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First Trimester Bleed
Abnormal Pregnancy
Random
Third trimester bleed
PPH
100
Occurs 5‐12 days after conception (prior to positive HCG test) • Lighter and shorter than normal pg • Often mistaken for a “period” • Unrelated to pregnancy outcomes
What is implantation bleed
100
1:250 – 1:87 • 15% of all maternal mortality • 98% occur in the fallopian tube • 2% other portions of cornua, cx, ovary, abd • increased incidence with risk factors
What is ectopic pregnancy
100
• 1:1500‐1:2000 pregnancies • more common in pts >40 y.o. • historically diagnosed later • potential for metastases HCG high (hyperemesis common) • uterus is large for dates • vaginal bleeding • Ultrasound – typical US presentation – “Grape clusters”
What is HYDATITIDIFORM MOLE or Gestational trophoblastic disease (GTD)
100
A 32 yo G2P1 presents at 36 weeks complaining of bright red vaginal bleeding. Upon further questioning she does admit to having had some light bleeding on 1 to 2 occasions last week. Her previous pregnancy was delivered at term by a Classical Cesarean Section for footling breech presentation
What is your differential. Placenta Previa Uterine Rupture Placental Abruption Vasa Previa Laceration Vaginal mass
100
Definition of PPH ( NSVD/ c/s) early and delayed
Primary PPH – blood loss of 500ml or more (1000c/s) within 24hours of delivery. Secondary PPH – significant blood loss between 24 hours and 6 weeks after birth.
200
A: Bleeding or cramping with closed cx, + fetal heart tone - 90-96 % of pregnancies with + FH and VB at 7-11 weeks do not miscarry. B: Bleeding or cramping with dilatation of cervix, +/- fetal heart tones -management expectant, medical/surgical
What is • Threatened Ab  What is : inevitable Ab
200
What are the risk factors and clinical presentation for ectopic pregnancy
What is RISK FACTORS FOR ECTOPIC PREGNANCY • Risk factor – Previous ectopic – Tubal surgery – BTL – IUD – Infertility – DES exposure – Previous STD – Previous abd surgery - Smoking Clinical presentation: -Pelvic/abd pain – 100% • Tenderness on exam – 80% • Bleeding – 75% • Amenorrhea – 74% • Adnexal mass‐ 50%
200
What are the potential side effects from systemic methotrexate administration?
Methotrexate morbidity usually is dose and treatment duration dependent. Because methotrexate affects rapidly dividing tissues, gastrointestinal side effects, such as nausea, vomiting, and stomatitis, are the most common. Therefore, women treated with methotrexate should be advised not to use alcohol and nonsteroidal antiinflammatory drugs (NSAIDs). Elevation of liver enzymes usually is seen only with multidose regimens and resolves after discontinuing methotrexate use or increasing the rescue dose of folinic acid (27). Alopecia is a rare side effect with the doses used to treat ectopic pregnancy. Women should report any fever or respiratory symptoms because pneumonitis has been reported
200
What is the picture represent and what are the risk factors
What is placenta previa
200
hematologic changes in pregnancy
uteroplacental increase in flow from 100ml to 450-650ml/min term -blood volume increases by 50 %, plasma volume increases 50 % begins by 6 wks, RBC mass increases 20-35 % begins by 12 weeks -coag factors: increase 1,7,8,9,10, stable: 2,5,12, decrease 11,13, fibrinogen increased by 50 %
300
How should patients be counseled regarding prevention of alloimmunization after early pregnancy loss?
Women who are Rh(D) negative and unsensitized should receive 50 micrograms of Rh(D)-immune globulin immediately after surgical management of early pregnancy loss or within 72 hours of the diagnosis of early pregnancy loss with planned medical management or expectant management in the first trimester (50). It is reasonable to use the more readily available 300-microgram dose if the 50-microgram dose is unavailable.
300
How should patients be counseled regarding inter pregnancy interval after early pregnancy loss?
There are no quality data to support delaying conception after early pregnancy loss to prevent subsequent early pregnancy loss or other pregnancy complications. Small observational studies show no benefit to delayed conception after early pregnancy loss (46, 47). Abstaining from vaginal intercourse for 1–2 weeks after complete passage of pregnancy tissue generally is recommended to reduce the risk of infection, but this is not an evidence-based recommendation
300
Other causes for first trimester bleeding
ectropion, cervicitis, cervical dysplasia, cervical polyp, UTI, foreign body, trauma
300
Defined as the premature separation of the placental from the uterine wall Occurs in 0,9% Neonatal death incidence of 10 to 30%.
