Week 4 - I - Bleeding in Late Pregnancy, APH - Placental abruption, praevia, accreta, uterine rupture, vasa praevia - PPH

Question 1

What is the cut off for bleeding in early pregnancy to bleeding in late pregnancy? What is bleeding in late pregnancy known as?

Answer 1

Bleeding in early pregnancy is a bleeding occuring before 24 weeks

Bleeding in late pregnancy is bleeding occuring from 24 weeks gestation

Bleeding late pregnancy is known as an antepartum haemorrhage - genital tract bleeding from 24 weeks gestation

Question 2

Globally, obstetric haemorrhage is a major cause of death but remains relatively uncommon in the UK What are some of the causes of antepartum haemorrhage?

Answer 2

• Placental praevia
• Placental abruption
• Vasa praevia
• Bloody show - this is benign and normal
  
  • Bloody show is the passage of a small amount of blood or blood-tinged mucus through the vagina near the end of pregnancy. It can occur just before labor or in early labor as the cervix changes shape, freeing mucus and blood that occupied the cervical glands or cervical os.

Question 3

When does the placenta become the sole source of nutrition for the foetus? What are its function?

Answer 3

The placenta becomes the sole source of nutrition for the foetus from week 6 of gestation It is important for nutrition/waste exchange and gas exchange from foetus to mother Also involved in hormone production during pregnancy

Question 4

Bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour. Bleeding from or into the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby What are these two definitions talking about?

Answer 4

These are the definitions for Antepartum haemorrhage

Question 5

Placenta praevia, placental abruption, vasa praevia and the benign blood show are all causes of APH Name any other causes?

Answer 5

Local causes eg polyps, cervical cancer, cervicitis Uterine rupture

Question 6

There are different ways to quantify an APH Spotting Minor Major Massive Describe each of these

Answer 6

Spotting - staining or streaking noticed on underwear or sanitary protection Minor - blood loss less than 50ml that has settled Major - blood loss of 50-1000ml with no signs of clinical shock Massive - blood loss of greater than 1000mls and/or signs of clinical shock

Question 7

What is the volume of blood lost in a post-partum haemorrhage?

Answer 7

Volume of blood lost in post-partum haemorrhage is greater than 500mls in the first 24 hours after delivery

Question 8

The most common cause of APH is blood (heavy) show which is benign What is the most common pathological cause?

Answer 8

The most common pathological cause of APH is placenta abruption

Question 9

What is placental abruption?

Answer 9

Placental abruption is when there is partial or complete separation of the placenta from the uterine lining

Question 10

Placental abruption occurs in 1% of pregnancies but 40% of APH What is the pathophysiology of placental abruption? The exact cause is unkown

Answer 10

• Vasospasm of small arteries bleeding into muscle layers. This causes bleeding between muscle fibres making the uterus contract until it becomes rock hard. It interrupts the placental circulation causing hypoxia for the baby.

Question 11

When the blood from placental abruption penetrate the myometium what can this cause? This is a life threatining condition that can result in foetal hypoxia and death

Answer 11

This can cause tonic uterine contractions interrupting the placental circulation resulting in couvelaire uterus Couvelaire uterus is a life-threatening condition in which loosening of the placenta (abruptio placentae) causes bleeding that penetrates into the uterine myometrium forcing its way into the peritoneal cavity.

Question 12

Couvelaire uterus is an emergency condition and what is its treatment?

Answer 12

The treatment would be to have emergency delivery of the baby The increase in intrauterine pressure associated with the uterine contractions risks a uterine rupture

Question 13

What are the risk factors for placental abruption? (large for gestational dates causes are causes of abruption)

Answer 13

Pre-eclampsia/hypertension Smoking/cocaine/amphetamine Trauma - blunt force Polyhdramnios, multiple pregnancy, diabetes

Question 14

What are the symptoms of placenta abruption? If the placenta lies posteriorly what is the symptom?

Answer 14

Severe continous abdominal pain Backache if posterior placenta Bleeding - which may be concealed Preterm labour Maternal collapse

Question 15

If the placental abruption is concealed, this can potentially lead to maternal shock and should beware of renal failure and sheehan syndrome here What is sheehan syndrome?

