Antepartum bleeding Flashcards
antepartum haemorrhage (APH) definition
bleeding from the genital tract after 24 weeks gestation and before the end of the second stage of labour
i.e. >24/40 and before the baby is delivered
what are the commonest causes of antepartum haemorrhage?
placental abruption and placenta praevia
minor APH
<50ml
settled
major APH
50-1000ml
no shock
massive APH
> 1000ml
and/or shock
what is placental abruption?
separation of a normally implanted placenta - partially or completely before birth of the fetus
what percentage of APHs does placental abruption make up?
40% of APH
what tests should we do if we think there is placental abruption?
NO TIME FOR TESTS !
Clinical diagnosis
when is placental abruption most likely to occur?
the last trimester, particularly during the last few weeks prior to birth
what percentage of cases of placental abruption occur in low-risk pregnancies?
70%
placental abruption risk factors
- unknown (low risk pregnancies!)
- pre-eclampsia/hypertension
- trauma
-smoking/cocaine/ amphetamine
-thrombophilias/renal diseases/diabetes/hypothyroidism
-polyhydramnios - multiple pregnancy
- preterm-PROM
-Placenta insufficiency
-previous abruption
placental abruption symptoms
- CONTINUOUS severe abdominal pain
- backache with posterior placenta
- bleeding (may be concealed)
- preterm labour
- may present with maternal collapse
placental abruption overall signs
- unwell distressed patient
- signs may be inconsistent with revealed blood
placental abruption signs on abdominal examination
- uterus large for date or normal
- uterine tenderness
- woody hard uterus
- fetal parts difficult to identify
- may be in preterm labour
“woody hard uterus”
placental abruption
placental abruption fetal condition
- bradycardia
- absent HR (intrauterine death)
- CTG shows irritable uterus
placental abruption management
- ABCDE approach
- RESUSCITATE MOTHER
- Assess and deliver baby
- Manage complications
- Debrief the parents
how do we assess fetal heart in placental abruption management?
CTG
USS if no fetal heart
fetal complications of placental abruption
- intrauterine death (14%)
- hypoxia
- prematurity
- small for gestation age and fetal growth restriction
what is placenta praevia
when the placenta lies directly over the internal os
when should the term “low-lying placenta” be used?
after 16/40 when the placental edge is less than 20mm from the internal os on TA or TV scanning
Risk factors for placenta praevia
- previous c section
- previous termination of pregnancy
- maternal age >40
- multiparity
- assisted conception
- multiple pregnancy
- smoking
- deficient endometrium due to presence or history of: uterine scar, endometritis, manual removal of placenta, D+C, submucous fibroid
placenta praevia symptoms
- painless bleeding >24 weeks
- usually unprovoked but coitus can trigger bleeding
- bleeding can be minor e.g. spotting, or severe
- fetal movements usually present
do not perform vaginal examination until you exclude ______ ________
placenta praevia
what scan confirms placenta praevia
transvaginal US
what scan excludes placenta accreta
MRI
when could a mother have a vaginal delivery with placenta praevia?
if placenta >2cm from os and no malpresentation
when should delivery be considered in placenta praevia?
34-36 weeks if history of PVB or other risk factors for preterm delivery
36-37 weeks for uncomplicated placenta praevia
what is placenta accreta?
a placenta abnormally adherent to the uterine wall
what puts a woman at increased risk of placenta accreta?
previous c section - increasing risk with multiple c sections
placenta praevia
placenta accreta management
- prophylactic internal iliac artery balloon
- caesarean hysterectomy
- blood loss >3L expected
- conservative management - incision upper segment
uterine rupture definition
full thickness opening of the uterus
including serosa
uterine rupture risk factors
- previous c section
- previous uterine surgery e.g. myomectomy
- multiparity and use of prostaglandins/syntocinon
- obstructed labour
uterine rupture symptoms
severe abdominal pain
shoulder tip pain
maternal collapse
PV bleeding
uterine rupture signs
- intra-partum - loss of contractions
- acute abdomen
- presenting part rises
- peritonism
- fetal distress/intrauterine death
what is vasa praevia?
blood vessels travelling from baby to placenta, unprotected by placental tissue or the umbilical cord, pass near to the cervix. If these blood vessels tear, this can be very dangerous for your baby.
vasa praevia foetal mortality
around 60%
vasa praevia type 1
the vessel is connected to a velamentous umbilical cord
vasa praevia type II
the vessel connects the placenta with a succenturiate or accessory lobe
vasa praevia management
antenatal diagnosis
- steroids from 32 weeks
- consider inpatient management if risks of preterm birth (32-34 weeks)
- deliver by elective c section before labour (34-36 weeks)
APH from vasa praevia: emergency C section
placenta for histology
