Antepartum haemorrhage

Question 1

Causes of antepartum haemorrhage

Answer 1

1. 50% are unexplained causes
2. Placenta previa
3. Placental abruption
4. Vasa previa

Question 2

Definition of placenta previa

Answer 2

The placenta is completely or partially attatched to the lower segment of the uterus

Question 3

risk factors of placenta previa

Answer 3

1. increasing maternal age
2. increasing parity
3. multiple pregnancies
4. Previous caesareans section

Question 4

Examination of placenta previa

Answer 4

1. Abdominal & uterine exam - the uterus is soft and non tender
2. Palpate for the fetus - if cephalic presentation, fetus is not engaged due to low lying placenta in the way.
3. Speculum - to exclude lower genital tract causes of APH. Digital examination can provoke a massive bleed.

Question 5

Uterus in placenta previa

Answer 5

Soft and non tender

Question 6

Diagnosis of placenta previa

Answer 6

1. Transvaginal ultrasound at 20 weeks - placental site is localised. if low lying placenta is noted at this time;
2. Follow up scan in third trimester - placenta previa is diagnosed - majority of patients, the upper segment of the uterus grows and seems as though placenta is moved p and away from the internal os.

Question 7

investigations of placenta previa

Answer 7

1. Blood typing - blood for transfusion if necessary
2. Identify if anti D antibodies are necessary
3. Renal function test - if urine output is poor
4. Corticograph - for fetal wellbeing

Question 8

management of placenta previa

Answer 8

1. C section if placenta is enroaching within 2 cm of the internal os
2. Massive bleeding if labour ensues and dilation of the internal os which is overlied by the placenta

Question 9

complication of placenta previa

Answer 9

1. PPH - lower uterine segment is less effective at retraction following deliveyr of the placenta
2. Placenta accreta - part or all of the placenta remains attatched to the uterus walls because it grows too deep into the uterine wall

Question 10

How to manage a low lying placenta at 16 - 20 week scan

Answer 10

1. rescan at 34 weeks
2. Still present at 34 weeks grade1/2 -> rescan every 2 weeks
3. C section performed if high presenting part or abnormal lie at 37 weeks

Question 11

Placental abruption

Answer 11

• detachment of the placenta from the uterus wall - blood dissects under the placenta into the uterine wall - blood can leave via the uterine walls via the cervix ‘revealed haemorrhage’ - blood may become trapped within the uterine cavity - ‘concealed haemorrhage’

Question 12

Causes of placental abruptions

Answer 12

1. Pre eclampsia 2. Cigarette smoking and cocaine abuse

Question 13

Investigation of placental abruption

Answer 13

1. Vaginal bleeding associated with abdominal pain
2. Palpation of uterus - hard and tender - bleeding extends into uterine muscle - tonic contraction - uterus feels hard
3. Transvaginal ultrasound if placental site has not been located 4. Urinalysis for proteinuria - strong link between preclampsia and abruption
4. Renal function tests - if bleeding and urine output is low
5. Blood typing - identify blood group and improve stocks of blood for transfusion
6. Kleihauer test - check for fetal blood cells in the maternal circulation to confirm for fetomaternal haemorrhage which occurs in placental abruption
7. Cardiotocograph - check for fetal wellbeing

Question 14

management of placental abruption

Answer 14

1. Assess the severity of symptoms 2. If fetal and maternal wellbeing is retained - allow for symptoms to pass 3. If not - active resuscitation

Question 15

complications of placental abruption

Answer 15

1. Postpartum haemorrhage - reduced blood flow and hypovolemic shock during/after child birth –> Sheehan’s syndrome –> postpartum pituitary gland necrosis due to ischameia
2. Placental insufficiency caused fetal anoxia or death

Question 16

Vasa Previa definition

Answer 16

• vasa previa, is a condition in which fetal blood vessels cross or run near the internal opening of the uterus. - These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.

Question 17

Blood loss in Placenta Previa

Answer 17

Shock in proportion to visible loss

Question 18

Blood loss in placental abruption

Answer 18

Shock not in proportion with visible loss

Question 19

Pain in Placental abruption

Answer 19

Constant pain

Question 21

Pain in placenta previa

Answer 21

Painless bleeding

Question 22

Uterus in placental abruption

Answer 22

Tender, tense uterus

Question 23

Uterus in placenta previa

Answer 23

Uterus is not tender

Question 24

Lie in placental abruption

Answer 24

Normal lie and presentation

Question 25

Lie in Placental previa

Answer 25

Abnormal lie and presentation due to the position of the placenta Breech presentation and transverse lie are common

Question 26

Fetal heart rate in placental abruption

Answer 26

Absent/distressed

Question 27

Coagulation in placental abruption

Answer 27

Coagulation problems

Question 28

Coagulation problems in placenta previa

Answer 28

rare

Question 29

Complication of placenta previa

Answer 29

Small intermittent bleeds until large, gradually get worse and increase in frequency

Question 30

Complication of placental abruption

Answer 30

1. Pre eclampsia 2. DIC 3. Anuria

Question 31

Treatment of placenta previa

Answer 31

1. admission of all women with bleeding 2. Anti Rhesius prophylaxis and blood typing 3. Deliver via C section if \> 39 weeks 4. Give steroids if gestation is \< 34 weeks

Question 33

Vasa previa

Question 34

Placenta accreta

Answer 34

attatchment of the placenta to the myometrium of the uterua rather than being constricted to the decidua basalis over growth of the placenta into the uterus wall

Question 35

Three types of placenta accreta are

Answer 35

1. Accreta - chorionic villi attatch to myometrium 2. Increta - invade into the myometrium 3. Perceta - invade through the perimetrium