Antepartum hemorrhage

Question 1

what are 3 common causes of bleeding during 1st tri?

Answer 1

SAB
ectopic
normal spotting

Question 2

what are major causes of antepartum hemorrhage?

Answer 2

placenta previa
placental abruption
vasa previa
uterine rupture
fetal vessel rupture
cervicitis
cervical polyps
cervical ca.
cervical, vaginal, or vulvar lacs
hemorrhoids
congenital bleeding disorder
pelvic trauma
hematuria

Question 3

what is a placenta previa?

Answer 3

abnormal implantation of placenta over internal cervical os

Question 4

diff types of placenta previa

Answer 4

complete
partial
marginal - edge of placenta reaches margin of os

Question 5

what is vasa previa

Answer 5

a fetal vessel lies over cervical os

Question 6

what is placenta accreta

Answer 6

abnl invasion of placenta into uterine wall => inability to separate from uterine wall after delivery

Question 7

placenta increta

Answer 7

invasion of placenta into myometrium

Question 8

placenta percreta

Answer 8

invasion of placenta into uterine serosa

Question 9

most women w/both a placenta previa & a placenta accreta require what? Why?

Answer 9

hysterectomy

b/c inability of placenta to separate => profuse hemorrhage

Question 10

what is the incidence of placenta previa

Answer 10

1 in 200

Question 11

women with placenta previa are at increased risk of placenta accreta if they have a hx of what?

Answer 11

prior c/s

Question 12

what are predisposing factors for placenta previa

Answer 12

prior c/s
prior uterine surgery (ex: myomectomy)
multiparity
multiple gestation
erythrobastosis
smoking
hx of placenta previa
AMA

Question 13

what usually happens to marginal previa or low-lying placenta?

Answer 13

they migrate upwards as uterus grows

Question 14

what is velamentous placenta?

Answer 14

umb bv’s insert at the edge of placenta instead of middle => fetal bv’s pass over internal os (vasa previa)

Question 15

what is succenturiate placenta?

Answer 15

an extra lobe of placenta is implanted at some distance away from the rest, w/bv’s coursing b/w them which c/=> vasa previa

Question 16

what is a sentinel bleed?

Answer 16

the first bleeding 2/2 a placenta previa. Usually after 28 weeks

Question 17

CP of placenta percreta?

Answer 17

usually asx’c, but c/h hematuria or hematochezia if invasion into bladder or rectum

Question 18

what must you NOT do if a pt has a placenta previa?

Answer 18

place a speculum!

Question 19

how do you dx placenta previa?

Answer 19

transabdominal or translabial u/s (not transvaginal)

Question 20

what m/you make sure to do before doing u/s to look for placenta previa? why?

Answer 20

empty bladder. B/c full bladder can give illusion of placenta previa.

Question 21

mgt of placenta previa pts who are antepartum:

Answer 21

strict pelvic rest
modified bed rest
some ppl do this right away, some wait till sentinel bleed.

Question 22

mgt of placenta previa pts who make it to 36 weeks without a bleed:

Answer 22

Amnio to dtm fetal lung maturity, then delivery by c/s b/w weeks 36 and 37

Question 23

mgt of a bleeding pt with a placenta previa:

Answer 23

1) stabilize pt. Need continuous FHR monitoring and 2 large-bore IVs
2) obtain Hct, type & cross, maybe d-dimer, fibrinogen, PT and PTT.
3) if mom is Rh-, perform Kleihauer-Betke test. (dtm extent of fetomaternal transfusion so you know how much RhoGam to give)
4) prepare for disaster. Have 2U of blood ready.
5) Transfuse to maintain Hct 25% or more.
6) Prepare for preterm delivery - give betamethasone if before 34 weeks. Give tocolytics if not up to 34 weeks.

Question 24

what is placental abruption?

Answer 24

premature separation of implanted placenta from uterine wall

Question 25

what are complc'ns of placental abruption?

Answer 25

PTD uterine tetany DIC shock

Question 26

what factors are ass'd w/placental abruption?

Answer 26

``` maternal HTN hx of placental abruption maternal cocaine use maternal trauma rapid decompression of uterus (MVA, trauma) ```

Question 27

what is concealed hemorrhage? what % of cases?

Answer 27

placental abruption in which bleeding is confined w/in uterine cavity 20% of cases

Question 28

CP of placental abruption:

Answer 28

vaginal bleeding frequent ctr'ns ab'l pain maybe shock

Question 29

what is a couvelaire uterus?

Answer 29

blood penetrating into myometrium, only seen at time of c/s

Question 30

mgt of suspected placental abruption:

Answer 30

1) stabilize pt, order labs, give RhoGam if Rh- 2) Prepare for possibility of future hemorrhage (place 2 large-bore IVs, order blood) 3) prepare for PTD - give betamethasone or tocolytics 4) Immediate c/s if bleeding is life-threatening or fetal testing is non-reassuring

Question 31

T or F: vaginal delivery is CI'd if placental abruption is present.

Answer 31

F. Most abruptions are small. Vaginal delivery is possible of pt is stable.

Question 32

what's the risk of uterine rupture in pts w/previous c/s?

Answer 32

0.5%

Question 33

CP of uterine rupture:

Answer 33

``` severe ab'l pain vag bleeding - spotting or profuse nonreassuring FHTs cessation of uterine ctr'ns regression of presenting part ```

Question 34

mgt of uterine rupture

Answer 34

immediate laparotomy & delivery. | Can try to repair rupture site, but hysterectomy may be indicated.

Question 35

what advice is given regarding future pg'ies

Answer 35

avoid. If they do get pg, cannot do a VBAC. Need repeat c/s at week 36 after confirming lung maturity.

Question 36

where are umb bv's supposed to insert? Where do they insert in velamentous cord insertion?

Answer 36

supposed to insert at chorionic plate of placenta | in velamentous cord, they insert b/w amnion and chorion => exposed

Question 37

what increases the likelihood of velamentous cord insertion?

Answer 37

multiple gestation

Question 38

CP of fetal vessel rupture:

Answer 38

seen thru dilated cervix, or vag bleeding | sinusoidal variation of FHR

Question 39

what does sinusoidal variation of FHR indicate

Answer 39

fetal anemia

Question 40

what is the Apt test?

Answer 40

test used to examine vaginal blood to dtm if its maternal or fetal. If it turns pink after addition of NaOH, its fetal.

Question 41

mgt of ruptured fetal vessel:

Answer 41

immediate c/s. Or AROM if pt elects a TOL