disorders, risk factors, fibroids/
physical examination of first trimester bleeding
vital signs
abdominal exam (pain, FHTs)
SPECULUM EXAM- observe internal and external
bimanual exam: CMT, adnexal masses, uterine enlargement.
spontaneous abortion (SAB)
most common early pregnancy complication
80% are in the 1st 12th week of gestation
incidence varies 25-30% of all conceptions
Chromosomal errors most common reason
SAB risk factors
smoking
alcohol
immune factors (recurrent loss)
inherited blood dyscrasias (recurrent loss)
excessive caffeine >500mg daily
environmental exposures : pesticides arsenic, lead, formaldehyde, benzene.
threatened SAB
closed cervix, uterus appropriated sized
inevitable SAB
cervix dilated, increased bleeding with cramps, ctx, products of conception can be at os
completed SAB
small contracted uterus, open cervix, scant bleeding/cramping
incomplete SAB
placental tissue remaining, cervix open, POC can be at the os, uterus smaller than expected for gestational but not well contracted, variable bleeding/ cramping
missed SAB
in utero death of embryo prior to 20th week with retention of pregnancy for prolonged period of time. Cervix closed. +/- bleeding.
diagnosis SAB
Ultrasound KEY
may see abnormal yolk sac, slow or absent FHT, hematoma
Serial b-hCG adjunct to determine viability
serial b-hCG
adjunct to determine viability
double every 2-3 days
max levels at 8-10 weeks, then decline
serial measures.
management of SAB
type and screen
give Rhogam if Rh negative
management of threatened AB
expectant management if no infection present
inevitable & complete AB
per MD (consult & referral) can be expectant or D&C
ectopic pregnancy
approximately 2% of pregnancies (or 20/1000)
increasing incidence
clinical manifestation commonly between 6-8 weeks, can occur later
many women asymptomatic when you see them.
ectopic pregnancy risk factors (HIGH)
tubal ligation
tubal pathology/surgery
prior ectopic
IUD- esp. mirena
ectopic pregnancy risk factors (moderate)
infertility
assisted reproduction technology
prior hx of genital tract infection (Chlamydia, GC, salpingitis)
multiple sex partner (secondary to increase risk for PID)
smoking (dose dependent)
african american
ectopic pregnancy risk factors( lower )
prior cesarean
douching
signs &symptoms of ectopic pregnancy
abdominal pain
amenorrhea - positive pregnancy test
bleeding (profuse if cervical pregnancy)
many women no symptoms
may have breast tenderness, nausea, other pregnancy signs.
signs of rupture : shoulder pain (blood irritating diaphragm)
Urge to defecate (blood pooling in the cul de sac)
evaluation of ectopic pregnancy
pregnancy test on all reproductive aged women with abdominal pain
pelvic exam for adnexal mass
assess cervical motion tenderness ( sometimes your first clue on routine 1st visit exam)
ultrasound - may or may not see extrauterine sac
serial B-hCG - may see slower rise, may be normal.
management of ectopic pregnancy
refer
surgery for rupture or failed medical therapy
METHOTREXATE therapy: unrupture
hcG < 500 !
Gestational trophoblastic disease
made up of interrelated lesions from trophoblastic epithelium of placenta Hydatidiform mole (80%) gestational trophoblastic neoplasia (GTN)
hydatidiform mole
complete - no fetal tissue- high incidence of becoming malignant
partial-some fetal tissue
gestational trophoblastic neoplasia
invasive mole, choriocarcinoma
characterized by persistent B-hCG, no tissue.
incidence: 1-2/1000 pregnancies
gestational trophoblastic neoplasia risk factors
teens and age >35
prior molar pregnancy
oral contraceptive use
smoking
gestational trophoblastic neoplasia clinical manifestation
marked NAUSEA & VOMITING of pregnancy
increase uterine size
bleeding - occasional spotting to heavy bleeding.
diagnosis gestational trophoblastic neoplasia
USN
B-hCG ** may see abnormally high level, SLOWER rise
Management of gestational trophoblastic neoplasia
D & C
hysterectomy
post evacuation surveillance.
subchorionic hemorrhage
bleeding r/t separation of chorion from uterine lining
see on USN
outcomes usually good
midwifery care for FIRST TRIMESTER pregnancy
feeling of loss & grief, often more than women expect
emotional healing takes longer than physical healing
loss of future plans, dreams, and hope
sensitive, caring language
reassurance about what does not cause early loss to reduce blame
causes of late pregnancy bleeding
placenta previa abruption rupture vasa previa uterine scar dehiscence cervical polyp bloody show preterm labor/labor cervicitis or cervical ectropion vaginal trauma cervical cancer STIs
Placenta Previa
1/300
at 16-20 weeks gestations, low liine placenta is seen in 50% of the women, however 90% of those will be normal implantation by 30 weeks gestation. therefore, reassure women during normal ultrasound.
