First Trimester Vaginal Bleeding

Transcription

1 Trauma, Bleeding and other Complications UCSF Family Medicine Board Review Course Topics First trimester vaginal bleeding Management of early pregnancy loss 2nd-3rd trimester bleeding Trauma Post-partum Hemorrhage Lisa Ward and Erin Lunde October 6 th, 2012 First Trimester Vaginal Bleeding Differential for Vaginal Bleeding in the 1 st Trimester Ectopic pregnancy Miscarriage: : threatened, inevitable, missed, incomplete or complete Pregnancy implantation Vaginal or cervical lesions Infection Subchorionic hemorrhage Gestational trophoblastic disease Evaluation of Vaginal Bleeding in the 1 st Trimester Urine pregnancy test Confirm pregnancy Ultrasound Identify IUP and document it Confirm cardiac motion Establish gestational age Speculum exam Visualize os and POC if present Confirm villi with float test, formal path is not always covered Consider RhoGAM Consider cultures to r/o infection Key Questions H/o ectopic pregnancy, PID, pelvic surgery H/o uterine malformation H/o DM H/o autoimmune disease like APL antibody H/o recurrent pregnancy loss Does she have an IUD? Rh Status? Fundamentals of Obstetrics 1

2 Ultrasound Use in Evaluation of Bleeding-IUP Ultrasound Use in Evaluation of Bleeding-IUP Yolk Sac Ultrasound Use in Evaluation of Bleeding- Anembryionc Pregnancy GS >13 mm with no yolk sac >18 mm with no embryonic pole Empty sac >38 days GA and no interval growth in 1 week Funny looking ultrasound Bubbles Grainy Greyed out Ultrasound Use in Evaluation of Bleeding- Trophoblastic Disease Uterus Ectopic Pregnancy Ectopic Ultrasound Findings & betahcg Anembryonic pregnancy: Gestational sac of >18 mm Without pole or yolk sac OR if < 18 mm with no change on rescan 7 days later Embryonic Demise: Fetal pole of >6mm by CRL without heart beat OR if <6 mm no change in rescan 7 days later A GS should be visible in the uterus on vaginal sono if the HCG> Fundamentals of Obstetrics 2

3 Early Pregnancy Loss 30% of pregnancies end in miscarriage 80% will occur before 12 weeks About 25% of pregnancies will have bleeding before 20 weeks About 50% of those will end in miscarriage 50% of losses due to chromosomal abnormality Also, infection, toxins, maternal uterine anomaly or endocrine issue Categories of Early Pregnancy Loss Subcategory Definitions Ultrasound Findings Anembryonic gestation Complete Ectopic pregnancy Embryonic or fetal demise Incomplete Inevitable Gestational sac with no embryonic structures, blighted ovum All POCs have passed Any pregnancy out side the endometrium Pregnancy loss after the development of the embryo or fetus; no vaginal bleeding, os is closed; missed AB Some but not all POCs have passed Cervix has dilated; usually vaginal bleeding; miscarriage is unavoidable GS >18 mm with no yolk sac or >18 mm with no embryonic poleor empty sac >38 days GA and no interval growth in 1 week Empty uterus; endometrial lining may be thickened Empty uterus; may see complex or cystic mass in adenexa, free fluid, or cardiac motion (rare) Embryonic pole >6mm with no cardiac motion; embryonic pole >6mm with no interval growth in 1 wk Heterogenous or echogenic along endometrial strip or in cervix POCs visible; + cardiac motion When to follow betas? Suspicion of gestational trophoblastic disease Levels decrease to 0 Then follow monthly for 2 months or more Suspicion for ectopic pregnancy Make sure it is not rising or plateaued eg. No IUP with quant of 5K and a little bleeding this is ectopic until proven otherwise If you aspirate or give misoprostil and if falls by 50% in 2 days, then it was NOT an ectopic Eg. No IUP with quant of 400 and a little bleeding, then this may be an early pregnancy or an ectopic or a miscarriage Follow betas: if rising, then repeat betas and u/s q2-3 days until find location of IUP By beta 1800K-2000K, if no visualized gestational sac (TV), ectopic likely This is the discriminatory zone Principles of Miscarriage Management There are 3 relatively equivalent options: expectant, medication, or aspiration The tradeoffs are related to side effects, time course, and privacy Women should choose their preference of management They also may choose to exercise a different choice along the way Types of early pregnancy loss Incomplete Embryonic demise Anembryonic gestation Management of Early Pregnancy Loss Completed Miscarriage with Expectant Management By day 7* By day 14* By day 49* Completed Miscarriage taking Misoprostil By day 8* 53% 84% 91% 93% 30% 59% 76% 88% 25% 52% 66% 81% All Categories 40% 70% 81% 84% *From day of diagnosis Luise C, et al. BMJ 2002; 324(7342):873-5 Patient-Centered Management R Wallach, TEACH Manual, 2012 Wallach, TEACH Manual, 2012 Fundamentals of Obstetrics 3