Answer 15

In sheehan syndrome, there is a massive post partum haemorrhage resulting in the pituitary gland not receiving enough blood This leads to hypopituitarism (decreased functioning of the pituitary gland), due to ischaemic necrosis of the gland and therefore the hormones produced by the pituitary gland will show symptoms due to their absence Lack of ACTH, TSH, GnRH, LH, FSH, Prolactin (ADH and oxytocin)

Question 16

What is another name for bloody show? it signifies that the patient is actually in preterm labour?

Answer 16

This would be heavy show The passage of a small amount of blood or blood-tinged mucus through the vagina near the end of pregnancy. It can occur just before labor or in early labor as the cervix changes shape, freeing mucus and blood that occupied the cervical glands or cervical os. Bloody show is a relatively common feature of pregnancy, and it does not signify increased risk to the mother or baby

Question 17

What are the different signs of placental abruption?

Answer 17

A tender tense uterus Inconsistent signs in proportion to the amount of blood lost Foetal heart - bradycardia/absent

Question 18

What is the immediate management of placental abruption?

Answer 18

Resussitae mother Assess and deliver the baby Manage the complications

Question 19

The first thing to do in a placental abruption incident is to resuscitate the mother (The baby cannot be saved if the mother is collapsed. Then make a plan to deliver baby. ) What is done in the rapid assessment of the mother?

Answer 19

Oxygen - 15l/min non rebreather 2large bore cannulas (grey) IV access Full blood count, U&Es, cross match the blood, coagulation studies also Give IV fluids Kliehaur test Foetal heartbeat Catheterisation of mother

Question 20

When should be careful if giving IV fluids to treat placental abruption?

Answer 20

Should be careful in patients with pre-eclampsia - driving the blood pressure too high can be very dangerous

Question 21

Kleihauer test is done in patients whom present with APH symptoms What is this test? Who is it done in?

Answer 21

The Kleihauer test should be performed in rhesus D (RhD)-negative women to quantify fetomaternal haemorrhage (FMH) in order to gauge the dose of anti-D immunoglobulin (anti-D Ig) required.

Question 22

Kliehauer’s test equates the number of foetal red cells/over the number of maternal red cells which gives the foetal volume/maternal volume For every 4mls of foetal red blood cells in the maternal blood, how much anti-D is given?

Answer 22

If the mother is over 20 weeks pregnant and there is blood tranfusion between baby and rhesus negative mother, give 500units antiD and do a Kleihauer test - for every 4mls of foetal red blood cells measured in the test, give 500units anti-D (500 units only can suppress immunisation by up to 4mL of foetal red cells)

Question 23

In a women with placental abruption, it is important to catheterise the patient to measure hourly urine outputs - checks to measure sure patient is not entering acute renal failure How is the foetal heart beat assessed in this condition?

Answer 23

The foetal heartbeat is assessed using a pinard stethosocpe If you are unable t auscultate the baby then set up a CTG if the CTG does not register a foetal heart beat then use an ultrasound scan

Question 24

What abnormalities on CTG tracing would suggest placental abruption for the foetus?

Answer 24

Late decelerations are indicative of foetal hypoxia and Foetal bradycardia due to the poor placental perfusion

Question 25

Do ultrasound scans often detect a foetal heartbeat in placental abruption? Are ultrasound scans used for diagnosing the placental abruption?

Answer 25

USS are used to detect a foetal heartbeat if unable to on CTG USS scans are good for ruling out placenta praevia but are not good for diagnosing placental abruption - will only detect abruption inn 3/4cases

Question 26

What should the urine production of the mother in the catheter be?

Answer 26

Hourly check ups to monitor urine production - want a 30ml/hour urine production

Question 27

After resus of the mother FBC, U&Es, LFTs, crossmatching, coag screen, Kleihauers test, IV fluids Cathertisation Assessing foetal heartbeat It is important to decide what the management of the delivery will be What are the management options? When is conservative management carried out?

Answer 27

Conservative management - if no evidence of maternal coagulopathy, hypotension or severe ongoing blood loss- aim to conservatively manage and give birth to a term baby Can try artificial membrane rupture and induction of labour in mild cases If unstable fetal/maternal status - cesarean section

Question 28

For all patients who experience placental abruption, what is given to help promote lung maturation in the foetus?

Answer 28

Give a steroid - betamethasone IM

Question 29

What are some of the complications of antepartum haemorrhage due to placental abruption?

