Complicated Pregnancy: Vaginal Bleeding

ectopic, implantation, fibroids, ectropion, loss, abruption, rupture

Vaginal Bleeding During Pregnancy

-First Trimester

• ______ pregnancy, early pregnancy loss, threatened abortion, __________ bleeding, vaginitis, polyps, uterine ________, cervical __________

-Second and Third Trimester

• Pregnancy ____, placenta previa, placental _________, bloody show associated with labor, uterine ________, and vasa previa

fallopian tube, hemorrhage, first, PID, IUD

Ectopic Pregnancy: Background

-Pregnancy in which the developing blastocyst implants at a site other than the endometrium of the uterine cavity, with 96% occurring in the _______ _____

-___________ from ectopic pregnancy is the leading cause of maternal mortality in the _____ trimester

-Risk Factors → previous ectopic pregnancy, tubal pathology (from ___), tubal sterilization, ___ use, and IVF

pain, 5-7, bleeding, reproductive, rupture, hypotension, transabdominal, resucitation

Ectopic Pregnancy: Signs and Symptoms

-Abdominal or pelvic ____, usually adnexal or lower quadrant

• Usually presents between _____ weeks gestation as the tube becomes distended

• May be continuous or intermittent, dull or sharp, or mild or severe

• Abrupt onset of severe pain → possible tubal rupture

-Irregular vaginal __________ or spotting

-Ectopic pregnancy should be suspected in any patient of ___________ age with these symptoms, especially those who have risk factors for ectopic pregnancy

-Patients may become hemodynamically unstable if there is a _______ and hemorrhage from the structure in which the pregnancy is implanted

• Severe or persistent pain, feeling faint, ___________, tachycardia, shoulder pain due to diaphragmatic irritation by blood in the peritoneal cavity

• If hemodynamically unstable → ___________ ultrasound to assess for intraperitoneal hemorrhage. Fluid ___________ and immediate surgical treatment is indicated

hCG, gestational sac, TVUS, 3510, intrauterine, extraovarian

Ectopic Pregnancy: Diagnosing in Hemodynamically Stable Patient

-___

• hCG discriminatory zone → the serum hCG level above which a __________ ___ should be visualized on a transvaginal ultrasound (____)

• Discriminatory zone for TVUS is ____ milli-IU

-TVUS

• __________ pregnancy (IUP) visualized → ectopic ruled out

• >89% of ectopic pregnancies show an __________ adnexal mass

methotrexate, <, cardiac, salpingectomy, instability, breastfeeding, rupture

Ectopic Pregnancy: Management

-______________ if the patient meets the following criteria

• Hemodynamically stable

• hCG _ 5000

• No fetal _____ activity detected on TVUS

• Ectopic mass size < 4 cm

• Patient is willing to comply with post-treatment follow up

-Surgery (___________ or salpingostomy) if the following are true

• Hemodynamic instability

• Coexisting visible intrauterine pregnancy or ______________ (MTX contraindicated)

• Signs or symptoms of impending ________

• Renal insufficiency, immunodeficiency, active TB, PUD

early, intrauterine, 20, loss, decreases, not

Spontaneous Pregnancy Loss: Background

-The most common complication of _____ pregnancy 

-Generally defined as a nonviable ______________ pregnancy up to __ weeks gestation

-Most common type is early pregnancy ____ (first trimester)

-Incidence of spontaneous abortion

• First trimester → as high as 31% 

• ___________ to approximately 10% when considering only losses occurring in clinical recognized pregnancies. Meaning, a lot of woman do ___ know they have had an early pregnancy loss and just assumes that their period was late 

• Second trimester → <1%

Abortion

Refers to pregnancy loss up to 20 weeks (sometimes called spontaneous abortion) or pregnancy termination at any gestational age

Anembryonic Pregnancy

Refers to a nonviable pregnancy with a gestational sac that does not contain a yolk sac or embryo

-”Blighted ovum”

-Includes pregnancies in which an embryo may have been present but has since been resorbed

Early pregnancy loss

A nonviable, intrauterine pregnancy within the first trimester

Embryonic demise

A pregnancy measuring <10 weeks by ultrasound with a visible embryo >7mm without cardiac activity

Fetal Demise

A fetus without cardiac activity is visualized, > 10 weeks

Miscarriage, two, 13, 20, infection, 20

Additional Terms: Fetal Loss

-__________ → synonymous with pregnancy loss

-Recurrent pregnancy loss → spontaneous loss of ____ or more pregnancies 

-Second trimester pregnancy loss → pregnancy loss that occurs after __ weeks and prior to __ weeks of gestation

