{"id":2616,"date":"2020-08-13T16:26:39","date_gmt":"2020-08-13T16:26:39","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=216"},"modified":"2021-05-09T20:41:05","modified_gmt":"2021-05-09T20:41:05","slug":"23-third-trimester-bleeding","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/overview\/23-third-trimester-bleeding\/","title":{"rendered":"23. Third Trimester Bleeding"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/17oGC5m3NgI\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration = 7:15<\/p>\n<input type='hidden' bg_collapse_expand='69e9b59c4f6a81088422524' value='69e9b59c4f6a81088422524'><input type='hidden' id='bg-show-more-text-69e9b59c4f6a81088422524' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b59c4f6a81088422524' value='Hide Transcript'><button id='bg-showmore-action-69e9b59c4f6a81088422524' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b59c4f6a81088422524' ><\/p>\n<p>00:00<br \/>\nAPGO educational topic number 23 third<br \/>\n00:02<br \/>\ntrimester bleeding bleeding in the third<br \/>\n00:04<br \/>\ntrimester of pregnancy can range from<br \/>\n00:06<br \/>\nspotting to life-threatening hemorrhage<br \/>\n00:08<br \/>\nremember that at term a woman&#8217;s total<br \/>\n00:10<br \/>\nblood volume has increased by 40 percent<br \/>\n00:12<br \/>\nand our cardiac output has increased by<br \/>\n00:14<br \/>\n30 percent 20 percent of cardiac output<br \/>\n00:17<br \/>\ngoes to the gravid uterus so significant<br \/>\n00:19<br \/>\nbleeding can be quickly catastrophic the<br \/>\n00:21<br \/>\nobjectives of this video are to list the<br \/>\n00:23<br \/>\ncauses of third trimester bleeding to<br \/>\n00:25<br \/>\ndescribe the initial evaluation of a<br \/>\n00:26<br \/>\npatient with third trimester bleeding<br \/>\n00:28<br \/>\ndifferentiate the signs and symptoms<br \/>\n00:30<br \/>\nwith third trimester bleeding list the<br \/>\n00:32<br \/>\nmaternal and fetal complications of<br \/>\n00:34<br \/>\nplacenta previa and placental abruption<br \/>\n00:35<br \/>\ndescribe the initial evaluation and<br \/>\n00:38<br \/>\nmanagement plan for acute blood loss<br \/>\n00:39<br \/>\nlists the indications and potential<br \/>\n00:42<br \/>\ncomplications of blood product<br \/>\n00:43<br \/>\ntransfusion the causes of third<br \/>\n00:45<br \/>\ntrimester bleeding include placenta<br \/>\n00:47<br \/>\nprevia placental abruption preterm labor<br \/>\n00:49<br \/>\nuterine rupture and vaso previa as well<br \/>\n00:52<br \/>\nas vaginal or cervical tear or<br \/>\n00:55<br \/>\nlaceration from intercourse cervical<br \/>\n00:57<br \/>\npolyp or severe cervicitis<br \/>\n00:58<br \/>\nwe will focus on the first two on this<br \/>\n01:01<br \/>\nlist the Sun to previa &amp; placental<br \/>\n01:03<br \/>\nabruption in this video the first five<br \/>\n01:05<br \/>\ncauses can lead to serious neonatal and<br \/>\n01:07<br \/>\nmaternal morbidity and mortality the<br \/>\n01:09<br \/>\nlast three on this list are considered<br \/>\n01:11<br \/>\nthe benign causes of third trimester<br \/>\n01:13<br \/>\nbleeding we are all familiar with the<br \/>\n01:15<br \/>\nABCs of cardiopulmonary resuscitation<br \/>\n01:17<br \/>\ndon&#8217;t forget in a pregnant third<br \/>\n01:19<br \/>\ntrimester patient with bleeding there<br \/>\n01:21<br \/>\nneeds to be another b4 baby remember to<br \/>\n01:24<br \/>\nalways assess fetal heart rate status as<br \/>\n01:26<br \/>\npart of the initial evaluation of third<br \/>\n01:28<br \/>\ntrimester bleeding once you are assured<br \/>\n01:30<br \/>\nthat the patient is stable and that<br \/>\n01:32<br \/>\nthere is a reassuring fetal heart rate<br \/>\n01:33<br \/>\npattern then a careful history should be<br \/>\n01:35<br \/>\nobtained here the PP qrst mnemonic is<br \/>\n01:40<br \/>\nhelpful to frame your questions P is<br \/>\n01:42<br \/>\nthere pain with the bleeding P placenta<br \/>\n01:45<br \/>\nhas she had a formal ultrasound during<br \/>\n01:47<br \/>\nthe pregnancy that assess for some &#8211;<br \/>\n01:48<br \/>\nlocation Q quantity of bleeding are<br \/>\n01:51<br \/>\nrecreational drugs during this pregnancy<br \/>\n01:53<br \/>\ns sex recently and T the timing of the<br \/>\n01:57<br \/>\nbleeding then move on to the physical<br \/>\n02:00<br \/>\nexamination look at the maternal vital<br \/>\n02:02<br \/>\nsigns again remember to assess the fetal<br \/>\n02:04<br \/>\nheart rate ensure that there is good IV<br \/>\n02:07<br \/>\naccess if you are concerned about heavy<br \/>\n02:09<br \/>\nbleeding<br \/>\n02:09<br \/>\nlook at the skin carefully for petechiae<br \/>\n02:13<br \/>\nI&#8217;ll pick the uterus to assess if it is<br \/>\n02:14<br \/>\nsoft hard or tender remember do not<br \/>\n02:18<br \/>\nperform a cervical examination until the<br \/>\n02:20<br \/>\nplacental location has been confirmed a<br \/>\n02:22<br \/>\nspeculum examination can be performed to<br \/>\n02:25<br \/>\nvisually assess the cervix let&#8217;s now<br \/>\n02:27<br \/>\ndiscuss placenta previa here is the<br \/>\n02:30<br \/>\nuterus with the external off internal<br \/>\n02:33<br \/>\noff and endometrial cavity a complete<br \/>\n02:36<br \/>\nprevia completely covers the AHS where<br \/>\n02:39<br \/>\nas a marginal previa partially covers<br \/>\n02:42<br \/>\nthe AHS the classic presentation for<br \/>\n02:45<br \/>\nplacenta previa is painless vaginal<br \/>\n02:47<br \/>\nbleeding the center previa is diagnosed<br \/>\n02:49<br \/>\nby ultrasound remember that with a<br \/>\n02:52<br \/>\nplacenta praevia a digital cervical<br \/>\n02:54<br \/>\nexamination should not be performed for<br \/>\n02:56<br \/>\ndigital manipulation can cause bleeding<br \/>\n02:58<br \/>\nif there is heavy bleeding volume<br \/>\n03:00<br \/>\nresuscitation and possibly betamethasone<br \/>\n03:02<br \/>\nfor fetal lung maturity the management<br \/>\n03:05<br \/>\nof placenta previa must balance the<br \/>\n03:07<br \/>\nrisks of prematurity with the risks to<br \/>\n03:09<br \/>\nmom of heavy vaginal bleeding delivery<br \/>\n03:12<br \/>\nwhere the placenta previa should be<br \/>\n03:13<br \/>\nperformed via caesarean section let&#8217;s<br \/>\n03:16<br \/>\nnow discuss potential complications with<br \/>\n03:18<br \/>\nplacenta previa there can be bleeding<br \/>\n03:19<br \/>\nfrom the lower uterine segment where the<br \/>\n03:21<br \/>\nplacenta was abnormally attached in<br \/>\n03:23<br \/>\naddition there can be abnormal extension<br \/>\n03:26<br \/>\nof placental tissue placenta accreta<br \/>\n03:28<br \/>\ninvolves extension of the central tissue<br \/>\n03:31<br \/>\ninto the superficial layer the<br \/>\n03:32<br \/>\nmyometrium in Krita involves extension<br \/>\n03:35<br \/>\nfurther into the myometrium and percreta<br \/>\n03:37<br \/>\ninvolves extension completely through<br \/>\n03:38<br \/>\nthe myometrium to the serosa and<br \/>\n03:40<br \/>\nsometimes into adjacent viscera note<br \/>\n03:42<br \/>\nthat the depth of invasion corresponds<br \/>\n03:44<br \/>\nto alphabetical order these three<br \/>\n03:46<br \/>\nabnormal placental extensions are<br \/>\n03:48<br \/>\nassociated with significant bleeding and<br \/>\n03:50<br \/>\nmorbidity cesarean hysterectomies need<br \/>\n03:52<br \/>\nto be performed for these three<br \/>\n03:54<br \/>\nconditions let&#8217;s now discuss the central<br \/>\n03:56<br \/>\nabruption this is an abnormal separation<br \/>\n03:58<br \/>\nof the placenta and the classic<br \/>\n04:00<br \/>\npresentation is vaginal bleeding with<br \/>\n04:02<br \/>\nabdominal pain here is the placenta that<br \/>\n04:04<br \/>\nis normally attached to the endometrial<br \/>\n04:06<br \/>\nwall if this starts to separate with a<br \/>\n04:08<br \/>\nplacental abruption then there is<br \/>\n04:09<br \/>\nusually painful vaginal bleeding note<br \/>\n04:12<br \/>\nthat there can be concealed bleeding if<br \/>\n04:13<br \/>\nthe blood is trapped behind the placenta<br \/>\n04:15<br \/>\nand cannot exit the term Cavalleria<br \/>\n04:17<br \/>\nuterus refers to the extrapolation of<br \/>\n04:19<br \/>\nblood into the uterine musculature which<br \/>\n04:21<br \/>\ncauses the uterus to appear purple or<br \/>\n04:23<br \/>\nblue risk factors for placental<br \/>\n04:25<br \/>\nabruption include trauma<br \/>\n04:26<br \/>\nsuch as a motor vehicle accident<br \/>\n04:28<br \/>\ndomestic violence or fall cocaine use<br \/>\n04:30<br \/>\nhypertension and multiple gestation the<br \/>\n04:33<br \/>\ndiagnosis of placental abruption is by<br \/>\n04:35<br \/>\nclinical examination the management of<br \/>\n04:38<br \/>\nplacental abruption involves monitoring<br \/>\n04:39<br \/>\nof the vital signs fluid administration<br \/>\n04:41<br \/>\nclose monitoring of fetal heart rate<br \/>\n04:43<br \/>\npattern and delivery for severe<br \/>\n04:45<br \/>\nhemorrhage<br \/>\n04:46<br \/>\nnote that abruption is the most common<br \/>\n04:48<br \/>\ncause of coagulopathy and pregnancy<br \/>\n04:50<br \/>\nlet&#8217;s conclude this video by discussing<br \/>\n04:51<br \/>\nevaluation and plan for managing acute<br \/>\n04:54<br \/>\nblood loss obstetric hemorrhage is one<br \/>\n04:56<br \/>\nof the leading causes of massive blood<br \/>\n04:57<br \/>\ntransfusion along with trauma ruptured<br \/>\n05:00<br \/>\nabdominal aortic aneurysm and liver<br \/>\n05:01<br \/>\ntransplant massive blood transfusion is<br \/>\n05:04<br \/>\ndefined as a transfusion of greater than<br \/>\n05:06<br \/>\n10 units of packed red blood cells and<br \/>\n05:07<br \/>\n24 hours remember that one unit of<br \/>\n05:10<br \/>\npacked red blood cells is approximately<br \/>\n05:12<br \/>\n200 cc&#8217;s of red cells and should raise<br \/>\n05:14<br \/>\nthe hematocrit by approximately 3 to 4<br \/>\n05:16<br \/>\npercent a key point to remember is that<br \/>\n05:18<br \/>\noxygen delivery is greater than four<br \/>\n05:20<br \/>\ntimes oxygen consumption so there is<br \/>\n05:22<br \/>\nalways enormous reserve<br \/>\n05:23<br \/>\nso if intravascular volume is maintained<br \/>\n05:27<br \/>\nduring bleeding and cardiovascular<br \/>\n05:28<br \/>\nstatus is not impaired then oxygen<br \/>\n05:30<br \/>\ndelivery can be maintained until<br \/>\n05:32<br \/>\nbleeding