NLE High-Risk Pregnancy & Obstetric Complications — High-Risk Pregnancy & Bleeding DisordersCheat Sheet

Important facts

• LEADING CAUSE: Chromosomal abnormalities account for >50% of first-trimester abortions.
• Risk factors: maternal infection, endocrine imbalance (especially thyroid), incompetent cervix, immunologic factors, maternal age >35.
• Assessment: count/weigh perineal pads (1 g = 1 mL blood loss), note amount/character of bleeding, cramping intensity, passage of tissue (SAVE all tissue for pathology).
• Monitoring: serial beta-hCG, hemoglobin/hematocrit for anemia, vital signs for shock.
• NO STRONG EVIDENCE that strict bed rest prevents loss, but activity limitation is advised for threatened abortion.
• Rh-negative, unsensitized mothers require Rho(D) immune globulin to prevent isoimmunization.
• Emotional care is CRITICAL: never minimize the loss, use respectful language (avoid 'miscarriage' if family prefers 'loss'), offer grief support and referrals.

Key definitions

Diagrams to know

• Cervical os status in each abortion type (threatened=closed, inevitable/incomplete=open, complete=closed)
• Timeline of beta-hCG rise/fall in normal vs. arrested pregnancy

Common values

Important facts

• Risk factors: pelvic inflammatory disease (PID), prior tubal surgery, previous ectopic pregnancy, intrauterine device (IUD) use, endometriosis, assisted reproductive techniques.
• Classic UNRUPTURED triad: unilateral lower-quadrant abdominal pain + delayed/abnormal menses + scant DARK vaginal spotting.
• RUPTURED TRIAD (EMERGENCY): sudden sharp stabbing pain + referred SHOULDER pain (Kehr sign) + RAPID signs of hypovolemic shock (tachycardia, hypotension, pallor, diaphoresis).
• Diagnostics: serial beta-hCG (abnormally SLOW rise, fails to double every 48-72 hours); transvaginal ultrasound (empty uterus + adnexal mass); culdocentesis (+blood = hemoperitoneum).
• Beta-hCG in ectopic typically lower than intrauterine pregnancy at same gestational age.
• Management UNRUPTURED: Methotrexate (MTX) 50 mg/m² IM dissolves trophoblastic tissue; requires folic acid AVOIDANCE, NO ALCOHOL, NO SUN EXPOSURE, strict follow-up hCG (must decline).
• Management RUPTURED: EMERGENCY salpingostomy (tube-sparing) or salpingectomy; prepare for shock → large-bore IV, 0.9% NaCl or LR, blood products, oxygen, continuous monitoring.
• Rho(D) immune globulin 300 mcg IM to Rh-negative, unsensitized mothers (or 50 mcg microdose if <13 weeks).
• Post-MTX teaching: pregnancy AVOID for 3 months (teratogenic), bleeding normal for 1-2 weeks, persistent/worsening pain = seek ER.

Key definitions

Diagrams to know

• Ectopic implantation sites (interstitial, isthmic, ampulla, fimbrial, ovarian, cervical, abdominal) and rupture risk by location
• MTX mechanism: inhibits dihydrofolate reductase → blocks DNA synthesis in rapidly dividing trophoblastic cells

Common values

Important facts

• Manifestations: UTERUS LARGER THAN EXPECTED for dates, dark-brown ('prune juice') or bright-red vaginal bleeding with possible PASSAGE OF VESICLES (grape-like tissue), EXCESSIVELY HIGH beta-hCG (often >100,000 mIU/mL).
• Hyperemesis gravidarum is SEVERE due to very high hCG production.
• RED FLAG: Preeclampsia signs (hypertension, proteinuria, edema) BEFORE 20 WEEKS → think molar pregnancy (preeclampsia normally after 20 weeks).
• Ultrasound findings: 'SNOWSTORM' appearance (echogenic tissue with multiple small anechoic spaces) or 'CLUSTER OF GRAPES' pattern; NO FETAL HEART TONES.
• Management: SUCTION CURETTAGE (vacuum evacuation) is primary treatment; RhoGAM to Rh-negative mothers.
• CRITICAL FOLLOW-UP: Serial beta-hCG for 6–12 MONTHS (monthly until normal, then every 3 months) to detect choriocarcinoma.
• hCG should progressively FALL to ZERO; rising/plateaued hCG = malignant transformation → chemotherapy (MTX).
• STRICT CONTRACEPTION for at least 1 YEAR: pregnancy would mask rising hCG and delay cancer detection.
• Teach patient to report abnormal bleeding, persistent hCG elevation, or any symptoms.
• Emotional support: acknowledge grief over loss of pregnancy while explaining careful monitoring for health protection.