What is placenta abruption
300
Risk factors for pph
Previous PPH Antepartum haemorrhage Grand multiparity Multiple pregnancy Polyhydramnios Fibroids Placenta previa Prolonged labour (&oxytocin)
400
A:History of bleeding/ cramping/ passage of tissue, empty uterus B: death of the fetus with no signs or symptoms of pregnancy loss,
What is complete ab What is missed Ab and what are the risk factors Risk Factors – maternally related • Age (50% rate > 45 y.o.) • Structural anomalies • Maternal infections • Endocrine problems • Autoimmune/coag problems • Blood group incompatibility • Severe malnutrition • Toxins (lead, smoking, ETOH, caffeine>300mg/d), radn, anesthesia
400
Absolute and relative contraindications to methotrexate.
Absolute: Breastfeeding, immunodeficiency, alcoholism , chronic liver disease, leukopenia, thrombocytopenia, profound anemia, peptic ulcer disease, active pulmonary disease, hypersensitivity to it, Relative: FH, SAc more than 3.5 CM
400
Findings diagnostic of early pregnancy loss
CRL 7mm or > sac 25mm and no embryo no Fh 2weeks or more after GS no embryo with FH 11 days after GS + YS
400
Reported in 0.03-0.08% of all delivering women, but 0.3-1.7% among women with a history of a uterine scar, 13% occur outside the hospital Morbidity is hemorrhage and subsequent anemia, requiring transfusion Fetal morbidity is more common with extrusion and includes respiratory distress, hypoxia, acidemia, and neonatal death
What is uterine rupture
400
Evaluation of PPH
Has the placenta been delivered and is it complete? Is the uterus well-contracted? Is the bleeding due to trauma? ( vaginal wall, cervical) Foley catheter, bimanual massage
500
Are there any effective interventions to prevent early pregnancy loss?
There are no effective interventions to prevent early pregnancy loss. Therapies that have historically been recommended, such as pelvic rest, vitamins, uterine relaxants, and administration of β-hCG, have not been proved to prevent early pregnancy loss (55–57). Likewise, bed rest should not be recommended for the prevention of early pregnancy loss (58). A 2008 Cochrane review found no effect of prophylactic progesterone administration (oral, intramuscular, or vaginal) in the prevention of early pregnancy loss (59). For threatened early pregnancy loss, the use of progestins is controversial, and conclusive evidence supporting their use is lacking (60). Women who have experienced at least three prior pregnancy losses, however, may benefit from progesterone therapy in the first trimester
500
As opposed to a normal gestational sac, it is typically located centrally and may fill the entire endometrial cavity and it also lacks the “double ring” sign. Look at the picture for hint.
What is pseudosac
500
How is methotrexate used in the management of ectopic pregnancy?
Three protocols are published for the administration of methotrexate to treat ectopic pregnancy: 1) single dose, 2) two dose, and 3) fixed multidose (see the box, "Methotrexate Treatment Protocols"). The single 50 mg/m2 dose regimen is the simplest and has been shown by some to be as effective as the fixed multidose regimen, eliminating the need for folinic acid rescue to minimize side effects (22). However, a recent meta-analysis has shown the fixed multidose regimen to be more effective, especially in treating women with more advanced gestations and those with embryonic cardiac activity (19). A recent prospective study evaluating a two-dose regimen found high patient satisfaction, few side effects, and 87% treatment success (23).
500
Rarely reported condition in which the fetal vessels from the placenta cross the entrance to the birth canal Reported incidence varies, but most resources note occurrence in 1:2500 pregnancies Associated with a high fetal mortality rate (50-95%) which can be attributed to rapid fetal exsanguination resulting from the vessels tearing during labor
What is vasa previa
500
Management: medical/ surgical
Medical : Oxytocin 5IU Oxtocin infusion – 40IU in 500mls Ergometrine 0.5mg Carboprost (Haemabate©) 0.25mg IM every 15 minutes x 8 doses Misoprostol 600 mcg sublingually Surgical: - dilatation and curettage -balloon tamponade -B-lynch suture -uterine artery ligation -internal illiac ligation -IR -hysterectomy