Causes of Early Bleeding in Pregnancy (< 20 Weeks)

Causes of Early (<20 Weeks) and Late Bleeding in Pregnancy - Differential Diagnosis Algorithm Early Bleeding in Pregnancy (<20 Weeks): • Not Bleeding from the Os • Cervix Open - Passing Tissue and Clots • Cervix Open - Not Passing Tissue and Clots • IUP on Transvaginal U/S • ß-hCG doubled in 72h • ß-hCG not doubled in 72h Late Bleeding in Pregnancy (2nd & 3rd Trimester): • Bleeding from Os - Painful • Bleeding from Os - Painless • Not Bleeding from the Os #Early #Late #Bleeding #Pregnancy #Differential #Diagnosis #Algorithm #Causes #Obstetrics #OBGyn

Causes of Late Bleeding in Pregnancy (2nd & 3rd Trimester) - Differential Diagnosis Algorithm Bleeding from Os - Painful: • Placental abruption • Uterine rupture • Labour (bloody show) Bleeding from Os - Painless: • Placenta previa • Vasa previa Not Bleeding from the Os: • Cervical polyp/Ectropion • Cervical/Vaginal neoplasm • Vaginal laceration • Infection #Late #Bleeding #Pregnancy #Differential #Diagnosis #Algorithm #Causes #Obstetrics #OBGyn

Causes of Recurrent Pregnancy Loss - Differential Diagnosis Algorithm Environmental: • Toxin (organic solvents, mercury, lead) • Smoking • Alcohol • Drugs • Ionizing radiation Other: • Maternal infection • Thrombophilia Autoimmune: • Antiphospholipid syndrome • Lupus anticoagulant Endocrine: • Diabetes mellitus • Hypo/hyperthyroidism • PCOS • Luteal phase deficiency Genetic: • Maternal age • Maternal / paternal chromosomal abnormality Cervix: • Cervical insufficiency Uterus: • Fibroids • Congenital anomaly • Polyps • Asherman's Syndrome #Recurrent #Pregnancy #Loss #Spontaneous #Abortion #Differential #Diagnosis #Algorithm #Causes #Obstetrics #OBGyn

Causes of Abnormal Genital Bleeding - Differential Diagnosis Algorithm Non-Gynecologic: • Medical (e.g. coagulopathy, liver disease, renal disease) • Drugs Uterus: • Anovulatory • Atrophy • Fibroid • Polyp • Exogenous estrogen • Neoplasm • Infection • Endometrial Hyperplasia Cervix: • Polyp • Ectropion • Dysplasia • Neoplasm • Infection • Trauma Vagina: • Atrophy • Vulvovaginitis • Neoplasm • Infection • Trauma Vulva: • Vulvar dystrophy • Vulvar Atrophy • Vulvovaginitis • Neoplasm • Infection • Trauma #Genital #Pelvic #Bleeding #Differential #Diagnosis #Algorithm #Causes #OBGyn #Gynecology

Causes of Abnormal Uterine Bleeding Non-pregnant bleeding that is inegular in timing, frequency, or flow Mnemonic: PALM-COEIN STRUCTURAL CAUSES Polyps - Endometrial - Cervical Adenomyosis - Painful heavy periods in women 30s-40s Leiomyoma - Increase in size in pregnancy or with OCPs Malignancy / hyperplasia - Consider in all peri- and postmenopausal women NON-STRUCTURAL CAUSES Coagulopathy - Undiagnosed coagulopathy in adolescents - Acquired (anticoagulants, cirrhosis) Ovulatory dysfunction - Adolescents - Perimenopause - PCOS - Hypothyroidism - Anorexia - Athletes Endometrial causes - Diagnosis of exclusion Iatrogenic - Hormonal contraceptive use - Hormone replacement therapy - Post-GYN surgery Not otherwise classified - Endometritis - Cervical erosions, cervicitis - Vaginal trauma - Foreign bodies #AUB #Abnormal #Uterine #Bleeding #Mnemonic #PALMCOEIN #Diagnosis #Obstetrics #Gynecology #Differential #Causes

#Abnormal Uterine bleeding. #Late #Bleeding #Pregnancy #Differential #Diagnosis #Algorithm #Causes #Obstetrics #OBGyn #AUB #Abnormal #Uterine #Bleeding #Mnemonic #PALMCOEIN #Diagnosis #Obstetrics #Gynecology #Differential #Causes

