Bleeding In Pregnancy + Ectopic

Question 1

What are the main causes of vaginal bleeding in late pregnancy?

Answer 1

Placenta Previa,
Placental Abruption,
Ruptured Vasa Previa,
Uterine rupture

These four causes are considered life-threatening.

Question 2

What is the classification of Placenta Previa?

Answer 2

Low Lying: 2-3cm from os
Marginal: encroaching, not covering
Complete: Covering entire os

Low lying is very common in early pregnancy and may resolve; marginal encroaches on cervix; complete covers the cervix.

Question 3

What are the risk factors for Placenta Previa?

Answer 3

Previous C/S,
Previous placenta previa,
Multiparity,
Advanced maternal age,
Smoking,
Fibroids in lower uterine segment

Previous surgical scars on the uterus are significant risk factors.

Question 4

What are the consequences of Placenta Previa?

Answer 4

'’POMP’’
Maternal hemorrhage
Operative delivery
Premature baby
Placenta accreta/increta/percreta

These complications arise due to the placenta’s abnormal position.

Question 5

What is a ‘Sentinel bleed’ in the context of Placenta Previa?

Answer 5

First bleed that stops, warning of a larger bleed to come

This can indicate a serious condition developing.

Question 6

What should NEVER be done when assessing a woman with bleeding and suspected Placenta Previa?

Answer 6

Assess cervical dilation with vaginal exam

This should only be done once the placenta’s position is confirmed.

Question 7

How would you assess someone with a bleed in pregnancy?

Answer 7

Hx + clinical exam + vitals: SFH, determine fetal lie and presentation, auscultation
Speculum exam - assess appearance of cervix
Investigation:
FBC, blood type and crossmatch, Rh status, coagulation tests
TVUS

Question 8

How to manage a bleed due to Placenta Previa in late pregnancy?

Answer 8

ACBD - STAP

ABCD + vitals + clinical exam + Speculum Exam
CTG if after 28 weeks
Consider steroids + tocolysis: (Dexamethasone 12mg x 2 doses 12 hours apart IM or beclamethasone 12mg x 2 doses 24 hours apart IM. )
Analgesia: Pethidine or paracetamol
Plan for delivery: C/S @ 37 weeks

Question 9

What is the hallmark symptom of Placental Abruption?

Answer 9

Pain

Pain can vary from mild cramping to severe abdominal pain.

Question 10

What are the risk factors for Placental Abruption?

Answer 10

A - Abruption previously
BP - HTN or pre eclampsia
R - Ruptured membranes
U - Uterine injury like trauma
P - Polyhydramnios
T - Twins for multiple gestation
I - infection like chorioamnionitis
N - Narcotic use (cocaine or smoking)

These factors can significantly increase the risk of abruption.

Question 11

What are the complications associated with Placental Abruption?

Answer 11

Prematurity,
Growth restriction,
Stillbirth,
Bloody amniotic fluid
DIC
Retroplacental clot

Complications can also include retroplacental clot.

Question 12

What are the causes of Uterine Rupture?

Answer 12

Previous C/S incision, uterine curettage, inappropriate oxytocin use, trauma

These are the most common causes leading to uterine rupture.

Question 13

Risk factors for uterine rupture (FAG-POP)

Answer 13

Fetal Anomaly / Congenital uterine anomaly
Adenomyosis
GTN

Prev uterine surgery
Overdistension of uterus
Placenta Increta / Percreta

Question 14

Complications of uterine rupture?

Answer 14

Maternal:
Hemorrhage leading to anemia
Bladder rupture
Hysterectomy
Death

Fetal: RDS
death

Question 15

Clinical features of someone with uterine rupture

Answer 15

Pain
Bleeding
Cessation of contractions
Maternal tachy and hypotension

Investigate with TVUS or MRI
Fetal HR

Question 16

How to manage placental abruption?

Answer 16

Stabilise using ABCD for Mum and fetus + IV cannulla
Take bloods: FBC/Coag Screen/Cross-match for 4 units of blood
Give fluids, replace blood
Expedite delivery - amniotomy
Prep for neonatal resuscitation (umbilical IV catheter for fluid of transfusion)
If DIC, give platelets, FFP, factor 8

Question 17

What are the major risks associated with C-sections?

