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Obstetrics and Gynaecology > 3.7 - Antepartum Hemorrhage > Flashcards

3.7 - Antepartum Hemorrhage Flashcards

1
Q

Haemorrhage in pregnancy is divided into:
1) Threatened Miscarriage:
2) Antepartum Haemorrhage:
3) Intrapartum Haemorrhage:
4) Post-Partum Heamorrhage:
Define Each

A

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

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2
Q

What is the Puerperium

A

First 6 week period from delivery. It signifies when the mother should physiologically return to pre-pregnancy status

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3
Q

A pregnant patient at 34 weeks gestation is presenting with PV bleed. Give your top 8 differentials

A

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

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4
Q

What is cervical ectropion

A

This is when endocervical cells grow faster than ectocervical cells => becomes visible outside the cervix due to increased exposure of oestrogen

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5
Q

30% of patients presenting with antepartum haemorrhage have placenta praevia.
1) Define Placenta Praevia
2) How is it classified?

A

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)

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6
Q

Why is it important to distinguish between an anterior and posterior placenta

A

Anterior praevia is more likely to be Accreta or percreta especially in the presence of hx of C-section

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7
Q

Give 5 risk factors for Placenta Praevia?

A

1) Previous C-section or other surgery
2) increased parity
3) Multiple pregnancy
4) Increased age of pregnancy
5) Smoking
6) IVF

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8
Q

What are the risks associated with placenta previa. Give 2

A

Risk of bleeding and hemorrhage
Placental insufficiency => IUGR
Death

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9
Q

What is the typical presentation of a patient presenting with placenta previa

A

Painless vaginal bleeding that is either
1) unprovoked
2) post-coital
3) post-uterine contractions
+/- Sx of shock (hypotension, tachycardia, tachypnea, lightheadedness, syncope)

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10
Q

You are asked to conduct a vaginal examination on a patient presenting with antepartum haemorrhage. What findings do you expect?

A

Vaginal exam in CI in any patient with antepartum bleeding. As the most common cause, placenta praevia must first be excluded via US scan

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11
Q

Is transvaginal ultrasound contraindicated in placenta praevia?

A

Nope

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12
Q

How do you diagnose placenta praevia

A

Hx, exam, and TVUS

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13
Q

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)

A

Ask patient to empty bladder, Placental localization + measurement from cervical Os to determine classification.

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14
Q

You are asked to examine a patient with placenta praevia confirmed on transvaginal ultrasound. What findings do you expect to find?

A

I would only do an obstetric examination.
!!! High presenting part
!! Soft-nontender uterus

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15
Q

What are the delivery options for placenta praevia and how would you decide which to go for?

A

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

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16
Q

Would you delay for steroids?

A

You would give steroids anyways and hope for the best. Tocolytics may be used in some cases.

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17
Q

How would you manage a patient after confirming the presence of complete placenta praevia.

A

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

18
Q

What is morbidly adherent placenta?

A

Abnormal attachment of placenta such that the chorionic villi invade beyond the endometrium

19
Q

List the types of morbidly adherent placenta along with the definition of each

A

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%)

20
Q

What is the biggest RF for placenta Accreta

A

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

21
Q

How would you diagnose Placenta Accreta?

A

MRI +/- Colour doppler US

22
Q

Define Placental Abruption
What are the 2 types

A

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

23
Q

What is the main non-traumatic pathophysiology of placental abruption

A

Retroplacental clotting. They are large and basically indent the placenta => easier to displace.

24
Q

Give 6 RF of placental abruption

A

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

25
Q

How would you identify a concealed placental abruption

A

Severe abdominal pain and wood-like uterus on palpation

26
Q

What is the typical clinical presentation of a patient with placental abruption?

What would you find on exam?

A

Severe abdominal pain
Backache
+/- vaginal bleeding if revealed type
Sx of shock

Exam findings:
! This is a antepartum bleed => before conducting an exam I will need to confirm that there is no placenta praevia via TVUS
Severe abdominal pain
Wood-like uterus
Inaudible fetal HR
Irritable uterus

27
Q

What is an irritable uterus?

A

An irritable uterus is characterised by frequent, non-labor contractions during pregnancy, which can cause discomfort but do not lead to cervical dilation or labor. This condition is often distinguished from Braxton Hicks contractions by the regularity and frequency of the contractions, though it does not progress to actual labor.

28
Q

How do you diagnose placental abruption

A

Retroplacental clot => Confirmed after delivery.

29
Q

How would you manage a patient with placental abruption?

A

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) If foetus is alive, emergency C-section. If theyre dead, AROM and vaginal delivery, refer to social services for help and console family.

30
Q

What is the main complication of placental abruption and its management?

A

Coagulopathy and DIC

This is caused by the release of thromboplastins from the damaged placenta => thrombocytopenia => coagulopathy.
This then causes an increase of PPH after C-section.

Another complication to note is rhesus isoimmunization in Rh-ve mothers

31
Q

What is Vasa Praevia

A

Vessels of the umbilical cord run in the fetal membranes AND cross the internal cervical os.

32
Q

How does Vasa Previa typically present?

A

Intrapartum haemorrhage due to rupture of membranes. This may occur spontaneously or iatrogenically due to AROM

33
Q

Why is Vasa previa more severe than placenta previa and placental abruption?

A

The blood lost here is foetal blood so a much smaller amount of blood can lead to life-threatening foetal compromise

34
Q

How would you manage a pregnant patient that you have admitted 1 week ago. Youve ruptured their membranes via an amnihook and liquor was red in colour.

A

Give Anti D if Rh-ve
Emergency C-section

35
Q

how would you diagnose Vasa previa

A

Retrospectively via examination of placenta and membranes showing vessels in the foetal membranes

36
Q

Theoretically, how can you diagnose that the blood in vasa praevia is in fact foetal blood?

A

Kleinhauer test or APT test (gamma globulin?)

37
Q

Briefly explain the pathophysiology of Rhesus Isoimmunisation

A

If mother is Rh-ve and foetus is Rh+ve, on first contact, IgM is produced => it cannot cross the placenta => no haemolysis. but the second time, IgG would be produced => it can cross the placenta => foetal hemolysis and anemia (hydrops).

38
Q

In what scenarios should an Rh-ve mother receive anti D injection (Give 5)

A

Any PV Bleeding
Invasive foetal testing (amniocentesis, chorionic villus sampling)
Miscarriage or ectopic
Post-partum
abdominal trauma
prolonged rupture of membranes
chorioamnionitis

39
Q

What type of injection is Anti-D
How do you dose the injection?

A

IM
Kleinhauer test (Estimates the amount of foetal blood in maternal circulation and uses it to calculate the dose of Anti D)

40
Q

When would women have their blood group and antibody status identified? What test is used to determine this?

A

At booking clinic via NIPT

41
Q

If a sensitising event occurred requiring administration of Anti-D, give 3 methods of monitoring

A

Maternal Anti-D titres
US MCA doppler looking at Peak systolic velocity!!! (only thing looking at the peaks)
US hydrops (signs of anemia)
Foetal BPP

42
Q

If isoimmunisation occurs, how will you treat that?

A

1) Transfusion via In-utero blood stream transfusion and sampling. This is conducted by US-identification of the umbilical vein allowing for the sampling followed by transfusion

2) Then deliver if >34 weeks
3) With NICU observation for jaundice -> Phototherapy, regular feeds and hydration to prevent jaundice

Obstetrics and Gynaecology (46 decks)

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