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Women's Health > Third Trimester Bleeding > Flashcards

Third Trimester Bleeding Flashcards

1
Q

What is placenta praevia?

A

Placenta is lying at the bottom of the womb, covering the cervix, underneath the baby.

  • Major placenta praevia: completely covers the cervix
  • Minor placenta praevia: could just be touching the edge of the cervix
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2
Q

What is the likelihood of having placenta praevia at term?

A
  • If major placenta praevia is seen at 20-22 weeks then 11% of those women will still have a low placenta at 32-36 weeks
  • If placenta still covering cervix completely at 32-36 weeks - 90% will have a low placenta at term
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3
Q

What are the implications of placenta praevia?

A
  • If placenta is blocking cervix - baby can’t come out during labour
  • Heavy bleeding
  • If follow-up scan still shows placenta praevia - needs C-section so no risk of baby coming out through placenta and less risk of placenta bleeding when cervix dilates
  • Not guaranteed to bleed, so can carry on with daily activities; just acknowledge increased bleeding risk
  • Women with lower placenta are more likely to go into labour slightly earlier - any signs of labour, any pains, then call hospital asap
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4
Q

When will the position of the placenta for birth be confirmed by USS?

A

If no bleeding/symptoms occur, then rescan at 32+36 weeks - transvaginal USS, won’t make the woman bleed but it’s more accurate than an abdominal USS.

  • If it shows bleeding - call hospital. Might have to stay in overnight to make sure bleeding stops.
  • If heavy bleeding, then more scans need to be done
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5
Q

How should the mode of delivery be determined with placenta praevia?

A

If placental edge <2cm away from internal os in 3rd trimester - likely need C-section delivery. But mode of delivery should be based on clinical judgement and USS information.

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6
Q

What is the management for placenta praevia?

A

If placenta praevia with bleeding (usually painless bleeding) - admit, treat, shock and cross match blood

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7
Q

What is the classic presentation of placenta praevia?

A

Non-painful bleeding and may be associated with an abnormal lie as the low lying placenta may prevent engagement of the presenting part.

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8
Q

What physiological changes occur during pregnancy?

A

WCC goes from 6000 to 16,000 iUL in 2nd trimester and from 20,000 to 30,000 in labour. Also, consider effects of radiation on foetus for investigations.

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9
Q

What are causes of abdominal pain in pregnancy?

A
  • Preterm labour
  • Placental abruption
  • Chorioamnionitis - usually ascending bacterial infection of amniotic fluid/membranes/placenta. Preterm rupture of membranes is a major risk factor, as sterile environment exposed to pathogens. Deliver baby + IV abx = initial treatment
  • Acute fatty liver of pregnancy - abdo pain, n+v, jaundice, headache, hypoglycaemia if severe > pre-eclampsia, ALT typically elevated, management via supportive care and once stable, delivery is definitive management
  • Epigastric pain associated with pre-eclampsia
  • Torsion of pregnant uterus
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10
Q

What are GI causes of abdo pain in pregnancy?

A
  • Appendicitis, pancreatitis, peptic ulcer, gastritis, hepatitis, bowel obstruction, bowel perforation, hernias, constipation and irritable bowel, cholecystitis
  • Ask about bowel movements, eating make it worse, yellowing/itching of skin, n+v
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11
Q

What are GU causes of abdo pain in pregnancy?

A
  • Acute pyelonephritis; acute cystitis (more common in pregnancy so be aware of them); ovarian cyst rupture; adnexal torsion; renal stones, uteral obstruction (if UTI present, even asymptomatic > abx for 7 days)
  • Ask about urine symptoms, genital pain/discharge
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12
Q

What are other causes of abdominal pain in pregnant women?

A
  • Intraperitoneal haemorrhage
  • Red degeneration of fibroid
  • Trauma to abdomen (consider physical abuse)
  • DKA
  • Splenic rupture
  • Respiratory disease like pneumonia or PE
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13
Q

What things later in pregnancy cause abdominal pain?

