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HMS303 Reproductive, Ageing & Development > Ante Partum Hemorrhage / Late pregnancy bleeding > Flashcards

Ante Partum Hemorrhage / Late pregnancy bleeding Flashcards

1
Q

Source of bleeding during pregnancy is virtually never ________.

A

fetal

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2
Q

Common origins/sites of bleeding

A
  • disruption of blood vessels in the decidua (pregnancy endometrium)
  • lesions in cervix or vagina
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3
Q

Define Antepartum hemorrhage

A

Vaginal bleeding that occurs after 20wks gestation & unrelated to labor & delivery

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4
Q

Major causes of Antepartum Hemorrhage

A
  • Placenta praevia (20%)
  • Placenta abruption (30%)
  • Uterine rupture (rare)
  • Vasa praevia (rare)
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5
Q

Minor causes of Antepartum Hemorrhage

A
  • Cervical = polyps, infection (cervicitis), carcinoma.
  • Vaginal = infection (vaginitis), vaginal warts, vaginal cancer, trauma.
  • Uterine pathology = leiomyoma (fibroids), polyps.
  • Trauma
  • Bloody show = passage of operculum (mucous plug)
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6
Q

Define Placenta Praevia

A

Implantation of the placenta in the lower segment of the uterus so that it partially or totally covers the internal os of the cervix.

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7
Q

Prevalence of Placenta Praevia

A

Approx. 4 per 1000 births but varies worldwide.

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8
Q

Placenta Praevia is higher at 20 weeks than at birth because of?

A

Because the placenta migrates upwards as gestation advances.

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9
Q

Major risk factors - Placenta Praevia

A
  • Previous placenta praevia (4 - 8% recurrence)
  • Previous caesarian delivery (increase risk 47 - 60%)
  • Multiple gestations (40% higher risk compared to single)
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10
Q

Other risk factors - Placenta Praevia

A
  • Previous uterine surgical procedures
  • Increasing parity
  • Increasing maternal age
  • Infertility treatment
  • Previous pregnancy termination
  • Maternal smoking
  • Male fetus
  • Maternal cocaine use
  • Prior uterine artery embolization
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11
Q

Placental bleeding is a major sequelae. What does this mean?

A

Means it results from a prior disease, injury or trauma to the body.

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12
Q

Partial detachment of placenta are due to shearing forces from:

A
  • changes in cervix & lower uterine segment
  • vaginal examination (digital examination) = iatrogenic
  • coitus (sex)
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13
Q

Where does the bleeding occur in placenta praevia?

A

Bleeding primarily maternal blood in the intervillous space

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14
Q

Ultrasound examination of placenta praevia

A
  • asymptomatic (incidental) finding
  • 16-20wks
  • gestational age, fetal anatomy & cervical length
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15
Q

90% placenta praevia on ultrasound before 20 weeks resolves before delivery. Why is this?

A
  • This is because the lower segment lengthens (5mm at 20wks to 50mm at term) & relocates lower edge of placenta away from os.
  • Placenta trophotropism = with less vascular lower segment, the placenta tends to migrate upwards to more vascular decidua.
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16
Q

Placenta trophotropism

A

Process by which the placenta migrates upwards from a less vascular lower segment to a more vascular decidua.

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17
Q

The more the placenta extends over the _____ _____, the more likely it is to ________ until ______.

A

internal os, persist, delivery

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18
Q

Bleeding in placenta praevia

A
  • Painless (90%):
    1/3 initial onset <30wks
    1/3 initial onset between 30wks-36wks
    1/3 initial onset >36wks
  • Unpredictable & may occur at any time without warning
  • May range from slight intermittent bleeding to heavy profuse bleeding
  • Uterine contractions & pain may occur (10 - 20%)
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19
Q

Classification of placenta praevia (3)

A
  1. Marginal - placenta is positioned at the edge of the cervix.
  2. Partial - placenta partially covers the internal os.
  3. Total - complete coverage of the internal os by the placenta.
20
Q

Diagnosis of Placenta Praevia

A
  • Clinical suspicion
  • vaginal bleeding (painless) after 20wks of gestation
  • persistent abnormal fetal lie = transverse, oblique
  • Ultrasonography - gold standard
21
Q

Goal of managing Placenta Praevia

A

To keep pregnancy intrauterine until risk of continuing pregnancy outweighs risk of preterm delivery.

(prolonging pregnancy to get as close as to the due date without complications)

22
Q

What examination is not performed in a patient with Placenta Praevia, & why?

A

Vaginal exam - bc it may exacerbate bleeding when the placenta is disturbed, therefore an ultrasound scan (excludes placenta praevia) is always done before considering a vaginal exam.

23
Q

Management of Placenta Praevia
- Stabilize & monitor mother

A
  • Admit patient
  • Insert a large bore IV cannula = for FBC, Blood group, Rhesus, Crossmatch (blood transfusion)
  • Ultrasound to confirm diagnosis
24
Q

Management of Placenta Praevia (4)
- Less than 37wks & minimal bleeding

A
  • Expectant management
  • Limited physical activity, no vaginal douching or sexual intercourse
  • Consider corticosteroids for fetal lung maturity (helps mature the development of the lungs)
  • Deliver when fetus is mature or hemorrhage threatening fetal or maternal wellbeing.
25
Q

Management of Placenta Praevia
- Greater than 37wks

A

Deliver = mode of delivery is to be determined by degree of placenta praevia:
- complete placenta praevia = caesarian section
- low lying placenta = may consider trial of vaginal delivery.

