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Per Vaginal Bleed In 28 Weeks, 3 types 1: minor (low lying placenta <…

- - - - spotting
      - severe hemorrhage
    - - hyperventilation
      - restlessness
      - agitation
      - tachycardia
    - - abnormal fetal heart rate pattern
      - presenting part may found to have retracted on pelvic examination
      - fetal parts are more easily palpable abdominally
  - - - placenta abruption
      - placenta previa
    - - to monitor blood loss
  - - - general condition of mother
      - degree of hemorrhage
      - extent of uterine rupture
      - mother's dedire for future childbearing
    - - low parity and desire more child
  - - - high vertical scar- 4-7%
      - prior lower- segment transverse section- <1%
      - previous myomectomy
  - - - hemorrhage
      - shock
    - - commonly develop fetal distress and fetal death or long- term neurologic sequelae- in 10% of cases
      - rapid intervention will minimize morbidity and mortality
- - - - Where the placenta is in relationship to cervical os
      - Whether the placenta has multiple lobes
      - The location of the umbilical cord
  - - - 1) Emergency C-section
    - - Pregnancy plan
        
        -Non-stress tests (around twice a week)
        -Assess fetus’s heart rate and are completely safe for both mother and the fetus
        
        Corticosteroids such as dexamethasone to promote pulmonary maturation in preparation for a c-section delivery
        
        Inpatient management. Go to the hospital early so can be closely monitored in the days leading up to delivery.
        
        A scheduled c-section (weeks 34 to 37)
  - - - -Umbilical cord blood vessels travel outside the placenta, where they are unprotected and at risk of breaking
        -If placenta sits low in the uterus, the exposed blood vessels are vulnerable to bursting once labor begins
    - - -Placenta splits into two lobes, with the umbilical cord connecting one lobe to the other
        -If the exposed blood vessels traveling between the lobes lie close to the cervix, they can burst and bleed once labor starts.
- - - - Extravasation of blood into myometrium cause pain
    - - Uterus contract --> reduce bleeding
  - - - After 1 abruption the risk is 10% & after 2 is 25%
  - - - determining the placental location and eliminating the diagnosis of placenta previa
    - - The platelet count, if low, may indicate a consumptive
        process seen in relation to significant abruption
    - - For blood transfusion
    - - Monitor baby condition to influent time and mode of delivery
  - - - for fluid resuscitation
    - - DIC - monitor coagulation profile 1-4 hourly until stable
      - Hypovolaemia - monitor haemodynamic status
    - - help reduce the risk of respiratory distress syndrome (RDS)
        
        promote lung maturity
  - - - blood tracks from site of placental separation between decidua and chorion to cervix lead to vaginal bleed
    - - blood form retroplacental clot between placenta and uterus with no vaginal bleed
    - - only a portion of the placenta separates from the uterine wall, while the remaining part of the placenta remains attached.
    - - entire placenta detaches from the uterine wall, resulting in a complete separation.
    - - Class 1
        
        Mild
        
        Normal maternal BP & HR
        
        Slightly tender uterus
        
        No coagulopathy
        
        No vaginal bleeding to mild vaginal bleeding
        
        No fetal distress
      - Class 2
        
        Hypofibrinogenemia (50 to 250mg/Dl)
        
        Fetal distress
        
        Moderate
        
        Moderate to severe uterine tenderness
        
        No to moderate vaginal bleeding
        
        Maternal tachycardia with orthostatic changes in BP & HR
      - Class 0
        
        Asymptomatic
      - Class 3
        
        No to heavy vaginal bleeding
        
        Maternal shock
        
        Severe
        
        Hypofibrinogenemia (<150mg/Dl)
        
        Very painful tetanic uterus (sustained and continuous contraction of the uterine muscles that lasts for an extended period without relaxation)
        
