VAGINAL BLEEDING IN PREGNANCY

68
VAGINAL BLEEDING IN PREGNANCY Dr Sattam Alenezi ED Consultant

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description

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 - PowerPoint PPT Presentation

Transcript of VAGINAL BLEEDING IN PREGNANCY

Page 1: VAGINAL BLEEDING IN PREGNANCY

VAGINAL BLEEDING IN PREGNANCY

Dr Sattam AleneziED 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

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

Three primary causes

ABORTION

ECTOPIC PREGNANCY (EP)

TROPHOBLASTIC DISORDERS

Abortion

Incidence-1 in 5 pregnancies 80 occur in the first trimester Incidence decreases with gestational age

If fetal heart activityviability 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

Abortion

Etiology-

Maternal factors Infectious-Mycoplasma ToxoplasmosisListeria Environmental-Alcohol abuse Smoking Uterine - Septum Fibroids Cervical

Incompetence Systemic Disease-Thyroid Diabetes

1048715 Paternal factors-Chromosomal

translocation

Fetal Factors-Chromosomal 50 of 1st trimester abortions caused by

chromosomal anomalies

Symptoms

Vaginal bleeding in almost all patients

Cramping and pelvic pain very common

Hemorrhage can lead to syncope from hypovolemiashock

Often discovered when fetal heart activity cannot be detected on exam

Abortion

Differential Diagnosis

Threatened Abortion - bleeding cervix closed

Inevitable Abortion - cervix open ormembranes ruptured

Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage

or Observation

Complete Abortion - passed all products ofconception (POC)

Septic Abortion uterine infection during any stage of

abortion

Missed Abortion Embryo larger than 5 mm without

cardiac activity

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 MISCARRIAGE

THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME

THREATENED MISCARRIAGE - Treatment

SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT

THREATENED MISCARRIAGE

DISCHARGE HOME IS SAFE

MUST INCLUDE MANDATORY OB FOLLOW UP

SERIAL BHCG IN 48 HRS

INEVITABLE INCOMPLETEMISCARRIAGE

BOTH HAVE EARLY PREGNANCY LOSS

BOTH PRESENT AND ARE TREATED SIMILARLY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 2: VAGINAL BLEEDING IN PREGNANCY

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

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

Three primary causes

ABORTION

ECTOPIC PREGNANCY (EP)

TROPHOBLASTIC DISORDERS

Abortion

Incidence-1 in 5 pregnancies 80 occur in the first trimester Incidence decreases with gestational age

If fetal heart activityviability 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

Abortion

Etiology-

Maternal factors Infectious-Mycoplasma ToxoplasmosisListeria Environmental-Alcohol abuse Smoking Uterine - Septum Fibroids Cervical

Incompetence Systemic Disease-Thyroid Diabetes

1048715 Paternal factors-Chromosomal

translocation

Fetal Factors-Chromosomal 50 of 1st trimester abortions caused by

chromosomal anomalies

Symptoms

Vaginal bleeding in almost all patients

Cramping and pelvic pain very common

Hemorrhage can lead to syncope from hypovolemiashock

Often discovered when fetal heart activity cannot be detected on exam

Abortion

Differential Diagnosis

Threatened Abortion - bleeding cervix closed

Inevitable Abortion - cervix open ormembranes ruptured

Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage

or Observation

Complete Abortion - passed all products ofconception (POC)

Septic Abortion uterine infection during any stage of

abortion

Missed Abortion Embryo larger than 5 mm without

cardiac activity

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 MISCARRIAGE

THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME

THREATENED MISCARRIAGE - Treatment

SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT

THREATENED MISCARRIAGE

DISCHARGE HOME IS SAFE

MUST INCLUDE MANDATORY OB FOLLOW UP

SERIAL BHCG IN 48 HRS

INEVITABLE INCOMPLETEMISCARRIAGE

BOTH HAVE EARLY PREGNANCY LOSS

BOTH PRESENT AND ARE TREATED SIMILARLY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 3: VAGINAL BLEEDING IN PREGNANCY

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

Three primary causes

ABORTION

ECTOPIC PREGNANCY (EP)

TROPHOBLASTIC DISORDERS

Abortion

Incidence-1 in 5 pregnancies 80 occur in the first trimester Incidence decreases with gestational age

If fetal heart activityviability 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