Answer 17

Bleeding, infection, hysterectomy, bladder injury, bowel involvement, future risk of APH/Stillbirth

Other risks include hypoglycemia and TTN (transient tachypnea of the newborn).

Question 18

What is the definition of Spontaneous Abortion?

Answer 18

Involuntary loss of pregnancy during the first 20 weeks

This is commonly referred to as miscarriage.

Question 19

Define vasa previa

Answer 19

Fetal blood vessels cover the cervical os - rarest cause of hemorrhage. Caused by low lying placenta

Question 20

Causes/Differentials of bleeding in first trimester?

Answer 20

'’STEM-C’’
Spontaneous abortion
Trophoblastic Disease
Ectopic pregnancy
Miscarriage / Molar

Cervical polyps, cervicitis, cancer

Question 21

How would you assess someone with a bleed in early pregnancy

Answer 21

ABCDE approach
History
Clinical Exam - Abdo, bimanual, speculum
Investigations - FBC, group and cross match, urinary bHCG, TVUS

Question 22

What labs would you do for first trimester bleed?

Answer 22

Quantitative bHCG, 2 measurements 2-3 days apart and it should double
Falling or plateauing levels = Bad

Progesterone: >25 = intrauterine pregnancy
<5 = poor outcome possible

Question 23

When is an US indicated in first trimester?

Answer 23

Miscarriage
Molar or ectopic pregnancy
Vaginal bleeding
Uterine abnormality
Maternal pelvic mass
CVS procedures
Dating

Question 24

Define Blighted Ovum

Answer 24

No embryo but sac and placenta present

Question 25

Risk factors for misscarriage

Answer 25

Uterine anomalies: fibroids, incompetent cervix Lifestyle: Smoking, alcohol, cocaine, infection (i.e. parvovirus or flu)

Question 26

Define miscarriage

Answer 26

Spontaneous loss of pregnancy prior to viability <24 weeks.

Question 27

Clinical features of miscarriage

Answer 27

Lower abdo pain, cramps, back ache products of conception passed

Question 28

How would you assess a miscarriage?

Answer 28

Clinical Hx and abdo exam Speculum: cervical dilation Bimanual exam: Uterine size and adnexal tenderness, rule out ectopic pregnancy US: Large yolk sac, no fetal hr

Question 29

How would you treat miscarriage?

Answer 29

Analgesia Anti-emetics Misoprostol vaginally (causes contraction and evacuation)

Question 30

How would you surgically manage a a miscarriage?

Answer 30

Evacuation of retained products of conception (ERPC) under general anaesthetic.

Question 31

What characterizes an Ectopic Pregnancy?

Answer 31

Pregnancy occurring outside the uterus, often in the fallopian tube ## Footnote It is a leading cause of maternal mortality if not diagnosed early.

Question 32

How might an ectopic pregnancy present?

Answer 32

Pelvic pain + positive pregnancy test have ectopic pregnancy until proven otherwise. If rupture: Bleed, dizziness, syncope, shoulder pain

Question 33

What might you find on assessment of a suspected ectopic pregnancy?

Answer 33

Abdo tenders +/- guarding/rigidity Enlarged uterus Pain on vaginal exam Cervical excitation

Question 34

What is a Complete Hydatidiform Mole?

Answer 34

Placental proliferation in the absence of a fetus, characterized by swollen villi ## Footnote This condition involves abnormal placental tissue growth.

Question 35

What is the management for a stable Ectopic Pregnancy?

Answer 35

Methotrexate, if no contraindications ## Footnote This is a medical management option to preserve fertility.

Question 36

What should be done if a patient with an ectopic pregnancy is unstable and has hemoperitoneum?

Answer 36

Must do explorative laparotomy ## Footnote Explorative laparotomy is a surgical procedure to investigate the abdominal cavity.

Question 37

What are the characteristics of placental villi in a complete hydatidiform mole?

Answer 37

Swollen, grape-like ## Footnote The appearance of the villi is a key diagnostic feature.

Question 38

What is a partial mole?

Answer 38

Molar placenta + nonviable fetus; 69XXY ## Footnote This condition involves both abnormal placental growth and a fetus that cannot survive.

