Week 3- Bleeding in Pregnancy

Question 1

Can their be bleeding in early pregnacy?

Answer 1

In the first 12 weeks it is common 1/4 pregnancies
can be healthy baby
can be heavy, light, painful, not painful

Question 2

What are the four major scorces of bleeding in early pregnancy?

Answer 2

Implantation of the pregnanacy
Miscarriage
ectopic pregnancy
rarer or non-pregnancy related causes

Question 3

Why can bleeding ouccur during implantation of the pregnancy? what characterises this?

Answer 3

When embroy implants into lining of uterus (endometrium)

Bleeding is light and will last for a few days

Question 4

What is the definition of a miscarriage?

Answer 4

Expulsion of the products of conception from the uterus via the birth canal before the 20th weel

Question 5

What are the four causes of miscarriages?

Answer 5

Foetal- abmonralities, poor implantation, bruption of ovum

Genital tract- cervical incompitances, uterus malformation

Maternal- diseases, age, ABO incompatability, drugs, pschycological

Trauma- Direct blow, abdominal surgery

Question 6

What is a threatened miscarriage?

Answer 6

Defintion: closes cervis, membranes intact
Presentation: Pain, vaginal bleeding
Prognosis: good chance of ongoing pregnancy

Question 7

What is an inevitable missacarriage?

Answer 7

Defintion: cervix is open
Presnetation: free vaginal bleeding, ruptured memb ranes-amniotic fluid seen, more acute abdominal pain

Prognosis: pregnancy will not continue

Question 8

What is a missed misscariage?

Answer 8

Definition: prodcuts of conception not viable, retained in the uterus and no signs of abortion

Signs: often no signs, the physiological sings of pregnancy regress
Usuallt identified incidently on ultrasound

Prognosis: pregnancy not viable- requires medical intervention to complete the miscarriage

Question 9

What is a complete miscarriage?

Answer 9

Definition: expulsion of all prodcuts of conception

Presentation: usually occurs in the < 8th week of genstation
Often painful
Vaginal loss: slight to moderate

Prognosis: pregnancy has resulted in complete misscariage

Question 10

What is a incomplete miscarriage?

Answer 10

Definition: not all products of conception are expelled: part of placenta retained

Presentation: usually between 8 and 20 weeks
Profuse bleeding
severe abdominal pain
risk of cervical shock if foetus caught in the cervix

Prognosis: requires surgical manamgment to complete misscariage

Question 11

What is an ectopic pregnancy?

Answer 11

fertilised ovum embeds outside the uterine cavity, usually in the fallopian tub

Question 12

What are the causes/risk factors for an ectopic pregnancy?

Answer 12

Narrowing of the tube- oedema , inflamation, infection
Kinking of the tube: adhesions, scarring
Damage to the lining of the tube: endometriosis
Previous surgery: IVF or Tubal surgery

Question 13

What are the different implantation sites of an ectopic pregnancy?

Answer 13

Abdominal- free in abdominal cavity
Ovairan- in ovary
Infundibular- (ostial) begining of tube
Tubul (ampullar) most common - middle of tube
Tubal (isthmus) end of tube
Intersitial- interstital space
Peritoneal - Outside of uterus
Cervical - in cervix

Question 14

What is the presentation of an ectopic pregnancy?

Answer 14

Lower abdominal pain- usually localised to affected side- sharp, stabbing, increasing intensity
Dissiness, fainting, nausea, diorhea, tachycardia, postural hypotension
maybe have vaginal bleeding or discharge

Question 15

What is the presentation of a ruptured ectopic pregnancy?

Answer 15

Sudden abdominal pain
profound signs of shock
vaginal bleeding - minimal
referred pain to the shoulder tip

Question 16

How does the pain often differ between a misscariage and ectopic pregnancy?

Answer 16

Miscarriage- usually cramp like pain in centre abdomen/back- onset sudden or slow

Ectopic- sharp constant pain, usually on one side of the abdomen and shoulder tip pain

Question 17

How does blood loss differ between a miscarriage and ectopic pregnancy?

Answer 17

Misscarraige: small brown loss to severe bleeding, may be some products of conception

Ectopic: may or may not have blood loss- usually older (brown)
may display signs of shock if bleeding into the abdomen
Blood loss out or proportion to signs of shock

Question 18

What is the difference in gestation time relating to the onset of signs in a miscarriage vs ectopic pregnancy?

Answer 18

Miscarriage: <20 weeks

Ectopic: usually < 8 but definetly <12

Question 19

What is cervical shock?

Answer 19

Products of conception partially caught in cervix
Clinical history similar to miscarriage
level of shock is disproportiont to blood loss

Question 20

What are the rarer/non pregnacy related cause of bleeding in early pregnancy?

Answer 20

Cervical, vaginal or uteren pathology (polups or inflamation/disease)

Trophoblastic disease

Question 21

What is tropoblastic disease?