-Septic abortion → refers to any abortion, spontaneous or induced, that is complicated by uterine ____________

-Stillbirth/fetal death → pregnancy loss that occurs at __ weeks gestation or later, or at a weight of 350 grams or greater 

35, chromosomal abnormalities, obesity, lead

Spontaneous Loss: Risk Factors

-Advanced maternal age ( > __ years)

• Due to strong association with __________ ___________

-Prior pregnancy loss

-Maternal morbidity → CV disease, _______, thyroid disease, thrombophilia, infection

-Substance use

-Exposure to toxins and pollutants like ionizing radiation, ____, and arsenic

-Black, indigenous, and other POC

chromosomal, 20, polyps, trauma, infection, uterine, trisomy, premature

Spontaneous Pregnancy Loss: Etiology

-General Etiologies

• ___________ abnormalities cause up to 70% of pregnancy loss before __ weeks 

• Maternal anatomic anomalies such as fibroids, ______, and adhesions 

• Significant _______

-Second Trimester 

• _________ like chorioamnionitis, maternal viral infection

• Chronic stressors of racial/ethnic disparities, financial disparities, food or housing insecurity 

• _____ malformation

• Cervical insufficiency

• Fetal malformation/syndromes like anencephaly, ______, renal agenesis, hydrops 

• Thrombophilia

• Abruption

• _________ preterm rupture of membranes 

bleeding, dilated, infection

Spontaneous Pregnancy Loss: Presentation and Complications

-Clinical presentation → __________, cramping, asymptomatic

-Cervix may be ________

-Complications → hemorrhage and ___________

hCG, decrease

Spontaneous Pregnancy Loss: Diagnosis

-Ultrasound

-____ monitoring → hCG will _________ if there has been a spontaneous abortion or if it is a nonviable pregnancy

-If the hCG does not go down over time, you need to worry about retained products of conception

first, pass, 13, NSAIDs, opioids, hCG, emptying, antibiotics, DIC

Expectant Management of Spontaneous Pregnancy Loss

-70-80% of ______ trimester (early) pregnancy loss will ____ on its own

• If > __ weeks, medication or surgical management is preferred

-________ for pain, may need _______ if beyond first trimester

-Follow-up/confirmation of a completed miscarriage → can be done using US, serum ___ levels, patient symptoms or a combination

• Follow-up every one to two weeks until completion

-Complications

• Incomplete uterine _________/retained tissue 

• Infection → if infection is identified, uterine aspiration is needed with _________

• Bleeding → heavy bleeding and cramping is expected but should improve. if bleeding heavily, uterine aspiration may be needed

• ___ is a very serious but rare condition in which small blood clots develop throughout the bloodstream 

Mifepristone, misoprostol, diarrhea, retained, hemorrhage, ultrasound

Spontaneous Pregnancy Loss: Medication Management

-___________ taken orally followed by ___________ given vaginally, buccally, or sublingually

-Med ADRs → nausea, vomiting, ________, abdominal pain, and pyrexia

-Complications → _______ products of conception, infection, __________ requiring transfusion

-Follow-up → __________ to confirm passage of gestational sac

antibiotic, aspiration, dilation, 16, perforation

Spontaneous Pregnancy Loss: Surgical Management

-Requires ___________ prophylaxis and cervical preparation

-First-trimester up to 16 weeks → uterine ___________

-Second-trimester → ________ and evacuation

• Wide mechanical dilation of the cervix performed in an OR

• Beginning at __ weeks gestation

• Complications can be related to anesthesia, uterine _________, cervical trauma, infection, and intrauterine adhesions

infection, endometritis, pain, discharge, bleeding, fluids, antibiotics

Septic Abortion

-Abortion that is complicated by ________, commonly _________

-S/S → pelvic and/or abdominal ____, uterine tenderness, purulent vaginal ________, vaginal _________, fever, sepsis

-Workup → blood cultures, STI testing, urinalysis, and urine culture

-If hemodynamically unstable, resuscitate first (______, transfusion, vasopressors) then treated with IV __________ and surgical evacuation of the uterus

two, genetic, uterine, lupus, antiphospholipid, thrombosis, karyotype

Recurrent Pregnancy Loss

-Evaluation of recurrent pregnancy loss is indicated after ___ consecutive pregnancy losses