Answer 29

Hypovalaemia Coagulopathy - ie could have DIC due to thromboplastin release Anaemia PPH Infection

Question 30

Due to placental abruption being a potential risk for coagulaopathy which could cause disseminated intravscular coagulation, what would be given if this was detected?

Answer 30

Would give fresh frozen plasma to return the patient the clotting factors

Question 31

What is the percentage of foetal mortality in cases of placental abruption? What are other consequences to the foetus?

Answer 31

14% foetal mortality Foetal hypoxia Prematurity Small for gestational age and IUGR

Question 32

What are the ways in which to prevent placental abruption? it is important to try and control the risk factors A known risk for placental abruption is anti-phospholipid syndrome, what is given for this?

Answer 32

Risk factor Preeclapmsia - give 75mg aspirin from Smoking - smoking cessation Anti-phospholipid syndrome - give LMWH and 75mg aspiring from week 12 Dont do drugs like cocaine and amphetamine

Question 33

Placenta is partially or totally implanted in the lower uterine segment WHat is this condition?

Answer 33

This condition is placenta praevia

Question 34

What is the lower segment of the uterus? What is the other name for placental praevia?

Answer 34

The lower segment of the uterus is the part of the uterus that lies below the utero-vesical pouch It contains less muscle fibres than the upper segment The other name for placental praevia low lying placenta

Question 35

Approx half the amount of placental abruption cases causing APH is the amount of APH due to placental praevia WHat percentage are therefore due to placental abruption and which percentage is due to placental praevia?

Answer 35

Approx 40% due to placental abruption Approx 20% due to placental praevia

Question 36

What are different risk factors for placental praevia?

Answer 36

Previous cesaerean section Previous placental praevia Smoking Asian Multiparity Advanced maternal age \> 40 years

Question 37

What are the different types of placenta praevia? What is used to classify the type of placenta praevia?

Answer 37

Major placenta praevia - this is where the placenta lies over the internal cervical os Minor placenta pravia - if the leading edge of the placenta lies in the lower uterine segment but does not cover the internal cervical os USS used to classify type

Question 38

What are the placental praevia symptoms?

Answer 38

Painless bleeding \>24 weeks gestation Bleeding is usually unprovoked but can be brought on by coitus Bleeding usually starts of minor and then becomes severe

Question 39

What are the signs of placental praevia? What is seen on CTG?

Answer 39

Usually the shock in the patient is in proportion to the bleeding uterus is soft and not tender There are usually malpresentations with the foetus Coagulopathy is rare CTG is usually normal

Question 40

What examination should be avoided in patients with antepartum haemorrhage and why? What examaintion may be useful in the diagnosis of placental praevia?

Answer 40

Avoid vaginal examination as placental praevia may bleed catastrophically Speculum examination may be useful

Question 41

What scan should be checked for diagnosing placental praevia? How is it otherwise diagnosed? What scan is useful for excluding placenta accreta?

Answer 41

Check the 20 week anomaly scan to exclude abnormalities including placenta praevia Diagnosed via ultrasound scan - transvaginal is best MRI is useful for excluding placenta accreta - occurs when placenta attaches deeply and penetrates into the uterine muscle

Question 42

What is the management of placenta praevia?

Answer 42

Do not carry out a vaginal examination as bleeding can increase from mild to severe very rapidly in placenta praevia Resuscitation of the mother - ABC Assess baby Investigations

Question 43

When carrying out the resuscitation of the mother in placenta praevia, oxygen can be given for breathing. What should be carried out when managing the circulation of the mother in the ABC approach?

Answer 43

Maternal pulse, BP, heart sounds, cap refill Two large bore cannulas (16G) - IV access FBC, LFTs and U&Es, Kleihauer if Rhesus negative Crossmatch 4-6units red blood cells Anti-D if Rh Negative

Question 44

In the management of placental praevia, what is done to measure the foetal heartbeat? Are there any abnormalities on this usually? What two drugs can be given and why? What weeks can these drugs be given from?

Answer 44

Carry out cardiotocography to measure the foetal heartbeat - should be normal Give steroids from 24 to 34+6 weeks - this will help lung maturation in case of a premature delivery Can give magnesium sulphate from 24to32 weeks for neuroprotection against cerbropasly if planning early delivery

Question 45

What should be given within 72 hours of the bleed to the mother? Can be given up to 10days postbleed but best within 3 days What test is carried out to see the appropriate dose?