risk factors for placenta previa
maternal age >35 multiparity of 5 or greater smoking unexplained MSAFP frequent D & Cs Previous C/S Previous placenta previa
potential problem from placenta previa
Cesarean section
preterm birth
Third stage issues: placenta accreta, hemorrhage, hysterectomy
signs & symptoms of placenta previa
BRIGHT red PAINLESS BLEEDING
often is intermittent
may occur with : intercourse, vaginal exam, cervical dilation & no preceding event.
midwifery management of placenta previa
consider STERILE SPECULUM exam as a first line assessment
no vaginal exam
confirmation by ultrasound
delivery by C/S for most
midwifery management for woman is stable & preterm
consult/collaborate bed rest or modified activity outpatient monitoring pad counts abstinence, nothing in vagina education & support
placenta abruption
partial separation or all of the placenta from the uterine wall.
secondary to clot or hematoma . size of clot or hematoma determine the extend of seperation
prevalence & risk factors of placental abruption
1/200
a severe abruption leading to fetal death occurs in 1/830
hypertensive disorder
cigarette smoking
scar tissue
abdominal trauma: blunt force
cocaine use (vasocontriction)
previous placental abruption
advance maternal age and less than 20 years of age.
poor nutritional status
chorionitist
hx thrombofibrin
any that decrease the uterine volume such as rupture placental membrane
elevated maternal placental protein which is associated with increase abruption
history : placental abruption
onset duration & severity color amount characteristic of discharge any precipitory event? any contraction? describe abdominal pain or not at all recent examination or intercourse trauma ? gestational age? when is the last ultrasound done ? gravid para blood type risk factors: multiparity, age greater than 35, previous placeta previa, uterine scar, multiple pregnancy
physical examination of placenta abruption
vital sign
pain
FHT
abdominal exam –hard board like
speculum exam: visualize dilation, check for erosion, polyps, STI ?
bimanual exam to check for : dilation, effacement, station, presenting part, status of membrane
potential problems with placental abruption
hemorrhage shock coagulopathies/DIC hysterectomy stillbirth hypoxia preterm delivery fetal death
signs & symptoms of ABRUPTION
PAIN (hallmark symptom) - mild to severe bleeding -may or may not (conceal? ) backache- posterior abruption ? contractions may report decreased fetal movement
frequency of symptoms with abruption
vaginal bleeding : 80%
Abdominal or back pain and uterine tenderness: 70 %
fetal distress: 60%
abnormal uterine contractions (hypertonic, high frequencty): 35%
idiopathic premature labor: 25%
complications associated with placental abruption –FETAL
growth restriction (chronic abruption)
preterm birth and associated morbidity
perinatal mortality
fetal hypoxemia or asphyxia
complications associated with placental abruption- MATERNAL
Hypovolumia (secondary to blood loss) blood transfusion DIC cesarean section renal failure ARDS multisystem organ failure death
midwifery management for placental abruption
call for USN
call for consultant
NST
Labs per consultant: CBC PTT fibrinogen BUN type & Rh
emergency management of placental abruption
mask O2 at 10L/min
assess uterine tone, any relaxation, contractions
pain monitoring and management-dont want to mask pain that may be diagnostic
IV fluids-volum support, replacement and venous assess
foley cath-output monitoring, expect decreased amount, increased concentration
pathophysiology of preeclampsia
increase BP is most common presentation, pathologic process starts well before maternal signs & symptoms
Pathologic process originated with placental development, early in 1st trimester
characterized by widespread maternal endothelial cell dysfunction
result in mild-severe microangiopathy of target organs such as brain, liver, kidney, placenta
causes preeclampsia
placental or maternal response to placenta development
- -> SHALLOW PLACENTATION: invasion of fetal trophoblasts into the maternal spiral arteries incomplete
- -> this causes the SPIRAL ARTERIES to REMAIN SMALLER, FIRM and RESISTANT, instead of remodeling to relaxed and less resistant (pseudovascularization)
why pseudovascularization is incomplete
genetic factors
immunologic factors
early hypoxic episode to differentiating cells
causes of late pregnancy bleeding
placenta previa abruption rupture vasa previa uterine scar dehiscence cervical polyp bloody show preterm labor/labor cervicitis or cervical ectropion vaginal trauma cervical cancer STIs
Placenta Previa
1/300
at 16-20 weeks gestations, low liine placenta is seen in 50% of the women, however 90% of those will be normal implantation by 30 weeks gestation. therefore, reassure women during normal ultrasound.
risk factors for placenta previa
maternal age >35 multiparity of 5 or greater smoking unexplained MSAFP frequent D & Cs Previous C/S Previous placenta previa
potential problem from placenta previa
Cesarean section
preterm birth
Third stage issues: placenta accreta, hemorrhage, hysterectomy
signs & symptoms of placenta previa
BRIGHT red PAINLESS BLEEDING
often is intermittent
may occur with : intercourse, vaginal exam, cervical dilation & no preceding event.
