Complicated Pregnancy 1 (APH and miscarriage)

Question 1

Define a misscarriage/abortion?

Answer 1

Spontaneous termination <24wks gestation with no evidence of life

Question 2

What if a patient presents <24wks with vaginal bleeding and the cervix is dilating?

Answer 2

At that point its termed an Inevitable Miscarriage

Question 3

Whats the difference between a complete or incomplete abortion?

Answer 3

In complete all the Products of conception have been expelled, the cervix closed and bleeding stopped.
In incomplete the POC are still partly inside, cervix open and bleeding ongoing

Question 4

How do we confirm if a woman has had a complete abortion?

Answer 4

We need to either see the POC and confirm them to be that.

Or have a previous scan that confirms there was a viable pregnancy before

Question 5

Define a septic miscarriage?

Answer 5

When infection ascends into the uterus and throughout the pelvis following a miscarriage.
Its most common if it was an incomplete abortion

Question 6

Define a missed abortion?

Answer 6

When the foetus has died but the uterus hasn’t attempted to expel the POC.

It can appear on US like a gestational sac lacking a foetus or a foetal pole without a developed heart

Question 7

List all the major causes of a miscarriage you can think of?

Answer 7

• Abnormal conceptus (problems with the foetus, mainly chromosomal)
• Uterine abnormality (problems with the uterus)
• Cervical Incompetence (problems with cervix)
• Maternal conditions (problems with the mother)

Question 8

What uterine abnormalities could cause a misscarriage?

Answer 8

A congenital abnormality

Fibroids

Question 9

What causes cervical incompetence?

Answer 9

Trauma including past surgical procedures

Question 10

What maternal problems could cause a misscarriage?

Answer 10

Low progesterone
Diabetes 
SLE
Thyroid disease
Acute infections e.g. appendicitis

Question 11

How would we manage a threatened abortion?

Answer 11

Conservative Management, best to try to get the foetus past 24wks so we can deliver and it will survive

Question 12

How would we manage an inevitable abortion?

Answer 12

At this point there’s no point trying to save the foetus.

If the bleeding is heavy they may need evacuation of the uterus

Question 13

How would we manage a missed misscarriage?

Answer 13

Several options:

• Conservative in the hope the uterus will self-evacuate
• Push the uterus with prostaglandins (MIsoprostol)
• Surgical Management of Misscarriage (SMM)

Question 14

How do we manage a septic misscarriage?

Answer 14

Abx

Evacuate the uterus of remaining POC

Question 15

Define an Antepartum Haemorrhage?

Answer 15

Bleeding from genital tract >24wks but before delivery
Contrast to a miscarriage which is used for bleeds <24wks

This is because 24wks is when the foetus is considered viable

Question 16

List the major causes of an APH?

Answer 16

Placenta Praevia
Placental Abruption
Local lesion of genital tract
Idiopathic
Vasa Praevia (Very rare)

Question 17

In what women is Placenta Praevia a risk?

Answer 17

Multiparous
Multiple pregnancy
Previous C-section

Question 18

What are the types of placenta praevia?

Answer 18

GRaded 1-4:

1) Placenta doesn’t touch internal cervical orifice (Os)
2) Placenta reaches Os
3) Placenta covers Os
4) Central Placenta Praevia (directly over Os)

Question 19

How does a case of placenta praevia present?

Answer 19

• Painless PV bleeding >24wks
• a soft non-tender uterus
• malpresentation.

Often they present because we spot malpresentation on exam, send for an US and discover placenta praevia as the source of the bad alignment

Question 20

How do we confirm a case of placenta praevia?

Answer 20

US!

Don’t do vaginal exam till you’ve ruled it out with US as it could trigger a bigger bleed

Question 21

How do we handle a Placenta Praevia?

Answer 21

If possible be conservative e.g. blood transfusions etc to get the baby to term then deliver by C-section.
Either way you can’t deliver vaginally.

Question 22

Define placental Abruption?

Answer 22

The placenta seperates from the wall early, usually with a retroplacental clot forming

Question 23

What are the types of placental abruption?

Answer 23

Revealed - blood can escape through Os
Concealed - Blood trapped between placenta/uterine wall
Mixed

Question 24

How does a Placental Abruption present?

Answer 24

Severe abdo pain and APH
May increase uterine tone & have contractions
Foetus will be longitunidal

Question 25

How extra can a Concealed placental abruption present?

Answer 25

Blood can’t escape through os so builds up –> Uterine volume increases –> Fundal height excessive

Couvelaire Uterus

Question 26

What are the risk factors for a placenta abruption?

Answer 26

-Hypertensive disorders (chronic hyp or pre-eclampsia)
-Multiple pregnancy
-Polyhydramnios
-Smoking, Age & Parity
H/o
-Cocaine

Question 27

Placenta Abruption can be very dangerous, especially if the bleed is concealed. What complications can it trigger? (Think big bleed and clot)

Answer 27

• Maternal shocked collapse
• Foetal Death
• Maternal DIC ; renal failure
• PPH
• Coevelaire Uterus

Question 28

List some local genital tract lesions that could be the source of APH?

Answer 28

• Cervical polyps
• Cervical Cancer
• Vaginal Thrush

Question 29

So how do manage an APH over?

Answer 29

IT varies based on:

• amount of bleeding
• maternal/foetal condition -gestation
• Expectant treatment
• Conservative e.g. blood transfusions
• Attempt a vaginal delivery
• Emergency C-sections

Question 30

Classification of miscarriages

Answer 30

• Threatened
• Inevitable
• Incomplete
• Complete
• Septic
• Missed

Question 31

What is placenta praaevia

Answer 31

placenta is attached to the lower segment of the uterine segment

Question 32

What is Couvelaire Uterus

Answer 32

bruising in myometrium

Question 33

What is vasa Praevia?

Answer 33

Small rupture to metal vessels