Week 3- Bleeding in Pregnancy Flashcards
Can their be bleeding in early pregnacy?
In the first 12 weeks it is common 1/4 pregnancies
can be healthy baby
can be heavy, light, painful, not painful
What are the four major scorces of bleeding in early pregnancy?
Implantation of the pregnanacy
Miscarriage
ectopic pregnancy
rarer or non-pregnancy related causes
Why can bleeding ouccur during implantation of the pregnancy? what characterises this?
When embroy implants into lining of uterus (endometrium)
Bleeding is light and will last for a few days
What is the definition of a miscarriage?
Expulsion of the products of conception from the uterus via the birth canal before the 20th weel
What are the four causes of miscarriages?
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
What is a threatened miscarriage?
Defintion: closes cervis, membranes intact
Presentation: Pain, vaginal bleeding
Prognosis: good chance of ongoing pregnancy
What is an inevitable missacarriage?
Defintion: cervix is open
Presnetation: free vaginal bleeding, ruptured memb ranes-amniotic fluid seen, more acute abdominal pain
Prognosis: pregnancy will not continue
What is a missed misscariage?
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
What is a complete miscarriage?
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
What is a incomplete miscarriage?
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
What is an ectopic pregnancy?
fertilised ovum embeds outside the uterine cavity, usually in the fallopian tub
What are the causes/risk factors for an ectopic pregnancy?
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
What are the different implantation sites of an ectopic pregnancy?
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
What is the presentation of an ectopic pregnancy?
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
What is the presentation of a ruptured ectopic pregnancy?
Sudden abdominal pain
profound signs of shock
vaginal bleeding - minimal
referred pain to the shoulder tip
How does the pain often differ between a misscariage and ectopic pregnancy?
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
How does blood loss differ between a miscarriage and ectopic pregnancy?
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
What is the difference in gestation time relating to the onset of signs in a miscarriage vs ectopic pregnancy?
Miscarriage: <20 weeks
Ectopic: usually < 8 but definetly <12
What is cervical shock?
Products of conception partially caught in cervix
Clinical history similar to miscarriage
level of shock is disproportiont to blood loss
What are the rarer/non pregnacy related cause of bleeding in early pregnancy?
Cervical, vaginal or uteren pathology (polups or inflamation/disease)
Trophoblastic disease
What is tropoblastic disease?
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
What are the 5 checks for bleeding in pregnancy?
Check vagina for bleeding at introitus (opening)
Check the thoracic area (any internal bleeding)
Checking abdominal area
Check pelivs
check femur
WHat are the functions of the placenta?
Nutritive- amino acids, simple sugars Respiritory: O and CO2 exchange Excretory: waste products Endocrine: HCG, HPL, Oestrogens, progesterone Barrier
What is an antiepartum heamoraage?
Bleeding from the birth cannel in excess of 15mls from the 20th (24th) week of gestation to the birth of the neonate
What are the genral risk factors for antiparum heamorrage?
Maternal age >40 years Complex medical history Muligravida Known placenta praevia history of abrubtion coagulopathies use of crack
What is placenta praevia?
Where the placenta partially or wholy implants in the lower part of the uterus
What happens in the third tirmester if there is placenta praevia?
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
What are the grades of placenta previa?
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
What are the causes of placenta praevia?
Unknown- attributed to: delay in implantation, multiparity, multiple pregnancy, uterine scarring, large placenta
What are the presentations of placenta praevia?
Painless- recurrent bleed of various amounts- tends to be bright red
DX by transvaginal ultrasound, premature labour, shock, foetal malpresentation
What is vasa preavia?
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)
What are the two different types of vasa preavia?
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
What is the presentation of vasa preavia?
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
What is placental abruption?
Premature speration of the placenta from the uterine lining after 20 weeks. Occurs in 3-5% of pregnancies
What is the seris of bleeding events that occur during placental abruption?
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
What are the risk factors for placental abruption?
Presense of medical disorders before pregancy Substance abuse especially meth mulit gravida age >40 previous hx of abruption hypertension pre-eclampsea trauma
what are the types of placental abruptions?
Central/concealed- speration in the middle
Revealed/arginal- speration near edge of placenta (visable bleeding)
Partially revealed- combination of both
What is the presentation of a placental abrution?
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
What are the complications of a placental abruption?
Disseminated intravascular coagulation (DIC) Post partum heamorrage (PPH) Renal failure Pituitary necrosis Distressed baby Foetal death in uterio (FDIU)
What is a uterine rupture?
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
What are the risk factors for uterin abruption?
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
What are the clinical manifestations of uterine abruption?
If in labour- sudden cessation of contractions, elevation of the presenting part
Sevre constant pain
FDIU
Maternal shock disproportianted with clincal signs- concealed haemorrage