Abortion

Etiology-

Maternal factors Infectious-Mycoplasma ToxoplasmosisListeria Environmental-Alcohol abuse Smoking Uterine - Septum Fibroids Cervical

Incompetence Systemic Disease-Thyroid Diabetes

1048715 Paternal factors-Chromosomal

translocation

Fetal Factors-Chromosomal 50 of 1st trimester abortions caused by

chromosomal anomalies

Symptoms

Vaginal bleeding in almost all patients

Cramping and pelvic pain very common

Hemorrhage can lead to syncope from hypovolemiashock

Often discovered when fetal heart activity cannot be detected on exam

Abortion

Differential Diagnosis

Threatened Abortion - bleeding cervix closed

Inevitable Abortion - cervix open ormembranes ruptured

Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage

or Observation

Complete Abortion - passed all products ofconception (POC)

Septic Abortion uterine infection during any stage of

abortion

Missed Abortion Embryo larger than 5 mm without

cardiac activity

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 MISCARRIAGE

THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME

THREATENED MISCARRIAGE - Treatment

SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT

THREATENED MISCARRIAGE

DISCHARGE HOME IS SAFE

MUST INCLUDE MANDATORY OB FOLLOW UP

SERIAL BHCG IN 48 HRS

INEVITABLE INCOMPLETEMISCARRIAGE

BOTH HAVE EARLY PREGNANCY LOSS

BOTH PRESENT AND ARE TREATED SIMILARLY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 4: VAGINAL BLEEDING IN PREGNANCY

BLEEDING AND THE FIRST 20 WEEKS

Three primary causes

ABORTION

ECTOPIC PREGNANCY (EP)

TROPHOBLASTIC DISORDERS

Abortion

Incidence-1 in 5 pregnancies 80 occur in the first trimester Incidence decreases with gestational age

If fetal heart activityviability 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

Abortion

Etiology-

Maternal factors Infectious-Mycoplasma ToxoplasmosisListeria Environmental-Alcohol abuse Smoking Uterine - Septum Fibroids Cervical

Incompetence Systemic Disease-Thyroid Diabetes

1048715 Paternal factors-Chromosomal

translocation

Fetal Factors-Chromosomal 50 of 1st trimester abortions caused by

chromosomal anomalies

Symptoms

Vaginal bleeding in almost all patients

Cramping and pelvic pain very common

Hemorrhage can lead to syncope from hypovolemiashock

Often discovered when fetal heart activity cannot be detected on exam

Abortion

Differential Diagnosis

Threatened Abortion - bleeding cervix closed

Inevitable Abortion - cervix open ormembranes ruptured

Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage

or Observation

Complete Abortion - passed all products ofconception (POC)

Septic Abortion uterine infection during any stage of

abortion

Missed Abortion Embryo larger than 5 mm without

cardiac activity

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 MISCARRIAGE

THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME

THREATENED MISCARRIAGE - Treatment

SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT

THREATENED MISCARRIAGE

DISCHARGE HOME IS SAFE

MUST INCLUDE MANDATORY OB FOLLOW UP

SERIAL BHCG IN 48 HRS

INEVITABLE INCOMPLETEMISCARRIAGE

BOTH HAVE EARLY PREGNANCY LOSS

BOTH PRESENT AND ARE TREATED SIMILARLY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 5: VAGINAL BLEEDING IN PREGNANCY

Abortion

Incidence-1 in 5 pregnancies 80 occur in the first trimester Incidence decreases with gestational age

If fetal heart activityviability 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

Abortion

Etiology-

Maternal factors Infectious-Mycoplasma ToxoplasmosisListeria Environmental-Alcohol abuse Smoking Uterine - Septum Fibroids Cervical

Incompetence Systemic Disease-Thyroid Diabetes

1048715 Paternal factors-Chromosomal

translocation

Fetal Factors-Chromosomal 50 of 1st trimester abortions caused by

chromosomal anomalies

Symptoms

Vaginal bleeding in almost all patients

Cramping and pelvic pain very common

Hemorrhage can lead to syncope from hypovolemiashock

Often discovered when fetal heart activity cannot be detected on exam

Abortion

Differential Diagnosis

Threatened Abortion - bleeding cervix closed

Inevitable Abortion - cervix open ormembranes ruptured

Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage

or Observation

Complete Abortion - passed all products ofconception (POC)

