3.7 - Antepartum Hemorrhage Flashcards
Haemorrhage in pregnancy is divided into:
1) Threatened Miscarriage:
2) Antepartum Haemorrhage:
3) Intrapartum Haemorrhage:
4) Post-Partum Heamorrhage:
Define Each
PV bleeding during pregnancy between
1) Threatened Miscarriage: Viable IU pregnancy -> Viability (24 weeks)
2) Antepartum Haemorrhage: From viability/24weeks until the onset of labour
3) Intrapartum Haemorrhage: Onset of labour until the end of the 2nd stage
4) Post-Partum Heamorrhage: 3rd stage of labour until the end of the Puerperium
What is the Puerperium
First 6 week period from delivery. It signifies when the mother should physiologically return to pre-pregnancy status
A pregnant patient at 34 weeks gestation is presenting with PV bleed. Give your top 8 differentials
Placental/uterine:
1) Placenta previa (30%)
2) Placental Abruption (20%)
3) Vasa Previa (<0.1%)
4) Placenta Accreta
5) Subchorionic Haematoma
Local: (vaginal/cervical)
1) Cervical cancer
2) Cervical Ectropion
3) Cervicitis (check last smear)
4) Foreign body
5) Trauma
6) Polyposis
7) Infectious (e.g. STI)
Must include: 45% unclassified
What is cervical ectropion
This is when endocervical cells grow faster than ectocervical cells => becomes visible outside the cervix due to increased exposure of oestrogen
30% of patients presenting with antepartum haemorrhage have placenta praevia.
1) Define Placenta Praevia
2) How is it classified?
Placenta praevia is partially or wholly situated placenta in the lower uterine segment and is classified into
a) Marginal Praevia (within 2 cm of cervical os but does not cover) - 98% move upwards.
b) Partial Praevia (covers part of Os)
c) Complete praevia (Fully covers Os)
Why is it important to distinguish between an anterior and posterior placenta
Anterior praevia is more likely to be Accreta or percreta especially in the presence of hx of C-section
Give 5 risk factors for Placenta Praevia?
1) Previous C-section or other surgery
2) increased parity
3) Multiple pregnancy
4) Increased age of pregnancy
5) Smoking
6) IVF
What are the risks associated with placenta previa. Give 2
Risk of bleeding and hemorrhage
Placental insufficiency => IUGR
Death
What is the typical presentation of a patient presenting with placenta previa
Painless vaginal bleeding that is either
1) unprovoked
2) post-coital
3) post-uterine contractions
+/- Sx of shock (hypotension, tachycardia, tachypnea, lightheadedness, syncope)
You are asked to conduct a vaginal examination on a patient presenting with antepartum haemorrhage. What findings do you expect?
Vaginal exam in CI in any patient with antepartum bleeding. As the most common cause, placenta praevia must first be excluded via US scan
Is transvaginal ultrasound contraindicated in placenta praevia?
Nope
How do you diagnose placenta praevia
Hx, exam, and TVUS
You conduct a transvaginal ultrasound after being asked to perform a vaginal exam on a pregnant patient with PV bleed. What do you expect to see on Ultrasound to confirm your diagnosis? (Placenta praevis)
Ask patient to empty bladder, Placental localization + measurement from cervical Os to determine classification.
You are asked to examine a patient with placenta praevia confirmed on transvaginal ultrasound. What findings do you expect to find?
I would only do an obstetric examination.
!!! High presenting part
!! Soft-nontender uterus
What are the delivery options for placenta praevia and how would you decide which to go for?
Expectant delivery if Mild bleed, reassuring CTG, AND GA <34 weeks.
Immediate delivery if severe bleeding, non-reassuring CTG, OR GA>34 weeks + Steroids already given
Would you delay for steroids?
You would give steroids anyways and hope for the best. Tocolytics may be used in some cases.
How would you manage a patient after confirming the presence of complete placenta praevia.
So, youve completed hx and ecamination
1) Call for help and admit patient from 24 week viability
2) It is still a haemorrhage => Emergency ABCDE to stabilize the mother (2xwide bore IV cannulas + Group and crossmatch 4 units of blood). As this is a bleed, Anti-D should be given to mothers that are Rh-ve
3) Monitoring and surveillance of both mother and foetus (CTG)
4) After this, it is important to decide if we would like
- Expectant delivery if Mild bleed, reassuring CTG, AND GA <34 weeks.
-Immediate delivery if severe bleeding, non-reassuring CTG, OR GA>34 weeks + Steroids already given
What is morbidly adherent placenta?
Abnormal attachment of placenta such that the chorionic villi invade beyond the endometrium
List the types of morbidly adherent placenta along with the definition of each
Placenta Accreta: Chorionic villi in contact with myometrium, <50% of myometrium (80%)
Placenta Increta: Chorionic villi invade into the myometrium >50% of myometrium (15%)
Placenta Percreta: Chorionic villi invade into serosa and beyond (5%)
What is the biggest RF for placenta Accreta
Prior C-section, endometrial surgery, curretage, myomectomy
think of it as when the surgeon cuts into the endometrium, that area is scarred and loses its basal layer. It is the primary deficiency of Decidua basali
How would you diagnose Placenta Accreta?
MRI +/- Colour doppler US
Define Placental Abruption
What are the 2 types
Premature separation of a normally-sited placenta classified into Revealed hemorrhage where the blood tracks down along the uterine wall or concealed where it remains inside the cavity with no evidence of bleeding
What is the main non-traumatic pathophysiology of placental abruption
Retroplacental clotting. They are large and basically indent the placenta => easier to displace.
Give 6 RF of placental abruption
Non-traumatic => Clotting
Chronic HTN/Pre-eclampsia
Prolonged PROM
High parity
Cocaine-use
Smoking
Antiphospholipid syndrome
Maternal thrombophilia
Traumatic:
Abdominal Trauma
ECV (external Cephaloversion) in breech
IPV (Internal Podalic Version) in multiple births
