Bleeding in Pregnancy

bleeding at _____________ would be considered early in pregnancy

< 14 weeks

what things are considered "normal" causes of bleeding in early (< 14 wks) pregnancy?

- implantation

- cervical

- subchorionic hemorrhage

implantation bleeding =

- brief

- light

- around missed menses

cervical bleeding =

- brief

- light

- post coital

what are the most common causes of cervical bleeding?

- polyps (post coital)

- ectropion (sporadic)

what is a subchorionic hemorrhage?

bleeding between uterine wall and chorion

- may be asymptomatic or w/ light bleeding

- associated w/ increased miscarriage risk

how are subchorionic hemorrhages managed?

- if light bleeding: conservative

- Rhogam if indicated

- clinic f/u w/i 1-2 wks

what is the most common cause of miscarriage?

chromosomal abnormalities (aneuploidy)

- may be:

*pre-embryonic (< 6 wks)

*embryonic (6-9 wks)

*fetal (10-19 wks)

causes of miscarriage:

- embryo chromosomes

- infection

- maternal uterine abnormalities

- antiphospholipid antibody syndrome

- low progesterone

- chronic stress

- trauma/IPV (intimate partner violence)

during which phase is miscarriage due to chromosomal abnormalities most common?

a. pre-embryonic (< 6 wks)

b. embryonic (6-9 wks)

c. fetal (10-19 wks)

b. embryonic (6-9 wks)

is it more common for a bacterial or viral infection to cause miscarriage?

viral

1 multiple choice option

infection causes ____ of late (>10-14 wks) miscarriages

66%

infection causes ____ of early (<10-14 wks) miscarriages

15%

maternal uterine anomalies that may cause miscarriage:

*uncommon (up to 15%)

- adhesions

*rare (0-10%)

- fibroids

- polyps

- septum

what is antiphospholipid antibody syndrome?

an acquired thrombophilia; body makes antibodies that attack fat molecules found naturally in blood cells and lining of blood vessels

- should test for this in a patient w/ recurrent miscarriage

what are the types of miscarriage?

on a spectrum of completion:

- missed

- threatened

- inevitable

- incomplete

- complete

spontaneous abortion =

miscarriage

missed abortion

- sx: variable bleeding (none to very light)

- cervical os: closed

- ultrasound (US): specific criteria used based on measurement or timeline

- viability: no

what are the measurement based US diagnostic criteria for missed abortion?

- crown rump length (CRL) >/= 7 mm w/ no cardiac activity

- gestational sac >/= 25 mm w/o embryo ("blighted ovum")

what's the difference between the gestational sac & yolk sac?

yolk sac is inside of the gestational sac

what are the timeline based US diagnostic criteria for missed abortion?

no cardiac activity:

14+ days from seeing gestational sac

or

11+ days from seeing yolk sac

threatened abortion

- sx: bleeding (light to moderate)

- cervical os: closed

- ultrasound (US): normal for GA

- viability: yes

- prevalence: 15-20%

inevitable abortion

- sx: bleeding (light to heavy) & cramping

- cervical os: open

- ultrasound (US): normal for GA

- viability: yes

incomplete abortion

- sx: bleeding (moderate to heavy), cramping, & tissue passage

- cervical os: open

- ultrasound (US): retained products

- viability: no

complete abortion

- sx: bleeding (moderate to heavy), cramping, & tissue passage

- cervical os: closed

- ultrasound (US): empty uterus

- viability: no

ectopic pregnancy =

pregnancy of unknown location

- implantation of the fertilized egg in any site other than the normal uterine location

what is a septic miscarriage?

any of the above (missed, threatened, inevitable, incomplete or complete) in presence of sepsis

RhoGAM should be given for ____ patients

Rh-

w/ Rh+ babies

a _________ dose of RhoGAM is sufficient for < 14 wks

50 mcg

- 300 mcg doses are sometimes available in pharmacy for other indications

RhoGAM should cover for ____________

12 weeks

- may be repeated around procedures or completion of miscarriage

miscarriage return precautions:

- soaking through a pad in 1 hr (front to back & side to side)

- 2 consecutive hours

- per patient's judgement/intuition

workup for missed abortion =

blood type & screen

workup for threatened abortion =

blood type & screen

+ US for viability

workup for inevitable abortion =

blood type & screen

+ US for viability

+/- CBC

workup for incomplete abortion =

blood type & screen

+ US to assess for tissue

+/- CBC

workup for complete abortion =

blood type & screen

+/- US

+/- CBC

workup for abortion of pregnancy of unknown location (ectopic) =

hCG & US

workup for septic abortion =

- hCG

- US

- CBC

- blood cultures

GYN clinic setting abortion management =

for all: RhoGAM if Rh-

- missed: counsel on options (expectant, medical, surgical)

- threatened: return precautions

- inevitable: return precautions vs send to hospital

- incomplete: counsel on options (medical or surgical)

- complete: return precautions

- unknown location (ectopic): hCG & return precautions

- septic: send to hospital

ER setting abortion management =

- missed: follow up in clinic

- threatened: return precautions

- inevitable: consult GYN (may need observation)

- incomplete: consult GYN (needs treatment)

- complete: return precautions

- unknown location (ectopic): consult GYN

- septic: consult GYN (needs treatment)

when someone presents w/ bleeding in early pregnancy, you should be sure to visualize the ______________!!

cervical os

- use suction &/or ring forceps w/ gauze to determine if patient is still actively bleeding &/or where it is coming from

what findings confirm an intrauterine pregnancy?

- yolk sac

- embryo

is an empty gestational sac enough to confirm an intrauterine pregnancy (IUP)?

no, you need to see the yolk sac inside of the gestational sac to confirm IUP

1 multiple choice option

what is a heterotopic pregnancy?

intrauterine pregnancy + ectopic pregnancy

- very rare, but technically possible even when IUP is confirmed

what things can confirm an ectopic pregnancy?

- endometrial aspiration w/o chorionic tissue

- laparoscopy

what findings are highly suspicious for an ectopic pregnancy?

- unspecified mass separate from ovary

- moderate or greater free fluid on US

- hCG > 5000 w/o confirmation of IUP

what findings are non-specific for an ectopic pregnancy?

- hCG < 3500

- unspecified adnexal masses (usually corpus luteum cyst)

- empty gestational sac

what is the goal when evaluating pregnancy of unknown location?

get to one of the aforementioned categories

are hCG trends helpful in establishing pregnancy location?

no

1 multiple choice option

are abnormal rises in hCG much more likely miscarriage or ectopic?

miscarriage

1 multiple choice option

do normal rises in hCG r/o ectopic?

no

1 multiple choice option

"doubling" hCG levels q 48hrs..

too high a standard for many pregnancies

if your initial hCG is higher, then..

you won't see as much of a rise

you should always assess patient's reliability to follow-up, what does this include?

- live with at least 1 adult?

- live w/i an hour or so of hospital?

- have means of transportation?

what should you do if you are highly suspicious for ectopic?

consider consulting GYN for obs admit

- place an IV, blood type/screen, & NPO

ED mgmt if pregnancy location is nonspecific/unknown

- if exam is reassuring: provide return precautions

- if exam is concerning: consult GYN

clinic mgmt if highly suspect ectopic

call/consult GYN

- if rupture suspected: laparoscopy

- if rupture unlikely: counsel on options (laparoscopy or methotrexate)

clinic mgmt if pregnancy location is nonspecific/unknown

- trend hCGs

- arrange f/u US

what is done for treatment of ruptured ectopic pregnancy?

laparoscopic salpingectomy

what is placenta previa?

placental tissue over the internal cervical os

- complications: contraindicates labor, intrapartum or postpartum hemorrhage

bleeding w/ placenta previa usually occurs _____ 20 wks

after

1 multiple choice option

is the bleeding w/ placenta previa painful?

no, painless

you should always anticipate the possibility of previa; therefore, w/o confirming placental location..