Septic Abortion uterine infection during any stage of

abortion

Missed Abortion Embryo larger than 5 mm without

cardiac activity

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 MISCARRIAGE

THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME

THREATENED MISCARRIAGE - Treatment

SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT

THREATENED MISCARRIAGE

DISCHARGE HOME IS SAFE

MUST INCLUDE MANDATORY OB FOLLOW UP

SERIAL BHCG IN 48 HRS

INEVITABLE INCOMPLETEMISCARRIAGE

BOTH HAVE EARLY PREGNANCY LOSS

BOTH PRESENT AND ARE TREATED SIMILARLY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 6: VAGINAL BLEEDING IN PREGNANCY

Abortion

Etiology-

Maternal factors Infectious-Mycoplasma ToxoplasmosisListeria Environmental-Alcohol abuse Smoking Uterine - Septum Fibroids Cervical

Incompetence Systemic Disease-Thyroid Diabetes

1048715 Paternal factors-Chromosomal

translocation

Fetal Factors-Chromosomal 50 of 1st trimester abortions caused by

chromosomal anomalies

Symptoms

Vaginal bleeding in almost all patients

Cramping and pelvic pain very common

Hemorrhage can lead to syncope from hypovolemiashock

Often discovered when fetal heart activity cannot be detected on exam

Abortion

Differential Diagnosis

Threatened Abortion - bleeding cervix closed

Inevitable Abortion - cervix open ormembranes ruptured

Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage

or Observation

Complete Abortion - passed all products ofconception (POC)

Septic Abortion uterine infection during any stage of

abortion

Missed Abortion Embryo larger than 5 mm without

cardiac activity

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 MISCARRIAGE

THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME

THREATENED MISCARRIAGE - Treatment

SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT

THREATENED MISCARRIAGE

DISCHARGE HOME IS SAFE

MUST INCLUDE MANDATORY OB FOLLOW UP

SERIAL BHCG IN 48 HRS

INEVITABLE INCOMPLETEMISCARRIAGE

BOTH HAVE EARLY PREGNANCY LOSS

BOTH PRESENT AND ARE TREATED SIMILARLY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 7: VAGINAL BLEEDING IN PREGNANCY

Symptoms

Vaginal bleeding in almost all patients

Cramping and pelvic pain very common

Hemorrhage can lead to syncope from hypovolemiashock

Often discovered when fetal heart activity cannot be detected on exam

Abortion

Differential Diagnosis

Threatened Abortion - bleeding cervix closed

Inevitable Abortion - cervix open ormembranes ruptured

Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage

or Observation

Complete Abortion - passed all products ofconception (POC)

Septic Abortion uterine infection during any stage of

abortion

Missed Abortion Embryo larger than 5 mm without

cardiac activity

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 MISCARRIAGE

THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME

THREATENED MISCARRIAGE - Treatment

SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT

THREATENED MISCARRIAGE

DISCHARGE HOME IS SAFE

MUST INCLUDE MANDATORY OB FOLLOW UP

SERIAL BHCG IN 48 HRS

INEVITABLE INCOMPLETEMISCARRIAGE

BOTH HAVE EARLY PREGNANCY LOSS

BOTH PRESENT AND ARE TREATED SIMILARLY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 8: VAGINAL BLEEDING IN PREGNANCY

Abortion

Differential Diagnosis

Threatened Abortion - bleeding cervix closed

Inevitable Abortion - cervix open ormembranes ruptured

Incomplete Abortion - passed some of the POC Treatment ndash Suction Dilitation and Curettage

or Observation

Complete Abortion - passed all products ofconception (POC)

Septic Abortion uterine infection during any stage of

abortion

Missed Abortion Embryo larger than 5 mm without

cardiac activity

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 MISCARRIAGE

THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME

THREATENED MISCARRIAGE - Treatment

SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT

THREATENED MISCARRIAGE

DISCHARGE HOME IS SAFE

MUST INCLUDE MANDATORY OB FOLLOW UP

SERIAL BHCG IN 48 HRS

INEVITABLE INCOMPLETEMISCARRIAGE

BOTH HAVE EARLY PREGNANCY LOSS

BOTH PRESENT AND ARE TREATED SIMILARLY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 9: VAGINAL BLEEDING IN PREGNANCY

