Antepartum and post-partum haemorrhage Flashcards
Causes of antepartum haemorrhage
Placental abruption
-
Antepartum haemorrhage
- Definition
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
Causes of bleeding during pregnancy
Minor/spotting:
- Cervical ectropion
- Cervical/vaginal laceration
Major/ massive:
- Placental abruption
- Placenta praevia
- Vasa praevia
- Uterine rupture
Placental abruption
- Definition
- Presentation
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
Placenta praevia
- Definition
- Presentation
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
Risk factors for placenta praevia (4)
Previous C-section
Maternal smoker
Structural uterine abnormalities
Older maternal age
Risk factors for placental abruption (6)
Previous abruption
Trauma
Multiple pregnancy
Pre-eclampsia/ hypertension
Older maternal age
Cocaine/amphetamine use
Placenta accreta
- Definition
Deep growth of placenta into uterine wall
Risk factors for placenta accreta
Previous C-section
Placenta praevia
Older maternal age
Management of low lying placenta
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.
Vasa praevia
- Definition
Covering of the internal cervical os by exposed fetal vessels
Velamentous umbical cord insertion
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
Management of placenta accreta
Plan for delivery between 35 and 36+6 weeks
Surgery post delivery
- Elective hysterectomy
- Uterus preserving surgery (high risk of further bleeding)
DIC prevention in placental abruption
Cryoprecipitate
- 10 units
Fresh frozen plasma
- 4 units
Rhesus D immunisation in antepartum haemorrhage
Anti-D immunoglobulins should be given to any RhD- pregnant woman after presenting with APH
- at least 500IU
Definitions of major PPH
Blood loss >1000mL
Causes of PPH
4 Ts
- Tone= Uterine atony. Most common
- Trauma= Perineal tear.
- Tissue= Retrained tissue/ placenta.
- Thrombin= bleeding disorder
Pre-birth risk factors of PPH
Before birth
- Maternal Anaemia
- Pre-eclampsia
- Obesity (BMI>35)
- Previous PPH.
- Placentra praevia/ antepartum haemorrhage
- Fibroids
Acute management of primary PPH
- Appropriate A-E evaluation
- Initiate haemorrhage call
- Vaginal examination to remove any placenta present
- Uterine atony
- Massaging the fundus of uterus to stimulate contraction
- IM synctocinon/syntometrine- - FBC, clotthing and cross match
- Catheterisation
- allows uterine contraction
Other medication
- IV/IM Ergometrine
- Prostaglandins analogues: Carboprost, Misoprostol
- IV tranexamic acid
Units of oxytocin during PPH
40 units in 500mL
Surgical management of PPH
Uterine balloon tamponade
B-Lynch suture
- Compresses the uterus
Uterine artery ligation
Final resort= hysterectomy
First degree perineal tear involves injury to the _______ and _______
Frenulum of the labia minora and the superficial skin
Second degree perineal tear involves injury to the _______
Perineal muscles
Third degree perineal tear involves injury to the _______
3A involves ….
3B involves ….
3C involves ….
Anal sphincter
3A= <50% of the external sphincter 3B= >50% of external sphincter 3C= involves external and internal sphincter
4th degree perineal tear involves injury to the _______ and _______
Internal + External sphincter AND the anorectal mucosa
Risk factors for anal sphincter injuries
Large baby
Forceps delivery
Management of perineal anal sphincter injury
Suturing in the operating theatre
- Can be done under GA/ spinal or epidural
Antibiotics
- At the repair and post-op
Post-operative management of anal sphincter injury
Analgesia + antibiotics
Laxative
- Reduces constipation + straining
Physiotherapy
- Pelvic floor exercises
Gynae outpatients
- Evaluation symptoms of incontinence
Peripartum risk factors for PPH
- Instrumental delivery
- Prolonged labour (>12) and induced labour
- Prolonged stage 3
- Large baby
- Cord prolapse, shoulder distocia
- C-section
- Primagravida > 40
- Fever
Sheehan syndrome describes…
Necrosis of anterior pituitary after significant PPH (hypovolaemia + shock_
