Podcast: Play in new window | Download

Third Trimester Bleeding

Placenta previa

This is when the placenta has implanted over the cervical os. Previa comes comes from the Latin word praevia meaning “go before.” This can be either partial or complete. Do not do a digital exam on a patient with 3rd trimester bleeding.

Risk factors

• Advanced maternal age
• Smoking
• History of a C-Section
• History of a D&C
• Multiparity

Clinical presentation

Painless third trimester bleeding

Diagnostic Tests

• U/S is very reliable in diagnosing placenta previa
• CBC
• Coagulation studies
• Type and cross

Treatment

• Close monitoring
• Corticosteroids given at 24 –32 weeks to promote lung development
• Delivered by c-section
• Blood transfusion if necessary
• Nothing per vagina during pregnancy

Placental Abruption

Placental abruption is the premature detachment of an otherwise normal placenta from the uterine wall. This occurs in about 1% of pregnancies. Fetal demise is as high as 20–40% and maternal morbidity is as high as 1%.

Risk Factors

• Advanced maternal age
• Smoking
• Cocaine use
• Use of alcohol
• Multiple gestations
• Preeclampsia
• Hypertension
• Uterine abnormalities
• History of placental abruption
• Abdominal trauma
• Decreased folic acid levels

Clinical presentation

• Painful 3rd trimester bleeding
• Pain – abdomen or back pain
• Vaginal bleeding is present in 85% of cases
• Uterus can be hypertonic, irritable and tender.
• Couvelaire uterus – bleeding into the myometrium and then into the peritoneal cavity.
• Fetal heart rate irregularities

Diagnostic Tests

• Diagnosis is made clinically as U/S is not reliable
• U/S to monitor fetal distress
• Fetal distress will vary with the degree of separation
• CBC
• Coagulation studies
• Type and cross

Treatment

• Delivery is definitive treatment
• I have read both vaginal and c-section as the preferred method of delivery in these cases. You want to control blood loss as much as possible.

Infectious complications of pregnancy

Group B Strep

• Up to 30% of pregnant women are asymptomatic carriers.
• An active Group B strep infection at the time of delivery can be very bad for both the mother and the baby whether the child is delivered vaginally or by C-section.
• Mom can develop a urinary tract infection, endometritis
• Newborn may develop pneumonia, sepsis and meningitis

Labs and studies

• Vaginal cultures for group B strep at 35–37 weeks.

Treatment

• Treatment is given if the cultures are positive or if there are no cultures done.
• Antibiotics are given during labor
• Penicillin is the most commonly used antibiotic, but ampicillin, clindamycin and vancomycin are also options especially if the patient is allergic to penicillin

Urinary Tract Infection

• The urinary tract is very susceptible to infection during pregnancy.
• A urinary tract infection may increases the risk of preterm labor

Labs and Studies

• A urine culture is performed as part a routine prenatal care.

Treatment

• Ampicillin, cephalexin or nitrofurantoin (Macrobid) are all good choices

HIV/AIDS

• HIV/AIDS does not have any effect the ability to get pregnant nor does it alter the course of the pregnancy.
• HIV does not cross the placenta.

Labs and Studies

• ELISA screening for HIV

Treatment

• Transmission rate from mother to baby are between 25 and 45% according to the WHO
• The transmission rate is between 1 and 8% with proper treatment.
• Treatment is antiretroviral therapy throughout pregnancy for mom and 6 weeks of antiretrovirals for the newborn.
• HIV can be transmitted through breast milk so it is recommended that patients bottle feed.

Herpes Genitalis

• Neonatal herpes can be fatal and is very serious

Clinical presentation

• Active herpes chancre

Treatment

• Acyclovir starting at 36 weeks can be used to prevent active disease during time of delivery
• Active genital herpes is an indication for a C-section

Syphilis

• Vertical transmission can occur at any time during pregnancy
• Syphilis may cause still birth, late term abortions, transplacental infection and congenital syphilis, intrauterine growth restriction

Labs and studies

• U/S for fetal abnormalities -All pregnant patients should have blood work to test for syphilis

Treatment

• Penicillin
• Untreated there is a 50% to 100% vertical transmission rate
• Properly treated there is a 1–2% vertical transmission rate

Cholecystitis

Clinical presentation

• Right upper quadrant pain

Labs and studies

• Transaminases, alkaline phosphatase and direct bilirubin may be significantly elevated
• U/S

Treatment

• Supportive care including pain management, fluids and antibiotics
• Surgery

Appendicitis

Clinical presentation

• Right lower quadrant pain
• Anatomy may be different, so tenderness over Mcburney’s point may not be helpful.
• Nausea and vomiting

Labs and studies

• U/S
• MRI

Treatment

• Surgery