vaginal bleeding in pregnancy n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
VAGINAL BLEEDING IN PREGNANCY PowerPoint Presentation
Download Presentation
VAGINAL BLEEDING IN PREGNANCY

Loading in 2 Seconds...

play fullscreen
1 / 68

VAGINAL BLEEDING IN PREGNANCY - PowerPoint PPT Presentation


  • 131 Views
  • Uploaded on

VAGINAL BLEEDING IN PREGNANCY . Dr Sattam Alenezi ED Consultant. VAGINAL BLEEDING DURING PREGNANCY . 1. DURING PREGNANCY -FIRST 20 WEEKS -SECOND 20 WEEKS. PREGNANCY AND VAGINAL BLEEDING. By the Numbers: 40% EXPERIENCE BLEEDING IN THE COURSE OF PREGNANCY

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'VAGINAL BLEEDING IN PREGNANCY' - willow-beck


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
vaginal bleeding in pregnancy
VAGINAL BLEEDING IN PREGNANCY

Dr Sattam Alenezi

ED Consultant

vaginal bleeding during pregnancy
VAGINAL BLEEDING DURING PREGNANCY

1. DURING PREGNANCY

-FIRST 20 WEEKS

-SECOND 20 WEEKS

pregnancy and vaginal bleeding
PREGNANCY AND VAGINAL BLEEDING
  • By the Numbers:
    • 40% EXPERIENCE BLEEDING IN THE COURSE OF PREGNANCY
    • Up to 20% OF PREGNANCIES TERMINATE IN MISCARRIAGE
    • 2% OF PREGNANCIES ARE ECTOPIC
    • 9%-13% OF FIRST TRIMESTER MATERNAL DEATHS ARE DUE TO ECTOPIC PREGNANCIES
bleeding and the first 20 weeks
BLEEDING AND THE FIRST 20 WEEKS
  • Three primary causes:
    • ABORTION
    • ECTOPIC PREGNANCY (EP)
    • TROPHOBLASTIC DISORDERS
abortion
Abortion
  • Incidence-1 in 5 pregnancies
  • 80% occur in the first trimester
  • Incidence decreases with gestational age
  • If fetal heart activity/viability is noted on ultrasound, the loss rate is only 2-3%
  • Loss rate is 20% in those with first trimester

bleeding

  • Risk increases with increasing maternal age, paternal age, and parity
abortion1
Abortion

Etiology-

  • Maternal factors
    • Infectious-Mycoplasma, Toxoplasmosis,Listeria
    • Environmental-Alcohol abuse, Smoking
    • Uterine - Septum, Fibroids, Cervical Incompetence
    • Systemic Disease-Thyroid, Diabetes

􀂋

  • Paternal factors-Chromosomal translocation
  • Fetal Factors-Chromosomal
    • 50% of 1st trimester abortions caused by chromosomal anomalies
symptoms
Symptoms

Vaginal bleeding in almost all patients

  • Cramping and pelvic pain very common
  • Hemorrhage can lead to syncope from hypovolemia/shock
  • Often discovered when fetal heart activity cannot be detected on exam
abortion2
Abortion

Differential Diagnosis

  • Threatened Abortion - bleeding, cervix closed
  • Inevitable Abortion - cervix open or

membranes ruptured

  • Incomplete Abortion - passed some of the P.O.C.
    • Treatment – Suction, Dilitation and Curettage or Observation
  • Complete Abortion - passed all products of

conception (P.O.C.)

slide9

Septic Abortion:

uterine infection during any stage of abortion.

  • Missed Abortion :

Embryo larger than 5 mm without cardiac activity.

threatened miscarriage
THREATENED MISCARRIAGE
  • UTERINE BLEEDING IN THE FIRST 20 WEEKS WITHOUT PASSAGE OF TISSUE OR CERVICAL DILATION
  • ULTRASOUND MAY DETECT AN IUP, INDETERMINATE OR EMPTY UTERUS. CORRELATE WITH BHCG TO RULE OUT EP
threatened miscarriage1
THREATENED MISCARRIAGE
  • THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME
threatened miscarriage treatment
THREATENED MISCARRIAGE - Treatment
  • SUCCESS RATES ARE SIMILAR (93%) FOR BOTH UTERINE CURETTAGE VS. EXPECTANT MANAGEMENT
threatened miscarriage2
THREATENED MISCARRIAGE
  • DISCHARGE HOME IS SAFE
    • MUST INCLUDE MANDATORY OB FOLLOW UP
    • SERIAL BHCG IN 48 HRS
inevitable incomplete miscarriage
INEVITABLE / INCOMPLETEMISCARRIAGE
  • BOTH HAVE EARLY PREGNANCY LOSS
  • BOTH PRESENT AND ARE TREATED SIMILARLY
inevitable incomplete miscarriage1
INEVITABLE / INCOMPLETEMISCARRIAGE
  • INEVITABLE: VAGINAL BLEEDING OR PASSAGE OF TISSUE IN CONJUNCTION WITH CERVICAL DILATION: OPEN CERVIX IS AN IMPORTANT FINDING
  • INCOMPLETE: INCOMPLETE PASSAGE OF TISSUE
inevitable incomplete miscarriage2
INEVITABLE / INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE:

