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OBGYN: Third trimester bleeding
third trimester bleeding: OBGYN
61
Anatomy
Graduate
09/08/2011

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Term
2 common causes of antepartum bleeding:
Definition
- Placenta previa
- Abrutio placentae
Term
look up terms like antepartum and perperiunium
Definition
Term
Uncommon causes of antepartum bleeding:
Definition
- uterine rupture
- fetal chorionic vessel rupture
- cervical/vaginal lacerations
- cervical/vaginal lesions like cancer
- congenital bleeding disorders
Term
Placenta previa is the implantation of the placenta over the __ __.
Definition
cervical os
Term
3 types of placenta previa:
Definition
- Total/complete placenta previa
- Partial previa
- Marginal previa
Term
A __ __ can give false appearance of placenta previa.
Definition
full bladder
Term
1 in 200 live births - placenta previa
Definition
Term
Risk factors for placenta previa:
Definition
- Previous placenta previa
- Previous C section
- 4 prior C sections
- Multiparity
- Advanced maternal age
- Smoking
- Asian or African
- Previous D&C
Term
Suspect previa in all patients with __ __ after __ weeks.
Definition
- vaginal bleeding after 24 weeks
Term
Placenta previa dx:
Definition
- ultrasound: abdominal (7% false positive rate) or transabdominal
Term
Management of expectant pregnant woman with placenta previa?
Definition
1. Hospitalization
2. Daily fetal monitoring
3. Steroids for fetal lung maturation
5. Tocolysis
Term
Management for delivery of mother with placenta previa?
Definition
- Elective at greater than 37 weeks or positive fetal lung maturation
- Emergent: threat to mother and nonreassuring fetal status
Term
Complications of placenta previa:
Definition
1. Fetal morbidity b/c preterm delivery
2. Maternal morbidity: shock, PPH, pituitary necrosis, and placenta accreta
Term
Placenta accreta is growth of the placenta into the ___.
Definition
- myometrium
- 4% incidence of accreta with previa
- 16-25% incidence of accreta with C section
Term
Placenta accreta:
Definition
an abnormal placental implantation in which the anchoring placental villi attach to the myometrium, rather than being contained by decidual cells. This results in a placenta that is abnormally adherent to the uterus.
Placenta Increta
Placenta Percreta
Term
Placenta Increta and Placenta Percreta, look up difference:
Definition
Placenta percreta has gone past the myometrium and into the serosa

look up differences
Term
Placenta accreta occurs when there is abnormal placental implanation in which the anchoring __ __ attach to the ___, rather than being contained in the __ __. This placenta is abnormally ___ to the uterus.
Definition
- placental villia
- myometrium
- decidual cells
- adherent
Term
A 26 year old G2P1 with previous C/S, presents to labor and delivery at 32 weeks gestation with complaints of vaginal bleeding. She reports that she had a gush of bright red blood prior to arrival. She denies abdominal pain or contractions. A small amount of bright red blood is noted at the introitus and there is no free bleeding. Her BP is 120/80, pulse 92, fetal status is reassuring, no contractions are noted. Labs: Hgb of 9.2, hct 27, elevated fibrinogen and nl coags. The next step in her evaluation should be:
Definition
sonogram
Term
The patient is hospitalized and placed on bed rest. Her pregnancy progresses to 35 weeks gestation and she begins to bleed profusely. A C/S is performed and the placenta is noted to extend through the uterine serosa to the bladder. This is most consistent with:
Definition
Placenta percreta
Term
The umbilical cord normally starts in the middle of the uterus and is covered in Wartons jelly. If vessels start on the __ of the ___ and are ___, it is called a __ __ insertion. When the __ cord passes over the cervical os, it called ___ __.
Definition
- edge of the placenta and is unprotected, it is called a vilamentous cord insertion
- vilatmentous cord passes over the cervical os it is called vasa previa

