WEEK 3 Flashcards
what is Antepartum haemorrhage?
defined as
bleeding from the genital tract in the second half of
pregnancy, remains a major cause of perinatal mortality and maternal morbidity in the developed world.
In approximately half of all women presenting
with APH, a diagnosis of placental abruption or placenta praevia will be made; no firm diagnosis will be made
in the other half even after investigations.
What is Hyperemesis Gracidarum (HEG)
Sever vomiting in pregnancy
persistant vomiting leading to fluid and electrolyte depletion, marked ketourinea and nutritional deficience and rapid weight loss
What causes Hyperemesis Gracidarum (HEG)?
Unknown, thought to be endocrine in origin
WHen does Hyperemesis Gracidarum (HEG) usually start?
Usually around 6/40
What history based questions should you ask with Hyperemesis Gracidarum (HEG)?
- characteristic of the vomit
- this pregnancy - gestation problems
- Last time to toilet
- Previous pregnancy - problems G’s P’s
- previous medical history
What are potential causes of Early PV bleeding?
- impantation bleed
- cervical lesions
- miscarraige
- ectopic pregnancy
- incompetent cervix
- hydatidiform mole
what is a hydatidiform mole?
AKA molar pregnancy
characterised by rapid growth of trophoblastic tissue
where chorion villi become fluid filled, with no viable embryo
WHat are the two types of hydatidiform moles?
- complete (no fetal tissue, develops from empty egg)
- incomplete
what are some causes of hydatidiform moles?
- poor nutrition
- advanced age >40
- young age <18
- mexican and asian decent increased risk
What are signs & symptoms of hydatidiform moles?
- preggo test
- ## nausea etcPartial signs: signs consistent with incomplete miscarriage
Complete signs: dark brown vaginal bleeding
Define a miscarriage?
Expulsion of the products of conception from the uterus via the birth canal before the 20th week
what are the 2 classifications of misscarriage?
- spontaneous
- induced
What re the causes of misscarriage?
- Foetal
- Genital tract
- Maternal
- Trauma
What are the foetal causes of miscarriage?
– Foetal abnormality
(chromosomal)
– poor implantation
– Abruption of the ovum
What are the maternal causes of miscarriage?
– Diseases-rubella, influenza,
acute fever, renal disease,
hypertension, – Age – ABO incompatibility, – Drugs- anaesthetics,
chemotherapy, toxic – Psychological- stress, anxiety
What are the Genital tract causes of miscarriage?
– Retroverted uterus
– Bicornuate uterus
– Myomas
– cervical incompetence
What are the trauma tract causes of miscarriage?
– MCA – Direct blow – criminal interference – abdominal surgery
what are the classifications of spontaneous miscarriage?
- missed
- threatened
- inevitable
- complete
- incomplete
- septic
What is the definition of a threatened spontaneous miscarriage?
cervix closed, membrane in tact
what is the presentation of threatened spontaneous miscarraige?
Pain
– Slight →severe; cramps;
– lower abdominal/back
Vaginal bleeding
– Nil → Slight → Heavy
What is the Inevitable of a threatened spontaneous miscarriage?
cervix is open
what is the presentation of inevitable spontaneous miscarraige?
– Free vaginal bleeding,
– ? ruptured membranes -amniotic fluid seen
– Foetal sac & contents protruding through dilating
cervical os
– More acute abdominal pain-rhythmic
What is the Missed of a threatened spontaneous miscarriage?
Products of conception not viable, retained in
the uterus & no signs of abortion
what is the presentation of missed spontaneous miscarraige?
Physiological signs of pregnancy regress
Any signs of pain & bleeding cease
→ brown discharge- +/- offensive → decay
Blood coagulation disorders may develop
– if missed abortion of > 6 to 8 weeks
What is the complete of a threatened spontaneous miscarriage?
Expulsion of all products of conception
– embryo, placenta and intact membranes
what is the presentation of complete spontaneous miscarraige?
Usually occurs < the 8th week of gestation
Pain (A/A)
Vaginal loss
– slight. → mod; bright red → brown
What is the incomplete of a threatened spontaneous miscarriage?
Not all products of conception are expelled.
– Foetus usually expelled but part of placenta is
retained
what is the presentation of incomplete spontaneous miscarraige?
Usually occurs >8 weeks but < 20 weeks
Bleeding mod → profuse
Abdominal pain &/or backache ++++
Risk of cervical shock if foetus caught in cervix
What is the septic of a threatened spontaneous miscarriage?
Infection due to lack of removal of the products of
conception
what is the presentation of septic spontaneous miscarraige?
History of abortion
Unwell, headache, nausea, sweating & shivering,
flushed/hot skin, ↑ temp, abdo pain
Tender uterus- bulky, offensive vaginal
discharge, may be pinkish in color
What are the general signs of miscarriage?
Pain-
– central, in low abdomen,
– intermittent backache
Vaginal bleeding- blood stained discharge
– brown spotting/bright red loss
• Minimal → heavy
May experience
– Uneasiness prior to onset of symptoms
What is cervical shock?
where products of coneption partially caught in cervix
- signs of shock not due to hypovolaemia
What are some risk factors of cevical shock?
- past Hx of miscarriage
- potential miscarriage on ultrasound
- smoking
- obesity
What are some symptoms of cevical shock?
− Pain – cramps; signs of pregnancy ? Subsiding; PV loss;
light or heavy bleeding – with jelly like clots; may have
nausea or tender breasts
− Level of shock out of proportion to blood loss
define ectopic pregnancy?
Fertilized ovum
embeds outside the
uterine cavity, usually
in the fallopian tubes
WHat are the various possible implantation sites for ecotopic pregnancy?
