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Vaginal bleeding during pregnancy is normal or abnormal?
Abnormal
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Vaginal haemorrhage may be two things during pregnancy:
Revealed – evident blood loss • E.g. miscarriage and placenta previa
Concealed – occurs within the abdomen / uterus • E.g. ruptured ectopic pregnancy and placental abruption
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What are the causes of Haemorrhaging in early pregnancy (≤24 weeks)?
Miscarriage
Ectopic pregnancy/Ruptured Ectopic pregnancy
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What are the causes of Haemorrhaging in late pregnancy (>24 weeks)?
Placenta praevia
Placental abruption
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Define miscarriage:
Loss of pregnancy before 23 completed weeks gestation.
Commonly seen at 6 – 14 weeks gestation; can occur after 14 weeks
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What percentage of confirmed pregnancies result in miscarriage?
15% of confirmed pregnancies result in miscarriage
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What causes miscarriages?
Fetal cause – chromosomal, genetic or structural abnormalities of the fetus
Maternal cause – maternal age, structural abnormalities of the genital tract, infections, maternal diseases and environmental factors
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What is the Pathophysiology of miscarriage?
Products of conception are partly passed through the cervix, become trapped leading to blood loss
– Mother may present with level of shock out of proportion to the amount of blood loss
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How is a miscarriage resolved?
Situation resolves with removal / expulsion of the products – complete miscarriage or surgical removal
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What is an Incomplete miscarriage
Incomplete miscarriage – remnants of placenta remain within the uterus causing excessive bleeding and can be fatal; commonly complication of septic miscarriage
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Miscarriage – Signs & Symptoms?
Bleeding - Light or heavy, often with clots and/or jelly-like tissue
Pain - Central, crampy, suprapubic, or backache Can be as intense as labour pains
Signs of pregnancy subsiding (E.g. nausea; breast tenderness)
Hypotension and bradycardia
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What is the RED FLAG amount of blood loss in pregnancy?
50ml.
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How do you manage a potential miscarriage?
A B C D issues – rapid transport
Oxygen
Assess blood volume lost
Early call for Paramedic
History of fetal movement
Pain relief
Transport to hospital (ED) – pre alert
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Define ectopic pregnancy:
The egg implants somewhere other than the uterine wall
Presents at around 6-8 weeks gestation
Usually only one missed period
Estimated rate of ectopic pregnancies is 11:1000
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Ectopic pregnancy risk factors?
Previous ectopic pregnancy
Previous surgery on the uterine tube
An intra-uterine contraceptive device fitted
Sterilisation or reversal of sterilisation
Endometriosis
Previous infections
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Ectopic pregnancy signs and symptoms?
Acute localised, lower abdominal pain
Vaginal bleeding or spotting – may present as brownish vaginal discharge
Amenorrhoea
Signs of blood loss within the abdomen with tachycardia and skin coolness
Nausea, vomiting and unusual bowel symptoms
Unexplained dizziness and fainting
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Management of Ectopic pregnancy?
A B C D issues – rapid transport
Oxygen
Assess blood volume lost
Early call for Paramedic
Pain relief: Paracetamol; Entonox
Transport to hospital (ED) – pre alert
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Antepartum Vaginal bleeding (APH) in late pregnancy (after 24 weeks) is confined to what?
Vaginal bleeding in late pregnancy (after 24 weeks) is confined to placental separation
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What are the two types of antepartum haemorrhage (APH) in late pregnancy?
Placenta Praevia • Placental Abruption
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Antepartum Haemorrhage (APH) affects how many pregnancies?
3-5%
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What is Placenta Praevia?
The placenta is partially / wholly implanted in the lower uterine segment
Segment grows and stretches ++ after 12th week of pregnancy
Later weeks may cause placenta to separate and severe bleeding can occur
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How does Placenta Praevia present?
Usually presents at 24-32 weeks with small episodes of painless bleeding
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What are the four types of placenta previa?
Complete - placenta central over cervix. High risk of bleeding. WIll need c-section.
Partial - Placenta over internal cervical os (mouth). Risk of severe haemorrhage – will require caesarean section
Marginal - Placenta is located lower segment of uterus. Vaginal delivery possible with moderate risk of bleeding
Low-lying - Placenta mainly located upper segment of uterus. Vaginal delivery possible with mild risk of bleeding
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Risk Factors for Placenta Praevia?