4 Vaginal Bleeding Later in Pregnancy Differential for Vaginal Bleeding Later in Pregnancy Mid pregnancy Late pregnancy Vaginal or cervical Placenta previa lesions Abruption Miscarriage Vasa previa Cervical insufficiency Infection Preterm labor Vaginal or cervical Infection lesions Bloody show -Trauma Uterine rupture -Fibroid rupture -Warts -Polyps Management of Vaginal Bleeding in Late Pregnancy Maternal ABCs Fetal monitoring Ultrasound r/o placenta previa 1st Caution w/ digital exam Sterile speculum exam Consider steroids Consider RhoGAM Labs: cbc, type and cross, antibody, coags, Kleihauer-Betke Cultures: urine, GC/CT, KOh/WM Management Changes with Gestational Age <32 weeks If mild & resolves, expectant management If severe or recurs, likely c-section weeks If mild & resolves, expectant management If severe or recurs, likely c-section 36 weeks or beyond Delivery by NSVD if maternal & fetal stability If not stable, c-section Post-Partum Partum Hemorrhage Now the most common cause of maternal peri-natal mortality in Western countries Incidence is about 2.5% (1%-5%) in the US Definition 10% drop in HCT Symptomatic blood loss > 500ml of blood loss with NSVD or > 1000ml with c-section Postpartum Hemorrhage Call for help Establish IV access Replace fluid and blood Begin fundal massage and/or pressure Start medications early Determine cause Uterine atony is cause in 50% Laceration vaginal, cervical or uterine Retained placenta or placental fragments Uterine rupture Coagulopathy Repair lacerations Fundamentals of Obstetrics 4

5 Postpartum Hemorrhage: Interventions Treat atony Fundal massage Oxytocin U in 1 L saline or 10 U IM Methergine 0.2 mg IM NOT if co-morbid hypertension, migraines, renal disease Prostaglandin F2 alpha (Hemabate Hemabate) ) 250 mcg IM repeat q min to max 2 mg NOT if co-morbid asthma Misoprostil 200mcg-800mcg SL or PR Oxygen Transfusion Information WHEN TO START: Exact guidelines are not clear Consider if unstable OR if >1500ml Transfuse 2 units prbcs Continue to check h/h q4 hours until stable then decrease WHEN TO STOP: Stable patient H/H >7.5 Platlets > 50,000 Pt/INR > 1.5 Fibrinogen > 100 Surgical Interventions for Bleeding OB consultation Arterial embolization Uterine vessel ligation Internal iliac artery ligation Laparotomy/hysterectomy Trauma in Pregnancy Largest nonobstetrical cause of maternal mortality Ddx: MVA, followed by DV, other assaults, and falls Assess maternal ABC s if CV instability or CPR, displace uterus to the left need for diagnostic imaging nearly always outweighs radiation risk After maternal stabilization (or simultaneously, but not before) - assess fetus Gestational age and EFW Viability and well-being Obstetric Complications of Trauma Abruption, preterm labor or fetomaternal hemorrhage Can occur with relatively mild maternal trauma or symptoms All women past 24 wks with abdominal trauma Monitor FHT and uterine activity for 4 hour minimum Consider CBC, plat, fibrinogen, Kleinhauer- Betke Consider anti-d immune globulin (Rhogam) if Rh negative and unsensitized Obstetric Complications of Trauma Discharge home when all of the following: No maternal indication for continued observation No abdominal pain No vaginal bleeding Normal FHR tracing Contractions less than every 10 minutes Fundamentals of Obstetrics 5

6 Summary Management of bleeding is driven by gestational age and the stability of the patient and her fetus Exercise patient-centered management of early pregnancy loss Trauma in pregnancy can have be a red flag for DV and safety issues Questions & Answers Examinations are formidable even to the best prepared, for the greatest fool may ask more than the wisest man can answer. Charles Caleb Colton, Fundamentals of Obstetrics 6