-Diagnostic evaluation → complete medical, surgical, _______, and family history and a physical examination

-Laboratory and imaging tests

• Sonohysterography for assessment of _______ abnormalities

• Anticardiolipin antibody (IgG and IgM) titer and _____ anticoagulant performed twice, 12 weeks apart

• ____________ syndrome causes vascular ________ and pregnancy morbidity

• TSH and thyroid peroxidase antibodies

• Parental ___________ and karyotype of the abortus if the above examinations are normal

painless, recurrent, preterm, 24, weakness, trauma, congenital, short

Cervical Insufficiency: Background

-_________ cervical dilation that leads to second-trimester fetal expulsion

-A cause of ________ second-trimester pregnancy losses or extremely _______ live births 

• Often before __ weeks 

-Defined by ACOG as “the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions, labor, or both”

-Pathogenesis → likely structural cervical __________

-Risk Factors → cervical _____, _________ cervical abnormality, and history of _____ cervical length 

asymptomatic, pressure, contractions, discharge

Cervical Insufficiency: Symptoms

-Often ___________

-May have mild symptoms of pelvic ________, Braxton-Hicks-like contractions, premenstrual-like cramping and/or backache, change in vaginal ________

-Symptoms, if present, typically begin between 14-20 weeks

transvaginal, short, amniotic, history, ultrasound

Cervical Insufficiency

-___________ ultrasound

• Cervical length is typically _____

• Debris may be seen in the _________ fluid

-Making the diagnosis

• Based on either a classic obstetric _______ or on a combination of obstetric history and transvaginal ___________ measurement of cervical length

cerclage, progesterone, suture, strength, transvaginally

Cervical Insufficiency: Treatment

-Cervical _________ + vaginal ___________ supplementation 

• Cerclage → surgical procedure where a _______ is used to mechanically increase the tensile _________ of the cervix of patients with cervical insufficiency

• Essentially stitching the cervix closed 

-Can be done ___________ or transabdominally 

• Transvaginal usually attempted first 

• If not successful at preventing preterm labor, then transabdominal is done

unrelated, previa, rupture

Third Trimester Bleeding

-Bleeding _________ to labor and delivery 

-Seen in 4-5% of pregnancies 

-Causes → placenta _____, placental abruption, uterine _______, and vasa previa 

internal, bleeding, 20, painless, contractions, placental, before, hemorrhage

Placenta Previa: Background

-The presence of placental tissue that extends over the _______ cervical os, which can potentially lead to severe antepartum ________, preterm birth, and postpartum hemorrhage

-Should be suspected in any pregnant woman beyond __ weeks gestation who presents with __________ vaginal bleeding

• Causes bleeding when uterine ___________ or gradual changes in the cervix and lower uterine segment apply shearing forces to the inelastic _________ attachment site

-For women who have not had a second-trimester ultrasound, bleeding after 20 weeks of gestation should prompt an ultrasound ______ a digital vaginal examination is performed

• Palpation of the placenta can cause severe ___________

cesarean, surgery, age, endometriosis

Placenta Previa: Risk Factors

-Previous placenta previa

-Previous _________ delivery

-Multiple gestation

-Previous uterine ________

-Increasing parity

-Increasing maternal ___

-Infertility treatment

-Maternal smoking

-Maternal cocaine use

-Male fetus

-_____________

-Abortion

asymptomatic, 20, painless, persistent, transabdominal, TVUS, not, internal

Placenta Previa: Clinical Presentation and Diagnosis 

-___________ is the most common

• Found on anatomy ultrasound at 18-20 weeks 

• 90% found on ultrasound before __ weeks of gestation resolve before delivery 

-_________ vaginal bleeding is the cardinal symptom

• 90% of ________ cases 

• 10-20% of women present with uterine contractions, pain, and bleeding 

-Diagnosis → _________ ultrasonography

• Subsequent ____ is performed when optimal visualization of the placenta and cervix is needed 

-Low lying placenta → when the placental edge is <20 mm from, but ___, over the ________ os, the placenta is labeled as “low-lying” 

• These can go back up on their own or become complete previa

digital, orgasm, bleeding, exercise, c-section

Placenta Previa: Management of Asymptomatic Patients

-Avoid ______ cervical exam 

-After 20 weeks, avoid any sexual activity that may lead to ________

• Orgasm may be associated with uterine contractions which may provoke ________

• Vaginal penetration might cause direct trauma to the previa, resulting in bleeding

