Shared Flashcard Set

Details

Antenatal Bleeding and TB
Antenatal Bleeding and TB
64
Health Care
Professional
02/05/2013

Additional Health Care Flashcards

 


 

Cards

Term
List the differential diagnosis for first trimester vaginal bleeding
Definition
  • Impending abortion
  • Ectopic pregnancy
  • Severe cervicitis
  • Cervical lesions
  • Cervical polyp
  • Postcoital bleeding
  • Spotting during implantation
  • Subchorionic bleed
  • Demise of a twin
  • Hydatiform mole (rare)
Term
List the differential diagnosis for third trimester vaginal bleeding
Definition
  • placenta previa
  • placental abruption
  • vasa previa
Term
Define abortion
Definition

abortion is premature birth before a live birth is possible, and in this sense it is synonymous with miscarriage. It also means an induced pregnancy termination to destroy the fetus.


National Center for Health Statistics, the Centers for Disease Control and Prevention, and the World Health Organization define abortion as pregnancy termination prior to 20 weeks' gestation or with a fetus born weighing less than 500 g

Term
Define spontaneous abortion
Definition
the spontaneous loss of a fetus before the 20th week of pregnancy
Term
Signs and symptoms of SAB
Definition
  • Low back pain or abdominal pain that is dull, sharp, or cramping

  • Tissue or clot-like material that passes from the vagina

  • Vaginal bleeding, with or without abdominal cramps


Term
Objective findings with SAB
Definition
  • Dilation and/or effacement of cervix

  • Ultrasound - FHT? normal development?  amount of bleeding?

  • Tissue or clot-like material may be in the vagina

  • Vaginal bleeding
Term
Midwife management of SAB
Definition
  • Blood type (if you have an Rh-negative blood type, you would require a treatment with Rh-immune globulin. See: Rh incompatibility)

  • Complete blood count (CBC) to determine how much blood has been lost

  • HCG (qualitative) to confirm pregnancy

  • HCG (quantitative) done every several days or weeks

  • WBC and differential to rule out infection

  • Counseling/Education:

    • Assess her support system.  Who is at home to support her?  Refer to SW if she is interested.  

    • Reassure her that miscarriage is incredibly common - ⅓ of pregnancies and this does not mean that she can’t stay pregnant in the future.  

    • Her cycle will return in 4-6 weeks and she can try to get pregnant again or she can take all the time she needs to process this loss.

    • Teach s/s infection

    • Anticipatory guidance that she may bleed and need to use pads.  If she is farther along or uncomfortable, she can stay in the clinic.  She may pass a large clot/fetal tissue.  Some women don’t expect this.   
      • When a miscarriage occurs, the tissue passed from the vagina should be examined to determine if it was a normal placenta or a hydatidiform mole. It is also important to determine whether any pregnancy tissue remains in the uterus.

      • If the pregnancy tissue does not naturally exit the body, the woman may be closely watched for up to 2 weeks. Surgery (D and C) or medication (such as misoprostol) may be needed to remove the remaining contents from the womb. Monitor for infection.

      • After treatment, the woman usually resumes her normal menstrual cycle within 4 - 6 weeks. Any further vaginal bleeding should be carefully monitored. It is often possible to become pregnant immediately. However, it is recommended that women wait one normal menstrual cycle before trying to become pregnant again.


Term
How soon should a woman expect her period after a SAB?
Definition
Her cycle should return in 4-6 weeks
Term
How soon can a woman become pregnant  after a SAB?
Definition
  • It is often possible to become pregnant immediately. However, it is recommended that women wait one normal menstrual cycle before trying to become pregnant again.


Term
What complications can occur after a SAB?
Definition
Infection, excessive bleeding, sadness/depression
Term
Define habitual abortion/recurrent pregnancy loss
Definition
3 consecutive pregnancy losses prior to 20 weeks from the last menstrual period
Term
What is the midwifery management of habitual pregnancy loss?
Definition

The timing and extent of evaluation of women with recurrent miscarriage is based on maternal age, coexistent infertility, symptoms, and the level of anxiety.


With otherwise normal findings, we perform tests including parental karyotyping, uterine cavity evaluation, and testing for antiphospholipid antibody syndrome.


60 to 70 percent had a successful subsequent pregnancy with no treatment.

Term
S/sx and etiology of implantation bleeding
Definition
appears around the time of expected menses i.e., 17 days after conception or 4 ½ weeks after LMP. Usually the amount is no more than the first day of a period. no associated pain or backache.  Results from invasive activitiy of chorionic villi of blastocyst in uterine lining during implantation.
Term
Plan for implantation bleeding?
Definition

pregnancy test.

depending on the situation. need to r/o ectopic pregnancy, SAB or hydatidiform mole

Term
Etiology of bleeding caused by cervical lesions
Definition

A. Cervicitis – Infections of the endocervix caused by a variety of organisms including: Chlamydia, trichamonas, gonorrhea. The cervix is reddened with profuse purulent discharge.