26
Q

Placenta Abruption
(abruptio placentae)

A

Partial or complete placental detachment from the uterine wall after 20wks of gestation.

27
Q

Placenta Abruption - complicates approx. _______ per _____ births.

A

2-10 per 1000 births

28
Q

Pathophysiology of Placenta Abruption

A

Rupture of placental vessels in the decidua basalis (basal layer) → accumulating blood splits the decidua from its placental attachment → leads to the development of potentially life-threatening complications = severe bleeding, maternal DIC (disseminated intravascular coagulation), fetal compromise.

29
Q

Placenta Abruption - Risk factors

A
  • previous abruption
  • hypertension/preeclampsia
  • multiparity
  • increased age
  • smoking/alcohol use
  • cocaine use
  • polyhydramnios
  • premature rupture of membranes
  • external trauma
  • uterine anomalies (bicornuate uterus/ uterine synaechae/ leiomyomata)
30
Q

Clinical Features of Placenta Abruption

A
  • pain = sudden onset, constant, localized to uterus & lower back.
  • painful vaginal bleeding (80%)
  • external/revealed = presents with vaginal bleeding
  • internal/concealed (20%) = may or may not present with vaginal bleeding.
  • uterine tenderness/ uterine contractions/ hypertonus (uterus doesn’t relax between contractions)
  • shock/anemia = out of proportion to external blood loss
  • fetal distress/ fetal demise/ bloody amniotic fluid
  • couvelaire uterus = extravasation of blood into the uterine musculature and beneath the uterine peritoneum.
31
Q

Placenta Abruption - 2 main types

A
  1. Revealed
    - bleeding tracks down from the site of placental separation & drains through the cervix
    - results in vaginal bleeding
  2. Concealed
    - bleeding remains within the uterus, and typically forms a clot retroplacentally (behind).
    - bleeding is not visible but can be severe enough to cause systemic shock.
32
Q

Management of Placenta Abruption
- Maternal stabilization

A
  • large bore IV with fluids = FBC, Group, Crossmatch, Coagulation profile.
  • monitoring of vital signs, urine output, blood loss.
33
Q

Management of Placenta Abruption
- Fetal monitoring

A

Cardiotocogram (CTG)

34
Q

Management of Placenta Abruption
- Abruption without fetal/maternal compromise (mild)

A

<37 wks
- close monitoring
- deliver when fetus is mature or signs of fetal/maternal compromise

> 37 wks
- deliver

35
Q

Complications of Placenta Abruption
- Maternal

A
  • hypovolemic shock
  • DIC = disseminated intravascular coagulation
  • blood transfusion
  • hysterectomy (removal of uterus)
  • renal failure
  • in hospital death
36
Q

Complications of Placenta Abruption
- Fetal

A
  • non-reassuring status
  • growth restriction
  • death
37
Q

Complications of Placenta Abruption
- Newborn

A
  • pre-term birth
  • small for gestational age
  • death
38
Q

Vasa Previa

A

Rare condition where one of the branches of the fetal umbilical vessels lies in the membranes & across the cervical os.

39
Q

If vasa praevia is undiagnosed…

A

50% perinatal mortality, increasing to 75% if membranes rupture.

40
Q

If vasa praevia is diagnosed antenatally using ultrasound without labour or symptoms…

A

97% survival

41
Q

Management of Vasa Praevia

A
  • Planned c-section delivery at 37wks
  • Emergency c-section if bleeding earlier
42
Q

Rupture of uterus can occur?

A

*During pregnancy - before or after the onset of labor.

  • Spontaneously
  • previous caesarian scar (classical c/section more than lower segment c/section)
  • uterine anomaly
  • intact uterus (rare)
  • as a side effect of uterotonic agents (oxytocin)

*Acquired
- trauma (car accidents, physical violence)
- obstetrics procedures (e.g. forceps rotation, external cephalic version)

43
Q

Rupture of the uterus may lead to ____ of both ____ & ____.

A

death, mother, fetus

44
Q

Clinical features - Rupture of uterus

A
  • high index of suspicion
  • vaginal bleeding
  • absence of contractions in a woman who was contracting regularly
  • abdominal distension
  • fetal distress & possibly death
  • maternal reduction in level of consciousness & shock
45
Q

Management - Rupture of the uterus

A
  • Obstetrics emergency
  • Multidisciplinary team effort
  • ABC
  • Stabilize woman & transfer for urgent laparotomy - uterine repair vs hysterectomy.
46
Q

Complications of Rupture of the uterus
- Fetal

A
  • hypoxia
  • acidosis
  • NICU admission
  • death
47
Q

Complications of Rupture of the uterus
- Maternal

A
  • severe blood loss
  • blood transfusion
  • surgical risk with possible hysterectomy
  • death

HMS303 Reproductive, Ageing & Development (9 decks)

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