Septic Abortion uterine infection during any stage of

abortion

Missed Abortion Embryo larger than 5 mm without

cardiac activity

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 MISCARRIAGE

THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME

THREATENED MISCARRIAGE - Treatment

SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT

THREATENED MISCARRIAGE

DISCHARGE HOME IS SAFE

MUST INCLUDE MANDATORY OB FOLLOW UP

SERIAL BHCG IN 48 HRS

INEVITABLE INCOMPLETEMISCARRIAGE

BOTH HAVE EARLY PREGNANCY LOSS

BOTH PRESENT AND ARE TREATED SIMILARLY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 10: VAGINAL BLEEDING IN PREGNANCY

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 MISCARRIAGE

THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME

THREATENED MISCARRIAGE - Treatment

SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT

THREATENED MISCARRIAGE

DISCHARGE HOME IS SAFE

MUST INCLUDE MANDATORY OB FOLLOW UP

SERIAL BHCG IN 48 HRS

INEVITABLE INCOMPLETEMISCARRIAGE

BOTH HAVE EARLY PREGNANCY LOSS

BOTH PRESENT AND ARE TREATED SIMILARLY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 11: VAGINAL BLEEDING IN PREGNANCY

THREATENED MISCARRIAGE

THERE IS NO CONVINCING EVIDENCE THAT ANY INTERVENTION OR TREATMENT WILL CHANGE OUTCOME

THREATENED MISCARRIAGE - Treatment

SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT

THREATENED MISCARRIAGE

DISCHARGE HOME IS SAFE

MUST INCLUDE MANDATORY OB FOLLOW UP

SERIAL BHCG IN 48 HRS

INEVITABLE INCOMPLETEMISCARRIAGE

BOTH HAVE EARLY PREGNANCY LOSS

BOTH PRESENT AND ARE TREATED SIMILARLY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 12: VAGINAL BLEEDING IN PREGNANCY

THREATENED MISCARRIAGE - Treatment

SUCCESS RATES ARE SIMILAR (93) FOR BOTH UTERINE CURETTAGE VS EXPECTANT MANAGEMENT

THREATENED MISCARRIAGE

DISCHARGE HOME IS SAFE

MUST INCLUDE MANDATORY OB FOLLOW UP

SERIAL BHCG IN 48 HRS

INEVITABLE INCOMPLETEMISCARRIAGE

BOTH HAVE EARLY PREGNANCY LOSS

BOTH PRESENT AND ARE TREATED SIMILARLY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 13: VAGINAL BLEEDING IN PREGNANCY

THREATENED MISCARRIAGE

DISCHARGE HOME IS SAFE

MUST INCLUDE MANDATORY OB FOLLOW UP

SERIAL BHCG IN 48 HRS

INEVITABLE INCOMPLETEMISCARRIAGE

BOTH HAVE EARLY PREGNANCY LOSS

BOTH PRESENT AND ARE TREATED SIMILARLY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 14: VAGINAL BLEEDING IN PREGNANCY

INEVITABLE INCOMPLETEMISCARRIAGE

BOTH HAVE EARLY PREGNANCY LOSS

BOTH PRESENT AND ARE TREATED SIMILARLY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 15: VAGINAL BLEEDING IN PREGNANCY

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 INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 16: VAGINAL BLEEDING IN PREGNANCY

INEVITABLE INCOMPLETEMISCARRIAGE

TREATMENT OF CHOICE UTERINE CURETTAGE

(DampC)

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 17: VAGINAL BLEEDING IN PREGNANCY

COMPLETE MISCARRIAGE

OCCURS WHEN ALL PRODUCTS OF CONCEPTION HAVE PASSED AND VAGINAL BLEEDING HAS STOPPED

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 18: VAGINAL BLEEDING IN PREGNANCY

Products of Conceptoin

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 19: VAGINAL BLEEDING IN PREGNANCY

MISSED MISCARRIAGE

OCCURS WITH RETENTION OF PRODUTS OF CONCEPTION FOR A PROLONGED PEROID OF TIME AFTER DOCUMENTED FETAL DEMISE

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 20: VAGINAL BLEEDING IN PREGNANCY

SEPTIC MISCARRIAGE

UTERINE INFETION OCCURS AND MAY LEAD TO SEPSIS

OCCURS IN ANY TYPE OF SPONTANEOUS OR ELECTIVE MISCARRIAGE

LATE COURSE SEPTIC SHOCK

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 21: VAGINAL BLEEDING IN PREGNANCY