Answer 45

Give 500units antiD immunoglobulin (if greater than 20weeks gestation - it will be greater than 24 weeks in APH anyway) within 72 hours to rhesus negative mothers to protect against Rhesus disease Carry out Kleihauers test - for every 4mL of foetal red blood cells, give 500units anti-D

Question 46

If the patient is stable, what is the management of the placenta praevia? What should be avoided?

Answer 46

If the patient is stable then keep the patient in for at least 24 hours after the bleeding has ceased and then conservative/expected management Avoid penetrative sexual intercourse after placenta praevia - want to avoid huge haemorrhag e

Question 47

If the patient is unable to be stabilised or there is significant foetal compromise, what is the recommended management? (regardless of the type of placenta praevia) What is the management of major placenta praevia?

Answer 47

If the patient is unable to be stabilised - urgent cesarean section is recommended The management of major placenta praevia is cesarean section also - be that expected if the patient is stabilised or immediate if not stabilised

Question 48

What is the delivery options for a patient with minor/partial placental praevia?

Answer 48

If the tip of the placental encroaches within 2cm of the internal os then c-section with consultant present If the tip of the placental is greater than 2cm from internal os and no malpresentation of the foetus then vaginal delivery is aimed for

Question 49

Placental abruption vs placenta praevia * Shock is in proportion to visible blood loss? * Continuous pain? * Tender and tense uterus? * Malpresentation of the foetus? * CTG abnromal - late decelerations/absent foetal heart rate? * Coagulation problems are rare? * Fresh forzen plasma required? * Small bleeds before large?

Answer 49

Placental abruption * Shock out of keeping with visible loss, severe continuous abdominal pain, tender and tense uterus, normal lie and presentation of the foetus, CTG abnormalities, Coagulation problems - give fresh froen plasma if DIC, may have concealed bleeding Placental praevia * Shock in proportion to visible loss, no pain, uterus not tender, malpresentation of foetus, normal CTG, coag problems are rare, small bleeds before large

Question 50

A morbidly adherent placenta: abnormally adherent to the uterine wall What is this?

Answer 50

This is placenta accreta

Question 51

What are the major risk factors for placenta accreta?

Answer 51

The maor risk factors for this condition are placenta praevia and previous C section

Question 52

What type of bleeding is placenta accrete asssociated with?

Answer 52

associated with severe bleeding, post partum haemorrhage and hysterectomy may be required

Question 53

When placenta accreta invades into the myometrium what is it known as? What is it known as when it invades into the bladder?

Answer 53

Morbidly adherent placenta to the uterine wall is placental accreta When the placenta invades the myometrium - placental increta Placenta percreta when the placenta invades the uterine wall and serosa penetrating to the bladder

Question 54

Placenta percreta is when the placenta reaches the uterine serosa What tests may help diagnose placenta accreta?

Answer 54

Transvaginal ultrasound and MRI

Question 55

What is the management of placenta accreta?

Answer 55

Prophylactic internal iliac balloon occlusion can be given to prevent the massive blood loss that may occur during delivery Cesarean hysterectomy is usually carried out as there can be an expected \> 3L blood loss if not

Question 56

Uterine rupture is defined as full thickness rupture of the uterus What are the risk factors for uterine rupture? What drugs can increase the risk of uterine rupture? What type of scars are more likely to rupture?

Answer 56

Previous c-section / uterine surgery ie myomectomy - removal of uterine fibroids - LSCS are far less likley to rupture than vertical line incision Multiparity - especially if oxytocin was used Obstructed labour

Question 57

What are the symptoms of uterine rupture? When does rupture usually coccur?

Answer 57

Rupture usually occurs in labour - during stage 2 of labour but can occur during the third trimester Symtpoms - severe abdominal pain, maternal collapse, can have shoulder tip pain, PV bleeding (per vaginal)

Question 58

What are the signs of uterine rupture?

Answer 58

Intrapartum -loss of contractions Acute abdomen - abdominal pain Peritonism Foetal distress/intrauterine death

Question 59

Urgent Resuscitation & Surgical management is imperative in uterine rupture What is the ABC management in resuscitation? Same as for placental abruption and placenta praevia

Answer 59

Oxygen 2 large bore 16G IV access cannulas FBC, LFTs and U&Es, Kleihauers if Rh Negative Crossmatch with 4-6 units Red blood cells May need major haemorrhage protocol Anti-D if Rh Negative IV fluids required

Question 60

What type of operation is usually carried out in a uterine rupture? What antibitoics are given post op?