Key definitions

Diagrams to know

• Complete vs. partial mole comparison (karyotype, fetal tissue, hCG level, malignancy risk)
• Post-molar pregnancy hCG monitoring timeline and when choriocarcinoma is suspected

Common values

Important facts

• Risk factors: multiparity, prior cesarean delivery or previa, advanced maternal age (>35), multiple gestation (twins/multiples), smoking, cocaine use, prior uterine curettage/D&C.
• Classic presentation: PAINLESS, bright-red vaginal bleeding, usually AFTER 28 weeks; may occur with Braxton-Hicks contractions.
• Uterus is SOFT, NON-TENDER with NORMAL tone (unlike abruption).
• Malpresentation common: breech, transverse lie (placenta blocks engagement of vertex).
• Diagnosis: TRANSVAGINAL (NOT transabdominal) ultrasound is gold standard; avoids speculum/digital exam until previa ruled out.
• ABSOLUTE CONTRAINDICATION: DO NOT perform vaginal exam, speculum exam, or rectal exam until previa excluded → can perforate low-lying placenta and cause catastrophic hemorrhage.
• Management STABLE PRETERM: Expectant management aims to prolong pregnancy; admit, bed rest, IV access, blood typed/crossmatched.
• Betamethasone 12 mg IM every 24 hours × 2 doses if delivery likely before 34 weeks (accelerates fetal lung maturity).
• Delivery: CESAREAN SECTION for total/partial previa at term or with heavy bleeding; marginal may allow trial of vaginal delivery if stable.
• HIGH RISK: Postpartum hemorrhage (lower segment contracts poorly; placental site may not compress adequately) → have uterotonic agents ready (oxytocin, ergot, carboprost).
• Pelvic rest: NO sexual intercourse, douches, or strenuous activity.

Key definitions

Diagrams to know

• Placental implantation locations in previa (total, partial, marginal, low-lying) relative to internal os
• Transvaginal ultrasound interpretation and distance measurement from os

Common values

Important facts

• STRONGEST RISK FACTOR: Maternal hypertension (chronic or gestational/preeclampsia); also cocaine use, trauma (MVA, falls, intimate partner violence), short umbilical cord, smoking, anticoagulation, uterine anomaly.
• Pathophysiology: retroplacental bleeding causes placental separation → loss of placental function → fetal hypoxia + maternal hemorrhage + release of thromboplastin into maternal circulation → DIC.
• Classic triad: (1) PAINFUL vaginal bleeding, (2) RIGID, BOARD-LIKE, TENDER uterus with INCREASED TONE, (3) Signs of SHOCK (may exceed visible bleeding if concealed).
• Bleeding is DARK RED (as opposed to bright red in previa).
• Fetal distress and uterine hyperactivity/tetany are common.
• Diagnosis: clinical (no imaging can rule out abruption definitively); ultrasound may show retroplacental clot but normal ultrasound does NOT exclude abruption.
• Severity grading: Grade 0 (asymptomatic, found at delivery), Grade 1 (minor separation, stable), Grade 2 (moderate, fetal distress), Grade 3 (severe, fetal demise, DIC risk).
• Management is OBSTETRIC EMERGENCY: position LEFT LATERAL TILT (improves perfusion), oxygen, large-bore IV × 2, aggressive fluid/blood replacement (0.9% NaCl, LR, RBC, FFP, platelets, cryoprecipitate for DIC).
• Continuous fetal heart rate monitoring; measure fundal height (expanding girth suggests CONCEALED bleeding).
• Monitor coagulation: platelets, PT/PTT, fibrinogen, D-dimer (watch for oozing from IV sites, gums, petechiae, hematuria = DIC).
• EMERGENCY CESAREAN DELIVERY for significant abruption, fetal compromise, or maternal instability.
• Expectant management only for GRADE 1 (minor) abruption with stable vitals and reassuring FHR; frequent reassessment mandatory.
• Complication: DIC develops in up to 10% of abruptions; risk increases with severity and fetal demise.