UTERINE CURETTAGE

(D&C)

complete miscarriage
COMPLETE MISCARRIAGE
  • OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED
missed miscarriage
MISSED MISCARRIAGE
  • OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE
septic miscarriage
SEPTIC MISCARRIAGE
  • UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS
    • OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE
    • LATE COURSE: SEPTIC SHOCK
septic miscarriage1
SEPTIC MISCARRIAGE
  • INFECTION IS POLYMICROBIAL
  • TRIPLE ANTIBIOTIC COVERAGE IS REQUIRED
    • GRAM (+) COVERAGE: PENICILLIN, AMPICILILN OR CEPHALOSPORIN
    • GRAM (-) AREOBIC COVERAGE: AMINOGLYCOSIDE OR AZTREONAM
    • GRAM(-) ANAEROBIC COVERAGE: CLINDAMYCIN OR METRONIDAZOLE
ectopic pregnancy
Ectopic Pregnancy
  • Pregnancy anywhere outside uterine cavity
    • Fallopian tube most common location
    • Second leading cause of maternal mortality
  • COMMON THEME IS SCARRED FALLOPIAN TUBE
ectopic pregnancy risk factors
GREATEST RISK

PREVIOUS EP

PREVIOUS TUBAL SURGERY

DIETHYSTILBESTROL EXPOSURE

DOCUMENTED TUBAL SCARRING

IUD USE

PID

AIDS & STD.

Ectopic Pregnancy Risk Factors
ectopic pregnancy risk factors1
Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID

-IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

ectopic pregnancy risk factors2
Ectopic Pregnancy Risk Factors

LESS RISK:

  • PREVIOUS PELVIC/ABDOMINAL SURGERY
  • CIGARETTE SMOKING
  • AGE OF FIRST INTERCOURSE <18
ectopic pregnancy pathophysiology
ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL, GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT IT’S SIZE.

ectopic pregnancy1
ECTOPIC PREGNANCY
  • MEAN GESTATIONAL AGE OF RUPTURE IS 7.2 WEEKS
  • UP TO 23 % OF EP RUPTURE
  • UP TO 11% OF EP RUPTURED AT BHCG <100
ectopic pregnancy2
ECTOPIC PREGNANCY
  • CLINICAL PRESENTATION

CLASSIC HX :

- ABDOMINAL PAIN

-VAGINAL BLEEDING

-AMENORRHEA

-SYNCOPE +/- ( SHOCK).

ectopic pregnancy3
ECTOPIC PREGNANCY
  • ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL
ectopic pregnancy4
ECTOPIC PREGNANCY
  • PHYSICAL FINDINGS
  • Vaginal bleeding
  • Hypotension, tachycardia(shock)
  • Adnexal mass or tenderness in one sided adnexa
  • Uterus-normal size
  • Peritoneal Signs
ectopic pregnancy5
ECTOPIC PREGNANCY
  • DIAGNOSTIC MODALITIES – LABS

HUMAN CHORIONIC GONADOTROPIN- BHCG DOUBLES(66%) EVERY 48 HOURS NORMALLY

    • IN EP, BHCG LEVELS FALL, PLATEAU OR FAIL TO REACH THE PREDICTED SLOPE BEFORE 9 WEEKS OF GESTATION.
ectopic pregnancy6
ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES – LABS

  • PROGESTERONE

-SINGLE LEVEL >25 CORRELATES TO A VIABLE GESTATION

-LEVEL<5 MAY INDICATE A NONVIABLE GESTATION

ectopic pregnancy7
ECTOPIC PREGNANCY
  • ULTRASOUND

SINGLE MOST VALUABLE MODALITYAVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR :

