Antepartum Haemorrhage Flashcards
Bleeding in late pregnancy is defined as what gestation?
24 weeks +
Antepartum haemorrhage is often due to problems with what?
The placenta
Antepartum haemorrhage is defined as bleeding from or into the genital tract between what times?
24 weeks gestation and the end of the second stage of labour (i.e. delivery)
What are some placental causes of antepartum haemorrhage?
Placenta praevia/abruption/accreta
A uterine rupture is more likely to be the cause of an antepartum haemorrhage in who?
Women who have had a previous C-section or have had more than 4 children
What are some local causes of an antepartum haemorrhage?
Cervical ectropion, polyps, cancer, infection
With any women presenting with antepartum haemorrhage, what are the two most important things to check for first?
Placental abruption and placenta praevia
What are some differential diagnoses of an antepartum haemorrhage?
Heavy show, cystitis, haemorrhoids
What is a heavy show?
A mixture of mucus and blood which passes when the woman is about to labour
What is defined as a minor haemorrhage?
Blood loss < 50ml which has settled
What is defined as major haemorrhage?
Blood loss of 50-1000ml, with no signs of clinical shock
What is defined as massive haemorrhage?
Blood loss > 1000ml +/- clinical shock
What is placental abruption?
The separation of a normally implanted placenta (partially or totally) before the birth of the foetus
In placental abruption, where does the actual separation take place between?
The uterine wall and decidua basalis
How is placental abruption diagnosed?
It is a clinical diagnosis
Describe briefly the pathophysiology of placental abruption?
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
What impact does placental abruption have on the foetus?
Interrupts the placental circulation which leads to hypoxia
Placental abruption can result in Couvelaire uterus - what is this?
Bleeding which penetrates into the myometrium and forces its way into the peritoneal cavity
What are some risk factors for placental abruption?
Previous abruption, hypertension/pre-eclampsia, trauma, smoking/drugs (especially cocaine)
What is the main symptom of placental abruption?
Severe abdominal pain which is continuous
If the placenta is posterior, placental abruption can also present with what?
Back pain
What is important to be aware of about bleeding in placental abruption?
It may be concealed - foetal compromise and maternal collapse may seem disproportionate to the amount of blood loss
What are the only reasons that an US should be used for in placental abruption?
Initially, to rule out placenta praevia, and then to establish foetal viability
Describe the uterus that may be seen in placental abruption?
Large for dates, tender, woody hard
What can happen to the foetal heart beat in placental abruption? How should this be monitored?
Bradycardic or absent - cardiotocography once the mother is stable enough
What are some features which may be seen on cardiotocography for placental abruption?
1 contraction per minute, loss of variability, decelerations
What are the 4 stages of management of placental abruption?
Resuscitate the mother, assess and deliver the baby, manage any complications, debrief the parents
What are some important aspects of maternal resuscitation for antepartum haemorrhage?
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
Which women with placental abruption should receive a Kleihauer Betke test? What is this for?
Only used for Rh - women who have not been sensitised to guide the amount of anti-D required
How should the baby be delivered in placental abruption?
C-section
How should delivery be managed in placental abruption?
Expectantly, but give steroids if < 35 weeks
What are some maternal complications of placental abruption?
Hypovolaemic shock, PPH, renal failure, coagulopathy, infection…
What are some foetal complications of placental abruption?
Hypoxia, prematurity, SGA, IUD
How can placental abruption be prevented a) generally? b) in women with anti-phospholipid syndrome?
Low dose aspirin and smoking cessation / LMWH and LDA
What is placenta praevia?
The placenta is partially or totally implanted in the lower uterine segment
What is the difference between the terms placenta praevia and low lying placenta?
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
What are some risk factors for placenta praevia?
Previous C-section(s), previous termination of pregnancy, smoking, assisted conception
What is the first time during screening that placenta praevia or low lying placenta should be picked up?
On the anomaly scan
If the anomaly scan shows signs of placenta praevia or low lying placenta, what is the management?
Rescan at 32 and 36 weeks if persistent (ideally transvaginal)
If placenta accreta is suspected as a diagnosis, what investigation should be done?
MRI
How does placenta praevia present?
Painless bleeding which can be continuous or intermittent > 24 weeks (can be anything from minor spotting to severe bleeding)
Bleeding from placenta praevia is usually unprovoked, but can be initiated by what?
Sex
In placenta praevia, the patient’s condition is directly proportional to what?
The amount of bleeding that can be seen
What are some signs around the uterus that may be seen in placenta praevia?
Soft, non-tender, may have a high presenting part, may be malpresentations
What does a CTG in placenta praevia usually show?
It is usually normal
In any undiagnosed antepartum haemorrhage it is important to not perform what examination? Why? What must you do first?
Digital vaginal examination - if the cause is placenta praevia, then this can trigger significant bleeding / Ultrasound first
How is placenta praevia diagnosed?
Transvaginal ultrasound scan
What are the management principles of placenta praevia?
Resuscitate mother, assess baby, investigations, deliver if at/near term
What is the management for placenta praevia if the mother is a) stable? b) still bleeding/distant from hospital etc?
a) inpatient for at least 24 hours until bleeding has stopped b) admit
If you discharge a patient with placenta praevia, what should you advise them?
Advise them to come back if they have any bleeding or pain / don’t have sex
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?
Steroids < 35 weeks / MgSO2 if 24-32 weeks / consider tocolysis to give these medications time to work
When would a C-section be indicated for placenta praevia?
If the placenta is < 2cm from or covers the internal cervical os
When would a vaginal delivery be indicated for placenta praevia?
If the placenta is > 2cm from the internal cervical os and there is no malpresentation
What is placenta accreta?
A placenta which is abnormally adherent to the uterine wall
What are the two major risk factors for placenta accreta?
Having placenta praevia, or having previous C-sections
What are some risks of placenta accreta?
Severe bleeding, PPH, hysterectomy requirement
How is placenta accreta managed?
MDT - iliac artery balloon, C-section hysterectomy and expect major blood loss
What is the definition of uterine rupture?
Full thickness opening of the uterus
When does uterine rupture generally present?
After the onset of contractions in labour
What are the risk factors for uterine rupture?
Previous C-section or uterine surgery, multiparity, use of prostaglandins/syntocinon or obstructed labour
What are some symptoms of uterine rupture?
Severe abdominal pain, shoulder tip pain, maternal collapse, PV bleeding
What are some signs of uterine rupture?
Intrapartum loss of contractions, hypertension, peritonism, acute abdomen, foetal distress
What is the management for uterine rupture?
Urgent resuscitation and emergency laparotomy to remove the baby
What is vasa praevia?
Unprotected foetal vessels transverse the internal cervical os
What happens to the unprotected foetal vessels in vasa praevia at labour?
They will rupture
How can vasa praevia be picked up antenatally?
TA and TV US with Doppler
If vasa praevia is not already known and it occurs at labour, how is it diagnosed?
Clinical diagnosis
Describe what happens in vasa praevia at delivery?
Rupture of membranes leads to sudden painless bleeding and foetal bradycardia/death
What are some risk factors for vasa praevia?
Placental anomalies, history of low lying placenta in 2nd trimester, multiple pregnancy, IVF
How is vasa praevia managed if it is an antenatal diagnosis?
Steroids from 32 weeks and consider inpatient management if risks of preterm birth. Deliver by C-section before 37 weeks.
How is vasa praevia managed if diagnosed in labour?
Emergency C-section and neonatal resuscitation including the use of blood transfusion if required