-After 20 weeks of gestation, avoid moderate and strenuous ________, heavy lifting, or standing for prolonged periods of time 

• Activity has been linked to increases in preterm birth

-_-_______ at 36-37 weeks of gestation 

hospitalize, fetal, labor, bleeding, 34, magnesium sulfate

Placenta Previa: Management of Acutely Bleeding Patients

-__________ for monitoring

-Order a CBC, type and cross-match, coagulation tests

• Give fluids and/or transfusion as needed

-Continuous _____ monitoring

-C-section if in active _____, concerning fetal heart rate tracing, severe and persistent vaginal _________ such that maternal hemodynamic stability cannot be achieved or maintained, or significant vaginal bleeding after __ weeks gestation

-___________ ________ for neuroprotection for pregnancies < 32 weeks

34, stable, corticosteroids, anemia, negative, C-section

Placenta Previa: Expectant Management

-<__ weeks of gestation who are hemodynamically ______ or quickly stabilized and have a normal fetal heart rate pattern are candidates for expectant management

-Antenatal _____________

-Correction of ______ with iron supplementation

-Rhogam for RhD-_________ patients

-_-_______ at 36 to 37 weeks

separation, decidua, 20, rupture, vessels

Placental Abruption: Background

-Also known as abruptio placentae 

-Premature ___________ of the placenta from the ________ at or after __ weeks gestation

• Decidua → specialized layer of endometrium that forms the base of the placental bed 

• Can be partial or complete 

-Pathophysiology → immediate cause is _______ of maternal ________ in the decidua basalis 

• Can be acute or chronic 

hemorrhage, complete, decompression, strain, stretch

Placental Abruption: Acute Severe Abruption

-High-pressure arterial ____________ in the placenta dissects through the placental-decidual interface and causes ________ or nearly complete placental separation

-A small proportion of abruptions are due to

• Sudden mechanical events

• Rapid uterine ____________

• Due to strain between the pliable myometrium and the inelastic placenta

• In MVAs, rapid acceleration-deceleration of the uterus causes uterine ______ exceeding concomitant placental _______ → leads to shearing force between the placenta and uterine wall

spiral, necrosis, hemorrhage, self-limited, hypertension, cocaine, smoking

Placental Abruption: Chronic and Risk Factors

-Abnormalities in the early development of the ______ arteries lead to decidual _________, placental inflammation and possibly infarction, and ultimately low-pressure venous ____________ at the periphery of the placenta

-Tends to be ____-__________ and results in a small area of separation

-Most common risk factors → _____________, ________, ________ use

abrupt, bleeding, pain, irritability, decidua, bleeding, preeclampsia

Placental Abruption: Features

-Acute abruption → ______ onset of vaginal _________, mild to moderate abdominal and/or back ____, uterine contractions, and firm/rigid/tender uterus 

-Concealed abruption → uterine contractions/________ only 

• All or most of the blood is trapped between the fetal membranes and _______

-Chronic abruption → relatively light, chronic, intermittent, _________

• At risk for developing oligohydraminos, fetal growth restriction, and _________

DIC, fibrinogen, hematoma

Placental Abruption: Labs and Imaging

-Labs

• Severe abruptions → ___ → disruption of hemostasis

• ___________ level, which correlates best with severity of bleeding, presence of overt DIC, and the need for transfusion

-Ultrasound

• Retroplacental __________ is more likely to be seen with more extensive placental separation and in patients who go on to have adverse who go on to have adverse maternal and perinatal outcomes

• Absence does not exclude any interference

monitoring, transfuse, magnesium, corticosteroids, Rhogam, C-section, 37-38, Pitocin, 4

Placental Abruption: Management

-Continuous fetal heart rate _____________

-Assessment of blood loss and maternal hemodynamic status → resuscitate and _________ blood if needed

-Lactated ringers to maintain urine output above 30 mL/hour

-For patients likely to deliver within 24-48 hours:

• _________ sulfate for neuroprotection for pregnancies <32 weeks of gestation

• Antenatal _____________ for pregnancies <34 weeks

• __________ for patients who are RhD-negative

-If mother is hemodynamically unstable → __-_______

-If fetal heart rate pattern is concerning → c-section

-If 34-36 weeks → vaginal delivery or C-section

-If <34 weeks and fetus and mother are both stable → monitor closely and deliver by _______ weeks (unless condition worsens)

