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40 Cards in this Set
- Front
- Back
Define Late pregnancy bleeding
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Vaginal bleeding occurring after 20 weeks' gestation. Prevalence is <5%, but when it does occur, prematurity and perinatal mortality quadruple.
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Differential Dx for Late pregnancy bleeding
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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. |
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For late pregancy bleeding what is the initial
1. evaulation (6) 2. labs (4) 3. Tx |
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. |
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Placenta abruption triad
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1. Late trimester painful bleeding
2 Normal placental implantation 3. Disseminated intravascular coagulopathy (DIC) |
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Etiology/Pathophysiology of placenta abruption
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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.
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Risk factors for placenta abruption
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1. previous abruption
2. hypertension 3. maternal trauma. 4.maternal cocaine abuse 5. premature membrane rupture. |
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Clinical presentation of placenta abruption
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1. most common cause of late-trimester bleeding,
2. most common cause of painful late-trimester bleeding. |
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Dx of placenta abruption
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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
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Tx of placenta abruption
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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. |
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Complications of placenta abruption
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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
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Characteristics of severe abruption
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1. abrupt knifelike uterine pain
2. severe late decels 3. bradycardia 4. fetal death 5. severe DIC |
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Characterististics of moderate abruption
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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. |
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Characteristics of mild abruption
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1. vaginal bleeding is minimal
2. no fetal monitor abnormality. 3. Localized uterine pain and tenderness is noted, with incomplete relaxation between contractions |
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Placenta previa triad
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1.Late trimester bleeding
2.Lower segment placental implantation 3.No pain |
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cause of placenta previa
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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.
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Pathophysiology of placenta previa
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Usually the lower implanted placenta atrophies and the upper placenta hypertrophies, resulting in migration of the placenta
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risk factors for placenta previa
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1. previous placenta previa
2. multiple gestation. 3.multiparity 4. advanced maternal age |
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Clinical presentation of placenta previa
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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 |
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Types of placenta previa
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1. total, complete or central previa
2. Partial previa 3. Marginal or low-lying previa |
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describe total complete or central previa
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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
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describe partial previa
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Partial previa exists when the placenta partially covers the internal os.
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Describe marginal or low lying previa
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Marginal or low-lying previa exists when the placental edge is near but not over the internal os
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Placenta previa Dx
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1. painless late-trimester vaginal bleeding
2. ultrasound showing placental implantation over the lower uterine segment |
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Tx of placeta previa
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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. |
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Complications of placeta previa
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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
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What is placenta accreta
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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.
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What is placenta increta
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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
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What is placenta percreta
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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.
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Vasa previa Triad
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1. Amniotomy-AROM
2.Painless vaginal bleeding 3.Fetal bradycardia |
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Cause of Vasa Previa
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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.
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Dx of Vasa Previa
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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.
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Clinical presentation of vasa previa
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1. rupture of membranes
2. painless vaginal bleeding 3. fetal bradycardia. |
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Risk factors for vasa previa
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1.velamentous insertion of the umbilical cord, accessory placental lobes
2. multiple gestations |
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Tx for vasa previa
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Immediate cesarean delivery of the fetus is essential or the fetus will die from hypovolemia.
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Tx for uterine rupture
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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. |
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define uterine rupture
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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).
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clinical presentation of uterine rupture
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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. |
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Dx of uterine rupture
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Confirmation of the diagnosis is made by surgical exploration of the uterus and identifying the tear.
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Risk factors for uterine rupture
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1. previous classic uterine incision
2. myomectomy 3. excessive oxytocin stimulation 4. grand multiparity 5. marked uterine distention |
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What is the significance of uterine rupture
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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.
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