ICL 15.9: Placental Disorders Flashcards
(19 cards)
34 y/o G4P3003 with LMP of July 11, 2020 presents to OB unit with sudden onset of vaginal bleeding. She has had no prenatal care. She has good FM.
by LMP, EDD April 17, 2021
bleeding started 2 hours ago, was sitting calmly watching basketball, soaked 2 pads and passed clot, no pain, no perceived contractions
current medications: PNV
no tobacco, alcohol or drugs
what do you want to know about her history/risk factors?
4 pregnancies, 3 term deliveries, 3 living children
- tobacco
- previous surgery
- D&C
- advanced maternal age
- drug use
- trauma/falls
- pelvic irradiation
- C-section
- myomectomy
what is the purpose of endometrial ablation? how can it effect pregnancy?
used to destroy the basalis
usually for women who are struggling with heavy bleeding
this is a problem for implantation since that’s where the blastocyst binds! and it’s where the placenta needs to stop and not invade into myometrium
how does cocaine/trauma effect pregnancy?
can cause abruption of the placenta
acute traumatic disruption of placenta from the implantation site that isn’t associated with the pregnancy
34 y/o G4P3003 with LMP of July 11, 2020 presents to OB unit with sudden onset of vaginal bleeding. She has had no prenatal care. She has good FM.
by LMP, EDD April 17, 2021
bleeding started 2 hours ago, was sitting calmly watching basketball, soaked 2 pads and passed clot, no pain, no perceived contractions
current medications: PNV
no tobacco, alcohol or drugs
what’s in your differential?
- placenta previa (placenta implanted on internal os)
- placental abruption
- accreta spectrum
other things on the differential that are less likely:
1. cervicitis
- trauma
- preterm labor
- vasa previa (umbilical cord is not on the placenta leaving umbilical vessels unprotected by wharton’s jelly; they could be bleeding and if they run along the cervix it could be causing her vaginal bleeding) –> not as worried about
34 y/o G4P3003 with LMP of July 11, 2020 presents to OB unit with sudden onset of vaginal bleeding. She has had no prenatal care. She has good FM.
by LMP, EDD April 17, 2021
bleeding started 2 hours ago, was sitting calmly watching basketball, soaked 2 pads and passed clot, no pain, no perceived contractions
current medications: PNV
no tobacco, alcohol or drugs
what tests do you want to do?
ultrasound! and get CBC
US will show you placenta on the anterior wall of the uterus extending down and over the internal os
34 y/o G4P3003 with LMP of July 11, 2020 presents to OB unit with sudden onset of vaginal bleeding. She has had no prenatal care. She has good FM.
by LMP, EDD April 17, 2021
bleeding started 2 hours ago, was sitting calmly watching basketball, soaked 2 pads and passed clot, no pain, no perceived contractions
current medications: PNV
no tobacco, alcohol or drugs
why it is more likely that she has a vasa previa than an abrupt placenta?
no pain, no traum and no hypertension
abruptions are usually incredibly painful
if you know someone has an acretta, is there something else you should keep in mind when treating a patient?
during implantation, Netebuch’s layer is critical because during delivery we want the placenta to shear off nicely but if that layer is infiltrated by the placenta, then this layer could be undefined and the placenta can grow into the uterus and not allow for easy separation!
this is commonly caused by trauma like C-sections
accreta = not really invasive
increta = invasive into myometrium; visibly obvious
percreta = goes all the way through the serosa and even to other organs like the blaadder
which organs should you be concerned about with a percreta?
bladder
when is the MRI the superior tool to the US?
US you have to go through anterior abdominal wall and get really see posteriorly and the US also is best when viewing through liquid
so if the placenta is located behind the baby then MRI is better to view that
how do you treat/manage someone with an vasa previa?
as long as the bleeding slows and stops:
- antenatal corticosteroids
- monitor maternal hemodynamic status
- monitor fetal status
- goal of 36-37 week gestation in presence of placenta previa
36 y/o presents for her 23 week prenatal visit.
Previous anatomy scan at 20 weeks without abnormal finding
Findings today are notable for a FH of 30, FHTs are normal in the 140s
what do you want to do next?
pubic height to the funds of the uterus aka the fundal height
once the pregnancy is 20+ weeks the number of cm of the FH should correlated +/-3 to the gestational age
so since she’s 23 weeks, at most she should be at 26 cm so her FH is huge!
so next you should get an US
what can cause an increase in the measurement of the fundal height?
- polyhydramnios
- baby growing too fast
- myomyoma aka fibroids
- maternal obesity
what is the qualification of polyhydramnios?
DVP > 8 cm
AFI > 90% for gestational age
what are some of the causes of polyhydramnios?
- fetal GI tract issues since fetus should be swallowing amniotic fluid (cleft palette, intestinal issues, etc.)
- maternal DM –> hyperglycemia causes polyuria
- fetal CNS issues
is it better to have polyhydramnios in the 2nd or 3rd trimester?
3rd trimester
in the 3rd trimester it’s usually idiopathic
the earlier it’s diagnosed, the higher the likelihood of fetal anomalies
what are the complications associated with polyhydramnios?
MATERNAL
1. uncomfortable
- respiratory symptoms if infringing on diaphragm
- abnormal labor because muscles are so stretched out they can’t contract come labor
- postpartum hemorrhage due to the muscles being so stretched out they can’t contract to stop bleeding after labor
FETAL
1. risk for cord prolapse because the baby doesn’t have a head often
- hydrops
- abruptions
- risk for preterm labor/birth because the uterus gets confused as to why it’s so big and thinks it’s time for labor
- neonatal hypoglycemia if there was maternal DM during gestation
why do we not just tap polyhydramnios and remove the fluid?
it can come back and usually does, especially with fetal anomalies
the only thing you can do is if it’s being caused by maternal DM and then fixing that would resolve the polyhydramnios
18 y/o G1P0 presents at 34 weeks gestation with headache that did not respond to acetaminophen,as well as worsening abdominal pain and vaginalbleeding.
Has attended her prenatal care appts.
Normal 20 week anatomy survey
Pregnancy has been uneventful until today.
Meds: PNV
PMH: Asthma
PSH: Appendectomy
FH: Parents, Grandparents with CHTN.
Maternal uncle with DM, colon cancer
150/92 P 100 RR 16 Afebrile BMI 45
Acute distress Writhing in bed
Abdomen: Right upper quadrant tenderness noted
Uterus tender to palpation, Firm, gravid
Extr: Brisk reflexes with clonus
Pelvic exam notable for bright blood in vagina from cervical os.
Actively bleeding. No evidence of SROM
Fetal status: normal baseline with decreased variability and late decelerations, contractions frequent
diagnosis?
preeclampsia + HELLP syndrome?
firm uterus, active vaginal bleeding…possible abruption too!! the leading risk factor for an abruption is HTN and she definitely has that!
deliver this baby!!!
differential: previa, abruption, accreta, vasa previa, trauma, cervicitis, bleeding disorder
what is one of the feared complications of abruption?
DIC!