Causes of Post-Partum Hemorrhage - Differential Diagnosis Algorithm Blood Loss: >500mL post vaginal delivery OR >1000 mL post Caesarean section Uterine Atony (70%): • Uterine fatigue (e.g. prolonged/induced labor, rapid labor, grand multiparity) • Overdistension of uterus (e.g. multiple gestation, polyhydramnios, fetal macrosomia) • Bladder distension • Uterine infection (e.g. chorioamnionitis) • Functional/anatomic distortion of uterus • Drugs — Uterine relaxants (e.g. nifedipine, magnesium sulfate, NSAlDs) Trauma (20%): • Perineal laceration (e.g. episiotomy) • Vaginal laceration / hematoma • Cervical laceration (e.g. forceps/vacuum delivery) • Uterine rupture • Uterine inversion Remnant Tissue (10%): • Retained blood clots • Retained cotyledon or succenturiate lobe • Abnormal placentation (placenta accreta, increta, or percreta) Thrombin (1%): • Thrombocytopenia • Idiopathic thrombocytopenic purpura (ITP) • Thrombotic thrombocytopenic purpura (TTP) • HELLP syndrome • Disseminated intravascular coagulation (DIC) • Anti-coagulation agents (e.g. heparin) • Pre-existing coagulopathy (e.g. von Willebrand's disease, Hemophilia A) #PostPartum #Hemorrhage #PPH #Differential #Diagnosis #Algorithm #Causes #Obstetrics #OBGyn

Hypertension in Pregnancy - Differential Diagnosis Algorithm Pre-existing Hypertension - Before Pregnancy OR <20 weeks gestational age - No Proteinuria - Chronic Hypertension • Primary • Secondary - Proteinuria (>0.3g/24hr urine) OR one or more Adverse Conditions • Pre-existing Hypertension with Pre-Eclampsia Gestational Hypertension - Previously normotensive, >20 weeks gestational age • No Proteinuria - Gestational Hypertension • Proteinuria (> 0.3 g/24hr urine) OR one or more Adverse Conditions - Gestational Hypertension with Pre-Eclampsia • Pre-Eclampsia + Seizures/Coma - Eclampsia #Hypertension #Pregnancy #Differential #Diagnosis #Algorithm #causes #obstetrics #obgyn

Causes of Growth Discrepancy: Large for Gestational Age - Differential Diagnosis Algorithm Maternal Factors: • Multiparity • Previous history of large for gestational age fetus • Aboriginal, Hispanic, and Caucasian races • Maternal co-morbidities (e.g. diabetes, obesity) • Excessive weight gain over course of pregnancy (>40 lbs) Maternal Complications: • Prolonged labour • Operative vaginal delivery • Caesarean section • Genital tract lacerations • Post-partum hemorrhage • Uterine rupture Fetal Factors: • Male infant • Prolonged gestation (>41 weeks) • Genetic disorder (e.g. Sotos syndrome, Beckwith-Wiedemann syndrome, Weaver's syndrome) Fetal Complications: • Shoulder dystocia • Birth injury (brachial plexus injury, clavicular fracture) • Cerebral palsy secondary to hypoxia • Hypoglycemia • Polycythemia • Perinatal asphyxia • Hyperbilirubinemia #Large #GestationalAge #LGA #Complications #Pregnancy #Differential #Diagnosis #Algorithm #Causes #Obstetrics #OBGyn

Intrapartum Abnormal Fetal HR Tracing - Causes of Variability & Decelerations - Differential Diagnosis Algorithm Minimal/Absent Variability (< 5 bpm): • Fetal sleep • Prematurity • Medications (analgesia, sedatives) • Hypoxic acidemia • Congenital anomalies Marked Variability (> 25 bpm): • Mild hypoxia Sinusoidal Pattern Variability: • Severe fetal anemia (Hgb < 70) • Tissue hypoxia in fetal brain stem Variability Absent Accelerations: • Hypoxic acidemia • Fetal abnormality Early decelerations: • Fetal head compression (mirror contractions) Variable decelerations: • Cord compression • Fetal acidemia if complicated variable decelerations Late decelerations: • Uteroplacental insufficiency • Maternal hypotension • Reduced maternal arterial oxygen saturation • Hypertonic uterus • Fetal acidemia Prolonged deceleration: • Hypertonic uterus • Unresolving umbilical cord compression • Maternal hypotension • Maternal seizure • Rapid fetal descent #Decelerations #Variability #FetalHR #FetalHeartRate #Tracing #Differential #Diagnosis #Algorithm #Causes #Obstetrics #OBGyn