becomes too excessive this is<br \/>\n05:34<br \/>\nwhy it is so important for anesthesia<br \/>\n05:36<br \/>\ncolleagues to aggressively give IV<br \/>\n05:37<br \/>\nfluids during a hemorrhage in order to<br \/>\n05:39<br \/>\nmaintain this intravascular volume in<br \/>\n05:41<br \/>\ncases of massive transfusion if only red<br \/>\n05:44<br \/>\nblood cells and crystalloid volume are<br \/>\n05:45<br \/>\nadministered and they&#8217;ll be dilution of<br \/>\n05:47<br \/>\nthe plasma clotting proteins the one to<br \/>\n05:50<br \/>\none to one ratio reflects a ratio of 1<br \/>\n05:52<br \/>\nunit of fresh frozen plasma to one unit<br \/>\n05:55<br \/>\nof packed red blood cells to one unit of<br \/>\n05:57<br \/>\nplatelets let&#8217;s take a step back to<br \/>\n05:59<br \/>\ndiscuss when do we decide to give a<br \/>\n06:00<br \/>\nblood transfusion<br \/>\n06:01<br \/>\nwe have to consider the risks of<br \/>\n06:03<br \/>\ntransfusion and the desire to avoid an<br \/>\n06:05<br \/>\nunnecessary transfusion in this<br \/>\n06:06<br \/>\ndiscussion in cases of massive<br \/>\n06:09<br \/>\nhemorrhage the need for transfusion is<br \/>\n06:10<br \/>\ngreat in order to avoid significant<br \/>\n06:12<br \/>\nmorbidity and mortality in less acute<br \/>\n06:15<br \/>\nsituations the patient&#8217;s overall health<br \/>\n06:16<br \/>\nstatus and blood counts will help with<br \/>\n06:18<br \/>\nthe decision-making in general when the<br \/>\n06:21<br \/>\nhemoglobin is 6 to 7 a transfusion is<br \/>\n06:23<br \/>\nrecommended between 7 &amp; 8 that a<br \/>\n06:25<br \/>\ntransfusion should be strongly<br \/>\n06:26<br \/>\nconsidered and between 8 and 10<br \/>\n06:28<br \/>\ntransfusion is needed generally only if<br \/>\n06:30<br \/>\nthe patient has symptomatic anemia or<br \/>\n06:32<br \/>\nacute coronary syndrome the risks of<br \/>\n06:35<br \/>\nblood transfusion that must be<br \/>\n06:36<br \/>\nconsidered are the risk of infection the<br \/>\n06:38<br \/>\nrisk of HIV is approximate<br \/>\n06:40<br \/>\none out of 450,000 to 650,000 the risk<br \/>\n06:44<br \/>\nof allergy or immune reaction and risk<br \/>\n06:46<br \/>\nof volume overload the final point to<br \/>\n06:49<br \/>\nremember with third trimester bleeding<br \/>\n06:51<br \/>\nis to remember to give rhogam to Rh<br \/>\n06:53<br \/>\nnegative mom&#8217;s this concludes the aapko<br \/>\n06:55<br \/>\nvideo and third trimester bleeding we<br \/>\n06:57<br \/>\nhave discussed the causes evaluation and<br \/>\n06:59<br \/>\nmanagement of the most common causes a<br \/>\n07:01<br \/>\nthird trimester bleeding and the<br \/>\n07:02<br \/>\nmanagement of acute blood loss<\/p>\n<p><\/div>\n<hr>\n","protected":false},"excerpt":{"rendered":"<p>Duration = 7:15<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":46,"menu_order":23,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2616","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/2616","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/comments?post=2616"}],"version-history":[{"count":1,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/2616\/revisions"}],"predecessor-version":[{"id":2826,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/2616\/revisions\/2826"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/46"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/media?parent=2616"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}