Previous history of placenta praevia
Previous caesarean section or other uterine surgery
Advanced maternal age
Multiparity / increasing parity
Smoking
Cocaine use during pregnancy
Previous spontaneous or induced abortion
Deficient endometrium due to past history of e.g. endometritis, manual removal of placenta, curettage
Assisted conception
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What is Placental Abruption?
Premature separation of a normally situated placenta occurring after the 22nd week of pregnancy
Bleeding occurs between the placenta and wall of the uterus, where the placenta has detached from the uterine wall
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How common is is Placental Abruption?
Estimated occurrence is 6:1000 births
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Risk factors for Placental Abruption?
Previous abruption carries the highest risk
Pregnancy Induced Hypertension / Pre-eclampsia
Trauma – RTC, domestic violence, Iatrogenic e.g. external cephalic version
Multiple pregnancy e.g. twice as common with a twin pregnancy
Multiparity
Threatened miscarriage earlier in current pregnancy
Smoking and substance abuse e.g. cocaine, amphetamine use
Previous caesarean section
Intrauterine infections
Polyhydramnios
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Signs and Symptoms for Placental Abruption?
Continuous severed / sudden abdominal or back pain
Placental abruption commonly have concealed bleeding but may also have revealed bleeding
There is a risk of underestimating the amount of blood loss
50ml of revealed blood loss in pregnancy is considered significant
Tender abdomen – rigid or ‘woody’, no signs of relaxation
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How should you manage any Later Antepartal Haemorrhaging (APH)?
A B C D issues – rapid transport
Oxygen
Assess blood volume lost
Early call for Paramedic
Take soaked pads to the hospital
History of fetal movement
Pain relief
Transport to nearest Obstetric Unit – pre alert
Think woman positioning
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What is Uterine Rupture?
Can be:
• Complete – tear in the wall of the uterus (with or without explusion of fetus)
• Incomplete – tearing of uterine wall but not perimetrium
Rare and tends to occur during labour
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Causes of Uterine Rupture?
Previous caesarean section, most common cause
High parity
Obstructed labour e.g. shoulder dystocia, pressure or excess thinning of uterus
Previous uterine trauma from assisted birth e.g. forceps
Trauma – e.g. blast injury or accident i.e. seatbelt injury in RTC
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Signs and Symptoms of complete Uterine Rupture?
Maternal tachycardia and signs of shock
Sudden collapse of mother
Severe abdominal pain
Vaginal bleeding
Uterine contractions may stop
Fetus may be palpable in abdomen
Scar pain and tenderness
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Signs and Symptoms of incomplete Uterine Rupture?
May have minimal pain or blood loss
Labour may progress normally
Disproportionate signs of haemorrhagic shock in the third stage of labour – may manifest as postpartum haemorrhage
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Where should you take any cases of APH pre 20 weeks?
Time critical transfer to ED.
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Where should you take any cases of APH post 20 weeks?
Nearest obstetrics unit
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What is Pregnancy Induced Hypertension (PIH)?
A generic term for a significant rise in blood pressure after 20 weeks gestation, in the absence of proteinuria or other features of pre-eclampsia.
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What is pre-ecalampsia?
PIH (pregancy induced hypertension) associated with proteinuria with or without oedema
Is relatively common condition but can be fatal for mother and baby - commonly occurs 24-28 weeks gestation
Primarily a placental disorder – poor placental perfusion
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How is severe pre-eclampsia classified?
Severe - >160 / 110mmHg
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What is the incidence of severe pre-eclampsia?
Incidence of severe pre eclampsia is approximately 5:1000
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Risk factors for pre-eclampsia?
10 years or more since last pregnancy
Primiparity or first pregnancy with new partner
Previous severe pre-eclampsia
Essential hypertension
Diabetes (type I or II)
Obesity
Twins or higher multiples
Renal disease
Advanced or Young maternal age (over 40 or less than 16 years)
Pre existing cardiovascular disease
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Signs and symptoms for severe pre-eclampsia?