midwifery management of placenta previa
consider STERILE SPECULUM exam as a first line assessment
no vaginal exam
confirmation by ultrasound
delivery by C/S for most
midwifery management for woman is stable & preterm
consult/collaborate bed rest or modified activity outpatient monitoring pad counts abstinence, nothing in vagina education & support
placenta abruption
partial separation or all of the placenta from the uterine wall.
secondary to clot or hematoma . size of clot or hematoma determine the extend of seperation
prevalence & risk factors of placental abruption
1/200
a severe abruption leading to fetal death occurs in 1/830
hypertensive disorder
cigarette smoking
scar tissue
abdominal trauma: blunt force
cocaine use (vasocontriction)
previous placental abruption
advance maternal age and less than 20 years of age.
poor nutritional status
chorionitist
hx thrombofibrin
any that decrease the uterine volume such as rupture placental membrane
elevated maternal placental protein which is associated with increase abruption
history : placental abruption
onset duration & severity color amount characteristic of discharge any precipitory event? any contraction? describe abdominal pain or not at all recent examination or intercourse trauma ? gestational age? when is the last ultrasound done ? gravid para blood type risk factors: multiparity, age greater than 35, previous placeta previa, uterine scar, multiple pregnancy
physical examination of placenta abruption
vital sign
pain
FHT
abdominal exam –hard board like
speculum exam: visualize dilation, check for erosion, polyps, STI ?
bimanual exam to check for : dilation, effacement, station, presenting part, status of membrane
potential problems with placental abruption
hemorrhage shock coagulopathies/DIC hysterectomy stillbirth hypoxia preterm delivery fetal death
signs & symptoms of ABRUPTION
PAIN (hallmark symptom) - mild to severe bleeding -may or may not (conceal? ) backache- posterior abruption ? contractions may report decreased fetal movement
frequency of symptoms with abruption
vaginal bleeding : 80%
Abdominal or back pain and uterine tenderness: 70 %
fetal distress: 60%
abnormal uterine contractions (hypertonic, high frequencty): 35%
idiopathic premature labor: 25%
complications associated with placental abruption –FETAL
growth restriction (chronic abruption)
preterm birth and associated morbidity
perinatal mortality
fetal hypoxemia or asphyxia
complications associated with placental abruption- MATERNAL
Hypovolumia (secondary to blood loss) blood transfusion DIC cesarean section renal failure ARDS multisystem organ failure death
midwifery management for placental abruption
call for USN
call for consultant
NST
Labs per consultant: CBC PTT fibrinogen BUN type & Rh
emergency management of placental abruption
mask O2 at 10L/min
assess uterine tone, any relaxation, contractions
pain monitoring and management-dont want to mask pain that may be diagnostic
IV fluids-volum support, replacement and venous assess
foley cath-output monitoring, expect decreased amount, increased concentration
pathophysiology of preeclampsia
increase BP is most common presentation, pathologic process starts well before maternal signs & symptoms
Pathologic process originated with placental development, early in 1st trimester
characterized by widespread maternal endothelial cell dysfunction
result in mild-severe microangiopathy of target organs such as brain, liver, kidney, placenta
causes preeclampsia
placental or maternal response to placenta development
- -> SHALLOW PLACENTATION: invasion of fetal trophoblasts into the maternal spiral arteries incomplete
- -> this causes the SPIRAL ARTERIES to REMAIN SMALLER, FIRM and RESISTANT, instead of remodeling to relaxed and less resistant (pseudovascularization)
why pseudovascularization is incomplete
genetic factors
immunologic factors
early hypoxic episode to differentiating cells
inflammation and preeclampsia
maternal infection like UTI, periodontal disease, chlamydia, etc, are associated with increased rates of preeclampsia
endothelial dysfunction
endothelium regulates vascular elasticity, permeability and coagulation cascade
increase insulin resistance
linked to pathophysiology of preeclampsia
- characterized by microvascular dysfunction
- may be primary pathway for adverse fetal effects- like FGR- in severe preeclampsia
- check this out for a deeper understating of relationship
how preeclampsia lead to high blood pressure
increased vascular resistance –> decrease cardiac output–> widespread vasoconstriction–> increase BP
Maternal effects from preeclampsia
kidney - capillary edema, glomerular cell dysfunction
CNA- vasospasm= headaches, visual changes
liver- fibrin deposits
Blood- hemoconcentration
- thrombocytopenia
uterus- underperfusion, utero-placental insufficiency.
Fetal effects from preeclampsia
decreased utero-placental blood flow may cause:
- placental infarctions
- oligohydramnios
- placental abruption
- fetal growth restriction
- non-reassuring fetal status