SO IF YOU FEEL PULSE> DO NOT RUPTURE MEMBRANES B/C WOULD CAUSE FETAL BLEED
Term
A Velamentous cord placental insertion is __. The vessels are only surrounded by __ __, not Wharton's jelly.
Definition
- membranous
- fetal membranes
Term
Velamentous cord insertion is more common with __.
Definition
twins
Term
Placental abruption is __ __ of a __ __ placenta after __ weeks of gestation.
Definition
- premature separation
- normally implanted placenta
- after 20 weeks of gestation
Term
premature abruption occurs in 1 in 75 to 200 births
Definition
Term
Placental Abruption risk factors:
Definition
- maternal HTN
- Cocaine
- PPROM
- Maternal trauma
- Sudden decompression
- Cigarette smoking
- Fibroids
- Thrombophilias
Term
Placental abruption after 20 wks gestation becomes ___, anything before this becomes __ __.
Definition
delivery
spontaneous abortion
Term
Placental abruption:
Definition
Blood accumulating around placenta> will have vaginal bleeding But not every abruption will present with bleed b/c may be concealed bleeding. Pain, contractions, vaginal bleeding, and feta distress.
Term
Triad of placental abruption:
Definition
PAIN
BLEEDING
FETAL DISTRESS
Term
Placental abruption is a __ __, whereas placenta previa is diagnosed via __.
Definition
- clinical diagnosis
- ultrasound
Term
Diagnosis of placental abruption:
Definition
- Fetal Heart Rate
- Premature uterine contractions
- Ultrasound
- Lab tests: low platelets, low fibrinogen, and anemia
Term
what abnormal lab findings could be indicative of placental abruption?
Definition
- low platelets
- low fibrinogen
- anemia

These patients are at risk for DIC
Term
placental abruption puts one at risk for:
Definition
DIC
Term
Placental abruption management:
Definition
Admit to L&D
Delivery may be delayed if Fetus stable.
Deliver if maternal or fetal condition deteriorates, vaginal delivery desirable.
Tocolytic drugs; MgSo4, avoid B-mimetics (Terbutaline)and prostaglandin inhibitors.
Term
2 drugs to avoid with placental abruption:
Definition
beta agonists (terbutaline)
prostaglandin inhibitors
Term
What type of delivery is best for placental abruption and why?
Definition
vaginal delivery is best if possible b/c C section is more stress and bleeding
Term
Placental Abruption complications:
Definition
- hemorrhagic shock
- DIC (consumptive coagulopathy)
- renal failure
- couvelaire uterus
- fetal maternal hemorrhage
Term
Look for fetal cells in maternal circulation, if there are cells, you know some type of abruptioin happened. Trichlor V test with V stain
Definition
Term
A 36 yr old female G2P1 at 32 weeks gestation presents with a history of uterine tenderness and dark red vaginal bleeding. She has chronic hypertension and smokes ½ pack cigarettes/day. FHR tracing is reassuring, uterine irritability is noted. She has mild abdominal tenderness on exam and scant blood at the introitus. Ultrasound reveals anterior placenta, normal fluid, normal fetal status. A speculum exam reveals friable cervix but no free bleeding. Cervix is not dilated. Her hgb is 10.2 g/dl.
Definition
placental abruption
Term
A 24 year old female, G3 P2 at 40 weeks gestation, with one previous c/s presents to labor & delivery with severe abdominal pain and vaginal bleeding. She has had an uneventful pregnancy. An ultrasound in 2nd trimester revealed a fundal placenta. The cervix is 4 cm dilated and no presenting part is palpable. Fetal monitoring reveals a bradycardic fetus. At the time of C/S, most likely you will find
Definition
uterine rupture
Term
Abruptio Placenta
Predisposing factors
Maternal hypertension
Previous abruption
Trauma
Tobacco use
Diagnosis
Painful bleeding
Clinical
Maternal risks
Massive hemorrhage/DIC
Fetal risks
Perinatal mortality – 35%
Fetal demise
Neurologic sequelae
Definition
Term
Placenta previa
Predisposing factors
Multiparity
Age > 35
Prior previa
Multiple gestation
Diagnosis
Painless bleeding
Ultrasound
Maternal risks
Accreta, increta, percreta
Massive hemorrhage/DIC
Fetal risks
Preterm morbidity/mortality
Fetal death
Definition
Term
Risk factors for uterine rupture:
Definition
- trauma
- prior uterine scar
- spontaneous
Term
Dx of uterine rupture:
Definition
- sudden intense pain
- +/- vaginal bleeding
- retraction of fetal parts
- fetal distress
Term
Uterine rupture
Predisposing factors
Trauma
Prior uterine scar
Spontaneous
Diagnosis
Sudden intense pain
+/- vaginal bleeding
Retraction of fetal parts
Fetal distress
Maternal risks
Shock
Death
Fetal risks
32% mortality rate
Definition
Term
Vasa Previa
Predisposing factors
Velamentous cord insertion
Multiple gestation
Diagnosis
Severe vaginal bleeding
Fetal distress
Apt test
Maternal risks
This is fetal bleeding
Fetal risks
75% mortality
Definition
Term
Postpartum hemorrhage is defined as occuring within the first __ hours after delivery. For a vaginal delivery it is more than ___. For a C/S it is more than ___.
Definition
- 24
- 500 cc EBL
- 1000 cc EBL
Term
Causes of post-partum hemorrhage:
Definition
- UTERINE ATONY
- genital tract trauma
- retained placental tissue
- uterine inversion
- Coagulation d/o
- Abrupto placentae
- Amniotic fluid embolism
- Retained dead fetus
- inheritid coagulopathy
Term
PP hemorrhage continued:
Definition
top 3 causes:
Failure of compression of blood vessels at the implantation site of the placenta
(atonic ut., retention of placental tissue)
Trauma to genital tract
Coagulation defects.
Term
Management of postpartum hemorrhage:
Definition
1. Vigorous massage trying to make it contract again to stop bleeding
2. Use of uterus contractile agents: Oxytocin (main one) or Methylergonovine, prostaglandin F2α, manual exploration, inspection, curettage, tamponade, hysterectomy.
Term
A 27 year old gravida 6 para 5 presents for induction of labor at 38 weeks for hypertension. After 18 hours of pitocin, she has a spontaneous vaginal delivery of a 9 lb baby. Following delivery, she experiences a postpartum hemorrhage. The most common cause of postpartum hemorrhage is:
Definition
uterine atony (number 1 cause)
Term
While evaluating the possible causes of her bleeding, you note that the uterus is boggy despite vigorous fundal massage and the use of an oxytocin drip. You determine that she is in need of an additional uterine contractile agent. Which of the following is CONTRAINDICATED in this patient? She has HTN.
Definition
Methylergonovine (Methergine): DON'T GIVE THIS TO SOMEONE WITH HTN B/C IT IS A VERY POWERFUL VASOCONTSRICTOR