Severe:
BP > 160/110 with proteinuria and any one or more of the following:
- • Headache (severe and frontal)
- • Visual disturbances
- • Epigastric pain
- • Side sided upper quadrant abdominal pain • Muscle twitching or tremor
- • Nausea
- • Confusion
- • Rapidly progressive oedema
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How should you manage suspected pre-eclampsia?
– Is it Mild / Moderate or Severe?
– Assess <c> A B C D E F • Are there any TIME CRITICAL features?
• If YES, pre-alert to Nearest Obstetric Unit • If NO, continue with thorough assessment
– Observations – BP, Blood Glucose, SP02 [maintain 94-98%], positioning
- – Consider early call for Paramedic assistance
- • Management of seizure
- • Caution – ambulance lights and sirens
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What is eclampsia?
The new onset of convulsions during pregnancy or postpartum, generally in a woman with pre-eclampsia
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How does eclampsia present?
Presents as generalized tonic / clonic convulsion – identical to epilepsy
1/3 of cases present for first time post delivery (within 48 hours)
BP may only be mildly elevated at presentation
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How should you manage suspected eclampsia?
– Rapid assessment <c> A B C D E F
• Patient past medical history
• Consider non self limiting or recurrent convulsions – Epileptic convulsion VS Eclampsic convulsion?
• Early call for Paramedic / APP assist but do not delay – Can administer Diazepam / IV Magnesium
– Observations – BP, Blood Glucose, SP02 [maintain 02 at 94-98%]
– Positioning – full lateral (i.e. recovery position) or if interventions required, supine with manual uterine displacement (MUD)
– Pre-alert to Nearest Obstetric Unit
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What is HELLP Syndrome?
- A complication of pre-eclampsia / Eclampsia – Haemolysis
- – Elevated Liver Enzymes
- – Low Platelet count
• Typically manifests between 32-34 weeks gestation, can present postpartum
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What is an amniotic fluid embolism?
Entry of amniotic fluid into the maternal circulation via the placental bed
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Risk factors for amniotic fluid embolism?
Risk Factors
- – Termination of pregnancy
- – Amniocentesis
- – Placental abruption
- – Trauma
- – C section
- – Prior to and up to 30 mins post delivery
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Signs and symptoms for amniotic fluid embolism?
Signs & Symptoms
- – Often rapid collapse in advanced labour
- – Dyspnoea
- – Cyanosis
- – Acute hypotension
- – Cardiac arrest
- – May have feeling of impending doom, agitation, restlessness
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What is a Pulmonary Embolism? (PE)
Pulmonary embolism [PE] is an obstruction of the pulmonary vessels reducing perfusion
Can be small, major or massive
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Risk factors for maternal PE?
Risk Factors
- – Age (esp >35)
- – Obesity
- – Previous History of PE
- – Gross varicose veins
- – Major concurrent illness e.g cancer
- – Prolonged immobility
- – Long haul travel
- – Lower segment C-section
- – Prolonged labour (>12 hrs)
- – Surgical procedures during pregnancy
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Signs and symptoms for maternal PE?
Signs & Symptoms
- – Dyspnoea
- – Tachycardia
- – Pleuritic / substernal chest pain
- – Apprehension
- – Cough
- – Haemoptysis
- – Syncope / sudden collapse
- – Signs of DVT – check legs
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What is maternal sepsis?
Can be – Directly related – i.e. pregnancy or genital tract related – Indirectly related e.g. influenza, pneumonia, E-coli, Group A & B strep
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Risk factors for maternal sepsis?
High risk factors:-
– Impaired immune system due to illness / drugs
– Gestational diabetes, diabetes or other comorbidities
– Undergone invasive procedures e.g. C-section, forceps delivery, removal of retained product of conception
– Prolonged rupture of membranes
– Been in close contact with people with Group A strep
– Have continued vaginal bleeding or offensive vaginal discharge
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Signs and Symptoms:-
- • History of infection
- • SBP < 90 mmHg
- • Tachypneoa
- • Body temperature < 36°C or > 38°C
- • Cardiovascular compromise – tachycardia; prolonged capillary refill (> 2 seconds)
- • Altered mental state
- • Diarrhoea or vomiting
- • Mottled skin or Rash – generalised / purpuric (non-blanching)
- • Abdominal / pelvic pain
- • Offensive vaginal discharge or wound
- • Productive cough
- • Not passed urine in last 12-18 hours
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