A
  • Torsion of pedunculated fibroid
  • Placental abruption
  • HELLP syndrome - spontaneous rupture of liver
  • Uterine rupture
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14
Q

What is pre-term labour and what are the risks of it?

A
  • PTL 5-12%
  • Regular painful contractions which result in cervical change prior to 37 weeks gestation
  • Risks: increased perinatal morbidity and mortality particularly in extreme prematurity
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15
Q

What are the predisposing risk factors for pre-term labour?

A
  • Maternal age (<20 or >35), low BMI, LLETZ, smoking
  • Socio-economic factors
  • Past reproductive history i.e. previous PTL increases risk 2-fold and up to 70% if more than 2 PT births
  • Present history: uterine over distension such as polyhydramnios, multiple pregnancy
  • Infection: bacterial vaginosis
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16
Q

What tests can you do to indicate whether PTL is going to occur?

A
  • Foetal fibronectin: extracellular matrix glycoprotein produced by amniocytes which can be determine by cervical vaginal secretions - PPV (positive predictive value) 46-80% (46-80% that woman will go into labour)
  • Actim partus detects IGFBP-1, a protein present in cervical secretions (PPV 40% and negative predictive value of 98% > if test negative, 98% sure the woman won’t go into PTL)
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17
Q

What medications can be given for pre-term labour?

A
  • Corticosteroids: develop foetal lungs - betamethasone 12mg - 2 doses 24hrs apart
  • Tocolysis (anti-contraction meds): nifedipine, atosiban, indomethacin (don’t prevent PTL, only delay it to give time for steroids to work)
  • Magnesium sulfate: for foetal neuroprotection > decreases risk of cerebral palsy
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18
Q

What is placental abruption?

A
  • Premature separation of placenta from uterine wall
  • <2% of pregnancies
  • Risk factors: maternal thrombophilia, abdominal trauma, PET, smoking, cocaine use
  • Bleeding within decidua basalis, causes further separation
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19
Q

What are the signs and symptoms of placenta praevia?

A
  • Bleeding (though may not always be present as blood may pool up within uterus > if this happens, can cause significant abdominal pain)
  • Abdominal pain
  • Revealed may be minimal compared to the abruption - concealed (bleeding trapped behind placenta)
  • Uterine tenderness (woody hardness)
  • Vaginal bleeding > fetal compromise
  • Maternal shock
  • Coagulopathy
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20
Q

What is the management for placenta praevia?

A
  • Depends on severity and complications
  • Minor: expectant particularly if <37 weeks
  • With monitoring and steroids for fetal lung maturity <36 weeks
  • If maternal or foetal compromise > immediate delivery
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21
Q

What are the complications of massive placental abruption?

A
  • Associated with ischaemia of overlying myometrium
  • Couvelaire uterus > life-threatening condition where loosening of placenta causes bleeding that penetrates into uterine myometrium, forcing its way into peritoneal cavity > uterus may not contract properly > PPH
  • Associated with foetal death in utero and maternal coagulopathy
22
Q

What is uterine rupture?

A
  • Generally hx of previous C-section
  • Trial of vaginal delivery after CS: risk is around 7/1000
  • Manual induction of labour increases risk 2-3x fold
  • Significant maternal and perinatal morbidity and mortality
  • Rupture of all the layers > blood flowing into abdomen
23
Q

What are the signs and symptoms of uterine rupture?

A
  • Abdominal pain
  • Hypovolaemia shock i.e. tachycardia, pallor, decreased BP
  • CTG abnormalities (typically shows prior to rupture happening)
  • Uterine contractions may stop
  • Palpation of foetus outside uterus
24
Q

How does appendicitis present in pregnancy?

A
  • Course and acuteness of onset
  • Most common non-obstetric cause: 1/2000 to 1/6000
  • 1st trimester: pain in right low quadrant
  • 2nd trimester: appendix found at level of umbilicus
  • 3rd trimester: pain is diffuse or in RUQ
  • Rebound tenderness in 55-75% of patients
  • Direct abdominal tenderness - most patients
  • Pain at McBurney point is the same in pregnancy
25
Q

What are the signs and symptoms of appendicitis in pregnant women?

