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Obstetrics and Gynaecology > Antepartum haemorrhage > Flashcards

Antepartum haemorrhage Flashcards

1
Q

What is antepartum haemorrhage?

A

Bleeding from the genital tract after 24 weeks gestation.

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2
Q

What are the causes of APH?

A

Common: undetermined origin, placental abruption, placenta praevia
Uncommon: incidental genital tract pathology, uterine rupture, vasa praevia

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3
Q

What is placenta praevia?

A

Placenta praevia occurs when the placenta is implanted in the lower segment of the uterus.

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4
Q

Why does the placenta tend to move during the pregnancy?

A

Because of the formation of the lower segment of the uterus in the third trimester: it is the myometrium where the placenta implants that moves away from he internal cervical os.

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5
Q

How (not into what) is placenta praevia classified?

A

According to the proximity of the placenta to the internal os of the cervix. It may be predominantly on the anterior or posterior uterine wall.

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6
Q

What is a marginal placenta praevia?

A

Placenta in lower segment, not over os

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7
Q

What is a major placenta praevia?

A

Placenta completely or partially covering the os

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8
Q

What risk factors are there for placenta praevia?

A

multiparity
multiple pregnancy
embryos are more likely to implant on a lower segment scar from previous caesarean section

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9
Q

What are the features due to a placenta praevia?

A
  1. shock in proportion to visible loss (The placenta in the lower segment obstructs engagement of the head. Haemorrhage can be severe.)
  2. no pain
  3. uterus not tender
  4. lie and presentation may be abnormal
  5. fetal heart usually normal
  6. coagulation problems rare
  7. small bleeds before large
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10
Q

Why is there haemorrhage in placenta praevia?

A

The lower segment of the uterus is unable to contract and constrict the maternal blood supply so the haemorrhage can be severe and may continue during and after delivery.

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11
Q

What is placenta accreta?

A

Placenta accreta occurs when all or part of the placenta attaches abnormally to the myometrium (the muscular layer of the uterine wall).

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12
Q

How does placenta praevia lead to placenta accreta?

A

If a placenta implants into a previous C section scar, it may be so deep as to prevent placental separation

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13
Q

What is placenta percreta?

A

When the placenta invades through the uterine wall and into surrounding structures such as the bladder

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14
Q

What would you find on examination of placenta praevia?

A

Breech presentation and transverse lie are common. The fetal head is not engaged and high. Vaginal examination can provoke massive bleeding and is never performed in a woman who is bleeding vaginally until exclusion of placenta praevia.

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15
Q

How do you investigate placenta praevia?

A

US, CTG to assess fetal well-being

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16
Q

How do you manage placenta praevia?

A

If low-lying placenta at 16-20 week scan:

  1. Rescan at 32 weeks
  2. In women with a persistent low‐lying placenta or placenta praevia at 32 weeks of gestation who remain asymptomatic, an additional TVS is recommended at around 36 weeks of gestation to inform discussion about mode of delivery.
  3. For women presenting with uncomplicated placenta praevia, delivery should be considered between 36+0 and 37+0 weeks of gestation.

Placenta praevia with bleeding:

  1. admit
  2. treat shock
  3. cross match blood
  4. final ultrasound at 36-37 weeks to determine method of delivery, Caesarean section for grades III/IV between 37-38 weeks. If grade I then vaginal delivery
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17
Q

What is placental abruption?

A

Placental abruption is when part (or all) of the placenta separates before delivery the fetus. It occurs in 1% of pregnancies.

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18
Q

What is the pathology of placental abruption?

A

When part of the placenta separates, considerable maternal bleeding may occur behind it. Further placental separation and acute fetal distress may follow.

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19
Q

Where does the blood from the placental separation usually go in a placental abruption?

A

Blood usually tracks down between the membranes and the myometrium to be revealed as an APH. It may also enter the liquor or it may just enter the myometrium.

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20
Q

Is placental abruption always visible?

A

No, it 20% it is absent as the blood only enters the myometrium.

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21
Q

What are the complications of placental abruption?

A

Fetal death (30%); blood transfusions; DIC and renal failure may rarely lead to maternal death

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22
Q

What are the risk factors of placental abruption?

A

IUGR, PE, autoimmune disease, maternal smoking, cocaine usage, previous history of placental abruption, multiple pregnancy, high maternal parity, trauma

23
Q

What are the clinical features of placental abruption?

A 
shock out of keeping with visible loss
pain constant
tender, tense uterus
normal lie and presentation
fetal heart: absent/distressed
coagulation problems
beware pre-eclampsia, DIC, anuria
24
Q

Does the degree of vaginal bleeding reflect the severity of the abruption?

A

No, because some may not escape from the uterus.

25
Q

What is the difference between a concealed placental abruption and a revealed placental abruption?

A

If pain occurs alone, the abruption is concealed. If vaginal bleeding is evident, it is revealed.

