Ob Kaplan Chap 6 Late Pregnancy Bleeding

Front 1

Define Late pregnancy bleeding

Back 1

Vaginal bleeding occurring after 20 weeks' gestation. Prevalence is <5%, but when it does occur, prematurity and perinatal mortality quadruple.

Front 2

Differential Dx for Late pregnancy bleeding

Back 2

1. Cervical causes include erosion, polyps, and, rarely, carcinoma
2. Vaginal causes include varicosities and lacerations.
3.Placental causes include abruptio placenta, placenta previa, and vasa previa.

Front 3

For late pregancy bleeding what is the initial
1. evaulation (6)
2. labs (4)
3. Tx

Back 3

1. What are patient's vital signs? Are fetal heart tones present? What is fetal status? What is the nature and duration of the bleeding? Is there pain or contractions? What is the location of placental implantation?
2.Complete blood count, disseminated intravascular coagulation (DIC) workup (platelets, prothrombin time, partial thromboplastin time, fibrinogen, D-dimer), type and cross-match, and sonogram for placental location. Never perform a digital or speculum examination until ultrasound study rules out placenta previa.
3.Start an IV line with a large-bore needle; if maternal vital signs are unstable, run isotonic fluids without dextrose wide open and place a urinary catheter to monitor urine output. If fetal jeopardy is present or gestational age is ±36 weeks, the goal is delivery.

Front 4

Placenta abruption triad

Back 4

1. Late trimester painful bleeding
2 Normal placental
implantation
3. Disseminated intravascular
coagulopathy (DIC)

Front 5

Etiology/Pathophysiology of placenta abruption

Back 5

1.A normally implanted placenta (not in the lower uterine segment) separates from the uterine wall before delivery of the fetus. Separation can be partial or complete.

Front 6

Risk factors for placenta abruption

Back 6

1. previous abruption
2. hypertension
3. maternal trauma.
4.maternal cocaine abuse
5. premature membrane rupture.

Front 7

Clinical presentation of placenta abruption

Back 7

1. most common cause of late-trimester bleeding,
2. most common cause of painful late-trimester bleeding.

Front 8

Dx of placenta abruption

Back 8

This is based on the presence of painful late-trimester vaginal bleeding with a normal fundal or lateral uterine wall placental implantation not over the lower uterine segment

Front 9

Tx of placenta abruption

Back 9

1. Emergency cesarean delivery-performed if maternal or fetal jeopardy is present as soon as the mother is stabilized.
2. Vaginal delivery-performed if bleeding is heavy but controlled or pregnancy is >36 weeks. Perform amniotomy and induce labor. Place external monitors to assess fetal heart rate pattern and contractions. Avoid cesarean delivery if the fetus is dead
3.Conservative in-hospital observation- performed if mother and fetus are stable and remote from term, bleeding is minimal or decreasing, and contractions are subsiding. Confirm normal placental implantation with sonogram and replace blood loss with crystalloid and blood products as needed.

Front 10

Complications of placenta abruption

Back 10

Severe abruption can result in hemorrhagic shock with acute tubular necrosis from profound hypotension, and DIC from release of tissue thromboplastin into the general circulation from the disrupted placenta. Couvelaire uterus refers to blood extravasating between the myometrial fibers, appearing like bruises on the serosal surface

Front 11

Characteristics of severe abruption

Back 11

1. abrupt knifelike uterine pain
2. severe late decels
3. bradycardia
4. fetal death
5. severe DIC

Front 12

Characterististics of moderate abruption

Back 12

1. uterine pain
2. moderate vaginal bleeding can be gradual or abrupt in onset. From 25 to 50% of placental surface is separated. 3. Fetal monitoring may show tachycardia, decreased variability, or mild late decelerations.

Front 13

Characteristics of mild abruption

Back 13

1. vaginal bleeding is minimal
2. no fetal monitor abnormality.
3. Localized uterine pain and tenderness is noted, with incomplete relaxation between contractions

Front 14

Placenta previa triad

Back 14

1.Late trimester bleeding
2.Lower segment placental implantation
3.No pain

Front 15

cause of placenta previa

Back 15

present when the placenta is implanted in the lower uterine segment. This is common early in the pregnancy, but is most often not associated with bleeding.

Front 16

Pathophysiology of placenta previa

Back 16

Usually the lower implanted placenta atrophies and the upper placenta hypertrophies, resulting in migration of the placenta

Front 17

risk factors for placenta previa

Back 17

1. previous placenta previa
2. multiple gestation.
3.multiparity
4. advanced maternal age

Front 18

Clinical presentation of placenta previa

Back 18

1. painless late-pregnancy bleeding, which can occur during rest or activity, suddenly and without warning. It may be preceded by trauma, coitus, or pelvic examination.
2.The uterus is nontender and nonirritiable

Front 19

Types of placenta previa

Back 19

1. total, complete or central previa
2. Partial previa
3. Marginal or low-lying previa

Front 20

describe total complete or central previa

Back 20

Total, complete, or central previa is found when the placenta completely covers the internal cervical os. This is the most dangerous location because of its potential for hemorrhage

Front 21

describe partial previa

Back 21

Partial previa exists when the placenta partially covers the internal os.

