6: Bleeding in late pregnancy Flashcards
What is bleeding called after 24 weeks gestation?
Antepartum haemorrhage
Bleeding before 24 weeks is a sign of what?
Miscarriage
threatened, inevitable etc.
Which report accounts for maternal deaths and is published every year?
MMBRACE
At what gestational age does the placenta develop?
6 weeks
What is the function of the placenta?
Gas exchange
Nutrient and metabolite exchange
Hormone production
What is an ante-partum haemorrhage?
PV bleeding from 2nd trimester (24 weeks) until the end of labour
What are some placental causes of APH?
Placenta praevia
Placental abruption
Placenta accreta
Name four placental causes of ante-partum haemorrhage.
Placental abruption
Placenta praevia
Placenta accreta
Vasa praevia
Name a uterine cause of ante-partum haemorrhage.
Uterine rupture
Name three cervical causes of ante-partum haemorrhage.
Cervical cancer
Cervical polyps
Infection
What is spotting?
Minor staining of blood on underwear or pads
What volumes of blood are lost in a
a) minor
b) major
c) massive APH?
a) < 50ml
b) 50 - 1000ml
c) > 1000ml
What is placental abruption?
Separation of placenta from uterus BEFORE birth
What are the symptoms of placental abruption?
Continuous abdominal pain - not intermittent as in labour
Bleeding
Pre-term labour
What is the recurrence rate for placental abruption?
10%
What does the uterus feel like on abdominal examination of a woman with placental abruption?
“Woody hard”
If you check for a foetal heartbeat in a woman with placental abruption and there is one, how is it managed?
Resuscitate the mother
Caesarean section
If you check for a foetal heartbeat in a woman with placental abruption and there isn’t one, how is it managed?
Resuscitate the mother
Spontaneous passage / manual removal of pregnancy? wasn’t explained
How is placental abruption managed?
Resuscitate mother
Deliver baby
Which investigations can be used to determine foetal heart rate?
Pinard stethoscope
Doppler ultrasound
CTG
If a mother with placental abruption is pre-term, how is her baby delivered?
Either caesarean section
or artificial rupture of membranes and IOL
What rheu condition may cause placental abruption?
Anti-phospholipid syndrome
Treated with LMWH and low dose aspirin
What condition is caused by implantation of the placenta in the lower uterus?
Placenta praevia
What terms are used when the placenta lies
a) close to the internal os
b) over the internal os
of the cervix?
a) Low-lying placenta
b) Placenta praevia
What is the lower segment of the uterus?
Thinner, non-contractile part of the uterus which is close to the internal os
Where the placenta goes in low-lying placenta / praevia and where you cut in a caesarean section
What is a LSCS?
Lower segment Caesarean section
What percentage of ante-partum haemorrhages are caused by placenta praevia?
20%
What percentage of deliveries are carried out by Caesarean section?
25 - 30%
What type of delivery is a risk factor for placenta praevia?
Caesarean section
Which investigation picks up placenta praevia?
Ultrasound
which is part of the reason they’re routinely done at 12 and 20 weeks
What are the symptoms of placenta praevia?
Painless bleeding
Post-coital bleeding
What are some signs of placenta praevia on abdominal examination?
High presenting part (because placenta is inferior)
Malpresentation and malposition more likely
Why shouldn’t you do a PV exam in a woman with placenta praevia?
Touching the placenta will trigger bleeding
How is placenta praevia managed?
Resuscitate mother
Assess baby
Deliver baby at term if stable
Advise not to have intercourse, attend immediately if bleeding
Which drugs are given to pregnant women if they are going to deliver pre-term?
Why?
Steroids (speed up lung development)
Magnesium sulphate (neuroprotection)
When should delivery happen if a woman’s placenta praevia is uncomplicated i.e they’re not bleeding?
36 - 37 weeks
When would you consider
a) vaginal delivery
b) C section
in a woman with placenta praevia?
a) Vaginal delivery if placenta > 2cm from internal os
b) C section if placenta covering os or malpresentation, ridiculous bleeding
In which condition does the placenta remain stuck to the uterine wall?
Placenta accreta
What is placeta accreta called if the placenta
a) invades the myometrium
b) penetrates the uterus?
a) Placenta increta
b) Placenta percreta
What happens if a woman with placenta accreta has a vaginal delivery?
Massive APH
How is placenta accreta managed?
If caught before birth:
Conservative - curettage, ballooning and ligation if you want to spare the uterus
C section and hysterectomy - effective but woman will be infertile
In which condition of pregnancy does a full-thickness tear occur in the uterus?
Uterine rupture
What increases your chances of uterine rupture?
Previous uterine surgery
Multiparity
Obstructed labour
What are the maternal symptoms of uterine rupture?
Abdominal pain
Shoulder-tip pain - blood irritating the diaphragm, as in ruptured ectopic pregnancy
Syncope - blood loss
PV bleeding
What are the foetal signs of uterine rupture?
Foetal distress
brady/tachycardia, late decelerations on CTG
What is vasa praevia?
Unprotected foetal vessels lying over the internal os
They rupture during labour, causing bleeding
Which examination may rupture abnormal vessels in vasa praevia?
PV exam
How is vasa praevia investigated?
Doppler ultrasound
but more often a clinical diagnosis with careful examination
How is vasa praevia managed?
Caesarean section
What is post-partum haemorrhage?
> 500ml blood loss following birth
How can post-partum haemorrhage be categorised?
Primary - within 24h of delivery
Secondary - within 6 weeks of delivery
Minor - 500 - 1000ml blood loss
Major - > 1000ml blood loss; evident shock
The causes of post-partum haemorrhage can be described by the Four Ts.
What are they?
Tone
Trauma
Tissue
Thrombin
What does tone describe in the causes of post-partum haemorrhage?
Atonic uterus
Most common cause of PPH - uterus doesn’t contract properly and can’t expel placenta
What does trauma describe in the causes of post-partum haemorrhage?
Trauma :)
What does tissue describe in the causes of post-partum haemorrhage?
Remnant placental or pregnancy tissue which causes haemorrhage
What does thrombin describe in the causes of post-partum haemorrhage?
Coagulopathies which cause increased bleeding risk in women
e.g thrombocytopaenia, DIC and haemophilia
Why do you need to be careful with Jehova’s Witnesses in the context of major haemorrhage?
They refuse blood transfusions from donors
So you either don’t do it or perform cell salvage - suck their own blood up with a machine, filter it and put it back in
:/
What is ergometrine?
Drug which induces uterine contractions and reduces bleeding by decreasing blood flow to the uterine arteries
What is an important side effect of ergometrine?
Hypertension
Which drug can ergometrine be combined with to treat PPH?
What is this combination drug called?
Syntocinon (synthetic oxytocin) - because it has a similar effect
Syntometrine
When would you avoid using syntometrine and instead use syntocinon individually?
Woman with hypertension
As hypertension is a side effect of ergometrine
How do you treat PPH?
Stop the bleeding (non-surgical or surgical methods)
Replace lost fluids
Which disease is APH a sensitising event for?
Rhesus disease
Antepartum haemorrhage is a ___ event for Rhesus disease.
sensitising event
if baby is Rhesus +ve and mother is Rhesus -ve, APH may be the trigger required for maternal antibody formation
What test determines the volume of Anti D a Rhesus -ve woman requires?
Kleihauer test
What is a Kleihauer test?
Lab test which determines how much Anti-D a Rhesus -ve woman requires to prevent isoimmunisation