ON EXAMS
- cervical
- peritoneal
- interstitial
- tubal (isthmus)
- Tubal (ampullar)
- Infundibular (osital)
- Ovarian
- Abdominal
What are the risk factors for ectopic pregnancy?
Narrowing of the tube
– ?oedema ?inflammation ?infection
Kinking of tube
– ?adhesions ? Scarring
Damage to lining of tube
– endometriosis or PID; smoking
Delay in transit of ovum; mini pill
– Previous surgery;
IVF-tubal surgery
what are signs and symptoms of ectopic pregnancy?
- History of amenorrhea
Mild lower abdominal pain-
– occasionally sharp, stabbing; ↑ intensity over a few days
especially with bowels; tenderness on one side; rebound
tenderness; adnexal tenderness
Shoulder tip pain (KEY MARKER)
Tachycardia
Postural hypotension
Dizziness and fainting
Nausea & diarrhoea
+/- bleeding or slight brown discharge
U/S: Uterus empty
what are signs and symptoms of Ruptured ectopic pregnancy?
Sudden severe abdominal pain
Profound shock- collapse
Vaginal Bleeding - minimal
Referred shoulder tip pain
Define incompetent cervix?
Painless dilatation of cervix; the foetus, placenta &
membranes completely expelled
what causes incompetent cervix
Unknown - ? weakness of retaining sphincter
mechanism at the junction of the uterus & cervix;
what is the presentation of incompetent cervix?
Painless delivery of foetus b/n 16-23/40
where is the normal site for implantation?
endometrium of upper uterus
how much does the placenta weigh?
1/6 of baby weight
What does the placenta do?
transfer nutrients and excretory products via diffusion
no mixingof maternal and foetal blood
what are 5 functions of the placenta?
Nutritive – Amino acids; simple sugars
Respiratory – O & CO2 exchange
Excretory – Waste products
Endocrine – βHCG; HPL; Oestrogens, Progesterone,
Barrier – For most but not all
define antepartum haemorrhage?
Bleeding from the birth canal in excess of 15mls
from the 20th (approx) week of gestation to the birth
of the neonate
what are the 3 main types of antepartum haemorrhage?
Placenta Praevia
Placental abruption
Vaso praevia
what are the risk factors of antepartum haemorrhage?
- Maternal age >40
- Complex medical history prior to pregnancy
- Multigravida
- Known placenta praevia
- History of abruption
- Coagulopathies
- Use of Crack Cocaine
What is placenta pravia?
Placenta partially or wholly
implanted in the lower part of the uterus.
with placenta pravia, when do bleeding signs start to show?
• Can start spotting from 28
weeks
• more severe around 32-36
weeks
What are the 4 grades of placenta pravia?
1 - placenta lies in lower segment but does not
reach the internal os
2 - edge of placenta is attached to lower
segment of uterus & reaches internal os
3 - edge just covers internal os -bleeds once
cervix starts to dilate past 3-4cm
4 - placenta centrally covers the internal os -
torrential haemorrhage is likely
What is the presentation of placenta pravia?
Painless recurrent bleed of various amounts – tends to be BRIGHT RED Dx by transvaginal ultrasound Premature labour Shock Foetal malpresentation
What is Vasa preavia?
(type 1) Foetal vessels
crossing or running in
close proximity to the
inner cervical os.
(Type 2) Vessels course within the membranes (unsupported by the umbilical cord or placental tissue)
what is the presentation of Vasa Preavia?
Can be detected on transvaginal U/Sound
– 2nd trimester
Painless Vaginal bleeding – fresh blood
– Usually limited; non continuous
– Usually when the membranes rupture
Lack of foetal movements
– After membranes rupture
Usually late 3rd trimester of pregnancy
– Associated with labour
What is placental abruption?
Premature separation of the placenta from the uterine lining (after 20 weeks)
how often does placental abruption occur?
Occurs in 3-5% of all pregnancies
what is the process of placental abruption?
– bleeding from maternal venous sinuses into
placental bed → further separates placenta →
blood retained behind placenta → infiltrates
myometrium → extravasation causing marked
damage such as bruising & oedema
what are the risk factors for placental abruption?
Presence of complex medical disorders before pregnancy Substance abuse especially methamphetamine use Multi gravida Maternal age over 40 Previous history of abruption Hypertension Pre-eclampsia Trauma Unknown
What are the 3 types of placental abruption?
• Central/concealed
- Separation is in the middle
• Revealed/marginal
- Separation is near the edge of the placenta
• Partially revealed
- Combination of both of the above
what is the presentation of placental abruption?
Vaginal bleeding may or may not occur
(depending on type)
↑ Pulse ↓ BP, hypovolaemic shock,
Abdo pain ++
Tender uterus
Anxious; “impending doom”
→ Concealed bleeding into uterine muscle
→ Causes uterine enlargement
→ Extreme pain & hard & rigid abdomen
What are some complications of placental abruption?
Disseminated Intravascular coagulation (DIC)-
– inappropriate coagulation within blood vessels
Post partum Haemorrhage (PPH)
Renal failure
Pituitary necrosis
Distressed baby
Foetal death in-utero (FDIU)
What is a uterine rupture?
Tear in the uterus
– often associated with
prior caesarean section
What are the risk factors for uterine rupture?
Previous caesarean section
Other uterine surgery or termination of pregnancy
Grand multiparity (>6)
Undiagnosed cephlopelvic disproportion
Macrosomic (large) baby
Placenta percreta
External cephalic version
Uterine abnormalities
What are the clinical signs of placental rupture?
If in labour
– Sudden cessation of contractions
– Elevation of the presenting part
Severe constant pain
Foetal death (FDIU)
Maternal shock disproportionate with clinical signs
– Concealed haemorrhage