Key definitions

Diagrams to know

• Abruption severity grading (0-3) with clinical features and management approach
• Pathophysiology cascade: placental separation → hemorrhage → thromboplastin release → DIC activation

Common values

Important facts

• Mechanism: RhoGAM provides PASSIVE antibody (does NOT stimulate mother's own B cells to make anti-D); suppresses maternal immune response, protecting future pregnancies from hemolytic disease.
• STANDARD DOSE: 300 mcg IM at 28 weeks gestation + again WITHIN 72 HOURS after delivery of Rh-positive infant.
• MICRODOSE: 50 mcg IM used for FIRST-TRIMESTER events (spontaneous/induced abortion, ectopic pregnancy, molar pregnancy) if <12-13 weeks gestation.
• Also indicated after: amniocentesis, chorionic villus sampling (CVS), cordocentesis, abdominal trauma, placental abruption, antepartum hemorrhage, external cephalic version, fetal demise.
• Eligibility MUST CHECK: (1) Mother is Rh-NEGATIVE (RhD negative), (2) Mother's indirect Coombs is NEGATIVE (not already sensitized), (3) Baby is Rh-POSITIVE (RhD positive) OR baby's type is UNKNOWN.
• CONTRAINDICATION: Do NOT give if mother is already sensitized (positive indirect Coombs test) — RhoGAM provides no benefit and may worsen hemolytic disease.
• Dose adjustment: If excessive fetomaternal hemorrhage (>4 mL fetal RBCs or >15 mL fetal whole blood), calculate additional RhoGAM: 1 mL fetal RBCs requires 20 mcg RhoGAM; 1 mL fetal whole blood requires 4 mcg RhoGAM.
• Kleihauer-Betke test or flow cytometry quantifies fetal RBCs in maternal circulation to determine RhoGAM dose.
• Administration: Intramuscular (never IV); note lot number and document in chart.
• Timing: 28-week dose given regardless of prior sensitization (routine); post-event doses within 72 hours (efficacy decreases after 72 hours, minimal benefit after 28 days).
• Informed consent: Explain that RhoGAM is derived from human plasma (blood product); rare risk of infection but standard precautions minimize risk.
• Advise mother: avoid future pregnancies with non-Rh-negative partners if already sensitized; all non-O blood types carry transfusion risks in sensitized mothers.

Key definitions

Diagrams to know

• RhoGAM timing: 28-week routine dose + post-event doses within 72 hours for specific obstetric situations
• Eligibility decision tree: Rh status, Coombs result, baby's Rh status, sensitization history

Reactions or equations

Common values

Important facts

• ESTIMATION: Classify bleeding as SPOTTING (light), LIGHT (moderate amount), MODERATE (soaks 1-2 pads/hour), or HEAVY (>2 pads/hour).
• Count and WEIGH all perineal pads (save for measurement); note color (bright vs. dark red), presence of clots (>2 cm = significant), passage of tissue (SAVE for pathology).
• Monitor vital signs frequently: tachycardia is EARLY sign of shock (often >100 bpm before BP drops); hypotension is LATE sign.
• Other early shock signs: narrow pulse pressure, cool/clammy skin, restlessness/anxiety, delayed capillary refill, concentrated urine.
• Urine output target: ≥30 mL/hour (sign of adequate perfusion); oliguria (<25 mL/hr) suggests shock progression.
• ABSOLUTE CONTRAINDICATION with third-trimester bleeding: NO vaginal exam, NO digital cervical exam, NO rectal exam until previa ruled out by ultrasound → risk of catastrophic hemorrhage.
• Speculum exam is safe (visualize bleeding without digital trauma).
• IV access: Two LARGE-BORE (18-gauge or larger) peripheral lines for rapid fluid/blood infusion; central line for massive transfusion protocol.
• Fluid resuscitation: 0.9% NaCl or Lactated Ringer's for initial bolus (20-30 mL/kg), then maintain at 50-100 mL/hr depending on ongoing loss and urine output.
• Blood products: O-negative for emergent transfusion (before type/cross complete); transition to type-specific when available.
• Continuous fetal heart rate monitoring: assess baseline (110-160 bpm), variability (reassuring if 6-25 bpm fluctuation), accelerations (reassuring), decelerations (concerning if variable/late patterns).
• Monitor for DIC: watch for oozing from IV insertion sites, gums, petechiae, hematuria; assess coagulation labs (platelets, PT/PTT, fibrinogen, D-dimer).
• Position: LEFT LATERAL tilt in preterm (improves uteroplacental perfusion); semi-Fowler's in term (if not contraindicated by type of bleed).
• Nothing by mouth: NPO status in case emergency surgery needed.
• Emotional support: acknowledge loss, avoid clichés ('everything happens for a reason'), offer privacy for parents to grieve, facilitate baptism/blessing if desired, provide referrals to grief counseling and support groups (e.g., SHARE, RESOLVE in Philippines).

