Flashcards in vaginal bleeding Deck (116)
2-3 mo pregnant women complaining of severe abdominal pain and bleeding
POC glu 80
ETA 4-6 mins
any woman that comes in with abdominal pain and bleeding need ectopic on ddx
belly full of blood on ULS with + pregnancy test
fluid collects in morrison's pouch any trauma pt or hypotensive pt will see this space
need type and cross need a surgeon and operating room
Most ectopics happen in the
scarring form STDs cause the fetus to get stuck
blood work up in a pt with ectopic
not especially helpful
Blood WBC 8K, Hgb 11.9; Urine WBC 10-20 + LE
in a UA we are looking for undiagnosed UTI not helpful for ectopic
CBC +/- chemistry (if in case pt requires methotrexate later),
UA (check for infxn like undetected pyelo or STI – associated with preterm labor). A lot of preterm labor deliveries we see can be traced back to an infection
how does the cervix differ from the ULS
1. Cervix cant respond to active bleeding – if it is ripped in any way, you will bleed to death (like if you have a pregnancy there)
no hemostasis in the cevix
what are the ectopics we miss
The ectopics that we miss are in the cervical area
fimbriae in the ovary – they are hard to detect b/c on US they are sitting next to a lot of other structures
Ectopics hiding near the uterus will present with
More difficult to diagnose - both can appear intrauterine.
More likely to cause catastrophic bleeding.
iHigher rates in ART patients.
close to the insertion of the uterine artery
RF for cervical ectopic
prior instrumentation, fibroids, IUDs, IVF, uterine structural abnormalities (Asherman’s Syndrome, DES)
one is in the uterus and one is not
i. 1 in 4,000 pregnancies
ii. 1 in 100 pregnancies in patients using assisted reproductive technology
always start with the transabdominal view
2 large bore IV
type and cross
OB on board
i. Make sure you are oriented correctly!
ii. Find the uterine cavity.
iii. Find the endocervical canal.
iv. Always look in the adnexa and ovaries.
Always scan trans-abd AND trans vaginal
When in doubt, get a formal study!
just have bleeding
pain, OS may or may not be closed, bleeding, some tissue left behind
labs on pregnant ptds
CDC type and screen
need to know if there is incompatibility
don't want mom to build a response
Quantitative beta hCG
Primarily used to trend an early pregnancy.ii. Indicates when we should see an IUP.
above 7500 -abd uLS
if you have a completely early uterus with a Low HcG --> suspicious .
iii. Ectopic pregnancies have been reported from 5-200,000 mIU.
with super high suspect molar pregnancies or multiple gestations
Address the possibility of ectopic pregnancy, and include the patient in this discussion.
Standard labs include CBC, CMP, UA, STI testing, Rh status, and quantitative hCG for trending purposes.
iv. 48-hour follow-up either in the ED or with an OB provider.
v. Strict return precautions.
what can you assess in a patient coming 30+ weeks pregnant with blleding and pain
anything outside a labor and delivery suite is precipitous delivery
two placental catastrophes
previa= over the cervix usually painless
abruption= part of the placenta has separated away from the uterine wall
classic abruption and sxs and dx tests
uterine cramping or pain with bleeding. Can occur from sheer forces as well
ULS not very sensitive for abruption
1. CBC, type/crossmatch
2. Coagulation profile
3. Renal function studies
maternal wellness and fetal variability on fetal heart rate strips
RF for abruption
1. MCC HTN
2. Maternal trauma
6. Cocaine use
7. Previous abruptions
can go into DIC
what is the major problem with cord prolapse
deprieving oxygen and blood to the fetus
As uterus is contracting, there are decelerations which means the cord is being squeezed which means there are times baby is not getting O2 so there is a lack of circulation
need to elevate the presenting part
tx of cord prolapse
a. Elevate the foot off the cord and put pt in trendelenberg and take pt to the OR
Infusing the bladder with saline - although not as helpful if a presenting part is visible.
how do you know is the cord isn't in danger
success with pulsations in the cord
you do not want to pull the baby being delivered unitl
2. DO NOT PULL until the umbilicus is delivered.
should be delivered
Infant should deliver face down.
premi more likely to be breeched
presentation of shoulder dystocia
Buddha like faces – very plethoric, can appear purplish
if the head comes out and back in
what could indicate a possible shoulder dystocia
Fetal macrosomia- is used to describe a newborn who's significantly larger than average.
(less than 3 hours)
how to resolve should dystocia
NO fundal pressure/hold pushing until repositioned.
knees to chest in the mom
Want suprapubic pressure and turn the baby to dislodge the shoulder
c section preferred
a. McRobert’s Maneuver
b. Suprapubic pressure
c. Delivering the posterior shoulder
d. Rubin, Woods Corkscrew
e. Zavenelli Maneuver