        Fetal death
        
        Coagulopathy
  - - - Hypovolemic shock
        
        due to blood loss
      - Disseminated intravascular coagulation (DIC) due maternal blood loss, activation of the coagulation and fibrinolytic systems, and resulting imbalance in the body's clotting and bleeding mechanisms
      - Acute renal failure
        
        secondary to hypovolaemia
      - Post partum haemorrhage (PPH)
    - - Intrauterine hypoxia & asphyxia (a condition arising when the body is deprived of oxygen, causing unconsciousness or death; suffocation.)
      - Premature birth
        
        placenta abruptio-> reduce oxygen & nutrition supply-> fetal distress
- - - - Hx of Preterm delivery
      - -low socioeconomic status
      - -maternal age <18 years old or > 40 years old
      - -PPROM
      - multiple gestation
      - -maternal history of one or more spontaneous
      - -2nd trimenster abortions
      - smoking
      - -illicit drugs
    - - intra uterine growth restriction
      - intra uterine fetal defect
      - congenital anomalies
    - - myomata
      - uterine septum
      - cervical incompetence
  - - - Inhibit/reduce strength & frequency of contractions → delay delivery : TOCOLYTIC THERAPY
        
        2) Optimize fetal status: corticosteroids
        
        3) Identify modifiable risk factors and and treat them : ANTIBIOTICS
        
        4) Delivery → good neonatal care: TERTIARY CARE
    - - Admit patient to high dependency unit for frequent monitoring
        
        ● Monitor vital signs closely.
        
        ● Hydrate patient.
        
        ● Keep patient nil by mouth.
        
        ● Put the patient on CTG to confirm uterine activity and for fetal monitoring
        
        ● Assess cervical status, progress of labour and presnting parts
        
        ● Vaginal swab for bacterial vaginosis and streptococcus
        
        ● Advice patient for complete bed rest
        
        ● Counsel the couple on the current diagnosis and treatment given
        
        ● Arrange for neonatal ventilator support
        
        In-utero transfer if no ventilator available
- - - - Antenatal management (Expectant)
        -Transfer to Hospital with LSCS facility (Anest and Obstetrician)
        -Monitor further bleeding (Vitals, FBC, Pad chart)- bed rest
        
        blood transfusion if severe bleeding
        
        screen for anemia
        -Regular CTG and doppler, Consider IM Dexa if need to deliver prem.
        -Admission to ward to delivery (Symptomatic – admit ASAP)
        
        management if bleeding PP
        
        resuscitate
        
        vital sign
        
        take blood: hb , gxm, coagulation profile
        
        immediate CS delivery : if bleed> 500 ml
- - - - Puberty
      - Pill
      - Pregnancy
  - - - Treated with heat to destroy abnormal cells
    - - Reepitheliazation of the area of ectropion
        
        Reducing size
  - - - Exclude chlamydia or other sexually- transmitted infections, cervicitis
    - - Exclude premalignancy or malignancy
- - - - Viral vaginitis
        
        inflammation caused by a virus, like the herpes simplex virus (HSV) or human papillomavirus (HPV), which spread through sex. Sores or warts on the genitals can be painful.
      - Trichomoniasis
        
        an infection spread by sex that’s caused by a parasite.
      - Gonorrhea
        
        another common STI
      - Chlamydia
        
        most common sexually transmitted infection (STI) in women, usually in those ages 18 to 35 who have multiple sex partners.
      - Candida or "yeast" infection
        
        an overgrowth of the fungus candida, which is normally found in small amounts in the vagina
      - Bacterial vaginosis
        
        inflammation of the vagina due :to an overgrowth of bacteria.
        
        grayish-white, foul-smelling discharge. The odor, often described as a fishy odor, might be more obvious after sex.
  - - - Hormonal changes, such as those associated with pregnancy, birth control pills or menopause
      - Sexual activity
      - Having a sexually transmitted infection
      - Medications, such as antibiotics and steroids
      - Use of spermicides for birth control
      - Uncontrolled diabetes
      - Use of hygiene products such as bubble bath, vaginal spray or vaginal deodorant
      - Douching
      - Wearing damp or tight-fitting clothing
      - Using an intrauterine device (IUD) for birth control
  - - - leucocytosis
    - - KOH
      - NaCl