Front 22

Describe marginal or low lying previa

Back 22

Marginal or low-lying previa exists when the placental edge is near but not over the internal os

Front 23

Placenta previa Dx

Back 23

1. painless late-trimester vaginal bleeding
2. ultrasound showing placental implantation over the lower uterine segment

Front 24

Tx of placeta previa

Back 24

1. Emergency cesarean delivery-This is performed if maternal or fetal jeopardy is present after stabilization of the mother.
2. Vaginal delivery-This may be attempted if the lower placental edge is more than 2 cm from the internal cervical os.
3.Conservative in-hospital observation-Conservative management of bed rest is performed in preterm gestations if mother and fetus are stable and remote from term.

Confirm abnormal placental implantation with sonogram and replace blood loss with crystalloid and blood products as needed.
4. Scheduled cesarean delivery-This is performed if the mother has been stable after fetal lung maturity has been confirmed by amniocentesis, usually at 36 weeks' gestation.

Front 25

Complications of placeta previa

Back 25

1. If placenta previa occurs over a previous uterine scar, the villi may invade into the deeper layers of the decidua basalis and myometrium. This can result in intractable bleeding requiring cesarean hysterectomy.2. Profound hypotension can cause anterior pituitary necrosis (Sheehan syndrome) or acute tubular necrosis

Front 26

What is placenta accreta

Back 26

Placenta accreta occurs when the villi invade the deeper layers of the endometrial decidus basalis but do not penetrate the myometrium. Placenta accreta is the most common, accounting for approximately 75% of all cases.

Front 27

What is placenta increta

Back 27

Placenta increta occurs when the villi invade the myometrium but do not reach the uterine serosal surface or the bladder. It accounts for approximately 15% of all cases

Front 28

What is placenta percreta

Back 28

Placenta percreta occurs when the villi invade all the way to the uterine serosa or into the bladder. Placenta percreta is the least common of the three conditions, accounting for approximately 5% of all cases.

Front 29

Vasa previa Triad

Back 29

1. Amniotomy-AROM
2.Painless vaginal bleeding
3.Fetal bradycardia

Front 30

Cause of Vasa Previa

Back 30

Vasa previa is present when fetal vessels traverse the fetal membranes over the internal cervical os. These vessels may be from either a velamentous insertion of the umbilical cord or may be joining an accessory (succenturiate) placental lobe to the main disk of the placenta. If these fetal vessels rupture the bleeding is from the fetoplacental circulation, and fetal exsanguination will rapidly occur, leading to fetal death.

Front 31

Dx of Vasa Previa

Back 31

This is rarely confirmed before delivery but may be suspected when antenatal sonogram with color-flow Doppler reveals a vessel crossing the membranes over the internal cervical os. The diagnosis is usually confirmed after delivery on examination of the placenta and fetal membranes.

Front 32

Clinical presentation of vasa previa

Back 32

1. rupture of membranes
2. painless vaginal bleeding
3. fetal bradycardia.

Front 33

Risk factors for vasa previa

Back 33

1.velamentous insertion of the umbilical cord, accessory placental lobes
2. multiple gestations

Front 34

Tx for vasa previa

Back 34

Immediate cesarean delivery of the fetus is essential or the fetus will die from hypovolemia.

Front 35

Tx for uterine rupture

Back 35

Treatment is surgical. Immediate delivery of the fetus is imperative.
1. Uterine repair is indicated in a stable young woman to conserve fertility.
2. Hysterectomy is performed in the unstable patient or one who does not desire further childbearing.

Front 36

define uterine rupture

Back 36

Uterine rupture is complete separation of the wall of the pregnant uterus with or without expulsion of the fetus that endangers the life of the mother or the fetus, or both. The rupture may be incomplete (not induding the peritoneum) or complete (including the visceral peritoneum).

Front 37

clinical presentation of uterine rupture

Back 37

1. vaginal bleeding
2. loss of electronic fetal heart rate signal
3. abdominal pain
4. loss of station of fetal head. ***Rupture may occur both before labor as well as during labor.

Front 38

Dx of uterine rupture

Back 38

Confirmation of the diagnosis is made by surgical exploration of the uterus and identifying the tear.

Front 39

Risk factors for uterine rupture

Back 39

1. previous classic uterine incision
2. myomectomy
3. excessive oxytocin stimulation
4. grand multiparity
5. marked uterine distention

Front 40

What is the significance of uterine rupture

Back 40

A vertical fundal uterine scar is 20 times more likely to rupture than a low segment incision. Maternal and perinatal mortality is also much higher with the vertical incision rupture.