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

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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 22: VAGINAL BLEEDING IN 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 amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 23: VAGINAL BLEEDING IN PREGNANCY

Ectopic Pregnancy Risk Factors

GREATEST RISK

PREVIOUS EP PREVIOUS TUBAL SURGERY DIETHYSTILBESTROL EXPOSURE DOCUMENTED TUBAL SCARRING IUD USE PID AIDS amp STD

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 24: VAGINAL BLEEDING IN PREGNANCY

Ectopic Pregnancy Risk Factors

MODERATE RISK

-PREVIOUS PID -IN VITRO FERTILIZATION

-MULTIPLE SEXUAL PARTNERS

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 25: VAGINAL BLEEDING IN PREGNANCY

Ectopic Pregnancy Risk Factors

LESS RISK

PREVIOUS PELVICABDOMINAL SURGERY

CIGARETTE SMOKING AGE OF FIRST INTERCOURSE lt18

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 26: VAGINAL BLEEDING IN PREGNANCY

ECTOPIC PREGNANCY -PATHOPHYSIOLOGY

TROPHOBLAST IMPLANTS ON THE TUBAL WALL GROWS (SLOWER THAN NORMAL) INSIDE THE FALLOPIAN TUBE UNTIL THE LUMEN IS UNABLE TO SUPPORT ITrsquoS SIZE

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 27: VAGINAL BLEEDING IN PREGNANCY

ECTOPIC PREGNANCY

MEAN GESTATIONAL AGE OF RUPTURE IS 72 WEEKS

UP TO 23 OF EP RUPTURE UP TO 11 OF EP RUPTURED AT

BHCG lt100

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 28: VAGINAL BLEEDING IN PREGNANCY

ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 29: VAGINAL BLEEDING IN PREGNANCY

ECTOPIC PREGNANCY

CLINICAL PRESENTATION

CLASSIC HX - ABDOMINAL PAIN -VAGINAL BLEEDING-AMENORRHEA

-SYNCOPE +- ( SHOCK)

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 30: VAGINAL BLEEDING IN PREGNANCY

ECTOPIC PREGNANCY

ALL CHILDBEARING FEMALES WITH CHIEF COMPLAINT OF SYNCOPE SHOULD HAVE ECTOPIC PREGNANCY IN THEIR DIFFERENTIAL

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 31: VAGINAL BLEEDING IN PREGNANCY

ECTOPIC PREGNANCY

PHYSICAL FINDINGS

Vaginal bleeding Hypotension tachycardia(shock) Adnexal mass or tenderness in one

sided adnexa Uterus-normal size Peritoneal Signs

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 32: VAGINAL BLEEDING IN PREGNANCY

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash 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 PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 33: VAGINAL BLEEDING IN PREGNANCY

ECTOPIC PREGNANCY

DIAGNOSTIC MODALITIES ndash LABS

PROGESTERONE

-SINGLE LEVEL gt25 CORRELATES TO A VIABLE GESTATION

-LEVELlt5 MAY INDICATE A NONVIABLE GESTATION

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 34: VAGINAL BLEEDING IN PREGNANCY

ECTOPIC PREGNANCY

ULTRASOUNDSINGLE MOST VALUABLE

MODALITY AVAILABLE

-BHCG DISCRIMINATORY THRESHOLD FOR

TVU 1500 FOR TAU 5000

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 35: VAGINAL BLEEDING IN PREGNANCY

ECTOPIC PREGNANCY

ULTRASONIC SIGNS OF NORMAL INTRAUTERINE PREGNANCY (IUP)

GESTATIONAL SAC YOLK SAC EMBRYONIC POLE FETAL CARDIAC ACTIVITY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 36: VAGINAL BLEEDING IN PREGNANCY

ECTOPIC PREGNANCY

ED ULTRASOUND

SHOULD BE EMPLOYED TO DEMONSTRATE AN EMPTY UTERUS OR A NORMAL INTRAUTERINE PREGNANCY WITH A BHCG gt THE DISCRIMINATORY THRESHOLD

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 37: VAGINAL BLEEDING IN PREGNANCY

ED ULTRASOUND

Echogenic adenexal mass Empty uterus Free fluids in pelvis Cardiac activity outside the uterus