Question 39

What is a potential complication of a complete hydatidiform mole?

Answer 39

Recurrence leading to metastatic choriocarcinoma ## Footnote Choriocarcinoma is a malignant tumor that can arise from trophoblastic tissue.

Question 40

What are some predisposing factors for trophoblastic disease?

Answer 40

* Previous molar disease * Pregnancy at ends of reproductive life (teens or late 40s) ## Footnote These factors increase the risk of developing trophoblastic disease.

Question 41

What are the clinical features of a hydatidiform mole?

Answer 41

* Vaginal bleeding 1st/early 2nd trimester * bhCG HIGHER than expected * Uterine size > dates with NO heart tones * Ovarian enlargement * Hyperemesis * Early pregnancy-induced HTN * Thyrotoxicosis * U/S: snowstorm appearance ## Footnote These symptoms can help in the diagnosis of a molar pregnancy.

Question 42

What is the management for a complete hydatidiform mole?

Answer 42

* Prompt evacuation of uterus via dilatation and curettage * Serial bhCG monitoring with one year of contraception ## Footnote Monitoring is crucial due to the risk of choriocarcinoma.

Question 43

What treatment should be given if trophoblastic disease invades the myometrium or becomes metastatic?

Answer 43

Give METHOTREXATE ## Footnote Methotrexate is a chemotherapy agent used to treat certain types of trophoblastic disease.

Question 44

What are the indications for suction dilatation and curettage?

Answer 44

* Heavy bleeding * Fetal demise and patient does not want to wait for spontaneous loss * Ruling out ectopic pregnancy ## Footnote This procedure is done to evacuate the uterus in specific clinical situations.

Question 45

What are the contraindications for suction dilatation and curettage?

Answer 45

* Active pelvic infection * Coagulopathy * Fetal demise not yet proven or patient will wait for spontaneous loss ## Footnote These conditions can increase the risk of complications during the procedure.

Question 46

When is suction dilatation and curettage not required?

Answer 46

* Uterus small and firm with no/very little bleeding * Tissue passed appears complete * Patient is reliable for f/u * TV U/S shows empty uterus ## Footnote In these cases, the procedure may be unnecessary.

Question 47

What are some complications of suction dilatation and curettage?

Answer 47

* Uterine perforation * Incomplete evacuation * Infection/Bleed * Late: intrauterine synechiae (adhesions – Asherman) * Depression/psych ## Footnote These complications can arise from the procedure and may require further management.

Question 48

What is important in the psychological management of patients after a molar pregnancy?

Answer 48

* Acknowledge grief, guilt * Support and comfort * Counsel on how to tell others * Reassure about future, can still conceive * Warn of anniversary phenomenon ## Footnote Psychological support is essential for coping with the loss and future pregnancy concerns.

Question 49

Risk factors for ectopic pregnancy

Answer 49

Prev ectopic Prev tubal surgeries / infections IUDs Endometriosis IVF

Question 50

Complication of ectopic pregnancy?

Answer 50

Intraperitoneal hemorrhage - shock - syncope - death

Question 51

Investigating someone with ectopic pregnancy

Answer 51

Urinary bHCG Bloods: 1. FBC 2. Serum bHCG 3. U&Es + LFTs (must be normal to give methotrextate) 4. Group and Save (crossmatch) Ultrasound

Question 52

Diagnosis of ectopic pregnancy

Answer 52

Failure of bHCG to double in 48-72 hours Low progesterone US: No gestation sac, echogenic mass with fluid Laparoscopy

Question 53

Medical management of Ectopic pregnancy

Answer 53

Methotrexate 1mg/kg IM provided no fetal heart beat, bHCG 1500-500, hemodynamically stable. Must measure bHCG 4th and 7th day post treatment

Question 54

Contraindications to methotrexate

Answer 54

Hepatic disease Renal Failure Pulmonary Fibrosis Bone marrow suppression

Question 55

Risks of methotrexate

Answer 55

Tubal rupture Photosensitivity Abdo pain

Question 56

Surgical management of ectopic pregnancy

Answer 56

1. Salpingostomy - if both tubes 2. Salpingectomy - one tube 3. If hemoperitoneum - explorative laparotomy