Midterm-3rd Trimester Bleeding

Question 1

DDx of 3rd trimester bleeding

Answer 1

Abruption of placenta or vessel at os

Cervical/vaginal bleeding

Bloody show

Uterine rupture

Question 2

Placental abruptions associated factors

Answer 2

Multiparas

Older women

Twins

Dietary deficiencies

Uterine anomaly or tumor

Pressure on vena cava

Drug use –> esp cocaine

Question 3

Etiologic factors of placental abruption

Answer 3

Chronic htn

Trauma

Short umbilical cord

Sudden decompression of uterus

Increased stretch of uterus

Question 4

Placental abruption pathophysiology

Answer 4

Hemmorhage into decidua basilis causes decidue to split –> causes a hematomoa and loss of function of adjacent placenta

Question 5

Prognosis for placental abruption

Answer 5

Perinatal mortality up to 50%

Maternal mortality 1.8-2.8%

Question 6

Mortality factors for mother in placental abruption

Answer 6

Amount of blood loss

Whether hemorrhage is concealed or apparent

Clotting rxn

Time between abruption and tx

Question 7

Mortality factors for fetus in placental abruption

Answer 7

Extent of decreased placental function

Time between abruption and tx

Prematurity

Question 8

Ssx placental abruption

Answer 8

1. vaginal bleeding 2. uterine tenderness or very painful contractions (blood irritant to uterus and induces contractions) 3. fetal distress 4. hypertonic uterus 5. severe back pain 6. ssx of shock 7. idiopathic premature labor

Question 9

Lab tests for placental abruption

Answer 9

1. US 2. Non-stress test 3. Complete CBC, coagulation panel, electrolytes 4. Ab screen on Rh= moms

Question 10

Placental abruption management: non-severe bleeds

Answer 10

US

Fetal hrt tones

Bedrest

Vaginal rest

Fetal mvmnt counts

Non stress test or biophysical profile

RTC in 3-7 days or sooner if bleeding returns

Question 11

Placental abruption management: moderate to severe bleeds

Answer 11

Same as for non-severe bleeds but you need to refer -asses coagulation status

Referring doc will asses and consider induction or C-section

Question 12

Complications of placental abruption

Answer 12

1. DIC 2. Fetal death 3. Maternal hemorrhage leading to maternal shock: renal damage, Sheehan’s syndrome 4. Preterm labor

Question 13

Ssx of rupture of marginal sinus

Answer 13

1. mild vaginal bleeding which does not continue 2. painless 3. not associated with uterine rigidity 4. not associated w/ fetal heart tone changes

Question 14

Rupture of marginal sinus rupture management

Answer 14

1. US 2. Fetal heart tones, uterine exam, vitals 3. Bed rest 4. Vaginal rest 5. Mom monitors fetal mvmnt 6. Consider biophysical profile or non-stress test 7. RTC in 3-7 days

Question 15

Tx marginal sinus rupture

Answer 15

Viburnum prunifolium: 30 qtt tincture Q 30 minutes to TID

Homeopathy: Arnica. -Bell, cinnam, Ip, Sabina, Secale. Repertorize.

Question 16

Placenta Previa

Answer 16

Placenta implanted over or near internal os.

4 degrees: 1. Total: Internal os completely covered 2. Partial: Internal os partially covered 3. Marginal: Edge of placenta at margin of internal os 4. Low-lying: placental edge does not touch internal os, but is close to it

Question 17

Risk factors for placenta previa

Answer 17

>3 multiparity

>30 y/o

Previous C-section or other uterine surgery

Poor quality of uterine lining

Endometritis following previous pregnancy

Question 18

Ssx placenta previa

Answer 18

Painless vaginal bleeding usu at 28-30 wks -usu small but can be life threatening hemorrhage

-intermittent or continuous bright red bleeding -can be precipitated by trauma or intercourse

Possibly early spontaneous abortion

Question 19

Dx of placenta previa

Answer 19

US to determine placement of placenta

Do NOT do a vaginal exam w/ a 3rd trimester bleed before doing an US

Question 20

PE placenta previa

Answer 20

1. Gently check presentation 2. Presenting part high 3. Uterus soft and non-tender 4. Fetal heart tones usu normal

Question 21

Management of placenta previa

Answer 21

Delayed delivery with the following conditions: 1. blood loss is not life threatening 2. labor hasn’t begun, membranes intact 3. baby alive and not in distress 4. premature fetus

Question 22

Management of delayed delivery in palcenta previa

Answer 22

1. bed rest 2. pt must go to hospital immediately with any bleeding or w/ onset of labor 3. IV fluids or dx and tx of anemia 4. L/S ratio at 36 wks to determine fetus maturity 5. No fetal anomalies or erythroblastosis 6. Mom will stay in bed and there is adequate blood supply ready

Question 23

Indications for C-section in placenta previa

Answer 23

1. usu wait until fetus is mature but may not wait is profuse uncontrollable bleeding or fetal distress
2. total or partial placeta previa: MUST DO C-SECTION
3. abnormal presentation: MUST DO C-SECTION

Question 24

Indications for vaginal birth in placenta previa

Answer 24

1. placental <10% of internal os
2. cervix well effaced and >/= 3 cm dilated
3. fetal head in pelvis
4. minimal bleeding

Question 25

Vasa Pevia

Answer 25

Fetal blood vessel lying across os

Question 26

Complications of vasa previa

Answer 26

1. compressed vessel leads to decreased fetal heart tones and fetal distress 2. torn vessel leads to fetal exsanguination

Question 27

Dx of vasa previa

Answer 27

1. vaginal exam 2. Wright stain of vaginal blood shows nucleated RBCs 3. Kleinhauer test of vaginal blood: differentiates maternal and fetal blood 4. Amount of bleeding

Question 28

Management vasa previa

Answer 28

Transport Immediately! Monitor fetal heart tones C-section Poor prognosis if vessel has ruptured

Question 29

Cervical/Vaginal bleeding may be due to..

Answer 29

1. Cervicitis, cervical erosion, polyps, cancer 2. Lacerations, foreign bodies 3. Varicosities

Question 30

Tx for varicosities

Answer 30

1. Decrease standing 2. Truss w/ foam pad along perineum supported by sanitary belt 3. Botanicals a. Collinsonia b. Hamamelis 4. Homeopathics: calc, carb-v, ham, lyc, thuj, zinc 5. Pycnogenols