Answer 60

Usually a laparotomy is carried out - need wide access to the abdominal cavity - midline incision Usually give amox and gentamicin post sugery as antiobitoic coverage

Question 61

Define vasa praevia?

Answer 61

This a condition where unprotected foetal vessels traverse the foetal membranes over the internal cervical os

Question 62

Why is there such a high mortality rate in vasa praevia pregnancies? - 60% rate

Answer 62

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Question 63

What are the risk factors for vasa praevia? How is it diagnosed?

Answer 63

Risk factors are IVF pregnacies, multiple pregnancies, and low lying placenta Diagnosed via ultrasound

Question 64

What is the classical triad of the signs of vasa praveia?

Answer 64

Painless vaginal bleeding Following rupture of membranes Causing foetal bradycardia/death

Question 65

Pregnancies complicated by unexplained APH are also at increased risk of adverse maternal and perinatal outcomes. What percentgae of antepartum haemorrhage does unxeplained causes account for?

Answer 65

Accounts for 1/3rd of antepartum haemorrhage

Question 66

What is the recommended delivery for a person with vasa praevia? Cesarean if emergency of course

Answer 66

Recommended is elective cesarean surgery for delivery - decreases risk of foetal haemorrhage prior to rupture of membranes - around 35/36 weeks gestation

Question 67

We have now discussed causes of APH \* Placental abruption \* Placenta praevia \* Placenta accreta (increta (myometrium) and percreta (serosa) \* Uterine rupture \* Vasa praevia Now will discuss postpartum haemorrhage Define post partum haemorrhage?

Answer 67

Postpartum haemorrhage is defined as a blood loss greater than 500ml int he first 24 hours after delivery

Question 68

What is the difference between primary and secondary post-partum haemorrhage?

Answer 68

Primary PPH - blood loss greater than 500mls in first 24 hours after pregnancy Secondary PPH - blood loss greater than 500mls \>24 hours to 12 weeks post delivery usually due to retained placental tissue or clot

Question 69

State the difference between spotting, minor, major and massive APH? What is the difference between minor and major PPH?

Answer 69

* APH * Spotting - streaking or spotting of blood on underwear * MInor - blood loss less than 50ml * Major -blood loss 50-1000ml with no signs of clinical shock * Massive - blood loss \>1000ml and/or signs of clincal shoc * Remember Kleihauer, Anti-D & Steroids for APH * PPH * Minor - blood loss 500-1000ml without clinical shock * \* Major - blood loss greater than 1000ml or signs of cardiovascular collapse or on going bleeding

Question 70

What are the causes of PPH? The 4Ts

Answer 70

\* Tone - uterine atony \* Trauma - any trauma to cervix or vagina \* Tissue - retained placental tissue \* Thrombin - coagulation disorders

Question 71

Between tone, trauma, tisse and thrombin, what is the most common cause of PPH?

Answer 71

Tone 70% Trauma 20% Tissue 10% Thrombin \<1%

Question 72

How does uterine atony cause post partum haemorrhage?

Answer 72

uterine atony is the loss of tone in the uterine musculature - normally uterine contractions compresses blood vessels and reduces blood flow increasing the likelihood of coagulation and reducing haemorrhage A lack of uterine muscle contraction, however, can lead to an acute hemorrhage, as the uterine blood vessels are not sufficiently compressed.

Question 73

The causes of PPH were the 4Ts - tone, trauma, tissue, thrombin What are risk factors for PPH? What is given in the active management of the third stage of labour? - this can reduce risk of PPH

Answer 73

Risk factors Prolonged labour Operative vaginal delivery - trauma Cesarean section Retained placenta Syntocinon/seyntometrine - shown to decrease risk of PPH and reduce the time of the third stage of labour

Question 74

What is the third stage of labour? How long should it take? What is a prolonged third stage of laobour? What are the signs that placental separation has occured?

