Antepartum Haemorrhage Flashcards
List the causes of antepartum haemorrhage
Common:
- Undetermined origin
- Placental abruption
- Placenta praevia
Rare:
- Incidental genital tract pathology
- Uterine rupture
- Vasa praevia
Define placenta praevia
Placenta implanted in lower segment of the uterus
Classification of Placenta Praevia
- Marginal = in lower segment not over os
- Major = completely or partially covering os
List the risk factors for placenta praevia
- Twins
- High parity
- High maternal age
- Scarred uterus
What are the complications of placenta praevia?
- Obstructs engagement of the head
- Transverse lie
- Haemorrhage - may continue during and after delivery
- Placenta accrete - deep implantation in C-section scar which prevents placental separation
- Placenta percreta - penetrates uterine wall and into surrounding structures
How does placenta praevia present?
History:
- Intermittent painless bleeds which increase in frequency and intensity
- Asymptomatic
Examination:
- Breech presentation and transverse lie common
- Fetal head high and not engaged
- NEVER DO VE unless placenta praevia excluded
What investigations are performed for placenta praevia?
- US - make dx
- Repeat US at 32wks if diagnosed 2nd trimester
- MRI can be useful
- FBC
- CTG
- Clotting studies
- Cross match
Describe admission in pts with placenta praevia
- Necessary for all with bleeding
- Blood available
- Anti-D administered to Rh-, IV access, steroids if <34wks
- If asymptomatic delay admission until delivery
Describe delivery in pts with placenta praevia
- EL LSCS at 39wks
- Intraoperative and PPH common
- Earlier emergency delivery for severe bleeding
- Very preterm - prolonged with observation and transfusion
What needs to be done in delivery of a pt with placenta accrete or percreta?
- Anticipated and clear plan for EL LSCS
- Interventional radiology and surgical anaesthetic support
- Uterine incision away from placenta
- Tx of massive haemorrhage = compression with Rush balloon ,excision of affected uterine segment or total hysterectomy
Define placental abruption
When part or all of the placenta separates before delivery of the fetus
List the complications of placental abruption
- Fetal death
2. Blood transfusion, DIC and renal failure = maternal death (rare)
List the risk factors for placental abruption
- IUGR
- Pre-eclampsia
- Autoimmune disease
- Maternal smoking
- Cocaine usage
- Previous hx of placental abruption
- Multiple pregnancy
- High maternal parity
- Trauma
- Sudden reduction in uterine volume
How does placental abruption present?
History:
- Painful bleeding
- Pain constant with exacerbations
- Dark blood
- Degree of PV bleeding does not reflect severity
- Pain occurring alone = concealed
Exam:
- Tachycardia (profound blood loss)
- Hypotension
- Uterus tender; often contracting
- Severe = uterus woody and hard
- Fetal heart abnormal or absent
How is placental abruption investigated?
- CTG and US to estanlish fetal well being
- FBC, coag screen, cross match
- Catheterisation with hrly urine output, regular FBC, coags and U&E
List the features of major placental abruption
- Maternal collapse
- Coagulopathy
- Fetal distress or demise
- ‘Woody’ hard uterus
- Poor urine output or renal failure
How do we assess and resuscitate a woman with placental abruption?
- Admission required if pain and uterine tenderness
- Resuscitation
- IV fluid, with steroids if <34wks
- Opiate analgesia
- Anti-D in Rh-
How is delivery managed in a woman with placental abruption?
- Depends on fetal state and gestation
- Stabilise mother first
- Fetal distress = EM LSCS
- No fetal distress and GA >37wks = induction
- Fetus is dead = blood products (as coagulopathy likely) given and induction
- MAJOR RISK OF PPH
Is there conservative management for placental abruption?
- Yes = if no fetal distress, pregnancy preterm and degree of abruption minor can give steroids and monitor closely
- Settles down = discharge but now high risk pregnancy; repeated US for fetal growth
Discuss ruptured vasa praevia
- When fetal BV runs in the membranes in front of the presenting part
- Umbilical cord attached to membranes instead of placenta (velamentous insertion)
- Can be diagnosed on US
- Rupture when membranes rupture = massive fetal bleeding
- Presentation = painless, moderate vaginal bleeding at ROM accompanied by severe fetal distress
- C-section often not fast enough to save fetus
Discuss uterine rupture
- Of LSCS scar
- Rare
- Occasionally in women with other uterine scars or congenitally abnormal uterus
Discuss bleeding of gynaecological origin
- Cervical carcinoma can present in pregnancy
- Speculum and colposcopy
- Caused by cervical polyps, ectropions and vaginal lacerations also
