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Reproduction Week 4 2018/19 > 6: Bleeding in late pregnancy > Flashcards

6: Bleeding in late pregnancy Flashcards

1
Q

What is bleeding called after 24 weeks gestation?

A

Antepartum haemorrhage

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2
Q

Bleeding before 24 weeks is a sign of what?

A

Miscarriage

threatened, inevitable etc.

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3
Q

Which report accounts for maternal deaths and is published every year?

A

MMBRACE

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4
Q

At what gestational age does the placenta develop?

A

6 weeks

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5
Q

What is the function of the placenta?

A

Gas exchange

Nutrient and metabolite exchange

Hormone production

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6
Q

What is an ante-partum haemorrhage?

A

PV bleeding from 2nd trimester (24 weeks) until the end of labour

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7
Q

What are some placental causes of APH?

A

Placenta praevia

Placental abruption

Placenta accreta

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8
Q

Name four placental causes of ante-partum haemorrhage.

A

Placental abruption​

Placenta praevia

Placenta accreta

Vasa praevia

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9
Q

Name a uterine cause of ante-partum haemorrhage.

A

Uterine rupture

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10
Q

Name three cervical causes of ante-partum haemorrhage.

A

Cervical cancer

Cervical polyps

Infection

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11
Q

What is spotting?

A

Minor staining of blood on underwear or pads

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12
Q

What volumes of blood are lost in a

a) minor
b) major
c) massive APH?

A

a) < 50ml

b) 50 - 1000ml

c) > 1000ml

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13
Q

What is placental abruption?

A

Separation of placenta from uterus BEFORE birth

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14
Q

What are the symptoms of placental abruption?

A

Continuous abdominal pain - not intermittent as in labour

Bleeding

Pre-term labour

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15
Q

What is the recurrence rate for placental abruption?

A

10%

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16
Q

What does the uterus feel like on abdominal examination of a woman with placental abruption?

A

“Woody hard”

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17
Q

If you check for a foetal heartbeat in a woman with placental abruption and there is one, how is it managed?

A

Resuscitate the mother

Caesarean section

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18
Q

If you check for a foetal heartbeat in a woman with placental abruption and there isn’t one, how is it managed?

A

Resuscitate the mother

Spontaneous passage / manual removal of pregnancy? wasn’t explained

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19
Q

How is placental abruption managed?

A

Resuscitate mother

Deliver baby

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20
Q

Which investigations can be used to determine foetal heart rate?

A

Pinard stethoscope

Doppler ultrasound

CTG

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21
Q

If a mother with placental abruption is pre-term, how is her baby delivered?

A

Either caesarean section

or artificial rupture of membranes and IOL

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22
Q

What rheu condition may cause placental abruption?

A

Anti-phospholipid syndrome

Treated with LMWH and low dose aspirin

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23
Q

What condition is caused by implantation of the placenta in the lower uterus?

A

Placenta praevia

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24
Q

What terms are used when the placenta lies

a) close to the internal os
b) over the internal os

of the cervix?

A

a) Low-lying placenta

b) Placenta praevia

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25
Q

What is the lower segment of the uterus?

A

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

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26
Q

What is a LSCS?

A

Lower segment Caesarean section

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27
Q

What percentage of ante-partum haemorrhages are caused by placenta praevia?

A

20%

28
Q

What percentage of deliveries are carried out by Caesarean section?

A

25 - 30%

29
Q

What type of delivery is a risk factor for placenta praevia?

A

Caesarean section

30
Q

Which investigation picks up placenta praevia?

A

Ultrasound

which is part of the reason they’re routinely done at 12 and 20 weeks

31
Q

What are the symptoms of placenta praevia?

A

Painless bleeding

Post-coital bleeding

32
Q

What are some signs of placenta praevia on abdominal examination?

A

High presenting part (because placenta is inferior)

Malpresentation and malposition more likely

33
Q

Why shouldn’t you do a PV exam in a woman with placenta praevia?

A

Touching the placenta will trigger bleeding

34
Q

How is placenta praevia managed?

A

Resuscitate mother

Assess baby

Deliver baby at term if stable

Advise not to have intercourse, attend immediately if bleeding

35
Q

Which drugs are given to pregnant women if they are going to deliver pre-term?

Why?