B. Erosions – loss of superficial layers of squamous epithelium, may be friable and bleed on contact.

Term
What objective data would you collect for bleeding due to cervical lesions?
Definition

a. Spec Exam: discharge, cervix with erythema/friable, lesions

b. Lab: pap, GC, CT, Wet prep, maybe Hct (if severe bldg)


Term
What is your plan for bleeding caused by cervical lesions?
Definition

a. Treat offending organism

b. No organism identified – may treat with clindamycin 2% cream for any non-specific vaginitis


Term
5 causes of polyps (that may lead to vaginal bleeding)
Definition

a. uncertain

b. chronic inflammation

c. local vascular congestion

d. hyperestringinism

e. malignancy is rare ~ 1%

Term
Management of bleeding caused by polyps
Definition

a. usually avoid tx until postpartum unless bleeding enough to cause anemia (often resolves with birth)

b. pap

c. Hct (rare: depending on amount of bleeding)

d. Education: draw/show picture etc.

e. MD mgt – hemostat and twist. (CNM can do this) electrosurgical excision if large, send polyp to pathology. D&C if pedicle not visible


Term
Management of bleeding caused by cancer.
Definition
SIL or CIN are referred for colposcopy and/or directed biopsy. These procedures are safe during pregnancy. Conization increases risk for ROM, premature labor, and bleeding. Refer for MD management
Term
Signs and symptoms of a subchorionic hemorrhage
Definition
Not all women with subchorionic hematomas experience bleeding and sometimes the hematomas are first noted on ultrasounds in asymptomatic women.
Term
Etiology of subchorionic hemorrhage
Definition
A subchorionic hemorrhage (subchorionic hematoma) collects between the uterine wall and the chorionic membrane and may leak through the cervical canal.  
Term
What are the risks associated with subchorionic hemorrhage?
Definition

Later in the first trimester and early second trimester, the subchorionic hematoma may partially strip the developing placenta away from its attachment site and cause miscarriage.


Pregnancy outcome associated with subchorionic hematoma appears to depend upon location, with worse outcomes for retroplacental than marginal hematomas.


Most hematomas resolve, but they are linked to higher risks of placental abruption and preterm labor so we should provide solid education on danger signs but don’t need to make her overly concerned.  

Term
What objective information would you collect if you suspect subchorionic hematoma?
Definition
ultrasound to determine location of the hematoma and also presence of viable pregnancy, FHT, FH, presence of blood in vagina.
Term
Plan for subchorionic hematoma
Definition
The only management option for subchorionic hematoma is expectant management. Some clinicians repeat an ultrasound in two weeks to confirm fetal viability and assess for change in size of the hematoma. This is often reassuring to the patient, but does not alter management.
Term
What is a hydatiform mole?
Definition
developmental placental abnormality in which the chorionic villi become edematous and degenerate into grapelike vesicles
Term
What is the etiology of a hydatidiform mole?
Definition
probably arises as a consequence of a defective ovum or sperm. *complete mole typically has 2 sets of paternal chromosomes, while partial typically has 2 sets of paternal and one of maternal.
Term
3 risk factors for hydatidiform mole
Definition

1. Age >40 or adolescence

2. Residence:

a. US and Europe 1:1500-1:2000

b. Asia, Indonesia, Taiwan, Phillippines have much higher incidence, 1.5-2.5 times greater than American rates (S.E. Asia 1:500)

*per Williams, higher rates in US Hispanic and Native American women

*also mentions higher rates in OCP users

3. Previous molar pregnancy: 1:500


Term
Subjective data with hydatidiform mole
Definition

1. Vaginal Bleeding

a. 90-97% experience abnormal uterine bleeding

b. may begin as early as 8 wks after LMP

c. frequently described as being “like prune juice”

d. champagne grape-like vesicles may be passed

2. Pregnancy Symptoms

a. 20-26% have excessive vomiting/hyperemesis

b. no fetal movement


Term
Objective data collected with hydatidiform mole
Definition

1. VS – B/P may be elevated if preeclampsia develops. 10-27% become preeclamptic. If preeclampsia develops in early pregnancy the diagnosis of exclusion is mole.


