8.2 Late Pregnancy Bleeding

Question 1

What are the causes of late pregnancy bleeding?

Answer 1

• Pregnancy specific: Placenta praevia, placental abruption, vasa praevia, uterine rupture, morbidly adherent placenta, excessive show (non-pathological)
• Unrelated: Cervical lesions (polyps/ectropion), trauma to genital tract (e.g. lacerations), lower genital tract infections, genital tract malignancies

Question 2

what is the definition of late pregnancy bleeding?

Answer 2

Late pregnancy bleeding is defined as bleeding from the genital tract > 24 weeks gestation until delivery (antepartum haemorrhage/APH)

Question 3

what are maternal complications of late pregnancy bleeding?

Answer 3

PPH, anaemia, infection, maternal shock, renal tubular necrosis, consumptive coagulopathy, prolonged hospital stay, psychological sequelae, complications of blood transfusion

Question 4

what are foetal complications of late foetal bleeding?

Answer 4

Foetal anaemia & hypoxia, SGA/IUGR, prematurity (iatrogenic/spontaneous), hypoxic ischaemic encephalopathy, foetal death

Question 5

What is the definition of placenta praevia>

Answer 5

Placenta praevia is defined as partial or full insertion of the placenta into the lower uterine segment (LUS)

Question 6

what is considered Grade I placenta praevia minor?

Answer 6

Placenta encroaches LUS but does not reach cervical os

Question 7

what is considered Grade II placenta praevia minor?

Answer 7

Placenta reaches cervical os but does not cover it

Question 8

what is considered Grade III placenta praevia major?

Answer 8

Placenta covers part of the cervical os

Question 9

what is considered Grade IV placenta praevia major?

Answer 9

Placenta completely covers cervical os

Question 10

which part of the uterus is considered the lower uterine segment?

Answer 10

part of the uterus below the vesicouterine fold of peritoneum (need to open it and push down the bladder to visualise LUS in C-sections)

Question 11

what is the clinical presentation of placenta praevia?

Answer 11

Placenta praevia presents with bright red, painless, recurrent vaginal bleeding occurring usually near the end of the 2nd trimester (or later):
• Sentinel bleed (first bleeding) is rarely so profuse as to cause death (ceases → recurs)
• Foetal movements and condition are normal
• Other clinical features (eluding to PP): high presenting part, abnormal foetal lie

Question 12

what is the gold standard for diagnosis of placenta praevia?

Answer 12

The gold standard for diagnosis is transvaginal ultrasound (TVUS), which is safer and more accurate than transabdominal ultrasound in locating the placenta.

Question 13

what is placenta accreta?

Answer 13

Penetrates through

decidua basalis

Question 14

what is placenta increta?

Answer 14

Penetrates through myometrium

Question 15

what is placenta percreta?

Answer 15

Penetrates through serosa (surrounding uterus)

Question 16

Placental abruption refers to premature separation of a normally sited placenta from the uterine wall → clinical diagnosis:
• Usually associated with constant severe abdominal pain (whereas placenta praevia tends to be painless) → due to infiltration of blood into the ____________
o Features: vaginal bleeding, pain, uterine tenderness & irritability, foetal distress/death, evidence of DIC
• Ultrasound is usually requested to confirm ____________ and exclude ___________

Answer 16

myometrium;

foetal viability;

praevia

Question 17

Vasa praevia occurs when the foetal vessels traverse the foetal membranes over the ____________ (below the foetal presenting part) → affects ~1 in 1000 pregnancies:
• Associated with _____________ (vessels run between the main lobe and accessory placental lobe → may rupture when membranes rupture)
• No risk to the mother; significant risk to foetus (50% mortality risk) → unprotected foetal vessels are disrupted when membranes rupture → foetal/APH → foetal distress

Answer 17

internal os;

velamentous cord insertion

Question 18

Uterine rupture is a rare but very dangerous condition for both mother and baby, where the uterine wall spontaneously tears and may expel the foetus into the peritoneal cavity:
• Associated with previous uterine surgery (C-sections, myomectomy, D & C if cavity has been breached)
o May occur with no previous uterine surgery when _____________ (to increase intensity and frequency of contractions) is used inappropriately
• Other risk factors: trauma, grand multiparity (> 5 pregnancies before), excessive oxytocin use, ___________ (obstruction in labour), high forceps delivery

Answer 18

oxytocin infusion;

shoulder dystocia

Question 19

what is the clinical presentation of uterine rupture?

Answer 19

• Pain over site of uterine scar, vaginal bleeding
• Disruption of labour: Abnormal cardiotocograph (CTG) → abnormal foetal heartbeat and/or uterine contractions, cessation of uterine contractions, inability to feel the foetal presenting part in the pelvis
• Hypovolaemic shock: Hypotension, tachycardia, pallor
• Haematuria (if rupture involves bladder → bleeding into urine)

Question 20

Show is a sign of the early stage of labour where the ________________ (which seals off the cervix and uterus during pregnancy) is expelled due to cervical dilatation:
• May be associated with bleeding (bloody show) → ________________ mucus
• Common harmless cause of bleeding in late pregnancy → careful evaluation is required to exclude other pathological causes of APH (e.g. placental abruption)

Answer 20

cervical mucus plug;

blood-tinged

Question 21

Cervical ectropion (ectopy/erosion) occurs when the ____________ exposes the ________________ to the vaginal milieu:
• Common normal finding in pregnancy → exposed columnar epithelium is prone to light bleeding when touched (e.g. coitus, speculum insertion, bimanual examination, cervical specimen obtained for cytology/culture)
• Therapy is usually unnecessary

Answer 21

eversion of the endocervix;

columnar epithelium

Question 22

what are cervical causes of bleeding?

Answer 22

• cervical ectropion
• cervical polyp
• cervicitis
• cervical cancer