Key definitions

Diagrams to know

• Progression of hypovolemic shock: early/compensated → late/decompensated → irreversible
• Assessment checklist: vital signs, urine output, skin perfusion, mental status, bleeding characteristics, fetal response

Reactions or equations

Common values

Important facts

• Triggers in obstetrics: missed abortion (retained fetus >4-6 weeks), abruptio placentae, amniotic fluid embolism (AFE), severe sepsis/chorioamnionitis, placental abruption with fetal demise, HELLP syndrome.
• Pathophysiology: release of thromboplastin (tissue factor) into maternal circulation → triggers coagulation cascade → consumes platelets, fibrinogen, and factors II, V, VIII → microthrombi form in capillaries → organ damage + bleeding from factor depletion (coagulopathy) + hemolysis.
• Laboratory findings: DECREASED platelets (<100,000/μL), DECREASED fibrinogen (<100 mg/dL), ELEVATED PT/INR, ELEVATED aPTT, ELEVATED D-dimer (>500 ng/mL).
• Clinical signs: OOZING from IV insertion sites, surgical wounds, gums; petechiae/purpura (especially on lower extremities, buttocks); hematuria; hematemesis; vaginal bleeding beyond expected; decreased urine output; altered mental status (microthrombi in brain).
• Severity: DIC scoring combines laboratory findings (platelets, D-dimer, PT prolongation, fibrinogen) + overt bleeding; >5 points = overt DIC (requires aggressive treatment).
• Management: (1) REMOVE THE TRIGGER (deliver baby, evacuate molar pregnancy, treat infection, remove dead fetus), (2) Restore circulating volume (0.9% NaCl, LR), (3) Replace consumed factors (packed RBCs, fresh frozen plasma for factors II/V/VII/X, platelets for count <50,000, cryoprecipitate for fibrinogen <100 mg/dL), (4) Monitor coagulation labs every 4-6 hours until stable.
• Cryoprecipitate: contains fibrinogen, von Willebrand factor, factors VIII and XIII; dosed at 10 units (each unit contains 150-250 mg fibrinogen); give 10 units (40 g fibrinogen) to target fibrinogen >150 mg/dL.
• Fresh frozen plasma: contains all vitamin K–dependent and other labile factors; dosed at 10-15 mL/kg to correct PT/aPTT prolongation.
• Nursing: maintain two large-bore IVs; monitor labs closely; watch for signs of bleeding/clotting; maintain urine output ≥30 mL/hr; avoid invasive procedures (NG tube, Foley if possible) that increase bleeding; explain treatment plan to family.
• Prognosis: DIC in obstetrics has better outcomes than in other settings (removal of trigger often curative); maternal mortality is ~10-15% with modern management; monitor for long-term sequelae (organ damage, psychological trauma).

Key definitions

Diagrams to know

• DIC pathophysiology cascade: trigger → thrombin generation → platelet/fibrinogen consumption → coagulopathy + microthrombi + bleeding
• Coagulation lab interpretation in DIC: platelets ↓, fibrinogen ↓, PT ↑, aPTT ↑, D-dimer ↑

Common values

Important facts

• Betamethasone dose: 12 mg IM given as TWO DOSES, 24 hours apart.
• Indication: PRETERM DELIVERY EXPECTED before 34 weeks (placenta previa with bleeding, preeclampsia, abruption, etc.).
• Efficacy peak: 24 hours to 7 days after administration; benefit decreases after 7 days.
• Benefits: Reduces RDS by ~50%, intraventricular hemorrhage (IVH) by ~50%, neonatal mortality by ~30%.
• Contraindications: Active infection (chorioamnionitis, maternal sepsis) — steroid may worsen; ongoing maternal seizures (not absolute but caution); maternal hypersensitivity.
• Side effects: Maternal hyperglycemia (monitor glucose, especially in diabetics), insomnia, mood changes, transient increase in WBC.
• Use in diabetes: May require insulin adjustments; monitor glucose closely.
• Documentation: Record lot number, dates/times of both doses, route (IM), site; educate mother on expected mild hyperglycemia and sleep disturbance.
• Dexamethasone: Alternative agent (8 mg IM × 4 doses, 12 hours apart) — less commonly used; betamethasone is preferred.
• Repeat courses: Single repeat course may be considered if risk of preterm delivery persists and <7 days since first course; excessive repeat courses increase neonatal infections and growth restriction (not routine).
• Must be given BEFORE delivery — has NO benefit if given after baby is born.

Key definitions

Diagrams to know

• Betamethasone efficacy timeline: onset at 24 hours, peak at 7 days, minimal benefit after 7 days
• Indications for betamethasone in obstetric bleeding (previa with bleeding, abruption, preeclampsia)

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