TVU: 1500

FOR TAU: 5000

ectopic pregnancy8
ECTOPIC PREGNANCY
  • ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)
    • GESTATIONAL SAC
    • YOLK SAC
    • EMBRYONIC POLE
    • FETAL CARDIAC ACTIVITY
ectopic pregnancy9
ECTOPIC PREGNANCY
  • ED ULTRASOUND
    • SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG > THE DISCRIMINATORY THRESHOLD
ed ultrasound
ED ULTRASOUND
  • Echogenicadenexal mass.
  • Empty uterus.
  • Free fluids in pelvis.
  • Cardiac activity outside the uterus .
ectopic pregnancy10
ECTOPIC PREGNANCY
  • PREVENTING MISDIAGNOSIS
      • EP CAN RUPTURE AT BHCG AS LOW AS 100
      • UP TO 40% OF EP WERE MISDIAGNOSED AT 1ST ED VISIT
      • ABOUT 50% OF TRANSABDOMINAL ULTRASOUND WERE NONDIAGNOSTIC
        • ED US – If non diagnostic – need “official” study
      • PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE
ectopic pregnancy treatment
ECTOPIC PREGNANCYTreatment
  • MEDICAL MANAGEMENT
    • METHOTREXATE: DRUG OF CHOICE
      • unruptured, small, no cardiac activity, compliant patient

CONTRAINDICATIONS:

-OBVIOUS SIGNS OF RUPTURE

-BHCG > 2000

-SUSPECTED HETEROTOPIC PREGNANCY

ectopic pregnancy treatment1
ECTOPIC PREGNANCY Treatment
  • SURGICAL TREATMENT - MAINSTAY OF TREATMENT
  • Laparoscopy
    • Salpingostomy
    • Salpingectomy
  • Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