-_________ (IV oxytocin) administered postpartum to stop bleeding

-In subsequent pregnancies, ultrasound every _ weeks starting at 24-28 weeks until birth to screen for growth restriction

umbilical, vessels, membranes, Wharton’s, os, unprotected

Vasa Previa: Definitions

-Wharton’s Jelly → a gelatinous connective tissue in the _________ cord present between the amniotic epithelium and the umbilical ________

-Velamentous umbilical cord insertion → when the placental end of the cord consists of divergent umbilical vessels surrounded only by fetal ___________, with no ___________ jelly 

-Vasa previa → when fetal blood vessels are present in the membranes covering the internal cervical __, _________ by placental tissue or Wharton’s jelly 

lower, previa, IVF, multiple

Vasa Previa: Risk Factors

-Velamentous cord insertion

-Umbilical cord insertion in the ______ third of the uterus at first-trimester ultrasound

-Placenta _______ or low-lying placenta on second-trimester ultrasound scan

-___ or other forms of ART

-_________ gestation

internal, sonolucency, normal, palpable, rupture, death, preterm

Vasa Previa: Diagnostics

-Imaging

• Ultrasound → linear sonolucent area that passes over the _______ os

• Color doppler flow and waveform analysis → umbilical artery or vein waveforms and confirms that the ___________ is a blood vessel

-Physical Exam

• Usually ________

• Rarely, pulsating vessels in the membranes overlying the cervical os are __________ on digital examination

-Why it’s dangerous

• Spontaneous or iatrogenic ________ of the membranes → fetal bleeding → hypotension → fetal heart rate abnormalities → fetal ______ due to exsanguination

• Pregnancies complicated by vasa previa and area also at increased risk for __________ birth

third, rest, 4, Betamethasone, c-section, transfusion

Vasa Previa: Management

-Confirm the diagnosis in the early _____ trimester

-Pelvic ____ and avoid high-impact activities 

-Ultrasounds to evaluate fetal growth every _ weeks starting at 24 weeks 

-____________ by 34 weeks gestation

-Hospital admission for close fetal surveillance between 30-34 weeks

-Scheduled _-________ at 34 to 35 weeks 

-Emergency c-section if patient spontaneously goes into labor, has PROM, concerning fetal tracings, or vaginal bleeding accompanies by fetal tachycardia 

-Type O negative blood should be available for emergency ___________ of a severely anemic newborn

Ectopic pregnancy

What is the most likely diagnosis in this patient?

A 29 y/o woman presents with left lower abdominal pain and light vaginal spotting for one day. Her last menstrual period was 7 weeks ago. She describes the pain as sharp and unilateral. Vital signs show BP 98/62, HR 112. A urine pregnancy test is positive. On pelvic exam, she has cervical motion tenderness and adnexal tenderness on the left. Transvaginal ultrasound does not show an intrauterine pregnancy. 

Miscarriage

What is the most likely diagnosis in this patient?

A 33 y/o woman who is 10 weeks pregnant presents with vaginal bleeding and cramping pelvic pain. She reports passing “tissue” earlier today. On exam, the cervical os is open, and products of conception are visible in the vaginal vault. Ultrasound shows heterogenous material in the uterus but no identifiable embryo.

Cervical insufficiency

What is the most likely diagnosis in this patient?

A 26 y/o G2P1 woman at 18 weeks gestation presents for a routine prenatal visit. She reports mild pelvic pressure but no bleeding or contractions. Ultrasound shows a shortened cervix measuring 1.8 cm with funneling. Her first pregnancy ended in a painless delivery at 22 weeks.

Placenta previa

What is the most likely diagnosis in this patient?

A 35 y/o G3P2 woman at 32 weeks gestation presents with painless bright red vaginal bleeding after intercourse. She denies contractions and has normal fetal movement. Vital signs are stable. Fetal heart rate is 120 BPM. Transabdominal ultrasound shows the placenta covering the internal cervical os. 

Placental abruption

What is the most likely diagnosis in this patient?

A 30 y/o woman at 36 weeks comes to the ED with sudden-onset severe abdominal pain, back pain, and vaginal bleeding. She is rigid and tender on exam. Fetal heart monitoring shows late decelerations. She has a history of cocaine use and chronic hypertension.

Vasa previa

What is the most likely diagnosis in this patient?

A 27 y/o woman at 35 weeks pregnant presents with painless vaginal bleeding that began after spontaneous rupture of membranes. Soon after the bleeding started, fetal heart tracing showed bradycardia. Ultrasound earlier in pregnancy noted a velamentous cord insertion.