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 38: VAGINAL BLEEDING IN PREGNANCY

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 ndash If non diagnostic ndash need ldquoofficialrdquo study

PASSAGE OF TISSUE DOES NOT INDICATE A MISCARRIAGE

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 39: VAGINAL BLEEDING IN PREGNANCY

ECTOPIC PREGNANCYTreatment

MEDICAL MANAGEMENT

METHOTREXATE DRUG OF CHOICE unruptured small no cardiac activity

compliant patient

CONTRAINDICATIONS -OBVIOUS SIGNS OF RUPTURE-BHCG gt 2000-SUSPECTED HETEROTOPIC

PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 40: VAGINAL BLEEDING IN PREGNANCY

ECTOPIC PREGNANCY Treatment

SURGICAL TREATMENT - MAINSTAY OF TREATMENT

Laparoscopy Salpingostomy Salpingectomy

Laparotomy

LAPARASCOPIC APPROACH IS SUPERIOR TO LAPARTOMY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 41: VAGINAL BLEEDING IN PREGNANCY

Ectopic Pregnancy-Unusual Variants

Heterotopic Pregnancy Simultaneous IUP and ectopic gestations Rare- 1 in 4000 pregnancies

More in women on fertility drugs

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 42: VAGINAL BLEEDING IN PREGNANCY

TROPOBLASTIC DISORDERS

ABNORMAL PROLIFERATION OF TROPHOBLASTIC TISSUE

EG COMPLETEPARTIAL MOLE INVASIVE HYADTIFORM MOLE CHORIOCARCINOMA

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 43: VAGINAL BLEEDING IN PREGNANCY

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 ldquoSNOWY PATTERNrdquo

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 44: VAGINAL BLEEDING IN PREGNANCY

Molar Pregnancy US

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 45: VAGINAL BLEEDING IN PREGNANCY

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

lt12 WEEKS OF GESTATION ADMINISTER RHOGAM 50 MCG

gt12 WEEKS OF GESTATION ADMINISTER RHOGAM 300 MCG

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 46: VAGINAL BLEEDING IN PREGNANCY

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 UA

Rad Pelvic US

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 47: VAGINAL BLEEDING IN PREGNANCY

BLEEDING AND SECOND 20 WEEKS OF GESTATION

ABRUPTIO PLACENTA

PLACENTA PREVIA

UTERINE RUPTURE

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 48: VAGINAL BLEEDING IN PREGNANCY

Abrutio Placentae

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 49: VAGINAL BLEEDING IN PREGNANCY

ABRUPTIO PLACENTA

PREMATURE SEPARATION OF ABNORMALLY IMPLANTED PLACENTA

MOST COMMON CAUSE OF INTRAPARTUM FETAL DEMISE

MOST COMMONLY OCCURS SHORTLY BEFORE LABOR

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 50: VAGINAL BLEEDING IN PREGNANCY

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 PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 51: VAGINAL BLEEDING IN PREGNANCY

ABRUPTIO PLACENTA RISK FACTORS

MATERNAL HYPERTENSION ECLAMPSIAPREECLAMPSIA 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 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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 52: VAGINAL BLEEDING IN PREGNANCY

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 PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 53: VAGINAL BLEEDING IN PREGNANCY

ABRUPTIO PLACENTA

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 54: VAGINAL BLEEDING IN PREGNANCY

ABRUPTIO PLACENTA

DIAGNOSIS IS CLINICAL LABORATORY WORK UP IS DIRECTED

TOWARDS THE COMPLICATIONS

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 55: VAGINAL BLEEDING IN PREGNANCY

ABRUPTIO PLACENTA

ULTRASOUND CAN MISS UP TO 50 OF ABRUPTIONS

ULTRASONOGRAPHIC FINDINGS INCLUDE SUBCHORFIONIC RETORPLACENTAL OR PRELACENTAL HEMATOMAS

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 56: VAGINAL BLEEDING IN PREGNANCY

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 Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 57: VAGINAL BLEEDING IN PREGNANCY

Placenta Previa

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 58: VAGINAL BLEEDING IN PREGNANCY

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 PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 59: VAGINAL BLEEDING IN PREGNANCY

PLACENTA PREVIA

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 60: VAGINAL BLEEDING IN PREGNANCY