NO digital vaginal exams after 20 wks

should you worry when placenta previa is noted around 20 weeks?

no

1 multiple choice option

those w/ placenta previa should avoid:

- strenuous exercise

- heavy lifting

- activites likely to cause orgasm

*due to association w/ bleeding, NOT inducing labor

after placenta previa is found, monitor placental location every _____________

4-7 wks

if found in 2nd trimester, ______ of the time placenta previa will resolve by delivery

90%

if bleeding after 20 wks..

send to hospital

if bleeding persists, plan scheduled c-section at _____________

36-37 wks

ER approach to placental previa:

- prior to 20 wks: disregard

- after 20 wks: send to L&D if bleeding

no _______________ after 20 wks until placental location confirmed

vaginal exams

placental abruption takes place at _________________ 20 wks GA

greater than (>)

subchorionic hemorrhage takes place at _________________ 20 wks GA

less than (<)

what is placental abruption?

partial or complete detachment of placenta before delivery of fetus

- rupture of maternal vessels in decidua basalis

clinical findings w/ placental abruption:

- vaginal bleeding (highly variable)

- abdominal pain

- uterine tenderness

- uterine tachysystole (frequent contractions)

risk factors for placental abruption:

- history of abruption

- abdominal trauma

- hypertension/preeclampsia/eclampsia

- drugs (especially cocaine)

- smoking

- premature rupture of membranes (PROM)

what should you do if placental abruption is at all suspected?

send to hospital

ER mgmt of placental abruption

- continuous fetal monitoring

- stabilize patient (1-2 large bore IVs, fluid bolus, frequent vitals)

- labs (CBC, blood type & screen, coags)

- transfer to OB service (notify anesthesia if applicable)

when should you give a baby magnesium?

if born at < 32 wks

- for fetal neurodevelopment (protective against cerebral palsy)

when should you give a baby steroids?

if born < 36 wks 6 days

when should you give a baby group B strep (GBS) antibiotics?

if preterm & unknown GBS status

when should RhoGAM be given (if mom Rh- & baby Rh+)?

- 28 wks (clinic)

- with bleeding

- postpartum

what is your ddx for 1st trimester bleeding?

- spontaneous abortion (complete or incomplete)

- threatened abortion

- inevitable abortion

- anembryonic pregnancy/blighted ovum

- ectopic pregnancy

- GTD (complete or partial moles)

what is a blighted ovum?

a fertilized ovum that fails to develop

what is the most common type of gestational trophoblastic disease (GTD)?

complete mole

3 multiple choice options

what is the clinical presentation of a complete mole?

vaginal bleeding in early pregnancy, with either “prune-juice” discharge or expulsion of grape-like clusters

- anemia

- LGA

- hyperemesis gravidarum

- pre-eclampsia before 20 weeks gestation

- hyperthyroidism with tachycardia

- absence of fetal heart sounds

- ovarian cysts

- extremely high β-hCG levels (>100,000)

what is the clinical presentation of a partial mole?

symptoms are much less severe, present similarly to a spontaneous abortion (vaginal bleeding after a + pregnancy test)

- fetal cardiac activity may be present as a XXY fetus initially develop

- β-hCG levels are only slightly elevated, which is why the symptoms are less

what is the clinical presentation of a persistent mole?

varies widely

- most common symptom is abnormal uterine bleeding after the evacuation of a complete or partial mole

what is the clinical presentation of choriocarcinoma?

often present with late postpartum bleeding

- may have symptoms from metastatic lesions

what is the treatment/follow-up for a complete or partial mole?

both require immediate removal of uterine contents and close monitoring of β-hCG levels for 6 mo to ensure resolution of the disease.

- no pregnancy during this time (contraception!)

what is the treatment/follow-up for a persistent mole?

- D&C

- single-agent chemo (methotrexate or actinomycin-D) if pt is high risk

- OCPs

what is the treatment/follow-up for coriocarcinoma?

- single-agent or multi-agent chemotherapy

- OCPs