A

Steroids (speed up lung development)

Magnesium sulphate (neuroprotection)

36
Q

When should delivery happen if a woman’s placenta praevia is uncomplicated i.e they’re not bleeding?

A

36 - 37 weeks

37
Q

When would you consider

a) vaginal delivery
b) C section

in a woman with placenta praevia?

A

a) Vaginal delivery if placenta > 2cm from internal os

b) C section if placenta covering os or malpresentation, ridiculous bleeding

38
Q

In which condition does the placenta remain stuck to the uterine wall?

A

Placenta accreta

39
Q

What is placeta accreta called if the placenta

a) invades the myometrium
b) penetrates the uterus?

A

a) Placenta increta

b) Placenta percreta

40
Q

What happens if a woman with placenta accreta has a vaginal delivery?

A

Massive APH

41
Q

How is placenta accreta managed?

A

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

42
Q

In which condition of pregnancy does a full-thickness tear occur in the uterus?

A

Uterine rupture

43
Q

What increases your chances of uterine rupture?

A

Previous uterine surgery

Multiparity

Obstructed labour

44
Q

What are the maternal symptoms of uterine rupture?

A

Abdominal pain

Shoulder-tip pain - blood irritating the diaphragm, as in ruptured ectopic pregnancy

Syncope - blood loss

PV bleeding

45
Q

What are the foetal signs of uterine rupture?

A

Foetal distress

brady/tachycardia, late decelerations on CTG

46
Q

What is vasa praevia?

A

Unprotected foetal vessels lying over the internal os

They rupture during labour, causing bleeding

47
Q

Which examination may rupture abnormal vessels in vasa praevia?

A

PV exam

48
Q

How is vasa praevia investigated?

A

Doppler ultrasound

but more often a clinical diagnosis with careful examination

49
Q

How is vasa praevia managed?

A

Caesarean section

50
Q

What is post-partum haemorrhage?

A

> 500ml blood loss following birth

51
Q

How can post-partum haemorrhage be categorised?

A

Primary - within 24h of delivery

Secondary - within 6 weeks of delivery

Minor - 500 - 1000ml blood loss

Major - > 1000ml blood loss; evident shock

52
Q

The causes of post-partum haemorrhage can be described by the Four Ts.

What are they?

A

Tone

Trauma

Tissue

Thrombin

53
Q

What does tone describe in the causes of post-partum haemorrhage?

A

Atonic uterus

Most common cause of PPH - uterus doesn’t contract properly and can’t expel placenta

54
Q

What does trauma ​describe in the causes of post-partum haemorrhage?

A

Trauma :)

55
Q

What does tissue ​describe in the causes of post-partum haemorrhage?

A

Remnant placental or pregnancy tissue which causes haemorrhage

56
Q

What does thrombin ​describe in the causes of post-partum haemorrhage?

A

Coagulopathies which cause increased bleeding risk in women

e.g thrombocytopaenia, DIC and haemophilia

57
Q

Why do you need to be careful with Jehova’s Witnesses in the context of major haemorrhage?

A

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

:/

58
Q

What is ergometrine?

A

Drug which induces uterine contractions and reduces bleeding by decreasing blood flow to the uterine arteries

59
Q

What is an important side effect of ergometrine?

A

Hypertension

60
Q

Which drug can ergometrine be combined with to treat PPH?

What is this combination drug called?

A

Syntocinon (synthetic oxytocin) - because it has a similar effect

Syntometrine

61
Q

When would you avoid using syntometrine and instead use syntocinon individually?

A

Woman with hypertension

As hypertension is a side effect of ergometrine

62
Q

How do you treat PPH?

A

Stop the bleeding (non-surgical or surgical methods)

Replace lost fluids

63
Q

Which disease is APH a sensitising event for?

A

Rhesus disease

64
Q

Antepartum haemorrhage is a ___ event for Rhesus disease.

A

sensitising event

if baby is Rhesus +ve and mother is Rhesus -ve, APH may be the trigger required for maternal antibody formation

65
Q

What test determines the volume of Anti D a Rhesus -ve woman requires?

A

Kleihauer test

66
Q

What is a Kleihauer test?

A

Lab test which determines how much Anti-D a Rhesus -ve woman requires to prevent isoimmunisation

Reproduction Week 4 2018/19 (9 decks)

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