Answer 74

Third stage of labour is the delivery of the placenta Normally takes around 10minutes (the drugs can reduce this to 5 minutes) and is normal up to one hour Prolonged is greater than one hour * Signs * Uterus contracts hardens and rises * There is a rush of blood - PV bleeding * Umbilical cord lengthens permanently

Question 75

In the intial management of PPH, should assess volume of blood loss, stop the bleeding and fluid replace all at the same time It is important to determine the cause of the bleeding when assessing blood loss WHat blood smaples are collected after 2large bore cannulas have been inserted?

Answer 75

FBC, LFTs, U&Es, Clotting factors Crossmatch 6units red packed cells

Question 76

What is given to stop bleeding intitially in PPH?

Answer 76

Bimannual uteirne massgae and 5units oxytocin IV

Question 77

If bleeding continues despite the uterine massage and the 5units oxytocin, insert a Foley catheter what is then given next?

Answer 77

If bleeding continues give patient * ergometrine 0.5 mg (500 micrograms) by slow intravenous or intramuscular injection (contraindicated in women with hypertension) * oxytocin infusion (40 iu in 500 ml isotonic crystalloids at 125 ml/hour) unless fluid restriction is necessary

Question 78

How does ergometrine work? When should the injection of ergometrine be avoided?

Answer 78

Give ergometrine IV - directly stimulates the uterine muscle to increase force and frequency of contractions. Also works as an alpha agonist Avoid giving this drug in patients with hypertension or cardiac abnormalities Can cause increased blood pressure

Question 79

Despite giving 5units oxytocin and uterine massage, then giving ergometrine and oxytocin infusion in Hartman's solution, if bleeding continues what should be given? What is the max amount of doses of the next drug? What drug is given after this?

Answer 79

If bleeding continues give * carboprost 0.25 mg by intramuscular injection repeated at intervals of not less than 15 minutes to a maximum of eight doses (use with caution in women with asthma) * misoprostol 800 micrograms sublingually.

Question 80

PPH Run through the entire management of PPH from start to finish?

Answer 80

* Step 1 = palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’) i.e. uterine massage + also can do bimanual compression (life-saving measure) * Step 2 = ensure that the bladder is empty (Foley catheter, leave in place) * Step 3 = oxytocin 5 iu by slow IV injection (may have to repeat dose) * Step 4 = ergometrine 0.5 mg by slow IV/IM injection (contraindicated in women with hypertension) * Step 5 = oxytocin infusion (40 iu in 500 ml isotonic crystalloids at 125 ml/hour) unless fluid restriction is necessary * Step 6 = carboprost 250 micrograms by intramuscular injection repeated at intervals of not less than 15 minutes to a maximum of eight doses (use with caution in women with asthma) * Step 7 = misoprostol 800 micrograms sublingually.

Question 81

After giving the carboprost ( a synthetic prostaglandin analogue of PGF2α with oxytocic properties - given under brand name hemabate) and misoprostolol, what drugs can be tried before sending to operating theatre?

Answer 81

Try giving tranexamic acid before sending to theatre where they are under anaesthesia to determine the cause

Question 82

When sent to theatre, rule out cervical trauma or retained tissue products What type of suture can be attempted to stop the bleeding before considering uterine and internal iliac artery ligation?

Answer 82

Consider a B-Lynch brace uterine suture The B-Lynch suture or B-Lynch procedure is a form of compression suture used in gynecology. It is used to mechanically compress an atonic uterus in the face of severe postpartum hemorrhage.

Question 83

Assess the cause of bleeding in PPH, stop the bleeding and now fluid resuscitate What is given for fluids? What is given for the potential coagulaopathy/DIC?

Answer 83

Fluids Crystalloid hartmanns - 0.9% slaine Potential coagulaopthy/DIC - FFP, Cryoprecipitate, platelets PPH common but most women respond to utero-tonic agents.

Question 84

What was secondary PPH again? Whtt is the usual cause of it? How can this be diagnosed?

Answer 84

This is haemorrgae greater than 500mls \>24hours post delivery to 12 weeks Retained placental tissue is usually the cause and can be diagnosed on USS

Question 85

If heavy blood loss in PPH, can give antibiotic to cover against infection and also take a curettage of the uterus to rule out which cancer?

Answer 85

Rules out choriocarcinoma - Choriocarcinoma is a fast-growing cancer that occurs in a woman's uterus (womb). The abnormal cells start in the tissue that would normally become the placenta