Antepartum and post-partum haemorrhage

Question 1

Causes of antepartum haemorrhage

Answer 1

Placental abruption

-

Question 2

Antepartum haemorrhage

- Definition

Answer 2

PV bleeding in pregnancy >24weeks prior to birth of baby

Volume

• Spotting: staining, streaking spotting
• Minor: less than 50ml, has settled
• Major: 50-100ml loss, no clinical shock
• Massive: >100ml loss +/- signs of clinical shock

Question 3

Causes of bleeding during pregnancy

Answer 3

Minor/spotting:

• Cervical ectropion
• Cervical/vaginal laceration

Major/ massive:

• Placental abruption
• Placenta praevia
• Vasa praevia
• Uterine rupture

Question 4

Placental abruption

• Definition
• Presentation

Answer 4

Separation of the placenta from the uterine wall.

Presentation

• Painful, profuse PV bleeding
• Dark red blood
• Tense, painful uterus
• Non-palpable fetal parts, non-countable fetal HR

Question 5

Placenta praevia

• Definition
• Presentation

Answer 5

Placenta lying below the presenting baby
- High risk of major haemorrhage during birth

Presentation

• Painless, PV bleeding
• Bright red blood
• Progressive, profuse bleeding
• SNT uterus
• Fetal heart countable, parts palpable

Question 6

Risk factors for placenta praevia (4)

Answer 6

Previous C-section

Maternal smoker

Structural uterine abnormalities

Older maternal age

Question 7

Risk factors for placental abruption (6)

Answer 7

Previous abruption

Trauma

Multiple pregnancy

Pre-eclampsia/ hypertension

Older maternal age

Cocaine/amphetamine use

Question 8

Placenta accreta

- Definition

Answer 8

Deep growth of placenta into uterine wall

Question 9

Risk factors for placenta accreta

Answer 9

Previous C-section

Placenta praevia

Older maternal age

Question 10

Management of low lying placenta

Answer 10

Low-lying placenta (Class 1)

• If identified at 20 weeks, rescan at 32 and 36 weeks
• If low lying after 36 weeks, elective C-section between 36-37.

Question 11

Vasa praevia

- Definition

Answer 11

Covering of the internal cervical os by exposed fetal vessels

Question 12

Velamentous umbical cord insertion

Answer 12

Insertion of the umbilical cord (fetal vessels) into the fetal membranes instead of the middle of the placenta.

• The vessels do not have the protective Wharton’s jelly

Question 13

Management of placenta accreta

Answer 13

Plan for delivery between 35 and 36+6 weeks

Surgery post delivery

• Elective hysterectomy
• Uterus preserving surgery (high risk of further bleeding)

Question 14

DIC prevention in placental abruption

Answer 14

Cryoprecipitate
- 10 units

Fresh frozen plasma
- 4 units

Question 15

Rhesus D immunisation in antepartum haemorrhage

Answer 15

Anti-D immunoglobulins should be given to any RhD- pregnant woman after presenting with APH
- at least 500IU

Question 16

Definitions of major PPH

Answer 16

Blood loss >1000mL

Question 17

Causes of PPH

Answer 17

4 Ts

• Tone= Uterine atony. Most common
• Trauma= Perineal tear.
• Tissue= Retrained tissue/ placenta.
• Thrombin= bleeding disorder

Question 18

Pre-birth risk factors of PPH

Answer 18

Before birth

• Maternal Anaemia
• Pre-eclampsia
• Obesity (BMI>35)
• Previous PPH.
• Placentra praevia/ antepartum haemorrhage
• Fibroids

Question 19

Acute management of primary PPH

Answer 19

1. Appropriate A-E evaluation
2. Initiate haemorrhage call
3. Vaginal examination to remove any placenta present
4. Uterine atony
   - Massaging the fundus of uterus to stimulate contraction
   - IM synctocinon/syntometrine-
5. FBC, clotthing and cross match
6. Catheterisation
   - allows uterine contraction

Other medication

• IV/IM Ergometrine
• Prostaglandins analogues: Carboprost, Misoprostol
• IV tranexamic acid

Question 20

Units of oxytocin during PPH

Answer 20

40 units in 500mL

Question 21

Surgical management of PPH

Answer 21

Uterine balloon tamponade

B-Lynch suture
- Compresses the uterus

Uterine artery ligation

Final resort= hysterectomy

Question 22

First degree perineal tear involves injury to the _______ and _______

Answer 22

Frenulum of the labia minora and the superficial skin

Question 23

Second degree perineal tear involves injury to the _______

Answer 23

Perineal muscles

Question 24

Third degree perineal tear involves injury to the _______
3A involves ….
3B involves ….
3C involves ….

Answer 24

Anal sphincter

3A= <50% of the external sphincter
3B= >50% of external sphincter
3C= involves external and internal sphincter

Question 25

4th degree perineal tear involves injury to the _______ and _______

Answer 25

Internal + External sphincter AND the anorectal mucosa

Question 26

Risk factors for anal sphincter injuries

Answer 26

Large baby

Forceps delivery

Question 27

Management of perineal anal sphincter injury

Answer 27

Suturing in the operating theatre
- Can be done under GA/ spinal or epidural

Antibiotics
- At the repair and post-op

Question 28

Post-operative management of anal sphincter injury

Answer 28

Analgesia + antibiotics

Laxative
- Reduces constipation + straining

Physiotherapy
- Pelvic floor exercises

Gynae outpatients
- Evaluation symptoms of incontinence

Question 29

Peripartum risk factors for PPH

Answer 29

• Instrumental delivery
• Prolonged labour (>12) and induced labour
• Prolonged stage 3
• Large baby
• Cord prolapse, shoulder distocia
• C-section
• Primagravida > 40
• Fever

Question 30

Sheehan syndrome describes…

Answer 30

Necrosis of anterior pituitary after significant PPH (hypovolaemia + shock_