PLACENTA PREVIA

RISK FACTORS(SCARRED UTERUS) MULTIPARITY PRIOR C-SECTION PRIOR PLACENTA PREVIA MULTIPLE GESTATIONS PRIOR ABORTION WITH CURETTAGE

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 61: VAGINAL BLEEDING IN PREGNANCY

PLACENTA PREVIA

CLINICAL PRESENTATION PAINLESS VAGINAL BLEEDING (UP TO

70) DEFER ALL VAGINAL EXAM UNTIL

ULTRASONOGRAPY IS COMPLETED

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 62: VAGINAL BLEEDING IN PREGNANCY

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 PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 63: VAGINAL BLEEDING IN PREGNANCY

PLACENTA PREVIA

TREATMENT No PV exam at ED OBGY consultation

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 64: VAGINAL BLEEDING IN PREGNANCY

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

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 65: VAGINAL BLEEDING IN PREGNANCY

CAUSES

Early Uterine atony Genital tract trauma Abnormal placenta attachment Retain products of conception Uterine inversion

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 66: VAGINAL BLEEDING IN PREGNANCY

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

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68
Page 67: VAGINAL BLEEDING IN PREGNANCY

Late Endometritis RPOC

  • VAGINAL BLEEDING IN PREGNANCY
  • VAGINAL BLEEDING DURING PREGNANCY
  • PREGNANCY AND VAGINAL BLEEDING
  • BLEEDING AND THE FIRST 20 WEEKS
  • Abortion
  • Abortion
  • Symptoms
  • Abortion (2)
  • Slide 9
  • THREATENED MISCARRIAGE
  • THREATENED MISCARRIAGE (2)
  • THREATENED MISCARRIAGE - Treatment
  • THREATENED MISCARRIAGE (3)
  • INEVITABLE INCOMPLETE MISCARRIAGE
  • INEVITABLE INCOMPLETE MISCARRIAGE (2)
  • INEVITABLE INCOMPLETE MISCARRIAGE (3)
  • COMPLETE MISCARRIAGE
  • Products of Conceptoin
  • MISSED MISCARRIAGE
  • SEPTIC MISCARRIAGE
  • SEPTIC MISCARRIAGE (2)
  • Ectopic Pregnancy
  • Ectopic Pregnancy Risk Factors
  • Ectopic Pregnancy Risk Factors (2)
  • Ectopic Pregnancy Risk Factors (3)
  • ECTOPIC PREGNANCY -PATHOPHYSIOLOGY
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY - SITES OF IMPLANTATIONS
  • ECTOPIC PREGNANCY
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (3)
  • ECTOPIC PREGNANCY (4)
  • ECTOPIC PREGNANCY (5)
  • ECTOPIC PREGNANCY (2)
  • ECTOPIC PREGNANCY (6)
  • ECTOPIC PREGNANCY (7)
  • ED ULTRASOUND
  • ECTOPIC PREGNANCY (8)
  • Slide 39
  • ECTOPIC PREGNANCY Treatment
  • ECTOPIC PREGNANCY Treatment
  • Ectopic Pregnancy- Unusual Variants
  • TROPOBLASTIC DISORDERS
  • TROPHOBLASTIC DISORDERS
  • Molar Pregnancy US
  • RHESUS FACTOR
  • Bleeding in First 20 weeks Evaluation
  • BLEEDING AND SECOND 20 WEEKS OF GESTATION
  • Abrutio Placentae
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (3)
  • ABRUPTIO PLACENTA
  • ABRUPTIO PLACENTA (4)
  • ABRUPTIO PLACENTA (5)
  • ABRUPTIO PLACENTA (2)
  • ABRUPTIO PLACENTA (6)
  • Placenta Previa
  • PLACENTA PREVIA
  • PLACENTA PREVIA (2)
  • PLACENTA PREVIA
  • PLACENTA PREVIA (3)
  • PLACENTA PREVIA (4)
  • PLACENTA PREVIA (5)
  • Postpartum hemorrhage
  • CAUSES
  • UTERINE RUPTURE
  • Slide 68

START: Implantation and early pregnancy - Fertility Society · pregnancy and a 95% chance in the presence of vaginal bleeding. Clinical ... • Implantation of a pregnancy is still

START: Implantation and early pregnancy - Fertility Society · pregnancy and a 95% chance in the presence of vaginal bleeding. Clinical ... • Implantation of a pregnancy is still

Vaginal Bleeding in Late Pregnancy

Vaginal Bleeding in Late Pregnancy

Approach to vaginal bleeding in early pregnancy - EM Cases · PDF fileApproach to vaginal bleeding in early pregnancy SUMMARY OF EPISODE 23: VAGINAL BLEEDING IN EARLY PREGNANCY ...

