antepartum haemorrhage Flashcards
define antepartum haemorrhage
bleeding after 24wks but prior to delivery
risk factors for placenta praevia
multiparity
multiple pregnancy
previous c-section - embryos more likely to implant on lower segment scar
presentation of placenta praevia
- bleed, usually small (shock proportional to visible loss)
- NO pain
- uterus NOT tender
- lie/presentation may be abnormal
- fetal heart usually normal
diagnosing placenta praevia
- picked up on routine 20wk abdominal US
diagnosis = tranvaginal US (to localise, safe to use)
digital vag exam should NOT be performed before an US - may provoke severe bleed
management of placenta praevia
if low lying at 20wk -
- rescan at 32wks - if still present, US every 2wks
final US at 36-7wks
- elective csection for grades III/IV between 37-38wks
- grade 1 - trial vaginal delivery
if women with known placenta praevia goes into labour –> emergency csection (PPH risk)
placental abruption
separation of a normally sited placenta from the uterine wall, result in maternal haemorrhage into intervening space
causes of placental abruption
- proteinuric hypertension
- cocaine use
- multiparity
- maternal trauma
- increasing maternal age
placenta abruption presentation
- shock - out of keeping with visible blood loss
- constant pain
- tender, tense uterus
- fetal heart distressed/absent
- normal lie/presentation
management of placenta abruption
fetus alive + <36wks
- fetal distress - immediate csection
- no fetal distress - observe, steroids, NO tocolysis, threshold to deliver depends on gestation
fetus alive + >36wks
- fetal distress - immediate csection
- no fetal distress - deliver vaginally
fetus dead = induce vaginal delivery
complications of placenta abruption
maternal
- shock
- DIC
- renal failure
- PPH
fetal
- IUGR
- hypoxia
- death
placenta accreta
when the placenta implants deeper, through and past the endometrium
- makes difficult to separate placenta after delivery of baby
spectrum of disease - varies how deep etc
placenta accreta risk factors
- previous placenta accreta
- previous endometrial curettage procedures (miscarriage/abortion)
- previous caesarean section
- multigravida
- increased maternal age
- low lying placenta
types of placenta accreta
placenta accreta - implants in sirface of myometrium, not beyond
placenta increta - placenta attaches deeply into myometrium
placenta perceta - placenta invades past myometrium + perimetrium, potentially reaching other organs (eg bladder)
placenta accreta presentation
- typically no symptoms, can present with bleeding in 3rd trimester (antepartum haem)
may be diagnosed at birth when it becomes difficult to deliver placents
- big cause of PPH
management of placenta accreta
MRI scans to assess depth of invasion
delivery planned for 35-36+6wks
- steroids given to mature lungs before delivery
options during C-section:
1. hysterectomy (recommended)
2. uterus preserving - resect myometrium + placenta
3. expectant mx - leaving placenta to be reabsorbed, v risky (bleeding,infection)
if placenta accreta spotted whilst doing elective csection
the abdomen can be closed and delivery delayed whilst specialist services are put in place
- if placenta accreta is discovered after delivery of the baby, a hysterectomy is recommended
vasa praevia
where the fetal vessels are within the fetal membranes (chorioamniotic membranes) and travel across the internal cervical os
(fetal vessels usually in cord but abnormalities can mean their not)
vasa praevia risk factors
low lying placenta
IVF pregnancy
multiple pregnancy
vasa praevia presentation
may be picked up on US - can plan a c-section
may present with antepartum haem in 2nd or 3rd trimester
may be detected by vag exam during labour - pulsating vessels felt
management of vasa praevia
asymptomatic
- corticosteroids from 32wks
- elective csection 34-36wks
antepartum haemorrage
- emergency csection
