Bleeding in Pregnancy

Question 1

A 30-year-old G1P0 at gestational age 6 weeks and 3 days by LMP presents with 2 days of vaginal bleeding without any cramps or abdominal pain. Serology tests confirm blood type is A+ and an hCG level of 20,000 mlU/ml. The abdomen is soft and the pelvic exam reveals a closed cervical os. A bedside ultrasound confirms intrauterine pregnancy. What defines this pregnancy?

Answer 1

Threatened abortion

Question 2

A 27-year-old G1P0 at 8 weeks gestational age by LMP presents with 1 day of vaginal bleeding and intense cramps. Blood tests confirm maternal blood type is B+ and hCG is within the normal range for her gestational age. Bedside ultrasound confirms intrauterine products of conception. Exam shows several clots in the vaginal vault and small pieces of tissue. How would you categorize this miscarriage?

Answer 2

Incomplete abortion

Question 3

A 27-year-old G1P0 presents in the antenatal clinic for her routine 15-week antenatal appointment. She previously had an ultrasound early during this pregnancy to confirm intrauterine pregnancy and gestational age. On review of her first trimester labs, her blood type is O negative and her hemoglobin level is 13. On doppler assessment, no fetal heart tones are heard. What is the primary concern?

Answer 3

Possible missed abortion

Question 4

A 28-year-old female presents to the emergency room with 1 day of heavy vaginal bleeding, abdominal pain, and dizziness. The abdomen is soft. She has several clots in the vaginal vault with the cervix open to 1 cm. Her heart rate is 110, and her blood pressure is 90/45. Blood tests show a positive hCG of 10,000, hematocrit of 34%, and O positive blood. Bedside ultrasound confirms intrauterine pregnancy. What should be the best choice of management for this patient?

Answer 4

Surgical dilation and curretage

Question 5

Early causes of bleeding

Answer 5

• Spontaneous abortion
• Ectopic pregnancy
• Gestational trophoblastic disease

Question 6

Late Causes

Answer 6

• Placenta previa
• Abruptio placenta
• Preterm labor
• Vasa previa
• Postpartum hemmorhage

Question 7

Spontaneous

Answer 7

<20 weeks
<550 grams

Question 8

Types of spontaneous abortion

Answer 8

Threatened
Inevitable
Incomplete
Complete
Missed

Question 9

Threatened abortion

Answer 9

Closed cervical OS
IUP on US

Question 10

Inevitable abortion

Answer 10

Open Cervical OS
IUP on US w stopped or slowed hb

Question 11

Incomplete abortion

Answer 11

Partially expelled IUP

Question 12

Complete abortion

Answer 12

Closed os
IUP on ultrasound absent, previously presentM

Question 13

Missed abortion

Answer 13

Fetus present, no cardiac motion
Closed Cervical os

Question 14

Management

Answer 14

Expectant management
Dilation and curettage or evacuation
Misoprostol (For evacuation)

Question 15

Ectopic Pregnancy

Answer 15

Abnormal implantation, outside uterine cavity. 0.5%-2% of all pregnancies

Question 16

Types

Answer 16

Interstitial
TubaL
Ovarian
Cervical
Pelvic (rare)

Question 17

Risk Factors

Answer 17

STI, consequence
IVF
Tubal surgery

Question 18

what happens to HCG and signs

Answer 18

Abnormal hCG,
Unilateral stabbing pain
Delayed or light menses
Dark red
Cullens Sign

Question 19

Interventions

Answer 19

Dilation and Curettage
Methotrexate
Surgical

Question 20

(H. Mol) Gestational Trophoblastic Disease

Answer 20

Increase trophoblastic tissue

Fetus does not develop beyond primordial stage

1-1000 Pregnancy

Question 21

Partial Mole

Answer 21

2 sperms
some fetal parts but anomalies

Question 22

Complete mole

Answer 22

No fetus, placenta, or amniotic fluid

20% will progress to carcinoma

may cause bleeding

Question 23

Risk

Answer 23

Previous Hmol
>35
<20

Question 24

Symptoms

Answer 24

Dark red blood
Early pregnancy symptoms
Increased hCG
hyperemesis gravidarum

Question 25

Diagnosis

Answer 25

Ultrasound

Question 26

Management

Answer 26

Suction and curettage hCG monitoring education

Question 27

Placenta Previa

Answer 27

Occurs when placenta attaches near or over cervix rather than fundus 1 in 200

Question 28

Risk factors

Answer 28

Previous placenta previa >35 Multiple gestation Close pregnancy spacing Smoking Multipara Previous uterine scarring

Question 29

Symptoms

Answer 29

Painless bright red Soft uterus Increase fundal height Unfavorable fetal presentation Hgb/Hct drop

Question 30

Diagnosis

Answer 30

Kleihauer- Betke test Heart rate change, late deceleration Changes in vitals

Question 31

Management

Answer 31

Ultrasound, finding placenta Monitoring Education Avoid vaginal exams IV Fluid and medications as ordered

Question 32

Abruptio Placenta

Answer 32

Serparation of the placenta from the uterine wall Usually occurs after 20 weeks of gestation and can be partial or complete

Question 33

Risk factors

Answer 33

Hypertension Abdominal Trauma Cocaine use History of abruption smoking Multiple gestation Oxytocin

Question 34

Symptoms

Answer 34

Sharp sudden- onset, localized pain Hypertonic contraction Fetal distress Shock Hgb/Hmt changes Clotting issues (DIC)

Question 35

Management

Answer 35

- Utrasound of blood collection between the uterine wall and placenta - Biophysical profile - Complete abruption emergement cs delivery of the fetus - Uterine assessment hard uterus with severe pain - Monitor fetal well-being - Administer IV Fluid - Monitor fluid output

Question 36

Vasa Previa

Answer 36

Umbilical vessels implant in the membranes rather than in the placenta

Question 37

Types of Vasa Previa

Answer 37

Velamentous insertion, cord sit above placenta Succenturiate love Placenta divided into two lobes Battledore, marginal insertion of cord, weak structure

Question 38

Assessment

Answer 38

Ultrasound to determine placement Check bleeding

Question 39

Management

Answer 39

Normal delivery for (2) or (3) CS for velamentous insertion Bleeding management