Answer 21

At time of implantation, chorion villi become fluid filled, no viable embryo
Mostly diagnosed in 1st trimester- may present with dark brown vaginal bleeding
Requires surgical managment

Question 22

What are the 5 checks for bleeding in pregnancy?

Answer 22

Check vagina for bleeding at introitus (opening)
Check the thoracic area (any internal bleeding)
Checking abdominal area
Check pelivs
check femur

Question 23

WHat are the functions of the placenta?

Answer 23

Nutritive- amino acids, simple sugars
Respiritory: O and CO2 exchange
Excretory: waste products
Endocrine: HCG, HPL, Oestrogens, progesterone
Barrier

Question 24

What is an antiepartum heamoraage?

Answer 24

Bleeding from the birth cannel in excess of 15mls from the 20th (24th) week of gestation to the birth of the neonate

Question 25

What are the genral risk factors for antiparum heamorrage?

Answer 25

Maternal age >40 years
Complex medical history
Muligravida
Known placenta praevia
history of abrubtion 
coagulopathies
use of crack

Question 26

What is placenta praevia?

Answer 26

Where the placenta partially or wholy implants in the lower part of the uterus

Question 27

What happens in the third tirmester if there is placenta praevia?

Answer 27

The placenta can sperate as the uterus grows and strechers which can lead to bleeding
Spotting from 28 weeks
More sevre around 32-36 weeks

Question 28

What are the grades of placenta previa?

Answer 28

Grade one- placenta lies in the lower segmant but does not reach the internal OS

Grade 2- edge of placenta attached to lower uterus and reaches internal os

Grade 3- edge just covers internal os- bleeds once cervix starts to dialate past 3-4cm

Grade 4- placenta centrally covers internal os- torrential hemorrage is likley

Question 29

What are the causes of placenta praevia?

Answer 29

Unknown- attributed to: delay in implantation, multiparity, multiple pregnancy, uterine scarring, large placenta

Question 30

What are the presentations of placenta praevia?

Answer 30

Painless- recurrent bleed of various amounts- tends to be bright red
DX by transvaginal ultrasound, premature labour, shock, foetal malpresentation

Question 31

What is vasa preavia?

Answer 31

Where the foetal blood vessles are crossing or running in close proximity to the inner cervical os. Vessles course within membranes (unsuported by the umbilical cord of placental tissue)

Question 32

What are the two different types of vasa preavia?

Answer 32

Type one- umbilical chord located in wrong position with vessles comming out of placemnta witha segment not in umbilical chord but still covered by membrane

Type 2- vessles come from placenta not covered in membarane

Question 33

What is the presentation of vasa preavia?

Answer 33

Can be detected in trans-vaginal ultra sound in 2nd trimester

Painless vaginal bleeding- usually limited not continuous and when membranes ruptures

Lac of foetal movement after rupture

Usually in late 3rd trimster of pregnancy and is assocaited with labour

Question 34

What is placental abruption?

Answer 34

Premature speration of the placenta from the uterine lining after 20 weeks. Occurs in 3-5% of pregnancies

Question 35

What is the seris of bleeding events that occur during placental abruption?

Answer 35

Bleeding from maternal venous sinuses into placental bed- further spertation- blood retained behind placenta- inflitrates myimetrium- extavasation causing marked damage such as brusing and odema

Question 36

What are the risk factors for placental abruption?

Answer 36

Presense of medical disorders before pregancy
Substance abuse especially meth
mulit gravida
age >40
previous hx of abruption 
hypertension
pre-eclampsea
trauma

Question 37

what are the types of placental abruptions?

Answer 37

Central/concealed- speration in the middle

Revealed/arginal- speration near edge of placenta (visable bleeding)

Partially revealed- combination of both

Question 38

What is the presentation of a placental abrution?

Answer 38

Vaginal bleeding (dependent on type)
increased HR, decreased BP, hypovolemica shock
Abdo pain
Tender uterus
Anxious- conceled bleeding into uterine muscle, rigidity and pain on plapation

Question 39

What are the complications of a placental abruption?

Answer 39

Disseminated intravascular coagulation (DIC)
Post partum heamorrage (PPH)
Renal failure
Pituitary necrosis
Distressed baby
Foetal death in uterio (FDIU)

Question 40

What is a uterine rupture?

Answer 40

tear in the uterus often associated with prior c section
rare- 3:10000
Most likley to occur in labour and is life threatening to mum and baby

Question 41

What are the risk factors for uterin abruption?

Answer 41

Previopus c section 
other uterine surgery or termination of preganacy 
grand multiparity
Undiganosed cephlopelivc disproportion
Macrosomic (large baby)
placenta percreta 
external cephalic version 
uterine abnomalities

Question 42

What are the clinical manifestations of uterine abruption?

Answer 42

If in labour- sudden cessation of contractions, elevation of the presenting part
Sevre constant pain
FDIU
Maternal shock disproportianted with clincal signs- concealed haemorrage