A
  • Perforation approx 25% more if delayed
  • Nausea
  • Vomiting
  • Anorexia
  • In appendicitis, fetal loss is >30% when ruptured appendix and 2% with unruptured appendix
26
Q

What investigations should be done for appendicitis in pregnancy?

A
  • FBC (raised WCC - polymorphonuclear leucocytosis)

- US and MRI (MRI more sensitive)

27
Q

What is the management for appendicitis in pregnancy?

A

Surgical - open or laparoscopic (must be aware of uterus, particularly in 2nd and 3rd trimester) - liaise with obstetrician

28
Q

How does acute cholecystitis present in pregnancy?

A
  • Gallstones will be present in >95% of patients with acute cholecystitis
  • Previous known history
  • RUQ pain - radiates to right shoulder (Murphy’s sign on examination)
  • Vomiting
  • Fever, general malaise
  • Differentials: appendicitis
29
Q

What are the investigations for acute cholecystitis?

A
  • USS (1st line)
  • Blood tests - ALP (often raised in pregnancy) and ALT but often LFTs are normal
  • Amylase may be raised
30
Q

What are symptoms of pancreatitis?

A
  • Acute epigastric pain + tenderness (may radiate to back)
  • N+v
  • Low grade fever
  • Occasional jaundice
  • Diminished bowel sounds
31
Q

What would investigations show for pancreatitis in pregnancy?

A
  • Raised serum amylase (only slightly elevated in pregnancy and doesn’t correlate to disease severity) - serum lipase more sensitive, specific and longer half life
  • Hyperglycaemia (pancreas not releasing insulin)
  • Hyperbilirubinaemia
  • Hypocalcaemia (damaged pancreas releases lipase which releases free fatty acids which bind to Ca to form salts in the peritoneum)
  • Haemoconcentration
  • Electrolyte abnormalities
32
Q

What is the treatment of pancreatitis?

A
  • IV fluids
  • Correction of electrolyte imbalances, glucose levels and calcium disturbances
  • Withholding of oral intake with NG tube if necessary
33
Q

What are the signs and symptoms of renal stones?

A
  • Pain, usually in the flank
  • N+v
  • Dysuria, urgency, gross haematuria
  • Fever
  • Hx of prior episode - in 25%
34
Q

What investigations can you do for renal stones?

A
  • Microscopic haematuria
  • USS of kidneys - look for obstruction
  • However there is physiologic dilatation of right side particularly in late pregnancy (kidneys get bigger in pregnancy due to increased fluid)
35
Q

What are the symptoms of ovarian torsion?

A
  • 20% of ovarian cysts occur in pregnancy
  • Caused by ovary (usually enlarged) twists on its pedicle > impairs blood flow
  • Sudden onset, severe, unilateral colicky abdominal pain
  • N+v
  • Fever: usually low grade
  • Mass (present in ~90% of cases)
  • In pregnant women can present with systemic symptoms, raised inflammatory markers (leucocytosis)
36
Q

What would ovarian torsion show on USS?

A

Free fluid (whirlpool sign)

37
Q

What is ovarian hyperstimulation syndrome (OHSS)?

A

Causes ovaries to swell and become painful > risk factor for ovarian torsion (causes exaggerated response to excess hormones) > complication of some forms of infertility treatment.

38
Q

What are the lower ano-genital tract/cervical causes of ante-partum haemorrhage?

A
  • Post-coital bleeding (either vaginal abrasion or cervical ectropions)
  • Anal fissures
  • Vaginal infections and associated damage - candidiasis
  • Cervical dilation - as long as at term, no consequence, early > causes early labour
  • Cancer (cervical/vaginal) - rare due to screening
39
Q

What are the placental causes of ante-partum haemorrhage?

