Antepartum haemorrhage Flashcards
When does bleeding in early pregnancy occur
<24 weeks
When does bleeding in late pregnancy occur
> =24 weeks
At which week of gestation is the foetus said to be viable
24 weeks
Define antepartum haemorrhage APH
bleeding from the genital tract after 24/40 and before the end of the second stage of labour
Aetiology of APH
Placental: previa, abruption Uterine: rupture Indeterminate Foetal: vasa previa Local causes: cervical, vaginal
How much blood is seen in spotting
streaks, stains or upon wiping
How much blood is lost in minor APH
<50 ml
settled
How much blood is lost in major APH
50-1000ml
NO shock
How much blood is lost in a massive APH
> 1000ml
+/or shock
What is placental abruption
separation of a normally implanted placenta - partially/totally before the birth of the foetus
Placental abruption needs imaging to confirm the diagnosis, true or false
FALSE
Placental abruption is a clinical diagnosis
What is the pathophysiology behind placental abruption
vasospasm followed by arteriole rupture into the decidua
blood escapes into amniotic sac or further under the placenta into the myometrium
causes tonic contraction
interrupts placental circulation –> hypoxia
What is Couvelaire uterus and in which condition is it seen
“blue” uterus from extravasation of blood into uterus
seen in placental abruption
List risk factors for placental abruption
HTN/PET smoking trauma cocaine / amphetamine thrombophilias DM / renal disease polyhydramnios multiple pregnancy PPROM abnormal placenta previous placental abruption
What are the symptoms of placental abruption
Continuous severe abdominal pain backache if placenta lies posteriorly Maternal collapse Bleeding (may be concealed) Pre term labour
What are signs of placental abruption
Distressed patient Appearance of patient may not match up to how much blood they have lost Normal / LFD uterus Tender uterus Woody hard uterus Difficult to identify foetal parts Foetal HR - bradycardia / absent CTG shows irritable uterus
Management of placental abruption
RESUSCITATE mother 2 large bore IV access FBC, clotting, U+E, LFT, crossmatch 4-6 units Kleihauer - Rh -ve IV fluids Catheterise assess foetus and foetal HR category 1 c-section
In which groups of patient should care be taken in administering IV fluids
Those with pre eclampsia or heart conditions –> pulmonary oedema
What are maternal complications of placental abruption
infection hypovolaemic shock anaemia PPH renal failure - renal tubular necrosis DIC VTE PTSD
List foetal complications of placental abruption
IUD
hypoxia
pre term delivery
SGA + FGR
Define placenta previa
placenta lies directly over internal cervical os
Define low lying placenta
> 16/40
placental edge is <20mm from internal cervical os on TVUSS/TAUSS
List risk factors for developing placenta previa
previous c-section previous placenta previa smoking assisted conception treatment previous TOP multiparity age >40 damaged endometrium
Is placenta previa screened for and if so what is the process
Yes
screened at 20 week anomaly scan
If abnormal, repeat scan at 32 + 36 weeks
Which method is better for diagnosing placenta previa, TVUSS or TAUSS
TVUSS
If placenta accreta is suspected, what imaging should be done
MRI
Symptoms of placenta previa
painless bleeding > 24 weeks
unprovoked or post-coital
patients condition directly proportional to amount of bleeding seen
Signs of placenta previa
uterus is soft and non-tender
presenting part high
malpresentation
Normal CTG
It is ok to perform a digital PV/PR exam for placenta previa, true or false
FALSE!
This should not be done until you have excluded placenta previa as a diagnosis
management of placenta previa in stable mother
Resuscitate mother assess foetus anti-D if Rh- prevent and treat anaemia avoid sex antenatal steroids magnesium sulphate 24-32 weeks neuroprotection
management of placenta previa in unstable mother
resuscitate mother assess foetus 2 large bore IV access FBC, clotting, LFT, U+E, crossmatch 4-6 units Kleihauer - Rh- --> anti D major haemorrhage protocol IV fluids/blood transfusion
in placenta previa, when should a symptomatic mother consider delivery
34-36+6 weeks
in placenta previa, when should an asymptomatic mother consider delivery
36-37 weeks
in placenta previa, what is the indication for a c-section
the placenta directly covers the internal cervical os
or is < 2 cm from os
in placenta previa, what is the indication for a vaginal delivery
placenta >2cm from internal cervical os and there is no malpresentation
Define placenta accreta
morbidly abnormal adherent placenta to the uterine wall
What increases the risk of placenta accreta
multiple c-sections
placenta previa
symptoms of placenta accreta
bleeding
PPH
define placenta percreta
penetrating uterus to bladder
define placenta increta
invading myometrium
what is the management for placenta accreta
prophylactic iliac artery balloon by IR
caesarean hysterectomy
Define uterine rupture
full thickness (including serosa) opening of the uterus
what increases the risk of uterine rupture
previous c-section or uterine surgery
multiparity
use of syntocin
obstructed labour
symptoms of uterine rupture
severe abdominal pain
shoulder tip pain
maternal collapse
PV bleeding
signs of uterine rupture
loss of uterine contractions in labour acute abdomen presenting part rises peritonism foetal distress IUD
Management of uterine rupture
Resuscitate 2 large bore IV access FBC, U+E, LFT, crossmatch 4-6 units, clotting Kleihauer - Rh- --> anti D major haemorrhage protocol IV fluids / blood transfusion
Define vasa previa
rupture of unprotected foetal vessels that traverse the membrane below the presenting part but over the internal cervical os during labour or ARM/amniotomy
there is screening for vasa previa, true or false
FALSE
how is vasa previa diagnosed
TAUSS + TVUSS
risk factors for vasa previa
bi-lobed/succenturiate placenta
low lying placenta in 2nd trimester
multiple pregnancy
IVF
Management of vasa previa
antenatal steroids 32-34 weeks
elective c-section before labour
emegency c-section if diagnosed during labour
placenta for histology
