Third-Trimester Vaginal Bleeding Flashcards by Korey koper

Third-Trimester Vaginal Bleeding MC causes ?

Cervical bleeding

Abruptio placentae

Placenta previa

Vasa previa

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Cervical Bleeding

Associated with cervical change of pregnancy

Vascular engorgement

Thinning and effacement

Benign

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Abruptio Placentae aka ?

placental abruption

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Abruptio Placentae patho ?

Premature separation of placenta from uterine wall

After 20 weeks, but before delivery

May be diagnosed after delivery

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Abruptio Placentae: causes ___ of all antepartum bleeding

1/3

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Abruptio Placentae prevalence ?

Common – 1 in 75-225 deliveries

1 in 830 abruptions result in fetal death

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Abruptio Placentae can be due to ?

Chronic vascular problem or a single event

Blood from vascular disruption can accumulate, causing further separation

May be partial, with a self-limited hematoma
May become complete

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Abruptio Placentae grade 1 ?

Small amount bleeding, uterine irritability, fetal heart WNL

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Abruptio Placentae grade 2 ?

Mild-mod amt bleeding, uterine tetany or contractions, fetal heart with ↓variability or late decels, maternal orthostatic hypotension, BP maintained

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Abruptio Placentae grade 3 ?

Mild (concealed) to severe bleeding. Uterus painful and tetanic, Fetal death, maternal hemodynamics unstable

Deliver it!

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Abruptio Placentae RF ?

Often unknown

Mechanical force or trauma (violence, MVA)

Maternal HTN

Smoking

Maternal age - ? Conflicting studies

Increasing parity

Thrombophilia

PROM – which comes first is unclear

Cocaine abuse

Hx of previous abruption

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Abruptio Placentae signs and sxs. ?

Fetal distress or death seen on fetal monitoring

Tetanic uterus or contractions

Uterine bleeding (80% of patients present with this c/o)

May be obvious
May be concealed ( cause it is in pocket and may no see it until delivery)

Ultrasound
-Evaluate size and location - important predictors

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Abruptio Placentae prevention ?

No prevention, but can reduce risk factors

-Smoking, HTN, cocaine use

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Abruptio Placentae tx. ?

Stabilize mom’s hemodynamic status
-Large bore IV’s, PRBC if anemic ( packed RBCs)

Delivery

Dependent on grade of abruption and gestational age
vagial delivery is preferred cause tamponade

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Most common cause of 3rd trimester bleeding ?

Placenta Previa

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Placenta Previa: Placental implantation is adjacent to or overlying the _______ cervical os

internal

Placenta Previa: Marginal ?

close to os

Placenta Previa: Partial ?

partial occlusion of os

Placenta Previa: complete

os is fully covered

Placenta Previa MC in ?

More common in early pregnancy

Placenta Previa: As lower uterine segment develops, most previas _______ .

resolve

more distance created between placenta and cervix

Placenta Previa RF ?

Multiparity

Past uterine surgeries (C-sections, D&C’s, etc.)

Multiple gestation - many sites of implantation

Maternal age – unclear why

Smoking

Placenta Previa higher risk in developing ?

Placenta accreta

Placenta increta

Placenta percreta

Placenta Previa Signs and sxs. ?

PAINLESS vaginal bleeding, usually in 3rd trimester

As lower uterine segment grows, myometrium thins

The thin myometrium can’t contract to minimize bleeding at implantation site

Average presentation of bleeding is at 34 weeks

Most previas are known due to 2nd semester sonos and most will resolve

Placenta Previa Tx. ?

Monitor and stabilize hemodynamic status of mom Large bore IV lines – crystalloid infusion, PRBC’s Continuous fetal heart rate monitoring Delivery – depending on stability of mom and baby and gestational age -24-36 gest weeks and stable – expectant management trying to prolong pregnancy. Bedrest with BRP, tocolytics, stool softeners. Steroids for fetal lung maturity if <34 weeks, serial US

Placenta Previa prognosis has improved because of ?

Conservative management Better neonatal care Earlier diagnosis Biggest risk is prematurity

Placenta accreta ?

abnormally adherent placenta scape off

Placenta increta ?

placenta invades myometrium wont come off

Placenta percreta ?

placenta penetrates myometrium and may invade nearby organs perforated U

Complete previa and uncomplicated Tx ?

surgical delivery at 36-37 weeks

Marginal previa Tx. ?

vaginal delivery may be possible cause the head with tamponade the bleeding ** C-section – careful not to cut placenta OR should be prepared for hysterectomy **

Vasa Previa pathology ?

Blood vessels in the placenta or the umbilical cord are trapped between the fetus and the internal os

Vasa Previa: when vessels rupture it is known as ?

fetus exsanguinates **umbilical cord vessels are over the oss so during delivery it is going to compress the cord and the vessels can rupture and the baby can bleed out and the baby get no oxygen **

Vasa Previa prevalence ?

1: 1000-1500 pregnancies

Vasa Previa dx. ?

With improved US, more often diagnosed antepartum

Vasa Previa If not previously diagnosed and mother presents with bleeding, tx ?

is immediate C-section ( to avoid cord compression)

Vasa Previa If dx’d before labor/bleeding – Tx. ?

close monitoring with delivery at 35 weeks (risk of prematurity outweighs risk of delivery)

Third Trimester Vaginal Bleeding less common causes ?

DIC Uterine rupture Cervical cancer/dysplasia Cervicitis Cervical polyps Vaginal laceration Vaginitis