9 Placental Complications / Long Term Implications of Pregnancy Complexity

Question 1

APH & risk factors

Answer 1

Antepartum haemorrhage: any bleeding from the genital tract after 20 weeks gestation, and before the onset of labour

Question 2

Placenta previa / placental abruption / vasa previa

Answer 2

Placenta previa: the lower uterine segment and internal os is covered by the placenta, meaning a caesarean is necessary

Placental abruption: the placenta detaches from the uterus before delivery, depriving the foetus of oxygen and nutrients

Vasa previa: unprotected blood vessels from the umbilical cord travel across the opening of the cervical os, potentially causing extreme blood loss for the foetus when membranes rupture and expose the blood vessels

Question 3

Placenta previa pathophysiology

Answer 3

• Idiopathic
• ? Upper uterus endometrium is not well vascularised or damaged (previous C-section, abortion, surgery) therefore the placenta implants on the lower uterus
• Lower uterine segment grows throughout pregnancy, disrupting placental vessels, causing bleeding
• Placenta may completely, partially, or marginally (2cm) cover cervix os

Question 4

Placental abruption pathophysiology

Answer 4

Rupture of maternal vessels within the basal layer of the endometrium causes blood to accumulate and split the placenta from the basal layer

Question 5

Vasa previa pathophysiology

Answer 5

Fetal blood vessels traverse between the amniotic fluid membrane and the uterine wall’s inner surface

Question 6

Incidental genital tract bleeding

Answer 6

Small amount of blood, or blood-tinged mucus that usually passes, bruised or tender cervix, trauma, post coital bleeding, carcinoma, infection

Question 7

APH/IPH assessment & management

Answer 7

• Is there evidence of maternal or fetal compromise?
• Is transfer indicated? (Depending on health service’s capability, call PIPER if needed)

BLOOD LOSS - weigh blood loss, document ongoing blood loss, document history of blood loss in this pregnancy

EXAMINATION - maternal vital signs, abdo palp, pain, rigidity, fetal presentation/size/movement, fetal HR/CTG

HISTORY - obstetric, medical, surgical, social

SPECULUM - blood loss, cervical dilation, length, membranes, presenting part

ULTRASOUND - placental position and condition, fetal growth and wellbeing, cervical length

INVESTIGATIONS - FBC, group, liver function tests, renal function tests, coagulation studies, fibrinogen, Kleihaur especially for RhD pos mothers

RESUSCITATION - consider calling MET, code pink or code blue. IV access, fluid replacement, oxygen, IDC, potentially bloods