Also this drug is only PO or IM, if given IV> heart attack
Term
What drugs could you give a lady with HTN to get her uterus to contract down again if oxytocin is not working?
Definition
B. Prostaglandin (Hemabate)
C. Dinoprostone (Prostin)
D. Misoprostol (Cytotec)
E. Continuation of oxytocin
Term
A 22 year old gravida 2 para 1 with a previous c/s presents in labor. After an uneventful vaginal delivery of a 7 lb baby, you decide to manually remove the placenta after 35 minutes. Following removal the patient bleeds profusely. Fundal massage reveals firmness alternating with bogginess. Uterotonic agents are utilized without success. The most likely cause of her hemorrhage is:
Definition
retained products of conception (bogginess alternating with firmness)

treat with curettage
Term
An 18 year old female presents in labor. She has a known history of VonWillebrands disease. Following delivery, she has profuse vaginal bleeding requiring replacement transfusions. Which product will replace the deficiency that causes VonWillebrand’s Disease?
Definition
Cryoprecipitate (if that is not available give fresh frozen plasma- has all the factors)
Term
FFP has all clotting factors, and NO platelets.
Definition
Term
Cryoprecipitate has __, factors __ and __, and __.
Definition
- fibrinogen
- VIII
- XIII
- vWF
Term
An 18 year old gravida 1 presents in labor. Five minutes after an uneventful delivery the placenta is delivered. Excessive hemorrhage is noted. On exam, there is a purple mass at the introitus and the fundus is not palpable. The most common cause of this catastrophic event is:
Definition
mismanagement of third stage of labor, She delivered the placenta really really fast so something happened. Probably pulled too hard on the cord. Should be gentle tension on the cord, not a jerk. This is a catastrophic event. Severe hypotension and bleeding results. Patient collapses. Immediately call anesthesia pple to help get bp up.
Term
Management of uterine inversion:
Definition
- Nitroglycerin to relax
- Call anesthesia for backup
- Replace the uterus
Term
what would be contraindicated with uterine inversion:
Definition
pitocin infusion
Term
A 32 year old female gravida 2 para 1 delivers a healthy 8 lb baby. After an uneventful vaginal delivery, the patient becomes cyanotic and experiences cardiopulmonary arrest. You begin CPR and the patient expires. The most likely diagnosis is:
Definition
amniotic fluid embolism
Term
A 17 year old gravida 1 was delivered by forceps following a 2 hour second stage of labor. A midline episiotomy was performed to assist with delivery. The patient recovers and is transferred to the postpartum unit. Four hours later, the patient becomes hypotensive and tachycardic. She has minimal vaginal bleeding and her fundus is firm. The most likely cause is:
Definition
genital tract trauma
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