Third-Trimester Vaginal Bleeding Flashcards
Third-Trimester Vaginal Bleeding MC causes ?
Cervical bleeding
Abruptio placentae
Placenta previa
Vasa previa
Cervical Bleeding
Associated with cervical change of pregnancy
Vascular engorgement
Thinning and effacement
Benign
Abruptio Placentae aka ?
placental abruption
Abruptio Placentae patho ?
Premature separation of placenta from uterine wall
After 20 weeks, but before delivery
May be diagnosed after delivery
Abruptio Placentae: causes ___ of all antepartum bleeding
1/3
Abruptio Placentae prevalence ?
Common – 1 in 75-225 deliveries
1 in 830 abruptions result in fetal death
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
Abruptio Placentae grade 1 ?
Small amount bleeding, uterine irritability, fetal heart WNL
Abruptio Placentae grade 2 ?
Mild-mod amt bleeding, uterine tetany or contractions, fetal heart with ↓variability or late decels, maternal orthostatic hypotension, BP maintained
Abruptio Placentae grade 3 ?
Mild (concealed) to severe bleeding. Uterus painful and tetanic, Fetal death, maternal hemodynamics unstable
Deliver it!
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
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
Abruptio Placentae prevention ?
No prevention, but can reduce risk factors
-Smoking, HTN, cocaine use
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
Most common cause of 3rd trimester bleeding ?
Placenta Previa
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
