Exam 3 - Third Trimester Bleeding

Question 1

Vaginal bleeding in late pregnancy (third trimester) is associated with what?

Answer 1

Placental abnormalities

Question 2

What are examples of placental abnormalities that are associated with late pregnancy bleeding?

Answer 2

• Placental structure or size abnormalities
• Abnormal placement
• Abnormal attachment or premature detachment

Question 3

What implications do placental abnormalities have on the mother and fetus?

Answer 3

• Can cause maternal or fetal bleeding
• Affect fetal growth and oxygenation

May require early delivery to prevent compromise to the fetus and maternal morbidity

Question 4

What are small placentas associated with during pregnancy?

Answer 4

Intrauterine infection

Question 5

What are large or edematous placentas associated with during pregnancy?

Answer 5

Diet, maternal diabetes, fetal high drops

Question 6

What is velamentous cord insertion?

Answer 6

Example of structural placental abnormality

• Portion of umbilical cord is lifted off the placental surface
• Umbilical cord strings up and out –> looks like tree roots

Question 7

What is a potential complication associated with velamentous cord insertion?

Answer 7

Leaves span of vessels exposed and vulnerable to rupture or tear from fetal moveemnt or traction during delivery

Question 8

What is vasa previa?

Answer 8

Velamentous vessels precede the fetus or cross the cervix

• Fetal blood vessels cross the cervical opening resulting in life threatening hemorrhage at birth

Question 9

What are risk factors for vasa previa?

Answer 9

• Velamentous cord insertion
• Low lying placenta
• Multilobar placenta

Question 10

When should vasa previa be suspected on physical exam?

Answer 10

Suspected on vaginal exam when pulsations from cord are palpated

Question 11

What is placenta previa?

Answer 11

Anterior or posterior developed placenta, extending to or across the cervical os

Malposition of placenta in lower uterine segment and extends across cervical os

Question 12

Can placenta previa be detected on ultrasound?

Answer 12

Low lying placenta may be identified on ultrasound early in pregnancy (first or second trimester) when edge of placenta is 3 cm or less from cervical os

Question 13

Complete previa

Answer 13

Body of placenta fills lower uterine segment entirely and overlay cervical os

Question 14

Partial previa

Answer 14

Placental edge covers cervical os

Question 15

Marginal previa

Answer 15

Edge of placenta is near but not actually covering internal cervical os

Question 16

What is the cardinal sign of placenta previa?

Answer 16

Sudden onset painless vaginal bleeding

Question 17

If a patient has a low lying or partial placenta previa, when should they follow up with ultrasound?

Answer 17

At 24-28 weeks

Question 18

What happens if the placenta remains over the cervix by the third trimester?

Answer 18

Vaginal birth contraindicated

Question 19

How would the provider manage placenta previa early in pregnancy?

Answer 19

Watchful waiting, no further intervention required

Question 20

Management of complete previa

Answer 20

Pelvic rest for duration of pregnancy

• Avoid orgasm which can stimulate uterine contractions

Question 21

What should patients do if they had been previously diagnosed with placenta previa and has vaginal bleeding?

Answer 21

Report to hospital immediately

• If bleeding subsides and mother and infant are stable, expectant management advised

Question 22

Complications associated with placenta previa

Answer 22

• Hemorrhage and fetal demise when placenta separates before birth
• Associated with uterine scar from c-section or other uterine surgery
• Increased risk with repeat c-sections

Question 23

What is abruptio placentae?

Answer 23

Premature separation of normally implanted placenta

Question 24

What is the leading cause of hemorrhage in late pregnancy?

Answer 24

Abruptio placentae

Question 25

Can bleeding from abruptio placentae be concealed?

Answer 25

Yes - blood accumulates behind placenta with no obvious bleeding * Can penetrate through uterine decidua and collect in peritoneum

Question 26

Risk factors for abruptio placentae

Answer 26

* Hypertensive disorder * Previous abruption * Maternal smoking and cocaine use * Abdominal trauma * Polyhydramnios * Chorioamnionitis

Question 27

Signs of abruptio placentae

Answer 27

* Early signs mimic labor: back or pelvic pain * Blood discharge * Tender abdomen to firm, rigid, board-like belly that is diffusely painful