A
  • Abruption (occurs in ~0.5% pregnancies) - commonest in: smokers, previous abruptions, >35yrs, multiple pregnancies, hypertensive disorders, drug abuse
  • Placenta praevia: can be graded but judging severity depends more on position and associated factors - previous CS, multiple pregnancy, multiparity
  • Vasa praevia: (rare) occurs when anomalous chorionic plate vessels run over surface of amniotic membranes > placental cord fails to fuse into placenta (usually see foetal bradycardia) - difficult to detect unless late USS performed
40
Q

When would you get unexplained ante-partum haemorrhage?

A

For whatever reason ~1/3 of presentations of ante-partum haemorrhage are unexplained, diagnosis of exclusion so caution making this diagnosis.

41
Q

What is the immediate management for antepartum haemorrhage?

A
  • Does the woman need resuscitation? - does she look unwell, pale, clammy? Is there evidence of shock (tachycardia or hypotension)?
  • If this is the case then proceed to ABC - help, breathing (high flow O2), circulation (2 large bore cannulas, FBC/cross match/clotting + fluid)
  • Assess fetal heart
42
Q

What questions do you want to ask in a history about ante-partum haemorrhage?

A
  • Is this the 1st time the bleeding has happened?
  • How heavy is the bleeding?
  • Is there any associated abdominal pain, if so is this episodic?
  • Is the vulva/vaginal itchy/sore and any discharge?
  • Is is following sexual intercourse?
  • Up to date with normal cervical smears?
  • Has the woman had a placental localisation at 20 weeks?
43
Q

What further investigations do you want to do for ante-artum haemorrhage?

A
  • Examination - abdominal (tenderness, uterine contractions, uterine rigidity ‘woody’), vaginal (external introitus, speculum - blood, cervix), ?digital (caution in placental praevia
  • General obs (HR +BP)
  • FBC/GS (for rhesus and transfusion)
  • Clotting screen (abruption frequently cause coagulopathy)
  • Kleihaur
  • CTG - fetal heart
  • USS - only in non-acute scenario, main reason is to assess placental site and fetal growth as APH strongly associated with FGR
44
Q

What is the management of ante-partum haemorrhage?

A

Minor bleeds:
- Investigate, treat any potential causes
- Observe
Major bleeds:
- Seek assistance
- Resuscitate
- Deliver - depending on viability of foetus

45
Q

What is the Kleihauer test?

A

It detects the presence of fetal red cells in maternal circulation. If there is >5ml estimated feto-maternal haemorrhage then a further dose of anti-D will be needed.

46
Q

What causes primary post-partum haemorrhage?

A
  • Vaginal trauma (larger tears often associated with instrumental delivery can lead to rapid bleeding)
  • Uterine atony
  • Placenta - retained products, placenta accreta
    Classified as minor (500-1000ml) or major (>1000ml)
47
Q

What causes secondary post-partum haemorrhage?

A
  • Retained products
  • Infection
  • Dysfunctional Uterine Bleeding (DUB)
48
Q

What is uterine atony associated with in PPH?

A
  • Prolonged labour
  • Macrosomia
  • Sepsis
  • Multiple pregnancy
  • Grand multiparity (>5 children)
  • May lead to rapid and significant blood loss if unrecognised
49
Q

How does placenta cause PPH?

A
  • Occurs when whole or part of placenta remains in uterus, can recognise by examining the placenta or digital exam
  • Increasingly may reflect placental implantation abnormalities - placenta accreta, increta, perceta (placenta has invaded beyond depth of endometrium into myometrium) - can be extremely difficult to remove placenta - strongly associated with previous CS or uterine ablative surgery
50
Q

How do you treat PPH?

A
  • Suture vaginal tears
  • Remove retained products (unless adherent)
  • Give uterotonic drugs
  • Examination under anaesthetic +/or proceed to hysterectomy in cases where bleeding cannot be stopped or acreeta
51
Q

What is the treatment for secondary PPH?

A
  • Retained products and infection often go hand in hand with 2ndary PPH
  • 1st line: broad spectrum abx e.g. co-amoxiclav
  • 2nd line: EUA and removal of products
  • Avoid USS as difficult to interpret
  • If abx fail and no RPOC likely DUB - treat with COCP

Women's Health (19 decks)

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