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Reproductive - Childbirth > Antepartum Haemorrhage > Flashcards

Antepartum Haemorrhage Flashcards

1
Q

Bleeding in late pregnancy is defined as what gestation?

A

24 weeks +

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2
Q

Antepartum haemorrhage is often due to problems with what?

A

The placenta

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3
Q

Antepartum haemorrhage is defined as bleeding from or into the genital tract between what times?

A

24 weeks gestation and the end of the second stage of labour (i.e. delivery)

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4
Q

What are some placental causes of antepartum haemorrhage?

A

Placenta praevia/abruption/accreta

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5
Q

A uterine rupture is more likely to be the cause of an antepartum haemorrhage in who?

A

Women who have had a previous C-section or have had more than 4 children

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6
Q

What are some local causes of an antepartum haemorrhage?

A

Cervical ectropion, polyps, cancer, infection

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7
Q

With any women presenting with antepartum haemorrhage, what are the two most important things to check for first?

A

Placental abruption and placenta praevia

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8
Q

What are some differential diagnoses of an antepartum haemorrhage?

A

Heavy show, cystitis, haemorrhoids

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9
Q

What is a heavy show?

A

A mixture of mucus and blood which passes when the woman is about to labour

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10
Q

What is defined as a minor haemorrhage?

A

Blood loss < 50ml which has settled

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11
Q

What is defined as major haemorrhage?

A

Blood loss of 50-1000ml, with no signs of clinical shock

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12
Q

What is defined as massive haemorrhage?

A

Blood loss > 1000ml +/- clinical shock

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13
Q

What is placental abruption?

A

The separation of a normally implanted placenta (partially or totally) before the birth of the foetus

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14
Q

In placental abruption, where does the actual separation take place between?

A

The uterine wall and decidua basalis

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15
Q

How is placental abruption diagnosed?

A

It is a clinical diagnosis

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16
Q

Describe briefly the pathophysiology of placental abruption?

A

Vasospasm leads to arteriole rupture which causes bleeding into the amniotic sac or myometrium - it is this bleeding which causes the placenta to separate from the uterine wall

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17
Q

What impact does placental abruption have on the foetus?

A

Interrupts the placental circulation which leads to hypoxia

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18
Q

Placental abruption can result in Couvelaire uterus - what is this?

A

Bleeding which penetrates into the myometrium and forces its way into the peritoneal cavity

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19
Q

What are some risk factors for placental abruption?

A

Previous abruption, hypertension/pre-eclampsia, trauma, smoking/drugs (especially cocaine)

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20
Q

What is the main symptom of placental abruption?

A

Severe abdominal pain which is continuous

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21
Q

If the placenta is posterior, placental abruption can also present with what?

A

Back pain

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22
Q

What is important to be aware of about bleeding in placental abruption?

A

It may be concealed - foetal compromise and maternal collapse may seem disproportionate to the amount of blood loss

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23
Q

What are the only reasons that an US should be used for in placental abruption?

A

Initially, to rule out placenta praevia, and then to establish foetal viability

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24
Q

Describe the uterus that may be seen in placental abruption?

A

Large for dates, tender, woody hard

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25
Q

What can happen to the foetal heart beat in placental abruption? How should this be monitored?

A

Bradycardic or absent - cardiotocography once the mother is stable enough

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26
Q

What are some features which may be seen on cardiotocography for placental abruption?

A

1 contraction per minute, loss of variability, decelerations

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27
Q

What are the 4 stages of management of placental abruption?

A

Resuscitate the mother, assess and deliver the baby, manage any complications, debrief the parents

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28
Q

What are some important aspects of maternal resuscitation for antepartum haemorrhage?

A

2 large bore IV cannulas, FBC/LFT/Us and Es/clotting/crossmatch 4-6 units RBCs, IV fluids, catheterise and monitor hourly urine volumes, anti-D if needed

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29
Q

Which women with placental abruption should receive a Kleihauer Betke test? What is this for?

A

Only used for Rh - women who have not been sensitised to guide the amount of anti-D required

30
Q

How should the baby be delivered in placental abruption?

A

C-section

31
Q

How should delivery be managed in placental abruption?

A

Expectantly, but give steroids if < 35 weeks

32
Q

What are some maternal complications of placental abruption?

A

Hypovolaemic shock, PPH, renal failure, coagulopathy, infection…

33
Q

What are some foetal complications of placental abruption?

A

Hypoxia, prematurity, SGA, IUD

34
Q

How can placental abruption be prevented a) generally? b) in women with anti-phospholipid syndrome?

A

Low dose aspirin and smoking cessation / LMWH and LDA

35
Q

What is placenta praevia?

A

The placenta is partially or totally implanted in the lower uterine segment

36
Q

What is the difference between the terms placenta praevia and low lying placenta?