ectopic pregnancy unusual variants
Ectopic Pregnancy-Unusual Variants
  • Heterotopic Pregnancy
    • Simultaneous IUP and ectopic gestations
    • Rare- 1 in 4,000 pregnancies
  • More in women on fertility drugs.
tropoblastic disorders
TROPOBLASTIC DISORDERS
  • ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE
  • E.G.: COMPLETE/PARTIAL MOLE, INVASIVE HYADTIFORM MOLE, CHORIOCARCINOMA
trophoblastic disorders
TROPHOBLASTIC DISORDERS
  • VAGINAL BLEEDING, SEVERE OR PERSISTENT HYPERMESIS, EARLY DEVELPOMENT OF PREECLAMPSIA
  • LARGE FOR DATES UTERUS IS PALPATED
  • BHCG LEVELS ARE MUCH HIGHER THAN FOUND IN NORMAL PREGNANCY
  • ULTRASOUND WILL SHOW A “SNOWY PATTERN”
rhesus factor
RHESUS FACTOR
  • UP TO 15% OF PATIENTS ARE RH(-) AND ARE AT RISK FOR CARRYING A RH (+) CHILD
  • SENSITIZATION OCCURS AT 8 WEEKS OF GESTATION
  • <12 WEEKS OF GESTATION, ADMINISTER RHOGAM 50 MCG
  • >12 WEEKS OF GESTATION, ADMINISTER RHOGAM 300 MCG
bleeding in first 20 weeks evaluation
Bleeding in First 20 weeks Evaluation
  • Hx (specific OB Hx) and Px (w/ pelvic exam), VITALS!
  • IV
    • May need 2 large bore IV if hypotensive etc.
  • Labs
    • BHCG quant
    • Type and Rh
    • CBC +/-
    • Coags +/-, Type and Cross
    • U/A
  • Rad: Pelvic US
bleeding and second 20 weeks of gestation
BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • ABRUPTIO PLACENTA
  • PLACENTA PREVIA
  • UTERINE RUPTURE
abruptio placenta
ABRUPTIO PLACENTA
  • PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA
  • MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE
  • MOST COMMONLY OCCURS SHORTLY BEFORE LABOR
abruptio placenta1
ABRUPTIO PLACENTA
  • PATHOPHYSIOLOGY
    • ABNORMAL SMALL VESSLES BLEED INTO THE BASAL LAYER OF THE DECIDUA
    • BLEEDING MAY OCCUR VAGINALLY OR MAY BE CONCEALED ENTIRELY INSIDE THE UTERUS
abruptio placenta2
ABRUPTIO PLACENTA
  • RISK FACTORS:
          • MATERNAL HYPERTENSION
          • ECLAMPSIA/PREECLAMPSIA
          • HISTORY OF PREVIOUS ABRUPTION
          • UTERINE DISTENTION
          • VASCUALR DISEASE
          • TOBACCO SMOKING
          • COCAINE USE
          • MICROANGIOPATHIC HEMOLYTIC ANEMIA
          • PREMATURE RUPTURE OF MEMBRANE
          • BLUNT UTERINE TRAUMA
          • SHORT UMBILICAL CORD
abruptio placenta3
ABRUPTIO PLACENTA
  • PAINFUL VAGINAL BLEEDING
      • GRADE I: SLIGHT OR MINIMAL BLEEDING, LIMITED UTERINE IRRITABILITY, NORMAL BP, FHT ARE NORMAL, FIBRINOGEN IS NORMAL
      • GRADE II: EXTERNALUTERINEBLEEDING IS MILD OR MODERATE (HEAVY PERIOD), UTERINE IRRITABILITY, COMPROMISED FHT PATTERNS, FIBRINOGEN IS LOWERED
      • GRADE III: BLEEDING IS MODERATE TO SEVER, HEMODYNAMIC INSTABILITY, REDUCED FIBRINOGEN LEVEL, FETAL DEATH IS COMMON
abruptio placenta5
ABRUPTIO PLACENTA
  • DIAGNOSIS IS CLINICAL
  • LABORATORY WORK UP IS DIRECTED TOWARDS THE COMPLICATIONS
abruptio placenta6
ABRUPTIO PLACENTA
  • ULTRASOUND CAN MISS UP TO 50% OF ABRUPTIONS
  • ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC, RETORPLACENTAL OR PRELACENTAL HEMATOMAS
abruptio placenta7
ABRUPTIO PLACENTA
  • TREATMENT
      • 2 LARGE BORE IV
      • CARDIAC MONITORING
      • FETAL MONITORING
      • TYPE AND CROSS 2-4 UNITS OF BLOOD
      • COAGULATION PROFILE: CBC, PT, PTT, FIBRINOGEN, D-DIMER REPEAT IF HEMODYNAMIC STATUS DETERIORATES
      • OBSTETRICAL CONSULTATION
      • RHOGAM IF NECESSARY
placenta previa1
PLACENTA PREVIA
  • IMPROPER IMPLANTATION OF PLACENTA OVER THE CERVICAL OS IMPAIRING THE DESCENT OF THE FETUS
  • HEMORRHAGE OCCURS WITH SEPARATION OF THE PLACENTA FROM THE UTERUS
placenta previa3
PLACENTA PREVIA
  • RISK FACTORS(SCARRED UTERUS)
  • MULTIPARITY
  • PRIOR C-SECTION
  • PRIOR PLACENTA PREVIA
  • MULTIPLE GESTATIONS
  • PRIOR ABORTION WITH CURETTAGE
placenta previa4
PLACENTA PREVIA

CLINICAL PRESENTATION

  • PAINLESS VAGINAL BLEEDING (UP TO 70%)
  • DEFER ALL VAGINAL EXAM UNTIL ULTRASONOGRAPY IS COMPLETED
placenta previa5
PLACENTA PREVIA
  • IMAGING STUDIES
    • TRANSABDOMINAL ULTRASOUND IS THE MODALITY OF CHOICE WITH AN OVERALL ACCURACY OF 93%
  • EVEN MINOR SIGNS OF HYPOVOLEMIA SHOULD BE ADDRESSED AGGRESIVELY
placenta previa6
PLACENTA PREVIA
  • TREATMENT:
  • No PV exam at ED.
  • OBGY consultation.
postpartum hemorrhage
Postpartum hemorrhage:
  • Early : within 24hrs from delivery.
  • Late : up to 1-2 weeks PP.
  • More 500 cc blood loss after PVD.
  • More 1000cc blood loss after CS.
causes
CAUSES :
  • Early :
  • Uterine atony.
  • Genital tract trauma.
  • Abnormal placenta attachment.
  • Retain products of conception.
  • Uterine inversion.
uterine rupture
UTERINE RUPTURE
  • SUDDEN DETERIORATION IN VITAL SIGNS DURING LABOR
  • RISK FACTORS INCLUDE PREVIOIUS, C-SECTIO, FIBROIDREMOVAL, PLACENTAL ABRUPTION, BLUNT ABDOMINAL TRAUMA, UTERINE PAIN OR IRRITABILITY`
  • EMERGENCT C-SECTION IS THE TREATMENT
slide68

Late :

  • Endometritis.
  • RPOC.