2. General Exam – S/Sx of dehydration and weight loss if excessive vomiting present.


3. Abdominal Exam

a. uterus larger than expected for dates in 40-50%

b. uterus is enlarged from proliferating trophoblastic tissue and clotted blood

c. S=D in 30% S<D in 15-20%

d. FHT’s absent


4. Pelvic Exam

a. Speculum – blood or grape-like vesicles in vagina or cervix

b. Bimanual

i. S>D *may feel “softness” of uterus

ii. 15-25% develop enlarged, tender ovaries/thecalutein cysts


Term
Lab findings with molar pregnancy
Definition

1. Anemia is common

2. UA with proteinuria suggests preeclampsia

3. Beta HCG-quantitative, is dramatically elevated. It is also elevated with multiple gestations so it does not discriminate


Term
Management of molar pregnancy
Definition

 

1. diagnosis is usually made around 10-12 wks into pregnancy

 

2. Ultrasound scan 98% accurate in making diagnosis

3. Consult with MD if suspicious, when diagnosis established REFER for immediate termination *usually uterine evacuation/curettage, with f/u to detect persistent trophoblastic disease


Patient should not get pregnant for 1 year


Term
What is the risk of choriocarcinoma after a molar pregnancy?
Definition
2-3%
Term
S/sx of an ectopic pregnancy
Definition

Depending on when the pt presents, may be abdominal/pelvic pain (usually more on one side than the other, not bilateral/midline) generally persistent and worsening with time and not improving with rest or medication, bleeding/spotting, cervical motion tenderness, pooling in posterior fornix, “decidual cast,” pain on vag exam.  


Sx of a ruptured ectopic are shoulder pain radiating down the arm, shock-y (low BP, tachy, dizzy), may appear pale/diaphoretic, diarrhea possible d/t peritoneal irritation from hemorrhage.

Term
Etiology & (6) risk factors of ectopic pregnancy
Definition

unknown;

risk factors include hx PID, smoking, previous ectopic, surgery (e.g., oophorectomy), fertility issues/tx, TL/IUD

Term
Objective data collected with suspected ectopic pregnancy
Definition
Rebound tenderness, uterine S<D; may feel adnexal mass (boggy).  Hcg may also be off--if no IUP seen on U/S, need quant B-hCG, WBC may be elevated d/t inflammatory process.  
Term
Management of ectopic
Definition
CONSULT!  Ectopic pregnancy is an emergent and potentially life-threatening condition.  Caught early, can tx with MTX and follow with betas. MUA also possible to r/o sac/villi.  If not caught until later/ruptured--surgery necessary.
Term
What is abruptio placenta
Definition
remature separation of placenta from uterine wall. Hemorrhage can be concealed of the separation and bleeding are from an area central to the placenta or it may be obvious if the separation of bleeding are at the border or cause a disruption of the edges of the placenta.
Term
Risks for placental abruption
Definition
  • maternal HTN disorders, 
  • AMA or parity, 
  • maternal smoking, 
  • poor maternal nutrition, 
  • chorioamnionitis, 
  • blunt abdominal trauma, 
  • hx of previous abruption, 
  • sudden decrease in uterine volume or size- ROM in polyhydraminos or between delivery of twins or multiples, 
  • ECV, 
  • cocaine (crack cocaine in particular) usage
Term
Subjective information reported with placental abruption
Definition
  • generalized back pain, colicky, discoordinate UCs, can be mistaken for PTL or false labor. 
  • painful localized or generalized uterine tenderness, 
  • FM may be decreased or absent or have violent FM with large bleeds.
Term
Objective signs of placental abruption
Definition
  • Classic hypertonic, boardlike uterus and uterine rigidity occur with a large abruptions. (I have had pt get an epidural with a partial abruption and that one spot on their uterus is still painful and firm in between CTXs even with the epidural). 
  • FHR may be normal or variables, late decels or sinusoidal rhythm.
  • SXS of shock
  • enlarging uterus d/t concealed bleed.
Term
Differential diagnosis for abruption
Definition

PTL

Early labor

Previa 

Term
Management plan for abruption
Definition
  • MD consult and immediate delivery- if small bleed vaginal delivery may be feasible. If Preterm with small bleed consider tocolytics and Mag to get BMZ on board. 
  • Send: CBC, PT, PTT and INR, fibrinogen, Type and screen for possible transfusion.
Term

Can you do a speculum exam if you suspect a placental abruption?

 

What about a digital exam?

Definition

Speculum exam, especially if she is late to care and you have not r/o previa


Digital exam, after confirmation of no previa with small bleed check for dilation if vaginal birth is feasible.

Term
Mangement plan for bloody show
Definition
If the woman is not sure how much bleeding she’s having: have her put on a pad and monitor it.  If she’s preterm or you suspect it’s more than minimal spotting, you may have her come into the office.

