Antepartum Haemorrhage Flashcards
1
Q
DEFINITION
A
Bleeding >24w gestation.
2
Q
PLACENTA PRAEVIA
EPIDEMIOLOGY
A
- 5% low-lying placenta at 16-20w USS
- 10% low-lying placentas will be praevia at term.
- 0.5% pregnancies at term
3
Q
CLASSIFICATION(PP)
CLASSICAL GRADING(I-IV)
A
- Marginal: not over os
- Major: Completely/partially covering os.
Type I: placenta reaches lower segment, not internal os.
Type II: placenta reaches internal os but X cover it.
Type III: Placenta covers internal os before dilation but not after dilation.
Type IV: Placenta completely covers internal os.
4
Q
AETIOLOGY(PP)
A
More common in: twins, multiparity, aged, uterus scarred
5
Q
COMPLICATIONS(PP)
A
- Obstructs engagement of head
- necessitates C-section
- may cause transverse lie - Increase haemorrhage drg delivery
- lower segment can’t contract as well. - Placenta accreta
- 10% of women w placenta praevia and prev Cesarean scar
- Massive haemorrhage at delivery, may need hysterectomy - Placenta percreta
6
Q
CLINICAL FEATURES(PP)
A
- Intermittent, painless bleeding
- Abnormal lie, breech presentation
* never do vaginal examination on bleeding patient unless placenta praevia has been excluded.
7
Q
INVESTIGATIONS(PP)
A
- US
- If low-lying placenta and posterior, TVUS @32w:
- if <2cm from internal os, likely praevia at term
- no need to limit activity/intercourse unless bleed.
- if @32w, grade I/II, scan every 2w. @37w, if high presenting part/abnormal lie, C-section. - If placenta ant. and underneath C-section scar, 3D power US
- assess for placenta accreta - CTG, FBC, coag, cross-match
8
Q
MANAGEMENT(PP)
A
- Admit all bleeding cases usually until delivery.
- If asymptomatic, can delay admission until 37w.
- Anti-D if Rh -ve, keep blood available
- Steroids if <34w
- Elective C-section for grades III/IV btw 37-38w. btw 36-37 w if placenta accreta. Emergency if before that. If grade I, vaginal delivery
- Intraoperative and PPH may req. Rusch balloon/hysterectomy
9
Q
PLACENTAL ABRUPTION
EPIDEMIOLOGY
A
about 1 in 200 pregnancies
10
Q
COMPLICATIONS(PA)
A
- Acute fetal distress
- Fetal death(30%)
- Massive haemorrhage req blood transfusion
- DIC, renal failure, maternal death
11
Q
AETIOLOGY(PA)
A
Major risk f:
- Pre-eclampsia, pre-existing hypert.
- IUGR
- Previous abruption(risk 6%)
- Maternal smoking
Other risk f;
- Cocaine use
- Multiparity
- Multiple pregnancy
- Age
- Maternal trauma
12
Q
CLINICAL FEATURES(PA)
A
- Severe abdominal pain
- Constant w exacerbations - Vaginal bleeding
- usually dark blood
- if no bleed but abdominal pain, concealed abruption. - Tachycardia
- Hypot. if severe
- Tender uterus on palpation, can be woody hard.
- Abn./absent fetal heart sounds
- widespread bleeding w coag failure
- Poor urine output/renal failure
13
Q
INVESTIGATIONS(PA)
A
- CTG
- US to estimate fetal W and exclude placenta praevia
- FBC, U&E, coag, cross-match
- Urinary catheterization and monitor urine output hourly
- CVP monitoring in severe cases
14
Q
MANAGEMENT(PA)
- Assessment and resus
- Conservative Mx.
- Delivery
- Postpartum
A
- Admit even all pts with pain and uterine tenderness even if no bleeding
- IV fluids
- Steroids if <34w
- Anti-D to Rh-ve
- Consider blood transfusion
- May req opiate analgesia - If minor abruption, no fetal distress, preterm pregnancy
- steroids if <34w
- monitor closely on ward
- D/C when Sx. settle but tx as high-risk
- USS to monitor fetal growth. - Urgent C-section if fetal distress
- if no fetal distress, gestation ≥37w, IOL w amniotomy; continuous fetal heart monitoring; monitor maternal health; C-section if fetal distress
- if fetus death, coagulopathy likely. Blood products transfusion and IOL - PPH likely
15
Q
VASA PRAEVIA
A
- fetal blood vessels run in membranes in front of presenting part
- can be detected on US but seldom.
- may rupture in 1 in 5000 pregnancies.
- painless, moderate vaginal bleeding at amniotomy or SRM + severe fetal distress
- C-section usually X fast enough to save fetus.
- fetal bradycardia is classic sign