26
Q

What would you find on examination of placental abruption?

A

Tachycardia and hypotension after massive bloodless. The uterus is often tender and contracting, labour often ensues. In severe cases, the uterus is ‘woody’ hard and the foetus is difficult to feel. Fetal heart tones are often abnormal or absent.

27
Q

What investigations would you perform in placental abruption?

A

CTG to establish fetal wellbeing. US to rule out placenta praevia. FBC, coagulation screen and cross match, catheterisation with measured urine output, U&E to establish maternal wellbeing.

28
Q

How do you manage placental abruption?

A

Admission is required, IV fluids and potentially steroids and anti-D. If fetal distress, deliver immediately. If no fetal distress and >37 weeks, induce and monitor closely. If no fetal distress and <37 weeks, mother is monitored closely on the ward.

29
Q

Does APH increase the risk of PPH?

A

Yes

30
Q

What are the causes of APH?

A

Placenta praevia, bleeding of undetermined origin, ruptured vasa praevia, uterine rupture, bleeding of gynaecological origin

31
Q

What is vasa praevia?

A

It occurs when a fetal blood vessel runs in the membranes in front of the present part. Tends to occur when the umbilical cord is attached to the membranes rather than the placenta

32
Q

What is the typical presentation of vasa praevia?

A

Painless, moderate vaginal bleeding at amniotomy or spontaneous rupture of the membranes, which is accompanied by severe fetal distress, C section is often not quick enough to save the foetus.

33
Q

What are the prinicipal causes of perinatal mortality?

A

Unexplained; preterm delivery; IUGR; congenital abnormalities; intrapartum, including hypoxia; placental abruption

34
Q

What is small for gestational age? (SGA)

A

The weight of the fetus is less than the tenth centile for its gestation.

35
Q

What is fetal distress?

A

An acute situation, such as hypoxia, that may result in fetal damage or death if it is not reversed, or if the fetus is delivered urgently.

36
Q

What is fetal compromise?

A

A chronic situation, when conditions for the normal growth and neurological development are not optimal (poor nutrient transport/placental dysfunction)

37
Q

What are the aims of fetal surveillance?

A

Identify high risk pregnancy; monitor fetal growth and wellbeing; intervene at an appropriate time

38
Q

What are the problems with fetal surveillance?

A

All methods have a false positive rate, the ‘medicalise’ pregnancy.

39
Q

What are some prepregnancy identifications of high risk pregnancy?

A

Poor past obs history; maternal disease; assisted conception; extremes of reproductive age; heavy smoking; drug abuse

40
Q

What are some identifications of high risk pregnancy during the pregnancy?

A

HTN/proteinuria; vaginal bleeding; SGA; prolonged pregnancy; multiple pregnancy

41
Q

Does the abdomen or head stop growing first in IUGR?

A

The abdomen, resulting in a ‘thin’ fetus or ‘asymmetrical’ growth restriction

42
Q

What is and why do we use a doppler artery waveform?

A

It is used to measure velocity waveforms in the umbilical arteries.

43
Q

What is an abnormal uterine artery doppler?

A

Evidence of a high resistance circulation, i.e. reduced flow in fetal diastole compared to systole suggests placental dysfunction.

44
Q

Which arteries does a doppler look at when looking at the fetal circulation?

A

Middle cerebral artery and the ductus venous.

45
Q

What would an abnormal fetal circulation doppler show?

A

In fetal compromise, the MCA develops a low resistance pattern in comparison to the thoracic aorta, which reflects a head-sparing effect.

46
Q

What are some physiological causes of a small baby?

A

Low maternal height and weight, nulliparity, asian, female fetal gender.

47
Q

What are some pathological causes of SGA?

A

IUGR; pre-existing maternal disease; maternal pregnancy complications; multiple pregnancy; smoking; drug use; infection; extreme malnutrition; congenital abnormalities;

48
Q

What are the complications of SGA?

A

Increased risk of cerebral palsy, preterm delivery and maternal complications

49
Q

What would you find on US of SGA?

A

Small baby; abnormal umbilical artery doppler; reduced amniotic fluid (oligohydramnios), head-sparing MCA doppler.

50
Q

What is a prolonged pregnancy?

A

If the pregnancy is prolonged over 42 weeks gestation.

51
Q

At what gestation after term does increased perinatal mortality risk occur?

A

Between 41 and 42 weeks.

52
Q

What are the risk factors for prolonged pregnancy?

A

Previous prolonged pregnancy; in nulliparous women; rarer in south asian and black women

53
Q

What are the risks of prolonged pregnancy?

A

Stillbirth; neonatal illness and encephalopathy; meconium passage; fetal distress.

54
Q

At what gestation would you normally induce labour?

A

Between 41 and 42 weeks, before 41 weeks it does not have as many benefits. ‘Sweeping’ the cervix helps spontaneous labour start earlier.

Obstetrics and Gynaecology (27 decks)

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