If she’s having a lot of bleeding (like a period), you would advise her to go to L&D right away.  In L&D she would get a sonogram to determine cause of bleeding and fetal surveillance.    

If you decide it is bloody show/labor, management depends on where she is in labor!
Term
Management plan for asymptomatic low-lying or marginal previa
Definition
< 20 weeks, expectant management is done. Transvaginal ultrasound (TVU) done at approx 32 weeks with the hopes the previa has shifted. If previa has moved and is > 2 cm from internal os, expect vaginal delivery. If previa has not moved, repeat TVU at 36 weeks. Patient would be a candidate for vaginal delivery if placenta > 2 cm, if < 2 cm, pt may have an attempt at a vaginal delivery or may be scheduled for c/s.
Term
Management plan for asymptomatic complete or partial previa
Definition
With asymptomatic complete or partial previa < 20 weeks management is the same as above. Patient would have TVU at 32 weeks to determine location of previa and if previa has not moved, pt would receive education regarding danger signs and scheduled for c/s >37 weeks.
Term
Management plan for bleeding with known previa
Definition
If patient experiences bleeding from any type of previa, she is put on pelvic rest and educated about danger signs.
Term

What is placenta previa?

What are the three categories of previa?

Definition

Malposition of the placenta in the lower uterine segment, either anteriorly or posteriorly, so that the fully developed placenta extends into the cervical os.

1. Complete or central means the body of the placenta completely covers the cervical os.

2. Partial means partially covered os.

3. Marginal means near the os but not actually covering it.

Term
What are 6 risk factors for placenta previa?
Definition

multips

AMA

previous preg with placenta previa

previous uterine surgery (incl C/S)

multiple gestations

and/or smoking.

Term
What are the signs and symptoms of placenta previa?
Definition

cardinal sign is painless vaginal bleeding w a sudden onset.

Occurs during 3rd tri, may be accompanied by uterine irritability. Malpresentation is a common finding.

Term
Should you do a speculum or digital exam if a woman presents with vaginal bleeding?
Definition
do not perform speculum or digital exam until placental position is identified, because movement may exacerbate or initiate hemorrhage.
Term
Describe vasa previa
Definition
Vasa Previa is a condition in which fetal vessels cross or run in close proximity to the internal cervical os. Vasa Previa can occur in two ways: the umbilical cord inserts directly into the membranes, leaving the unprotected vessels running to the placenta(velamentous insertion) or vessels can cross between lobes of the placenta such as in succenturiate or bilobate placenta. These vessels course within the membranes and can rupture when the supporting membranes rupture. Rupture of these vessels which carry fetal blood increases risk of perinatal mortality
Term
How is vasa previa diagnosed?
Definition
Vasa Previa is best diagnosed by transvaginal ultrasound with color doppler over the cervix after raised suspicion with abdominal ultrasound.
Term
Risk factors for vasa previa
Definition
low-lying placentas, multi-lobed placentas, multiples pregnancy, in-vitro fertilization, unidentified cord insertion or abnormal flow over the cervix.
Term
What are some of the challenges to TB treatment?
Definition

- Duration of treatment

- People with latent TB don't want to be treated for a disease with no symptoms

- Access to care

- Language and cultural barriers

- Other underlying medical conditions or substance abuse

- Delayed detection

 

Term
What are the 4 possible outcomes with TB exposure?
Definition

1. Immediate clearance

2. Rapid progression to active disease (primary disease)

3. Latent infection w/reactivation

4. Latent infection w/o reactivation

Term
Discuss maternal and perinatal complications of TB
Definition

Pregnant women with tuberculosis have been noted to have an increased incidence of preeclampsia, vaginal bleeding, early fetal death, prematurity, small for date, low birth weight, and low APGAR scores and perinatal death compared with pregnant women without tuberculosis.


Statistically significant increases in the neonatal morbidity rate and number of adverse obstetric outcomes have been demonstrated in pregnant woman with tuberculosis compared with a matched control group of nontuberculous pregnant women.


Risk of passing TB to fetus and newborn.

Term
Management plan with positive PPD, physical exam, or history of TB in pregnancy?
Definition
CXR in 2nd trimester to r/o active vs latent TB.
Term
Management plan for latent TB in pregnancy
Definition
Almost always wait to treat until after delivery.  Prophylactic TB treatment postpartum is considered to be safe while breastfeeding.
Term
Management plan for active TB in pregnancy
Definition

Women diagnosed with active TB will need treatment during pregnancy and will need to be isolated from others until the TB is no longer contagious.


Isoniazid + Rifampin for 9 months

OR


pyrazinamide+Isoniazid + Rifampin for 6 months

Supporting users have an ad free experience!