A

Placenta praevia is when the placenta is lying directly over the internal cervical os, while low lying placenta means the placental edge is < 20mm from the internal cervical os

37
Q

What are some risk factors for placenta praevia?

A

Previous C-section(s), previous termination of pregnancy, smoking, assisted conception

38
Q

What is the first time during screening that placenta praevia or low lying placenta should be picked up?

A

On the anomaly scan

39
Q

If the anomaly scan shows signs of placenta praevia or low lying placenta, what is the management?

A

Rescan at 32 and 36 weeks if persistent (ideally transvaginal)

40
Q

If placenta accreta is suspected as a diagnosis, what investigation should be done?

A

MRI

41
Q

How does placenta praevia present?

A

Painless bleeding which can be continuous or intermittent > 24 weeks (can be anything from minor spotting to severe bleeding)

42
Q

Bleeding from placenta praevia is usually unprovoked, but can be initiated by what?

A

Sex

43
Q

In placenta praevia, the patient’s condition is directly proportional to what?

A

The amount of bleeding that can be seen

44
Q

What are some signs around the uterus that may be seen in placenta praevia?

A

Soft, non-tender, may have a high presenting part, may be malpresentations

45
Q

What does a CTG in placenta praevia usually show?

A

It is usually normal

46
Q

In any undiagnosed antepartum haemorrhage it is important to not perform what examination? Why? What must you do first?

A

Digital vaginal examination - if the cause is placenta praevia, then this can trigger significant bleeding / Ultrasound first

47
Q

How is placenta praevia diagnosed?

A

Transvaginal ultrasound scan

48
Q

What are the management principles of placenta praevia?

A

Resuscitate mother, assess baby, investigations, deliver if at/near term

49
Q

What is the management for placenta praevia if the mother is a) stable? b) still bleeding/distant from hospital etc?

A

a) inpatient for at least 24 hours until bleeding has stopped b) admit

50
Q

If you discharge a patient with placenta praevia, what should you advise them?

A

Advise them to come back if they have any bleeding or pain / don’t have sex

51
Q

If you are planning early delivery for a woman with placenta praevia, what medications are important to give the foetus and when are they indicated? If the woman and foetus are stable, what might be a sensible management plan here?

A

Steroids < 35 weeks / MgSO2 if 24-32 weeks / consider tocolysis to give these medications time to work

52
Q

When would a C-section be indicated for placenta praevia?

A

If the placenta is < 2cm from or covers the internal cervical os

53
Q

When would a vaginal delivery be indicated for placenta praevia?

A

If the placenta is > 2cm from the internal cervical os and there is no malpresentation

54
Q

What is placenta accreta?

A

A placenta which is abnormally adherent to the uterine wall

55
Q

What are the two major risk factors for placenta accreta?

A

Having placenta praevia, or having previous C-sections

56
Q

What are some risks of placenta accreta?

A

Severe bleeding, PPH, hysterectomy requirement

57
Q

How is placenta accreta managed?

A

MDT - iliac artery balloon, C-section hysterectomy and expect major blood loss

58
Q

What is the definition of uterine rupture?

A

Full thickness opening of the uterus

59
Q

When does uterine rupture generally present?

A

After the onset of contractions in labour

60
Q

What are the risk factors for uterine rupture?

A

Previous C-section or uterine surgery, multiparity, use of prostaglandins/syntocinon or obstructed labour

61
Q

What are some symptoms of uterine rupture?

A

Severe abdominal pain, shoulder tip pain, maternal collapse, PV bleeding

62
Q

What are some signs of uterine rupture?

A

Intrapartum loss of contractions, hypertension, peritonism, acute abdomen, foetal distress

63
Q

What is the management for uterine rupture?

A

Urgent resuscitation and emergency laparotomy to remove the baby

64
Q

What is vasa praevia?

A

Unprotected foetal vessels transverse the internal cervical os

65
Q

What happens to the unprotected foetal vessels in vasa praevia at labour?

A

They will rupture

66
Q

How can vasa praevia be picked up antenatally?

A

TA and TV US with Doppler

67
Q

If vasa praevia is not already known and it occurs at labour, how is it diagnosed?

A

Clinical diagnosis

68
Q

Describe what happens in vasa praevia at delivery?

A

Rupture of membranes leads to sudden painless bleeding and foetal bradycardia/death

69
Q

What are some risk factors for vasa praevia?

A

Placental anomalies, history of low lying placenta in 2nd trimester, multiple pregnancy, IVF

70
Q

How is vasa praevia managed if it is an antenatal diagnosis?

A

Steroids from 32 weeks and consider inpatient management if risks of preterm birth. Deliver by C-section before 37 weeks.

71
Q

How is vasa praevia managed if diagnosed in labour?

A

Emergency C-section and neonatal resuscitation including the use of blood transfusion if required

Reproductive - Childbirth (9 decks)

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