Approach to vaginal bleeding in early pregnancy - EM Cases · PDF fileApproach to vaginal bleeding in early pregnancy SUMMARY OF EPISODE 23: VAGINAL BLEEDING IN EARLY PREGNANCY ...

Vaginal Bleeding in Late Pregnancykho-health.mui.ac.ir/sites/kho-health.mui.ac.ir/files/kargah/allame... · Identify major causes of vaginal bleeding in the second half of pregnancy

Vaginal Bleeding in Late Pregnancykho-health.mui.ac.ir/sites/kho-health.mui.ac.ir/files/kargah/allame... · Identify major causes of vaginal bleeding in the second half of pregnancy

VAGINAL BLEEDING IN PREGNANCY

VAGINAL BLEEDING IN PREGNANCY

Efficacy of Prophylactic Uterine Artery Embolization …...patient due to her painful memory of postpartum bleeding in a previous pregnancy. Symptomatic vaginal bleeding was present

Efficacy of Prophylactic Uterine Artery Embolization …...patient due to her painful memory of postpartum bleeding in a previous pregnancy. Symptomatic vaginal bleeding was present

Vaginal bleeding in early pregnancy

Vaginal bleeding in early pregnancy

approach to patient vaginal bleeding in 2nd half of pregnancy

approach to patient vaginal bleeding in 2nd half of pregnancy

Bleeding during pregnancy

Bleeding during pregnancy

Research Article Circumvallate Placenta: Associated Clinical …downloads.hindawi.com/journals/ogi/2014/986230.pdf · 2019. 7. 31. · vaginal bleeding during pregnancy causes hemosiderin

Research Article Circumvallate Placenta: Associated Clinical …downloads.hindawi.com/journals/ogi/2014/986230.pdf · 2019. 7. 31. · vaginal bleeding during pregnancy causes hemosiderin

Vaginal Bleeding in Early Pregnancy Dr Dalya Alhamdan Consultant Ob/ Gyn Salmaniya Medical Complex.

Vaginal Bleeding in Early Pregnancy Dr Dalya Alhamdan Consultant Ob/ Gyn Salmaniya Medical Complex.

Vaginal Bleeding in Early Pregnancy Patterns Pred-1

Vaginal Bleeding in Early Pregnancy Patterns Pred-1

Bleeding in late pregnancy

Bleeding in late pregnancy

Ectopic Pregnancy - aium.s3.amazonaws.comaium.s3.amazonaws.com/uls/handouts/17EP.pdf · Classic presentation: pain, vaginal bleeding, adnexal mass Positive pregnancy test Ultrasound

Ectopic Pregnancy - aium.s3.amazonaws.comaium.s3.amazonaws.com/uls/handouts/17EP.pdf · Classic presentation: pain, vaginal bleeding, adnexal mass Positive pregnancy test Ultrasound

Arteriovenous malformation in uterine cervix during pregnancy · Sung-Mee Kim, et al. AVM in uterine cervix during pregnancy uterine bleeding which was uncontrolled with vaginal packing

Arteriovenous malformation in uterine cervix during pregnancy · Sung-Mee Kim, et al. AVM in uterine cervix during pregnancy uterine bleeding which was uncontrolled with vaginal packing

Final- Abnormal Vaginal Bleeding in 1st Trimester

Final- Abnormal Vaginal Bleeding in 1st Trimester

Early pregnancy bleeding:-

Early pregnancy bleeding:-

Vaginal bleeding du ing pregnancy (1)

Vaginal bleeding du ing pregnancy (1)

Postmenopausal vaginal bleeding

Postmenopausal vaginal bleeding

Abnormal vaginal bleeding in second half of pregnancy · painless bleeding uterus : soft, no tenderness ... (Couvelaire Uterus) : extravasations of blood into the uterine musculature

Abnormal vaginal bleeding in second half of pregnancy · painless bleeding uterus : soft, no tenderness ... (Couvelaire Uterus) : extravasations of blood into the uterine musculature